Guidelines for the Identification and Management of Lead Exposure

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TABLE OF CONTENTS Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .i Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iiiSummary of Public Health Actions Based on Maternal and Infant Blood Lead Levels . . . . . . . . . . . .viMembers of the Work Group on Lead and Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viiAcknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .viiiMembers of the Advisory Committee on Childhood Lead Poisoning Prevention. . . . . . . . . . . . . . ixGlossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiiiChapterChapterChapterChapterChapterChapterChapterChapterChapter1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12. Adverse Health Effects of Lead Exposure in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . .53. Biokinetics and Biomarkers of Lead in Pregnancy and Lactation . . . . . . . . . . . . . . . . . . . 274. Distribution of BLLs, Risk Factors For and Sources of Lead Exposure in Pregnant and Lactating Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355. Blood Lead Testing in Pregnancy and Early Infancy . . . . . . . . . . . . . . . . . . . . . . . . . . . 516. Management of Pregnant and Lactating Women Exposed to Lead . . . . . . . . . . . . . . . . . 637. Nutrition and Lead in Pregnancy and Lactation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 778. Chelation of Pregnant Women, Fetuses, and Newborn Infants . . . . . . . . . . . . . . . . . . . . 899. Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97Chapter 10. Research, Policy, and Health Education Recommendations . . . . . . . . . . . . . . . . . . . . . 107Chapter 11. Resources and Referral Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113List of References by Chapter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116IIIIIIIVVVIVIIVIIIIXXXIXIIXIIIAPPENDICESExisting State Legislation Related to Lead and Pregnant Women . . . . . . . . . . . . . . . . . . . . . . . 151Charge Questions to the Lead and Pregnancy Work Group . . . . . . . . . . . . . . . . . . . . . . . . . . 155Commonly Ingested Substances in Pregnancy-related Pica, Reasons for Use, and Country/Race-Ethnicity of Origin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159List of Occupations and Hobbies that Involve Lead Exposure . . . . . . . . . . . . . . . . . . . . . . . . . 163Alternative Cosmetics, Food Additives, and Medicines That Contain Lead . . . . . . . . . . . . . . . . . 167Recommendations for Medical Management of Adult Lead Exposure . . . . . . . . . . . . . . . . . . . 171Medical Management Guidelines for Lead-Exposed Adults . . . . . . . . . . . . . . . . . . . . . . . . . . 183Pregnancy Risk Assessment Form, NYC DOH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201Assessment Interview Form, Minnesota DOH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219Lead-Based Paint Risk Assessment Form, Minnesota DOH . . . . . . . . . . . . . . . . . . . . . . . . . . . 223Primary Prevention Information Form, NYC DOH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233Child Risk Assessment Form, NYC DOH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239Nutritional Reference Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
XIV Template for Letter to Construction Employer re: Occupational Exposure . . . . . . . . . . . . . . . . . 263XVWorkplace Hazard Alert for Lead, Occupational Lead Poisoning Prevention Program CA DOH. . . . . . . . . . . . . . . . . . . . . . . . . . 267LIST OF FIGURESChapter 1Figure 1-1. Distribution of Blood Lead Levels in U.S. Women of Childbearing Age. . . . . . . . . . . . . . . . . . 3Chapter 3Figure 3-1. Major Lead Exposure Pathways from Mother to Infant. . . . . . . . . . . . . . . . . . . . . . . . . . . 33Chapter 5Figure 5-1. New York City Department of Health and Mental Hygiene: Recommended Lead Risk Assessment Questions for Pregnant Women . . . . . . . . . . . . . . . . . . . . . . . . . . 61Figure 5-2. Minnesota Department of Health: Recommended Lead Risk Assessment Questions for Pregnant Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62LIST OF TABLESChapter 2Table 2-1. Summary of Studies Estimating Association of Prenatal Lead Exposure with Neurodevelopmental Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Chapter 4Table 4-1. Risk Factors for Lead Exposure in Pregnant and Lactating Women. . . . . . . . . . . . . . . . . . . . 48Table 4-2. Key Recommendations to Prevent or Reduce Lead Exposure in Pregnant and Lactating Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49Chapter 5Table 5-1. Follow-up of Initial Blood Lead Testing of the Neonate (
Page 1 and 2: GUIDELINES FOR THE IDENTIFICATION A
Page 3: This document is dedicated to the m
Page 8 and 9: EXECUTIVE SUMMARYDespite improvemen
Page 10 and 11: pregnant women with BLL
Page 12 and 13: MEMBERS OF THE WORK GROUP ON LEAD A
Page 14 and 15: MEMBERS OF THE ADVISORY COMMITTEE O
Page 16 and 17: Sally OdlePresident and Owner, Safe
Page 18 and 19: GLOSSARYabatement: any set of measu
Page 20 and 21: cumulative: increasing by successiv
Page 22 and 23: lead-safe work practices: low-techn
Page 24: enovation: construction and/or home
Page 27 and 28: Finally, there is evidence that a s
Page 30 and 31: CHAPTER 2.ADVERSE HEALTH EFFECTS OF
Page 32 and 33: lead exposure (Tabacova et al. 1994
Page 34 and 35: The strongest evidence to date is a
Page 36 and 37: Epidemiologic Evidence for Neurodev
Page 38 and 39: Table 2-1. Summary of Studies Estim
Page 40 and 41: EstimateStudy Study of Prenatal Lea
Page 52 and 53: CHAPTER 3.BIOKINETICS AND B
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this biomarker may be a useful rese
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Recent studies have documented that
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Figure 3-1. Major Lead Exposure Pat
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Additionally, recent evidence has s
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in the study population was 12%
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Mobilization of Endogenous Bone Lea
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Most of the published literature re
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On occasion, imported foods and foo
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Case Study 4-3. A Case of Lead Pois
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Table 4-1. Risk Factors for Lea
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CHAPTER 5.BLOOD LEAD TESTING
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Blood Lead Testing in the General P
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absorption spectrophotometry (GFAAS
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ally, the measured BLL of pregnant
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Table 5-2. Schedule for Follow-up B
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Figure 5-1. New York City Departmen
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CHAPTER 6.MANAGEMENT OF PRE
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y providing information to health d
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upon eliciting accurate information
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tivity that disturbs paint can incr
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Case management of pregnant women w
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Interpretation and follow-up of blo
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Table 6-2. Suggested Factors to Ass
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Decades of laboratory and clinical
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tion of skeletal mineral. Observati
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of follow up, suggesting decreased
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Supplemental Nutrition Program for
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Inadequate vitamin D status is comm
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CHAPTER 8.CHELATION OF PREGNANT
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CLINICAL EVIDENCE IN PREGNANCY AND
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Table 8-1. Chelating Agents Used
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Table 8-3. Published Experience wit
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CHAPTER 9.BREASTFEEDINGKey Consid
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maternal blood exceeds 40 µg/dL (L
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guidance for breastfeeding by women
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Table 9-1. Frequency of Maternal Bl
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Table 9-3. Estimated a Increase in
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CHAPTER 10.RESEARCH, POLICY, AND HE
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Identification and development of n
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Mandatory Reporting of All Adult Bl
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CHAPTER 11. RESOURCES AND REFERRAL
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Offce of Pollution Prevention and T
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Marino PE, Landrigan PJ, Graef J, N
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Dietrich KN, Ris MD, Succop PA, Ber
Page 146 and 147:
McMichael AJ, Vimpani GV, Robertson
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Vigeh M, Yokoyama K, Mazaheri M, Be
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Gulson BL, Jameson CW, Mahaffey KR,
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Satin KP, Neutra RR, Guirguis G, Fl
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Centers for Disease Control and Pre
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Lee MG, Chun OK, Song WO. 2005. Det
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Simpson E, Mull JD, Longley E, East
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Rothenberg SJ, Khan F, Manalo M, Ji
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Piazza C, Fisher W, Hanley G, LeBla
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Godwin HA. 2001. The biological che
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Looker AC, Loyevsky M, Gordeuk VR.
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Willoughby RA, Thirapatsakun T, McS
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Bachrach VR, Schwarz E, Bachrach LR
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U.S. Food and Drug Administration.
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Appendices 149
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Appendix IExisting State Legislatio
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Guidelines for the Identification &
Page 180 and 181:
Appendix IICharge Questions to the
Page 182 and 183:
Page 184 and 185:
Appendix IIICommonly Ingested Subst
Page 186 and 187:
Page 188 and 189:
Appendix IVList of Occupations and
Page 190 and 191:
Page 192 and 193:
Appendix VAlternative Cosmetics, Fo
Page 194 and 195:
Page 196 and 197:
Appendix VIRecommendations for Medi
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Research | Mini-Monograph Recommend
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Recommendations for medical manag
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Recommendations for medical manag
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Recommendations for medical managem
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Recommendations for medical managem
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Appendix VIIMedical Management Guid
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Medical Management Guidelines for L
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Because lead interferes with bioche
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The clinician, with the patient’s
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i.e., at least monthly. In general,
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If elevated maternal blood lead is
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TABLE 2Non-occupational and Environ
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TABLE 4TABLE 4Health Based Health M
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Gulson BL, Mizon KJ, Korsch MJ, Pal
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Appendix VIIIPregnancy Risk Assessm
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EDC:_________________ID:___________
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ID:___________________________B. HO
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ID:___________________________10. I
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ID:___________________________14a.
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ID:___________________________G. NO
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ID:___________________________I. PA
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SUMMARYInstructions: Check all thos
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ID:___________________________APPEN
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Appendix IXAssessment Interview For
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RISK ASSESSMENT INTERVIEW FORMDate:
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Appendix XLead Based Paint Risk Ass
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Lead-Based Paint Risk Assessment Re
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(Use one of the following sentences
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Appendix ATesting Locations229
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Appendix CDust Wipe and Soil Sample
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Appendix XIPrimary Prevention Infor
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LI #:NEW YORK CITY DEPARTMENT OF HE
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LI #:8a. If yes >> Please tell me h
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Appendix XIIChild Risk Assessment F
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CHILD ID: Page 1 of 12PNEW YORK CIT
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CHILD ID: Page 3 of 126. Does [chil
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CHILD ID: Page 5 of 1217a. If yes >
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CHILD ID: Page 7 of 1224. [Imported
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CHILD ID: Page 9 of 12Home renovati
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CHILD ID: Page 11 of 12Provide the
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Appendix XIIINutritional Reference
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Nutrition Reference InformationRECO
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Blood hemoglobin levels are routine
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Beef, chuck, blade roast, lean, coo
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Sunflower oil, 1 TbspCottonseed oil
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Appendix XIVTemplate for Letter to
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Template for Letter to Construction
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Appendix XVWorkplace Hazard Alert f
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WORKPLACE HAZARD ALERTNew Health Da
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What should I tell my doctor?Your d
Page 298 and 299:
Make sure you don’t accidentally
Page 300 and 301:
Worksite Evaluation FormWhat your e
Page 302:
CS2016857
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Guidelines for the Identification and Management of Lead Exposure

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