Arsenic in a Child's World

Ann Pike-Paris, MS, RN

Pediatr Nurs. 2004;30(3)

Abstract and Introduction

Ten-year-old Tim P. presented at a local emergency room complaining of bloody diarrhea. Despite treatment, his diarrhea continued with additional symptoms of nausea, raspy voice, headaches, abdominal pain, tingling of the feet and hands, lethargy, and eczema. Do you recognize the health risks and clinical aspects of arsenic, and could you assist Tim and his family?

Environmental exposure in our children's world to known and unknown toxins is an evolving area of concern and research. Over the past several years the heavy metal arsenic (As) has been found in high concentrations in ground and surface water supplies and soil. If you have a deck, a large wooden playground structure, or you frequent water resources recreationally and use a dock, perhaps you have also become aware of arsenic's unwanted presence in the wood. Pressure treated wood, referred to as CCA (copper chromium arsenate) and once commonly used in multiple applications, is recognized as a primary source of arsenic. Use the case study below to familiarize yourself with the clinical aspects of arsenic, the self-assessment questions to explore your knowledge, the information provided to increase it, and the resources listed to guide you to more expert help.

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Table 1. Resources
For Your Education Agency for Toxic Substances and Disease Registry (ATSDR) Information Center 1-888-42-ATSDR atsdirc@cdc.gov www.atsdr.cdc.gov Materials available include Case Studies in Environmental Medicine: Taking an Exposure History and numerous chemical specific case studies. The National Center for Environmental Health (NCEH), CDC (add) 770-488-7000 http://www.cdc/nceh/ Provides information on prevention and control of illness between people and the environment outside the workplace. Some health topics include asthma, lead, and mold. Fact sheets and brochures are available. Greater Boston Physicians for Social Responsibility (GBPSR) 617-497-7440 www.igc.org/psr/ Publishes Fact Sheets, including one for health care providers to guide history taking, advice on toxins, and diet. Web site features the report In Harm's Way: Toxic Threats to Child Development. Healthfinder® www.healthfinder.gov Developed by the U.S. Department of Health and Human Services and provides numerous resources: Online publications, databases, and other Web sites producing reliable information. For Parents Environmental Protection Agency (EPA) www.epa.gov/ebtpages/watewaterparsenic.html Provides the new standards for arsenic in drinking water. EPA Office of Children's Health Protection http://yosemite.epa.gov/ochp/ochpweb.nsf/homepage EPA's branch devoted to protecting children's health. Multiple suggestions on protecting children from exposures, explanations of environmental hazards, current news, available publications and more. Environmental Defense www.scorecard.org Provides geographically specific details of toxic chemicals and the human effects. For Professional Support Agency for Toxic Substances and Disease Registry (ATSDR) www.atsdr.cdc.gov/HEC/HSPH/v1n1-2indx.html Click on Children's Exposures and read about the 10 regional EPA Pediatric Environmental Health Specialty Units.

Sidebar: Hot Box - Arsenic

Sources. Organic arsenic, which typically combines with carbon or hydrogen and is considered less harmful than inorganic compounds, is found in seafood (cod, haddock) and shellfish (mussels, lobster, etc.); pesticides (methylated) in pentavalent compounds; and used as herbicides on cotton, citrus, and sod (ATSDR, 2001).

Absorption. Pentavalents are water-soluble and absorbed by mucous membranes. Oral ingestion is the typical route. Dermal absorption is poor.

Clinical effects. Ingestion of organic arsenic via seafood is not believed toxic and should have no effect upon children (AAP, 2003). Organic compounds are absorbed by the gastrointestinal tract and cause toxic injuries to the central nervous system (CNS) and virtually all organs. In acute poisoning, symptoms appear within an hour: garlic breath, vomiting, abdominal pain, bloody diarrhea, headache, dizziness, drowsiness, cardiac arrhythmia. Liver and renal damage and death occur within 1-3 days (EPA, 1999). In chronic exposure there is generalized fatigue; peripheral and CNS effects such as sensory changes, paresthesia, muscle tenderness, complaints of pain in the feet, liver injury, anorexia; and skin changes such as hyperkeratosis on palms and soles, hyperpigmentation in non-sun exposed areas (Children's Environmental Health Network [CEHN] 1999), melanosis, eczema like eruptions, and Mees lines on the fingernails (AAP, 2003).

Diagnosis. Due to arsenic's excretion in the urine, in both acute and chronic exposure, diagnosis is made with an 8-24 hour urine collection. It is important to remember that ingestion of seafood prior to testing may raise urine levels for 2-5 days. Blood is not an accurate test due to the short half-life of arsenic. Hair samples in chronic exposure have not been widely accepted as a diagnostic tool (EPA, 1999).

Treatment. Both acute and chronic exposure is treated with chelation with dimercaprol (BAL), DMSA (succimer), d-penicillamine DMPS (CEHN, 1999; AAP, 2003).

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Arsenic-As

Sources. Inorganic arsenic is found in ground and surface water; hazardous waste sites, smelting facilities, incinerators, mines, and agricultural facilities, which leach arsenic into the air, water, and soil; wood treated with CCA; pesticides as used in utility poles; batteries; solar cells; feed additives for poultry and swine; treatment of acute promyelocytic leukemia (APL); and alternative medicines from China and India (Espinoza, Mann, & Bleasdell, 1995).

Absorption. Ingestion via the GI tract is the most common route in children. Inorganic arsenic may also be inhaled as the gas form, arsine, which is extremely toxic, or as ambient air. Arsenic has a half-life of 10 hours and is detoxified in the body by conversion to the organic species and excreted in the urine. Children appear less able to detoxify arsenic and, consequently, have slower rates of clearing it from the body. It is when these rates of detoxification are outpaced by exposure that toxicity occurs (CEHN, 1999; AAP, 2003).

Clinical effects. Acute symptoms are identical to organic. Chronic exposure is also identical; however, skin changes serve as an important clue. Symptoms may not appear for at least 5 years and other issues such as genetics, age, metabolism, diet, and overall health may have an impact on the onset as well (Physicians for Social Responsibility [PSR], 2001). Arsenic is classified as a known human carcinogen.

Diagnosis. Inorganic exposure is diagnosed in the same manner as for organic, an 8-24 hour urine collection. Spot urine has not been validated as a reliable test for children (Committee for Environmental Health, 2003).

Treatment. If significant exposure has been clinically shown, chelation therapy with BAL, DSMA, or DMPS is used. Arsine (gas) exposure would mandate supportive care (oxygen and maybe blood transfusions) and heavy fluid intake to dilute and aid in excretion of arsenic (CEHN, 1999; EPA, 1999).

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