Disclosure Statement

1
Disclosure Statement

• No financial interest or affiliation concerning
  material discussed in this presentation
• Will not discuss any non FDA approved or
  investigational drugs/medical devices

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Congenital Lead Poisoning

• Nachammai Chinnakaruppan,MD
• Neonatologist
• Lehigh Valley Health Network, Allentown, PA

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Outline

• 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

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Introduction

• 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
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Introduction-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)
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Case Presentation
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The 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

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The 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

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Basophilic Stippling
Lead poisoning (arrow indicates an erythrocyte
with basophilic stippling, NEJM 2005.
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Treatment Options

• CaNa2EDTA
• BAL
• BAL/ CaNa2EDTA
• Succimer
• Other

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Management

• 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

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Management- 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

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Double volume exchange transfusion
BAL/CaNa2EDTA
succimer
Mothers Blood lead
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Should we Breastfeed?
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Nashashibi et al. Gyn Ob. Invest 199948158-162
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Follow-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

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Sources 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

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Sources -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

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Lead 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
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Is there a safe BLL?

• 2002-2004, CDC LPPC analyzed 23 reports on 16
  populations and concluded that

BLL ?1/ Cognitive function
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Is 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

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Lead 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
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Routine 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

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Recommended 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?

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Anticipatory 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.

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Management 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

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Why 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
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Strategies 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

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Strategies 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

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Advisory Committee on CLPP-Clinicians

• Anticipatory Guidance
• Occupation
• Toys, folk remedies, candy, make-up
• Developmental Assessment
• Nurture Kids
• Use good labs

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Advisory 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

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Conclusion

• No consensus on managing the results of a
  gestational screen
• Focus should be on education of target population
  to decrease lead exposure

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• Thank you