Environmental Lead Exposure p

Jerold C. Woodhead, MD Ambulatory Practice Module

What is your opinion?
Anemia is the most common finding in children who have elevated Blood Lead Levels.

1. True 2. False

Blood Lead Level
What blood lead level identifies excessive lead exposure in a child?

1. 1 mcg/dl 2 5 mcg/dl 2. 3. 10 mcg/dl 4. 15 mcg/dl g 5. 25 mg/dl

What is your opinion?
Iowa ranks LOW nationally in % of the child population with elevated BLL.

1. Strongly Agree 2 Agree 2. 3. Neutral 4. Disagree g y Disagree g 5. Strongly

Additional Topics • • • • • What is the 1o source of environmental lead? Wh i Who is most at risk i kf for l lead d poisoning? i i ? 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? ? .

Why Worry About Lead? • Most lead exposed patients are asymptomatic BUT • Lead L di is a N Neurotoxin t i – Disrupts cell migration/cell adhesion during brain de elopment development – Interferes with neurotransmission – Lowers IQ – Behavioral concerns in 10-20% lead exposed children – Cognitive decline in the elderly .

Impact of Lead on Intelligence .

org.Lead & Population IQ Lead Education and Abatement Design Group (LEAD) http://www.au/bblp/sld001.lead.htm .

Blood Lead Levels Over Time 70 60 50 Blood 40 Lead mcg/dl 30 20 Lead level considered diagnostic of excessive lead exposure 10 0 up to 1970 19711974 19751985 19851991 1991 to now .

2% Est.00 890 000 890.700.2% 8.6 27 2.6% 4 4% 4.000 434.000 1.BLL > 10 mcg/dl – US 1976-2000 LEAD REMOVED Interior paint 1960 Exterior paint 1978 Gasoline 1970s-1995 1970s 1995 Mean BLL BLL >=10 µg/dL Prevalence 88.2 .500.7 2.000 1976 1980 1988 1991 1991 1994 1999 2000 14.4% 2. # 13.9 3.

8% 1% .BLL >10 mcg/dl .US 1997-2007 7.

1999 . Environmental Science and Technology 33(22):3942-3947.Thomas etal .

MMWR May 27.513-516 . 2005: 54(20).

Why Worry about Lead in Iowa? • Iowa I ranks k high hi h i in US f for l lead d exposure – >50% of Iowa homes have lead-based paint – 43% built b ilt b before f 1950 • Environmental lead is mostly from housing – Dust contaminated with lead-based paint – All homes built before 1960 have lead-based paint on interior and exterior walls .

Iowa BLL 1997-2008 1500 600 .

Screening R t Rate 7% 19% Low High 55% 23% .

Poorly Maintained Housing .

Other Sources of Lead • Environmental contamination – Gasoline in the past – Battery factory or other lead industry – Water supplies that use lead pipes • Parental job or hobby • Herbs. Herbs medications and cosmetics – India – Mexico • Candy from Mexico • Toys from China and India • In utero exposure .

Lead “Jewelry” From Vending Machine Child swallowed this and developed p abdominal p pain and vomiting and later a seizure. BLL = 123 mcg/dl .

Recent additions --Keychains at Walmart --Pajamas at Children’s Place Stores .

How Should Iowa Respond? • Primary prevention is key – Toxic CNS effects cannot be reversed • Develop local/county lead programs – 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. Medicaid eligible .g.3X risk) .

Screening for lead exposure • Exposure incidence peaks between 18-30 18 30 months • Who should be screened in Iowa? – All children 6 months – 3 years • Why are these children at risk? – Developmental p stage: g Hand-to-mouth behavior – Brain growth and development • What screening g method? – Questionnaire – Routine blood lead levels – Routine anemia screen (Hb or Hct) .

or smelter? Folk remedies.g. cosmetics Immigrant from Mexico or undeveloped country? . candy. recycling plant. or Visit (e.Screening Questions • Do you live in a house built before 1960? – Home. Daycare. grandparents)? • • • • • • • • Chipped pp or p peeling gp paint? Current remodeling? Pica? Sibling or playmate with lead level ≥ 15 mcg/dl? Job or hobby lead-related? Live near battery plant.

Iowa Screening Guidelines .

Action . Environmental History and cleaning. Refer for chelation Hospitalize. Chelation. R t t in Re-test i 1 week.C Ca CDC and d AAP Management of Elevated BLL Blood Lead Level (mcg/dL) <10 10-14 15-19 20 44 20-44 45-69 ≥ 70 Routine screening Education and re-test in 3 months Education and re-test in 1 month. k R Refer f Re-test in 2 days.

• BLL returns 3 days later: 26.How Would You Manage? • 2-year-old boy has a screening blood lead level done by capillary sample.5 mcg/dl • What will you do? .

Management of Elevated Capillary BLL • Obtain a venous sample to repeat BLL – Since contamination of skin with lead is possible – Venous sample allows confirmation that the sample reflects true BLL • Patient results: – – – – Capillary BLL 26.4 mcg/dl Child lives in a new home and plays outside in the dirt P Parents t have h called ll d th the contractor t t .5 mcg/dl Venous BLL 2.

Adult Lead Exposure • Occupational and environmental exposure • Environmental lead exposure before public health measures were introduced • Adults mostly asymptomatic at levels < 25 mcg/dl – Anemia >40 mcg/dl – CNS dysfunction and Renal failure >80 mcg/dl • Low Low-level level Chronic lead toxicity – Hypertension – Cognitive Decline – Atherosclerosis .

2002 Adult BLL ≥ 25 mcg/dl Iowa >20/100 000 >20/100.000 With BLL ≥ 25 mcg/dl .

000 with BLL ≥25 mcg/dl Note decline in rate with improved surveillance ill .2004 Adult BLL ≥25 mcg/dl Iowa 10-19/100.

2007Ad lt BLL ≥25 mcg/dl 2007Adult /dl Back sliding .

What affects Adult BLL? • Continued exposure: p Occupation p or hobbies • Mobilization of stored lead from bones – Pregnancy g y • Hypertension/Toxemia • Spontaneous abortion • Exposes the fetus to possible CNS developmental abnormalities – Lactation – Fractures – Immobilization – Osteoporosis/Menopause .

pain paresthesias.3 mcg/dl / .Prenatal Lead Poisoning • Mother M th used d an h herbal b l preparation ti d during i pregnancy – Lead and Mercury • Abdominal pain. paresthesias anemia during pregnancy – BLL 102 mcg/dl – Chelated for 2 months w/ succimer • Infant born when maternal BLL = 36 mcg/dl – Cord blood BLL 54. Despite chelation w/succimer • At 18 months infant BLL was still 21 mcg/dl – Mother’s BLL was 11.5 mcg/dl – Infant BLL 59 mcg/dl g – Infant BLL 62 mcg/dl on day 10.

2 1/2 Cord BLL 54.BLL: Birth .5 BLL Mcg/dl 10 mcg/dl = Cut Off for excessive exposure Date .

Development and Cord BLL LOW < 3 mcg/dl MED 6-7 mcg/dl HIGH > 10 mcg/dl (Needleman 1991) .

Elevated BLL pregnancy • Decline in BLL >10 10 micro-g/dl micro g/dl since 1990 – BLL ≥10 mcg/dL1990 estimate 4.000) pregnant women – 1% with BLL >15 mcg/dL • 2005 BLL in women of child-bearing age: 1.4 million women of childbearing age – 13% (400.5 mcg/dL .78 mcg/dL • Cord C d bl blood d BLL d declined li d 82% since i 1980 – 1999 study in Quebec: cord BLL = 1.

Screening of Pregnant Women? • No controlled clinical trials • Low prevalence of BLL > 15 mcg/dl • Fair evidence that BLL > 15 mcg/dl Æ Elevated BP • NO evidence for other adverse events in pregnancy • THUS no data to support for or against screening .

Am J Epidem. 160:901-911. .Blood Lead and Menopause Demineralization during menopause releases Pb into plasma. 2004.

even low BLL may be associated with • • • • Hypertension Renal impairment Cognitive g disorders Atherosclerosis .Lead Toxicity in Elderly • L Longer d duration ti of fl lead d exposure • Higher bone lead levels than younger individuals – Bone lead correlates with deterioration of cognitive function • Osteoporosis p releases lead into the blood – BLL associated with toxicity unclear – BUT.

Adult Lead Toxicity • Consider – Adults who might be at risk for lead toxicity – Judicious use of testing blood lead levels. . • In the future future. treatment of osteoporosis may prevent low-level Pb toxicity such as hypertension or even cognitive decline.

Beethoven Had Lead Poisoning Partly related to lead salts used to clean wounds after paracentisis .

There is no solid evidence that lead poisoning was a cause of Beethoven's deafness.Beethoven’s Lead Poisoning • Chronic lead exposure and absorption – Elevated lead levels in skull bone fragments • Sx S of f lead l d poisoning i i started t t di in adolescence d l – Change of personality – Severe abdominal pain – Both persisted throughout his adult life • Rare documented cases of deafness resulting from lead poisoning. .

CNS • Adult – Low level and chronic: BP. anemia vomiting vomiting. CNS • Special populations – Pregnant women: eclampsia – Fetus and newborn: CNS developmental delay y – Geriatric: Dementia . renal. BP atherosclerosis. GI.Key Points: Lead Toxicity • Infancy Infanc and childhood – Low level and chronic: Neurodevelopmental delay – High level and acute: anemia. renal renal. atherosclerosis dementia – High level and acute: anemia.

160:901-911 • Needleman HL. 1036-1046 on-line article • Nash etal: Am J Epidem. . 1991.114 (P t 2):448-50. 116 No. (Part 2) 448 50 . Yankowitz J J. pp. • Shamshirsaz AA AA. 12:111-140. PEDIATRICS Vol. Obstet Gynecol. etal etal. p 2004.Resources • Centers for Disease Control and Prevention – MMWR: Seizures/Death (Blood lead > 70 mcg/dL) • Iowa Department of Public Health • Lead Exposure in Children: Prevention. Detection. Severe lead poisoning caused by use of health supplements presenting as acute abdominal pain during pregnancy. Ann Publ Hlth. 2009. and Management. 4 October 2005. Bellinger D: Health effects of low level exposure to lead.

Resources.au/bblp/sld001. 2000 2000. Neurology 2006.neurology. Neurology 2006. 48: 1501 1501-1506 1506 • Balser B: Lead Poisoning.org/cgi/content/full/67/9/1556 http://www neurology org/cgi/content/full/67/9/1556 • Stewart WF etal: Past adult lead exposure is linked to neurodegeneration measured by brain MRI. Lead Education and Abatement Design g Group p( (LEAD) ) http://www.htm . continued • Shih RA etal: Environmental lead exposure p and cognitive g function in community-dwelling older adults.lead.org/cgi/content/full/66/10/1476 • Vig and Hu: J Am Geriatric Soc Soc. 66:1476-1484 – http://www. 67:1556-1562 – http://www.org.neurology.

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