1. Mini Med School 2012 Dr. Laura H. Finkelstein, MD, FAAP

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

3.  Metal  Soft and flexible  Sweet tasting  Chemically similar to Iron and Calcium

4.  Pottery  Plumbing

5. Cosmetics  Ancient Egypt  Japan  India

6.  Stained glass  Leaded glass (675 AD)  Solder

7.  Lead acid batteries  Invented in 1859  Gasoline  Lead in gasoline known to be toxic in 1920’s

8.  Paint additive  Speeds drying  More durable  Makes white paint more white  Resists moisture, which causes metals to corrode  Toys, Jewelry

9.  Pencil “Lead” is NOT lead!

11.  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

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

14.  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

16.  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.

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)

19.  Primary Prevention  Secondary Interventions  Tertiary Treatments  Medical treatment of dangerously high levels (greater than 45 mcg / dL)  Involves admission to hospital

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%

21.  1970 Clean Air Act Volume 31, Part B, Pages 1-531 (2011) Homeostasis and Toxicology of Non-Essential Metals Edited by Chris M. Wood, Anthony P. Farrell and Colin J. Brauner

22.  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.  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

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!

26.  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  199010 mcg / dL  20125 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 21 st century.  Overall cost of lead-related healthcare in U.S. is estimated at $43.5 billion dollars

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

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

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 21 st Century Challenges, D Lalarque & L Trasande, Pediatrics in Review 2005; 26; 435- 443

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=9 0&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_Kek4B3GQfI M:&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

33. SLIDE 12 http://www.google.com/imgres?q=inhalation+of+lead&um=1&hl=en&qscrl=1&nord=1&rlz=1T4TSHB_enUS298US298&b iw=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:140ved= 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_enUS298 US298&biw=1280&bih=574&tbm=isch&tbnid=SEEgXvFRgmYaKM:&imgrefurl=http://morbidholiday.com/comics/lea d-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