II. Epidemiology

  1. Lead levels in children increased during the 20th century, peaking in the 1970s
  2. Even in the U.S. in 2017, lead levels >5 mcg are seen in more than 500,000 children

III. Causes: Most Common

  1. Lead-based paint and lead contaminated soil account for 70% of cases
  2. Contaminated drinking water and imported goods (e.g. candies, spices, pottery) account for 30% of cases

IV. Causes: General

  1. Home renovation or remodel
    1. Household dust
    2. Paint chips from lead-based paint
      1. Lead-based paint was banned in U.S. in 1978
      2. Older housing is likely to still contain residual lead
  2. Drinking water from lead pipes (or contaminated from lead solder, valves or fixtures)
    1. Restricted use of lead in pipes was restricted as of 1986 in U.S. (but still found in municipal pipes, older homes)
    2. Flint Water Crisis started in 2014 and resulted from lead contaminated water
      1. https://en.wikipedia.org/wiki/Flint_water_crisis
  3. Industrial waste exposure (e.g. soil contaminated with lead)
  4. Residence near busy highway
  5. Regional airport with piston engine aircraft
  6. Tea Kettles and pottery
  7. Vinyl mini blinds
  8. Imported candy (e.g. Tamarind candy from Mexico stored in lead-contaminated ceramics)
  9. Imported eye cosmetics (e.g. Kohl or Surma from India, or other eye cosmetics from Pakistan)
  10. Imported Jewelry or Toys
  11. Parents with occupational exposure (i.e. Take-home exposures)
    1. Lead production or smelting
    2. Battery manufacturing or battery reclamation
    3. Brass, copper or lead foundry
    4. Radiator repair
    5. Scrap handling
    6. Ship and bridge demolition
    7. Old painted metal welding
    8. Thermal paint stripping of old buildings
    9. Old paint sanding
    10. Lead soldering
    11. Ceramic glaze mixing
    12. Cable stripping
    13. Firing range staff
    14. Machining or grinding lead alloys
  12. Pica secondary to Anemia
    1. Eating lead paint or soil
  13. Herbal remedies containing lead
    1. See Lead-Containing Herbal Remedies

V. Risk Factors

  1. Children younger than 5 years (esp. 6-12 months, peaking at ages 18-36 months)
  2. Iron Deficiency Anemia (4-5x Relative Risk)
    1. Lead and iron are both absorbed from gastrointestinal tract via the same transporter
    2. In Iron Deficiency, the transporter is upregulated and therefore absorbs more lead
  3. Communities with lead-containing water service lines (or poor anticorrosion control, e.g. Flint, MI)
  4. Communities with known elevated blood lead levels
  5. Formula fed infants living in communities with lead contaminated water supplies
  6. Close proximity to current or former industrial plants with lead emissions (batteries, smelting plants)
  7. High poverty regions with older, poorly maintained homes
  8. Immigrants or Refugees
  9. Parent with occupation or hobby that exposes them to lead (see causes below)

VI. Symptoms

  1. Nonspecific even at high levels (45 mcg/dl)
    1. Anorexia
    2. Headache
    3. Abdominal Pain
    4. Constipation
  2. Very high levels
    1. Vomiting
    2. Agitation
    3. Somnolence
    4. Incoordination
    5. Confusion

VII. Signs

  1. Lead line in gums
  2. Papilledema
  3. Ocular palsy
  4. Wrist Drop
  5. Foot drop
  6. Slurred speech
  7. Reflex changes
  8. Bradycardia
  9. Mental status changes
    1. Seizures
    2. Delirium
    3. Coma

VIII. Labs: Screening

  1. Blood Lead Level
    1. See below for protocol
    2. May screen lead level with capillary blood test
    3. Confirm all abnormal capillary blood tests with venous blood draw lead level
  2. Indications
    1. Previously universal screening was in place before 1997 in United States
      1. Now screen child considered high risk or all children for whom risk is unknown or uncertain
    2. All Medicaid enrolled or eligible children
      1. Obtain lead level at 12 months and 24 months
      2. Catch-up at age 36-72 months if not already done
    3. All recent Immigrant Children (or Refugees, adoptees)
      1. Initial lead level on arrival in U.S.
      2. Repeat screening in 3-6 months later (for ages 6 months to 6 years old)
    4. High risk children
      1. Identified by CDC, state or local screening recommendations (i.e. high risk zip codes)
      2. Child lives in, visits, or attends child care in a house built before 1950
      3. Child lives in, visits, or attends child care in a house built before 1978 with renovation in last 6 months
      4. Child has sibling or playmate that has Lead Poisoning

IX. Labs: Advanced (indicated for lead level >20 mcg/dl or 0.97 umol/L)

X. Labs: Other findings suggestive of Lead Toxicity

  1. Urine lead level elevated
  2. Urine microscopy of sediment or renal biopsy
    1. Acid-fast inclusion bodies in tubular nuclei
    2. Pathognomonic for Lead Poisoning
  3. Free Erythrocyte Protoporphyrin (FEP) > 0.6 umol/L

XI. Imaging

  1. Abdominal XRay
    1. Indicated for moderate, high or very high lead level of 20 mcg/dl or greater
    2. Identifies lead remaining in the intestinal tract (radiodense)
  2. Long bone XRay
    1. Epiphyseal lead line

XII. Protocol

  1. Precautions
    1. Education and evaluation should be done at all abnormal lead levels
      1. Counseling regarding common lead exposures and prevention
      2. Nutrition counseling to increase calcium and iron intake
      3. Evaluate Developmental Milestones and environmental exposures
      4. Formal environmental evaluation
    2. There is no known safe level of lead, and lead plays no beneficial role in human physiology
    3. Even blood lead levels 5 mcg/dl have been associated with permanent neurocognitive and behavioral deficits
  2. Lead level 5-9 mcg/dl (0.24 to 0.43 umol/L): Low Lead Toxicity level
    1. Obtain venous lead level confirmation at one to three months
  3. Lead level 10-14 mcg/dl (0.48 to 0.68 umol/L): Low Lead Toxicity level
    1. Obtain venous lead level confirmation within one month
    2. Lead level at 0 months
    3. Lead level at 3 months
    4. Lead level at 6-9 months
  4. Lead level 15-19 mcg/dl (0.72 to 0.92 umol/L): Low Lead Toxicity level
    1. Obtain venous lead level confirmation within one month
    2. Lead level at 0 months
    3. Lead level at 1-3 months
      1. If lead level still >15 mcg/dl proceed to follow lead level of 20-44 mcg/dl
      2. If lead level <15 mcg/dl, continue with education and observation
    4. Lead level at 3-6 months
  5. Lead level 20-44 mcg/dl (0.97 to 2.13 umol/L): Moderate Lead Toxicity level
    1. Obtain venous lead level confirmation within one month
    2. Lead level at 0 months
      1. Environmental investigation and lead hazard reduction
      2. Complete history, exam, XRay as above
      3. Obtain Hemoglobin, Hematocrit and lead level
      4. Consider bowel Decontamination if ingestion suspected (consider abdominal XRay)
        1. Enemas used to clear retained lead products
    3. Lead level at 2-4 weeks
    4. Lead level at 1 month
  6. Lead level 45-69 mcg/dl (2.17 to 3.33 umol/L): High Lead Toxicity level
    1. Obtain venous lead level confirmation within 48 hours (24 hours if >60)
      1. Complete history, exam, Neurologic Exam, XRay as above
      2. Obtain Hemoglobin, Hematocrit and lead level
    2. Lead level at 0 months
      1. Includes measure done for lead level of 20-44 mcg/dl
    3. Lead level pre-chelation
      1. Outpatient Chelation therapy
    4. Lead level post-chelation
  7. Lead level >70 mcg/dl (>3.38 umol/L): Very high Lead Toxicity level
    1. Obtain venous lead level confirmation emergently
    2. Lead level at 0 months
      1. Includes measure done for lead level of 20-44 mcg/dl
      2. Immediate hospitalization for chelation therapy
    3. Lead level pre-chelation
      1. Inpatient chelation therapy
    4. Lead level post-chelation

XIII. Management: Chronic lead chelation

  1. Precautions
    1. Consult toxicologist (typically poison control in U.S.) before using chelation
    2. Obtain labs and diagnostics as above before chelation
    3. Dosing regimens should be checked with toxicology
  2. First-Line
    1. Succimer or Chemet (Meso-2,3-dimercaptosuccinic acid or DMSA)
      1. Initial: 10 mg/kg (or 350 mg/m2) PO every 8 hours for 5 days
      2. Next: 10 mg/kg (or 350 mg/m2) PO every 12 hours for 14 days
  3. Other parenteral agents that have been used for lead chelation
    1. Edetate Calcium Disodium (Calcium Disodium Versenate)
      1. Dose: 0.5-1.0 g/m2/day
      2. Maximum: 1.5 grams per day
    2. Dimercaprol (BAL in oil)
      1. Dose: 12-24 mg/kg/day for 5 days
  4. Other oral agents that have been used for lead chelation
    1. Penicillamine (Cuprimine)
      1. Dose: 20-40 mg/kg/day for 3 to 6 months
      2. Maximum: 1 grams per day
  5. Efficacy
    1. Chelation not affective if lead <45 mcg/dl
    2. Dietrich (2004) Pediatrics 114:19-26 [PubMed]

XIV. Management: Acute Lead Chelation

  1. Indications
    1. Acute encephalopathy (e.g. Seizures, Altered Mental Status) AND
    2. Lead Toxicity confirmed with whole blood lead level
  2. Chelation agents
    1. British anti-Lewisite (BAL)
      1. Administered intramuscular (IM)
      2. Contraindicated in peanut allergy and G6PD Deficiency
    2. Calcium Disodium EDTA
      1. Administered after BAL
      2. Poor CNS penetration
  3. Protocol
    1. Consult poison control
    2. First: British anti-Lewisite (BAL) IM (if not contraindicated)
    3. Next: Calcium Disodium EDTA IV given 4 hours after BAL
  4. References
    1. Swadron and Nordt in Herbert (2016) EM:Rap 16(6): 13-4

XV. Prognosis (Untreated)

  1. Aggressive and delinquent behavior
  2. Mental Retardation
  3. Language and cognitive deficits
  4. References
    1. Needlman (1996) JAMA 275:363-9 [PubMed]

XVI. Prevention

  1. Precautions regarding drinking water from lead pipes
    1. Allow tap to flow for 30 seconds, then collect water
      1. Alternatively shower, bath, and flush toilets before using tap water for cooking
    2. Do not use hot water from tap for drinking (use only cold water or bottled water)
    3. Consider formal testing of house tap water for lead
  2. Basic house measures
    1. Wash childrens hands and toys frequently
    2. Wet mop floors and window sills every 2 weeks
    3. Remove shoes before entering house
    4. Avoid folk remedies, imported medicines, candies, pottery (esp. from developing countries)
  3. Avoid living near highways or industrial plants
  4. Eliminate lead exposures (soil, dust, paint, water)
    1. CDC and local data can be used to identify areas for environmental testing (e.g. house paint)
  5. Replace all lead paint with non-lead paints using lead-safe practices
    1. Carefully limit child's exposure during remodeling
    2. Carefully dispose of removed lead paint

XVII. Resources

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Ontology: Lead Poisoning (C0023176)

Definition (MEDLINEPLUS)

Lead is a metal that occurs naturally in the earth's crust. Lead can be found in all parts of our environment. Much of it comes from human activities such as mining and manufacturing. Lead used to be in paint; older houses may still have lead paint. You could be exposed to lead by

  • Eating food or drinking water that contains lead. Water pipes in older homes may contain lead.
  • Working in a job where lead is used
  • Using lead in a hobby, such as making stained glass or lead-glazed pottery
  • Using folk remedies such as herbs or foods that contain lead

Breathing air, drinking water, eating food, or swallowing or touching dirt that contains lead can cause many health problems. Lead can affect almost every organ and system in your body. In adults, lead can increase blood pressure and cause infertility, nerve disorders, and muscle and joint pain. It can also make you irritable and affect your ability to concentrate and remember.

Lead is especially dangerous for children. A child who swallows large amounts of lead may develop anemia, severe stomachache, muscle weakness, and brain damage. Even at low levels, lead can affect a child's mental and physical growth.

Agency for Toxic Substances Disease Registry

Definition (CSP) poisoning due to absorption or ingestion of lead or one of its salts; symptoms include loss of appetite, weight loss, colic, constipation, insomnia, headache, dizziness, irritability, moderate hypertension, albuminuria, anemia, encephalopathy, and peripheral neuropathy leading to paralysis.
Concepts Injury or Poisoning (T037)
MSH D007855
ICD9 984.9, 984
ICD10 T56.0 , T56.0X, T56.0X1
SnomedCT 38342005, 157695008, 212842003, 212519002
LNC LA10482-0
English Lead Poisoning, Lead Poisonings, Poisoning, Lead, Poisonings, Lead, Toxic effect of unspecified lead compound, Toxic effect of lead and its compounds (including fumes), LEAD POISONING, SATURNISM, Saturnism, Lead compound causing toxic effect NOS, Lead compound-toxic effect NOS, Lead and its compounds, Lead and lead compounds causing toxic effect, Lead+Pb comp causng tox effect, Toxic effect of lead and its compounds, LEAD POIS, POIS LEAD, Lead compound poisoning, poisoning by lead, poisoning by lead (diagnosis), Tox eff lead compnd NOS, Toxic effects of lead and its compounds, Lead Poisoning [Disease/Finding], lead poison, Poisoning;lead, lead poisoning, Toxic effects of lead and its compounds NOS, Lead and lead compounds causing toxic effect (disorder), Lead compound causing toxic effect NOS (disorder), Lead compound poisoning (disorder), Lead intoxication, Plumbism, Lead poisoning, Saturnine poisoning, Lead - toxic effect, Toxic effect of lead compound (disorder), Toxic effect of lead compound, painter's colic, plumbism, saturnism, Toxic effect of lead compound, NOS, Toxic effect of lead and its compounds, including fumes, Poisoning by compounds of lead
French SATURNISME, Effet toxique du plomb et ses composés (incl les fumées), Effet toxique d'un composé du plomb non précisé, INTOXICATION AU PLOMB, Saturnisme, Intoxication par le plomb, Intoxication au plomb, Intoxication saturnine
Dutch loodvergiftiging, toxisch gevolg van niet-gespecificeerde loodverbinding, toxisch gevolg van lood en zijn verbindingen (inclusief gassen), Lood en loodverbindingen, Loodvergiftiging, Vergiftiging, lood-
German toxischer Effekt von Blei und seinen Verbindungen (einschliesslich Daempfe), toxischer Effekt unspezifischer Bleiverbindungen, Toxische Wirkung: Blei und dessen Verbindungen, Bleivergiftung
Italian Saturnismo, Effetti tossici del piombo e dei suoi composti (compresi i vapori), Effetti tossici dei composti del piombo non specificati, Avvelenamento da piombo
Portuguese Intoxicação pelo chumbo, Saturnismo, Efeito tóxico de composto de chumbo NE, INTOXICACAO PELO CHUMBO, SATURNISMO, Efeito tóxico de chumbo e seus compostos (incluindo vapores), Intoxicação por Chumbo
Spanish Intoxicación por plomo, Efecto tóxico de compuestos del plomo no especificados, Efecto tóxico del plomo y de sus compuestos (incluido el humo), Saturnismo, efecto tóxico de compuesto con plomo (trastorno), efecto tóxico de compuesto con plomo, efecto tóxico del plomo (trastorno), efecto tóxico del plomo, intoxicación por compuesto de plomo, compuesto de plomo que produce efecto tóxico, SAI, compuesto de plomo que produce efecto tóxico, SAI (trastorno), intoxicación por compuesto de plomo (trastorno), Envenenamiento por Plomo, intoxicación plúmbica, intoxicación por plomo, intoxicación saturnina, plumbismo, Intoxicación por Plomo
Japanese 詳細不明の鉛化合物の毒作用, ショウサイフメイノエンカゴウブツノドクサヨウ, ナマリチュウドク, 中毒-鉛, 鉛中毒, なまり中毒
Swedish Blyförgiftning
Czech olovo - otrava, Toxický účinek olova a jeho sloučenin (včetně výparů), Saturnismus, Toxický účinek blíže neurčených sloučenin olova, Otrava olovem
Finnish Lyijymyrkytys
Russian SVINTSOVYE OTRAVLENIIA, СВИНЦОВЫЕ ОТРАВЛЕНИЯ
Korean 납 및 그 화합물의 중독작용
Croatian OTROVANJE OLOVOM
Polish Ołowica, Zatrucie ołowiem
Hungarian Ólommérgezés, Ólom és vegyületeinek toxikus hatása (beleértve füstök), Nem meghatározott ólomvegyület toxikus hatása
Norwegian Plumbisme, Blyforgiftning

Ontology: Lead Poisoning, Nervous System (C0751859)

Definition (MSH) Injury to the nervous system secondary to exposure to lead compounds. Two distinct clinical patterns occur in children (LEAD POISONING, NERVOUS SYSTEM, CHILDHOOD) and adults (LEAD POISONING, NERVOUS SYSTEM, ADULT). In children, lead poisoning typically produces an encephalopathy. In adults, exposure to toxic levels of lead is associated with a peripheral neuropathy.
Concepts Injury or Poisoning (T037)
MSH D020263
Swedish Blyförgiftning, nervsystemet
English POIS LEAD NEUROLOGIC, NEUROTOX SYNDROME LEAD, POIS LEAD NERVOUS SYSTEM, LEAD POIS NERVOUS SYSTEM, NERVOUS SYSTEM POIS LEAD, LEAD IND NERVOUS SYSTEM DIS, NERVOUS SYSTEM DIS LEAD IND, LEAD POIS NEUROLOGIC, Lead-Induced Nervous System Diseases, Nervous System Diseases, Lead-Induced, Lead Poisoning, Nervous System, Nervous System Poisoning, Lead, Poisoning, Lead, Nervous System, Lead Poisoning, Neurologic, Neurologic Lead Poisoning, Poisoning, Lead, Neurologic, Lead Neurotoxicity Syndrome, Lead Neurotoxicity Syndromes, Neurotoxicity Syndrome, Lead, Neurotoxicity Syndromes, Lead, Syndrome, Lead Neurotoxicity, Syndromes, Lead Neurotoxicity, Nervous System Plumbism, Plumbism, Nervous System, Neurologic Plumbism, Plumbism, Neurologic, Lead Poisoning, Nervous System [Disease/Finding]
Czech nemoci nervového systému vyvolané olovem, syndrom neurotoxicity - olovo, otrava olovem - nervový systém
Finnish Hermoston lyijymyrkytys
Italian Malattie del sistema nervoso indotte da piombo, Avvelenamento neurologico da piombo, Sindrome neurotossica da piombo, Saturnismo del sistema nervoso, Saturnismo neurologico, Avvelenamento del sistema nervoso da piombo
Russian SVINTSOVYE OTRAVLENIIA, NERVNAIA SISTEMA, СВИНЦОВЫЕ ОТРАВЛЕНИЯ, НЕРВНАЯ СИСТЕМА
Polish Zatrucie ołowiem układu nerwowego, Zespół neurotoksyczny ołowiowy
Japanese 神経系疾患-鉛誘発性, 鉛中毒-神経系, 中毒-鉛-神経系, 神経毒性症候群-鉛誘発性, 神経系中毒-鉛, 神経系鉛中毒, 鉛誘発性神経毒性症候群, 鉛誘発性神経系疾患
Norwegian Nevrologisk blyforgiftning, Plumbisme i nervesystemet, Blyforgiftninger i nervesystemet, Nevrologisk plumbisme
Spanish Envenenamiento Neurológico por Plomo, Enfermedades del Sistema Nervioso Inducidas por Plomo, Envenenamiento del Sistema Nervioso por Plomo, Intoxicación del Sistema Nervioso por Plomo, Intoxicación Neurológica por Plomo, Plumbismo del Sistema Nervioso, Plumbismo Neurológico, Síndrome de Neurotoxicidad por Plomo
German Bleiinduzierte Nervensystemkrankheiten, Bleivergiftung, Nervensystem, Nervensystemkrankheiten, bleiinduzierte, Nervensystemvergiftung, durch Blei, Saturnismus, Nervensystem, Saturnismus, neurologischer, Vergiftung durch Blei, Nervensystem, Vergiftung durch Blei, neurologische, Neurotoxizitätssyndrom, durch Blei
Dutch Loodvergiftiging van het zenuwstelsel, Neurotoxiciteitsyndroom, lood-, Plumbisme, neurologisch, Vergiftiging van het zenuwstelsel, lood-, Vergiftiging, neurologische lood-, Zenuwstelselvergiftiging, lood-, Loodgeïnduceerde zenuwstelselziekte, Zenuwstelselziekte, loodgeïnduceerde
Portuguese Doenças do Sistema Nervoso Induzidas por Chumbo, Intoxicação do Sistema Nervoso por Chumbo, Intoxicação Neurológica por Chumbo, Plumbismo do Sistema Nervoso, Plumbismo Neurológico, Síndrome da Neurotoxicidade por Chumbo
French Troubles neurologiques dus à l'intoxication par le plomb, Atteintes neurologiques du saturnisme, Neuropathie saturnine, Troubles neurologiques de l'intoxication par le plomb, Troubles neurologiques du saturnisme