Clerkship Ready: Pediatrics

In this episode, we discuss lead toxicity and lead screening. We will talk about what lead is, what happens when a child is exposed to lead, what to ask parents about if you’re worried about lead exposure, how to screen for lead toxicity, and what to do if your patient has an elevated lead level.

1. Sources of lead exposure
   
   
   1. Ingestion of contaminated food or water
   
   
   2. Ingestion or breathing in of lead dust
   
   
   3. Other sources: lead-acid batteries, ammunition, lead-based pigments and paints, stained glass, lead crystal glasses, ceramic glazes, jewelry, toys
   
   
   4. For families from other cultures, think about ceramic glazes, traditional cosmetics, traditional medicines
   
   



2. Government policies to decrease lead exposure
   
   
   1. Unleaded gasoline
   
   
   2. Lead-free paint
   
   
   3. Lead-free solder in food cans
   
   
   4. Lead-free water pipes
   
   



3. Why young children are at risk for lead toxicity
   
   
   1. Hand-to-mouth behavior
   
   
   2. Increased absorption of lead
   
   
   3. Developing nervous system is vulnerable
   
   
   4. Calcium or iron deficiency increase absorption of lead
   
   



4. Effects of lead toxicity in children can be seen at levels as low as 3.5 µg/dL
   
   
   1. Growth and development delays
   
   
   2. Lower IQ
   
   
   3. Learning and behavior problems
   
   
   4. Hearing and speech problems
   
   
   5. School underperformance
   
   
   6. At higher levels, you may see
      
      
      1. Irritability
      
      
      2. Loss of appetite, weight loss, fatigue
      
      
      3. Abdominal pain, vomiting, and/or constipation
      
      
      4. Anemia
      
      
      5. Pica
      
      
      6. Seizures, coma, death
      
      
   
   
   



5. Universal lead screening at 1 and 2 years
   
   
   1. Screening questionnaires are not very sensitive or specific
   
   
   2. Blood lead test
      
      
      1. Capillary – get results quickly, but can be falsely elevated
      
      
      2. Venous – results more accurate, but may take some time to come back
      
      
   
   
   



6. Management of elevated lead level
   
   
   1. Repeat it if it was a capillary sample
   
   
   2. Review results with family
   
   
   3. Ask about potential exposures – may need to contact health department, landlord, or independent certified lead inspector to test home for lead
   
   
   4. Assess risk factors for iron or calcium deficiency
   
   
   5. Ask about developmental milestones – may need to refer to early intervention services
   
   
   6. Consider abdominal xray if history of pica
   
   
   7. For levels >45, may need chelation therapy
   
   

Resources/Links:

• CDC, Childhood Lead Poisoning Prevention, https://www.cdc.gov/nceh/lead/default.htm


• AAP policy statement. Prevention of Childhood Lead Toxicity, Pediatrics 2016: 138(1):e20161493. https://publications.aap.org/pediatrics/article/138/1/e20161493/52600/Prevention-of-Childhood-Lead-Toxicity


• Mona Hanna-Attisha, What the Eyes Don't See: A Story of Crisis, Resistance, and Hope in an American City, 2018. https://www.amazon.com/What-Eyes-Dont-See-Resistance/dp/0399590838