Department of Health
Susan R. Cooper, MSN, RN, Commissioner

The current health standard requires a capillary (finger or heel stick) blood test for lead screening at 12 months and at 24 months. All children aged 36-72 months who have not previously received a blood test for lead screening should be tested. A lead risk assessment questionnaire should be completed at each well child checkup on all children 6 months to 72 months of age. This questionnaire will help the health care professional determine your child's risk for lead exposure and if anything has changed in the child's home environment that would put the child at a higher risk for lead exposure.

The first three questions must be asked and the remaining nine questions may be asked at the provider's discretion. If the parent/guardian answers "yes" or "don't know" to any of the questions, the child is considered to be at high risk and should be screened with a blood lead test.
(see the assessment below).

1. Does your child live in or regularly visit a house built before 1950? (This could include a day care center, home of a baby sitter, or a relative.)
2. Does your child live in or regularly visit a house built before 1978 with recent, ongoing, or planned renovations or remodeling (within the past six (6) months)?
3. Does your child have a sibling or a playmate that has or did have lead poisoning?
4. Does your child frequently come in contact with an adult who works with lead? (Examples: construction, welding, pottery, etc.)
5. Does your home contain any plastic or vinyl mini blinds?
6. Have you ever been told that your child has low iron?
7. Have you seen your child eating paint chips, crayons, soil or dirt?
8. Does your child live near or visit with someone who lives near a lead smelter, battery recycling plant or other industry that could release lead?
9. Do you give your child any home or folk remedies that may contain lead? (such as moonshine, Azarcon, Greta, Paylooah)
10. Does your child live within 80 feet (or one block) of a heavily traveled road or a heavily traveled street?
11. Does your home's plumbing have lead pipes or copper pipes with lead solder joints?
12. Does your family use pottery ware or leaded crystal for cooking, eating, or drinking?

(Not recommended for children less than 1 year of age.)
FOLLOW CDC RECOMMENDED UNIVERSAL PRECAUTIONS
FOR OBTAINING BLOOD

It is important that the blood circulates freely in the finger sampled. DO NOT USE fingers with tight rings. The patient's fingers should be straight, but not tense, to avoid the stasis effect which occurs when the fingers are bent. The middle finger is recommended for use to obtain the best blood flow.

For children less than one year of age, use the heel for a puncture site.
See HEEL STICK METHOD FOR BLOOD LEAD SCREENING

Purpose: Detect lead exposure.

For accurate test results, environmental lead contamination must be avoided. Use clean white paper towel as a work surface as recycled or colored towels can contain trace levels of lead.

Equipment:

• disposable gloves
• alcohol swab
• dry sterile gauze pads
• sterile lancet
• microtubes (250 microliters)
• appropriate laboratory request form

Procedure:

1. Explain to the parent the reason for the test and how important it is to the child's learning ability to have the test done.
2. Wash your hands and put on clean gloves
3. Thoroughly clean the child's hands with soap and warm water; rinse well, then dry the hands. Remember to use clean white paper towels as recycled or colored towels can contain trace levels of lead. (Once washed, the finger to be punctured must not be allowed to come into contact with any surface.)
4. Grasp the finger that has been selected (usually the middle finger) for puncture between your thumb and index finger with the palm of the child's hand facing up.
5. If not done during washing, massage the fleshy portion of the finger gently.
6. Clean the ball or pad of the finger to be punctured with the alcohol swab. Dry the fingertip using the sterile gauze.
7. Grasp the finger and quickly puncture it with a sterile lancet in a position slightly lateral of the center of the fingertip. The cut should be perpendicular to ridges of the skin. Ask the child to hang her/his arm down or assist her/him to do so to permit the steady flow of unclotted blood into the tube.
8. Dispose of the lancet in an appropriate biohazard waste container, e.g., sharp container.
9. Wipe off the first droplet of blood with the sterile gauze or cotton ball. (The first drop of blood contains tissue fluids that will produce inaccurate results.)
10. Hold the puncture site downward and gently apply pressure to the surrounding tissue to enhance blood flow. Strong repetitive pressure (milking) should be avoided as it may cause hemolysis or contamination of the specimen with tissue fluid.
11. Continuing to grasp the finger, touch the tip of the collection container to the beaded drop of blood. Collect the second and third drops of blood in the microtube and mix with the EDTA in the tube to prevent clotting. Continue collecting blood and periodically mixing the blood with the EDTA throughout the collection until 250 microliters are collected.
12. Once the required amount of blood is collected, cap the tube and rock it 8-10 times to further mix the blood with the EDTA.
13. Apply a bandaid when appropriate (it is not advisable to apply a bandaid over skin puncture sites in children less than two years old. Adhesive bandages in infants can irritate the skin. An older infant may remove the bandage, put it in the mouth, and possibly aspirate it.)
14. Send sample to the lab for analysis.

(Preferred method for children less than one year of age.)
FOLLOW CDC RECOMMENDED UNIVERSAL PRECAUTIONS
FOR OBTAINING BLOOD

For accurate test results, environmental lead contamination must be avoided. Use clean white paper towel as a work surface as recycled or colored towels can contain trace levels of lead.

Equipment:   SAME AS FOR FINGER STICK METHOD.

Procedure:

1. Explain to the parent the reason for the test and how important it is to the child's learning ability to have the test done.
2. Wash your hands and put on clean gloves.
3. Thoroughly clean the child's heel with soap and warm water; rinse well, then dry the heel. Remember to use clean white paper towels as recycled or colored towels can contain trace levels of lead. (Once washed, the heel must not be allowed to come into contact with any surface.)
4. Select the puncture site on the heel. The preferred puncture site is indicated by the shaded areas on the following diagram. The least hazardous sites for heel puncture are at the sites indicated below.
5. Thoroughly wash the puncture site with soap and water.
6. Clean the area of the heel to be punctured with the alcohol swab and let air dry. Vigorous rubbing during this step stimulates blood flow in the area.
7. Puncture the skin with one continuous motion using a sterile lancet with a 2.5 mm tip. Longer tips may cause excessive tissue damage.
8. Wipe away and discard the first drop of blood since it is contaminated by the disinfectant or tissue fluid.
9. Allow the second drop to form by the spontaneous free flow of blood.
10. Grasp the heel, touch the tip of the collection container to the beaded drop of blood. Collect the second and third drops of blood in the microtube and mix with the EDTA in the tube to prevent clotting. Continue collecting blood and periodically mixing the blood with the EDTA throughout the collection until 250 microliters are collected.
11. Once the required amount of blood is collected, cap the tube and rock it 8-10 times to further mix the blood with the EDTA.
12. Once the blood collection is completed, and while the patient's foot is held above the heart level, press a sterile gauze to the puncture site until the bleeding has stopped.
13. Send specimen to the lab for analysis.

All elevated blood lead levels must be confirmed by venous blood sampling. The time between the initial capillary screening and venous confirmation must be based on the criteria listed below. A venous confirmation is required if comprehensive case management and environmental follow-up services are to be rendered.

RECOMMENDED SCHEDULE FOR A CONFIRMATORY VENOUS SAMPLE

*The higher the BLL on the screening test, the more urgent the need for confirmatory testing.

SCHEDULE FOR FOLLOW-UP BLOOD LEAD TESTING

Medical management includes follow-up blood lead testing. The following table presents the suggested frequency of follow-up tests and should be used as guidance. Case managers and PCPs should consider individual patient characteristics and caregiver capabilities and adjust the frequency of follow-up tests accordingly.

a Seasonal variation of BLLs exists and may be more apparent in colder climate areas.  Greater exposure in the summer months may necessitate more frequent follow-ups.

b Some case managers or PCPs may choose to repeat blood lead tests on all new patients within a month to ensure that their BLL is not rising more quickly than anticipated.

MEDICAL MANAGEMENT SUMMARY OF LEAD POISONING IN ACCORDANCE WITH CONFIRMED BLOOD LEAD LEVELS

10-14
15-19*
20-44
45-69
>70

  *Shift down to next row if level goes up.
**Contact CLPPP when an environmental investigation is indicated. (615) 741-0355