Putting Guide line s into Prac tic e Je r ome A. Paulson, MD, F - PowerPoint PPT Presentation

NG in the 21 st Ce ntury L E AD POI SONI Putting Guide line s into Prac tic e Je r ome A. Paulson, MD, F AAP Pro fe sso r o f Pe dia tric s & E nviro nme nta l & Oc c upa tio na l He a lth Ge o rg e Washing to n Unive rsity Me dic a l Dire c to r fo r Na tio na l & Glo b a l Affa irs Child He a lth Advo c a c y I nstitute Dire c to r, Mid-Atla ntic Ce nte r fo r Childre n’ s He a lth & the E nviro nme nt Childre n’ s Natio nal Me dic al Ce nte r 1

Disc lo sure s • T his ma te ria l wa s de ve lo pe d b y the Mid-Atla ntic Ce nte r fo r Childre n’ s He a lth & the E nviro nme nt a nd funde d unde r the c o o pe ra tive a g re e me nt a wa rd numb e r 1U61T S000118-03 fro m the Ag e nc y fo r T o xic Sub sta nc e s a nd Dise a se Re g istry (AT SDR). • Ac kno wle dg e me nt: T he U.S. E nviro nme nta l Pro te c tio n Ag e nc y (E PA) suppo rts the PE HSU b y pro viding funds to AT SDR unde r I nte r-Ag e nc y Ag re e me nt numb e r DW-75-92301301-0. Ne ithe r E PA no r AT SDR e ndo rse the purc ha se o f a ny c o mme rc ia l pro duc ts o r se rvic e s me ntio ne d in PE HSU pub lic a tio ns. • Dr. Pa ulso n ha s c o nsulte d with la wye rs in le a d po iso ning c a se s 2

OBJE CT I VE S • Afte r a tte nding this se ssio n the pa rtic ipa nt will b e a b le to – disc uss why le a d po iso ning is still a pro b le m – disc uss the e xte nt o f le a d po iso ning in the US – e xpla in the impo rta nc e o f prima ry pre ve ntio n – utilize pe dia tric e nviro nme nta l he a lth spe c ia lty units a s a c linic a l a nd e duc a tio na l a id 3

Sc o pe o f the Pro b le m • Ha ve the po te ntia l to e limina te c hildho o d le a d po iso ning – le a st 4 millio n ho use ho lds ha ve c hildre n living in the m tha t a re b e ing e xpo se d to le a d – Ab o ut 500,000 c hildre n with b lo o d le a d le ve ls o ve r 5 µg / dL http://www.cdc.gov/nceh/lead/ 4

Pr imar y Pr e ve ntion is the Only Appr opr iate Appr oac h to the Re solution of the L e ad Poisoning Pr oble m • Sc re e ning o f c hildre n ma y ha ve b e e n a ppro pria te in the pa st & must c o ntinue until… • Ma king ho using le a d -sa fe is wha t is a ppro pria te no w a nd in the future 5

“L o w L e ve l L e a d E xpo sure Ha rms Childre n: A Re ne we d Ca ll o f Prima ry Pre ve ntio n” • Mo st re c e nt CDC do c ume nt – June 2012 • “E limina tio n o f the use o f the te rm “b lo o d le a d le ve l o f c o nc e rn” b a se d o n the c o mpe lling e vide nc e tha t lo w BL L s a re a sso c ia te d with I Q de fic its, a tte ntio n-re la te d b e ha vio rs, a nd po o r a c a de mic a c hie ve me nt.” • T he a b se nc e o f a n ide ntifie d BL L witho ut de le te rio us e ffe c ts, c o mb ine d with the e vide nc e tha t the se e ffe c ts a ppe a r to b e irre ve rsib le , unde rsc o re s the c ritic a l impo rta nc e o f prima ry pre ve ntio n. 6

Blo o d L e a d L e ve l fo r Childre n Ag e d 1-5 Ye a rs b y Ye a r o f NHANE S, US Centers for Disease Control. (2012). Fourth National Report on Human Exposure to Environmental Chemicals: Updated Tables September 2012. Accessed at: http://www.cdc.gov/exposurereport/ Jones, R., Homa, D., Meyer, P., Brody, D., Caldwell, K., Pirkle, J., & Brown, M. (2009). Trends in blood lead levels and blood lead testing among US children aged 1 to 5 years, 1988-2004. Pediatrics , 123 (3), e376-e385. doi:10.1542/peds.2007-3608 Mahaffey KR, Annest JL, Roberts J, Murphy RS. National estimates of blood lead levels: United States, 1976-1980. N Engl J Med 1982;307:573-9. 7

Whe re Did Suc c e ss I n L o we ring L e a d L e ve ls Co me F ro m? • Gasoline • Paint • Cans • Water • Ceramics http://www.epa.gov/bns/lead/Fig_01.gif 8

Ho w Do Childre n Ge t L e a d Po iso ne d T o da y? • Old pa int • L e a d o n the g ro und – F ro m pa int – F ro m pa st use o f le a de d g a so line – I ndustria l so urc e s – sme lte rs – So lde r • As le a d pa int b e c o me s le ss c o mmo n, “Othe r” b e c o me s pro po rtio na te ly mo re impo rta nt 9

Othe r Po te ntia l So urc e s Of L e a d I n T he E nviro nme nt • L e a d g la ze d po tte ry • Bra ss fitting s in we ll pumps • L e a d wa te r pipe s • I mpo rte d ho me re me die s, c o sme tic s, spic e s, a yurve dic me dic a tio ns • F iring ra ng e s • Auto mo tive re pa ir • Ca sting a mmunitio n, fishing we ig hts o r sinke rs • Burning le a d pa inte d wo o d o r le a d b a tte rie s 10

Ne uro b e ha vio ra l E ffe c ts o f “L o w” L e a d L e ve ls • L o we rs I Q – I ndividua l impa c t sma ll - a b o ut 4 I Q po ints fo r b lo o d le a d le ve ls o f 2.4-10 mc g / dL – Po pula tio n impa c t ve ry sig nific a nt • Qua druple risk o f I Q < 80: 16% vs. 4% • 5% o f lo w le a ds with I Q > 125, O% o f hig h le a ds. 11

Sma ll I ndividua l E ffe c ts Ca n Ha ve L a rg e Po pula tio n E ffe c ts 57% increase in “Intellectually Impaired “Population Weiss B. Neurotoxicology . 1997;18:581–6. 12

Childho o d le a d e xpo sure ha s a sig nific a nt a nd pe rsiste nt impa c t o n b ra in o rg a niza tio n a sso c ia te d with la ng ua g e func tio n Ac tiva tio n in le ft fro nta l c o rte x, a dja c e nt to Bro c a 's a re a , a nd le ft middle te mpo ra l g yrus, inc luding We rnic ke 's a re a , we re fo und to b e sig nific a ntly a sso c ia te d with diminishe d a c tiva tio n in sub je c ts with hig he r me a n c hildho o d b lo o d le a d le ve ls, whe re a s the c o mpe nsa to ry a c tiva tio n in the rig ht he misphe re ho mo lo g o f We rnic ke 's a re a wa s e nha nc e d in sub je c ts with hig he r High Lifetime Mean Blood Low Lifetime Mean Blood b lo o d le a d le ve ls. Lead (26 µ g/dL) Lead (7.6 µ g/dL) Yua n, e t a l. 2006 13

Wha t I s T he Curre nt Blo o d L e a d Re fe re nc e Va lue ? 5 µg/ dL 14

Ca se 1 • T his is a 2-ye a r o ld Hispa nic ma le who ha d a b lo o d le a d le ve l o f 42 mc g / dL o n a ro utine sc re e ning te st. • Wha t do yo u wa nt to kno w? 15

Ca se 1 • Whe re do e s he live ? • Ho w o ld is the ho me ? • I s the re a ny le a d in the wa te r? • Wha t o the r e xpo sure s c o uld the re b e ? 16

Ca se 1 • Po ssib le e xpo sure so urc e s in Hispa nic fa milie s – c a ndy pro duc e d in Me xic o (ta ma rind c a ndy) – po tte ry – fo lk re me die s use d in so me Hispa nic ho use ho lds to tre a t "e mpa c ho ," • le a d o xide , a ye llo w-o ra ng e po wde r (g re ta ), • le a d te tro xide , a b rig ht o ra ng e po wde r (a za rc o n(a lso kno wn a s re uda , lig a , c o ra l, a la rc o n a nd ma ria luisa ) CDC. Lead Poisoning Associated with Ayurvedic Medications---Five States, 2000--2003. MMWR . July 9, 2004; 53(26):582-584. 17

Ro le o f Prima ry Ca re Pe dia tric ia n • Clinic ia ns sho uld b e a re lia b le so urc e o f info rma tio n o n le a d ha za rds a nd ta ke the prima ry ro le in e duc a ting fa milie s a b o ut pre ve nting le a d e xpo sure s. T his inc lude s re c o mme nding e nviro nme nta l a sse ssme nts PRI OR to b lo o d le a d sc re e ning o f c hildre n a t risk fo r le a d e xpo sure . CDC Re spo nse to Ad viso ry Co mmitte e o n Child ho o d L e a d Po iso ning Pre ve ntio n Re c o mme nd a tio ns in “ L o w L e ve l L e ad E xpo sur e Har ms Childr e n: A Re ne we d Call e ve ntio n ” 05-12 o f Pr imar y Pr 18

PE HSUs’ Re c o mme nda tio ns fo r Ope ra tio na lizing the Ne w CDC Re c o mme nda tio ns • BL L < 5 mc g/ dL – e sults with fa mily. F o r re fe re nc e , the g e o me tric me a n b lo o d le a d Re vie w la b r le ve l fo r c hild re n 1-5 ye a rs o ld is le ss tha n 2 mc g / d L . – Re pe a t the blood le a d le ve l in 6-12 months if the c hild is a t hig h r isk or r isk a me . E nsure le ve ls a re d o ne a t 1 a nd 2 ye a rs o f a g e . c ha ng e s dur ing the time fr – F or c hildr e n sc r e e ne d a t a g e < 12 months, c onside r r e te sting in 3-6 months a s le a d e xposur e ma y inc r e a se a s mobility inc r e a se s. – outine he a lth ma inte na nc e inc lud ing a sse ssme nt o f nutritio n, physic a l Pe r for m r a nd me nta l d e ve lo pme nt, a s we ll a s iro n d e fic ie nc y risk fa c to rs. – Pr ovide a ntic ipa tor y g uida nc e on c ommon sour c e s of e nvir onme nta l le a d e : pa int in ho me s b uilt prio r to 1978, so il ne a r ro a d wa ys o r o the r e xposur so urc e s o f le a d , ta ke -ho me e xpo sure s re la te d to a d ult o c c upa tio ns, impo rte d spic e s, c o sme tic s, fo lk re me d ie s, a nd c o o kwa re . 19