I.

Causes A. Home 1. 2. B. C. D. E. F. G. H. I. J. renovation or remodel Household dust Paint chips from lead-based paint Drinking water from lead pipes (or contaminated from lead solder, valves or fixtures) Industrial waste exposure (e.g. soil contaminated with lead) Residence near busy highway Tea Kettles Vinyl mini blinds Imported candy (e.g. Tamarind candy from Mexico stored in leadcontaminated ceramics) Imported eye cosmetics (e.g. Kohl or Surma from India, or other eye cosmetics from Pakistan) Imported Jewelry or Toys Parents with occupational exposure (i.e. Take-home exposures) 1. Lead production or smelting 2. Battery manufacturing 3. Brass, copper or lead foundry 4. Radiator repair 5. Scrap handling 6. Ship and bridge demolition 7. Old painted metal welding 8. Thermal paint stripping of old buildings 9. Old paint sanding 10.Lead soldering 11.Ceramic glaze mixing 12.Cable stripping 13.Firing range staff 14.Machining or grinding lead alloys K. Pica secondary to Anemia 1. Eating lead paint or soil L. Herbal remedies containing lead 1. See Lead-Containing Herbal Remedies II. Symptoms

A. Anorexia B. Headache C. Abdominal Pain D. Nausea and Vomiting E. Constipation II. Signs A. Lead line in gums B. Papilledema C. Ocular palsy D. Wrist drop E. Foot drop F. Slurred speech

G. Reflex changes H. Bradycardia I. Mental status changes 1. Seizures 2. Delirium 3. Coma II. Labs: Screening A. Blood Lead Level 1. See below for protocol B. Indications 1. Previously universal screening was in place before 1997 in Uniited States a. Now screen child considered high risk or all children for whom risk is unknown or uncertain 2. All Medicaid enrolled or eligible children (age 1-2 years or catch-up at age 36-72 months) 3. All recent Immigrant Children on arrival and again in 3-6 months later (ages 6 months to 6 years old) 4. High risk children a. Identified by state or local screening recommendations b. Child lives in, visits, or attends child care in a house built before 1950 c. Child lives in, visits, or attends child care in a house built before 1978 undegoing renovation in last 6 months d. Child has sibling or playmate that has Lead Poisoning II. Labs: Advanced (indicated for lead level >20 mcg/dl or 0.97 umol/L)

A. Peripheral Smear 1. Stippled erythrocytes B. Complete Blood Count (CBC) 1. Microcytic Anemia 2. Leukocytosis C. Reticulocyte Count D. Urinalysis E. Comprehensive metabolic panel F. Iron Deficiency Anemia labs (TIBC, Ferritin) II. Labs: Other findings suggestive of Lead Toxicity
A. Urine lead level elevated B. Urine microscopy of sediment or renal biopsy 1. Acid-fast inclusion bodies in tubular nuclei 2. Pathognomonic for Lead Poisoning C. Free Erythrocyte Protoporphyrin (FEP) > 0.6 umol/L II. Imaging

A. Abdominal XRay 1. Indicated for moderate, high or very high lead level of 20 mcg/dl or greater 2. Identifies lead remaining in the intestinal tract (radiodense) B. Long bone XRay 1. Epiphyseal lead line II. Protocol A. General 1. Education should be done at all abnormal lead levels B. Lead level 10-14 mcg/dl (0.48 to 0.68 umol/L): Low Lead Toxicity level 1. Lead level at 0 months 2. Lead level at 3 months 3. Lead level at 6-9 months C. Lead level 15-19 mcg/dl (0.72 to 0.92 umol/L): Low Lead Toxicity level 1. Lead level at 0 months 2. Lead level at 1-3 months a. If lead level still >15 mcg/dl proceed to follow lead level of 20-44 mcg/dl b. If lead level <15 mcg/dl, continue with education and observation 2. Lead level at 3-6 months B. Lead level 20-44 mcg/dl (0.97 to 2.13 umol/L): Moderate Lead Toxicity level 1. Lead level at 0 months a. Environmental investigation and lead hazard reduction b. Complete history, exam, lab, XRay as above c. Consider bowel Decontamination if ingestion suspected (consider abdominal XRay) i. Enemas used to clear retained lead products 2. Lead level at 2-4 weeks 3. Lead level at 1 month B. Lead level 45-69 mcg/dl (2.17 to 3.33 umol/L): High Lead Toxicity level 1. Lead level at 0 months a. Includes measure done for lead level of 20-44 mcg/dl 2. Lead level pre-chelation a. Outpatient Chelation therapy 2. Lead level post-chelation B. Lead level >70 mcg/dl (>3.38 umol/L): Very high Lead Toxicity level 1. Lead level at 0 months a. Includes measure done for lead level of 20-44 mcg/dl

b. Immediate hospitalization for chelation therapy 2. Lead level pre-chelation a. Inpatient chelation therapy 2. Lead level post-chelation II. Management: Lead chelation A. Precautions 1. 2. 3. B. First-Line 1.

Consult toxicologist before using chelation Obtain labs and diagnostics as above before chelation Dosing regimens should be checked with toxicology Succimer or Chemet (Meso-2,3-dimercaptosuccinic acid or DMSA)

a. Initial: 10 mg/kg (or 350 mg/m2) PO every 8 hours for 5 days b. Next: 10 mg/kg (or 350 mg/m2) PO every 12 hours for 14 days B. Other agents that have been used for lead chelation 1. Edetate Disodium a. Dose: 0.5-1.0 g/m2/day b. Maximum: 1.5 grams per day 2. Dimercaprol a. Dose: 12-24 mg/kg/day for 5 days 2. Penicillamine a. Dose: 20-40 mg/kg/day for 3 to 6 months b. Maximum: 1 grams per day B. Efficacy 1. Chelation not affective if lead <45 mcg/dl 2. Dietrich (2004) Pediatrics 114:19-26 II. Prognosis (Untreated) A. Aggressive and delinquent behavior B. Mental Retardation C. Language and cognitive deficits D. References 1. Needlman (1996) JAMA 275:363-9 Prevention

II.

A. Precautions regarding drinking water from lead pipes 1. Allow tap to flow for 30 seconds, then collect water 2. Do not use hot water from tap for drinking B. Avoid living near highways or industrial plants C. Replace all lead paint with non-lead paints 1. Carefully limit child's exposure during remodeling 2. Carefully dispose of removed lead paint II. References