May 2002, Volume 52, Issue 5

Review Articles

Lead-Based Paint is a Hazard to Young Children: Implications for Pakistani Children

S. Hozharbi  ( Dapartment of Community Health Sciences, Aga Khan University Hospital, Karachi. )


The toxicity of lead, espesilly among young children, is well documented worldwide1,2. Yet it is only during the past 15 years that the histroy of this tragic situation has been addressed in any detail3.
Lead is a soft bluish-white heavy metallic element that combines with other substances and is one of the most useful materials in the world4. However, elevated blood lead levels (greater then 10 mg/dl) causes numerous discomfort-abilities and diseases5, even though evidence exists for subtle effects at lower levels6 as well. Although lead can affect every system in the body, the major systems affected are the central nervous, blood and the renal systems7-9 Low levels of lead in children can result in reduced intellectual abilities and anti-social behaviors10,11.
while high kvcIs may cause coma and even death12-14. Poor children are especially at higher risk because inadequate nutrition increases lead absorption by the body15-17, as a study from Cape province of South Africa revealed that over 90% of children in urban and rural communities have blood lead levels greater or equal to 10 mm/dl18.
Among all sources of lead19-25, lead-based paint26 is the major source of childhood lead poisoning in the United States. This finding is consistent as a study conducted in India exhibited 67% elevated bkod lead levels among children between age 6-72 months, where lead-based paint was the strongest associated risk factor for this rise27. Study in Hong Kong also suggests that color of the wall-paint used in the house may be a factor influencing the house dust Contamination28, while another study from Beijing29 revealed that toys which have been coated by a type of paint were responsible for the elevated blood lead level among children.
Lead has been used in paint since ancient times, as a pigment and drying agent in oil based paint for making it durable, to inhibit the growth of mold on the surface of the paint and to give it a bright color26. Thus, paints with higher lead levels were used where exposure to moisture is greatest: on windows, doors, bathrooms and exterior walls.
In 1904, an Australian was among the first English-language author who directly linked lead-based paint to childhood lead poisoning, specifically noting the dangers to children from painted walls and verandas of houses30. Frequent hand to mouth activity (pica) of young children in a lead-contaminated home provided an important path of ingestion of leaded dust, which could deliver enough lead to cause irreversible damage to the developing nervous system of a child under the age of 7 years26. A child’s digestive tract will absorb a high proportion of lead (50%) in comparison to adults (10%)31. Most importantly, the period of rapid growth and development in the early years of life leaves the body’s system most vulnerable to the effects of lead toxins, as lead deposition in bone causes growth failure32,33.
Pathways and Sources of Lead-Based Paint
If lead paint is in proper condition and not chalking or flaking, it is not dangerous34. However, paint can become a threat when it is damaged due to abrasion, water, poor maintenance, poor construction work and the opening and closing of lead-painted windows and doors. A remodeling or repair job can release lead particles, especially if it involves breaking of a lead-painted wall or ceiling. Based on a report34 that many schools, parks and community playgrounds across the United States have painted metal or wood playground equipments that causes an additional source of lead paint poisoning hazard for young children. Equipments as stated in the report, were painted with lead paint and over time exposure to sunlight, heat, moisture and normal wear and tear caused the paint to deteriorate into chips and dust containing lead. Young children who put their hands on the equipment while playing and then put their hands in their mouths can ingest the lead paint chips and lead dust. By glancing at the equipments in public playgrounds in Pakistan, it is evident that they are old enough to have all the above-mentioned situations.
Lead could be found both in interior and exterior-painted surfaces, interior woodwork, doors and windows. When properly maintained and managed, this paint poses little risk, however friction surfaces such as windows and windowsills, doors and doorframes, stairs and railings are of concern. Lead-based paint that peels (choona) or deteriorates is especially risky.
Basically the older a home, the greater the risk lead-based paint poses. Based on a report from New Zealand, until 1965 paints in the NZ market contained high lead levels, specifically before 1945. Even if a building has been recently painted, it may have been painted with lead-based paint or have layers of old paint covered with new paint and in US approximately three-quarter of the homes built before 1978 contained lead-based paint. Children whose homes are being renovated are also extremely at high risk. A study in New York35 concluded that those persons exposed to lead were affected more not only through lead-based paint chips and flakes that were visible, but also through fine dust particles. This dust can get onto carpets, floors, furniture, toys, under objects such as cabinets and refrigerators that are difficult to clean or mop. In addition, adults and children alike bring into the home fine dust particles on their hands from places where they play and work. Lead is very resistant to corrosion and it can remain a problem until removed. We might have lead in and around of our home without knowing it, because we cannot see or smell it. Hence, it exhibits all the above possible conditions and exposures that pose a potential threat to our children.
An estimate based on a report, discounted cost in 1998 for treatment of a single lead-poisoned child exceeds $40,000 15. The prevention of exposure to lead is more cost-effective than the treatment36, which is revealed by three national health and nutrition examination surveys in US from 1976 to 1980, 1988-to 1991 and 1991 to 1994. These surveys showed a decrease in the overall mean blood lead levels for the general US population from 12.8 to 2.8 to 2.3 mg/dl37-40. These declines were attributed to the removal of lead from paint, gasoline and food cans.
In Pakistan, low-income household commonly utilize water-soluble-paint, as it is cheaper. Due to humid weather in most cities, which causes paints on the walls to start bulging, deteriorating and peeling subsequently young children living in such an environment are likely to be exposed to lead. Furthermore, poor water piping in these cities leads to water leaking from pipes that adds an additional factor to this situation.
Few articles have been published from Pakistan41,42. For example; a recent study in Karachi43 showed that 80.5% of study subjects had blood lead levels above 10 ug/dl, which is defmed as “elevated blood lead levels"11. Nevertheless, none of them specifically emphasized that lead-based paint was the cause for elevated blood lead levels.


Primary intervention of lead poisoning seems to be more cost effective28, than treating children who are affected14. Public health efforts are required for the removal of environmental lead hazards which are present in almost all parts of the environment44, by preventing exposure to children who are exposed to such conditions especially paint on a daily basis in their homes, schools, playground and parks. Companies providing lead paint need to be informed of the hazardous effects of lead and be advised to not add lead to their products. Community orientation and provision of health education is necessary and special emphasis needs to be placed on continued research on environmental hazards in general and lead-based paint in particular.


I am grateful to Dr. Franklin White for his guidance in developing this paper. I also thank Dr. Khalil Ahmed Shaikh and Zahra Hirani for their assistance.


1.Baker NJ. A 13 years review of childhood head poisoning in Christchurch and Nelson. NZ Med. J., 1995; 108: 249.51.
2.Paulson JA, Jackson RJ, Sussman D. Expanding the physician’s role in pediatric environmental health, 3. Med. Assoc. Ga., 1999; 88: 13-7.
3.Markowitz G, Rosner D. Public health then and now: cater to the children: the role of the lead industry in a public health tragedy, 1900-1955. Am. J. Pub Health, 2000; 90: 36-43.
4.Behrman, RE, Kliegm RM, Arvin, AM, (eds.). Nelson Textbook of Pediatrics. 15th ed. Philadelphia: WB Suanders, 1996, pp. 2010-13.
5.Manser WWT, Khan MA, Hasan z. Trace element studies in Karachi populations, Part Ill: Blood copper, zinc, magnesium and lead levels in psychiatric patients with disturbed behavior. J. Pak. Med. Assoc., 1989; 39: 235-38.
6.Schwartz J, Low-level lead exposure and children’s IQ: a meta-analysis and search for a threshold. Environment, 1994; 65: 42-55.
7.WHO. Inorganic lead: environmental health criteria 165; international program on chemical safety. Geneva: World Health Organization,l995.
8.Osman K, Pawals K, Schutz A, et al. Lead exposure and hearing effects in children in Katowice, Poland. Environ Res., 1999; 80:1-8.
9.Kumar BD, Krishnaswamy K. Detection of occupational lead nephropathy using early renal markers. 3. Toxicology. Clin. Toxicol., 1995; 33: 33 1-35.
10.Needlemen HL, Riess JA, Tobin MJ, et al. Bone lead levels and delinquent behavior. J. Am. Med. Assoc., 1996; 275: 363-69.
11.Bums PA, Baghurst MG, Sawyer MG, et al, Lifetime low-level exposure to environmental lead and children’s emotional and behavioral development at ages 11-13. Am J Epidemiol., 1999; 149:740-49.
12.Manser WWT, Khan MA, Hasan Z. Trace element studies in Karachi populations Part III: Blood copper, zinc, magnesium and lead levels in Psychiatric patients with disturbed behavior. J. Pak. Med. Assoc.,1989: 235-38.
13.The nature and extent of lead poisoning in the children in the United States: a report to Congress. Altianta. GA, United States Department of Health and Human Services, 1988.
14.Goldstein GW. Neurological concepts of lead poisoning in children. Pediatric Annals., 1992; 21: 384-8.
15.Schererow U. Lead-Based Paint Poisoning Prevention: Federal Mandates for Local Govemment,CRC Report, 1997-22 (on line). Available: reports/pesticides/pest-6.cfm
16.Health~onlinelAvailable Feb 28, 2001].
17.Children’s Environmental Health Network: Resource Guide on Children’s Environmental Health onlinel. Emeryville, CA, CEHN, 1999. Available: ~Feb 28, 2001].
18.Nriagu JO, Blankson ML, Ocran k. Childhood lead poisoning in Africa: a growing public health problem. Sci. Total Environ., 1996; 181: 93-100.
19.Lanphear BP, Burgoon DA, Rust SW, et al. Environmental exposures to lead and urban children’s blood lead levels. Environ Res., 1998; 76: 120-30.
20.Momeshora C, Osibanjo 0, and Ajayi SO. Pollution studies on Nigerian rivers. Toxic heavy metals status on surface waters in Ibadan city. Environ In., 1981; 5: 49-53.
21.GloagD. Sources of lead. Br, Med. J., 1981; 281: 41- 44.
22.von Schirnding Y, Bradshaw D, Fuggle R, et al. Blood lead levels in South African inner city children. Environ Health Perspect., 1991; 94: 125-30.
23.Manser WWT. Lead: review of the recent literature. J. Pak. Med. Assoc., 1989; 39: 296-302.
24.Nir A, Tamir A, Zelnik N, et al.. Is eye cosmetic a source of lead poisoning? Isr. J. Med. Sci., 1992; 28: 417-21.
25.Shenoi RP, Khandekar RN, Jaykar AV, et al. Sources of lead exposure in urban slum school children. Indian Pediatr., 1991; 28: 1021-27.
26.Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report 46 (1997): 141 cited in BP Labphear, The Paradox of Lead Poisoning Prevention, Since 281, 1998; pp. 1617-8.
27.Patel Ab, Williams SV, Frumkin H, et al. Blood lead in children and its determinants in Nagpur, India. Int. J. Occup. Environ. Health, 2001; 7: 119-26.
28.Tong ST, Lam KC. Home sweet home? A case study of household dust contamination in Hong Kong. Sci. Total Environ., 2000; 256: 115-23.
29.Yu XM, Ye GJ. Detennination of lead and cadmium concentration in children’s toys. Zhnghua Yu Fang Yi Xue Za Zhi., 1991; 25: 214-6.
30.Gibson JL. A plea for painted railing and painted walls of rooms as the source of lead poisoning amongst Queens land children. Aus. Med. gazette, 1904; 149-53.
31.Kehoe, RA, Metabolism of lead in man in health and disease (The horben Lectures, 1960. J. Inst. Public Health, 1961; 24: 81, 101, 177.
32.Shen-X, Rosen JF, Guo D, et al. Childhood lead poisoning in China. Sci. Total Environ., 1996; 181: 101-9.
33.Rust SW, Kumar P, Burgoon DA, et al. Influence of bone-lead stores on the observed effectiveness of lead hazard intervention. Environ Res., 1999; 8: 175-84.
34.Consumer Product Safety Commission Staff Recommendation from Identifying and Controlling Lead Paint on Public Playground Equipment, 1996 Oct, USA.
35.Children with elevated blood lead levels attributed to home renovation and remodeling activities- New York, 1993-1994. Mob Mortal Wkly Rep., 1997; 54: 1120-3.
36.American Academy of Pediatrics. Screening for elevated blood lead levels (RE9815). Pediatrics, 1998; 101: 1072-78.
37.Centers for Disease Control and Prevention Update: blood lead levels-United State, 1991-1994. Mob Mortal Wkly Rep., 1997; 46: 141-46.
38.Centers for Disease Control and Prevention Update: blood lead levels-United State, 1991-1994. Mob Mortal Wldy Rep., 1997; 46: 607.
39.Mahaffey KR, Annest JL, Roberts J, et al. National estimates of blood lead levels: United 1976-1980: association with selected demographic and socioeconomic factors. N EngI J Med., 1982; 307: 573-79.
40.Brody DJ, Prikle JL, Kramer RA, et al. Blood lead levels in the US population: phase I of the Third Health and Nutrition Examination Survey (NHANES III, 1988 to 1991). J. Am. Med. Assoc., 1994; 272: 277-83.
41.Manser WT, Lalani R, Haider S. et al. Trace element studies on Karachi Population part V: Blood lead levels in normal healthy adults and grammar school children. J. Pak. Med. Assoc., 1990;40: 150-53.
42.Ali SR. Iqbal Ml, Yaqub M. Surma - a toxic cosmetic? J. Pak. Med. Assoc., 1988; 38: 281-82.
43.White F, Rahbar M H, Agboatwalla M, et al. . Elevated blood lead in Karachi Children. Bull. World Health Organ., 2001; 79: 173.
44.Srianujata S. Lead-the toxic metal to stay with humans. Toxicol Sci., 1998; 23: 237-40.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: