Removing lead from gasoline and paint beginning in the 1970s led to significant declines in childhood blood lead levels (BLLs) across the United States. Underlying this great public health success, however, is a complicated and nuanced story of persistent disparities in exposure to lead, access to testing and services, and health outcomes.
Pediatricians are well-positioned to address these contemporary challenges in lead poisoning prevention.
Ongoing exposure, disparities
Decades of lead use in consumer paint, motor vehicle fuels and other products has made lead a ubiquitous environmental hazard. Data from the American Healthy Homes Survey II estimate that millions of U.S. children have ongoing exposure to lead-based paint, placing them at risk for adverse health effects.
Data from the Centers for Disease Control and Prevention (CDC) demonstrate ongoing disparities in childhood BLLs. Children from low-income households, those living in housing built before 1978 and those who identify as African American are at greater risk for lead exposure. Children from certain other race/ethnicities, immigrants and refugees also are at higher risk due to exposures they faced in their country of origin as well as in the United States.
While these patterns remain important, data from CDC’s state partners highlight that childhood lead exposure can occur across all racial and ethnic groups; urban, suburban and rural geography; and any family income level.
Importance of blood lead testing
Though primary prevention of lead exposure remains the goal for both medical and public health communities, strong evidence shows the value of secondary prevention, such as blood lead testing (Kaufmann RB, et al. Pediatrics. 2000;106:e79; Christensen K, et al. WMJ. 2019;118:16-20).
In October 2021, the CDC lowered the blood lead reference level from 5 micrograms/deciliter (mcg/dL) to 3.5 mcg/dL. However, no level of lead exposure or BLL is safe, and even low levels can impact neurodevelopment.
With approximately 500,000 U.S. children having a BLL of 3.5 mcg/dL or higher, the CDC and state health agencies recommend targeted blood lead testing to identify children exposed to lead.
However, inconsistent state and local testing and reporting policies, inadequate resources and loss to follow-up are important barriers that disproportionately affect certain populations. The COVID-19 pandemic and a recent recall affecting lead point-of-care testing kits have further impacted testing rates.
Overt lead toxicity is uncommon, with most contemporary lead exposure resulting in subclinical health effects. Therefore, some providers may feel lead exposure is less prevalent and less consequential. While it is important for providers to exercise clinical judgment when deciding which children to test, these decisions should be informed by local data, guidance from local or state health departments and the CDC, and evidence-based approaches such as those outlined in Bright Futures.
Factors such as a belief that one practices in a low-risk area, that only certain populations are at risk or that health effects are unlikely until BLLs reach higher levels can affect decisions on testing and delay or prevent recognition of children exposed to hazardous levels of lead (Markowitz M. Pediatr Rev. 2021;42:302-315; Neuwirth LS. Int J Occup Environ Health. 2018;24:86-100).
Pediatricians’ role in prevention
Pediatricians can help address challenges in preventing childhood lead exposure — including disparities in exposure, testing and follow-up — in several ways:
- Continue to inform and educate families about lead exposure through day-to-day clinical interactions and via broader community outreach though AAP chapters and community-based organizations.
- Help ensure equitable screening, diagnosis and follow-up for children at greatest risk for lead exposure by following guidelines and partnering with local or state health department, health system and community to address disparities.
- Be a voice for policy, systems and environmental change through advocacy, educating policymakers and speaking as a trusted expert in your community.
The CDC is taking steps to increase awareness and promote blood lead testing by health care providers. These include sharing examples of lead exposure in children, with a focus on those who were not initially identified as at high risk; developing materials to encourage health care providers to test children at risk for lead exposures; and working with medical and social services.
Pediatricians have partnered with public health agencies to drive significant reductions in the U.S. population’s exposure to lead since the 1970s. The CDC is optimistic that by reengaging with medical professionals, we can strengthen our partnership and redouble our efforts to address contemporary challenges in preventing childhood lead exposure.
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the CDC.
Dr. Allwood is chief of Lead Poisoning Prevention and Surveillance at the CDC. Dr. Karwowski is chief medical officer of the Division of Laboratory Sciences in CDC’s National Center for Environmental Health and CDC Liaison to the AAP Council on Environmental Health and Climate Change.
Perri Ruckart Dr.P.H., M.P.H., lead health scientist in the CDC’s Lead Poisoning Prevention and Surveillance Branch, and Jonathan Lynch, M.B.A.-P.M., health communications specialist, Division of Environmental Health Science and Practice, contributed to this article.
- Information from the CDC on lead poisoning prevention
- CDC’s recommended actions based on blood level results
- AAP information on lead exposure and prevention