Literature Review Health Effects Final July 2019

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LITERATURE REVIEW: OVERVIEW OF CHILDHOOD LEAD POISONING AND ITS HEALTH EFFECTS

July 2019

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

INTRODUCTION*

Lead poisoning is a preventable disease caused by exposure to common sources, such as lead-containing dust or lead-paint.1 The scientific community has documented lead’s toxic effects since the Greek physician Nicander of Colophon identified paralysis and saturnine colic as consequences of exposure.2 Benjamin Franklin noted in his 1786 letter to Benjamin Vaughn that “Plumbers, Glasiers, Painters” and others in trades involving lead suffered health consequences from their work.3 Historically, lead compounds have been widely used as paint pigments and agents in gasoline.4 Lead toxicity in children was first reported in Queensland5 in 1892 by Dr. John Lockhart Gibson, who described children with severe neurologic disease associated with exposure to deteriorating white lead paint.6

In the United States, blood lead levels (BLLs) in children have decreased dramatically over the past four decades. Still, many children live in homes with deteriorating lead-based paint, putting them at risk for lead-associated cognitive impairment and behavioral problems,7 among others. Prior to the mid-1950s, a significant percentage of house paint available to Americans was 50% lead. The allowable lead content of paint was lowered by the Consumer Product Safety Commission to 1.0 % in 1971, to 0.06% in 1977, and to 0.009% in 2009.8 Lead-based paint in pre-1978 housing is the most common and highly concentrated source of lead exposure for children. In 2002, Jacobs and colleagues assessed that “despite considerable progress, significant lead-based paint hazards remain prevalent, existing in 25% of all U.S. housing.”9 They also found that “2.7 million homes without lead-based paint had dust lead hazards,” and that even if lead-based paint hazards were not present in the home, they could be reintroduced into the environment through rehabilitation, maintenance, and repainting.10

From 2007 to 2010, approximately 2.6% of preschool children in the United States reported a blood lead concentration greater than or equal to 5 micrograms per deciliter (µg/dL) (≥50 ppb), which represents about 535,000 children 12 months to 5 years of age.11 This number was calculated using the National Health and Nutrition Examination Survey (NHANES), which collects data from interviews and physical examinations.12 Thus, this percentage only captures reported cases and does not reflect all lead poisoning cases in the United States. A 2017 study using the same NHANES data, in addition to information on underreporting and under-

* Natalie Alvarado, MPH, authored this document under the supervision of Professor Emily A. Benfer. In addition, Virginia Morgan, MPH, contributed research to the literature review. Nga Bui, MPH and MSW candidate, authored the Appendix: Effects of Lead Poisoning by Blood Lead Level. The literature review was completed during the Spring 2019 semester in the Health Justice Advocacy Clinic at Columbia Law School and Mailman School of Public Health and finalized in July 2019. 1 Parsons and McIntosh, Human Exposure to Lead and New Evidence of Adverse Health Effects: Implications for Analytical Measurements, (International Centre for Diffraction Data, 2010), 289. 2 Riva, Michele Agusto, et al, (Safety and Health at Work, 2012), 11-6. 3 Franklin, Benjamin edited by Goodman, N. G. The Ingenious Dr. Franklin: Selected Scientific Letters of Benjamin Franklin. Philadelphia: University of Pennsylvania Press (1931), 31-32. 4 Parsons and McIntosh, Human Exposure, 289. 5 Rosner, David et al. J. Lockhart Gibson and the Discovery of the Impact of Lead Pigments on Children's Health: A Review of a Century of Knowledge, Public Health Reports (2005), 296-300. 6 Bennett et al., Lead Poisoning: What's New About an Old Problem? (Contemporary Pediatrics 2015), 15. 7 American Academy of Pediatrics Council on Environmental Health, Prevention of Childhood Lead Toxicity. (Pediatrics, 2016), 4. 8 Agency for Toxic Substances, Case Studies in Environmental Medicine, 59 https://www.atsdr.cdc.gov/csem/lead/docs/CSEM-Lead_toxicity_508.pdf 9 Jacobs, David E. et al, The Prevalence of Lead-Based Paint Hazards in U.S. Housing, (Environmental Health Perspectives, 2002), A603-A604. 10 Jacobs, et al, The Prevalence of, A603-A604. 11 Centers for Disease Control, Blood Lead Levels in Children Aged 1–5 Years — United States, 1999–2010, (Morbidity and Mortality Weekly Report, April 2013), Table 1. 12 Centers for Disease Control National Center for Health Statistics, National Health and Nutrition Examination Survey Overview, CS269889-A.

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

testing, estimates there are approximately 1.2 million cases of elevated blood lead level (EBLL) among children between 12 months and 5 years of age.13

It is recognized by the Centers for Disease Control and Prevention (CDC), among others, that no BLL is free of adverse health risks and no safe level of blood lead has been identified.14 In recognition of this, the CDC adopted a “reference value” of 5 µg/dL in 2012.15 The CDC plans to continue updating the reference value every four years using the two most recent NHANES surveys.16

The Mayo Clinic recommends removing the source of the lead hazard from a child’s environment once an EBLL has been identified.17 In severe cases, such as where the EBLL exceeds 45 µg/dL, children may be referred to chelation therapy options, which are administered orally or through injection. Chelation works through the binding of the administered medication to the lead compounds in the body, resulting in the lead being excreted through urine.18 However, as noted by the American Academy of Pediatrics (AAP), “Primary prevention of lead exposure is now widely recognized as the optimal strategy because of the irreversible effects of low-level lead toxicity.”19

LEAD EXPOSURE

Ingestion of lead-contaminated house dust, residential soil, and water are major pathways for lead toxicity.20 Other sources such as drinking water, ceramics, toys, children’s jewelry, imported candy and its candy wrappers, home and folk remedies, and cosmetics can also pose risks.21 In the United States, lead-based paint is a primary source of exposure to lead in a child’s environment.22 Lead may be released from lead-based paint if the paint is disturbed, deteriorated, or subject to friction or impact. Situations that can cause lead exposure include disturbing paint during renovation, paint that is disturbed from the everyday use of windows, doors and porches; and paint that is chalking, chipping, or peeling. 23 Lead-based paint was banned in 1978, increasing the likelihood that units built before that time contain possible lead-based paint hazards. According to Jacobs and colleagues, “Housing built before 1960 had five to eight times the prevalence of hazards compared with units built between 1960 and 1978.”24 Jacobs and colleagues also assessed that while only 16% of housing in the South and West regions of the

13 Roberts, Eric M., et al, Assessing Child Lead Poisoning Case Ascertainment in the US, 1999–2010, Pediatrics May 2017, 139 (5) e20164266; DOI: 10.1542/peds.2016-4266 14 Centers for Disease Control and Prevention, Childhood Lead Poisoning Prevention Program https://www.cdc.gov/nceh/lead/default.htm; see also Green and Healthy Homes Initiative, Home & Health: Lead, (GreenandHealthyHomes.org, 2019). 15 The reference value was adopted in May 2012, upon accepting the recommendations of its Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP). Prior to 2012, the CDC defined BLLs greater than or equal to 10 µg/dL as the standard "level of concern" for children between 1- to 5-years-of-age. Centers for Disease Control, Response to Advisory Committee on Childhood Lead Poisoning Prevention Recommendations in “Low Level Lead Exposure Harms Children: A Renewed Call of Primary Prevention, 2012. 16Centers for Disease Control and Prevention, What Do Parents Need to Know to Protect Their Children?, 2017. The current reference level is based on NHANES data of blood lead distribution in children from 2007-2008 and 2009-2010. 17 Mayo Clinic, Lead Poisoning, (MayoClinic.org, 2019). 18 Graziano JH. Role of 2,3-dimercaptosuccinic acid in the treatment of heavy metal poisoning. Med. Tox.;1:155–162 (1986). 19 American Academy of Pediatrics, Prevention of , 4. 20 American Academy of Pediatrics, Prevention of, 5. 21 US Department of Housing and Urban Development, (Guidelines for the Evaluation and Control of Lead-Based Paint Hazards in Housing, 2012), 1-8. 22 Agency for Toxic Substances and Disease Registry, Registry Case Studies in Environmental Medicine (CSEM) Lead Toxicity, Course WB2832, (2017), 20. 23 Agency for Toxic Substances, Registry Case Studies in Environmental Medicine, 36. 24 Jacobs, David E. et al, The Prevalence of Lead-Based Paint Hazards in U.S. Housing, (Environmental Health Perspectives, 2002), A601-A602.

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

country has lead-based paint hazards, hazards were found in approximately 36% of the housing in the Northeast and Midwest.25 While the oldest housing stock and therefore the greatest number of housing hazards are found in the Northeast and Midwest, the greatest numbers based on prevalence are from the South.26 Lanphear and colleagues found that children who lived in rental housing were at increased risk for higher blood lead concentration.27 They also found that 33% percent of rental housing was in poor condition compared with 13% of owner-occupied housing.28

According to the American Community Survey, 53.37% of housing stock in the United States was built before 1980, and 27.47% was built before 1960.29 New York, Rhode Island, Massachusetts, Connecticut, and Pennsylvania have the oldest housing stock in both of these categories. Table 1 describes these percentages, ranked by the percentage of homes built before 1980. Homes built before 1950 are most prevalent in New York State, with 41% of housing falling into this category. Children residing in these homes have an increased risk of lead exposure. If pre-1978 housing is not properly remediated and maintained, remnants of lead-based paint can pose a hazard to occupants, especially children.

30 Table 1: Age of Housing Stock in the United States (Top 5 States) State Percentage of Housing Percent of Housing Percent of Housing Stock Built before 1978 Stock Built 1959 or Stock Built Before 1950 or Before Before 1. New York 77.8% 55.1% 41.0% 2. Rhode Island 72.5% 47.2% 38.3% 3. Massachusetts 70.5% 49.2% 39.5% 4. Connecticut 70.2% 42.9% 29.5% 5. Pennsylvania 68.9% 46.5% 34.4%

LEAD ABSORPTION IN A CHILD’S BODY

Lead toxicity can affect every organ system. The body accumulates lead over the life cycle and typically releases it very slowly. Young children become exposed to lead dust or paint chips when they crawl on the floor and engage in typical hand-to-mouth behaviors. Hand-to-mouth behavior in young children increases the risk of lead exposure through dust and paint.31 This behavior is especially prevalent between ages 9 and 24 months.32 Children absorb 4-5 times more lead than adults, even when comparing the same source.33 Children can absorb about 50% of ingested lead if they have a meal prior to exposure.34 On an empty stomach, absorption jumps up to 100%.35 Children also have a higher breathing rate compared to adults, breathing in a higher volume of air per pound of

25 Jacobs, David E. et al, The Prevalence of, A601-A602. 26 Roberts, Eric M., et al, Assessing Child Lead Poisoning Case Ascertainment in the US, 1999–2010, Pediatrics May 2017, 139 (5) e20164266; DOI: 10.1542/peds.2016-4266 27 Lanphear, Bruce et al, Environmental Lead Exposure during Early Childhood, (The Journal of Pediatrics, 2002), 45. 28 Lanphear, Bruce et al, Environmental Lead, 45. 29 American Community Survey 1-Year Estimates, Physical Housing Characteristics for Occupied Housing Units, (FactFinder.Census.gov, 2017). 30 American Community Survey, Physical Housing Characteristics. The chart excludes the District of Columbia. 31 Hipkins, Karen L et al, Family Lead Poisoning Associated with Occupational Exposure, (Clinical Pediatrics, 2004), 845. 32 Bennett et al., Lead Poisoning, 19. 33 Lead Free NYC, A Roadmap to Eliminating Childhood Lead Exposure, (2019), 6. 34 U.S. Department of Health and Human Services Public Health Service Agency for Toxic Substances and Disease Registry, Toxicological Profile for Lead, (August 2007), 7. 35 Agency for Toxic Substances, Registry Case Studies in Environmental Medicine, 64.

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

body mass.36 This puts them at risk for lead exposure through particles in the air from lead-based paint that has become a part of household dust. Being exposed to lead through a respiratory route may result in higher absorption than exposure through the digestive route.37 On average, it requires a little over a year for children with a case management intervention after having BLLs over or equal to 10 µg/dL to get back under that threshold.38 Lead absorption depends on factors such as the size of the lead particle, the route of exposure, nutritional status, health status, age at time of exposure, and the size of the exposed individual.

Lead slows growth in children by preventing the absorption of iron, zinc, and calcium. These minerals are essential to nerve and brain development.39 Since bones can hold between 90-95% of the lead absorbed by the body, the measurement of lead in bone is indicative of past exposure.40 Bones are constantly renewing themselves,41 but it takes about 10 to 30 years before half of the stored lead is eliminated or broken down depending on the rate of bone turnover.42 As children are continuously growing and developing, they experience constant bone remodeling.43 Thus, bone lead in children is more likely to be exchanged with blood lead,44 and make its way to other body systems (as compared to adults). This bone-to-blood transfer increases during lifetime events such as advanced age, broken bones, chronic disease, hyperthyroidism, immobilization, kidney disease, lactation, menopause, physiologic stress, and pregnancy.45

Blood carries only a small fraction of total lead in the body, but serves as the initial repository of lead absorbed. Blood is responsible for distributing lead throughout the body, and makes the toxin available to other tissues.46 Lead is then absorbed by soft tissues and into bone, where it can remain for decades.47 Differences in the composition of the blood brain barrier between adults and children means that the nervous systems of children and developing fetuses have an increased risk of lead toxicity after exposure.48 Primarily due to its ability to substitute for calcium, lead is able to cross the blood brain barrier quickly.49

Blood screenings can be conducted through capillary (finger-prick) samples or a venous blood draw. Capillary tests can result in false positives, though it should be noted that an elevated capillary lead level can be an indication of the presence of lead in the child's environment even if the venous level is low.50 As BLLs in U.S. children continue to decrease, more laboratories will need to be able to accurately measure concentrations below current levels of detection. BLLs in U.S. children one to five years old have declined to a point that challenges the detection limit of many laboratories.51

36 Agency for Toxic Substances, Registry Case Studies in Environmental Medicine, 44. 37 Agency for Toxic Substances, Registry Case Studies in Environmental Medicine, 18. 38 Dignam, Timothy A, Reduction of Elevated Blood Lead Levels in Children in North Carolina and Vermont, 1996–1999, (Environmental Health Perspectives, 2008), 981. 39 Agency for Toxic Substances, Registry Case Studies in Environmental Medicine, 72. 40 Parsons and McIntosh, Human Exposure, 292-293. 41 Deal, Chad, How Do Your Bones Change Over Time? (ClevelandClinic.org, 2018). 42 Rabinowitz, MB, Toxicokinetics of Bone Lead, (Environmental Health Perspectives, 1991), 35, Figure 3. 43 O’Flaherty, Ellen, Physiologically Based Models for Bone-Seeking Elements. V: Lead Absorption and Disposition in Childhood, (Toxicology and Applied Pharmacology, 1995), 297. 44 National Toxicology Program U.S. Department of Health and Human Services, NTP Monograph on Health Effects of Low- Level Lead, (2012), xvii, citing reviews by Barbosa et al. 2005, Hu et al. 2007. 45 Agency for Toxic Substances, Registry Case Studies in Environmental Medicine, 67. 46 Agency for Toxic Substances, Registry Case Studies in Environmental Medicine, 66. 47 Parsons and McIntosh, Human Exposure, 292-293 48Agency for Toxic Substances, Registry Case Studies in Environmental Medicine, 45. 49 Sanders, Talia et al, Neurotoxic Effects and Biomarkers of Lead Exposure: A Review (Rev Environ Health 2009), 5 50 American Academy of Pediatrics, Detection of Lead Poisoning, (AAP.org, 2016). 51 Caldwell et al, Laboratory Measurement Implications of Decreasing Childhood Blood Lead Levels, (Pediatrics 2017), 3,7.

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

IRREVERSIBLE HEALTH EFFECTS OF LEAD POISONING IN CHILDREN

Lead is a potent neurotoxin, and has a half-life in the brain of about two years.52 Lead exposure can lead to neurons malfunctioning, disrupt the formation of synapses, and can prompt neuronal death.53 Research, conducted primarily in mice and non-human primates, suggests that early-life lead exposure may possibly even hold neurodegenerative consequences in old age.54

No subgroup, whether racial or economic, is free from the risk of lead levels high enough to result in adverse health effects.55 Lead exposure is known to be related to both acute and chronic health conditions such as: loss of appetite, constipation, abdominal colic, anemia, hearing/balance problems, dental caries, growth delay, delayed puberty, cardiovascular disease, and renal disease.56 Neurological impairments can develop into behavioral problems (including inattentive, hyperactive, or disorganized behaviors), decreased IQ, encephalopathy, convulsions, or coma.57 In extreme cases, lead poisoning can lead to death of the affected individual. The EPA has called the effects of lead poisoning “devastating and irreversible.”58 Studies have shown that lead acts as a neurotoxin at low BLLs. Adverse health effects are detectable even at levels of 2 µg/dL.59

These health effects are subtle, yet severe. In the 2004 Annual Review of Medicine, researcher Herbert Needleman advised, “Any child with growth failure, abdominal pain, behavior change, hyperactivity, language delay, or anemia should have a blood lead test to rule out lead toxicity.”60 Following his landmark 1979 study, Needleman found there was a persistence of health effects over time. Twelve years after the 1979 study, Needleman followed up with the study population (at the average age of 18-years-old) and found subjects whose lead levels were in the high-lead group had “more school failure, reading disabilities, lower class standing in their final year of high school, and disturbances in fine motor function.” 61

The National Toxicology Program (NTP), located at the National Institute of Environmental Sciences as part of the National Institutes of Health, completed an assessment focusing on epidemiological evidence of BLL between 5 µg/dL and 10 µg/dL. The NTP evaluation was conducted through the Office of Health Assessment and Translation and completed in April of 2012. Findings of sufficient evidence of adverse health effects in children are summarized in Table 2 and provided in detail in the Appendix.

52 Reuben, Aaron, Childhood Lead Exposure and Adult Neurodegenerative Disease, (Journal of Alzheimer’s Disease, 2018), 18. 53 Reuben, Childhood Lead, 19. 54 Reuben, Childhood Lead, 19. 55 Crocetti, Annemarie F. et al, Determination of Numbers of Lead-Exposed U.S. Children by Areas of the United States: An Integrated Summary of a Report to the U.S. Congress on Childhood Lead Poisoning, (Environmental Health Perspectives, 1990), 214. 56 Bennett et al., Lead Poisoning, 19. 57 Bennett et al., Lead Poisoning, 19. 58 Environmental Protection Agency, What You Need to Know about Lead Poisoning, (EPA.gov, 2014). 59 Bennett et al., Lead Poisoning, 19. 60 Needleman, H., Lead Poisoning, (Annual Review of Medicine, 2004), 217. 61 Needleman, H., Lead Poisoning, (Annual Review of Medicine, 2004), 214.

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

Table 2: Sufficient Evidence of Adverse Health Effects at Low Blood Lead Levels in Children62 Blood Lead Level Principal Health Effects <5 µg/dL Decreased academic achievement, IQ, and specific cognitive measures; increased incidence of attention-related and problem behaviors <10 µg/dL Decreased hearing <10 µg/dL Delayed puberty, reduced postnatal growth

Intelligence Quotient

The intelligence quotient (IQ) reduction associated with the increase in blood lead concentration from under 1 µg/dL to 30 µg/dL was 9.2 IQ points, but the reduction associated with an increase in blood lead concentration from less than 1 µg/dL to 10 µg/dL was 6.2 IQ points.63 This shows that the most damage to a child’s intellectual capabilities can happen at the lowest levels of lead exposure. Lanphear and colleagues found that concurrent blood lead levels or average lifetime estimates of lead exposure were usually stronger indicators of intellectual deficits after lead exposure than peak or early childhood blood lead levels.64

Lead toxicity accounts for an estimated total loss of 23 million IQ points among a cohort of today’s U.S. children.65 As noted by the AAP in 2016, “if the focus is only on reducing exposures for children who have a blood lead concentration ≥5 µg/dL (≥50 ppb), we will fail to preserve more than 20 million (>80% of total) of the 23 million IQ points lost among US children with lower lead exposure because there are so many more children who have low to moderate blood lead concentrations.”66 In 2017, the total IQ loss in young children that was attributable to modern lead exposures exceeded those caused by conditions such as brain tumors, congenital heart disease, and traumatic brain injury.67

Academic Achievement

Early childhood lead exposure has been associated with worse achievement on standardized tests, even at low BLLs. A 2015 study involving third graders in the Chicago Public School system showed that small increases in BLL, even at concentrations below 5 µg/dL, were associated with significant reduction in standardized test performance. In this population, 1 µg/dL increase in BLL was associated with a 0.7 point decrement in arithmetic and a 1-point decrement in reading scores on the Wide Range Achievement Test-Revised. Children who had BLLs under 10 µg/dL had more than twice the odds of scoring “non-proficient” in classroom subjects (mathematics, science, and reading) than did children whose BLLs were under 1 µg/dL.68 Often times, children show no signs of lead toxicity until they are enrolled in school. The effects could be unnoticeable even as late as middle school, when expectations for academic achievement increase.69

62 Adapted from National Toxicology Program, NTP Monograph, Table 1.1 and Table 1.2. See Appendix for detailed health effects. 63 American Academy of Pediatrics, Prevention of, 3. 64 Lanphear, Bruce E. et al, Low-Level Environmental Lead Exposure and Children’s Intellectual Function: An International Pooled Analysis, (Environmental Health Perspectives, 2005), 898. 65 American Academy of Pediatrics, Prevention of, 3. 66 American Academy of Pediatrics, Prevention of, 3-4. 67 Bellinger, David C, Childhood Lead Exposure and Adult Outcomes, (Journal of the American Medical Association, 2017), 1220. 68 Evens, Kathleen L. et al, The Impact of Low-Level Lead Toxicity on School Performance Among Children in the Chicago Public Schools: A Population-Based Retrospective Cohort Study, (Environmental Health, 2015), 1-2. 69 Agency for Toxic Substances, Registry Case Studies in Environmental Medicine, 72.

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

Behavioral Disorders

Low-level lead exposure during childhood is associated with poorer emotional/behavioral functioning in later childhood and adolescence.70 Approximately 1 in 5 cases of ADHD diagnosed among U.S. children have been attributed to lead exposure.71 Sampson and Winters followed a cohort of more than 200 Chicago infants, and found that “Children with higher levels of lead exposure around age 3 exhibited more antisocial behavior, on average, around age 17 than did those with lower levels of childhood exposure.”72

It has been found that adolescents who showed higher bone lead concentrations had higher scores for delinquency and aggression.73 Numerous studies link elevated bone or blood lead levels with aggression, destructive and delinquent behavior, and criminal behavior.74 Mielke and Zahran found that, holding other factors equal, there was a significant association between the amount of air lead released 22 years prior with present period aggravated assault rate, signaling both childhood sensitivity to lead and its latent effects on “future societal behavior and welfare.”75

HEALTH EFFECTS ON EXPECTANT MOTHERS AND THE DEVELOPING FETUS

As the brain is developing in utero and throughout childhood, children are especially prone to the adverse effects of lead on the central nervous system.76 Mothers who had exposure to lead in the past may store lead in their bones, from where it is released during times of calcium stress such as pregnancy and lactation. Lead crosses the placenta and has been measured in the fetal brain as early as the end of the first 12 weeks of development.77 Pregnant women with EBLLs themselves may have an increased chance of preterm labor, miscarriage, neurological effects, intrauterine growth restriction, spontaneous abortion, stillbirth, and low birth weight.78 For additional health effects on the developing fetus, see the Appendix.

HEALTH EFFECTS OF LEAD POISONING ON ADULTS

Americans born in the 1960s and the 1970s represent those currently living with the greatest childhood lead exposures. From 1976–1980, the average BLL for a child under the age of 5 was 16 µg/dL.79 A 2010 study associated cumulative lead dose with persistent, but not likely progressive, structural changes in the brain.80 Latent effects of childhood lead exposure include chronic advanced renal disease or a reduction in renal function in adulthood.81 Studies have also shown possible links between lead exposure and cardiovascular disorders in

70 McFarlane, Alexander C. et al., Prospective Associations Between Childhood Low-Level Lead Exposure and Adult Mental Health Problems: The Port Pirie Cohort Study, (NeuroToxicology, 2013), 11. 71 American Academy of Pediatrics, Prevention of, 4. 72 Sampson, Robert J. and Alix S. Winter, Poisoned Development: Assessing Childhood Lead Exposure as a Cause of Crime in a Birth Cohort Followed Through Adolescence, (Criminology, 2018), 269. 73 American Academy of Pediatrics, Prevention of, 4. 74 Agency for Toxic Substances, Registry Case Studies in Environmental Medicine, 73, citing Wright et al. 2008, Braun et al. 2006, Needleman et al. 2004, Needleman et al. 2002, Nevin 2000 and Bellinger et al. 1994. 75 Mielke, Howard and Sammy Zahran, The Urban Rise and Fall of Air Lead (Pb) and the Latent Surge and Retreat of Societal Violence, (Environmental International 2012), 54. 76 Parsons and McIntosh, Human Exposure, 291. 77 Centers for Disease Control, Guidelines for the Identification and Management of Lead Exposure in Pregnant and Lactating Women, (U.S. Department of Health and Human Services, 2010), 27. 78 Agency for Toxic Substances, Registry Case Studies in Environmental Medicine, 50. 79 Reuben, Childhood Lead, 28. 80 Swartz, Brian S. et al, Evaluation of Cumulative Lead Dose and Longitudinal Changes in Structural MRI in Former Organolead Workers, (J Occup Environ Med, 2010), 5-6. 81 Agency for Toxic Substances, Case Studies in Environmental Medicine, 59 https://www.atsdr.cdc.gov/csem/lead/docs/CSEM-Lead_toxicity_508.pdf

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

adults;82 disorders include: ischemic coronary heart disease, cerebrovascular accidents, peripheral vascular disease, elevated blood pressure, and the onset and development of hypertension.83

Intelligence Quotient

Conducted by Reuben and colleagues, a 2017 study looking at a cohort born in New Zealand in 1972–1973 found that childhood lead exposure was associated with lower cognitive function at age 38 (participants in this study were initially evaluated at age 11). After controlling for participants’ own childhood IQ score, their mothers’ IQ score, and their socioeconomic background, it was found that each 5 µg/dL higher of BLL in childhood was associated with a decrease of 1.61 points in IQ in adulthood. This lower cognitive performance was seen on tests measuring perceptual reasoning and working memory.84

In the same study, higher childhood blood-lead level was also associated with lower socioeconomic status in adulthood. These associations were also found to be significant after adjusting for the participant’s own childhood IQ, their mother’s IQ, and their social class background. This was measurable as small, but detectable, downward social mobility by midlife for those participants who were the most-exposed as children. These findings were true regardless of participants’ socioeconomic origins.85 As noted by Bellinger, the follow-up timeframe in this study was almost 20 years longer than that of any other cohort of individuals exposed to lead in childhood, helping expand knowledge about the persistence of the adverse effects of early-life exposure.86

Further, Bellinger points out that these deficits explored by Reuben and colleagues could put some of those affected on a trajectory that leads to poorer educational attainment, reduced job opportunities, and lower income. As a result, this could potentially place them in a lower socioeconomic status than they otherwise would have been able to access or achieve. As such, exposure to lead in early childhood might also have the effect of reducing an individual’s wealth accumulation, as well as ability to respond to future health issues, such as stroke or degenerative diseases, which are seen with frequency in aging populations.87

Osteoporosis

The release of lead stored in the bone has been documented in older men and women with osteoporosis.88 Several scientific authors have suggested that this is a result of the natural aging process.89 Campbell and colleagues speculated that lead exposure quickens bone maturation, which may ultimately result in a lower peak bone mineral density in young adulthood. This could possibly predispose individuals to osteoporosis later in life.90 Future studies are needed to confirm this hypothesis, but current knowledge merits further study, particularly as the most lead-exposed population ages.

82 Bruce P. Lanphear et al., Low-level exposure and mortality in US adults: a population-based cohort study, Lancet Public Health (March 2018). 83 Agency for Toxic Substances, Case Studies in Environmental Medicine, 59 https://www.atsdr.cdc.gov/csem/lead/docs/CSEM-Lead_toxicity_508.pdf 84 Reuben, Aaron et al, Association of Childhood Blood-Lead Levels with Cognitive Function and Socioeconomic Status at Age 38 Years and with IQ Change and Socioeconomic Mobility Between Childhood and Adulthood, (Journal of the American Medical Association, 2017), 1244-1251. 85 Reuben et al, Association of Childhood, 7 of author manuscript. 86 Bellinger, Childhood Lead, 1219. 87 Bellinger, Childhood Lead, 1219. 88 Reuben, Childhood Lead, 31. 89 National Toxicology Program, NTP Monograph, 16 90 Campbell, James R., The Association between Environmental Lead Exposure and Bone Density in Children, (Environmental Health Perspectives, 2014): 1200-1203.

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

COSTS TO CITIZENS AND SOCIETY

Any exposure to lead causes extreme costs to society. A recent report documented the costs of lead exposure for a single cohort of children with BLL above 2 µg/dL. The 2019 cohort, which includes a total of 341,602 children, have a total lifetime economic burden of 72.6 billion.91 In a cost-benefit analyses based on the lifetime impacts of interventions for a single cohort of U.S. children born in 2018, colleagues from the Pew Charitable Trusts found that “eradicating lead paint hazards from older homes of children from low-income families would provide $3.5 billion in future benefits, or approximately $1.39 per dollar invested, and protect more than 311,000 children.”92 They determined that “targeted evidence-based academic and behavioral interventions” could increase affected children’s’ lifetime family incomes, likelihood of graduating from high school, and likelihood of attending college. These interventions were also found to have the potential to reduce an affected population’s risk for being involved in a teenage pregnancy and/or criminal conviction.93 It was also assessed that if measures are taken to ensure contractors comply with the EPA’s lead-safe Renovation, Repair, and Painting Rule (RRP) practices, it could result in protecting about 211,000 children and “provide future benefits of $4.5 billion, or about $3.10 per dollar spent.”94 Thus, eradicating lead hazards for children stands to benefit not only the health of the nation’s children, but would also avail considerable public resources.

EFFECT OF PUBLIC POLICIES ON BLOOD LEAD LEVELS

Children who grew up in the 1970s had higher BLLs as compared to children exposed in more recent years. Figure 1 shows a decrease in childhood blood lead levels that correlates with the passing of legislation to reduce sources of lead in the environment (e.g. paint, gasoline, water pipes/solder, consumer products, etc.). Average BLLs in children ages 1-5 decreased 10-fold over the last three decades, going from 15.1 µg/dL in the period between 1976 and 1980 to 1.51 µg/dL in 2007-2008. U.S. adults who were born before 1980 had blood lead levels over 10 µg/dL during early childhood on average (See Figure 1).

91 This figures include the calculations for every state. Altarum, VALUE of Lead Prevention Calculator at http://www.valueofleadprevention.org 92 Pew Charitable Trusts, 10 Policies to Prevent and Respond to Childhood Lead Exposure: An Assessment of the Risks Communities Face and Key Federal, State, and Local Solutions, (2017), 2. 93 Pew Charitable Trusts, 10 Policies, 2. 94 Pew Charitable Trusts, 10 Policies, 2.

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

Figure 1. Federal Lead Poisoning Prevention Policies Impact Mean Blood Lead Levels among Children in the U.S., 1972-201295

In addition to federal laws, many states have adopted innovative approaches to address lead poisoning.96 Based on local community needs and local government capacity, these laws vary in BLL reference level, level of intervention, enforcement, and age. Some states require environmental investigations when a child has an EBLL at CDC reference value of 5 µg/dL. In 17 cities and states, primary prevention interventions require the identification of lead hazards before children are exposed in rental units. Korfmacher and Hanley examined select U.S. cities and described local law and policy that require the removal of lead hazards from rental properties (Figure 2).97

Any interventions should be health-based in nature. Health-based interventions are those that 1) create social and physical environments that improve health, 2) consider the social determinants that affect health, such as, but not limited to, the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life; 3) are designed to address gaps in health or health equity, and 4) achieve the highest quality of physical, mental, and social well-being for individuals, among other strategies.

95 Adapted from https://ptfceh.niehs.nih.gov/features/assets/files/key_federal_programs_to_reduce_childhood_lead_exposures_ and_ eliminate_associated_health_impactspresidents_508.pdf and Brown MJ and Falk H. Toolkit for establishing laws to control the use of lead paint. Module C.iii. Conducting blood lead prevalence studies. Global Alliance to Eliminate Lead Paint (2017) 96 Emily A. Benfer, Emily Coffey, Allyson E. Gold, Mona Hanna-Attashi, Bruce Lanphear, Helen Y. Li, Ruth Ann Norton, David Rosner, Kate Walz, Health Justice Strategies to eradicate lead poisoning: An Urgent Call to Action to Safeguard Future Generations, Yale Journal of Health Policy, Law, and Ethics, Vol. 19, No. 1, (2019). 97 Korfmacher, K. and Michael L. Hanley, Are Local Laws the Key to Ending Childhood Lead Poisoning?, (Journal of Health Politics, Policy and Law, 2013), 761.

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

Figure 2: How Local Lead Laws Protect Children from Lead Hazards in Housing98

DIRECTIONS FOR FUTURE RESEARCH

There is no safe level of lead. Further research is necessary to understand the effects of lead associated with poisoning between 5-10 micrograms per deciliter and for exposure below the CDC reference value of 2-4 micrograms per deciliter. Additionally, studies should be focused on identifying populations at greatest risk and to identify the sources of lead exposure in various communities. All research should strive to be publicly available, including information on low-level lead exposure in the home.

In order to further understand the effects of lead on children, adults, and the environment it is important to study policy implementation and impacts. Areas of policy to be studied include: the effects of pre-rental and at point of sale lead hazard inspection laws on blood lead levels, such as a difference in difference study and studies that evaluate specific aspects of enforcement mechanisms; effect of early intervention and special education on lead poisoning outcomes; effect of neuropsychological evaluation versus early intervention diagnostics; qualitative study of stakeholders who control or have access to property, such as tenants, property owners, and affected populations; reliability of consumer lead-dust and -dirt testing kits; evaluation of predictive modeling and electronic medical record flag programs; policy surveillance to determine effectiveness of lead poisoning prevention laws, such as mapping or tracking laws and policies and their characteristics across jurisdictions and over time; and effect of energy efficiency and weatherization on residents’ health and safety outcomes, as well as the value added to properties after receiving lead remediation services, among other studies.

In the next decade, those born in the 1960s through the 1980s will begin to enter the stage in life when dementia symptoms tend to appear. As Reuben notes, many will also enter the age in which lead mobilization from bones will increase, particularly for those undergoing menopause and osteoporosis. Future studies should explore the

98 Borrowed from Korfmacher and Hanley, Are Local Laws, 761, Figure 1.

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

link between childhood lead exposure and degenerative diseases such as Alzheimer’s and Parkinson’s.99 This research can also be instrumental in revealing the lifelong effects of childhood lead exposure, particularly as related to cognitive decline, socioeconomic status, aggressive behavior and crime, and patterns within families and communities. It is important to continue to monitor the long-term impacts of lead, even at lower lead poisoning levels.

CONCLUSION

Currently, lead toxicity is identified in children through blood lead level testing. While this is a measure that can start necessary interventions, it is far from sufficient to keep children safe from harm. Primary prevention of lead exposure is widely recognized as the optimal strategy, given that the effects of even low-level lead toxicity are irreversible. Lead poisoning prevention education that emphasizes hand-washing or dust control does not reduce children’s BLLs.100 Thus, it is important that children’s environments be inspected and affected homes be identified and successfully remediated before a child is exposed to the neurotoxin. The inspection and remediation standards should be primary prevention oriented and health-based, updated as appropriate,101 and made accessible to landlords and homeowners whose units are found to have hazards.

Renovating, repairing, or painting a pre-1978 residence can release particles of lead-based paint. Proper maintenance of homes by experienced professionals trained in lead-safe practices can guard against future exposures. It is recommended that contractors engaged in renovating or remodeling homes with high-lead paint be certified through the EPA Lead-Safe Certification Program, and complete any additional required certification at the state or Federal level to ensure these processes are conducted safely.102 Adherence and commitment to these safety standards can prevent lead hazards from re-entering the home or prevent future adverse health effects.

The effects of childhood lead exposures on the rates of degenerative disease may not be clear for another decade.103 As the cohort of individuals born in the 1960s through 1980s ages, the scientific and medical fields should prepare to gain a better understanding of effects of childhood lead poisoning on later life stages. In the meantime, it is important that we evaluate current intervention methods for this preventable disease, which has already affected millions of children’s trajectories.

As Rosner and Markowitz point out, “…lead is a multiheaded hydra whose dangers are constantly being revealed in new forms. Like an onion, every time we peel away a layer, we are forced to confront another set of problems that challenge our science, our epidemiology, our morality, and our sense of social justice.” 104 With as many stakeholders, sources, and adverse consequences as the epidemic has, it is important to take a comprehensive approach when addressing lead poisoning rates in communities. Only through collective action can we give all of our nation’s children the opportunity to realize their full potential.

99 Reuben, Childhood Lead, 17. 100 American Academy of Pediatrics, Prevention of, 1. 101 Bellinger, Childhood Lead, 1220. 102 National Toxicology Program, NTP Monograph, 15. 103 Reuben, Childhood Lead, 28-29. 104 Rosner David and Gerald Markowitz, Building the World That Kills Us: The Politics of Lead, Science, and Polluted Homes, 1970 to 2000, (Journal of Urban History, 2016), 340.

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

APPENDIX

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

EFFECTS OF LEAD POISONING BY BLOOD LEAD LEVEL

Effects of Lead Poisoning Prenatally by Blood Lead Level

BLL Effects Symptoms (µg/dL)

<5 Cognitive function • Decrease in measures of cognitive function105 Developmental • Reduced fetal growth106 <10 Cognitive function • Decreased IQ107 Developmental • Reduced postnatal growth (i.e. head circumference in children up to 4 years)108 • Associated with low birth length109 • Lowered birth weight 110 Behavioral • Increased incidence of attention-related behaviors111 • Increased incidence of problem behaviors112 Sensory organs • Decreased hearing113 Immune • Increased hypersensitivity and allergy (e.g. positive skin prick test114 <15 Developmental • Increased risk of preterm birth115

105 National Toxicology Program U.S. Department of Health and Human Services, NTP Monograph on Health Effects of Low-Level Lead, (2012), 22. 106 National Toxicology Program, NTP Monograph, 89. 107 National Toxicology Program, NTP Monograph, xx, Table 1.2. 108 National Toxicology Program, NTP Monograph, xx, Table 1.2. 109 Hernandez-Avila, Mauricio et al, Effect of Maternal Bone Lead on Length and Head Circumference of Newborns and 1- Month-Old Infants, (Archives of Environmental Health: An International Journal, 2002), 482-88. 110 Zhu, Motao et al, Maternal Low-Level Lead Exposure and Fetal Growth, (Environmental Health Perspectives 2010), 1471. 111 National Toxicology Program, NTP Monograph, xx, Table 1.2. 112 National Toxicology Program, NTP Monograph, xx, Table 1.2. 113 National Toxicology Program, NTP Monograph, xx, Table 1.2. 114 National Toxicology Program, NTP Monograph, xx, Table 1.2. 115 National Toxicology Program, NTP Monograph, xxiv.

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

Effects of Lead Poisoning in Children by Blood Lead Level and Relevant Supports for Children

BLL Effects Symptoms Supports (µg/dL)

<5 Cognitive • Decrease in academic • Provide education of effects of lead function achievement116 hazards and how to remove the source • Associated with decrease in of the lead hazard from a child’s arithmetic and reading skills117 environment122 • Decreased IQ118 • Nurse Case Management, including • Decreased specific cognitive home visits, counseling and measures119 monitoring123 • Attention, executive function, • Automatic eligibility for Early language, learning and memory, Intervention and Special Education and visual-spatial processing120 Programs, under the Individuals with • Altered adrenocortical response to Disabilities Education Act124 acute stress121 • Neuropsychological assessment to ensure child’s specific challenges are addressed and to inform development of Individualized Education Plan125 • Parent-focused interventions by community health and social workers with focus on lead control/removal, parental coaching, and positive behavioral responses126 • Provide nutritional supports, connect to programs that provide affordable access to fresh fruits and vegetables along with education127 • Child enrichment opportunities, i.e.

116 National Toxicology Program, NTP Monograph, xix, Table 1.1. 117 Lanphear, B. P. Cognitive Deficits Associated with Blood Lead Concentrations, (Public Health Reports 2000), 521. 118 National Toxicology Program, NTP Monograph, xix, Table 1.1. 119 National Toxicology Program, NTP Monograph, xx, Table 1.2. 120 National Toxicology Program, NTP Monograph, 27. 121 Gump, Brooks B et al, Low-Level Prenatal and Postnatal Blood Lead Exposure and Adrenocortical Responses to Acute Stress in Children, (Environmental Health Perspectives, 2007), 249. 122 Mayo Clinic, Lead Poisoning: Diagnosis and Treatment, (MayoClinic.org, 2019). Retrieved 4/25/2019. 123 Health Impact Project (HIP), 10 Policies to Prevent and Respond to Childhood Lead Exposure (Pew Charitable Trusts, 2017), 71. 124 Hamp, Nicole et al, Advocating for Automatic Eligibility for Early Intervention Services for Children Exposed to Lead, (Pediatric Annals, 2018), e416. 125 Silver, C. et al, The Importance of Neuropsychological Assessment for the Evaluation of Childhood Learning Disorders: NAN Policy and Planning Committee, (Archives of Clinical Neuropsychology, 2006), 733. 126 Health Impact Project (HIP), 10 Policies, 71. 127 Food and Nutrition Service, Federal Nutrition Programs: Reducing the Impact of Lead Exposure, (FNS.USDA.gov, 2016), Retrieved 4/25/2019.

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

Head Start and School Readiness programs128

Behavioral • Increased evidence of attention- • Dialectical behavioral therapy130 related behaviors, i.e. ADHD, inattention129 Organs • Increased chronic kidney disease • Nurse case management132 (CKD) and decreased glomerular • Refer to pediatric nephrologist133 filtration rate (GFR) in children > 12 years old131 Musculoskelet • Increased caries in urban cities134 • Provide oral health education135 al • Provide restorative therapy, i.e. Atraumatic Restorative Treatment136 <10 Cognitive • Associated with decrements in • See cognitive at level <5 Function domains of attention executive • Social-emotional development function, visual-motor integration, programs138 social behavior and motor skills137 Developmenta • Decreased postnatal growth139 • Refer to pediatric endocrinologist. If l • Delayed sexual maturation or appropriate, hormone therapy141 puberty onset in children 8-17 years of age140 Sensory • Decreased auditory acuity142 • If eligible for IDEA, supports through Organs Early Intervention Services or Education143

128 Centers for Disease Control and Prevention, Educational Interventions for Children Affected by Lead (2015), 16-19. 129 National Toxicology Program, NTP Monograph, 34. 130 Gharamaleki, Nasser S. et al. The Effectiveness of Dialectical Behavior Therapy in Decreasing High Risk Behaviors Among Students Suffering from Attention Deficit / Hyperactivity Disorder, (Zahedan Journal of Research in Medical Sciences, 2017), 1. 131 National Toxicology Program, NTP Monograph, 77. 132 Health Impact Project (HIP), 10 Policies to Prevent and Respond to Childhood Lead Exposure (2017), 71. 133 National Institute of Diabetes and Digestive and Kidney Diseases, Kidney Disease in Children, (NIDDK.NIH.gov, 2014), Retrieved 4/25/2019. 134 Gemmel, Allison et al. Blood Lead Level and Dental Caries in School-age Children, (Environmental Health Perspectives, 2002), A625-A630. 135 Dülgergil, Çoruht et al, Early Childhood Caries Update: A Review of Causes, Diagnoses, and Treatments, (Journal of Natural Science, Biology and Medicine, 2013), 29. 136 Dülgergil, Early Childhood Caries, 33. 137 Tellez-Rojo, M. M. et al, Longitudinal Associations Between Blood Lead Concentrations Lower Than 10 g/dL and Neurobehavioral Development in Environmentally Exposed Children in Mexico City (Pediatrics 2006), e323-e324. 138 Health Impact Project (HIP), 10 Policies to Prevent and Respond to Childhood Lead Exposure (2017), 71. 139 National Toxicology Program, NTP Monograph, 89. 140 National Toxicology Program, NTP Monograph, xviii. 141 Soliman A, De Sanctis V, Elalaily R, Bedair S. Advances in pubertal growth and factors influencing it: Can we increase pubertal growth?. Indian J Endocrinol Metab. 2014;18(Suppl 1):S53–S62. doi:10.4103/2230-8210.145075 142 National Toxicology Program, NTP Monograph, xxi. 143 Centers for Disease Control and Prevention, Hearing Loss Treatment and Intervention Services, (CDC.gov, 2018), Retrieved 4/25/2019.

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

• Early Hearing Detection and Intervention (EHDI)144 Immune • Increased serum immunoglobulin • Nurse case management148 E (IgE)145 • Allergen preventive therapy or • Linked to increased risk of immunotherapy149 developing asthma146Increased • Asthma should be monitored, develop hypersensitivity and allergy an individualized treatment plan, and 150 (e.g. positive skin prick test)147 have regular follow-up care Cardiovascula • Increased risk of hypertension in • Nurse case management152 r adulthood151 <15 Cognitive • Increased likelihood to have • See cognitive at level <10 function learning disability153 • Learn/practice mindfulness • Associated with higher levels of techniques156 general psychopathology in • Special education services, adulthood (i.e. higher neuroticism, individualized education programs, lower agreeableness, lower and individualized interventions for conscientiousness, greater specific learning disabilities157 externalizing and internalizing symptoms,154 development of adult-onset psychiatric disorders- schizophrenia155) Heme- • ALA-D inhibition158 • Nurse case management159 synthesis

144 Centers for Disease Control, Hearing Loss Treatment, Retrieved 4/25/2919. 145 National Toxicology Program, NTP Monograph, 59, Table 5.4. 146 Wang, I-J et al, Lead Exposure, IgE, and the Risk of Asthma in Children, (Journal of Exposure Science and Environmental Epidemiology, 2017), 478-483. 147 National Toxicology Program, NTP Monograph, 59, Table 5.4. 148 Health Impact Project (HIP), 10 Policies to Prevent and Respond to Childhood Lead Exposure (2017), 71. 149 Chad Z. Allergies in children. Paediatr Child Health. 2001;6(8):555–566. doi:10.1093/pch/6.8.555 150 Chad Z. Allergies in children. Paediatr Child Health. 2001;6(8):555–566. doi:10.1093/pch/6.8.555 151 Agency for Toxic Substances and Disease Registry, Registry Case Studies in Environmental Medicine (CSEM) Lead Toxicity, Course WB2832, (2017), 74. 152 Health Impact Project (HIP), 10 Policies to Prevent and Respond to Childhood Lead Exposure (2017), 71. 153 Geier, David A. et al, Blood Lead Levels and Learning Disabilities: A Cross-Sectional Study of the 2003–2004 National Health and Nutrition Examination Survey (NHANES), (International Journal of Environmental Research and Public Health, 2017), 1202. 154 Reuben, Aaron, et al, Association of Childhood Lead Exposure With Adult Personality Traits and Lifelong Mental Health, (JAMA Psychiatry, 2019), 418. 155 Opler, Mark G.et al, Prenatal Exposure to Lead, δ-Aminolevulinic Acid, and Schizophrenia: Further Evidence, (Environmental Health Perspectives, 2008), 1586. 156 Zenner, Charlotte et al, Mindfulness-Based Interventions in Schools—a Systematic Review and Meta-Analysis, (Frontiers in Psychology 2014), 1-20. 157 National Institute of Child Health and Human Development, What are the treatments for learning disabilities? 158 Parsons, P. J and K. G. McIntosh, Human Exposure To Lead And New Evidence Of Adverse Health Effects: Implications For Analytical Measurements, (Advances in X-ray Analysis, 2010), 291. 159 Health Impact Project (HIP), 10 Policies to Prevent and Respond to Childhood Lead Exposure (2017), 71.

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

<20 Behavioral • Increased anxiety160 • See cognitive at level <15 • Increased social problems161 <30 Neurological • Increased peripheral nerve • Various therapies, including dysfunction 162(slower reactions) transcutaneous electrical nerve stimulation or physical therapy163 <40 Heme- • Decreased hemoglobin synthesis164 • Nurse case management165 synthesis <65 Endocrinologi • Decreased Vitamin D levels, • Chelation therapy beginning at 45 cal leading to possible impairment of mcg/dL167 cell growth, maturation and tooth and bone development166 70+ Neurological • May produce encephalopathy, and accompanying signs of Ataxia, Coma, Convulsions, death, Hyperirritability, and Stupor168

160 Roy, Ananya et al, Lead Exposure and Behavior among Young Children in Chennai, India, (Environmental Health Perspectives, 2009): 1607-611. 161 Roy, Ananya et al, Lead Exposure and Behavior,1607-611. 162 Parsons, and McIntosh, Human Exposure To Lead, 291. 163 Mayo Clinic, Peripheral Neuropathy: Diagnosis and Treatment, (MayoClinic.org, 2017), Retrieved 4/25/2019. 164 Agency for Toxic Substances, Registry Case Studies, 83. 165 Health Impact Project (HIP), 10 Policies to Prevent and Respond to Childhood Lead Exposure (2017), 71 166 Woo, Winston WK at al, Serum Vitamin D Metabolites and Bone Mineralization in Young Children With Chronic Low to Moderate Lead Exposure, (Pediatrics 1991), 680-868. 167 Mayo Clinic, Lead Poisoning: Diagnosis and Treatment, (MayoClinic.org, 2019). Retrieved 4/25/2019. 168 Agency for Toxic Substances, Registry Case Studies, 77.

Literature Review: Overview of Childhood Lead Poisoning and Its Health Effects

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