Re: Errata for Prevention of Childhood Lead Toxicity

In 2017, the American Academy of Pediatrics Council on Environmental Health clarified the use of terminology related to testing children’s blood lead levels in an erratum to its June 2016 Policy Statement, “Prevention of Childhood Lead Toxicity.”¹ Although we applaud this effort to develop consistent terminology, we offer the following cautions for consideration.

First, all but 5 states have regulatory language that defines health care providers’ obligations in terms of blood lead testing or screening in children <6 years old. The language in these regulations is not necessarily consistent with that proposed by the American Academy of Pediatrics. It is incumbent on providers to follow the requirements in the state where the child lives. State lead poisoning prevention programs provide this information on their Web sites.

Second, the sensitivity and specificity of the Centers for Disease Control and Prevention (CDC) lead screening questionnaire has been tested in a wide variety of practice settings and subpopulations.² It has never been demonstrated to reasonably predict risk of high blood lead levels, and in a systematic review, it performed little better than chance at predicting lead poisoning risk among children.³ This is not surprising given that the questionnaire was originally developed to ensure that reimbursement was available for testing at shorter intervals, if necessary, in a state with universal annual testing of children <6 years old.

Finally, the 1997 CDC guidance in Screening Young Children for Lead Poisoning⁴ is not mentioned in the erratum.¹ In this document, later adopted by the Centers for Medicare and Medicaid Services, the CDC recommended that public and clinical health professionals collaborate to develop screening plans that are responsive to local conditions by using local data. In the absence of such plans, universal blood lead testing remains the default, as does the Centers for Medicare and Medicaid Services requirement that all Medicaid-enrolled children be tested at 1 and 2 years of age.

In the recent high-profile reports on the continued threat of lead exposure for US children, the authors underscore the need to ensure that all children living in high-risk areas have blood lead tests periodically, at least until 2 years of age. This testing is key to state and local lead programs’ abilities to respond to the children most at risk for continued exposure. Unfortunately, blood lead testing rates are extremely variable, even in areas where testing is legally required.⁵

The CDC remains committed to supporting state and local efforts to engage pediatric health care providers in identifying and evaluating children who are exposed to lead and ensuring that these children receive the necessary follow-up services. We believe that blood lead testing remains the best method to screen children for lead exposure and to enforce local efforts to prevent childhood lead poisoning.