Lead-associated deficits in stature, mental ability and behaviour in children in Karachi

Association of exposures to environmental chemicals estimated through primary teeth biomatrix and health outcomes in children and adolescents - A systematic review

Children's heightened susceptibility to environmental exposure arises from their underdeveloped detoxification mechanisms and augmented per-unit body-weight absorption capacity for chemical compounds. Primary teeth are an emerging biomatrix, which aid in storing crucial data on early exposure to harmful substances and developmental illnesses. This systematic review aimed to evaluate the association between environmental chemical exposure and health outcomes in children and adolescents using primary teeth as a matrix. The study protocol was registered with PROSPERO (CRD42023428013). The review spanned studies published between 1974 and 2023, identified through an extensive literature search on databases like MEDLINE, EMBASE, LILACS, CINAHL, the Cochrane Oral Health Group Specialized Register, Scopus, and Web of Science. Distiller SR software was used to assess study quality and extract the outcome data. The NTP-OHAT scale assessed evidence quality, and case-control, cross-sectional, and cohort studies in English were included. Comprehensively reviewing 5287 articles resulted in 29 studies being included in the final analysis, comprising 15 cross-sectional, seven case-control, and seven cohort studies. All 29 studies qualified for qualitative analysis. Eleven studies analyzed lead (Pb) effects on health outcomes, four analyzed manganese (Mn), and 14 investigated other element groups. Primary teeth biomatrix assessed various health outcomes: neurobehavior, childhood behaviour, ADHD, birth outcomes, fetal alcohol syndrome disease, inflammatory bowel disease, and dental caries. This study contributes to existing evidence, reinforcing a link between environmental metal exposure and health consequences. The evidence extends to prenatal and postnatal periods, substantiated by primary teeth biomatrix analysis. Lead level fluctuations can influence neuropsychological functioning, potentially causing cognitive impairments. Altered manganese levels correlate with behavioral issues, adverse effects on visuospatial development, and birth weight changes. Primary teeth biomatrices aid fetal alcohol spectrum disorders diagnosis, and correlations between organo-chemical exposure and autism were observed.

Attention deficit among preschool and school-aged children living near former metal-processing plants in Romania

Industrial areas affected by high and long-term heavy metal pollution have a great impact on health of the resident population. Children represent a group at high-risk with an increased susceptibility to chronic heavy metal intoxication. Our work included the assessment of attention particularities through a case-control study in pre-school and school-aged children (4-6 years and 8-11 years) from two study areas, Copşa Mică and Zlatna, compared to a non-polluted locality with no history of heavy metal pollution. Copşa Mică and Zlatna are two of the most polluted heavy metals regions in Romania due to non-ferrous metallurgy for a long period of time. Recruitment of participants was made by a random selection of an entire class for each age within the schools and kindergartens from the study areas (Copşa Mică and Zlatna) and from the non-polluted region. Interpretation of data was performed using statistical analysis (ANOVA and Student's t-test). Preschool children (4-6 years) were tested using Wechsler Preschool and Primary Scale of Intelligence (WPPSI) tests, Animal House and labyrinth samples. The results of the attention tests applied to pre-school children were lower in the study areas compared to the control group, but no statistical differences were found. The results of the attention tests applied to children aged between 8 and 11 years (Toulouse-Pieron test and Traffic light test) indicate lower average scores within the study groups from polluted areas, compared to the control group. Differences with statistically significance were registered for the 8 years age group (p = 0.037). In these areas efficient strategies and precise intervention measures are needed in order to limit or remove the heavy metal exposure and protect the human health, especially the groups exposed to a high level of risk.

Heavy metals and neurodevelopment of children in low and middle-income countries: A systematic review

BACKGROUND

The presence of harmful environmental exposures, which disproportionately affects low-and-middle income countries (LMICs), contributes to >25% of deaths and diseases worldwide and detrimentally affects child neurodevelopment. Few resources succinctly summarize the existing literature on this topic. Our objective is to systematically review and characterize the evidence regarding the relationship between heavy metals and neurodevelopment of children in LMICs.

METHODS

We conducted a medical librarian-curated search on multiple online databases to identify articles that included individuals <18 years living in a LMIC, quantitatively measured exposure to a heavy metal (either prenatal or postnatal), and used a standardized measurement of neurodevelopment (i.e. cognitive, language, motor, and behavior). Reviews, editorials, or case studies were excluded. Results were analyzed qualitatively, and quality was assessed.

RESULTS

Of the 18,043 screened articles, 298 full-text articles were reviewed, and 100 articles met inclusion criteria. The included studies represented data from 19 LMICs, only one of which was classified as a low-income country. Ninety-four percent of postnatal lead and all postnatal manganese studies showed a negative association with metal exposure and neurodevelopment, which were the strongest relationships among the metals studied. Postnatal exposure of mercury was associated with poor neurodevelopment in only half of studies. Limited data on postnatal arsenic and cadmium suggests an association with worse neurodevelopment. Findings were mixed for prenatal arsenic and lead, although some evidence supports that the neurotoxicity of lead was amplified in the presence of manganese.

CONCLUSIONS AND POTENTIAL IMPACT

We found that lead and manganese appear to consistently have a detrimental effect on the neurodevelopment of children, and more evidence is needed for mercury, arsenic, and cadmium. Better characterization of these effects can motivate and inform prioritization of much needed international policies and programs to reduce heavy metal exposures for young children within LMICs.

Association of serum microcystin levels with neurobehavior of school-age children in rural area of Southwest China: A cross-sectional study

To investigate whether microcystin-LR (MC-LR) influences children's cognitive function and memory ability, we measured serum MC-LR and whole blood lead levels in 697 primary students, and collected their academic and neurobehavioral test scores. The median of serum MC-LR levels was 0.80 µg/L (the value below the limit of detection to 1.67 µg/L). The shapes of the associations of serum MC-LR levels (cut-point: 0.95 µg/L) with scores on academic achievements, digit symbol substitution test and long-term memory test were parabolic curves. Logistic regression analysis showed that MC-LR at concentrations of 0.80-0.95 µg/L was associated with the increased probability of higher achievements on academic achievements [odds ratio (OR) = 2.20, 95% confidence interval (CI): 1.28-3.79], and also with scores on digit symbol substitution test (OR = 1.73, 95% CI: 1.05-2.86), overall memory quotient (OR = 2.27, 95% CI: 1.21-4.26), long-term memory (OR = 1.85, 95% CI: 1.01-3.38) and short-term memory (OR = 2.13, 95% CI: 1.14-3.98) after adjustment for confounding factors. Antagonism of MC-LR and lead on long-term memory was observed (synergism index = 0.15, 95% CI: 0.03-0.74). In conclusion, serum MC-LR at concentrations of 0.80-0.95 µg/L was positively associated with higher scores on cognitive and neurobehavioral tests, and antagonism between MC-LR at concentrations of 0.80-1.67 µg/L and lead exposure was obviously observed on long-term memory in children. Concerning that MC-LR is a neurotoxin at high doses, our observation is interesting and need further investigation.

Lead exposure and indices of height and weight in Uruguayan urban school children, considering co-exposure to cadmium and arsenic, sex, iron status and dairy intake

Child growth depends on complex factors including diet, nutritional status, socioeconomic, and sanitary conditions, and exposure to environmental chemicals. Lead exposure is known to impair growth in young children but effects in school-age children are less clear. The effects of co-exposure to low-level lead and other toxic metals on child growth are not well understood. We examined cross-sectional associations of blood lead (BLL) with growth indices (Z scores of body mass index for age, BAZ, and height for age, HAZ) in Uruguayan urban school children (n = 259; ~7 y). Potential differences in these associations in children with lower vs. higher urinary inorganic arsenic metabolites (U-As), urinary cadmium (U-Cd), sex (42% girls), iron deficiency (ID, 39% children), or intake of dairy foods below recommended levels were examined. BLL was measured using AAS, U-As using HPLC-HGICP-MS, and U-Cd using ICP-MS. Dietary information was obtained by two 24-h recalls completed by caregivers. Children's linear growth was within age and sex-appropriate reference values. Overweight (BAZ > 1 2 SD) was found in 20.1%, and obesity (BAZ > 2 SD) in 18.5%, of children. Ranges (5th, 95th percentile) of biomarker concentrations were: BLL, 0.8-7.8 μg/dL; U-Cd, 0.01-0.2 μg/L, and U-As, 4.0-27.3 μg/L. BLL was inversely associated with HAZ ([95% CI]: 0.10 [-0.17, -0.03]) in covariate-adjusted models. Although this association was slightly more pronounced in girls, children without ID, and children with lower U-As, there was little evidence of effect modification due to overlapping CIs in stratified models. BLLs were not associated with BAZ, except for a suggestion of a negative relationship in girls (-0.10 [-0.23, 0.02]) but not boys [0.001 [-0.11, 0.12]). Our findings indicate that exposure to low levels of lead was associated with lower HAZ in apparently normally growing urban school children. Larger future studies should help elucidate if these associations persist over time and across populations.

Effects of ALAD genotype on the relationship between lead exposure and anthropometry in a Cohort of Mexican children

OBJECTIVES

Lead exposure is associated with children's growth, but this relationship may depend on the presence of susceptibility factors, including genetic variation. Blood lead levels (BLL) differ by ALAD (aminolevulinic acid dehydratase) genotype. We investigated the association between BLL and growth in Mexican first-graders with different ALAD genotypes.

METHODS

Children between the ages of 6-8 years (n = 602) attending first grade in schools within the vicinity of a metal foundry in Torreón, Mexico were enrolled into a randomized controlled trial (RCT) testing the efficacy of iron and/or zinc supplementation on blood lead levels (BLL) and cognition. BLL and anthropometry were assessed at baseline (height, height-for-age z-score (HAZ), knee height, head circumference), after 6 (head circumference) and 12 months (height, HAZ, knee height). Children with ALAD_1-1 and ALAD_1-2/2-2 were compared. The study sample included 538 and 470 participants who had complete data at baseline and follow-up, respectively. Separate multivariable linear regression models adjusted for covariates were used to test the association between BLL at baseline and each anthropometric measure. Covariates included age, sex, hemoglobin, crowding, and maternal education. BLL x ALAD genotype interaction term was tested.

RESULTS

Median BLL (10.1 μg/dL) did not differ by ALAD genotype. After covariate adjustment, baseline BLL was inversely associated with baseline height, HAZ, and knee height. The association (β [95% CI]) between BLL and baseline height (-0.38[-0.68, -0.09]), HAZ (-0.07[-0.12, -0.02]) and knee height (-0.14[-0.25, -0.02]), was somewhat stronger in children with ALAD_1-2/2-2 than ALAD_1-1 (-0.09[-0.16, -0.02], -0.02[-0.03, -0.004] and -0.04[-0.06, -0.01], respectively). No associations between BLL and growth at 6 or 12 months were detected irrespective of ALAD genotype.

CONCLUSIONS

BLL was adversely associated with anthropometric measures among Mexican children. ALAD genotype may be a susceptibility factor for the effects of lead on child growth.

Lead exposure during childhood and subsequent anthropometry through adolescence in girls

INTRODUCTION

Cross-sectional studies suggest that postnatal blood lead (PbB) concentrations are negatively associated with child growth. Few studies prospectively examined this association in populations with lower PbB concentrations. We investigated longitudinal associations of childhood PbB concentrations and subsequent anthropometric measurements in a multi-ethnic cohort of girls.

METHODS

Data were from The Breast Cancer and the Environment Research Program at three sites in the United States (U.S.): New York City, Cincinnati, and San Francisco Bay Area. Girls were enrolled at ages 6-8 years in 2004-2007. Girls with PbB concentrations collected at ≤10 years old (mean 7.8 years, standard deviation (SD) 0.82) and anthropometry collected at ≥3 follow-up visits were included (n = 683). The median PbB concentration was 0.99 μg/d (10th percentile = 0.59 μg/dL and 90th percentile = 2.00 μg/dL) and the geometric mean was 1.03 μg/dL (95% Confidence Interval (CI): 0.99, 1.06). For analyses, PbB concentrations were dichotomized as <1 μg/dL (n = 342) and ≥1 μg/dL (n = 341). Anthropometric measurements of height, body mass index (BMI), waist circumference (WC), and percent body fat (%BF) were collected at enrollment and follow-up visits through 2015. Linear mixed effects regression estimated how PbB concentrations related to changes in girls' measurements from ages 7-14 years.

RESULTS

At 7 years, mean difference in height was -2.0 cm (95% CI: -3.0, -1.0) for girls with ≥1 μg/dL versus <1 μg/dL PbB concentrations; differences persisted, but were attenuated, with age to -1.5 cm (95% CI: -2.5, -0.4) at 14 years. Mean differences for BMI, WC, and BF% at 7 years between girls with ≥1 μg/dL versus <1 μg/dL PbB concentrations were -0.7 kg/m2 (95% CI: -1.2, -0.2), -2.2 cm (95% CI: -3.8, -0.6), and -1.8% (95% CI: -3.2, -0.4), respectively. Overall, these differences generally persisted with advancing age and at 14 years, differences were -0.8 kg/m2 (95% CI: -1.5, -0.02), -2.9 cm (95% CI: -4.8, -0.9), and -1.7% (95% CI: -3.1, -0.4) for BMI, WC, and BF%, respectively.

CONCLUSIONS

These findings suggest that higher concentrations of PbB during childhood, even though relatively low by screening standards, may be inversely associated with anthropometric measurements in girls.

The level and distribution of heavy metals and changes in oxidative stress indices in humans from Lahore district, Pakistan

Human biomonitoring is a well-recognized tool for estimating the exposure of humans to environmental pollutants. However, heavy metals' pollution from anthropogenic origin is a cause for concern because of its potential accumulation in the environment and living organisms, leading to long-term toxic effects. This study was aimed to assess the concentrations of cadmium (Cd), chromium (Cr), lead (Pb), copper (Cu), nickel (Ni), cobalt (Co), manganese (Mn), iron (Fe), and zinc (Zn) in human biological samples (urine, whole blood, hair, and nails) and antioxidant response in blood samples from 48 individuals exposed to heavy metals and to compare them with different age classes and sites. The results indicated that there were metal-specific differences in concentration in exposure groups among the studied sites. The concentration of heavy metals in blood samples showed the following order : Pb > Cd > Ni > Co > Cr. In urine samples, the order was Cu > Pb > Cr > Ni > Co > Cd; in nails samples, the order was Pb > Ni > Cr > Co > Cd > Mn; and in hair samples, the trend was Pb > Ni > Cr > Mn > Cd > Co. A significant (p > 0.05) decrease in antioxidants enzymes activity was observed with increase in heavy metals concentrations. This is the first study reporting biological evidence of altered toxic metals' concentration in humans in Lahore, Pakistan, due to environmental exposure. Further research, including risk analysis studies, food chain contamination, and epidemiological and clinical investigations, are needed to assess optimal levels for dietary exposure in the study area and associated adverse health outcomes.

Metal exposure in schoolchildren and working children. A urinary biomonitoring study from Lahore, Pakistan

In order to document the exposure to trace metals among urban schoolchildren and rural working children, we measured the urinary concentrations of metals in schoolchildren from two areas of differing traffic intensity in Lahore, and in children working in carpet weaving or the brick industry outside Lahore. In a cross-sectional design, we recruited a convenience sample of 339 children aged 8-12 years (mean age 9.9 y, SD 1.4; 47% girls) from two elementary schools in Lahore - one situated in a high air pollution area (n=100) and one situated in an area with lower air pollution (n=79) - and from the carpet weaving industry (n=80) and brick industry (n=80). A spot urine sample was collected and concentrations of 20 metals and metalloids were measured by inductively coupled plasma-mass spectrometry (ICP-MS). Samples of drinking water were similarly analyzed. In general, the urinary concentrations of several toxic metals (including Cr, Mn, As, Mo, Cd, Pb, U) were higher than international reference values. Concentrations of As were especially elevated in children working in the brick making industry [geometric mean (GM) 118 μg/L], but they were also high among urban schoolchildren (GM 68 μg/L and 56 μg/L). Lead (Pb) was higher in urine from schoolchildren in the high air pollution area (GM 11 μg/L) than in those from the lower pollution area (GM 5.3 μg/L). Uranium (U) was high in both carpet weavers (GM 0.28 μg/L) and brick kiln workers (GM 0.45 μg/L). Concentrations of As, Pb, and U in drinking water corresponded well with urinary concentrations of metals. This descriptive study provides evidence for a high exposure to several toxic metals in this area of Pakistan. The concentrations of urinary As are in the order of those found in other regions of the world with high environmental exposure to As. The sources and pathways of exposure and the health significance of these findings need to be further investigated.

Learning disorder and blood concentration of heavy metals in the United Arab Emirates

Children are frequently exposed to toxic metals in the environment, and their developing central nervous system is particularly vulnerable to their effects. This study examined the blood level of heavy metals in children with learning disorder (LD) as compared to children without LD in the United Arab Emirates (UAE). Significantly high blood concentrations of seven heavy metals were found in children with LD. Further analysis using forward stepwise logistic regression showed that molybdenum levels and family history of developmental problems were the best predictors of LD. Our findings suggest the need for monitoring for toxic metals in the environment.

Adipose tissue: another target organ for lead accumulation? A study on Sardinian children (Italy)

OBJECTIVES

This study analyzes the relationship between lead levels and adipose tissue in Sardinian children. As an environmental pollutant, lead occurs in two different chemical forms: inorganic and organic lead; organic lead is present in the environment mainly as lead-alkyls (tetramethyl and tetraethyl lead). The lead-alkyls are characterized by their liposolubility; because of this characteristic, the behavior of organic Pb in the organism is similar to that of persistent organic pollutants (POPs). In fact, the high liposolubility of POPs, synthetic chemical substances highly resistant to biodegradation in both the environment and the human body, gives them a preferential tendency to accumulate in adipose tissue.

METHODS

The study sample consisted of 759 children between 11 and 15 years resident in various municipalities of Sardinia. Hair lead levels (PbH) were used as the biomarker of exposure, while several anthropometric indexes were adopted to evaluate the adipose tissue: weight, body mass index, waist circumference, waist to hip circumference ratio, and sum of skinfolds (Σskf).

RESULTS

The results of the multivariate ridge regression analysis, controlling for sex and age, show a significant positive relationship between logPbH and logΣskf but not the other adiposity indicators.

CONCLUSIONS

This results suggests that organic lead tends to accumulate in adipose tissue, although it would be appropriate to measure lead levels in the adipose tissue itself in order to verify the results. Hence this tissue could be considered a possible new biological matrix for the evaluation of environmental lead exposure.

Evaluation of association between biomarkers of lead exposure in Sardinian children (Italy)

The aim of this work is to verify whether there are statistically significant correlations between the concentrations of lead in blood, urine, and hair in children. The sample collected in 2007 consists of 163 children of both sexes from 11-14-year-olds, living in three municipalities of Sardinia (Italy). Inductively coupled plasma atomic mass spectrometry has been used in the determination of lead concentration in biological material. For the overall sample, there is a non-significant partial correlation among the three matrices. However, for subjects with blood lead levels ≥5 μg/dL, there is a significant positive partial correlation between the lead levels in blood and hair, but not between blood and urine or between urine and hair. The results suggest that blood is the preferred biomarker to ascertain lead exposure in human populations, whereas hair can be used as a tool screening when an area is exposed to medium or high lead pollution.

Cloud point extraction for determination of lead in blood samples of children, using different ligands prior to analysis by flame atomic absorption spectrometry: a multivariate study

The phase-separation phenomenon of non-ionic surfactants occurring in aqueous solution was used for the extraction of lead (Pb(2+)) from digested blood samples after simultaneous complexation with ammonium pyrrolidinedithiocarbamate (APDC) and diethyldithiocarbamate (DDTC) separately. The complexed analyte was quantitatively extracted with octylphenoxypolyethoxyethanol (Triton X-114). The multivariate strategy was applied to estimate the optimum values of experimental factors. Acidic ethanol was added to the surfactant-rich phase prior to its analysis by flame atomic absorption spectrometer (FAAS). The detection limit value of Pb(2+) for the preconcentration of 10 mL of acid digested blood sample was 1.14 μg L(-1). The accuracy of the proposed methods was assessed by analyzing certified reference material (whole blood). Under the optimized conditions of both CPE methods, 10 mL of Pb(2+) standards (10 μg L(-1)) complexed with APDC and DDTC, permitted the enhancement factors of 56 and 42, respectively. The proposed method was used for determination of Pb(2+) in blood samples of children with kidney disorders and healthy controls.

The influence of environmental exposure on lead concentrations in scalp hair of children in Pakistan

In the present study the environmental and occupational exposure of Pb has been assessed by analyzing the scalp hair (SH) of children (both genders), residing in the vicinity of industrial area of Hyderabad, Pakistan. A total of 339 children attending primary schools situated in the industrial area, age ranged 5-10 years, while for comparative purpose children of the same age group from schools located in an area devoid of industries, were selected. The scalp hair was oxidized by acid mixture in a microwave oven prior to determination of Pb by graphite furnace atomic absorption spectrometry. The concentration profile of Pb in SH of children showed that the level changed significantly (44-64%) with changes of living habits or environmental exposure. The influence of age, sex, and family occupation on the children's hair Pb concentration was also evaluated. Significant differences in SH-Pb levels were observed between the exposed (EXC) and non-exposed (NEC) children (p<0.01). The concentration of Pb in boys of exposed (EX) and non-exposed (NEX) area was more than in girls of the corresponding localities. The boys and girls of NEX and EX areas have SH-Pb in the range of 3.97-5.4 and 6.06-13.7 μg g(-1) and 3.41-7.4 and 5.56-11.5 μg g(-1), respectively. The Pb levels increased with age in both study groups.

Iron, Lead, and Children's Behavior and Cognition

Iron deficiency (ID) is the most common micronutrient deficiency in the world, with consequences of ID and ID anemia (IDA) in young children including behavioral and cognitive deficits. In turn, lead exposure is one of the most common environmental toxicants affecting children. Elevated blood lead levels (BLLs) in young children are also associated with behavioral and cognitive deficits. The metabolic and physiological connections between iron and lead, including a common route of entry into the body and similar neural targets, suggest a considerable overlap in their effects on functional outcomes. Very few studies have examined the existence of increased susceptibility to lead neurotoxicity in children with ID, but there is evidence that ID and BLL are independently associated with cognition and behavior. Children's susceptibility to both ID and elevated BLLs will likely depend on the timing and severity of both exposures, something that should be investigated systematically.

Tooth element levels indicating exposure profiles in diabetic and hypertensive subjects from Mysore, India

Element contents of teeth elucidate exposure nature, but less is known about association of tooth element concentrations of diabetics and hypertensives with exposure profile. Present study aims to estimate copper, chromium, iron, zinc, nickel, and lead concentrations in the permanent teeth of control, diabetic, and hypertensive subjects from Mysore. The results show that lead levels of teeth (Pb-T) are higher in the hypertensives and diabetics, whereas copper levels of teeth (Cu-T) are lower in the hypertensives and users of stainless steel utensils than that of controls and users of mixed utensils. The elevated Cu-T levels found in the users of mixed utensils that being made of several metals are ascribed to leaching effect of sour and spicy food of Indian cuisine. The element levels were influenced by diet (Zn-T), place of living, sex and income (Pb-T) of the subjects, but not by age, drinking water from different sources, and certain habits viz., smoking, alcohol consumption, chewing betel, and nut. Thus, it is evident that high Pb-T and low Cu-T levels may be related with diabetes and hypertension and high Pb-T and Cu-T levels, respectively, in the urbanites, and the users of mixed utensils may show different exposure profiles from environment and utensils.

Economics of preventing premature mortality and impaired cognitive development in children through home-fortification: a health policy perspective

BACKGROUND

Home-fortification is a new strategy of adding micronutrients including zinc and iron to home-made foods. Zinc supplementation may prevent morbidity and mortality related to diarrheal illnesses, and iron supplementation may improve cognitive development, in children.

OBJECTIVES

To project clinical and economic effects of home-fortification in children in an urban slum of Karachi, Pakistan.

METHODS

This is a cost benefit analysis of 5,000 simulated male and female infants (6-12 months) assigned to micronutrients or placebo for 4 months and followed for 55 years. We linked the effect of zinc on longitudinal prevalence of diarrhea to mortality, and the effect of iron on hemoglobin to IQ scores and lifetime earnings. Cost estimates were based on volumes of resource utilization from the Pakistan Sprinkles Diarrhea study. Main outcome was incremental benefit defined as the gain in lifetime earnings after accounting for the incremental costs of micronutrients over placebo (societal perspective).

RESULTS

Our model projected that the reduction in diarrhea and improvement in hemoglobin concentrations through home-fortification was associated with reduced child mortality, higher IQ scores, and higher earnings. The present value of incremental benefit was $106 (95 percent probability interval = $17 to $193) U.S. dollars, which corresponds to $464.79 ($74.54 to $846.27) international dollars using a purchasing power parity exchange rate.

CONCLUSIONS

Home-fortification appears to improve clinical outcomes at a reasonable cost, and may actually be cost beneficial when lifetime earnings are considered.

Status of children's blood lead levels in Pakistan: implications for research and policy

OBJECTIVES

Data on blood lead levels, sources of lead and health effects were reviewed among children in Pakistan.

METHODS

A systematic review was conducted of published studies found through PubMed, an index of Pakistani medical journals PakMediNet and unpublished reports from governmental and non-governmental agencies in Pakistan.

RESULTS

With the exception of a few studies that had adequate sample sizes and population-based samples, most studies were small and used convenience sampling methods to select study subjects. Overall, blood lead levels declined from 38 microg/dl in 1989 to 15 microg/dl in 2002. The major sources of lead that directly or indirectly resulted in lead exposure of children included: leaded petrol; father's occupation in lead-based industry; leaded paint; traditional cosmetics; and remedies. Apart from leaded petrol, there was no information regarding the level of lead in other sources such as paints and the household environment. Very little information was available regarding the adverse health effects of lead among children.

CONCLUSION

The phasing out of leaded petrol was a commendable mitigation measure undertaken in July 2001 in Pakistan. A comprehensive assessment is now needed urgently to explore other sources of lead contributing to adverse health effects, and to plan intervention options with the ultimate goal of reducing the burden of disease due to lead exposure.

Associations between cognitive function, blood lead concentration, and nutrition among children in the central Philippines

OBJECTIVE

Because little is known about its effects on cognitive function among children in less-developed countries, we determined the impact of lead exposure from other nutritional determinants of cognitive ability.

STUDY DESIGN

Data were from a cross-sectional population-based stratified random sample of 877 children (age 6 months-5 years) participating in the Quality Improvement Demonstration Study we are conducting in the Philippines. With data from validated psychometric instruments, venous blood samples, and comprehensive survey instruments, we developed multi-stage models to account for endogenous determinants of blood lead levels (BLLs) and exogenous confounders of the association between BLLs and cognitive function.

RESULTS

A 1 microg/dL increase in BLL was associated with a 3.32 point decline in cognitive functioning in children aged 6 months to 3 years and a 2.47 point decline in children aged 3 to 5 years olds. BLL was inversely associated with hemoglobin and folate levels. Higher folate levels mitigated the negative association between BLL and cognitive function.

CONCLUSIONS

These population-based data suggest greater lead toxicity on cognitive function than previously reported. Our findings also suggest that folate and iron deficient children are more susceptible to the negative cognitive effects of lead. Folate supplementation may offer some protective effects against lead exposure.

Lead contents in the surface enamel of deciduous teeth sampled in vivo from children in uncontaminated and in lead-contaminated areas

This study aimed to: (1) measure lead contents in the surface enamel of two populations consisting of 4-6-year-old children, one from an apparently uncontaminated area (Ribeirão Preto, São Paulo State, SP, Brazil, n=247) and the other from an area notoriously contaminated with lead (Bauru, São Paulo State, Brazil, n=26); (2) compare biopsy depths between the two populations; (3) correlate biopsy depth with lead content; (4) stratify samples according to biopsy depth to compare lead contents in samples from similar biopsy depths. A surface enamel acid-etch microbiopsy was performed in vivo on a single upper deciduous incisor for each sample. Lead was measured by graphite furnace atomic absorption spectrometry (GFAAS) while phosphorus was measured colorimetrically to establish biopsy depth. Samples from both populations were classified into categories of similar biopsy depths based on biopsy depth quartiles. Median lead contents were statistically different between the Ribeirão Preto population (206 microg/g, range: 5-1399 microg/g) and the Bauru population (786 microg/g, range: 320-4711 microg/g) (p<0.001); however, biopsy depth did not differ between the Ribeirão Preto (3.9 microm, Standard Deviation, SD=0.9) and Bauru (3.8 microm, SD=0.9) populations (p=0.7940). Pearson's correlation coefficient for biopsy depths versus log10 lead values was -0.29 for Ribeirão Preto and -0.18 for Bauru. Lead contents were statistically different between the two populations for all quartiles of biopsy depth. These findings suggest that lead accumulated in the surface enamel of deciduous teeth is linked to the environment in which people reside, indicating that this tissue should be further explored as an accessible biomarker of lead exposure.

Deficits in cognitive function and achievement in Mexican first-graders with low blood lead concentrations

Elevated blood lead levels in children are associated with lower scores on tests of cognitive functioning. Recent studies have reported inverse relations between lifetime exposure and intellectual functioning at blood lead concentrations below 10 microg/dL, the Centers for Disease Control and Prevention's (CDC) level of concern. We report associations between blood lead and cognitive performance for first-grade Mexican children living near a metal foundry. Using a cross-sectional design, we examined the relation between children's concurrent blood lead concentrations (mean (SD) 11.4 microg/dL (6.1)) and their performance on 14 tests of global or specific cognitive functions. The blood lead-cognition relations were modeled using both linear and nonlinear methods. After adjustment for covariates, a higher blood lead level was associated with poorer cognitive performance on several cognitive tests. Segmented linear regressions revealed significant effects of lead but only for the segments defined by a concurrent blood lead concentration below 10-14 microg/dL. One implication of these findings is that at the age of 7 years, even in the absence of information on lead exposure in infancy and early childhood, a test result with blood lead < 10 microg/dL should not be considered safe. Together with other recent findings, these results add to the empirical base of support available for evaluating the adequacy of current screening guidelines and for motivating efforts at primary prevention of childhood lead exposure.

Health and road transport in Pakistan

OBJECTIVE

The 1998 Global Burden of Disease Study estimated that road traffic injuries (RTIs) will become the third leading cause of lost disability-adjusted life years, with two-thirds of the deaths occurring in the least developed nations. Moreover, automobile-based transport systems are associated with air pollution (lead toxicity, asthma and greenhouse gas accumulation), noise disturbances, physical inactivity and obesity.

STUDY DESIGN

This study (1) reviewed road transport literature in Pakistan and the impacts on health outcomes; (2) examined health policies to assess their focus on transport-related health problems; and (3) identified policy gaps for future research.

METHODS

A methodological review of the literature on direct and indirect effects of road transportation in Pakistan. This review includes government documents, memos, statements and draft policies as well as relevant articles indexed in MEDLINE.

RESULTS

A systematic review revealed no approved transport policy in Pakistan, despite three national health policy documents. The Health Chapter of the 9th Five Year Plan appreciates the grave threat of unchecked RTI, but fails to offer specific policy interventions. Despite ambitious plans by the Pakistan Environmental Protection Agency, actual projects and their implementation remain scarce, resulting in ever-increasing air pollution. The health impact of lead toxicity, noise pollution and RTIs remain high, while obesity is on the rise.

CONCLUSION

The increasing health impact of road transport on 140 million people calls for immediate policy action. Government agencies must intervene effectively to establish monitoring and decentralised enforcement nationwide, while simultaneously supporting alternative modes of transportation.

Lead neurotoxicity: From exposure to molecular effects

The effects of lead (Pb(2+)) on human health have been recognized since antiquity. However, it was not until the 1970s that seminal epidemiological studies provided evidence on the effects of Pb(2+) intoxication on cognitive function in children. During the last two decades, advances in behavioral, cellular and molecular neuroscience have provided the necessary experimental tools to begin deciphering the many and complex effects of Pb(2+) on neuronal processes and cell types that are essential for synaptic plasticity and learning and memory in the mammalian brain. In this review, we concentrate our efforts on the effects of Pb(2+) on glutamatergic synapses and specifically on the accumulating evidence that the N-methyl-D-aspartate type of excitatory amino acid receptor (NMDAR) is a direct target for Pb(2+) effects in the brain. Our working hypothesis is that disruption of the ontogenetically defined pattern of NMDAR subunit expression and NMDAR-mediated calcium signaling in glutamatergic synapses is a principal mechanism for Pb(2+)-induced deficits in synaptic plasticity and in learning and memory documented in animal models of Pb(2+) neurotoxicity. We provide an introductory overview of the magnitude of the problem of Pb(2+) exposure to bring forth the reality that childhood Pb(2+) intoxication remains a major public health problem not only in the United States but worldwide. Finally, the latest research offers some hope that the devastating effects of childhood Pb(2+) intoxication in a child's ability to learn may be reversible if the appropriate stimulatory environment is provided.

Recent developments in low-level lead exposure and intellectual impairment in children

In the last decade children's blood lead levels have fallen significantly in a number of countries, and current mean levels in developed countries are in the region of 3 Mu g/dL. Despite this reduction, childhood lead poisoning continues to be a major public health problem for certain at-risk groups of children, and concerns remain over the effects of lead on intellectual development in infants and children. The evidence for lowered cognitive ability in children exposed to lead has come largely from prospective epidemiologic studies. The current World Health Organization/Centers for Disease Control and Prevention blood level of concern reflects this and stands at 10 Mu g/dL. However, a recent study on a cohort of children whose lifetime peak blood levels were consistently less than 10 Mu g/dL has extended the association of blood lead and intellectual impairment to lower levels of lead exposure and suggests there is no safety margin at existing exposures. Because of the importance of this finding, we reviewed this study in detail along with other recent developments in the field of low-level lead exposure and children's cognitive development. We conclude that these findings are important scientifically, and efforts should continue to reduce childhood exposure. However, from a public health perspective, exposure to lead should be seen within the many other risk factors impacting on normal childhood development, in particular the influence of the learning environment itself. Current lead exposure accounts for a very small amount of variance in cognitive ability (1-4%), whereas social and parenting factors account for 40% or more.