Lead Toxicity Screening: Updates

The goal of lead screening is to minimize the neurodevelopmental effects of lead poisoning through source control and early detection.

Lead is absorbed from the GI tract more efficiently in younger children, so they are at higher risk of symptoms owing to lead poisoning. Similarly, kids under 6yo are more susceptible to the toxic effects of lead because they have an incomplete blood-brain barrier that permits the entry of lead into the developing nervous system. (Want to know more? Check out this blog post!)

As of 2021, the national standard for an elevated blood lead level changed from ≥5 to ≥3.5 μg/dL. CDC’s decision to implement this change was based on data from the 2015-2016 and 2017-2018 National Health and Nutrition Examination Survey (NHANES) cycles.

Rhode Island is one of only 11 states that mandate lead screening in children, and appears to be one of the strongest in percentage of young children screened—around 40% (generally second only to Massachusetts, which hovers around 47%.) Nevertheless, we have room to improve:

Source: CDC’s Blood Lead Levels (µg/dL) among U.S. Children < 72 Months of Age, by State, Year, and Blood Lead Level (BLL) Group

Although the percentage of children with elevated blood lead levels is declining nationally and in Rhode Island, low-income children continue to be at higher risk of lead exposure. In Rhode Island, children living in the four core cities (Providence, Pawtucket, Central Falls, and Woonsocket) are at increased risk for lead exposure because the housing stock tends to be older.

Rhode Island law has specific requirements for lead levels, including drawing at least 2 studies by 3 years of age, and that these tests be no less than 12 months apart (i.e., two tests ordered 9 months apart would be considered noncompliant with Rhode Island law.)

Per RIDOH’s website:

  • In Rhode Island, healthcare providers are required by law to conduct at least two blood lead screening tests on all children by three years of age. Results must be reported to the Rhode Island Department of Health within 10 days of the screening. Children should then be screened annually through six years of age.
  • If a child was screened at least twice prior to 36 months of age and all test results were less than 3.5 μg/dL, the Lead Screening and Referral Intervention Process can be used instead of a blood lead test to screen for lead poisoning.
  • Compliance with lead screening guidelines is assessed by measuring the proportion of children born in a given year with at least one blood lead test by 18 months of age, and at least two blood lead tests, no less than 12 months apart, by 36 months of age.

In clinic, we typically check a lead level at the 12-month and 24-month well-child visits, in keeping with guidance from AAP’s Bright Futures Recommendations for Preventive Pediatric Health Care. Of note, the AAP also recommends that the risk for lead poisoning be assessed at 6, 9, 12, 18, and 24 months of age, and annually thereafter through 6 years of age.

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