NEW HAVEN — Lead is poisonous, lead is sneaky, and lead doesn’t go away.
And while the level of lead in a child’s blood that would trigger abatement of the family’s house or apartment is under review — with a city consultant suggesting the maximum allowable level be raised — “the bottom line is there is no safe level of lead,” said Dr. Carl Baum, director of the Yale Lead Program. “The right number is zero because lead serves no purpose in the human body.”
Baum also is a toxicologist and pediatrician with the Lead Poisoning and Regional Treatment Center at Yale New Haven Children’s Hospital.
The problem with lead poisoning is that “it’s very difficult to predict in the individual child … how lead will affect that child,” Baum said.
Many children who have been exposed do not show symptoms. In others, “we will see children who have difficulty with school performance and difficulty copying figures from a blackboard or whiteboard, difficulty concentrating,” or who have behaviors associated with attention deficit hyperactivity disorder.
“Kids who have developing brains are the ones who bear the burden of this,” Baum said.
Children who have repetitive behaviors such as putting their hands to their mouths, including children who have autism, increase their potential for lead poisoning, he said.
Lead, a neurotoxin, was banned in paint in 1978 but, according to a 2016 report, 83 percent of New Haven’s 57,500 housing units had been built before then. (New housing has been built since 2016.) New Haven had remediated about 1,250 housing units by 2016, according to Paul Kowalski, city environmental health director.
Earlier this year, a consultant to New Haven Mayor Toni Harp, Nancy Mendel, said the city could use the state standard before triggering testing for lead in a housing unit: 20 micrograms per deciliter of blood or two tests within three months registering 15 micrograms in a child under age 6. The city now requires testing and abatement at 5 micrograms per deciliter, but cases are increasingly ending up in Housing Court and costing the city thousands of dollars.
Legal assistance attorneys, including Amy Marx, have argued that raising the standard would be “outrageous” and that Section 8 federally subsidized housing still would be held to the 5 microgram standard, creating two criteria within the city.
Baum said children who have ingested lead — mostly from dust created by “friction surfaces” such as door jambs and window sills — may become anemic because lead reduces “the normal synthesis of hemoglobin” in the blood, which carries oxygen to the body. The problem is a vicious circle because anemia makes a child more vulnerable to lead.
Lead also doesn’t go away, in the environment or in the body.
“Lead doesn’t wash away with the next rainstorm,” Baum said. “It’s environmentally very persistent.” Lead removed from a house may end up in the soil, he said.
Baum said urban centers with a lot of 40-year-old housing stock are threats to the children who live there as the result of inaction almost a century ago. In 1921, the League of Nations began attempts to ban lead in paint, but the United States never signed on. “We’re still dealing with that legacy almost 100 years later,” Baum said.
Lead is most dangerous in children under 3, when their brains are developing most rapidly.
“We’re all born with billions and billions of neurons in our brain,” and lead disrupts their normal functioning. The result can be a lower IQ, inattentiveness, antisocial behavior and hearing and speech problems, according to the Centers for Disease Control and Prevention, which set the 5 microgram standard.
Marx, who has brought court cases against the city to get apartments abated as children’s blood lead levels increased, has estimated through statistical ratio analysis that 363 children ages 6 and under suffered from lead poisoning in New Haven in 2017, according to a revised city and state Department of Health standard, as well as the standard set by the Centers for Disease Control and Prevention (over 5 micrograms of lead per deciliter of blood).
If a child has a lead level of 45 micrograms or above, “that’s when we pull the trigger and say this child needs to be chelated.” The treatment is to give a medication, preferably the oral medication Chemet, the brand name for succimer, which “physically grabs onto lead,” which is then excreted, Baum said.
Other ways of chelating lead — chelation is a chemical bonding process — are intravenous or intramuscular, but doctors prefer the oral form because it can be given as an outpatient, Baum said.
He said the therapy is not used below 45 micrograms because it doesn’t work well at lower levels and it’s “not without its side effects.” It can affect blood counts and cause inflammation of the liver, he said.
If the child is anemic, it’s important he or she eat foods high in iron, especially red meat. “The hope is that the lead level will fall as the child gets older and has less hand-to-mouth activity,” Baum said.
But the most important intervention is to remove the child from the environment, or, if the lead is contained to an area of the home, making sure the child does not come in contact with it. “That’s really the treatment for the vast majority of kids that we encounter,” Baum said. “The environment is literally the treatment.
“Socially, it’s a tough problem,” Baum said. “Moving is among the greatest stresses that any of us endures,” involving changing schools, shopping destinations and commutes. “We don’t want to disrupt people’s lives, but sometimes we have to, at least temporarily.”
Marta Kostecki, the social worker at the Yale Regional Lead Treatment Center at 150 Sargent Drive, said in an email that having a child who has been affected by lead can be embarrassing for parents who did not realize the problem until it was too late.
“Even when the lead level has resolved, the impact of lead poisoning may not be apparent until the school-aged years when the child is struggling in the classroom. Even though the issue is in the past, intellectual and behavioral deficits can be a lasting reminder, which is painful for a parent to talk about,” she said.
During home visits, “I always ask that the patient is present during the visit so that we can assess the child within their environment,” Kostecki said. “I look for potential lead hazards and consider what normal daily activities the child may be engaging in that puts them at risk for exposure. Usually, if we can diagnose these areas in the home, we can empower parents to place interim controls right away that reduce on-going exposure. Every family is unique, so we try to be mindful of any financial and cultural factors that may impact compliance.”
Access barriers, proper cleaning and better nutrition are often implemented.
“Families are much more responsive when you can give them a definitive list of things to do within their own home,” Kostecki said. “Saying things such as ‘the lead is everywhere’ induces too much anxiety. While comments such as, ‘there’s barely any lead here’ completely minimizes the problem. A ‘little lead’ in the most accessible area of the home can create a huge problem.”
Kostecki also discusses tenants’ legal rights and offers information about federal funds available for abatement.
Baum said it doesn’t help that housing isn’t tested until a child is found to have a measurable level of lead in his or her bloodstream. He compared the problem to miners sending canaries into coalmines because the birds would die more quickly if exposed to poisonous gas.
“Unfortunately, what we’re doing with housing is we’re allowing children to, in effect, serve as canaries, as biological monitors,” he said.
Rather than allowing children to move into pre-1978 housing, “what we ought to be doing is identifying lead-contaminated housing first, taking care of it first, before the child moves in,” Baum said. “Any house, any apartment, any building that is older than 1978 is likely to have lead in it unless it has been gut-renovated.”
But “renovations themselves can actually create a bigger hazard” because of the dust created. “They don’t get it from obvious paint chips anymore,” he said. Either one “can be up to 50 percent lead, so that’s a big dose.”
State law requires children to be screened annually between 9 and 35 months old, Baum said, which in practice usually means they are screened at their 1- and 2-year-old checkups. “Pediatricians in Connecticut are very good at getting that 12-month test, not so good about getting that 24-month test,” he said.
The blood test is better than the way lead poisoning was diagnosed in the past.
“In the 1970s, we had lead levels that were based on health effects,” Baum said, but that less useful because of the lack of consistent symptoms among those exposed to lead. The standard has been lowered over the years, from as high as 60 micrograms per deciliter to 25, 10 and then to 5.
Adding to the complexity, “When we get a lead level, we don’t know if it’s going to rise,” Baum said.
Identifying how lead is affecting a particular child is not easy either.
“It’s very difficult in a world where there are multiple factors” that affect children’s behavior, Baum said. “We may not know the exact effect in the individual child.”
At the monthly Lead Clinic at the Children’s Hospital, children are screened and their care followed by pediatricians, while social workers work with families to find safe, affordable housing. For more information, call 203-688-2195.