Lead Poisoning in Children

 

Am Fam Physician. 2019 Jul 1;100(1):24-30.

  Patient information: See related handouts on lead poisoning in children, written by the authors, and at https://familydoctor.org/lead-poisoning-in-children/.

Author disclosure: No relevant financial affiliations.

Asymptomatic lead poisoning has become more common in children. Blood lead levels of less than 5 μg per dL are associated with impairments in neurocognitive and behavioral development that are irreversible. Risk factors for lead poisoning include age younger than five years, low socioeconomic status, living in housing built before 1978, and use of imported food, medicines, and pottery. The U.S. Preventive Services Task Force released a recommendation in 2019 citing insufficient evidence to assess the balance of benefits and harms of universal screening for elevated blood lead levels in asymptomatic children and pregnant women. Local risk factors can be substantial, and the Centers for Disease Control and Prevention (CDC) recommends that states and cities formulate their own targeted screening guidelines. In the absence of local guidance, the CDC recommends screening all Medicaid-eligible children at 12 months and again at 24 months, or at least once between 36 and 72 months if not previously screened. The CDC also recommends universal screening in areas where more than 27% of the housing was built before 1950, or where at least 12% of children 12 to 36 months of age have blood lead levels greater than 10 μg per dL. Life-threatening lead levels are treated with chelation therapy, and lower levels should prompt case management and environmental investigations to identify and remove the source of exposure. Primary prevention strategies are essential to eliminate the harmful effects of lead on child development.

Lead has been used in construction, paint, gasoline, food, pottery, folk medicines, and herbal remedies for centuries,1,2 and its harmful effects are a clinical and public health concern because of its pervasive presence in the environment and its continued use in industry.

WHAT IS NEW ON THIS TOPIC

In 2012, the Advisory Committee on Childhood Lead Poisoning Prevention of the Centers for Disease Control and Prevention lowered the blood lead level to 5 μg per dL (0.24 μmol per L) to trigger further investigation and case management. More than 500,000 U.S. children were estimated to have high blood lead levels in 2017.

Blood lead levels of 5 μg per dL or less in apparently asymptomatic children have been repeatedly associated with impaired neurocognitive and behavioral development.

Children residing in communities with lead-containing water service lines, or poor anticorrosion control, are at an increased risk of lead poisoning from drinking water. Formula-fed infants have heightened risk of developing lead toxicity in these communities.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Screening of all Medicaid-eligible children for blood lead exposure should occur at 12 and 24 months, or at least once between 36 and 72 months if not previously tested.5,14

C

Expert consensus and elevated blood lead level prevalence data

Targeted screening questionnaires should be used to identify children who may be at elevated risk for lead poisoning.5,14

C

Expert consensus

A capillary blood test is an acceptable screening method for lead poisoning, but any abnormal value should be confirmed with a venous sample.9

C

Expert consensus

Chelation therapy should be used when a child's blood lead levels are greater than 45 μg per dL (2.17 μmol per L).4

C

Expert consensus


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Screening of all Medicaid-eligible children for blood lead exposure should occur at 12 and 24 months, or at least once between 36 and 72 months if not previously tested.5,14

C

Expert consensus and elevated blood lead level prevalence data

Targeted screening questionnaires should be used to identify children who may be at elevated risk for lead poisoning.5,14

C

Expert consensus

A capillary blood test is an acceptable screening method for lead poisoning, but any abnormal value should be confirmed with a venous sample.9

C

Expert consensus

Chelation therapy should be used when a child's blood lead levels are greater than 45 μg per dL (2.17 μmol per L).4

C

Expert consensus


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Lead poisoning is often asymptomatic. Even at higher blood lead levels (45 μg per dL [2.17 μmol per L] or greater) the symptoms are nonspecific and include headache, abdominal pain, anorexia,

The Author

LAURA MAYANS, MD, MPH, is an assistant professor in the Department of Family and Community Medicine and director of the Family Medicine Clerkship at the University of Kansas School of Medicine–Wichita.

Address correspondence to Laura Mayans, MD, MPH, 855 N. Hillside St., Wichita, KS 67214. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

References

show all references

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2. Warniment C, Tsang K, Galazka SS. Lead poisoning in children. Am Fam Physician. 2010;81(6):751–757.

3. Hauptman M, Bruccoleri R, Woolf AD. An update on childhood lead poisoning. Clin Pediatr Emerg Med. 2017;18(3):181–192.

4. Advisory Committee on Childhood Lead Poisoning Prevention of the Centers for Disease Control and Prevention. Low level lead exposure harms children: a renewed call for primary prevention. January 4, 2012. https://www.cdc.gov/nceh/lead/acclpp/final_document_030712.pdf. Accessed March 2, 2018.

5. Reuben A, Caspi A, Belsky DW, et al. Association of childhood blood lead levels with cognitive function and socioeconomic status at age 38 years and with IQ change and socioeconomic mobility between childhood and adulthood. JAMA. 2017;317(12):1244–1251.

6. Centers for Disease Control and Prevention. What do parents need to know to protect their children? Updated May 17, 2017. https://www.cdc.gov/nceh/lead/acclpp/blood_lead_levels.htm. Accessed March 2, 2018.

7. Raymond J, Brown MJ. Childhood blood lead levels in children aged <5 years – United States, 2009–2014. MMWR Surveill Summ. 2017;66(3):1–10.

8. Canfield RL, Henderson CR Jr, Cory-Slechta DA, Cox C, Jusko TA, Lanphear BP. Intellectual impairment in children with blood lead concentrations below 10 microg per deciliter. N Engl J Med. 2003;348(16):1517–1526.

9. Council on Environmental Health. Prevention of childhood lead toxicity [published correction appears in Pediatrics. 2017;140(2):e20171490]. Pediatrics. 2016;138(1):e20161493.

10. McClure LF, Niles JK, Kaufman HW. Blood lead levels in young children: U.S., 2009–2015. J Pediatr. 2016;175:173–181.

11. Brown MJ, Margolis S. Lead in drinking water and human blood lead levels in the United States. MMWR Suppl. 2012;61(4):1–9.

12. Lanphear B. Still treating lead poisoning after all these years. Pediatrics. 2017;140(2):e20171400.

13. Centers for Disease Control and Prevention. CDC response to Advisory Committee on Childhood Lead Poisoning Prevention recommendations in “low level lead exposure harms children: a renewed call of primary prevention.” https://www.cdc.gov/nceh/lead/acclpp/cdc_response_lead_exposure_recs.pdf. Accessed March 2, 2018.

14. Levin R, Brown MJ, Kashtock ME, et al. Lead exposures in U.S. children, 2008: implications for prevention [published correction in Environ Health Perspect. 2008;116(10):1291]. Environ Health Perspect. 2008;116(10):1285–1293.

15. Hanna-Attisha M, LaChance J, Sadler RC, Champney Schnepp A. Elevated blood lead levels in children associated with the Flint drinking water crisis: a spatial analysis of risk and public health response. Am J Public Health. 2016;106(2):283–290.

16. Roberts EM, Madrigal D, Valle J, King G, Kite L. Assessing child lead poisoning case ascertainment in the U.S., 1999–2010. Pediatrics. 2017;139(5):e20164266.

17. U.S. Preventive Services Task Force. Final recommendation statement: elevated blood lead levels in children and pregnant women: screening. Updated April 2019. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/elevated-blood-lead-levels-in-childhood-and-pregnancy-screening. Accessed April 17, 2019.

18. Centers for Disease Control and Prevention. Recommended actions based on blood lead level. Updated March 26, 2018. https://www.cdc.gov/nceh/lead/acclpp/actions_blls.html. Accessed April 12, 2019.

19. Centers for Disease Control and Prevention. Prevention tips. Updated June 19, 2014. https://www.cdc.gov/nceh/lead/tips.htm. Accessed March 2, 2018.

20. Nussbaumer-Streit B, Yeoh B, Griebler U, et al. Household interventions for preventing domestic lead exposure in children. Cochrane Database Syst Rev. 2016;(10):CD006047.

21. Centers for Disease Control and Prevention. Blood lead levels in children: what do parents need to know to protect their children? https://www.cdc.gov/nceh/lead/acclpp/lead_levels_in_children_fact_sheet.pdf. Accessed March 2, 2018.

 

 

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