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following a 2023 outbreak of elevated levels of lead in children associated with consumption of contaminated applesauce.
Federal legislation in the 1970s eliminated lead from gasoline, paints, and other consumer products, and resulted in significantly reduced blood lead levels (BLLs) in children throughout the United States.
But recently published studies highlight persistent issues with lead in drinking water and consumer products, suggesting that the fight is not over.
It’s in the Water
In 2014 the city of Flint, Michigan, changed its water supply and high levels of lead were later found in the municipal water supply.
Effects of that crisis still plague the city today. An initial study found that elevated BLLs had doubled among children between 2013 and 2015.
Lead exposure in young children is associated with several negative outcomes, including decreased cognitive ability, brain volume, and social mobility, and increased anxiety/depression and impulsivity, and higher rates of criminal offenses later in life.
Many other water systems still contain lead pipes, despite a 1986 ban by the US Environmental Protection Agency on using them for installing or repairing public water systems. The mayor of Chicago announced a plan to start replacing lead service lines in 2020; however, 400,000 households are still served by these pipes, the most in the nation.
Benjamin Huynh, a native of Chicago, was curious about the impact of all those lead service lines. Now an assistant professor in the Department of Environmental Health and Engineering at Johns Hopkins University in Baltimore, Maryland, he and his colleagues researched how many children under the age of 6 years were exposed to contaminated water.
The results showed that lead contamination of water is widespread.
“We’re estimating that 68% of kids under the age of 6 in Chicago were exposed to lead-contaminated drinking water,” Mr. Huynh said.
He added that residents in predominantly Black and Latino neighborhoods had the highest risk for lead contamination in their water, but children living on these blocks were less likely to get tested, suggesting a need for more outreach to raise awareness.
Meanwhile, a little over one third of Chicago residents reported drinking bottled water as their main source of drinking water.
But even bottled water could contain lead. The US Food and Drug Administration (FDA) has set a limit for lead in bottled water to five parts per billion. The FDA threshold for taking action in public drinking water systems is 15 parts per billion. But the American Academy of Pediatrics states that no amount of lead in drinking water is considered safe for drinking.
Mr. Huynh also pointed out that not all home water filters remove lead. Only devices that meet National Sanitation Foundation 53 standards are certified for lead removal. Consumers should verify that the filter package specifically lists the device as certified for removing contaminant lead.
Lead-tainted Cinnamon
Last fall, the North Carolina Department of Health and Human Services identified several children with elevated levels of lead who had consumed WanaBana Apple Cinnamon Fruit Puree pouches.
An investigation by the FDA identified additional brands containing lead and issued a recall of applesauce pouches sold by retailers like Dollar Tree and Amazon.
According to the US Centers for Disease Control and Prevention, nearly 500 children were affected by the tainted applesauce. The FDA traced the source of the lead to cinnamon from a supplier in Ecuador.
An FDA spokesperson told this news organization the episode appears to have resulted from “economically motivated adulteration,” which occurs when a manufacturer leaves out or substitutes a valuable ingredient or part of a food. In the case of spices, lead may be added as a coloring agent or to increase the product weight.
“When we look at domestically made products from large, reputable companies, in general, they do a pretty good job of following safe product guidelines and regulations,” said Kevin Osterhoudt, MD, professor of pediatrics at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “But when we use third-party sellers and we import things from other countries that aren’t regulated as closely, we certainly take a lot more risk in the products that we receive.”
While the Food Safety Modernization Act of 2011 aimed to improve agency’s capacity to manage the ever-rising volume of food produced domestically and imported from overseas, the funding has stayed flat while the volume of inspections has increased. In the early 1990s, the number of shipments screened by the agency numbered in the thousands annually. Last year the FDA screened 15 million shipments from more than 200 countries, according to the agency.
Prompted by the finding of lead in applesauce, the FDA began a wider investigation into ground cinnamon by sampling the product from discount retail stores. It recalled an additional six brands of cinnamon sold in the United States containing lead.
Dr. Osterhoudt’s message to families who think their child might have been exposed to a contaminated product is to dispose of it as directed by FDA and CDC guidelines.
In Philadelphia, where Dr. Osterhoudt practices as an emergency room physician, baseline rates of childhood lead poisoning are already high, so he advises families to “do a larger inventory of all the source potential sources of lead in their life and to reduce all the exposures as low as possible.”
He also advises parents that a nutritious diet high in calcium and iron can protect their children from the deleterious effects of lead.
Current Standards for Lead Screening and Testing
Lead is ubiquitous. The common routes of exposure to humans include use of fossil fuels such as leaded gasoline, some types of industrial facilities, and past use of lead-based paint in homes. In addition to spices, lead has been found in a wide variety of products such as toys, jewelry, antiques, cosmetics, and dietary supplements imported from other countries.
Noah Buncher, DO, is a primary care pediatrician in South Philadelphia at Children’s Hospital of Pennsylvania and the former director of a lead clinic in Boston that provides care for children with lead poisoning. He follows guidelines from the American Academy of Pediatrics that define an elevated BLL as ≥ 3.5 µg/dL. The guidelines recommend screening children for lead exposures during well child visits starting at age 6 months up to 6 years and obtaining a BLL if risks for lead exposure are present.
Dr. Buncher starts with a basic environmental history that covers items like the age, condition, zip code of home, parental occupations, or hobbies that might result in exposing family members to lead, and if another child in the home has a history of elevated BLLs.
But a careful history for potential lead exposures can be time-consuming.
“There’s a lot to cover in a routine well child visit,” Dr. Buncher said. “We have maybe 15-20 minutes to cover a lot.”
Clinics also vary on whether lead screening questions are put into workflows in the electronic medical record. Although parents can complete a written questionnaire about possible lead exposures, they may have difficulty answering questions about the age of their home or not know whether their occupation is high risk.
Transportation to a clinic is often a barrier for families, and sometimes patients must travel to a separate lab to be tested for lead.
Dr. Buncher also pointed to the patchwork of local and state requirements that can lead to confusion among providers. Massachusetts, where he formerly practiced, has a universal requirement to test all children at ages 1, 2, and 3 years. But in Pennsylvania, screening laws vary from county to county.
“Pennsylvania should implement universal screening recommendations for all kids under 6 regardless of what county you live in,” Dr. Buncher said.
Protective Measures
Alan Woolf, MD, a professor of pediatrics at Harvard Medical School, Boston, Massachusetts, and director of the Pediatric Environmental Health Center at Boston Children’s Hospital, has a few ideas about how providers can step up their lead game, including partnering with their local health department.
The CDC funds Childhood Lead Poisoning Prevention Programs based in state and local health departments to work with clinicians to improve rates of blood lead testing, monitor the prevalence of lead in their jurisdictions, and ensure that a system of referral is available for treatment and lead remediation services in the home.
Dr. Woolf also suggested that clinicians refer patients under age 3 years with high BLLs to their local Early Intervention Program.
“They’ll assess their child’s development, their speech, their motor skills, their social skills, and if they qualify, it’s free,” Dr. Woolf said.
He cited research showing children with elevated lead levels who received early intervention services performed better in grade school than equally exposed children who did not access similar services.
Another key strategy for pediatric clinicians is to learn local or state regulations for testing children for lead and how to access lead surveillance data in their practice area. Children who reside in high-risk areas are automatic candidates for screening.
Dr. Woolf pointed out that big cities are not the only localities with lead in the drinking water. If families are drawing water from their own well, they should collect that water annually to have it tested for lead and microbes.
At the clinic-wide level, Dr. Woolf recommends the use of blood lead testing as a quality improvement measure. For example, Akron Children’s Hospital developed a quality improvement initiative using a clinical decision support tool to raise screening rates in their network of 30 clinics. One year after beginning the project, lead screenings during 12-month well visits increased from 71% to 96%.
“What we’re interested in as pediatric health professionals is eliminating all background sources of lead in a child’s environment,” Dr. Woolf said. “Whether that’s applesauce pouches, whether that’s lead-containing paint, lead in water, lead in spices, or lead in imported pottery or cookware — there are just a tremendous number of sources of lead that we can do something about.”
None of the subjects reported financial conflicts of interest.
A former pediatrician, Dr. Thomas is a freelance science writer living in Portland, Oregon.
A version of this article appeared on Medscape.com.
following a 2023 outbreak of elevated levels of lead in children associated with consumption of contaminated applesauce.
Federal legislation in the 1970s eliminated lead from gasoline, paints, and other consumer products, and resulted in significantly reduced blood lead levels (BLLs) in children throughout the United States.
But recently published studies highlight persistent issues with lead in drinking water and consumer products, suggesting that the fight is not over.
It’s in the Water
In 2014 the city of Flint, Michigan, changed its water supply and high levels of lead were later found in the municipal water supply.
Effects of that crisis still plague the city today. An initial study found that elevated BLLs had doubled among children between 2013 and 2015.
Lead exposure in young children is associated with several negative outcomes, including decreased cognitive ability, brain volume, and social mobility, and increased anxiety/depression and impulsivity, and higher rates of criminal offenses later in life.
Many other water systems still contain lead pipes, despite a 1986 ban by the US Environmental Protection Agency on using them for installing or repairing public water systems. The mayor of Chicago announced a plan to start replacing lead service lines in 2020; however, 400,000 households are still served by these pipes, the most in the nation.
Benjamin Huynh, a native of Chicago, was curious about the impact of all those lead service lines. Now an assistant professor in the Department of Environmental Health and Engineering at Johns Hopkins University in Baltimore, Maryland, he and his colleagues researched how many children under the age of 6 years were exposed to contaminated water.
The results showed that lead contamination of water is widespread.
“We’re estimating that 68% of kids under the age of 6 in Chicago were exposed to lead-contaminated drinking water,” Mr. Huynh said.
He added that residents in predominantly Black and Latino neighborhoods had the highest risk for lead contamination in their water, but children living on these blocks were less likely to get tested, suggesting a need for more outreach to raise awareness.
Meanwhile, a little over one third of Chicago residents reported drinking bottled water as their main source of drinking water.
But even bottled water could contain lead. The US Food and Drug Administration (FDA) has set a limit for lead in bottled water to five parts per billion. The FDA threshold for taking action in public drinking water systems is 15 parts per billion. But the American Academy of Pediatrics states that no amount of lead in drinking water is considered safe for drinking.
Mr. Huynh also pointed out that not all home water filters remove lead. Only devices that meet National Sanitation Foundation 53 standards are certified for lead removal. Consumers should verify that the filter package specifically lists the device as certified for removing contaminant lead.
Lead-tainted Cinnamon
Last fall, the North Carolina Department of Health and Human Services identified several children with elevated levels of lead who had consumed WanaBana Apple Cinnamon Fruit Puree pouches.
An investigation by the FDA identified additional brands containing lead and issued a recall of applesauce pouches sold by retailers like Dollar Tree and Amazon.
According to the US Centers for Disease Control and Prevention, nearly 500 children were affected by the tainted applesauce. The FDA traced the source of the lead to cinnamon from a supplier in Ecuador.
An FDA spokesperson told this news organization the episode appears to have resulted from “economically motivated adulteration,” which occurs when a manufacturer leaves out or substitutes a valuable ingredient or part of a food. In the case of spices, lead may be added as a coloring agent or to increase the product weight.
“When we look at domestically made products from large, reputable companies, in general, they do a pretty good job of following safe product guidelines and regulations,” said Kevin Osterhoudt, MD, professor of pediatrics at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “But when we use third-party sellers and we import things from other countries that aren’t regulated as closely, we certainly take a lot more risk in the products that we receive.”
While the Food Safety Modernization Act of 2011 aimed to improve agency’s capacity to manage the ever-rising volume of food produced domestically and imported from overseas, the funding has stayed flat while the volume of inspections has increased. In the early 1990s, the number of shipments screened by the agency numbered in the thousands annually. Last year the FDA screened 15 million shipments from more than 200 countries, according to the agency.
Prompted by the finding of lead in applesauce, the FDA began a wider investigation into ground cinnamon by sampling the product from discount retail stores. It recalled an additional six brands of cinnamon sold in the United States containing lead.
Dr. Osterhoudt’s message to families who think their child might have been exposed to a contaminated product is to dispose of it as directed by FDA and CDC guidelines.
In Philadelphia, where Dr. Osterhoudt practices as an emergency room physician, baseline rates of childhood lead poisoning are already high, so he advises families to “do a larger inventory of all the source potential sources of lead in their life and to reduce all the exposures as low as possible.”
He also advises parents that a nutritious diet high in calcium and iron can protect their children from the deleterious effects of lead.
Current Standards for Lead Screening and Testing
Lead is ubiquitous. The common routes of exposure to humans include use of fossil fuels such as leaded gasoline, some types of industrial facilities, and past use of lead-based paint in homes. In addition to spices, lead has been found in a wide variety of products such as toys, jewelry, antiques, cosmetics, and dietary supplements imported from other countries.
Noah Buncher, DO, is a primary care pediatrician in South Philadelphia at Children’s Hospital of Pennsylvania and the former director of a lead clinic in Boston that provides care for children with lead poisoning. He follows guidelines from the American Academy of Pediatrics that define an elevated BLL as ≥ 3.5 µg/dL. The guidelines recommend screening children for lead exposures during well child visits starting at age 6 months up to 6 years and obtaining a BLL if risks for lead exposure are present.
Dr. Buncher starts with a basic environmental history that covers items like the age, condition, zip code of home, parental occupations, or hobbies that might result in exposing family members to lead, and if another child in the home has a history of elevated BLLs.
But a careful history for potential lead exposures can be time-consuming.
“There’s a lot to cover in a routine well child visit,” Dr. Buncher said. “We have maybe 15-20 minutes to cover a lot.”
Clinics also vary on whether lead screening questions are put into workflows in the electronic medical record. Although parents can complete a written questionnaire about possible lead exposures, they may have difficulty answering questions about the age of their home or not know whether their occupation is high risk.
Transportation to a clinic is often a barrier for families, and sometimes patients must travel to a separate lab to be tested for lead.
Dr. Buncher also pointed to the patchwork of local and state requirements that can lead to confusion among providers. Massachusetts, where he formerly practiced, has a universal requirement to test all children at ages 1, 2, and 3 years. But in Pennsylvania, screening laws vary from county to county.
“Pennsylvania should implement universal screening recommendations for all kids under 6 regardless of what county you live in,” Dr. Buncher said.
Protective Measures
Alan Woolf, MD, a professor of pediatrics at Harvard Medical School, Boston, Massachusetts, and director of the Pediatric Environmental Health Center at Boston Children’s Hospital, has a few ideas about how providers can step up their lead game, including partnering with their local health department.
The CDC funds Childhood Lead Poisoning Prevention Programs based in state and local health departments to work with clinicians to improve rates of blood lead testing, monitor the prevalence of lead in their jurisdictions, and ensure that a system of referral is available for treatment and lead remediation services in the home.
Dr. Woolf also suggested that clinicians refer patients under age 3 years with high BLLs to their local Early Intervention Program.
“They’ll assess their child’s development, their speech, their motor skills, their social skills, and if they qualify, it’s free,” Dr. Woolf said.
He cited research showing children with elevated lead levels who received early intervention services performed better in grade school than equally exposed children who did not access similar services.
Another key strategy for pediatric clinicians is to learn local or state regulations for testing children for lead and how to access lead surveillance data in their practice area. Children who reside in high-risk areas are automatic candidates for screening.
Dr. Woolf pointed out that big cities are not the only localities with lead in the drinking water. If families are drawing water from their own well, they should collect that water annually to have it tested for lead and microbes.
At the clinic-wide level, Dr. Woolf recommends the use of blood lead testing as a quality improvement measure. For example, Akron Children’s Hospital developed a quality improvement initiative using a clinical decision support tool to raise screening rates in their network of 30 clinics. One year after beginning the project, lead screenings during 12-month well visits increased from 71% to 96%.
“What we’re interested in as pediatric health professionals is eliminating all background sources of lead in a child’s environment,” Dr. Woolf said. “Whether that’s applesauce pouches, whether that’s lead-containing paint, lead in water, lead in spices, or lead in imported pottery or cookware — there are just a tremendous number of sources of lead that we can do something about.”
None of the subjects reported financial conflicts of interest.
A former pediatrician, Dr. Thomas is a freelance science writer living in Portland, Oregon.
A version of this article appeared on Medscape.com.
following a 2023 outbreak of elevated levels of lead in children associated with consumption of contaminated applesauce.
Federal legislation in the 1970s eliminated lead from gasoline, paints, and other consumer products, and resulted in significantly reduced blood lead levels (BLLs) in children throughout the United States.
But recently published studies highlight persistent issues with lead in drinking water and consumer products, suggesting that the fight is not over.
It’s in the Water
In 2014 the city of Flint, Michigan, changed its water supply and high levels of lead were later found in the municipal water supply.
Effects of that crisis still plague the city today. An initial study found that elevated BLLs had doubled among children between 2013 and 2015.
Lead exposure in young children is associated with several negative outcomes, including decreased cognitive ability, brain volume, and social mobility, and increased anxiety/depression and impulsivity, and higher rates of criminal offenses later in life.
Many other water systems still contain lead pipes, despite a 1986 ban by the US Environmental Protection Agency on using them for installing or repairing public water systems. The mayor of Chicago announced a plan to start replacing lead service lines in 2020; however, 400,000 households are still served by these pipes, the most in the nation.
Benjamin Huynh, a native of Chicago, was curious about the impact of all those lead service lines. Now an assistant professor in the Department of Environmental Health and Engineering at Johns Hopkins University in Baltimore, Maryland, he and his colleagues researched how many children under the age of 6 years were exposed to contaminated water.
The results showed that lead contamination of water is widespread.
“We’re estimating that 68% of kids under the age of 6 in Chicago were exposed to lead-contaminated drinking water,” Mr. Huynh said.
He added that residents in predominantly Black and Latino neighborhoods had the highest risk for lead contamination in their water, but children living on these blocks were less likely to get tested, suggesting a need for more outreach to raise awareness.
Meanwhile, a little over one third of Chicago residents reported drinking bottled water as their main source of drinking water.
But even bottled water could contain lead. The US Food and Drug Administration (FDA) has set a limit for lead in bottled water to five parts per billion. The FDA threshold for taking action in public drinking water systems is 15 parts per billion. But the American Academy of Pediatrics states that no amount of lead in drinking water is considered safe for drinking.
Mr. Huynh also pointed out that not all home water filters remove lead. Only devices that meet National Sanitation Foundation 53 standards are certified for lead removal. Consumers should verify that the filter package specifically lists the device as certified for removing contaminant lead.
Lead-tainted Cinnamon
Last fall, the North Carolina Department of Health and Human Services identified several children with elevated levels of lead who had consumed WanaBana Apple Cinnamon Fruit Puree pouches.
An investigation by the FDA identified additional brands containing lead and issued a recall of applesauce pouches sold by retailers like Dollar Tree and Amazon.
According to the US Centers for Disease Control and Prevention, nearly 500 children were affected by the tainted applesauce. The FDA traced the source of the lead to cinnamon from a supplier in Ecuador.
An FDA spokesperson told this news organization the episode appears to have resulted from “economically motivated adulteration,” which occurs when a manufacturer leaves out or substitutes a valuable ingredient or part of a food. In the case of spices, lead may be added as a coloring agent or to increase the product weight.
“When we look at domestically made products from large, reputable companies, in general, they do a pretty good job of following safe product guidelines and regulations,” said Kevin Osterhoudt, MD, professor of pediatrics at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “But when we use third-party sellers and we import things from other countries that aren’t regulated as closely, we certainly take a lot more risk in the products that we receive.”
While the Food Safety Modernization Act of 2011 aimed to improve agency’s capacity to manage the ever-rising volume of food produced domestically and imported from overseas, the funding has stayed flat while the volume of inspections has increased. In the early 1990s, the number of shipments screened by the agency numbered in the thousands annually. Last year the FDA screened 15 million shipments from more than 200 countries, according to the agency.
Prompted by the finding of lead in applesauce, the FDA began a wider investigation into ground cinnamon by sampling the product from discount retail stores. It recalled an additional six brands of cinnamon sold in the United States containing lead.
Dr. Osterhoudt’s message to families who think their child might have been exposed to a contaminated product is to dispose of it as directed by FDA and CDC guidelines.
In Philadelphia, where Dr. Osterhoudt practices as an emergency room physician, baseline rates of childhood lead poisoning are already high, so he advises families to “do a larger inventory of all the source potential sources of lead in their life and to reduce all the exposures as low as possible.”
He also advises parents that a nutritious diet high in calcium and iron can protect their children from the deleterious effects of lead.
Current Standards for Lead Screening and Testing
Lead is ubiquitous. The common routes of exposure to humans include use of fossil fuels such as leaded gasoline, some types of industrial facilities, and past use of lead-based paint in homes. In addition to spices, lead has been found in a wide variety of products such as toys, jewelry, antiques, cosmetics, and dietary supplements imported from other countries.
Noah Buncher, DO, is a primary care pediatrician in South Philadelphia at Children’s Hospital of Pennsylvania and the former director of a lead clinic in Boston that provides care for children with lead poisoning. He follows guidelines from the American Academy of Pediatrics that define an elevated BLL as ≥ 3.5 µg/dL. The guidelines recommend screening children for lead exposures during well child visits starting at age 6 months up to 6 years and obtaining a BLL if risks for lead exposure are present.
Dr. Buncher starts with a basic environmental history that covers items like the age, condition, zip code of home, parental occupations, or hobbies that might result in exposing family members to lead, and if another child in the home has a history of elevated BLLs.
But a careful history for potential lead exposures can be time-consuming.
“There’s a lot to cover in a routine well child visit,” Dr. Buncher said. “We have maybe 15-20 minutes to cover a lot.”
Clinics also vary on whether lead screening questions are put into workflows in the electronic medical record. Although parents can complete a written questionnaire about possible lead exposures, they may have difficulty answering questions about the age of their home or not know whether their occupation is high risk.
Transportation to a clinic is often a barrier for families, and sometimes patients must travel to a separate lab to be tested for lead.
Dr. Buncher also pointed to the patchwork of local and state requirements that can lead to confusion among providers. Massachusetts, where he formerly practiced, has a universal requirement to test all children at ages 1, 2, and 3 years. But in Pennsylvania, screening laws vary from county to county.
“Pennsylvania should implement universal screening recommendations for all kids under 6 regardless of what county you live in,” Dr. Buncher said.
Protective Measures
Alan Woolf, MD, a professor of pediatrics at Harvard Medical School, Boston, Massachusetts, and director of the Pediatric Environmental Health Center at Boston Children’s Hospital, has a few ideas about how providers can step up their lead game, including partnering with their local health department.
The CDC funds Childhood Lead Poisoning Prevention Programs based in state and local health departments to work with clinicians to improve rates of blood lead testing, monitor the prevalence of lead in their jurisdictions, and ensure that a system of referral is available for treatment and lead remediation services in the home.
Dr. Woolf also suggested that clinicians refer patients under age 3 years with high BLLs to their local Early Intervention Program.
“They’ll assess their child’s development, their speech, their motor skills, their social skills, and if they qualify, it’s free,” Dr. Woolf said.
He cited research showing children with elevated lead levels who received early intervention services performed better in grade school than equally exposed children who did not access similar services.
Another key strategy for pediatric clinicians is to learn local or state regulations for testing children for lead and how to access lead surveillance data in their practice area. Children who reside in high-risk areas are automatic candidates for screening.
Dr. Woolf pointed out that big cities are not the only localities with lead in the drinking water. If families are drawing water from their own well, they should collect that water annually to have it tested for lead and microbes.
At the clinic-wide level, Dr. Woolf recommends the use of blood lead testing as a quality improvement measure. For example, Akron Children’s Hospital developed a quality improvement initiative using a clinical decision support tool to raise screening rates in their network of 30 clinics. One year after beginning the project, lead screenings during 12-month well visits increased from 71% to 96%.
“What we’re interested in as pediatric health professionals is eliminating all background sources of lead in a child’s environment,” Dr. Woolf said. “Whether that’s applesauce pouches, whether that’s lead-containing paint, lead in water, lead in spices, or lead in imported pottery or cookware — there are just a tremendous number of sources of lead that we can do something about.”
None of the subjects reported financial conflicts of interest.
A former pediatrician, Dr. Thomas is a freelance science writer living in Portland, Oregon.
A version of this article appeared on Medscape.com.
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This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>Experts say pediatricians and primary care clinicians should do more to prevent the toxic effects of lead in their young patients</metaDescription> <articlePDF/> <teaserImage/> <teaser>Despite efforts to reduce lead decades ago, recent contamination in food and water mean pediatricians and PCPs should be vigilant.</teaser> <title>Lead Has Not Gone Away — What Should Pediatric Clinicians Do?</title> <deck/> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear/> <pubPubdateMonth/> <pubPubdateDay/> <pubVolume/> <pubNumber/> <wireChannels/> <primaryCMSID/> <CMSIDs/> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>pn</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>fp</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> </publications_g> <publications> <term canonical="true">25</term> <term>15</term> </publications> <sections> <term canonical="true">39313</term> </sections> <topics> <term canonical="true">258</term> <term>271</term> <term>280</term> </topics> <links/> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>Lead Has Not Gone Away — What Should Pediatric Clinicians Do?</title> <deck/> </itemMeta> <itemContent> <p><span class="tag metaDescription">Experts say pediatricians and primary care clinicians should do more to prevent the toxic effects of lead in their young patients</span> following a 2023 outbreak of elevated levels of lead in children associated with consumption of contaminated applesauce.</p> <p>Federal legislation in the 1970s <span class="Hyperlink"><a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/su6104a1.htm">eliminated lead from gasoline, paints, and other consumer products, and resulted in significantly reduced blood lead levels</a></span> (BLLs) in children throughout the United States.<br/><br/>But recently published studies highlight persistent issues with lead in drinking water and consumer products, suggesting that the fight is not over.<br/><br/></p> <h2>It’s in the Water</h2> <p>In 2014 the city of Flint, Michigan, changed its water supply and high levels of lead were later found in the municipal water supply.<br/><br/>Effects of that crisis still <span class="Hyperlink"><a href="https://emedicine.medscape.com/article/235627-overview">plague</a></span> the city today. An <span class="Hyperlink"><a href="https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2015.303003">initial study</a></span> found that elevated BLLs had doubled among children between 2013 and 2015.<br/><br/><span class="Hyperlink"><a href="https://www.annualreviews.org/content/journals/10.1146/annurev-soc-073117-041222">Lead exposure in young children is associated with several negative outcomes</a></span>, including decreased cognitive ability, brain volume, and social mobility, and increased anxiety/<span class="Hyperlink"><a href="https://emedicine.medscape.com/article/286759-overview">depression</a></span> and impulsivity, and higher rates of criminal offenses later in life. <br/><br/>Many other water systems still contain lead pipes, despite a 1986 ban by the US Environmental Protection Agency on using them for installing or repairing public water systems. <span class="Hyperlink"><a href="https://www.wbez.org/stories/despite-a-promise-chicago-has-made-no-progress-on-removal-of-lead-pipes/02644e18-4cd5-4e7e-b595-3ebc111c62a6">The mayor of Chicago announced a plan</a></span> to start replacing lead service lines in 2020; however, 400,000 households are still served by these pipes, the most in the nation.<br/><br/>Benjamin Huynh, a native of Chicago, was curious about the impact of all those lead service lines. Now an assistant professor in the Department of Environmental Health and Engineering at Johns Hopkins University in Baltimore, Maryland, he and his colleagues researched how many children under the age of 6 years were exposed to contaminated water.<br/><br/>The results showed <span class="Hyperlink"><a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/2815850">that lead contamination of water is widespread</a></span>. <br/><br/>“We’re estimating that 68% of kids under the age of 6 in Chicago were exposed to lead-contaminated drinking water,” Mr. Huynh said. <br/><br/>He added that residents in predominantly Black and Latino neighborhoods had the highest risk for lead contamination in their water, but children living on these blocks were less likely to get tested, suggesting a need for more outreach to raise awareness.<br/><br/>Meanwhile, a little over one third of Chicago residents reported drinking bottled water as their main source of drinking water.<br/><br/>But even <span class="Hyperlink"><a href="https://www.fda.gov/consumers/consumer-updates/bottled-water-everywhere-keeping-it-safe">bottled water could contain lead</a></span>. The US Food and Drug Administration (FDA) has set a limit for lead in bottled water to five parts per billion. The FDA threshold for taking action in public drinking water systems is 15 parts per billion. But the <span class="Hyperlink"><a href="https://publications.aap.org/pediatrics/article/138/1/e20161493/52600/Prevention-of-Childhood-Lead-Toxicity">American Academy of Pediatrics states that no amount of lead in drinking water is considered safe</a></span> for drinking. <br/><br/>Mr. Huynh also pointed out that not all home water filters remove lead. Only devices that meet <span class="Hyperlink">National Sanitation Foundation 53 standards are certified for lead removal</span>. Consumers should verify that the filter package specifically lists the device as certified for removing contaminant lead.<br/><br/></p> <h2>Lead-tainted Cinnamon </h2> <p>Last fall, the <span class="Hyperlink"><a href="https://www.ncdhhs.gov/news/press-releases/2023/10/28/ncdhhs-urges-caution-after-reportable-lead-found-wanabana-brand-apple-cinnamon-puree">North Carolina Department of Health and Human Services identified several children with elevated levels</a></span> of lead who had consumed WanaBana Apple Cinnamon Fruit Puree pouches.<br/><br/>An investigation by the FDA identified additional brands containing lead and issued a recall of applesauce pouches sold by retailers like Dollar Tree and Amazon.<br/><br/><span class="Hyperlink"><a href="https://www.cdc.gov/nceh/lead/news/lead-poisoning-outbreak-linked-to-cinnamon-applesauce-pouches.html?ACSTrackingID=USCDC_1052%20-%20DM119761&ACSTrackingLabel=COCA%20Now%3A%20Recalled%20Cinnamon%20Applesauce%20Pouches%20due%20to%20High%20Blood%20Lead%20Levels%20and%20Potential%20Chromium%20Exposure&deliveryName=USCDC_1052%20-%20DM119761">According to </a></span>the US <span class="Hyperlink"><a href="https://www.cdc.gov/nceh/lead/news/lead-poisoning-outbreak-linked-to-cinnamon-applesauce-pouches.html?ACSTrackingID=USCDC_1052%20-%20DM119761&ACSTrackingLabel=COCA%20Now%3A%20Recalled%20Cinnamon%20Applesauce%20Pouches%20due%20to%20High%20Blood%20Lead%20Levels%20and%20Potential%20Chromium%20Exposure&deliveryName=USCDC_1052%20-%20DM119761">Centers for Disease Control and Prevention</a></span>, nearly 500 children were affected by the tainted applesauce. The FDA traced the source of the lead to cinnamon from a <span class="Hyperlink"><a href="https://www.nytimes.com/2024/02/27/world/europe/lead-applesauce-food-safety.html">supplier in Ecuador</a></span>.<br/><br/>An FDA spokesperson told this news organization the episode appears to have resulted from “economically motivated adulteration,” which occurs when a manufacturer leaves out or substitutes a valuable ingredient or part of a food. In the case of spices, <span class="Hyperlink">lead may be added as a coloring agent or to increase the product weight</span>.<br/><br/>“When we look at domestically made products from large, reputable companies, in general, they do a pretty good job of following safe product guidelines and regulations,” said Kevin Osterhoudt, MD, professor of pediatrics at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “But when we use third-party sellers and we import things from other countries that aren’t regulated as closely, we certainly take a lot more risk in the products that we receive.”<br/><br/>While the <span class="Hyperlink">Food Safety Modernization Act of 2011</span> aimed to improve agency’s capacity to manage the ever-rising volume of food produced domestically and imported from overseas, the funding has stayed flat while the volume of inspections has increased. In the early 1990s, the number of shipments screened by the agency numbered in the thousands annually. Last year the FDA screened 15 million shipments from more than 200 countries, according to the agency.<br/><br/>Prompted by the finding of lead in applesauce, the FDA began a wider investigation into ground cinnamon by sampling the product from discount retail stores. It <span class="Hyperlink"><a href="https://www.fda.gov/food/alerts-advisories-safety-information/fda-alert-concerning-certain-cinnamon-products-due-presence-elevated-levels-lead">recalled an additional six brands of cinnamon sold in the United States containing lead</a></span>.<br/><br/>Dr. Osterhoudt’s message to families who think their child might have been exposed to a contaminated product is to dispose of it as directed <span class="Hyperlink"><a href="https://www.fda.gov/food/outbreaks-foodborne-illness/investigation-elevated-lead-chromium-levels-cinnamon-applesauce-pouches-november-2023">by FDA and CDC guidelines</a></span>. <br/><br/>In Philadelphia, where Dr. Osterhoudt practices as an emergency room physician, baseline rates of childhood lead poisoning are already high, so he advises families to “do a larger inventory of all the source potential sources of lead in their life and to reduce all the exposures as low as possible.” <br/><br/>He also advises parents that a nutritious diet high in calcium and iron can protect their children from the deleterious effects of lead.<br/><br/></p> <h2>Current Standards for Lead Screening and Testing</h2> <p>Lead is ubiquitous. The common routes of exposure to humans include use of fossil fuels such as leaded gasoline, some types of industrial facilities, and past use of lead-based paint in homes. In addition to spices, <span class="Hyperlink"><a href="https://www.cdc.gov/nceh/lead/prevention/children.htm">lead has been found in a wide variety of products</a></span> such as toys, jewelry, antiques, cosmetics, and dietary supplements imported from other countries.<br/><br/>Noah Buncher, DO, is a primary care pediatrician in South Philadelphia at Children’s Hospital of Pennsylvania and the former director of a lead clinic in Boston that provides care for children with lead poisoning. He follows guidelines from the <span class="Hyperlink"><a href="https://publications.aap.org/pediatrics/article/138/1/e20161493/52600/Prevention-of-Childhood-Lead-Toxicity?autologincheck=redirected">American Academy of Pediatrics</a></span> that define an elevated BLL as ≥ 3.5 µg/dL. The guidelines recommend screening children for lead exposures during well child visits starting at age 6 months up to 6 years and obtaining a BLL if risks for lead exposure are present. <br/><br/>Dr. Buncher starts with a basic environmental history that covers items like the age, condition, zip code of home, parental occupations, or hobbies that might result in exposing family members to lead, and if another child in the home has a history of elevated BLLs. <br/><br/>But a careful history for potential lead exposures can be time-consuming. <br/><br/>“There’s a lot to cover in a routine well child visit,” Dr. Buncher said. “We have maybe 15-20 minutes to cover a lot.” <br/><br/>Clinics also vary on whether lead screening questions are put into workflows in the electronic medical record. Although parents can complete a written questionnaire about possible lead exposures, they may have difficulty answering questions about the age of their home or not know whether their occupation is high risk.<br/><br/>Transportation to a clinic is often a barrier for families, and sometimes patients must travel to a separate lab to be tested for lead. <br/><br/>Dr. Buncher also pointed to the patchwork of local and state requirements that can lead to confusion among providers. Massachusetts, where he formerly practiced, has a universal requirement to test all children at ages 1, 2, and 3 years. But in Pennsylvania, screening laws vary from county to county. <br/><br/>“Pennsylvania should implement universal screening recommendations for all kids under 6 regardless of what county you live in,” Dr. Buncher said.<br/><br/></p> <h2>Protective Measures </h2> <p>Alan Woolf, MD, a professor of pediatrics at Harvard Medical School, Boston, Massachusetts, and director of the Pediatric Environmental Health Center at Boston Children’s Hospital, has a few ideas about how providers can step up their lead game, including partnering with their local health department. <br/><br/>The CDC funds <span class="Hyperlink"><a href="https://www.cdc.gov/nceh/lead/programs/default.htm">Childhood Lead Poisoning Prevention Programs</a></span> based in state and local health departments to work with clinicians to improve rates of blood lead testing, monitor the prevalence of lead in their jurisdictions, and ensure that a system of referral is available for treatment and lead remediation services in the home.<br/><br/>Dr. Woolf also suggested that clinicians refer patients under age 3 years with high BLLs to their local <span class="Hyperlink"><a href="https://www.cdc.gov/ncbddd/actearly/parents/states.html">Early Intervention Program</a></span>. <br/><br/>“They’ll assess their child’s development, their speech, their motor skills, their social skills, and if they qualify, it’s free,” Dr. Woolf said. <br/><br/>He cited research showing <span class="Hyperlink"><a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/2789416?guestAccessKey=43cb0bc4-06d4-4b9e-ba84-b91d20b11338&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=030722">children with elevated lead levels who received early intervention services</a></span> performed better in grade school than equally exposed children who did not access similar services.<br/><br/>Another key strategy for pediatric clinicians is to learn local or state regulations for testing children for lead and how to access lead <span class="Hyperlink"><a href="https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/CLPPB/Pages/GeospatialIndicatorMaps-2021.aspx">surveillance data</a></span> in their practice area. Children who reside in high-risk areas are automatic candidates for screening. <br/><br/>Dr. Woolf pointed out that big cities are not the only localities with lead in the drinking water. If families are drawing water from their own well, they should collect that water annually to have it tested for lead and microbes.<br/><br/>At the clinic-wide level, Dr. Woolf recommends the use of blood lead testing as a quality improvement measure. For example, <span class="Hyperlink"><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8476064/">Akron Children’s Hospital developed a quality improvement initiative</a></span> using a clinical decision support tool to raise screening rates in their network of 30 clinics. One year after beginning the project, lead screenings during 12-month well visits increased from 71% to 96%. <br/><br/>“What we’re interested in as pediatric health professionals is eliminating all background sources of lead in a child’s environment,” Dr. Woolf said. “Whether that’s applesauce pouches, whether that’s lead-containing paint, lead in water, lead in spices, or lead in imported pottery or cookware — there are just a tremendous number of sources of lead that we can do something about.”<br/><br/>None of the subjects reported financial conflicts of interest.<span class="end"/></p> <p> <em>A former pediatrician, Dr. Thomas is a freelance science writer living in Portland, Oregon.</em> </p> <p> <em>A version of this article appeared on <span class="Hyperlink"><a href="https://www.medscape.com/viewarticle/lead-has-not-gone-away-what-should-pediatric-clinicians-do-2024a10006hx">Medscape.com</a></span>.</em> </p> </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> </itemContent> </newsItem> </itemSet></root>