What Contaminants Are Found On A Child Taken From a Meth Lab?

Patient Presentation
A pediatrician received a telephone call from the local director of the emergency child care center in the community. A toddler was being placed with them that afternoon that had been taken from a home that was running a clandestine methamphetamine manufacturing laboratory. In her professional training she had learned that usually there were numerous chemicals in the laboratory environment, that hazardous materials cleanup is necessary and that people living in these environments usually need to leave clothing and belongings behind because of the contamination. However, her training did not cover decontamination of people and if the child could potentially pose a risk to others such as her child care professionals.

The diagnosis of a child with methamphetamine exposure and possible other chemical contamination was made. The pediatrician said that he did not know the exact answer but would check with the local child protection team. From other safety training about biological and radiation hazards he said that the child care providers should follow universal precautions as they always did, and thought that the child would probably not pose a risk as the child should have been bathed thoroughly already which is usually the second step for any decontamination process after removal from the environment. Additionally, the pediatrician felt it was unlikely that the child would have contaminated sweat, tears or other body fluids that would pose a risk to the child care provider. He recommended contacting the fire department’s hazardous materials division for more information if needed. Later, the child protection team confirmed that the child should be bathed with regular soap and water and should not pose additional risk to his/herself or others because of the clandestine laboratory exposure.

Discussion
Methamphetamine is an illegal, man-made, powerful central nervous system drug that gives the user an intense pleasurable feeling that is longer lasting than cocaine which it is similar to. Methamphetamine is highly addictive when used by smoking, inhaling, injecting or being swallowed. Because of unregulated manufacturing, numerous known and unknown chemical contaminants are possible in the manufacturing environment. Areas of highest contamination are in the area of direct manufacturing and chemical discharge such as drains and soil, but other locations where the chemicals can be tracked into such as wall and floors can be contaminated. Clean-up involves properly trained and protected workers using hazardous materials procedures including removal and proper disposal of contaminated materials (i.e. heavily soiled materials such as manufacturing equipment, tables, floor coverings), washing with water and/or plain soap (i.e. mopping of non-directly contaminated areas such as linoleum, clothing, persons, etc.), and containment (i.e. using permeable barrier to contain the chemical such as epoxy paint over walls). Clean-up is regulated by local and state regulations.

Learning Point
Chemical contaminants from methamphetamine manufacturing include, but are not limited to methamphetamine, 1,2-dimethyl-phenyl-aziridine, phenyl-2-propanone, 1-benzyl-methylnaphthalene, 1,3-dimethyl-2-phenylnaphthalene, iodine, hydrochloric acid, and hydriodic acid. While these chemicals can be dangerous, the greatest risk is the behavior of the persons making and using the drug. Children in the environment are often exposed to fires and explosions, numerous safety problems, abuse and neglect, and multitudes of social problems. The United State Justice Department’s Office of Victims of Crimes has a brief yet detailed overview of these potential exposures (see To Learn More below).

Questions for Further Discussion
1. What local resources are available to clean up potentially hazardous materials in your local environment?
2. What are the procedures for medical evaluations of children being placed into the foster care system locally?
3. What problems can infants born to mothers using methamphetamine during pregnancy have?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Methamphetamine

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Office for Victims of Crimes. U.S. Justice Department. Dangers to Children Living at Meth Labs. Available from the Internet at:http://www.ovc.gov/publications/bulletins/children/pg5.html (rev. 6/2003, cited 2/28/2011)

California Department of Toxic Substances Control. Initial Evaluation of Emission from Methamphetamine Manufacuring Via the Ephedrine/Red Phosphorus/Hydriodic Acid Method.
Available from the Internet at http://www.dtsc.ca.gov/sitecleanup/erp/upload/smbrb_memo_initial-eval.pdf (rev. 6/23/2003, cited 2/28/2011).

Illinois Department of Public Health. Methamphetamine Laboratories.
Available from the Internet at http://www.idph.state.il.us/envhealth/factsheets/meth-labs.htm (cited 2/28/2011).

ACGME Competencies Highlighted by Case

  • Patient Care
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Do You Call That Again?

    Patient Presentation
    A 3-year-old male came to clinic with swelling of the penile shaft that was noted after awakening. He complained that his penis “felt funny” but had no distinct pain, burning, itching. He had a full diaper in the morning and had urinated since the edema was noticed. The family denied trauma including potential abuse, bug bites, or being around allergic plants or fevers. The day before he had been playing outside without incident, had been bathed at night and went to bed. The past medical history was positive for eczema and getting welts easily with bug bites.

    The pertinent physical exam showed a well-appearing male with normal vital signs and growth parameters in the 25-75%. His testes were easily palpable and retractile and no hernias were present. He was circumcised and had generalized swelling and erythema of the shaft of his penis and glans which ended at the lower abdomen. There was not excessive warmth or tenderness. During the examination he had an erection which then subsided and still left the shaft somewhat erect. The bodies of the corpus cavernosum and spongiosum did not feel distinctly taut, but the entire shaft seemed edematous. There was no external blood vessel engorgement,meatal discharge, localized skin changes or areas of trauma noted on the genitals, perineum, lower abdomen and upper legs. The rest of his physical examination was normal.

    The physicians examining the patient were not sure what was causing the penile edema and weren’t sure what to call it. This extended farther down the shaft than infectious balanitis and although they did not think this was priapism, they were still worried that perhaps it was a variant that may need urological treatment. The resident urologist was uncertain of the cause also, but the attending urologist immediately recognized the diagnosis of a localized histamine reaction. He confirmed that this was not priapism as the corpora were not engorged and that the edema was generalized. He said that this was a variation of a localized angioedema reaction and because the patient had no other systemic symptoms, that it could be treated with antihistamines like other exaggerated histamine reactions and monitored closely. The urologist thought that maybe this was caused by a bug bite but probably not as he also did not see any trauma.

    Discussion
    Because histamine reactions such as urticaria or angioedema are usually thought of as systemic problems, localized involvement of many different body parts is often not considered in the differential diagnosis. The location and often unusual presentation may cause the clinician to consider more worrisome causes and therefore appropriately begin more evaluation and workup. Additional information about localized angioedema can be found here. Penile edema can also be caused by frequent or vigorous intercourse, insect bites, generalized edema or vasculitis such as Henoch Schonlein Purpura, in addition to some of the other problems listed below.

    Learning Point
    Clinicians may often confuse the terminology of common penile problems.

    Phimosis is a normal or abnormal condition where the distal foreskin cannot be retracted over the glans penis. Physiologic phimosis is normal at birth and the foreskin separates from the glans over time. Around 90% of boys have this occur by age 3 and 98-99% by adolescence. Acquired phimosis often occurs because of inadequate hygiene, chronic balanitis or forceful retraction of the foreskin, and occurs only in uncircumcised males. Phimosis itself should not cause urinary retention or obstruction of the urinary stream. But proper hygiene is necessary to decrease the risk of balanitis, posthitis, and skin infections. Forceful foreskin retraction can cause fibrosis of the foreskin or paraphimosis. Phimosis is not a surgical emergency. It is usually treated with improved hygiene, but topical steroids are also used in certain patients.

    Paraphimosis is an abnormal condition where a retracted foreskin cannot be replaced to its normal position over the glans penis. It occurs only in uncircumcised males including those who have undergone circumcision but still retain some foreskin tissue. It is a surgical emergency. The retained retracted foreskin acts like a tourniquet, with potential venous engorgement which may over time, cause edema of the glans and foreskin. The increased pressure can then increase to cause arterial occlusion, with risk of loss of parts or the entire glans because of ischemia. It is usually treated by manual reduction, but surgical interventions may be necessary. Paraphimosis usually is an indication for circumcision in the future.

    Balanitis is inflammation of the glans penis, often caused by infection. This can occur in uncircumcised or circumcised males. Posthitis is inflammation of the foreskin, also often caused by infection. This occurs only in uncircumcised males. Balanoposthitis is inflammation of the glans penis and the foreskin, often caused by infection. This occurs only in uncircumcised males. The affected area is usually warm, erythematous, edematous and tender. A thin exudate may be seen that is seropurulent. Infectious causes may be mixed flora (usually young children), candida and trichomonas (usually in sexually active males). Topical and oral antibiotics along with warm soaks, and pain control are the usual treatment.

    Priapism a persistent, prolonged, penile erection lasting more that 4 hours, that is not associated with sexual stimulation or interest.

    Questions for Further Discussion
    1. What causes priapism in children?
    2. What are indication for urology consultation?
    3. What are possible indications for non-elective circumcision?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Penis Disorders

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Kim YC, Davies MG, Lee TH, Hagen PO, Carson CC 3rd. Characterization and function of histamine receptors in corpus cavernosum. J Urol. 1995 Feb;153(2):506-10.

    Neveus A, von Gontard A, Hoebeke, et.al., The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children’s Continence Society, J Urol. 2006;176:314.

    Angel CA, Santos C Jr., Circumcision. eMedicine. Available from the Internet at: http://emedicine.medscape.com/article/1015820-overview (rev. 1/25/2010, cited 2/22/2011).

    Levey H, Bivilacquq T. Priapsism. ePocrates.
    Available from the Internet at https://online.epocrates.com/u/2921505/Priapism/Basics/Definition (rev. 8/2/2010, cited 2/22/2011).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    16. Learning of students and other health care professionals is facilitated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Are the New Medicines Available for Head Lice?

    Patient Presentation
    A 2 1/2-year-old female came to clinic with head lice. She and her family had been treated multiple times with Nix®, mayonnaise, using cream rinse daily and combing with a metal nit comb and multiple cleanings of the house. The family was frustrated as was the resident. When the resident talked with her staff, the attending said that he had just heard of a new medication at a professional meeting that suffocated the lice with benzyl alcohol, but he hadn’t tried it yet. He also had read that another new medication had just been approved by the Federal Drug Administration (FDA) but wasn’t in pharmacies yet. They decided to try the benzyl alcohol medication and gave verbal and written instructions for cleaning the home and the babysitter’s home also. They also asked the family to call back in 2 weeks to tell them how well this medicine had worked.

    Discussion
    Head lice (Pediculosis capitus) is a common problem for worldwide. Multiple treatments are available with mixed success because of the life cycle of the parasite, the parasites’ ability to be transmitted between objects and persons, and the difficulty to clean the environment to rid the infestation. A previous review of lice can be found here that contains descriptions of the organism, other treatments and instructions for environmental cleaning.

    Learning Point
    In 2009, Ulesfia® was approved by the FDA. It is a 5% benzyl alcohol lotion that suffocates the lice; it is not directly ovicidal. It is approved for infants and children older than 6 months of age to age 60 years. It cannot be used in infants less than 6 months because of the potential for neonatal gasping syndrome which is characterized by “…central nervous depression, metabolic acidosis, gasping respirations, and high levels of benzyl alcohol and its metabolites.” Ulsefia is applied to the dry scalp, left on for 10 minutes and then washed off. A second application is recommended at 7 days. More than one bottle may be needed for the length of hair and an Internet search of cost was ~$65 for an 8 ounce bottle. Ulsefia’s main side effects include pruritis and erythema of the scalp. Ocular irritation also occurs in some patients. Parents should be warned not to have fire or other heated items around the patient as the product is flammable.

    The FDA reviewed Ulsefia in 8/2010 and found that ~9000 prescriptions had been written and only 19 instances of problems were reported. These problems were expected such as pruritis.

    Natroba® was approved by the FDA on January 18, 2011. It contains 0.9% spinosad and some benzyl alcohol. It is approved for children more than 4 years of age. It is applied to scalp and hair for 10 minutes, and if live lice are seen one week later, patients should be re-treated. In a study of 552 individuals, 86% were lice free after 14 days compared to 44% for the control group. Natroba should be available in pharmacies in the first 6 months of 2011.

    Questions for Further Discussion
    1. How far out on the hair shaft can live lice live?
    2. How long can lice live in the environment?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Head Lice and Parasitic Diseases
    and at Pediatric Common Questions, Quick Answers for this topic: Head Lice

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    FDA. FDA Approves Head Lice Treatment for Children and Adults.
    Available from the Internet at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm240302.htm (rev. 1/18/2011, cited 2/4/2011).

    FDA. Ulesfia After Market Evaluation.
    Available from the Internet at http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/PediatricAdvisoryCommittee/UCM234373.pdf (rev. 8/18/2011, cited 2/4/2011).

    RxList. Ulesfia. eMedicine.
    Available from the Internet at http://www.rxlist.com/ulesfia-drug.htm (rev. 2011, cited 2/4/11).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health ar

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital