The Chief Complainant: History of the complaint
The case study involves a two-year-old, overweight boy who has been brought to the hospital to undergo a medical check-up because the boy has undescended testicles. According to the boy’s mother, the boy has been doing well for the last year. During her last visit to the hospital (one year ago), she was informed that this condition usually outgrows and corrects itself. However, the boy’s mother is worried because she is not sure whether her son’s condition is curable. Apparently, the boy has got no other complaints. The main concern is his undescended testicles.
The General Past Medical History (Developmental, dietary and immunization)
The boy’s medical history is remarkable following his preterm birth at 28 weeks by normal spontaneous vaginal delivery. The boy was admitted to the neonatal intensive care unit for some time and one month in the special care nursery unit. During his two weeks stay in the care units, the boy was fed through tubes in his veins and mouth. After that, the boy was fed on soy formula and he was never breastfed. The boy feeds normally and is not allergic to anything. His immunization is also up to date.
Family and Social History (includes occupational and environmental exposures)
The boy’s mother received intravenous fluids on several occasions during her pregnancy. Several relatives from the mothers’ side have breast cancer. The boy’s father has leukemia, diabetes and hypertension. In addition, the boy’s elder brother is healthy with no reported disorders. The boy’s mother had several miscarriages. The mother works as a beautician. Furthermore, the boy’s parents smoke. The family has used DET-based repellants on several occasions. Moreover, the boy’s family lives close to a highway in an urban setting.
Diagnosis and Treatment Plan
This condition does not have diagnostic laboratory tests at the moment. Physical examination indicates that the boy’s scrota are empty. Pertinent diagnoses for this boy are bilateral undescended testicles and hypospadias. The treatment of undescended testicles after the first year of life involves surgically fixing the testis in the scrotum. Hormonal injections can also be used to stimulate the movement of the testicle into the scrotum. On the other hand, hypospadias does not require treatment.
Discussion
Testicular digenesis syndrome was first observed in rodents following exposure to phthalates. This was characterized by fetal death, reduced anal genital distance, malfunctioned epididymis, reduced spermatogenesis and testicular cancers. The boy’s disorder can be attributed to endocrine disruption by phthalates, in particular DEHP. Newborn infants may be exposed to phthalates through medical devices or procedures. This can occur when infants are given treatment using PVC devices. The boy spent some time in the neonatal intensive care unit and one month in the special care nursery unit. During his two weeks stay in the care units, the boy was fed through tubes in his veins and mouth. These are possible causes of the boy’s exposure to phthalates. The boy’s mother also received intravenous fluids on several occasions while she was pregnant. This might be another cause of exposure. In addition, other types of endocrine disruptors to which the boy was exposed include antiandrogenic compounds found in pesticides used in the house and cadmium found in cigarette smoke and smoke produced by vehicles.
Why Phthalates is a Problem
The definition of phthalates
According to the U.S Environmental Protection Agency (EPA 2006, p. 1), “phthalates are a group of chemicals used as plasticizers which provide flexibility and durability to plastics such as polyvinyl chloride”. Phthalates are ester derivatives of 1, 2- benzenedicarboxylic acid. These substances appear as clear liquids in their pure state. A number of them have sweet odors and some of them appear in the form of a faint yellow color. Phthalates are incorporated in a number of applications. Phthalates are used in building materials clothing, cosmetics, perfumes food packaging and toys. They are also found in a number of vinyl products including flooring, shower curtains and raincoats. On top of that, phthalates are used in the manufacture of medical applications such as blood transfusion bags and tubing, intravenous’s bags and tubing and other numerous medical devices.
Pathological aspects of phthalates
Phthalates often disrupt the endocrine system of the body. Increased incidences of developmental abnormalities such as the cleft palate and skeleton malfunctions have been attributed to the pathological aspects of phthalates. In addition, increased fetal deaths in experimental animal studies have been proven to be a result of the pathological effects of phthalates. Researchers have identified the developing male reproductive system to be the most vulnerable system in humans. Studies have proven that exposure of immature male reproductive systems to phthalates leads to undescended, decreased testes weight and decreased testes, and decreased anal genital distance. A recent study conducted in Sweden indicated slow sperm motility in men who had high urine concentrations of phthalate metabolite MEP and polychlorinated biphenyls. Another study has proven that increased concentrations of butyl benzyl phthalate lead to an increase in the cases of rhinitis and eczema in children. The effects of phthalates on the reproductive e system have been extensively researched using experimental rats. Most of these studies have shown that phthalates significantly affect the reproductive system of both male and female rats. In addition, studies in rats have indicated that phthalates have carcinogenic effects. These findings from experimental studies indicate the potential health risks posed by phthalates. Furthermore, various studies have proven that increased concentrations of di 2-ethylihxyl phthalate in house dusts lead to elevated cases of asthma in children. Other studies have attributed poor development in young girls due to an exposure to phthalate metabolites. These studies also pointed out that the exposure of some infants to di 2-ethylihxyl phthalate (DEHP) found in medical devises led to reduced bile flow and unusual lung disorders in the affected subjects.
Mode of exposure
Various studies have illustrated different ways through which humans might be exposed to phthalates metabolites. Children and infants “are usually exposed to phthalates metabolites through food sources and mouthing of plastic toys and use of plastic-eating containers” (EPA 2006, p. 2). According to a study conducted in Denmark, almost all analyzed samples of baby food contained DEHP and other phthalates in varying concentrations. Phthalate residues were also found in plastic bags and gloves used in the packaging of infant food. Studies have indicated that phthalate metabolites like DEHP and diisonylphthalate can be extracted from toy food and plastic bags in a solution that mimics saliva (Dart 2004). In addition, phthalate metabolites may also be found in dust that has accumulated in homes. Significant concentrations of phthalate metabolites have been found in the blood and urine of expectant women, newborns and children, and in the milk of lactating mothers. On the other hand, newborn infants may be exposed to phthalates through medical devices or procedures (Dart 2004). This often occurs when infants are given treatment using PVC devices. Medical procedures that have been linked to phthalate exposure include “intravenous tubing, extracorporeal membrane oxygenation (ECMO), mechanical ventilation and intravenous, parenteral feeding with nutrients” (Dart 2004, p.34).
Measures taken to address the Problem
The U.S EPA has narrowed down its protection policies on eight phthalates. They include “dibutyl phthalate (DBP), diisobutyl phthalate (DIBP), butyl benzyl phthalate (BBP), di-n-pentyl phthalate (DnPP), di 2-ethylihxyl phthalate (DEHP), di-n-octyl phthalate (DnOP), diisonylphthalate (DNP), and diisodecyl phthalate (DIDP)” (EPA 2006, p. 1). EPA has indicated that close to 47 million pounds of phthalate are produced per year. EPA has been prompted to develop actions plans that address the environmental and human health risks posed by phthalates. The approach is based on a number of guidelines. They include their presence in humans, persistent and toxic, and bioaccumulation features. These guides also include exposure to consumer products and the production volumes. The action plan is based on the use, potential hazard, and exposure information available with regard to the eight readily known phthalates (NRC 2008).
Thus, other alternative plasticizers have been proposed. EPA encourages the use of citrate-based plasticizers, phosphate esters, trioctylmellitate, non-phthalate substitutes in flooring like dipropylene glycol benzoate. Other alternatives include sebacate and azelate esters, isosorbide esters, and other organic esters such as diethyl succinate and isobutyrate trimethylpentanediol. Furthermore, low molecular weight polymeric esters plasticizers derived from polymeric multifunctional alcohols, adipic and sebacic or glutaric acid can be used. Studies have indicated that isosorbide esters can be prepared under solvent-free conditions and thus provide an environmentally friendly approach to manufacturing. EPA is in the process of designing regulations that will regulate the use of phthalates. The agency is also seeking to comply with some legal clauses that will enhance its management of phthalates. The agency is also assessing the risk posed by these substances in children and other subpopulations. The agency argues “the assessment will add to the existing knowledge, and it will consider exposure to all human populations and environmental exposure” (EPA 2006, p. 3).
In addition, the federal government continues to study and regulate phthalates. Government agencies other than EPA involved in these practices include the consumer products safety commission (CPSC), food and drug administration (FDA) (NRC 2008). The current information available on phthalates is enough to necessitate the formulation of policies that regulate the use of these substances. On top of that, a number of foreign agencies devised various strategies that aim at curbing the use of phthalates. The European Commission, for example, has illegalized the use of, DBP, BBP and DEHP in toys (OECD 2012). Canada has already harmonized its phthalate requirements in accordance with those already in existence n the U.S and the European Union (CCOHS 1988). The Australian government has also embarked on developing techniques that will ensure the safe use of phthalates. The federal government and other stakeholders should hasten their regulatory policies in order to minimize the health and environmental risks bought about by phthalates. International agencies should be established to monitor phthalate levels in different products that have been identified as possible routes of exposure (OECD 2012).
Bibliography
Canadian Council for Occupatoional Health and Safety (CCOHS). Phthalates. Ottawa: CCOHS Press, 1988.
Dart, Richard. Medical Toxicology. Philadelphia: Lippincott Williams & Wilkins, 2004.
EPA. Phthalates: U.S EPA, Toxicity and Exposure Assessment for Children’s Health. Pennsylvania: EPA press, 2006.
National Reserach Council (NRC). Phthalates and Cumulative Risk Asessment: The Task Ahead. Washington: National Academis Press, 2008.
Organisation for Economic Co-Operation and Development (OECD). OECD Environmental Outlook to 2050: Paris: OECD Press, 2012.