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Appendixes

Managing Elevated Blood Lead Levels Among Young Children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention



Appendix I. Published Reports of Less Common Causes of Elevated Blood Lead Levels (EBLLs) in Children.

Exposure SourceDescription/Exposure PathwayStudy
Type*
Study Description
Ref. #
Occupational Take 
Home Exposures

Battery reclamation

Lead carried home by battery workers. (Only a minority of battery workers showered or changed clothes before going home.)
E
Twelve (75%) of 16 children of lead-exposed workers had EBLLs and a higher average BLL than neighborhood controls (22.4 vs. 9.8 µg/dL, p=.049).
28

Ceramics

Ceramic-coated capacitors made with fritted glass containing lead.
E
Case-control study of 51 children under 6 years (20 exposed, 31 controls) showed higher average BLLs in exposed children (13.4 vs. 7.1 µg/dL, p<.001).
31

Furniture
refinishing

Lead carried home by workers who restored furniture that had undergone chemical stripping and was thought to be lead-free.
CR
Report of six workers and three of their children aged 4-18 months
19

Construction

Lead dust on skin and clothes taken home.
E
Case-control study of 50 children under 6 years (31 exposed, 19 controls) showed 25.8% of workers’ children had EBLLs compared to 5.3% of control children (OR=6.1).
53

Radiator repair

Lead carried home by workers who did soldering to repair radiator.
E
The mean BLL for 18 children (under 7 years) of lead-exposed workers was 10 µg/dL.
42,34
Imported Cosmetics

Kohl (Middle East, India, Pakistan, some parts of Africa)

A gray or black eye cosmetic applied to the conjunctival margins of the eyes. Can contain up to 83% lead. It is believed to strengthen and protect the eyes against disease. Also known as Al Kohl.
E
A study of 538 girls aged 6 to 12 years demonstrated that the application of kohl was associated with higher BLLs (p=0.0461).
3, 37

Pakistani eye cosmetics

Eye cosmetics are often applied to the eyes of children.
E
Retrospective chart review of 175 children aged 8 months to 6 years showed an average BLL of 4.3 µg/dL for Pakistani/Indian children not using eye cosmetics and 12.9 µg/dL for those using eye cosmetics (p=0.03).
50, 52

Surma (India)

A black fine powder applied to the eyes for medicinal and cosmetic reasons.
E
A case-control study of 62 children demonstrated higher BLLs in children using surma (p<.001).
2, 15
Contaminated Foods

Apple cider

Cider was made in a maple syrup evaporator that had lead solder joining the interior seams.
CR
Report of a 7-year-old child.
8

Flour (Middle East)

Lead fillings used in stone mills contaminated flour.
E
Investigation of 43 symptomatic patients aged zero to 80 years and their families and of 563 children aged 10 to 18 years demonstrated that 33 (23%) of 146 community stone mills had lead contamination and that 171 (30.4%) of 563 children had BLLs exceeding 30 µg/dL.
25

Lozeena

An orange powder used to color rice and meat that contains 7.8%-8.9% lead.
CR
Report of brothers aged 2 and 3 years and their parents. In addition, 9 of 18 extended family members had EBLLs.
15

Infant formula

Infant formula was made with contaminated tap water from copper pipes with lead solder.
CR
Report (with environmental sampling data) of a 13-month-old child.
46, 47

Tamarind candy (Mexico)

Tamarind candy jam products from Mexico. During the manufacturing process, the candied jam is packaged in stoneware or terra cotta ceramic jars that can leach lead.
CR
Report of two children under 6 years old, six older children, and one adult.
14
Beverage Containers

Bulk-water storage tank

Lead leached from soldered seams and brass fittings in bulk-water storage tanks.
CR
Report of three children aged 6, 12, and 14 months.
11

Ceramic glaze

Lead in ceramic glaze can leach into stored beverages, especially juices since they are acidic. The risk is highest for improperly fired containers.
CR
Multiple reports.
7, 12, 49

Cocktail glass

Lead leached from cocktail glass.
CR
Report of a family with one adult and children aged 4, 5, and 14 years.
22

Iranian urn (samovar)

Lead spot solder from the original manufacturing process leached into water used to make baby formula.
CR
Reports of a 10-week-old child with seizures and of a 4-month-old child.
33, 48

Lead-soldered kettle

Lead leached into infant formulas.
CR
Reports of a 3-month-old child and of a 1-day-old child.
40
Folk Remedies

Azarcon

Also known as alarcon, coral, luiga, maria luisa, or rueda. Bright orange powder used to treat empacho (an illness believed to be caused by something stuck in the gastrointestinal tract, resulting in diarrhea and vomiting). Azarcon is 95% lead.
E
Report of 15-month-old and 3-year-old siblings who expired with seizures and a subsequent survey of 545 systematically selected households for azarcon and greta usage.
16, 15, 18, 4, 51

Ayurvedic medicine (Tibet)

Unnamed traditional medicine.
CR
Single case.
15

Ba-Baw-San (China)

Herbal medicine used to treat colic pain or to pacify young children.
E
Study of 319 children aged 1 to 7 years demonstrated that consumption was associated with increased BLLs (p=.038).
21

Bint Al Zahab (Iran)

Rock ground into a powder and mixed with honey and butter given to newborn babies for colic and early passage of meconium after birth.
CR
Report of six children aged 2 days to 3 months.
44

Bint Dahab (Saudi Arabia; means "daughter of gold")

A yellow lead oxide used by local jewelers and as a home remedy.
CR
Report of 10 children aged 7 days to 13 months, including three who took bint dahab.
35

Bokhoor (Kuwait)

A traditional practice of burning wood and lead sulphide to produce pleasant fumes to calm infants.
CR
Report of four children aged 16 days to 4.5 months.
27

Ghasard

Brown powder used as a tonic to aid in digestion.
CR
Report of a 9-month-old child who died.
17

Greta (Mexico)

Yellow powder used to treat empacho (see azarcon); can be obtained through pottery suppliers, as it is also used as a glaze for low-fired ceramics. Greta is 97% lead.
E
See azarcon.
4, 16, 18, 51

Jin Bu Huan (China)

An herbal medicine used to relieve pain.
CR
Report of three children aged 13 and 23 months and 2.5 years.
10

Pay-loo-ah (Vietnam)

A red powder given to children to cure fever or rash.
CR
Report of a 6-month-old child.
13, 15

Po Ying Tan (China)

An herbal medicine used to treat minor ailments in children.
CR
Report of a 4-month-old child.
20

Santrinj (Saudi Arabia)

An amorphous red powder containing 98% lead oxide used principally as a primer for paint for metallic surfaces, but also as a home remedy for "gum boils" and "teething."
CR
Report of 10 children aged 7 days to 13 months, including 7 who took santrinj.
35

Surma (India)

Black powder used as a cosmetic and as teething powder.
E
A case-control study of 62 children demonstrated higher BLLs in children using surma (p<.001).
2, 15

Tibetan herbal vitamin

Used to strengthen the brain.
CR
Report of a 5-year-old child.
38

Traditional Saudi medicine

Orange powder prescribed by a traditional medicine practitioner for teething; also has an antidiarrheal effect.
CR
Report of three children aged 11, 22, and 44 months.
1
Miscellaneous

Automobile key-chain emblem

Ingestion of lead-containing automobile key-chain emblem.
CR
Report of a 23-month-old child.
5

Clothing accessory

Ingestion of a "simulated watch."
CR
Report of 3-year-old child who required endoscopy.
26

Curtain weights

Ingestion of lead-containing curtain weights.
CR
Report of deaths of a 23-month-old child and a 2-year-old child.
30, 6

Fishing sinkers

Ingestion of a lead-containing fishing sinker.
CR
Report of an 8-year-old.
39

Gasoline sniffing

Lead in gasoline absorbed through gasoline sniffing.
CR
Report of six of seven siblings aged 10 to 17 years.
9, 24

Lead bullet

Lead absorbed from a retained bullet.
CR
Report of one adult and review of 18 other cases including seven children under 2 years old.
23, 32

Lead pellets

Ingestion of lead pellets from pellet gun.
CR
Report of a 6-year-old child.
45

Lead shot and toy (boat keel)

Lead shot used in a toy boat keel that was eaten by a child.
CR
Report of a 4-year-old child.
28

Newsprint fireplace log

Lead inhaled during burning of a log made from old newsprint.
CR
Report of a 6-month-old child.
43

Pool cue chalk

Lead contained in pool cue chalk.
CR
Report of two children aged 28 and 27 months.
36

Vinyl miniblinds

Lead dust from vinyl miniblinds.
E
A study of 92 children aged 6 to 72 months attributed 9% of lead poisoning cases to vinyl miniblind exposure.
41
*CR = case report, E = epidemiological study

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References

  1. Abu Melha A, Ahmed NA, el Hassan AY. Traditional remedies and lead intoxication. Trop Geogr Med 1987;39:100-3.
  2. Ali AR, Smales OR, Aslam M. Surma and lead poisoning. BMJ 1978;2:915-6.
  3. Al-Saleh I, Nester M, DeVol E, et al. Determinants of blood lead levels in Saudi Arabian schoolgirls. Int J Occup Environ Health 1999;5:107-14.
  4. Baer RD, De Alba JG, Cueto LM, et al. Lead-based remedies for empacho: patterns and consequences. Soc Sci Med 1989;29:1373-9.
  5. Biehusen FC, Pulaski EJ. Lead poisoning after ingestion of a foreign body retained in the stomach. N Engl J Med 1956;254:1179-81.
  6. Blank E, Howieson J. Lead poisoning from a curtain weight. JAMA. 1983;249:2176-7.
  7. Browder AA. Lead poisoning from glazes. Ann Intern Med 1972;76:665.
  8. Carney JK, Garbarino KM. Childhood lead poisoning from apple cider. Pediatrics 1997;100:1048-9.
  9. CDC. Epidemiologic notes and reports: Gasoline sniffing and lead toxicity among siblings—Virginia. MMWR 1985;34:449-50,455.
  10. CDC. Epidemiologic notes and reports - Jin Bu Huan toxicity in children—Colorado, 1993. MMWR 1993;42:633-6.
  11. CDC. Epidemiologic notes and reports: Lead-contaminated drinking water in bulk-water storage tanks—Arizona and California, 1993. MMWR 1994; 43:751, 757-8.
  12. CDC. Epidemiologic notes and reports: Lead poisoning following ingestion of homemade beverage stored in a ceramic jug. MMWR 1989;38:379-80.
  13. CDC. Folk Remedy-associated lead poisoning in Hmong children—Minnesota. MMWR 1983;32:555-6.
  14. CDC. Lead poisoning associated with imported candy and powdered food coloring—California and Michigan. MMWR 1998;47:1041-3.
  15. CDC. Lead poisoning associated with use of traditional ethnic remedies—California, 1991-1992. MMWR 1993;42:521-4.
  16. CDC. Lead poisoning from Mexican folk remedies—California. MMWR 1983;32:554-5.
  17. CDC. Lead poisoning-associated death from Asian Indian folk remedies—Florida. MMWR 1984;33;638,643-5.
  18. CDC. Use of lead tetroxide as a folk remedy for gastrointestinal illness. MMWR 1981;30:546-7.
  19. CDC. Occupational and take-home lead poisoning associated with restoring chemically stripped furniture—California, 1998. MMWR 2001;50:246-8.
  20. Chan H, Billmeier GJ Jr, Evans WE, et al. Lead poisoning from ingestion of Chinese herbal medicine. Clin Toxicol 1977;10:273-81.
  21. Cheng TJ, Wong RH, Lin YP, et al. Chinese herbal medicine, sibship, and blood lead in children. Occup Environ Med 1998;55:573-6.
  22. Dickinson L, Reichert EL, Ho RC, et al. Lead poisoning in a family due to cocktail glasses. Am J Med 1972;52:391-4.
  23. Dillman RO, Crumb CK, Lidsky MJ. Lead poisoning from a gunshot wound. Report of a case and review of the literature. Am J Med 1979;66:509-14.
  24. Eastwell HD. Elevated lead levels in petrol "sniffers." Med J Aust 1985;143(9 suppl):S63-S64.
  25. Eisenberg A, Avni A, Grauer F, et al. Identification of community flour mills as the source of lead poisoning in West Bank Arabs. Arch Intern Med 1985;145:1848-51.
  26. Esernio-Jenssen D, Donatelli-Guagenti A, Mofenson HC. Severe lead poisoning from an imported clothing accessory: "watch" out for lead. J Toxicol Clin Toxicol 1996;34:329-33.
  27. Fernando NP, Healy MA, Aslam M, et al. Lead poisoning and traditional practices: the consequences for world health. A study in Kuwait. Public Health 1981;95:250-60.
  28. Gittleman JL, Engelgau MM, Shaw J, et al. Lead poisoning among battery reclamation workers in Alabama. J Occup Med 1994;36:526-32.
  29. Greensher J, Mofenson HC, Balakrishnan C, et al. Leading poisoning from ingestion of lead shot. Pediatrics 1974;54:641-3.
  30. Hugelmeyer CD, Moorhead JC, Horenblas L, et al. Fatal lead encephalopathy following foreign body ingestion: case report. J Emerg Med 1988;6:397-400.
  31. Kaye WE, Novotny TE, Tucker M. New ceramics-related industry implicated in elevated blood lead levels in children. Arch Environ Health 1987;42:161-4.
  32. Kikano GE, Stange KC. Lead poisoning in a child after a gunshot injury. J Fam Pract 1992;34:498-500, 502, 504.
  33. Lockitch G, Berry B, Roland E, et al. Seizures in a 10-week-old infant: lead poisoning from an unexpected source. CMAJ 1991;145:1465-8.
  34. Lussenhop DH, Parker DL, Barklind A, et al. Lead exposure and radiator repair work. Am J Public Health 1989;79:1558-60.
  35. McNiel JR, Reinhard MC. Lead poisoning from home remedies. Clin Pediatr (Phila) 1967;6:150-6.
  36. Miller MB, Curry SC, Kunkel DB, et al. Pool cue chalk: a source of environmental lead. Pediatrics 1996;97:916-7.
  37. Mojdehi GM, Gurtner J. Childhood lead poisoning through kohl. Am J Public Health 1996;86:587-8.
  38. Moore C, Adler R. Herbal vitamins: lead toxicity and developmental delay. Pediatrics 2000;106:600-2.
  39. Mowad E, Haddad I, Gemmel DJ. Management of lead poisoning from ingested fishing sinkers. Arch Pediatr Adolesc Med 1998;152:485-8.
  40. Ng R, Martin DJ. Lead poisoning from lead-soldered electric kettles. Can Med Assoc J 1977;116:508-9.
  41. Norman EH, Hertz-Picciotto I, Salmen DA, et al. Childhood lead poisoning and vinyl miniblind exposure. Arch Pediatr Adolesc Med 1997;151:1033-7.
  42. Nunez CM, Klitzman S, Goodman A. Lead exposure among automobile radiator repair workers and their children in New York City. Am J Ind Med 1993;23:763-77.
  43. Perkins KC, Oski FA. Elevated blood lead in a 6-month-old breast-fed infant: the role of newsprint logs. Pediatrics 1976;57:426-7.
  44. Rahman H, Al Khayat A, Menon N. Lead poisoning in infancy—unusual causes in the U.A.E. Ann Trop Paediatr 1986;6:213-7.
  45. Roberts JR, Landers KM, Fargason CA Jr. An unusual source of lead poisoning. Clin Pediatr (Phila) 1998;37:377-9.
  46. Shannon M, Graef J. Hazard of lead in infant formula (letter). N Engl J Med 1992;326:137.
  47. Shannon M, Graef JW. Lead intoxication from lead-contaminated water used to reconstitute infant formula. Clin Pediatr (Phila) 1989;28:380-2.
  48. Shannon M. Lead poisoning from an unexpected source in a 4-month-old infant. Environ Health Perspect 1998;106:313-6.
  49. Sitarz AL. Letter: Severe lead poisoning in a 6-month-old infant. J Pediatr 1975;86:810-1.
  50. Sprinkle RV. Leaded eye cosmetics: a cultural cause of elevated lead levels in children. J Fam Pract 1995;40:358-62.
  51. Trotter RT 2d. Greta and Azarcon: a survey of episodic lead poisoning from a folk remedy. Hum Organ 1985;44:64-72.
  52. Warley MA, Blackledge P, O’Gorman P. Lead poisoning from eye cosmetic. BMJ 1968;1:117.
  53. Whelan EA, Piacitelli GM, Gerwel B, et al. Elevated blood lead levels in children of construction workers. Am J Public Health 1997;87:1352-5.

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Appendix II. Sources of Information on Lead Abatement

  • The Office of Lead Hazard Control of the U.S. Department of Housing and Urban Development(HUD) publishes a manual that explains how renovations and remodeling projects can be safely conducted. Single copies of this publication (LeadPaint Safety—A Field Guide for Painting, Home Maintenance and Renovation Work) can be ordered from the National Lead Information Center at 1-800-424-5323 or downloaded from the HUD Office of Lead Hazard Control Web site at www.hud.gov/offices/lead.

  • The Center for National Lead-Safe Housing (now the National Center for Healthy Housing) provides information about safe repair. The Web sites is http://www.healthyhomestraining.org/LSWP/index.htm

  • The Alliance to End Childhood Lead Poisoning (now the Alliance for Healthy Homes) provides information about safe repair. The Web site is http://www.afhh.org/dah/dah_lead_safe_painting.htm

  • HUD offers a web-based, one-hour training course on how to visually assess the condition of paint films. The Web site is www.hud.gov/offices/lead.

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