Lead exposure may result from contact with lead in the environment, including lead-based paint, dirt, cosmetics, hobby products, water, and other sources. Lead exposure generally occurs when contaminants with lead are inhaled or ingested. Children exposed to lead during childhood are at increased risk for delays in development and growth. This clinical resource discusses assessment, screening and testing, and interventions for elevated lead levels in children.

Screening Recommendations

Ongoing Assessment

Remove the Source of Lead Exposure

Guidelines, recommendations, and reviews of the literature are provided by the Centers for Disease Control and Prevention (CDC) and American Academy of Pediatrics (AAP). [Centers: 2010] [Council: 2016] [Council: 2017]

Of note, the 2019 U.S. Preventive Services Task Force (USPSTF) guideline concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for elevated blood lead levels in asymptomatic children. [Curry: 2019]

Signs and Symptoms

• Constipation
• Anorexia
• Vomiting
• Inattentiveness, distractibility, impulsivity
• Anemia
• Learning problems
• Decreased growth
• Neurodevelopmental delays
• Intellectual disability (see the Portal’s module on Intellectual Disability & Global Developmental Delay for more information)
• Attention deficit hyperactivity disorder [Daneshparvar: 2016] (see the Portal’s module on Attention-Deficit/Hyperactivity Disorder (ADHD) for more information)

Surveillance and Screening

Approximately 3% of children between ages 1 and 5 years have blood lead levels at or above 5 μg/dL. Rates vary by geography, age of housing, poverty, etc. [Centers: 2013]

Worse outcomes, including developmental delays and growth problems, are correlated with increased blood lead levels (BLLs).

There is no safe blood lead level. The AAP Pediatric Environmental Health Specialty Units (PEHSUs) recommend more frequent testing, interventions, and other steps at higher blood lead levels (see Recommendations on Medical Management of Childhood Lead Exposure and Poisoning (AAP) ( 133 KB) and Sample Management Guidelines on Childhood Lead Poisoning for Health Care Providers ( 659 KB)). [Pediatric: 2013] [Centers: 2010] Recommended criteria and steps for treatment may be different by state. Determining the source of the exposure and eliminating or limiting the lead exposure, such as lead in paint or toys, is a key step in the treatment and management of a child with lead exposure.

Screen for developmental and other neurodevelopmental delays. See Developmental Screening.

The medical home can provide care coordination including anticipatory guidance; care planning; identification of resources and specialists; appointment coordination; collection and coordination of testing and treatment results; and other care coordination activities.

For recommendations for initiating breastfeeding, see Maternal Lead Exposure.

Recommendations for continuation of breastfeeding:

• Breastfeeding should continue for all infants with BLLs below 5 μg/dL.
• Infants born to mothers with BLL ≥5 μg/dL can continue to breastfeed unless there are indications that the breast milk is contributing to elevating BLLs. These infants should have blood lead tests at birth and be followed at:
  • 1 month for levels of 5 μg/dL to 24 μg/dL
  • 2 weeks for levels of 55 μg/dL to 44 μg/dL
  • Within 24 hours for levels over 45 μg/dL
• For infants whose blood lead levels are rising or failing to decline by 5 μg/dL or more, environmental and other sources of lead exposure should be evaluated. If no external source is identified, and maternal BLLs are >20 μg/dL and infant BLL ≥5 μg/dL, then breast milk should be suspected as the source, and temporary interruption of breastfeeding until maternal blood lead levels decline should be considered.

• Infant formula requiring reconstitution (i.e., powder or concentrated formula) should be made with water from the cold water tap and then heat the water. If you live in an older home, consider running the water in the morning for a few minutes before using it. Alternatively, use lead-free bottled or filtered tap water or ready-to-feed formula (which is more costly). [Centers: 2010] [Committee: 2012] [American: 2021]

Common treatment interventions, including removal from the source of the exposure and nutritional interventions are attempted before medications are considered due to the risks of using the medications.

Oral chelation may improve blood lead levels and reduce symptoms of acute lead intoxication but may have limited usefulness in reducing other existing symptoms, such as neurodevelopmental delays. [Kosnett: 2007]

Chelation is considered when blood lead levels are greater than 45 μg/dL, when the individual has been removed from the lead exposure, and based on the individual situation of the exposed mother and/or child. An expert in lead poisoning should be consulted for chelation. Chelation medications bind to and release lead and other essential minerals from bone and other tissues. Lead can be stored by the bones for many years. [Family: 2022] The blood lead level may drop immediately after chelation treatment but usually increases about two weeks after treatment. [Centers: 2010] [Family: 2022] Blood lead levels may remain high for years even after chelation therapy, particularly if there has been longstanding exposure, and chelation may not affect long-term neurodevelopmental outcomes in children. [Cantor: 2018] In pregnant women, the loss of other minerals from the therapy may increase risks of complications for the fetus. [Centers: 2010]

Recommendations for chelation therapy include: [Centers: 2010]

• Infants (0-6 months of age) with a confirmed BLL of ≥45 μg/dL should be considered as candidates for chelation in consultation with an expert in pediatric lead chelation therapy.
• Chelation therapy must occur in a lead-safe environment; therefore, prior to initiating chelation therapy, the patient should be removed from further lead exposure.
• Children should not return to an environment where lead hazards are present and continued exposure is likely following chelation.

Chelating agents used to treat lead poisoning include: [Centers: 2010]

• Calcium edetate
  • Administered IM or IV, inpatient only
  • Always use with calcium
• Succimer
  • Administered PO
  • Does not lower BLL with single course of treatment
• Dimercaprol (British anti-Lewisite (BAL))
  • Administered IM, inpatient only
  • Used with calcium edetate
• D-penicillamine
  • Administered PO

Public Health Services (see RI providers [6])
After blood lead levels are identified, local health department and other experts will perform important roles depending upon the source of the lead exposure.

Developmental - Behavioral Pediatrics (see RI providers [12])
After blood lead levels are identified, an expert in lead poisoning should be consulted for chelation. [Centers: 2010] See the section above, Medications Used to Treat Lead Exposure, for details on chelation.

Pediatric Hematology/Oncology (see RI providers [11])
A pediatric hematology/oncology specialist may provide consultation for diagnosis and treatment of lead poisoning.

Z77.011, Contact with and (suspected) exposure to lead
R78.71, Abnormal lead level in blood
Z13.88, Encounter for screening for disorder due to exposure to contaminants
See ICD-10 related to lead exposure (icd10data.com) for further coding details.