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| Managing Elevated Blood Lead Levels Among Young Children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Chapter 1. Introduction | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Chapter 2. Assessment and Remediation of Residential Lead Exposure | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Chapter 3. Medical Assessment and Interventions | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Chapter 4. Nutritional Assessment and Interventions | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Chapter 5. Developmental Assessment and Interventions | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Chapter 6. Educational Interventions for Caregivers | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Appendixes | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Chapter 1. Introduction | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Development of the Case Management Recommendations |
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This report from the Advisory Committee on Childhood Lead Poisoning
Prevention (ACCLPP) is intended to facilitate the management of children
with elevated blood lead levels (EBLLs) by providing case managers with
information and guidance. Some of the assessments and interventions
recommended herein will be the primary responsibility not of case
managers, but of other individuals or groups—primary care providers
(PCPs), public health agencies, nutritionists, managed care organizations,
and environmental inspectors—for whom this document should be considered
as only a supplementary, not primary, source of information. Through this
document, however, case managers can become familiar with the activities
and responsibilities of others, and thus be better prepared to offer them
guidance, assistance, and support. Many studies published since the 1991 Centers for Disease Control and Prevention (CDC) report Preventing Lead Poisoning in Young Children (1) have provided updated or new information that can assist case managers of affected children and their families. In response, some states and localities have implemented a variety of changes in case management procedures. The plethora of new information and the marked variation in assessment and management policies among various jurisdictions were the main stimuli for the development of these guidelines. This report is divided into five chapters other than this introduction: four that present assessment and intervention guidelines from environmental, medical, nutritional, and developmental viewpoints plus one that presents caregiver education guidelines. Experts in each subject area were asked to summarize recommended case management actions; to provide a detailed, referenced basis for their recommendations; and to suggest the most important areas for future research to support, modify, or eliminate poorly justified or empirically based recommendations. Recommendations in each chapter are based on the results of evidence-based studies wherever possible. The most convincing basis for a specific recommendation is data from prospective, randomized, controlled trials. Unfortunately, such data are scarce; therefore, experts who developed each chapter had to rely primarily on softer data from cross-sectional studies, cohort or case controlled studies, uncontrolled studies, epidemiologic data, and—if appropriate—case reports or animal studies. They were also asked to note whether studies of interventions used to support their recommendations were efficacy studies (studies performed under ideal conditions) or effectiveness studies (studies performed in ordinary settings). In the absence of sufficient study data, the opinions of respected authorities were considered in the formulation of these recommendations. Recommendations, particularly those not based on controlled studies, were often modified by the ACCLPP working group and subsequently by the full committee. Thus, in their final form, the recommendations in this report represent the consensus of the ACCLPP rather than individual opinions of the authors of each chapter. |
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This report is written
primarily for those who will provide case management for children with
EBLLs and for health department personnel who oversee case management
follow-up. Because there is unavoidable overlap among chapters, interested
professionals may gain insight from chapters covering areas outside their
own expertise. For example, a nutritionist or a PCP will find iron stores
and anemia discussed in both the medical and the nutritional sections. Although the primary cause of EBLLs in children is exposure to deteriorated paint in housing built before 1950, other sources of lead are found in some states and localities. Consequently, users of these guidelines may need to modify them to meet the needs unique to specific communities. Further, because the prevalence of EBLLs among children will vary markedly among and within states, the number of children managed will show corresponding variation. Because there is no apparent threshold below which adverse effects of lead do not occur, "EBLL" must be defined arbitrarily. This report uses the definition given in the 1997 CDC report Screening Young Children for Lead Poisoning (2), which defined child blood lead levels (BLLs) >=10 µg/dL as elevated. Although the BLL at which particular elements of case management will be initiated is variable, education and follow-up BLL monitoring should be available for any child who has a confirmed BLL >=10 µg/dL. More intense management, including home visiting and environmental investigation, should be available to any child with a BLL >=20 µg/dL, or persistent levels in the 15 to 19 µg/dL range. Another variable, the duration of management, will depend on the effects of lead on the child being treated. As noted in Chapter 5, "Developmental Assessment and Interventions," the effect of lead on a child may not be demonstrable until the child is well into the elementary school years, meaning that some children will need continued tracking by PCPs or others long after their case management ends. The interventions recommended in this report are for the secondary prevention of EBLLs—which is to prevent further lead exposure and to reduce BLLs in children who have been identified as having EBLLs—and involve a number of scientific, technical, and implementation issues. The ultimate goal, primary prevention—the removal of harmful lead exposure sources (especially older, deteriorated housing) and the elimination of lead from products with which children may come in direct or indirect contact—involves other, sometimes overlapping, issues. The importance of primary prevention should not be overlooked, since the behavioral and cognitive effects of EBLLs in young children are apparently irreversible. Overview of Comprehensive Case Management What Is Case Management?
Case management of
children with EBLLs involves coordinating, providing, and overseeing the
services required to reduce their BLLs below the level of concern (i.e.,
10 µg/dL). It is based on the efforts of an organized team that includes
the child’s caregivers. A hallmark of effective case management is
ongoing communication with the caregivers and other service providers, and
a cooperative approach to solving any problems that may arise during
efforts to decrease the child’s BLL and eliminate lead hazards in the
child’s environment. Case management is not simply referring a child to
other service providers, contacting caregivers by telephone, or other
minimal activities.
An environmental inspector should also visit the child’s residence, with the case manager if possible, to conduct a thorough investigation of the site and identify sources of environmental lead exposure. The case management team can then use the results of this investigation to develop a plan to protect the child and correct hazardous conditions. Although environmental services may be provided by the case manager, the environmental inspector, or other program staff, the case manager is responsible for ensuring that a child receives services in a timely fashion. Funding
Nationally, an estimated
83% of children with BLLs >=20 µg/dL are eligible for Medicaid
(4). Both the case management of eligible children and the environmental
investigation of their surroundings are reimbursable according to federal
Medicaid policy, with each state responsible for setting reimbursement
rates for eligible services. Who Provides Case Management?
Ninety percent of
programs use professionals (nurses or social workers) to deliver case
management services (6). The case manager is usually a member
of the local health department staff, although nearly half of all states
also use other providers to deliver case management services. Time Frames for Initiating Case Management Services A case manager should schedule an appointment with the child’s caregiver as soon as possible after being assigned to the case. Where feasible, public health agencies providing case management services should give priority to children with the highest BLLs and those less than 2 years of age. If the caregiver does not have a telephone, the case manager should visit the child’s home and leave information at the door if no one is there. For children with BLLs >=45 µg/dL, the case manager should contact the child’s PCP immediately to determine whether the child is being chelated at home or in the hospital. If the child is hospitalized, the initial visit may take place at the hospital. However, it is critical that team members conduct a hazard assessment in the child’s home as quickly as possible. (See Chapter 2, "Assessment and Remediation of Residential Lead Exposure," and Chapter 3, "Medical Assessment and Interventions.")
*two venous BLL measurements at this level more than 3 months apart The Case Management Plan The case manager is responsible for developing and implementing a written management plan based on a needs assessment done at visits to the child’s home and other sites where the child spends significant amounts of time. Although all cases require a minimum of two home visits, additional visits are often necessary. The caregivers also should be involved in developing the plan to ensure that it is realistic and meets their perceived needs. Areas the plan should cover are detailed in Table 1.1 and in specific sections of this report. Coordination of Care by the Case Manager The case manager is responsible for coordinating care and ensuring that all team members, including the caregiver, stay in communication and work together. Such communication includes verbal consultations with and written summaries of progress for team members. Case managers need not directly provide all follow-up care, but they are responsible for seeing that needed care is provided, including medical follow-up. In most jurisdictions, the environmental inspector or program issues and enforces lead hazard remediation orders. The case manager must be sufficiently knowledgeable about environmental investigation and follow-up, however, to ensure that inspection and remediation take place in a timely fashion and that short-term efforts are made to decrease an affected child’s exposure to lead hazards. Similarly, the case manager is responsible for ensuring that someone follows up on referrals for other problems identified during case management. Case Closure It often takes an extended period of time to complete all the elements in a case management plan. When the environmental lead hazards have been eliminated, the child’s BLL has declined to below 15 µg/dL for at least 6 months, and other objectives of the plan have been achieved, the case should be closed. However, the case manager should discuss with the PCP and caregiver provisions for appropriate long-term developmental follow-up. (See Chapter 5, "Developmental Assessment and Interventions".) Case closure criteria should also include provisions for administrative closeout if at least three documented attempts to locate or gain access to the child and caregiver have failed. Public Health Agency Role Although the recommended public health agency activities are not part of case management per se, they are necessary to achieve optimum results. With their focus on the core public health functions of assessment, policy development, and quality assurance, public health agencies play a broad role in coordinating care at the state and local level. They also are responsible for initiating and implementing laws and regulations that will help to eliminate childhood lead poisoning. Local jurisdictions must have the political will to take enforcement actions, where needed, to protect the health of children. The identification of affected children and exposure sources will have little impact unless lead hazards are eliminated in a timely manner. Public health agencies should take the following steps to coordinate care in six areas:
There are several guiding principles to consider when making recommendations for children with EBLLs. First, interventions should be directed at children whose risk for lead exposure is high. Second, where possible, interventions should be targeted at children less than 2 years old because neurotoxicity is greater and lead exposure is more likely to result in a rapid increase in BLLs in very young children. Finally, when intervention recommendations are based on tenuous data or on expert opinion, as are some in this document, case managers and other involved professionals should more than ever remember primum non nocere (first, do no harm). Most children with EBLLs come from economically disadvantaged families who may have difficulty meeting the daily challenges of life and who may be overwhelmed if presented with a long list of interventions. Further, as has been found in many studies of interventions to combat other childhood problems (injury prevention, dietary counseling), behavioral change recommendations usually have only a modest effect at best. Thus, better results may be achieved by focusing on the most important recommendations (usually those designed to eliminate environmental lead hazards) and assisting caregivers in implementing them. Encouraging and supporting families without making them feel guilty for their child’s EBLL or making unrealistic demands on them may offer the greatest benefit to the child. 1. CDC. Preventing lead poisoning in young children. Atlanta, Georgia: US Department of Health and Human Services, CDC; 1991. 2. CDC. Screening young children for lead poisoning: guidance for state and local public health officials. Atlanta, Georgia: US Department of Health and Human Services, CDC; 1997. 3. Weil M, Karls JM. Case management in human service practice. San Francisco, CA: Jossey Bass Publishers; 1985. 4. US General Accounting Office (GAO). Medicaid: elevated blood lead levels in children. GAO/HEHS-98-78. Washington, DC: GAO; 1998. 5. National Center for Lead-Safe Housing. Another link in the chain update: state policies and practices for case management and environmental investigation for lead-poisoned children. Washington, DC: Alliance to End Childhood Lead Poisoning and the National Center for Healthy Housing; 2001. 6. Alliance To End Childhood Lead Poisoning, the National Center for Lead-Safe Housing. Another link in the chain: state policies and practices for case management and environmental investigation for lead-poisoned children. Washington, DC: Alliance to End Childhood Lead Poisoning and the National Center for Lead-Safe Housing;1999: p. 33. 7. Epstein SG, Taylor AB, Brown MJ. Coordinating care from clinic to community. Boston, MA: New England SERVE, Rhode Island Department of Health; 1998. Table 1.1. Possible Elements of a Case Management Plan Based on Individualized Child Assessment
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