Providers are the first line of defense for keeping our children safe from childhood blood lead poisoning through education and preventative screening.
We realize physicians and healthcare providers are incredibly busy! This section 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 information included in this section provides guidance and best practices to identify, treat, and report incidences of pediatric elevated blood lead levels.
The Nevada Childhood Lead Poisoning Prevention Program (NvCLPPP) aims to eliminate one of the most preventable environmental outcomes in children: lead poisoning. Many healthcare professionals believe that lead exposure does not exist in Western states like Nevada because much of our housing is newer. However, new research is showing that very low levels of exposure can have deleterious health effects. Further, older homes exist in Nevada and lead exposure is being identified more frequently in other sources as well. Spices, toys, jewelry, keys, cultural and ceremonial items, and parents whose occupations or hobbies may bring lead into the home. Children in Nevada are at risk.
A growing consensus of scientific studies find no safe level of lead exposure exists and that lead levels between 5 µg/dL and 10 µg/dL present no obvious outward symptoms and have damaging effects on cognitive abilities as well as cardiovascular, endocrine, and immune systems. In response, the Centers for Disease Control and Prevention (CDC) Advisory Committee on Childhood Lead Poisoning and Prevention (ACCLPP) recommended to lower the threshold for identifying children in need of follow-up for elevated blood lead levels from 10 µg/dL to 5 µg/dL of lead concentration in blood.
We hope you will find this resource valuable and suited to the needs of your practice:
Testing recommendations from the Centers for Disease Control and Prevention
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
- Or at least once before age 6 if not previously tested
- Guidelines for Testing by Coverage Type
- Council of State and Territorial Epidemiologists Definitions
- Additional Screening Recommendations
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)||Yearly blood lead test unless annual risk assessment questionnaire|
Council of State and Territorial Epidemiologists Definition of Lead Poisoning
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.
- 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..
Additional Screening Recommendations
Currently, screening rates in Nevada for blood lead levels in children are 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 accordance with the CDC guidelines for blood lead to ensure the best health outcomes.
Providers should also screen children who are symptomatic or potential exposure to lead has been identified, regardless of the child's age.
Providers for children not eligible for Medicaid or NV Checkup 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 chips or object that might contain lead
Recommended Testing Schedule for Recently Arrived Children Who Are Refugees
- Perform a blood lead test for children aged 6 months to 16 years within 30 days of entry to the US
- Within 3-6 months of an initial test, conduct a follow-up test for children aged 6 months to 6 years, regardless of the initial test result
- Consult the US the CDC screening guidelines for children who are immigrants and refugees.
Screening Via Capillary Test Or Traditional Venous Draw
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, as required by 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|
Notification of the local health authority
- Lead Exposure Is A Reportable Condition By Law
- Clark County
- Washoe County
- Carson City
- Rural Counties
Lead Exposure Is A Reportable Condition By Law
In the state of Nevada, lead exposure is a reportable condition by law. Per NRS 441A, reports of specified diseases, outbreaks, and extraordinary occurrences of illness MUST be made to the local health authority. This law requires physicians, registered nurses, and directors of medical facilities report lead exposure and elevated blood lead levels as events of concern. Failure to report is a misdemeanor and subject to an administrative fine of $1,000 for each violation. Provider Disease Reporting may be accomplished by contacting your local health authority through the following methods:.
- Electronically (Preferred) SNHD Reporting Forms https://www.southernnevadahealthdistrict.org/diseasereports/forms/disease-reporting
- Telephone Southern Nevada Health District 702-759-1300
- Fax the Nevada Confidential Morbidity Report Form to 702-759-1454
- Telephone Washoe County Health District 775-328-2447 or Email email@example.com
- Fax the Nevada Confidential Morbidity Report Form to 775-328-3764
- Telephone Carson City Health and Human Services 775-887-2190
- Fax the Nevada Confidential Morbidity Report Form to 775-887-2138
- Telephone Nevada Division of Public and Behavioral Health 775-684-5289
- Fax the Nevada Confidential Morbidity Report Form to 775-850-1144
|BLL Test Results (μg/dL)||Venous Confirmation -Retest Within||Recommended Actions based on BLL||Venous Retest – After Recommended Actions|
||Retest according to Blood Lead Screening Plan|
|5 – 9||3 mo||
Above Actions, plus:
||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:
||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:
||Every 24 hours or as medically indicated|
Resources for education and lead-safe homes
Services are available for families of children with elevated blood lead levels to evaluate and place them into programs appropriate for their level of ability. The Southern Nevada Health District provides a full lead investigation of a child’s home environment when a venous blood lead test result is 5 μg/dL or greater.
- Nevada Early Intervention Services (NEIS)
- Child Find Department
- Las Vegas Lead Hazard Control and Healthy Homes Program
Nevada Early Intervention Services (NEIS)
Nevada Early Intervention Services (NEIS) provides an evaluation of children’s development and services at no cost to children 3 years old and younger at no cost. dhhs.nv.gov/programs/idea/early_intervention_programs Clark County 702-486-7670 Washoe County 775-688-1341 Carson City 775-687-0101 Statewide 1-800-522-0066.
Child Find Department
Child Find Department offers services for children age 4 and older through the family’s local school district at no cost. dhhs.nv.gov/programs/idea/projectassist/local-resources Clark County 702-799-7463 Washoe County 775-327-0685.
Las Vegas Lead Hazard Control and Healthy Homes Program
Las Vegas Lead Hazard Control and Healthy Homes Program offers free lead risk assessments to qualified residents who meet eligibility requirements and have a child, visiting child, or pregnant woman in the home. If lead is found, LVLHCHHP will conduct a more in-depth healthy homes assessment of the dwelling to identify hazards that may be remediated through the program, such as broken air conditioners, windows, door locks, plumbing issues, and more. The program will then make repairs to the home to improve the home's health and safety at no cost to the home's owner or occupants. Rental units are also eligible. Additionally, the program offers free blood lead testing to children under 6.
- Lead-based paint and healthy homes assessments
- If a lead hazard is found:
- Repair or removal of lead-based paint
- Home repairs (electrical, plumbing, windows, etc.)
- Blood lead testing for young children
To qualify, dwellings must be in the following zip codes: 89101, 89102, 89104, 89106, 89107, 89108, 89109, 89110, 89117, 89124, 89128, 89129, 89130, 89131, 89134, 89138, 89143, 89144, 89145, 89146, 89149, 89166.
For more information, contact Earlie King at 702-229-5935 or firstname.lastname@example.org or view the flyer here.
Below is a small selection of leading and novel research in the field of environmental lead exposure that discusses the health, cognitive, social and physiological effects of lead exposure in our communities. Continued research is essential to assisting healthcare providers and public health practitioners in advocating for best practices that lead to the best health outcomes for the populations that we serve.
Lead Poisoning in Children, Warniment, Tsang, Galazka, 2010. A thorough refresher of lead poisoning prevalence, routes of exposure, screening, and management of positive test results published in the Journal of the American Family Physician. This resource explains the common sources of exposure beyond lead-based paint, to include cultural items like eye makeup and alternative remedies. Further, this paper shares how to counsel families to exclude dangerous contaminants, adjust their child’s diet to reduce lead absorption, and connect families to community resources that may help them avoid further exposure while also responding in a responsible fashion.
Low-level lead exposure and mortality in US adults: a population-based cohort study, Lanphear, Rauch, Auinger, Allen, Hornung, 2018. This paper discusses the effects of chronic, low-level lead exposure on human development and physiology resulting in increased morbidity, particularly cardiovascular disease.
Childhood Lead Poisoning, World Health Organization, 2010. This report outlines the need for universal testing and concludes that there is sufficient evidence for adverse health effects resulting from blood lead levels less than 5 μg/dL. Blood lead levels, once considered safe, are now understood to compromise health and injure multiple systems, even in the absence of multiple symptoms. This document describes the broader threat to public health posed by lead exposure and outlines morbidity rates and their sources, as well as socioeconomic contributors to disease incidence.
Pb Neurotoxicity: Neuropsychological Effects of Lead Toxicity, Mason, Harp, Han, 2014. This article describes lead exposure’s effects on neuropsychological function that varies across a lifespan. This review elaborates that intelligence, memory, executive functioning and attention, processing speed, language, motor skills, and many more functional areas are affected by lead exposure at any age.
Policy Statement - Lead Exposure in Children: Prevention, Detection, and Management, American Academy of Pediatrics, Committee on Environmental Health, 2005. The AAP discusses the need for continued surveillance of blood lead levels among pediatric patients despite the reduction in catastrophic lead injury in recent years. Further, evidence continues to mount that there are serious negative health outcomes for patients that have blood lead levels even below 10 μg/dL. Additionally, there is a need to shift from case identification and management to primary prevention.
NTP Monograph on Health Effects of Low-Level Lead, US Department of Health and Human Services, 2012. US Department of Health and Human Services, 2012. This monograph by the National Toxicology Program of the US Department of Health and Human Services summarizes the evidence for lead-associated health effects in children and adults at these low exposure levels. The evidence provides support for adverse health effects in both children and adults at blood lead levels below 10 μg/dL, and for some effects, below 5 μg/dL, including neurological, immunological, cardiovascular, renal, reproductive, and developmental effects.
Low-level environmental lead exposure still negatively associated with children’s cognitive abilities, Earl, Burns, Nettelbeck, Baghurst, 2016. A new study conducted in Australia, this paper describes the intellectual deficits children develop with increased exposure to environmental lead as assessed in 7 and 8-year-olds. The researchers found that the study clearly found a significant negative correlation between blood lead levels and IQ, even when controlling for socioeconomic, environmental, and familial variables. Further, the group challenges the perception that IQ reduction due to lead exposure is not serious, as they found the changes were a deleterious to cognitive development and that the effect was so great that the same findings may be reached within modest samples.
Lead in Spices, Herbal Remedies, and Ceremonial Powders Sampled from Home Investigations for Children with Elevated Blood Lead Levels - North Carolina, 2011-2018, Angelon-Gaetz Klaus, Chaudhry, Bean, 2018. This article in Morbidity and Mortality Weekly Report follows the elevated blood lead levels in children to the source. Though the overall number of elevated blood lead levels are down, an increasing cause for exposure is the result of spices, herbal remedies, and ceremonial powders in their homes. As much as 28% of spices, herbal remedies, and ceremonial powders sampled from homes inspected contained 1.0 mg/kg lead or greater.
Intellectual Impairment in Children with Blood Lead Concentrations below 10 μg per Deciliter, Canfield, Henderson, Cory-Slechta, Cox, Jusko, Lanphear, 2003. This article discusses the effect low-level exposure has on the development of 172 children varying in age up to 60 months. Researchers found blood lead concentration was inversely and significantly associated with IQ and other cognitive markers.
Very low lead exposure and children's neurodevelopment, Bellinger, 2008. In Current Opinion in Pediatrics, Bellinger describes negative health outcomes, including reduced intelligence quotient, academic deficits, and neuropsychiatric disorders such as attention deficit hyperactivity disorder and antisocial behavior occurring with exposure levels at or below 10 μg/dL, concluding that the current safe and low levels used to describe lead exposure still lead to morbidity.
Children's Lead Exposure: A Multimedia Modeling Analysis to Guide Public Health Decision-Making, Zartarian, Xue, Tornero-Velez, Brown, 2017. This paper describes the development of a coupled exposure-dose modeling approach that may be used to determine what drinking water lead concentrations keep children’s blood lead levels below specified values with consideration of exposure to water, soil, dust, food, and air.
Prevention of Childhood Lead Toxicity, Council on Environmental Health, 2018. A policy statement of the Council on Environmental Health, the American Academy of Pediatrics explains the path to childhood lead toxicity via primary prevention. The AAP recognizes that while the average blood lead concentration in US children has dropped over the last 4 decades, many children are still at risk of lead exposure.
Blood Lead Concentrations and Child Intelligence at 6 Years of Age, Jusko, Henderson, Lanphear, Cory-Slechta, Parsons, Canfield, 2008. This paper examines the association between blood lead concentrations assessed throughout early childhood and children’s IQs at 6 years of age. When children were followed from 6 months to 6 years of age, children with increased blood lead levels across that span performed more poorly on IQ tests at age 6.
Educational Interventions Children Affected by Lead, Centers for Disease Control and Prevention, 2015. This CDC document outlines the available scientific data on the effects of lead and describes major gaps in our understanding of how successful educational interventions are for reversing academic problems in children affected by lead. Targeted to public health and education professionals, healthcare providers, and those who work with children, the studies cited here focus on the effects of low-level lead exposure on children’s brains, learning system, and development.