New York City Health Department A girl wears kohl around her eyes. Similar products are known in other languages as tiro and surma.
After a Massachusetts doctor found high levels of lead in an infant's blood last year, hospital staff found no hazards in common sources of the toxic metal – paint at the family's home, residue from workplace exposure, kitchenware and diet. Instead, they identified an unusual culprit: makeup.
For months, three to four times a week, the family had applied a Nigerian cosmetic and folk remedy called "tiro" to the boy's eyelids. The amount of lead in the boy's blood – 13 micrograms per deciliter – was more than double the level of concern set by the Centers for Disease Control and Prevention. A test revealed the cosmetic was 82.6 percent lead.
The findings, published earlier this month by the CDC, raise concerns about a product that certain immigrant populations often use but that health care providers rarely question as a source of lead exposure. The case is the first to the CDC's knowledge of an infant being poisoned by a cosmetic like tiro, said Jay Dempsey, the agency's health communications specialist.
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"We're recommending (that) health care providers and workers should ask about eye medications and cosmetics when seeking a source of exposure to lead in children that have been diagnosed with elevated lead levels – particularly if they're from an immigrant population," Dempsey said.
Lead can build up in the body and damage the nervous system and brain, kidneys and other major organs. There is no known safe level of lead, which can cause learning and behavior problems, seizures and death. Children are especially vulnerable because they absorb the toxin more easily, are still developing and often put their hands or objects that can be contaminated with lead in their mouths.
Born in the United States to Nigerian parents, the Massachusetts boy received tiro from a grandparent who had purchased the black powder from a street vendor in Kwara State, Nigeria. Similar products are used in other parts of Africa, Asia and the Middle East, and are known in different languages as "kohl," "surma," "kajal," "tozali" and "kwalli."
In Nigeria, tiro is generally used on infants and by women for both cosmetic and medicinal purposes, Dr. Abdulsalami Nasidi, project director of the Nigeria Centre for Disease Control, said in an email. The product is used to cleanse eyes, beautify eyelids and improve eyesight.
That use of tiro could result in lead poisoning has come as a surprise in Nigeria, where the product is a widely accepted traditional practice, Nasidi said. The center is working with government health agencies and traditional institutions and leaders to create educational materials on the dangers of tiro, but Nasidi said information alone is not enough.
"People here are so used to this product that we believe we must carefully choose the right health education messages and also find an alternative, even among modern cosmetics, before embarking on (a) large scale campaign," he said.
In the United States, the Food and Drug Administration and various state and local health departments have published warnings about such products, most often identified as kohl or surma. Still, cosmetics are a little-known source of possible lead exposure, said Lisa Archer, campaign director of the Campaign for Safe Cosmetics, which has conducted tests that found lead in lipsticks.
"People just don't know – they don't know that cosmetics could be dangerous," she said. "They think that somebody's watching the aisle in the store, and in reality, that's just not the case."
It's unknown how widespread the use of tiro and similar products is in California. The California Department of Public Health estimates that cosmetics are involved in less than 5 percent of childhood lead poisoning cases in the state, according to a statement provided to California Watch by Dr. Rick Kreutzer, chief of the California Department of Public Health's environmental and occupational disease control division.
Some eyeliners and shadows use the word "kohl" to describe their black coloring but do not actually contain kohl; the FDA advises consumers to avoid products that do not list approved color additives in their ingredients.
Real kohl is illegal in the United States. But unlike the Consumer Product Safety Commission, which can issue mandatory recalls of lead-tainted toys and jewelry, the FDA does not have recall authority over cosmetics.
California's Safe Cosmetics Program requires commercial vendors of cosmetics to report products that contain any amount of certain chemicals, including lead, that are known to cause cancer, or reproductive or developmental harm. But even if a vendor reports that a cosmetic contains harmful ingredients, the state cannot ban the product's sale, Kreutzer said.
The program has not received any reports of eye cosmetics containing lead, Kreutzer said. And among cases of childhood lead poisoning in California involving surma, which date back to 1993, none stemmed from commercial cosmetics. Surma and products like it are often brought into the country by individuals.
The Massachusetts case is "an example of the bigger problem where cosmetics are virtually unregulated in this country," Archer said. Still, she said, "even if we had the best laws in the world, it might be challenging to keep this stuff out of people's homes."