Why what’s missing is sometimes the most important detail

There is no safe blood lead level in children, according to the Centers for Disease Control and Prevention. But, more than 500,000 U.S. children have elevated levels, which can cause lifelong developmental delays.

One of our clients, an insurance company, pulled in MKC Medical Management to review the alleged lead poisoning case of a toddler. The child was healthy as an infant, but he developed significant speech and other developmental delays. Doctors eventually diagnosed the child with pervasive developmental disorder (PDD), which is on the autism spectrum.

What we found, according to the medical records, was that the child had lived in a building with toxic levels of lead. Tests also revealed that he had elevated blood lead levels.

But, those findings don’t necessarily mean that lead poisoning was behind the child’s diagnosis and delays. In any case under review, correlation doesn’t always mean causation.

Here are the facts of the case:

Overview: The claimant is a three-year-old child who, the plaintiff attorney alleges, has developmental and behavioral issues because of lead exposure in the home. MKC’s legal nurse consultants worked on the defense team for the insurance carrier.   

What the records say about the child’s lead levels

At one year of age, the child’s blood level was 5 mcg/dL, which is considered elevated. Five months later, it was up to 5.3 mcg/dL. Six months later, it was up to 6.9 mcg/dL. The blood lead level was later reported to have spiked to 16 mcg/dL before dropping to 11 mcg/dL, but no lab reports for these final two tests were submitted for review.

What the records say about the child’s home

When the child was age two, city officials sent a letter to the property owners of the building the child was living in to notify them that there were “toxic levels of lead in or on the dwelling.” A lead abatement plan was required. It’s unknown how long the child had lived in the home and whether he had lived anywhere else. After the abatement order was issued, the family was relocated.

Red flags

Missing lab reports were just one of this case’s red flags. Here are some other warning signs:

  • The child lived with five siblings, ages 2 to 12, but no test results were submitted to indicate that any of the other children had elevated levels of lead in their blood.
  • According to an assessment with the family, there is a family history of genetic issues, sickle cell trait and seizure disorders, but the relationship to the individuals with these medical issues and more specific diagnoses were not identified. If the child has a genetic history for autism, for instance, then this could be the cause or at least contribute to his developmental delays – not lead poisoning. More information about the family’s genetic history is needed to understand the origin of the child’s issues.
  • The child’s parents failed to follow through on several of the doctors’ orders, including timely follow up with appointments, medication recommendations and possible failure to monitor lead levels. The medical records aren’t clear, but if the parents missed appointments to check lead levels, that detail could be critical for the defense.
  • When the child is diagnosed with autism at age 2, the pediatrician does not ask for a repeat lead level blood test to determine if lead poisoning is a contributing factor to the child’s developmental issues. Did the pediatrician not believe that lead was the cause of the child’s delays? Why didn’t doctors recommend the family relocate?
  • Anytime the medical records are incomplete, it’s suspicious. In this case, both lab results and genetic testing were completed, but the results were not submitted for review. Is the information being withheld because it might provide documentation for the defense to argue that the elevated lead level wasn’t the cause of the delays?
  • At age 3, the child was diagnosed with pervasive development disorder, part of the autism spectrum. The condition’s learning and developmental delays can be similar to lead poisoning. What’s more, the disorder occurs during infancy, but, like the claimant’s diagnosis, is typically is not identified until age 3. For the defense, this could be a critical point in case.

Follow up

After reviewing the case records, we recommended the client seek expertise and obtain missing medical information to better analyze the case. Those recommendations included:

  • Working with a toxicologist, who specializes in lead poisoning, to identify at what level a child typically becomes symptomatic for lead poisoning. The child also was exposed to secondhand smoke, another source of lead exposure. A toxicologist also could help determine if that could be one reason for the elevated lead level.
  • Seeking advice from a genetic specialist with expertise in genetic issues, including the sickle cell trait and autism, and the developmental disabilities they can cause. Determining other factors that could contribute to the child’s elevated lead levels, including whether any other children in the home have high lead blood levels; whether the child comes into contact with an adult whose job or hobby involves exposure to lead; and does the family use products or natural remedies that could be high in lead.
  • Obtaining all records of genetic testing, lab results and any other information not submitted for the initial review.

At the outset, the case might seem clear cut: “Toxic” levels of lead in the home and elevated blood lead levels in a child, who, over time, develops intellectual and behavioral delays.

But, with a family history of genetic issues, lack of concern about lead from doctors and missing documentation, it’s impossible to determine the exact cause of the child’s issues. The plaintiff’s attorney might argue that the issues are directly related to lead exposure, but until all the medical records are reviewed by experts, clear causation can remain elusive. It is also possible that a clear causative factor cannot be determined and that in this particular case the child’s issues are caused by more than one factor.