A Call for Training Pediatric Practitioners About Industrial Chemicals and Child Health

Introduction

We have existed as an industrial culture for approximately 200 years. During that time, manufacturers have poured chemicals into the air, water, and soil. For the first hundred years, the public barely noticed the effects that those chemicals were having on people’s health. Then, 100 years ago, the danger of exposure to chemicals burst into public consciousness in the United States. On October 26 to 30, 1924, 5 men working at the Standard Oil processing plant in Bayway, New Jersey, died, and 35 others developed mental health symptoms so severe that some were placed in psychiatric hospitals. Because the men complained of severe palsies, tremors, and hallucinations, the place they worked was dubbed the “loony gas building.” It was there that Standard Oil made leaded gasoline, a new product first sold in the United States in February 1923. Forty of the 49 workers at this plant died or were severely poisoned by lead.

Until this occurred, the general public had virtually no awareness that chemicals used in manufacturing might have a downside. Although lead poisoning had been described in 1914 in a 5-year-old child in Baltimore with recurrent convulsions who was eating the paint from his crib,¹ it was thought that once the acute symptoms abated, there would be no residual problems. The chronic effects of lead exposure on children were only brought to light in 1943, when 20 children who had been discharged as “cured” from acute lead poisoning were evaluated at school age, and all but 1 had persistent learning disabilities.²

Besides lead, other chemicals used in industry were soon discovered to cause health problems. In early 1956, for example, an unusual disease surfaced in Japan, later coined Minamata disease. A 5-year-old girl living in a fishing village on Minamata Bay began experiencing difficulty walking, difficulty speaking, and seizures. By the end of the year, 40 patients had surfaced, and 14 had died. Some children were born with a condition resembling cerebral palsy. A local physician suspected that the health problems were associated with eating fish; cats that ate locally caught fish also were having convulsions, likened to a “cat dancing disease.” It was eventually determined that the fish from the bay were contaminated with mercury because a chloralkali plant was discharging huge amounts of mercury directly into Minamata Bay, and the mercury bioaccumulated up the food chain into the fish.

By the middle of the 20^th century, many chemicals polluted the air of US cities. In 1948, an atmospheric inversion in the small, industrial town of Donora, Pennsylvania (population 14,000), killed 20 people and caused approximately 6000 others to be sick. This raised the town’s death rate by 400%.^3,4 Also, the use of leaded gasoline throughout the nation caused massive amounts of lead to enter the air, resulting in a sharp rise in blood lead concentrations among US children between 1900 and 1975.⁵

These episodes signaled that the Industrial Revolution had various serious unintended consequences for human health. Nonetheless, the pace of introduction of industrial chemicals into the environment accelerated after World War II, and thousands of new synthetic organic chemicals were introduced into the marketplace. Today, there are an estimated 350,000 manufactured chemicals, chemical mixtures, and plastics listed in global inventories.⁶ Concerns that were rare 100 years ago have now become mainstream concerns; many people now worry about the effects of environmental pollution on human health. There is special concern about the health of children because they are not just little adults; on a per-kilogram basis, children breathe more air, drink more water, and eat more of certain foods than adults. Their bodies are still developing, and during certain critical windows of time, exposure to industrial chemicals can lead to irreversible damage. Starting in the 1950s, the American Academy of Pediatrics began drawing attention to the special vulnerability of children to environmental hazards, which gave rise to the field of environmental pediatrics, also known as children’s environmental health.^7,8

Today, at the end of the first quarter of the century, Americans live in an increasingly complex and heavily industrialized environment, and manufactured chemicals are becoming a larger concern for child health.⁹ Prevalent chemicals, such as the per- and polyfluoroalkyl substances (PFAS), contaminate much of our food and water.¹⁰ Endocrine-disrupting chemicals, such as dichlorodiphenyltrichloroethane (DDT), phthalates, and bisphenol A, pose risks to child health and development.¹¹ The current focus is no longer on deaths from hazardous pollutants (although they do make headlines when they happen), but the long-term effects of chronic exposures, which begin even before conception and have a lifelong impact.¹² We now understand that exposures during pregnancy and early life to lead,^13,14 mercury,^15–18 polybrominated diphenyl ethers,^19,20 PCBs,^21,22 pesticides,^23,24 and phthalates^25,26 can result in IQ deficits in children and developmental and learning disorders. Many years after the air pollution disaster in Donora, studies have documented that exposure to chemicals in outdoor air, such as polycyclic aromatic hydrocarbons,^27–29 can have a detrimental impact on children’s IQ. Overlaid on these risks is the risk of climate change.³⁰

Health professionals play a crucial role in drawing attention to the adverse effects of industrial pollution on children and reducing their exposure. There are multiple reasons why engaging more pediatric practitioners to protect environmental health makes sense. Because of their extensive training, clinicians with expertise in pharmacology are particularly well-equipped to contribute to understanding and reducing exposures to industrial chemicals, as well as protecting children’s health.

First, some industrial chemicals act like pharmaceuticals. The endocrine-disrupting chemicals, for example, have effects on the child’s endocrine system.³¹ DDT and its metabolite, dichlorodiphenyldichloroethylene, act as xenoestrogens and anti-androgens.³² They can compete with endogenous hormones for binding to their receptors, leading to altered reproductive health, including early menarche and increased risk of breast cancer. DDT may even have intergenerational effects.

Second, industrial contaminants can change the metabolism of pharmaceuticals. This has been understood for decades.³³ Exposure of humans to DDT or lindane in a pesticide factory results in an enhanced rate of metabolism of antipyrine and an increased urinary excretion of 6-beta-hydroxycortisol.^34,35 Another well-characterized example is that tobacco smoking significantly increases theophylline clearance.³⁶ Recent evidence documents that PFAS (so-called “forever chemicals”) can impair the antibody response to vaccination against tetanus, diphtheria, measles, mumps, and rubella.^37,38

Third, some pharmaceuticals can increase the excretion of chemical contaminants. For example, folic acid supplementation increases arsenic methylation in adults. A randomized controlled trial showed that folic acid and B₁₂ supplementation improved arsenic methylation and elimination in children, potentially reducing arsenic toxicity.³⁹

Fourth, pharmacists play important roles in educating patients. Pharmacists have substantial experience counseling patients on nutrient-drug interactions^40,41 and complementary medicine-drug interactions⁴² and are effective communicators with patients about other important topics. In the US, more than 2.8 million antimicrobial-resistant infections occur each year, and more than 35,000 people die as a result.⁴³ Because of concerns about antimicrobial resistance,^44,45 pharmacists teach people to dispose of medication safely and appropriately, helping to reduce pharmaceuticals in water.⁴⁶

Finally, the public trusts pharmacists. In the annual Gallup poll taken in December 2024, 57% of respondents rated the honesty and ethics of pharmacists as very high or high. A smaller proportion (53%) rated medical doctors very high or high.⁴⁷

The pediatric clinician must have a high index of suspicion to recognize illness linked to industrial chemicals because the onset of the illness often is gradual. Establishing the environmental cause of a given illness is further complicated by the similarity of symptoms resulting from pollutant effects to those of other diseases. Clinicians may suspect that an illness is linked to the environment when the symptoms are unusual, persistent, or when multiple people in the same home (or school, childcare setting, etc.) exhibit similar symptoms. A thorough environmental history should be obtained, including the age, condition, and location of the home, as well as exposure to gas stoves or pesticides, dietary exposure to mercury in fish and arsenic in rice products and juice, and parental occupations and hobbies. For example, if a child presents with developmental delay or attention-deficit/hyperactivity disorder, the clinician can ask the parent about the home’s age and inquire about leaded paint, lead pipes, and other possible sources of lead, and order a blood lead test. If a child presents with insomnia, loss of appetite, and tremors, the parents can be asked if the child played with elemental mercury, and a urine mercury concentration can be measured.

There are many resources available for clinicians who wish to learn more about children’s health and environmental chemicals. The American Academy of Pediatrics publishes Pediatric Environmental Health, a book that describes how to identify, prevent, and treat pediatric environmental health problems.⁷ The book’s 66 topic-based chapters cover a broad range of industrial chemicals, including lead, arsenic, mercury, DDT, polychlorinated biphenyls, PFAS, pesticides, plasticizers, and much more. The Textbook of Children’s Environmental Health presents carefully documented data on rising rates of disease among children, offers a critical summary of new research linking pediatric disease with environmental exposures, and explores the cellular, molecular, and epigenetic mechanisms underlying diseases of environmental origin.⁸ A new, free online Introduction to Children’s Environmental Health course is available from the United Nations Children’s Fund and the World Health Organization.⁵⁴ Finally, the New England Journal of Medicine has videos, including Climate, Pollution, and Children’s Health.⁵⁵

Clinicians with expertise in pharmacology have already stepped up to address the climate crisis. The greenhouse gas emissions associated with pharmaceutical consumption and production are considerable,⁴⁸ and the “green pharmacy” movement aims to implement eco-friendly methods for producing and disposing of pharmaceutical products to mitigate their environmental impact.⁴⁹ The 2021–2022 report of the American Association of Colleges of Pharmacy (AACP) called on the specialty to develop more materials to prepare pharmacists for the changing climate.⁵⁰ At the 2024 AACP annual meeting, faculty from 2 schools at the forefront of climate change education, the University of California at San Francisco School of Pharmacy and the University of Montana Skaggs School of Pharmacy, described how they weave climate change into the pharmacy curriculum and urged more schools to train pharmacists to combat the climate crisis. Pharmacists have expressed a desire for such training. In a recent survey of pharmacy interns in Ohio, 62% stated that climate change is relevant to pharmacists or pharmacy practice and believed that there should be more education about climate change and its impact on health in the pharmacy curriculum.⁵¹ Almost 52% of administrators of US-based, fully accredited Doctor of Pharmacy programs surveyed in 2024 thought climate change was relevant to pharmacists/pharmacy practice.⁵²

Although the 2021–2022 AACP report identified the need to prepare pharmacists for the changing climate, it remained silent on the issue of environmental chemical contamination. Given that emissions from manufacturing are projected to increase by 17% between 2024 and 2050,⁵³ it may be time for the pharmacy profession to prepare its students to contribute not only on climate change but also on chemical pollution. Clinicians with expertise in pharmacology have the training and experience that uniquely prepare them to assume responsibility for helping to reduce the child health impacts of industrial pollution.

ABBREVIATIONS

AACP

American Association of Colleges of Pharmacy;

DDT

dichlorodiphenyltrichloroethane;

PFAS

per- and polyfluoroalkyl substances