Preventing and Screening for Childhood Lead Poisoning
A Reference Guide for Physicians and Health Care
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
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 mothers 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
- 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
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 childs 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
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
- 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
DONT 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 citys
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
WHAT METHOD SHOULD I USE TO TEST BLOOD LEAD LEVELS?
The only reliable way to test lead levels is to obtain a blood lead
- 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 childs 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
WHAT IS THE RECOMMENDED FREQUENCY OF FOLLOW-UP TESTING FOR CHILDREN WITH
ELEVATED BLOOD LEAD LEVELS?
|Screening blood lead result
||Follow-up test and treatment *
||Retest in 3 months.
||Perform monthly follow-up tests until lead exposures are reduced and blood
lead level is falling.
||Confirm within 48 hours. Begin chelation therapy. Perform follow-up tests
in response to treatment protocols.
|70 µg/dL 3
||Confirm and hospitalize immediately. Perform follow-up tests in response to
*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 childrens
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.
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:
- 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.
- 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 childrens
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.
- 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
- 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.
- 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 childs 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
- 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 IDPHs 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
- 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).
- Centers for Disease Control and Prevention. Update: Blood
lead levels - United States, 1991-1994. MMWR Morb Mortal Wkly Rep
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.
- 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.
- Census 2000 Supplementary Survey Summary Tables.
- 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.
- Illinois Compiled Statutes, Public Health, Lead Poisoning
Prevention Act, 410 ILCS 45/.
- Illinois Administrative Code, Title 77, Part 845.
WHO CAN I CONTACT FOR MORE INFORMATION?
|Illinois Department of Public
Childhood Lead Poisoning Prevention Program
Information and Referral Hotline
TTY (hearing impaired use only)
|Lead Education Materials
||Parental Handouts, Physician Guidelines
|Lead Abatement Program
||For information about licensed lead inspectors or lead abatement
contractors, or about abatement/remediation funds
|Childhood Blood Lead Test Reporting
|State Laboratory - Springfield
|Chicago Department of Public
||Childhood Lead Poisoning Prevention Program
||Help Me Grow Help Line
|Other Sources of
|National Lead Information Center
|National Lead Information
|Alliance to End Childhood Lead
|Lead Poisoning Resource
||(handouts, reporting forms, Illinois and Chicago lead statistics)
|Illinois Compiled Statutes
Health Lead Poisoning Prevention Act 410 ILCS 45/
Administrative Code, Chapter 1, Section 845, Lead Poisoning Prevention