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Lead Poisoning Medical Guidelines 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 environmental 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 414-225-LEAD.

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 6 months (3 times before age 3 years)

    • Age 36 to 72 months: In 12 months

 See Blood Lead Testing Recommendations
 


 
5 - 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 lead poisoning prevention literature.

    • Nutrition

    • Dangers of improper abatement

    • Chronic nature of problem (The need to monitor blood lead levels frequently)

  • Iron supplement if deficient.

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

  • Repeat venous blood lead test every 3 - 4 months until blood lead level is less than 10 ug/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 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 (The need to monitor blood lead levels frequently)

  • Iron supplement if deficient.

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

  • Repeat venous blood lead test every 3 - 4 months until blood lead level is less than 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 (Including 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 (The need to monitor blood lead levels 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 less than 6 years old in the home.

  • Repeat venous blood lead and EP or ZPP every 1-3 months (Higher levels and children less than or equal to 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 (Including 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)

  • 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 at 225-LEAD.

  • Educate family regarding:

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

    • Dangers of improper abatement

    • Chronic nature of problem (The need to monitor blood lead levels frequently)

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

  • If confirmed by venous result:

    • ​Chelation - CONSULT EXPERT IN CHELATION:

      • Treat with CaEDTA or DMSA.

      • Consult MHD CLPPP at 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 verified 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).


 
More than 70 µg/dL
 

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 at 225-LEAD.                  

  • If confirmed by venous result:

    • ​Chelation - CONSULT EXPERT IN CHELATION:

      • Treat with CaEDTA or DMSA.

      • Consult MHD CLPPP at 225-LEAD for resources and environmental status.

 

These guidelines updated 5-13-10