For the third time and the first time in 10 years, the U.S. Environment Protection Agency (EPA) released a comprehensive report regarding children’s environmental health. The stated purpose of America’s Children and the Environment (3rd edition), or ACE3, “is to compile information, and make it available to a broad audience, that can help identify areas that warrant additional attention, potential issues of concern, and persistent problems.” As such, environmental and children’s health advocates look to the ACE3 for information and indicators that may influence clinical protocols, directions for future research and framework for public health and environmental regulatory policies.
I turned to my colleague, Elise Miller, Director of the Collaborative on Health and the Environment (who served as a member of the U.S. EPA's Children's Health Protection Advisory Committee from 2007-2011 and as an advisory group member for the ACE3 report), for commentary on the significance of this long-awaited publication:
"With the third edition of the ACE report, the U.S. EPA provides the public with an updated and useful synthesis of the evidence-based science regarding children's environmental health. Though its conclusions are inherently conservative and it does not offer an analysis of actions families might take in response to the information, this new volume is the most comprehensive compendium on links between environmental factors and children's health offered by any government agency to my knowledge."
As expected, key findings of the ACE3 report include good news and bad news. First, the good. Significant gains have been made in reducing targeted environmental contaminant exposures and biomonitoring levels.
1. Exposure to poor outdoor air quality reduced: The percentage of children’s days that were designated as having “unhealthy” air quality decreased from 9% in 1999 to 3% in 2009 and the percentage of children’s days with “good” air quality increased from 41% in 1999 to 57% in 2009.
2. Exposure to poor indoor air quality reduced: In 2010, 6% of children ages 0 to 6 years lived in homes where someone smoked regularly, compared with 27% in 1994.
3. Food less contaminated: In 1999, 81% of sampled apples had detectable organophosphate pesticide residues, and in 2009, 35% had detectable residues. In 2000, 10% of sampled carrots had detectable organophosphate pesticide residues, and in 2007, 5% had detectable residues. In 2000, 21% of sampled grapes had detectable organophosphate pesticide residues, and in 2009, 8% had detectable residues. In 1998, 37% of sampled tomatoes had detectable organophosphate pesticide residues, and in 2008, 9% had detectable residues.
4. Lead levels dropped: The median concentration of lead in the blood of children between the ages of 1 and 5 years dropped from 15 micrograms per deciliter (μg/dL) in 1976–1980 to 1.2 μg/dL in 2009– 2010, a decrease of 92%.
5. BPA levels dropped: Among children ages 6 to 17 years the median concentration of BPA in urine decreased from 4 μg/L in 2003–2004 to 2 μg/L in 2009–2010.
Encouraging news? Yes. All of these contaminants (air pollution, environmental tobacco smoke, lead, pesticides and BPA) have been increasingly targeted as harmful and efforts to reduce exposure are paying off. However, the bad news is that specific health outcomes in many areas are worsening. The rates of most environmentally-linked chronic pediatric illnesses are on the rise and health care disparities have, in some cases, widened.
1. Asthma: The proportion of children reported to currently have asthma has increased from 8.7% in 2001 to 9.4% in 2010. In 2007–2010, the percentages of Black non-Hispanic children and children of “All Other Races” reported to currently have asthma, 16.0% and 12.4% respectively, were greater than for White non-Hispanic children (8.2%), Hispanic children (7.9%), and Asian non-Hispanic children (6.8%).
2. Cancer: The age-adjusted annual incidence of cancer increased from 1992–2009. The incidence ranged from 153 to 161 cases per million children between 1992 and 1994 and from 172 to 175 cases per million children between 2007 and 2009.
3. Neurodevelopmental disorders: From 1997 to 2010, the proportion of children ages 5 to 17 years reported to have ever been diagnosed with attention-deficit/hyperactivity disorder (ADHD) increased from 6.3% to 9.5%. The percentage of children ages 5 to 17 years reported to have ever been diagnosed with autism increased from 0.1% in 1997 to 1.0% in 2010.
4. Obesity: Between 1976–1980 and 2007–2008, the percentage of children identified as obese showed an increasing trend. In 1976–1980, 5% of children ages 2 to 17 years were obese. This percentage reached a high of 17% in 2007–2008.
5. Prematurity: Between 1993 and 2008, the rate of preterm birth showed an increasing trend, ranging from 11.0% in 1993 to its highest value of 12.8% in 2006.
How to explain these trends? As the report notes, “In some instances, the indicators show that the prevalence of a health outcome is increasing while important environmental exposures are decreasing. Although this could suggest that the environmental exposures addressed in the indicators are unrelated to the health outcomes being measured, it could also result from a lag between environmental improvements and changes in related health outcomes, or changes in other important environmental exposures that are not currently measured by the indicators in the report.”
Going forward, we must continue to monitor both exposures and outcomes. It may be that the strategy of targeting specific contaminant exposures for reduction will eventually lead to better measurable health outcomes. However, chronic diseases are not due to one factor, and it is unlikely we will see a reduction in illness prevalence rates without a comprehensive, multidisciplinary, integrative approach. This is the strategy advocated by the Deirdre Imus Environmental Health Center. One model to consider is CHE’s intergenerational and integrative ecological health initiative, ”Healthy Environments Across Generations.” Complex problems call for complex solutions, and we must encourage and support collaboration between scientists, clinicians, educators and public health advocates.
Lawrence Rosen, MD is an integrative pediatrician and co-author of Treatment Alternatives for Children, an evidence-based guide for parents interested in natural solutions for common childhood ailments. He is the founder of one of the country’s first “green” pediatric practices, The Whole Child Center, in Oradell, NJ, and serves as Medical Advisor to the Deirdre Imus Environmental Health Center at HackensackUMC. Dr. Rosen is a founding member and Past Chair of the AAP Section on Integrative Medicine and is appointed as Clinical Assistant Professor in Pediatrics at UMDNJ. A graduate of New York Medical College and the Massachusetts Institute of Technology, he completed his residency and chief residency in pediatrics at Mount Sinai Hospital in New York. Dr. Rosen has been featured on Good Morning America, CNN, and Imus in the Morning, and he is a frequently cited expert on children’s and environmental health matters. He is a contributing editor and pediatric columnist for Kiwi Magazine, as well as a contributing author/editor for several books, including Integrative Pediatrics, Green Baby, and Pediatric Clinics of North America: Complementary and Alternative Medicine. Dr. Rosen serves on many integrative health advisory boards, including the Holistic Moms Network, Teleosis Institute, IntegrativePractitioner.com and Integrative Healthcare Symposium, Integrative Touch for Kids, PedCAM, Kula for Karma, and MarbleJam Kids.