Childhood lead poisoning: Exposure and prevention
- Jennifer A Lowry, MD
Jennifer A Lowry, MD
- Professor of Pediatrics
- University of Missouri- Kansas City School of Medicine
- Chief, Section of Clinical Toxicology
- Medical Director, Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation
- Medical Director, Center for Environmental Health
- Children's Mercy Kansas City
- Section Editors
- Donald H Mahoney, Jr, MD
Donald H Mahoney, Jr, MD
- Section Editor — Pediatric Hematology
- Professor of Pediatrics
- Baylor College of Medicine
- Michele M Burns, MD, MPH
Michele M Burns, MD, MPH
- Section Editor — Pediatric Toxicology
- Assistant Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
- Jan E Drutz, MD
Jan E Drutz, MD
- Section Editor — General Pediatrics
- Professor of Pediatrics
- Baylor College of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The sources of childhood lead exposure and strategies for primary and secondary prevention of exposure are reviewed here. The clinical manifestations, diagnosis, and treatment of lead poisoning are discussed separately. (See "Childhood lead poisoning: Clinical manifestations and diagnosis" and "Childhood lead poisoning: Management".)
Children are exposed to lead in a variety of ways. Despite the removal of lead from gasoline and paint in the late 1970s, ingestion of chips and dust from the continued presence of lead paint remains the primary source of lead poisoning in children. In addition, contaminated soil from gasoline emissions continues as an important source. Other important pediatric exposures include elevated maternal blood lead levels (BLLs) during pregnancy and breastfeeding, food, or water contamination and excess lead in parental occupations, toys, cosmetics, and herbal/ayurvedic remedies.
Prenatal exposure — Lead exposure during fetal development may result from mobilization of bone lead stored from past exposure into the maternal bloodstream and/or from direct elevation of maternal BLLs caused by acute or chronic environmental lead exposure during pregnancy [1,2]. In utero lead exposure is associated with impairment of postnatal neurodevelopment with an increased risk for developmental delay, lowering of IQ, and behavioral abnormalities .
In the United States, blood lead screening is recommended for pregnant women with important risk factors for lead exposure (table 1). (See "Prenatal care: Initial assessment", section on 'Lead level'.)
A maternal BLL over 5 mcg/dL is a marker of significant exposure to lead above background levels for pregnant women in the United States population. Because lead crosses the placenta readily and a toxicologic threshold for adverse effects to the fetus or newborn has not been identified, maternal BLLs elevated above background warrant follow-up testing in the mother during and after pregnancy and in the newborn infant. Providers for pregnant women with elevated BLLs should ensure that the maternal lead level is known by the provider managing the newborn infant. Levels of both the mother and infants should be documented in both of their medical records. (See "Adult occupational lead poisoning", section on 'Pregnancy and breastfeeding' and "Childhood lead poisoning: Management", section on 'Prenatal exposure'.)
- Ettinger AS, Gurthrie Wengrovitz A. Guidelines for the identification and management of lead exposure in pregnant and lactating women. National Center for Environmental Health/Agency for Toxic Substances and Disease Registry; Centers for Disease Control and Prevention, Atlanta, GA 2010.
- Committee on Obstetric Practice. Committee opinion No. 533: lead screening during pregnancy and lactation. Obstet Gynecol 2012; 120:416.
- Lanphear BP, Matte TD, Rogers J, et al. The contribution of lead-contaminated house dust and residential soil to children's blood lead levels. A pooled analysis of 12 epidemiologic studies. Environ Res 1998; 79:51.
- Centers for Disease Control and Prevention. Preventing lead poisoning in young children: a statement by the Centers for Disease Control, 1991.
- Agency for Toxic Substances and Disease Registry. Case Studies in Environmental Medicine (CSEM): Lead Toxicity Cover Page. www.atsdr.cdc.gov/csem/lead/pbcover_page2.html (Accessed on January 02, 2008).
- Centers for Disease Control and Prevention (CDC). Children with elevated blood lead levels attributed to home renovation and remodeling activities--New York, 1993-1994. MMWR Morb Mortal Wkly Rep 1997; 45:1120.
- Jacobs DE, Clickner RP, Zhou JY, et al. The prevalence of lead-based paint hazards in U.S. housing. Environ Health Perspect 2002; 110:A599.
- Dewalt FG, Cox DC, O'Haver R, et al. Prevalence of Lead Hazards and Soil Arsenic in U.S. Housing. J Environ Health 2015; 78:22.
- Screening for elevated blood lead levels. American Academy of Pediatrics Committee on Environmental Health. Pediatrics 1998; 101:1072.
- Campbell C, Osterhoudt KC. Prevention of childhood lead poisoning. Curr Opin Pediatr 2000; 12:428.
- Environmental Protection Agency: Review of studies addressing lead abatement effectiveness: Updated edition. Washington, DC: Environmental Protection Agency; 1998.
- Binns HJ, Campbell C, Brown MJ, Centers for Disease Control and Prevention Advisory Committee on Childhood Lead Poisoning Prevention. Interpreting and managing blood lead levels of less than 10 microg/dL in children and reducing childhood exposure to lead: recommendations of the Centers for Disease Control and Prevention Advisory Committee on Childhood Lead Poisoning Prevention. Pediatrics 2007; 120:e1285.
- Centers for Disease Control (CDC). Childhood lead poisoning--United States: report to the Congress by the Agency for Toxic Substances and Disease Registry. MMWR Morb Mortal Wkly Rep 1988; 37:481.
- Needleman HL. The removal of lead from gasoline: historical and personal reflections. Environ Res 2000; 84:20.
- Needleman HL. The persistent threat of lead: medical and sociological issues. Curr Probl Pediatr 1988; 18:697.
- Lovei, M. Phasing Out Lead From Gasoline: Worldwide Experience And Policy Implications. World Bank Technical Paper No. 397. The World Bank Group, Washington, D.C, 1998.
- Mielke HW, Reagan PL. Soil is an important pathway of human lead exposure. Environ Health Perspect 1998; 106 Suppl 1:217.
- Mielke HW, Blake B, Burroughs S, Hassinger N. Urban lead levels in Minneapolis: the case of the Hmong children. Environ Res 1984; 34:64.
- Environmental Protection Agency. Air quality criteria for lead. 1986; EPA/600/8-83/028aF.
- Trepka MJ, Pekovic V, Santana JC, Zhang G. Risk factors for lead poisoning among Cuban refugee children. Public Health Rep 2005; 120:179.
- ATSDR (Agency for Toxic Substances and Disease Registry). The nature and extent of lead poisoning in children in the United States: a report to Congress, 1988.
- Brown MJ, Margolis S. Lead in drinking water and human blood lead levels in the United States. MMWR Morb Mortal Wkly Rep 2012; 61:1.
- Hanna-Attisha M, LaChance J, Sadler RC, Champney Schnepp A. Elevated Blood Lead Levels in Children Associated With the Flint Drinking Water Crisis: A Spatial Analysis of Risk and Public Health Response. Am J Public Health 2016; 106:283.
- Kennedy C, Yard E, Dignam T, et al. Blood Lead Levels Among Children Aged <6 Years - Flint, Michigan, 2013-2016. MMWR Morb Mortal Wkly Rep 2016; 65:650.
- Romieu I, Palazuelos E, Hernandez Avila M, et al. Sources of lead exposure in Mexico City. Environ Health Perspect 1994; 102:384.
- Srianujata S. Lead--the toxic metal to stay with human. J Toxicol Sci 1998; 23 Suppl 2:237.
- Woolf AD, Woolf NT. Childhood lead poisoning in 2 families associated with spices used in food preparation. Pediatrics 2005; 116:e314.
- Shannon M. Lead poisoning from an unexpected source in a 4-month-old infant. Environ Health Perspect 1998; 106:313.
- Agency for Toxic Substances and Disease Registry. 1999. Toxicological profile for lead. Atlanta: US Department of Health and Human Services.
- Mushak P, Davis JM, Crocetti AF, Grant LD. Prenatal and postnatal effects of low-level lead exposure: integrated summary of a report to the U.S. Congress on childhood lead poisoning. Environ Res 1989; 50:11.
- Mowad E, Haddad I, Gemmel DJ. Management of lead poisoning from ingested fishing sinkers. Arch Pediatr Adolesc Med 1998; 152:485.
- Blank E, Howieson J. Lead poisoning from a curtain weight. JAMA 1983; 249:2176.
- Gorospe EC, Gerstenberger SL. Atypical sources of childhood lead poisoning in the United States: a systematic review from 1966-2006. Clin Toxicol (Phila) 2008; 46:728.
- Centers for Disease Control and Prevention (CDC). Lead exposure from indoor firing ranges among students on shooting teams--Alaska, 2002-2004. MMWR Morb Mortal Wkly Rep 2005; 54:577.
- Centers for Disease Control and Prevention (CDC). Children with elevated blood lead levels related to home renovation, repair, and painting activities--New York State, 2006-2007. MMWR Morb Mortal Wkly Rep 2009; 58:55.
- Shannon, MW. Minimizing lead exposure. AAP News 2008; 29:1.
- Centers for Disease Control and Prevention (CDC). Lead poisoning from ingestion of a toy necklace--Oregon, 2003. MMWR Morb Mortal Wkly Rep 2004; 53:509.
- Consumer Product Safety Improvement Act of 2008. www.cpsc.gov.cpsia.pdf (Accessed on August 25, 2008).
- Centers for Disease Control and Prevention. Potential exposure to lead in artificial turf. www.cdc.gov/nceh/lead/artificialturf.htm (Accessed on August 13, 2008).
- COUNCIL ON ENVIRONMENTAL HEALTH. Prevention of Childhood Lead Toxicity. Pediatrics 2016; 138.
- Errata: Prevention of childhood lead toxicity. Pediatrics 2017; 140.
- Rogan WJ, Dietrich KN, Ware JH, et al. The effect of chelation therapy with succimer on neuropsychological development in children exposed to lead. N Engl J Med 2001; 344:1421.
- Nussbaumer-Streit B, Yeoh B, Griebler U, et al. Household interventions for preventing domestic lead exposure in children. Cochrane Database Syst Rev 2016; 10:CD006047.
- Jackson RJ, Cummins SK, Tips NM, Rosenblum LS. Preventing childhood lead poisoning: the challenge of change. Am J Prev Med 1998; 14:84.
- CDC response to Advisory Committee on Childhood Lead Poisoning Prevention Recommendations in "Low Level Lead Exposure Harms Children: A Renewed Call of Primary Prevention" http://www.cdc.gov/nceh/lead/ACCLPP/activities.htm (Accessed on May 17, 2012).
- Schwab LT, Roberts JR, Reigart JR. Inaccuracy in parental reporting of the age of their home for lead-screening purposes. Arch Pediatr Adolesc Med 2003; 157:584.
- National Center for Healthy Housing, University of Cincinnati, Department of Environmental Health. Evaluation of the HUD lead-based paint hazard control grant program: final report. National Center for Healthy Housing, Cincinnati, OH 2004. Available at: www.centerforhealthyhousing.org/HUD_National_Evaluation_Final_Report.pdf. Accessed January 2, 2008.
- Farfel MR, Chisolm JJ Jr. Health and environmental outcomes of traditional and modified practices for abatement of residential lead-based paint. Am J Public Health 1990; 80:1240.
- Amitai Y, Graef JW, Brown MJ, et al. Hazards of 'deleading' homes of children with lead poisoning. Am J Dis Child 1987; 141:758.
- Staes C, Matte T, Copley CG, et al. Retrospective study of the impact of lead-based paint hazard remediation on children's blood lead levels in St. Louis, Missouri. Am J Epidemiol 1994; 139:1016.
- Swindell SL, Charney E, Brown MJ, Delaney J. Home abatement and blood lead changes in children with class III lead poisoning. Clin Pediatr (Phila) 1994; 33:536.
- Taha T, Kanarek MS, Schultz BD, Murphy A. Low-cost household paint abatement to reduce children's blood lead levels. Environ Res 1999; 81:334.
- Aschengrau A, Beiser A, Bellinger D, et al. Residential lead-based-paint hazard remediation and soil lead abatement: their impact among children with mildly elevated blood lead levels. Am J Public Health 1997; 87:1698.
- Amitai Y, Brown MJ, Graef JW, Cosgrove E. Residential deleading: effects on the blood lead levels of lead-poisoned children. Pediatrics 1991; 88:893.
- Weitzman M, Aschengrau A, Bellinger D, et al. Lead-contaminated soil abatement and urban children's blood lead levels. JAMA 1993; 269:1647.
- U.S. Environmental Protection Agency. Urban Soil Lead Abatement Demonstration Progect, Volume III: Baltimore Report (2 Parts). EPA Report 600/ap-93/001c.
- U.S. Environmental Protection Agency. Lead-based paint abatement and repair and maintenance study in Baltimore: Preintervention findings. EPA Report 747-R-95-012.
- U.S. Environmental Protection Agency. Lead-based paint abatement and repair maintenance study in Baltimore: Findings based on the first year of follow-up. EPA Report 747-R-97-001.
- U.S. Environmental Protection Agency. Lead-based paint abatement and repair maintenance study in Baltimore: Findings based on two years of follow-up. EPA Report 747-R-97-005.
- Campbell C, Schwarz DF, Rich D, Dockery DW. Effect of a follow-up professional home cleaning on serial dust and blood lead levels of urban children. Arch Environ Health 2003; 58:771.
- Farrell KP, Brophy MC, Chisolm JJ Jr, et al. Soil lead abatement and children's blood lead levels in an urban setting. Am J Public Health 1998; 88:1837.
- United States Environmental Protection Agency. Basis for educational recommendations on reducing childhood lead exposure. www.epa.gov/oppt/lead/pubs/educationexesum.htm (Accessed on January 02, 2008).
- https://www.epa.gov/sites/production/files/2015-11/documents/2005_11_17_faq_fs_healthseries_filtration.pdf (Accessed on December 19, 2016).
- American Academy of Pediatrics Committee on Environmental Health. Lead exposure in children: prevention, detection, and management. Pediatrics 2005; 116:1036.
- Gallicchio L, Scherer RW, Sexton M. Influence of nutrient intake on blood lead levels of young children at risk for lead poisoning. Environ Health Perspect 2002; 110:A767.
- Korioth, T. Lead found in dust from worn athletic turf. AAP News 2008; 29:35.
- Recommendations for blood lead screening of young children enrolled in medicaid: targeting a group at high risk. MMWR Morb Mortal Wkly Rep 2000; 49 RR-14:1.
- Yiin LM, Weber J, Sannoh S, Rhoads G. Efficacy of the Community Reinvestment Act in promoting lead abatement. J Environ Health 2005; 67:44.
- Kaiser J. Environmental health. Lead paint experts face a barrage of subpoenas. Science 2005; 309:362.
- Prenatal exposure
- - Paint
- - Soil
- - Water
- - Food
- - Leaded objects
- Children's products and toys
- Ethnic products
- Artificial athletic fields
- Paint and soil
- - Abatement
- - Education and dust control
- Children's products
- Artificial athletic fields
- Abatement funding
- SOCIETY GUIDELINE LINKS