Poisoning - Lead Exposure

Victoria Samonte
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Poisoning - Management
Managing Elevated Blood Lead Levels Among Young Children
The recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP) are detailed in Table 3. Important Note from CDC: This document refers to a blood-lead level of 10 micrograms per deciliter (µg/dL) as the CDC level of concern for adverse health outcomes in children. This terminology is outdated and readers are referred to the ACCLPP recommendations of 2012. However, the 2012 document does not recommend changes to the guidelines for the evaluation and treatment of children with BLLs = 15 µg/dL or those requiring chelation (BLLs = 45 µg/dL) published here.
Nutritional Management
Managing a child’s nutrition, particularly when elevated blood lead levels are noted, is imperative. Since adequate stores of calcium, iron, phosphorus and zinc decrease the gut absorption of lead, despite exposure, appropriate intake of food and sources of these minerals is indicated. The following are the guidelines for nutritional management in children with elevated blood lead levels:
• Consumer adequate amounts of bioavailable calcium and iron
• Consume at least 2 servings daily of foods high in vitamin V, such as fruits, vegetables, and juices
• Eat in areas that pose a low risk for lead exposure.
• Participate in a special supplemental nutrition program.

Follow up blood lead monitoring
Table 4: Schedule for Follow-up Blood Lead Testing
Chelation Therapy
Table 5 enumerates and briefly describes the commonly used chelation agents in the management of lead poisoning. While chelation therapy is considered the mainstay in the treatment of children with elevated blood lead levels (=45 µg/dL), caution must be observed and consult with relevant experts is strongly recommended.

Table 3: Recommended actions based on Blood Lead Levels (BLL)
Table 3: Recommended actions based on Blood Lead Levels (BLL)
BLOOD LEAD LEVELS (µg/dL)
Lead education
-Dietary/Nutritional
-Environmental
Lead education
-Dietary/Nutritional
-Environmental
Lead education
-Dietary/Nutritional
-Environmental
Hospitalize and commence chelation therapy (following confirmatory venous blood lead test) in conjunction with consultation from a medical toxicologist or a pediatric environmental health specialty unit
Environmental assessment for pre -1978 housing Complete history and physical exam Complete history and physical exam Proceed according to actions for 45-69 µg/dL
Follow-up blood lead monitoring Follow-up blood lead monitoring Follow-up blood lead monitoring  
  Lab work:
- Iron status
Consider Hemoglobin or hematocrit

? - Abdominal X-ray
? (if particulate lead ingestion is suspected) with bowel decontamination if indicated
Lab work:
? -Hemoglobin
or
? hematocrit

? -Iron status

? -Free erythrocyte protoporphyrin
- Abdominal X-ray with bowel decontamination if indicated
 
  Environmental investigation
Lead hazard reduction
Environmental investigation
Lead hazard reduction
 
  Neurodevelopmental monitoring Neurodevelopmental monitoring  
    Oral Chelation therapy
Consider hospitalization if
lead-safe environment cannot be assured
 
Reference: Low Level Lead Exposure Harms Children: A Renewed Call for Primary Prevention Report of the Advisory Committee on Childhood Lead Poisoning Prevention of the Centers for Disease Control and Prevention January 4, 2012


Table 4: Schedule for Follow-up Blood Lead Testing
Table 4: Schedule for Follow-up Blood Lead Testing
Venous Blood lead level µg/dl Early follow up testing
(2-4 tests after identification)
Later follow up testing
after blood lead level declining
= Reference Value – 9 3 months * 6-9 months
10 - 19 1-3 months * 3-6 months
20 - 24 1-3 months * 1-3 months
25 - 44 2 weeks- 1 month 1 months
=45 As soon as possible As soon as possible
* Some case managers or PCPs may choose to repeat blood lead tests on all new patients within a month to ensure that their BLL level is not rising more quickly than anticipated
Reference: Low Level Lead Exposure Harms Children: A Renewed Call for Primary Prevention Report of the Advisory Committee on Childhood Lead Poisoning Prevention of the Centers for Disease Control and Prevention January 4, 2012


Table 5: Medicines used to treat childhood lead poisoning
Table 5: Medicines used to treat childhood lead poisoning
2.3-dimercaptopropanol; British anti-Lewisite, dimercaprol
• Only given parenterally (intramuscular)
• Usual dose is 75 mg/m2 body surface area every 4 hours
• Dissolved in peanut oil
• Contraindicated in children allergic to nuts or those who have glucose-6-phosphatase deficiency
• Can cause kidney dysfunction or zinc depletion

Calcium disodium ethyleneaminetetraacetate; edetate disodium calcium
• Only given parenterally (intramuscular or intravenous)
• Usual maximum dose is 1000 mg/m2 body surface area/d
• Can cause kidney dysfunction

DMSA
• Comes as 100-mg capsules only
• Usual dose is one to four capsules, depending on child’s weight, given three times daily for 5 days, then twice daily for 14 days
• Can cause elevated liver enzymes (uncommon) or skin rash (uncommon)
• Contraindicated in children who have hepatic insufficiency or those who have ongoing exposure to lead
• Capsules should be aired out before contents are mixed with food

D-penicillamine (3-mercapto-D-valine)
• Available as 250-mg capsule or tablet
• Do not give with milk, milk products, or iron supplements
• Give in juice or jelly on an empty stomach
• Often causes mild upset stomach or loose stools
• Can cause skin rash or zinc/iron depletion (common) or kidney or marrow dysfunction (uncommon)
• Usual dose is 10 to 15 mg/kg/d
• Contraindicated in children who have renal insufficiency or ongoing exposure to lead
• Capsules should be aired out before contents are mixed with food




References
Poisoning - Lead Exposure Poisoning - Lead Exposure 05/11/2016
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