Title: Disclosure Statement
1Disclosure Statement
- No financial interest or affiliation concerning
material discussed in this presentation - Will not discuss any non FDA approved or
investigational drugs/medical devices
2Congenital Lead Poisoning
- Nachammai Chinnakaruppan,MD
- Neonatologist
- Lehigh Valley Health Network, Allentown, PA
3Outline
- Case presentation
- Association between BLL and development
- ??Screen pregnant women
- Strategies to enhance development
- Strategies to decrease exposure
- Latest CDC recommendations on prevention of
childhood lead poisoning
4Introduction
- Lead poisoning is the most common preventable
cause of neurotoxicity in children - Associated with impaired cognitive, motor, and
behavioral abilities
Binns et al Advisory Committee on Childhood Lead
poisoning , Pediatrics 2007
5Introduction-continued
- In 1991,CDC defined the BLL of concern to be 10
mcg/dl - Advisory Committee on CLP concluded that there is
no safe BLL. - BLLlt10 have been associated with decreased scores
on psychometric tests in children
Dietrich et al,Treatment of Lead exposed children
in clinical trial, Pediatrics 2004)
6Case Presentation
7The Mother
- 23 yo Mexican woman 36 weeks into a gestation is
screened for lead - Result 58.4 mcg/dl
- Rescreened 4 days later 57.2 mcg/dl
- Anemic Hb 9.5g
- Prescribed iron supplements
- Spontaneous labor 2 weeks later
8The Child
- Normal term female infant, AGA 3030g
- Good Apgars, normal neurological exam
- Sent to nursery
- Pb level available at 36 hours of age 72 mcg/dl
- Other labs Hb 17g, FEP 175 mcg/dl,
- No basophillic stippling in peripheral blood
smears
9Basophilic Stippling
Lead poisoning (arrow indicates an erythrocyte
with basophilic stippling, NEJM 2005.
10(No Transcript)
11(No Transcript)
12Treatment Options
- CaNa2EDTA
- BAL
- BAL/ CaNa2EDTA
- Succimer
- Other
13Management
- Transferred to NICU
- Consult with toxicologist
- Decision made to perform a double volume exchange
transfusion despite the risks of the procedure - BLL 6 hours after exchange was 11mcg/dl
- Also started on chelation therapy
14Management- Continued
- 6 doses of IM dimercaprol (BAL)
- Infusion of calcium disodium ethylenediaminetetraa
cetate (CaNa2EDTA) - Oral succimer for 3 weeks
- Infant discharged home on full feeds and normal
discharge neurological exam
15Double volume exchange transfusion
BAL/CaNa2EDTA
succimer
Mothers Blood lead
16Should we Breastfeed?
17Nashashibi et al. Gyn Ob. Invest 199948158-162
18Follow-Up
- At 1 year, healthy, not on any medications
- Weight at 10, length 50, head circumference 25
- Bayleys assessment showed cognitive score of 135,
motor score of 103 - 2 y.o sister with BLL of 8mcg/dl
19Sources found
- Treats made in Mexico
- Flowered bowls made in Thailand
- Gibson plates made in China
- Express china bowl made in China
- Atelier plate made in Indonesia
- Small metal pitcher made in Colombia
- Cerebyl (Suplemento Alimentico) from Mexico
20Sources -Continued
- Mother has pica
- Lipstick (tested hersnegative)
- Chews nail polish( hersnegative)
- Eats bean stones
- Chews bottle tops and knitting needles and on her
necklace all tested negative
21(No Transcript)
22Lead And The Brain
- Pb disrupts synapse formation
- Increases transmitter release
- Decreases stimulated transmitter release
- Interferes with neurotransmission
- Decreases synapse formation
- Decreases neuron growth
Johnston et al Current Opinions Neurology 1998
23Is there a safe BLL?
- 2002-2004, CDC LPPC analyzed 23 reports on 16
populations and concluded that
BLL ?1/ Cognitive function
24Is there a safe BLL- continued
- IQ decreases more than 7 points over the first 10
mcg/dl increase in lifetime average BLL - Likely causal association
- NO SAFE BLL
25Lead in Pregnancy
- 0.5 women still have BLL more than 10mcg/dl
- Pb moves freely from mother to baby by diffusion
and there is net accretion over time - Results in babies that are growth restricted,
delayed dentition and adverse neurological
outcomes
Gardella Obst and Gyn Survey 2001
26Routine Prenatal Screening??
- Argue that this identifies at risk women and
remove the lead sources to decrease neonatal
morbidity - Dont know how to respond to the blood screens.
Who responds? - Chelation well tolerated by mothers but it
mobilizes Pb stores and can potentially increase
transmission to the fetus
27Recommended Lead Risk Assessment Questions for
Pregnant Women
- Were you born, or have you spent any time,
outside of the United States? - In NYC, approximately 95 of identified
lead-poisoned pregnant women are foreign-born.
Countries of birth in descending order of
frequency include Mexico, India, Bangladesh,
Russia, Pakistan, Ecuador, Haiti, Jamaica, - Morocco, Dominican Republic, Guatemala, Guyana,
El Salvador, Gambia, Ghana, Honduras, Israel,
Ivory - Coast, Korea, Nepal, Sierra Leone, and Trinidad.
- During the past 12 months, did you use any
imported health remedies, spices, foods,
ceramics, or cosmetics? - At any time during your pregnancy, did you eat,
chew on, or mouth non-food items such as clay,
crushed pottery, soil, or paint chips? - In the last 12 months, has there been any
renovation or repair work in your home or
apartment building? - Have you ever had a job or hobby that involved
possible lead exposure, such as home renovation
or working with glass, ceramics, or jewelry?
28Anticipatory Guidance and Risk Reduction
Education For Pregnant Women
- Avoid using health remedies, spices, foods, or
cosmetics from other countries. - Avoid using clay pots and dishes from other
countries to cook, serve, or store food and do
not use pottery that is chipped or cracked. - Never eat non-food items such as clay, soil,
pottery, or paint chips. - Stay away from any repair work being done in the
home. - Avoid jobs or hobbies that may involve contact
with lead, such as home renovation or working
with glass, ceramics, or jewelry.
29Management Options
- Chelation of mother
- Prenatal
- Postnatal
- Chelation of newborn
- Role of prenatal counseling, induction,
termination - Timing of lead screening
- Breastfeeding
- Role of exchange transfusion in the newborn with
extremely elevated BLL
30Why concentrate on the Newborn?
- Chelation at 12 months should improve outcome
- DB Placebo controlled 1994-2003, multiple centers
(n800) - Randomized and stratified by BLL and language to
treatment or placebo - Tested at 7 years
- All kids received lead control measures
- Results Chelation decreased BLL for 6 months
with NO benefit in cognition, behavior and
neuromotor end points - SO PREVENTION is the only way
Rogan et al Pediatrics 2007
31Strategies to Enhance Development
- Elevated BLL does not guarantee problems
- Greater impact on the at risk children i.e. those
with other environmental, genetic, biological,
social risk factors. Nurture them. Early
intervention
32Strategies to Decrease Exposure
- 4.1 million homes have lead paint
- Home inspection limited to children with elevated
BLL - Funds to repair not available
- Case management to homes with BLLgt10
- Relocating families during renovation, containing
dust - Screen at risk 12mth, 24 mths, (36 to 72 mths)
- Education
33Advisory Committee on CLPP-Clinicians
- Anticipatory Guidance
- Occupation
- Toys, folk remedies, candy, make-up
- Developmental Assessment
- Nurture Kids
- Use good labs
34Advisory Committee on CLPP-Government
- Decrease Lead Based Hazard
- Safe Elimination of Lead Hazards
- Decrease Pb exposure in Food
- Primary Prevention in Highest risk areas
- Additional Research
35Conclusion
- No consensus on managing the results of a
gestational screen - Focus should be on education of target population
to decrease lead exposure
36