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Q&A: How to interpret the new USPSTF lead screening recommendations
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In April, the U.S. Preventive Services Task Force, or USPSTF, found there was insufficient evidence to weigh the benefits and harms of screening asymptomatic children for lead exposure.
Lead exposure was pushed to the forefront for many Americans when the source of drinking water for the city of Flint, Michigan, was switched from Lake Huron and the Detroit River to the Flint River in 2014. Research showed that the city’s young children had higher blood lead levels after the switch. However, other environmental exposures of lead, including dust from lead-based paint and contaminated soil, can also place children at risk for negative developmental outcomes.
“There is no safe level of lead,” Michael Weitzman, MD, professor of pediatrics and environmental medicine at the New York University School of Medicine, told Infectious Diseases in Children. “Any child who is exposed has the potential of having problems. It varies from loss of IQ points to increased risk of ADHD or behavior problems. Often, there are oppositional defiant disorders, school failure and difficulties navigating life.”
Weitzman added that as blood lead levels increase, the risks associated with them grow more severe. At extremely high levels, children may experience coma, seizures or even death.
Infectious Diseases in Children spoke with Weitzman about the USPSTF recommendations and how pediatricians and physicians can identify and care for patients who have been exposed to lead. – by Katherine Bortz
Q: How routinely are children screened for blood lead levels in the United States , and are there recommendations that physicians are more likely to follow?
A: Different groups, organizations and federal agencies have different recommendations. The AAP is the single most respected organization because it relates to the care of children. It recommends that pediatricians follow the rules and regulations of local municipalities and states but encourages pediatricians to screen either universally — all children at 1 and 2 years of age — or those who are at greatest risk. You can see that even the AAP ideally recommends that children be screened but recognizes that there are variations from place to place.
The CDC recommends screening for children who live in communities with high lead levels or who are at high risk. Medicaid also requires screening all children who get coverage at age 1 and 2 years.
Q: How might the USPSTF recommendation change current practice?
A: The USPSTF is an independent, nongovernmental agency that consists of physicians and scientists with great expertise in the effectiveness of preventive services and how to evaluate the value of paying attention to those things. It has no regulatory authority. Some organizations do follow what they recommend, and others do not.
How this recommendation will change people’s behavior is uncertain. What is clear is that nowhere in the most recent statement do they say children should not be screened. They simply say that the evidence is insufficient for them to make a judgment one way or the other.
Q: What research is needed to make a more definitive recommendation for blood lead level screening?
A: Part of the recommendations were made because there isn’t good evidence that once we identify a child as having an elevated lead level that anything short of abating the home of lead is going to protect that child. However, all those studies have been done with substantially higher blood lead levels, and there are a limited number of such studies. Studies need to be done again at lower levels that reflect what we’re currently seeing. Nobody has looked at the effectiveness of special education services for children affected by lead exposure when we know that special education works wonders for children with any number of other disabilities.
We need a significant amount of research, and when we identify a child through screening who has an elevated lead level or is at risk of having an elevated lead level, pediatricians and families should work closely with other agencies that service children, including housing services, DHS and people who use the courts and litigation to make sure children’s rights are not impinged upon.
Most people don’t think of medicine or science as using the same sort of approach as the legal system. It really comes down to different sorts of evidence and the weight of the evidence before organizations make decisions. What the USPSTF is saying is that the weight of the evidence doesn’t show that there’s a net benefit to children by screening them. It in no way says that physicians should not be doing it.
Q: What needs to be done to better target children who should be screened for blood lead levels?
A: That’s a great question, and we know the answer, but we don’t necessarily have the political will or the commitment of resources to do it. For decades, people have recognized that relying on screening makes it so that we use children to identify sick houses. That is, rather than identify and remediate homes with dangerous levels of lead and abate those homes before children are exposed, we have used a system that first screens children and, if they have elevated blood lead levels, we then address the lead-based problems in homes. If you rely only on screening to do environmental inspections and cleanups, then a child must have an elevated lead level before you begin to do any kind of environmental inspection or intervention.
We could figure out quite easily which properties or communities or places where children are likely to be exposed and what the source of exposure is before children have elevated lead levels. We know that lead was removed from paint that was used in the interior of homes in 1978. We know that there are about half a million children who have elevated lead levels and several million housing units that have unsafe levels of lead or lead-based paint in disrepair. One could target those very areas and remediate the homes and other potential sources. What Flint, Michigan, showed us is that water is one of them. We do have an aging infrastructure of water in the U.S.
This strategy lends itself to an infrastructure project of great magnitude that would give large numbers of people — often impoverished individuals — jobs for any number of years while protecting the nation’s children and, at the same time, saving aging houses and increasing their values.
The model that we have used has accomplished a large number of things in the past 50 years. We have removed lead from solder in food cans and from plastic bottles used to feed children formula, and we have regulated lead in toys. We’ve done a fair amount, but we’ve not done enough.
References:
USPSTF. JAMA. 2019;doi:10.001/jama.2019.3326.
Disclosure: Weitzman reports no relevant financial disclosures.