EAPERENCE INPEDIATAIG EDUCATION AND PRACTICE Ambulatory Child Health (2001) 7: 43-51 Environmental illness: educational needs of pediatric care providers Alan Woolf'** and Sabrina Cimino** ‘Department of Pediatrics, Harvard Medical School, “Pediatric Environmental Health Center, Division of General Pediatrics, Children’s Hospital and °Regional Poison Control & Prevention Center Serving Massachusetts & Rhode Island, Boston, MA, USA ABSTRACT Background Objective Methods Results Conclusion Implications for practice Assessing the impact of children's exposures to environmental toxins is an emerging new subspecially in cinical pediatrics. However, pediatric health professionals in practice may not be familiar wit critical information necessary to diagnose and manage environmental toxic exposures in children, The objective of this study was to investigate the perceptions of pediatrcians, nurses, and nurse practitioners regercing their own practices and educational needs concerning pediatric environmental exposures. Health professionals attending a general pediatric postgraduate course were administered @ 22-tem questionnaire on ther practices and educational needs in children’s enviconmental health. A total of 93% of participants returned usable questionnaires. Within the previous 6 months, over 90% of pediatricians and nurse practitioners had Giagnosed food possoning: almost 50% had diagnosed lead poisoning; 50% had diagnosed a child's illness as due to exposure to a toxic chemical; and 24% had diagnosed ‘building-related illness.” Although 90% of pediatricians and 82% of nurses and nutse practitioners stated that they routinely asked families about parental occupations, only 35% of both groups asked about parental hobbies. Only 58% of the groups asked about smoke detectors in the home, and only 18% of nurses and 9% of pediatricians queried families about their use of radon detectors. Over 70% of all three groups indicated a high intrest level in the folowing postgraduate educational tops: taking in environmental history, breast mik contaminants, food allergies, food Contarination, and illness related to tobacco smoke, Topics that did not garner as high an intrest level included: ctildhood lead poisoning, radon poisoning, and building-related iliness. Pediatric health professionals commonly diagnose environment-elated illnesses, and they include such topics during well child care, They indicale a variety of educational needs concerning pediatic environmental health issues. Health care professionals are increasingly asked by parents to include environmental toxins among the possible causes of a child’ il health. Our ‘The research was presonted tte annul meeting ofthe Ambulatory Pedic Asseclaton on May, 1999, n San Francisco, Caltoria| (© 2001 Bleckwet Science Lis44 A Woolf and § Cimino PERIENCE IN PEDIATRIC EDUCATION AND PRACTICE results suggest that clinicians recognize their own need for futher training in the principles of pediatric environmental health Further research is needed in determining which modalties are best suited to achieve such educational objectives Keywords Introduction The impact of environmental toxins on children's health is of growing concem around the world. Almost 25% of ‘Americans live near one of the more than 1400 Super- Parental concems about children’s exposures to contaminants in foods and breast milk, the effects of hormone- environmental bealth, environmental toxicology. pediatrio, postgraduate education, toxicology exposures to contaminants in foods and breast milk, the effects of hormone-like chemicals on growth and development, natural carcinogens such as radon, the ubiquity of air and water pol lutants, and other environ- imental threats to children's health are growing. Building- related illness, irrtant-type symptoms caused by poor fund sites (abandoned toxic ‘lke chemicals on growth and develop- indoor air quality, is more waste dumps slated for | ment, nalural carcinogens such as often being used in conjunc cleanup by the US gov- fadon, and other environmental threats tion with children and is a emment), with 12.5 milion tochildren’s health are growing. source of parental concer people (including 3-4 milion children) living within + mile cof a toxie waste dump.'? The prevalence of childhood asthma increased steadily in London, UK, between 1978 and 1991.° There is good evidence that in part this increasing prevalence is related to and exacer- bated by increasing amounts of indoor and outdoor air polutants.*® Athough the incidence of lead poison- ing has decreased in the United States, more than 940000 children stil have blood lead levels greater than 10ygidL, with disproportionately more minority and inner-city children living in poverty affected.® The prevalence of respiratory conditions was higher among second- and fith-grade schoolchildren grow ing up in highly polluted Israeli neighbourhoods.” An investigation into the contamination of indoor air by molds in Stockholm, Sweden, showed a correlation between fungi in dust samples and the sensitization cf atopic children.’ An epidemiological study. in Germany, England, Canada, and Sweden quantified aan excessive risk of lung cancer related to high levels, ‘of domestic indoor radon concentrations? The scope of pediatric environmental illness broadly tefers to those elements in the environment, such as allergens, man-made or natural chemicals, gases, radiation, food or water contaminants, and other toxins, that have the potential to adversely impact on a child's health. Parental concems about children’s about schools and day care centres. Yet these environmental toxins receive scant atten- tion in medical or nursing school, and many health providers have limited knowledge of how to properly assess the role of such toxins in a childs illness. In this regard, recent review articles on pediatric envi- ronmental health have begun to address issues of importance for health care providers.'™"" The Envi- ronmental Protection Agency (EPA) is devoting more resources to the study of how environmental contam- inants may adversely affect the health of children Many professional organizations, including the Cri dren's Environmental Health Network, have already started to address research needs with regard to assessing the child with environmentally related illness. The American Academy of Pediatrics has recently published a manual to address the gaps in pediatricians’ knowledge in the environmen- tal health problems of children, a testament to the growing importance ofthis emerging field of pediatric, medicine." In this study the current practices and educational needs of pediatricians, nurses, and nurse practition- ers in office practice were surveyed. The purpose of the investigation was to uncover the perceptions of pediatricians, nurses, and nurse practitioners regard- heel Sclnce Lc, Ambulatory Chil Heath 71). 49-51EXPERENG EIN PEDIATAIC EDUCATION AND PRACTICE ing their own practices and educational needs con- cerning pediatric environmental toxic exposures and their diagnosis and management. Methods A cross-sectional survey of health professionals’ experience and perceived educational needs con- ceming pediatric environmental health was prepared (see Appendix). The survey was given to a conve- rience sample drawn from health professionals who were already interested in pursuing continued medical education. Participants in ‘Advances in Pediatric Health Care’, a general pediatrics (no environmental health topics) postgraduate course offered by Chil- dren's Hospital, Boston in April 1998, were asked to fill outa brief, forced choice 22-item questionnaire that had previously been informally piloted. Participants were asked about environmental health topics they routinely include in conversations with parents during a well child care visit. They were asked if they had made specific environmentally related diagnoses within the past 6 months (RSV bronchiolitis, iron defi- cienoy anemia, and contact dermatitis were included as high-frequency indicator diagnoses for compari- son). Finally, participants were asked which topics in pediatric environmental health to include in future Table 1: Characteristics of survey respondents Practitioners knowledge of environmental heath 45 postgraduate course offerings. Information on the respondents’ age, gender, year of graduation, profes- sional degrees, years in practice, and current patient volume was also collected. Data were analysed descriptively: comparisons were also made between professional groups using the chi-square statistic and Fishers’ exact test for smaller sample sizes. All analy- ses were performed using SAS for the PowerMac software;'* and o. was set at 0.05 for the demonstra- tion of statistical significance Results As stated in the methods section, the data represent responses from a convenience sample of health pro- fessionals who were already interested in continued medical education. Of the 217 course participants, 201 health care providers returned usable question- naires: pediatricians (n = 121), pediatric nurse prac- titioners (n = 36), nurses (n= 41) and three ‘other’ health professionals, for a response rate of 93% Demographic details of the respondents are shown in Table 1. Of the 121 pediatricians, two-thirds were 41 years or older, and two-thirds of the sample had been in practice for at least 11 years. These pediatricians had an active practice: almost 80% were ministering to more than 30 patients weekly Practitioners Pediatricians Nurses RN n 124 4a 36 ‘Age range (years) 26-30 33% 9.8% 91% 31-40 29.8% 24.4% 30.3% 41-50 33.9% 39.0% 39.4% 260 33.0% 26.8% 21.2% ‘Years in professional practice IV. Food contamination A. Food-borne iliness B. Breast mik contaminants C. Food allergies D. Pesticide contaminants of foods VV. Indoor air pollution and children's health A. Environmental tobacco smoke B. Dust mites, allergens, and chitdhood asthma C. Damp housing, molds, and childhood respiratory disease Respirable particulate contaminants Volatile organic compounds Indoor use of pesticides Carbon monoxide, ritrogen oxides, and other gases H. Asbestos, formaldehyde, and building materials |. Building-elated illness Vi. Advocacy aspects of pediatric environmental health AA, Regulatory authority and model legislation and resolutions B. Social cisparties and chidhood environmental health C. National and international searchable data bases, Web sites, other resources in pediatric environmental health VIL. International aspects of pediatric environmental health Vill. Pediatric environmental health: a research agenda ommo kal Slence Lt, Ambulatory Chis Heath 71), 2-5150 AWoolf and $ Cimino EXPERIENCE IN PEDIATRIC EDUCATION AND PRACTIOE regarding such environmental health topics as food- associated illnesses, tobacco-related diseases, and how to take a comprehensive pediatric environmental history. Knowledge of community-based resources and specialized referral centres in children's environ- mental health can also help them to become more proficient in the management ofthese patients. References 1. US Environmental Protection Agency (1996) National Protas list for hazardous waste sites: proposed rule. Federal Register, 61: 67655-67682, 2 Agency for Toxic Substances and Disease Registy (1998) Promoting Children's Health: Progress Report ofthe Child Heath Workgroup, Board of Scientific Counselors. US Department of Health and Human Services, Public Health Service, Agency for Toxie Substances & Disease Registry, Atanta, Georgia. 3. Anderson H R, Butland B K and Strachan D P (1994) ‘Trends in prevalence and severty of childhood asthma. British Medical Journal, 308: 1600-1604 4 Smith K R, Samet J M, Romieu | and Bruce N (2000) Indoor air pollution in developing countries and acute lower respiratory infections in children. Thorax, 65: 518-532. 5 Jones A P (1998) Asthma and domestic air quality. Society of Science Medicine, 47: 755-764 6 Centers for Disease Control and Prevention (1997) Update: blood lead levels. United States, 1991-94. Mor- bidity and Mortality Weekly Report, 46: 141-146. 7 Goren A | and Helmann $ (1995) Respiratory cond- tions among schoolchildren and their elationship to envi ronmental tobacco smoke and other combustion products. ‘Archives of Environmental Health, 60: 112-18. 8 Wickman M, Gravesen S, Nordvall $ L, Pershagen G ‘and Sundell J (1992) Indoor viable dust-bound microfungi in relation to residential characteristics, lving habits, and ‘symptoms in atopic and contol children. Journal of Allergy and Clinical Immunology, 88: 752-758. 9 Jacobi W and Paretzke H G (1985) Risk assessment {or indoor exposure to radon daughters, Science of the Total Environment, 45: 551-562. 410. Balk S J (1996) The environmental history: asking the right questions. Contemporary Pediatrics, 13: 19-36. ‘1 Lille D N (1995) Children and environmental toxins. Primary Care, 22: 69-79. 12. Landtigan P J, Carison J E, Bearer C F, Crammer JS, Bullard R D and Etzel R A (1998) Children's heath and the environment: a new agenda for pediatric research. Envi= ronmental Health Perspective Supplement, : 787-794, 13 Committee on Environmental Health American Academy of Pediatrics (Eds RA Etzel and S J Balk) (1999) Handbook of Pediatric Environmental Health. AAP, Ek Grove Vilage, Iincs. 14. SAS Insitute Inc. (1985) SAS® User's Guide: Basic Version (Sth edn). SAS Institute, Cary, NC. 18 Daaschner CW (1990) The division chief as a teacher of adults. American Journal of Disease in Childhood, 144: 891-893, 46 Shannon M, Wool! Aand Goldman R (2000) Children's ‘environmental health: one year in a pediatric environmental health clini. Journal of Toxicology ~Cinical Toxicology, 98: 559-560. 17 Roberts K B, DeWitt T G, Goldberg RL, Scheiner A P (1994) A program to develop residents as teachers. Archives of Pediatric and Adolescent Medicine, 148, 405-410, Biosketches Dr Alan Woolf is the Director of the Program in Ci- nical Toxicology at Children’s Hospital, Boston, the Director of the Massachusetts/Rhode Island Poison Control Center, the CoDirector of the Pediatric Envi- ronmental Health Subspecialty Unit at Children's Hos- pital, and an Associate Professor of Pediatrics at Harvard Medical School, Boston. Ms. Sabrina Cimino is a graduate of Tufts University with a baccalaureate degree in Honors Biology. She is currently a research associate in the Division of General Pediatrics, Children’s Hospital, Boston. Financial disclosure: The authors have no afiia- tions with organizations with a financial interest in the subject matter of this research. This work was sup- ported in part by funds from the Comprehensive Envi- ronmental Response, Compensation, and Liability Act (CERCLA) trust fund through a co-operative agree- ‘ment with the Agency for Toxic Substances & Disease Registry, Public Health Service, US Deparment of Health and Human Services. Correspondence: Alan Woolf, MD, MPH, Regional Poison Control Center, Children’s Hospital, IC Smith Building, 300 Longwood Ave, Boston, MA 02115, USA Tel: (617) 3555187; Fax: (617) 7380032 © 2001 Blachwol Sionce Lid, Amauatory Child Health (1) 48-51ATION AND P ENCE IN PEDIATRIC Practitioners knowledge of environmental health 51 Appendix 1 Course needs assessment survey How frequently do you ask at least one question about the following topics during a preschool well child care visit: ‘Almost always Sometime Almost never 1. Parental tobacco use 1 2 i 2, Child's exposure to lead 1 2 3 3. Family's use of car seats i 2 3 4. Family's use of smoke detectors 1 2 3 5. Family's use of radon detectors 1 2 3 6. Parental occupation 1 2 3 7. Parental hobbies 1 2 3 How many patients have you seen in the past 6 months for whom you made a diagnosis of one of the following health problems: 1, Lead poisoning 0 18 46 79 10-42 1345 >15 2. lron-deficiency anemia 0 13 46 79 10-42 1345 >15 3. Bronchiolitis 0 13 46 79 1042 1315 15 4, Sick building syndrome 0 13 46 79 1042 1315 15 5. Food-related allergy 0 13 46 7-9 1042 1845 >15 6. Exposure to toxie chemicals 0 13 46 79 1042 1845 >15 7. Contact dermatitis 0 1-3 46 79 1042 1845 >15 What is your interest level for each of the following topics for future CME education: Low Moderate High Chiidhood lead poisoning 1 Radon: diagnosis & management 1 Taking a pediatric environmental history 1 Sick school syndrome 1 Childhood food allergies 1 Pesticides, food & children 1 Smoking and tobacco-related illness 1 Breast milk contaminants 1 DUO BORD aaanaunaad © 2001 lac