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Twin States Work to Raise Lead Testing Rates in Young Children

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Valley News Staff Writer
Sunday, November 12, 2017

Lebanon — On a recent weekday evening, Lydia Roberg, a spunky almost 3-year-old, snuggled with her mother, Krystal “Kassi” LaRose, on a couch in their apartment while putting together a puzzle on a coffee table. The television was on and Curious George, the inspiration for Lydia’s Halloween costume this year, played. 

As with most young children, Lydia has ups and downs. But, when a bout of anger begins with repeated shouts of “no” and progresses to violent, uncontrollable kicking, her mother fears the behavior is a symptom resulting from Lydia’s lead poisoning. LaRose also worries that Lydia may have other difficulties with behavior or brain function in the future as a result of her exposure to lead, a neurotoxin found in Flint, Mich.’s water supply in 2012 and in Vermont and New Hampshire can be found in paint in some buildings. Seventy percent of Vermont homes and nearly 60 percent of New Hampshire homes were constructed before 1978, the year lead-based paint was banned.

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When Lydia was 11-months-old, a contractor came to the family’s Enfield apartment, constructed in the late 1800s, to replace some windows, but something about the way he did the replacement made LaRose worry about the dust. She called Lydia’s pediatrician at Alice Peck Day Memorial Hospital, who immediately ordered a lead blood test. The results confirmed LaRose’s fears.

Lydia had a blood lead level of 13 micrograms per deciliter. Though no amount of lead in the blood is safe, New Hampshire currently uses a level of 10 micrograms per deciliter as a trigger to bring state inspectors to a family’s home. In 2015, Lydia was one of 82 children in New Hampshire to test at or above that level and one of 660 children to test above the Centers for Disease Control and Prevention’s guideline of 5 micrograms per deciliter.

At first, LaRose blamed herself: “I’m such a terrible mom,” she recalled thinking. But now she realizes, “I was uneducated,” and she hopes to play a role in informing others about the risks of lead poisoning.

Two States, Two Approaches

The number of children who are poisoned in New Hampshire is likely higher than known. Just 54 percent of 1-year-olds and 35 percent of 2-year-olds living in communities with universal testing requirements were tested in 2015, the most recent year for which data is available from the state’s Department of Health and Human Services. Universal testing requires that children be tested for lead poisoning at their 12-month and 24-month well child visits.

“We know there are many more children poisoned (and) currently being exposed to lead that are not being identified," said Gail Gettens, a health promotion adviser for the state's Healthy Homes and Lead Poisoning Prevention Program.

New Hampshire does not currently require universal testing in all communities, only those in which children are thought to be the most at risk, in part, due to the age of the housing stock. Universal lead blood testing is required for 1- and 2-year-olds in all Vermont towns, as well as most in New Hampshire. But, in Grafton, Grantham, Springfield, Sunapee, New London and Unity, communities in which the state recommends “targeted” testing, only children covered by Medicaid, receiving benefits through the federal Women, Infants, and Children program, or considered at risk for some other reason are required to be tested.

Public health advocates aim to boost lead testing rates, as well as the identification of lead hazards and their removal through a concerted legislative and public relations campaign to give families and state officials a better chance of reducing children’s exposure.

“It’s a high priority," said Dr. Laura Greer, a pediatrician at Alice Peck Day Memorial Hospital in Lebanon. "It’s one that I feel very strongly about — vaccines, lead, car seats. It’s one of the top subjects that I will talk about." 

Legislation, approved by the House Finance Committee on Wednesday and supported by the state chapter of the American Academy of Pediatrics, would require universal testing of all 1- and 2-year-olds in the state and reduce the level of lead in the blood that triggers state action, including an inspection of a child’s home for lead paint, from 10 to 5 micrograms per deciliter, in accordance with the CDC’s guidelines. 

In the New Hampshire part of the Upper Valley, communities with a higher incidence of elevated lead blood levels include Claremont, with 194 children testing above the CDC guideline in 2015; Lebanon, which had 32 children with blood levels above the guideline; and Haverhill with 10.

Focusing on getting information out to providers has been important in Claremont, where community leaders — representing the city, the schools and the hospital — have teamed up to boost lead testing rates, said Peter Wright, the chief executive of Valley Regional Hospital. 

In 2016, Claremont became the first community in the state to require mandatory testing of children in its schools. The school district began offering lead blood testing to preschoolers and kindergartners this fall.

Valley Regional providers have also begun to bring a renewed focus to the importance of lead testing, Wright said. Providers have so many things to focus on for each patient, that it can be difficult for them to remember to order a lead blood test, Wright said. But, giving providers data about the challenges facing Claremont seems to be making a difference, he said.

“Anytime you put some education in front of providers; put some numbers in front of them ... then they really focus on it," Wright said. 

Valley Regional’s testing rates have gone up about 10 percent year-to-date this year from last year, but without a full year’s worth of data to look at, Wright said he doesn’t want to draw any conclusions yet.

In Vermont, Dr. Louis DiNicola, a longtime pediatrician and the current medical director of primary care at Gifford Health Care in Randolph, said the good news is that rates of lead poisoning has decreased over time.

Vermont adopted the level of 5 micrograms per deciliter in 2008. Of those tested in 2016, approximately 7 percent of 1-year-olds and 5 percent of 2-year-olds were found to have blood lead levels above 5 micrograms per deciliter, according to the Vermont Department of Health. That’s down from about 23 percent of 2-year-olds and 19 percent of 1-year-olds who were tested in 2006 having a level at or above 5 micrograms per deciliter.

But, DiNicola said those reductions have contributed to some complacency among providers and families. 

“I think because we’ve reduced it ... a lot of people just don’t move it up their radar screen,” he said.

In terms of testing rates, Vermont instituted universal testing in 2008, but hasn’t achieved that goal yet. Testing rates among the state’s 1-year-olds has stayed steady at about 80 percent. Universal testing, which requires providers to send results to the state, does seem to have helped boost testing rates for 2-year-olds from about 44 percent in 2006 to about 68 percent last year.

Importantly, DiNicola said universal testing takes the provider’s discretion out of the equation. One of the highest blood lead levels he saw in his practice — 22 micrograms per deciliter — came from a child in an affluent family who lived in a new house with a source of clean water. The child was exposed to lead paint by teething on an old Adirondack chair. 

“The point is all kids should be tested," he said.

At Gifford, DiNicola said they have worked to boost their testing rates and in the most recent quarter they were at 84 percent for 2-year-olds and about at the state average for 1-year-olds.

To get closer to 100 percent, DiNicola is looking to a new electronic medical record, which he says will offer providers a reminder when patients come in for their one-year and two-year check-ups. He also said hitting providers with some form of financial penalty and increasing education of providers and families could help.

A Different Type of Test

Moving to statewide universal testing is not the only way advocates in New Hampshire hope to boost the state’s lead testing rate. They also aim to install point-of-care blood-testing machines in pediatric offices throughout the state. The machines use blood from a finger prick to get an immediate result in the pediatrician’s office, rather than requiring that parents bring their young children to a lab after an office visit and wait a few days for results.

The offices that have switched to point-of-care testing have boosted their testing rates substantially, said Dr. Steven Chapman, a pediatrician at Dartmouth-Hitchcock Medical Center in Lebanon and the current president of the N.H. chapter of the American Academy of Pediatrics.

“The point-of-care testing is great," said Chapman.

Though the results may be less accurate due to lead contamination on the skin, the finger prick testing errs on the side of caution and an elevated lead test result from a finger prick is confirmed through a venous blood draw.

There are, however, some obstacles to implementing point-of-care testing. D-H clinics have not yet adopted it. APD is planning to put a new machine to use next month, and Valley Regional has one, though it’s mainly used for testing outside of regular office visits.

Chapman said pediatricians have a variety of priorities that they’re juggling, including the opioid epidemic, other substance misuse disorders, obesity and diabetes.

Moving to a point-of-care blood test for lead would change a clinic’s workflow, require the purchase of equipment — a new machine costs about $2,500 — and staff training to use it, he said. 

Despite the challenges, “It’s an investment well worth making,” Chapman said.

He said people at the Children’s Hospital at Dartmouth-Hitchcock are looking into how best to add the testing to their office and he expects it will be installed in the coming months.

"Many, many issues that affect kids fly under the radar," Chapman said. "It's one that we just need to get right."

In Vermont, however, where point-of-care tests make up about 50 percent of the lead tests conducted, officials haven’t seen an increase in testing rates, said Matthew Bradstreet, Vermont's Healthy Homes program chief. Because providers have to then schedule a venous draw to confirm the finger prick test, Bradstreet said, “I don’t know that you’re gaining a lot."

But, he said, with New Hampshire’s screening rates being low, point-of-care tests might have more of an impact. 

Once a child has been exposed to lead, there is no way to reverse the damage, said Gettens, the health promotion adviser for the state’s Healthy Homes program. The priority then is to prevent further poisoning by removing the source. Diets high in iron and vitamin C, and low in fat also can help prevent children from absorbing additional lead.

And, parental support and interaction can help rebuild pathways damaged by lead poisoning, she said.

“The good part of a child’s brain is it is rapidly developing," said Gettens.

LaRose is doing her part. The family moved out of the contaminated apartment a couple of weeks after the first blood test and for a while Lydia was eating so many oranges that she got sick of them, LaRose said.

LaRose tries to stimulate Lydia’s brain by using more detail than a parent of a young child might otherwise.

“I make way fuller sentences than I would,” LaRose said.

It takes time for some of the effects of lead poisoning to become apparent. Some behavioral or developmental issues may not show up until children are school-aged, Gettens said.

But, so far, aside from the occasional violent outburst, Lydia seems to be doing well.

“Other than that, she’s a smart cookie,” LaRose said.

Focused on the task at hand on the coffee table, Lydia finished piecing together the puzzle and said, “I did it!”

Valley News Staff Writer Nora Doyle-Burr can be reached at ndoyleburr@vnews.com or 603-727-3213.