Exposure to lead-based paint is the leading cause of high-dose lead exposure among children in the United States. However, previous reports have documented childhood lead poisoning related to the use of traditional ethnic remedies (1-4), and such exposures may not be considered routinely. This article describes a case report of lead poisoning resulting from use of a traditional ethnic remedy and summarizes the identification of this problem as a result of lead poisoning surveillance in California from December 1991 through December 1992. Case Report

In March 1992, a 2-year-old boy of Mexican origin was tested for lead poisoning as part of a routine well-child examination in Los Angeles. His blood lead level (BLL) was 83 ug/dL, a level classified by CDC as a medical emergency. The child had no apparent clinical manifestations, and his mother was unaware of obvious sources of lead exposure, including traditional ethnic remedies. However, when the term "greta" (a traditional Mexican remedy employed as a laxative) was used in the interview, the mother acknowledged giving the boy this remedy regularly since he was 8 months of age. Analysis of Surveillance in California

From December 1, 1991, through December 31, 1992, the California Department of Health Services received reports of 40 cases of BLLs greater than or equal to 20 ug/dL in children who had received traditional ethnic remedies (Table 1). BLLs ranged from 20 ug/dL to 86 ug/dL (median: 33 ug/dL). Ages of the children ranged from 8 months to 5 years (median: 2 years). Of the 36 children for whom sex was known, 27 (75%) were male. Of the 37 children with known surnames, 33 (89%) had Hispanic surnames; two (5%), Asian/ Pacific Islander; and two (5%), Asian Indian. More than half (57%) of the children resided in southern California, 24% in the San Francisco Bay area, 12% in the Central Valley, and 7% in rural northern California. By comparison, 72% of all publicly funded childhood blood lead screening tests were performed in southern California, 11% in the Bay area, 14% in the Central Valley, and 3% in rural northern California.

Of the 40 children, 24 were asymptomatic; of these, five had BLLs greater than 50 ug/dL, including two in whom the BLL was greater than 80 ug/dL. For 36 of the 40 cases, the traditional remedies reported were the Hispanic remedies azarcon or greta. Other remedies were paylooah (Southeast Asia, two cases), surma (India, one case), and an unnamed ayurvedic substance from Tibet (one case). In many cases, family members initially denied remedy use but reported such use during subsequent case follow-up efforts.

Results of environmental investigations were available for 18 of the 40 children. For seven of these children, investigators identified other environmental lead sources at levels that probably contributed to the exposures. These sources included paint (levels greater than 5000 parts per million {ppm}, maximum of 150,000 ppm), bean pots or other large hollowware (leaching greater than 1 ppm lead), and soil (lead levels above 500 ppm).

Reported by: J Flattery, MPH, R Gambatese, MPH, R Schlag, MSC, L Goldman, MD, California Dept of Health Svcs; M Bartzen, San Diego County Health Dept, San Diego; J Reyes, A Martinez, MPH, M Derry, Los Angeles County Dept of Health Svcs, Los Angeles; C Fuller, L Moore, Santa Clara County Health Dept, San Jose; P Chase, MD, Oakland Children's Hospital, C Giboyeaux, S Lampkin, Alameda County Health Dept, Oakland; K Adams, H Meyers, MD, Orange County Health Dept, Santa Ana; K Peterson, Glenn County Health Dept, Willows; R Rao, MD, Loma Linda Univ Medical Center; T Barber, Siskiyou County Health Dept, Yreka; V Ramshaw, Butte County Health Dept, Oroville; C Berkshire, D Gough, G Bennett, Kern County Health Dept, Bakersfield; E Lynes, L Flores, Kings County Health Dept, Hanford; M Shipp, MD, S Young, Mendocino County Health Dept, Ukiah; K Ehnert, DVM, S Volwiler, Monterey County Health Dept, Salinan; A Wilcox, Sonoma County Health Dept, Santa Rosa; S Firestone, D Papenhausen, Tulare County Health Dept, Tulare; M MacManus, C Sandel, City of Long Beach Health Dept. Lead Poisoning Prevention Br, Div of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC.

Editorial Note

Editorial Note: In this report, more than half the children had clinically inapparent cases of lead poisoning; nearly all were identified as a result of routine screening of children that had been initiated in California in late November 1991. All of these children had BLLs that substantially exceeded the CDC level of concern (10 ug/dL) (5). Investigation of these cases resulted in the recognition that traditional ethnic medicines may be used not only to treat abdominal complaints but also to prevent illness.

Although neurobehavioral development may be impaired in children with BLLs as low as 10 ug/dL (6-8), overt manifestations of lead poisoning generally may not be detected until BLLs exceed 50 ug/dL (9). Frank encephalopathy has been noted in children with levels as low as 70 ug/dL (10). The detection of BLLs greater than 50 ug/dL in children who were asymptomatic underscores the role of screening as a means for identifying children with dangerous levels of lead exposure.

The reluctance of family members to report the use of traditional ethnic medicines during initial interviews may reflect factors such as uncertainty about the legality of using such medicines, belief in the effectiveness of these remedies, and concerns regarding responsibility for the child's elevated BLL. In addition, because some persons may not consider these substances to be "remedies" or "medicines," health-care providers and public health investigators should ask about the use of these substances by their common names.

The finding of additional sources of lead probably contributing to exposure in seven cases underscores the importance of searching for all possible sources of lead exposure in cases of lead poisoning. Health professionals serving communities with high-risk populations should be aware of these high-dose sources of lead exposure. Education of parents about the risks of administering lead-containing substances to their children should be a routine part of health-care maintenance in such high-risk groups or settings.

References

1. CDC. Use of lead tetroxide as a folk remedy for gastrointestinal illness. MMWR 1981;30:546-7.

2. CDC. Lead poisoning from Mexican folk remedies -- California. MMWR 1983;32:554-5.

3. CDC. Folk remedy-associated lead poisoning in Hmong children -- Minnesota. MMWR 1983; 32:555-6.

4. CDC. Lead poisoning-associated death from Asian Indian folk remedies -- Florida. MMWR 1984;33:638,643-5.

5. CDC. Preventing lead poisoning in young children: a statement by the Centers for Disease Control, October 1991. Atlanta: US Department of Health and Human Services, Public Health Service, 1991.

6. Bellinger DC, Stiles KM, Needleman HL. Low-level exposure, intelligence and academic achievement: a long-term follow-up study. Pediatrics 1992;90:855-61.

7. Baghurst PA, McMichael AJ, Wigg NR, et al. Environmental exposure to lead and children's intelligence at the age of seven years. N Engl J Med 1992;327:1279-84.

8. Dietrich KN, Berger OG, Succop PA, et al. The developmental consequences of low to moderate prenatal and postnatal lead exposure: intellectual attainment in the Cincinnati lead study cohort following school entry. Neurotoxicol Teratol 1993;15:37-44.

9. Piomelli S, Rosen JF, Chisolm JJ Jr, Graef JW. Management of childhood lead poisoning. J Pediatr 1984;105:523-32.

10. Chisolm JJ Jr. Chelation therapy in children with subclinical plumbism. Pediatrics 1974; 53:441-3.

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