How Do You Manage a Child with Known Environmental Exposures?

Upon completion of this section, you will be able to

• describe how to medically manage a child exposed to hazardous substances.

Six clinical interventions are recommended to manage a pediatric environmental medicine problem:

1. Ending or minimizing the offending exposures.
2. Delivering standard symptomatic supportive medical therapy.
3. Determining and delivering substance-specific medical interventions.
4. Referring to specialists in toxicology and pediatric environmental medicine.
5. Educating the family and communicating risk.
6. Public health reporting.

The pediatrician has a key role in orchestrating the elimination or reduction of a child’s ongoing exposure.

For example, if hospitalizing a child poisoned by a heavy metal such as lead is necessary, the pediatrician initiates hazard reduction by removing the child from the offending environment. Before returning the child to the home, however, pediatrician must ensure elimination or mitigation of the environmental hazard. Whenever possible, the offending chemical should be entirely removed. Substitution should be made if the chemical serves an important function and it is possible to substitute a less toxic alternative. For example, homeowners and public health authorities must ensure that leaded paint is replaced with a non-lead alternative.

A toxicant is hazardous only to the extent exposure occurs. Measures other than removal can often accomplish the goal of hazard reduction more quickly and inexpensively. Measures may include

• blocking pathways of exposure—e.g., friable asbestos insulation on pipes may be encapsulated to reduce indoor air asbestos contamination,
• putting household chemicals out of children’s reach and using a charcoal filter to manage certain contaminants in tap water, and
• running the water a few minutes before drinking.

In many cases, pediatricians can provide information and guidance to the family in order to make an environment safer for a child. Information from the American Academy of Pediatrics and other organizations will help pediatricians:

• inform parents about reducing environmental asthma triggers,
• reduce hazards of pesticides and other household chemicals, and
• properly store medicines.

Improper attempts by untrained persons to mitigate environmental contaminants can lead to dramatic exposures. For example, an untrained individual who attempts to remove lead paint might acutely increase contamination levels of exposure for children and pregnant women, and such levels could cause acute poisoning. The untrained individual can even poison himself/herself if not taking proper protective measures. Pediatricians should always collaborate with specialists in pediatric environmental medicine and public health agencies to obtain names of licensed remediation specialists.

In some acute exposures, exposure cessation involves medical interventions. For example, first responders to a person exposed to a hazardous pesticide must

• First assess the scene and protect themselves and others near the scene,
• then remove the individual from the contaminated environment,
• then remove tainted clothing, and
• finally grossly decontaminate the individual’s body (e.g., by giving the individual a shower).

More refined decontamination then continues in the medical setting. First responders must always be mindful of their own safety in these situations because an offending chemical may cause symptoms, or even death, in responders.

Some medical interventions aim to stop the absorption of certain toxicants. Interventions for acute ingestions include using

• activated charcoal,
• gastric lavage, emetics, and
• cathartics for acute ingestion.

It is important to remember, however, that these measures are not recommended for all toxicants and might be contraindicated for some. It is important to consult an up-to-date resource, such as a poison control center or pediatric toxicologists, for substance-specific treatment recommendations.

Standard supportive medical protocols and pharmaceuticals are used to treat the majority of environmental illnesses. In most situations, the environmental contribution to an illness will not be immediately apparent. Standard therapies pending determination of an environmental cause or trigger are called for in cases of

• respiratory failure,
• cancer,
• asthma,
• contact dermatitis, and
• other medical conditions.

Even then, medical treatment only rarely involves the use of medical therapies specific to a particular chemical agent. The Medical Management Guidelines for Acute Chemical Exposures [ATSDR 2001] reviews the appropriate medical management of many of the most common acute chemical exposures. A pediatrician should strongly consider consultation for many acute known exposures when or if the child is very ill or for unknown exposures when the child’s signs and symptoms do not follow a usual pattern. Such consultation can be with

• pediatric emergency specialists,
• pediatric intensive care specialists,
• medical toxicologists, and/or
• pediatric environmental medicine specialists (e.g., PEHSUs).

Although only relatively few substances have specific medical therapies, the use of such therapies can

• enhance the elimination of an agent,
• block its absorption,
• reverse its effect, or otherwise
• render it less harmful.

After identifying the offending agent, the pediatrician should consult specialists, texts, electronic databases, appropriate agencies such as the Agency for Toxic Substances and Disease Registry (ATSDR), or other experts to ascertain whether specific therapies exist for the exposure. Telephone hotlines through regional poison control centers and ATSDR provide 24-hour support for clinical decision-making in cases of acute exposure.

The pediatrician’s privileged position of trust provides an opportunity to effectively communicate with parents and coordinate medical care in the event of an exposure. The pediatric generalist, however, will rarely have the specialized knowledge needed to manage less common environmental problems. The pediatrician should work with specialized professionals to develop and support an appropriate therapeutic plan. Indications for referral to a pediatric environmental medicine specialist or government or private organization include

• uncertainty about the extent and nature of relevant exposures,
• uncertainty about an environmental relationship to a specific health problem,
• uncertainty in how to characterize a child’s risk of exposure and illness (risk characterization),
• the need for assistance in how to accurately and understandably communicate a child’s risk to parent (risk communication),
• presentation of similar problems from similar environments for several children,
• the need for specialized diagnostic or therapeutic interventions,
• the need for expensive environmental mitigation management, and
• consideration of a novel environmental diagnosis from a hazardous exposure with public health implications.

Effective communication is essential in the formation of a therapeutic alliance between the pediatrician and the family. Unlike standard health education and risk communication, environmental risk communication has its own unique aspects. Among these aspects are

• physician unfamiliarity with environmental risk assessment, and
• lack of information on the child health effects of many chemicals [Kilpatrick et al. 2002; Galvez et al. 2007].

The pediatrician may need more than one visit to fully inform parents of the possible consequences of their child’s exposure. Thus, after delivery of specific, understandable information about the risks due to a child’s exposure, it is also important to give accurate written information to be reviewed by parents at a later time. It is wise to schedule a follow-up appointment to share results of any medical screening tests and to answer questions. The follow-up visit will also provide the opportunity to ask how the child and parents are feeling and to give the family the chance to discuss the emotions the members have experienced. The main goals of these interactions are to give accurate information that enables parents to understand relative risk and to help the family gain and maintain a sense of control over its health risks and concerns.

For concerned parents of well children and for parents whose children may have been exposed to an environmental toxicant, a good way to prevent further exposure is by using problem-focused risk communication.

Among the common substances to which children may be exposed in the home, school, or such outdoor environments as playgrounds are

• second-hand smoke,
• mold,
• radon (indoors),
• carbon monoxide,
• lead,
• mercury,
• pesticides, and
• other chemicals.

Talking to parents about ways to safely prevent exposure (hazard mitigation, removal of hazardous substances, substitution of less toxic products) and referring them to accurate sources of information are good ways to prevent pediatric exposures.

Specific pointers on how to deliver information about environmental risks.

• Use familiar terms to discuss risk (i.e., use air pollution rather than PM2.5 (particulate matter less than 2.5 microns in diameter) or PM10 particulates (particle matter less than 10 microns in diameter). Avoid medical and technical jargon and abbreviations.
• Anxious or upset people can process only a limited amount of information in a short time. Use the rule of threes—present only three main items of information in the first visit.
• Keep messages short and simple.
• Provide concrete steps that parents can take to prevent exposures to their children or to limit health effects from past exposures.
• Provide take-home written materials for parents. Such materials should address exposure-specific information, child sick care, and risk reduction actions needed. Pick materials with visual information, materials that have been developed by experts who have scientific expertise and health education and communication expertise (Galvez et al.2007).

Many states require reporting of specific environmental illnesses, such as lead or pesticide poisoning. Beyond these requirements, however, every case of environmental illness that a pediatrician identifies presents the opportunity to prevent further harm to the patient and to others. If one household member is exposed, others in the household or community may also be exposed. Pediatricians should initiate an appropriate environmental investigation, in consultation with environmental health specialists, in such cases to prevent additional exposures. In cases where public health reporting is not an issue (e.g., urging parents to eliminate exposure to second-hand smoke or removing animals from the home), anticipatory guidance is sufficient. In complex situations, the pediatrician should report environmental exposures and illnesses to public health authorities.

• Six interventions are recommended to manage a pediatric environmental medicine problem:
  1. Ending or minimizing offending exposures.
  2. Delivering standard symptomatic supportive medical therapy.
  3. Determining and delivering substance-specific medical interventions.
  4. Referring to specialists in toxicology and pediatric environmental medicine.
  5. Educating the family and communicating risk.
  6. Public health reporting