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Childhood lead poisoning: Exposure and prevention

Childhood lead poisoning: Exposure and prevention
Literature review current through: Jan 2024.
This topic last updated: Nov 16, 2023.

INTRODUCTION — 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".)

EXPOSURE — 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, water, and/or air contamination and excess lead in children's, parent, or primary caregiver occupations; toys; cosmetics; and herbal/ayurvedic remedies.

Prenatal exposure — In the United States, the American College of Obstetrics and Gynecology recommends blood lead screening 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 infant should be documented in both of their medical records. (See "Childhood lead poisoning: Management", section on 'Prenatal exposure' and "Lead exposure, toxicity, and poisoning in adults", section on 'Pregnancy and breastfeeding'.)

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 [1].

The United States Preventative Services Taskforce (USPSTF) has found "inadequate evidence regarding the accuracy of questionnaires and other clinical prediction tools to identify asymptomatic pregnant women with elevated blood lead levels" [3]. In contrast, the USPSTF failed to find harm in screening or treatment of pregnant women with elevated BLLs. We support screening of pregnant women, especially those who have risk factors for lead exposure.

Ingestion — The ingestion of lead-containing dust is the primary source of lead exposure in children [4]. The major sources of lead dust are oxidation and/or mechanical disruption of lead-containing paint and soil. In addition, lead dust may be carried into the child's environment on the clothing or skin of children and adults who have hobbies or occupations that expose them to lead (table 2) or who live in households that have been inadequately decontaminated. Additionally, other sources of lead in children include toys, cosmetics and herbal/ayurvedic remedies often from sources outside of the United States.

The normal progression of developmental skills and the behavior of young children places them at risk for lead ingestion in lead-containing environments. Young children spend much of their time on the floor as they learn to crawl and then to walk; during this time, their hands often are in direct contact with lead-contaminated dust or soil. Young children also have normal hand-to-mouth and mouthing behaviors, especially when they are teething (between 6 and 24 months), that increase the likelihood of ingesting lead-containing paint, dust, or soil.

Alternatively, children with intellectual and developmental disabilities may continue mouthing behaviors beyond two years of age. Likewise, these children are more likely to have pica (eating of nonfood items), which places them at increased risk of ingestion of lead-contaminated products [5].

Paint — Despite the early 1900 publication of the significant toxicity of lead, lead-based paint has continued as the major source of lead exposure for children in the United States [6]. The lead content of dust in homes is typically highest in window wells and windowsills because of the mechanical disruption that occurs with raising and lowering the windows [7-9].

Before 1955, the lead content of white house paint was as high as 50 percent [10]. After 1955, the lead content of paint was reduced, but lead was not eliminated until 1978, when the Consumer Product Safety Commission (CPSC) restricted lead content to 0.06 percent for any paint intended to be used on residential surfaces, toys, or furniture [11]. Despite the elimination of lead from newly manufactured paint, paint that was applied to homes before 1978 remains in place. A United States housing survey performed from 2005 to 2006 found that over 3 million homes with children under six years of age had lead-based paint hazards with over a third residing in low-income households [12,13]. The prevalence is much higher in resource-limited countries or resource-rich countries with poor environmental laws. For example, one study found high lead levels in paints in China (116,200 ppm), Cameroon (500,000 ppm), South Africa (189,000 ppm), Thailand (505,716 ppm), and Brazil (170,258.4 ppm) [14].

Soil — Before lead was removed from petroleum products in the United States, automobile exhaust emitted millions of pounds of lead into the environment each month [6,15,16]. The elimination of lead from gasoline was a successful nationwide primary prevention measure [17]. Between 1976 and 1989, the amount of lead consumed in gasoline in the United States decreased by 50 percent (figure 1), and BLL decreased by 37 percent. The European Union banned leaded gasoline in 2000. The World Bank and the United Nations Commission on Sustainable Development called for worldwide elimination of lead from petroleum products in 1998 [18] and worldwide elimination is almost complete.

Lead found in soil may also be the result of industrial environmental releases from lead-zinc mining and battery smelters within and outside the United States. Studies from Bangladesh, Palestine, Vietnam, and Serbia have correlated childhood elevated BLLs with close vicinity to industrial sites [19-22].

Contamination of the soil surrounding residential areas can be an important source of lead dust inside the home as well as for the child who plays outdoors [23,24]. Soil contamination typically is restricted to 2 to 5 cm below the surface if the soil is undisturbed [25]. Soil contamination may be increased in homes at which car repair activities are performed in the home or yard [26]. In addition, soil that is brought in for raised garden beds may contain lead and should be tested prior to its use. The accepted safety standard for lead in bare soil is <400 parts per million (ppm) for play areas, and <1200 ppm for nonplay areas. Information about testing soil for lead can be obtained from the National Lead Information Center.

Water — Lead in drinking water probably is absorbed more completely than lead in food and may account for more than 50 percent of the lead that is ingested by infants [27]. Municipal water supplies are controlled and regulated to prevent contamination at the source [28], although these precautions sometimes fail [29,30]. However, once the water reaches the home, it is rarely regulated, tested, or treated. The United States Environmental Protection Agency (EPA) action level for lead in water is 15 parts per billion (ppb) although this is not a health-based standard but one that is based upon old data for the feasibility of water companies to achieve the level. The American Academy of Pediatrics states that this number should be much lower and recommends 1 ppb in schools. The EPA is in the process of reviewing and revising the Lead and Copper Rule; however, it is unknown when, or if, a completion date can be anticipated.

Most lead contamination of household water is caused by copper plumbing that is joined with lead solder [28]. Lead pipes may contribute to lead contamination, but lead plumbing usually is old enough to have its inner surface coated with mineral deposits, which prevent leaching of lead into the water supply. However, disruption of the pipes or first use of water that has been standing in the system can result in higher levels of lead in the water. Recommendations include running cold water for 10 minutes prior to first use in the morning before consumption. However, adherence to this recommendation is likely low in practice.

Other potential sources for lead contamination include storage cisterns, sources of water that are outside the municipal water districts, and aging water coolers or water heaters, particularly in areas where the water has a relatively low pH [6]. Acidity and elevated temperature increase the ability of the water to leach lead from the solder or pipes, as does standing in the pipes for extended periods of time (eg, overnight).

Additional information about lead in drinking water is available on the United States Environmental Protection Agency's website.

Food — A careful dietary history in children with lead poisoning may help to identify dietary sources of lead exposure [31-33]. Although uncommon, food can be contaminated with lead during production, processing, packaging, preparation, or storage [34,35].

Produce that is grown in lead-containing soil or exposed to exhaust from vehicles that use lead-containing fuel can be contaminated [6,27,34,36]. Although lead has been banned from petroleum products in the United States, the soil along certain major transportation routes and in urban cooperative gardens may still be contaminated with significant amounts of lead. Lead-based petroleum products continue to be used in many resource-limited agricultural countries from which food is imported.

Canned food can become contaminated with lead if lead solder is used in the canning process. The lead is leached into the food during oxidation, which begins to occur once the can is opened, particularly if the food is acidic. However, lead was banned from use, including imported products, in 1995.

Food may be contaminated during preparation by the addition of lead-contaminated spices (purchased in other countries and not tested for purity) [37,38]. Food also may be contaminated with lead if it is stored, prepared, or served in lead-glazed pottery, leaded-crystal glassware, lead-containing cooking vessels [39], or plastic bags decorated with red or yellow lead-containing pigments (eg, bread bags) [34,40,41]. Lastly, boiling water to reduce infectious agents may concentrate the lead in water and increase the risk for poisoning.

In recent years, growing concerns have been raised regarding lead and other heavy metals in baby foods [42]. The US Food and Drug Administration (USFDA) has responded with instituting the Closer to Zero campaign to assess and recommend changes to the allowable levels of metals in baby foods. The first draft guidance focuses on the levels of lead in apple juice and aims to decrease the allowable levels, as this is a common juice consumed by toddlers and young children. It is unknown when or if any new standards will be forthcoming.

Breastfeeding — Levels of lead in breast milk are up to 3 percent of BLLs in the mother and are directly correlated with maternal blood lead concentration [1]. Based upon estimates of infant blood level elevation occurring from breast milk ingestion, breastfeeding should be encouraged for all mothers with a venous BLL <40 mcg/dL (table 3). In the United States, infants whose mothers have a BLL ≥40 mcg/dL should not breastfeed initially. The mother should be instructed to pump her breast milk and discard it. Breastfeeding should be instituted if the maternal BLL falls below 40 mcg/dL.

Whether the risks of breastfeeding, for mothers with a BLL ≥40 mcg/dL who live in a resource-limited country, outweigh the benefits is uncertain. Continuation of breastfeeding is based upon whether there is evidence that breast milk is contributing to infant lead levels on the follow-up maternal and infant screening. (See "Childhood lead poisoning: Management", section on 'Breastfeeding' and "Lead exposure, toxicity, and poisoning in adults", section on 'Pregnancy and breastfeeding'.)

Leaded objects — Ingestion of leaded objects (eg, fishing weights, curtain weights, buckshot, recreational items, folk remedies) in children may be associated with a sudden acute rise in BLLs with the potential to cause lead encephalopathy and death [43-46]. However, chronic exposure from these objects may also result in lead exposures from ingestion of lead dust. Children with sensory disorders are especially at risk if they chronically use these objects for calming purposes.

Inhalation — Inhalational exposures to lead can cause elevated lead levels due to direct contact by small particles with lung capillaries and from ingestion at the same time. The exposure of children in the United States to lead via inhalation decreased after the elimination of lead from automobile gasoline products in 1978. However, children who live near industrial plants where lead is used, smelted, or mined, and children who live in countries that have not banned lead from petroleum products may continue to be exposed by this route [23-26]. Researchers from North Carolina have continued to document take-home exposures and elevated BLLs in children of lead oxide manufacturing employees [47]. Children also may be exposed to lead through inhalation during home renovation or if they or their parents/primary caregivers engage in hobbies that involve the use, melting, or spraying of lead-containing products (eg, target shooting at indoor firing ranges (table 2) [11,48,49]). A pilot study in Nigeria was able to document declining BLLs in children with outreach and education to miners as well as supplying wet wipes for cleaning lead dust in the homes [50].

Children's products and toys — Toys that are commonly mouthed by children with elevated BLLs should be tested for lead as part of the home investigation. Children's products and toys provide another potential route for lead exposure. Lead may be present in any of the following forms [51,52]:

Paint on the surface of the product

Pigment throughout the product

In jewelry (eg, pewter bracelets)

In vinyl or plastic (eg, bibs, backpacks, car seats, lunch boxes)

The lead in these products is not absorbed through intact skin and cannot be inhaled if the toy is undamaged and intact. The risk of lead poisoning from these products is low unless there is significant mouthing, chewing, or swallowing by children or the product is damaged or deteriorating [51].

The Consumer Product Safety Improvement Act (CPSIA) of 2008 reduces the permissible lead content of toys and children's products from 0.06 percent (600 ppm) lead by weight to 0.03 percent (300 ppm) by 2009, and ≤0.01 percent (100 ppm) by 2012 [53]. The CPSIA also requires third party testing of children's products to ensure compliance with the safety standards and to the extent possible, the placement of permanent tracking labels.

The CPSC standard applies to toy jewelry, but not to costume jewelry, which is often given to children.

While this standard applies to all children's products, every product that is imported from another country cannot be tested for the presence of lead, and lead content is variable. For example, a study of toys made from polyvinyl chloride in countries around the world found lead levels markedly higher than those recommended by the CPSC. These countries include China (860,000 ppm), South Africa (145,000 ppm), and the United States (22,550 ppm) [20].

Ethnic products — In addition to toys imported from other countries, cosmetics, pottery and herbal/ayurvedic remedies may contain lead due to decreased regulations in other countries. Kohl, an ancient eye make-up that is commonly applied to children from the Middle East, Asia, or Africa, may contain lead. Pottery from Mexico or other countries can leach lead from the ceramic especially when used to store acidic liquids, such as orange juice.

Lastly, ethnic remedies, ceremonial powders, and spices purchased from outside of the United States may contain lead and result in significant poisoning [54-58].

Asking the question "Where do you purchase these items?" can also verify whether the items were purchased at an ethnic store. Families may purchase items within the United States, but ethnic stores may have contaminated imported items. These should be assessed during a home investigation.

Artificial athletic fields — Artificial turf playing fields made of nylon or nylon/polyethylene blend fibers may contain unhealthy levels of lead dust [59]. With wear, frequent use, and weathering, the nylon fibers break down into dust that may be ingested or inhaled. This potential exposure route has not resulted in any reports of elevated BLLs in children. The EPA and the CDC/Agency for Toxic Substances and Disease Registry are evaluating the risk of exposure to lead and other contaminants during play on artificial turf. Part one of the final report found higher lead levels in the synthetic turf infill compared with "fresh" tire crumb from the factory, implying that other sources of lead may result in contamination of the artificial turf [60]. We support limiting use of these products pending the full results because safer alternatives are available.

PREVENTION — The elimination of lead from the environment is essential to the prevention of lead poisoning and its sequelae [61,62]:

Primary prevention efforts focus on removal of lead from the environment so that exposure cannot occur. The primary prevention approach contrasts with practices and policies that too often have relied predominantly on detection of lead exposure only after children develop elevated blood lead concentrations. Primary prevention is the only way to reduce the neurocognitive effects of lead poisoning.

Primary prevention of childhood lead poisoning involves the removal of lead-based hazards from the environments of children (eg, lead-painted surfaces, including windows, lead-contaminated soil, or lead-soldered pipes) prior to any exposure to the child.

Discussions with expecting parents/primary caregivers and, after delivery, prior to nursery discharge have the potential to identify and eliminate lead sources in the home and to prevent the risk of elevated blood lead levels (BLLs) in the future.

Secondary prevention involves early detection of lead-poisoned children and minimizing ongoing exposure and absorption (table 4A-B). Secondary prevention is used to determine the sources of lead and to ameliorate the exposures after they have been identified.

Tertiary prevention reduces the morbidity associated with lead intoxication through chelation of lead from the blood and soft tissues of an exposed individual. Chelation can reduce the immediate toxicity associated with acute lead ingestion but has limited ability to reverse the neurocognitive effects of chronic exposure [63]. (See "Childhood lead poisoning: Management".)

Aggressive environmental remediation has the potential to benefit children by reducing their exposure to lead. However, the efficacy of aggressive environmental remediation largely is unproven, the methods are controversial, and the costs are high. It is known that household educational interventions such as dust control and soil abatement may not be effective in reducing BLLs as a population health measure [64]. In addition, no studies have reported on cognitive gains with remediation. That said, studies evaluate BLLs after the child has already been exposed, whereas remediation is more likely to be beneficial before the exposure. Additionally, these studies do not account for other sources that may result in elevated BLLs. Nonetheless, complete removal of lead from the child's environment is considered to be the only effective preventive measure and treatment for reducing the lead body burden, but it must occur prior to the child’s exposure to prevent harm [65].

Family education regarding methods to decrease exposure and absorption is recommended for all children with childhood lead poisoning. Education is the major intervention in the management of children with any elevated BLL [61]. Education of the public, parents/primary caregivers, and health professionals can decrease the number of children with elevated BLLs [66]. While the CDC and AAP recommend home investigations with BLL >3.5 mcg/dL (0.14 micromol/L) [67], this may not be available in every locality or state. Thus, the practicing physician may need to use other resources to fully evaluate the source of the elevated BLL [9,68]. (See 'Additional resources' below.)

Screening questionnaire — The CDC and AAP recommend that all children who receive Medicaid have BLLs assessed.

Targeted testing is recommended for the remainder of children by parental completion of the screening questionnaire and obtaining BLLs on those with positive responses. However, the USPSTF found inaccuracies in identifying children at risk using the questionnaire as the standard for further testing [3]. As an example, one study found a sensitivity of 26 percent and specificity of 72 percent with the use of the questionnaire [69]. Thus, clinicians should consider all aspects of the patient evaluation when deciding about lead screening in these patients. Further questioning regarding hobbies (eg, firing ranges, self-manufacturing of ammunition or lead weights), use of ethnic spices despite purchasing in the United States, and alternative places where children spend time may result in a positive history. When in doubt, the clinician should opt to test for lead exposures. (See "Screening tests in children and adolescents", section on 'Lead poisoning'.)

Paint and soil — As described above, lead-contaminated house dust is the major source of lead exposure for children in the United States. The age of the home is important in determining the risk of exposure, particularly for homes built before 1950. Unfortunately, parental awareness of the age of the home may be inaccurate. In a survey where parents'/primary caregivers’ answers about the age of their home were compared with information in tax assessor records, only 52 percent of those living in housing built before 1950 accurately identified their home as such [70]. Thus, the identification of homes needing abatement should not rely solely on parental report.

Abatement — Professional cleaning, paint containment, and removal and replacement of building components can interrupt lead exposure in children [71]. However, extensive onsite removal of leaded paint can raise the concentration of lead in house dust and in resident children [71,72]. Abatement that is improperly performed also increases lead exposure [9].

The impact of properly performed lead-based-paint remediation on lead levels in affected children is difficult to quantitate. The results are confounded by elevation of BLLs from continued release of lead from tissue stores and/or exposure to increased lead dust during removal of lead-based paint [73,74]. The observable effect of abatement appears to be related directly to pre-abatement BLL [71,74-76].

Limited data are available regarding the efficacy of environmental remediation in reducing BLL or preventing the neurodevelopmental consequences of lead poisoning in children [8]. Well-designed studies are difficult to perform because the expense of lead abatement prohibits a study large enough to document a clear benefit. However, treatment of elevated BLLs in children should focus on the removal of the source of lead exposure, as studies have shown that lead levels decrease significantly when the source is ameliorated. However, preventing the neurodevelopmental consequences can be optimized by preventing the initial exposure from occurring. (See 'Prevention' above.)

In 1993 and 1994, the United States Department of Housing and Urban Development (HUD) provided funding to address lead-based paint hazards in low-income housing in more than 12 jurisdictions [71]. Information was gathered before, within 6 weeks of, and 6 to 12 months after the intervention; 2682 dwellings were treated and had final results. Additional data were collected two and three years after the intervention for approximately 40 percent of the dwellings. Interior intervention strategies ranged from cleaning and spot painting to full lead removal. The exterior building was treated in 70 percent of dwellings (eg, paint stabilization, paint removal). Soil or site work (eg, application of mulch/seed/sod/plants, soil removal, structure removal) was conducted at 13 percent of dwellings. The following findings were noted:

Lead hazard control activities reduced the floor, window sill, and window trough dust lead levels compared with preintervention levels (by 78 percent, 89 percent, and 95 percent, respectively); reduced levels were maintained for at least three years.

All interior strategies resulted in decreased average floor dust levels. However, differential effects between strategies were identified. Full interior abatement was associated with the greatest reduction, whereas window abatement and full paint stabilization were associated with the smallest reduction.

Nine percent of children who had BLL measured before and immediately after the intervention had increases of BLL of ≥5 microg/dL (0.24 micromol/L).

One year after the intervention, geometric mean BLL were 2.7 microg/dL (0.13 micromol/L) lower than preintervention BLL (9 microg/dL [0.43 micromol/L]); two years after the intervention, geometric mean BLL were 3.8 microg/dL (0.18 micromol/L) lower, reductions of 27 percent and 37 percent, respectively.

Geometric mean BLL among children with preintervention BLL <10 microg/dL (0.48 micromol/L) declined by 20 percent one year after the intervention.

Factors that modified the effects of lead-hazard control included preintervention BLL, parental reports of previous lead poisoning, child's age, and the season in which the child was tested.

By contrast, a more recent longitudinal, community-based trial enrolled pregnant women and their children to assess if lead-reduction interventions would decrease BLLs and improve neurobehavioral outcomes [65]. While not all groups had statistical changes to their BLLs, non-Hispanic Black children had substantially decreased BLLs after home lead removal. This is most likely due to this cohort living in homes with higher baseline lead and having higher BLLs at the beginning of the observations. Neurobehavioral improvements with abatement after exposure did not occur, which supports the need for primary prevention of lead exposures in children.

Attempts to remove existing lead-containing paint from surfaces can create more lead dust if not done properly, increasing the risk for lead exposure and causing at least temporary elevation of BLL [11,73,77,78]. The Occupational Safety and Health Administration (OSHA), the EPA, and the United States Department of Housing and Urban Development have established guidelines for the safe removal of lead-based paint, which can be accessed here.

Incomplete or temporary remediation can be performed by painting over existing lead-based paint on walls, doors, and windowsills using nonlead-based paint. This remediation is considered temporary because over time, lead dust will reaccumulate because of further oxidation and mechanical disruption of the lead-based paint. Home restoration or remodeling of the home will re-expose the lead paint. Nonetheless, interim control strategies have resulted in decreased lead dust content and modest declines in the BLL of resident children 9 to 15 months after the intervention [8,79-83]. Certain measures can be taken to limit exposure of children to lead-based paint in homes that contain such lead-based paint (table 5).

Thorough cleaning of the home by professionals trained in a lead abatement protocol is another temporary means of reducing lead dust contamination. In one study, professional cleaning reduced lead dust levels on windowsill surfaces by 89 percent [84]. However, within three months of cleaning the levels returned to precleaning levels. Thus, families should learn the same techniques and utilize them regularly to reduce the lead hazards. Using a wet mop and dusting can reduce a child’s exposure if done several times a week.

Removal and replacement of lead-contaminated soil has minimal independent effect on BLL in children [79,85]. Like paint abatement, soil abatement may cause transient elevation of BLL [77]. In addition, disposal of the contaminated soil is problematic, particularly the large volume of soil from industrial sites. Certain measures can be taken to minimize the exposure and absorption of lead from contaminated soil as described in the table (table 6).

Education and dust control — Given the expense and lack of proven efficacy of lead hazard abatement, families who are unwilling or unable to have their homes professionally abated must receive information regarding alternative interventions. For children found to have BLLs between 3.5 and 20 mcg/dL (0.14 and 0.96 micromol/L), education is the primary type of intervention recommended by the Centers for Disease Control and other organizations; formal home investigations may not be performed at these levels in many regions due to cost [68,86]. Certain measures can be taken to limit exposure of children to lead in homes that contain lead-based paint (table 5). These educational measures are often supplemented by dust control interventions (table 7). Although the use of high-phosphate detergents (eg, TSP) was recommended in the past, use of high-phosphate detergents is no longer recommended [87].

However, the benefits of lead exposure education and dust control measures are unclear. A meta-analysis of 14 studies (2643 children) did not show a significant impact on mean BLLs 6 to 18 months after initiation of household education, dust control measures, or both (mean difference in BLL between intervention and control groups 0.02 mcg/dL [0.001 micromol/L] higher in the intervention groups) [64]. Neurocognitive outcomes are highly heterogeneous with regard to BLL, and the studies included in the meta-analysis did not evaluate these outcomes. (See "Childhood lead poisoning: Clinical manifestations and diagnosis", section on 'Neurologic'.)

Of note, the cleaning methods that were used in the dust control studies were labor intensive, expensive, and not likely to be followed outside of a study setting (eg, biweekly wet mopping of floors, damp-sponging of walls and horizontal surfaces, and vacuuming with a high-efficiency particle accumulating [HEPA] vacuum) [7,8].

Despite these limitations, most experts still advocate that caregivers of children with elevated BLLs receive education and perform dust control measures as part of the overall approach to reduce ongoing lead exposure.

Water — The use of lead solder and other lead-containing materials to connect household plumbing to public water supplies was banned by the EPA in June 1988. The current lead standard set by the Lead and Copper Rule (15 parts per billion [ppb]) is not a health-based standard, but a feasibility standards set decades ago. Regulations regarding the lead content of drinking-water coolers in schools went into effect in 1989 [34]. However, lead-contaminated water continues to be a potential problem in homes built before 1988. Removal of the source of lead is the most reliable way to eliminate water-based exposure to lead. However, many home-owners do not know the type of pipes in their homes. In addition, water treatment facilities are required to test water for lead, but their jurisdiction ends at the sidewalk of the home.

The ability of home water filters or purifiers to remove lead depends upon the type of filter. Ion-exchange, reverse-osmosis filters, and distillation are effective in removing lead, but the most commonly available home filters (glass fiber and carbon) usually include packaging material that specifies that they do not efficiently remove heavy metals. However, some home carbon filters can remove lead [88,89]. Depending on the contaminant or the source of contaminant, point-of-entry or point-of-use devices may be used. Point-of-entry filters will not be effective in homes containing lead pipes.

Water to be used for cooking or drinking should come from the cold tap because hot water is more able to leach lead from the pipes. In addition, the water should be run for some time (eg, 10 minutes) before it is collected; this flushes the water that has a higher lead content (caused by standing in the pipes) down the drain [90].

Food — The United States canned food industry voluntarily phased out the use of lead-soldered cans between 1979 and 1991. In 1995, the US Food and Drug Administration (FDA) prohibited the use of lead solder for all food cans, including imported products.

Education regarding the way the food and beverages are grown, purchased, stored, or prepared can help to diminish the dietary exposure to lead (table 8).

Independent of food contamination, diet quality may influence absorption or retention of lead from other sources. The diets of children should include adequate intake of iron, calcium, and vitamin C since adequate iron and calcium stores may decrease lead absorption and vitamin C may increase renal excretion [91]. In addition, diets high in calories, total fat, and saturated fat among toddlers are associated with higher lead levels [92]. This association may be related to food handling with lead-contaminated hands, since many of the high calorie/high fat foods ingested by children are "finger foods" [92]. Nonetheless, parents/primary caregivers of children who are at risk for lead exposure may be counseled regarding the merits of a well-balanced diet that limits high calorie/high fat foods while maintaining an adequate intake of these nutrients and the importance of washing the child's hands before meals and snacks. (See "Dietary recommendations for toddlers and preschool and school-age children", section on 'General guidance'.)

Children's products — To minimize the risk of purchasing children's products and toys that are contaminated with lead, clinicians can advise parents/primary caregivers to avoid [51]:

Purchasing nonbrand toys

Purchasing toys from discount shops and private vendors

Purchasing old toys

Giving costume jewelry to young children

Using commercial lead test kits to identify potentially hazardous products is not recommended, because commercial kits may give false-negative results [51].

Artificial athletic fields — The EPA and the CDC/Agency for Toxic Substances and Disease Registry is examining the risk of exposure to lead and other contaminants during play on artificial turf. Part one of the final report found higher lead levels in the synthetic turf infill compared with "fresh" tire crumb from the factory, implying that other sources of lead may result in contamination of the artificial turf [60]. We support limiting use of these products pending the full results because safer alternatives are available. (See 'Artificial athletic fields' above.)

However, if they are already present in the community, to minimize the risk of lead exposure from worn nylon or nylon/polyethylene artificial turf, clinicians can advise parents/primary caregivers to [93,94]:

Keep children younger than six years of age off of worn, dusty, artificial turf known to contain more than 400 parts per million (ppm) lead.

Wash hands and bodies with soap and water for at least 20 seconds after playing on artificial fields.

Avoid eating on the field.

Keep drinking containers in a bag or covered container when not in use.

Avoid tracking of contaminated dust from the play area by removing clothes worn on the field and turning them inside out as soon as possible after leaving the field. If clothing cannot be removed, players should sit on towels or blankets in vehicles. Contaminated clothes, towels, and blankets should be washed separately from other items.

Keep shoes worn on the field outside of the home.

ADDITIONAL RESOURCES

General — Various United States agencies have established standards for lead detection, toxicity, or methods of abatement. They include:

Department of Housing and Urban Development (HUD), Office of Healthy Homes and Lead Hazard Control

Environmental Protection Agency (EPA), Office of Prevention and Toxics

Centers for Disease Control and Prevention, Lead Poisoning Prevention Program

National Center for Healthy Housing

Occupational Safety and Health Administration (OSHA)

United States Consumer Product Safety Commission

National Library of Medicine, National Institutes of Health

Abatement funding — Safe removal of environmental lead is a costly process. However, because the identification of lead poisoned children in the United States is incomplete and the treatment of lead intoxicated children cannot reverse the neurocognitive effects, environmental remediation remains the gold standard for treatment. Not only do the Medicaid program and other third-party payers often cover the cost of blood lead testing in children, but they can also cover the cost of environmental lead testing or remediation through the Affordable Care Act if states allow this provision. The CDC’s Lead Poisoning Prevention Subcommittee has recommended that Medicaid cover the cost of testing the home environment [95]. Of note, for primary prevention to occur, these services must occur prior to the child’s exposure and preferably before the child enters this environment. Unfortunately, funding for primary prevention is lacking in most regions.

Financial reimbursement for lead remediation of the environment is available from government sources, but it is limited. The Health Care Finance Administration (HCFA) has approved some pilot programs and other money is available primarily through the United States Department of Housing and Urban Development (HUD).

Cooperative programs between local government and private sector organizations in high-risk communities may be designed to help fund the high cost of lead abatement. These programs are effective and may lead to increased abatement rates and more complete abatement interventions [96]. In addition, compensation for the high cost of lead abatement is being sought from manufacturers of lead-based paint through the court system [97].

Pediatric Environmental Health Specialty Units (PEHSUs) — PEHSUs are a national network of experts in children's exposures to environmental contaminants. Each PEHSU is geographically sited around the United States with the mission to "improve reproductive and children's health by leading the integration of environmental health into clinical care and public health while supporting communities to address historical injustices and ongoing environmental racism and address the existential threat of climate change." This model is being reproduced globally. PEHSUs can be found through their website.

Regional poison control centers — Regional poison control centers in the United States are available at all times for consultation on patients with known or suspected poisoning, and who may be critically ill, require admission, or have clinical pictures that are unclear (1-800-222-1222). In addition, some hospitals have medical toxicologists available for bedside consultation. Whenever available, these are invaluable resources to help in the diagnosis and management of ingestions or overdoses. Contact information for poison centers around the world is provided separately. (See "Society guideline links: Regional poison control centers".)

Society guideline links — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lead and other heavy metal poisoning" and "Society guideline links: Poisoning prevention".)

SUMMARY AND RECOMMENDATIONS

Exposure – Children are exposed to lead in a variety of ways. Despite the removal of lead from gasoline and paint, lead-based paint continues as the major source of lead exposure for children in the United States. Soil continues to be a common source of exposure, as well. (See 'Exposure' above.)

Other important pediatric exposures include elevated maternal blood lead levels (BLLs) during pregnancy and breastfeeding, food (including spices), water, air contamination, and excess lead in toys. Other increasingly common or known sources include parental occupations, hobbies and ethnic practices such as cosmetics and remedies from other countries. (See 'Exposure' above.)

Primary prevention – Primary prevention of childhood lead poisoning involves the removal of lead-based hazards from the environments of children (eg, lead-painted surfaces, including windows, lead-contaminated soil, lead-soldered pipes) prior to the child’s exposure. Ideally, this removal would occur prior to the child entering the contaminated environment because remediation can increase the risk for poisoning, as well. Discussions with expecting parents/primary caregivers and, after delivery, prior to nursery discharge have the potential to identify and eliminate lead sources in the home and to prevent the risk of elevated BLLs in the future. (See 'Prevention' above.)

Secondary prevention – Secondary prevention involves early detection of lead-poisoned children through appropriate questionnaire screening, lead testing, and minimizing further lead exposure and absorption (table 4A-B). However, knowing the inaccuracies of the questionnaire screening is important; providers should lean towards screening children in equivocal cases. (See "Screening tests in children and adolescents", section on 'Lead poisoning'.)

Tertiary prevention – Tertiary prevention reduces the morbidity associated with lead intoxication through chelation of lead from the blood and soft tissues of an exposed child. Chelation can reduce the immediate toxicity associated with acute lead ingestion but has limited ability to reverse the neurocognitive effects of chronic exposure. It is important to note that the best treatment is removing the source of lead from the child’s environment. (See "Childhood lead poisoning: Management".)

Abatement – Attempts to remove existing lead-containing paint from surfaces can create more lead dust if not done properly, increasing the risk for lead exposure and causing at least temporary elevation of BLLs in family members. The Occupational Safety and Health Administration (OSHA), the EPA, and the United States Department of Housing and Urban Development (HUD) have established guidelines for the safe removal of lead-based paint, which can be accessed here. (See 'Abatement' above.)

Safe removal of environmental lead is a costly process. However, because the identification of lead intoxicated children in the United States is incomplete and the treatment of lead intoxicated children cannot reverse the neurocognitive effects, environmental remediation remains the gold standard for prevention and should be considered prior to exposure. (See 'Abatement funding' above.)

Education and dust control – Families who are unwilling or unable to have their homes professionally abated should undergo education regarding ways to diminish their child's exposure to lead and to control dust in their household (table 5 and table 6 and table 7 and table 8). However, the benefits of these interventions are unclear. (See 'Education and dust control' above.)

ACKNOWLEDGMENT

The UpToDate editorial staff acknowledges both Richard L Hurwitz, MD and Dean A Lee, MD, PhD, who contributed to earlier versions of this topic review.

The UpToDate editorial staff acknowledges extensive contributions of Donald H Mahoney, Jr, MD to earlier versions of this topic review.

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Topic 6493 Version 41.0

References

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