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Preventing Lead Poisoning in Young Children |
CHAPTER 4. The Role Of The Pediatric Health-Care Provider | |||||||
Pediatric health-care providers, working as part of the public health team, must play a critical role in the prevention and management of childhood lead poisoning. Their roles include: 1) educating parents about key causes of childhood lead poisoning; 2) screening children and interpreting blood lead test results; 3) working with appropriate groups in the public and private sectors to make sure that poisoned children receive appropriate medical, environmental, and social service follow-up; and 4) coordinating with public health officials and others involved in lead-poisoning prevention activities. |
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Anticipatory
Guidance
Pediatric health-care providers consider education to be an integral part of well-child care. Along with educating parents about nutrition and developmental stages, providers should discuss the potential hazards of lead. They should focus on the major preventable sources of high-dose lead poisoning-lead-based paint and take-home exposures from parents' occupations and hobbies. Parents should be told of the potential dangers of peeling lead-based paint, the potential hazards of renovating older homes, and the need for good work practices if their occupations or hobbies expose them to lead. (These sources and pathways of exposure are discussed in Chapter 3.) Other education should be tailored to likely exposures in the community. For example, in some communities parents should be warned about the potential for lead exposure from improperly fired ceramic ware and imported pottery. Where water lead levels are a concern, parents could be advised to use only fully-flushed water (that is, water that has not been standing in pipes for a prolonged time) from the cold-water tap for drinking, cooking, or preparing infant formula. |
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The recommended screening schedule is discussed in detail in Chapter 6. Since virtually all children are at risk for lead poisoning, universal screening is recommended, except in communities where large numbers or percentages of children have been screened and found not to have lead poisoning. (A more inexpensive and widely available blood lead test is under development.) Just as pediatric health-care providers ask screening questions about a child's development and eating habits, providers should also ask questions about a child's risk for high-dose lead exposure at every visit. (It is important to ask at every visit, since children's exposures may change over time.) On the basis of the parents' answers to these questions, the pediatric provider will be able to classify most children as being at either high or low risk for high-dose exposure to lead. The highest risk children should be screened starting when they are 6 months old, since that is when blood lead levels begin to rise. Lower risk children should be screened for the first time when they are 12-15 months old. Follow-up screening schedules should be based on the pediatric health-care provider's assessment of the child's risk for high-dose lead exposure and previous blood lead levels. |
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Doing
Appropriate Diagnostic Blood Lead Testing Pediatric health-care providers should include lead poisoning in the differential diagnosis of a number of conditions. These include growth failure, developmental delays, hyperactivity, behavior disorders, hearing loss, and anemia. Children with parasites may be exhibiting pica, and the pediatric health-care provider should also consider measuring blood lead levels in such children. |
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Interpretation
Of Blood Lead Levels
The studies which form the basis of our concern about childhood lead poisoning are described in Chapter 2. These studies suggest that adverse effects of lead occur at blood lead levels at least as low as 10 µg/dl The following paragraphs provide guidance on what might be told to a parent, depending on the blood lead levels of the child. BLOOD LEAD LEVEL < 10 µg/dl. A blood lead level < 10 µg/dl is not considered to be indicative of lead poisoning. BLOOD LEAD LEVEL 10-14 µg/dl. Children with blood lead levels in this range are in a border zone. Since the laboratory tests for measuring blood lead levels are not as accurate and precise as we would like them to be at these levels, many of these children's blood lead levels may, in fact, be <10 µg/dL Although a detailed environmental history should be taken since an obvious remediable source of lead may be found, it is unlikely that there is a single predominant source of lead exposure for most of these children. Thus, a full home inspection is not recommended. It is however, prudent to
try and decrease exposure to lead with some simple instructions. (The
required education can be done face-to-face or by distributing brochures or
other written materials.) In addition, these children should receive follow-up
blood lead testing in about 3 months. The adverse effects of blood lead
levels of 10-14 µg/dL are subtle and are not likely to be recognizable or
measurable in the individual child. It is important to make sure that these
children's blood lead levels do not go up.
BLOOD LEAD LEVEL 15-19 µg/dl. Children with venous blood lead levels 15-19 µg/dL need more careful follow-up. The pediatric health- care provider should take a careful history, about sources of lead exposure (Chapter 3). Parents should receive guidance about interventions to reduce blood lead levels (Educating Parents about Reducing Blood Lead Levels). Children with blood lead levels in this range are at risk for decreases in IQ of up to several IQ points and other subtle effects. The effects of lead at these levels are significant enough that the health-care provider should emphasize to parents the importance of follow-up screening to make sure the levels do not increase. The provider should also discuss interventions to reduce the blood lead levels. In addition, these children should receive follow-up testing (Chapter 6). If their blood lead levels persist at greater than or equal to 15 µg/dL, environmental investigation and remediation should be completed, if resources permit. In some communities, childhood lead poisoning prevention programs may be able to manage the environmental investigation and remediation. BLOOD LEAD LEVEL 20-69 µg/dl. Children with venous blood lead levels in this range should have a full medical evaluation (Chapter 7). This includes a detailed environmental and behavioral history (asking about reading or other learning disabilities, language development, pica, etc.), a physical examination, and tests for iron deficiency. Particularly for children needing urgent medical follow-up (that is, blood lead level greater than or equal to 45 µg/dL), pediatric health- care providers with limited experience in treating lead poisoning should consider referring such children to a clinic with experience in managing childhood lead poisoning. These children should also have complete environmental investigations so that lead hazards can be reduced. The local public childhood lead poisoning prevention programs will often work as a team with the pediatric health-care provider and the child's family to ensure appropriate environmental follow-up. BLOOD LEAD LEVEL GREATER THAN OR EQUAL TO 70 µg/DL. Children with blood lead levels this high constitute a medical emergency that preferably should be managed by someone with experience in treating children who are critically ill with lead poisoning. Medical and environmental management must begin immediately (Chapter 7 and Chapter 8). |
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Educating
Parents About Reducing Blood Lead Levels WHAT CAN PARENTS DO TO REDUCE BLOOD LEAD LEVELS?
There are many interventions parents can use to help reduce blood lead levels. These interventions are not a substitute for lead hazard abatement. |
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Housekeeping Interventions Particularly in older homes, which may have been painted with lead- based paint, interventions to reduce exposure to dust may help reduce blood lead levels. These include:
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Other Interventions to Reduce Exposure to Lead
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Nutrition
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Coordinating
With Public Sector Officials
The responsibilities of public sector officials are described in Chapter 5. These officials are an important source of information for the pediatric health-care provider. They can alert the provider to the extent of the lead poisoning problem in the provider's catchment area. They can provide information about particular lead sources that may be of concern in a given neighborhood. Often these officials can assist in the management of the lead-poisoned child, doing follow-up screening, conducting environmental investigations, and ensuring lead hazards are abated. They should keep the provider informed of actions they take on the child's behalf. The pediatric health-care provider is responsible for informing public health officials about lead-poisoned children, reporting any unusual sources or pathways of exposure, and reporting elevated blood lead levels, if this is required. |
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Appropriate
Follow-Up APPROPRIATE FOLLOW-UP INCLUDES:
Not all aspects of a poisoned child's follow-up will be managed by the pediatric health-care provider, although the provider is an important part of the team. Through his or her interactions with the child and family and the responsible public health agency, the provider should make sure that any appropriate interventions are occurring. The provider should make sure that the family receives education about childhood lead poisoning and ways of preventing it, and he or she should make sure that the child receives the appropriate follow-up blood lead testing. If the child needs a medical evaluation (for a blood lead level greater than or equal to 20 µg/dL) or pharmacological treatment (Chapter 7), either the provider should do it or should refer the child to a place that treats large numbers of poisoned children. The provider should make sure that the child receives an appropriate environmental investigation and remediation with the help of the public health agencies. Particularly if the child is developmentally delayed, the provider should refer the child to an appropriate infant stimulation or child development program. In many cases, lead-poisoned children and their families will also benefit from social services follow-up. |
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