Lead Poisoning in Children: Emergency Department Recognition and Management (Pharmacology CME)

Table of Contents

 

About This Issue

Lead poisoning can be challenging to identify due to the nonspecific presentation and frequent lack of known exposure. This issue will discuss how to identify patients at risk for lead poisoning, appropriately manage lead-poisoned patients, and formulate a safe discharge plan. You will learn:

Why children are at increased risk for lead exposure

Common sources of lead exposure

The effects of lead in the body

Health effects on children, based on BLL

Common signs and symptoms of lead poisoning in children

Recommendations and guidelines for lead screening

Potential misdiagnoses of patients with lead poisoning

Recommendations for BLL testing, laboratory studies, and imaging studies

When chelating agents are indicated, and which agents should be used

How to contact an environmental health specialist to help guide management of lead-poisoned patients

Which groups of children are at increased risk for lead poisoning

When a pediatric patient should be admitted, and when a child can be safely discharged home, as well as factors that can help ensure a safe discharge

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Screening and Prevention of Lead Poisoning
7. Differential Diagnosis
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
9. Diagnostic Studies
   1. Blood Lead-Level Testing
   2. Laboratory Studies
   3. Imaging Studies
10. Treatment
    1. Chelation Therapy
       1. Succimer/Dimercaptosuccinic Acid
       2. Calcium Disodium Edetate
       3. D-penicillamine
       4. Dimercaprol/British Anti-Lewisite
11. Special Populations
    1. Children With Autism Spectrum Disorder or Developmental Delay
    2. Children With Sickle Cell Disease
12. Controversies and Cutting Edge
13. Disposition
14. Summary
15. Time- and Cost-Effective Strategies
16. Risk Management Pitfalls for Pediatric Patients With Lead Poisoning
17. Case Conclusions
18. Clinical Pathway for Emergency Department Management of Pediatric Patients With Lead Poisoning
19. Tables and Figures
20. References

Abstract

Millions of children continue to be at risk for lead exposure despite a dramatic decline over the past 4 decades, and hundreds present annually to emergency departments with lead poisoning. These patients can be challenging to identify due to their nonspecific presentation and frequent lack of known exposure. This issue will prepare the emergency clinician to identify and care for the lead-poisoned patient, focusing on: (1) identifying key historical features, signs, and symptoms at presentation; (2) the medical management of lead poisoning; and (3) formulation of a safe discharge plan.

Case Presentations

A 4-year-old boy with a history of autism spectrum disorder presents to the ED with a chief complaint of abdominal pain...

• The patient is nonverbal, but his mom states that he is intermittently holding his abdomen and crying. He has not had fever or emesis. He has not stooled in 10 days. The mom tells you that he has been constipated “since he was a baby,” and it has been managed with polyethylene glycol, but he has never gone this long without stooling. The patient has a decreased appetite, but his urine output has been normal. On further questioning, the mom says that her son has pica behaviors and that their apartment was recently renovated.
• On physical examination, you note that the patient appears comfortable, but has a slightly distended abdomen with generalized tenderness, without rebound or guarding. You discuss with the mom your concern that his symptoms may be due to lead poisoning. You relay the plan to obtain a blood lead level.
• What risk factors for lead poisoning does this patient have? What other tests should you consider as part of your initial workup? How much of this workup needs to be done in the ED? How will you determine whether the patient needs to be admitted?

A 15-month-old previously healthy girl presents to the ED after swallowing her grandmother’s heirloom necklace...

• Earlier today, the girl’s grandmother was looking for her necklace, and the patient’s 8-year-old sister said that she saw the patient swallow it. The sister says that last week, the patient was playing with the necklace and started chewing on it. The patient then coughed for a few minutes and swallowed the necklace. As soon as the parents heard about this, they immediately rushed their daughter to the ED.
• On arrival, the patient appears comfortable, with normal vital signs and no respiratory distress. The remainder of the physical examination is normal. The mom is particularly concerned because the grandmother mentioned that the necklace is made from lead, and she remembers their pediatrician talking to her about the risks of lead exposure.
• In addition to obtaining imaging studies to assess the location of the foreign body, what other workup should you consider? Can the patient become lead-poisoned from this foreign body? What is your management plan?

A 13-year-old girl presents to the ED with chronic abdominal pain...

• The patient’s pain started 5 months ago, at which time she was diagnosed with appendicitis and underwent an appendectomy. The pain has persisted, and she has developed anorexia and constipation. She has been afebrile, with some nausea but no vomiting or diarrhea. Two months ago, she was diagnosed with iron deficiency anemia. Her mother also mentions that the girl has been increasingly irritable and depressed, which the family has attributed to frustration with her prolonged abdominal pain.
• On examination, the patient has a blood pressure of 150/90 mm Hg and is noted to be pale. Her abdomen is soft, with generalized tenderness. You obtain laboratory tests, which are significant for microcytic anemia but show a normal WBC count and inflammatory markers. An abdominal ultrasound looking for abscess is normal. While talking to one of the nurses, the patient mentions that she spends a lot of time working in her family’s pottery shop. On further questioning, her mother reveals that the patient’s uncle had lead poisoning 2 years ago.
• You are concerned for lead poisoning and send a blood lead level. Could this patient have become lead-poisoned from being around lead, without ingesting it? Is her irritability and depression related to her underlying diagnosis? What is your next management step?

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Clinical Pathway for Emergency Department Management of Pediatric Patients With Lead Poisoning

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Hauptman M, Bruccoleri R, Woolf AD. An update on childhood lead poisoning. Clin Pediatr Emerg Med. 2017;18(3):181-192. (Review article) DOI: 10.1016/j.cpem.2017.07.010

3. U.S. Centers for Disease Control and Prevention. CDC response to Advisory Committee on Childhood Lead Poisoning Prevention recommendations in "low level lead exposure harms children: a renewed call of primary prevention." Accessed March 5, 2022. (Guideline)

6. President’s Task Force on Environmental Health Risks and Safety Risks to Children. Key federal programs to reduce childhood lead exposures and eliminate associated health impacts. Accessed March 5, 2022. (Guideline)

7. President's Task Force on Environmental Health Risks and Safety Risks to Children. Federal action plan to reduce childhood lead exposures and associated health impacts. Accessed March 5, 2022 (Guideline)

11. * Dapul H, Laraque D. Lead poisoning in children. Adv Pediatr. 2014;61(1):313-333. (Review article) DOI: 10.1016/j.yapd.2014.04.004

12. U.S. Centers for Disease Control and Prevention. Childhood lead poisoning prevention. Blood lead reference value. Accessed March 5, 2022. (CDC website)

14. * Chandran L, Cataldo R. Lead poisoning: basics and new developments. Pediatr Rev. 2010;31(10):399-405. (Review article) DOI: 10.1542/pir.31-10-399

22. Tarragó O, Demers R. Agency for Toxic Substances and Disease Registry Case Studies in Environmental Medicine (CSEM) Lead Toxicity. Accessed March 5, 2022. (Review article)

23. American Academy of Pediatrics. Detection of lead poisoning. Accessed March 5, 2022. (AAP website)

38. * VanArsdale JL, Leiker RD, Kohn M, et al. Lead poisoning from a toy necklace. Pediatrics. 2004;114(4):1096-1099. (Case report) DOI: 10.3109/15563650.2013.792114

39. * Clifton JC 2nd, Sigg T, Burda AM, et al. Acute pediatric lead poisoning: combined whole bowel irrigation, succimer therapy, and endoscopic removal of ingested lead pellets. Pediatr Emerg Care. 2002;18(3):200-202. (Case report) DOI: 10.1097/00006565-200206000-00013

52. Agency of Toxic Substances and Disease Registry. How should patients exposed to lead be treated and managed? Accessed March 5, 2022. (Guideline)

53. * Rogan WJ, Dietrich KN, Ware JH, et al. The effect of chelation therapy with succimer on neuropsychological development in children exposed to lead. N Engl J Med. 2001;344(19):1421-1426. (Multicenter randomized double blind placebo controlled trial; 780 patients) DOI: 10.1056/NEJM200105103441902

55. BAL in oil ampules. Accessed March 5, 2022. (Data sheet)

57. Calcium disodium versenate. Accessed March 5, 2022. (Data sheet)

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Keywords: lead, lead poisoning, lead exposure, blood lead level, BLL, lead encephalopathy, lead lines, chelating agents, chelating drugs, chelating medications, chelation therapy, chelation treatment, succimer, dimercaptosuccinic acid, DMSA, calcium disodium edetate, CaNa2EDTA, D-penacillamine, dimercaprol, British Anti-Lewisite, BAL