Infant toxicology: State of the science and considerations in evaluation of safety

Utility of life stage-specific chemical risk assessments based on New Approach Methodologies (NAMs)

The safety assessments for chemicals targeted for use or expected to be exposed to specific life stages, including infancy, childhood, pregnancy and lactation, and geriatrics, need to account for extrapolation of data from healthy adults to these populations to assess their human health risk. However, often adequate and relevant toxicity or pharmacokinetic (PK) data of chemicals in specific life stages are not available. For such chemicals, New Approach Methodologies (NAMs), such as physiologically based pharmacokinetic (PBPK) modeling, biologically based dose response (BBDR) modeling, in vitro to in vivo extrapolation (IVIVE), etc. can be used to understand the variability of exposure and effects of chemicals in specific life stages and assess their associated risk. A life stage specific PBPK model incorporates the physiological and biochemical changes associated with each life stage and simulates their impact on the absorption, distribution, metabolism, and elimination (ADME) of these chemicals. In our review, we summarize the parameterization of life stage models based on New Approach Methodologies (NAMs) and discuss case studies that highlight the utility of a life stage based PBPK modeling for risk assessment. In addition, we discuss the utility of artificial intelligence (AI)/machine learning (ML) and other computational models, such as those based on in vitro data, as tools for estimation of relevant physiological or physicochemical parameters and selection of model. We also discuss existing gaps in the available toxicological datasets and current challenges that need to be overcome to expand the utility of NAMs for life stage-specific chemical risk assessment.

The regulation of endocrine-disrupting chemicals to minimize their impact on health

Endocrine-disrupting chemicals (EDCs) are substances generated by human industrial activities that are detrimental to human health through their effects on the endocrine system. The global societal and economic burden posed by EDCs is substantial. Poorly defined or unenforced policies can increase human exposure to EDCs, thereby contributing to human disease, disability and economic damage. Researchers have shown that policies and interventions implemented at both individual and government levels have the potential to reduce exposure to EDCs. This Review describes a set of evidence-based policy actions to manage, minimize or even eliminate the widespread use of these chemicals and better protect human health and society. A number of specific challenges exist: defining, identifying and prioritizing EDCs; considering the non-linear or non-monotonic properties of EDCs; accounting for EDC exposure effects that are latent and do not appear until later in life; and updating testing paradigms to reflect 'real-world' mixtures of chemicals and cumulative exposure. A sound strategy also requires partnering with health-care providers to integrate strategies to prevent EDC exposure in clinical care. Critical next steps include addressing EDCs within global policy frameworks by integrating EDC exposure prevention into emerging climate policy.

Trends in ingredients added to infant formula: FDA's experiences in the GRAS notification program

While human milk is considered the optimal source of nutrition for infants for the first six and twelve months of age, with continued benefit of breastfeeding with complementary foods, a safe alternative, nutritionally adequate to support infant growth and development, is necessary. In the United States, the Food and Drug Administration (FDA) establishes the requirements necessary to demonstrate the safety of infant formula within the framework of the Federal Food, Drug, and Cosmetic Act. FDA's Center for Food Safety and Applied Nutrition/Office of Food Additive Safety evaluates the safety and lawfulness of individual ingredients used in infant formula, whereas the Office of Nutrition and Food Labeling oversees the safety of infant formula. Most infant formula ingredients are either from sources with history of safe consumption by infants or are like components in human milk. Information demonstrating the regulatory status of all ingredients is required in submissions for new infant formulas, and ingredient manufacturers often use the Generally Recognized as Safe (GRAS) Notification program to establish ingredient regulatory status. We provide an overview of ingredients used in infant formula evaluated through the GRAS Notification program to highlight trends and discuss the data and information used to reach these GRAS conclusions.

Evaluating adverse effects of environmental agents in food: a brief critique of the US FDA's criteria

BACKGROUND

In the US, the Food and Drug Administration (US FDA) is charged with protecting the safety of food from both pathogens and chemicals used in food production and food packaging. To protect the public in a transparent manner, the FDA needs to have an operational definition of what it considers to be an "adverse effect" so that it can take action against harmful agents. The FDA has recently published two statements where, for the first time, it defines the characteristics of an adverse effect that it uses to interpret toxicity studies.

OBJECTIVE

In this brief review, we examine two recent actions by the FDA, a proposed rule regarding a color additive used in vegetarian burgers and a decision not to recall fish with high levels of scombrotoxin. We evaluated the FDA's description of the criteria used to determine which outcomes should be considered adverse.

OVERVIEW

We describe three reasons why the FDA's criteria for "adverse effects" is not public health protective. These include an unscientific requirement for a monotonic dose response, which conflates hazard assessment and dose response assessment while also ignoring evidence for non-linear and non-monotonic effects for many environmental agents; a requirement that the effect be observed in both sexes, which fails to acknowledge the many sex- and gender-specific effects on physiology, disease incidence and severity, and anatomy; and a requirement that the effects are irreversible, which does not acknowledge the role of exposure timing or appreciate transgenerational effects that have been demonstrated for environmental chemicals.

CONCLUSIONS

The FDA's criteria for identifying adverse effects are inadequate because they are not science-based. Addressing this is important, because the acknowledgement of adverse effects is central to regulatory decisions and the protection of public health.

Neurobehavioral effects of cinnabar and the cinnabar-containing pediatric prescription, Yi-Nian-Jin, in juvenile rats

BACKGROUND

Cinnabar, a mercury-containing mineral medicine, has long been widely used in pediatric prescriptions. The safety of cinnabar-containing prescriptions, particularly for children, is drawing increasing attention worldwide. However, whether cinnabar and these pediatric prescriptions have adverse effects on neurobehavior is unknown. Yi-Nian-Jin (YNJ), a classic pediatric prescription, contains 5.66% (w/w) cinnabar, along with other four herbs. YNJ is widely prescribed to promote digestion, eliminate phlegm, and prevent constipation in children (aged 0-6 years). In this study, we used YNJ as an example of cinnabar-containing pediatric prescriptions to determine mercury absorption, distribution, and accumulation and further investigate its potential neurotoxicity in juvenile rats.

MATERIAL AND METHODS

Low (67.9 mg/kg), middle (169.8 mg/kg), and high dose (339.6 mg/kg) of cinnabar, and low (1.2 g/kg), middle (3.0 g/kg), and high dose (6.0 g/kg) of YNJ were used in this study, corresponding to 3, 7.5, and 15 times the clinically equivalent dose, respectively. Juvenile rats were orally administered different doses of cinnabar or YNJ for 14 consecutive days. The mercury content in rat blood and tissues (brain, liver, and kidney) and serum biochemical changes on day 14 of consecutive administration and on day 14 after cessation were measured. Moreover, a series of behavioral assays (open field, elevated plus-maze, and Morris water maze assays) were performed after 14 consecutive days of administration.

RESULTS

The mercury absorption, distribution, and accumulation of cinnabar and YNJ in juvenile rats were substantially different. Mercury in cinnabar was absorbed to a greater extent than that in YNJ, and the mercury content in cinnabar high-dose group (cinnabar-H) was approximately seven times higher than that in YNJ high-dose group (YNJ-H) on day 14 of administration. In contrast, compared with that of cinnabar, the mercury content in YNJ accumulated more in the tissues, especially in the brain and kidney. Repeated administration of cinnabar or YNJ did not affect liver function, renal function, learning, and memory in juvenile rats. However, repeated administration of YNJ at a high dose (6.0 g/kg) affected locomotor activity in juvenile rats. Repeated administration of cinnabar (339.6 mg/kg) or YNJ (>1.2 g/kg) induced anxiety-related behavior in juvenile rats.

CONCLUSIONS

Mercury in YNJ exhibited lower absorption but higher accumulation in tissues than those of the mercury in cinnabar. Consecutive oral administration of cinnabar or YNJ had no impact on liver function, renal function, learning, and memory, but could cause motor dysfunction and anxiety in juvenile rats.

Toxicity of ceria nanoparticles to the regeneration of freshwater planarian Dugesia japonica: The role of biotransformation

Cerium oxide nanoparticles (n-CeO₂) have wide applications ranging from industrial to consumer products, which would inevitably lead to their release into the environment. Despite the toxicity of n-CeO₂ on aquatic organisms has been largely reported, research on developing organisms is still lacking. In this study, we investigate the toxic effects of n-CeO₂ on the stem cells, tissue- and neuro-regeneration, using freshwater planarian Dugesia japonica as a model. Effects of bulk sized (μ-) CeO₂ and ionic Ce (Ce³⁺) were compared with that of n-CeO₂ to explore the origin of the toxic effects of n-CeO₂. No overt toxicity was observed in μ-CeO₂ treatment. n-CeO₂ not only impaired the homeostasis of normal planarians, but also inhibited the regeneration processes of regenerated planarians, demonstrated by the inhibited blastema growth, disturbed antioxidant defense system at molecular levels, elevated DNA-damage and decreased stem cell proliferation. Regenerating organisms are more susceptible to n-CeO₂ than the normal ones. Ce³⁺ exhibited significantly higher toxicity than n-CeO₂, even though the total Ce uptake is 0.2 % less in Ce³⁺ than in n-CeO₂ treated in planarian. X-ray absorption near edge spectroscopy (XANES) analysis revealed that 12.8 % of n-CeO₂ (5.95 mg/kg Ce per planarian) was transformed to Ce³⁺ after interaction with planarian, suggesting that biotransformation at the nano-bio interface might play an important role in the observed toxicity. Since the biotransformation of n-CeO₂ is a slow process, it may cause long-term chronic toxicity to planarians due to the slow while sustained release of toxic Ce³⁺ ions.

Graphene oxide disruption of homeostasis and regeneration processes in freshwater planarian Dugesia japonica via intracellular redox deviation and apoptosis

The aquatic system is a major sink for engineered nanomaterials released into the environment. Here, we assessed the toxicity of graphene oxide (GO) using the freshwater planarian Dugesia japonica, an invertebrate model that has been widely used for studying the effects of toxins on tissue regeneration and neuronal development. GO not only impaired the growth of normal (homeostatic) worms, but also inhibited the regeneration processes of regenerating (amputated) worms, with LC₁₀ values of 9.86 mg/L and 9.32 mg/L for the 48-h acute toxicity test, respectively. High concentration (200 mg/L) of GO killed all the worms after 3 (regenerating) or 4 (homeostasis) days of exposure. Whole-mount in situ hybridization (WISH) and immunofluorescence analyses suggest GO impaired stem cell proliferation and differentiation, and subsequently caused cell apoptosis and oxidative DNA damage during planarian regeneration. Mechanistic analysis suggests that GO disturbed the antioxidative system (enzymatic and non-enzymatic) and energy metabolism in the planarian at both molecular and genetic levels, thus causing reactive oxygen species (ROS) over accumulation and oxidative damage, including oxidative DNA damage, loss of mitochondrial membrane integrity, lack of energy supply for cell differentiation and proliferation leading to retardance of neuron regeneration. The intrinsic oxidative potential of GO contributes to the GO-induced toxicity in planarians. These data suggest that GO in aquatic systems can cause oxidative stress and neurotoxicity in planarians. Overall, regenerated tissues are more sensitive to GO toxicity than homeostatic ones, suggesting that careful handling and appropriate decisions are needed in the application of GO to achieve healing and tissue regeneration.

Determination of six thyroid hormones in dog brain and liver using acidic extraction, mixed-mode cleanup, and liquid chromatography-tandem mass spectrometry

Thyroid hormones (THs) play a critical role in the regulation of biological processes, such as growth, metabolism, and development, in various animal species. Prohormone L-thyroxine (T4) is secreted from the thyroid gland and carried to peripheral tissues. T4 is then biotransformed to several metabolites which play different roles, mainly by iodothyronine deiodinases. Determination of deiodinated TH metabolites in key organs such as liver and brain would help to understand tissue-specific TH metabolism and homeostasis. In this study, we thus developed a highly sensitive method for the determination of six THs [T4, 3,5,3'-triodo-L-thyronine (T3), 3,3',5'-triiodo-L-thyronine (rT3), 3,5-diiodo-l-thyronine (3,5-T2), 3,3'-diiodo-l-thyronine (3,3'-T2), and 3-iodo-l-thyronine (3-T1)] in the brain and liver by using stored dog samples. The analytical method consisted of ultrasonic-assisted extraction in acetone acidified with formic acid, cleanup with a EVOLUTE® EXPRESS CX cartridge (reversed-phase combined with strong cation-exchange cartridge), and quantification with liquid chromatography-tandem mass spectrometry. Acceptable accuracy (internal standard-corrected recovery: 80%-120%) and intra- and inter-day precision (coefficient of variation: <6% and <15%, respectively) (n = 3/ batch, three days) were obtained for both brain and liver samples. In addition, low method detection limits were achieved for both brain (0.013-0.12 ng g^-1) and liver (0.030-0.78 ng g^-1), which resulted in the quantitation of not only T4, T3, and rT3, but also 3,3'-T2 in both dog brain and liver samples. The developed method was successfully applied to the analysis of THs in the brain and liver of dogs (Canis lupus familiaris) which were exposed to polychlorinated biphenyls (PCBs). As a result, concentration ratios of rT3/T4 and 3,3'-T2/T3 in the PCB-exposed dogs were significantly higher than those in the control groups, suggesting the enhanced inner (tyrosyl)-ring deiodination (5-deiodination) by PCB exposure. The analytical method developed in the present study enables comprehensive evaluation of alterations in peripheral TH metabolism which are caused by exposure to environmental pollutants.

Role of epidemiology in risk assessment: a case study of five ortho-phthalates

BACKGROUND

The association between environmental chemical exposures and chronic diseases is of increasing concern. Chemical risk assessment relies heavily on pre-market toxicity testing to identify safe levels of exposure, often known as reference doses (RfD), expected to be protective of human health. Although some RfDs have been reassessed in light of new hazard information, it is not a common practice. Continuous surveillance of animal and human data, both in terms of exposures and associated health outcomes, could provide valuable information to risk assessors and regulators. Using ortho-phthalates as case study, we asked whether RfDs deduced from male reproductive toxicity studies and set by traditional regulatory toxicology approaches sufficiently protect the population for other health outcomes.

METHODS

We searched for epidemiological studies on benzyl butyl phthalate (BBP), diisobutyl phthalate (DIBP), dibutyl phthalate (DBP), dicyclohexyl phthalate (DCHP), and bis(2-ethylhexyl) phthalate (DEHP). Data were extracted from studies where any of the five chemicals or their metabolites were measured and showed a statistically significant association with a health outcome; 38 studies met the criteria. We estimated intake for each phthalate from urinary metabolite concentration and compared estimated intake ranges associated with health endpoints to each phthalate's RfD.

RESULT

For DBP, DIBP, and BBP, the estimated intake ranges significantly associated with health endpoints were all below their individual RfDs. For DEHP, the intake range included associations at levels both below and above its RfD. For DCHP, no relevant studies could be identified. The significantly affected endpoints revealed by our analysis include metabolic, neurodevelopmental and behavioral disorders, obesity, and changes in hormone levels. Most of these conditions are not routinely evaluated in animal testing employed in regulatory toxicology.

CONCLUSION

We conclude that for DBP, DIBP, BBP, and DEHP current RfDs estimated based on male reproductive toxicity may not be sufficiently protective of other health effects. Thus, a new approach is needed where post-market exposures, epidemiological and clinical data are systematically reviewed to ensure adequate health protection.

Acrylamide Content in Breast Milk: The Evaluation of the Impact of Breastfeeding Women's Diet and the Estimation of the Exposure of Breastfed Infants to Acrylamide in Breast Milk

Acrylamide in food is formed by the Maillard reaction. Numerous studies have shown that acrylamide is a neurotoxic and carcinogenic compound. The aim of this study was to determine the level of acrylamide in breast milk at different lactation stages and to evaluate the impact of breastfeeding women's diet on the content of this compound in breast milk. The acrylamide level in breast milk samples was determined by LC-MS/MS. Breastfeeding women's diet was evaluated based on the 24 h dietary recall. The median acrylamide level in colostrum (n = 47) was significantly (p < 0.0005) lower than in the mature milk (n = 26)-0.05 µg/L and 0.14 µg/L, respectively. The estimated breastfeeding women's acrylamide intake from the hospital diet was significantly (p < 0.0001) lower than that from the home diet. We found positive-although modest and borderline significant-correlation between acrylamide intake by breastfeeding women from the hospital diet µg/day) and acrylamide level in the colostrum (µg/L). Acrylamide has been detected in human milk samples, and a positive correlation between dietary acrylamide intake by breastfeeding women and its content in breast milk was observed, which suggests that the concentration can be reduced. Breastfeeding women should avoid foods that may be a source of acrylamide in their diet.

Differential effect of silver nanoparticles on the microbiome of adult and developing planaria

Silver nanoparticles (AgNPs) are widely incorporated in household, consumer and medical products. Their unintentional release via wastewaters raises concerns on their environmental impact, particularly for aquatic organisms and their associated bacterial communities. It is known that the microbiome plays an important role in its host's health and physiology, e.g. by producing essential nutrients and providing protection against pathogens. A thorough understanding of the effects of AgNPs on bacterial communities and on their interactions with the host is crucial to fully assess AgNP toxicity on aquatic organisms. Our results indicate that the microbiome of the invertebrate Schmidtea mediterranea, a freshwater planarian, is affected by AgNP exposure at the tested 10 μg/ml concentration. Using targeted amplification of the bacterial 16S rRNA gene V3-V4 region, two independent experiments on the microbiomes of adult worms revealed a consistent decrease in Betaproteobacteriales after AgNP exposure, mainly attributed to a decrease in Curvibacter and Undibacterium. Although developing tissues and organisms are known to be more sensitive to toxic compounds, three independent experiments in regenerating worms showed a less pronounced effect of AgNP exposure on the microbiome, possibly because underlying bacterial community changes during development mask the AgNP induced effect. The presence of a polyvinyl-pyrrolidone (PVP) coating did not significantly alter the outcome of the experiments compared to those with uncoated particles. The observed variation between the different experiments underlines the highly variable nature of microbiomes and emphasises the need to repeat microbiome experiments, within and between physiological states of the animal.

Exploring the use of current immunological assays for the developmental immunotoxicity assessment of food contact materials

The mammalian immune system is a highly complex, interactive network of cells that facilitates innate and adaptive immune responses. The neonatal immune system may be more susceptible to chemical perturbations than that of the adult. The effects of immunotoxicants during development may not be fully detected in toxicity studies performed on adult animals. Studies characterizing the ontogeny of the immune system in developing animals have shown that there are different critical windows of susceptibility to immunotoxicants. Developmental differences are evident among species compared to humans. Functional immune assays, such as the T-cell antibody dependent response assay, in rat models have been validated for use in the assessment of immunotoxicity with other assays. Recently, published studies have explored the feasibility of using additional techniques, such as in vitro studies using human whole blood cells or cell lines, mostly lacking either sensitivity or proper validation for regulatory purposes. However, some techniques may be developed further to enable translation of animal toxicity findings to human risk assessment of potential immunotoxicants. This paper summarizes the information on the developing immune system in humans versus rats and how the currently available assays might be used to contribute to the safety assessment of food contact substances.

Sodium nitrite negatively affects reproductive ability and offspring survival in female mice

Sodium nitrite (NaNO₂) is an industrial chemical that is frequently used as a food additive to prevent botulism and enhance glossiness, such as curing meat. In addition, in some regions, water source NaNO₂ concentrations exceed standard regulatory levels. Whether the excessive intake of NaNO₂ has toxic effects on female fertility and fetal development remain unknown. In this study, we administered ICR mice control saline, low-dose NaNO₂ (60 mg/kg/day), or high-dose NaNO₂ (120 mg/kg/day) by intragastric gavage for 21 days. We then assessed oocyte morphology, spindle-chromosome dynamics, mitochondrial distribution, ATP content, apoptotic cell numbers, DNA damage levels, histone modifications, reactive oxygen species (ROS) levels, and offspring survival. Results showed that NaNO₂ treatment decreased oocyte number, impaired polar body extrusion, and increased zona pellucida thickness in oocytes. Furthermore, NaNO₂ disrupted MII spindle integrity, caused abnormal mitochondrial distribution, decreased ATP content, and increased levels of ROS and H3K4me2. Moreover, the number of oocytes in early stages of apoptosis and with levels of DNA damage increased in NaNO₂-treated mice along with decreased offspring numbers and survival rates. We demonstrated the negative effects of NaNO₂ on female reproductive abilities in mice.

The toxicological analysis of lead and cadmium in prescription food for special medical purposes and modified milk products for newborns and infants available in Polish pharmacies

There is currently a lack of risk assessments around Pb and Cd in prescription food for special medical purposes (FSMPs) and modified milk products available in from pharmacies in Poland. This article describes and evaluates a toxicological analysis of lead and cadmium in prescription FSMPs (n = 6) and modified milk products (n = 6) available in Polish pharmacies. The metals were determined using electrothermal atomisation atomic absorption spectrometry. To make the appropriate risk assessment, we considered (1) the levels of lead and cadmium in a powdered product, (2) the amount of the metals consumed in one portion (single exposure), (3) the daily dose depending on age (months) and body weight and (4) the weekly intake of Pb and Cd in samples in comparison to provisional tolerable weekly intake (PTWI). The results demonstrated that the samples analysed do not represent a health hazard to newborns and infants. This study is important because of the concerns around the complex risk assessment of prescription FSMP's and modified milk products available in Polish pharmacies related to lead and cadmium.

Utility of generational developmental and reproductive toxicity and juvenile animal study protocols for the infant safety assessment of food contact materials

The US Food and Drug Administration (FDA) Division of Food Contact Notifications (DFCN) performs infant lifestage-specific exposure and safety assessments during the premarket review of FCNs proposed for use with infant formula or human milk. DFCN previously identified two protocols that may be best suited to support infant safety: the multigenerational developmental and reproductive toxicology (Gen-DART) protocol and the juvenile animal study (JAS) protocol. The Gen-DART protocol tests chemical exposure from prior to mating through one or two generations in rodents, while JAS protocols test a chemical during a specific developmental window. At FDA, Gen-DART studies are currently recommended to support the safety of food additives (FAs), including food contact substances, across lifestages (from conception through adulthood). JAS protocols are recommended in the nonclinical safety assessment of drugs seeking pediatric indications. To improve our recommendations regarding the use of either Gen-DART or JAS protocols for the infant safety assessment of food contact materials, we created a database of FDA-reviewed Gen-DART or JAS. Our database contains information from 41 Gen-DART studies (38 FAs) and 51 JAS (29 drugs). Both protocols can detect toxicity relevant to infant safety assessment, such as developmental toxicity in neurological, endocrine, reproductive, immunological, or skeletal systems. Selection of either protocol will depend on the amount of information available for the chemical under study. The Gen-DART protocol may be preferred when limited data on the mode of action or target organ of the chemical are available. However, if these data are available, a JAS may provide the best assessment of potential juvenile toxicity.

Scientific opinion on pesticides in foods for infants and young children

Following a request from the European Commission, the EFSA Panel on Plant Protection Products and their Residues (PPR Panel) prepared a scientific opinion to provide a comprehensive evaluation of pesticide residues in foods for infants and young children. In its approach to develop this scientific opinion, the EFSA PPR Panel took into account, among the others, (i) the relevant opinions of the Scientific Committee for Food setting a default maximum residue level (MRL) of 0.01 mg/kg for pesticide residues in foods for infants and young children; (ii) the recommendations provided by EFSA Scientific Committee in a guidance on risk assessment of substances present in food intended for infants below 16 weeks of age; (iii) the knowledge on organ/system development in infants and young children. For infants below 16 weeks of age, the EFSA PPR Panel concluded that pesticide residues at the default MRL of 0.01 mg/kg for food for infants and young children are not likely to result in an unacceptable exposure for active substances for which a health-based guidance value (HBGV) of 0.0026 mg/kg body weight (bw) per day or higher applies. Lower MRLs are recommended for active substances with HBGVs below this value. For infants above 16 weeks of age and young children, the established approach for setting HBGVs is considered appropriate. For infants below 16 weeks of age the approach may not be appropriate and the application of the EFSA guidance on risk assessment of substances present in food intended for infants below 16 weeks of age is recommended. The contribution of conventional food to the total exposure to pesticide residues is much higher than that from foods intended for infants and young children. Because of the increased intake of conventional food by young children, these have the highest exposure to pesticide residues, whereas infants 3-6 months of age generally have lower exposure. The impact of cumulative exposure to pesticide residues on infants and young children is not different from the general population and the EFSA cumulative risk assessment methodology is also applicable to these age groups. Residue definitions established under Regulation (EC) No 396/2005 are in general considered appropriate also for foods for infants and young children. However, based on a tier 1 analysis of the hydrolysis potential of pesticides simulating processing, the particular appropriateness of existing residue definitions for monitoring to cover processed food, both intended for infants and young children as well as conventional food, is questionable.

A systematic review of the risk factors for clinical response to opioids for all-age patients with cancer-related pain and presentation of the paediatric STOP pain study

BACKGROUND

Inter-patient variability in response to opioids is well known but a comprehensive definition of its pathophysiological mechanism is still lacking and, more importantly, no studies have focused on children. The STOP Pain project aimed to evaluate the risk factors that contribute to clinical response and adverse drug reactions to opioids by means of a systematic review and a clinical investigation on paediatric oncological patients.

METHODS

We conducted a systematic literature search in EMBASE and PubMed up to the 24th of November 2016 following Cochrane Handbook and PRISMA guidelines. Two independent reviewers screened titles and abstracts along with full-text papers; disagreements were resolved by discussion with two other independent reviewers. We used a data extraction form to provide details of the included studies, and conducted quality assessment using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.

RESULTS

Young age, lung or gastrointestinal cancer, neuropathic or breakthrough pain and anxiety or sleep disturbance were associated to a worse response to opioid analgesia. No clear association was identified in literature regarding gender, ethnicity, weight, presence of metastases, biochemical or hematological factors. Studies in children were lacking. Between June 2011 and April 2014, the Italian STOP Pain project enrolled 87 paediatric cancer patients under treatment with opioids (morphine, codeine, oxycodone, fentanyl and tramadol).

CONCLUSIONS

Future studies on cancer pain should be designed with consideration for the highlighted factors to enhance our understanding of opioid non-response and safety. Studies in children are mandatory.

TRIAL REGISTRATION

CRD42017057740 .

Endocrine Disrupters and the Safety of Food Chains

Endocrine disrupters (ED) are a heterogeneous group of chemicals including persistent contaminants, pesticides, as well as compounds present in consumer products and natural substances. For most ED, the food chain is a current major exposure route for the general population. ED can enter the food chain through the living environment (e.g., feeds, fertilizers) of food-producing organisms, be directly employed in food production (e.g., pesticides) or be released from food contact materials (such as bisphenol A or phthalates); in addition, the endocrine disruption potential of some natural compounds in edible plants, including the so-called phytoestrogens, should not be overlooked. An exposure assessment has to consider the specific liability of food commodities to contamination with specific ED (e.g., polychlorinated and polybrominated chemicals in lipid-rich foods). The paper discusses the main toxicological research issues in order to support the risk assessment of ED in food chains, including: the potential for additive, 'cocktail' effects (as from multiple pesticide residues); the long-term effects on target body systems (e.g., reproductive, nervous) elicited by exposure during prenatal as well as postnatal life stage windows, and toxicant/nutrient interactions (e.g., thyroid-targeting ED and iodine status). Food safety systems should exploit the available knowledge to improve prevention of long-term risks along the whole food chain.

An integrated approach to the safety assessment of food additives in early life

During the development of international standards by the Codex Alimentarius Commission, infant foods and their constituent ingredients are subject to rigorous risk analysis and are strictly regulated by many authorities. Various jurisdictions have approved only a limited number of additives specifically with regard to infant foods to fulfill specific technical requirements of quality. As part of the approval process, a rigorous safety assessment is essential to confirm that the use of additives does not pose any health risk for the consumer. An acceptable daily intake (ADI) may be derived from the toxicological databases. However, the ADI may not be applicable to infants because of the possible developmental sensitivities and potentially high exposure scenarios, leading to possible lower margins of safety than would often be determined for adult populations. There is interest in defining better food safety assessment approaches for pre-weaned infants aged less than 12–16 weeks. To confirm safe use in infants, we reviewed the suitability of the existing safety databases of six additives with historical uses in infant nutrition products. To determine further toxicity testing strategies, it is necessary to understand whether the chemical used in the additives is identical to endogenous physiological metabolites and/or whether immature organs of infants are targets of toxicity. Combined with an in-depth review of the existing relevant toxicological and nutritional studies, this integrated approach will facilitate decision-making. We propose a decision tree as a tool within this approach to help guide appropriate data requirements and identify data gaps. In cases of reasonable uncertainty, studies of targeted juvenile should be considered to investigate the safe use levels in food products.

Guidance on the risk assessment of substances present in food intended for infants below 16 weeks of age

Following a request from the European Commission to EFSA, the EFSA Scientific Committee (SC) prepared a guidance for the risk assessment of substances present in food intended for infants below 16 weeks of age. In its approach to develop this guidance, the EFSA SC took into account, among others, (i) an exposure assessment based on infant formula as the only source of nutrition; (ii) knowledge of organ development in human infants, including the development of the gut, metabolic and excretory capacities, the brain and brain barriers, the immune system, the endocrine and reproductive systems; (iii) the overall toxicological profile of the substance identified through the standard toxicological tests, including critical effects; (iv) the relevance for the human infant of the neonatal experimental animal models used. The EFSA SC notes that during the period from birth up to 16 weeks, infants are expected to be exclusively fed on breast milk and/or infant formula. The EFSA SC views this period as the time where health-based guidance values for the general population do not apply without further considerations. High infant formula consumption per body weight is derived from 95th percentile consumption. The first weeks of life is the time of the highest relative consumption on a body weight basis. Therefore, when performing an exposure assessment, the EFSA SC proposes to use the high consumption value of 260 mL/kg bw per day. A decision tree approach is proposed that enables a risk assessment of substances present in food intended for infants below 16 weeks of age. The additional information needed when testing substances present in food for infants below 16 weeks of age and the approach to be taken for the risk assessment are on a case-by-case basis, depending on whether the substance is added intentionally to food and is systemically available.

EDCs Mixtures: A Stealthy Hazard for Human Health?

Endocrine disrupting chemicals (EDCs) are exogenous chemicals that may occur naturally (e.g., phytoestrogens), while others are industrial substances and plasticizers commonly utilized worldwide to which human exposure, particularly at low-doses, is omnipresent, persistent and occurs in complex mixtures. EDCs can interfere with/or mimic estrogenic hormones and, consequently, can simultaneously trigger diverse signaling pathways which result in diverse and divergent biological responses. Additionally, EDCs can also bioaccumulate in lipid compartments of the organism forming a mixed “body burden” of contaminants. Although the independent action of chemicals has been considered the main principle in EDCs mixture toxicity, recent studies have demonstrated that numerous effects cannot be predicted when analyzing single compounds independently. Co-exposure to these agents, particularly in critical windows of exposure, may induce hazardous health effects potentially associated with a complex “body burden” of different origins. Here, we performed an exhaustive review of the available literature regarding EDCs mixtures exposure, toxicity mechanisms and effects, particularly at the most vulnerable human life stages. Although the assessment of potential risks to human health due to exposure to EDCs mixtures is a major topic for consumer safety, information regarding effective mixtures effects is still scarce.

Regulatory risk assessments

A critical evaluation of several recent regulatory risk assessments has been undertaken. These relate to propyl paraben (as a food additive, cosmetic ingredient or pharmaceutical excipient), cobalt (in terms of a safety-based limit for pharmaceuticals) and the cancer Threshold of Toxicological Concern as applied to food contaminants and pharmaceutical impurities. In all cases, a number of concerns can be raised regarding the reliability of the current assessments, some examples being absence of data audits, use of single-dose and/or non-good laboratory practice studies to determine safety metrics, use of a biased data set and questionable methodology and lack of consistency with precedents and regulatory guidance. Drawing on these findings, a set of recommendations is provided to reduce uncertainty and improve the quality and robustness of future regulatory risk assessments.

Assessment of health risks resulting from early-life exposures: Are current chemical toxicity testing protocols and risk assessment methods adequate?

Abstract Over the last couple of decades, the awareness of the potential health impacts associated with early-life exposures has increased. Global regulatory approaches to chemical risk assessment are intended to be protective for the diverse human population including all life stages. However, questions persist as to whether the current testing approaches and risk assessment methodologies are adequately protective for infants and children. Here, we review physiological and developmental differences that may result in differential sensitivity associated with early-life exposures. It is clear that sensitivity to chemical exposures during early-life can be similar, higher, or lower than that of adults, and can change quickly within a short developmental timeframe. Moreover, age-related exposure differences provide an important consideration for overall susceptibility. Differential sensitivity associated with a life stage can reflect the toxicokinetic handling of a xenobiotic exposure, the toxicodynamic response, or both. Each of these is illustrated with chemical-specific examples. The adequacy of current testing protocols, proposed new tools, and risk assessment methods for systemic noncancer endpoints are reviewed in light of the potential for differential risk to infants and young children.