Traditional Eye Cosmetics and Cultural Powders as a Source of Lead Exposure.

OBJECTIVES: We aimed to describe the characteristics of traditional eye cosmetics and cultural powders, including the types, lead concentrations, origin, and regional variation in product names, and assess the differences in blood lead levels (BLLs) between product users and non-users. METHODS: We analyzed 220 samples of traditional eye cosmetics and cultural powders collected in New York City between 2013 and 2022 during lead poisoning investigations and store surveys. We compared the BLLs of children who used these products with those of non-users. RESULTS: Lead levels in traditional eye cosmetics surma and kohl were much higher than levels in kajal and other cultural powders. Although the terminologies surma, kohl, and kajal are often used interchangeably, findings suggest regional variations in the product names. The majority of the surma in this study were from Pakistan, kohl was from Morocco, and kajal was from India. The results also show that these products can contribute to elevated BLLs in children. CONCLUSIONS: Our study reveals that traditional eye cosmetics and cultural powders are used among children as young as newborns, and exposure to these products can significantly add to their lead body burden. The study findings also reveal that lead concentrations in these products can vary by product type and product names can vary by region. Public health officials must be cognizant of these unique variations and use culturally appropriate terminologies for these types of products because such distinctions can be critical when conducting risk assessments, risk communication, and risk reduction activities.

Perspectives on Childhood Lead Exposure Prevention: Looking Back and Looking Ahead.

Lead's neurotoxic properties and potential harmful effects to humans, particularly young children, have been recognized for decades, influencing public health policies to reduce its admixture in house paint and passenger car gasoline. We signal 3 emergent trends: firearm proliferation, complex international food supply chains, and equally complex product marketing strategies, which have opened opportunities for lead exposure to children from guns and ammunition, and lead contamination in children's food and consumer goods. Readers will also be apprised of Childhood Lead Poisoning Prevention Program and education strategies cultivated and advanced by the Centers for Disease Control and Prevention and its lead prevention partners. A national governmental policy update is included, as are future considerations.

The Challenges of Treating Lead Toxicity During the COVID-19 Pandemic.

Despite decades of environmental reform, legacy lead is a persistent health hazard within communities. Secondary prevention with screening for childhood lead exposure typically occurs at the 12-month and 24-month well visits, and early identification of toxicity is of vital importance to reduce morbidity and mortality. Over the past few years, there have been multiple challenges impacting the management of lead toxicity, including the coronavirus disease 2019 pandemic, a national shortage of the chelation agent CaNa2EDTA, and housing-related concerns that may result in re-exposure of lead before lead abatement. This report identifies the importance of lead screening and limitations that a pandemic has placed on health care while emphasizing access to care and community resources needs to be a priority.

Recently Recalled Children's Products Due to Lead Hazards.

OBJECTIVE: We reviewed recent reports of recalled children's products contaminated with lead to learn more about what could be done to inform public health partners about the recalls in a timely manner to assist with broader consumer notification for proactive lead poisoning prevention efforts. METHODS: Centers for Disease Control and Prevention staff reviewed lead-related recall notices for children's products issued during June 2022 through April 2024. Recall notices were extracted from the Consumer Product Safety Commission using Really Simple Syndication feed technology to identify and capture the most current recall information. Specific product details in the database were extracted and analyzed descriptively to identify response trends and best practices. RESULTS: Centers for Disease Control and Prevention's automated tool identified 30 recalls from Consumer Product Safety Commission. Lead-contaminated toys were the most frequent type of product recalled (n = 11, 37%). Most products were manufactured in China (n = 24, 86%). Products were on the market for an average of 25 months before they were recalled. No injuries were reported. The 30 recalls resulted in a combined number of 914 598 recalled units sold. CONCLUSIONS: The current approach to protecting children from lead hazards in consumer products could be augmented by timely notifying the public health community about recalls so they can broadly disseminate information through their channels to reduce lead exposure in children. Additional steps to reduce lead contamination in children's products when sourcing raw materials and components may help to decrease the number of recalls.

Sickle Cell Disease and Lead Poisoning in New York City, 2005-2019.

OBJECTIVES: Previous analyses of New York City (NYC) health department's lead registry indicated that, among children with lead poisoning, an increased prevalence of sickle cell disease (SCD) exists. However, SCD is not considered a risk factor for lead poisoning. We assessed the association between SCD and childhood lead poisoning to determine if specific lead poisoning prevention efforts are needed for children with SCD. METHODS: We analyzed NYC's lead registry data for children with venous blood lead levels (BLLs) ≥15 mcg/dL during 2005 to 2019. t tests and χ2 tests were performed to compare demographic characteristics, BLLs, and lead exposure risks in non-Hispanic Black children with and without SCD. A t test was used to compare observed SCD prevalence among Black children with BLLs ≥15 mcg/dL with an estimated 0.43% SCD prevalence among Black NYC children. RESULTS: Among 1728 Black children with BLLs ≥15 mcg/dL identified, 37 (2.14%) had SCD. When comparing children with and without SCD, both mean age at peak BLL (62.8 versus 42.7 months; P = .003) and peak BLL (42.59 versus 23.06 mcg/dL; P = .008) were higher for children with SCD. Among risk factors for lead exposure, children with SCD had higher prevalence of pica. Observed SCD prevalence was 1.71% higher than estimated SCD prevalence among Black NYC children (P < .001). CONCLUSIONS: We found a potential association between SCD and childhood lead poisoning. Pica emerged as a potentially important risk factor. Our findings might have implications for lead poisoning prevention guidelines for children with SCD.

Blood Lead Testing and Follow-up Testing Among Children Hospitalized for Lead Poisoning.

BACKGROUND AND OBJECTIVES: US children experience lead poisoning, which has detrimental health effects and significant individual and societal costs. This study aimed to describe the sociodemographic and hospitalization characteristics of children hospitalized for lead poisoning and assess the proportion of inpatients who received blood lead testing and appropriate follow-up testing before hospitalization. METHODS: 2015-2021 hospital discharge data were linked to lead surveillance data for Pennsylvania children aged 0 to 5 years. Demographics, hospitalization characteristics, and lead testing data from children with a primary diagnosis code of lead poisoning were used. The number of hospitalizations, associated hospital length of stay and charges, and the proportion of inpatients who received lead testing and follow-up testing after identification of high blood lead levels before hospitalization were analyzed by selected characteristics. RESULTS: During the study period, there were 93 children hospitalized for lead poisoning, incurring 443 inpatient days and approximately 6 million dollars in inpatient charges. Of these inpatients, 69.9% were males, 36.6% were non-Hispanic Black, 67.7% were aged 0 to 2 years, 14% had repeated admissions, and 88.2% of admissions were paid by Medicaid. In addition, 20.4% did not have lead testing, and 34.4% had appropriate follow-up testing before hospitalization. Non-Hispanic whites and children with developmental, behavioral, and emotional disorders had relatively low proportions of having appropriate follow-up testing. CONCLUSIONS: Severe childhood lead poisoning is a significant health and economic burden, especially among children with Medicaid. Further improvements in blood lead testing and follow-up testing can help prevent childhood lead poisoning.

State-Level Childhood Lead Poisoning Prevention Policies and Practices in the United States: 2022-2023.

OBJECTIVES: The purpose of this analysis is to better understand laws and practices guiding prevention activities in childhood lead poisoning prevention programs funded by the Centers for Disease Control and Prevention (CDC). METHODS: In 2022, CDC surveyed 62 funded programs using the Awardee Lead Profile Assessment. Information was collected about childhood lead poisoning-related laws and guidance, surveillance and prevention strategies, and program services including at what blood lead levels (BLLs) various activities are performed. Separately, CDC reviewed state health department websites to obtain information on which states implemented CDC's updated blood lead reference value. RESULTS: Awardee Lead Profile Assessment results are only reported for 47 states, the District of Columbia, and Puerto Rico. Almost all programs (96%) have laws requiring reporting of BLLs, and 51% require BLLs be reported electronically to jurisdictional health departments. Most programs (80%) prioritize areas and populations that are high risk for lead poisoning prevention activities. Approximately half of the programs (51%) have a lead elimination plan or goal. Thirty-nine percent of the programs have already implemented policies, laws, or regulations to achieve lead elimination, and 74% are in the Northeast and Midwest regions of the country. As of March 2023, 71% of the programs have implemented CDC's updated blood lead reference value, and most (65%) did so via guidance for health care providers and laboratories for what BLL should initiate case management and other services for lead-exposed children. CONCLUSIONS: Almost all programs have mandatory BLL reporting laws, and about two-thirds of the programs updated their BLLs that trigger public health action.

Effects of Blood Lead Levels <10 µg/dL in School-Age Children and Adolescents: A Scoping Review.

CONTEXT: Lead exposures among school-age children are a major public health issue. Although the harmful effects of lead exposure during the first years of life are well known, there is not as much understanding of the effects of low levels of lead exposure during later childhood. OBJECTIVES: To review the effects of blood lead levels (BLLs) <10 µg/dL in school-age children and adolescents. DATA SOURCES: We searched Medline, Embase, Global health, CINAHL, Scopus, and Environmental Science Collection databases between January 1, 2000, and May 11, 2023. STUDY SELECTION: We included peer-reviewed English-language articles that presented data on the effects of BLLs <10 µg/dL in individuals ages 5 through 18 years. DATA EXTRACTION: Data on country, population, analytic design, sample size, age, BLLs, outcomes, covariates, and results were extracted. RESULTS: Overall, 115 of 3180 screened articles met the inclusion criteria. The reported mean or median BLL was <5 µg/dL in 98 articles (85%). Of the included articles, 89 (77%) presented some evidence of an association between BLLs <10 µg/dL during school age and detrimental outcomes in a wide range of categories. The strongest evidence of an association was for the outcomes of intelligence quotient and attention-deficit/hyperactivity disorder diagnoses or behaviors. LIMITATIONS: Few articles controlled for BLLs at age <5 years, limiting conclusions about the relation between later BLLs and outcomes. CONCLUSIONS: BLLs <10 µg/dL in school-age children and adolescents may be associated with negative outcomes. This review highlights areas that could benefit from additional investigation.

Low-Level, Early Life Lead Exposure and School Behavior.

OBJECTIVES: To measure how early childhood exposure to lead affects school behavior from third to eighth grade, measured by the number and days of total school suspensions and out-of-school suspensions (OSS). METHODS: We estimate Poisson models using a cohort of 284 701 students with school records from 2006-2008 in North Carolina. We adjust for demographic and socioeconomic variables and school-grade-year cohort effects, and use coarsened exact matching to ensure similar characteristics across children with blood lead levels (BLLs) 2-10 µg/dL and children in the reference group with BLLs ≤1 µg/dL. RESULTS: BLLs ≥3 µg/dL are positively and significantly associated with all school suspension measures for sixth through eighth graders. The estimated effects on OSS for sixth through eighth graders are larger than the effects on total suspensions. For example, students with BLL = 3 µg/dL receive OSS 16% (95% confidence interval 3.6%-30%) more often and for 22% (95% confidence interval 7.3%-33%) more days than students with BLL ≤1 µg/dL. For third through fifth grade students, we only find a significant effect of lead exposure on suspensions at relatively high BLLs of 8-10 µg/dL. CONCLUSIONS: Our analysis demonstrates that BLL has significant adverse effects on third through eighth grade students' behavior, including at levels below the current Centers for Disease Control and Prevention's blood lead reference value of 3.5 µg/dL. We find that the adverse effects of lead are most strongly associated with more severe disruptive behavior in sixth through eighth graders, as measured by OSS. Our results underscore the long-term benefits of preventing early childhood exposure to lead.

Collaboration for Lead Poisoning Prevention in Puerto Rico.

In 2010, Puerto Rico experienced a cluster of childhood lead poisoning cases stemming from parental occupational exposure to lead. Following the immediate response to this crisis, a dedicated coalition of pediatricians and public health practitioners sustained a collaborative effort to advance pediatric environmental health initiatives across Puerto Rico. Their commitment laid the groundwork for the establishment and evolution of Puerto Rico's comprehensive Childhood Lead Poisoning Prevention and Blood Lead Level Surveillance Program. This compelling case study showcases the potential for concerted, multidisciplinary action to leverage an acute event to influence public policy and clinical practice to promote children's health. By drawing on the lessons learned and strategies used in Puerto Rico, other jurisdictions can overcome challenges in pursuit of enhanced secondary lead poisoning prevention measures, with the goal of achieving primary prevention in the near future.

A Possible Nocebo Effect in Children Following the Flint Water Crisis: Evidence From Schoolteacher Perceptions and Neuropsychological Evaluations.

OBJECTIVE: Special education enrollment increased in Flint following the 2014-2015 Flint Water Crisis, but lead exposure is not plausibly responsible. Labeling Flint children as lead poisoned and/or brain damaged may have contributed to rising special education needs (ie, nocebo effect). To better document this possibility, we surveyed schoolteachers and reviewed neuropsychological assessments of children for indications of negative labeling. METHODS: A survey of Flint and Detroit (control) public schoolteachers using a modified Illness Perception Questionnaire was conducted 5 years post-crisis. We also examined neuropsychological assessments from a recently settled class lawsuit. RESULTS: Relative to Detroit (n = 24), Flint teachers (n = 11) believed that a higher proportion of their students had harmful lead exposure (91.8% Flint vs 46% Detroit; P = 0.00034), were lead poisoned (51.3% vs 24.3%; P = 0.018), or brain damaged (28.8% vs 12.9%; P = 0.1), even though blood lead of Flint children was always less than half of that of Detroit children. Neuropsychological assessments diagnosed lead poisoning and/or brain damage from water lead exposure in all tested children (n = 8), even though none had evidence of elevated blood lead and a majority had prior learning disability diagnoses. CONCLUSION: Teachers' responses and neuropsychological assessments suggest Flint children were harmed by a nocebo effect.

Lead Poisoning in Milwaukee: A Medical and Public Health Update.

INTRODUCTION: Every year, children are poisoned with lead with irreversible effects. This exposure most often occurs in older housing built before 1978 with chipping paint from windowsills where children play and ingest the lead particulates. Exposure to lead can cause neurological and psychological dysfunction, among other health issues. OBJECTIVE: This quality improvement study aims to evaluate our knowledge of at-risk children through a public health approach by analyzing the current public health data and possible barriers to lead screening, testing follow-up, and identifying at-risk children. METHODS: We received data on lead-poisoned children and inspected properties from the City of Milwaukee Health Department. We analyzed each child's initial blood lead level, as well as follow-up tests recorded, ZIP code of residence, and family renter versus home ownership. RESULTS: Over 90% of children in the database had recorded follow-up blood lead testing following an initial elevated blood lead level. There was no difference in initial recorded blood lead levels between children with recorded follow-up blood lead levels and children without (21.40, SD = 11.26); t[1.17], P = 0.24). Most affected children were from economically disadvantaged ZIP codes (53206, 53208, 53215), and 94% lived in rented properties. CONCLUSIONS: Over 90% of children in the database had recorded follow-up blood lead testing following an initial elevated blood lead level. There was no difference in initial recorded blood lead levels between children with recorded follow-up blood lead levels and children without (21.40, SD = 11.26); t[1.17], P = 0.24). Most affected children were from economically disadvantaged ZIP codes (53206, 53208, 53215), and 94% lived in rented properties.

High lead contamination in Mother's breastmilk in Bihar (India): Health risk assessment of the feeding children.

Lead poisoning in the recent times has caused serious health threats in the exposed human population. It is estimated that about 815 million people are exposed to lead poisoning worldwide and in India total 275 million children are exposed to blood lead contamination. The present study was carried outed in 6 districts of Bihar to know the extent of lead exposure in the children through their mother's breastmilk. The biological samples such as breastmilk, mother's urine, child's urine, and mother's blood samples were collected for quantitative lead estimation. Moreover, the selected household water sources (handpump) and the food consumed by the individuals-wheat, rice and potato samples were also collected for lead quantification. The study reveals that the breastmilk had high lead content in 92% of the samples (highest value 1309 µg/L), in blood presence of lead was observed in 87% studied samples (highest value 677.2 µg/L). In mother's urine the highest lead value was 4168 µg/L (62%) and in child's urine the highest value was 875.4 µg/L (62%) respectively of the studied samples. Moreover, in the studied food samples, wheat had lead content in 45% the studied samples (highest value 7910 µg/kg). In rice in 40% of the studied samples (highest value 6972 µg/kg) and in potato 90% of the studied samples (highest value = 13786 µg/kg) were found with elevated lead content respectively. The hazard quotient (HQ) and the cancer risk (CR) for lead contamination was very much higher in mothers followed by their children. The entire study indicated that lead exposure through food (wheat, rice and potato) has reached the mother's breastmilk and from their it has reached their child's body. This could cause serious hazards in the exposed children causing serious neurological damages, low IQ, low memory, and low mental growth in them. Therefore, a strategic action is required to control the present problem.

Knowledge, attitude, and practices related to lead pollution among adolescents and caregivers of young children living near Used Lead Acid Battery (ULAB) recycling sites in Bangladesh: a cross-sectional study.

BACKGROUND: Lead, a potent neurotoxin, causes irreversible damage to the nervous system, and low- and middle-income countries face huge health and economic productivity losses due to childhood lead exposure. In Bangladesh, informal Used Lead Acid Battery (ULAB) recycling sites are an important source of lead pollution. Little is known about lead awareness among communities exposed to ULAB recycling. Therefore, this study aims to assess knowledge, attitudes, and practices related to lead pollution among caregivers of young children and adolescents living adjacent to informal ULAB sites. METHODS: A cross-sectional study was conducted among 732 mothers of young children and adolescents in 4 districts of Bangladesh (survey and observation). Simple and multiple linear regression was conducted to describe patterns and predictors of lead-related knowledge and practices. RESULTS: 60% of respondents had heard the name 'lead' ("shisha"). The mean knowledge score was low (19 out of 44). Residents of high-risk districts, male respondents, and those with more than 5 years of schooling were significantly more likely to have higher knowledge scores than others. In terms of attitude, 52% of respondents perceived lead to be risky for human health but 43% thought lead pollution was controllable. Observation of households for lead exposure revealed that 63% of children and adolescents play or pass by ULAB sites, 29% ate non-food items, 41% of households had visible paint chips on the walls, 59% households used polished turmeric and 15% used lead-soldered cans to store foods. Among protective practices, 70% reported cleaning floors, 84% consumed iron-rich foods, and 48% consumed calcium-rich foods. CONCLUSIONS: The population had a high potential for lead exposure. Their knowledge about lead was limited, and risk perception was moderate. To reduce lead exposure and increase knowledge and awareness among the at-risk population, it is crucial to take measures such as mass awareness campaigns through media and schools. It is important to strengthen the implementation of existing policies, such as policies on leaded gasoline, paints, and lead-acid batteries, that can address the sources of lead exposure for the community.

A Snapshot of Lead in Consumer Products Across Four US Jurisdictions.

BACKGROUND: Following the removal of lead from gasoline, paint and pipes were thought to be the main sources of lead exposure in the United States. However, consumer products, such as certain spices, ceramic and metal cookware, traditional health remedies, and cultural powders, are increasingly recognized as important sources of lead exposure across the United States. OBJECTIVE: This paper reviews data from four US jurisdictions that conduct in-home investigations for children with elevated blood lead levels (BLLs) to examine the prevalence of lead exposures associated with consumer products, in comparison with housing-related sources. METHODS: Authors reviewed investigation data (2010-2021) provided by California, Oregon, New York City, and King County, Washington, and compared the extent of lead exposures associated with housing-related vs. consumer products-related sources. DISCUSSION: The proportion of investigations identifying consumer products-related sources of lead exposure varied by jurisdiction (range: 15%-38%). A review of US CDC and US FDA alerts and New York City data indicates that these types of lead-containing products are often sourced internationally, with many hand carried into the United States during travel. Based on surveillance data, we believe that US immigrant and refugee communities are at an increased risk for lead exposures associated with these products. To engage health authorities, there is a need for evidentiary data. We recommend implementing a national product surveillance database systematically tracking data on consumer products tested by childhood lead poisoning prevention programs. The data repository should be centralized and accessible to all global stakeholders, including researchers and governmental and nongovernmental agencies, who can use these data to inform investigations. Effectively identifying and addressing the availability of lead-containing consumer products at their source can focus resources on primary prevention, reducing lead exposures for users abroad and in the United States. https://doi.org/10.1289/EHP14336.

Lead exposure sources and public health investigations for children with elevated blood lead in England, 2014 to 2022.

BACKGROUND: Lead exposure at any concentration can adversely impact health, with children being more vulnerable to its effects. In England, children with an elevated blood lead concentration (BLC) are reported to Health Protection Teams (HPTs) for public health investigation. A detailed review of these cases has not yet been conducted. OBJECTIVES: The objectives of this study were to describe the demographics, likely setting and sources of lead exposure, risk behaviours, public health investigations and outcomes for children aged <16 years with a BLC requiring public health action reported to HPTs between 2014-2022 in England. METHODS: Data were collected via a lookback questionnaire and a live enhanced surveillance questionnaire. Data were deduplicated, cleaned and results summarised as numbers and percentages using R studio. A thematic analysis was conducted on qualitative responses to a question relating to problems experienced during case investigation. RESULTS: There were 340 cases in our study: the majority were aged 1-4 years old (53%) and male (69%). Ethnicity data was poorly recorded. A higher than expected proportion (31%) lived in the most deprived areas. Pica (76%) and learning difficulties (60%) were often present. Cases were primarily exposed to lead in the domestic setting (92%) with paint (43%) and soil (29%) the most common exposures. Most cases lived in rented accommodation (63%), with a higher proportion in social rentals (48%) than privately rented (37%). Case investigations were resource intensive and poor stakeholder engagement/response was most frequently identified as challenging by HPTs. CONCLUSIONS: Lead exposure is harmful to children and requires public health and clinical management, which can be complex and challenging. Prevention of lead exposure in children should be the focus of intervention efforts. Outreach, engagement and preventative work should focus on both renters and homeowners. Collecting ethnicity data consistently may enable identification of more specific groups at increased risk of lead exposure in England.

Determinant Factors of Children's Blood Lead Levels in Java, Indonesia.

INTRODUCTION: Lead poisoning contributes to a significant burden of disease as a toxic substance found in air, soil, and water. In Indonesia, the risk of exposure is high due to the inappropriate recycling of used lead batteries. The objective was to investigate the factors that influence lead levels in children's blood. METHODS: This cross-sectional study assessed blood lead levels (BLLs) in children aged 12-59 months in four communities exposed to used lead-acid batteries (ULABs) recycling activities, comparing them to a control area. The study employed a threshold level of 20 µg/dL to identify high BLLs and utilized a sample size of 324 children from exposed sites and 240 from control sites. Questionnaires, blood lead tests and a home-based assessment for environmental exposures were applied. RESULTS: The study participants comprised 295 boys and 269 girls, with an average age of 35 months. Significant disparities in soil lead concentrations median: Q1-Q3 were found between exposed (6581.7 : 2432.6-16647.1) ppm and control areas (253.5 : 158.8-417.1) ppm. Children in exposed areas had 3.9 times higher odds of BLL ≥20 µg/dL. Fathers with BLL ≥20 µg/dL had children with similarly elevated BLLs. Multivariate analysis identified socioeconomic status, study areas, environmental factors (cookware, food ware, spices, house cleaning), and children's behavior (breastfeeding duration) as determinants of elevated BLLs. Reported environmental factors had notable impact on BLLs, with aluminum cookware (aOR = 1.4, 95%CI [1.2-1.6]), food ware materials (aOR = 1.15, 95%CI [1.0-1.3]), type of spices (aOR = 2.7, 95%CI [1.7-48.0]), and house cleaning method (aOR = 2.9, 95%CI [1.2-7.1]). CONCLUSION: This study highlighted key risk factors affecting children's blood lead levels (BLL) and emphasized the urgency of employing effective strategies to remediate lead-contaminated soils in exposed regions. The findings underscore the need for prompt medical intervention and monitoring for children in these areas, with additional research essential to fully understand lead poisoning pathways in the environment.

Synergistic susceptibility to environmental lead toxicity in chronic kidney disease.

PURPOSE OF REVIEW: While high levels of lead exposure, as occurs accidentally or occupationally, can cause toxicity across multiple organ systems, the hazard of commonly encountered levels of lead in the environment remains unresolved. Challenges to researching the health effects of lead include its complex interplay with renal function, rendering analyses at risk of unaccounted confounding, and the likely small effect size of environmental levels of exposure. While children are known to be disproportionately susceptible to lead toxicity, resulting in appropriately more stringent regulatory surveillance for those under 5 years old, emerging evidence suggests that those with chronic kidney disease (CKD) similarly are at a greater risk. This review summarizes the role of environmental lead toxicity as a potential cause and consequence of CKD. RECENT FINDINGS: Whether environmental lead exposure causes CKD remains debatable, with little recent research advancing the conflicting, mostly cross-sectional, analyses from years ago. However, an emerging body of evidence suggests that CKD increases the susceptibility to lead toxicity. Higher circulating lead levels and lower urinary excretion result in greater lead accumulation in CKD, with simultaneous greater risk of clinically meaningful disease. Recent studies suggest that levels of lead found commonly in the United States drinking water supply, and currently permissible by the Environmental Protection Agency, associate with hematologic toxicity in those with advanced CKD. Whether environmental lead contamination may have additional negative health impact among this at-risk population, including cardiovascular and neurocognitive disease, warrants further study. SUMMARY: The underlying pathophysiology of kidney disease synergizes the susceptibility to environmental lead toxicity for those with CKD. Low levels of exposure, as found commonly in the United States water supply, may have adverse health impact in CKD. Further research will be needed to determine if more stringent environmental regulations are warranted to protect the health of all.

Childhood Lead Exposure Linked to Apple Cinnamon Fruit Puree Pouches - North Carolina, June 2023-January 2024.

Lead exposure is toxic even at low levels, resulting in impairments that can affect a child's lifelong success. In North Carolina, testing for lead is encouraged for all children at ages 1 and 2 years and required for children covered by Medicaid; investigations are performed to identify potential exposure sources for children with blood lead levels (BLLs) ≥5 µg/dL. During June-August 2023, routine lead testing identified four asymptomatic North Carolina children with BLLs ≥5 µg/dL. Home investigations identified only WanaBana brand apple cinnamon fruit puree pouches as a potential exposure source; product samples contained 1.9-3.0 ppm of lead. An expanded nationwide investigation led to identification of approximately 500 cases of childhood lead exposure believed to be linked to consumption of apple cinnamon purees, including 22 cases in North Carolina. Fewer than one half (45%) of the 22 North Carolina cases were among children covered by Medicaid. A coordinated multiagency communication strategy was implemented in North Carolina to notify consumers of the hazard and provide recommendations for preventing further exposure. The Food and Drug Administration issued a nationwide public health advisory on October 28, 2023; 2 days later, the manufacturer issued a voluntary recall. Routine testing of young children for lead exposure, combined with thorough environmental investigations, can identify emerging sources of lead exposure and limit further harm.