RISK FACTOR (bu putri)

Risk factors identified in this patient were exposure to pesticides or herbicide from the palm oil
plantation area since during pregnancy, palm oil plantation fertilizers, obat nyamuk bakar., and an active
smoker father. Meta-analysis of 15 studies showed that exposures during pregnancy to unspecified
residential pesticides, insecticides, and herbicides were positively associated with increasing risk of
childhood leukemia for 1.54, 2.05, and 1.61 times respectively. Exposures during childhood to
unspecified residential pesticides and insecticides were also positively associated with increasing risk for
childhood leukemia for 1.38, and 1.61 times respectively, but there was no association with herbicides.10
(LoE 1) Childhood leukemia also associated with paternal smoking as much as 1.11 times during any time
period, 1.25 times in preconception; 1.24 times during pregnancy, and 1.24 times after birth, with a
dose-response relationship between childhood ALL and paternal smoking preconception or after birth.11
(LoE 1)

standardized mortality ratios SMR results showed increased leukemia mortality (1,74) in a full
cohort of the phosphate fertilizer production facility.

Faktor resiko yang terdapat pada pasien ini adalah adanya paparan pestisida dan pupuk yang
rutin digunakan oleh perkebunan kelapa sawit di sekitar tempat tinggal pasien sejak pasien dalam
kandungan, penggunaan obat nyamuk bakar setiap malam, dan ayah perokok aktif.
Meta-analysis of 15 studies showed that exposures during pregnancy to unspecified residential
pesticides, insecticides, and herbicides were positively associated with increasing risk of childhood
leukemia for 1.54, 2.05, and 1.61 times respectively. Exposures during childhood to unspecified
residential pesticides and insecticides were also positively associated with increasing risk for childhood
leukemia for 1.38, and 1.61 times respectively, but there was no association with herbicides. 10 (LoE 1)
(Turner MC, Wigle DT, Krewski D. Residential pesticides and childhood leukemia: a systematic review
and meta-analysis. Environ Health Perspect. 2010 Jan; 118(1): 33–41. doi: 10.1289/ehp.0900966)
Sebuah penelitian lain, a full cohort, menunjukan bahwa resiko terjadinya leukemia yang
menyebabkan kematian meningkat sebesar 1.74 kali pada para pekerja parbik pupuk fosfat. Yiin JH,
Daniels RD, Kubale TL, Dunn KL, Stayner LT. A study update of mortality inworkers at a phoaphate
fertilizer production facility. Am J Ind Med. 2016 Jan; 59(1): 12–22 (kohort)
The researchers concluded that children who had been exposed to insecticides indoors, such as
mosquitocides, were 47% more likely to have leukemia. Propoxur (2-isopropoxyphenyl
methylcarbamate), was first registered as an insecticide, is detected and persists in indoor air
and dust. On surfaces, pesticide residues can persist for 60 hours or longer. 18 (case control)
(Alexander F. E., et al. Transplacental chemical exposure and risk of infant leukemia with MLL gene
fusion. Cancer Res. 2001;61(6):2542–2546.)
Childhood leukemia also associated with paternal smoking as much as 1.11 times during any
time period, 1.25 times in preconception; 1.24 times during pregnancy, and 1.24 times after birth, with
a dose-response relationship between childhood ALL and paternal smoking preconception or after
birth.11 (LoE 1) (Liu R, Zhang L, McHale CM, Hammond SK. Paternal smoking and risk of childhood
acute lymphoblastic leukemia: systematic review and meta analysis. J Oncol. 2011;854584)

The mortality due to all-causes (SMR = 1.07, 95% confidence interval [CI] 1.02–1.13, observed
deaths [n] = 1,473), all-cancers (SMR = 1.16, 95%CI 1.06–1.28, n = 431), and a priori outcomes of
interests including lung cancer (SMR = 1.32, 95%CI = 1.13–1.53, n = 168) and leukemia (SMR = 1.74,
95%CI = 1.11–2.62, n = 23) were statistically significantly elevated. Regression modeling on employment
duration or estimated radiation scores did not show exposure–response relation with lung cancer or
leukemia mortality.

The researchers concluded that children who had been exposed to insecticides indoors, such as
mosquitocides, were 47% more likely to have leukemia. Propoxur (2-isopropoxyphenyl
methylcarbamate), was first registered as an insecticide, is detected and persists in indoor air16
and dust.17 On surfaces, pesticide residues can persist for 60 hours or longer.18

Childhood leukemia also associated with paternal smoking as much as 1.11 times during any
time period, 1.25 times in preconception; 1.24 times during pregnancy, and 1.24 times after birth, with a
dose-response relationship between childhood ALL and paternal smoking preconception or after birth.11
(LoE 1)

The researchers concluded that children who had been exposed to insecticides indoors were 47% more
likely to have leukemia and 43% more likely to have lymphoma. Leukemia affects about five in 100,000
children in the United States among the common types of childhood cancers. A the study found an
association between only indoor use of insecticides and increased rates of cancer makes sense, because
there is less fresh air indoors to dilute the chemicals. And insecticides could be particularly damaging
because they are sprayed around the home. In the case of how insecticides could be causing cancer,
that the same ingredients that kill insects could be causing genetic mutations in blood cells that lead to
leukemia and lymphoma.
Some studies have reported 3- to 4-fold increased risks with use of specific pesticides such as pest
strips(23) or Baygon/mosquitocides(18).

Known by the trade name Baygon™ and found in numerous registered products, propoxur (2-
isopropoxyphenyl methylcarbamate) was first registered as an insecticide by Bayer AG in 1963.
It is used to control ticks, fleas, and a variety of insects including crickets, ants, wasps,
cockroaches and silverfish. It is an N-methyl residual carbamate insecticide, a family of toxic
chemicals that includes carbaryl, aldicarb and carbofuran. Propoxur currently has registered
uses for in-and-around industrial, commercial (including food handling establishments and food
processing plants), and residential facilities.1 Indoor residential uses of sprays for cracks and
crevices were voluntarily cancelled in 2007, but formulations such as bait traps, pastes, and
impregnated shelf paper are still registered for residential use. The primary outdoor uses are
structural perimeter bait applications, as well as liquid and aerosol spot treatments. There are
no agricultural uses.

Propoxur is detected and persists in indoor air16 and dust.17 On surfaces, pesticide residues can
persist for 60 hours or longer.18 One study found that airborne concentrations are still detectable
33.5 hours after spraying propoxur indoors.19Another determined that the volatilization of
propoxur from treated surfaces increases with humidity, resulting in higher air concentrations.20

Significant case-control differences were apparent for ingestion of several groups of drugs,
including herbal medicines and drugs classified as "DNA-damaging," and for exposure to
pesticides with the last two being largely attributable, respectively, to one nonsteroidal anti-
inflammatory drug, dipyrone, and mosquitocidals (including Baygon). Elevated odds ratios were
observed for MLL+ve (but not MLL-ve) leukemias (2.31 for DNA-damaging drugs, P = 0.03; 5.84
for dipyrone, P = 0.001; and 9.68 for mosquitocidals, P = 0.003).

Case control study

In a study investigating indoor-air insecticide levels in inner-city residences, propoxur is found in

over 90% of indoor air samples of homes with pregnant women.21 Inhalation studies have found
that propoxur exposure effects a depression of plasma by 20 to 30 percent and erythrocyte and
brain cholinesterase activities.22 Dermal absorption studies,23 which have shown that propoxur
is absorbed through the skin, also find that skin moisture (affected by high temperatures and
humidity) influences the dermal uptake of propoxur.24 A dermal LD50 study with laboratory rats
found that on the day of propoxur application to the skin, muscular fasciculations suggestive of
cholinesterase inhibition were observed along with decreased motor activity.2

TITIP PERTANYAAN :

BBL : 3300 gr

- Usia kehamilan 40 minggu

- BB ibu saat hamil : -+ 70 kg

- GPA: G1P0A0 ( Anak merupakan anak pertama dari 2 bersaudara, abortus (-))

- Riw diabetes(-)

- Suku : Dayak

- Diet (selama hamil ibu jarang konsumsi makanan yang dibakar), merokok Ibu -> (-)

- Usia ibu dan bapak saat lahir -> Bapak : 23 Tahun

Ibu : 18 tahun

- Kontak dg pestisida -> ibu, bpk kerja di kebun sawit

- Pekerjaan org tua -> ibu berkerja di bidang pemasakan, bpk bekerja sebagai pemetik kelapa
sawit namun dengan mesin

- Riw paparan radiasi apa pun (-)

- Riw menyusui -> ASI eksklusif (lahir-6 bulan)

- Ayah merokok -> ya, sehari kurang lebih habis 1 bungkus rokok kretek, asap obat nyamuk

- Jumlah kakak kandung, saudara kandung yg sakit keganasan (tidak ada)

- Sosek -> kurang

Penghasilan bapak sebulan -+ 3,5 jt

Ibu -+ 2,5 jt

In summary, data from published studies on ALL wereconsistent with a dose-response-like association
betweenbirth weight and risk, with ALL risk increasing approxi-mately 14 percent per 1,000-g increase in
birth weight.These results emphasize the need for studies to clarify thebiologic mechanisms underlying
the birth weight-leukemiaassociation

REVIEW 2007

ALL and AML are the most common malig-nancies of childhood. Despite many advancesin the treatment
of childhood leukemia, thecausative factors of ALL and AML remainunclear. Identifying risk factors for
childhoodleukemia (e.g., environmental, genetic, infec-tious) is an important step in the reduction ofthe
overall burden of the disease. In general,benzene and ionizing radiation are two envi-ronmental
exposures strongly associated withthe development of childhood AML or ALL.However, identifying other
environmentalrisk factors associated with leukemia is diffi-cult for several reasons:• inability to confirm
and quantify exposures; • lack of a prospective cohort; • presence of different variants of
leukemia;presence of confounders; and • inadequate understanding of the pathophys-iology of
leukemia (e.g., gene–environmentor infection–environment interaction). Future attempts to overcome
these obsta-cles (e.g., through improving laboratorydetection methods to confirm exposure;prospective
cohort studies; focusing on spe-cific types of leukemia and specific chemicalagents) could possibly
uncover other environ-mental risk factors associated with childhoodleukemia and mitigate potentially
harmfulexposures to reduce the risk for disease.Future studies, when appropriate, shouldattempt to use
common questionnaires,address timing and route of exposure, docu-ment evidence that exposure has
actually beentransferred from the workplace to the child,and store biological samples when possible.

[08/12, 13:43] dr. Khotimatun Hasanah: Faktor risiko bapaknya perokok

[08/12, 13:44] dr. Khotimatun Hasanah: Klo radiasi, sutet, ga ada. Bapak ibu kerja di perkebunan sawit.
Kmgknn terpapar pestisida mngkn ya.. klo asi eksklusif

[08/12, 13:57] Dr. Vanessa Abhinaya: Mohon ijin menambahkan faktor risiko Bu:

Semenjak anak kecil orangtua biasa menggunakan obat bakar nyamuk kurang lebih habis satu putaran
setiap hari dibakar di dalam ruang tamu yang berdekatan dengan ruang tidur.