Low level lead exposure in the prenatal and early preschool periods: intelligence prior to school entry

Sex difference of pre- and post-natal exposure to six developmental neurotoxicants on intellectual abilities: a systematic review and meta-analysis of human studies

BACKGROUND

Early life exposure to lead, mercury, polychlorinated biphenyls (PCBs), polybromide diphenyl ethers (PBDEs), organophosphate pesticides (OPPs), and phthalates have been associated with lowered IQ in children. In some studies, these neurotoxicants impact males and females differently. We aimed to examine the sex-specific effects of exposure to developmental neurotoxicants on intelligence (IQ) in a systematic review and meta-analysis.

METHOD

We screened abstracts published in PsychINFO and PubMed before December 31st, 2021, for empirical studies of six neurotoxicants (lead, mercury, PCBs, PBDEs, OPPs, and phthalates) that (1) used an individualized biomarker; (2) measured exposure during the prenatal period or before age six; and (3) provided effect estimates on general, nonverbal, and/or verbal IQ by sex. We assessed each study for risk of bias and evaluated the certainty of the evidence using Navigation Guide. We performed separate random effect meta-analyses by sex and timing of exposure with subgroup analyses by neurotoxicant.

RESULTS

Fifty-one studies were included in the systematic review and 20 in the meta-analysis. Prenatal exposure to developmental neurotoxicants was associated with decreased general and nonverbal IQ in males, especially for lead. No significant effects were found for verbal IQ, or postnatal lead exposure and general IQ. Due to the limited number of studies, we were unable to analyze postnatal effects of any of the other neurotoxicants.

CONCLUSION

During fetal development, males may be more vulnerable than females to general and nonverbal intellectual deficits from neurotoxic exposures, especially from lead. More research is needed to examine the nuanced sex-specific effects found for postnatal exposure to toxic chemicals.

Criminal arrests associated with reduced regional brain volumes in an adult population with documented childhood lead exposure

Childhood lead exposure interferes with brain maturation, which adversely impacts cognitive and behavioral development. Lower intelligence scores, impairments in decision making, and increased rates of delinquent and criminal behavior are adverse outcomes linked to childhood lead absorption. The present study examined the relationships between childhood blood lead concentrations, structural brain volume, and measures of adult criminality. We hypothesized that increased rates of criminal arrests in adulthood would be inversely correlated with regional gray and white matter volumes, especially prefrontal areas responsible for decision making and self-control. We obtained childhood blood lead histories and anatomical magnetic resonance imaging from a subset of the longitudinally followed birth cohort known as the Cincinnati Lead Study. Criminality data for cohort participants were extracted from public databases. Voxel based morphometry was used to examine spatial differences in regional gray and white matter volumes associated with childhood blood lead concentrations and measures of adult criminality, respectively. Conjunction analyses allowed for the exploratory evaluation of common regions of volume change. Childhood blood lead concentrations were inversely associated with gray and white matter volume in the frontal, parietal and temporal lobes. Gray matter volumes were also inversely associated with criminal arrests with key regions within the cingulate, precuneus, several frontal gyri and the supplementary motor area. Conjunction analyses identified regions in the anterior cingulate, frontal gray matter and supplementary motor area associated with childhood lead absorption and criminality. The results from this study suggest that reduced brain volumes in regions responsible for cognition and emotional regulation are associated with childhood lead exposure and criminal arrests.

The effect of confounding variables in studies of lead exposure and IQ

Methods proposed to address confounding variables frequently do not adequately distinguish confounding from covariation. A confounder is a variable that correlates both with the outcome and the major exposure variable. Accurate treatment of confounding is crucial to low dose extrapolation of the effects of chemical exposures based on epidemiology studies. This study explores the limitations of current regression models in extrapolation to the low dose region of the dose-response curve due to the existence of unrecognized and uncontrolled confounding, using epidemiological data for lead. Based on the reported data in analyses by Lanphear and colleagues and Crump and colleagues, and drawing on other studies, Wilson and Wilson considered maternal IQ, HOME score, SES, parental education, birthweight, smoking, and race as characteristic variables which may have interaction effects. This analysis identifies confounding variables based on the seven longitudinal cohorts in analyses conducted by Lanphear and colleagues and by Crump and colleagues and confirms maternal IQ, HOME score, maternal education and maternal marital status at birth are "Highly Likely" confounders, while race is a "Likely" confounder. The cohort data were reanalyzed using the methods presented by Crump and colleagues while also considering the interaction among the identified confounding variables. This analysis determined that confounders influence IQ estimates in a quantifiable way that may exceed or at least obscure previously-reported effects of blood lead on IQ with blood lead levels below 5 µg/dL; however, limitations in the datasets make predictions of the low dose dose-response analysis questionable.

Evaluation of Pb concentrations in selected vegetables and portable drinking water, and intelligent quotients of school children in Ishiagu-a Pb mining community: health risk assessment using predictive modelling

This study evaluates the concentrations of lead (Pb) in 6 selected vegetables and drinking water samples taken from an agricultural/mining town Ishiagu. This evaluation is important because these vegetables and water are major gateway of lead exposure through ingestion, especially children in the Pb mining environment. Pb at even very low concentrations has been shown to have adverse effect on developing brain and hence children's intellectual ability. The impact of lead-contaminated food/water intake on the cognitive function was focused on school children whose parents have lived in the Pb mining town for over 25 years before they were born. Non-invasive, "target risk quotient" (TRQ) methodology, based on the principle of predictive toxicology was adopted for our analysis. Samples of these vegetables harvested in July and August 2015, and water taken from homes at 4 different villages in Ishiagu town and neighbouring community Akaeze (control), were subjected to appropriate chemical treatment/digestion procedures and the concentrations of Pb determined using AA-700 Shimadzu model atomic absorption spectrophotometer. From 642 structured questionnaire administered to the teachers/children, the daily vegetable ingestion rates for each vegetable (mg/child/day) and estimated daily intakes (EDI) of lead were obtained. The results show that the concentrations of Pb in water samples and the 6 vegetables harvested from the lead mining town vary as distances increase from the mining sites while the total target hazard quotients (TTHQs) for the vegetable crops were greater than one (˃ 1). The cognitive functions of 160 school children (aged 6-8 years), sampled from 265 families based on their meeting the criteria for distances away from the mining site, were evaluated using Raven's Standard Progressive Matrices and psychometrics. The data generated were analysed using (SPSS) version 21.0 and results expressed as mean ± standard deviation of intelligent quotient (IQ). Students' t tests for independent samples were used to compare the IQ results for children in the lead mining area and non-mining area. A model based on predictive toxicology paradigm which can show a relationship between concentrations of lead in vegetables/water and cognitive function was developed. This model shows that there is a positive correlation between total lead concentrations in vegetables/water and children's cognitive function.

Childhood Lead Exposure and Adult Neurodegenerative Disease

Millions of Americans now entering midlife and old age were exposed to high levels of lead, a neurotoxin, as children. Evidence from animal-model and human observational studies suggest that childhood lead exposure may raise the risk of adult neurodegenerative disease, particularly dementia, through a variety of possible mechanisms including epigenetic modification, delayed cardiovascular and kidney disease, direct degenerative CNS injury from lead remobilized from bone, and lowered neural and cognitive reserve. Within the next ten years, the generation of children with the highest historical lead exposures, those born in the 1960s, 1970s, and 1980s, will begin to enter the age at which dementia symptoms tend to emerge. Many will also enter the age in which lead stored in the skeleton may be remobilized at greater rates, particularly for women entering menopause and men and women experiencing osteoporosis. Should childhood lead exposure prove pro-degenerative, the next twenty years will provide the last opportunities for possible early intervention to forestall greater degenerative disease burden across the aging lead-exposed population. More evidence is needed now to characterize the nature and magnitude of the degenerative risks facing adults exposed to lead as children and to identify interventions to limit long-term harm.

Prevalence of elevated blood lead levels among pregnant women and sources of lead exposure in rural Bangladesh: A case control study

Prenatal and early childhood lead exposures impair cognitive development. We aimed to evaluate the prevalence of elevated blood lead levels (BLLs) among pregnant women in rural Bangladesh and to identify sources of lead exposure. We analyzed the BLLs of 430 pregnant women randomly selected from rural communities in central Bangladesh. Fifty-seven cases were selected with the highest BLLs, ≥ 7 μg/dL, and 59 controls were selected with the lowest BLLs, < 2 μg/dL. An exposure questionnaire was administered and soil, rice, turmeric, water, traditional medicine, agrochemical, and can samples were analyzed for lead contamination. Of all 430 women, 132 (31%) had BLLs > 5 μg/dL. Most women with elevated BLLs were spatially clustered. Cases were 2.6 times more likely than controls to consume food from a can (95% CI 1.0-6.3, p = 0.04); 3.6 times more likely to use Basudin, a specific brand of pesticide (95% CI 1.6-7.9, p = 0.002); 3.6 times more likely to use Rifit, a specific brand of herbicide (95% CI 1.7-7.9, p = 0.001); 2.9 times more likely to report using any herbicides (95% CI 1.2-7.3, p = 0.02); and 3.3 times more likely to grind rice (95% CI 1.3-8.4, p = 0.01). Five out of 28 food storage cans were lead-soldered. However, there was minimal physical evidence of lead contamination from 382 agrochemical samples and 129 ground and unground rice samples. Among 17 turmeric samples, one contained excessive lead (265 μg/g) and chromium (49 μg/g). Overall, we found evidence of elevated BLLs and multiple possible sources of lead exposure in rural Bangladesh. Further research should explicate and develop interventions to interrupt these pathways.

Low blood lead levels impair intellectual and hematological function in children from Cartagena, Caribbean coast of Colombia

Lead produces numerous biochemical and physiological changes in humans, including hematological disorders, toxic effects on the central nervous system and in the function of several organs. The aim of this study was to determine blood lead levels (BLL) in children from Cartagena, Colombia, associating those with hematological and liver damage markers, the intelligence quotient (IQ), as well as with gene expression of the aminolevulinate dehydratase (ALAD), superoxide dismutase 1 (SOD1), gamma interferon (INF-γ), tumor necrosis factor (TNF) and tumor protein (p53). To achieve this purpose, 118 blood samples were collected from children 5-16 years old, with their respective informed consent from their parents. BLL was measured by atomic absorption; hematological parameters were obtained with automated systems; plasma was utilized to analyze hepatic toxicity markers, alanine aminotransferase (ALT), gamma-glutamyltransferase (γ-GT) and alkaline phosphatase (ALP); the Kaufman Brief Intelligence Test (K-BIT) was administered to measure the IQ; and gene expression was quantified from blood RNA. The mean BLL was 1.7±0.3μg/dL. A low proportion of the children (3.4%) had BLL above the CDC recommended limit (5μg/dL). BLL were correlated weakly, but negatively with child age, weight, height, body mass index, platelets wide distribution, mean platelet volume, γ-GT and IQ. There were not significant changes in the expression of evaluated genes. These results support the hypothesis that BLL below 5μg/dL may still be a detrimental factor on children's cognitive abilities, development and hematology, in line with recent concerns that there is no safe level of pediatric lead exposure.

Confounding and causation in the epidemiology of lead

The National Health and Medical Research Council recently reported that there were not enough high-quality studies to conclude that associations between health effects and blood lead levels <10 μg/dL were caused by lead. It identified uncontrolled confounding, measurement error and other potential causal factors as common weaknesses. This paper supports those findings with evidence of uncontrolled confounding by parental education, intelligence or household management from several papers. It suggests that inappropriate statistical tests and aggregation of data representing different exposure routes partly explain why confounding has been overlooked. Inadequate correction of confounding has contributed to incorrect conclusions regarding causality at low levels of lead. Linear or log-linear regression models have tended to mask any threshold. While the effects of higher levels of lead exposure are not disputed, overestimation of health effects at low lead exposures has significant implications for policy-makers endeavouring to protect public health through cost-effective regulations.

Time for the Changing of the Guard: A Farewell to Short Forms of Intelligence Tests

The development of short forms of intelligence tests, especially of Wechsler's scales, has been a pastime of researchers and clinicians for decades. These short forms have usually been of the two- or four-subtest variety, but other variants such as Satz-Mogel split-half short forms have also been common. The literature is replete with proposed short forms and with controversies over their proper use, the statistical problems associated with validity coefficients when the short-form data are obtained from a complete administration of the test battery, and the logic of choosing subtests that are long to administer and score in view of the goal to reduce time. This article argues that the time has come to abandon short forms of intelligence tests in favor of brief tests such as the K-BIT, WASI, and WRIT, which are reliable, valid, well normed, and easy both to give and score.

Long-Term Developmental Outcomes of Prenatal Cocaine Exposure

The developmental outcomes of prenatal cocaine/polydrug exposure were evaluated using a multivariate research design that controlled for the possible confounding variables of age, sex, socioeconomic status, ethnicity, and caregiver status (i.e., biological parent, relative, foster care, and adoptive parent) using an exposed (n = 41) and nonexposed (n = 35) cohort of preschool children (mean age = 4.25). Results indicated that in utero drug exposure had no effect on cognitive, social, language, and behavioral developmental outcomes as measured by the Stanford-Binet Intelligence Scale: 4th ed., the Social Skills Rating System, the Preschool Language Scale: 3rd ed., the Child Behavior Checklist, and the Vineland Adaptive Behavior Scale-Survey Form.

Prenatal chemical exposures and child language development

The goal of this review is to summarize the evidence that prenatal and/or early postnatal exposure to certain chemicals, both manmade (insulating materials, flame retardants, pesticides) and naturally occurring (e.g., lead, mercury), may be associated with delays or impairments in language development. We focus primarily on a subset of more extensively studied chemicals-polychlorinated biphenyls (PCBs), lead, and methyl mercury-for which a reasonable body of literature on neurodevelopmental outcomes is available. We also briefly summarize the smaller body of evidence for other chemicals including polybrominated diphenyl ether flame retardants (PBDEs) and organophosphate pesticides. Very few studies have used specific assessments of language development and function. Therefore, we included discussion of aspects of cognitive development such as overall intellectual functioning and verbal abilities that rely on language, as well as aspects of cognition such as verbal and auditory working memory that are critical underpinnings of language development. A high percentage of prospective birth cohort studies of PCBs, lead, and mercury have reported exposure-related reductions in overall IQ and/or verbal IQ that persist into middle or late childhood. Given these findings, it is important that clinicians and researchers in communication sciences and disorders are aware of the potential for environmental chemicals to impact language development.

LEARNING OUTCOMES

The goal of this review is to summarize the evidence that prenatal and/or early postnatal exposure to certain chemicals may be associated with delays or impairments in language development. Readers will gain an understanding of the literature suggesting that early exposure to polychlorinated biphenyls (PCBs), lead, and mercury may be associated with decrements in cognitive domains that depend on language or are critical for language development. We also briefly summarize the smaller body of evidence regarding polybrominated diphenyl ether flame retardants (PBDEs) and organophosphate pesticides. Very few studies of exposure to these chemicals have used specific assessments of language development; thus, further investigation is needed before changes in clinical practice can be suggested.

Blood lead concentration and thyroid function during pregnancy: results from the Yugoslavia Prospective Study of Environmental Lead Exposure

BACKGROUND

Although maternal hypothyroidism increases the risk of adverse neonatal and obstetric outcomes as well as lower IQ in children, the environmental determinants of maternal thyroid dysfunction have yet to be fully explored.

OBJECTIVES

We aimed to examine associations between mid-pregnancy blood lead (BPb) and concomitant measures of thyroid function among participants in the Yugoslavia Prospective Study of Environmental Lead Exposure.

METHODS

As part of a population-based prospective study of two towns in Kosovo-one with high levels of environmental lead and one with low-women were recruited during the second trimester of pregnancy, at which time blood samples and questionnaire data were collected. We measured concentrations of BPb, free thyroxine (FT4), thyroid-stimulating hormone (TSH), and thyroid peroxidase antibodies (TPOAb) in archived serum samples.

RESULTS

Compared with women from the unexposed town, women from the exposed town had lower mean FT4 (0.91 ± 0.17 vs. 1.03 ± 0.16 ng/dL), higher mean TPOAb (15.45 ± 33.08 vs. 5.12 ± 6.38 IU/mL), and higher mean BPb (20.00 ± 6.99 vs. 5.57 ± 2.01 μg/dL). No differences in TSH levels were found. After adjustment for potential confounders, for each natural log unit increase in BPb, FT4 decreased by 0.074 ng/dL (95% CI: -0.10, -0.046 ng/dL), and the odds ratio for testing positive to TPOAb was 2.41 (95% CI: 1.53, 3.82). We found no association between BPb and TSH.

CONCLUSIONS

Prolonged lead exposure may contribute to maternal thyroid dysfunction by stimulating autoimmunity to the thyroid gland.

A statistical reevaluation of the data used in the Lanphear et al. ( 2005 ) pooled-analysis that related low levels of blood lead to intellectual deficits in children

A pooled-analysis by Lanphear et al. (2005) of seven cohort studies of the association between blood lead (BPb) concentrations in children and measures of their intelligence concluded that "environmental lead exposure in children who have maximal blood lead levels <7.5 μg/dL is associated with intellectual deficits." This study has played a prominent role in shaping the public understanding of the effects upon children's IQ of low BPb exposures (e.g., BPb ≤ 10 μg/dL). Here we present a reanalysis of the data used by Lanphear et al. to evaluate the robustness of their conclusions. Our analysis differed from that of Lanphear et al. primarily in how we controlled for non-lead variables (allowing a number of them to be site-specific), how we defined summary measures of BPb exposure, and in how we decided which BPb measures and transformations best modeled the data. We also reproduced the Lanphear et al. analysis. Although we found some small errors and questionable decisions by Lanphear et al. that, taken alone, could cause doubt in their conclusions, our reanalysis tended to support their conclusions. We concluded that there was statistical evidence that the exposure-response is non-linear over the full range of BPb evaluated in these studies, which implies that, for a given increase in blood lead, the associated IQ decrement is greater at lower BPb levels. However at BPb below 10 µg/dL, the exposure-response is adequately modeled as linear. We also found statistical evidence for an association with IQ among children who had maximal measured BPb levels ≤7 μg/dL, and concurrent BPb levels as low as ≤5 μg/dL.

Tracing the long-term legacy of childhood lead exposure: a review of three decades of the port Pirie cohort study

Several prospective cohort studies have demonstrated that childhood lead levels show small but statistically significant adjusted associations with subsequent development in later childhood and adolescence. The Port Pirie Cohort study is one of the few prospective cohort studies to follow participants into adulthood. This paper reviews all childhood and adulthood findings of the Port Pirie Cohort study to date. Cohort members (initially, 723 infants born in/around the lead-smelting town of Port Pirie) showed a wide range of childhood blood lead levels, which peaked around 2 years old (M=21.3μg/dL, SD=1.2). At all childhood assessments, postnatal lead levels - particularly those reflecting cumulative exposure - showed small significant associations with outcomes including cognitive development, IQ, and mental health problems. While associations were substantially attenuated after adjusting for several childhood covariates, many remained statistically significant. Furthermore, average childhood blood lead showed small significant associations with some adult mental health problems for females, including anxiety problems and phobia, though associations only approached significance following covariate adjustment. Overall, there did not appear to be any age of greatest vulnerability or threshold of effect, and at all ages, females appeared more susceptible to lead-associated deficits. Together, these findings suggest that the associations between early childhood lead exposure and subsequent developmental outcomes may persist. However, as the magnitude of these effects was small, they are not discernible at the individual level, posing more of a population health concern. It appears that the combination of multiple early childhood factors best predicts later development. As such, minimising lead exposure in combination with improving other important early childhood factors such as parent-child interactions may be the best way to improve developmental outcomes.

An international pooled analysis for obtaining a benchmark dose for environmental lead exposure in children

Lead is a recognized neurotoxicant, but estimating effects at the lowest measurable levels is difficult. An international pooled analysis of data from seven cohort studies reported an inverse and supra-linear relationship between blood lead concentrations and IQ scores in children. The lack of a clear threshold presents a challenge to the identification of an acceptable level of exposure. The benchmark dose (BMD) is defined as the dose that leads to a specific known loss. As an alternative to elusive thresholds, the BMD is being used increasingly by regulatory authorities. Using the pooled data, this article presents BMD results and applies different statistical techniques in the analysis of multistudy data. The calculations showed only a limited variation between studies in the steepness of the dose-response functions. BMD results were quite robust to modeling assumptions with the best fitting models yielding lower confidence limits (BMDLs) of about 0.1-1.0 μ g/dL for the dose leading to a loss of one IQ point. We conclude that current allowable blood lead concentrations need to be lowered and further prevention efforts are needed to protect children from lead toxicity.

A blood lead benchmark for assessing risks from childhood lead exposure

Lead exposure is an insidious problem, causing subtle effects in children at low exposure levels where clinical signs are not apparent. Although a target blood lead concentration (Pb(B)) of ten micrograms per deciliter (10 microg/dL) has been used as the basis for environmental decision-making in California for nearly two decades, recent epidemiologic evidence suggests a relationship between cognitive deficits and Pb(B) at concentrations < 10 microg/dL. Based on a published meta-analysis of children's IQ scores and their blood lead concentrations, we developed a new blood lead benchmark: an incremental increase in blood lead concentration (DeltaPb(B)) of 1 microg/dL, an increase that we estimate could decrease the IQ score in an average school child in California by up to one point. Although there is no evidence to date for a threshold for the neurobehavioral effects of lead, a one-point IQ decrement was chosen to represent a de minimus change. To safeguard the intellectual potential of all children, additional efforts to reduce or eliminate multiple-source exposures to lead are warranted.

Altered myelination and axonal integrity in adults with childhood lead exposure: a diffusion tensor imaging study

Childhood lead exposure is associated with adverse cognitive, neurobehavioral and motor outcomes, suggesting altered brain structure and function. The purpose of this work was to assess the long-term impact of childhood lead exposure on white matter integrity in young adults. We hypothesized that childhood lead exposure would alter adult white matter architecture via deficits in axonal integrity and myelin organization. Adults (22.9+/-1.5 years, range 20.0-26.1 years) from the Cincinnati Lead Study were recruited to undergo a study employing diffusion tensor imaging (DTI). The anatomic regions of association between water diffusion characteristics in white matter and mean childhood blood lead level were determined for 91 participants (52 female). Fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) were measured on an exploratory voxel-wise basis. In adjusted analyses, mean childhood blood lead levels were associated with decreased FA throughout white matter. Regions of the corona radiata demonstrated highly significant lead-associated decreases in FA and AD and increases in MD and RD. The genu, body, and splenium of the corpus callosum demonstrated highly significant lead-associated decreases in RD, smaller and less significant decreases in MD, and small areas with increases in AD. The results of this analysis suggest multiple insults appear as distinct patterns of white matter diffusion abnormalities in the adult brain. Neurotoxic insults from the significant lead burden the participants experienced throughout childhood affect neural elements differently and may be related to the developmental stage of myelination at periods of exposure. This study indicates that childhood lead exposure is associated with a significant and persistent impact on white matter microstructure as quantified with diffusivity changes suggestive of altered myelination and axonal integrity.

Epidemiologic evidence of relationships between reproductive and child health outcomes and environmental chemical contaminants

This review summarizes the level of epidemiologic evidence for relationships between prenatal and/or early life exposure to environmental chemical contaminants and fetal, child, and adult health. Discussion focuses on fetal loss, intrauterine growth restriction, preterm birth, birth defects, respiratory and other childhood diseases, neuropsychological deficits, premature or delayed sexual maturation, and certain adult cancers linked to fetal or childhood exposures. Environmental exposures considered here include chemical toxicants in air, water, soil/house dust and foods (including human breast milk), and consumer products. Reports reviewed here included original epidemiologic studies (with at least basic descriptions of methods and results), literature reviews, expert group reports, meta-analyses, and pooled analyses. Levels of evidence for causal relationships were categorized as sufficient, limited, or inadequate according to predefined criteria. There was sufficient epidemiological evidence for causal relationships between several adverse pregnancy or child health outcomes and prenatal or childhood exposure to environmental chemical contaminants. These included prenatal high-level methylmercury (CH(3)Hg) exposure (delayed developmental milestones and cognitive, motor, auditory, and visual deficits), high-level prenatal exposure to polychlorinated biphenyls (PCBs), polychlorinated dibenzofurans (PCDFs), and related toxicants (neonatal tooth abnormalities, cognitive and motor deficits), maternal active smoking (delayed conception, preterm birth, fetal growth deficit [FGD] and sudden infant death syndrome [SIDS]) and prenatal environmental tobacco smoke (ETS) exposure (preterm birth), low-level childhood lead exposure (cognitive deficits and renal tubular damage), high-level childhood CH(3)Hg exposure (visual deficits), high-level childhood exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) (chloracne), childhood ETS exposure (SIDS, new-onset asthma, increased asthma severity, lung and middle ear infections, and adult breast and lung cancer), childhood exposure to biomass smoke (lung infections), and childhood exposure to outdoor air pollutants (increased asthma severity). Evidence for some proven relationships came from investigation of relatively small numbers of children with high-dose prenatal or early childhood exposures, e.g., CH(3)Hg poisoning episodes in Japan and Iraq. In contrast, consensus on a causal relationship between incident asthma and ETS exposure came only recently after many studies and prolonged debate. There were many relationships supported by limited epidemiologic evidence, ranging from several studies with fairly consistent findings and evidence of dose-response relationships to those where 20 or more studies provided inconsistent or otherwise less than convincing evidence of an association. The latter included childhood cancer and parental or childhood exposures to pesticides. In most cases, relationships supported by inadequate epidemiologic evidence reflect scarcity of evidence as opposed to strong evidence of no effect. This summary points to three main needs: (1) Where relationships between child health and environmental exposures are supported by sufficient evidence of causal relationships, there is a need for (a) policies and programs to minimize population exposures and (b) population-based biomonitoring to track exposure levels, i.e., through ongoing or periodic surveys with measurements of contaminant levels in blood, urine and other samples. (2) For relationships supported by limited evidence, there is a need for targeted research and policy options ranging from ongoing evaluation of evidence to proactive actions. (3) There is a great need for population-based, multidisciplinary and collaborative research on the many relationships supported by inadequate evidence, as these represent major knowledge gaps. Expert groups faced with evaluating epidemiologic evidence of potential causal relationships repeatedly encounter problems in summarizing the available data. A major driver for undertaking such summaries is the need to compensate for the limited sample sizes of individual epidemiologic studies. Sample size limitations are major obstacles to exploration of prenatal, paternal, and childhood exposures during specific time windows, exposure intensity, exposure-exposure or exposure-gene interactions, and relatively rare health outcomes such as childhood cancer. Such research needs call for investments in research infrastructure, including human resources and methods development (standardized protocols, biomarker research, validated exposure metrics, reference analytic laboratories). These are needed to generate research findings that can be compared and subjected to pooled analyses aimed at knowledge synthesis.

Reduced intellectual development in children with prenatal lead exposure

OBJECTIVE

Low-level postnatal lead exposure is associated with poor intellectual development in children, although effects of prenatal exposure are less well studied. We hypothesized that prenatal lead exposure would have a more powerful and lasting impact on child development than postnatal exposure.

DESIGN

We used generalized linear mixed models with random intercept and slope to analyze the pattern of lead effect of the cohort from pregnancy through 10 years of age on child IQ from 6 to 10 years. We statistically evaluated dose-response nonlinearity.

PARTICIPANTS

A cohort of 175 children, 150 of whom had complete data for all included covariates, attended the National Institute of Perinatology in Mexico City from 1987 through 2002.

EVALUATIONS/MEASUREMENTS

We used the Wechsler Intelligence Scale for Children-Revised, Spanish version, to measure IQ. Blood lead (BPb) was measured by a reference laboratory of the Centers for Disease Control and Prevention (CDC) quality assurance program for BPb.

RESULTS

Geometric mean BPb during pregnancy was 8.0 microg/dL (range, 1-33 microg/dL), from 1 through 5 years was 9.8 microg/dL (2.8-36.4 microg/dL), and from 6 through 10 years was 6.2 microg/dL (2.2-18.6 microg/dL). IQ at 6-10 years decreased significantly only with increasing natural-log third-trimester BPb (beta=-3.90; 95% confidence interval, -6.45 to -1.36), controlling for other BPb and covariates. The dose-response BPb-IQ function was log-linear, not linear-linear.

CONCLUSIONS

Lead exposure around 28 weeks gestation is a critical period for later child intellectual development, with lasting and possibly permanent effects. There was no evidence of a threshold; the strongest lead effects on IQ occurred within the first few micrograms of BPb.

RELEVANCE TO CLINICAL PRACTICE

Current CDC action limits for children applied to pregnant women permit most lead-associated child IQ decreases measured over the studied BPb range.

Mercy Mercy Me: Social Injustice and the Prevention of Environmental Pollutant Exposures Among Ethnic Minority and Poor Children

Children's lead and pesticide exposures are used as examples to examine social disparities in exposure reduction efforts as well as environmental policies impacting children in poverty and minority children. The review also presents an estimate of the effect of social disparities in lead exposure on standardized test performance. Because including measures of pollutants with potential behavioral effects can alter the observed effects of race/ethnicity, income, and other variables, suggestions are made for including measures of pollutants in longitudinal studies and studies of multiple and cumulative risk. Continued basic research on developmental correlates and effects of pollution exposure, participatory action-research with at-risk and underrepresented populations, and contributions to public awareness and education are important leadership areas for developmental researchers.

Testing the dose-response specification in epidemiology: public health and policy consequences for lead

Statistical evaluation of the dose-response function in lead epidemiology is rarely attempted. Economic evaluation of health benefits of lead reduction usually assumes a linear dose-response function, regardless of the outcome measure used. We reanalyzed a previously published study, an international pooled data set combining data from seven prospective lead studies examining contemporaneous blood lead effect on IQ (intelligence quotient) of 7-year-old children (n = 1,333). We constructed alternative linear multiple regression models with linear blood lead terms (linear-linear dose response) and natural-log-transformed blood lead terms (log-linear dose response). We tested the two lead specifications for nonlinearity in the models, compared the two lead specifications for significantly better fit to the data, and examined the effects of possible residual confounding on the functional form of the dose-response relationship. We found that a log-linear lead-IQ relationship was a significantly better fit than was a linear-linear relationship for IQ (p = 0.009), with little evidence of residual confounding of included model variables. We substituted the log-linear lead-IQ effect in a previously published health benefits model and found that the economic savings due to U.S. population lead decrease between 1976 and 1999 (from 17.1 microg/dL to 2.0 microg/dL) was 2.2 times (319 billion dollars) that calculated using a linear-linear dose-response function (149 billion dollars). The Centers for Disease Control and Prevention action limit of 10 microg/dL for children fails to protect against most damage and economic cost attributable to lead exposure.

Low-level environmental lead exposure and children's intellectual function: an international pooled analysis

Lead is a confirmed neurotoxin, but questions remain about lead-associated intellectual deficits at blood lead levels < 10 microg/dL and whether lower exposures are, for a given change in exposure, associated with greater deficits. The objective of this study was to examine the association of intelligence test scores and blood lead concentration, especially for children who had maximal measured blood lead levels < 10 microg/dL. We examined data collected from 1,333 children who participated in seven international population-based longitudinal cohort studies, followed from birth or infancy until 5-10 years of age. The full-scale IQ score was the primary outcome measure. The geometric mean blood lead concentration of the children peaked at 17.8 microg/dL and declined to 9.4 microg/dL by 5-7 years of age; 244 (18%) children had a maximal blood lead concentration < 10 microg/dL, and 103 (8%) had a maximal blood lead concentration < 7.5 microg/dL. After adjustment for covariates, we found an inverse relationship between blood lead concentration and IQ score. Using a log-linear model, we found a 6.9 IQ point decrement [95% confidence interval (CI), 4.2-9.4] associated with an increase in concurrent blood lead levels from 2.4 to 30 microg/dL. The estimated IQ point decrements associated with an increase in blood lead from 2.4 to 10 microg/dL, 10 to 20 microg/dL, and 20 to 30 microg/dL were 3.9 (95% CI, 2.4-5.3), 1.9 (95% CI, 1.2-2.6), and 1.1 (95% CI, 0.7-1.5), respectively. For a given increase in blood lead, the lead-associated intellectual decrement for children with a maximal blood lead level < 7.5 microg/dL was significantly greater than that observed for those with a maximal blood lead level > or = 7.5 microg/dL (p = 0.015). We conclude that environmental lead exposure in children who have maximal blood lead levels < 7.5 microg/dL is associated with intellectual deficits.

Trends in environmental lead exposure and troubled youth, 1960-1995: an age-period-cohort-characteristic analysis

Beginning in the mid-1980s and extending into the early 1990s, the United States experienced a wave of increased youth violence and teenage pregnancy. Nevin (2000) proffers a cohort-based explanation that these trends can be attributed to corresponding trends in gasoline lead exposure during the youths' early years. He contends that the increased consumption of adversely impacted their intelligence levels (IQs). This decreased their intellectual ability, resulted in poor decisions made during their teen and young adult years, and in turn, led to disproportionally high level of criminal involvement and unwed pregnancies among this cohort. The present study evaluates Nevin's causal model by testing the connection between trends in lead exposure and youthful problem behavior with age-period-cohort-characteristic (APCC) models. Our research finds no support for this cohort explanation.

Temporal pattern in the effect of postnatal blood lead level on intellectual development of young children

To determine the temporal pattern of the effect of postnatal blood lead level on the General Cognitive Index (GCI) of the McCarthy Scales of Children's Abilities, we used data from 112 children of the Mexico City Prospective Lead Study with complete evaluations from 36 to 60 months of age at 6-month intervals. We measured blood lead level every 6 months from 6 to 54 months. We controlled for 5-min Apgar, birth weight, birth order, sex, socioeconomic level, maternal IQ, and maximum maternal educational level in a repeated measures ANCOVA using child blood lead level grouped by 6-18 month (geometric mean 10.1 microg/dl, range 3.5-37.0 microg/dl), 24-36 month (geometric mean 9.7 microg/dl, range 3.0-42.7 microg/dl), and 42-54 month (geometric mean 8.4 microg/dl, range 2.5-44.8 microg/dl) averages. There were significant interactions between the 6-18 month blood lead level and age with GCI as the endpoint and between 24-36 month blood lead level and age. The regression coefficient of blood lead at 6-18 months became more negative with age until 48 months, when the rate of decline moderated (linear polynomial contrast p=0. 047). The regression coefficient of blood lead at 24-36 months with CGI became more negative as well from 36 to 48 months but then started decreasing toward zero from 48 to 60 months (quadratic polynomial contrast p=0.019). Significant between-subjects lead effects on GCI were found for 24-36 month blood lead level at 48 months (p=0.021) and at 54 months (p=0.073). The greatest effect (at 48 months) was a 5.8-point GCI decrease with each natural log unit increase in blood lead. Significant between-subjects lead effects on GCI were found for 42-54 month blood lead level at 54 months (p=0. 040) and at 60 months (p=0.060). The effect of postnatal blood lead level on GCI reaches its maximum approximately 1-3 years later, and then becomes less evident. Four to five years of age appears to be a critical period for the manifestation of the earlier postnatal blood lead level effects.

Interactions between environmental lead exposure and sociodemographic factors on cognitive development

A total of 375 children who lived in Port Pirie, South Australia, and surrounding towns were followed from birth to ages 11-13 y. Possible interactions between lifetime average blood lead concentration and sociodemographic factors (including gender, parents' occupational prestige [as a surrogate of socioeconomic status], quality of home environment, and maternal intelligence quotient) on children's intelligence quotients were examined. Although no statistically significant interaction between blood lead concentration and any of these covariates was found, the results suggested that-after adjustment for a wide range of covariates--children from socially disadvantaged backgrounds (adjusted regression coefficient = -9.6 intelligence quotient points per log unit of blood lead concentration; 95% confidence interval = -2.5, -17.7) were more sensitive to the effects of lead than those of a higher socioeconomic status (adjusted regression coefficient = -2.9; 95% confidence interval = 3.8, -9.6). In addition, girls (adjusted regression coefficient = -7.4; 95% confidence interval = -1.7, -13.1) were more sensitive to the effects of lead than boys (adjusted regression coefficient = -2.6; 95% confidence interval = 2.9, -8.0). These results were basically consistent with our findings observed at ages 2 y, 4 y, and 7 y.

Human health implications of environmental contaminants in Arctic Canada: a review

This paper assesses the impact on human health of exposure to current levels of environmental contaminants in the Canadian Arctic, and identifies the data gaps that need to be filled by future human health research and monitoring. The concept of health in indigenous groups of the Arctic includes social, cultural, and spiritual dimensions. The harvesting, sharing and consumption of traditional foods are an integral component to good health among Aboriginal people influencing both physical health and social well-being. Traditional foods are also an economic necessity in many communities. Consequently, the contamination of country food raises problems which go far beyond the usual confines of public health and cannot be resolved by health advisories or food substitutions alone. The primary exposure pathway for the contaminants considered in this paper is through the traditional northern diet. For the Inuit, the OCs of primary concern at this time from the point of view of exposure are chlordane, toxaphene, and PCBs. Exposures are higher in the eastern than in the western region of the North. For Dene/Metis, exposure to OCs is in general below a level of concern. However, estimated intake of chlordane and toxaphene has been found to be elevated for certain groups and is a cause for concern if exposures are elevated on a regular basis. The developing foetus and breast-fed infant are likely to be more sensitive to the effects of OCs and metals than individual adults and are the age groups at greatest risk in the Arctic. Extensive sampling of human tissues in the Canadian north indicate that a significant proportion of Dene, Cree and Inuit had mean maternal hair mercury levels within the 5% risk-range proposed by the WHO for neonatal neurological damage. Based on current levels, lead does not appear to pose a health threat while cadmium is likely only a major risk factor for heavy smokers or consumers of large amounts of organ meats. Consumers of traditional foods are exposed to an approximately seven-fold higher radiation dose than non-consumers of traditional foods due predominantly to the bioaccumulation of natural radionuclides in the food chain. Risk determination for contaminants in country food involves a consideration of the type and amounts of food consumed and the sociocultural, nutritional, economic, and spiritual benefits associated with country foods. Risk management options that minimize the extent to which nutritional and sociocultural aspects of Aboriginal societies are compromised must always be considered.

The effect of dust lead control on blood lead in toddlers: a randomized trial

BACKGROUND

Contaminated household dust is believed to be a major source of exposure for most children with elevated blood lead levels. To determine if a vigorous dust clean-up effort would reduce this exposure we conducted a randomized controlled field trial.

METHODS

We randomized 113 urban children between the ages of 6 and 36 months: 56 children to a lead dust intervention composed of maternal education and biweekly assistance with household cleaning and 57 children to a control group. Household cleaning was done by two trained lay workers who focused their efforts on wet mopping of floors, damp-sponging of walls and horizontal surfaces, and vacuuming with a high-efficiency particle accumulating vacuum. Household dust lead levels, child blood lead levels, and maternal knowledge of lead poisoning and sources of exposure were measured before and after the intervention.

RESULTS

Ninety-nine children were successfully followed for 12 +/- 3 months: 46 children in the lead group and 53 children in the control group. Age and blood lead were similar in the two groups at baseline and averaged 20 months and 12.0 micrograms/dL, respectively. Blood lead fell 17% in the intervention group and did not change among controls. Household dust and dust lead measures also fell significantly in the intervention group. Children in homes cleaned 20 or more times throughout the year had an average blood lead reduction of 34%.

CONCLUSIONS

Regular home cleaning, accompanied by maternal education, is a safe and partially effective intervention that should be recommended for the large majority of lead-exposed children for whom, unfortunately, removal to lead-safe housing is not an option.

Pre- and postnatal lead effect on head circumference: a case for critical periods

We examined the association of maternal prenatal [range of median blood lead level 7.5-9.0 microg/dl (0.36-0.43 micromol/l) during pregnancy] and child postnatal blood lead level [range of median blood lead level from birth to 48 months 7.0-10.0 microg/dl (0.34-0.48 micromol/l)] with head circumference in from 119 to 199 children from the Mexico City Prospective Lead Study. We used repeated multiple regression modeling with a standard set of control variables, entering blood lead level last. Using Bonferroni-corrected probability values to control for inflation of Type I error due to multiple testing at each age, we found significant negative associations (p<0.05, two-tailed) between 6-month head circumference and 36-week maternal blood lead level, and 36-month head circumference and 12-month blood lead level. Over the 25-75% interquartile range of measured blood lead, head circumference decreased around 0.4 cm. Over the 1-35 microg/dl (0.05-1.68 micromol/l) range of maternal blood lead at 36 weeks, the estimated reduction in 6-month head circumference was 1.9 cm (95% CI = 0.9-3.0 cm). These results suggest that children are more vulnerable to certain effects of lead exposure at specific age ranges, and that the effect of lead on head circumference only becomes evident for brief periods in the first 4 years of life. We discuss various artifacts as well as possible mechanisms by which lead might have produced the observed pattern of results. We suggest that higher lead exposure prevalent several decades ago might have subtly influenced published normative human growth data.

Lead exposure and children's intelligence: do low levels of lead in blood cause mental deficit?

OBJECTIVE

It has come to be generally accepted that low levels of lead exposure may result in mental deficit. This causal inference is based on claimed time precedence of the lead exposure and on biological plausibility. The objective of this study is to argue that mental deficit causes pica which causes lead exposure (i.e. to support the theory of reverse causation).

METHODOLOGY

The literature since the 1930s has been interpreted in the light of our own long experience in the investigation of lead exposure in children and adults to support the arguments in favour of reverse causation.

RESULTS

The arguments for reverse causation are based on: (i) analogy with mental retardation which causes increased lead exposure; (ii) the results of published prospective studies that show a special relationship between blood lead levels at 24 months and intelligence tested later, exactly what would be predicted by the reverse causation theory; and (iii) on an alternative explanation for mental retardation following lead encephalopathy (i.e. that mental retardation following encephalopathy is due to anoxia and not due to a direct destructive effect on the brain neurones). The arguments, which have been proposed for the conventional view, are rejected for the following reasons: (i) none of the prospective studies have found a relationship between cord blood lead levels and intelligence tested later, undermining the argument based on time precedence of lead exposure; and (ii) there is no convincing evidence that lead poisoning, short of encephalopathy, causes mental retardation.

CONCLUSION

We believe that the reverse causation hypothesis is a more plausible explanation of the facts.

Lifetime exposure to environmental lead and children's intelligence at 11-13 years: the Port Pirie cohort study

OBJECTIVE

To examine the association between environmental exposure to lead and children's intelligence at age 11-13 years, and to assess the implications of exposure in the first seven years of life for later childhood development.

DESIGN

Prospective cohort study.

SUBJECTS

375 children born in or around the lead smelting town of Port Pirie, Australia, between 1979 and 1982.

MAIN OUTCOME MEASURE

Children's intelligence quotient (IQ) measured at 11-13 years of age.

RESULTS

IQ was inversely associated with both antenatal and postnatal blood lead concentrations. Verbal, performance, and full scale IQ were inversely related to blood lead concentration with no apparent threshold. Multivariate analyses indicated that after adjustment for a wide range of confounders, the postnatal blood lead concentrations (particularly within the age range 15 months to 7 years) exhibited inverse associations with IQ. Strong associations with IQ were observed for lifetime average blood lead concentrations at various ages. The expected mean full scale IQ declined by 3.0 points (95% confidence interval 0.07 to 5.93) for an increase in lifetime average blood lead concentration from 0.48 to 0.96 mumol/l (10 to 20 micrograms/dl).

CONCLUSION

Exposure to environmental lead during the first seven years of life is associated with cognitive deficits that seem to persist into later childhood.

Toxocara canis infection in preschool age children: risk factors and the cognitive development of preschool children

Risk factors for Toxocara canis (T. canis) infection were evaluated in a prospective study of disadvantaged preschool children. In addition, the hypothesis that T. canis exposure is associated with lower intelligence was tested. Seropositivity was tested at 2 years, 3 years, and at 4 years 10 months (4-10). Intelligence was measured at age 4-10 by the Full Scale IQ of the Wechsler Preschool and Primary Scales of Intelligence (WPPSI). Pica and ownership of a dog were unrelated to seropositivity. Seropositive children had lower scores on the Mental Development Index (MDI) of the Bayley Scales of Infant Development at age 1 year (prior to likely exposure). They also had less favorable scores on a measure of the quality of childrearing. These findings suggest that, for disadvantaged children, lower initial intelligence and less advantageous child rearing are risk factors for T. canis exposure. Seropositive children also had higher blood lead levels, probably as a result of the common pathway of hand to mouth transmittal. Seropositivity at 3 years, at age 4-10, or, cumulatively, at any of the age 2, 3, or 4-10 assessments was associated with the WPPSI IQ after adjustment for sociodemographic factors. Exposure at age 4-10-years was significantly associated with reduced IQ scores (p = 0.030). However, when the age 1 year MDI score was controlled, the estimate became nonsignificant. We, thus, can neither confirm nor deny a relationship of T. canis and intelligence, but the importance of considering prior developmental status is emphasized.

The neurobehavioural toxicology and teratology of lead

When comparing neurobehavioural observations from occupational lead-exposure of adults on the one hand, and environmental lead exposure of children on the other, it appears that the developing relative to the mature brain is more at risk. Neurobehavioural toxicity in occupational lead-exposure has typically not been observed at blood lead-concentrations (PbBs) below 400 micrograms/l, whereas ih environmentally exposed children such deficit has been reported to occur down to PbB of 100-150 micrograms/l and, perhaps, even below this range. Both cross-sectional and prospective studies have arrived at similar conclusions in this respect. The preferred endpoint in most such studies has been the IQ-measure, which has good psychometric qualities, is sufficiently well standardized to be comparable across studies, and exhibits attractive simplicity for the regulator in a public health context. At the same time, however, this IQ-focus has also interfered with systematic efforts to identify more specific lead-induced functional deficits by means of more detailed neurobehavioural analyses (Bellinger 1995). Metanalyses on both cross sectional and prospective studies in lead-exposed children have concluded that a typical doubling of PbB from 100 to 200 micrograms/l is associated with an average IQ-loss of 1-3 points (Pocock et al. 1994; WHO 1995), and no threshold has as yet been identified. Since, however, cause-effect contingencies necessarily remain doubtful in epidemiological studies if the observed effects are as subtle as these, experimental studies in animals have become helpful in supporting the causative role of lead to produce neurobehavioural deficit at steady-state PbB down to about 150 to 200 micrograms/l. Such deficit has been demonstrated by means of a variety of learning/memory models with positive and negative reinforcement contingencies in the rat--and in primates as well. It has also been shown in such studies that neurobehavioural deficit subsequent to early developmental exposure extends long into adulthood after cessation of exposure at weaning. It, therefore, appears that the neurobehavioural teratology of lead has more convincingly been demonstrated in animal models than in human exposure conditions, so far. A coherent theory to explain the particular vulnerability to lead of the developing brain is still lacking. Recent data do suggest, however, that Pb-induced disruption of calcium homeostasis in the immature brain might interfere with normal brain development.

Metals and school learning: a review of investigative techniques

A growing body of literature suggests a relationship between metals and a threatened health status among children, adolescents, and adults. Recently, several investigators have reported a direct link between exposure to metal and diminished affective, behavioral, and cognitive performance of school children. The purpose of the present study was to review and analyze methods and procedures used to understand the relationship between exposure to metals and cognitive, social, and motor functioning of school children.

Neonatal diagnosis of fetal alcohol syndrome: not necessarily a hopeless prognosis

A neonatal examination for fetal alcohol syndrome (FAS) should promote the guidance of parents, the planning of remediation for affected children, and the collection of prevalence data. A blinded examination of FAS characteristics conducted as part of a large prospective study of disadvantaged alcohol-exposed infants identified eight neonates who met the published criteria for FAS. These children were followed through the preschool years with a blinded assessment protocol. Seven of these children were found to have no impairment in cognitive and language development, when compared with their peers, and to be of average size. The one child who was mentally and growth retarded at follow-up who had been diagnosed as FAS might not have been diagnosed FAS using clinical criteria (as opposed to blinded research criteria), because his mother provided in-pregnancy reports of only low alcohol intake; she later acknowledged drinking an average of over 21 drinks/week during the pregnancy. The findings are positive in that they provide hope for children who present FAS at birth, although concern with adverse outcomes is certainly not dispelled. In particular, the possibility of later-emerging impairment in more complex tasks is not ruled out.

Endpoints of developmental neurotoxicity in environmentally exposed children

An overview is given of endpoint measures used or to be used in studying developmental neurotoxicity in environmentally exposed children. A variety of neurodevelopmental assessment methods is available covering either more general or rather sepcific aspects of the neuromotor or the neurobehavioral development, respectively. The available assays, not covered in any exhaustive manner, are classified into (1) neurodevelopmental assays for neonates, (2) neurodevelopmental assays for infants and older children, and (3) assays for cognitive development. Illustrative examples are given to demonstrate the use of several such assays in prospective cohort studies on neurodevelopmental effects of inorganic lead and of polychlorinated biphenyls (PCBs). Using these case studied crucial problems of the causative interpretation of findings due to interactions and confounding are discussed.