Lead Screening Policy & Guidance - Clinical Management

Office of Environmental Health

The Screening Policy & Guidance for Preventing Childhood Lead Poisoning in Arizona

Table of Contents	The AZ Childhood Lead Screening Policy	Lead Poisoning/Prevention

Health Effects	Pathways to Lead Exposure	Sources of Lead Exposure

Childhood Lead Poisoning in AZ	Anticipatory Guidance	Blood Lead Screening Recommendations

Diagnostic Testing For Children w/ Elevated Blood Lead Levels	Follow-Up Testing For Children w/ Elevated Blood Lead Levels	Reporting of Elevated Blood Lead Levels and Follow-Up Svcs

Comprehensive Follow-Up Svcs	Clinical Mgmt	Environmental Case Follow-Up

Mgmt of Lead Hazards	References	Appendix A

Appendix B [PDF 79K] (Acrobat Reader^™ needed for viewing)	Appendix C-1	Appendix C-2

Clinical Management

Health Care Providers should conduct clinical management for children with elevated blood lead levels. Clinical management includes:

Clinical evaluation for complications of lead poisoning
Lead education materials (sent by ADHS to families of lead poisoned children)
Chelation therapy, if appropriate
Follow-up testing at appropriate intervals

Clinical evaluation
Components of Clinical Evaluation:
       Medical history:
            Symptoms
            Developmental history, including failure to thrive
            Mouthing activities
            Pica
            Previous blood lead levels; history of anemia
            Family history of lead poisoning.
       Environmental history:
            Age, condition, repainting or remodeling of residence or any other place the child
                  spends time (secondary homes, relatives' homes, day-care centers, etc.)
       Occupational and hobby histories of adults with whom the child spends time
       Other local sources of potential exposure
       Nutritional history:
             Dietary history
             Food Stamps or WIC participation
       Physical examination with particular attention to:
             Growth curve
             Neurologic examination
             Psychosocial and language development.
       Additional diagnostic assessment depending on circumstances
             Diagnostic testing may include:
             Formal neurobehavioral assessment
             Abdominal X ray for radiopaque material
             Long-bone films for growth arrest lines
             Zinc protoporphyrin or free erythrocyte protoporphyrin

Findings of language delay, developmental delay or other neurobehavioral or cognitive problems should prompt referral to other appropriate programs, i.e., AzEIP (See Appendix A). Children may need early intervention programs and further examinations during the early school years to facilitate entry into an appropriate educational program.

Family education
Identified nutritional problems should be corrected. Absorption and toxicity of lead may be increased by :

Calcium and iron deficits
An empty stomach. Eating smaller and more frequent meals is recommended.

Refer children for appropriate social services if problems such as inadequate housing, lack of routine health care, or need for early intervention educational services are discovered. ADHS may also provide referral sources. (See Appendix A).

Chelation therapy
Prior to initiation of chelation, it is important to be certain that there is no ongoing source of lead, either in the child's immediate environment or in the gastrointestinal tract. Abdominal X ray may be useful prior to commencing treatment.

>20 µg/dL Patient is a possible candidate for oral chelation. Consult medical toxicologist for guidance.

>45 µg/dL Initiate oral chelation therapy promptly. Remove child from sources of lead exposure.

>70 µg/dL Initiate chelation therapy immediately. If such an elevated result is obtained on a capillary sample, order an immediate diagnostic test and initiate chelation while that test is being performed, if there is reason to believe that the results of the screening test are accurate (e.g., if it was obtained by a skilled phlebotomist under controlled conditions). Discourage the family from returning the child to the same lead-poisoned environment.

Before chelation is initiated:

<70 µg/dL Perform a second blood lead level test on a venous specimen to ensure that therapy is based on the most recent and reliable information possible. Levels of 60-69 µg/dL should have a venous test within 24 hours.

>70 µg/dL Perform an urgent repeat test, but begin chelation therapy immediately, without waiting for the repeat test result.

A child who is receiving chelation therapy should be tested at least once a month. When chelation is terminated, blood lead levels should be monitored frequently to address the possibility of lead rebound from the bones into the blood and until sources of lead have been identified.

See Appendix A for M.D. toxicologists who can provide physician guidance.

Follow-up testing
A follow-up test is a venous blood lead test used to monitor:

The status of a child with an elevated blood lead level on a diagnostic test
The effectiveness of the services that child is receiving (i.e., prevention advice and counseling, lead hazard control, chelation therapy).

Children who are receiving clinical management should be tested at 1- to 2-month intervals until all of these conditions are met:

The blood lead level has remained <15 µg/dL for at least 6 months, and
Lead hazards have been resolved, and
There are no new exposures.

When these conditions have been met, children should be tested approximately every 3 months.

Children for whom these three conditions are met and who have reached 36 months of age no longer need to receive follow-up testing.

A downloadable version of The Screening Policy & Guidance for Preventing Childhood Lead Poisoning in Arizona [PDF 586K] is available. The download is in PDF format. It is necessary to have Acrobat Reader^™ on your machine to view the download.

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