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Diagnosis and Treatment of Lead Poisoning in Children

Washington Poison Center
The Antidote: Toxicology Tidbits & Trends

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Lead poisoning is a challenging condition to recognize and manage effectively, due to its insidious nature and diverse clinical manifestations. This is concerning, as promptly diagnosing, initiating appropriate treatment, and referring patients to developmental services is essential to minimize long-term health consequences.

Lead poisoning occurs from prolonged or high-level exposure to contaminated products and environments, including lead-based paint, soil, consumer products, and water (see our previous post on common sources of lead exposure). When lead enters the bloodstream, it is distributed throughout the body where it accumulates in organs, including the brain, kidneys, and bones. The body confuses lead with calcium and mistakenly incorporates it into processes where calcium is normally used. Accumulation of lead can subsequently lead to neurological, hematological, renal, reproductive, and developmental effects.

While individuals of any age can experience lead poisoning, infants and young children are particularly vulnerable. Young children often engage in behaviors that increase their risk of lead exposure, such as crawling on the ground and placing hands or contaminated items in their mouths. Children have higher baseline respiratory rates, which can increase the amount of lead dust they breathe in. Children’s gastrointestinal tracts can absorb 4–5 times as much ingested lead compared to adults. And, children are at higher risk for neurotoxicity.

Screening

Lead poisoning rarely causes visible symptoms unless lead is present in extremely high levels in the body. Most children with lead poisoning will not look or act sick. And, developmental impacts from lead poisoning may not be visible until years later, when the child is in school.

A blood lead test is the only guaranteed method of diagnosing lead poisoning. To assess if a child needs a blood lead test, providers should screen all children at 12 and 24 months of age for lead risks and possible exposures. Screening criteria include the age of their home, parent/caregiver hobbies and occupations, if the family uses traditional remedies, and if the family has come from a different country. Children enrolled in Medicaid are required to receive a blood lead test at 12 and 24 months of age.

The Washington State Department of Health provides the following screening tools to assess for potential lead exposure:

Testing

If a child meets any risk factors when screening, perform a blood lead test to measure the amount of lead in the bloodstream (blood lead level, or BLL). The test can be conducted with a capillary (via a finger- or heel-prick) or venous sample. Capillary testing provides fast results, but may be inaccurately high if lead is present on the skin. If a capillary test shows an elevated BLL, confirm with a venous draw.

Understanding results

Blood lead level test results are shown as micrograms of lead per deciliter of blood (µg/dL). Compare the child’s BLL to the BLL reference level, which identifies if the child has a higher BLL compared to most other children. The CDC establishes this value based on the 97.5th percentile of BLLs among U.S. children ages 1–5 years. For many years, the CDC’s BLL reference level was 10 µg/dL. In 2012, they dropped the value to 5 µg/dL, and then decreased it again in 2021 to 3.5 µg/dL. Some states, including Washington, have not updated their BLL reference value to mirror the CDC’s. We encourage healthcare providers to provide education on prevention and harm reduction strategies to their patients at the 3.5 µg/dL value, as we know there is no safe level of lead. Even low levels of lead can have negative impacts on a child’s growth and development.

In Washington, all blood testing results (non-elevated and elevated BLL) must be reported to the Washington State Department of Health (DOH), including capillary results. BLL greater than or equal to 5 µg/dL must be reported to DOH within 48 hours. DOH will then contact your local health jurisdiction to notify them that a new case was reported. The local health jurisdiction may perform additional BLL testing.

If you need assistance interpreting BLL test results, contact the Washington Poison Center at 1–800–222–1222.

Treatment

Identifying and eliminating the source(s) of lead is the most important step with treatment. Providers can interrupt the exposure pathway by taking an in depth environmental history, providing recommendations to remove potential sources, and educating on strategies to prevent continued or future exposure. Some county health departments in Washington also provide follow up services, including testing of the patient’s environment.

According to a 2022 study in JAMA Pediatrics, children exposed to lead before age three who are able to access early intervention services are significantly more likely to perform on grade level in math and English. A blood lead test above the BLL reference value is an automatic qualifier for developmental services through the state. Providers are encouraged to speak to families about available resources and to refer them to developmental services providers. Children three and under are eligible for services through the Early Supports for Infants and Toddlers program. Children over three are eligible for services through their school district.

Additional measures to support the child’s health may include a nutritious diet rich in calcium, iron, vitamin D, and vitamin C. These nutrients can help reduce lead absorption and promote the body’s natural removal of lead. Test for iron deficiency and consider starting an iron supplement or multivitamin with iron if needed.

In cases of significantly elevated BLLs, chelation therapy may be necessary. Chelators are agents that bind to lead (or other metals) in the bloodstream, allowing lead to be excreted through urine. Some chelators, such as succimer (dimercaptosuccinic acid — DMSA), are given orally. In certain cases, hospitalization and intravenous chelator medications may be needed. It’s important to note that chelation therapy is not recommended for all cases of lead poisoning and should be determined based on the individual’s circumstances and BLL. Call the Washington Poison Center (1–800–222–1222) for assistance in making this decision.

Review the CDC’s recommended actions based on BLL for further information on treatment and education.

The Washington Poison Center is available 24/7/365 to answer questions or provide consult for lead poisoning cases. Call us at 1–800–222–1222.

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Washington Poison Center
The Antidote: Toxicology Tidbits & Trends

Written by Washington Poison Center

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