Opinion

VIEWPOINT

David C. Bellinger,
PhD, MSc
Boston Children’s
Hospital, Boston,
Massachusetts; and
Harvard Medical
School, Boston,
Massachusetts.
Aimin Chen, MD, PhD
University of Cincinnati
College of Medicine,
Cincinnati, Ohio.
Bruce P. Lanphear,
MD, MPH
Simon Fraser
University, Vancouver,
British Columbia,
Canada.

Corresponding Author:
David C. Bellinger, PhD,
MSc, Department of
Neurology, Boston
Children’s Hospital,
300 Longwood Ave,
Boston, MA 02115
(david.bellinger
@childrens.harvard
.edu).
jamapediatrics.com

Establishing and Achieving National Goals
for Preventing Lead Toxicity and Exposure
in Children
Children are exposed to chemicals in consumer products, household dust, food, air, water, and soil that, at
exceedingly low levels, interfere with healthy brain development, causing long-lasting neurodevelopmental effects. The failure to protect children from widespread exposure to neurotoxic chemicals led a group of clinicians,
scientists, and advocates to form Project TENDR (Targeting Environmental Neurodevelopmental Risks) and
craft a consensus statement that identifies examples of
chemicals that are known or suspected to increase children’s risk for neurodevelopmental disorders: organophosphate pesticides, air pollutants, polybrominated diphenyl ether flame retardants, lead, mercury, and
polychlorinated biphenyls.1 Phthalates were identified
as an example of chemicals that emerging evidence suggests can impair brain development.1 With the consensus statement as a foundational call to national action,
the group has formulated specific recommendations to
prevent and reduce prenatal and childhood exposures
to these exemplar chemicals. Herein, we present Project TENDR’s recommendations for steps to reduce lead
exposure and toxicity in children.

housing units, the economic benefit would be $17 to $221
(representing a net savings of $181 to $269 billion for a
cohort of children under 6 years of age), a cost-benefit
ratio comparable to that of childhood vaccines.6 Another analysis estimated the economic benefits that
resulted from the reduction in children’s blood lead
concentrations between the 1970s and 1990s to be
$110 to $319 billion for each year’s cohort of 3.8 million
children aged 2 years.7 The estimated benefits were
primarily attributable to improvements in worker productivity as a result of increased IQ scores.
The most common pathway for childhood lead poisoning is exposure to deteriorating lead-based paint or
improper renovation and repair activities. Low-income
and minority children bear a disproportionate burden of
lead toxicity because of residence in pre-1978 housing
that contains chipping or peeling lead-based paint or in
homes with water contamination due to the presence
of lead service lines, lead solder in the plumbing, or brass
faucets and fixtures containing lead. The key to preventing lead toxicity in children is to reduce or eliminate
sources of lead exposure in their environments.

Blood Lead Levels and Toxicity in Children

Recommendations

No level of lead exposure is safe for a fetus or young
child.2 Policies to phase out or restrict lead in gasoline,
paints, and other consumer products have dramatically lowered blood lead concentrations in the American population over the past 4 decades. Nevertheless,
lead exposure remains a major preventable cause of neurodevelopmental morbidity in US children.
More than one-half million children 1 to 5 years of
age have a blood lead concentration greater than
5 μg/dL (to convert to micromoles per liter, multiply
by 0.0483), and approximately 50% have a concentration greater than 1 μg/dL. It is difficult to detect levels below 1 μg/dL using common analytical methods.
Children with a blood lead concentration of 5 μg/dL
or greater will experience an average IQ score deficit of
approximately 6 points.3 In 2012, the US National Toxicology Program reported that the evidence was sufficient to conclude that intellectual deficits, diminished
academic abilities, attention deficits, and problem behaviors, including impulsivity, aggression, and hyperactivity, occur even in children with blood lead concentrations less than 5 μg/dL.4
The economic costs of childhood lead toxicity are
substantial. Despite the recent reduction in population
blood lead concentrations, the estimated annual cost of
childhood lead exposure in the United States is $50
billion.5 For every $1 invested to reduce lead hazards in

Project TENDR recommends that the US government
adopt the following national goals: ensure that, by 2021,
no child has a blood lead level greater than 5 μg/dL and,
by 2030, no child has a blood lead level greater than
1 μg /dL. To achieve these goals, we recommend several
actions.
Recommendation 1

Project TENDR calls on federal agencies to adopt healthbased standards and action levels that rely on the most
up-to-date scientific knowledge. The current US standards for allowable levels of lead in dust, soil, air, and
drinking water are outdated and fail to protect pregnant women and children.
• The US Environmental Protection Agency (EPA) should
promulgate health-based standards for lead in paint,
dust, soil, and drinking water that are designed to
prevent all children from having a blood lead concentration greater than 1 μg/dL.
• The EPA should strengthen the National Ambient Air
Quality Standards for Lead to reduce ambient air levels.
• The Centers for Disease Control and Prevention (CDC)
should follow through on its commitment to update its
definition of an elevated blood lead level (ie, reference level) every 4 years.
• In the future, the US Department of Housing and
Urban Development (HUD) should amend the Lead
(Reprinted) JAMA Pediatrics Published online May 15, 2017

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 Opinion Viewpoint

Safe Housing Rule in a timely manner when the CDC modifies its
reference level for identifying children with an elevated blood
lead concentration.
Recommendation 2

Project TENDR calls on federal, state, and local governments to protect pregnant women and children by identifying and remediating
sources of lead exposure (in paint, dust, air, soil, water, and consumer products) before pregnant women and children are exposed. In addition, governments should continue targeted screening of children to identify those who already have had lead exposures
that place them in need of case management and educational and
other services. To improve the lives of children in communities that
are disproportionately exposed to lead and other environmental
stressors, Project TENDR calls on federal, state, and local governments to provide a dedicated funding stream to identify and eliminate sources of lead exposure and to provide educational, social, and
clinical services to mitigate the harms of lead toxicity.
• HUD should remediate or require remediation of all public and other
federally supported housing (eg, Section 8 housing) before children occupy these units.
• The federal government should permit and encourage the Centers for Medicare & Medicaid Services and private health insurance companies to cover the cost of investigating lead hazards
before children move to a property.
Recommendation 3

Project TENDR calls on the federal government to prevent the
release of lead into the environment. Accomplishing this goal
ARTICLE INFORMATION
Published Online: May 15, 2017.
doi:10.1001/jamapediatrics.2017.0775
Conflict of Interest Disclosures: Dr Bellinger has
received compensation as an expert witness for
plaintiffs and defendants in civil litigation involving
lead exposure. Dr Lanphear is a paid consultant to
public health agencies about lead toxicity and its
prevention and is an expert witness in civil litigation
involving lead exposure, but he receives no
personal compensation. No other disclosures are
reported.
Funding/Support: Project TENDR (Targeting
Environmental Neurodevelopmental Risks) was
supported by National Institutes of Health
conference grant 1R13ES026504-01, the John
Merck Fund, Passport Foundation, and the Ceres
Trust Fund.
Role of the Funder/Sponsor: The funding sources
had no role in the preparation, review, or approval
of the manuscript and decision to submit the
manuscript for publication.
Additional Contributions: Other members of the
Project TENDR Lead Workgroup who contributed
to the development of these recommendations are
Carla Campbell, MD, MS, University of Texas at
El Paso, ElPaso; Eve Gartner, Esq, Earthjustice,

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requires the government to ban or phase out all remaining use
of lead in products, including aviation gas, cosmetics, wheel
weights, industrial paints, batteries, and lubricants; ban the import
and export of products containing lead; and set more protective
limits on releases from battery recyclers and other sources of lead
emissions.
Recommendation 4

Project TENDR urges Congress to establish an independent expert
advisory committee to develop a long-term national strategy to
eliminate lead toxicity in pregnant women and children, defined as
a blood lead level greater than 1 μg /dL. This plan should set goals
for eliminating legacy sources of lead, including abatement of residential hazards, full service line replacement of lead drinking
water pipes, and remediation of lead-contaminated soils from former industrial sites in residential areas. Project TENDR also urges
Congress to provide dedicated funding to implement the national
strategy.

Conclusions
Project TENDR scientists, health professionals, and advocates believe that eliminating lead toxicity and lead exposures in pregnant
women and children are eminently achievable goals. Further delay
will result in more children experiencing lifelong health problems.
We hope that lessons learned from the long struggle to prevent
health morbidities caused by lead exposure can be applied to
other environmental toxicants so that effective primary prevention measures are implemented more rapidly than they have been
for lead.

New York, New York; Mark Mitchell, MD, Mitchell
Environmental Health Associated, LLC, Hartford,
Connecticut; Maureen Swanson, MPA, Learning
Disabilities Association of America, Pittsburgh,
Pennsylvania; and Nsedu Witherspoon, MPH,
Children’s Environmental Health Network,
Washington, DC. They were not compensated for
their work.

January 4, 2012 https://www.cdc.gov/nceh/lead
/acclpp/final_document_030712.pdf. Accessed
December 22, 2016.

REFERENCES

4. National Toxicology Program, US Department
of Health and Human Services. US health effects
of low-level lead. June 13, 2012. https://ntp
.niehs.nih.gov/ntp/ohat/lead/final
/monographhealtheffectslowlevellead_newissn
_508.pdf. Accessed January 3, 2017.

1. Bennett D, Bellinger DC, Birnbaum LS, et al;
American College of Obstetricians and
Gynecologists (ACOG); Child Neurology Society;
Endocrine Society; International Neurotoxicology
Association; International Society for Children’s
Health and the Environment; International Society
for Environmental Epidemiology; National Council
of Asian Pacific Islander Physicians; National
Hispanic Medical Association; National Medical
Association. Project TENDR: Targeting
Environmental Neuro-Developmental Risks: the
TENDR consensus statement. Environ Health
Perspect. 2016;124(7):A118-A122.
2. Centers for Disease Control and Prevention. Low
level lead exposure harms children: a renewed call
for primary prevention report of the advisory
committee on childhood lead poisoning prevention.

3. Lanphear BP, Hornung R, Khoury J, et al.
Low-level environmental lead exposure and
children’s intellectual function: an international
pooled analysis. Environ Health Perspect. 2005;113
(7):894-899.

5. Trasande L, Liu Y. Reducing the staggering costs
of environmental disease in children, estimated at
$76.6 billion in 2008. Health Aff (Millwood). 2011;
30(5):863-870.
6. Gould E. Childhood lead poisoning: conservative
estimates of the social and economic benefits of
lead hazard control. Environ Health Perspect. 2009;
117(7):1162-1167.
7. Grosse SD, Matte TD, Schwartz J, Jackson RJ.
Economic gains resulting from the reduction in
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JAMA Pediatrics Published online May 15, 2017 (Reprinted)

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