PEDIATRICS Vol. 116 No. 4 October 2005, pp. 1051 (doi:10.1542/peds.2005-1644)
Lead Poisoning From a Toy Necklace: In Reply
Michael Weitzman, MDAmerican Academy of Pediatrics Center for Child Health Research and Department of Pediatrics,
Strong Children's Research Center,
University of Rochester School of Medicine and Dentistry,
Rochester, NY 14620
Todd A. Florin, MD
Children's Hospital of Philadelphia,
Philadelphia, PA 19104
Robert L. Brent, MD, PhD
Alfred I. duPont Hospital for Children,
Thomas Jefferson University,
Wilmington, DE 19803
In Reply.—
We thank Dr Merritt and his colleagues for their original publications about a case of childhood lead poisoning associated with the ingestion of a lead-contaminated toy necklace1,2 and Dr Merritt for the letter above. He disagrees with our assessment that this child had chronic lead exposure rather than simply 1 "acute" exposure from the swallowed medallion and offer the fact that a thorough environmental investigation failed to uncover a source of lead exposure as evidence that this child's problem was caused exclusively by this ingestion. They also point in their letter to their ongoing neurocognitive surveillance of this youngster rather than offer input on our suggestion that this child still deserves ongoing blood lead-level evaluations.
Dr Merritt is entitled, of course, to his opinion, but we still respectfully disagree with several of the conclusions from his article. Because few pediatricians today (fortunately) care for children whose lead exposure is severe enough to result in overt signs, symptoms, and biochemical alterations, we felt compelled to write our commentary3 for the pediatric community. We offer the following points, as well as our previous comments, with the same intentions as the author above: other children will be protected from untoward lead exposure and the consequences of that exposure.
The main point of our commentary and this letter is to call attention to pediatricians that lead poisoning is still occurring and sometimes by unconventional routes, not necessarily by lead in paint and plaster or even from what seems to be a single apparent source such as a piece of lead-containing jewelry. We disagree that the child reported had "pure" acute lead poisoning versus a more chronic exposure, and we believe that the finding of >1 foreign object in the stomach suggests the possibility of pica, which warrants careful monitoring of this child's ongoing lead exposure. Having said this:
- We applaud the excellent clinical care provided, the collaboration with the health department, the advocacy efforts, and the effects of those efforts. Truly, we appreciate the care provided to this child and the potential benefit to other children of these advocacy efforts.
- We are pleased that neurodevelopmental assessment has revealed no abnormalities and agree with the planned ongoing surveillance. The neurocognitive effects of this child's exposure may be too subtle to be picked up by many developmental assessments at this age. Although subtle, these effects may have serious consequences that should not be left unrecognized and unattended.
- We agree that children should not be exposed to lead in toy jewelry and are pleased that their efforts resulted in the recall of 150 million pieces of jewelry with high lead content.
- We agree that the medallion was very likely a source of substantial exposure in the weeks preceding its extraction.
- We still, however, believe that laboratory results point to an exposure that was longer than that of the swallowed medallion (level of elevation of the zinc protoporphyrin, normochromic anemia, and basophilic stippling).
- Thorough environmental assessments, unfortunately, often fail to identify major sources of ongoing exposure. The ingestion of a quarter, as well as the medallion, clearly raises the possibility of pica.
One hundred and fifty million pieces of jewelry for children, high in lead, available to children from gum-ball machines, childhood lead poisoning from various types of gun-shot wounds reported in the clinical literature over some time—how sad and shameful. Clearly, there is a need for continued vigilance.
REFERENCES
- VanArsdale JL, Leiker RD, Kohn M, Merritt TA, Horowitz BZ. Lead poisoning from toy necklace.
Pediatrics. 2004;114
:1096
–1099
[Abstract/Free Full Text] - Centers for Disease Control and Prevention. Lead poisoning from ingestion of a toy necklace—Oregon, 2003. MMWR Morb Mortal Wkly Rep. 2004;53 :509 –511; copublished in JAMA. 2004;292:430
- Florin TA, Brent T, Weitzman M. The need for vigilance: the persistence of lead poisoning in children [commentary].
Pediatrics. 2005;115
:1767
–1768
[Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics
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