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PEDIATRICS Vol. 101 No. 6 June 1998, pp. 1072-1078
AMERICAN ACADEMY OF PEDIATRICS:
Screening for Elevated Blood Lead Levels
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ABSTRACT |
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Top
Abstract
Introduction
References
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Although recent data continue to demonstrate a
decline in the prevalence of elevated blood lead levels (BLLs) in
children, lead remains a common, preventable, environmental health
threat. Because recent epidemiologic data have shown that lead exposure is still common in certain communities in the United States, the Centers for Disease Control and Prevention recently issued new guidelines endorsing universal screening in areas with 
27% of housing built before 1950 and in populations in which the percentage of
1- and 2-year-olds with elevated BLLs is 12%. For children living in
other areas, the Centers for Disease Control and Prevention recommends
targeted screening based on risk-assessment during specified pediatric
visits. In this statement, The American Academy of Pediatrics supports
these new guidelines and provides an update on screening for elevated
BLLs. The American Academy of Pediatrics recommends that pediatricians
continue to provide anticipatory guidance to parents in an effort to
prevent lead exposure (primary prevention). Additionally, pediatricians
should increase their efforts to screen children at risk for lead
exposure to find those with elevated BLLs (secondary prevention).
In 1991, the Centers for Disease Control and Prevention
(CDC) statement Preventing Lead Poisoning in Young
Children1 redefined elevated blood lead levels (BLLs)
as those In response, the 1987 Statement on Childhood Lead
Poisoning2 by the American Academy of Pediatrics (AAP)
was replaced in July 1993 by Lead Poisoning: From Screening to
Primary Prevention.3 The revised statement supported
most of the 1991 CDC recommendations. Specifically, the AAP recommended
"blood lead screening as part of routine health supervision for
children at about 9 through 12 months of age and, if possible, again at
about 24 months of age." Since publication of the 1993 AAP statement,
although some areas of the United States have continued to find a high
incidence of elevated BLLs,4-6 epidemiologic
investigations have identified many locales where, because of limited
exposure to lead, the prevalence of elevated BLLs is so low that
targeted (selective) screening is more appropriate than universal
screening.7-12 In consideration of these data, the CDC
revised its 1991 guidelines. This policy statement updates the 1993 AAP
statement on childhood lead screening.
Significant exposure to lead is a preventable environmental threat to
optimal health and developmental outcomes for young children. Many
children with elevated BLLs who require individualized management still
are not being identified because of inadequate screening efforts in
their communities. Conversely, recent data indicate that exposure to
lead is so low in some communities that cost-benefit analyses do not
justify universal screening in those areas. Against this background,
the CDC, after detailed review with its Advisory Committee on Childhood
Lead Poisoning Prevention, updated its screening
guidelines.13a The revised guidelines provide, for the
first time, a basis for public health authorities to decide on
appropriate screening policy using local BLL data and/or housing data
collected by the US Bureau of the Census. This strategy is intended to
"increase the screening and follow-up care of children who most need
these services, to ensure that prevention approaches are appropriate to
local conditions," and to reduce unnecessary testing of children
unlikely to be exposed to lead. These new recommendations will have
important ramifications on pediatricians' efforts to participate in
the early identification, treatment, and eradication of childhood lead
poisoning.14 In areas where universal screening is not
warranted, the pediatrician's focus must be to evaluate children who
may be at risk and to screen as recommended by state health
departments.
In the most recent study (1991 to 1994) of the National
Health and Nutrition Examination Survey, 2.2% of the US population had
BLLs Lead exposure continues to present a problem for many communities.
Although poor, African-American, and urban children are the most
exposed, both rural children and those from moderate to high
socioeconomic status also may be exposed
significantly.19-21 Approximately 74% of privately owned
and occupied housing units are likely to contain lead paint. Age and
condition of housing, not geographic location, are the best predictors
for the presence of hazards related to lead-based paint;22
if a home contains lead but is well maintained, risk of exposure to
lead is substantially lower compared with the risk from living in a
home with chipping paint or window frames and sills in poor condition.
No threshold for the toxic effects of lead has been identified.
The impact of lead exposure on cognition in young children at BLLs A number of studies recently reviewed by the National Research Council
found an association between lead levels and intellectual function in
children.23 In one population, for example, moderately increased body lead burden (defined as a dentine lead level of >24
ppm, corresponding with a peak BLL of >30 µg/dL) was correlated with
an increase in the percentage of children with severe deficits (ie, IQ
<80) from an expected 4% to 16% and a decrease in the percentage of
children with an IQ In recent years, research has been directed to other aspects of the
developmental neurotoxicity of lead. This research has been aided by
the creation of instruments that provide valid, reliable measures of
attention, behavior, and other aspects of neurodevelopment. Using these
instruments, some investigators have identified associations between
lead exposure and weaknesses in attention/vigilance,31
aggression, somatic complaints, and antisocial or delinquent
behaviors.32,33 Other adverse neurodevelopmental sequelae
that have been associated with low to moderate elevated BLLs include
reduction in auditory threshold,34,35 abnormal postural
balance,36 poor eye-hand coordination, longer reaction times,29 and sleep disturbances.37 Other
studies have failed to confirm many of these results. Although these
findings may be statistically significant, in some cases they may not
be clinically significant.
Primary prevention of lead ingestion through the provision of
anticipatory guidance is a major role of pediatricians. It is through
education about common sources of lead, such as paint and dust, and
less common sources, such as water or contaminated soil, that parents
can take measures to minimize their child's exposure to lead. Also,
discussions about nutrition and the importance of dietary iron may help
prevent elevated BLLs. Educational brochures are available from the AAP
to assist in preventive education.
Public health efforts to prevent lead exposure through the removal of
environmental lead hazards continue to be a most effective measure. The
child's residence and site of routine care are most important, because
high lead exposures occur most frequently where children spend the
majority of their time. Housing data from the Bureau of the Census, in
combination with blood lead data when available from screening, can
help prevent lead exposure by identifying neighborhoods in need of
abatement. Financing through local, state, and federal loan and grant
programs may be available in many communities through health
departments or housing offices.
Lead poisoning and its sequelae can be prevented by blood lead
screening followed, when appropriate, by education and case management,
as well as by environmental abatement to prevent lead exposure in
siblings and playmates. However, a 1994 national telephone survey
showed that only one quarter of young children and only one third of
poor children, who are at higher risk of lead exposure, had been
screened.38 The AAP surveyed its members and found that slightly more than half stated that they routinely screened their
patients younger than 37 months of age.39 The revised CDC
guidelines are a response to poor screening of high-risk children and
to concerns about wasting resources by universal screening in low-risk
settings.13 The 1997 CDC publication provides comprehensive guidance to public health authorities for developing a screening policy
based on local blood lead and housing age data. The goal of the new CDC
screening recommendations remains unchanged: to ensure that children at
risk of exposure to lead are tested. Universal screening still is the
policy for communities with inadequate data on the prevalence of
elevated BLLs and in communities with Public health authorities in each state are responsible for setting
state and local policy on childhood lead screening. Pediatricians should rely on the policies promulgated by their health officials to set practice-specific standards. They also should be involved, both
individually and through their AAP chapters, in the development of
local screening policies. Areas as large as counties and as small as
some determined by ZIP codes or census tracts have practical utility
for identifying children appropriate for either universal or targeted
screening. In a targeted screening locale, the decision to perform a
lead test on a child should be based in part on the responses to a
community-specific risk-assessment questionnaire.1,5,11-13 All questionnaires should include the following three risk assessment questions. Children whose parents respond "yes" or "not sure" to any of these three risk-assessment questions should be considered for screening: 1) Does your child live in or regularly visit a house or
child care facility built before 1950?; 2) Does your child live in or
regularly visit a house or child care facility built before 1978 that
is being or has recently been renovated or remodeled?; 3) Does your
child have a sibling or playmate who has or did have lead poisoning?
Other candidates to be considered for targeted screening include
children 1 to 2 years of age living in housing built before 1950 situated in an area not designated for universal screening (especially
if the housing is not well maintained), children of ethnic or racial
minority groups who may be exposed to lead-containing folk remedies,
children who have emigrated (or been adopted) from countries where lead
poisoning is prevalent, children with iron deficiency, children exposed
to contaminated dust or soil, children with developmental delay whose
oral behaviors place them at significant risk for lead
exposure,40 victims of abuse or neglect,41,42 children whose parents are exposed to lead (vocationally,
avocationally, or during home renovation), and children of low-income
families who are defined as receiving government assistance
(Supplemental Feeding Program for Women, Infants, and Children;
Supplemental Security Income; welfare; Medicaid; or subsidized child
care). According to the CDC, children who receive government assistance and who live in areas where targeted screening is recommended do not
require screening if they are at low risk based on the screening
questionnaire (see Table 1) and if <12% of the children have BLLs
TABLE 1
INTRODUCTION
Top
Abstract
Introduction
References
10 µg/dL and recommended a new set of guidelines for the
treatment of lead levels 15 µg/dL. In the 1991 document, universal
screening was recommended for children 9 to 72 months of age except in
communities with sufficient data to conclude that children would not be
at risk of exposure. Because at that time, there were few
community-based data, the 1991 CDC statement, in essence, called for
universal screening.
EPIDEMIOLOGY
10 µg/dL. The decrease in the overall mean BLL for the general
US population from 12.8 to 2.8 to 2.3 µg/dL demonstrated by the three
National Health and Nutrition Examination Survey investigations (1976 to 1980, 1988 to 1991, 1991 to 1994) is dramatic.15-18 These declines can be attributed to removal of lead from gasoline, paint, and food cans. The percentage of US children 1 to 5 years of age
with BLLs 10 µg/dL has decreased from 88.2% to 4.4%. Of children
1 to 2 years of age, however, 5.9% had BLLs 10 µg/dL, with the
highest rates among African-American, low-income, or urban
children.18 This means that an estimated 890 000 children in the United States have elevated BLLs 10 µg/dL.
NEURODEVELOPMENTAL EFFECTS OF LEAD
10
µg/dL has been amply demonstrated,23 and the
literature is remarkably consistent.23-25 The magnitude of
the effect of blood lead on IQ in young children has been estimated as
an average loss of two to three points for BLLs averaging 20 µg/dL,
compared with BLLs averaging 10 µg/dL.23,26-28
125 from an expected 5% to 0%.29,30
PRIMARY PREVENTION: ABATEMENT, ASSESSMENT, AND ANTICIPATORY
GUIDANCE
SECONDARY PREVENTION THROUGH LEAD SCREENING
27% of the housing built
before 1950. Targeted screening is recommended in communities where
<12% of children have BLLs 10 µg/dL or where <27% of houses
were built before 1950, based partially on an analysis suggesting that
the benefits of universal screening outweigh the costs only when the
prevalence of elevated BLLs is in the range of 11% to 14% or
higher.13
10 µg/dL in that community.
A Basic Personal-Risk Questionnaire*
In addition to screening of children on the basis of risk questionnaires, screening for lead exposure should be considered in the differential diagnosis of children with unexplained illness such as severe anemia, seizures, lethargy, and abdominal pain.
The standard procedure to determine BLLs requires a blood sample that has been collected properly by venipuncture and analyzed accurately.1 When feasible, venous blood samples should be used for initial screening. A capillary (fingerstick) blood sample may be a practical screening alternative. When collected properly (Table 2), the capillary specimen can approach the venous blood sample in accuracy.43 A poorly collected fingerstick sample is contaminated easily by environmental lead, thereby increasing the false-positive rate. Fingerstick values >10 µg/dL should be confirmed with a venous blood sample.
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The laboratory technique used to measure BLLs must have a high degree of accuracy. Use of a laboratory that participates in a proficiency testing program is necessary to prevent the misidentification (both false-negative and false-positive findings) of lead exposure.43,44 Laboratories participating in a proficiency program can be determined by calling the CDC. The CDC blood lead proficiency program allows an error of ±4 µg/dL.45 A recently developed portable machine that reliably measures BLLs may provide a means of rapid, accurate screening.46 The measurement of erythrocyte protoporphyrin, used formerly as the primary lead screening tool, is insensitive for BLLs <35 µg/dL and should not be used.
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MANAGEMENT OF ELEVATED BLLS |
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The toxicity of lead is a function of the dose, the duration of exposure, and the developmental and nutritional vulnerability of the child. It is the role of the pediatrician to give realistic reassurance that early detection and source control in children found to have high BLLs can minimize the consequences for the child.
Recommendations by the AAP regarding the urgency and extent of follow-up, which differ slightly from those of the CDC, depend on the risk classification and on confirmed venous BLLs (Table 3). The first step is to perform a confirmatory venous BLL. This should be performed immediately if the screening result is >70 µg/dL; within 48 hours if the result is between 45 and 69 µg/dL; within 1 week if the result is 20 to 44 µg/dL; and within 1 month if the result is 10 to 19 µg/dL.
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In children with BLLs of 10 to 14 µg/dL, a point source of lead exposure is usually not found. Therefore, general education on measures to reduce lead exposure may be useful to parents. If the confirmatory BLL still is between 10 and 14 µg/dL, BLL testing should be repeated within 3 months.13 For children with BLLs of 15 to 19 µg/dL, the pediatrician should take a careful environmental history. The history should be tailored to the family characteristics and the pediatrician's practice setting; potential questions include those about housing and child care facilities, use of folk remedies and imported pottery, lead testing results among siblings and playmates, and personal habits (eg, hand-washing, hobbies, or occupations that may involve lead). Parents should receive guidance about interventions to reduce BLLs, including environmental hazard reduction as well as optimal nutrition. Nutritional interventions including iron and calcium supplementation, a reduced-fat diet, and frequent meals should be considered because all are associated with reduced gastrointestinal absorption of ingested lead.13 If the confirmatory BLL is still between 15 and 19 µg/dL, BLL testing should be repeated within 2 months.
Individualized case management, which includes a detailed medical
history, nutritional assessment, physical examination, environmental investigation, and hazard reduction, begins at a BLL of 20 µg/dL. Chelation therapy may be considered, but is not recommended routinely at BLLs <45 µg/dL.47 Consultation with clinicians who
are experienced in lead chelation is useful in making the decision to
chelate an individual child.48 Support services from other
professionals, including visiting nurses and environmental health
specialists, are essential in providing assistance with environmental
assessment, lead abatement, or alternative housing.
Childhood lead exposure continues to be a public health problem. The following recommendations address the need for more realistic and cost-effective screening methods, follow-up, and environmental abatement programs.
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RECOMMENDATIONS TO PEDIATRICIANS |
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1. Pediatricians should provide anticipatory guidance to
parents of all infants and toddlers. This includes information on potential risk factors for lead exposure and specific prevention strategies (Table 4) that should be
tailored for the family and for the community in which care is
provided.
2. Pediatricians, in conjunction with local
health agencies, should help develop risk assessment questionnaires
that supplement the standard questions recommended by the CDC (Table
1).
3. Pediatricians should screen children at risk. To prevent lead poisoning, lead screening should begin at 9 to 12 months of age and be considered again at ~24
months of age when BLLs peak. The CDC developed explicit guidance to
state health departments for developing community screening policies.
In communities where universal screening is recommended, pediatricians
should follow this recommendation. In communities where targeted
screening is recommended, pediatricians should determined whether each
young patient is at risk and screen when necessary. Managed health care
organizations and third-party payors should cover fully the costs of
screening and follow-up.
4. A history of possible lead
exposure should be assessed periodically between 6 months and 6 years
of age, using community-specific risk-assessment questions (Table 4).
Blood lead testing also should be considered in abused or neglected
children and in children who have conditions associated with increased
lead exposure.
5. Pediatricians individually and through
AAP chapters should be actively involved and provide input in state and
local community recommendation development.
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RECOMMENDATIONS TO GOVERNMENT |
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1. Testing and treating children for lead exposure must be
coupled with public health programs to ensure environmental
investigation, transitional lead-safe housing assistance, and follow-up
for individual cases. Lead screening programs in high-risk areas should
be integrated with other housing and public health
activities.
2. The AAP supports efforts of
environmental and housing agencies to eliminate lead hazards from
housing and other areas where children may be exposed. These include
financial incentives that can be used to promote environmental
abatement. Training and certification of abatement workers are needed
to avoid additional lead exposure during deleading activities. Local
health authorities should provide oversight of abatement activities to
ensure that additional environmental contamination does not occur.
Also, less expensive, safe technologies for abatement are needed to
make primary prevention efforts more cost-effective.
3. The AAP supports legislation to reduce the entry of lead into the environment and into consumer products with
which children may come in contact.
4. Government, like
the medical community, should focus its efforts on the children who are
most at risk. To do this, more data about the prevalence of elevated
BLLs in specific communities are needed. A better understanding of the
distribution of lead in the environment would allow more efficient
screening efforts.
5. Research is needed to determine the
effectiveness of various strategies to prevent and treat lead
poisoning, to compare methods for abating lead in households, and to
determine the effectiveness of chelating agents with long-term
follow-up through controlled trials. Studies to determine the
effectiveness and cost of educational interventions also are
needed.
6. The CDC should review studies of the efficacy of lead screening and monitor the scientific literature to
ensure that screening is being performed in the most public health-protective, least intrusive, and most cost-effective manner possible. In particular, the risk-assessment questions, follow-up recommendations, and models of case management need periodic
reevaluation.
7. Federal and state government agencies and
legislative bodies should require coverage of lead testing for at-risk
children by all third-party payors, by statute or by regulation.
COMMITTEE ON ENVIRONMENTAL HEALTH, 1997 TO 1998
Ruth A. Etzel, MD, PhD, Chairperson
Sophie J. Balk, MD
Cynthia F. Bearer, MD, PhD
Mark D. Miller, MD
Michael W. Shannon, MD, MPH
Katherine M. Shea, MD, MPH
LIAISON REPRESENTATIVES
Henry Falk, MD
Centers for Disease Control and Prevention
Lynn R. Goldman, MD
Environmental Protection Agency
Robert W. Miller, MD
National Cancer Institute
Walter Rogan, MD
National Institute of Environmental Health
Sciences
SECTION LIAISON
Barbara Coven, MD
Section on Community Pediatrics
CONSULTANTS
Birt Harvey, MD
Peter Simon, MD, MPH
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FOOTNOTES |
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aCopies of this document can be obtained by request to Lead Poisoning Prevention Branch, Centers for Disease Control and Prevention, Mail Stop F 42, 4770 Buford Hwy, NE, Atlanta, GA 30341-3724, or by calling 770-488-7330. The document is also posted on the Internet at http://www.cdc.gov/nceh/programs/lead/guide/1997/guide97.htm.
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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CDC, Centers for Disease Control and Prevention. BLL, blood lead level. AAP, American Academy of Pediatrics.
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REFERENCES |
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Introduction
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Pediatrics (ISSN 0031 4005). Copyright ©1998 by the American Academy of Pediatrics
The following policy statement is a revision:
- Lead Exposure in Children: Prevention, Detection, and Management
- Committee on Environmental Health
Pediatrics 2005 116: 1036-1046.[Abstract] [Full Text] [PDF]
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  A. N. Feinberg and C. K. Cummings Blood Lead Screening Clinical Pediatrics, September 1, 2005; 44(7): 569 - 574. [Abstract] [PDF]
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 M. J. Trepka Using Surveillance Data to Develop and Disseminate Local Childhood Lead Poisoning Screening Recommendations: Miami--Dade County's Experience Am J Public Health, April 1, 2005; 95(4): 556 - 558. [Abstract] [Full Text] [PDF]
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K. L. Hipkins, B. L. Materna, S. F. Payne, and L. C. Kirsch Family Lead Poisoning Associated with Occupational Exposure Clinical Pediatrics, November 1, 2004; 43(9): 845 - 849. [PDF]
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T. A. Dignam, A. Evens, E. Eduardo, S. M. Ramirez, K. L. Caldwell, N. Kilpatrick, G. P. Noonan, W. D. Flanders, P. A. Meyer, and M. A. McGeehin High-Intensity Targeted Screening for Elevated Blood Lead Levels Among Children in 2 Inner-City Chicago Communities Am J Public Health, November 1, 2004; 94(11): 1945 - 1951. [Abstract] [Full Text] [PDF]
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 A. Schulz and M. E. Northridge Social Determinants of Health: Implications for Environmental Health Promotion Health Educ Behav, August 1, 2004; 31(4): 455 - 471. [Abstract] [PDF]
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G. Erdem, X. Hernandez, M. Kyono, C. Chan-Nishina, and L. K. Iwaishi In-utero Lead Exposure After Maternal Ingestion of Mexican Pottery: Inadequacy of the Lead Exposure Questionnaire Clinical Pediatrics, March 1, 2004; 43(2): 185 - 187. [PDF]
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S. M. Bernard Should the Centers for Disease Control and Prevention's Childhood Lead Poisoning Intervention Level Be Lowered? Am J Public Health, August 1, 2003; 93(8): 1253 - 1260. [Abstract] [Full Text] [PDF]
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 H. Falk International Environmental Health for the Pediatrician: Case Study of Lead Poisoning Pediatrics, July 1, 2003; 112(1): 259 - 264. [Abstract] [Full Text] [PDF]
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 M. Shevell, S. Ashwal, D. Donley, J. Flint, M. Gingold, D. Hirtz, A. Majnemer, M. Noetzel, and R.D. Sheth Practice parameter: Evaluation of the child with global developmental delay: Report of the Quality Standards Subcommittee of the American Academy of Neurology and The Practice Committee of the Child Neurology Society Neurology, February 11, 2003; 60(3): 367 - 380. [Abstract] [Full Text] [PDF]
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 M. D. Sanborn, A. Abelsohn, M. Campbell, and E. Weir Identifying and managing adverse environmental health effects: 3. Lead exposure Can. Med. Assoc. J., May 1, 2002; 166(10): 1287 - 1292. [Abstract] [Full Text] [PDF]
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P. M. Vivier, J. W. Hogan, P. Simon, T. Leddy, L. M. Dansereau, and A. J. Alario A Statewide Assessment of Lead Screening Histories of Preschool Children Enrolled in a Medicaid Managed Care Program Pediatrics, August 1, 2001; 108 (2): e29 - e29. [Abstract] [Full Text] [PDF]
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P. L. Geltman, M. J. Brown, and J. Cochran Lead Poisoning Among Refugee Children Resettled in Massachusetts, 1995 to 1999 Pediatrics, July 1, 2001; 108(1): 158 - 162. [Abstract] [Full Text] [PDF]
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E. K. Chung, D. Webb, S. Clampet-Lundquist, and C. Campbell A Comparison of Elevated Blood Lead Levels Among Children Living in Foster Care, Their Siblings, and the General Population Pediatrics, May 1, 2001; 107(5): 81e - 81. [Abstract] [Full Text]
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R. B. Kaufmann, T. L. Clouse, D. R. Olson, and T. D. Matte Elevated Blood Lead Levels and Blood Lead Screening Among US Children Aged One to Five Years: 1988-1994 Pediatrics, December 1, 2000; 106(6): 79e - 79. [Abstract] [Full Text]
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D. Litaker, C. M. Kippes, T. E. Gallagher, and M. E. O'Connor Targeting Lead Screening: The Ohio Lead Risk Score Pediatrics, November 1, 2000; 106(5): 69e - 69. [Abstract] [Full Text]
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B. P. Lanphear, S. Eberly, and C. R. Howard Long-Term Effect of Dust Control on Blood Lead Concentrations Pediatrics, October 1, 2000; 106(4): 48e - 48. [Abstract] [Full Text]
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 M. Markowitz Lead Poisoning Pediatr. Rev., October 1, 2000; 21(10): 327 - 335. [Full Text]
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C. Moore and R. Adler Herbal Vitamins: Lead Toxicity and Developmental Delay Pediatrics, September 1, 2000; 106(3): 600 - 602. [Abstract] [Full Text]
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 S.-C. Lin, K. Roumina, A. Fadlalla, and W. H. Henricks Integrating Data from Legacy Systems Using Object Linking and Embedding Technology: Development of a Reporting System for Heavy Metal Poisoning Results J. Am. Med. Inform. Assoc., July 1, 2000; 7(4): 357 - 360. [Abstract] [Full Text] [PDF]
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 N. Stanton, J. Maney, and R. Jones More on Filter Paper Lead Testing Clin. Chem., July 1, 2000; 46(7): 1028 - 1029. [Full Text] [PDF]
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 Elevated Blood Lead Levels Among Internationally Adopted Children--United States, 1998 JAMA, March 15, 2000; 283(11): 1416 - 1418. [Full Text] [PDF]
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T. F. Jones, W. L. Moore, A. S. Craig, R. L. Reasons, and W. Schaffner Hidden Threats: Lead Poisoning From Unusual Sources Pediatrics, November 1, 1999; 104(5): 1223 - 1225. [Full Text]
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B. P. Lanphear, C. Howard, S. Eberly, P. Auinger, J. Kolassa, M. Weitzman, S. J. Schaffer, and K. Alexander Primary Prevention of Childhood Lead Exposure: A Randomized Trial of Dust Control Pediatrics, April 1, 1999; 103(4): 772 - 777. [Abstract] [Full Text]
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J. D. Sargent, M. Dalton, and R. Z. Klein Diagnostic Testing Unwarranted for Children With Blood Lead 10 to 14 µg/dL Pediatrics, April 1, 1999; 103(4): 51e - 51. [Abstract] [Full Text]
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