Document 8RnNz6rJ9MeQz2q33qjmJbwOa

Introduction Great progress has been made in the past few decades to prevent and con trol the absorption of lead by both adults and children. Cases of lead in toxication. or plumbtsm. among adults are rare today, even in lead-process ing and lead-using industries where the possibility of over-exposure seems greatest. Such improvement is the result of broadly increasing knowledge about the physiological effects of lead, of the application of proper controls and safeguards to prevent over-exposure that can bring on illness and of better diagnosis and improved treatment of piumbism. Much of this increase in knowledge has come directly from scientific research encouraged or spon sored by the Lead Industries Associa tion. Inc. (LIA) and its members. One vexing problem area, however, remains a challenge. That is the ab sorption of lead by some children, par ticularly in city slum areas, as a result of eating leaded paint that was applied to the interior surfaces of buildings generally 30 years or more ago. LIA's concern with lead poisoning problems is not new. The lead indus try has for several decades supported research at leading universities and hospitals on the metabolism of lead and the diagnosis and treatment of lead poisoning in an effort to bring about better understanding of the problem. The information developed from such research has been dis seminated in medical and public health journals and at various sym posia. Basic research on lead intoxica tion was reported by Dr. Joseph C. Aub et al. of Harvard University in a monograph published in 1926. In 1933 the Kettering Laboratory of Ap plied Physiology at the University of Cincinnati, under the direction of Dr. Robert A. Kehoe. began publishing studies on lead absorption and excre tion. LIA sponsored the early investi gations of childhood lead poisoning by Dr. J. Julian Chisolm. Jr. et ai. of Johns Hopkins University School of Medicine, as well as research on the treatment of lead absorption by chela tion. Since 1937 a number of symposia on lead poisoning have been con ducted by LIA, both alone and in co operation with such organizations as the American Industrial Hygiene Association and the American Medi cal Association. These conferences have been held to make available to health professionals and interested laymen the facts concerning plumbism which underlie present-day con cepts of its causation, prevention, and treatment. The lead industry today continues to support research in such areas as lead in the environment, the biological basis for lead intoxication, and the normal metabolism of lead, as part of its overall research program on all aspects of the use of lead. Support for Legislation For many years, representatives of LIA have met and consulted with public health officials concerning the problem of childhood lead intoxica tion. The industry has supported legis lation designed to stop the use of leaded paints in interiors of residences and on furniture, toys and other items which children might chew. Contents Introduction Piumbism is Preventable Seven Steps to Prevention Some Campaign Histories Cause and Incidence of Childhood Piumbism Medical Aspects of Childhood Piumbism Tests for Piumbism References Representatives of LIA have been members of the Sectional Committee on Prevention or Control of Hazards to children since it was organized in 1953 by the American Standards Association (now known as the USA Standards Institute) under the spon sorship of the American Academy of Pediatrics. This Committee developed a standard fZ66.1), in effect since 1955. which specifies that all paints for articles such as toys, furniture and the like, and for use in interiors of dwellings, should contain no harmful quantities of lead. (1) Childhood lead intoxication, though relatively rare in the general popula tion. still is a problem, particularlv in the underprivileged areas of large cities. It is directly traceable to the fact that a number of children, manv with pica (an unnatural craving for nonfood items), pick up and eat chips of paint flaking from walls or ceilings of old buildings erected when leaded paints were used in interiors (as they no longer are), or chew on leadpainted windowsills, baseboards or other surfaces. Prevention Needs Cooperation The knowledge and means are at hand for controlling this problem. But com plete prevention calls for cooperative efforts among many groups, including parents, social and public health work ers. doctors, landlords, city officials, and public-spirited citizens. Lead intoxication is a man-made dis ease. and as such is subject to com plete control. To help achieve this objective, LIA has prepared this book let especially for distribution to physi cians. public health authorities, social workers, city officials and others who can help eventually achieve a solution. Much has been done; much more re mains to be done. LIA hopes this booklet, "Lead and Pediatrics." will contribute to the success of efforts aimed at preventing lead absorption by children. For additional informa tion and. recommendations, we sug gest a careful reading of "Lead Poisoning in Children." by Dr. Jane S. Lin-Fu. a pamphlet (No. 452) pub lished by the Children's Bureau of the U.S. Department of Health. Education and Welfare in 1967 (see copy en closed). (2) N 4153 Plumbism is Preventable The seven steps to prevention and con trol outlined in the box have been the basis of campaigns against childhood plumbism in a number of cities. Some of these experiences will be discussed in detail. Physicians and public health authori ties agree that lead intoxication in children is preventable. The source is known: old leaded paint in poor hous ing associated with poverty. There is no disputing that slum area dwellings painted many years ago with lead bearing paint are the setting for virtu ally all cases of plumbism in children. But many years of urban renewal and rehabilitation will be required before these sources of lead are eradicated. Lead problems can continue to occur in children whose parents neither keep their home free of lead paint sources nor seek medical attention until severe damage has been incurred. Clean-up and constant alertness can prevent children, getting at old paint and plaster chips. Parents can be urged into action. Peeling paint can be removed and chips cleaned up and removed from areas in which the child crawls or plays. Crumbling painted piaster and painted woodwork can be cleaned up. repaired and painted with modern interior-type paint. Parents and baby sitters must be alerted to the dangers of children chewing on iead painted surfaces. Alertness to Symptoms Diagnosis of lead intoxication will de pend to a large degree on how hard physicians look for it. They must be alert for vague and early symptoms in children and should investigate quickly and thoroughly the child's en vironment and history. They should not be lulled by the fact that modern interior paints are safe: the problem results mostly from underlying paints applied indo'ors years ago, frequently in once fine buildings that now lie within economically deprived areas of many cities. Seven Steps to Prevention The problem of childhood plumbism is so clearly understood that it would seem prevention should be simple, ft is not. This is because the problem is rooted in social, educational, eco nomic. medical, technical and political factors. Even so. a formula for prevention and control is offered: making it work will take time, patient effort, and per haps new ideas and approaches. Some suggestions may be termed "imprac tical.'- Nonetheless, they pose a chal lenge to find a "practical" way of doing them. The booklet will discuss in detail the components of this basic preventive formula which physicians, social workers, public health workers, par ents and others should be aware of. The following steps are essential. 1 A lert and warn parents and others * who live in dwellings which have leaded paint in interiors. As with other accidents involving children, parents (and other child caretakers)-can do much to keep children from eating paint and chewing painted surfaces and can keep chips off floors and out of reach of infants. (Almost all cases occur in children 5 years old or under.) 'J Remove sources of lead that chil^ dren can eat. This source is almost invariably old leaded paint on interior walls, ceilings and trim. This leaded paint must be removed or effectively covered. One city (Baltimore) reports good results from covering walls to a height of four feet with waiiboard. Lead paint on woodwork should be removed. Peeling paint and old plaster should be swept from floors and scraped from walls and ceilings. 0 Take steps to keep any child sus*' pected of eating lead from further exposure. Remove the source of lead or keep the child from the source. "From three to six months of steady lead ingestion" precedes overt symp toms in almost all cases, according to the enclosed Children's Bureau pam phlet. (2) A Phvsicians. public health nurses ** and others should watch for early symptoms of lead absorption--vague, nonspecific symptoms of lethargy, ir ritability. and stomach pains and vom iting--and proceed at once to see that appropriate tests are made. C Quick and accurate diagnosis prevents serious consequences. This should be done by the most modern methods to be sure whether lead in gestion has taken place, and should be based on clinical findings and sup ported by biochemical evidence of ex cessive lead absorption. Blood iead tests are considered the most reliable and accurate. Iron deficiency anemia is quite common in lead-poisoned chil dren but not all children with this ailment turn out to have plumbism. Careful diagnosis of an ailing child's problem is essential. Lead frequently is not the cause and. if such proves true, a quite different treatment may be required. fC Proper and careful treatment should start immediately after diagnosis of lead intoxication. *7 When a case is found, check other ' children in the home immediately for possible signs of iead absorption. 3 Some Campaign Histories Experience shows that when well or ganized programs are pursued in a city the incidence of childhood plumbism can be reduced, usually after an initial rise in reported cases, and that fatalities and crippling illnesses can be greatly curtailed. Baltimore: The long-term, intensive campaign in Baltimore is a prime ex ample of what can be done through intelligent cooperation by all con cerned. (3) The hazard to children from old paint was first recognized by the Baltimore Health Department in 1931. and since 1935. the Health Department's Bu reau of Laboratories has provided free blood lead determinations to physi cians and hospitals, tn 1949 a public health nurse was assigned to investi gate reported instances of abnormal lead ingestion by children and to make sure that the old paint, or other source, was removed. In 1951 the city adopted a regulation barring the use of heavily leaded paints in interiors of dwellings. A Baltimore ordinance requires a warn ing label on paint that contains more than 1 percent lead. The label must state that the paint contains lead, is harmful if eaten, and should not be used for interiors or for toys, cribs or other accessible, potentially hazard ous surfaces. Throughout the years the Baltimore Health Department has continued to maintain awareness of the problem through all available media. It has pre pared pamphlets used by public health nurses and sanitarians in clinics and in home visits: in addition, informa tion on lead hazards in paint has been mailed periodically to hospitals and physicians. Exhibits and other visual aids have been shown at meetings and in public buildings. Newspapers, radio and television stations, medical and public health publications, and other media have been used to inform the public of the hazards of ingestion of leaded paint by children. Prevention Committee Organized In order to pinpoint sources of lead paint. Baltimore s City Health Com missioner in 1957 organized a preven tion committee of staff personnel directly concerned with the problem. The committee surveyed 100 blocks of dwellings and found more than 1 percent lead in paint in 70 percent of 667 dwelling units. Public health nurses collected paint scrapings from 300 homes of indigent persons and positive tests for lead were found in scrapings from 58 percent of the houses. Then action was taken to see that such paint was removed. Five years later the committee began a pilot, "hard sell" educational pro gram aimed at parents and others responsible for the care of children under 4 years of age living in selected areas where a high potential existed for lead intoxication from paint inges tion. The three-year program encom passed a person-to-person approach. Painted surfaces accessible to children were inspected in the presence of the persons charged with their care. These people were instructed by the visiting sanitarian in the hazards of lead ia paint and a leaflet was discussed and left for further study. When this leaf let was found to be above the educa tional levei in the study area, a simpler version was prepared. In all. the sani tarian made five visits to each home to remind the parents of the hazards. Morbiditv-Mortalitv Data The results may be seen in a 1968 pamphlet on the subject prepared by the Baltimore City Health Depart ment which illustrates dramatically Official Baltimore Figures* Child Lead Paint Poisoning 1931-1967 YEAR TOTAL 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 TOTAL l.in 15 32 32 45 42 44 48 53 66 133 56 48 35 34 49 29 77 31 34 31 11 13 8 9 10 13 15 12 11 13 10 19 17 10 2 2 CASES WHITE 203 4 2 4 3 7 3 4 9 T 17 4 8 5 8 10 6 20 ** ll 4 i 7 4 5 3 1 4 3 6 9 7 12 2 4 i i -- NONWHITE 908 11 30 28 42 35 41 44 44 64 116 52 40 30 26 39 23 57 29 23 27 10 6 4 4 7 12 11 9 5 4 3 7 15 6 J 1 2 TOTAL 136 l 1 0 1 3 1 1 4 2 10 3 3 1 3 6 5 9 2 4 4 3 4 2 I 5 5 3 7 4 6 2 8 10 6 2 2 2 DEATHS WHITE 46 1 0 0 0 0 0 0 l 1 3 *> I -- 1 3 3 -- 1 l 1 2 1 -- 2 -- -- 3 4 i 4 2 i i -- n o n w h it e 90 0 i 0 t 3 1 I 3 1 7 1 2 1 2 3 3 6 2 3 3 2 2 I t 3 5 1 7 1 I 4 8 4 i i 'Lead Paint Potsomn* tn Children," pamphlet issued in 1968 by Baltimore City Health Department. 4 the results of a well-organized, inten sive program. I 4 > Reproduced on the opposite page is a table from this pamphlet summarizing child lead poi soning cases in Baltimore from 1931 through 1967. Briefly, the table shows that in 1931 two cases of lead poisoning in children were reported and both were fatal. No deaths occurred from childhood lead poisoning in 1965, which was the first year of record in which there were no deaths from this illness in Baltimore: furthermore, childhood lead poison ing cases totaled 32, the lowest since 1952. The slight decline in case-findings from 1941 to 1945 reflects a wartime shortage of physicians. On the other hand, the sudden peak in 1958 re sulted from the entry into the program of a large university hospital, plus the organization of the city prevention staff and the two lead-in-housing sur veys of the previous year. Further more, it should be noted that the 10 deaths among 1958's 133 cases--or 7 percent of the total--were equalled only in 1935 when there were only 17 cases and the 10 deaths were over half of the total. The experience recorded in the table shows that fatalities from lead can be reduced or prevented. It also demon strates that in such a campaign, deaths decline as the number of cases rise, indicating improvement in speed and efficacy of treatment: and that there after. cases aiso tend to decline as pre vention becomes more efficient. Chicago: This city has been giving in creasing attention to childhood plumbism in recent years. The City Board of Health has a preventive program under way and various citi zens' groups also are actively involved in efforts to find and controi the dis ease. The problem is a serious one in Chicago because of its large areas of old, rundown housing. In the summer of 1965 residents of the East Garfield Park district organ ized a Citizens Committee to End Lead Poisoning (CCELP). This was done after the occurrence of several cases of lead intoxication in that area. With the help of the American Friends Service Committee. CCELP began an educational and case-finding campaign. The City Board of Health, and later the Medical Committee for Human Rights, helped CCELP in test ing urine samples obtained by high school students. Four piumbism cases were reported in the district from Sep tember through November. The Board of Health undertook a widespread and continuing testing program: addresses of apartments where cases were found were turned over to the City Building Commission for corrective action. From the start of the program in 1965 through September 1966. the Board of Health tested 30.000 urine samples. The city switched to a blood lead test in October. (In February 1963. the Board had begun a urinary coproporphvrin screening program in its clin ics.) As a result of the Board's expanded screening program, there was an in crease in total cases being reported, from 24 in 1957 to 304 in 1966. At the same time, there was a significant drop in the fatality rate among re ported cases, from 29.2 percent in 1957 to 1.6 percent in 1966. The Health Commissioner of Chicago, Or. Morgan J. O'Connell, reported that the number of deaths among Chicago children from lead poisoning fell to 10 in 1968 from 14 in 1967. (5) Mass Screening Program In August 1966 the Chicago Board of Health began a mass screening pro gram using a blood lead test. The chil dren screened were from 10 high-risk Urban Progress Center areas. By April 1969 approximately 90.UU0 chil dren had been tested. During 1967 a total of 27.959 chil dren had a blood test, and of these 8.5 percent (2.3791 had lead values above 50 micrograms per 100 milli liters of blood. These children were referred to a special clinic established by the Board for the diagnosis and treatment of piumbism. Of these children. 582 (24.6 percent of the suspects) were promptly treated with chelates. Three percent of those treated were 5 years of age. 8 percent were 4 years old. and the remaining 89 percent were 1-3 years old. As a result of this program aau its educational impact in these slum areas, the average blood lead level in the same population in 1968 was markedly lower. According to Drs. Lorry A. Blanksma. Henrietta K.. Sachs and Edward F. Murray, all of the Chicago Board of Health, "Mass screening programs of blood lead determination can discover incipient intoxication weeks and prob ably months before the onset of en cephalopathy, thus reducing the case fatality rate." (6) Recently the Chicago Board of Health made a film on the subject of lead poi soning in children. This film, titled "To Save a Life." provides a descrip tion of the steps taken, and the spe cialists involved, in combatting the problem and is betng used especially in neighborhoods where lead poison ing may be a problem. (7) Other Cities: Physicians in New York are encouraged to send blood speci mens on all suspected cases to city health department laboratories where there are technicians specially trained to do blood lead level analyses quickly and accurately. As a result, the num ber of cases reported increased from 80 in 1954 to 725 in 1968. During the same period the fatalities among re ported cases declined from 15 percent (12 deaths) to less than 1 percent (five deaths) in 1968. New York's program on lead poi soning is being enlarged under the direction of a special task force within the city health department. The de- ISR000481 partment holds sessions on the prob lem for physicians, social workers and Cause and ready afflicted with plumbism. Of 105 children in a new housing project, nurses. Literature is distributed to the public, particularly to parents in "high Incidence of only three (2.85 percent) were found to have abnormal lead concentrations risk" areas, by public health nurses and sanitarians. The city also uses peo ple who live in the high risk areas to help identify possible cases of lead intoxicated children and to provide families with firsthand information about the dangers of eating lead paint. Childhood Plumbism Although plumbism in children is a in their urine and there were no cases ; of plumbism. (10) In some instances, a child may ingest lead from objects such as windowsills or repainted cribs when care has not been taken to avoid lead paints. Other possible sources are rarely reported Reported cases of childhood lead in distinct and specific problem, its con and even more rarely established. toxication are followed up by a public trol must be viewed as one aspect of Some epidemiological studies have health nurse to ensure treatment and ' protecting infants and children from indicated that symptomatic lead in Jnecessary follow-up. Public health sanitarians inspect premises for other home hazards. The National Clearinghouse. Poison toxication, particularly encephalopa thy, is more common in the June- sources of lead, effect necessary re- ; Control Branch, Division of Direct ' September perjod. However, lead pair and repainting, sample and anal Health Services, of the U.S. Public intoxication may occur at any time of yze peeling paint for lead content, and Health Service, finds that 90 percent the year, and there is no season in check other places where the child of all reported poisoning cases involve which physicians and other public may regularly spend time. (8) children under the age of 5 who have health workers should be less alert. (11) The Philadelphia Department of Pub eaten or drunk substances found Plumbism also shows close family re lic Health's program has been under around the house. (9) In about half lationships. If one member of a fam way since 1956, with the cooperation ! the cases, these substances are medi ily is found to have plumbism. all the of realtors, landlords, various indus- j cines of one kind or another. In the children between 1 and 5 years of age tries (including a member company other half, household products such should be carefully checked, since of LIA) and the Society of Friends. as cleaning and polishing agents, pesti there is a 33 percent incidence among It includes systematic investigation of cides. turpentine, petroleum products children iiving in the same household. all reported cases. The Department issues a checklist of possible sources of lead for use in field investigations when the source of lead ingestion isn't readily apparent. It also issues specifi cations and safety standards for the removal of lead paint from interiors. The Department sponsored a two-day seminar on lead poisoning in June 1967 in which representatives of the lead industry participated. ' ! j ) j j and cosmetics are involved. In 1967, for example, among all substances "most frequently ingested" by such children, paint (leaded and nonieaded) ranks 26th. and involved 1 percent of I Most victims are between 1 and 6 years of age, with 85 percent in the 1-3 year old group, as noted on page 5 of the Children's Bureau pam the total reported from 395 centers in 43 states. However, many lead poison ing cases are not reported to these cen phlet. (2) These toddlers often crawl about without supervision. Either as an aspect of pica, or of the oral ex ters, so that such figures indicate the extent of acute poisoning cases from other substances but not from lead ploration usual to children of this age, they may pick up and eat paint chips found on the floors, or chew on cribs ingestion. or windowsills that were long ago covered with lead-bearing paint. Cer Studies have shown that almost every tain lead compounds are known to case of childhood plumbism is related j have a somewhat sweet taste which to old lead paint in old buildings, a ; may accentuate the appeal to chii- situation found mostly in large cities, | dren's palates. As pointed out on page mainly those east of the Mississippi 6 of the Children's Bureau booklet River. In Baltimore, for example, (2), "from three to six months of fairly where childhood plumbism has been i steady lead ingestion" precedes the brought under control, early studies j appearance of overt symptoms in al showed that from 50 to 70 percent of most all patients. old houses in some slum sections had flaking paint that contained lead. j The Factor of Pica I Pica, a very common precondition, is Housing-Plumbism Relation j the medical term for an unnatural The relation of housing to plumbism craving for dirt or other nonfood was shown in a home survey of pre i items. Some studies found that from school children in Cleveland, which 70 to 90 percent of children suffering has had a study and control program from plumbism had a history of pica. for years. Of SOI children living in * In a New York City study, more than old houses, 216 (27 percent) had ab I 30 percent of children with a diagnosis normal lead concentrations in their i of pica were found to have lead poi- urine, and 38 (4.7 percent) were al I soning. (11) A study of 784 Baltimore ISR0004a2 children from underprivileged areas disclosed that nearly 22 percent had pica. (12) In most cases, pica was es tablished as a habit by the second year but had disappeared by the fourth or fifth year. The causes of pica are unknown de spite various theories. In the present state of knowledge, it should be rec ognized that pica is widespread, occurs particularly often in poor fam ilies, and is a potential source of metal and other poisoning, as well as of in testinal parasites. Dr. Chisolm of Johns Hopkins, a | i long-time investigator in the field of childhood plumbism. notes that his torically, pica "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 are the members of the group most vulnerable to pica." : (13) i The Emotional Environment i j Dr. Chisolm also points out that the | symptom of pica is most likely to occur in children with a high level of | mouth activity whose oral relief of i anxiety "is reinforced by cultural pat terns and to whom the mothering nec | essary to stop it is unavailable for a variety of reasons. When such a child j is exposed to hazardous environmeni tal lead sources, the likelihood of ! plumbism is indeed great." (13) j j | j ' 1 Medical Aspects of Childhood Plumbism It is not the function of this booklet to give specific medical advice, but a brief review is given of the extensive literature on plumbism which the phy sician may consult in the usual man ner. The diagnosis and treatment of lead intoxication in children are complex and must be placed in the hands of experienced physicians. The enclosed pamphlet by the Children's Bureau offers 37 authoritative references. (2) In addition, a bibliography of refer ences to some works in these fields by experts is printed at the end of this booklet. However, everyone concerned with the problem should be aware of cer tain findings which should arouse sus picion at once. To physicians not actively engaged in pediatrics, symp toms and signs often are so commonplace and nonspecific that initially they may be overlooked. Cases may occur without being suspected; on the other hand, there are instances of ill nesses erroneously diagnosed as lead poisoning. It is important that all physicians, public health workers and others real ize there is a childhood plumbism problem in urban slum areas. Being aware of this fact should make phy sicians more inclined to recognize and investigate symptoms they ordinarily would not associate with lead intoxi cation. . I | | ; I Check on Chewing and Pica The presence of pica should especially arouse a physician's suspicions, Though most children pass through a stage of chewing on almost anything in reach, this habit should be gone by the age of 1S months and should never be of great intensity. Though the presence and history of pica is important, diagnosis should not rest on these alone. Many lead intoxicated patients have been found to have no history of pica when first examined. A careful check should be made to determine the child's physical envi ronment. A child with lead intoxica tion has almost always chewed lead painted materials, such as woodwork, plaster, wallpaper or putty, for at least three months before clinical signs appear. Though these materials themselves do not contain lead, they were often coated with leaded paint many yean ago. When a suspected case of childhood plumbism is seen, a check should be made to learn if the child lives in or frequently visits a house built before World War II. A list of "high-risk" addresses could be posted in all pedi atric clinics, to help physicians un familiar with the city. Most cities with the problem do have such areas of high risk. Signs and Symptoms A diagnosis of lead poisoning should be based on clinical findings and sup ported by biochemical evidence of excessive lead absorption, and. if possible, by evidence of unusual expo sure. There are a number of signs and symptoms which should arouse the suspicion of physicians and others, particularly if the patient lives in a slum area. They are not diagnostic by themselves, but are indications that emergency laboratory tests are required. The signs and symptoms listed below are not intended to be either definitive or exhaustive. For a thorough consideration of these sub- j : ! i j I ! 1SR000463 jects, the physician should consult the medical literature. The signs and symptoms of lead ac cumulation in children chiefly involve three organ systems: the gastroin testinal system, the central nervous system, and the hematologic svstem. (14) The gastrointestinal symptoms are those which are most likely to be noticed first by parents and other lay- men. They consist of vomiting, com plaints of vague abdominal pain and constipation. These are fairly common complaints among children, but the examining physician should be aware that plumbism may be the true underlying cause, He should also be aware that parents often are not of much help in his efforts to obtain definitive information. A survey of 300 children with confirmed cases of plumbism showed that 76 percent of them had no pre- senting complaints, but when specific and detailed inquiry was made, it was found that 58 percent had loss of appetite and 9 percent had vomiting. In another study of 22 children afflicted with severe lead encephalo pathy, it was found that 18 had been treated symptomatically for "gastro enteritis" for different periods of time before symptoms of central nervous system involvement became apparent. Some of these children had also been treated for anemia, constipation, sugar in the urine, gait disturbance, and sudden onset of crossed or skewed eyes. Central nervous system involvement: The most serious manifestations of childhood plumbism are those that result from involvement with the brain. These may range from drowsi ness to deep unconsciousness (coma), or repeated fits (grand mal seizures). In some cases the first clues to the in toxication are repeated- falling, clum siness or loss of coordination. In other cases, convulsions may bring the child to medical attention. There also may be reading or behavior problems. From the physician's point of view, there is nothing especially character istic about the convulsions, for they may occur without fever and may be focal or generalized. However, if in the course of a few hours, the pattern j | : j | j i ! , , ! of the seizures switches back and forth between right-sided, left-sided and generalized, the possibility of plumbism should be investigated. The physical examination in such cases may reveal inflammation of the optic nerve, ataxia (lack of muscular coor dination), lethargy or seizures--with or without local paralysis and with or without reflex changes-and as such serves to confirm the involvement of the central nervous system but does not provide exact evidence of cause. Hematological findings: Parents will be unable to detect changes in the blood of a possibly affected child. The physician may wish to check for anemia before asking for specific blood lead tests. Iron deficiency anemia is common in toddlers, and does not necessarily mean that the child has absorbed potentially toxic amounts of lead. According to Dr. Chisolm, there are two groups of children involved: those with asymptomatic increased lead absorption, and those with lead poisoning. The first group, which probably contains the largest number, are children who show evidence of increased body lead burden without evidence of toxicity. The diagnosis of lead poisoning. Dr. Chisolm says, should be reserved for those children who, in addition to evidence of an increased body lead burden, also show biochemical evidence of toxicity. This latter evidence includes increased out put of coproporphyrin and/or deltaaminolevulinic acid in urine. "Some of these will show no clinical signs," Dr. Chisolm says. "Because of the nebulous nature of the clinical signs and symptoms, we should de mand that patients with signs and symptoms suggestive of lead intoxi cation also have biochemical evidence of intoxication." (15) Tests for Plumbism As noted above, the presence of one or more hematological, intestinal or neurological signs or symptoms is not in itself diagnostic of pediatric lead intoxication. Laboratory tests are necessary for the physician to de termine whether his patient has ab sorbed lead in quantities sufficient to 1 induce illness. | By far the most reliable test for lead absorption is *the quantitative deter mination of the lead content of the blood. Since speed is often extremely important in diagnosis of childhood plumbism so that proper treatment j can be undertaken, such a test ought to be ordered immediately upon the first suspicion. Blood lead concentrations should be interpreted with caution as these val| ues can be affected by a number of | factors such as competence and ex| perience of laboratories and labora| tory technicians, methods used in the collection and storing of samples, and possible recent administration of che lating agents. Blood-lead concentrations of 40 to 60 micrograms per 100 milliliters of blood have been used by various agencies as the upper limit of the normal range for children. For ex ample. the Chicago Board of Health refers all children with lead values above 50 micrograms to a special clinic for the diagnosis and treatment of lead poisoning, whereas other agencies have suggested 60 micrograms as the upper normal limit of blood lead concentrations. (11, 16, 17) There appears to be general agreement that blood-lead concen trations between 60-80 micrograms are indicative of abnormal absorp tion of lead, but often not of a degree of absorption which is capable of in ducing symptoms of intoxication. Blood concentrations of 80 micro grams and above are considered to be potentially capable of inducing intoxi cation. requiring immediate action in cluding both referral for treatment and removal of the child from the source of exposure. ISR000484 I Blood lead determinations are the most reliable method currently avail able to communities with active pro grams aimed at controlling childhood plumbism. According to Or. Chisolm, a test recently developed for estimat ing delta-aminolevulinic acid (ALA) in urine is simple, rapid and inexpen sive and may be suited for most screening if it can be shown that the concentration of ALA in random samples of urine provide sufficient discrimination between normal and lead-exposed children. However, further evaluation is necessary before it can be accepted. (Chicago Health Commissioner O'Connell says a 1967 study in that city, which is to be pub lished. found ALA does not correlate with blood lead in screening for asymptomatic lead intoxication.) > ! j i collected for eight hours after intra muscular injection of EDTA. The test is very useful, he says.) A recent major discussion of medical aspects is "Childhood Lead Poisoning -- Comprehensive Management and Prevention." by Drs. J. Julian Chisolm and Eugene Kaplan, both of Johns Hopkins Medical School in Baltimore. Published in the December 1968 Journal of Pediatrics (Vol. 73, No. 6, pp. 942-950), this sums up the views and contributions of the authors and six other experts in the field who participated in a symposium held at Happy Hills Hospital in Baltimore on April 24, 1967. The symposium was held "to call attention to the need for a cooperative community approach to the social, environmental, and psy chological aspects of the problem of children with lead intoxication." Other major contributions include: "The Use of Chelating Agents in the Treatment of Acute and Chronic Lead Intoxication in Childhood." J. Julian Chisolm, Jr. in Journal of Pedi atrics (Vol. 73,1968); "Lead Poison ing in Childhood: Signs, Symptoms, Current Therapy, Clinical Expres sions." Joseph Creengard. in Clinical Pediatrics, May 1966; and "Pediatric Lead Poisoning," Hugo Dunlop Smith, in Archives of Environmental Health, February 1964. References Urine lead analyses are generally limited to usefulness in clinical re search and in management of hos pitalized cases because they require 24-hour collections of urine to yield useful data, says Dr. Chisolm. The edathamil calcium disodium (EDTA) mobilization test for lead also requires quantitative collection of urine and seems to be mostly useful in the study of older children suspected of having chronic plumbism. he notes. (13) (Dr. O'Connell says the EDTA mobil ization test is used in all age groups in Chicago's lead clinic with urine 1. USA Standards Institute (formerly American Standards Association). American Standards Specifications to Minimize Hazards to Children from Residual Surface Coating Materials. Standard Z66.1 1964. 2. Lin-Fu. Jane S., M.D. Lead Poisoning in Children. U.S. Department of Health. Education and Welfare. Chil dren's Bureau publication No. 4521967. 3. Schucker. George W,, Vail. Edward H., Kelley, Elizabeth B.. and Kaplan, Emanuel. Prevention of Lead Paint Poisoning Among Baltimore Children. Public Health Reports 80(H):969974. November 1965. 4. Baltimore City Health Department. Lead Paint Poisoning in Children, * 1968. 5. Dr. Morgan J. O'Connell. Personal I communication. 6.Blanksma. Lorry A.. Ph.D.. Sachs. Henrietta K.. M.D.. and Murray. Ed ward F.. M.D. Incidence of High Blood Lead Levels in Chicago Chil dren. Paper presented at annual meet ing of American Association of Poison Control Centers. Chicago, Oct. 21. 1968. 7. Chicago Board of Health. To Save A Life. Film, 1968. 8. Dr. Felicia Oliver-Smith. New York City Health Department. Personal communication. 9. Verhulst. Henry L. and Crotty. John J. Childhood Poisoning Accidents. Journal of the American Medical As sociation 203(12):145-146, March 18. 1968. 10. Griggs, R.C.. Sunshine, I.. Newill, V.A., Newton. B.W., Buchanan. S., and Rasch. C.A. Environmental Fac tors in Childhood Lead Poisoning. Journal of the American Medical As sociation 187:703-707, 1964. 11. Jacobziner. Harold. Lead Poisoning in Childhood: Epidemiology, Manifes tations, and Prevention. Clinical Pedi atrics 5(5):277-286, May 1966. 12. Cooper, Marcia. Pica. Charles C. Thomas, publisher, Springfield, 111. 1957. 13. Chisolm. J.J.. Jr. and Kaplan, Eugene. Childhood Lead Poisoning--Compre hensive Management and Prevention. Journal of Pediatrics 73(6):952-950, December 1968. 14. Dr. Hugo Dunlop Smith. Personal communication. 15. Dr. J.J. Chisolm. Jr. Personal com munication. 16. Chisolm. J.J.. Jr. Lead Intoxication in Children. Developmental Medicine and Child Neurology 7:529-536. Octo ber 1965. 17. Greengard. Joseph. Lead Poisoning in Childhood: Signs, Symptoms, Current Therapy, Clinical Expressions. Clini cal Pediatrics 5(5):269-276, May 1966. For other reading on lead and pedia trics see next page. Other References Byers. R.K., and Lord E.E. Late Ef fects of Lead Poisoning on Mental Development. American Journal of Diseases of Children, 66:471. Novemher 1943. Chisolm. J.J.. Jr., and Harrison. H.E. The Exposure of Children to Lead, Pediatrics. 18:943-957, December 19S6. Chisolm, J.J.. Jr. Treatment of Lead Poisoning. Modern Treatment. 4:710, July 1967. Chisolm. J.J.. Jr. The Use of Chelating Agents in the Treatment of Acute and Chronic Lead Intoxication in Child hood. Journal of Pediatrics, 73:1.1968. Christian. J.R.. Celewycz, B.S.. and Andelman. S.L. A Three-Year Study of Lead Poisoning in Chicago. American Journal of Public Health, 54:1241-1251, August 1964. Coffin, R.. Phillips. J.L.. Staples. W.I.. and Spector. S. Treatment of Lead Encephalopathy in Children. Journal of Pediatrics, 69:198-206, August 1966. Davis, J.R.. and Andelman, S.L. Uri nary Delta-Aminolevulinic Acid Levels in Lead Poisoning. I. A Modified Method for the Rapid Determination of Urinary Delta-Aminoevuiinic Acid Using Disposable (on-Exchange Chro matography Columns. Archives of En vironmental Health, 15:53. 1967. Davis, Joseph R.. Abrahams. Ronald H., Fishbein. William I., and Fabrega, Enrique A. Urinary Delta-Aminoievu- linic Acid (ALA) Levels in Lead Poi soning II. Correlation of ALA Values , With Clinical Findings in 250 Children With Suspected Lead Ingestion. Ar i chives of Environmental Health. 17 (2): 164-171, August 1968. 1 Feigin, R.D., Shannon. D.C.. Rey nolds, S.L., Shapiro. L.W., and Con 1 nelly, J.P. Lead Poisoning in Children. j Clinical Pediatrics, 4:38-45, January I 1965. Gordon, Neil. King, E., and MacKay, | R. I., Lead Absorption in Children. British Medical Journal, 2:480-482, i May, 1967. Greengard, J., Adams. B., and Ber j man. E. Acute Lead Encephalopathy in Young Children. Journal of Pedia trics, 66:707-711, April 1965. Gutelius. M.F., Millican. F.K.. Lay j man. E.M., Cohen. G.J. and Dublin. ! C.C. Nutritional Studies of Children I with Pica. I. Controlled Study Evalu j ating Nutritional Status. II. Treatment of Pica With Iron Given Intramuscu j larly. Pediatrics. 29:1012.1962. ! Ingalls, T.H., Tiboni. E.M.. and Werj rin, M. Lead Poisoning in Philadelphia 1955-1960. Archives of Environmen tal Health, 3:575-579, November 1964. Jenkins, C.D.. and Mellins, R.B. Lead | Poisoning in Children: A Study of 46 Cases. Archives of Neurology and Psychiatry, 77:70-78, January 1957. Kaplan. E., and Shaull, R.S. Determi nation of Lead in Paint Scrapings as an Aid in the Control of Lead Paint Poisoning in Young Children. Ameri can Journal of Public Health. 51:64, j 1961. Lourie. R. S., Layman, E.M.. and Mil- i lican, F.K. Why Children Eat Things That Are Not Food. Children. 10:143. j 1963. i Mellins. R. B.. and Jenkins. C.D. Epi demiological and Psychological Study of Lead Poisoning in Children. Jour- ( nal of the American Medical Associa tion, 158:15-20. May 1955. Millican. F. K., Layman. E. M.. Louj rie. R. S.. and Takahashi. L. Y. Study j of an Oral Fixation: Pica. Journal of ] the American Academy of Child PsvI chiatry, 7:79. 1968. j Moncrieff. A- A.. Koumides. O. P.. j Clayton. B. E., Patrick, A. D.. Reni wick, A. G. C.. and Roberts. G. E. | Lead Poisoning in Children. Archives of Diseases in Childhood. 39:1-13. :I February 1964. Perlstein. M. A., and Attala. R. Neu rologic Sequelae of Plumbism in Chilj dren. Clinical Pediatrics. 5:292-298. ; May 1966. i j Sartain. P.. Whitaker, J. A., and Mar tin, J. The Absence of Lead Lines in Bones of Children With Early Lead Poisoning. American Journal of : Roentgenology, 91:597-601, March 1964. Smith, H. D. Pediatric Lead Poisoning. Archives of Environmental Health, 8:256-261. February 1964. Whitaker, J. A., and Vietta. T. J. Fluo rescence of the Erythrocytes in Lead i Poisoning in Children: An Aid to i Rapid Diagnosis. Pediatrics. 24:734738, November 1959. Diagnosis of Inorganic Lead Poison ing: A Statement. British Medical Jour nal, P. 501, November 23, 1968. i ' .i i I | The Lead Industries Association. Inc. i is a non-profit organization of lead mining, smelting, refining and fabrieating companies throughout the Free World and is incorporated under the Membership Corporation Law of the State of New York. Among other things, its purposes are to disseminate accurate information regarding lead products and how they may be used, to develop methods for the improve ment of the welfare of those engaged in the lead industries, or in the use of its product and, in general, to promote the serviceability of lead industries to the community at large. - LEAD INDUSTRIES ASSOCIATION, INC. 292 Madison Avenue, New York, New York 10017 ' 1 ! i j I T