Education Guidelines for the Prevention and Management of Lead Poisoning in Children

Lead Prevention and Intervention Resources for Educators

Because educators work closely with children and families, they are likely to know of a family or child in the community who may be at high risk for exposure to environmental lead or who has recently been identified as having an elevated blood lead level. Because preventive education and early intervention are critical in reducing the toxic effects of lead on children, educators should become familiar with the resources and services for families identified in section 4 "Lead Prevention and Intervention: Resources and Services for Parents." Educators must be knowledgeable about these resources in order to provide or direct families to them, and to refer families to appropriate medical, public health, social service, and housing services. Educators should also review the DPH screening data and map indicating the rate of screening by town (see section 4 under Connecticut Department of Public Health: Resources for Prevention, Screening, and Education). In towns where compliance has been low, school districts should encourage provider and parent compliance with mandated screening requirements.

group of children learning with flashcards This section contains citations for many professional articles published in peer-reviewed professional journals and a few related publications covering a variety of topics on lead poisoning in children, prevention and intervention, and the effects of lead exposure on the developing brains of children, including effects related to intelligence, learning, and behavior. For articles where a link for access to a free copy existed at the time of publication of the guidelines, that link is provided. If the link does not work directly, the reader can copy the URL and paste it into a computer’s URL address box.

For other articles, readers can search for access to a free copy online and seek assistance from a medical library. School nurses can access most, if not all, of these articles through the Yale School of Nursing School Information Resources for School Nurses program. School nurses can contact a librarian for assistance from this online location.

The articles cited below include those where controversy exists among experts, particularly related to the effects of lead exposure on brain development. It is important to read many of these articles in order to understand all sides of the controversies regarding lead, its effects in children, and the research methodologies used to identify those effects. Past controversies are critical to understand and must also be considered in light of the current literature and the breadth and depth of the research available today.

Best Review Article

The following article is recommended as an excellent overview of the state of knowledge, as of 2003, related to lead exposure in children, dispersion of lead in the body, effects on the brain, effects on cognitive/behavioral development, and strengths and limitations of related research. It is available online, if not by clicking directly on the “Full Text (PDF)” option, then by copying the URL and pasting it into your computer’s URL address box. Readers are advised to read other articles, especially those published after this one for more recent studies.

Lidsky, TI; Schneider, JS. Lead neurotoxicity in children: basic mechanisms and clinical correlates. Brain. 2003;126(1):5-19.

Articles Providing a General Overview of Lead Poisoning in Children and Lead Poisoning Prevention

Advisory Committee on Childhood Lead Poisoning Prevention. (January, 2012). Low Level Lead Exposure Harms Children: A Renewed Call for Primary Prevention. U.S. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.

Bellinger DC. Effect modification in epidemiological studies of low-level neurotoxicant exposures and health outcomes. [Review]. Neurotoxicol Teratol 2000; 22: 133±40.

Centers for Disease Control and Prevention (CDC) Ten great public health achievements--United States, 2001-2010. MMWR Morb Mortal Wkly Rep. 2011 May 20;60(19):619-23. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6019a5.htm.

Committee on Environmental Health, American Academy of Pediatrics. (2005; reaffirmed, 11/2008). Lead Exposure in Children: Prevention, Detection, and Management. Pediatrics Vol. 116 No. 4, pp. 1036 -1046.

Lanphear BP, Dietrich KN. and Berger, O. Prevention of Lead Toxicity in US Children. Ambulatory Pediatrics, Volume 3, Issue 1, January–February 2003, Pages 27–36.

Lanphear BP. Childhood lead poisoning prevention-too little, too late. JAMA. 2005;293 (18):2274-6.

Lin-Fu JS. Undue absorption of lead among children: a new look at an old problem. N Engl J Med. 1972;286(13):702-10.

Moyer PA, Pivetz T, Dignam TA, et al. CDC Centers for Disease Control and Prevention (CDC). Surveillance for elevated blood lead levels among children - United States 1997-2001. MMWR. 2003;52(SS10):1-21.

Needleman H. Lead poisoning. Annu Rev Med. 2004;55:209-22.

Nicholson, JS. Get the lead out: Reducing lead exposure for children in poverty.

Dissertation Abstracts International: Section B: The Sciences and Engineering. Vol.72(4-B), 2011, pp. 2468.

Rosen J, Mushak P. Primary prevention of lead poisoning—the only solution. N Engl J Med. 2001;344 :1470– 1471.

Silbergeld, E.K. Preventing Lead Poisoning in Children. Annu. Rev. Public Health. 1997. 18:187–210.

Warniment C, Tsang K, Galazka SS. Lead poisoning in children.

Am Fam Physician. 2010 Mar 15;81(6):751-7.

Articles Related to Lead and Neuropsychological, Cognitive and Learning Deficits

See also “Best Review Article “ above by Lidsky and Schneider.

Adler, T. Questioning Lead Standards: Even Low Levels Shave Points off IQ. Environ Health Perspect. 2005 July; 113(7): A473–A474.

Bellinger, DC. Lead . Pediatrics. 2004;113(Supplement_3):1016-1022. Abstract.

Bellinger, DC. Interpreting the literature on lead and child development: The neglected role of the “experimental system. ” Neurotoxicology and Teratology. Volume 17, Issue 3, May–June 1995, Pages 201–212.

Bellinger DC, Stiles KM, Needleman HL. Low-level lead exposure, intelligence and academic achievement: a long-term follow-up study. Pediatrics. 2001;90(6):855–861.

Bellinger D, Hu H, Titlebaum L, Needleman HL. Attentional correlates of dentin and bone lead levels in adolescents. Arch Environ Health 1994; 49: 98±105.

Canfield RL, Henderson CR Jr, Cory-Slechta DA, Cox C, Jusko TA, Lanphear BP. Intellectual impairment in children with blood lead concentrations below 10 µg per deciliter. N Engl J Med. 2003;348 :1517– 1526.

Canfield, RL; Kreher, DA; Cornwell, C; Henderson, CR Jr. Low-level lead exposure, executive functioning, and learning in early childhood. Child Neuropsychology. Vol.9(1), Mar 2003, pp. 35-53.

Chen, A; Cai, B; Dietrich, KN; Radcliffe, J; Rogan WJ. Lead Exposure, IQ, and Behavior in Urban 5- to 7-Year-Olds: Does Lead Affect Behavior Only by Lowering IQ? Pediatrics. 2007;119(3):e650-e658.

Chandran, et al. (2010). Poisoning: Basics and New Developments. Pediatr. Rev. 2010; 31:10 399-406

Chiodo LM, Jacobson SW, Jacobson JL. Neurodevelopmental effects of postnatal lead exposure at very low levels. Neurotoxicology. 2004;26(3):359-71.

Coscia, Juliet M; Ris, M. Douglas; Succop, Paul A; Dietrich, Kim N.

Cognitive development of lead exposed children from ages 6 to 15 years: An application of growth curve analysis. Child Neuropsychology. Vol.9(1), Mar 2003, pp. 10-21.

Ernhart, C. Effects of Lead on IQ in Children” Environ Health Perspect. 2006 February; 114(2): A85–A86. (an answer to Lanphear, 2005 below).

Gentile, Jennifer K. Relationship between pediatric lead poisoning and executive system functioning. Dissertation Abstracts International: Section B: The Sciences and Engineering. Vol.67(5-B), 2006, pp. 2834.

Goldstein GW. Lead poisoning and brain cell function. Environ Health Perspect. 1990 Nov; 89:91-4.

Hornung RW, Lanphear BP, Dietrich KN. Age of greatest susceptibility to childhood lead exposure: a new statistical approach. Environ Health Perspect. 2009 Aug;117(8):1309-12. Epub 2009 May 7.

Hubbs-Tait, L., Mulugeta, A.,Bogale, A.,Kennedy, T.S.,Baker, E.R.,Stoecker, B.J. Main and interaction effects of iron, zinc, lead, and parenting on children’s cognitive outcomes. Developmental Neuropsychology. Volume 34, Issue 2, March 2009, Pages 175-195.

Hubbs-Tait, L., Nation, J.R., Krebs, N.F., Bellinger, D.C. Neurotoxicants, micronutrients, and social environments individual and combined effects on children’s development ( Review ). Psychological Science in the Public Interest, Supplement.

Volume 6, Issue 3, December 2005, Pages 57-121.

Kaufman, A.S. How dangerous are low (not moderate or high) doses of lead for children’s intellectual development? (Review) Archives of Clinical Neuropsychology Volume 16, Issue 4, 2001, Pages 403-431.

Kaufman, A.S. Do low levels of lead produce IQ loss in children? A careful examination of the literature Archives of Clinical Neuropsychology Volume 16, Issue 4, 2001, Pages 303-341

Koller K, Brown T, Spurgeon A, Levy L. Recent developments in low-level lead exposure and intellectual impairment in children. Environ Health Perspect. 2004 Jun;112 (9):987-94.

Lanphear BP, Hornung R, Khoury J, et al. Low-level environmental lead exposure and children’s intellectual function: an international pooled analysis. Environ Health Perspect. 2005;113(7):894–899. WEB OF SCIENCE | PUBMED.

Lanphear BP, Hornung R, Khoury J, et al Lead and IQ in Children: Lanphear et al. Respond Environ Health Perspect. 2006 February; 114(2): A86–A87.

Lanphear BP, Dietrich K, Auinger P, Cox C. Cognitive deficits associated with blood lead concentrations <10mg/dl in US children and adolescents. Public Health Rep 2000; 115: 521±9.

Lidsky, T I, and J S SSchneider. Adverse effects of childhood lead poisoning: the clinical neuropsychological perspective. Environmental research 100.2 (2006):284-293.

Liu, et al. Do Children With Falling Blood Lead Levels Have Improved Cognition? Pediatrics. 2002;110(4):787-791. Abstract.

Mendelsohn, AL; Dreyer, BP; Fierman, AH; Rosen, CM; Legano, LA; Kruger, HA; Lim, SW; Barasch, S; Au, L; Courtlandt, CD. Low-level lead exposure and cognitive development in early childhood. Journal of Developmental and Behavioral Pediatrics. Vol.20(6), Dec 1999, pp. 425-431.

Min, MO. , Singer, LT., Kirchner, HL, Minnes, S., Short, E., Hussain, Z. and Nelson, S. Cognitive development and low-level lead exposure in poly-drug exposed children. Neurotoxicology and Teratology. Volume 31, Issue 4, July–August 2009, Pages 225–231

Miranda ML, Kim D, Reiter J, Overstreet Galeano MA, Maxson P. Environmental contributors to the achievement gap. Neurotoxicology. 2009 Nov;30(6):1019-24. Epub 2009 Jul 28.

Needleman HL, Bellinger D. Studies of lead exposure and the developing central nervous system: a reply to Kaufman. Arch Clin Neuropsychol. 2001 May;16(4):359-74.

Needleman HL, Gunnoe, C, Leviton, A, Reed, R, Peresie, H, Maher, C, and Barrett, P. Deficits in Psychologic and Classroom Performance of Children with Elevated Dentine Lead Levels. N Engl J Med 1979; 300:689-695.

Needleman HL, Schell A, Bellinger D, Leviton A, Allred EN. The long-term effects of exposure to low doses of lead in childhood: an 11-year follow-up report. N Engl J Med.1990;322 :83– 88.

Rogan WJ Intellectual impairment in children with blood lead concentrations below 10 microg per deciliter. et al. J Pediatr. Nov;143(5):687-8 (2003).

Ruff, Holly A. Population-based data and the development of individual children: The case of low to moderate lead levels and intelligence. Journal of Developmental and Behavioral Pediatrics. Vol.20(1), Feb 1999, pp. 42-49.

Surkan PJ, Zhang A, Trachtenberg F, Daniel DB, McKinlay, S. and Bellinger DC. Neuropsychological function in children with blood lead levels <10 µg/dL.

NeuroToxicology, Volume 28, Issue 6, November 2007, Pages 1170–1177.

Tellez-Rojo MM, Bellinger DC, Arroyo-Quiroz C, Lamadrid,-Figueroa H, Mercado-Garcia, A, Schnaas-Arrieta L, Wright RO, Hernandez-Avila M, and Hu H. Longitudinal Associations Between Blood Lead Concentrations Lower Than 10 µg/dL and Neurobehavioral Development in Environmentally Exposed Children in Mexico City. August 1, 2006. Pediatrics Vol. 118 No. 2 pp. e323 -e330.

Tong S, Baghurst PA, Sawyer MG, Burns J, McMichael AJ. Declining blood lead levels and changes in cognitive function during childhood: the Port Pirie Cohort Study. JAMA.1998;280 :1915.

Wasserman, GA; Factor-Litvak, P; Liu, X; Todd, AC; Kline, JK; Slavkovich, V; Popovac, D; Graziano, JH. The relationship between blood lead, bone lead and child intelligence. Child Neuropsychology. Vol.9(1), Mar 2003, pp. 22-34.

Wasserman GA, Factor-Litvak P. Methodology, inference and causation: environmental lead exposure and childhood intelligence. Arch Clin Neuropsychol. 2001 May;16(4):343-52.

Articles Related to Lead and Behavior

Bellinger D, Leviton A, Allred E, Rabinowitz M. Pre- and postnatal lead exposure and behavior problems in school-aged children. Environ Res. 1994;66:12–30.

Fergusson D M , Boden J M , Horwood L J. Dentine lead levels in childhood and criminal behaviour in late adolescence and early adulthood. J. Epidemiol. Community Health. 2008;62(12):1045-1050.

Marcus, David K; Fulton, Jessica J; Clarke, Erin J. Lead and conduct problems: A meta-analysis. Journal of Clinical Child and Adolescent Psychology. Vol.39(2), Mar 2010, pp. 234-241.

Mendelsohn, AL; Dreyer, BP; Fierman, AH; Rosen, CM; Legano, LA; Kruger, HA; Lim, SW; Courtlandt, CD. Low-Level Lead Exposure and Behavior in Early Childhood. Pediatrics Vol. 101 No. 3 March 1, 1998 pp. e10.

Narag, RE, Pizarro J, Gibbs, C. Lead Exposure and Its Implications for Criminological Theory Criminal Justice and Behavior. 2009;36(9):954-973. Abstract.

Needleman HL, McFarland C, Ness RB, Fienberg SE, Tobin MJ. Bone lead levels in adjudicated delinquents. A case control study. Neurotoxicol Teratol.2002;24 :711– 717 CrossRef Medline Web of Science.

Needleman HL, Riess JA, Tobin MJ, Biesecker GE, Greenhouse JB. Bone lead levels and delinquent behavior. JAMA.1996;275 :363– 369.

Needleman, Herbert L. The neurobehavioral consequences of low lead exposure in childhood. Neurobehavioral Toxicology & Teratology. Vol.4(6), Nov-Dec 1982, pp. 729-732.

Nevin, Rick. Understanding international crime trends: the legacy of preschool lead exposure. Environmental Research. 104(3):315-36, 2007 Jul.

Olympio KP, Gonçalves C, Günther WM, Bechara EJ. Neurotoxicity and aggressiveness triggered by low-level lead in children: a review. Rev Panam Salud Publica. 2009 Sep;26(3):266-75.

Shaheen, Sandra J. Neuromaturation and behavior development: The case of childhood lead poisoning. Developmental Psychology. Vol.20 (4), Jul 1984, pp. 542-550.

Stretesky PB; Lynch MJ. The Relationship Between Lead Exposure and Homicide. Arch Pediatr Adolesc Med. 2001;155(5):579-582. Abstract Full Text Full Text (PDF).

Wright, J.P. , Boisvert, D, and Vaske, J. Blood Lead Levels in Early Childhood Predict Adulthood Psychopathy. Youth Violence and Juvenile Justice July 2009 7: 208-222, first published on May 11, 2009.

Articles on Lead and Other Clinical Issues

Dietrich KN, Ware JH, Salganik M, Radcliffe J, Rogan WJ, Rhoads GG, Fay ME, Davoli CT, Denckla MB, Bornschein RL, Schwarz D, Dockery DW, Adubato S, Jones RL; Treatment of Lead-Exposed Children Clinical Trial Group. Effect of chelation therapy on the neuropsychological and behavioral development of lead-exposed children after school entry. Pediatrics. 2004 Jul;114(1):19-26.

Fadrowski JJ, Navas-Acien A, Tellez-Plaza M, Guallar E, Weaver VM, Furth SL.

Blood lead level and kidney function in US adolescents: The Third National Health and Nutrition Examination Survey. Arch Intern Med. 2010 Jan 11;170(1):75-82.

George M; Heeney MM; Woolf AD. Encephalopathy from lead poisoning masquerading as a flu-like syndrome in an autistic child. Pediatric Emergency Care. 26(5):370-3, 2010 May.

Piomelli S. Childhood lead poisoning. Pediatric Clinics of North America. 49(6):1285-304, vii, 2002 Dec.

Sood A, Midha V, Sood N. Pain in abdomen-do not forget lead poisoning. Indian J Gastroenterol. 2002;21(6):225-226.

Woolf AD, Goldman R, Bellinger DC. Update on the clinical management of childhood lead poisoning. Pediatr Clin North Am. 2007;54(2):271-294.

Articles Related to Sources of and Risk Factors for Lead Exposure

Brown MJ. Raymond J. Homa D. Kennedy C. Sinks T. Association between children’s blood lead levels, lead service lines, and water disinfection, Washington, DC, 1998-2006. Environmental Research. 111(1):67-74, 2011 Jan.

Centers for Disease Control and Prevention (CDC). Childhood lead poisoning associated with lead dust contamination of family vehicles and child safety seats - Maine, 2008.

MMWR - Morbidity & Mortality Weekly Report. 58(32):890-3, 2009 Aug 21.

Centers for Disease Control and Prevention (CDC). Childhood lead poisoning from commercially manufactured French ceramic dinnerware-- New York City, 2003.

MMWR Morb Mortal Wkly Rep. 2004 Jul 9;53(26):584-6.

Eisenberg KW, van Wijngaarden E, Fisher SG, Korfmacher KS, Campbell JR, Fernandez ID, Cochran J, Geltman PL. Blood lead levels of refugee children resettled in Massachusetts, 2000 to 2007. Am J Public Health. 2011 Jan;101(1):48-54. Epub 2010 Nov 18.

George M. Heeney MM. Woolf AD. Encephalopathy from lead poisoning masquerading as a flu-like syndrome in an autistic child. Pediatric Emergency Care. 26(5):370-3, 2010 May.

Gorospe EC. Gerstenberger SL. Atypical sources of childhood lead poisoning in the United States: a systematic review from 1966-2006. Clinical Toxicology: The Official Journal of the American Academy of Clinical Toxicology & European Association of Poisons Centres & Clinical Toxicologists. 46(8):728-37, 2008 Sep.

Jacobs DE, Clickner RP, Zhou JY, et al. The prevalence of lead-based paint hazards in U.S. housing. Environ Health Perspect.2002;110 :A599– A606

Khan DA, Qayyum S, Saleem S, Ansari WM, Khan FA. Lead exposure and its adverse health effects among occupational worker’s children. Toxicol Ind Health 2010; 26:8 497-504. Abstract Full Text (PDF)

Lambrinidou Y. Triantafyllidou S. Edwards M. Failing our children: lead in U.S. school drinking water. New Solutions. 20(1): 25-47, 2010.

Lin CG, Schaider LA, Brabander DJ, Woolf AD. Pediatric lead exposure from imported Indian spices and cultural powders. Pediatrics. 2010 Apr;125(4):e828-35. Epub 2010 Mar 15.

Miranda ML, Anthopolos, R and Hastings, D. 2011 October. A Geospatial Analysis of the Effects of Aviation Gasoline on Childhood Blood Lead Levels., Environ Health Perspect.: 119(10): 1513–1516. Published online 2011 July 13. doi: 10.1289/ehp.1003231

Rabito, F A. Iqbal, S. Shorter, C F. Osman, P. Philips, P E. Langlois, E. White, L E. The association between demolition activity and children’s blood lead levels.

Environmental Research. 103(3):345-51, 2007 Mar.

Sharmer L. Northrup-Snyder K. Juan W.Newly recognized pathways of exposure to lead in the middle-income home. Journal of Environmental Health. 70(3):15-9, 48; quiz 51-2, 2007 Oct.

Zierold KM. Havlena J. Anderson H. Exposure to lead and length of time needed to make homes lead-safe for young children. American Journal of Public Health. 97(2):267-70, 2007 Feb.

Articles Related to Nutrition

See also above, Best Review Article by Lidsky and Schneider.

Hubbs-Tait, L., Nation, J.R., Krebs, N.F., Bellinger, D.C. Neurotoxicants, micronutrients, and social environments individual and combined effects on children’s development (Review ). Psychological Science in the Public Interest, Supplement Volume 6, Issue 3, December 2005, Pages 57-121.

Kwong WT, Friello P, Semba RI. Interactions between iron deficiency and lead poisoning: epidemiology and pathogenesis. Sci Total Environ. 2004;330(1-3):21-37.

Liu J, McCauley L, Compher C, Yan C, Shen X, Needleman H, Pinto-Martin JA. Regular breakfast and blood lead levels among preschool children. Environ Health. 2011 Apr 1;10:28.

Ramos CL, Barros HM, Stein AT, Costa JS. Risk factors contributing to childhood poisoning. J Pediatr (Rio J). 2010 Sep-Oct;86 (5):435-40.

[Article in English, Portuguese].

Articles on Lead and Children with Pervasive Developmental Disorders

Accardo P, Whitman B, Caul J, et al. Autism and plumbism. A possible association. Clin Pediatr (Phila). 1988;27(1):41-44. SFX [Context Link]

George M. Heeney MM. Woolf AD. Encephalopathy from lead poisoning masquerading as a flu-like syndrome in an autistic child. Pediatric Emergency Care. 26(5):370-3, 2010 May.

Kaiser MY. Kearney G. Scott KG. DuClos C. Kurlfink J. Tracking childhood exposure to lead and developmental disabilities: examining the relationship in a population-based sample. Journal of Public Health Management & Practice. 14(6):577-80, 2008 Nov-Dec.

Shannon M, Graef JW. Lead intoxication in children with pervasive developmental disorders. J Toxicol Clin Toxicol. 1996;34:177.

Articles on Lead and Maternal/Prenatal Exposure

Cleveland LM. Minter ML. Cobb KA. Scott AA. German VF. Lead hazards for pregnant women and children: part 1: immigrants and the poor shoulder most of the burden of lead exposure in this country. Part 1 of a two-part article details how exposure happens, whom it affects, and the harm it can do. American Journal of Nursing. 108(10):40-9; quiz 50, 2008 Oct.

Jedrychowski W, Perera F, Maugeri U, Miller RL, Rembiasz M, Flak E, Mroz E, Majewska R, Zembala M. Intrauterine exposure to lead may enhance sensitization to common inhalant allergens in early childhood: a prospective prebirth cohort study.

Environ Res. 2011 Jan;111(1):119-24. Epub 2010 Nov 20.

Patel, AB; Mamtani, MR; Thakre, TP; Kulkarni, H. Association of umbilical cord blood lead with neonatal behavior at varying levels of exposure. Behavioral and Brain Functions. Vol.2 Jun 2006, ArtID 22.

Other Publications

DPH 2010 surveillance report.

Miranda ML Kim D; Osgood C; Hastings D. The Impact of Early Childhood Lead Exposure on Educational Test Performance among Connecticut Schoolchildren, Study Phase 1, 2011, February 14. Children’s Environmental Health Initiative, Duke University: Durham, North Carolina.

Fiedler, Nancy L. Gender (sex) differences in response to prenatal lead exposure. In Lewis, Michael [Ed]; Kestler, Lisa [Ed]. (2012). Gender differences in prenatal substance exposure. (pp. 171-185). xviii, 227 pp. Washington, DC, US: American Psychological Association; US.

Stanford, Lisa D. Lead Astray: The Controversies of Childhood Lead Poisoning. Heilbronner, Robert L [Ed]. (2005). Forensic Neuropsychology Casebook. (pp. 218-235). xiv, 370 pp. New York, NY, US: Guilford Press; US.

Morley, R. (Reviewer). The Cost of Being Poor: Poverty, Lead Poisoning, and Policy Implementation. Review in JAMA 2006; 295:14 1711-1712 .

Richardson, JW. The Cost of Being Poor: Poverty, Lead Poisoning, and Policy Implementation. 2005. 204 pp, ISBN 0-275-96912-6, Praeger: Westport, Conn.

Connecticut State Department of Education