Q. Are you aware of the health hazards posed by DEHP?
The mother of a baby in my care asked for phthalate-free care. What does this mean?
A. Di-(2-ethylhexyl) phthalate—or DEHP—is not yet a household word among nurses, but it can be found in many health care products, including iv tubing, iv bags, and feeding tubes. A member of a group of chemicals known collectively as phthalates, DEHP is a chemical compound added to polyvinyl chloride (PVC) plastic during the manufacturing process to make the final product flexible, strong, and moldable into various shapes and designs. By weight, DEHP makes up 20% to 40% of PVC products on average.
DEHP poses risks to health and human development because it does not bind with plastic, so it can leach out of PVC medical products during medical procedures. During medical interventions such as hemodialysis or extracorporeal membrane oxygenation (ECMO), that require long-term exposure to iv lines DEHP exposure is significantly increased. Pediatric and in-utero exposures are of the greatest concern. The multiple, relatively high-level exposures that can occur in the neonatal intensive care unit are potentially at or in excess of levels equivalent to those known to cause adverse health effects in relevant animal studies.
Adverse effects in exposed rats have included suppressed or delayed ovulations, suppressed estradiol production, polycystic ovaries, reduced kidney function, kidney atrophy, reduced liver function, respiratory distress, and decreases in heart rate and blood pressure, as well as testicular damage in their male offspring. While there is an absence of data on effects in humans, the nature of the effects on animals with systems similar to human systems has led the Food and Drug Administration (FDA) and the U.S. National Toxicology Program to conclude that humans face similar risks from DEHP exposure.
In January 2002, Health Canada, the national health agency (similar to the U.S. Department of Health and Human Services), reiterated these concerns in a report from its expert advisory panel on DEHP in medical devices. The Health Canada report calls for the substitution of less toxic, non–DEHP-containing devices in the treatment of pregnant women, breast-feeding mothers, infants, prepubescent males, and patients undergoing cardiac bypass hemodialysis or heart transplant surgery. Specifically, the report states: “Alternate measures are immediately justifiable and should be introduced as quickly as possible to protect those subpopulations at greatest risk, namely the fetus, newborns, infants and your children receiving transfusions, ECMO, cardiopulmonary bypass, exchange transfusion, hemodialysis, TPN [total parenteral nutrition] and lipophilic drug formulations.”
As frontline care providers, nurses should take the following steps to learn more about the risks of DEHP and to protect their patients:
- Substitute non-DEHP and non-PVC products when caring for vulnerable populations. (Go to www.sustainablehospitals.org and www.noharm.org/library/docs/Going_Green_3-5_PVC_Alternatives.pdf for guidance).
- Read package inserts—if the product calls for non-DEHP tubing or is lipophilic, which increases its leaching potential, use administration sets made from alternative materials such as polypropylene.
- Urge the FDA to require labeling of products that contain DEHP.
- Work with your institution’s purchasing department to obtain samples of alternative products and get involved in training colleagues when a new product is implemented.
- Volunteer to work in your unit on clinical trials of alternatives to PVC-containing products.
- Report adverse reactions to DEHP to the FDA MedWatch program (go to www.fda.gov/medwatch).
- Learn more about environmentally preferable products. A good place to start is the Web site of Health Care Without Harm (go to www.noharm.org). For information about CleanMed 2002, to be held October 25–26, 2002, in Chicago, go to www.cleanmed.org.
Susan Wilburn is a senior specialist for occupational safety and health at the ANA; Ann Melamed is a geologist, nurse, and consultant in pollution prevention for the ANA and Health Care Without Harm; and Barbara Sattler is director, Environmental Health Education Center, at the University of Maryland School of Nursing.