Journal of Pediatric Nursing (2016) 31, e333e341

Assessing Pediatric Nurses' Knowledge About

Chemical Flame Retardants1
Laura Distelhorst DNP, MSN, CPNP, RN , Amy Bieda PhD, APRN, PNP-BC, NNP-BC,
Marguerite DiMarco PhD, RN, CPNP, Susan Tullai-McGuinness MPA, PhD, RN
Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH

Received 24 February 2016; revised 23 June 2016; accepted 24 June 2016

Key words:
Background: Chemical flame retardants are routinely applied to children's products and are harmful to
Chemical flame retardants;
their health. Pediatric nurses are in a key position to provide education to caregivers on methods to
Pediatric nurses;
decrease their children's exposure to these harmful chemicals. However, a critical barrier is the absence
Nursing education;
of any program to educate nurses about chemical flame retardants. In order to overcome this barrier, we
Environmental policy
must first assess their knowledge. This article provides key highlights every pediatric nurse should know
about chemical flame retardants and reports the results of a knowledge assessment study.
Purpose: The purpose of this study was to (1) assess pediatric nurses' knowledge of chemical flame
retardants, (2) determine what topic areas of chemical flame retardants pediatric nurses lack knowledge
in, and (3) determine the best method to educate nurses about chemical flame retardants.
Design and Methods: A single sample cross-sectional questionnaire design was used. A total sample of
417 advanced practice registered nurses and registered nurses completed an online survey about
chemical flame retardants.
Results: Pediatric nurses' knowledge of chemical flame retardants was low (M = 13.4 out of 51).
Articles, webinars, and e-mails were the primary preferred methods for education on the subject
identified as a result of the survey.
Conclusions: Pediatric nurses have a large knowledge deficit related to chemical flame retardants. The
data collected from this study will help structure future educational formats for pediatric nurses on
chemical flame retardants to increase their knowledge.
2016 Elsevier Inc. All rights reserved.

Chemical flame retardants are marketed to the public as a
mechanism of protection from fires, yet products containing
flame retardants provide no more protection against fires
than other safety barriers (Babrauskas, Blum, Daley, &
Birnbaum, 2011). Moreover, research demonstrates that all
chemicals in flame retardants are harmful to a person's health
(Babrauskas et al., 2011; Gascon et al., 2011; Herbstman et
al., 2010). Vulnerable populations, such as rapidly physically
developing infants and children, are especially susceptible to
the negative health impacts from exposure to flame
retardants. The continued use of flame retardants is misleading
to the public as one assumes that domestic products, especially
children's products, are safe to use. Until federal law prohibits
the use of these harmful chemicals, pediatric nurses, including
registered nurses (RNs) and advanced practice registered
nurses (APRNs), should provide education to parents and
guardians on ways to decrease their child's exposure. In order
to develop an education module that pediatric nurses can use,
we must first assess pediatric nurses' knowledge of chemical
flame retardants.

1
Conflict of Interest: None.
Background
Corresponding author: Laura Distelhorst DNP, MSN, CPNP, RN. Flame retardants are chemicals added to materials for the
E-mail address: ldistel@gmail.com. purpose of making those materials more resistant to fire, or

http://dx.doi.org/10.1016/j.pedn.2016.06.007
0882-5963/ 2016 Elsevier Inc. All rights reserved.
e334 L. Distelhorst et al.

Table 1 Chemical flame retardants.

Chemical name Current state of use Health effects linked to
Polybrominated diphenyl ethers 2004: voluntarily withdrawn Hyperactivity & learning disabilities in children
(PBDEs) from production
Firemaster 550 2001: released for use Endocrine disruptor in rats
Tris(1-chloro-2-propyl) phosphate Currently in use Possible carcinogenicity, skin irritation,
(TCPP) destruction of red blood cells
(limited research)
Tris(1,3-dichloro-2-propyl) phosphate 1977:banned from children's Cancer in animals
or chlorinated tris (TDCPP) clothing; still used in other
children's products
Tris(2-chloroethyl) phosphate 1992: carcinogen on the Fertility problems, thyroid and kidney cancers,
(TCEP) Proposition 65 list and hyperactivity; neurotoxic
Note. Data developed from American Academy of Pediatrics, 2013; Blum & Ames, 1977; Gold, Blum, & Ames, 1978; Center for Environmental Health,
2013; National Resource Defense Council, 2010; Patisaul et al., 2012; State of California, 2015.
Proposition 65 list: chemicals known to State of California to cause cancer or reproductive toxicity.

reducing the speed that a flame spreads. Currently there are
five major known chemical flame retardants on the market
today (Table 1). The majority of chemical flame retardants
are lipophilic (adhering to fat cells) and have nonadherent
properties to the products on which they are placed. Due to
these properties, the chemicals are easily dispersed into the
environment and can be inhaled, absorbed through the skin,
and ingested. With children's frequent hand-to-mouth
behavior, they have a higher rate of ingestion of the
chemicals than adults. The chemicals can be found in dust,
sewage sludge, and marine animals, ultimately impacting the
food supply chain (Babrauskas et al., 2011).
The use of chemical flame retardants in the manufacturing
of upholstered furniture began in 1975 when California
adopted the Furniture Flammability Standard, Technical
Bulletin 117 (TB117) (Babrauskas et al., 2011). This
standard requires products containing polyurethane foam
sold in California to resist a small open flame for 12 seconds,
but does not require companies to add chemical flame
retardants to meet the standard if it can be achieved using a
different method. This standard came about when the
tobacco industry was asked to make a safer cigarette to
help decrease the risk of house fires because cigarettes had
been cited as a major contributing factor to house fires
(California Government, 2013; Callahan & Roe, 2012).
Instead of the tobacco industry creating a safer product, the
tobacco industry and the chemical industry promoted
chemical flame retardants for upholstered furniture and
distorted research findings of chemical flame retardants'
effectiveness to ultimately play on the public's emotions on
fire safety (Callahan & Roe, 2012). Babrauskas et al. (1988)
conducted a study on chemical flame retardants and
Babrauskas later testified that the chemical industry clearly
distorted the research findings because the experiment was
not based on real world conditions. The researchers used a
large amount of chemical flame retardants which are not
found in consumer products and compared this to
non-treated flame retardant products. TB117 treated foam
was not tested as a comparison. In addition, the products
were not tested individually, but in a room with multiple
combustibles (Babrauskas, n.d.; Babrauskas et al., 1988,
2011; Callahan & Roe, 2012). Even though the law only
affected products sold to California consumers, companies
only created one product line to meet this standard to be sold
throughout the United States.
The addition of chemical flame retardants to consumer
products started with products containing polyurethane foam,
such as mattresses and couches, but rapidly progressed to the
widespread use of these chemicals in multiple baby and
children's products, such as infant mattresses, car seats, booster
seats, changing pads, baby carriers, children's foam furniture,
rocking chairs, nursing pillows, children's computer tablets, crib
wedges, and portable mattresses (Clean and Healthy New York,
2011; Department of Ecology State of Washington, 2014;
Ecology Center, 2011, 2013; Stapleton et al., 2011).
In 2013, California passed a new fire safety law,
Technical Bulletin 1172013 (TB 1172013), that went
into effect on January 1, 2014. This new fire safety standard
allows companies to make fire retardant chemical-free
products, but does not ban the use of flame retardant
chemicals. Companies can use materials that are naturally
fire retardant or barrier methods to adhere to the new
standard.This new standard states that a product must not
smolder for more than 45 minutes after a lit cigarette is
placed on it (Center for Environmental Health [CEH], 2013).
The new standard addresses the root cause of how fires start
by evaluating the coverings versus the foam, creating a safer
product that will be more fire resistant.
Research has found that chemical flame retardants are not
effective at reducing fires (Babrauskas, 1983; Babrauskas
et al., 2011; Schuhmann & Hartzell, 1989). These chemicals
are applied to polyurethane foam, which is then covered by
fabric or another covering. During fires, the covering is
ignited first. By the time flames reach the foam, the fire is no
longer a small open flame and the flame retardants are no
longer effective (Babrauskas et al., 2011; CEH, 2013).
According to Babrauskas, research was conducted by T. H.
Talley in 1995 to determine if TB117-treated foam made a
Pediatric Nurses' Knowledge About Chemical Flame Retardants e335

Table 2 Negative health effects from chemical flame retardant exposure.

Authors/Year Sample Age range Chemical flame Significant findings p values
size (N) retardant exposure
Roze/2009 62 56 years Prenatal exposure fine motor development & attention p b 0.05
Hoffman/2012 222 Birth-3 years Breastmilk activity/impulsivity behaviors
Eskenazi/2013 323 5 & 7 years Prenatal rates of impaired attention, poor
fine motor skills, & verbal &
full scale IQ
Chen/2014 309 15 years Prenatal Hyperactivity p b 0.05
Gascon/2011 244 4 years Prenatal risk of attention deficit symptoms,
poor social skills
Herbstman/2010 118 1248 months Prenatal scores on administered tests for
& 72 months mental & physical development
Kincinski/2012 515 Adolescents Unknown FT3 ;TSH ;motor speed p= .020 & p = 0.045;
(13.617 years) p= 0.033; p = 0.029
Herbstman/2008 297 Birth Prenatal T4 ^ pb 0.05
Small/2009 464 males 518 years Prenatal Hydroceles and hernias p= 0.04
Main/2007 280 males Birth-3 months Breastmilk Cryptorchidism pb 0.007
Chen/2011 271 females 1219 years Unknown menarche age pb 0.05
Blanck/2000 327 females 524 years Prenatal earlier age of menarche
Chao/2007 20 Newborns Breastmilk Altered birth growth measurements p= 0.015 & 0.004
Blanck/2002 308 females 524 years Prenatal Current decreased weights
Note: * Research articles reported significance, but there were no p values.
(p .05).
FT3 = free T3.
TSH = thyroid stimulating hormone, ^T4 = total thyroxine.

significant difference in fire safety by testing 15 different fabrics
that covered TB117-treated foams and non-treated foams.
Talley found that TB117-treated foam did not make a difference
in fire ignition or the spread of fires compared to nontreated
foams. In 1997, the United States Consumer Product Safety
Commission conducted burn tests of upholstered chairs and
concluded that the standards in California's TB117 do not
provide a significant fire safety benefit, confirming the findings
of Talley (Babrauskas et al., 2011).
Chemical flame retardants have been linked to multiple
health problems in children and are capable of disrupting
their normal development (Chen et al., 2014; Eskenazi et al.,
2013; Gascon et al., 2011; Hoffman, Adgent, Davis Gold-
man, Sjodin, & Daniels, 2012; Roze et al., 2009) (Table 2).
Children have been found to have higher levels of chemical
flame retardants in their bodies compared to adults (Butt,
Congleton, Hoffman, Fang, & Stapleton, 2014; Lunder,
Hovander, Athanassiadis, & Bergman, 2010). Exposure
routes to these harmful chemicals may occur prenatally,
postnatally, and through breastmilk. Disorders of minimal
brain dysfunction, including increased attention deficit,
decreased fine motor skills, increased activity/impulsivity
behaviors, and decreased scores on mental and physical
development tests have been observed in young children
who have increased serum levels of chemical flame
retardants in their bodies (Chen et al., 2014; Eskenazi
et al., 2013; Gascon et al., 2011; Herbstman et al., 2010;
Hoffman et al., 2012; Roze et al., 2009). These studies
validated previous findings demonstrating the negative
impact chemical flame retardants have prenatally on school
age children's neurologic and cognitive development (Boersma
& Lanting, 2000; Jacobson, Jacobson, & Humphrey, 1990;
Stewart et al., 2008; Vreugdenhil, Lanting, Mulder, Boersma, &
Weisglas-Kuperus, 2002).
Chemical flame retardants are endocrine disruptors and
have been known to alter thyroid hormone levels, ultimately
impacting a child's developing brain (Herbstman et al., 2008;
Kicinski et al., 2012; Legler, 2008). Reproductive compli-
cations, including hydroceles, hernias, cryptorchidism, and
altered age of menarche in children have also been associated
with increased blood levels of chemical flame retardants
(Blanck et al., 2000; Chen, Chung, DeFranco, Pinney, &
Dietrich, 2011; Main et al., 2007; Small et al., 2009).
Researchers have found an association between increased serum
levels of chemical flame retardants with altered growth
measurements at birth, including weight, length, and chest
circumference, and decreased weights in later childhood (Blanck
et al., 2002; Chao, Wang, Lee, Wang, & Papke, 2007).
Purpose
The purpose of this study was to assess pediatric nurses'
knowledge of chemical flame retardants. The second purpose
of this study was to assess what topic areas of chemical flame
retardants pediatric nurses lack knowledge in. This study
also determined the best method to educate pediatric nurses
about chemical flame retardants. The research questions
were (1) What is the knowledge base of pediatric nurses with
respect to chemical flame retardants?, (2) What are the
e336
knowledge deficits in pediatric nurses with respect to
chemical flame retardants?, and (3) What are the best
educational methods to provide education to pediatric nurses
with respect to chemical flame retardants?
Design and Methods
The Knowledge to Action Process framework by
Graham et al. (2006) was utilized to guide this research
(Figure 1). This framework guides the process of knowledge
to practice with a holistic approach by starting with
knowledge creation through practice implementation (Graham
& Tetroe, 2010).
Design
A single sample cross-sectional questionnaire design was
used to assess pediatric nurses' knowledge on chemical
flame retardants via Survey Monkey. The participants
accessed the survey link through an e-mail blast sent to
them from their respective organizations. Institutional review
board approval through Case Western Reserve University
was obtained prior to conducting this study.
Participants
The sample included pediatric nurses, both advanced
practice registered nurses (APRNs) and registered nurses
(RNs), who are members of the National Association of
Figure 1 Knowledge to Action Process Framework.
L. Distelhorst et al.
Pediatric Nurse Practitioners (NAPNAP) or the Society of
Pediatric Nurses (SPN).
Inclusion/Exclusion Criteria
Inclusion criteria for this study consisted of currently
practicing as a nurse in a pediatric setting and active
membership in either NAPNAP or SPN. Exclusion criteria
included retired and unemployed nurses, and pediatric nurses
who are not members of SPN or NAPNAP.
Instrument
The data collection instrument was an electronic ques-
tionnaire developed for use in this study. In addition to
demographic information, the topic areas in the survey were
(1) what are chemical flame retardants, (2) where are they
found in products children are exposed to in their homes, (3)
why are they harmful to children's health, and (4) how do
children reduce their exposure to chemical flame retardants.
Topic areas for question development were obtained through
review of the literature and interviews with environmental
health nurse experts in this field. Initial question content
validity was achieved through piloting the questionnaire to a
group of six local pediatric nurses. To further strengthen
content validity, the content validity index by Waltz and
Bausell (Burns & Grove, 2009) was used to evaluate each
question by six pediatric nurses: three of the original nurses
Pediatric Nurses' Knowledge About Chemical Flame Retardants
and three newly recruited pediatric nurses. The instrument
demonstrated good internal consistency (K-R 20 = 0.906).
Results
The study evaluated nursing knowledge of chemical
flame retardants and gaps in this knowledge. There were 449
survey responses. Of those 449, 22 survey responses had
incomplete data and 10 responses did not qualify and were
deleted from the data set, for a final sample of n = 417.
Responses to questions in each main topic area that were
incorrect were coded as a zero. A correct response was coded
as a one. Data were stored in a locked, password-protected
USB flash drive in a locked office of the primary investigator
(PI). Only the PI had access to the data.
Description of Sample
Survey participants' (n = 417) ages ranged from 2375
and 38.7% were parents of a child less than 18 years old.
Years of nursing experience ranged from 153 years. The
majority of survey respondents currently practice in an
outpatient clinic (48.2%) or inpatient hospital (45.8%). The
majority of the respondents have a master's degree (60.5%)
or a bachelor's degree (22.8%) in nursing. Ninety-one
percent of the survey respondents are currently practicing as
a nurse with pediatric patients. Only 17.4% of the sample has
obtained environmental health continuing education in the
past 5 years.
Research question 1: What is the knowledge base of
pediatric nurses with respect to chemical flame retardants?
A total score of 51 was possible to demonstrate 100%
knowledge of chemical flame retardants. Scores ranged from
0 to 46 (M = 13.4; SD = 9.8).
Research question 2: What are the knowledge deficits in
pediatric nurses with respect to chemical flame retardants?
This question was divided into four sections in order to
identify the specific topic areas pediatric nurses may be
deficient in. Section 1 assessed general knowledge with 12
questions. Scores ranged from 0 to 12 (M = 3.3; SD = 2.2).
Section 2 assessed knowledge of where chemical flame
retardants are found with 21 questions. Scores ranged from 0
to 20 (M = 6.3, SD = 5.2). Section 3 assessed knowledge of
health impacts from chemical flame retardant exposure with
15 questions. Scores ranged from 0 to 15 (M = 2.6, SD =
4.3). Section 4 assessed knowledge of how to decrease a
child's exposure to chemical flame retardants with 3
questions. Scores ranged from 0 to 3 (M = 1.3, SD = 1.1).
In addition, section 4 asked survey respondents to provide
examples of ways to decrease children's exposure to
chemical flame retardants. The open-ended question re-
sponses were translated into themes. The most common
examples given were to purchase products that are free of
chemical flame retardants (n = 58) and to read labels to
identify if chemical flame retardants have been applied to the
item (n = 49). Other strategies survey respondents provided
are included in Table 3 which lists important facts pediatric
nurses should know about chemical flame retardants.
e337
To further assess what knowledge deficits pediatric nurses
may have regarding chemical flame retardants, each survey
question was analyzed individually using descriptive
statistics. The results are listed in Table 4. With 14 questions,
and 5 multiple questions within the main question, there was
a possible 51 answers. Only six questions were answered
correctly by more than 50% of the respondents. Major
knowledge deficits included chemical flame retardant
properties including mode of transmission, where they are
found, health problems linked with chemical flame retardant
exposure, and chemical flame retardant laws.
Research question 3: What are the best methods to
provide education to pediatric nurses with respect to
chemical flame retardants? Survey participants were able
to choose as many education platforms as they liked. The
most popular educational methods selected to receive
education about chemical flame retardants were articles
(n = 319), webinars (n = 209), and e-mails (n = 204).Addi-
tional educational methods included conferences (n = 135),
workshops (n = 58), and other methods (n = 11).
Discussion/Practice Implications
Pediatric nurses, RNs, and APRNs who provide care to
children are key players in educating parents and caregivers
on how to protect their children's health. Standard 5B of the
Pediatric Nursing: Scope and Standards of Practice states
that health promotion and health education are an essential
part of pediatric nursing (American Nurses Association,
2008). In order to provide accurate, up-to-date education that
will make a significant impact on children's health, pediatric
Table 3 Important chemical flame retardant facts.
Do not protect you from fires
Present in a large number of children products (mattress, car
seats, toys, couches, baby carrier, dust)
Health Issues linked to exposure
Cancer
Developmental Impairments (hyperactivity, lower IQ)
Neurological Impairments (learning, memory)
Endocrine Impairments (type 2 DM, obesity)
Ways to decrease exposure
Wash hands, especially after dusting or emptying dryer lint
Read labels, look for TB 1172013 to be marked no
chemical flame retardants added
Wet mop or HEPA filter vacuum weekly to decrease dust
Buy cotton/organic/natural clothing and wood toys
Do not let children play or mouth electronic devices with
known chemical flame retardants
Open windows at least 10 minutes/day
Increase awareness of products that contain chemical flame
retardants
e338 L. Distelhorst et al.

Table 4 Survey question results.

Survey questions N %
(correct answer) (correct answer)
Q1: Chemical flame retardants stop the spread of fires. 151 36.2
Q2: There are many different types of chemical flame retardants. 319 76.5
Q3: Chemical flame retardants protect children from fireinjuries and death. 70 16.8
Q4: Chemical flame retardants pass through the placenta. 80 19.2
Q5: Chemical flame retardants pass through breastmilk. 85 20.4
Q6: Chemical flame retardants enter the body through the air we breathe. 179 42.9
Q7: Chemical flame retardants enter the body through the skin. 214 51.3
Q8: Children have a higher percentage of chemical flame retardants present in their bodies than adults. 205 49.2
Q9: Have you heard of Technical Bulletin 117 (TB117), the California consumer product standard? 22 5.3
Q9a: If yes, do you understand TB117? 8 1.9
Q10: Have you heard of Technical Bulletin 1172013 (TB 1172013), the California 18 4.3
consumer product standard?
Q10a: If yes, do you understand TB1172013? 7 1.7
Q11: Are chemical flame retardants found in the following products?
Crib mattresses 291 69.8
Carpet 232 55.6
Car seats 216 51.8
Bassinet pads 208 49.9
Changing pads 186 44.6
Wood building blocks 186 44.6
Family couches 158 37.9
Children's plush chairs 157 37.6
Strollers 142 34.1
Baby carriers 138 33.1
Dust particles 132 31.7
Nursing pillows 110 26.4
Rocking chairs/gliders 102 24.5
High chairs 99 23.7
Electronic tablets 40 9.6
Plastic toys 40 9.6
Televisions 38 9.1
Computers 36 8.6
Cell phones 36 8.6
TV remotes 34 8.2
Food 25 6.0
Q12: Do chemical flame retardants cause any of the following health problems?
Cancer 146 35.0
Learning difficulties 119 28.5
Memory difficulties 113 27.1
Alteration in fine motor development 96 23.0
Altered thyroid hormone levels 94 22.5
Lower IQ 87 20.9
Infertility 83 19.9
Hyperactivity 82 19.7
Decreased birth weight 63 15.1
Early onset of menarche in girls 55 13.2
Cryptorchidism 34 8.2
Obesity 32 7.7
Insulin resistance 29 7.0
Type 2 diabetes 28 6.7
Hydrocele 28 6.7
Q13: Can consumers purchase everyday-use products for children that do not contain 195 46.8
chemical flame retardants?
Q13a: If yes, are the products safe? 84 20.1
Q14: Are there ways a parent or caregiver can decrease their child's exposure to 243 58.3
chemical flame retardants?
Pediatric Nurses' Knowledge About Chemical Flame Retardants
nurses need to be given the tools and resources that
are reflective of current research findings and changing
societal patterns.
Since Florence Nightingale wrote about the importance of
clean water and fresh air in order to protect a person's health,
the impact that environment has on a person's health has
been evident in nursing literature. In 1986, the International
Council of Nursing published their position statement, The
Nurse's Role in Safeguarding the Human Environment,
stating that it is nursing professional's responsibility to
protect people's health by safeguarding the environment,
including the dangers of environmental toxins and how to
avoid the negative effects from these toxins (Pope, Snyder, &
Mood, 1995). In 2008, Alliance of Nurses for Healthy
Environments was formed with a mission to educate nurses and
advance policy related to environmental impacts on health.
In 2003, the American Nurses Association (ANA)
adopted the precautionary principle related to environmental
health. This principle states that when activities raise a
concern for risk to human health or the environment,
precautionary measures should be taken to decrease that
harm. This concern can be raised even without sound
scientific evidence that shows a direct cause and effect
(American Nurses Association, 2007). In 2010, the ANA
used the Precautionary Principle as a guide to update Nur-
sing: Scopes and Standards of Practice, Standard 16:
Environmental Health, which specifies that main competen-
cies of a nurse are to obtain knowledge of environmental
health concepts and communicate health risks and reduction
strategies to patients (American Nurses Association, 2010).
Scientific studies have linked exposure to chemical flame
retardants to pediatric health concerns (Babrauskas et al.,
2011; Gascon et al., 2011; Herbstman et al., 2010). The
results of this study demonstrate that pediatric nurses have a
large knowledge deficit related to chemical flame retardants,
as indicated by only 6 out 51 questions with a correct
response of greater than 50% of the sample.The major
knowledge deficits of pediatric nurses with respect to
chemical flame retardants identified in this study included
the role of chemical flame retardants, their properties, mode
of transmission, where they are found in products and the
environment, health problems linked with chemical flame
retardant exposure, and chemical flame retardant laws.
In 2011, the American Association of Colleges of Nursing
(AACN) released recommendations on addressing the need
for environmental curriculum in undergraduate and graduate
education. Yet environmental health education is still lacking
in the majority of today's basic and advanced nursing
curriculum. Environmental health education can be easily
threaded through community, pediatric, and women's health
nursing courses. In this study, practicing nurses, RNs and
APNs, indicated that it was important to be knowledgeable
(97.3%) and educated (98.1%) about chemical flame
retardants. Pediatric nurses indicated that they would be
interested in receiving education through articles (n = 319),
webinars (n = 209), and e-mails (n = 204).
e339
In 1976, the United States government passed the Toxic
Substance Control Act (TSCA). This Act gives the United
States Environmental Protection Agency (EPA) the authority
to regulate chemical substances used in consumer products,
including chemical flame retardants, in order to protect
citizens' health and the environment. The law states the EPA
must prove the chemical to be harmful before its removal and
does not require chemical companies to demonstrate safety
of a chemical before it is used in consumer products. When
TSCA was passed, 60,000 chemicals were grandfathered in,
bypassing testing regulations. Due to the shortcomings of
this Act, the EPA has only tested around 200 of 80,000 plus
chemicals that are in production, restricting only 5 of them,
ultimately failing to protect consumer health and the
environment (Safer Chemicals Healthy Families, 2015).
Over the past several years the United States government,
environmental health organizations, and chemical companies
have recognized the need to revise the 1976 TSCA law. Both
the U.S. Senate and House of Representatives have passed
bills that would revise TSCA, which are currently in final
negotiations. Both bills have major flaws which could
negatively affect public health (Safer Chemicals Healthy
Families, 2016). Pediatric nurses can help influence the final
outcome of these bills. A majority of the sample, 74%, felt
comfortable advocating for families on elimination of
chemical flame retardants if given the right education and
resources. With the data provided by this survey, the
researcher will be able to design educational resources to
be distributed to pediatric nurses in the preferred formats
identified. This will help increase pediatric nurses' knowl-
edge of chemical flame retardants and give them the power to
influence environmental laws at the federal and state levels,
ultimately protecting the pediatric patient. After education is
provided, further research may be conducted to evaluate
whether there is an increase in knowledge related to chemical
flame retardants. See Table 3 for key highlights on what a
pediatric nurse should know about chemical flame retardants.
Conclusions
Chemical flame retardants are marketed to the public as a
mechanism of protection from fires, yet products containing
flame retardants provide no more protection against fires
than other safety barriers (Babrauskas et al., 2011).
Moreover, research demonstrates that all chemicals in
flame retardants are harmful to a person's health (Babrauskas
et al., 2011; Gascon et al., 2011; Herbstman et al., 2010),
especially to rapidly developing infants and children. Federal
law does not prohibit the use of these harmful chemicals, so
pediatric nurses, RNs, and APNs should provide education to
parents and guardians on ways to decrease their children's
exposure. This study assessed pediatric nurses' knowledge
and knowledge deficits of chemical flame retardants through
an online survey. Overall, their knowledge is very low (M =
13.4), with multiple areas of knowledge deficits. Only 6
questions out of 51 had greater than a 50% correct response
rate. In addition, the study assessed pediatric nurses' desire to
e340
be educated and knowledgeable about flame retardants, and
how they would like to receive this education. The majority
of the pediatric nurses felt that it was important to be
educated and knowledgeable, and would like to receive the
education via articles, webinars, and e-mails. These findings
set the foundation for developing educational modules that
pediatric nurses can use in order to increase their knowledge
of chemical flame retardants and impact policy change at the
state and federal levels.
Acknowledgments
1. Funding was received from the Ohio Nurses Founda-
tion. They did not have any involvement in study
design, collection, analysis and interpretation of data,
writing of the report, or the decision to submit the article
for publication.
2. Society of Pediatric Nursing and National Association
of Pediatric Nurse Practitioners provided access to
membership databases for survey distribution.
3. Katie Huffling for guidance with topic selection for
survey questions.
4. Greg Graham for help with statistical analysis.
References
American Academy of Pediatrics (2013). Flame retardants may be toxic to
children. Retrieved from http://www.aap.org/en-us/about-the-aap/aap-
press-room/pages/Flame-Retardants-May-be-Toxic-to-Children.aspx
American Association of Colleges of Nursing (2011). Toward an
environmentally sustainable academic enterprise: An AACN guide for
nursing education. (Retrieved from http://www.aacn.nche.edu/leading-
initiatives/Sustainability.pdf).
American Nurses Association. (2007). ANAs principles of environmental health
for nursing practice with implementation strategies. Retrieved from http://
www.nursingworld.org/MainMenuCategories/WorkplaceSafety/
HealthyNurse/ANAsPrinciplesofEnvironmentalHealthforNursingPractice.pd.
American Nurses Association (2008). Pediatric nursing: Scope and
standards of practice. Silver Spring, MD: Nursesbooks.org.
American Nurses Association (2010). Nursing: Scope and standards of
practice (2nd ed.). Silver Spring, MD: Nursesbooks.org.
Babrauskas, V. (n.d.) The 1988 NIST FR products study and industry
misrepresentations of its implications. (Retrieved from https://www.
doctorfire.com/NIST_1988_study_comments.pd).
Babrauskas, V (1983). Upholstered furniture heat release rates: Measure-
ments and estimation. Journal of Fire Sciences, 1, 932. http://dx.doi.
org/10.1177/073490418300100103.
Babrauskas, V, Blum, A, Daley, R, & Birnbaum, L (2011). Flame retardants
in furniture foam: Benefits and risks. Fire Saf Sci, 10, 265278. http://
dx.doi.org/10.3801/IAFSS.FSS.10-265.
Babrauskas, V, Harris, RH, Gann, RG, Levin, BC, Lee, BT, Peacock, RD, ...
Clark, HM (1988). Fire hazard comparison of fire-retarded and non-fire-
retarded products. U.S. Department of Commerce National Bureau of
standards: NBS special publication 749.
Blanck, HM, Marcus, M, Rubin, C, Tolbert, PE, Hertzberg, VS, Henderson,
AK, & Zhang, RH (2002). Growth in girls exposed in utero and
postnatally to polybrominated biphenyls and polychlorinated biphenyls.
Epidemiology, 13, 205210.
Blanck, HM, Marcus, M, Tolbert, PE, Rubin, C, Henderson, AK, Hertzberg,
VS, ... Cameron, L (2000). Age at menarche and tanner stage in girls
exposed in utero and postnatally to polybrominated biphenyl.
Epidemiology, 11, 641647.
L. Distelhorst et al.
Blum, A, & Ames, BN (1977). Flame-retardant additives as possible cancer
hazards. Science, 195, 1723.
Boersma, ER, & Lanting, CI (2000). Environmental exposure to
polychlorinated biphenyls (PCBs) and dioxins. Consequences for
longterm neurological and cognitive development of the child lactation.
Advances in Experimental Medicine and Biology, 478, 271287. http://dx.
doi.org/10.1007/0-306-46830-1_25.
Burns, N, & Grove, SK (2009). The practice of nursing research; appraisal,
synthesis, and generation of evidence (6th ed.). St. Louis, MO: Elsevier.
Butt, CM, Congleton, J, Hoffman, K, Fang, M, & Stapleton, HM (2014).
Metabolites of organophosphate flame retardants and 2-ethylhexyl
tetrabromobenzoate in urine from paired mothers and toddlers.
Environmental Science & Technology, 48, 1043210438. http://dx.
doi.org/10.1021/es5025299.
California Government (2013). Department of Consumer Affairs: Bureau of
Electronic and Appliance Repair, home furnishings, and thermal
insulation. Final statement of reasons: new flammability standards for
upholstered furniture and articles exempt from flammability standards
(Retrieved from http://www.bhfti.ca.gov/about/laws/tb_fsor.pdf).
Callahan, P, & Roe, S (2012). Playing with fire. Chicago tribune (Retrieved
from) http://media.apps.chicagotribune.com/flames/index.html
Center for Environmental Health (2013). Killer couch. Retrieved from
http://killercouch.ceh.org/facts/the-killer-chemicals/
Chao, HR, Wang, SL, Lee, WJ, Wang, YF, & Papke, O (2007). Levels of
polybrominated diphenyl ethers (PBDEs) in breastmilk from Central
Taiwan and their relation to infant birth outcome and maternal
menstruation effects. Environment International, 33, 239245. http://
dx.doi.org/10.1016/j.envint.2006.09.013.
Chen, A, Chung, E, DeFranco, EA, Pinney, SM, & Dietrich, KN (2011).
Serum PBDEs and age at menarche in adolescent girls: Analysis of the
national health and nutrition examination survey 2003-2004.
Environmental Research, 111, 831837. http://dx.doi.org/10.1016/j.
envres.2011.05.016.
Chen, A, Yolton, K, Rauch, SA, Webster, GM, Hornung, R, Sjdin, A, ...
Lanphear, BP (2014). Prenatal polybrominated diphenyl ether exposures
and neurodevelopment in U.S. children through 5 years of age: The
HOME study. Environmental Health Perspectives, 122, 856862.
http://dx.doi.org/10.1289/ehp.1307562.
Clean and Healthy New York (2011). The mattress matters: Protecting
babies from toxic chemicals while they sleep. Retrieved from http://
media.wix.com/ugd/a2c2a6_7d59219c7ef3023b5472ef84017c6ab7.
pdf
Department of Ecology State of Washington (2014). Flame retardants in
general consumer and children's products. Retrieved from https://
fortress.wa.gov/ecy/publications/publications/1404021.pdf
Ecology Center (2011). 2011 children car seat findings. Retrieved from
http://www.healthystuff.org/about.findings.carseats.2011.php
Ecology Center (2013). Toxic chemicals found in some of this year's hottest
electronic kids tablets. Retrieved from http://www.healthystuff.org/
release.12162013.childrenstablets.php
Eskenazi, B, Chevrier, J, Rauch, SA, Kogut, K, Harley, KG, Johnson, C, ...
Bradman, A (2013). In utero and childhood polybrominated diphenyl
ether (PBDE) exposures and neurodevelopment in the CHAMACOS
study. Environmental Health Perspectives, 121, 257262. http://dx.doi.
org/10.1289/ehp.1205597.
Gascon, M, Vrijheid, M, Martnez, D, Forns, J, Grimalt, JO, Torrent, M, &
Sunyer, J (2011). Effects of pre and postnatal exposure to low levels of
polybromodiphenyl ethers on neurodevelopment and thyroid hormone
levels at 4 years of age. Environment International, 37, 605611. http://
dx.doi.org/10.1016/j.envint.2010.12.005.
Gold, MD, Blum, A, & Ames, BN (1978). Another flame retardant, tris-
(1,3-dichloro-2-propyl)-phosphate, and its expected metabolites are
mutagens. Science, 200, 785787.
Graham, I, Logan, J, Harrison, M, Straus, S, Tetroe, J, Caswell, W, &
Robinson, N (2006). Lost in knowledge translation: Time for a map?
Journal of Continuing Education in the Health Professions, 26,
1324. http://dx.doi.org/10.002/chp.
Pediatric Nurses' Knowledge About Chemical Flame Retardants
Graham, ID, & Tetroe, JM (2010). The knowledge to action framework. In
J. Rycroft-Malone, & T. Bucknall (Eds.), Models and frameworks for
implementing evidence-based practice: linking evidence to action
(pp. 207222). Malden, MA: Wiley-Blackwell.
Herbstman, JB, Sjdin, A, Apelberg, BJ, Witter, FR, Halden, RU, Patterson,
DG, ... Goldman, LR (2008). Birth delivery mode modifies the
associations between prenatal polychlorinated biphenyl (PCB) and
polybrominated diphenyl ether (PBDE) and neonatal thyroid hormone
levels. Environmental Health Perspectives, 116, 13761382. http://dx.
doi.org/10.1289/ehp.11379.
Herbstman, JB, Sjdin, A, Kurzon, M, Lederman, SA, Jones, RS, Rauh, V,
... Perera, F (2010). Prenatal exposure to PBDEs and neurodevelopment.
Environmental Health Perspectives, 118, 712719. http://dx.doi.org/10.
1289/ehp.0901340.
Hoffman, K, Adgent, M, Davis Goldman, B, Sjodin, A, & Daniels, JL
(2012). Lactational exposure to polybrominated diphenyl ethers and its
relation to social and emotional development among toddlers.
Environmental Health Perspectives, 120, 14381442. http://dx.doi.
org/10.1289/ehp.1205100.
Jacobson, JL, Jacobson, SW, & Humphrey, HE (1990). Effects of in utero
exposure to polychlorinated biphenyls and related contaminants on
cognitive functioning in young children. Journal of Pediatrics, 116,
3845. http://dx.doi.org/10.1016/S0022-3476(05)81642-7.
Kicinski, M, Viaene, MK, Den Hond, E, Schoeters, G, Covaci, A, Dirtu, A, ...
Nawrot, TS (2012). Neurobehavioral function and low-level exposure to
brominated flame retardants in adolescents: A cross-sectional study.
Environmental Health: A Global Access Science Source, 11, 86. http://
dx.doi.org/10.1186/1476-069X-11-86.
Legler, J (2008). New insights into the endocrine disrupting effects of
brominated flame retardants. Chemosphere, 73, 216222. http://dx.doi.
org/10.1016/j.chemosphere.2008.04.081.
Lunder, S, Hovander, L, Athanassiadis, I, & Bergman, A (2010).
Significantly higher polybrominated diphenyl ether levels in young U.
S. children than in their mothers. Environmental Science & Technology,
44, 52565262. http://dx.doi.org/10.1021/es1009357.
Main, KM, Kiviranta, H, Virtanen, H, Sundqvist, E, Tuomisto, JT,
Tuomisto, J, ... Toppari, J (2007). Flame retardants in placenta and
breast milk and cryptorchidism in newborn boys. Environmental
Health Perspectives, 115, 15191526. http://dx.doi.org/10.1289/ehp.
9924.
National Resource Defense Council (2010). Congress must act to remove
toxic substances from products our families use everyday: flame
retardants TDCP and TCEP. (Retrieved from http://www.nrdc.org/
health/files/flameretardantsFS.pdf).
e341
Patisaul, HB, Roberts, SC, Mabrey, N, McCaffrey, KA, Gear, RB, Braun, J, ...
Stapleton, HM (2012). Accumulation and endocrine disrupting effects
of the flame retardant mixture Firemaster 550 in rats: An exploratory
assessment. Journal of Biochemical and Molecular Toxicology, 27,
124136. http://dx.doi.org/10.1002/jbt.21439.
A, position statement from the international council of nurses: The nurse's
role in safeguarding the human environment. Pope, A. M., Snyder, M.
A., & Mood, L. H. (Eds.). (1995). Nursing practice, nursing health, &
environment: strengthening the relationship to improve the public's
health (pp. 131133). Washington (DC): Institute of Medicine National
Academies Press (US).
Roze, E, Meijer, L, Bakker, A, Van Braeckel, K, Sauer, P, & Bos, A (2009).
Prenatal exposure to organohalogens, including brominated flame
retardants, influences motor, cognitive, and behavioral performance at
school age. Environmental Health Perspectives, 117, 19531958.
http://dx.doi.org/10.1289/ehp.0901015.
Safer Chemicals Healthy Families (2015). What is TSCA? Retrieved from
http://saferchemicals.org/get-the-facts/what-is-tsca/
Safer Chemicals Healthy Families (2016). Chemical reform coalition calls
on congress to immediately resume TSCA negotiations. Retrieved from
http://saferchemicals.org/newsroom/chemical-reform-coalition-calls-
on-congress-to-immediately-resume-tsca-negotiations/
Schuhmann, JG, & Hartzell, GE (1989). Flaming combustion characteristics
of upholstered furniture. Journal of Fire Sciences, 7, 368402. http://
dx.doi.org/10.1177/073490418900700602.
Small, CM, DeCaro, JJ, Terrell, ML, Dominguez, C, Cameron, L, Wirth, J,
& Marcus, M (2009). Maternal exposure to a brominated flame retardant
and genitourinary conditions in male offspring. Environmental Health
Perspectives, 117, 11751179. http://dx.doi.org/10.1289/ehp.0800058.
Stapleton, HM, Klosterhaus, S, Keller, A, Ferguson, PL, van Bergen, S, Cooper,
E, ... Blum, A (2011). Identification of flame retardants in polyurethane foam
collected from baby products. Environmental Science & Technology, 45,
53235331. http://dx.doi.org/10.1021/es2007462.
State of California (2015). Chemicals known to the state to cause cancer or
reproductive toxicity. Retrieved from http://oehha.ca.gov/prop65/
prop65_list/files/P65single012315.pdf
Stewart, PW, Lonky, E, Reihman, J, Pagano, J, Gump, BB, & Darvill, T
(2008). The relationship between prenatal PCB exposure and intelli-
gence (IQ) in 9-year-old children. Environmental Health Perspectives,
116, 14161422. http://dx.doi.org/10.1289/ehp.11058.
Vreugdenhil, H, Lanting, C, Mulder, P, Boersma, E, & Weisglas-Kuperus,
N (2002). Effects of prenatal PCB and dioxin background exposure on
cognitive and motor abilities in Dutch children at school age. Journal of
Pediatrics, 140, 4856.