RISK FACTORS
• Children with pica
• Children with iron deficiency anemia
• Residence or frequent visitor in deteriorating, pre-1960 housing with leaded-paint surfaces
• Children with seizures
• Children with hyperkinetic or autistic behavior
• Sibling or playmate with lead poisoning
• Dust from clothing of lead worker
• Lead dissolved in water from lead or lead-soldered plumbing
• Lead glazed ceramics, especially with acidic food or drink
• Food stored in inverted plastic bread bags printed with colored ink
• Colored comics
• Soil/dust near lead industries and roads
• Folk remedies (Mexican - azarcon, greta; Asian - chuifong tokuwan, pay-loo-ah, ghasard, bali goli, kandu;
Middle Eastern - alkohl, surma, saoott, cebagin)
• Exposure to litargirio, topical agent from Dominican Republic
• Exposure to Ayurvedic herbal medicine from South Asia
APPROPRIATE HEALTH CARE Outpatient unless parenteral chelation required. Consider consultation if chelation required.
GENERAL MEASURES
• Case report to local health department for Class III-V. Complete inspection of home or work-place to determine source of lead. Screen all family members.
• Consider oral chelation for Class III or IV. Chelation (preferably parenteral) for Class V or symptomatic Class III or IV.
• Remove from potential source of lead for Class IV or V, until complete inspection is performed
ACTIVITY
• Avoid activity at any site of potential contamination
DIET
• If symptomatic, avoid excessive fluids
• Avoidance of pica
• Consume adequate calcium and iron
• Eat a low fat diet to reduce absorption and retention of lead
• Consume at least 2 servings daily of foods high in vitamin C, such as fruits, vegetables, and juices
DRUG(S) OF CHOICE
. Oral chelation:
. Succimer (Chemet, dimercaptosuccinic acid, DMSA) 10 mg/kg q8h x 5 days, then 10 mg/kg q12h x 2
weeks. May be repeated after 2 weeks off if lead levels are not stabilized <15 ƒÊg/dL (< 0.72 ƒÊmol/L).
. Parenteral chelation (begin after establishment of adequate urine output):
. Class V or symptomatic: dimercaprol (British anti-Lewisite, BAL) 75 mg/m2 given deep IM, then BAL 450 mg/m2/d divided q4h x 5 days + Ca EDTA (edetate calcium disodium) 1500 mg/m2/d continuous IV infusion x 5 days. If rebound lead level . 45 ƒÊg/dL (. 2.17 ƒÊmol/L), chelation may be repeated after 2 day interval if symptomatic, after 5 day interval if asymptomatic.
. Class IV asymptomatic: Ca EDTA 1000 mg/m2/d x 5 days. May be repeated after 5-7 days.
. Diazepam for initial control of seizures, further control maintained with paraldehyde
ALTERNATIVE DRUGS
. Oral chelation with penicillamine (d-penicillamine, Depen, Cuprimine)
. Penicillin allergic patient should not receive D-penicillamine (cross-sensitivity is common)
. 10-20 mg/kg bid mixed in apple juice/sauce on empty stomach (not FDA approved)
. D-penicillamine may cause gastrointestinal upset, renal failure, granulocytopenia, liver dysfunction, iron
deficiency, drug induced lupus-like syndrome
PATIENT MONITORING
• After chelation, check for rebound Pb level in 7-10 days. Follow with regular monitoring, initially biweekly
or monthly.
• Correct iron defi ciency or any other nutritional defi ciencies present
• For Class II or higher, repeat testing every 3 months until Class I level achieved
PREVENTION/AVOIDANCE
• Family should receive counseling on potential sources of lead and methods to decrease lead exposure. Wet
mopping and dusting with a high phosphate solution (e.g., powdered automatic dishwasher detergent with
1/4 cup per gallon of water) will help control lead-bearing dust.
• If the source is in the home, the patient must reside elsewhere until the abatement process is completed
POSSIBLE COMPLICATIONS
• CNS toxicity may be long lasting or permanent
• Long-term lead exposure may cause chronic renal failure (Fanconi-like syndrome); gout; lead line (blueblack)
on gingival tissue
EXPECTED COURSE/PROGNOSIS
• Symptomatic lead poisoning without encephalopathy generally improves with chelation, but subtle CNS toxicity may be long lasting or permanent
• If encephalopathy occurs, permanent sequelae (mental retardation, seizure disorder, blindness, hemiparesis) in 25-50%