The American Academy of Pediatrics (AAP) wishes to clarify terminology in its policy statement “Prevention of Childhood Lead Toxicity” (Pediatrics. 2016;38[1]: e20161493; http://pediatrics.aappublications.org/content/138/1/e20161493) to avoid potential confusion that could occur related to the use of the words “screening” versus “testing.” Throughout the document, the words “screening” and “testing” are used interchangeably, leading potentially to confusion and the possibility of decreased screening and testing of children at risk for lead exposures.
As stated in the 2016 policy, “anticipatory guidance, screening children’s blood for lead after exposure, and iron or calcium supplementation to reduce lead absorption” has been a historical focus of the efforts of the AAP to prevent low-level lead toxicity. Of these, screening children’s blood for lead is available as a secondary prevention measure for providers to determine who has been exposed. For primary prevention to occur, the pediatrician must determine lead hazard risks in the...
Comments
RE: Errata, Prevention of Childhood Lead Toxicity
To the Editor:
In 2017, the American Academy of Pediatrics (AAP) Council on Environmental Health clarified the use of terminology related to testing children’s blood lead levels in an Errata to its June 2016 Policy Statement on Prevention of Childhood Lead Toxicity (AAP, 2017). While we applaud this effort to develop consistent terminology, we offer the following cautions for consideration.
First, all but five states have regulatory language that defines health care providers’ obligations in terms of blood lead testing or screening in children less than 6 years old. The language in these regulations is not necessarily consistent with that proposed by AAP. It is incumbent on providers to follow the requirements in the state where the child lives. State lead poisoning prevention programs provide this information on their websites.
Second, the sensitivity and specificity of the Centers for Disease Control and Prevention (CDC) lead screening questionnaire has been tested in a wide variety of practice settings and sub-populations (Nicholson and Cleeton, 2016). It has never been demonstrated to reasonably predict risk of high blood lead levels and, in a systematic review, performed little better than chance at predicting lead poisoning risk among children (Osiander, 2013). This is not surprising given that the questionnaire was originally developed to ensure that reimbursement was available for testing at shorter intervals, if necessary, in a state with universal annual testing of children less than 6 years old.
Finally, the Errata (AAP, 2017) does not mention the 1997 CDC guidance on Screening Young Children for Lead Poisoning (CDC, 1997). This document, later adopted by the Center for Medicaid Services, recommended that public and clinical health professionals collaborate to develop screening plans that are responsive to local conditions using local data. In the absence of such plans, universal blood lead testing remains the default as does the CMS requirement that all Medicaid enrolled children be tested at 1 and 2 years of age.
The recent high-profile reports on the continued threat of lead exposure for U.S. children underscore the need to ensure that all children living in high-risk areas have blood lead tests periodically at least until 2 years of age. This testing is key to state and local lead programs’ ability to respond to the children most at-risk for continued exposure. Unfortunately, blood lead testing rates are extremely variable even in areas where testing is legally required (Dickman, 2017).
CDC remains committed to supporting state and local efforts to engage pediatric health care providers in identifying and evaluating children who are exposed to lead and ensuring that these children receive the necessary follow-up services. We believe that blood lead testing remains the best method to screen children for lead exposure and to enforce local efforts to prevent childhood lead poisoning.
Adrienne S. Ettinger, ScD, MPH, MS
Chief, Healthy Homes and Lead Poisoning Prevention Branch
Centers for Disease Control and Prevention (CDC)
Mary Jean Brown, ScD, RN
Adjunct Assistant Professor, Harvard School of Public Health, and
Chief (retired), CDC Healthy Homes and Lead Poisoning Prevention Branch
References:
American Academy of Pediatrics (AAP) Council on Environmental Health. Prevention of Childhood Lead Toxicity. Pediatrics 2016;138(1):e20161493; Errata. Pediatrics 2017 Aug: 140 (2); e20171490.
Nicholson J and Cleeton M. Validation and Assessment of Pediatric Lead Screener Questions for Primary Prevention of Lead Exposure. Clinical Pediatrics 2016; 55:129–136.
Ossiander EM. A systematic review of screening questionnaires for childhood lead poisoning. J Public Health Manag Pract. 2013 Jan-Feb;19(1):E21-9.
Centers for Disease Control and Prevention (CDC). Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials. Atlanta: CDC, November 1997.
Dickman J. Children at Risk: Gaps in State Lead Screening Policies. Safer Chemicals Health Families, January 2017.
RE: Errata, Prevention of Childhood Lead Toxicity
To the Editor:
In 2017, the American Academy of Pediatrics (AAP) Council on Environmental Health clarified the use of terminology related to testing children’s blood lead levels in an Errata to its June 2016 Policy Statement on Prevention of Childhood Lead Toxicity (AAP, 2017). While we applaud this effort to develop consistent terminology, we offer the following cautions for consideration.
First, all but five states have regulatory language that defines health care providers’ obligations in terms of blood lead testing or screening in children less than 6 years old. The language in these regulations is not necessarily consistent with that proposed by AAP. It is incumbent on providers to follow the requirements in the state where the child lives. State lead poisoning prevention programs provide this information on their websites.
Second, the sensitivity and specificity of the Centers for Disease Control and Prevention (CDC) lead screening questionnaire has been tested in a wide variety of practice settings and sub-populations (Nicholson and Cleeton, 2016). It has never been demonstrated to reasonably predict risk of high blood lead levels and, in a systematic review, performed little better than chance at predicting lead poisoning risk among children (Osiander, 2013). This is not surprising given that the questionnaire was originally developed to ensure that reimbursement was available for testing at shorter intervals, if necessary, in a state with universal annual testing of children less than 6 years old.
Finally, the Errata (AAP, 2017) does not mention the 1997 CDC guidance on Screening Young Children for Lead Poisoning (CDC, 1997). This document, later adopted by the Center for Medicaid Services, recommended that public and clinical health professionals collaborate to develop screening plans that are responsive to local conditions using local data. In the absence of such plans, universal blood lead testing remains the default as does the CMS requirement that all Medicaid enrolled children be tested at 1 and 2 years of age.
The recent high-profile reports on the continued threat of lead exposure for U.S. children underscore the need to ensure that all children living in high-risk areas have blood lead tests periodically at least until 2 years of age. This testing is key to state and local lead programs’ ability to respond to the children most at-risk for continued exposure. Unfortunately, blood lead testing rates are extremely variable even in areas where testing is legally required (Dickman, 2017).
CDC remains committed to supporting state and local efforts to engage pediatric health care providers in identifying and evaluating children who are exposed to lead and ensuring that these children receive the necessary follow-up services. We believe that blood lead testing remains the best method to screen children for lead exposure and to enforce local efforts to prevent childhood lead poisoning.