Answers from Amy Zimmerman, JD and Nicole Hamp, MD for EITP Webinar on 2/14/18

Transcription

1 1. What is chelation? Chelation is the type of medical treatment used to remove lead from the bloodstream. If a child has a blood lead level greater than or equal to 45 micrograms per deciliter, they may be admitted to the hospital to receive chelation treatment in an effort to prevent some of the more serious, acute effects of lead poisoning including seizures, coma, and death. Chelation treatment can be administered by mouth or by injection. Medications bind with lead in the bloodstream and are subsequently excreted in the urine. Specific chelation treatments have been shown to decrease mortality from 66% without treatment to between 1 2% with treatment. However, chelation treatment does not mitigate the chronic neurocognitive effects of lead toxicity. 2. Is blood lead level checked or routinely screened? There are many different guidelines regarding when to screen for lead risk versus when to perform a blood lead test. These guidelines vary based on the age of the child, where they live, their insurance, and whether they have tested positive for lead poisoning in the past. In Illinois we have different guidelines depending on insurance status and zip code, they are as follows: o The first group is comprised of our patients who are on Medicaid all of whom, across the state, should receive a blood lead test by the age of 12 and 24 months regardless of risk. Children who have never received a blood test before should receive one between 36 and 72 months. o The second group is comprised of all children who live in a high risk zip code, who also should receive a blood test by the time they are 12 and 24 months. o The third group is all of the children under 6 years old who are not on Medicaid or in a high risk zip code **AND** who do not live in Chicago. These children should receive a risk assessment questionnaire at all their well child checks from 6 months to 6 years. If they are determined to be at risk, then they too require a blood test. o The final group is comprised of all the children who live in Chicago and thus are considered to be at high risk. These children should receive blood lead testing at EITHER 6, 12, 18, 24 and 36 months OR 9, 15, 24, and 36 months, as well as an annual blood lead test for children 4 6 years old UNLESS there is a prior history of two or more blood tests with results less than the current Illinois level of concern of 10 ug/dl UNLESS patient otherwise meets high risk criteria.

2 3. Why not [test] earlier if it can cause so many problems and build up in the system over time? Lead exposure typically doesn t occur until a child is mobile, often when they start to crawl and are engaging in hand to mouth behavior. Thus it is unlikely for a blood lead test to be useful in the general population before 6 12 months of age. 4. Is this recording available after the fact? Yes, i0 5. What was that percentage of kiddos in Illinois with problems from lead? It s important to note that not every child exposed to lead is necessarily going to experience serious negative outcomes from their exposure. However, no level of lead exposure is safe, and any exposure can put a child at risk. In the Illinois Lead Program 2015 Annual Surveillance Report, 1 in 25 children tested, or 4%, met the recommended federal reference value ( 5 µg/dl) of lead for public health intervention, and the average blood lead level of children tested in Illinois in 2015 was 2.3µg/dL. As discussed in the webinar, children can experience neurocognitive effects at blood lead levels below 5µg/dL. For example, one of the studies that we referenced by Miranda et al. found a statistically significant decrease in end of grade test scores for children with lead exposure as low as 2µg/dL. Applying her research findings to our statistics would mean that around 50% of the children tested for lead in Illinois may have lead levels high enough to experience decreased educational outcomes, and that s only out of the children tested. 6. Is there a resource to refer to when doing a home visit for checking environmental risks? It can be difficult to know if there are environmental risks inside or outside the house. If the building was built before 1978, it is likely that it has lead paint in it and a home visitor can point out potential sources of lead exposure. These were briefly discussed in the presentation. However, a family should obtain a lead inspection by a licensed professional to know for sure whether their home has lead. Depending on where the family lives they can contact the Chicago Department of Public Health ( ), the Illinois Department of Public Health ( , or ), or the Cook County Department of Public Health ( ) to request an inspection. If a family lives in Chicago, they can also call 311 to receive a test for lead in their tap water. The Protect Your Family from Lead in Your Home booklet is a good resource to provide families worried about lead in their homes. It is available in English, Spanish, Vietnamese, Russian, Arabic, and Somali at the following link: your family lead your home real estate disclosure. An additional resource is the Lead Safe Illinois Healthy Homes Page available here:

3 7. Is [a child with a] high lead level automatically eligible for early intervention services in IL now? No the child is not currently automatically eligible. However, we are hoping to change that! 8. Given the impact of lead on development, what considerations might be made by EI or medical providers to have a child identified with high lead levels to see a dietitian to optimize nutrition and potentially offset the impact of high lead levels on health and development? Nutrition does play a role in preventing and/or mitigating lead exposure. Specifically, ensuring lead exposed children and children at risk for lead exposure have adequate amounts of iron, calcium and Vitamin C in their diets is very important. We do think referring to a nutritionist or dietician can be beneficial for the child and family. 9. Do you have ideas on how to reduce the risk of being exposed to lead? The primary way is to reduce the risk of lead exposure is to ensure a child is to abate or mitigate lead hazards. If a source of lead is identified in a child s home environment, the family should be referred to the resources provided in question 7 as the public health departments listed should be able to help them request that lead risks be resolved if they are renters or provide resources to help them safely resolve the risks if they are home owners. However, that process can be long, challenging and potentially unsuccessful. Below is a list of practices families should use to decrease the risk of lead exposure if they are living amongst lead hazards. The list is from Mayo Clinic ( conditions/lead poisoning/symptoms causes/syc ). o Wash hands and toys. To help reduce hand to mouth transfer of contaminated dust or soil, wash your children s hands after outdoor play, before eating and at bedtime. Wash their toys regularly. o Clean dusty surfaces. Clean your floors with a wet mop and wipe furniture, windowsills and other dusty surfaces with a damp cloth. o Remove shoes before entering the house. This will help keep lead based soil outside. o Run cold water. If you have older plumbing containing lead pipes or fittings, run your cold water for at least a minute before using. Don t use hot tap water to make baby formula or for cooking. o Prevent children from playing on soil. Provide them with a sandbox that s covered when not in use. Plant grass or cover bare soil with mulch. o Eat a healthy diet. Regular meals and good nutrition might help lower lead absorption. Children especially need enough calcium, vitamin C and iron in their diets to help keep lead from being absorbed. o Keep your home well maintained. If your home has lead based paint, check regularly for peeling paint and fix problems promptly. Try not to sand, which generates dust particles that contain lead.

4 10. Why was Chicago left out of the project? We wish we had the funding to do pilots in more locations. Unfortunately, the funding and resources for the pilot are very limited and we only were able to choose two CFCs. We chose the pilot CFCs based on the number of lead exposed children in their area, the ability of the CFCs to quickly take on additional children, and the involvement of CFC staff in the EI and Lead Workgroups. While we did not choose a Chicago CFC, the plan is to eventually roll out automatic EI eligibility across the state, and when this happens, we will be provide trainings and resources on serving lead exposed kids through EI at each CFC in Illinois including the Chicago CFCs. 11. Did you cover iron and lead connection? We did somewhat cover this in the first half of the presentation, but we can probably elaborate further. The gist is that lead looks like multiple other elements, such as iron and calcium, that are present in the body for normal physiologic functions. When the body is low on iron, it does its best to get as much iron as it can from the gastrointestinal tract. It does so by increasing the numbers of receptors for iron in the GI tract. These receptors absorb the iron, but also the lead that has been ingested. Therefore, an individual who is deficient in iron can be predisposed to increased lead absorption. Once absorbed, lead can be incorrectly incorporated into body processes in place of other elements and can lead to cell death and irreversible damage. 12. At CFC3, we are having kiddos referred to us with a 5 or greater lead level. Parents are not concerned with development at the time of evaluation, but they are automatically eligible...what do you recommend for ongoing services and/or just monitoring? We absolutely recommend services. However, what these look like, including how often they are provided, what is provided, etc., has to be determined on a case by case basis by that child s EI team in collaboration with the family. We are working on a service guidelines document through our pilot that we eventually hope the EI Bureau can make available to all CFC s in the state. However, in the webinar we provided multiple examples of resources that may be helpful in the meantime. One is listed below. Children with a lead level of 5 and above are at risk for developing delays in areas of executive functioning. By leading these families in activities that teach executive functioning skills, you may be able to lessen the risk of these delays manifesting. Below are three free online resources that we recommend you use with these families: o Enhancing and Practicing Executive Function Skills with Children from Infancy to Adolescence An activities guide for building executive functioning This 16 page guide from the Center on the Developing Child at Harvard University describes a variety of activities and games that represent age appropriate ways for adults to support and strengthen various components of executive function and self regulation in children. o Vroom Website Vroom is a set of tools and resources from the Bezos Family Foundation designed to inspire families to turn everyday moments into brain building moments by layering activities that are essential to healthy brain development onto existing routines.

5 There is a Vroom app families can download in English and Spanish. The app has families create a child profile and sends daily activities for a family to do based on their child s age. o Zero to Three Family Friend & Neighbor Care resource series. These resources from Zero to Three give early interventionists a variety of tools to help in building their knowledge base for supporting families on many topics from early brain development to building school readiness and many others. 13. What should we do if we enter a home that looks to have lead paint? Have the family request a home inspection (see question 7) and provide them with tips on reducing risk of lead exposure (see question 10). 14. Can a one time exposure cause issues or prolonged exposure? Both one time exposure and prolonged exposure can put a child at increased risk for long term, negative effects. No exposure to lead is safe.