Risk-Factor Based Lead Screening and Correlation with Blood Lead Levels in Pregnancy.

OBJECTIVES: Lead exposure has devastating neurologic consequences for children and may begin in utero. The American College of Obstetricians and Gynecologists recommends prenatal lead screening using a risk factor-based approach rather than universal blood testing. The clinical utility of this approach has not been studied. We evaluated a risk-factor based questionnaire to detect elevated blood lead levels in pregnancy. METHODS: We performed a secondary analysis of a cohort of parturients enrolled to evaluate the association of lead with hypertensive disorders of pregnancy. We included participants in this analysis if they had a singleton pregnancy ≥ 34 weeks' gestation with blood lead levels recorded. Participants completed a lead risk factor survey modified for pregnancy. We defined elevated blood lead as ≥ 2 µg/dL, as this was the clinically reportable level. RESULTS: Of 102 participants enrolled in the cohort, 92 had blood lead measured as part of the study. The vast majority (78%) had 1 or more risk factor for elevated lead using the questionnaire yet none had clinical blood lead testing during routine visits. Only two participants (2.2%) had elevated blood lead levels. The questionnaire had high sensitivity but poor specificity for predicting detectable lead levels (sensitivity 100%, specificity 22%). CONCLUSIONS FOR PRACTICE: Prenatal risk-factor based lead screening appears underutilized in practice and does not adequately discriminate between those with and without elevated blood levels. Given the complexity of the risk factor-based approach and underutilization, the benefit and cost-effectiveness of universal lead testing should be further explored.

Novel founder intronic variant in SLC39A14 in two families causing Manganism and potential treatment strategies.

Congenital disorders of manganese metabolism are rare occurrences in children, and medical management of these disorders is complex and challenging. Homozygous exonic mutations in the manganese transporter SLC39A14 have recently been associated with a pediatric-onset neurodegenerative disorder characterized by brain manganese accumulation and clinical signs of manganese neurotoxicity, including parkinsonism-dystonia. We performed whole exome sequencing on DNA samples from two unrelated female children from the United Arab Emirates with progressive movement disorder and brain mineralization, identified a novel homozygous intronic mutation in SLC39A14 in both children, and demonstrated that the mutation leads to aberrant splicing. Both children had consistently elevated serum manganese levels and were diagnosed with SLC39A14-associated manganism. Over a four-year period, we utilized a multidisciplinary management approach for Patient 1 combining decreased manganese dietary intake and chelation with symptomatic management of dystonia. Our treatment strategy appeared to slow disease progression, but did not lead to a cure or reversal of already established deficits. Clinicians should consider testing for noncoding mutations in the diagnosis of congenital disorders of manganese metabolism and utilizing multidisciplinary approaches in the management of these disorders.

Toxicants in folk remedies: implications of elevated blood lead in an American-born infant due to imported diaper powder.

Though most childhood lead exposure in the USA results from ingestion of lead-based paint dust, non-paint sources are increasingly implicated. We present interdisciplinary findings from and policy implications of a case of elevated blood lead (13-18 mcg/dL, reference level <5 mcg/dL) in a 9-month-old infant, linked to a non-commercial Malaysian folk diaper powder. Analyses showed the powder contains 62 % lead by weight (primarily lead oxide) and elevated antimony [1000 parts per million (ppm)], arsenic (55 ppm), bismuth (110 ppm), and thallium (31 ppm). These metals are highly bioaccessible in simulated gastric fluids, but only slightly bioaccessible in simulated lung fluids and simulated urine, suggesting that the primary lead exposure routes were ingestion via hand-mouth transmission and ingestion of inhaled dusts cleared from the respiratory tract. Four weeks after discontinuing use of the powder, the infant's venous blood lead level was 8 mcg/dL. Unregulated, imported folk remedies can be a source of toxicant exposure. Additional research on import policy, product regulation, public health surveillance, and culturally sensitive risk communication is needed to develop efficacious risk reduction strategies in the USA. The more widespread use of contaminated folk remedies in the countries from which they originate is a substantial concern.

An Update on Childhood Lead Poisoning.

Childhood lead poisoning is a multi-faceted, complex condition, which affects not only the child's health and well-being, but also the family's housing security, economic status, job security, and stress level. This review updates the emergency department clinician on the management of childhood lead poisoning. Infants and children are at higher risk than adults for lead exposure due to their smaller size and proportionately larger dose of ingested toxins, their proximity to ground dirt and indoor dust, their energy and curiosity, their oral exploratory and pica behaviors, their proportionately larger daily water and milk intake, and dietary preferences that differ markedly from those of adults. Pediatric health care providers working in the emergency department can provide medical management, as well as preventive counseling and guidance, to parents of children presenting with evidence of acute or chronic lead poisoning.

Graduate medical education in humanism and professionalism: a needs assessment survey of pediatric gastroenterology fellows.

The deterioration of humanism and professionalism during graduate medical training is an acknowledged concern, and programs are required to provide professionalism education for pediatric fellows. We conducted a needs assessment survey in a national sample of 138 first- and second-year gastroenterology fellows (82% response rate). Most believed that present humanism and professionalism education met their needs, but this education was largely informal (eg, role modeling). Areas for formal education desired by >70% included competing demands of clinical practice versus research, difficult doctor-patient relationships, depression/burnout, angry parents, medical errors, work-life balance, and the patient illness experience. These results may guide curricula to formalize humanism and professionalism education in pediatric gastroenterology fellowships.

Education on Preventing Early Childhood Injuries Using a Video Game: The VirtualSafeHome Platform.

Poisonings and household injuries are frequent events among toddlers. We developed VirtualSafeHome (VSH)-a novel self-contained, Internet-based home-safety learning tool-to improve awareness of household hazards. Study aims were to investigate VSH usage characteristics. A prototype, screen-based VSH kitchen was built in Unity and delivered through the web using 3DVista and Wix. Players spot and click 21 embedded hazards. A unique feature is the ability to capture the "child's perspective" in identifying hazards. We recruited a convenience sample of adults in 2021-2022. Outcomes included number of hazards discovered, session duration, and pretest/posttest knowledge scores. Twenty-four adults identified a median 15.5 hazards; median playing time was 1022 seconds. Players reported satisfaction with ease of navigation and game features. Mean pretest/posttest knowledge scores rose from 2.0 to 2.79 (P < .035). A web-enabled video game can provide easily accessed, enjoyable training on home safety.

An Update on Pediatric Environmental Health Specialty Units: Activities and Impacts, 2015-19.

OBJECTIVE: Pediatric Environmental Health Specialty Units (PEHSUs) address health concerns impacting children and their families related to environmental hazards by providing consultation and education to families, communities, and health care professionals. This analysis evaluated the productivity of the national PEHSU program. METHODS: PEHSUs reported data on services provided to US communities between October 1, 2014 and September 30, 2019. Descriptive statistics and qualitative analysis are presented. RESULTS: During this period, 6102 consultations and 4644 educational outreach activities were recorded. PEHSU faculty and staff published 462 articles, reviews, book chapters, fact sheets, commentaries, short informational pieces, and other materials between 2014 and 2019. These included 190 articles in scientific peer-reviewed journals and 29 textbook chapters to increase professional capacity in pediatric and reproductive environmental health. Lead, other metals, substances of abuse, pesticides, mold, and air pollution were frequently reported as agents of concern and educational topics. Requests for an overview of pediatric environmental health and outdoor pollutants were other frequently reported topics. CONCLUSIONS: PEHSUs work to decrease harmful exposures and improve children's health. They serve as expert resources for families, health care professionals, and communities on health effects related to environmental exposures. Data show the breadth and depth of concerns addressed and demonstrate the productivity and impact of this national program.

Drinking Water From Private Wells and Risks to Children.

Drinking water for >23 million US households is obtained from private wells. These wells can become contaminated by chemicals, naturally occurring toxic substances, or pathogenic organisms that can cause illness in children. Although the US Environmental Protection Agency and most states offer some guidance for the construction, maintenance, and testing of private wells, most states only regulate the construction of new private water wells. With few exceptions, well owners are responsible for their own wells after the initial construction. Children may also drink well water at childcare or when traveling. This policy statement provides recommendations for the inspection, testing, and remediation of private wells to provide safe drinking water for children.

Drinking Water From Private Wells and Risks to Children.

Drinking water for approximately 23 million US households is obtained from private wells. These wells can become contaminated by pollutant chemicals or pathogenic organisms, leading to significant illness. Although the US Environmental Protection Agency and all states offer guidance for construction, maintenance, and testing of private wells, most states only regulate the construction of new private water wells. With a few exceptions, there is little regulation after construction. Well owners are responsible for their own wells. Children may also drink well water at child care or when traveling. Illness resulting from children's ingestion of contaminated water can be severe. This report reviews relevant aspects of groundwater and wells; describes the common chemical and microbiologic contaminants; gives an algorithm with recommendations for inspection, testing, and remediation for wells providing drinking water for children; and provides references and Internet resources for more information.

The more you know: Insights from integrated pre-visit surveys in a pediatric environmental health center.

The Pediatric Environmental Health Center (PEHC) at Boston Children's Hospital is a specialty referral clinic that provides consultation for approximately 250 patients annually. Identifying environmental hazards is key for clinical management. Exposure concerns include lead, mold, pesticides, perfluoroalkyl substances (PFAS), impaired air quality, and more. Our goal was to identify concerns and visit priorities of our patient population to guide visits. A 47-question pre-visit survey was created exploring potential environmental hazards and administered prior to visits using a platform integrated into the electronic medical record (EMR). The study group was a convenience sample of patients from June 2021 to June 2022. Of 204 total visits, 101 surveys were submitted, yielding a response rate of 49.5%. 66/101 (65.3%) were surveys from initial consultations used for descriptive analysis. The majority of patients were seen for a chief complaint of lead exposure (90.1%). Most respondents had concerns about peeling paint (40.0%), and those reporting peeling paint were more likely to report additional concerns [75.0%, p < 0.001]. Other concerns highlighted were mold (15.2%), pests (15.2%), asbestos (10.6%), air pollution (9.1%), temperature regulation (7.6%), pesticides (6.1%), PFAS (4.5%), and formaldehyde (4.5%). A knowledge gap was identified; 45.5% (30/66) respondents responded "no" to the question asking if the Poison Control Center phone number was stored in their phone. This study illustrates how the implementation of a pre-visit EMR integrated survey engages families, informs clinical care, and serves as a point-of-care education tool for specific knowledge gaps. Findings will guide development of future environmental health screeners.

Encephalopathy from lead poisoning masquerading as a flu-like syndrome in an autistic child.

Acute encephalopathy from childhood lead poisoning is fortunately rare. However, in pediatric patients with developmental disabilities and pica, there is a risk of lead exposure at a dose commensurate with encephalopathy, coupled with a risk of delayed diagnosis because of difficulty in distinguishing between baseline and altered behavior. We report here a 4-year old autistic boy who presented to the pediatrician's office with gastrointestinal symptoms and behavioral changes and was at first thought to have a viral syndrome. He returned 2 days later with a worsening illness; increasing pallor, vomiting, abdominal colic, and changes in consciousness were recognized in the emergency department as lead-induced anemia and encephalopathy, associated with a positive abdominal film for paint chips and a blood lead level equal to 216 microg/dL (10.43 micromol/L) (reference, <10 microg/dL or 0.483 micromol/L). As this case illustrates, prompt recognition is dependent on the skills and suspicions of an astute clinician, especially in the busy emergency department.

The COVID-19 Pandemic and Children's Environmental Health.

The coronavirus disease 2019 pandemic has dramatically altered the health and well-being of children, particularly as they have been isolated indoors and in their homes as a result of social distancing measures. In this article, we describe several of the environmental threats that are affecting the health of children during the pandemic. These include increased exposure to household cleaning products, chemicals and lead in dust, indoor air pollutants, screen time, family stress, and firearms, as well as decreased availability of food, social supports, and routine childhood screenings. Importantly, many of these threats disproportionately affect children of racial or ethnic minorities or who have low socioeconomic status. Pediatric health care providers will need to screen and treat children and counsel their parents and/or other caregivers during well-child visits with an eye for these new or worsened environmental threats. [Pediatr Ann. 2020;49(12):e537-e542.].

Severe lead poisoning requiring hospitalization: A case report.

Cases of severe childhood lead poisoning (a blood lead level (BLL) ≥45 mcg/dL) in the United States have decreased with time. Clinicians will encounter such cases only rarely. When such cases arise, however, recognizing their complexities and identifying resources that can help in management are important. We present here a case of severe childhood lead poisoning, highlighting the variable presentation, the rebound phenomenon of BLL after chelation, the usefulness of the zinc protoporphyrin as an adjunctive monitoring parameter, and the importance of early involvement of an inter-professional team.

Puberty and resultant increased bone turnover as a possible etiology of an increased lead concentration in a pre-adolescent girl.

Introduction: We present a case in which puberty likely resulted in an increased lead concentration in a pre-adolescent girl.Case report: A 12-year-old girl was referred to the pediatric environmental health clinic (PEHC) after her blood lead level (BLL) was found to be elevated to 30 µg/dL (reference <5 µg/dL). She had been seen in the PEHC 6 years previously for management of a BLL as high as 36 µg/dL. Fifteen months prior to her repeat PEHC referral, her BLL had been 10 µg/dL. In those intervening 15 months, she grew 10.42 cm. Thyroid studies were normal. Four months after re-referral, her osteocalcin concentration, a marker of bone turnover, was 212 ng/mL (normal 9-42 ng/mL in adults >18 years); 10.5 months after the peak BLL of 32 mcg/dL, her BLL was 16 µg/dL, osteocalcin was 69 ng/mL, and her rate of growth had declined to 0.20 cm/30 days (peak: 1.07 cm/30 days). No external source of her exposure was found.Discussion: Osteocalcin concentrations and plotting the changes in growth velocity over time may assist clinicians in determining if pubertal growth is playing a role in unexpectedly increased BLL discovered in adolescents for whom no external source of lead exposure can be found.

Lead exposure and association with angiogenic factors and hypertensive disorders of pregnancy.

OBJECTIVES: Lead exposure has been associated with hypertensive disorders of pregnancy. Angiogenic factors, including soluble fms-like tyrosine kinase 1 (sFlt1) and placental growth factor (PlGF), are aberrant in preeclampsia, but have not been correlated with lead levels. We evaluated the association of lead exposure with angiogenic factors. STUDY DESIGN: This cross sectional study utilized a convenience sample of singleton pregnancies ≥34 weeks' gestation. Blood lead and angiogenic factors were measured before delivery; bone lead was measured postpartum. We dichotomized bone and blood lead into the top tertile versus the bottom tertiles and used log-binomial regression to assess the association between lead and a high angiogenic ratio. MAIN OUTCOME MEASURES: The outcomes were high sFlt1 to PlGF ratio and development of a hypertensive disorder of pregnancy. RESULTS: We enrolled 102 participants, of whom 98 had at least one lead measurement and an angiogenic factor result. Median bone lead was 3.8 ug/g (2.0 - 6.6) and median blood lead was 0.2 ug/dL (0.2 - 0.4). Incidence of hypertensive disorders of pregnancy was 31%. When comparing the highest tertile of bone lead to the bottom two tertiles, there was no association with a high sFlt1/PlGF ratio or hypertensive disorders of pregnancy. Similar results were observed for the exposure of blood lead. CONCLUSIONS: Lead exposure was not an important contributor to an elevated angiogenic factor ratio or hypertensive disorders of pregnancy in our U.S. POPULATION: However, lead exposure was modest in our population and we cannot exclude a relationship with hypertensive disorders of pregnancy.

Elevated Blood Lead Levels in Infants and Children in Haiti, 2015.

OBJECTIVE: Few studies have reported blood lead levels (BLLs) in Haitian children, despite the known presence of lead from environmental factors such as soil, water, leaded paint and gasoline, improperly discarded batteries, and earthquakes. We sought to determine the prevalence of elevated blood lead levels (EBLLs) among healthy Haitian children. METHODS: We enrolled children aged 9 months to 6 years from 3 geographic areas in Haiti (coastal, urban, and mountain) from March 1 through June 30, 2015. We obtained anthropometric measurements, household income, potential sources of lead exposure, and fingerstick BLLs from 273 children at 6 churches in Haiti. We considered a BLL ≥5 µg/dL to be elevated. RESULTS: Of 273 children enrolled in the study, 95 were from the coastal area, 78 from the urban area, and 100 from the mountain area. The median BLL was 5.8 µg/dL, with higher levels in the mountain area than in the other areas ( P < .001). BLLs were elevated in 180 (65.9%) children. The prevalence of EBLL was significantly higher in the mountain area (82 of 100, 82.0%; P < .001) than in the urban area (42 of 78, 53.8%) and the coastal area (56 of 95, 58.9%; P < .001). Twenty-eight (10.3%) children had EBLLs ≥10 µg/dL and 3 (1.1%) children had EBLLs ≥20 µg/dL. Exposure to improperly discarded batteries ( P = .006) and living in the mountain area ( P < .001) were significant risk factors for EBLLs. CONCLUSIONS: More than half of Haitian children in our study had EBLLs. Public health interventions are warranted to protect children in Haiti against lead poisoning.

Building Capacity in Pediatric Environmental Health: The Academic Pediatric Association's Professional Development Program.

BACKGROUND: Environmental exposures contribute to multiple diseases in children; yet, few pediatricians have training in pediatric environmental health (PEH), and few academic health centers have PEH expertise. To build national capacity in PEH, the Academic Pediatric Association (APA) launched a professional development program that since 2002 has encouraged the establishment of post-residency/post-doctoral training programs, supported a special interest group, and convened an annual mentored retreat for PEH trainees. OBJECTIVE: Describe the APA's professional development program in PEH and assess its impact by tracking careers of former trainees. METHODS: Careers were tracked through interviews with trainees and program directors supplemented by searches of institutional websites. Publication listings were obtained through PubMed. Publication impact was assessed using bibliometric and altmetric measures. Grant histories were accessed through the National Institutes of Health RePORTER project. Information on advocacy work was obtained through interviews with program directors. RESULTS: Fifty-five trainees (36 physicians and 19 health scientists) completed PEH training and attended the APA retreat between 2002 and 2017. Forty-one (75%) are pursuing academic careers, 11 are associate or full professors, 11 are practicing general pediatrics or a pediatric subspecialty, 2 are Centers for Disease Control and Prevention epidemiologists, and 1 is a data scientist. Forty-two former trainees (76%) listed "environment" or "environmental" in their job titles or on their websites. Former trainees have published 632 scientific papers. These papers have been cited 3094times, have a relative citation ratio of 2.97, and have been read or viewed 1,274,388times. Twenty-one former trainees have been awarded 43 National Institutes of Health grants. Trainees have developed education and advocacy skills by teaching medical students and residents, presenting grand rounds, preparing policy papers, presenting legislative testimony, and making presentations to public audiences. CONCLUSIONS: The APA's professional development program has contributed to the expansion of national capacity in PEH. Former trainees are populating the field, generating new knowledge, and moving into leadership positions.

Elemental mercury exposure: an evidence-based consensus guideline for out-of-hospital management.

UNLABELLED: The objective of this guideline is to assist poison center personnel in the out-of-hospital triage and initial management of patients with suspected exposures to elemental mercury. An evidence-based expert consensus process was used to create this guideline. It is based on an assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and health professionals providing care. The grade of recommendation is in parentheses. RECOMMENDATIONS: 1) Patients with exposure due to suspected self-harm, abuse, misuse, or potentially malicious administration should be referred to an emergency department immediately regardless of the exposure reported (Grade D). 2) Patients with symptoms of acute elemental mercury poisoning (e.g., cough, dyspnea, chest pain) should be referred immediately to an emergency department for evaluation regardless of the reported dose. Patients with symptoms of chronic toxicity (rash, tremor, weight loss, etc.) should be referred for healthcare evaluation, the timing and location of which is guided by the severity of illness and circumstances of the exposure (Grade C). 3) If the elemental mercury was recently heated (e.g., from stove top, oven, furnace) in an enclosed area, all people within the exposure area should be evaluated at a healthcare facility due to the high risk of toxicity (Grade C). 4) If the elemental mercury was vacuumed or swept with a broom, the health department should be contacted to perform an environmental assessment for mercury contamination. Consider healthcare referral for those exposed to documented high air mercury concentrations (Grade C). 5) Patients ingesting more mercury than in a household fever thermometer or those with abdominal pain after ingestion should be referred to an emergency department for evaluation (Grade C). Do not induce emesis or administer activated charcoal. 6) Asymptomatic patients with brief, unintentional, low-dose vapor exposures can be observed at home. Asymptomatic patients can be evaluated as non-urgent outpatients if there is concern for exposures to high doses (e.g., more than contained in a thermometer) or for chronic duration (Grade D). 7) Pregnant patients unintentionally exposed to elemental mercury and who are asymptomatic should be evaluated by their obstetrician or primary care provider as an outpatient. Immediate referral to an ED is not required (Grade D). 8) Patients with elemental mercury deposited or injected into soft tissue should be referred for evaluation of surgical removal (Grade C). 9) All elemental mercury spills should be properly cleaned up, including the small amount of mercury from a broken thermometer. Brooms and vacuum cleaners should not be used to clean up elemental mercury. The clean-up of any spill larger than a broken thermometer should be performed by a professional company, state health department, or the EPA. Detailed instructions are provided on the EPA website: www.epa.gov/epaoswer/hazwaste/mercury/faq/spills.htm (Grade D). 10) Patients with dermal exposures should remove all jewelry and wash the affected area with mild soap and water. Remove all contaminated clothing and place these items in a sealed plastic double-bag for proper disposal (Grade D). 11) Do not discard elemental mercury in household trash, plumbing drains, or sewer systems. Consult local authorities for the proper disposal of low-level elemental mercury-contaminated household items and thermometers (Grade D).

Per- and polyfluoroalkyl substance (PFAS) exposure assessment in a community exposed to contaminated drinking water, New Hampshire, 2015.

BACKGROUND: Per- and polyfluoroalkyl substances (PFAS) are synthetic chemicals used in manufacturing that resist environmental degradation, can leach into drinking water, and bioaccumulate in tissues. Some studies have shown associations with negative health outcomes. In May 2014, a New Hampshire public drinking water supply was found to be contaminated with PFAS from a former U.S. Air Force base. OBJECTIVES: We established a serum testing program to assess PFAS exposure in the affected community. METHODS: Serum samples and demographic and exposure information were collected from consenting eligible participants. Samples were tested for PFAS at three analytical laboratories. Geometric means and 95% confidence intervals were calculated and analyzed by age and exposure variables. RESULTS: A total of 1578 individuals provided samples for PFAS testing; >94% were found to have perfluorooctane sulfonic acid (PFOS), perfluorooctanoic acid (PFOA), and perfluorohexane sulfonic acid (PFHxS) detectable in serum. Geometric mean serum concentrations of PFOS, PFOA, and PFHxS were 8.6 µg/L (95% CI:8.3-8.9), 3.1 µg/L (95% CI: 3.0-3.2), and 4.1 µg/L (95% CI: 3.9-4.3), respectively, which were statistically higher than the general U.S. POPULATION: Significant associations were observed between PFAS serum concentrations and age, time spent in the affected community, childcare attendance, and water consumption. CONCLUSIONS: PFOS, PFOA, and PFHxS were found in significantly higher levels in the affected population, consistent with PFAS drinking water contamination. Given increased recognition of PFAS contamination in the U.S, a coordinated national response is needed to improve access to biomonitoring and understand health impacts.