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L E A D C E N T E R P O I N T Counseling Families: Blood Lead Levels 5-9 mcg/dL Carrin Schottler-Thal MD F A L L - W I N T E R 2 0 1 5 V O L U M E 8 , I S S U E 2 There is no “safe” level of lead in the human body. The body of evidence in the published medical literature demonstrates that levels of lead between 5 and 9 mcg/dL are associated with lower IQ, behavioral problems, and learning problems. In January 2012, an expert committee recommended a change in the blood lead reference value from 10 mcg/dL to 5 mcg/dL. This new level is based on the population of children aged 1-5 years in the U.S. who are in the top 2.5% of children tested. To aid the health care provider in caring for children whose lead level is reported between 5 and 9 mcg/dL, the CDC (2007)1 has suggested that providers: 1) understand the laboratory error range for blood lead values and choose a lab that achieves performance within 2 mcg/dL; 2) obtain an environmental history on all patients; 3) provide lead prevention counseling; 4) follow blood lead screening recommendations for their area (state); 5) consider early referral to developmental programs for children at high risk of exposure to lead; 6) consider more frequent testing of children whose lead levels are approaching 10 mcg/dL; and 7) direct parents to sources of information that will help them establish a lead safe environment for their children. The CDC website has excellent information for parents.2 ( http://www.cdc.gov/nceh/lead/parents.htm) Information on how to counsel families regarding lead in the environment is also provided by the NYSDOH (2009) in the handout entitled “What your Child’s Blood Lead Test Means.”3 According to the NYSDOH, environmental counseling should include the following factors: 1) Lead Paint/Repairs: keep children away from lead paint:, if making repairs on a home built before 1978 call the local DOH, and keep children/pregnant women away from repairs that disturb old paint; 2) Cleaning: wash child’s hands/face after play, before meals and before bed; wash toys, stuffed animals, pacifiers and bottles with soap and water; mop floors often and use damp paper towels to clean window sills; Continued on page 3 Contact Information: Central/Eastern New York Lead Poisoning Prevention Resource Center Howard L. Weinberger MD, Medical Director Maureen J. Butler RN, BSN, Program Coordinator Jean Szkotak, Administrative Assistant Upstate Golisano Children's Hospital Department of Pediatrics Room 5600 750 E. Adams Street Syracuse, NY 13210 Phone: [PHONE REDACTED] Fax: [PHONE REDACTED] E-mail: [EMAIL REDACTED] Carrin Schottler-Thal MD, Assistant Medical Director Hannah DuJack RN, Program Coordinator Jennifer Bub, Administrative Assistant Albany Medical Center 1 Clara Barton Street Albany, NY 12208 Phone: [PHONE REDACTED] Fax: [PHONE REDACTED] E-mail: [EMAIL REDACTED] ---PAGE BREAK--- Page 2 LEAD CENTERPOINT The New York State Department of Health requires blood lead testing for all children, regardless of risk, at the 1 year well child visit and the 2 year well child visit. The most recent document, released in June 2009 summarizes the Public Health Law and Regulation.1 The document clarifies the statewide requirements for lead screening. At each routine visit from six months to six years, children are to be assessed for risk of lead exposure using a seven question format. If the answers to the questions indicate the child may have lead exposure, a blood lead test should be collected. The second part of the public health law states that every child, regardless of risk, is to have a blood lead sample drawn and analyzed at the first and second birthday. Some health care providers believe that there is no need for the second test if the first year blood lead level is < 5 mcg/dl and the child’s home address has not changed. A report released by the New York State Department of Health in May, 2015 2 provides statistics regarding the percentage of children who received the two required blood tests. In the 31 county region of Central and Eastern New York, the percentage is reported as less than 10% in 3 counties. The best testing rate is 58.1% in one county. Why does New York State require a second test if the first year lead level is < 5 mcg/dl? Developmentally, most children become much more active in the second year of life. The child may also be exposed to new lead hazards in day care settings, or relative’s and friend’s homes. Two year olds continue to have developmentally appropriate hand to mouth activity, the most common route of exposure in children. The toxic effects of childhood lead poisoning are primarily subclinical.3 Children are almost always at the time a blood lead level is elevated. Decreased intelligence and behavioral alterations are identified at school entry when the actual lead exposure and subsequent elevated blood lead levels had occurred in the pre-school period. New York State housing remains some of the oldest in the U.S. and the risk of exposure to lead paint continues. Routine blood lead testing at one and two years of age will be necessary for the foreseeable future. 1 NYS Regulations for Lead Poisoning Prevention and Control - Title X, Part 67 Amended effective June 20, 2009. Retrieved from 2 Percentage of children born in 2010 with a lead screening—aged 9—17 months. Source: 2010—2013 NYS Child Health Lead Poisoning Prevention Program Data as of May, 2015. Retrieved from http://www.health.ny.gov/statistics/chac/general/g26.htm 3 Textbook of Children’s Environmental Health, Landrigan, P and Etzel R, Oxford University Press 2013, p. 11. Blood Lead Testing Rates in Central/Eastern New York Maureen Butler RN, BSN ---PAGE BREAK--- Page 3 V O L U M E 8 , I S S U E 2 The impact of low-level lead toxicity on school performance among children in the Chicago Public Schools: a population–based retrospective cohort study. Evens A, Hryhorczuk D, Lanphear BP, Rankin KM, Lewis DA, Forst L, Rosenberg D. Environ Health 2015 April 7. The authors examined the association between blood lead levels and performance on the 3rd grade Illinois Standard Achievement Test in 58,650 children. The study controlled for a number of factors including early pre-term birth and very low birth weight. BPb levels below 10 mcg/dl were inversely associated with reading and math scores in this cohort. With a 5 mcg/dl increase in blood Pb, the risk of failing reading and math increased by 32%. It is estimated that 13% of reading failure and 14.8% of math failure can be linked to blood lead levels of 5-9 mcg/dl versus 0-4 mcg/dl in Chicago school children. Retrospective Investigation of a Lead Poisoning Outbreak from the Consumption of an Ayurvedic Medicine: Durban, South Africa. Mathee A, Naicker N, Teare J. Int. J. Environ. Res. Public Health 2015 Jul 10; 12(7):7804-7813. This article reports on a cluster of elevated blood lead levels, range 34-116 mcg/dl, in a group of adolescents taking ayurvedic medication for acne and other skin conditions. There was delay in diagnosing the lead poisoning until basophilic stippling was observed by a lab technician. This report can be of interest in the U. S. as ayurvedic medications are imported for use and have been identified as contaminated with lead, mercury and/or arsenic. ISEE Call for Action for Global Control of Lead Exposure to Eliminate Lead Poisoning. Rosenthal F, Lanphear B, Gottesfeld P, M, et al Epidemiology 2015 September; 26(5). In this article, the International Society for Environmental Epidemiology (ISEE) calls for a global effort to eliminate lead poisoning. The authors list specific actions all nations need to implement to eliminate lead poisoning. They also call for the goal of the elimination of lead poisoning to be included in the United Nations Sustainable Development Goals. Journal Reviews Maureen Butler RN, BSN Counseling Families (continued) 3) Bringing Lead Home: sign up for children’s product recall alerts (www.cpsc.gov/cpslist); if exposed to lead at work or with hobbies, make sure parents wash work clothes separately, take shoes off at the door, wash face, hands and uncovered skin before going home; 4) Lead in food/water: let tap water run for one minute before using it if it hasn’t been run for a few hours, only use cold tap water for cooking (boiling does not get rid of lead), use lead free dishes (no pewter, or cracked pottery); 5) Serve foods high in calcium, iron, and Vitamin C. 1 C D C , (N o v em b er 2, 2 0 0 7) . I n t e rp r et in g a n d m a n a g in g b l o o d l e a d l e v el s < 10 m c g / d l in c h i l d r en a n d r e d u c in g ch i ld h o o d ex p os u r es t o le a d : r e c om m en d a t i on s o f c d c ' s a d v i s o ry c om m i t t e e on c h il d h o o d l e a d p o is on in g p r e v e n t i on . M M W R 5 6( R R 08 ) ; 1 - 1 4 , 1 6 . 2 C D C ( 20 1 5 ) I n f o rm a t i on F o r P a r en t s . R et r i e v e d f r om h t t p : / /w w w .c d c . g o v /n c e h / l e a d / p a r e n t s . h t m 3 N Y S D OH , ( 2 0 0 9) . W h a t y o u r c h i l d ' s b l o o d l ea d t es t m ea n s . R e t r i e v ed fr om h t t p : / /w w w . h e a lt h . n y .g o v / p ub l ic a t i o ns / 2 5 26 / i n d ex . h t m ---PAGE BREAK--- Central / Eastern New York Lead Poisoning Prevention Resource Center Upstate Golisano Children’s Hospital SUNY Upstate Department of Pediatrics, Room 5600 750 E. Adams Street Syracuse, NY 13210 Address service requested LEAD CENTERPOINT Lead Safety in Rifle and Shooting Sports School pistol and rifle clubs are found in many school districts in the Central and Eastern part of New York State. Teens who participate in these groups should have blood lead tests periodically. The lead released from the bullet when a gun is fired can be inhaled from the air, or ingested when hands are not washed before eating. Those at risk include the members of the shooting club and those who work cleaning the indoor range. In 2012, a committee of experts recommended to the CDC that the reference level of concern be changed from 10 mcg/dl to 5 mcg/dl. The CDC recommends that teens and young adults should keep their lead exposure as low as possible. A lead-safe environment should be created to minimize lead exposure and a blood lead monitoring program should be established for the teens involved in pistol and rifle clubs. Parents should share all blood lead level test results with their child’s health care provider to ensure that any follow-up is undertaken as needed.