Disclosure Statement

No financial interest or affiliation concerning material discussed in this presentation

Will not discuss any non FDA approved or investigational drugs/medical devices

Congenital Lead Poisoning

Nachammai Chinnakaruppan,MDNeonatologistLehigh Valley Health Network, Allentown, PA

Outline

Case presentation Association between BLL and

development ??Screen pregnant women Strategies to enhance development Strategies to decrease exposure Latest CDC recommendations on

prevention of childhood lead poisoning

Introduction

Lead poisoning is the most common preventable cause of neurotoxicity in children

Associated with impaired cognitive, motor, and behavioral abilities

Binns et al Advisory Committee on Childhood Lead poisoning , Pediatrics 2007

Introduction-continued

In 1991,CDC defined the BLL of concern to be 10 mcg/dl

Advisory Committee on CLP concluded that there is no safe BLL.

BLL<10 have been associated with decreased scores on psychometric tests in children

Dietrich et al,Treatment of Lead exposed children in clinical trial, Pediatrics 2004)

Case Presentation

The Mother

23 yo Mexican woman 36 weeks into a gestation is screened for lead Result: 58.4 mcg/dl Rescreened 4 days later: 57.2 mcg/dl Anemic Hb 9.5g% Prescribed iron supplements Spontaneous labor 2 weeks later

The Child

Normal term female infant, AGA 3030g Good Apgars, normal neurological exam Sent to nursery Pb level available at 36 hours of age: 72

mcg/dl Other labs: Hb 17g%, FEP 175 mcg/dl,

No basophillic stippling in peripheral blood smears

Lead poisoning (arrow indicates an erythrocyte with basophilic stippling, NEJM 2005.

Basophilic Stippling

Treatment Options

CaNa2EDTA BAL BAL/ CaNa2EDTA Succimer Other

Management

Transferred to NICU Consult with toxicologist Decision made to perform a double

volume exchange transfusion despite the risks of the procedure

BLL 6 hours after exchange was 11mcg/dl

Also started on chelation therapy

Management- Continued

6 doses of IM dimercaprol (BAL) Infusion of calcium disodium

ethylenediaminetetraacetate (CaNa2EDTA)

Oral succimer for 3 weeks Infant discharged home on full feeds

and normal discharge neurological exam

0

10

20

30

40

50

60

70

80

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35

Mother’s Blood lead

Double volume exchange transfusion

BAL/CaNa2EDTA

succimer

Should we Breastfeed?

Nashashibi et al. Gyn & Ob. Invest 1999;48:158-162

Follow-Up

At 1 year, healthy, not on any medications

Weight at 10%, length 50%, head circumference 25%

Bayleys assessment showed cognitive score of 135, motor score of 103

2 y.o sister with BLL of 8mcg/dl

“Sources” found

Treats made in Mexico Flowered bowls made in Thailand Gibson plates made in China Express china bowl made in China Atelier plate made in Indonesia Small metal pitcher made in Colombia Cerebyl (Suplemento Alimentico) from

Mexico

Sources -Continued

Mother has pica Lipstick (tested hers=negative) Chews nail polish( hers=negative) Eats “bean stones” Chews bottle tops and knitting needles

and on her necklace: all tested negative

Lead And The Brain

Pb disrupts synapse formation Increases transmitter release Decreases stimulated transmitter

release Interferes with neurotransmission Decreases synapse formation Decreases neuron growth

Johnston et al Current Opinions Neurology 1998

Is there a safe BLL?

2002-2004, CDC LPPC analyzed 23 reports on 16 populations and concluded that

BLL →1/ Cognitive function

Is there a safe BLL- continued

IQ decreases more than 7 points over the first 10 mcg/dl increase in lifetime average BLL

Likely causal association NO SAFE BLL

Lead in Pregnancy

0.5% women still have BLL more than 10mcg/dl

Pb moves freely from mother to baby by diffusion and there is net accretion over time

Results in babies that are growth restricted, delayed dentition and adverse neurological outcomes

Gardella Obst and Gyn Survey 2001

Routine Prenatal Screening??

Argue that this identifies at risk women and remove the lead sources to decrease neonatal morbidity

Don’t know how to respond to the blood screens. Who responds?

Chelation well tolerated by mothers but it mobilizes Pb stores and can potentially increase transmission to the fetus

Recommended Lead Risk Assessment Questions for Pregnant Women

Were you born, or have you spent any time, outside of the United States?

In NYC, approximately 95% of identified lead-poisoned pregnant women are foreign-born. Countries of birth in descending order of frequency include Mexico, India, Bangladesh, Russia, Pakistan, Ecuador, Haiti, Jamaica,

Morocco, Dominican Republic, Guatemala, Guyana, El Salvador, Gambia, Ghana, Honduras, Israel, Ivory

Coast, Korea, Nepal, Sierra Leone, and Trinidad. During the past 12 months, did you use any imported health

remedies, spices, foods, ceramics, or cosmetics? At any time during your pregnancy, did you eat, chew on, or mouth

non-food items such as clay, crushed pottery, soil, or paint chips? In the last 12 months, has there been any renovation or repair work in

your home or apartment building? Have you ever had a job or hobby that involved possible lead

exposure, such as home renovation or working with glass, ceramics, or jewelry?

Anticipatory Guidance and Risk Reduction Education For Pregnant Women

Avoid using health remedies, spices, foods, or cosmetics from other countries.

Avoid using clay pots and dishes from other countries to cook, serve, or store food and do not use pottery that is chipped or cracked.

Never eat non-food items such as clay, soil, pottery, or paint chips.

Stay away from any repair work being done in the home.

Avoid jobs or hobbies that may involve contact with lead, such as home renovation or working with glass, ceramics, or jewelry.

Management Options

Chelation of mother Prenatal Postnatal

Chelation of newborn Role of prenatal counseling, induction,

termination Timing of lead screening

Breastfeeding Role of exchange transfusion in the

newborn with extremely elevated BLL

Why concentrate on the Newborn?

Chelation at 12 months should improve outcome DB Placebo controlled 1994-2003, multiple centers

(n=800) Randomized and stratified by BLL and language to

treatment or placebo Tested at 7 years All kids received lead control measures Results: Chelation decreased BLL for 6 months with NO

benefit in cognition, behavior and neuromotor end points SO PREVENTION is the only way

Rogan et al Pediatrics 2007

Strategies to Enhance Development

Elevated BLL does not guarantee problems

Greater impact on the at risk children i.e. those with other environmental, genetic, biological, social risk factors. Nurture them. Early intervention

Strategies to Decrease Exposure

4.1 million homes have lead paint Home inspection limited to children with

elevated BLL Funds to repair not available Case management to homes with BLL>10 Relocating families during renovation,

containing dust Screen at risk 12mth, 24 mths, (36 to 72

mths) Education

Advisory Committee on CLPP-Clinicians

Anticipatory Guidance Occupation Toys, folk remedies, candy, make-up

Developmental Assessment Nurture Kids Use good labs

Advisory Committee on CLPP-Government

Decrease Lead Based Hazard Safe Elimination of Lead Hazards Decrease Pb exposure in Food Primary Prevention in Highest risk

areas Additional Research

Conclusion

No consensus on managing the results of a gestational screen

Focus should be on education of target population to decrease lead exposure

Thank you