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blood samples, and they estimated early childhood exposure by analyzing levels of PAH metabolites in urine. The researchers used the Childhood Behavioral Checklist and the Conners' Parent Rating Scale- Revised to determine levels of ADHD behavior problems. "Children born to mothers who were exposed to high levels of PAH during preg- nancy had fi ve times the odds of having an increased number of symptoms and a higher degree of symptoms that characterize ADHD — specifi cally, inattentive type — than children born to mothers with lower PAH exposure," Perera says. "Our fi ndings support the need for policies to further reduce the levels of combustion-related airborne pollutants. Clinicians can also provide information to pregnant women about reducing exposure to PAHs in the home. We are continuing to follow our cohort through adolescence to understand the potential long-term consequences of exposure to PAHs early in life." One of Perera's collaborators, Deliang Tang, MD, MS, DrPH, Associate Professor of Environmental Health Sciences at the Columbia University Mailman School of Public Health, agrees that both policymak- ers and clinicians have a role to play in protecting children from PAH exposure. "Airborne pollution doesn't belong to one country or region; it travels," Dr. Tang says. "We're making efforts, based on studies I've conducted into PAH exposure in China, to bring this issue to the attention of the Chinese government and alert them to the signifi cant impact PAHs have on their own population, as well as to their country's contribution to worldwide pollution." According to Dr. Tang, obstetricians' advice to prospective mothers about reduc- ing PAH exposure should include quitting smoking, limiting time around secondhand smoke and charcoal-burning grills, and, for urban residents, avoiding outdoor running or walking in the morning, when pollution from vehicle emissions is trapped lower to the ground by warm air. Obstetric Obstacles Obstetricians face a quandary, however: They are best positioned to discuss risks of exposure to toxic environmental agents, such as PAHs, with pregnant women, but many lack the knowledge to do so. That is one of the fi ndings of a study led by Naomi E. Stotland, MD, Associate P rof e s s or i n t he D e p a r t ment of Obstetrics, Gynecology and Reproductive Sciences at the University of California San Francisco and San Francisco General Hospital, and published in PLOS One in 2014. Dr. Stotland's team sent a survey to all obstetrician members of The American Congress of Obstetricians and Gynecologists and conducted focus groups with obstetricians in the San Francisco Bay Area in an effort to gauge attitudes toward environmental expo- sures counseling. "Almost 80 percent of respondents agreed they could reduce toxic exposures among patients through counseling, but half said they rarely took an environ- mental health history, and fewer than 20 percent said they routinely asked women about common environmental exposures," Dr. Stotland says. "Only one in 15 respondents reported having received some training on the issue." The study revealed that high-income pregnant women were more concerned about environmental exposures and inquired about them more often than lower-income women, who, despite having higher risks for exposure, were more concerned about other pregnancy- related issues. Their obstetricians, therefore, felt obliged to discuss the issues of highest priority to their patients, at the expense of environmental expo- sures counseling. "Obstetricians described discussing environmental exposures with patients as like opening Pandora's box — they did not feel equipped to dea l with anticipated questions and the anxiety they might create by addressing the topic," Dr. Stotland says. "Some of the barriers we uncovered can be addressed with improved education and training, but it is also important to press for policy changes that will lead to an overall re du c t ion of t ox ic c hem ic a l s i n the environment." ■ It is impossible for prospective mothers to avoid every toxin: Many consumer products, from tableware to wallpaper, may contain potentially harmful chemicals, such as bisphenol A, phthalates and formaldehyde. Exposure can also occur by inhalation of airborne toxins, such as trichloroethylene and methylene chloride. A Link between PAHs and ADHD Another harmful airborne toxin is polycy- clic aromatic hydrocarbons (PAHs), which enter the air as byproducts of combustive activities, such as driving vehicles, grilling, heating homes by burning oil and using coal to generate power. A group of Columbia University researchers led by Frederica P. Perera, DrPH, PhD, Professor of Public Health and Director of the Columbia Center for Children's Environmental Health in the Department of Environmental Health Sciences at the Columbia University Mailman School of Public Health, has docu- mented the hazards of prenatal exposure to PAHs. Perera and her colleagues have studied the effects of PAH exposure on a group of New York City mothers and children since 1998, beginning with the prenatal period. "That is a particularly susceptible time to PAH exposure because of the extensive and rapid structural and cellular-level changes that occur," Perera says. "High concentra- tions of PAHs are found in urban areas due to the increased number of sources. We have found that prenatal exposure to PAHs is associated with adverse birth outcomes, developmental delays, reduced intelligence quotient, diverse behavior problems and childhood obesity." In a recent study in the journal PLOS One, Perera and her team identifi ed an association between early-childhood PAH exposure and development of attention defi cit hyperactivity disorder (ADHD) behavioral problems in childhood. The researchers followed their cohort — 233 nonsmoking pregnant women and their children — from the prenatal period to the children's ninth birthdays. The team estimated levels of prenatal PAH exposure by measuring PAH-DNA adducts obtained from maternal blood and cord SPECIAL CLINICAL SECTION: WOMEN'S HEALTH M D N E W S . CO M ■ MD NEWS Long Island | 2 3

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