NORTH
CAROLINA
Childhood
Lead
Testing
and
Follow-Up
Manual
NC Department of Environment and Natural Resources
Division of Environmental Health
Environmental Health Services Section
Children's Environmental Health Branch
Revised 2005
Revised 2008
Revised 3/2010
Table of Contents
Minimum Recommendations for Lead Poisoning Prevention
Quick Reference Guide
Chapter 1
Introduction
Background
Sources and Pathways of Lead Exposure in Children
Staff Roles
Training Required
Chapter 2
Requirements and Recommended Guidelines
Medicaid
Refugee Children
Use of State Lab of Public Health for Blood Lead Analysis
NC General Statutes
Assessment and Testing Methodology
Reporting Blood Lead Results 10 ug/dL.
The State Laboratory is available to analyze blood specimens on all children less than six
years of age collected by all providers at no charge. A listing of independent laboratories
certified for blood lead testing is maintained by the Division of Environmental Health for
distribution to providers who choose to use independent laboratories for testing.
Hand Held Blood Lead Analyzers
The Clinical Laboratory Improvements Amendments (CLIA) designates facilities that use
hand held blood lead analyzers as laboratories. All such blood lead test results for
children less than 6-years-old, even if determined in a clinical setting are required to be
reported to the Children’s Environmental Health Branch.
Medical and Environmental Response to Test Results
An outline of medical and environmental responses to test results can be found in the
Quick Reference Section or Chapter 4 (Case Management and Follow-up) for more
detail. We hope the outline is helpful. It is not intended to replace professional judgment,
which must be based on the blood lead level, the presence of symptoms and other
circumstances peculiar to an individual child in question.
Reference and background information can be found in the CDC Booklet, “Screening
Young Children for Lead Poisoning.” The Booklet is available through CDC or the
Division of Environmental Health.
FOLLOW-UP SCHEDULE FOR DIAGNOSTIC / CONFIRMED LEAD LEVELS
Blood Lead Level Response
70 µg/dL • Hospitalize child and begin medical treatment immediately.
• Provide clinical management, including family lead education.
(Diagnostic test • Provide environmental investigation and lead hazard control.
immediately as • Refer to WIC Program
emergency lab test) • Refer children ages birth to 36 months to CDSA Early Intervention
• Refer children ages 3-5 to CSC
• Refer to Social Services as needed for housing or additional medical assistance.
• Continue testing every 2-3 months until 2 consecutive tests are 60µg/dl. Requisition forms are retained
by the State Lab for two years plus the current and are filed according to laboratory
accession number.
Occasionally, results are
given as one of several
CODE LONG DESCRIPTION
Unsatisfactory Specimen
Codes. These require
100 BROKEN IN TRANSIT-NEEDS TO BE REPEATED
submission of another
101 LABORATORY ACCIDENT-NEEDS TO BE REPEATED
specimen for analysis.
103 QUANTITY NOT SUFFICIENT-NEEDS TO BE REPEATED
107 GREATER THAN 14 DAYS OLD-NEEDS TO BE REPEATED
112 APPEARS TO BE CONTAMINATED
125 RECEIVED CLOTTED--NEEDS TO BE REPEATED
150 OTHER-NEEDS TO BE REPEATED
159 IMPROPER SPECIMEN FOR TEST REQUESTED
161 NO SPECIMEN RECIEVED-NEEDS TO BE REPEATED
188 APPEARS TO BE DENATURED-NEEDS TO BE REPEATED
190 PERSON IS PAST THE AGE LIMIT AND INELIGIBLE FOR TEST
200 UNCAPPED, LEAKED IN TRANSIT
204 NO COLLECTION DATE-NEEDS TO BE REPEATED
208 NO SUBMITTER ADDRESS
210 NAME ON SPECIMEN AND FORM DO NOT MATCH
214 NO NAME ON SPECIMEN-NEEDS TO BE REPEATED
215 PATIENT ID QUESTIONABLE
216 OUT OF STATE RESIDENT, INELIGIBLE FOR TESTING
217 INSTRUMENT PROBLEMS-NEEDS TO BE REPEATED
Chapter 3 -- Page 4
Revised April, 2008
Receiving Results of Blood Lead Tests
Specimens are usually analyzed and reported on the day received by the State
Laboratory. Results are reported in micrograms per deciliter (µg/dL) of whole blood.
The range of results reported is 1 µg/dl to >60µg/dl. Paper lab slips are retained by
the State Lab for two years and are filed according to laboratory accession number.
Occasionally, results are given as one of several Unsatisfactory Specimen Codes.
These require submission of another specimen for analysis.
CODE LONG DESCRIPTION
100 BROKEN IN TRANSIT-NEEDS TO BE REPEATED
101 LABORATORY ACCIDENT-NEEDS TO BE REPEATED
103 QUANTITY NOT SUFFICIENT-NEEDS TO BE REPEATED
107 GREATER THAN 14 DAYS OLD-NEEDS TO BE REPEATED
112 APPEARS TO BE CONTAMINATED
125 RECEIVED CLOTTED--NEEDS TO BE REPEATED
150 OTHER-NEEDS TO BE REPEATED
159 IMPROPER SPECIMEN FOR TEST REQUESTED
161 NO SPECIMEN RECIEVED-NEEDS TO BE REPEATED
188 APPEARS TO BE DENATURED-NEEDS TO BE REPEATED
190 PERSON IS PAST THE AGE LIMIT AND INELIGIBLE FOR TEST
200 UNCAPPED, LEAKED IN TRANSIT
204 NO COLLECTION DATE-NEEDS TO BE REPEATED
208 NO SUBMITTER ADDRESS
210 NAME ON SPECIMEN AND FORM DO NOT MATCH
214 NO NAME ON SPECIMEN-NEEDS TO BE REPEATED
215 PATIENT ID QUESTIONABLE
216 OUT OF STATE RESIDENT, INELIGIBLE FOR TESTING
217 INSTRUMENT PROBLEMS-NEEDS TO BE REPEATED
3-4
Chapter 4
FOLLOW-UP SCHEDULE FOR DIAGNOSTIC / CONFIRMED LEAD LEVELS
Blood Lead Level Response
70 µg/dL • Hospitalize child and begin medical treatment immediately.
• Provide clinical management, including family lead education.
(Diagnostic test • Provide environmental investigation and lead hazard control.
immediately as • Refer to WIC Program
emergency lab test) • Refer children ages birth to 36 months to CDSA Early Intervention
• Refer children ages 3-5 to CSC
• Refer to Social Services as needed for housing or additional medical assistance.
• Continue testing every 2-3 months until 2 consecutive tests are 10 ug/dl, mental retardation, alcohol or drug
abuse.
Information about the North Carolina WIC program is available from your county
health department or by calling the North Carolina Family Health Resource Line
or at http://www.nutritionnc.com.
Early Intervention. Children with confirmed lead poisoning (≥20 µg/dL) are
eligible for Early Intervention Services. Children birth to 36 months of age should
be referred to the Children’s Developmental Service Agency (CDSA) for Early
Intervention as an entitlement of the Individuals with Disabilities Act. The CDSA
contact information may be found at www.ncei.org.
Child Service Coordination Program. Children 36 months to five years of age
with confirmed lead poisoning (≥20 µg/dL) may be referred to the Child Service
Coordination Program. For referral information, contact the local health
department.
Lead Team. Comprehensive services are best provided by a team that includes
the health-care provider, care coordinator, community health nurse or health
Chapter 4 -- Page 4
Revised April, 2008
advisor, environmental specialist, social services liaison, and housing specialist.
Coordination of care, environmental services (i.e., identifying and controlling
sources of lead exposure) and relocation to safe housing are typically provided or
coordinated by the health department.
Housing/Social Services/Educational Services. Refer children to appropriate
services if problems such as inadequate housing, lack of routine health care, or
need for early intervention educational services are identified. Because
childhood lead exposure is often associated with poverty, children with EBLs may
also have problems such as inadequate housing, lack of routine medical care,
and poor nutrition. Children may also need educational services, and the team
may be instrumental in ensuring that children with a history of EBLs receive early
intervention or special education services for which they are eligible. The health
department may also provide referral sources, such as social service agencies,
parent support groups and housing services.
Chelation
Chelation Therapy: Children with confirmed blood lead levels ≥45 µg/dL may
be candidates for chelation therapy. Providers wishing to discuss medical
treatment and follow-up of specific children with lead poisoning may contact
physicians associated with the Children's Environmental Health Branch:
ECU School of Medicine
Dr. Dale Newton
252-744-4422
Department of Pediatrics
Greenville, NC 27858
Education
The first opportunity to educate families about the causes and consequences of a
child’s elevated blood lead level (EBL) usually occurs in the health-care
provider’s office. Anticipatory guidance should be provided prenatally and again
when children are 3-6 months of age. Parental guidance at these times might
prevent some lead exposure and the EBLs that often occur during a child’s
second year of life. When children are 12 and 24 months of age, parental
guidance should be provided at well-child visits when the personal-risk
questionnaire is administered and/or the blood lead test is performed.
Anticipatory guidance on lead poisoning covers many of the same areas as the
Family Lead Education provided to children with elevated blood lead levels.
Discuss with families:
♦ Their child's blood lead level (if testing has taken place) and what it means.
♦ Potential adverse health effects of lead exposure.
Chapter 4 -- Page 5
Revised April, 2008
♦ Sources of lead and suggestions on how to reduce exposure.
Include discussion of ceramic dishes and traditional remedies
as possible sources of lead.
♦ Wet cleaning to remove lead-contaminated dust on floors,
windowsills and other surfaces. Discuss the ineffectiveness of
dry methods of cleaning, such as sweeping or vacuuming
(unless a HEPA vacuum is used) for lead removal.
♦ The importance of good nutrition in reducing the absorption of lead.
If there are poor eating habits and dietary patterns, discuss ways to improve
the diet, and in particular ensure there is adequate intake of iron, vitamin C,
calcium and zinc. Encourage regular meals and snacks.
♦ The need for follow-up blood lead testing to monitor the child's blood lead
level, as appropriate.
♦ Results of environmental investigation, as appropriate.
♦ Hazards of improper removal of lead-based paint. Particularly hazardous are
open-flame burning, power sanding, water blasting, methylene chloride-based
stripping, and dry sanding or scraping.
♦ Other information on remediation is available in the “Do's and Don'ts”
brochure (available in English and Spanish), and from EPA publications.
Health departments may provide printed materials, flipcharts and videos to assist
in the family education process. Health care providers should discuss short-term
repercussions of elevated blood lead levels (e.g., the need for follow-up testing /
treatment and the need to control lead hazards in the child’s environment) and
long-term repercussions (e.g., the potential for future learning problems and the
availability of early intervention services).
Helpful Tips
When testing children for blood lead levels, try to obtain multiple telephone
numbers for follow-up contact.
Lead follow-up is easiest to do when using computerized tickler files. In the
absence of these, a double-tickler file system has been used successfully by
many health care providers. In this system, first file children's cards/record by
name, in order to respond to questions from providers, schools, etc. A second
file should be kept by dates, to keep track of testing and follow-up schedules.
F Jun
E May
D C Apr Mar
B Feb
A Jan
Lead Files Lead Files
by Name by Month
Chapter 4 -- Page 6
Revised April, 2008
Coordinate WIC Program appointments and lead testing whenever possible to
repeat blood tests. When reviewing WIC PROGRAM charts for immunization
status, look for blood lead levels.
Communication between the Medical Home and the Environmental Health
Specialist is critical to ensure that children are not lost to appropriate follow-up.
This may be facilitated by meeting at least quarterly to review state surveillance
reports.
Be sure to use Medicaid numbers on lab slips for children who are on
Medicaid! Omission of the Medicaid number means that the State Laboratory
cannot be reimbursed for processing a specimen.
The Two-Bucket Method is recommended for lead cleaning, to ensure that lead
debris is not re-deposited onto cleaned surfaces, walls, and floors.
1. Place sponge or mop into bucket of detergent or cleaning solution.
2. Wipe surface.
3. Place contaminated sponge or mop into second bucket of rinse water,
allowing debris to fall to the bottom. Do not rinse surfaces with this water.
4. Repeat Steps 1-3.
5. Change rinse water often.
Clear Water
Detergent or
cleaning
solution
Rinse cleaned
surface s with
fresh water.
Change rinse water often.
Chapter 4 -- Page 7
Revised April, 2008
NORTH CAROLINA LEAD CONTACTS
CHILDREN’S ENVIRONMENTAL HEALTH BRANCH (CEHB)
DEBORAH HARRIS, PUBLIC HEALTH NURSING CONSULTANT
Division of Environmental Health 252/824-2911
Department of Environment and Natural Resources FAX: 252/824-0967
email: deborah.harris@ncdenr.gov
♦Medical Follow-up, Clinical Procedures, Case Management
BEVERLY BALDINGER, HUD GRANT MANAGER
Division of Environmental Health 252-200-4664
Department of Environment and Natural Resources CELL 252-382-0184
email: beverly.baldinger@ncdenr.gov
♦HUD Lead Hazard Control Grant, Preventive Maintenance Program
DAVID BROWN, SURVEILLANCE COORDINATOR
Division of Environmental Health 919/733-3351
Department of Environment and Natural Resources FAX: 919/715-5237
1632 Mail Service Center
Raleigh, NC 27699-1632 email: w.David.Brown@ncdenr.gov
♦Surveillance, Medical Follow-up, Regional Specialist for Franklin, Johnston, Orange & Wilson
TALYTHA MOORE, DATA ANALYST
Division of Environmental Health 919/715-5385
Department of Environment and Natural Resources FAX: 919/715-5237
1632 Mail Service Center
Raleigh, NC 27699-1632 email: Talytha.Moore@ncdenr.gov
♦Data Analysis
ED NORMAN, PROGRAM MANAGER
Division of Environmental Health 919/715-3293
Department of Environment and Natural Resources FAX: 919/715-4739
1632 Mail Service Center
Raleigh, NC 27699-1632 email: ed.norman@ncdenr.gov
♦Overall Contact, Public Outreach, Screening, Surveillance
TENA WARD, DATA MANAGER
Division of Environmental Health 919/715-1004
Department of Environment and Natural Resources FAX: 919/715-5237
1632 Mail Service Center
Raleigh, NC 27699-1632 email: tena.ward@ncdenr.gov
♦Data Management
REGIONAL ENVIRONMENTAL HEALTH SPECIALISTS (CEHB)
Kimly Blount (Field Supervisor)
PHONE : (252) 903-7925
EMAIL: Kimly.Blount@ncdenr.gov
COUNTIES: Edgecombe, Greene, Nash, Wake & Wayne
Patricia Gilmartin
PHONE: (252) 339-9558
EMAIL: Patricia.Gilmartin@ncdenr.gov
COUNTIES: Beaufort, Bertie, Camden, Chowan, Craven, Currituck, Dare, Gates,
Granville, Halifax, Hertford, Hyde, Martin, Northampton, Pamlico, Pasquotank,
Perquimans, Pitt, Tyrell, Vance, Warren & Washington
Alan Huneycutt (Radiation Safety Officer)
PHONE: (704) 618-0138
EMAIL: Alan.Huneycutt@ncdenr.gov
COUNTIES: Buncombe, Cabarrus, Cherokee, Clay, Cleveland, Gaston, Graham,
Haywood, Henderson, Jackson, Macon, Madison, McDowell, Mecklenburg, Polk,
Rutherford, Swain, Transylvania & Union
Wayne Jones
PHONE: (910) 290-3047
EMAIL: Wayne.Jones@ncdenr.gov
COUNTIES: Bladen, Brunswick, Carteret, Columbus, Duplin, Hoke, Jones, Lenoir,
New Hanover, Onslow, Pender, Robeson, Sampson & Scotland
Sheila Nichols
PHONE: (336) 466-1507
EMAIL: Sheila.Nichols@ncdenr.gov
COUNTIES: Alexander, Alleghany, Ashe, Avery, Burke, Caldwell, Catawba,
Davidson, Davie, Forsyth, Guilford, Iredell, Lincoln, Mitchell, Randolph, Rowan, Stokes,
Surry, Watauga, Wilkes, Yadkin & Yancey
Warren Richardson
PHONE: (336) 312-5069
EMAIL: Warren.Richardson@ncdenr.gov
COUNTIES: Alamance, Anson, Caswell, Chatham, Cumberland, Durham, Harnett, Lee,
Montgomery, Moore, Person, Richmond, Rockingham & Stanley
STATE LABORATORY
JENNIFER ANDERSON, MEDICAL LAB SUPERVISOR
State Laboratory of Public Health 919/807-8617
Department of Health and Human Services FAX: 919/715-8610
P.O. Box 28047
Raleigh, NC 27611-8047 email: Jennifer.a.anderson@dhhs.nc.gov
♦Blood Lead Analysis
JOHN NEAL, ENVIRONMENTAL SCIENCE UNIT HEAD
State Laboratory of Public Health 919/733-7308
Department of Health and Human Services FAX: 919/715-8611
P.O. Box 28047
Raleigh, NC 27611-8047 email: john.neal@dhhs.nc.gov
♦Environmental Sample Analysis
OTHER LEAD CONTACTS
JEFF DELLINGER, INDUSTRIAL HYGIENE CONSULTANT
Division of Public Health 919/707-5950
Department of Health and Human Services FAX: 919/870-4808
1912 Mail Service Center
Raleigh, NC 27699-1912 email: jeff.dellinger@dhhs.nc.gov
♦Worker Protection, Training, Certification, Accreditation
DARYL FRASIER, HEALTH CHECK CONSULTANT
Division of Medical Assistance 919/647-8170
Department of Health and Human Services FAX: 919/733-2796
2501 Mail Service Center email: daryl.frasier@dhhs.nc.gov
Raleigh, NC 27699-2501
♦Medical Follow-up
MARY GIGUERE, HEALTH HAZARD CONTROL UNIT MANAGER
Division of Public Health
Department of Health and Human Services 919-707-5950
1912 Mail Service Center FAX: 919-870-4808
Raleigh, NC 27699-1912 email: mary.giguere@dhhs.nc.gov
♦EPA Lead-Based Paint Grant, Worker Protection, Training, Certification, Accreditation
LEBEED KADY, ENVIRONMENTAL ENGINEER
Division of Waste Management 919/508-8546
Department of Environment and Natural Resources FAX: 919/715-3605
401 Oberlin Road, Suite 150
Raleigh, NC 27605 email: lebeed.kady@ncdenr.gov
♦ Hazardous Waste
KATHY LAMB, NUTRITION PROGRAM CONSULTANT
Division of Public Health
Department of Health and Human Services 919/707-5756
1914 Mail Service Center FAX: 919/870-4818
Raleigh, NC 27699-1914 email: kathy.lamb@dhhs.nc.gov
♦ WIC, Nutrition
AMY MACDONALD, ENVIRONMENTAL HEALTH EDUCATOR
UNC-Chapel Hill Environmental Resource Program 919/966-2463
114 Miller Hall CB 1105 FAX: 919/966-9920
Chapel Hill, NC 27599 email: amyjmac@email.unc.edu
♦ CDC Childhood Lead Poisoning Prevention Grant; Educational Materials; Training
DR. DALE NEWTON, DEPARTMENT OF PEDIATRICS
East Carolina University School of Medicine 252/744-3041
Brody 3E139 FAX: 252/744-2398
Greenville, NC 27834 email: NEWTOND@ecu.edu
♦ Pediatric Consultant
DR. DAVID ELDRIDGE, DEPARTMENT OF PEDIATRICS
East Carolina University School of Medicine 252/744-2539 or
Brody 3E139 252/744-2535
Greenville, NC 27834 FAX: 252/744-2398
email: ELDRIDGED@ecu.edu
♦ Pediatric Consultant
Appendix
A. Glossary
B. Contact Information
Children’s Environmental Health Branch Staff
State Laboratory Staff
Other Lead Contacts
Regional Environmental Health Specialists
C. Memos
Memo Re: Follow-up Testing Policy
Memo Re: WIC
D. Forms
North Carolina County Codes
Form 3651: Evaluation of Child with Elevated Blood Lead Level
Form 3958: Lead Risk Assessment Questionnaire
DHHS Form 3707: Blood Lead Analysis
E. Educational Materials
Lead Poisoning Do’s and Don’ts: English
Lead Poisoning Do’s and Don’ts: Spanish
F. Other
Nutrition Focus Article: Childhood Lead Poisoning and the Role of Nutrition
North Carolina Childhood Lead Screening Data by County
Glossary
Children Developmental Services Agency (CDSA). Provides evaluation
and intervention services primarily birth to age three. Serves as the local head
agency for the Early Intervention Infant Toddler Program. Contact information may
be found at www.ncei.org
CEHB Children’s Environmental Health Branch). Branch within the
Environmental Health Services Section that administers the Childhood Lead
Poisoning Prevention Program and Child Care Sanitation Program.
Child Service Coordination (CSC). Provides formal care coordination and
case management services at no charge to eligible children birth to five at risk for or
diagnosed with special needs and their families. Services are provided by local
health departments, Sickle Cell Agencies, Federally Qualified Health Centers and
Rural Health Centers to children not enrolled in the Infant Toddler Program. For
more information, call your local health department or the Children with Special
Health Care Needs Help Line, 1-800-737-3028.
Clinical Management. Comprehensive follow-up care, usually given by a health
care provider to a child with an elevated blood lead level. Clinical management
includes:
1. Clinical evaluation for complications of lead poisoning (Chap 4-Table 3)
2. Family lead education and referrals.
3. Chelation therapy, if appropriate.
4. Follow-up testing at appropriate intervals.
Confirmed lead poisoning. A blood lead concentration of 20 µg/dL or greater,
determined by the lower of two consecutive blood tests within a six-month period.
Diagnostic Test. A laboratory test for lead that is performed on the blood of a
child who has a screening blood level of 10 µg/dL or greater. The diagnostic test is
usually the first venous blood lead test performed within six months of the screening
test.
Early Intervention. Identification of young children who have a developmental
delay or may be at risk for developing problems and providing different types of
services to support the family and the child. Early Intervention services are provided
by many agencies under the leadership of the local CDSA.
Elevated Blood Lead Level (EBL). A blood lead concentration of 10 µg/dL or
greater determined by the lower of two consecutive blood tests within a six-month
period.
GLS-1
Revised March 2007
Family Lead Education. This service provides families with prompt and
individualized education regarding:
1. Their child's blood lead level, and what it means.
2. Potential adverse health effects of lead exposure.
3. Sources of lead and suggestions on how to reduce exposure.
4. The importance of wet cleaning to remove lead-contaminated dust on
floors, windowsills, and other surfaces; the ineffectiveness of dry
methods of cleaning, such as sweeping.
5. The importance of good nutrition in reducing the absorption of lead. If
there are poor nutritional patterns, discuss adequate intake of calcium,
iron and zinc and encourage regular meals and snacks.
6. The need for follow-up blood lead testing to monitor the child's blood
lead level, as appropriate.
7. Results of environmental investigation, as appropriate.
8. Hazards of improper removal of lead-based paint. Particularly
hazardous are open-flame burning, power sanding, water blasting,
methylene chloride-based stripping, and dry sanding or scraping.
Follow-up test. A laboratory test for lead that is performed on the blood of a child
with an elevated diagnostic test for lead in order to monitor the child’s status.
Initial Blood Lead Test. A laboratory test for lead that is performed on the
blood of an asymptomatic child to determine if the child has an elevated blood lead
level.
Refugee. Refugees are a special group of immigrants who are admitted into the
United States because of persecution or a well-founded fear of persecution on
account of race, religion, nationality, membership in a particular social group, or
political opinion. These individuals enter the United States legally as a refugee
pursuant to Section 207 of the Immigration and Naturalization Act. For the most part,
refugees cannot return home because of the danger they would face upon returning.
WIC Program. WIC stands for Women, Infants, and Children and is also called
the Special Supplemental Nutrition Program. WIC is a federal program for low-
income pregnant, postpartum and breastfeeding women, infants and children until
the age of five and provides supplemental foods, nutrition education, breastfeeding
support, and referrals for health care. This Program is effective in preventing and
improving nutrition-related health problems within its population.
GLS-2
Revised March 2007
North Carolina Department of
Environment And Natural Resources
Division of Environmental Health
Michael F. Easley, Governor
William G. Ross Jr., Secretary
Terry L. Pierce, Director
Bart Campbell, Section Chief
April 1, 2005
MEMORANDUM
To: Childhood Lead Poisoning Prevention Coordinators,
Health Care Providers,
Regional Nursing Consultants
From: Deborah W. Harris, Public Health Nursing Consultant
Children’s Environmental Health Branch
Through: Ed Norman, Program Manager
Children’s Environmental Health Branch
Re: Revisions to the North Carolina Screening and Follow-up Manual
And Follow-up Testing Policy
The North Carolina Screening and Follow-up Manual is currently in the process of being
revised. The completion and distribution of the revised manual is anticipated for early to mid-
summer.
In the process of revising the manual, it was decided that one change should be implemented
now. Currently, children with confirmed elevated blood lead levels are tested until they have
three consecutive blood lead tests less than 10 µg/dL. Once the child has received three
consecutive tests less than 10 µg/dL, the child’s name is removed from the surveillance report.
This recommendation was derived from the 1991 CDC guidance document at a time when the
lowest blood lead level requiring follow-up testing was 15 µg/dL.
Effective with the date of this memorandum, children with confirmed elevated blood lead levels
will only need to receive two consecutive blood tests less than 10 µg/dL and these children’s
names will be removed from the periodic surveillance report.
If you have any questions, please contact me at (252) 824-2911.
Environmental Health Services Section – Children’s Environmental Health Branch
1632 Mail Service Center, Raleigh, North Carolina 27699-1632 Telephone 919-715-5237 FAX 919-715-4739
An Equal Opportunity / Affi rmative Action Employer
NORTH CAROLINA COUNTY CODES
001 Alamance 026 Cumberland 051 Johnston 076 Randolph
002 Alexander 027 Currituck 052 Jones 077 Richmond
003 Alleghany 028 Dare 053 Lee 078 Robeson
004 Anson 029 Davidson 054 Lenoir 079 Rockingham
005 Ashe 030 Davie 055 Lincoln 080 Rowan
006 Avery 031 Duplin 056 Macon 081 Rutherford
007 Beaufort 032 Durham 057 Madison 082 Sampson
008 Bertie 033 Edgecombe 058 Martin 083 Scotland
009 Bladen 034 Forsyth 059 McDowell 084 Stanly
010 Brunswick 035 Franklin 060 Mecklenburg 085 Stokes
011 Buncombe 036 Gaston 061 Mitchell 086 Surry
012 Burke 037 Gates 062 Montgomery 087 Swain
013 Cabarrus 038 Graham 063 Moore 088 Transylvania
014 Caldwell 039 Granville 064 Nash 089 Tyrrell
015 Camden 040 Greene 065 New Hanover 090 Union
016 Carteret 041 Guilford 066 Northampton 091 Vance
017 Caswell 042 Halifax 067 Onslow 092 Wake
018 Catawba 043 Harnett 068 Orange 093 Warren
019 Chatham 044 Haywood 069 Pamlico 094 Washington
020 Cherokee 045 Henderson 070 Pasquotank 095 Watauga
021 Chowan 046 Hertford 071 Pender 096 Wayne
022 Clay 047 Hoke 072 Perquimans 097 Wilkes
023 Cleveland 048 Hyde 073 Person 098 Wilson
024 Columbus 049 Iredell 074 Pitt 099 Yadkin
025 Craven 050 Jackson 075 Polk 100 Yancey
NC Department of Environment and Natural Resources Patient's Name:
Division of Environmental Health
Medical Record Number:
LEAD RISK ASSESSMENT
QUESTIONNAIRE
Purpose: For clinical use to identify children who need to be screened for lead poisoning. All children
should receive a blood lead test at both 12 and 24 months of age (or between 24 and 72 months of age if
they have never been tested) unless the child lives in one of the low-risk zip codes listed on the back of
this page and the answers to all five screening questions are no.
Instructions: At 12 and again at 24 months of age (or at the time of the clinic visit closest to these ages)
determine the residential zip code for all children. Also determine the zip code for children between 24
and 72 months of age who have never been tested or for whom lead screening status is unknown. Conduct
a blood lead test for children who live in one of the high risk zip codes listed on the back of this page. For
children who do not live in high risk zip codes ask the five screening questions. A yes or I don't know
answer to any question also indicates the need for a blood lead test.
Reordering Information: Additional copies of this form may be ordered from:
Environmental Health Services Section
Division of Environmental Health
1632 Mail Service Center
Raleigh, NC 27699-1632
Telephone: 919-733-3351
Date: Age: Residential Zip Code:
1. Receive Women, Infants, and Children (WIC) Program Services or is
your child enrolled in Medicaid (Health Check) or Health Choice?
2. Live in or regularly visit a house that was built before 1950, including
home child care centers or homes of relatives?
3. Live in or regularly visit a house that was built before 1978, with
recent or ongoing renovations or remodeling (within the last 6
months)?
4. Live in or regularly visit a house that contains vinyl miniblinds
5. Have a brother, sister, other relative, housemate or playmate who has
or has had a high blood lead level
Date Age: Residential Zip Code:
1. Receive Women, Infants, and Children (WIC) Program Services or is
your child enrolled in Medicaid (Health Check) or Health Choice?
2. Live in or regularly visit a house that was built before 1950, including
home child care centers or homes of relatives?
3. Live in or regularly visit a house that was built before 1978, with
recent or ongoing renovations or remodeling (within the last 6
months)?
4. Live in or regularly visit a house that contains vinyl miniblinds
5. Have a brother, sister, other relative, housemate or playmate who has
or has had a high blood lead level
DENR 3958 (Revised 2/10)
Environmental Health Services (Review 6/08)
North Carolina Zip Codes for Children at High Risk for Lead Exposure
These zip codes m eet the criteria for universal screening.
27014 27530 27810 27850 27920 27983 28205 28358 28434 28516 28580
27027 27534 27812 27852 27922 27983 28206 28362 28435 28516 28581
27042 27536 27812 27853 27923 27983 28208 28362 28435 28516 28585
27047 27542 27813 27855 27923 27985 28212 28363 28435 28516 28585
27053 27544 27814 27856 27924 27986 28215 28364 28435 28516 28586
27053 27546 27814 27857 27924 28001 28216 28365 28435 28516 28586
27053 27549 27816 27860 27925 28006 28217 28367 28436 28516 28589
27101 27549 27817 27862 27925 28007 28301 28368 28438 28518 28606
27105 27551 27818 27864 27926 28009 28301 28369 28439 28519 28611
27107 27553 27819 27866 27927 28017 28303 28372 28441 28520 28616
27202 27559 27820 27869 27928 28019 28304 28373 28442 28520 28622
27212 27559 27821 27870 27929 28032 28305 28376 28444 28521 28624
27217 27563 27822 27871 27932 28038 28306 28377 28447 28523 28629
27217 27565 27822 27872 27936 28043 28306 28379 28447 28524 28631
27242 27568 27823 27873 27936 28052 28307 28382 28448 28524 28642
27252 27570 27824 27874 27937 28072 28311 28383 28451 28526 28645
27256 27573 27826 27875 27938 28073 28314 28384 28451 28528 28646
27260 27577 27827 27876 27941 28077 28315 28385 28451 28530 28649
27262 27582 27828 27877 27942 28083 28320 28387 28451 28532 28662
27288 27584 27829 27878 27943 28089 28323 28390 28451 28532 28663
27288 27589 27830 27882 27944 28090 28325 28392 28452 28537 28668
27291 27601 27831 27883 27946 28091 28328 28393 28453 28538 28671
27305 27610 27831 27883 27950 28098 28330 28395 28454 28540 28671
27305 27610 27831 27884 27953 28101 28332 28396 28456 28543 28677
27306 27701 27831 27885 27956 28102 28333 28398 28458 28544 28682
27311 27703 27831 27885 27957 28109 28334 28399 28463 28551 28685
27314 27704 27832 27886 27960 28119 28337 28401 28464 28552 28693
27320 27706 27832 27888 27962 28128 28337 28401 28466 28553 28707
27326 27707 27834 27889 27964 28135 28338 28401 28466 28553 28708
27342 27801 27839 27890 27965 28144 28338 28403 28471 28553 28710
27343 27803 27840 27891 27967 28150 28339 28420 28472 28554 28718
27371 27803 27841 27892 27968 28150 28340 28421 28478 28555 28735
27379 27804 27842 27893 27970 28150 28342 28422 28501 28556 28736
27401 27804 27842 27897 27972 28152 28343 28423 28501 28560 28743
27403 27805 27843 27909 27973 28159 28345 28425 28504 28560 28743
27405 27805 27844 27910 27973 28160 28347 28429 28510 28560 28745
27406 27806 27845 27915 27974 28167 28347 28430 28510 28560 28755
27506 27809 27846 27916 27979 28169 28349 28431 28511 28560 28757
27507 27810 27847 27917 27980 28170 28351 28432 28511 28573 28765
27508 27810 27849 27917 27980 28202 28352 28432 28513 28575 28774
27509 27810 27850 27917 27982 28203 28352 28432 28515 28577 28781
27525 27810 27850 27919 27983 28204 28357 28433 28516 28579 28784
28801
DENR 3958 (Revised 2/10)
Environmental Health Services (Review 6/08)
1. Last Name First Name MI
N.C. Department of Environment and Natural Resources
2. Medicaid No.
- H Division of Environmental Health
3. Date of Birth
Month Day Year EVALUATION OF CHILD WITH
4. Race 1. White
3. Am. Ind.
2. Black
4. Other
Ethnicity: Hispanic Origin?
Yes No
ELEVATED BLOOD LEAD LEVEL
5. Sex 1. Male 2. Female
6. County of Residence
Current Address of Child: Phone: ( )
Length of Resident at Child's Current Address: years months
Parents Name:
Laboratory Findings:
Date: Blood Lead: Hematocrit:
Date: Blood Lead: Hematocrit:
Date: Blood Lead: Hematocrit:
Dietary Update:
Yes No
Does the family store food in open cans?
Does the family prepare, store, or serve food in homemade or imported ceramic dishes?
Does the family use traditional medicines such as greta, azarcon or pay-loo-ah?
Does the child receive dolomite or bonemeal as a calcium or phosphorus supplement?
Is the child on an iron supplement?
Is the child enrolled in the WIC program?
Comments:
Possible Non-food Sources of Child's Lead Exposure:
Yes No Explain
Does child eat dirt?
Does child eat or chew on:
Paint chips/plaster?
Furniture, crib, or window sill?
Other non-food items?
Does family store old car batteries?
Does the child come in contact with vinyl
miniblinds?
DENR3651 (Revised 6/05)
Environmental Healt h Services Section (Review 6/08)
Possible Non-food Sources of Child's Lead Exposure: (Continued)
Yes No Explain
Does family used the following for fuel:
painted boards?
battery casings?
Are there plastic or vinyl miniblinds at the
child's home?
Is there peeling paint or plaster inside or out at
the child's primary residence?
Is the primary residence being remodeled or
has it been remodeled during the past six
months?
Does any family member work in lead-related
industry such as battery salvage, fishing weight
production, car repair or painting, smelting or
house renovating?
Approximate Age of Dwelling: Owner of Dwelling:
Number of children in household less than 6 years old: Screened for lead poisoning during past six months?
Name/age / Yes No
/ Yes No
/ Yes No
/ Yes No
INTERVIEWER: Have I completed the following:
Yes No Comments
Discussed effects of lead poisoning and need for patient follow-up.
Provided education on house cle aning measures to prevent lead poisoning.
Provided nutritional information to reduce lead absorption.
Made arrangements for subsequent laboratory testing.
Has referral been made to physician if needed?
If yes, give date and time:
Explained reason for environmental investigation.
Referral sent to sanitarian for environmental investigation.
Date: INTERVIEWER:
Purpose: To be used by the health care provider to determine potential sources of lead exposure for a child with an elevated blood lead level and to
educate the family about lead poisoning.
Preparation: Fill in the blanks and check the appropriate answers.
Distribution: Retain original at county health department with child's record. Send a copy to the lead investigator upon a referral for an environmental
investigation. Send a second copy to the address below.
Disposition: This form may be destroyed in accordance with Standard 5 of the Records Disposition Schedule published by the North Carolina Division of
Archives and History.
Additional forms may be ordered from: N.C. Department of Environmental and Natural Resources
Division of Environmental Health
Environmental Health Services Section
1630 Mail Service Center
Raleigh, NC 27699-1630
DENR3651 (Revised 6/05)
Environmental Healt h Services Section (Review 6/08)
1. Last Name First Name MI DO NOT WRITE IN THIS SPACE North Carolina
LABORATORY NUMBER Department of Health and Human Services
State Laboratory of Public Health
Lou F. Turner, Dr.P.H., Director
2. Patient Number 306 N. Wilmington St, P.O. Box 28047
(Soc. Security No.) — H Raleigh, North Carolina 27611-8047
3. Address
4. Date of Birth
Month Day Year
ESSENTIAL SPECIMEN DATA
BLOOD LEAD
DATE COLLECTED
5. Race 1. White 2. Black 3. American Indian
5. Native Hawaiian/Other Pacific Islander
4. Asian
6. Unknown
M D Y ANALYSIS
6. Hispanic or Latino Origin? 1. Yes 2. No 6. Unknown
7. Sex 1. Male 2. Female 8. Co. of Residence
9. Medicaid Client Yes
If yes, enter # No — SEND REPORT TO:
EMPLOYER IDENTIFICATION NUMBER: _________________________________
10. WIC Patient? If yes, please check box: ADDRESS:
Initial blood lead test
Follow-up blood lead test
Microtainer
EDTA blood specimen
(full, unopened tube)
DHHS 3707 (Revised 4/05)
LABORATORY (Review 4/08)
✁
1. Last Name First Name MI DO NOT WRITE IN THIS SPACE North Carolina
LABORATORY NUMBER Department of Health and Human Services
State Laboratory of Public Health
Lou F. Turner, Dr.P.H., Director
2. Patient Number 306 N. Wilmington St, P.O. Box 28047
(Soc. Security No.) — H Raleigh, North Carolina 27611-8047
3. Address
4. Date of Birth
Month Day Year
ESSENTIAL SPECIMEN DATA
BLOOD LEAD
DATE COLLECTED
5. Race 1. White 2. Black 3. American Indian
5. Native Hawaiian/Other Pacific Islander
4. Asian
6. Unknown
M D Y ANALYSIS
6. Hispanic or Latino Origin? 1. Yes 2. No 6. Unknown
7. Sex 1. Male 2. Female 8. Co. of Residence
9. Medicaid Client Yes
If yes, enter # No — SEND REPORT TO:
EMPLOYER IDENTIFICATION NUMBER: _________________________________
10. WIC Patient? If yes, please check box: ADDRESS:
Initial blood lead test
Follow-up blood lead test
Microtainer
EDTA blood specimen
(full, unopened tube)
DHHS 3707 (Revised 4/05)
LABORATORY (Review 4/08)
COLLECTION INSTRUCTIONS FOR COLLECTION INSTRUCTIONS FOR
BLOOD LEAD ANALYSIS BLOOD LEAD ANALYSIS
Preparation of Child Preparation of Child
1. Wash hands with soap and water, using hand brush. Rinse well. Dry. 1. Wash hands with soap and water, using hand brush. Rinse well. Dry.
2. Grasp child's hand so that blood drawer's thumb is across top of child's 2. Grasp child's hand so that blood drawer's thumb is across top of child's
fingers. fingers.
3. Hold child's hand so that palm faces him. 3. Hold child's hand so that palm faces him.
4. Use child's middle or ring finger for sample. 4. Use child's middle or ring finger for sample.
5. Use alcohol sponge to scrub briskly an area on child's fingertip for 20 5. Use alcohol sponge to scrub briskly an area on child's fingertip for 20
seconds. seconds.
6. Wipe scrubbed area once, using dry gauze. 6. Wipe scrubbed area once, using dry gauze.
7. Use lancet to stick finger slightly left of center. 7. Use lancet to stick finger slightly left of center.
8. Use dry gauze to wipe off first drop of blood. 8. Use dry gauze to wipe off first drop of blood.
Collection of Blood Sample Collection of Blood Sample
1. Continuing to grasp the finger, touch the tip of the capillary to the beaded 1. Continuing to grasp the finger, touch the tip of the capillary to the beaded
drop of blood. drop of blood.
2. Capillary must be held continuously in a horizontal position during 2. Capillary must be held continuously in a horizontal position during
collection to prevent air bubbles forming in the capillary tube. collection to prevent air bubbles forming in the capillary tube.
3. After 3-4 drops of blood fall off the full capillary into the microtainer, you 3. After 3-4 drops of blood fall off the full capillary into the microtainer, you
have enough blood. (150-250 ul) have enough blood. (150-250 ul)
4. Turn capillary/tube unit immediately in a vertical position to allow the 4. Turn capillary/tube unit immediately in a vertical position to allow the
blood to flow into the tube. blood to flow into the tube.
5. Remove capillary with holder at the same time. Close microtainer with 5. Remove capillary with holder at the same time. Close microtainer with
attached cap. attached cap.
6. Agitate the specimen to mix the anticoagulant through the blood. 6. Agitate the specimen to mix the anticoagulant through the blood.
7. Properly label with patient's name. Place in appropriate storage until 7. Properly label with patient's name. Place in appropriate storage until
shipping. shipping.
8. Specimens must be received in the Laboratory within 2 weeks, however, 8. Specimens must be received in the Laboratory within 2 weeks, however,
immediate shipping is recommended to ensure specimen integrity and immediate shipping is recommended to ensure specimen integrity and
suitability for analysis. suitability for analysis.
FOR ADDITIONAL INFORMATION SEE FOR ADDITIONAL INFORMATION SEE
"SCOPE" OR CALL (919) 733-3937 "SCOPE" OR CALL (919) 733-3937
DHHS 3707 (Revised 4/05) DHHS 3707 (Revised 4/05)
LABORATORY (Review 4/08) LABORATORY (Review 4/08)
Possible
Sources of
Lead
Lead
Poisoning
1. Lead-based
paint
DOs 2. Dust and soil
& 3. Pottery
4. Home remedies
DON’Ts such as
azarcon and
greta
5. Plastic or vinyl
miniblinds
6. Fishing and
hunting
supplies
Do:
Wash your child’s hands and face often.
Keep your child’s fingernails cleaned
and trimmed.
Wash toys daily.
Feed children three meals and two or
three snacks daily. Include foods high
in iron and calcium.
Clean floors, walls, windows and window
sills often with a cleaning agent.
Change rinse water often.
Make sure children play in
safe, grassy areas.
Have your child tested for lead
poisoning at your doctor’s
office or local health department. Keep
follow-up appointments.
Don’t:
Don’t let your child play in bare soil
or eat dirt.
Don’t let your child put toys or
small objects that have been on
the floor into his mouth.
Don’t burn painted boards,
newspapers, colored paper or
magazines in woodstove or fireplace.
Don’t vacuum paint chips or dust.
Always damp mop or wipe.
Don’t use hot tap water when cooking or
preparing infant formula. Always
use cold water that has run for a
few minutes.
Don’t let your child chew on painted
surfaces, woodwork or wood chips.
Don’t let your child play
with batteries or items
used in hobbies such as
stained glass or furniture
refinishing.
Feed Children Food Lead
High in Iron and poisoning
Calcium can be
Iron: prevented.
♦ beef ♦ pork
♦ deer ♦ veal Do all you
♦ clams ♦ oysters
♦ shrimp ♦ tuna can to protect
♦ iron-rich cereals
♦ raisins* and prunes your child
♦ cooked dried beans and peas from
♦ peas
becoming
Calcium:
lead-
♦ milk
♦ cheese poisoned.
♦ yogurt
♦ canned salmon
For more
♦ green leafy
vegetables information,
(collards, spinach, broccoli) call your child’s
doctor or
your local health
*WARNING: department.
Children under age 3 or 4 can
choke on foods like raisins,
hotdogs, Vienna Sausages®,
popcorn, peanut butter, raw North Carolina Division of
Environment and Natural Resources
carrots, nuts, jelly beans or State of North Carolina
Department of Environment and Natural Resources
Division of Environmental Health
whole grapes. Children’s Environmental Health Branch 919-715-5381
This appendix was adapted for the 1999 Lead Chapter of the Child Health Manual from the 1996
“Lead Poisoning Do’s and Don’ts” brochure, produced by the Children’s Environmental Health Branch
Fuentes
Envenenamiento posibles del
causado por el plomo
Plomo
1. Pintura a base
de plomo
Lo que se
2. Polvo y tierra
debe hacer
3. Cerámicas
y
4. Remedios
lo que no se caseros como:
debe hacer azarcon y
greta
5. Persianas de
plástico
6. Equipos de
caza y pesca
Usted Debe:
Lavar frecuentemente las manos y la cara de sus
niños.
Mantener cortas y limpias las uñas de sus niños.
Lavar los juguetes diariamente.
Darle diariamente a los niños tres comidas
principales y dos o tres meriendas o
refrigerios. Incluya los alimentos ricos en
hierro y calcio.
Lavar a menudo los pisos, las paredes, las
ventanas y los bordes o antepechos de las
ventanas con jabón o con detergente.
Cambiar frecuentemente el agua de enjuagar
los platos.
Hacer que los niños juegen en áreas
seguras y con césped.
Pedirle a su doctor o al Departamento de Salud de
su localidad que le hagan la prueba para
saber el contenido de plomo en la
sangre de sus niños. Por
favor no faltar a las
consultas siguientes.
Chapter F – Appendix 08.01 - Page 4
No Se Debe:
No deje jugar a su niño con tierra y
no lo deje comer tierra.
No deje que sus niño meta los
jugetes u objetos pequeños
en la boca.
No queme maderas pintadas,
periódicos, papel de colores
o revistas en la chimenea o
en la hoguera.
No use la aspiradora para limpiar los
residuos de pintura que contengan
plomo.
No prepare la fórmula o el tetero para los
bebes con agua caliente del chorro, grifo
o llave; use solamente agua fría del
chorro para beber y para cocinar y déjela
correr por unos minutos antes de usarla.
No deje a su niño morder las
superficies pintadas y las
escamas de pintura.
No deje jugar a su niño con las
baterias o las pilas. Tampoco lo
deje jugar con los materiales
usados para la restauración de
muebles y la fabricación de
vidrio de colores.
Dé de comer a los niños El envenenamiento
alimentos ricos en calcio causado por el plomo
y hierro se puede prevenir.
Hierro: Haga todo lo que pueda
♦ carne de res ♦ ternera para proteger a su niño
♦ cerdo ♦ almejas del envenenamiento
♦ pescado ♦ ostras causado por el plomo.
♦ venado ♦ atún
♦ camarones
♦ *pasas y ciruelas
♦ cereales ricos en hierro
Para obtener más
♦ frijoles cocidos y arvejas informacíon, llame el
o guisantes Departamento de Salud
de su localidad o al
Calcio:
doctor de su niño.
♦ leche
♦ yogurt
♦ queso
♦ salmón enlatado
♦ verduras verdes como:
collards, espinacas y brócoli
*AVISO:
Los niños menores de 4 años
de edad pueden estrangularse
con alimentos tales como: uvas
pasas, salchichas, rosetas,
crispetas de maiz, mantequilla
North Carolina Division of
de mani o cacahuete, North Carolina Division
Environment and Natural Resources
of
Environment and Natural
Resources State of North Carolina
State of North Carolina • James B. Hunt, Jr., Governor
Department of Environment and Natural Resources
zanahoria, nueces, caramelos o Department of Environment and Natural Resources • Wayne
Division of Environmental Health
McDevitt, Secretary
Children’s Environmental Health Branch 919-715-5381
Division of Environmental Health
dulces y uvas. Children’s Environmental Health Branch (919) 715-5381
This appendix was adapted for the 1999 Lead Chapter of the Child Health Manual from the 1996
“Lead Poisoning Do’s and Don’ts” brochure, produced by the Children’s Environmental Health Branch
This appendix adapted for the 1999 Lead Chapter Child Health from the
of the 1996
“Lead Poisoning Do’s and Don’ts” brochure, produced by the Children’s Environmental
Manual
Health Branch
Nutrition
for children with
special health care needs
Volume 17, No. 3
FOCUS May/June 2002
Childhood Lead Poisoning and the Role of
Nutrition
Kathy Lamb, MS, RD, Nutrition Consultant
Women’s and Children’s Health Section, Division of Public Health
North Carolina Department of Health and Human Services Editor’s Note – This edition is an
update of an earlier Nutrition Focus,
Claudia S. Rumfelt-Wright, MSW, Public Health Educator Lebeuf, JS and Norman, EH.
Environmental Health Services Section, Division of Environmental Health Nutritional Implications of Lead
Poisoning in Children. Nutrition
North Carolina Department of Environment and Natural Resources
Focus. Volume 8, #5, September/
October 1993. Lead poisoning is still
a health problem for children and this
issue provides current information
about this continuing public health
BACKGROUND issue.
Childhood lead poisoning is a major, had BLLs >20 µg/dL, 83% were Medicaid
preventable, environmental health problem. enrollees, as were 60% of those with BLLs
The persistence of lead poisoning in light of >10 µg/dL.2 For some states, the Medicaid mented cases of childhood lead poisoning
present knowledge about the sources, path- burden is even greater. For example, from resulting from a pet whose fur was contami-
ways and prevention of lead exposure, con- 1998 to 2000 in North Carolina, more than nated with lead dust. Imported vinyl mini-
tinues to challenge clinicians and public 75% of children with BLLs >10 µg/dL were blinds made with a lead formula have poi-
health authorities. Lead has no known physi- Medicaid enrollees. Unfortunately, while soned children. The growing immigrant
ological value and children are particularly Medicaid children have a prevalence of population in the United States is a chal-
susceptible to its toxic effects. Most poi- elevated BLLs three times that of children in lenge for public health professionals to be
soned children have no apparent symptoms, the same age group who are not Medicaid aware of the cultural differences and tradi-
and consequently, many cases go undiag- enrollees, 65% of them are not screened tional products that may put these children
nosed and untreated. Recent studies sug- according to recent estimates by the Gov- at high risk. For example, many household
gest that even blood lead levels (BLLs) be- ernment Accounting Office (GAO).3 As a items from Mexico have been found to con-
low 10 micrograms per deciliter (µg/dL) can result, the CDC recommended targeted tain lead including ceramic bean pots and
adversely affect children’s ability to learn, screening for all high-risk children at ages tamarind candy. Some imported traditional
and their behavior. No socioeconomic one and two in 1998. An example of targeted medicines, aphrodisiacs and other herbal
group, geographic area, racial or ethnic popu- screening is the establishment of different preparations have also been found to con-
lation is spared. screening strategies for low and high-risk tain high levels of lead.
zip codes, based on the age of housing stock
The percentage of children ages 1-5 in and the number of children with elevated
the United States with elevated blood lead BLLs. HEALTH EFFECTS
levels has decreased from 88.2% (1976 – 80)
to 4.4% (1991 – 1994) according to data from Sources of lead exposure are listed in Severe lead exposure (>70 µg/dL) can
the Second and Third National Health and Table 1 and include lead-based paint, soil, cause lethargy, convulsions, coma and even
Nutrition Examination Surveys (NHANES). house dust and drinking water. While lead- death in young children. Lower levels can
However, the Centers for Disease Control based paint is still the major source of expo- cause adverse effects on the kidneys, and
and Prevention (CDC) estimate that ap- sure, the concern has shifted from children the hematopoietic and central nervous
proximately 890,000 children in the United eating paint chips to ingestion of lead-con- systems. According to the CDC, even blood
States have blood lead levels >10 µg/dL.1 taminated dust. There have even been, lead levels below 10 µg/dL, which do not
Moreover, among U.S. children ages 1-5 who through hand-to-mouth activities, docu- cause specific symptoms, are associated
CENTER ON HUMAN DEVELOPMENT AND DISABILITY, UNIVERSITY OF WASHINGTON, SEATTLE, WASHINGTON
with decreased intelligence and impaired A recent study analyzed data on 4,835 social behavior are particularly affected.
neurobehavioral development. Other children, ages 6-16 years, from the NHANES These results argue for a reduction in blood
adverse effects begin at low levels of expo- III.4 The relationship between blood lead con- lead levels that are considered acceptable.
sure, including decreased growth and centration and performance on tests of arith- No detectable threshold for the adverse ef-
growth velocity, decreased hearing acuity, metic, reading, nonverbal reasoning and fects of exposure was found by these re-
decreased ability to maintain a steady pos- short-term memory was assessed. The re- searchers.
ture and impaired synthesis of vitamin D. searchers found an inverse relationship be-
Lead also competes with iron for incorpora- tween blood lead concentrations and defi- In a number of prospective studies, pre-
tion into the heme molecule and can contrib- cits in cognitive functioning and academic natal exposures have been associated with
ute to iron-deficiency anemia. Epidemiologic achievement in children at levels below 5.0 delayed sensory-motor and early cognitive
studies provide ample evidence on the as- µg/dL. Reading abilities were especially af- development. However, these effects appear
sociation between low-level lead expo- fected. Behaviorally, the study suggests that to diminish as children grow older, given low
sure and the effects on child development. attention, judgment and decision-making postnatal exposure and favorable socioeco-
abilities, visual-motor reasoning skills, and nomic conditions.5
Table 1
Sources and Pathways of Lead Exposure in Children
Lead-based paint: The most common source of lead exposure for young children is lead-based paint. The use of lead-based paint for
homes, furniture and toys is now prohibited; however, it is still found in homes built before 1978, and homes built before 1950 can
contain paint with high concentrations of lead exceeding 50% by weight.
Soil and house dust: Contaminated by deteriorated paint, leaded gasoline and industry emissions, soil containing lead is found near
the foundation of homes, in industrial areas and near major roads. The phase-out of lead in gasoline mandated by the EPA was
completed in 1987. Remodeling and renovation, which is done without using lead-safe work practices, can generate lead dust. Dust in
deteriorated window areas is often contaminated with lead.
Ceramic ware: Imported and decorated dishes or handmade pottery can be frequent sources of lead for immigrants and others. Foods
stored or served in leaded crystal or food cooked and/or stored in improperly fired ceramic dishes can contain lead.
Drinking water: Water can be contaminated by plumbing in homes with lead pipes or copper pipes soldered with lead.
Food and supplements: Some imported canned products, “natural” dietary supplements such as bone meal, and some calcium supple-
ments such as dolomitic limestone and oyster shells, while not widely recommended for young children, can be a source of lead.
Levels vary considerably from trace amounts to higher levels.
Air: Emissions from active lead smelters and other lead-related industry can be inhaled.
Occupations and hobbies: Workers may take home lead dust on their clothing or bring scrap material home from work with radiators,
car batteries, dirt near freeways, paint removal, smelters and factories. Hobbies such as making stained glass, pottery, fishing weights, or
jewelry; reloading or casting ammunition; and refinishing furniture are sources of lead.
Traditional medicines: Folk remedies from Latin America used to treat “empacho” (upset stomach) such as greta and azarcon (also
known as Rueda, Coral, Maria Luisa, Alarcon or Liga) have been found to contain more than 90% lead by weight. Pay-loo-ah is a
reddish powder used by the Hmong to treat fever and rash. Some Chinese herbal remedies and teas have also been found to contain
high levels of lead. Lead has also been found in aphrodisiacs imported from India and Africa.
Cosmetics: Cosmetics used by some Indian, African and Middle Eastern immigrants such as surma and kohl contain lead.
Vinyl Products: As they age and deteriorate, imported, lead containing vinyl mini-blinds may have lead dust on their surfaces. In 1996,
the Arizona and North Carolina Departments of Health first alerted the U.S. Consumer Product Safety Commission (CPSC) to the
problem of lead in the imported vinyl mini-blinds. Lead was added to stabilize the plastic in imported blinds. Using electron microscopy,
it was confirmed that as the blinds deteriorated from sunlight and heat, lead-containing dust formed on the surface of the blind slats,
posing a potential risk to young children. Young children can ingest lead by touching the mini-blinds and then putting their hands in
their mouths, mouthing the window, or mouthing the blinds themselves. In some tested blinds, the levels of lead in the dust was so
high that a child ingesting dust from less than one square inch of blind a day for 15 – 30 days could result in blood levels at or above
10 µg/dL. Children’s vinyl toys may be another source of lead for young children. Studies done at the University of North Carolina in
Asheville have demonstrated that as some soft vinyl toys are exposed to light and to chewing they can release lead as well as cadmium,
another toxic heavy metal. This was particularly true among soft vinyl toys from Asia. Highest levels of cadmium were found in toys,
soft lunchboxes and rainwear that were bright yellow.6
Nutrition Focus Vol. 17 #3 2 May/June 2002
RECOMMENDATIONS FROM Table 2
THE CENTERS FOR DISEASE Interpretation of Screening Test Results and Recommended Follow-up
CONTROL Blood Lead
The CDC’s level of concern remains at 10 Level (µg/dL) Comments
µg/dL. Targeted screening, based on geo-
graphic areas or demographic populations 10 µg/dL. In most states, abdominal x-ray is completed if particulate lead ingestion is suspected.
children with blood lead levels >10 µg/dL
are medically eligible for participation in the >70 A child with a BLL >70 requires immediate hospitalization as lead poisoning at
Special Supplemental Nutrition Program for this level is a medical emergency. Confirmatory venous testing should be
Women, Infants and Children (WIC Pro- done as soon as possible. An abdominal x-ray is completed if particulate lead
gram). Individual case management, includ- ingestion is suspected and chelation therapy should begin immediately. Case
ing nutrition and education interventions and clinical management including nutrition, education, medical and environ-
(described below and in Table 5) and fre- mental interventions, must take place as soon as possible.
quent retesting, is recommended for children
with blood leads > 15 µg/dL. In many areas, Information from Centers for Disease Control and Prevention. Screening Young
families of children with BLLs >10 µg/dL are Children for Lead Poisoning: Guidance for State and Local Public Health Offices.
offered environmental investigations. November 1997. Atlanta, Georgia. United States Department of Health and Human
Services, Public Health Services, CDC, 1997 and Centers for Disease Control and
Prevention. Managing Elevated Blood Lead Levels Among Children:
More involved medical and environmen- Recommendations from the Advisory Committee on ChildhoodLead Poisoning
tal interventions are indicated for children Prevention. March 2002
with blood lead levels > 20 µg/dL. The medi-
cal evaluation consists of a careful history
and a physical examination as well as evalu- (home investigation) and reducing lead Chelation therapy (the administration of
ation of iron status and other special diag- hazards (abatement or remediation). For BLLs a drug(s) that bind with lead to remove it
nostic tests. A medical evaluation should be > 20 µg/dL an abdominal x-ray is recom- from the body) is recommended for children
conducted whether or not symptoms are mended if particulate lead ingestion is sus- with BLLs >45µg/dL.7 An oral chelating
present. Environmental interventions are pected. If positive, bowel decontamination agent, “succimer”, that can be used on an
aimed at identifying the source of exposure is indicated. outpatient basis, was approved for use in
Nutrition Focus Vol. 17 #3 3 May/June 2002
children with blood leads > 45 µg/dL. Chela- Table 3 line; consequently lead can be deposited on
tion therapy may be considered if the BLLs and retained by crops, particularly leafy veg-
Questions for Families to Assess
are >25 µg/dL however recent studies con- etables. Lead in soil can also be taken up by
the Risk of Exposure to Lead
cluded that this treatment offers limited ben- plants as they grow. Lead glazes are used in
efits to children with BLLs 15 µg/
dL)? It is estimated that drinking water con-
! Live in or regularly visit a house that tributes 10-20% of total lead exposure in
THE ROLE OF NUTRITION contains vinyl mini-blinds? young children. Typically, lead gets into the
water supply after it leaves the treatment
Young children, particularly one- and two- plant or well. The source of lead in homes is
year-old children, are at greatest risk for lead most likely leaded pipe or lead-soldered
poisoning due to their increased mobility plumbing despite the Environmental Protec-
and hand-to-mouth activity. With greater which is possibly due to the higher density tion Agency’s ban in 1988 on using lead sol-
access to lead hazards and normal “mouth- of intestinal transport proteins during peri- der and other lead-containing materials in
ing” of hands and other items, there is greater ods of growth. In turn, the effects of lead in connecting household plumbing to public
ingestion of lead. Nutrition, in its broadest children generally occur at lower blood lead water. Many older structures still have lead
application, plays an integral role in young levels than in adults. For example, the de- pipe or lead-soldered plumbing which may
children’s susceptibility to lead. Young veloping nervous system in children can substantially increase the lead content of
children’s dietary intake and nutritional sta- be affected adversely at levels even below water at the tap. Also, lead solder is still
tus can influence the absorption, retention 10 µg/dL compared to adults. widely available and may be misused.
and effects of lead toxicity through total food
intake and lead-nutrient interactions involv- Consumption-Related Exposure to Calcium supplements from natural
ing iron, calcium, Vitamin C, and zinc. In turn, Lead sources, such as dolomitic limestone and
lead can influence nutritional status through Efforts to limit exposure to lead-contain- oyster shells, while not widely recommended
its effect on growth in stature, iron status ing paints, gasoline, and food and beverage for young children, can be a source of lead.
and vitamin D metabolism. containers have made a tremendous impact. Levels vary considerably from trace amounts
The U.S. Food and Drug Administration’s to higher levels.
Ingestion and Absorption of Lead in 1994-1996 Total Diet Studies showed that,
Young Children since 1982-1984, daily intakes of lead from As previously defined in Table 1, some
Lead poisoning begins with ingestion and food dropped 96 percent in 2- to 5-year-olds traditional medicines which may contain lead
inhalation of lead. Studies show that chil- (from 30 to 1.3 micrograms).10 However, the may be used by immigrant families. Children
dren absorb close to 50 percent of the lead most common source of lead exposure for who are given these powders may actually
they ingest or inhale in contrast to adults young children continues to be deteriorat- be ingesting lead, and they may develop the
who absorb only approximately 10 percent. ing lead-based paint chips and dust inside same symptoms that these medicines are in-
It is estimated that young children’s absorp- and outside homes, particularly those built tended to treat.
tion rates of lead from non-food sources ex- before 1950 when paint containing as much
ceed 50 percent. Rates are closer to 40 per- as 50% or more lead by weight was still Human Milk
cent when the lead source is infant formula, widely used. Children can ingest loose paint Lead levels in human milk are lower than
milk, and other beverages.9 Reasons for more as a result of pica (compulsive eating of non- would be expected based on maternal blood
efficient lead absorption by young children food items). lead levels. Lead’s inability to attach to the
include their lower body weights and the lack fat in human milk prevents it from becoming
of effective mechanisms adults develop for When food contains lead, it may be from concentrated. However the Health Re-
clearing lead once ingested or inhaled. Young the environment or from containers used for sources and Services Administration recom-
children also have an enhanced capacity to food or beverage storage. Agricultural ve- mends that women with blood lead levels of
absorb lead from the gastrointestinal tract hicles are not required to use unleaded gaso- 40 µg/dL or above not breastfeed their in-
fants.
Nutrition Focus Vol. 17 #3 4 May/June 2002
Nutritional Influences on Lead Absorption that when lead is introduced into the body in sufficient quantities, it
There is wide individual variation in the gastrointestinal absorp- displaces zinc and ultimately disrupts brain cell growth.
tion of lead. Factors which impact absorption and susceptibility to
lead toxicity include age, frequency of eating, quality of the diet, and Although several animal studies suggest a protective relation-
nutritional status. The state of satiety affects lead absorption. When ship between blood lead concentrations and ascorbic acid, there
adults ingest lead on a “full stomach”, about 8% of the lead is ab- are no conclusive results regarding the beneficial effect of vitamin C
sorbed compared to about 35% when ingested after a brief fast.9 As on lead concentrations in human studies. Serum ascorbic acid con-
previously stated, lead absorption rates are much higher in children. centrations were inversely associated with the prevalence of el-
Absorption is further enhanced, and in many situations, exposure evated blood lead concentrations, but there was no significant rela-
to lead occurs more frequently, in children who have not eaten re- tionship between dietary vitamin C intake and blood lead
cently. Children playing in lead-contaminated soil, eating paint chips
or inhaling lead dust hours after their last meal are at significant risk.
Parents and caretakers of young children should be encouraged to Table 4
provide frequent meals and snacks to children at risk for lead expo- NUTRITION ASSESSMENT FOR CHILDREN
sure. WITH ELEVATED BLOOD LEAD LEVELS
Nutrients: Calcium, Iron, Vitamin C, Zinc and Fat Anthropometric
Dietary recommendations which are typically made in an effort to Assess growth parameters including:
help protect children from lead poisoning are still not consistently
- weight-for-age
backed up with scientific evidence. These recommendations are not
controversial from a nutrition point of view, and in fact, can be easily - appropriate rate of weight gain if indicated
endorsed for all children regardless of their risk of lead exposure. - length/height-for-age
But, care must be taken not to make assumptions about specific - weight-for-length for infants and children 2 years of age
- calculate mid-parental height if height-for-age is below the 5th
Animal absorption studies have demonstrated that dietary cal- percentile
cium can decrease gastrointestinal lead absorption. Human studies
in adult and children indicate there may be a direct interaction be- Biochemical
tween lead and calcium which are consumed simultaneously, sug- - Assess test results for blood lead level
gesting possible competition for absorptive sites in the gut. Fur-
- Review tests for iron deficiency
thermore, it has been postulated that when lead interferes with normal
calcium absorption, normal growth and development may be affected.
But the evidence is not strong enough to demonstrate that dietary Clinical
calcium can actually reduce lead toxicity. - determine nutritional implications of medical management of
lead toxicity
It has been known for a long time that iron deficiency and lead
toxicity frequently coexist. In the mid-1980’s, the American Acad-
emy of Pediatrics, in their Statement on Childhood Lead Poisoning, Dietary
stated that “Iron deficiency, even in the absence of anemia, appears Assess dietary intake for:
to be the single most important predisposing factor for increased - adequate food supply
absorption of lead”.11 One theory for the association between iron
- number of meals and snacks eaten on a typical day
and lead levels in the blood comes from the fact that the two are
biochemically similar and symptoms of severe iron deficiency even - water supply and usage patterns for infant formula, bever-
mimic those of lead poisoning including lethargy, inattentiveness ages and foods
and delays in cognitive development. This theory has also postu- - adequacy of calcium iron, and zinc, and vitamin C intake
lated that the absence of iron creates a nutrient deficit in the body, - food storage techniques
which responds by grabbing more of the lead that is ingested by the - use of imported canned foods/candy
child, or hanging onto the lead more strongly once it is in the body. - use of traditional medicines that might contain lead
However, as in the case of calcium, more recent studies indicate
there is no strong evidence that increasing dietary iron will defi-
nitely decrease lead absorption and lead toxicity. Ecosocial
- Review findings from environmental assessment if available
Zinc status influences lead absorption at the gastrointestinal level.
- Ask questions regarding pica or excessive mouthing
Animal research has demonstrated an increase in tissue lead levels
behaviors
and lead toxicity as dietary zinc content decreases. There is some
clinical data associating zinc status and elevated lead levels in chil- - Assess home sanitation:
dren. For proper brain development in children, the body relies on - meal preparation area
the trace mineral zinc to help regulate genes that coordinate brain - hand washing practices
cell growth. In findings that shed new light on understanding how - washing pacifiers/bottle nipples/toys
lead affects the developing brains of children, researchers believe
Nutrition Focus Vol. 17 #3 5 May/June 2002
concentrations. There is however enough evidence to support the tivities include public education and providing anticipatory guid-
beneficial effect vitamin C has on iron absorption thereby improv- ance to families about the causes of lead poisoning.
ing iron status and helping prevent lead absorption.12
Participation of young children in targeted public health
Fat Intake programs, such as the WIC Program, has helped lead poisoning
There is limited scientific evidence showing that increased prevention and detection efforts. Nutrition education, referrals and
intakes of dietary fat increase absorption and retention of lead. supplemental foods are the cornerstones of helping families; and
Dietary fat intake was found to enhance the absorption of lead foods provided by WIC are nutritious and include nutrients previ-
in animal studies but these results have not been replicated in ously mentioned. A study published in 1998 used data from the
children. 1989-1991 Continuing Survey of Food Intakes by Individuals (CSFII)
conducted by the U.S. Department of Agriculture. The study found
that the WIC Program had major effects in improving nutrient in-
PREVENTION, EDUCATION AND takes among low-income preschoolers.13 WIC had significantly posi-
INTERVENTION tive effects on preschoolers’ intakes of ten nutrients including three
of the four nutrients most frequently deficient in the diet of
Primary Prevention preschoolers—iron, zinc, and vitamin E. The researchers noted that
Public health departments and health care practitioners should, iron deficiency is the single most prevalent nutritional deficiency in
at a minimum, support, oversee, and monitor the activities neces- the United States and that anemia rates are still high among young
sary to prevent childhood lead poisoning. Primary prevention ac- low-income children. They also noted that previous studies indicate
zinc deficiencies may be related to growth retardation.
Table 5
Preventing Lead Poisoning in Young Children - Guidelines for Education, Nutrition and Hygiene
Recommendation Rationale
Offer young children breakfast and other Lead is more readily absorbed when the body is in a fasting state, such as when the
meals and snacks at regular, well spaced body has been without food for an extended period (e.g. after a night’s sleep). Children
intervals, such as every 2-3 hours. exposed to lead absorb less when they have recently consumed food.
Ensure that young children’s daily intake Children with diets adequate in these nutrients may absorb and retain less lead than
of calcium, iron,Vitamin C, and zinc meet children with inadequate intakes.
recommendations.
Use fully-flushed cold water for drinking Lead or lead-soldered pipes leach lead into the water supply. Hot tap water leaches
and food preparation. more lead from pipes and pipe solder than cold water. Water that has been sitting in the
pipes for several hours or overnight has higher lead levels than water from flushed
pipes. If the cold water hasn’t been used for more than two hours, run it for 30-60
seconds before drinking it or using it for cooking.
Store food and beverages in glass, Lead soldered cans (used sometimes for imported foods), improperly glazed ceramic
plastic or other lead-free containers pottery, and lead crystal can contribute to a child’s overall lead level. Food stored in or
regularly consumed from leaded containers may contain significant amounts of lead.
Avoid use of traditional medicines which Traditional medicines may contain significant amounts of lead and cause the same
have been found to contain lead, such symptoms for which they are taken in addition to contributing to elevated lead
as: azarcon, greta, payloo-ah exposure
Be aware of and limit opportunities for Pica, or the consumption of non-food items such as paint chips or lead-contaminated
pica. Also keep children from chewing on soil, is the leading cause of lead poisoning in young children. Children may ingest lead
or licking anything painted like from places which have been painted with lead-based paint.
windowsills.
Wash the child’s hands and face before Hand and face washing before eating cuts down on the possibility of lead-laden dust
every meal and snack. Wash toys, being transferred to the food and into the child’s mouth. Washing items which go into
pacifiers and cups after each time they the child’s mouth will also decrease the amount of dust and dirt ingested.
fall on the floor or ground.
Discourage “cruising” while eating meals Food eaten “on the run” gets dropped on the floor, dragged over furniture, or placed
or snacks. Food needs to be eaten at a on a window sill and then retrieved and eaten along with the potentially lead-laden
clean table or kitchen counter under the dust it has collected.
supervision of an adult.
Nutrition Focus Vol. 17 #3 6 May/June 2002
Secondary Prevention SUMMARY 7. Centers for Disease Control and Prevention.
Secondary prevention activities include Managing Elevated Blood Lead Levels Among
conducting blood lead level screenings, pro- Lead is the number one environmental Children: Recommendations from the Advisory
viding medical management when problems pollutant affecting the health of children Committee on ChildhoodLead Poisoning
Prevention. March 2002
are identified and providing education to in the United States. The CDC guidelines
8. Rogan, Walter J., et. al. The Effect of Chelation
manage lead poisoning and prevent further were developed in response to evidence that
Therapy with Succimer on Neuropsychological
lead exposure. In most of the target commu- blood lead levels even below 10 µg/dL
Development in Children Exposed to Lead. New
nities in North Carolina, for example, families in young children are associated with England Journal of Medicine 2001; Vol. 344 (19):
of children with elevated BLLs receive a decreased intelligence, impaired neuro- 1421-6.
home visit, a cleaning kit and instructions behavioral development, decreased growth 9. Zeigler, E.E. et al. Absorption and Retention of
on how to do specialized cleaning to remove in stature, decreased hearing acuity, and Lead by Infants. Pediatr Res. 1978; 12: 29 -34.
lead dust. Clinical management of individu- other adverse effects. There is a growing U.S. Food and Drug Administration, FDA
als with elevated BLLs includes a nutrition body of evidence that levels as low as 2.5 Consumer, January-February 1998
assessment, obtaining the ABCDE param- µg/dL are associated with decreased read- 10. Bruening, K., Kemp, F., Simone, N. et al. Dietary
eters: anthropometric, biochemical, clinical, ing skills and antisocial behavior. No lower Calcium Intakes of Urban Children at Risk of Lead
dietary, eco-social. See Table 4. Within these limit or threshold has been established be- Poisoning. Environmental Health Perspectives.
parameters are areas which warrant special low which no health effects occur. It is im- 1999; 107: 431-435.
consideration when assessing the nutri- perative that pre-school children be tested 11. American Academy of Pediatrics. Statement on
tional status of children exposed to lead or for lead poisoning, especially at ages 1 and Childhood Lead Poisoning. Pediatrics. 1987;
at high-risk for lead poisoning. 2 years. Healthcare and education profes- 79:457 - 465.
sionals as well as parents and caretakers of 12. Houston, D.K., Johnson, M.A. Does Vitamin C
Secondary preventive measures include young children should be informed about Protect Against Lead Toxicity?. Nutr Rev. 2000;
nutrition education and counseling aimed at: the sources of lead exposure and trained in 58:73-75.
• ensuring an intake of calcium, iron, both primary and secondary lead poisoning 13. Rose, D., Habitch, J., Devaney, B. Household
Vitamin C, and zinc sufficient to meet prevention activities, especially the impor- Participation in the Food Stamp and WIC
Programs Increases the Nutrient Intakes of
daily requirements tance of nutrition.
Preschool Children. J Nutr. 1998; 128: 548-555.
• ensuring the young child’s total dietary
intake over three meals and at least two
snacks ADDITIONAL REFERENCES
• preparing infant formula, beverages and
Childhood Lead Poisoning Prevention: Strategies and
foods with cold tap water from fully
Resources. April 1997. Building Communities.
flushed pipes
REFERENCES Washington, DC: U.S.Public Health Service
• storing foods in lead-free containers
• washing hands before eating, and 1. Centers for Disease Control and Prevention. Ballew, C., Bowman, B. Recommending Calcium to
cleaning bottle and pacifier nipples, and Screening Young Children for Lead Poisoning: Reduce Lead Toxicity in Children: A Critical
toys each time they fall on the ground Guidance for State and Local Public Health Review. Nutr Rev. 2001; 59: 71-78.
• limiting opportunities to eat non-food Offices. November 1997. Atlanta, Georgia. United
States Department of Health and Human Lawrence, R.A. A Review of the Medical Benefits and
items such as lead-contaminated soil or
Services, Public Health Services, CDC, 1997. Contraindications to Breastfeed in the U.S. MCH
lead-based paint chips.
2. Centers for Disease Control and Prevention. Technical Information Bulletin. Arlington, VA:
Recommendations for Blood Lead Screening of National Center for Education in Maternal and
Table 5 provides additional guidelines for Young Children Enrolled in Medicaid: Targeting a Child Health, Health Resources and Services
the prevention of lead poisoning in young Group at High Risk. MMWR. December 8, 2000; Administration, 1997.
children. 49/RR-14.
3. United States General Accounting Office. Mahaffey, K.R. Nutritional Factors in Lead Poisoning,
Medicaid : Elevated Blood Lead Levels in Children. Nutrition Review 1981; 39:353-362.
Washington, DC, United States General
Accounting Office, 1998. GAO Publications No.
GAO/HEHS-98-78. Strupp BJ. Childhood Lead Exposure: Effects and
Potential Treatments. Cornell Cooperative
4. Lanphear. BP, et. al. Cognitive Deficits
Extension via the Internet. www.cce.cornell.edu/
Associated with Blood Lead Concentrations 10 >10 Screened 10-19 >20
ALAMANCE 3,652 963 26.4 10 1.0 1,349 3
ALEXANDER 814 324 39.8 2 0.6 440
ALLEGHANY 180 95 52.8 0 0.0 137 1
ANSON 682 460 67.4 6 1.3 639 3 1
ASHE 492 232 47.2 1 0.4 370 1
AVERY 347 192 55.3 3 1.6 241
BEAUFORT 1,192 774 64.9 5 0.6 908 3
BERTIE 493 370 75.1 4 1.1 513 1
BLADEN 877 337 38.4 8 2.4 389 1
BRUNSWICK 1,690 864 51.1 9 1.0 1,244 2
BUNCOMBE 5,069 1,530 30.2 9 0.6 2,043 4
BURKE 2,011 898 44.7 6 0.7 1,332 4
CABARRUS 4,427 2,552 57.6 15 0.6 3,628 3 2
CALDWELL 1,844 514 27.9 4 0.8 1,312 1
CAMDEN 182 76 41.8 3 3.9 106
CARTERET 1,167 725 62.1 7 1.0 1,051 2
CASWELL 513 156 30.4 7 4.5 225 2 1
CATAWBA 4,112 1,790 43.5 12 0.7 2,254 3
CHATHAM 1,382 494 35.7 6 1.2 673 2
CHEROKEE 532 68 12.8 0 0.0 105
CHOWAN 332 189 56.9 5 2.6 257 2
CLAY 182 106 58.2 0 0.0 145
CLEVELAND 2,416 1,136 47.0 16 1.4 1,594 4 3
COLUMBUS 1,527 433 28.4 3 0.7 699 3
CRAVEN 3,056 1,573 51.5 12 0.8 2,048 5
CUMBERLAND 10,707 2,421 22.6 24 1.0 3,678 9 1
CURRITUCK 443 189 42.7 1 0.5 299
DARE 783 294 37.5 3 1.0 325 1
DAVIDSON 3,843 1,721 44.8 20 1.2 2,042 8 1
DAVIE 842 301 35.7 5 1.7 417 1
DUPLIN 1,530 863 56.4 19 2.2 1,109 8
DURHAM 7,768 2,634 33.9 37 1.4 4,226 11 5
EDGECOMBE 1,457 1,110 76.2 39 3.5 1,419 13 1
FORSYTH 9,148 3,875 42.4 43 1.1 4,494 11 1
FRANKLIN 1,310 574 43.8 13 2.3 768 2
GASTON 5,060 1,224 24.2 10 0.8 1,616 5
GATES 216 107 49.5 3 2.8 168 1
GRAHAM 209 121 57.9 1 0.8 162
GRANVILLE 1,190 640 53.8 6 0.9 741 2
GREENE 478 221 46.2 3 1.4 364 2
GUILFORD 11,716 4,889 41.7 75 1.5 6,089 15 3
HALIFAX 1,492 1,126 75.5 22 2.0 1,277 11 1
HARNETT 2,833 1,157 40.8 13 1.1 1,739 4
HAYWOOD 1,167 567 48.6 4 0.7 690 2
HENDERSON 2,212 814 36.8 6 0.7 1,256 3
HERTFORD 574 404 70.4 3 0.7 467 2
HOKE 1,378 407 29.5 3 0.7 548
HYDE 116 52 44.8 2 3.8 66 1
IREDELL 3,641 1,182 32.5 12 1.0 1,409 5
JACKSON 718 327 45.5 3 0.9 454
JOHNSTON 4,325 1,229 28.4 9 0.7 1,649 1
*Target Population is based on the number of live births in 2002 and 2003 Prepared by CEHB
Last updated 03/10/2005
2
2004 NORTH CAROLINA CHILDHOOD LEAD SCREENING DATA BY COUNTY
Ages 1 and 2 Years Ages 6 Months to 6 Years
Target Number Percent Lead Percent Number Confirmed
County Population* Screened Screened >10 >10 Screened 10-19 >20
JONES 175 136 77.7 3 2.2 163 2
LEE 1,672 906 54.2 12 1.3 1,357 4 1
LENOIR 1,541 971 63.0 30 3.1 1,516 9 3
LINCOLN 1,712 389 22.7 1 0.3 565
MACON 634 313 49.4 2 0.6 462
MADISON 436 189 43.3 3 1.6 262 2
MARTIN 611 425 69.6 6 1.4 598
MCDOWELL 1,021 440 43.1 2 0.5 583
MECKLENBURG 25,069 6,324 25.2 55 0.9 8,186 14 1
MITCHELL 331 160 48.3 3 1.9 210
MONTGOMERY 768 493 64.2 7 1.4 780 5 2
MOORE 1,802 845 46.9 12 1.4 1,252 5 3
NASH 2,350 1,497 63.7 32 2.1 1,915 7 1
NEW HANOVER 4,118 2,753 66.9 25 0.9 3,730 7 1
NORTHAMPTON 459 281 61.2 5 1.8 360 1
ONSLOW 6,295 1,589 25.2 25 1.6 2,278 4 1
ORANGE 2,662 469 17.6 2 0.4 624
PAMLICO 210 151 71.9 4 2.6 246 1
PASQUOTANK 973 551 56.6 15 2.7 698 4 1
PENDER 927 547 59.0 5 0.9 794 4
PERQUIMANS 248 135 54.4 2 1.5 197 2
PERSON 910 326 35.8 5 1.5 531 3
PITT 3,985 1,297 32.5 36 2.8 2,221 15 2
POLK 329 84 25.5 0 0.0 172
RANDOLPH 3,583 1,393 38.9 12 0.9 1,712 6 3
RICHMOND 1,199 637 53.1 8 1.3 837 1
ROBESON 4,005 2,281 57.0 35 1.5 3,032 11 1
ROCKINGHAM 2,233 901 40.3 8 0.9 1,322 4 2
ROWAN 3,355 770 23.0 9 1.2 1,066 2 1
RUTHERFORD 1,514 390 25.8 6 1.5 710
SAMPSON 1,796 1,120 62.4 18 1.6 1,376 3
SCOTLAND 980 618 63.1 8 1.3 658 1
STANLY 1,454 1,098 75.5 16 1.5 1,231 4 1
STOKES 989 479 48.4 10 2.1 606
SURRY 1,836 1,036 56.4 21 2.0 1,325 7
SWAIN 332 290 87.3 0 0.0 355
TRANSYLVANIA 546 253 46.3 2 0.8 436 1
TYRRELL 85 75 88.2 5 6.7 90 2
UNION 4,706 1,106 23.5 19 1.7 1,899 5
VANCE 1,361 964 70.8 17 1.8 1,158 4 2
WAKE 22,266 6,139 27.6 53 0.9 8,674 10 4
WARREN 405 279 68.9 10 3.6 379 2 1
WASHINGTON 320 248 77.5 6 2.4 311 1
WATAUGA 692 373 53.9 4 1.1 451 2
WAYNE 3,367 2,572 76.4 34 1.3 3,090 11
WILKES 1,699 533 31.4 6 1.1 674 3
WILSON 2,081 1,298 62.4 25 1.9 1,479 9
YADKIN 902 410 45.5 6 1.5 493 2
YANCEY 328 223 68.0 5 2.2 248 2
STATE 235,599 92,057 39.1 1,167 1.3 124,486 349 52
*Target Population is based on the number of live births in 2002 and 2003 Prepared by CEHB
Last updated 03/10/2005
3
State of North Carolina
Department of Environment and Natural Resources
Division of Environmental Health
Children’s Environmental Health Branch
4,000 copies of this public document were printed at a cost of $15,875.77 or $3.97 per copy.