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Environmental Lead Ex osure
Jerold C. Woodhead, MD
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What is your opinion?
Anemia is the most common finding in children who haveelevated Blood Lead Levels.
1.True
2.False
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Blood Lead Level
What blood lead level identifies excessive lead exposurein a child?
1. 1 mcg/dl
.
3.10 mcg/dl
4.15 mcg/dl
5.25 m /dl
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What is your opinion?
Iowa ranks LOW nationally in % of the childpopulation with elevated BLL.
1.Strongly Agree
.
3.Neutral
4.Disagree
5.Stron l Disa ree
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Additional Topics
What is the 1o source of environmental lead?
Who is most at risk for lead poisoning?
What does chronic lead toxicity cause in adults? Which adults have risks for lead toxicity?
How does a pregnant woman put her newborn at
risk?
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Why Worry About Lead?
BUT
ea s a eurotox n
Disrupts cell migration/cell adhesion during braineve opmen
Interferes with neurotransmission
Behavioral concerns in 10-20% lead exposed children
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Impact of Lead on Intelligence
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Lead & Population IQ
Lead Education and
Abatement Design
http://www.lead.org.au/bblp/sld001.htm
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Blood Lead Levels Over Time
60
70
30
40Blood
Lead
10
20
0
up to
1970
1971-
1974
1975-
1985
1985-
1991
1991 to
now
considered
diagnostic of
excessive
lead exposure
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BLL > 10 mcg/dl US 1976-2000
MeanBLL BLL >=10 g/dLPrevalence Est. #
LEAD
REMOVED
1976 -
1980
14.9 88.2% 13,500,000
1960
Exterior paint
1988 -
1991
3.6 8.6% 1,700,00
-
1978
Gasoline
-
1994
. . ,
1999 - 2.2 2.2% 434,000
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BLL >10 mcg/dl - US 1997-2007
7.8%
1 %
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Thomas etal. Environmental Science and Technology33(22):3942-3947, 1999
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MMWR
May 27, 2005:
54(20);513-516
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Why Worry about Lead in Iowa? owa ran s g n or ea exposure
>50% of Iowa homes have lead-based paint
u e ore
Environmental lead is mostly from housing Dust contaminated with lead-based paint
All homes built before 1960 have lead-based paint on
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Iowa BLL 1997-2008
1500
600
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Screening
Lowa e7%
19%
High
23%
55%
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Poorly Maintained Housing
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Other Sources of Lead
Gasoline in the past Battery factory or other lead industry
Water supplies that use lead pipes
Parental job or hobby
, India
Mexico
Candy from Mexico Toys from China and India
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Lead Jewelry From
Child swallowed this and develo ed abdominal ain and
vomiting and later a seizure. BLL = 123 mcg/dl
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Recent additions
--Keychains at
--Pajamas at
Childrens Place
Stores
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How Should Iowa Respond?
Toxic CNS effects cannot be reversed
Develo local/count lead ro rams
Community awareness
Educate physicians and families Plan for lead abatement in housing
Screen all children for blood lead targeted to risk
Required for daycare and school entry
High risk populations (e.g. Medicaid eligible - 3X risk)
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Screening for lead exposure -
Who should be screened in Iowa?
Why are these children at risk?
Develo mental sta e: Hand-to-mouth behavior
Brain growth and development
What screenin method?
Questionnaire
Routine blood lead levels
Routine anemia screen (Hb or Hct)
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Screening Questions
Home, Daycare, or Visit (e.g. grandparents)? Chi ed or eelin aint?
Current remodeling?
Pica? Sibling or playmate with lead level 15 mcg/dl?
Job or hobby lead-related?
Live near battery plant, recycling plant, or smelter? Folk remedies, candy, cosmetics
Immigrant from Mexico or undeveloped country?
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Iowa Screening Guidelines
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CDC and AAPManagement of Elevated BLL
Blood Lead Level(mcg/dL) Action
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How Would You Manage?
2-year-old boy has a screening blood lead leveldone by capillary sample.
BLL returns 3 days later: 26.5 mcg/dl
What will you do?
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Elevated Capillary BLL
Obtain a venous sample to repeat BLL
Venous sample allows confirmation that the sample
reflects true BLL Patient results:
Capillary BLL 26.5 mcg/dl
Venous BLL 2.4 mcg/dl Child lives in a new home and plays outside in the dirt
aren s ave ca e e con rac or
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Adult Lead Exposure
Environmental lead exposure before public health
Adults mostly asymptomatic at levels < 25 mcg/dl
CNS dysfunction and Renal failure >80 mcg/dl
Low-level Chronic lead toxicit
Hypertension
Cognitive Decline
Atherosclerosis
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2002 Adult BLL 25 mcg/dl
Iowa
,
With BLL 25 mcg/dl
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2004 Adult BLL 25 mcg/dl
Iowa
10-19/100,000 with
Note decline in rate
with improvedsurve ance
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u mcg
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What affects Adult BLL? Continued ex osure: Occu ation or hobbies
Mobilization of stored lead from bones Pregnancy
Hypertension/Toxemia
Spontaneous abortion Exposes the fetus to possible CNS developmental
abnormalities
Fractures
Immobilization
Osteoporosis/Menopause
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Prenatal Lead Poisoning ot er use an er a preparat on ur ng pregnancy
Lead and Mercury
, ,
BLL 102 mcg/dl
Chelated for 2 months w/ succimer Infant born when maternal BLL = 36 mcg/dl
Cord blood BLL 54.5 mcg/dl
Infant BLL 59 mc /dl
Infant BLL 62 mcg/dl on day 10, Despite chelation w/succimer
At 18 months infant BLL was still 21 mcg/dl
Mothers BLL was 11.3 mcg/dl
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Cord
BLL
54.5
BLL
Mcg/dl
10 mcg/dl = Cut Off for excessive exposure
Date
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and Cord
BLLLOW < 3 mcg/dl
MED 6-7 mcg/dl
HIGH > 10 mcg/dl
(Needleman 1991)
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Elevated BLL pregnancy > -
BLL 10 mcg/dL1990 estimate 4.4 million women ofchildbearing age
13% (400,000) pregnant women
1% with BLL >15 mcg/dL
2005 BLL in women of child-bearing age: 1.78
mcg/dL
or oo ec ne s nce 1999 study in Quebec: cord BLL = 1.5 mcg/dL
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Screening of Pregnant Women?
No controlled clinical trials
Low prevalence of BLL > 15 mcg/dl
Fair evidence that BLL > 15 mcg/dl Elevated
BP NO evidence for other adverse events in
pregnancy
THUS no data to support for or againstscreening
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Blood Lead and Menopause
during
menopause
into plasma.
Am J Epidem. 2004, 160:901-911.
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Lead Toxicity in Elderly
onger ura on o ea exposur e Higher bone lead levels than younger individuals
function
Osteo orosis releases lead into the blood BLL associated with toxicity unclear
BUT, even low BLL may be associated with
Hypertension Renal impairment
Co nitive disorders
Atherosclerosis
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Adult Lead Toxicity
Adults who might be at risk for lead toxicity
Judicious use of testing blood lead levels.
,
prevent low-level Pb toxicity such as hypertension
or even cognitive decline.
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Beethoven Had Lead Poisoning
lead salts used
after paracentisis
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Beethovens Lead Poisoning
Chronic lead exposure and absorption
Elevated lead levels in skull bone fragments
x o ea po son ng s ar e n a o escence
Change of personality
Both persisted throughout his adult life
poisoning. There is no solid evidence that lead poisoningwas a cause of Beethoven's deafness.
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Key Points: Lead Toxicity y
Low level and chronic: Neurodevelopmental delay
, , ,
Adult
, ,
High level and acute: anemia, GI, renal, CNS
Pregnant women: eclampsia
Fetus and newborn: CNS developmental delay
Geriatric: Dementia
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Centers for Disease Control and Prevention
Iowa Department of Public Health Lead Exposure in Children: Prevention, Detection, and
Management, PEDIATRICS Vol. 116 No. 4 October 2005, pp.
1036-1046 on-line article
Nash etal: Am J E idem. 2004 160:901-911 Needleman HL, Bellinger D: Health effects of low level
exposure to lead. Ann Publ Hlth. 1991, 12:111-140.
, , .
caused by use of health supplements presenting as acute
abdominal pain during pregnancy. Obstet Gynecol. 2009;114
ar : - .
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Resources, continued Shih RA etal: Environmental lead ex osure and co nitive
function in community-dwelling older
adults. Neurology 2006; 67:1556-1562
. .
Stewart WF etal: Past adult lead exposure is linked to
neurodegeneration measured by brain MRI. Neurology 2006;66:1476-1484
http://www.neurology.org/cgi/content/full/66/10/1476
. , -
Balser B: Lead Poisoning. Lead Education and Abatement
Design Group (LEAD) http://www.lead.org.au/bblp/sld001.htm
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