NH Department of Health & Human Services, Division of Public Health Services Revised July 2021 1-800-897-LEAD (5323) or LeadRN@dhhs.nh.gov Initial Capillary Blood Lead Level Schedule For Obtaining Venous Sample Capillary Blood Lead Confirm With Venous Test < 5mcg/dL Confirmation not necessary unless other risk factors. Test child < 12 mos. old in 3 - 6 months as BLL may increase with mobility. Retest child at 1 and 2 years old. 5 – 9 mcg/dL Within 1 month 10 - 19 mcg/dL Within 2 weeks 20 - 44 mcg/dL Within in 1 week 45 - 64 mcg/dL Re-Test: Wash child’s hands with soap and water. Collect new sample and retest. If same results: confirm within 48 hours.* 65+ mcg/dL ‘HIGH’ result on Lead Care II. Confirm BLL immediately - emergency test. Contact NH Lead RN: 1-800-897-5323 *Note: No STAT PB venous available in NH. The higher the capillary test result, the more urgent the need for a confirmatory venous test Initial Venous Blood Lead Level Venous Follow-Up and Re-testing < 5 mcg/dL Retest child at 1 and 2 years old. Retest child in 6 – 12 months if child is at high risk, or risk changes during time frame. 5 - 9 mcg/dL Every 3 months* Child enters nurse case management. 10 - 19 mcg/dL Every 3 months 20 - 39 mcg/dL Every 1-2 months 40 - 64 mcg/dL Every 1-2 weeks (even after chelation) 65+ mcg/dL Initiate chelation and re-test within 1-2 weeks *Some providers may choose to repeat BLL tests within 1 month to ensure BLL is not rising quicker than anticipated. Clinical Treatment Guidelines for Venous Confirmed Blood Lead Levels 3 - 4.9 mcg/dL 5 - 44 mcg/dL 45 - 64 mcg/dL 65 + mcg/dL  Provide parents three factsheets -Lead & Children -Lead & Nutrition -Lead Hazards  Follow-up BLL monitoring  Retest infants earlier than 3-6 months  Test siblings for EBLL  The HHLPPP sends letter notifying parents of EBLL Continue management, AND:  Rule out iron deficiency & prescribe iron if needed  Neurodevelopmental monitoring & consider referral for evaluation  For BLL 25 - 44mcg/dL, CHEMET (succimer) is NOT recommended as there is no cognitive benefit  The HHLPPP provides nurse case management & an environmental lead investigation. EMERGENCY!  Contact Northern New England Poison Control for immediate consultation on lead toxicity therapy at 1-800-222-1222. Available 24/7.  Contact NH Lead RN: 1-800-897-5323  Stop iron therapy prior to chelation  Begin chelation in consultation with clinician experienced in lead toxicity therapy  Consider directly observed therapy with CHEMET (succimer)  Child should be discharged to a lead-free environment. EMERGENCY! AND:  Hospitalize even if asymptomatic Child Medical Management Quick Guide for Lead Testing & Treatment LEAD POISONING LEAD POISONING NH Department of Health & Human Services, Division of Public Health Services 1-800-897-LEAD (5323) or LeadRN@dhhs.nh.gov NH UNIVERSAL TESTING LAW  Test all children at 12 mos. and again at 24 mos. (2 tests)  Test all children 3 to 6 yrs. old who haven’t been tested Lead Risk Questions To Ask Parents of Children with EBLL’s ≥ 5 mcg/dL  Developmental delays or learning disabilities?  Behavioral problems? (e.g. aggression & attention issues)  Excessive mouthing or pica behavior?  Ingestion of non-food items?  Living in pre-1978 housing?  Attending child care in pre-1978 building?  Recent renovations in pre-1978 housing?  Recent renovations in pre-1978 child care?  Recent immigrant, refugee, or international adoption?  Parent occupation or hobbies have lead exposure? (e.g. renovations, painting, welding, fishing, target shooting, stain glass, jewelry making)  Imported ethnic spices/ powders that contain lead? (e.g. sindoor, surma, greta, orange shringar, asafetida, turmeric)  Does child have sibling or playmate with an EBLL? Interventions to Help Limit Exposure Educate caregivers by providing three DHHS factsheets: “Lead and Nutrition”, “Lead and Children” and “Lead Hazards“  Hand washing with soap and water  Clean child’s toys, bottles & pacifiers often  Feed child foods with Calcium, Iron & Vitamin C daily  Have barriers blocking access to lead hazards  Wet wipe window sill, door jams, & door frames  Wet mop floors and stairs once a week or more  Use HEPA filter vacuum to clean up dust and paint chips Developmental Assessment & Intervention for Children with EBLL For any child with a venous BLL ≥ 5mcg/dL ‒ Annual developmental surveillance and screening at ages 3, 4 and 5 years is recommended ‒ Developmental surveillance at annual visit for all ages to identify emerging/unaddressed behavioral, cognitive, or developmental concerns For any child with a venous ≥ 20 mcg/dL or persistently ≥ 15 mcg/dL with other developmental risk factors: neurodevelopmental monitoring is needed Action Steps  Long term developmental monitoring should be a component of the child’s management plan.  A history of EBLL should be included in the problem list maintained in the child’s permanent medical record, even if BLL is reduced.  Refer child to early intervention or child-check for developmental screening.  Recommend early childhood education and stimulation programs.  Refer to NH Division of Developmental Services for a list of local Family-Centered Early Supports & Services at (603)-271-5143 Developmental Surveillance should include:  Vigilance for physical, social, emotional, academic challenges at critical transition points in childhood (e.g. preschool, 1st, 4th, 6th & 7th grades).  Vigilance for in-attention, distractibility, aggression, anti-social behavior, irritability, hyperactivity, low impulse control and poor emotional regulation.  Refer children experiencing neurodevelopmental problems for a complete diagnostic medical evaluation.  Continue to monitor development through a child’s early and middle- school years, even if BLL is reduced. For children of any age: if issues arise between annual visits, encourage parents to bring them to attention of the medical office and school personnel. Revised July 2021 Child Medical Management Quick Guide for Clinical Evaluation & Management Nurse Case Management Services  Children with EBLLs ≥ 5 mcg/dL enter nurse case management.  Public health nurse visits home and provides family education.  Environmental lead investigation to determine source(s) of lead exposure provided.