Philosophy Engineering Ethics Essay

DOI: 10.1542/peds.2012-2757 ; originally published online November 26, 2012; 2012;130;e1757Pediatrics

COUNCIL ON ENVIRONMENTAL HEALTH Pesticide Exposure in Children

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POLICY STATEMENT

Pesticide Exposure in Children

abstract 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. Pediatrics 2012;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 influences 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 poisoning, evaluate patients for pesticide-related illness, provide appropriate treatment, and prevent unnecessary exposure and poisoning.1 Recommendations 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 reviewed 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 conflict of interest statements with the American Academy of Pediatrics. Any conflicts 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 reaffirmed, revised, or retired at or before that time.

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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

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residues.3–9 For many children, diet may be the most influential 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 significant 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’s role in clinical decision-making.18 Pediatric care providers have a poor track record for recognition of acute pesticide poison- ing.19–21 This reflects their self-reported lack of medical education and self- efficacy 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.

Thelocal or regionalpoisoncontrolcenter 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 Notifica- tion System for Occupational Risks,27,28

capture limited information about acute poisoning and trends over time.

There is also no national systematic 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 significantly improve reporting and surveillance. Such tools would be 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 specific relevant medical information. The label does not specify the pesticide class or “other”/“inert” ingredients that may have significant 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 significant 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 Sodium fluoroacetate 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

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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 identified in epidemiologic studies include adverse birth outcomes including preterm birth, low birth weight, and congenital

TABLE 2 Common Pesticides: Signs, Symptoms, and Management Considerationsa

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

significant 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 hyperreflexia • Lindane blood level available as send out Glyphosate (phosphonate herbicides) • Nausea and vomiting • Supportive 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. a Expanded version of this table is available in the accompanying technical report.1

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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-deficit/ hyperactivity disorder and autism. The need to better understand the health implications of ongoing pesticide use practices on child health has benefited 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 specific types of pesticide products in schools. Pediatricians canTA

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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- tification, 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 identification: 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 specific to “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- ish in addition to English.

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 identification 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’s exposure 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

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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

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