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Periodic Survey #28 Lead Screening Practices of Pediatricians

 
PERIODIC SURVEY OF FELLOWS
American Academy of Pediatrics
Division of Child Health Research

EXECUTIVE SUMMARY


This report presents findings from Periodic Survey #28 which explored the current lead screening practices of pediatricians, their opinions regarding issues surrounding lead screening, as well as their attitude toward the AAP/CDC recommendations on lead screening. This topic was initiated by James Campbell, MD, a researcher from the University of Rochester, NY; the survey was developed in collaboration with the AAP Committee on Environmental Health.

PS #28 was an eight-page self-administered questionnaire sent to a random sample of 1,610 active US FAAPs. The original mailing and four follow-up mailings to recontact nonrespondents were conducted from November 1994 to February 1995. After five mailings we received a total of 1035 completed questionnaires for a response rate of 64.3%. The questions on this survey were addressed primarily to the 734 pediatricians who provide preventive care to children £ 36 months of age (71% of the respondents).

Screening for Lead Poisoning:

The majority of pediatricians screen their patients £ 36 months of age for lead poisoning.

  • 53% of pediatricians attempt to screen ALL of their patients £ 36 months of age with a blood test for lead toxicity, 38% attempt to screen SOME of their patients, while 9% screen NONE of their patients in this age group.

  • Screening practices vary by practice location: 83% of inner city pediatricians screen ALL of their patients £ 36 months of age for lead poisoning, compared to 50% of other urban pediatricians, 39% of suburban and 43% of rural pediatricians (p<.001).

  • Overall, pediatricians attempt to screen about one-half of their patients age 9-24 months for lead poisoning: pediatricians report screening an average of 52% of their 9-12 months olds, 48% of their 13-14 month olds, and 37% of their patients aged 25-36 months.

Among pediatricians who selectively screen their patients, almost all screen children whose parents request lead screening and children in high-risk groups; the average age at which they begin to screen high-risk patients is 9.7 months

  • 98% of pediatricians who selectively screen patients £ 36 months of age report do so at the parents' request. Nearly all pediatricians (97%) also screen children of this age who have a history of pica, who live in or regularly visit an older home that has peeling or chipping paint (95%), whose sibling has an elevated lead level (95%), who lives in an older home that has recent renovations (93%), or who live near an industry that releases lead (93%), are enrolled in Medicaid (93%), whose parents use lead compounds in a hobby or occupation (92%), and who have a past history of toxic ingestion (90%).

The primary reason given by pediatricians for not universally screening their patients for lead poisoning is prevalence of low lead levels among the children in their practice.

  • 90% of pediatricians who do not universally screen (including those who do not screen any of) their patients £ 36 months of age say they do not do so because of the low prevalence of venous lead levels ³ 10mcg/dl among their patients. About one-third of pediatricians who selectively screen for lead poisoning say lead screening is too costly (33%) and that other issues are more important to review with parents (34%).

Screening Practices

The data in this section are limited to the 91% (666) respondents who screen some or all of their patients £ 36 months of age for lead poisoning.

Forty-one percent of pediatricians who screen for lead poisoning use a lead poisoning risk-assessment questionnaire designed to identify children at greater risk of lead exposure; two-thirds of these pediatricians (64%) use the questionnaire to focus education on parents and 60% do so to decide whether to screen.

Nearly all pediatricians (96%) use the blood lead level test to screen for lead poisoning; 2% use erythrocyte protoporphyrin level test. One-half (52%) use venipuncture to collect blood for screening and 39% use fingerstick. All pediatricians (99%) usually screen for lead poisoning at well-child visits; however, 48% say they screen at follow-up chronic illness visits and 40% screen at follow-up acute illness visits.

Slightly more than one-third of pediatricians (37%) say their lead screening practices have changed with the last 24 months; most (55%) of these pediatricians say they have increased the number of patients screened and increased the frequency with which patients are screened (49%), while 41% say they just began to screen for lead poisoning. These changes are primarily due to the AAP recommendations (62% of these pediatricians so reported) and CDC recommendations (45% so reported).

Most pediatricians (52%) have read the 1991 CDC statement on lead poisoning and 61% have read the 1993 AAP statement on lead poisoning; most of the balance are aware that statements on lead poisoning exist, but they have not read them. One-third of pediatricians (33%) say they are aware of local or state laws that require them to screen children for lead poisoning; although nearly as many (28%) do not know if such laws exist.

Lead Poisoning Education/Services Available

Most pediatricians who screen for lead poisoning (67%) say either they or other medical personnel in their office provide education on the sources and effects of lead before they perform lead screening.

  • 63% of pediatricians who screen for lead poisoning usually provide parents with lead screening information before screening their patients; 37% provide such information after screening for lead poisoning when their patients blood level is 10.6 mcg/dl or higher.

  • Three-fourths of pediatricians say lead poisoning information is delivered by them or by other medical personnel (77% of pediatricians so reported) and by printed material (75% so reported). Nearly all pediatricians say the information covers sources of lead (99%) as well as the effects of lead (91%).

  • 39% of pediatricians who screen for lead poisoning say there is a center in their community (other than their state or local health department) that specializes in the treatment of lead poisoning where children with lead poisoning can be referred for various services, 37% say there is no such center available, and 24% do not know.

Most of the 734 pediatricians who provide well child care to children £ 36 months old are aware of state or local health department provides services for children who have lead poisoning , 30% do not know of such services.

  • Nearly two-thirds of all pediatricians who provide well child care to children £ 36 months old (64%) report that their state or local health department provides services for children who have lead poisoning, 30% do not know of such services.

Opinions Regarding Lead Screening

Most pediatricians (73%) agree 10mcg/dl is the lowest lead level that should be considered elevated. They believe elevated lead levels are a common problem only among inner-city and other high-risk groups of children. Many are unsure about the benefits of universal screening; most all would like to have epidemiologic studies performed to determine high-risk communities.

  • 79% of pediatricians think lead levels ³ 10 mcg/dl among children 9-36 months old are a common problem in US urban inner cities. Only 20% think this lead level is commonly found in suburban children, while 29% are unsure. One-forth (24%) of pediatricians agree and 38% are unsure as to whether lead levels ³ 10 mcg/dl are common in US rural communities.

  • Overall, most pediatricians (67%) do not think lead levels ³ 10 mcg/dl are common in their practice. However, this varies substantially by location: 85% of pediatricians practicing in suburban areas, 74% of those in urban, inner-city pediatricians do not believe lead levels ³ 10mcg/dl are common in their practice areas (p<.001). Two-thirds of pediatricians describe their primary practice area as urban, not inner-city or suburban, while 28% describe their practice area as urban, inner-city.

  • 60% of pediatricians believe children £ 12 months of age are at risk for lead levels between 10-19 mcg/dl; 25% are unsure.

  • Most pediatricians (64%) agree Head Start programs should require lead screening for enrollment. However, their opinion is divided on whether daycare centers should require lead screening for program enrollment (37% agree, 37% disagree, and 25% are unsure).

  • 59% of pediatricians believe that interventions for children 9-36 months of age who have lead levels between 10-19 mcg/dl are effective in reducing lead levels.

  • The majority of pediatricians (90%) think epidemiologic studies should be performed to determine which communities have significant proportions of children who have elevated lead levels.

  • Pediatricians are evenly divided on their opinion regarding whether the benefits of universal screening for lead exposure for children 9-36 months of age outweigh its costs (38% agree, 35% disagree, and 28% are unsure)

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