Childhood Lead Prevention Toolkit

Lead poisoning is a common, but preventable cause of learning disabilities and behavioral problems in children. No blood lead concentration is children is considered “safe.”
This toolkit is designed to:
  • Support primary care providers with lead poisoning prevention and management resources, including anticipatory guidance, testing, and follow-up guidelines.
  • Provide resources and trainings to accurately address elevated blood lead levels.
  • As a result of using this toolkit:
  • Providers will be able to implement the information into their practice using the techniques, resources, and trainings provided in modules.
  • Each module provides specific information relevant to testing guidance and follow-up.
  • The goal of the toolkit is to provide structured guidance to pediatric providers.
  • Information on lead:
  • Ohio law requires blood lead testing at 12 and 24 months of age for children insured by Medicaid or who live in a high-risk ZIP code.
  • Only 50% of children meeting these criteria are being tested currently.
  • There are state and local resources to support families with children who have lead poisoning.
  • Iron insufficiency increases children’s risk for lead poisoning.
  • Ohio Department of Health Lead Testing Requirements and High-Risk Zip Codes

    Please fill out this survey before using the toolkit.
    Contact Alex Miller, Program Manager with questions or comments.

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    Effects of lead poisoning in children:
  • Loss of IQ points (6.2 points by BLL 10mcg/dL, 9.2 points by BLL 30 mcg/dL) (COUNCIL ON ENVIRONMENTAL HEALTH et al., 2016)
  • Increased risk for ADHD symptoms (20% of cases of ADHD are attributed to lead exposure) (Froehlich et al., 2009).
  • Decreased kindergarten reading readiness scores (McLaine et al., 2013)
  • Approximately 2x increased risk for failing standardized math test in 3rd grade (Blackowicz et al., 2016; Zhang et al., 2013)
  • Lifelong consequences:
  • Increased risk for conduct problems (Marcus, Fulton, & Clarke, 2010).
  • Decline in IQ during adulthood and decreased social mobility (Reuben et al., 2017)
  • Increased risk for kidney disease and cardiovascular disease (COUNCIL ON ENVIRONMENTAL HEALTH et al., 2016)
  • Most commonly, exposure is acutely asymptomatic, but long-term effects are observed at low and acutely asymptomatic levels. This is why testing is important. High-risk children who did not receive lead testing at age 1 or 2 must have their blood lead level checked at least once by the age of 6.

    Blood lead testing is required by state law for 1 & 2 year olds who live in a high-risk zip code or are covered by Medicaid insurance. Additionally, every child in Ohio younger than 6 who:
    1. Is Medicaid eligible.
    2. Lives in a high risk ZIP code. (See map)
    3. Lives in or regularly visits a home or building built before 1950.
    4. Lives in or regularly visits a home or building built before 1978 that has deteriorated paint.
    5. Lives in or regularly visits a home or building built before 1978 that has current or planned renovation/remodeling.
    6. Has a sibling or playmate who has or did have an elevated blood lead level.
    7. Frequently encounters an adult who has a lead-related hobby or occupation.
    8. Lives near an active lead smelter, battery recycling plant, or other industry known to generate airborne lead dust.

    • While capillary testing is acceptable for screening purposes, medical and environmental testing should be planned based on venous confirmatory test following positive capillary test.
    • Venous confirmatory testing should be performed on all children with a capillary blood lead level of 5 μg/dL or higher and all future lead level testings for those children should be venous testing.
    • Follow up testing guidelines are available at the ODH website
    Implementation Process

    Tips for Implementation

    1. Plan for implementation.
  • Create an office flow that works best for your practice, with clear and specific roles assigned to staff members, that includes a plan for testing and follow up.
  • Pre-visit planning that may include the family rack card, additional resources for families, etc
  • Documentation with an EMR dot phrases.
  • Include follow-up information, if applicable.
  • 2. Incorporating EMR dot phrases into the EMR system.
  • Create the dot phrases ahead of time and practice using them to become efficient in providing information for patients as well as for documentation.
  • Ask your EMR help desk for information on how to create dot phrases and/or how to link resources into the after visit summary.
  • 3. Engage all staff members.
  • Explain the importance of lead testing and follow up with your office staff and how their role as a team member has an impact on patients and families.
  • Train staff members on the lead resources and invite them to view additional resources or trainings.
  • Physician Resource Guide-The lead resource guide provides lead facts, Ohio testing information and follow-up guidelines, sources of exposure, prevention resources, signs and symptoms, and medical managements information.
    Parent Information Rack Card- Resource to use with families.
    Spanish Rack Card
    Visit the Ohio AAP Lead Website for additional information.
    Components that should be included in the well visit/documented in the chart:
    Documentation of anticipatory guidance at six-month well-child visit:
  • Run drinking water until cold, sources of lead exposure, advice about paint remediation, wet mopping/dusting, taking off shoes, washing hands.
  • Documentation of lead test ordered at 12- and 24-month well visits (venous or capillary).
  • Documentation of completed lead test.
  • Results of completed lead test.
  • If positive capillary results, document the following items: a confirmatory venous draw was ordered; an actual blood lead level; additional counseling offered.
  • Documentation at the 6 month well child visit:
    Anticipatory guidance to reduce lead exposure reviewed, including:
  • Sources of lead exposure.
  • Running water until cold when used for consumption.
  • Taking off shoes at the door.
  • Wet mopping/dusting.
  • Advice regarding paint remediation.
  • Example EMR dot phrase to document anticipatory guidance:
    Kids are exposed to lead mostly from paint chips and soil. To prevent exposure to lead, it is important to:
  • Take off shoes before coming indoors.
  • Use a damp cloth to wipe down windowsills and baseboards.
  • Regularly wipe down floors and vacuum carpets.
  • Run tap water cold for a couple of minutes before drinking or using to mix formula, especially when running the water first thing in the morning.
  • Wash hands well before meals and snacks.
  • Wash toys that have been on the floor.
  • Have your child eat a healthy diet, with plenty of iron and calcium.
  • If you notice peeling or chipping paint either inside or outside your home (including the porch), this should be repaired using lead-safe practices.
  • Recorded trainings:
  • Adventures in Lead Prevention
  • How to Implement Lead Poisoning Prevention Strategies, Resources, and Education During Home and Virtual Visits
  • Part 1: Epidemiology of Lead
  • Part 2: Lead Resource Management
  • Literature:
  • Blackowicz, M. J., Hryhorczuk, D. O., Rankin, K. M., Lewis, D. A., Haider, D., Lanphear, B. P., et al. (2016). The impact of low-level lead toxicity on school performance among hispanic subgroups in the chicago public schools. International Journal of Environmental Research and Public Health, 13(8), 1.
  • COUNCIL ON ENVIRONMENTAL HEALTH, Lanphear, B. P., Lowry, J. A., Ahdoot, S., Baum, C. R., Bernstein, A. S., et al. (2016). Prevention of childhood lead toxicity. Pediatrics, 138(1), e20161493. doi:10.1542/peds.2016-1493
  • Froehlich, T. E., Lanphear, B. P., Auinger, P., Hornung, R., Epstein, J. N., Braun, J., et al. (2009). Association of tobacco and lead exposures with attention-deficit/hyperactivity disorder. Pediatrics, 124(6), e1054-e1063. Retrieved from Association of tobacco and lead exposures with attention-deficit/hyperactivity disorder database.
  • Marcus, D., Fulton, J., & Clarke, E. (2010). Lead and conduct problems: A meta-analysis. Journal of Clinical Child & Adolescent Psychology, 39(2), 234-241. doi:10.1080/15374411003591455
  • McLaine, P., Navas-Acien, A., Lee, R., Simon, P., Diener-West, M., & Agnew, J. (2013). Elevated blood lead levels and reading readiness at the start of kindergarten. Pediatrics (Evanston), 131(6), 1081-1089.
  • Reuben, A., Caspi, A., Belsky, D. W., Broadbent, J., Harrington, H., Sugden, K., et al. (2017). Association of childhood blood lead levels with cognitive function and socioeconomic status at age 38 years and with IQ change and socioeconomic mobility between childhood and adulthood. JAMA : The Journal of the American Medical Association, 317(12), 1244-1251.
  • Zhang, N., Baker, H. W., Tufts, M., Raymond, R. E., Salihu, H., & Elliott, M. R. (2013). Early childhood lead exposure and academic achievement: Evidence from detroit public schools, 2008-2010. American Journal of Public Health, 103(3), 72. doi:10.2105/AJPH.2012.301164; 10.2105/AJPH.2012.301164
  • What are the requirements by law for lead testing of children in Ohio?
    All children insured via Medicaid or who live in a high-risk zip code must have blood lead levels tested at 1 and 2 years of age. If testing at these ages has not been done, the law requires at least one test before the age of 6. In addition, the same testing requirements apply to any children with “yes” or “don’t know” answers to the lead risk questionnaire that can be found on the Ohio Department of Health website.

    Should capillary or venous blood lead testing be performed?
    In office capillary testing can increase convenience for families and increase the likelihood that an ordered lead test will be completed – especially if families need to proceed to a separate location for access to phlebotomy. However, elevated blood lead levels (>4.9 mcg/dL) obtained through capillary sampling must be confirmed with a venous sample due to the potential for false positive tests due to lead containing dust on the skin. In settings where phlebotomy is readily available, initial venous sampling may therefore be preferred.

    What communication do families receive from the Ohio Department of Health for children with EBLL?
    State law requires that blood lead levels be reported to the ODH. An EBLL (of 5mcg/dL or greater) determined through capillary sampling results in a letter being sent from ODH to the family indicating that a confirmatory venous sample should be performed. An EBLL determined through venous sampling results in a letter being sent from ODH to the family with information about the need for follow up testing, preventing further exposure (including information about home inspection), and indicating that the child will be referred to Early Intervention.Local health departments perform home inspections when is BLL 10mcg/dL or greater, or in some counties 5mcg/dL or greater. Overall, there will be a public health response for any blood lead level of 5 mcg/dL or greater.

    How does an Early Intervention referral occur?
    As always, parents can self-refer and clinicians can also refer. ODH will automatically refer children with BLL 5ug/dL or greater. It is okay if referrals from more than one source are received.

    What resources are available to help with managing challenging cases (such as persistent EBLL, unclear source of exposure, need for chelation)?
    There is a network of Pediatric Environmental Health Specialty Units across the U.S. to help clinicians who have questions regarding environmental exposures in children, lead included. The regional PEHSU for Ohio is located at Cincinnati Children’s Hospital Medical Center to provide these consultations. The phone number is 513-803-3688. In cases of acute lead intoxication (such as encephalopathy) where emergency care is needed, it is best to call the local poison control center at 800-222-1222. The primary approach to lead poisoning is to stop the exposure.
    Ohio Environmental Protection Agency

    What dietary recommendations are helpful for children with EBLL?
    Dietary changes are not a “treatment” for lead poisoning. However, ensuring iron, calcium, and vitamin C sufficiency is recommended. Recommending balanced, regular meals and snacks has multiple health benefits. There is no benefit to “mega” doses of vitamins in children without deficiencies. There are no foods or herbs that can “remove” lead from the body.

    Is lead testing covered by insurance?
    Yes. There can be case specific challenges if the lab where the blood is drawn is not in network, or there was a coding error. The Ohio Department of Health Childhood Lead Poisoning Prevention Program wants to be informed about these difficulties with payment.

    I have a family who owns their home and is worried about the cost of getting rid of the lead hazards in their home. Are there resources available to help with the cost?
    At the state level, there are three basic programs to help defray the costs of lead abatement. For low-income families (Medicaid eligible or equivalent), there is the SCHIP program. There is also a state income tax credit program for other property owners. The details for these programs are available on the ODH website. Information about the middle-income grant program (for families who do not qualify for SCHIP) is also available through ODH. Additionally, several cities and counties in Ohio have other lead abatement grant programs available that can be accessed through local health departments.

    With the coronavirus pandemic, families are concerned about having people come into the home. What can I tell them about the health department’s inspection process?
    Ohio law requires that all lead risk assessors be licensed. Since most of them work for local health departments, they have developed protocols to assess homes for lead hazards in a professional, responsible, and safe way. All department of health guidelines and protocols will be follow.

    When I was a resident, I took care of kids with lead levels that were over 70 mcg/dL. Why are we spending so much time worrying about lead levels 5 mcg/dL and above? If a level of 5 mcg/dL is so important, why doesn’t the health department go to the home?
    Well designed research studies over the past 20 years have demonstrated that early life lead exposure (even levels less than 5 mcg/dL) are associated with decreases in IQ and behavioral problems. There is no safe level of lead. Although acute lead poisoning is rare, all the children with lead levels of 70 mcg/dL started with a lead level that was much lower in past. Since studies demonstrate that both the lead level and the length of time that the lead level is elevated are important in these long-term outcomes, taking steps to lower lead levels quickly is the best secondary prevention activity that we have. The health departments are unfortunately not adequately funded to make home visits for all children with a blood lead level of 5 mcg/dL. Some jurisdictions have implemented limited home visits for children with BLL 5-9 mcg/dL.

    I take care of many children from immigrant families who are not insured by Medicaid, their zip code consists of mostly newer hosting, and do not have occupational risks from their family members. Do I need to check their lead levels?
    The ODH recommendations set out minimum testing requirements, they are not meant to replace clinical judgement in cases where a clinician suspects possible lead exposure. Lead is frequently found in certain ethnic remedies, cultural powders, food seasonings, tumeric and spices. For example, sindoor, or vermilion powder, used in South Asian cultural traditions, is a common source of lead exposure. If a child in this situation has an elevated blood lead level that requires a home lead risk assessment, the health department will test these items through the toxicology lab and can help the family identify a source of lead that was previously unknown. In addition, the Food and Drug Administration will investigate any domestically purchased items such as these containing lead and there may be many others who could be helped by identifying a contaminated batch of spices from a supermarket.
    Alex Miller, MPH- Ohio AAP, Program Manager
    Aparna Bole, MD, FAAP- UH Rainbow and Babies Hospital
    Nicholas Newman, DO, MS, FAAP- Cincinnati Children's Hospital
    Matthew Tien, MD, FAAP- MetroHealth
    Roopa Thakur, MD, FAAP- Cleveland Clinic
    Jennifer Hilgeman, MD, FAAP- Dayton Children's Hospital
    Gabriella Celeste- Ohio Lead Free Children's Coalition
    Lora Miller- UHC
    Tamara Drayton- UHC
    Chris Alexandra- Ohio Department of Health
    Lisa Salyers- Ohio Department of Health
    John Belter- Ohio Department of Health