Elevated Blood Lead in Pregnant Women and Infants. Megan M. Sparks, MPH Grand Rounds April 25, 2018

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1 Elevated Blood Lead in Pregnant Women and Infants RECOMMENDATIONS AND BEST PRACTICES FOR PROVIDERS Megan M. Sparks, MPH Grand Rounds April 25, 2018

2 Lead in the Environment There is no safe level of lead in the body. No known beneficial biological role Used as pigment in paint Discontinued in the 1970s Heavily-leaded paint can be found in: Two-thirds of homes built before 1940 One-half of homes built between 1940 and 1960 Home exposure accounts for many cases of childhood lead poisoning Painters and contractors may also be exposed during renovation

3 Lead in the Environment Lead can remain in the environment in the form of dust indefinitely Soils near highways and smelting activities have higher lead content Used as an anti-knock agent in gasoline during the 1920s through the 1970s Blood lead levels in the U.S. averaged around 15 µg/dl (micrograms per deciliter) during that time, but have since dropped to an average of 2 µg/dl Approx. 1% of women of childbearing age have BLLs 5 µg/dl No longer used as an additive in most gasoline, it is still used in other types of fuel, such as aviation fuel It is believed that two generations of children born between the 1930s and 1980s suffered at least subclinical impairment*

4 Lead in the Body Lead is a cumulative toxin Build up in the body over an extended period of time (years) until it reaches toxic levels Lead can be distributed to the brain, liver, kidneys, and bones Stored in the teeth and bones Lead stored in the bones can be mobilized during pregnancy Source of exposure to developing fetuses and nursing infants There is no known level of lead exposure that is considered safe Lead poisoning is entirely preventable Source:

5 What is blood lead poisoning? Blood Lead Poisoning is caused by the ingestion or inhalation of lead. This can be in the forms of lead paint, dust, soil, and some foods. The CDC recommends public health actions be taken for levels of 5 µg/dl (micrograms per deciliter) or greater. Infants and children younger than six years old have a greater risk of permanent effects. Developmental delays Learning difficulties Behavioral problems Lower IQ Source:

6 Risk Factors for Lead Exposure CHILDREN Living in a home built prior to 1978 Sibling with elevated blood lead Parent or other adult with a leadrelated occupation or hobby Living near an active leadproducing industry Adoptees, refugees, or foster children Poor hand hygiene Chewing behavior PREGNANT WOMEN Most commonly, adults are exposed to lead through an occupation or a hobby Living near a point-source for lead Recent emigration Home renovating/remodeling History of previous lead exposure or lead poisoning in childhood PICA

7 Occupational Lead Exposure

8 What are the signs and symptoms of elevated blood lead?

9 Signs and Symptoms: Children vs. Adults Most children and adults experience no symptoms. CHILDREN Lethargy Hyperactivity Reduced attention span Poor appetite Weight loss Abdominal pain Constipation Irritability Fatigue Hearing loss PREGNANT WOMEN Lethargy Irritability Trouble sleeping Headache Difficulty concentrating Abdominal pain or nausea Loss of appetite Constipation Weight loss Joint pain INFANTS Lethargy Poor appetite Constipation Hearing loss Failure to thrive Difficulty sleeping

10 What are the adverse health effects associated with elevated blood lead?

11 Adverse Health Effects: Children vs. Adults Lead poisoning affects every organ and system in the body. High levels of lead exposure can cause seizures, coma and death. CHILDREN Brain damage Developmental delays Behavioral problems Learning difficulties Hyperactivity Impaired speech and Slowed growth Kidney and liver damage Hearing damage PREGNANT WOMEN Gestational hypertension Spontaneous abortion Digestive problems Kidney problems Anemia Reproductive system problems Hearing, vision and muscle coordination problems INFANTS Brain and nervous system damage Low birth weight Developmental delays Slowed growth Kidney and liver damage Hearing damage Anemia

12 Long-Term Health Effects: Multiple Targets Reproductive Elevated blood lead in pregnant women can lead to premature birth, low birth weight, and miscarriage Lead can pass through the placenta and into breast milk In utero exposure has been associated with developmental delays Kidneys Damage to the kidneys can occur at both high and low levels of exposure Nephropathy Impaired proximal tubular function Cardiovascular Research suggests a correlation between lead exposure and high blood pressure, coronary heart disease, heart rate variability

13 Long-Term Health Effects: Nervous System Lead effects both the peripheral and central nervous system CNS effects are more prominent in infants and children while PNS effects are more prominent in adults Lead has a degenerative effect on the axons of nerve cells Loss of myelin sheaths

14 What does Sedgwick County do?

15 Provider Lead Testing Practices Survey, 2017 Working with the Medical Society of Sedgwick County, a survey was distributed to providers with goals to determine: Number of children being screened in Sedgwick County Testing practices for providers in Sedgwick County Only 24% of respondents indicated that they use a risk assessment to determine potential exposure to lead Almost half of respondents indicated that they do not have any documented clinic procedures to test for lead exposure Many indicated that they only treat adults Some respondents stated that they were unaware of the seriousness At least two respondents believe that testing for pregnant women is not indicated in the literature More than 82% of respondents do not provide any educational materials to clients

16 Elevated Blood Lead in Sedgwick County In 2017, Sedgwick County investigated 116 reports of elevated blood lead in children 0 15 years old Of those, 74 were confirmed by venous collection 69 were children under the age of six There were 14 cases with EBL results of 10 μg/dl or greater The highest value reported in 2017 was 31 μg/dl Since April 2016, Sedgwick County has investigated 5 cases of EBL in pregnant women

17 When should a pregnant woman be tested?

18 Detection of Lead Poisoning in Pregnant Women Risk Assessment Risk assessment completed at earliest contact with pregnant or lactating patient. Confirmatory Venous Test Public health receives test result via electronic laboratory report and medical provider. If venous confirmatory test is 5µg/dL, Sedgwick County Division of Health: Conducts phone interview and provides education; Performs home assessment if criteria are met and when no exposure is identified during the phone interview; Contacts medical provider to ensure appropriate follow-up and monitoring. Follow-Up Based on elevated blood lead level, Public Health will follow-up with mother and provider to: Ensure the level is declining, or: Make appropriate recommendations, as needed.

19 Recommendations and Best Practices The CDC and the ACOG do not recommend blood lead testing for all pregnant women Obstetric health care providers should consider lead as part of a comprehensive health risk assessment Venous testing is recommended for women if a single risk factor is identified Risk assessments should take place at the earliest contact with the pregnant patient Women with risk factors who were not screened during pregnancy should be screened postpartum if they plan to breastfeed Breastfeeding should be encouraged postpartum in mothers with BLL < 40 µg/dl Breastfeeding is not recommended in mothers with BLL 40 µg/dl Pump and discard until the level is < 40 µg/dl

20 Screening Process for Elevated Blood Lead in Pregnant Women 1. At earliest contact with patient, determine the risk for lead exposure by asking a few questions, including but not limited to: Recent emigration Living near point-source of lead Working with lead or living with someone who works with lead 2. Measuring blood lead levels in pregnant women or lactating women* who are at risk for lead exposure 3. Conducting necessary follow-up blood lead testing of pregnant patient 4. Conducting necessary follow-up blood lead testing of infant at birth

21 » If a parent answers Yes or Don t know to any of these questions, then the child should be tested.» If the child has never been tested, then they should be tested.

22 Testing for Lead: When to Retest? A risk assessment helps determine a woman s risk for lead exposure. Women at high risk for lead exposure receive a venous lead test. Risk Assessment at Earliest Contact If there are risk factors indicated If NO risk factors are indicated Confirmatory Venous Test No follow-up needed.* 5 14 µg/dl Retest within 1 month µg/dl Retest within 1 month AND every 2 3 months µg/dl Retest within 1 to 4 weeks AND every month 45 µg/dl Retest within 24 hours AND at frequent intervals

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24 Lead and Nutrition Nutritional deficiencies increase lead absorption Foods that limit lead absorption: Iron Beef, chicken, eggs, fish, legumes, iron-fortified cereals, green leafy vegetables Calcium (1,200 mg/day*) Milk, yogurt, cheese, spinach, calcium-fortified orange juice, pudding Vitamin D Potatoes, oranges, tomatoes, berries, broccoli, grapefruit, green peas, Brussels sprouts

25 Questions? Megan Sparks, MPH Epidemiologist Sedgwick County Division of Health (316)