Document ykQwQ7r3NLZMYnaGVv5aKNwbX

Lead poisoning in chiMhood--co?nprehmsive management and prmntion *' ; A symposium washeld at Happy Hills Hospital in Baltimore on April 24, 1967, to call "attention to the need for a cooperative community approach to the social, environmental, . and psychological aspects of the problems of children with lead intoxication. . . Comprehensive care is jiisl as urgent for the asymptomatic child with an increased body burden of lead as it is for the child with manifest acute plumbism. While . ' chelation therapy for the acute toxic episodes of chronic lead poisoning is deservedly , emphasized, hospitalization in a chronic disease facility which has a positive program of child and family rehabilitation serves an important role in the total care of the . __ _ ' affected child. Experience in Baltimore and other large cities has shown that coordinated and sustained efforts by health departments, pediatricians, medical social workers, . and child guidance workers are essential for an effective program for the prevention . ' and treatment of childhood lead intoxication. . . '' J. Julian Chisolm, jr., M.D.,* and Eugene Kaplan, M.D. BALTIMORE, MO.' | - '. . _ / *. ' From the Departments of Pediatries of.the _ Le a d p o is o n in g in the young child Johns Hopkins Medical School. Baltimore City is a chronic disease. It results from the im Hospitals, Sinai Hospital of Baltimore, Inc., ' and Happy Hills Hospital,,Inc. pact upon the urban slum child, in particu - This work was supported in part by United ' lar, of a variety of causative factors--pica States Public Health Service Grant Ho. . and environmental exposure to lead, cultural . ) UI00299 from the National Center for Urban and Industrial Health. and behavioral patterns of parents, and cer 9Address for reprirts: Baltimore City Hospitals, \ tain aspects of lead metabolism. Current 4940 Eastern Baltimore, Sid. 21224. knowledge with respect to each of these This paper summririze; the zlezvs end contributions presented at the Hanpv Itiiii Syrr.posjum oy the several factors, although imperfect and limited, is participants here listed. Sf. t.arrie Piue, Sl.D., _ Instructor in Pediatries, Johns Hopkins V-nxvcrtiiv School sufficient to provide the basis for an effective of Medicine; Assistant Medical Director, Happy Hills, . ' Hospital, Inc. Randolph K. B'/'rt, M.D., Associate _ approach to the problem. . \ Clinical Professor of Pcdijlr-.es, Harvard Medical School; i Coniu'iant in Kcurofozy, Children's ikfedical Center, Boston, Matt. J. Ju'inn Chisolm, Jr., Sf.D., Associate CAUSATIVE FACTORS '. Professor of Pediatrics, Johns. Hopkins University School i of Medicine; A utricle Chief Pedijlrichn, Bill.more City ffo;pi>als. Slnzic R"Prot'orl. Pica. Centuries ago, pica' was the Latin i Director, Deportment of J.frdieal Social Work, v Baltimore Citv Hospitals. P-fcrriz M. Cooper, Sl.D., word for magpie, a bird of voracious and in < Associate P'ofrtsor nf Menial Hyzi.r.', Johns Hop-kins University School of Hygiene end Public Health. discriminate appetite. Today the term pica F.-ipenc Kaplan, M.D., Associate Professor of Pediatrics, Johns. Hopkins University School of denotes the habitual, purposeful, and com- Medicine: Medical Director, Happy Hills Hospital; Pediatricl-cr..Chief, Sf-ai Hospital of Baltimore. ' pulsive search for and ingestion of such un Rczimld S. Lrurie, M.D., Profenn'' of Pediitdc Psvchictry, Georze Washing-ton oil: etsily 'School of natural food substances as clay, piaster, ashes, Medie'.ne; Director, Dep-irt>nenl of Prychialry, Children's ,Hnspii~l, Washington, D. C. Maltkizo . laundry starch, string, putty, pain: chips, . Tayhcch, Sc.D., DePittv Commissioner of .Health, ' Baltimore City Health Deportment, paper [especially newspaper), dirt, crayons, VoL 7ZsNom*6, pp. -942-950. N11988 3. . ...... i .,-------------- Kunioja-sx. \ ' . i i j :i ;:d .cr-J .cse , is . vM'i :ivc ' ' i ' 'M } ii \\ MfV:i AZZ un\ >1 `cigarette butts,, yarn, and matches. Although the list is long and varied, many children and adults with pica tend to be highly selec tive; Each exhibits a craving for oniy one (or very few) of the above items. Pica had been known to medicine since the time of Galen. Iu>'distribution is worldwide. Incidence in the general population increases during times of stress. Historically, it seems to be related mainly to the relative availability of a diet adequate both in quantity and quality to. the social group as a whole. Women (especially pregnant women) and young children are most vulnerable to pica. Rural groups are, affected more often than urban groups.0'17* Lourie and his associates10'17 could find no evidence that any nutritional deficiency , was Gtiologically related to pica among urban children in Washington, D. C. Preliminary studies suggest that pica in large cities of the 1 United States is most prevalent among fam- /`jies--particularly Negroes--recently arrived from the rural South. Lourie postulated that such families respond to the stress of their social and economic deprivation in their tra ditional rural behavior patterns, one of which is clay-eating among women. After 3 or 4 generations as urban dwellers and with im proved social and economic security, rural behavior patterns including pica are largely dropped. . The child. Infants are apparently born with differing innate levels of oral activity. During the first 12 months of life, this takes the form of mouthing--but not ingesting-- almost anything the infant can place in his mouth. For reasons unknown, children be tween 12 and 18 months of a<Ore mav beOtrin to ingest foreign materials as an extension of normal mouthing activity. As many as, 50 . per cent of children carefully studied in both middle class and poverty groups habitually and selectively ingest objects other than food. Between 3 and 5 years of age, this behavior . tends to disappear. During these years, the child may indoctrinate his younger siblings ihto the same activity. ' j '"These numbers guide the reader to the use. of the j Selected Bibliography at the end of the article. They are 1 not die usual "reference numbers" of this Jo u r n al . Interaction of child and parcnt(s)--the emotional climate. The interaction of child and mother is often a critical determinant . of pica activity. As many as 50 per cent of mothers of children with pica may also have pica themselves. A''chiid's. high level of oral activity may be reinforced by a mother with similar oral interest. Thus, while a bottle or pacifier is offered the fussy child at first, later the mother may substitute the clay or laun dry starch that she habitually ingests. The pattern of relieving the child's anxiety by oral activity may become fixed in this man ner and may later continue as an aggressive . form of behavior: "If you don't let me go . out to play, I'll eat paint." ,. Anxiety in the child for which oral grati fication may serve a relieving function is often a response to an absent or a poorly functioning mother. She may be absent in order to earn a living outside the home, and there may be no father to share the domestic responsibilities. She may be hospitalized by illness or repetitive childbirths. She may be overwhelmed by too many children to care for and thus be deficient in her caring role for the toddler. Indeed, the onset of pica in the toddler often coincides with the arrival ' of the next infant. Emotional difficulties in the mother often accompany a child with pica. Maternal dependency is the most com mon pattern observed: Such mothers have a life history of despair, passivity, and inactiv ity except in crisis. In such a family, children ^ with plumbism may escape early detection and appear for health care only when sei zures or coma demand urgent intervention. Another pattern encountered is the mother ' who is not aware of the child's pica. This may reflect a basic ignorance that ingestion of these materials could be harmful, or she may be absent from the home for much of the day and not realize that the persons who care for her child allow or support his pica activity. In a small number of families, the .. inadequacy of the maternal role results from the mother's own gross intellectual or psychi atric handicaps. To sum up, the symptom of pica is most likely to occur in children with : a high level of mouth activity whose oral ,, : 0000-NLI-000020882 relict of anxiety is reinforced by cultural patterns and io whom the mothering neces sary to stop it is unavailable for a variety of reasons. When such a child is exposed to hazardous environmental sources of lead, the likelihood of plumbism is indeed great.10*12-17-18 . Environment. The vast majority of cases of plumbism in young children in the United States today arc recognized in those who live in old, deteriorating urban housing. The in terior woodwork, painted wallpaper, and painted plaster of houses built prior to 1940 and still in use may contain layers of lead- pigment paints which have never been re moved.2 A few small chips of such paint may contain lOOjmg. or more of lead. (The safe daily intake of lead Is < 0.5 mg.) Recent studies in Baltimore reveai that 50 to 70 per cent of old houses in selected slum areas contain dangerous quantities of flaking lead pigments on the painted interior surfaces.10 The clear relationship between childhood nlumbism and old urban housing is shown in Table I.8 Studies indicate that a com parable situation exists in many large cities of the continental United States. It seems' likely that small towns and rural areas may also contain children wth pica w-ho dwell in dilapidated old houses; nevertheless,' plumb ism is infrequently recognized outside of large cities. The usual interior locations of leaded paints chewed by poisoned children are windowsills and paintedplaster and wail- Table I. Environmental exposure of young children to lead in new and old urban housing*, . Location of home No. of children studied No. with abnormal No. with urincj plumbism Old housing Is'cw housing project 801 216 38 (4.7%) (27%) 105 3 0 'Adapted from the data of Grifigs, R. C., Sunshine, I., Ncwiil, V. A., cC al.: Environmental factor* in childhood lead poisoning, J. A. M. A. 187:703, 1564, and based upon a prospective home survey of preschool children in Cievelau'd, Ohio, *. fCoaceniration of both lead and coproporphyria increased. paper. Common exterior sources are door frames, fences, porches, and houscwalk. . There is increasing concern over the prob- , , 'J icm of environmental pollution of-all sorts. ; 'j Much of the controversy with respect to lead was raised by Patterson, who inferred that the body-lead burden in urban dwellers may be 100 times greater than the burdenpvould be under ideal but primitive living conditions. , ; .1 j ! This difference, he surmised, is due to the ! continuing accumulation of lead wastes in - j urban areas from lead alkyls, lead arsenate, food can solder, paints, alloys, piping, glazing, and spent ammunition. Atmospheric lead pollution is greatest in the urban areas, with the chief contribution coming from motor vehicle exhausts.0 On the basis of balance ' ,studies, atmospheric lead pollution, even in urban areas, has not yet reached toxic levels i 'j j j ... ; | -j ,j for the general population.11 Metabolism of lead. Lead intoxication,re- suits from chronic increased ingestion of lead. This is so because inorganic lead compounds j ! I .I are poorly absorbed into the body, retained leadTs-stored largely in bone, and an excessive body-lead burden is only very slowly excreted. It follows that repetitive ingestion (or inhalation) of small amounts of lead is . usually far more dangerous than a single massive exposure. The meticulous long-term balance studies of Kehoe11 in human adult [ j' _j I .1 j t volunteers indicate that the average adult_ in the United States today ingests about 0.3 ,' 1 .j mg. Pb daily in food and beverage, and in .urban areas currently has a respiratory intake 1 --j of 0.03 to 0.04 mg. Pb daily. Of this total exposure, approximately 40 to 50 p.g Pb Is absorbed into the body and promptly excreted by urinary and biliary tracts so that * no net retention of lead results. Such "nor mal" lead exposure is associated with a con- .! | 1 j -* j centration in blood of 15 to 40 fig Pb per I 100 Gm. whole blood in both children and adults, As yet, no untoward effect of this "normal" exposure has been demonstrated. As mean daily lead ingestion increases be yond 0.5 mg. Pb, the entire load cannot be excreted, so that the accumulation of an excessive body-lead burden begins and will increase progressively as long as abnormal , j j 0000-NLI-000020883 NumberS .j U jJUttL* Stug t^ ingestion continues.. Comparable balance data for young children arc not available; nevertheless, it is blatantly obvious that re petitive ingestion of paint chips containing 50 to 100 mg. Pb per few small chips con stitutes truly massive exposure. Studies in human adult volunteers and in dogs indicate that once excessive intake of lead is stopped, it takes at least twice as long to excrete the excessive body burden of lead as it did to accymuiate it. For example, if a child with pica ingests lead over a 2 year period (from 1 to 3 years of age), it will require at least 4 years (or until 7 years of age) to excrete the load by normal physiologic mceha- nisms.5- 9- 16 ` ' The biosynthesis of heme is exquisitely sensitive to the toxic effects of lead.11 In creased excretion of the heme precursors, coproporphyrin and S-aminoIcvulinic acid, in the urine, is virtually always found prior to the onset of clinical symptoms. The quali tative urinary coproporphyria test (UGP)4 is well suited, for clinic'and emergency room use for the rapid presumptive diagnosis of manifest or incipient acute plumbism.'This test can be performed in 5 minutes and should be available in all metropolitan hos pitals serving high-risk urban areas. When blood-lead concentration exceeds 80 /ig Pb per I0Q Gm. whole biooa in a toddler , ac tively ingesting lead, the UCP test is strongly positive; but at lesser concentrations of lead in blood, this qualitative test is not suffi ciently `sensitive or discriminating, so that . its usefulness as a screening test for the early detection of the child with asymptomatic in creased lead , absorption is quite limited. Detection of fluorocytes (erythrocytes fluo rescent owing to increased content of proto porphyrin) does not distinguish between plumbism and iron deficiency anemia and requires specially skilled technicians; never theless, the rapidity and simplicity of the basic technique make it attractive' as a screening technique where a skilled techni- cOn can be found.20 In industry, serial mea surement'of S-aminoIevulinic acid {ALA) in urine provides one of the best means of monitoring occupational lead exposure.11 The recent development by Davis7 of a simplified .technique employing commercially available prefiiled disposable ion-exchange resin col umns for the estimation of ALA in urine holds great promise: At the. moment, this L the pest mass-screening technique available. With it, children with blood-lead concen trations > 6CL/tg Pb per .100 Gm. whole blood can apparently be detected with a high degree of accuracy. ` Fundamentally, the diagnosis of plumbism' depends upon the demonstration of an ex cessive body burden of lead.3'14 The most useful and direct index of this is measure ment of blood-lead content. Accurate deter minations require specialized techniques and proper collection of samples. At the moment, blood-lead analyses are too difficult and time consuming to permit their widespread use in mass-screening programs. Byers and Kopito13 are developing a technique for measuring lead in hair and are currently evaluating its suitability as`a screening technique. Urine- lead analyses require quantitative 24 hour collections of urine to yield useful data, so ' that this measure is most useful in cimical research and in the management of hos pitalized cases. The EDTA mobilization test . for lead also requires quantitative collection, of urine. It appears to have its main use in the study of older children suspected of chronic plumbism.4 . . .. THE DISEASE , Natural course. Uncurbed, pica tends to persist until 3 to 5 years of age: In the brain damaged child, the habit may persist much longer.13 Such protracted abnormal lead in gestion is accompanied clinically by recur rent acute toxic episodes of symptomatic plumbism.. For reasons not fully apparent, 80 per cent or more of acute toxic episodes occur during the summer months. Clinical manifestations tend to vary with both the age of the child' and magnitude of the ab normal lead Ingestion. Encephalopathy is most common in children 15 to 30 months of age, while intoxication without cncephalop' athy in this age range usually presents as some form of hyperirri table or aggressive bc- 000O-NLI-OQOO20884 havior disturbance. Associated iron deficiency anemia is vitually always present. Careful questioning, usually reveals delay or reversal in verbal maturation and loss of recently ac quired motor skills.. Vomiting and decreased interest in play arc especially ominous signs, as they may portend incipient cnccphalop-, athy. As the preschool child grows older, acute toxic episodes; tend to be less severe. Thus the 2 to 5-year-old child with unrccog- . nized plumbism may present with, a con vulsive disorder (without features of en cephalopathy and not distinguishable from' idiopathic epilepsy), chronic impulsive, ag gressive hyperkinetic behavior disorder, or mental retardation. Uncommon syndromes include progressive loss of mental function simulating degenerative cerebral diseases, peripheral neuropathy or bouts of acute crampy abdominal pain usually attended by vomiting, constipation and pain and tender ness in trunk and proximal girdle muscles.3'4 Sequelae. Permanent central nervous sys tem injury and late-onset renal insufficiency have been reported to follow the plumbism of early childhood.1'3 At least 25 per cent of the survivors of acute encephalopathy sustain severe permanent brain damage.2 Whether children without overt encephalopathy sus tain significant CNS injmry as. a`result of plumbism in early childhood is not clear. Although the usual psychometric tests and performance in school indicate deficiencies in comparison with norms derived from more privileged groups of children, it has not been shown that they differ greatly from other underprivileged children not known to have had plumbism who also reside in deprived urban areas. In a long-term, follow-up study of childhood plumbism in Australia, Hender son found that 94 of 352 patients had died of chronic nephritis, 15 to 40 years after the initial intoxication.3 Onsc t of renal insufficiency began during or after adolescence. Similar work in the Unit!:d States has not revealed any link between childhood plumbism and chronic renal insufficiency. This and other evidence suggests tljiat lead nephrop^ athy may be a sequel limited to very pro tracted childhood plumbism. Bycrs and others have delineated the , , the nature of the CNS injury which .follows early childhood lead poisoning.1'12 Injury resulting from lead docs hot differ from that ; vvhich follows any, diffuse cerebral injury r sustained during cAtiy.. childhood (i.c., en- . cephalitis, meningitis, trauma). In its most ' severe form, acute encephalopathy may re- . suit in cortical atrophy, hydrocephalus ex : vacuo, severe convulsive disorder, idiocy, and ; " blindness: Such a- result is becoming incrcasingly rare. Subtle neurologic deficits arc the more common outcome, such as lack of 1 sensory perception and perseveration despite . I.Q. scores of 80 to 100 or better on the Stanford-Binet test. Form and proportion are distorted. The affected child tends to break a drawing down into its components rather than to recognize the design as a whole, integrated unit. Such children also perseverate: For example, if you teach the child that 5 x 5 is 25 and then ask him what 4 x 3 is, the child says 25. If, on the other hand, you ask him quite apart from the first question (5 x 5) what 4 x 3 is, he may be able to say 12. Once he learns a correct answer, he repeats it even when the question is changed. The unwitting teacher (or . mother) may conclude that such a child is insolent, whereupon she will punish him and so reinforce and aggravate the behavioral problems often present in such children. They . also have short attention spans and arc easily distracted. Although it is difficult to deter mine how much is due to organic brain j damage and how much represents response to environment, many lead-poisoned children develop hostile, aggressive, and destructive behavior patterns which in turn may pre cipitate exclusion from school and the de mand for institutionalization. Such behavior as well as convulsions may abate as puberty approaches, but intellectual deficits persist. Early recognition-mass screening. A sys tematic program is essential in each com munity for early detection of the high-risk toddler, the high-risk mother," and the highrisk dwelling. The program should be imple mented throughout the year, but should be most intensive during the spring and sum- 0000-NLI-000020885 the 'lows'; .jury ... ;:.r-.t iuiT ' . en-' most : . ' IC- - cx r.acl .' ' : ;; arc A; of spite . dlC rtioa is to .nents as also i .1 me whatother o first ay be orrcct rstion .- (or ..lid is :hand . .-local .They . easily deter- brain ponse hidren -active v p re de ocliavior. uberty rsist. A sys. comgh-risk. o highimpie. raid be d sum- \ \ i ! !i i j i ! ! ! ! { incr mofiths, For early recognition, efforts be confirmed by laboratory tests, these clin-'. . should be concentrated on children 12 to . ical indications call-for biood-lead determina -V 18 months of. age. In selected slum areas,- the ' tion. and UCP or urine-ALA in asyrnpto- -estimated incidence of excessive lead inges- .' made children. Suggestive symptoms or the ' tion among preschool children is 10 to 25 . presence of a positive UCP call for complete ..: per cent and of children requiring therapy- . diagnostic evaluation and hospitalization* .' ' / .'for plumbism it is 2 to 5 per cent. In such ' areas, mass, screening techniques are clearly needed. Currently, the. simplified urinary- T COMPREHENSIVE ." :*yl'y ;A. : A,; . ' MANAGEMENT.'..-'\v y : ALA test of Davis7 is the best available: It.' ,!- . In years past, mothers, of children with, ; -' - h is economically feasible, but requires the i plumbism were, sternly admonished not to : -:' facilities of an analytical laboratory, which' . ' let their children cat lead paint. Only those - -- is the responsibility of the local health de- children with acute lead encephalopathy ' partment. The analysis of lead in hair by were admitted to the hospital, and, follow atomic absorption spectrophotometry13 and ing a brief course of chelation therapy, they fluorescent erythrocyte20 techniques warrant were discharged to the same leaded environ further evaluation to determine their suita - ment with the same parental admonition. bility for mass screening. Each abnormal test In the light of current knowledge, the inade result calls for thorough clinical evaluation quacy of this casual approach should be 'of the patient and, at the very least, a con- obvious, and its ineffectiveness in preventing flrmatory blood-lead determination. . , severe neurologic scquellae not surprising. ' In. the absence of mass-screening programs, Today every child with asymptomatic in ! early recognition is dependent upon the de- creased lead absorption should be hospital velopment of interview and observational ized. A team approach to his problem should techniques designed to identify the child include the comprehensive efforts of the with incipient pica and his dependent, dc- . local health department, physician, medical , - pressed, overwhelmed, or unaware mother. social worker, and psychologist. For optimal ' . Clinical indications for blood-lead and other results, a specific course of action can be laboratory determinations include: (1) pica . outlined during an early conference by these '. in the child by history or observation in the various health personnel. ' clinic waiting area, or evidence of chewing Local health department. It should in on windowsills, etc., reported by visiting spect the housing, see that all hazardous ' ' health nurse; (2) symptoms of plumbism as paint is removed, and back this up. with . outlined previously; (3) nutritional anemia, ' penalties on the owner who docs not comply especially after 12 months of age; (4) aber with local health ordinances. In Baltimore, ' rant behavior, especially hyperirritable or paint in housing interiors of more than 1 ' aggressive behavior in a toddler; (5) dc- per cent lead is illegal. The Baltimore City velopmcntal delay, especially in speech de Health Department provides free laboratory velopment. Maternal indications, for blood- service for the analysis of lead in blood, lead determination in the child include: (I) urine, and environmental samples. A public working mother unable to account satis health nurse evaluates the family, refers all - factorily for her toddler's activities during preschool children for medical examination, her absence; (2) neglect of toddler due to and obtains samples of paint from multiple arrival of newborn infant; (3) depressed, sites in the home for chemical analysis.13 psychotic, or alcoholic mother; (4) history Similarly, should the family decide to change of pica in mother or in previous children _ _ dwellings, the new home is also inspected of the mother; (5) in short, any evidence of before occupancy. ' lack of mothering of a toddler residing in Medical social worker. He works directly ' a dilapidated pre-World War II house. Since with tlie parent, helping her deal with the a definitive diagnosis of plumbism can only guilt, hostility, and dependency so often T-1 VTT 0000-NLI-000020886 t present in this circuihstancc. Tile goal is to substitute'constructive parental behavior for 4-i. . ' 'hopelessness or anger, and this is often pos- . siblc through a parent's direct participation v in tiie area of improving the dwelling or . seeking a suitable new dwelling for her farn- j . ily. In this, and in other activities of social t . worker and mother, the parent is assisted in functioning to her best ability while she is 1 secure in knowing that the child's safety will J :- ' definitely be provided for. Hopefully, family behavior can be so modified by...external sup- ::j , ports and internal strengthening that the f deleterious factors operating for continuous J ' . pica activity can be alleviated. In some in ; stances, such goals are not realistic and foster ' home placement or other protective services ,'i ' . must be utilized with court approval in 4. : 1 order to insure a child's future safety. . Role of child psychologist and psychiatrist. ; These serve the pediatrician and medical . .`1 ' social worker in a consultant capacity. In 4 . view of the behavioral aspects of pica, psy- 4 ' chiatric advice may be especially needed in ) ' -.f instances of severe maternal inadequacy. Jt ^Psychometric testing early and just prior to '} ' entry into school is needed to assess the j : ; damage and to facilitate appropriate school 4 ; ' . placement, especially in survivors of enceph- I ': alopathy. In this regard, far better com- \i , munication between the school system and j medical facilities is needed than is often 1 1 practiced. Role of the pediatrician. It is the pedia- ' trician's function to establish the diagnosis and to assess the severity of intoxication in , each case. This, in turn, determines the i \ supportive medical care and selection of P. ; chelating agents required.'4'5 He must deter- J mine the nature and extent of residual cen- '; : tfal nen'ous system injury sustained so that ; ] : appropriate therapy and .'school placement J1 . can be selected early. In concert with the j, ! others he works to modify the emotional : | '' climate which initially promoted pica, ana he ' j j . must make certain that hazardous lead ex- 4 ; - -posure is terminated. Most important, how- i ' ever, the pediatrician must accept the final l responsibility for seeing that the program ; of management selected in each case is effec- . Role of convalescent hospital. If the maxim of never returning a child with increased body-lead burden to a.'`leaded" home is to be implemented in good faith, a convalescent facility is vital to provide temporary safe residence for the affected child. This gives the health department, medical social work er, and child guidance personnel the time they need to initiate remedial action. For the child with asymptomatic increased lead ab sorption, such a facility together with ap propriate amelioration of his home environ ment may prevent the occurrence of overt intoxication. The child recovering from acute encephalopathy often exhibits behavioral aberrations which his limited parents may be unable to cope with at home: A convalescent home' provides personnel professionally trained to deal with such children. A con valescent hospital also provides a structured environment in which toddlers may learn orderly patterns of play and diet--a pattern which many children with plumbism have, never known. In addition, an active Child Life Program provides the mechanism for terminating the habit of pica. Discharge from the convalescent hospital occurs when a safe new residence is available. Readmission from time to time as indicated can prevent the recurrence of pica during the times of crisis in the family. Baltimore is fortunate in hav ing a community-supported facility such as Happy Hills Hospital which fulfills, these protective and reconstructive needs of the child. Periodic follow-up in the outpatient clinic is continued at least until entry into school or longer in damaged children. Throughout these preschool years, the med ical social worker and physician encourage ' the family to enroll the child in nursery school programs and assist the parents of "minimally brain-damaged children" to find the special facilities they need. PRIMARY PREVENTION OF CHILDHOOD ------ LEAD POISONING Childhood lead poisoning is a preventable ' disease. An effective program of preventionhas not yet been evolved for the disadvan taged urban child and family. Such a pro- 1. .' . ' i - .0000-NLI-000020887 V,W.'/U54 ^mjnwvtm .'grain requires two essential ingredients: a be carried out by public health nurses both clear recognition of the pattern of ctiologic in the clinic and on home visits and should factors, and a clear commitment of responsi be concentrated on children 12 to 18 months bility by physician, public health worker, city of age and repeated as the family situation official, and aroused public. . . warrants. The ctiologic pattern which results in Since the harmful effects of lead exposure irreversible lead encephalopathy consists of in homes have been public knowledge for a triad; the child, the parent, and the place. many years, many cities have passed local The child is a toddler with exaggerated oral ordinances designed to eradicate such haz activities. The parent is a mother with in ards to children. Unfortunately, enforcement adequate resources to cope with her family's often occurs after the poisoning of the child needs. The place is a neglected slum housing and is not always effective. Too often the unit with lead flakes within reach of a small disadvantaged family will move from one -child's grasp. : ' . slum house to another which has not been . m 'Each of these three factors is readily vis- ' . properly screened for lead exposure. The - ijble to the trained professional and should neighborhoods, where the greatest number signal appropriate action for early recogni of susceptible children coincide with the tion and effective prevention of further risk greatest number of substandard housing to that individual child. However, the re units, may receive spasmodic exhortations or sponsible commitment of these very pro visits from local health units. Such spasmodic fessionals on behalf of the disadvantaged ex post facto action cannot be called "pre child and parent is not always forthcoming. vention" and will not suffice. . The child's health needs are often provided What families in such neighborhoods re in municipal well baby clinics where nutri quire are the imaginative and continuous tion and immunization in the first year of life ` efforts of health and social action teams di are stressed above questions of childhood rected at parent participation and education. behavior in the second year and above mater- . Were such action coupled, as in Australia, . nal difficulties in housing and child-rearing. with a strenuous public demand for .the ' For acute illness, the hospital emergency systematic elimination of the environmental . room or pediatric clinic may provide satis lead exposure associated with old dwellings, factory symptom-related diagnosis and treat childhood lead poisoning could be largely ment, but the physician or nurse may remain eradicated in the United States. Immediately inattentive to the possibility of pica in the following the birth of an infant of a family child or the mother's inability to cope with ' residing in a pre-World War II dwelling, the this and other environmental hazards. More prospective dwelling could be inspected and * over, the usual fragmentation of medical and sampled for lead so that hazardous condi social sendees in our clinics and hospitals tions could be corrected before the infant favor ineffective follow-up of already identi reaches the age of pica. . fied high-risk children. . -I ' ^ The recent establishment of comprehensive ^health clinics for disadvantaged children in ' REFERENCES " (SELECTED BIBLIOGRAPHY) >,mahy cities provides a-suitable module for more effective child and parent health care in this area. In high-risk areas, the incor poration of a screening test for excessive lead ingestion into the regular laboratory__ procedures in such clinics together with the development of interview techniques designed to identify the child with incipient pica offer the best current hope for the prevention of childhood plumbum. These procedures can 1. Byers, R. K., and Lord, E. E.: Late effects of lead poisoning on mental development, Am. J.Dis. Child. 66: 471, 1943. 2. Chisolm, J. J., Jr., and Harrison, II. E.: The exposure of children to lead. Pediatrics 18: 943, 1956. _. 3. Chisolm, J. J., Jr.: Chronic' lead intoxication in children, Dev. Med. & Child Neurol. 7: 529, 1965. 4. Chisolm, J. J., Jr.: Treatment of lead poison- ing. Mod. Treat. 4: 710, 1967. 5. Chisolm, J. J., Jr.: The use of chelating agents . in the treatment of acute and chronic lead _' . " 0000-NLI-000020888