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Taking a Pediatric Exposure History
What Exposure Questions Should Be Included in a Well Child Visit?

Course: WB 1905
CE Original Date: June 3, 2011
CE Renewal Date: June 3, 2013
CE Expiration Date: June 3, 2015
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Learning Objective

Upon completion of this section, you will be able to

  • describe how to take a screening exposure history for a well child visit.

Taking a Screening Exposure History for the Well Child

Pediatricians should take two environmental medicine actions for every well child who presents to an office or a clinic.

  1. A routine screening history for potential environmental exposures.
  2. If necessary, age-appropriate risk-based screening for lead poisoning, using the Centers for Disease Control and Prevention’s (CDC) lead poisoning prevention guidelines [CDC 1997].

A general pediatrician’s practice allows little time for an extensive environmental exposure history. However, initial and subsequent well child visits do give pediatricians opportunities to provide parents and caregivers with educational materials on preventing exposures and actions to take if an exposure occurs. Table 2 lists recommended screening questions and appropriate corrective actions. A written checklist completed by parents may be used to facilitate obtaining the history.

An example of this checklist is the National Environmental Education Foundation Screening Environmental History Form [PDF - 112 KB] at http://www.neefusa.org/health/PEHI/HistoryForm.htm.

Table 2. Screening Questions for the Well Child Screening Exposure History

Any Age - First Visit
Corrective Actions
Where does your child live and spend most of his/her time?
  • The home, day care, school, and, for adolescents, the job setting may have unique environmental hazards.
What is the age and condition of your home?
  • If the home was built prior to about 1978, discuss risks of lead exposure from lead paint.
  • If parents are unsure of the age, they can test paint with an instant lead paint tester.
Are renovations planned or in progress?
  • If a parent is planning renovation, advise how to avoid lead paint exposure.
  • If paint is old, peeling, or in poor repair, the parent should consider de-leading by using a certified contractor.
  • If a patient has been exposed to lead paint, consider blood lead testing for pregnant women and children under age 6.
Do you have fuel-burning appliances and/or chimneys regularly inspected and maintained?
  • If not, advise of the need for regular maintenance to avoid the hazards of carbon monoxide (CO) and other hazardous emissions.
  • Ask about proper ventilation for combustion products from fireplaces, wood stoves, gas stoves, and gas dryers, etc.
Do you have smoke detectors and CO detectors?
  • If there are none, recommend parents to purchase and install smoke detectors and carbon monoxide detectors. When a parent is purchasing CO detectors, recommend they look for UL certification 2034.
Has your home been tested for radon?
  • If not, recommend the homeowner learn how to test for radon exposures that may increase cancer risks (see EPA www.epa.gov/radon).
Does anyone in the family smoke?
  • If yes, provide smoking cessation advice and help.
  • If a smoker can’t stop now, advise that smoker to smoke outside in order to decrease the risk to children and the spouse.
  • The car should be smoke-free.
  • Make sure to advise smokers to change clothes and wash hands before interacting with children.
  • If the smoker is pregnant, strongly urge the smoker to quit smoking in order to avoid health risks to the fetus.

What are the occupations of adults in the household?

Is there an occupational exposure that could affect children’s health?

  • If yes, advise the parents about information sources for job exposures.
Is there an occupational exposure that could affect reproduction?
  • If the occupation is known for exposures that can cause reproductive injury, discuss use of protective equipment and temporary change of duties during the pregnancy.
Is there a chance of take-home contamination from work-related toxicants on clothing?
  • If there is potential for take-home contamination, recommend showering (if possible) and changing to clean clothing and shoes before returning home.
  • Have the adult associated with potential take-home clothing contaminant check with the employer regarding laundering work-related clothes. Provide advice to not wash work-related clothes at home if hazardous exposures could result.
Do you have concerns about environmental hazards in your home or in the surrounding neighborhood?
  • Environmental hazards in the home or surrounding neighborhood may include
    • air quality issues
    • drinking water contamination (check source of drinking, cooking, and bathing water),
    • exposure to hazardous waste sites,
    • toxic releases from industrial facilities,
    • recent spills or chemical accidents near the home, school, day care, or play areas.
    • environmental health issues at school or day care or play areas.
  • Advise parents to call the environmental section of their local health department or the regional EPA if they have concerns about environmental hazards in the surrounding neighborhood.
  • For information on health concerns related to environmental exposures, you or the parents may call the nearest Pediatric Environmental Health Specialty Unit (PEHSU).
For the mother—Do you eat fish?
  • If yes, inquire about the type of fish eaten and how often it is eaten.
Does your child eat fish?
  • If yes, reinforce the value of eating fish for nutritional benefits but advise that fish with known high levels of methylmercury, such as swordfish, shark, king mackerel, and tilefish, should be avoided in the child’s diet.

    Women who are pregnant or nursing and young children should completely avoid eating these fish (for more information see http://www.fda.gov/Food/FoodSafety/
    Product-SpecificInformation/Seafood/
    FoodbornePathogensContaminants/Methylmercury/
    ucm115662.htm

  • Also advise patients to follow local fish advisories for other types of fish or types of contamination, such as high levels of polychlorinated biphenyls (PCBs) in some farm-raised salmon.
Do you take herbal remedies or Ayurvedic (a system of health care native to the Indian subcontinent) medications? If so, which ones?
  • Advise against uses of potentially toxic herbal remedies.
  • If a patient is using Ayurvedic or other folk remedies, check blood lead level, or if the patient is using azogue, check urine elemental mercury levels in consultation with PEHSU experts ( http://aoec.org/PEHSU/).
Do you put creams that could contain paints, pigments, or heavy metals on your skin?
  • Some folk remedy creams or cosmetics can contain lead.
  • If suspicious, check blood lead levels of mother and/or children.
Is your child at risk for lead exposure ?
  • If answers to CDC screening questions are positive, check the blood lead level (CDC, 2005).
  • Federal law requires screening of all Medicaid-eligible children for blood level leads at ages 1 and 2 [AAP Statement on Lead, 2005].
Is your child at risk for sunburn?
  • Sunburns during childhood and adolescence raise the risk of melanoma later in life.
  • Whenever possible, outdoor activities should occur during non-peak sun exposure hours (before 10 AM and after 4 PM).
  • Advise parents to protect children from sunburn with clothing and hats whenever feasible, to have children wear ultraviolet protective sunglasses, and to have children use sunscreen with frequent reapplication (National Council on Skin Cancer Prevention http://www.skincancerprevention.org).

Questions for Well Baby Visits

The following questions can help pediatricians assess environmental exposures especially relevant to infants.

Table 3. Additional Questions for a Well Baby Visit

Well Baby Visit Questions
Corrective Actions
Are you breastfeeding? If yes, potentially exposed mothers should still breastfeed, since the benefits of breastfeeding still outweigh the risks from exposure in most instances.

Do you bottle-feed the baby, or are you planning to introduce bottle-feeding?

If yes, what water will you be using to mix with the formula—tap water, bottled water, or well water?

If tap water, is it from the municipal water system?

If a parent is using well water, it is important to know if there are harmful contaminants, such as nitrates, that can cause methemoglobinemia in young infants.
If well water, have you had it tested for the presence of contaminants, such as bacteria, lead, and nitrates?

If the well water has not been recently tested, advise parents to use municipal water, bottled spring water, or distilled water to mix baby formula and to use as the baby’s drinking water until the well is tested and shown safe for infant feeding.

If tap water is used, advise against over-boiling to avoid concentrating such contaminants as lead. One minute of a rolling boil is sufficient. Alternatively, water may be tested for lead.

Questions to Ask Parent During a Well Toddler and Young School-age Child Visit

For a routine well toddler or young school-age visit, pediatricians should ask the following screening questions in order to determine if any toxic exposures are occurring:

Table 4. Screening Questions for Well Toddler and Young School-age Visit

Toddler and Young School-age Questions
Corrective Actions
Any changes in your home surroundings or jobs? If yes, advise appropriately per initial visit guidance.

Where does the child spend most of his/her time?

Do you have concerns about potential environmental risks?

If the child stays in a child care setting with a neighbor or a relative, ask about exposure to second-hand smoke or lead paint and the presence of CO meters.

Draw blood and check lead levels if the child is at risk, per CDC guidelines (CDC 2005).

Are pesticides used inside or outside your home?

If yes, what type of pesticides? Where are they stored?

Advise parents to store pesticides out of the reach of children.

Be sure that pesticides are not applied in areas where children crawl or play.

Does the child eat fish? Some children may eat excessive amounts of fish high in mercury or other contaminants—advise parents about safer alternatives.
Is the child protected from excessive ultra violet (UV) exposure? Children in child care or pre-school may play outside without adequate UV protection—advise parents about timing activities, using clothing and hats, and proper use of sunscreen.

Questions for Well Adolescent Visit

The following screening questions should be asked during all well adolescent visits.

Table 5. Screening Questions for the Well Adolescent Visit

Well Adolescent Questions
Corrective Actions

Does the adolescent work?

If yes, what is the type of work?

Inform the parent and adolescent about rules regarding child labor restrictions (both national and state regulations).

Does the work expose the adolescent to toxic chemicals, fumes, or dusts or does it involve excessive musculoskeletal stress or work with slicing machines?

Encourage use of protective measures, if indicated.

Does the adolescent smoke?

Is there exposure to SHS?

Advise about the dangers of active and passive smoking.
Is the adolescent protected from excess UV exposure?

Advise about protective measures.

Strongly discourage visits to tanning salons—UV rays from tanning salons are carcinogenic.

Key Points

  • An initial well child visit presents an excellent opportunity to ask basic screening questions about common environmental hazards, including lead exposure.
  • It is important to incorporate age-appropriate questions about environmental hazards during other routine office visits.

   

Progress Check

4. Which of the following statement(s) about taking screening exposure histories is/are true?

A. It is necessary to ask all the screening questions at every visit.
B. A pediatrician should perform age-appropriate risk-based screening for lead poisoning during an initial well child visit, if necessary.
C. There is no need to ask age-specific screening questions because all children are exposed equally.
D. All of the above.
E. None of the above.

Answer:

To review relevant content, see "Taking a Screening Exposure History for the Well Child" in this section.

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