Impact of the COVID-19 Pandemic on Blood Lead Testing in Children in the United States.

The study objective was to evaluate the impact of the coronavirus disease (COVID-19) pandemic on pediatric blood lead testing in the United States. Clinical laboratory pediatric (ages <6 years) blood lead level (BLL) tests performed by Quest Diagnostics, January 2019-March 2022, were analyzed. Patients were categorized by age, by sex, and, through matching by ZIP code with US Census data, for race, ethnicity, pre-1950 housing, and poverty estimates. Over 2.8 million results from children (<6 years old) from all 50 states and the District of Columbia were included. Compared to March-May 2019, BLL testing was lower by 53.6% in March-May 2020 and lower by 14.6% in March-May 2021. Testing rebounded more for children in predominantly White non-Hispanic communities and among children living in communities, based on ZIP codes, with the least pre-1950 housing stock and lowest poverty rates. The proportion of children with BLL at or above the United States Centers for Disease Control and Prevention reference values of 3.5 and 5.0 µg/dL fell by 19% and 24%, respectively, in 2021 versus 2019. In conclusion, pediatric BLL testing has rebounded from sharp declines during the early pandemic period but unevenly. Declines in the proportion of children with elevated BLL should be interpreted with caution, as testing rebounds were less robust among communities with the highest risk of lead poisoning, notably communities with the oldest housing stock and higher poverty rates. More public health efforts are needed to address lead toxicity throughout the United States, especially in communities that did not experience a full rebound subsequent to the early COVID-19 pandemic period.

Environmental Impact of a Pediatric and Young Adult Virtual Medicine Program: A Lesson from the COVID-19 Pandemic.

OBJECTIVES: The Coronavirus Disease 2019 (COVID-19) pandemic led to the expansion of virtual medicine as a method to provide patient care. We aimed to determine the impact of pediatric and young adult virtual medicine use on fossil fuel consumption, greenhouse gas, and nongreenhouse traffic-related air pollutant emissions. METHODS: We conducted a retrospective analysis of all virtual medicine patients at a single quaternary-care children's hospital with a geocoded address in the Commonwealth of Massachusetts prior to (March 16, 2019-March 15, 2020) and during the COVID-19 pandemic (March 16, 2020-March 15, 2021). Primary outcomes included patient travel distance, gasoline consumption, carbon dioxide and fine particulate matter emissions as well as savings in main hospital energy use. RESULTS: There were 3,846 and 307,273 virtual visits performed with valid Massachusetts geocoded addresses prior to and during the COVID-19 pandemic, respectively. During 1 year of the pandemic, virtual medicine services resulted in a total reduction of 620,231 gallons of fossil fuel use and $1,620,002 avoided expenditure as well as 5,492.9 metric tons of carbon dioxide and 186.3 kg of fine particulate matter emitted. There were 3.1 million fewer kilowatt hours used by the hospital intrapandemic compared to the year prior. Accounting for equipment emissions, the combined intrapandemic emission reductions are equivalent to the electricity required by 1,234 homes for 1 year. CONCLUSIONS: Widespread pediatric institutional use of virtual medicine provided environmental benefits. The true potential of virtual medicine for decreasing the environmental footprint of health care lies in scaling this mode of care to patient groups across the state and nation when medically feasible.

Predictors of Subspecialty Appointment Scheduling and Completion for Patients Referred From a Pediatric Primary Care Clinic.

Failure to complete subspecialty referrals decreases access to subspecialty care and may endanger patient safety. We conducted a retrospective analysis of new patient referrals made to the 14 most common referral departments at Boston Children's Hospital from January 1 to December 31, 2017. The sample included 2031 patient referrals. The mean wait time between referral and appointment date was 39.6 days. In all, 87% of referrals were scheduled and 84% of scheduled appointments attended, thus 73% of the original referrals were completed. In multivariate analysis, younger age, medical complexity, being a non-English speaker, and referral to a surgical subspecialty were associated with a higher likelihood of referral completion. Black and Hispanic/Latino race/ethnicity, living in a Census tract with Social Vulnerability Index (SVI) ≥ 90th percentile, and longer wait times were associated with a lower likelihood of appointment attendance. Future interventions should consider both health care system factors such as appointment wait times and community-level barriers to referral completion.

Impact of the COVID-19 Pandemic on Childhood Lead Testing and Blood Lead Levels.

OBJECTIVE: To evaluate the effect of the COVID-19 pandemic on childhood lead testing and blood lead levels. METHODS: A retrospective analysis of lead tests and results was performed across 3 urban medical centers during the pre-COVID-19 (March 10, 2019-March 9, 2020) and COVID-19 (March 10, 2020-March 10, 2022) periods. Interrupted time series analysis with quasi-Poisson regression was used to evaluate changes in lead testing between study periods. The relationship between sociodemographic features with detectable (≧2 µg/dL) and elevated (≧3.5 µg/dL) blood lead levels (BLLs) was assessed with multivariable logistic regression. RESULTS: Among a total of 16,364 lead tests across 10,362 patients, weekly testing rates significantly decreased during COVID-19 (relative risk (RR) 0.64, 95% (confidence interval) CI 0.53-0.78). Census tracts with the greatest proportion of pre-1950s housing had a stronger association with detectable BLLs during the COVID-19 period (pre-COVID-19 adjusted odds ratio (aOR) 1.73, 95% CI 1.35-2.20; aOR 2.58, 95% CI 2.13-3.12; interaction P value .014). When limited to 1 year following COVID-19 (March 10, 2020-March 10, 2021), the association between both elevated BLLs (pre-COVID-19: aOR 1.49, 95% CI 0.87-2.53; COVID-19: aOR 3.51, 95% CI 1.98-6.25; interaction P value .032) and detectable BLLs with pre-1950s housing were greater during the COVID-19 period (pre-COVID-19: aOR 1.73, 95% CI 1.35-2.20; COVID-19: aOR 2.56, 95% CI 1.95-3.34; interaction P value .034). CONCLUSIONS: The COVID-19 pandemic led to a significant reduction in lead surveillance and magnified the effect of known risk factors for lead exposure. Concerted clinical, public health, and community advocacy are needed to address care gaps and excess cases of lead poisoning.

Preferred Language Mediates Association Between Race, Ethnicity, and Delayed Presentation in Critically Ill Patients With COVID-19.

Which social factors explain racial and ethnic disparities in COVID-19 access to care and outcomes remain unclear. OBJECTIVES: We hypothesized that preferred language mediates the association between race, ethnicity and delays to care. DESIGN SETTING AND PARTICIPANTS: Multicenter, retrospective cohort study of adults with COVID-19 consecutively admitted to the ICU in three Massachusetts hospitals in 2020. MAIN OUTCOME AND MEASURES: Causal mediation analysis was performed to evaluate potential mediators including preferred language, insurance status, and neighborhood characteristics. RESULTS: Non-Hispanic White (NHW) patients (157/442, 36%) were more likely to speak English as their preferred language (78% vs. 13%), were less likely to be un- or under-insured (1% vs. 28%), lived in neighborhoods with lower social vulnerability index (SVI) than patients from racial and ethnic minority groups (SVI percentile 59 [28] vs. 74 [21]) but had more comorbidities (Charlson comorbidity index 4.6 [2.5] vs. 3.0 [2.5]), and were older (70 [13.2] vs. 58 [15.1] years). From symptom onset, NHW patients were admitted 1.67 [0.71-2.63] days earlier than patients from racial and ethnic minority groups (p < 0.01). Non-English preferred language was associated with delay to admission of 1.29 [0.40-2.18] days (p < 0.01). Preferred language mediated 63% of the total effect (p = 0.02) between race, ethnicity and days from symptom onset to hospital admission. Insurance status, social vulnerability, and distance to the hospital were not on the causal pathway between race, ethnicity and delay to admission. CONCLUSIONS AND RELEVANCE: Preferred language mediates the association between race, ethnicity and delays to presentation for critically ill patients with COVID-19, although our results are limited by possible collider stratification bias. Effective COVID-19 treatments require early diagnosis, and delays are associated with increased mortality. Further research on the role preferred language plays in racial and ethnic disparities may identify effective solutions for equitable care.

Effect of radon exposure on asthma morbidity in the School Inner-City Asthma study.

BACKGROUND: Radon may have a role in obstructive lung disease outside its known carcinogenicity. Little is known about radon's effects on asthma morbidity. OBJECTIVE: To determine the effect of radon on fractional exhaled nitric oxide (FE NO), asthma symptom-days, and lung function in inner-city asthmatic school children. METHODS: Two hundred ninety-nine school-aged asthmatic children enrolled in the School Inner-City Asthma Study (SICAS-1) were followed. One and two-month averaged radon was assessed using a spatiotemporal model predicting zip code-specific monthly exposures. FE NO and spirometry were measured twice during the academic year. Asthma symptoms were assessed four times during the academic year. The interaction between indoor radon exposure (Bq/m3 ) and seasonality predicting log-transformed FE NO, forced expiratory volume in 1 s (FEV1 ) % predicted, forced vital capacity (FVC) % predicted, FEV1 /FVC, and asthma symptom-days was evaluated. RESULTS: Participants with high radon exposure had greater change in FE NO from warm to cold periods compared to low radon exposure (interaction p = 0.0013). Participants with >50th percentile radon exposure experience significant FE NO increase from warm to cold weather ( ß $\beta $ = 0.29 [95% confidence interval [CI]: 0.04-0.54], p = 0.0240). We report a positive association between radon 1-month moving average (incidence rate ratio [IRR] = 1.01, p = 0.0273) and 2-month moving average (IRR = 1.01, p = 0.0286) with maximum asthma symptom-days (n = 299, obs = 1167). CONCLUSIONS: In asthmatic children, radon may be associated with increased asthma morbidity, suggesting radon may be a modifiable environmental risk factor for airway inflammation.

Neighborhood disparities and the burden of lead poisoning.

BACKGROUND: To assess the persistence of neighborhood-level lead poisoning disparities in Rhode Island. METHODS: Rhode Island Department of Health blood lead levels (BLL) collected from 2006-2019 were linked to census block group rates of poverty and housing built pre-1950. We computed multivariate logistic regression models of elevated BLLs (≥5 µg/dL and ≥10 µg/dL). RESULTS: Of the 197,384 study children, 12.9% had BLLs ≥5 µg/dL and 2.3% had BLLs ≥10 µg/dL. The proportion of children with BLL ≥ 5 µg/dL increased across quintiles of poverty and old housing. The odds ratio for highest quintiles was 1.44 (95% CI: 1.29, 1.60) and 1.92 (95% CI: 1.70, 2.17) for poverty and pre-1950 housing, respectively. A significant temporal decline was observed for BLL ≥ 5 µg/dL (2006: 20.5%, 2019: 3.6%). Disparities narrowed over the study period across quintiles of poverty and old housing with a similar trend appearing in the proportion of children with BLL ≥ 10 µg/dL. CONCLUSION: Despite tremendous progress in reducing lead exposure, substantial neighborhood disparities in lead poisoning persist. These findings provide valuable considerations for primary childhood lead exposure prevention. IMPACT: Through linkage of Rhode Island Department of Health childhood lead poisoning and census data, this study captures neighborhood-level disparities in lead poisoning from 2006-2019. This study demonstrates that the odds of lead poisoning increased in a stepwise fashion for neighborhood quintiles of poverty and housing built pre-1950. While the magnitude of lead poisoning disparities narrowed across quintiles of poverty and old housing, disparities persist. Children's exposure to sources of lead contamination continues to be an important public health concern. The burden of lead poisoning is not equally distributed among all children or communities.

HEPA filtration intervention in classrooms may improve some students' asthma.

OBJECTIVE: The School Inner-City Asthma Intervention Study 2 (SICAS 2) tested interventions to reduce exposures in classrooms of students with asthma. The objective of this post-hoc analysis was limited to evaluating the effect of high-efficiency particulate (HEPA) filtration interventions on mold levels as quantified using the Environmental Relative Moldiness Index (ERMI) and the possible improvement in the students' asthma, as quantified by spirometry testing. METHODS: Pre-intervention dust samples were collected at the beginning of the school year from classrooms and corresponding homes of students with asthma (n = 150). Follow-up dust samples were collected in the classrooms at the end of the HEPA or Sham intervention. For each dust sample, ERMI values and the Group 1 and Group 2 mold levels (components of the ERMI metric) were quantified. In addition, each student's lung function was evaluated by spirometry testing, specifically the percentage predicted forced expiratory volume at 1 sec (FEV1%), before and at the end of the intervention. RESULTS: For those students with a higher Group 1 mold level in their pre-intervention classroom than home (n = 94), the FEV1% results for those students was significantly (p < 0.05) inversely correlated with the Group 1 level in their classrooms. After the HEPA intervention, the average Group 1 and ERMI values were significantly lowered, and the average FEV1% test results significantly increased by an average of 4.22% for students in HEPA compared to Sham classrooms. CONCLUSIONS: HEPA intervention in classrooms reduced Group 1 and ERMI values, which corresponded to improvements in the students' FEV1% test results.

A cross-validation based approach for estimating specific gravity in elementary-school aged children using a nonlinear model.

Environmental research often relies on urinary biomarkers which require dilution correction to accurately measure exposures. Specific gravity (SG) and creatinine (UCr) are commonly measured urinary dilution factors. Epidemiologic studies may assess only one of these measures, making it difficult to pool studies that may otherwise be able to be combined. Participants from the National Health and Nutrition Examination Survey 2007-2008 cycle were used to perform k-fold validation of a nonlinear model estimating SG from UCr. The final estimated model was applied to participants from the School Inner-City Asthma Intervention Study, who submitted urinary samples to the Children's Health Exposure Analysis Resource. Model performance was evaluated using calibration metrics to determine how closely the average estimated SG was to the measured SG. Additional models, with interaction terms for age, sex, body mass index, race/ethnicity, relative time of day when sample was collected, log transformed 4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and asthma status were estimated and assessed for improvement. The association between monobenzyl phthalate (MBZP) and asthma symptom days, controlling for measured UCr, measured SG, and each estimated SG were compared to assess validity of the estimated SG. The model estimating SG from UCr alone, resulted in a beta estimate of 1.10 (95% CI: 1.01, 1.19), indicating agreement between model-predicted SG and measured SG. Inclusion of age and sex in the model improved estimation (ß = 1.06, 95% CI: 0.98, 1.15). The full model accounting for all interaction terms with UCr resulted in the best agreement (ß = 1.01, 95% CI: 0.93,1.09). Associations between MBZP and asthma symptoms days, controlling for each estimated SG, were within the range of effect estimates when controlling for measured SG and measured UCr (Rate ratios = 1.28-1.34). Our nonlinear modeling provides opportunities to estimate SG in studies that measure UCr or vice versa, enabling data pooling despite differences in urine dilution factors.

The Coronavirus Disease 2019 Pandemic and Mental Health-Related School-Nurse Visits in United States Schools.

OBJECTIVE: No studies have examined school-nurse visits related to mental health (MH) during the coronavirus disease 2019 (COVID-19) pandemic. We examined changes in the rate of MH-related school-nurse visits before and during the COVID-19 pandemic. METHODS: We analyzed school-nurse visit data (n = 3,445,240) for subjects Grade K-12 in US public schools using electronic health record software (SchoolCare, Ramsey, NJ). Data between January 1 and December 31 in 2019 (pre-COVID-19 pandemic) versus January 1 to December 31 in 2020 (during COVID-19 pandemic) were compared. For each year, total visits to a school-nurse were calculated for general MH, anxiety, and self-harm. The exposure was number of school-nurse visits in each time period (2019 vs 2020). The main outcome was change in the rate of general MH, anxiety, and self-harm visits in 2019 versus 2020. RESULTS: There were 2,302,239 total school-nurse visits in 2019 versus 1,143,001 in 2020. During the COVID-19 pandemic, the rate of visits for general MH increased by 30% (4.7-6.1 per 10,000 visits, 95% confidence interval [CI] {18%, 43%}; P < .001), and visits for anxiety increased by 25% (24.8-31 per 10,000 visits, 95% CI [20%,30%]; P < .001). There was no significant difference in self-harm visits across all ages during the COVID-19 pandemic. CONCLUSIONS: Our study found a significant increase in the rate of school-nurse visits for MH and anxiety during the COVID-19 pandemic, suggesting the pediatric population is at-risk for increased negative MH-effects associated with the pandemic and highlights a critical role of school-nurses in identifying youth with potential MH-needs.

The more you know: Insights from integrated pre-visit surveys in a pediatric environmental health center.

The Pediatric Environmental Health Center (PEHC) at Boston Children's Hospital is a specialty referral clinic that provides consultation for approximately 250 patients annually. Identifying environmental hazards is key for clinical management. Exposure concerns include lead, mold, pesticides, perfluoroalkyl substances (PFAS), impaired air quality, and more. Our goal was to identify concerns and visit priorities of our patient population to guide visits. A 47-question pre-visit survey was created exploring potential environmental hazards and administered prior to visits using a platform integrated into the electronic medical record (EMR). The study group was a convenience sample of patients from June 2021 to June 2022. Of 204 total visits, 101 surveys were submitted, yielding a response rate of 49.5%. 66/101 (65.3%) were surveys from initial consultations used for descriptive analysis. The majority of patients were seen for a chief complaint of lead exposure (90.1%). Most respondents had concerns about peeling paint (40.0%), and those reporting peeling paint were more likely to report additional concerns [75.0%, p < 0.001]. Other concerns highlighted were mold (15.2%), pests (15.2%), asbestos (10.6%), air pollution (9.1%), temperature regulation (7.6%), pesticides (6.1%), PFAS (4.5%), and formaldehyde (4.5%). A knowledge gap was identified; 45.5% (30/66) respondents responded "no" to the question asking if the Poison Control Center phone number was stored in their phone. This study illustrates how the implementation of a pre-visit EMR integrated survey engages families, informs clinical care, and serves as a point-of-care education tool for specific knowledge gaps. Findings will guide development of future environmental health screeners.

Multilevel Risk Factors for Sleep-Disordered Breathing-Related Symptom Burden in an Urban Pediatric Community-Based Sample.

BACKGROUND: Pediatric sleep-disordered breathing (SDB) disproportionately affects children with low socioeconomic status (SES). The multilevel risk factors that drive these associations are not well understood. RESEARCH QUESTION: What are the associations between SDB risk factors, including individual health conditions (obesity, asthma, and allergies), household SES (maternal education), indoor exposures (environmental tobacco smoke [ETS] and pests), and neighborhood characteristics (neighborhood disadvantage), and pediatric SDB symptoms? STUDY DESIGN AND METHODS: Cross-sectional analyses were performed on 303 children (aged 6-12 years) enrolled in the Environmental Assessment of Sleep Youth study from 2018 to 2022. Exposures were determined by caregiver reports, assays of measured settled dust from the child's bedroom, and neighborhood-level Census data (deriving the Childhood Opportunity Index to characterize neighborhood disadvantage). The primary outcome was the SDB-related symptom burden assessed by the OSA-18 questionnaire total score. Using linear regression models, we calculated associations between exposures and SDB-related symptom burden, adjusting for sociodemographic factors, then health conditions, indoor environment, and neighborhood factors. RESULTS: The sample included 303 children (39% Hispanic, Latino, Latina, or Spanish origin; 30% Black or African American; 22% White; and 11% other). Increasing OSA-18 total scores were associated with low household SES after adjustment for demographic factors, and with asthma, allergies, ETS, pests (mouse, cockroach, and rodents), and an indoor environmental index (sum of the presence of pests and ETS; 0-2) after adjusting for sociodemographic factors. Even after further adjusting for asthma, allergies, and neighborhood disadvantage, ETS and pest exposure were associated with OSA-18 (ETS: ß = 12.80; 95% CI, 7.07-18.53, also adjusted for pest; pest exposure: ß = 3.69; 95% CI, 0.44-6.94, also adjusted for ETS). INTERPRETATION: In addition to associations with ETS, a novel association was observed for indoor pest exposure and SDB symptom burden. Strategies to reduce household exposure to ETS and indoor allergens should be tested as approaches for reducing sleep health disparities.

Invited Commentary: There's No Place Like Home-Integrating a Place-Based Approach to Understanding Sleep.

Light exposure at night impedes sleep and shifts the circadian clock. An extensive body of literature has linked sleep deprivation and circadian misalignment with cardiac disease, cancer, mental health disorders, and other chronic illnesses, as well as more immediate risks, such as motor vehicle crashes and occupational injuries. In this issue of the Journal, Zhong et al. (Am J Epidemiol. 2022;191(9):1532-1539) build on this literature, finding that in a cohort of 50,000 California teachers, artificial light at night, noise, green space, and air pollution were all associated with sleep disturbances. Light, noise, air pollution, and the lack of green space are problems inequitably distributed across the population, concentrated among vulnerable populations in inner cities. Zhong et al. provide novel data on the manner in which these local environmental exposures drive sleep deprivation. Future research should explore the degree to which place-based disparities in sleep in turn drive disparities in short and long-term health. Addressing home-based sleep disparities could be an avenue to addressing systemic racism and achieving environmental justice.

Impact of Prenatal Exposure to Smoking on Child Health.

Prenatal exposure to tobacco smoke remains common, through active smoking and/or passive environmental exposure, and is linked to adverse childhood outcomes. Not only have high-quality studies and meta-analyses demonstrated increased risks of prenatal as well as postnatal complications, but adverse child outcomes are well described. In utero exposure to tobacco smoke has been associated with congenital anomalies, infant and teenager overweight and obesity, and neuropsychiatric sequelae. In addition, certain childhood malignancies have been linked to paternal smoking during pregnancy. In this chapter, adverse childhood outcomes related to intrauterine exposure to electronic cigarettes and marijuana are described.

Factors Influencing Classroom Exposures to Fine Particles, Black Carbon, and Nitrogen Dioxide in Inner-City Schools and Their Implications for Indoor Air Quality.

BACKGROUND: School classrooms, where students spend the majority of their time during the day, are the second most important indoor microenvironment for children. OBJECTIVE: We investigated factors influencing classroom exposures to fine particulate matter (PM2.5), black carbon (BC), and nitrogen dioxide (NO2) in urban schools in the northeast United States. METHODS: Over the period of 10 y (2008-2013; 2015-2019) measurements were conducted in 309 classrooms of 74 inner-city schools during fall, winter, and spring of the academic period. The data were analyzed using adaptive mixed-effects least absolute shrinkage and selection operator (LASSO) regression models. The LASSO variables included meteorological-, school-, and classroom-based covariates. RESULTS: LASSO identified 10, 10, and 11 significant factors (p<0.05) that were associated with indoor PM2.5, BC, and NO2 exposures, respectively. The overall variability explained by these models was R2=0.679, 0.687, and 0.621 for PM2.5, BC, and NO2, respectively. Of the model's explained variability, outdoor air pollution was the most important predictor, accounting for 53.9%, 63.4%, and 34.1% of the indoor PM2.5, BC, and NO2 concentrations. School-based predictors included furnace servicing, presence of a basement, annual income, building type, building year of construction, number of classrooms, number of students, and type of ventilation that, in combination, explained 18.6%, 26.1%, and 34.2% of PM2.5, BC, and NO2 levels, whereas classroom-based predictors included classroom floor level, classroom proximity to cafeteria, number of windows, frequency of cleaning, and windows facing the bus area and jointly explained 24.0%, 4.2%, and 29.3% of PM2.5, BC, and NO2 concentrations, respectively. DISCUSSION: The adaptive LASSO technique identified significant regional-, school-, and classroom-based factors influencing classroom air pollutant levels and provided robust estimates that could potentially inform targeted interventions aiming at improving children's health and well-being during their early years of development. https://doi.org/10.1289/EHP10007.

Risk-Factor Based Lead Screening and Correlation with Blood Lead Levels in Pregnancy.

OBJECTIVES: Lead exposure has devastating neurologic consequences for children and may begin in utero. The American College of Obstetricians and Gynecologists recommends prenatal lead screening using a risk factor-based approach rather than universal blood testing. The clinical utility of this approach has not been studied. We evaluated a risk-factor based questionnaire to detect elevated blood lead levels in pregnancy. METHODS: We performed a secondary analysis of a cohort of parturients enrolled to evaluate the association of lead with hypertensive disorders of pregnancy. We included participants in this analysis if they had a singleton pregnancy ≥ 34 weeks' gestation with blood lead levels recorded. Participants completed a lead risk factor survey modified for pregnancy. We defined elevated blood lead as ≥ 2 µg/dL, as this was the clinically reportable level. RESULTS: Of 102 participants enrolled in the cohort, 92 had blood lead measured as part of the study. The vast majority (78%) had 1 or more risk factor for elevated lead using the questionnaire yet none had clinical blood lead testing during routine visits. Only two participants (2.2%) had elevated blood lead levels. The questionnaire had high sensitivity but poor specificity for predicting detectable lead levels (sensitivity 100%, specificity 22%). CONCLUSIONS FOR PRACTICE: Prenatal risk-factor based lead screening appears underutilized in practice and does not adequately discriminate between those with and without elevated blood levels. Given the complexity of the risk factor-based approach and underutilization, the benefit and cost-effectiveness of universal lead testing should be further explored.