partment holds sessions on the problem for physicians, social workers and nurses. Literature is distributed to the public, particularly to parents in "high risk" areas, by public health nurses and sanitarians. The city also uses people who live in the high risk areas to help identify possible cases of lead intoxicated children and to provide families with firsthand information about the dangers of eating lead paint. Reported cases of childhood lead intoxication are followed up by a public health nurse to ensure treatment and necessary follow-up. Public health sanitarians inspect premises for sources of lead, effect necessary repair and repainting, sample and analyze peeling paint for lead content, and check other places where the child may regularly spend time. (8)

The Philadelphia Department of Public Health's program has been under way since 1956, with the cooperation of realtors, landlords, various industries (including a member company of LIA) and the Society of Friends. It includes systematic investigation of all reported cases. The Department issues a checklist of possible sources of lead for use in field investigations when the source of lead ingestion isn't readily apparent. It also issues specifications and safety standards for the removal of lead paint from interiors. The Department sponsored a two-day seminar on lead poisoning in June 1967 in which representatives of the lead industry participated.

Cause and
Incidence of
Childhood
Plumbism

Although plumbism in children is a distinct and specific problem, its control must be viewed as one aspect of protecting infants and children from other home hazards.

The National Clearinghouse, Poison Control Branch, Division of Direct Health Services, of the U.S. Public Health Service, finds that 90 percent of all reported poisoning cases involve children under the age of 5 who have eaten or drunk substances found around the house. (9) In about half the cases, these substances are medicines of one kind or another. In the other half, household products such as cleaning and polishing agents, pesticides, turpentine, petroleum products and cosmetics are involved. In 1967, for example, among all substances "most frequently ingested" by such children, paint (leaded and nonleaded) ranks 26th, and involved 1 percent of the total reported from 395 centers in 43 states. However, many lead poisoning cases are not reported to these centers, so that such figures indicate the extent of acute poisoning cases from other substances but not from lead ingestion.

Studies have shown that almost every case of childhood plumbism is related to old lead paint in old buildings, a situation found mostly in large cities, mainly those east of the Mississippi River. In Baltimore, for example, where childhood plumbism has been brought under control, early studies showed that from 50 to 70 percent of old houses in some slum sections had flaking paint that contained lead. Housing-Plumbism Relation

The relation of housing to plumbism was shown in a home survey of preschool children in Cleveland, which has had a study and control program for years. Of 801 children living in old houses, 216 (27 percent) had abnormal lead concentrations in their urine, and 38 (4.7 percent) were al

ready afflicted with plumbism. Of 105 children in a new housing project, only three (2.85 percent) were found to have abnormal lead concentrations in their urine and there were no cases of plumbism. (10)

In some instances, a child may ingest lead from objects such as windowsills or repainted cribs when care has not been taken to avoid lead paints. Other possible sources are rarely reported and even more rarely established. Some epidemiological studies have indicated that symptomatic lead intoxication, particularly encephalopathy, is more common in the JuneSeptember period. However, lead intoxication may occur at any time of the year, and there is no season in which physicians and other public health workers should be less alert. (11) Plumbism also shows close family relationships. If one member of a family is found to have plumbism, all the children between 1 and 5 years of age should be carefully checked, since there is a 33 percent incidence among children living in the same household. Most victims are between 1 and 6 years of age, with 85 percent in the 1-3 year old group, as noted on page 5 of the Children's Bureau pamphlet. (2) These toddlers often crawl about without supervision. Either as an aspect of pica, or of the oral exploration usual to children of this age, they may pick up and eat paint chips found on the floors, or chew on cribs or windowsills that were long ago covered with lead-bearing paint. Certain lead compounds are known to have a somewhat sweet taste which may accentuate the appeal to children's palates. As pointed out on page 6 of the Children's Bureau booklet (2), "from three to six months of fairly steady lead ingestion" precedes the appearance of overt symptoms in almost all patients.

The Factor of Pica

Pica, a very common precondition, is the medical term for an unnatural craving for dirt or other nonfood items. Some studies found that from 70 to 90 percent of children suffering from plumbism had a history of pica. In a New York City study, more than 30 percent of children with a diagnosis of pica were found to have lead poisoning. (11) A study of 784 Baltimore

children from underprivileged areas disclosed that nearly 22 percent had pica. (12) In most cases, pica was established as a habit by the second year but had disappeared by the fourth or fifth year.

The causes of pica are unknown despite various theories. In the present state of knowledge, it should be recognized that pica is widespread, occurs particularly often in poor families, and is a potential source of metal and other poisoning, as well as of intestinal parasites.

Dr. Chisolm of Johns Hopkins, a long-time investigator in the field of childhood plumbism, notes that historically, pica "seems to be related mainly to the relative availability of a diet adequate both in quantity and quality to the social group as a whole. Women (especially pregnant women) and young children are the members of the group most vulnerable to pica." (13)

The Emotional Environment

Dr. Chisolm also points out that the symptom of pica is most likely to occur in children with a high level of mouth activity whose oral relief of anxiety "is reinforced by cultural patterns and to whom the mothering necessary to stop it is unavailable for a variety of reasons. When such a child is exposed to hazardous environmental lead sources, the likelihood of plumbism is indeed great." (13)

Medical Aspects

of Childhood Plumbism

It is not the function of this booklet to give specific medical advice, but a brief review is given of the extensive literature on plumbism which the physician may consult in the usual man

ner.

The diagnosis and treatment of lead intoxication in children are complex and must be placed in the hands of experienced physicians. The enclosed pamphlet by the Children's Bureau offers 37 authoritative references. (2) In addition, a bibliography of references to some works in these fields by experts is printed at the end of this booklet.

However, everyone concerned with the problem should be aware of certain findings which should arouse suspicion at once. To physicians not actively engaged in pediatrics, symptoms and signs often are so commonplace and nonspecific that initially they may be overlooked. Cases may occur without being suspected; on the other hand, there are instances of illnesses erroneously diagnosed as lead poisoning.

It is important that all physicians, public health workers and others realize there is a childhood plumbism problem in urban slum areas. Being aware of this fact should make physicians more inclined to recognize and investigate symptoms they ordinarily would not associate with lead intoxication.

Check on Chewing and Pica

The presence of pica should especially arouse a physician's suspicions. Though most children pass through a stage of chewing on almost anything in reach, this habit should be gone by the age of 15 months and should never be of great intensity. Though the presence and history of pica is important, diagnosis should not rest on these alone. Many lead intoxicated patients have been found to have no history of pica when first examined. A careful check should be made to

determine the child's physical environment. A child with lead intoxication has almost always chewed lead painted materials, such as woodwork, plaster, wallpaper or putty, for at least three months before clinical signs ap. pear. Though these materials themselves do not contain lead, they were often coated with leaded paint many years ago.

When a suspected case of childhood plumbism is seen, a check should be made to learn if the child lives in or frequently visits a house built before World War II. A list of "high-risk" addresses could be posted in all pediatric clinics to help physicians unfamiliar with the city. Most cities with the problem do have such areas of high risk.

Signs and Symptoms

A diagnosis of lead poisoning should be based on clinical findings and sup

ported by biochemical evidence of excessive lead absorption, and, if possible, by evidence of unusual expo

sure.

There are a number of signs and symptoms which should arouse the suspicion of physicians and others, particularly if the patient lives in a slum area. They are not diagnostic by themselves, but are indications that emergency laboratory tests are required. The signs and symptoms listed below are not intended to be either definitive or exhaustive. For a thorough consideration of these sub

jects, the physician should consult the medical literature.

The signs and symptoms of lead accumulation in children chiefly involve three organ systems: the gastrointestinal system, the central nervous system, and the hematologic system. (14)

The gastrointestinal symptoms are those which are most likely to be noticed first by parents and other laymen. They consist of vomiting, complaints of vague abdominal pain and constipation.

These are fairly common complaints among children, but the examining physician should be aware that plumbism may be the true underlying cause. He should also be aware that parents often are not of much help in his efforts to obtain definitive information. A survey of 300 children with confirmed cases of plumbism showed that 76 percent of them had no presenting complaints, but when specific and detailed inquiry was made, it was found that 58 percent had loss of appetite and 9 percent had vomiting. In another study of 22 children afflicted with severe lead encephalopathy, it was found that 18 had been treated symptomatically for "gastroenteritis" for different periods of time before symptoms of central nervous system involvement became apparent. Some of these children had also been treated for anemia, constipation, sugar in the urine, gait disturbance, and sudden onset of crossed or skewed eyes.

Central nervous system involvement: The most serious manifestations of childhood plumbism are those that result from involvement with the brain. These may range from drowsiness to deep unconsciousness (coma), or repeated fits (grand mal seizures). In some cases the first clues to the intoxication are repeated falling, clumsiness or loss of coordination. In other cases, convulsions may bring the child to medical attention. There also may be reading or behavior problems. From the physician's point of view, there is nothing especially characteristic about the convulsions, for they may occur without fever and may be focal or generalized. However, if in the course of a few hours, the pattern

of the seizures switches back and forth between right-sided, left-sided and generalized, the possibility of plumbism should be investigated. The physical examination in such cases may reveal inflammation of the optic nerve, ataxia (lack of muscular coordination), lethargy or seizures-with or without local paralysis and with or without reflex changes-and as such serves to confirm the involvement of the central nervous system but does not provide exact evidence of cause. Hematological findings: Parents will be unable to detect changes in the blood of a possibly affected child. The physician may wish to check for anemia before asking for specific blood lead tests. Iron deficiency anemia is common in toddlers, and does not necessarily mean that the child has absorbed potentially toxic amounts of lead.

According to Dr. Chisolm, there are two groups of children involved: those with asymptomatic increased lead absorption, and those with lead poisoning. The first group, which probably contains the largest number, are children who show evidence of increased body lead burden without evidence of toxicity. The diagnosis of lead poisoning, Dr. Chisolm says, should be reserved for those children who, in addition to evidence of an increased body lead burden, also show biochemical evidence of toxicity. This latter evidence includes increased output of coproporphyrin and/or deltaaminolevulinic acid in urine.

"Some of these will show no clinical signs," Dr. Chisolm says. "Because of the nebulous nature of the clinical signs and symptoms, we should demand that patients with signs and symptoms suggestive of lead intoxication also have biochemical evidence of intoxication." (15)

Tests for
Plumbism

As noted above, the presence of one or more hematological, intestinal or neurological signs or symptoms is not in itself diagnostic of pediatric lead intoxication. Laboratory tests are necessary for the physician to determine whether his patient has absorbed lead in quantities sufficient to induce illness.

By far the most reliable test for lead absorption is the quantitative determination of the lead content of the blood. Since speed is often extremely important in diagnosis of childhood plumbism so that proper treatment can be undertaken, such a test ought to be ordered immediately upon the first suspicion.

Blood lead concentrations should be interpreted with caution as these values can be affected by a number of factors such as competence and experience of laboratories and laboratory technicians, methods used in the collection and storing of samples, and possible recent administration of chelating agents.

Blood-lead concentrations of 40 to 60 micrograms per 100 milliliters of blood have been used by various agencies as the upper limit of the normal range for children. For example, the Chicago Board of Health refers all children with lead values above 50 micrograms to a special clinic for the diagnosis and treatment of lead poisoning, whereas other agencies have suggested 60 micrograms as the upper normal limit of blood lead concentrations. (11, 16, 17) There appears to be general agreement that blood-lead concentrations between 60-80 micrograms are indicative of abnormal absorption of lead, but often not of a degree of absorption which is capable of inducing symptoms of intoxication. Blood concentrations of 80 micrograms and above are considered to be potentially capable of inducing intoxication, requiring immediate action including both referral for treatment and removal of the child from the source of exposure.

Blood lead determinations are the most reliable method currently available to communities with active programs aimed at controlling childhood plumbism. According to Dr. Chisolm, a test recently developed for estimating delta-aminolevulinic acid (ALA) in urine is simple, rapid and inexpensive and may be suited for most screening if it can be shown that the concentration of ALA in random samples of urine provide sufficient discrimination between normal and lead-exposed children. However, further evaluation is necessary before it can be accepted. (Chicago Health Commissioner O'Connell says a 1967 study in that city, which is to be published, found ALA does not correlate with blood lead in screening for asymptomatic lead intoxication.)

Urine lead analyses are generally limited to usefulness in clinical research and in management of hospitalized cases because they require 24-hour collections of urine to yield useful data, says Dr. Chisolm. The edathamil calcium disodium (EDTA) mobilization test for lead also requires quantitative collection of urine and seems to be mostly useful in the study of older children suspected of having chronic plumbism, he notes. (13) (Dr. O'Connell says the EDTA mobilization test is used in all age groups in Chicago's lead clinic with urine

collected for eight hours after intramuscular injection of EDTA. The test is very useful, he says.)

A recent major discussion of medical aspects is "Childhood Lead Poisoning - Comprehensive Management and Prevention," by Drs. J. Julian Chisolm and Eugene Kaplan, both of Johns Hopkins Medical School in Baltimore. Published in the December 1968 Journal of Pediatrics (Vol. 73, No. 6, pp. 942-950), this sums up the views and contributions of the authors and six other experts in the field who participated in a symposium held at Happy Hills Hospital in Baltimore on April 24, 1967. The symposium was held "to call attention to the need for a cooperative community approach to the social, environmental, and psychological aspects of the problem of children with lead intoxication."

Other major contributions include: "The Use of Chelating Agents in the Treatment of Acute and Chronic Lead Intoxication in Childhood," J. Julian Chisolm, Jr. in Journal of Pediatrics (Vol. 73, 1968); "Lead Poisoning in Childhood: Signs, Symptoms, Current Therapy, Clinical Expressions," Joseph Greengard, in Clinical Pediatrics, May 1966; and "Pediatric Lead Poisoning," Hugo Dunlop Smith, in Archives of Environmental Health, February 1964.

References

1. USA Standards Institute (formerly American Standards Association). American Standards Specifications to Minimize Hazards to Children from Residual Surface Coating Materials. Standard Z66.1 1964.

2. Lin-Fu, Jane S., M.D. Lead Poisoning in Children. U.S. Department of Health, Education and Welfare. Children's Bureau publication No. 4521967.

3. Schucker, George W., Vail, Edward H., Kelley, Elizabeth B., and Kaplan, Emanuel. Prevention of Lead Paint Poisoning Among Baltimore Children. Public Health Reports 80(11):969974, November 1965.

4. Baltimore City Health Department. Lead Paint Poisoning in Children, 1968.

5. Dr. Morgan J. O'Connell. Personal communication.

6. Blanksma, Lorry A., Ph.D., Sachs, Henrietta K., M.D., and Murray, Edward F., M.D. Incidence of High Blood Lead Levels in Chicago Children. Paper presented at annual meeting of American Association of Poison Control Centers, Chicago, Oct. 21, 1968.

7. Chicago Board of Health. To Save A Life. Film, 1968.

8. Dr. Felicia Oliver-Smith, New York City Health Department. Personal communication.

9. Verhulst, Henry L. and Crotty, John J. Childhood Poisoning Accidents. Journal of the American Medical Association 203(12):145-146, March 18, 1968.

10. Griggs, R.C., Sunshine, I., Newill, V.A., Newton, B.W., Buchanan, S., and Rasch, C.A. Environmental Factors in Childhood Lead Poisoning. Journal of the American Medical Association 187:703-707, 1964.

11. Jacobziner, Harold. Lead Poisoning in Childhood: Epidemiology, Manifestations, and Prevention. Clinical Pediatrics 5(5):277-286, May 1966.

12. Cooper, Marcia. Pica. Charles C. Thomas, publisher, Springfield, Ill. 1957.

13. Chisolm, J.J., Jr. and Kaplan, Eugene. Childhood Lead Poisoning-Comprehensive Management and Prevention. Journal of Pediatrics 73(6):952-950, December 1968.

14. Dr. Hugo Dunlop Smith. Personal communication.

15. Dr. J.J. Chisolm, Jr. Personal communication.

16. Chisolm, J.J., Jr. Lead Intoxication in Children. Developmental Medicine and Child Neurology 7:529-536, October 1965.

17. Greengard, Joseph. Lead Poisoning in Childhood: Signs, Symptoms, Current Therapy, Clinical Expressions. Clinical Pediatrics 5(5):269-276, May 1966.

For other reading on lead and pediatrics see next page.

Other
References

Byers, R.K., and Lord E.E. Late Ef. fects of Lead Poisoning on Mental Development. American Journal of Diseases of Children, 66:471, November 1943.

Chisolm, J.J., Jr., and Harrison, H.E. The Exposure of Children to Lead, Pediatrics, 18:943-957, December 1956.

Chisolm, J.J., Jr. Treatment of Lead Poisoning. Modern Treatment, 4:710, July 1967.

Chisolm, J.J., Jr. The Use of Chelating Agents in the Treatment of Acute and Chronic Lead Intoxication in Childhood. Journal of Pediatrics, 73:1, 1968. Christian, J.R., Celewycz, B.S., and Andelman, S.L. A Three-Year Study of Lead Poisoning in Chicago. American Journal of Public Health, 54:1241-1251, August 1964.

Coffin, R., Phillips, J.L., Staples, W.I., and Spector, S. Treatment of Lead Encephalopathy in Children. Journal of Pediatrics, 69:198-206, August 1966.

Davis, J.R., and Andelman, S.L. Urinary Delta-Aminolevulinic Acid Levels in Lead Poisoning. I. A Modified Method for the Rapid Determination of Urinary Delta-Aminoevulinic Acid Using Disposable Ion-Exchange Chromatography Columns. Archives of Environmental Health, 15:53, 1967.

Davis, Joseph R., Abrahams, Ronald H., Fishbein, William I., and Fabrega, Enrique A. Urinary Delta-Aminolevu

linic Acid (ALA) Levels in Lead Poisoning II. Correlation of ALA Values With Clinical Findings in 250 Children With Suspected Lead Ingestion. Archives of Environmental Health, 17 (2):164-171, August 1968.

Feigin, R.D., Shannon, D.C., Reynolds, S.L., Shapiro, L.W., and Connelly, J.P. Lead Poisoning in Children. Clinical Pediatrics, 4:38-45, January 1965.

Gordon, Neil, King, E., and MacKay, R. I., Lead Absorption in Children. British Medical Journal, 2:480-482, May, 1967.

Greengard, J., Adams, B., and Berman, E. Acute Lead Encephalopathy in Young Children. Journal of Pediatrics, 66:707-711, April 1965.

Gutelius, M.F., Millican, F.K., Layman, E.M., Cohen, G.J. and Dublin, C.C. Nutritional Studies of Children with Pica. I. Controlled Study Evaluating Nutritional Status. II. Treatment of Pica With Iron Given Intramuscularly. Pediatrics, 29:1012, 1962.

Ingalls, T.H., Tiboni, E.M., and Werrin, M. Lead Poisoning in Philadelphia 1955-1960. Archives of Environmental Health, 3:575-579, November 1964. Jenkins, C.D., and Mellins, R.B. Lead Poisoning in Children: A Study of 46 Cases. Archives of Neurology and Psychiatry, 77:70-78, January 1957.

Kaplan, E., and Shaull, R.S. Determination of Lead in Paint Scrapings as an Aid in the Control of Lead Paint Poisoning in Young Children. American Journal of Public Health, 51:64, 1961.

Lourie, R. S., Layman, E.M., and Mil

lican, F.K. Why Children Eat Things That Are Not Food. Children, 10:143, 1963.

Mellins, R. B., and Jenkins, C.D. Epidemiological and Psychological Study of Lead Poisoning in Children. Journal of the American Medical Association, 158:15-20, May 1955.

Millican, F. K., Layman, E. M., Lourie, R. S., and Takahashi, L. Y. Study of an Oral Fixation: Pica. Journal of the American Academy of Child Psychiatry, 7:79. 1968.

Moncrieff, A. A., Koumides, O. P., Clayton, B. E., Patrick, A. D., Renwick, A. G. C., and Roberts, G. E. Lead Poisoning in Children. Archives of Diseases in Childhood, 39:1-13, February 1964.

Perlstein, M. A., and Attala, R. Neurologic Sequelae of Plumbism in Children. Clinical Pediatrics, 5:292-298, May 1966.

Sartain, P., Whitaker, J. A., and Martin, J. The Absence of Lead Lines in Bones of Children With Early Lead Poisoning. American Journal of Roentgenology, 91:597-601, March

1964.

Smith, H. D. Pediatric Lead Poisoning. Archives of Environmental Health, 8:256-261, February 1964.

Whitaker, J. A., and Vietta, T. J. Fluorescence of the Erythrocytes in Lead Poisoning in Children: An Aid to Rapid Diagnosis. Pediatrics, 24:734738, November 1959.

Diagnosis of Inorganic Lead Poisoning: A Statement. British Medical Journal, P. 501, November 23, 1968.