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Lead Exposure Pathways and Mitigation of its Effects

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this presentation was developed by the agency for toxic substances and disease registry ATSDR to familiarize health care providers with lead provide patient management guidance and share strategies on addressing potential patient concerns you may also want to review atsdr's physician-led fact sheet to begin we will explain what lead is where it is found and different routes of exposure next we will discuss some of the potential health effects and finally we will present patient management strategies which include risk assessment using an environmental health clinical history laboratory test effective communication and Risk Reduction activities at the end of this presentation you will be able to identify the most important routes of exposure to lead in the United States today identify the populations most at risk of lead exposure explain why lead is a problem in water state the CDC's level of concern for lead and children's blood and recommendations for screening list steps patients can take to reduce lead exposures name the most useful test for lead toxicity and describe appropriate treatment for lead exposure lead is a blue grey metal found in the natural environment it was added to paint in gasoline in the past and used in pipe solder and some old water service lines the emissions from vehicles which used leaded gasoline released lead into the air depositing it into the surrounding areas and contaminating the soil when old paint that contains lead appeals or chips it becomes lead containing dust businesses that work with lead such as lead recycling plants battery manufacturing automobiles shops ammunition manufacturing and LED mines and smelters have led that workers can carry home on their clothes skin and shoes lead can leach from old lead service lines or into pipes soldered with lead-based solder contaminating the water this is of particular importance in older water systems and housing units lead is still used in some consumer products this graph shows the percentage of increase in children's blood lead level by type of exposure lead Indust is the most important exposure responsible for an increase of almost 35% in blood lead levels water follows with 20% soil ingestion approximately 15% and dust from renovations and lead in soil just above 10% in the United States most of the lead in dust comes from lead paint making it the major source of exposure lead in drinking water is a problem that particularly affects communities with lead service lines however it is not the primary source of lead exposure in this country the water distribution system brings water to your home through a water main the water main has service lines to households there are different types of pipes that can bring water to your home the American Water Works Association estimates that approximately seven percent of homes representing fifteen to twenty two million Americans have lead service lines in addition some homes built before 1978 may still have lead-based solder in their pipes even if they do not have lead service lines lead can leach from old service lines pipes that have lead solder lead containing pipes and brass faucets exposing those who drink the water to lead LED cannot be removed by boiling water to remove standing LEDs that may have accumulated in pipes CDC recommends that cold water is run before use to test drinking water for lead the Environmental Protection Agency EPA recommends that you contact your local or state health department they can provide information about certified Laboratories available in your state in addition EPA's safe drinking water hotline can provide you with local information for testing your water for lead by calling 1-800 four two six four seven nine one children pregnant women and their developing fetuses living in homes with old and deteriorated paint water LED service lines pipes that have led solder and brass faucets are most at risk for adverse health effects from lead exposure in water children and fetuses rapidly grow and develop thus making them more susceptible to damage most lead is excreted from the body through the digestive system the lead which stays in the blood will transfer between soft tissues liver kidneys lungs brain spleen muscles and heart and bones which typically contain the vast majority of the lead body burden children as well as pregnant women and their fetuses absorb more lead than others in times of stress particularly during pregnancy and lactation the body can mobilize lead stores which is the lead kept in bones thereby increasing the level of lead in the blood and the amount that is transferred to the fetus and newborn both past and current exposures to lead increase a patient's risk for adverse health effects due to lead there is no known threshold for negative effects of lead in other words there is no no safe level of lead in the body lead can affect all organ systems at any level of exposure the neurological development of children is more susceptible to lead in children health effects generally occur at lower blood lead levels or B LLS than in adults you can get more information on the developmental neurologic effects and children at / NC eh / lead research has shown that there are negative neurologic effects in children with blood lead levels below five micrograms per deciliter these effects include lowered IQ attention deficits and impaired hearing in 2012 as an advisory level for environmental and educational intervention CDC adopted 5 micrograms per deciliter as the upper reference range value for blood lead levels in children with levels of exposure greater than 60 micrograms per deciliter we can also see irritability convulsions coma or death adults show similar effects but at higher levels of exposure let exposure can also lead to renal effects such as Fanconi like syndromes chronic nephropathy and gout it may lead to increased risk for hypertension and its sequelae most led associated renal effects results from continued or previous chronic exposures or current high exposure acute high level led exposure has been associated with hemolytic anemia due to leads high affinity for sulf hydral groups making it particularly toxic to multiple enzyme systems including heme biosynthesis this affects the production of hemoglobin with induced hemolytic anemia often accompanied by basophils stipling of the erythrocytes in chronic lead exposure lead induces anemia by interfering with heme biosynthesis and by diminishing red blood cell survival the heme synthesis pathway is involved in many other processes in the body including endocrine hepatic neural and renal pathways the threshold for children is lower than that for adults studies of children with high lead exposure have found that a strong inverse correlation exists between blood lead levels and vitamin D levels lead impedes vitamin D conversion into its hormonal form largely responsible for the maintenance of extra and intracellular calcium homeostasis in general these adverse effects seem to be restricted to children with chronically high blood blood levels most striking in children with blood lead levels greater than 62 micrograms per deciliter and chronic nutritional deficiency especially with regard to calcium phosphorus and vitamin D exposure to lead can lead to an increased risk of high blood pressure due to kidney damage evidence suggests an association between lead exposure and certain reproductive and developmental outcomes lead crosses the placenta thus affecting fetal viability neurologic development and early childhood development developmental effects include pregnancy outcomes such as premature births and low birth weights and post birth effects on growth or neurologic development lead has been linked to problems with the development of health of bones at high lead levels lead can result in slowed growth and children the clinical evaluation includes a preventive screening and exposure history and a physical evaluation with signs and symptoms most state health departments have guidelines for lead screening if your state does not have them you can use CDC's guidelines the CDC guidelines recommend testing children's blood lead levels at ages one and two and annually to age six if they are at high risk of exposure to lead to determine risk ask the family the lead exposure risk questions developed by your state here are some examples of things that increase a child's risk for exposure enrollment in Medicaid headstart or WIC sibling with bll of 10 micrograms per deciliter or higher living in a home built before 1978 living in a factory where lead is used for example a smelter living in a high-risk zip code area identified with contamination in water or another source exposure to repairs or remodeling in homes built before 1978 refugee or adoptee from a foreign country or exposure to lead from foreign made cosmetics home remedies folk medicine or glazed pottery the environmental exposure history is a tool that assists you in the assessment of the potentially exposed patients looking at the age and condition of the home and any remodeling activities that may have disturbed the old paint and dispersed lead dust it also asks for occupations and hobbies of family members to identify potential exposure risks it is available at ATSDR dot /c sem slash c SE m dot ASP question mark C SEM equal 3 3 & / Stan Pio equals 0 the family history includes maternal exposure and the use of home remedies especially those of Mexican Asian or middle-eastern origin that may contain lead and the use of imported glazed ceramics or LED crystal the pediatric environmental exposure history assists you with the assessment of children who may have been exposed to lead including the child's immediate surroundings and play areas and siblings or playmates that may have lead poisoning it also asks about the child's caretaker who may not be a parent or relative and if they have had their water tested for lead it's available at ATSDR dot /c s ee m / CS e m dot asp question mark CS e m equal twenty-six ampere Stan P Oh equal zero because children may have adverse health effects from low lead exposure but not exhibit symptoms it is important that you complete an exposure assessment and screening to determine which of your patients may be at risk impaired abilities may include decreased learning and memory lowered i q– decreased verbal ability impaired speech and hearing functions or early signs of hyperactivity or ADHD all these signs and symptoms can be shown at different blood lead levels neurologic status irritability hearing deficit tremor headache difficulty concentrating paresis or paralysis or encephalopathy which may abruptly lead to seizure change in consciousness coma and death hematologic status lethargy or general or mild fatigue some abnormalities are similar to those of other diseases or conditions for example in the differential diagnosis of microcytic anemia lead poisoning can usually be ruled out by obtaining a venous blood lead concentration if the blood lead level is less than 25 micrograms per deciliter the anemia usually reflects iron deficiency or hemoglobinopathies cardiovascular status hypertension gastrointestinal status occasional abdominal discomfort constipation diffuse abdominal pain vomiting weight loss colic or intermittent severe abdominal cramps musculoskeletal status myalgia or paresthesia arthralgia or muscular exhaust ability more information is available at ATSDR . / c SE m / CS e m dot asp question mark CSE m equal 34 ampere Stan P Oh equal 12 generally beginning with blood lead levels of 40 micrograms per deciliter these signs and symptoms can be present progressing from paresis or paralysis to severe colleagues and encephalopathy that may abruptly lead to seizures coma or death at BLS greater than 100 micrograms per deciliter sustained blood lead levels over 40 micrograms per deciliter can lead to gingival lead lines the erythrocyte protoporphyrin is no longer considered useful to identify elevated blood lead levels to determine a blood lead level the fingerstick test is good for rapid screening and can show levels above 5 micrograms per deciliter but it is not very sensitive to have an accurate measurement a venous blood sample is necessary a peripheral blood smear may show basal philic stippling and patients with extended significant lead exposure but can also be seen in arsenic poisoning a standard CBC will only show decreased hemoglobin decreased mean corpuscular hemoglobin concentration and decreased mean corpuscular volume consistent with hyperchromic microcytic anemia hypochromic microcytic anemia should be appropriately differentiated from other causes especially iron deficiency anemia sometimes we can find leaded objects that have been ingested through abdominal radiographs however this is not a diagnostic method children with long term exposure to lead may show lead lines in long bone radiographs these lines may show that a bone has stopped growing with LED exposures over 70 micrograms per deciliter and are not indicative of lead poisoning nor deposits of lead what is most meaningful about this radiograph is that these lines indicate that this child's lead levels were once much greater than what is shown here these lead lines show an increased density on the growth plate of the knees of a three-year-old girl the lines indicate a higher previous lead exposure level absence of lead lines does not rule out lead poisoning in 2012 as an advisory level for environmental and educational intervention CDC adopted five micrograms per deciliter as the upper reference range value for B LLS and children the National Institute of Occupational Safety and Health NIOSH recommends that the medical community implement the reference blood lead level of 5 micrograms per deciliter the most important step in clinical management is the removal of lead exposure it is important to refer the child to the local health department to implement an environmental investigation to identify potential sources of lead and to educate the family about prevention chelation therapy is considered a procedure for those at very high blood lead levels over 40 micrograms per deciliter for children and should only be performed by physicians or medical centers with chelation therapy experience more information is available at NC eh slash lead slash publications slash books slash p l py c / chapter 7 dot HTM pound signed treatment guidelines families should be encouraged to test their paint and water for lead patients can get more information from their regional poison control center local or state health department the epa national lead information center at one eight hundred four to four lead and act slash lead slash NL icy dot HTM in summary led is very dangerous to young children and a developing fetus the primary sources are deteriorated paint contaminated dust or soil some consumer products and water the focus must be on preventing exposure by removing the source you can get more information from your regional poison control center your State Health Department and these websites the agency for toxic substances and disease registry at ATSDR dot the pediatric environmental health specialty units pay Sue's at PHS u dot net the American College of medical toxicologists at a CMT net the american college of preventive medicine at a CPM org the association of occupational and environmental clinics at 800 CC org and the American College of occupational and environmental medicine at a coem org EPA information on lead-safe work practices is available at slash lead / e PA h UD r r m OD e l dot HTM you can find more information about lead in the home at lead in your home a parent's reference guide at slash lead /l e ad re v PDF and the alliance for healthy homes at AF h h org

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