Lead Level

1. The limit of detection for lead can vary by lab and is typically between 1 and 3.3 µg/dL.
2. Review laboratory results with the family. For reference, the geometric mean blood lead level for children 1-5 years old in the United States is less than 1 µg/dL. Emphasize with the family the dangers of lead and the need for vigilance.
3. Repeat the blood lead level (BLL) in 6-12 months if the child is at high risk or if the environmental risk changes during the timeframe.  Ensure lead testing is done at 1 and 2 years of age and thereafter, based on local and state guidelines.
4. For children tested at age
5. Perform routine health maintenance including assessment of nutrition, physical and mental development, as well as iron deficiency risk factors as per the recommendations in the American Academy of Pediatrics’ (AAP) Bright Futures Guidelines.
6. Provide preliminary advice about reducing/eliminating exposures (e.g., wash children’s hands/toys frequently; damp-mop floors, windows and windowsills; leave shoes at the home’s threshold; place duct-tape or contact paper over chipping/peeling paint; avoid renovations that may create a dust hazard).

Lead Level 3.5-19 µg/dL

1. Perform steps as described above for levels
2. Re-test venous BLL within 1-3 months to ensure the lead level is not rising.  If it is stable or decreasing, retest the BLL in 3 months.  Refer patient to local health authorities if services are available.  Most states require elevated BLL be reported to the state health department. Contact the CDC at 800-CDC-INFO (800-232-4636), the National Lead Information Center at
   800-424-LEAD (5323), or the national PEHSU network (pehsu@aap.org) for resources. regarding lead-poisoning prevention and local childhood lead-poisoning prevention programs.
3. Take a careful environmental history to identify potential sources of exposure (see #6 above). Consider young siblings and other children who may be exposed.  If lead paint in older homes is the exposure concern, advise that lead paint abatement is the best solution, and refer the family to local health department for resources and information.
4. Provide nutritional counseling related to calcium, vitamin D, and iron. In addition, recommend having fruit at every meal, as iron absorption quadruples when taken with vitamin C-containing foods.  Encourage the consumption of iron-enriched foods (e.g., cereals, meats).  Some children may be eligible for Special Supplemental Nutrition Program for Women, Infants and Child (WIC) or other nutritional resources.
5. Ensure iron sufficiency with adequate laboratory testing (complete blood count (CBC), ferritin, and reticulocyte count) and treatment per AAP guidelines. Consider starting a multivitamin with iron or iron supplementation as indicated.
6. Perform structured developmental screening evaluations at child health maintenance visits per recommendations in Bright Futures Guidelines, and, if indicated, refer to therapeutic and special educational programs (e.g., Early Intervention Program (EIP), a CORE evaluation and Individualized Education Plan (IEP)), as lead’s effect on development may manifest over years.

Lead Level 20-44 µg/dL

1. Perform steps listed above for levels 3.5-19 µg/dL. Report results to state/local health authorities.
2. Determine if there are any symptoms, which may be subtle and can include anorexia and abdominal discomfort.
3. Confirm BLL with venous sample within 1 to 2 weeks, or more rapidly for higher levels.
4. Work with the family to identify and remove potential lead sources. Refer to local health department to conduct home investigation to assess for the lead source, if available.  If not available, consult with a regional Pediatric Environmental Health Specialty Unit (PESHU) regarding other options.
5. Additional, specific evaluation of the child, such as an abdominal x-ray, should be considered based on the environmental investigation and history (e.g., pica for paint chips, mouthing behaviors). Gastrointestinal decontamination may be considered if radio-opaque foreign bodies consistent with ingested lead are visualized on x-ray.  Any treatment for BLL in this range should be done in consultation with an expert.
6. Contact your regional PEHSU or Poison Control Center (PCC) for guidance; see resources on back for contact information.

Lead Level ≥ 45 µg/dL

1. Follow above guidance for BLL 20-44 µg/dL. Report results to state and local health authorities.
2. Confirm the BLL with repeat venous lead level within 48 hours or more rapidly for higher levels.
3. Obtain a complete blood count, electrolytes, blood urea nitrogen, creatinine, liver transaminase enzyme levels, and urinalysis in anticipation of chelation therapy.
4. Abdominal X-ray should be done to look for radio-opaque foreign bodies suggestive of recent ingestion, as this may change management. Consider gastrointestinal decontamination if radio-opaque foreign bodies consistent with ingested lead are visualized on x-ray.
5. Emergently admit all symptomatic children to a hospital; if there is evidence of significant central nervous system pathology, consider pediatric intensive care unit admission. If asymptomatic, consider hospitalization and/or chelation therapy (managed with the assistance of an experienced provider). Chelation in the context of ongoing exposure is ineffective and may result in increasing lead levels in the central nervous system. Factors that may influence management include the status of the home with respect to lead hazards, ability to isolate the lead source, family social situation, and chronicity of the exposure. An elevated blood zinc-chelated protoporphyrin level (ZPP) can confirm either an iron-deficiency anemia as a comorbidity in the lead-poisoned child or, if there is no iron deficiency present, a more chronic lead exposure. Contact your regional PEHSU or Poison Control Center (PCC) (1-800-222-1222) for assistance.
6. Prior to initiating chelation therapy for outpatient therapy, it is critical that the home environment is inspected, temporary mitigation measures applied, and preferably demonstration of stable or down trending lead levels indicating the primary of lead exposure has been removed prior to starting chelation therapy. There is a risk of worsening lead exposure if chelation therapy continues in a residence with persistent lead hazards. It is expected, after a course of chelation therapy, that the blood lead level will rebound as the lead re-equilibrates. After chelation is completed, continue to follow the child until the BLL declines steadily; consider re-exposure if the BLL remains stable or rebounds above pre-chelation levels.