Clinical Assessment – Exposure History

Most environmental and occupational diseases either manifest as common medical problems or have nonspecific symptoms. Unfortunately, hazardous exposures rarely enter into the clinician’s differential diagnosis. As a result, clinicians may miss the opportunity to make correct diagnoses that might influence the course of disease. A correct diagnosis may help stop exposure and might prevent disease in others by avoiding exposure [ATSDR 2015].

What can a clinician do to improve recognition of disease related to current or past exposures?

• First, one must be suspicious and think about the possibility of environmental and occupational factors of disease.
• Next, one needs to incorporate an exposure history questionnaire into clinical practice.

ATSDR Case Study in Environmental Medicine: Taking an Exposure History

illustrates the principles and practices involved in the development of a differential diagnosis that includes possible hazardous exposure related etiologies.

Taking an exposure history may enable physicians to

• Make more accurate diagnoses,
• Influence the course of disease by stopping current exposure,
• Prevent disease in others by avoiding future exposure, and
• Prompt workplace evaluations and the protection of workers.

In the past, the Centers for Disease Control and Prevention (CDC) emphasized primary prevention, but also recommended screening blood lead levels (BLLs) in children to alert policymakers and others of potential lead contamination in communities.

Generally, sources of lead exposure were only identified and remediated after a child was identified with an elevated BLL, which is now a practice considered ineffective [ACCLPP 2012].

The strategy of identifying lead poisoning or elevated blood lead levels (BLLs) relied on detection in the child, relegating the child to the function of the proverbial ‘canary in the coal mine’ for

• Poor/contaminated housing,
• Contaminated water, and/or
• Tainted consumer products.

This strategy, which relies on identifying extant elevated BLLs, does not prevent the damage already incurred. Chelating agents can be used to treat overt lead poisoning, and possibly reduce the case fatality rate and other severe effects. However, chelating agents are not benign and can cause adverse health effects, especially when used by someone without expertise and experience treating lead poisoned patients. These agents have been demonstrated not to improve IQ or behavioral consequences of lead exposure [ACCLPP 2012]. Therefore, primary prevention is the most important and significant strategy [ACCLPP 2012].

The first step in evaluating a possibly lead-related health concern in a child is to take an environmental pediatric exposure history.

Screen all immigrant, refugee, and internationally-adopted children when they arrive in the United States, and for children Screening Questions

The clinical setting allows little time for an extensive environmental pediatric exposure history. However, initial and subsequent well-child visits offer opportunities to provide parents and caregivers with educational materials on preventing exposures and actions to take if an exposure occurs. CDC [2012] recommends using screening questions.

Written checklists completed by parents may be used to facilitate obtaining an exposure history. Examples of these checklists are the National Environmental Education Foundation’s [NEEF] Pediatric Environmental History (0-18 Years of Age). The Screening Environmental History, and Additional Categories and Questions to Supplement The Screening Environmental History, 2005. Also available in Spanish.

ATSDR Case Study in Environmental History: Taking a Pediatric Exposure History

For a sick child whose illness might be environmentally related, the physician should consider an environmental agent as potentially related to the child’s current illness, particularly when the illness does not follow a usual pattern or when more than one family member or a schoolmate is affected.

Physicians should take two environmental medicine actions for every well-child who presents to an office or a clinic.

1. A routine screening history for potential environmental exposures.
2. Age-appropriate risk-based screening for lead poisoning, using the CDC’s lead poisoning prevention guidelines [CDC 2012].

Table 5. Screening Questions for Children’s Lead Exposure History [modified from ATSDR 2013]

• Home, day care, school, and,
• For working adolescents, the job setting may have unique environmental hazards.

What is the age and condition of your home?

• If the home was built prior to 1978, discuss risks of lead exposure from higher lead content paint.
• If parents are unsure of the age, they can test paint with an instant lead paint tester from a hardware store.

Are renovations planned or in progress?

• If a parent is planning renovation, advise how to avoid higher lead content paint exposure.
• If paint is old, peeling, or in poor repair, the parent should consider using a certified contractor.

Does anyone in the family smoke?

Is there exposure to second hand or third hand (residual tobacco) smoke (SHS & THS)?

What are the occupations and hobbies of adults in the household?

Is there an occupational exposure that could affect children’s health?

Is there a chance of take-home contamination from work-related toxicants on

Do you have concerns about environmental hazards in your home or in the surrounding neighborhood?

• Lead in drinking water (check source of drinking water).
• Lead in the ground or play areas.
• Exposure to hazardous waste sites.

Do you take herbal remedies or Ayurvedic (a system of health care native to the Indian subcontinent) medications? If so, which ones? Do you give any of these to your children?

Do you use skin creams that could contain paints, pigments, or heavy metals? Do you use any of these on your children? Some folk remedy creams or cosmetics may contain lead.

Other questions of interest:

• Condition of household pets.
• Past living conditions (international background is important).
• Siblings or playmates diagnosed with lead poisoning.
• Use of imported or glazed ceramics.

Assess the nutritional status, diet, and dietary behaviors of young children.

• If no, are you using water to mix with the formula?
• If using water to mix with the formula, what water will you be using (tap water, bottled water, well water, etc.)?
• If tap water, is it from the municipal water system? What type of water service delivery and home plumbing pipes are used (galvanized, etc.)?

If well water, have you had it tested for the presence of contaminants, such as bacteria, lead, and nitrates?

Where does the child spend most of his/her time?

If yes, what is the type of work?

Does the work expose the adolescent to toxic chemicals, fumes, or dust, or does it involve excessive musculoskeletal stress or work with slicing machines? Is use of heavy or industrial machinery involved in the work?

Is the adolescent involved in hobbies that involve lead (leaded glass, fishing gear (weights), home reloading of shotgun cartridges)?

Does the adolescent consume illicit drugs or used them in the past? Examples: “huffing” (with intent to alter mood) of products that may contain or be contaminated with lead?

Alcohol use (ask about source and storage of alcohol). Does the adolescent smoke or vape? Is there exposure to second hand smoke (SHS)?

In order to establish that lead exposure is the cause of an illness, it is necessary to ask if the exposure to the substance of concern occurred before the onset of the health condition.

Timing and duration of exposure can be important in determining whether a negative health effect may result. If the exposure is known, it is important to ask how long and how often the child was exposed to lead (daily, weekly, monthly, etc.). It is also important to ask about the amount or concentration (how much).

Others similarly affected can point to a possible lead exposure-related cause at home, at child care, at school, or the workplace. For public health reporting purposes, the appropriate authorities must be notified if an illness is found to be related to a lead environmental exposure.

After completing the screening exposure history and asking more specific exposure-related questions, the physician should then answer these questions to determine whether the illness might be lead exposure-related.

• What is the child’s specific health condition?
• Is lead known to cause this type of health problem?
• If so, what is the weight of scientific evidence linking that health condition to lead?
• Did any other exposures occur that might be related to the identified signs and symptoms?

If the answers to these questions, previous questions and the physical and laboratory findings point to a link between an illness and an exposure, the physician can consult with a specialist in pediatric environmental medicine as needed (see http://www.pehsu.net/ .)

• Clinicians must be suspicious and think about the possibility of environmental and occupational factors of disease.
• Clinicians need to incorporate an exposure history questionnaire into clinical practice.
• The initial well-child visit presents an excellent opportunity to ask basic screening questions about common environmental hazards, including lead exposure.
• For a sick child, the physician should consider an environmental agent as potentially related to the child’s current illness, particularly when the illness does not follow a usual pattern or when more than one family member or a schoolmate is affected.
• It is important to incorporate age-appropriate questions about lead hazards during other routine office visits.
• Screen all immigrant, refugee, and internationally-adopted children when they arrive in the United States, and for children
• Assess the nutritional status, diet, and dietary behaviors of young children.