CDC Recommendations on Lead Poisoning in Refugee Children

The Centers for Disease Control and Prevention (CDC) has released recommendations on identifying and treating lead exposure in refugee children. The full report, “Recommendations for Lead Poisoning Prevention in Newly Arrived Refugee Children,” is available online at http://www.cdc.gov/nceh/lead.

Although blood lead levels in children one to five years of age are decreasing in the United States, the prevalence of elevated blood lead levels among newly resettled refugee children is substantially higher than in children born in the United States.

The CDC recommends that physicians test blood lead levels for all refugee children six months to 16 years of age upon entering the United States. After children six months to six years of age are placed in permanent residences, testing should be repeated in three to six months. In older children, testing should be repeated if a child has a sibling with elevated blood lead levels, regardless of his or her initial test results.

The CDC guidelines recommend performing nutritional evaluations for all refugee children upon their arrival in the United States, and providing appropriate nutritional and vitamin supplements when needed. Physicians also should evaluate the value of iron supplementation in refugee children.

AAP Policy on Caring for Immigrant, Migrant, and Homeless Children

The Committee on Community Health Services of the American Academy of Pediatrics (AAP) has developed a new policy statement on providing health care for immigrant, homeless, and migrant children. The policy statement, which appears in the April 2005 issue of Pediatrics, supports a community-based approach to ensure that underserved children get the care they need. Persons in medically underserved communities face many obstacles to health care—such as poverty, lack of insurance, low level of English language proficiency, and the more urgent need for food and accommodation—and often seek health care on a crisis-oriented rather than preventive basis. The AAP urges physicians to provide compassionate and effective health care services to all children living in the United States, regardless of status. Physicians should be aware of alternative sources of funding or medical provision, and of supportive resources in their local area (a list of resources is provided in the statement). In addition, the AAP committee recommends that physicians develop and maintain cultural and linguistic knowledge and skills, and advocate on behalf of underserved children.

According to the AAP committee, physicians fill a unique role in medically under-served communities and should therefore understand the particular health issues common to these communities. Many of these issues are listed in the statement. For migrant families (e.g., farm workers), potential issues include overcrowded housing, poor sanitation, and cultural isolation. Migrant children are at increased risk for respiratory, skin, and ear infections, as well as gastroenteritis, parasites, tuberculosis, lead exposure, poor nutrition, undiagnosed congenital abnormalities, delayed development, and occupational injuries.

Specific issues faced by homeless children include trauma-related injury, developmental delays, visual or neurologic deficits, sinusitis, anemia, bowel dysfunction, obesity, and hunger. Homeless children also are at increased risk for violence, substance abuse, pregnancy, and sexually transmitted diseases.

Stressors experienced by immigrant families include acculturation-induced depression; separation from support systems; traumatic experiences such as war or persecution; and trouble adapting to the school environment, with consequent depression, posttraumatic stress disorder, or conduct disorders. Physicians also need to be mindful of diseases that are rare in the United States but common to the patient’s country of origin (e.g., malaria).

Children may be lacking screening and vaccinations that are routine in the United States, and the AAP recommends that physicians perform these according to standard protocols. Screenings for developmental delays should be part of the initial well-child assessment. Children who do not meet established weight or height measures should be monitored closely. The AAP committee also states that physicians should be aware of traditional medications that may interfere with prescribed therapy, and of medical beliefs that may cause noncompliance.

The AAP committee recommends that physicians caring for homeless, migrant, and immigrant children incorporate screening for social and environmental circumstances into routine assessments. Information about housing, healing practices, and medication use should be obtained respectfully as part of the patient history. The AAP advises the introduction of tracking systems such as portable medical records to ensure that homeless children receive at least basic health care. Physicians need to consider the limitations concomitant with homelessness, such as lack of refrigeration for medications.