AMERICAN ACADEMY OF PEDIATRICS: Toxic Effects of Indoor Mold

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PEDIATRICS Vol. 101 No. 4 April 1998, pp. 712-714

AMERICAN ACADEMY OF PEDIATRICS:

Toxic Effects of Indoor Molds

Committee on Environmental Health

ABSTRACT

This statement describes molds, their toxic properties, and their

potential for causing toxic respiratory problems in infants.

Guidelines for pediatricians are given to help reduce exposures to

mold in homes of infants. This is a rapidly evolving area and more

research is ongoing.

INTRODUCTION

The growth of molds is pervasive throughout the outdoor environment.

Given the proper conditions, molds may also proliferate in the

indoor setting. Because Americans spend 75% to 90% of their time

indoors,1 they are exposed to molds that are growing indoors.

Molds readily enter indoor environments by circulating through

doorways, windows, heating, ventilation systems, and air

conditioning systems. Spores in the air also deposit on people and

animals, making clothing, shoes, bags, and pets common carriers of

mold into indoor environments. The most common indoor molds are

Cladosporium, Penicillium, Aspergillus, and Alternaria.2,3

Molds proliferate in environments that contain excessive moisture,

such as from leaks in roofs, walls, plant pots, or pet urine.4-6

Many building materials are suitable nutrient sources for fungal

growth. Cellulose substrates, including paper and paper products,

cardboard, ceiling tiles, wood, and wood products, are particularly

favorable for the growth of some molds. Other substrates such as

dust, paints, wallpaper, insulation materials, drywall, carpet,

fabric, and upholstery commonly support mold growth.3 Molds also may

colonize near standing water.7-9

Some indoor molds have the potential to produce extremely potent

toxins called mycotoxins.10-12 Mycotoxins are lipid-soluble and are

readily absorbed by the intestinal lining, airways, and skin.13

Species of mycotoxin-producing molds include Fusarium, Trichoderma,

and Stachybotrys. In general, the presence of these molds indicates

a long-standing water problem.

DIRECT TOXIC EFFECTS FROM MOLD EXPOSURE

The toxic effects from mold exposure are thought to be associated

with exposure to toxins on the surface of the mold spores, not with

the growth of the mold in the body. Until recently, there was only

one published report in the United States linking airborne exposure

to mycotoxins with health problems in humans.14 This report

described upper respiratory tract irritation and rash in a family

living in a Chicago home with a heavy growth of Stachybotrys atra

(also known as Stachybotrys chatarum). The investigators documented

that this mold was producing trichothecene mycotoxins. The symptoms

disappeared when the amount of mold was substantially reduced.

More recently, molds that produce potent toxins have been associated

with acute pulmonary hemorrhage among infants in Cleveland, Ohio.15

In November 1994, physicians and public health officials in

Cleveland reported a cluster of eight cases of acute pulmonary

hemorrhage and hemosiderosis that had occurred during January 1993

through November 1994 among infants in neighborhoods of eastern

metropolitan Cleveland.16 Two additional cases were identified in

December 1994. Pulmonary hemorrhage recurred in five of the

discharged infants after they returned to their homes; of these

infants, one died from pulmonary hemorrhage.

A case-control study comparing those 10 infants who had acute

pulmonary hemorrhage and hemosiderosis with 30 age-matched control

infants from the same area in Cleveland17 revealed that the infants

with pulmonary hemorrhage were more likely to have resided in homes

with major water damage from chronic plumbing leaks or flooding (95%

confidence interval = 2.6 to infinity). The quantity of molds,

including the toxigenic fungus Stachybotrys atra, was higher in the

homes of infants with pulmonary hemorrhage than in those of

controls. Simultaneous exposure to environmental tobacco smoke

appeared to increase the risk of acute pulmonary hemorrhage among

these infants.

Stachybotrys atra requires water-saturated cellulose-based materials

for growth in buildings. In studies conducted in North America, it

has been found in 2% to 3% of home environments sampled.8,18

Although Stachybotrys atra has been associated with gastrointestinal

hemorrhaging in animals that had consumed moldy grain,19 the fungus

previously had not been associated with disease in infants. Infants

may be particularly susceptible to the effects of these inhaled

mycotoxins because their lungs are growing very rapidly. In an

animal model, intranasal administration of toxic spores of

Stachybotrys atra to mice resulted in severe interstitial

inflammation with hemorrhagic exudates in the alveoli.20

The county coroner re-examined all infant deaths in Cleveland during

January 1993 through December 1995 to determine whether pulmonary

hemosiderin-laden macrophages were present in the lung tissue.

Postmortem examinations were reviewed for all 172 infants who died

during that period, including 117 deaths attributed to sudden infant

death syndrome (SIDS). Pathologic lung specimens were sectioned,

stained with Prussian blue, and screened for the presence of

hemosiderin. The presence of hemosiderin-laden macrophages in

alveoli indicates alveolar bleeding at least 2 days before death.21

Hemosiderin-laden macrophages were abundantly present in the lung

tissue of nine (5%) infants. Of these nine deaths, two resulted from

homicide, and one had a recent history of child abuse. The other six

deaths that were accompanied by hemosiderin-laden macrophages in the

lung thus may have been misclassified as deaths from SIDS. All six

infants had lived in the same limited geographic area as the

previously described cases of pulmonary hemosiderosis.

The extent of this problem in other areas of the United States is

still unknown. Further investigation is needed to establish

causation and prevent further health effects if the findings in

Cleveland are confirmed in other areas.

CONCLUSION

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Abstract

Introduction

Conclusion

Recommendation

References

Very little is currently known about acute idiopathic pulmonary

hemorrhage among infants. This is a newly recognized problem and

knowledge is expected to be evolving rapidly. In view of the

severity of the problem, environmental controls to eliminate water

problems and to reduce the growth of indoor molds are wise. Until

more is known about the etiology of idiopathic pulmonary hemorrhage,

prudence dictates that pediatricians try to ensure that infants

under 1 year of age are not exposed to chronically moldy, water-

damaged environments.

Coroners and medical examiners should consider using the recently

published Guidelines for Death Scene Investigation of Sudden,

Unexplained Infant Deaths, which includes a question about dampness,

visible standing water, or mold growth.

Little is known about the prevalence of toxigenic molds in homes,

nor is it clear how extensive measures must be to achieve

environments sufficiently free of molds to avoid disease. Bulk mold

must be removed, followed by a thorough cleaning with soap and

water. Caution must be used, because it is possible that homeowners

could actually increase the levels of mold spores in the air by

attempting extensive clean-up efforts without guidance from a

professional (a certified industrial hygienist or ventilation

engineer). These specialists can be found in the yellow pages in the

telephone directory under the listing for Industrial Hygiene

Consultants. Additional research is needed before the most

appropriate recommendations for home clean-up can be determined.

Until then, interim guidelines have been formulated.

RECOMMENDATIONS

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Abstract

Introduction

Conclusion

Recommendation

References

In areas where flooding has occurred, prompt cleaning of walls and

other flood-damaged items with water mixed with chlorine bleach,

diluted four parts water to one part bleach, is necessary to prevent

mold growth. Never mix bleach with ammonia. Moldy items should be

discarded.

Pediatricians should ask about mold and water damage in the home

when they treat infants with idiopathic pulmonary hemorrhage. If

mold is in the home, pediatricians should encourage parents to try

to find and eliminate sources of moisture. Testing the environment

for specific molds is usually not necessary. It appears to be

important to clean up moldy conditions before the infant is

discharged from the hospital to prevent recurrent pulmonary

hemorrhage, although this needs further study. Interim clean-up

guidelines are available through the Centers for Disease Control and

Prevention (CDC), 1600 Clifton Rd, Atlanta, GA 30333.

Infants with idiopathic pulmonary hemorrhage must not be exposed to

environments in which smoking occurs.

Pediatricians should report cases of idiopathic pulmonary hemorrhage

and hemosiderosis to state health departments. A reporting form is

available through the CDC.

Pediatricians should be aware that there is currently no method to

test humans for toxigenic molds such as Stachybotrys or mycotoxins.

Infants who die suddenly without known cause should have an autopsy

done including a Prussian blue stain of lung tissue to look for the

presence of hemosiderin.

COMMITTEE ON ENVIRONMENTAL HEALTH, 1997 TO 1998

Ruth A. Etzel, MD, PhD, Chairperson

Sophie J. Balk, MD

F. Bearer, MD, PhD

Mark D. , MD

W. , MD, MPH

M. Shea, MD, MPH

LIAISON REPRESENTATIVES

Henry Falk, MD

Centers for Disease Control and Prevention

Lynn R. Goldman, MD

Environmental Protection Agency

W. , MD

National Cancer Institute

Walter Rogan, MD

National Institute of Environmental Health Sciences

SECTION LIAISON

Barbara Coven, MD

Section on Community Pediatrics

CONSULTANT

Holly J. Fedeyko, MPH

FOOTNOTES

The recommendations in this statement do not indicate an exclusive

course of treatment or serve as a standard of medical care.

Variations, taking into account individual circumstances, may be

appropriate.

ABBREVIATIONS

SIDS, sudden infant death syndrome. CDC, Centers for Disease Control

and Prevention.

REFERENCES

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Abstract

Introduction

Conclusion

Recommendation

References

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[Abstract]

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Pediatrics (ISSN 0031 4005). Copyright ©1998 by the American Academy

of Pediatrics

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