Philosophy Engineering Ethics Essay

DOI: 10.1542/peds.2012-2757; originally published online November 26, 2012; 2012;130;e1757 Pediatrics COUNCIL ON ENVIRONMENTAL HEALTH Pesticide Exposure in Children http://pediatrics.aappublications.org/content/130/6/e1757.full.html located on the World Wide Web at:

Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by th\ e American Academy published, and trademarked by the American Academy of Pediatrics, 141 No\ rthwest Point publication, it has been published continuously since 1948. PEDIATRICS i\ s owned, PEDIATRICS is the official journal of the American Academy of Pediatrics\ . A monthly by guest on December 12, 2012 pediatrics.aappublications.org Downloaded from POLICY STATEMENT Pesticide Exposure in Childrenabstract This statement presents the position of the American Academy of Pe- diatrics on pesticides. Pesticides are a collective term for chemicals intended to kill unwanted insects, plants, molds, and rodents. Children encounter pesticides daily and have unique susceptibilities to their po- tential toxicity. Acute poisoning risks are clear, and understanding of chronic health implications from both acute and chronic exposure are emerging. Epidemiologic evidence demonstrates associations between early life exposure to pesticides and pediatric cancers, decreased cog- nitive function, and behavioral problems. Related animal toxicology studies provide supportive biological plausibility for these ﬁndings.

Recognizing and reducing problematic exposures will require attention to current inadequacies in medical training, public health tracking, and regulatory action on pesticides. Ongoing research describing toxico- logic vulnerabilities and exposure factors across the life span are needed to inform regulatory needs and appropriate interventions. Pol- icies that promote integrated pest management, comprehensive pes- ticide labeling, and marketing practices that incorporate child health considerations will enhance safe use. Pediatrics2012;130:e1757 –e1763 INTRODUCTION Pesticides represent a large group of products designed to kill or harm living organisms from insects to rodents to unwanted plants or ani- mals (eg, rodents), making them inherently toxic (Table 1). Beyond acute poisoning, the in ﬂuences of low-level exposures on child health are of increasing concern. This policy statement presents the position of the American Academy of Pediatrics on exposure to these products.

It was developed in conjunction with a technical report that provides a thorough review of topics presented here: steps that pediatricians should take to identify pesticide p oisoning, evaluate patients for pesticide-related illness, provide appropriate treatment, and prevent unnecessary exposure and poisoning. 1Recommendations for a regula- tory agenda are provided as well, recognizing the role of federal agen- cies in ensuring the safety of children while balancing the positive attributes of pesticides. Repellents r eviewed previously (eg, N,N-diethyl- meta-toluamide, commonly known as DEET; picaridin) are not discussed. 2 SOURCES AND MECHANISMS OF EXPOSURE Children encounter pesticides daily in air, food, dust, and soil and on surfaces through home and public lawn or garden application, household insecticide use, application to pets, and agricultural product COUNCIL ON ENVIRONMENTAL HEALTH KEY WORDS pesticides, toxicity, children, pest control, integrated pest management ABBREVIATIONS EPA —Environmental Protection Agency IPM —integrated pest management This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have ﬁled con ﬂict of interest statements with the American Academy of Pediatrics. Any con ﬂicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaf ﬁrmed, revised, or retired at or before that time.

www.pediatrics.org/cgi/doi/10.1542/peds.2012-2757 doi:10.1542/peds.2012-2757 PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2012 by the American Academy of Pediatrics PEDIATRICS Volume 130, Number 6, December 2012 e1757 FROM THE AMERICAN ACADEMY OF PEDIATRICS Organizational Principles to Guide and Deﬁne the Child Health Care System and/or Improve the Health of all Children by guest on December 12, 2012 pediatrics.aappublications.org Downloaded from residues. 3– 9 For many children, diet may be the most in ﬂuential source, as illustrated by an intervention study that placed children on an organic diet (produced without pesticide) and observed drastic and immediate de- crease in urinary excretion of pesticide metabolites.

10 In agricultural settings, pesticide spray drift is important for residences near treated crops or by take-home exposure on clothing and footwear of agricultural workers. 9,11,12 Teen workers may have occupational exposures on the farm or in lawn care. 13 –15 Heavy use of pesticides may also occur in urban pest control. 16 Most serious acute poisoning occurs after unintentional ingestion, although poisoning may also follow inhalational exposure (particularly from fumigants) or signi ﬁcant dermal exposure. 17 ACUTE PESTICIDE TOXICITY Clinical Signs and Symptoms High-dose pesticide exposure may re- sult in immediate, devastating, even lethal consequences. Table 2 summa- rizes features of clinical toxicity for the major pesticides classes. It high- lights the similarities of common clas- ses of pesticides (eg, organophosphates, carbamates, and pyrethroids) and underscores the importance of dis- criminating among them because treat- ment modalities differ. Having an index of suspicion based on familiarity with toxic mechanisms and taking an envi- ronmental history provides the oppor- tunity for discerning a pesticide ’srolein clinical decision-making. 18Pediatric care providers have a poor track record for recognition of acute pesticide poison- ing. 19 –21 This re ﬂects their self-reported lack of medical education and self- ef ﬁcacy on the topic. 22– 26 More in-depth review of acute toxicity and manage- ment can be found in the accompanying technical report or recommended resources in Table 3.

The local or regional poison control center plays an important role as a resource for any suspected pesticide poisoning.

There is no current reliable way to de- termine the incidence of pesticide ex- posure and illness in US children. Existing data systems, such as the American Association of Poison Control Centers ’National Poison Data System or the Na- tional Institute for Occupational Safety and Health ’s Sentinel Event Noti ﬁca- tion System for Occupational Risks, 27,28 capture limited information about acute poisoning and trends over time.

Thereisalsononationalsystematic reporting on the use of pesticides by consumers or licensed professionals. The last national survey of consumer pesti- cide use in homes and gardens was in 1993 (Research Triangle Institute study). 29 Improved physician education, accessi- ble and reliable biomarkers, and better diagnostic testing methods to readily identify suspected pesticide illness would signi ﬁcantly improve reporting andsurveillance.Suchtoolswouldbe equally important in improving clinical decision-making and reassuring fami- lies if pesticides can be eliminated from the differential diagnosis.

The Pesticide Label The pesticide label contains informa- tion for understanding and preventing acute health consequences: the active ingredient; signal words identifying acute toxicity potential; US Environ- mental Protection Agency (EPA) regis- tration number; directions for use, including protective equipment rec- ommendations, storage, and disposal; and manufacturer ’s contact informa- tion. 30 Basic ﬁrst aid advice is pro- vided, and some labels contain a “note for physicians ”with speci ﬁc relevant medical information. The label does not specify the pesticide class or “ other ”/“ inert ”ingredients that may have signi ﬁcant toxicity and can ac- count for up to 99% of the product.

Chronic toxicity information is not in- cluded, and labels are predominantly available in English. There is signi ﬁcant use of illegal pesticides (especially in immigrant communities), off-label use, and overuse, underscoring the impor- tance of education, monitoring, and enforcement. 31 TABLE 1 Categories of Pesticides and Major Classes Pesticide category Major Classes Examples Insecticides Organophosphates Malathion, methyl parathion, acephate Carbamates Aldicarb, carbaryl, methomyl, propoxur Pyrethroids/pyrethrins Cypermethrin, fenvalerate, permethrin Organochlorines Lindane Neonicotinoids Imidacloprid N-phenylpyrazoles Fipronil Herbicides Phosphonates Glyphosate Chlorophenoxy herbicides 2,4-D, mecoprop Dipyridyl herbicides Diquat, paraquat Nonselective Sodium chlorate Rodenticides Anticoagulants Warfarin, brodifacoum Convulsants Strychnine Metabolic poison Sodiumﬂuoroacetate Inorganic compounds Aluminum phosphide Fungicides Thiocarbamates Metam-sodium Triazoles Fluconazole, myclobutanil, triadimefon Strobilurins Pyraclostrobin, picoxystrobin Fumigants Halogenated organic Methyl bromide, Chloropicrin Organic Carbon disulﬁde, Hydrogen cyanide, Naphthalene Inorganic Phosphine Miscellaneous Arsenicals Lead arsenate, chromated copper arsenate, arsenic trioxide Pyridine 4-aminopyridine e1758 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on December 12, 2012 pediatrics.aappublications.org Downloaded from CHRONIC EFFECTS Dosing experiments in animals clearly demonstrate the acute and chronic toxicity potential of multiple pesticides.

Many pesticide chemicals are classi- ﬁed by the US EPA as carcinogens. The past decade has seen an expansion of the epidemiologic evidence base supporting adverse effects after acute and chronic pesticide exposure in children. This includes increasingly sophisticated studies addressing combined exposures and genetic susceptibility. 1 Chronic toxicity end points identi ﬁed in epidemiologic studies include adverse birth outcomes including preterm birth, low birth weight, and congenital TABLE 2 Common Pesticides: Signs, Symptoms, and Management Considerations a Class Acute Signs and Symptoms Clinical Considerations Organophosphate and N-methyl carbamate insecticides Headache, nausea, vomiting, abdominal pain, and dizziness Obtain red blood cell and plasma cholinesterase levels Hypersecretion: sweating, salivation, lacrimation, rhinorrhea, diarrhea, and bronchorrhea Atropine is primary antidote Muscle fasciculation and weakness, and respiratory symptoms (bronchospasm, cough, wheezing, and respiratory depression) Pralidoxime is also an antidote for organophosphate and acts as a cholinesterase reactivator Bradycardia, although early on, tachycardia may be present Because carbamates generally produce a reversible cholinesterase inhibition, pralidoxime is not indicated in these poisonings Miosis Central nervous system: respiratory depression, lethargy, coma, and seizures Pyrethroid insecticides Similar ﬁndings found in organophosphates including the hypersecretion, muscle fasciculation, respiratory symptoms, and seizures At times have been mistaken for acute organophosphate or carbamate poisoning Headache, fatigue, vomiting, diarrhea, and irritability Symptomatic treatment Dermal: skin irritation and paresthesia Treatment with high doses of atropine may yield signi ﬁcant adverse results Vitamin E oil for dermal symptoms Neonicotinoid insecticides Disorientation, severe agitation, drowsiness, dizziness, weakness, and in some situations, loss of consciousness Supportive care Vomiting, sore throat, abdominal pain Consider sedation for severe agitation Ulcerations in upper gastrointestinal tract No available antidote No available diagnostic test Fipronil (N-phenylpyrazole insecticides) Nausea and vomiting Supportive care Aphthous ulcers No available antidote Altered mental status and coma No available diagnostic test Seizures Lindane (organochlorine insecticide) Central nervous system: mental status changes and seizures Control acute seizures with lorazepam Paresthesia, tremor, ataxia and hyperre ﬂexia Lindane blood level available as send out Glyphosate (phosphonate herbicides) Nausea and vomiting Suppor tive care Aspiration pneumonia type syndrome Pulmonary effects may be secondary to organic solvent Hypotension, altered mental status, and oliguria in severe cases Pulmonary effects may in fact be secondary to organic solvent Chlorophenoxy herbicides Skin and mucous membrane irritation Consider urine alkalinization with sodium bicarbonate in IV ﬂuids Vomiting, diarrhea, headache, confusion Metabolic acidosis is the hallmark Renal failure, hyperkalemia, and hypocalcemia Probable carcinogen Rodenticides (long-acting anticoagulants) Bleeding: gums, nose, and other mucous membrane sites Consider PT (international normalized ratio) Bruising Observation may be appropriate for some clinical scenarios in which it is not clear a child even ingested the agent Vitamin K indicated for active bleeding (IV vitamin K) or for elevated PT (oral vitamin K) IV, intravenous; PT, prothrombin time.aExpanded version of this table is available in the accompanying technical report. 1 PEDIATRICS Volume 130, Number 6, December 2012 e1759 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on December 12, 2012 pediatrics.aappublications.org Downloaded from anomalies, pediatric cancers, neuro- behavioral and cognitive deﬁcits, and asthma. These are reviewed in the accompanying technical report. The evidence base is most robust for associations to pediatric cancer and adverse neurodevelopment. Multiple case-control studies and evidence re- views support a role for insecticides in risk of brain tumors and acute lym- phocytic leukemia . Prospective con- temporary birth cohort studies in the United States link early-life exposure to organophosphate insecticides with reductions in IQ and abnormal behav- iors associated with attention-de ﬁcit/ hyperactivity disorder and autism. The need to better understand the health implications of ongoing pesticide use practices on child health has bene ﬁted from these observational epidemiologic data. 32 EXPOSURE PREVENTION APPROACHES The concerning and expanding evidence base of chronic health consequences of pesticide exposure underscores the importance of efforts aimed at de- creasing exposure.

Integrated pest management (IPM) is an established but undersupported approach to pest control designed to minimize and, in some cases, replace the use of pesticide chemicals while achieving acceptable control of pest populations. 33 IPM programs and knowledge have been implemented in agriculture and to address weeds and pest control in residential settings and schools, commercial structures, lawn and turf, and community gar- dens. Reliable resources are available from the US EPA and University of California —Davis (Table 3). Other local policy approaches in use are posting warning signs of pesticide use, restrict- ing spray zone buffers at schools, or restricting speci ﬁctypesofpesticide products in schools. Pediatricians can TABLE 3 Pesticide and Child Health Resources for the Pediatrician Topic/Resource Additional Information Contact Information Management of acute pesticide poisoning Recognition and Management of Pesticide Poisonings Print:ﬁfth (1999) is available in Spanish, English; 6th edition available 2013 http://www.epa.gov/pesticides/safety/healthcare/handbook/ handbook.htm Regional Poison Control Centers 1 (800) 222-1222 Chronic exposure information and specialty consultation The National Pesticide Medical Monitoring Program (NPMMP) Cooperative agreement between Oregon State University and the US EPA.

NPMMP provides informational assistance by E-mail in the assessment of human exposure to pesticides [email protected] or by fax at (541) 737-9047 Pediatric Environmental Health Specialty Units (PEHSUs) Coordinated by the Association of Occupational and Environmental Clinics to provide regional academically based free consultation for health care providers www.aoec.org/PEHSU.htm; toll-free telephone number (888) 347-AOEC (extension 2632) Resources for safer approaches to pest control US EPA Consumer information documents www.epa.gov/oppfead1/Publications/Cit_Guide/citguide.pdf Citizens Guide to Pest Control and Pesticide Safety Household pest control Alternatives to chemical pesticides How to choose pesticides How to use, store, and dispose of them safely How to prevent pesticide poisoning How to choose a pest-control company Controlling pests Recommended safest approaches and examples of programs www.epa.gov/pesticides/controlling/index.htm The University of California Integrative Pest Management Program Information on IPM approaches for common home and garden pests www.ipm.ucdavis.edu Other resources National research programs addressing children ’s health and pesticides NIEHS/EPA Centers for Children ’s Environmental Health & Disease Prevention Research www.niehs.nih.gov/research/supported/centers/prevention The National Children ’s Study www.nationalchildrensstudy.gov/Pages/default.aspx US EPA Pesticide product labels www.epa.gov/pesticides/regulating/labels/product-labels.

htm#projects The National Library of Medicine “Tox Town ” Section on pesticides that includes a comprehensive and well-organized list of web link resources on pesticides http://toxtown.nlm.nih.gov/text_version/chemicals.php?id=23 e1760 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on December 12, 2012 pediatrics.aappublications.org Downloaded from play a role in promotion of develop- ment of model programs and practices in the communities and schools of their patients.

RECOMMENDATIONS Three overarching principles can be identiﬁed: (1) pesticide exposures are common and cause both acute and chronic effects; (2) pediatricians need to be knowledgeable in pesticide iden- ti ﬁcation, counseling, and management; and (3) governmental actions to improve pesticide safety are needed. Whenever new public policy is developed or ex- isting policy is revised, the wide range of consequences of pesticide use on chil- dren and their families should be con- sidered. The American Academy of Pediatrics, through its chapters, com- mittees, councils, sections, and staff, can provide information and support for public policy advocacy efforts. See http:// www.aap.org/advocacy.html for addi- tional information or contact chapter leadership.

Recommendations to Pediatricians 1. Acute exposures: become familiar with the clinical signs and symp- toms of acute intoxication from the major types of pesticides. Be able to translate clinical knowledge about pesticide hazards into an appropriate exposure history for pesticide poisoning.

2. Chronic exposures: become familiar with the subclinical effects of chronic exposures and routes of exposures from the major types of pesticides.

3. Resource identi ﬁcation: know lo- cally available resources for acute toxicity management and chronic low-dose exposure (see Table 3).

4. Pesticide labeling knowledge: Under- stand the usefulness and limitations of pesticide chemical information on pesticide product labels.

5. Counseling: Ask parents about pes- ticide use in or around the home to help determine the need for provid- ing targeted anticipatory guidance.

Recommend use of minimal-risk products, safe storage practices, and application of IPM (least toxic methods), whenever possible.

6. Advocacy: work with schools and governmental agencies to advocate for application of least toxic pesti- cides by using IPM principles. Pro- mote community right-to-know procedures when pesticide spray- ing occurs in public areas.

Recommendations to Government 1. Marketing: ensure that pesticide products as marketed are not at- tractive to children.

2. Labeling: include chemical ingredi- ent identity on the label and/or the manufacturer ’s Web site for all product constituents, including inert ingredients, carriers, and solvents.

Include a label section speci ﬁcto “ Risks to children, ”which informs users whether there is evidence that the active or inert ingredients have any known chronic or develop- mental health concerns for children.

Enforce labeling practices that en- sure users have adequate informa- tion on product contents, acute and chronic toxicity potential, and emer- gency information. Consider printing or making available labels in Span- ishinadditiontoEnglish.

3. Exposure reduction: set goal to re- duce exposure overall. Promote appli- cation methods and practices that minimize children ’s exposure, such as using bait stations and gels, advis- ing against overuse of pediculicides.

Promote education regarding proper storage of product.

4. Reporting: make pesticide-related suspected poisoning universally re- portable and support a systematic central repository of such inci- dents to optimize national surveil- lance. 5. Exportation: aid in identi ﬁcation of least toxic alternatives to pesticide use internationally, and unless safer alternatives are not available or are impossible to implement, ban export of products that are banned or restricted for toxicity concerns in the United States.

6. Safety: continue to evaluate pesti- cide safety. Enforce community right-to-know procedures when pes- ticide spraying occurs in public areas. Develop, strengthen, and en- force standards of removal of con- cerning products for home or child product use. Require development of a human biomarker, such as a urinary or blood measure, that can be used to identify exposure and/or early health implications with new pesticide chemical regis- tration or reregistration of existing products. Developmental toxicity, including endocrine disruption, should be a priority when evaluat- ing new chemicals for licensing or reregistration of existing products.

7. Advance less toxic pesticide alter- natives: increase economic incen- tives for growers who adopt IPM, including less toxic pesticides. Sup- port research to expand and im- prove IPM in agriculture and nonagricultural pest control.

8. Research: support toxicologic and epidemiologic research to better identify and understand health risks associated with children ’sexposure to pesticides. Consider supporting another national study of pesticide use in the home and garden setting of US households as a targeted ini- tiative or through cooperation with existing research opportunities (eg, National Children ’s Study, NHANES).

9. Health provider education and sup- port: support educational efforts to increase the capacity of pediatric health care providers to diag- nose and manage acute pesticide PEDIATRICS Volume 130, Number 6, December 2012 e1761 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on December 12, 2012 pediatrics.aappublications.org Downloaded from poisoning and reduce pesticide ex- posure and potential chronic pesti- cide effects in children. Provide support to systems such as Poison Control Centers to provide timely, expert advice on exposures. Require the development of diagnostic tests to assist providers with diagnosing (and ruling out) pesticide poisoning. LEAD AUTHORS James R. Roberts, MD, MPH Catherine J. Karr, MD, PhD COUNCIL ON ENVIRONMENTAL HEALTH EXECUTIVE COMMITTEE, 2012–2013 Jerome A. Paulson, MD, Chairperson Alice C. Brock-Utne, MD Heather L. Brumberg, MD, MPH Carla C. Campbell, MD Bruce P. Lanphear, MD, MPH Kevin C. Osterhoudt, MD, MSCE Megan T. Sandel, MD Leonardo Trasande, MD, MPP Robert O. Wright, MD, MPH FORMER EXECUTIVE COMMITTEE MEMBERS Helen J. Binns, MD, MPH James R. Roberts, MD, MPH Catherine J. Karr, MD, PhD Joel A. Forman, MD James M. Seltzer, MD LIAISONS Mary Mortensen, MD –Centers for Disease Control and Prevention/National Center for Environmental Health Walter J. Rogan, MD –National Institute of Environmental Health Sciences Sharon Savage, MD –National Cancer Institute STAFF Paul Spire REFERENCES 1. Roberts JR, Karr CK; American Academy of Pediatrics, Council on Environmental Health. Technical report —pesticide expo- sure in children. Pediatrics. 2012:130(6) 2. Katz TM, Miller JH, Hebert AA. Insect repellents: historical perspectives and new developments. J Am Acad Dermatol . 2008; 58(5):865 –871 3. Lewis RG, Fortune CR, Blanchard FT, Camann DE. Movement and deposition of two organophosphorus pesticides within a residence after interior and exterior applications. J Air Waste Manag Assoc .

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