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To the Editor.—
The recent report by Brown et al1 regarding the effectiveness of a randomized, controlled trial of an in-home intervention in reducing the blood lead level (BLL) of children with lead poisoning is of great interest. Although the authors conclude that such counseling did not reduce BLL, they should clarify some important considerations.
The authors do not comment on whether guidance given to both groups included the need for careful, frequent hand-washing by the children, which is recommended by the American Academy of Pediatrics.2 Because mouthing behaviors are closely correlated with the degree of risk for lead dust ingestion, hand-washing and frequent washing of toys and mouthable objects may help mitigate that risk. Such guidance could have reduced the chance of an additive effect resulting from the intervention.
In their "Methods" section, it is noteworthy that nurses providing follow-up care to the controls were blinded to group assignment, whereas those providing care to the children receiving the intervention were not. This difference might very well have led to a confounding source of bias in the expected direction of the results when the Nurse Child Assessment Satellite Teaching Scale was administered to determine maternal-child interactions at the end of the study. Intervention nurses, convinced that their counseling worked, would have been more likely to rate maternal-child interactions as having improved.
Finally, the authors described their outcome as a negative finding, although one could view that interpretation as seeing the glass as half empty. The fact that both groups experienced substantial declines in their BLL 1 year later (a 47% reduction) is gratifying. The decline is perhaps, in part, a result of the child's continued physical growth (diluting the body burden of lead), reduced oral behaviors, or lead's redistribution between compartments, as suggested by the investigators. In addition, another interpretation of the study's results is that even general guidance on lead poisoning prevention by visiting nurses effectively works to reduce the hazard of continued contamination. If this were not the case, at least some children would have been expected to experience a continued rise in their BLL to even more problematic levels over the course of the study.
REFERENCES
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