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Pediatric Lead Exposure From Imported Indian Spices and Cultural
Powders
Cristiane Gurgel Lin, MD, PhD,
Embargo Release Date: Monday, March 15, 2010 - 12:01am (ET)
Embargo Policy:
Information in this article is embargoed for release until the
date indicated above. Interviews may be conducted prior to the
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upcoming press events, or other matters, please contact AAP
Communications staff at 847-434-7877, or via e-mail at commun@aap.org
The American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village, IL 60007
Pediatric Lead Exposure From Imported Indian Spices
and Cultural Powders
WHAT’S KNOWN ON THIS SUBJECT: Lead is a neurotoxin, and
elevated BLLs in children are a public health concern. Immigrant
children are at risk because of additional exposure to imported
culture-specific leaded products. Lead contamination in many
imported products has not been characterized.
WHAT THIS STUDY ADDS: We report here lead-poisoning cases
from Indian cultural powders or spices. Imported products
surveyed contained lead, and chronic exposure could increase
the prevalence of elevated BLLs. These results increase leaded-
product awareness and aid lead-poisoning prevention.
abstract
BACKGROUND: Significant lead poisoning has been associated with
imported nonpaint products.
OBJECTIVES: To describe cases of pediatric lead intoxication from im-
ported Indian spices and cultural powders, determine lead concentra-
tions in these products, and predict effects of ingestion on pediatric
blood lead levels (BLLs).
PATIENTS AND METHODS: Cases and case-study information were ob-
tained from patients followed by the Pediatric Environmental Health
Center (Children’s Hospital Boston). Imported spices (n ⫽86) and
cultural powders (n⫽71) were analyzed for lead by using x-ray fluo-
rescence spectroscopy. The simple bioaccessibility extraction test was
used to estimate oral bioavailability. The integrated exposure uptake bio-
kinetic model for lead in children was used to predict population-wide
geometric mean BLLs and the probability of elevated BLLs (⬎10
g/dL).
RESULTS: Four cases of pediatric lead poisoning from Indian spices or
cultural powders are described. Twenty-two of 86 spices and foodstuff
products contained ⬎1
g/g lead (for these 22 samples, mean: 2.6
g/g
[95% confidence interval: 1.9 –3.3]; maximum: 7.6
g/g). Forty-six of 71
cultural products contained ⬎1
g/g lead (for 43 of these samples, mean:
8.0
g/g [95% confidence interval: 5.2–10.8]; maximum: 41.4
g/g). Three
sindoor products contained ⬎47% lead. With a fixed ingestion of 5
g/day
and 50% bioavailability, predicted geometric mean BLLs for children aged
0 to 4 years increased from 3.2 to 4.1
g/dL, and predicted prevalence of
children with a BLL of ⬎10
g/dL increased more than threefold (0.8%–2.8%).
CONCLUSIONS: Chronic exposure to spices and cultural powders may
cause elevated BLLs. A majority of cultural products contained ⬎1
g/g lead, and some sindoor contained extremely high bioaccessible
lead levels. Clinicians should routinely screen for exposure to these
products. Pediatrics 2010;125:e828–e835
AUTHORS: Cristiane Gurgel Lin, MD, PhD,
a,b,c
Laurel Anne
Schaider, PhD,
d
Daniel Joseph Brabander, PhD,
e
and Alan
David Woolf, MD, MPH
b,f
a
Pediatric Residency Program, Department of Medicine, and
f
Pediatric Environmental Health Center, Division of General
Pediatrics, Children’s Hospital Boston, Boston, Massachusetts;
b
Department of Pediatrics, Harvard Medical School, Boston,
Massachusetts;
c
Department of Neonatology, Pediatrix Medical
Group, Seton Medical Center, Austin, Texas;
d
Department of
Environmental Health, Harvard School of Public Health, Boston,
Massachusetts; and
e
Department of Geosciences, Wellesley
College, Wellesley, Massachusetts
KEY WORDS
pediatric lead poisoning, childhood plumbism, spices, herbal
products, cosmetics, religious powders, lead contamination,
Indian, sindoor, culture-specific exposure
ABBREVIATIONS
CDC—Centers for Disease Control and Prevention
BLL— blood lead level
FDA—Food and Drug Administration
IEUBK—integrated exposure uptake biokinetic model for lead in
children
PEHC—Pediatric Environmental Health Center
XRF—x-ray fluorescence
NIST—National Institute of Standards and Technology
LOD—limit of detection
SBET—simple bioaccessibility extraction test
XRD—x-ray diffraction
ZPP—zinc-chelated protoporphyrin
CI— confidence interval
www.pediatrics.org/cgi/doi/10.1542/peds.2009-1396
doi:10.1542/peds.2009-1396
Accepted for publication Nov 16, 2009
Address correspondence to Cristiane Gurgel Lin, MD, PhD,
Neonatology Department, Seton Medical Center, 1201 W 38th St,
Austin, TX 78705. E-mail: cristiane.lin@gmail.com
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2010 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
e828 LIN et al
Lead is a neurotoxin that can cause
permanent neurocognitive deficits in
children.1–3 The current Centers for
Disease Control and Prevention (CDC)
blood lead level (BLL) of concern is 10
g/dL, although a BLL of ⬍5
g/dL
also may result in cognitive deficits.4–8
A national objective of Healthy People
2010 is to eliminate elevated BLLs in
children. As part of this effort, the CDC
has worked to identify at-risk popula-
tions and nonpaint sources of lead ex-
posure.3,9 Among those at risk are im-
migrant children, who are more likely
than US-born children to have an ele-
vated BLL through exposure to non-
paint lead sources.10,11 Culture-specific
nonpaint lead sources have been iden-
tified, including imported utensils,12
foods such as Mexican tamarind
candy,13 cosmetics such as kohl14 and
henna,15 and ayurvedic traditional
medicines16,17 and Mexican digestive
remedies.18
Culture-specific lead sources have
placed South Asian and Indian commu-
nities at risk. Woolf and Woolf19 re-
ported 2 cases of pediatric lead poi-
soning from imported Indian spices. In
addition, a Thai infant suffered lead
poisoning from a powder applied to his
tongue,20 and an Indian child devel-
oped an elevated BLL from ingestion of
sindoor (a powder applied to a wom-
an’s scalp as a marriage sign).21 Re-
cently, the US Food and Drug Adminis-
tration (FDA) recalled a brand of
ceremonial Indian powders because of
lead contamination and confirmed
cases of lead poisoning.22
To date, few studies have systemati-
cally investigated the lead content of
imported Indian spices and ceremo-
nial powders and considered related
risks posed to children living in the
United States. The goals of our investi-
gation were to (1) describe recent
cases of pediatric lead poisoning
caused by contaminated Indian spices
and religious powders, (2) survey and
assess lead contamination among var-
ious commercially available imported
Indian spices and ceremonial prod-
ucts sold in stores in the Boston, Mas-
sachusetts, area, and (3) predict the
prevalence of elevated BLLs in children
caused by chronic exposure to these
products by using the integrated expo-
sure uptake biokinetic model for lead
in children (IEUBK).23
PATIENTS AND METHODS
Case-Study Information
Case-study information was acquired
through the review of medical charts
of patients who were referred to the
Pediatric Environmental Health Center
(PEHC) at Children’s Hospital Boston
from 2006 to 2008 for an elevated BLL.
The cases represent ⬃2% of new pa-
tient referrals to the PEHC. All patients
were asymptomatic. Home environ-
ments were assessed for lead by the
Massachusetts Department of Public
Health via dust wipe and direct sam-
pling of surfaces and by the PEHC via
environmental inventory and soil-
testing. In all cases, no other signifi-
cant sources of lead were found.
Collection Methods: Market-Basket
Survey
In this article, we use the terms “cul-
tural powder,” “religious powder,” and
“ceremonial powder” interchangeably.
Collection and analysis of spices and
powders were based on the protocol
outlined by Saper et al.16 Boston-area
stores that sell spices and religious
powders were identified through an
online national directory of Indian gro-
cery stores24 and a New England area
Indian community business directo-
ry.25 In early 2008, 15 randomly se-
lected stores were visited within 20
miles of Children’s Hospital Boston.
Spices and ceremonial powders were
purchased if they were manufactured
in India and were (1) spices/foodstuffs
(edible, used in food preparation) or
(2) religious powders (used in reli-
gious or cultural practices, not in-
tended for consumption, not labeled
for use as medication). When more
than 1 store carried the same brand of
a given product, it was only purchased
once. The name, manufacturer, manu-
facturer’s location, packaging loca-
tion, lot number, expiration date, store
name, and purchase date were re-
corded when available. For compari-
son, 10 types of spices produced by US
manufacturers were purchased at a
large New England supermarket, al-
though in most cases, the country of
origin was not listed.
To assess variability between lots of
the same product, all products that
contained ⬎10
g/g lead were repur-
chased for additional analysis. In addi-
tion, 10% of the spices and powders
were randomly selected for repur-
chase and reanalysis.
Heavy-Metal Analysis
Samples were labeled with a numeri-
cal identifier only. Four grams of each
sample were transferred into x-ray flu-
orescence (XRF) analytical cups (Pre-
mier Lab Supply, Port St Lucie, FL) with
4-
m windows (Spex Certiprep,
Metuchen, NJ) after thorough homog-
enization. Repurchased products re-
ceived new numerical identifiers, and
2 aliquots of each repurchased prod-
uct were analyzed.
The concentration of lead in each sam-
ple was determined by using a Spectro
XEPOS polarized energy-dispersive XRF
instrument (Spectro Analytical, Kleve,
Germany). Measurement accuracy
was determined by using a standard
reference material (National Institute
of Standards and Technology [NIST]
2709, San Joaquin [California] soil).26
The measured mean lead concentra-
tion for NIST 2709 (18.5 ⫾0.9
g/g; n⫽
48) was consistent with the certified
value (18.9 ⫾0.5
g/g). The limit of
detection (LOD) is ⬃1.0
g/g.
ARTICLES
PEDIATRICS Volume 125, Number 4, April 2010 e829
Because many spice samples were be-
low the XRF LOD, total lead concentra-
tion was also determined in a subset of
spices by using microwave digestion in
concentrated nitric acid followed by in-
ductively coupled plasma mass spec-
trometry (Elan 6100 [Perkin Elmer,
Shelton, CT]) analysis. The LOD is
⬃0.03
g/g. Average recovery of lead
from NIST 1515 (apple leaves) was 88%
(n⫽2).
Bioaccessibility Analysis
For a random subset of samples, lead
bioaccessibility (ie, fraction of metal
mobilized in a biologically relevant
fluid) was estimated by using the sim-
ple bioaccessibility extraction test
(SBET). The SBET is an in vitro gastric
fluid extraction that simulates metal
dissolution in the stomach and has
been shown to predict in vivo lead ab-
sorption in juvenile swine, a model for
gastrointestinal absorption in chil-
dren.27,28 The SBET was performed by
following a previously published proto-
col.29 Bioaccessibility was calculated
as extracted lead concentration/total
lead concentration.
To determine the crystalline phases
linked with high-lead sindoor products
(⬎47% lead), x-ray diffraction (XRD)
analyses were conducted by using a
rotating copper anode RU 300 genera-
tor (Rigaku, Tokyo, Japan). Resulting
XRD patterns were fit by using Jade
software (Materials Data, Livermore,
CA) with search/match of the FIZ-
Inorganic Crystal Structure Database
(http://icsd.ill.eu/icsd/index.html) and
Rietveld whole-pattern fitting. XRD
analyses provide both phase identifi-
cation and the general bonding envi-
ronment of lead. Combining XRD char-
acterization with SBET analysis is an
effective and underutilized approach
to evaluating the chemical form and
relative solubility of lead in various ex-
posure media (soils, spices, religious
powders).30
IEUBK Modeling
The IEUBK model, Windows version 1.0,
build 264 (US Environmental Protec-
tion Agency, Washington, DC), is a nu-
merical blood lead predictive mod-
el.23,31 The IEUBK model estimates
population-level BLLs on the basis of
various lead-exposure sources, uptake
via inhalation or ingestion, and bioki-
netics. Probability distributions are
used to estimate variability in BLLs
among exposed children.23 The IEUBK
model has been widely used since 1994
and independently validated and veri-
fied.32 Because it has been used to es-
timate mean BLLs and predict the
probability of elevated BLLs in a popu-
lation of children exposed to lead-
contaminated tamarind candy,33 the
model was considered appropriate for
the goals, age ranges, and exposure du-
ration for our population of concern.
We used the IEUBK model to estimate
the geometric mean BLL for a popula-
tion and to predict the probability of
elevated BLLs caused by intentional
or accidental ingestion of lead-
contaminated spices or powders. Lead
exposure from other environmental
sources was held constant, and stan-
dard model inputs, comparable to Bos-
ton background levels,26,34,35 were used
to incorporate background lead expo-
sure. Diet inputs were calculated from
FDA food-monitoring data.36 For model
runs, an alternate exposure function
was used to model additional ingestion
of spices or powders. Bioaccessibility,
based on SBET data, was used as an
upper-bound estimate of bioavailability
(ie, fraction of lead that is absorbed and
reaches the systemic circulation).28,37
RESULTS
Case Summaries
Case 1
A 10-month-old Indian boy was re-
ferred for an elevated BLL (43
g/dL), a
mean corpuscular volume of 69.7 fL,
hemoglobin level of 11.2 g/dL, and
hematocrit level of 31.7%. He received
5 days of parenteral chelation with
intravenous Na
2
CaEDTA. His zinc-
chelated protoporphyrin (ZPP) level
was elevated at 152
mol/mol of heme
(normal ZPP level, based on a hemato-
crit level of 35%: 25– 65
mol/mol),
which suggested chronic lead expo-
sure. The parents described rubbing a
religious powder on the patient’s fore-
head since he was several weeks old.
They did not add powders to foods.
Lead analyses revealed 89 000
g/g
lead in the religious powder and 300
g/g lead in an eye cosmetic. The par-
ents stopped using the powder, and
the child received oral chelation with
dimercaptosuccinic acid for 6 months,
which reduced the BLL to ⬍21
g/dL.
By 21 months of age, the child’s BLL
was stable (15
g/dL), and he required
no additional oral chelation therapy.
Case 2
A 9-month-old Indian boy was referred
for an elevated BLL (21
g/dL). The par-
ents described applying an orange
powder (orange shringar) to his fore-
head as a religious tradition. They did
not add powders to food. Lead analy-
ses revealed 220 000
g/g in the pow-
der and 49
g/g in both holy ash and
kumkum. Analyses of family spices and
utensils did not detect lead. The par-
ents stopped using the powders, and 4
weeks later the patient’s BLL was 17
g/dL, with a ZPP level of 85
mol/mol
and hemoglobin level of 10.7 g/dL. Two
months later, his BLL decreased to 13
g/dL. No chelation was administered.
Case 3
A 3-year, 9-month-old Indian girl was
referred for an elevated BLL (18
g/
dL), a ZPP level of 88
mol/mol, and a
hemoglobin level of 10.9 g/dL. No con-
taminated herbs, spices, or ethnic
remedies were discovered. However, a
religious powder ingested regularly by
the patient contained 4800
g/g lead.
e830 LIN et al
The family discontinued use of this
powder, and over the next 8 months,
the patient’s BLL decreased to 8
g/dL.
Case 4
A 12-month-old Indian boy was re-
ferred for an elevated BLL (28
g/dL), a
ZPP level of 103
mol/mol, and a hemo-
globin level of 9 g/dL. Analyses of
spices, herbal remedies, and religious
powders revealed that several Indian
spices, used daily, contained lead: an
herb mix (11
g/g), brown mustard
seed (0.6
g/g), asafoetida (0.8
g/g),
and turmeric (1.4
g/g). The family
discontinued use of all imported
spices, and the patient’s BLL declined
to 14
g/dL within 6 months.
Religious Powders
Seventy-one religious products manu-
factured by 28 companies were pur-
chased (Table 1). Forty-three products
listed packaging location, and 5 prod-
ucts provided lot numbers. Sixteen
products were categorized as cosmet-
ics and hair products for daily use, and
55 were categorized as ceremonial re-
ligious powders for daily to monthly
use.
Of the 71 cultural products tested, 46
(65%) contained ⬎1
g/g lead. The
mean lead concentration in 43 sam-
ples with detectable lead (excluding 3
high-lead sindoor products) was 8.0
g/g (95% confidence interval [CI]:
5.2–10.8
g/g), with a maximum of
41.4
g/g (kajal). Three sindoor prod-
ucts contained ⬎47% lead by weight
and were treated separately in the sta-
tistical analysis (Table 3). These sin-
door lead concentrations are compa-
rable to those in published reports.21,38
Cosmetics and ceremonial powders
had similar lead concentration and
ranges (Table 3).
Indian Spices and Foodstuff
Eighty-six food products manufac-
tured by 53 companies were pur-
chased (Table 2). Sixty-three prod-
ucts listed packaging location, and 38
products listed lot numbers. Thirty-
eight products were categorized as
common spices, used daily in food
preparation, whereas 48 were catego-
rized as foodstuff, including spice
mixes, food coloring, or other food ad-
ditives, which may be used less fre-
quently. Of the 86 products tested by
XRF, 22 (26%) contained ⬎1
g/g lead,
with a mean lead concentration in
these 22 samples of 2.6
g/g (95% CI:
1.9 –3.3) and a maximum of 7.6
g/g
(sea salt). Food products had a lower
percentage of samples with detected
lead and lower mean lead concentra-
tion compared with religious prod-
ucts. Spices and foodstuff contained
similar ranges of lead concentration
(Table 3).
On the basis of a direct comparison of
10 types of spices (US brands and im-
ported) analyzed by inductively cou-
pled plasma mass spectrometry, im-
ported spices had a mean lead
concentration of 0.5
g/g (95% CI:
0.18 – 0.72), which was twice the mean
lead concentration of US-brand spices
TABLE 1 Examples of Cosmetics, Hair Products, and Ceremonial Powders Purchased
Product Name Brand Name Uses
Cosmetics and hair products
Aritha powder Hesh Shampoo
Henna Al-aroosa, Ancient Secret, Ayur, Dulhan Hand decoration
Kajal Shingar Ltd, Western Indian Chemical Co Eyeliner
Hairwash Meera Shampoo
Sandalwood Nirav Cosmetic, medicinal
Ceremonial powders
Abil Bhavani, Nirav Pooja ceremony
Gulal MDHD, Swad, Durbar Pooja ceremony
Kumkum Shringar, Topaz, Butala Emporium Bindi
Sindoor MDHD, Swad, Nirav, Butala Emporium Marriage symbol
TABLE 2 Examples of Spices and Foodstuff
Purchased
Product Name Brand Name
Spices
Black pepper Laxmi, Swad, Deep
Cardamom DEEP
Chili powder Saras, Noer, Swan
Coriander MDHD, Periyar, Swad, Swan
Fennel powder Deep
Fenugreek Swad
Garam masala MDHD, Swan
Garlic power Shalimar
Ginger powder Himgiri, Swad
Paprika Swad
Sindav salt Deep, Swad
Turmeric Laxmi, Nirav, Swad, Swan
Foodstuff
Food coloring Bush, Bhavani, Narmada,
Vesco
Dabelli masala Bombay Magic
Fish curry MDH
Vada mix MTD
Chappli kabab
masala
Roopak
Vermacelli mix MTR
Tulsi powder Bhavani
Karela powder Swad
Asafoetida Laljee Godhoo, Ruchi, Swad
Amchur powder Deep
Hajmola candy Dabur India Ltd
TABLE 3 Mean Concentration, CI, and Range of Lead in Spices, Foodstuff, Cosmetics, Ceremonial
Powders, and High-Lead Sindoor With a Detectable Lead Level by XRF
Product No. of
Samples
Samples With
Detectable Lead, %
Lead Level, Mean
(95% CI),
g/g
a
Range,
g/g
a
Spices 38 24 2.6 (1.2–4.0) 1–7.6
Foodstuff 48 27 2.6 (1.8–3.4) 1–6.3
Cosmetics 16 81 7.6 (1.3–13.9) 1–41.4
Ceremonial powders 52 58 8.2 (6.0–10.4) 1–39.9
High-lead sindoor 3 100 559 000 (463 000–655 000) 469 000–638 000
a
Serial dilutions of NIST 2709 suggest that the LOD (based on the criteria that samples run in triplicate maintain ⬍10%
relative SD) is 1.0
g/g (data not shown). LOD estimates based on serial dilution of NIST 2709 were supported by 15 replicate
analyses of NIST 1515 (apple leaves) in which a 20% SD was observed for an expected lead concentration of 0.47
g/g.
ARTICLES
PEDIATRICS Volume 125, Number 4, April 2010 e831
(0.19
g/g [95% CI: 0.1– 0.28]) (Table
4). However, this difference was not
significant on the basis of a pairwise t
test (P⬎.1). The lead concentration in
these 10 imported spices was up to
fivefold higher than the recommended
maximum level in hard candy (0.1
g/
g).39 In addition, imported spices had a
similar range of lead concentrations
as spices manufactured in Pakistan
(0.02–9.2
g/g).40 Although the FDA has
no recommended maximum lead con-
centration for spices, the European
Union’s recommended limit for dried
herbs is 2 to 3
g/g.41
Bioaccessibility
We determined bioaccessibility for a
subset of samples by SBET as a reason-
able approximation for bioavailabil-
ity.28 Spices had a mean lead bioacces-
sibility of 49% (95% CI: 32– 66) (Table
5), which is consistent with previously
published data37,42 and with the default
IEUBK value of 50% for lead absorption
from food.37 Religious and cosmetic
products and sindoor (with ⬎47%
lead) had similar mean lead bioacces-
sibility (50%–56%) as spices (Table 5).
XRD results indicated that Pb
3
O
4
(minium, “red lead”) is the chemical
form of lead in these samples. Minium
is commonly used as a pigment in
henna and lead paint.15,43
IEUBK Modeling
The IEUBK model was used to predict
the effects of chronic ingestion of
spices or religious powders on popula-
tion BLLs. For a fixed ingestion rate
(
g/day), the geometric mean BLL and
percentage of children with an ele-
vated BLL (defined as a BLL of ⬎10
g/
dL) were calculated. When the model
was run with default inputs only, the
background geometric mean BLL for
children aged 1 to 5 years was 3.1
g/
dL. This value is higher than the na-
tional geometric mean BLL of 1.9
g/dL
but comparable to that of black chil-
dren (2.8
g/dL) and children in low-
income households (2.5
g/dL).44 The
percentage of children with an ele-
vated BLL (0.6%) was lower than the
national average (1.6%).44 Overall, these
data suggest that the model can reason-
ably approximate background BLL for
children who live in the United States.
To model increased exposure resulting
from spice or accidental powder inges-
tion, we used a fixed lead-ingestion rate
(5
g/day). Spice-ingestion rates for
various lead concentrations are listed
in Table 6 and are comparable to those
in published reports.45,46 When the
model was run with a fixed ingestion
rate of 5
g/day and 50% bioavailabil-
ity, the predicted geometric mean BLL
for children aged 0 to 4 years in-
creased from 3.2 to 4.1
g/dL, and the
predicted prevalence of children with
an elevated BLL increased threefold,
from 0.8% to 2.8%. The difference is
more dramatic with small increases in
ingested amount and bioavailability
(Figs 1 and 2); at 5
g/day and 80%
bioavailability, 4.9% of children were
predicted to have an elevated BLL, and
at 10
g/day and 50% bioavailability,
6.5% of children were predicted to
have an elevated BLL. These results
suggest that infants and children can
develop lead poisoning by chronic in-
gestion of contaminated spices and
ceremonial powders.
DISCUSSION
Our analyses demonstrate the risk of
lead poisoning associated with con-
taminated ceremonial powders and
rituals that involve the external appli-
cation of these powders to young in-
fants. Of particular concern are (1) the
extremely high lead concentrations
found in some readily available sin-
door powders (47%– 64% lead), (2) the
moderate lead concentrations found
in other cultural powders (up to 40
g/
g), (3) the young age at which parents
commence such practices, and (4) the
chronic nature of the exposure (up to
several times per week). Although the
powders are not meant for consump-
tion, we speculate that infants may be
inadvertently exposed by hand-to-
mouth transference of topically ap-
plied powders or by the hands of par-
ents who handle the powder and then
prepare foods for the infant’s con-
sumption. Infants may also be exposed
to these products in utero, through
breastfeeding, inhalation of aerosol-
ized particles, or dermal absorption.12
As predicted by IEUBK modeling,
chronic exposure can have a dramatic
effect on BLL. For instance, ingesting
20
g of high-lead sindoor increases
lead exposure by 10
g/day and the
probability of elevated BLL by eightfold.
TABLE 4 Mean Concentration, CI, and Range
of Lead in US-Brand Spices and
Indian Brand Spices (N⫽10)
Product
a
Lead Level, Mean
(95% CI),
g/g
Range,
g/g
US brands 0.19 (0.1–0.28) 0.03–0.41
Indian brands 0.45 (0.17–0.73) 0.12–1.54
a
Spices tested included garlic powder, black pepper, fen-
nel powder, ginger powder, coriander, garam masala, tur-
meric, chili powder, paprika, and cardamom.
TABLE 5 Mean Bioaccessibility, CI, and Range
of Bioaccessibility of Religious
Powders, Spices, and High Lead
Sindoor
Product No. of
Samples
Mean
Bioaccessibility,
% (95% CI)
Range,
%
Powders 6 56 (20–92) 20–80
Spices 10 49 (32–66) 22–100
High-lead
sindoor
3 50 (38–62) 40–62
TABLE 6 Ingestion Rate as a Function of Lead
Concentration for Lead Ingestion of
5
g/g
Lead
Concentration,
g/g
Daily Ingestion
Rate
a
Weekly
Ingestion Rate
g Teaspoons g Teaspoons
0.5 10 2 70 14
151357
5 1 0.2 7 1.4
10 0.5 0.1 3.5 0.7
20 0.25 0.05 1.75 0.35
a
Mean ingestion rate of spices in g/day for children aged
1 to 3 years, living in India, was reported to be 5 g/day, with
a range of 3 to 10 g/day, as reported by the National Nutri-
tion Monitoring Bureau.
45,46
e832 LIN et al
Ingestion of 250 mg of sandalwood, an
amount comparable to pediatric soil
ingestion through hand-to-mouth ac-
tivities,47 increases exposure by 5
g/
day and the probability of elevated
BLL by threefold. Although previous
studies have shown risks to children
from remedies, foods, and spices
meant for consumption,16–19,48 lead
poisoning from contaminated prod-
ucts intended only for external appli-
cation has not been fully appreci-
ated. Such items include cosmetics,
such as kohl,14 and we now extend
the product list to include Indian
powders intended for use in reli-
gious practices.
We also found that under certain cir-
cumstances, exposure to imported In-
dian spices may increase the preva-
lence of elevated BLL. IEUBK modeling
predicted that chronic ingestion of
spices that contained our highest mea-
sured lead concentration (7.6
g/g)
may result in elevated BLLs. Therefore,
a risk for lead poisoning exists if there
is sufficient lead contamination or a
high daily dose. This risk is not theoret-
ical, as indicated by our case report of
lead poisoning from chronic ingestion
of imported spices with similar lead
concentrations (1–11
g/g).
There are several limitations of our
study. First, although we analyzed
more than 150 products, our samples
did not represent all types of Indian-
manufactured products. Second, there
may be lot-to-lot variability in lead
concentration depending on manu-
facturing and packaging practices
and on natural spice-plant accumu-
lation of lead. Third, regional varia-
tion in Indian product availability and
distribution may limit the applicabil-
ity of the study to other locations.
Fourth, family usage patterns will af-
fect the overall cumulative exposure
and risk of injury. We did not acquire
end-user information regarding
these products. Nevertheless, to our
knowledge, our study represents the
first attempt to investigate a variety
of cultural products and to carefully
consider their potential effects on
pediatric BLL.
CONCLUSIONS
Our investigation of Boston-area
stores that sell Indian spices and reli-
gious powders revealed a ready avail-
ability of lead-contaminated items.
Similar products can also be pur-
FIGURE 1
The IEUBK model was used to predict mean geometric BLLs in children aged 0 to 4 years with varying
exposures. In this simulation, daily lead ingestion and bioavailability were varied, and resulting BLLs
are shown.
FIGURE 2
The IEUBK model was used to predict the prevalence of BLLs of ⬎10
g/dL in a population of children
aged 0 to 4 years with varying exposures. In this simulation, daily lead ingestion and bioavailability
were varied.
ARTICLES
PEDIATRICS Volume 125, Number 4, April 2010 e833
chased on the Internet. Furthermore,
we were able to purchase highly con-
taminated items that were previously
banned or recalled by the FDA. The high
prevalence, availability, chronic and
widespread use,49 and potential toxic-
ity of these products pose a public
health risk. Clinicians should be aware
of these and other imported hazards
and inquire about their use during rou-
tine health supervision visits. Further-
more, per CDC and American Academy
of Pediatrics recommendations, clini-
cians who work with South Asian com-
munities should perform targeted BLL
screening on new immigrants and rou-
tinely administer lead-exposure risk-
assessment questionnaires (provided
by state departments of health50,51),
modified to include these hazards.52,53
Because of the high lead concentra-
tions found in some sindoor sam-
ples, import, sale, and labeling of
these items should be carefully mon-
itored, and low-lead sindoor (⬍5
g/g) could be suggested as a safer
alternative. Closer inspection and
testing of other religious products is
warranted.
ACKNOWLEDGMENTS
Dr Lin was supported by the Lovejoy
Residency Research Fund (Children’s
Hospital Boston). Dr Woolf was sup-
ported in part by a grant from the
Agency for Toxic Substances and Dis-
ease Registry Superfund Reconcilia-
tion and Reclamation Act, adminis-
tered through the Association of
Occupational and Environmental Clin-
ics Association (Washington, DC). Chil-
dren’s Hospital Boston, Harvard Medi-
cal School, Harvard School of Public
Health, Wellesley College, Stanford Uni-
versity School of Medicine (Dr Lin’s
former affiliation), and Pediatrix
Medical Group had no role in the de-
sign or conduct of the study; collec-
tion, management, analysis, or inter-
pretation of the data; or preparation,
review, or approval of the manu-
script for submission.
Ms Suzanne Giroux (PEHC, Children’s
Hospital Boston) assisted in ascertain-
ing the clinic families identified for in-
clusion in the case series. James Be-
sancon, PhD (associate professor of
geosciences at Wellesley College) con-
ducted the XRD analyses on the sin-
door samples. Ms Emily Estes, Ms
Nooreen Meghani, and Ms Megan
Carter-Thomas (Wellesley College) as-
sisted with XRF sample analysis and
assessment of standards performance.
Ami Zota, ScD (Program on Repro-
ductive Health and the Environment,
University of California, San Fran-
cisco, CA) and Ananya Roy, ScD (De-
partment of Health Sciences, School
of Public Health, University of Michi-
gan, Ann Arbor, MI) reviewed earlier
drafts of this manuscript. None re-
ceived compensation.
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