Ruth A. Etzel, MD, PhD


March 29, 2006

In This Article


Rapid advances are being made in understanding the role of the environment in the illnesses of infancy and childhood. The emerging body of knowledge, known as environmental pediatrics (or pediatric environmental health), shows that children are uniquely vulnerable to the effects of environmental contaminants, in part because their developing organs may be more susceptible to environmental contaminants than are the target organs of adults, and also because they may absorb and metabolize chemicals differently from adults.[1] These findings have implications for policy,[2] research,[3] and practice.[4]

Nevertheless, many clinicians who care for children have been slow to incorporate this knowledge into their practices. The situation is not unlike that of the field of nutrition at the dawn of the 20th century. During the first third of that century, as new vitamins were being isolated and named, the medical profession remained largely unconvinced of their importance because their proposed role in disease did not fit with the prevailing theory of the day -- the theory that disease was caused by infectious agents. Even when the role of vitamin deficiencies in scurvy and pellagra was firmly established, practitioners were slow to acknowledge the role of vitamins in the development of chronic and infectious diseases.

One of the most significant obstacles that the burgeoning field of nutrition encountered was the notion that the amounts of nutrients that were absent were too small to be important. Likewise, until recently, many clinicians believed that the amounts of contaminants present in children's bodies were too small to be important.

Exposure to environmental tobacco smoke provides an excellent example. Before the 1980s, most pediatricians thought that the amount of "side-stream" cigarette smoke contaminants absorbed by nonsmoking children was too small to be important. But in the past 20 years, a large body of evidence has accumulated documenting that the amount of exposure infants receive by passive smoking is sufficient to increase the risk for lower respiratory tract illnesses,[5] middle ear effusions,[6] sudden infant death syndrome,[7,8,9] and asthma.[10,11] Additionally, a growing body of evidence shows that passive smoking is linked to intellectual impairments[12] and behavioral problems in children.[13] Though counseling about the risks of passive smoking has now become commonplace, other findings about the effect of the environment on child health have not been incorporated as widely into practice.

A conceptual impediment to translating the existing knowledge into practice is the belief than man-made toxicants produced by the chemical industry are the problem and that there is little an individual clinician can do about it. This is, however, not the case. The vast majority of exposures to children take place in the home environment to naturally occurring substances, and there is guidance that clinicians can provide to reduce these exposures.


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