Childhood Lead Poisoning Prevention

• Children and Lead Poisoning
• Screening for Lead Poisoning
• Health Care Management of the Lead Poisoned Child
• Preventing Lead Poisoning
• Sources of Lead
• Removing Lead-Based Paint
• Community Resources
• Educational materials
• Publications
• Childhood Lead Poisoning Prevention Projects
• New Jersey Childhood Lead Poisoning Case Management Model
  

Children and Lead Poisoning

How are children exposed to lead?
Young children can be exposed by:

• swallowing lead dust or soil that is on their hands or other objects, such as some toys, that they put into their mouths;
• swallowing lead paint chips;
• breathing lead dust or lead contaminated air;
• eating food or drinking water that is contaminated with lead.

Why is exposure to lead harmful to children?
Scientists have found that lead can disrupt the normal growth and development of a child's brain and central nervous system.

What age are children most at risk for lead poisoning?
All children less than six years old, particularly those between six months and three years.  This is because:

• The first six years, particularly the first three years of life, is the time when the human brain grows the fastest, and when the critical connections in the brain and nervous system that control thought, learning, hearing, movement, behavior and emotions are formed.
• The normal behavior of children at this age - crawling, exploring, teething, putting objects in their mouth - puts them into contact with any lead that is present in their environment.

What are the symptoms of lead poisoning in children?
Most children with lead in their in their bodies will  not have obvious symptoms! Lead poisoning generally causes symptoms only at very high levels, and even then those symptoms - stomach aches, anemia - are similar to those of much less serious illnesses. However, because most children with lead poisoning will not show obvious symptoms, it is important that all children be tested to detect lead poisoning.

What are the effects of lead poisoning in children?
Very high levels of lead can cause seizures, severe brain damage resulting in mental retardation, coma, and even death. Lower levels can cause stomach pains and anemia. Long term exposure to lead, even at relatively low levels, have been found to be associated with decreased hearing, lower intelligence, hyperactivity, attention deficits, and problems in school.

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Screening for Lead Poisoning

Does New Jersey require that children be screened for lead poisoning?
Yes!  All children in New Jersey are at risk of lead poisoning;  therefore, New Jersey State law (Public Law 1995, chapter 328) requires every physician, professional registered nurse, and health care facility to screen all children under six years of age who come to them for care.

When should children be screened for lead poisoning?
All children should be screened for lead poisoning at 12 and 24 months of age, and any child between three and six years of age who has never previously been screened.

Any child who is six months of age or older, and is exposed to a known or suspected lead hazard, should be screened. Parents have the right to refuse to have the test done for any reason.

What questions will my doctor ask to know if my child needs to be screened more frequently?

Does your child:

• Live in or regularly visit a house with peeling or chipping paint built before 1960?  (This could include a child care center, preschool, home of a baby sitter.)
• Live in or regularly visit a house built before 1960 with recent (past 6 months), ongoing or planned renovation?
• Live with an adult whose job or hobby involves exposure to lead? Examples include working in/with foundries, construction, batteries, pottery.
• Have an elevated blood lead level (10 ug/dL or higher) when last tested?  If child has not been previously tested and is 12 months or older, consider this a “yes” response.

A “yes” or “I don’t know” answer to any of these questions indicates a need for more frequent screening. 

Will my health insurance pay for the cost of lead screening?
Yes!  State law (Public Law 1995, Chapter 316) requires every health insurance plan covering a group of 50 or more persons, including HMOs and Managed Care, to cover the cost of lead screening and childhood immunizations, without any deductible.

What if I am uninsured and can't afford to pay for the cost of the screening for my child or my insurance does not pay for the cost of lead screening?
Free screening is available through your local health department. Every local health department in the state is required to provide well child services for its community, including lead screening and immunization. For the dates, times, and locations of your local Child Health Conference, call your local health department.

In addition, Federally Qualified Health Centers (FQHC) throughout the state provide no or low cost testing.

If you are uncertain about which local health department covers your area or to locate a FQHC near you, call the Child and Adolescent Health Program at (609) 292-5666.

What amount of lead is considered lead poisoning?
Unlike other natural minerals, such as zinc and iron, that are necessary for our bodies to function properly, but are toxic in high doses, lead has no natural function in the human body.  Scientists have been able to correlate problems in children at lead levels above 10 micrograms per deciliter (ug/dL) in the blood. 

What does the screening result mean? 
Blood lead levels between 10 and 19 are considered borderline, and the child is retested every few months.  In New Jersey, any blood lead level of 20 or more is considered significant.  Levels above 45 are considered especially dangerous and need immediate attention of a doctor. A level of 70 or more is considered an emergency, requiring hospitalization.

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Health Care Management of the Lead Poisoned Child

What happens when a child has been identified as having lead poisoning?
The laboratory that analyzes the screening (blood lead test), must report the result to the Department of Health and Senior Services and the physician that requested the test.  The Department then alerts the local health department where the child lives. The local health department sends out a Public Health Nurse, who works with the child’s physician and if applicable the child’s insurance carrier, to inform the family about lead poisoning and to help the caregiver get the medical attention the child needs.  Other children living in the household may be tested to identify additional cases of lead poisoning.   The local health department also sends an inspector to locate the lead hazards. The inspector will write a report to the property owner, telling him/her where the lead hazards are and what to do about them. The property owner is legally required to remove those hazards.

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Preventing Lead Poisoning

What can parents do to prevent their children from getting lead poisoning?
There are a number of simple, low-cost steps parents can take to reduce their children’s lead exposure:

• DO:  Wash, or have children wash, their hands frequently, especially before eating, after playing outside or on the floor, and before sleeping.
• DO:  Wash toys and other objects young children handle and put in their mouths.
• DO:  Have everyone take off their shoes and leave at the door entrance to the home.
• DO:  Offer children a nutritious diet high in iron and calcium and low in fat.
• DO:  Clean floors and window sills by using a damp mop or sponge and detergent.
• DO:  Know if any paint has lead.  DO:  Remove only using special precautions, or by a state-certified Lead Abatement Contractor.
• DO:  Wash work clothes separately from the family laundry if parents or caregivers work in a job that uses lead.  DO:  Shower and change clothes before leaving work if possible.
• DO:  Keep children away from hobbies that use lead. Keep children out of the workshop, or clean-up carefully after using lead.

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Sources of Lead

Keep informed about new sources of lead and consumer products that are recalled due to lead hazards.  The Centers for Disease Control and Prevention (CDC), Childhood Lead Poisoning Prevention Branch, has a current list of recalls that can be found at www.cdc.gov/nceh/lead/Recalls/default.htm.

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Removing Lead-Based Paint

How do I know if there is lead-based paint on or in my house?
You can pretty much assume that any house built before 1960 has some lead-based paint on it, unless you know that all the old paint was removed some time in the past. If you want to be certain, you can hire a state-certified Lead Evaluation Contractor. New Jersey law requires that any person who does inspections for lead paint must meet certain training and experience requirements, pass a test, and obtain a permit from the New Jersey Department of Health and Senior Services. Any company in the business of doing lead inspections must be certified by the New Jersey Department of Community Affairs (DCA). For more information, or a list of state-certified lead evaluation contractors, call the NJDCA at 877-DCA-LEAD or go to www.leadsafenj.org.

There are also simple test kits that you can buy in a hardware store that you can use to test paint, water, or dishes for lead. Be aware however, that these tests, while reasonably accurate, do not always detect lead even when it is present. For example, if lead paint is covered with several layers of non-lead paint, the test kit may not show positive. You can also take paint chips or water samples and send them to a laboratory for testing. There are many environmental laboratories that perform this service. They are listed in the Yellow Pages under "Laboratories - Testing".

Wipe Out Lead New Jersey is an initiative to help families identify harmful lead dust in their homes.  Home lead test its are free of charge and easy to use.   The initiative is coordinated by Family Health Initiatives, a subsidiary agency of the Southern NJ Perinatal Cooperative.  For more information contact Family Health Initiatives at 856-665-6000.

What should I do if I want to remove old paint from my house?

• Assume that the paint is leaded unless you know for certain that it is not.
• Don't assume that every painter knows how to remove lead paint safely. State-certified Lead Abatement Contractors must meet requirements set by the NJ Department of Community Affairs (NJDCA) and follow work practices set by the NJDCA. Their workers must meet training requirements, pass a test, and have a permit issued by the NJ Department of Health and Senior Services. For a list of state-certified Lead Abatement Contractors, call the NJDCA at 877-DCA-LEAD or go to www.leadsafenj.org.
• Don't remove the lead paint yourself unless you know how to do it safely.

The NJ Department of Health and Senior Services has a pamphlet, "Important Information for Homeowners and Renters about Lead Paint Hazards", that explains these precautions in more detail. For a copy, call the Child and Adolescent Health Program at (609) 292-5666.

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Community Resources

Where can I get more information about  preventing lead poisoning in children?
Regional Childhood Lead Poisoning Prevention Coalitions were created in January 2003 to coordinate educational initiatives on a regional level.

Central Regional CLPP Coalition
Coordinating Agencies: Monmouth County Health Department and Regional Perinatal Consortium of Monmouth and Ocean Counties
Coordinator: 732-363-5400
County Service Areas: Monmouth, Ocean, Hunterdon, Somerset, Mercer, and Middlesex

Southern Regional CLPP Coalition
Coordinating Agency: Camden County Health Department
Coordinator: 856-374-6140
County Service Areas: Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester and Salem

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Educational materials

• Be in the Know About Lead Poisoning -- Flyer for health fairs and other events [pdf 142k]
• An Important Message About Lead Poisoning from Your Child's School -- Flyer for schools [English 91k] [Español 326k]
• An Important Message About Lead Poisoning for Residents of Multi-Unit Buildings-- Flyer for local health departments [pdf 58k]

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Publications

• FY 2003 Annual Report – Childhood Lead Poisoning in New Jersey [pdf 305k]

• FY 2004 Annual Report – Childhood Lead Poisoning in New Jersey [pdf 224k]
           Additional Data Tables for FY 2004 [pdf 140k]

• FY 2005 Annual Report – Childhood Lead Poisoning in New Jersey [pdf 900k]
           Additional Data Tables for FY 2005 [pdf 290k]

• FY 2006 Annual Report – Childhood Lead Poisoning in New Jersey [pdf 1.49m]
  
  
• FY 2007 Annual Report – Childhood Lead Poisoning in New Jersey [pdf 3.65m]

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Childhood Lead Poisoning Prevention (CLPP) Projects

The focus of the CLPP case management team is to identify and remove the child from the source of lead.     Through the CLPP Projects, lead poisoned children and their families are provided services that include:

• Oversight of the case management team to ensure that the lead source is identified, a full environmental assessment has been conducted as well as an assessment for non- paint lead sources and take home occupational exposures. 
• Assistance in obtaining a medical home and in  scheduling medical follow-up visits
• Provision of  education and counseling on lead poisoning prevention measures
• Assistance  in relocation to lead safe housing
• Assistance in obtaining funding from Department of Community Affairs for relocation and abatement
• Oversight of the abatement process
• Assessment of the nutritional status of the child/family and referral to the WIC Program
• Monitoring timely follow-up of lead blood retesting
• Assessment of the  growth, developmental and health status of the child
• Collaboration  with the PCP and family to ensure follow-up  referrals as required
• Assessment of the psychosocial and economic needs of the family with referral to community resources as indicated (WIC, Family Planning, housing, education, job training and other social services).

The following agencies are supported by the Department of Health and Senior Services to deliver comprehensive lead poisoning outreach and case management to families with children six years of age and younger.

Managing Elevated Blood Lead Levels Among Young Children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention, Centers for Disease Control and Prevention (CDC), March 2002.

www.cdc.gov/nceh/lead/CaseManagement/caseManage_main.htm

Childhood Lead Screening Requirements (PL 1995, ch 328 and NJAC 8:51A) with Medical Evaluation Follow-Up Recommendations for Asymptomatic Children.

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New Jersey Childhood Lead Poisoning Case Management Model

Preface

On July 1, 2006, local health departments receiving grants for case management from the Department of Health and Senior Services (DHSS) began to institute the following protocols for children with blood lead levels of 15 ug/dL or above.  In addition, these same grantees will in time respond to blood lead levels of 15 ug/dL or lower requiring a different set of protocols.

Local health departments not receiving grants for case management will only be required to provide case management services mandated under Chapter XIII regulations (NJAC 8:51).  However, DHSS will continue to provide training and assist those local health departments that want to voluntarily expand their provision of case management to lead poisoned children beyond the requirements of Chapter XIII. 

Definition of Childhood Lead Poisoning Case Management

Case management interventions focus on secondary prevention measures.  This includes but is not limited to preventing further exposures to lead and the monitoring of the reduction of blood lead levels.

The Centers for Disease Control and Prevention (CDC) defines case management of children with elevated blood lead levels as “the coordination, provision and oversight of the services required to reduce their blood lead levels below the level of concern.”  CDC’s current definition of the level of concern is 10 ug/dL.  The case management team includes the case manager, environmental inspector, child’s parent(s) or primary caregiver, child’s primary care provider (PCP), and local public health agency.   The team may also include a Medicaid Managed Care case manager, NJ Department of Community Affairs (DCA) representative, an outreach worker, health educator, or registered dietician.

The current CDC case management model has eight components:

• client identification and outreach;
• individual assessment and diagnosis;
• service planning and resource identification;
• linking of clients to needed services;
• service implementation and coordination; and
• monitoring of service delivery;
• advocacy; and
• evaluation.

Not all components of the case management model need to be performed by the case manager, but the case manager is responsible for coordinating the care and assuring that all team members stay in communication and work together. The case manager is also responsible for monitoring medical oversight, as well as ensuring follow-up on all referrals made for problems identified in the assessment process.

Overview of Case Management Responsibilities

• Visit the child’s residence, and other sites where the child spends a significant amount of time, as often as required to educate parents and/or caregivers, and assist in identifying a lead-free environment for the child and the family.
• Assess factors that may impact the child’s blood lead level, including but not limited to sources of lead, access to nutritious foods, access to health care and human services, family interaction, and caregiver understanding.
• Oversee the activities of the case management team.
• Develop a written case management implementation plan.
• Coordinate the case management implementation plan.
• Evaluate compliance with and success of the case management implementation plan.
• Close the case when all discharge criteria have been met.

An environmental inspector will also visit the child’s residence, with the case manager if possible, to inspect the residence, identify sources of environmental lead exposure, and assess lead risks.

Discussion

DHSS is aggressively focused on prevention strategies.  State inter-governmental departments including DCA and the NJ Department of Human Services (DHS), as well as local inter-governmental agencies are collaborating to enhance the provision of community-based health education, to increase access to and performance of age-appropriate blood lead testing, and to create and maintain  lead-safe housing that positively impact the prevention and early identification of  lead poisoning.
 
State FY 2005 (July 1, 2004-June 30, 2005) statistics indicate of the children tested:

• 2.26% had blood lead levels between 10-19ug/dL (4,100 children)
• 0.40% had blood lead levels between 20-44 ug/dL (725 children)
• 0.03% had blood lead levels 45ug/dL or greater (54 children).

Counties with 100 or more children with blood lead levels over 10ug/dL include:  Camden, Essex, Hudson, Mercer, Middlesex, Monmouth, Passaic, Union and Cumberland.  DHSS and its State, regional, and local partners target these counties for outreach and education, and environmental interventions.  By doing so, more costly interventions associated with treatment and diagnostic testing can be avoided.

New Jersey Childhood Lead Poisoning Case Management Protocols

Blood Lead Level 0-9ug/dL

Regulatory change to Chapter XIII would be required for all local public health agencies to provide case management for children with blood lead levels between 0-9 ug/dL.
In the meantime, there is continued collaboration between DHSS with its state partners, DCA and DHS, and with its local partners--Maternal and Child Health Consortiums, local health departments, and Regional Childhood Lead Poisoning Prevention Coalitions--to focus on primary prevention.  

Blood Lead Level 10-44ug/dL

Reducing the blood lead levels of children in this range requires that the source of lead exposure be identified and abated (removed).  To accomplish this goal, the child’s residence must be inspected and assessed.  Following is a proposed two tier case management protocol.

Tier I:   10-14ug/dL
Note:  Chapter XIII (NJAC 8:51) will need to be revised to require the commencement of an environmental investigation and case management services.

The case manager will:

• Make a home visit within two weeks of receipt of case management notification.
• Determine if the child has a regular provider of medical care.
• Provide education and counseling regarding effects of lead poisoning.
• Provide written information to the parents and/or primary caregivers regarding the prevention of lead poisoning.
• Assure visual environmental inspection for deteriorated paint of any and all primary and secondary residences
• Require abatement pursuant to New Jersey housing regulations as indicated.
• Monitor blood lead retesting and results (retest schedule).

Tier II:  15-44ug/dL
Note: Chapter XIII (NJAC 8:51) will need to be revised to require the commencement of an environmental investigation and case management services at blood lead levels at 15ug/dL to less than 20ug/dL.

The case manager will:

• Make a home visit within one week of receipt of case management notification. 
• Determine if the child has a regular provider of medical care.
• Collaborate with the Medicaid case manager if applicable, or the local health department for a referral to a licensed physician or health care facility, such as a Federally Qualified Health Center, if the child does not have a primary care provider.
• Collaborate with the Medicaid case manager if applicable to assist the family in arranging for medical evaluation, follow-up venous blood lead tests, and related medical treatment in cooperation with the child’s physician.
• Assure full environmental inspection for deteriorated paint of any and all primary and secondary residences within one week of receipt of notification.
• Provide the physician with the results of all environmental inspections.
• Collaborate with the physician as needed, and the Medicaid case manager if applicable,  to arrange for blood lead testing of siblings and/or other children between 6 months and 6 years of age living in the same household.
• Provide nutrition education and counseling to parents and/or caregivers, emphasizing the role of nutrition in reducing lead absorption.
• Educate parents and/or caregivers about the effects of lead poisoning.
• Educate parents and/or caregivers about other sources of lead that may be on the premises.
• Educate and counsel parents and/or caregivers about personal hygiene and housekeeping measures.
• Educate parents and/or caregivers regarding interim controls.
• Educate the parents and/or caregiver about funding available through DCA for abatement and emergency relocation.
• Collaborate with DCA to obtain funding for abatement and emergency relocation as indicated.
• Assist the parents and/or caregivers in completing the emergency relocation application and planning for long-term lead-free/lead-safe housing.
• Assess the health, developmental, and socio-economic needs of the child and family.
• Inform the primary care provider of any identified health and developmental deficiencies.
• Collaborate with the primary care provider as needed, and the Medicaid case manager if applicable, to evaluate and refer the child(ren)/family to appropriate resources and services.
• Monitor case management team activities to ensure that medical, environmental and educational interventions are followed-up by the parents and/or caregiver, and are delivered in a timely, safe and coordinated manner according to current standards of care.
• If a forwarding address is available, refer to the respective Board of Health in writing of a child(ren)/family that is under active case management who moves from one jurisdiction to another.
• Provide education and counseling on lead poisoning prevention.
• Monitor blood lead retesting and results. (retest schedule)
• Inform the primary care provider of all blood lead retest results.
• Maintain ongoing communication with the primary care provider as needed, and the Medicaid case manager if applicable, regarding the child’s medical, nutritional and neurodevelopmental status.
• Ensure ongoing communication with the primary care provider, and the Medicaid case manager if applicable, regarding the housing and abatement process.

Blood Lead Levels 45ug/dL and higher

Children with blood lead levels of 45 ug/dL and higher generally require hospitalization, aggressive medical treatment, and follow-up.  These children must be case managed by a nurse.
If the child is enrolled in Medicaid, collaboration with the Medicaid case manager is essential to develop the post-hospital discharge plan.

The responsibilities of the nurse case manager for children with elevated blood lead
levels 45ug/dL and over include all of the delineated case management
protocols for children with elevated blood lead levels between 15 ug/dL and
44ug/dL

Additional responsibilities include:

• Make a home visit within 48 hours of receipt of case management notification
• If the blood lead level is at or above 70 ug/dL the child must be visited immediately and hospitalized for chelation.

• Collaborate with the primary care provider, attending physician, hospital discharge planner, Medicaid case manager if applicable, DCA, and the family to relocate the family to lead safe housing.
• Assure full environmental inspection is completed within 24 hours of receipt of notification.
• Assess the need for emergency relocation funding.  Collaborate with DCA staff and hospital discharge planner to complete the application process before hospital discharge.
• Assure environmental inspection is completed at the relocation residence prior to hospital discharge.
• Collaborate with the primary care provider, hospital discharge planner, and Medicaid case manager if applicable, to assist the family in obtaining the oral chelation prescription 2-3 days before discharge.
• Collaborate with the primary care provider, hospital discharge planner, and Medicaid case manager if applicable, to assist the family in identifying a pharmacy that will fill a prescription for the oral chelating agent.
• Teach the child’s parents and/or caregivers the medication regimen and monitor proper administration of the medication.
• Collaborate with the Medicaid case manager if applicable, to obtain visiting nurse services for medication instruction and oversight.        
• Collaborate with the primary care provider and the Medicaid case manager to ensure timely medical follow-up of the child during and after chelation.
• Monitor blood lead retesting and results. (retest schedule)
• Maintain ongoing communication with the primary care provider, and the Medicaid case manager if applicable, regarding the child’s response to the treatment regimen, neurodevelopmental reassessments, and referral process, as well as the abatement status of the primary residence.

Case Management Discharge Criteria
       
It often takes an extended period of time to complete all of the elements in a case management implementation plan for a lead poisoned child.   A child can be discharged from case management if the following criteria are met:

• Environmental hazards have been identified and abated.
• Blood lead levels have declined to below 10ug/dL for 6 months.
• Assessments and referrals have been completed.
• All elements of the case management implementation plan have been achieved.
• Plans have been completed with the primary care provider and the parents and/or caregiver for long-term developmental follow-up.

After consultation with the primary care physician, and collaboration with the Medicaid case manager if applicable, an administrative discharge can be done if at least three aggressive unsuccessful attempts have been made to locate or gain entrance to the child’s residence.  All affected agencies and members of the case management team are to be notified in writing of the child’s discharge.    
             
CDC Time Frames for Case Management Functions

Initial Home Visit

Recommended Schedule for Obtaining a Confirmatory Venous Sample

The higher the BLL on the screening test, the more urgent the need for venous confirmatory testing.

If a child is less than 12 months old, or if there is reason to believe that the BLL is rising rapidly, an earlier diagnostic confirmation may be indicated.

Recommended Schedule for Follow-Up Blood Lead Testing

Seasonal variation of blood lead levels (BLL) exists and may be more apparent in colder climate areas.  Greater exposure in the summer months may necessitate more frequent follow-ups.

Some case managers or primary care physicians may choose to repeat blood lead tests on all new patients within a month to ensure that their BLL is not rising more quickly than anticipated.

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