Document BXozE57VgzyZyNDb3Gp43v38

*NYCQGQG6539 N11478 f Introduction Great progress Has. been made in the past rev. Jec,avle> to prev enc and con trol the absorption' or fend by both adults and children. Cases of feadincoxicatron. or piurrmsm. among adults are rare todas. e--en .n 'eaU-pfC'CessiQg, and: lead-using industries ,here the possibility of over-exposure seems greatest . Su':ch improvement is the result of broadly/ increasing knowledge about the phys'iologicai'erfects of lead, of the application of proper controls and safeguards to prevertt! over-exposure that can bring drl'iIInesS and of better d'ia:|;no^'s:i;3;nd improved treatment of piumbistn. Much of this increase m knowledge has come directly from scientmp research encouraged dr spon sored by the l+eajd Industries Associa tion. Inc. itilA) 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 stum areas, as a result of eating'leaded pamt that was applied to :tib'e!|;!:i!ntiprtpr'' ^ir.ifaciss'.6't buildings generally 30 years or more ago.' LlA's concern with lead poisoning pro.bleJrjs is not new. The lead .indus try has :or se^er^ljO^aiiits: Sbpippfted respd'riali'.iat; leading universities and hospital > on ':the|;,,ni|ta!bplji5pi''|::f|!f !!ad and the diagnous and treatment of lead =f*<c> sooirtg i|ir ;i^f!drt|J to'briog about' ^efte'r^iuhd^fanjilihli: ipr the problem. The information developed troirrt >|ich,pleveirphhasjlbjeljh1 pis- semmated medlical'lajlnljd' public health ournals and at various sym posia Basic research on lead intoxica tion wan reported bv Dr Joseph C Aub et al of Harvard Lmvcrxnv m a mono gjap iiijplbbliisibiipxSj ||i:d ||l $2'6J In 1933 the Kettering Laboratory of Ap Cpl.iend,,nPahnvus.iouloog<vLra,tht.hde.rUecnnivoenrsioitfyDor.f Robert A. . lKe.huole.. Ibe.g.an.Upubllis-Lh. i_n_g studies on lead absorption andl exerttion. LIA sponsored the eairiv I'nvestlgluons of childhood lead poisooinl bv Or J. Julias .Chisolm! .r.-...e..t..a...l...o...f Johns Hopkins University School of Medicine, as well as research on the trratmeri or lead absorption 'by chela- tiojli. jSijijw'I fbfy |||iij|n^sia on lead ducted operation with such organizations as me 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 piurnhism which underlie present-day con cepts of its causation, prevention., and treatment. The lead industry today, continues; to support research m such areas as lead in the environment. the biological basis for lead intoxication, aod1 the normal metabolism of lead, as part of its overall research program on all aspects of the use of lead. Support lor Legislation For many vears. representatives of ' with p;ubltiC'''H'^aif:Hji!!offi:e:iis;:!,dOacerDing. the pr^ble^!; of chrldhood lead intoxica tion. The industry has supported legist 1 .;'p|is^'i;ci!^jijibi||Ht the' Use' of f' resideoc which children might chew. item Contents Introduction Plumbism is Preventable Seven Steps to Prevention Some Campaign Histones Cause and Incidence of Childhood Plumbism Medical Aspects of Childhood Plumbism Tests for Plumbism References Representatives of LIA have been members of the Sectional Committee on Prevention or Control of Hazards to children since it was organized m 1953 by the American Standards Association ( now knowQ as the USA Standards Institute) under the spon sorship of the American Academv of Pediatrics. This Committee developed a standard (Z66.I). m effect since l;95J. which specifies that ai'i paints for articles such as toys, furniture and the like, and for use. m. interiors of dwellings, should contain no harm:-a.quantities of lead: U > Childhood lead: intoxication, though relatively rare tn the general popula tion, sirll a problem. particular:', n the underprivileged areas of large tPtgi^^iiiEtjj tiiijiid^^ttitlV'iltracieabl.e ro :he fabttftiatiiafipufftber;;jo! children, man-, vijjitjh:'I'pitaljjl^aO;I'uOtiaidrali craving for nonfood ifettisV. pick up and eat chips of pamtifllkipglfrcifnil'wal'ls.or'cetitngs otj:bltH;;'bbil^lh^s':erle^ed' when leaded ^^ntillwer^i^wd1 :ib'ilnteriorS' las thev nO:!i'ilb:b|,e:r|'||ifif:. or chew on lead- s!fJs: baseboards, or other surfaces. ' Prevention Needs Cooperation The knowledge and means are at hand for controlling this problem. But com plete ;prevention .calls for coocerat;'.e efforts among many groups, tnciud.ng parents, social and public health work ers. doctors, landlords, citv orhcia.s. and public-spirited citizens. Lead intoxication is a man-made dis ease, and is such is subject to com plete control. To help achieve this obiedfivp.';lliA^^ prepared this book let w^iaiiy fclr disinbution to phv>,Ctap^i;|p:ubi|bi^edith authorities. socra. workers, citv officials and others -*no can help eventually achieve a: solution I|^tbi^ablfe<fiep1 pone,: much'more recniilblsi^tpi^lbe:, |tfpe. LIA hopes cr> booklet. '`Lead and Pediatrics.' * contribute to the success of efforts i^e^jjj^fi'i'preyje^ting;' lead absorption b^:;|e||iiii^r|nl'Fpr additional informa tion and recommendations, we >wggest a careful reading of Le.d Poisoomg in Children.' bv Dr Ja.-.e S;|[pil|i^ilii^i|ipar^phlet (No. 45Ii p l c lished bv the Children s Bureau ot U.S. t^jiSipl^iQtioTHellth. Educat.c- 1967 (see copv 2 PMTC0C006540 Plumbism is Preventable The seven steps. to prevention and con trol .outlined ,n the ~o\ \ive ~een the hasis or -ampaicrs ^jam.-yt childhood p;mbism :n a1 harhcer or cities. 'Sorrte. of these experiences'wid; be discussed' in detail. Physicians and public, health authori ties agree chat lead iQtoxicat.on in. children is presentable. The source' is. known: old leaded paint in poor hous ing associated with poverty. There is aOiidlisputiing that- slum area dwellings painted many years ago with leadbearing paint are the setting for virtu ally ail cases of plumbism in children. But many years of urban renewal and ."ehapiitt^uoa will be required before tne>e sources ot lead are eradicated. Lead problems can continue to occur >n children whose parents neither keep their home tree ot iead paipt sources nor seek medical attention until severe damage has seen incurred. Clean-up and constant alertness can prevent, children getting at old paint and. plaster chips. Parents caa: 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 plaster and painted woodwork can be c!eaQed'up:fepaired^ modern interior-type paint. Parents and baby sitters must be a.er*.ed :c dangers of children crew-ng 0r. painted surfaces. Alertness to S> mptoms Diagnosis of lead intoxication v pend to i large degree on how physicians Io o j c ror.d. Thev - aiert for vague and ear:'* children and -mould quickly and thorough.*. -,-.e . vironmeac ana history T-e-. --o- q o i be lulled by the tact -: intenor paints ire we T.i r-.* results mostly from unuer . r_ - applieit ;ifidoor$ years ago. in once hne buiidmgs -c . withineconomically depr..cc many cities. Seven Steps to Prevention The problem of childhood plumbism is so clearly understood that it would seefn prevention should be simple, ft is not. This is because the problem is rooted in social, educational, eco nomic. medical, technical add political factors. Ev<ln 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. Thej booklet will discuss in detail the components of this basic preventive formula which physicians, social workers, public health workers, par ents1' and others should be aware of. The1 following steps are essential. | Alert ami warn parents and others * who Uvc m dwellings which have leaded paint in interiors. As with other accidents involving children, parents land 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 to children S years old or under.) Remove sources of lead that chilJren can eat. This source is almost invariably old leaded paint on interior walls, ceilings and trim. This leaded pamt must be removed or effectively covered. One city (Baltimore) reports good results from coveeing wails to a height' of four feet with waHboard. Lead paint on woodwork should be removed. Peeling pamt and old plaster should be swept from floors and scraped from walls and ceilings. *5 Take steps to keep any child sus'J* peered ot 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 m almost all cases, according to the enclosed Children's Bureau pam phlet. i 1} A Physicians, public health nurses * and others should watch for early symptoms of lead absorption-vag\.e. nonspecific symptoms of lethargy ir ritability. and stomach pains aru voriting--and proceed at once to -ee :r,,: appropriate tests are made. Quick and accurst? C.-crV' vents serious con-ec^erc.:' T~ should be done bv the mo-t -r.ccerr methods to be sure whether ew rgestion has taken place, and --v.. a be based on ciimcai findings .,,r.d -..rported by biochemical evidence -rt ex cessive lead absorption. Blood cad tests are considered the most rei.a^e and accurate. Iron denciencv uremia is quite common m lead-poisoned cnidren but aot all children with -h;-> ailment turn out to have piufr.b:-rrr Careful diagnosis of an ailing problem is essential. Lead frequer:;x is not the cause and. if suer, rre-.es true, a quite different treatment mw be required. i I! ( C Proper and careful tre^tmert ' J* should start immeduteiv wer diagnosis of lead intoxication When a case is found, creek other ' children in the home immec;-:e-.v for possible signs of lead absorption PNYCOGOC6541 f J Some Campaign Histories Experience'shows that when well or ganized programs; are pursued m a c::y;he inc.dence or.childhood. plumb* :sm can re reduced., usuaily jft.er an initial rise m reported cases, and that fatalities and crippitng. tiEnesses can be greatly curtailed.' Baltimore: The long-term, intensive campaign m Baltimore is a prime ex ample of what can be done through [ptel'liigletit:' cPo{>erattpni:,: by all' con cerned. f3t The:;|h^a;r^!;to:chiidrtfh':from old patot waiiiRrlsr-r^Cogpize^.fey lithe Baltimore Health Department in 1931 and since !'9t',S';:;^hp:iMea1th . Department s Burea!u;|p'^j--lL-aj^ci!riat<>Ti(idfS!iftj:ais'-pro.v-|j(^ed free biopd;:[||af determinations to fphysi- ciacis;lit^^9 a public health nurse was assumed: to investi gate jireported iinitaB^:: pf' abnormal ieaditngesnon bv children and to make sure'that the old paint, l>|r other source. I a M? 1' adopted,* regulation b!a|^ibj| t^ij, dse-i! of heavily leaded paints m interiors of dwellings. A BiIlta:rreor^l!jB'^!nd;ipce;:ir;le.q^ires a warni ng;: jiiijriji'pi1! m th'di'i^prlliaifis! more thaip!:!iil|!;pjer^(en;c:';;l|saidj:i:iir^ label must 1 ^iiiep'aittit!'ijMiioitiieis lead, is ^^n,!|'artp:i'|H6^ld>ciot: be ittors or for toys, cribs or fipiE ''pdiepiiaiiy hazard- the vears the Baltimore rtmeot has continued to bareness of the problem NiiablEjinpti'iE': It has prelets usedb^publi^ health Unitarians: in clinics and in addition, idforma- azards in paint has been callv. to frospitils and . hibits aod other visual n shown at meetings*and op. Newspapers, radio is(ationS.|imdi:^al; 'and r ublicattods. anti other been used to ito rm the azards of ingestion of by'Children. Prevention. Committee Organized In order ro> pinpoint sources of lead paint; Baltimore s Citv Health Com missioner m 1957 organized a preven tion committee of vtatf personnel directiv concerned with the problem. The committee surveyed 100 blocks ot dwellings and found more than l percent' !ead in paint in 70 percent ot dwelling units. Public health nurses coillscred paint scrapings from 5uu homes ot indigent persons and poviuve tests for 5ead were found m .crapings .from' 58 percent of the houses. Then action was taken to see that such paint was removed. Five years later fhp eommittee began a , f^iioti; ''hardi^seir'.neducational; pro gram, aimed !i;t' parents, and others responsible for fheii, care!.; of''Children Under::^: years Of age living in selected aj^ajy''Wbere a ;jhjigh;ji potential existed for lead intoxication from paint tnges* tioQ. The three-year program eaccmpassed a person-to-person apprcac." Pamted surfaces accessible to children were inspected in the presence ot me persons charged with their care. Trese people were instructed by the \;sit.ng sanitarian m the. hazards ot ieau paiQt and a leaflet was Ji>cu-s>ed anu left for further study.. When this let was round to be above the educa tional level tn the study area, a '.rr.r er version was prepared. In a.l. :r.e -j O tarian made five visits to-each home to remind the parents ot me nazarc>. Morbidity-Mortality Data The results may be seen in a 1 rhs pamphlet on the subject prepared bv the. Baltimore City Health Depart ment which illustrates dramatically Official Baltimore Fiftires* Child Lead Paint Poisoning 1931-1967 YE Ut TOTa L 1967 1966 1965 1964 1965 1962 1961 i960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 193:8 1937 1936 1935 1934 1933 1932 1931 TOTaL l.UI 15 32 32 45 42 44 48 53 66 133 56 48 35 34 49 29 77 3i 34 51 ri 13 8 9 10 13 15 12 U 13 id 19 17 id 2 > * CASES WHITE . : 203' ' 4 2 4 3 7 3 4 9 17 4 8 5 8 10 6 20 M 4 l 7 4 J 3 1 4 3 6 9 7 u 2 4 l 1 * VOSWHITE 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 2 l 2 TOTAL 136 l 1 0 I 3 l 1 4 2 10 3 3 1 3 6 5 9 * 4 4 3 4 2 I 5 5 3 7 4 6 2 8 10 6 deat hs WHITE , 46 1 0 0 0 0 0 0 t :I 3 2 l -- 1 3 2 3 _ 1 1 l 2 1 -- 2 -- 2 -- 3 4 1 4 2 1 J T SO^WHITS 90 0 l I t 2 l 2 3 3 6 2 3 2 2 1 t 3 5 i i 2 l 4 3 4 l I --Lea4 Paint Poionm| m OnlflreiV pimphlet luueii m by Itimorc City Heaim Department pHtC0000^2 a che results of a well-organized, mienuve program. i4 Reproduced on the depOMte page i* a table crom this pjfnpnlei xumnurirma child lead poi soning. Caxe> m Baltimore from 193.1 mrcugn Bfter?y. :he table 'hows chat ;n 1931 : w.o, cases. orOead. poisoning :a children Acre rerorte-j ...no "`otn were fatal. No deaths .occurred' from childhood lead poisoning in-WhJ. which was the first year of record io which there were no deaths from this lilness m. Baltimore: furthermore: childhood lead poison ing cases totaled 52. the lowest since [952. The slight decline in case^findiags from 19-11 to 1945 reflects a wartime sHorrageof'physicians,. On the other hand- the sudden peak in 1958 re* suited from the entry into the program o;f a large university hospital, plus the organization of jche city prevention start: and :the;j!two lead-in-housing sur veys of the previous vear. Further more. it should -tfe' noted that the 10 deaths aifnion|<:f9^g*Sji;3i i|:a$jfc$j--of % percent pfrithej total--were equalled onlv in 1935 when there were onlv 17 c|se!si 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 presented. It also demon strates wat in such a campaign, deaths decline as the number of .cases rise, indicating improvement in. speed and erttcibiy: of ireatmeni: and that there after. cases also tend to decline as pre vention becomes more efficient. i' ....... Chicago;, This city has been giving in- creasing attention to childhood plumbum m recent years. The City Board of Health has a preventive program under; wiav and various citi zens groups also are actively involved in efforts to i find and control the dis ease. The problem is a serious one in Chicago because of us large areas of old: rundown housing. r In the summer of 1965 residents of the Hast Garfield Park district organ ized a Citizens Committee to End Lbad Poisoning iCCELP). This was done alter the occurrence of several cases or lead intoxication m that area. With the help of the Amertean Friends Service Committee. CCELP began an educational and case-finding campaign. The Otv BoarJ or Health, and later the Medical Committee for Human Rights, helped CCELP m test ing urine samples obtained by high school students. Four plumbism cases were reported m the district from Sep tember through November. The Board of Health undertook a widespread and continuing testing program: . addresses i of apartments where cases were found were turned over to the '^ifv BuildingiCdmmissioti for corrective action. Frdm;:the.S:tart!Pf :the'p;rp(gra:m in 19.6:5 chrougn September 1 the Board of Health tested 30.000 urine samples. The city switched to a blood lead test in October, i In February 1963. the Board had begun a urinary coproporphvrm screening program in its Clintcs.) As ia result ofkhe: Board's expanded screening program, there was an mcrease;:|io total cases being reported, from 2ja in f9|57 to 304 m 1966. Ait a significant drppytjRij] the fatality rate among Re ported cases, from 19 2 percent m IThe siooer of Chicago. Dr. ^6D'|iL: reported that deaths among Chicago from-:lead poisoning fell' to 10 m 1968 from U m 1967 (5) Mass Screening Program the Chicago Board of Health began .a mas* screening pro gram using a blood lead test. The chil- TT^=?i t * mi] v * ,v" -> --- -=i--j* C00006**3 dreo screened were trom . . - Urban Progress Center _-.I. April I9bv approximate.v dreo had been tested. : During 1967 a total or dreo had a blood tot. a.percent i2.3"9:t had above 50 microgfarrs ; liters of blood, these referred to a special c..r by the 'Board *4r me treatment ot .piumb.sm. Of these'children,. 5*2 I- - rer-^ of the'suspectsi were prerr- with chelates. Three porcc-: - treated were ;5 years or _ce. ' per:, were 4 years did. and -- 89 percent were il-5 year- o c As a result of this program .nu educational impact :n tne-e - _ areas, the average blood .eau c-e. the same population -n . . markedly lower. According to Drs. Lorry A. Blunksn Henrietta K. Sacns and Edward f Murray, all of the Chicago Board . Health. "Mass screening programs s blood lead determination can d>co-- . incipient intoxication wee*< artu proably months .before the ur.>e: ,,-t cephalopachy. thus reducing --e fatality rate.'* (6i Recently the Chicago Board of Hea.: made a film on the subiect or e^d ro soomg in children. This mm. :.:.e "^OiSaveia Life.'; provides a cescr: tioa of the steps taken, and me -.c-. cj'aBsfii involved, in combati ng p^bllrn, and'i>;h;eing used .-cecio... m neighborhoods where ecu poiscr mg' may be a problem, i " > OtherCittes: Phvsiciaos in 'vew York are encouraged to send blood -p<c:mens on all suspected cases to c:-.v health department iaborator-.es w-.ere t^|re|ijarejtec'hn^cians specia.iv ira.ned. to'do biood lead level anaivses cuicA.v apd accurately. As a re^u t. me ber of cases reported increased me; 80'.!!iQ!jiI:95^4 to 725 in 19*>8 During m same period the fatalities among n ported cases declined rrom 15 cercer {12 deaths) to less man I percent r.v deaths) in 1968. New York's program on ;ead po soinihg, is being enlarged under :r difjfeetiidnjpf a special task force wuh: the city heaith department. The d= partment holds sessions on the prob lem for physicians, social workers and nurses. Literature is distributed to the public, particularly to parents in "high r:*k" areas, bv. public health nurses and sanitarians. The citvaiso uses peo ple who,jive id the high risk areas to help, identit'v possible cases of lead, intoxicated children and' to provide families with 'firsthand information about the dangers of eating lead paint.' Repci^^d; cases: p;f childhood lead in toxication are'followed up bvia public health nurse to ensure treatment and necessary rollow-up Public health Cause and Incidence of Childhood Plumbism Although plumbism in children is a distinct and specific problem, its con trol must be v tewed as one aspect of protecting infants and children from other home hazards. ready afflicted with plumbism. Of 105 children m a new housing project, only three <2.85 percent! were found to have abnormal lead concentrations iq their urine and there were no cases of plumbism. (10) In some instances, a child may mgest lead from objects such as windowisiils or repainted cribs when care has lot been taken to avoid lead paints. Other possible sources are rarefv reported and even more rarely established. Some epidemiological -studies have indicated that symptomatic lead in toxication. particularly encepnaiopa- sanitarians inspect premises for souices ot lead, effect necessary re pair and repainting, sample and anal-; Vie peeling paint tor lead content, and: check other places where the child may regularly spend time IS) The National Clearinghouse. Poison Control Branch. Division of Direct Health Services, of the U.S. Public Health Service, hods that 90 percent of all reported fiibjispnipg ic^es involve children under the age of 5 Who have thy, is; more cpmmontntrie luceSeptember period. However.. iejij intoxication may occur at any time or the year, and there is no season m which physicians and other public hddith;WpirikiSrt;isJiii5uId'bd less alert. \ 1 h TheiPhtladeiphiaiDepartmentiiof Pub lic i'Healrhs program has beer, utljdelr1 wav since i956 with the cooperation ot realtors, 'andlords. various indus tries i including a member company Ot LlA) and the Soctetv of Friends. U icciudes systematic investigation of all reported cases. The Deoartrrient issues a .'e: is: of posiib'c purees of lpnd for use irt field investigations when, the source of lead ingestion1 isn't; readih aopar at It also issues spe|id eations and safety standards for the removalipf lead paint from intni^. The Department sponsored a tw^iy semicar on <ead poisoning in '.inline | eaten or drunk substances found around the ihcHJjseaj'i;^)' lid! about half the cases; iheserisubstances are medi cines of one kind or another. In' the ofhk?y^if;|i;;hb'^hiid' products such as cleaning and polishing agents, pesti cides^: turpenuoe; petroleum products and cosmetics are involved: In 1967, for example, among all substances 'most frequently ingested'* by such children, paint.:! leaded and nonleaded) ranks ;26th. and involved i percent of tji'tjc>ka||Ifjin' 395 centers in 43 states. However, manv leadpoison- ingicasesiaremot: reported to: these cen ters. .so that such figures indicate: the exjt^ntilojf'i^cjucelipoAopfo0'1 cases from, other substances but not from lead ingeauoa. : ':: Studies have shown thar almost every Plumbism also shows close family re lationships. If ooe member of a fam ily; 'I' found to have plumbism. all the children between 1 and S vean of age should be carefully checked, since there it a 33 percent incidence among children living m the same household Most v u 'it s are betweea 1 aad 6 years or age. with 85 percent m the 1-3 year old group, as noted;da page 5 of the Children s Bureau pam phlet (2) These toddlers loftesi crawl acout wrheut SLDerision. Either as an aspect of pica cr r the oral ex ploration usual to childreniof this age. chey-iimayi!iipick;!i,up,ii:and'i.ea^!;p|Wt' chips fouad on the floorsL or chew o q phbs or windowsills that were long ago covered with lead-beariog paiof. Cer tain lead compounds irje; ^npw;d',to case of chudhood plumbism is related to old lead paint in old buildinp. a situation found mostly in large cities, { numiv these east of the Mississippi | River 'o Baltimore for example, have a romewhat weet! taste: which may accentuate the app eil!:: tb chil dren s paiares As pointed put do page 6 of 'he Children sii'iiBureau booklet f2), from three to||t{j^ii|t^s'!^f!fii.i:iy j where childhood plumbism has; been j brought under control, early studies I showed that from 50 (o 70 percent of steadv lead rgesnon precedes ne appearance of 3veW:iyWptoms m al most a.I patients ! old houses id ome slum sections had : flaking paint that contained lead. The Factor of Piet i P'ca. a >erv common precondition, is Housing-Plumbtsm Relation the medical term for an unnatural The relation of housing ito plumbism craving for dirt or other nonfood was mown a a Rome survey of pre- items Some studies found that from schoiol'children in Cleveland, which "0 to 90 percent of children suffering ! has had a studv and control program from plumoism had a history of pica. for vears Of *01 -.'i.ldren living m In a New York City study, more than I old houses. 216 >2" percent) i had ab- J urmalmlewd concentrations to their 30 percent ot children with a diagnosis of.p.ca were found to have lead poi urme, and 38 (4 7 percent) were al- soning. (ilill) lAnstudy of 7S4 Baltimore children from underprivileged areas disclosed that nearly 22 percent had pica. fl2) Ip most cases, pica was es tablished . as a habit by the second year but had disappeared by the fourth or fifth yeari The causes of pica are unknown de spite various.theories, to the present' scate.of'.kQowiedge. it, should be rec ognized that pica is widespread, occurs pahtcuiarly, often in poor fam ilies. and is a poteotiai source of metal add other poisoning, as well as of in testinal parasites. : Df. Chisolm of Johns Hopkins, a liitijin: the field' of cHillu.irii|b'i/.oicsitep1:'.,ihatt - fti%toi;icill|.1;lpiica|:!i:^SpjsimS' ; |p!!!be:i:|ifeiated' mainiv 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 i Emotional Eoviroameat DnChisoimalso 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 anxiety fisixemforced; by cultural pat terns and to whom the mothering nec essary to stop it is unavailable for a varietv of reasons. When such a child is exposed to hazardous environmen tal lead sources, the likelihood of plumbism is indeed great." (13) ! ! Medical Aspects of Childhood Plumbism It is oot 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 andi must be placed iirt <!the: hands of experienced physicians. The enclosed pamphlet by . the Children's Bureau offers37 authoritative: references. (2) In addition. ai: 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 acuveiv engaged in pediatrics, symp toms and signs often are so common place and nonspecific that initially thev mav be overlooked. Cases may occur without being suspected; o q 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 plumbam problem ui urban slum areas. Being aware of this fact should make phy sicians more inclined to recognize tod investigate symptoms they ordinarily would not associate with lead intoxi cation. ------- 1 Check on Chewing end Pics 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 bv the age of 15 months and should never be of great intensity. Though the presence and history of pica is important, diagnosis should not rest on these alone; Manv lead intoxicated patients ha*e been found to have no historv of ptca 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, suchas woodwork, plaster, wallpaper or putty, for at least three months before clinical signs ap pear. Though these materials them selves do not contain Lead, they were often coated with, leaded pamt rr.an.vvears ago. When a suspected case of childhood^ plumbism xs seen, a check should be made to learn if the c^iid fives m or frequently visits a house built before World War II. A list of "high-risk" addressed could1 ;be ported ;n ail pedi atry: clinics to help physicians un familiar with the city. Most cities withthe problem do have such areas of high nsk. Signs and Symptoms A diagnosis of lead poisoning should bp^baied'i'din.clinicarfiudmgs and sup ported by biochemical evidence of excessive lead absorption, and.pos sible, by evidence of unusual expo sure. There are a number of signs and symptoms which should arouse the suspicion of physicians and orders, particularly if the patient >ivs n a slum area. They are not diagnostic by themselves, but are mdicatioos that emergency laboratory tests are required. The signs and svrrptoms listed below are not intended -o be either definitive or exhaustive for a thorough consideration of these ->~b- pMC00006^ > jecu. the physician should consult the medical literature. of. the seizures switches back aod forth between right-sided, left-sided Tests for The sigrts 'and.symptoms of lead ac cumulation in children chiefly involve three organ systems: the gastroin testinal astern. the. central', nervous and generalized, the possibility of plumbism should be investigated. The physical examination in such cases may reveal inflammation of the optic Plumbism As noted above, the presence of one svstem. and the hematologic svstem. nerve, ataxia Hack of muscular coor or more hematological, intestinal or (if) , dination), lethargy or seizures--with neurological signs or svmptoms :s not $ The; gastrointestinal symptoms are or without local paralysis and with or without reflex changes-and as such tn itself diagnostic of pediatric iead ifltoxipauop, Laboratory tests are those which are most, likely to be no ticed first by parents and other lay men. Thev consist of vomiting, complants: of vague abdominal patn' 'and constipation. serves to confirm the involvement of the central nervous system but does opt provide exact evidence of cause. Hematological findings: Parents will necessary for the p.h>sician to de termine whether hts patient has aesorbed Jead m quantities sutficieat to induce illness. ''.' Tihese'ljare fairly common complaints among children, but. the examining physician should be aware that plumbsm m*v b* the true . ndcrlving cause. be unable to detect changes in the blood lisf'i.:possibly affected child. The physician may , wish to r. check tor anemia before asking for specific blood l<:ad tests; Iron deficiency By far the most reliable test for 'ead absorption is the quantitative deter mination of the lead content of the blood. Sioce speed isotten extremely irn^ortarit 'j'in,: diagnosis of childhood He should also be aware that parents anemia is common in toddlers, and b|ui^bism:i ijji^ that proper treatment often are ooc of much help to his efforts to obtain definitive informs> does not necessarily mean that the child has absorbed potentially toxic can be undertaken, such a test ougnt tj): fee ordered iimmediitjely upon the cion A survev of 300 children iwtth aiTvOUntsibfj'iead;: '' ' ' firsti suspicion. confirmed cases of plumbism showed that 76 percent of them had no preert.Af cnmpla ms rut when specific and deta ted nqu*rv was made t was found that 58 percenr had loss of aopet te and v percent had vomiting: In arofet sudv of .2 children Aificieii with severe 'ead encephalop*nv t was found 'hat I* had been ''rated > mptoiTiaiicxilv for gastro enteritis for JiTepent periods of time "ercre svmptcns of central nervous s en n o emert became aupa'enr Tome of *he*e children had also been 'rated ter anemia, ..cnstipauopl sugar n trie urn* gait disturbances and sudder. onset of crossed or skewed eyes; ! Accord ng *o Dr Chisolm iKere are i wo g'OLos cf children evolved: **ose with asvmptomanc increased lead absorption, and those with lead pcisco og The hrst group which prnnabU contains the 'argest number. re chi dren who show evidence <:of increased body lead burden without evidence of toxicitv The diagnosis of lead coiscniog Dr Chisolm: isays. *ould be peserved fcp those children who m addition to evidence irof ian increased body lead burden. aJsonshow biochemical evidence of toxicitv This latter evidence includes increned output of coppoporphvpiQ Ind/or deltaminolevuiintc acid in urine Blood lead concentrations should be interpreted with caution as these val- by a number of flcfOrsl^f: 'Competence and ex perience of laboratories and laboratdry technicians. methods used in the collection and storing ot: samples, and possible ree'ent administration of cneUtmg agents. 1 ' Blood-lead concentrations of -0 to 60 :per 100 rruilihters of blood have been used bv various agencies as the upper limit of the J'fo.r children. For ex ample. the Chicago Board of Health reters.ail children with lead vaiues Cental itrvoui n item mvolvtmtnt: The most sene us manifestations of cmldhood plumbism are those that emit from nvolvemem iwtth the brain These mav range from drown* ceas to deep unconsciousness (coma); or repeated fits (grand mo/ seizuws). Io some cases ih first dues to the in Some of 'hese will show no clinical *igns. Dr Chisoim savi Because of tne nebulous nature of the clinical signs aud svmptoms we should de mand that patients with signs , and svmptoms suggestive of lead mioxication aiso have biochemical evidence of mtorics.ion ' 115) above 50 micrograms to a soec-.al chnit.^orlme1 diagnosis and treatment of lead'poisoning, whereas other Suggested1 60 rmcro- drams;j|-a*li|ihe: upper normal limit ot blood lead concentrations. 111. 16. 17).There appears to be general ajgrt^ concen trate ns between b0*80 micrognrr* toxication are repeated falling;chjm* abnormal ansorp- smess or loss of coordination. In other tion of 'ead. but often not of a degree cases convulsions mav bn ng the child of absorption which is capable or in to medical alter tioo. There also may ducing svmptoms of intoxication. be reading or behavior problems; Blood concentrations of 30 micro- Frcm ne physicians pomt of view. thepe is nothing especiaJIv character istic about the ;on*ulsioris*ii:fdr they mav ocrur without fever and imay be focal or genera ized However; if io the course of a few hours, the pattern grams and aoove are considered to ne potentially capable of inducing intoxi r cation. requiring immediate action mciudme.'iboih referral for treatment and removal ot the child from me _ source df : exposure; PNYC00006546 Blood lead determinations are the most reliable method currently avail able to communities with active pro grams aimed at controlling childhood piumbrsm. According to Dr. Chisolm, a test receatlv developed for estimat ing deita-aminolevulimc acid (ALA) to urine is simple, rapid and inexpen sive aod may be suited for;,;most screening if it can be shown that the concentration of ALA in ' random sarripies of urine provide sufficient discrimination: between normal and : children. ' However, ti Ifet iiiitfi^nijjtis;;n^cfes^iaiiiiy;':.fee^9^c Commissioner O'Connell slVsijlaii^fi?1 st^d^;:tii'::t;hai:i^ityi. ;|*||Hic:hi;|iiij!|^b! 'j^e.'^iibii wif^||^|tii^|i;;||feay ;i in: ^spre^ilng'' i'ifjsr asymptomaticleadintoxiciuon.) L'nne lead analyses are generally limited to usefulness in clinical re search and in manajpsneae of hos pitalized cases became they require 24-hour collection of urine to yield useful data, says Or:: Chisolm. The edath2mt! 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 haying chronic plumbum.3he notes. (13) < Dr. O'Connell says the EDTA mobil ization test is used in ail age group* in Chicago's lead clinic with urine 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 view* and, contributions of the authors and six other experts iq the Held 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 m Childhood." J. Julian Chisolm,1 Jr., us Journal of Pedt* atnes (Vol. 73, 1968), "Lead Poison ing in;:Childhood: Signs; Symptoms. Current Therapy, Clinical Expres sions." Joseph Greengard. in Clinical Pediatrics. May 1966; and "Pediatric Lead Poisoning," Hugo Dunlop Smxihmis Archives"\of Environmental Health, February 1964. References 1. USA Standards Institute (formerly American Standards Association). American Standards Specifteatiow to Minimize Hazards to ChBdre* from Residual Surface Coating MaaertoJa. Standard 2664 1964. 2. Lm-Fu. Jane S.. M.D. Lead Pofaoatag la Children. U S Department of Health. Education and Welfare. Chil ....... .dren's Bureau publication No. 4J2- 3. Scbucker. George W.. Vail, Edward H4 Kelley. Elizabeth 8.. and Kaplan. Emanuel Preveadoa of Lead Fatal Potooatag Among Baltimore Children. Public Health Reports 80(U):969974, November 1965. 4. Baltimore Cuv Health Department. LeadPaiat Poisoning la Children, ISIMLiti.: ' 5. Dr. Morgan J. O'Connell. Personal communication. | 6. Blanlcsma. Lorry A.. Ph,D.. Sachs. , Henrietta K.. M D. and Nturnv. Ed ward F. M.D. Incidence of High Blood Lead Levels in Chicago Chil dren, Paper presented at annual meermgof American Association of Poison Control Centers. Chicago. Oct. 21. \968. 7. Chicago Board of Health. To Save A Life. Film. 1968. 8. Dr. Felicia Oliver-Smuh. y_>\ ; Citv Health, Department Personal i comraunicatioa. j 9. Verhulst. Henrv L. and Crottv. John j J. Childhood Poisoning Accidents. I Journal of the American Medical As, socianon 203(12):U5-U6, March 13. 1 1968. : | 10. Griggs. R:C-. Sunshine. L. NewdL | V.A.. Newton. B W.. Buchanan. S. ! and Rasch. C.A Environmental Fac- j too l* Childhood Lend Poisoning. ' Journal of the American Medical As* | sociation 187:703-707, 1964. | 11. Jacobzmer Harold. Lead Poisoning I in Childhood: Epidemiology. Manifes- } tattoos^ nod Prevention. Clinical Peji- j ames 5(5):277-286. May :966. 12. Cooper. Marcia. Pica. Charles C Thomas, publisher. Spnngrietd. Hi 1 1957. 13. Chisolm, J.J.. Jr. and Kaplan. Eugene. Childhood Lend Poisoning--Compre hensive Management and Prevention. Journal of Pediatrics 73(6i:952-950. December 1968- J 14. Dr.1 Hugo Dunlop Smith. Personal. communication. j IS. Dr. J.J. Chisolm. Jr. Personal comI menfeatioo. ^ 16. Chisolm. J.J,. Jr. Lend Intoxication in Children. Developmental Medicine and Child Neurology 7:529-536. Octo ber 1965. 17. Green gard, Joseph. Lead Poisoning in Childhood: Signs. Symptoms. Current Therapy, CUakai Expressions. Clini cal Pediatrics5(5):269-276. Ma> For other reading on lead and pedia1 tries see next page. pHtCOOOO*^ Other References Bvers. R K.. and Lord E E, Late Ef fects of Lead Poisoning on Mental Development. American Journal of Diseases of Children. 66:4?t. Novem ber 1943, Chisolm. JJ.. Jr., and Harrison. H E. The Exposure of Children to Lead. Pediatrics. 18:943-957. December 1956: Chisolm. J J.. Jr. Treatment of Lead Poisoning. Modern Treatment. 4:710, Julv 1967. link Acid (ALA) Levels in Lead Polsooing II. Correlation of ALA Valuta With Clinical findings in 250 Children With Suspected Lead Ingestion. Ar chives of Environmental Health. 17 (2):164-l7l, August 1968. Feigm. R.D.. Shannon. DC.. Rey nolds. S.L.. Shapiro. L-W, and Con nelly. J P. Lead Poisoning in Children. Clinical Pediatrics. 4:38-45. January 1965. ' Gordon. Neil. King. E.. and MacKay. R. I , Lead Absorption in Children. British! Medical Journal. 2:480-482, Mav. 1967. Greengard. J.. Adams. B. and Berman. E. Acute Lead Encephalopathy in Young Children. Journal of Pedia trics. 66.707-711. Apnl 1565. Guieiius. M.F.. Milhcanii F.K., Lay man. E.M . Cohen. G J and Dublin, C.C. Nutritional Studies of Children with Pica. I. Controlled Study Evahe ating Nutritional Sums. IX. Treatment of Ptct With Iron Given iotnauacatarty. Pediatrics. 29 1012. 1962. Ingalls. T H . Tibom. E M . and Werrin, M. Lead Poisoning in Philadelphia 1955-1960. Archives of Environmen tal Healthi3:575*579, November 1964. Jenkins CD and Mellins R3 Lend Poisoning in Children: A Study of 46 Cases.; Archives1 of Neurology and Psychiatry, 77:70-78. January 1957. lican. F K. Why Children Eat Things That An Not Food. Children. 10 u;> 1963. Mellins. R. B-. and Jenkins. C D Epidemiologicai and Psychological Study of Lead Poisoning in Children. Jour nal of the American Medical. Associa tion, 158:15-20. May 1955. Millican. F. K., Lav man. E. M Lourie. R. S.. and T.akahashi. L. Y Srudv of an Oral Fixation: Pica. Journal ot the American Academy ot Child Psv. chiatry, 7:79. L968. Moncrieff. A. A... Koumides. O. P . Clayton. B. E.. Patrick: A D. Renwick. A. G. C.. and Roberts. G E Lead Poisoning in Children. Archives of Diseases m Childhood. 39:i-i3. February 1964, Perlstern. M. A., and Attala. R. Neu rologic Sequelae of Plumbum tn Chil dren. Clinical Pediatrics. 5:292-298. May 1966. Sanaim P.: Whitaker, J. A., and Mar tin, J, i The'Absence of Lead Lines io of Children With Eariv Lead Poisonings American Journal of Roentgenology, 9l::597-oOl. March ; 1964. Smith, H. D. Pediatric Lead Poisoolag. Archives of Environmental. Health; 8:256-261, February 1964. ! Whitaker. J. A., and Vietta. T J Fluo* rtscence of the iErythrocytes in Lead Poisoning in Children: An Aid to Rapid Diagnosis. Pediatrics. 24:~34. I 738. November 1959. Diagnosis of Inorganic Lead Poison ing: A Statement. British Medical Jour nal. P. 501. November 23. 1968. t I PNYC00006549 The Lead Industries Association. Inc. i is a non-profit organization of lead ! mining, smelting, refining and fabri cating companies throughout the Free [ World and is incorporated under the Membership Corporation Law of the j State of New York. Among other- things, its purposes are to disseminate 1 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 I its product and. in general, to promote the serviceability of lead industries to I the community at large. ' LEAD INDUSTRIES I ASSOCIATION, INC. ) 292 Mftdtaoa Avene. I New Yoffc, New Yoct 10017 11 PNYC00006550