Lead Exposure and Healthy Homes - Diagnosing & Managing Lead Exposures

Blood Lead Level (BLL) (μg /dL)

Medical Intervention

Other Actions

5-7

• If a capillary test was performed, speak with parent/caregiver about confirming with venous test within 1 week

• Screen any sibling under 6 years of age

• Discuss & assess the possible sources of lead
• Nutritional counseling for adequate iron and calcium intake
• Parent education about exposure prevention
• Parent can expect communication from CLPPP (1)

8-14

• Recheck venous BLL within 1 week (2)

• Screen any sibling under 6 years of age

• Discuss & assess the possible sources of lead
• Nutritional counseling for adequate iron and calcium intake
• Parent education about exposure prevention
• Parent can expect follow up from CLPPP (1)

15-19

• Recheck BLL within 3 days (2)

• Evaluate for iron deficiency

• Screen any sibling under 6 years of age

• Discuss & assess the possible sources of lead
• Nutritional counseling for adequate iron and calcium intake.
• Parent education about exposure prevention
• Parent can expect follow up from CLPPP (1)

20-44

• Recheck venous BLL within 1 day (2)

• Screen for iron deficiency

• Provide close medical attention

• Screen any sibling under 6

• Discuss & assess the possible sources of lead
• Nutritional counseling for adequate iron and calcium intake
• Parent education about exposure prevention
• Parent can expect follow up from CLPPP (1)

45-69

Emergency

• Immediately recheck BLL (2), and if confirmed, begin oral chelation therapy with BAL and CaNa2 EDTA (3, 4, 5)

• Screen any sibling under 6

• Report to CLPPP (1) for case management immediately
• Discuss & assess the possible sources of lead
• Nutritional counseling for adequate iron and calcium intake
• Parent education about exposure prevention
• Parent can expect follow up from CLPPP (1)

70 and Above

Emergency

• Medical Emergency: Hospitalize and treat with ‘BAL’ and CaNa2 EDTA (3, 4, 5)

• Screen any sibling under 6

• Report to CLPPP (1) for case management immediately

• Discuss & assess the possible sources of lead
• Nutritional counseling for adequate iron and calcium intake
• Parent education about exposure prevention
• Parent can expect follow up from CLPPP (1)

1. Childhood Lead Poisoning Prevention Program (CLPPP), telephone (202) 535-2624.
2. Frequency of further testing depends on the recheck result and the upward or downward trend in BLL results.  Fairly frequent follow-up testing is recommended by CDC for cases under clinical management until the exposure issue has been resolved, and BLL has stabilized, at which point less frequent testing is recommended.           CaNa2 EDTA (Versenate), 1000 mg/m2/day (or 25 mg/kg/day) x 5 days ≤0.5% in D5W or NS, continuous infusion or, in divided doses.  Allow 5 to 7 medication free days if additional treatment is required (BLL staying ≥45).
3. Start treatment with a dose of 75 mg/m2 BAL only, given by deep intramuscular injection; administer BAL at a dose of 450 mg/m2/day in divided doses of 75 mg/m2 every 4 hours.
4. Once the BAL dose is given and an adequate urine flow is established, administer CaNa2EDTA at a dose of 1,500 mg/m2/day.  Give CaNa2EDTA as a continuous intravenous infusion in dextrose and water or in a 0.9% saline solution.  The concentration of CaNa2EDTA should not exceed 0.5% in the parenteral fluid.  (When treating a child with encephalopathy, the physician may choose to give CaNa2EDTA intramuscularly to reduce the amount of fluid administered.)  Treat with combined BAL-CaNa2EDTA therapy for a total of 5 days.  During treatment, monitor renal and hepatic function and serum electrolyte levels daily (Piomelli et al., 1984).
5. A second course of chelation therapy with CaNa2EDTA alone (at blood lead levels 45-69 µg/dL) or combined with BAL (at blood lead levels 70 µg/dL), may be required once there is a rebound in the blood lead level after chelation.  Wait at least 2 days before giving a second course of chelation.   A third course is required only if the blood lead concentration rebounds to a value ≥ 45 µg/dL within 48 hours after the second course of treatment.  Unless there are unusual and compelling clinical reasons, wait at least 5 to 7 days before beginning a third course of CaNa2EDTA (Piomelli et al., 1984).

Prepared by the Childhood Lead Poisoning Prevention Program (CLPPP) of DOEE, based on CDC recommendations.  Consult this chart and the manufacturer’s information about the precautions required in administration of specific medication listed in this chart.

For consultation, call CLPPP (202) 535-2624.

Revised: July 2013