Lead-contaminated Foods, Levels of Satisfaction in Pediatric Residents – Ep. 189

Support for Pediatrics on Call comes from Floristor Kids and Floristor Baby Probiotics, which.

Help protect children's gut health during and after antibiotic therapy and can be taken concomitantly with antibiotics. Order free samples of floristor kids@www.floristorhcp.com from the American Academy of Pediatrics. The Food and Drug Administration continues to investigate the recent lead contamination in applesauce pouches.

For Pediatric, that means vigilant screening and testing.

The first priority is to prevent further exposure to lead, the second priority is to prevent further exposure to lead and the third priority is to prevent further exposure to lead.

Plus, a survey of graduating Pediatrics residents shows we have work to do.

I would venture to say that most trainees are sufficiently prepared to start practice, but they don't feel confident that they are.

These stories and more on Pediatrics on Call the podcast on Children's health from the AAP. I'm Dr. Joanna Pargavelenki.

And I'm Dr. David Hill. This podcast is for everyone in the medical community keeping our children healthy and safe.

It's a show by pediatricians for pediatricians.

But anyone who cares about kids will get a lot out of it as well. Let's start today's episode with a conversation about lead and other heavy metals in foods.

David I wish I could be the type of person who made all my own baby food, like got into baby lead weaning all the way and was chopping things up to the perfect shape and size or pureed my own food. But realistically I did have to rely on pre made packaged meals and snacks with my first two kids and I'm sure with my third I'll need to a little bit more.

There is so much to think about when you're feeding young children. You mentioned the consistency of the foods you give them. But then there's also when to introduce solids and monitoring for food allergies. It's a lot. So what do you do when you worry store bought packaged foods might not be safe?

That is what I am struggling with. In December 2023 there were reports of lead in cinnamon applesauce pouches that cause poisoning in children in the United States. This is not the first time there has been concern about heavy metal contamination in foods and and it won't be the last. So how do I as a parent and we as pediatricians prepare families for this?

I'm not a toxicologist Joanna, but our guest today is Dr. Kevin Osterhout. Kevin is a professor of pediatrics and the medical director of the Poison Control center at the Children's Hospital of Philadelphia, where you work. He has also served on the executive committee of the Council on Injury, Violence and poison prevention. Dr. Osterhout, welcome to the show.

Hi, good afternoon. Thanks for having me.

Thanks for joining us. And it might be nice to start with a story. Can you walk us through how, in December 2023, the FDA and CDC started to suspect cinnamon applesauce pouches were contaminated with lead.

Pediatricians, following American Academy of Pediatrics guidelines on lead screening, often test children for their blood lead concentration or blood lead level. And back in December, some children were found to have elevated blood lead levels. And so what do we do at that point in time? We try to find what's the source of that lead. And so you go and you investigate common sources that might be lead in the house, paint, lead in the water, lead from other environmental and occupational sources. And I think they're really coming up empty until they realized, hey, these children were eating this applesauce. And they tested it and found high lead concentrations in the applesauce.

Okay. That alone is just a very alarming story, especially the fact that it took a number of exposures before people had a clue as to where this stuff was coming from. How in the world, I think everybody wants to know, does lead get into applesauce?

Well, you know, we live in a polluted world, and there are metals that live in our earth, things like arsenic and mercury and lead, and we talk about those all the time. And as we bring out of the earth, it can get into our world. In this particular instance, it's believed that the lead got into the applesauce through the cinnamon spice that was used to flavor that applesauce, and that cinnamon was sourced from an out of country source.

Are there guardrails in place in the United States to sort of keep that kind of thing from happening?

I believe that there are several guardrails, including good manufacturing processes from in country manufacturers. And also we do have safeguarding organizations like the Food and Drug Administration and the Consumer Product Safety Commission that help to try to watch over and keep these things safe.

Kevin, is lead the most common heavy metal? We worry about causing toxicity in food and how does it get in there?

Lead is certainly the most common metal that we find, contaminating spices that go into flavoring our foods. Metals like lead and arsenic and mercury are naturally occurring on earth. And as we engage in industrial processes with earth and we pull them out, we run risk of being exposed to them. Lead has a fascinating History. Back in colonial America and even back in Victorian England, lead acetate was called sugar of lead, and it was felt to be a nice, sweet substance. And actually, in the 1800s in the United States, they used to make anti colic baby bottle nipples out of lead because they felt that the children would actually suck on those nipples because they tasted sweet and it would calm them down.

So they were intentionally putting it in food products back then.

Intentionally. We didn't have the knowledge of what we were doing with lead at that time. Now that we have the knowledge, it sneaks in there more insidiously. So lead is a natural element in the earth, and lead is in solder and in different materials that we used to work with. And so in manufacturing, if the manufacturing isn't carefully controlled, you can imagine lead sneaking in there kind of by accident, if you will. However, there are a couple of other things about lead that's interesting. Lead is a pigment, and lead oxide is sometimes called red lead, and it can make things red. And so if you're making a spice like cinnamon, if you have a consumer like me, and I'm looking at three or four different brands of cinnamon, I like to pick the one that has that nice bright red color. I think it's fresher. Well, you can actually enhance that color a little bit with some lead oxide. Lead chromate is called yellow lead. And so if you have a spice like turmeric or certain curries that you want to look a little bit more yellow, you could enhance that color with a little bit of lead chromate. And then if you think about the way spices are sold, they're often sold by weight, especially on a commercial level. And so what's a better way to make them weigh a little heavier than to have a little bit of lead in them? That brings a little bit of weight and a little nice color and makes them easier to sell. And we rarely, if ever, ever see that happen in the United States with commercial products. But when we go into international manufacturing processes where there aren't quite the same safeguards, it can sometimes sneak in.

Is chromium also something that sneaks in? Because I think I remember reading that these pouches also contained some of that. And when you have these heavy metals in foods, are these kids exhibiting signs that they're sick or have a symptomatology?

Yeah. So when the FDA tested this applesauce, they did find chromium in the applesauce. They weren't able to tell what form or exactly where it came from. But one of the forms of lead that I mentioned to you was lead chromate, and that's essentially leading connected to a chromium atom. And so it would make sense that lead chromate would be the chromium source in these materials. I think, by far, the lead is the bigger issue for our children than the chromium. Chromium actually is an essential nutrient. We need to take some into our diet, and at the amount that they found in these, these lead packets, it's not a large concern for me, but certainly something that we want to keep exposures as low as possible. With all of these metals that are sometimes found to be in baby foods or spices or things, generally they're causing high enough blood lead levels that we think that they are of concern, but often not high enough that parents would be expected to recognize overt symptoms in their children. Which is why, following the American Academy of Pediatrics guidelines on lead screening of children, to detect children who've been exposed is so important.

Kevin over the course of my career, I have seen what we consider a toxic level of lead fall. I think now it's as low as 3.5 micrograms per deciliter. What do we do to respond to various levels of lead intoxication if we find them?

Treatment of lead exposure is really important. David and I usually say that there are three priorities in treating a child with a high blood lead level. The first priority is to prevent further exposure to lead. The second priority is to prevent further exposure to lead. And the third priority is to prevent further exposure to lead. After that, there are other treatments that we can do. When blood lead concentrations get very high, we can offer medicines called chelating drugs that can help to lower that blood lead level. Typically, we recommend that when blood lead levels get to be about 45 micrograms per deciliter, we think that cognitive enrichment helps children with lead exposure. Making sure that children get educational enrichment activities in our Red 2 is very important. We think that sleep hygiene is very important. And for children that are getting their lead exposure through their intestinal tract, we think having a diet that is rich in iron and calcium is important overall. Trying to reduce adverse childhood experiences to as low a level as we can can also help children with lead considerably.

So we've been dancing around screening, and I think it might be helpful for our listeners to just kind of go over what screening is recommended. And also if you do screen positive, I mean, I'm assuming food is not the primary source of lead contamination in the United States. So what things should you be on the Hunt for. Because you mentioned that getting rid of that lead exposure is so important.

Joanna, you can't tell if your child has an elevated blood lead level unless you get a blood test and you check their blood lead level. And there are many ways to do that in the office. They can do it with capillary screening with just a little pin prick in a finger. A little bit more accurate is venous blood lead testing. And overall, we try to recommend having two tests by the age of two years, usually one around one year of age, and another at age two. If you are fortunate, you find that your child doesn't have exposure to lead. But if your child's blood lead level is high, then, yeah, we want to figure out what the source of that lead is. For the majority of children in the United States who have elevated blood lead concentrations, it's from the dust from old lead paint that's on our houses that were built before 1978.

So, Kevin, let me see what you do. I know in our office, if we find an elevated finger stick lead, the first thing we do is confirm with a venous sample, if that's how we call the health department. But can you talk to me about what you do when you're investigating one of these exposures?

Absolutely. The first thing that we try to do is a very good environmental history. And because most children do get exposed to lead through their house paint, we ask where they live, where else they spend time, where they go to school, and we try to get an estimate for when those properties were built in the United States. We cut the amount of lead we put in house paint down in 1950, and we eliminated it in 1978. So if they're living in a home that was built after 1978, we feel relatively comfortable with that. Sometimes the families don't know. And a little trick that I use, I look up their address on Zillow, and Zillow often lists when it was built, what the heating supply is, what the water supply is. Also, because elevated blood lead concentrations are a reportable disease, they reported to the health department, and it should instigate some environmental inspection of the home where the child lives to see if there are any lead hazards there. But I also want to ask about water supply. I asked the family what family occupations are. I asked what family hobbies are. People that go to gun ranges and shoot lead ammunition can bring lead dust home. Here in Philadelphia, we have a shipyard, and people work at the shipyard and on ships. You're still allowed to use some lead based paint. And so you could bring dust home from there. Other hobbies might be stained glass windows, as we've talked about with the applesauce. We worry about imported spices, so I'll often ask if people buy spices at bulk markets or if they bring in imported spices as a potential source. We also think about imported cosmetics, imported candies, and even old ceramics that some families will use kind of culturally to continue preparing foods for their children over long periods of time.

And are there resources outside our clinic walls we can provide if we think a family has been exposed?

We're here to support you, David. We have a couple of venues that we can offer expert help. There's the Poison Control center network at 1-800-222-1222. And there's a highly trained nurse and pharmacist on the line 247 there to answer the questions that you have. And along with that, the American Academy of Pediatrics has been a partner in creating a network of pediatric environmental health specialty units across the country that have a number of pediatricians with environmental expertise and some medical toxicologists that would work. And so you can just go ahead and look up your region's pediatric environmental health specialty unit, and they can be of great assistance.

Those are some great tips for pediatricians. And, Kevin, before we let you go, do you have any last takeaways or stories about food contamination with heavy metals that you can share?

I think that it's important to realize that for every action I learned in physics, there's an equal and opposite reaction, and we have to be careful about the problems that we don't know. I have had children referred to me where the family decided that dairy products were unhealthy and they wanted to find something healthier. And so they switched to rice milk, and they gave their children nothing but rice milk until somebody did an arsenic level on the child, found that their arsenic was high. And we say, yeah, because we know that rice grows in patties on the earth and can have a lot of arsenic contamination and can be brought in, and you can find arsenic in that way. So it's important to use trusted forms of food to talk to your pediatrician and your pediatric healthcare provider about good, healthy nutrition practices for your child and for all toxicants. We want to keep our levels as low, as achievable, and as low as practical for us, and we have to make those determinations. One other story I tell that's pretty funny is a lot of people get into a new car, right? And they do that. Breathe in. And they love that new car. Smell that they get. And it's such a happy moment to have a new car. Well, in my world, those are volatile organic compounds and are yet one more toxic hazard we have in our life. And so it's easy for us to snowball our thought into all of these things and just eat a well balanced diet, use good sources and help your children grow and prosper.

And buy used cars. No?

Dr. Kevin Osterhout, thank you so much for covering this heavy topic with us today.

My pleasure, anytime. And stay lead safe.

To learn more about lead exposure and food contamination, visit our website@ AAP.org podcast.

Coming up, we'll look at how graduating residents view pediatrics and their abilities to practice.

At the national conference each year, we do an informal survey of our listeners to see who engages in the podcast and how we can improve our content.

In the three plus years we've been doing the podcast, we found that trainees are a big part of our audience and so we wanted to thank all the pediatric trainees squeezing in some AAP content as they go about their busy days.

One thing I really love about having worked with the AAP for many years is how much they value pediatric trainees. So much so that we aren't the only ones doing the surveys. Joanna, the AAP surveys graduating residents every year to see how their training went and where they think their careers are going.

Wow. That information is especially important for me in academic medicine because I'm always curious how prepared our neonatology fellows feel when they enter their subspecialty training. And I always want make sure I'm tailoring my teaching and mentoring to what trainees really need.

Well, Pediatrics just published a study, Pediatric Residents Preparedness and Training Satisfaction 2015-2022, and we have the senior author, Dr. Hilary Halfdell, here to talk us through the paper.

Dr. Halfdell is an Emeritus professor of Pediatrics, Internal medicine and Medical education at the University of Michigan Medical School. Since 2018, she's also been the Senior Vice President of education for the AAP. Dr. Haftel, welcome to the show.

Thank you. I'm very happy to be here.

So let's start with the annual survey the AAP puts out for residents. I know it's emailed to trainees at the end of their training, but what is on it?

Excellent question. It is mailed to actually a subset of all trainees. About one third of the trainees who are graduating receive the survey. And mind you, of course, that it is delivered electronically now, but it used to be done by paper, obviously in prior era. But it covers everything from how satisfied they are with their overall training, how satisfied they are with different components of their training, specifically with their primary care training, their preparation for subspecialty training or fellowship, and their preparation for hospital based practice, like a hospitalist would do nowadays. And then they asked different specific questions, depending on the year, about smaller focuses of training such as advocacy. We asked about telemedicine in the last couple years of the survey most recently, and other subjects like that.

And if we send it out to a third of residents, how many respond?

There's a variety. This last study, slightly under 50% responded. And that's over 1000 trainees per year. So ultimately we had about 4000 out of a potential 8000 over the span of all those years respond to the survey over time.

And how long have you been collecting data for this survey?

Oh, it's been quite a long time. Several decades.

Oh, wow. And Hilary, what made you decide to publish now since you've been collecting this data for decades?

Well, we actually have tried to publish this in aggregate form over time, looking at trends in education and training. This cohort has been particularly important primarily because there's been such a shift over time from primary care to some specialty care. And then particularly in the last couple years, the impact of the pandemic on training and whether or not that actually impacted career choices and satisfaction with training. Impact on training.

So let's dig into these results. How satisfied were pediatric residents with their training and do they feel prepared to enter the workforce after residency?

Well, it is definitely true yet again, and this has been true over time, that pediatric residents are actually highly satisfied with their choice of pediatrics as a career. And in general, over 90% of trainees surveyed say that they would choose pediatric residency again and pediatric training again. So they are relatively highly satisfied now with respect to preparation, that can vary. And of course that is impacted by their program, their personality, because you're self assessing their extent of how they feel prepared. Right. And you'd worry about people who thought they were completely prepared, frankly. Right. You want people to come in with a, you know, be a little nervous when they're going into the workforce. Right. But. But you also want to make sure that they are ready. And the board in fact asks program directors to certify that trainees are prepared and able to practice independently. Right. So they had a lot of external assessment, but whether or not they themselves internally feel confident can vary widely. And it is true, however, that in general, depending on the topic, most trainees feel relatively Comfortable, particularly with respect, the main areas that they look at are primary care. They look at preparation for fellowship or subspecialty training, and they look at preparation for being a hospital. Those are the sort of three big umbrella groups that they're queried about. And in general, they all feel that they're fairly prepared. But the interesting thing, and the important thing about these data that were collected in this cohort of samples was that their perception of their preparedness actually went down from the time from 2015 to the time to 2022. It went from as high as in the mid-70s to as low as in the mid-40s to 50%. So fairly substantial decline in how well they felt their training prepared them for entering their field. The other important thing to know about this is that those numbers stayed largely the same regardless of whether they were pursuing a career in primary care, subspecialty care or hospitalist. So the hospitals felt as well prepared in primary care as the people going into primary care did, for example, but they all went down. And so there's a number of factors that could go into that, as you can imagine, but it was a substantial decline and enough to raise concern worth sharing with everyone else to think about the factors behind that.

So, presuming that this data is at least consistent in how it's collected from year to year, even if there may be some bias, what do you think accounts for the fact that in recent years, these residents feel less prepared? Do you think it was all the pandemic, or is the practice of pediatrics changing faster than our teaching can keep up with it?

Well, I think it's both of those and more the trend in the data, the decline in feelings of preparation were going down before the pandemic. So it's not just the pandemic. Clearly, the pandemic did contribute to that. Right? I mean, because they were in less clinical settings, they had more limited curricula.

Right.

They saw less patients, they had less direct teaching. I mean, there are a lot of factors that went into the changes in education that were required based on the SARS CoV2 pandemic. But again, those were going down even before the pandemic. And I think some of it is the reduction in the amount of exposure that trainees get. There's a much broader curriculum, there's more focus on the ambulatory setting. And although some trainees would say there's still too much focus on the hospital setting, there is quite a bit of focus away from the hospital than there was. So maybe they don't feel as prepared with some of those hospital based disciplines. A lot of programs don't have as much exposure to certain subspecialty disciplines as others do. So if you're going to a fellowship area where you have not had a lot of exposure because of the location or construct of your program, you may not feel as well prepared. And just overall, I mean, I'm old enough that I was trained pre duty hours, right? So no one controlled sort of my exposure and volume of patients that I saw. And I felt like I came out pretty well prepared because of so much time spent in the hospital. But then I didn't have the time to reflect and learn on my own that trainees of today's era may have. So there's a lot that goes into the definition of feeling prepared, right? Do you feel clinically prepared? Do you feel cognitively prepared? We don't have the granularity to measure those differences within the study. So I think we have to assume that a lot of this is multifactorial. But I do believe that some of it is probably within our control and requires reflection about how we construct pediatric training over the course of the whole three years to provide our trainees with sufficient experiences in all of these areas in order for them to feel, regardless of what they decide to go into, they feel prepared across the spectrum of pediatrics.

Speaking of what we can control, I know this wasn't covered in the paper, Hillary, but you're an education expert. What can pediatricians do to help support residents who are leaving training and feeling like maybe it just wasn't quite enough?

So I think these require frank discussions and the willingness to assume that everyone is coming out with different degrees of confidence. I would venture to say that most trainees are sufficiently prepared to start practice, but they don't feel confident that they are. But it's up to your partners, your ongoing supervisors to make those assessments. It's a lot harder, obviously, in primary care when you are not going on to further training and you no longer have direct supervision, right? I mean, someone who's becoming a fellow and a hospitalist is now a fellowship as well. Right? These are people who are going to get more supervision and much more ongoing assessment of their level of preparedness. It's a little harder in primary care and you have to hope that you have sufficient good collegial relationships with your partners and colleagues so that you can share your areas where you don't feel completely confident and then feel more vulnerable so that they can support you as you learn through experience.

That's Definitely a thoughtful discussion of this issue. Do you have any last takeaways for our listeners before we let you go?

Well, thank you very much. I think that we are very fortunate of the people that go into pediatrics that they are invested, they're engaged, they are and continue to be excited about pediatrics as a discipline. That's clear from the data that they still don't feel as prepared as they could be. But that is also a good foundation for further growth and development, right. As a clinician, as a learner. Because all these people need to be lifelong learners, right. To add to the growing and rapidly expanding breadth of the discipline that we need to know about. It's always going to be a challenge, but that training programs in their current constructs need to make sure that they are meeting all of their different training needs and continuing to assess them for all the areas that they may feel have gaps or require more work. And the nice thing about the newer ACGME requirements is they are built with more individualization and more flexibility to allow trainees to identify their gaps and work on filling those within the course of their curriculum through residency.

Well, David and I consider ourselves lifelong learners. So we want to thank you, Dr. Hilary Haftel, for coming on the show and sharing your wisdom with us.

It's been my pleasure. Thank you for asking me to read.

The article Pediatric Residents Preparedness and Training Satisfaction 2015-2022. Go to our website at AAP.org podc at the end of every episode, we like to leave you with something positive or enlightening. We call this segment say Ah. David, what's your say Ah, this week?

You know, I have to think of yesterday afternoon. We have one of those grocery stores where they put in a bar. Okay. And it's the most generic. It's like ridiculous. Just this generic bar in the middle of the cheese section. Right. But I wanted to get together with my 24 year old daughter who lives nearby, and it was the perfect place to meet her and have a conversation. So we got cheese from the cheese section and we sat down at the bar and we each had one glass of wine and I had the most wonderful chance to talk to her and connect and hear about her life. And so it's weird, but it's, you.

Know, ah, I'm not at the point where I could be getting drinks with my children yet. But one thing I was really proud of was that I actually took the baby outside for a walk, which, you know, it's winter in Philadelphia and I'm on maternity leave. So it's kind of like the little things that you have to celebrate. So we got outside, I bundled her up. She's been outside, not to the pediatrician once in her life. And I think that's a huge accomplishment. I'm really proud of myself for actually taking that.

That's kind of a say brrr if you ask me.

Definitely.

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Pediatricsoncall Pediatrics on Call is a production of the American Academy of Pediatrics. Our producer and editor is Anne Johnsos. Our audio engineer is Doug Nagle. Joe Puskars is our associate producer, and Susan Martin is our executive producer. Our theme music was composed by Matthew Simonson. Join us next week when we'll bring you the February edition of First Up.

We'll also talk to Dr. Stephen Abrams about new AAP policy on genetically modified organisms, or GMOs. I'm Dr. David Hill.

And I'm Dr. Joanna Parker of Linky. Thanks for listening.