1. Lead Exposure & Breastfeeding
Dr. Mary Jean Brown, ScD, RN
Harvard Chan School of Public Health

2. Adverse Health Effects of Lead
Death
Colic
Decreased hemoglobin synthesis
Developmental toxicity
Decreased IQ
Decreased hearing, growth

3. Major Lead Exposure Pathways of Mother to Infant

4. Risk Factors for Elevated Blood Lead Levels in Pregnant/Lactating Women
Living near or working in a source of lead
lead mines, smelters, battery recycling
Recent emigration from a country with high ambient lead
Use of lead-glazed ceramics or imported pottery
Lead-contaminated drinking water
Use of complementary / alternative medicines, herbs or therapies
Use of imported cosmetics or certain food products

5. Risk Factors…continued
Take home exposures
High-risk hobbies or recreational activities
Renovating or remodeling older homes
Pica behavior
History of previous lead exposure, evidence of elevated BLL
Living with in home or close environment with someone identified with a high lead level

6. Lead in Breast Milk
Calcium administered during pregnancy and early postpartum may constitute a practical intervention to prevent transient skeletal loss.
Ettinger et al. Nutrition Journal 2014
Breast milk lead accounted for 12% of the variance of infant blood lead levels while maternal blood lead accounted for 30%.
Even among a population of women with relatively high lifetime exposure to lead, levels of lead in breast milk are low, influenced both by current lead exposure and by redistribution of bone lead accumulated from past environmental exposures.
Ettinger et al. EHP 2004

8. Key Considerations for Breastfeeding
Human breast milk is specific to the needs of the infant and is the most complete and ideal source for infant nourishment in the first year of life.

9. Initiation of Breastfeeding
Key Recommendations for
Initiation of Breastfeeding
• Measurement of levels of lead in breast milk is not recommended.
• Mothers with BLLs <40 μg/dL should breastfeed.
• Mothers with confirmed BLLs ≥40 μg/dL should begin breastfeeding when their blood lead levels drop below 40 μg/dL. Until then, they should pump and discard their breast milk.
These recommendations are not appropriate in countries where infant mortality from infectious diseases is high. World Health Organization Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality 2000

10. Key Recommendations …continued
• Breastfeeding should continue for all infants with BLLs below 5 μg/dL.
• Infants born to mothers with BLL ≥5 μg/dL can continue to breastfeed unless there are indications that the breast milk is contributing to elevating BLLs.
• For infants whose blood lead levels are rising or failing to decline by 5 μg/dL or more, environmental and other sources of lead exposure should be evaluated. If no external source is identified, and maternal BLLs are >20 μg/dL and infant BLL ≥5 μg/dL, then breast milk should be suspected as the source, and temporary interruption of breastfeeding until maternal blood lead levels decline should be considered.

11. Continuation of Breastfeeding
Key Recommendations for
Continuation of Breastfeeding
• Breastfeeding should continue for all infants with BLLs below 5 μg/dL.
• Infants born to mothers with BLL ≥5 μg/dL can continue to breastfeed unless there are indications that the breast milk is contributing to elevating BLLs.
• For infants whose blood lead levels are rising or failing to decline by 5 μg/dL or more, environmental and other sources of lead exposure should be evaluated. If no external source is identified, and maternal BLLs are >20 μg/dL and infant BLL ≥5 μg/dL, then breast milk should be suspected as the source, and temporary interruption of breastfeeding until maternal blood lead levels decline should be considered.

12. Use of Reconstituted Infant Formula
Key Recommendations for
Use of Reconstituted Infant Formula
Infant formula requiring reconstitution should be made only with water from the cold water tap.
Flush the tap for at least 3 minutes before use and then heat the water or use bottled or filtered tap water known to be free of lead.

13. x Nutritional Recommendations
Pregnant and lactating women with a current or past BLL ≥5 μg/dL should be assessed for the adequacy of their diet and provided with prenatal vitamins and nutritional advice emphasizing calcium and iron.
Dietary calcium intake of 2,000 milligrams
Women with anemia (defined in pregnancy as a hemoglobin level <11 g/dL in the first trimester and third trimester and <10.5 g/dL in the second trimester), require higher dosing (Institute of Medicine 1990).
60 to 120 mg of iron daily in divided doses
reduce to 30 mg once anemia is corrected
Obstetrical providers should advise pregnant women against using herbal medicines
Pregnant and lactating women with a current or past BLL ≥5 μg/dL should be assessed for the adequacy of their diet and provided with prenatal vitamins and nutritional advice emphasizing calcium and iron intake.
A balanced diet with a dietary calcium intake of 2,000 milligrams daily should be maintained, either through diet and/or by supplementation
Additionally, iron status should be evaluated and supplementation provided to correct or
prevent any iron deficiency
Women with anemia (defined in pregnancy as a hemoglobin level <11 g/dL in the first trimester and third trimester and <10.5 g/dL in the second trimester), requires higher dosing (Institute of Medicine 1990).
Generally, pregnant women with iron deficiency anemia should be prescribed 60 to 120 mg of iron daily in divided doses. Dosage can be reduced to 30 mg daily once anemia is corrected. Women receiving supplemental iron or calcium should be encouraged to split the dose, taking no more than 500 mg of calcium or 60 mg of iron at one time, as only small amounts of these nutrients can be absorbed at any one time.
Obstetrical providers should advise pregnant women should not use herbal medicines, since there is no evidence of their safety and some are known to be lead-contaminated. x

14. Frequency of Follow-up Testing
Assess Risk for Infant Lead Exposure from Maternal Breast Milk
BLL
5-19 µg/dl
Every 3 months, per guidelines for adult blood lead testing unless infant blood lead levels are rising or fail to decline.
BLL
20-39 µg/dl
2 weeks postpartum and then at 1- to 3-month intervals if levels are decreasing and the magnitude of trend in infant BLLs.
BLL
>40µg/dl
Within 24 hours postpartum and then at frequent intervals depending on clinical interventions and trend in BLLs. Consultation with a clinician experienced in the management of lead poisoning is advised.

16. Thank You

17. References
Reserving the use of chelating agents for later in pregnancy is consistent with the general concern about the use of unusual drugs during the period of organogenesis
When chelation is being considered, it should be performed in an inpatient setting only with close monitoring of the patient and in consultation with a physician with expertise in the field of lead chelation therapy.