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Preventing Lead Poisoning in Young Children: Chapter 4


Chapter 4. Role of the Pediatric Health-Care Provider

The Pediatric Health-Care Provider Should

Provide anticipatory guidance about childhood lead poisoning and its prevention.

Provide screening for lead poisoning following established screening schedules.

Conduct appropriate diagnostic blood lead testing in children with symptoms or signs consistent with lead poisoning or pica.

Interpret blood lead results.

Educate parents about reducing blood lead levels.

Coordinate with local public health officials.

Ensure that poisoned children receive appropriate medical, environmental, and social service followup.

Pediatric health-care providers, working as part of the public health team, must play a critical role in the prevention and management of childhood lead poisoning. Their roles include: 1) educating parents about key causes of childhood lead poisoning; 2) screening children and interpreting blood lead test results; 3) working with appropriate groups in the public and private sectors to make sure that poisoned children receive appropriate medical, environmental, and social service followup; and 4) coordinating with public health officials and others involved in lead-poisoning prevention activities.


Anticipatory Guidance

Anticipatory guidance means

Teaching parents about major sources of lead and how to prevent poisoning.

Tailoring guidance to likely hazards in the community.

Pediatric health-care providers consider education to be an integral part of well-child care. Along with educating parents about nutrition and developmental stages, providers should discuss the potential hazards of lead. They should focus on the major preventable sources of high-dose lead poisoning—lead-based paint and take-home exposures from parents' occupations and hobbies. Parents should be told of the potential dangers of peeling lead-based paint, the potential hazards of renovating older homes, and the need for good work practices if their occupations or hobbies expose them to lead. (These sources and pathways of exposure are discussed in Chapter 3.) Other education should be tailored to likely exposures in the community. For example, in some communities parents should be warned about the potential for lead exposure from improperly fired ceramic ware and imported pottery. Where water lead levels are a concern, parents could be advised to use only fully-flushed water (that is, water that has not been standing in pipes for a prolonged time) from the cold-water tap for drinking, cooking, or preparing infant formula.


Screening for Childhood Lead Poisoning

Screening for lead poisoning requires
  • Determining the child's risk for high-dose lead exposure by asking a few questions.
  • Measuring blood lead levels in children who are at the greatest risk for high-dose lead poisoning when they are 6 months old.
  • Measuring blood lead levels in children who are at lower risk for high-dose lead exposure at 12-15 months of age.
  • Conducting necessary followup blood lead testing of children.

The recommended screening schedule is discussed in detail in Chapter 6. Since virtually all children are at risk for lead poisoning, universal screening is recommended, except in communities where large numbers or percentages of children have been screened and found not to have lead poisoning. (A more inexpensive and widely available blood lead test is under development.) Just as pediatric health-care providers ask screening questions about a child's development and eating habits, providers should also ask questions about a child's risk for high-dose lead exposure at every visit. (It is important to ask at every visit, since children's exposures may change over time.) On the basis of the parents' answers to these questions, the pediatric provider will be able to classify most children as being at either high or low risk for high-dose exposure to lead. The highest risk children should be screened starting when they are 6 months old, since that is when blood lead levels begin to rise. Lower risk children should be screened for the first time when they are 12-15 months old. Followup screening schedules should be based on the pediatric health-care provider's assessment of the child's risk for high-dose lead exposure and previous blood lead levels.


Doing Appropriate Diagnostic Blood Lead Testing

Pediatric health-care providers should include lead poisoning in the differential diagnosis of a number of conditions. These include growth failure, developmental delays, hyperactivity, behavior disorders, hearing loss, and anemia. Children with parasites may be exhibiting pica, and the pediatric health-care provider should also consider measuring blood lead levels in such children.


Interpretation of Blood Lead Levels

In interpreting blood lead levels, the provider should

Understand the scientific basis for concern.

Understand the degree of imprecision and inaccuracy in blood lead measurements.

Explain carefully why followup is or is not needed.

The studies which form the basis of our concern about childhood lead poisoning are described in Chapter 2. These studies suggest that adverse effects of lead occur at blood lead levels at least as low as 10 µg/dL. The following paragraphs provide guidance on what might be told to a parent, depending on the blood lead levels of the child.

Blood Lead Level < 10 µg/dL. A blood lead level < 10 µg/dL is not considered to be indicative of lead poisoning.

Blood Lead Level 10-14 µg/dL. Children with blood lead levels in this range are in a border zone. Since the laboratory tests for measuring blood lead levels are not as accurate and precise as we would like them to be at these levels, many of these children's blood lead levels may, in fact, be <10 µg/dL. Although a detailed environmental history should be taken since an obvious remediable source of lead may be found, it is unlikely that there is a single predominant source of lead exposure for most of these children. Thus, a full home inspection is not recommended.

It is, however, prudent to try and decrease exposure to lead with some simple instructions. (The required education can be done face-to-face or by distributing brochures or other written materials.) In addition, these children should receive followup blood lead testing in about 3 months. The adverse effects of blood lead levels of 10-14 µg/dL are subtle and are not likely to be recognizable or measurable in the individual child. It is important to make sure that these children's blood lead levels do not go up.

Example: Johnny was a 12 month old child without any risk factors for high-dose exposure. A capillary blood lead test was performed, and his blood lead level was 14 µg/dL. His pediatrician told his mother that Johnny's blood lead test was in a kind of "border" zone, but that it was high enough to require careful followup. The pediatrician explained that laboratory test results have some inaccuracy and imprecision, but, nevertheless, suggested some housekeeping and nutritional interventions to reduce Johnny's exposure. Johnny had a venous blood lead measurement three months later, which was 7 µg/dL. Three months after that, when Johnny was 18 months old, his blood lead level was 5 µg/dL. His blood lead level was measured one year later and was 5 µg/dL, and he received no further followup.

Blood Lead Level 15-19 µg/dL. Children with venous blood lead levels 15-19 µg/dL need more careful followup. The pediatric health-care provider should take a careful history, asking about sources of lead exposure (Chapter 3). Parents should receive guidance about interventions to reduce blood lead levels (Educating Parents about Reducing Blood Lead Levels). Children with blood lead levels in this range are at risk for decreases in IQ of up to several IQ points and other subtle effects. The effects of lead at these levels are significant enough that the health-care provider should emphasize to parents the importance of followup screening to make sure the levels do not increase. The provider should also discuss interventions to reduce the blood lead levels. In addition, these children should receive followup testing (Chapter 6). If their blood lead levels persist at > or = to 15 µg/dL, environmental investigation and remediation should be completed, if resources permit. In some communities, childhood lead poisoning prevention programs may be able to manage the environmental investigation and remediation.

Blood Lead Level 20-69 µg/dL. Children with venous blood lead levels in this range should have a full medical evaluation (Chapter 7). This includes a detailed environmental and behavioral history (asking about reading or other learning disabilities, language development, pica, etc.), a physical examination, and tests for iron deficiency. Particularly for children needing urgent medical followup (that is, blood lead level > or = to 45 µg/dL), pediatric health-care providers with limited experience in treating lead poisoning should consider referring such children to a clinic with experience in managing childhood lead poisoning. These children should also have complete environmental investigations so that lead hazards can be reduced. The local public childhood lead poisoning prevention programs will often work as a team with the pediatric health-care provider and the child's family to ensure appropriate environmental followup.

Blood Lead Level > or = to 70 µg/dL. Children with blood lead levels this high constitute a medical emergency that preferably should be managed by someone with experience in treating children who are critically ill with lead poisoning. Medical and environmental management must begin immediately (Chapter 7 and Chapter 8).


Educating Parents about Reducing Blood Lead Levels

What can parents do to reduce blood lead levels?

  • Housekeeping interventions to reduce exposure to dust.
  • Interventions to reduce exposure to other sources of lead.
  • Attention to nutrition.

There are many interventions parents can use to help reduce blood lead levels. These interventions are not a substitute for lead hazard abatement.

Housekeeping Interventions

Particularly in older homes, which may have been painted with lead-based paint, interventions to reduce exposure to dust may help reduce blood lead levels. These include:
  • Make sure your child does not have access to peeling paint or chewable surfaces painted with lead-based paint. Pay special attention to windows and window sills and wells.
  • If the house was built before about 1960 and has hard surface floors, wet mop them at least once a week with a high phosphate solution (for example, 5-8% phosphates). (The phosphate content of automatic dish washing detergents and other cleaning substances is often listed on the label and may be high enough for this purpose. Otherwise, trisodium phosphate can be purchased in hardware stores.) Other hard surfaces (such as window sills and baseboards) should also be wiped with a similar solution. Do not vacuum hard surface floors or window sills or wells, since this will disperse dust. Vacuum cleaners with agitators remove dust from rugs more effectively than vacuum cleaners with suction only.
  • Wash your child's hands and face before he/she eats.
  • Wash toys and pacifiers frequently.

Other Interventions to Reduce Exposure to Lead

  • If soil around the home is or is likely to be contaminated with lead (for example, if the home was built before 1960 or the house is near a major highway), plant grass or other ground cover. Since the highest concentrations of lead in a yard tend to be near surfaces that were once painted with lead paint, like exterior walls, if exterior lead paint was likely to be used, plant bushes around the outside of your house so your child cannot play there.
  • In areas where the lead content of water exceeds the drinking water standard, use only fully flushed water from the cold-water tap for drinking, cooking, and making formula. In communities where water conservation is a concern, use the first-flush water for other purposes.
  • Do not store food in open cans, particularly if the cans are imported.
  • Do not use pottery or ceramicware that was inadequately fired or is meant for decorative use for food storage or service.
  • Make sure that take-home exposures are not occurring from parental occupations or hobbies (Chapter 3).

Nutrition

  • Make sure your child eats regular meals, since more lead is absorbed on an empty stomach.
  • Make sure your child's diet contains plenty of iron and calcium.

Examples of Sources of Iron and Calcium
   
Iron
Liver
Fortified cereal
Cooked legumes
Spinach
Calcium
Milk
Yogurt
Cheese
Cooked greens


Coordinating with Public Sector Officials

Public health officials should tell the pediatric health-care provider about

  • The magnitude of the childhood lead poisoning problem in the provider's community.
  • Unusual sources of lead exposure in the provider's community.
  • Public sector services that can be used to ensure appropriate followup for poisoned children.
  • Interventions being conducted through public sector actions for children with lead poisoning.

Pediatric health-care providers should notify public sector officials about

  • Poisoned children they identify.
  • Unusual sources or pathways of exposure they identify.

The responsibilities of public sector officials are described in Chapter 5. These officials are an important source of information for the pediatric health-care provider. They can alert the provider to the extent of the lead poisoning problem in the provider's catchment area. They can provide information about particular lead sources that may be of concern in a given neighborhood. Often these officials can assist in the management of the lead-poisoned child, doing followup screening, conducting environmental investigations, and ensuring lead hazards are abated. They should keep the provider informed of actions they take on the child's behalf. The pediatric health-care provider is responsible for informing public health officials about lead-poisoned children, reporting any unusual sources or pathways of exposure, and reporting elevated blood lead levels, if this is required.


Appropriate Followup

Appropirate followup includes

  • Education.
  • Followup blood lead testing.
  • Medical evaluation, if appropriate.
  • Pharmacologic treatment, if appropriate.
  • Environmental investigation, if appropriate.
  • Referral to infant stimulation or child development programs, if appropriate.
  • Referral for social services.

Not all aspects of a poisoned child's followup will be managed by the pediatric health-care provider, although the provider is an important part of the team. Through his or her interactions with the child and family and the responsible public health agency, the provider should make sure that any appropriate interventions are occurring. The provider should make sure that the family receives education about childhood lead poisoning and ways of preventing it, and he or she should make sure that the child receives the appropriate followup blood lead testing. If the child needs a medical evaluation (for a blood lead level > or = to 20 µg/dL) or pharmacologic treatment (Chapter 7), either the provider should do it or should refer the child to a place that treats large numbers of poisoned children. The provider should make sure that the child receives an appropriate environmental investigation and remediation with the help of the public health agencies. Particularly if the child is developmentally delayed, the provider should refer the child to an appropriate infant stimulation or child development program. In many cases, lead-poisoned children and their families will also benefit from social services followup.


    
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