District law requires a Blood Lead Level (BLL) test for all children between 6 months and 14 months of age and another BLL screening test between 22 months and 26 months of age, unless an identical test was performed in the previous 12 months. If a child over 26 months of age has not been tested for lead, the law requires two BLL tests before the child turns six years of age.
On October 28, 2021, CDC updated the blood lead reference value (BLRV) from 5.0 μg/dL to 3.5 μg/dL. In compliance with CDC’s change in reference value, CLPPP uses a blood lead reference value (BLRV) of 3.5 micrograms per deciliter (µg/dL) to identify children with blood lead levels that are higher than most children’s levels. By updating the BLRV to 3.5 μg/dL, children with blood lead levels (BLLs) within the range of 3.5–5 μg/dL can now also receive quick actions to reduce health effects and remove or control sources of lead.
All blood lead results are required by law to be reported to the Department of Energy and Environment’s Childhood Lead Poisoning Prevention Program (CLPPP). Providers are responsible for making sure their results are consistently submitted in accordance with DC regulations. In emergency cases, doctors should report results to the CLPPP directly and immediately.
Below are recommendations for follow-up and case management for children with an elevated BLL.
A provider may opt to conduct one of two types of blood tests:
- Capillary sample: A finger-prick or heel-prick is used to take a small amount of blood to test for lead.
- Venous Sample: A small amount of blood is taken after a needle is inserted into the patient’s vein to test for lead.
Capillary Blood Lead Level
If the capillary results are equal to or greater than CDC’s Blood Lead Reference Value (BLRV) of 3.5 micrograms per deciliter (µg/dL), providers should collect a venous sample.
Schedule for obtaining a confirmatory venous sample:
Table 1
|
Capillary (Finger Prick) Level (μg/dL) |
Time for Confirmatory Testing |
|
≥3.5–9 |
Within 3 months |
|
10–19 |
Within 1 month |
|
20–44 |
Within 2 weeks |
|
≥45 |
Within 48 hours |
Confirmed Venous Blood Lead Level
DOEE recommends that healthcare providers use a venous draw for confirmatory BLL screening. If the initial screening test used a venous sample, the patient does not need another venous draw.
Schedule for Follow-Up Blood Lead Testing:
Table 2
|
Venous blood lead levels (µg/dL) |
Early follow up testing (2–4 tests after initial test above specific venous BLLs) |
Later follow up testing after BLL declining |
|
≥3.5–9 |
3 months* |
6–9 months |
|
10–19 |
1–3 months* |
3–6 months |
|
20–44 |
2 weeks–1 month |
1–3 months |
|
≥45 |
As soon as possible |
As soon as possible |
*Some case managers or healthcare providers may choose to repeat blood lead tests on all new patients within a month. Repeated testing may confirm that the child’s BLL is decreasing.
Confirmed BLL is <3.5 micrograms per deciliter (µg/dL)
- Provide education about common sources of lead exposure and information on how to further prevent exposure.
- During well-child visits, check development to make sure age-appropriate milestones are being met.
- During well-child visits, discuss diet and nutrition with a focus on iron and calcium intake.
- Conduct follow-up blood lead testing at recommended intervals based on the child’s age.
- District law requires all children residing in the District to get tested for lead between 6 months and 14 months of age and another BLL screening test between 22 months and 26 months of age,
Confirmed BLL is 3.5 – 19 micrograms per deciliter (µg/dL)
- Follow the recommendations above for BLL < 3.5 μg/dL.
- Report the test result to your state or local health department.
- Obtain an environmental exposure history to identify potential sources of lead.
- Arrange for an environmental investigation of the home to identify potential sources of lead, as required.
- During an environmental investigation, professionals check the child’s environment for possible causes of lead exposure and recommend ways to prevent further lead exposure.
- BLLs < 5 μg/dL may not trigger a Department of Housing and Urban Development (HUD) environmental investigation when the housing is covered by the HUD’s Lead Safe Housing Rule. Additionally, environmental investigations for BLLs that are 3.5–19 μg/dL vary based on jurisdictional requirements and available resources.
- Ensure the child does not have iron deficiency using testing and treatment. Follow testing and treatment guidelines from the American Academy of Pediatrics (AAP).
- Discuss the child’s diet and nutrition with a focus on calcium and iron intake. Refer caregivers to supportive services, as needed (e.g., Special Supplemental Nutrition Program for Women, Infants and Children).
- Check the child’s development to ensure appropriate milestones are being met per AAP guidelines. Refer caregivers to supportive services, as needed (e.g., developmental specialists, Early Intervention Program).
- Provide follow-up BLL testing at recommended intervals. See schedule shown in Table 2.
Confirmed BLL is 20 – 44 micrograms per deciliter (µg/dL)
- Follow the recommendations above for BLL is 3.5–19 μg/dL.
- Perform a complete history and physical exam, assessing the child for signs and symptoms related to lead exposure.
- Arrange for or refer the family for an environmental investigation of the home and a lead hazard reduction program.
- Consider performing an abdominal X-ray to check for lead-based paint chips and other radiopaque foreign bodies. This is important for young children who tend to swallow or eat non-food items. Children may also put their mouths on surfaces that could be covered with lead dust. Initiate bowel decontamination if indicated.
- Contact a Pediatric Environmental Health Specialty Unit (PEHSU) or the Poison Control Center (1-800-222-1222) for guidance.
- PEHSUs provide information on protecting children and reproductive-age adults from environmental hazards. PEHSUs work with healthcare professionals, parents, schools, and community groups.
Confirmed BLL is >/=45 micrograms per deciliter (µg/dL)
- Follow recommendations for BLL 20–44 μg/dL.
- Perform a complete history and physical exam including a detailed neurological exam.
- Perform an abdominal X-ray and, if needed, initiate bowel decontamination.
- If the patient exhibits signs or symptoms of lead poisoning, including, confusion, weakness, seizures, coma, nausea, vomiting, and abdominal pain, admit them to a hospital as soon as possible.
- Consider admitting the patient to a hospital if one of these conditions exists:
- The patient’s home is not lead-safe, and they are unable to find a lead-free living space.
- The source of lead exposure has not been identified, and the potential for further lead exposure is still possible.
- The healthcare provider is consulting with a medical toxicologist or pediatrician with experience in treating lead poisoning to initiate:
- Gastrointestinal decontamination (removal of swallowed lead using laxatives) or
- Chelation therapy (a treatment that uses a medication to remove lead from the body when BLLs are very high).
- Contact a PEHSU or Poison Control Center (1-800-222-1222) for assistance.
Additional Resources
Single Family Residential Rehabilitation Program: Home Rehabilitation CBOs | dhcd (dc.gov)
References
cdc.gov/nceh/lead/advisory/acclpp/actions-blls.htm#anchor_1647349462703