Patient Presentation
A 6-month-old female came to clinic for her health supervision visit. She was sitting up, making vowel and some consonant sounds and loving playing with toys she could put into her mouth. Her mother said that she continued to nurse well but was very interested in people eating foods and wanted to know when she could start solid foods. The past medical history showed an uneventful pregnancy and delivery. The infant was fully immunized.

The pertinent physical exam revealed a playful infant with growth parameters around the 25%. During the exam she showed that she could roll both ways, sit without difficulty and had no head lag. She said “m” and “b” sounds and the rest of her examination was normal. The diagnosis of of a healthy infant was made. The pediatrician recommended starting solid foods by introducing thinned cereals or other easily swallowed foods one at a time to allow for any potential allergies. The mother had been reading about potential arsenic in rice cereal and asked what types of cereal she could use. The pediatrician offered, “her most important food now is breastmilk, but learning to eat a variety of foods is also important. In addition to rice cereal there are also barley, oat and multigrain cereals that you can use. Check to make sure the cereals are iron-fortified. She is getting some iron from the breastmilk but it isn’t enough anymore for her. She needs more and cereals are usually the way for her to get that.” She went on, “just take a small amount of the cereal and thin it with breastmilk, or water and try it with a spoon. She how she does and over time you can thicken it more as she learns.”

Discussion
Children are particularly susceptible to heavy metals in the environment and while arsenic is not regarded as a heavy metal by chemists (it is a semi-metal) it is often lumped in with mercury and lead because all have similar toxic affects. Elemental arsenic is not toxic itself, but inorganic and organic compounds are toxic. Inorganic compounds are particularly toxic because they are highly lipid soluble. Arsenic sources include water, air, marine animals, and fossil fuels. Fruits, vegetables, milk and rice can also be contaminated. As rice plants grow they can absorb more arsenic than some other grains. The American Academy of Pediatrics recommends, “Parents commonly feed infants rice cereal as a first food, but other foods are equally acceptable as a first food. Finely chopped meat provides a source of iron. Cereals made from other grains may be given first, or vegetable purees. For older children, the advice is the same: A varied diet will decrease a child’s exposure to environmental toxins in any one food, while providing a wide variety of nutrients.” To learn more about environmental arsenic, click here.

Learning Point
Environmental pollution includes those that are more traditional such as air or water pollution, but also include more modern problems including toxic chemicals, climate change, and e-waste. Environmental pollution is a large contributor to morbidity and mortality for the fetus, children and adults.

• Air Pollution
  • Air pollution both outside and inside the home has health affects.
  • Main problems are ozone, nitrogen oxide and particulate matter.
  • Problems include respiratory disease, cancer and neurodevelopmental problems
  • Can be transported across large areas because of dispersal (outdoor) or concentrated (indoor) where solid fuel cookstoves and fires increase particulate matter substantially.
    Tobacco products and their smoke also are large contributors to respiratory diseases.
• E-waste
  • There is rapidly increasing amounts of electronic waste or e-waste.
  • Hazardous materials include barium, cadmium, lead, lithium, mercury, nickel, flame retardants and organic pollutants such as polychlorinated biphenyls (PCBs).
  • There are also many e-waste components which are recycled and therefore exposure to these other chemicals often takes place then. Children are used in the e-waste recycling industry.
• Climate change
  • Can cause direct effects such as heat stress, air pollution, increase in infectious diseases (diarrhea and vector-borne diseases), and extreme weather events.
  • Indirect effects include water insecurity (including increased water salinity), malnutrition, and population displacement.
• Heavy Metal Pollution
  • See above
• Pesticides
  • Are chemicals that are made to kill or repel living things therefore are designed to be toxic.
  • While many chemicals have been abandoned, others believed to be less toxic are still necessarily used.
  • Over time, adverse problems of many of these compounds become known or better understood. For example, organochlorine pesticides have been associated with chronic health problems and glyphosate may be carcinogenic.
  • Regulations are not consistent world-wide and storage and use locally can be problems. Use in homes is one of the major exposures.
• Water Pollution
  • Microbial contamination continues to be a problem where consistent safe drinking water is not available.
  • Other contaminants include lead (neurotoxic effects), nitrates (causing methemoglobin), and perchlorate (inhibits iodine uptake). Radionuclides and arsenic can also be problems in addition to local contaminations from chemicals and pesticides.

Questions for Further Discussion
1. What environmental pollution risks do you have in your local environment?
2. How do you counsel your patients and families to mitigate these potential risks?
3. How do you counsel your families to start solid foods?

Related Cases

Disease: Environmental Health

Symptom/Presentation: Health Maintenance and Disease Prevention

Specialty: Nutrition / Dietetics | Preventive Medicine and Health Maintenance | Pharmacology / Toxicology

Age: Infant

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Environmental Health

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

American Academy of Pediatrics. AAP Offers Advice For Parents Concerned About Arsenic in Food. Available from the Internet at https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Offers-Advice-For-Parents-Concerned-About-Arsenic-in-Food.aspx (rev. 9/6/13, cited 5/2/16)

Vieira SE. The health burden of pollution: the impact of prenatal exposure to air pollutants. Int J Chron Obstruct Pulmon Dis. 2015 Jun 10;10:1111-21.

Suades-Gonzalez E, Gascon M, Guxens M, Sunyer J. Air Pollution and Neuropsychological Development: A Review of the Latest Evidence. Endocrinology. 2015 Oct;156(10):3473-82.

Miller MD, Marty MA, Landrigan PJ. Children’s Environmental Health: Beyond National Boundaries. Pediatr Clin North Am. 2016 Feb;63(1):149-65.

AAP Welcomes FDA Announcement on Limiting Arsenic in Infant Rice Cereal. Available from the Internet at https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AAP-Welcomes-FDA-Announcement-on-Limiting-Arsenic-in-Infant-Rice-Cereal.aspx (rev. 4/1/16, cited 5/2/16).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital