Diagnostic testing unwarranted for children with blood lead 10 to 14 microg/dL

Recent statements from the American Academy of Pediatrics and Centers for Disease Control and Prevention recommend diagnostic venous blood lead testing within 90 days of a marginally elevated screening test (10-14 microg/dL).

To evaluate the ability of a marginally elevated capillary (CScr) or venous (VScr) blood lead screening test to predict venous diagnostic (VPb) blood lead (taken within 90 days of the screening test) that would prompt environmental evaluation (>/=20 microg/dL).

Population-based follow-up study comparing CScr and VScr with VPb drawn within 90 days of the screening sample. This study population was drawn from all children aged 0 to 4 years who were screened in Worcester County, Massachusetts, and Providence County, Rhode Island, with CScr and VScr during calendar year 1994.

To evaluate predictive validity, CScr and VScr were correlated with VPb. CScr, VScr, and VPb results were then separated into the following categories: <10, 10 to 14, 15 to 19, and >/=20 microg/dL. CScr and VScr categories were cross-tabulated against VPb categories, and logistic regression analysis was used to evaluate categorical elevations of CScr and VScr as predictors of VPb >/=20 microg/dL.

Of 31 904 children screened with CScr, 5450 (17.1%) were elevated and 1278 were followed up with VPb within 90 days. Of 14 623 children screened with VScr, 2979 (20.4%) were elevated and 614 were followed up with VPb within 90 days. CScr was only weakly correlated with VPb (r = 0.39), whereas VScr was more strongly correlated with VPb (r = 0.73). Compared with CScr <10 microg/dL, CScr in the 10 to 14 microg/dL range did not identify a higher percentage of children with VPb elevation in any category, and falsely misclassified as lead poisoned some 77% of children. Compared with VScr <10 microg/dL, VScr in the 10 to 14 microg/dL range identified higher percentages of children with VPb in the 10 to 19 microg/dL range but not with VPb >/=20 microg/dL, and falsely misclassified as lead poisoned 42% of children. Compared with screening tests <10 microg/dL, the odds of identifying a child with VPb >/=20 were no different from 1 for CScr of 10 to 14 microg/dL (adjusted odds ratio 1.4 [95% confidence interval 0.3, 6.6]), CScr of 15 to 19 microg/dL (3.2 [0.7, 15.7]), or VScr of 10 to 14 microg/dL (0.9 [0.3, 3.0]). CScr and VScr in the 15 to 19 microg/dL range were associated with significantly higher odds of having VPb >/=20 microg/dL when compared with screening tests <10 microg/dL.

These data indicate that special diagnostic testing within 90 days for children with CScr and VScr in the 10 to 14 microg/dL range does not result in greater identification of VPb >/=20. Raising the set point for diagnostic testing to 15 microg/dL in this sample would eliminate the unnecessary follow-up of 5162 children, of whom 3360 were falsely misclassified as having undue lead exposure.