Guidelines and Methods

How to Respond
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We realize physicians and healthcare providers are incredibly busy! This page provides guides and reference material for identifying and following up on pediatric elevated blood lead levels.

Nevada ranks near the bottom of US states in childhood blood lead level testing, with as few as 3% of children tested annually. The following information provides guidance and best practices to identify, treat, and report incidences of pediatric elevated blood lead levels.

Providers should confirm all blood lead levels of 5 μg/dL or greater from venous blood draws. Lead test reporting is required for medical professionals by Nevada law.

CDC Guidelines for Testing for Lead in Children

There is no safe level of blood lead concentration. According to the CDC, children should be tested by venous blood draw for elevated blood lead levels at

  • 12 months
  • 24 months
  • at least once before age 6 if not previously tested

Guidelines for Testing by Coverage Type

Age Children Covered by Medicaid and NV Checkup Children Covered by Private Insurance
1 year (9-17 months)* Blood lead test mandatory Blood lead test unless annual risk assessment questionnaire is negative
2 years (18-36 months) Blood lead test mandatory Blood lead test unless annual risk assessment questionnaire is negative
3-5 years (36-72 months) 1. If not previously tested: conduct blood lead test

2. If previously tested: Blood lead test yearly unless annual risk assessment questionnaire is negative.

Yearly blood lead test unless annual risk assessment questionnaire

 

Additional Screening Recommendations

Currently, screening rates for blood lead levels in children lower than 3%, making it difficult to know the totality of pediatric lead poisoning in Nevada. Therefore, the NvCLPPP and CDC recommend universal screening as a method to adequately assess individual patient needs and population-level epidemiological data. However, at a minimum the NvCLPPP recommends:

Providers should screen all children in accord with the CDC guidelines for blood lead to ensure the best health outcomes.

Providers should also screen children who are symptomatic or a potential exposure to lead has been identified, regardless of children’s age.

Providers of non-Medicaid eligible children should – at a minimum – conduct a lead risk evaluation using the Childhood Lead Risk Questionnaire (CLRQ) to determine the risk of potential exposure during a healthcare visit if screening is not a viable option. The CLRQ was adapted from the Illinois Department of Public Health.

Children of all ages who are recent immigrants, refugees, or adoptees are more likely to have elevated blood lead levels and should be screened at the earliest opportunity.  Additionally, children who live in lower socioeconomic areas may be at higher risk.

Consider a blood test, regardless of age, if children have any of the following conditions:

  • Unusual oral behavior, pica, developmental delays, behavior problems, ADHD
  • Unexplained illness such as severe anemia, lethargy, abdominal pain
  • Ingestion of paint chip or object that might contain lead

Recommended Testing Schedule for Recently Arrived Children Who Are Refugees

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Methods for Conducting a Blood Lead Level Test in Children

Providers have the option of screening via capillary test or traditional venous draw. Capillary blood analysis may be completed using a CLIA waved in-office testing device such as the Magellan LeadCare II device and directly reporting the results to the local health authority. All capillary screening results must be reported to the local health authority per NRS 441A. For help obtaining an in-office capillary blood lead testing device, contact the NvCLPPP at 702-895-1040.
Higher capillary test results necessitate the urgent need for venous test confirmation. Venous test results are required to access health authority services.

Capillary Test Confirmation Schedule

Capillary Blood Lead Level Confirm with Venous Test Within*
5-9 µg/dL 3 months
10-44 µg/dL 1 month
45 -59 µg/dL 48 hours
60-69 µg/dL 24 hours
70+ µg/dL Immediately as an emergency test

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Council of State and Territorial Epidemiologists Definition

Laboratory Criteria for Diagnosis Blood lead concentration, as determined by a Clinical Laboratory Improvement Amendments (CLIA)-certified facility, of ≥5 µg/dL (0.24 µmol/L) in a child (person <16 years of age).
Criteria to Distinguish a New Case from an Existing Case Counted once per year, regardless of the number of elevated blood lead levels in the same year.
Case Classification

  • Confirmed One venous blood specimen with elevated lead concentration, or two capillary blood specimens, drawn within 12 weeks of each other, both with elevated lead concentration.
  • Unconfirmed A single capillary or unknown blood specimen with elevated lead concentration or two capillary blood specimens, drawn greater than 12 weeks apart, both with elevated lead concentration.
  • Case Classification Comments Elevated blood lead levels, as defined above, should be used as standard criteria for case classification for the purposes of surveillance but may not correspond to action levels determined by individual public health programs or by providers with respect to patient care.

Elevated BLL classification does not use any case classification categories other than “confirmed” and “unconfirmed”. The “unconfirmed” category identifies tested children with a potentially elevated BLL but where testing was inadequate to make that determination.

How to Respond

BLL Test Results

(μg/dL)

Venous Confirmation Retest Within Recommended Actions based on BLL Venous Retest –

After Recommended Actions

< 5 None •   Provide dietary counseling (calcium & iron) and environmental education

•   Follow-up blood lead monitoring at recommended intervals

Retest according to

Blood Lead Screening Plan

5 – 9 3 mo Above Actions, plus:

•       Complete history and physical exam

•       Lab work: iron status, hemoglobin, hematocrit

•       Refer to health department for environmental investigation

•       Recommend lead hazard reduction in home

•       Neurological, behavioral, and developmental monitoring

•       Abdominal x-ray (if lead ingestion is suspected with bowel decontamination)

•       Environmental assessment to identify potential lead sources

3 months for first 2 – 4 tests

6 – 9 months after BLL are declining

10 – 19 1 – 3 mo 1 – 3 months for first 2 – 4 tests

3 – 6 months after BLL are declining

20 – 24 1 – 3 mo 1 – 3 months for first 2 – 4 tests

1 – 3 months after BLL are declining

25 – 44 2 wk – 1 mo 2 weeks – 1 month for first 2 – 4 tests

1 month after BLL are declining

45 – 59 ASAP

48 hours

Above Actions, plus:

•   Environmental investigation of the home and lead hazard reduction

•   Oral chelation therapy

•   Consider hospitalization if lead-safe environment cannot be assured

Every 24 hours

or as medically indicated

Every 24 hours

or as medically indicated

60 – 69 ASAP

24 hours

≥ 70 Stat as emergency test Above Actions, plus:

•   Hospitalize and commence chelation therapy in conjunction with consultation from a medical toxicologist or a pediatric environmental health specialty unit

Every 24 hours

or as medically indicated

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