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Environmental History-Taking
Sophie J. Balk, MD, Stacie Walton-Brown, MD, MPH,
Andy Pope, PhD
This module presents a series of questions that will enable students or residents to
incorporate environmental and occupational history-taking into health supervision
("well child") visits of infants, toddlers/preschoolers, school-aged children, and adolescents.
The suggested questions can also be used to explore the source of persistent
symptoms in sick children. The module reviews the environmental toxicants most
commonly encountered by children and in some cases recommends steps parents
can take to reduce their child's exposure to these substances. The recommended learning
methods are lecture and small groups/role playing. A set of draft home audit questionnaires
to can be completed by the clinician or the parent are provided as samples
in an addendum.
Learning Objectives
After completion of this module, faculty will be able to teach students or residents to:
- Identify common environmental toxicants that may be present in a child's environment
- Integrate environmental questions into well-child visits
General Principles of Environmental History Taking
This section addresses how pediatric care providers may incorporate environmental
history-taking into practice during health supervision visits.
Health Supervision Visits
Health supervision visits are opportunities to:
- Inquire about environmental issues
- Provide anticipatory guidance to prevent or abate exposures
- Shed light on exposures that may relate to persistent symptoms
- Empower parents to seek answers to their environmental concerns from their health care provider and from local and national resources and organizations
Areas of Inquiry
Any environmental history will need to be tailored to the local environment of the
practicing clinician or faculty member. The health care provider should discuss the
following four areas of environmental health during comprehensive and interval visits:
- Daily environment (including the home, day-care setting, etc.)
- Occupational exposures (of the parents and children/teenagers, if pertinent)
- Lead exposures
- Child's diet
The suggested questions within each of these areas are basic, brief, and easily incorporated
into the standard medical history. Information is also provided to serve as a
basis for formulating further questions. As with other aspects of history-taking, each
question should consider the patient's developmental stage. Certain questions should
be tailored to specific community problems.
Daily Environment
The daily environment is any area in which the child spends significant, regular
amounts of time. It may encompass the:
- Home
- Day-care setting
- School
- Areas where the child engages in a hobby
Health care providers should question the parent about the following features of
the daily environment:
- What type of dwelling (apartment, private home, or mobile home) does the child live in?
Children living in private homes or apartments may be exposed to friable asbestos,
radon, or formaldehyde.
Friable Asbestos
Children who live in basements or on lower floors may be exposed to asbestos
(AAP, 1987). The main household uses of asbestos are as an insulator, an additive
to plaster compounds, and an ingredient of vinyl products. Asbestos becomes
a health hazard if it deteriorates and asbestos fibers are released into the
air. Asbestos does not have immediate health effects, but exposure increases the
risk of lung cancer (i.e. mesothelioma) many years later.
Parents may need advice about how to test for asbestos and what to do to prevent
exposure to friable asbestos. The Network's Resource Guide on Children's
Environmental Health publication and web site edition (www.cehn.org) can link
you to resources for further information on asbestos, including educational materials
and testing information.
Radon
Radon is also of particular concern if the family lives or spends significant time in
lower floors or basements, where this colorless, odorless gas tends to concentrate
(AAP, 1989). Radon is a natural by-product of uranium decay. Radon itself is
harmless, but its progeny attach to particulates in the air and are taken into the
lung, exposing the bronchial stem cells to radiation.. Radon has no immediate
health effects but is associated with an increased risk of lung cancer after a latency period of many years. Exposed individuals who smoke may increase their
risk of developing lung disease.
Radon is more prevalent in certain geographic regions, so health care providers
should consult their local health department to determine whether radon is considered
to be a significant risk in their area of practice. Parents may need advice
about how to test for radon and what to do to minimize exposure. The Network's
Resource Guide on Children's Environmental Health publication and web site
edition (www.cehn.org) can link you to resources for further information on radon,
including educational materials and testing information.
Formaldehyde
Children inhabiting mobile homes may be exposed to formaldehyde. Formaldehyde
may volatilize from construction materials, such as particle board and
pressed wood products, which are used heavily in mobile home construction
(Ritchie, 1987). Symptoms of formaldehyde exposure include respiratory and skin
irritation, headache, nausea, and vomiting.
- What is the age and condition of the building?
Dwellings built before 1960 are more likely to have leaded paint in poor condition,
which can flake or create dust which is then ingested by young children. Lead paint
is the major source of high-dose lead exposure for American children, and its use in
household paints was banned in 1978.
- Is the dwelling newly constructed or undergoing renovation?
Both newly built and remodeled homes can be a source of toxic exposures. Materials
used in modern construction, such as formaldehyde in carpet adhesive and
pressed wood products, can cause health problems. Toxicants used in the old home
(e.g. lead, asbestos) can be released during renovation.
- Are there smokers in the household?
Children exposed to environmental tobacco smoke (ETS) are at risk for significant
morbidity and mortality, such as increased incidence of sudden infant death syndrome
(SIDS), asthma and other respiratory conditions, and the development of
lung cancer as adults (Taylor, 1995; Janerich, 1990). ETS exposure exacerbates symptoms
in children with recurrent respiratory infections, reactive airway disease, and
middle ear disease (EPA, 1992; AAP, 1994). In addition, parents who smoke are more
likely to have children who smoke.
- What is the heating source for the home?
Exposure to wood smoke from a wood stove or fireplace may precipitate or worsen
respiratory symptoms (Honicky, 1985). Respiratory irritants such as nitrogen dioxide
(NO 2 ), respirable particulates, and polycyclic aromatic hydrocarbons can be
emitted in high concentrations from fireplaces and wood stoves that are not regularly
cleaned or are improperly vented. Another combustion by-product, carbon
monoxide (CO), can cause fatigue at low concentrations and headaches, dizziness,
weakness, confusion, nausea, or even death at higher concentrations. NO 2 exposure
can also result from combustion of natural gas, and may be a problem when gas
stoves are used either for supplemental heat or to boil water continuously to humidify
a room. (Sterling, 1979)
- Are any pesticides used in the home/yard?
Exposure to pesticides used indoors or in lawn-care products may have an acute or
chronic effect if the child comes in contact with a freshly sprayed surface. An infant's
breathing zone is close to the ground, where pesticide concentrations are highest;
exposure may also occur through dermal absorption. The most frequent exposures
are to carbonate and organophosphate insecticides.
- Does your child engage in any hobbies that may expose him/her to toxic chemicals?
Children and teenagers may be exposed to toxic chemicals during arts and crafts
activities and other hobbies. Lead can be encountered in artists' paint, stained glass
making, furniture refinishing, and shooting at indoor firing ranges (Babin, 1988).
Model-building can expose the child to toluene and other dangerous organic solvents.
Children at special risk include: those who are visually impaired and thus
likely to work close to a project, physically handicapped children who may inadvertently
contaminate themselves, and asthmatics.
- Are there any environmental factors in the larger community that may affect the child's health?
Health care providers should assess the local community in which their patients
reside. It is important to consider whether the home, school, or day-care center is
near any site of potential toxic exposureópolluted lakes or streams, industrial plants,
freeways, commercial businesses, or dump sites. Health care providers should be
aware of recent incidents of toxic emissions in the area. Poor air quality should also
be considered as an etiological factor in children with respiratory problems.
Occupational Exposures
Parental Occupation
Information about the parents' workplace environment should be obtained during
the course of a standard family health history.
- Take-home Exposures
"Take-home" exposures may result from parental occupational exposures to
toxicants which are brought home on clothes, shoes, skin surfaces, and in
cars (Chisolm, 1978). Take-home exposures described in the medical literature
include: lead poisoning in children of lead storage battery workers
(Watson, 1978); elevated mercury levels in children whose parents worked in
a mercury thermometer plant (Hudson, 1987); and asbestos-related diseases
in families of shipyard workers (Rilburn, 1985).
- At-home Occupations
At-home work and hobbies may also endanger children. Parents who work at
home with certain arts and crafts materials can expose children to toxicants such
as lead, which is used in solder in stained glass making and in pottery glazes.
Child and Adolescent Employment
An estimated 4 million children are legally employed in the United States, and
illegal employment of children is increasingly common (AAP, 1995). Children may
be employed in fields or sweatshops, often under dangerous conditions. Employment
may help a teenager to develop a sense of responsibility, learn new
skills, and earn money, but it also may interfere with school, sleep, and socializing.
Working children and teens risk exposure to toxins and physical injury. Recent
reports have documented that each year, working children and adolescents
account for more than 30,000 injuries, 20,000 compensation claims, thousands
of cases of permanent disability, and more than 100 deaths. Those illegally employed
have a much greater likelihood of injury (AAP, 1995).
Federal and state child labor laws regulate minimum ages for general and specific
types of employment, the maximum daily and weekly hours of work permitted,
and the types of work permitted. Work permits ("working papers") are issued
to children by state and local school systems. Health care providers are often
asked to provide medical clearance for these permits, which gives the provider
an opportunity to inquire about the extent and nature of the child's work. If it is
hazardous or illegal, it should be discussed with the patient and parent. The
clinician can withhold medical clearance for the work permit, if necessary.
Health care providers who treat an injured or toxically-exposed child or adolescent
should take a brief occupational history. If an occupational cause is established
or suspected, the provider can notify state labor and health agencies.
Lead
The following passages are based on the Childhood Lead Toxicity in this manual, by Morri Markowitz, MD.
Until 1997, the Centers for Disease Control and Prevention (CDC) recommended
universal screening of all preschool children. Given the fall in prevalence of lead
poisoning, the CDC revised its guidelines: the universal screening policy has been
replaced by a policy of local risk assessment of exposure to lead. State and local
health departments are now responsible for determining the level of risk of exposure
and for issuing policy guidelines for providers. In the absence of formal local
guidance, "universal screening should be carried out" (CDC,1997).
This means that all children should be screened by blood lead measurement at 12
and 24 months of age, and at 36-72 months of age if not previously screened. Targeted
screening may suffice when local risk has been officially defined and found to
be low.
Minimum Personal Risk Questionnaires (see below) may be used as a first-pass
screening method, followed by blood lead testing if the answers indicate high risk.
Overall, the sensitivity of questionnaires designed to identify lead-poisoned children
is about 60-70%. Sensitivity can be improved when local conditions are considered
and locally appropriate questions are added.
Minimum Personal Risk Questionnaire (CDC, 1997)
- Does the child reside in or regularly visit a house that was built before
1950? (Include settings such as daycare, and a babysitter, or relative's home)
- Does the child reside in or regularly visit a house built before 1978 under-going
recent (past 6 months) or current renovation?
- Does the child have a sibling or playmate who has been diagnosed with
lead poisoning?
Alternatively, selection for blood lead testing may be based on residence in a
geographic area known to have large amounts of lead or on membership in a
high-risk group, such as indigent children.
A blood lead level >10 mg/dL is considered elevated (CDC, 1991).
Diet
The child's diet may place him/her at risk for exposure to environmental toxicants.
Areas of particular concern are pesticides, PCBs and PBBs, and lead. Environmental
history taking questions should pertain to:
- Pesticides and other compounds in breast milk
Maternal medications and nicotine metabolites may be transferred from mother
to infant via breast milk. In addition, lipid-soluble chemicals such as pesticides,
polychlorinated biphenyls (PCBs), and polybrominated biphenyls (PBBs) may
contaminate breast milk (Schwartz, 1983). Health care providers should be aware
of any state or county health advisories warning against ingestion of fish contaminated
by polluted lakes or streams. Clinicians should continue to advise
breast feeding unless mothers have ingested contaminated fish (AAP, 1978).
- Lead in water used for formula preparation
Lead in water is of particular concern for formula-fed infants and toddlers. Parents
should consider testing their water supply for lead if the baby's formula is
made with tap water. If this is not feasible, water standing in pipes overnight
should be run for two minutes, or until cold, before use. (Flushing may not be
effective in high-rise buildings with large diameter pipes.)
Hot tap water and water from "instant" hot taps and refrigerator taps should not
be used in making formula because of the possibility of contamination with lead. It is recommended to prepare formula with water that has been sterilized: boil
the water for one minute after the water reaches a full (rolling) boil.
- Pesticide residues in fruits and vegetables
Recently, the National Academy of Sciences (NAS) raised concern about pesticide
residues in foodstuffs (NRC, 1993). There are many unknowns about the
long-term effects of exposure to pesticides, and children may be more vulnerable
than adults. Toddlers' diets typically contain large amounts per body weight of
fresh fruits and vegetables, potentially exposing them to chemicals with possible
carcinogenic, neurotoxic, endocrinologic, and immunotoxic effects. The degree
of implementation of regulatory approaches to control pesticide residues is not
currently considered adequate to protect infants and children.
Parents should encourage children to eat a variety of fruits and vegetables, since
their established health benefits outweigh the risk of consumption of pesticide
residues. Parents can reduce pesticide consumption by buying organic produce.
Buying in-season produce may avoid exposure to imported and heavily sprayed
items. Parents should wash produce with water only, as soap leaves a residue.
Washing will remove one-half to three-quarters of the residues left on the skin of
the fruit. Peeling removes residues left on the skin but does not affect exposure
to pesticide absorbed systematically within the fruit. Since peeling eliminates
much of the vitamins and fiber, it is recommended only for fruits and vegetables
that are normally peeled before eating, such as bananas and oranges.
The Home Audit
If the areas of concern mentioned above merit further exploration, the health care provider
can ask the parent to complete the home audit included at the end of this module.
Accessing Resources
Although the field of pediatric environmental health is in its infancy, information resources
and referral networks are available; further information can be found in the
Resource Guide on Children's Environmental Health, available in print and on the Network's
web site http://www.cehn.org. Health care providers should also make use of resources
in their community, such as local and state health departments and regional poison
control centers.
Learning Methods: Ten Tips for Teaching
In May 1996, the Children's Environmental Health Network conducted a "Train-the-Trainers"
session for pediatric residency faculty at the Ambulatory Pediatric
Association's annual meeting. Participants in the training session suggested the following
ten tips for teaching environmental history-taking to students and residents.
- Teach By Example
Have students and residents observe faculty taking an environmental history. Observation
is a key to learning. Strengthen faculty knowledge in environmental history
taking in order to improve the caliber of the modeling for residents and students.
Faculty can also ask environmental questions on rounds and serve as a
role model.
- Checklist/In-take Sheet
Utilize a check list of environmental history questions. Add environmental questions
to all standard forms completed by the resident. A check list can also be
used by a preceptor to evaluate and give feedback to the resident or student on
their history taking skills.
- Case Studies
Case studies are an ideal way to teach environmental history taking. Give trainees
simulated or mystery cases to solve. Integrate case studies into Grand Rounds
and noon conferences as part of a lecture. Case studies can also be the basis for
case discussions that will help to incorporate environmental history taking into
differential diagnosis. Flow charts can be created to illustrate how environmental
factors may influence clinical conditions.
- Role Plays
Develop opportunities for residents and students to role play environmental history
taking using hands-on experiences. The role play can be designed in several
ways. You might ask trainees to take an actual history of a colleague. Give a pair
of residents or students a scenario in which one plays a parent and one plays a
health care provider. Scripted environmental problems and pediatric conditions
can be discussed by residents and students in the role play. Ask trainees to use
an environmental history taking questionnaire when solving the scripted environmental
problem.
- Patient Participation
Involve patients in history taking, as exemplified by the checklist. Patients should
be asked about community conditions and the specific conditions where the child
lives. As a supplement, hand-outs and videos shown in the waiting area are good
educational tools for patients.
Determine a "counseling topic of the week" that all residents and students ask
their families that week. Information sheets can be available for both house staff
and families.
As necessary, residents and students can work with patients to assess the home
environment through the use of a home audit checklist.
- Community Participation
Successful environmental history taking is based on an accurate understanding
of the community in which residents and students practice. Take field trips to
learn about the local hazards, including organizing plant tours and visits with
local communities. Be in contact with local community leaders and be aware of
environmental health concerns in the area of your residency program. If possible,
find a week to involve community sites in the training program (e.g. poison control
centers, clinics belonging to the Association of Occupational and Environmental
Clinics). Involve community leaders as resource people for a Grand Rounds
on local conditions.
- Self-Directed Teaching
Develop self-directed teaching tools (e.g. CD-ROM). Video tapes and computerized
simulations are options for self-directed learning and self-assessment.
- Evaluation
Residents and students can be evaluated in a variety of ways to determine changes
in their history taking behavior. Chart audits can specifically look for the inclusion
of environmental history questions in history taking with patients. Skills can also
be evaluated through objective oriented testing, direct observation, or through
use of mock scenarios.
- Training Sites That Can Include Environmental History Taking
Be creative about sites for including environmental history taking. A sampling of
prime spots might include:
- Grand Rounds
- Noon Conferences
- Well Child Clinic
- Continuity Clinic
- PED/ER Clinic
- Prenatal clinics
- Inpatient Settings
- Adolescent Clinic
- School-based clinics
- Subspecialty Clinics
- Journal Clubs
- Things to Remember When Using an Environmental History Checklist
- Tailor questions to local concerns (e.g. urban vs. rural differences). To build
awareness of local concerns, develop a "What's in the community" mapping
exercise for your residents and/or students.
- Use prompts when asking questions of parents.
- Consider giving parents a questionnaire prior to clinical visit.
Questions for Further Discussion with Residents
and Students
- What are the most common environmental problems in your geographic vicinity?
- How much time should you spend taking an environmental health history during a
well-child visit?
- Should all patients fill out environmental health history forms? Home audits?
- What will you do with the information that you receive during the history-taking,
i.e., where will you refer patients who require environmental and occupational health
follow-up?
- What resources do you have at your disposal to assist you in counseling patients on
issues related to environmental health?
Acknowledgments
The training module draws upon previous work of Sophie J. Balk, MD in Contemporary
Pediatrics (Balk, 1996) and the Kids and the Environment: Toxic Hazards Manual (CPHF, 1992).
References
American Academy of PediatricsóCommittee on Environmental Health. PCBs in
breast milk. Pediatrics . 62:407 (1978).
American Academy of PediatricsóCommittee on Environmental Health. Asbestos
exposures in schools. Pediatrics . 79:301 (1987).
American Academy of PediatricsóCommittee on Environmental Health. Radon
exposure: a hazard to children. Pediatrics . 83:799 (1989).
American Academy of PediatricsóCommittee on Environmental Health. Lead
poisoning: From screening to primary prevention. Pediatrics . 92:176 (1993).
American Academy of PediatricsóCommittee on Environmental Health. Tobacco-free
environment: An imperative for the health of children and adolescents.
Pediatrics . 93:866 (1994).
American Academy of PediatricsóCommittee on Environmental Health. The hazards
of child labor. Pediatrics . 95:311 (1995).
Environmental Protection Agency. Respiratory Health Effects of Passive Smoking:
Lung Cancer and Other Disorders. EPA/600/6-90/008F. Washington, DC, Office of
Research and Development, Office of Air and Radiation, 1992.
Babin A, Peltz P, Rossol M. Children's Art Supplies Can Be Hazardous. New York: Center
for Safety in the Arts, 1988.
Balk SJ. The environmental history: asking the right questions. Contemporary Pediatrics
13(2):19-36 (1996).
California Public Health Foundation. Kids and the Environment: Toxic Hazards. Berkeley,
CA: California Public Health Foundation, 1992.
Centers for Disease Control and Prevention. Preventing Lead Poisoning in Young Children. Atlanta, GA: CDC, 1991.
Chisolm JJ. Fouling one's own nest. Pediatrics . 62:614 (1979).
Honicky RE, Osborne JS, Akpom CA. Symptoms of respiratory illness in young
children and the use of wood burning stoves for indoor heating. Pediatrics . 75:587
(1985).
Hudson PJ, Vogt RL, Brodrum J, et al. Elemental mercury exposure among children
of thermometer plant workers. Pediatrics . 79:935 (1987).
Janerich DT, Thompson WD, Varela LR, et al. Lung cancer and exposure to tobacco
smoke in the household. N Engl J Med. 323:632 (1990).
National Research Council. Pesticides in the Diets of Infants and Children. Washington, DC:
National Academy Press, 1993.
Rilburn KH, Lillis R, Anderson HA, et al. Asbestos disease in family contacts of
shipyard workers. Am J Public Health. 75(6):616 (1985).
Ritchie IM, Lehnen RG. Formaldehyde-related health complaints of residents living
in mobile and conventional homes. Am J Public Health. 77:323 (1987).
Schwartz PM, Jacobson SW, Fein GG, et al. Lake Michigan fish consumption as a
source of polychlorinated biphenyls in human cord serum, maternal serum and
milk. Am J Public Health. 73:293 (1983).
Sterling TD, Sterling E: Carbon monoxide levels in kitchens and homes with gas
cookers. Air Pollution Control Assoc J 29:238 (1979).
Taylor JA, Sanderson MA. Reexamination of the risk factors for the sudden infant
death syndrome. J Pediatr 126:887 (1995).
Watson WN, Witherell LE, Giguere GC: Increased lead absorption in children of
workers in a lead storage battery plant. J Occup Med 20:759 (1978).
Summary of Questions for an Environmental History Taking*
* American Academy of Pediatrics ñ Committee on Environmental Health. Lead poisoning: from
screening to primary prevention. Pediatrics 92:176 (1993)
| Issue |
What to Ask |
|
| The child's home,
school, or day-care
center may expose
him/her to potential
toxicants |
Do you live in an apartment, house, or mobile home?
On what level of your dwelling is the child's room located?
What is the age and condition of your home?
How is your home heated?
Do you have a fireplace or a wood stove?
Do you use pesticides inside or outside your home?
What hobbies do your child and other family members have?
Is your home (day-care center, etc.) near a polluted body of
water, industrial plant, commercial business, or dump site? |
|
| Family members'
jobs may involve
exposure to contaminants |
What is your occupation?
What is your spouse's occupation?
Do other members of the family have jobs?
If so, what are they?
For teenagers:
Do you work?
What kind of job do you have and what hours do you work? |
|
| The child may be
exposed to tobacco
smoke |
Do you smoke tobacco products?
If so, do you smoke in your home?
Does your spouse, other family member, or baby-sitter
smoke?
If you take your child to a baby-sitter, does he or she smoke
at home?
Do visitors smoke in your home?
Does anyone smoke in your car? |
|
| The child may eat
food contaminated
with environmental
toxicants |
For breast feeding mothers:
Have you tested your water supply for lead?
If not and you make the baby's formula with tap water,
what procedure do you follow?
Do you ever use hot tap water or water from instant hot
taps or refrigerator taps to make the formula?
Do you wash fruits and vegetables before giving them to
your child?
What do you wash them with?
What kind of produce do you usually buy? Organic? Local?
In season?
Does the child live with an adult whose job or hobby involves
exposure to lead? |
|
| The child may be at
high risk for lead
poisoning |
Is there a brother, sister, housemate, or playmate being
followed or treated
for lead poisoning (blood lead „15 mg/dL)?
Does the child live with an adult whose job or hobby in-volves
exposure to
lead?
Does the child live near an active lead smelter, battery
recycling plant, or
other industry likely to release lead?
Do you use home remedies or pottery from another country?
Issue |
When to Introduce Environmental Questions
| Topic |
The Right Time |
|
| Home renovation, smoking, breast and bottle issues |
Prenatal period |
| Environmental tobacco smoke |
When child is 2 months old |
| Poison exposures, including household pesticides and lead poisoning |
When child is 6 months old |
| Arts and crafts exposures |
Preschool period |
| Occupational exposures, exposures from hobbies |
When patient is a teenager |
| Lawn and garden products, lawn services, scheduled chemical applications |
Spring and summer |
| Wood stoves and fireplaces, gas stoves |
Fall and winter |
|
