Timeline of lead poisoning prevention policies and blood lead levels in children aged 1–5 years, by year—NHANES, United States, 1971–2008. BLL, blood lead level; GM BLL, geometric mean blood lead level. Adapted from Brown et al.1
Prevention paradox. The majority of IQ points lost due to lead exposure occur in children who have low to moderate blood lead levels. Using the current reference value of 5 µg/dL, we will protect only 3.1 million IQ points (about 13% of the total). Adapted from Bellinger.15
Other state or local standards may vary, and the most protective standard applies. FDA has not set a standard for lead in cosmetics.
1–7, adapted from HUD.36
8, from FDA Guidance for Industry, November 2006.
AAP Recommendations on Management of Childhood Lead Exposure and Poisoning
<5 µg/dL (<50 ppb)
1. Review laboratory results with family. For reference, the geometric mean blood lead concentration for US children 1–5 y old is <2 μg/dL (<20 ppb); 2.5% have a blood lead concentration ≥5 μg/dL (≥50 ppb).
2. Repeat the blood lead concentration in 6–12 mo if the child is at high risk for lead exposure or if risk profile increases. Follow all local and state lead screening recommendations.
3. For children initially screened before 12 mo of age, consider retesting in 3–6 mo for children at high risk; lead exposure may increase as mobility increases.
4. Perform routine assessment of nutrition and physical and mental development and assess risk factors for iron deficiency.
5. Provide anticipatory guidance about common sources of environmental lead exposure: paint in homes or child care facilities built before 1960, soil near roadways, take-home exposures related to adult occupations, and imported spices, cosmetics, folk remedies, and cookware.
5–14 µg/dL (50–140 ppb)
1. Perform steps as described above for blood lead concentrations <5 μg/dL (<50 ppb).
2. Retest venous blood lead concentration within 1–3 mo to verify that the lead concentration is not rising. If it is stable or decreasing, retest the blood lead concentration in 3 mo. Refer patient to local health authorities if such resources are available. Most states require elevated blood lead concentrations be reported to the state health department. Contact the CDC at 800-CDC-INFO (800-232-4636) or www.cdc.gov/nceh/lead or the National Lead Information Center at 800-424-LEAD (5323) for resources regarding lead poisoning prevention and local childhood lead poisoning prevention programs.
3. Take a careful environmental history to identify potential sources of exposures (see #5 above) and provide preliminary advice about reducing or eliminating exposures. Take care to consider other children who may be exposed.
4. Provide nutritional counseling related to calcium and iron. Encourage the consumption of iron-enriched foods (eg, cereals, meats). Encourage families to sign up for the Special Supplemental Nutrition Program for Women, Infants, and Children, if eligible.
5. Screen for iron sufficiency with adequate laboratory testing (complete blood cell count, ferritin, C-reactive protein) and provide treatment per AAP guidelines. Consider starting a multivitamin with iron.
6. Perform structured developmental screening evaluations at child health maintenance visits, because lead’s effect on development may manifest over years.
15–44 µg/dL (150–440 ppb)
1. Perform steps as described above for blood lead concentrations 5–14 μg/dL (50–140 ppb).
2. Confirm the blood lead concentration with repeat venous sample within 1–4 wk.
3. Abdominal radiography should be considered for children who have a history of pica for paint chips or excessive mouthing behaviors. Gut decontamination may be considered if leaded foreign bodies are visualized on radiography. Any treatment of blood lead concentrations in this range should be provided in consultation with an expert. Contact local pediatric environmental health specialty unit (www.pehsu.net or 888-347-2632) or local or regional Poison Control Center (www.aapcc.org or 800-222-1222) for guidance.
>44 µg/dL (>440 ppb)
1. Follow guidance for blood lead level 15–44 μg/dL (150–440 ppb) as listed above.
2. Confirm the blood lead concentration with repeat venous lead level within 48 h.
3. Consider hospitalization or chelation therapy (managed with the assistance of an experienced provider). Safety of the home or child care facility with respect to lead hazards, isolation of the lead source, family social situation, and chronicity of the exposure are factors that may influence management. Contact your regional pediatric environmental health specialty unit or Poison Control Center or the CDC for assistance.