Physician's Handbook on Childhood Lead Poisoning Prevention

Chapter One

Background Information

Summary

  • Because of their normal hand-to-mouth behavior, children under six years of age are at risk of ingesting lead from their environment.
  • The principal source of lead is lead-based paint. Lead-based paint may contaminate house dust and soil.
  • Other sources that may contribute to a child's lead exposure include: gasoline and industries that may contaminate air and soil; leaded solder and lead service lines that may contaminate drinking water; adult hobbies and occupations that may bring lead into the home; and folk remedies containing lead oxide and lead tetroxide that are used in some communities to treat common illnesses.
  • Exposure to even small amounts of lead can adversely affect children's growth and development, interfere with heme synthesis and directly damage the kidneys and central nervous system.
  • In 1995, more than 518,000 children were screened for lead poisoning in New York State; of these, 3,722 children were found to have confirmed blood lead levels greater than or equal to 20 μg/dL. Approximately 277,000 children or 54 percent of the population less than three years of age were screened.

The New York State Department of Health regulations require pediatric health care providers to screen all one- and two-year olds for elevated blood lead as part of well-child care. Additionally, pediatric health care providers must assess all children six months to six years of age for risk of high-dose exposure to lead and provide lead screening if the child is at risk for high-dose exposure.

Background Information

Population at Risk

Lead poisoning is one of the most prevalent and preventable childhood health problems in New York State.

The rapidly growing and developing organs of infants and toddlers are particularly susceptible to the toxic effects of lead. Because of their normal hand-to-mouth behavior, children six years old and under may ingest lead from their environment and are at greatest risk for lead poisoning.

Environmental Sources of Lead

Children continue to be exposed to environmental lead from past uses, despite the elimination of lead from most gasoline and paint. The principal source of lead exposure today is lead-based paint, principally in older dwellings, and dust from lead-based paint.

Other sources that contribute to children's lead exposure include:

  • lead in soil which originated from leaded paint, gasoline and industrial sources;
  • drinking water contaminated with lead from leaded solder, brass fittings and obsolete leadservice lines;
  • lead brought into the home by adults from occupational lead exposure or engaging in hobbies which use lead materials like stained glass, casting bullets for firearms, paints, pigments and glazes used for creative arts, lead figurines for games and collecting; and
  • folk remedies that contain lead oxide (greta) and lead tetroxide (azarcon) which may be used in some hispanic households to treat "empacho," a gastrointestinal illness.

Lead Poisoning in Children Today

Lead encephalopathy and death from lead poisoning have virtually been eliminated over the past 20 years as a result of screening higher risk children, medical treatment to reduce the body lead burden of children with elevated blood lead levels and environmental intervention to reduce lead exposure. The removal of lead from gasoline and paint manufactured for residential use has been responsible in large part for reducing childhood lead exposure.

More subtle forms of lead poisoning continue to occur. Evidence has accumulated from long term-studies that shows exposure to even small amounts of lead can harm a developing child. Low level exposure can contribute to behavior problems and learning disabilities and has been shown to reduce intelligence. Lead can slow growth, interfere with heme synthesis and directly damage the kidneys and central and peripheral nervous systems.

A concise summary of knowledge and practice is presented in the 1991 Centers for Disease Control and Prevention Statement, "Preventing Lead Poisoning in Young Children." Copies of this document may be obtained from your local health department's Childhood Lead Poisoning Prevention Program or the State Department of Health's Childhood Lead Poisoning Prevention Program in Albany. Also available is the 1997 CDC "Screening Young Children for Lead Poisoning: Guidance for State and Local Officials."

Blood Lead Levels in New York State

New York State is among the leading states in the nation for screening for childhood lead poisoning. The New York State screening rate of children under two years of age for lead poisoning was on average 62 percent during 1996-1999. In addition, among children enrolled in Medicaid Managed Care, childhood lead screening rates were 70 percent in 1998 and 74 percent in 1999.

In New York State (excluding New York City), the number of newly identified children, ages six months to less than six years, with elevated blood lead levels 10 micrograms per deciliter (ug/dL) or greater dramatically declined by 45 percent from 1996-1999 from 6,096 in 1996 to 3,377 in 1999. These children were clustered mostly in urban areas, but children with elevated blood lead readings were found in virtually every county.

The number of children newly identified with lead poisoning, meaning children with blood lead levels of 20 micrograms per deciliter or higher, has decreased by 46 percent from 1,111 in 1996 to 601 in 1999. This represents a decrease in incidence from 55/1,000 (0.55%) to 34/1,000 (0.35%). The New York City Health Department recently reported a similar decline in the incidence of childhood lead poisoning during the same period.

The complete "Protecting Our Children from Lead: The Success of New York's Efforts to Prevent Childhood Lead Poisoning" is available as an Adobe Acrobat portable document from the Health Department's website.

Summary of New York State Lead Screening and Follow-up Regulations, Part 67-1 and 67-3

Pediatric health care providers are required to:

  • screen all one and two-year olds for blood lead levels as part of well-child care; assess other children six months to six years of age for risk of high-dose exposure to lead (see Chapter 3 to determine risks for high-dose lead exposure) and provide lead screening as indicated;
  • ensure that all children six months to six years of age are appropriately screened by inquiring about lead screening status when children present for emergent or episodic care to nonprimary care providers;
  • provide parents with written documentation of blood lead testing; providers may use the New York State lead screening certificate, the revised immunization record or another parent-held child health record to indicate proof of a blood lead test;
  • provide risk reduction education and nutrition counseling to parents of children with blood lead levels of ten micrograms per deciliter or greater (μg/dL or mcg/dL);
  • provide follow-up testing to children with blood lead levels 10 μg/dL or greater in accordance with currently accepted medical standards and public health guidelines;
  • confirm fingerstick blood lead levels equal to or greater than 15 μg/dL with a venous sample;
  • provide a complete diagnostic evaluation, a detailed lead exposure assessment, a nutritional assessment and a developmental screening if a child has a blood lead level 20 μg/dL or greater; provide medical treatment as indicated;
  • refer children who have a confirmed blood lead level of 20 μg/dL or greater to the appropriate local or state health unit for environmental assessment and management; and
  • notify the local health unit of a blood lead level result greater than 45 μg/dL within 24 hours.

(See Appendix A and B for NYS Laws and Regulations.)

Bibliography

Agency for Toxic Substances and Disease Registry (1988). The Nature and Extent of Lead Poisoning in Children in the United States: A Report to Congress. (DHHS Publication No: 99-2926), Atlanta, GA.

Bellinger, D.S., & Needleman, H.L. (1992) Neurodevelopmental effects of low-level lead exposure in children. Human Lead Exposure. Boca Raton: CRC Press.

Huseman, C.A., Varma, M.M., & Angel, C.R. (1992). Neuroendocrine effects of toxic and low blood lead levels in children. Pediatrics. 90, 186-189.

Needleman, H.L., & Landrigan, P.J. (1981). The health effects of low level exposure to lead. Annual Review of Public Health, 2, 277-298.

Schwartz, J., & Otto, D. (1987). Blood lead, hearing thresholds and neurobehavioral development in children and youth. Archives of Environmental Health 42, 153-160.

Suggested Reading List

General

Cullen, M.R., Robins, J.M., & Eskenazi, B. (1983). Adult inorganic lead intoxication: presentation of 31 new cases and a review of recent advances in the literature. Medicine (Baltimore), 62, 221-47.

Gerber, G.B., Leonard, I.A., & Jacquet, P. (1980). Toxicity, mutagenicity and teratogenicity of lead. Mutation Research, 76, 115-41.

Kehoe, R.A. (1972) Occupational lead poisoning: clinical types. Journal of Occupational Medicine, 14, 298-300

Piomelli, S., Needleman, H.L., & Rosen, J.F. Lead poisoning (1988). American Academy of Pediatrics Update (audiotape available), 9, (No.4):1-9.

Putnam, R.D. Review of toxicology of inorganic lead. American Industrial Hygiene Association Journal, 47, 700-703.

Neurobehavioral Development

Bellinger, D., Leviton, A., Waternaux, C., Needleman, H., & Rabinowitz, M. (1987) Longitudinal analyses of prenatal and postnatal lead exposure and early cognitive development. New England Journal of Medicine, 316, 1037-43.

Needleman, H.L., Gunnor, C., & Leviton, A., et al. (1979). Deficits in psychologic and classroom performance of children with elevated dentine lead levels. New England Journal of Medicine, 300, 689-695.

Needleman, H.L., Schell, A., Bellinger, D., Leviton, A., & Allred, E.N. (1990) The long-term effects of exposure to lead in childhood. An 11-year follow-up report. New England Journal of Medicine, 322, 83-88.

Schwartz, J., & Otto, D. (1987) Blood lead, hearing thresholds, and neurobehavioral development in children and youth. Archives of Environmental Health, 42, 153-159.

Hematological Effects

Moore, M.R., Goldberg, A., & Yeung-Laiwah, A.C. (1985): Lead effects on the heme biosynthetic pathway. Annals of the New York Academy of Sciences, 191-202.

Nephropathy

Lurakis, M.F., & Pitone, J.M. (1984) Occupational lead exposure, acute intoxication, and chronic nephropathy: report of a case and review of the literature. Journal of the American Osteopathic Association, 83, 361-366.

Mitchell, J.W., ed. (1987) Occupational medicine forum: lead toxicity and reproduction. Journal of Occupational Medicine, 29, 397-399.

Uzych, L. (1985) Teratogenesis and mutagenesis associated with the exposure of human males to lead: a review. Yale Journal of Biology and Medicine, 58, 9-17.

Sources of Lead Exposure

Kunkel, D.B. The toxic emergency. (1986), Emergency Medicine, 18, 207-217.

Drinking Water

Marcus, W.L. Lead health effects in drinking water. (1986), Toxicology and Industrial Health, 2, 363-400

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