CHILDHOOD LEAD POISONING Blood Lead Level (BLL) Quick Reference for Primary Care Providers (Updated 9/17/2016) REMINDER: Medicaid requires all children to be tested at 12 and 24 months of age. Children between 36 and 72 months who were not previously tested must be tested at least once. Not Yet Tested Consider screening ALL children between between 1-72 months. Need for testing can be based on risk factors BLL <5 µg/dL Review lead levels with family Provide anticipatory guidance on common sources of environmental lead exposure. FOLLOW UP: Retest in months if child is at high risk BLL 5-14µg/dL Confirm capillary results with venous blood sample Review venous sample with family Take environmental history to identify sources of lead; provide advice about reducing/eliminating exposure Consider children who may be exposed Consider iron sufficiency; provide nutritional counseling related to calcium and iron Refer to Local Health Department for additional assessment and interventions FOLLOW UP: Retest venous sample within 1-3 months to ensure BLL is not rising BLL 15-44 µg/dL Confirm capillary results with venous sample Review venous sample with family Take environmental history to identify sources of lead; provide advice about reducing/eliminating exposure Consider other children who may be exposed Consider iron sufficiency, provide nutritional counseling related to calcium and iron Consider specific evaluation of the based on environmental history e.g. an abdominal x-ray re pica behavior Refer to Local health Department for additional assessment and interventions FOLLOW UP: Retest venous sample monthly until levels are <15, repeat every 1-3 months until levels are <5 BLL >44µg/dL Evaluate child for acute lead toxicity. Consider hospitalization and/or chelation therapy Confirm capillary results with venous blood sample within 48 hours Any treatment should be performed in consultation with an expert at the Michigan Poison Control Center: 1-800-222-1222 Work with Local Health Department to coordinate case management with family and ensure that child does not return to a lead-contaminated home. FOLLOW UP: As directed by expert. Monthly venous samples will be required.
Method of Data Input in HHLPSS After Looking Up a Child How to Open a Case: 1. Click the “Case Details” blue bar. 2. the “Disposition History” blue bar. 3. Click the “Create New Surveillance Case” button. How to Add an Event: Note: For each activity done with the child, an event must be recorded using these steps. DO NOT insert any narrative description regarding the event in the “Comment” box (It only allows a very limited entry and that is not visible when you create a PDF of the child’s record). Instead, the narrative description with more details about the event must be documented in the “Notes” tab (see below for instructions on adding a note). 1. the “Case Details” blue bar. 2. Click the “Case Information” blue bar. 3. Click the “Add Event” button.
How to Attach a Document to a Child’s Record: 1. the “Patient Attachments” blue bar. 2. Click the “Add New File” button. 3. Type a file description in the “File Description” box. 4. Click the “Browse” button.
How to Close a Case: Note: Closing a case is also consider as an event. Therefore, just must register the event and add a corresponding note. Click the “Case Details” blue bar. Click the “Case Disposition” blue bar. the “PHN Case Closed” box. Add the “Date Closed” in the box. Select the “Reason for Closure” from the drop down list. “Save” brown bar. Once you have clicked “Save” you will get an “Alert” stating the case has been closed.
Primary Caregiver is: ☐ Mother ☐ Father ☐ Foster Parent/Guardian ☐ Other Specify: Person Interviewed: Primary language of the household: What is the primary source of income for the family? Does family receive: ☐ WIC ☐ Food Assistance ☐ Medicaid/Medicare/SSI/SSDI ☐ MI Child ☐ Maternal Infant Health ☐ Public Housing ☐ Other: Social service agency support, food pantry etc ☐ Transportation Assistance Does the family own or rent the property? ☐ Own ☐ Rent If rented: Owners Name: Address: Phone #:
Check the answer that applies. Are there imported non-glossy vinyl mini blinds in the house? ☐ Yes ☐ No Is there an industrial area within one mile of the house? ☐ Yes ☐ No If yes, type of industry? Has any renovation work been done in the past six months? ☐ Yes ☐ No Have you or anyone in the household had lead-safe work practices training? ☐ Yes ☐ No Has painted wood ever been burned in a wood-stove or fireplace? ☐ Yes ☐ No Have ever been emptied onto soil? ☐ Yes ☐ No Does your child play at a park or playground? ☐ Yes ☐ No Were gasoline or other solvents ever used to clean parts or disposed of at the property? ☐ Yes ☐ No Has soil ever been tested for lead? ☐ Yes ☐ No Has the household water ever been tested for lead? ☐ Yes ☐ No Comments: Check all that apply: Latino: Cosmetics Foods ☐ Tamarind Candy ☐ Chile flavored candies ☐ Chocolate-Covered grasshoppers Remedies ☐ Azarcon ☐ Liga ☐ Maria Luisa ☐ Alarcon ☐ Coral ☐ ☐ Greta ☐ Albayalde ☐ Litargiri Middle Eastern, Indian, Pakistani, African: Cosmetics ☐ Alkohl ☐ Kohl ☐ Saoott ☐ Surma ☐ Henna □ Sindoor □ Kum Kum Foods ☐ Lozeena Remedies ☐ Bali Goli ☐ Ghasard ☐ Kandu ☐ Ayurvedic ☐ Kushta ☐ Deshi Dawa ☐ Bint ☐ Santrinj ☐ Bokhoor Cebagin Al Murrah Southeast Asian, Chinese Cosmetics Foods □ Plum Candy □ Ginger Remedies ☐ Chuifong Tokuwan ☐ Jin Bu Huan ☐ Po Ying Tan ☐ Ba-Baw- San ☐ Pay- Loo-Ah ☐ Hai Ge Fen ☐ Ju Hua ☐ Litharge ☐ Cordyceps Other:
Does anyone living in the household or regularly visiting do any of the following as a hobby or occupation? ☐ Yes ☐ No ☐ Home renovation (HVAC, plumbing, painting) ☐ Auto repair(radiator or body work) ☐ Furniture refinishing ☐ Electronics soldering ☐ Glass or metal soldering ☐ Jewelry making/crafts ☐ Glazed-pottery making/Ceramics ☐ Target shooting ☐ Stained-glass making ☐ Fishing or hunting ☐ Artistic painting ☐ Making bullets, or fishing sinkers ☐ Landscaping/Gardening ☐ Construction □ Welding Type: □ e-recycling Do any adults, involved with the hobbies or occupations listed change out of their work clothes as soon as they get home? ☐ Yes ☐ No
Height: (in/cm) Weight: (lbs/kg) ☐ Per parent report Initial Birth Weight: (libs/kg) Level of attention: ☐ Appropriate ☐ Somewhat distractible ☐ Very distractible ☐ Other: Interest in Surroundings: ☐ Alert ☐ Somewhat disinterested ☐ Seriously disinterested ☐ Other: Behavior: ☐ WNL for age Other: DESCRIBE any instances of impulsivity, difficulty following instructions, aggressiveness toward others observed during visit General Appearance: ☐ Well-nourished ☐ ☐ Thin ☐ Other: Skin: ☐ WNL ☐ Laceration ☐ Bruises ☐ Rashes ☐ Other: Stool: ☐ Toilet trained? ☐ Toilet training begun? Last BM: Usual Pattern: Other: Bladder: ☐ Toilet trained? ☐ Toilet training begun Other: Muscles: ☐ WNL ☐ Movement impaired ☐ Adaptive Devices: ☐ Eye glasses ☐ Hearing Aide ☐ Wheelchair ☐ Other:
Healthy Homes Section P.O. Box 30195 Lansing, Michigan 48909 (517) 335-9390 LEAD SAFE HOME PROGRAM INCOME CHECKLIST Please call (866) 691-5323 if you need assistance. This form must be filled out by the OCCUPANT of the property and income documentation must be attached for the OCCUPANT only. Please check the appropriate boxes if anyone age 18 and older receives any of the following income. Documentation must be included for ALL ITEMS CHECKED and any other income received that is not listed below: IRS tax from most recent year available – Form 1040 Copies of 3 most current payroll stubs Unemployment Statement Disability Compensation Worker’s Compensation Child Support Alimony Severance Pay Aid from Department of Human Services (Cash Assistance Only) Supplemental Security Income (SSI) Copies of Social Security earnings statements Other annuity or retirement income statements Any other documented income (Including Seasonal Income) Questions? Please call us at (866) 691-5323. Failure to submit checklist and necessary documentation may be cause for program denial. By signing below, the occupant acknowledges that this form has been completed truthfully and to the best of his/her knowledge. Penalty for false or fraudulent statements: U.S.C. Title 18, sec 1001, provides: “Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly falsifies, or makes, or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both.” Occupant Name Occupant Signature Date Mail completed application and income information to: MDHHS- Lead Safe Home Program PO Box 30195, Lansing, MI 48909 OR Fax application to (517) 335-8800
Problem Outcomes Actions Additional Information (specific for family) Date Covered PHN Initials Discussed ways to avoid exposure through food containers, folk remedies, or cosmetics. Encouraged the use of door mats. Other (Specify): Lead hazard present (continued) Lead hazards are addressed. (continued) PHN will ensure that ways to decrease the identified lead exposure risks (both short and long-term strategies) are discussed with the family. Specific LONG-TERM recommendations for family all that were discussed): Discussed ways to cover bare soil. Discussed remediation of lead hazards and follow-up dust testing. Discussed ways to reduce exposure to lead in drinking Reviewed use of lead-safe work practices in renovation. (Specify): PHN will work with the environmental investigator to complete the LSHP application to identify resources for addressing lead hazards. PHN will check with the MDHHS LSHP to see if the rental property owner/homeowner is aware of need to address lead hazards. PHN will check with the MDHHS LSHP to ensure that property owner is referred to prosecutor’s office or district court if lead hazards are not addressed within specified period of time.
Problem Outcomes Actions Additional Information (specific for family) Date Covered PHN Initials PHN will provide information on the food recommendations to the family. Nutrition information pamphlet provided to family. PHN will encourage families not to give children supplements unless under the direct supervision of a physician. Potential for poor nutrition. (continued) will be enrolled in WIC if eligible. PHN will determine WIC Eligibility. Check one: Family receiving WIC services Family referred to WIC Not eligible for WIC services Caregiver will get assistance in providing good nutrition for the child. PHN will provide families with additional nutritional referrals as needed. nutritional referrals recommended for the family: Need for long-term development al follow-up. Family will verbalize an understanding of the need for long- term development follow-up. PHN will discuss with the family the need to look for behaviors that may interfere with learning (e.g., inattention, distractibility, impulsivity). Date of ASQ screening if done: PHN will discuss with the family and primary care provider periods when development st th delays may be apparent (1 , 4 , th th 6 or 7 grade). PHN will encourage parental sharing of child’s diagnosis w/ classroom teacher(s) Specific recommendations for the family based on development screen (check all that apply): Recommend HeadStart/ Early HeadStart. Refer to Early On. Consider YMCA program/other enrichment programs. Encourage play groups. Recommended games for parents to play on-one-one with child. Provide contact information for the appropriate MSU Extension program if applicable in your area.
Problem Outcomes Actions Additional Information (specific for family) Date Covered PHN Initials Other (Specify): PHN will provide family with recommendations for informal/formal intervention programs and refer the child for additional testing if necessary. Potential for family lost to follow-up services. PHN and medical provider will be notified if family changes addresses. PHN will discuss with family the importance of maintaining contact with the PHN and medical provider. PHN will reinforce parent responsibility for ongoing health & developmental monitoring. Need for additional services. PHN Signature: Date:
Elevated Blood Lead Level Nursing Case Management Services Provided to the Following Patient Child’s Name: Date of Birth: Address: Parent/Guardian’s Name: EBL NCM Activities Provided (Check all that apply): ☐ Health Education ☐ Nursing Assessment ☐ Plan of Care ☐ Home Visit ☐ Visual Assessment of Home for Lead ☐ Assist with LSHP Application Referrals Made (Check all that apply): ☐ Re: Nutrition all that apply): ☐ Re: Housing all that apply): ☐ Re: Medical services (Check all that apply): WIC Food Pantry Lead home abatement Relocation to lead safe housing Medicaid/Medicare enrollment Children’s Special Health Care Services enrollment ☐ Re: Household assistance (Check all that apply): ☐ Re: Education (Check all that apply): Early On Head Start/Early Head Start ☐ Re: Transportation ☐Bus Tickets ☐Taxi Voucher Clothing Diapers Furniture ☐ Other Nursing Recommendations/Follow-up Activities/Case Disposition: _ _ _ _ Revised 11/21/2016 2