Physician's Handbook on Childhood Lead Poisoning Prevention
Chapter Three
Risk Assessment and Anticipatory Guidance
Risk Assessment and Anticipatory Guidance
Summary
In addition to universal blood lead testing of all one- and two-year old children, assessment of risk for high-dose lead exposure should be incorporated into routine pediatric care for children ages six months to six years (see next page for risk assessment questions).
Parents should be provided with anticipatory guidance which emphasizes precautions that all families can take to reduce their children's lead exposure.
Children found to be at risk for high-dose lead exposure should be screened with a blood lead test whenever such risk is identified.
Anticipatory guidance should include:
- the effects of lead poisoning on young children;
- the sources of lead in the environment;
- the pathways by which lead enters a child's body; and
- ways to prevent or decrease ingestion and absorption of lead.
Parents/guardians can decrease lead ingestion by:
- frequent washing of their children's hands and toys;
- housecleaning (damp mopping and damp dusting) to reduce house dust especially on window sills and in window wells; and
- close supervision of children to reduce their hand-to-mouth activities.
Parents may reduce absorption of ingested lead by providing a diet rich in calcium, iron, vitamin D and providing healthy snacks between meals.
Risk Assessment and Anticipatory Guidance
Risk Assessment
Assessment of risk for high-dose lead exposure should be incorporated into routine pediatric care. Parents should be provided with anticipatory guidance which emphasizes precautions all families can take to reduce children's lead exposure.
Assessment of risk for high-dose lead exposure should be done at each well-child visit, beginning at six months of age. The 1991 CDC Statement suggested five questions to assess risk of high-dose lead exposure. The DOH/AAP District II Task Force recommended use of the five questions from CDC and added a sixth.
- Does your child live in or regularly visit a house with peeling or chipping paint built before 1960? This could include a day care center, preschool, the home of a babysitter or a relative.
- Does your child live in or regularly visit a house built before 1960 with recent, ongoing or planned renovation or remodeling?
- Does your child have a brother or sister, housemate or playmate being followed or treated for lead poisoning?
- Does your child frequently come in contact with an adult whose job or hobby involves exposure to lead? Occupational examples are house painting, renovations, construction, welding or pottery making. Hobby examples are making stained glass or pottery, fishing, making firearms and collecting lead figurines.
- Does your child live near an active lead smelter, battery recycling plant or other industry likely to release lead?
- Does your child live near a heavily traveled major highway where soil and dust may be contaminated with lead?
Additional questions should be asked when there are conditions in the community known to be conducive to high-dose lead exposure. For example, in New York City, a provider may also ask if a child lives near a bridge or elevated train where soil or dust may be contaminated with lead.
If the answer to any of the above questions is yes, then the child is considered to be at risk for high-dose lead exposure and should be screened with a blood lead test when such risk is identified. The need for sibling screenings should also be considered.
Whether or not answers to the risk assessment questionnaire indicate that a child is at risk for high-dose lead exposure, the child should be routinely screened with a blood lead test at 12 months and at 24 months of age, unless the child is already being followed for elevated lead levels.
Anticipatory Guidance
Information regarding the major causes of lead poisoning and ways to prevent lead exposure should be provided to parents of all children aged six months to six years of age as part of routine primary care.
Affirmative answers to the risk assessment questions may provide the practitioner with clues regarding what information should be stressed as part of the anticipatory guidance portion of the encounter.
The following outline gives information that may be included in discussions about lead risk reduction with families:
EFFECTS OF LEAD POISONING
- Growth and development - may slow a child's physical and intellectual growth; at very high levels may cause mental retardation.
- Behavior - may cause irritability, attention deficit and/or hyperactivity.
- Bone marrow - interferes with red blood cell production.
- Kidney - may cause tubular damage, interferes with vitamin D metabolism.
- Ear - may cause hearing deficits.
SOURCES & PATHWAYS OF LEAD
Sources
- Lead-based paint - exists in older housing. Hazards are increased by sanding, scraping or burning paint during renovation. Deteriorating paint may flake and create dust. Children may chew on painted surfaces or transfer the dust to their mouth after touching these surfaces.
- Soil or dust - contaminated by automobile exhaust and by the weathering and deterioration of lead-based paint.
- Drinking water - corrosive water in contact with lead pipes or lead soldered pipes.
- Occupation and hobbies - construction or demolition workers or workers in smelters, foundries, battery factories and other lead-related industries may bring home highly concentrated lead dust on their skin or clothing. Engaging in artwork with stained glass and ceramics, fishing weights or hunting shot may result in lead exposure.
- Airborne lead - may result from industries such as smelters, battery burning, housing demolition or from home rehabilitation and repair.
- Food - acidic food in contact with lead containing pottery, glass or antique pewter can contain elevated levels of lead. Imported foods may come in lead soldered cans. Water used in cooking, food preparation and formula preparation may add to the lead content of food.
- Folk remedies.
Pathways of lead absorption
- Ingestion - principal route of lead absorption. Small children put things into their mouths which transfers lead - laden dust from the environment into their bodies.
- Inhalation - another important route of lead exposure. Lead-laden dust may be absorbed through the lungs. Dust may be increased during building renovation. Normal cleaning, vacuuming or sweeping may also increase lead dust.
- Maternal-fetal transfer - lead crosses the placenta.
WAYS TO PREVENT OR DECREASE EXPOSURE
- Frequent handwashing - decreases lead dust on the hands. Recommend handwashing before meals and snacks, after outdoor play and three or four times a day.
- Housecleaning and dusting - by wet mopping and damp dusting. Recommend thorough cleaning of floors, window sills and window wells, kitchen floors and counter tops with a solution containing a heavy duty household cleaner. Cleaners high in phosphate work particularly well. However, most cleaning products contain no more than trace amounts of phosphate, except for automatic dishwashing detergent. If lead dust is suspected, avoid the use of regular vacuum cleaners that may spread the lead dust. Use specially equipped High Efficiency Particulate Air (HEPA) vacuums to clean-up lead dust. Local health departments have additional information on HEPA vacuums. Wash children's toys every day.
- Lead content in water - can be reduced by running water until cold, at least three minutes before using.
- Workers in occupations involving lead - recommend changing clothes before coming home and washing prior to contact with family members. People who work in painting, construction, plumbing and certain other jobs can be exposed to lead.
- Home repairs - recommend keeping children away from remodeling and renovation sites or hobbies.
DIET COUNSELING (Age Appropriate)
- Increased calcium - recommend 3-4 servings a day from the following: dairy products, dried beans and peas, spinach, collard greens, kale and broccoli. Offer children whole milk between the ages of one- and two-years; then offer low-fat or skim milk.
- Increased iron - recommend beef, poultry, liver, fish, eggs, whole grain and iron-fortified breads, cereals, pasta, spinach, broccoli, collard greens, green peas and raisins.
- Provide healthy snacks between meals because more lead is absorbed from an empty stomach.
PATIENT EDUCATION MATERIALS
The following brochures available from the State Department of Health can be used to review risk reduction information with the parents:
A brochure for parents of infants, entitled, "If You Have a Baby, Get Ahead of Lead," (#2513 [ENG], #2514 [SPA]), explains why lead is harmful to infants and indicates simple household measures to prevent lead poisoning of infants.
A brochure for parents of young children, entitled, "If You Have Children, Get Ahead of Lead," (#2515 [ENG], #2516 [SPA]), explains why lead is harmful to children and the major causes of lead poisoning in children. This brochure also indicates who should have a lead test and explains how the test is done. Simple steps for parents to take to reduce their child's exposure to lead are also described.
A brochure for parents, entitled, "What Your Child's Blood Lead Test Means," (#2526 [ENG], #2527 [SPA]), explains the terminology associated with blood lead tests and interventions that are commonly associated with each category of elevated blood lead levels.
Posters for the public: One (#2524 [ENG], #2525 [SPA]), emphasizes the role of good nutrition in lead poisoning prevention. This poster depicts calcium and iron rich foods. Others (#2522 [ENG], #2523 [SPA]), depict risk reduction measures parents can take to prevent lead poisoning in their children and encourage parents to get their child tested for lead.
A brochure for pregnant women, entitled, "If You're Pregnant, Get Ahead of Lead," (#2511 [ENG], #2512 [SPA]), explains the danger of maternal transfer of lead to the fetus and emphasizes ways to reduce the pregnant woman's risk of lead exposure.
Bibliography
National Center for Education in Maternal and Child Health and Maternal Child Health Bureau, U.S. Department of Health and Human Services (1994). Nutrition and Childhood Lead Poisoning Prevention, A Quick Reference Guide for Health Providers.
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