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Red cell transfusion related toxic metals exposure for fetus and newborns: an under-recognized public health concern

Pediatric Research volume 97, pages 473–474 (2025)Cite this article

Exposure to environmental toxins, both natural as well as synthetic, continues to be a significant worldwide public health concern.1 The majority of these exposures are occurring as air pollutants, water contaminants, soil pollutants, chemical substances and radiological hazard and result in significant morbidity and mortality.2,3 Even at low doses with prolonged exposures, toxic metals can bio-accumulate leading to poor neurodevelopmental outcomes, with teratogenic and carcinogenic potential, and multiple organ damage including liver, kidney, blood, and brain.2,3 Most commonly studied naturally occurring toxic metals include lead (Pb), mercury (Hg), arsenic (As), and cadmium (Cd). Lead a known neurotoxin that disrupts the blood brain barrier was reported by World Health Organization to be responsible for half of the 2 million lives lost worldwide attributable to chemical exposure in 2019.4 Methylmercury another potent neurotoxin along with Pb has been significantly associated with autism.5 Similarly, Cd a developmental and carcinogenic toxin, damages lung, kidney, intestines, bones, and brain through exposures in diet and smoking.6 Arsenic, especially in its inorganic and hydrophilic toxic form, is labeled as human carcinogen by the Department of Health and Human Services and the International Agency for Research on Cancer, and is well known for epigenetic dysregulation and endocrine disorders.7 While risk remains for all age groups, fetus, infants, and young children are most vulnerable to irreversible developmental, cognitive, neurologic and behavioral deficits, with increased antisocial behavior, and reduced educational attainment.4 A relatively understudied area is fetal and neonatal perinatal exposures to these toxic metals through many sources, including from intrauterine blood products.6

In this issue of Pediatric Research, Al-Saleh and colleagues report fetal exposure to heavy metals secondary to intrauterine blood transfusions (IUBTs). In a prospective single center cohort of 30 South Arabic pregnant people and their infant, wherein IUBTs were performed for fetal anemia due to Rh allo-immunization, they measured levels for the four toxic metals - Pb, Hg, Cd, and As, from the transfusion bags, the maternal third trimester sample and the umbilical cord blood sample. Of the 127 transfusion bags sampled, majority had measurable levels of these toxins, with 100% bags with detectable lead level, with some being significantly higher than the standard safe reference ranges. Additionally, correlations between IUBT blood and umbilical cord blood metal concentrations were identified for Hg, Cd, and As, while correlation between maternal blood and umbilical cord blood metal concentration was limited to Cd. Most concerning were the cord blood samples from 17 fetuses with a hazard index (HI) > 1, indicating substantial health risk, for at least one metal. The most common metal with HI > 1 was Pb, followed by Hg and Cd. The authors call for re-evaluation of blood donor screening protocols and revised clinical guidelines to reduce fetal metal exposure during the most rapid development period, with potential for irreversible insult.

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Authors and Affiliations

  1. Department of Pediatrics, Tufts University School of Medicine, Boston, MA, US

    Neha Chaudhary, Ryan Kilpatrick & Rachana Singh

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  1. Neha Chaudhary
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  2. Ryan Kilpatrick
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  3. Rachana Singh
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All authors drafted the commentary and reviewed it critically for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

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Correspondence to Rachana Singh.

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Chaudhary, N., Kilpatrick, R. & Singh, R. Red cell transfusion related toxic metals exposure for fetus and newborns: an under-recognized public health concern. Pediatr Res 97, 473–474 (2025). https://doi.org/10.1038/s41390-024-03630-5

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