PEDIATRICS Vol. 106 No. 3 September 2000, pp. 600-602

EXPERIENCE AND REASON:
Herbal Vitamins: Lead Toxicity and Developmental Delay

	ABSTRACT

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A case of lead poisoning from an Indian herbal vitamin is presented. The patient who was developmentally delayed was given an herbal vitamin from India to strengthen his brain. The tablet contained large amounts of lead and mercury, leading to significant lead burden. Vulnerability of families and lack of awareness of health care professionals of dangers of unknown herbal supplementation are discussed.

Low levels of lead ingestion can lead to cognitive deficits and even long-lasting neurodevelopmental deficits.¹ In the United States the most common source of lead is paint, whereas, in other countries, folk remedies are a significant source.² Families with developmentally delayed children are always seeking ways to improve their child's status. This quest makes families especially vulnerable to nonstandard medical intervention and to folk remedies. Many immigrant families are acculturated to non-American remedies. Many of these products have become available and are being used in the United States.

We present a case of chronic lead poisoning in the United States in an Indian child who had an established neurodevelopmental delay. His mother was giving him a natural medication to strengthen his brain.

	CASE REPORT

S.P. is a 5-year-old Indian boy with static encephalopathy, seizures, and developmental delay from neonatal asphyxia. He was referred to a hematologist for persistent anemia (hemoglobin: 9.2 g/dL) without basophilic stippling, refractory to iron therapy. Initial investigation revealed normal iron stores and normal hemoglobin electrophoresis. To complete the workup, a blood lead level was obtained, which was 86 µg/dL. He was admitted to Childrens Hospital Los Angeles for chelation with calcium disodium ethylenediaminetetraacetic acid (EDTA) and dimercoprol (BAL). On physical examination he was alert and active but nonverbal. He was able to stand with support but not ambulate and had no focal neurologic defects. Skeletal and abdominal radiographs revealed no lead lines and no gastric lead particles. His lead level at the end of the chelation was 25.6 µg/dL. A 24-hour-urine collection (1245 mL) on day 3 of chelation revealed a lead level of 4480 µg/L or 5578 µg/24-hour (normally none detectable).

The mother who is well-educated and whose English is excellent, initially denied any exposure to lead or use of any folk medications. On further investigation, the mother had been giving S.P. a Tibetan Herbal Vitamin, in the form of tablets, 3 times per day for the past 4 years of his life. A traditional medicine healer told the parents that these tablets were pure medicinal herbs and plants that were prepared according to ancient Tibetan pharmacological traditions. These tablets were said to be free from any harmful or toxic substances and would actually promote brain growth and improve his mental capabilities. The tablets were produced in India and each was individually wrapped (Fig 1). The tablets were analyzed by the Los Angeles County Environmental Toxicology Laboratory for lead, arsenic, cadmium and mercury content (Table 1). It was estimated that S.P. ingested approximately 63 g of lead over the 4-year period. The radiographs of the tablets (Fig 2) were consistent with high lead and mercury content. The 24-hour-urine sample (1245 mL) was also analyzed for mercury (23 µg/L; 28.64 µg/24-hour) and arsenic (undetectable). Blood level of mercury was undetectable at <.5 µg/dL, and blood arsenic was .2 µg/dL (range: 0-3.0 µg/dL). Public health investigation of the home was negative for other sources of lead.

View larger version (111K): [in this window] [in a new window]   Fig. 1.   Individually wrapped vitamins.

View larger version (101K): [in this window] [in a new window]   Fig. 2.   Radiograph of vitamins.

He was followed as an outpatient and chelated with succimer without incidence. Seven months after his first admission, his blood level was 76 µg/dL and he was readmitted for EDTA and BAL chelation. On day 2 of chelation he had a 1-minute tonic clonic seizure. On day 2 random urinary lead was 2310 µg/L and his blood lead level on discharge was 41.3 µg/dL. During the next 4 years S.P. underwent a total of an additional 6 chelations with succimer when his lead levels were >45 µg/dL. He had no other complication of chelation and after 4 years, his latest lead level was 24.5 µg/dL. He has maintained his growth parameters and made developmental progress, achieving ambulation with minimum assistance and he understands simple directions but remains nonverbal.

	DISCUSSION

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Alternative medicine and folk remedies are widely used and accepted by the general public. It is estimated that in 1990 $13.7 billion was spent on unconventional therapy.³ Many academic centers have started programs to study and teach the use of alternative forms of therapy. When traditional therapies and medications cannot cure or significantly improve a chronic condition, families and patients are motivated to try alternative approaches. Children with developmental disabilities are especially vulnerable to the introduction of alternative therapies and medications. Past movements such as megavitamin therapy for retardation⁴ and the Doman-Delacato technique for brain-damaged children⁵ are examples of alternative interventions which were widely used in the United States without proven efficacy. Families in ethnic communities that have a tradition of alternative medicine and folk remedies will seek and support their use and availability in the community.

In our patient's case, the pressure on the family to use traditional medication arose from both the immediate family and from the community that had a great deal of experience and faith in the use of traditional medications from India. In discussing this with the mother, the perceived efficacy of these individually wrapped and colorful vitamins was enhanced by their designation as a Tibetan herbal medication.

In India, a form of traditional medicine called Ayurveda is usually made of vegetable products, occasionally from animal products and less often from metals and minerals.² The metals usually consist of lead, mercury, arsenic or, rarely, gold. Analysis of the patients' tablets demonstrated a variable and inconsistent amount of lead and mercury in each tablet. Although previous reports have identified Indian herbal medications as a source of lead, mercury, and arsenic poison, this is not widely appreciated by the lay population or medical community.^6-9 The vitamins had been obtained directly from a relative in India, costing approximately $40 for a 3-month supply. The mother was told it was formulated by a physician who was close to the Dalai Lama. The mother was very compliant with all traditional therapeutic interventions as she was with administering and securing a steady supply of the vitamin.

S.P.'s baseline developmental delay made the detection of the lead toxicity especially difficult. The effect of lead exposure during brain development has been well-documented.¹ The impact on S.P. of this level of toxicity over 4 years, in the context of a prior neonatal asphyxia, is not quantifiable. Two months after chelation the patient was able to walk with minimal support and was more communicative. Within 6 months of stopping the herbal vitamin, and after chelation, his mother and grandmother felt that he made significant progress in social interactions characterized by more awareness and joy of others, and responsiveness to directions. The persistence of the high lead levels after multiple chelations is not surprising given the estimated 63 g of lead ingested and the known half-life of lead in bone of approximately 10 000 days.¹⁰

Physicians who treat diverse ethnic populations need to become aware of traditional herbs as an alternative treatment. There is also increasing use by the general population of natural and folk remedies as alternatives or enhancements to traditional medical interventions and prescriptions. Physicians need to inquire about their use, and be knowledgeable about benefits and risks. This awareness is especially needed when working with families who have developmentally disabled children.

Cynthia Moore, MD^* and Robert Adler, MD
^* Division of General Pediatrics
 Department of Pediatrics
Childrens Hospital Los Angeles
Los Angeles, CA 90027

	FOOTNOTES

Childrens Hospital Los Angeles is affiliated with the University of Southern California, Keck School of Medicine.

Received for publication May 3, 1999; accepted Dec 22, 1999.

Reprint requests to (R.A.) Division of General Pediatrics, Childrens Hospital Los Angeles, CA, 90027. E-mail address: radler{at}chla.usc.edu

	ABBREVIATIONS

EDTA, ethylenediaminetetraacetic acid; BAL, dimercoprol.

	REFERENCES

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4. American Academy of Pediatrics. Megavitamins and mental retardation. Pediatrics. 1981;
5. Campbell SK, ed. Pediatric Neurologic Physical Therapy. New York, NY: Churchill Livingstone; 1984:320
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