Childhood Blood Lead Case
Management Guidelines
for Minnesota
Reference Manual
Developed by:
State and Local Public Health Officials
and Private Health Care Agencies
April 2001
Revised: July 2006
Intentionally Left Blank
Acknowledgments
Minnesota Department of Health (MDH) staff worked in collaboration with local public
health lead programs and the Council of Health Plans to create the blood lead CASE
MANAGEMENT guidelines in this document. Special thanks go to the following local
public health lead program representatives from throughout the state of Minnesota (MN)
for their vision, intensive time commitment, and dedication to seeing this project
through: Joe Jurusik, Hennepin County Community Health Department; Dianne Kelly,
Dakota County Public Health Department; Cheryl Lanigan & Mary Shea, Minnesota
Visiting Nurse Agency (MVNA); Myna Peterson, Goodhue County Public Health
Service; Mary Ellen Smith, St. Paul - Ramsey County Department of Public Health;
Michelle Sonnabend, Countryside Public Health Service (Serving Big Stone, Chippewa,
Lac Qui Parle, Swift, and Yellow Medicine); Janice Springer, Stearns County Human
Services; and Larry Sundberg, St. Louis County Public Health.
This project was made possible by the Centers for Disease Control and Prevention
(CDC) Childhood Lead Poisoning Prevention Program (CLPPP) Grant
#US7/CCU518477-01.
A second group met in February 2006 to discuss needed changes to the Childhood
Blood Lead Case Management Guidelines for Minnesota. Some partners were not able
to attend the meeting, but did give input that helped shape the revisions. MDH would
like to acknowledge and thank the following group for their time and commitment to
keeping the guidelines as applicable and current as possible.
2006 Revision Group:
Jodi Ammerman, Kandiyohi County
Jodie Carey, Carlton County
Doris Cogelaw, Kandiyohi County
Megan Curran, Sustainable Resources Center
Dana Eichelberger, Kandiyohi County
Amy Evans, Dodge County
Katie Jensen, Morris County
Deb Floren, Kandiyohi County
Franschetta Haupert, Morris County
Joe Jurusik, Hennepin County Community Health Department
Noreen Kleinfehn-Wald, Scott County
Cheryl Lanigan, Minnesota Visiting Nurse Agency
Christy Niemann, Olmsted County
Vicki Rakes-Meeks, Anoka County
Emily Robb, Washington County
Janelle Schroeder, Kanabec County
Bruce Scott, Bloomington Public Health
Mary Ellen Smith, St. Paul - Ramsey County Department of Public Health
Carol Wentworth, Carver County
If you require this document in another format,
call (651) 201-5000; or 1 (800) 657-3908; or TTY (651) 215-0707
Printed on Recycled Paper
i
April 2001
Revised: July 2006
Intentionally Left Blank
Table of Contents
Acknowledgments ...........................................................................................................i
Table of Contents ........................................................................................................... ii
Introduction: Background and Purpose .........................................................................1
Overview of the Guidelines ............................................................................................3
Recommended Minimum Qualifications for the Case Manager .....................................5
Home Visit Protocol........................................................................................................6
Referral Services: A Key Part of Case Management ....................................................8
Childhood Blood Lead Case Management Guidelines for Minnesota ............................9
Case Closure ...............................................................................................................11
Commonly Used Terms................................................................................................13
References...................................................................................................................17
Appendices ................................................................................................................... 19
ii
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Introduction: Background and Purpose
In 1998—the most recent year for which data has been analyzed—approximately 2,500
Minnesota CHILDREN under the age of six had ELEVATED BLOOD LEAD LEVELS* (EBLLs).
A variety of programs are in place across the state to manage the services that are
available for these children. Until recently, however, there has been no means of
assuring that children receive appropriate services after they are diagnosed with an
EBLL. By early 1999, the need for standardized protocols, which could be applied
statewide, became apparent. An informal needs assessment was conducted by
telephone, in an effort to get a sense of the follow-up procedures employed by local
public health programs and their partners. A more formal needs assessment was done
in those non-metro counties where EBLL risks are the highest. These assessments
concluded that:
•
•
•
•
most counties did not have standard protocols for following children with
elevated lead levels,
some counties were relying on outdated surveillance and education
information to guide their lead activities,
some counties had not identified lead exposure as a problem in their
communities, and
most counties wanted a clear description of how to follow and manage a
case, as well as clear determination for when to close a case.
A work group—the Blood Lead Case Management Work Group (CMWG)—was
convened and held its first meeting on December 15, 1999. This group represented a
cross-section of the skills and experience required to conduct comprehensive lead case
management, and included public health nurses, and lead risk assessors. The CMWG
was comprised of MDH staff and the following local public health lead program
representatives from throughout the state of Minnesota:
Joe Jurusik ........................Hennepin County Community Health Department
Dianne Kelly ......................Dakota County Public Health Department
Cheryl Lanigan ..................Minnesota Visiting Nurse Agency (MVNA)
Myna Peterson ..................Goodhue County Public Health Service
Mary Shea.........................Minnesota Visiting Nurse Agency (MVNA)
Mary Ellen Smith ...............St. Paul - Ramsey County Department of Public Health
Michelle Sonnabend..........Countryside Public Health Service**
Janice Springer .................Stearns County Human Services
Larry Sundberg .................St. Louis County Public Health
*
The first time a word appears in this document that is defined in the Commonly Used Terms list, it will be shown
in SMALL CAPITAL LETTERS.
**
Countryside Public Health Service serves the counties of Big Stone, Chippewa, Lac Qui Parle, Swift, and Yellow
Medicine.
1
Most members of the CMWG along with MDH staff became members of a number of
sub-committees. These sub-committees worked on specific areas of concern that the
CMWG felt should be covered in the final report. In order to save time, these smaller
sub-committees were convened to create drafts for the CMWG to critique. This
sometimes required the sub-committee to reconvene and work on problem areas that
the CMWG had found. They would then present a new draft to the CMWG for critique.
The entire process took approximately a year to complete, and required a great deal of
time and effort from the CMWG.
The case management guidelines outlined in this document are a result of these efforts,
and a response to the identified need for statewide guidelines in this area. The MDH
will continue to evaluate the guidelines. Changes will be made as needed, based on
evaluation results. The guidelines are intended to serve as minimum case management
guidelines for providing services to children with EBLLs. They were developed to
establish minimum levels of care and are not intended to limit the level of care provided.
Those counties that have greater resources available may wish to take a more rigorous
approach to case management. The MDH created a BLOOD LEAD SCREENING document
in March 2000 entitled, Childhood MDH Blood Lead Screening Guidelines for Minnesota
(Appendix A). A document created for use in a clinical setting by physicians and other
health care professionals was released in March 2001 entitled, Childhood Blood Lead
Clinical Treatment Guidelines (Appendix B). We encourage you to use all of these
documents together with the one-page Childhood Blood Lead Case Management
Guidelines (Appendix C) to provide comprehensive case management for children with
an EBLL.
Note:
Since this document was originally created, the MDH has released a guidelines
document for use with pregnant and breastfeeding women. The Blood Lead Screening
Guidelines for Pregnant Women in Minnesota (Appendix D) was released in 6/2004
and is to be used in concert with all of the MDH blood lead guidelines.
These guidelines are not statutory requirements. The objective is to ensure that a
qualified CASE MANAGER is available to oversee the treatment and recovery of each
child, and to ensure that steps are taken to prevent further exposure of the child to
potential sources of lead. Because this document is designed to serve the needs of
local health agencies in all parts of the state, the appendices may need to be
“customized” in order to reflect local resources and needs. Links to other resources can
be found on MDH’s Lead website: http://www.health.state.mn.us/divs/eh/lead/links.html
2
Overview of the Guidelines
The recommendations, which follow in this document, were developed to ensure that all
children in Minnesota with an elevated BLOOD LEAD LEVEL are receiving a
standardized, minimum amount of care. For some agencies, and case managers, these
recommendations may seem rudimentary. For others, the contents of this document
may be their introduction to both the topics of lead, and case management. The
recommendations are intended to help build the capacity for providing lead services in
each agency, which conducts home visits with families affected by lead. The wealth of
experiences, which each professional will bring to the case management position, will
only enhance the recommendations outlined below.
Section (1) begins at a basic level by suggesting minimum qualifications for
professionals who will become case managers. A recommended skill set, including
strong communicative and collaborative competencies, recommended areas of training
and knowledge, and suggested academic backgrounds, are provided.
In Section (2) an essential part of case management—the home visit—is reviewed.
This section describes why a home visit occurs. It also provides essential steps
necessary for completing an effective and thorough home visit.
Section (3) features a critical aspect of the case manager’s role—making REFERRALS.
This section describes the “team” —or set of cross-disciplinary professionals with whom
the case manager may likely collaborate to provide comprehensive services to children
affected by lead. This section also refers the reader to MDH’s Lead website:
http://www.health.state.mn.us/divs/eh/lead/links.html, which can be utilized by the case
manager.
Although Section (4) is found within the body of the document, it is meant to stand alone
as a hands-on tool for case managers. This “action plan” discusses the full spectrum of
elevated blood lead levels, and appropriate remedial and protective actions, which may
be taken at each level. To facilitate using this section as a convenient hands-on tool,
the recommendations have been formatted to fit in a single table (see Appendix C). It is
anticipated that this table may be posted in a visible location to aid case managers.
Perhaps the most challenging recommendations—from a case management
perspective—appear in Section (5). This section attempts to define when a child, who
has received case management services, no longer needs to be followed. The areas of
CASE CLOSURE, which are usually monitored by a case manager, are featured.
However, closure of an ENVIRONMENTAL CASE is also defined as a reminder of this
important aspect of FOLLOW-UP services for children and families affected by lead.
Commonly used terms have been included in Section (6) to provide support for some of
the case management, and lead-related terms, which are featured in this document.
The first time a word appears in this document that is defined in the Commonly Used
Terms list, it will be shown in SMALL CAPITAL LETTERS. Many of the definitions are a
product of consensus brainstorming by members of the CMWG, based on their
3
considerable experience in the field with children and families. When possible,
definitions were taken from Minnesota Statutes and Minnesota Rules to provide
established meaning for these terms.
In the Appendices, a variety of tools are featured for the case manager to be used in the
field when working with children and their families. We encourage you to make copies
as needed, or request additional copies from MDH.
4
Recommended Minimum Qualifications for the Case Manager
Role definition:
The role of the case manager is to collaborate with clients by assessing, facilitating,
planning, and serving as an advocate for their health needs on an individual basis.
Case management should be expected to achieve measurable results in terms of
decreasing exposure, decreasing blood lead levels, and improving the health of children
and their families, particularly young siblings. Programs that visit families multiple times
without reducing the child’s blood lead level are failing and need to reevaluate their
procedures. Case management programs should be expected to measure and report
relevant program outcomes. Program outcomes may include reduced blood lead levels
and reductions in environmental LEAD HAZARDS. Lead hazard reduction may involve
interventions ranging from cleaning and abatement, to emergency relocation.
Communication with the case management team is critical for effective case
management. Team players include, but are not limited to: the case manager, the
family, medical providers, WIC, the MDH, licensed LEAD RISK ASSESSORS,
paraprofessional home visitors, local funding sources, and other community sources.
The ability to work collaboratively with various outside groups and organizations to
reach common goals is also essential. Recommended skills include: positive
relationship building; ability to effect change, perform critical analysis, and efficiently
plan and organize; effective written and verbal communication; and effective promotion
of client/FAMILY autonomy. It is crucial that the case manager have knowledge of
funding resources, services, clinical standards, and outcomes for EBLL prevention and
treatment.
Recommended areas of knowledge and training:
1. case management,
2. nutrition and hygiene,
3. growth and development,
4. physiology and adverse effects of elevated blood lead levels,
5. environmental sources of lead, and LEAD HAZARD REDUCTION methods, and
6. referral services/resources in the community and state.
Recommendation:
The MDH recommends that the case manager be a professional with case
management and lead training or experience. Recommended qualifications for a case
manager are as follows:
•
•
•
If possible, the case manager should be a public health nurse (PHN) with a four year
nursing degree
If a PHN is not available, the case manager should be a health professional (e.g., a
health educator or a registered nurse (RN) without a bachelor’s degree).
If neither a PHN nor a health professional is available, the case manager can be any
professional with a health-related degree (e.g., a social worker or risk assessor).
Contact the MDH for training information at 651/201-4610 or www.health.state.mn.us
5
Home Visit Protocol
(Refer to Appendix C for recommendations on when to initiate a home visit.)
Purpose:
1. To stop further lead exposure to children with EBLLs and others in the home
environment.
2. To increase the knowledge of those in the home about the nature of an EBLL and
how to resolve it.
Steps:
1. Conduct an educational encounter using appropriate educational materials. The
following list of materials is suggested and can be ordered from MDH. The first four
are available in several languages (see Appendix E):
•
Cleaning Up Sources of Lead in the Home
•
Common Sources of Lead
•
Steps to Help Lower Your Child’s Blood Lead Level
•
What is Lead?
•
Food Pyramid
This is best done in the home of the child with an EBLL; however, according to
methods described in this document and Minnesota State Statutes, it may be
completed through a telephone call.
2.
Opening statements should explain case management, the role of the case
manager, the Tennessen statement utilized by your county, as well as obtaining a
verbal or signed release of information statement. The release of information is
highly valuable, as the case manager is the care coordinator for the child and must
have access to talk with all involved when resolving the lead case.
Sample role explanation:
“Due to your child’s elevated blood lead level, I have been assigned to help you
manage his/her lead level and the circumstances which have possibly contributed
to the lead level. We will work together to ensure your child’s blood lead level and
exposure to lead are reduced.”
3.
The case manager may utilize an Educational Encounter & Assessment Form.
Two examples are found in Appendix F. S/he will assess the family’s educational
needs and deliver appropriate informational brochures as well as hands-on teaching
as needed. It is recommended that the case manager utilize the MDH lead
educational flip chart, Healthy Homes, Healthy Kids, if available. MDH no longer
maintains a supply of this document.
4.
Conduct a cursory evaluation of the home including the age of the home, both
interior and exterior (gardens, barns, fences, neighborhood) for environmental
exposure sources of lead.
5.
Share information with the environmental assessor and vice versa for purposes of
case management and case closure.
6
6.
Develop a care plan and assess the need for more visits after the initial
assessment. When possible, it is recommended to complete at least one follow-up
home visit. Consult and obtain M.D. orders as needed. This should be done in
accordance with your agency policy, the level of nursing intervention provided, and
the pay source utilized.
7.
Alert the family regarding the hazards of lead reduction work and provide them with
information on LEAD-SAFE work practices. Encourage the family to have the work
done by a lead professional, and require children and pregnant or nursing women to
vacate the premises during the work process.
8.
Identify the property owner and obtain contact information. This may be done by
the environmental risk assessor.
9.
Encourage blood lead testing of other children less than 72 months of age, and
pregnant women.
10. Refer the family to needed services. For example, assess the child’s eligibility for
the Supplemental Food Program for Women, Infants, and Children (WIC) to ensure
that the child’s nutritional needs are met. Refer to WIC’s website at:
http://www.health.state.mn.us/divs/fh/wic/
A home visit should be conducted in the primary language of the family whenever possible.
7
Referral Services: A Key Part of Case Management
An extremely important aspect of the case manager’s role is making referrals. The case
manager is responsible for placing the family of a child with an EBLL in contact with
services and resources that are available in the local community, or at the state or
national level. Families that are working to resolve a lead exposure problem may need
these resources.
The case manager has a unique opportunity to enter a home, complete an
ASSESSMENT, and provide assistance to the family. The case manager’s role is not
limited to assisting with lead exposure prevention. It may also include helping families
gain access to resources for addressing other issues. The case manager strives to
involve a multi-disciplinary team of professionals in responding to each case of EBLL,
coordinating their efforts and ensuring that they have enough information about each
child’s situation. Team players include, but are not limited to: the case manager, the
family, medical providers, WIC, the MDH, licensed LEAD RISK ASSESSORS,
paraprofessional home visitors, local funding sources, and other community sources.
This process helps facilitate a successful resolution of the issues surrounding each
case.
A DEVELOPMENTAL ASSESSMENT is a crucial part of the overall assessment for a
child with an EBLL. It is strongly recommended that the child receive a developmental
screening test. The child may need to be referred to a local community program that
administers developmental screening tests. For advice on specific developmental tests,
go to http://www.health.state.mn.us/divs/fh/mch/devscrn/instruments.html.
MDH’s Lead website at http://www.health.state.mn.us/divs/eh/lead/links.html can be
used as a general guide in determining what resources may be needed by families
dealing with lead issues. Because the needs of individual families can vary greatly, a
wide variety of possible resources have been included. The case manager should
become familiar with the resources available locally to address the various needs of the
family. It takes creativity to meet the specific needs of each individual family. In cases
where there is no local contact listed, the case manager should call the other agencies
or organizations on the list, for help in obtaining information or resources.
8
Childhood Blood Lead Case Management Guidelines for Minnesota
based on blood lead levels (see identical actions in table format - Appendix C)
Reminder:
Blood lead testing is mandated by the federal government for all children
receiving Medical Assistance (MA)/Medicaid. These tests should be
performed at 1 and 2 years of age (or up to six years of age if not
previously tested).
Action based on results of CAPILLARY tests (used for screening only):
< 10 µg/dL
Provide educational materials* to the family.
According to Minnesota State Statute, all childhood blood lead levels ≥ 10 μg/dL are considered elevated.
10 - 14.9 µg/dL
Within one month:
Provide educational materials* to the family.
Contact the family with the recommendation to have a follow-up venous test.
VENOUS RETEST WITHIN THREE MONTHS
15 – 44.9 µg/dL
Within one week:
Provide educational materials* to family.
Contact the family to have a follow-up venous test.
If feasible contact the medical care provider regarding a follow-up venous test.
Offer the medical care provider MDH’s screening, treatment, and pregnancy
guidelines.
VENOUS RETEST WITHIN ONE WEEK
45-59.9 µg/dL
Within two business days:
Provide educational materials* to family.
Contact the family to have a follow-up venous test.
Contact the medical care provider regarding a follow-up venous test.
Ensure that the medical care provider is aware of the screening, treatment, and
pregnancy guidelines available from the MDH.
VENOUS RETEST WITHIN TWO BUSINESS DAYS
≥ 60 µg/dL
Immediately:
Provide educational materials* to family.
Contact the family to have a follow-up venous test.
Contact the medical care provider regarding a follow-up venous test.
Ensure that the medical care provider is aware of the screening, treatment, and
pregnancy guidelines available from the MDH.
VENOUS RETEST IMMEDIATELY
9
Action based on results of VENOUS tests:
< 10µg/dL
Provide educational materials* to the family.
According to Minnesota State Statute, all childhood blood lead levels ≥ 10 μg/dL are considered elevated.
10 - 14.9 µg/dL
Within one month:
Provide educational materials* to the family.
Contact family with the recommendation to have a follow-up venous test within
three months from the last blood lead test.
15 - 44.9 µg/dL
Within one week: Arrange for initial home visit.**
(in primary language when possible).
Complete an in-depth assessment of: medical, environmental, nutritional, and
developmental needs.
Provide educational materials* to the family.
Make necessary referrals.
Communicate with the risk assessor assigned to the case.
Encourage the family to obtain a follow-up venous test within three months from the
last test. Higher levels require more frequent monitoring.
Contact the family and/or medical care provider regarding the need for follow-up
venous testing if venous follow-up not completed within three months from the last test.
44 - 59.9 µg/dL
Within two business days: Arrange for initial home visit.**
(in primary language when possible).
Complete an in-depth assessment of: medical, environmental, nutritional, and
developmental needs.
Provide educational materials* to the family.
Make necessary referrals.
Attempt to facilitate alternative, lead-safe housing.
Communicate with the risk assessor assigned to the case.
Contact the medical care provider to determine blood lead level, medical status,
treatment and follow-up plans.
At this level the medical care provider will most likely provide chelation therapy (see
MDH treatment guidelines) and the child will need more frequent monitoring of their
blood lead level.
≥ 60 µg/dL
Immediately: Arrange for initial home visit.**
(in primary language when possible).
Complete an in-depth assessment of: medical, environmental, nutritional, and
developmental needs.
Provide educational materials* to the family.
Make necessary referrals.
Attempt to facilitate alternative, lead-safe housing.
Communicate with the risk assessor assigned to the case.
Contact the medical care provider to determine blood lead level, medical status,
treatment and follow-up plans.
At this level the medical care provider will most likely provide chelation therapy (see
MDH treatment guidelines) and the child will need more frequent monitoring of their
blood lead level. The child may be hospitalized at this level.
*Use suggested educational materials in the appropriate language (see Childhood Blood Lead Case Management Guidelines for
Minnesota – Reference Manual). MDH lead educational materials are available by calling (651) 201-4610 or by completing and
sending in the order form at http://www.health.state.mn.us/divs/eh/lead/fs/index.html.
Order EPA lead documents via the Internet at http://www.epa.gov/lead/nlicdocs.htm.
** When possible, it is recommended to complete at least one follow-up home visit.
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Case Closure
The ultimate objective of the case management process is to assure that both the
medical treatment of the lead poisoned child is accomplished and the environmental
exposure routes are addressed. Attainment of case closure status reflects the
successful completion of a particular aspect of the case management process. The
case manager is responsible for two different aspects of an EBLL case, and therefore
two potentially different forms of case closure:
•
Medical closure: is based on the blood lead level of the child and addresses the
medical aspects of the EBLL case. This aspect of the case is addressed by both the
child’s primary care provider and the case manager. Medical closure is defined as
one venous blood lead level less than 10 µg/dL.
•
Administrative closure: indicates that the child can no longer be followed, for a
variety of circumstances that are described below. The case manager must
determine if an administrative closure is appropriate.
Administrative closure generally represents the end of the process for the case
manager, with respect to lead, for that individual child. Circumstances that may
necessitate issuing an administrative closure include:
The blood lead level has been decreasing appropriately. The child is not
currently in a lead-safe environment, however, steps are being taken to address
lead exposure routes.
The child is greater than 72 months of age, the blood lead levels are still elevated
but show evidence of dropping, and the environmental LEAD ORDERS are
complete.
Factors unrelated to the medical or environmental circumstances, such as:
the child is lost to follow-up after three varied attempts to locate (*see below)
the child has missed three consecutive clinic appointments
the child has moved out of the health district jurisdiction
the parent has refused services and has been given information about EBLLs
and lead hazard control, or
repeat visits are too dangerous due to weapons, drug dealing, etc.
(Appropriate referrals should be made.)
*Three varied attempts to locate the child should include a variety of the following:
• send a letter
• inquire with the
• inquire with the U.S.
• send a certified letter
Welfare contact
Post Office for a
• make a home visit
• inquire with the Child
forwarding address
Protection contact
• inquire with the
• inquire with the contact
• inquire with the
Women Infants and
person given during
physician
Children (WIC) contact
admission
11
There are two key players in establishing closure on an EBLL case when an
environmental case is open at the child’s PRIMARY RESIDENCE. The Case Manager
has the responsibility for determining when to close the case of the child
(medical/administrative closure) while the licensed lead risk assessor is responsible for
determining when to close the case of the property (environmental closure). Maintain a
steady line of communication between the licensed lead risk assessor and the case
manager. In some counties, these may be the same person. Although the case
manager does not have any direct responsibility for the environmental case, it is very
important for the well being of the child to keep this communication open. The case
manager will want to ensure the child has a lead-safe environment in which to live.
Note:
It is the responsibility of a licensed lead risk assessor to open an environmental case
on a property when an EBLL is found that is greater than or equal to 15 µg/dL. An
environmental closure occurs when all lead hazard reduction orders are completed
and a CLEARANCE INSPECTION demonstrates no deteriorated lead paint, bare soil,
or lead dust levels that exceed the state standards (Minnesota Statutes 144.9504).
The case manager should be aware of this process as an indication of the mitigation of
lead exposure routes for the child.
In order to attain a complete closure, both the medical (the child) and environmental
(the property) closures must be complete. It may not always be possible to meet both
sets of goals, however. It may sometimes be acceptable, and necessary, to achieve
closure for one aspect of the case, but not the other. It could also be possible to close
different aspects of the case at different times. For example, the lead hazard reduction
orders may be complete (e.g. environmental closure is complete), yet the child’s blood
lead level remains elevated above 10 µg/dL (e.g. medical closure is not complete).
Whenever there are separate environmental and medical closures in the same case, it
is essential to maintain good communication between the licensed lead risk assessor,
the case manager, the parent, and the child’s primary care provider.
There may be unique circumstances associated with an individual lead case that would
necessitate additional attention beyond lead closure. However, this should be
determined on a case-by-case basis at the professional discretion of the case manager.
Additional referrals to social service agencies or complimentary programs may also be
considered, and is strongly recommended, depending on the specific circumstances of
the case.
12
Commonly Used Terms
Whenever possible the definitions in this section were taken from the Lead Poisoning
Prevention Act, Minnesota Statutes Sections 144.9501-144.9509 and the Lead
Poisoning Prevention Rules, Parts 4761.1000 to 4761-1220. In the absence of a
specific statute citation, these definitions are a consensus of the Blood Lead Case
Management Work Group. Any words that appear in SMALL CAPS have not been
used in the text of the document, but are commonly used terminology in the lead field.
Assessment: The process of identifying the health status and service needs of the
child and family. Relevant information such as environmental lead hazards, child’s
developmental status, needs of both the child and the family, etc. are gathered through
interviewing the client/family in conjunction with careful evaluation of the entire situation.
In the Case Management Society of America’s, “CMSA’s Standards of Practice,” there
are four categories of official assessments referred to: developmental, environmental,
medical, and nutritional.
DEVELOPMENTAL ASSESSMENT: In Minnesota, the primary recommendation
is to refer the child to a local community program that administers developmental
screening tests. There are several acceptable developmental assessment tests,
which can be administered to a child, but some require specific certification. For
advice on specific developmental tests go to:
http://www.health.state.mn.us/divs/fh/mch/devscrn/instruments.html
ENVIRONMENTAL ASSESSMENT: Includes a LEAD RISK ASSESSMENT,
which necessitates determining a quantitative measurement of the lead content
of paint, interior dust, and bare soil of residences where the child spends the
majority of his/her time.
MEDICAL ASSESSMENT: Blood lead level is the primary assessment data.
Signs and symptoms should be assessed to determine whether chelation is
indicated. (Physician ultimately determines this.)
NUTRITIONAL ASSESSMENT: The nutritional status of the child should be
evaluated for overall healthy eating with an emphasis on adequate intake of
calcium, protein, vitamin C, and iron, and avoiding excess fats. A few
assessment tools are available such as food intake recalls, or food diaries.
Assessing Agency: Assessing agencies are public health agencies with authority and
responsibility to conduct lead risk assessments in response to children or pregnant
women with EBLLs. Local assessing agencies are responsible within their respective
jurisdiction. In locations where there is no assessing agency, the MDH is responsible to
conduct lead risk assessments.
ASSURANCE: Delivery and coordination of services to ensure that the agreed upon
goals and needs of the client are met.
13
BLOOD LEAD FOLLOW-UP: Venous or capillary blood lead test performed to monitor
the child with an elevated blood lead level. (See Appendix C for details.)
Blood Lead Level: The concentration of lead in a sample of blood. Usually expressed
in micrograms of lead per deciliter (µg/dL) of whole blood.
Blood Lead Screening: A venous or capillary blood lead test performed on an
asymptomatic child. (See Appendix A for specific recommendations.)
Capillary: A “capillary blood sample” means a quantity of blood drawn from a capillary.
It generally is collected by fingerstick and should be confirmed using a venous sample
when evaluating potentially elevated blood lead. (See Venous)
Case Closure: When a child, who has received case management services, no longer
needs to be followed. Medical closure and administrative closure are described on
page 12 of this document.
Case Management: The integration and coordination of multiple entities to assure that
the medical treatment and environmental resolution for the child with an EBLL are
accomplished. Case management involves assessment, problem identification,
planning, monitoring, evaluation, referral, and advocacy. Case management is family
focused.
Case Manager: Professional with training and ability in EBLL prevention and
treatment, physiology, adverse effects of EBLL, growth and development, nutrition and
hygiene. See the “Recommended Minimum Qualifications for the Case Manager”
section in this document. In the role of Case Manager, one serves as an assessor,
planner, facilitator, and an advocate for the child and family.
CERTIFIED FIRM: All privately licensed lead personnel (inspector, risk assessor, LEAD
WORKER, LEAD SUPERVISOR) must be employed by a firm certified by the MDH,
unless the licensed person is a sole proprietor with no employees.
Child(ren): An individual up to 72 months of age.
Clearance Inspection: A visual identification of deteriorated paint and bare soil and a
resampling and analysis of interior dust lead concentrations in a residence to ensure
that lead standards are not exceeded.
CONFIRMATORY: The first venous blood lead test following a screening test is
considered a confirmatory blood lead test. (See Appendix C for time requirements.)
Elevated Blood Lead Level(s) (EBLL): A venous or capillary blood lead level of
10 µg/dL or higher is considered elevated. A confirmatory test must be venous.
Environmental Case: When a venous EBLL is found that is greater than or equal to 15
µg/dL, an environmental case is opened. This is required by Minnesota Statutes.
14
Family: Individuals consistently serving in the care-giving role for a child. A parent,
foster parent, guardian, brother or sister may fill this role. In some cases, other
members of the extended family such as an aunt, grandparent, or close friend may
represent or substitute for the family.
Follow-up: See Blood Lead Follow-Up.
Lead Hazard: A condition that causes exposure to lead from dust, bare soil, drinking
water, or deteriorated paint that exceeds the state standards.
Lead Hazard Reduction: Actions undertaken to make a residence, child care facility,
school, or playground lead-safe by complying with the State lead standards and
methods.
LEAD INSPECTION: An investigation to determine the presence of lead in dust, paint,
soil, or water.
LEAD INSPECTOR: A person who is licensed by the MDH Commissioner to perform a
lead inspection.
Lead Orders: A legal instrument to compel a property owner to engage in lead hazard
reduction according to the specifications given by the assessing agency.
Lead Risk Assessment: An investigation to determine the existence, nature, severity,
and location of lead hazards from dust, paint, soil, and water. A lead risk assessment
may not include the use of sodium rhodizonate.
Lead Risk Assessor: An individual who performs lead risk assessments or lead
inspections and whom the MDH Commissioner has licensed.
Lead-Safe: A condition in which lead may be present at the residence, child care
facility, school, or playground, if the lead concentration in the dust, paint, soil, and water
of a residence does not exceed state standards, or, if the lead concentrations in the
paint or soil do exceed the standards, the paint is intact and the soil is not bare.
Lead Supervisor: An individual who is responsible for the on-site performance of
REGULATED LEAD WORK, and who has been licensed by the MDH Commissioner.
Lead Worker: An individual who performs regulated lead work, and who has been
licensed by the MDH Commissioner.
MEDICAL CASE: A blood lead level equal to or greater than 10 µg/dL in a child from
birth to 72 months of age.
Primary Residence: The home of the parent or guardian in which the child spends the
majority of their time.
15
Referral(s): The process of directing clients to available services by providing them
with information about a specific program.
Regulated Lead Work: A lead hazard screen, a lead inspection, a lead risk
assessment, lead hazard reduction including abatement, or a lead project design
performed on or for affected property, whether required by law or undertaken
voluntarily.
SECONDARY RESIDENCE: A home where the child spends more than a few hours a
week. Examples include a second home, the home of a relative or daycare provider,
etc.
STATE CASE MONITOR: The state case monitor will track the MDH blood lead
surveillance database to ensure that: 1) reported cases of elevated blood lead are
disseminated to the appropriate assessing agency; and 2) appropriate follow up
activities are being coordinated by the assessing agency case manager. The state
case monitor will act as an advisor for case managers at local public health and other
agencies to increase their capacity to perform lead case management.
Venous: A “venous blood sample” means a quantity of blood drawn from a vein” —this
is considered a confirmatory blood lead test. (See Appendix C)
16
References
Alliance to End Childhood Lead Poisoning, and The National Center for Lead-Safe
Housing. Another Link in the Chain. June 1999
Case Management Society of America. Standards of Practice for Case management.
Little Rock, AR: 1995
Centers for Disease Control and Prevention. Screening Young Children for Lead
Poisoning: Guidance for State and Local Public Health Officials. Atlanta: CDC, 1997.
U.S. Department of Agriculture. My Pyramid. Food and Nutrition Service: September
2005
State of Minnesota. Lead Poisoning Prevention Act, Minnesota Statutes Sections
144.9501-144.9509. As amended through 1999.
State of Minnesota. Lead Poisoning Prevention Rules, Minnesota Rules, Parts 47611000 to 4761-1220. Effective February 1, 1999.
17
Intentionally Left Blank
18
Appendices
Appendix A - Childhood Blood Lead Screening Guidelines for Minnesota
Appendix B - Childhood Blood Lead Clinical Treatment Guidelines for Minnesota
Appendix C - Childhood Blood Lead Case Management Guidelines for Minnesota
Appendix D - Blood Lead Screening Guidelines for Pregnant Women in Minnesota
Appendix E - Recommended Educational Materials
Appendix F - Educational Encounter & Assessment Form
Appendix G - Sample Notification Letters
19
Intentionally Left Blank
Appendix A
Childhood Blood Lead Screening
Guidelines for Minnesota
Intentionally Left Blank
Childhood Blood Lead Screening Guidelines for Minnesota
A Physician Should Test a Child at Any Age:
• If the parent expresses a concern about, or asks for their child to be tested for, blood lead poisoning
• If the child moved from a major metropolitan area or another country within the last 12 months
Routine Screen:
Child health-care providers should use a blood lead test* to screen children at one and two years of
age, and children up to six years of age who have not previously been screened if:
The child lives within the city limits of Minneapolis or St. Paul;
or
The child receives services from Minnesota Care (MnCare), the Supplemental Food
Program for Women, Infants, and Children (WIC), or Medical Assistance (MA) - which
includes the Prepaid Medical Assistance Program (PMAP);
or
The child does not fit the criteria above, and the answer to any of the following
questions is “Yes” or “Don’t Know:”
•
•
•
During the past six months has the child lived in or regularly visited a home, childcare, or
other building built before 1950?
During the past six months has the child lived in or regularly visited a home, childcare, or
other building built before 1978 with recent or ongoing repair, remodeling or damage
(such as water damage or chipped paint)?
Has the child or his/her sibling, playmate, or housemate had an elevated blood lead level?
Periodic Evaluation:
In order to monitor a change in the child’s status, administer the following questions annually to all
children three to six years of age whose previous test results were less than 10 µg/dL. Screen the
child with a blood lead test* if the answer to any of the following questions is “Yes” or “Don’t Know.”
Since the child’s last blood lead test:
• Does the child have a playmate, housemate, or sibling who has recently been diagnosed
with an elevated blood lead?
• Has the child moved to or started regularly visiting a home, childcare, or other building built
before 1950?
• Has there been any repair, remodeling, or damage (such as water damage or chipped paint)
to a home childcare, or other building built before 1978 that the child lives in or regularly visits?
* A blood lead test for lead poisoning is a laboratory analysis for lead in the blood of a child or adult. An elevated blood lead test is a
result greater than or equal to 10 micrograms lead per deciliter (µg/dL) of blood. Laboratories performing blood lead analysis are
required to report all results to the Minnesota Department of Health.
Division of Environmental Health
Environmental Surveillance and Assessment Section
Environmental Impacts Analysis Unit
P.O. Box 64975
St. Paul, Minnesota 55164-0975
The following are general guidelines. For Childhood Blood Lead Clinical Treatment Guidelines for Minnesota,
please call the MDH at (651) 201-4610, or visit our website at: www.health.state.mn.us/divs/eh/lead/reports.
Follow-up Care
If result of capillary
screening test (µg/dL) is:
10-14.9
15-44.9
45-59.9
≥ 60
Perform diagnostic test
on venous blood within:
3 months
1 week
48 hours
Immediately
(as an emergency lab test)
Follow-up testing for children with elevated diagnostic BLLs
• Children with diagnostic BLLs of 10-14.9 µg/dL should have at least one follow-up test within 3 months.
• If the result of the follow-up testing is ≥ 15 µg/dL, the child should receive clinical management,
which includes follow-up testing.
Clinical management includes
•
•
•
•
Clinical evaluation for complications of lead poisoning.
Family lead education and referrals.
Chelation therapy, if appropriate.
Follow-up testing at appropriate intervals.
Provide appropriate chelation therapy
• A child with a BLL ≥ 45 µg/dL should be treated promptly with appropriate chelating agents and be removed
from sources of lead exposure.
Environmental Management
• Contact the Minnesota Department of Health/Local Public Health Agency.
Sources of Lead
THE MOST COMMON SOURCES OF LEAD ARE PAINT, DUST, SOIL, AND WATER. OTHER SOURCES INCLUDE:
Traditional Remedies/Cosmetics
IN ASIAN, AFRICAN, & MIDDLE
EASTERN COMMUNITIES:
As a cosmetic, or a treatment for skin
infections or umbilical stump.
alkohl, kajal, kohl, or surma (black
powder)
IN ASIAN COMMUNITIES:
For intestinal disorders.
bali goli (round flat black bean)
ghasard/ghazard (brown powder)
kandu (red powder)
IN HMONG COMMUNITIES:
For fever or rash.
pay-loo-ah (orange/red powder)
IN LATINO COMMUNITIES:
some salt-based candies made in Mexico
For abdominal pain/empacho.
azarcon (yellow/orange powder), also
known as: alarcon, cora, coral, liga,
maria luisa, and rueda
greta (yellow/orange powder)
Funded by CDC Grants:
H64/CCH512780-03 and
H64/CCH512780-04
IN SOUTH ASIAN (EAST INDIAN)
COMMUNITIES:
For bindi dots.
sindoor (red powder)
As a dietary supplement.
Ayurvedic herbal medicine products
Occupations/Industries
Ammunition/explosives maker
Auto repair/auto body work
Battery maker
Building or repairing ships
Cable/wire stripping, splicing or
production
Construction
Ceramics worker (pottery, tiles)
Firing range worker
Leaded glass factory worker
Industrial machinery/equipment
Jewelry maker or repair
Junkyard employee
Lead miner
Melting metal (smelting)
Painter
Paint/pigment manufacturing
Plumbing
Pouring molten metal (foundry work)
Radiator repair
Remodeling/repainting/renovating houses
or buildings
Removing paint (sandblasting, scraping,
sanding, heat gun or torch)
Salvaging metal or batteries
Welding, burning, cutting or torching
Steel metalwork
Tearing down buildings/metal structures
Hobbies/Miscellaneous
May include above occupations.
Some children’s jewelry
Antique/imported toys
Chalk (particularly for snooker/billiards)
Remodeling, repairing, renovating home
Painting/stripping cars, boats, bicycles
Soldering
Melting lead for fishing sinkers or bullets
Making stained glass
Firing guns at a shooting range
www.health.state.mn.us/divs/eh/lead
For more information about lead, contact the Lead Program at (651) 201-4610
If you require this document in another format, call:
(651) 201-5000 ˜ 1 (800) 657-3908 ˜ MDH TTY (651) 201-5797
or the Minnesota Relay Service TTY 1-800-627-3529
3/2000 (Last Updated 2/2006)
IC #141-0250
Printed on Recycled Paper
Appendix B
Childhood Blood Lead Clinical Treatment
Guidelines for Minnesota
Intentionally Left Blank
Childhood Blood Lead Clinical Treatment Guidelines for Minnesota1
These guidelines were created for children from 6 to 72 months of age.
Blood Lead Levels in Micrograms Per Deciliter (µg/dL)
10-14.9
15-44.9
45-59.9
≥ 60
3 Months
1 Week
48 Hours
IMMEDIATELY
X
X
X
X
Rule out iron deficiency and treat if present
X
X
X
X
Complete diagnostic evaluation (history, labs, iron studies, physical exam)
X
X
X
X
X
X
X
X
X
<10
Medical Evaluation
If capillary result, confirm with venous draw within:
Ask questions to identify sources of lead in the child’s environment
(age of home, condition of painted surfaces, pica, remodeling,
occupations/hobbies, folk remedies, etc.)
Contact the MDH for a list of additional lead sources.
X
If exhibiting clinical symptoms check:
• Nutritional status (especially iron and calcium)
• Neurological and developmental status (especially language skills
and concentration ability)
At this level check:
• Abdominal x-ray
Other diagnostic tests:
• BUN, CBC, Creatinine, UA and liver enzymes
TREAT AS AN EMERGENCY - potential encephalopathy
X
Medical Management
Anticipatory Guidance—discuss primary sources of lead poisoning and
measures to keep children safe from lead; provide lead poisoning
prevention literature
X
Assess for lead poisoning risk at every well-child visit
X
Educate family—discuss:
• Potential sources of lead and ways to reduce exposure; review and
provide literature
• Dangers of improper lead abatement and/or remodeling
• Nutrition—encourage high iron/high calcium diet
• Chronic nature of problem (need to monitor frequently)
Iron supplement if deficient
X
IDENTIFY AND REMOVE LEAD SOURCE
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
IMMEDIATELY
IMMEDIATELY
X
X
X
X
Persistently high levels in this range may require more aggressive
treatment (consult MDH for information regarding chelation treatment)
X
Be sure to stop iron therapy prior to chelation
X
This level requires chelation—recommend the use of succimer per
routine dosage (consult the MDH for further information if needed).
In-home treatment indicated only in situations of:
• Lead-safe environment
• Highly compliant family
• Home health care monitoring
Discharge inpatient cases ONLY to LEAD-SAFE ENVIRONMENT
Follow-up/Comment2
Review risk factors in 1 year
X
Screen other children in the home
X
Repeat venous test in 3 months
X
Repeat venous test in 1 to 3 months
(higher levels require more frequent monitoring)
X
X
Repeat venous and diagnostic tests 14 days after chelation therapy is
complete.
MDH or the local public health department will conduct an
environmental inspection and public health nursing home visit for
children up to 72 months of age.
X
1
Guidelines for clinical treatment of adults with elevated blood lead levels are available through the Minnesota Department of Health (MDH).
Additional guidelines for public health case management of children are also available through the MDH.
2
Division of Environmental Health
Environmental Surveillance and Assessment Section
Environmental Impacts Analysis Unit
P.O. Box 64975
St. Paul, Minnesota 55164-0975
Childhood Blood Lead Clinical Treatment Guidelines for Minnesota1
< 10 μg/dL
Medical Evaluation
• Ask questions to identify sources of lead in
2
the child’s environment
Medical Management
• Anticipatory Guidance—discuss primary
sources of lead poisoning and measures to
keep children safe from lead; provide lead
poisoning prevention literature
• Assess for lead poisoning risk at every
well-child visit
Follow-up/Comment3
• Review risk factors in 1 year
10-14.9 μg/dL
Medical Evaluation
• If capillary result, confirm with venous draw
within 3 months
• Ask questions to identify sources of lead in
2
the child’s environment
• Rule out iron deficiency and treat if present
• Complete diagnostic evaluation (history, labs,
iron studies, physical exam)
Medical Management
• Identify and remove lead source
• Educate family—discuss:
♦ Potential sources of lead and ways to
reduce exposure; review and provide
literature
♦ Dangers of improper
abatement/remodeling
♦ Nutrition—encourage high iron/high
calcium diet
♦ Chronic nature of problem (need to
monitor frequently)
• Iron supplement if deficient
Follow-up/Comment3
• Screen other children in the home
• Repeat venous test in 3 months
1
Guidelines for clinical treatment of adults with
elevated blood lead levels are available through the
Minnesota Department of Health (MDH). These
guidelines were created for children from 6 to 72
months of age.
15-44.9 μg/dL
Medical Evaluation
• If capillary result, confirm with a venous
draw within 1 week
• Ask questions to identify sources of lead in
the child’s environment (age of home,
condition of painted surfaces, pica,
remodeling, occupations/hobbies, folk
2
remedies, etc.)
• Rule out iron deficiency and treat if present
• Complete diagnostic evaluation (history, labs,
iron studies, physical exam)
• If exhibiting clinical symptoms check:
♦ Nutritional status (especially iron and
calcium)
♦ Neurological and developmental status
(especially language skills and
concentration ability)
Medical Management
• Identify and remove lead source
• Educate family—discuss:
♦ Potential sources of lead and ways to
reduce exposure; review and provide
literature
♦ Dangers of improper abatement and/or
remodeling
♦ Nutrition—encourage high iron/high
calcium diet
♦ Chronic nature of problem (need to
monitor frequently)
• Iron supplement if deficient
• Persistently high levels in this range may
require more aggressive treatment (consult
MDH for information regarding chelation
treatment).
• Be sure to stop iron therapy prior to chelation
Follow-up/Comment3
• Screen other children in the home
• Repeat venous lead in 1 to 3 months (higher
levels require more frequent monitoring)
• MDH or the local public health department
will conduct an environmental inspection and
public health nursing home visit for children
up to 72 months of age.
2
3
Contact the MDH for a list of lead sources.
Additional guidelines for public health case
management of children are also available
through the MDH.
≥ 60 μg/dL
45-59.9 μg/dL
Medical Evaluation
• If capillary result, confirm with a venous
draw within 48 hours
• Ask questions to identify sources of lead in
the child’s environment (age of home,
condition of painted surfaces, pica,
remodeling, occupations/hobbies, folk
2
remedies, etc.)
• Rule out iron deficiency and treat if present
• Complete diagnostic evaluation (history, labs,
iron studies, physical exam)
• If exhibiting clinical symptoms check:
♦ Nutritional status (especially iron and
calcium)
♦ Neurological and developmental status
(especially language skills and
concentration ability)
• At this level check:
♦ Abdominal x-ray
• Other diagnostic tests:
♦ BUN, CBC, Creatinine, UA and liver
enzymes
Medical Management
•
•
•
•
Identify and remove lead source
Educate family (as in 15-44.9 µg/dL)
Iron supplement if deficient
This level requires chelation—recommend
the use of succimer per routine dosage
(consult the MDH for further information if
needed).
• Be sure to stop iron therapy prior to chelation
• In-home treatment indicated only in situations
of:
♦ Lead-safe environment
♦ Highly compliant family
♦ Home health care monitoring
• Discharge inpatient cases ONLY to
LEAD-SAFE ENVIRONMENT
Follow-up/Comment3
• Screen other children in the home
immediately
• Repeat venous and diagnostic tests 14 days
after chelation therapy is complete.
• MDH or the local public health department
will conduct an environmental inspection and
public health nursing home visit for children
up to 72 months of age.
For more information about lead, contact the Minnesota Department of Health at (651) 201-4610
If you require this document in another format, such as large print, Braille or cassette tape, call:
(651) 201-5000 ˜ 1 (800) 657-3908 ˜ MDH TTY (651) 201-5797
or the Minnesota Relay Service TTY 1-800-627-3529
Medical Evaluation
• TREAT AS AN EMERGENCY - potential
encephalopathy
• If capillary result, confirm with a venous
draw IMMEDIATELY
• Ask questions to identify sources of lead in
the child’s environment (age of home,
condition of painted surfaces, pica,
remodeling, occupations/hobbies, folk
2
remedies, etc.)
• Rule out iron deficiency and treat if present
• Complete diagnostic evaluation (history, labs,
iron studies, physical exam)
• If exhibiting clinical symptoms check:
♦ Nutritional status (especially iron and
calcium)
♦ Neurological and developmental status
(especially language skills and
concentration ability)
• At this level check:
♦ Abdominal x-ray
• Other diagnostic tests:
♦ BUN, CBC, Creatinine, UA and liver
enzymes
Medical Management
•
•
•
•
Identify and remove lead source
Educate family (as in 15-44.9 µg/dL)
Iron supplement if deficient
This level requires chelation—recommend
the use of succimer per routine dosage
(consult the MDH for further information if
needed).
• Be sure to stop iron therapy prior to chelation
• In-home treatment indicated only in situations
of:
♦ Lead-safe environment
♦ Highly compliant family
♦ Home health care monitoring
• Discharge inpatient cases ONLY to
LEAD-SAFE ENVIRONMENT
Follow-up/Comment3
• Screen other children in the home
immediately
• Repeat venous and diagnostic tests 14 days
after chelation therapy is complete.
• MDH or the local public health department
will conduct an environmental inspection and
public health nursing home visit for children
up to 72 months of age.
Printed on Recycled Paper
Funded by CDC grant #US7/CCU518477-01
3/2001 (Last Updated 2/2006)
IC #141-0074
Appendix C
Childhood Blood Lead Case Management
Guidelines for Minnesota
Intentionally Left Blank
Childhood Blood Lead Case Management Guidelines for Minnesota
(This document is intended for use by local public health agencies and their partners. It should be used in
conjunction with the Childhood Blood Lead Case Management Guidelines for Minnesota – Reference Manual)
REMINDER: BLOOD LEAD SCREENING IS REQUIRED AT 12 AND 24 MONTHS FOR ALL CHILDREN RECEIVING MEDICAL ASSISTANCE (MA)
(OR UP TO SIX YEARS OF AGE IF NOT PREVIOUSLY TESTED)
Capillary
CAPILLARY TESTS ARE CONSIDERED A SCREENING TEST
ONLY, VENOUS TESTS ARE CONFIRMATORY
< 10
μg/dL
Provide educational materials* to the family.
Venous
Provide educational materials* to the family.
According to Minnesota State Statute, all childhood blood lead levels ≥ 10 μg/dL are considered elevated.
10 - 14.9
μg/dL
Within one month:
Provide educational materials* to the family.
Contact the family with the recommendation to have a
follow-up venous test.
Within one month:
Provide educational materials* to the family.
Contact family with the recommendation to have a follow-up
venous test within three months from the last blood lead test.
VENOUS RETEST WITHIN THREE MONTHS
15 – 44.9
μg/dL
Within one week:
Provide educational materials* to family.
Contact the family to have a follow-up venous test.
If feasible, contact the medical care provider regarding
a follow-up venous test.
Offer the medical care provider MDH’s screening,
treatment, and pregnancy guidelines.
VENOUS RETEST WITHIN ONE WEEK
Within one week: Arrange for initial home visit.**
(in primary language when possible).
Complete an in-depth assessment of: medical, environmental,
nutritional, and developmental needs.
Provide educational materials* to the family.
Make necessary referrals.
Communicate with the risk assessor assigned to the case.
Encourage the family to obtain a follow-up venous test within three
months from the last test. Higher levels require more frequent
monitoring.
Contact the family and/or medical care provider regarding the
need for follow-up venous testing if venous follow-up not completed
within three months from the last test.
45 – 59.9
μg/dL
Within two business days:
Provide educational materials* to family.
Contact the family to have a follow-up venous test.
Contact the medical care provider regarding a
follow-up venous test.
Ensure that the medical care provider is aware of the
screening, treatment, and pregnancy guidelines
available from the MDH.
VENOUS RETEST WITHIN TWO BUSINESS DAYS
Within two business days: Arrange for initial home visit.**
(in primary language when possible).
Complete an in-depth assessment of: medical, environmental,
nutritional, and developmental needs.
Provide educational materials* to the family.
Make necessary referrals.
Attempt to facilitate alternative, lead-safe housing.
Communicate with the risk assessor assigned to the case.
Contact the medical care provider to determine blood lead level,
medical status, treatment and follow-up plans.
At this level the medical care provider will most likely provide
chelation therapy (see MDH treatment guidelines) and the child
will need more frequent monitoring of their blood lead level.
≥ 60
μg/dL
Immediately:
Provide educational materials* to family.
Contact the family to have a follow-up venous test.
Contact the medical care provider regarding a
follow-up venous test.
Ensure that the medical care provider is aware of the
screening, treatment, and pregnancy guidelines
available from the MDH.
VENOUS RETEST IMMEDIATELY
Immediately: Arrange for initial home visit.**
(in primary language when possible).
Complete an in-depth assessment of: medical, environmental,
nutritional, and developmental needs.
Provide educational materials* to the family.
Make necessary referrals.
Attempt to facilitate alternative, lead-safe housing.
Communicate with the risk assessor assigned to the case.
Contact the medical care provider to determine blood lead level,
medical status, treatment and follow-up plans.
At this level the medical care provider will most likely provide
chelation therapy (see MDH treatment guidelines) and the child
will need more frequent monitoring of their blood lead level. The
child may be hospitalized at this level.
*Use suggested educational materials in the appropriate language (see Childhood Blood Lead Case Management Guidelines for Minnesota – Reference Manual).
MDH lead educational materials are available by completing and sending in the order form at http://www.health.state.mn.us/divs/eh/lead/fs/index.html or by calling
(651) 201-4610. Order EPA lead documents via the Internet at http://www.epa.gov/lead/nlicdocs.htm.
** When possible, it is recommended to complete at least one follow-up home visit.
Sources of Lead
The most common sources of lead are paint, dust, soil, and water.
Other sources include:
Products Used in Ethnic Communities
IN ASIAN, AFRICAN, & MIDDLE EASTERN COMMUNITIES:
As a cosmetic or a treatment for skin infections or umbilical stump.
alkohl, kajal, kohl, or surma (black powder)
IN ASIAN COMMUNITIES:
For intestinal disorders.
bali goli (round flat black bean)
ghasard/ghazard (brown powder)
kandu (red powder)
IN HMONG COMMUNITIES:
For fever or rash.
pay-loo-ah (orange/red powder)
IN LATINO COMMUNITIES:
Some salt-based candies made in Mexico
For abdominal pain/empacho.
azarcon (yellow/orange powder), also known as:
alarcon, cora, coral, liga, maria luisa, and rueda
greta (yellow/orange powder)
IN SOUTH ASIAN (EAST INDIAN) COMMUNITIES:
For bindi dots.
sindoor (red powder)
As a dietary supplement.
Ayurvedic herbal medicine products
Hobbies
Occupations/Industries
May also include some of the occupations listed.
Bronze Casting
Collecting, Painting or Playing Games with Lead
Figurines
Copper Enameling
Electronics with Lead Solder
Hunting and Target Shooting
Jewelry Making with Lead Solder
Liquor Distillation
Making Pottery and Ceramic Ware with Lead Glazes
and Paints
Making Stained Glass and Painting on Stained Glass
Melting Lead for Fishing Sinkers or Bullets or Lead
Figurines
Painting/Stripping Cars, Boats, and Bicycles
Print Making and Other Fine Arts (When Lead White,
Flake White and Chrome Yellow Pigments are Involved)
Remodeling, Repairing, and Renovating Homes
Miscellaneous
Antique/Imported Toys
Chalk (Particularly for Snooker/Billiards)
Imported Candy
Imported Pottery
Non-Commercially Prepared Pottery
Non-Commercially Prepared Leaded Crystal
Some Children’s Jewelry
For more information about lead,
contact the MDH Lead Program at (651) 201-4610
Ammunition/Explosives Maker
Auto Repair/Auto Body Work
Battery Manufacturing and Repair
Bridge, Tunnel and Elevated Highway Construction
Building or Repairing Ships
Cable/Wire Stripping, Splicing or Production
Ceramics Worker (Pottery, Tiles)
Construction
Firing Range Work
Glass Recycling, Stained Glass and Glass Work
Jewelry Maker or Repair
Lead Abatement
Lead Miner
Leaded Glass Factory Worker
Manufacturing and Installation of Plumbing Components
Manufacturing of Industrial Machinery and Equipment
Melting Metal (Smelting)
Metal Scrap Yards and Other Recycling Operations
Motor Vehicle Parts and Accessories
Occupations Using Firearms
Paint/Pigment Manufacturing
Pottery Making
Production and Use of Chemical Preparations
Radiator Repair
Remodeling/Repainting/Renovating Houses or Buildings
Removing Paint (Sandblasting, Scraping, Sanding, Heat
Gun or Torch)
Steel Metalwork
Tearing Down Buildings/Metal Structures
Welding, Burning, Cutting or Torching
Mailing Address:
Environmental Health
Lead Program
625 North Robert Street
P.O. Box 64975
St. Paul, MN 55164-0975
If you require this document in another format, call:
(651) 201-5000 ˜ 1 (800) 657-3908
MDH TTY (651) 201-5797
Minnesota Relay Service TTY 1-800-627-3529
Funded by CDC Grant #US7/CCU518477-01
Printed on Recycled Paper
5/2001 (Last Updated 6/2006) - IC #141-0278
Appendix D
Blood Lead Screening Guidelines for
Pregnant Women in Minnesota
Intentionally Left Blank
Blood Lead Screening Guidelines
for Pregnant Women in Minnesota
Prenatal lead exposure is of concern because it may have an effect on cognitive development and
may increase delinquent and antisocial behaviors when the child gets older. Prenatal lead
exposure may also reduce neonatal weight gain. In addition to fetal risk, lead may be a risk to the
mother by causing an increase in blood pressure.
Lead is transferred from the mother to the fetus because the placenta is a weak barrier to the
passage of lead. Therefore, it may be assumed that fetal blood contains the same concentration
of lead as maternal blood. The Centers for Disease Control and Prevention (CDC) and the
Minnesota Department of Health (MDH) consider 10 micrograms per deciliter (μg/dL) and above
to be an elevated blood lead level for children.
In many cases, high levels of lead in pregnant women arise from maternal occupational exposure.
However, other lead exposures may occur, such as: remodeling a home containing lead paint that
allows lead dust to become airborne and inhaled; a family member’s occupation or hobby resulting
in “take-home” lead; using non-commercial home remedies or cosmetics that contain lead; using
non-commercial glazed pottery for cooking; and pica behavior of the mother, such as eating soil or
pieces of clay pots. There may also be exposure of the fetus to lead coming out of the mother’s
bones. This may arise from long-term previous exposures of the mother even though lead
exposure is not happening during the pregnancy. Lead may come out of maternal bones faster
during pregnancy and lactation because of the mother’s and fetus’s need for calcium. A diet rich
in iron and calcium may help reduce absorption of lead during pregnancy.
Not every woman is at risk for lead exposure, so a risk screening questionnaire should be used to
decide when to test a pregnant, or potentially pregnant, woman for lead.
Blood Lead Screening Risk Questionnaire
for Pregnant Women in Minnesota
Health-care providers should use a blood lead test to screen pregnant women if they answer,
“yes” or “don’t know” to any of the following questions, or if they have moved to Minnesota from a
major metropolitan area or another country within the last twelve months:
1. Do you or others in your household have an occupation that involves lead exposure?
2. Sometimes pregnant women have the urge to eat things that are not food, such as clay,
soil, plaster, or paint chips. Do you ever eat any of these things—even accidentally?
3. Do you live in a house built before 1978 with ongoing renovations that generate a lot of
dust (for example, sanding and scraping)?
4. To your knowledge, has your home been tested for lead in the water, and if so, were you
told that the level was high?
5. Do you use any traditional folk remedies or cosmetics that are not sold in a regular drug
store or are homemade? (See list on back.)
6. Do you or others in your household have any hobbies or activities likely to cause lead
exposure? (See list on back.)
7. Do you use non-commercially prepared pottery or leaded crystal?
Environmental Health Division
Environmental Surveillance and Assessment Section
Environmental Impacts Analysis Unit – Lead Program
P.O. Box 64975
St. Paul, Minnesota 55164-0975
These guidelines have been reviewed and approved by the Minnesota Chapter
of the American College of Obstetricians and Gynocologists (ACOG)
The guidelines were based on the New York State Department of Health,
Lead Poisoning Prevention Guidelines for Prenatal Care Providers.
Sources of Lead
The most common sources of lead are paint, dust, soil, and water. Other sources include:
Traditional Remedies/Cosmetics
IN ASIAN, AFRICAN, & MIDDLE EASTERN
COMMUNITIES:
As a cosmetic or a treatment for skin infections or
umbilical stump.
alkohl, kajal, kohl, or surma (black powder)
IN ASIAN COMMUNITIES:
For intestinal disorders.
bali goli (round flat black bean)
ghasard/ghazard (brown powder)
kandu (red powder)
IN HMONG COMMUNITIES:
For fever or rash.
pay-loo-ah (orange/red powder)
IN LATINO COMMUNITIES:
Some salt-based candies made in Mexico
For abdominal pain/empacho.
azarcon (yellow/orange powder), also known as:
alarcon, cora, coral, liga, maria luisa, and rueda
greta (yellow/orange powder)
IN SOUTH ASIAN (EAST INDIAN) COMMUNITIES:
For bindi dots.
sindoor (red powder)
As a dietary supplement.
Ayurvedic herbal medicine products
Hobbies
May also include some of the occupations listed in the
right column.
Bronze Casting
Collecting, Painting or Playing Games with Lead
Figurines
Copper Enameling
Electronics with Lead Solder
Hunting and Target Shooting
Jewelry Making with Lead Solder
Liquor Distillation
Making Pottery and Ceramic Ware with Lead Glazes
and Paints
Making Stained Glass and Painting on Stained
Glass
Melting Lead for Fishing Sinkers or Bullets or Lead
Figurines
Painting/Stripping Cars, Boats, and Bicycles
Print Making and Other Fine Arts (When Lead
White, Flake White and Chrome Yellow Pigments
are Involved)
Remodeling, Repairing, and Renovating Homes
Occupations/Industries
Ammunition/Explosives Maker
Auto Repair/Auto Body Work
Battery Manufacturing and Repair
Bridge, Tunnel and Elevated Highway Construction
Building or Repairing Ships
Cable/Wire Stripping, Splicing or Production
Ceramics Worker (Pottery, Tiles)
Construction
Firing Range Work
Glass Recycling, Stained Glass and Glass Work
Jewelry Maker or Repair
Lead Abatement
Lead Miner
Leaded Glass Factory Worker
Manufacturing and Installation of Plumbing
Components
Manufacturing of Industrial Machinery and
Equipment
Melting Metal (Smelting)
Metal Scrap Yards and Other Recycling Operations
Motor Vehicle Parts and Accessories
Occupations Using Firearms
Paint/Pigment Manufacturing
Pottery Making
Production and Use of Chemical Preparations
Radiator Repair
Remodeling/Repainting/Renovating Houses or
Buildings
Removing Paint (Sandblasting, Scraping, Sanding,
Heat Gun or Torch)
Steel Metalwork
Tearing Down Buildings/Metal Structures
Welding, Burning, Cutting or Torching
Miscellaneous
Antique/Imported Toys
Chalk (Particularly for Snooker/Billiards)
Imported Candy
Imported Pottery
Non-Commercially Prepared Pottery
Non-Commercially Prepared Leaded Crystal
Some Children’s Jewelry
www.health.state.mn.us/divs/eh/lead
For more information about lead, contact the Lead Program at (651) 201-4610
If you require this document in another format,
such as large print, Braille, or cassette tape, call:
(651) 201-5000 ♦ 1-800-657-3908 ♦ MDH TTY (651) 201-5797
or the Minnesota Relay Service TTY 1-800-627-3529
Funded by CDC Grant:
#US7/CCU522841-01
Printed on Recycled Paper
6/2004 (Last Updated 2/2006)
IC #141-1508
Appendix E
Recommended Educational Materials
Intentionally Left Blank
Cleaning Up
Sources of Lead in the Home
2
STEP
STEP
1
Regular Washing
Cleaning With ASpecial Vacuum
Wash your child's hands and face often
with soap and water. Make sure your
child's hands and face are clean before
eating and going to bed.
You can use a special vacuum cleaner called a High Efficiency Particulate Air Filter
(HEPA) vacuum to clean up lead. The HEPA vacuum has a special filter that can
pick up and hold small pieces of lead. Call the Minnesota Department of Health at
(651) 215-0890 for a list of available HEPA vacuums.
Be sure to wash toys, bottles and pacifiers
often with soap, and water. Don't let your
child play with any toys that have fallen
on the ground until they have been
cleaned with soap and water.
Another option is to use a wet/dry vacuum in the wet setting to clean up
the wash or rinse water. When you use the wet/dry vacuum, be sure to keep
about two inches of water in the bottom of the canister. The water will help hold
the lead dust. Only use the wet/dry vacuum to vacuum up the wash
or rinse water, when you are cleaning up lead. Do not use the wet/dry vacuum to
pick up dry dust, or lead paint chips.
Don't let your child eat any food that has
fallen on the ground.
Never use your household vacuum cleaner to clean up paint dust or chips from
walls, floors or window sills and wells. Household vacuum cleaners are okay for
regular cleaning jobs, once lead has been cleaned up. But when it comes to
cleaning up lead, your household vacuum cleaner filter cannot pick up and hold
the small pieces of lead – it can blow lead dust into the air where people can
breathe it in.
Minnesota Department of Health Lead Program
STEP
3
Wet Washing
Wet washing is the best way to clean up lead dust. Wet wash window
sills, wells, walls, floors and door frames often to clean up lead dust.
Step One
Use two buckets – one for the cleaning solution, and one for the clean rinse
water. Clearly mark each bucket. Be sure to wear waterproof, chemical
resistant, rubber gloves while you are wet washing. Keep the children away
from this and all cleaners.
Step Two
Make a cleaning solution by adding one tablespoon of a phosphate cleaner,
such as trisodium phosphate (TSP), or automatic dishwashing detergent with
phosphate, with one gallon of water. If you can’t find a phosphate cleaner,
don't let that stop you from wet washing. Mix a cleaning solution made up
of household detergent and mix according to the directions on the container.
Step Three
Pick up any loose paint chips and other debris that can be found in the
window wells, sills, door frames, and floors. Put the paint chips and debris in a
double thick garbage bag. Seal the bag.
Step Four
Wash the window wells and sills, door frames, walls and floors thoroughly
with the cleaning solution. Use two separate sets of disposable rags or paper
towels – one set for the washing step and one set for the rinse step.
Step Five
Rinse the area that you washed with cleaning solution with clean water,
using a different disposable rag or paper towel. It is important to use a
different rag or paper towel for the cleaning and rinse steps.
Step Six
Put all the rags, paper towels and paint chips in a double thick garbage bag. Seal the bag. Keep the bag out of the reach of children and pets. Call your county offices to find out how you can dispose of the lead debris at a household hazardous waste collection site, or place it in the garbage for
pickup.
To request this material in another format contact:
Minnesota Department of Health Lead Program
P.O. Box 64975 • St. Paul, Minnesota 55164-0975
Phone: 651-215-0890 • TTY: 651-215-0707
Minnesota Relay Service TTY: 1-800-627-3529
Also visit our website at www.health.state.mn.us
Printed on recycled paper.
Questions?
Call the Minnesota
Department of Health
2/99 IC Number 141-0643
The children pictured in this fact sheet are not lead-poisoned. The products
and brands shown are examples only and do not constitute a stated
or implied endorsement from the Minnesota Department of Health.
at 651-215-0890
Finding Lead in the Home
Common Sources of Lead
Lead is part of our world today. It is found in the air, soil, dust and the paint of some homes or buildings
built before 1978. Being exposed to too much lead can cause serious health problems. Lead is never a
normal part of your body. The good news is that lead poisoning can be prevented. This fact sheet explains
common sources of lead in the home, and how to avoid them.
Lead Dust
Household dust is a common source of lead for young children. The dust can contain lead from
deteriorated, interior lead-based paint or tracked-in, contaminated soil. Lead dust can be created during
home remodeling or renovation projects, or when lead-based paint is not removed in a lead-safe way. Your
house can look clean and still have lead in it. A child can breathe in or eat this dust.
• Keep your home as dust-free as possible. Wet wash window wells, sills and floors with a cleaning
solution made up of household detergent. Mix the household detergent according to the directions on the
container. Be sure to use two separate buckets - one bucket for the cleaning solution, and one bucket for
the clean rinse water. Use separate sets of disposable rags or paper towels - one set for the wash step and
one for the rinse step.
• Wash your child's hands with soap and water before eating, naps and bedtime.
• Wash bottles, teething rings and toys with soap and water.
• Do not allow children to play or eat around window areas in older homes.
• Adults working in jobs where lead is used should shower, and change clothes and shoes before coming
home. This includes painters, remodelers, or workers in smelters, battery plants, radiator or auto body
shops.
• Clothes worn at work should not be washed with other clothes. Clean work clothes separately from other
clothing. Run the rinse cycle once before using the washer again.
• Keep windows closed on windy days so that lead-contaminated soil does not get into the house.
Lead-Based Paint
Eating cracking, chipping and peeling lead-based paint is also a lead source for young children. Lead paint
was used on the inside and outside of homes built before 1978.
• Be aware that lead-based paint may have been used on cribs, highchairs, windows, woodwork, walls,
doors, railings and ceilings.
• Don't let your child eat or chew on anything you think may contain lead-based paint. Look for teeth
marks on the woodwork in your home.
• Be sure to wet wash, as described above, the windows often. Loose paint and dust can build up inside
and under the window area.
• Do not use your household vacuum to clean up paint chips or leaded dust. The filter in your household
vacuum cleaner is not designed to pick up and hold small particles of lead. Using a regular vacuum
cleaner will spread lead dust into the air.
• Painting over chipping or peeling lead-based paint does not make it safe! You must first safely remove
chipping or peeling lead-based paint before repainting.
Minnesota Department of Health • Lead Program • P.O. Box 64975 • St. Paul, MN 55164-0975 • 651-201-4610
Soil
Soil can be contaminated with lead from deteriorated, exterior paint on homes, buildings, or fences. As the
result of past use of leaded gasoline, lead can also be found in the soil near major roadways or intersections
in urban areas. Neither of these places are safe play areas for a child.
• Don't let your child eat outside on bare soil areas, eat dirt, or play next to the house or the street where
bare soil is present.
• Cover bare soil (any soil you can see) with grass, mulch, shrubs, or another kind of durable ground cover.
• Keep washable rugs at all of the entrances to your home. Wash these rugs separately from other items.
Run the rinse cycle once before using the washer again.
• Take your shoes off at the door so soil and dust are not tracked into the house.
Food
Plants usually do not absorb lead unless there is a large amount of lead in the soil.
• Wash fruits and vegetables before eating to clean off any lead dust that may have settled on the food. Do
not store juices or food in open cans. Store food in glass, stainless steel or sturdy plastic.
• Remove the outer leaves of leafy green vegetables.
• Plant gardens away from the house, garage, fence or other structures covered with chipping paint.
Water
Lead levels in your water are likely to be highest if your home or water system has lead pipes or copper
pipes with lead solder.
• Plumbing put in before 1930 may contain lead pipes. Plumbing installed before 1985 may contain leadbased solder in the copper joints in the water supply system. Brass faucets and ball valves may contain
lead. Minnesota banned the use of lead-based solder in 1985.
• The only way to know if your water (or other lead source) has lead in it is to have it tested by a certified
lab. Call the Minnesota Department of Health for the name of an approved lab in your area.
If you think you may have lead in your water:
• Do not cook, drink or make baby formula with water from the hot water faucet. Hot water dissolves
more lead than cold water.
• Always use cold water for cooking or drinking. If the water has not been used for six or more hours, let
the cold water run for a couple of minutes, or until there is a temperature change.
• Stay away from the hot water tap for eating and drinking purposes. If you need hot water, heat cold
water from the tap or the refrigerator.
Folk Medicine
Many folk remedies contain lead and should not be used. Please talk to your doctor if you are using any of
the following folk remedies that may contain lead:
• alarcon
• bali gali
• greta
• kandu
• lozeena
• alkohl
• bint al zahab
• farouk
• kohl
• pay-loo-ah
• azarcon
• cora
• ghasard
• liga
• surma
To request this material in another format contact:
Minnesota Department of Health
P.O. Box 64975
St. Paul, MN 55076-0975
Phone: 651-201-5000
MDH TDD/TTY: 651-201-5797
Minnesota Relay Service: 800-627-3529
Printed on recycled paper. Revised 1/2006, IC #141-1329.
Questions?
Call the Minnesota Department
of Health Lead Program at
651-201-4610 or visit our website at
www.health.state.mn.us/divs/eh/lead
Steps To Help Lower
Your Child’s Blood Lead Level
S TEP
• Wash your child's hands often with soap and water. Make sure hands are clean
1
Regular
Washing
before meals, snacks, naps and bedtime.
• Keep your child's fingernails trimmed.
• Wash your child's toys, pacifiers, and bottles often with soap and water.
• If you come in contact with lead at your job be sure to shower, wash your hair,
and change work clothes and shoes before coming into the house.,
• Wash any clothes that have come in contact with lead separately
STEP
from other family clothes.
• Wet wash your home often – especially window sills and wells.
2
A
Safer
Home
• Do not use your regular household vacuum cleaner to pick up paint chips or
dust that contains lead.
• Place washable rugs at each entrance to the home.
Wash rugs separately from other items.
• Take your shoes off before coming into the home.
• Shampoo carpets often.
• Cover bare soil in your yard with sod, wood chips or other ground cover.
• Learn how to safely make home repairs on homes built before 1978. Never
dry-sand, dry-scrape or use a heat gun to burn old lead-based paint. Call the
STEP
Minnesota Department of Health at 651-215-0890 to learn more.
• Have your child eat healthy meals and snacks throughout the day.
3
STEP
Eat
Healthy
Foods
• Eat all meals and snacks at the table.
• Don't eat food that has fallen on the floor.
• Feed your child food that is high in calcium, iron and Vitamin C.
• Use only cold tap water for drinking, cooking, and making
food or baby formula.
• Do not use home remedies or cosmetics that contain lead.
Children with too much lead in their blood may need to have more blood tests. The
4
tests are to make sure that the lead is leaving the body. It is very important that you keep all of the medical appointments, and follow your doctor's instructions. Your doctor will also talk to you about other
things you can do to help lower the amount of lead in your child's blood. Medical
Care
Minnesota Department of Health Lead Program
StepsTo Help Lower
YourChild s Blood Lead Level
Notes
Medical Care
_____________________________
Doctor ______________________________________________________
Phone____________________________
_____________________________
Clinic _______________________________________________________
Phone____________________________
_____________________________
BLOOD LEAD LEVEL PROGRESS CHART
_____________________________
Appointment Date
_____________________________
__________________
__________________
_____________________
_________________________________
_____________________________
__________________
__________________
_____________________
_________________________________
_____________________________
__________________
__________________
_____________________
_________________________________
_____________________________
__________________
__________________
_____________________
_________________________________
_____________________________
__________________
__________________
_____________________
_________________________________
_____________________________
__________________
__________________
_____________________
_________________________________
_____________________________
__________________
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_____________________
_________________________________
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__________________
__________________
_____________________
_________________________________
_____________________________
__________________
__________________
_____________________
_________________________________
_____________________________
__________________
__________________
_____________________
_________________________________
Appointment Time
Blood Lead Level
Notes
_____________________________
_____________________________
Public Health Nurse
_____________________________
Name _______________________________________________________
Phone____________________________
_____________________________
Notes From Visit: ___________________________________________________________________
_____________________________
______________________________________________________________________________
_____________________________
______________________________________________________________________________
_____________________________
______________________________________________________________________________
_____________________________
_____________________________
_____________________________
Lead Risk Assessor
_____________________________
Name _______________________________________________________
_____________________________
Notes From Visit: ___________________________________________________________________
_____________________________
______________________________________________________________________________
_____________________________
______________________________________________________________________________
_____________________________
______________________________________________________________________________
To request this material in another format contact:
Minnesota Department of Health Lead Program St. Paul, Minnesota 55164-0975
P.O. Box 64975
TTY: 651-215-0707
Phone: 651-215-0890
Minnesota Relay Service TTY: 1-800-627-3529
Also visit our website at www.health.state.mn.us
Printed on recycled paper.
2/99
IC Number 141-0642
The children pictured in this fact sheet are not lead-poisoned.
The products and brands shown are examples only and do not
constitute a stated or implied endorsement from the Minnesota
Department of Health.
Phone____________________________
Questions?
Call the Minnesota Department
of Health
at 651-215-0890
Finding Lead in the Home
What is Lead Poisoning?
Lead is part of our world today. It is found in the air, soil, dust and the paint of some homes or buildings
built before 1978. Being exposed to too much lead can cause serious health problems. Lead is never a
normal part of your body. The good news is that lead poisoning can be prevented. This fact sheet provides
answers to some of the most commonly asked questions about lead poisoning.
How can I be exposed to lead?
Lead enters your body each time you inhale leaded dust or fumes, or swallow something that contains lead.
Exposure to lead may occur in several ways:
•
Eating foods or drinking water that contain lead.
•
Spending time in areas with deteriorating lead-based paint.
•
Working in jobs where lead is used.
•
Using traditional medicines that contain lead.
•
Participating in hobbies that may use lead, like making stained glass or fishing with lead sinkers.
How can lead affect adults?
The effects of lead are the same whether it enters the body through breathing or swallowing. The main target
in the body for lead toxicity is the nervous system. Long-term, and high-level exposure of adults to lead can
cause brain and kidney damage. High-level lead exposure in men and women can affect their reproductive
health. A pregnant woman’s exposure to lead can increase her risk for delivering her baby early, and for
having a small baby.
How can lead affect children?
Children are more vulnerable to lead poisoning than adults because their nervous systems are still developing.
Children’s bodies absorb more of the lead they take in than adult bodies. Babies and small children can
swallow or breathe in lead from contaminated dirt, dust, or sand while they play on the ground or floor.
These activities make it easier for children to be exposed because the dirt or dust on their hands, toys, or
other items may contain lead. Children are also more sensitive to the effects of lead than adults. Even at low
levels of exposure, lead can affect a child’s learning, behavior and growth.
How can I tell if my child/family member has too much lead in their body?
People with high levels of lead in their bodies often do not seem sick. The symptoms that might occur are
very general and can happen for many reasons. Therefore, the only way to find out if there is too much lead
in the blood is a simple blood test. Your local public health clinic or family doctor can do this test for you. It
involves taking a sample of blood from your family member’s finger or a vein in their arm. If the blood
sample shows a problem with lead, more testing may be done.
Is there a way to reduce a high blood lead level?
The best way to lower a high blood lead level is to prevent continued exposure to lead. There is a medication
that helps to remove lead from the body when the blood lead level is very high. The medication combines
with lead so the body can get rid of the lead more easily. A doctor will decide if this treatment is needed.
Minnesota Department of Health • Lead Program • P.O. Box 64975 • St. Paul, MN 55164-0975 • 651-201-4610
Who Should Be Tested
The Minnesota Department of Health (MDH) developed the Blood Lead Screening Guidelines for Minnesota
to help physicians understand who should be tested for lead, and at what intervals. These recommendations
include:
A physician should offer a blood lead test to a child at any age if:
•
The parent expresses a concern about, or asks for a blood lead test for their child;
•
The child moved from a major metropolitan area or another country within the last twelve months.
Child health-care providers should offer a blood lead test to children at one and two years of age, and
children up to age six who have not previously been tested if:
•
The child lives in Minneapolis or St. Paul; OR
•
The child receives services from assistance programs such as WIC, Medicaid, Minnesota Care, or
Prepaid Medical Assistance Programs; OR
•
The child meets any of the following criteria, including: regularly visiting a home, childcare, or other
building built before 1950 in the last six months; regularly visiting a home, childcare, or other building
built before 1978 that has undergone renovation, major repairs, or damage in the last six months; or
has a sibling, playmate, or housemate with an elevated blood lead level.
A health care provider should conduct an annual evaluation of children aged three to six years with previous
“normal” blood lead levels to determine if any changes have occurred to their environment. If the answer to
any of the following is “Yes” or “Don’t Know”, the child should receive a blood lead test:
•
Does the child have a playmate, sibling or housemate with a recent elevated blood lead level?
•
Has the child moved to or started regularly visiting a home, childcare, or other building built before
1950?
•
Has there been any repair, remodeling, or damage (such as water damage or chipped paint) to a
home, childcare, or other building built before 1978 that the child regularly visits?
For more information about the Blood Lead Screening Guidelines for Minnesota and other information about
lead please contact the MDH Lead Program at www.health.state.mn.us/divs/eh/lead or by telephone at
651-201-4610.
To request this material in another format contact:
Minnesota Department of Health
P.O. Box 64975
St. Paul, MN 55164-0975
Phone: 651-201-5000
MDH TDD/TTY: 651-201-5797
Minnesota Relay Service: 1-800-627-3529
Printed on recycled paper. Revised 1/2006
IC #141-1328.
Questions?
Call the Minnesota Department
of Health Lead Program at
651-201-4610 or visit our website at
www.health.state.mn.us/divs/eh/lead
Children
Children- Card
- Card1010
Food Guide Pyramid for Children
01/06 IC# 141-1258
If you require this document in another format, such as
large print, Braille or cassette tape, call 651.281.9900
This institution is an equal opportunity provider
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Fruits are nature's treats sweet and delicious.
Go easy on juice and
make sure it's 100%.
Limit juice to 4 ounces a
day.
Suggested serving size:
½ - 1 medium piece
1 - ½ cup canned
/3
½ cup juice
Milk
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2 ounces
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Eat lean or lowfat meat,
chicken, turkey, and fish.
Baked, broiled, or grilled is
best.
1 ounce equals:
1 ounce meat, poultry, or fish
1 Tablespoon peanut butter
1 egg
¼ cup cooked dry beans
Suggested serving size:
1 - 2 ounces meat
¼ - ½ cup cooked dry beans
Go lean with protein
Meat & Beans
2 cups (use fat free skim or 1%) 3-4 ounces
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Get your oils from fish and liquid oils like canola, olive, corn and soybean oils.
1 - 1 ½ cups
2 cups (use whole milk until
2nd birthday)
3 and 4 year-olds need the amounts below from each food group every day ○ ○ ○
1 cup
○
Move to the milk group to
get your calcium. Calcium
builds strong bones.
1 cup equals:
1 cup milk
1 ½ ounces cheese
1 cup yogurt
Suggested serving size:
½ - 1 ounce cheese
½ cup milk or yogurt
Get your calcium-rich foods
1 and 2 year-olds need the amounts below from each food group every day
1 ½ cups
○
Fruits
Focus on Fruits
Adapted from USDA MyPyramid for Kids. Go to www.mypyramid.gov for specific food and activity recommendations for your child.
Find your balance between food and fun
Fats and sugars - know your limits·
• Move more. Aim for at least 60 minutes everyday, or most days. • Check the Nutrition Facts on food labels for fat and sugar information.
• Limit solid fats as well as foods that contain them.
• Play, run, walk – it all counts!
• Choose food and beverages low in added sugars and other caloric
sweeteners.
4-5 ounces
○
○
○
○
○
○
1 cup
○
3 ounces
○
Color your plate with all
kinds of great-tasting
veggies. Try dark green
and orange vegetables!
Suggested serving size:
¼ cup cooked
¼ - ½ cup raw (caution:
choking danger)
1 cup raw leafy
½ cup vegetable juice
Look for whole-grain
cereals and breads. Make
sure the first word on the
ingredient list is "whole".
1 ounce equals:
1 slice bread
1 cup dry cereal
½ cup rice or pasta
Suggested serving size:
½ - 1 slice bread
½ - ¾ cup dry cereal
1
/3 - ½ cup pasta or rice
○
Vegetables
Vary your veggies
Grains
Make half your grains whole
Children - Card 10
TDD: 651.201.5797
FAX: 651.215.8951
WEBSITE: HEALTH.STATE.MN.US
WIC Program
Help Fight Lead Poisoning with the Food Guide Pyramid
Children who eat right can reduce their chances of getting lead poisoning. This fact sheet explains
how parents and other care givers can help prevent lead poisoning in children and other family
members by promoting good eating habits.
Promote these eating habits to reduce the
risk of lead poisoning
Here's why
Offer breakfast and other meals and snacks
at regular, well-spaced intervals. Small
children should probably be offered nutritious
food every three hours or so, starting with the
first meal after waking up.
Lead is more readily absorbed when it gets into a
body that is in a fasting state (the body has been
without for food for an extended period, like after
a nights sleep or after skipping a meal)
Wash the child's hands and face before every
meal and before every snack.
Washing hands and face before eating cuts down
on the possibility of lead-laden dust being
transferred to the food and into the child's mouth.
Discourage "cruising" while eating meals or
snacks. Food needs to be eaten at a clean
table, TV tray, kitchen counter, or even at a
small table in the living room and under the
supervision of an adult.
Food eaten "on the run" gets dropped on the
floor, dragged over furniture, or placed on a
window sill and then retrieved and eaten along
with the lead and germ-laden dust it has
collected.
Don't use hand-glazed pottery for food,
especially juices. Don't store juices in lead
crystal, ceramic pottery, glazed pottery,
pewter, or opened cans.
Store foods and juices in glass or sturdy plastic
containers. These containers are less likely to
have lead in them that could be absorbed by food,
especially acid foods like juices.
Don't use hot water from the faucet to make
infant formula or in other food preparation.
Use cold tap water and heat it on the stove if you
need hot water for food preparation. Hot tap water
absorbs more lead from pipes and pipe solder.
Let tap water run for at least two minutes if the
water has been standing in the pipes for 6 hours
or more. This flushes out the water that might
have absorbed lead from the pipes or the solder
that joins the pipes together.
Don't let ink from plastic bags or containers
touch food.
These inks may contain lead that could get into
the food.
Keep children from chewing on or licking
anything painted like woodwork or toys. Also
keep them from eating dirt.
Don't use folk medicine or home remedies
that contain lead such as azarcon, greta,
payloo-ah, or shung fa.
These items may have lead in them. Watch
children closely to make sure they don't eat or lick
any items that may have lead in them or on them.
Offer foods from the Food Guide Pyramid to
reduce the risk of lead poisoning
Here's How It Works
Breads, cereals, pasta, and other grains
Eat whole grain products like whole grain
breads, whole grain cereals, and brown rice.
Fortified breads and iron-fortified cereals contain
iron, which competes with lead for absorption by
the body. Whole grain breads and cereals offer
fiber, which decrease lead absorption.
Fruits
Eat fresh fruits, especially those high in vitamin
C, like oranges, orange juice, grapefruit,
grapefruit juice, strawberries and watermelon.
Fruits and vegetables high in vitamin C help the
body absorb iron and thus decrease the absorption
of lead. Fresh produce offers fiber, which may help
decrease lead absorption. Be sure to wash fresh
produce in cold running water before serving it
(warm tap water is more likely to absorb lead from
pipes). Do not use soap on produce because soap
residue is absorbed by the produce and can be
toxic. There are no good studies that tell us how
much soap residue is safe.
Vegetables
Eat fresh vegetables, especially those high in
vitamin C like dark green leafy vegetables
(spinach, kale, loose-leaf lettuce, endive),
broccoli, red and green peppers, potatoes
cooked in their skin (it is not necessary to eat
the skin).
Dairy
Use low-fat dairy products like skim or 1% milk,
fat free cottage cheese, fat free yogurt. Tofu is
another fair source of calcium. A source of
vitamin D, like fortified milk and sunshine, is
needed for the body to absorb calcium (cheese
or yogurt do not have vitamin D).
Foods high in calcium compete with lead for use
by the body. High-fat diets encourage lead
absorption, so stick with low fat dairy products
(except for children under the age of two years
who need the fat of whole milk)
Meat, poultry, fish, and meat substitutes
Eat foods high in iron and low in fat like lean
beef, very lean ground beef, pork, skinless
white meat of chicken and turkey, fish,
legumes (like dried beans and peas in soups
and hot dishes), and peanut butter.
These foods are high in iron, a mineral the body
needs. Iron competes with lead for use by the
body. Cut visible fat from the meat and bake, broil
or boil meat to keep the fat down. Skim the fat off
soups and stocks.
Sweets and fats
Go easy on foods like oily salad dressings,
butter, margarine, mayonnaise, buttered
popcorn, donuts, cookies, cake, pie, french
fries, fried or deep-fried foods (potatoes, fish,
chicken, donuts, cheese curds).
A high-fat intake encourages lead absorption.
Sweet and fat foods are also filling and may,
replace more nutritious, lead-fighting foods in a
child's meal plan. Eat fruits, vegetables, pretzels,
unbuttered popcorn and other low fat foods from
the food guide pyramid as snacks.
Appendix F
Educational Encounter & Assessment Form
Intentionally Left Blank
____________________________ County Public Health
(revised from a document received from Kandiyohi County)
ID #: ____________________________________
Mom’s Last Name
Mom’s First Name
Mom’s DOB
Home Phone #:
EDC:
Enrolled in EPC:
________________
DOB:
Baby(s) Last Name:
First Identified:
… PN
… Yes
Baby (1)’s First Name:
… PP
gender: … M
Other:
Date
… No
Type*
Stage**
…F
Baby (2)’s First Name:
Baby (3)’s First Name:
gender: … M
gender: … M
…F
Paycode
*Type of contact—ML, TC, UHV, SHV, GROUP, WIC, Other
**Stage—ASS (assessment), ONG (ongoing)
Comment
…F
Intentionally Left Blank
Appendix G
Sample Notification Letters
Intentionally Left Blank
Sample Notification Letters
<Date>
<Title> <FirstName> <LastName>
<Address>
<City, State Zip>
Dear <Title> <LastName>:
This letter is in response to a blood lead report received regarding your child, <ChildName>. The
report shows that your child’s blood lead level is <Result>. An acceptable blood lead level is any
result ranging from 0 to 9.9 Fg/dL (micrograms of lead per deciliter of blood). If your child’s blood
lead level is greater than 9.9 Fg/dL, it is very important that he/she receives a follow-up blood lead
test. Your child’s physician will need to track the blood lead level in order to effectively treat your
child. (If the blood lead level is greater than 9.9, include this sentence: Please have your child’s blood
retested within <TimeFrame>.)
Enclosed is educational material regarding lead exposure. This material will provide you with
information on things that you can do to help reach the goal of keeping your child’s blood lead level as
low as possible. Please make any necessary changes in the child’s environment that will minimize
exposure to lead.
If you have any questions, please feel free to contact me at <Number>. (If you know the name and
telephone number of the certified risk assessor assigned to the case, include them here.)
Sincerely,
<Name>
<Title>
<WrittersInitials>:<ReviewersInitials>
Enclosures
Intentionally Left Blank
<Date>
<DoctorName>
<Clinic>
<ClinicAddress>
<ClinicCity, State ZipCode>
Dear Doctor <DoctorLastName>:
I have been notified by the Minnesota Department of Health that your patient, <ChildsName>, whose
date of birth is <DOB> received a blood lead test on <TestDate>. The report shows that the <Type>
blood lead test resulted in a blood lead level of <Result> Fg/dL (micrograms of lead per deciliter of
blood).
(Please note here any follow-up activities initiated thus far, and the dates they were initiated. These
steps may include sending educational material to the family, conducting a home public health nurse
visit, and/or scheduling an environmental assessment. Please see Appendix D for recommended
follow-up activities for each blood lead level range.)
Patient contact name and address:
<Title> <FirstName> <LastName>
<Address>
<City, State ZipCode>
I am providing you with this information to assist you in your efforts to treat this child. If you have any
questions, feel free to contact me at <Number>. (If you know the name and telephone number of the
certified risk assessor assigned to the case, include them here.)
Sincerely,
<Name>
<Title>
<WritersInitials>:<ReviewersInitials>
Intentionally Left Blank