Household interventions for preventing domestic lead exposure in children

Why is this review important?

Lead poisoning at high levels can cause anaemia, multi-organ damage, seizures, coma and death in children. At chronic low levels it can lead to cognitive, psychological and neurobehavioural impairment. Researchers have studied many different educational and environmental household interventions to prevent lead exposure in children, such as parental education, removal of lead dust or home remediation work. However, it is not clear if and to what extent these interventions work in preventing lead exposure in children.

Who will be interested in this review?

- Parents and caregivers who want to prevent domestic lead exposure in children.

- Health professionals and decision-makers who are interested in methods to prevent domestic lead exposure in children.

What questions does this review aim to answer?

We wanted to find out if educational or environmental household interventions, or combinations of both, are effective in preventing or reducing domestic lead exposure in children up to 18 years of age. We were interested in looking at improvements in cognitive and neurobehavioural development, reductions in blood lead levels and household lead dust levels.

Which studies were included in the review?

We searched databases up to May 2016 for randomised controlled trials, or RCTs (where participants are randomly assigned to treatment and control groups, in this case with one group that does not receive any intervention and one or more other groups that do) and quasi-RCTs (where children are assigned to groups using methods that are not strictly random). We found 14 studies involving 2643 children that investigated educational or environmental interventions, or a combination of both, to reduce domestic lead exposure in children. Children in all studies were under six years of age. Thirteen studies took place in urban areas of North America, and one was in Australia. Most studies were performed in areas with low socioeconomic status. Boys and girls were equally represented in all studies. The duration of the intervention ranged from 3 months to 24 months in 12 studies, and 2 studies performed an intervention on a single occasion. Follow-up periods ranged from 6 months to 48 months. National or international research grants or governments funded 12 studies, and 2 studies did not report their funding sources.

What does the evidence from the review reveal?

We did not find any studies that evaluated effects on cognitive or neurobehavioural outcomes or adverse events in children. All studies reported on blood lead levels. The included studies found that educational interventions are not effective in reducing blood lead levels of young children; the quality of this evidence was moderate to high. Dust control interventions may lead to little or no difference in blood lead levels; however, future research might change these results because the quality of evidence was moderate to low for these interventions. There is currently insufficient evidence that soil abatement or combination interventions reduce blood lead levels, and further studies need to address this.

What should happen next?

More research is needed to find out what is effective for preventing children's exposure to lead. Studies should be carried out in different socioeconomic groups in high-, middle- and low-income countries to consider how interventions work in contexts shaped by different levels of industrialisation or environmental and occupational health safety regulations.

Authors' conclusions: 

Based on current knowledge, household educational interventions are ineffective in reducing blood lead levels in children as a population health measure. Dust control interventions may lead to little or no difference in blood lead levels (the quality of evidence was moderate to low, meaning that future research is likely to change these results). There is currently insufficient evidence to draw conclusions about the effectiveness of soil abatement or combination interventions. No study reported on cognitive or neurobehavioural outcomes or adverse events. These patient-relevant outcomes would have been of great interest to draw conclusions for practice.

Further trials are required to establish the most effective intervention for preventing lead exposure. Key elements of these trials should include strategies to reduce multiple sources of lead exposure simultaneously using empirical dust clearance levels. It is also necessary for trials to be carried out in low- and middle-income countries and in differing socioeconomic groups in high-income countries.

Read the full abstract...
Background: 

Lead poisoning is associated with physical, cognitive and neurobehavioural impairment in children, and trials have tested many household interventions to prevent lead exposure. This is an update of the original review, first published in 2008.

Objectives: 

To assess the effects of household interventions for preventing or reducing lead exposure in children, as measured by improvements in cognitive and neurobehavioural development, reductions in blood lead levels and reductions in household dust lead levels.

Search strategy: 

In May 2016 we searched CENTRAL, Ovid MEDLINE, Embase, nine other databases and two trials registers: the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov. We also checked the reference lists of relevant studies and contacted experts to find unpublished studies.

Selection criteria: 

Randomised controlled trials (RCTs) and quasi-RCTs of household educational or environmental interventions, or combinations of interventions to prevent lead exposure in children (from birth to 18 years of age), where investigators reported at least one standardised outcome measure.

Data collection and analysis: 

Two authors independently reviewed all eligible studies for inclusion, assessed risk of bias and extracted data. We contacted trialists to obtain missing information. We assessed the quality of the evidence using the GRADE approach.

Main results: 

We included 14 studies involving 2643 children: 13 RCTs (involving 2565 children) and one quasi-RCT (involving 78 children). Children in all studies were under six years of age. Thirteen studies took place in urban areas of North America, and one was in Australia. Most studies were in areas with low socioeconomic status. Girls and boys were equally represented in all studies. The duration of the intervention ranged from 3 months to 24 months in 12 studies, while 2 studies performed interventions on a single occasion. Follow-up periods ranged from 6 months to 48 months. Three RCTs were at low risk of bias in all assessed domains. We rated two RCTs and one quasi-RCT as being at high risk of selection bias and six RCTs as being at high risk of attrition bias. For educational interventions, we rated the quality of evidence to be high for continuous blood lead levels and moderate for all other outcomes. For environmental interventions, we assessed the quality of evidence as moderate to low. National or international research grants or governments funded 12 studies, while the other 2 did not report their funding sources.

No studies reported on cognitive or neurobehavioural outcomes. No studies reported on adverse events in children. All studies reported blood lead level outcomes.

We put studies into subgroups according to their intervention type. We performed meta-analyses of both continuous and dichotomous data for subgroups where appropriate. Educational interventions were not effective in reducing blood lead levels (continuous: mean difference (MD) 0.02, 95% confidence interval (CI) −0.09 to 0.12, I² = 0%; 5 studies; N = 815; high quality evidence (log transformed); dichotomous ≥ 10.0 µg/dL (≥ 0.48 µmol/L): risk ratio (RR) 1.02, 95% CI 0.79 to 1.30; I² = 0%; 4 studies; N = 520; moderate quality evidence; dichotomous ≥ 15.0 µg/dL (≥ 0.72 µmol/L): RR 0.60, 95% CI 0.33 to 1.09; I² = 0%; 4 studies; N = 520; moderate quality evidence). Meta-analysis for the dust control subgroup also found no evidence of effectiveness on blood lead levels (continuous: MD −0.15, 95% CI −0.42 to 0.11; I² = 90%; 3 studies; N = 298; low quality evidence (log transformed); dichotomous ≥ 10.0 µg/dL (≥ 0.48 µmol/L): RR 0.93, 95% CI 0.73 to 1.18; I² = 0; 2 studies; N = 210; moderate quality evidence; dichotomous ≥ 15.0 µg/dL (≥ 0.72 µmol/L): RR 0.86, 95% CI 0.35 to 2.07; I² = 56%; 2 studies; N = 210; low quality evidence). After adjusting the dust control subgroup for clustering in meta-analysis, we found no evidence of effectiveness. We could not pool the studies using soil abatement (removal and replacement) and combination intervention groups in a meta-analysis due to substantial differences between studies, and generalisability or reproducibility of the results from these studies is unknown. Therefore, there is currently insufficient evidence to clarify whether soil abatement or a combination of interventions reduces blood lead levels.

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