In late 2012, the American Academy of Pediatrics (AAP) Council on Environmental Health released a policy statement and in-depth technical report on the topic of pesticide exposure in children. The authors note that although acute toxicity from pesticides is relatively uncommon in the United States, subacute and chronic, low-level exposure through foods, dust, agricultural use, and pet exposures is common and may contribute to a range of disease and disability. Medscape spoke with James Roberts, MD, MPH, Professor of Pediatrics at the Medical University of South Carolina in Charleston and lead author of the documents, about the clinical and policy implications of this emerging body of evidence.
Medscape: The documents make clear that a growing body of epidemiologic evidence as well as animal models point to associations between exposure to pesticides in young children and a range of diseases from childhood cancers to autism. Yet, there remain a number of unanswered questions. Why did the AAP elect to develop this report at this time?
Dr. Roberts: This report really has been a long time in coming. There have been 3 previous editions of the AAP handbook on environmental health, and within that there was a pretty complete chapter on pesticide exposure in kids. But the handbook -- often referred to as the Green Book -- is not widely distributed. We wanted to distribute a policy statement that would be available to all pediatric providers. As we started looking at what we would say in the policy statement, we realized that the sheer volume of information on both acute and chronic poisoning required an accompanying technical report. The goal was to synthesize everything that we had in one publicly available place. The handbook is only available by purchase through the AAP. These 2 documents, published in the journal Pediatrics and offered online in full text, will be available to a much wider audience.
Medscape: The documents lament that, currently, there are no reliable data on the incidence of pesticide exposure in US children and no national systematic reporting. Are there anecdotal records or other means of estimating exposure risk? Does exposure risk vary by region? What is known about the size and seriousness of this problem?
Dr. Roberts: Tracking exposure incidence and assessing exposure risk are really problematic. One way of assessing risk is via poison control center reports. Those are available in the journal Clinical Toxicology. They are helpful in identifying the number of kids exposed to various pesticides. The weakness with using these reports is that they rely on self-reporting. Either the family or the hospital calls the poison control center for advice on how to handle the situation. If you have a hospital that gets a lot of pesticide poisoning, they may not feel the need to call the poison control center every single time. Providers in these areas may be better at recognizing a potential poisoning. So unless there is a reporting requirement in that provider's state, some events would go unreported. That data source, by itself, while useful and informative, does not reliably identify all cases of exposure.
Approximately 37 states have some requirement to report known poisoning cases. The effectiveness of reporting in each of those states is quite variable, and only a few states include a more active surveillance of pesticide poisoning cases. The other very important issue is that this reporting only includes those patients who are actually identified as pesticide poisoned. There are likely many other children who are poisoned by some pesticide product that no one ever identifies. I think that we are underestimating the risks out there.
It does vary region by region. Most people think of pesticide poisoning as happening in an agricultural area. Certainly, to some extent, these are high-use areas, and there may be some more exposure both through proximity to the fields and take-home exposure from parents who work in the fields. However, poisonings in the home do occur as a result of treatment for nuisance pests such as cockroaches, mice, ants, and other kinds of insects. Other sources at home include the application of herbicides used for weed control on lawns and the application of tick and flea control products to household pets.
Medscape: The policy statement notes that pediatric providers, by their own report, do not feel confident in their ability to recognize acute pesticide toxicity. One of the recommendations is that providers become familiar with the clinical signs and symptoms of acute ingestion. Are there commonalities to the presentation of pesticide toxicity across classes? Are there red flags that are particularly indicative of acute exposure?
Dr. Roberts: There are a lot of symptoms that are very nonspecific, gastrointestinal symptoms in particular. Most children will have some degree of nausea, vomiting, and abdominal pain. Although seizures can happen in many different scenarios, a large number of pesticide exposures do cause seizures. So that combination of gastrointestinal symptoms and seizure activity should increase the suspicion for pesticide exposure.
Most medical schools teach about the clinical scenario with organophosphate poisoning, and that is probably the most well-known pesticide to healthcare providers. The reason for that is that there are a fairly distinct set of signs and symptoms that occur with organophosphate poisoning. However, the issue with pediatric poisoning is that children do not always present with organophosphate poisoning in the same way as adults. While providers are familiar with the typical cholinergic signs of salivation, lacrimation, diarrhea, and other secretions in various places seen in adults, children are more likely than adults to present with mental status changes and seizures. So that can be tricky.
The other issue is that children poisoned with one of the more commonly used insecticide groups, the pyrethroids, can present with signs and symptoms that are very similar to those seen with organophosphate poisonings. Likewise, some of the other insecticides that are becoming more commonly used also can cause symptoms similar to those seen with organophosphates.
Medscape: Is the concern that these children could potentially be inappropriately treated with atropine?
Dr. Roberts: This could lead to inappropriate treatment; that is correct. But even earlier than the treatment phase is the issue of providers recognizing a potential exposure and conducting an appropriate environmental history so that not only is there a suspicion that this child may have suffered a pesticide poisoning, but the type of pesticide is explored.
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Cite this: Pesticides and Kids: An AAP Report - Medscape - Feb 15, 2013.