Lead Poisoning in Children and What you can do in your practice

1. Lead Poisoning in ChildrenandWhat you can do in your practice

4. LEARNING OBJECTIVES To identify clues in the environmental history of children of greater than average risk for lead poisoning To describe the most common sources of lead poisoning in the environment and cultural practices that may increase the exposure To identify symptoms associated with lead poisoning and describe the most common presentation of an elevated BLL To interpret blood lead levels and develop an appropriate management plan based on that level

5. Lead Toxicity: Who�s at Risk

6. True or False? There is a known safe threshold for lead exposure in children.

7. The answer is incorrect. There is currently no known safe threshold for lead exposure in children. A recent study (Canfield, 2003) demonstrated that blood lead levels (BLLs) even below 10 �g/dl, which is the current accepted level of concern are inversely related to IQ at 3-5 years-of-age. They estimated that the IQ declined by 7.4 points as lifetime BLL increased from 1 to 10 �g/dl and a further decline of ~ 2 points when the BLLs increased from 10-20 �g/dl. In addition, another study (Selevan, 2003) demonstrated that African-American girls with BLLs of 3 �g/dl at 8-18 years-of-age had evidence of delayed puberty in comparison with girls with BLLs of 1 �g/dl.

8. You are correct. There is no known safe threshold for lead exposure in children. A recent study (Canfield, 2003) demonstrated that blood lead levels (BLLs) even below 10 �g/dl, which is the current accepted level of concern are inversely related to IQ at 3-5 years-of-age. They estimated that the IQ declined by 7.4 points as lifetime BLLs increased from 1 to 10 �g/dl and a further decline of ~ 2 points when the BLLs increased from 10-20 �g/dl. In addition, another study (Selevan, 2003) demonstrated that African-American girls with BLLs of 3 �g/dl at 8-18 years-of-age had evidence of delayed puberty in comparison with girls with BLLs of 1 �g/dl.

9. EPIDEMIOLOGY In 2000, the CDC estimated there were still 454,000 children in the U.S. with BLL > 10 �g/dl The effects of lead toxicity appear to be long lasting and irreversible. Rogan (2001) demonstrated that chelation therapy given to lower moderately elevated BLLs in preschool children had no beneficial effects on cognition, behavior or neuropsychological function Lead is ubiquitous in the environment and does not decay for millions of years PREVENTION IS THE ONLY PLAUSIBLE STRATEGY

10. What percentage of U.S. homes where children under the age of 6 years live contain hazardous lead paint? Let me warn you� You may never drink the water again. We drive our cars and RUVs; we leave the car and AC running while waiting to pick up the kids; jet skiis, leaf blowers, power edgers, etc., even our outdoor barbecues. Let me warn you� You may never drink the water again. We drive our cars and RUVs; we leave the car and AC running while waiting to pick up the kids; jet skiis, leaf blowers, power edgers, etc., even our outdoor barbecues.

11. Let me warn you� You may never drink the water again. We drive our cars and RUVs; we leave the car and AC running while waiting to pick up the kids; jet skiis, leaf blowers, power edgers, etc., even our outdoor barbecues. Let me warn you� You may never drink the water again. We drive our cars and RUVs; we leave the car and AC running while waiting to pick up the kids; jet skiis, leaf blowers, power edgers, etc., even our outdoor barbecues.




15. SCREENING: WHO IS AT RISK? Lead exposure is more common among children who are disadvantaged, < 6 years-of-age, of African-American ethnicity, and who live in the city. No economic or racial/ethnic subgroup is free from the risk of having elevated BLLs, especially those who live in older houses or houses that are being renovated. A physical exam alone will not always reveal when a patient is at risk as lead poisoning is most commonly a sub-clinical disease. Children with developmental delay, behavioral disorders or speech impairment may have been exposed to lead.

16. SCREENING: WHO IS AT RISK?

17. CDC/AAP RECOMMENDED SCREENING PRACTICES Universal versus Targeted screening � The CDC recommended in 1997 universal or targeted screening based on local data of children�s BLL�s and local prevalence of housing built before 1950 Universal � all children should be screened at ages 1 and 2 years or between 36-72 months (if not previously screened) if the prevalence of children aged 12-36 months with BLL�s > 10 is > 12% or if the percentage of housing built before 1950 is > 27% Targeted screening � involves identifying children at high risk then screening them at the above ages.

18. RECOMMENDED SCREENING

19. Your practice is in an area where you do not have reliable epidemiological data on BLLs or age of housing stock. Of the following, which child does not need screening for lead? Let me warn you� You may never drink the water again. We drive our cars and RUVs; we leave the car and AC running while waiting to pick up the kids; jet skiis, leaf blowers, power edgers, etc., even our outdoor barbecues. Let me warn you� You may never drink the water again. We drive our cars and RUVs; we leave the car and AC running while waiting to pick up the kids; jet skiis, leaf blowers, power edgers, etc., even our outdoor barbecues.





24. SCREENING PRACTICES Targeted screening involves identifying children at risk of lead poisoning usually based on a personal risk questionnaire or risk factors gathered in the history. A Basic Personal Risk Questionnaire should contain at least the following 3 questions: Does your child live in or regularly visit a house that was built before 1950? Does your child live in or regularly visit a house built before 1978 with recent or ongoing renovations or remodeling (within last 6 months) Does your child have a sibling or a playmate who has or did have lead poisoning

25. You are taking a history from a family whose 15 month old daughter has a lead level of 25 �g/dl. What is the most likely environmental source of the lead exposure? Let me warn you� You may never drink the water again. We drive our cars and RUVs; we leave the car and AC running while waiting to pick up the kids; jet skiis, leaf blowers, power edgers, etc., even our outdoor barbecues. Let me warn you� You may never drink the water again. We drive our cars and RUVs; we leave the car and AC running while waiting to pick up the kids; jet skiis, leaf blowers, power edgers, etc., even our outdoor barbecues.





30. What are clues in the environmental history that put a child at increased risk for lead exposure?There are four general categories. Before turning to the next slide, think about what questions should be asked in the environmental history that would identify children at risk for lead exposure. The second case is far more difficult than the first, and is probably the most difficult scenerio to face. Except in clusters (such as Iran, Bophal, Japan) or certain classic cases (such as in case one) it is generally impossible to determine the effects of toxins on individual children. The second case is far more difficult than the first, and is probably the most difficult scenerio to face. Except in clusters (such as Iran, Bophal, Japan) or certain classic cases (such as in case one) it is generally impossible to determine the effects of toxins on individual children.

31. RISK FACTORS IN THE HOME AND DAY-CARE SETTING Age and condition of the dwelling (remodeling) Imported or vinyl mini-blinds made before 1997 Imported toys and crayons. Plays outside in the dirt near major roads Parental hobbies (ie. lead-containing artists paint, stained glass, refinish furniture, or shoot at an indoor firing range) Swallowed paint chips actually contribute a very small portion of lead to the total body burden, however fine dust licked from dirty hands or toys may provide proportionally greater amounts. Ask about all the environments in which the child spends time in.

32. OCCUPATIONAL RISK FACTORS What are the family members occupations? Are children and adolescents employed? Family members may bring workplace contaminants home on clothes, shoes, and skin surfaces. House painter Construction worker Lead storage-battery workers Furniture refinishers Radiator repair Manufacturers of ceramic-coated capacitors with fritted glass

33. CULTURAL PRACTICES THAT PLACE A CHILD AT RISK Imported cosmetics Kohl (Middle East, India, Pakistan, some parts of Afrika) Pakistani eye cosmetics Surma (India). Medicinal Kohl (also known as Al Kohl) is believed to strengthen and protect the eyes against disease. Colic treatments Azarcon and greta (Azarcon is 95% lead, greta 97%) which are used to treat empacho, a disorder of the intestinal tract characterized by diarrhea and vomiting.

34. CULTURAL PRACTICES THAT PLACE A CHILD AT RISK CONT.

35. DIETARY AND OTHER FOOD RELATED RISK FACTORS Pica behavior is the most common pathway of lead absorption. Iron deficiency: Wright (2003) demonstrated an association between iron deficiency and subsequent lead poisoning. Iron deficiency is known to increase the gastrointestinal absorption of ingested lead. Canned food packed outside the United States Tamarind candy jam products from Mexico Ceramic glaze (can leach into stored beverages, especially acidic fluids like juices) Crystal cocktail glasses and decanters

36. True or False? For formula fed infants it is best to use cold water to prepare the formula to decrease the risk of lead exposure.

37. Right on the money. Hot tap water and water from �instant� hot taps and refrigerator taps should not be used to make formula as these may be contaminated with lead. Have the parents run the water that has stood in the pipes overnight for at least 2 minutes or until cold. In addition, water should not be boiled for a long period of time as this can concentrate any lead that may be present. One minute of a full rolling boil is recommended for sterilization. Although the amount of lead in household plumbing has decreased, plumbing fixtures, pipes or pipe fittings may contain up to 8% lead.

38. Incorrect answer. Hot tap water and water from �instant� hot taps and refrigerator taps should not be used to make formula as these may be contaminated with lead. Have the parents run the water that has stood in the pipes overnight for at least 2 minutes or until cold. In addition, water should not be boiled for a long period of time as this can concentrate any lead that may be present. One minute of a full rolling boil is recommended for sterilization. Although the amount of lead in household plumbing has decreased, plumbing fixtures, pipes or pipe fittings may contain up to 8% lead.

39. You are seeing a patient in the clinic upon whom you drew a lead level secondary to the occupational risk factor of his father working in construction. The level returns back as 18 �g/dl. This child is MOST likely to develop which of the following? Let me warn you� You may never drink the water again. We drive our cars and RUVs; we leave the car and AC running while waiting to pick up the kids; jet skiis, leaf blowers, power edgers, etc., even our outdoor barbecues. Let me warn you� You may never drink the water again. We drive our cars and RUVs; we leave the car and AC running while waiting to pick up the kids; jet skiis, leaf blowers, power edgers, etc., even our outdoor barbecues.





44. SYMPTOMS OF LEAD EXPOSURE Effects of lead exposure vary according to exposure timing and levels � some effects may be latent Lead can cross the placenta premature delivery, increase in LBW and SGA infants GI symptoms Constipation, abdominal pain, anorexia, nausea & vomiting

45. SYMPTOMS OF LEAD EXPOSURE CONT. Children absorb lead 5-10X greater than adults and are more sensitive to elevated BLLs Neurocognitive and behavioral symptoms are most common and appear first Behavior problems, hyperactivity, developmental delay, fine motor coordination, speech delay, sleep disturbance, hearing loss, cognition (decrease in IQ) Delays in growth and puberty

47. True or False? The blood erythrocyte protoporphyrin level is the most sensitive measure of blood lead levels.

48. Incorrect answer. The blood erythrocyte protoporphyrin (EP) level was replaced by venous blood lead levels as the primary screening tool for lead poisoning based on the 1991 guidelines from the CDC because EP lacked sensitivity to detect lead levels below 35 �g/dl, the assay was not specific to lead (increased in iron deficiency) and it has a long lag time (~120 days) before showing effects of exposure. In addition, capillary blood lead levels are more likely to be inaccurate & may underestimate the true BLL if the finger is squeezed. If poorly collected, they can be contaminated with environmental lead thereby overestimating the true BLL. Fingerstick values greater than 10 �g/dl must be confirmed by a venous blood lead level.

49. Correct answer. Venous blood lead levels replaced the blood erythrocyte protoporphyrin (EP) level as the primary screening tool for lead poisoning based on the 1991 guidelines from the CDC because EP lacked sensitivity to detect lead levels below 35 �g/dl, the assay was not specific to lead (increased in iron deficiency) and it has a long lag time (~120 days) before showing effects of exposure. In addition, capillary blood lead levels are more likely to be inaccurate & may underestimate the true BLL if the finger is squeezed. If poorly collected, they can be contaminated with environmental lead thereby overestimating the true BLL. Fingerstick values greater than 10 �g/dl must be confirmed by a venous blood lead level.

50. OTHER EVALUATION METHODS

51. You are seeing a patient in the clinic on whom you performed a lead screening secondary to his brother having an elevated BLL. The venous blood lead level returns back as 18 �g/dl. When should you obtain a confirmatory venous blood lead level of this child? Let me warn you� You may never drink the water again. We drive our cars and RUVs; we leave the car and AC running while waiting to pick up the kids; jet skiis, leaf blowers, power edgers, etc., even our outdoor barbecues. Let me warn you� You may never drink the water again. We drive our cars and RUVs; we leave the car and AC running while waiting to pick up the kids; jet skiis, leaf blowers, power edgers, etc., even our outdoor barbecues.





56. RECOMEENDATIONS FOR CONFIRMING AN ELEVALTED BLL

57. RECOMEENDATIONS FOR FOLLOW-UP OF ELEVALTED BLLs

58. ENVIRONMENTAL CONTROL In the previous case scenario where the BLL was 18 �g/dl, and the most likely cause of the child�s elevated BLL was secondary to lead contaminated dust or soil, what housekeeping measures would you recommend to the family?

59. Provide information about potential lead sources Regularly wash children�s hands and toys Wet mop (do not dry sweep) Wet wipe down window sills and baseboards Use a high phosphate cleaner (5-8%) Remove shoes at the door, use doormats Do not let children play in the dirt, if possible provide sandboxes Do not put playpens/cribs near windows

60. Local, licensed lead-based paint inspectors can be located by calling 1-800-LEAD-FYI or at http://www.leadlisting.org Lead abatement should only be conducted by certified professionals Plant bushes around the outside of the house near the exterior walls to keep children from playing near potentially lead contaminated areas Do not use pottery or ceramic ware for food storage unless you know that it was adequately fired Have adults change work clothes at work if their jobs are at high risk of lead exposure

61. What nutritional interventions would you recommend to a family if their child�s BLL was 25 �g/dl?

62. Run the tap water cold for 1-2 minutes in the morning prior to use for cooking and drinking Do not store food in open cans Assess for iron deficiency and treat appropriately Provide a diet rich in foods with absorbable iron, vitamin C, and calcium 2 servings of fruit/day 2 servings of calcium rich foods/day Markowitz et all (2004) showed that in children with BLLs between 10 - 45 �g/dl, calcium supplementation at 1800 mg of Ca/day (nl dietary recommendation is 500 � 800 mg) had no effect on lowering BLLs

63. You receive a call from the lab stating that the confirmatory venous BLL you sent on one of your patients is 45 �g/dl. What is the recommended treatment for this child? Let me warn you� You may never drink the water again. We drive our cars and RUVs; we leave the car and AC running while waiting to pick up the kids; jet skiis, leaf blowers, power edgers, etc., even our outdoor barbecues. Let me warn you� You may never drink the water again. We drive our cars and RUVs; we leave the car and AC running while waiting to pick up the kids; jet skiis, leaf blowers, power edgers, etc., even our outdoor barbecues.





68. Chelation for BLLs between 20 � 44 �g/dl is controversial. Rogan et al (2001) demonstrated a lowering of the BLL but neurodevelopmental test scores failed to improve Chelation decreases BLLs by 30-40% however, BLLs rebound after treatment ends to as much as 75% of pretreatment levels. BLLs need to be rechecked in 7-21 days 90-95% of the total body burden of lead is in bone and no chelating agent can significantly remove lead from bone. Therefore bone lead remains a potential source of lead for many years PREVENTION IS THE KEY

69. Rhoads et al (1999) found that children in homes that received biweekly assistance with household cleaning and maternal education had an average BLL reduction of 34% Lanphear et al (1999) found that children in homes who received cleaning equipment and up to 8 visits by a dust control advisor did not significantly reduce their BLLs in comparison to the control group

70. Leigton et al (2003) found that early identification of lead-poisoned children with BLLs between 20 � 44 �g/dl and timely investigation and abatement did reduce BLLs, however the effect was modest (11%) Leigton et al (2003) also demonstrated that BLLs declined by 50% after a year regardless of whether or not remediation occurred.

71. Assess the environment and remove potential sources of lead toxicity Wash children�s hands often, and before eating. Clean toys regularly. Ensure adequate nutrition. Administer medication when appropriate to increase lead excretion. Follow BLLs at appropriate intervals. Avoid having children play on bare soil.

72. Long term developmental surveillance for children with BLLs > 20 �g/dl ( do not stop when a child reaches age 6 or when the level is reduced Specifically watch for difficulties at transition points (1st, 4th, and 6th / 7th grades) Any child with an elevated BLL at any age is at risk for developmental or neurocognitive problems currently or in the future

74. Summary/Review There is no known safe threshold for lead exposure in children. Lead exposure is more common among children who are disadvantaged, < 6 years-of-age, of African-American ethnicity, and who live in the city. The major source of lead exposure for children in the U.S. is house dust. There are multiple factors that can put a child at risk for lead exposure. A physical exam alone will not always reveal when a patient is at risk as lead poisoning is most commonly a sub-clinical disease. The first signs of lead toxicity are often subtle neurobehavioral problems.

75. Summary/Review Venous blood lead levels are the primary screening tool for lead toxicity in children. Chelation therapy is recommended for all children, even if asymptomatic, with BLL�s > 45 �g/dl. Measures to control house dust and other environmental exposures should be utilized to decrease lead exposure. Blood lead levels should be followed at appropriate intervals, the higher the level, the sooner the follow-up. Any child with an elevated BLL at any age is at risk for developmental or neurocognitive problems currently or in the future.

76. AAP: Screening for Elevated Blood Lead Levels - http://aappolicy.aappublications.org/cgi/content/full/pediatrics;101/6/1072?fulltext=lead&searchid=QID_NOT_SET CDC Childhood Lead Poisoning Prevention Program - http://www.cdc.gov/nceh/lead/lead.htm National Lead Information Center - http://www.epa.gov/lead/nlic.htm Texas Department of Health�s Environmental Lead Branch - http://www.tdh.state.tx.us/lead/ U.S.D.H.S. �Case Studies in Environmental Medicine: Lead Toxicity� - http://www.atsdr.cdc.gov/HEC/CSEM/lead/index.html

77. Alliance for Healthy Homes www.afhh.org Coalition to End Childhood Lead Poisioning www.leadsafe.org EPA Lead Awareness Program www.epa.gov/lead Department of Housing and Urban Development Office of Healthy Homes and Lead Hazard Control www.hud.gov/offices/lead Most states have reporting requirements for elevated BLLs. Contact your local health department for specific details.

78. THE ENDThank you for participating in this module.

79. Brody DJ, Pirkle JL, Kramer RA, Flegal KM, Matte TD, Gunter EW, Paschal DC. Blood lead levels in the US population. Phase 1 of the Third National Health and Nutrition Examination Survey (NHANES III, 1988 to 1991). JAMA. 1994 Jul 27;272(4):277- 83. Centers for Disease Control and Prevention. Managing Elevated Blood Lead Levels Among Young Children: Recommendations from the Advisory Committee on Childhood Lead Poisioning Prevention. Atlanta: CDC; 2002. Canfield RL, Henderson CR Jr, Cory-Slechta DA, Cox C, Jusko TA, Lanphear BP. Intellectual impairment in children with blood lead concentrations below 10 microg per deciliter. N Engl J Med. 2003 Apr 17;348(16):1517-26. Lanphear BP, Howard C, Eberly S, Auinger P, Kolassa J, Weitzman M, Schaffer SJ, Alexander K. Primary prevention of childhood lead exposure: A randomized trial of dust control. Pediatrics. 1999 Apr;103(4 Pt 1):772-7. Leighton J, Klitzman S, Sedlar S, Matte T, Cohen NL. The effect of lead-based paint hazard remediation on blood lead levels of lead poisoned children in New York City. Environ Res. 2003 Jul;92(3):182-90.

80. Markowitz ME, Sinnett M, Rosen JF. A randomized trial of calcium supplementation for childhood lead poisoning.Pediatrics. 2004 Jan;113(1 Pt 1):e34-9. Rhoads GG, Ettinger AS, Weisel CP, Buckley TJ, Goldman KD, Adgate J, Lioy PJ The effect of dust lead control on blood lead in toddlers: a randomized trial. Pediatrics. 1999 Mar;103(3):551-5. Rogan WJ, Dietrich KN, Ware JH, Dockery DW, Salganik M, Radcliffe J, Jones RL, Ragan NB, Chisolm JJ Jr, Rhoads GG; Treatment of Lead-Exposed Children Trial Group. The effect of chelation therapy with succimer on neuropsychological development in children exposed to lead. N Engl J Med. 2001 May 10;344(19):1421-6. Selevan SG, Rice DC, Hogan KA, Euling SY, Pfahles-Hutchens A, Bethel J. Blood lead concentration and delayed puberty in girls. N Engl J Med. 2003 Apr 17;348(16):1527-36. Wright RO, Tsaih SW, Schwartz J, Wright RJ, Hu H. Association between iron deficiency and blood lead level in a longitudinal analysis of children followed in an urban primary care clinic.J Pediatr. 2003 Jan;142(1):9-14.

Lead Poisoning in Children and What you can do in your practice

Lead Poisoning in Children and What you can do in your practice

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