Children with high blood lead levels often do not receive follow-up tests

May 10, 2005

Only about half of children who had an abnormal blood lead level screening had follow-up blood testing, according to an article in the May 11 issue of JAMA.

"In 1997, the Centers for Disease Control and Prevention (CDC) changed the recommendation for childhood lead poisoning prevention from near-universal testing of all children to targeted testing based on the risk of lead exposure," according to background information in the article. The recommendation was changed because of a decreased prevalence of lead poisoning due to the success of prevention strategies, such as the removal of lead from paint and gasoline. Efforts have been made to improve screening among at-risk children because even modest elevations of blood lead levels can be harmful. However, screenings are only effective with follow-up care.

Alex R. Kemper, M.D., M.P.H., M.S., from the University of Michigan, Ann Arbor, and colleagues determined the proportion of 3,682 Medicaid-enrolled children with elevated lead levels who had follow-up testing done. The study included children ages six years or younger who had a screening blood lead level of at least 10 ìg/dL (micrograms per deciliter) between January 1, 2002 and June 30, 2003. The researchers determined that follow-up testing had taken place if it was performed within 180 days of the initial blood lead screening.

The researchers found that 53.9 percent of the children received follow-up testing within 180 days of their elevated blood level tests. These children were given follow-up at an average of 68.5 days. The average blood lead level at follow-up was 3.6 ìg/dL lower than the initial testing, although 47.5 percent of children still had elevated blood levels. Follow-up testing was less likely for Hispanic or nonwhite children than for white children; for children living in urban settings compared to rural areas; and for children living in high- compared with low-risk lead areas. Among children who did not receive follow-up testing, 58.6 percent had at least one medical visit during the 180 days following the abnormal level screening.

"... follow-up testing is the cornerstone of lead poisoning management and an essential component of secondary prevention," the authors write. "To maximize cognitive development in these children, it is crucial to improve follow-up and to understand and develop interventions to overcome these unexpected disparities in care."

(JAMA. 2005; 293: 2232 - 2237. Available post-embargo at www.jama.com.)

Editor's Note: This work was funded by the Michigan Department of Community Health.

Editorial: Childhood Lead Poisoning Prevention - Too Little, Too Late

In an accompanying editorial, Bruce P. Lanphear, M.D., M.P.H., from Cincinnati Children's Hospital Medical Center and the University of Cincinnati, discusses the possible effects of lead exposure.

"Despite the dramatic decline in children's blood lead concentrations, lead toxicity remains a major public health problem. Environmental lead exposure in children ... has been associated with an increased risk for reading problems, school failure, delinquency, and criminal behavior," Dr. Lanphear writes. "The effects of lead exposure extend beyond childhood. In adults, lead exposure...has been associated with some of the most prevalent diseases of industrialized society: cardiovascular disease, tooth decay, spontaneous abortion, renal disease, cognitive decline, and cataracts."

"The key to primary prevention is to require screening of high-risk, older housing units to identify lead hazards before a child is poisoned. ... Screening and follow-up testing of high-risk children will remain an important part of lead poisoning prevention programs, but they should serve as a safety net, not the focus. Unfortunately, public health and housing agencies lack the resources they need to protect children from lead poisoning, and even when they do act, the study by Kemper and colleagues is a cogent reminder that it is too little, too late," the author concludes.

(JAMA. 2005; 293: 2274 - 2276. Available post-embargo at www.jama.com.)

Editor's Note: Dr. Lanphear has served as an expert witness in the state of Rhode Island's suit against the lead industry, on behalf of the city of Milwaukee, and the communities of Picher and Herculaneum. Dr. Lanphear was not compensated for this work but Cincinnati Children's Hospital Medical Center has been compensated for his testimony.
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