Orchestrating the elimination or reduction of ongoing exposure of a child to an environmental contaminant deemed hazardous or potentially hazardous is one important role for the child health care provider. By hospitalizing a child poisoned by a heavy metal, the physician might initiate hazard reduction by removing the child from the offending environment. Before returning the child to his or her home, however, the environmental hazard must be eliminated or mitigated. Whenever possible, the offending agent should be entirely removed from the child's environment. If the agent serves an important function and it is possible to substitute a less toxic alternative, substitution should be made. For example, homeowners might replace
lead paint with a nonleaded alternative. However, because a toxicant becomes hazardous only to the extent exposure occurs, other measures can often accomplish the goal of hazard reduction more quickly and inexpensively. For example, measures could include (a) blocking pathways of exposure by encapsulating friable
asbestos insulative lagging on pipes to reduce indoor air asbestos contamination or (b) putting household chemicals out of reach. Polluted tap water and poor indoor air quality can sometimes be managed through treatment technologies. Other measures for reducing hazards might include careful home and personal hygiene, including weekly wet-wiping of lead-dust-contaminated windowsills and, for those children living in homes with lead paint, enforced
hand washing before meals and at bedtime.
In many cases, specially trained workers and anticipatory guidance from child health care providers can provide appropriate direction to a family to make an environment safer for a child. Parents of children with
asthma can be given information from the American Lung Association on reducing environmental asthma triggers. Preprinted information for a variety of other hazards such as medicines, pesticides, or other household chemicals can supplement age-appropriate anticipatory guidance. Appendix D lists books and organizations that provide detailed information for families about reducing a child's exposure to environmental hazards.
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 poison himself or herself and others (such as children). When in doubt, medical providers should collaborate with public health agencies and remediation specialists. In some cases of typically acute exposures, the exposure cessation involves medical as well as environmental interventions. For example, the first responder's treatment of a person who has been exposed to a hazardous pesticide begins with removing the individual from the contaminated environment, removing the individual's tainted clothing, and grossly decontaminating the individual's body (e.g., by giving the individual a shower). More refined decontamination then continues in the medical setting. Other medical interventions designed to stop the absorption of certain toxicants include the use of activated charcoal, gastric lavage, emetics, and cathartics for acute ingestion. However, it is important to remember that these measures are not recommended for all toxicants and might be contraindicated for some. Therefore, you must check with an up-to-date resource, such as the local poison control center, for current 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. Respiratory failure, asthma, contact dermatitis, cancer, and other medical conditions call for standard therapies, pending determination of an environmental cause or trigger. 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 2001d) reviews the appropriate medical management of many of the most common acute chemical exposures. 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, consultation with hospital emergency room physicians, pediatric intensive care specialists, medical toxicologists, and/or environmental medicine specialists should be considered (e.g., PEHSUs).
Although only relatively few substances have specific medical therapies, these 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 child health care provider should consult texts, electronic databases, agencies, or experts to ascertain whether specific therapies exist for the exposure. Telephone hotlines through regional poison control centers, ATSDR, and PEHSUs, provide 24-hour support for clinical decision-making in cases of acute exposure (Appendix D).
The primary health care provider's privileged position of trust with patients provides an early opportunity for more effective communication with parents and coordination of medical care in the event of an exposure. The pediatric generalist, however, will rarely have the specialized knowledge necessary for the management of less common environmental problems. The practitioner should work with specialized professionals to develop and support an appropriate therapeutic plan. Indications for referral to an environmental medicine specialist or government or private organization for assistance include the following:
uncertainty about the extent and nature of relevant exposures,
uncertainty about an environmental relationship to a specific health problem,
uncertainty in risk characterization,
the need for assistance with accurate and understandable risk communication information,
presentation of similar problems from similar environments for several patients,
the need for specialized diagnostic or therapeutic interventions,
the need for expensive environmental mitigation management,
consideration of a novel environmental diagnosis, and
a hazardous exposure with public health implications.
Communication is essential in forming the necessary therapeutic alliance among the health care worker, the patient, and the patient's family. A communication tool designed by Bernzweig et al. (1994) can enhance clinician-patient interaction.
Many states require reporting of specific environmental illnesses such as lead or pesticide poisoning. Beyond these requirements, however, every case of environmental illness that the child health care provider identifies presents the opportunity for preventing further harm not only to the actual patient, but also to others. If one household member was exposed, presumably others in the household or community might also be exposed unless the physician initiates an appropriate environmental investigation with the help of those with special expertise. The physician has an obligation to take steps to prevent these additional exposures. In cases where public health reporting is not an issue (e.g., urging parents to eliminate exposure to ETS or remove animals from the home), anticipatory guidance could be important. In complex situations, the physician should report environmental exposures and illnesses to the appropriate public health authorities.
