Document K6gj6QdeX84reXkM5brgMajj6

Lead Poisoning in Childhood: Epidemiology, Manifestations, and Prevention HAROLD JACOBZINER, M.D * Lead intoxication in childhood is largely a disease of the big cities, and especially of the slum areas where old deteriorated housing prevails. Here is an account of observations and experiences .in the me tropolis of New York City. JL/EAD poisoning in child mimics to be a major public health probk )w York City and other urban areas. It lea*. ^ath in about 15 to 20 per cent of cases, and to neurologic and mental disturbances from encephalopathy in over 25 per cent of the survivors. Of 61,167 poisonings reported to the New York City Poison Control Center between 1955 and 1963, 3 per cent or 1,704 cases were due to lead. Figure 1 summarizes the distribution of poisonings according to etiology during this period. For many years, lead poisoning was recognized in children only when associated with lead en cephalopathy--when clinical signs and symptoms of central nervous system irritation aroused the examining physician's suspicion of the possibility o! lead poisoning. Little, if anything, was known by the average physician of the sub-clinical or asymptomatic phase. Systematic, careful epidemio logic investigations of the natural history of the disease were not widely available and many vic tims went unrecognized and untreated. Lead poisoning in children may be compared to an iceberg, with the small visible portion being cases of lead encephalopathy and the major por tion being the invisible and as yet asymptomatic patients. Epidemiology of Lead Poisoning Significant gains will he made in controlting and preventing lead poisoning in children, only when we have more knowledge of its natural history. * Deceased February 8. 1966. Request for reprints should be sent to the City of New Yoik Department of Health, 125 Worth Street, New \<nk. X. Y. 10013. The essential tools of epidemiology must be uti lized to obtain needed facts about the agent, host, environment, mode of occurrence, place of occur rence. and the interplay and interactions between these components. An intensive study must be nude of how lead poisoning occurs, where, when, to whom, and why. The population at risk, the injurious agent and the unsafe environment must be identified, investigated, and defined. The agent is usually lead-containing paint The host Is a child between one and five years of age, particularly, one with pica, the etiology of which has been extensively outlined elsewhere.* The usual environment is an old, poorly repaired house in a slum area with many coats of leadcontaining paint, one on top of another, cover ing the walls, ceilings, woodwork and other indoor surfaces. Fallen paint flakes from walls and win dow sills and painted plaster from walls are easily accessible to the young child who is a "mouther." While inhalation of lead fumes and absorption through the skin may also cause lead poisoning, all cases in children reported in New York City in the past decade have occurred as a result of ingestion. The Search for Cases Pica is a particularly valuable clue in the epi demiology of lead poisoning.* Its incidence is now an integral part of the medical records in child health stations of the New York City Department of Health. These agencies follow over 200,000 in fants and children from birth to school entrance. Since 1955, a history of pica has been a routine part of each medical history'. Inquiry h also made about pica in other members of the family. Where pica history is positive the examining physician, alerted to the possibility of lead poison ing. conducts examination with special reference to possible associated signs and symptoms. A specimen of blood is obtained in a lead-free tube from every child with pica, as well as from all siblings under six years of age. The blood is examined in Health Department Laboratories for lead content. If the eomeniraiion of lead is 0.06 mg./ml. whole blood or higher, the child is referred for CUNICAL PEDIATRICS Mr 1966 277 GL0351A8 MCOBZINE* Fig . I. Poison Coptrol Center, New .York City Department of Health, percentage distribution of 61.167 cases of poisoning re ported in children under 20 years of age. by type of poison. New York City: 1955-1963. ix t x w u i j bdo s teenur jsrocs a ccs'xnes accsEBota rutynurtoas yjsnotjKs ixa MSOlUWOOS treatment to his family physician or to a hospital clinic. Over SO per cent of children with pica in our study had lead poisoning. Siblings of con firmed lead poisoning cases, though usually asymp tomatic* produce a high case yield as determined by blood lead investigation. A diagnosis of lead poisoning is made if (he blood lead concentration is 0.06 mg./lOO ml. or higher and if two or more of the following signs and symptoms are present: gastrointestinal signs of anorexia, vomiting, abdominal pains or consti pation; hematologic findings of pallor or anemia; neurologic signs of irritability, stupor, lethargy or convulsions; and roentgenologic signs of increased density of the long bones or opacities representing lead Oakes in the abdomen. Jf there is a history of pica plus a blood con centration of lead of 0.06 mg. per 100 ml,, but no signs or symptoms of disease, the case is classi fied as ''possible" lead poisoning. The family is told of the harmful effects of pica and of the need for periodic repeat blood lead determina tions. 278 In addition, a public health sanitarian visits the home of all confirmed and possible lead poisoning cases io make a general sanitary in spection, with particular reference to evidence of availability and ingestion of lead paints. He also examines plumbing for lead pipes, takes samples of water for chemical examination where indi cated, and samples of paimed plaster and paint peelings for chemical analysis of lead content.' In the lead belt, the high incidence areas, pub lic health sanitarians visit every house in desig nated blocks. They take scrapings for lead deter mination, inquire about pica, take samples of urine from all children under six years for a coproporphyrin test, and advise the parent about die harmful effects of pica and its association with lead poisoning. In the case of a hospitalized child with lead poisoning, a public health nurse visits the home prior to discharge. She obtains addi tional epidemiological data, urges parents to bring siblings in for examination, and educates the family in the prevention of lead poisoning. Vot. $ N*. 5 CLINICAL PEDIATRICS GLD35149 ,y s LEAD POISONING: EPIDEMIOLOGY Incidence of Lead Poisoning in New York City Accurate information is not available on the true incidence of lead poisoning in childhood, since many cases go unidentified and undiscovered. Lead poisoning has been reportable in New York City for many years, but only 14S cases were re ported from 1950 to 1954, an average of 29 cases per annum. Last year, 1964, over 500 cases were reported. The case fatality rate from 1950 to 1954 was 27 per cent, compared with less than 2 per cent in 1964. There is no reason to believe that the incidence is higher in 1964 than it w*as in 1954. In fact, there is more new housing now with low lead-containing paint, plus the comprehensive educational pro gram carried on against lead poisoning. The ap parent increased incidence is undoubtedly due to the vigorous case-finding program carried on since 1955, which has discovered cases in the asymp tomatic stage, prior to the onset of encephalop athy. Prior to 1958, nearly 60 per cent of all cases were reported from only three hospitals, chiefly because one or more staff members were particu larly interested in the condition. Since 1958, how ever, public health officers have carried on an intensive professional training'"program. They speak before hospital staffs, display exhibits, and distribute published articles to acquaint physi cians in New York with the problem of lead poisoning in childhood. Last year, over 50 hos pitals reported cases and requested blood lead examinations. Table 1 summarizes the incidence. of lead poisoning in children, plus case fatalities in New York City from 1954 to 1965. The years through 1950 and 1954 produced only 14$ reported cases, but 50 of these germinated fatally--a case fatality ratqtof 27 per ceijt. The apparent increased inci dence, but decreased fatality rate in subsequent years as summarized in Figure 2 is, we feel sure, due primarily to the additional efforts in case findings currently employed and to the physicians* increased awareness of this problem. Table 1 also demonstrates a 264 per cent in crease occurring in the number of cases reported in 1964 compared to I960, and a decrease of 87 per cent occurring in the case fatality rate. In addition to the confirmed cases, there were over 100 possible cases in 1964 with blood lead levels of 0.05 to 0.06 rog./lOO ml. blood and with a history of pica, but with no symptoms indicative of lead poisoning. These cases are being followed. Case distribution by age. sex and race is shown in Tabfe 2. The younger age groups, the one to three year olds, contributed 82.5 per rent of the total cases. Distribution varied from 0.5 per cent Tabl e 1. Coses of Childhood Ltod Poisoning Plus FcInlilUs in Xcr York City From 19S4 to /9oi Year 1954 1955 1956 1957 1958 1959 1960 1961 1962 1965 1964 Total Cases 80 115 99 85 116 i?i 146 181 19S 358 509 2,038 Deaths 12 18 9 9 21 12 18 6 9 7 7 128 Case Fatality* 15.0 15.7 9.1 10.6 18.1 7.0 12.3 3.3 4J 2.1 1.4 63 * Deaths per 100 cases. in the group under one year to 40.7 per cent at age two. After the third year of life the incidence decreased with age. While more cases were re ported in males, sex distribution variation was not statistically significant. A marked ethnic variation was observed with a disproportionately high incidence in the Puerto Rican and nonwhite groups. Of the 1,460 known cases, nonwhites contributed 46.7 per cent; Puerto Ricans. 59.5 per cent; and Caucasians. 15.8 per cent. This is in marked contrast to the general population distribution in New York City. According to the 1960 census, the nonwhite population under five years of age was 19.9 per cent, and the Puerto Rican 15.6 per cent of the total. Thus, these two high risk groups contribute only 55.5 per cent of the total population under five years, but they contributed 86.2 per cent of reported cases of lead intoxication. Specific case rates by race are shown in Table S. It can be seen that the nonwhite rate is about five times higher than the white. Thu disparity is a reflection of environmental factors, particularly, dilapidated sub-standard hous ing. Such homes provide ready access to broken, painted plaster trots walls and paint peelings from window sills and ceilings. In nearly 90 per cent of the reported cases, a careful history revealed that affected children ingested flakes of plaster or paint peelings for several months prior to diagnosis. Distribution of Deaths Due to Lead Poisoning Nearly 54 per cent of all deaths from lead poisoning occurred in two year olds. No signifi cant difference was noted in the mortality inci dence based on sex, except among whites. Here, females outnumbered males two to one, but the total number of deaths in this group, however, arc too few to warrant any valid conclusions as CLINICAL fEOIATJtICS Mar )9U 279 GLD35150 JAC0SZ1NER Fig . 2. Age specific races of reported caret of lead poisoning in January, February and Much, 1963, for health dmrjcu not. 2, 3, 4, 6.6 in Brooklyn: rest of dty (per 30,000 population). to whether the female is more vulnerable. Death statistics are summarued in Table 4. The Dead Belt A majority of the cases of lead poisoning in New York City occur in several slum areas out lined in Tabte 5. A random study conducted from January' through March, 1963, showed 151 cases of confirmed and possible lead poisonings. Nearly 46 per cent came. from five health districts in Brooklyn and 54 per cent from the remaining 25 health districts. New York City is divided admin istratively into 50 Health Districts each with ap proximately 300,000 population. Tabl e 2. Distribution oj Lead Poisoning in Xex lark City According to Age, Sex, and Race From JP54 to JP63* Male Female Age (in Yrs.) Non- Unk, White White Race Tout Non- Dnk. White White Race Total Total Under 1 1 2 $ 4 5 6 k over Unk.age Total Per Cent 4 30 1 101 127 7 235 156 153 13 322 79 54 4 137 29 22 5 56 17 6 3 26 18 31 1 30 0 02 2 404 376 35 S15 26.5 24.6 2.3 53.4 0.9 ] 2S& 101 39.5 152 16.8 74 6.9 26 3.2 !! 3.7 7 0.2 3 100.0 374 24.5 0 0 1 0.1 8 97 8 206 29.0 441 132 14 298 42.0 620 56 7 137 t9S 274 13 1 40 5.6 96 7 0 18 25 44 1 0 8 1.1 38 0 0 2 OS 4 306 30 710 103.0 1525 20.1 2.0 46.6 100.0 0.5 28.9 40.7 17.9 63 2.9 2.5 0.3 100.0 * Four cases not included in the above figures, are 1 unknown age, sex and race. Puerto Ricans constitute 74.2^ of "White" race classification. 280 Vet. 5 N. 5 CLINICAL H0IATRICS LEAD POISONING: EPIDEMIOLOGY Tabl e 3. Xumber of Cases of Led Pchonws, in Perseus under 21 Years of Age per JOft/M Pepidjlhu will: Distribution Aeeording to Jtoce* Race 1954 1955 1956 1957 195S 1939 1960 1961 1962 196.1 White" Xon-white Total 1.5 3.3 6,4 8.0 2.4 4.2 2.2 2.3 33 5.1 4.0 4.3 4.5 8.1 11.7 8.3 104 15.4 14.7 21.3 21.4 36.3 3.9 3.4 4.7 7.0 5.9 7.3 7J0 13.1 * 1960 Population used as standard. * White race includes Puerto Ricans. Housing facilities, socio-economic standards and educational attainment are all poor in the dis tricts where the incidence of lead poisoning is highest. The.ages of affected children in these areas are outlined in Figure 3. Physicians in these areas of high incidence have developed great skill in diagnosing cases, particularly in the asymp tomatic stage. We previously indicated that identification of lead poisoning is to -a large degree dependent on how hard one looks for it. Our motto is "look and ye shall see." Because of our intensive pro fessional educational program, we are now find ing cases of lead poisoning in areas of the City which were formerly considered to be lead free.4 Lead paint poisoning is inextricably linked with old, dilapidated housing. No cases are be ing reported among children Jiving in newly constructed housing projects even in the districts of highest incidence. A house of old vintage in a slum area is an excellent clue, and blood lead determination in the children under five con firms many asymptomatic and previously unrecognired cases of lead poisoning; Seasonal Incidence Lead poisoning and lead encephalopathy is encofimered more, frequently in the summer months, but it is not strictly a summer time disease. Distribution of cases by month are out lined in Table 6. The higher the physician's awareness, the more cases he will identify even during the winter. In 1963, 42 cases of confirmed lead poisoning were reported during December; this figure increased to 66 iu December, 1964. Again, the more intensive the search, the greater the yield. There certainly is a marked seasonal variation in reported cases of lead poisoning with its peak during the summer. Forty-five per cent of the total cases reported between 1954 and 1963 oc curred between June and September. The exact cause for this seasonal variation is unknown. Reasons postulated include: (1) a metabolic dis turbance whereby there is increased lead absorp tion because of the actinic rays of the summer sun; and (2) a greater opportunity to ingest lead containing paint used for exterior surfaces. The seasonal incidence of deaths due to lead poisoning is striking as seen in Table 7. There has not been a single death in November, De cember, or January since 1961. Of the 121 deaths from lead poisoning since 1954, over 61 per cent occurred between June and September. This may indicate a greater risk and severity of lead in- Tabl e 4. Deaths ttt Children under Twenty Years Due to Lead Poisoning in Pice York City From M54toJS>63 - Race and Sex White Male Female Non-white Male Female Puerto Rican Male Female Total Under 2 2 --3 36 6 17 8 15 5 14 1 14 23 69 Apr 34 2-- 1-- 4-- 6-- 4-- 72 24 2 S 6 and Over --_ -- ---- ---- -- --* 2-- 1-- 3-- Total S 10 27 29 25 25 121 CLINICAL PEDIATRICS May 1966 28! GLD3515? JACOBZINER Tabl e 5. Xurnber ej Coses oj Ltd Pohcnnm Reported by Health Districts during January, February, and Merck, J963, in Kno York City (In Yrs.) Less than 3 3-4 5-9 Total Per Cent New York City . No. 90 59.6 40 26.5 21 13.9 151 100.0 100.0 Bedford No. % n 61.1 s 27.8 2 U.l 13 100.0 11.9 City & District Browns* viJJe Buslitricfc Ft. Greene No. tff No. % No. % 11 73.3 1 67 3 20.0 15 100.0 9.9 6 46.1 2 15.4 a 38.5 13 100.0 8.6 9 64J 4 28.6 1 7.1 14 100.0 94 Red-Hook Gowamis Rest of city No. -% No. % 5 55.6 3 33.3 1 11.t 9 100,00 6.0 48 58.5 25 30.5 9 11.0 82 100.0 544 toxication during the summer. If stored and in gested lead is, indeed, more readily absorbed and distributed to the tissues during the summer be cause of greater ultraviolet ray exposure, the nerve tell, being highly vulnerable, is more susceptible to the ravages of lead, and, hence, the higher fre quency of encephalopathy during the summer. Our epidemiologic studies show that lead en cephalopathy is much more frequent during the summer, but asymptomatic lead poisoning is a year-round disease. The same etiologic ingredients which cause lead poisoning prevail throughout the year, so it is exceedingly important to think of lead poisoning year-round and to detect cases in their incipiency, prior so the onset of the sum mer. This will minimize the possibility of lead encephalopathy with its resultant brain damage and possible death. Sources of Lead Lead enters the body by ingestion or inhaty lion. Sources include food, water, Contaminated air, glazed dishware, painted toys and cribs, and discarded lead battery casings. I have reviewed the lead source in each case reported in this study, however, and greatest sources by far are painted wall plaster and paint peelings from ceilings and window sills. Sources of lead in this study were: painted in door surface*--65 per cent; painted surfaces in the halls of multiple unit dwellings--4 per cent; undetermined and nonspecific--SO per cent. In 91 per cent of the cases, a definite history of pica was obtained, and evidence of broken painted surfaces and of paint peelings were evident in 85 per cent of the homes surveyed. The bedroom was the area of greatest potential exposure, fol- cass n u u n 282 Fc, S. Lead poisoning--ease fatality--deaths per 100 cases--New York City: 1954-1963. VW. $ No. 3 CLINICAL PEDIATRICS GLD35153 Tabl e 6. Distribution by Month of Coses of Lead Poisoning in AVu- York City, J9S4-J96J Month Total 19541963 1954 1955 1956 1957 1958 1959 1960 1961 1962 JanuaryFebruary March April May June July August September October Novembet December 71 __ 7 7 4 9 10 10 13 50 -- 6 6 3-- 3 9 12 2 95 1 12 5 3 2 6 15 13 19 87 4 , 7 5 2 12 11 6 18 106 4 5 58 3 14 15 11 17 132 1 12 4 5 10 19 17 18 17 179 3 10 15 12 15 21 14 28 19 163 11 4 13 11 9 26 15 IS 24 216 6 32 14 10 30 29 13 19 29 172 13 15 13 11 20 16 5 18 11 112 14 7 4 6 11 20 10 11 10 146 23 7 6 4 10 6 12 17 19 Total . ' 1,529 80 115 99 85 116 17! 146 m 198 1963 11 9 19 17 24 29 42 42 34 50 19 42 338 lovved by the kitchen, then the bathroom, and finally the Jiving room. Holes in vails were noted in 32 per cent of houses with highest frequency again in the bed room. followed by the kitchen, Jiving room and bathroom. Broken walls were observed in 20 per cent of the households with the bedroom still heading the list, and the kitchen and bath room close behind. Chewed window ledges were observed in 11 per cent of bouses surveyed with most again noted in the bedroom. No potential sources of lead were found in 17 per cent of the cases. The New York City Health Code prohibits the : use of lead paint in excess of I per cent. When the Department finds paint in dwellings which contain more than 1 per cent metabolic lead, based on the non-volatile content of the paim, it may order removal of the paint and the re finishing of the apartment, room, or part of a roonr wiih a suitable finish which is not in viola tion of the Health Code regulations. As soon as a real or possible case of lead poison ing is reported to the Department, a Public Health Sanitarian inspects the patient's dwelling looking for peeling paint, broken plaster, or lead water pipes and utensils. He notifies the landlord of any violations and also informs him of any ocher problems, such as plumbing defects or rodent conditions. He questions the mother about pica in any of her children under seven. He takes paint peelings and scrapings from any lead water pipes to the laboratory for analysts. The Sanitarian leaves specimen bottles so that the mother can collect urine samples of children from one to seven years of age and makes an appointment to pick these up and take them to the laboratory. He also undertakes the job of health education. He warm the mother about the dangers of eating paint and leaves literature explaining this hazard. Landlords are required to comply with the Health Code. The Department insists that loose paim be scraped oil and the walls and ceilings Tabl e 7. Monthly Distribution of Deaths Due to Lead Poisoning in .Yea- IVt City, J9S4-J96J Month Total 1934-1963 1954 1955 1956 1957 195$ 1959 1960 1961 1962 1963 January 2 0 0 00 0 1 1000 February 2 0 1 0 0 0 0 .0 0 1 0 March 5 0 1 0 1 0 0 01 1 1 April 3 0 1 00 0 0 1 010 May 9 0 1 I 2 0 1 2 0 1 1 June 14 4 1 3 2 2 1 0 0 2 1 July 22 0 2 1 3 6 2 3 3 1 1 August 16 3 1 3 0 1 1 4 1 2 0 September 22 1 6 J 1 3 4 3 1 . 0 2 October 8 0 2 1 0 2 2 000 1 November 4 0 0 00 4 0 0000 Dectnl>er 14 4 2 1 0 3 0 4 0 0 0 Total 121 12 18 9 9 21 12 IS 6 9 CLINICAL PEDIATRICS May 1966 283 GLD35154 JACOBZINER --3 be painted smoothly with lead free paint. Moth ers are advised to cover window sills with plastic. Premises are re-inspectcd to ensure that appro priate repairs are made. 284 Routine surveys are also carried out in the high lead areas. Sanitarians go from dwelling to dwell ing filling out questionnaires about the sires of families, history of pica, and other pertinent data. VoL 5 No. 5 CLINICAL PEDIATRICS GLD35I55 V LEAD POISONING: EPIDEMIOLOGY Considerable health education o j j prevention and control of lead poisoning is also provided during these visits.* We are pleased to find that in over 95 per cent of cases of Code violations, the landlord complies within two weeks to three months from the time of notification. We feel that this action has greatly reduced the number of repeat lead intoxications in children in the past two years. Family Characteristics Lead poisoning occurs to a high degree in fam ilies of low socio-economic and low educational level, and in those with a high degree of unem ployment. We also found a 'high incidence of home disorganization. There was no father pres ent in over 50 per cent of these families and 26 per cent of'the parents were separated. These percentages are higher than those which prevail in the same districts among the general popula tion In 17 per cent of the households, other en vironmental problems were also found, and 22 per cent of the families had additional medical problems. Over 80 per cent of the children were judged to be active and curious and 15 per cent mischievous--not dissimilar to the general child population distribution in this age group. Supervision in the home of the affected child was judged to be inadequate by the visiting pub lic health nurse in about 50 per cent of the cases. Many children were under no adult supervision and a considerable number were under the super vision of grandparents, uncles, aunts or older siblings. Over 90 per cent of the families were cooperative and provided information'freely to the visiting public health nurse or sanitarian. Most important to us, however, was the fact that in also 90 per cent of the cases of lead poisoning, thj,family knew that the child was ingesting paint, but did not know that this practice was hazardous. In many families, multiple cases were found as a result of our routine search for siblings and performing on them blood lead determinations. This has proven a valuable case-finding device with a very high yield. Signs and Symptoms of Lead Poisoning A recently reported random sample of 500 con firmed cases showed that 76 per cent had no pre senting complaints. On inquiry, however, 48 per cent had anorexia and 9 per cent had vomiting. Twenty-four per cent had roentgenologic changes in the long bones, but only 2 per cent had x-ray findings in the abdomen. Twelve per cent had encephalopathy. The blood lead content ranged Iroin 0.00 mg. per 100 ml. to 0.54 mg. per 100 ml. The acerage was 0.08 mg. per 100 ml. of blood. The child with the highest Mood level in this group was a two-yearold Negro female with a history of pica of undetermined duration. The only presenting complaint was anorexia: she was otherwise entirely asymptomatic. Her hemoglobin on admission to the hospital was 7.5 grams and the urinary coproporphyrin was ! f. X-rays of the Jong bones showed condensations at the epiphyses. The child was subsequently treated with Calcium Versenate and made a complete recovery. . Blood Lead Determinations The blood lead determination is the most re liable procedure for identifying lead intoxication, particularly, in asymptomatic cases. We consider 0.06 tng./iOO ml. whole blood as abnormal and requiring further investigation. A blood lead de termination should be done when there is the slightest suspicion of lead poisoning. Blood lead determinations on suspected cases in New York City during 1965 yielded a 37 per cent positive result--a concentration of 0.06 mg./ J00 ml. of blood or higher. A urinary copropor phyria, however, gave a yield of only 5.5 per cent of coproporphyrin values of 2*f or higher. We, therefore, believe that die blood lead determina tion test is the only reliable indicator of lead intoxication. Though our current accepted limit is 0.06, at the upper limit of normal, we have had a number of patients with lower concentrations, 0.05 mg./ 100 ml. or lower, who did have severe clinical plumbism. Recently, Moncrieff* re-investigated die value of blood lead estimation, and based on his studies, he suggested that 0.05 or 0.04 should be taken as the upper limit of normal. The number of diagnosed lead poisonings in New York City has increased markedly with the routine use of blood lead determinations in cases of pica and their siblings and in all other sus pected cases. In 1950 only one case of lead poison ing was reported in New York City. Obviously, many eases and fatalities were erroneously ascribed to other causes. Now, there is a marked correla tion in the number of blood lead determinations done and the number of cases diagnosed. For a program of case-finding to be successful, provision must be made by Health Departments for blood lead levels to be performed, and to make it freely available to all physicians and hospitals. In New York City, physicians and hos pitals are encouraged to send blood specimens to Health Department Laboratories on all sus pected cases. If the concentration is 0.06 mg./ 100 ml. or higher, the j^iysician or hospital notified by phone on the same day and a written CLINICAL fD|ATKIC5 May )966 285 Hi it ' r v: li \j t 3 1* 1 M i I ii* .j i *, t: ;1 J CL035156 JACOBZINER report is also promptly submitted. The Depart* mem of Health Laboratories also train hospital technicians to do blood lead levels within thenown laboratories. The number of blood lead estimations done in our laboratories increased from 538 in 1956 to 3.113 in J964. Other Diagnostic Tests The measurement of lead exaction after a standard intramuscular dose of sodium calciumedetate was recently reported by Whitaker.* She reports a significant difference in excretion be tween normal children and those with definite or probable lead poisoning. Another test for the rapid diagnosis of lead poisoning described by the same author is the Fluorescence Erythrocyte Test. Red fluorescence of erythrocytes occurs in lead poisoning, and this observation of marked fluorescytosis may serve as a valuable aid, accord ing to the author, in very early diagnosis of lead poisoning in children. Another screening test recently described is a deposition of pigment in the retina.7 It has been recommended as a reliable sign in the diagnosis of incipient lead poisoning. Stippling around the optic disc may be readily detected on an oph thalmoscopic examination. All these tests require further confirmation. Increased Physician Awareness There are no pathognomonic mani'festations of lead poisoning in children. Thus, a prime pre requisite for diagnosis is an increased awareness of the diagnosis by physicians and a high index of suspicion--a lead poisoning "consciousness." Any slum area child between one and four years, particularly one who is nonwhite or Puerto Rican, and who is suffering from poor appetite, slight pallor, possible irritability, a sudden change of personality, or who may have headaches and other vague symptoms, should have a blood lead investi gation. Prevention--The Ideal Goal Prevention of lead poisoning is, of course, the ideal goal. The disease is inextricably linked with poor housing. It is a community problem associ ated also with geography, culture, deprivation, education and many other influencing factors. Lead poisoning will be entirely wiped out only when old housing is eliminated and when lead free paint is universally employed. The physician, however, plays a unique role in the control of morbidity and mortality, preven tion of recurrent attacks and in the prevention of brain damage. This ran and should be done by early diagnosis of die asymptomatic cases and early institution of appropriate treatment. Prime prerequisites for prevention of morbid ity and death are: 1. Increased physician awareness. 2. Increased index of suspicion. S. Routine inquiry about pica. 4. Blood lead determination on ail children with pica and also on their siblings. 5. Free and ample laboratory facilities for blood lead estimations. 6. Appropriate facilities for treatment. 7. Legislative action restricting the use of high lead-containing paints. 8. Repair of the physical environment prior to a child's return from the hospital to prevent re-exposure. 9. A view of lead poisoning 'as a common^dis ease of childhood, endemic in slum areas, and of year-round prevalence. 10. Health education at all levels, professional and parental, .on tire harmful effects of pica. 11. Pai'cnts who will take exposed children im mediately to a physician for examination ' and possible treatment, , Lead poisoning is preventable and must be eliminated. While the problem is formidable, it is capable of solution. Intensive and systematic research is needed on many phases of this com plex and multifaceted problem. We need more information about its etiology, its seasonal distri bution. about the treatment and prevention of pica, about productive health' education ap proaches, and about many other areas associated with tire prevention of lead poisoning. References J. Gutclius, M, F.: .The etiology of pica. Fed. Digest 57-68, August 1961. 2. Jacobziner, Harold: The accidental clinical poison ing problem. Postgrad. Med. 22: 283. September 1957. ' 3. Greenberg, M., Jacobziner. H., McLaughlin, M,, Fuent, H. T. and PcIIitieri, O.t A study of pica in relation to lead poisoning. Pediatrics 22: 756, October 1958. 4. Jacobziner, H. and Raybin, H. W- The epidemiol ogy of lead poisoning in children. Arch. Pediat. 79: 72. February 1962. 5. Moncrieff, A. A- Kounides. O. P.. Clayton, ., Pat- ride, A. D.. Ren-wick, G. C. and Roberts, G. .: Lead poisoning in children. Arch. His. Child. 39: 1. February 1964. 6. Whitaker, J. A., Austin, W. and Nelson. J. D.: Ethyldiamine calcium disodium diagnostic ieu for early lead poisoning. Ah j c t . J. Dis. Child. 102*. 779. November 1961. 7. Sorkin, K.t Stippling of the retina--a pc **- physician sign in early diagnosis of lead poisoning. New Eng. J. Med. 269: 779. October 10, 19G3. 286 Vet. 5 No. S CLINICAL PEDIATRICS 6LD35157