Know the appropriate procedures for lead screening, diagnosis, treatment, and abatement
Know the appropriate procedures for lead screening, diagnosis, treatment, and abatement: Excerpt from Avoiding Common Pediatric Errors
Author:
Ellen Hamburger, MD
What to Do - Gather Appropriate Data,
Interpret the Data, Make a Decision,
Take Action
Theprevalenceof elevatedblood lead levels(BLLs)amongU.S. children has
declined sharply in the last decade primarily because of marked reductions
of lead in residential paint, gasoline, and dietary sources. The prevalence of
BLLs >10 µg/dLamongchildren1to5yearsolddeclinedfrom9%to1.6%
between 1991 and 2002, but there remain communities and populations that
bear a disproportionate burden of plumbism, with over 300,000 children
remaining at risk for exposure to harmful levels of lead.
The ingestion of lead-containing dust is the primary source of lead
exposure in children. The major sources of lead dust are disruption of lead-
containing paint and soil. Other sources of lead exposure include water and
contaminated clothing of adults who have occupational exposure to lead.
Although lead-based paint has not been in use for decades in the United
States, it is estimated that more than 20 million housing units still contain
lead-based paint or lead-soldered pipes, units more likely to be in poor
condition and occupied by low-income families. Risk factors for increased
lead burden include:
• Minority race/ethnicity (African American highest risk)
• Urban residence
• Low educational attainment
• Older (pre-1950) housing
• Recent immigration (including international adoption).
Screening efforts focus on high-risk children from 1 to 5 years of age because they are most likely to ingest lead in their environment from increased
hand-to-mouth activity. Furthermore, once ingested, lead is more easily
absorbed in young children and their central nervous system is more vulnerable to its effects, as compared to adults. Neurotoxicity of lead includes
acute encephalopathy as well as long-term impairment. Population-based
studies consistently demonstrate impaired neurocognitive development in
children with a BLL >10 µg/dL even in the asymptomatic child. Further, a clear negative effect on cognition has been demonstrated with BLLs
<10 µg/dL, previously thought to have little to no effect. Although intelligence is the primary outcome in most studies, there is evidence that lead is
implicated in attention deficit and learning disorders as well.
Older recommendations called for universal screening of children between 1 and 2 years of age. Targeted screening of high-risk populations is
the current guideline because of the reduced prevalence of elevated BLL.
Current recommendationsforscreening are basedoncommunityprevalence
figures to avoid unnecessary costs and false-positive diagnosis in low-risk areas and populations. All children receiving Medicaid; Supplemental Food
Program for Women, Infants and Children, as well as those living in communities where more than 27% of housing was built before 1950, should have
BLLdeterminedatleast once,startingwhentheyare1yearold.Forchildren
not eligible for Medicaid, screening guidance should be sought from state or
local health agencies. Screening can include the use of questionnaires that
have been locally validated and that have acceptable sensitivity and specificity. A risk questionnaire developed by the Centers for Disease Control and
Prevention has been shown to correctly identify 64% to 87% of urban and
suburban children who had BLLs >10 µg/dL.
A progressive series of recommendations exist for children who have
positive blood lead screens. Those with levels >10 µg/dL should have the
blood test repeated and followed closely. Children with levels from 20 to
44 µg/dL warrant having environmental evaluation, including abatement
of housing if warranted. Abatement can increase BLLs if children live in
the housing while walls are scraped and repainted. Thus, families must relocate during abatement. Chelation and evaluation for iron deficiency is
recommended for children whose levels are >44 µg/dL, with hospitalization for those whose neurologic status is concerning because of levels >=70
µg/dL. Detailed management recommendations can be found in the American Academy of Pediatrics statement referenced below.
Suggested Readings
American Academy of Pediatrics, Committee on Environmental Health. Lead exposure in
children: prevention, detection, and management. Pediatrics. 2005;116:1036–1046.
Centers for Disease Control and Prevention. Preventing Lead Poisoning in Young Children: A
Statement by the Centers for Disease Control—October 1991. Atlanta, GA: Department of
Health and Human Services; 1991.
Rischitelli G, Nygren P, Bougatsos C, et al. Screening for elevated lead levels in childhood and
pregnancy: an updated summary of evidence for the US Preventive Services Task Force.
Pediatrics. 2006;118:e1867–e1895.
>
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
More About Lead poisoning
More Medical Textbooks Online about Lead poisoning
Review other book chapters online related to Lead poisoning:
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- Poisoning
- "Professional Guide to Diseases (Eighth Edition)" (2005)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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