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Childhood Lead Poisoning Prevention

Children and Lead

What is lead?
Lead is a naturally occurring metal in our environment. It has been used for centuries in many industrial processes. The most common source of lead in New Jersey is paint that was used on the interior and exterior surfaces (such as porches, windows and door) of homes built before 1978.

How are children exposed to lead?
Young children can be exposed by:

  • swallowing leaded dust or soil that gets on their hands or other objects, that they put into their mouths such as toys;
  • swallowing leaded paint chips;
  • breathing leaded dust or lead contaminated air;
  • eating food or drinking water that is contaminated with lead.
Videos

Prevent Lead Poisoning - lead rap, 4:08 [English]
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If You Don’t Know, Ask About Lead, 4:15 [Spanish]
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Renovating? Look Out for Lead!, 11:50 [English]
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Why is exposure to lead harmful to children?
Scientists have found that lead can disrupt the normal growth and development of a child's brain and central nervous system.

At what ages are children most at risk for exposures to lead?
The first six years, in particular the first three years of life, is the time when the human brain grows the fastest, and when the critical connections in the brain and nervous system that control thought, learning, hearing, movement, behavior and emotions are being formed. The normal behavior of children at this age - crawling, exploring, teething, and putting objects in their mouths – also puts them into contact with any lead that is present in their environment.

What is lead poisoning?
Lead poisoning is when there is too much lead in the blood. The Centers for Disease Control and Prevention (CDC) defines lead poisoning in children as a blood lead level of 10 micrograms per deciliter (µg/dL) or above. This is based on research conducted by scientists that have been able to correlate problems in children at those blood lead levels.

What are the symptoms of lead poisoning in children?
Most children with lead poisoning will not have symptoms! Lead poisoning generally causes symptoms only at very high levels, and even then, those symptoms - stomachaches, anemia - are similar to those of much less serious illnesses. That is why it is important that all children be tested to determine how much lead is in their blood.

What are the effects of lead poisoning in children?
Very high levels of lead can cause seizures, severe brain damage resulting in developmental or intellectual disabilities, coma, and even death. Exposure to lead, even at relatively low levels, has been found to be associated with decreased hearing, lower intelligence, hyperactivity, attention deficits, and developmental problems that may make learning harder.

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Preventing Lead Poisoning

What can parents do to prevent their children from getting lead poisoning?
There are a number of simple, low-cost steps parents can take to reduce their children’s lead exposure:

  • DO:  Wash, or have children wash, their hands frequently, especially before eating, after playing outside or on the floor, and before sleeping.
  • DO:  Wash frequently toys and other objects young children handle and put in their mouths.
  • DO:  Have everyone take off their shoes and leave at the door entrance to the home.
  • DO:  Keep children away from bare soil when playing outdoors.
  • DO:  Offer children a nutritious diet high in iron such as eggs, lean red meat, and beans. Offer children foods high in calcium such as dairy products (milk, yogurt, cheese).
  • DO:  Store food and liquids in lead-free containers that are not made from leaded crystal or imported pottery.
  • DO:  Clean at least weekly floors and windowsills by using a damp mop or sponge and detergent.
  • DO:  Know if any paint has lead before undertaking any renovations or remodeling projects.
  • DO:  Remove leaded paint using special precautions called lead-safe work practices or by hiring a contractor that is certified by the United States Environmental Protection Agency (EPA) to perform renovations in homes built before 1978.
  • DO:  Use only cold tap water to prepare formula, for drinking and cooking.
  • DO:  Run water for 15 to 30 seconds before drinking it, especially if you have not used your water for a few hours.
  • DO:  Wash work clothes separately from the family’s laundry if parents or caregivers work in a job that uses lead.
  • DO:  Shower and change clothes before leaving work if your job uses lead.
  • DO:  Keep children away from hobbies that use lead.
  • DO:  Always clean-up carefully after using lead.

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Community-Based Educational Resources

Where can I get more information about  preventing lead poisoning in children?
Regional Childhood Lead Poisoning Prevention (CLPP) Coalitions provide and coordinate educational initiatives in high-risk communities statewide.

Northern Regional CLPP Coalition
Coordinating Agency:   Northern NJ MCH Consortium
201-843-7400
Service Areas: Bergen, Passaic, Union, Essex (excluding City of Newark),  Hudson, Sussex, Warren, and Morris

Central Regional CLPP Coalition
Coordinating Agencies: Monmouth County Health Department and Central Jersey Family Health Consortium
732-363-5400
Service Areas: Monmouth, Ocean, Hunterdon, Somerset, Mercer, and Middlesex

Southern Regional CLPP Coalition
Coordinating Agency: Southern NJ Perinatal Consortium
856-665-6000
Service Areas: Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester and Salem

Newark Partnership for Lead-Safe Children
Coordinating Agency: Newark Department of Child and Family Well Being
973-622-0913
Service Area: City of Newark

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Educational Materials

The following educational materials, available in limited quantities, can be requested by calling 609-292-5666, Monday-Friday, 10am-4pm.

  • Important Information for Homeowners & Renters About Lead-Based Paint Hazards [Topics include: guidelines for DIY safe removal of lead-based paint in owner-occupied homes and questions to ask prior to selecting a contractor]
  • Questions Parents Ask About Childhood Lead Poisoning [Topics include: when children should and where children can be tested, what do the test results mean, prevention checklist for parents]
  • Lead Poisoning and Your Children [7 steps parents can take to protect their children, also includes a mini-poster appropriate for placement in waiting rooms]

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Sources of Lead

Although leaded paint is the most common source of lead in the United States, many consumer products also can contain lead. Keep informed about consumer products that are recalled due to hazardous amounts of lead. The Centers for Disease Control and Prevention (CDC) has a complete list of current recalls due to lead content issued by the Consumer Product Safety Commission (www.cdc.gov/nceh/lead/Recalls/default.htm).

In addition, many types of ammunition contain lead. Information for hunters and other consumers of game, specifically venison (deer), which may have been harvested with lead ammunition, is offered by the NJ Department of Environmental Protection, Division of Fish and Wildlife at www.nj.gov/dep/fgw/news/2008/venisonlead.htm.

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Removing Lead-Based Paint

How do I know if there is lead-based paint on or in my house?
You can assume that any house built before 1978 has lead-based paint, unless you know that all the old paint was removed some time in the past. If you want to be certain, you can hire a state-certified Lead Evaluation Contractor. New Jersey law requires that any person who performs inspections for lead-based paint must meet certain training and experience requirements, pass a test, and obtain a permit from the New Jersey Department of Health (DOH). Any company in the business of performing lead-based paint inspections must be certified by the New Jersey Department of Community Affairs (DCA). For more information, or a list of state-certified Lead Evaluation Contractors, call the DCA at 877-DCA-LEAD or visit www.leadsafenj.org.

There are also test kits, recognized by the EPA, which you can buy in a hardware store to test paint or dust for lead. Be aware however that these tests, while reasonably accurate, do not always detect lead even when it is present. For example, if leaded paint is covered with several layers of non-leaded paint, the test kit may not show a positive reading. You can also take paint chips or water samples and send them to a laboratory for testing. Many environmental laboratories perform this service. They are listed in the Yellow Pages under "Laboratories – Testing."

What should I do if I want to remove old paint from my house?

  • In properties built before 1978, assume that the paint contains lead unless you know for certain that it does not.
  • Do not assume that every painter knows how to remove lead paint safely. State-certified Lead Abatement Contractors must meet licensing requirements and follow work practices set by the DCA. Contractors and their employees must meet training requirements, pass a test, and have a permit issued by the DOH. For a list of state-certified Lead Abatement Contractors, call the DCA at 877-DCA-LEAD or visit www.leadsafenj.org.
  • Don't remove lead-based paint yourself unless you are trained to remove it safely.

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Environmental Resources

United States Environmental Protection Agency (EPA) Region 2
http://www.epa.gov/aboutepa/region2.html
Serving New Jersey, New York, Puerto Rico, the U.S. Virgin Islands and eight tribal nations.

EPA Renovation, Repair and Painting (RRP) Rule
http://www.epa.gov/lead/pubs/renovation.htm
On April 22, 2008, EPA issued a rule requiring the use of lead-safe practices and other actions aimed at preventing lead poisoning. Under the rule, beginning April 22, 2010, contractors performing renovation, repair and painting projects that disturb lead-based paint in homes, childcare facilities, and schools built before 1978 must be certified and must follow specific work practices to prevent lead contamination.

HUD Environmental Topics
http://portal.hud.gov/hudportal/HUD?src=/topics/environment
This web page provides information on environmental review requirements for HUD programs and the projects they fund in communities across the country. HUD-funded projects vary widely as to their complexity, and there are different levels of environmental review triggered by different kinds of projects.

New Jersey Department of Health (DOH), Indoor Environments Program
http://www.state.nj.us/health/iep/lead.shtml
In 1995, the Department of Health (DOH) adopted regulations that require certain individuals who conduct lead activities in NJ to be permitted. The disciplines covered by those regulations are lead abatement workers, supervisors, planner/project designers, and lead inspector/risk assessors. As such, each individual involved in the evaluation or abatement of lead-based paint must be permitted by the DOH. In addition, the regulations also established certification standards for training providers and training courses for each discipline.

New Jersey Department of Community Affairs (DCA)
http://www.state.nj.us/dca/dcr/leadsafe/contractor.html
As you browse through this page, you will be able to select a lead abatement contractor in your area who has been certified by the New Jersey Department of Community Affairs (DCA). There are two general categories of lead abatement contractors:

  1. Residential contractors who work on residential properties; and
  2. Commercial contractors who work on steel structures and superstructures.

DCA, Division of Codes and Standards - Lead Hazard Evaluation and Abatement
http://www.state.nj.us/dca/divisions/codes/offices/leadhazard_abatement.html
This program provides for the public safety, health and welfare insofar as they are affected by the identification and abatement of lead-based paint hazards.

Lead Safe New Jersey Program
http://www.state.nj.us/dca/dcr/leadsafe/index.shtml

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Screening for Lead Poisoning

Since young children are the most at risk of being diagnosed with lead poisoning, does New Jersey require that children be screened?
Yes!  All children by law (N.J.A.C. §8:51A) are required to be screened. Every primary care provider and health care facility that provides care to children less than six years of age is required to comply with the law.

When should children be screened for lead poisoning?

  • All children should be screened for lead poisoning at 12 and 24 months of age.
  • Any child between three and six years of age who has never previously been screened.
  • Any child who is six months of age or older, and is exposed to a known or suspected lead hazard, should be screened.

Note: Parents have the right to refuse to have the screening done for any reason.

How are children screened?
There are currently two CDC approved screening methods. One involves taking blood from a finger (capillary) and the other from a vein (venous). If the blood is taken from a finger and the blood lead level is 10 µg/dL or above, the child must be retested. The retest will involve taking a blood sample from a vein. A venous blood test is required to diagnose a child with lead poisoning.

What questions will the primary care provider ask to know if children need to be screened more frequently?
Does your child:

  • Live in or regularly visit a house with peeling or chipping paint built before 1960  (This could include a childcare center, preschool, home of a baby sitter).
  • Live in or regularly visit a house built before 1960 with recent (past 6 months), ongoing or planned renovation?
  • Live with an adult whose job or hobby involves exposure to lead? Examples include working in foundries and construction or with batteries, pottery or other materials containing lead.
  • Have an elevated blood lead level (10 or higher) when last screened?  (If the child has not been previously tested and is 12 months or older, consider this a “yes” response).

A “yes” or “I don’t know” answer to any of these questions indicates a need for more frequent screening. 

Does health insurance pay for the cost of lead screening?
Yes!  State law (N.J.S.A. §17B:27-46.11) requires every health insurance plan covering a group of 50 or more persons, including Health Maintenance Organizations (HMO) and Managed Care Organizations (MCO), to cover the cost of lead screening and childhood immunizations, without any deductible.

What if a child is uninsured, his/her family can't afford to pay, or insurance does not cover the cost of lead screening?
Free screening is available through local health departments. Every local health department in the state is required to provide well child services for its community, including lead screenings and immunizations.

In addition, Federally Qualified Health Centers (FQHC) throughout the state provide no or low cost testing.

Use these links to locate a local health department ("http://nj.gov/health/lh/directory/lhdselectcounty.shtml) or a FQHC (http://www.njpca.org/FQHC/directory.aspx).

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Case Management of the Lead Poisoned Child

What is case management?
Case management’s purpose, as performed by the local health department, is to coordinate, provide and oversee services required to prevent a lead poisoned child’s further exposure to lead and to monitor and reduce a child’s blood lead level to below 10 µg/dL. The case management team includes the local health department case manager and environmental lead inspector/risk assessor, child’s parent(s) or primary caregiver, and child’s primary care provider (PCP). The team may also include a Medicaid case manager, DCA representative, an outreach worker, health educator, or registered dietician.

What case management services should a lead poisoned child and his/her household expect to receive from the case management team?

  • Education and counseling of the primary caregiver about the effects of lead, lead hazards that may be present on the premises, nutrition and its role in reducing lead absorption, and personal hygiene and housekeeping measures that reduce the household’s exposure to lead hazards.
  • Evaluation of the child’s environment for non-paint lead hazards.
  • Assistance in retesting to monitor blood lead levels in cooperation with the child’s primary care provider.
  • Referral to a primary care provider or licensed health care facility to provide primary medical care to the child.
  • Assistance in arranging for a medical evaluation, venous follow-up blood lead tests and related medical treatment in cooperation with the child's primary care provider
  • Arrangement for lead screening of siblings of the lead poisoned child and other children between six months and six years of age and of pregnant women living in the same household.
  • Determination if emergency relocation is necessary and assistance in accessing funding and initiating collaboration with the appropriate agencies.
  • Ensure that a hazard assessment is completed at all proposed relocation addresses.
  • Completion of assessments to determine additional services that the family may be eligible to receive along with referrals to appropriate community resources. This may include Special Child Health Services; Women, Infants and Children (WIC) Program; transportation services; and other community-based health, housing and social community services.
  • Referral to another local health department if the household makes a permanent residential move.

In addition, whenever a child has a confirmed blood lead level of 45 µg/dL or greater, the household can expect:

  • A recommendation be made to the primary care provider for immediate hospitalization.
  • Collaboration with the primary care provider, health insurance carrier case manager, hospital discharge planner, and other appropriate agencies and personnel to ensure timely follow-up during medical treatment and after hospital discharge.
  • Assistance in identifying a pharmacy and obtaining any required prescriptions before the lead poisoned child is discharged from the hospital.
  • Counseling the child's caregiver regarding the medication regimen and proper administration of the medication.
  • Ongoing communication with the primary care provider and the health insurance carrier case manager regarding the child's response to the medication regimen, results of any neurodevelopmental reassessments, the referral process and the abatement status of the primary residence.

Time Frames for Case Management Functions

Initial Home Visit

Blood Lead Level (µg/dL) Time frame
10-14 within 3  weeks of referral
15-19 within 2 weeks of referral
20-44 within 1 week of referral
45-69 within 48 hours of referral
>70 within 24 hours of referral

Recommended Schedule for Obtaining a Confirmatory Venous Sample

Screening test result (µg/dL) Perform a confirmation test within
10-14 1 to 3 months
15-19 3 months
20-44 1 week – 1 month
45-59 48 hours
60-69 24 hours
>70 Immediately as an emergency lab test

If a child is less than 12 months old, or if there is reason to believe that the BLL is rising rapidly, an earlier diagnostic confirmation may be indicated.

Recommended Schedule for Follow-Up Blood Lead Testing

Venous Blood Lead Level (µg/dL) Early follow-up (first 2-4 tests after identification) Late follow-up (after BLL begins to decline)
10-14 1 to 3 months 6-9 months
15-19 1-3 months 3-6 months
20-24 1-3 months 1-3 months
25-44 2 weeks-1 month 1 month
>45 As soon as possible Chelation with subsequent follow-up

Note: Seasonal variations in blood lead screening results exists. Greater exposure in the summer months may necessitate more frequent follow-ups. Some case managers or primary care providers may choose to repeat blood lead tests on all new patients within a month to ensure that their BLL is not rising more quickly than anticipated.

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Case Management Resources

New Jersey

Childhood Lead Poisoning (N.J.A.C. §8:51) and Screening of Children for Lead Poisoning (N.J.A.C. §8:51A) can be accessed by going to http://lexisnexis.com/njoal/

N.J.A.C. §8:51 Appendixes can be accessed and downloaded from http://web.doh.state.nj.us/apps2/forms/

LP-4  Hazard Assessment Questionnaire (Appendix A) [pdf 51k]  [doc 198k]
LP-5  Environmental Intervention Report (Appendix B) [pdf 28k] [doc 145k]
LP-D1  Standard Housing Component Terminology (Appendix C) [pdf 603k] [doc 891k]
LP-D2  Protocol for Data Entry in the Childhood Lead Poisoning Information Database and Communication (Appendix D) [pdf 22k] [doc 33k]
LP-6  User Confidentiality Agreement (Appendix E) [pdf 11k] [doc 32k]
LP-7  Notice of Violation (Appendix F) [pdf 24k] [doc 34k]
LP-8  Childhood Lead Poisoning Home Visit (Appendix G) [pdf 41k] [doc 34k]
CH-14  Universal Child Health Record (Appendix H) [pdf 36k] [doc 88k], instructions [pdf 28k] [doc 34k]
LP-9  Nutritional Assessment (Appendix I) [ pdf 17k] [doc 51k]
LP-10  Quality Assurance and Improvement (Appendix J) [pdf 19k] [doc 42k]
LP-11  Childhood Lead Poisoning Case Closure (Appendix K) [pdf 21k] [doc 39k]

Federal

Guidelines for Pregnant and Lactating Women
www.cdc.gov/nceh/lead/tips/pregnant.htm

International Adoption and Lead Testing
www.cdc.gov/nceh/lead/tips/adoption.htm

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Childhood Lead Poisoning Prevention (CLPP) Projects

The focus of the CLPP case management team is to identify and remove the child from the source of lead. Through the CLPP Projects, lead poisoned children and their families are provided services that include:

  • Oversight by a case management team to ensure that the lead source is identified, a full environmental assessment has been conducted as well as an assessment for non- paint lead sources and any take home occupational exposures. 
  • Assistance in securing a medical home and in  scheduling medical follow-up visits.
  • Provision of  education and counseling on lead poisoning prevention measures.
  • Assistance  in relocation to lead safe housing.
  • Assistance in obtaining funding from Department of Community Affairs and other sources as appropriate for relocation and abatement.
  • Oversight of the abatement process.
  • Assessment of the nutritional status of the child/family and referral to the WIC Program.
  • Monitoring timely follow-up of blood lead retesting.
  • Assessment of the growth, developmental and health status of the child.
  • Collaboration  with the primary care provider and family to ensure follow-up  referrals as required are completed.
  • Assessment of the psychosocial and economic needs of the family with referral to community resources as indicated (WIC, family planning, housing, education, job training and other social services).

The following agencies are supported by the DOH to deliver comprehensive lead poisoning case management to families with children six years of age and younger.

Camden County:  Camden County Department of Health and Human Services
DiPiero Center
Lakeland Road
512 Lakeland Road, Suite 211
Blackwood, NJ  08012-0088
856-374-6320
Cumberland County:  Cumberland County Department of Health
7309 Buck Street
Millville, NJ 08332
856-327-7602
Essex County: 

East Orange Department of Health and Human Services
143 New Street
East Orange, NJ 07017
973-266-5465

Irvington Department of Neighborhood Services
Municipal Building
Civic Square
Irvington, NJ 07111
973-399-6647

Newark Department of Child and Family Well-Being
94 William Street
Newark, NJ 07102
973-733-5323

Hudson County:  Jersey City Dept of Health and Human Services
360 Martin Luther King Drive
Jersey City, NJ 07304
201-522-4395
Mercer County:   Trenton Division of Health
218 North Broad Street
Trenton, NJ 08608
609-989-3242
Middlesex County: Middlesex County Department of Health
75 Bayard Street, 5th floor
New Brunswick, NJ 08901
732-745-3100
Monmouth County: Monmouth County Health Department
3435 Highway 9
Freehold, NJ 07728
732-431-7456
Passaic County: 

Passaic City Health Department
330 Passaic Street
Passaic, NJ 07055
973-365-5606

Paterson Division of Health
176 Broadway
Paterson, NJ 07505
973-321-1277

Union County: Muhlenberg Campus JFK Medical Center
1200 Park Avenue
Plainfield, NJ 07061
908-668-2780

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Publications and Sources of Public Health Data

New Jersey State Health Assessment Data (NJ SHAD) provides access to public health datasets and information on the health status of New Jerseyans. (http://www4.state.nj.us/dhss-shad/home)

State Fiscal Year (SFY) Summary

SFY 2010 (July 1, 2009-June 30, 2010) statistics indicate of the children (<17 years old) tested:

  • 0.5% had blood lead levels between 10-19 µg/dL (1,092 children)
  • 0.11% had blood lead levels between 20-44 µg/dL (246 children)
  • 0.01% had blood lead levels 45 µg/dL or greater (20 children).

Counties with 50 or more children reported with blood lead levels greater than 10 µg/dL include: Camden, Cumberland, Essex, Hudson, Mercer, Middlesex, Monmouth, Passaic, and Union. The highest number of children reported with an elevated blood lead level resided in Essex County (396 cases). DOH and its State, regional, and local partners target these counties for outreach and education, and environmental interventions. By doing so, more costly interventions associated with treatment and can be avoided.

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Healthy Homes Resources

Centers for Disease Control and Prevention (CDC), Healthy Homes Initiative
http://www.cdc.gov/nceh/lead/healthyhomes.htm

U.S. Department of Housing and Urban Development (HUD), Healthy Homes and Lead Hazard Control
http://portal.hud.gov/hudportal/HUD?src=/program_offices/healthy_homes

U.S. Environmental Protection Agency (EPA)
http://www.epa.gov/lead/

U.S. Department of Agriculture (USDA), Healthy Homes Initiative
http://www.csrees.usda.gov/nea/family/in_focus/housing_if_healthyhomes.html

U.S. Department of Energy
http://www.energy.gov/yourhome.htm

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