By Coverys Risk Management

Lead toxicity among children in the United States has been a public health issue for decades, and one that continues to shine a glaring light on healthcare disparities between socioeconomic groups. A disproportionate number of the more than 500,000 children estimated to have elevated lead levels are black, migrants, refugees, foreign adopted, and/or on Medicaid. However, lead poisoning is not confined to these demographics and it’s important to consider ways to enhance your screening, testing, and education protocols.

Here are four considerations for your medical practice:
  1. Nutrition impacts absorption of lead. It’s important to provide appropriate nutrition counseling to all families, regardless of risk for elevated blood lead level (BLL). A well-balanced diet is essential for all children and certain vitamins and minerals ― especially calcium, iron and vitamin C ― play a specific role in minimizing lead absorption. Regular assessment of the child’s nutritional status during well-child care can identify children with inadequate intake of these and other nutrients, and allow you to proactively recommend supplementation.
  2. Restoration of older homes is putting more children at risk. While screening standards should still be structured upon what we know about the socioeconomics of lead poisoning (i.e., with particular attention to children who are black, migrants, refugees, foreign adopted and/or on Medicaid), our screening criteria must become broader. An increasing trend to purchase and renovate older homes means that children in all walks of life are being exposed to lead-based paint, drinking water tainted with lead, and other sources of toxicity.
  3. Insurance guidelines put lead testing within reach for most families. Under the Affordable Care Act*, lead testing is considered a preventative service, and most insurance companies (inclusive of Marketplace and Medicaid) must provide coverage at no cost to high risk children.
  4. Your zip code matters. Find out if your medical practice is located in or near a high-risk zip code (most states maintain such zip code lists, which are available online). And consider whether there’s more you can do to partner with public health and parents to address risk in your broader community.
Back to Basics: A Quick Review of What You Can Do About Pediatric Lead Poisoning
If your medical practice is like most, you changed your frame of reference when the Centers for Disease Control and Prevention (CDC) lowered the threshold for blood lead toxicity from 10 µg per dL to 5 µg per dL (micro grams per deciliter of blood) in 2012, but you changed very little else.

When it comes to reducing the high incidence of lead poisoning among children in America, there are three key things to keep in mind:
  1. Screening and education make a world of difference. As a physician, there’s much you can do to help families understand whether their children are at risk of lead poisoning. Risk questionnaires and improved educational efforts in your office can leave you and the families in your care better informed, and ultimately safer.
  2. Testing is simple, typically covered by insurance, and should be part of the preventive healthcare for all children at high risk. Vigilance in testing at-risk children (e.g., those under the age of six and those whose environment may expose them to lead) is a responsibility that falls heavily to pediatricians and family physicians. A simple blood test can yield vital information about lead toxicity.
  3. Physicians are important members of a larger team needed to address lead exposure. The effects of lead exposure ― which can include cognitive deficiencies that impact reading, vocabulary, fine motor skills, reaction time, and hand-eye coordination ― are irreversible. As such, it’s imperative that the United States does all it can to prevent exposure. While physicians and other healthcare professionals cannot create or enforce environmental legislation, their efforts in educating families and identifying sources of lead exposure among their patients helps to protect entire communities.
A Smart Screening Strategy
It is recommended, by the CDC and others, that annual check-ups with pediatric patients (particularly those aged six and younger) include asking the parent or guardian the following questions:
  1. Does your child live in or regularly visit homes built before 1950?
  2. Does your child live in or regularly visit a home built before 1978 that has had recent or ongoing renovation?
  3. Does your child have a sibling or playmate who has had lead poisoning?
  4. Does your child spend time with an adult whose job exposes him or her to lead? (Examples: construction, painting, metalwork.)
If the answer to any of these questions is “yes,” the child should receive a blood test to measure his or her lead level. (It should be noted that, because there is a potential for exposure to infants in utero, OB/GYNs should also be asking similar questions to pregnant patients.)

When determining whether to test a patient for lead, also consider the following in your decision-making:
  • The CDC recommends that all children on Medicaid be tested because of a high correlation between poverty and elevated blood lead levels (BLL).
  • Black children have twice the risk of having elevated BLL.
  • Migrants, refugees, and foreign-adopted children are at high risk as well.
  • Any child living in a home built before 1978 is potentially at risk for exposure.
What You Should Know About Testing
For children who are considered at high risk of exposure, annual testing is recommended. Venous blood samples are preferred but finger sticks, when performed properly, can be an effective initial test. If a child tests positive through a finger stick, a follow-up venous sample should be obtained to verify the results.
According to the CDC, “Clinicians should ensure that BLL values at or above the reference value [≥5 µg/dL] are reported to local and state health and/or housing departments if no mandatory reporting exists and collaborate with these agencies in providing appropriate services and resources to children and their families.”

Educational Resources for Your Patients
Knowledge is power. Be sure to maintain a stock of educational brochures for distribution to parents during well-child visits on topics like:
  • Lead sources
  • What to do if you live in a home that was built prior to 1978
  • How to properly clean up lead dust
  • How to renovate safely
The CDC has produced a series of brochures about pediatric lead poisoning that can be downloaded, printed and shared.

And, as suggested previously, you can play an important role in educating families about adequate nutrition and the minimization of lead absorption.

What’s at Stake?
The stakes are high when the potential victims are the littlest and most innocent among us. The CDC reports that children in at least 4 million U.S. households are being exposed to high levels of lead. And while the reference value was lowered to 5 µg per dL in 2012, there is no safe level of lead in the blood. Values as low as 2 µg per dL can reduce IQ.  

There is always more to know and do to keep American children safe from lead poisoning. It’s imperative that physicians screen for risk, test children who are deemed to be at-risk, and educate families about keeping their children healthy.

Pediatricians and family physicians are necessary and important members of a larger team needed to address lead exposure. Remaining vigilant about screening and testing for lead among pediatric patients will make a meaningful difference in the health of countless children.
 
*As of January 2017.
 
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No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.