What Happened
We wanted to share some good news regarding blood lead testing.
Lead in Blood is Not “Normal”: Senators Maggie Hassan (D-NH) and Todd Young (R-IN) shared on December 22 that Quest and Labcorp, the nation’s two largest lab testing companies, had agreed not to report blood lead levels (BLLs) below 3.5 µg/dL as “normal.” Instead the labs will say there is no safe level of lead in a child’s blood. The senators reached out to the companies in November to change the subtle but flawed signal the word “normal” sends in a lab report. The senators acted because “parents looking at these test results may not have understood that their children’s even slightly elevated lead blood levels could cause long-lasting health problems.”
Testing Pregnant People: New Jersey unanimously enacted a law (S3616 and A4848) requiring healthcare professionals who provide prenatal maternity care to test their patient’s blood for lead based on CDC and American College of Obstetricians and Gynecologists (ACOG) guidelines. The ACOG guidelines say the doctor “should perform blood lead testing if a single risk factor is identified.” There are 12 risk factors. (See below.)
If the blood lead test is elevated, the healthcare professional must:
- Notify the patient in writing about the test results with a plain language explanation of the significance of lead poisoning.
- Take appropriate measures to ensure that any of the patient’s children or other members of the patient’s household who are under age 6 are or have been screened for lead exposure.
The lab analyzing the sample must report the test results to the state and the local health department where the pregnant person resides within 5 days. The information reported to and compiled by the state health department must be kept confidential except for use in statistical reports that exclude the name and other personally identifying information of the patient. The state needs to issue regulations to implement the new law.
Why It’s Important
Effectively assessing and communicating risk is challenging even under the best of circumstances. A parent getting a lab report saying their child has a blood lead level of 2 µg/dL needs context. They will likely focus on the word “normal” and not recognize that their child has been exposed to lead and that they need to be vigilant about lead risks.
Similarly, a busy OB-GYN trying to quickly assess a patient for 12 nuanced risk factors (see below) may be inclined to assume things are “normal” and skip the test and the complicated communications that it may entail. CDC developed its prenatal blood lead testing guidelines in 2010, before the agency had acknowledged there was no safe level of lead in the blood. Two years later, ACOG adopted CDC’s risk factors and last reaffirmed their use without change in 2023.
In October 2024, two respected OB-GYNs, Katherine Johnson and Blair Wylie, and two pediatricians, Alan Woolf and Marissa Hauptman, published a call for universal lead testing in pregnancy in the journal, Pediatrics. They reported that:
Prenatal exposure may be independently neurotoxic to the developing fetus and can contribute to the overall body burden in childhood because of placental transfer, which occurs unencumbered because of lack of a barrier to placental–fetal lead transport. In addition to fetal effects, lead in blood during pregnancy appears to be associated with preterm birth, impaired fetal growth, and hypertensive complications of pregnancy.
Unfortunately, lead screening based on prenatal risk factors appears underused in practice and does not adequately discriminate between those with and without lead in their blood. This underutilization is not surprising because translating risk factors into simple screening questions is not straightforward . . ..”
They gave five reasons for universal testing:
- Risk-factor–based screening paradigms inadequately predict the BLL during pregnancy.
- Universal blood testing for other conditions, such as hepatitis C or HIV, is routine in pregnancy.
- Pregnancy offers a unique opportunity for health promotion.
- The BLL assay is a relatively inexpensive test.
- Identifying lead in the blood of a pregnant individual offers an opportunity to intervene earlier and at a vulnerable time period for the fetus.
Two compelling presentations at the National Lead and Healthy Housing Conference in Kansas City, Missouri, this past August reinforced the importance of blood lead testing for pregnant people. Eric Bind of the New Jersey Health Department of Health and the Newark Hospital gave case studies showing the results of universal testing for lead and mercury in the hospital and how it can effectively be used to protect the child. In addition, Elyse Pivnick of Isles of New Jersey highlighted the link between prenatal exposure and preeclampsia as well as cardiovascular and kidney disease.
Our Take
We applaud Senators Hassan and Young for their bipartisan action to convince Quest and Labcorp not to report blood lead levels below 3.5 µg/dL as normal. We also thank the companies for their constructive response. Lead in blood may be all-too-common and below reference values that would flag it for intervention, but that does not make it normal or acceptable. Parents need to know there is no safe level of lead in blood so they can take steps to reduce lead exposure.
Regarding prenatal blood lead testing, we share concerns that CDC’s and ACOG’s 12 risk factors are unworkable. A close look at the risk factors makes clear that a healthcare professional is likely to have enough knowledge to address only a handful of them. For example, how are they to know what countries still use leaded gasoline (hint – the US still uses it in aviation) or does not effectively control industrial emissions? Is it realistic for them to check EPA maps to determine if the person lives near a lead smelter or battery recycling plant, especially if they are closed? How are they supposed to know if the family has lead-glazed ceramic pottery or engages in high-risk hobbies or recreational activities?
Nonetheless, we applaud New Jersey for unanimously passing the law requiring healthcare professionals to test pregnant people for lead in their blood. This type of bipartisan support is an important step to reducing the risk to both the patient and the fetus. We understand it is the first state in the country to take legislative action to address the problems.
We also encourage the New Jersey Health Department to move quickly to adopt the implementing regulations and provide tools to help healthcare professionals learn how to assess all 12 risk factors. Finally, we thank Elyse Pivnick for her tireless efforts to help people to recognize the need for action.
CDC’s and ACOG’s 12 Risk Factors for Prenatal Blood Lead Testing
CDC published guidelines in 2010 for the identification and management of lead exposure. Table 4-1 (page 74 of the PDF) provides the risk factors for lead exposure in pregnant and lactating women. ACOG has the same risk factors. The 12 risk factors are:
- Recent immigration from or residency in areas where ambient lead contamination is high. Women from countries where leaded gasoline is still being used (or was recently phased out) or where industrial emissions are not well controlled.
- Living near a point source of lead, such as lead mines, smelters, or battery recycling plants (even if the establishment is closed).
- Working with lead or living with someone who does. Women who work in or who have family members who work in lead-industry (take-home exposures).
- Using lead-glazed ceramic pottery. Women who cook, store, or serve food in lead-glazed ceramic pottery made in a traditional process and usually imported by individuals outside the normal commercial channels.
- Eating nonfood substances (pica). Women who eat or mouth nonfood items that may be contaminated with lead (such as soil or lead-glazed ceramic pottery).
- Using alternative or complementary medicines, herbs, or therapies. Women who use imported home remedies or certain traditional herbs that may be contaminated with lead.
- Using imported cosmetics or certain food products. Women who use imported cosmetics, such as kohl or surma, or certain imported foods or spices that may be contaminated with lead.
- Engaging in certain high-risk hobbies or recreational activities. Women who engage in high-risk activities or have family members who do.
- Renovating or remodeling older homes without lead hazard controls in place. Women who have been disturbing lead paint and/or creating lead dust or spending time in such a home environment.
- Consumption of lead-contaminated drinking water. Women whose homes have leaded pipes or source lines with lead.
- Having a history of previous lead exposure or evidence of elevated body burden of lead. Women who may have high body burdens of lead from past exposures, particularly those who are deficient in certain key nutrients (calcium, iron).
- Living with someone identified with an elevated lead level. Women who may have exposures in common with a child, close friend, or other relative living in the same environment.