Nevada RN - May 2019

Page 6 • Nevada RNformation May, June, July 2019
NNA Environmental Health Committee
What’s new about Pediatric Lead Poisoning?
Bernadette M. Longo,
PhD, RN, CNL, PHNA-BC,
FAAN
As nurses we know that
young children are most
vulnerable to the toxic effects
of lead and can suffer profound
and permanent adverse health
effects, particularly on the
development of the brain and
nervous system (WHO, 2018). Over the last 40 years in
the United States there has been a significant reduction
of lead in the environment due to the removal of
lead in gasoline and paint. Typical pediatric screening
asks about living in a home constructed before 1978
for a basis of exposure (thinking of paint sources as
contamination). However, homes and buildings built
between 1982 - 1988 are likely to have lead in pipes,
fixtures and solder resulting in the drinking water as
a source of exposure. In 2011, Congress passed the
Reduction of Lead in Drinking Water Act revising
the definition of lead free by lowering the maximum
lead content of plumbing products from 8% to
0.25% (EPA). In addition to environmental sources
of lead, starting in the 1990’s the FDA, the California
Department of Health Services, and independent
laboratories had identified that certain imported
candies contained hazardous levels of lead. Candies
with elevated lead levels appeared to primarily be
imported from Mexico, Malaysia, China and India. All
these efforts were making progress on reducing the
risk of exposure to children.
Suddenly, lead poisoning was again in the
forefront as the Flint (Michigan) water crisis resulted in
~140,000 individuals being exposed to lead and other
contaminants in their drinking water for 18 months.
Yet, each day in our country children continue to be
exposed to lead and suffer with the adverse effects.
According to Healthy People 2020, no safe blood lead
level has been identified for children. Nearly 500,000
U.S. children ages one to five have blood lead levels ≥ 5
micrograms per deciliter (µg/dL), which is currently the
reference level at which the Centers for Disease Control
recommends public health actions be taken. Even
blood lead exposure levels as low as 2 µg/dL can affect
a child’s cognitive function.
New Considerations on
Exposure to Lead
Exposure to lead occurs from two routes: (1)
inhalation of lead particles (dust, fumes), and (2)
ingestion of lead-contaminated dust/soil, water (leaded
plumbing), and food, materials or contaminated hands.
As you are already aware, young children explore
by touch and hand-to-mouth behaviors potentially
resulting in exposure to lead. Recently, attention has
been given to unexpected new sources of lead exposure
and provide an opportunity for nurses to revise their
screening criteria for which children should be tested.
Lead-contaminated Spices, Herbal Remedies, and
Ceremonial Powders
Recent studies found that spices in the homes of
lead-positive children had elevated lead concentrations
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and suggested that these contaminated products
might represent an important source of childhood
lead exposure (Angelon-Gaetz et al., 2018; Hore et
al., 2019). The potentially lead-contaminated spices
included: saffron supplement, turmeric, and paprika. A
study by Hore et al. (2019) found spices and spice mixes
commonly used in South Asian cuisine (curry & masala)
contained elevated lead levels. The researchers further
identified various other seasonings used in different
cuisines, such as bouillon cubes and powders, broth,
or soup spices, as well as hot pepper, chili powder, and
paprika. They concluded that spices purchased abroad
were more likely to have elevated lead concentrations
compared with similar spices purchased locally in the
United States (Hore et al., 2019). The countries included
Georgia, Bangladesh, Nepal, Pakistan, Morocco,
Mexico and Jamaica. In comparison, another study
by Angelon-Gaetz et al. (2018) found some leadcontaminated
products were purchased in the US.
Contamination of spices can occur at any point
along the supply chain due to intentional or inadvertent
addition of lead. Intentional adulteration includes
adding a lead-based coloring agent or adding
weight for products sold by weight. Unintentional
contamination can occur by growing the spice plant
in lead contaminated soils and enters the plant/spice
by contaminated water or dust. Lead can also be
introduced during the grinding process of the spice
from lead-based equipment.
Non-food items can also be sources of lead exposure
to children. These include ceremonial powders and
topical remedies such as kumkum, sindoor, surma,
Balguti Kesaria (an ayurvedic medicine) and turmeric
(Angelon-Gaetz et al., 2018). In 2017, the U.S. FDA
issued a warning about Balguti Kesaria when it
confirmed it contained lead in addition to arsenic, and
mercury. Although ceremonial powders are not food,
they might be accidentally ingested by children.
Marksmanship
Shooting for sport and competition requires
commitment to training, discipline and regular practice.
Competitive shooting, from high school teams to
the Olympics, requires shooting excellence in three
positions, including the prone position on the ground.
Training usually begins around 8 to 10 years old.
Exposure to lead is from both inhalation and ingestion
routes and can occur from a variety of shooting-related
activities. Many bullets are made of lead, which is
vaporized at the base of the bullet when it is released
at the muzzle of the gun. Lead is also involved in the
Neurotoxic Effects from
Lead Poisoning
• Executive functions: remaining on task
• Visual-spatial skills
• Speech & language deficits
• Fine & gross motor skills
• IQ
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EOE
primer (lead styphnate) to start the combustion of the
gun powder, which propels the bullet down the barrel.
Powder and particles are shed by friction of the bullet
moving through the barrel during firing. The inhalation
exposure primarily occurs when the lead-containing
vapors of shooting blow back into the breathing
zone of the shooter, especially in the prone position.
Secondary exposure also occurs from the environment
of the firing range, especially indoor ranges with
poor ventilation. Lead can collect on finely-sized dust
particles and be inhaled. Ingestion of lead occurs from
handling the bullets, eating or drinking at the shooting
range, contaminated soils or floors, and contaminated
clothing and shoes of the marksman. Furthermore,
if dry sweeping is used for cleaning, this action can
resuspend lead-ladened particles. Goldman et al. (2017)
have been advocates to bring awareness and offer
personal protective and hygiene measures for shooters,
as well as environmental measures to reduce exposure
of lead at firing ranges.
Brain development is a fragile process of
myelinogenesis that continues until about age 25.
Lead exposure is believed to affect the health of
myelin coating on the neurons in the brain. Hence,
adolescents with lead exposure may be facing
associated long-term risks that present in adulthood.
These include a decrease in renal function, blood
pressure and cardiovascular effects, hematological
effects, essential tremor and cognitive effects overtime
(Goldman et al., 2017).
NURSING INTERVENTIONS
Provider engagement with patients and
community education are successful methods
to increase lead screening rates!
Spices and herbal remedies are a part of
many children’s diets and might be a source
of lead exposure. Therefore, communicate
the risks for lead contamination in spices,
especially those purchased abroad.
Identify children/adolescents involved in
marksmanship activities – add them to your
screening list!
Nevada’s Low Blood Lead
Testing Rate
Alarmingly, only 3% of Nevada's 217,000 children