Toolkit Library

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As part of ISCHE’s commitment to bridging the gap between science and policy, we are pleased to share the first in what we hope will become an essential reading list of documents that have shaped children’s environmental health. We call this the ISCHE Toolkit Library. The annotations in these documents will reflect conversations between senior and early-stage colleagues about the document’s historical context, strengths, and other teachable moments for CEH professionals across all career stages. The ISCHE toolkit library is an evolving project that intends to bring ISCHE members together in informal discussions of research translation, promote mentorship, and cultivate dynamic reading of milestone scientific policy documents in CEH. This first installment of the ISCHE toolkit library focuses on the landmark. Appendix of the 2005 CDC Statement on Preventing Lead Poisoning in Young Children [1].

Those of us who do research in Children’s Environmental Health (CEH) believe that our work will make a difference in children’s lives. This was certainly true of Herb Needleman, a pediatrician and psychiatrist who did the first persuasive study of cognitive effects from lead exposures so low that they did not produce symptoms. However, ISCHE past-president and club co-founder David Bellinger tells a story about Herb, who was David’s post-doctoral mentor. Herb’s 1979 paper reported that school children with no evidence of lead poisoning but relatively high levels of lead in their teeth had lower scores on IQ and other neuro-cognitive tests. The day after it appeared, in the influential New England Journal of Medicine [2], Herb said “I’m so disappointed. I thought the world would change.” Research may be an important first step, but advocacy, policy, regulation, and other, often many other, steps have to be taken before the science prevents harm to children.

Setting the Context

This 2005 CDC statement documents the Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP, pronounced A-Clip) accepting the report of their Work Group on the effects of lead at low exposures on children. In 2005, lead was the most-studied pediatric environmental toxicant, and arguably still is. While many studies showed that children with higher blood leads had lower IQ, there remained controversy about whether these studies showed that lead, and not some other factor, caused the lower IQ. What level of evidence should be required to eliminate such a well-studied exposure? The answer must not only be good enough scientifically, but also must meet the needs of policy makers. The ACCLPP Work Group responded to this challenge with something close to a formal review article, but designed to answer a specific question – does the research support a causal relationship between lead exposure and deficits in IQ when blood lead has not exceeded 10 ug/dl? If so, how can the arguments of those who do not accept that causal relationship be refuted?

To review and make annotations to this article, please click here and follow the instructions.

Food for Thought

During our conversations about this document, we visited and re-visited the role of scientific research in policy and regulation. That discussion yielded new information for both of us, but also lots of questions about where we go from here. In addition, when we had a few members  look at the material, they noticed things we missed.  Some of these questions might lead to other influential papers for the ISCHE toolkit, or to sessions at future meetings.

  1. Is lead exposure actually controlled today? Children’s blood lead levels have fallen substantially since the mid-1970s. The fall is due to banning leaded gasoline and eliminating lead from new residential paint. However, at the turn of the 21st century (around the time of this 2005 document), about 16% of children 6 years and under lived in housing with lead hazard, mainly from lead paint [3]. Why was lead poisoning from deteriorating paint in homes not eliminated? What actions could have been taken, or should be taken now? Much of the housing around in 2005 is gone now, but much of it remains.

  2. 2. Widespread lead exposure in Flint MI in 2014 [4] and Newark via water distribution systems with old lead pipes have more recently demonstrated that lead continues to be an environmental justice issue. What role does science play now, as decisions are made about replacing lead pipe? Are current surveillance systems adequate to detect ongoing lead exposures? If not, should they be?

    3. What does lead policy in the US tell us about lead policy in other countries? When Dorota Jarosinska, now at WHO Euro, was a Fulbright fellow with Walter, they compared Polish and US lead policy, and found little overlap [5]. WHO has an Initiative in Children's Environmental Health, once directed by ISCHE member Ruth Etzel. It provides materials, convenes workshops, etc. But much more could be done to collaborate and build capacity for lead policy internationally.

    4. Some have recommended precaution in the face of uncertainty: “Where there are threats of serious or irreversible damage, lack of full scientific certainty shall not be used as a reason for postponing cost-effective measures to prevent environmental degradation.”[6] This approach is more popular in Europe than in the US. Would precaution have been a better strategy?


  1. Centers for Disease Control and Prevention. Preventing Lead Poisoning in Young Children. Atlanta: CDC; 2005.
  2. Needleman HL et al Deficits in Psychologic and Classroom Performance of Children with Elevated Dentine Lead Levels N Engl J Med 1979; 300:689-695
    DOI: 10.1056/NEJM197903293001301
  3. Rio Declaration on Environment and Development, Principle 15, U.N. Doc. A/CONF. 151/26 (Aug. 12, 1992)
  4. Jacobs DE, Clickner RP, Zhou JY, Viet SM, Marker DA, Rogers JW, Zeldin DC, Broene P, and Friedman W. The prevalence of lead-based paint hazards in U.S. housing.Environmental Health Perspectives 2002110:10 CID:
  5. Ruckart PZ, Ettinger AS, Hanna-Attisha M. The Flint Water Crisis: A Coordinated Public Health Emergency Response and Recovery Initiative. J Public Health Management Practice 2019: 25; S84-S90
  6. Jarosinska D, Rogan WJ. Preventing lead poisoning in children: can the US experience inform other countries? The case of Poland. Cent Eur J Public Health. 2003;11(4):192-197)

Reading List

We hope the reading list will be augmented with other people’s favorite papers.

Childhood Lead Poisoning: The Promise and Abandonment of Primary Prevention

Needleman HL. American Journal of Public Health December 1998, Vol. 88, No. 12 1871-7

Childhood lead poisoning: the torturous path from science to policy.

Bellinger DC. Bellinger AM. J Clin Invest. 2006;116(4):853-857. ttps://

Calls for Removing All Lead Paint From US Housing Are Misguided.

Ryan D. Am J Public Health. 2013 May; 103(5): e5. doi: 10.2105/AJPH.2013.301262

Interpreting the literature on lead and child development: The neglected role of the “experimental system”. 

Bellinger DC. Neurotoxicology Teratology  1995:17;201-212.

       Related: A Higher Level of Analysis: Bellinger's - Interpreting the 

       Literature on Lead and Child Development. Dietrich KN. 

       Neurotoxicology Teratology 1995:17; 223-225.

Call For An Accurate Historical Account Of Childhood Lead Poisoning Prevention.

Jacobs D. Am J Public Health 2013:103;e5.

With the best of intentions: lead research and the challenge to public health

Rosner D, Markowitz G. Am J Public Health. 2012:102;e19-e33.

Clamped in a Straitjacket: The Insertion of Lead into Gasoline.

Needleman HL. Environmental Research 1997: 74; 95-103

CDC’s Lead Poisoning Prevention Program: A Long-standing Responsibility and Commitment to Protect Children From Lead Exposure
Ettinger AS. Leonard ML. Mason J, J Public Health Management Practice  2019:25 Supp; 5-12. 

Lead Poisoning Prevention: The Unfinished Agenda
Ettinger, Adrienne S.; Ruckart, Perri Z.; Dignam, TimothyJournal of Public Health Management and Practice. 25:S1-S2, January/February 2019.(Note- this supplement was given over entirely to childhood lead exposure in the US. It is a useful sampler – we recommend at least taking a look at the Table of Contents – also copied below)

1. Lead Elimination for the 21st Century
Breysse, Patrick N.Journal of Public Health Management and Practice. 25:S3-S4, Jan/Feb 2019.

2. CDC's Lead Poisoning Prevention Program: A Long-standing Responsibility and Commitment to Protect Children From Lead Exposure
Ettinger, Adrienne S.; Leonard, Monica L.; Mason, JacquelynJournal of Public Health Management and Practice. 25:S5-S12, January/February 2019.

3. Control of Lead Sources in the United States, 1970-2017: Public Health Progress and Current Challenges to Eliminating Lead Exposure
Dignam, Timothy; Kaufmann, Rachel B.; LeStourgeon, Lauren, et alJournal of Public Health Management and Practice. 25:S13-S22, January/February 2019.

4. LAMP: A CDC Program to Ensure the Quality of Blood-Lead Laboratory MeasurementsCaldwell, Kathleen L.; Cheng, Po-Yung; Vance, Kathryn A., et alJournal of Public Health Management and Practice. 25:S23-S30, January/February 2019.

5. Successfully Changing a State's Climate to Increase Blood Lead Level Testing
Gettens, Gail Coppins; Drouin, Beverly BaerJournal of Public Health Management and Practice. 25:S31-S36, January/February 2019.

6. Evaluation of the Blood Lead Screening Component of the Southern Nevada Childhood Lead Poisoning Prevention Program
Haboush-Deloye, Amanda; Marquez, Erika; Marshall, Melissa, et alJournal of Public Health Management and Practice. 25:S37-S43, January/February 2019.

7. Screening for Elevated Blood Lead Levels: False-Positive Rates of Tests on Capillary Samples, Minnesota, 2011-2017
Wang, Amy; Rezania, Zaynab; Haugen, Kathryn M. B., et alJournal of Public Health Management and Practice. 25:S44-S50, January/February 2019.

8. Using Medicaid Data to Improve Childhood Lead Poisoning Prevention Program Outcomes and Blood Lead Surveillance
Bruce, Shelley A.; Christensen, Krista Y.; Coons, Marjorie J., et alJournal of Public Health Management and Practice. 25:S51-S57, January/February 2019.

9. Improving Childhood Lead Poisoning Surveillance and Data Management in Arizona Through an Evaluation of the Transition to a New Surveillance SystemAsburry, Amber; Blatt, MiyukiJournal of Public Health Management and Practice. 25:S58-S62, January/February 2019.

10. A Spoonful of Lead: A 10-Year Look at Spices as a Potential Source of Lead Exposure
Hore, Paromita; Alex-Oni, Kolapo; Sedlar, Slavenka, et alJournal of Public Health Management and Practice. 25:S63-S70, January/February 2019.

11. Blood Lead Surveillance and Exposure Sources Among Alaska ChildrenBressler, Jonathan M.; Yoder, Sarah; Cooper, Stacey, et alJournal of Public Health Management and Practice. 25:S71-S75, January/February 2019.

12. Findings of a Statewide Environmental Lead Inspection Program Targeting Homes of Children With Blood Lead Levels as Low as 5 μg/dL
Cluett, Rachel; Fleisch, Abby; Decker, Kathy, et alJournal of Public Health Management and Practice. 25:S76-S83, January/February 2019.

13. The Flint Water Crisis: A Coordinated Public Health Emergency Response and Recovery Initiative
Ruckart, Perri Zeitz; Ettinger, Adrienne S.; Hanna-Attisha, Mona, et alJournal of Public Health Management and Practice. 25:S84-S90, January/February 2019.

14.Response to the US FDA LeadCare Testing Systems Recall and CDC Health Alert
Mason, Jacquelyn; Ortiz, Denise; Pappas, Siobhan, et alJournal of Public Health Management and Practice. 25:S91-S97, January/February 2019.

15. Integrating Childhood and Adult Blood Lead Surveillance to Improve Identification and Intervention Efforts
Egan, Kathryn B.; Tsai, Rebecca J.; Chuke, Stella O.Journal of Public Health Management and Practice. 25:S98-S104, January/February 2019.

16. Evaluation of the Implementation of CDC's Health Alert Related to the FDA LeadCare Recall From the State Health Department Perspective
Trinh, Eva; Mason, JacquelynJournal of Public Health Management and Practice. 25:S105-S110, January/February 2019.

17. Identifying and Chronicling Childhood Lead Poisoning Prevention Program Achievements With “Success Stories”
Lockamy-Kassim, Elise; Friedberg, Jared; Newby, Christina, et alJournal of Public Health Management and Practice. 25:S111-S114, January/February 2019.

18. Childhood Lead Poisoning: A Perpetual Environmental Justice Issue?
Whitehead, LaToria S.; Buchanan, Sharunda D.Journal of Public Health Management and Practice. 25:S115-S120, January/February 2019.

Prepared by Drs. Walter Rogan (Senior Investigator for Epidemiology Branch, NIEHS, retired) and Jennifer Ames (Postdoctoral Research Fellow at the Division of Research, Kaiser Permanente Northern California)

Children are essential to our future and the continuation of human life. Children around the world are confronted by multiple environmental threats to health, including toxins, air pollution, psychosocial stress, and climate change. Infants and children are often exquisitely vulnerable to these threats; exposures during critical windows of vulnerability have been associated with a wide range of childhood diseases. Early life exposures can also increase the risk of chronic diseases in adulthood.