Boost efforts to reduce lead poisoning before children are exposed: AAP policy
Bruce P.Lanphear, M.D., M.P.H., FAAP
Blood lead levels below 5 micrograms per deciliter (µg/dL) (50 parts per billion [ppb]),
which were thought to be safe or innocuous, have been shown to be a risk factor for
diminished intellectual and academic abilities, higher rates of attention-deficit/hyperactivity
disorder and lower birthweight in children. An updated AAP policy Prevention of Childhood Lead Toxicity, http://dx.doi.org/10.1542/peds.2016-1493, reflects the recognition that there is no safe level of lead in children’s blood
and calls for renewed effort to further reduce children’s exposure to lead.
About 2.5% of U.S. preschoolers have a blood lead concentration ≥5 µg/dL, which represents
about 535,000 children ages 1-5 years.
Children who have blood lead concentrations ≥5 µg/dL will, on average, experience
an IQ deficit of five to six points, after adjusting for other factors. Some have
argued that a five-point reduction in IQ is of little consequence. However, a five-point
shift in the mean population IQ of American children would increase the number of
children having an IQ lower than 70 from 6 million to 9.4 million (see link to video
in resource box).
Primary prevention — reducing or eliminating the myriad sources of lead in the environment
of children before exposure occurs — is the most reliable and cost-effective way to
protect children from lead toxicity, according to the policy from the AAP Council
on Environmental Health. No treatments are known to reverse the developmental effects
of low-level lead toxicity.
Pediatricians and other health professionals who care for children and their families
are in a key position to advocate for public health efforts to screen children’s environments
and reduce sources of lead before they are exposed. The updated policy outlines recommendations for government and
for physicians and public health officials.
Children who lived in older housing units are at higher risk for having a blood lead
concentration >5 µg/dL; 15% of U.S. children who lived in housing units built before 1950 had a blood
lead concentration ≥5 µg/dL compared with 2.1% of children who lived in housing units
built after 1978. Some of the most important sources of lead in children’s environments
include lead-based paint, lead-contaminated soil, dust and water, as well as imported
ceramics, aviation gas from regional airports, industries and consumer products.
For every $1 invested to reduce lead hazards in housing, society would benefit by
an estimated $17 to $221 — a cost-benefit ratio that is comparable to that of childhood
Education, counseling critical
In the primary care office, prevention begins with education and counseling about
reducing children’s exposure. Parents who live in older housing should be advised
to screen their homes for lead hazards before a child is born or during the newborn period so that lead hazards can be identified
and eliminated. Housing built before 1960 should be screened for lead hazards, especially
if it has undergone repair and renovation or if it is poorly maintained.
Lead-safe work practices and collecting dust clearance levels after the work is completed
are essential to control lead hazards; if renovation or abatement is done wrong, it
can increase the risk of a child developing lead poisoning.
Pediatricians and other primary care providers should screen children in the first
three years of life to determine if a blood lead test is indicated. A blood lead test
should be considered for children who are younger than 3 years if they live in a house
with an identified lead hazard or that was built before 1960, especially if it is
in poor repair or was renovated in the past six months.
Pediatricians and hospitals should use labs that provide blood lead tests with laboratory
error of ±2 µg/dL; labs should report results down to 1 µg/dL to enhance case management
The Academy has adopted a blood lead level of ≥5 µg/dL as an action level for case
management.Local or state health departments should conduct environmental investigations to identify
sources of lead exposure for a child who has a blood lead concentration ≥5 µg/dL.
In many cases, however, sources of lead become evident by taking a careful history.
Pediatricians should be familiar with collection and interpretation of reports about
lead hazards in house dust, soil, paint and water, or refer families to another pediatrician,
health care provider or specialist who is familiar with these tools.
Recommendations for pediatricians
Screen children and work with public health officials to conduct surveys of blood
lead concentrations among children in their states or communities at regular intervals
to identify trends in blood lead concentrations. Periodic surveying is especially
important for children who live in highly contaminated communities.
Routinely recommend individual environmental assessments of older housing.
Advocate for strict legal standards based on empirical data that regulate allowable
levels of lead in air, water, soil, house dust and consumer products.
Be familiar with federal, state, local and professional recommendations or requirements
for screening children and pregnant women for lead poisoning.
Test asymptomatic children for elevated blood lead concentrations according to federal,
local and state requirements. Immigrant, refugee and internationally adopted children
also should be tested when they arrive in the U.S.
Conduct targeted screening for elevated blood lead concentrations in children ages
12-24 months if they live in communities or census block groups with 25% or more of
housing built before 1960 or a prevalence of children’s blood lead concentrations
≥5 µg/dL (≥50 ppb) of 5% or greater.
Test children if they live in or visit a home or child care facility with an identified
lead hazard or a home built before 1960 that is in poor repair or was renovated in
the past six months.
Great progress has been made in reducing childhood lead poisoning, but too many children
continue to be exposed to levels shown to be harmful.
Dr. Lanphear, lead author of the policy, is a former member of the AAP Council on
Environmental Health Executive Committee.