Pesticides and Kids: An AAP Report

James Roberts, MD, MPH; Laurie Scudder, DNP, PNP

Disclosures

February 15, 2013

Environmental History

Medscape: What are the main components of an environmental history? Are there resources that clinicians can turn to for questionnaires and other documents to assist in obtaining this history?

Dr. Roberts: In general, physicians are not comfortable conducting an environmental history. There are a few very good resources for clinicians, however. The National Environmental Education Foundation Website provides several documents, including a tool for a screening environmental history that allows for an assessment of exposure to common substances such as pesticides, lead, radon, and cigarette smoke. That tool can serve as a first-pass screen. Then, if the screening indicates a potentially significant source of exposure, there is a more in-depth supplemental form on that same Website that has more details for follow-up. Those are very good tools to help clinicians learn how to do an environmental history.

Medscape: When should an environmental history be obtained? Should it be conducted with routine well-child visits or only when something is suspected?

Dr. Roberts: The goal is to conduct an environmental history at well visits. Having parents complete a checklist of environmental history questions as part of the regular intake history is a great way to begin the process of routinely assessing for home exposures. Certainly in every day sick visits where time is very limited, we do not expect that a full environmental history will be done. However, a second goal is that pediatric providers, when evaluating a child with an unusual set of signs and/or symptoms, will think about potential environmental exposures in more detail.

One important point: When talking about environmental history, providers must consider not only the child's home but the school, the grandparent's home if the children might be staying over there after school while the parents are at work, or any other environment where kids spend a great deal of time.

Medscape: Chronic exposure has been linked to a range of disease, most notably common childhood cancers including acute lymphocytic leukemia and brain tumors. Should children with these specific malignancies undergo specific diagnostic evaluation to determine pesticide exposure?

Dr. Roberts: We wanted to present the data on chronic exposures to increase awareness of the diseases with which exposures to pesticides have been associated. I want to be careful to note that the technical report talks about associations and not necessarily cause and effect. With epidemiologic studies, we cannot always prove cause and effect. However, there is a growing body of literature that does support the notion that exposure to pesticides can contribute to neurodevelopmental disorders and some malignancies.

Most of the studies included in the report examined exposures during pregnancy or in the immediate postnatal period. So these exposures are often happening years before a child may be found to have leukemia or a brain tumor. The reason for addressing this issue in this document is to begin to focus on primary prevention. We should be preventing undue exposure early on so that we reduce the risks for malignancy. This is very important for women's health providers, especially when seeing patients who are thinking about starting a family as well as seeing women early in their pregnancy. It is also important for pediatric providers who will have the opportunity to talk with mothers of young infants and children and can discuss this information prior to subsequent pregnancies.

The other issue is that, by and large, there really is not very good diagnostic testing for most pesticide poisonings. We do have a test for acute organophosphate poisoning, which is the red blood cell and plasma cholinesterase levels. But for other commonly encountered insecticides, there are no diagnostic indicators. And that is also true for most herbicides, fungicides, and rodenticides.

Medscape: Do you have concluding messages for our members?

Dr. Roberts: Yes. First, children are not adults. Their developmental habits can increase their exposure through normal hand and mouth activity. They will crawl on the floor and around the yard. Their oral intake of both food and fluids is much greater in terms of the amount per kilogram of body weight of intake than that of an adult. All of those factors can increase a child's risk from exposure to pesticides more than in adults. Secondly, children with acute poisonings sometimes present differently. And finally, children are more susceptible to chronic effects of exposure, including neurodevelopmental abnormalities and cancer.

With all of these factors in mind, the message from the AAP is about prevention. Pediatric providers should be familiar with common pesticides in use and their signs and symptoms so that the diagnosis of acute pesticide poisoning is not delayed or missed. Clinicians should ask about pesticide use to help shape preventive anticipatory guidance. The AAP recommends minimal risk products, safe storage practices, and application of least toxic methods for individual patients and community settings. Counseling parents who work with pesticides to take steps to reduce the "take-home" exposure from their clothing and footwear is also very important.

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