RECENT CHANGES TO NH’S CHILDHOOD LEAD POISONING LAW:
What Granite State Pediatricians Need to Know
Each year an estimated 1,000 New Hampshire children under the age of six test positive for elevated blood lead levels greater than 5 micrograms per deciliter (mcg/dL), the threshold set by the Center for Disease Control and Prevention indicating a child has lead exposure and the need for case management. According to the Division of Health and Human Services, New Hampshire’s pediatric elevated blood lead level (EBLL) rates are 2.5 times the national average. Currently, 37% children currently enrolled in New Hampshire’s public schools, who have been tested for lead exposure, have had an EBLL greater than 5mcg/dL at some point in their lives. In New Hampshire during 2014, of the 10,281 5 year-olds who were tested for lead at some point in their lives, 15% had an EBLL greater than or equal to 5 mcg/dL. Most of these children will be entering kindergarten within the next year. It is quite possible that these numbers are actually much higher.
According to the Department of Health and Human Services, testing rates for one and two year olds in New Hampshire have remained flat and in some communities have declined over recent years. In 2014, blood lead testing rates for New Hampshire 2 year olds were only 37%. (See chart below.) The successful passing of Senate Bill 135 in July 2015 includes requirements intended to improve New Hampshire’s testing rates, especially for children in high-risk communities, including an 85% testing rate milestone for one- and two-year olds living in universal testing communities, receiving Medicaid or WIC (Woman, Infant, Children supplemental nutrition program) benefits or enrolled in Head Start.
Why is childhood lead poisoning still a health issue in our State? New Hampshire has some of the oldest housing stock in the country with more than half of the housing built before lead paint was banned in 1978. Children living in homes built prior to 1978 are at increased risk for lead exposure. Near trace amounts of lead dust generated from friction, impact or chipping lead paint surfaces is the primary source of nearly every EBLL in New Hampshire. Children are exposed to lead from crawling on floors and touching surfaces where lead dust collects and then placing hands or objects in mouths. Home renovations and repairs completed by either uninformed DIY homeowners or contractors not certified by the EPA in lead-safe work practices are another common source of lead exposure. 1 in 3 children who have an EBLL were exposed to lead during home renovations.
Lead Exposure’s Negative Impact on Children’s Brain Development
Study after study demonstrates that even low blood lead levels negatively impact a child’s development. The Center for Disease Control and Prevention (CDC) released a paper Educational Interventions for Children Affected by Lead (April 2015) which identifies lead’s ‘Neurobehavioral Signature," and the negative impact that lead exposure has on children’s cognitive abilities, speech and language, hearing, visual-spatial skills, attention, impulse control, social behavior, emotional regulation, and motor skills. The CDC paper outlines the importance of early intervention, education and nutrition support services for children with an EBLL.
The impact of childhood lead poisoning on New Hampshire’s children, families, classrooms and communities is significant. Yet this environmental public health issue has often been ignored up until recent changes to the State’s Lead law, RSA 130-A. Recent legislation has brought much needed attention to childhood lead poisoning, low testing rates, and prevention.
New Legislation – Childhood Lead Poisoning BLL Testing Rates
Changes to New Hampshire’s current childhood lead poisoning statues were made with the passing of Senate Bill 135 that was signed by Governor Hassan in July 2015. All Granite State pediatricians are impacted by these changes. Here are the key points of the new legislation:
Improve Pediatric Blood Lead Testing Rates
To prevent children from being missed and to provide children the treatment and protection they need, this new law establishes a 85% testing rate milestone for one- and two-year olds living in universal testing communities, receiving Medicaid or WIC benefits or enrolled in Head Start. The new law also requires, should this BLL testing target not be reached by 2017, that the NH Division Public Health Services (DPHS) change current rules and move to compliance enforcement. Click here to see law.
Establishes the Childhood Lead Poisoning & Screening Commission
This Commission with its two working subcommittees on 1) screening and 2) prevention will explore new initiatives to both improve detection through increased BLL testing rates and to reduce exposure through prevention. Dr. William Storo, pediatrician at Dartmouth-Hitchcock Concord and President of New Hampshire Pediatric Society has been appointed a member of this new commission. Click here to see list of members.
Getting information to parents of children with EBBL greater than 5mcg/dl.
New Hampshire’s statute has not been amended to reflect CDC’s lowering of the blood lead reference value in 2013 to 5 mcg/dL with strong statement of "no safe level of lead exposure". The new legislation attempts to address this gap by ensuring that DPHS notifies each and every parent of a child with an EBLL >5mcg/dL with information to ensure they understand the consequences of lead poisoning and the steps that can be taken to avoid lead hazards. Information is also will be provided to landlords, to enable them to take action to eliminate lead hazards when a tenant’s child has been found to be poisoned.
New Lead Fact Sheet for Providers conducting capillary testing.
Any medical provider conducting capillary blood lead testing shall provide their patients with Lead and Children factsheet prepared by DPHS to any parent or guardian of a child whose test indicates any presence of lead. This new Lead and Children fact sheet describes the health effects of childhood lead poisoning, the advisability of obtaining a venous blood test, and the benefits of identifying and addressing lead hazards. The Lead and Children factsheet also includes a statement that, in the case of rental properties, it is advisable to inform the property owner of the EBLL and that the family cannot be evicted based on the child’s EBLL.
NH Childhood Lead Poisoning Medical Testing Guidelines
The American Academy of Pediatrics (AAP), in absence of a state guideline, recommends that all children be tested for lead exposure at 1 and 2 years old. Many other New England states, follow the AAP guideline and have what is known at "Universal Testing" where all children are tested for lead exposure at age 1 and age 2.
New Hampshire uses a "risk-based approach "to recommend which children be tested for lead. Individual towns and their demographics are evaluated and are designated either a Universal or a Target community. In New Hampshire, 52% of our communities are classified as high risk, or Universal (U) testing communities. Children living in Universal communities, along with all children receiving Medicaid or WIC benefits or enrolled in Head Start and Early Head Start, are to be tested for elevated lead levels at ages 1 and 2; no questions asked.
Children residing in communities thought to have less risk or Target (T) communities and are not receiving Medicaid or WIC benefits or enrolled in a Head Start program are tested using a targeted approach. The NH Childhood Lead Poisoning Screening and Management Guidelines have a Risk Questioner for Pediatricians that includes five simple questions to assess the child’s risk: If answer is yes, or ‘unknown’ to any of the questions, the child should be tested.
Source: NH DPHS 2014 Lead Blood Surveillance Report
In New Hampshire, BLL testing rates are very low for 1 and 2 year olds, with only 37% of 2 year olds being tested in 2014. (See chart above.) All pediatric health providers need to put attention on improving BLL testing rates to identify lead exposure and support protective and early interventions for healthier outcomes. In-office, blood lead testing is gaining the attention of more New Hampshire pediatricians as a means of improving BLL testing rates and supporting better health outcomes.
In-Office Capillary BLL Testing: Proven Effective in Improving Testing Rates
The implementation and use of in-office, capillary BLL equipment, is an effective, highly accurate, and proven means of increasing testing rates. These small analyzers are designed for efficient, in-office BLL testing, using a capillary sample drawn during work flow of the 1 and 2 year old Well Child Check. The LeadCare II analyzers are easy to use and provide accurate results within minutes before a child leaves the office.
In the 1990’s the CDC had recommended venous blood for blood lead testing because of capillary samples presented a risk of false positives due to skin contaminated with lead dust. However, the CDC discovered that venous blood draws were a significant deterrent to pediatric blood testing because venous collection meant a second, additional trip to a lab and a significant percentage of children did not go for the test. In addition, the CDC discovered that the venous blood draw on a very young child was perceived as more traumatic to child and parent, leading more parents to refuse the blood draw at their child’s 2 year old Well Child Check appointment. In the early 2000’s, response to these deterrents, the CDC investigated capillary collection for BLL testing. The CDC determined that, with proper sampling technique, the benefits of capillary blood lead testing (increased testing rates) significantly outweighed the very low incidence (~2%) of contaminated samples. In 2004, the CDC, armed with information from recent research, made two significant contributions to help pediatric providers improve BLL screening rates. First, the CDC provided grant funding for the development of LeadCare II system that requires just two drops (50 μL) of blood, and provides results within three minutes. Second, the CDC produced an Instructional Video describing how to collect capillary (finger stick) samples for blood lead testing. The CDC's goal in supporting the development of a point-of-care, capillary BLL testing system was to improve compliance with AAP BLL testing guidelines by making lead testing available in more locations, especially high risk communities where compliance is low.
The CDC’s goal in developing the LeadCare II was to improve compliance with AAP BLL testing guidelines by offering an easier, less traumatic sample collection technique. In-office, capillary BLL testing LeadCare II analyzers are proven effective to increase screening rates and allow pediatric providers to share the results and important preventative education with families before the Well Child Check visits ends and the child leaves the exam room. Learn more about LeadCare II analyzers.
Guidelines and Resources Available for Pediatricians
In early 2015, the Division of Public Health Services (DPHS), Healthy Homes and Lead Poisoning Prevention Program sent by US mail to all pediatric practices the new NH Childhood Lead Poisoning Screening and Management Guidelines booklet with current childhood lead poisoning testing, treatment, clinical evaluation and management information. Lists in this booklet identify all New Hampshire communities with the Universal ‘U’ or Target ‘T’. It also contains the five (5) screening questions for Target communities and many other resources for pediatricians to share with patient families to support lead poisoning awareness and education.
In addition, new childhood lead testing and medical management quick guides are now available for pediatricians to use in exam rooms. The laminated medical management quick guides include 1) Child Lead Testing and Treatment, Clinical Evaluation and Management 2) Lead Testing Designation by Community and 3) Lead Testing With LeadCare II Analyzers.
New Hampshire DPHS Health Homes and Lead Poisoning and Prevention Program has new parent information fact sheets on Childhood Lead Poisoning, Lead Hazards, Lead and Pregnancy, Lead and Nutrition, Lead in the Environment, and Take Home Lead. These are available printed or electronically for pediatricians to distribute to parents.
Additional Childhood Lead Poisoning Screening and Management Guideline booklets that include laminated quick guide reference sheets for exam rooms are available at no cost by request. Short educational sessions on NH childhood blood lead level testing requirements, medical management guidelines, NH DPHS public health nurse EBLL case management, and impact of recent legislation, can be scheduled at your practice or hospital affiliate. Convenient before clinic hours, lunchtime, or evening education sessions can easily be arranged. For more information about any of these resources, contact Gail Gettens, MS, child development specialist and Health Promotion Advisor, Division of Public Health Services, Healthy Homes and Lead Poisoning Prevention Program at 271-1393 or gail.gettens@dhhs.state.nh.us
