eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Toxicology

Toxicity, Lead: Follow-up

Author: Mohamed K Badawy, MB, BCh, MD, Assistant Professor, Departments of Emergency Medicine and Pediatrics, University of Rochester and Golisano Children's Hospital at Strong Memorial Hospital
Coauthor(s): Gregory P Conners, MD, MPH, MBA, Interim Chair of Emergency Medicine, Professor of Emergency Medicine and Pediatrics, Departments of Emergency Medicine and Pediatrics, University of Rochester School of Medicine and Dentistry
Contributor Information and Disclosures

Updated: Nov 12, 2008

Follow-up

Further Inpatient Care

  • Closely monitor cardiovascular and mental status in patients with lead poisoning.
  • Maintain an adequate urine output.
  • Assess renal and hepatic functions.
  • Diphenhydramine may help alleviate the adverse effects of British antilewisite (BAL).
  • Iron supplementation should be avoided in patients receiving BAL chelation therapy because BAL forms a complex with iron, leading to toxicity.

Further Outpatient Care

  • All children being treated for lead poisoning need close follow-up care. Monitoring their blood lead levels (BLL) is important.

Inpatient & Outpatient Medications

  • Outpatient treatment seems a good option for asymptomatic children with blood levels in the range of 45-69 μ g/dL. However, be absolutely sure that the environment in which the child is placed is safe and lead free. If this is impossible to ensure, inpatient treatment is needed until the environmental situation is investigated in collaboration with social services and the local health department.

Transfer

  • When children have lead encephalopathy, the best approach is to transfer them to a children's hospital where pediatric intensivists and other resources are available.

Deterrence/Prevention

  • Primary prevention: The 2010 Healthy People objective to eliminate childhood lead poisoning can be achieved through primary prevention. Pediatricians and family practitioners provide a fundamental role with anticipatory guidance about potential sources of lead exposure and its hazards for the development of children. A successful primary prevention should focus on the 2 main exposure sources for children in the United States: lead in housing and nonessential uses of lead in certain products, such as imported and domestically manufactured toys, eating and drinking utensils, cosmetics, and traditional medicines.
  • Secondary prevention: The CDC and AAP have issued recommendations regarding screening for lead poisoning as follows:
    • Universal screening - In areas where at least 27% of houses were built before 1950 and places where the prevalence of elevated blood levels in children aged 1-2 years is 12%
    • Targeted screening - In all other areas when a positive response is received to one or more of the following screening questionnaire items issued by the CDC:
      • Does your child live in or regularly visit a house that was built before 1950?
      • Does your child live in or regularly visit a house built before 1978 with recent or ongoing renovations or remodeling (within the past 6 mo)?
      • Does your child have a sibling or a playmate that has or did have lead poisoning?

Complications

  • Lead-related deaths have become extremely rare since the advent of lead screening measures and decreased use of lead.
  • Sequelae of lead intoxication include retardation and growth failure.

Prognosis

  • Prognosis depends on the BLL and whether the patient was symptomatic on presentation. Asymptomatic patients tend to have a better prognosis, and studies demonstrate some improvement in intellectual functions following lowering of the BLL.
  • Severe neurologic damage may follow lead encephalopathy. Research has demonstrated that cognitive defects may occur at levels below the currently accepted BLL of 10 μ g/dL.4
  • Lanphear et al found an inverse relationship between blood-lead concentration and all cognitive function scores; this result was observed in math and reading scores for concentrations as low as 2.5 μ g/dL.8

Patient Education

  • For excellent patient education resources, visit eMedicine's Poisoning Center. Also, see eMedicine's patient education article Poisoning.

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize lead poisoning in a symptomatic patient
  • Inadequate screening measures, with the treating physicians not targeting the high-risk population
  • Failure to secure the airway before the initiation of gastric lavage in an obtunded child with acute lead ingestion

Special Concerns

  • Significant intravascular hemolysis may occur in patients with glucose-6-phosphate dehydrogenase (G-6-PD) deficiency who are receiving British antilewisite (BAL) as a chelating agent.
 


More on Toxicity, Lead

Overview: Toxicity, Lead
Differential Diagnoses & Workup: Toxicity, Lead
Treatment & Medication: Toxicity, Lead
Follow-up: Toxicity, Lead
References
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References

  1. Murata K, Iwata T, Dakeishi M, Karita K. Lead Toxicity: Does the Critical Level of Lead Resulting in Adverse Effects Differ between Adults and Children?. J Occup Health. Nov 6 2008;[Medline].

  2. American Academy of Pediatrics Committee on Environmental Health. Lead exposure in children: prevention, detection, and management. Pediatrics. Oct 2005;116(4):1036-46. [Medline]. [Full Text].

  3. American Academy of Pediatrics Committee on Environmental Health. Lead. In: Handbook of Pediatric Environmental Health. American Academy of Pediatrics. Elk Grove, IL: AAP; 1999:131-43.

  4. Canfield RL, Henderson CR Jr, Cory-Slechta DA, et al. Intellectual impairment in children with blood lead concentrations below 10 microg per deciliter. N Engl J Med. Apr 17 2003;348(16):1517-26. [Medline].

  5. CDC. Preventing Lead Poisoning in Young Children. CDC, United States Department of Health and Human Services:1991. [Full Text].

  6. CDC. Screening Young Children for Lead Poisoning. Guidance for State and Local Public Health Officials. Atlanta, GA: United States Department of Health and Human Services; 1997:[Full Text].

  7. Rogan WJ, Dietrich KN, Ware JH, et al. The effect of chelation therapy with succimer on neuropsychological development in children exposed to lead. N Engl J Med. May 10 2001;344(19):1421-6. [Medline].

  8. Lanphear BP, Winter NL, Apetz L, Eberly S, Weitzman M. A randomized trial of the effect of dust control on children's blood lead levels. Pediatrics. Jul 1996;98(1):35-40. [Medline].

  9. Florin TA, Brent RL, Weitzman M. The need for vigilance: the persistence of lead poisoning in children. Pediatrics. Jun 2005;115(6):1767-8. [Medline].

  10. Graeme KA, Pollack CV. Heavy metal toxicity, part II: lead and metal fume fever. J Emerg Med. Mar-Apr 1998;16, No.2:171-177. [Medline].

  11. Koller K, Brown T, Spurgeon A, Levy L. Recent developments in low-level lead exposure and intellectual impairment in children. Environ Health Perspect. Jun 2004;112(9):987-94. [Medline].

  12. Lanphear BP, Hornung R, Ho M. Screening housing to prevent lead toxicity in children. Public Health Rep. May-Jun 2005;120(3):305-10. [Medline].

  13. Markowitz M. Lead poisoning. Pediatr Rev. Oct 2000;21(10):327-35. [Medline].

  14. Moss ME, Lanphear BP, Auinger P. Association of dental caries and blood lead levels. JAMA. Jun 23-30 1999;281(24):2294-8. [Medline].

  15. Schaffer SJ, Campbell JR. The new CDC and AAP lead poisoning prevention recommendations: consensus versus controversy. Pediatr Ann. Nov 1994;23(11):592-9. [Medline].

  16. Tong S, von Schirnding YE, Prapamontol T. Environmental lead exposure: a public health problem of global dimensions. Bull World Health Organ. 2000;78(9):1068-77. [Medline].

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Further Reading

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Keywords

lead toxicity, plumbism, blood lead level, BLL, lead poisoning, lead-based paint, paint chips, lead encephalopathy, anorexia, vomiting, constipation, abdominal pain, hyperactivity, respiratory depression, hypertension

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Contributor Information and Disclosures

Author

Mohamed K Badawy, MB, BCh, MD, Assistant Professor, Departments of Emergency Medicine and Pediatrics, University of Rochester and Golisano Children's Hospital at Strong Memorial Hospital
Mohamed K Badawy, MB, BCh, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Gregory P Conners, MD, MPH, MBA, Interim Chair of Emergency Medicine, Professor of Emergency Medicine and Pediatrics, Departments of Emergency Medicine and Pediatrics, University of Rochester School of Medicine and Dentistry
Gregory P Conners, MD, MPH, MBA is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

William T Zempsky, MD, Associate Director, Assistant Professor, Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
William T Zempsky, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
Jeffrey R Tucker, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, and Massachusetts Medical Society
Disclosure: Merck Salary Employment

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD, Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin
Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society
Disclosure: Nothing to disclose.

 
 
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