Preventing Lead Poisoning in Young Children: Chapter 1

• Table of Contents
• Chapter 1. Introduction
  • Summary
  • References
• Chapter 2. Background
• Chapter 3. Sources and Pathways of Lead Exposure
• Chapter 4. The Role of the Pediatric Health-Care Provider
• Chapter 5. The Role of State and Local Public Agencies
• Chapter 6. Screening
• Chapter 7. Diagnostic Evaluation and Medical Management of Children with Blood Lead Levels > or = to 20 µg/dL
• Chapter 8. Management of Lead Hazards in the Environment of the Individual Child
• Chapter 9. Management of Lead Hazards in the Community
• Appendix I. Capillary Sampling Protocol
• Appendix II. Summary for the Pediatric Health-Care Provider
• Tables
• Figures

Chapter 1. Introduction

Childhood lead poisoning is one of the most common pediatric health problems in the United States today, and it is entirely preventable. Enough is now known about the Sources and Pathways of Lead Exposure and about ways of preventing this exposure to begin the efforts to eradicate permanently this disease. The persistence of lead poisoning in the United States, in light of all that is known, presents a singular and direct challenge to public health authorities, clinicians, regulatory agencies, and society.

Lead is ubiquitous in the human environment as a result of industrialization. It has no known physiologic value. Children are particularly susceptible to lead's toxic effects. Lead poisoning, for the most part, is silent: most poisoned children have no symptoms. The vast majority of cases, therefore, go undiagnosed and untreated. Lead poisoning is widespread. It is not solely a problem of inner city or minority children. No socioeconomic group, geographic area, or racial or ethnic population is spared.

Previous lead statements issued by the Centers for Disease Control (CDC) have acknowledged the adverse effects of lead at lower and lower levels. In the most recent previous CDC lead statement, published in 1985, the threshold for action was set at a blood lead level of 25 µg/dL, although it was acknowledged that adverse effects occur below that level. In the past several years, however, the scientific evidence showing that some adverse effects occur at blood lead levels at least as low as 10 µg/dL in children has become so overwhelming and compelling that it must be a major force in determining how we approach childhood lead exposure.

This document provides guidelines on childhood lead poisoning prevention for diverse groups. Public health programs that screen children for lead poisoning look to this document for guidance on screening regimens and public health actions. Pediatricians and other health-care practitioners look to this document for information on screening and guidance on the medical treatment of poisoned children. Government agencies, elected officials, and private citizens seek guidance about what constitutes a harmful level of lead in blood—what the current definition of lead poisoning is and what blood lead levels should trigger environmental and other interventions.

It is not possible to select a single number to define lead poisoning for the various purposes of all these groups. Epidemiologic studies have identified harmful effects of lead in children at blood lead levels at least as low as 10 µg/dL. Some studies have suggested harmful effects at even lower levels, but the body of information accumulated so far is not adequate for effects below about 10 µg/dL to be evaluated definitively. As yet, no threshold has been identified for the harmful effects of lead.

Because 10 µg/dL is the lower level of the range at which effects are now identified, primary prevention activities—communitywide environmental interventions and nutritional and educational campaigns—should be directed at reducing children's blood lead levels at least to below 10 µg/dL. Blood lead levels between 10 and 14 µg /dL are in a border zone. While the overall goal is to reduce children's blood lead levels below 10 µg/dL, there are several reasons for not attempting to do interventions directed at individual children to lower blood lead levels of 10-14 µg/dL. First, particularly at low blood lead levels, laboratory measurements may have some inaccuracy and imprecision, so a blood lead level in this range may, in fact, be below 10 µg/dL. Secondly, effective environmental and medical interventions for children with blood lead levels in this range have not yet been identified and evaluated. Finally, the sheer numbers of children in this range would preclude effective case management and would detract from the individualized follow up required by children who have higher blood lead levels.

The single, all-purpose definition of childhood lead poisoning has been replaced with a multitier approach, described in Table 1-1. Community prevention activities should be triggered by blood lead levels > or = to 10 µg/dL. Medical evaluation and environmental investigation and remediation should be done for all children with blood lead levels > or = to 20 µg/dL. All children with blood lead levels > or = to 15 µg/dL should receive individual case management, including nutritional and educational interventions and more frequent screening. Furthermore, depending on the availability of resources, environmental investigation (including a home inspection) and remediation should be done for children with blood lead levels of 15-19 µg/dL, if such levels persist. The highest priority should continue to be the children with the highest blood lead levels.

Other differences between the 1985 and 1991 statements are as follows:

Screening test of choice: Because the erythrocyte protoporphyrin level is not sensitive enough to identify children with elevated blood lead levels below about 25 µg/dL, the screening test of choice is now blood lead measurement.

Universal screening: Since virtually all children are at risk for lead poisoning, a phase in of universal screening is recommended, except in communities where large numbers or percentages of children have been screened and found not to have lead poisoning. The full implementation of this will require the ability to measure blood lead levels on capillary samples and the availability of cheaper and easier-to-use methods of blood lead measurement.

Primary prevention: Efforts need to be increasingly focused on preventing lead poisoning before it occurs. This will require communitywide environmental interventions, as well as educational and nutritional campaigns.

Succimer:: In January, 1991, the U.S. Food and Drug Administration approved succimer, an oral chelating agent, for chelation of children with blood lead levels over 45 µg/dL.

Childhood lead poisoning prevention programs have had a tremendous impact on reducing the occurrence of lead poisoning in the United States. Because of these programs, deaths from lead poisoning and lead encephalopathy are now rare. These programs have targeted high-risk children for periodic screening; provided education to caretakers about the causes, effects, symptoms, and treatments for lead poisoning; and ensured medical treatment and environmental remediation for poisoned children. Screening and medical treatment of poisoned children avid remain critically important until the environmental sources most likely to poison children are eliminated.

Federal regulatory and other actions have resulted in substantial progress in reducing blood lead levels in the entire U.S. population. In the last two decades, the virtual elimination of lead from gasoline has been reflected in reductions in blood lead levels in children and adults. Lead levels in food have also decreased since most manufacturers stopped using leaded solder in cans and since atmospheric deposition of lead on food crops declined as a result of reductions of lead in gasoline. In 1978, the Consumer Product Safety Commission banned the addition of lead to new residential paint.

Nevertheless, important environmental sources and pathways of lead remain. Lead-based paint and lead-contaminated dusts and soils remain the primary Sources and Pathways of Lead Exposure for children. In addition, children continue to be exposed to lead through air, water, and food, as well as occupations and hobbies of parents and caretakers. The focus of prevention efforts, therefore, must expand from merely identifying and treating individual children to include primary prevention—preventing exposure to lead before children become poisoned. This will require a shared responsibility among many public and private agencies. Public agencies will have to work with pediatric health-care providers to identify communities with childhood lead-poisoning prevention problems and unusual sources of lead and to ensure environmental followup of poisoned children. Public housing and economic development agencies will have to integrate lead paint abatement into housing rehabilitation policies and programs. Health-care providers will need to phase in virtually universal screening of children. Public and private organizations must continue to develop economical and widely-available blood lead tests to make such screening possible. Public and private housing owners must bear a portion of the financial burden for abatement.

The changes in this statement are not meant to create an enormous burden on primary pediatric health-care providers. These changes will only be useful if public health and other agencies effectively complement health-care providers' activities. Several efforts have begun to increase federal support of childhood lead poisoning prevention programs and of followup activities. Ongoing efforts to develop infrastructure and technology by the public and private sectors include 1) the development of inexpensive, easy-to-use portable methods for measuring blood lead levels; 2) the development of training and certification programs for lead paint inspectors and abatement contractors; and 3) the development and testing of new abatement methods, including encapsulants. The changes in this statement are also not meant to increase the emphasis on screening of children; the long-term goal of this statement is prevention. Until primary prevention of childhood lead poisoning can be achieved, however, increased screening and followup of poisoned children is essential.

In February 1991, the U.S. Department of Health and Human Services released a Strategic Plan for the Elimination of Childhood Lead Poisoning (HHS, 1991). This plan describes the first 5 years of a 20-year societywide effort to eliminate this disease. It places highest priority on first addressing the children at greatest risk for lead poisoning. The U.S. Department of Housing and Urban Development (HUD, 1990) and the Environmental Protection Agency (EPA, 1991) have both released plans dealing with the elimination of lead hazards. To eliminate this disease will require a tremendous effort from all levels of government as well as the private sector, but we believe that the benefits to society will be well worth it. We look forward to the day when childhood lead poisoning is no longer a public health problem.

References

CDC (Centers for Disease Control). Preventing lead poisoning in young children: a statement by the Centers for Disease Control. Atlanta: CDC, 1985; CDC report no. 99-2230.

EPA (Environmental Protection Agency). Strategy for reducing lead exposures: report to Congress. Washington (DC): EPA, 1991.

HHS (U.S. Department of Health and Human Services). Strategic plan for the elimination of childhood lead poisoning. Atlanta: CDC, 1991.

HUD (U.S. Department of Housing and Urban Development). Comprehensive and Workable plan for the abatement of lead-based paint in privately owned housing: report to Congress. Washington (DC): HUD, 1990.