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Lead Poisoning Management for Medical Professionals

To assist providers with their medical management, the City of Milwaukee Health Department Childhood Lead Poisoning Prevention Program has developed easy to follow guidelines. These guidelines are based on current recommendations from the Centers for Disease Control and Prevention and the American Academy of Pediatrics and reflect Milwaukee's local environmental conditions. The guidelines were developed with input from area physicians, and take into consideration the high levels of lead contamination of Milwaukee's oldest housing stock. As part of Case Management, the Public Health Nurse (PHN) Coordinator provides direct service to community physicians and clinic staff.

The potentially complex medical, psychosocial, socioeconomic, and environmentaal needs surrounding lead poisoned children and their families necessitates communication and collaboration between the child's primary care provider and Milwaukee Health Department Childhood Lead Poisoning Prevention Program. Collaborative efforts are critical to achieve optimal health outcomes for Milwaukee's children.

For further information contact the Childhood Lead Poisoning Prevention Program at 414-286-5987.

 


<10 µg/dL
 

  • Lead-related examination not necessary

  • Anticipatory Guidance - discuss primary sources of lead poisoning and measures to keep children safe from lead. Provide lead poisoning prevention literature

  • Assess for lead poisoning risk at every well-child visit

  • Test other children < 6yrs in the home

  • Retest: Age 6 months to 35 months in 6 months (3 times before age 3 yrs) OR Age 36 months to 72 months in 12 months

 See Blood Lead Testing Recommendations

 


10-14 µg/dL

  • Ask questions to identify sources of lead in child's environment

  • Educate family regarding:

    • Potential sources of lead and ways to reduce exposure; review and provide literature

    • Nutrition

    • Dangers of improper abatement

    • Chronic nature of problem (need to monitor frequently)

  • Iron supplement if deficient 

  • Test other children < 6 yrs in the home

  • Repeat venous blood lead every 3-4 months until lead < 10ug/dL

     

15-19 µg/dL
 

  • Confirm capillary result with venous blood lead test within 1 month

  • Complete diagnostic evaluation for venous blood lead test result (history, labs including iron status, physical exam)

  • Educate family regarding:

    • Potential sources of lead and ways to reduce exposure; review and provide literature

    • Nutrition

    • Dangers of improper abatement

    • Chronic nature of problem (need to monitor frequently)

  • Iron supplement if deficient

  • Test other children < 6 yrs in the home

  • Repeat venous lead every 3-4 months until lead < 10ug/dL

     

20-44 µg/dL
 

  • Confirm capillary result with venous blood lead test within 1 week

  • Order Erythrocyte Protoporphyrin (EP) or Zinc Protoporphyrin (ZPP) level with every blood lead test

  • Complete diagnostic evaluation (history, labs including iron status using Ferritin level, physical exam)

  • Assess clinical symptoms:

    • Neurological and developmental status (especially language skills and concentration    ability)

    • Nutritional status (especially iron and calcium)

    • Sources of exposure (age of home, condition of painted surfaces, pica, remodeling, occupations/hobbies, folk remedies, etc)

  • Educate family regarding:

    • ·Potential sources of lead and ways to reduce exposure; review and provide literature

    • ·Nutrition

    • ·Dangers of improper abatement

    • ·Chronic nature of problem (need to monitor frequently)

  • Iron supplement if deficient

  • Chelation is NOT recommended

  • Persistently high levels may require more aggressive treatment - consult MHD CLPPP at 225-LEAD         

  • Test other children < 6 yrs in the home

  • Repeat venous blood lead and EP or ZPP every 1-3 months (higher levels and children < 3 years old require more frequent monitoring)

 


45-69 µg/dL
 

  • Confirm blood lead result with venous blood lead test within 48 hours and include Erythrocyte Protoporphyrin (EP) or Zinc Protoporphyrin (ZPP) level

  • Complete diagnostic evaluation (history, labs including iron status using Ferritin level, physical exam):

  • Assess clinical symptoms:

    • Neurological and developmental status (especially language skills and concentration ability)

    • Nutritional status (especially iron and calcium)

    • Sources of exposure (age of home, condition of painted surfaces, pica, remodeling, occupations/hobbies, folk remedies, etc)

  • Other diagnostic tests: BUN, CBC, Creatinine, UA and liver enzymes

  • Emergency hospital admission for clinical symptoms

  • IMMEDIATE telephone report (capillary or venous result) to MHD CLPPP (call 225-LEAD)

  • Educate family regarding:

    • Potential sources of lead and ways to reduce exposure; review and provide literature ·Nutrition

    • Dangers of improper abatement

    • Chronic nature of problem (need to monitor frequently)

  • Test other children < 6 yrs in the home

  • Chelation (if venous-confirmed):

    • Treat with CaEDTA or DMSA CONSULT EXPERT IN CHELATION

    • Consult MHD CLPPP (225-LEAD) for resources and environmental status

    • Stop iron therapy prior to chelation

  • In-home treatment indicated only in situations of:

    • Lead-safe environment

    • Highly compliant family

    • Home Health Care monitoring

  • Discharge inpatient cases ONLY to LEAD-SAFE ENVIRONMENT

  • If child on oral chelation repeat blood lead and appropriate labs weekly

  • Repeat venous lead, EP/ZPP and labs in 10-14 days post-treatment

  • Rebound of blood lead level after treatment is common. Lead and EP/ZPP levels need to be checked every 2 weeks for several months post chelation.  Re-chelation may be necessary for children with high levels of bone and soft tissues stores (monitored through EP levels).

 


70 µg/dL and Greater

Follow same guidelines as 45-69 µg/dL

Additionally:

  • Confirm lead result with venous draw IMMEDIATELY and include Erythrocyte Protoporphyrin (EP) or Zinc Protoporphyrin (ZPP) level

  • TREAT AS AN EMERGENCY - potential encephalopathy

  • Emergency admission to hospital with pediatric ICU capacity

  • IMMEDIATE telephone report (capillary or venous result) to MHD CLPPP (call 225-LEAD)                   

  • Chelation (if venous-confirmed):  Treat with BAL/CaEDTA  CONSULT EXPERT IN CHELATION


 

These guidelines updated 5-13-10

Home Environmental Health

City of Milwaukee Health Department

841 N Broadway
Room 118
Milwaukee, WI  53202
414-225-5323