TECHNICAL REPORT

Pediatric Considerations Before, During,Martha S. Linet, MD, MPH, and​a,b​ Ziad Kazzi, After MD,c,​ ​d Jerome A. RadiologicalPaulson, MD, FAAP,e​ COUNCIL ON ENVIRONMENTAL HEALTH or Nuclear Emergencies Infants, children, and adolescents can be exposed unexpectedly to ionizing abstract radiation from nuclear power plant events, improvised nuclear or radiologic dispersal device explosions, or inappropriate disposal of radiotherapy equipment. Children are likely to experience higher external and internal radiation exposure levels than adults because of their smaller body and aRadiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland; bAgency for organ size and other physiologic characteristics as well as their tendency to Toxic Substances and Disease Registry, Centers for Disease Control pick up contaminated items and consume contaminated milk or foodstuffs. and Prevention, Atlanta, Georgia; cNational Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia; This technical report accompanies the revision of the 2003 American dDepartment of Emergency Medicine, Emory University, Atlanta, Georgia; and eDepartment of Pediatrics, School of Medicine and Health Academy of Pediatrics policy statement on pediatric radiation emergencies Sciences, and Department of Environmental and Occupational Health, by summarizing newer scientific data from studies of the Chernobyl and the Milken Institute School of Public Health, George Washington University, Washington, District of Columbia Fukushima Daiichi nuclear power plant events, use of improvised radiologic Drs Linet and Kazzi contributed much of the technical information in dispersal devices, exposures from inappropriate disposal of radiotherapy this report, and Dr Paulson was responsible for drafting the document; equipment, and potential health effects from residential proximity to and all authors approved the final manuscript as submitted. nuclear plants. Also included are recommendations from epidemiological This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have studies and biokinetic models to address mitigation efforts. The report filed conflict of interest statements with the American Academy includes major emphases on acute radiation syndrome, acute and long-term of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of psychological effects, cancer risks, and other late tissue reactions after Pediatrics has neither solicited nor accepted any commercial low-to-high levels of radiation exposure. Results, along with public health involvement in the development of the content of this publication. and clinical implications, are described from studies of the Japanese atomic Technical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and bomb survivors, nuclear plant accidents (eg, Three Mile Island, Chernobyl, external reviewers. However, technical reports from the American and Fukushima), improper disposal of radiotherapy equipment in Goiania, Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. Brazil, and residence in proximity to nuclear plants. Measures to reduce The guidance in this report does not indicate an exclusive course of radiation exposure in the immediate aftermath of a radiologic or nuclear treatment or serve as a standard of medical care. Variations, taking disaster are described, including the diagnosis and management of external into account individual circumstances, may be appropriate. and internal contamination, use of potassium iodide, and actions in relation All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, to breastfeeding. revised, or retired at or before that time.

DOI: https://​doi.​org/​10.​1542/​peds.​2018-​3001

To cite: Linet MS, Kazzi Z, Paulson JA. Pediatric Considerations Before, During, and After Radiological or Nuclear Emergencies. Pediatrics. 2018;142(6):e20183001

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 142, number 6, December 2018:e20183001 FROM THE AMERICAN ACADEMY OF PEDIATRICS BACKGROUND AND RATIONALE FOR UPDATE recommendations for treating, led to long-term follow-up studies of mitigating, and preventing serious mortality (established in 1950) and Children can be exposed to health effects in children. An update cancer incidence (begun in 1958) environmental radiation as a result to the policy statement is needed that continue to the present day and of nuclear power, fuels reprocessing, that incorporates (1) new scientific have 10yielded critically important “ and weapons production plant knowledge from late-effects studies data. ” of the Chernobyl event, (2) lessons (hereafter designated nuclear Four major nuclear plant accidents from the 2011 Fukushima Daiichi plant ) events; from an improvised have occurred: Windscale in Japanese nuclear power plant event, nuclear device or radiologic dispersal Seascale, Cumbria, in the United (3) information pertinent to the use device; or from abandoned medical Kingdom (1957); Three Mile Island of improvised radiologic dispersal radiation equipment that could in Pennsylvania (1979); Chernobyl devices and the specter of nuclear potentially result in substantial levels in Ukraine (1986); and Fukushima detonation in heavily populated of radiation exposure and associated Daiichi nuclear power plant in regions, (4) radiation exposures health effects. Because the radiation Fukushima Prefecture, Japan (2011). levels from these sources could lead from the inappropriate disposal of to a radiation emergency, this term radiotherapy equipment, (5) reports Beginning in 1945, atmospheric is used to refer to these types of of potential health effects associated nuclear testing was undertaken exposures hereafter in this report. with radiation exposures of children by the United States (New Mexico, Children and their families are living in proximity to nuclear plants, Nevada, and the Marshall Islands), likely to be extremely anxious about and (6) recommendations based on the Soviet Union (Kazakhstan), such events and about residential new knowledge from epidemiological the United Kingdom (Australian proximity to nuclear plants (the studies and from biokinetic models to territories and some Pacific Islands), latter being associated with very low address mitigation efforts. France (French Polynesia), and China (Gobi Desert in Xinjiang Province) or no radiation exposure) and may A number of AAP publications and resulted in 504 devices exploding turn to their medical professional are related to the material in “ at 13 sites. A 1963 treaty led to a for advice. Health care professionals this technical report, including limited test ban by the Soviet Union, are concerned about these exposures (1) Medical Countermeasures the United States, and the United because, in general, children are for Children in Public Health ” “ Kingdom, but atmospheric testing more sensitive to radiation and are Emergencies, Disasters, or 6 ” continued until 1974 by France more likely to develop the short-term Terrorism ‍ ; (2) Ensuring the 4 “ 7 and until 1980 by China. Health and some of the long-term effects Health of Children in Disasters ‍ ; studies have been focused on cancer of radiation exposure. Children are and (3) Providing Psychosocial risks in military participants and/ likely to experience higher external Support to Children and Families ” or observers and on thyroid cancer and internal radiation exposure in the Aftermath of Disasters and 8 and leukemia occurring among levels than adults because children Crises. ‍ This technical report the general population living in are shorter and have smaller 1 presents detailed information that 19,24​ body diameters and organ sizes. proximity to the testing sites. ‍ supports the recommendations of9 the Children have a longer time to accompanying policy statement. Events involving abandoned medical live and, thus, more time in which TYPES OF RADIATION EMERGENCIES radiation equipment have resulted to develop adverse outcomes. AND RELATED EXPOSURES in acute radiation sickness and In addition, children may ingest deaths as well as contamination 22of radioactive material from picking thousands of people and homes. up contaminated items and putting 2 The description and findings from Since 1983, concerns about excess hands in their mouths3 when crawling,​ ingesting soil,​ or consuming milk epidemiological studies of the leukemia among children living most important types of radiation in proximity to nuclear power, from cows feeding4 on contaminated pastures or feed. emergencies and related exposures fuels reprocessing, and weapons- are summarized in Table 1. Concern production facilities have led to

In a policy5 statement published about health effects associated with epidemiological studies of more in 2003,​ the American Academy radiation emergencies began with the than 200 nuclear23 facilities in 10 atomic bombings in Hiroshima and countries. Most of the studies of Pediatrics (AAP) Council on Environmental Health summarized Nagasaki in 1945 that killed more reveal no association. Confounding the history, features, and health than 100000 people and injured cannot be ruled out in the few studies effects associated with radiation nearly as many. Concern about that have revealed an association, emergencies in children and provided adverse health and genetic effects particularly because small Downloaded from www.aappublications.org/news by guest on September 26, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS Health Outcomes increased twofold at 15 – 22 y; no downturn. was first observed after 5 decades of follow-up. 5 decades of follow-up; risks were higher than those in utero at the time of bombings. most anatomic sites; risks were highest for those exposed at youngest ages; risks declined 17% per decade of age at exposure; excess cancer risks persist throughout life. exposed (within 10 miles of Three Mile Island) versus 4000 unexposed pregnant women for prematurity, congenital abnormalities, hypothyroidism, neonatal deaths, or other factors. No excess leukemia or cancer was noted in entire exposed population or offspring. increases in risk from solid cancer, leukemia, and breast cancer will be increased by 1.06%, 0.03%, and 0.28%, respectively. validation; accident may have resulted in 240 excess cases of thyroid cancer. Incidence of thyroid cancer significantly Significant excess of all solid cancers Significant excess of all solid cancers after Significant excess risks for cancers of No measurable differences between 3582 Risk projection suggests that lifetime Risk projection assessment only, without – 3 Sv – 3 Sv –≥ 3 Gy NA 0.005 – 3 Sv 0.005 0.005 <0.05 Radiation Levels be about the same as natural background radiation exposure nearby locations ranged from 1.03 to 1.66 mSv/y from external radiation and 0.0058 – 0.019 mSv/y from internal radiation. Doses were estimated to Measurements in 3 Population Studied 514 people <18 y 388 <6 y 000 children residentially proximate in Ukraine at exposure; 65 incident thyroid cancers separately for those exposed as children. development of children residing in proximity

12 2452 in utero 15 30 Dose data were not available Epidemiological study under No epidemiological study I 131 Xe, and particulate 133 Radiation Released Cs and 740 TBq of 137 Cs, 1150 PBq tellurium-132, 5200 PBq radionuclides 137 produced minimal fallout; direct radiation was important only within 3 km produced minimal fallout; direct radiation was important only within 3 km produced minimal fallout; direct radiation was important only within 3 km were released, including 22 TBq of were from krypton and xenon; iodine was released in barely measurable quantities atmosphere as of 2014, with 80% falling into the Pacific Ocean 750 TBq of radioactive materials 1760 PBq radioiodines, 85 340 – 800 PBq released into the Exposed Populations accident, 2011 Hiroshima, Nagasaki Detonation at high altitudes Hiroshima, Nagasaki Detonation at high altitudes Hiroshima, Nagasaki Detonation at high altitudes Windscale, 1957 Three Mile Island, 1979 The highest radiation doses Chernobyl, 1986 Fukushima Daiichi nuclear 14 t 15 11 11 12 l 16 l l l 13 l l t of the President ’ s  Characteristics of Physical Health Outcomes From Radiation Disasters and Related Events

Commission on the Three Mile Island acciden Harada et a Preston et a Preston et a Cooper et a Brenner et a Repor Nagasaki, 1945 Preston et a

Nuclear plant accidents, 1957 – 2013

Disaster or Event Category; Publication Atomic bombings, Hiroshima and TABLE 1

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 142, number 6, December 2018 3 000 people were

Health Outcomes assessment was fivefold increased; too few thyroid cancers were present to estimate risks. Marshall Islands residents alive between 1948 and 1970 were attributable to the radiation from the testing observed; high excess risk of thyroid cancer with wide confidence intervals modules; risk was fivefold increase in male individuals, but only 27% (and nonsignificantly) higher in female individuals. in proximity to Sellafield and Dounreay nuclear reprocessing plants in the United Kingdom and in Elbmarsch near Kr ü mmel plant in Germany and perhaps (United Aldermaston and Burghfield Kingdom) and La Hague (France), but multisite studies reveal no increase in risk. screened, 249 had significant radiation levels; 42 homes were decontaminated or destroyed. Incidence of thyroiditis 20 y after baseline Estimated that 1.6% of all cancers among Significant dose-response relationship Significant dose response for thyroid Some clusters were observed including 4 people died, 112 120 mGy Radiation Levels ranged from 5 to 2000 mGy; thyroid doses ranged from 12 to 7600 mGy. from 0 to 39 mGy for cases and 0 – 36 mGy for controls. Average dose to cases for those <15 y of age was 1.8 mGy. External: range = 0 – 0.55, and mean = 0.056; internal: range = 0 – 3.1, and mean = 0.20 levels were lower than levels from natural background radioactivity. doses of <0.5 Gy, but several had substantially higher doses up to 6 Gy. Whole-body doses Thyroid doses ranged Estimated doses, Gy Measured radiation Most had estimated Population Studied projection thyroid cancer cases versus 373 controls detected thyroid nodules in 2376 people <21 y from nuclear tests, 1949 – 1962 leukemia in people <25 y (most studied younger ages) study 2497 children ages 12 – 18 y 0 – 400+ mGy; mean = No epidemiological study, risk Case-control study: 229 Prevalence of ultrasound- Some variation, but generally No systematic epidemiological Radiation Released Cs 137 1951 – 1962 1946 – 1958 1966 – 1974 1949 – 1989 stolen, dismantled, and handled by many people; contained sites in proximity to nuclear plants in 10 countries; 25 multisite studies 86 atmospheric tests during 66 atmospheric tests during 41 atmospheric tests during 456 atmospheric tests during Old radiotherapy source was Studies of close to 200 geographic Exposed Populations United Kingdom, States, France, Germany, and other countries Nevada test site Marshall Islands French Polynesia Semipalatinsk Goiania, Brazil Populations in proximity gy 19 l 23 ​ 21 ‍ l 18 – present l 20, 22 17 l l y Continued

Agenc Simon et a de Vathaire et a Land et a International Atomic Ener medical equipment Laurier et a plant, 1983 1949 – 1980 Lyon et a Xe, xenon-133; NA, not applicable; PB, petabecquerel, TB, terabecquerel.

Inappropriately discarded radiation

Residence in proximity to nuclear Disaster or Event Category; Publication Aboveground nuclear tests, TABLE 1 133

Downloaded from www.aappublications.org/news by guest on September 26, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS increases in risk were observed with Exposure may occur to the whole inhalation, by ingestion, or by blast distance from sites for proposed body (eg, external radiation from injection into a wound. Dermal nuclear power25 stations that were natural background exposures or absorption is usually limited, except never built. radiation emergencies) or may in cases of skin contamination with CHARACTERISTICS, UNITS, SOURCES, involve partial body exposure tritium. The clinical consequences of AND BIOLOGICAL EFFECTS OF (eg, radiographs from medical internal contamination depend on RADIATION EXPOSURE radiography and most forms of the type and amount of radioactive radiotherapy). Sources of exposure material that is taken up by the Terminology may include natural background body and its chemical and physical γ exposure (eg, radon, natural (radioactive) properties. background -rays, cosmic rays) or Biological Effects Ionizing radiation, a type of manmade exposures (eg, radiographs high-frequency energy that can from medical radiography, produce adverse effects through radionuclides administered in damage to DNA and cells, includes Ionizing radiation may interact γ nuclear medicine procedures, and the electromagnetic (eg, radiographs directly with target tissues or “ ” radioactive materials used in nuclear and -rays, involving streams of power or weapons plants). Several indirectly through the production photons or packets of energy) of free radicals from its interaction α key forms of ionizing radiation β with water molecules. Effects of and particulate forms (eg, electrons, are encountered in radiation- ’ protons, -particles, neutrons, related emergencies. -particles radiation on cells differ depending muons, and heavy-charged ions). are emitted from radionuclides on the cell s rate of division and Radionuclides (often referred to as that are created as by-products of with the level of cell differentiation. radioactive isotopes) are atoms with Tissue sensitivity to radiation γ nuclear reactors (such as radioactive unstable nuclei that release excess iodines) or may be released from varies from highest to lowest as α β γ energy by the emission of -rays or radionuclides used in medicine follows: lymphocytes, erythroblasts, spermatogonia, epidermal stem cells, - or -particles when26 they undergo (such as xenon). -Rays are emitted radioactiveUnits decay. from various radionuclides like and gastrointestinal stem cells. Other isotopes of cesium and cobalt and types of cells (muscle, bone, and nerve after a nuclear detonation. Neutrons cells) are less sensitive to the effects Energy from radiation is measured are mostly emitted after a nuclear of radiation. DNA appears to be the é γ in several types of units. The principal target for biological effects ’ é detonation and are more effective at international system (Syst me producing tissue damage than -rays. of radiation, including cell death, α International d Unit s [SI]) unit Gy Other forms of radiation, such as mutation, and carcinogenesis. If cells (1 Gy = 100 rad) is the radiation -particles, which are emitted from are irradiated with ionizing radiation, absorbed dose. The SI unit Sv single-strand or double-strand DNA radon or from 4polonium-210, have a (1 Sv = 100 rem) takes into account shorter range. breaks or other DNA changes may a weighting or quality factor that occur. This can be followed by error- free DNA repair, but if the repair is is based on the relative biological Children can become internally × incorrect, it can result in cell death, effectiveness of doses from contaminated with radioactive chromosomal instability, mutation, particulate radiation (eg, Sv = Gy material in a number of scenarios, 26 and/or carcinogenesis. Indirect relative biological effectiveness). such as the detonation of an effects may occur through the The SI unit of activity for radiation improvised nuclear device (a device production of free radicals in living emission of a radionuclide is that incorporates radioactive tissue and nontargeted effects, such Bq, which is defined as 1 atomic materials designed to result in × as release of cytokines and other disintegration per second (for10 dispersal of radioactive material). products of inflammation. conversion, 1 Bq = 1/3.7 10 Ci). Other examples include the release The most important radionuclides of radioactive material in the EXAMPLES OF MEASURES TO REDUCE and radioactive emissions associated environment from a radiologic RADIATION EXPOSURES DURING AN with radiation emergencies are dispersal device (a bomb made EMERGENCY Characteristicsshown in Table 2. and Sources from radioactive material combined with conventional explosives that is capable of spreading radioactive Children can be exposed to radiation material over a wide area) or from a Below are examples of strategies to emitted from sources that are nuclear plant accident. The radioactive reduce exposure to radiation and external or internal to the body. material may enter the body through associated health risks. Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 142, number 6, December 2018 5 TABLE 2 Radionuclides Potentially Released From a Radiation Disaster, Routes of Absorption and Treatments Element, Symbol, Type of Radiation; Half-life Respiratory Gastrointestinal Primary Toxicity Treatment Source Absorption Absorption Americium 241Am α; 432 y 75% Minimal — Calcium or zinc DTPAa Californium 252Cf α, strong neutron emitter; — 25% absorbed in liver 65% absorbed in bone; Calcium or zinc DTPA 2.4 y half deposited in skeleton and liver are gone in 50 and 20 y, respectively Carbon 14C Weak β emitter; 5730 y Yes Yes Can cross placenta, No treatment available becomes organically bound to developing cells and hence endangers fetuses Cesium 137Cs β, γ; 30 y Complete Complete — Prussian bluea Cobalt 60Co β, γ; 5.3 y High <5% — — Iodine 131I, 125I β, γ; 8 d, 60 d, respectively High High — KIa immediately before or within 4 h of exposure Plutonium 238 239 Pu α, radiographs; 24 400 y High Minimal — Calcium or zinc DTPAa Strontium 90Sr β, γ; 28 y Limited Moderate — Aluminum hydroxide; calcium chloride suspension; calcium gluconate Thallium 201Tl Potassium analog, when — — — Prussian blue injected emits 80 keV radiographs; 73 h Tritium 3H Hydrogen isotope, decays — — Tritiated water is taken Force fluids; water with emission of low- easily into the body by diuresis energy electron; 10 d inhalation, ingestion, or transdermal absorption; instantaneously absorbed and mixes with body water Uranium 235U and α; 4.47 billion y Inhalation can Ingestion can cause bone — Bicarbonate to alkalinize radon daughters cause lung and liver cancer the urine cancer Other important radionuclides in radioactive fallout that may contribute to internal dose and are not included in the table are as follows: iron-55 (55Fe), ruthenium-106 (106Ru), antimony-125 (125Sb), cerium-144 (144Ce), neptunium-239 (239Np), technetium-132 (132Te), barium-140 (140Ba), molybdenum-99 (99Mo), lanthanum-140 (140La), rhodium-105 (105Rh), promethium-149 (149Pm), praseodymium-143 (143Pr). Adapted from American Academy of Pediatrics Committee on Environmental Health. Radiation disasters and children. Pediatrics. 2003;111(6 pt 1):1455–1466. Adapted from Goans RE. Medical Management of Radiological Casualties. 4th ed. Bethesda, MD: Armed Forces Radiobiology Research Institute, Uniformed Services University of the Health Science; 2013.27 3H, tritium-3; 14C, carbon-14; 60Co, cobalt-60; 90Sr, strontium-90; 125I, iodine-125; 201Tl, thallium-201; 235U, uranium-235; 238PU, plutonium-238; 239Pu, plutonium-239; 241Am, americium-241; 252Cf, californium-252; DFOA, deferoxamine; DMSA, dimercaptosuccinic acid; DTPA, diethylenetriaminepentaacetic acid; EDTA, edetic acid (ethylene-dinitrillo tetraacetic acid); NAC, N-acetyl cysteine. —, not applicable. a Approved by the FDA for this indication.

Measures to Reduce Contamination Immediately After an Incident by children and parents to reduce appropriate radiation detection ’ external and internal contamination devices, decontaminating critical according to the person s location infrastructure, conducting waste Guidance to individuals and at the time of the emergency. More management, and many other key professionals on measures to detailed information on many Potassiumelements. Iodide reduce contamination in the different aspects of responding immediate aftermath of a radiologic to a nuclear event was published or nuclear disaster is provided in 2010 by a federal interagency In the event that radioactive by the US Department28, of29​ Health expert committee led by the 31 iodine is released into the and Human Services ‍ and the Executive Office of the President. environment, potassium iodide (KI)

National Council on Radiation 30 Information in the document is a supplementary or secondary Protection and Measurements. produced by the Federal Interagency protective measure. The primary The immediate measures, Committee addresses such topics protection is sheltering in place or summarized in Table 3, include as identifying an expanded zone for evacuation (as instructed by local specific actions to be undertaken management of activities, selecting public health officials) to prevent Downloaded from www.aappublications.org/news by guest on September 26, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 3 Guidance to Parents on Individual Measures Immediately After a Radiation Emergency Location or Topic Actions to Be Taken If outside or close to the location of Cover nose and mouth to reduce particulate exposures the incident Do not touch objects thrown off by incident or dust Quickly go to nearest intact building with thick walls Once inside, take off outer clothes, place in a sealed bag, and place bag where others will not touch Shower and wash body and hair with soap and water Turn on radio and/or television for further instructions If inside building If building is not intact (ie, there are broken windows or walls), go to the nearest intact building Shut all windows, doors, and fireplace dampers Turn off all fans and heating and air conditioning units Turn on radio and/or television for further instructions If in car Close windows and vents and turn off heat and air conditioner Cover nose and mouth with a cloth If you cannot get to home or another intact building safely, stay in car and park in a safe place Turn off engine Turn on radio and listen for instructions Stay in car until told it is safe to get back on the road Children and family If with children and family, stay together If children are in another building or school, children should stay there, and parents should not travel to children until told it is safe to travel Children should stay in emergency shelter at school Pets Bring pets inside an intact building Wash pets with soap and water Food and water Do not consume any food or water out in the open air Food inside cans and sealed containers is safe, but food outside of cans and/or containers should be washed to remove dust Obtain guidance from authorities about other food and/or water

•• exposure in the first place. Guidance infants, children, and pregnant and Thyroshield solution (65 mg/mL; to federal agencies and state and local breastfeeding women, because they Arco Pharmaceuticals, LLC, St governments on safe and effective are at the highest risk of developing Louis,36 MO; www.​thyroshield.​ use of KI is provided by the US Food32 thyroid cancer. Treatment should be •• com) ; and and Drug Administration (FDA). commenced immediately before or The adoption and implementation during the passage of a radioactive KI oral solution (65 mg/mL; of the recommendations are at cloud in an event in which Mission Pharmacal, San Antonio, the discretion of the state and radioiodines are released, although TX). treatment may still have a substantial local governments responsible for KI provides protection for protective effect even if 3 or 4 developing regional emergency approximately 24 hours and hours have passed. If the release of response plans related to radiation should be given daily until the radioiodines and secondary exposure emergencies. KI has been well risk of exposure no longer exists. is protracted, then even delayed established to block thyroid Pregnant women and neonates administration may result in benefits. radioiodine uptake and is effective should not receive repeated doses in reducing the risk of development Shown in Table 4 are the threshold of KI, because it has the potential of thyroid cancer in individuals and thyroid radioactive exposures to suppress thyroid function in populations at risk after inhalation 32,33​ and recommended doses of KI for the fetus and neonate (they must or ingestion of radioiodines. ‍ different risk groups. At the time of be prioritized for other protective The mechanism of action involves the preparation of this document, measures, such as evacuation). The KI saturating the thyroid gland there are 5 FDA-approved over-the- benefits of KI treatment to reduce with nonradioactive iodine, the risk of thyroid cancer outweigh counter•• KI products: thereby preventing uptake of the risks of transient hypothyroidism. radioiodines, which are then excreted iOSAT tablets (65 and 130 mg; However, given the potential in urine. KI only prevents the uptake sequelae of transient hypothyroidism Anbex, Inc, Williamsburg,34 VA; of radioiodines not the uptake of •• www.​anbex.​com) ; for intellectual development, the other radionuclides and is, therefore, FDA recommends that neonates not a general radioprotective agent. Thyrosafe tablets (65 mg; treated with 1 dose or more of

The FDA prioritizes treatment with Recipharm, Jordbro, Sweden;35 KI be monitored for this effect by KI on the basis of age, focusing on www.​thyrosafe.com​ ) ; measurement of thyroid-stimulating Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 142, number 6, December 2018 7 TABLE 4 Guidance on Use of KI Age Group Predicted Thyroid Gland KI Dose, mg No. or Fraction of 130- No. or Fraction of 65-mg Milliliters of Oral Exposure, mGy mg Tablets Tablets Solution, 65 mg/mL >40 y ≥5000 130 1 2 2 18–40 y ≥100 130 1 2 2 Pregnant or lactating ≥50 130 1 2 2 women 12–18 ya ≥50 65 0.5 1 1 3–12 y ≥50 65 0.5 1 1 1 mo–3 y ≥50 32 Use KI oral solutionb 0.5 0.5 0–1 mo ≥50 16 Use KI oral solutionb Use KI oral solutionb 0.25 a Adolescents approaching adult size (≥150 lb) should receive the full adult dose (130 mg). b KI oral solution is supplied in 1-oz (30-mL) bottles with a dropper marked for 1-, 0.5-, and 0.25-mL dosing. Each milliliter contains 65 mg of KI iodide.

hormone– and be treated with thyroid substantial concentrations in and stored before the exposure) or hormone37 therapy39 if hypothyroidism human milk– and result in significant ready-to-feed infant formula, to avoid occurs. ‍‍ Allergy to seafood, radiation40 exposures43 to nursing131 potentially contaminated tap water, radiocontrast media, and povidone- children. ‍‍ Higher levels of I should be provided as a temporary iodine preparations should not may be transferred to infants from solution. Breastfeeding can resume be considered iodine allergy and breastfeeding than to the fetus44, from45​ once public health officials indicate are not a contraindication to the intake of the pregnant mother. ‍ that it is safe.’ administration of KI. People with When the risk of exposure to If the mother s internal true iodine sensitivity should radioactive iodine is temporary, contamination with radioactive avoid KI, as should individuals mothers who are at risk for becoming iodine is high or if repeat doses with dermatitis herpetiformis and internally contaminated can continue of KI to the infant are necessary hypocomplementemic vasculitis, to breastfeed on the first day of (because of lack of availability of both rare conditions associated exposure if appropriate doses of ’ noncontaminated food sources), with increased risk of iodine KI are administered to her and to the infant should be evaluated for hypersensitivity. People with Graves the infant within 4 hours of the secondary hypothyroidism that could disease and autoimmune thyroiditis contamination. If not, the mother and have 48resulted from the repeat dosing should be treated with caution, infant should then be prioritized to of KI. especially if treatment extends receive other protective measures beyond a few days. Adverse effects of like evacuation. As a general measure, the mother KI may include skin rashes that can should wash the nipple and breast thoroughly with soap and warm be severe (iododerma), swelling of According to the Centers for Disease ’ salivary glands, and iodism (metallic Control and Prevention, women who water and gently wipe around and taste, burning mouth and throat, sore are breastfeeding should take only 1 away from the infant s mouth before teeth and gums, upper respiratory dose of KI if they have been internally breastfeeding. congestion, and occasionally contaminated with (or are likely to Again, as noted above, it is important gastrointestinal symptoms and be internally contaminated46 with) to reiterate that KI will not be diarrhea). Although KI is available radioactive iodine. They should be protective if the exposure has been over the counter, people should prioritized to receive other protective to radionuclides other than the check with their doctors32 if there are action measures (https://​emergency.​ radioiodines. Many radiation events anyMeasures health Relatedconcerns to. Breastfeeding cdc.​gov/​radiation/​ki.​asp). If the will be a mix of radionuclides and/ situation is such that the exposure to or not contain radioactive iodine. radioactive iodine is prolonged and Public health officials will provide Data are limited on quantitative more than 1 dose of KI is indicated breastfeeding guidance after estimates of human131 milk activity for the mother and the infant, then considering the risks and benefits from iodine-131 ( I) administered breastfeeding must be temporarily that are particular to the specific for nuclear medicine diagnostic or suspended because of the risks event and radionuclides. therapeutic procedures and from associated with47 KI therapy in infants DIAGNOSIS AND MANAGEMENT OF radionuclides resulting from radiation and neonates. Mothers must be CONTAMINATION emergencies. Estimates based on supported to express their milk to biokinetic and other modeling data maintain their milk supply until the suggest that internal contamination infant can resume breastfeeding. The Radiation Emergency from such sources could reach Safe human milk (that was pumped Medical Management Web site Downloaded from www.aappublications.org/news by guest on September 26, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 5 Guidance to Professionals on Drugs Available for the Treatment of Internal Contamination Medical Countermeasure Indication Comment (https://www.​ remm.​ nlm.​ gov/​ )​ provides a wealth of information on Prussian blue Enhances the fecal elimination Considered safe in children of radioactive cesium or because it is not absorbed management of radiologic emergency thallium by interrupting their into the body. Not approved for incidents for both clinicians and enterohepatic circulation ages <2 y. Use preemergency managers. The Radiation Injury use authorization for ages 6 Treatment Network is another mo–2 y. important resource (https://​ritn.​net/​ Causes constipation and blue feces. default.​aspx). Pediatric patients and Pentetate calcium trisodium Enhances the renal elimination Approved in children. If >1 dose their accompanying family members of plutonium, americium, and is needed, the zinc form is who may have been contaminated curium preferred. from fallout and related radionuclides Pentetate zinc trisodium Enhances the renal elimination Approved in children. from radiation emergency events of plutonium, americium, and curium should be referred (or redirected if KI Saturates the thyroid with See Table 3 and text. they appear at a pediatric practice) stable iodine, which prevents to hospital emergency departments the uptake of radioiodine. with staff trained in decontamination, evaluation, and treatment measures for acute radiation syndrome (ARS), associated injuries, and related Once the amount of radioactive assist clinicians in assessing and problems in patients, as well as material inside the body is managing internal contamination. Externalprotective Contamination measures for staff. estimated, it is compared with the This tool, the Internal Contamination corresponding radionuclide-specific30 Clinical Reference application, can be Clinical Decision Guide. The Clinical downloaded to a mobile device free Decision Guide is meant to assist of charge at http://​emergency.cdc.​ ​ Initial efforts to manage external 51 gov/​radiation/​iccr.asp​ .‍ contamination of parents and clinicians in determining whether It would be children at the community level are the level of internal radionuclides is prudent to download and print this described in previous sections of clinically significant. If the amount information in hard copy and arrange this report and in Table 3. If parents of radionuclide measured inside to keep the material easily available and children have not removed and the body is greater than or equal to before a radiologic emergency, when bagged clothing in sealed plastic bags the corresponding Clinical Decision communication problems may make Guide, further medical management it difficult to do so. and showered with soap and water 49 is warranted. For radionuclides before arriving at a central location Many of the drugs and equipment other than the isotopes of iodine, or medical facility, they should do so. specifically for use in disasters of Internal Contamination the Clinical Decision Guide values all types, including nuclear and for children are 20% of those for radiation disasters, are not used for adults because of their increased 50 other purposes and are therefore The diagnosis of internal radiosensitivity. not routinely stocked in hospitals, contamination can be made by direct pharmacies, or physician offices. measurement of radiation emissions The medical management of patients The US government has created by using an external detector for with internal contamination consists γ the Strategic National Stockpile, a radionuclides that decay by emitting primarily of supportive care and 131 national repository of antibiotics, -rays, such as I and cesium-137 long-term monitoring for cancer and 137 vaccines, chemical antidotes, ( Cs). Alternatively, analysis of other health outcomes. Additional antitoxins, and other critical medical urine or feces can be used to detect management strategies attempt to equipment and supplies. Material the radionuclides inside the body decrease the radiation dose received γ can be shipped to locations of need for radionuclides that do not emit over the lifetime of the patient by on short notice. Some individual -rays, such as polonium-210 and enhancing the elimination of the states, particularly those with nuclear strontium-90. Performing these radionuclide through diuresis or reactors, may have their own stocks measurements in children will be chelation therapy or by preventing of KI. more challenging than adults because uptake into the target organ. Specific of different body sizes that affect drug therapies are available for a HEALTH OUTCOMES the radiation detector instrument limited number of radionuclides and calibration and because of greater are listed in Table 5. The Centers difficulty in obtaining urine or fecal for Disease Control and Prevention Some mental health effects of a samples. has developed an application to radiation event may begin as soon Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 142, number 6, December 2018 9 56 as the public becomes aware of the postdisaster circumstances, such as 2 years) or death. ARS may also event; other mental health effects will adequacy of emotional support and be conceptualized as a clinical be delayed. Physical health effects access to professional interventions; continuum of manifestations that after radiation exposure include and personal characteristics that encompass multiple organs or short-term effects that appear within increase susceptibility, including systems and feature an important days to months after radiation being female, having young children, role for inflammation. This clinical exposure and long-term effects that and having53 previous psychiatric continuum encompasses multiorgan generally appear 18 months to many problems. Long-standing research injury, multiorgan dysfunction years later. The intervals between on the psychological effects of syndrome, and multiorgan failure,57 first exposure and long-term10 effects radiation disasters has been focused the latter being irreversible. may be decades in length. The types primarily on adults and has revealed Treatments for emesis include and severity of short-term effects acute as well as long-term anxiety, ondansetron (approved for children are related in part to the level of depressive symptoms, and somatic of all ages) or granisetron (approved exposure and the tissues exposed. In symptoms, particularly54 in mothers for children 2 years and older); general, children are more sensitive of young children. Although bone marrow depression is treated to radiation and are more likely to short- and long-term effects on with colony-stimulating factors develop both the short-term and psychological functioning, emotional like filgrastim,58 sargramostim, and some of the long-term effects of adjustment, and developmental pegfilgrastim. These drugs are radiation exposure. trajectory of children subsequent available, in some cases in limited

to nonradiation disasters 8,have55​ quantities, in the Strategic National Mental health effects have long been studied extensively,​ ‍ mental Symptoms,Stockpile. Outcomes, and Exposure been known to be a major clinical health effects in children exposed Level problem associated with most to radiation disasters were not types of radiation8,52​ and other types evaluated in methodologically rigorous longitudinal epidemiological of disasters. ‍ Psychological The type, severity, and rate of studies until after the Three Mile effects potentially include anxiety; 54 53 appearance of clinical symptoms Island and Chernobyl accidents,​ depression; fear; somatic complaints; depend on the radiation dose as described in more detail later in and social, thought, and behavioral received and the part of the body this report. problems and other elements of Short-term Outcomes exposed. The larger the radiation posttraumatic stress disorder. ARS dose absorbed by the body above the Overall, the excess adverse levels at which clinical symptoms psychological effects attributable to are manifest, the more compressed natural and manmade disasters is the timeline of these phases approximately 20% after the first ARS is an acute illness caused by 53 and the more severe the clinical 12 months. Radiation-related irradiation of the whole or a large manifestation. The threshold whole- disasters are of particular concern part of the body by a high dose body dose for developing clinically because of the intangible nature of penetrating radiation over a apparent ARS is 1 Gy, although of radiation exposure, lack of short period of time (usually a few children may have a lower threshold information about the actual level of minutes). The time course of ARS than adults (Table 6). At whole- radiation exposure to individuals in can be divided into 4 nondiscrete body doses of approximately 4.5 the exposed population, conflicting phases: prodrome (occurring within Gy, approximately 50% to 60% of reports about the details of the minutes to hours of the radiation exposed untreated patients will die. event by authorities and the media, exposure and characterized by At doses of 8 Gy or more, virtually no widespread rumors about adverse nausea, vomiting, fever, diarrhea, and patients will’ survive. effects on humans and animals, a fatigue); a latent phase (beginning – tendency to attribute all subsequent a few hours after the exposure and A patient s survival will depend on short- and long-term health lasting up to 2 5 weeks, during the dose of radiation received, the problems to radiation exposure, which patients may feel well but presence of other injuries (eg, trauma fears about health effects in future adverse effects occur at the tissue and burns), and comorbid medical generations, nonsystematic health level); a manifest illness stage conditions. During a mass-casualty monitoring after the event,52 and social (potentially beginning as soon as a incident, limited treatment resources and economic disruptions. Risk few hours after the exposure and will be allocated to patients who factors for adults that are associated lasting up to a few months); and have survivable injuries, whereas with mental health consequences recovery (beginning a few weeks others will be triaged for palliative include the severity of the disaster; after the event and lasting up to care, highlighting the importance Downloaded from www.aappublications.org/news by guest on September 26, 2021 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 6 Clinical Effects in Relation to Whole-body Radiation Dose Clinical Effect Whole-body Dose, Gy of determining the radiation dose received by a patient. This dose Threshold for developing clinically apparent ARS 1 (children may have a lower threshold than adults) can be estimated by using time to 59–63 LD50/60 without significant medical therapy ‍ ∼4.5 emesis and absolute lymphocyte (http://​www.​remm.​nlm.​gov/​LD50-​60.​htm) counts based on data in adults. LD100 8 The Radiation Emergency Medical Hematopoietic syndrome 2–6 Management Web site provides tools Gastrointestinal syndrome 6–10 64 Cerebrovascular syndrome >20 to estimate radiation dose Using Cutaneous syndrome >2 (to the skin) the history and physical examination LD , lethal dose that will kill 50% of the exposed population within 60 days; LD , lethal dose, 100%. in addition to these estimation tools, 50/60 100 health care providers can identify patients who are likely to develop the potentially survivable form of “ compared with the general 71 detail in a separate AAP clinical the ARS and therefore benefit from population of women in Ukraine. report titled Providing Psychosocial available medical countermeasures In both the Three Mile Island and Support to Children and Families (Table 7). ” Short- and Long-term Effects: Mental Chernobyl (Ukraine) accidents, in the Aftermath of Disasters and Health Conditions 8 mothers of young children were 3 Crises.Long-term‍ Effects: Cancer and times as likely as women without Related Conditions “ ” “ ” young children to describe their As noted previously, a major health as fair or poor,​ which clinical problem associated with the investigators observed to be most types of radiation disasters is Several tissues (eg, thyroid, bone notable, given the differences in occurrence of mental health effects, marrow, breast, and brain) are more the levels of radiation exposure, including depression, anxiety, sensitive to radiation in children than evacuation, culture, and postdisaster posttraumatic stress disorder, and ’ 67 in adults, and children are at higher sociopolitical environment. The medically unexplained67 somatic risk of radiation-related73 cancers of symptoms. These problems may President s Commission review these tissues. Other tissues do not affect populations for many years of the health outcomes associated appear to be more sensitive in children after the event. As 1 example, long- with the Three Mile Island accident than in adults (eg, lung and bladder). term psychological– effects have been concluded that the greatest public 14 ‍Table 1 lists the key types of radiation documented68 70among atomic bomb health problem was mental health,​ emergencies considered, the affected survivors. ‍‍ Another example similar to the conclusion of the populations, exposure information, is the twofold increased lifetime Chernobyl Forum 2072 years after the whether a risk projection or depression rates among women Chernobyl accident. Psychosocial epidemiological study was conducted, living in proximity to Chernobyl issues are addressed in much more and key physical health outcomes. TABLE 7 Medical Countermeasures for Treating the Hematopoietic Subsyndrome of ARS Medical Countermeasure Indication Comment Granulocyte colony-stimulating factor Neutropenia Approved for use in adults and children. (filgrastim and pegfilgrastim) Granulocyte-macrophage colony-stimulating Neutropenia The liquid formulations containing benzyl alcohol or lyophilized formulations factor (sargramostim) reconstituted with bacteriostatic water for injection, USP (0.9% benzyl alcohol), should not be administered to neonates and young infants. Antibacterials Neutropenia Follow guidelines provided by professional societies (eg, Infectious Diseases Society of America and the American Society of Clinical Oncology65,‍66​ ). Antivirals Neutropenia Follow guidelines provided by professional societies (eg, Infectious Diseases Society of America and the American Society of Clinical Oncology65,‍66​ ). Antifungals Neutropenia Follow guidelines provided by professional societies (eg, Infectious Diseases Society of America and the American Society of Clinical Oncology65,‍66​ ). Platelets Thrombocytopenia Irradiated and leukocyte reduced. Packed red blood cells Anemia Irradiated and leukocyte reduced. Stem cell transplant Failure to respond to other Contact the Radiation Injury Treatment Network (https://​ritn.​net/​default.​ therapies aspx) Absence of significant combined injuries or comorbid conditions USP, US Pharmacopeia.

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 142, number 6, December 2018 11 Japanese Atomic Bomb Survivors: Life Span Study younger than 6 years (based on 649 maximum effective doses and thyroid – incident cancers) and followed-up equivalent doses. A large thyroid

Much of our understanding of health during 1958 1999. The excess disease clinical ultrasonographic effects from radiation disasters and relative risks at 50 years of age for a screening of approximately 300000 given dose was substantially higher residents 18 years or younger emergencies is based on results of – long-term follow-up of the survivors for those exposed postnatally than residing in the Fukushima Prefecture76 of the bombings in 1945 of Hiroshima for those exposed in utero. Excess was conducted during 2011 2014. and Nagasaki. The populations in absolute rates were markedly higher The investigators reported a 50-fold – these 2 cities each experienced for a given attained age among those excess incidence rate ratio when exposed in early childhood compared compared with the Japanese national a single high dose-rate10 external radiation exposure. The Life Span with a substantially lower increase thyroid cancer incidence for people Study includes mortality follow-up for a given attained age among those of the same age. Despite the absence 11 since 1950 and cancer incidence exposed in utero (see Table 1). of individual organ radiation doses, follow-up since 1958 of 120000 Researchers of this study could not, the investigators indicated that survivors, including approximately however, provide cancer incidence the findings suggested a notable – risk estimates during childhood increase in thyroid cancer incidence 30000 children. The wide dose range – (<0.005 Gy to 2 4 Gy; mean dose = in the absence of complete cancer attributable to the accident. However, 0.2 Gy), broad variation in age at incidence data during 1945 1957 many other radiation experts have exposure, and long-term follow-up has (the period after bombings but before concluded that this screening led to several key results (see Table the establishment of population- program identified the thyroid 1). First, the radiation-related risks of based cancer registries in Hiroshima cancer incidence rates expected after solid cancers, and to a lesser extent the andNuclear Nagasaki). Plant Accidents: Windscale, screening. Other criticisms of the leukemias, except for acute myeloid Three Mile Island, Chernobyl, conclusions included the use of an leukemia, has persisted for more than Fukushima inappropriate external comparison of 5 decades after exposure and may a screened population with national persist during the entire lifetime. rates not based on screening; absence of a statistical difference Second, there is evidence of a linear No epidemiological studies were of the internal comparisons among dose response for all solid tumors conducted in the population the low, intermediate, and highly combined, including a statistically residentially proximate to the contaminated areas within the significant dose response for Windscale nuclear plant after the Fukushima Prefecture; low measured survivors with cumulative estimated accident. An investigation of cancer thyroid radiation levels that are doses under 0.15 Gy. Significant incidence in the population living in inconsistent with the high risk radiation-associated excess risks proximity to the Three Mile Island estimates reported; lack of broad- were observed for most, but not all, facility revealed no association based individual thyroid organ specific types of solid cancers and for for childhood cancers overall; an measurements; and the ecologic all types of leukemia except chronic increased risk for childhood leukemia nature of the screening study (eg, lymphocytic leukemia, although the was based on only 4 cases, but no individual thyroid radiation level of the excess relative risks per Gy incidence rates were low compared 74 doses were reported, so it is unclear and the excess absolute rates varied with regional and national rates. according to organ or tissue and by whether thyroid– cancer cases had age at exposure. Third, the relative After the release of radioactivity from higher radiation77 79 exposures than and absolute patterns of occurrence the Fukushima Daiichi nuclear power noncases). ‍ plant in March 2011 resulting from of solid tumors have been shown to be Approximately 5% to 7% of children the Great East Japan Earthquake and strongly modified by age at exposure, from the Fukushima Prefecture tsunami, an effort was undertaken with children and adolescents 10 who participated in the mental Japanese Atomic Bomb Survivors: In to estimate internal radiation demonstrating the highest risks. health surveys (participation rates Utero Study levels, but information is limited ranging from 55% to 66%) required because of initial organizational 80 immediate support and counseling. difficulties, high natural background

The solid cancer incidence among radiation, and contamination75 of Compared with other nuclear plant atomic bomb survivors who were radiation measuring devices. Direct accidents, the dose estimation effort in utero at the time of the bombings measurements in a small number and assessment of long-term health (based on 94 incident cancers) of early responders and evacuees risks conducted after the Chernobyl was compared with risks among who stayed in Fukushima for several accident have been much more survivors exposed postnatally at days after the accident revealed low comprehensive. From follow-up Downloaded from www.aappublications.org/news by guest on September 26, 2021 12 FROM THE AMERICAN ACADEMY OF PEDIATRICS studies of children and adolescents nuclear power plants and weapons identified impairment of growth exposed to radioiodines in the facilities in 10 countries have mostly and maturation, neurologic effects fallout from Chernobyl, studies have shown no increase in risk, with23,25​ a (attributable to loss of brain volume consistently revealed sizeable dose- small number of exceptions. ‍ or interference with myelinization related increases in thyroid cancer, Pediatric leukemia clusters have of nerve axons or development of with risks greatest in those youngest been identified in proximity to synapses), cardiovascular system at exposure and potentially among Sellafield and Dounreay nuclear abnormalities, decreased pulmonary those with a deficiency of stable fuels reprocessing plants in the function, thyroid and other 81 ü iodine levels. Studies of pediatric United Kingdom, in Elbmarsch near neuroendocrine effects (attributable leukemia in Ukraine, Belarus, and the Kr mmel plant in Germany, to hypothyroidism, reduction in Russia after the Chernobyl accident and perhaps in proximity to the growth hormone secretion, other have shown inconsistent results, Aldermaston and Burghfield weapons hormonal deficiencies, and primary but there was no evidence of excess production plants in the United gonadal failure in male individuals), leukemia in European82 countries after Kingdom and the La Hague23 nuclear reproductive effects, cataracts theAboveground accident. Nuclear Testing power plant in France. There and cortical opacities, hearing and is no clear evidence of increased23 vestibular abnormalities, and a risk based on multisite studies. range of effects on teeth (the latter Alternate hypotheses used to explain particularly notable among children Thyroid cancer and other thyroid these childhood leukemia clusters younger than 5 years at exposure). diseases have been evaluated in have been proposed, but to date Many of these studies lack detailed children and adolescents exposed to there is no confirmatory evidence information on estimated organ the fallout from aboveground testing that can be used to support these doses.Tissue Effects After Low-to-Moderate in Nevada, the Marshall Islands, hypotheses. The limitations of many Doses of Radiation Exposure French Polynesia, and Kazakhstan. of the studies conducted to date Most of these studies have revealed– include inadequate study designs, dose-response increases in17 the20 risk of residence information restricted Data are more limited on late effects, Inappropriatelythese outcomes Discarded (Table 1) .Medical‍ to the location at the diagnosis of other than cancer, in relation to Radiation Equipment childhood leukemia and absence low-to-moderate doses of radiation of complete address histories, low exposure. Adverse effects on statistical power because of the low mental and cognitive function have levels of radiation exposure and been observed among children

For the most part, there has been small numbers of childhood leukemia and adolescents undergoing95 scalp little systematic study and no long- outcomes, limited understanding of irradiation for tinea capitis and term follow-up of populations the etiology of childhood leukemia among infants treated with radiation exposed to radiation from events (including relevant time windows of for hemangiomas96 on the face, head, involving abandoned medical exposure and latency), and inability83 or other sites. Increased risks radiation equipment. The incident in to adjust for potential confounders. of lens opacities (eg, cortical and Long-term Effects: Tissue Reactions Goiania, Brazil, has been described posterior subscapular opacities) 137 and Conditions Other Than Cancer in detail (see Table 1). An old Cs have been associated with low- teletherapy source stolen from Tissue Effects After High-Dose to-moderate doses of radiation Radiotherapy an abandoned hospital in 1987 in among infants97 irradiated for – Goiania, Brazil, was dismantled, and hemangiomas and atomic bomb98 101 many people handled the pieces. survivors exposed at young ages. ‍‍ As a result of this event, among the Compared with adults, children Internal exposure of children and 112000 people that were monitored, undergoing radiotherapy appear adolescents to radioiodines from 4 people died, 1 person had an to experience higher risks of the the Chernobyl nuclear accident has arm amputated, 249137 people were harmful tissue reactions, other been associated with subsequent contaminated with Cs, and 42 than cancer, that occur at relatively increased risks of102 nonmalignant homes had22 to be decontaminated or high radiation exposure levels. thyroid nodules. Similar Residentialdestroyed. Proximity to Nuclear Plants Valuable sources of data about increased risks of nonmalignant adverse effects other than cancer thyroid nodules have been observed associated with high-dose radiation among those exposed as children or Extensive investigations quantifying exposures include– follow-up adolescents to radioiodines from the risks of childhood leukemia in studies of 84childhood94 cancer fallout from the Semipalatinsk Test proximity to approximately 200 survivors. ‍ ‍ These studies have Site in Kazakhstan at the time of the Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 142, number 6, December 2018 13 COUNCIL ON ENVIRONMENTAL HEALTH 20 EXECUTIVE COMMITTEE, 2017–2018 aboveground testing as well as in features of radiation-related health Jennifer Ann Lowry, MD, FAAP, Chairperson those exposed at ages younger than outcomes are described for short- Samantha Ahdoot, MD, FAAP 20 years to the atomic bombings103 term (eg, ARS), short- and long- Carl R. Baum, MD, FACMT, FAAP in Hiroshima and Nagasaki. term (eg, mental health conditions), Aaron S. Bernstein, MD, FAAP Findings were inconsistent for and long-term (eg, cancer and Aparna Bole, MD, FAAP Lori G. Byron, MD, FAAP radiation exposure and risk of tissue reactions and conditions Philip J. Landrigan, MD, MSc, FAAP hypothyroidism, hyperthyroidism, other than cancer) effects. This Steven M. Marcus, MD, FAAP and measures of thyroid report summarizes newer scientific Susan E. Pacheco, MD, FAAP Adam J. Spanier, MD, PhD, MPH, FAAP autoimmune disease from studies– data on cancer and other serious Alan D. Woolf, MD, MPH, FAAP of Chernobyl residents exposed104 108 in health effects from long-term childhood or adolescence. ‍ follow-up of the Japanese atomic FORMER EXECUTIVE COMMITTEE MEMBERS High doses of ionizing radiation bomb survivors and the Chernobyl Heather Lynn Brumberg, MD, MPH, FAAP have long been associated with nuclear accident and populations Leonardo Trasande, MD, MPP, FAAP circulatory disease, but evidence exposed to aboveground nuclear for an association at lower testing. The health outcomes LIAISONS exposure is more controversial. reported since the 2011 Fukushima John M. Balbus, MD, MPH – National Institute of Authors of a meta-analysis of Daiichi nuclear plant event are Environmental Health Sciences populations exposed in adulthood critically evaluated. Also described Nathaniel G. DeNicola, MD, MSc – American support a relationship between are short-term health effects from Congress of Obstetricians and Gynecologists Ruth A. Etzel, MD, PhD, FAAP – US Environmental circulatory disease mortality and inappropriately discarded medical Protection Agency low and moderate109 doses of ionizing radiation equipment, of which there Diane E. Hindman, MD, FAAP – Section on radiation. Growing evidence has have been no long-term studies. Pediatric Trainees been used to link radiation exposure In addition, results are scrutinized Mary Ellen Mortensen, MD, MS – Centers for from the atomic bombings during for the large number of studies of Disease Control and Prevention and National Center for Environmental Health childhood with subsequent risk health effects among populations – Mary H. Ward, PhD – National Cancer Institute of hypertension,110 112 stroke, and heart living in proximity to nuclear disease. ‍ ‍ A few studies have plants. Recommendations for STAFF evaluated health effects among pediatricians and the health care Paul Spire those exposed113, in114​ utero to sector, government, and families radioiodines. ‍ can be found in the accompanying 9 ABBREVIATIONS policy statement. CONCLUSIONS ACKNOWLEDGMENTS 131 137I: iodine-131 Cs: cesium-137 This technical report summarizes We thank Dr Steve Simon for AAP: American Academy of clinically relevant information scientific review and Ms Ka Lai Lou Pediatrics about the characteristics, sources, for technical assistance with the ARS: acute radiation syndrome and biological effects of radiation LEADarticle AUTHORS preparation. FDA: US Food and Drug exposure to clarify the rationale Administration for the specific measures to reduce Martha S. Linet, MD, MPH é Ziad Kazzi, MD, FACMT, FAACT, FAAEM, FACEP KI: potassium iodide radiation exposures and adverse ’ é Jerome A. Paulson, MD, FAAP SI: Syst me International health effects from a radiation d Unit s emergency. Clinical and related

Address correspondence to Jerome A. Paulson, MD, FAAP. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2018 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Supported by the intra-agency agreement between the National Institute of Allergy and Infectious Diseases and the National Cancer Institute, National Institute of Allergy and Infectious Diseases agreement Y2-A1-5077 and National Cancer Institute agreement Y3-CO-5117.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.​ or​ g/cgi/​ doi/​ 10.​ 1542/​ peds.​ ​2018-3000.​

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