Lead Poisoning Prevention Guidelines for Prenatal Care Providers

New York State Department of Health & American College of Obstetricians and Gynecologists, District II

Prenatal Care Provider's Reference Card - Part I

Guidelines for the Prevention and Identification of Lead Poisoning in Pregnant and Postpartum Women

Since bloodborne lead crosses the placenta, a pregnant woman with an elevated blood lead level may expose her fetus to the toxic effects of lead.

  • 1. All pregnant women should receive anticipatory guidance on preventing lead poisoning during pregnancy. They should be informed about the major sources of lead in the environment and the means of preventing exposure.
  • 2. At the initial prenatal visit, health care providers should assess a woman's risk for current high dose lead exposure. The questions below are the recommended risk assessment. Those women found to be at risk for current high dose exposure should be tested for blood lead levels and counseled on how to reduce or eliminate current exposure.
  • 3. Women found to have a blood lead level of 10 micrograms per deciliter (μg/dL) or greater, should receive additional risk reduction counseling based on their responses to the risk assessment. There is currently no medical treatment recommended for women with elevated lead levels during pregnancy. Women who may be occupationally exposed should be referred to a state Occupational Health Clinic for individual guidance. (A list of these clinics and their telephone numbers can be found in the management guidelines, see Prenatal Care Providers Reference Card-Part II.)
  • 4. At the postpartum visit, providers should advise all women about the major causes of lead poisoning in infants and the means of preventing exposure.

Risk Assessment Questions for Pregnant Women

The following questions are suggested to determine if a pregnant woman is at risk for current high dose exposure to lead. They are adapted from a risk assessment questionnaire for children developed by the Centers for Disease Control and Prevention (CDC).

  • Do you or others in your household have an occupation that involves lead exposure? (See section A.)
  • Sometimes, pregnant women have the urge to eat things other than food, such as clay, soil, plaster or paint chips. Do you ever eat paint chips?
  • Do you live in an old house with ongoing renovations that generate a lot of dust (e.g., sanding and scraping)?
  • To your knowledge, has your home been tested for lead in the water and, if so, were you told that the level was high? (Note: a level over 15 parts per billion [ppb] or micrograms per liter [μg/L] is considered high.)
  • Do you use any traditional folk remedies or cosmetics that are not sold in a regular drug store or are homemade, which may contain lead? (See section B.)
  • Do you or others in your household have any hobbies or activities likely to cause lead exposure? (See section C.)
  • Do you use noncommercially prepared pottery or leaded crystal?

Testing is not recommended for women who are not at risk. If the woman answers "yes" to any of these questions, she is at risk for current high dose lead exposure, and should have a blood lead test. Given the relatively low incidence of elevated lead levels in pregnancy, it is suggested that unless a woman responds "yes" to a risk assessment question, she not be tested unless there is other reason to suspect potential ongoing exposure to lead. A blood lead test during pregnancy is not indicated for a previous history of childhood lead exposure.

A. Lead Related Occupations & Industries

  • Lead abatement
  • Use of lead based paints
  • Home renovation/restoration
  • Metal scrap yards and other recycling operations
  • Manufacturing and installation of plumbing components
  • Brass/copper foundry
  • Glass recycling, stained glass and glass manufacturing
  • Occupations using firearms
  • Firing range work
  • Pottery making
  • Production and use of chemical preparations
  • Bridge, tunnel and elevated highway construction
  • Motor vehicle parts and accessories
  • Automotive repair shops
  • Manufacturing of industrial machinery and equipment
  • Battery manufacturing and repair

If a pregnant woman is exposed to lead at work, she has rights to a safe working environment under federal and state laws. To obtain information on employees' workplace rights under OSHA (Occupational Safety and Health Administration) and PESH (Public Employee Safety and Health) call the New York State Department of Health, Center for Environmental Health Information line, at 1-800-458-1158. If a woman is unsure about her lead exposure at work, she may call a state Occupational Health Clinic for further information. (See list Part II.)

B. Traditional/Folk Remedies or Cosmetics that Have Been Found to Contain Lead

Alkohl (also known as kohl, surma)
A black powder used within Middle Eastern, African, and Asian cultures as an eye cosmetic and umbilical stump remedy.
Azarcon (also known as reuda, liga, coral, alarcon and maria luisa)
A bright orange powder used within Hispanic cultures to treat gastrointestinal upset and diarrhea.
Bali goli
A round, flat black bean which is dissolved in "gripe water" and used within Asian Indian cultures for stomach ache.
Ghazard
A brown powder used within Asian Indian cultures to aid digestion.
Greta
A yellow-orange powder used within Hispanic cultures to treat digestive problems.
Pay-loo-ah
An orange red powder used within Southeast Asian cultures to treat rash or fever.

Source: "Lead Poisoning Associated With Use Of Traditional Ethnic Remedies- California 1991-1992," MMWR 1993; 42 (27): 521-524.

C. Hobbies and Activities that May Cause Lead Exposure

The most common household activities associated with lead hazards are home renovations and repairs. These include scraping, sanding or burning of lead-based paint on woodwork, walls or other household structures. Also, sanding, stripping or burning of lead-based painted furniture generates a lead hazard. Pregnant women and children are especially sensitive to these hazards and should not be present when this work is done. The following are other potential sources of exposure:

  • making stained glass and painting on stained glass
  • copper enameling
  • bronze casting
  • making pottery and ceramic ware with lead glazes and paints
  • casting ammunition, fishing weights or lead figurines
  • collecting, painting or playing games with lead figurines
  • jewelry making with lead solder
  • electronics with lead solder
  • glassblowing with leaded glass
  • print making and other fine arts (when lead white, flake white
  • and chrome yellow pigments are involved)
  • liquor distillation
  • hunting and target shooting

D. Nutritional Information for Pregnant and Lactating Women

  • 1. Eat frequent and regular meals. Environmental lead is more easily absorbed on an empty stomach.
  • 2. Iron or calcium deficits promote lead absorption. A diet rich in iron and calcium reduces the absorption of lead. Calcium supplements made from bone should be avoided as they may contain lead.
  • 3. Breastfeeding is generally safe even if a woman has an elevated blood lead level. However, if a mother with an elevated blood lead level is breastfeeding, the infant's blood lead level should be carefully and frequently monitored. (See Prenatal Care Providers' Reference Card-Part II for details.)

Examples of Sources of Iron and Calcium

Iron
  • fortified breads and cereals
  • cooked legumes (dried beans and dried peas)
  • spinach
  • lean red meat
Calcium
  • milk
  • yogurt
  • cheese
  • cooked greens
  • calcium fortified orange juice

Brochures to assist with prenatal and postpartum risk reduction education are available from the New York State Department of Health, Box 2000, Albany, NY 12220. Request the titles:

  • "If You're Pregnant, Get Ahead of Lead" (English #2511, Spanish #2512) and
  • "If You Have A Baby, Get Ahead of Lead" (English #2513, Spanish #2514).

E. Methods to Reduce Lead Exposure in Pregnant Women - Do's and Don'ts

  • Do discuss with your employer ways to reduce possible lead exposure on the job.
  • Do damp mop and damp dust rather than sweep and dry dust.
  • Do avoid drinking acidic liquids from imported ceramic cups, mugs or from leaded crystal.
  • Do avoid the use of traditional folk remedies or cosmetics which might contain lead.
  • Do avoid lead-related crafts to avoid exposure to lead.
  • Do wash hands thoroughly before meal preparation.
  • Do run water from the faucet for at least a minute until it runs cold before collecting for drinking and cooking.
  • Don't be in the home when renovations that may involve leadbased paint are taking place.
  • Don't clean-up after renovations involving lead-based paint.
  • Don't strip paint from antique furniture, such as cribs and rocking chairs.
  • Don't store food in open imported cans.

F. Education for Postpartum Women to Prevent Lead Poisoning In Infants

  • Breastmilk usually is best for babies, even if your blood lead level is elevated. (See detailed information in Part II.)
  • If baby formula is used, take care when preparing it. Use cold tap water - not hot - to make infant formula. Let the cold water run for at least a minute, to flush any lead picked up from the pipes. Purchase bottled water if the home's drinking water exceeds the U.S. Environmental Protection Agency's action level of 15 ppb (μg/L).
  • Feed your baby foods that get ahead of lead. Iron fortified formula and cereals can lower your baby's lead risk. Serving foods that are high in iron and calcium can help lower the family's lead risk.
  • Obtain a pacifier that can be attached to your baby's shirt so it won't fall on the floor. Wash the pacifier often. This will help remove any lead dust.
  • Wash your baby's hands and toys often. Babies suck their fingers and put things in their mouths - things that might have lead dust on them. Washing helps lower the lead risk.
  • Take your baby for regular health care visits and follow the health provider's lead test advice. All children should be tested by their first birthday, and again when they are two years of age.

Prenatal Care Provider's Reference Card - Part II

Guidelines for Management of Lead Poisoning in Pregnant Women and Postpartum Women

All women should receive at the initial prenatal visit:

  • Risk assessment* (for current high dose lead exposure);
    • *If the pregnant woman is at risk for current high dose lead exposure, a blood lead test should be performed.
  • Anticipatory guidance (on avoiding lead exposure):

All women should receive at the postpartum visit:

  • Anticipatory guidance for prevention of lead poisoning in infants.

Blood Lead Level Actions (Management during pregnancy)

0-9 (μg/dL)
  • Provide information on sources of lead, how to avoid exposure and nutrition information. (See Part I, section A, B, C, D and E.)
10-19 (μg/dL)(mildly elevated)
  • Retest blood lead level to determine if the level is increasing. If there is a significant rise in the blood lead level (to 20 (μg/dL or higher), seek consultation from an information center for further risk reduction and patient management information. (See attached list of Regional Resource Centers.) If there is no upward trend, repeat blood lead level during third trimester close to term to assess need for newborn evaluation.
  • Provide counseling on possible sources of lead and information on how to reduce or eliminate exposure. (See Part I, section A, B, C and risk reduction practices, section E.)
  • Provide nutrition counseling to reduce absorption of ingested lead. (See Part I, section D.)
20-44 (μg/dL) (moderately elevated)
  • Retest blood lead level to determine if the level is increasing. If repeat blood level is between 10-19, repeat elevated blood lead test during third trimester close to term to assess need for newborn evaluation. If blood lead level remains above 20 μg/dL, seek consultation from an information center for further risk reduction and patient management information. (See attached list of Regional Resource Centers.)
  • Provide counseling on possible sources of lead and information on how to reduce exposure. (See Part I, section A, B and C, and risk reduction practices section E.)
  • Provide nutrition counseling to reduce absorption of ingested lead. (See Part I, section D.)
  • Refer woman to an Occupational Health Clinic if occupational exposure is suspected. (See attached list of clinics.)
  • Refer woman to the local public health agency for an environmental investigation if occupational exposure, hobbies and folk remedies have been ruled out as a source of lead exposure.
  • For advice about patient counseling concerning teratogenic effects, consult a teratogen information service. (See attached centers.)
45 μg/dL or greater (severely elevated)
  • Consult with a Regional Lead Poisoning Prevention Resource Center or other professional with expertise in clinical management of lead poisoning in adults. (See attached list of centers.) Early symptoms of lead poisoning may include: fatigue, irritability and depression, difficulty sleeping and concentrating, stomach cramps, constipation, weakness in the arms and legs and problems with coordination. Very high levels may cause convulsions, coma and even death. Consider hospitalization. Immediate removal from the contaminated environment may be indicated.
  • Provide counseling on possible sources of lead and provide information on how to eliminate or reduce exposure. (See Part I, section A, B, C, and risk reduction practices section E.)
  • Provide nutrition counseling to reduce absorption of ingested lead. (See section D.)
  • Refer woman to an Occupational Health Clinic if occupational exposure is suspected. (See attached list of centers.)
  • Refer woman to the local health agency for environmental investigation if occupational exposure, hobbies and folk remedies have been ruled out as a source of lead exposure.
  • For advice about patient counseling concerning teratogenic effects, consult a teratogen information service. (See attached list of centers.)

Management at time of delivery

If a baby is born to a mother with an elevated blood lead level (10 μg/dL or greater), umbilical cord blood should be tested to determine the newborn's blood lead level. The infant's pediatrician should be informed so that appropriate follow-up can take place, including early follow-up testing of the baby.

Breastfeeding recommendations for women with an elevated blood lead level

However, if a mother with an elevated blood lead level is breastfeeding, the infant's blood lead level should be carefully and frequently monitored, within two weeks of baseline measurement and then at least monthly. If the infant's blood lead level is 10 μg/dL or greater and rising, and no remediable environmental source of lead can be detected, breastfeeding should be discouraged.

Information Centers

Occupational Health Centers in the Clinic Network

Western New York Region (West Seneca)

  • Union Occupational Health Center
    Phone: (716) 668-8800

Finger Lakes Region (Rochester)

Central New York Region (Syracuse)

Southern Tier Region (Binghamton)

Adirondack Region (Canton)

Mid-Hudson / Eastern New York Region (Albany)

  • Occupational and Environmental Health Center of Eastern New York affiliated with GHI
    (518) 690-4420 or (800) 419-1230
    http://www.occmedgroup.com

Lower Hudson Valley Region (Yonkers)

New York City (Manhattan)

Long Island Region (Stony Brook)

Specialty Agricultural Clinic (Cooperstown)

  • New York Center for Agricultural Medicine and Health affiliated with Bassett Hospital
    Phone: (607) 547-6023 or (800) 343-7527
    http://www.nycamh.com

Regional Lead Poisoning Prevention Resource Centers

Metropolitan/Hudson Valley Region

Montefiore Medical Center

  • John F. Rosen MD, Medical Director
    Environmental Sciences Lead Program
    111 East 210th Street
    Bronx, New York 10467
    Phone: (718) 547-2789 Ext. 217
    Fax: (718) 547-2881/8251
    E-mail: Jrosen5@ix.netcom.com
  • Dana Politis, Program Administrator
    Phone: (718) 547-2789 Ext. 216
    Fax: (718) 547-2881/8251
    E-mail: dpolitis@montefiore.org
  • Nancy Redkey
    Phone: (914) 475-2793 (Cell)
    E-mail: nredkey@aol.com

Geographic Area: Nassau, Suffolk, Queens, Bronx, Richmond, Kings, New York, Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester

Central/Eastern Region

SUNY Upstate Medical University (Sub Contractor)

  • Howard L. Weinberger MD, Medical Director
    Pediatric Medical Services Group
    Department of Pediatrics
    750 East Adams Street
    Syracuse, New York 13210
    Phone: (315) 464-5450
    Fax: (315) 464-7564
    E-mail: Weinberh@upstate.edu
  • Maureen Famiglietti BSN, Project Coordinator
    Phone: (315) 464-7584
    Fax: (315) 464-7564
    E-mail: Famiglim@upstate.edu

Albany Medical College

  • Carrin Schottler-Thal MD, Medical Director
    Department of Pediatrics
    43 New Scotland Avenue
    Albany, New York 12209
    (518) 262-7860
    Fax: (518) 262-5589
    Email: schottc@mail.amc.edu
  • Kasey Roman, Administrative Assistant
    Phone: (518) 262-7860
    E-mail: Romank1@mail.amc.edu

Geographic Area: Albany, Broome, Cayuga, Chenango, Clinton, Columbia, Cortland, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Herkimer, Jefferson, Lewis, Madison, Montgomery, Oneida, Onondaga, Oswego, Otsego, Rensselaer, St. Lawrence, Saratoga, Schenectady, Schoharie, Tioga, Tompkins, Warren, Washington

Western Region

Kaleida Health/Women & Children's Hospital of Buffalo (Sub Contractor)

  • Melinda S. Cameron MD, Medical Director
    Judge Joseph S Mattina Community Health Center
    300 Niagara Street
    Buffalo, New York 14201
    Phone: (716) 859-4199
    Fax: (716) 859-4219
    E-mail address: MCamero@buffalo.edu
  • Stephanie Kellner, Project Coordinator
    Phone: (716) 859-4199
    Fax: (716) 859-4219
    E-mail address: SKellner@kaleidahealth.org

University of Rochester

  • Stanley Schaffer MD, Medical Director
    Department of Pediatrics, Division of General Pediatrics
    University of Rochester Medical Center
    601 Elmwood Ave., Box 777
    Rochester, NY 14642
    Phone: (585) 275-0267 (Direct #)
    Fax: (585) 273-1037
    E-mail: Stanley_Schaffer@urmc.rochester.edu
  • James Campbell MD MPH Co-Director
    Phone: (585) 922-3919
    Fax: (585) 922-3929
    E-mail: James.Campbell@rochestergeneral.org
  • Judy McMaster, Project Coordinator

Geographic Area: Allegany, Cattaraugus, Chautauqua, Chemung, Erie, Genesee, Livingston, Monroe, Niagara, Ontario, Orleans, Schuyler, Seneca, Steuben, Wayne, Wyoming, Yates

Teratogen Information Services

PEDECS: Perinatal Environmental and Drug Exposure Consultation Service (Teratogen Information Service)

  • Dr. Richard Miller, Director
    University of Rochester Medical Center
    Department of Obstetrics and Gyneocology
    601 Elmwood Avenue
    Rochester, NY 14642-8668
    Phone: (585) 275-3638
    Fax: (585) 244-2209

New York State Pregnancy Risk Network

  • Luba Djurdinovic MS, Director
    Ferre Institute, Inc.
    124 Front Street
    Binghamton, NY 13905
    Phone: (800) 724-2454