Physician's Handbook on Childhood Lead Poisoning Prevention
Chapter Ten
Lead Poisoning Prevention During Pregnancy
Lead Poisoning Prevention During Pregnancy
Guidelines for Management of Lead Poisoning in Pregnant Women and Postpartum Women, Part 1
Guidelines for Management of Lead Poisoning in Pregnant Women and Postpartum Women, Part 2
Summary
- Fetal lead exposure is harmful at very high blood lead levels and may be harmful at lower levels, consistent with what is now known about blood lead levels of concern in infants and children.
- All pregnant women must be given anticipatory guidance regarding sources of lead exposure for themselves and for their children as part of prenatal and postpartum care.
- Prenatal care providers must assess pregnant women for current high-dose lead exposure using a risk assessment questionnaire. Women found to be at risk for high-dose exposure must be screened with a blood lead test.
- Studies of lead in pregnancy have suggested that most women with levels over 10 μg/dL have occupational lead exposure. Eight occupational health clinics supported by the State Department of Health are located throughout the state (see appendix E). Women thought to have occupational lead exposure should be referred to one of these clinics.
Lead Poisoning Prevention During Pregnancy
Pregnant women with elevated blood lead levels transfer lead to the fetus. Fetal lead exposure is definitely harmful at very high blood lead levels and may be harmful at lower levels which are now known to be harmful to infants and children.
All pregnant women must be given anticipatory guidance regarding sources of lead exposure for themselves and for their children as part of prenatal and postpartum care. The State Department of Health has developed educational materials for pregnant and postpartum women which explain the hazards of lead exposure, common sources in the environment and simple measures all families can take to reduce exposure of their children to lead. These are available to prenatal care providers.
Medical interventions to reduce body lead burden are contraindicated in pregnancy due to the potential toxicity of chelating agents to the fetus. The only intervention available is to reduce current exposure to lead hazards during the pregnancy. For this reason, the State Department of Health has chosen to limit lead screening of pregnant women to those who are at risk due to current high-dose exposure.
Prenatal care providers must assess pregnant women for current high-dose lead exposure using a risk assessment questionnaire. The Department of Health has collaborated with the New York District of the American College of Obstetricians and Gynecologists to develop a questionnaire to identify pregnant women at risk for current high-dose exposure. Women found to be at risk for high-dose lead exposure must be screened with a blood lead test.
Studies of lead in pregnancy have suggested that most women with levels equal to or greater than 10 μg/dL have occupational lead exposure. If a pregnant woman has a venous blood lead level greater equal to or greater than 10 μg/dL and is at risk for current occupational lead exposure, she should be referred to an occupational health clinic for follow-up. Eight occupational health clinics supported by the Department of Health are located throughout the state. See appendix E for a list of these clinics, their contacts and telephone numbers.
An estimated 32,000 pregnant women will require blood lead screening annually due to risk of current high-dose exposure. This includes about 5,000 who work in lead-related industries as well as those exposed through home renovation and hobbies that utilize lead.
>New York State Department of Health & American College of Obstetricians and Gynecologists, District II Prenatal Care Provider's Reference Card
( Part I )
Guidelines for the Prevention and Identification of Lead Poisoning in Pregnant and Postpartum Women
Since bloodborne lead crosses the placenta, a pregnant woman with an elevated blood lead level may expose her fetus to the toxic effects of lead.
- All pregnant women should receive anticipatory guidance on preventing lead poisoning during pregnancy. They should be informed about the major sources of lead in the environment and the means of preventing exposure.
- At the initial prenatal visit, health care providers should assess a woman's risk for current high-dose lead exposure. The questions below are the recommended risk assessment. Those women found to be at risk for current high-dose exposure should be tested for blood lead levels and counseled on how to reduce or eliminate current exposure.
- Women found to have a blood lead level of 10 micrograms per deciliter (μg/dL) or greater, should receive additional risk reduction counseling based on their responses to the risk assessment. There is currently no medical treatment universally recommended for women with elevated lead levels during pregnancy, however the Regional Resource Centers are available for consultation on individual cases. Women who may be occupationally exposed should be referred to a State Occupational Health Clinic for individual guidance. (A list of these clinics and their telephone numbers can be found in appendix E.)
- At the postpartum visit, providers should advise all women about the major causes of lead poisoning in infants and the means of preventing exposure.
The following questions are suggested to determine if a pregnant woman is at risk for current high-dose exposure to lead. They are adapted from a risk assessment questionnaire for children developed by the Centers for Disease Control and Prevention (CDC).
- Do you or others in your household have an occupation that involves lead exposure? (See section A.)
- Sometimes pregnant women have the urge to eat things which are not food, such as clay, soil, plaster or paint chips. Do you ever eat paint chips?
- Do you live in an old house with ongoing renovations that generate a lot of dust (e.g., sanding and scraping)?
- To your knowledge, has your home been tested for lead in the water, and if so, were you told that the level was high? (Note: a level over 15 parts per billion (ppb) or micrograms per liter (mcg/L) is considered high.)
- Do you use any traditional folk remedies or cosmetics that are not sold in a regular drug store or are homemade, which may contain lead? (See section B.)
- Do you or others in your household have any hobbies or activities likely to cause lead exposure? (See section C.)
- Do you use noncommercially prepared pottery or leaded crystal?
Testing is not recommended for women who are not at risk. If the woman answer "yes" to any of these questions, she is at risk for current high-dose lead exposure and should have a blood lead test. Given the relatively low incidence of elevated lead levels in pregnancy, it is suggested that unless a woman responds "yes" to a risk assessment question, she not be tested unless there is other reason to suspect potential ongoing exposure to lead. A blood lead test during pregnancy is not indicated for a previous history of childhood lead exposure.
- Lead related occupations and industries
- Lead abatement
- Use of lead based paints
- Home renovation/restoration
- Metal scrap yards and other recycling operations
- Manufacturing and installation of plumbing components
- Brass/copper foundry
- Glass recycling, stained glass and glass
- Occupations using firearms
- Firing range work
- Pottery making
- Production and use of chemical preparations
- Bridge, tunnel and elevated highway construction
- Motor vehicle parts and accessories
- Automotive repair shops
- Manufacturing of industrial machinery and equipment
- Battery manufacturing and repair
If a pregnant woman is exposed to lead at work, she has a right to a safe working environment under federal and state laws. To obtain information on employee workplace rights under Occupational Safety and Health Administration (OSHA) and Public Employee Safety and Health (PESH), call the New York State Department of Health, Center for Environmental Health Information line at 1-800/458-1158. If a woman is unsure about her lead exposure at work, she may call a state Occupational Health Clinic for further information (see list appendix E).
- Traditional/folk remedies or cosmetics that have been found to contain lead:
- Alkohl (also known as kohl, surma):
- A black powder used within Middle Eastern, African and Asian cultures as an eye cosmetic and umbilical stump remedy.
- Azarcon(also known as reuda, liga, coral, alarcon and maria luisa):
- >A bright orange powder used within Hispanic cultures to treat gastrointestinal upset and diarrhea.
- Bali goli:
- A round, flat black bean which is dissolved in "gripe water" and used within Asian Indian cultures for stomach ache.
- Ghazard:
- A brown powder used within Asian Indian cultures to aid digestion.
- Greta:
- A yellow-orange powder used within Hispanic cultures to treat digestive problems.
- Pay-loo-ah:
- An orange red powder used within Southeast Asian cultures to treat rash or fever.
- Source: "Lead Poisoning Associated With Use Of Traditional Ethnic Remedies-California 1991-1992," MMWR 1993; 42(27): 521-524.
- Alkohl (also known as kohl, surma):
- Hobbies and activities which may cause lead exposure:
The most common household activities associated with lead hazards are home renovations and repairs. These include scraping, sanding or burning of lead-based paint on woodwork, walls or other household structures. Also, sanding, stripping or burning of lead-based painted furniture generates a lead hazard. Pregnant women and children are especially sensitive to these hazards and should not be present when this work is done.
The Following are Other Potential Sources of Exposure:
- Making stained glass and painting on stained glass
- Copper enameling
- Bronze casting
- Making pottery and ceramic ware with lead glazes and paints
- Casting ammunition, fishing weights or lead figurines
- Collecting, painting or playing games with lead figurines
- Jewelry making with lead solder
- Electronics with lead solder
- Print making and other fine arts (when lead white, flake white and chrome yellow pigments are involved)
- Liquor distillation
- Hunting and target shooting
- Nutritional information for pregnant and lactating women:
- Eat frequent and regular meals. Environmental lead is more easily absorbed on an empty stomach.
- Iron or calcium deficits promote lead absorption. A diet rich in iron and calcium reduces the absorption of lead. Calcium supplements made from bone should be avoided as they may contain lead.
- Breastfeeding is generally safe even if a woman has an elevated blood lead level. However, if a mother with an elevated blood lead level is breastfeeding, the infant's blood lead level should be carefully and frequently monitored. (See Prenatal Care Providers' Reference Information-Part II for details.)
Examples of Sources of Iron and Calcium:
Iron
- fortified breads & cereals
- cooked legumes (dried beans & dried peas)
- spinach
- lean red meat
Calcium
- milk
- yogurt
- cheese
- cooked greens
- calcium fortified orange juice
Brochures to assist with prenatal and postpartum risk reduction education are available from the New York State Department of Health, Box 2000, Albany, NY 12220. Request the titles: "If You're Pregnant, Get Ahead of Lead" (ENG. #2511, SPA #2512) and "If You Have A Baby, Get Ahead of Lead" (ENG #2513, SPA #2514).
- Methods to reduce lead exposure in pregnant women - do's and don'ts:
- Do discuss with your employer ways to reduce possible lead exposure on the job.
- Do damp mop and damp dust rather than sweep and dry dust.
- Do avoid drinking acidic liquids from imported ceramic cups, mugs or from leaded crystal.
- Do avoid the use of traditional folk remedies or cosmetics which might contain lead.
- Do avoid lead related crafts to avoid exposure to lead.
- Do wash hands thoroughly before meal preparation.
- Do run water from the faucet for at least a minute until it runs cold before collecting for drinking and cooking.
- Don't be in the home when renovations that may involve lead-based paint are taking place.
- Don't clean-up after renovations involving lead-based paint.
- Don't strip paint from antique furniture, such as cribs and rocking chairs.
- Don't store food in open imported cans.
- Education for postpartum women to prevent lead poisoning in infants:
- Breastmilk usually is best for babies, even if your blood lead level is elevated. (See detailed information in Part II.)
- If baby formula is used, take care when preparing it. Use cold tap water - not hot - to make infant formula. Let the cold water run for at least a minute, to flush any lead picked up from the pipes. Purchase bottled water if the home's drinking water exceeds the Environmental Protection Agency's action level of 15 ppb (mcg/L).
- Feed your baby foods that get ahead of lead. Iron fortified formula and cereals can lower your baby's lead risk. Serving foods that are high in iron and calcium can help lower the family's lead risk.
- Obtain a pacifier that can be attached to your baby's shirt so it won't fall on the floor. Wash the pacifier often. This will help remove any lead dust.
- Wash your baby's hands and toys often. Babies suck their fingers and put things in their mouths - things that might have lead dust on them. Washing helps lower the lead risk.
- Take your baby for regular health care visits and follow the health provider's lead test advice. All children should be tested by their first birthday, and again when they're two.
New York State Department of Health & American College of Obstetricians and Gynecologists, District II
Prenatal Care Provider's Reference Information
( Part II )
Guidelines for Management of Lead Poisoning in Pregnant Women and Postpartum Women
All women should receive:
- At the initial prenatal visit:
Risk assessment (for current high-dose lead exposure)
Anticipatory guidance (on avoiding lead exposure) - At the postpartum visit:
Anticipatory guidance for prevention of lead poisoning in infants
If the pregnant woman is at risk for current high-dose lead exposure, a blood lead test should be performed.
Blood Lead Level Actions (management during pregnancy)
| 0-9 μg/dL | Provide information on sources of lead, how to avoid exposure and nutrition information. (See Part I, section A, B, C, D and E.) |
| 10-19 μg/dL | Retest blood lead level to determine if the level is mildly increasing. If there is a significant rise in the blood elevated lead level (to 20 μg/dL or higher), seek consultation from an information center for further risk reduction and patient management information. (See appendix E for a list of Regional Resource centers.) If there is no upward trend, repeat blood lead level during third trimester close to term to assess need for newborn evaluation. Provide counseling on possible sources of lead and information on how to reduce or eliminate exposure. (See Part I, section A, B, C, and risk reduction practices, section E.) Provide nutrition counseling to reduce absorption of ingested lead. (See Part I, section D.) |
| 20-44 μg/dL | Retest blood lead level to determine if the level is moderately increasing. If repeat blood level is between 10-19, repeat elevated blood lead test during third trimester close to term to assess need for newborn evaluation. If blood lead level remains above 20 μg/dL, seek consultation from an information center for further risk reduction and patient management information. (See appendix E for a list of Regional Resource centers.) Provide counseling on possible sources of lead and information on how to reduce exposure. (See Part I, section A, B and C, and risk reduction practices section E.) Provide nutrition counseling to reduce absorption of ingested lead. (See Part I, section D.) Refer woman to an Occupational Health Clinic if occupational exposure is suspected. (See attached list of clinics.) Refer woman to the local public health agency for an environmental investigation if occupational exposure, hobbies and folk remedies have been ruled out as a source of lead exposure. For advice about patient counseling concerning teratogenic effects, consult a Teratogen Information Service. (See attached list of centers.) |
| 45 ug/dL or Greater |
Consult with a Regional Lead Poisoning Prevention Resource Center (see attached list of centers) or other professional (if severely elevated) with expertise in clinical management of lead poisoning in adults. Early symptoms of lead poisoning may include: fatigue, irritability and depression; difficulty sleeping and concentrating; stomach cramps; constipation; weakness in the arms and legs; and problems with coordination. Very high levels may cause convulsions, coma and even death. Consider hospitalization. Immediate removal from the contaminated environment may be indicated. Provide counseling on possible sources of lead and provide information on how to eliminate or reduce exposure. (See Part I, section A, B, C, and risk reduction practices from section E.) Provide nutrition counseling to reduce absorption of ingested lead. (See section D.) Refer woman to an Occupational Health Clinic if occupational exposure is suspected. (See appendix E.) Refer woman to the local health agency for environmental investigation if occupational exposure, hobbies and folk remedies have been ruled out as a source of lead exposure. For advice about patient counseling concerning teratogenic effects, consult a Teratogen Information Service. (See appendix G for a list of centers.) |
Management at time of delivery:
If a baby is born to a mother with an elevated blood lead level (10 μg/dL or greater), umbilical cord blood should be tested to determine the newborn's blood lead level. The infant's pediatrician should be informed so that appropriate follow-up can take place, including early follow-up testing of the baby.
Breastfeeding recommendations for women with an elevated blood lead level:
Breastfeeding is generally safe for women with elevated blood lead levels. However, if a mother with an elevated blood lead level is breastfeeding, the infant's blood lead level should be carefully and frequently monitored. This should be performed within two weeks of baseline measurement and then at least monthly. If the infant's blood lead level is 10 μg/dL or greater and rising, and no remediable environmental source of lead can be detected, breastfeeding should be discouraged.