ED Pathway for the Evaluation and Treatment of Elevated Blood Lead Levels in Children

Step 1: History and Physical

Targeted Lead History

Housing

  • Where does the patient live?
  • How long has the child lived there?
  • Does the child spend a significant amount of time in daycare, at a grandparent’s house, etc.?
  • Was the home built before 1978? (Lead was removed from house paint in 1978).
  • Who owns the home? (Landlords are responsible for providing lead-safe housing for tenants. Lead abatement can be very expensive).

Environment

  • Is there peeling paint in the home?
  • Has the home ever had a lead inspection?
  • Are there any industries nearby?
  • Are there any unusual hobbies performed in the home?
  • Is there exposure to imported art supplies or jewelry?

Social

  • What are the parental occupations?
  • Is the child a foreign born adoptee?

Medical

  • Was the elevated lead level drawn venous or fingerstick? (Fingerstick lead levels are sometimes contaminated with surface lead).
  • Has the child had previous lead levels?
  • Have siblings had previous lead levels?
  • Does the child have G-6-PD deficiency or peanut allergy? (These are contraindications for BAL chelation therapy).
  • Does the child have kidney problems? (EDTA chelation may be nephrotoxic).
  • Does the child have blood or liver problems? (Chelation therapy has been associated with neutropenia and transaminitis).

ROS

  • Is the child pica-prone?
  • Has the child recently eaten paint chips?
  • Has the child had stomach aches, anorexia, irritability?
  • How is the child’s development?
  • Is the child hyperactive?

Targeted Lead Exam

Hyperpigmentation of the gums and extensor muscle weakness is rarely seen in children with plumbism. A thorough neurologic exam, searching for evidence of encephalopathy, is most important.

Interpretation of Specific Laboratory Tests

CBC Lead poisoned children often have a microcytic anemia, and the smear may show basophilic stippling. Iron deficiency is often coincident.
EP An elevated erythrocyte protoporphyrin may help distinguish chronic from acute plumbism (but is also elevated in iron deficiency).
Chemistry Chronic lead poisoning rarely may be associated with nephropathy.
UA Proteinuria may be evident.
Radiographs Abdominal XR may reveal lead foreign bodies in the GI tract.
Wrist or knee XR may reveal dense metaphyseal bands or "lead lines."

Interpretation of Lead Levels

0-5ug/dL "Normal"
5-19ug/dL Slightly elevated; follow levels and check environment.
20-44 Lead poisoning. Suggest dietary and environmental intervention. May consider outpatient chelation in special circumstances.
45-69 Lead poisoning. Merits chelation therapy. Severe lead poisoning. At risk for encephalopathy.
70+ Hospitalization strongly suggested.

Step 2: What to Do

Upon arrival, examine for encephalopathy. All encephalopathic patients should be admitted to an intensive care unit; and Toxicology and Neurology specialists should be consulted immediately.

For Patients Referred for Lead Levels <45ug/dL

  • Patients with lead levels below 20ug/dL should be offered reassurance and follow-up.
  • Patients with lead levels between 20 and 45ug/dL should have a CBC with diff, and a stat lead level obtained.
  • An abdominal radiograph can be obtained if there is a history of eating paint chips or other lead foreign body.
  • Well-appearing patients can be discharged for outpatient follow-up. Environmental lead control is the principle therapy.

For Patients Referred for Lead Levels >45ug/dL

  • Obtain lab tests including CBC with diff, BUN/Cr, hepatic transaminases, and urinalysis. A stat whole blood lead level should be obtained. It may be necessary to call the hospital lab supervisor to arrange for this test to be obtained emergently.
  • Obtain a flat plate abdominal radiograph if history suggests recent pica. If lead is noted within the GI tract, consideration should be given to GI decontamination.
  • An FEP is most useful if trying to differentiate acute from chronic poisoning.
  • Wrist or knee radiographs are most useful in evaluating an encephalopathic patient in whom you are trying to find evidence of lead poisoning prior to the availability of levels.
  • Chelation therapy should be considered as outlined below.

An outpatient development evaluation may be useful in identifying children with developmental delays in need of intervention services.

Social work intervention may be beneficial in helping families find resources for home inspection, home renovation, temporary relocation, and medical follow-up.

Notify the local health department to report the elevated blood lead level, and to arrange for environmental home inspection. In Philadelphia, the phone number is 215-685-2794.

Chelation Guidelines

Lead Level 45-69ug/dL, compliance expected, lead-safe environment

  • Succimer 10mg/kg/dose po TID X 5days, then BID X 14 days. Dose needs to be rounded to multiples of 100mg capsules.
  • Obtain repeat CBC, transaminases, stat Pb at 7 and 21 days.
  • Close outpatient follow-up.

Lead Level 45-69ug/dL, compliance not expected, lead in environment

  • Admit to hospital.
  • Either
  • Succimer 10mg/kg/dose po TID X 5 days, then BID X 14 days. Obtain repeat CBC, transaminases, stat Pb at 7 and 21 days. Discharge when compliance and/or environment problems remediated.
  • Or
  • CaNa 2 EDTA 12.5mg/kg/dose (max: 1g) iv q6hrs x 5 days. (dilute solution, infused over > 1hr). Maintain hydration to keep good urine flow. Monitor urine dips for increasing proteinuria. Check Ca, BUN/Cr, transaminases at days #3 and #5, repeat stat Pb on day #5.

Lead Level >70ug/dL, asymptomatic (*in rare circumstances, might opt for inpatient Succimer therapy)

  • Admit to hospital, hold any iron supplements.
  • BAL 4mg/kg/dose im q8hrs* X 2 days (if no contraindications).
    • [*Administer same dose q4hrs X 2 days if Pb >100.]
    • Consider pre-treatment of BAL injection with diphenhydramine.
  • CaNa 2 EDTA 12.5mg/kg/dose (max: 1g) iv q6hrs x 5 days.
    • (dilute solution, infused over > 1hr)
    • !!! Note that first dose of EDTA should be delayed at least 4 hrs after first dose of BAL.
  • Maintain hydration to keep good urine flow, but avoid fluid overload.
  • Monitor blood pressure closely after BAL injections.
  • Monitor urine dips for increasing proteinuria.
  • Check CBC, Ca, BUN/Cr, transaminases at days #3 and #5.
  • Repeat stat Pb on day #5.

Encephalopathy

  • Admit to intensive care unit. Immediate toxicology and neurology consults.
  • CT or MRI brain. Treat for intracranial hypertension as necessary.
  • BAL 75mg/M 2 /dose im q4hrs X 5 days.
    • Consider pre-treatment of BAL injection with diphenhydramine.
  • CaNa 2 EDTA 1500mg/ M 2 /day via continuous infusion X 5 days.
    • !!! Note that administration of EDTA should be delayed 4 hrs after first dose of BAL.
  • Hold iron supplementation.
  • Maintain good urine flow, but avoid fluid overload.
  • Monitor blood pressure closely after BAL injections.
  • Monitor urine dips for increasing proteinuria.
  • Check CBC, Ca, BUN/Cr, transaminases daily; repeat stat Pb on days #3 and #5.

Notes Pertaining to Chelating Agents

Succimer

  • Oral chelating agent, crosses blood/brain barrier.
  • Fairly expensive.
  • Carried by few pharmacies. Stocked by CHOP outpatient pharmacy.
  • Tastes bad and smells worse. Capsules can be sprinkled into pudding, jelly, etc.
  • Side effects:
    • nausea (common)
    • rash, neutropenia, transaminitis (uncommon)

CaNa 2 EDTA

  • Can be given iv or im, does not cross blood/brain barrier.
  • Side effects:
    • Calcium and sodium load
    • Anaphylactoid reactions if infused too quickly
    • Proteinuria
    • Tubular necrosis
    • Transaminitis

BAL

  • Mixed in peanut oil, can only be given as painful im injection, crosses into brain.
  • Care should be taken to administer properly im (sterile abscesses occur after subcutaneous injection)
  • Side effects:
    • Hypertension (dose related)
    • Hemolysis in G-6-PD deficient patients
    • Peanut allergy
    • Iron co-administration may increase vomiting and decrease efficacy
    • Fever
    • Transaminitis
    • Neutropenia

* Please note : These guidelines were developed solely for use by Children’s Hospital of Philadelphia (CHOP) house physicians and nurse practitioners caring for patients under the supervision of the Section of Clinical Toxicology, and are not implied to apply to all lead poisoned patients or to have been peer-reviewed. They have been provided as information, but Drs. Osterhoudt and Henretig assume no responsibility for the use of these protocols outside CHOP.

Updated : July 2007
Authors : Kevin C. Osterhoudt, MD, Fred M. Henretig, MD