VIEWS: 24 PAGES: 56 POSTED ON: 6/13/2012
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 2- year-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) Food and liquids stored in lead crystal In soil around homes or lead-glazed Gasoline (phase-out pottery or porcelain 1973) Industries that Household dust release lead into the air Drinking water Hobbies that use Workplaces lead Old painted toys and Folk remedies that furniture 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
"LEAD POISONING PREVENTION IDENTIFICATION AND"