• The home, day care, school, and, for adolescents, the job setting may have unique environmental hazards.

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

• If a parent is planning renovation, advise how to avoid lead paint exposure.
• If paint is old, peeling, or in poor repair, the parent should consider de-leading by using a certified contractor.
• If a patient has been exposed to lead paint, consider blood lead testing for pregnant women and children under age 6.

• If not, advise of the need for regular maintenance to avoid the hazards of carbon monoxide (CO) and other hazardous emissions.
• Ask about proper ventilation for combustion products from fireplaces, wood stoves, gas stoves, and gas dryers, etc.

• If there are none, recommend parents to purchase and install smoke detectors and carbon monoxide detectors. When a parent is purchasing CO detectors, recommend they look for UL certification 2034.

• If not, recommend the homeowner learn how to test for radon exposures that may increase cancer risks (see EPA www.epa.gov/radon).

• If yes, provide smoking cessation advice and help.
• If a smoker can’t stop now, advise that smoker to smoke outside in order to decrease the risk to children and the spouse.
• The car should be smoke-free.
• Make sure to advise smokers to change clothes and wash hands before interacting with children.
• If the smoker is pregnant, strongly urge the smoker to quit smoking in order to avoid health risks to the fetus.

What are the occupations of adults in the household?

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

• If yes, advise the parents about information sources for job exposures.

• If the occupation is known for exposures that can cause reproductive injury, discuss use of protective equipment and temporary change of duties during the pregnancy.

• If there is potential for take-home contamination, recommend showering (if possible) and changing to clean clothing and shoes before returning home.
• Have the adult associated with potential take-home clothing contaminant check with the employer regarding laundering work-related clothes. Provide advice to not wash work-related clothes at home if hazardous exposures could result.

• Environmental hazards in the home or surrounding neighborhood may include
  • air quality issues
  • drinking water contamination (check source of drinking, cooking, and bathing water),
  • exposure to hazardous waste sites,
  • toxic releases from industrial facilities,
  • recent spills or chemical accidents near the home, school, day care, or play areas.
  • environmental health issues at school or day care or play areas.
• Advise parents to call the environmental section of their local health department or the regional EPA if they have concerns about environmental hazards in the surrounding neighborhood.
• For information on health concerns related to environmental exposures, you or the parents may call the nearest Pediatric Environmental Health Specialty Unit (PEHSU).

• If yes, inquire about the type of fish eaten and how often it is eaten.

• If yes, reinforce the value of eating fish for nutritional benefits but advise that fish with known high levels of methylmercury, such as swordfish, shark, king mackerel, and tilefish, should be avoided in the child’s diet.

  Women who are pregnant or nursing and young children should completely avoid eating these fish (for more information see http://www.fda.gov/Food/FoodSafety/
  Product-SpecificInformation/Seafood/
  FoodbornePathogensContaminants/Methylmercury/
  ucm115662.htm

• Also advise patients to follow local fish advisories for other types of fish or types of contamination, such as high levels of polychlorinated biphenyls (PCBs) in some farm-raised salmon.

• Advise against uses of potentially toxic herbal remedies.
• If a patient is using Ayurvedic or other folk remedies, check blood lead level, or if the patient is using azogue, check urine elemental mercury levels in consultation with PEHSU experts ( http://aoec.org/PEHSU/).

• Some folk remedy creams or cosmetics can contain lead.
• If suspicious, check blood lead levels of mother and/or children.

• If answers to CDC screening questions are positive, check the blood lead level (CDC, 2005).
• Federal law requires screening of all Medicaid-eligible children for blood level leads at ages 1 and 2 [AAP Statement on Lead, 2005].

• Sunburns during childhood and adolescence raise the risk of melanoma later in life.
• Whenever possible, outdoor activities should occur during non-peak sun exposure hours (before 10 AM and after 4 PM).
• Advise parents to protect children from sunburn with clothing and hats whenever feasible, to have children wear ultraviolet protective sunglasses, and to have children use sunscreen with frequent reapplication (National Council on Skin Cancer Prevention http://www.skincancerprevention.org).

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 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.

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 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 protective measures.

Strongly discourage visits to tanning salons—UV rays from tanning salons are carcinogenic.