The Illinois Department of Public Health (IDPH) is providing you with these recommendations for lead risk assessment and blood lead screening. This document summarizes key guidelines and directs you to more detailed sources of information and related agencies.

WHAT IS THE RISK OF LEAD POISONING FOR ILLINOIS CHILDREN?

In 2000, more than 20,000 Illinois children had an elevated blood lead level (defined as blood lead >=10 µg/dL). Among children tested, one of every 17 children in areas outside of Chicago and one of every six children tested in Chicago had an elevated lead level. These statistics may underestimate the Illinois problem. Many children do not have their blood tested for lead, nor are they assessed for risk of poisoning. For example, although all children age 6 and under in Chicago are considered at high risk for lead poisoning, only one-third had a blood lead test in 2000.

WHICH CHILDREN ARE AT HIGHEST RISK?

• The risk of lead poisoning falls disproportionately on low-income children. The United States General Accounting Office estimated that one in 12 children on Medicaid had an elevated blood lead level. It also found that blood lead screening among children on Medicaid was low: 81 percent of Medicaid children had NOT received a blood lead test.¹
• National data demonstrate that minority children are at high risk.² In Illinois, African-American children are more than three times as likely to have elevated blood lead levels as Caucasian children, and the risk of elevated blood lead for Hispanic children is double compared to Caucasian children.
• Children residing in older houses and apartments are at greatest risk. A recent national survey estimated that in older homes where children younger than age 6 reside, the vast majority have lead-based paint hazards. For homes built before 1940, 94 percent are estimated to contain lead- based paint hazards; for homes built between 1940 through 1959, 87 percent have lead-based paint hazards.³ In Illinois, 23 percent of homes were built between 1940 and 1959; 25 percent of Illinois homes and 46 percent of Chicago homes were built in 1939 or earlier.⁴

WHAT ARE THE EFFECTS OF LEAD POISONING?

Lead damages the developing brain and nervous system. A majority of studies suggest that the effects of lead are NOT reversible. Following are the most prominent health effects of lead poisoning in children:

• Learning disabilities, including speech and language delays, some of which may remain latent until school age tasks are encountered;
• Behavior problems, including aggression and hyperactivity; Interference with red blood cell formation leading to anemia; and
• In its most advanced stages, seizures, coma and sometimes death.

Newer studies suggest that cognitive abilities - math and reading skills, nonverbal reasoning and short-term memory - are affected at levels below 10 µg/dL.⁵

WHAT ARE THE EFFECTS OF MATERNAL LEAD ON THE DEVELOPING FETUS?

Although lead transfers from mother to fetus during pregnancy and through breast milk, adequate calcium intake during both pregnancy and lactation significantly decreases the amount of lead released from maternal bone stores and available for transfer to the fetus or infant. Breastfeeding has many beneficial effects, and it should be encouraged unless the mother’s lead level is quite high, currently identified at levels of 45 µg/dL or above.

WHAT ARE THE SYMPTOMS OF LEAD POISONING?

Despite suffering the effects of lead poisoning, a majority of children with lead poisoning have no obvious symptoms. Symptoms of severe lead poisoning may include—

• Irritability
• Headaches
• Vomiting
• Seizures
• Anemia/fatigue
• Loss of appetite and/or weight loss
• Stomachaches and cramping/constipation

Since these symptoms are not specific to lead poisoning, rigorous risk assessment and blood lead testing are the only effective ways to detect lead poisoning.

WHY ARE YOUNG CHILDREN AT A HIGH RISK FOR LEAD POISONING?

Children can absorb approximately 50 percent to 70 percent of ingested lead, whereas adults generally absorb about 5 percent. Certain developmental phases expose children to new sources of lead; for example, child oral behaviors and hand exposures to lead-containing dust on floors and windows promote lead ingestion. Children who are 1 or 2 years of age should be considered the highest priority for assessment and testing.

WHAT ARE THE MAJOR SOURCES OF LEAD?

The most common source of lead poisoning is deteriorated lead-based paint and lead-contaminated dust in older homes. Unsafe renovation or remodeling practices can greatly increase the risk of exposure to lead dust from paint deterioration. Particularly in urban areas, soil has become contaminated with lead due to exterior paint deterioration and the past use of lead in gasoline. Other sources include parental hobbies or occupations that involve exposure to lead, water contamination from lead solder/pipes in older homes, use of lead-containing traditional medicines or cosmetics, food in imported metal-seamed cans or use of lead-containing pottery. Vinyl mini-blinds purchased before July 1997 also are likely to contain lead.

There continues to be an ever increasing array of imported products that contain lead. Contact IDPH for an updated product list.

YOUR RESPONSIBILITIES AS A HEALTH CARE PROVIDER

WHAT TYPE OF EVALUATION DO CHILDREN NEED FOR LEAD POISONING?

IDPH has determined high-risk and low-risk ZIP code areas for Illinois, based on age of housing stock and poverty level. ZIP codes identified as high risk are listed in Appendix A. Please note that all Chicago ZIP codes are high risk. Based on the ZIP code of a child’s residence and participation in public assistance programs, the appropriate screening or assessment strategy, as discussed below should be applied. Additionally, all children with siblings who have elevated blood lead levels should have a blood lead test.

CHILDREN ELIGIBLE FOR MEDICAID OR KIDCARE ASSISTANCE

IN ALL AREAS OF THE STATE, CHILDREN ELIGIBLE FOR MEDICAID OR KIDCARE ASSISTANCE ARE REQUIRED TO HAVE A BLOOD LEAD TEST AT 1 AND 2 YEARS OF AGE. If a child is 3 years old through 6 years old and has not been tested, a blood lead test is required.

CHILDREN NOT ELIGIBLE FOR EITHER MEDICAID OR KIDCARE ASSISTANCE

• IN HIGH-RISK ZIP CODE AREAS; BLOOD LEAD TESTING IS REQUIRED.
  You should routinely obtain blood lead tests on children ages 6 months through 6 years old. The U.S. Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics highly recommend that children have a blood lead test at ages 1 and 2 years. If lead exposures change, or if a child is new to your practice and you do not know his/her past blood lead levels, blood lead testing at ages 3 through 6 years should also be performed.
  
  
• IN LOW-RISK ZIP CODE AREAS; RISK ASSESSMENT IS REQUIRED, FOLLOWED BY BLOOD LEAD TESTING, AS NECESSARY.
  You should routinely assess risk of exposure to lead sources at office visits of children 6 months through 6 years old by using the Childhood Lead Risk Assessment Questionnaire (Appendix B). A “YES” or “DON’T KNOW” response to any of the questions means that the child has a higher likelihood of exposure to lead contamination and will require you to perform a blood lead test. (Additional copies of the risk assessment questionnaire are available by contacting IDPH.)
  
  
• IN CHICAGO, A BLOOD LEAD TEST IS REQUIRED.
  Because of the high risk of exposure to lead for children in Chicago and high rates of lead poisoning, the Chicago Department of Public Health (CDPH) has established blood lead screening guidelines for all of the city’s children. CDPH guidelines call for the following:
  
  
  • A blood lead test for children age 3 and younger should be obtained at 6, 12, 18, 24 and 36 months OR at 9, 15, 24 and 36 months.
    
    
  • Children 4 through 6 years of age with prior blood lead levels <10 µg/dL should have an annual risk assessment. A blood lead test should be performed if risk increases or if the child exhibits persistent oral behaviors.

WHAT METHOD SHOULD I USE TO TEST BLOOD LEAD LEVELS?

The only reliable way to test lead levels is to obtain a blood lead measurement.

• Blood samples collected via venous draw provide the most reliable means of measuring lead and are more cost-effective in high prevalence areas.
• Blood samples collected via finger stick into capillary tubes can be utilized for screening purposes. However, capillary samples can be contaminated by lead-containing dust on the child’s hand. Contamination can be minimized if proper collection technique is followed. Elevated test results need prompt venous confirmation.
• Blood samples collected onto filter paper are not recommended by the CDC. However, IDPH recognizes the filter paper methodology may be appropriate for some providers in low prevalence communities. Filter paper lead results may be less accurate in children with anemia. Elevated test results need prompt venous confirmation using an analysis method other than filter paper.

WHAT IS THE RECOMMENDED FREQUENCY OF FOLLOW-UP TESTING FOR CHILDREN WITH ELEVATED BLOOD LEAD LEVELS?

*The CDC has published treatment and case management recommendations: Managing Elevated Blood Lead Levels Among Young Children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention, U.S. Dept. of Health and Human Services, Public Health Service, March 2002, http://www.cdc.gov/nceh/lead/lead.htm. The CDC recommends that primary care providers consult with an expert in the management of lead chelation therapy prior to using chelation agents. Contact IDPH or your local health department for appropriate referrals. Because blood lead levels (“BLLs”) of patients undergoing chelation therapy with succimuer can rebound after treatment ends, the CDC recommends rechecking children’s BLLs seven to 21 days after completion of chelation therapy.

AM I OBLIGATED UNDER ILLINOIS LAW TO CONDUCT LEAD RISK ASSESSMENTS AND, AS APPROPRIATE, BLOOD LEAD SCREENING?

Yes. The Illinois Lead Poisoning Prevention Act mandates that every physician and health care provider must screen (using a blood lead measurement) in high-risk areas and must assess (using the Childhood Lead Risk Assessment Questionnaire) in low-risk areas, all children 6 months through 6 years of age for possible lead poisoning (410, ILCS 45/6.2)6. All cites to Illinois law can be found at http://www.ilga.gov.

DO I HAVE ANY REPORTING OBLIGATIONS?

Yes. In order to ensure that children receive appropriate public health follow-up services, physicians and other health providers have an obligation to report blood lead results greater than or equal to 10 µg/dL within 48 hours to the IDPH Childhood Lead Poisoning Reporting System at 217-782-0403. Providers using the IDPH lab are not required to report blood lead results. Directors of private laboratories performing blood lead analyses are legally required to report all results to IDPH: results >=10 µg/dL within 48 hours and results <=10 µg/dL within 30 days ( 410 ILCS 45/7; 77 Ill. Adm. Code 845.20)7. <www.legis.state.il.us/ilcs/ch410/ch410act45.htm>.

WHAT PUBLIC HEALTH FOLLOW-UP SERVICES ARE AVAILABLE?

Follow-up and case management services are provided by nearly all local health departments in Illinois. IDPH contracts with 84 city and county health departments to act as delegate agents for the state to track and coordinate the care of lead poisoned children. The following is a brief summary of services provided by these agencies:

1. Confirmed levels 10 - 19 µg/dL. Parents are counseled on possible sources of lead hazards and are provided with educational handouts on nutrition, hygiene and prevention, the need for repeat testing in three months, and possible referral for social services.
   
   
2. Confirmed levels 20 - 44 µg/dL. Parents are referred to a physician for medical evaluation and treatment within 10 working days; a home visit is conducted by a health department nurse; and parents are counseled on possible sources of lead hazards and are provided with educational handouts on nutrition, hygiene and prevention, the need for repeat testing monthly or per physician instructions, and possible referral for social services.
   
   At levels >=25 µg/dL, an environmental investigation is conducted by a licensed lead risk assessor. Inspections also are conducted at children’s residences for three successive blood lead levels of 15 - 24 µg/dL, a level of >=15 µg/dL with a subsequent result of at least 5 mcg/dL or higher than the first level. A physician may also request an investigation at levels of 20 µg/dL (77 Ill. Adm. Code 845.26). The Chicago Department of Public Health conducts environmental inspections at confirmed levels of 15 µg/dL and higher.
   
   
3. Confirmed levels 45 - 69 µg/dL. Parents are referred to a physician for medical evaluation and treatment within 48 hours; a home visit is conducted by a health department nurse within five working days; and parents are counseled on possible sources of lead hazards and are provided with educational handouts on nutrition, hygiene and prevention, the need for repeat testing monthly or per physician instructions, and possible referral for social services. The environmental investigation is conducted within five working days.
   
   
4. Confirmed levels >=70 µg/dL. Parents are referred to a physician for medical evaluation and treatment IMMEDIATELY. THIS IS A MEDICAL EMERGENCY. A home visit is conducted by a health department nurse within 24-48 hours. Environmental investigation is conducted within 24-48 hours. Education is provided to the family, as are referrals to social services as needed.
   
   
5. Services provided by the health department or other agencies within the community to which the patient may be referred include nutrition programs such as WIC and food stamps, public assistance, Early Intervention, DCFS and social service agencies. In addition, patients may receive a Denver Developmental assessment and information on special education, financial aid and housing resources. Free or low-cost blood lead testing may be available through the local health department.

DO CHILDREN NEED PROOF OF A BLOOD LEAD SCREENING OR RISK ASSESSMENT BEFORE ADMISSION TO A CHILD CARE FACILITY OR SCHOOL?

Yes. Under Illinois law, a parent or guardian of any child between the ages of 6 months through 6 years is required to provide a statement from a physician or health care provider certifying that his or her child has been screened/assessed for lead poisoning before that child may be admitted to a day care center, day care home, preschool, nursery school, kindergarten or other licensed child care facility. This statement must be provided prior to admission and subsequently in conjunction with required physical examinations (410 ILCS 45/7.1; www.ilga.gov).

WHAT INFORMATION DO I NEED TO PROVIDE TO FAMILIES WITH CHILDREN HAVING ELEVATED BLOOD LEAD LEVELS?

Educate the family

Tell the family the blood lead level result. Inform them about lead poisoning and its effects. Provide information about lead sources and the following strategies to decrease lead exposure:

• The most frequent source of lead exposure for children is lead- contaminated dust and lead-based paint chips from peeling lead paint in old houses (especially windows, doors, floors, and porches). Keep areas where the child spends time free of dust and paint chips by regular wet cleaning.
• Encourage families to have their homes inspected. The best treatment for household lead poisoning is to avoid the lead source and have a licensed lead abatement contractor safely remove the source of lead.
• Use a wet rag, paper towels or mop to wash dust and loose paint chips from window wells, woodwork and floors. Use household detergent and rinse with clean water. Clean dust rags separately from other laundry or throw away.
• Wash child’s hands frequently, especially before eating, napping and bedtime and after play.
• Ensure iron sufficiency and provide a healthy diet, particularly with recommended amounts of iron and calcium to slow the absorption of lead into the blood.
• Water can be contaminated from lead pipes in older homes. Cold tap water should be run for 30 seconds prior to use, and families should avoid hot tap water for drinking and cooking.
• Supervise where and what children play with to monitor for lead exposure. Wash toys that are mouthed frequently.

Free handouts for parents are available through IDPH’s Web address or by contacting IDPH directly (see below). Parent handouts to assess risk and to recommend ways to reduce exposures can also be downloaded at www.chicagolead.org.

References

1. U.S. General Accounting Office. Medicaid: elevated blood lead levels in children. Washington, D.C.: U.S. General Accounting Office, 1998; GAO publication no. GAO/HEHS 98-78 (data analyzed was collected during the Third National Health and Nutrition Examination Survey (1991-1994).
   
   
2. Centers for Disease Control and Prevention. Update: Blood lead levels - United States, 1991-1994. MMWR Morb Mortal Wkly Rep 1997;46:141-146.
   
   Brody DF, Pirkle FL, Kramer RA, et al. Blood lead levels in the US population: Phase I of the Third National Health and Nutrition Examination Survey (NHANES III, 1988 to 1991). JAMA. 1994;272:277-283.
   
   
3. National Survey of Lead and Allergens in Housing, Final Report, Volume 1, Analysis of Lead Hazards, Office of Lead Hazard Control, U.S. Department of Housing and Urban Development, April, 2001.
   
   
4. Census 2000 Supplementary Survey Summary Tables.
   
   
5. Lanphear B, et al. Cognitive Deficits Associated with Blood Lead Concentrations <10 µg/dL in US Children and Adolescents. Pub Health Rep 2000;115:521-529.
   
   
6. Illinois Compiled Statutes, Public Health, Lead Poisoning Prevention Act, 410 ILCS 45/.
   
   
7. Illinois Administrative Code, Title 77, Part 845.

WHO CAN I CONTACT FOR MORE INFORMATION?