Lead Poisoning in Children - Part III: Lead Screening Successes and Challenges

Lead Poisoning in Children: Early Detection, Intervention and Prevention

Part III: Blood Lead Screening - Successes and Challenges

Part III Objectives:

Upon completion of Part III you will be able to:

  • Discuss the limitations of Minnesota's statistics in presenting the entire picture of lead poisoning
  • Describe one barrier to getting at-risk children screened for lead poisoning
  • Describe one potential solution to increasing the number of at-risk children who get screened for lead poisoning
  • Describe one project that Minnesota has undertaken to increase the number of children who receive BLL screenings

Although the number of children tested for blood lead levels had increased over the years, and has since begun to drop (see figure #1), the percent of Minnesota Health Care Programs (MHCP)-enrolled children who are tested is relatively low (see figure #2). Medicaid's Early and Periodic Screening Diagnosis and Treatment program requires that well-child visits include blood lead testing at both 12 and 24 months. This is particularly important given that Medicaid-enrolled children are three times more likely to have elevated blood lead levels (EBLLs) that non-enrolled children, according to national studies. In Minnesota, MHCP-enrolled children are twice as likely to have an EBLL compared to non-enrolled children (see figure #3). MHCP-enrolled children are more likely to be exposed to risk factors for lead exposure, including older housing with lead-based paint. See "Risk Factors" for additional information about sources of lead in our environment.

Figure #1: Number of Children Tested (Less than 6 years of age)

Figure 1: Number of children tested for elevated blood lead levels in Minnesota 2000-2014. Has increased steadily, peaking at over 90,000 in 2008. Has since leveled out and begun to drop off down to 88,842 in 2014.

Figure #2: Percent of Children enrolled in Minnesota Health Care Plans (MHCP) tested for blood lead levels

Figure 2: This bar graph shows the percent of children enrolled in Minnesota Health Care Plans less than 72 months who were tested for blood lead levels and the percent of children enrolled in Minnesota Health Care Plans between 9 and 30 months who were tested for blood lead levels between the years 1999-2009. There has been a steady increase in the percent of children 9 to 30 months who were tested, ranging from approximately 18 percent in 1999 to approximately 40 percent in 2009. There has been a steady increase in the percent of children less than 72 months who were tested, ranging from  approximately 15 percent in 1999 to approximately 25 percent in 2009.

Figure #3: Percentage of Tested Children Less than 72 Months Old with EBLLs

This bar graph shows the percent of tested children less than 72 months old with elevated blood lead levels between the years of 1999-2009. Percentages are provided for children who are enrolled in Minnesota Health Care Programs and children who are not enrolled in Minnesota Health Care Programs. For both Minnesota Health Care Program-enrolled and non Minnesota Health Care Program-enrolled children, the percent of elevated blood lead levels has steadily decreased between 1999 and 2009.  For Minnesota Health Care Program-enrolled children, elevated blood lead levels range from approximately 8 percent in 1999 to approximately 1 percent in 2009. For non-Minnesota Health Care Program-enrolled children, elevated blood lead levels range from approximately 4 percent to approximately .5 percent.

Challenge: Barriers to BLL Screening Test
During Fall 2003, the MDH Childhood Lead Poisoning Prevention Program collaborated with Minnesota Health Plans to conduct regional workshops for primary care clinics to educate providers and other clinic staff about the Federal requirement. During these workshops, the following barrier to BLL screening tests was identified: the belief of some providers that it is not medically necessary to screen all enrolled children at their 12 and 24 months C&TC well-child exams.

BLL Screening Test Barriers:
In May 2009 at a meeting of the Minnesota Head Start Association, Head Start Health Coordinators from all over the state reported that the most common reason primary care providers gave for not doing BLL testing on children enrolled in Head Start programs is that they believe it is unnecessary because, "There is no lead problem in our community".

Clearly this erroneous perception still persists. Evidently MDH, C&TC Program staff at DHS and partners at the county and tribal level have more work to do in educating providers and the general public about the continued danger of lead exposure and lead poisoning of young children.

Collaboration Strategies:

  • Federal Government (WIC)
  • Between States
  • Between State Agencies (Head Start, MDH, DHS)

See what else is being done nationally and in Minnesota with regard to Lead Screening and data tracking:

An example of a project in which this type of coordination of services was employed was the MDH Childhood Lead Poisoning Prevention Program (CLPPP). This program conducted several special projects in search of successful strategies to increase blood lead level testing for high risk children in Minnesota. A blood lead testing pilot project conducted at WIC clinics was conducted in four Minnesota counties.

For further information contact your local county WIC program or Pat Faulkner, WIC Program Supervisor, at MDH Phone: 651-201-4402 or visit the WIC website.

Advantages of Collaboration with WIC Clinics

  • Access to a number of high risk children
  • Public Health Nurses (PHN) do the BLL test at the same time as WIC Hemoglobin (eliminates 2nd needle stick)
  • WIC participants include children without medical insurance, so less children fall through the cracks
  • Medicaid eligible children who do not participate in the Child and Teen Checkups program

Suggestions to Address Potential Problems

  • Clear delineation of tasks so that the WIC staff will be compliant with their requirements.
  • Ensure that proper follow-up will occur.
    • Identifying and/or connecting a child and family to a health care home and primary care provider
    • Test results must be forwarded to the health care home
    • Check to see that the appropriate interventions have been done
  • Payment
    • Agreement between collaborating agencies
    • Determine what to do about children with no insurance
  • Communications
    • Between WIC, local PH, and home clinic

MDH-DHS Lead Screening Pilot Project
In 2008, C&TC staff from DHS and MDH collaborated with the MDH Environmental Health Lead Program to initiate the "Lead Poisons Kids" pilot project. Eight Minnesota counties are participating. The main goal of this project is to increase BLL screening among C&TC eligible children ages 1-3 years by providing crucial information to parents at key points in their child's development.

Pilot counties distributed educational brochures about lead poisoning and the importance of lead screening to parents, clinics, Early Head Start and other programs. The project extended through May 2009. Feedback from pilot counties was positive and the primary goal of the project, to increase lead testing in children eligible for Child and Teen Checkups, was met. Six of the eight participating counties increased their rates of lead testing. One strategy that was reported as the most successful was collaboration with a local WIC program.

The Countryside Lead Study which was a study of lead poisoning in Chippewa, Swift, and Yellow Medicine Counties in Minnesota through funding obtained from Centers for Disease Control (CDC) and from UCARE Minnesota conducted in 2001-2. These counties were chosen for the study because one public health service agency provided services in all three counties and because of a high number of homes built before 1950, a major risk factor for EBLLs in children.

Minnesota Head Start: BLL Testing
Head Start (HS) must follow federally mandated performance standards. Those performance standards are based on the EPSDT service, Medicaid's comprehensive and preventive child health program for children birth through age 20. In Minnesota, the program is called Child and Teen Checkups or C&TC. One such performance standard involves BLL testing.

  • Every child who participates in Head Start programming is required to have a BLL test at 12 months, 24 months and one BLL test between the ages of 3 and 6 years if there is no previously documented BLL test.

Challenge:
When families are participating in multiple programs such as WIC and Head Start, it is likely they will be approached by more than one agency and/or the health care clinic to perform a BLL screening for their child. Frequent complaints from clinics and Head Start organizations is that obtaining the results of a BLL screening test-that may or may not have been performed on a child by another agency or clinic-is very costly and time-consuming. Frequently parents or caregivers' memories of previous screening tests is either erroneous (they believe the last blood test to be a BLL screening test when it was a hemoglobin check or something else) or they do not remember where the test was conducted or whether the test was done at all. It becomes more cost effective to repeat a BLL screening test than to locate and obtain the results of a BLL screening; thus creating duplication of services.

Success:
Communication and coordination of care are essential in providing comprehensive health and dental services to children and for Head Start (HS) to achieve their performance standards.

Possible strategies to achieve HS performance standard:

  • Develop relationships with staff from involved agencies to share information about BLL tests and other child health screenings.
    • Identify involved agencies and a contact person from each one
    • Obtain appropriate release of information signed by the parent
  • Meet with local insurance company representatives and clinic managers to enlist their collaboration and elicit ideas for potential solutions
    • Use of uniform documentation forms (e.g. C&TC forms for providers and clinics)
    • Develop hard copy form to accompany electronic chart forms and give a copy to the parents
  • Inform local clinics of
    • Head Start Performance Standards
    • Head Start Contact Info (Phone/Fax)
    • Patients who are Head Start participants

Improving Utilization of Risk Assessment Questionnaires
Multiple studies have been conducted to investigate the predictive value of the CDC lead risk assessment questionnaire and EBLL. Most have reported sensitivity of 60-70% or less. Some studies have reported greater sensitivity if population specific questions were added. Several studies indicated that questions specifically related to the child's home were the most predictive of EBLL; yet in the June 2003 edition of the Archives of Pediatric & Adolescent Medicine, a study that measured accuracy in parental reporting home age found that most parents did not know the age of their home.

However, the meta-analysis of research from 1995-2005 discussed in the article published in Pediatrics, December 2006 concludes that adding regional and population specific modifications and/or additions to the CDC risk assessment questionnaire does increase its sensitivity and should be added to the tool.

BLL Screening: Spending Priorities

Some may question the merits of blood testing when compared to needed funding for interventions aimed at other significant public health issues. However, the irreversibility of some of the more serious effects of lead poisoning results in higher lifetime medical costs. Intervention and prevention measures are pivotal for health issues such as obesity; however, we cannot address other health problems at the expense of lead poisoning.

Most states have requirements of testing of newborns for multiple disorders (some rare) at birth because of a public health determination that the benefits of prevention and/or early intervention greatly outweigh the cost of such testing. Continued screening for lead poisoning can be justified by applying the same standard, since the costs of BLL screening tests are minimal and the benefits to the individual child and to society in preventing the disease are overwhelmingly greater.

BLL Testing Requirements
The federal EPSDT requirement, per the Centers for Medicare & Medicaid Services (CMS), is to perform a BLL test at the 12 and 24 month C&TC screenings or if never tested, perform a BLL screening for children up to age 6 years.

This is consistent with the 12 and 24 month AAP recommendation but is a requirement for C&TC rather than a recommendation based on the risk factors (i.e. low income, higher likelihood of older housing, increased nutritional risk) of children receiving C&TC well child exams.

Other Recommendations:

The AAP/Bright Futures' recommendation for lead poisoning is to perform a risk assessment (with appropriate action for a positive result) with the well child exams at ages 6,9, & 18 months and 3,4,5,& 6 years old; at the 12 and 24 month visits the provider may perform a blood level test or risk assessment. View the Bright Futures Lead Screening Periodicity Schedule (PDF).

The U.S. Preventive Services Task Force (USPSTF) does not recommend routine BLL screening for asymptomatic children aged 1-5 years or those children whose risk assessment is "average" but it does not specifically define "average" risk. Read the recommendation statement on Screening for Elevated Blood Lead Levels in Children and Pregnant Women. The American Academy of Family Physicians (AAFP) follows the USPSTF recommendation. See AAFP's recommendation on Lead Poisoning.

The Centers for Disease Control and Prevention recommends targeting outreach, education and screening programs to populations with the greatest risk of lead exposure (Facts on CDC's Screening Lead Poisoning in Young Children: Guidance for State and Local Public Health Officials). This is in contrast to the previously recommended universal screening. Additionally, they recommend that providers become aware of and comply with lead screenings policies issued by Medicaid, state and local health departments. The CDC offers more information on the new screening guidelines on their website: Questions and Answers on CDC's New Guidance on Childhood Lead Screening.

Discussion, Summary and Best Practice

In 1991 there was consensus among pediatric health care providers/experts when the CDC recommended universal BLL screening for all young children in the U.S. Since that time, rates of EBLL in children have substantially decreased causing pediatric providers/experts to reconsider recommendations for universal screening.

Many groups, such as MDH, now recommend targeted BLL screening for high risk groups and a risk assessment to be done at well child exams throughout early childhood. Others believe that a risk assessment would identify any children that would be high risk and therefore only a select number of children would need a BLL test performed. The difficulty in forming a single recommendation is that risk factors depend heavily on environmental conditions creating the need to regionalize the risk assessment questions.

Child and Teen Checkups must follow the federal mandates in EPSDT; therefore, MHCP providers must perform a BLL test at 12 and 24 months. If no previously documented BLL screening test exists, perform a BLL screening test up to the age of 6 years and any time a child's health history indicates risk factors.

SUMMARY

There are a number of good strategies to employ in order to ensure all children have BLL testing at 12 and 24 months but it will require the effort and collaboration of all the people who provide services to young children and families. Strong two-way communications will be at the top of the list of critical components to successful collaboration. MDH encourages forming cooperative agreements at the local level with all the providers of services to children and families to help us achieve our goal of eliminating lead poisoning in our children.



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