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Laccetta G, Di Chiara M, Cardillo A, De Nardo MC, Terrin G. The effects of industrial chemicals bonded to plastic materials in newborns: A systematic review. ENVIRONMENTAL RESEARCH 2023; 239:117298. [PMID: 37821060 DOI: 10.1016/j.envres.2023.117298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/21/2023] [Accepted: 10/02/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Phthalates are a family of industrial chemicals noncovalently bonded to plastic materials to enhance flexibility and durability. These compounds are extensively used in a variety of consumer products and even in many medical devices. Newborns present a higher susceptibility to phthalates. OBJECTIVE To assess the short- and long-term health consequences of exposure to phthalates during the neonatal period. METHODS Systematic review in accordance with the PRISMA statements. Eligible articles in English language were searched in MEDLINE, Scopus, ISI Web of Science, and Ovid databases using the following terms: "phthalate", "newborn", and "neonate". Unpublished data were searched in ClinicalTrials.gov website. All in vivo studies of any design published before May 16th, 2023 and fulfilling the following criteria were included: 1) investigations in which preterm and/or term newborns underwent one or more measurement of concentrations of phthalates on biological samples taken during the neonatal period; 2) studies in which quantitative measurement of phthalates was related to any kind of health outcome. Subgroup analysis was conducted by type of outcome. The quality assessment was performed according to the criteria from the "NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies". RESULTS 11,895 records were identified; finally, 5 articles were included for review. A mixture of phthalates was associated with improved performance on the NNNS summary scales of Attention, Handling, and Non-optimal reflexes before NICU discharge. At 2 months' corrected age, some phthalates were positively associated with problem-solving and gross motor abilities; increased levels of mono (2-ethylhexyl) phthalate, mono (2-ethyl-5-carboxypentyl) phthalate, and sum of di (2-ethylhexyl) phthalate (DEHP) metabolites (∑3DEHP and ∑4DEHP) were associated with worse fine motor performance. Furthermore, DEHP was associated with transient alteration of gut microbiota and increased IgM production after vaccine. A linear positive association between a mixture of phthalates and slope of the first growth spurt was even reported in preterm newborns. No relationship emerged between phthalates and bronchopulmonary dysplasia. Three studies out of 5 had fair quality. CONCLUSION Given some methodological issues and the paucity of related studies, further investigations of flawless quality aimed at clarifying the relationship between early exposure to phthalates and health outcomes are needed.
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Affiliation(s)
- Gianluigi Laccetta
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Maria Di Chiara
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Annalisa Cardillo
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Maria Chiara De Nardo
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Gianluca Terrin
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
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Zafirovska M, Zafirovski A, Rotovnik Kozjek N. Current Insights Regarding Intestinal Failure-Associated Liver Disease (IFALD): A Narrative Review. Nutrients 2023; 15:3169. [PMID: 37513587 PMCID: PMC10385050 DOI: 10.3390/nu15143169] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/30/2023] Open
Abstract
Intestinal failure-associated liver disease (IFALD) is a spectrum of liver disease including cholestasis, biliary cirrhosis, steatohepatitis, and gallbladder disease in patients with intestinal failure (IF). The prevalence of IFALD varies considerably, with ranges of 40-60% in the pediatric population, up to 85% in neonates, and between 15-40% in the adult population. IFALD has a complex and multifactorial etiology; the risk factors can be parenteral nutrition-related or patient-related. Because of this, the approach to managing IFALD is multidisciplinary and tailored to each patient based on the etiology. This review summarizes the current knowledge on the etiology and pathophysiology of IFALD and examines the latest evidence regarding preventative measures, diagnostic approaches, and treatment strategies for IFALD and its associated complications.
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Affiliation(s)
- Marija Zafirovska
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
- Association of General Practice/Family Medicine of South-East Europe (AGP/FM SEE), St. Vladimir Komarov No. 40/6, 1000 Skopje, North Macedonia
| | - Aleksandar Zafirovski
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
- General Hospital Jesenice, Cesta Maršala Tita 112, 4270 Jesenice, Slovenia
- Clinical Institute of Radiology, University Medical Centre Ljubljana, Zaloška Cesta 7, 1000 Ljubljana, Slovenia
| | - Nada Rotovnik Kozjek
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
- Department for Clinical Nutrition, Institute of Oncology Ljubljana, Zaloška Cesta 2, 1000 Ljubljana, Slovenia
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3
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Landrigan PJ, Raps H, Cropper M, Bald C, Brunner M, Canonizado EM, Charles D, Chiles TC, Donohue MJ, Enck J, Fenichel P, Fleming LE, Ferrier-Pages C, Fordham R, Gozt A, Griffin C, Hahn ME, Haryanto B, Hixson R, Ianelli H, James BD, Kumar P, Laborde A, Law KL, Martin K, Mu J, Mulders Y, Mustapha A, Niu J, Pahl S, Park Y, Pedrotti ML, Pitt JA, Ruchirawat M, Seewoo BJ, Spring M, Stegeman JJ, Suk W, Symeonides C, Takada H, Thompson RC, Vicini A, Wang Z, Whitman E, Wirth D, Wolff M, Yousuf AK, Dunlop S. The Minderoo-Monaco Commission on Plastics and Human Health. Ann Glob Health 2023; 89:23. [PMID: 36969097 PMCID: PMC10038118 DOI: 10.5334/aogh.4056] [Citation(s) in RCA: 53] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 02/14/2023] [Indexed: 03/29/2023] Open
Abstract
Background Plastics have conveyed great benefits to humanity and made possible some of the most significant advances of modern civilization in fields as diverse as medicine, electronics, aerospace, construction, food packaging, and sports. It is now clear, however, that plastics are also responsible for significant harms to human health, the economy, and the earth's environment. These harms occur at every stage of the plastic life cycle, from extraction of the coal, oil, and gas that are its main feedstocks through to ultimate disposal into the environment. The extent of these harms not been systematically assessed, their magnitude not fully quantified, and their economic costs not comprehensively counted. Goals The goals of this Minderoo-Monaco Commission on Plastics and Human Health are to comprehensively examine plastics' impacts across their life cycle on: (1) human health and well-being; (2) the global environment, especially the ocean; (3) the economy; and (4) vulnerable populations-the poor, minorities, and the world's children. On the basis of this examination, the Commission offers science-based recommendations designed to support development of a Global Plastics Treaty, protect human health, and save lives. Report Structure This Commission report contains seven Sections. Following an Introduction, Section 2 presents a narrative review of the processes involved in plastic production, use, and disposal and notes the hazards to human health and the environment associated with each of these stages. Section 3 describes plastics' impacts on the ocean and notes the potential for plastic in the ocean to enter the marine food web and result in human exposure. Section 4 details plastics' impacts on human health. Section 5 presents a first-order estimate of plastics' health-related economic costs. Section 6 examines the intersection between plastic, social inequity, and environmental injustice. Section 7 presents the Commission's findings and recommendations. Plastics Plastics are complex, highly heterogeneous, synthetic chemical materials. Over 98% of plastics are produced from fossil carbon- coal, oil and gas. Plastics are comprised of a carbon-based polymer backbone and thousands of additional chemicals that are incorporated into polymers to convey specific properties such as color, flexibility, stability, water repellence, flame retardation, and ultraviolet resistance. Many of these added chemicals are highly toxic. They include carcinogens, neurotoxicants and endocrine disruptors such as phthalates, bisphenols, per- and poly-fluoroalkyl substances (PFAS), brominated flame retardants, and organophosphate flame retardants. They are integral components of plastic and are responsible for many of plastics' harms to human health and the environment.Global plastic production has increased almost exponentially since World War II, and in this time more than 8,300 megatons (Mt) of plastic have been manufactured. Annual production volume has grown from under 2 Mt in 1950 to 460 Mt in 2019, a 230-fold increase, and is on track to triple by 2060. More than half of all plastic ever made has been produced since 2002. Single-use plastics account for 35-40% of current plastic production and represent the most rapidly growing segment of plastic manufacture.Explosive recent growth in plastics production reflects a deliberate pivot by the integrated multinational fossil-carbon corporations that produce coal, oil and gas and that also manufacture plastics. These corporations are reducing their production of fossil fuels and increasing plastics manufacture. The two principal factors responsible for this pivot are decreasing global demand for carbon-based fuels due to increases in 'green' energy, and massive expansion of oil and gas production due to fracking.Plastic manufacture is energy-intensive and contributes significantly to climate change. At present, plastic production is responsible for an estimated 3.7% of global greenhouse gas emissions, more than the contribution of Brazil. This fraction is projected to increase to 4.5% by 2060 if current trends continue unchecked. Plastic Life Cycle The plastic life cycle has three phases: production, use, and disposal. In production, carbon feedstocks-coal, gas, and oil-are transformed through energy-intensive, catalytic processes into a vast array of products. Plastic use occurs in every aspect of modern life and results in widespread human exposure to the chemicals contained in plastic. Single-use plastics constitute the largest portion of current use, followed by synthetic fibers and construction.Plastic disposal is highly inefficient, with recovery and recycling rates below 10% globally. The result is that an estimated 22 Mt of plastic waste enters the environment each year, much of it single-use plastic and are added to the more than 6 gigatons of plastic waste that have accumulated since 1950. Strategies for disposal of plastic waste include controlled and uncontrolled landfilling, open burning, thermal conversion, and export. Vast quantities of plastic waste are exported each year from high-income to low-income countries, where it accumulates in landfills, pollutes air and water, degrades vital ecosystems, befouls beaches and estuaries, and harms human health-environmental injustice on a global scale. Plastic-laden e-waste is particularly problematic. Environmental Findings Plastics and plastic-associated chemicals are responsible for widespread pollution. They contaminate aquatic (marine and freshwater), terrestrial, and atmospheric environments globally. The ocean is the ultimate destination for much plastic, and plastics are found throughout the ocean, including coastal regions, the sea surface, the deep sea, and polar sea ice. Many plastics appear to resist breakdown in the ocean and could persist in the global environment for decades. Macro- and micro-plastic particles have been identified in hundreds of marine species in all major taxa, including species consumed by humans. Trophic transfer of microplastic particles and the chemicals within them has been demonstrated. Although microplastic particles themselves (>10 µm) appear not to undergo biomagnification, hydrophobic plastic-associated chemicals bioaccumulate in marine animals and biomagnify in marine food webs. The amounts and fates of smaller microplastic and nanoplastic particles (MNPs <10 µm) in aquatic environments are poorly understood, but the potential for harm is worrying given their mobility in biological systems. Adverse environmental impacts of plastic pollution occur at multiple levels from molecular and biochemical to population and ecosystem. MNP contamination of seafood results in direct, though not well quantified, human exposure to plastics and plastic-associated chemicals. Marine plastic pollution endangers the ocean ecosystems upon which all humanity depends for food, oxygen, livelihood, and well-being. Human Health Findings Coal miners, oil workers and gas field workers who extract fossil carbon feedstocks for plastic production suffer increased mortality from traumatic injury, coal workers' pneumoconiosis, silicosis, cardiovascular disease, chronic obstructive pulmonary disease, and lung cancer. Plastic production workers are at increased risk of leukemia, lymphoma, hepatic angiosarcoma, brain cancer, breast cancer, mesothelioma, neurotoxic injury, and decreased fertility. Workers producing plastic textiles die of bladder cancer, lung cancer, mesothelioma, and interstitial lung disease at increased rates. Plastic recycling workers have increased rates of cardiovascular disease, toxic metal poisoning, neuropathy, and lung cancer. Residents of "fenceline" communities adjacent to plastic production and waste disposal sites experience increased risks of premature birth, low birth weight, asthma, childhood leukemia, cardiovascular disease, chronic obstructive pulmonary disease, and lung cancer.During use and also in disposal, plastics release toxic chemicals including additives and residual monomers into the environment and into people. National biomonitoring surveys in the USA document population-wide exposures to these chemicals. Plastic additives disrupt endocrine function and increase risk for premature births, neurodevelopmental disorders, male reproductive birth defects, infertility, obesity, cardiovascular disease, renal disease, and cancers. Chemical-laden MNPs formed through the environmental degradation of plastic waste can enter living organisms, including humans. Emerging, albeit still incomplete evidence indicates that MNPs may cause toxicity due to their physical and toxicological effects as well as by acting as vectors that transport toxic chemicals and bacterial pathogens into tissues and cells.Infants in the womb and young children are two populations at particularly high risk of plastic-related health effects. Because of the exquisite sensitivity of early development to hazardous chemicals and children's unique patterns of exposure, plastic-associated exposures are linked to increased risks of prematurity, stillbirth, low birth weight, birth defects of the reproductive organs, neurodevelopmental impairment, impaired lung growth, and childhood cancer. Early-life exposures to plastic-associated chemicals also increase the risk of multiple non-communicable diseases later in life. Economic Findings Plastic's harms to human health result in significant economic costs. We estimate that in 2015 the health-related costs of plastic production exceeded $250 billion (2015 Int$) globally, and that in the USA alone the health costs of disease and disability caused by the plastic-associated chemicals PBDE, BPA and DEHP exceeded $920 billion (2015 Int$). Plastic production results in greenhouse gas (GHG) emissions equivalent to 1.96 gigatons of carbon dioxide (CO2e) annually. Using the US Environmental Protection Agency's (EPA) social cost of carbon metric, we estimate the annual costs of these GHG emissions to be $341 billion (2015 Int$).These costs, large as they are, almost certainly underestimate the full economic losses resulting from plastics' negative impacts on human health and the global environment. All of plastics' economic costs-and also its social costs-are externalized by the petrochemical and plastic manufacturing industry and are borne by citizens, taxpayers, and governments in countries around the world without compensation. Social Justice Findings The adverse effects of plastics and plastic pollution on human health, the economy and the environment are not evenly distributed. They disproportionately affect poor, disempowered, and marginalized populations such as workers, racial and ethnic minorities, "fenceline" communities, Indigenous groups, women, and children, all of whom had little to do with creating the current plastics crisis and lack the political influence or the resources to address it. Plastics' harmful impacts across its life cycle are most keenly felt in the Global South, in small island states, and in disenfranchised areas in the Global North. Social and environmental justice (SEJ) principles require reversal of these inequitable burdens to ensure that no group bears a disproportionate share of plastics' negative impacts and that those who benefit economically from plastic bear their fair share of its currently externalized costs. Conclusions It is now clear that current patterns of plastic production, use, and disposal are not sustainable and are responsible for significant harms to human health, the environment, and the economy as well as for deep societal injustices.The main driver of these worsening harms is an almost exponential and still accelerating increase in global plastic production. Plastics' harms are further magnified by low rates of recovery and recycling and by the long persistence of plastic waste in the environment.The thousands of chemicals in plastics-monomers, additives, processing agents, and non-intentionally added substances-include amongst their number known human carcinogens, endocrine disruptors, neurotoxicants, and persistent organic pollutants. These chemicals are responsible for many of plastics' known harms to human and planetary health. The chemicals leach out of plastics, enter the environment, cause pollution, and result in human exposure and disease. All efforts to reduce plastics' hazards must address the hazards of plastic-associated chemicals. Recommendations To protect human and planetary health, especially the health of vulnerable and at-risk populations, and put the world on track to end plastic pollution by 2040, this Commission supports urgent adoption by the world's nations of a strong and comprehensive Global Plastics Treaty in accord with the mandate set forth in the March 2022 resolution of the United Nations Environment Assembly (UNEA).International measures such as a Global Plastics Treaty are needed to curb plastic production and pollution, because the harms to human health and the environment caused by plastics, plastic-associated chemicals and plastic waste transcend national boundaries, are planetary in their scale, and have disproportionate impacts on the health and well-being of people in the world's poorest nations. Effective implementation of the Global Plastics Treaty will require that international action be coordinated and complemented by interventions at the national, regional, and local levels.This Commission urges that a cap on global plastic production with targets, timetables, and national contributions be a central provision of the Global Plastics Treaty. We recommend inclusion of the following additional provisions:The Treaty needs to extend beyond microplastics and marine litter to include all of the many thousands of chemicals incorporated into plastics.The Treaty needs to include a provision banning or severely restricting manufacture and use of unnecessary, avoidable, and problematic plastic items, especially single-use items such as manufactured plastic microbeads.The Treaty needs to include requirements on extended producer responsibility (EPR) that make fossil carbon producers, plastic producers, and the manufacturers of plastic products legally and financially responsible for the safety and end-of-life management of all the materials they produce and sell.The Treaty needs to mandate reductions in the chemical complexity of plastic products; health-protective standards for plastics and plastic additives; a requirement for use of sustainable non-toxic materials; full disclosure of all components; and traceability of components. International cooperation will be essential to implementing and enforcing these standards.The Treaty needs to include SEJ remedies at each stage of the plastic life cycle designed to fill gaps in community knowledge and advance both distributional and procedural equity.This Commission encourages inclusion in the Global Plastic Treaty of a provision calling for exploration of listing at least some plastic polymers as persistent organic pollutants (POPs) under the Stockholm Convention.This Commission encourages a strong interface between the Global Plastics Treaty and the Basel and London Conventions to enhance management of hazardous plastic waste and slow current massive exports of plastic waste into the world's least-developed countries.This Commission recommends the creation of a Permanent Science Policy Advisory Body to guide the Treaty's implementation. The main priorities of this Body would be to guide Member States and other stakeholders in evaluating which solutions are most effective in reducing plastic consumption, enhancing plastic waste recovery and recycling, and curbing the generation of plastic waste. This Body could also assess trade-offs among these solutions and evaluate safer alternatives to current plastics. It could monitor the transnational export of plastic waste. It could coordinate robust oceanic-, land-, and air-based MNP monitoring programs.This Commission recommends urgent investment by national governments in research into solutions to the global plastic crisis. This research will need to determine which solutions are most effective and cost-effective in the context of particular countries and assess the risks and benefits of proposed solutions. Oceanographic and environmental research is needed to better measure concentrations and impacts of plastics <10 µm and understand their distribution and fate in the global environment. Biomedical research is needed to elucidate the human health impacts of plastics, especially MNPs. Summary This Commission finds that plastics are both a boon to humanity and a stealth threat to human and planetary health. Plastics convey enormous benefits, but current linear patterns of plastic production, use, and disposal that pay little attention to sustainable design or safe materials and a near absence of recovery, reuse, and recycling are responsible for grave harms to health, widespread environmental damage, great economic costs, and deep societal injustices. These harms are rapidly worsening.While there remain gaps in knowledge about plastics' harms and uncertainties about their full magnitude, the evidence available today demonstrates unequivocally that these impacts are great and that they will increase in severity in the absence of urgent and effective intervention at global scale. Manufacture and use of essential plastics may continue. However, reckless increases in plastic production, and especially increases in the manufacture of an ever-increasing array of unnecessary single-use plastic products, need to be curbed.Global intervention against the plastic crisis is needed now because the costs of failure to act will be immense.
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Affiliation(s)
- Philip J. Landrigan
- Global Observatory on Planetary Health, Boston College, Chestnut Hill, MA, US
- Centre Scientifique de Monaco, Medical Biology Department, MC
| | - Hervé Raps
- Centre Scientifique de Monaco, Medical Biology Department, MC
| | - Maureen Cropper
- Economics Department, University of Maryland, College Park, US
| | - Caroline Bald
- Global Observatory on Planetary Health, Boston College, Chestnut Hill, MA, US
| | | | | | | | | | | | | | - Patrick Fenichel
- Université Côte d’Azur
- Centre Hospitalier, Universitaire de Nice, FR
| | - Lora E. Fleming
- European Centre for Environment and Human Health, University of Exeter Medical School, UK
| | | | | | | | - Carly Griffin
- Global Observatory on Planetary Health, Boston College, Chestnut Hill, MA, US
| | - Mark E. Hahn
- Biology Department, Woods Hole Oceanographic Institution, US
- Woods Hole Center for Oceans and Human Health, US
| | - Budi Haryanto
- Department of Environmental Health, Universitas Indonesia, ID
- Research Center for Climate Change, Universitas Indonesia, ID
| | - Richard Hixson
- College of Medicine and Health, University of Exeter, UK
| | - Hannah Ianelli
- Global Observatory on Planetary Health, Boston College, Chestnut Hill, MA, US
| | - Bryan D. James
- Department of Marine Chemistry and Geochemistry, Woods Hole Oceanographic Institution
- Department of Biology, Woods Hole Oceanographic Institution, US
| | | | - Amalia Laborde
- Department of Toxicology, School of Medicine, University of the Republic, UY
| | | | - Keith Martin
- Consortium of Universities for Global Health, US
| | - Jenna Mu
- Global Observatory on Planetary Health, Boston College, Chestnut Hill, MA, US
| | | | - Adetoun Mustapha
- Nigerian Institute of Medical Research, Lagos, Nigeria
- Lead City University, NG
| | - Jia Niu
- Department of Chemistry, Boston College, US
| | - Sabine Pahl
- University of Vienna, Austria
- University of Plymouth, UK
| | | | - Maria-Luiza Pedrotti
- Laboratoire d’Océanographie de Villefranche sur mer (LOV), Sorbonne Université, FR
| | | | | | - Bhedita Jaya Seewoo
- Minderoo Foundation, AU
- School of Biological Sciences, The University of Western Australia, AU
| | | | - John J. Stegeman
- Biology Department and Woods Hole Center for Oceans and Human Health, Woods Hole Oceanographic Institution, US
| | - William Suk
- Superfund Research Program, National Institutes of Health, National Institute of Environmental Health Sciences, US
| | | | - Hideshige Takada
- Laboratory of Organic Geochemistry (LOG), Tokyo University of Agriculture and Technology, JP
| | | | | | - Zhanyun Wang
- Technology and Society Laboratory, WEmpa-Swiss Federal Laboratories for Materials and Technology, CH
| | - Ella Whitman
- Global Observatory on Planetary Health, Boston College, Chestnut Hill, MA, US
| | | | | | - Aroub K. Yousuf
- Global Observatory on Planetary Health, Boston College, Chestnut Hill, MA, US
| | - Sarah Dunlop
- Minderoo Foundation, AU
- School of Biological Sciences, The University of Western Australia, AU
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Bernard L, Masse M, Boeuf B, Chennell P, Decaudin B, Durand N, Genay S, Lambert C, Le Basle Y, Moreau E, Pinguet J, Ponsonnaille V, Richard D, Saturnin N, Storme L, Sautou V. Medical devices used in NICU: The main source of plasticisers' exposure of newborns. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 858:159994. [PMID: 36368381 DOI: 10.1016/j.scitotenv.2022.159994] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/06/2022] [Accepted: 11/02/2022] [Indexed: 06/16/2023]
Abstract
Phthalates and other plasticisers are extensively used in medical devices (MD) from which they can leach out and lead to potential multiple problems for the patients. This exposure is a major issue because it is associated with reproductive and neurodevelopment disorders. The Neonatal Intensive Care Units (NICU) population is at high risk due to the daily intensive medical interventions, the reduced ability of newborns to remove these contaminants and their higher sensitivity to endocrine disruptors. We conducted a multicentric biomonitoring study to assess and compare the urinary levels of DEHP (di-(2-ethylhexyl)phthalate), DEHTP (di-(2-ethylhexyl)terephthalate) and TEHTM (tri-(2-ethylhexyl)trimellitate) metabolites as biomarkers of this exposure during and after the newborns' stay in NICU. Daily urinary samples were collected in NICU and at discharge from the hospital for each patient. MD sources and exposure factors were also investigated. 508 urinary samples from 97 patients enrolled in centres 1 and 2 (C1/C2) were collected. The exposure of newborns to DEHP was greater than that of DEHTP and TEHTM, with a median concentration of DEHP metabolites (C1:195.63 ng/mL;C2:450.87 ng/mL) respectively 5 to 10 times higher and 57 to 228 times higher than the median concentrations of DEHTP and TEHTM metabolites. The urinary concentrations of DEHP and TEHTM metabolites were significantly lower at discharge than in NICU, with a 18-and 35-fold decrease for DEHP and a 4 and 8-fold decrease for TEHTM, respectively for C1 and C2, but were similar for DEHTP metabolites. MD used for respiratory assistance, infusion therapy,enteral nutrition and transfusion were the main sources of exposure. Smaller gestational age and body weight significantly increased the newborns' exposure. The elevated levels of DEHP metabolites in NICU patients are still alarming. Additional efforts are necessary to promote its substitution in MD by possibly safer alternatives such as TEHTM and DEHTP, particularly when used for the care of newborns.
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Affiliation(s)
- Lise Bernard
- Université Clermont Auvergne, Clermont Auvergne INP, CNRS, CHU Clermont Ferrand, ICCF, F-63000 Clermont-Ferrand, France.
| | - Morgane Masse
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, F-59000 Lille, France
| | - Benoît Boeuf
- CHU Clermont-Ferrand, Service Réanimation pédiatrique et médecine néonatale, Clermont-Ferrand, France
| | - Philip Chennell
- Université Clermont Auvergne, Clermont Auvergne INP, CNRS, CHU Clermont Ferrand, ICCF, F-63000 Clermont-Ferrand, France
| | - Bertrand Decaudin
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, F-59000 Lille, France
| | - Nelly Durand
- CIC 1405, Unité CRECHE, INSERM, Université Clermont Auvergne, F-63000 Clermont-Ferrand, France
| | - Stéphanie Genay
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les Formes Injectables et les Technologies Associées, F-59000 Lille, France
| | - Céline Lambert
- CHU Clermont-Ferrand, Direction de la Recherche Clinique et Innovation, Clermont-Ferrand, France
| | - Yoann Le Basle
- Université Clermont Auvergne, Clermont Auvergne INP, CNRS, CHU Clermont Ferrand, ICCF, F-63000 Clermont-Ferrand, France
| | - Emmanuel Moreau
- Université Clermont-Auvergne, INSERM U1240 Imagerie Moléculaire et Stratégies Théranostiques, F-63000 Clermont Ferrand, France
| | - Jérémy Pinguet
- CHU Clermont-Ferrand, Université Clermont-Auvergne, service de Pharmacologie médicale, UMR INSERM 1107 Neuro-Dol, F-63000 Clermont-Ferrand, France
| | - Varlane Ponsonnaille
- CHU Clermont-Ferrand, Service Réanimation pédiatrique et médecine néonatale, Clermont-Ferrand, France
| | - Damien Richard
- CHU Clermont-Ferrand, Université Clermont-Auvergne, service de Pharmacologie médicale, UMR INSERM 1107 Neuro-Dol, F-63000 Clermont-Ferrand, France
| | - Nathalie Saturnin
- CHU Clermont-Ferrand, Service Réanimation pédiatrique et médecine néonatale, Clermont-Ferrand, France
| | - Laurent Storme
- CHRU Lille, Service de Médecine Néonatale, F-59000 Lille, France; Université Lille I, UPRES EA 4489, Laboratoire de Périnatalité et croissance, F-59000 Lille, France
| | - Valérie Sautou
- Université Clermont Auvergne, Clermont Auvergne INP, CNRS, CHU Clermont Ferrand, ICCF, F-63000 Clermont-Ferrand, France
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Gaynor JW, Burnham NB, Ittenbach RF, Gerdes M, Bernbaum JC, Zackai E, Licht DJ, Russell WW, Zullo EE, Miller T, Hakonarson H, Clarke KA, Jarvik GP, Calafat AM, Bradman A, Bellinger DC, Henretig FM, Coker ES. Childhood exposures to environmental chemicals and neurodevelopmental outcomes in congenital heart disease. PLoS One 2022; 17:e0277611. [PMID: 36395323 PMCID: PMC9671412 DOI: 10.1371/journal.pone.0277611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 10/31/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Children with congenital heart defects have an increased risk of neurodevelopmental disability. The impact of environmental chemical exposures during daily life on neurodevelopmental outcomes in toddlers with congenital heart defects is unknown. METHODS This prospective study investigated the impacts of early childhood exposure to mixtures of environmental chemicals on neurodevelopmental outcomes after cardiac surgery. Outcomes were assessed at 18 months of age using The Bayley Scales of Infant and Toddler Development-III. Urinary concentrations of exposure biomarkers of pesticides, phenols, parabens, and phthalates, and blood levels of lead, mercury, and nicotine were measured at the same time point. Bayesian profile regression and weighted quantile sum regression were utilized to assess associations between mixtures of biomarkers and neurodevelopmental scores. RESULTS One-hundred and forty infants were enrolled, and 110 (79%) returned at 18 months of age. Six biomarker exposure clusters were identified from the Bayesian profile regression analysis; and the pattern was driven by 15 of the 30 biomarkers, most notably 13 phthalate biomarkers. Children in the highest exposure cluster had significantly lower adjusted language scores by -9.41 points (95%CI: -17.2, -1.7) and adjusted motor scores by -4.9 points (-9.5, -0.4) compared to the lowest exposure. Weighted quantile sum regression modeling for the overall exposure-response relationship showed a significantly lower adjusted motor score (β = -2.8 points [2.5th and 97.5th percentile: -6.0, -0.6]). The weighted quantile sum regression index weights for several phthalates, one paraben, and one phenol suggest their relevance for poorer neurodevelopmental outcomes. CONCLUSIONS Like other children, infants with congenital heart defects are exposed to complex mixtures of environmental chemicals in daily life. Higher exposure biomarker concentrations were associated with significantly worse performance for language and motor skills in this population.
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Affiliation(s)
- J. William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- * E-mail:
| | - Nancy B. Burnham
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Richard F. Ittenbach
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States of America
| | - Marsha Gerdes
- Department of Psychology, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Judy C. Bernbaum
- Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Elaine Zackai
- Division of Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Daniel J. Licht
- Division of Neurology, Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - William W. Russell
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Erin E. Zullo
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Thomas Miller
- Division of Pediatric Cardiology, Maine Medical Center, Portland, ME, United States of America
| | - Hakon Hakonarson
- The Center for Applied Genomics, The Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Kayan A. Clarke
- Department of Environmental and Global Health, University of Florida, Gainesville, FL, United States of America
| | - Gail P. Jarvik
- Departments of Medicine (Division of Medical Genetics) and Genome Sciences, University of Washington Medical Center, Seattle, WA, United States of America
| | - Antonia M. Calafat
- Division of Laboratory Sciences, National Center for Environmental Health, Atlanta, GA, United States of America
| | - Asa Bradman
- Department of Public Health, University of California, Merced, Merced, CA, United States of America
| | - David C. Bellinger
- Department of Neurology, Boston Children’s Hospital and Harvard Medical School, Boston, MA and Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Frederick M. Henretig
- Emergency Medicine, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Eric S. Coker
- Department of Environmental and Global Health, University of Florida, Gainesville, FL, United States of America
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6
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Saab Y, Oueis E, Mehanna S, Nakad Z, Stephan R, Khnayzer RS. Risk Assessment of Phthalates and Their Metabolites in Hospitalized Patients: A Focus on Di- and Mono-(2-ethylhexyl) Phthalates Exposure from Intravenous Plastic Bags. TOXICS 2022; 10:toxics10070357. [PMID: 35878262 PMCID: PMC9324282 DOI: 10.3390/toxics10070357] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/23/2022] [Accepted: 06/27/2022] [Indexed: 02/05/2023]
Abstract
Phthalate esters (PAEs) are plasticizers associated with multiple toxicities; however, no strict regulations have been implemented to restrict their use in medical applications in Lebanon. Our study aimed at assessing the potential risks correlated with phthalate exposure from IV bags manufactured in Lebanon. GC–MS analysis showed that di-(2-ethylhexyl) phthalate (DEHP) is the predominant phthalate found in almost all samples tested with values ranging from 32.8 to 39.7% w/w of plastic. DEHP concentrations in the IV solutions reached up to 148 µg/L, as measured by SPME-GC–MS/MS, thus resulting in hazard quotients greater than 1, specifically in neonates. The toxicity of DEHP is mainly attributed to its metabolites, most importantly mono-(2-ethylhexyl) phthalate (MEHP). The IV bag solution with the highest content in DEHP was therefore used to extrapolate the amounts of urinary MEHP. The highest concentrations were found in neonates having the lowest body weight, which is concerning, knowing the adverse effects of MEHP in infants. Our study suggests that the use of IV bags manufactured in Lebanon could pose a significant risk in hospitalized patients, especially infants in neonatal care. Therefore, Lebanon, as well as other countries, should start imposing laws that restrict the use of phthalates in medical IV bags and substitute them with less toxic plasticizers.
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Affiliation(s)
- Yolande Saab
- Pharmaceutical Sciences Department, School of Pharmacy, Lebanese American University, Chouran, Beirut 1102-2801, Lebanon; (E.O.); (R.S.)
- Correspondence: (Y.S.); (R.S.K.)
| | - Emilia Oueis
- Pharmaceutical Sciences Department, School of Pharmacy, Lebanese American University, Chouran, Beirut 1102-2801, Lebanon; (E.O.); (R.S.)
| | - Stephanie Mehanna
- Department of Natural Sciences, Lebanese American University, Chouran, Beirut 1102-2801, Lebanon;
| | - Zahi Nakad
- Electrical and Computer Engineering Department, School of Engineering, Lebanese American University, Chouran, Beirut 1102-2801, Lebanon;
| | - Rita Stephan
- Pharmaceutical Sciences Department, School of Pharmacy, Lebanese American University, Chouran, Beirut 1102-2801, Lebanon; (E.O.); (R.S.)
| | - Rony S. Khnayzer
- Department of Natural Sciences, Lebanese American University, Chouran, Beirut 1102-2801, Lebanon;
- Correspondence: (Y.S.); (R.S.K.)
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7
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Xiang S, Dong J, Li X, Li C. Urine Phthalate Levels and Liver Function in US Adolescents: Analyses of NHANES 2007–2016. Front Public Health 2022; 10:843971. [PMID: 35317511 PMCID: PMC8934389 DOI: 10.3389/fpubh.2022.843971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Phthalates are non-persistent chemicals with endocrine-disrupting abilities widely used in a variety of consumer products. Evidence for the effects of phthalate exposure on liver function in adolescents is lacking. Methods Data were analyzed from the combined 2007–2016 National Health and Nutrition Examination Survey (NHANES). Ultimately, a total of 1,650 adolescents aged 12–19 years were selected as the samples. Weighted linear regression was used to investigate the effects of urinary phthalate metabolites on liver function indexes. Results Weighted Linear regression models showed that MCOP was negatively associated with TBIL (β = −0.0435, PFDR = 0.007), ΣDEHP (β = −0.0453, PFDR = 0.003) and MCOP (β = −0.0379, PFDR = 0.006) were negatively correlated with ALB, while MCPP was positively correlated with ALB (β = 0.0339, PFDR = 0.024), and MCOP was negatively correlated with TP (β = −0.0551; PFDR = 0.004). Conclusions Phthalate metabolites were significantly but weakly associated with changes in liver function indicators among US adolescents. Future work should further examine these relationships.
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Affiliation(s)
- Shiting Xiang
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, Changsha, China
| | - Jie Dong
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, Changsha, China
| | - Xun Li
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, Changsha, China
- *Correspondence: Xun Li
| | - Chao Li
- Department of Epidemiology and Medical Statistics, Xiangya School of Public Health, Central South University, Changsha, China
- Chao Li
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8
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Secor JD, Yu L, Tsikis S, Fligor S, Puder M, Gura KM. Current strategies for managing intestinal failure-associated liver disease. Expert Opin Drug Saf 2020; 20:307-320. [PMID: 33356650 DOI: 10.1080/14740338.2021.1867099] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Introduction: Intestinal failure-associated liver disease (IFALD) refers to hepatic dysfunction that results from prolonged parenteral nutrition (PN) use. IFALD is multifactorial in origin and remains a major cause of morbidity and mortality. Prior to 2004, IFALD was associated with mortality as high as 90% in infants who remained on PN greater than 1 year. The advent of new strategies for intravenous lipid emulsion (ILE) administration and improved catheter care now allow many patients to remain on PN and recover from this once fatal condition. Several additional treatment modalities are often used to further improve outcomes for IFALD patients and they are reviewed here.Areas covered: The etiology of IFALD is presented, as well as the rationale behind the use of ILEs that contain fish oil. Other management strategies are addressed, including the effects of several pharmacologic and nutritional interventions.Expert opinion: Like its etiology, the management of IFALD is multifactorial. Prompt recognition of patients at risk, avoiding macronutrient excess, and preventing central line associated bloodstream infections will improve outcomes. In patients who develop IFALD, the use of fish oil monotherapy seems to be efficacious. The most effective intervention, however, continues to be discontinuation of PN and achieving full enteral feedings.
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Affiliation(s)
- Jordan D Secor
- Harvard Medical School, Vascular Biology Program, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Lumeng Yu
- Harvard Medical School, Vascular Biology Program, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Savas Tsikis
- Harvard Medical School, Vascular Biology Program, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Scott Fligor
- Harvard Medical School, Vascular Biology Program, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Mark Puder
- Harvard Medical School, Vascular Biology Program, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Kathleen M Gura
- Department of Pharmacy, Boston Children's Hospital, Boston, MA, USA.,Division of Gastroenterology, Hepatology and Nutrition, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
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9
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Genco M, Anderson-Shaw L, Sargis RM. Unwitting Accomplices: Endocrine Disruptors Confounding Clinical Care. J Clin Endocrinol Metab 2020; 105:5862419. [PMID: 32614432 PMCID: PMC7442273 DOI: 10.1210/clinem/dgaa358] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/05/2020] [Indexed: 01/05/2023]
Abstract
Burgeoning evidence over the last 25 years has identified myriad synthetic chemicals with the capacity to alter various aspects of hormone synthesis and action. These endocrine-disrupting chemicals (EDCs) have been linked to various diseases, including reproductive disorders, metabolic diseases, and developmental abnormalities, among others. Exposure to EDCs arises from industrial activity, use of personal and home care products, and consumption of contaminated food and water; however, the role of healthcare in exposing individuals to EDCs is grossly underappreciated. Indeed, through the use of medications as well as medical equipment and devices, healthcare providers are unknowing mediators of exposure to EDCs, chemicals that might not only promote disease but that may also antagonize the efficacy of treatments. The ethical implications of provider-dependent exposure are profound. A failure to disclose the endocrine-disrupting properties of medical interventions violates core principles of nonmaleficence, patient autonomy, and justice as well as the practice of informed consent. Furthermore, physicians' lack of knowledge regarding EDCs in medical practice artificially skews risk-benefit calculations that are fundamental to informed medical decision-making. To combat this underappreciated ethical challenge, urgent action is required. Healthcare providers must be educated about endocrine disruption. Known EDCs, defined by endocrinologists, should be clearly labeled on all medical products, and all medication components and devices should be screened for endocrine-disrupting properties. Finally, communication strategies must be devised to empower patients with knowledge about these risks. Providing ethically competent care requires an open acknowledgment of endocrine risks imposed by the medical community that have heretofore been ignored.
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Affiliation(s)
- Matthew Genco
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, US
| | - Lisa Anderson-Shaw
- Department of Medical Education, University of Illinois at Chicago, Chicago, IL, US
| | - Robert M Sargis
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, US
- Chicago Center for Health and Environment (CACHET); University of Illinois at Chicago, Chicago, IL, US
- Correspondence and Reprint Requests: Robert M. Sargis, MD, PhD, Division of Endocrinology, Diabetes, and Metabolism, University of Illinois at Chicago, 835 S. Wolcott Suite E625; M/C 640, Chicago, IL 60612.
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10
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Wang JQ, Gao H, Sheng J, Tao XY, Huang K, Zhang YW, Mao LJ, Zhou SS, Jin ZX, Tao FB. Urinary concentrations of phthalate metabolites during gestation and intrahepatic cholestasis of pregnancy: a population-based birth cohort study. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2020; 27:11714-11723. [PMID: 31975012 DOI: 10.1007/s11356-020-07675-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/07/2020] [Indexed: 06/10/2023]
Abstract
Phthalates, a class of widely used endocrine-disrupting chemicals (EDCs), are toxic to various organ systems in animals and humans. Intrahepatic cholestasis of pregnancy (ICP) is a reversible liver dysfunction causing cholestasis in late pregnancy. Evidence on the associations between exposure to phthalates and ICP is still lacking. In the present study, we investigated the relationships between urinary concentrations of phthalate metabolites and the risk of ICP in a Chinese population-based birth cohort. Pregnant women participated in the Ma'anshan Birth Cohort (MABC) study in China. Seven phthalate metabolites were detected in a urine sample in early pregnancy. Chemical concentrations were grouped by quartiles, and associations with outcomes were examined using logistic regression with adjustment for urine creatinine, race, education, poverty status, smoking status, alcohol consumption, maternal age, prepregnancy body mass index (BMI), parity, twin pregnancy, and pregnancy-related liver complications. Of 3474 women recruited into the Ma'anshan Birth Cohort, 2760 met the inclusion criteria and contributed to further analysis and biomonitoring data. Elevated odds ratios (ORs) of ICP were observed in the highest quartiles of monomethyl phthalate (MMP) exposure (OR = 1.59, 95% confidence intervals (CI) = 1.01-2.51) and monobutyl phthalate (MBP) exposure (OR = 1.82, 95% CI = 1.16-2.85) in the adjusted analyses. Our findings add to the evidence that supports the role of maternal phthalate exposure in the first trimester of gestation as a risk factor for ICP.
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Affiliation(s)
- Jian-Qing Wang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
- MOE Key Laboratory of Population Health Across Life Cycle, No 81 Meishan Road, Hefei, 230032, Anhui, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, No 81 Meishan Road, Hefei, 230032, Anhui, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
- The Fourth Affiliated Hospital, Anhui Medical University, Hefei, 230022, Anhui, China
| | - Hui Gao
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Jie Sheng
- MOE Key Laboratory of Population Health Across Life Cycle, No 81 Meishan Road, Hefei, 230032, Anhui, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Xing-Yong Tao
- MOE Key Laboratory of Population Health Across Life Cycle, No 81 Meishan Road, Hefei, 230032, Anhui, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Kun Huang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
- MOE Key Laboratory of Population Health Across Life Cycle, No 81 Meishan Road, Hefei, 230032, Anhui, China
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, No 81 Meishan Road, Hefei, 230032, Anhui, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Yun-Wei Zhang
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Lei-Jing Mao
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Shan-Shan Zhou
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Zhong-Xiu Jin
- MOE Key Laboratory of Population Health Across Life Cycle, No 81 Meishan Road, Hefei, 230032, Anhui, China
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Fang-Biao Tao
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China.
- MOE Key Laboratory of Population Health Across Life Cycle, No 81 Meishan Road, Hefei, 230032, Anhui, China.
- NHC Key Laboratory of Study on Abnormal Gametes and Reproductive Tract, No 81 Meishan Road, Hefei, 230032, Anhui, China.
- Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, No 81 Meishan Road, Hefei, 230032, Anhui, China.
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11
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Cober MP, Gura KM. Enteral and parenteral nutrition considerations in pediatric patients. Am J Health Syst Pharm 2020; 76:1492-1510. [PMID: 31532507 DOI: 10.1093/ajhp/zxz174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Current clinical practice guidelines on management of enteral nutrition (EN) and parenteral nutrition (PN) in pediatric patients are reviewed. SUMMARY The provision of EN and PN in pediatric patients poses many unique considerations and challenges. Although indications for use of EN and PN are similar in adult and pediatric populations, recommended EN and PN practices differ for pediatric versus adult patients in areas such as selection of EN and PN formulations, timing of EN and PN initiation, advancement of nutrition support, and EN and PN goals. Additionally, provision of EN and PN to pediatric patients poses unique compounding and medication administration challenges. This article provides a review of current EN and PN best practices and special nutrition considerations for neonates, infants, and other pediatric patients. CONCLUSION The provision of EN and PN to pediatric patients presents many unique challenges. It is important for pharmacists to keep current with pediatric- and neonatal-specific guidelines on nutritional management of various disease states, as well as strategies to address compounding and medication administration challenges, in order to optimize EN and PN outcomes.
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Affiliation(s)
- Mary Petrea Cober
- Department of Pharmacy, Akron Children's Hospital, Akron, OH, and Northeast Ohio Medical University, Rootstown, OH
| | - Kathleen M Gura
- Department of Pharmacy, Boston Children's Hospital, Boston, MA, and Harvard Medical School, Boston, MA
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12
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Kaestner F, Seiler F, Rapp D, Eckert E, Müller J, Metz C, Bals R, Drexler H, Lepper PM, Göen T. Exposure of patients to di(2-ethylhexy)phthalate (DEHP) and its metabolite MEHP during extracorporeal membrane oxygenation (ECMO) therapy. PLoS One 2020; 15:e0224931. [PMID: 31999712 PMCID: PMC6992201 DOI: 10.1371/journal.pone.0224931] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/24/2019] [Indexed: 01/13/2023] Open
Abstract
The plasticizer di(2-ethylhexyl)phthalate (DEHP) is often used for PVC medical devices, that are also largely used for intensive care medical treatments, like extracorporeal membrane oxygenation (ECMO) therapy. Due to the toxicological potential of DEHP, the inner exposure of patients with this plasticizer is a strong matter of concern as many studies have shown a high leaching potential of DEHP into blood. In this study, the inner DEHP exposure of patients undergoing ECMO treatment was investigated. The determined DEHP blood levels of ECMO patients and the patients of the control group ranged from 31.5 to 1009 μg/L (median 156.0 μg/L) and from 19.4 to 75.3 μg/L (median 36.4 μg/L), respectively. MEHP blood levels were determined to range from < LOD to 475 μg/L (median 15.9 μg/L) in ECMO patients and from < LOD to 9.9 μg/L (median 3.7 μg/L) in the control group patients, respectively. Increased DEHP exposure was associated with the number of cannulas and membranes of the ECMO setting, whereas residual diuresis decreased the exposure. Due to the suspected toxicological potential of DEHP, its use in medical devices should be further investigated, in particular for ICU patients with long-term exposure to PVC, like in ECMO therapy.
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Affiliation(s)
- Franziska Kaestner
- Department of Internal Medicine V, University Hospital of Saarland, Homburg, Germany
| | - Frederik Seiler
- Department of Internal Medicine V, University Hospital of Saarland, Homburg, Germany
| | - Daniel Rapp
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg/Saar, Germany
| | - Elisabeth Eckert
- Institute and Outpatient Clinic of Occupational, Social and Environmental Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Johannes Müller
- Institute and Outpatient Clinic of Occupational, Social and Environmental Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Carlos Metz
- Department of Internal Medicine V, University Hospital of Saarland, Homburg, Germany
| | - Robert Bals
- Department of Internal Medicine V, University Hospital of Saarland, Homburg, Germany
| | - Hans Drexler
- Institute and Outpatient Clinic of Occupational, Social and Environmental Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Philipp M. Lepper
- Department of Internal Medicine V, University Hospital of Saarland, Homburg, Germany
| | - Thomas Göen
- Institute and Outpatient Clinic of Occupational, Social and Environmental Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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13
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Stroustrup A, Bragg JB, Spear EA, Aguiar A, Zimmerman E, Isler JR, Busgang SA, Curtin PC, Gennings C, Andra SS, Arora M. Cohort profile: the Neonatal Intensive Care Unit Hospital Exposures and Long-Term Health (NICU-HEALTH) cohort, a prospective preterm birth cohort in New York City. BMJ Open 2019; 9:e032758. [PMID: 31772104 PMCID: PMC6887035 DOI: 10.1136/bmjopen-2019-032758] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/31/2019] [Accepted: 11/01/2019] [Indexed: 01/25/2023] Open
Abstract
PURPOSE The Neonatal Intensive Care Unit Hospital Exposures and Long-Term Health (NICU-HEALTH) longitudinal preterm birth cohort studies the impact of the NICU exposome on early-life development. NICU-HEALTH collects multiple biospecimens, complex observational and survey data and comprehensive multisystem outcome assessments to allow measurement of the impact of modifiable environmental exposures during the preterm period on neurodevelopmental, pulmonary and growth outcomes. PARTICIPANTS Moderately preterm infants without genetic or congenital anomalies and their mothers are recruited from an urban academic medical centre level IV NICU in New York City, New York, USA. Recruitment began in 2011 and continues through multiple enrolment phases to the present with goal enrolment of 400 infants. Follow-up includes daily data collection throughout the NICU stay and six follow-up visits in the first 2 years. Study retention is 77% to date, with the oldest patients turning age 8 in 2019. FINDINGS TO DATE NICU-HEALTH has already contributed significantly to our understanding of phthalate exposure in the NICU. Phase I produced the first evidence of the clinical impact of phthalate exposure in the NICU population. Further study identified specific sources of exposure to clinically relevant phthalate mixtures in the NICU. FUTURE PLANS Follow-up from age 3 to 12 is co-ordinated through integration with the Environmental Influences on Child Health Outcomes (ECHO) programme. The NICU-HEALTH cohort will generate a wealth of biomarker, clinical and outcome data from which future studies of the impact of early-life chemical and non-chemical environmental exposures can benefit. Findings from study of this cohort and other collaborating environmental health cohorts will likely translate into improvements in the hospital environment for infant development. TRIAL REGISTRATION NUMBERS This observational cohort is registered with ClinicalTrials.gov (NCT01420029 and NCT01963065).
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Affiliation(s)
- Annemarie Stroustrup
- Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Jennifer B Bragg
- Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Emily A Spear
- Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Andrea Aguiar
- Beckman Institute, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Emily Zimmerman
- Communication Sciences and Disorders, Northeastern University, Boston, Massachusetts, USA
| | - Joseph R Isler
- Pediatrics, Columbia University, New York City, New York, USA
| | - Stefanie A Busgang
- Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Paul C Curtin
- Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Chris Gennings
- Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Syam S Andra
- Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Manish Arora
- Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
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14
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Jaimes R, McCullough D, Siegel B, Swift L, McInerney D, Hiebert J, Perez-Alday EA, Trenor B, Sheng J, Saiz J, Tereshchenko LG, Posnack NG. Plasticizer Interaction With the Heart: Chemicals Used in Plastic Medical Devices Can Interfere With Cardiac Electrophysiology. Circ Arrhythm Electrophysiol 2019; 12:e007294. [PMID: 31248280 PMCID: PMC6693678 DOI: 10.1161/circep.119.007294] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Phthalates are used as plasticizers in the manufacturing of flexible, plastic medical products. Patients can be subjected to high phthalate exposure through contact with plastic medical devices. We aimed to investigate the cardiac safety and biocompatibility of mono-2-ethylhexyl phthalate (MEHP), a phthalate with documented exposure in intensive care patients. METHODS Optical mapping of transmembrane voltage and pacing studies were performed on isolated, Langendorff-perfused rat hearts to assess cardiac electrophysiology after MEHP exposure compared with controls. MEHP dose was chosen based on reported blood concentrations after an exchange transfusion procedure. RESULTS Thirty-minute exposure to MEHP increased the atrioventricular node (147 versus 107 ms) and ventricular (117 versus 77.5 ms) effective refractory periods, compared with controls. Optical mapping revealed prolonged action potential duration at slower pacing cycle lengths, akin to reverse use dependence. The plateau phase of the action potential duration restitution curve steepened and became monophasic in MEHP-exposed hearts (0.18 versus 0.06 slope). Action potential duration lengthening occurred during late-phase repolarization resulting in triangulation (70.3 versus 56.6 ms). MEHP exposure also slowed epicardial conduction velocity (35 versus 60 cm/s), which may be partly explained by inhibition of Nav1.5 (874 and 231 µmol/L half-maximal inhibitory concentration, fast and late sodium current). CONCLUSIONS This study highlights the impact of acute MEHP exposure, using a clinically relevant dose, on cardiac electrophysiology in the intact heart. Heightened clinical exposure to plasticized medical products may have cardiac safety implications-given that action potential triangulation and electrical restitution modifications are a risk factor for early after depolarizations and cardiac arrhythmias.
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Affiliation(s)
- Rafael Jaimes
- Sheikh Zayed Institute for Pediatric Surgical Innovation (R.J., D. McCullough, L.S., D. McInerney, J.H., N.G.P.), Children's National Health System, Washington DC.,Children's National Heart Institute (R.J., B.S., L.S., N.G.P.), Children's National Health System, Washington DC
| | - Damon McCullough
- Sheikh Zayed Institute for Pediatric Surgical Innovation (R.J., D. McCullough, L.S., D. McInerney, J.H., N.G.P.), Children's National Health System, Washington DC
| | - Bryan Siegel
- Children's National Heart Institute (R.J., B.S., L.S., N.G.P.), Children's National Health System, Washington DC
| | - Luther Swift
- Sheikh Zayed Institute for Pediatric Surgical Innovation (R.J., D. McCullough, L.S., D. McInerney, J.H., N.G.P.), Children's National Health System, Washington DC.,Children's National Heart Institute (R.J., B.S., L.S., N.G.P.), Children's National Health System, Washington DC
| | - Daniel McInerney
- Sheikh Zayed Institute for Pediatric Surgical Innovation (R.J., D. McCullough, L.S., D. McInerney, J.H., N.G.P.), Children's National Health System, Washington DC
| | - James Hiebert
- Sheikh Zayed Institute for Pediatric Surgical Innovation (R.J., D. McCullough, L.S., D. McInerney, J.H., N.G.P.), Children's National Health System, Washington DC
| | - Erick A Perez-Alday
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland (E.A.P.-A., L.G.T.)
| | - Beatriz Trenor
- Ci2B-Universitat Politècnica de València, Spain (B.T., F.J.S.R.)
| | | | - Javier Saiz
- Sheikh Zayed Institute for Pediatric Surgical Innovation (R.J., D. McCullough, L.S., D. McInerney, J.H., N.G.P.), Children's National Health System, Washington DC
| | - Larisa G Tereshchenko
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland (E.A.P.-A., L.G.T.)
| | - Nikki Gillum Posnack
- Sheikh Zayed Institute for Pediatric Surgical Innovation (R.J., D. McCullough, L.S., D. McInerney, J.H., N.G.P.), Children's National Health System, Washington DC.,Children's National Heart Institute (R.J., B.S., L.S., N.G.P.), Children's National Health System, Washington DC.,Departments of Pediatrics and Pharmacology and Physiology, School of Medicine and Health Sciences: George Washington University, Washington DC (N.G.P.)
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15
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Lu L, Rong H, Wu C, Cui B, Huang Y, Tan Y, Zhang L, Peng Y, Garcia JM, Chen JA. Levels of phthalate acid esters and sex hormones and their possible sources in traffic-patrol policemen in Chongqing. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2019; 26:9005-9013. [PMID: 30715702 DOI: 10.1007/s11356-019-04265-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 01/16/2019] [Indexed: 06/09/2023]
Abstract
To investigate the correlation between the air phthalate acid ester (PAE) exposure and serum PAE concentration and the effects of PAE exposure on reproductive health among Chongqing traffic-patrol policemen. In 2013, 32 traffic-patrol policemen working in an area with poor air quality in Chongqing and 28 traffic-patrol policemen working in an area with good air quality were selected. Their blood levels of 14 PAEs and six reproductive hormones were determined. Air samples were collected from four traffic-patrol platforms. The concentrations of 14 PAEs in the air samples were evaluated. All 14 PAEs were detected in the blood samples. The concentrations of seven PAEs in the total suspended particulate, namely, dimethyl phthalate, diethyl phthalate, dibutyl phthalate, bis (2-ethox-yethyl) phthalate, dihexyl phthalate, benzyl butyl phthalate, and bis (2-n-butoxyethyl) phthalate, were positively and significantly associated with the blood levels of these PAEs in the participants. All the sex hormone levels measured here were significantly different between the participants from the two areas. The PAE concentrations in the blood samples were correlated with the reproductive hormone levels in the participants. Air PAE pollution may be a major source of PAE exposure in the traffic-patrol policemen of Chongqing.
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Affiliation(s)
- Lu Lu
- Department of Health Education, Army Medical University (Third Military Medical University), Chongqing, China
| | - Honghui Rong
- Department of Health Education, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chong Wu
- Academic Affairs of Army Medical University (Third Military Medical University), Chongqing, China
| | - Bo Cui
- Department of Health Education, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yujing Huang
- Department of Environmental Hygiene, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yao Tan
- Department of Environmental Hygiene, Army Medical University (Third Military Medical University), Chongqing, China
| | - Ling Zhang
- Department of Health Education, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yi Peng
- Department of Health Education, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jose M Garcia
- GRECC, VA Puget Sound Health Care System and University of Washington, Seattle, WA, USA.
| | - Ji-An Chen
- Department of Health Education, Army Medical University (Third Military Medical University), Chongqing, China.
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16
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Malarvannan G, Onghena M, Verstraete S, van Puffelen E, Jacobs A, Vanhorebeek I, Verbruggen SCAT, Joosten KFM, Van den Berghe G, Jorens PG, Covaci A. Phthalate and alternative plasticizers in indwelling medical devices in pediatric intensive care units. JOURNAL OF HAZARDOUS MATERIALS 2019; 363:64-72. [PMID: 30308366 DOI: 10.1016/j.jhazmat.2018.09.087] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/23/2018] [Accepted: 09/29/2018] [Indexed: 05/07/2023]
Abstract
The present study aimed to identify plasticizers present in indwelling plastic medical devices commonly used in the pediatric intensive care unit (PICU). We have analyzed a wide range of medical devices (n = 97) daily used in the PICUs of two academic hospitals in Belgium and the Netherlands. Identified compounds varied between the samples. Most of the indwelling medical devices and essential accessories were found to actively leach phthalates and alternative plasticizers. Results indicated that DEHP was predominantly present as plasticizer (60 of 97 samples), followed by bis(2-ethylhexyl) adipate (DEHA, 32 of 97), bis(2-ethylhexyl) terephthalate (DEHT, 24 of 97), tris(2-ethylhexyl) trimellitate (TOTM, 20 of 97), and tributyl-O-acetyl citrate (ATBC, 10 of 97). Other plasticizers, such as di-isononyl-cyclohexane-1,2-dicarboxylate (DINCH, 2 of 97), di-isononyl phthalate (DiNP, 4 of 97), di(2-propylheptyl) phthalate (DPHP, 4 of 97) and di-isodecyl phthalate (DiDP, 2 of 97) were detected in < 5% of the investigated samples. Several devices contained multiple plasticizers, e.g. devices containing TOTM contained also DEHP and DEHT. Our data indicate that PICU patients are exposed to a wide range of plasticizers, including the controversial DEHP. Future studies should investigate the exposure to APs in children staying in the PICU and the possible health effects thereof.
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Affiliation(s)
| | | | - Sören Verstraete
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Esther van Puffelen
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - An Jacobs
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Ilse Vanhorebeek
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Sascha C A T Verbruggen
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Koen F M Joosten
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Philippe G Jorens
- Department of Intensive Care Medicine and Clinical Pharmacology, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Adrian Covaci
- Toxicological Centre, University of Antwerp, Wilrijk, Belgium.
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17
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Sargis RM, Heindel JJ, Padmanabhan V. Interventions to Address Environmental Metabolism-Disrupting Chemicals: Changing the Narrative to Empower Action to Restore Metabolic Health. Front Endocrinol (Lausanne) 2019; 10:33. [PMID: 30778334 PMCID: PMC6369180 DOI: 10.3389/fendo.2019.00033] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 01/16/2019] [Indexed: 12/17/2022] Open
Abstract
Metabolic disease rates have increased dramatically over the last four decades. Classic understanding of metabolic physiology has attributed these global trends to decreased physical activity and caloric excess; however, these traditional risk factors insufficiently explain the magnitude and rapidity of metabolic health deterioration. Recently, the novel contribution of environmental metabolism-disrupting chemicals (MDCs) to various metabolic diseases (including obesity, diabetes, and non-alcoholic fatty liver disease) is becoming recognized. As this burgeoning body of evidence has matured, various organic and inorganic pollutants of human and natural origin have emerged as metabolic disease risk factors based on population-level and experimental data. Recognition of these heretofore underappreciated metabolic stressors now mandates that efforts to mitigate the devastating consequences of metabolic disease include dedicated efforts to address environmental drivers of disease risk; however, there have not been adequate recommendations to reduce exposures or to mitigate the effects of exposures on disease outcomes. To address this knowledge gap and advance the clinical translation of MDC science, herein discussed are behaviors that increase exposures to MDCs, interventional studies to reduce those exposures, and small-scale clinical trials to reduce the body burden of MDCs. Also, we discuss evidence from cell-based and animal studies that provide insights into MDC mechanisms of action, the influence of modifiable dietary factors on MDC toxicity, and factors that modulate MDC transplacental carriage as well as their impact on metabolic homeostasis. A particular emphasis of this discussion is on critical developmental windows during which short-term MDC exposure can elicit long-term disruptions in metabolic health with potential inter- and transgenerational effects. While data gaps remain and further studies are needed, the current state of evidence regarding interventions to address MDC exposures illuminates approaches to address environmental drivers of metabolic disease risk. It is now incumbent on clinicians and public health agencies to incorporate this knowledge into comprehensive strategies to address the metabolic disease pandemic.
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Affiliation(s)
- Robert M. Sargis
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Jerrold J. Heindel
- Program on Endocrine Disruption Strategies, Commonweal, Bolinas, CA, United States
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18
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Di (2-Ethylhexyl) Phthalate and Its Role in Developing Cholestasis: An In Vitro Study on Different Liver Cell Types. J Pediatr Gastroenterol Nutr 2018; 66:e28-e35. [PMID: 29095348 DOI: 10.1097/mpg.0000000000001813] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Di(2-ethylhexyl) phthalate (DEHP) is a plasticizer used in many polyvinylchloride medical devices and is washed out easily. Thereby critically ill infants can become exposed to DEHP concentrations significantly exceeding the recommended threshold. We suspect DEHP to play an important role in the development of intestinal failure-associated liver disease. The aim of this study was therefore to determine the direct influence of DEHP on different liver cell types. METHODS HepG2, human upcyte hepatocytes, primary murine hepatocytes, LX-2, human upcyte hepatic stellate cells, and liver organoids were cultured with DEHP (0.5-500 μmol/L) and parameters including cytotoxicity, cell-cell interactions, and expression of metabolizing enzymes were investigated. RESULTS DEHP modulated the expression of xenobiotic metabolizing enzymes, reduced the formation of bile canaliculi and cell polarity, and inhibited Cyp-activity in hepatocytes. DEHP had a toxic effect on LX-2 and induced the fibrogenic activation of hepatic stellate cells. The mode of action of DEHP was different in monolayer cultures compared to 3D-liver organoids, which were more sensitive to DEHP. CONCLUSIONS This study suggests that DEHP modulates expression and activity of drug-detoxifying liver enzymes in humans at a clinically relevant concentration. Furthermore, it may contribute to the development of cholestasis and fibrosis. These findings strongly support the opinion, that there is a significant potential for serious adverse effects of DEHP derived from medical devices on human health, especially in very young infants with immature livers.
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19
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Jaimes R, Swiercz A, Sherman M, Muselimyan N, Marvar PJ, Posnack NG. Plastics and cardiovascular health: phthalates may disrupt heart rate variability and cardiovascular reactivity. Am J Physiol Heart Circ Physiol 2017; 313:H1044-H1053. [PMID: 28842438 PMCID: PMC5792203 DOI: 10.1152/ajpheart.00364.2017] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/17/2017] [Accepted: 08/17/2017] [Indexed: 12/11/2022]
Abstract
Plastics have revolutionized medical device technology, transformed hematological care, and facilitated modern cardiology procedures. Despite these advances, studies have shown that phthalate chemicals migrate out of plastic products and that these chemicals are bioactive. Recent epidemiological and research studies have suggested that phthalate exposure adversely affects cardiovascular function. Our objective was to assess the safety and biocompatibility of phthalate chemicals and resolve the impact on cardiovascular and autonomic physiology. Adult mice were implanted with radiofrequency transmitters to monitor heart rate variability, blood pressure, and autonomic regulation in response to di-2-ethylhexyl-phthalate (DEHP) exposure. DEHP-treated animals displayed a decrease in heart rate variability (-17% SD of normal beat-to-beat intervals and -36% high-frequency power) and an exaggerated mean arterial pressure response to ganglionic blockade (31.5% via chlorisondamine). In response to a conditioned stressor, DEHP-treated animals displayed enhanced cardiovascular reactivity (-56% SD major axis Poincarè plot) and prolonged blood pressure recovery. Alterations in cardiac gene expression of endothelin-1, angiotensin-converting enzyme, and nitric oxide synthase may partly explain these cardiovascular alterations. This is the first study to show an association between phthalate chemicals that are used in medical devices with alterations in autonomic regulation, heart rate variability, and cardiovascular reactivity. Because changes in autonomic balance often precede clinical manifestations of hypertension, atherosclerosis, and conduction abnormalities, future studies are warranted to assess the downstream impact of plastic chemical exposure on end-organ function in sensitive patient populations. This study also highlights the importance of adopting safer biomaterials, chemicals, and/or surface coatings for use in medical devices.NEW & NOTEWORTHY Phthalates are widely used in the manufacturing of consumer and medical products. In the present study, di-2-ethylhexyl-phthalate exposure was associated with alterations in heart rate variability and cardiovascular reactivity. This highlights the importance of investigating the impact of phthalates on health and identifying suitable alternatives for medical device manufacturing.
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Affiliation(s)
- Rafael Jaimes
- 1Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Health System, Washington, District of Columbia; ,2Children’s National Heart Institute, Children’s National Health System, Washington, District of Columbia; and
| | - Adam Swiercz
- 3Department of Pharmacology and Physiology, George Washington University, Washington, District of Columbia
| | - Meredith Sherman
- 1Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Health System, Washington, District of Columbia;
| | - Narine Muselimyan
- 3Department of Pharmacology and Physiology, George Washington University, Washington, District of Columbia
| | - Paul J. Marvar
- 3Department of Pharmacology and Physiology, George Washington University, Washington, District of Columbia
| | - Nikki Gillum Posnack
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, District of Columbia; .,Children's National Heart Institute, Children's National Health System, Washington, District of Columbia; and.,Department of Pharmacology and Physiology, George Washington University, Washington, District of Columbia
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20
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Huang Y, Garcia JM, Shu W, Rong H, Zhang L, Wang Y, Tan Y, Lin H, Zeng H, Chen JA. Peroxisome proliferator activated receptor gamma in human placenta may mediate the adverse effects of phthalates exposure in pregnancy. Reprod Toxicol 2017; 75:121-126. [PMID: 29061543 DOI: 10.1016/j.reprotox.2017.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 09/03/2017] [Accepted: 10/12/2017] [Indexed: 12/13/2022]
Abstract
Peroxisome-proliferator activated receptor gamma (PPARG) in placenta play an important role in pregnancy. Our previous study showed that it mediated the effects of phthalates on placental mRNA expression of estrogen synthetases in rats. To assess the effects of phthalate exposure on PPARG placental expression, and the contribution of PPARG to the effects of phthalates in human. 207 healthy pregnant women were recruited and their cord blood and placenta were collected upon delivery. Three phthalates, estrogens in cord blood and protein expression of PPARG in placenta were measured. Linear regression were used to analyze the relationship between phthalates exposure, PPARG expression and hormones. Phthalate levels in cord blood were positively associated with PPARG protein expression in placenta (p<0.05), whereas estrogens in cord blood were negatively associated with phthalate levels and PPARG expression (p<0.05). This study shows that PPARG in placenta may mediate the adverse effects of phthalates on pregnancy in human.
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Affiliation(s)
- Yujing Huang
- Department of Environmental Hygiene, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, China.
| | - Jose M Garcia
- Geriatric Research, Education and Clinical Center, VA Puget Sound Health Care System, Building 1, Room 815J, 1660 South Columbian Way (S-182-GRECC), Seattle, WA, 98108-1597, USA.
| | - Weiqun Shu
- Department of Environmental Hygiene, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, China.
| | - Honghui Rong
- Department of Health Education, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, China.
| | - Lin Zhang
- Department of Health Education, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, China.
| | - Yanzhou Wang
- Department of Gynecology and Obstetrics, Southwest Hospital, Army Medical University (Third Military Medical University), Chongqing, China.
| | - Yao Tan
- Department of Environmental Hygiene, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, China.
| | - Hui Lin
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, China.
| | - Hui Zeng
- Department of Environmental Hygiene, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, China.
| | - Ji-An Chen
- Department of Health Education, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing, China.
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21
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Faessler D, McCombie G, Biedermann M, Felder F, Subotic U. Leaching of plasticizers from polyvinylchloride perfusion lines by different lipid emulsions for premature infants under clinical conditions. Int J Pharm 2017; 520:119-125. [PMID: 28126549 DOI: 10.1016/j.ijpharm.2017.01.046] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 01/22/2017] [Accepted: 01/23/2017] [Indexed: 11/28/2022]
Abstract
Plasticizers migrate from polyvinylchloride (PVC) infusion systems into lipid emulsions. The aim of this study was to investigate the leaching of different plasticizers from PVC perfusion lines by a selection of lipid emulsions under clinical conditions. Seven PVC perfusion lines with an equal length of 150cm and three internal diameters were perfused with three lipid emulsions: Intralipid® 20%, ClinOleic® 20% and SMOFlipid® 20%, mimicking clinical conditions. The concentrations of the plasticizers were measured directly in the emulsions by gas chromatography - mass spectrometry. Of the four plasticizers examined in this study, di (2-ethylhexyl) phthalate (DEHP) leached the most and was found, on average, at 46.5μg/ml in the emulsions - around one order of magnitude higher than the other plasticizers. This study demonstrates that the leaching of DEHP by lipid emulsions in conditions of total parenteral nutrition is many times higher than should be accepted and higher when compared to the other plasticizers. There was no significant difference in leaching of plasticizers in relation to the type of lipid emulsion. The influence of tube diameter on the leaching rate of plasticizers should be taken into account especially in particular exposed patients.
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Affiliation(s)
- David Faessler
- Division of Visceral, Neonatal, and Fetal Surgery, Department of Pediatric Surgery, University Children's Hospital Zurich, Switzerland
| | - Gregor McCombie
- :Official Food Control Laboratory of the Canton of Zurich, Zurich, Switzerland
| | - Maurus Biedermann
- :Official Food Control Laboratory of the Canton of Zurich, Zurich, Switzerland
| | - Florian Felder
- :Official Food Control Laboratory of the Canton of Zurich, Zurich, Switzerland
| | - Ulrike Subotic
- Division of Visceral, Neonatal, and Fetal Surgery, Department of Pediatric Surgery, University Children's Hospital Zurich, Switzerland.
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22
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Nghiem-Rao TH. Potential Hepatotoxicities of Intravenous Fat Emulsions in Infants and Children. Nutr Clin Pract 2016; 31:619-28. [DOI: 10.1177/0884533616663487] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- T. Hang Nghiem-Rao
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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23
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Outcome reporting bias in observational epidemiology studies on phthalates. Ann Epidemiol 2016; 26:597-599.e4. [DOI: 10.1016/j.annepidem.2016.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 06/28/2016] [Accepted: 07/01/2016] [Indexed: 12/19/2022]
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Abstract
The ubiquitous nature of plastics has raised concerns pertaining to continuous exposure to plastic polymers and human health risks. Of particular concern is the use of endocrine-disrupting chemicals in plastic production, including di(2-ethylhexyl)phthalate (DEHP) and bisphenol A (BPA). Widespread and continuous exposure to DEHP and BPA occurs through dietary intake, inhalation, dermal and intravenous exposure via consumer products and medical devices. This article reviews the literature examining the relationship between DEHP and BPA exposure and cardiac toxicity. In vitro and in vivo experimental reports are outlined, as well as epidemiological studies which examine the association between these chemicals and cardiovascular outcomes. Gaps in our current knowledge are also discussed, along with future investigative endeavors that may help resolve whether DEHP and/or BPA exposure has a negative impact on cardiovascular physiology.
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Affiliation(s)
- Nikki Gillum Posnack
- Pharmacology and Physiology Department, The George Washington University School of Medicine and Health Sciences, 2300 Eye Street NW, Washington, DC, 20052, USA,
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25
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Gholami A, Hajian M, Rafiemanzelat F, Zanjanijam AR. Plasticized poly(vinyl chloride) composites: Influence of different nanofillers as antimigration agents. J Appl Polym Sci 2015. [DOI: 10.1002/app.42559] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Abed Gholami
- Faculty of Chemistry; University of Isfahan; Isfahan 81746-73441 Iran
| | - Morteza Hajian
- Faculty of Chemistry; University of Isfahan; Isfahan 81746-73441 Iran
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26
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Santos J, Pearce SE, Stroustrup A. Impact of hospital-based environmental exposures on neurodevelopmental outcomes of preterm infants. Curr Opin Pediatr 2015; 27:254-60. [PMID: 25635585 PMCID: PMC4410011 DOI: 10.1097/mop.0000000000000190] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Over 300,000 infants are hospitalized in a neonatal intensive care unit (NICU) in the United States annually during a developmental period critical to later neurobehavioral function. Environmental exposures during the fetal period and infancy have been shown to impact long-term neurobehavioral outcomes. This review summarizes evidence linking NICU-based environmental exposures to neurodevelopmental outcomes of children born preterm. RECENT FINDINGS Preterm infants experience multiple exposures important to neurodevelopment during the NICU hospitalization. The physical layout of the NICU, management of light and sound, social interactions with parents and NICU staff, and chemical exposures via medical equipment are important to long-term neurobehavioral outcomes in this highly vulnerable population. SUMMARY Existing research documents NICU-based exposure to neurotoxic chemicals, aberrant light, excess sound, and restricted social interaction. In total, this creates an environment of co-existing excesses (chemicals, light, sound) and deprivation (touch, speech). The full impact of these co-exposures on the long-term neurodevelopment of preterm infants has not been adequately elucidated. Research into the importance of the NICU from an environmental health perspective is in its infancy, but could provide understanding about critical modifiable factors impacting the neurobehavioral health of hundreds of thousands of children each year.
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Affiliation(s)
| | - Sarah E. Pearce
- Icahn School of Medicine at Mount Sinai
- Division of Newborn Medicine, Department of Pediatrics
| | - Annemarie Stroustrup
- Icahn School of Medicine at Mount Sinai
- Division of Newborn Medicine, Department of Pediatrics
- Department of Preventive Medicine
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27
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Fischer Fumeaux CJ, Stadelmann Diaw C, Palmero D, M'Madi F, Tolsa JF. [Phthalate exposure in the neonatal intensive care unit]. Arch Pediatr 2014; 22:203-10. [PMID: 25554670 DOI: 10.1016/j.arcped.2014.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 09/16/2014] [Accepted: 10/29/2014] [Indexed: 12/12/2022]
Abstract
There are growing concerns on long-term health consequences, notably on fertility rates, of plasticizers such as phthalates. While di(2-ethylhexyl)phthalate (DEHP) is currently used in several medical devices, newborns in the neonatal intensive care unit are both more exposed and more vulnerable to DEHP. The objectives of this study were to identify, count, and describe possible sources of DEHP in a neonatal care unit. Our method consisted in the listing and the inspection of the information on packaging, complemented by contact with manufacturers when necessary. According to the results, 6% of all products and 10% of plastic products contained some DEHP; 71% of these involved respiratory support devices. A vast majority of the items showed no information on the content of DEHP. Further research is needed, particularly to determine the effects of such an early exposure and to study and develop safer alternatives.
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Affiliation(s)
- C J Fischer Fumeaux
- Service de néonatologie, département médico-chirurgical de pédiatrie, université de Lausanne, CHU Vaudois, avenue Pierre-Decker 2, CH-1011 Lausanne, Suisse
| | - C Stadelmann Diaw
- Service de néonatologie, département médico-chirurgical de pédiatrie, université de Lausanne, CHU Vaudois, avenue Pierre-Decker 2, CH-1011 Lausanne, Suisse
| | - D Palmero
- Service de néonatologie, département médico-chirurgical de pédiatrie, université de Lausanne, CHU Vaudois, avenue Pierre-Decker 2, CH-1011 Lausanne, Suisse; École de pharmacie Lausanne-Genève, section des sciences pharmaceutiques, université de Lausanne et université de Genève, avenue Pierre-Decker 2, CH-1011 Lausanne, Suisse; Service de pharmacie, CHU Vaudois, avenue Pierre-Decker 2, CH-1011 Lausanne, Suisse
| | - F M'Madi
- Service d'ingénierie biomédicale, CHU Vaudois, Lausanne, avenue Pierre-Decker 2, CH-1011 Lausanne, Suisse
| | - J-F Tolsa
- Service de néonatologie, département médico-chirurgical de pédiatrie, université de Lausanne, CHU Vaudois, avenue Pierre-Decker 2, CH-1011 Lausanne, Suisse.
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Phthalates and critically ill neonates: device-related exposures and non-endocrine toxic risks. J Perinatol 2014; 34:892-7. [PMID: 25357096 DOI: 10.1038/jp.2014.157] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 07/15/2014] [Accepted: 07/18/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the types and magnitudes of non-endocrine toxic risks to neonates associated with medical device-related exposures to di(2-ethylhexyl)phthalate (DEHP). STUDY DESIGN Dose-response thresholds for DEHP toxicities were determined from published data, as were the magnitudes of DEHP exposures resulting from neonatal contact with polyvinyl chloride (PVC) devices. Standard methods of risk assessment were used to determine safe levels of DEHP exposure in neonates, and hazard quotients were calculated for devices individually and in aggregate. RESULT Daily intake of DEHP for critically ill preterm infants can reach 16 mg/kg per day, which is on the order of 4000 and 160,000 times higher than desired to avoid reproductive and hepatic toxicities, respectively. The non-endocrine toxicities of DEHP are similar to complications experienced by preterm neonates. CONCLUSION DEHP exposures in neonatal intensive care are much higher than estimated safe limits, and might contribute to common early and chronic complications of prematurity. Concerns about phthalates should be expanded beyond endocrine disruption.
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Phthalate levels in cord blood are associated with preterm delivery and fetal growth parameters in Chinese women. PLoS One 2014; 9:e87430. [PMID: 24503621 PMCID: PMC3913614 DOI: 10.1371/journal.pone.0087430] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 12/20/2013] [Indexed: 01/01/2023] Open
Abstract
Data concerning the effects of phthalate exposure on preterm delivery and fetal growth are limited in humans. In this paper, we assessed the relationship between 15 phthalate levels in cord blood and preterm delivery and fetal growth parameters in 207 Chinese women going into labor. Exposure to phthalates except DCHP was associated with gestational age reduction and preterm delivery (p<0.05). There were associations between phthalates and fetal growth parameters, many of which disappeared when analyses were adjusted for gestational age, especially in male infants (Only DEEP was associated with birth weight; DEP, DNHP, BBP, DNP with abdominal circumference; DEP, DBP, DCHP, DEHP with femur length in female infants. And DPP, DBEP was associated with birth length in male infants. p<0.05). This study indicates that prenatal exposure to phthalates is associated with younger gestational age and preterm delivery. Also, phthalate exposure may adversely affect fetal growth parameters via gestational age reduction and preterm delivery with a significant gender effect.
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30
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Fischer CJ, Bickle Graz M, Muehlethaler V, Palmero D, Tolsa JF. Phthalates in the NICU: is it safe? J Paediatr Child Health 2013; 49:E413-9. [PMID: 23714420 DOI: 10.1111/jpc.12244] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2012] [Indexed: 11/30/2022]
Abstract
AIMS As growing concerns exist regarding phthalate exposure, which could be teratogenic, carcinogenic or induce reproductive toxicity, we aimed to review the evidence of the risks due to the use of medical devices containing di(2-ethylhexyl)phthalate in hospitalized neonates. METHODS We reviewed the literature, searching through medical literature databases (Pubmed, MEDLINE, EBM reviews, Cochrane database, Embase and Google Scholar) using the following keywords: phthalate, di(2-ethylhexyl)phthalate, newborn and neonate. RESULTS We identified several associations with short and long term health dangers, mainly subfertility, broncho-pulmonary dysplasia, necrotising enterocolitis, parenteral nutrition associated cholestasis and neuro-developmental disorders. These data are based mainly on animal or observational human studies. CONCLUSION Clinicians must be aware of the potential risks due to phthalate exposure in the NICU. Di(2-ethylhexyl)phthalate containing materials should be identified and alternative devices should be considered. There is a need to improve knowledge in this area.
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Affiliation(s)
- Céline J Fischer
- Clinic of Neonatology, Department of Paediatrics, University Hospital of Lausanne
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31
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Perspectives on alternatives to phthalate plasticized poly(vinyl chloride) in medical devices applications. Prog Polym Sci 2013. [DOI: 10.1016/j.progpolymsci.2013.03.001] [Citation(s) in RCA: 192] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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32
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Abstract
Intestinal failure-associated liver disease (IFALD), a serious complication occurring in infants, children, and adults exposed to long-term parenteral nutrition (PN), causes a wide-spectrum of disease, ranging from cholestasis and steatosis to fibrosis and eventually cirrhosis. Known host risk factors for IFALD include low birth weight, prematurity, short bowel syndrome, and recurrent sepsis. The literature suggests that components of PN may also play a part of the multifactorial pathophysiology. Because some intravenous lipid emulsions (ILEs) may contribute to inflammation and interfere with bile excretion, treatment with ILE minimization and/or ILEs composed primarily of omega-3 fatty acids can be helpful, but requires careful monitoring for growth failure and essential fatty acid deficiency (EFAD). Data from randomized controlled trials are awaited to support widespread use of these approaches. Other IFALD treatments include cycling PN, ursodeoxycholic acid, sepsis prevention, photoprotection, and polyvinylchloride-free tubing. Management and prevention of IFALD remains a clinical challenge.
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Affiliation(s)
- Bram P Raphael
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
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33
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Salvador A, Janeczko M, Porat R, Sekhon R, Moewes A, Schutzman D. Randomized controlled trial of early parenteral nutrition cycling to prevent cholestasis in very low birth weight infants. J Pediatr 2012; 161:229-33.e1. [PMID: 22424948 DOI: 10.1016/j.jpeds.2012.02.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 01/13/2012] [Accepted: 02/01/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare the incidence of cholestasis in very low birth weight infants receiving cycled versus continuous parenteral nutrition, and to determine factors that predispose to parenteral nutrition-associated cholestasis (PNAC). STUDY DESIGN Preterm infants weighing ≤ 1250 g (n = 70) at birth were randomly assigned within the first 5 postnatal days to either cycle (n = 34) or continuous (n = 36) parenteral nutrition. Liver function tests were obtained at baseline, and sequentially thereafter. Cholestasis was defined as direct bilirubin >2 mg/dL. Infants with major congenital anomalies, congenital hepatic disease, clinically apparent congenital viral infection, and those who required major abdominal surgery were excluded. RESULTS The incidence of PNAC was similar in the 2 groups (cycle 32% vs continuous 31%; P = 1.0). Bilirubin and transaminases were similar in both groups by repeated measures of ANOVA. Gestational age, birth weight, and Apgar scores were significantly lower, and Clinical Risk Index for Babies II scores were significantly higher in infants who developed PNAC. Using backward selection logistic regression, bronchopulmonary dysplasia, duration of parenteral nutrition, and days to full enteral nutrition emerged as factors independently associated with PNAC. CONCLUSIONS Early prophylactic parenteral nutrition cycling in very low birth weight infants in this study did not reduce cholestasis. Time to full feedings is a significant predictor for PNAC in very low birth weight infants. Preterm infants with bronchopulmonary dysplasia are more likely to have PNAC as a comorbidity. The Clinical Risk Index for Babies II score may help identify those preterm infants who might benefit from future prospective prevention trials.
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Affiliation(s)
- Agnes Salvador
- Division of Neonatology, Department of Pediatrics, Albert Einstein Medical Center, Philadelphia, PA, USA
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34
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Kambia N, Dine T, Gressier B, Luyckx M, Brunet C, Guimber D, Turck D, Gottrand F, Michaud L. Strong variability of di(2-ethylhexyl)phthalate (DEHP) plasmatic rate in infants and children undergoing 12-hour cyclic parenteral nutrition. JPEN J Parenter Enteral Nutr 2012; 37:229-35. [PMID: 22722103 DOI: 10.1177/0148607112450914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Medical devices such as perfusion materials in polyvinyl chloride may contain di(2-ethylhexyl)phthalate (DEHP). Several studies have questioned the harmlessness of phthalates, which have been shown to have toxic effects on the reproductive system and general development. This study was designed to assess DEHP exposure in infants and children benefitting from cyclic parenteral nutrition (PN). The results are compared with those obtained from children used as controls and receiving no PN, to estimate the potential risk to this pediatric population, taking into account exposure levels and already published data. METHODS Plasmatic concentrations of DEHP were assessed by high-performance liquid chromatography from blood samples taken from 22 children at the start and finish of a 12-hour cyclic PN period and compared with those obtained from 20 control children of comparable age and gender. RESULTS After a 12-hour cyclic PN period, DEHP migration varied widely among the patients. The concentrations were not quantifiable in 4 children at the start of PN. In 1 child, they were quantifiable neither at the start nor at the end of PN. However, for 17 children, DEHP concentrations were quantifiable at the start of PN and were very variable from one child to another. At the end, DEHP concentrations had significantly but variably increased in these children. No trace of DEHP was found in the blood samples from 20 healthy controls. CONCLUSION Considering published data on phthalate toxicity, it would appear advisable to encourage the use of medical devices that are either phthalate or DEHP free.
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Reducing hazardous chemical exposures in the neonatal intensive care unit: a new role for nurses. Crit Care Nurs Q 2012; 35:102-12. [PMID: 22157496 DOI: 10.1097/cnq.0b013e31823b2084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A wide range of toxic chemicals have been found in the umbilical cord blood of newborns, indicating the potential for health risks from chemical exposure that begin in utero. The neonatal intensive care unit (NICU) setting may also have potential chemical exposures that create health risks. Given the extreme vulnerability of this patient population, it is critical to minimize unnecessary hazardous chemicals. Neonatal intensive care unit nurses have an important role to play in making the NICU as safe as possible for their patients and themselves. This article will focus on the human health effects of several chemical exposures commonly found in the NICU for which nurses can help to eliminate or select safer alternatives: (1) diethylhexyl phthalates (a plasticizer commonly found in intravenous tubing/bags and other products); (2) bisphenol A (commonly found in the lining of baby formula cans); (3) personal care products used in the NICU; (4) cleaning, sterilants, and disinfectants; and (5) mercury. A tool for assessing environmental health risks will be presented and associated intervention options including purchasing policies; hospital-wide chemical policies; and development of institutional infrastructures, such as Green Teams, to address NICU and hospital-wide environmental health concerns. Nursing's evolving role in environmental health will be reviewed.
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36
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Rusyn I, Corton JC. Mechanistic considerations for human relevance of cancer hazard of di(2-ethylhexyl) phthalate. Mutat Res 2011; 750:141-158. [PMID: 22198209 DOI: 10.1016/j.mrrev.2011.12.004] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 12/06/2011] [Accepted: 12/12/2011] [Indexed: 12/28/2022]
Abstract
Di(2-ethylhexyl) phthalate (DEHP) is a peroxisome proliferator agent that is widely used as a plasticizer to soften polyvinylchloride plastics and non-polymers. Both occupational (e.g., by inhalation during its manufacture and use as a plasticizer of polyvinylchloride) and environmental (medical devices, contamination of food, or intake from air, water and soil) routes of exposure to DEHP are of concern for human health. There is sufficient evidence for carcinogenicity of DEHP in the liver in both rats and mice; however, there is little epidemiological evidence on possible associations between exposure to DEHP and liver cancer in humans. Data are available to suggest that liver is not the only target tissue for DEHP-associated toxicity and carcinogenicity in both humans and rodents. The debate regarding human relevance of the findings in rats or mice has been informed by studies on the mechanisms of carcinogenesis of the peroxisome proliferator class of chemicals, including DEHP. Important additional mechanistic information became available in the past decade, including, but not limited to, sub-acute, sub-chronic and chronic studies with DEHP in peroxisome proliferator-activated receptor (PPAR) α-null mice, as well as experiments utilizing several transgenic mouse lines. Activation of PPARα and the subsequent downstream events mediated by this transcription factor represent an important mechanism of action for DEHP in rats and mice. However, additional data from animal models and studies in humans exposed to DEHP from the environment suggest that multiple molecular signals and pathways in several cell types in the liver, rather than a single molecular event, contribute to the cancer in rats and mice. In addition, the toxic and carcinogenic effects of DEHP are not limited to liver. The International Agency for Research on Cancer working group concluded that the human relevance of the molecular events leading to cancer elicited by DEHP in several target tissues (e.g., liver and testis) in rats and mice can not be ruled out and DEHP was classified as possibly carcinogenic to humans (Group 2B).
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Affiliation(s)
- Ivan Rusyn
- Department of Environmental Sciences and Engineering, University of North Carolina, Chapel Hill, NC 27599-7431, USA.
| | - J Christopher Corton
- Integrated Systems Toxicology Division, National Health and Environmental Effects Research Laboratory, US Environmental Protection Agency, Research Triangle Park, NC 27711, USA
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37
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Bagel S, Dessaigne B, Bourdeaux D, Boyer A, Bouteloup C, Bazin JE, Chopineau J, Sautou V. Influence of Lipid Type on Bis (2-ethylhexyl)phthalate (DEHP) Leaching From Infusion Line Sets in Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2011; 35:770-5. [PMID: 21868720 DOI: 10.1177/0148607111414021] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sandrine Bagel
- CHU Clermont-Ferrand, Department of Pharmacy, G Montpied Hospital, Clermont-Ferrand, France
| | - Bérangère Dessaigne
- CHU Clermont-Ferrand, Department of Pharmacy, G Montpied Hospital, Clermont-Ferrand, France
| | - Daniel Bourdeaux
- CHU Clermont-Ferrand, Department of Pharmacy, G Montpied Hospital, Clermont-Ferrand, France
- Faculty of Pharmacy, Laboratory of Clinical Pharmacy and Biotechnics, University Clermont 1, Clermont-Ferrand, France
| | - Anne Boyer
- CHU Clermont-Ferrand, Department of Pharmacy, G Montpied Hospital, Clermont-Ferrand, France
- Faculty of Pharmacy, Laboratory of Clinical Pharmacy and Biotechnics, University Clermont 1, Clermont-Ferrand, France
| | - Corinne Bouteloup
- CHU Clermont-Ferrand, Department of Hepato-gastroenterology, Estaing Hospital, Clermont-Ferrand, France
| | - Jean-Etienne Bazin
- CHU Clermont-Ferrand, Surgical Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, Estaing Hospital, Clermont-Ferrand, France
| | - Jean Chopineau
- CHU Clermont-Ferrand, Department of Pharmacy, G Montpied Hospital, Clermont-Ferrand, France
- Faculty of Pharmacy, Laboratory of Clinical Pharmacy and Biotechnics, University Clermont 1, Clermont-Ferrand, France
| | - Valérie Sautou
- CHU Clermont-Ferrand, Department of Pharmacy, G Montpied Hospital, Clermont-Ferrand, France
- Faculty of Pharmacy, Laboratory of Clinical Pharmacy and Biotechnics, University Clermont 1, Clermont-Ferrand, France
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Van Vliet EDS, Reitano EM, Chhabra JS, Bergen GP, Whyatt RM. A review of alternatives to di (2-ethylhexyl) phthalate-containing medical devices in the neonatal intensive care unit. J Perinatol 2011; 31:551-60. [PMID: 21311501 PMCID: PMC3377474 DOI: 10.1038/jp.2010.208] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Revised: 11/28/2010] [Accepted: 12/03/2010] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To conduct an extensive literature and toxicological database review on substitute compounds and available alternative medical products to replace polyvinyl chloride (PVC) and/or di(2-ethylhexyl) phthalate (DEHP), and conduct a DEHP-medical inventory analysis at a large metropolitan neonatal intensive care unit (NICU). STUDY DESIGN A systematic search for DEHP-free alternative products was performed using online databases. An informal audit of a large metropolitan NICU was undertaken in 2005 and 2006; 21 products were identified that could potentially contain DEHP. Availability of DEHP-free alternatives was determined through company websites and phone interviews. RESULT Two alternative approaches are available for replacing DEHP in NICU medical products: (1) replacement by DEHP-free plasticizers; and (2) replacement of PVC entirely through the use of other polymers. Both approaches seem to provide less harmful substitutes to DEHP, but support PVC-free polymers as the preferred alternative. However, significant data gaps exist, particularly for the alternative polymers. In all, 10 out of 21 (48%) products in the NICU audit were DEHP-free; six consisted of alternative polymers and four of alternative plasticizers. Of the remaining 11 products, only three were available without DEHP at the time of the audit. CONCLUSION Because of significant data gaps, systematic toxicological testing of DEHP-free alternatives is imperative. Continued development of alternative products is also needed.
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Affiliation(s)
- E D S Van Vliet
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY 10032, USA.
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39
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The Prevention and Treatment of Intestinal Failure-associated Liver Disease in Neonates and Children. Surg Clin North Am 2011; 91:543-63. [PMID: 21621695 DOI: 10.1016/j.suc.2011.02.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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40
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Chiellini F, Ferri M, Latini G. Physical–chemical assessment of di-(2-ethylhexyl)-phthalate leakage from poly(vinyl chloride) endotracheal tubes after application in high risk newborns. Int J Pharm 2011; 409:57-61. [DOI: 10.1016/j.ijpharm.2011.02.024] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 02/14/2011] [Accepted: 02/17/2011] [Indexed: 10/18/2022]
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Bagel S, Décaudin B, Neuville S, Chopineau J, Odou P, Sautou V. Les phtalates dans les dispositifs médicaux destinés à la nutrition artificielle. NUTR CLIN METAB 2011. [DOI: 10.1016/j.nupar.2010.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Parenteral nutrition liver disease (PNLD) develops in 40-60% of infants who require long-term PN for intestinal failure. The clinical spectrum includes hepatic steatosis, cholestasis, cholelithiasis, and hepatic fibrosis. Progression to biliary cirrhosis and the development of portal hypertension and liver failure occurs in a minority who require combined liver and intestinal transplantation. The pathogenesis is multifactorial and is related to prematurity, low birth weight, duration of PN, short bowel syndrome requiring multiple laparotomies and recurrent sepsis. Other important mechanisms include lack of enteral feeding which leads to reduced gut hormone secretion, reduction of bile flow and biliary stasis which leads to the development of cholestasis, biliary sludge and gallstones, which exacerbate hepatic dysfunction, especially in premature neonates with immature hepatic function. The use of lipid emulsions, particularly soy bean emulsions have been associated with hepatic cholestasis in children, although there are little data now to support toxicity from other PN components. Management strategies for the prevention of parenteral nutrition liver disease include consideration of early enteral feeding, a multidisciplinary approach to the management of parenteral nutrition with a specialized nutritional care team and aseptic catheter techniques to reduce sepsis. The use of specialized lipid emulsions such as fish oil emulsions and or SMOF (Soy bean/Medium Chain Triglyceride/Olive Oil/Fish oil) improves established cholestasis and may prevent the onset. Oral administration of ursodeoxycholic acid may improve bile flow and reduce gall bladder stasis, although there is little data to suggest that prophylactic use prevents the onset of PNLD. Survival following either isolated small bowel or combined liver and small bowel transplantation is approximately 50% at 5 years making this an acceptable therapeutic option in children with irreversible liver and intestinal failure.
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Parenteral Nutrition–Associated Conjugated Hyperbilirubinemia in Hospitalized Infants. ACTA ACUST UNITED AC 2010; 110:1684-95. [DOI: 10.1016/j.jada.2010.08.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 07/08/2010] [Indexed: 11/23/2022]
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44
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Le HD, Fallon EM, de Meijer VE, Malkan AD, Puder M, Gura KM. Innovative parenteral and enteral nutrition therapy for intestinal failure. Semin Pediatr Surg 2010; 19:27-34. [PMID: 20123271 PMCID: PMC2819138 DOI: 10.1053/j.sempedsurg.2009.11.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Children with intestinal failure (IF) suffer from insufficient intestinal length or function, making them dependent on parenteral nutrition (PN) for growth and survival. PN and its components are associated with many complications ranging from simple electrolyte abnormalities to life-threatening PN-associated liver disease, which is also called intestinal failure-associated liver disease (IFALD). From a nutrition perspective, the ultimate goal is to provide adequate caloric requirements and make the transition from PN to full enteral nutrition (EN) successful. Upon review of the literature, we have summarized the most effective and innovative PN and EN therapies for this patient population. Antibiotic-coated catheters and antibiotic or ethanol locks can be implemented, as they appear effective in reducing catheter-related infection and thus further reduce the risk of IFALD. Lipid emulsions should be given judiciously. The use of an omega-3 fatty acid-based formulation should be considered in patients who develop IFALD. Trophic feeding is important for intestinal adaptation, and EN should be initiated early to help wean patients from PN. Long-term management of children with IF continues to be an emerging field. We have entered uncharted territory as more children survive complications of IF and IFALD. Careful monitoring and individualized management to ensure maintenance of growth while avoiding complications are the keys to successful patient outcomes.
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Affiliation(s)
- Hau D. Le
- Department of Surgery and the Vascular Biology Program, Children’s Hospital Boston, Boston, MA 02115
| | - Erica M. Fallon
- Department of Surgery and the Vascular Biology Program, Children’s Hospital Boston, Boston, MA 02115
| | - Vincent E. de Meijer
- Department of Surgery and the Vascular Biology Program, Children’s Hospital Boston, Boston, MA 02115
| | - Alpin D. Malkan
- Department of Surgery and the Vascular Biology Program, Children’s Hospital Boston, Boston, MA 02115
| | - Mark Puder
- Department of Surgery and the Vascular Biology Program, Children’s Hospital Boston, Boston, MA 02115
| | - Kathleen M. Gura
- Department of Pharmacy, Children’s Hospital Boston, Boston, MA 02115
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