Many Doctors Unaware of Hazards : Little Routine Testing for Lead Is Done on Children

Despite convincing new evidence that lead in children is harmful even at low levels, few pediatricians routinely test for it, and removing it from homes remains costly and potentially dangerous.

The lead poisoning of 20-month-old Daniel Tell, for example, would not have been detected if his parents had not insisted that their reluctant pediatrician test him. “We fought our pediatrician tooth and nail to do a test,” said the child’s mother, Louise Tell, 31, a physicist whose son was poisoned when her husband tried to remove paint from their 140-year-old Massachusetts home. “He said, ‘Your child has no symptoms. Why would you do this?’ ”

After the child was diagnosed and treated, the Tells hired a private contractor to remove the rest of the lead paint from their home. To the family’s horror, the lead levels rose in their household dust and in their child’s blood after the so-called “deleading.”

“We were just about psychotic with paranoia about the dust at that point,” recalled her husband, David Tell, 32, a newspaper copy editor who is still anguished at the memory.

The hazards of removal combined with the discovery of harm from even low lead levels are forcing public health authorities to look more toward prevention. Ranging from more frequent washing of children’s hands to sealing or replacing all lead-painted surfaces, the public health recommendations are arising from a growing concern about the potentially permanent effects of lead on children’s intellectual and learning potential.

Most childhood poisonings in the United States are caused by lead paint, which oxidizes and releases particles that contaminate household dust. At low levels, a child’s exposure may result from a variety of sources, including water, paint, soil, food and air, and prevention becomes more complicated.

The American Academy of Pediatrics recommends that “ideally” all preschool children should be screened for lead, particularly those who live in or frequently visit older, dilapidated housing or who have siblings, house mates, visitors or playmates with lead toxicity.

Age Factor

Children who live in older housing undergoing renovation or in older, run-down housing are also to be given priority, along with children whose parents work in lead-related industries, such as printing, or who live near lead-emitting smelters and processing plants, highways or hazardous waste sites contaminated by lead.

The frequency of screening is to be determined by the child’s age and nutritional health. Regular testing is recommended for children age 9 months to 6 years, with more frequent tests for those 1 to 3, the ages when children are most prone to putting dust-covered objects, including their thumbs, into their mouths and the phase of their most rapid neurological development.

Despite these guidelines, few pediatricians in California screen for lead and many are unfamiliar with the hazards of low-level exposure. In a recent case that came to the attention of state health authorities, a pediatrician failed to treat a child who had been poisoned because the physician did not know the lead level at which medical intervention is required.

State health officials say parents have called the state’s Emeryville-based Childhood Lead Poisoning Prevention Program to ask where to have their children tested because their pediatricians refused to take blood samples. Many laboratories are also unfamiliar with the proper methods for analyzing lead in blood, and mistakes and omissions in their reports are not uncommon. Some laboratories, for example, are uninformed about the federal action levels for lead in children.

“There just isn’t any awareness on the part of physicians in California,” said Mary Haan, an epidemiologist and project director of the California Department of Health Services’ childhood lead program. “By and large, they think it’s something that happens in Boston or Baltimore or New York City--if they think about it at all.”

Many pediatricians in California believe lead paint is not a problem in California because the state’s housing stock is relatively new, and therefore less contaminated. But even in cities with a lot of old housing, like San Francisco, there apparently is little testing.

“We are not seeing too many at this time because physicians in general are not testing for it,” said Peter Vaernet, a disease investigator with San Francisco’s Bureau of Communicable Disease Control. “Nobody really knows how much of a problem is out there.”

Screening is considered important because children with low and moderate lead exposure often have no symptoms, and the longer a child has an elevated level of lead, the greater the damage. In addition to reducing IQ, lead in young children can cause impaired hearing and learning problems such as distraction, hyperactivity, impulsiveness, inability to follow directions and poor attention span.

Adults can be poisoned by lead, but children are more vulnerable because their brain, the primary target of lead, is still developing and they absorb lead at a substantially higher rate than adults. Lead poisoning in adults can cause damage to the kidneys, central nervous system, gastrointestinal system and the reproductive system.

The federal Centers for Disease Control in Atlanta recommends intervention at blood levels of 25 micrograms of lead per deciliter in young children. Recent research has shown harmful effects at levels as low as 15 and 10 micrograms, and the CDC level is expected to be reduced within a year. Except for ensuring that a child is receiving adequate iron, calcium and zinc, there is little a physician can do for a child with such exposure. Reducing it becomes an environmental, rather than a medical, challenge.

Different Tests

In addition to a “blood lead” test, children who may be at risk are also given a free erythrocyte protoporphyrin (FEP) test, which tells how lead affects the production of red blood cells. An FEP of 35 micrograms per deciliter or greater is considered elevated.

In interviews with leading childhood lead poisoning authorities throughout the country, most said they believed that high-risk children should be routinely tested, and some believe the screening should be more widespread. Two experts on lead toxicity who support general screening said they have had their own children regularly tested for lead.

But the ambivalence of many physicians was best expressed by Dr. Richard Jackson, chairman of the Committee on Environmental Hazards for the American Academy of Pediatrics and chief of the office of environmental health hazard assessment for the state health department. He lives in a San Francisco East Bay home built in 1926, and his three sons have never been tested for lead. He said he has made sure they were not chewing painted surfaces and would have removed his children had he ever remodeled.

Screening View

Jackson, like many physicians, believes screening should be aimed only at high-risk groups. Lead tests generally require that blood be drawn from the vein, and in young children this can be technically difficult and unacceptable to parents. Young children often cry and scream furiously at being restrained, and the blood test may leave them bruised. Jackson said he believes screening of children who are not at particular risk wastes money.

“Across the board, I think the emphasis has to be on prevention, and not on sticking needles in kids,” Jackson said.

Prevention can be exhaustive, particularly for children who already have elevated lead levels. Inside the Montreal apartment of Zoe Thomas, a 21-month-old who was poisoned when her father removed paint from their New York country home last summer, no one wears street shoes lest lead dust from auto and industrial pollution be tracked in.

The water pipes to the apartment contain lead solder, so Zoe drinks only bottled water. The family has also tested its dishes for lead, which can be found in some pottery glazes, particularly in imports from Mexico and Italy, and can leach into food and juices.

Minda Bernstein, Zoe’s mother, routinely inspects food cans for lead solder, running her fingers along the seam to see if it is raised and looking for a metallic “smear” that might betray lead’s presence. About 5.8% of the food cans produced in the United States in 1988 contained lead solder, according to an industry spokesman, and a tin solder substitute now being used is indistinguishable to the touch.

Hazards in Fresh Foods

Because of the possibility of lead particles on produce, Bernstein peels the child’s fresh vegetables and fruits. Produce can be tainted by airborne lead dust and by lead deposited into the soil by vehicle exhaust. Urban gardens, for example, are a particular problem because they may be in ground contaminated by lead from old paint dust and industrial pollution. Lead-tainted forage can also contaminate meat.

“We can’t fool around with Zoe getting lead from any other sources,” said Bernstein, 36, a mime performer. “The average kid could take it, but in her case, the well has already been filled up.”

For the average child, prevention may be less complicated. Margo Derry, a Los Angeles County public health nurse who handles childhood lead poisoning cases, tells parents of children living in older homes to wash children’s hands frequently and to wet-mop floors where dust collects, preferably with a phosphate detergent that will act as a magnet for lead particles.

“You can drive yourself crazy finding lead sources,” Derry said. “So rather than making everyone crazy, if we can just use some forethought and look at how we do things . . . just being aware of the safety of the child is probably enough.”

A recent study by the state Department of Health Services found that 20% of young children who were tested in Compton and Wilmington and 19.1% in Oakland had potentially hazardous levels of lead in their blood.

Paint Samples Taken

After this report, The Times submitted various paint samples from employees’ homes for lead testing. Paint on an outside balcony in a San Bernardino mountain cabin built in the late 1920s contained 390 parts lead per million paint, well below the 600 p.p.m. standard for household paint.

But in the other samples, taken from two Pasadena bungalows built in the 1920s, the lead content ranged from 24,000 p.p.m. to 88,000 p.p.m., substantially higher than the current legal limit. By comparison, lead levels of 300,000 p.p.m. have been found in the exterior paint of some San Francisco Victorians.

Most lead experts say intact lead paint covered with more modern paint is relatively safe. The danger of contamination by dust or paint chips occurs when a lead-painted surface is water-damaged, cracked, peeling or flaking.

Some public health authorities are more conservative, however. In Massachusetts, for example, lead paint on “mouthable” surfaces accessible to children must be removed from residential dwellings. Because even an intact surface can crack and weather, industrial hygienists generally recommend that all woodwork covered with lead paint, such as windows and doors, be removed and stripped or replaced and that walls be covered with Sheetrock or plywood.

Removing Old Paint

If paint must be removed through scraping, children and women of child-bearing age are supposed to be evacuated from the home until the work is over and an exhaustive and detailed cleanup of the dust has been completed. Furniture, toys, clothes and rugs are supposed to be stored to prevent contamination.

Such abatement can be expensive. A Long Beach couple whose daughter was poisoned earlier this year said they had spent at least $7,000 replacing windows, covering walls and having the paint removed from a detached garage. The Tells had to take out a $25,000 loan to pay for the “deleading” of their Massachusetts home.

Most experts agree that exposed lead paint is unsafe, despite the fact that millions of children grew up in homes with lead paint on their walls and did not get lead poisoning. While many children may be safe in such conditions, federal health and environmental officials worry that chalking from the paint could contaminate household dust and contribute to potentially hazardous low-level exposure, particularly in children made vulnerable by poor nutrition.

Cautious Approach

This increasingly cautious approach raises questions about the effects of low-level lead exposure a few decades ago, when many more children came into contact with potentially hazardous levels in air, paint and water. “We’ve done pretty well, and how could it be all that bad? Surely it’s not as bad as it sounds?” J. Michael Davis, a health scientist with the federal Environmental Protection Agency, asked rhetorically. “The response to that is, ‘We don’t know how much better it could be, how much better our children could be performing if they weren’t subject to this additional insult.’ ”

In fact, dust from intact lead paint has produced moderate poisonings of children. In January, a 3-year-old San Francisco girl who had been treated for eight months for severe anemia was discovered to have an elevated level of lead in her blood. An investigation by public health authorities found high levels of lead in the paint on her bedroom walls and windowsills.

The paint was not flaking or peeling. In fact, it was difficult to scrape enough off for a laboratory sample. Authorities blamed the poisoning on contaminated dust, created by the oxidation of the paint and the opening and closing of the windows. The girl’s anemia, a condition that can increase lead absorption, made her vulnerable.

For the Tell family, the nightmare of their son’s poisoning and the recontamination during abatement is not over. A contractor has yet to remove the lead paint from the exterior of their home, and they are fearful that the work might once again send their son’s lead level up.

Removing exterior lead paint usually involves protecting the ground with dropcloths, closing the windows to the house and limiting the work to windless days. Soil contaminated by flaking exterior paint is a significant source of lead poisoning.

“I am very concerned about what’s going to occur when they do the outside,” said David Tell. “I’m just hopeful they can do it properly.”

HOW TO REMOVE LEAD FROM THE HOME SOIL--Plant grass or other ground cover, turn soil over 12-18 inches deep, pave with asphalt, cement or similar material or replace top layer (3 to 6 inches) with new top soil.

WATER--Lead may be present if plumbing has been changed in the last five years, if house is between two to five years old, if lead pipes, which are made of soft, dull grey metal, are present. Use treatment devices or run cold tap for several minutes before drinking or cooking with it. Do not drink or cook with hot tap water.

PAINT ON DOORS, WINDOWS OR WOODWORK--Replace or send off-site to be chemically stripped.

PAINT ON WALLS--Cover with a durable material such as paneling or sheetrock. Remove only as a last resort.

HOUSEHOLD DUST--Wet-mop with trisodium phosphate, TSP, weekly. Use only a high-efficiency or water-based vacuum cleaner capable of trapping and holding tiny particles.

Source: State Childhood Lead Poisoning Prevention Program

SUGGESTED PRIORITIES FOR LEAD SCREENING The Centers for Disease Control suggests that all children between 9 months and 6 years of age should be screened, but particularly the groups below, listed in order of importance. 1. Children, age 12 to 36 months, who live in or are frequent visitors in older, dilapidated housing.

2. Children, age 9 months to 6 years, who are siblings, housemates, visitors and playmates of children with known lead toxicity.

3. Children, age 9 months to six years, living in older, dilapidated housing.

4. Children, age 9 months to 6 years, who live near lead smelters and processing plants or whose parents or other household members participate in a lead-related occupation for hobby.

5. Children, age 9 months to 6 years, who live near highways with heavy traffic or near hazardous waste sites where lead is a major pollutant.

6. All children 12 to 36 months of age.

7. All children 9 months to 6 years of age.

Source: U.S. Centers for Disease Control