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Lead: information for 2012

Mini Med School 2012 Dr. Laura H. Finkelstein, MD, FAAP. Lead: information for 2012. To review what lead is and where it is found To review what causes lead poisoning and why it is a problem To discuss what government, society and individuals can do to fight this problem. Goals of this talk.

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Lead: information for 2012

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  1. Mini Med School 2012 Dr. Laura H. Finkelstein, MD, FAAP Lead: information for 2012

  2. To review what lead is and where it is found To review what causes lead poisoning and why it is a problem To discuss what government, society and individuals can do to fight this problem Goals of this talk

  3. What is lead? • Metal • Soft and flexible • Sweet tasting • Chemically similar to Iron and Calcium

  4. Lead and society: history of use • Pottery • Plumbing

  5. Cosmetics Ancient Egypt Japan India Lead and society: history of use

  6. Lead and society: history of use • Stained glass • Leaded glass (675 AD) • Solder

  7. Lead and society: history of use • Lead acid batteries • Invented in 1859 • Gasoline • Lead in gasoline known to be toxic in 1920’s

  8. Lead and society: history of use • Paint additive • Speeds drying • More durable • Makes white paint more white • Resists moisture, which causes metals to corrode • Toys, Jewelry

  9. Lead and society: history of use • Pencil “Lead” is NOT lead!

  10. Lead in environment

  11. Lead poisoning: How does it get in? • Ingestion (Eating & Drinking) • Children absorb more from the gut than adults • Mouthing objects with lead in/on them • Food-bourne • Food grown in contaminated soil • Cans with lead solder • Leaded spices (not US)

  12. Prenatal • Inhalation • Lead dust • Air pollution • Absorption • Objects Lead poisoning: How does it get in?

  13. Lead poisoning: How does it get in? Simplified representation Pb in ambient air penetrates indoors Re-entrainment deposition outdoor soil Food (crops) Drinking water deposition to indoor dust Pb paint Auto Pb ingestion of outdoor soil ingestion of indoor dust dietary and drinking water ingestion inhalation Pathways of Pb Exposure - USEPA, November, 2008

  14. Lead poisoning: Why is it bad? • Lead competes with “good ions” (iron, calcium) • Stored in bone • Lasts decades • 70% of lead burden is in bone

  15. Neurologic • Neurobehavioral effects • Effects on cognition and behavior with levels >10 • Prenatal exposure • Persist to adolescence • Hearing loss – high frequency • Poor nerve conduction • Peripheral neuropathy • Encephalopathy Lead poisoning: Why is it bad?

  16. Lead poisoning: Why is it bad? • Blood • Anemia is rarely caused by Pb • Decreased synthesis of Hgb • Short RBC lifespan • Hemolysis (breakage of RBC) • Iron-deficiency • Makes Pb absorption more likely

  17. Renal (kidney) • Lead nephropathy – prolonged high lead exposure • Direct kidney damage • more common in adults • Seen more with HTN, DM, chronic kidney disease • Gastrointestinal • Pb “colic” – vomiting, abdominal pain, constipation • Lead levels >60 • Endocrine & Growth • Decreased Vitamin D levels • Delayed puberty and height in minority girls with minor difference in BLL. Lead poisoning: Why is it bad?

  18. “Toxic” level of lead is decided by CDC • Redefined based on understanding of complications and prevalence in community • Blood lead levels considered toxic (UpToDate 2012) • Prior to 1971 ≥ 60 mcg/dL (2.88 micromol/L) • 1972-1975 ≥ 40 mcg/dL (1.93 micromol/L) • 1975-1985 ≥ 30 mcg/dL (1.45 micromol/L) • 1985-1991 ≥ 25 mcg/dL (1.20 micromol/L) • 1991-2012 ≥ 10 mcg/dL (0.48 micromol/L) • 2010 (newborn infants ) ≥ 5 mcg/dL (0.24 micromol/L) • 2012 ≥ 5 mcg/dL (0.24 micromol/L) Definition of lead poisoning

  19. Primary Prevention • Secondary Interventions • Tertiary Treatments • Medical treatment of dangerously high levels (greater than 45 mcg / dL) • Involves admission to hospital The fight against lead poisoning

  20. 1970 Clean Air Act set standards for lead in gasoline • 90% of lead in air produced by cars • Goal – phase out leaded gas by October 1979 • Achieved for consumers in US by 12/31/95 • Some race cars and commercial vehicles still use leaded gas • Phase out lead paint • 1950 – standard of amount of lead in paint was lowered • In 1978, the U.S. Consumer Product Safety Commission lowered the legal lead content in most residential paint to 0.06% The fight against lead poisoning: Primary prevention - Environmental

  21. The fight against lead poisoning Volume 31, Part B, Pages 1-531 (2011) Homeostasis and Toxicology of Non-Essential MetalsEdited by Chris M. Wood, Anthony P. Farrell and Colin J. Brauner • 1970 Clean Air Act

  22. The fight against lead poisoning • 1930 lead pipes replaced with copper • 1986 Safe Drinking Water Act • Stopped use of lead solder • 1991 EPA established safe level in drinking water at 15 ppb

  23. The fight against lead poisoning: secondary interventions • Screening to identify children with low levels of lead • Routine testing at 12 and 24 months • Questionnaires • Earlier and more frequent testing if risk seen • Education about nutrition and risk factors • Adequate nutrients (iron, calcium, Vitamin D) • Regular timing of meals • Sources of lead in environment

  24. Repeat blood testing • Repeat lead to confirm, check for increasing level • Testing for iron deficiency • Testing of other children in household • Close monitoring of neuro-developmental status and behavior. • Education of families about reducing exposure • Referral to Lead Poisoning Prevention Programs (level >15) • For higher levels (>45) remove child from environment by relocating family to lead-free environment and begin medication treatment • For extremely high levels (>70) admit child emergently to hospital to begin treatment The fight against lead poisoning: secondary interventions: what if lead is found?

  25. Lead-Safe Housing • If you are moving, make sure the residence is certified lead-safe • If your home was built before 1977, get it checked for lead. If lead is present, have chipping and peeling paint professionally removed by a lead abatement specialist, and remove children from home while this is being done. • Good hand-washing before eating and sleeping • Healthy eating habits with recommended amounts of iron • Avoid herbal and folk remedies • Pottery that may have lead glaze should not be used to serve food. If you don’t know, use it for decoration only. • Run water cold for several minutes before collecting it for cooking or drinking. Not all filters remove lead! • Be careful of hobbies and jobs that involve lead. Keep lead dust away from kids! What can families do?

  26. Jobs and hobbies that increase risk • Plumbing, pipe fitting • Lead processing (mining and refineries) • Auto repair • Glass, rubber and plastic manufacturing • Police officers • Steel & construction workers • Battery manufacturers & recyclers • Bridge workers • Firing Range instructors • Glazed pottery making • Target shooting • Lead soldering (electronics) • Painting • Stained glass making • Car or boat repair • Home remodeling • Furniture refinishing • Hunting and fishing • Preparing lead shot • Preparing fishing lures

  27. Rates and severity of lead poisoning have declined • “Normal Level” Thresholds have been decreasing • 1970 40 mcg /dL • 1990 10 mcg / dL • 2012 5 mcg / dL • Health People 2010 Objective to eliminate BLL > 10 was not met • Percent of children with levels > 10 dropped from 88% since 1970’s to <1.2% in the 21st century. • Overall cost of lead-related healthcare in U.S. is estimated at $43.5 billion dollars Where are we now?

  28. http://www.google.com/imgres?q=lead+paint&start=90&um=1&hl=en&sa=N&qscrl=1&nord=1&rlz=1T4TSHB_enUS298US298&biw=1280&bih=574&tbm=isch&tbnid=SEEgXvFRgmYaKM:&imgrefurl=http://morbidholiday.com/comics/lead-paint/&docid=koJmBXmR_fhx7M&imgurl=http://morbidholiday.com/comics/2012-06-08-lead-paint.png&w=780&h=600&ei=mfAfUOKBLqnD0QHl04HoBA&zoom=1http://www.google.com/imgres?q=lead+paint&start=90&um=1&hl=en&sa=N&qscrl=1&nord=1&rlz=1T4TSHB_enUS298US298&biw=1280&bih=574&tbm=isch&tbnid=SEEgXvFRgmYaKM:&imgrefurl=http://morbidholiday.com/comics/lead-paint/&docid=koJmBXmR_fhx7M&imgurl=http://morbidholiday.com/comics/2012-06-08-lead-paint.png&w=780&h=600&ei=mfAfUOKBLqnD0QHl04HoBA&zoom=1 Where are we now?

  29. Questions?

  30. CDC Website http://www.cdc.gov/nceh/lead/ Coalition to End Childhood Lead Poisoning http://www.leadsafe.org/ Baltimore City Health Department Lead Poisoning Program http://www.baltimorehealth.org/lead.html resources

  31. Childhood Lead Poisoning: Clinical manifestations and diagnosis, R Hurwitz & D Lee, UpToDate, 29 May 2012 Childhood Lead Poisoning: Exposure and Prevention, D Lee & RHurwitz, UpToDate, 29 May 2012 Childhood Lead Poisoning: Management, R Hurwitz & D Lee, UpToDate, 5 June 2012 Lead Poisoning: Basics and New Developments, L Chandran & R Cataldo, Pediatrics in Review 2010; 31;399-406 Lead Poisoning: Sucesses and 21st Century Challenges, D Lalarque & L Trasande, Pediatrics in Review 2005; 26; 435-443 References

  32. SLIDE 3 SLIDE 4 http://www.fda.gov/ucm/groups/fdagov-public/documents/image/ucm233717.jpg http://www.romanaqueducts.info/aquasite/foto/lead_gt_Vb.jpg SLIDE 5 http://www.google.com/imgres?num=10&hl=en&biw=1280&bih=574&tbm=isch&tbnid=_75K7zdiMKOzkM:&imgrefurl=http://roadtickle.com/ancient-make-up/&docid=hQf4GnhQAZYF2M&imgurl=http://roadtickle.com/img/miscellaneous/ancient-make-up/cosmetics.jpg&w=476&h=291&ei=t-kfUPf0OMni0QHsxYHwDA&zoom=1&iact=hc&vpx=936&vpy=147&dur=951&hovh=175&hovw=287&tx=118&ty=92&sig=116330191480647850356&page=1&tbnh=90&tbnw=147&start=0&ndsp=21&ved=1t:429,r:6,s:0,i:94 http://www.google.com/imgres?num=10&hl=en&biw=1280&bih=574&tbm=isch&tbnid=R5ZRjX8Tl1b_XM:&imgrefurl=http://content.usatoday.com/communities/sciencefair/post/2010/10/samurai-kids-lead-poisoning-cosmetics/1&docid=thqZWrCGTFHSlM&imgurl=http://i.usatoday.net/communitymanager/_photos/science-fair/2010/10/29/samuraibonex-large.jpg&w=490&h=364&ei=t-kfUPf0OMni0QHsxYHwDA&zoom=1 http://www.trekearth.com/gallery/Asia/India/East/Orissa/Puri/photo375052.htm http://www.google.com/imgres?q=japanese+makeup&um=1&hl=en&qscrl=1&nord=1&rlz=1T4TSHB_enUS298US298&biw=1280&bih=574&tbm=isch&tbnid=Rj_Kek4B3GQfIM:&imgrefurl=http://thegloss.com/beauty/japanese-geisha-maiko-makeup-tools/&docid=iFtrAWgm42BpHM&imgurl=http://thegloss.com/files/2007/10/kyoto_japan_geisha200.jpg&w=200&h=229&ei=XewfULnQOqWP7AHkyIDYAg&zoom=1 SLIDE 6 http://www.squidoo.com/lead_poision_at_home?utm_source=google&utm_medium=imgres&utm_campaign=framebuster http://en.wikipedia.org/wiki/File:S%C3%BCddeutscher_Glasmaler_001.jpg SLIDE 7 http://www.earthyreport.com/site/worldwide-phase-out-of-leaded-gasoline/ http://id108719093.trustpass.alibaba.com/product/115860630101552681/N100_Dry_Charged_Automotive_Car_Battery.html SLIDE 8 http://upload.wikimedia.org/wikipedia/commons/thumb/6/69/LeadPaint1.JPG/220px-LeadPaint1.JPG SLIDE 10 http://www.extension.umn.edu/distribution/horticulture/DG2543.html SLIDE 11 http://www.google.com/imgres?q=lead+paint&um=1&hl=en&sa=N&qscrl=1&nord=1&rlz=1T4TSHB_enUS298US298&biw=1280&bih=574&tbm=isch&tbnid=u2sBFFq7iUxoiM:&imgrefurl=http://findmeacure.com/2008/12/23/10-dangerous-everyday-things-in-your-home/&docid=LKRJk_B_IZe13M&imgurl=http://findmeacure.com/wp-content/uploads/2008/12/edible20lead20paint.jpg&w=604&h=500&ei=z-8fUI8vz4fRAc76gPgO&zoom=1 http://www.google.com/imgres?q=lead+paint&um=1&hl=en&sa=N&qscrl=1&nord=1&rlz=1T4TSHB_enUS298US298&biw=1280&bih=574&tbm=isch&tbnid=a7bC_clLdvgX-M:&imgrefurl=http://thecarpentryway.blogspot.com/2012/02/cap-and-boots-iv.html&docid=Ak1wXb1_IdvvtM&imgurl=http://2.bp.blogspot.com/-SBp3UCt7ZeA/Ty7S0kE7lkI/AAAAAAAAMUM/emMlJXi7UIE/s400/lead_child1.jpg&w=392&h=306&ei=z-8fUI8vz4fRAc76gPgO&zoom=1 http://www.filtersfast.com/blog/wp-content/uploads/2011/11/sharma-obesity-tap-water1.gif Photo references

  33. SLIDE 12 http://www.google.com/imgres?q=inhalation+of+lead&um=1&hl=en&qscrl=1&nord=1&rlz=1T4TSHB_enUS298US298&biw=1280&bih=574&tbm=isch&tbnid=Ed7394uVH8hzdM:&imgrefurl=http://www.ters.com/indoor_air_quality/lead/&docid=mJ0szOdcEY5DgM&imgurl=http://www.ters.com/images/secondary_images/ters_lead_removal_team.jpg&w=225&h=203&ei=rfIfUMzrJqaB0QGnroDQDA&zoom=1&iact=hc&vpx=119&vpy=293&dur=1263&hovh=162&hovw=180&tx=118&ty=106&sig=116330191480647850356&page=2&tbnh=127&tbnw=141&start=21&ndsp=27&ved=1t:429,r:0,s:21,i:140 SLIDE 16 http://health-7.com/Atlas%20of%20Pediatric%20Physical%20Diagnosis/Red%20Blood%20Cell SLIDE 22 http://www.thedailygreen.com/environmental-news/latest/lead-pvc-pipes-47052805 SLIDE 23 http://www.harrisoncountyhealth.com/nursing.htm SLIDE 28 http://www.google.com/imgres?q=lead+paint&start=90&um=1&hl=en&sa=N&qscrl=1&nord=1&rlz=1T4TSHB_enUS298US298&biw=1280&bih=574&tbm=isch&tbnid=SEEgXvFRgmYaKM:&imgrefurl=http://morbidholiday.com/comics/lead-paint/&docid=koJmBXmR_fhx7M&imgurl=http://morbidholiday.com/comics/2012-06-08-lead-paint.png&w=780&h=600&ei=mfAfUOKBLqnD0QHl04HoBA&zoom=1 SLIDE 29 http://www.nyc.gov/html/doh/pregnancy/html/after/healthy-hom-lead.shtml Photo references

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