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Lead exposure during breastfeeding
Jacquelyn Choi, Toshihiro Tanaka, MD, Gideon Koren, MD FRCPC and Shinya Ito, MD FRCPC
Owing to the recent concerns of lead (Pb) leaking into tap water, one of our female patients is concerned about the effects of Pb exposure to newborns while breastfeeding. How should I advise her and should she switch to formula feeding?
Lead exposure through drinking tap water while breastfeeding is not associated with any serious concerns in most available studies. There is currently no safe level of Pb exposure, but environmental exposure within Canada is low. At present, Pb levels in drinking water are carefully monitored by Health Canada and are not likely to be of concern to breastfeeding mothers. Switching to formula feeding is not necessary and not recommended, as improperly prepared formula can have higher Pb levels.
À la lumière des récentes inquiétudes à propos de la présence de plomb (Pb) dans leau du robinet, une de mes patientes sinquiète des effets de lexposition au plomb chez les nouveaunés qui sont allaités. Quels conseils devraisje lui donner, et devraitelle plutôt donner du lait maternisé?
Dans la plupart des études publiées, on ne parle pas dinquiétudes sérieuses à propos de lexposition au Pb dans leau du robinet pendant lallaitement. On na pas encore établi de taux sécuritaires dexposition au Pb, mais lexposition environnementale au Canada est faible. À lheure actuelle, les taux de Pb présents dans leau potable sont étroitement surveillés par Santé Canada et ne devraient pas causer dinquiétudes aux mères qui allaitent. Il nest pas nécessaire ni recommandé de donner plutôt du lait maternisé, parce que si on le prépare mal, le lait maternisé peut contenir des taux plus élevés de Pb.
Lead (Pb) is ubiquitous in our environment. Because of the concern of Pb in drinking water, urban cities are replacing Pb water pipes, which were used during house construction before the 1950s. Other sources of Pb exposure include industrial pollution and hazards through occupations related to mining, household renovation, battery or automobile manufacturing, and the production of plastics, ceramics, paints, and pigments.1
Lead accumulates in bones and remains in the body for a long period of time. Owing to the increased demand for calcium during pregnancy and lactation, calcium from bone is released along with Pb2; this mobilizes Pb stored in the bones, resulting in higher Pb levels in the blood. According to a study,3 Pb redistributed from tissues into blood might have a greater effect on blood-Pb levels than dietary intake does, unless Pb is directly consumed. Currently, there is no safe level of Pb exposure; however, the World Health Organization established provisionally tolerable weekly intakes of 3.75 µg/kg daily.4 The World Health Organization also reported 2 to 5 ng/g to be acceptable Pb levels in breast milk5 and 10 µg/L as the safe limit of Pb in drinking water.6 Health Canada enforces this restriction through routine monitoring of tap water. However, some researchers have suggested that the acceptable Pb levels should be lowered to 1.2 to 1.3 µg/kg daily in young children and pregnant women.7
Lead poisoning is known to adversely affect neuropsychologic development.8 According to a study from Boston, Mass, blood-Pb levels greater than 10 µg/dL were associated with lower neurobehavioural performance, as measured by the Bayley Scales of Infant Development at 6 to 18 months of age.9 Several studies have concluded that Pb in breast milk does depend on the level of maternal exposure, but that the absolute degree of transfer is controversial. Comparison of blood and breast milk samples in northern Ontario indicated a low milk-to-blood ratio (0.09),10 which suggests that the mammary gland barrier is effective in maintaining a low transfer between maternal blood-Pb levels and breast milk. Although studies indicate a low milk-to-blood ratio, samples of breast milk–Pb levels vary extensively.
At present, most studies agree that Pb poisoning through breast milk is only a concern if the mother has high blood-Pb levels. A study conducted in Toronto, Ont, showed that pregnant women had average blood-Pb levels of 2.9 µg/dL and only 1 in 95 women had blood-Pb levels greater than 9.9 µg/dL.11 Lead levels that are sufficiently high for concern (>10 µg/dL) are rarely exhibited in urban areas in Canada. Levels of Pb contamination in drinking water from Pb pipes are not sufficiently high to greatly increase Pb levels in breast milk and are typically lower than the tolerable range of Pb exposure. While there are reports of Pb poisoning caused by drinking water,12,13 there are currently no reported cases of Pb poisoning in infants attributed to breastfeeding mothers who have been exposed to Pb through drinking water. Therefore, continued breastfeeding is recommended for mothers whose blood-Pb levels are not excessively high.
Employees who are exposed to airborne Pb levels above 30 µg/m3 are required by the Occupational Safety and Health Administration to have their blood-Pb levels measured every 6 months and routinely complete a zinc protoporphyrin (ZPP) test. Zinc protoporphyrin levels increase exponentially above 40 µg/dL (400 µg/L) blood-Pb levels, but a paucity of data on the blood-Pb–ZPP correlations and ZPP levels associated with adverse health effects limits its usefulness in determining Pb toxicity.6 Although the normal range of ZPP is 32 to 69 µmol/mol of heme,14 ZPP is relatively higher in preterm neonates or in those suffering from hypoxemia.15 Moreover, while ZPP levels do correlate with blood-Pb levels, there is considerable individual variability of ZPP measurements and poor sensitivity to Pb exposure at low ranges.16 The pediatric reference range for ZPP is 16.6 to 73.6 µmol/mol of heme in females and 15.6 to 63.5 µmol/mol of heme in males, from birth to 12 months old,17 when most breastfeeding is completed. However, little research has been completed regarding the accuracy of ZPP tests in determining Pb poisoning, so this test should only be used in conjunction with a blood-Pb measurement.
Mothers who have a history of Pb poisoning or who are sustaining high levels of occupational Pb exposure might have high blood-Pb levels. These mothers should be routinely monitored. If maternal blood-Pb levels are excessively high, the breastfed infants should also be observed.
Switching to formula feeding is not recommended as a method to avoid urban Pb exposure. Cows milk, the most utilized source of milk in diets of non-breastfed infants, can be a source of Pb due to the bone meal used for cattle feed18 and can increase risks of iron deficiency.19 Furthermore, during preparation, infant formulas also tend to be overconcentrated, which can further elevate Pb intake.20,21 In summary, is recommended that unless maternal blood-Pb levels are excessively high, breastfeeding should continue.
- Dorea JG. Mercury and lead during breast-feeding. Br J Nutr 2004;92(1):21-40.[Medline]
- Gulson BL, Mahaffey KR, Jameson CW, Mizon KJ, Korsch MJ, Cameron MA, et al. Mobilization of lead from the skeleton during the postnatal period is larger than during pregnancy. J Lab Clin Med 1998;131(4):324-9.[Medline]
- Manton WI, Angle CR, Stanek KL, Kuntzelman D, Reese YR, Kuehnemann TJ. Release of lead from bone in pregnancy and lactation. Environ Res 2003;92(2):139-51.[Medline]
- Lead, cadmium and mercury. World Health Organization. Trace elements in human nutrition and health. Geneva, Switz: World Health Organization; 1996. p. 195-216.
- World Health Organization. Minor and trace elements in human milk. Geneva, Switz: World Health Organization; 1989.
- World Health Organization, Volume 1: recommendations. Guidelines for drinking-water quality. 3 ed. Geneva, Switz; 2006. Available from: www.who.int/water_sanitation_health/dwq/gdwq0506.pdf. Accessed 2008 Mar 10.
- Müller L, Dieter HH. [Lead in drinking water—determination of a new limit value and the problem of lead pipes]. Gesundheitswesen 1993;55(10):514-20.[Medline]
- Sanín LH, González-Cossío T, Romieu I, Peterson KE, Ruíz S, Palazuelos E, et al. Effect of maternal lead burden on infant weight and weight gain at one month of age among breastfed infants. Pediatrics 2001;107(5):1016-23.
[Abstract/Free Full Text]
- Bellinger D, Leviton A, Waternaux C, Needleman H, Rabinowitz M. Longitudinal analyses of prenatal and postnatal lead exposure and early cognitive development. N Engl J Med 1987;316(17):1037-43.[Abstract]
- Hanning RM, Sandhu R, MacMillan A, Moss L, Tsuji LJ, Nieboer E. Impact on blood Pb levels of maternal and early infant feeding practices of First Nation Cree in the Mushkegowuk Territory of northern Ontario, Canada. J Environ Monit 2003;5(2):241-5.[Medline]
- Koren G, Chang N, Gonen R, Klein J, Weiner L, Demshar H, et al. Lead exposure among mothers and their newborns in Toronto. CMAJ 1990;142(11):1241-4.[Abstract]
- Costa RA, Nuttall KL, Shaffer JB, Peterson DL, Ash KO. Suspected lead poisoning in a public school. Ann Clin Lab Sci 1997;27(6):413-7.[Abstract]
- Watt GC, Britton A, Gilmour HG, Moore MR, Murray GD, Robertson SJ. Public health implications of new guidelines for lead in drinking water: a case study in an area with historically high water lead levels. Food Chem Toxicol 2000;38(1 Suppl):S73-9.[Medline]
- Hudák A, Kiss G, Náray M, Süveges E. Evaluation of delta-aminolaevulinic acid excretion in random urine samples of children. Eur J Pediatr 1994;153(3):187-9.[Medline]
- Lott DG, Zimmerman MB, Labbé RF, Kling PJ, Widness JA. Erythrocyte zinc protoporphyrin is elevated with prematurity and fetal hypoxemia. Pediatrics 2005;116(2):414-22.
[Abstract/Free Full Text]
- Martin CJ, Werntz CL 3rd, Ducatman AM. The interpretation of zinc protoporphyrin changes in lead intoxication: a case report and review of the literature. Occup Med (Lond) 2004;54(8):587-91.[Medline]
- Soldin OP, Miller M, Soldin SJ. Pediatric reference ranges for zinc protoporphyrin. Clin Biochem 2003;36(1):21-5.[Medline]
- Akayezu JM, Hansen WP, Otterby DE, Crooker BA, Marx GD. Yield response of lactating Holstein dairy cows to dietary fish meal and bone meal. J Dairy Sci 1997;80(11):2950-63.[Abstract]
- Ziegler EE. Adverse effects of cows milk in infants. Nestle Nutr Workshop Ser Pediatr Program 2007;60:185-99.[Medline]
- Shannon M, Graef JW. Lead intoxication from lead-contaminated water used to reconstitute infant formula. Clin Pediatr (Phila) 1989;28(8):380-2.
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- Lucas A, Lockton S, Davies PS. Randomised trial of a ready-to-feed compared with powdered formula. Arch Dis Child 1992;67(7):935-9.[Abstract]