New Hampshire

Most families do not engage with lead poisoning prevention education materials until after their children have been exposed to lead. Research has demonstrated that children’s literature can be a very effective education vehicle for anticipatory guidance due to the emotional engagement when reading, its use of simple language, and potential for repeated readings. A children’s board book on lead poisoning prevention and the importance of pediatric blood lead level testing, distributed to families before their children are exposed, would be a valuable primary prevention tool. After completing an extensive review of children’s literature, the New Hampshire Healthy Homes and Lead Poisoning Prevention Program (NH HHLPPP) identified that none existed.

The NH HHLPPP staff developed a children’s board book, Happy, Healthy, Lead-Free Me!, with technical support from contracted vendor JSI, and clinical support provided by both the NH Chapter of the American Academy of Pediatrics and Region 1 Pediatric Environmental Health Specialty Unit at Boston Children’s Hospital.  The goal of developing this children’s board book was to educate families on lead poisoning prevention and the importance of blood lead testing in children. The plans for the book included engaging illustrations and rhyming children’s text, along with using subtitles on each page. Internal and external partners reviewed the draft book. Beta editions, printed in English and Spanish, were distributed to families statewide, to read to their children and provide feedback. A webpage (www.leadfree.me) was developed to accompany the book which included additional resources and information. A social media toolkit, which includes graphics, sample posts, and video content, is available to partners to promote their use of the book, along with messaging on lead exposure prevention and the importance of pediatric blood lead testing.

In December 2021, 13,000 books were distributed to pediatricians statewide, at no cost, for them to provide to children at the 9-month well child check (WCC) appointments. This is an optimal time to introduce lead exposure prevention and the importance of blood lead testing education as children become more mobile and in advance of a 12-month WCC appointment when the first blood lead level test takes place. NH’s Women, Infant and Children program and Maternal and Child Health Program purchased 14,000 printed books for distribution to young children through their community-based programs. A total of 27,000 books were printed. The book is available to download from the webpage in seven additional languages, including Chuukese, Dari, Nepali, Portuguese, Somali, and Swahili.

Response to the book has been robust and positive, followed by a nationwide demand for printed editions. A partnership was established with a non-profit organization, Cribs for Kids, LLC, to handle book orders and fulfillment logistics. This has allowed for easy and affordable access to ordering printed books in multiple languages and by the case (40 books). Books may be ordered from the book’s website www.leadfree.me.

In 2015, 660 (5%) children under the age of 6 in New Hampshire were reported to have blood lead levels (BLLs) ≥ 5µg/dL, the level then recommended for public health action by the Centers for Disease Control and Prevention (CDC). Yet, statewide, only 53% of one-year-olds and 26% of two-year-olds were tested in 2015, suggesting that the actual number of children under 6 years old with elevated blood lead levels (BLLs) is likely much higher.

Using state blood lead surveillance data, the New Hampshire’s Healthy Homes and Lead Poisoning Prevention Program (HHLPPP) identified the five largest communities with lowest testing rates: Concord, Dover, Nashua, Manchester, and Rochester. The program then worked with the New Hampshire Chapter of the American Academy of Pediatrics (NH-AAP) and pediatric healthcare providers to identify barriers to blood lead testing and opportunities to improve testing rates for one- and two-year-olds. Through collaboration with providers, the HHLPPP discovered two major obstacles to blood lead testing of young children: (1) a heavy reliance on venous blood lead testing and (2) a lack of understanding in the medical community about the importance of blood lead testing.

To address these obstacles, the HHLPPP developed a collaborative partnership with the NH-AAP to educate pediatric healthcare providers about current surveillance data and testing rates, BLL testing options, information about the best practices in clinical evaluation, and guidance for medical management of children with elevated BLLs. Additionally, HHLPPP held four regional pediatric medical education dinners from July 2016 through April 2018. These dinners were held in the five communities mentioned above and featured medical experts.

As a result of the intervention, HHLPPP educated 375 medical and public health professionals, resulting in an increase of BLL testing rates in the five target communities for one- and two-year-olds: a 10% and 12% increase in these ages in Manchester, respectively; a 16% and 41% increase in these ages in Nashua, respectively; a 13% and 73% increase in these ages in Concord, respectively; an 84% and 184% increase in these ages in Dover, respectively; and a 3% and 16% increase in these ages in Rochester, respectively.