Commissioner's Letter To Physicians Regarding Lead Screening

August 2005

Dear Colleague:

The purpose of this letter is to provide you with an update on the current status of childhood lead poisoning prevention in New York and to reinforce that universal childhood lead screening is the standard of medical care in New York.

The national goal to eliminate childhood lead poisoning by 2010 is a priority for the New York State Department of Health (NYSDOH), New York State Academy of Family Physicians, the New York State Chapter of the American Academy of Pediatrics and the Medical Society of the State of New York. Lead has long been recognized as the leading preventable environmental health hazard for young children. Despite significant reductions in the incidence of childhood lead poisoning, thousands of children are identified with elevated blood lead levels each year in New York State.1 As a health care provider, you play a critical role in the prevention of lead poisoning in young children.

The primary way in which most young children in the United States are exposed to harmful levels of lead is through contact with deteriorating lead paint and lead-contaminated dust in their home environments (pre-1978 housing). Less commonly, secondary sources such as water contaminated by its flow through lead pipes or brass fixtures; soil contaminated by lead dust, and certain consumer products that contain lead can be significant contributory sources. 2

Multiple studies have demonstrated that the early years of a child's life are critical for their cognitive, social and emotional development. Lead is a known neurotoxin and young children are particularly vulnerable to lead in the environment.3 Lead exposure is harmful to the developing brain and nervous system of fetuses and young children.4 Recent studies have demonstrated that the harmful effects of lead may occur at concentrations below the current designated level of concern of 10µg/dL.5 Exposure to even small amounts of lead leading to levels of <10µg/dL may contribute to behavior problems, learning disabilities, and lowered intelligence scores, underscoring the importance of conducting lead screening for all children.

Although childhood lead screening rates in New York are higher than in many other states, there is still work to be done to reach our screening goals. In the most recent surveillance report of upstate counties, 51.5 % of all children received initial blood lead tests before 16 months of age, with 32.8% of this group receiving second lead tests by age two.6 The NYC Department of Health and Mental Hygiene (NYCDOHMH) also recently reported improved lead testing rates for children at one and two years of age.7 The importance of testing at age two is supported by a review of the 1994-1997 birth year cohorts which showed that 8% of children with lead levels within normal limits at age one were found to have elevated lead levels when re-screened at age two, representing approximately 25,000 children over this six-year period.6 Lead screening is important in children living in all communities because there may be unrecognized sources of exposure. Universal screening enables the construction of a statewide picture of childhood lead levels.

As a reminder, New York State Public Health Law and regulations mandate the following lead prevention practices:

  • Universal blood lead testing by health care providers of all children at age one year and again at age two years.
  • Risk assessment of high dose lead exposure for each child six months to six years of age at each well-child visit or at least annually, with blood lead testing for children found to be at risk. Provide or make reasonable efforts to ensure the provision of risk reduction education and nutritional counseling to the parent/guardian of a child with BLL ≥10µg/dL.
  • Provide or make reasonable efforts to ensure the completion of a complete diagnostic evaluation and referral to the appropriate local health department for any child with an elevated blood lead level ≥ 20µg/dL. A complete diagnostic assessment consists of a detailed lead exposure assessment, a nutritional assessment including iron status and a developmental screening.8
  • Communicate and coordinate with local county health departments or the New York City Department of Health and Mental Hygiene to ensure that each child with an elevated blood lead level receives appropriate follow-up.

Additional information on lead poisoning is available from NYSDOH, including the recent documents, Eliminating Childhood Lead Poisoning in New York State by 2010 and Promoting Lead Free Children in New York State: A Report of Lead Exposure Status Among New York State Children 2000-2001. These reports and other information can be found on the NYSDOH web site. The NYC Department of Health and Mental Hygiene document, Surveillance of Childhood Blood Lead Levels in New York City, 1995-2002, can be found on their web site at: http://www.nyc.gov/html/doh/html/lead/l2002.shtml.

We thank you for your support of our efforts to eliminate childhood lead poisoning in NYS, and encourage you to redouble your efforts to help achieve the goal of elimination. Over the upcoming year, we will be developing and disseminating additional clinical tools and materials to support lead prevention activities in your practice. Enclosed is an order form for existing educational materials that are available free of charge from the state health department, a contact list for county health departments and lead clinical resource centers, and a risk assessment tool.

If you have any questions or need additional information, please contact your local health department or the New York State Department of Health Childhood Lead Poisoning and Prevention Program at 518-473-4602.

Sincerely,

Antonia C. Novello, M.D., M.P.H, Commissioner of Health Chairperson
Dr.P.H. Robert Corwin, M.D. Chairperson, American Academy of Pediatrics, District II
Marianne LaBarbera, M.D. President, New York State Academy of Family Physicians
Robert A. Scher, M.D. President, Medical Society of the State of New York

Enclosures

  1. Surveillance for Elevated Blood Lead Levels Among Children --- United States, 1997—2001, MMWR, September 12, 2003 / 52(SS10);1-21.
  2. Centers for Disease Control and Prevention. Managing Elevated Blood Lead Levels Among Young Children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention. Atlanta: CDC; 2002. http://www.cdc.gov/nceh/lead/CaseManagement/caseManage_main.htm
  3. America's Children and the Environment: Measures of Contaminants, Body Burdens, and Illnesses. EPA 240R03001 (2003); Second Edition: 56. http://www.epa.gov/envirohealth/children/ace_2003.pdf
  4. Centers for Disease Control and Prevention. Preventing Lead Poisoning in Young Children: A Statement by the Centers for Disease Control. Atlanta: CDC, October 1991. http://www.cdc.gov/nceh/lead/publications/books/plpyc/contents.htm
  5. Canfield, R.L., Henderson, C.R., Cory-Slechta, D.A., Cox, C., Jusko, T.A., Lanphear, B.P. Intellectual impairment in children with blood lead concentrations below 10 m g per deciliter. New England Journal of Medicine 2003;348:1517-1526.
  6. Promoting Lead Free Children in New York State: A Report of Lead Exposure Status Among New York State Children 2000-2001. NYS Department of Health. http://www.health.state.ny.us/environmental/lead/exposure/report/index.htm
  7. NYC Childhood Lead Poisoning Prevention Program Annual Report, 2003. NYC Department of Health and Mental Hygiene. http://www.nyc.gov/html/doh/downloads/pdf/lead/lead-2003report.pdf
  8. NYS Public Health Regulations, Title X, Subpart 67, 1. 2 (9).