The National Children's Study: a critical national investment.Patterns of disease in American children have changed dramatically in the past 200 years. Acquired immunodeficiency syndrome acquired immunodeficiency syndrome, see AIDS. (AIDS), severe acute respiratory syndrome Severe Acute Respiratory Syndrome (SARS) Definition
Severe acute respiratory syndrome (SARS) is the first emergent and highly transmissible viral disease to appear during the twenty-first century. (SARS), and tuberculosis notwithstanding, vaccines, antibiotics, and improved hygiene have controlled the classic infectious diseases. Infant mortality has decreased by 90%. Life expectancy has nearly doubled.
Yet amid this success a new challenge has arisen. Chronic diseases have increased sharply in incidence and have become the leading causes of childhood illness:
* Asthma incidence and mortality have more than doubled [Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (CDC See Control Data, century date change and Back Orifice.
CDC - Control Data Corporation ) 1995a, 1995b].
* Despite declining mortality, incidence of acute lymphocytic leukemia acute lymphocytic leukemia
See acute lymphoblastic leukemia.
acute lymphocytic leukemia Acute lymphoblastic leukemia, ALL A malignant lymphoproliferative process that commonly affects children and young adults increased by 61.7% from 1973 to 1999 (Robison et al. 1995).
* Incidence of primary brain cancer increased by 39.6% from 1973 to 1994 (Schechter 1999).
* Birth defects of the male reproductive system, such as hypospadias hypospadias /hy·po·spa·di·as/ (-spa´de-is) a developmental anomaly in which the urethra opens inferior to its normal location; usually seen in males, with the opening on the underside of the penis or on the perineum. , doubled in frequency from 1970 to 1993 (Paulozzi et al. 1997).
* Neurodevelopmental disorders--including learning disabilities, dyslexia, mental retardation, attention deficit disorder attention deficit (hyperactivity) disorder (ADD or ADHD)
Behavioral syndrome in children, whose major symptoms are inattention and distractibility, restlessness, inability to sit still, and difficulty concentrating on one thing for any , and autism--are highly prevalent and affect 5-10% of the 4 million babies born in the United States each year (Bertrand et al. 2001; CDC 2004a, 2004b; LeFever et al. 1999; Safer et al. 1996; Zito et al. 2000).
* Prevalence of childhood obesity has trebled (Galvez et al. 2003).
* Incidence rates of chronic neurodegenerative diseases of late life such as Parkinson disease and dementia and of certain cancers have increased markedly, raising the possibility of early-life antecedents (Coty-Slechta et al., unpublished data).
Although much remains to be learned about the causes of these trends, evidence is accumulating that environmental factors make important contributions.
* Airborne fine particulates have been shown to cause asthma and to trigger asthmatic atttacks (Salam et al. 2004).
* Ozone, oxides of nitrogen, environmental tobacco smoke environmental tobacco smoke (ETS/passive smoke),
n the gaseous by-product of burning tobacco products, including but not limited to commercially manufactured cigarettes and cigars; contains toxic elements harmful to the health of adults and children , and indoor air pollutants all are now recognized triggers for asthma (Suh et al. 2000; Wallace et al. 2003).
* Childhood cancer has long been linked to ionizing radiation. More recently, benzene, 1,3-butadiene, and pesticides have been etiologically associated (Daniels et al. 2001; Lee et al. 2004).
* Neurobehavioral impairment has been observed following exposure of the fetal brain to even low levels of lead (Baghurst et al. 1987; Canfield et al. 2003; Dietrich et al. 1987; Lanphear et al. 2000; Opler et al. 2004; Wasserman et al. 2000), methyl mercury (Grandjean et al. 1997, 2004; Kjellstrom et al. 1986, 1989; Murata et al. 2004; National Research Council 2000), pesticides (Berkowitz et al. 2004; Perera et al. 2003), polychlorinated biphenyls (Jacobson and Jacobson 1996), and ethanol (Lupton et al. 2004). A recent National Academy of Sciences study (2000) suggests that at least 28% of developmental disabilities in children are caused by environmental factors acting alone or in concert with genetic susceptibility.
Until now, progress in elucidating the role of the environment in chronic childhood disease has been slow and incremental. Nearly all studies have examined relatively small populations of children; have considered only one chemical toxicant toxicant /tox·i·cant/ (tok´si-kant)
1. A poison or poisonous agent.
2. An intoxicant.
adj. at a time; have had little statistical power to examine interactions among chemical, social, and behavioral factors in the environment; have had limited ability to examine gene-environment interactions (Olden 2004); and have suffered from brief duration of follow-up. Also, many previous studies have been retrospective in design and thus have been forced to estimate past exposures from limited and sometimes biased historical data.
To overcome these difficulties, the President's Task Force on Environmental Health and Safety Risks to Children recommended in 1998 (U.S. Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Health and Human Services, HHS 2004) that a large prospective epidemiologic study of American children be undertaken. In response, the U.S. Congress through the Children's Health Act The Children's Health Act of 2000 (Public Law 106-310 Sec. 1004) is a legislative measure, passed by the United States Congress which directs federal agencies to undertake a national, long-term study of children's health and development in relation to environmental exposures, of 2000 authorized the National Institute of Child Health and Human Development (NICHD NICHD National Institute of Child Health and Human Development. ) "to conduct a national longitudinal study of environmental influences (including physical, chemical, biological and psychosocial) on children's health and development" (Children's Health Act 2000). The National Institute of Environmental Health Sciences The National Institute of Environmental Health Sciences (NIEHS) is one of 27 Institutes and Centers of the National Institutes of Health (NIH),which is a component of the Department of Health and Human Services (DHHS). The Director of the NIEHS is Dr. David A. Schwartz. (NIEHS NIEHS National Institute of Environmental Health Sciences (NIH, DHHS) ), the CDC, and the U.S. Environmental Protection Agency Environmental Protection Agency (EPA), independent agency of the U.S. government, with headquarters in Washington, D.C. It was established in 1970 to reduce and control air and water pollution, noise pollution, and radiation and to ensure the safe handling and (EPA EPA eicosapentaenoic acid.
n.pr See acid, eicosapentaenoic.
n. ) join the NICHD in planning and conducting this study.
Key features of this far-reaching study--now termed the National Children's Study The National Children’s Study (NCS) will examine the effects of environmental influences on the health and development of more than 100,000 children across the United States, following them from before birth until age 21. (NCS (Network Call Signaling) CableLabs version of MGCP. See MGCP/MEGACO.
NCS - Network Computing System: Apollo's RPC system used by DEC and Hewlett-Packard.The protocol has been adopted by OSF. )--are that it will follow a representative sample of 100,000 American children from early pregnancy through age 21; a subset maybe recruited before conception. Exposure histories and biologic samples will be obtained during pregnancy and from children as they grow, obviating the need for retrospective assessments of exposures. The large sample size will facilitate simultaneous examination of the effects of multiple chemical exposures, of interactions among them, and of interactions among biologic, chemical, behavioral, and social factors. Each child will be screened genetically, thus permitting study of gene-environment interactions. Follow-up will extend over decades. For the past four years, working groups convened by NICHD have been developing the NCS: formulating core hypotheses, delineating research protocols, and planning logistics. The study is now ready for the field.
Previous major prospective epidemiologic studies have yielded invaluable gains in knowledge of disease causation and have provided critical tools for prevention and treatment. The Framingham Heart Study The Framingham Heart Study is a cardiovascular study based in Framingham, Massachusetts. The study began in 1948 with 5,209 adult subjects from Framingham, and is now on its third generation of participants. (Framingham, MA), for example, was established in 1948 at a time when heart disease and stroke were epidemic in the United States. The goal was to identify preventable risk factors. Within a few years, data from Framingham identified cigarette smoking (Dawber 1960) and elevated cholesterol and hypertension as preventable causes of cardiovascular disease (CVD CVD Cardiovascular disease, see there ) (Kannel et al. 1961, 1978); later analyses elucidated the role of elevated triglycerides, sedentary lifestyle, and diabetes. This information provided the blueprint for the major reductions in incidence of CVD that we have achieved in the United States over the past four decades (CDC 1999).
We anticipate that the NCS will yield equally enormous societal benefits. Six of the chronic diseases that the study plans to examine--obesity, injury, asthma, diabetes, schizophrenia, and autism--cost America $642 billion per year (Bromet and Fennig 1999; CDC 2004a, 2004b, 2004c, 2004d, 2004e, 2004f, 2004g; National Alliance for Autism Research The National Alliance for Autism Research (NAAR), based in Princeton, New Jersey, was a non-profit advocacy organization, founded by parents of children with autism concerned about the limited funding available for research. 2002; U.S. Department of Health and Human Services 2001; Weiss 2001; Yeargin-Allsop et al. 2002). If the NCS were to produce a reduction of only 1% in incidence of these diseases, the annual savings would amount to $6.4 billion, far more than the $2.7 billion price tag of the study over 25 years.
Despite the enormous potential of the NCS, its funding is in critical jeopardy. In each of the past 4 years, the annual budget has been $12 million, a sum provided by contributions from the NICHD, the NIEHS, the CDC, and the U.S. EPA. But now to move the study forward, there is need in 2005 to establish a data-coordinating center, a repository for secure storage of biologic samples, and a series of regionally distributed vanguard recruitment sites. For these tasks, NICHD needs $15 million in new dollars above their regular budget. Without at least $27 million in federal funding in 2005, NICHD will likely be forced to cancel or at least postpone the study.
The NCS has benefited from strong and bipartisan leadership in Congress and from the support of a broad-based coalition that includes the American Academy of Pediatrics The American Academy of Pediatrics ("AAP") is an organization of pediatricians, physicians trained to deal with the medical care of infants, children, and adolescents. Its motto is: "Dedicated to the Health of All Children. , the U.S. Conference of Catholic Bishops, the American Chemistry Council The American Chemistry Council (ACC), formerly known as the Chemical Manufacturers' Association, is an industry trade association for American chemical companies.
The American Chemistry Council (ACC) is in charge of improving the public image of the chemical industry. , the Learning Disabilities Association, and the March of Dimes
The NCS represents an extraordinary opportunity. If the study receives the funding that it needs in 2005, it will begin as early as 2009 to produce data that will save children's lives and improve their health. The NCS is a national investment in the future that for the sake of our children we must make today.
Baghurst PA, Robertson EF, McMichael AJ, Vimpani GV, Wigg NR, Roberts RR. 1987. The Port Pirie Cohort Study: lead effects on pregnancy outcome and early childhood development. Neurotoxicology 8(3):395-401.
Berkowitz GS, Wetmur JG, Birman-Deych E, Obel J, Lapinski, RH, Godbold JH, et al. 2004. In utero pesticide exposure, maternal paraoxonase activity, and head circumference. Environ Health Perspect 112:388-391.
Bertrand J, Mars A, Boyle C, Bove E, Yeargin-Allsopp M, Decoufle P. 2001. Prevalence of autism in a United States population: the Brick Township, New Jersey Brick Township is a Township in Ocean County, New Jersey, United States. As of the United States 2000 Census, the township had a total population of 76,119, making it the second most populous municipality in Ocean County behind Toms River Township. , investigation. Pediatrics 108(5):1155-1161.
Bromet El, Fennig S. 1999. Epidemiology and natural history of schizophrenia. Biol Psychiatry 46(7):871-881.
Canfield RL, Henderson CR Jr, Cory-Slechta DA, Cox C, Jusko TA, Lanphear BP. 2003. Intellectual impairment in children with blood lead concentrations below 10 microg per deciliter deciliter /dec·i·li·ter/ (dL) (des´i-le?ter) one tenth (10minus;1) of a liter; 100 milliliters.
100 cubic centimeters (cc).
Mentioned in: Hypercholesterolemia . N Engl J Med 348(16):1517-1526.
CDC. 1995a. Children at risk from ozone air pollution, 1991-1993. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg, Morb Mortal Wkly Rep 44:309-312.
CDC. 1995b. Asthma--United States, 1982-1992. MMWR Morb Mortal Wkly Rep 43:952-955.
CDC. 1999. Achievements in public health, 1900-1999: decline in deaths from heart disease and stroke--United States, 1900-1999. MMWR Morb Mortal Wkly Rep 48(30):649-656.
CDC. 2004a. Developmental Disabilities. Available: http://www.cdc.gov/ncbddd/dd/default.htm [Accessed 21 June 2004].
CDC. 2004b. Economic costs associated with mental retardation, cerebral palsy, hearing loss, and vision impairment--United States 2003. MMWR Morb Mortal Wkly Rep 53(03):57-59.
CDC. 2004c. National Asthma Control Program. Available: http://www.cdc.gov/nceh/airpollution/asthma/asthmaAAG.htm [Accessed 30 August 2004].
CDC. 2004d. National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States. Available: http://www.cdc.gov/diabetes/pubs/factsheet.htm [Accessed 30 August 2004].
CDC. 2004e. National Center for Injury Prevention and Control. Injuries among Children and Adolescents. Available: http://www.cdc.gov/ncipc/factsheets/children.htm [Accessed 30 August 2004].
CDC. 2004f. Cost of Injury in the United States: A Report to Congress. Available: http://www.cdc.gov/ncipc/pub-res/cost_of_injury/ch2-3.pdf [Accessed 13 September 2004].
CDC. 2004g. National Center for Health Statistics National Center for Health Statistics (NCHS) is part of the Centers for Disease Control and Prevention (CDC), which is part of the United States Department of Health and Human Services.
NCHS is the United States' principal health statistics agency. . Asthma Prevalence, Health Care Use and Mortality, 2000-2001. Available: http://www.cdc.gov/nchs/products/pubs/pubd/ hestats/asthma/asthma.htm [Accessed 30 August 2004]. Children's Health Act of 2000. 2000. Public Law 106-310.
Daniels JL, Olshan AF, Teschke K, Hertz-Picciotto I, Savitz DA, Blatt J, et al. 2001. Residential pesticide exposure and neuroblastoma Neuroblastoma Definition
Neuroblastoma is a type of cancer that usually originates either in the tissues of the adrenal gland or in the ganglia of the abdomen or in the ganglia of the nervous system. . Epidemiology 12(1):20-27.
Dawber TR. 1960. Summary of recent literature regarding cigarette smoking and coronary heart disease coronary heart disease: see coronary artery disease.
coronary heart disease
or ischemic heart disease
Progressive reduction of blood supply to the heart muscle due to narrowing or blocking of a coronary artery (see atherosclerosis). . Circulation 22:164-66.
Dietrich KN, Krafft KM, Bornschein RL, Hammond PB, Berger O, Succop PA, et al. 1987. Low-level fetal lead exposure effect on neurobehavioral development in early infancy. Pediatrics 80(5):721-730.
Grandjean P, Murata K, Budtz-Jorgensen E, Weihe P. 2004. Cardiac autonomic activity in methylmercury neurotoxicity neurotoxicity /neu·ro·tox·ic·i·ty/ (noor?o-tok-sis´it-e) the quality of exerting a destructive or poisonous effect upon nerve tissue. : 14-year follow-up of a Faroese birth cohort. J Pediatr 144(2):169-176.
Grandjean P, Weihe P, White RF, Debes F, Araki S, Yokoyama K, 1997. Cognitive deficit in 7-year-old children with prenatal exposure to methylmercury. Neurotoxicol Teratol 19(6):417-428.
Galvez MP, Frieden TR, Landrigan PJ. 2003. Obesity in the 21st century. Environ Health Perspect 111:A684-A685.
Jacobsen JL, Jacobsen SW. 1996. Intellectual impairment in children exposed to polychlorinated biphenyls in utero. N Engl J Med 335:783-789.
Kannel WB, Dawber TR, Kagan A, Revotskie N, Stokes JI. 1961. Factors of risk in the development of coronary heart disease--six year follow-up experience; the Framingham Study. Ann Intern Mad 55:33-50.
Kannel WB, Wolf PA, Dawber TR. 1978. Hypertension and cardiac impairments increase stroke risk. Geriatrics 33:71-83.
Kjellstrom T, Kennedy P, Wallis S, Mantall C. 1986. Physical and Mental Development of Children With Prenatal Exposure to Mercury From Fish. Stage I: Preliminary Tests at Age 4. Report 3080. Solna, Sweden:National Swedish Environmental Protection Board.
Kjellstrom T, Kennedy P, Wallis S, Stewart A, Friberg L, Lind B, et al. 1989. Physical and Mental Development of Children With Prenatal Exposure to Mercury From Fish. Stage II: Interviews and Psychological Tests at Age 6. Report 3642. Solna, Sweden:National Swedish Environmental Protection Board.
Lanphear BP, Dietrich K, Auinger P, Cox C. 2000. Cognitive deficits associated with blood lead concentrations < 10 microg/dL in US children and adolescents. Public Health Rep 115(6):521-529.
Lee WJ, Cantor KP, Berzofsky JA, Zahm SH, Blair A. 2004. Non-Hodgkin's lymphoma among asthmatics exposed to pesticides. Int J Cancer 111(2):298-302.
LeFever GB, Dawson KV, Morrow AL. 1999. The extent of drug therapy for attention deficit-hyperactivity disorder attention deficit-hyperactivity disorder Attention deficit disorder Psychiatry An inability to control behavior due to difficulty in processing neural stimuli, resulting in ↑ motor activity, ↓ attention span Epidemiology ADHD is the most common among children in public schools. Am J Public Health 89:1359-1364.
Lupton C, Burd L, Harwood R. 2004. Cost of fetal alcohol spectrum disorders. Am J Med Genet 127C(1):42-50.
Murata K, Weihe P, Budtz-Jorgensen E, Jorgensen PJ, Grandjean P. 2004. Delayed brainstem auditory evoked potential An auditory evoked potential is a type of evoked potential which can be used to trace the signal generated by a sound, from the cochlear nerve, through the lateral lemniscus, to the medial geniculate nucleus, and to the cortex. latencies in 14-year-old children exposed to methylmercury. J Pediatr 144(2):177-183.
National Academy of Sciences, Committee on Developmental Toxicology. 2000. Scientific Frontiers in Developmental Toxicology and Risk Assessment. Washington, DC:National Academies Press.
National Alliance for Autism Research. 2002. What is Autism? Available: http://www.naar.org/aboutaut/whatis.htm [Accessed 30 August 2004].
National Research Council. 2000. Toxicological Effects of Methylmercury. Washington, DC: National Academies Press.
Olden K. 2004. Genomics in environmental health research--opportunities and challenges. Toxicology 198(1-3):19-24.
Opler MG, Brown AS, Graziano J, Desai M, Zheng W, Schaefer C, et al. 2004. Prenatal lead exposure, [delta]-aminolevulinic acid, and schizophrenia. Environ Health Perspect 112:548-552.
Paulozzi LJ, Erickson JD, Jackson RJ. 1997. Hypospadias trends in two US surveillance systems. Pediatrics 100(5):831-834.
Perera FP, Rauh V, Tsai WY, Kinney P, Camann D, Barr D, et al. 2003. Effects of transplacental transplacental /trans·pla·cen·tal/ (-plah-sen´tal) through the placenta.
Relating to or involving passage through or across the placenta. exposure to environmental pollutants on birth outcomes in a multiethnic population. Environ Health Perspect 111:201-206.
Robison LL, Buckley JD, Bunin G. 1995. Assessment of environmental and genetic factors in the etiology of childhood cancers: the Childrens Cancer Group epidemiology program. Environ Health Perspect 103(suppl 6):111-116.
Safer DJ, Zito JM, Fine EM. 1996. Increased methylphenidate methylphenidate /meth·yl·phen·i·date/ (meth?il-fen´i-dat) a central stimulant, used in the form of the hydrochloride salt in the treatment of attention-deficit in children and narcolepsy. usage for attention deficit disorder in the 1990s. Pediatrics 98:1084-1088.
Salam MT, Li YF, Langholz B, Gilliland FD, Children's Health Study. 2004. Early-life environmental risk factors for asthma: findings from the Children's Health Study. Lancet 363(9403):119-125.
Schechter CB. 1999. Re: Brain and other central nervous system cancers: recent trends in incidence and mortality. J Natl Cancer Inst 91:2050-2051.
Suh HH, Bahadori T, Vallarino J, Spengler JD. 2000. Criteria air pollutants and toxic air pollutants. Environ Health Perspect 108(suppl 4):625-633.
U.S. Department of Health and Human Services. The President's Task Force on Environmental Health Risks and Safety Risks to Children. Available: http://nationalchildrensstudy.gov/about/task_force.cfm [Accessed 13 September 2004].
U.S. Department of Health and Human Services. Public Health Service, Office of the Surgeon General. 2001. The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity. Available: http://www.surgeongeneral.gov/topics/obesity/calltoaction/ CalltoAction.pdf [Accessed 30 August 2004].
Wallace LA, Mitchell H, O'Connor GT, Neas L, Lippmann M, Kattan M, et al. 2003. Particle concentrations in inner-city homes of children with asthma: the effect of smoking, cooking, and outdoor pollution. Environ Health Perspect 111:1265-1272.
Wasserman GA, Liu X, Popovac D, Factor-Litvak P, Kline J, Waternaux C, et al. 2000. The Yugoslavia Prospective Lead Study: contributions of prenatal and postnatal lead exposure to early intelligence. Neurotoxicol Teratol 22(6):811-818.
Weiss KB, Sullivan SD. 2001. The health economics of asthma and rhinitis Rhinitis Definition
Rhinitis is inflammation of the mucous lining of the nose.
Rhinitis is a nonspecific term that covers infections, allergies, and other disorders whose common feature is the location of their symptoms. . I. Assessing the economic impact. J Allergy Clin Immunol 107:3-8.
Yeargin-Allsopp M, Rice C, Karapurkar T, Doernberg N, Boyle C, Schendel D. 2002. Prevalance of autism in a US metropolitan city. JAMA JAMA
Journal of the American Medical Association 289(1):49-55.
Zito JM, Safer DJ, dosReis S, Gardner JF, Boles M, Lynch F. 2000. Trends in the prescribing of psychotropic medications to preschoolers. JAMA 283:1025-1030.
Center for Children's Health and the Environment, Department of
Community and Preventive Medicine, New York, NY
Philip J. Landrigan
Center for Children's Health and the Environment, Department of
Community and Preventive Medicine, New York, NY
Leonardo Trasande is assistant director of the Center for Children's Health and the Environment, and an instructor in Community and Preventive Medicine and in Pediatrics at the Mount Sinai School of Medicine
Mount Sinai School of Medicine is a medical school found in the borough of Manhattan in New York City. . He also holds a lectureship lec·ture·ship
1. The status or position of a lecturer.
2. An endowment or foundation supporting a series or course of lectures.
[Alteration of lecturership. in Pediatrics at Harvard Medical School Harvard Medical School (HMS) is one of the graduate schools of Harvard University. It is a prestigious American medical school located in the Longwood Medical Area of the Mission Hill neighborhood of Boston, Massachusetts. .
Philip J. Landrigan is the Ethel H. Wise Professor and chair of the Department of Community and Preventive Medicine, and director of the Center for Children's Health and the Environment at the Mount Sinai School of Medicine.