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Getting the Lead Out
Abstract & Commentary
By Philip R. Fischer, MD, DTM&H
Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
Dr. Fischer reports no financial relationship to this field of study,
Synopsis: Lead toxicity can compromise health and kill children anywhere in the world. With less lead-based paint and gasoline in the United States, lead toxicity is increasingly associated with oral ingestion of lead from imported jewelry and cosmetics.
Source: Mann M, et al. Lead poisoning of a child associated with the use of a Cambodian amulet New York City, 2009. Morb Mortal Wkly Rep 2011;60:69-71.
Routine lead screening of a 1-year-old u.s.-born son of Cambodian immigrants living in New York revealed an elevated blood lead level (10 mcg/dL). No lead paint or other identifiable risk for lead toxicity was identified during a home interview and inspection. Three months later, a follow-up lead level was 20 mcg/dL. The father then admitted that the child had been wearing a necklace as an amulet "to protect him" since the age of 3 months, and that the child had been seen mouthing the amulet. The metal beads on the amulet were tested and found to consist of 45% lead. Eight days after removing the amulet from the boy's home, his lead level had dropped to 14 mcg/dL, and 5 weeks after that, the lead level was 10 mcg/dL. Five months after removing the amulet from the child's home, his lead level was 5 mcg/dL.
Interestingly, another young child in the same home had previously had a high lead level (17 mcg/dL), which also dropped to 7 mcg/dL 3 months after he stopped wearing a Cambodian amulet. A 10-year-old in the home who also wore a similar amulet (but presumably did not lick it or put it in her mouth) had a blood lead level of 4 mcg/dL.
Many children in southeast Asia wear "protective" strings around their necks, wrists, or waists. Often, the knotted strings include metal beads, and it has been suggested that the metal is often derived from lead bullets.
Lead toxicity usually results from oral ingestion of lead. When leaded paints were used in the United States, toxicity often occurred in children with pica. They either ate paint chips or played with paint chips and subsequently touched their fingers to their mouths. Lead toxicity also was associated with locations near high-volume road traffic, where soil in play areas was presumably contaminated with vehicle exhaust from cars and trucks burning leaded gasoline. As lead has been removed from commercial paints and gasoline, other sources of lead exposure deserve increased attention.1-3
In some parts of the world, parents use eye cosmetics on their children to line the eyelids with black and/or bluish pigment. Often called "kohl," these cosmetics sometimes contain high quantities of lead and they are often imported from India and the Middle East.4,5 In Nigeria, lead toxicity has been associated both with the use of eye cosmetics and playing in yards where truck batteries are recycled, presumably contaminating the soil with leaded battery waste.6 The current case reminds us that lead bead-containing amulets, even when imported from other countries, can serve as a source of lead toxicity in children.
While preparing this commentary for Travel Medicine Advisor, I visited a rural health center in Cambodia. Many patients came with amulets to prevent evil spirits from "landing on them" or otherwise influencing them. Some mothers carried scissors to medical visits to ward off evil spirits along the way. Interesting, though, I saw no amulet that was loose enough around the neck to allow oral contact or represent a choking hazard, and I did not see lead-containing amulets on wrists where children could get them into their mouths. Perhaps parents who insist on putting lead-containing amulets on their children could follow the practices of these Cambodian parents to keep the lead out of the mouths of their children.
Lead toxicity can be fatal, such as seen in a Minnesota child who swallowed a lead-laden charm.7 Whatever the cause of lead toxicity, careful environmental evaluation and individualized case management are important; the Centers for Disease Control and Prevention offers guidelines.8