Management. The most important part of the treatment plan is preventing further exposure to lead.4,8 Removing the source of lead is a consistent strategy for any child with a positive blood lead level.8 If removal of lead from the environment is not possible, encapsulation processes by certified lead abatement contractors are another available option.4 The primary care provider may consider consultations with a toxicologist, a nephrologist, the Occupational Safety and Health Administration (OSHA) for occupational exposures, and local health departments.8 Coordinating with local authorities and organizations is necessary to investigate the source of lead.5 The management of an elevated lead level in a child will also include monitoring through adulthood, as the effects of lead toxicity may not manifest initially.4 

Evaluating the patient’s diet is a part of managing elevated lead levels. The CDC recommends assessing iron levels and encouraging an iron-rich diet because of the associations between iron deficiencies and elevated blood lead levels. Calcium supplements should also be included in the treatment plan as calcium impedes lead absorption and bioavailability.4,9 In addition, deficiencies of zinc, vitamin C, protein, and phosphorus can increase the absorption of lead.9 

Continue Reading

Studies show that a nurturing, supportive home environment has a positive effect on outcomes in children with high lead levels.4,10 This is significant information for parents because a nurturing environment is something that they can provide to mitigate the mostly irreversible consequences of lead exposure. Children with developmental delays respond better to interventions at an earlier age, and this is also true for those with delays resulting from lead exposure. Early and high-quality education for patients and their families is imperative in counteracting the negative effects of lead.10 Programs like Head Start aim to provide early education and can further the development of children with elevated lead levels.4 

Factors to be considered in formulating a treatment plan include the patient’s age, blood lead level, and symptoms. Environmental interventions should be undertaken for children with levels between 10 and 19 mcg/dL, and they should be followed up in 1 month (Table 3). Those with levels between 15 and 19 mcg/dL for 3 consecutive months or a first level between 20 and 44 mcg/dL may need a more complete workup, including measurement of their hemoglobin and iron levels.9 Oral chelation therapy is indicated for those with a blood lead level below 44 mcg/dL if they have significant symptoms.9 However, although chelation therapy in children with blood lead levels between 20 and 44 mcg/dL may lower the levels, it has not been shown to reverse any neuropsychological effects.16 More simply, chelation therapy may be required for children with blood lead levels of 45 mcg/dL or higher.4 Those with levels between 40 and 79 mcg/dL should be referred to a clinical toxicologist, and those with levels above 80 mcg/dL require urgent medication evaluation and probable chelation therapy. Children with blood lead levels above 100 mcg/dL require hospitalization and parenteral chelation therapy.9 


Click to enlarge

Anticipatory guidance

Primary care providers play an essential role in educating families on how to prevent lead exposure. Primary prevention—for example, removing lead from paint and gasoline—is key to avoiding the irreversible neurological effects of lead toxicity.9 Primary prevention by primary care providers includes prenatal education.4 Providers should educate parents about all potential sources of lead exposure. Families with infants should receive guidance on how to use tap water to prepare infant formulas and information on the safety of local water. Parents can request the Environmental Protection Agency to test their water if concerned.16 Parents should also be educated on the topics of home renovation, possible sources of exposure within the home, and occupational hazards that may put them or the children of the household at risk.4 In addition, counseling on proper diet, including sufficient intake of vitamin C, iron, calcium, and zinc, can aid in decreasing risk in children.4 

Conclusions

The results of research indicate that any level of lead in the body carries a potential for harm. Primary care providers are essential in preventing, screening for, and managing lead toxicity. They deliver critical education to patients and families that can prevent exposure to lead and the long-term consequences of exposure. Understanding who is at risk and the possible sources of lead exposure will help guide providers in this task. Primary care providers are an integral part of the long-term management of persons with lead toxicity. 

Sarah O’Brien, BSN, RN, is a pediatric emergency nurse at Wolfson Children’s Hospital in Jacksonville, Fla. She is currently in graduate school to obtain a doctorate in nursing practice at the University of North Florida.

References

  1. McWhirter C, Maher K. Flint water crisis shines light on lead pipes across U.S. The Wall Street Journal website. http://www.wsj.com/articles/flint-water-crisis-shines-light-on-lead-pipes-crisscrossing-the-u-s-1453977180. Published January 28, 2016. 

  2. Wines M, Schwartz J. Safety net lacking for clean water; experts say aging infrastructure and lack of regulation pose widespread threats. The Register-Guard (Eugene, OR). February 9, 2016. 

  3. What do parents need to know to protect their children? Centers for Disease Control and Prevention website. http://www.cdc.gov/nceh/lead/acclpp/blood_lead_levels.htm. Updated March 15, 2016. 

  4. Schnur J, John R. Childhood lead poisoning and the new Centers for Disease Control and Prevention guidelines for lead exposure. J Am Assoc Nurse Pract. 2014;26(5):238-247. 

  5. Advisory Committee on Childhood Lead Poisoning Prevention of the Centers for Disease Control and Prevention. Low-level lead exposure harms children: a renewed call for primary prevention. http://www.cdc.gov/nceh/lead/acclpp/final_document_030712.pdf. Published January 4, 2012. 

  6. Lead poisoning and health. World Health Organization website. http://www.who.int/mediacentre/factsheets/fs379/en/ Updated August 2016. 

  7. Leafe M, Irigoyen M, DeLago C, Hassan A, Braitman L. Change in childhood lead exposure prevalence with new reference level. J Environ Health. 2015:77(10):14-16.

  8. Kathuria P. Lead toxicity. Medscape website. http://emedicine.medscape.com/article/1174752-overview. Updated February 8, 2016. 

  9. Kianoush S, Sadeghi M, Balali-Mood M. Recent advances in the clinical management of lead poisoning. Acta Med Iran. 2015:53(6):327-336.

  10. Educational Services for Children Affected by Lead Expert Panel. Educational interventions for children affected by lead. http://www.cdc.gov/nceh/lead/publications/Educational_Interventions_Children_Affected_by_Lead.pdf. Published April 2015. 

  11. Young A, Nichols M. Beyond Flint: Excessive lead levels found in almost 2,000 water systems across all 50 states. USA Today. March 11, 2016. http://www.usatoday.com/longform/news/2016/03/11/nearly-2000-water-systems-fail-lead-tests/81220466/ 

  12. Infographic: Prevent childhood lead poisoning. Centers for Disease Control and Prevention website. http://www.cdc.gov/nceh/lead/­infographic.htm. Updated December 18, 2013. 

  13. Nicholson J, Cleeton M. Validation and assessment of pediatric lead screener questions for primary prevention of lead exposure. Clin Pediatr (Phila). 2016;55(2):129-136. 

  14. Final recommendation statement: Lead levels in childhood and pregnancy, screening. US Preventive Services Task Force website. http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/lead-levels-in-childhood-and-pregnancy-screening. Updated December 2006. 

  15. Ossiander E. A systematic review of screening questionnaires for childhood lead poisoning. J Public Health Manag Pract. 2013;19(1):E21-E29. 

  16. Detection of lead poisoning. American Academy of Pediatrics website. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/lead-exposure/Pages/Detection-of-Lead-Poisoning.aspx. Published 2016. 

All electronic documents accessed September 1, 2016.

From the October 01, 2016 Issue of Clinical Advisor

Topics:

Neurology Pediatrics