Health Care Guidance for Lead-Poisoned Children

Image of a female African American doctor examining a young patient.Medical care of lead poisoning in children is considered to be secondary prevention, i.e., intervention after an elevated blood lead level has been detected.

Screening programs are the main vehicle for identifying children at risk for lead poisoning. Confirmatory venous testing is recommended to confirm that the capillary screening test is indeed elevated.

Once a child is identified as at risk for lead poisoning, ongoing monitoring is provided by physicians through follow-up blood lead testing.

Monitoring of the child's developmental milestones is critical as the child ages, as the effects from lead exposure often can't be seen until later on in that child's life.

In addition, children with elevated blood lead levels should receive overall health, health history, and nutrition evaluation and treatment and be given any associated laboratory tests.


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Health Care Interventions

The Centers for Disease Control and Prevention (CDC) recommends that medical providers and public health take action according to the blood lead level (BLL).

CDC recommended actions for follow-up and case management of children based on confirmed BLLs

Venous BLL less than 5*
Routine assessment of nutritional and developmental milestones
Anticipatory guidance about common sources of lead exposure
Follow-up blood lead testing at recommended intervals based on child's age
Venous BLL 5 to 9
Routine assessment of nutritional and developmental milestones
Environmental assessment of detailed history to identify potential sources of lead exposure
Nutritional counseling related to calcium and iron intake
Follow-up blood lead testing at recommended intervals based on child's age
Venous BLL 10 to 19
Routine assessment of nutritional and developmental milestones
Environmental assessment of detailed history environmental investigation** including home visit to identify potential sources of lead exposure
Nutritional counseling related to calcium and iron intake; consider lab work to assess iron status
Follow-up blood lead monitoring at recommended intervals
Venous BLL 20 to 44
Complete history and physical exam
Neurodevelopmental assessment
Environmental investigation the home and lead hazard reduction
Lab tests: iron status and hemoglobin or hematocrit
Abdominal x-ray (with bowel decontamination if indicated)
Follow-up blood lead monitoring at recommended intervals
Venous BLL 45 to 69
Complete history and physical exam
Complete neurological exam including neurodevelopmental assessment
Environmental investigation and lead hazard reduction
Lab tests: iron status and hemoglobin or hematocrit
Abdominal x-ray (with bowel contamination if indicated)
Oral chelation therapy: consider hospitalization, if lead-safe environment cannot be assured
Follow-up blood lead testing at recommended intervals
Venous BLL greater than or equal to 70
Hospitalize and commence chelation therapy in conjunction with consultation with a medical toxicologist or a pediatric environmental specialty health care unit
Proceed with additional actions according to interventions for BLLs between 45 to 69
 

*While no level of lead is safe in the body, the reference value, 5 mcg/dL, was selected to identify children whose BLLs are in the top 2.5 percent of the U.S. population of children under age 6.

**Environmental investigations at BLLs of 10 to 19 vary according to local conditions based on jurisdictional requirements and available resources.

Information for medical providers

Blood Lead Levels in Children: What Do Parents Need to Know to Protect Their Children? (PDF)

Wisconsin Blood Lead Screening Recommendations (PDF) Two-page summary of the recommendations for assessing a child's risk for lead poisoning and whether the child should be tested.

PESHU Recommendations on Medical Management of Childhood Lead Exposure and Poisoning (PDF)

Information to share with families

Parents: Look Out for Lead, P-44535A (Multiple Languages) (PDF)

What You Should Know about Your Child's Blood Lead Results (PDF)

Lead poisoning: 5 things you can do to help lower your child’s lead level (PDF) En Español (PDF)

Lead Poisoning Home Checklist for Families (PDF)

Are You Pregnant? Prevent Lead Poisoning. Start Now. (PDF) En Español (PDF)

Other reliable sources of information

Low Level Lead Exposure Harms Children: A Renewed Call for Primary Prevention. (PDF) While there is no level of lead in blood that is safe, the Centers for Disease Control and Prevention (CDC) recommends that children with blood lead levels (BLLs) of 5 micrograms per deciliter (mcg/dL) or above get some follow-up action.

Developmental Surveillance and Screening of Infants and Young Children. (PDF) Provides recommendations for screening infants and young children and intervening with families to identify developmental delays and disabilities in the primary care setting to assure access to early intervention services. (Adapted from: Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officers. Atlanta: CDC; 1997).

Monitor Lead Levels

Best medical practice is to confirm a blood lead test that is a capillary screening test with a venous draw, depending on the level of the test result. The higher the blood lead level test result the more quickly the confirmation of that elevated capillary blood lead test is needed. See the table for the details.

CDC recommended schedule for obtaining a confirmatory venous sample following a capillary screening blood lead test

Recommended schedule for obtaining a confirmatory venous sample
Capillary BLL 5* to 9
1 to 3 months
Capillary BLL 10 to 44
1 week to 1 month**
Capillary BLL 45 to 59
48 hours
Capillary BLL 60 to 69
24 hours
Capillary BLL greater than or equal to 70
Urgently as emergency test
 

*While no level of lead is safe in the body, the reference value, 5 mcg/dL, was selected to identify children whose BLLs are in the top 2.5 percent of the U.S. population of children under age 6.

**The higher the BLL on the capillary screening test, the more urgent the need for confirmatory testing.

Best medical practice for follow-up blood lead testing is also a venous draw and depending on the initial BLL, the time lapse for follow-up testing may be different. Also, once the BLL begins to decline, the schedule for testing extends out. See table below for the details.

CDC recommended schedule for follow-up blood lead testing

Venous BLL 5* to 9
Early follow-up testing 2 to 4 tests after identification: 3 months**
Later follow-up testing after BLL decreasing: 6 to 9 months
Venous BLL 10 to 19
Early follow-up testing 2 to 4 tests after identification: 1 to 3 months**
Later follow-up testing after BLL decreasing: 3 to 6 months
Venous BLL 20 to 24
Early follow-up testing 2 to 4 tests after identification: 1 - 3 months**
Later follow-up testing after BLL decreasing: 1 to 3 months
Venous BLL 25 to 44
Early follow-up testing 2 to 4 tests after identification: 2 weeks to 1 month**
Later follow-up testing after BLL decreasing: 1 month
Venous BLL greater than or equal to 45
Early follow-up testing 2 to 4 tests after identification: As soon as possible
Later follow-up testing after BLL decreasing: As soon as possible
 

Note: Seasonal variation of BLLs exists and may be more apparent in colder climate areas. Greater exposure in the summer months may necessitate more frequent follow-up tests.

*While no level of lead is safe in the body, the reference value, 5 mcg/dL, was selected to identify children whose BLLs are in the top 2.5 percent of the U.S. population of children under age 6.

**Some case managers or clinicians may choose to repeat blood lead tests on all new patients within a month to ensure that their BLL is not rising more quickly than anticipated.

Emphasize Nutrition

Regular well-balanced meals are important for adequate growth and development in all children. Adequate intake of certain vitamins and minerals, especially calcium, iron, and vitamin C, beyond their requirement for overall good nutrition, can specifically minimize absorption of ingested lead. Research indicates that adequate iron intake can decrease lead absorption and should be considered an essential secondary tool to protect children from absorbing lead they ingest from their environments.

Nutrient: Calcium
Examples: Milk, cheese, yogurt, kale, collards, turnip greens, canned salmon, sardines with bones
Nutrient: Iron
Lean meats and poultry, seafood, cereals and breads fortified with iron, peanut butter, nuts, dried beans and peas, raisins, prunes, prune juice, greens such as broccoli and spinach
Nutrient: Vitamin C
Tomatoes, oranges, grapefruits, juices, juices fortified with Vitamin C, strawberries, kiwi, green peppers, watermelon, cantaloupe, potatoes
 

People with iron deficiency absorb two to three times more lead than people with adequate levels of blood iron. Iron and lead interact and compete in heme synthesis. Even slight decreases in hematocrit allow increased lead absorption.

Many U.S. children aged 1 to 2 have daily iron intake below recommended amounts. When exposed to lead hazards, these children may see the lasting effects on cognitive development due to both iron deficiency in infancy and the long-lasting negative effects due to lead.

See Chapter 8: Medical Management of Lead Poisoned Children in our Prevention and Control Handbook, P-00660 (PDF) for more information on diagnosing iron deficiency.

Families of children with lead poisoning that are income eligible can receive nutritional support from WIC

Wisconsin Women, Infants and Children (WIC) Nutrition Program Clinic locations Children at risk for a poor diet and whose family is income eligible can receive education and support for improving or maintaining nutritional status.

Lead and a Healthy Diet (PDF) This pamphlet includes fun recipes for young children to encourage healthy eating.

For more Information

Managing Elevated Blood Lead Levels Among Young Children, Chapter 4, describes the research about the effects of dietary components on childhood lead poisoning.

Recommendations to Prevent and Control Iron Deficiency in the United States Vol 47, No RR03;1; 04/03/1998 (PDF). In children, iron deficiency causes developmental delays and behavioral disturbances, and in pregnant women, it increases the risk for a pre-term delivery and delivering a low birth weight baby.

Last Revised: December 7, 2018