To the editor:

Recently, Pasricha et al1  reported on the control of iron deficiency anemia in low- and middle-income countries.

The article discusses common contributory etiologies ranging from nutritional to infectious causes for iron deficiency anemia in the pediatric age group. Given that lead ingestion exacerbates iron deficiency,2-4  may accelerate the cognitive injuries of iron deficiency,5  and may also confound the diagnosis of microcytic anemia, we were surprised that the authors did not mention lead in their article.

Clune et al6  found that lead intoxication is remarkably common in many areas in the world including those described by the authors. Our own pilot study, conducted in a semiurban Indian setup, indicated strikingly high prevalence rates of lead intoxication. Fifty-six percent of the children in the age group of 0 to 6 years had a mean blood lead level (BLL) above 5 mcg/dL, with close to 10% of children in this age group having BLL dangerously above 15 mcg/dL.

Similar results were reported7,8  in separate moderate to large population-based studies from different parts of India with an average BLL in toxic ranges, well above the upper limit set by the World Health Organization and the Centers for Disease Control and Prevention for acceptable BLLs.9 

Increased existence of hotspots of lead exposure in the South Asian region exist, but the lack of universal lead-screening programs in the developing world underrecognizes lead poisoning as a significant health hazard. Given the geographical overlap, it is likely that many of the patients in the study of Pasricha et al had concomitant lead poisoning.

Given the value of the authors’ discussion in creating awareness and perhaps initiating legislation on the global level, we think the likely contribution of lead intoxication should be brought to the attention of investigators and public health officials.

Contribution: A.J. reviewed the literature and provided original research input; A.J. and L.C.W. wrote the manuscript; and G.J. provided statistics for original research.

Conflict-of-interest disclosure: The authors declare no competing financial interests.

Correspondence: Akshat Jain, Pediatric Hematology and Oncology, Steven and Alexandra Cohen Children’s Medical Center of New York, 26901 76th Ave, New Hyde Park, NY 11040; e-mail: ajain12@nshs.edu.

1
Pasricha
 
SR
Drakesmith
 
H
Black
 
J
Hipgrave
 
D
Biggs
 
BA
Control of iron deficiency anemia in low- and middle-income countries.
Blood
2013
, vol. 
121
 
14
(pg. 
2607
-
2617
)
2
Clark
 
M
Royal
 
J
Seeler
 
R
Interaction of iron deficiency and lead and the hematologic findings in children with severe lead poisoning.
Pediatrics
1988
, vol. 
81
 
2
(pg. 
247
-
254
)
3
Zimmermann
 
MB
Muthayya
 
S
Moretti
 
D
Kurpad
 
A
Hurrell
 
RF
Iron fortification reduces blood lead levels in children in Bangalore, India.
Pediatrics
2006
, vol. 
117
 
6
(pg. 
2014
-
2021
)
4
Choi
 
JW
Kim
 
SK
Association between blood lead concentrations and body iron status in children.
Arch Dis Child
2003
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88
 
9
(pg. 
791
-
792
)
5
Lidsky
 
TI
Schneider
 
JS
Lead neurotoxicity in children: basic mechanisms and clinical correlates.
Brain
2003
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126
 
Pt 1
(pg. 
5
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19
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6
Clune
 
A
Falk
 
H
Riederer
 
A
 
Mapping global environmental lead poisoning in children. J Health Pollution. 2011;1(2):14-23
7
Ahamed
 
M
Verma
 
S
Kumar
 
A
Siddiqui
 
MK
Blood lead levels in children of Lucknow, India.
Environ Toxicol
2010
, vol. 
25
 
1
(pg. 
48
-
54
)
8
The George Foundation
 
Project Lead-Free: a study of lead poisoning in major Indian cities. In: George AM, ed. Lead Poisoning Prevention and Treatment: Implementing a National Program in Developing Countries. Proceedings of the International Conference on Lead Poisoning, Prevention, and Treatment; February 8-10, 1999; Bangalore, India
9
Centers for Disease Control and Prevention (CDC). Blood lead levels in children aged 1-5 years - United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2013;62(13):245-248