Educating Pediatric Residents About Parenting: A Survey of Residency Program Leaders.

The American Academic of Pediatrics guides pediatricians to counsel parents about how to promote their children's cognitive, emotional, and self-regulatory development, but the extent to which pediatricians receive the training needed to do so is unknown. An online survey was distributed to members of the Association of Pediatric Program Directors. Although most respondents agreed that it was "very important" to educate residents about parenting skills, only 11% rated their program as doing so "very well." The most frequently reported reason for not doing very well was lack of a curriculum. Residents currently learn about parenting most commonly in continuity clinic talks, are educated via lectures, and are taught most frequently by clinic preceptors. Nearly half of the respondents reported that their residents relied on self-learning about parenting behaviors. When asked which topics respondents would like covered by an evidence-based parenting curriculum, the most commonly endorsed topic was positive discipline.

Building Capacity in Pediatric Environmental Health: The Academic Pediatric Association's Professional Development Program.

BACKGROUND: Environmental exposures contribute to multiple diseases in children; yet, few pediatricians have training in pediatric environmental health (PEH), and few academic health centers have PEH expertise. To build national capacity in PEH, the Academic Pediatric Association (APA) launched a professional development program that since 2002 has encouraged the establishment of post-residency/post-doctoral training programs, supported a special interest group, and convened an annual mentored retreat for PEH trainees. OBJECTIVE: Describe the APA's professional development program in PEH and assess its impact by tracking careers of former trainees. METHODS: Careers were tracked through interviews with trainees and program directors supplemented by searches of institutional websites. Publication listings were obtained through PubMed. Publication impact was assessed using bibliometric and altmetric measures. Grant histories were accessed through the National Institutes of Health RePORTER project. Information on advocacy work was obtained through interviews with program directors. RESULTS: Fifty-five trainees (36 physicians and 19 health scientists) completed PEH training and attended the APA retreat between 2002 and 2017. Forty-one (75%) are pursuing academic careers, 11 are associate or full professors, 11 are practicing general pediatrics or a pediatric subspecialty, 2 are Centers for Disease Control and Prevention epidemiologists, and 1 is a data scientist. Forty-two former trainees (76%) listed "environment" or "environmental" in their job titles or on their websites. Former trainees have published 632 scientific papers. These papers have been cited 3094times, have a relative citation ratio of 2.97, and have been read or viewed 1,274,388times. Twenty-one former trainees have been awarded 43 National Institutes of Health grants. Trainees have developed education and advocacy skills by teaching medical students and residents, presenting grand rounds, preparing policy papers, presenting legislative testimony, and making presentations to public audiences. CONCLUSIONS: The APA's professional development program has contributed to the expansion of national capacity in PEH. Former trainees are populating the field, generating new knowledge, and moving into leadership positions.

Building New York State Centers of Excellence in Children's Environmental Health: A Replicable Model in a Time of Uncertainty.

Public health programs may be seriously affected in periods of federal retrenchment. During these times, state-based strategies provide an alternate pathway for advancing public health.A 12-year campaign to secure state support for a network of Centers of Excellence in Children's Environmental Health (CEH) promoting health of children across New York State is described. It was driven by rising rates of asthma, birth defects, developmental disorders, and other noncommunicable diseases in children; growing evidence associating hazardous environmental exposures with these conditions; and recognition that federal resources in CEH are insufficient.Critical campaign elements were (1) formation of a statewide coalition of academic health centers, health care providers, public health officials, community advocates, and other stakeholders; (2) bipartisan collaborations with legislative champions and government leaders; (3) assessment of the burden of developmental disorders and noncommunicable diseases associated with environmental exposures among children; (4) maps documenting the presence of environmental hazards in every county statewide; (5) iterative charting of a changing political landscape; and (6) persistence. The 2017 award of a 5-year, $10 million contract to establish Centers of Excellence in CEH demonstrates the value of this statewide strategy.

Improving pediatrician knowledge about environmental triggers of asthma.

BACKGROUND: Control of environmental triggers (ETs) greatly improves asthma outcomes in children. Disseminating these findings to general pediatricians has not been well established. METHODS: After delivering a structured and standardized presentation on ET identification and control to pediatricians, we surveyed them about knowledge and practices of ET assessment and management. We analyzed matched responses for pre/post and 3- to 6-month follow-up using McNemar's χ(2) test. RESULTS: Matched data were available for 367 participants, and 3- to 6-month follow-up data were available for 83. There was a significant posttraining increase in intention to ask about ETs and recommend ET management. After 3 to 6 months, all responses remained significantly higher than baseline, except "likely to refer to an asthma specialist." CONCLUSION: Pediatricians reported a significant improvement in knowledge about ETs of asthma and a willingness to incorporate exposure history questions and remediation recommendations in their routine practice.

Organic foods: health and environmental advantages and disadvantages.

The US market for organic foods has grown from $3.5 billion in 1996 to $28.6 billion in 2010, according to the Organic Trade Association. Organic products are now sold in specialty stores and conventional supermarkets. Organic products contain numerous marketing claims and terms, only some of which are standardized and regulated. In terms of health advantages, organic diets have been convincingly demonstrated to expose consumers to fewer pesticides associated with human disease. Organic farming has been demonstrated to have less environmental impact than conventional approaches. However, current evidence does not support any meaningful nutritional benefits or deficits from eating organic compared with conventionally grown foods, and there are no well-powered human studies that directly demonstrate health benefits or disease protection as a result of consuming an organic diet. Studies also have not demonstrated any detrimental or disease-promoting effects from an organic diet. Although organic foods regularly command a significant price premium, well-designed farming studies demonstrate that costs can be competitive and yields comparable to those of conventional farming techniques. Pediatricians should incorporate this evidence when discussing the health and environmental impact of organic foods and organic farming while continuing to encourage all patients and their families to attain optimal nutrition and dietary variety consistent with the US Department of Agriculture's MyPlate recommendations. This clinical report reviews the health and environmental issues related to organic food production and consumption. It defines the term "organic," reviews organic food-labeling standards, describes organic and conventional farming practices, and explores the cost and environmental implications of organic production techniques. It examines the evidence available on nutritional quality and production contaminants in conventionally produced and organic foods. Finally, this report provides guidance for pediatricians to assist them in advising their patients regarding organic and conventionally produced food choices.

Environmental exposures and puberty in inner-city girls.

BACKGROUND: Hormonally active environmental exposures are suspected to alter onset of puberty in girls, but research on this question has been very limited. OBJECTIVE: We investigated pubertal status in relation to hormonally active environmental exposures among a multiethnic group of 192 healthy 9-year-old girls residing in New York City. METHODS: Information was collected on breast and pubic hair stages, weight and height. Phytoestrogen intake was estimated from a food-frequency questionnaire. Three phytoestrogens and bis-phenolA (BPA) were measured in urine. In a subset, 1,1'-dichloro-2,2'-bis(4-chlorophenyl)ethylene (DDE), polychlorinated biphenyls (PCBs) were measured in blood plasma and lead (Pb) in blood. Associations of exposures with pubertal stages (present=stage 2+ vs absent=stage 1) were examined using t-tests and Poisson multivariate regression to derive prevalence ratios (PR, 95%-confidence limits [CI]). RESULTS: Breast development was present in 53% of girls. DDE, Pb, and dietary intakes of phytoestrogens were not significantly associated with breast stage. Urinary phytoestrogen biomarker concentrations were lower among girls with breast development compared with no development. In multivariate models, main effects were strongest for two urinary isoflavones, daidzein (PR 0.89 [0.83-0.96] per ln microg/g creatinine) and genistein (0.94 [0.88-1.01]). Body mass index (BMI) is a hormonally relevant, strong risk factor for breast development. Therefore, BMI-modification of exposure effects was examined, and associations became stronger. Delayed breast development was observed among girls with below-median BMI and third tertile (high exposure) of urinary daidzein (PR 0.46 [0.26-0.78]); a similar effect was seen with genistein, comparing to girls >or= median BMI and lowest two tertiles (combined) of these isoflavones. With urinary enterolactone a phytoestrogen effect was seen only among girls with high BMI, where breast development was delayed among those with high urinary enterolactone (PR 0.55 [0.32-0.96] for the upper tertile vs lower two combined). There was no main effect of PCBs on breast stage, but girls with below-median BMI and >or= median PCB levels had reduced risk for breast development (any vs none) compared with other BMI-PCB groups. No biomarkers were associated with hair development, which was present in 31% of girls. CONCLUSIONS: Phytoestrogens and PCBs are environmental exposures that may delay breast development, especially in conjunction with BMI, which governs the endogenous hormonal milieu. Further research to confirm these findings may improve our understanding of the role of early life development in breast cancer risk and other chronic diseases related to obesity.

Impact of September 11 World Trade Center disaster on children and pregnant women.

BACKGROUND: Children are uniquely sensitive to toxic exposures in the environment. This sensitivity reflects children's disproportionately heavy exposures coupled with the biologic vulnerability that is a consequence of their passage through the complex transitions of early development. METHODS AND RESULTS: To assess effects on children's health associated with the attacks on the World Trade Center (WTC) of September 11, 2001, research teams at the Mount Sinai School of Medicine and other academic health centers in New York City launched a series of clinical and epidemiologic studies. Mount Sinai investigators undertook a prospective analysis of pregnancy outcomes in 182 women who were pregnant on September 11, 2001, and who had been either inside or within 0.5 miles of the WTC at the time of the attacks; they found a doubling in incidence of intrauterine growth retardation (IUGR) among infants born to exposed mothers as compared to infants born to unexposed women in northern Manhattan. A Columbia research team examined pregnancy outcomes in 329 women who lived, worked or gave birth in lower Manhattan in the 9 months after September 11; they found that these women gave birth to infants with significantly lower birth weight and shorter length than women living at greater distances from Ground Zero. NYU investigators documented increased numbers of new asthma cases and aggravations of preexisting asthma in children living in lower Manhattan. Mount Sinai mental health researchers documented a significant increase in mental health problems in children who directly witnessed the attacks and subsequent traumatic events; these problems were most severe in children with a past history of psychological trauma. The New York City Department of Health and Mental Hygiene established a WTC Registry that has enrolled over 70,000 persons of all ages in lower Manhattan and will follow the health of these populations to document on a continuing basis the health consequences of September 11.

The ambulatory pediatric association fellowship in pediatric environmental health: a 5-year assessment.

BACKGROUND: Evidence is mounting that environmental exposures contribute to causation of disease in children. Yet few pediatricians are trained to diagnose, treat, or prevent disease of environmental origin. OBJECTIVES: To develop a cadre of future leaders in pediatric environmental health (PEH), the Ambulatory Pediatric Association (APA) launched a new 3-year fellowship in 2001-the world's first formal training program in PEH. Sites were established at Boston Children's Hospital, Mount Sinai School of Medicine, George Washington University, University of Cincinnati, and University of Washington. Fellows are trained in epidemiology, biostatistics, toxicology, risk assessment, and preventive medicine. They gain clinical experience in environmental pediatrics and mentored training in clinical research, policy development, and evidence-based advocacy. Thirteen fellows have graduated. Two sites have secured follow-on federal funding to enable them to continue PEH training. DISCUSSION: To assess objectively the program's success in preparing fellows for leadership careers in PEH, we conducted a mailed survey in 2006 with follow-up in 2007. CONCLUSIONS: Fifteen (88%) of 17 fellows and graduates participated; program directors provided information on the remaining two. Nine graduates are pursuing full-time academic careers, and two have leadership positions in governmental and environmental organizations. Ten have published one or more first-authored papers. Seven graduates are principal investigators on federal or foundation grants. The strongest predictors of academic success are remaining affiliated with the fellowship training site and devoting < 20% of fellowship time to clinical practice. CONCLUSION: The APA fellowship program is proving successful in preparing pediatricians for leadership careers in PEH.

Grand rounds: nephrotoxicity in a young child exposed to uranium from contaminated well water.

CONTEXT: Private wells that tap groundwater are largely exempt from federal drinking-water regulations, and in most states well water is not subject to much of the mandatory testing required of public water systems. Families that rely on private wells are thus at risk of exposure to a variety of unmeasured contaminants. CASE PRESENTATION: A family of seven--two adults and five children--residing in rural northwestern Connecticut discovered elevated concentrations of uranium in their drinking water, with levels measured at 866 and 1,160 microg/L, values well above the U.S. Environmental Protection Agency maximum contaminant level for uranium in public water supplies of 30 microg/L. The uranium was of natural origin, and the source of exposure was found to be a 500-foot well that tapped groundwater from the Brookfield Gneiss, a geologic formation known to contain uranium. Other nearby wells also had elevated uranium, arsenic, and radon levels, though concentrations varied widely. At least one 24-hr urine uranium level was elevated (> 1 microg/24 hr) in six of seven family members (range, 1.1-2.5 microg/24 hr). To assess possible renal injury, we measured urinary beta-2-microglobulin. Levels were elevated (> 120 microg/L) in five of seven family members, but after correction for creatine excretion, the beta-2-microglobulin excretion rate remained elevated (> 40 microg/mmol creatinine) only in the youngest child, a 3-year-old with a corrected level of 90 microg/mmol creatinine. Three months after cessation of well water consumption, this child's corrected beta-2-microglobulin level had fallen to 52 microg/mmol creatinine. SIGNIFICANCE: This case underscores the hazards of consuming groundwater from private wells. It documents the potential for significant residential exposure to naturally occurring uranium in well water. It highlights the special sensitivity of young children to residential environmental exposures, a reflection of the large amount of time they spend in their homes, the developmental immaturity of their kidneys and other organ systems, and the large volume of water they consume relative to body mass.

Effective risk communication in children's environmental health: lessons learned from 9/11.

In situations with visible threats to children's health, pediatric health care providers must be prepared to communicate the health risks of environmental exposures. Several factors influence the effectiveness of such discussions: whether the individual providing the information is considered a reliable source, the familiarity of the physician and parent/guardian with these issues, and the limited research specifically assessing risk of exposure in childhood. This article describes the theory behind effective risk communication using examples from events following September 11, 2001. It shares lessons learned and provides a template for risk communication that can guide pediatric providers.

The environment in pediatric practice: a study of New York pediatricians' attitudes, beliefs, and practices towards children's environmental health.

Chronic diseases of environmental origin are a significant and increasing public health problem among the children of New York State, yet few resources exist to address this growing burden. To assess New York State pediatricians self-perceived competency in dealing with common environmental exposures and diseases of environmental origin in children, we assessed their attitudes and beliefs about the role of the environment in children's health. A four-page survey was sent to 1,500 randomly selected members of the New York State American Academy of Pediatrics in February 2004. We obtained a 20.3% response rate after one follow-up mailing; respondents and nonrespondents did not differ in years of licensure or county of residence. Respondents agreed that the role of environment in children's health is significant (mean 4.44 +/- 0.72 on 1-5 Likert scale). They voiced high self-efficacy in dealing with lead exposure (mean 4.16-4.24 +/- 0.90-1.05), but their confidence in their skills for addressing pesticides, mercury and mold was much lower (means 2.51-3.21 +/- 0.90-1.23; p < 0.001). About 93.8% would send patients to a clinic "where pediatricians could refer patients for clinical evaluation and treatment of their environmental health concerns." These findings indicate that New York pediatricians agree that children are suffering preventable illnesses of environmental origin but feel ill-equipped to educate families about common exposures. Significant demand exists for specialized centers of excellence that can evaluate environmental health concerns, and for educational opportunities.

Characteristics of pubertal development in a multi-ethnic population of nine-year-old girls.

PURPOSE: Early age at menarche increases future disease risk. Secular decline in age at menarche has been attributed to body size characteristics, diet, and energy expenditure. Risk factors for puberty have been less frequently explored. METHODS: A cross-sectional study of 186 New York Metropolitan Area, 9-year-old girls (54 African-American, 70 Hispanic, 62 Caucasians) used interviewer-administered questionnaires to assess exposures. Height and weight were measured. Pediatricians assessed pubertal development according to Tanner stages. RESULTS: African-Americans were more likely than Caucasians to have achieved puberty as determined by breast or hair development (stage 2 or higher) [age-adjusted odds ratios and 95% confidence intervals = 4.91 (2.15-11.19) and 4.25 (1.85-9.77), respectively]. Pubertal development was similar among Hispanics and Caucasians. Adiposity and height were significantly positively associated with breast or hair development. More sedentary activity hours non-significantly increased the likelihood of hair development. Lower energy, but higher polyunsaturated fat, consumption were suggestive of an association with breast development. Vitamin C and hair development were inversely related. No other nutrients or physical activity measures were related to pubertal development. CONCLUSIONS: Results are consistent with height and adiposity being associated with pubertal development. Sedentary activity or diet might possibly influence maturation.