Document YGZG1gzavmzDk3qLwGDn1R0DD

Lead Poisoning in Young Children By HUNTINGTON WILLIAMS, M.D., EMANUEL KAPLAN, Sc.D., CHARLES E. COUCHMAN, and R. R. SAYERS, M.D. I'l 0 , V';`j Lead poisoning in young children associated w ith eating lead-containing paint has been in creasingly recognized until it ranks as one of the most common causes of child m ortality due to poisoning. However, lead poisoning is not a reportable disease and, therefore, there is a lack of adequate m orbidity data {1). The widespread occurrence of lead poisoning throughout the U nited States and Canada is evident from reports of cases in which eat ing lead-containing paints was mentioned as the cause of poisoning in infants and young children {2 -3 7 ). A lth o u g h 19 different com m unities are mentioned, most of the cases were from large cities such as Baltim ore and Boston, w here ch ild ren 's h osp itals or local h ealth au thorities were especially interested in the prob lem. D uring the period 1931-40, the city of B altim ore alone reported 24.3 percent o f all the child deaths from lead poisoning reported from the entire U nited States registration area ( f). From January 1,1931, to June 30, 1951, a total o f 293 cases of lead poisoning was reported in Baltim ore children. O f these, 83 died (2). The most common cause of lead poisoning is D r. W illiam s is com m issioner of health of the B altim ore C ity H ealth D epartm ent; Dr. K a p lan is chief of the division of chem istry; Mr. Couchman is director of the bureau of indus trial hygiene; and D r. Sayers, a medical director {retired) o f the Public H ealth S ervice, is senior m edical supervisor o f occupational diseases. F or several years he was director of the Bureau o f M ines, D epartm ent of the Interior. apparently the habit o f chewing paint from cribs, toys, furniture, woodwork such as w in dow sills, and the eating of painted plaster and fallen paint flakes. The tendency to put things in the mouth, though norm al in the first year o f life, is considered abnormal if continued into the latter part o f in fa n cy , and is Referred to as pica, or perverted appetite {6, 3 0 ) i P ica is the usual forerunner of lead poisoning. A lthough pica does not exist on a seasonal basis, a striking number o f lead-poisoning cases resulting from this habit occur in the hot sum mer months. For this, no satisfactory explana- A tion is available, although several investigators have commented on the tendency for lead 4 poisoning' to occur in children during the A warm er weather {2, 21, 26, 37-1+0). Diagnosis, Prognosis, and Sequelae U nrecognized plum bism , lead poisoning, in children may explain many obscure nervous conditions and convulsions of undetermined etiology {12, 2 2 ). E rrors have been m ade in operating on cases presenting sym ptom s indi cating a need for surgery but which were caused by lead in toxication {11+, 3 1 ). Lead p oison in g is cum ulative. Som e weeks >or months follow ing the continued ingestion of sm all amounts of lead, symptoms begin to ap pear. E arly symptoms may be only irritability, fretfulness, or disturbed gastrointestinal func tion characterized by lack o f appetite, consti <'& pation, vom iting, or cramps. A secondary anemia w ith resulting pallor is often present. M ore severe in toxication resu lts in lead en- 230 Public Health Report* ' i \r' .^cephalitis due to increased intracranial pressure because o f cerebral edema. T he acute stages of the disease are m anifested in changes in mental state, ataxia, persistent vom iting, muscle weakness or paralysis, delirium , stupor, coma, convulsions, and, not infrequently, death. D iagnosis involves correlation of a history of paint-eating or pica w ith the physical findings, laboratory and X -ray data. The importance of eliciting a history of pica cannot be over emphasized in the early recognition of the disease. E xam ination o f blood sm ears often shows stip p lin g of the red blood cells. P or phyrinuria is frequently found. The demon stration by roentgenogram o f an increased density in the grow ing ends o f the long bones is a cardinal sign o f lead poisoning {34). In recent years, the quantitative determ ination of lead in blood or urine as an in d ex o f abnorm al lead absorption has proved an invaluable, aid in diagnosis {4 !, 42) . L ead p oison in g in ch il dren differs considerably from the disease in adults. Central nervous system involvem ent or encephalopathy, rarely seen in adults, is com mon in child ren , w hereas p eripheral neuritis, lead line on the gum s, and colic are usually absent. The prognosis in lead encephalitis in children is poor; the h ig h m o rta lity rate, as w ell as the incidence o f severe, lifelon g, residual nervous system injury, has been commented on by many investigators {86). The m ental development of even the less severe cases may be seriously impaired {16). Baltimore Experience Thomas and Blackfan {3) of the Johns H op kins H osp ital were the first to poin t out in American pediatric literature the frequency of occurrence o f lead encephalopathy in children. Subsequently, studies at the same institution provided pioneer inform ation on the diagno sis {4, 86, 34, 48) and treatm ent {25, lfi) o f plumbism in infancy. T he B altim ore C ity Health D epartm ent in 1932 began studies of nonindustrial lead poisoning in children in an investigation o f cases resulting from the use of storage battery casings for fuel {43). A fter wards, all cases of lead poisoning brought to the attention of the department were routinely investigated to ascertain the source o f the lead. Blood-Lead Laboratory Service A s an aid in diagnosis, since early in 1935, the bureau of laboratories of the Baltim ore City H ealth Departm ent has m aintained a free routine analytical service for the quantitative estim ation of lead in the blood of cases o f sus pected plumbism {41). The dithizone method is used. Especially prepared lead-free blood specimen collection containers known as "bloodlead outfits" are distributed to the local hos pitals and physicians in the same manner as outfits regularly provided for specimens in cases o f communicable diseases. Since 1935, alm ost 3,000 specim ens o f blood from about 1,800 children have been tested for lead. Increase in this service, as w ell as the increased number of cases diagnosed during the la st 4 years in contrast to th e preceding 13 years, is shown in the accompanying table. Undoubtedly, the improved educational activi ties in lead poisoning prevention in recent years have been a prom inent factor in this increase. Comparison of blood-lead laboratory service tests and cases of lead poisoning in Baltimore children for the periods 1948--51 and 1935-47 Period N um ber chil- Diagnosed cases dren given lead of lead poison- test ing Total Average per year Total Average per year 1948-51 (4 y e a rs )__ 1, 007 1935-47 (13 y e a r s ) .. 772 252 106 ' 41 59 161 12. 4 Field Investigation Field work, associated with a follow-up of the blood-lead laboratory service, has enabled the Baltim ore City H ealth Department to ac quire relatively accurate data concerning the incidence of lead poisoning in the community {1). A report of each blood analysis was for warded to the bureau of industrial hygiene, which investigated cases in which the blood showed an abnormal absorption of lead. The Vol. 67. No. 3, Mnrch 1952 231 i Figure 1. Lead poisoning cases reported in Baltimore, according to month of report, 1931--51. upper lim it o f norm al is considered to be 0.05 to 0.06 mg. percent o f lead. Adequate clinical and laboratory data were usually available because nearly all of the children were diagnosed and treated in hospitals. A fter learning the m edical history, a field worker visited the home of the affected child to obtain pertinent inform ation, particularly concerning exposure to lead. Alm ost without exception, the cause of poisoning was found to be pica associated w ith the ingestion of paint. T his was confirmed at the tim e of the home visit by obtaining for analysis a sample of paint scrapings, approxim ately 0.5 to 1 gm ., from surfaces where the child had chewed paint. Lead Poisoning in Children Over the past tw o decades, 347 cases of lead poisoning have been diagnosed in Baltim ore children. These do not include the storage bat tery cases referred to earlier.yO f the 347 cases 54 have been reported since June 30, 1951. A study o f these cases has led to th e discovery o. interesting patterns in the seasonal incident o f the disease, age and color distribution o f tin children, and the types of houses involved. I is evident from figure 1 that more cases wen reported in July and A ugust than in any othe m onths. T here w as no significant difference ii incidence between sexes. S ixty percent of th cases occurred am ong children in their secont year of life, at teething age, when they have ; greater tendency to put things into the mouth O nly 2.3 percent o f the cases were in childre: above 5 years of age. The annual attack rate for the age segmen under 5 years during the period 1931-51 wa 7.5 tim es as h igh am ong the N egro populatio (71 per 100,000) as it was am ong the whit 2 3 2 Public Health Report population (9.5 per 100,000). "When th e m ore recent experience of the past 4 years is con sid ered , the attack rates for both white and Negro children as w ell as the difference between races are significantly elevated above the average experience cited. The high rates among N egro children are a problem o f con siderable public health significance since 30 percent o f B altim o re's preschool p op u lation is Negro. T he racial difference in incidence is believed to be due to environm ental factors 4 probably resulting chiefly from economic dis, advantage. For the past few years inform ation has been collected on home ownership in neighborhoods where child lead poisoning cases occurred. A l. most 90 percent o f the houses were tenantoccupied. In the early years o f the study some of the cases arose in well-kept property, but with the continued com m unity education by press and radio, cases in th is category have be come relatively rare. T he problem in B a lti more at present involves chiefly slum or blighted-area properties. The cases are con centrated in tw o areas w hich are o f known slum status and where the houses are old and have had m any coats o f paint, usually lead paint, applied throughout several decades. A ty p i cal home where a case o f lead poisoning oc curred is shown in figure 2 . Methods of Prevention 1 Education and Publicity In an effort to prevent lead poisoning, re peated public w arnings about this child health hazard have been given by the Baltim ore City Health Departm ent in the press, by radio, and on television. T he B altim ore H e a lth N ew s-- mailed each m onth to over 10,000 persons, in cluding 1,800 local physicians and 6,000 school teachers-- devoted a number o f issues (2, l/l, 47) to the subject. The bureau of child h y giene issued a leaflet (4-5) en titled "L ead P o i soning in Children, a D isease Y ou Can P re vent." The leaflet directs attention to 220 cases and 78 deaths from lead poisoning in B a lti more during the past 18 years, makes sugges tions to parents for preventing children from contracting the disease, lists the w arning sig- nals to be watched for, and stresses the im portance of early diagnosis and treatment. I t is not unusual now for a mother to take a child to a physician and to volunteer infor mation on pica and suggest that the child may be suffering from lead poisoning. The Public Health Nurse One of the most prom ising advances in the prevention of child plumbism was the assign ment several years ago of a public health nurse supervisor to investigate lead poisoning cases. W ith the knowledge gained by intim ate associa tion w ith the problem, the supervisor was able to interest other public health nurses. They not only make home visits .and dissem inate in form ation in the most-affected areas of the city, but may take part in well-baby clinics, where mothers are told of the dangers connected with pica. Lead Paint Removal For the past 4 years, landlords of properties where lead poisoning has occurred have been notified, in accordance w ith the Baltim ore ordi nance on the hygiene of housing {44), to remove lead paint from the surfaces where there is flaking or where a child has chewed. O f 96 such notices during this period only 2 were not complied w ith in the tim e allotted. Both ow ners were sum m oned to the M agistrate's Court, where they were found guilty and fined; only then did they fully comply w ith the health departm ent's orders. M any sanitarians on the health department staff who inspect property, prim arily on the basis of other types of com plaints or because of rodent and housing sur veys, also require correction of a flaking paint condition in the notice sent to the property owner. The sanitarians are instrumental in the distribution to slum dwellers o f the leaflet on the lead poisoning prevention {45). Legislation Because of the danger to small children, man ufacturers of cribs and toys have for many years {0, 17, 48) used paints free of lead pigm ent. For various reasons legislation against the use of lead paint has existed in w idely sepa rated jurisdictions for a number of decades. Germany has had a national law on the matter Vol. 67. No. 3, March 1952 233 Figure 2. House doorway in home of patient with lead poisoning. since about 1900. R egulations prohibiting the use o f lead -con tain in g paints on toys, children's furniture, and for interior work have been en forced in France since 1917 {17). A s early as 1922, the nations adhering to the International Labor Office in G eneva proposed a convention prohibiting the use of white-lead paint in in terior painting of buildings as a health meas ure affecting painters {43). Since 1932, factory legislation in Ontario has required all leadcontaining paints supplied to plants m anufac tu rin g ch ild ren 's toys and furniture to be so labeled {17, Ifi)- No cases of lead poisoning related to chewing on new furniture or painted toys have been reported in recent times. W hen such objects are involved, the source of lead has been 'repainted furniture--parents frequently use lead-base paints for repainting jobs. Never theless, the M aryland S tate L egislature in 1949 enacted chapter 517 o f the A cts o f 1949, w hich made it com pulsory to affix a label to any toy or to any children's fu rn itu re decorated with paint or other material containing lead or any other poisonous substance, stating clearly the poisonous nature of the paint or decoration. Unenforceable, the law was repealed a year later. On June 27, 1951, regulation N o. 17 was adopted by the commissioner of health of Baltim ore under the ordinance on the hygiene of housing. The text follow s: I n t e r i o r P a i n t i n g . No paint shall be used for in terior painting of any dwelling or dwelling unit or any p art thereof unless the paint is free from any lead pigment. The wording was studied carefully so as not to prohibit the use of paints containing either lead driers, usually present in amounts corre sponding to less than 1 percent o f lead in the finished paint, or pigm ents contaminated with 234 Public Health Reports IK ' 4 ^ traces of lead. T h e use o f th e term "lead-free * paint" was purposely avoided, since it is doubtful if the usual com m ercial product could be made w ithout having a detectable amount o f ' lead present. T h is regu lation has h ad prop k nounced salutary effect as shown by an increas` A ihg interest on the part o f hom e owners, health i: $ agencies, and local p a in t m anufacturers, som e whom have recently advertised paints free from lead pigm ent. . '! -5> Lead Content of Paint The health d epartm ent's su ggestion s to . parents interested in the purchase o f "lead15,. free" paint em phasizes a selection based upon the labeled com position o f th e product. A lthough there is no M aryland law on the subject, V, many o f the p ain ts sold lo ca lly contain a stateu-... ment o f com position on th e label. S u ch labels (Jp' provide inform ation on the presence o f leadbearing com pounds and are adequate except in , those instances where the terms "chrome yel- low," "chrome green," or "chrome orange" camouflage the fact that these pigm ents contain substantial am ounts o f lead chromate. For this reason, when inquiry is made, it has been recommended that no yellow , green, or orange colors be used in refm ishing articles o f furniture intended for use by children unless the pigment com position as declared on the label clearly excludes the presence o f lead. \ ii- Summary Lead poisoning in children caused by inf gesting lead from surfaces coated w ith lead- containing paint is apparently widespread f i throughout m any parts of the Nation. The disease has a high rate o f incidence in the city o f B altim ore, wThere it occurs in chil# dren o f teething age liv in g in old, run-down ; rented properties where lead paint had been used indoors for m any years. Public health education, coupled w ith a "lead consciousness" on the part of physicians and the pediatric clinics o f local hospitals, and w ith a blood-lead laboratory service offered by the city health department has resulted in a marked in crease in case recognition. It is hoped that the application of principles Vol. 67, No. 3. March 1952 involving education and the enforcement of measures regulating the use of lead-containing paints w ill result in a m aterial reduction and the eventual eradication of child lead poisoning in Baltim ore City. ACKNOWLEDGMENTS The authors are Indebted to Matthew L. Taback, di rector of the bureau of biostatistics, and to M argaret Galbreath, supervisor assigned by the bureau of public health nursing to the bureau of industrial hygiene, for assistance in the preparation of this article. REFERENCES (1) McDonald, J. M,, and Kaplan, E .: Incidence of lead poisoning in the city of Baltimore. J. A. M. A. 119: 870-872 (1942). (2) Williams, H untington: Lead poisoning killed 83 children. Baltimore Health News 28:113-116 (1951). (3) Thomas, H. M., and Blackfan, K. D .: R ecurrent meningitis due to lead in a child of five years. Am. .T. Dis. Child. 8 : 377-380 (1914). (4) Blackfan, K. D .: Lead poisoning in children w ith especial reference to lead as a cause of con vulsions. Am. J. Med. Sc. 153: 877-887 (1917). (5) Strong, R. A.: Meningitis caused by lead poison ing in a child of nineteen months. Arch. Bed. 37: 532-537 (1920). ( 6) Ruddock, J. C .: Lead poisoning in children with special reference to pica. J. A. M. A. 82: 1G82-16S3 (1924). (7) McKhann, C. F . : Lead poisoning in children. Am. J. Dis. Child. 32:386-392 (1926). (8) McKhann, C. F . : Lead poisoning in children. The cerebral manifestations. Arch. Neurol. Psychiat. 27:294-304 (1932). ( 9) McKhann, C. F., and Vogt, E. C .: Lead poison ing in children. J. A. M. A. 101:1131-1135 (1933). (10) Donnally, H. H., Schutz, C. A., and Nimetz, A.: Chronic lead poisoning in early childhood. Virginia Med. Monthly 62:83-89 (1935). ` (11) Nicholson, W. W .: Lead poisoning in children. Kentucky Med. J. 33:180-181 (1935). (12) Cushing, H. B .: Diagnosis of lead poisoning in children. In tern at. Clin. 44th Series 1: 189-195 (1934). (13) Gant, V. A .: Lead poisoning. Chicago, Indus tria l H ealth Book Co., 1939, pp. 39-42. (14) Bucy, P. C., and Buchanan, D. N .: The sim ula tion of intracranial tumor by lead encephalop a t h y 'i n children. J. A. M. A. 105:244-250 (1935). (15) Kowaloff, I .: Lead encephalopathy. Am. .T. Dis. Child. 61: 547-556 (1941). 235 i ( 16 ) Byers, R. K., and Lord, E. E . : L ate effects of lead poisoning on m ental development. Am. J. Dis. Child. 66: 471-494 (1943). (17) Ross, R. J\, and Brown, A .: Poisonings common in children. Canad. Pub. H ealth J. 26: 237-243. (1935). (IS ) Parker, G. M. (Division of In d u strial Hygiene, Toronto) : Personal communication. ( 1 9 ) Taylor, H. W., and Schram, M .: Abdominal symptoms of lead poisoning in children. Arch. Ped. 53: 182-180 (1930). ( 20 ) Anonymous: Lead toys--lead paint--lead poi soning. Safety Education 22 : 74 (1942). (21) Rapoport, M., and Rubin, M. I .: Lead poisoning. A chemical and experimental study of the fac tors influencing the seasonal incidence in chil dren. Am. J. Dis. Child. 61: 245-255 (1941). (22) Netzley, R. E .: Lead encephalitis precipitated by acute infection. California West. Med. 46: 306-308 (1937). (23) Golden, J. T .: W atch out for lead poison. The Cincinnati Inquirer, Sunday, August 12, 1951, p. 3. (21)) Goettsch, E., and Mason, H. H .: Glycosuria in lead poisoning. Am. J. Dis. Child. 59: 119-128 (1940). (25) Ennis, J. M., and H arrison, H. E . : T reatm ent of lead encephalopathy w ith BAL (2,3-dimercaptopropanol). Pediatrics 5 : 853-868 (1950). (26) Blackman, S. S., J r . : The lesions of lead encepha litis in children. Bull. Johns Hopkins Hosp. 61: 1-61 (1937). (27) Dannenberg, A. M., W iderman, Arnold H., and Friedman, Paul S .: Ascorbic acid in the treat m ent of chronic lead poisoning. J. A. M. A. 114: 1439-1440 (1940). (28) Haverfleld, W. T., Bucy, P aul C., and Elonen, Anna S .: The surgical treatm ent of lead en cephalopathy. J. A. M. A. 114: 2432-2437 (1940). (29) Wilkinson, E. E .: Sodium citrate in treatm ent of lead encephalopathy. Texas S tate J. Med. 43: 442-445 (1947). (SO) Stetson, C. A .: P ica : Its relationship to lead poisoning in children. J. Maine Med. Assoc. 38: 10-12 (1947). (31) Sibley, W. L .: Lead poisoning in infancy. A case in which two operations were performed on the stomach. Soutii. Surgeon 15 : 427--430 (1949). (32) Akelaitis, A. J . : Lead encephalopathy. A clinico- pathological study. J. Nerv. & Ment. Dis. 93: 313-331 (1941).i i (33) McGovern, J. 1\, and Simmons, E . : Chronic lead poisoning associated with eosinophilia and splenomegaly. Clin. Proc. Child. Hosp. 6: 33-38 (1950). (34) P ark, E. A., Jackson, Deborah, and K ajdi, Laslo: ^ Shadows produced by lead in the X-ray pic tures of th e growing skeleton. Am. J. Dis. "Sf Child. 41: 485-^99 (1931). (35) Seifert, H. E. (Virginia Bureau of In d u strial Hy- giene) : Personal communication. (36) McKhann, C. F . : Lead poisoning. I n Brenne- m ann's P ractice of Pediatrics, Hagerstown, Md., W. F. P rio r Co., Inc., 1948, vol. 1, ch. 18, p. 1-8. (37) Feldman, II. T .: Lead poisoning. - Salient fea- ; tu res in its diagnosis and treatm ent. Clin.'^ i Proc. Child. Hosp. 7: 194-205 (1951). (38) Brienl, A., and Young, W. J . : The occurrence of lead poisoning among North Queensland chil-' * drea. Ann. Trop. Med. 8: 575-589 (1914-15). ; (39) Fukushim a, M., and M atsumato, H . : Statistics of 298 cases of in fan tile lead poisoning. Ori ental J. Dis. In fan ts 3: 27-31 (1928). ( 40 ) Shelling, D. H., and Hopper, K. B .: Calcium and phosphorus studies. Bull. Johns Hopkins Hosp. 58: 137-211 (1936). ( 4 1 ) K aplan, E., and McDonald, J. M .: Blood-lead determinations as a health departm ent labora tory service. Am. J. Pub. H ealth 32: 4S1-480 (1942). (42) Blumberg, H., and Scott, T. F. Me.: The quanti tativ e speetrographic estim ation of blood lead and its value in the diagnosis of lead poisoning. Bull. Johns Hopkins Hosp. 56: 276-293 (1935). ( 4 3 ) W illiams, Huntington, Schulze, W. H., Rothchild, ' H. B., Brown, A. S., and Smith, F. R., J r . : Lead poisoning from the burning of battery casings. J. A. M. A. 100:1485-1489 (1933). ( 4 4 ) Baltim ore ordinance on the hygiene of housing. - No. 384, approved March 6, 1941, as amended M by No. 902, approved March 29, 1943. ( 4 5 ) Lead poisoning in children--A disease you can. prevent. B altim ore City H ealth Department Is Leaflet, 1949. (46) Lead poisoning in children. Baltimore Health News 14: 109-110 (1937)-. it ( 4 7 ) Lead poisoning in children is preventable and can be fatal. Baltim ore H ealth News 26: 122- 124 (1949). ( 4 8 ) Jepheott, C. M .: Lead in certain colored chalks and th eir danger to children. Canad. Pub. H ealth J. 28: 391-393 (1937). (49) Hamilton, Alice: Recent changes in the painters' ; trade. U. S. D epartm ent of Labor, Division of * Labor Statistics, Bulletin No. 7, 1937, p. 40. f 1 j! $ 2 3 6 Public Health Reports I