What Exposure Questions Should Be Included in a Well Child Visit?
Pediatricians should take two environmental medicine actions for every well child who presents to an office or a clinic.
- A routine screening history for potential environmental exposures.
- If necessary, age-appropriate risk-based screening for lead poisoning, using the Centers for Disease Control and Prevention’s (CDC) lead poisoning prevention guidelines [CDC 1997].
A general pediatrician’s practice allows little time for an extensive environmental exposure history. However, initial and subsequent well child visits do give pediatricians opportunities to provide parents and caregivers with educational materials on preventing exposures and actions to take if an exposure occurs. Table 2 lists recommended screening questions and appropriate corrective actions. A written checklist completed by parents may be used to facilitate obtaining the history.
An example of this checklist is the National Environmental Education Foundation Screening Environmental History Form [PDF – 112 KB] at http://www.neefusa.org/health/PEHI/HistoryForm.htm.
Any Age – First Visit | Corrective Actions |
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Where does your child live and spend most of his/her time? |
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What is the age and condition of your home? |
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Are renovations planned or in progress? |
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Do you have fuel-burning appliances and/or chimneys regularly inspected and maintained? |
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Do you have fuel-burning appliances and/or chimneys regularly inspected and maintained? |
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Do you have smoke detectors and CO detectors? |
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Has your home been tested for radon? |
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Does anyone in the family smoke? |
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What are the occupations of adults in the household?
Is there an occupational exposure that could affect children’s health? |
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Is there an occupational exposure that could affect reproduction? |
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Is there a chance of take-home contamination from work-related toxicants on clothing? |
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Do you have concerns about environmental hazards in your home or in the surrounding neighborhood? |
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For the mother—Do you eat fish? |
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Does your child eat fish? |
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Do you take herbal remedies or Ayurvedic (a system of health care native to the Indian subcontinent) medications? If so, which ones? | |
Do you put creams that could contain paints, pigments, or heavy metals on your skin? |
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Is your child at risk for lead exposure ? |
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Is your child at risk for sunburn? |
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The following questions can help pediatricians assess environmental exposures especially relevant to infants.
Well Baby Visit Questions | Corrective Actions |
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Are you breastfeeding? | If yes, potentially exposed mothers should still breastfeed, since the benefits of breastfeeding still outweigh the risks from exposure in most instances. |
Do you bottle-feed the baby, or are you planning to introduce bottle-feeding?
If yes, what water will you be using to mix with the formula—tap water, bottled water, or well water? If tap water, is it from the municipal water system? |
If a parent is using well water, it is important to know if there are harmful contaminants, such as nitrates, that can cause methemoglobinemia in young infants. |
If well water, have you had it tested for the presence of contaminants, such as bacteria, lead, and nitrates? | If the well water has not been recently tested, advise parents to use municipal water, bottled spring water, or distilled water to mix baby formula and to use as the baby’s drinking water until the well is tested and shown safe for infant feeding.
If tap water is used, advise against over-boiling to avoid concentrating such contaminants as lead. One minute of a rolling boil is sufficient. Alternatively, water may be tested for lead. |
For a routine well toddler or young school-age visit, pediatricians should ask the following screening questions in order to determine if any toxic exposures are occurring:
Toddler and Young School-age Questions | Corrective Actions |
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Any changes in your home surroundings or jobs? | If yes, advise appropriately per initial visit guidance. |
Where does the child spend most of his/her time?
Do you have concerns about potential environmental risks? |
If the child stays in a child care setting with a neighbor or a relative, ask about exposure to second-hand smoke or lead paint and the presence of CO meters.
Draw blood and check lead levels if the child is at risk, per CDC guidelines (CDC 2005). |
Are pesticides used inside or outside your home?
If yes, what type of pesticides? Where are they stored? |
Advise parents to store pesticides out of the reach of children.
Be sure that pesticides are not applied in areas where children crawl or play. |
Does the child eat fish? | Some children may eat excessive amounts of fish high in mercury or other contaminants—advise parents about safer alternatives. |
Is the child protected from excessive ultra violet (UV) exposure? | Children in child care or pre-school may play outside without adequate UV protection—advise parents about timing activities, using clothing and hats, and proper use of sunscreen. |
The following screening questions should be asked during all well adolescent visits.
Well Adolescent Questions | Corrective Actions |
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Does the adolescent work?
If yes, what is the type of work? |
Inform the parent and adolescent about rules regarding child labor restrictions (both national and state regulations). |
Does the work expose the adolescent to toxic chemicals, fumes, or dusts or does it involve excessive musculoskeletal stress or work with slicing machines? | Encourage use of protective measures, if indicated. |
Does the adolescent smoke?
Is there exposure to SHS? |
Advise about the dangers of active and passive smoking. |
Is the adolescent protected from excess UV exposure? | Advise about protective measures.
Strongly discourage visits to tanning salons—UV rays from tanning salons are carcinogenic. |