Healthy Home Fundamentals

Children’s Health and the Environment:
Environmentally Healthy Homes
by the American Nursing Association, copyright 2003

Introduction

We like to think that our homes are a safe haven. However, in recent years we have been discovering that certain products, designs, and even the locations of our homes can create health risks. When families moved into a new development in Waynesville, North Carolina, called "Barber Orchard," they were ecstatic about their new surroundings -- the fresh air, mountain views, and clean water. When one of the new residents had his well water tested, the dream homes took on a different character. The water was reflective of the years of pesticide use on the former orchard on which their homes were situated; it contained DDT (dichlorodiphenyltrichloroethane), DDE (dichlorodiphenyldichloroethylene), and benzene hydrochlorides.^[1] The soil was contaminated with lead and arsenic, also the result of pesticide applications. The Environmental Protection Agency (EPA) sent in an emergency response team, removed topsoil, and advised residents to install carbon filters on their water systems.

Sometimes, we unintentionally bring pollution into our homes. In the homes of middle-income families with small children, vacuum dust was found to have pesticide concentrations 10-100 times greater than those found in the surface soils surrounding their houses.^[2] The human health risks associated with chlorpyrifos are substantial (including headaches, dizziness, muscle twitching, vomiting, and blurred vision); hence, in 2000, the EPA eliminated the widely used pesticide for nearly all household purposes.

The purpose of this Clinical Update is to introduce the reader to basic concepts and issues associated with environmental health risks to children in homes and communities. In this Clinical Update, some of the key hazardous exposures occurring in the home will be discussed. Indoor air quality, drinking water, lead, mercury, pesticides, radon, and UV radiation have been selected as topics of focus. A Related Resource section provides a brief listing of related organizations, hotlines, and fact sheets; many of these are Web sites, which, in turn will link the reader to additional resources. The EPA's Web site is particularly helpful. The University of Maryland School of Nursing's new Web site is included, which features links to all of the Web sites noted in this Clinical Update.

Children's Special Vulnerabilities

Children are not just little adults. They are different in many ways, particularly with regard to their exposures and responses to the environment. As nurses, we know that infants and young children breathe more rapidly than adults. This increase in respiratory rate may translate into a proportionately greater exposure to air pollutants. While infants' lungs are developing, they may also be susceptible to environmental toxicants. Behaviors characteristic of early childhood also affect a child's exposure to toxicants. In the first years of life, the young child spends hours close to the ground where he or she may be exposed to toxicants in dust, soil, and carpets, as well as to pesticide vapors in low-lying layers of air.

Infants and young children drink more fluids per body weight than adults, potentially increasing the dose of contaminants (particularly pesticides) found in their drinking water, milk, and juices. "Consider the amount of water that an infant who receives formula reconstituted in boiled tap water drinks every day. The average infant consumes six ounces of formula per kilogram of body weight. For the average male adult, this is equivalent to drinking 35 cans of soda pop a day. If the water contains a contaminant, then infants will receive more of it relative to their size than will an adult."^[3] Children also eat more per body weight, and they eat different proportions of food. How many adults could eat the same amount of raisins pound-for-pound as the average 2-year-old? Children consume many more fruits and fruit juices than adults, which may result in larger doses of exposure to pesticide residues.

Children play on the floor, the grass, and the playground, placing them at increased risk for exposure to toxic chemicals that may be applied to or settle on the floors or ground, including lead-based paint dust, cleaning product residues, and horticultural/agricultural chemicals (fertilizers, herbicides, pesticides). The hand-to-mouth exploration of the infant and young child that helps them to learn about their world also places them at higher risk of exposures. This is particularly true in the case of lead-based paint dust when it is present in homes and schools. Because metabolic systems are still developing in children (and fetuses), their ability to detoxify and excrete toxins differs from that of adults. This difference is sometimes to children's advantage, but more frequently they are not able to excrete toxins as well as adults, and thus are more vulnerable to them.

The rate at which children absorb nutrients from the gastrointestinal tract is different from the rate for adults, a fact that can affect their exposure to toxicants. For example, children have a greater need for calcium for bone development than do adults. As such, children will absorb more of this element when it is present in the gastrointestinal tract. When lead has been ingested into the gut, however, the body will absorb it in place of calcium. Consequently, an adult will absorb 10% of ingested lead, while a toddler will absorb 50% of ingested lead.^[3] Some of the protective mechanisms that are well developed in adults, like the blood-brain barrier, are immature in young children, thereby making them more vulnerable to the effects of some toxic chemicals.

The Right to Know: Access to Information About Chemicals in Our Environment

Most of us have read the label on a food package. We take for granted that we should have access to the information we seek on a food label, such as the ingredients, the nutritional breakdown, and the calorie count. The food-labeling law, one of the first major "right to know" laws in the United States, was passed in 1958 in response to concerns about artificial coloring, preservatives, and other additives that were being placed in processed foods. It is administered by the federal Food and Drug Administration (FDA) and the Department of Agriculture. Concerns about chemicals in our environment continued to be raised throughout the 1960s. Rachel Carson's seminal work, Silent Spring, brought to light new connections between exposures to manmade chemicals (particularly DDT) and their negative impact in nature.

In 1983, the Hazard Communication Standard, commonly known as the Worker Right-to-Know, gave employees the right to know about the hazardous chemicals with which they work, including information about reproductive hazards that might be in their work environments. Some reproductive toxicants, such as lead, can increase the risk of developmental problems in children. The Hazard Communication Standard is administered by the US Occupational Safety and Health Administration.

In 1986, a community right-to-know initiative provided information to community members regarding the pollution in their neighborhoods with the enactment of the Emergency Planning and Community Right-to-Know Act (EPCRA). This legislation identified a list of 600 chemicals that must be reported to the EPA if they are emitted into the air or water above a weight-based action level. This reporting is called the Toxic Release Inventory (TRI). This information is available to all citizens from the EPA via the EPA's Web site (see Related Resources). Environmental Defense, an environmental organization, has also published this TRI on a unique, user-friendly Web site (see Related Resources), in which they provide information on the health risks associated with the reported chemicals, information on the chemical-producing entities, and guidance for further action and advocacy. Nurses can use this information when assessing an individual or community.

Chemical Risk Management Plans

When the Clean Air Act was reauthorized in 1990, a new directive required workplaces in which there are hazardous chemicals to predict the possible ways that there could be an accidental spill, leak, transportation accident, or other hazardous chemical-related event that would expose workers or the community. These risk management plans describe potential hazards and emergency response plans, and inform workers and the public about safety features. In addition, employers must provide a discussion of the methods by which such events are being prevented and the contingencies for response should an accidental release or spill occur. This information is to be reported to the EPA, but is currently not available to the public.

Food and Agricultural Process and the Right to Know

In 1906, the Pure Foods Act and Meat Inspection Act began the modern era of American food and consumer protection. In 1938, the Federal Food, Drug, and Cosmetic Act replaced the 1906 statute and required a label on processed, packaged food to include the name of the food, its net weight, and the name and address of the manufacturer. On certain products, ingredients were also required. It was not until 1973 that nutritional labeling began, and in 1984 a sodium-content requirement was added to the label.

The latest installment of labeling statutes is the 1990 National Labeling and Education Act, which requires nutritional labeling of most foods (except meat and poultry). Definitions were established for labeling language, such as "fat free," "lite," and "healthy," and the health claims used on labels were further regulated.

Indoor Air Quality

Although many of our air-quality efforts have proven successful for serious outdoor air pollutants, particularly those discharged from stationary sources, millions of Americans still suffer from health effects associated with air pollution. Additionally, we are becoming increasingly concerned about indoor air pollution. Given the substantial time that we all spend indoors and the fact that air pollutants often concentrate in our indoor environs, sometimes at levels as much as 100 times higher than with outdoor air pollutants, as well as the increase in respiratory diseases such as asthma, there is a critical need for nurses to understand and address indoor air quality. (See Related Resources for American Lung Association). Lung disease is one of many health effects that may be associated with air quality.

Indoor pollution sources that release gases or particles into the air are the primary cause of indoor air-quality problems in homes. Studies from the United States and Europe show that people in industrialized nations spend more than 90% of their time indoors. For infants, the elderly, persons with chronic diseases, and most urban residents of any age, the proportion is probably higher. The places in which people spend substantial amounts of time -- their homes, schools, and workplaces -- are critical potential sources of indoor air pollutants. Well-documented triggers of allergies and asthma include: pet dander, molds, dust mites, cockroaches, and environmental tobacco smoke. For more information on asthma and indoor air quality, see the ANA online program on environmentally healthy schools, listed in the Related Resources section at the end of this program. In addition, the EPA's Office of Indoor Air and the American Lung Association have excellent Web sites on these issues (see Related Resources).

Mold/Mildew

Molds are microscopic fungi that comprise 25% of the earth's biomass. They can be found almost anywhere and can grow on virtually any organic substance as long as moisture and oxygen are present. Molds can grow on wood, paper, carpet, foods, and insulation. Moisture encourages mold growth. People who are allergic to mold or whose asthma is triggered by mold usually react to the spores, the reproductive bodies for molds. The process by which these spores are released into the air becomes intensified when moldy material is damaged or disturbed. Sometimes mold can produce a toxic substance called mycotoxins, which also can cause illness in sensitive populations, especially those with substantial exposures, such as agricultural workers.^[4] It is impossible to eliminate all mold and mold spores in the indoor environment. However, mold growth can be controlled indoors by controlling moisture.

Many types of molds exist and they all have the potential to cause health effects. Molds produce allergens that can trigger allergic reactions or asthma attacks. Health concerns are an important reason to prevent mold growth and to remedy/clean up any existing indoor mold growth. The range of symptoms of overexposure to mold include cough, congestion, runny nose, eye irritation, and asthma symptoms.^[5] As is true of all environmentally-related illnesses, the sensitivity and vulnerability of the person will dictate the level of response to any given exposure.

Mold Prevention and Remediation Tips

Prevention

• Fix leaky plumbing and leaks in the home as soon as possible.
• Prevent moisture from condensation by increasing surface temperature or reducing the moisture level in air (humidity). To increase surface temperature, insulate or increase air circulation. To reduce the moisture level in air, repair leaks, increase ventilation (if outside air is cold and dry), or dehumidify (if outdoor air is warm and humid).
• Keep heating, ventilation, and air conditioning drip pans clean, flowing properly, and unobstructed.
• Vent moisture-generating appliances, such as dryers, to the outside where possible.
• Maintain low indoor humidity, below 60% relative humidity, ideally 30% to 50%, if possible.
• Clean and dry wet or damp spots within 48 hours. Provide drainage and slope the ground away from the foundation.
• Wash mold from hard surfaces and dry completely.

Remediation

• Always use gloves and eye protection when cleaning up mold. For extensive mold clean-up personal protective equipment (PPE) should be used. An explanation of PPE use can be found on the EPA Web site (see Related Resources).
• A variety of mold cleanup methods are available for remedying damage to building materials and furnishings. The specific method or group of methods used will depend on the type of material affected. For an explanation of remediation methods see the EPA Web site.
• Absorbent materials, such as ceiling tiles and carpet, may have to be replaced if they are contaminated with mold.

Is Sampling for Mold Needed?

In most cases, if visible mold growth is present, sampling is unnecessary. In specific instances, such as cases in which litigation is involved, the source(s) of the mold contamination is unclear, or health concerns are a problem, consider sampling as part of the site evaluation. An experienced professional, such as an industrial hygienist, should be consulted to do the sampling. It is important to note that the results of sampling may have limited use or application. Sampling may help locate the source of mold contamination, identify some of the mold species present, and differentiate between mold and soot or dirt. Pre- and post-remediation sampling can also be useful in determining whether remediation efforts have been effective. After remediation, the types and concentrations of mold in indoor air samples should be similar to what is found in the local outdoor air. There are no EPA or other federal threshold limits for mold or mold spores. Keep in mind that air sampling for mold provides information only for the moment in time in which the sampling occurred, much like a snapshot.

Dust Mites

Dust mites (Figure 1) are microscopic animals that are found in every home. They survive by consuming dead skin cells. They can be powerful triggers for asthma and allergies. Dust mites live in mattresses, pillows, carpets, fabric-covered furniture, bedcovers, clothes, and stuffed toys. Body parts and feces of dust mites can be asthma triggers. To protect members of the household from dust mites:

• Wash sheets and blankets once a week in hot water.
• Choose washable stuffed toys, wash them often in hot water, and dry thoroughly. Keep stuffed toys off beds.
• Cover mattresses and pillows in dust-proof (allergen-impermeable) zippered covers.
• Maintain low indoor humidity.

Figure 1. Dust mite.
Source: American Academy of Allergy, Asthma and Immunology.

Environmental Tobacco Smoke

Secondhand smoke, or environmental tobacco smoke (ETS), is a mixture of the smoke given off from the burning end of a cigarette, pipe, or cigar and the smoke exhaled from the lungs of smokers. Environmental tobacco smoke is made up of a number of different chemicals, including hydrogen cyanide and sulfur dioxide, which are irritants and systemic toxicants; benz[a]pyrene, formaldehyde, and 4-aminobiphenyl, which are mutagens and carcinogens; and nicotine, cadmium, and carbon monoxide, which are reproductive toxicants.^[5] Exposure to environmental tobacco smoke has been linked to a variety of adverse health effects, including eye, nose, and throat irritation, headaches, and lung cancer, and may contribute to heart disease. Specifically for children, there is an increased risk of lower respiratory tract infections (such as bronchitis and pneumonia), ear infections (caused by build-up of fluid in the middle ear), increased severity and frequency of asthma episodes, and decreased lung function (Table 1).

Table 1. Health Effects Associated With Exposure to Environmental Tobacco Smoke

Nursing Actions

• Inform nonsmokers that they have a right to healthy and safe environments and that environmental tobacco smoke places their health in jeopardy.
• Promote and support smoke-free schools, day-care settings, workplaces, and homes (especially homes with children).
• Develop information about effective smoking cessation programs. The ultimate goal for all smoking policies is to encourage complete smoking cessation.
• Educate people about the need to establish smoke-free public places and the need to regulate tobacco products.
• Teach smokers about the harmful effects of environmental tobacco smoke exposure on all individuals, especially their children.^[6]

Radon

Radon is a naturally occurring radioactive gas emitted from the natural decay of uranium and found in nearly all soils; it may seep into buildings from the surrounding soil. The EPA ranks indoor radon among the most serious environmental health problems facing us today. It is the second leading cause of lung cancer in the United States (smoking is the first), causing an estimated 14,000 lung cancer deaths per year.^[7] The combination of exposure to radon and smoking significantly increases the risk of cancer. Approximately 1 out of every 15 homes in the United States is estimated to have elevated radon levels. You cannot see, taste, or smell radon.

Radon decays into radioactive particles that can be trapped in the lungs where they damage lung tissue and may lead to lung cancer. The risk of developing lung cancer from radon exposure depends on: (1) the amount of radon in the home (dose); (2) the amount of time spent in the home (duration); and (3) whether the individual is a smoker or has ever smoked (host factor).

Figure 2 shows how radon may enter buildings.

Figure 2. Radon may enter buildings through:
A. Cracks in concrete slabs
B. Spaces behind brick veneer walls that rest on uncapped hollow-brick foundation
C. Pores and cracks in concrete blocks
D. Floor-wall joints
E. Exposed soil, as in a sump
F. Weeping (drain) tile, if drained to open sump
G. Mortar joints
H. Loose-fitting pipe penetrations
I. Open tops of block walls
J. Building materials such as some rock
K. Water (from some wells)

If radon is present in well water, radon gas may be released into the air when the water is used for showering and other household uses. Research suggests that drinking water with high radon levels may also pose risks; however, this risk is much lower than risks associated with breathing radon.

Testing is the only way to know if a home has an elevated radon level. The EPA and the Surgeon General recommend testing all homes below the third floor for radon. There are many kinds of low-cost "do-it-yourself" radon test kits that homeowners can purchase in hardware stores and other retail outlets. State radon offices also provide a list of trained contractors who conduct the tests. Nurses should test their homes and encourage neighbors and patients to test theirs.

Testing for Radon

Short-term testing. The quickest way to test for radon is with short-term tests. Short-term tests remain in your home for 2-90 days, depending on the device. Charcoal canisters, alpha track, electret ion chamber, continuous monitors, and charcoal liquid scintillation detectors are most commonly used for short-term testing. Because radon levels tend to vary from day to day and season to season, a short-term test is less likely than a long-term test to tell you your year-round average radon level. If you need results quickly, however, a short-term test followed by a second short-term test may be used to decide whether to fix your home.

Long-term testing. Long-term tests remain in your home for more than 90 days. Alpha track and electret detectors are commonly used for this type of testing. A long-term test will give you a reading that is more likely to tell you your home's year-round average radon level compared with a short-term test.

How to use a radon test kit. Follow the instructions that come with your test kit. If you are doing a short-term test, close your windows and outside doors and keep them closed as much as possible during the test. (If you are doing a short-term test lasting just 2 or 3 days, be sure to close your windows and outside doors at least 12 hours before beginning the test, too. You should not conduct short-term tests lasting just 2 or 3 days during unusually severe storms or periods of unusually high winds.) The test kit should be placed in the lowest lived-in level of the home (for example, the basement if it is frequently used, otherwise the first floor). It should be put in a room that is used regularly (like a living room, playroom, den, or bedroom) but not your kitchen or bathroom. Place the kit at least 20 inches above the floor in a location where it won't be disturbed -- away from drafts, high heat, high humidity, and exterior walls. Leave the kit in place for as long as the package says. Once you have finished the test, reseal the package and send it to the lab specified on the package right away for study. You should receive your test results within a few weeks.

For additional information on how to use a radon test kit see Related Resources for Radon Test Kit.

Carbon Monoxide in the Home

Carbon monoxide (CO) is a colorless, odorless, tasteless, poisonous gas. More than 3800 people die every year in the United States from carbon monoxide poisoning (both accidental and intentional). An additional 10,000 people receive a sublethal exposure which causes them to miss at least 1 day of work or to seek medical attention.^[8] Centers for Disease Control and Prevention data from 1996 indicate that there were 525 unintentional deaths in the United States due to CO poisoning.^[9]

CO is produced by the incomplete combustion of carbon materials. Any flame or combustion device is likely to emit CO. CO can get trapped inside an area when appliances do not work properly, when a stove or furnace is not working properly due to a clogged chimney or vent, when a car is left running in an enclosed space, or when a charcoal grill is used in a closed area.^[10]

CO Poisoning Symptoms

CO combines with hemoglobin to form carboxyhemoglobin, which is incapable of carrying oxygen, resulting in tissue anoxia. The health threat from exposure to CO is especially serious for unborn babies, infants, and people with anemia or a history of heart or respiratory disease. At moderate levels, CO can cause severe headaches, dizziness, confusion, and nausea. If these levels persist for a long time, death can occur. Low levels can cause shortness of breath, mild nausea, and mild headaches, and may have longer-term effects on health. These symptoms are often mistaken for the flu or other illnesses, and may result in delayed or misdiagnosed treatment.

Chronic CO poisoning usually involves lower levels of the gas in the air and lower blood CO (COHb) concentrations. Chronic CO poisoning may not elicit the typical symptoms of (acute) CO poisoning, such as headache, nausea, weakness, and dizziness. Mucous membranes of the body will almost never be cherry pink in chronic poisoning as they are in acute CO poisoning. Chronic CO poisoning is often misdiagnosed as chronic fatigue syndrome, a viral or bacterial pulmonary or gastrointestinal infection, a "run-down" condition, or immune deficiency. Patients occasionally present with polycythemia, with an increased hematocrit. Similar symptoms seen simultaneously in more than 1 person, and which decrease upon removal from an environment, are tip-offs that CO may be involved.^[11]

Carbon Monoxide Detectors

CO toxicity levels are usually expressed in airborne concentration levels read in parts per million (ppm) and duration of exposure. CO detectors are designed to protect against acute high levels of carbon monoxide; they are not required or equipped to alarm at lower levels of CO. The Underwriters Laboratories (UL) standard requires detectors to alarm within 90 minutes when exposed to 100 ppm, 35 minutes when exposed to 200 ppm, and 15 minutes when exposed to 400 ppm. (The actual UL standard must be purchased. The Underwriters Laboratories Web site is: http://www.ul.com/) The National Institute for Occupational Safety and Health (NIOSH) time-weighted average standard for CO exposure is 35 ppm, which is well below the lowest UL standard alarm trigger of 100 ppm. Also, both NIOSH and the Occupation Safety and Health Administration have set a standard for CO exposure at 200 ppm as an absolute ceiling that "should not be exceeded at any time."^[12]

There are several types of CO detectors on the market. However, they are not as reliable as smoke detectors, and due to the colorless, odorless nature of CO, it is more difficult to identify the cause of a CO alarm. If you shop for a CO detector to warn of acute CO exposures, look for UL certification. Nongovernmental organizations such as Consumers Union (publisher of Consumer Reports), the American Gas Association, and UL can help you make an informed decision. Carefully follow manufacturers' instructions for placement, use, and maintenance of detectors. While a UL-certified CO detector will alarm in the case of high-level CO incidents, it will not alarm at low levels that could pose significant health risks. To prevent and address low-level, chronic CO exposures, maintaining appliances and recognizing symptoms of possible poisoning are essential.

Important Tips for Preventing CO Poisoning

• Never burn charcoal inside a home, garage, vehicle, or tent;
• Never use portable fuel-burning camping equipment inside a home, garage, vehicle, or tent;
• Never leave a car running in an attached garage, even with the garage door open;
• Never service fuel-burning appliances without proper knowledge, skills, and tools. Always refer to the owner's manual when performing minor adjustments or servicing fuel-burning appliances;
• Never use gas appliances such as ranges, ovens, or clothes dryers for heating your home;
• Never operate unvented fuel-burning appliances in any room with closed doors or windows or in any room where people are sleeping; and
• Do not use gasoline-powered tools and engines indoors. If use is unavoidable, ensure that adequate ventilation is available and, whenever possible, place engine unit to exhaust outdoors.

From http://cpsc.gov/cpscpub/pubs/cospot.html#prevention

If the CO Detector Alarm Goes Off

• Check to see if any member of the household is experiencing symptoms of poisoning;
• If they are, get them out of the house immediately and seek medical attention;
• If no one is feeling symptoms, ventilate the building with fresh air; turn off all potential sources of CO (oil or gas furnace, gas water heater, gas range and oven, gas dryer, gas or kerosene space heater, and any vehicle or small engine); and
• Have a qualified technician inspect fuel-burning appliances and chimneys to make sure they are operating correctly and that there is nothing blocking the fumes from being vented out of the house.

Lead

Lead is a poison. Childhood lead poisoning remains a major preventable environmental health problem in the United States. Children's still-developing nervous systems are particularly vulnerable to the toxic effects of lead, and their normal play and hand-to-mouth activities expose them to lead-paint hazards and lead-contaminated dust and soil. According to the Centers for Disease Control, estimates from the National Health and Nutrition Examination Survey indicated that Medicaid enrollees accounted for 83% of children aged 1-5 years who had elevated blood lead levels (BLLs).^[13] Despite longstanding requirements for blood lead screening in the Medicaid program, an estimated 81% of young children enrolled in Medicaid have not been screened with a blood lead test. Over 20% of the children tested in some US states had BLLs high enough to adversely affect learning and development.^[14]

Lead has been ubiquitous in the environment since the advent of industrialization. Major sources of environmental lead exposure are lead-based paint, lead-contaminated soil, occupational exposures, and industrial pollution. Lead can be found in some foods and drinking water from both natural sources and man-made pollution, ie, pipes and solder that contain lead. Lead-based paint remains the most common source of environmental lead exposure for children. The Consumer Product Safety Commission banned the manufacturing of most interior and exterior lead-based paint in 1978; however, leaded paint still remains a threat in many homes built before 1978. Also, lead-based paint is still available and currently used in industrial, military, and marine areas.

Nearly 1 million children in the United States have elevated BLLs. This problem is especially acute in certain population groups. For example, among children living in pre-1946 dwellings (when the use of lead in paint was most common), the prevalence of lead poisoning is 5 times higher than among children living in homes built after 1978 (most of which do not have lead paint).^[15] Interior surfaces that are likely sources of lead paint poisoning are trim-work, doorways, windowsills, and painted toys. Soil near painted buildings or roadways is often contaminated with lead and should be tested before being used for play areas or for planting edibles.

Hand-to-mouth activity and the efficiency of children's gastrointestinal absorption of lead-based paint dust place children at greater risk than adults.^[16] Adult lead exposure is a pediatric concern, as more than 1 million workers in more than 100 different occupations may be exposing their families to "take-home lead" if showers and changes of clothing are not provided at the end of a workday.^[17] Additionally, occupational exposures to pregnant women may cross the placenta and damage the developing nervous system of the fetus.

Physiologic effects of lead toxicity are noted in virtually every system. The central nervous system, hematopoietic and renal system, and vitamin D metabolism are significantly affected. Symptoms of lead toxicity can range from nonspecific complaints to irreversible and sometimes fatal damage to the central nervous system. Lower IQ, diminished speech and language processing, and decreased attention span are common effects of lead poisoning in children.

Symptomatic lead poisoning constitutes a medical emergency. Acute lead poisoning may be characterized by 1 or more of the following symptoms: headaches, clumsiness, anorexia, constipation, vomiting, agitation, bizarre behavior, apathy, and loss of developmental skills recently mastered. Central nervous system damage can progress to seizures and coma. Appropriate intensive care for very high-level lead poisoning can prevent death, but severe permanent brain damage is likely despite treatment.^[16]

Even low levels of lead are harmful. Levels as low as 10 micrograms of lead per deciliter of blood (mcg/dL) are associated with decreased intelligence, behavior problems, reduced physical stature and growth, and impaired hearing.^[18,19] A child is estimated to lose 2 IQ points for each 10-mcg/dL increase in BLL. One study suggests that lead exposure may be associated with increased risk of juvenile delinquent behavior.^[18,19]

Screening Homes for Lead Exposures

Nurses can perform dust sampling and/or train family and community members to sample for lead-based paint dust. There are also professional inspectors who can help homeowners make a lead assessment. The requisite "tools" for dust sampling are a tape measure, a baby wipe, and a sealed plastic bag.

Dust-wipe sampling for lead. Sample rooms where children spend the most time (bedroom, kitchen, playroom, etc); at the most used entrance door; where there are areas of failing paint; in areas where renovation is under way or planned. Sample spots in the room such as the inside windowsill; the window trough; the floor in front of the most used entrance.

Materials needed for lead sampling include:

• Baby or hand wipes -- use thin wipes that pull through a hole in the top of the container (avoid wipes with aloe, scent, or alcohol);
• Container (sealed plastic freezer bags, 35-mm film container, or centrifuge tube);
• A permanent marking pen, disposable gloves, a ruler or tape measure, and a mailing envelope; and
• A form to identify and record samples.

The procedure for taking a sample is as follows:

• Throw out the first baby wipe, as it may be dry or dirty. Measure a 12 x 12 inch area;
• Using a moderate amount of pressure, wipe the 12-inch square in one direction, side to side, in a zigzag motion. Try to wipe the entire surface with a minimum of overlap;
• Fold the wipe, dirty side in, and wipe the same square in the same way in the opposite direction (top to bottom). Place the wipe in a sealed plastic bag and label;
• For the windowsill and trough, follow the same procedure as above, but instead of a 12-inch square, wipe the entire sill. Measure length and width and label the bag with the information; and
• Take a separate dust sample for the floor in front of the most used door. Do not take a composite sample.

Composite samples are sometimes required. Composite samples combine samples from several sites and provide an average exposure level. Composite sampling can help to identify lead-safe houses and indicate the need for further evaluation in homes where elevated lead levels are found. Points to keep in mind include:

• Advantage: less expensive; disadvantage: the composite will only give an average;
• Be certain the lab will accept composite samples;
• Put up to 4 wipes from different floor areas in 1 container;
• Do not put windowsill and floor wipes in same container;
• Know where to send the samples; a lab that is recognized by the National Lead Laboratory Accreditation Plan should be used. A list of these labs can be obtained by calling 1-800-424-5323;
• Be sure that the lab will analyze composite tests;
• Ask if the lab will accept samples in a sealed plastic bag. Some labs will only accept centrifuge tubes;^[20]

Nurses' Role in Lead-Poisoning Prevention

Primary-prevention efforts involve identifying and eliminating lead hazards before children are poisoned. Until this can be achieved, screening and follow-up of lead-poisoned children is essential. Tests for BLLs are recommended for children at ages 1 and 2, and more frequently for children if they are at higher risk. Any home built before 1978 should be tested for lead exposure. Nurses and homeowners can test for lead dust or the presence of lead in the paint.

Education efforts can include the provision of information to parents regarding federal regulations (24 CFR Part 35, 40 CFR Part 745), which require that property sellers and landlords provide families with information about lead poisoning and about any known lead-based paint or lead hazards in a dwelling before its sale or lease.

The only way to prevent lead poisoning is to remove the source of exposure. However, the process of removal often creates more exposure. If lead-based paint is in good condition (as in not chipped, flaking, or in areas of high friction), it is safer and easier to simply cover the area with non-lead-based paint. The outermost paint surface should be lead-free. If there is lead-based paint underneath the intact paint, and the top surface is lead-free, there will not be an exposure unless the surface begins to deteriorate or if renovations or other activities are implemented that compromise the integrity of the paint.

Nurses should educate parents and local healthcare providers about lead poisoning and the importance of screening homes and children. Excellent materials exist from the EPA, the Alliance to End Childhood Lead Poisoning, and the National Safety Council. A helpful publication titled "Lead in Your Home: a Parents Reference Guide" can be accessed from the brochure and training section of the EPA Web site (see Related Resources).

Fatal Pediatric Lead Poisoning

On March 29, 2000, a 2-year-old girl was seen at a community hospital emergency department with a low-grade fever and vomiting for approximately 1 day. The child had been well since arriving in New Hampshire from Egypt with her Sudanese refugee family 3 weeks earlier. Laboratory findings included a microcytic anemia (hemoglobin: 7.6 g/dL; lower limit of normal: 11.5 g/dL) with occasional basophilic stippling of red blood cells. A throat swab streptococcal antigen screening test was positive. She was discharged from the emergency department with prescriptions for an antibiotic and antiemetic to treat her presumed strep throat. However, her vomiting worsened, and she was admitted to the same hospital on April 17, and then transferred to a tertiary-care hospital the next day. On April 19, approximately 5 hours after the transfer, she became unresponsive, apneic, and hypotensive. She was intubated and placed on a ventilator. Computerized tomography of the head showed diffuse cerebral edema and dilated ventricles. Later that day, the results of a blood test drawn on April 18 showed a BLL of 391 g/dL and an erythrocyte protoporphyrin level of 541 g/dL. Chelation therapy was initiated. Despite a decrease in her BLL to 72 g/dL and treatment for increased intracranial pressure, including surgical ventricular drainage, she remained comatose without spontaneous respirations, brain electrical activity, and intracranial blood flow. She was pronounced brain-dead on April 21.

An investigation revealed that after living in Egypt for approximately 18 months, on March 9, 2000, the family had moved to Manchester, New Hampshire, into an apartment constructed before 1920. A wall in a sibling's bedroom had multiple holes from which the patient had been seen removing and ingesting plaster. Two of 7 samples of plaster with the adhering surface paint contained lead at levels of 5% and 12%. Peeling paint (35% lead) was present on the balusters and floor (3% lead) of a porch outside the apartment entrance where the patient sometimes had played. She also had played near and looked out of a living room window that occasionally was opened during meal preparation. A wipe sample of dust from the window well showed 6732 mcg lead/square foot, well above the hazardous level of 800 mcg lead/square foot.^[4] The New Hampshire Department of Health and Human Services ordered the apartment owner to correct the lead hazards identified during the inspection. The patient's family relocated to another dwelling.^[21]

Mercury

Mercury is another poisonous heavy metal that is a naturally occurring element. However, its increased presence in our environment is due to a variety of human pollutant sources. Most mercury pollution is released into the air and then falls directly into waterways or is deposited onto land where it can be washed into the water. Mercury concentrations in air are usually low and of little direct concern. When mercury is in water, however, biological processes transform it into a highly toxic form: methyl mercury. Methyl mercury bioaccumulates in fish, with larger fish generally accumulating higher levels.

The Mercury-Fish Connection: FDA and EPA Advisories

Methyl mercury is a highly toxic compound and the fetus is extremely vulnerable to its toxicity.^[22] Women of childbearing age must be counseled about exposure to methyl mercury before and during pregnancy. In the past year, the FDA and the EPA have both issued advisory warnings for pregnant women advising them to limit their consumption of certain types of fish. The FDA advisories are for commercial fish and the EPA's advisories are for noncommercial fish. These advisories are based on the sometimes dangerously high levels of methyl mercury that are bioaccumulated in both freshwater and saltwater fish. Freshwater fish from contaminated waters have been shown to have particularly high levels of methyl mercury, posing potential risks for recreational anglers and people who regularly fish for food. A recent report by the National Academy of Sciences^[23] confirms that methyl mercury is a potent toxin, and concludes that children born to women who consume large amounts of fish during pregnancy are at greater risk for changes in their nervous system that can affect their ability to learn.

A recent report, titled "Brain Food: What Women Should Know About Mercury Contamination of Fish," asserts that the new fish advisories issued by the FDA, though a step in the right direction, are not protective enough.^[24] The report recommends that tuna steaks, sea bass, oysters, marlin, halibut, pike, walleye, and largemouth bass be added to the FDA's list of fish that should not be eaten by pregnant and nursing women or women of childbearing age. In addition, they recommend that the FDA advise women to eat no more than 1 meal per month of the following fish species combined: canned tuna, white croaker, mahi mahi, blue mussel, eastern oyster, cod, pollock, haddock, salmon from the Great Lakes, blue crab from the Gulf of Mexico, channel catfish (wild, not farmed), and lake whitefish.

Fish can be an important source of nutrition for the pregnant woman, developing baby, and young child. However, the following recommendations should be considered when choosing the type and amount of fish to consume. According to the EPA, if a woman is pregnant or could become pregnant, is nursing a baby, or is feeding fish to a young child, limit consumption of freshwater fish caught by family and friends to 1 meal per week. For adults, 1 meal is 6 ounces of cooked fish or 8 ounces of uncooked fish; for a young child, 1 meal is 2 ounces of cooked fish or 3 ounces of uncooked fish. Many states collect data on mercury levels in fish from local waters. Check with state or local health departments for specific advice on local waters where family and friends are fishing.

In addition, the FDA has issued an advisory on mercury in fish bought from stores and restaurants, which includes ocean and coastal fish as well as other types of commercial fish. The FDA advises that women of childbearing age and pregnant women, nursing mothers, and young children should not eat shark, swordfish, king mackerel, or tilefish. FDA also advises that women of childbearing age and pregnant women may eat an average of 12 ounces of fish purchased in stores and restaurants each week. Therefore, if in a given week a woman eats 12 ounces of cooked fish from a store or restaurant, then she should not eat fish caught by family or friends that week. This is important to keeping the total level of methyl mercury contributed by all fish at a low level. (See Related Resources for FDA Fish Advisory.)

Reducing Mercury in the Environment

The EPA and the states are working to reduce mercury pollution in the environment, but because methyl mercury is very persistent, it will be many years before methyl mercury levels in fish and the environment are reduced.

Coal-burning power plants are the single largest source of mercury pollution. Another significant source of mercury is from medical waste incineration because of the large quantities of mercury typically used in healthcare (eg, thermometers, sphygmomanometers, batteries, fluorescent lamps). The latter source is one in which nurses can have a direct influence. A national coalition of healthcare providers and others, called Health Care Without Harm, has launched an international campaign to eliminate mercury from use in the healthcare sector. The American Nurses Association is one of the more than 300 organizations involved in the campaign. See "Health Care Without Harm" in the Related Resources section for more information on mercury reduction in healthcare settings.

In addition, Hospitals for a Healthy Environment is a partnership program that also focuses in part on mercury reduction in hospitals (see Related Resources for their Web site).

Table 2 is a useful guide for detecting sources of mercury in the home and substituting them with mercury-free alternatives. It is not intended as an inclusive list, however.

Table 2. Hunt for Mercury at Home

Cultural Beliefs/Practices

Mercury has unique significance in some cultural practices. For example, in some ethnic folk remedies and in some religious practices, metallic mercury is used. It is described by several names, including "azogue," which can be found in stores called "botanicas" that specialize in items used in Esperitismo (a spiritual belief system of Puerto Rico), as well as voodoo and Santeria. In some Hispanic cultures, the use of azogue is recommended by spiritualists, card readers, and santeros, where the azogue is typically sealed in a pouch and recipients are advised to sprinkle it in their homes or cars. It may also be recommended by botanic owners to mix in bath water or perfume or place it in devotional candles.^[15]

In addition, there is some use of mercury-containing skin care products (soap, makeup, creams to lighten skin and hair) by Asian and African cultures. One study of a population in Tanzania discovered very high concentrations of mercury in women who used such products.^[25]Accident Spill Response

In the event of an accidental skin contact, recommendations are to remove contaminated clothing and to wash with soap and water. Eyes should be washed with water for at least 15 minutes, lifting both upper and lower lids, and then medical attention should be sought. If mercury is ingested or large quantities are inhaled, this constitutes a medical emergency and the person should be immediately seen in a clinical setting. See Related Resources for Accident Spill Response information.

Nursing Actions

• Nurses should assess individuals and communities for the cultural use of mercury and educate the individual or community about potential health risks.
• Nurses should make a dietary assessment of those at increased risk for mercury poisoning (young children, pregnant women, and women of childbearing age) using EPA and FDA fish advisories.
• To assess the mercury content in household chemicals and products, consult the mercury audit at the EPA Web site (see Related Resources).
• Do not throw mercury products in the trash, which will either be incinerated or landfilled, either of which release the mercury back to the environment. Contact the local government hazardous waste division (usually housed in the department of the environment, the fire department, or health department) and ask where the mercury can be safely disposed. The mercury from 1 thermometer (roughly the size of an M&M candy) is enough to contaminate a 20-acre lake.
• If a mercury spill occurs, there are specific methods that should be used for clean up. It will require the evacuation of persons and animals from the contamination site, the use of special equipment and ventilation, and the need to assess the health effects on people who have come in contact with the contamination site. In addition, cordon off the spill area so that mercury is not accidentally tracked throughout the building. For an explanation of the components of this process, go to the Health Care Without Harm Web site (see Related Resources).

Pesticides

Pesticides are chemical compounds that have been formulated to kill, control, or repel a pest. Pests come in many forms: weeds, insects, rodents, and microbes, including bacteria. As is true of all potentially hazardous chemicals, the resulting effects are dependent on the dose. Pesticides are associated with a host of health risks, including cancer and acute and chronic injuries to the respiratory, nervous, reproductive, immune, and endocrine systems.^[26] Some pesticides are formulated to biodegrade, but many persist in our environments. Children are particularly susceptible to pesticide exposure for all of the reasons that children are more vulnerable to all environmental exposures: Their "dose" per body weight is likely to be much higher, they consume more fruits and fruit juices (that may have pesticide residues), their metabolic rate is higher than adults', and they are more like to be on the ground (floors and lawns) where pesticides are likely to have been applied.^[26]

There is a growing body of scientific data about the harmful effects that pesticides have on children's health, both acute and chronic. Routes of exposure to pesticides include inhalation, ingestion, and dermal penetration. Eighty percent of exposures to pesticides occur indoors; measurable levels of up to a dozen pesticides have been found in the air inside of homes.^[27] Acute effects of exposure include eye and throat irritation, skin rashes, nausea, vomiting, diarrhea, headaches, flu-like symptoms, upper respiratory distress, and, in extreme cases, death.

Chronic effects, ie, those that appear long after exposure, include an increased risk of some types of cancer, reproductive impairment, and neurologic damage.^[26] Several studies have noted the relationship between childhood cancers (brain cancer, Ewing's sarcoma, Wilm's tumor, acute lymphoblastic leukemia, non-Hodgkin's lymphoma) and pesticide exposures.^[28-32] The potential risks illustrated by these studies suggest a need for a precautionary approach when dealing with pesticide exposures generally, but especially with children.

The EPA is responsible for registering all pesticides and is currently conducting a review of older pesticides to ensure adherence to current scientific standards under the Food Quality Protection Act (FQPA). FQPA, signed into law in 1996, sets a tougher standard for pesticide use on food, with a focus on children's environmental health. There are more than 20,000 registered pesticide products, each formulated for a specific use or uses. In fact, the biocides that are now included in many hand-cleaning products are registered pesticides.

Instead of using pesticides, follow these tips to ward off insects and other pests in the home:

• Clean up spills and crumbs right away;
• Keep food in sealed containers;
• Eat at the table instead of walking around with food;
• Clean dirty dishes right away and drain the dishwater;
• Keep a tight lid on trash and empty it often;
• Don't leave pet food out overnight;
• Wipe water off counters and fix leaky faucets;
• Check boxes and bags for insects before bringing them into the house;
• Get rid of stacks of paper; and
• Caulk cracks or openings around baseboards and behind the kitchen and bathroom counters.

Integrated Pest Management

Integrated Pest Management (IPM) is really an approach to, rather than a rigid system for, pest control. It calls for the employment of the least hazardous methods for controlling pests before even beginning to think about the employment of potentially hazardous options. For example, incorporated into this approach is the removal of food and water sources from insects and/or other pests.^[33] Traditional pest control has relied heavily on pesticides as the first plan of attack. Integrated Pest Management differs in that it does not automatically rely on pesticide application. For more information, see Related Resources.

EPA Registration of Pesticides

All pesticides (insecticides, fungicides, etc., even biocidal soaps) must be registered with the EPA. Each registration is for a specific use, such as agricultural application (including specification of the type of plant to which it may be applied), home use, pet collars, and so on. If evidence emerges regarding ecologic or human health risks associated with a pesticide or a particular use of a pesticide, the EPA may ban it completely or withdraw its registration for a particular use. For example, chlorpyrifos (Dursban), a commonly used household pesticide, was banned in 2000 for household and garden use. It can still be used in agricultural settings (except on tomatoes), and it can still be used on "new homes" until 2005 for treatment of termites. (See Related Resources for Pesticide Product Recalls.)

Nursing Actions

• During home visits, assess pest status and the use and storage of pesticides.
• Inform patients about banned and phased-out pesticides.
• Discourage lawn services that routinely spray pesticides.
• Teach proper disposal of pesticides. (Contact the hazardous waste management division of your State Department of the Environment for the location of the closest hazardous waste collection point.)
• Teach clients how to prevent pests.

Drinking Water

Water is essential to life and comprises 60% to 70% of body weight. Children drink more water per body weight than adults. While the United States has made great efforts to provide safe and healthy water, not all drinking water is contaminant-free. Children, because of their special physiologic vulnerabilities and increased consumption of water, may be particularly sensitive to contaminants found in their drinking water. Contaminants may be microbial (virus, bacteria, protozoa), chemical, or radiologic. Nurses need to be aware of the quality of their patients' and community's drinking water and counsel those patients who may be more vulnerable to the contaminants in their water.

Millions of pounds of potentially hazardous industrial and agricultural chemicals are released into the environment each year in the United States. Some of the releases are intentional and some are accidental. Our drinking water, which is derived either from surface waters or from underground sources, are vulnerable to contamination from the pollutant releases, including agricultural and household chemicals, industrial waste, and uncontrolled releases from leaking underground storage tanks and landfills.^[34] Preventing source-water contamination should be incorporated as a community education concern.

In addition to chemical contaminants, pathogenic microbes account for an estimated 900,000 waterborne infections annually.^[35] The majority of waterborne disease incidence may be underestimated because not all outbreaks are recognized, investigated, or reported. Children exposed to microbial contaminants in drinking water may experience a range of gastrointestinal symptoms depending on their immune status and virulence of the microbe. Symptoms range from mild gastric distress to explosive diarrhea. Several microbial contaminants cause more than gastrointestinal symptoms. Exposure to the Coxsackie and ECHO viruses can lead to meningitis and encephalitis. In 1999, an outbreak of E coli 0157:H7 from contaminated drinking water led to 9 deaths in New York from toxic hemolytic uremic syndrome.

Chemical contaminants of particular concern for children include pesticides, heavy metals, nitrates, and disinfection by-products. Infants under the age of 6 months who are exposed to elevated levels of nitrites in drinking water (due to contamination from fertilizer use or sewage runoff) are at risk for developing "blue baby syndrome" (methemoglobinemia), a rare but life-threatening illness. Nurses, as primary health providers in the community, must be able to field questions about water quality and guide vulnerable populations to informed decisions.

The introduction of disinfectants to the drinking water supply was one of the greatest public health successes of the 20th century. Public drinking water is often disinfected by the addition of chlorine to the water during the treatment process. Although chlorine is effective in controlling many microorganisms, it forms organic chlorine compounds, referred to as disinfection byproducts, when it reacts with organic matter found in water distribution pipes. Epidemiologic studies indicate that there may be an increased risk of miscarriage in women and developmental effects to the fetuses of pregnant women exposed to high levels of these by-products.^[36-38]

Although lead paint and dust are the primary sources of exposure to lead, lead in drinking water can contribute up to 20% of this amount. Lead can leach out of household plumbing (lead pipes and lead solder) or from older public water distribution pipes made of lead. In addition, boiling water for more than 1 minute may raise the concentration of lead and other heavy metals present in the water.

If lead is found in drinking water there are several options that should be considered:

• First, have blood lead level tests performed on any children living in the home. Attempt to identify and eliminate the source;
• Do not use water containing lead for mixing a baby's formula;
• Consider a water treatment device or an alternative drinking water source;
• Reverse osmosis treatment devices will remove approximately 85% of the lead; distillation systems can remove about 99%. If these systems are used, then all water used for drinking or cooking must come from the treated faucet (See Related Resources for Lead Distillation Systems);
• Replace lead pipes and solder;
• If it is not feasible to remedy or if a temporary solution is needed, then flushing the water system before using the water for drinking or cooking may be an option. If the water from a particular faucet has not been used for several hours, the cold-water tap should be run until it becomes as cold as it will get. Each faucet should be flushed before using. This may not be an effective method in high-rise buildings; and
• Avoid cooking with or consuming water from hot water taps because hot water dissolves lead more readily than cold.

A 1996 Amendment to the Safe Drinking Water Act allows consumers and their healthcare providers to have access to information concerning the quality of their drinking water. This Amendment requires public water system providers to produce and make available to consumers a Right to Know or Consumer Confidence Report (CCR). These reports are issued annually and must provide information on how to contact the water provider; the source of drinking water (river, reservoir, aquifer); any contaminants detected and their health effects; and compliance with federal drinking water standards. If people have not received their reports, they can call their water company or talk with their landlord to receive a copy. The reports include a recommendation for people with compromised immune systems to consult with their healthcare provider regarding appropriate precautions to take to avoid infection in the event of microbial contamination. Therefore, it is important to be informed about drinking water and who is more susceptible to microbial illness. The EPA has a Web site where many local CCRs can be found (see Related Resources for EPA Safe Water). A water supplier must notify its customers by newspaper, mail, radio, TV, or hand-delivery if water does not meet EPA or state standards or if there is a waterborne disease.

Largest Waterborne E coli O157:H7 Outbreak in United States History

In September 1999, 3-year-old Rachel Aldrich died after being infected with the toxic E coli O157:H7 strain at a New York county fair. Hundreds of others, including Rachel's sister, Kaylea, became ill as well. The New York Department of Health identified 71 people who were hospitalized during the outbreak. Of these, 14 developed hemolytic uremic syndrome, a severe complication of E coli O157:H7 infection that can lead to kidney failure. An investigation by epidemiologists identified 781 persons with confirmed or suspected illness (persons who developed symptoms) related to this outbreak. Of these, 127 cases of E coli and 45 cases of Campylobacter were confirmed by culture. (See Related Resources for International Bottled Water Association.)

Alternative Sources of Drinking Water

When a water source is considered unsafe because of a chemical, microbial, or radionuclide contamination, or because an individual is considered too vulnerable to drink tap water, tap water should be avoided. Alternatives include boiled water, bottled water, and treated or filtered water.

Boiled water. Most harmful microbes found in water will be killed if water is allowed to reach a full rolling boil for 1 minute. However, boiling water for more than 1 minute may concentrate some chemicals (such as lead, arsenic, and nitrates) and may cause some chemical contaminants to be released in the steam where they then can be inhaled.

Bottled water. More than half of all Americans drink bottled water; about a third of the public consumes it regularly. The National Resource Defense Council ^[39] completed a 4-year study to evaluate the quality of bottled water. They found that bottled water regulations are inadequate to assure consumers of safety. At least a third of the bottled water tested violated a state standard or guideline for microbials. The FDA is responsible for good manufacturing practices for bottled water; however, it does not have jurisdiction over intrastate commerce of bottled water, which exempts roughly 60% to 70% of bottled water from FDA regulation. In addition, FDA regulations do not apply to carbonated water. The following organizations can provide information on bottled water:

• NSF International (877-8-NSF-HELP)
• International Bottled Water Association (see Related Resources)

Water filters. There are a variety of water treatment units on the market. No one filter removes all sources of contamination; therefore, it is important to identify the contaminant(s) of concern before recommending or investing in a filtration device for the home. For help in picking a unit, contact either of the independent nonprofit organizations listed below. (Water treatment units certified by these organizations will indicate certification on their packaging labels.)

• NSF International (877-8-NSF-HELP) tests and certifies home water treatment units
• Water Quality Association (630-505-0160; see Related Resources for Web site) classifies units according to the contaminants they remove and also lists units that have earned its approval.
• Underwriters Laboratory (see Related Resources for Web site) also certifies some home water treatment units.

Tap Water Testing

Although public water utilities are required to test for regulated contaminants and report the results, there may be instances when consumers may want additional information. For example, consumers may want to check for lead in the water. Water utilities are not required to check the lead level at each end point. In addition, most states have some regulations regarding the water testing of new wells; however, there are seldom requirements for periodic retesting. Private wells are not regulated by the EPA as public utilities are, although EPA does recommend that private wells be tested annually.

The right to know statutes do not apply to personal wells. Therefore, consumers with private wells should have them checked annually for bacteria and some chemical contaminants, such as nitrates. Information for private well owners about how to protect a private water supply, as well as links to a list of state-certified drinking water laboratories, can be found in Related Resources for EPA, Info on Private Wells. In addition, most state health departments can provide a list of state-certified independent water testing laboratories. Prices for water testing vary according to the type and number of contaminants being detected.

NSF International

NSF International is an organization that tests and verifies that products they certify meet all of the requirements of specified standards and that manufacturers' claims are true. NSF does not recommend, rate, or compare products. An NSF mark indicates assurances that the product will perform as claimed. NSF will issue certification to water bottlers that meet the basic FDA requirements. If the product meets the NSF standards, the bottled water label should indicate the certification. In addition, NSF will issue certifications for water treatment devices if they meet NSF standards. More information about this service can be found at the NSF Web site (see Related Resources).

Sun Safety for Children

Children spend lots of time outdoors. While some exposure to sunlight can be enjoyable and healthy, too much can be dangerous. Overexposure to ultraviolet (UV) radiation can cause serious health effects, including skin cancer and other skin disorders, eye damage and cataracts, and immune system suppression. Malignant melanoma is of particular concern because its rates are increasing, faster than any other cancer. While the lifetime risk of melanoma was 1 in 1500 in 1935, by 1980 it was 1 in 250, and was 1 in 71 by 2000. ^[40] The projections are for a continuing rise. Incidence rates are more than 10 times higher in whites than in blacks.^[41] Given that we receive an estimated 80% of our lifetime sun exposure while we are young (by age 18 years), it is particularly critical that we address sun exposure in children.^[42]

UV radiation comes in several forms (UV-A, UV-B, and UV-C) and affects human health in different ways. In particular, children (and others) must be protected from UV-A and UV-B, which penetrate the earth's stratospheric ozone layer. Due to the depletion of the ozone layer, increased levels of harmful UV radiation are likely to penetrate. These heightened levels may cause the incidence and severity of UV-related health effects to rise, particularly given current sun-protection practices in the United States. Since the condition of the ozone layer is not expected to improve significantly in the near future, sun behaviors must change in order to protect our future health.

Many believe that only lighter-skinned people need to be concerned about the effects of overexposure to the sun. Though it is true that darker skin has more natural pigment, which acts as a protectant, the skin is still susceptible to many of the damaging effects of UV radiation. The incidence of skin cancer is lower in dark-skinned people, but it still occurs and is often not detected until later stages when it is more dangerous. The risk of other UV-related health effects, such as cataracts, premature aging of the skin, and immune suppression, is not dependent upon skin type. The good news is that UV-related health effects are largely preventable by instituting sun-protection practices early and consistently. Additional information on health effects and action steps for sun protection can be found in Related Resources for EPA, UV Protection.

The UV Index

The UV Index provides a daily forecast of the expected risk of overexposure to the sun (which may also be referred to as the sunburn rate). The Index predicts UV intensity levels on a scale of 0 to 10+, where 0 indicates a minimal risk of overexposure and 10+ means a very high risk (Table 3). Calculated on a next-day basis, the UV Index takes into account clouds and other local conditions that affect the amount of UV radiation reaching the ground in different parts of the country.

Table 3. UV Index

Watch for UV Index reports in your local newspapers and on television. Information on the daily UV Index can usually be found in the newspaper. In addition, the UV Index is available for all communities across the United States in a zip code-searchable format (see Related Resources for EPA, UV Protection).

Protecting Children From Overexposure to UV Radiation

Children (and adults!) should be taught to protect themselves from the harmful effects of UV radiation. Here are tips that everyone should follow.

Limit time in the midday sun.The sun's rays are strongest between 10 am and 4 pm. Whenever possible, limit exposure to the sun during these hours.

Seek shade. Staying under cover is one of the best ways to protect a child from the sun. Remember the shadow rule: "Watch your shadow; no shadow, seek shade!"

Always use sunscreen. Choose a broad-spectrum sunscreen with a Sun Protection Factor (SPF) of at least 15 or higher. Apply it liberally to exposed skin and reapply it every 2 hours when working or playing outdoors. Even waterproof sunscreen can come off when you towel-dry, sweat, or spend extended periods of time in the water.

Wear a hat. A hat with a wide brim offers good sun protection to eyes, ears, face, and the back of the neck, areas particularly prone to overexposure to the sun.

Cover up. Wear tightly woven, loose-fitting, and full-length clothing.

Wear sunglasses that block 99% to 100% of UV radiation. Sunglasses that provide 99% to 100% UV-A and UV-B protection will greatly reduce sun exposure that can lead to cataracts and other eye damage. Check the label when buying sunglasses.

Avoid sunlamps and tanning parlors. The light source from sunbeds and sunlamps damages the skin and unprotected eyes. It's a good idea to avoid artificial sources of UV light.

Watch for the UV Index. Keep tabs on the UV Index (Table 3) so that you know how likely you or your child are to get a sunburn on a given day.

Conclusion

In our homes, there are a number of environmentally related health threats that can be avoided by good assessment activities and the removal of the threats. All homes should be tested for the presence of radon. In homes where fuel powers the heating system, furnaces should be inspected annually. Carbon monoxide detectors should be considered for homes in which gas fuels the furnace or stoves. Homes built before 1978 should be tested for lead-based paint. Nurses, as role models for their families and communities, should be the first to know whether such environmental health threats exist in their own homes; they should then include such assessments when they do home visits or prepare new moms and recovering patients for their return home from the hospital.

So many of the environmental health threats in homes can endanger children and their ability to learn. Working with daycare settings and schools to incorporate environmental health education can help to improve the community's knowledge about preventable environmental diseases. Nurses are uniquely qualified members of the community to initiate such educational and awareness programs.

According to a Roper poll (contracted by the National Environmental Education and Training Foundation,^[43]) on public knowledge, attitudes, and behavior, healthcare providers are among the most trusted sources of information about certain environmental health issues. It demands that we, as nurses, educate ourselves about the relationship between environmental exposure and potential human health effects so as to honor this trusted position that we hold with our patients and the community.

There are many great resources that nurses can access for additional information. A variety of Web sites, including EPA's, the National Library of Medicine's, and the University of Maryland School of Nursing's, all present information that has been screened for accuracy, as well as many more resources suggested in this Clinical Update.

Equally important, nurses need to be at the tables where environmental health policies are being made -- locally, at the state level, and nationally. The ANA has passed several resolutions, such as The Reduction of Health Care Production of Toxic Pollution Resolution (see Related Resources for Nursing World Organization), that focus on environmental health and have the potential for a significant presence on environmental health issues. Individual nurses and nursing professional organizations have a great potential to affect environmental health and make a difference in creating environmental health policies and practices that are protective for all, including our most vulnerable populations.

Two other CE activities on environmental health are available at the ANA Web site. They include Environmental Health in the Health Care Setting and Environmentally Healthy Schools.

Related Resources

http://nursingworld.org/mods/mod370/cehcver.htm
Environmental Health in the Health Care Setting

http://nursingworld.org/mods/mod250/CESAVERS.HTM
Environmentally Healthy Schools

http://enviRN.umaryland.edu
A one-stop shop created by the University of Maryland School of Nursing for nurses interested in environmental health.

Environmental Health Listserv
This listserv (online discussion) was created 5 years ago for nurses who are especially interested in environmental health. The listserv is moderated, meaning that there is a gatekeeper and information can only be sent by the moderator, who is on staff at the Environmental Health Education Center at the University of Maryland School of Nursing. Anyone can send the moderator information for distribution to the listserv. (To join the listserv, please email bsattler@son.umaryland.edu. Place "enviRN" in the subject area of the email message.)

www.epa.gov/
United States Environmental Protection Agency (EPA)

• Safe Drinking Water Hotline: 1-800-426-4791
• Ground Water and Drinking Water:
  www.epa.gov/safewater
• Surf Your Watershed (database):
  www.epa.gov/surf
• Info on private wells - www.epa.gov/safewater/pwells1.html
• Office of Pesticides
  Telephone: 703-305-5017
  Web site:
  www.epa.gov/pesticides

National Directory of Integrated Pest Management in schools:

• http://www.epa.gov/pesticides/ipm/
• Office of Children's Health Protection:
  http://yosemite.epa.gov/ochp/ochpweb.nsf/homepage
• The National Lead Information Center: 1-800-424-LEAD
• EPA Lead Programs:
  www.epa.gov/lead
• National Pesticide Telecommunications Network: 1-800-858-7378
• Health effects information on individual pesticides:
  www.epa.gov/pesticides/reregistration/status.htm
• UV Protection (Sun Wise School Program):
  www.epa.gov/sunwise
• Indoor Air Quality:
  www.epa.gov/iaq
• Envirofacts Data Warehouse:
  www.epa.gov/enviro/index_java.html
• Mold Prevention Tips:
  www.epa.gov/iaq/molds/prevention.html
• Mold Remediation Protective Clothing:
  www.epa.gov/iaq/molds/whattowear.html
• Mold Remediation Cleanup Methods:
  www.epa.gov/iaq/molds/mold_remediation.html
• Dust Mites (Clear Your Home of Asthma Triggers):
  http://www.epa.gov/asthma/asthma.html
• Radon Test Kit (A Citizen's Guide to Radon):
  www.epa.gov/iaq/radon/pubs/citguide.html#howtotest
• Protect Your Family and Yourself from Carbon Monoxide Poisoning:
  www.epa.gov/iaq/pubs/coftsht.html
• Mercury: In Your Community and the Environment:
  www.epa.gov/grtlakes/bnsdocs/merccomm/merccomm.pdf
• Pesticide Product Recalls:
  www.epa.gov/pesticides/factsheets/alpha_fs.htm

www.CEHN.org
Children's Environmental Health Network -- Online resource guide

www.chej.org
Center for Health, Environment and Justice

www.cdc.gov/nceh/default.htm
National Center for Environmental Health (NCEH), Centers for Disease Control and Prevention (CDC). NCEH provides expertise in environmental pesticide surveillance and disease outbreak investigations.

www.cpsc.gov
U.S. Consumer Product Safety Commission

CO Prevention:
cpsc.gov/cpscpub/pubs/cospot.html#prevention
www.atsdr.cdc.gov/toxfaq.html
Agency for Toxic Substances and Disease Registry (ATSDR). For fact sheets and information on pesticides.

• Information Center: 1-888-422-8737 or ATSDRIC@cdc.gov
• Emergency Response Hotline: 404-639-4270

www.preventingharm.org
Preventing Harm, is a resource and action center on children and the environment.

www.noharm.org
Health Care Without Harm

www.h2e-online.org
Hospitals for a Healthy Environment

www.lungusa.org
The American Lung Association
Telephone: 1-800-LUNG-USA

www.scorecard.org
Environmental Defense Toxic Release Inventory

www.fda.gov/bbs/topics/ANSWERS/2001/advisory.html
FDA Fish Advisory

www.oehha.org/pdf/exec.pdf
Health Effects of Exposure to Environmental Tobacco Smoke (California Environmental Protection Agency)

http://www.cpsc.gov/cpscpub/pubs/5010.html
Underwriters Laboratories (UL) Standard for Carbon Monoxide Detectors

http://www.ianr.unl.edu/PUBS/water/g1333.htm
Lead Distillation Systems

www.wqa.org
Water Quality Association

www.nsf.org
NSF International: The Public Health and Safety Company

www.NursingWorld.org
Nursing World Organization

References

1.     Manual JS. Land Use: A toxic house in the country. Environ Health Perspect. 2000;8:115.

2.     Lewis RG, Fortmann RC, Camann DD. Evaluation of methods for the monitoring of the potential exposure of small children to pesticides in the residential environment. Arch Environ Contam Toxicol. 1994;26:37-46. Abstract

3.     Bearer C. Environmental health hazards: how children are different from adults. Future Child. 1995;5:11-26. Abstract

4.     New York City Department of Health & Mental Hygiene. Environmental & Occupational Disease Epidemiology: Facts about mold. February 2001. Available at:
http://www.ci.nyc.ny.us/html/ doh/html/epi/epimold.html Accessed July 25, 2003.

5.     California Environmental Protection Agency: Office of Environmental Health, Hazard Assessment. Health effects of exposure to environmental tobacco smoke. September 1997.Available at:
http://www.oehha.org/air/environmental_tobacco/ finalets.html#download Accessed July 25, 2003.

6.     American Nurses Association Position statement: Environmental tobacco smoke. 1997. Available at:
http://www.nursingworld.org/readroom/ position/social/scenvtob.htm Accessed July 25, 2003.

7.     US Environmental Protection Agency: Office of Air and Radiation. A Citizen's Guide to Radon: The Guide to Protecting Yourself and Your Family From Radon. 3rd ed. September 1992. Available at:
http://www.epa.gov/iaq/ radon/pubs/citguide.html Accessed July 25, 2003.

8.     Greiner T. Carbon monoxide: the current situation. 1998. Iowa State University of Science and Technology.
http://www.abe.iastate.edu/ human_house/aen196.asp

9.     Wayne State University School of Medicine. Deaths from carbon monoxide poisoning in the United States, 1988-1996. 1999.

10. United States Consumer Product Commission. Protect your family and yourself from CO poisoning. (US Consumer PSC No 0-356-764). Washington, DC: Government Printing Office; 1993.

11. Penney D. Carbon monoxide poisoning: What is chronic carbon monoxide poisoning? 2001.
http://www.coheadquarters.com/cochronic1.htm

12. US Department of Health and Human Services, Centers for Disease Control and Prevention and National Institute for Occupational Safety and Health. NIOSH Pocket Guide to Chemical Hazards. (DHHS Publication No. 94-116). Washington, DC; 1994.

13. Centers for Disease Control and Prevention. Recommendations for blood lead screening of young children enrolled in Medicaid: targeting a group at high risk. MMWR Morb Mortal Wkly Rep. 2000;49(RR14): 1-13. Available at:
http://www.cdc.gov/mmwr/preview/ mmwrhtml/rr4914a1.htm Accessed July 25, 2003.

14. Centers for Disease Control and Prevention. Blood lead levels in young children--United States and selected states, 1996-1999. MMWR Morb Mortal Wkly Rep. 2000;49:1133-1137. Abstract

15. Centers for Disease Control and Prevention. Update: blood lead levels -- United States 1991-1994. MMWR Morb Mortal Wkly Rep. 1997;46:141-146, erratum: 1997;46(26):607. Atlanta, Georgia: U.S. Department of Health and Human Services/Public Health Service.

16. Centers for Disease Control and Prevention. Preventing lead poisoning in young children: A statement by the Centers for Disease Control. Report No. 99-2230. 1991. Atlanta, Georgia: US Department of Health and Human Services, Public Heath Service.

17. Centers for Disease Control and Prevention. National alert: a warning about continuing patterns of metallic mercury exposure. 1997. Available at:
http://www.atsdr.cdc.gov/alerts/970626.html Accessed July 25, 2003.

18. US General Accounting Office. Lead poisoning, federal health care programs are not effectively reaching at-risk children. GAO/HEHS-99-18. Washington, DC; 1999.

19. Needleman H, Riess J, Tobin M, Biesecker G, Greenhouse J. Bone lead levels and delinquent behavior. JAMA. 1996;275: 363-369. Abstract

20. Livingston D. Maintaining a Lead Safe Home. Baltimore, Md: Community Resources; 1997.

21. Centers for Disease Control and Prevention. Fatal pediatric lead poisoning -- New Hampshire, 2000. MMWR Morb Mortal Wkly Rep. 2001;50;457-459. Available at:
http://www.cdc.gov/mmwr/preview/ mmwrhtml/mm5022a1.htm Accessed July 25, 2003.

22. Centers for Disease Control and Prevention. Blood and hair mercury levels in young children and women of childbearing age -- United States, 1999. MMWR Morb Mortal Wkly Rep. 2001;50:140-143. Abstract

23. National Academy of Sciences: National Research Council. Toxicological effects of methyl mercury. Washington, DC: National Academy Press; 2000.

24. Houlihan J, Wiles R. Brain food: What women should know about mercury contamination of fish. Washington, DC: Environmental Working Group & U.S. PIRG Education Fund and the State Pirgs; 2001.

25. Glahder C, Appel P, Asmund G. Mercury in Soap in Tanzania. Ministry of Environment and Energy: National Environment Research Institute. (NERI Technical Report No. 306); 1999. Available at:
http://www.dmu.dk/1_viden/2_Publikationer/ 3_fagrapporter/rapporter/fr306.pdf Accessed July 25, 2003.

26. United States Environmental Protection Agency: Region 8. Pesticides, toxic chemicals & children. Available at:
http://www.epa.gov/Region8/humanhealth/ children/pesticides/pesticides.html

27. United States Environmental Protection Agency. The inside story: a guide to indoor air quality. Washington, DC: Office of Air and Radiation, EPA; 1988.

28. McBride M. Childhood cancer and environmental contaminants. Can J Public Health. 1998;89:53-62. Abstract

29. Daniels J, Olshan A, Savitz D. Pesticides and childhood cancers. Environ Health Perspect. 1997;105:1068-1077. Abstract

30. Buckley J, Meadows A, Kadin M, Le Beau M, Siegel S, Robison L. Pesticide exposures in children with non-Hodgkin lymphoma. Cancer. 2000;89: 2315-2312. Abstract

31. Meinert R, Schuz J, Kalersch U, Kaatsch P, Michaelis J. Leukemia and non-Hodgkin's lymphoma in childhood and exposure to pesticides: results of a register-based case-control study in Germany. Am J Epidemiol. 2000;151: 639-646. Abstract

32. Infante-Rivard C, Labuda D, Krajinovic M, Sinnett D. Risk of childhood leukemia associated with exposure to pesticides and gene polymorphisms. Epidemiology. 1999;10:481-487. Abstract

33. American Academy of Pediatrics, Committee on Environmental Health. Handbook of Pediatric Environmental Health. Elk Grove Village, Ill: American Academy of Pediatrics; 1999.

34. Physicians for Social Responsibility. Drinking water and disease: What health care providers should know. Washington, DC: Physicians for Social Responsibility; 2000.

35. American Society for Microbiology. Microbial pollutants in our nation's water. Washington, DC: American Society for Microbiology; 1999.

36. King W, Dodds L, Allen A. Relation between stillbirth and specific chlorination by-products in public water supplies. Environ Health Perspect. 2000;108:883-886.

37. Moline J, Golden A, Bar-Chama N, et al. Exposure to hazardous substances and male reproductive health: A research framework. Environ Health Perspect. 2000;108:803-813.

38. Swan S, Waller K, Hopkins B, et al. A prospective study of spontaneous abortion: Relation to amount and source of drinking water consumed in early pregnancy. Epidemiology. 1998;9:126-133. Abstract

39. Natural Resource Defense Council. Bottled water: Pure drink or pure hype? New York: Natural Resource Defense Council; 1999.

40. Rigel D. Melanoma update. Skin Cancer Foundation Journal. 2001;XIX:13-14.

41. American Cancer Society. Cancer facts & figures. 2001. Available at:
http://www.cancer.org/docroot/STT/content/ STT_1x_2001_Facts_and_Figures.pdf.asp Accessed July 25, 2003.

42. American Academy of Dermatology. Children at risk: protecting our children from skin cancer. [Press release] April 26, 2000. Available at:
http://www.aad.org/PressReleases/protectchild.html Accessed July 25, 2003.

43. The National Environmental Education & Training Foundation and Roper Starch Worldwide. The national report card on safe drinking water, knowledge, attitudes, and behaviors. Washington, DC: The National Environmental Education & Training Foundation; 1999.

Copyright 2003 American Nursing Association