Chapter 5. Phthalate exposure in children: Assessing knowledge, attitudes and behaviors in families with low socioeconomic status
Rachana Charla, David Collier, MD PhD, Melissa Johnson, MPH, Brittany Meier, MA, Andrew Binder, PhD, and Katlyn May, MS
Center for Human Health and the Environment, Brody School of Medicine,
East Carolina University, Greenville, North Carolina, United States of America
Phthalates are a family of synthetic chemicals used in the manufacturing of plastic products, scented products, and personal care products. Exposure to phthalates is a concern as they are considered endocrine disrupting chemicals (EDCs). Here we employed a survey to assess the knowledge, attitudes, and behaviors (KAB) related to phthalates and the use of personal care products that may contain phthalates among 50 parents and caregivers with children no more than five years old at the Brody School of Medicine’s Pediatric Outpatient Clinic found at East Carolina University. We found significant relationships between race and product usage with Black respondents more likely to use spray air fresheners, lotions, and candles compared to the non-Black respondents. Additionally, there were significant correlations between income and education level regarding knowledge and recognition of terms like phthalates. Low socioeconomic status (SES) and lack of knowledge notably affect potential phthalate exposure in children from personal care products as well as cleaning products. Further studies are needed to confirm the significance of these observations.
 Pell T, Eliot M, Chen A, Lanphearc BP, Yolton K, Sathyanarayana S, Braun JM.
Parental concern about environmental chemical exposures and children’s urinary
concentrations of phthalates and phenols. J Pediatrics 2017;186:138–44.
 Dutta S, Haggerty DK, Rappolee DA, Ruden DM. Phthalate exposure and long-term epigenomic consequences: A review. Front Genetics 2020;11:405.
 Hlisníková H, Petrovičová I, Kolena B, Šidlovská M, Sirotkin A. Effects and
mechanisms of phthalates’ action on reproductive processes and reproductive
health: A literature review. Int J Environ Res Public Health 2020;17(18):6811.
 Diamanti-Kandarakis E, Bourguignon JP, Giudice LC, Hauser R, Prins GS, Soto
AM, Zoeller RT, Andrea C Gore AC. Endocrine-disrupting chemicals: an endocrine
society scientific statement. Endocr Rev 2009;30:293–342.
 Kamai EM, McElrath TF, Ferguson KK. Fetal growth in environmental
epidemiology: mechanisms, limitations, and a review of associations with
biomarkers of non-persistent chemical exposures during pregnancy. Environ Health 2019;18:43.
 Qian Y, Shao H, Ying X, Huang W, Hua Y. The endocrine disruption of prenatal
phthalate exposure in mother and offspring. Front Public Health 2020;83:66.
 Swan SH, Main KM, Liu F, Stewart SL, Kruse RL, Calafat AM, Mao CS, Redmon
JB, Ternand CL, Sullivan S, Teague JL, Study for Future Families Research Team.
Decrease in anogenital distance among male infants with prenatal phthalate
exposure. Environ Health Perspect 2009;113:1056–61.
 Bornehag, CG, Lindh, C, Reichenberg, A, Wikström, S, Unenge Hallerback, M,
Evans, SF, Sathyanarayana, S, Barrett, ES, Nguyen, RHN., Bush, NR, & Swan, SH.
Association of prenatal phthalate exposure with language development in early
childhood. JAMA Pediatr 2018;172:1169–76.
 Swan SH. Environmental phthalate exposure in relation to reproductive outcomes
and other health endpoints in humans. Environ Res 2008;108:177–84.
 Meeker JD, Sathyanarayana S, Swan SH. Phthalates and other additives in plastics:
human exposure and associated health outcomes. Philos Trans R Soc Lond B Biol
 Ginsberg G, Ginsberg J, Foos B. Approaches to children’s exposure assessment:
case study with diethylhexylphthalate (DEHP). Int J Environ Res Public Health 2016;13:670.
 National Center for Health Statistics (NCHS). National health and nutrition
examination survey data. Hyattsville, MD: US Department of Health and Human
Services, Centers for Disease Control and Prevention, 2003-2004.
 Zota AR, Calafat AM, Woodruff TJ. Temporal trends in phthalate exposures:
Findings from the National Health and Nutrition Examination Survey, 2001-2010.
Environ Health Perspect 2014;122(3):235-41.
 Braun JM, Sathyanarayana S, Hauser R. Phthalate exposure and children’s health.
Curr Opin Pediatr 2013;25(2):247–54.
 Harley KG, Kogut K, Madrigal DS, Cardenas M, Vera IA, Meza-Alfaro G, She J,
Gavin Q, Zahedi R, Bradman, A, Eskenazi B, Kimberly LP. Reducing phthalate,
paraben, and phenol exposure from personal care products in adolescent girls:
findings from the HERMOSA intervention study. Environ Health Perspect
 Whyatt RM, Liu X, Rauh, VA, Calafat AM, Just AC, Hoepner L, Diaz D, Quinn J,
Adibi J, Perera FP, Factor-Litvak P. Maternal prenatal urinary phthalate metabolite concentrations and child mental, psychomotor and behavioral development at age three years. Environ Health Perspect 2012;120(2):290-5.
 Hammel SC, Levasseur JL, Hoffman K, Phillips AL, Lorenzo AM, Calafat AM,
Webster TF, and Heather M. Stapleton HM. Children’s exposure to phthalates and
non-phthalate plasticizers in the home: The TESIE study. Environ Int 2019;132:105061.
 Finn S, O’Fallon L. The emergence of environmental health literacy-from its roots
to its future potential. Environ Health Perspect 2019;125(4):495–501.
 Dodson RE, Cardona B, Zota AR, Robinson Flint J, Navarro S, Shamasunder B.
Personal care product use among diverse women in California: Taking Stock Study.
J Expo Sci Environ Epidemiol. 2021;31(3):487-502.
 Binder AR, May K. Public views on environmental health topics in NC. Raleigh,
NC: Center Human Health and Environment, 2021.
 Kochhar R. Are you in the American middle class? find out with our income
calculator. Washington, DC: Pew Research Center, 2021.
 Genuis SJ, Beesoon S, Lobo RA, Birkholz D. Human elimination of phthalate
compounds: blood, urine, and sweat (BUS) study. Scientific World Journal 2012;2012:615068.
 Daniel L, Michot M, Esvan M, Guérin P, Chauvet G, Pelé F. Perceptions,
knowledge, and practices concerning indoor environmental pollution of parents or
future parents. Int J Environ Res Public Health 2020;17(20):7669.
 Watkins DJ, Eliot M, Sathyanarayana S, Calafat AM, Yolton K, Lanphear BP, Braun
J M. Variability and predictors of urinary concentrations of phthalate metabolites
during early childhood. Environ Sci Technol 2014;48(15):8881–90.
 Koniecki D, Wang R, Moody RP, Zhu J. Phthalates in cosmetic and personal care
products: Concentrations and possible dermal exposure. Environ Res 2011;111(3):329–36.
 Pacyga DC, Sathyanarayana S, Strakovsky RS. Dietary predictors of phthalate and
bisphenol exposures in pregnant women. Adv Nutr 2014;10(5):803–15.
 Parlett LE, Calafat AM, Swan SH. Women’s exposure to phthalates in relation to
use of personal care products. J Expo Sci Environ Epidemiol 2013;23(2):97–206.
 Whyatt RM, Liu X, Rauh, VA, Calafat AM, Just AC, Hoepner L, Diaz D, Quinn, J,
Adibi, J, Perera, FP, & Factor-Litvak, P. Maternal prenatal urinary phthalate
metabolite concentrations and child mental, psychomotor and behavioral
development at age three years. Environ Health Perspect 2012;120(2):290-5.
 Fisher JS. Environmental anti-androgens and male reproductive health: Focus on
phthalates and testicular dysgenesis syndrome. Reprod 2004;127(3):305-15.
 Sathyanarayana S, Karr CJ, Lozano P, Brown E, Calafat AM, Liu F, Swan SH. Baby
care products: possible sources of infant phthalate exposure. Pediatrics 2008;121(2):e260-8