Information Memorandums (IMs)—2008

Lead Screening (ACF–IM–HS–08–07)

INFORMATION MEMORANDUM

TO: Head Start and Early Head Start Grantees and Delegate Agencies

SUBJECT: Lead Screening

INFORMATION:

In May 2000, the Office of Head Start (OHS) issued an Information Memorandum regarding the “Childhood Lead Poisoning Prevention Collaboration” (ACYF–IM–HS–00–13). The purpose of this Information Memorandum is to reiterate the importance of lead screenings and to clarify the requirements for lead toxicity screening for Head Start children.

The United States has made progress in reducing lead exposure among children. However, the issue remains a serious environmental health hazard for those living in poverty and young children under the age of six. Estimates based on screenings show that low-income and Medicaid-eligible children are nearly five times more likely to have harmful blood lead levels than the general child population.

Lead, a poisonous metal, contains a neurotoxin that is harmful to fetuses and developing young children. Extremely high levels can result in seizures, coma, even death. Lead poisoning is a serious yet preventable condition that is particularly damaging to young children; it can affect a child’s brain, kidneys, bone marrow and other body systems. There can be adverse health effects even at low blood lead levels. According to the Centers for Disease Prevention and Health Promotion, a “threshold” has not yet been determined regarding the minimum level of lead that could result in negative cognitive and behavioral development. This is of concern since children often do not display obvious symptoms of elevated lead levels. Therefore, the best way to detect elevated lead levels is through a blood test.

Children may be exposed to lead poisoning from a variety of environmental sources. The primary source in young children is through contaminated dust from deteriorating lead-based paint in older homes. Newly immigrant children may be at risk due to cultural traditions that commonly use lead-glazed cooking vessels and lead-based home remedies. Occupational exposure, another potential source, introduces lead into the home or a woman’s womb from individuals who work with the metal daily.

Low-income families are disproportionately at risk as these families tend to live in older housing which may contain lead-based paint or lead plumbing. The Centers for Medicare & Medicaid Services (CMS) require that all low-income, Medicaid-eligible children be screened for lead toxicity using a blood test. In 2001, the Journal of the American Academy of Pediatrics estimated 60% of children with elevated lead levels were Medicaid recipients and 83% of children with lead levels greater than 20ug/dL were on Medicaid (Journal of the American Academy of Pediatrics, December 2001). For this reason, all children who qualify for Medicaid are considered “at risk" for the Early and Periodic Screening, Diagnostic, and Treatment program (EPSDT) blood risk assessment.

INFORMATION:

In order for programs to meet and comply with Head Start Program Performance Standards, Head Start programs must ensure that all children receive a lead toxicity screening. The CMS requirement states that, “At this time, states may not adopt a statewide plan for lead poisoning that does not require blood screening for lead toxicity for all Medicaid-eligible children.”

CMS requires that all Medicaid-eligible children receive a screening blood test at 12 months and 24 months of age. Children between the ages of 36 to 72 months must also have a screening blood test if a lead toxicity screening has not been previously conducted. For cases where a blood “finger stick” test result is equal to or greater than 10ug/dL, the result must be confirmed through a venous blood draw.

There are several factors that Head Start programs must address and consider in order to ensure that this important health screening is provided to all Head Start children.

• 45 CFR 1304.20(a)(1)(ii) requires a determination of whether a child is up-to-date on a schedule of age appropriate preventative and primary health care. This schedule must incorporate the requirements for well child care utilized by the state Medicaid EPSDT program. It is a Medicaid EPSDT requirement that a lead screening blood test be performed to determine a lead toxicity level for all Medicaid-eligible children. A “risk assessment” (i.e. a paper and pencil questionnaire or parent interview) does not meet this requirement.
• If parents are unable to provide written documentation that their child received a lead screening blood test at ages 12 and 24 months, then CMS requires that the children receive a lead screening blood test between the ages of 36 and 72 months. Head Start programs must work in partnership with parents to make sure every enrolled child receives this screening.
• If a child’s medical provider will not perform a lead screening blood test, then the Head Start program is required to assist the family in obtaining the screening from other community resources [45 CFR 1304.20(a)(1)(ii(A)]. If there are no other resources available, the program must comply with the Head Start Program Performance Standard 45 CFR 1304.52(d)(2) that a licensed certified health professional perform the screening.
• The Health Services Advisory Committee (HSAC) can be instrumental in assisting programs to identify community resources to provide lead screening blood tests. The HSAC also can advocate for children and educate on the importance of complying with the CMS regulation. The HSAC may not, however, waive the Medicaid requirement for a blood screening for lead toxicity.
• Many Head Start children are eligible to participate in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). Partnering with local WIC offices can serve as an important resource for Head Start programs to make sure children are screened for elevated blood lead levels. In fact, some state WIC programs are requiring children to have a lead screening blood test. WIC counselors can reinforce the importance of lead screening and address the nutritional and environmental needs of a child with elevated lead levels.
• 45 CFR 1304.20(e)(2) requires programs to ensure that the results of diagnostic and treatment procedures are shared with and understood by parents. In addition, Head Start programs are required to develop and implement a follow-up plan for any condition during the well child care visit [45 CFR 1304.20(a)(1)(iv)]. Head Start programs must work in partnership with parents to identify the resources needed to execute the follow-up plan.

Strategies to reduce blood lead levels in the home and in the classroom include:

Housekeeping

• Keep children away from peeling or chipping paint, and accessible or chewable surfaces covered with lead-based paint, especially windows, window sills, and window wells.
• Wet mop and wet wipe hard surfaces using soap and water.
• Do not vacuum hard surfaces suspected of lead contamination. This activity may scatter dust. If vacuuming is done, “hepa-vac” or use other comparably sensitive filters.
• Wash children’s hands and faces before they eat.
• Wash toys and pacifiers frequently, as young children have a tendency to put things in their mouth and share their toys with others.

Nutrition

• Make sure children eat regular nutritious meals. Lead is more easily absorbed into the body on an empty stomach.
• Make sure children’s diets contain plenty of iron and calcium.
  • Examples of foods high in iron are: liver, fortified cereal, cooked beans, spinach, and raisins.
  • Examples of foods high in calcium are: milk, yogurt, cheese, and cooked greens.
• Do not store canned food in open containers, especially imported canned items. Do not store or serve food or beverages in pottery that is meant for decorative use or in lead crystal or lead-based china.

Lead Paint in Toys

• In August 2007, numerous toys were recalled by major manufacturers due to the use of lead-based paint. To stay informed about other health and safety toy recalls, visit the Consumer Product Safety Commission Web site: www.cpsc.gov/cpscpub/prerel/category/toy.html.

RESOURCES:

For additional information regarding lead toxicity screening for Medicaid-eligible children, visit http://www.cms.hhs.gov/MedicaidEarlyPeriodicScrn/02_Benefits.asp.

Information on lead poisoning prevention can be found at http://www.cdc.gov/nceh/lead/ as well as the Head Start Early Childhood Learning and Knowledge Center at http://www.eclkc.ohs.acf.hhs.gov.

Thank you for working to ensure the health of our nation’s children.

(Download in PDF)