Fatal lead encephalopathy has disappeared and blood lead concentrations have decreased in US children, but approximately 25% still live in housing with deteriorated lead-based paint and are at risk of lead exposure with resulting cognitive impairment and other sequelae. Evidence continues to accrue that commonly encountered blood lead concentrations, even those less than 10 microg/dL, may impair cognition, and there is no threshold yet identified for this effect. Most US children are at sufficient risk that they should have their blood lead concentration measured at least once. There is now evidence-based guidance available for managing children with increased lead exposure. Housing stabilization and repair can interrupt exposure in most cases. The focus in childhood lead-poisoning policy, however, should shift from case identification and management to primary prevention, with a goal of safe housing for all children.