Lead-Safe Wisconsin: Health Care Guidance for Children and Perinatal Patients
Local health departments and clinicians work together to support lead poisoning case management. This page provides a breakdown of the State of Wisconsin's lead testing and case management guidelines for children and perinatal patients.
Lead testing for children
Wisconsin recommends universal testing. Universal testing means that every child should be tested for lead. The state recommends:
- All children should receive a blood lead test at both age 1 and age 2.
- All children between ages 3 and 5 should receive a blood lead test if they have not yet been tested.
Lead can affect any child, and symptoms commonly do not appear until it is too late to prevent substantial health problems. Universal testing ensures that no child is missed.
To learn more about the state's stance on blood lead testing, visit Get Your Child Tested for Lead
State definitions for different blood lead levels
There is a difference between how the state of Wisconsin defines a lead-poisoned child and a child with an elevated blood lead level (EBLL). The difference is important, because it informs what healthcare responses are required.
The official definitions of lead poisoning and elevated blood lead level can be found under Wisconsin Stat. § 254.11 definitions.
In Wisconsin, a child is considered to have an elevated blood lead level (EBLL) if either of the following are true:
- One venous blood lead level is greater than or equal to 20 µg/dL.
- Two venous blood lead levels are greater than or equal to 15 µg/dL when drawn at lead 90 days apart.
An EBLL prompts public health actions like home visits, inspections, and nursing case management.
There is no safe level of lead in the blood. Even small amounts of lead can harm a child's development. However, both the CDC (Centers for Disease Control and Prevention) and the Wisconsin Department of Health Services (DHS) have set action levels to help identify and respond to children who are most at-risk for serious health impacts.
Wisconsin recognizes any blood lead level greater than or equal to 3.5 µg/dL as evidence of lead poisoning. This is based on the CDC's current reference value. At this level, clinicians should offer follow-up testing and educational support. Families should take steps to reduce further exposure.
Childhood lead poisoning case management guidance
The State of Wisconsin recommends different actions depending on a child's blood lead level. The following information can also be found in the Childhood Blood Lead Level Case Management Guidance, P-03474 (PDF).
| Blood lead levels | Local health department actions | HHLPSS actions |
|---|---|---|
| 0 - 3.4 µg/dL | Continue to follow Wisconsin's universal testing recommendations. Confirmatory blood lead tests are not required for blood lead levels below 3.5 µg/dL. If applicable, provide clinical case management guidance per local health department (LHD) policy or consolidated contract, whichever is more protective. | New clinical case does not open. New environmental investigation does not open. "New blood lead test" alert is sent for open clinical cases. |
| 3.5 - 4.9 µg/dL | Follow recommendations above for 0-3.4 µg/dL. Ensure that the child's provider schedules a confirmatory venous sample, if applicable. Provide clinical case management (if applicable) per LHD policy or consolidated contract, whichever is more protective. View the CDC's Recommended Actions Based on Blood Lead Level for the:
Document case management activities related to the child in the HHLPSS clinical tab until closure criteria are met. Refer children enrolled in Medicaid to the Lead-Safe Homes Program. | A new clinical case opens; "new case" alert is sent. "New blood lead test" alert is sent for open clinical cases. A new environmental investigation opens. A "new investigation" alert is sent for venous samples only. |
| 5 - 45 µg/dL | Clinical case management and environmental investigation is recommended for all cases. Follow recommendations for 3.5 - 4.9 µg/dL. Follow LHD consolidated contract objectives found in the Grants and Contracts (GAC) system. At minimum, cases where children meet the EBLL definition require:
Refer to Children's Wisconsin Lead Poisoning Guidelines.
Refer to the case closure requirements to understand when to close an environmental investigation in HHLPSS. | Actions are the same as those for 3.5 - 4.9 µg/dL. |
| ≥ 45 µg/dL | Follow all recommendations for 5 - 45 µg/dL. Ensure that the child's healthcare provider is consulting with a medial toxicologist to initiate gastrointestinal decontamination or chelation therapy. Ensure that hospitalized children are released to a lead-safe environment.
Consult with Poison Control at 800-222-1222 or Region 5 Pediatric Environmental Health Specialty Unis (PESHU). | Actions are the same as those for 3.5 - 4.9 µg/dL. |
Clinical cases
Type of case | When a case may be closed |
|---|---|
| Clinical case meets EBLL definition | Child has 2 consecutive BLLs less than 15 µg/dL at least 6 months apart. Child is living in a lead-safe environment. Including:
The case meets LHD policy and procedure closure criteria (if applicable). |
| Clinical case does not meet EBLL definition | Reasons vary. Follow LHD policy and procedures. |
Other reasons for closure
- Unable to locate child or family.
- Family refuses further investigation.
Note: for children who change jurisdictions, move to another state, or do not meet any of the criteria above, contact the Childhood Lead Poisoning Prevention Program at DHSLeadPoisoningPrevention@wi.gov.
Environmental investigations
Type of case | Directions for closure |
|---|---|
| Properties where no investigation is planned because the child has a BLL below the EBLL definition and below the LHD consolidated contract objective | The LHD should close the HHLPSS investigation as soon as possible. HHLPSS will not send new environmental alerts when an investigation is open. |
| Properties associated with a child's BLL meeting the EBLL definition or LHD consolidated contract objective | After all identified hazards have been corrected by the property owner, the LHD successfully clears the property of any orders, and the LHD has completed and uploaded all required forms into HHLPSS, the Childhood Lead Poisoning Prevention Program staff at DHS will close the property investigation. |
Other reasons for closure*
- The child never resided at the property.
- The property owner refuses an investigation.
- Unable to local the residents of the property.
Note: these other reasons do not apply if the case is associated with a child that met the EBLL definition.
*If a child moves, the BLL at the time that they moved determines if the new address should be investigated or if the case can be closed based on the above criteria.
The following case management activities can be done by the public health nurse or the primary care provider.
Lead education
Lead prevention information
Developmental assessment
Nutritional counseling
Referrals for support as needed
History and physical exam
| Blood Lead Level (µg/dL) | Time between BLL notification and investigation |
|---|---|
| 3.5 - 19.9 µg/dL | Within 2 weeks |
| 20 - 44.9 µg/dL | Within 1 week |
| 45 - 69.9 µg/dL | Within 48 hours |
| 70 µg/dL or higher | Within 24 hours |
Case management forms
Environmental investigation forms and templates
- Property Investigation Report F-44771C
- Property Investigation Closure Report F-44771D
- Scope of Work to Correct Lead Hazards
- Work Specification Language for Lead Hazard Reduction
- Risk Assessment Report
- Lead Work Orders Letter (Word)
- Lead Clearance Examination Report (Word)
- U.S Department of Housing and Urban Development: Resident Questionnaire for Investigations of Children with EBLLs
Additional resources for medical providers
- Childhood Blood Lead Level Case Management Guidelines, P-03474
- Guidelines for reporting employer information to Wisconsin Adult Blood Lead Epidemiology and Surveillance Program, P-03347 (PDF)
- Elevated Blood Lead (EBL) Investigation Forms and Supplies Tool, P-03266 (PDF)
- Blood Lead Lab Reporting, F-00017
- Training: Childhood Lead Poisoning Prevention (CDC)
- COLE Stellar Practices to Increase Lead Testing (PDF)
Lead testing and screening for perinatal patients
Lead can harm both pregnant person and baby. Lead in the blood during pregnancy has been associated with poor health outcomes, such as:
- Pre-eclampsia
- Miscarriage
- Gestational hypertension
- Low birth weights
- Impaired fetal neurodevelopment
Lead can cross the placental barrier, which can expose the developing fetal brain to lead.
During pregnancy: actions to take starting at the first prenatal visit
Early screening, testing, and action can prevent harm to both the pregnant person and the infant. The following steps should be taken to minimize the health risks associated with lead exposure and lead poisoning. Healthcare providers should:
- Determine the patient's lead exposure risk;
- Educate the patient on how to prevent exposure to lead;
- Encourage healthy nutrition.
Educational information and handouts can be found under the heading educational information for all patients.
Determine your patient's lead exposure risk
Use this Risk Factor Questionnaire (PDF) to screen a pregnant patient for their risk of lead exposure or lead poisoning. The Risk Factor Questionnaire allows providers to quickly determine if there's a chance that a patient is being exposed to lead. It also helps determine if there's a chance that a patient was exposed to lead in childhood. Both scenarios can put a pregnant patient and their baby at risk. If a patient presents with any risk of lead poisoning or lead exposure, a provider should order a venous blood lead test.
If it is determined that a patient is at risk of lead exposure or lead poisoning, providers should:
- Order a venous blood lead test.
- Follow the guidance below.
- Work with the patient to identify and interrupt the source of lead exposure.
The Risk Factor Questionnaire (PDF) is designed to help providers in screening their patients for their risk of lead exposure or lead poisoning. If a patient answers 'yes' to any of the questions on the risk factor questionnaire, the provider should order a venous blood test.
Risk factor questions
Individual questions
| Question | Yes? |
|---|---|
| Have your ever been told that you have an elevated blood lead level or lead poisoning? | |
| Were you born outside of the U.S.? | |
| During this pregnancy, have you craved, eaten, or chewed on any non-food items such as clay, soil, pottery, or paint chips? | |
| Do you live with someone who currently has an elevated blood lead level or who has been diagnosed with lead poisoning? |
Occupation or hobbies
| Question | Yes? |
|---|---|
Do you, or does anyone in your household, work with lead or lead paint? (Examples include construction, renovation, painting, metalwork, battery manufacturing, or ammunition manufacturing.) | |
Do you, or does someone in your household, have any hobbies that involve lead? (Examples include casting or reloading ammunition, making fishing weights, restoring cars or boats, making pottery, making stained glass, or using paints or glazes that might contain lead.) |
Home and environment
| Question | Yes? |
|---|---|
| Do you live in or regularly visit a house or building constructed before 1978? | |
Is your house or rental on a lead service line? (By October 2024, all Wisconsin public water systems were required to submit an inventory of their lead services lines to the DNR. Check your local municipality's webpage for more info.) | |
| Do you live near an open or closed smelter, old factory, mine, small airport, racetrack, or battery recycling plant? |
Products, food, and traditional remedies*
| Question | Yes? |
|---|---|
Do you use any imported or traditional remedies or medicines? (Examples include arzacon, greta, or herbal mixtures from East Indian, Middle Eastern, or Hispanic cultures.) | |
Do you use any imported cosmetics? (Examples include kohl, surma, or henna.) | |
| Do you use any antique, thrifted, vintage, handmade, or imported pottery for cooking, serving food, or storing food? |
*It's important to keep in mind that some cultural practices may involve the consumption of spices or other products that have historically contained lead. Some types of kohl and sindoor, products commonly used as cosmetics, have also tested positively for lead.
To learn more about lead in cultural products, visit DHS's webpage Sources of Lead: Consumer Products.
Blood lead testing: Recommended actions by blood lead level
The state of Wisconsin considers an individual with a venous blood lead level (BLL) greater than or equal to (≥) 3.5 µg/dL to be lead poisoned. If a patient has an initial capillary blood lead test result of ≥ 3.5 µg/dL, they should receive a confirmatory venous test. This test confirms that the initial capillary blood lead test was accurate.
Subsequent follow-up tests help to monitor the patient. If blood lead levels go down, the source of lead exposure was potentially identified and eliminated or reduced.
The following blood lead testing recommendations are based on the guidance from the American College of Obstetricians & Gynecologists (ACOG): Lead Screening During Pregnancy and Lactation.
| Initial BLL | First follow-up test | Subsequent follow-up tests | Test at delivery |
|---|---|---|---|
| 3.5 - 14 µg/dL | Venous, within 1 month. | None needed, unless the first follow-up test places the patient into the next tier. | Maternal venous and/or cord blood. |
| 15 - 24 µg/dL | Venous, within 1 month. | Venous, every 2-3 months. | Maternal venous and/or cord blood. |
| 25 - 44 µg/dL | Venous, within 1 month. | Venous, monthly. | Maternal venous and/or cord blood. |
| ≥ 45 µg/dL | Venous, within 24 hours. Consult with an expert in lead poisoning and chelation. | Venous, at frequent intervals depending on clinical interventions and trend in blood lead levels. | Maternal venous and/or cord blood. Consult with a maternal fetal medicine specialist. |
After pregnancy: guidance for lactating patients
It is possible for babies to be exposed to lead through breast milk. Patient monitoring is vital in protecting the health of both the breastfeeding patient and baby.
Determine your patient's lead exposure risk
If not completed during pregnancy, use the Risk Factor Questionnaire (PDF) to screen a lactating patient for their risk of lead poisoning or lead exposure.
If you identify that the patient is a risk of lead exposure or poisoning,
- Order a venous blood lead test.
- Provide patient education on preventing exposure to lead.
Breastfeeding recommendations by patient's blood lead level
Breastfeeding gives babies optimal nutrition and protects them against common illnesses. While formula is a safe alternative, breastfeeding offers superior short-term health advantages. For this reason, breastfeeding is recommended for all patients except for those with extremely high blood lead levels.
| Blood lead level | Recommended action |
|---|---|
| < 40 µg/dL | Continue breastfeeding. |
| ≥ 40 µg/dL | Pump and discard breastmilk until blood lead levels drop below 40 µg/dL. |
For any patient with a blood lead level ≥ 15 µg/dL, providers should continue to:
- Monitor the patient's blood lead level.
- Notify the infant's clinician that continued BLL monitoring is recommended.
- Provide patient education about reducing sources of lead exposure.
More information for providers of perinatal patients
- Risk Factors and Pregnancy | Childhood Lead Poisoning Prevention | CDC
- Lead Screening During Pregnancy and Lactation | ACOG
- Lead and pregnancy: Know the risks | Poison Control
- Adult Lead Program (DHS)
Educational information for all patients
| Title | Description | Language(s) |
|---|---|---|
| 3 ways to protect your child from lead poisoning, P-03557B | Three top tips to prevent lead poisoning and keep your child safer. | English, Spanish, Hmong |
| How to Talk with your Child's Doctor about Lead Testing, P-03557J | Doctor's appointments can be filled with lots of activity, questions, and information, but your health care team is there to help you. Learn how to talk to your doctor. | English, Spanish, Hmong |
| Sources of Lead Exposure, P-03605 | Understand common sources of lead exposure. | English, Spanish |
| Keeping You and Your Family Safe from Lead, P-02409 | Information about potential lead exposures and your work, hobbies, or pregnancy. | English, Spanish, Hmong |
| Lead in Drinking Water Fact Sheet, P-02602 | Understand how to protect yourself from lead in water. | English, Spanish, Hmong |
| Lead-Safe Homes Program: Making Homes Lead-Safe for Kids, P-03292 | The Lead-Safe Homes program works with eligible families to renovate their pre-1978 homes. | English |
| Know the facts: Protect your child from lead exposure (CDC) | This fact sheets provides information that can help you protect your child from lead exposure. | English, Spanish |
| Lead poisoning: 5 things you can do to lower your child's lead level (CDC) | If your child has a high blood lead level, there are things you can do at home to help. | English, Spanish |
| Fight Lead Poisoning with a Healthy Diet (EPA) | Brochure for parents explaining lead hazards and providing information on how a healthy diet can protect against lead's harmful effects. | English, Spanish |
| What You Should Know about Your Child's Blood Lead Test Result (NCHH) | Understand your child's blood lead test result. | English |
| Keep Your Family Safe - Don't Bring Lead Home From Your Job, P-01737 | You can come into contact with lead through your job or hobbies. Don't bring it home! | English, Spanish, Hmong |
| The Lead-Safe Certified Guide to Renovate Right (EPA) | General information about legal requirements for safe lead practices for homeowners, tenants, child care providers, and parents during renovation activities. | English, Spanish |
| Lead Bullets and Venison: What every hunting family should know (DNR, DHS) | Protect yourself and your family from the hazards associated with lead bullets. | English |
| Are You Pregnant? Prevent Lead Poisoning: Start Now (CDC) | Lead can pass from mother to baby. The good news is that lead poisoning is preventable. | English, Spanish |
A healthy diet can help reduce how much lead the body absorbs. Certain nutrients make it harder for lead to stay in the body.
During pregnancy and lactation, lead from prior exposures can be mobilized from the bones due to increased bone turnover. Adequate calcium intake can help reduce lead from remobilizing into the blood steam.
Patients, or their guardians, should be educated on the importance of a diet that includes:
Iron, calcium, and zinc
Iron, calcium, and zinc compete with lead for absorption. Eating foods rich in these nutrients can result in less lead being absorbed by the body.
Iron-rich foods
- Meat
- Beans
- Iron-fortified whole grains and cereals
- Eggs
- Fish
Calcium-rich foods
- Milk
- Yogurt
- Cheese
- Calcium-fortified foods and drinks
- Tofu
- Cooked spinach and broccoli
- Legumes
Zinc-rich foods
- Red meat
- Beans
- Fortified cereals
- Dairy products
- Legumes
Note: People with an iron deficiency absorb two to three times more lead than people with enough iron in their blood. Iron and lead interact and compete in heme synthesis. Even slight decreases in hematocrit can lead to increased lead absorption.
Many 1- and 2-year-olds in the United States don’t take in enough iron. This can lead to lasting cognitive development effects if they’re exposed to lead.
Find more information on iron deficiency in the CDC recommendations to prevent and control iron deficiency in the United States.
Vitamins C, D, and E
Vitamin C helps the body absorb iron, which offers increased protection from lead. Vitamin D and E can also help to support the body's ability to handle lead exposure.
Vitamin C-rich foods
- Citrus fruits
- Tomatoes
- Bell peppers
- Kiwi
- Strawberries
- Melons
- Mango
- Cauliflower
Vitamin D-rich foods
- Fish cheese
- Mushrooms
- Egg yolks
- Fortified:
- Milks
- Cereals
- Juices
- Yogurts
Vitamin E-rich foods
- Nuts and seeds
- Seafood
- Oils
- Avocado
- Apricot
- Broccoli
- Asparagus
- Leafy greens
Supplementation
If needed, nutritional supplementation can be considered, particularly for iron and calcium.
Patients should talk to their providers before taking supplements.
Recommended dosages for adults:
| Supplement | Recommended Dosage | Recommended dose size* |
|---|---|---|
| Calcium | Up to 2,000 mg/day | 4 doses of 500 mg |
| Iron | 60-120 mg/day | 1-2 doses of 600mg |
*Recommended dose size encourages absorption. Breaking up a dose throughout the day allows the body to absorb as much of the supplement as possible.
There are many statewide and local programs to support both families with lead-poisoned children and expecting parents. These include:
- The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). WIC supports people who are pregnant, breastfeeding, or postpartum, as well as infants and children up to age five. Foster parents and relatives may also apply on behalf of an infant or child in their care.
- The Well Badget Resource Center helps connect families to community, social, health, and government programs.
- Local Public Health Departments can help families get connected with local resources and programs.
- The Wisconsin Poison Center can help answer questions about lead poisoning and recommend next steps.