-----------

AAP Headquarters 

141 Northwest Point Blvd 

Elx Grove Village, IL 60007·1019 

Phone: 8471434-4000 

Fax: 847/434-8000 

E-mail: kidsdocs@aap.org 

www.aap.org 

Reply to 

Department of Federal Affairs 

Homer Building. Suite 400 N 

601 13th St NW 

Washington, DC 20005 

Phone: 2021347-8600 

Fax: 202/393-6137 

E-mail: kidslst@aap.org 

Executive Committee 

President 

O. Manon Surton, MD, FAAP 

President-Elect 

Robert W Block, MD, FAAP 

Immediate Put President 

JudIth S. Palfrey, MD, FAAP 

Executive Director/CEO 

Errol R. Alden, MD, FAAP 

Board of Directors 

District I 

Carole E. Allen, MD, FAAP 

Arlington, MA 

District II 

Henry A. Schaeffer, MD, FAAP 

Brooklyn, NY 

District III 

Sandre Gibson Hassink. MD, FAAP 

Wilmington, DE 

District IV 

Francis E. Rushton, Jr, MD, FAAP 

Beaufort. SC 

District V 

Manlyn J Bull, MD, FAAP 

Indianapolis, IN 

District VI 

Michael V. Severson, MD, FAAP 

Brainerd, MN 

District VII 

Kenneth E Matthews, MD, FAAP 

College Station, TX 

District VIII 

Mary P Brown. MD, FAAP 

Bend, OR 

District IX 

Myles B. Abbott, MD, FAAP 

Berkeley, CA 

District X 

Jotm S, Curran, MD. FAAP 

Tampa, FL 

Anlerican AcadenlV of Pediatrics .I 

DEDICATED TO THE ilEA Ttl OF AI.!. CHll.lllU-:;\J 

---....-------~, ~-------

March 24,20 II 

The Honorable Ann Northup 

Commissioner 

U,S. Consumer Product Safety Commission 

4330 East West Highway 

Bethesda, MD 20814 

Dear Commissioner Northup: 

Thank you for this opportunity to respond to your questions following my 

testimony on behal f ofthe American Academy of Pediatrics (AAP) on February 

16, 20 II at the Consumer Product Safety Commission (CPSC) hearing, 

"Children's Products Containing Lead: Technological Feasibility of 1OOppm for 

Lead Content." 

I. 	 In your written testimony, you state that an object with 77ppm "would be 

capable of' raising a child's blood lead level to a level that would result in the 

loss ofone IQ point. By "capable oJ:" do you mean that ifan o~ject with 

77ppm were swallowed and allowed to pass through a child's digestive\)'slem. 

that would be the result? Please provide the study or studies upon which that 

conclusion is based. 

Your understanding of my statement is correct Attached is a version of my 

testimony with all sources cited. I have also attached a copy of a January 2009 

letter provided to Senate Commerce Committee Chairman John Rockefeller 

explaining in detail the development ofthe AAP's recommendation to limit lead in 

children's products to 40 parts per milIion (ppm). 

2. 	 Your testimony also identffies the consequence ofthe "ingestion" ofan ilenl 

containing 300ppm oflead. By ingestion, do you mean a child's swallowing of 

an object and the object then passing through the child's digestive system? 

Please provide the study or studies upon which those consequences are based. 

In my testimony, ingestion refers to the process of taking an item or material into 

the body by oral consumption. Most such items will pass through the digestive 

tract, although in the case of very small amounts of material (e.g. lead dust), it may 

be absorbed directly into the bloodstream before reaching the lower reaches of the 

digestive tract. Some items may pass through the digestive tract relatively rapidly, 

while others could remain in the stomach for very long periods oftime. The 

attached copy of my testimony contains rderences to the studies used to formulate 

these conclusions. 
3. 	 Is it true that the amount ofbioavailable lead in an object that is ingested by a child 

is afimction ofboth the ppm oflead in the object and the total size ofthe object? !l 

so, how does the data you cited regarding the potential effoct ofobjects with 

particular ppm oflead take into account the size ofthe object? 

The amount ofbioavailable lead in an object may vary based on a range of factors related 

to both the object and the individual child. With regard to the object involvcd, variables 

may include the parts per million, the particular type of material (metal, plastic, vinyl, 

crystal, etc.), the age or condition of the item (new versus worn), and the size or number 

of items ingested, among other things. In addition, each individual child may have a 

greater or lower risk than average, which can vary based on factors such the child's age, 

stage of growth (Le. sensitive windows of development) and nutritional status. 

The surface area presented by the object can also affect the amount of lead released into 

the digestive tract. Digestive fluids interact with surfaces of larger items to increase 

absorption from those items. A significant surface area can be presented by one larger 

item or several small items if ingested. In the case of lead dust, the individual particles 

may be invisible to the naked eye but are absorbed directly from the digestive tract into 

the bloodstream with high efficiency. 

4. 	 Does the amount ofbioavailable lead in an object also depend upon other 

characteristics ofthe material in which the lead is contained, such as its density, 

hardness or the other components it contains (i.e. brass, other metal alloy, paint)? !l 

so, how does the data you cited regarding the potential effect ofobjects with 

particular ppm of/ead take into account the other characteristics ofthe material in 

which the lead is contained? 

As noted in the question above, the amount of bioavailable lead may vary depending on 

factors related to both the material and the individual child, making computations 

difficult. Chang et al., found high bioaccessibility in the stomach (up to 77%) of lead 

vacuumed from carpets. 1 This high bioaceessibility limit worked best in models to 

predict children's blood lead levels. 

5. 	 Please provide me with any studies ofwhich you are aware that show the afJecl to a 

child's health, IQ. or otherrllise, caused by a child licking, but not swallowing, a 

metal object containing lead in the metal substrate. 

The main pathway for lead ingestion is getting lead on hands and putting hands in mouth. 

Lead can be transferred from a surface to the hand and then to food or other objects put 

into the mouth or the hand directly put into the mouth. Onc particularly high quality study 

involved observation of chi Idren playing in a yard; researchers video-observed their 

hand-to-mouth behavior and then evaluated relationship of oral behaviors to children's 

blood lead levels. Children with higher hand-to-mouth occurrences had correspondingly 

higher blood lead levels. Investigators video-observed children ages I years putting a 

hand in their mouth 7 times hourly (maximum 67 times/hour) and an object or food in 

their mouth 17 times hourly (maximum 125 timeslhour).2 
A review of reports that describe children's mouthing was published by the U.S. 

Environmental Protection Agency (EPA) in 2009.3 The EPA report has a significant 

quantity of simi lar data, with frequency of oral behaviors and minutes/day of mouthing. 

The amount of lead that would be transterred to a child may depend on mouthing 

behavior (times/hour and minutes/day) and the transfer rate of lead from the object to the 

hand (if the object is touched and not directly mouthed). Children as old as 10-12 years 

put their hand in their mouth an average of 4 times hourly. This rate is much higher 

among younger children, and exposures from mouthing behaviors can be occurring for 

several hours daily per child. Even for adult workers, hand lead is associated with blood 

lead leveJ.4 

In addition, the Centers for Disease Control and Prevention's Mortality and Morbidity 

Weekly Report (CDC MMWR) has published cases of lead poisoning not related to 

ingestion of objects. Most recently, the MMWR published a case study of a toddler 

poisoned by a metal charm on a necklace he wore and mouthed regularly.5 The MMWR 

has also published cases of lead poisoning from eating off lead-tainted dishware;6 lead 

dust contamination of family vehicles;7 and exposure to lead at a firing range among 

adolescent members of a shooting team. 8 

6. 	 Please explain how the studies upon which you rely to correlate precise IQ pOint 1: 'ss 

with the ingestion ofobjects with particular ppm oflead control for other factors 

known or suspected to also reduce IQ in children, such as glues and other solvenls, 

poor nutrition, and tobacco. 

Studies that examine the effect of lead on IQ and other outcomes measure the 

confounding factors associated with lead. While each study may vary in what is 

measured, key variables to assess include maternal TQ, Home Observation for 

Measurement ofthe Environment Inventory score (which is a measure of the quality and 

quantity of stimulation and support available to a child in the home environment), 

maternal education, and birth weight. Many studies to examine the impacts of lead on 

children have rigorously assessed and adjusted findings for numerous other influences 

which theoretically could be associated with the outcome measured. 

The findings of maternal solvent exposures during pregnancy negatively influencing 

child developmental outcomes is a relatively new report, with exposures occurring in the 

workplace and other characteristics of the mother not differing between exposed and 

control groups.9 While this is an important issue that bears further investigation, it does 

not cast any doubt upon the substantial literature documenting IQ decrements associated 

with lead exposure. 

7. 	 Please provide me with all ofthe studies upon which you relied in preparing your 

written testimony. 

See attached copy of my testimony as well as the letter to Chairman Rockefeller. 
8. 	 Please tell me with re~pect to each study provided in response to Question 7 whether 

it is peer reviewed, whether it is recognized by the Centers for Disease Control and 

the National Institute ofHealth. and who commissioned the study. 

All ofthe published studies referenced in my testimony appeared in peer-reviewed 

journals. The CDC and NIH do not "recognize" studies per se. InJurmation on funding 

lor each study is generally required to be disclosed and is pubUshcd as part of the study. 

As you will see in the attached letter to Chairman Rockefeller, the AAP also made use of 

the California Office of Environmental Health Hazard Assessment analysis that evaluated 

the upper 97.5% confidence level of blood lead level associated with this effect, a 1 IQ 

point loss would be prevented by limiting a child's BLL increase to no more than I 

mcg/dL. JO The AAP utilized the CPSC's data and calculations set out in its 2005 Interim 

Enforcement Policy Lead Levels. 11 Finally, the AAP took into account the U.S. Food 

and Drug Administration's upper limit for lead in food at 6 mcg/lead/day for children 

aged <6 years, which the FDA states is expected to cause a child's blood lead level to rise 

by I mcg/dL. 

9. 	 Why does the AAP website. which contains extensive writing.'}' and warnings 

concerning the hazards oflead ingestion by children, not recommend taking away 

from children, including even those at the "tipping point" for lead poisoning, older 

bicycles, tricycles, toy trucks, scooters, wagons, and any other products containing 

substantially more lead in the substrate than ;,'1 permitted under current law? 

Because lead is invisible to the consumer or parent, it is impossible to know whether any 

given toy or children's product contains lead. The AAP strongly urges parents to follow 

the age recommendations for toys and to be vigilant about products that may contain 

lead. However, because it is essentially impossible for parents, caregivers or 

pediatricians to determine if an individual product contains lead, it remains incumbent 

upon the CPSC to protect children by minimizing lead exposure in consumer products. 

10. 	 How do you reconcile Environmental Protection Agency regulations that permit 

80,OOOppm oflead in pipes carrying waterfor human consumption with your 

testimony that more than 40ppm oflead in substrate is an unacceptable safety 

hazard? 

The EPA permits the use of water pipes and fittings that contain up to 8% lead, wh ich is 

equivalent to 80,OOOppm. It should be noted, however, that EPA's "action level" for lead 

in the drinking water supplied by those pipes is 15 parts per billion (ppb), while bottled 

water is subject to the even stricter standard of 5 ppb. Under normal circumstances, tap 

water is not corrosive in nature, and so should not typically extract lead from water pipes. 

Human saliva and digestive fluids are corrosive, however. Ira chi ld happened to ingest a 

fragment of pipe containing 8% lead, a significant amount of lead would be released and 

absorbed into the bloodstream. 
The AAP has a long history of expressing concern about the safety of drinking water and 

urging the EPA and other regulators to act in the best interests of children when 

considering water standards options. However, the pernicious nature of lead requires that 

efforts proceed with great caution. In January 2011, the AAP wrote to the EPA calling 

upon the agency to declare an immediate halt to all partial replacement of lead lines after 

studies indicated that partial line replacement may actually cause the release of additional 

lead into water supplies. The AAP continually follows the developing science and 

literature to ensure that our positions renect the latest and most up-to-date science and 

refine our positions accordingly to protect child health. 

Again, thank you for this opportunity to respond to your questions. If the American 

Academy of Pediatrics or I may be of further assistance, please contact Cindy Pellegrini 

in the AAP's Washington, DC office at 202/347-8600. 

Sincerely, 

Dana Best, MD MPH FAAP 

1 Chang H, Lih-Ming Y, Lioy P. The Bioaccessibility of Lead (Pb) from Vacuumed House Dust on 


Carpets in Urban Residences. Risk Analysis. 2006 Feb;26(1): 125-134. 


2 Ko S, Schaefer P, Vicario C, Binns H, Safer Yards Project. Relationships of video assessments of 


touching and mouthing behaviors during outdoor play in urban residential yards to parental perceptions of 


child behaviors and blood lead levels. J Expo Sci Environ l~pidemio/. 2007 Jan; 17( I ):47-57. 


Iml1ilwv. IV .lid)i . n1m .nih. g (1 !1u~lb)11 C'lLL(1~2~tHllZ 

3 U.S. Environmental Protection Agency. Child-Specit1c Exposure Factors Handbook. August 2009, 


(EPA/600/R-08/] 35). 


4 Rodrigues E, Virji M, McClean M, Weinberg J, Woskie S, Pepper L. Personal exposure, behavior, and 


work site conditions as determinants of blood lead among bridge painters. J Occup Environ Hyg, 20 10 


Feb;7(2):80-7. 


5 Lead Poisoning ofa Child Associated with the Use ofa Cambodian Amulet New York City, 2009. 


lyfMWR, January 28, 2011. 60(03);69-71. 


httlLl '\\ ww.cdc.gl).yLIJ.!.!ll Ivr/prev iel v jIlj}1~YIIJlmlilln1()O():; a2JJlm 


6 Childhood Lead Poisoning from Commercially Manufactured French Ceramic Dinnerware - New York 


City, 2003. MMWR, July 9,2004. 53(26);584-586. 


hI tp;i/I~.,.;;:di,: .go"IIII mwr!prev il:V.'/l1lm wrlllmIL.!.1lln5 .1.:(,:1"1 .htm 


7 Childhood Lead Poisoning Associated with Lead Dust Contamination of Family Vehicles and Child 


Safety Seats - Maine, 2008. MMWR, August 21, 2009. 58(32);890-893. 


1ll.!1l~'/ \\ow \£~:.ill;.. g(lvIIII fJl\:!lit21:£yiQ!~m!'~J VV rh til]II I11 111.5..&.3 2<1:1. hIll] 


8 Lead Exposure from Indoor Firing Ranges Among Students on Shooting Teams - Alaska, 2002-2004. 


MMWR, June 17,2005.54(23);577-579. 


hljlL/i\\\v~y,edc.gOY~WlmY!:::nreviewiI11Inl\EIl.Lln!· mm~42:SJJ.ltm 

9 Laslo-Baker D, Barrera M. Knittel-Keren 0, Kozer E, Wolpin J, Khattak S, Hackman R, Rovet 1, Koren 

G. Child neurodevelopmental outcome and maternal occupational exposure to solvents. Arch l'edialr 

Ado/esc Med 2004 Oct;158(10):956-61. 

10 Carlisle J, Dowling K. Development of Health Criteria for School Site Risk Assessment Pursuant to 

Health and Safety Code Section 90 l(g): Child-Specific Benchmark Change in Blood Lead Concentration 
for School Site Risk Assessment. I ntegrated Risk Assessment Branch Office of Environmental Health 

Hazard Assessment California Environmental Protection Agency. April 2007. Available at 

hHn.::jwww,oehha.cwglpubllc; illnl!pllbli1~L1j~l82d[l:lllJG V041.i07 .p~r 

II Consumer Product Safety Commission. Interim Enforcement Policy Lead Levels. February 14,2005. 

A vailable at http://.\j}v\V.cl!~~~l.yO:ll:'S INF();llhJ!Cwl '.j~ll. 
American Academy of Pediatrics 

DEDICATED TO THE IIEAl.TH OF ALL CHll..llRI;N' 

AAP Headquarters 

141 Northwest Point Blvd 

Elk Grove Village, IL 60007·1098 

Phone: 847/434-4000 

Fax: 8471434·8000 

E·mail: kidsdocs@aap,org 

www,aap,org 

Reply to 

Department of Federal Affairs 

Homer Building. Suite 400 N 

601 13th St NW 

Washmgton, DC 20005 

Phone: 2021347·8600 

Fax: 2021393-6137 

E,mail kidslst@aap,org 

Executive Committee 

Prasident 

David T, Tayloe, Jr, MD, FAAP 

Presldent·Elect 

Judith S, Palfrey, MD, FAAP 

Immediate Past President 

Ramie R, Jenkins, MD, FAAP 

Executive DirectorlCEO 

Errol R. Alden, MD, FAAP 

Board of Directors 

District I 

Edward N, Bailey, MD, FAAP 

Salem, MA 

District II 

Henry A. Schaeffer, MD, FAAP 

Brooklyn, NY 

District III 

Sandra Gibson Hassink, MD, FAAP 

Wilmington, DE 

District IV 

Francis E. Rushton, Jr, MD, FAAP 

Beaufort, SC 

District V 

Marilyn J. Bull, MD, FAAP 

Indianapolis, IN 

District VI 

Mich"el V, Severson, MD, FAAP 

Brainerd, MN 

District VII 

Kennelh E. Matthews, MD, FAAP 

College Station, TX 

District VIII 

Mary p, Brown, MD, FAAP 

Bend, OR 

District IX 

Myles S, Abbol\, MD, FAAP 

Berkeley, CA 

District X 

Jelln S. Cllmm, MD, FAAP 

Tampa, FL 

January 21, 2009 

The Honorable John D, Rockefeller TV 

Chairman 

Committee on Commerce, Science and Transportation 

508 Dirksen Senate Office Building 

Washington, DC 20510 

Dear Chairman Rockefeller: 

The American Academy of Pediatrics, a non-profit professional organization of 60,000 

primary care pediatricians, pediatric medical sub-specialists, and pediatric surgical 

specialists dedicated to the health, safety, and well-being of infants, chi Idren, adolesccnts, 

and young adults, appreciates this opportunity to respond to your inquiry for morc details 

on the development of our recommendations for limiting lead content in children's 

products. 

Lead and Children;s Health 

There is no "safe" level of lead exposure. The vulnerability of children to lead poisoning 

during development oftheir brain:, and nervous system has been amply demonstrated, and 

the literature is very consistent. On average, children whose blood lead levels (BLLs) rise 

from IOta 20 micrograms per deciliter (mcg/dL) lose two to three 10 points. More recent 

studies have shown an even greater impact on 10 of BLLs under 10 mcg/dL. Key studies 

reported a loss of 4 to 7 10 points in children whose lead levels rose from I meg/dL to 10 

mcg/dL,I,2 These studies suggest that "low" levels of exposure - meaning BLLs less than 

10 mcg/dL cause proportionately greater harm than higher levels. The effects of lead on 

health do not stop once the child's brain and nervous system mature or the I3LL falls, !\ 

recent study found that in a group of7 year old children who had experienced a BLL of20­

44 mcg/dL around age 2 years, the concurrent BLL (i.e., BLL taken at age 7 years when the 

TO test was administered), was more closely associated with [0 at age 7 years that BLL at 

age 2 or age 5 years.3 

Another important lasting effect of lead exposure is on behavior, with higher rates of 

behavioral problems reported in teens and adults exposed to lead during childhood, 

Children with elevated lead are more likely to have problems with inattention and reading, 

and are at higher risk of failing to graduate from high school,4 Investigators have idenlilied 

associations between lead exposure and increased aggression, commission of crime and 

antisocial or delinquent behaviors.s 

,6,7,X Studies have suggested that several nations which 

began reducing lead exposure aggressively in the 1970s experienced corresponding 

decreases in crime rates two to three decades later.9 Other effects include abnormal 

balance, poor eye-hand coordination, longer reaction times, and sleep disturbanccs. 1o,lu2 
Lead is easily absorbed by ingestion or inhalation. The most common route of exposure 

of children is through ingestion, usually by putting hands and other objects in their 

mouth·. Both hand-to-mouth exploration and playing on floors are typical behaviors for 

children, especially younger children. Studies using videos to record oral behaviors of 

young children report hand or object in mouth activities 20 or more times per hour.' '.: ~ If 

hands or objects placed in the mouth have lead, these usual childhood activities deliver 

doses of lead. 

Once lead enters the body it remains there for years. Lead is similar to calcium from the 

elemental perspective. This means that our bodies "sec" lead as calcium, absorb it into 

blood and then store it in bone. These stores of lead can be released years later, when 

bone changes occur or demands on calcium stores are made. ls Another consequence of 

storing lead in bone is that exposures separated by months or years have an additive 

effect on the body's burden of lead and can exert effects over decades. Acquisition of 

lead in the body even in small amounts (i.e., amounts that result in BLLs less than 10 

mcg/dL) contributes to this accumulation of lead. This means that even short term or 

small cumulative exposures can have lasting negative effects. 

Over the past 30 years, average BLL has declined dramatically in the U.s., due largely to 

the elimination of Icad from gasoline and mandated restriction of lead content in paint. 

At the same time, however, elevated BLL is still not uncommon. Eliminating elevated 

blood lead levels was established as a key goal under the federal Healthy People 2010 

initiative. 16 The AAP believes firmly that our nation must continue efforts to reduce 

childhood lead exposure and its pernicious impacts. In the past three years alone, the 

AAP has pushed the Environmental Protection Agency to reduce airborne lead emissiuns 

under the National Ambient Air Quality Standards; urged the Food and Drug 

Administration to eliminate lead in imported candies and their wrappers; and continued 

our long-term engagement with the Department of Housing and Urban Development to 

reduce children's exposure to lead paint in older housing and through home renovation 

activities. We intend to sustain these efforts to ensure that children's potential for 

exposure to lead is reduced as much as possible and new avenues of exposure are not 

created. 

Lead in Children's Products 

As you know, prior to the passage of the Consumer Product Safety Improvement Act 

(CPSIA), our government had never set limits for acceptable lead content in children's 

products, with the exception of lead in surface paint. The restriction of lead content to 

600 parts per million (ppm) dates back to 1978 and does not apply to any other material 

or component in toys or children's products. As a result, toys and children'S products 

could have unlimited amounts of lead in areas other than surface paint without violating 

any mandatory standard. Further, the 600 ppm limit for paint docs not represent a healthbased standard. 

Lead can tind its way il1to toys and children's products as a naturally-occurring 

component of materials used or as a deliberate or incidental additive. Lead is used 

2 
directly in certain materials, such as to stabilize some vinyl compounds and in lead 

crystal. Lead may also be a contaminant in air, water or soil that comes into contact with 

materials or components during the manufacturing process. Regardless of its source, 

however, lead's toxic effect on the developing brain requires us to examine these 

processes and minimize exposure whenever possible. Because there is no "safe" blood 

lead level in children, the AAP focused attention on limiting lead to trace amounts that 

would not represent "added" lead to products. 

Development ofthe AAP Lead Recommendation 

In September 2007, the AAP was asked by the House Committee on Energy and 

Commerce to testify about the hazards of lead and to make specific recommendations for 

lead content that would be used in the development of product safety legislation. While 

the AAP had published guidelines on lead exposure prevention, detection and 

management in the past, we had never attempted nor been requested to provide specific 

targets for lead content in products. The recommendation delivered to Congress was an 

ancillary effort that builds upon but is not inconsistent with or contradictory to our 

previously published statements. 

The AAP's recommendations were developed by our Committee on Environmental 

Health (COEH), which comprises 9 top pediatric environmental health experts serving in 

a volunteer capacity. While child health issues were their guiding principle, the COEH 

also went to great lengths to examine the associated practical issues involved to ensure 

that the final recommendations would be pragmatic and feasible. The primary 

considerations were: 1) no "safe" threshold for blood lead levels for chi Idren has been 

identified;l? 2) lead negatively affects health and development at levels well below 10 

micrograms per deciliter (mcg/dL) blood lead level;18 and 3) lead is a naturally-occurring 

element and may therefore be present is a wide array or materials so "lead-free" status 

may not be achievable in some products. Therefore, children's exposures to lead in 

products should be severely limited, but some low level of exposure, a "trace" amount, 

could be expected. 

The primary goal of the COEH in developing these recommendations was to establish a 

guideline based directly on child health issues, rather than the selection of an arbitrary 

number. After much discussion, the committee agreed that the appropriate benchmark for 

its recommendation should be the loss of 1 IQ point. Using California Office of 

Environmental Health Hazard Assessment analysis that evaluated the upper 97.5% 

confidence level of blood lead level associated with this effect, a I IQ point loss would be 

prevented by limiting a child's BLL increase to no more than I mcg/dL. 19 Supporting a 

rationale on 1 mcg/dL rise is the FDA upper limit for lead in food at 6 mcg/lead/day for 

children aged <6 years, which is expected to cause a child's BLL to rise by I mcg/dL.20 

There is no logical reason to accept a higher rise in blood lead level from product 

exposure than from food exposure. 

3 
The COEH's next task was to determine the amount of lead that would result in a child's 

BLL increasing by 1 mcg/dL from exposure to a child's product. This evaluation focllscci 

on information posted by CPSC evaluations.21 The committee determined as follows: 

• 	 Based on the 1999-2000 National Health and Nutrition Examination Survey 

(NHANES), the average blood lead level of a child aged 1-5 years in the US in 

1999-2000 was 2.2 mcg/dL. 

• 	 In developing its recommendation for lead in toy jewelry, the CPSC calculated 

that an extractable lead content of 175 mcg would cause an average child's BLL 

to rise to J0 mcg/dL over a 1 month exposure period. The agency determined that 

this level of exposure occurs at a level of 0.06% lead hy weight (600 ppm, 

coincidentally, the same limit as the 1978 lead paint ban).22 

• 	 As noted above, however, the COEH had already determined that waiting for 

BLL to rise to 10 mcg/dL was not acceptable due to the neurological damage that 

would occur. In order to limit the BLL rise to I mcg/dL, the CPSC figures were 

divided by 7.8, which represents the rise in BLL from 2.2 mcg/dL to 10 mcg/dL, 

to obtain the figure that would correlate to a BLL increase of I mcg/dL. 

Accordingly, 600 ppm lead divided by 7.8 equals 77 ppm lead being capable or 

causing a BLL increase of 1 mcg/dL. 

In its next step, the COEH took into account the fact that most children are exposed to 

lead from a variety of sources, which may include lead paint hazards in the home, 

airborne lead emissions, contaminated soil, and other consumer products. Since lead is 

bioaccumulative and highly persistent in the body, it is important to provide a margin of 

safety to ensure that exposure to a single toy or children's product cannot cause BLL to 

increase 1 mcg/dL. 

In determining how to set this margin of safety, the com.. examined the practical issues 

associated with lead exposure. Lead occurs naturally in the environment, so setting lead 

content at zero was not deemed to be a feasible recommendation. The committee 

examined data from a variety of sources to learn about the natura I geological occurrence 

of lead in the United States. The U.S. Geological Survey provides nationwide data on 

lead exposure, which illustrates that naturally occurring lead levels generally top out at 30 

ppm.23 The AAP confirmed this data with Geological Survey and independent 

geologists. Given this evidence, the COEH recommended a two-fold margin of safety for 

lead content in children's products, dropping the recommendation from 77 ppm to 40 

ppm. You may note that this is considerably lower than the margin of safety mandated 

under other federal laws; for example, the tolerance for pesticide residue on food requires 

a ten-fold margin ofsafety (i.e., limit set at one tenth ofthe amount estimated to cause the 

negative effect) for vulnerable populations, including children. 

Development ofthe CPSIA Stmulcml (f1U1 Exceptions Clause 

Over the year that Congress spent working intensively on this legislation, the AAP 

engaged in a detailed dialogue with both House and Senate offices regarding the merit of 

various possible exemptions to the lead guidelines. In partnership with these offices, the 

4 
AAP collaborated on the development of legislative language that empowers the 

Consumer Product Safety Commission (CPSC) to accept and evaluate applications for 

such exemptions. This process will include possible exemption for inaccessible lead, 

although the definition of inaccessibility was the subject of much debate. For example, it 

was questioned whether lead would be considered inaccessible if it were covered by paint 

or electroplating, or included in a compound such as vinyl or lead crystal. In each of 

these cases, the COEH advised that lead was not inaccessible because barriers like paint 

and electroplating can be breached, vinyl deteriorates with time and use, and lead leaches 

from crystal in the presence of acid (including stomach fluids). 

In the final legislation, the CPSC is specifically directed to examine the application of the 

lead standard to electronic products, including batteries, and to develop guidelines for 

minimizing children's exposure to lead that cannot be eliminated from these products. 

The AAP supported these proposals, which will allow for the transparent, science-based 

evaluation of proposals to permit lead in certain components oftoys and children's 

products. The AAP anticipates offering our views and guidance to the CPSC as such 

applications are submitted and examined. 

The AAP is acutely aware of the impact our recommendations can have, and we strive to 

ensure that all AAP recommendations are based on science and practical to implement. 

Led by the COEH, the AAP engaged in a thorough, evidence-driven review to develop 

our lead recommendations. Following that, AAP members and staff spent countless 

hours engaged with numerous Congressional offices to explore the issues associated with 

lead in children's products and to assist in crafting a final bill that would protect 

children's health through pragmatic, feasible standards. The AAP strongly supported this 

legislation and looks forward to working with the Consllmer Product Safety Commission 

on its implementation in the coming years. 

I hope this letter satisfies your request for information and gives you confidence that the 

AAP's recommendations represent an empirically-based solution grounded in science. If 

the Academy may be of further assistance, please contact Cindy Pellegrini in our 

Washington, D.C. Office at 202/347~8600. 

Sincerely, 

""l (\ 1'.'-7 f c:~JV<.~5~/ J ~ ,,~ ~~K. 1\(\ , 

David T. Tayloe, Jr., MD FAAP 

President 

DTT:cp 

5 
I Canfield RL, Henderson CR, Jr., Cory-Slechta DA, Cox C, Jusko TA. Lanphear BP. Intellectual impairment in 

children with blood lead concentrations below 10 microg per deciliter. N Engl J Med 2003;348( 16): 15 I 7-J526. 

2 Lanphear BP, Hornung R, Khoury J, et at. Low-level environmental lead exposure and children's intellectual 

function: an international pooled analysis. Environ Health Perspect. lui 2005; 113(7):894-899. 

3 Chen A, Dietrich KN, Ware lH, Radcliffe J, Rogan WJ. IQ and blood lead from 2 to 7 years of age: are the efTecls 

in older children the residual of high blood lead concentrations in 2-year-olds? Environ H£'alth Perspect. 

2005;113(5):597-601. 

4 Centers for Disease Control and Prevention. !Ifaf1aging Elevated Blood Lead Levels Among Young Childrell 

Recommendations/rom the Advisory Committee on Childhood Lead Poisoning Prevention. Atlanta, GA: Centers for 

Disease Control and Prevention.; 2002. 

5 Dietrich KN, Ris MD, Succop PA, Berger OG, Bornschein RL. Early exposure to lead and juvenile delinquency. 

Neurotoxico/ Terato!' Nov-Dec 2001 ;23( 6):511-518. 

6 Ris MD, Dietrich KN, Succop PA, Berger OG, Bornschein RL. Early exposure to lead and neuropsychological 

outcome in adolescence. J Int Nl;iurop,lycho! Soc. Feb 2004:261-270. 

1 Burns JM, Baghurst PA, Sav.yer MG, McMichael AJ, Tong SL. Lifetime low-level exposure to environmental lead 

and children's emotional and behavioral development at ages 11-13 years. The Port Pirie Cohort Study. Am J 

E"pidemiol. Apr 151999;149(8):740-749. 

8 Nevin R. Understanding international crime trends: the legacy of preschool lead exposure. "~nl'iron Res, 

2007;104(3):315-336. 

9 Ibid. 

I(J Centers for Disease Control and Prevention. Managing Elevated Blood Lead Levels Among Young Children. 

Recommendations/rom the Advisory Committee on Childhood Lead Poisoning Prevention. Atlanta, GA: Centers for 

DIsease Control and Prevention; 2002. 

II Bhattacharya A, Shukla R, Dietrich KN, Bornschein RL. Effect of early lead exposure on the maturation of 

children's postural balance: a longitudinal study. Neurotoxicol Terato!' 2006;28(3):376-385. 

12 Chiodo LM, Covington C, Sokol RJ, et al. Blood lead levels and specific attention effects in young children. 

Neurotoxical Teratol. Apr 21 2007. 

I] Reed KJ, Jimenez M, Freeman NC, Lioy P J. Quantification of children's hand and mouthing activities through a 

videotaping methodology. J Expo Anal Environ Epidemiol. 1999;9(5):513-520. 

14 Ko S, Schaefer PO, Vicario CM, Binns HJ. Relationships of video assessments of touching and mouthing 

behaviors during outdoor play in urban residential yards to parental perceptions of child behaviors and blood lend 

levels. J Expo Sci Environ Epidemiol. 2007; 17(1 ):47-57. 

15 O'Flaherty EJ. A physiologically based kinetic model for lead in children and adults. Environ Health Perspecl. 

1998;106 SuppI6:1495-1503. 

16 Centers for Disease Control and Prevention, Healthy People 2010. '.:"":I.:..:.~ ...:._:....:.. :..C .. :_='.':.:.".'.:~.~=..:.,,'=C=".: 

17 Centers for Disease Control and Prevention. Preventing Lead Poisoning in Young Children. Atlanta: 

CDC; 200S. 

IS Centers for Disease Control and Prevention. Interpreting and Managing Blood Lead Levels <1 0 ~g/dL in 

Children and Reducing Childhood Exposures to Lead: Recommendations ofCDC's Advisory Committee 011 

Childhood Lead Poisoning Prevention. lvlMWR. November 2, 2007; 56(RR08): 1-14; J6. 

19 Carlisle J, Dowling K. Development of Health Criteria for School Site Risk Assessment Pursuant to Health and 

Safety Code Section 901 (g): Child-Specific Benchmark Change in Blood Lead Concentration for School Site Risk 

Assessment. Integrated Risk Assessment Branch Office of Environmental Health Hazard Assessment California 

Environmental Protection Agency. April 2007. Available at 

11!illJW\, \If:ncb hi.Lm.!:!lj)J1 bl ie info,] 1I b I icil..id"indm:!illL;v()413U7.!.l1s.Ij'. 

20 "Dangers of Lead Still Linger," FDA Consumer. U,S. Food and Drug Administration, January-February 1998. 

A vai Iab Ie at ~j"c;••-'-'--''-.':..'.c~C!.!.!.!.'-'-''.',',.';;.:''-'-'--._.'''.''.,'....' ",,,-,,-,'..'!,". ',-!.,.,~. 

21 Consumer Product Safety Commission. Interim Enforcement Policy Lead Levels. February 14.2005. Available 


at b.!!.i~~. c;z."'.e,, '4"="'-1=-'C:""'.""""'!'~_' ,.._,-""-,,.,,:'""--'-".!.o!:.j.'''''' 


:2 Consumer Product Safety Commission. Interim Enforcement Policy Lead Levels. February 14,2005. Available 


at bJ1Jl:.!iW\vw.cpsc ,!!.Q.Y!.ltLSI N F O!pble-.;.cJ::CJ)ilJ 


23 U.s. Geological Survey Professional Paper 1648. Geochemical Landscapes ortlle Conterminous united States­


New Map Presentations for 22 Elements. Figure 17. November 200 I. Available at 


hIm:' ipubs.usgs.gov!ppip I 64S'nlS1'13.:pdf. 


6 
Anlerican Academy 

of Pediatrics 

DEUIt.:.'HElj 10 IHI. 11!',lIIT!! OF :\11 (fili j)R!:.:\ 

Wednesday, February 16, 2011 

Testimony of 

Dana Best, MD, MPH, FAAP 

On behalf ofthe 

American Academy of Pediatrics 

Before the Consumer Product Safety Commission 

"Children's Products Containing Lead: Technological Feasibility of 100ppm for 

Lead Content" 

American Academy of Pediatrics • Department of Federal Affairs 


601 13th Street NW, Suite 400 North • Washington, DC 20005 


Tel: 800.336.5475 • E-mail: kids1st@aap.org 

Dana Best, MD, MPH, FAAP 

American Academy of Pediatrics 

Children's Products Containing Lead: 

Technological Feasibility of lOOppm for Lead Content 

February 16, ::011 

Chairman Tenenbaum and Commissioners Adlcr, Moore, Nord and Northup, thank you for this 

opportunity to speak to you today. My name is Dana Best, MD, MPH, FAAP, and I am pleased 

to represent the American Academy of Pediatrics (AAP), a non-profit professional organization 

of 60,000 primary care pediatricians, pediatric medical sub-specialists, and pediatric surgical 

specialists dedicated to the health, safety, and well-being of infants, children, adolescents, and 

young adults. I am an Associate Professor of Pediatrics at George Washington University School 

of Medicine and an attending physician at Children's National Medical Center in Washington, 

D.C. I served tor six years on the AAP's Committee on Environmental Health, which is the 

primary body within the AAP that handles lead and other environmental health issues. 

Under the Consumer Product Safety Improvement Act of2008 (CPSIA), the Consumer Product 

Safcty Commission (CPSC) is directed to reduce to 100 parts per million (ppm) the allowable 

levels of lead in chi Idren's products in August 20 11, "unless the Commission determines that a 

limit of 100 parts per million is not technologically feasible for a product or product category." 

The AAP appreciates the Commission's diligence in seeking public input about the public health 

and other impacts of reducing the permissible lead levels to lOOppm. 

The Commission has undoubtedly received and reviewed a tremendous amount of material about 

the research behind lead exposure and its impact on child health. I will therefore give only a 

brief overview ofthe state of the science. 

Lelltll\' a Known Neurotoxin 

Lead has been recognized as a potent neurotoxin since the time ofthe Roman empire, although 

the mechanisms by which it inflicts brain damage have only been explored and understood in the 

past century. The brain damage caused by lead exposure is permanent and irreversible. Few 

options exist tortreating lead exposure at high levels, and these treatments have potentially 

dangerous side effects. No options exist for treating lead exposure at [ow to moderate levels. 

Exposure to lead is amply documented to cause the loss of intellectual capacity. On average, 

children whose blood lead levels (BLLs) rise from 10 to 20 micrograms per deciliter (mcg/dL) 

lose two to three IQ points. More recent studies have shown an even greater impact on IQ of 

BLLs under 10 mcg/dL. Key studies reported a loss of 4 to 7 IQ points in children whose lead 

levels rose from I mcg/dL to 10 mcg/dL. I

,2 These studies suggest that "low" levels of exposure 

meaning BLLs less than 10 mcg/dL - cause proportionately greater harm than higher levels. 

In addition to these impacts on IQ, lead exposure has documented effects on behavior, with 

higher rates of behavioral problems reported in young children, teens and adults exposed to lead 

during childhood. Investigators have identified associations between lead exposure and 

increased aggression, commission of crime and antisocial or delinquent behaviors.J

,4,5.6 Children 

with elevated lead are more likely to have problems with attention deficit, reading disabilities, 

and to fail to graduate from high school. Other effects include abnormal balance, poor eye-hand 

8 coordination, longer reaction times, and sleep disturbances.7

. ,9 

Page 2 of 6 
Dana Best, MD, MPH, FAAP 

American Academy of Pediatrics 

Children's Products Containing Lead: 

Technological Feasibility of lOOppm for Lead Content 

February 16, 2011 

With all of this information in mind, it is critically important to note that lead is bioaccumulative. 

A percentage of lead will be excreted by the body, and the rate of clearance is dependent on a 

number of factors, including nutritional status. But a percentage of lead is also stored in the 

body, primarily in bone. These body stores can persist over decades. When a woman becomes 

pregnant, her body draws upon its calcium stores to create her fetus's bone structure. If lead has 

been stored in the bone, the developing fetus will be exposed to doses of lead at points 

throughout pregnancy. 10 Further, a women's blood lead in pregnancy puts her at higher risk for 

complications from high blood pressure. A recent study in Environmental Health Perspectives 

found blood pressure to be about 4-6 mmHg higher in women giving birth to infants with a cord 

blood lead level of 1-6 mcg/dL versus cord blood levels of:::;0.46 mcg/dL,11 

The costs associated with lead exposure arc tremendous. Health economists estimate that every 

time average blood lead level increases by a small amount" across the children born in any given 

year, $7.5 billion is lost in potential earnings forthose children. 12 Other studies have estimated 

the annual cost of lead poisoning in American children at $43.4 billion. 13 Costs are borne by our 

health care, education, and justice systems, among others. 

Lead is naturally present in our environment at low levels. I-Iuman activities have raised those 

levels through contamination, whether by adding lead actively to products like paint or gasol inc 

or producing it as a byproduct of activities like burning coal. Lead is present at low levels in our 

air, soil, and water, but often very dif11cult to remediate in those cases. It is therefore critical to 

restrict lead exposure in environments directly under our control, such as consumer products. 

AAP's Role in the CPSIA 

During the development of the CPS lA, the AAP was asked by Congress to recommend a limit 

for permissible levels of lead in children's products. The Academy engaged in a rigorous 

scientific process involving a review ofthe pertinent literature and ultimately recommended that 

lead be limited to 40ppm. AAP pediatric environmental health experts determined that, based on 

the most up-to-date science, an object with 77ppm lead would be capable of raising a child's 

blood lead level to a level that would result in the loss of one IQ point. Recognizing that 1110SL 

children are exposed to other sources of lead and that it is bioaccumulative, the AAP 

recommended a twofold margin of safety and reduced the recommendation from 77 to 40ppm. 

The level of 40ppm was also selected to fall above the naturally-occurring background levels DC 

lead seen in various parts of the United States. 14 

The AAP worked closely with Congress throughout the development of tile CPSJA to provide 

access to pediatric environmental health experts and researchers, who consulted on varioLis 

aspects ofthe legislation. The final bill represented a significant step toward reducing children's 

• "Small amount" is defined here as I mcg/dL increase in blood lead level. 

Page 3 of 6 
Dana Best, MD, MPH, rAAP 

American Academy of Pediatrics 

Children's Products Containing Lead: 

Technological Feasibility of 100ppm for Lead Content 

February 16, 2011 

exposure to lead, particularly by setting limits where none had previously cxisted on matcrials 

other than surface coatings in children's products. 

Health Effects ()fReducing Lead Limits from 300 to 100ppm 

1 n the January 26 Federal Register notice, "Children's Products Containing Lead; Technological 

Feasibility of 100 ppm for Lead Content," the CPSC requested public comment on several 

specific questions. The AAP would like to provide information on #6: "What health effects are 

associated with a reduction of the lead content limit from 300 ppm to 100 ppm? From 300 ppm 

to some other level above 100 ppm?" 

Based on the AAP's previously-noted calculations, an object containing 77ppm of lead is 

capable of raising a child's blood lead level to a level that would result in the loss of one lQ 

point. Please note that this is not meant to be interpreted as a definitive statement tor each 

exposed individual; rather, it is a public health statement representing what will be truc r(,,·th,.~ 

majority of children. Individual children will have factors that either increase or decrease their 

vulnerabi lity. 

For the majority of children, ingestion of an item containing 300ppm of lead would result in the 

loss of almost 4 (3.9) IQ points. I ngestion ofan object contain ing 100ppm lead would result in 

the loss ofjust over one (1.3) IQ points. 

When averaged across even a modest population of children, the public health harm causcd by 

lead is significant. Considering that there arc about 75 million children in our nation, impacting 

one-halfofone percent of all children would mean exposure of3.75 million children. Respected 

economic studies estimate the Joss of lifetime income at $8,346 (1995 dollars) for each loss or 

one IQ point. For 10,000 children, this equals approximately $83.4 million; for 100,000 

children, it would be $834 million. For one million children, it would total over $8.3 billion. 

Other Importallt Issues Related to Lead Exposure 

The Commission has received numerous comments regarding the feasibility of reducing 

permissible lead levels trom 300 to 100ppm. With those in mind, the AAP would urge the 

Commission to keep some additional points in mind. 

Childrell must be protected/rom both acute and chronic exposure to lead. Cases where 

exposure to a single lead-laden object can cause severe or fatal lead poisoning arc, happily, rarc. 

The CPSIA focused 011 preventing the often-invisible but perniciolls cases of si lent lead 

poisoning, where parents or caregivers are unaware that lead exposure ever occurs. The 

Commission must remember that lead accumulates in the body and exposure can come from 

mUltiple sources, so exposure must be limited as much as possible from each individual product 

to avoid accumulation to dangerous levels. 

Page 4 of 6 
Dana Best, MD, MPH, FAAP 

American Academy of PediJtrics 

Children's Products Containing Lead: 

Technological Feasibility of lOOppm for Lead Content 

February 16,2011 

Harmfrom lead is usually invisible. Most children are tested either once or twice for lead 

exposure, either around the ages of one or two years, or both. Exposures in infancy will not be 

detected until at least age one, and those that take place after the age of two years may never be 

detected. In some communities where the risk of lead poisoning from older housing stock is 

deemed low, testing for blood lead levels may not be performed at all. As a result, parents may 

never be aware oftheir child's elevated blood lead level or associated damage. Moreover, there 

is no way for parents to know if a given object contains lead, so they arc powerless to control 

exposure or protect their children. It is the responsibility ofthe Commission to provide that 

protection for children and families. 

Risk assessment ofindividual products or classes ofproducts is impractical and SUbjective. 

Some have recommended that the CPSC engage in some form of risk assessment to determine 

the levels of lead permitted in children's products. From a medical perspective, the benefit of 

lead exposure is zero, and so the considerable risk will always outweigh the benefit of having 

lead in children's products. A risk assessment scheme would introduce tremendous levels of 

subjectivity into this process and remove any certainty for parents and caregivers about the safety 

ofthe items they purchase. In addition, the CPSC would shoulder an untenable burden in 

attempting to perform or confirm risk assessment on variolls products. For all of these reasons, 

the AAP urges you to reject calls for risk assessment related to individual products and tl1-, 

amount of lead that should be permitted in them. 

Lead limits should be based 011 total, rather than accessible, lead levels. Congress thoroughly 

explored the issues related to accessible versus total lead and issued a clear statutory direction for 

the agency to regulate based on total lead. The variability among laboratory tests for aceessible 

lead and the fact that accessibility can change over time (e.g. as certain materials degrade) led 

Congress to reject accessibility as the appropriate standard for regulation. In fact, Congress 

directed the CPSC to use total lead as a way to provide greater certainty and consistency, making 

it easier for companies to measure compliance reliably. Challenges with consistency among tests 

performed by laboratories should lead the CPSC to work more closely with those entities 10 

ensure the appropriateness and consistency of protocols used. Laboratory issues do not, 

however, negate the validity of 100ppm as the appropriate standard protective of child health. 

CPSC should collaborate closely with companies working to comply in goodfail/I. The AAP 

appreciates that both the Commission and individual companies will undoubtedly face 

challenges related to compliance. In particular, very small producers may face difficulties 

related to the cost or complexity oftesting. The AAP urges the CPSC to work closely with these 

entities to craft creative, flexible solutions that reduce the regulatory burden while also 

preserving child health and safety. 

In conclusion, I appreciate this opportunity to oITer comments on behalf ofthe American 

Academy of Pediatrics. The AAP urges the Commission to continue placing the highest priority 

on protecting children from lead exposure and its devastating consequences. Large number of 

children's products currently on the market already comply with lead limits; we encourage you 

Page 5 of 6 
Dana Best, MD, MPH, FAAP 

American Academy of Pediatrics 

Children's Products Containing Lead: 

Technological Feasibility of 100ppm for Lead Content 

February 16, 2011 

to work closely with those remaining companies who sti II face compl iance challenges to identifY 

solutions. In any small number of cases where the CPSC may determine that the 100ppm limit is 

not technologically feasible, the CPSC should use the flexibility granted by Congress und..:r the 

CPSIA. The AAP stands ready to assist you in any way in this important undertaking. Please do 

not hesitate to call upon us. 

I Canfield RL, Henderson CR, Jr., Cory-Slechta DA, Cox C, Jusko TA, Lanphear SP. Intellectual impairment ill 

children with blood lead concentrations below 10 microg per deciliter. N Eng!J ivIed. 2003;348( 16): 1517-1526. 

2 Lanphear BP, Hornung R, Khoury J, et al. Low-level environmentallcad exposure and children's intellectual 

function: an international pooled analysis. Environ Health Perspect. Jul 2005; 113(7):894-899. 

3 Dietrich KN, Ris MD, Succop PA, Berger OG, Bornschein RL. Early exposure to lead and juvenile delinqucm:y, 

Neurotoxicol Teratol. Nov-Dec 200 1;23(6):511-518. 

4 Ris MD, Dietrich KN, Succop PA, Berger OG, Bornschein RL. Early exposure to lead and neuropsychological 

outcome in adolescence. J /nt Nellrop.\~vchnl Soc, Feb 2004:261-270, 

5 Burns JM, Baghurst PA, Sawyer MG, McMichael AJ, Tong SL. Lifetime low-level exposure to environmental lead 

and children's emotional and behavioral development at ages 11-13 years. The Port Pirie Cohort Study. Am J 

Epidemiof. Apr 15 1999;149(8):740-749, 

6 Nevin R. Understanding international crime trends: the legacy of preschool lead exposure, Environ l?es 

2007; 104(3):315-336, 

7 Centers for Disease Control and Prevention . .Managing Elevated Blood /,ead Levels Among Young Children: 

Recommendationsfrom the AdvisOlY Committee on Childhood Lead Poisoning Preventiol1. Atlanta, GA: Centers for 

Disease Control and Prevention; 2002. 

8 Bhattacharya A, Shukla R, Dietrich KN, Bornschein RL. Effect of early lead exposure on the maturation 01 

children's postural balance: a longitudinal study. Neurotoxicol Terata!. 2006;28(3):376-385. 

9 Chiodo LM, Covington C, Sokol RJ, et al. Blood lead levels and specific attention effects in young children. 

Nellrotoxi"ol Teratof. Apr 21 2007. 

10 Schnaas L, Rothenberg SJ, Flores MF, et aL Reduced intellectual development in children with prenatal lead 

exposure. Environ Health Perspect, 2006; 114(5 ):791-797, 

II Wells E, Navas-Acien A, Herbstman J, Apelberg 8, Silbergeld E, Caldwell K, Jones R, Halden R, Witter F, 

Goldman L. Low Level Lead Exposure and Elevations in Blood Pressure During Pregnancy, £nviron I lea/til 

Perspect. 2011; doi: I 0.1289/ehp.1 002666 

12 Salkever D. Updated Estimates of Earnings Benefits from Reduced Exposure of Chi Idren to Environmental Lead, 

Environmental Res. 1995: 70:1·6, 

13 Landrigan PJ, Schechter CB, Lipton JM, Fahs MC, Schwartz J. Environmental pollutants and disease in 

American children: estimates of morbidity, mortality, and costs for lead poisoning, asthma, cancer, and 

developmental disabilities. Environ Health Perspect 2002; J 10:721-8. 

14 lJ .S, Geological Survey Professional Paper 1648. Geochemical Landscapes of the Conterminous United StatesNew Map Presentations for 22 Elements, Figure 17. November 2001. Available at 

IlliELJ211l!~cCLl'ill.3hmyiillUJ2lJY 18.D.L(>.:l~:UQJ. 

Page 6 of 6 
Hammond, Rocky 

From: Fellin, Mark 

Sent: Friday, April 01, 2011 9:28 AM 

To: Hammond, Rocky 

Subject: FW: QUestions for the Record 

Attachments: 03-24-11 CPSC Northup 100ppm questions Itr.PDF 

From: Cindy Pellegrini [mailto:CPellegrini@aap.org] 


Sent: Thursday, March 24, 2011 3:43 PM 


To: Fellin, Mark 


Subject: Re: Questions for the Record 


Dear Mark, 

Attached please find a letter from Dr. Best responding to Commissioner Northup's questions for the record of the Feb. 


16 hearing. Please let me know if there's anything further I should do to ensure that the response appears in the 


hearing record. Thank you! 


Regards, 


Cindy 


Cindy Pellegrini 


Associate Director, Dept. of Federal Affairs 


American Academy of Pediatrics 


60113th St, NW, Suite 400N 


Washington, DC 20005 


(202) 347-8600 main 

(202) 724-3307 direct 

(202) 393-6137 fax»> "Fellin, Mark" <MFellin@cpsc.gov> 3/1/2011 9:54 AIVl »> 


Dr. Best, 


Attached you will find Comm. Northup's follow-up questions for the record. I will also be sending you a hard copy for 

your records. Please let me know if you have any questions. Thanks! 

Mark S. Fellin 


Office of Commissioner Anne M. Northup 


Consumer Product Safety Commission 


(301) 504-7780 

http://www.safetyandcommonsense,blogspot,comL 

*****!!! Unless otherwise statedr any views or opinions expressed in this e-mail (and any attachments) are solely those 

of the author and do not necessarily represent those of the U.S. Consumer Product Safety Commission. Copies of 

product recall and product safety information can be sent to you automatically via Internet e-mailr as they are released 

by CPSC. To subscribe or unsubscribe to this service go to the following web page: https:/Iwww.cpsc.qov/cpsclist.aspx 

*****!!! 

1