Menu

Childhood Lead Exposure

Introduction

Lead exposure may result from contact with lead in the environment, including in lead-based paint, dirt, cosmetics, hobby products, water, and other sources. Lead exposure occurs, generally, when contaminants with lead are inhaled or ingested.
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]
Children exposed to lead during childhood are at increased risk for delays in development and growth. Worse outcomes correlate with greater blood lead levels (BLL). Screening for lead is recommended for children between 12 and 24 months of age. Ongoing monitoring is recommended for those with BLL above 5 μg/dL, though symptoms may not be present even at levels above 45 μg/dL. The first priority for treatment is removing 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]
The medical home is key in risk assessment, testing, care coordination, and anticipatory guidance for the child.

ICD-10 Coding

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 ICD10 related to lead exposure (icd10data.com) for further coding details.

Presentations

Signs and symptoms of elevated lead levels in infants and young children may include:

Surveillance and Screening

Assess Risk Factors

Risk assessment questions should regularly be asked at all well child visits for young children, and if positive, a blood lead screening test should be obtained. Common sources of lead exposure include, but are not limited to, lead paint, water, soil, industry, toys, and supplements. [Atkinson: 2011] Children should be tested for lead with a blood test as required by state laws or, in the absence of such laws, according to CDC and AAP recommendations.

Screening with a Blood Lead Test

The American Academy of Pediatrics (AAP) recommends periodic lead exposure risk assessments and testing at 12 and 24 months, as noted on the 2017 Bright Futures Periodicity Schedule (AAP) (PDF Document 119 KB). However, recommendations vary and some states and insurers require testing:
  • The CDC recommends universal blood lead screening in communities where >12% of children have blood lead levels >10 μg/dL or where >27% of housing was built before 1950. [Centers: 2018]
  • Medicaid requires blood lead screening for all Medicaid-eligible children at 12 and 24 months of age as part of well-child checkups. [Centers: 2018]
  • The Children’s Health Insurance Program (CHIP) does not require universal lead screening.
  • Several states have laws requiring universal blood lead screening tests for children at specific ages while several other states require targeted testing. [Dickman: 2017]
For more detail, see Sample Management Guidelines on Childhood Lead Poisoning for Health Care Providers (PDF Document 659 KB) and Recommendations on Medical Management of Childhood Lead Exposure and Poisoning (AAP) (PDF Document 133 KB).

Testing

Labs
Venous blood lead testing is recommended to determine exposure levels since skin contamination can cause a capillary blood lead level to be falsely elevated. State laws and recommendations regarding environmental inspections for children with elevated blood lead levels vary. In most cases, such inspections are prompted when a child has a venous blood lead level above a particular threshold level and is performed by the local public health department.
Check with the lab that will perform the test to ensure that blood samples are submitted in the correct tube (lead-free) and that the lab is familiar with blood lead testing. The CDC provides additional instructions for blood collection and storage. [Advisory: 2013]

Treatment & Mangement

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) (PDF Document 133 KB) and Sample Management Guidelines on Childhood Lead Poisoning for Health Care Providers (PDF Document 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.
Recommendations for use of reconstituted infant formula:
  • Infant formula requiring reconstitution should be made only with water from the cold water tap. Flush the tap for at least 3 minutes before use and then heat the water or use bottled or filtered tap water known to be free of lead.
See Acknowledgement 1 below. [Centers: 2010] [Committee: 2012]

Medications Used to Treat Lead Exposure

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. [Lowry: 2010] The blood lead level may drop immediately after chelation treatment but usually increases about two weeks after treatment. [Centers: 2010] [Lowry: 2010] 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:
  • 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.
See Acknowledgement 2 below. [Centers: 2010]
Chelating agents used to treat lead poisoning include:
  • Calcium edetate
    • Administered IM or IV, inpatient only
    • Always use with calcium
  • Succimer
    • Administered PO
    • Does not lower BLL with single course of treatment
  • BAL
    • Administered IM, inpatient only
    • Used with calcium edetate
  • D-penicillamine
    • Administered PO
See Acknowledgement 3 below. [Centers: 2010]

Consultation

Local health department and other experts will perform important roles depending upon the source of the lead exposure.
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.

Acknowledgements

  1. Recommendations adapted from Chapter 5. Blood Lead Testing in Pregnancy and Early Infancy and Chapter 9. Breastfeeding. CDC. Guidelines for the identification and management of lead exposure in pregnant and lactating women. Atlanta (GA): CDC; 2010. Available at Guidelines for the Identification and Management of Lead Exposure in Pregnant Women (CDC) (PDF Document 3.7 MB). And adapted from ACOG. Committee Opinion: Lead screening during pregnancy and lactation. Number 533. Washington D.C. ACOG; 2012 and Reaffirmed 2016. Available at Lead Screening During Pregnancy and Lactation (ACOG). [Centers: 2010], [Committee: 2012]
  2. Recommendations adapted from Chapter 8. Chelation of Pregnant Women, Fetuses, and Newborn Infants. CDC. Guidelines for the identification and management of lead exposure in pregnant and lactating women. Atlanta (GA): CDC; 2010. Available at Guidelines for the Identification and Management of Lead Exposure in Pregnant Women (CDC) (PDF Document 3.7 MB). [Centers: 2010]
  3. Adapted from Table 8-1. Chelating Agents Used to Treat Lead Poisoning. CDC. Guidelines for the identification and management of lead exposure in pregnant and lactating women. Atlanta (GA): CDC; 2010. For additional details including other names see Guidelines for the Identification and Management of Lead Exposure in Pregnant Women (CDC) (PDF Document 3.7 MB). [Centers: 2010]

Resources

Information & Support

For Professionals

Recommendations on Medical Management of Childhood Lead Exposure and Poisoning (AAP) (PDF Document 133 KB)
Table of recommendations for testing, management, and anticipatory guidance for various blood lead levels from the Pediatric Environmental Health Specialty Units (PEHSU) of the American Academy of Pediatrics (AAP).

Where We Stand: Lead Screening (AAP)
List of resources for lead screening and prevention for providers and parents from HealthyChildren.org, American Academy of Pediatrics.

Sample Management Guidelines on Childhood Lead Poisoning for Health Care Providers (PDF Document 659 KB)
Guidelines with detailed table of evaluation, testing, and management at higher blood lead levels from the California Department of Public Health.

Guide For States Interested in Transitioning to Targeted Blood Lead Screening for Medicaid-Eligible Children (PDF Document 669 KB)
Detailed guidance for state Medicaid officials.

Practice Guidelines

Centers for Disease Control and Prevention.
Guidelines for the Identification and Management of Lead Exposure in Pregnant and Lactating Women.
Center for Disease Control and Prevention; (2010) https://www.cdc.gov/nceh/lead/publications/leadandpregnancy2010.pdf. Accessed on 10/2/2018.

Patient Education

Blood Lead Levels in Children (AAP)
Website with information for parents about blood lead levels and links to more resources, from HealthyChildren.org, American Academy of Pediatrics.

Blood Lead Levels in Children (CDC) (PDF Document 292 KB)
Fact sheet with information for parents about blood lead levels, treatment, and action steps, from the Centers for Disease Control and Prevention.

Services for Patients & Families in Montana (MT)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: January 2019; last update/revision: April 2019
Current Authors and Reviewers:
Author: Alfred N. Romeo, RN, PhD
Reviewers: Beth Conover, MS, APRN, LCGC
Stanley Schaffer, MD, MS, FAAP
Funding: Developed by the Organization of Teratology Information Specialists / MotherToBaby in collaboration with and funding from the Association of Maternal & Child Health Programs (AMCHP) Cooperative Agreement #UJ9MC31105, U.S. Department of Health and Human Services’ Health Resources and Services Administration, Maternal and Child Environmental Health (MCEH) Collaborative Improvement and Innovation Network (CoIIN) for $849,999. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by, HRSA, HHS or the US government.

Page Bibliography

Advisory Committee on Childhood Lead Poisoning Prevention.
Guidelines for Measuring Lead in Blood Using Point of Care Instruments.
Centers for Disease Control and Prevention; (2013) https://www.cdc.gov/nceh/lead/ACCLPP/20131024_POCguidelines_final.pdf. Accessed on 10/31/2018.

Atkinson RL.
Human adenovirus-36 and childhood obesity.
Int J Pediatr Obes. 2011;6 Suppl 1:2-6. PubMed abstract

Cantor A, Hendrickson R, Blazina I, Griffin J, Grusing S, McDonagh M.
Screening for Elevated Blood Lead Levels in Children: A Systematic Review for the U.S. Preventive Services Task Force.
Agency for Healthcare Research and Quality. 174; October 2018. / https://www.uspreventiveservicestaskforce.org/Home/GetFile/1/16900/lea...

Centers for Disease Control and Prevention.
Blood lead levels in children aged 1-5 years - United States, 1999-2010.
MMWR Morb Mortal Wkly Rep. 2013;62(13):245-8. PubMed abstract / Full Text

Centers for Disease Control and Prevention.
Guidelines for the Identification and Management of Lead Exposure in Pregnant and Lactating Women.
Center for Disease Control and Prevention; (2010) https://www.cdc.gov/nceh/lead/publications/leadandpregnancy2010.pdf. Accessed on 10/2/2018.

Centers for Medicaid & CHIP Services.
CMCS Informational Bulletin: Coverage of Blood Lead Testing for Children Enrolled in Medicaid and the Children’s Health Insurance Program.
Centers for Medicare & Medicaid Services; (2018) https://www.medicaid.gov/federal-policy-guidance/downloads/cib113016.p.... Accessed on 10/2/2018.

Committee on Obstetric Practice.
Committee opinion No. 533: Lead screening during pregnancy and lactation.
Obstet Gynecol. 2012;120(2 Pt 1):416-20. PubMed abstract / Full Text
American College of Obstetricians and Gynecologists Committee Opinion.

Council on Environmental Health AAP.
Prevention of Childhood Lead Toxicity.
Pediatrics. 2016;138(1). PubMed abstract / Full Text
See correction for this article at PMID 28771419.

Council on Environmental Health AAP.
Prevention of Childhood Lead Toxicity.
Pediatrics. 2017;140(2). PubMed abstract / Full Text
Correction for the article "Prevention of Childhood Lead Toxicity" PMID 27325637.

Daneshparvar M, Mostafavi SA, Zare Jeddi M, Yunesian M, Mesdaghinia A, Mahvi AH, Akhondzadeh S.
The role of lead exposure on attention-deficit/ hyperactivity disorder ‎in children: A systematic review.
Iran J Psychiatry. 2016;11(1):1-14. PubMed abstract / Full Text

Dickman J.
Children at Risk: Gaps in State Lead Screening Policies.
Safer Chemicals, Healthy Families; (2017) https://saferchemicals.org/sc/wp-content/uploads/2017/01/saferchemical.... Accessed on 11/15/2018.

Kosnett MJ, Wedeen RP, Rothenberg SJ, Hipkins KL, Materna BL, Schwartz BS, Hu H, Woolf A.
Recommendations for medical management of adult lead exposure.
Environ Health Perspect. 2007;115(3):463-71. PubMed abstract / Full Text

Lowry JA.
Oral Chelation Therapy for Patients with Lead Poisoning.
Children's Mercy Hospitals and Clinics; (2010) https://www.who.int/selection_medicines/committees/expert/18/applicati.... Available on the World Health Organization's website. Accessed on 10/31/2018.

Pediatric Environmental Health Specialty Units.
Recommendations on Medical Management of Childhood Lead Exposure and Poisoning.
American Academy of Pediatrics; (2013) https://www.pehsu.net/_Library/facts/medical-mgmnt-childhood-lead-expo.... Accessed on 10/2/2018.
PEHSU recommendations from the AAP