Breastfeeding Grand Rounds - State University of New York · 1-800-222-2222. 3 Residential Exposure History ... Case Study. Chapter 5, Pages 95 to 143 in: Environmental Toxicology

Breastfeeding

Agenda

I. Welcome and Introduction Mary Applegate, M.D., M.P.H. New York State Department of Health II. Common Potential Environmental Judith S. Schreiber, Ph.D.

Contaminants in Breast Milk Toxicologist and Senior Public Health Scientist New York State Office of the Attorney General III. Risk-benefit Trade-off Between the Ruth A. Lawrence, M.D. Potential Risks Posed by University of Rochester Contaminants in Breast Milk and Benefits of Breastfeeding IV. Case Studies

Participant questions will follow each case study: Call: 1-888-313-4822 (toll free) or Fax: 518-629-8136

Major support for this program comes from the New York State Department of Health and the USDHHS Maternal and Child Health Bureau.

Presented by New York State Institute for Human Lactation Jointly sponsored by the New York State Department of Health and The School of Public Health, University at Albany, SUNY

Grand

Rounds

May 9, 2002 7:30 – 9:30 a.m.

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Breastfeeding Grand Rounds

May 9, 2002

Ruth A. Lawrence, M.D.

Judith Schreiber, Ph.D.

Mary Applegate, M.D., M.P.H.

Presented by

The New York State Institute for Human Lactation

Part of the

Women’s Health Grand Rounds Series

2

Jointly sponsored by

New York State Department of Health

The School of Public Health, University at Albany, State University of New York

Today’s Topics:

Common potential environmental contaminants in breast milk

Heavy metal contaminants in breast milk and the risk to the breastfeeding infant

Free copies:

Breastfeeding: First Step to Good Health

NYS DOH Bureau of Community Relations

(518) 474-5370)

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Common Potential Environmental Contaminants

in Breast Milk

Judith S. Schreiber, Ph.D.Senior Public Health ScientistNew York State Office of the

Attorney General

Chemicals in Breastmilkvs. the Benefits of Breastfeeding• Benefits of breast milk

compelling • Chemical levels in breast milk

generally low• Risks of formula feeding well

documented

Ask Mothers About Potential Exposures• Complete medical history and

clinical evaluation• Health and exposure history

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Occupational Exposure History• Any of job you think relates to

your concern about breast milk? • What is current job title?• What type of industry or

business?• What year did you begin working

this job?

Occupational Exposure History• Briefly describe job duties – any

health hazards• How many hours work in average

week?• Any protective equipment such as

a mask respirator, gloves, etc.?

Occupational Exposure History• What potential chemical

exposure? (fumes and dusts, metals, solvents pesticides, resins, formaldehyde and glues)

• Are there Material Safety Data Sheets (MSDSs)?

• National Poison Control: 1-800-222-2222

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Residential Exposure History• Others in household with job

involving chemicals or other exposure?

• Industries or hazardous waste sites in the area?

Residential Exposure History• Anyone with hobbies using

chemicals? (ex: stained glass, model building, painting)

• Anyone in the household smoke?

• Is home likely to have lead paint or lead dust?

Dermal & Dietary Exposure History• Does mother eat fish from

lakes or rivers with high levels of environmental contaminants?

• Does mother have pica for certain materials such as paint chips, soil?

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Dermal & Dietary Exposure History• Dermal exposures that may be

of concern?(cleaning products, pesticides, solvents, gasoline) Pica for certain materials such as paint chips, soil?

Avoid or Reduce Exposure • Reduce use of cleaning

products with solvents • Reduce or eliminate pesticides

– wash produce, buy organic produce

Avoid or Reduce Exposure • Use personal protective

equipment• Temporarily move to job with

less exposure

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To ensure breast milk is best, reduce exposure to chemicals in workplace and at home.

ReferencesJ. Schreiber, 2001. Parents worried about breast milk contamination: What is best for baby? Pediatric Clinics of North America.48(5):1113-1127

J. Schreiber, 1997. Transport of Organic Chemicals to Breastmilk: Tetrachloroethene Case Study. Chapter 5, Pages 95 to 143 in: Environmental Toxicology and Pharmacology of Human Development, Taylor and Francis, Washington, DC, Kacew and G. Lambert, editors

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Heavy Metal Contaminants in Heavy Metal Contaminants in Breastmilk Breastmilk and the Risk to the and the Risk to the

Breastfeeding InfantBreastfeeding Infant

Ruth A. Lawrence, MDProfessor of Pediatrics, Obstetrics and Gynecology

University of Rochester School of Medicine & DentistryRochester, NY

I. I. Heavy Metals

II. II. Well Water

III . III . The Work Place

IssuesIssues

•• LeadLead•• MercuryMercury•• CadmiumCadmium•• ArsenicArsenic

Heavy MetalsHeavy Metals

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• Data supports neuro-developmental deficits with long-term exposure to the child

• Most secure data involves lead exposure

• Little has been done on other heavy metals

Heavy MetalsHeavy Metals

•• Lead mobilization from Lead mobilization from maternal skeleton during maternal skeleton during pregnancy pregnancy

•• Lactation is one of the Lactation is one of the greatest problems of lead greatest problems of lead toxicitytoxicityCord blood : maternal blood 0.993-1.002

LeadLead

Namihira D. J Tox Environ Hlth, 1993.

Lead in Blood & Human MilkLead in Blood & Human Milk

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Lead in ChildrenLead in Children•• Action determined by blood level Action determined by blood level

-- less than 10less than 10 µgµg//dLdL: considered nontoxic, no action required.-- 1010--1414 µgµg//dLdL : repeat screening, educate parents-- 1515--1919 µgµg//dLdL : repeat screening, and if elevated, identify and abate the source

Lead in ChildrenLead in Children•• Action determined by blood level Action determined by blood level

-- 2020--4444 µgµg//dLdL : identify & abate source, perform complete medical evaluation; consider DMSA chelation-- 4545--6969 µgµg//dLdL : identify & abate source, perform medical evaluation,chelate with oral DMSA-- 70 70 µgµg//dLdL or higheror higher : immediately perform medical evaluation

• Lead poisoning from Indian herbal vitamin

• Developmentally delayed patient given herbal vitamin from India to strengthen his brain

• Tablet contained large amounts of lead and mercury, leading to significant lead burden

Pediatrics 2000; 106:600-602

Herbal Vitamins : Lead Herbal Vitamins : Lead ToxicityToxicity

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““Mad Hatters” DiseaseMad Hatters” Disease

MercuryMercury

lThermometerslThermostatslBarometerslWork clothes from

industrial exposurelFolk medicines and

ceremonies

Mercury Sources in Home: Mercury Sources in Home: Elemental & InorganicElemental & Inorganic

l Only 14% of dental O.R.’s exceed threshold– Threshold limit values 0.1

mg/m3

l Dentist’s mean urinary mercury levels 14.2 µg/L (levels at which early symptoms appear 100 µg/L)

Dental ExposuresDental Exposures

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lOnly total and inorganic blood levels are elevatedlNo effect on pregnancy in

dental workers (highest concentration of Hg in placenta, a barrier role)

Dental ExposuresDental Exposures

l Due to mercuric oxide from medications and teething compounds

l Seen in children, not newborns or adults

l Painful extremitiesl Pink, puffy, painful, parasthetic,

perspiring and peeling

Acrodynia Acrodynia (Pink (Pink Disease)Disease)

lWomen in child bearing years should not be exposed to Mercury vapors in concentrations greater than 10 µg/m3l In workplace, fetal exposure

can result in neurological problems

MercuryMercury

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Summary of Absorption and Toxicity of Summary of Absorption and Toxicity of Mercury CompoundsMercury Compounds

Absorption Absorption ToxicityToxicityOral Inhalation Oral Inhalation Neurologic Neurologic RenalRenalFormForm

Elemental (metallic) Elemental (metallic) mercurymercury

Hg° liquidHg° liquid Poor NA* Rare RarePoor NA* Rare Rare

Hg° vapor NA* Good LikHg° vapor NA* Good Likely Possibleely Possible

Inorganic mercuric Inorganic mercuric saltssalts

Hg Hg 2+ 2+ Good RareGood Rare Rare Likely Rare Likely but possiblebut possible

Organic (alkyl) Organic (alkyl) mercurymercury

RHgRHg++ Good RareGood Rare Likely PossibleLikely Possiblebut possiblebut possible

*NA = Not applicableChart taken from Poisoning and Drug Overdose; Olson,RK

lFish advisories for New York State are also available for mercury and cadmiumlEat NO MORENO MORE than one

meal a month

MercuryMercury

lNervous System

lRenal System

lFetus

Methyl Mercury EffectsMethyl Mercury Effects

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Long term studies Long term studies underway in Seychelles underway in Seychelles and and Faroe Faroe Islands where Islands where there are low levels of there are low levels of Methyl Mercury in ocean Methyl Mercury in ocean fishfish

l The more breastfeeding the more developmentally advanced they are

Seychelles Children Seychelles Children and Breastfeedingand Breastfeeding

Folk medicine and Folk medicine and ceremonial events often ceremonial events often involve Mercury involve Mercury predominantly in predominantly in inorganic forms that inorganic forms that vaporizevaporize

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lA heavy metal associated with– Industrial exposures– Contaminated shellfish and some

other fish– Drinking acidic beverages from

certain vessels– Contaminated materials: rice,

cigarettes, soil

CadmiumCadmium

l Yellow teeth linel Renal insufficiencyl Vertigol FatiguelOsteopenia – Osteomalacia

Chronic CadmiumChronic Cadmium

l Normal population : 0.4 to 1.0 0.4 to 1.0 µµg/Lg/L

l Smokers: 1.4 to 4.0 1.4 to 4.0 µµg/Lg/L

l Occupationally exposed:

10 to 100 10 to 100 µµg/Lg/L

Blood LevelsBlood Levels

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l Does cross the placenta

l Probably crosses into breast milk

Perinatal Perinatal RiskRisk

lWhere is it? – Fish lCod, Haddock

– Shellfish– Industry– Intentional ingestion

ArsenicArsenic

llAresnobetaine Aresnobetaine & & Arsenocholine Arsenocholine forms found forms found in foodin foodllRapidly cleared in urine : Rapidly cleared in urine :

excreted in 1 excreted in 1 -- 2 days2 daysllHalf life of organic arsenic : Half life of organic arsenic :

4 4 –– 6 hours6 hours

ArsenicArsenic

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ll Inorganic arsenic crosses Inorganic arsenic crosses placentaplacentallNo data on breast milkNo data on breast milkllRare problem except in Rare problem except in

chronic exposure or acute chronic exposure or acute overdoseoverdose

ArsenicArsenic

Summary of Absorption and Toxicity of Summary of Absorption and Toxicity of Mercury CompoundsMercury Compounds

Absorption Absorption ToxicityToxicityOral Inhalation Oral Inhalation Neurologic Neurologic RenalRenalFormForm

Elemental (metallic) Elemental (metallic) mercurymercury

Hg° liquidHg° liquid Poor NA* Rare RarePoor NA* Rare Rare

Hg° vapor NA* Good LikHg° vapor NA* Good Likely Possibleely Possible

Inorganic mercuric Inorganic mercuric saltssalts

Hg Hg 2+ 2+ Good RareGood Rare Rare Likely Rare Likely but possiblebut possible

Organic (alkyl) Organic (alkyl) mercurymercury

RHgRHg++ Good RareGood Rare Likely PossibleLikely Possiblebut possiblebut possible

*NA = Not applicableChart taken from Poisoning and Drug Overdose; Olson,RK

• Disinfection by products (DBP’s)

• Lead

• Arsenic, cadmium

• Mercury

• Nitrates

• Synthetic organic chemicals / pesticides

Drinking Water: Chemical Drinking Water: Chemical Contaminants of Greatest Contaminants of Greatest ConcernConcern

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• Surface Water - rivers, streams, lakes

• Groundwater

• Distribution system contaminated with sewage

How Does Drinking Water: How Does Drinking Water: Get ContaminatedGet Contaminated

Waterborne Disease Outbreaks Associated with Drinking Water, by Type of Water Source (1997-1998)

Spring5.9%

Surface Water11.8%

Well and Spring11.8%

Well70.5%

Spring5.9%

Surface Water11.8%

Well and Spring11.8%

Well70.5%

Adapted from CDC MMMWR, May 26, 2000

Summary of Known Benefits Summary of Known Benefits to the Infant and Mother From to the Infant and Mother From Constituents in Breast MilkConstituents in Breast Milk

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Nutritional benefits for Nutritional benefits for human brain growth, human brain growth, especially from especially from cholesterol , DHA, and cholesterol , DHA, and taurine in breast milktaurine in breast milk

Improved efficiency of Improved efficiency of digestion and absorption digestion and absorption because of the greater because of the greater bioavailability of essential bioavailability of essential nutrients in breast milk nutrients in breast milk compared to infant formulacompared to infant formula

Psychological and cognitive Psychological and cognitive benefits, including more rapid benefits, including more rapid improvement in visual acuity, improvement in visual acuity, detectable improvements in detectable improvements in educational achievement, and educational achievement, and improved progressions on improved progressions on developmental scalesdevelopmental scales

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Protection against Protection against infections of the upper infections of the upper and lower respiratory and lower respiratory system and inner ear, system and inner ear, due to the presence of due to the presence of living cells and living cells and macrophagesmacrophages

Protection against Protection against ulcerative colitis, ulcerative colitis, bacteremia, bacterial bacteremia, bacterial meningitis, urinary tract meningitis, urinary tract infections, and infections, and necrotizing enterocolitisnecrotizing enterocolitis

Protection against the Protection against the development of allergic development of allergic diseases, childhood diseases, childhood leukemia, lymphoma, leukemia, lymphoma, celiac disease and celiac disease and Crohn’s DiseaseCrohn’s Disease

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The psychological bond The psychological bond created by breastfeedingcreated by breastfeeding

Known Benefits of Known Benefits of Breastfeeding for the MotherBreastfeeding for the Motherl Improved post partum

recoverylPsychological benefits,

including a feeling of empowerment and the development of a strong human bond between mother and infant

Known Benefits of Known Benefits of Breastfeeding for the MotherBreastfeeding for the MotherlDecreased risk of

osteoporosislReduced risk incidence of

pre-menopausal breast cancer and ovarian cancerlReduced risk of pregnancy

initiated long term obesity

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Risk : BenefitRisk : Benefit

RISKRISK

BENEFITBENEFIT

Pollutants In Breast MilkPollutants In Breast MilkBreast-feeding is recommended despite the presence of chemical residues. The prenatal period in the child and the initiation of lactation in the mother may be sensitive periods to the toxicity of the chemicals that are considered here, and the potential for poisoning at higher levels is clear. However, in the vast majority of women, the benefits of breastfeeding appear to outweigh the risks, and those who advise women about infant nutrition should continue to support breastfeeding.

Rogan, Arch Pediat Adolesc Med 1996

•• BreastfeedingBreastfeeding is the most precious is the most precious gift a mother can give to her infantgift a mother can give to her infant

•• When there isWhen there is malnutrition and malnutrition and illnessillness, it may be a lifesaving gift, it may be a lifesaving gift

•• When there isWhen there is povertypoverty, it may be the , it may be the only giftonly gift

RA Lawrence, 1992

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Case Study 1• 34 y.o. health care professional • had her first child last month• Baby exclusively breastfed• Family heirloom crib – c100 yrs. Old;

play to refinish• Advice about crib?

• 22 y.o. Caribbean American migrant worker

• Travels Eastern seaboard doing seasonal farm work

• 2-month-old baby - exclusively breastfed since birth

• Baby carried by mother in sling during day

• Plans to hand express milk when child care available

Case Study 2

• 25 y.o. breastfeeding mother with a 6-month old infant

• Dropped and broke mercury thermometer

• Concerns about cleanup, continuing breastfeeding

Case Study 3

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• 28 y.o. Native American woman in upstate New York

• Fish caught in local waters an important source of food

• Stopped eating fish 3 years ago before birth of first child

• Second child due in 1 month• Plans to breastfeed to lose weight

(currently 200 lbs., 130 lbs. before first pregnancy)

Case Study 4

• 38 y.o. mother• 11-month-old infant - breastfeeding plus

variety of solid foods• Dentist recommended mother replace

old amalgam fillings with porcelain

Case Study 5

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Free copies:

Breastfeeding: First Step to Good Health

NYS DOH Bureau of Community Relations

(518) 474-5370)

Thanks to

Ruth A. Lawrence, M.D.University of Rochester

Judith Schreiber, Ph.D.NYS Attorney General’s Office

Mary Applegate, M.D., M.P.H.Bureau of Women’s Health, NYS Department of

Health

2

Major support for this program comes from the New York State Department of Health and the U.S. Department of Health and Human Services, Child Health Bureau.

has been presented by

The New York State Institute for Human Lactation

Breastfeeding Grand RoundsMay 9, 2002

Jointly sponsored by New York State Department of

Health

The School of Public Health, University at Albany, State University of New York

3

Part of the

Women’s Health Grand Rounds Series

For additional information, contact:Continuing Education and Professional DevelopmentSchool of Public HealthUniversity at Albany, SUNYOne University PlaceRensselaer, NY 12144-3456

518-402-0330www.Albany.edu/sph/coned