Prevention and Management Travis Hobart, MD, MPH CNY Lead Poisoning - - PowerPoint PPT Presentation

Lead Toxicity: Prevention and Management

CNY Lead Poisoning Resource Center CNY Children’s Environmental Health Center Travis Hobart, MD, MPH Medical Director

Objectives

• Identify sources of lead exposure in the environment
• Describe acute and chronic effects of lead exposure
• Describe prevention and treatment of lead exposure
• Describe the long term benefits of preventing exposure

20 month old child in Broome County

• BLL of 45.9 mcg/dL (venous)
• Prior BLL (fingerstick) was < 3.3 mcg/dL at age 10 months
• Exterior trim of windows was chipping
• They own the home and were certified lead safe to fix the issues by

themselves

The Problem

https://www.cdc.gov/nceh/lead/

https://www.cdc.gov/nceh/lead/

https://www.cdc.gov/nceh/lead/

Source: Prevention of Childhood Lead Toxicity, Pediatrics, 2017

Progress Has Been Made Over Time

Definition of “Elevated” Has Changed Over Time

https://www.atsdr.cdc.gov/csem/csem.asp?csem=34&po=8

Challenges in in New York State

Built before 1979: Norwich 91.4% Chenango County 68.2%

(American Fact Finder, US Census Bureau, Selected Housing Characteristics:2013-2017 American Community Survey 5-Year Estimates)

Screening

NYS Lead Testing and Assessment

• Test all children for lead poisoning at age 1 and again

at age 2

• Assess all children age 6 months to 6 years at each

well child check for risk of lead exposure using the Risk Assessment Questionnaire. Test children found to be at high risk.

• Educate all families on lead poisoning prevention

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Public Health Law Changes - 2019

• Requires health care providers to:
• Confirm any capillary blood lead specimens ≥ 5 µg/dL with a venous

blood sample and perform risk reduction and nutrition counseling (previously ≥ 10 µg/dL).

• Provide comprehensive follow-up services for all children (<18yo) with

confirmed venous blood lead levels ≥ 5 µg/dL (previously ≥ 15 µg/dL)

• Requires local health departments to:
• Provide care coordination and environmental management for all

children with confirmed venous blood lead levels ≥ 5 µg/dL (previously ≥ 10 µg/dL and ≥ 15 µg/dL, respectively)

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Risk Assessment Questions

Screened by 35 months

Percent of NY children screened

Screened by 17 months

Pathophysiology

Toxicokinetics

Lead Half-life:

• Blood: 28 to 36

days

• Soft tissues: 40

days

• Bone: >25 years

O’Flaherty, E.J. 1993. Physiologically based models for bone-seeking elements. IV. Kinetics of lead disposition in humans.

• Toxicol. Appl. Pharmacol. 118(1):16-29.

Why are kids so vulnerable to lead exposure?

• Hand to mouth behavior
• Higher absorption from gut than adults
• Higher levels in brain tissue than adults
• Developing brain is particularly sensitive

to the effects

Theodore I. Lidsky, Jay S. Schneider; Lead neurotoxicity in children: basic mechanisms and clinical correlates, Brain, Volume 126, Issue 1, 1 January 2003, Pages 5–19, https://doi.org/10.1093/brain/awg014

Systems affected

• Neurologic
• Hematologic
• Renal
• Endocrine
• GI

Staudinger KC, Roth VS. Occupational Lead Exposure. Am Fam Physician. 1998 Feb 15;57(4):719-726.

Effect on Heme Synthesis

aka ALA dehydratase aka free erythrocyte protoporphyrin (FEP) FEP or ZnPP can be measured in the blood and indicate subacute or chronic lead levels approximately above 30 mcg/dL (ZnPP)

3.5 year old boy presents to PCP

• Significant autism spectrum disorder
• History of pica noted at home, including eating paint chips
• Family had just recently moved there, and were able to remediate

indoor of home after chelation

• Exterior hazards were not remediated right away but were done in

spring of 2017.

64 mcg/dL

Pregnancy and Lactation

15 month old girl

• Tested at WCC with BLL 70 mcg/dL
• Brother, aged 3 years, also tested and found to have BLL 45 mcg/dL
• Mom was pregnant in first trimester, so she was tested
• BLL 30 mcg/dL
• Family doing major home renovations with kids present
• Sadly, mom had a spontaneous abortion shortly thereafter

https://www.cdc.gov/nceh/lead/publications/leadandpregnancy2010.pdf

Pathophysiology in pregnancy

Pregnancy

• ACOG and CDC recommend screening for risk factors
• Blood testing of high risk women
• Pica
• Home renovations
• Occupational exposure
• Family member with high lead level
• Refugee or immigrant status
• Spices or cosmetics from abroad
• Lead easily crosses placenta

Adverse effects

• Maternal hypertension and maybe pre-eclampsia
• Impaired fetal growth
• Spontaneous abortion

Effects on the infant

• Impaired infant growth
• Impaired neurodevelopment
• Effects appear to be independent of post-natal exposure
• Some studies show the strongest postnatal effects are at low levels of

exposure

Breastfeeding

• Breastfeeding not recommended when maternal BLL over 40 mcg/dL
• Or if infant has BLL over 5 mcg/dL
• Recommended to pump and dump until below 40 or baby’s level

goes down

• Maternal calcium and vitamin C supplementation have been shown

to decrease lead levels in milk.

Treatment

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Confirmatory and Follow-up Testing (1)

March 11, 2020 36

Confirmatory and Follow-up Testing (2)

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Clinical Lead Exposure Assessment

Chela lation

• Chelating agent binds to lead in the blood forming the

“chelate”

• Allows body to excrete lead more readily
• Expect decreased BLL to about 50% of prior level
• Continue to monitor BLL closely
• BLL will rebound as body burden re-equilibrates to the blood
• Re-treat greater than 80% rebound or if above 45 mcg/dL

3 year old girl with BLL 68 mcg/dL

• Developmentally delayed
• Jan 2014 when initially admitted for chelation, child was in EI

program and had severe pica behavior.

3 year old girl with BLL 68 mcg/dL

• Developmentally delayed
• Jan 2014 When initially admitted for chelation, child was in EI program and

had severe pica behavior.

• Home was remediated (2013) prior to initial chelation when she had lower

BLL (around 20s), when reinspected there were no new exposures identified and paint was intact. Second chelation (2014) leads to reinspection, again. Furnace, ducts, and basement were targeted and lardlord responsible to hire someone to clean them. Family moves (2014).

• Now spends time in grandfather’s apartment, and still at the old home while

waiting for bus to pre-k.

• Remains in new apartment, family says she is not going anywhere else

(2016)

• Level comes down slowly between 2016-2019, in Aug 2019 she is admitted

to ER for abdominal pain, abd xray shows high density flecks, school also showed concern that she was ingesting non-food items.

2.5 year old boy with BLL 74 mcg/dL

• Developmentally delayed, pica behavior
• Home had lots of lead hazards, requiring significant amount of

remediation.

• Bedroom floor of child's room, dust wipe standards exceeded.
• Mom also reported that she catches the child trying to play with parts of the

window.

• Home was worked on by a community funded program in order to

remediate and replace windows. Old leaded windows were not properly removed and were stacked uncovered in the family's backyard (happened between May/June of 2018, where level increased again)

Prevention

Pri rimary Prevention

• There is no “safe” blood lead level
• Children living in poverty and children of color

disproportionately affected

• Education on lead poisoning prevention and available

community resources

• Abatement is the most effective strategy

Report From Pew Trusts in 2017

Intervention for kids born in 2018 Costs Future Benefits Removing lead paint from homes of low income children built before 1960 $2.5 Bil $3.5 Bil Ensuring lead safe renovation $1.4 Bil $4.5 Bil Removing lead pipes from homes $2 Bil $2.7 Bil

Conclusion

• Children are uniquely vulnerable to environmental exposure
• Lead is a potent neurotoxin with irreversible long-term effects
• The most effective strategy is primary prevention
• Investment in healthy housing makes a big difference

How long does it takes to return to “normal” depends on both amount and duration

• f exposure

100 200 300 400 500 600 10 20 30 40 50 60 70 80 90 12/31/2… 1/31/2017 2/28/2017 3/31/2017 4/30/2017 5/31/2017 6/30/2017 7/31/2017 8/31/2017 9/30/2017 10/31/2… 11/30/2… 12/31/2… 1/31/2018 2/28/2018 3/31/2018 4/30/2018 5/31/2018 6/30/2018 7/31/2018 8/31/2018 9/30/2018 10/31/2… 11/30/2… 12/31/2… 1/31/2019

DC Jefferson Co 2016-2019

50 100 150 200 250 300 350 400 450 10 20 30 40 50 60 70 80

3/1/2013 5/1/2013 7/1/2013 9/1/2013 11/1/2013 1/1/2014 3/1/2014 5/1/2014 7/1/2014 9/1/2014 11/1/2014 1/1/2015 3/1/2015 5/1/2015 7/1/2015 9/1/2015 11/1/2015 1/1/2016 3/1/2016 5/1/2016 7/1/2016 9/1/2016 11/1/2016 1/1/2017 3/1/2017 5/1/2017 7/1/2017 9/1/2017 11/1/2017 1/1/2018 3/1/2018 5/1/2018 7/1/2018 9/1/2018 11/1/2018 1/1/2019 3/1/2019 5/1/2019 7/1/2019 9/1/2019 11/1/2019 1/1/2020

LJ Cayuga Co 2013-2020

50 100 150 200 250 300 350 400 450 10 20 30 40 50 60 70 80 3/1/2013 4/1/2013 5/1/2013 6/1/2013 7/1/2013 8/1/2013 9/1/2013 10/1/2013 11/1/2013 12/1/2013 1/1/2014 2/1/2014 3/1/2014 4/1/2014 5/1/2014 6/1/2014 7/1/2014 8/1/2014 9/1/2014 10/1/2014 11/1/2014 12/1/2014 1/1/2015 2/1/2015 3/1/2015 4/1/2015 5/1/2015 6/1/2015 7/1/2015 8/1/2015 9/1/2015

LJ Cayuga Co 2013-2015