Transcript LEAD POISONING: PREVENTION, IDENTIFICATION, AND MANAGEMENT

LEAD POISONING:
PREVENTION,
IDENTIFICATION, AND
MANAGEMENT
Omar Chowdhury M.D.
Educational Objectives
Educate parents annually on how to
prevent lead exposure.
Test all children at ages 1 and 2, and other
children at risk of lead exposure.
Assess children up to 6 years of age
annually for risk of lead exposure.
Lead Poisoning
Lead poisoning remains a significant health
problem in New York City
In young children, exposure to lead can result in
long-lasting neurological damage, including
learning and behavioral problems and lowered
intelligence.
Health effects of lead poisoning may persist long
after a child’s blood lead level (BLL) has
declined and may go undetected until the child
enters school.
Lead Poisoning
Most children with lead poisoning show no
clinical symptoms.
Blood lead tests are routinely required for
diagnosis.
New York State law requires blood lead testing
for every child at both 1 and 2 years of age and
for other children found to be at risk.
In 2007 only 79% of 1-year-olds and 66% of 2year-olds in NYC were tested, and only 44% of
children had been tested at both ages.
Lead Poisoning
Fetal exposure to lead may also adversely
affect neurodevelopment.
A pregnant woman with an elevated BLL
can pass the lead to her developing fetus;
children born with elevated BLLs may
suffer cognitive and developmental
problems as a result of prenatal exposure.
Lead Poisoning
Recent research shows that adverse
health effects may occur at BLLs<10μg/dL
and that more children may be affected
than previously recognized
Health care providers can help by
educating families on ways to prevent lead
exposure, and by identifying lead
poisoning early through blood lead testing.
NEWLY REPORTED BLOOD LEAD LEVELS
5μg/dL AMONG CHILDREN AND
WOMEN OF REPRODUCTIVE AGE IN NYC
What is lead?
Lead (Pb) is a heavy, soft, bluish metal,
and occurs in nature in the form of ores.
Once Pb is mined, processed, and
introduced into the environment, it is a
potential problem forever.
There is no technology that will destroy
lead or render it permanently harmless.
Nearly all of the Pb in the environment is
due to man's activities.
What is lead poisoning?
Research tells us:
• Lead is a highly toxic substance that is harmful
when it enters the body.
• There are no safe levels of lead in the body.
• Lead poisoning is preventable.
• Lead poisoning is not contagious.
2.2 % of American children age 1-5 years have lead
level measuring at least 10μg/dL (CDC).
CDC Blood Lead Levels
Lead Compounds
Lead carbonate 2PbCO3Pb(OH)2
– Paint pigment (basic white lead) and
additive
Lead Compounds
Lead oxide Pb3O4
– Used as a pigment (red lead) in inks and dyes,
and as primer for rust protection on metal.
Lead oxide in wrapper
contaminating
candy from Mexico
Lead Compounds
Lead chromate PbCrO4
– Used as a pigment in inks and dyes, and as an
artist paint pigment (chrome yellow)
Lead Compounds
Tetraethyl lead Pb(C2H5)4
– Antiknock additive to gasoline.
Though lead was completely phased out of gasoline by 1995 in the U.S., lead
particles emitted in engine exhaust still persist in some soil near major roadways.
Lead Compounds
Lead arsenate Pb3(AsO4)2
– Insecticide
Lead Compounds
Lead azide Pb(N3)2
– Cartridge primers, primer cord for explosives
Lead azide is a rare source of lead contamination, as
most people in the general public will not be working
with explosive devises.
Lead Compounds
Lead silicate PbSiO3
– Glazes for china, porcelain, tiles
The Roman techniques of glazing
were most likely discovered
sometime in the first century B.C.
However, it is important to note
that lead glazing holds a long
history in the ancient world which
spans far before Roman times.
After the Roman period, the
tradition spread and eventually the
process became a practice for
mass produced ceramics.
Lead Compounds
Lead sulfide PbS
– Most abundant lead ore.
Lead sulfide is the most abundant lead ore. The Gingival “lead line” pictured,
also known as the “Burton line,” represents precipitation of lead sulfide along
the gum line and is associated with lead toxicity and poor oral hygiene.
Lead History
6200 BC. - Lead discovered in Turkey, first mine.
500 BC-300 AD.- Roman lead smelting produces
dangerous emissions.
100 BC. - Greek physicians give clinical description of lead
poisoning. "Lead makes the mind give way."
1904 - Child lead poisoning linked to lead-based paints.
1922 - League of Nations bans white-lead interior paint;
U.S. declines to adopt
1923 - Leaded gasoline goes on sale in selected markets
1971- U.S. Lead-Based Paint Poisoning Prevention Act
passed
1986 - Primary phase out of leaded gas in US completed
Where might lead be found?
Paint (before 1978)
In soil around homes
Gasoline (phase-out
1973)
Household dust
Drinking water
Workplaces
Old painted toys and
furniture
Food and liquids
stored in lead crystal
or lead-glazed
pottery or porcelain
Industries that
release lead into the
air
Hobbies that use
lead
Folk remedies that
contain lead
Possible Sources of Lead In Your Home
Lead Paint
Dusting, flaking and peeling lead paint is the
leading source of lead poisoning in children.
Lead was used in many paints until it was
banned for household use in 1978.
Homes built before 1978 may contain lead paint.
Lead paint can also be found on old playground
equipment and on old painted toys and furniture.
You cannot tell just from looking whether or not
paint contains lead.
Lead Paint
Children ages 1-3 are especially susceptible to lead
exposure; they spend considerable time crawling on,
touching, or mouthing dust covered surfaces like their
hands, their toys, and windowsills.
Young children will also readily eat visible chips of
flaking paint.
The Consumer Product Safety Commission (CPSC) has
determined that daily ingestion over about 15-30 days of
as little as one-tenth of a square inch of paint (about the
size of the head of a pencil eraser) could result in blood
lead levels at or above 10 ug/dl.
Lead Paint
A child presented to
the emergency
department with
colicky abdominal
pain.
The x-ray below was
obtained; the child had
numerous paint chips
in the area of the
rectum.
A blood lead level was
47 μg/ml.
Vinyl Mini-blinds
Vinyl mini-blinds were recalled and banned from
US shelves in 1997, but prior to 1997 millions of
these blinds were imported from China, Taiwan,
Mexico, and Indonesia, and are likely still in
many US homes.
Soil
Though lead was completely phased out of
gasoline by 1995, lead particles emitted in
engine exhaust still persist in some soil near
major roadways.
Also deteriorating exterior lead paint may
contaminate the soil around old homes.
Children who play in bare soil risk exposure to
lead, and family members may track
contaminated soil into the home on their shoes.
Lead in Water
Lead water pipes and lead-soldered plumbing used to be
widespread.
Lead pipes were used for transporting water in ancient
Rome, and have been cited as a contributing factor to
the downfall of that civilization.
The Environmental Protection Agency (EPA) banned the
use of lead water pipes in 1988.
Public systems that transport water from a main source
to a building have had lead pipes replaced. However,
many older buildings and homes still have lead pipe or
lead-soldered internal plumbing.
Lead in Water
Lead can leach into the water from lead pipes,
especially if it sits in these pipes for more than 8
hours.
Hot and/or acidic water leaches lead from pipes
at a faster rate.
The EPA considers water with a lead content of
<15 ppb (parts per billion) to be safe. The lead
level allowed for bottled water is <5 ppb.
Water from public sources is routinely tested.
The EPA rules do not apply to privately owned
wells. Most states have their own rules about
testing well water.
Lead in Imported Candy
Packaging
• Lead may be in wrappers printed with
lead- containing ink
• Candy may come in small, glazed pots. A
glaze called Greta contains lead that
leaches into candy
Ingredients
• Lead from dirt may be on chilies not
cleaned before they are milled
• Tamarind is sticky, and lead from
pesticides, fertilizers, or dirt can attach to it
Lead in Low-cost Metal Jewelry
Jewelry made with metal may
have lead
A study found that 4 out of 10
pieces of low-cost jewelry
have dangerous levels of lead
Lead-glazed Pottery
Pottery made outside of the US may
contain lead
Foods or drinks cooked or stored in
lead-glazed pottery can poison the
family
The bean pots found in many Hispanic
homes sometimes have high levels of
lead
Lead in Herbal Medicines
Some herbal medicines have dangerous
levels of lead
The US government does not test herbal
medicines to see if they are safe or if they
work (Dietary Supplement Health and
Education Act of 1994 (DSHEA))
A study about herbal medicines from Asia
found that nearly 1 out of 5 herbal medicines
had high levels of lead and other dangerous
metals
Profile of NYC Lead-Poisoned Children
Lead poisoning can affect children of all ages,
races, and income groups, but certain
populations are at greater risk.
These groups include children less than 3 years
of age, low-income children living in older,
deteriorated housing, and children of color.
In addition, children born outside the United
States (US) are among lead-poisoned children
in NYC.
Profile of NYC Lead-Poisoned Children
In 2007, of the children newly identified with
venous BLLs >15μg/dL:
• 87% were black, Asian, or Hispanic
• 82% lived in homes built before 1950
• 76% had lead-based paint hazards
found on inspection of their addresses
• 60% were less than 3 years old
• 17% were foreign-born
Lead Prevention
Annually educate parents of children 6
months to 6 years of age by providing
anticipatory guidance as required by NYS
law
Helping parents minimize their children’s
exposure to lead is the best way to
prevent the developmental and cognitive
deficits associated with lead poisoning.
Educational Messages For Parents
Provide parents with the following educational
messages:
• Keep your child away from peeling paint
and home repairs that disturb lead paint
• Report peeling paint to your landlord.
If your landlord does not make repairs, call
311
• Frequently wash hands, toys, pacifiers,
bottles, and other items your child puts in his
or her mouth
Educational Messages For Parents
continued
Clean floors, windowsills, and dusty places often
with wet mops and wet cloths;
Avoid using health remedies and eye cosmetics
(such as kohl, kajal, surma) from other countries.
Use caution when using candies, spices, snack
foods, and children’s toys and jewelry made in
other countries.
Use only cold tap water for making baby
formula, drinking, and cooking. Let the water run
for a few minutes before use;
Educational Messages For Parents
continued
Keep your child away from the work clothes and
tools of household members who do
construction work or other work and hobbies that
may expose them to lead.
Wash work clothes separately from other
laundry.
Remove shoes and work clothes before entering
your home;
Use safe work methods when doing home repair
that disturbs paint. For information on lead-safe
work methods, call 311.
Lead Prevention
Test all children at ages 1 and 2, and test other children
found to be at risk. Annually assess children from 6
months to 6 years of age for lead exposure risk.
Children between 9 months and 36 months of age are at
risk of lead exposure due to normal hand-to-mouth
toddler behavior. Rapid growth and development at
these ages also makes them more vulnerable to lead’s
toxic effects.
Household lead exposure, in either the child’s home or
homes they regularly visit, remains a concern. Although
lead-based paint for residential use in NYC was banned
in 1960, about 67% of NYC housing was built before
1960.
RECOMMENDED LEAD RISK
ASSESSMENT QUESTIONS FOR PARENTS
1. Is your child between 9 and 36 months of age?
2. Have any of your children or their playmates ever
had a high blood lead level?
3. Does your child live in, or regularly visit, an older home
or other place with peeling or damaged paint?
4. Does your child live in, or regularly visit, an older home
or other place that is being or was renovated within the
last 12 months?
RECOMMENDED LEAD RISK
ASSESSMENT QUESTIONS FOR PARENTS
5. Does your child have any developmental delays, have
hand-to-mouth behavior, or put non-food items, such as
paint chips or soil, in their mouth?
6. Has your child moved to the US from or traveled to a
foreign country where lead poisoning may be common?
7. Does your family use products from other countries such
as health remedies, spices, food, or pottery?
8. Does your child play near a heavily traveled highway,
bridge, or elevated train where there is peeling paint?
RECOMMENDED LEAD RISK
ASSESSMENT QUESTIONS FOR PARENTS
9. Does your child come into contact with an adult
whose job or hobby involves exposure to lead
(e.g., bridge painting and repair, building
demolition, home renovation and repair,
automotive and electronics repair, furniture
refinishing, working with firearms, and arts/crafts
work involving ceramics, metals, and color
pigments)?
10. Is your child enrolled in or planning to enroll in
Medicaid or the NYC Early Intervention
Program?
VENOUS VS FINGERSTICK BLOOD LEAD
SPECIMENS
Venous specimens are more accurate
than fingerstick specimens.
Environmental contamination of fingerstick
specimens can result in false positives,
and finger squeezing can dilute blood and
result in false negatives.
All fingerstick blood lead results ³10μg/dL
must be confirmed with venous specimens
within the time frames specified.
FOLLOW-UP BLOOD LEAD TEST
SCHEDULES FOR CHILDREN
FOLLOW-UP BLOOD LEAD TEST
SCHEDULES FOR CHILDREN
RECOMMENDED MANAGEMENT
BLL (μg/dL) Recommended Action 5–9
• Recognize that a BLL of 5–9μg/dL may indicate
lead exposure.
• Provide educational messages
• Evaluate for adequate intake of calcium, iron, and
vitamin C
• If initial positive test is a fingerstick specimen,
confirm with a venous specimen within time frame
specified.
• Monitor BLLs by retesting as per follow-up
schedule
RECOMMENDED MANAGEMENT
10–14 All actions for BLLs of 5-9μg/dL, plus:
• Patient’s complete name, date of birth,
complete address (including apartment
number), and phone number.
-Health care provider name and phone
number.
-Type of sample (venous or fingerstick)
and date of collection.
• DOHMH will send educational information
to the family and health care provider.
RECOMMENDED MANAGEMENT
15–44 All actions for BLLs 5-14μg/dL, plus:
• Provide a complete medical evaluation including a
detailed environmental history, thorough
developmental and nutritional assessment, and
physical exam.
• Evaluate for iron deficiency anemia, often
associated with lead poisoning.
• Consider abdominal x-ray if paint chip or other lead
solid ingestion suspected; if radio-opaque particles
found or recent ingestion witnessed, use cathartic.
• Consider monitoring erythrocyte protoporphyrin
levels (EP) for BLL ³25μg/dL to help assess timing of
exposure.
RECOMMENDED MANAGEMENT
15–44 All actions for BLLs 5-14μg/dL, plus:
• Monitor development even after BLLs decrease.
Consider this child at higher risk for developmental
delays and behavior problems.
• DOHMH will:
- Inspect the child’s home to identify potential lead
sources.
- Order the landlord to repair any lead paint hazards
identified.
- Refer families to temporary, lead-safe housing as
necessary.
- Refer children < 36 months of age to DOHMH
Early Intervention Program.
RECOMMENDED MANAGEMENT
>45 All actions for BLLs 5-44μg/dL, plus:
• Arrange hospitalization and chelation therapy at a
facility with expertise in treating lead-poisoned
children
• Perform complete neurological exam.
• Confirm BLL with venous specimen processed as
emergency test before providing chelation therapy,
unless symptoms of encephalopathy are present.
• Obtain abdominal x-ray to look for paint chip or
other lead solid ingestion; if radio-opaque particles
found or recent ingestion witnessed, use cathartic.
• Child must receive chelation therapy in, and be
discharged to, a lead-safe environment. Do not
discharge until DOHMH inspects the home.
RECOMMENDED MANAGEMENT
>45 All actions for BLLs 5-44μg/dL, plus:
• Inform NYC DOHMH of hospital admission by
calling (212) 676-6100.
• DOHMH can provide the following additional
services:
- Same-day BLL processing.
- Referrals to facilities and providers with
expertise in treating lead-poisoning.
- For treatment consultations on evenings or
weekends, call Poison Control Center at 311.
- Referrals to temporary lead-safe housing.
RECOMMENDED MANAGEMENT
RESOURCES AND ADDITIONAL INFORMATION
FOR HEALTH CARE PROVIDERS
Report BLLs ³10μg/dL within 24 hours:
– Children BLL results, fax to (212) 676-6326
or call (212) 676-6158.
Access the DOHMH Online Registry at
www.nyc.gov/html/doh/html/cir/a01.html to check children’s
blood lead and immunization records.
– Call (212) 676-2323 to obtain a user ID and password.
Obtain patient educational materials on lead poisoning
prevention for your office at DOHMH Web site
www.nyc.gov/lead, or call 311 and ask for the BAN-LEAD
information line.
Call (212) 676-6100 to request a telephone consultation with
a DOHMH physician about a lead-poisoned child.
RESOURCES AND ADDITIONAL INFORMATION
FOR HEALTH CARE PROVIDERS
Consult the CDC report “Managing Elevated Blood Lead
Levels Among Young Children: Recommendations from the
Advisory Committee on Childhood Lead Poisoning
Prevention” (CDC, March 2002) at
– www.cdc.gov/nceh/lead/CaseManagement/caseManage_
main.htm
Consult “Recommended Chelation Protocol for Children with
BLLs ³45μg/dL” at the DOHMH Web site:
– www.nyc.gov/health/lead/chelation
Consult the CDC’s “Capillary Blood Lead Sampling Protocol”
at
– www.cdc.gov/nceh/lead/guide/1997/pdf/c2.pdf
For more information on imported products that contain lead,
visit the following DOHMH Web sites:
– www.nyc.gov/html/doh/html/lead/lead-import-eyecos.shtml
– www.nyc.gov/html/doh/html/lead/lead-herbalmed.shtml
Thank you for your attention