Document kmrDdgRVxZ5q6y66LbVedRo3J

Lead Industries Association, Inc. 292 Mrtteon Av*nu fin Yorti. N. Y. 10017 TaMeooiM: (2121 S7W020 September 25, 1969 SUBJECTS FACTS ABOUT LEAD AN PEDIATRICS BULLETIN To Member* of Lead Industries Association, Inc. Enclosed is our newly published bulletin "Facts About Lead and Pediatrics" and its companion pamphlet "Lead Poisoning in Children" a publication of the Children's Bureau, U.S. Department of Health, Education and Welfare, reprinted with their consent by LLA. Both book lets cover in detail the problem of childhood lead poisoning, its causes, symptoms and treatment. The two booklets are being distributed by LIA to medical and public health officials, interested parties, legislators, and the press. We feel this to be a positive contribution from the lead industry for coping with the problem of lead poisoning in children. More and more communities are becoming concerned with lead paint poisoning among children. If you know of any local action about this problem, you may find it useful for you personally to give copies of the "Bulletin* to local health or other officials. Also we would appreciate being informed of any developments- relating to the lead paint problem. Extra copies of the publications are available upon request Sincerely yours. JUCi so _________________ Executive Vice President PNYC00006538 1S11097 PNYC00006539 N11097.01 Introduction Great orogrevs ha-> been made in.the pa>t lew JecjJe' to prevent and codtrot the absorption at lead by both adults and children. Caws of lead irttoxicaiion.dr piumbrsm..among adults are rare teduv. even <n `ead-process(Qg and lead-usmg. .nc-ustfies where the possibility of over-exposure seems greatest. Such improvement is the result of broadly increasing knowledge about the physiological, effects of lead, of the applicat/oQ^of proper controls and safeguards to present over-exposure that can bring on illness and of better diagnosis1 and improved treatment of plumbism. Much of this increase in knowledge has come directly from scientific research encouraged or spon sored by the Lead Industries Associa tion. fac >IIAi and us members. One vexmg problem area, however, remains a challenge. That is the ab sorption of. lead by some children, par ticularly in city slum areas, as a result of eating leaded paint that v?as applied to the interior surfaces of buddings generally 50 years or more ago. LlAs concern with lead poisoning problems is not new. The lead indus try has tor several decades supported research at leading universities and hospitals o q the metabolism of lead and the diagnosis and treatment of lead poivonmg i;o an effort: to bring jhoui berr.er understanding of the problem The information developed trom xu.h reveurch has been dis seminated m medical and public health loupaals,, and; at various sym posia. Basic research on lead intoxica tion was reported bv Dr. Joseph C. Aub et al. of Haryarii University in a monograph publisbiedj in 1926. Io 1933 the Kettering Laboratory of Ap plied Physiology at the University of Cincinnati, under fhe direction of Dr. Robert A. Kehoe, begin publishing, studies on lead absorption and excre tion. LIA sponsored the early investi gations of childhood lead poisoning bv Dr. J. Julian Chisolm. Jr., et al. of Johns Hopkins Lpiy^sity School of Medicine, as'vied a* research on the treatment ot lead absorption by chelatioa. Since 1937 a number of symposia on lead poisoning have been con ducted by LIA. both alone aad in co operation with such organizations as the American industrial Hygiene Association and the American Medi cal Association. These conferences have beea held (o make available to health professionals and interested laymen the facts concerning plumb ism which Underlie present-day con cepts or its causation, prevention, and treatment. The lead industry today continues to support research in such areas as lead in the environment, the biological basis for lead intoxication, and the normal metabolism of lead, as part of its overall research program on all aspects of the use of lead. Support tor Legislation For many years, representatives of LIA have met and consulted with public health officials concerning the problem of childhood lead intoxica tion. The industry hat supported legis lation designed to scop the use of leaded paints m interiors of residences and on furniture, toys and other items which children might chew. Contents Introduction Plumbism is Preventable Seven Steps to Prevention Some Campaign Histories Cause and incidence of Childhood Plumbism Medical Aspects of Childhood Plumbism Tests for Plumbism References Representatives of LIA have been members of the Sectional Commirr on Prevention or Control ot Hazards to children since n was organized m 1953 by the American Standards Association (now known as the USA Standards Institute! under the spon sorship of the American Academv of Pediatrics. This Committee developed a standard (Z66.U. m effect since 1955. which specifies'that ail oamts for articles such as toys, furniture and the like, and for vise m ,interiors of dwellings, should contain rioharmt-i quantities of lead, fit Childhood lead intoxication, though relatively race m the general copula tion, still is a problem, particular;* :r. the underprivileged areas of farge cities. It is directly, traceable to `h< fact that a number of children, nr.arr. with pica (an unnatural era* mg tor nonfood items), pick up and eat chips of paint flaking from walls or ce-.lmgs of old buildings erected when leaded paints were used in interiors (as the* no longer are), or chew on leadpainted windowsills, baseboards or other surfaces. Prevention Needs Cooperation The knowledge and means are at hand for controlling this problem. But ccrr.piete prevention calls for coocerat;--e efforts among many groups, ineiud.nz parents, speiaiand public health work ers., doctors. landlords, c h v otficu.i and public-spirited citizens. Lead intoxication is a man-made dis ease. and as such is subject to com plete control. To help achieve this objective. LIA has prepared this book let especially for distribution to ph* *>ciaos. pdbiic health authorities. soc-.ai workers, city officials and others * o can help eventually achieve a solution Much has been done; much more re mains! to be done. LIA hopes booklet. '`Lead and Pediatrics. ' * contribute to the success of efforts aimed at preventing lead absorption by children. For additional1 informa tion and recommendations. w< sug gest a careful reading of Leau Poisoning in Children." by Dr Jane S. Lm*Fiii a pamphlet (No. -452 puclishedby the Childrens Bureau ot "< U.S. Department of Health. J uc a t .c and Welfare in 19:67 (see cop* closed). (2) 2 PNXC0C006540 Plumbism is Preventable The seven steps to prevention and con trol ouifmeJ .n the uo.\ "ave been the of ..anpjicnx -ojinit enddhood p'-mburh m a Gumcer ot -.ties Some -vt these experiences wul be discussed m detail. Physiciaos and public, health authori ties agree chat lead; imoxxcatioa in ,`hiMrea is preventable- The source is kcowq; old leaded paint m poor hous ing associated with poverty. There is no disputing that slum area? dwellings pamted many years ago with leadbearmg pamt are the setting tor virtu ally all cases of plumbism m children. But many years of urban renewal aad rehabilitation will be required before tne-.e forces ot lead are eradicated. Lead problems can continue to occur n children whose parents neither keep their home tree or lead pamt sources nor s<-ek medical attention until severe damage has been incurred. Cleaa-up and constant alertness can prevent children getting at old paiat and plaster chips. Barents can be urged into actioq. Peeling pamt can be removed and chips cleaned up and removed from areas in which the child crawls orvplays.; Crumbling paiated plaster and. painted woodwork can be cleaned up. repaired and painted with modern interior-type pamt. Parents and baby sitters must be aierted to dangers of children anew me on eod painted surfaces. Alertness to 5s rnptoim Diagnosis of lead intoxication a pead to a large degree *n -ow - physicians look tor it. Thev alert tor vague and euflv matem* n children and -jTvouid .n .-are quickly and tborougr.r. the vifoameac and histor;. T-c- >-v-_ not be lulled by tne tact :nai -- interior paints are late 're rr - .-m results mostly from unuer - 'c r. *- applied, indoors,years ago. - m once fine buddings tr.at -c . within economically deprr-cc many cities. Seven Steps to Prevention The problem of childhood plumbism is so clearly understood that it would seem prevention should be simple. It is not. This is because the problem is rooted in social, educational, eco nomic. medical, technical and political factors. Even so. a formula for prevention and control is offered, making it work will take time, parent erfort. aod per haps new ideas and approaches. Some suggestions may be termed "imprac tical. " Nonetheless, they pose a chal lenge to hod a "practical'' way of doing them. The booklet will discuss in detail the components of this basic preventive formula which physicians, social workers, public health workers, par ents and others should be aware of. The follow mg steps are essential. J Alert and w arn parents and others * * who live m dwellings which have leaded pamt in interiors. As with other accidents involving children, parents land other child caretakerst-caa do much to keep children from eating paint and chewing painted surfaces and caa keep chips oft doors and out of reach of infants. (Almost all cases occur in children 5 years old or under.). ^ Remove sources of lead that chil* dren can eat. This source is almost invariably old leaded paint on interior walls, ceilings and trim. This leaded pamt must be removed or effectively covered. One city (Baltimore) reports good results from covering waffs to a height of four feet with wallboard. Lead paint on woodwork should be removed. Peeling pamt and old plaster should be swept from floors and scraped from walls and ceilings. Take steps to keep any child sus* pected 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 in almost all cases, according to the enclosed Children's Bureau pam phlet. 11) Physicians, public health nurses '* and others should watch for early symptoms of lead absorption-^ .c .e nonspecific v-mpioms of lethj.-cv : ritability. and stomach pains arc -.oriting--and proceed at once to iee :r,,: appropriate tests are made. < , | i r Quick and accurate J.-arv- r-:v^nts serious coiveaae-.:.-' 7- - should be done bv rhe mo^t mouorn methods to be sure whether e^d r.- gesuon has taken place, and --n . a be based on clinical finding* .r.d - ,rported by biochemical evidence or nvcessive lead absorption. Blood dad tests are considered the movt reaad accurate. Iron derieiencv uremia is quite common m lead-poisoned cnidreQ but not all children with -h * ailment turn out to have piurr.b^m Careful diagnosis of an ailing child's problem is essential. Lead frequent;-is not the cause and. it suen crows true, a quite different treatment m^-be required. . Proper and careful treatment should start immeduieiv diagnosis of lead intoxication 7 When a case i* found. creek oi rrer children in the home immej;-:e:v for possible signs of lead absoronv. -v PNYC0GGC6541 3 Some Campaign Histories Experience shows that when well or* ganized programs a,re pursued m a c:iy the incidence of childhood plumb.s-m can he reduced.- usually.after an initial rise ip reported. cases, and that fata/nics and cfipphng illnesses can be greatly curtailed. Baltimore: The long-term. intensive campaign m Baltimore is a prime ex ample of what cap be done through intelligent cooperation by all con cerned. t3l The hazard to children from old paint was prst recognized by the Baltimore Health Department io 1931. and since I935j; the Health Department's Bu reau of Laboratories has provided free blood lead determinations to physi cians and hospitals. In 1949 a public health nurse was assigned to investi gate reported instances of abnormal lead thgijsfidn'bvvhildfen and to make sure that the old paint, or other source, was removed. In 1951 the city adopted a regulation barring: the use of heavily leaded paints m interiors of dwellings. A Baltimore ordinance require* a warn ing ubel'-on punt that contains more than 1 percent lead- The label must state thal the paint contains lead, is harmful. if eaten, and should not be used for interiors or for toys., cribs or other accessible, potentially hazard ous surfaces. Throughout the years the Baltimore Health Depawrieat has continued to maintain awareness of the problem through all available media. It has pre pared pamphlets used by public health nurses and saauartaQS in clinics and m home visits; m addition, mformadoo on lead hazards ia pamt has been mailed periodically to hospitals and physictaas. Exhibits and other visual aids base been shown at nieetingvand in public buildiogs. Newspapers, rqdio aod television stations, medical and public health publications, and other media have beets used to inform the public ot the hazards of ingestion of leaded paint by children. Prevention Committee Organized In order to pinpoint sources of lead paint. 8^!timore s City Health Com- mis>joner in 1957 organized a preven tion committee of staff personnel directly concerned with the problem. The committee surveyed 100 blocks of dwellings and found more chart l percent lead in paint m 70 percent ot *h? dwelling units. Public health nurses collected pamt scrapings from ."ou homes ot indigent persons and poviaye tests for ieaJ were found in >crapirigv tram 38 percent of the houses. Then action was taken to see that such paim was removed. Five years later the committee began a pilot, "hard sell" educational pro gram aimed at parents aod others responsible for the care of children under 4 years of age liviQg in selected areas where a high potential existed for lead intoxication from paint tnges- tioQ. The three-year program encom passed a persoo-to-persofl apprcucr. Painted surfaces accessible to children were inspected in the presence ot the persons charged with their care. These people were instructed by the vising samtanaa m the hazards of :ead va pamt and a leaflet was Jiviu^sed ana. left for further study. When this '.e^rlet was toUod to be above the -.loca tional level m the study area, a M.m? er version was prepared.in a'.i. the -jaitarian made five visits to each home to remind the parents or me hazards. Morbidity-Mortality Data The results may be seen m a ;ghs pamphlet do the subject prepared bv the Baltimore City Health Depart ment which illustrates dramatically Official Baltimore Fitures* Child Lead Paint Poisoning 1931-1967 YH* rofvt. 196? 1966 1965 1964 1963 1962 1961 1960 1959 1958 195? 1956 1955 1954 1953 1952 1951 1950 1949 1948 194? !94tf IWJ 1944 1943 1941 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 t o t l 1.1(1 15 31 32 45 42 44 4g 53 66 13 3 56 48 35 34 49 29 77 31 34 31 11 13 8 9 VO (3 15 12 It 13 10 19 17 1j0 2 CASES WHIT* 203 4 2 4 3 7 3 4 9 2 17 4 .3 5 8 10 6 20 2 11 4 1 ? .4 5 3 t 4 3 6 9 7 12 2 4 l l - VONWHITE 908 11 30 28 42 35 41 44 44 64 116 52 40 30 26 39 23 57 29 23 27 (0 6 4 4 7 12 11 9 J 4 3 7 15 6 l l rOra 136 l 1 0 1 3 1 1 4 10 3 3 1 3 6 5 9 2 4 4 3 4 I 5 5 3 7 4 6 2 3 10 6 2 DEATHS WMtTt 46 1 0 0 0 0 0 0 t l 3 2 I _ i 3 2 3 _ l l 1 t 2 -- 2 - 3 4 l 4 2 2 l l " SOSWHtTg 90 0 f> 1 1 ~ l 2 l 2 3 3 6 2 X 2 2 l I 5 i i i \ a S a 1 - ~UaC pum Poiomn m Oul4.'' p*mpWi tuuc* mi WM St 8lun\ort Ot? Htiltft Oeo-mwe-n t -I the results of a well-organized, imen>iv< program, i 4) Reproduced op the oppoMtc page > a table from this pjmpnlet vumnurtzing child lead potwrung Ca-c *. n Baltimore trom 1^31 through I'-'*'' Bneflv. the table show* that ax 1931 tvi. o.cases ot lead poisoning :n children Acre reported -.no "Oth were fatal...So deaths occurred from childhood lead poiiomng in 19*5,'which was the first year of record ta which there were no deaths trpm this illness m Baltimore: furthermore.1 childhood lead potsonsag cases totaled 32. the lowest since 1952. The slight decline in case-findings from 1941 to, 1945 reflects a wartime shortage of physicians. Oft the other hand, the sudden peak in 1958 re* suited From the entry into the program of a large university ,hospital, plus the organization of the city prevention staff and the two lead-in-housing sur* ' eys of the previous year. Further more. it should be noted that; the., 10 deaths among 1958's 133 cases-or -7 percent of the total-were equalled only m 1935 when there wereontv l" cases and the 10 deaths were over half; of the total. The experience recorded in the fable shows that,fatalities from lead can be reduced or prevented, ft also demon strates wat trv such a campaign* deaths decline as the number of cases rise; indicating improvement tn speed and erficacy of treatment; and that there after. cases also tend w decline as pre vention becomes more efficient, Chicago: This city has been,jiving in creasing attention to childhood plumbum m recent Vears. The City 8oard of Health has a preventive program under wav and various citi zens' groups also are actively involved iq efforts to find and control t(w dis ease. The problem' is a serious one in Chicago because of its targe areas of old. rundown housing. (a the summer of 1965 residents of the Hast Garfield Park district organ ized a Citizens Committee to End Lead Poisoning tCCELPl. This was done after the occurrence of several cases of lead intoxication in that area. With the help of the American Friends Service Committee. CCELP began an educaaoaat and case-finding campaign. The Cit> Board of Health, and later the Medical Committee for Human Rights, helped CCELP in 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 of apartments where cases were found were turned over to the City Building Commission for corrective action. From the start of the program in; 1965 through September 1 the Board of Health tested 30.000 urine samples. The city switched to a blood lead test m October. < (n February 1963. the Board had begun a urinary copropor phyria screening program m ats clin ics.) As a result of the Board's expanded screening program, there was an in crease m total cases being reported, from 24 jn 1957 fo 304 ia 1966. At the same time, there was a significant drop in the fatality race among re ported cases, from 29.2 perceac ta 193? to 1.6 percent in 1966. The Health Commissioner of Chicago. Dr. Morgan J. O'ConneH. reported that the number of deaths among Chicago children from lead poisoning fell to 10 in 1968 from U m 1967.15) Mass Screening Program la August 1966 the Chicago Board of Health began a masv screening pro gram using a blood (Cad test. The chit- dren screened were trom L'rban Progress Ceaicr April 19bv approximately dren had been tested. i <;icr During 1967 a total ot 2" -5* Jrea had a blood test, ur.o _--s c - percent i2.3~9> haJ -Jd _ above 30 micrograms per -r liters of blood. These cr.ldren referred to a vpocui :;.nr.- by the Board tor the > _ treatment or plumbum. Of these children. 5-2 2--' rare; of the suspectsi. were prpmr* . with chlates. three percart * treated were 5 years ot ' per;, were 4 years old. and :.% r.r-> .- - 89 perceaf were 1-3 year-, o a As a result of this program _r.u educational impact i.o rreve - _ areas, the average blood ,sau e'-e. the same population m : a markedly joweri According to Qr*. Lorry A. Blanksn- Hennetta K. Sachs and Edward i Murray, all of the Chicago Board . Health. "M?ss screening programs . blood lead determiaacion can di'co-; incipient mtoxicatron weem j .i-j proably months betqre the croe: _-i cephalopathy. ihus redeem,' -*e fatality rate." (6i Recently the Chicago Board of He;/ made a film on the subieci ot e^d ao sonicg iq children. This mm. "To SavC a Life." provides a cescr tioa of the, steps, taken, and me >r cialists involved, in combat:.ru : problem and, tv being useo .`-ce;:-. in neighborhoods where le;u ro:so mg may be a problem, i ' > Other Cities: Physicians m N'e-.v Yc are encouraged to, send blood -ce mens on all suspected cases to c; health department laboratories there are technicians specials cra.ne to do blood lead level anatv %es j u .c k and accurately. As a re^uu. :~e -... ber of cases reported increased t.-c 80 iQ 1954 to 725 in WM. During : same period the fatalities among ported cases declined trom 5 cere (12 deaths) ;to less than 1 percent n deaths) in 1968. New York's program on iead ? soiling is being enlarged under direction of 4 special task force wu the city health department. The partmeot holds sessions on the prob lem for ph> sicians. social workers and nurses. Literature is distributed to the public, particularly to parents in "high n>k" areas*, by public health nurses arul sanitarians. The city also uses peo ple who live in the high risk areas to help identify possible cases of lead intoxicated children and to provide families 'with firsthand information about the dangers of eating lead paint. Reported cases of childhood lead in toxication are followed up by a public health nurse to ensure treatment and necessary follow-up, Public health santtarians inspect, premises for sources of lead, effect necessary re pair and repainting, sample and anal yze peeling paint for lead content, and check other places where the child may regularly spend time. (8) The Philadelphia Department of Pub lic Healthy program has been under wav since |9$6l.;;>yj;i'h!: the cooperation of realtors, landlords, various indus tries ctflc'ludiag, 4 J^em^er company ot LIAi and the Society of Friends. It includes isysiemancii investigation of ail reported cases. The Department issues a checklist of possible sources of lead for use' in held investigations w hen the source of lead ingestion isn't readily apparent. Uaiso issues specifi cations and safety standards for the removal of lead paint from interiors. The Department sponsored a two-day seminar j$ni lead poisoning in June 1967''iq which representatives of the lead industry participated. Cause and Incidence of Childhood Plumbism Although plumbism in children is a distinct and specific problem, its con trol must be viewed as one aspect of protecting infants and children from other home hazards. The National Clearinghouse. Poison Control Branch. Division of Direct Health Services, of the L'.S. Public Health Service, (tads that 90 percent of ail reported poisoning cases involve children under the age of 5 who have eaten or drunk substances found around the house: <9) la about half the cases, these substances are medi cines of one kind or another. In the other half: household products such as cleaning and polishing agents, pesti cides. curpentioe. petroleum products and cosmetics are involved. In 1967. for example, among! all substances '`most frequently ingested" by such children, paint Ueadedjaod nonleaded) ranks 26th. and involved i percent of the total reported from 395 centers in 43 states. However, many lead poison ing cases are not reported to these cen ters. so that such figures indicate the extent of acute poisoning cases from other substances but not from lead ingestion. - * Studies have shown that almost every case of childhood plumbism is related to old lead paint ia old buildings, a situation found mostly in large cities, mainly those east of the, Mississippi River. In Baltimore, for example, where childhood plumbism has been brought under control, early studies showed that from 50 to 70 percent of old houses in some stum sections had flaking paint that contained lead. Housiog-Plumbbra Relation The relation of housing to plumbism was shown in a home survey of pre school children in Cleveland: which has had a study and control program for years. Of SOI children living in old houses, 216 <27 percent! had ab normal lead concentrations in their urine, and 38 (4.7 percent) were al ready afflicted with plumbum. Of 105 children ia a new housing project, only three (2.85 percent} were found to have abnormal lead concentrations in their urine and there were no cases of plumbism. (10) In some instances, a child may ingest lead from objects siich as wmdowsiils or repainted cribs when tare has not been taken to avoid lead paints. Other possible Sources are rarely reported and even more rarely established. Some epidemiological studies have indicated that symptomatic lead, in toxication. particularly encephalopa thy, is more common in the iuoeSeptembec period. However, lead intoxication may occur at any time at the year, and there is no lesion m which physicians and other public health workers should be less alert, tin Plumbism also shows close family re lationships. If one member of a fam ily is found to have plumbism. all the children between l and 5- years of age 1 should be carefully checked, since there is a 33 percent incidence amoog children living in the same household. Most victims are between l and 6 years of age, with 85 percent in the 1-3 year old group, as noted oo page 5 of the Children's Bureau pam phlet. (2) These toddlers often crawl 1 about without supervision. Either as an aspect of pica, or of the oral ex ploration usual to children of this age. ; they huy pick up and eat paint chips 1 found on the floors, or chew on cribs or windowsills that -were long ago ; covered with lead-bearing paint. Cer* 1 tain lead compounds are known to ! have a somewhat sweet taste whtcn may accentuate the appeal to cmi! dren's palates: As pointed out on page i 6 of the Childrens Bureau booklet (2), "from ffireei to stx moqths of fairly > steady lead1 ingestion" precedes the 5 appearance of overt symptoms m aii most all patieots. Tbc Factoc of Pica Pica, a very Common precondition, ts | the medical term for an unnatural | craving for din or other aoofood 1 items. Some studies found (hat from ; 70 to 90 percent of children suffering ' from plumbum hid a history of pica. 1 In a New York City study, more than j 30 percent ^(flditjdrtin with a diagnosis i of pica were found to have lead poiI soning..(ll) A study of 784 Baltimore ^cooooo^ , l children from underprivileged areas disclosed that nearly 22 percent had pica. (121 In most cases, pica was es tablished as a habit by the second year but had disappeared by the fourth or fifth year. The causes of pica are unknown de spite various theories. In the present state,of knowledge, it should be rec ognised that pica ts widespread, occurs particularly often its poor famii ies. and is a potential source of metal and other poisoning, as well as of in testinal parasites. Dr. Chisolm of Johns Hopkins, a long-time investigator in the field of childhood plumbism, notes, that histortcally. pica "seems to be related mainly to the relative availability of a diet adequate both in quantity and quality to the social group an a whole. Women (especially pregnant women) and youag children are the members of the group most vuinerableito pica'* 03) i > . i The Emotional Eaviroament Dr. Chisolm also points out that the symptom of pica is most likely to occur is children with a high level of mouth activity whose oral relief of anxiety "is reinforced by cultural pat terns and to whom the mothering nec essary to .scop it is unavailable for a variety ofp'realsoos. )Vhen such a child is exposed to hazardous environmen tal lead sources., the likeiilhood of plumbism is indeed great." (13) 1 1 ! Medical Aspects I of Childhood Plumbism j It is not the function of this booklet to give specific medical advice, but a brief review is given of the extensive literature on plumbism which the phy-. sician may consult in the usual man ner. The diagnosis and, treatment of lead intoxication in children are complex and must be placed in the hands of experienced physicians. The enclosed pamphlet by the Children's Bureau offers 37 authoritative references. (2) In addition, a bibliography of refer ences to some works in these fields by experts is printed at the end of this booklet. However, everyone concerned with the problem should be aware of cer tain findings which should arouse sus picion at once. To physicians not actively engaged in pediatrics; symp toms, and signs ofteo are so common place and nonspecific that initially they may be overlooked: Cases may occur without being suspected; on the other hand, there are instances of ill nesses erroneously diagnosed as lead poisoning. It is important that all physicians, public health1 workers and others real ize there is a childhood plumbism problem in urban slum areas. Being aware of this fact should make phy sicians more inclined to recognize and investigate symptoms they ordinarily would not associate with lead intoxi cation: ; ; Check oa Chewing, and Pica The presence of pica should especially arouse a physician's suspicions. Though most children pass through a stage of chewing on almost anything in reach, this habit should be gone by the age of 15 months and should never be of great intensity. Though the ipresence and history of pica is important, diagnosis should not rest on these alone. Many lead intoxicated patients have been found to have no history of pica when first examined. A careful check should be made to determine the child's physical envi ronment. A child with lead iatoticatioo has almost always chewed lead painted materials, such as woodwork, plaster, wallpaper or putty, for it least three months before clinical signs ap pear. Though these materials them selves do not contain lead, they were often coated with leaded paint maov years ago. When ;a suspected case of childhood plumbism is seen, a check should be made to learn if the child fives m or frequently visits a house built before World War II, A list of `high-risk" addresses could be posted tn ail pedi atric Climes to help physicians un familiar with the city. Most cities with the problem do have such areas of high risk. Signs and Symptoms A ditfooiii of lead poisoning should be based on clinical findings and sup ported by biochemical evidence of excessive lead absorption, aad. .i pos sible, by evidence of unusual expo sure. There are a number of signs and symptoms which should arouse tr.e suspicion of physicians and others, particularly if the patient fives -a a slum area. They are not diagnostic by themselves, but are icdicdi.oas that emergency laboratory tests are required. The signs and wrrpton-.s listed below are not intended *o be either definitive or exhaustive For a thorough consideration of these >-b- ptrtCOOOO65**5 . jects. the physician should consult the medical literature. The signs and symptoms of lead ac cumulation to children chiefly involve three organ, systems: the gastroin testinal -.'stem, the central oervous svstem. and the hematologic system. <u>- The gastrointestinal symptoms are those which are most likely to he no* uced first by parents and other lay men. They consist of vomiting, com plaints of vague: abdominal pain and constipation. These' are fairly common complaints among children, but the examining physician should be aware that plumbisra.may be the true underlying cause. He should also be aware that parents often, are dot of much help in his efforts to obtain definitive informa tion. A survey of 300 children with confirmed cases of plumbism showed that 76 percent of them had no pre senting complaints, but when specific and' detailed inquiry was made, it was found that 38 percent had loss of appetite and 9 percent had vomiting, la another study of 22 children afflicted with severe lead encephalopathy, it was found that 18 had been treated symptomatically for "gastro* enteritis'* for different periods of time before symptoms of central nervous system, involvement became apparent. Some of these childrea had also been treated for anemia. constipation, sugar in the urine, gait disturbance, and sudden onset of crossed or skewed eyes. Central nervous svstem involvement: The moit serious i manifestations of childhood plumbism are those that result from involvement with the brain. These may range from drowntaess to deep unconsciousness (coma), or repeated fits (grand mol seizures). In some; cases the first clues to the in toxication are repeated falling, clum siness or loss ofcoordination. In other cases, convulsions may bring the child to medical attention. There also may be reading on behavior problems. From the physician's point of view, there is ,nothing||especiaHy character istic about the convulsions, for they may occur without fever and may bis focal or generalized. However, if in the course of a few hours, the pattern j ! j ! < i I ! : > of the seizures switches back and forth between right-sided. left-sided and generalized, the possibility of plumbism should be investigated. The physical examination in such cases may reveal inflammation.of the optic nerve, ataxia (lack of muscular coor dination). lethargy or seifures-with or without local paralysis and with or without reflex changes--and: as such serves to confirm the involvement of the central nervous system but does not provide exact evidence lof cause. Hematological findings: Parents will be unable to detect changes in the blood of a possibly affected child: The physician may wish to check for anemia before asking for specific blood ; lead tests. Iron deficiency anemia is common in toddlers, and does not necessarily mean that'the child has absorbed potentially toxic amounts of lead. Accordmg to Dr. Chisolm, there are two groups of children involved: those with asymptomatic increased lead absorption, and those with lead poisoning. The first group, which probably contains the largest number, are children who show evidence of increased body lead burden without evidence ofi toxicity. The diagnosis of lead poisoning,i Dr. Chisolm says, should i be reserved for those children who. in addition to evidence of an increased body lead burden, also show biochemical evidence of toxicity This latter evidence includes increased out put of coproporphyria and/or delta aminolevulinic acid in urine. "Some of these will show no clinical signs'^ Dr. Chisolm says: `Because of the nebulous nature of the clinical signs and lympioms. w should de mand that patients with signs and symptoms suggestive of lead mtoxicationalso have biochemical evidence of intoxication * (IS) Tests for Piumbism As noted above, the presence of one or more hematological; intestinal or neurological signs or symptoms is not to itself diagnostic of pediatric lead intoxication. Laboratory. tests are necessary for the physician to de termine whether his patient has ab sorbed lead iq quantities sufficient to induce illness. By far the' most reliable test for lead absorption is the quantitative deter mination of the lead coatebc of the blood. Since speed is often extremely important in diagnosis of childhood plumbism so that proper treatment caa be undertaken, such a test ought to be ordered immediately upon the first suspicion. Blood lead concentrations should be interpreted with caution as these vjiues .can be. affected by a number of factors such as competence and ex perience of laboratories and laboratofy technicians, methods used iq the collection and storing oi samples, and possible recent admimscranoa of che lating agents. Blood-lead concentrations of -0 to 60 micrograms per 100 milliliters of blood have been used by various agencies as the upper limit of :r.e j normal range for children. For e\j ample: the Chicago Btoard of Health { refers all children with lead vaiues above SO mtcrograms to a special clinic for the diagnosis and treatment of lead poisoning, whereas other agencies have suggested 60 micro grams as the upper normal limit ot blood lead concentrations, ill. 16. 171 There appears to be general agreement that, blood-lead coocen! trations between 60-30 micxograms are indicative of abnormal acsorptioa of lead, but often; not of a degree of absorption which is capable or mI discing symptoms of intoxication. Blood concentrations of 30 micro^ grams aind above are considered to be j potentially capable of inducing mtoxi, cation. ||sidrm| immediate action in cluding both referral, for treatment i and rerji^dlval' of the child from the j source of exposure. PNYC000065V6 Blood lead determinations are the most reliable method currently avail able to communities with active pro grams aimed at controlling childhood plumbism. According to Dr. Chisolm, a test recently developed for estimat ing defta-amijsoievuiimc acid (ALA) m urine is simple, rapid and inexpen sive and may be suited for ,mo screening if it can be shown that the concentration of ALA in random samples of urine provide sufficient discrimination between normal and lead-exposed children. However, further evaluation is necessary before it can-be. accepted. (Chicago Health Commissioner O'Connell says a 1967 study in that City, which is to be pub lished, found ALA does not correlate with blood lead ; in screening for asymptomatic lead intoxication.) fP yY Urine lead analyse* are foraUy limited to usefulneu in diatcal re search and in management of hos pitalized cases because they require 24-hour collections of urine to yield useful data, says Dr. Chisolm. The edathamil calcium disodium (EDTA) mobilization test for lead also requires quantitative collection of urine and seems to be mostly useful in the study of older children suspected of having chronic plumbism. he notes. (13) ( Dr. O'Coaaell says the EDTA mobil ization test is used in ail age groups ia 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. I. Julian Chisolm and Eugene Kaplan, both of Johns Hopkins Medical Schoolia Baltimore. Published in the December 1968 Journal of Pediatrics (Vol. 73. Mo. 6. pp. 942-950), this sums up the views aad contributions of the authors and sU other experts ia the field who participated in a symposium held at Happy Kills 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 ia the Treatment of Acute and Chronic Lead intoxication in Childhood." J. Juliaa Chisolm, Jr. in Journal of Pedi atrics (Vol. 73.1968); "Lead Poison ing im Childhood: Signs. Symptoms, Current Therapy, Clinical Expressions.'r Joseph Greeogard, in Clinical Pediatrics. May 1966: and "Pediatric Lead Poisaaing," Hugo Dunlop Smith, in Archives of Environmental Health, February 1964. References 1. USA Standards Institute (formerly American Standards Association). American Standard* SpecMcadom to Minimize Hazards to CUdrtt from Residual; Surface Coating Material*, standard Z66.1 1964. 2. Lin-Fu. Jane S.. M.D. Lead Poisoning In Children. U.S. Department of Health. Education and Welfare. Chil dren's Bureau "publication No. 4521967. 3. Schucker. George W.. VatL Edward H.. Kelley, Elizabeth B,, and Kaplan. Emanuel. Prevention of Lead Paint Poisoning Among Baltimore Children. Public Health Reports 8000:96$974, November 1963. 4. Baltimore City Health Department. Lead Paint Poisoning la Children, 1968. 5. Dr. Morgan J. O'Connell. Personal communication. 6. Bianksma. Lorry A,, Ph.D.. Sachs. Henrietta K.. M D.. and Murrav. Ed ward F-. M.D. Incidence of High Blood Lead Levels in Chicago Chit dren. Paper presented at annual meetingof American Association ot Poison Control Centers. Chicago. Oct. Z\. 1968. 7. Chicago Board of Health. To Save A , Life. Film. 1968. ; 8. Dr. Felicia Oliver-Smith. York ; City Health Department Personal j communication. ! 9. Verhulst. Henry L. and Crouv. John j J. Childhood Poisoning Accidents. Journal of the American Medical As- ! sociition 203(I2):145446. March 13. j 1968. . 10.Griggs. R.C.. Sunshine. 1.. Newill. | V.A., Newton. B.W.. Buchanan. 5.. j and Rasch. C A Environmental Fac- | ton ia Childhood Lead Poisoning. > Journal of the American Medical Asj sociation '187:703-707. 1964, M1. Jacobzmer. Harold. Lead Poisoning I is Childhood* Epidemiology. Manifesj tattoos, and Prevention. Clinical Peuij atrics 5(5):277-;86. May 1966. ; 12. Cooper, Marcia. Pica. Charles C : Thomas, publisher. Sprmgneld. 11! j 1957. 13. Chisolm. J.J.. Jr. and Kaplan. Eugene. Childhood Lead Poisoning-Comprebeflslvc Management and Prevention. Journal of Pediatrics 73(6r.95 2-950. December 1968. 14. Dr. Hugo Dunlop Smith. Personal communication. IJ. Dr. J./. Chisolm, Jr. Personal commtififcatioo. 16. Chisolm. J J.. Jr. Lead rntoxteatiom in Children. Developmental Medicine and Child Neurology 7-.529*536. Octo ber 1965. 17. Greengard, Joseph. Lead Poisoning in Childhood: Signs, Symptoms. Current Therapy, Cltakai Expressions. Clini cal Pediatrics 5(5):269-276. Mav ;9t?o. ] For other reading on lead and pedia{ tries see next page. PtrtCOQOO*^ l Other References Bvers. R.K.. and Lord E.E. Late Ef fects of Lead Poisoning on Menul Development. American Journal of Diseases of Children. 66:471, Novem ber 1943. Chisolm. J,JV. Jr., and Harrison. H.E. The Exposure of Children to Lead, Pediatrics. 18:943-957, December 1956; Chisolm. J }.. Jr. Treatment of Lead Poisoning. Modern Treatment. 4:710, July (967: Chisolm. J.J.. Jr. The L'se of Chelating Agents in the Treannent of Acute and Chronic Lead Intoxication (n Child hood. Journal of Pediatrics. 73:1.1968. Christian, J R... Cele^ycz. B.S.. and Andelman. S L. A Three-Year Study of Lead Poisoning in Chicago. Ameri can Journal of Public Health. <4:1241-1251. August 1964. Coffin. R., Phillips. J.L.. Staples. W.I., and Spector. S: Treatment of Lead En cephalopathy in Children. Journal of Pediatrics. 69: l^S-206. August 1966. Davis. J R,, and Andelman, S.L. Uri nary DeitX-Amiaolevutlnic Add Level* la Lead Poisoning* I. A Modified Method for the Rapid Determination of Urinary Deiu-AmlnoeruUnk Add Using Disposable Ion-Exchange Chro matography Columns. Archives of En vironmental Health. 15:53, 1967. Davis. Joseph R*. Abrahams* Ronald H.. Fishbein. William L. and Fabrega. Enrique A. Urinary Delta-Amiaofcvtt- Unic Add (ALAI Levels in Lead Poi soning ll. Correlation of ALA Values With Clinical Findings in 250 Children With Suspected Lead Ingestion. Ar chives of Environmental Health. 17 (2):l64-i?l, 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- L, Lead Absorption in Children. British Medical Journal. 2:480-482. May; 1967. Greengard. J- Adams* 8.. and Ber man. . Acute Lead Encephalopathy in Young Children. Journal of Pedia. tries. 66:707-7! 1. April 1965. Gucdius. M.F.. Millican. F.K., Lay man. E.M.. Cohen. G.J. and Dublin. C:C. Nutritional Studies of Children with Pk*u I. Controlled Study Eraluatiag Nutritional Status. II. Treannent of: Pica With Iron Given (ncramuscolariy. Pediatrics. 29UQ12, 1962. Ingalls. T.H.. Tiboni. E.M., and Wer. rm, M. Lead Poisoning in Philadelphia 1955-1960. Archives of Environmen tal Health. 3:575-579, November 1964. Jenkins. CD.. and Mellins. R 8. Lead Poisoning in Children: A Study of 46 Cases. Archives of Neurology and Psychiatry, 77:70-78. January 1957. ; Kaplan. E., and Shaullr R.S. DettraL ] nation of Lead in Paint Scrapings ns | an Addi in the Control of Lead1 Paint | Poisoning in Young; Children.- Ameri can Journal of Public Health. 51:64, I96L Lourie. R. S.. Layman. E.M.. and MU- lican. F.K. Why Children Eat Things That Are Not Food. Children. 19 U3 1963. Mellins. R. B.. and Jenkins. C.D Epi demiological and Psychological Study of Lead PoisoatQg la Children. Jour* nal of the American Medical Aisocration. 158:15-20. .Slav J955 Millican. F. K.. Layman. . M . Lou rie, R. S.. and Takahashi. L. V Study of an Oral Fixation: Pica. Journal ot the American Academy of Child P-ss chiatry, 7:79. 1968. MoncrietT. A. A.. Koumides. O. P. j Clayton. B. E.. Patrick. A. D. Ren- wick. A, G. C.. and Roberts. G Er j Lend PoboeJng in Children. Archives } of Diseases in Childhood. 39:i-u. February 1964. ; Perlstem. M. A., and Attala. R. Neu rologic Sequelae of Plumbisra in Chtl- , dfta. Clinical Pediatrics. 5.292-298. ; May 1966. , Sartam. P.. Whitaker. J. A., and Mar tin. J. The Absence of Lead Lines in Bones of Children With Early Lead Poisoning. American Journal of 1 Roentgenology. 91:597-601. March ; 1964. Smith. H. D. Pediatric Lead Poison* ing. Archives of Environmental Health; 8:256-2$l, February 1964. ; Whitaker. J. A., and Vietta.T J Fluo rescence of the Erythrocy tes in Lead ! Poisoning in Children: An Aid to Rapid, Diagnosis; Pediatrics. 24:'*3~ j 738. November 1959. ! Diagnosis of Inorganic Lead Poisonj tag: ^Statement. British Medical Jour] nal. P: 50i. November 23. 1968. I t 10 p,,tC000065Ve st'^asi^siwe=tiKfflr PNYCC00Q6549 ; The Lead Industries Association. Inc. j is a non-profit organization of lead ; mining, smelting, refining and fabriI catiog compaotes throughout the Free I World and is incorporated under the Membership Corporation Law of the : State of New York. Among other thinp, its purposes are to disseminate [ accurate information regarding lead products and how they may be used, i to develop methods for the improve ment of the welfare of those engaged j in the lead industries, or in the use of its product and. in general, to promote the serviceability of lead industries to { the community at large. j - LEAD INDUSTRIES i ASSOCIATION, INC. j 292 Mttlito* Av .o im. I New York, New York 10017 ti ;p33EISErp PNrcoooo 6550 PMTCC0CO6551 N11097.02 lead poisoning in children 1 PNYC00006562 ^WSWWWBIMIIPSBS^*^ ]