Children's low-level pesticide exposure and associations with autism and ADHD: a review.

Pesticides are chemicals that are designed specifically for the purpose of killing or suppressing another living organism. Human toxicity is possible with any pesticide, and a growing body of literature has investigated possible associations with neurodevelopmental disorders. Attention deficit disorder with or without hyperactivity (ADHD) and autism spectrum disorder (ASD) are two of these specific disorders that have garnered particular interest. Exposure to toxic chemicals during critical windows of brain development is a biologically plausible mechanism. This review describes the basic laboratory science including controlled pesticide dosing experiments in animals that supports a mechanistic relationship in the development of ADHD and/or ASD. Epidemiological relationships are also described for low-level pesticide exposure and ADHD and/or ASD. The available evidence supports the hypothesis that pesticide exposure at levels that do not cause acute toxicity may be among the multifactorial causes of ADHD and ASD, though further study is needed, especially for some of the newer pesticides.

Resource utilization and cost of inserting peripheral intravenous catheters in hospitalized children.

OBJECTIVE: The goal of this study was to measure the costs and difficulty in placing peripheral intravenous (IV) catheters in hospitalized children; measures of resource utilization. We measured the costs and difficulty in placing peripheral intravenous (IV) catheters in hospitalized children. This common procedure has implications for the utilization of hospital resources. METHODS: This was a prospective, large-scale observational study in 2 southeastern US pediatric teaching hospitals evaluating 592 children needing peripheral IV catheters in the inpatient setting. The median age was 2.25 years with an age range of 2 days to 18 years. Costs were estimated by using directly measured staff time and national salary data. Analyses included costs according to patient characteristics (age, weight, dehydration, and difficulty of stick attempts), and nurse characteristics (experience in years and anticipated difficulty). RESULTS: The median cost of the pediatric IV insertions was $41, and 60% of the placements were obtained with the first nurse. Seventy-two percent of the children had a successful IV insertion in 1 to 2 attempts and accounted for 53% of total costs. However, the 28% of children who required > or = 3 IV attempts had a cost range of $69 to more than $125, and they consumed 43% of the total IV costs. This subset was often < 2 years old or dehydrated (P = .0002). CONCLUSIONS: The insertion of peripheral IV catheters in an inpatient setting can be time intensive and requires significant skill. Our study suggests that resource utilization may improve when nurses and personnel proficient in starting peripheral IV catheters are used when the initial nurse has failed to obtain IV access. This systems improvement should result in shortened time to administration of parenteral therapies, positively improving outcomes and lessening length of stay, as well as improving patient/family satisfaction due to reduced perceptions of pain.

Are children still at risk for lead poisoning?

BACKGROUND: The prevalence of elevated blood lead levels (EBLLs) has decreased nationally, creating challenges in identifying children at risk. METHODS: In a community known to have lead hazards, we screened children with a field-administered capillary blood lead test and asked parents to complete a questionnaire about lead risk factors. RESULTS: Of the 77 child-parent pairs screened with a blood lead test and a parental questionnaire, 4 had finger stick blood lead levels of ≥10 µg/dL. Of these, one child had a confirmatory venous blood lead level >10 µg/dL (1.3%; 95% CI = 0.0%-4.7%), which is near the US prevalence but less than the historic prevalence for this region. A median of 2 risk factors for each of the environmental, behavioral, and knowledge/awareness domains were noted. CONCLUSIONS: Despite a low prevalence of children with EBLL, parental report suggested that approximately 29% of children had lead-based paint in their home environment.

Peripheral intravenous access in pediatric inpatients.

BACKGROUND: Peripheral intravenous (PIV) line placement is a time-consuming procedure performed on the majority of general pediatric inpatients, with significant discomfort to patients. OBJECTIVE: To determine parameters of pediatric PIV placement, including success rates, time to success, and factors associated with success. DESIGN: Prospective study involving direct observation of PIV placement by trained research staff. SETTING: General inpatient wards at 2 medium-sized pediatric hospitals. PATIENTS: Hospitalized children younger than 19 years. RESULTS: Successful placement was achieved in 95.8% (567/592) cases with a median time of 9 minutes. Children younger than 2 years were less likely to have success on the first attempt (38.9% vs 53.5%) and have longer time to success (11 minutes). CONCLUSIONS: Children younger than 2 years experienced lower first-attempt successful PIV placement and took longer. The overall success rate was similar to prior reports; these data are the first to show differential PIV success by patient age.

Acute disseminated encephalomyelitis following infectious mononucleosis.

Two months following an Epstein-Barr virus infection, a 17-year-old white female presented with seizures, intermittent visual changes, and altered mental status. Magnetic resonance imaging showed white matter changes of acute disseminated encephalomyelitis with a predilection for posterior cerebral artery distributions but without radiological evidence of arteritis. Epstein-Barr virus titers and polymerase chain reaction analysis results for the virus were consistent with postinfectious acute disseminated encephalomyelitis. The symptoms and signs improved following treatment with high-dose corticosteroids and intravenous immunoglobulin. Although Epstein-Barr virus can cause acute viral encephalomyelitis, the authors report a case of acute disseminated encephalomyelitis months after acute Epstein-Barr virus infection.

Does anything beat DEET?

In comparison trials, DEET is more effective than any other insect repellent. Despite some reports of serious adverse events, when comparing the thousands of other reports of exposure and millions of past users, DEET has a good safety record. The appropriate and safest concentration to use on children remains unclear, however. Due to potential absorption through the skin, prudence would dictate that the lowest effective concentration for the time period of exposure be used. Because research has shown that solvents with less skin permeation may be used as an alternative to the ethanol used in some commercial DEET preparations, manufacturers could develop products that are less likely to be absorbed. Pediatricians should be familiar with the duration of action of various formulations of DEET and the efficacy (and in some cases lack of efficacy) of other products in order to advise patients on safe but effective methods of insect control.

Environmental pediatrics and its impact on government health policy.

Recent public recognition that children are different from adults in their exposures and susceptibilities to environmental contaminants has its roots in work that began >46 years ago, when the American Academy of Pediatrics (APA) established a standing committee to focus on children's radiation exposures. We summarize the history of that important committee, now the AAP Committee on Environmental Health, including its statements and the 1999 publication of the AAP Handbook of Pediatric Environmental Health, and describe the recent emergence of federal and state legislative and executive actions to evaluate explicitly environmental health risks to children. As a result in large part of these efforts, numerous knowledge gaps about children's health and the environment are currently being addressed. Government efforts began in the 1970s to reduce childhood lead poisoning and to monitor birth defects and cancer. In the 1990s, federal efforts accelerated with the Food Quality Protection Act, an executive order on children's environmental health, the Agency for Toxic Substances and Disease Registry/Environmental Protection Agency Pediatric Environmental Health Specialty Units, and National Institute of Environmental Health Sciences/Environmental Protection Agency Centers of Excellence in Research in Children's Environmental Health. In this decade, the Children's Environmental Health Act authorized the National Children's Study, which has the potential to address a number of critical questions about children's exposure and health. The federal government has expanded efforts in control and prevention of childhood asthma and in tracking of asthma, birth defects, and other diseases that are linked to the environment. Efforts continue on familiar problems such as the eradication of lead poisoning, but new issues, such as prevention of childhood exposure to carcinogens and neurotoxins other than lead, and emerging issues, such as endocrine disruptors and pediatric drug evaluations, are in the forefront. More recently, these issues have been taken up by states and in the international arena.

Preventive services: blood pressure checks at well child visits.

The objective of this study was to determine rates of blood pressure (BP) screening at well-child visits as recommended by the Task Force on Blood Pressure Control in Children. The 1985 and 1996 National Ambulatory Medical Care Surveys were analyzed for changes in proportion of well visits for children aged 3-18 years at which BP was checked. Patient and physician demographics are described. BP screening increased from 50% in 1985 to 61% in 1996. For pediatricians, the estimates were 50% (95% CI, 43-57) and 60% (95% CI, 53-68). For family/general medicine the estimates were 51% (95% CI, 34-69) and 58% (95% CI, 43-74). Age, geographic location, and length of a visit were significant in predicting BP screening. Gender, race, ethnicity, or urban location were not. A stepwise logistic regression confirmed these results. Rates of screening BP at well-child visits have increased but fall short of current recommendations. High-risk children are not screened at a rate different from their lower risk peers.

Inaccuracy in parental reporting of the age of their home for lead-screening purposes.

OBJECTIVE: To determine the proportion of children living in pre-1950 housing who are correctly identified by parental report as being at risk for lead poisoning. DESIGN: Cross-sectional survey of parents. Parents' answers about the age of their home were compared with the age of the home found in tax assessor records. SETTING: The resident continuity clinic at an urban medical center and 4 private pediatric practices. PARTICIPANTS: A convenience sample of 199 parents accompanying children to their 9-month to 2-year well-child care visits. All parents agreed to participate. Twenty-six were excluded because they lived outside the predetermined geographic area or because the age of their home could not be confirmed, leaving 173 in the sample. MAIN OUTCOME MEASURE: We calculated the sensitivity of asking parents the age of their home in determining which children were at risk for lead poisoning because of residence in pre-1950 housing. RESULTS: According to tax assessor records, 42 children lived in or spent time in homes built before 1950. Of these 42 children, 22 of their parents reported this exposure when asked, for a sensitivity of 52% (95% confidence interval, 37%-67%). If a questionnaire was used to determine whether the child should be tested for lead poisoning, 20 of the 42 children who lived in older homes would not have been tested. CONCLUSION: Asking parents about the age of their home is no better than chance at determining which children are at risk for lead poisoning because of residence in older housing.

Using geographic information systems to assess risk for elevated blood lead levels in children.

OBJECTIVES: Targeted screening for childhood lead poisoning depends on assessment of risk factors including housing age. Using a geographic information system (GIS), we aim to determine high-risk regions in Charleston County, South Carolina, to assist public health officials in developing targeted lead-screening. METHODS: Properties built before 1978 were geocoded (assigned latitude and longitude coordinates) from tax assessor data. Addresses of Charleston County children who have been screened for lead poisoning were also geocoded. Locations of all housing, lead poisoning cases, and negative screens were created as separate map layers. Prevalence ratios of lead poisoning cases were calculated, as were relative risks for each category of housing. RESULTS: Maps of Charleston County were produced showing the location of old housing, where screening took place, and where cases were found. One thousand forty-four cases were identified. Twenty percent of children living in pre-1950 homes had elevated blood lead levels (EBLL). Children living in pre-1950 housing were 3.9 times more likely to have an EBLL than children living in post-1977 housing. There was no difference in risk of living in a 1950-1977 home vs. a post-1977 home. A large number of cases were also found in an area of newer houses, but near a potential point source. Eighty-two percent of all screens were from children in post-1977 homes. CONCLUSIONS: Children living in pre-1950 housing were at higher risk for lead poisoning. GIS is useful in identifying areas of risk and unexpected clustering from potential point sources and may be useful for public health officials in developing targeted screening programs.

Recognition and management of pesticide poisonings.

It provides health professionals with information on the health hazards of pesticides currently in use, and current consensus recommendations for management of poisonings and injuries caused by them. Adobe Acrobat Reader is required to read this manual (link available).