Impact of lead intoxication in children with iron deficiency anemia in low- and middle-income countries

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 reported^7,8  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.