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Childhood Lead Poisoning Guidelines for Clinicians

To assist clinicians with the prevention, detection, and medical management of childhood lead poisoning, the City of Milwaukee Health Department (MHD) reviews current recommendations from leading resources including the U.S. Centers for Disease Control and Prevention, the American Academy of Pediatrics, and the American Congress of Obstetricians and Gynecologists, and issues additional local guidelines when appropriate. These recommendations reflect Milwaukee’s local environmental conditions and risk factors.

For further information or to consult with MHD Childhood Lead Poisoning Prevention Program nursing staff, contact the MHD CLPPP at (414) 286-5987.

Lead Testing Recommendations

Testing of children: The City of Milwaukee Health Department follows guidelines issued by the State of Wisconsin Department of Health Services in recommending that that all children be tested three times before the age of 3. Children under the age of 6 should be tested if they have no record of a previous test, have a history of lead exposure, or if they are at greater risk for lead exposure based on an assessment of risk factors. Children enrolled in Medicaid or WIC should be tested annually to age 6.

View Wisconsin Blood Lead Screening recommendations (PDF)

Testing of pregnant or lactating women: The City of Milwaukee Health Department follows guidelines issued by the U.S. Centers for Disease Control and Prevention (CDC) and American College of Obstetricians and Gynecologists (ACOG) regarding blood lead testing of pregnant or lactating women. The routine universal testing of all pregnant or lactating women is not recommended. Risk assessment of lead exposure should take place and blood lead testing should be performed if a risk factor is identified.

View ACOG Lead Screening During Pregnancy and Lactation Recommendations
View CDC Guidelines for the Identification and Management of Lead Exposure in Pregnant and Lactating Women (PDF)

Reporting of Blood Lead Testing

State law Wis. Stat. 254.13  (link is external)(PDF) requires that all blood lead test results on Wisconsin residents be reported to the Wisconsin Department of Health Services (DHS). The specific requirements for reporting blood lead results, such as timetable, content, form, etc., are described in Wis. Admin. Rule 181 (link is external)(PDF). The Wisconsin Childhood Lead Poisoning Prevention Program (link is external) implements the reporting rule through a laboratory-based reporting system and works directly with laboratories to assure all blood lead results are reported. Health care providers are responsible for sending complete demographic information as required by Wis. Admin. Rule 181 (link is external) (PDF) to the analytical laboratory with each blood lead sample. This allows the laboratory to include the demographics in the blood lead report.

Medical Case Management of Blood Lead Levels

Childhood Lead Poisoning Case Management: All children who live in the city of Milwaukee and have a blood lead level of 5 micrograms per deciliter (µg/dL) or higher will receive follow-up by the City of Milwaukee Health Department Childhood Lead Poisoning Prevention Program (MHD CLPPP) based on the blood lead level reported. Clinicians are advised to follow the MHD CLPPP guidelines for medical case management.

View the MHD CLPPP intervention schedule

Medical Case Management Guidelines Based on Blood Lead Levels:

Less than 5 µg/dL
5 - 14 µg/dL

15 - 19 µg/dL
20 - 44 µg/dL
45 - 69 µg/dL
More than 70 µg/dL


 
Less than 5 µg/dL
  • Lead-related examination not necessary

  • Anticipatory guidance:

    • Discuss primary sources of lead poisoning and measures to keep children safe from lead. Review and provide lead poisoning prevention literature.

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

  • Test other children less than 6 years old in the home

  • Retest:

    • Age 6 to 35 months: In 12 months (3 times before 3 years of age)

    • Age 36 to 72 months: In 12 months

 See Blood Lead Testing Recommendations
 


 
5 - 14 µg/dL
  • Confirm capillary result with venous blood lead test within 1 month

  • 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 lead poisoning prevention literature

    • Nutrition

    • Dangers of improper abatement

    • Chronic nature of problem and the need to monitor blood lead levels frequently

  • Iron supplement if deficient

  • Test other children less than 6 years old in the home

  • Retest:

    • Venous blood lead test every 3 - 4 months until blood lead level is less than 5 µg/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

    • Including, but not limited to:

      • History

      • Lab work including iron status using Ferritin level

      • Physical exam

  • Educate family regarding:

    • Potential sources of lead and ways to reduce exposure; Review and provide lead poisoning prevention literature

    • Nutrition

    • Dangers of improper abatement

    • Chronic nature of problem and the need to monitor blood lead levels frequently

  • Iron supplement if deficient

  • Test other children less than 6 years old in the home

  • Retest:

    • Venous blood lead test every 3 - 4 months until blood lead level is less than 5 µg/dL


 
20 - 44 µg/dL
  • Confirm capillary result with venous blood lead test within 1 week and include Erythrocyte Protoporphyrin (EP) or Zinc Protoporphyrin (ZPP)
  • Complete diagnostic evaluation for venous blood lead test result

    • Including, but not limited to:

      • History

      • Lab work 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 levels)

    • Sources of exposure to lead (Age of home and condition of painted surfaces, pica, remodeling, occupations or hobbies, folk remedies, etc)

  • Educate family regarding:

    • Potential sources of lead and ways to reduce exposure; Review and provide lead poisoning prevention literature

    • Nutrition

    • Dangers of improper abatement

    • Chronic nature of problem and the need to monitor blood lead levels frequently

  • Iron supplement if deficient

  • Test other children less than 6 years old in the home.

  • Chelation is not recommended

  • Retest:

    • Venous blood lead and EP or ZPP every 1-3 months until blood lead level is less than 5 µg/dL

    • Higher levels and children less than or equal to 3 years old require more frequent monitoring

  • Persistently high levels may require more aggressive treatment

    • Consult MHD CLPPP for resources


 
45 - 69 µg/dL
  • Confirm capillary result with venous blood lead test immediately and include Erythrocyte Protoporphyrin (EP) or Zinc Protoporphyrin (ZPP)

  • If confirmed by venous result:

    • Emergency hospital admission for clinical symptoms

    • IMMEDIATE telephone report to MHD CLPPP

  • ​Chelation therapy

    • Stop iron therapy prior to chelation

    • Treat with CaEDTA or DMSA

    • Consult an expert in chelation

  • In-home treatment indicated only in situations of:

    • Lead-safe environment

    • Highly compliant family

    • Home Health Care monitoring

  • Discharge inpatient cases ONLY to a LEAD-SAFE ENVIRONMENT verified by MHD CLPPP

    • Consult MHD CLPPP for resources and environmental status

  • Complete diagnostic evaluation for venous blood lead test result

    • Including, but not limited to:

      • History

      • Lab work including iron status using Ferritin level

      • Physical exam

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

  • Assess clinical symptoms:

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

    • Nutritional status (Especially iron and calcium levels)

    • Sources of exposure to lead (Age of home and condition of painted surfaces, pica, remodeling, occupations or hobbies, folk remedies, etc)

  • Educate family regarding:

    • Potential sources of lead and ways to reduce exposure; Review and provide lead poisoning prevention literature

    • Nutrition

    • Dangers of improper abatement

    • Chronic nature of problem and the need to monitor blood lead levels frequently

  • Test other children less than 6 years old in the home

  • Retest:

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

    • Repeat venous blood 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

    • Additional chelation treatments may be necessary for children with high levels of bone and soft tissues stores (As monitored through EP levels)


 
More than 70 µg/dL
 

Follow same guidelines as 45 - 69 µg/dL

  • If confirmed by venous result:

    • Patient should be treated for emergency medical conditions

      • Emergency admission to hospital with pediatric ICU capacity

      • Child may develop encephalopathy or other life-threatening complications

    • IMMEDIATE telephone report to MHD CLPPP


Additional Information on Treatment Guidelines

Additional information can be found:

These guidelines updated 5-13-10