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NIH: Use of a Cumulative Exposure Index to Estimate the Impact of Tap Water Lead Concentration on Blood Lead Levels in 1- to 5-Year-Old Children (Montréal, Canada)

Gerard Ngueta,1,2 Belkacem Abdous,1,2 Robert Tardif,3 Julie St-Laurent,1 and Patrick Levallois1,2,4


  • Background: Drinking water is recognized as a source of lead (Pb) exposure. However, questions remain about the impact of chronic exposure to lead-contaminated water on internal dose.

    Objective: Our goal was to estimate the relation between a cumulative water Pb exposure index (CWLEI) and blood Pb levels (BPb) in children 1–5 years of ages.

    Methods: Between 10 September 2009 and 27 March 2010, individual characteristics and water consumption data were obtained from 298 children. Venous blood samples were collected (one per child) and a total of five 1-L samples of water per home were drawn from the kitchen tap. A second round of water collection was performed between 22 June 2011 and 6 September 2011 on a subsample of houses. Pb analyses used inductively coupled plasma mass spectroscopy. Multiple linear regressions were used to estimate the association between CWLEI and BPb.

    Results: Each 1-unit increase in CWLEI multiplies the expected value of BPb by 1.10 (95% CI: 1.06, 1.15) after adjustment for confounders. Mean BPb was significantly higher in children in the upper third and fourth quartiles of CWLEI (0.7–1.9 and ≥ 1.9 μg/kg of body weight) compared with the first (< 0.2 μg/kg) after adjusting for confounders (19%; 95% CI: 0, 42% and 39%; 95% CI: 15, 67%, respectively). The trends analysis yielded a p-value < 0.0001 after adjusting for confounders suggesting a dose–response relationship between percentiles of CWLEI and BPb.

    Conclusions: In children 1–5 years of age, BPb was significantly associated with water lead concentration with an increase starting at a cumulative lead exposure of ≥ 0.7 μg Pb/kg of body weight. In this age group, an increase of 1 μg/L in water lead would result in an increase of 35% of BPb after 150 days of exposure.



Adverse effects of lead in children have been widely studied for years. Exposure to lead has been linked to anemia (Flanagan et al. 1982Jain et al. 2005Schwartz et al. 1990Waldron 1966), renal dysfunction (de Burbure et al. 2006), impaired hearing and postnatal growth [U.S. National Toxicology Program (NTP) 2012], and neurotoxic effects (Lidsky and Schneider 2003Ronchetti et al. 2006). Pooled results of cohort studies indicated that, in young children, blood lead levels (BPb) < 7.5 μg/dL were associated with intellectual deficit, without any obvious threshold (Lanphear et al. 2005).

Drinking water has been identified as a source of oral exposure to lead (Brown et al. 2011Triantafyllidou and Edwards 2012). Children can absorb 40–50% of an oral dose of water-soluble lead, compared with 3–10% for adults [Agency for Toxic Substances and Disease (ATSDR) 2007]. Despite great interest for the influence of environmental lead on children’s health, few studies have investigated the impact of water lead levels (WLL) on BPb in those < 6 years of age. However, young children represent the most sensitive population and are at higher risk of deleterious effects of lead from drinking water (ATSDR 2007Gulson et al. 1997Triantafyllidou and Edwards 2012). A few epidemiologic studies including children < 6 years of age have reported a strong association between WLL and BPb (Lacey et al. 1985Lanphear et al. 19982002Levallois et al. 2014), but others have not (Gasana et al. 2006Rabinowitz et al. 1985).

The distribution of absorbed lead to organ systems appears to be quite similar in children and adults (ATSDR 2007Barry 1975Gross et al. 1975), with bone lead accounting for about 73% of the body burden in children (ATSDR 2007Barry 1975). It has been reported that the half-life of blood lead is approximately 30 days for adults [ATSDR 2007World Health Organization (WHO) 1995]. For young children, to our knowledge, no specific value has been reported. Duggan (1983) considered that the clearance rate of blood lead may be higher in children than in adults. However, the true value of this half-life, though shorter, might be very speculative. The time required to reach the steady-state is about five to six times the elimination half-life time (i.e., 5–6 months) after a repeated exposure (Greenblatt 1985). Therefore, BPb at a given time is related to the cumulative exposure over the previous 5 months. That is, 50% of blood lead is eliminated after approximately 1 month, 75% after 2 months, 87.5% after 3 months, etc.

Several authors reported that lead concentration in tap water increases with water temperature (Cartier et al. 2011Schock 1990), suggesting that WLL is likely to show seasonal fluctuations. More recently, we reported marked winter-to-summer changes in WLL in the Montreal area and a potential impact on children’s BPb using the integrated exposure uptake biokinetic model (IEUBK) (Ngueta et al. 2014). The geometric means of WLL (± SE) were 2.7 ± 2.2 μg/L during winter and 8.1 ± 1.5 μg/L during summer. However, previous cross-sectional studies did not take into account the fact that the tap water lead concentration may vary seasonally and did not consider the cumulative exposure to lead from water in the months preceding the blood sampling (Gasana et al. 2006Lanphear et al. 1998Levallois et al. 2014Morse et al. 1979Oulhote et al. 2013). Although the IEUBK model integrates several biological parameters, it assumes that exposure levels are stable over the year (Mickle 1998), and it does not capture cumulative lead exposure over time.

In the present study, we addressed the gap in knowledge about time-dependent cumulative lead exposure from tap water in relation with children’s BPb. More specifically, we aimed to estimate the dose–response relationship between drinking-water cumulative lead exposure and BPb in 1- to 5-year-old children. Given the low clearance of blood lead, a more accurate way to estimate cumulative exposure to lead should substantially improve our ability to accurately estimate the effects of lead exposure resulting from water.