Childhood Lead Poisoning Associated with Tamarind Candy and Folk Remedies ---California, 1999--2000

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Lead poisoning affects children adversely worldwide. In the United States, elevated blood lead levels (BLLs) (>10 µg/dL) result primarily from exposure to lead-based paint or from associated lead-contaminated dust and soil; however, other sources of lead exposure, including folk remedies, Mexican terra cotta pottery, and certain imported candies, also have been associated with elevated BLLs in children (1). This report describes five cases in California of lead poisoning from atypical sources. Health-care providers should be aware of the potential hazards of certain food products, and community members should be educated about potential sources of lead poisoning for children.

Case Reports

Cases 1 and 2. In March 1999, two Hispanic children residing in Stanislaus County in the Central Valley, a boy aged 4 years and his sister aged 6 years, were identified during routine screening by California's Child Health and Disability Prevention (CHDP) Program. The boy had a BLL of 88.0 g/dL and the girl a BLL of 69.0 µg/dL. Both children underwent chelation therapy. Their parents had not traveled recently outside the United States but had used greta, a Mexican folk remedy (taken commonly for stomachache or intestinal illness) that usually contains high levels of lead. No pottery in the home tested positive for lead, and tests on paint and dust from their home did not indicate high lead levels. Greta powder collected from the family's home had 770,000 parts per million (ppm) of lead, and miniblinds on the windows of the home tested positive for lead by swab. Imported candies, including Dulmex-brand Bolirindo lollipops, which were identified later to be contaminated with lead, were found in the home.

Case 3. In May 2000, a Hispanic boy aged 4 years residing in Fresno County was identified during routine CHDP screening with a BLL of 26 µg/dL. His family had moved to California recently from Oaxaca, Mexico, where they had used a ceramic bean pot and water jug regularly. An environmental investigation did not reveal high lead levels in dust, paint, or soil, but tests on imported candies collected from the home revealed a candy wrapper with a lead level of 16,000 ppm. The child's BLL had decreased to 13.2 µg/dL by February 2002.

Case 4. In June 2000, a Hispanic boy aged 2 years residing in Orange County was identified through routine screening as having a BLL of 26 µg/dL. The family's house was built in 1963 and had been renovated during early 2000. Tests on soil, paint, and dust in and around the child's home did not reveal high lead levels. The child had been given greta and azarcon (a folk remedy that usually contains substantial amounts of lead) and had eaten various imported tamarind fruit candies purchased routinely by his family in Mexico. High lead levels were found in one of the three brands of imported candies the child had eaten. A Dulmex-brand Bolirindo lollipop had levels of 404 ppm and 21,000 ppm of lead in the stick and wrapper, respectively, and 0.2 ppm and 0.3 ppm in the candy and seed, respectively. Subsequent tests by the Food and Drug Administration (FDA) confirmed high lead levels in the wrapper of this product, and a public health warning was issued by FDA and the California Department of Health Services (CDHS).

Case 5. In August 2000, a Hispanic boy aged 4 years residing in Los Angeles County was identified through routine screening by California's Medicaid program with a BLL of 22 µg/dL. When the child was tested at age 1 year, he had an acceptable BLL of 5 µg/dL. Family members reported that he had been eating Mexican candies regularly for 3 years but denied use of folk remedies and imported pottery. An environmental investigation of their apartment, which was built in 1986, did not reveal high lead levels. The child was born in the United States and had not traveled to Mexico, and investigators identified no other potential sources of lead other than the Mexican candies. The family was advised not to allow the child to eat Mexican candies. As of December 2001, the boy's BLL had decreased to 11 µg/dL.

Reported by: JG Courtney, PhD, S Ash, Childhood Lead Poisoning Prevention Br, California Dept of Health Svcs. N Kilpatrick, MPH, S Buchanan, PhD, P Meyer, PhD, Div of Environmental Hazards and Health Effects, National Center for Environmental Health; D Kim, MD, L Brown, MD, EIS officers, CDC.

Editorial Note:

The findings in this report underscore the importance of routine screening for lead and of conducting a thorough risk assessment of children with elevated BLLs including taking a complete history and environmental sampling. Although household paint and resulting contaminated dust and soil are the most common sources of exposure, all sources of lead poisoning should be identified and removed.

Of approximately 1,000 cases of elevated BLLs among California children that were reported to CDHS during May 2001--January 2002, candy produced in Mexico was identified as a possible exposure source in approximately 150 cases. When children eat lead-contaminated candies, exposure can exceed FDA's provisional tolerable daily intake level (PTIL) for lead of 6 µg in a typical 30-g food serving. FDA's PTIL corresponds to a lead intake capable of elevating the BLLs of a small child by 1 µg/dL. In the cases described in this report, the wrappers often contained amounts of lead that could greatly exceed FDA's PTIL if the lead were to leach into the candy. In addition, a substantial quantity of the lead could be released into saliva by a child licking the wrapper. When conducting investigations of lead exposures, clinicians and health educators are encouraged to consider inquiring about these products, together with folk remedies and the use of imported pottery, as potential sources of lead poisoning.

Lead poisoning associated with tamarind candy has been reported previously (2--5). Although the lead content of the particular candies that the five children described in this report ate could not be measured because the candy had been eaten, substantial concentrations of lead were found in the wrappers in four cases. Because the candies are sticky and can adhere to the wrapper, the children might have ingested lead from the wrapper; in addition, other sources of lead exposure (e.g., greta consumption) were found. In the cases described in this report, the frequency of eating Mexican candies and the brands eaten were not always ascertained. An investigation is ongoing to determine which specific candy products are contaminated with lead. CDHS has identified lead in several other tamarind candies. In addition, FDA has embargoed food products containing tamarind fruit from entry into the United States because of filth from insects, rodents, and other pests.

These cases illustrate successful cooperation between FDA and state and local health departments to identify lead-contaminated products. Health-care providers should be aware of the potential hazards of food products, including candy, when evaluating a child with an elevated BLL. In addition, increasing education efforts are needed to inform persons in Hispanic communities that certain Mexican candies, pottery, and folk remedies can be potential sources of lead poisoning for children (6). Additional information about childhood lead poisoning is available from CDHS at http://www.dhs.ca.gov/ps/deodc/childlead and from CDC at http://www.cdc.gov/nceh/lead/lead.htm.

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