Document 82oQEbowBKoxJBnMoNa0RoqbK

5HJbs!A.L /liv x o. Lead poisoning in childhood--co?nprehensive management and prevention *' .A symposium was held at Happy HUb Hospital in Ballimon on April 34, 1967, to soil attention to the need {or a eooperativs timmuniiy approach to the mini, environmental, and psychological aspects of the problems of children with lead intoxication. Comprehensive cere is just as urgent for the asymptomatic child with an increased body burden of lead as it is for the child with manifest acute plumbism. While chelation therapy for the acute toxic episodes of chronic lead poisoning ii deservedly . emphasised, hospitalisation in a chronic disease facility which has a positive program of child and family rehabilitation serves an important role in the total care of the * affected child. Experience in Baltimore and other targe cities has shown that coordinated and sustained efforts by health departments, pediatricians, medical social workers, and child guidance workers are essential for an effective program for the prevention and treatment of childhood lead intoxication. - it.;*;..". J. Julian Chisolm, Jrn MD^# and Eugene Kaplan, MJ>. BALTIMORE, MD, .. ..:v - / .. / r.\ * * **'. From thi Departments of Pediatrics of.the # Johns Hopkins Medical School, Baltimore City Hospitals, Sinai Hospital of Baltimore, Inc., and Happy Hills Hospital, Jnc. This work was supported in part by United States Public Health Service Grant Ho. Q UI00399 from the National Center for Urban * and Industrial Health. *AAirfit fat reprirtt: Roliimere CUy Hospitals, \ 4940 Eastern Ac*., Baltimore, Mi, 21224. TIa paper snmmnriset the cxeurs end contributions presented at the Matte Hair Symposium ***** user*1 partuiffenti here luted. St. Carrie due, M.D., _ ... imstrmeter i Pedixtries. Johns ffopksnt UntcerttSt School at Medicine; Anittorxt Sfedirel Director, Happy flaw Hospital, tne. Randolph K. Byert, M.D.. Associate _ Clinical Professor el 'Pediatries, lintcard Medical Scneels in Neurology, Children's Afcdieal Center, Batten, Alois. /. Ju'ien Chisolm, Jr., M.D., A neeinie Protestor / PedLiirici, fohnt Hotkins Unirertite School of Medicines A:**ciotg Chief Pediatrician, Baltimore Cite Hoipi*eit, Static R-ttoopotl, M.S.W.. A.C,W,2 Director, Deportment of Medical Social Work, , Baltimore Cite ffetpiteh. Marcia M. Ceefier, M.D., Aftoeist* Protestor of Mentoi Hygiene.^ fohnt Hopbine University School of Hygiene and Public Health. Eugene Kaplan, M.D., .41totints Professor of Pediatrics, Johns Hopkins University School of Sfedieine: Medieot Director, floppy fidlt Hospitals Pediatrieian*in*Chief, Sinai Hmpitcl of BnPimore, * Reginald S. Laurie, M.D., Projector of Peditiue Psychiatry, George University `Sekoot of Atedit '.me; Director, Deportment ef Psychiatry, Children's ilnipitr.f, Weshineton, D. C. MetthstO Toubeek, Sc.D., Deputy Commissioner of Health, ' Baltimore City Health Deportment VaL 7S, Ho.' 6, pp. 943.950 Lead poisonino in the young-child is a chronic disease. It. results from the im pact upon the urban slum child, in particu lar, of a variety of causative factors--pica and environmental exposure to lead, cultural and behavioral patterns of parents, and cer tain aspects of lead metabolism. Current knowledge with respect to each of these factors, although imperfect and limited, is sufficient to provide the basis for an effective approach to the problem. CAUSATIVE FACTORS Pica. Centuries ago, pica was the Latin word for magpie, a bird of voracious and in discriminate appetite. Today the term pica denotes the habitual, purposeful, and com"pulsive search for and ingestion of such un natural food substances as clay, plaster, ashes, laundry starch, string, putty, paint chips, paper (especially newspaper), dirt, crayons, M L I 001363 N 3858 Number 6 t *b v I. `cigarette butts, yarn, and matches. Although the list is long and varied, many children and adults with pica tend to be highly selec tive: Each exhibits a craving for only one (or very few) of the above items. Pica had been known to medicine since the time of Galen. Its distribution is worldwide. Incidence in the general population increases during times of stress. Historically, it seems to be related mainly to the relative availability of a diet . adequate both in quantity and quality to the social group as a whole. Women (especially pregnant women) and young children arc most vulnerable to pica. Rural groups arc. affected more often than urban groups.**lT* Lourie and his associates19*1T could find no evidence that any nutritional deficiency . was etiologicaliy related to pica among urban children in Washington, D. C. Preliminary studies suggest that pica in large cities of the United States is most prevalent among fam. ffies--particularly Negroes--recently arrived fromthe rural South. Lourie postulated that such families respond to the stress of their social and economic deprivation in their tra ditional rural behavior patterns, one of which is clay-eating among women. After 3 or 4 generations as urban dwellers and with im proved social and economic security, rural behavior patterns including pica are largely dropped. The child. Infants arc apparently born with differing innate levels of oral activity. During the first 12 months of life, this takes the fonn of mouthing--but not ingesting-- almost anything the infant can place in his mouth. For reasons unknown, children be tween 12 and 18 months of age may begin to ingest foreign materials as an extension of normal mouthing activity. As many as 50 per cent of children carefully studied in both middle class and poverty groups habitually and selectively ingest objects other than food. Between 3 and 5 years of age, this behavior . tends to disappear. During these years, the child may indoctrinate his younger siblings / to the same activity. *Th* number* (uidc the reider to the use of the / Selected SiSUogrmpbr t the cod of the erticle. They in / - no* the asual "refenaeo numbers" of this Jouuuu Interaction of child and parcnt(s)--the emotional climate. 'Hie interaction of child and mother is often a critical determinant of pica activity. As many as 50 per cent of mothers of children with pica may also have pica themselves. A**child's. high level of oral activity may be reinforced by a mother with similar oral interest Thus, while a bottle or pacifier is offered the fussy child at first, later the mother may substitute the clay or laun dry starch that she habitually ingests. The pattern of relieving the child's anxiety by oral activity may become fixed in this man ner and may later continue as an aggressive form of behavior: "If you don't let me go . out to play, I'll cat paint."' Anxiety in the child for which oral grati fication may serve a relieving function is often a response to an absent or a poorly functioning mother. She may be absent in order to earn a living outside the home, and there may be no father to share the domestic responsibilities. She may be hospitalized by . illness or repetitive childbirths. She may be overwhelmed by too many children to care for and thus be deficient in her caring role for the toddler. Indeed, the onset of pica in the toddler often coincides with the arrival ' of the next infant Emotional difficulties in the mother often accompany a child, with pica. Maternal dependency is the most com mon pattern observed: Such mothers have a life history of despair, passivity, and inactiv ity except in crisis. In such a family, children with plumbism may escape early detection and appear for health care only when sei zures or coma demand urgent intervention. Another pattern encountered is the mother who is not aware of the child's pica. This may reflect a basic ignorance that ingestion of these materials could be harmful, or she may be absent from the home for much of the day and not realize that the persons who care for her cliild allow or support his pica activity. In a small number of families, the __ inadequacy of the maternal role results from the mother's own gross intellectual or psychi atric handicaps. To sum up, the symptom of pica is most likely to occur in children with a high level of mouth activity whose oral N L 1 00136,5 relief of anxiety is reinforced by cultural paper. Common-, exterior sources are- doceb patterns and <o whom the mothering neces frames, fences, porches, and houscwaBL...'; sary to stop it is unavaiiablc for a variety There is increasing concern over the prob* * of reasons. When such a child is exposed Icm of environmental pollution of ail sorts. to hazardous environmental sources of lead, Much of the controversy with respect to h--d the likelihood of plumbism is indeed gRatMtU.ST.U was raised by Pattcxsoa, who inferred that , the body-lead burden in urban dwellers may Environment. The vast majority of cases ' be 100 times greater than the burden would of plumbum in young children in the United be under ideal but primitive living conditions. States today are recognized in those who live This difference, he surmised, is due u* the in old, deteriorating urban housing. The in* continuing accumulation of lead waster la tenor woodwork, painted wallpaper, and . . urban areas from lead alkyls, lead arsenate, painted plaster of houses built prior to 1940 food can solder, paints, alloys, piping, glazing, and still in use may contain layers of lead* and spent ammunition. Atmospheric lead pigment paints which have never been re* pollution is greatest in the urban areas, with moved.* A few small chips of such paint may the chief contribution coming from motor contain 100 mg. or more of lead. (The safe vehicle exhausts.* On the bans of balance ' daily intake of lead is < 0-5 mg.) Recent - 'Studies, atmospheric lead pollution, even in studies in Baltimore reveal that~50 to 70 urban areas, has not yet reached toxic levels per cent of old houses in selected slum areas ' for the general population.14 contain dangerous quantities of flaking lead- Metabolism of lead. Lead intoxication.re pigments on the painted interior surfaces.** sults from chronic increased ingestion of leatL The clear relationship between childhood This is so because inorganic lead compounds plumbum and old urban housing is shown are poorly absorbed into the body, retained in Table I.* Studies indicate that a com lead is stored largely in bone, and aft ex* parable situation exists in many large cities . ccssivc body-lead burden is only very slowly of the continental United States. It seems' excreted. It follows that repetitive ingestion likely that small towns and rural areas may (or inhalation) of small amounts of lead is also contain children wth pica who dwell in , usually far more dangerous than a single dilapidated old houses; nevertheless,4 plumb* massive exposure. The meticulous long-term . ism is infrequently recognized outside of balance studies of Kehoe14 in human adult large cities. The usual interior locations of volunteers indicate that the average adult leaded paints chewed by poisoned children ' in the United States today ingests about 0.3 are windowsills and painted'plaster and wall* mg. Pb daily in food and beverage, and in .urban areas currently hasa respiratory intake of~0.03 to 0.04 mg. Pb daily. Of this total Table I. Environmental exposure of young children to lead in new and old urban housing*, exposure, approximately 40 to 50 /ig Pb Is absorbed into the body and promptly ex* . ercted by urinary and biliary tracts so that - no net retention of lead results. Such Hnor* Location of homo Old housing New housing project No. of children studied 801 No. with abnormal No. with urincf plumbum 216 38 (4.7%) (27%) 105 ` 3 0 mal" lead exposure is associated with a con* centration in blood of 15 to 40 jig Pb per 100 Cm. whole blood in both children and adults. As yet, no untoward efTcct of this "normal" exposure has been demonstrated. As mean daily lead ingestion increases be* *Adapted (ram the data o( Griffis. R. C., Sunshine. I., Ntw9l, V. A., l al.i Environmental factor* u childhood lead pooaalaf, J. A. M. A. U7.-70J, 1964. and bared upon a ptorpcctMO homo rorvey of prmchoot chSdrca in Cleveland, Ohio. tCoacaaumlioa of both lead and coproporphyria Inertand. yond 0.5 mg. Pb, the entire load cannot be excreted., so that the accumulation of an excessive body-lead burden begins and will increase progressively as long as abnormal HJ'L I 001363 ...Its" . 1966 door 3rob- sorts. : lead I that s may .vould . itions. ; .0 the" tcsin- ;nalCj . zzing, 3 lead' , \vith motorilancc /cn in levels . * '* .on rc- : lead, pounds trained an ex- slowly gestion lead is . single . . . .g-tcrm adult . o adult :out 0.3 and in/. - intake / is total j Pb is otly ex- 50 that h "nor- i a con- ?b per ren and of this -.strated. ascs bc- cannot on of-an i and will onormal Number 6 jiouvautg_ at a . i->. * ' ' ingestion continues. Comparable balance * data, for young children are not available; ' nevertheless, it is blatantly obvious that re petitive ingestion of paint chips containing 50 to 100 mg. Pb per few small chips con stitutes. truly massive exposure. Studies in human adult volunteers and in dogs indicate that once excessive intake of lead is stopped, it takes at*least twice as Tong to excrete the excessive body burden of lead as it did to accumulate it. For example, If a child with pica ingesb lead over a 2 year period (from 1 to 3 years of age), it will require at least ' 4 years (or until 7 years of age) to excrete * the load by normal physiologic mecha. nisim.*' * ** * The biosynthesis of heme is exquisitely sensitive to the toxic effects of lead.1* In creased excretion of the heme precursors; - coproporphyrin and 5-aminolevulinic acid, '. in the urine, is virtually always found prior ; to the onset of clinical symptoms. The quali- \ tative urinary coproporphyrin test (UCP)4 -is wdl suited for clinic and emergency room . V use for the rapid presumptive diagnosis of manifest or incipient acute plumbism.'This . test can be performed in 5 minutes and ' should be available in all metropolitan hospitals serving high-risk urban areas. When - blood-lead concentration exceeds 80 ftg Pb . - per 10Q Gm. whole blood in a toddler ac tively ingesting lead, the UCP test is strongly positive; but at lesser concentrations of lead . in blood, this qualitative test is not sufficiently 'sensitive or discriminating, so that . its usefulness as a screening test for the early V detection of the child with asymptomatic in creased lead absorption is quite limited. Detection of fiuorocytcs (erythrocytes fluo rescent owing to increased content of proto* porphyrin) does not distinguish between plumbism and iron deficiency anemia and requires specially skilled technicians; never theless, the rapidity and simplicity of the basic technique make it attractive as a screening technique where a skilled techni cian can be found.2* In industry, serial mea surement-of 8-aminolcvulinic acid (ALA) in *' urine provides one of the best means of monitoring occupational lead exposure.TM The . - ... - V recent development by Davis2 ofa sunpGEed .technique employing commercially prefilled disposable ion-exchange resus. col umns for the estimation of ALA in mine holds great promise: At the momentj^hat-is the best mass-screening technique available. . With it, children* with blood-lead-'coocen^rations > 60'^ Pb per 100 blood can apparently be detected wife a' V.a -r 4. . high degree of accuracy. Fundamentally, the diagnosis of plumbism depends upon the demonstration of an ex cessive body burden of lead.*'14 The most useful and direct index of this is measure ment of blood-lead content Accurate deter minations require specialized techniques and ' proper collection of samples. At the moment, blood-lead analyses are too difficult and time- consuming to permit their widespread use in . mass-screening programs. Byers and Kopitou are developing a technique for measuring - lead in hair and are currently evaluating its suitability as' a screening technique^Urine- ***.; lead -analyses require quantitative 24 hour collections of urine to yield rueful datar so '/that this measure is most useful in durieal research and in the management of hos pitalized cases. The EDTA mobilization test . for lead also requires quantitative collection, of urine. It appears to have its main use in the study of older children suspected of chronic plumbism.4 .. THE DISEASE , Natural course. Uncurbed, pica tends to persist until 3 to 5 years of age: In the brain. damaged child, the habit may persist much longer.** Such protracted abnormal lead in gestion is accompanied clinically by recur rent acute toxic episodes of symptomatic plumbum. For reasons not fully apparent, 80 per cent or more of acute toxic episodes occur during the summer months. Clinical manifestations tend to vary with both the age of the child and magnitude of the ab normal lead ingestion. Encephalopathy is most common in children 15 to 30 months of age, while intoxication without encephalop athy in this age range usually presents as some form of hyperirri table or aggressive be- i : N'L I - 001366 *r 'I I <* *.. navior.disturbance. Associated iron deficiency - . . V :.' .' ? .'/: anemia,js. vitually. always present. Careful ; Y.,;-\. '7 ^questioning;usually reveals delay or reversal '. verbal maturation and loss of recently ac- ^`j/'j'-V v motor skills..Vomitinjj and decreased interest m play arc especially ominous signs, ';v. they may portend .incipient enccphalop-." `A* `A* preschool child grows older,' tqxfe episodes tend; to be less severe.-^, /yj'Thus the 2 to 5-ycar-old child with unrcccig- V .'.;:<;>.<Y-;v.'->*.'./*v hfitizvne/d} npllnummkbfucmm mmaty present twuiittkh a mcohn*. \7-'4 : vulsive disorder (without features of en-v ' A: t ' ..r/J/ccphatopathy and not distinguishable from' .... " .idiopathic epilepsy), chronic impulsive, ag- . gressive hyperkinetic behavior disorder, or mental retardation. Uncommon syndromes ' include progressive loss of mental function .simulating degenerative cerebral diseases, - peripheral neuropathy or bouts of acute crampy abdominal pain usually attended by ' vomiting, constipation and pain and tender* ness in trunk and proximal girdle muscles.**4 Sequelae. Permanent central nervous sys-t test injury and latc-onset renal insufficiency have been reported to follow the plumbum of early childhood.1* * At least 25 per cent of -. : . the survivors of acute encephalopathy sustain ! . \ severe permanent brain damage.* Whether children without overt encephalopathy sus tain significant CNS injury as.a*result of is plumbism in early childhood is not clear. Although the usual psychometric tests and performance in school indicate deficiencies in comparison with norms derived from more privileged groups of children, it has not been shown that they differ greatly from other underprivileged children not known to have had plumbism who also reside in deprived urban areas. In a long-term, follow-up study of chOdHood plumbism in Australia, Hender son found that 94 of 352 patients had died of chronic nephritis, 15 to 40 years after the initial intoxication.* Onset of renal insuffi ciency began during or after adolescence. Similar work in the United States has not revealed any link between childhood plumb ism and chronic renal insufficiency. This and other evidence suggests that lead nephrop athy may be a sequel limited to very pro tracted childhood plumbum. 1 ** *-? Byers and. othersJ haver delineated-. -1 Vl- ; .''j1 , .the natureof the CNS injury which. fotfowa-y* y*Hi early childhood'. lead poisoning,1' resulting from lead docs not diiTer from-that. -V .which.follows any- diffuse cerebral:.injury1. -'-`=7 V'*: sustained, during,"early .childhood (ek .cephalitis, meningitis, trauma). In ipmoarV: **i*''$j!* blindness: Such a;.'result. is bccoming:,&-:^K*-.vJ crcasingiy tare. Subtle neurologic deficits are ' the more common.outcome, such as laekof' ' ' sensory perception and perseveration despite . I.Q. scores of 80 to 100 or better on the ' Stanford-Binet test. Form and proportion are distorted. The affected child tends to break a drawing down into its components rather than to recognize the design as a whole, integrated unit. Such children also perseverate: For example, if you teach the child that 5 x 5 is 25 and then ask him what * 4 x 3 is, the child says 25. If, on the. other hand, you ask him-quite apart from the first ~ question (5 x 5) what 4 x 3 is, he may be . / ' able to say 12. Once he learns a correct answer, he repeats it even when the question .is changed. The unwitting teacher (or . mother) may conclude that such a child is insolent, whereupon she will punish him and so reinforce and aggravate the behavioral problems often present in such children*They also have short attention spans and are easily distracted. Although it is difficult to deter mine how much is due to . organic brain j damage and how much represents response to environment, many lead-poisoned children develop hostile, aggressive, and destructive behavior patterns which in turn may pre cipitate exclusion from school and the de- ., mand for institutionalization. Such behavior as well as convulsions may abate as puberty approaches, but intellectual deficits persist Early recognition-mass screening. A sys tematic program is essential in each com munity for early detection of the high-risk toddler, the high-risk mother,' and the high- risk dwelling. The program should be imple mented throughout the year, but should be post intensive during the spring and sum- P ill iiii^!|ijf;i NL I 00136 it "/ ' *vV;':. jaUbi-.J .u T i the v'-` J:ijdty;v; that.:.- :njury:';|-.v.,y;';.% .. Cttv most-;. 'v`;V-:;r> i*' xaa months^ For early recognition,. eiTorts^^' tie confirmed by labocatory tests^tbe**dSk^'t'^! should be concentrated on children 12 to .'? feajftidfra'tinnt^n forMood-l'-M Ai*&&L'i *r?r -7 js-.cx-; v; *, and-vV-jv*Ki:& ..s are : .ck of espitcii the ortion ids to anents- as a v also .h the what . other ` -.e first nay be correct j cation cr (or child is inland avioral .:. They c easily dctcrc brain esponse children :mctive ay predic dcchavior puberty ersist. A sys la com:gh-risk :c higha implc.ould be nd sum- . v'.-V ' jiv'ccsmonaicadly- feasible, but requires . the * V-plumbism wci^'st^y admohiih^ notcto.4;' facilities of an analytical laboratory, which* let their children cat lead paint. Onl&thosc: .,x.is the responsibility of the local health de-. . ; . children .with 'acute > lead encephalopathy `'.partment. The analysis of lead in hair by'- were admitted to the hospital, and, follow atomic absorption spectrophotometry*4 and* ing a brief course of chdation therapy, they- : . fluorescent erythrocyte1* techniques warrant ' were discharged to the same leaded environ further evaluation to determine their suita ment with the same parental admonition. bility for mass screening. Each abnormal test In the light of current knowledge, the inade " result calls for thorough clinical evaluation. quacy of this casual approach should be . 'of the patient and, at the very least, a con- obvious, and its ineffectiveness in preventing . firmatory blood-lead determination. severe neurologic scquellae not surprising. In die absence of mass-screening programs, . Today every child with asymptomatic in ' * early recognition is dependent upon the de-, . creased lead absorption should be hospital ' vdopment of interview and observational ized. A team approach to his problem should techniques designed to identify the child include the comprehensive efforts^ of the /' with incipient pica and his dependent,, de- / local health department, physiciaiy medical pressed, overwhelmed, or unaware mother. social worker, and psychologist. For optimal ' . Clinical indications for blood-lead and other' results, a specific course of action can be . laboratory determinations include: (1) pica .. ( outlined during an early conference by- these in the child by history or observation in the , various health personnel. - : clinic waiting area, or evidence of chewing Local health department It should in on windowsills, etc., reported by visiting spect the housing, see that all hazardous ' health nurse; (2) symptoms of plumbum as ' paint is removed, and back this up with . . outlined previously; (3) nutritional anemia, ' penalties on the owner who docs not comply - especially after 12 months of age; (4) aber with local health ordinances. In Baltimore, rant behavior, especially hypcrirritable or paint in housing interiors of more than 1 aggressive behavior in a toddler; (5) de- per cent lead is illegal. The Baltimore City . velopmcntal delay, especially in speech de- Health Department provides free laboratory vdopment. Maternal indications for blood- . service for the analysis of lead in blood, lead ddtermination in the child indude: (1). urine, and environmental samples. A public working mother unable to account satis health nurse evaluates the family, refers all' factorily for her toddler's activities during preschool children for medical examination, her absence; (2) neglect of toddler due to and obtains samples of..paint from multiple arrival of newborn infant; (3) depressed, sites in the home for chemical analysis.1* psychotic, or alcoholic mother; (4) history Similarly, should the family decide to change of pica in mother or in previous children____ 1 dwellings, the new home is alsoinspected of the mother; (5) in short, any evidence of before occupancy. * lack of mothering of a toddler residing in Medical social worker. He works directly a dilapidated prc-World War II house. Since with the parent, helping her deal with the a definitive diagnosis of plumbism can only guilt, hostility, and dependency so often *V J . N L'l 001368 .HijLU,I **' J *Sr : r*' present. ixt-thk-drcuiroUncc. The goal Rofcoroonva&^tJE^taLIf the substitute.constructive parental behavior for'""'1"'"' neverretununy'a' chM with hopelessness^air anger, ami this is often pot-' body-lead burden t a."leaded* sible through a parent's direct participation ~ ' ~ be implemented in good faith, a co: in the areas, of improving the dwelling or / facility is . vital to provide temporary safe seeking a suitable new dwelling for her fanw> ^'reddenee for the affected child- TBfifgfVw- Sy. In this,, and in other activities of social:' ''/the health department, medicalsodk^waiK^ worker and mother, the parent is assisted in er, and child guidance personnel thartfiSiC functioning to her best ability while she is . "they need to initiate remedial lriinn TTfaTi8e'_, J secure in knowing that the child's safety w3T* . child with asymptomatic increased lead'ah- *' definitely be provided for. Hopefully, family behavior can be so modified by externa! sup sorption, such a facility together witht-ap* propriatc amelioration of his home environ *- lit* ports and internal strengthening that the * deleterious factors operating for continuous ; pica activity can be alleviated. In some in ment may prevent the occurrence of overt intoxication. The child recovering from acute .encephalopathy often exhibits behavioral stances, such goals are not realistic and foster . aberrations which his limited parents may be home placement or other protective services ' unable .to cope with at borne: A convalescent must be utilized with court approval in - _ home provides personnel professionally order to insure a child's future safety. . trained to deal with such children. A con Role of child psychologist and psychiatrist. valescent hospital also provides a structured These serve the pediatrician and medical. ' environment in which toddlers may learn social worker in a consultant capacity. In orderly patterns of play and diet--a pattern view of the behavioral aspects of pica, psy ` which many children with plumbum have, chiatric advice may be especially needed in ever known. In addition, an active Child /. instances of severe maternal inadequacy. Psychometric testing early and just prior to Life Program provides the mechanising for /'terminating the habit of pica. Discharge from .' entry into school is needed to assess the the convalescent hospital occurs when esafe /.damage and to facilitate appropriate school new residence is available. Readmissibn from . placement, especially in survivors of enceph- <1. r..: alopathy. In this regard, far better com time to time as indicated can prevent, the recurrence of pica during the times of crisis munication between the school system and in the family. Baltimore is fortunate in hav medical facilities is needed than is often ing a community-supported facility such as ' practiced. -`-Happy Hills Hospital which fulfills these Role of the pediatrician. It is the pedia protective and reconstructive needs of the trician's function to establish the diagnosis child. Periodic follow-up in the outpatient and to assess the severity of intoxication in clinic is continued at least until entry- into ' each case. This, in turn, determines the school or longer in damaged children. supportive medical care and selection of Throughout these preschool years, the med chelating agents required.4*1 He must deter ical social worker and physician encourage * mine the`nature and extent of residual cen the family to enroll the child in nursery tra! nervous system injury sustained so that school programs and assist the parents, of appropriate therapy and .'school placement "minimally brain-damaged children" to find can be selected early. In concert with the the special facilities they need. others he works to modify the emotional climate which initially promoted pica, and he ' must make certain that hazardous lead ex- posure is terminated. Most important, how ever, the pediatrician must accept the final responsibility for seeing that the program PRIMARY PREVENTION OF CHILDHOOD LEAD POISONING Childhood lead poisoning is a preventable disease. An effective program of prevention of management selected in each case is effec tively and continuously implemented. has not yet been evolved for the disadvan taged urban child and family. Such a pro- I HU,1. NL I uw.ii.iiiiiimii .MMii!H"igii..iai 001363 ..a xim ucd 5 to ;nt safe Iv'CS . ark.ime the ab-* ap.onvert rate oral .* be sent ally son:rcd .sin :cm .-.ave .. 'hild . for- y .`rom . safe from '-' s the^" crisis nav al as ' ihese : the tient into iren. medarage arsery .its of ' o find .\ -.table sndon dvan. pro- il-: Ahutf it 'pjL"? .3.' .:: -.fe. r/ -, ; e- . gpun. requires two essential ingredients! a. bb carricd-but____ clor recognition of the pattern of etiologie . in the clone andosT factors, and" a clear commitment of responsi Ec conccnhratcckon children 12 to 1( bility by physician, public health worker, city of age; and. repeated u the family srttutfaoii official, and aroused public. ? warrants, t TE&. etiologie pattern which results in ^ Since the harrahlL eflccts of irreversible had encephalopathy consists of ' in HomejTHave- beem public a triad: the child, the parent, and the place. many yean, many cities have . The child is a toddler with exaggerated oral 'ordnumcesdcatgpetTto eradicate:' . activities. The parent is a mother with in- .* ards to children. Unfortunately, '* * adequate resources to cope with her family's often occurs afler the poisoning oftfechad needs. The place is a neglected slum housing ,and is not always effective. Too often: the unit with lead flakes within reach of a small disadvantaged family will move from one -child's grasp. slum house to another which has. not-been k >Each of these three factors is readily vis- * 'properly screened for lead exposures The ' * ' . : lible to the trained professional and should neighborhoods, where the greatest: number signal appropriate action for early recogni of susceptible children coincide widfc- the tion and effective prevention of further risk" greatest number of substandard- housing to that individual child. However, the re units, may receive spasmodic exhortations or sponsible commitment of these very pro visits from local health units. Such spasmodic. fessionals on behalf of the disadvantaged ex post facto action cannot be caQed^pre- . child and parent is not always forthcoming. ` vention" and will not suffice. * The child's health needs are often provided What families in such neighborhoods re in. municipal well baby clinics where nutri- quire are the imaginative and continuous . ' turn and immunization in the first year of life efforts of health and social action ,tom di are stressed above questions of childhood / rected at parent participation an<feducation. ... v - behavior in the second year and above mater- . Were suds action eoupled, as m-Aantalia," -* ; . ' }nal difficulties in housing and child-rearing. with a strenuous public demand"foe .the yi'For acute illness, the hospital emergency systematic elimination of the cnviitbmnental ''^^room or pediatric clinic may provide satis" ' .factory symptom-related diagnosis and treat lead exposure associated with olddmdlmgs, childhood lead poisoning could be-largely ment, but the physician or nurse may remain eradicated in the United States. Immediately * * inattentive to the possibility of pica in the .following the birth of an infant of a family child or the mother's inability to cope with . ` residing in a pre-World War II dwelling, the ..: this and other environmental hazards. More ' prospective dwelling oould be inspected and * over, the usual fragmentation of medical and sampled for lead so that hazardous condi social services in our clinics and hospitals tions, could be corrected before the. infant favor ineffective follow-up of already identi reaches the age of pica. fied high-risk children. .... <s The recent establishment of comprehensive .'health clinics for disadvantaged children in REFERENCES - - (SELECTED BIBLIOGRAPHY). tdany cities provides a-suitable module for more effective child and parent health care in this area. In high-risk areas, the incor poration' of a screening test for .excessive lead ingestion into the regular laboratory procedures in such clinics together with the development of interview techniques designed to identify the child with incipient pica offer . the best current hope for the prevention of childhood plumbum. These procedures can . 1. Byers, R. K, and Lord, E. E.: Lata effects of laid poisoning on mental development, Am. J.Dis. Child. 66:471,1943. 2. Chisolm, J. J., Jr., and Harrison, H. E.: The . exposure of children to lead. Pediatrics 18: __ -943, 1956. 3. Chisolm, J. J., Jra Chronic lead intoxication in children, Dev. Med. & Child Neurol. 7: 529, 1965. 4. Chisolm, J. J., Jr.: Treatment of lead poison ing, Mod. Treat 4t 710, 1967. 5. Chisolm, J. J., Jra The use of chelating agents in the treatment of acuta and chronic lead N L I 001370 jmir. ailSJWIsiisur "?S|?