Childhood lead poisoning: Management
- Jennifer A Lowry, MD
Jennifer A Lowry, MD
- Professor of Pediatrics
- University of Missouri- Kansas City School of Medicine
- Chief, Section of Clinical Toxicology
- Medical Director, Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation
- Medical Director, Center for Environmental Health
- Children's Mercy Kansas City
- Section Editors
- Donald H Mahoney, Jr, MD
Donald H Mahoney, Jr, MD
- Section Editor — Pediatric Hematology
- Professor of Pediatrics
- Baylor College of Medicine
- Michele M Burns, MD, MPH
Michele M Burns, MD, MPH
- Section Editor — Pediatric Toxicology
- Assistant Professor of Pediatrics
- Harvard Medical School
- Jan E Drutz, MD
Jan E Drutz, MD
- Section Editor — General Pediatrics
- Professor of Pediatrics
- Baylor College of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The management of lead poisoning in children will be reviewed here.
Clinical manifestations, diagnosis, exposure and prevention of childhood lead poisoning are discussed separately. (See "Childhood lead poisoning: Clinical manifestations and diagnosis" and "Childhood lead poisoning: Exposure and prevention".)
The identification of a neonate, infant, or child who has been exposed to lead must be viewed as a public health emergency. The only effective long-term treatment is ending further lead exposure by eradication of environmental lead contamination. Because the cognitive and behavioral effects of lead toxicity are not reversible, primary prevention of lead exposures is the single most important strategy in the management of childhood lead poisoning. (See "Childhood lead poisoning: Exposure and prevention", section on 'Prevention'.)
However, children at risk because of lead in their environment are often not found until the lead exposure is diagnosed through elevated blood lead levels (BLLs) during screening. At this point, secondary prevention of further lead exposure becomes the main treatment (table 1). Unfortunately, by the time a child is found with an elevated BLL, the neurodevelopmental harm from the exposure may have already occurred .
Chelation therapy may be necessary depending upon the degree of blood lead elevation (see 'Lead level 45 to 69 mcg/dL' below and 'Symptomatic lead poisoning' below). However, it has limited efficacy. With chronic ingestion or inhalation, lead can be incorporated into the skeletal system and become an endogenous reservoir of lead exposure that is resistant to elimination. While chelating agents can bind to lead in blood, they are ineffective in removing lead from the deep bone stores.
- 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 2001; 344:1421.
- Newman N, Binns HJ, Karwowski M, Lowry J, and the PEHSU Lead Working Group. Recommendations on Medical Management of Childhood Lead Exposure and Poisoning. Pediatric Environmental Health Specialty Units. American Academy of Pediatrics. http://www.pehsu.net/_Library/facts/medical-mgmnt-childhood-lead-exposure-June-2013.pdf (Accessed on November 23, 2015).
- American Academy of Pediatrics Committee on Environmental Health. Lead exposure in children: prevention, detection, and management. Pediatrics 2005; 116:1036.
- Bellinger D, Rappaport L. Developmental Assessment and Interventions. In: Managing Elevated Blood Lead Levels Among Young Children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention, Centers for Disease Control & Prevention, Atlanta 2002.
- Roberts JR, Reigart JR. Medical Assessment and Intervention. In: Managing Elevated Blood Lead Levels Among Young Children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention, Centers for Disease Control & Prevention, Atlanta 2002.
- Mahaffey KR. Nutrition and lead: strategies for public health. Environ Health Perspect 1995; 103 Suppl 6:191.
- Wasserman G, Graziano JH, Factor-Litvak P, et al. Independent effects of lead exposure and iron deficiency anemia on developmental outcome at age 2 years. J Pediatr 1992; 121:695.
- Bradman A, Eskenazi B, Sutton P, et al. Iron deficiency associated with higher blood lead in children living in contaminated environments. Environ Health Perspect 2001; 109:1079.
- Wright RO, Shannon MW, Wright RJ, Hu H. Association between iron deficiency and low-level lead poisoning in an urban primary care clinic. Am J Public Health 1999; 89:1049.
- Serwint JR, Damokosh AI, Berger OG, et al. No difference in iron status between children with low and moderate lead exposure. J Pediatr 1999; 135:108.
- Ruff HA, Markowitz ME, Bijur PE, Rosen JF. Relationships among blood lead levels, iron deficiency, and cognitive development in two-year-old children. Environ Health Perspect 1996; 104:180.
- Wasserman GA, Graziano JH, Factor-Litvak P, et al. Consequences of lead exposure and iron supplementation on childhood development at age 4 years. Neurotoxicol Teratol 1994; 16:233.
- Wright RO. The role of iron therapy in childhood plumbism. Curr Opin Pediatr 1999; 11:255.
- Wright RO, Tsaih SW, Schwartz J, et al. Association between iron deficiency and blood lead level in a longitudinal analysis of children followed in an urban primary care clinic. J Pediatr 2003; 142:9.
- CDC. Low-level lead exposure harms children: A renewed call for primary intervention. January 4, 2012. http://www.cdc.gov/nceh/lead/acclpp/final_document_030712.pdf (Accessed on January 27, 2016).
- Advisory Committee on Childhood Lead Poisoning Prevention. Low level lead exposure harms children: A renewed call for primary prevention. January 4, 2012. http://www.cdc.gov/nceh/lead/acclpp/final_document_030712.pdf (Accessed on June 13, 2016).
- Binns HJ, Campbell C, Brown MJ, Centers for Disease Control and Prevention Advisory Committee on Childhood Lead Poisoning Prevention. Interpreting and managing blood lead levels of less than 10 microg/dL in children and reducing childhood exposure to lead: recommendations of the Centers for Disease Control and Prevention Advisory Committee on Childhood Lead Poisoning Prevention. Pediatrics 2007; 120:e1285.
- US Environmental Protection Agency. Seasonal trends in blood lead levels in Milwaukee: Statistical Methodology. Publication EPA 747-R-95-010, US Environmental Protection Agency, Washington, DC 1996.
- US Environmental Protection Agency. Seasonal rhythms of blood lead levels: Boston 1979-1983. EPA 747-R-94-003, Protection Agency; Washington, DC 1995.
- Yiin LM, Rhoads GG, Lioy PJ. Seasonal influences on childhood lead exposure. Environ Health Perspect 2000; 108:177.
- Laidlaw MA, Mielke HW, Filippelli GM, et al. Seasonality and children's blood lead levels: developing a predictive model using climatic variables and blood lead data from Indianapolis, Indiana, Syracuse, New York, and New Orleans, Louisiana (USA). Environ Health Perspect 2005; 113:793.
- Lanphear BP, Dietrich K, Auinger P, Cox C. Cognitive deficits associated with blood lead concentrations <10 microg/dL in US children and adolescents. Public Health Rep 2000; 115:521.
- 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 2003; 348:1517.
- Lanphear BP, Hornung R, Khoury J, et al. Low-level environmental lead exposure and children's intellectual function: an international pooled analysis. Environ Health Perspect 2005; 113:894.
- Téllez-Rojo MM, Bellinger DC, Arroyo-Quiroz C, et al. Longitudinal associations between blood lead concentrations lower than 10 microg/dL and neurobehavioral development in environmentally exposed children in Mexico City. Pediatrics 2006; 118:e323.
- Treatment guidelines for lead exposure in children. American Academy of Pediatrics Committee on Drugs. Pediatrics 1995; 96:155.
- Markowitz ME, Bijur PE, Ruff H, Rosen JF. Effects of calcium disodium versenate (CaNa2EDTA) chelation in moderate childhood lead poisoning. Pediatrics 1993; 92:265.
- Chisolm JJ Jr. The road to primary prevention of lead toxicity in children. Pediatrics 2001; 107:581.
- O'Connor ME, Rich D. Children with moderately elevated lead levels: is chelation with DMSA helpful? Clin Pediatr (Phila) 1999; 38:325.
- Liebelt EL, Shannon M, Graef JW. Efficacy of oral meso-2,3-dimercaptosuccinic acid therapy for low-level childhood plumbism. J Pediatr 1994; 124:313.
- Roberts JR, Reigart JR. Chapter 3. Medical Assessment and Interventions. Managing elevated blood lead levels among young children: recommendations from the advisory committee on childhood lead poisoning prevention. Centers for Disease Control and Prevention; US Department of Health and Human Services, Atlanta, GA 2002. http://www.cdc.gov/nceh/lead/CaseManagement/caseManage_main.htm (Accessed on July 31, 2012).
- Dietrich KN, Ware JH, Salganik M, et al. Effect of chelation therapy on the neuropsychological and behavioral development of lead-exposed children after school entry. Pediatrics 2004; 114:19.
- Liebelt EL, Shannon MW. Oral chelators for childhood lead poisoning. Pediatr Ann 1994; 23:616.
- Woolf AD, Goldman R, Bellinger DC. Update on the clinical management of childhood lead poisoning. Pediatr Clin North Am 2007; 54:271.
- Graziano JH, Lolacono NJ, Moulton T, et al. Controlled study of meso-2,3-dimercaptosuccinic acid for the management of childhood lead intoxication. J Pediatr 1992; 120:133.
- Osterhoudt KC, Burns-Ewald M, Shannon M, Henretig FM. Toxicologic emergencies. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.951.
- Centers for Disease Control and Prevention. Managing elevated blood lead levels among young children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention. Atlanta, GA, Centers for Disease Control and Prevention, 2002. Available at http://www.cdc.gov/nceh/lead/CaseManagement/caseManage_main.htm. Accessed April 28, 2016.
- Thurtle N, Greig J, Cooney L, et al. Description of 3,180 courses of chelation with dimercaptosuccinic acid in children ≤ 5 y with severe lead poisoning in Zamfara, Northern Nigeria: a retrospective analysis of programme data. PLoS Med 2014; 11:e1001739.
- Piomelli S. Lead poisoning. In: Hematology of Infancy and Childhood, Nathan DG, Oski FA (Eds), WB Saunders, Philadelphia 1993. p.484.
- Chisolm JJ Jr. The use of chelating agents in the treatment of acute and chronic lead intoxication in childhood. J Pediatr 1968; 73:1.
- CHISOLM JJ Jr. Aminoaciduria as a manifestation of renal tubular injury in lead intoxication and a comparison with patterns of aminoaciduria seen in other diseases. J Pediatr 1962; 60:1.
- Perlstein MA, Attala R. Neurologic sequelae of plumbism in children. Clin Pediatr (Phila) 1966; 5:292.
- Centers for Disease Control and Prevention. Managing elevated blood lead levels among young children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention. Atlanta, GA, Centers for Disease Control and Prevention, 2002. http://www.cdc.gov/nceh/lead/CaseManagement/caseManage_main.htm. (Accessed on April 28, 2016).
- Friedheim E, Graziano JH, Popovac D, et al. Treatment of lead poisoning by 2,3-dimercaptosuccinic acid. Lancet 1978; 2:1234.
- Graziano JH, Lolacono NJ, Meyer P. Dose-response study of oral 2,3-dimercaptosuccinic acid in children with elevated blood lead concentrations. J Pediatr 1988; 113:751.
- Aposhian HV, Aposhian MM. meso-2,3-Dimercaptosuccinic acid: chemical, pharmacological and toxicological properties of an orally effective metal chelating agent. Annu Rev Pharmacol Toxicol 1990; 30:279.
- Rhoads GG, Rogan WJ. Treatment of lead-exposed children. Pediatrics 1996; 98:162.
- Graziano JH, Siris ES, LoIacono N, et al. 2,3-Dimercaptosuccinic acid as an antidote for lead intoxication. Clin Pharmacol Ther 1985; 37:431.
- Chisolm JJ Jr. Safety and efficacy of meso-2,3-dimercaptosuccinic acid (DMSA) in children with elevated blood lead concentrations. J Toxicol Clin Toxicol 2000; 38:365.
- Mann KV, Travers JD. Succimer, an oral lead chelator. Clin Pharm 1991; 10:914.
- Gerr F, Frumkin H, Hodgins P. Hemolytic anemia following succimer administration in a glucose-6-phosphate dehydrogenase deficient patient. J Toxicol Clin Toxicol 1994; 32:569.
- Cory-Slechta DA. Mobilization of lead over the course of DMSA chelation therapy and long-term efficacy. J Pharmacol Exp Ther 1988; 246:84.
- Rahmani R, Dan M, Fishel B, et al. [Fatal encephalopathy due to chronic lead poisoning]. Harefuah 1977; 93:246.
- Centers for Disease Control and Prevention (CDC). Deaths associated with hypocalcemia from chelation therapy--Texas, Pennsylvania, and Oregon, 2003-2005. MMWR Morb Mortal Wkly Rep 2006; 55:204.
- Piomelli S, Rosen JF, Chisolm JJ Jr, Graef JW. Management of childhood lead poisoning. J Pediatr 1984; 105:523.
- Markowitz ME, Rosen JF. Assessment of lead stores in children: validation of an 8-hour CaNa2EDTA provocative test. J Pediatr 1984; 104:337.
- Agency for Toxic Substances and Disease Registry. Toxicology Profile for Lead. US Department for Health and Human Services, Atlanta, 2002.
- Kassner J, Shannon M, Graef J. Role of forced diuresis on urinary lead excretion after the ethylenediaminetetraacetic acid mobilization test. J Pediatr 1990; 117:914.
- Markowitz ME, Rosen JF. Need for the lead mobilization test in children with lead poisoning. J Pediatr 1991; 119:305.
- Janakiraman N, Seeler RA, Royal JE, Chen MF. Hemolysis during BAL chelation therapy for high blood lead levels in two G6PD deficient children. Clin Pediatr (Phila) 1978; 17:485.
- Centers for Disease Control and Prevention. Managing elevated blood lead levels among young children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention. Atlanta, GA, Centers for Disease Control and Prevention, 2002. http://www.cdc.gov/nceh/lead/CaseManagement/caseManage_main.htm (Accessed on April 28, 2016).
- WALSHE JM. Penicillamine, a new oral therapy for Wilson's disease. Am J Med 1956; 21:487.
- Shannon M, Graef J, Lovejoy FH Jr. Efficacy and toxicity of D-penicillamine in low-level lead poisoning. J Pediatr 1988; 112:799.
- Sachs HK, Blanksma LA, Murray EF, O'Connell MJ. Ambulatory treatment of lead poisoning: report of 1,155 cases. Pediatrics 1970; 46:389.
- Ettinger, AS, Gurthrie Wengrovitz, A (Eds). Guidelines for the identification and management of lead exposure in pregnant and lactating women. National Center for Environmental Health/Agency for Toxic Substances and Disease Registry; Centers for Disease Control and Prevention, Atlanta, GA, 2010 available at http://www.cdc.gov/nceh/lead/publications/LeadandPregnancy2010.pdf.
- GENERAL MANAGEMENT
- ASYMPTOMATIC LEAD EXPOSURE AND POISONING
- Detectable BLL <5 mcg/dL (current reference level)
- Lead level 5 to 14 mcg/dL
- Lead level 15 to 44 mcg/dL
- Lead level 45 to 69 mcg/dL
- Lead level ≥70 mcg/dL
- SYMPTOMATIC LEAD POISONING
- Initial evaluation
- Initial stabilization
- - Encephalopathy
- - Seizures
- - Fluid administration
- Gastrointestinal decontamination
- Ensure lead-safe housing
- PHARMACOLOGIC AGENTS FOR CHELATION
- Calcium disodium edetate
- PERINATAL LEAD EXPOSURE
- Prenatal exposure
- ADDITIONAL RESOURCES
- SUMMARY AND RECOMMENDATIONS