Lead Testing of Children Varies Greatly by State in Northeast
Lebanon — No amount of lead is considered to be safe in a child’s body, and public health officials say the issue is still of significant concern throughout the nation.
Yet the chance that a child under the age of 2 will get screened for lead poisoning largely depends on where that child lives, as screening rates vary more than tenfold throughout northern New England, according to a new Dartmouth Atlas report.
Generally, children on Medicaid in Vermont are much more likely to be screened than their counterparts living in New Hampshire or Maine, according to the report.
The report found variations in many aspects of pediatric care, from the frequency of emergency room visits to use of medication and certain surgeries.
But the variations in lead screening, a simple test that is considered a standard part of pediatric care, offers a troubling sign of how geography determines whether a child receives even basic services, said David Goodman, lead author of the report and a professor of pediatrics at the Geisel School of Medicine.
“It’s a very simple blood test and gives great advantages to populations that are screened,” Goodman said when the report was released earlier this month. “And yet we find across the region that no hospital service area has 100 percent compliance with lead screening of its population and, by and large, many regions fall far short of the right rate, which is 100 percent.”
Between 2008 and 2010, only 59 percent of Medicaid children in Claremont, designated a “high risk” community for lead poisoning in New Hampshire, received lead screening by the age of 2. And yet, just across the Connecticut River, screening rates jumped to 68 percent in Windsor and were even higher down the road in Springfield, Vt., at 73 percent. In Lebanon, lead screening rates are just 55 percent, lower than the average for northern New England. But 79 percent of Medicaid children living in Randolph were screened by the time they turned 2, according to the report.
New England’s aging housing stock makes the threat of lead poisoning a very real concern in this region, health officials said.
Lead exposure can affect nearly every system in the body, and because it often occurs with no obvious symptoms, it frequently goes unrecognized, according to the Centers for Disease Control and Prevention. Young children are particularly susceptible, as high levels of lead in their bodies can lead to learning difficulties, slowed growth and even death.
And yet, because lead-based paint has been banned in the U.S. since 1978, many people consider it a problem of the past.
“Lead is sometimes dismissed as, OK, that problem is already solved,” said Andrea Haugen, who lead’s Vermont’s Healthy Homes and Lead Poisoning Prevention program.
A lot of the blame for differences in screening rates can be put on doctors, whose distinctive practice styles determine what kind of care a child receives, Goodman said. But the generally higher rates in Vermont suggest that there is a role for state policy and public education to play, as well.
Vermont has taken aggressive steps recently to boost screening rates. In 2007, the state established a “threshold of concern” for blood lead levels at five micrograms per deciliter of blood, the lowest in the nation. In many other states, including New Hampshire, that level is 10 micrograms. Vermont also has stepped up expectations for health care providers to screen toddlers and has a goal for universal testing of 1- and 2-year-old children.
Meanwhile, efforts such as the Vermont Child Health Improvement Program, at University of Vermont, have provided tools and support to doctors aimed at improving preventive care for children, including lead screening.
Last year, 81 percent of 1-year-old children and 67.5 percent of 2-year-old kids in Vermont were tested, according to state figures. Rates of testing for 1-year-olds have stayed fairly steady since 2006 but improved dramatically for 2-year-olds, rising 24 percentage points in just six years. During that time, the proportion of kids with elevated blood lead levels has come down.
New Hampshire also has high aims to improve screening rates. After the death of a Sudanese child from lead poisoning in Manchester 13 years ago, New Hampshire developed lead testing guidelines to screen and monitor refugee children. And four years later, in 2004, the state developed a plan to eliminate childhood lead poisoning.
Yet the screening rates remain stubbornly modest. Last year, 53 percent of New Hampshire children between the ages of 1 and 2 were screened, according to state figures. The screening rate dropped to just 16 percent for children under the age of 6.
“That’s nothing to write home about,” said Beverly Drouin, who leads the Healthy Homes and Environment Section of the N.H. Department of Health & Human Services.
Some of the problem has to do with physician bias, she said. A doctor sees a upper-middle class parent who appears healthy and engaged with her children and never thinks to ask whether the family lives in an older home where lead contamination could be an issue.
“It’s a lot of just, I’m looking at you and there’s no way your children could be poisoned,” Drouin said.
But the responsibility can’t all be put at the feet of physicians, said Jim Sargent, a professor of pediatrics at Geisel. Parents also need to be convinced that lead screening is important. Sargent knows there are parents who, even after the doctor has written a request for a lead test, leave the hospital without ever getting it done.
“In our clinic, we try to get everybody screened,” Sargent said. “But we know people leave with a (lab) slip without having their blood drawn.”
Families in newer homes may believe they are not at risk for lead poisoning, at least not enough to justify making their toddler cry after getting poked with a needle, Sargent said. But simply living in a newer home doesn’t mean a child is safe from harm.
Gifford pediatrician Lou DiNicola said one 18-month-old child came to him with a lead level that was more than four times the threshold for concern in Vermont.
The family lived in a newer home and could not figure out where the toddler was coming into contact with lead.
After some investigation, they discovered it had nothing to do with the house.
The child had been chewing on an Adirondack chair the parents had purchased at a yard sale. The chair had a layer of lead-based paint.
Vacant land can even pose a threat if there were an old barn or home that once stood there.
“There are other exposures (besides houses),” DiNicola said. “Even people who are doing organic gardening can have enough lead in their soil where there is a problem.”
Sargent believes the focus of lead poison prevention efforts should move away from just screening, and instead target homes that pose a risk of contamination. The current focus on screening is a “canary in a coal mine” approach, in which problems are addressed only after a child gets sick.
“Why should we wait until the kid is harmed before we do anything?” he said.
But as it stands now, physicians play a central role in efforts to protect children from lead poisoning, DiNicola said. That is where Vermont has excelled, he said, by getting doctors on board through education, aggressive policy and support.
“The number one thing is that the providers have to be convinced,” DiNicola said. “And it took us a long time in Vermont to convince providers.”
Chris Fleisher can be reached at 603-727-3229 or firstname.lastname@example.org.