Apr 08, 2022
6 minutes of reading
Source/Revelations
disclosures:
Woolf does not report any relevant financial disclosures. Brown reports to be a technical advisor to Magellan Scientific.
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A recent CDC review of the reference value used to identify children with high blood lead levels doubled the estimated number of children who should be referred for follow-up, according to guidelines, a few experts noted recently.
In a perspective published in Pediatrics, Alan D. Woolf, MD, MPH, director of the environmental medicine program at Boston Children’s Hospital, and Mary Jean Brown, ScD, RN, earlier chief of the CDC’s lead poisoning prevention division, also discussed the reissue of the LeadCare II test instrument following a recall.
We spoke to Woolf about blood lead testing in children.
Alan D. Woolf
healio: What are the CDCs doing? reference value (RV† for a child’s blood lead level †BLL† mean?
Woolf: The CDC calculates RV based on the National Health and Nutrition Examination Survey, which measures several chemicals, including lead, in blood samples from children in the United States. The CDC then takes that data and calculates the top 97.5th percentile of the population. That’s the number they call the “reference number” as the upper limit of an “acceptable” derivation level.
So it’s not really a health-based number; it is a population-based number. Whatever the lead level in the blood of the population, that reference number is specifically at the 97.5th percentile.
This is the first time the CDC has revised the reference level since 2012, when it was lowered to 5 mcg/dL. And again, it points to the fact that the BLL has declined in the preschool population over the past 9 years, so last October the CDC lowered the RV to 3.5 mcg/dL. An RV lets you know where the child stands relative to the preschool population across the country.
healio: What are the implications of the pandemic for monitoring the lead exposure status of children?
Woolf: We don’t have the same understanding of children and their families who have a health problem associated with lead contamination, because some preschoolers’ blood has not been tested for lead. The pandemic has put child checks on hold for a while in 2020, and the fact is that low body burden lead poisoning is often asymptomatic. A child can sometimes have a little bit of constipation or irritability or poor appetite, but often they just have no signs of lead exposure. That’s why we have screening in all 50 states, and then blood lead tests for those kids who were thought to be at high risk. Screening children varies from state to state, in terms of the criteria used to determine when to have a blood test on a child. But the fact is, for high-risk kids, if we don’t do the blood test, we might not know if the kid was exposed to lead, at home or in daycare.
It has really serious consequences when people went into lockdown during the pandemic. People were afraid to go to the doctor. Many doctors closed their practice for a short time in 2020 while adjusting their services. And if there is no proper childcare, there will be no lead testing of children.
As we noted in the article, across America there was a whopping 34% reduction in the number of children tested for lead. Healthcare providers were eventually able to turn around and make the necessary changes to their daily practice to ensure the safety of their patients. And they’ve been trying to catch up to testing kids for lead ever since.
healio: What happened to the LeadCare II blood lead measuring instrument?
Woolf: That was a technical issue with the accuracy of that test, which I believe first came to light in 2021. The company responded quickly to recall the test kit lot numbers. Under the direction of the FDA, use of the LeadCare II instrument was paused in 2021 until they could resolve these technical issues.
So pediatric practices, already under pressure to provide care during the pandemic, now had to turn around and find another way to test children for lead. That meant going to a hospital lab or commercial lab to have blood drawn, rather than testing in the office itself. That change placed an additional burden on both pediatric practices and families. For some of those labs, families had to make separate agreements. Sometimes the testing was inconvenient, and in some cases it was not done. Laboratory results had to be returned to the doctor’s office and entered into the child’s medical record. Sometimes that cannot be done correctly.
Those difficulties exacerbated the problems we already had getting children tested because of the effects of the COVID-19 pandemic. Fortunately, the company resolved the technical issues and with FDA approval, LeadCare II kits went back into production for distribution in February 2022.
healio: What Should Clinicians Do to Help Families of Children with Elevated? BLLs†
Woolf: Pediatric caregivers are using the new 3.5 mcg/dL RV to identify children at high risk for continued exposure to the metal. In the article, we urge clinicians to continue testing children to see if they have elevated lead levels. If children are at a higher level, this is a wonderful opportunity to mentor families. We made some points in the commentary on things that pediatric caregivers have been doing all along and should continue to do. For example, they can advise families on dietary intake of calcium, iron, vitamin D and other essential minerals and vitamins in foods. These can help a child with an elevated lead level and possible iron deficiency. And they should continue to monitor the child’s blood regularly until the lead level drops below the RV.
healio: What should families do at home?
Woolf: Families living in older apartments or houses built before 1978, and especially those built before 1960, should have their homes professionally inspected for lead contamination. And we recommend that all attention is paid to the living environment. Some of the things we’re proposing, interestingly enough, are the same things we’ve been doing over the past 2 years to prevent COVID-19 infection, such as cleaning and disinfecting high-touch surfaces, including table tops, baseboards, furniture, and windowsills. . In addition to reducing the risk of COVID-19 infection, cleaning floors and surfaces that touch a lot is also effective in reducing lead-containing dust that children can be exposed to by putting their fingers in their mouths. Dusting rooms, damp mopping floors and cleaning high-touch surfaces with soap and water several times a week will reduce the risk of lead contamination in older homes and apartments. Everyone should leave their shoes by the front door so they don’t get lead-containing dust or dirt from outside the house.
Careful and frequent hand washing is important. Just like we do for COVID-19, wash your hands for at least 20 seconds and wash your toddler’s hands regularly. Toddlers put their fingers in their mouths, they explore toys by mouthing, so by removing dust and washing hands carefully and regularly, we try to break the hand-mouth cycle of lead dust ingestion. The same goes for cleaning plastic toys with simple soap and water so that they don’t accumulate dust.
Again, we’re just trying to interfere with that hand-to-mouth behavior that puts kids at risk of getting lead from dust in the house.
healio: Are there other ways pediatric health care providers can help prevent lead poisoning in children?
Woolf: What we also recommend for practitioners is that they advocate for policies and laws — local, state-wide, and federal — that protect children and their families from lead.
Mary Jean Brown, who was my partner in writing this article, was the former head of the pediatric lead prevention program at the CDC and has years of experience in public health. She lists the things public health authorities can do in the article. For example, if a city decides it has enough money to replace its leaded water pipes, it must ensure that all service pipes are replaced so that they are no longer a source of drinking water contamination.
Reducing the lead hazard in housing is another important activity. Often homeowners and landlords struggle with lead reduction because of the economic cost. Focusing on new legislative initiatives to “lead the way” – regulation, resources and funding made available to landlords and homeowners – as well as funding available to public housing authorities will help to liberalize housing in the country with respect.
We want to make homes safe for children and give them a better environment to grow and thrive in. It is a big problem in our country.
Reference:
Woolf AD, et al. Pediatrics. 2022;doi:10.1542/peds.2021-055944.
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