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Posted on: November 20, 2023

Updated Advisory: High Blood Lead Levels in Children Consuming Recalled Cinnamon Applesauce Pouches

Update 1/5/2024: Potential Chromium Exposure for Children Consuming Recalled Applesauce Pouches

The Centers for Disease Control and Prevention (CDC) has shared updated information related to this advisory. The full update from CDC can be reviewed in the January 5 Clinician Outreach and Communication Activity (COCA) message here.

In summary, FDA product testing has identified high levels of chromium in cinnamon samples and recalled apple cinnamon puree pouches. Chromium is a naturally occurring element with trace levels normally found in the diet and comes in different forms, including one that is considered an essential nutrient. Another form, however, is a known carcinogen. Chronic, prolonged inhalational and skin exposure to this form – chromium(VI) – has been associated with chronic lung disease and ulceration of skin and mucous membranes. Lead chromate, which contains chromium(VI), has been used to adulterate turmeric and other spices. While harm resulting from ingesting lead-contaminated food is relatively well researched, the effects of eating food contaminated with chromium(VI), as a constituent of lead chromate, are not well understood. Recommended actions for clinicians can be found in the full COCA message.

Health Advisory: High Blood Lead Levels in Children Consuming Recalled Cinnamon Applesauce Pouches

November 20, 2023

Action Requested 

  • Be aware that multiple states have reported potential cases to the U.S. Food and Drug Administration (FDA) of high blood lead levels (BLLs) in children consuming recalled cinnamon-containing applesauce products that have high levels of lead.
  • Consider the possibility of illness due to lead exposure and report cases in Snohomish County to the Snohomish County Health Department or Washington State Department of Health. Call 425-258-8401 to reach the County’s Childhood Lead Poisoning Prevention Program.
  • Counsel patients or their caregivers and guardians not to eat specific cinnamon-containing apple purée or applesauce products named in the FDA recall announcements. The latest information on recalled products is available on the FDA’s website about the investigation
  • Educate patients or their caregivers and guardians about the health effects of lead exposure in children and the importance of seeking medical care. Most children have no obvious symptoms, but appropriate screening can detect lead in blood. Children who have consumed a recalled applesauce pouch product should be tested for lead exposure. Clinicians may refer to CDC’s guidance on testing children for lead exposure. The American Academy of Pediatrics has also published clinical guidance for managing lead exposure in children
  • Consider lead exposure in the differential diagnosis of patients presenting with compatible clinical findings associated with lead poisoning, which may include the following:
    • Constitutional symptoms such as generalized weakness, fatigue, malaise, arthralgias, myalgias, irritability, anorexia, insomnia, and weight loss.
    • Abdominal pain (“lead colic”), constipation, nausea, and other gastrointestinal symptoms.
    • Anemia (normochromic or microcytic, possibly with basophilic stippling).
    • Central nervous system effects, such as headache, impaired visual-motor coordination, tremor, and, in severe cases, seizure, encephalopathy, and coma.
    • Stunted growth, hearing problems, impaired neurobehavioral development, decreased intelligence, and failure to meet expected developmental milestones.
    • Impaired kidney function, such as acute tubular dysfunction.
  • Know that individuals with high BLLs may not be symptomatic and are identified through screening. Be familiar with CDC’s testing recommendations for lead, indications for confirmatory testing, and recommended actions based on BLL. CDC recommends a blood lead reference value (BLRV) of 3.5 µg/dL to identify children with BLLs that are higher than most.
  • Obtain a detailed exposure history in patients with suspected lead exposure. Ask about household members with known lead exposures and possible lead sources in and around the home.
  • Obtain early consultation with or provide a referral to a medical toxicologist or pediatric specialist with expertise in managing lead exposure for medical workup and managing patients with high BLLs. Snohomish County public health nurses provide case management for children with levels above the BLRV.
  • Report cases of individuals with BLLs above the reference value, including those who have consumed these recalled products. Learn more about reporting blood lead levels on the Snohomish County Health Department webpage, or call the Childhood Lead Poisoning Prevention Program at 425-258-8401.
  • Contact your local poison center (1-800-222-1222) for advice on diagnosing and managing lead toxicity.

Full CDC HAN Alert

Background

The FDA, along with CDC and state and local partners, is investigating reports of elevated blood lead levels in individuals with reported exposure to Apple Cinnamon Fruit Puree pouches manufactured in Ecuador and sold under WanaBana, Weis, and Schnucks brands.  

As of November 16, 2023, there have been 34 reports of illness potentially linked to recalled product submitted to FDA. FDA is continuing to evaluate incoming adverse reports of illnesses.  

FDA and other state partners collected and analyzed additional product samples of fruit puree and applesauce pouches. FDA detected elevated levels of lead in one finished product sample of WanaBana Apple Cinnamon Puree collected from Dollar Tree. The level detected in the FDA sample of WanaBana apple cinnamon puree is 2.18 parts per million (ppm), which, for context, is more than 200 times greater than the action level the FDA has proposed in draft guidance for fruit purees and similar products intended for babies and young children. 

To date, sample analysis of WanaBana, Weis, and Schnucks fruit puree pouches that do not contain cinnamon and are not part of the recall, have not shown elevated levels of lead.

As a reminder, there are other avenues of lead exposure aside from recalled products. Parents and caregivers who work in jobs, hobbies, or other activities that expose them to lead can bring lead-containing dust home with them. Lead-containing dust can be tracked onto carpets, floors, furniture, and other surfaces that a child may touch, and expose other family members without knowing. Known risk-factors for lead exposure include the following:

  • Lead paint and dust in homes built before 1978.
  • Lead in soil, for example due to prior contamination from leaded gasoline, exterior lead paint, or old home renovations.
  • Nearby active lead and other types of smelters, battery recycling plants, or other industries that release lead into the air (such as the Everett Smelter site).
  • Certain folk remedies (e.g. Ayurvedic or traditional Chinese herbal medicines, Azarcon, Greta), cosmetics (e.g. kohl, kajal, surma), religious powders (e.g. sindoor), and other cultural products.
  • Imported powdered spices, such as turmeric, chili, and curry powders.
  • Certain types of jewelry made with lead-containing metal alloys or paints.
  • Ceramics made with lead-containing glazes.
  • Older toys made with lead-based paint, lead-containing metal alloys, or certain types of plastic.

More information from the FDA.

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