Breastfeeding Grand Rounds

Transcription

1 Breastfeeding Grand Rounds May 9, :30 9:30 a.m. Agenda I. Welcome and Introduction Mary Applegate, M.D., M.P.H. New York State Department of Health II. Common Potential Environmental Contaminants in Breast Milk III. Risk-benefit Trade-off Between the Potential Risks Posed by Contaminants in Breast Milk and Benefits of Breastfeeding Judith S. Schreiber, Ph.D. Toxicologist and Senior Public Health Scientist New York State Office of the Attorney General Ruth A. Lawrence, M.D. University of Rochester IV. Case Studies Participant questions will follow each case study: Call: (toll free) or Fax: Major support for this program comes from the New York State Department of Health and the USDHHS Maternal and Child Health Bureau. Presented by New York State Institute for Human Lactation Jointly sponsored by the New York State Department of Health and The School of Public Health, University at Albany, SUNY

2 1 Breastfeeding Grand Rounds May 9, 2002 Ruth A. Lawrence, M.D. Judith Schreiber, Ph.D. Mary Applegate, M.D., M.P.H. Presented by The New York State Institute for Human Lactation Part of the Women s Health Grand Rounds Series

3 2 Jointly sponsored by New York State Department of Health The School of Public Health, University at Albany, State University of New York Today s Topics: Common potential environmental contaminants in breast milk Heavy metal contaminants in breast milk and the risk to the breastfeeding infant Free copies: Breastfeeding: First Step to Good Health NYS DOH Bureau of Community Relations (518) )

4 1 Common Potential Environmental Contaminants in Breast Milk Judith S. Schreiber, Ph.D. Senior Public Health Scientist New York State Office of the Attorney General Chemicals in Breastmilk vs. the Benefits of Breastfeeding Benefits of breast milk compelling Chemical levels in breast milk generally low Risks of formula feeding well documented Ask Mothers About Potential Exposures Complete medical history and clinical evaluation Health and exposure history

5 2 Occupational Exposure History Any of job you think relates to your concern about breast milk? What is current job title? What type of industry or business? What year did you begin working this job? Occupational Exposure History Briefly describe job duties any health hazards How many hours work in average week? Any protective equipment such as a mask respirator, gloves, etc.? Occupational Exposure History What potential chemical exposure? (fumes and dusts, metals, solvents pesticides, resins, formaldehyde and glues) Are there Material Safety Data Sheets (MSDSs)? National Poison Control:

6 Residential Exposure History Others in household with job involving chemicals or other exposure? Industries or hazardous waste sites in the area? Residential Exposure History Anyone with hobbies using chemicals? (ex: stained glass, model building, painting) Anyone in the household smoke? Is home likely to have lead paint or lead dust? Dermal & Dietary Exposure History Does mother eat fish from lakes or rivers with high levels of environmental contaminants? Does mother have pica for certain materials such as paint chips, soil? 3

7 4 Dermal & Dietary Exposure History Dermal exposures that may be of concern? (cleaning products, pesticides, solvents, gasoline) Pica for certain materials such as paint chips, soil? Avoid or Reduce Exposure Reduce use of cleaning products with solvents Reduce or eliminate pesticides wash produce, buy organic produce Avoid or Reduce Exposure Use personal protective equipment Temporarily move to job with less exposure

8 5 To ensure breast milk is best, reduce exposure to chemicals in workplace and at home. References J. Schreiber, Parents worried about breast milk contamination: What is best for baby? Pediatric Clinics of North America. 48(5): J. Schreiber, Transport of Organic Chemicals to Breastmilk: Tetrachloroethene Case Study. Chapter 5, Pages 95 to 143 in: Environmental Toxicology and Pharmacology of Human Development, Taylor and Francis, Washington, DC, Kacew and G. Lambert, editors

9 1 Heavy Metal Contaminants in Breastmilk and the Risk to the Breastfeeding Infant Ruth A. Lawrence, MD Professor of Pediatrics, Obstetrics and Gynecology University of Rochester School of Medicine & Dentistry Rochester, NY Issues I. Heavy Metals II. Well Water III. The Work Place Heavy Metals Lead Mercury Cadmium Arsenic

10 2 Heavy Metals Data supports neurodevelopmental deficits with long-term exposure to the child Most secure data involves lead exposure Little has been done on other heavy metals Lead Lead mobilization from maternal skeleton during pregnancy Lactation is one of the greatest problems of lead toxicity Cord blood : maternal blood Lead in Blood & Human Milk Namihira D. J Tox Environ Hlth, 1993.

11 3 Lead in Children Action determined by blood level - less than 10 µg/dl dl: considered nontoxic, no action required µg/dl : repeat screening, educate parents µg/dl : repeat screening, and if elevated, identify and abate the source Lead in Children Action determined by blood level µg/dl : identify & abate source, perform complete medical evaluation; consider DMSA chelation µg/dl : identify & abate source, perform medical evaluation, chelate with oral DMSA - 70 µg/dl or higher : immediately perform medical evaluation Herbal Vitamins : Lead Toxicity Lead poisoning from Indian herbal vitamin Developmentally delayed patient given herbal vitamin from India to strengthen his brain Tablet contained large amounts of lead and mercury, leading to significant lead burden Pediatrics 2000; 106:

12 4 Mercury Mad Hatters Disease Mercury Sources in Home: Elemental & Inorganic Thermometers Thermostats Barometers Work clothes from industrial exposure Folk medicines and ceremonies Dental Exposures Only 14% of dental O.R. s exceed threshold Threshold limit values 0.1 mg/m 3 Dentist s mean urinary mercury levels 14.2 mg/l (levels at which early symptoms appear 100 mg/l)

13 5 Dental Exposures Only total and inorganic blood levels are elevated No effect on pregnancy in dental workers (highest concentration of Hg in placenta, a barrier role) Acrodynia (Pink Disease) Due to mercuric oxide from medications and teething compounds Seen in children, not newborns or adults Painful extremities Pink, puffy, painful, parasthetic, perspiring and peeling Mercury Women in child bearing years should not be exposed to Mercury vapors in concentrations greater than 10 mg/m3 In workplace, fetal exposure can result in neurological problems

14 6 Summary of Absorption and Toxicity of Mercury Compounds Absorption Toxicity Form Elemental (metallic) mercury Oral Inhalation Neurologic Renal Hg liquid Poor NA* Rare Rare Hg vapor NA* Good Likely Possible Inorganic mercuric salts Hg Good Rare Rare Likely but possible Organic (alkyl) mercury RHg + Good Rare Likely Possible but possible *NA = Not applicable Chart taken from Poisoning and Drug Overdose; Olson,RK Mercury Fish advisories for New York State are also available for mercury and cadmium Eat NO MORE than one meal a month Methyl Mercury Effects Nervous System Renal System Fetus

15 7 Long term studies underway in Seychelles and Faroe Islands where there are low levels of Methyl Mercury in ocean fish Seychelles Children and Breastfeeding The more breastfeeding the more developmentally advanced they are Folk medicine and ceremonial events often involve Mercury predominantly in inorganic forms that vaporize

16 Cadmium A heavy metal associated with Industrial exposures Contaminated shellfish and some other fish Drinking acidic beverages from certain vessels Contaminated materials: rice, cigarettes, soil Chronic Cadmium Yellow teeth line Renal insufficiency Vertigo Fatigue Osteopenia Osteomalacia Blood Levels Normal population : 0.4 to 1.0 mg/l Smokers: 1.4 to 4.0 mg/l Occupationally exposed: 10 to 100 mg/l 8

17 9 Perinatal Risk Does cross the placenta Probably crosses into breast milk Arsenic Where is it? Fish Cod, Haddock Shellfish Industry Intentional ingestion Arsenic Aresnobetaine & Arsenocholine forms found in food Rapidly cleared in urine : excreted in 1-2 days Half life of organic arsenic : 4 6 hours

18 10 Arsenic Inorganic arsenic crosses placenta No data on breast milk Rare problem except in chronic exposure or acute overdose Summary of Absorption and Toxicity of Mercury Compounds Absorption Toxicity Form Elemental (metallic) mercury Oral Inhalation Neurologic Renal Hg liquid Poor NA* Rare Rare Hg vapor NA* Good Likely Possible Inorganic mercuric salts Hg Good Rare Rare Likely but possible Organic (alkyl) mercury RHg + Good Rare Likely Possible but possible *NA = Not applicable Chart taken from Poisoning and Drug Overdose; Olson,RK Drinking Water: Chemical Contaminants of Greatest Concern Disinfection by products (DBP s) Lead Arsenic, cadmium Mercury Nitrates Synthetic organic chemicals / pesticides

19 11 How Does Drinking Water: Get Contaminated Surface Water - rivers, streams, lakes Groundwater Distribution system contaminated with sewage Waterborne Disease Outbreaks Associated with Drinking Water, by Type of Water Source ( ) Well and Spring 11.8% Surface Water 11.8% Well 70.5% Spring 5.9% Adapted from CDC MMMWR, May 26, 2000 Summary of Known Benefits to the Infant and Mother From Constituents in Breast Milk

20 12 Nutritional benefits for human brain growth, especially from cholesterol, DHA, and taurine in breast milk Improved efficiency of digestion and absorption because of the greater bioavailability of essential nutrients in breast milk compared to infant formula Psychological and cognitive benefits, including more rapid improvement in visual acuity, detectable improvements in educational achievement, and improved progressions on developmental scales

21 13 Protection against infections of the upper and lower respiratory system and inner ear, due to the presence of living cells and macrophages Protection against ulcerative colitis, bacteremia, bacterial meningitis, urinary tract infections, and necrotizing enterocolitis Protection against the development of allergic diseases, childhood leukemia, lymphoma, celiac disease and Crohn s Disease

22 14 The psychological bond created by breastfeeding Known Benefits of Breastfeeding for the Mother Improved post partum recovery Psychological benefits, including a feeling of empowerment and the development of a strong human bond between mother and infant Known Benefits of Breastfeeding for the Mother Decreased risk of osteoporosis Reduced risk incidence of pre-menopausal breast cancer and ovarian cancer Reduced risk of pregnancy initiated long term obesity

23 15 Risk : Benefit BENEFIT RISK Pollutants In Breast Milk Breast-feeding is recommended despite the presence of chemical residues. The prenatal period in the child and the initiation of lactation in the mother may be sensitive periods to the toxicity of the chemicals that are considered here, and the potential for poisoning at higher levels is clear. However, in the vast majority of women, the benefits of breastfeeding appear to outweigh the risks, and those who advise women about infant nutrition should continue to support breastfeeding. Rogan, Arch Pediat Adolesc Med 1996 Breastfeeding is the most precious gift a mother can give to her infant When there is malnutrition and illness,, it may be a lifesaving gift When there is poverty,, it may be the only gift RA Lawrence, 1992

24 Case Study 1 34 y.o. health care professional had her first child last month Baby exclusively breastfed Family heirloom crib c100 yrs. Old; play to refinish Advice about crib? Case Study 2 22 y.o. Caribbean American migrant worker Travels Eastern seaboard doing seasonal farm work 2-month-old baby - exclusively breastfed since birth Baby carried by mother in sling during day Plans to hand express milk when child care available Case Study 3 25 y.o. breastfeeding mother with a 6-month old infant Dropped and broke mercury thermometer Concerns about cleanup, continuing breastfeeding 1

25 Case Study 4 28 y.o. Native American woman in upstate New York Fish caught in local waters an important source of food Stopped eating fish 3 years ago before birth of first child Second child due in 1 month Plans to breastfeed to lose weight (currently 200 lbs., 130 lbs. before first pregnancy) Case Study 5 38 y.o. mother 11-month-old infant - breastfeeding plus variety of solid foods Dentist recommended mother replace old amalgam fillings with porcelain 2

26 1 To sign up for LIN-L ListServ Send to: On subject line: LIN-L In note include: name affiliation address phone number Free copies: Breastfeeding: First Step to Good Health NYS DOH Bureau of Community Relations (518) ) Thanks to Ruth A. Lawrence, M.D. University of Rochester Judith Schreiber, Ph.D. NYS Attorney General s Office Mary Applegate, M.D., M.P.H. Bureau of Women s Health, NYS Department of Health

27 2 Major support for this program comes from the New York State Department of Health and the U.S. Department of Health and Human Services, Child Health Bureau. Breastfeeding Grand Rounds May 9, 2002 has been presented by The New York State Institute for Human Lactation Jointly sponsored by New York State Department of Health The School of Public Health, University at Albany, State University of New York

28 3 Part of the Women s Health Grand Rounds Series For additional information, contact: Continuing Education and Professional Development School of Public Health University at Albany, SUNY One University Place Rensselaer, NY