Physician screening practices at a hospital-based, university-affiliated pediatric primary care center serving an urban high-risk population in Rochester, NY were evaluated to determine the feasibility of the 1991 Centers for Disease Control guidelines. Among 632 children aged 9 to 25 months who attended the center between 1989 and 1991, screening was deficient in 55%, 34%, and 29% at ages 9-13 months, 14-19 months, and 20-25 months, respectively. Many high-risk children living in houses built before 1950, including those making well-child visits, were not appropriately screened for lead toxic effects, and opportunities for testing were frequently missed. [1]
COMMENT. The authors believe that the new CDC guidelines for biannual screening and retesting can be achieved with a modest increase in tests, if sick visits are also utilized for retesting. Proper cleansing of the fingertip or alternatively, venipuncture should decrease the proportion of false-positive results and reduce the need for additional visits. At this urban PC Center, 30% of the screened high-risk children had lead levels of 10 mcg/dL or higher, now considered to be toxic. In contrast, only 4.7% of children screened from a suburban, middle class private practice in Cherry Hill, NJ, were found to have elevated blood lead levels, and no child had a level of 25 mcg/dL or higher requiring treatment. [2]
Who Bears the Burden? Wical BS, of the Departments of Neurology and Pediatrics, University of New Mexico, Albuquerque, addresses the dilemmas and burdens of blood lead testing of 22 million children in the US from 6 to 72 months of age [3]. In Milwaukee, private physicians play a major role in lead poisoning screening and case identification. In 1992, the number of cases of poisoning identified (BPb 25 mcg/dL or higher) in the private sector increased by over 600% in a 2 year period, a higher number than in public centers. Physicians voluntarily changed their practice patterns in accordance with 1991 CDC recommendations, partly as a result of physician education by the Milwaukee Health Department and the Children’s Hospital of Wisconsin. [4]
The Child Neurologist’s Role. Pediatric neurologists may need to take some responsibility in the blood lead screening of their patients, particularly those in high-risk categories. No child is exempt from risk, however; one infant, a pediatric surgeon’s child, living in a high-rise co-op apartment, the first to be built in Chicago in 1924, and another, a house master’s child at a renown boarding school in Massachusetts, were exposed to lead containing paint in the homes. Blood lead levels, in both cases prompted by the mothers and found to be elevated, responded to a temporary change of residence and lead abatement measures.
Declining Lead Levels. Despite the dramatic overall decrease in blood lead levels in the US population in recent years to 2.8 mcg/dL, national estimates for children 1 to 5 years of age show that 8.9%, or 1.7 million children, have BPb levels of 10 mcg/dL or greater, high enough to be of concern [5]. Pirkle JL, Brody DJ et al, commenting on the decline in blood lead levels in the US, attribute the fall to the removal of lead from gasoline and soldered cans. Lead in paint, dust and soil needs to be addressed before the decline can continue, especially in children in low income, urban areas [6]. Goldman LR and Carra J, from the Office of Prevention, Pesticides, and Toxic Substances, US Environmental Protection Agency, Washington, DC, emphasize the need for both targeted screening efforts and improvements in screening methods in high-risk children. [7]
Public Lead Awareness and Responsibility. Since current compliance with CDC recommended guidelines for blood lead screening is not universally appropriate, an increased public and parent awareness of the hazards and the symptoms and signs of lead poisoning, especially in children, should be encouraged. [8]