Childhood Lead Exposure

Lead exposure may result from contact with lead in the environment, including lead-based paint, dirt, cosmetics, hobby products, water, and other sources. Lead exposure generally occurs when contaminants with lead are inhaled or ingested. Children exposed to lead during childhood are at increased risk for delays in development and growth. This clinical resource discusses assessment, screening and testing, and interventions for elevated lead levels in children.

Key Points

Screening Recommendations

Screening for lead is recommended for high-risk children between the ages of 6 months and 6 years, based on risk assessments.

Ongoing Assessment

Ongoing monitoring is recommended for those with BLL above 3.5 μg/dL, though symptoms may not be present even at levels above 45 μg/dL. Follow-up is based on the level: Recommended Actions Based on Blood Lead Level (CDC) [Center: 2018]

Remove the Source of Lead Exposure

The first priority for treatment is removing the source of lead exposure.

Practice Guidelines

Guidelines, recommendations, and reviews of the literature are provided by the Centers for Disease Control and Prevention (CDC) and American Academy of Pediatrics (AAP). [Centers: 2010] [Council: 2016] [Council: 2017]

Of note, the 2019 U.S. Preventive Services Task Force (USPSTF) guideline concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for elevated blood lead levels in asymptomatic children. [Curry: 2019]

Assessment

Signs and Symptoms

Surveillance and Screening

Assess Risk Factors

The American Academy of Pediatrics (AAP) recommends periodic lead exposure risk assessments at 6, 9, 12, 18, and 24 months and at 3, 4, 5, and 6 years, as noted on the Bright Futures/AAP Periodicity Schedule. Common sources of lead exposure include, but are not limited to, lead paint, water, soil, industry, toys, and supplements. [Atkinson: 2011] Children should be tested for lead with a blood test as required by state laws or, in the absence of such laws, according to CDC and AAP recommendations.

Screening with a Blood Lead Test

Recommendations for blood test screening vary and some states and insurers require testing:

  • The CDC recommends universal blood lead screening in communities where >12% of children have blood lead levels >10 μg/dL or where >27% of housing was built before 1950. [Centers: 2018]
  • Medicaid requirements vary by state. While some state Medicaid programs require blood lead screening for all Medicaid-eligible children at 12 and 24 months of age as part of well-child checkups, many states have adopted or are transitioning to targeted screening. [Centers: 2018] [Dickman: 2017] [Centers: 2012]
  • The Children’s Health Insurance Program (CHIP) does not require universal lead screening.
  • Several states have laws requiring universal blood lead screening tests for children at specific ages while several other states require targeted testing. [Dickman: 2017]

For more details, see Recommended Actions Based on Blood Lead Level (CDC)

Testing

Venous blood lead testing is recommended to determine exposure levels since skin contamination can cause a capillary blood lead level to be falsely elevated. State laws and recommendations regarding environmental inspections for children with elevated blood lead levels vary. In most cases, such inspections are prompted when a child has a venous blood lead level above a particular threshold level and is performed by the local public health department. Check with the lab that will perform the test to ensure that blood samples are submitted in the correct tube (lead-free) and that the lab is familiar with blood lead testing. The CDC provides additional instructions for blood collection and storage. [Advisory: 2013]

Prevalence

Approximately 3% of children between ages 1 and 5 years have blood lead levels at or above 5 μg/dL. Rates vary by geography, age of housing, poverty, etc. [Centers: 2013]

Prognosis

Worse outcomes, including developmental delays and growth problems, are correlated with increased blood lead levels (BLLs).

Treatment & Mangement

There is no safe blood lead level. The AAP Pediatric Environmental Health Specialty Units (PEHSUs) recommend more frequent testing, interventions, and other steps at higher blood lead levels (see Recommendations on Medical Management of Childhood Lead Exposure and Poisoning (AAP) (PDF Document 133 KB) and Sample Management Guidelines on Childhood Lead Poisoning for Health Care Providers (PDF Document 659 KB)). [Pediatric: 2013] [Centers: 2010] Recommended criteria and steps for treatment may be different by state. Determining the source of the exposure and eliminating or limiting the lead exposure, such as lead in paint or toys, is a key step in the treatment and management of a child with lead exposure.

Screen for developmental and other neurodevelopmental delays. See Developmental Screening.

The medical home can provide care coordination including anticipatory guidance; care planning; identification of resources and specialists; appointment coordination; collection and coordination of testing and treatment results; and other care coordination activities.

For recommendations for initiating breastfeeding, see Maternal Lead Exposure.

Recommendations for continuation of breastfeeding:

  • Breastfeeding should continue for all infants with BLLs below 5 μg/dL.
  • Infants born to mothers with BLL ≥5 μg/dL can continue to breastfeed unless there are indications that the breast milk is contributing to elevating BLLs. These infants should have blood lead tests at birth and be followed at:
    • 1 month for levels of 5 μg/dL to 24 μg/dL
    • 2 weeks for levels of 55 μg/dL to 44 μg/dL
    • Within 24 hours for levels over 45 μg/dL
  • For infants whose blood lead levels are rising or failing to decline by 5 μg/dL or more, environmental and other sources of lead exposure should be evaluated. If no external source is identified, and maternal BLLs are >20 μg/dL and infant BLL ≥5 μg/dL, then breast milk should be suspected as the source, and temporary interruption of breastfeeding until maternal blood lead levels decline should be considered.
Recommendations for use of infant formula:
  • Infant formula requiring reconstitution (i.e., powder or concentrated formula) should be made with water from the cold water tap and then heat the water. If you live in an older home, consider running the water in the morning for a few minutes before using it. Alternatively, use lead-free bottled or filtered tap water or ready-to-feed formula (which is more costly). [Centers: 2010] [Committee: 2012] [American: 2021]

Medications Used to Treat Lead Exposure

Common treatment interventions, including removal from the source of the exposure and nutritional interventions are attempted before medications are considered due to the risks of using the medications.

Oral chelation may improve blood lead levels and reduce symptoms of acute lead intoxication but may have limited usefulness in reducing other existing symptoms, such as neurodevelopmental delays. [Kosnett: 2007]

Chelation is considered when blood lead levels are greater than 45 μg/dL, when the individual has been removed from the lead exposure, and based on the individual situation of the exposed mother and/or child. An expert in lead poisoning should be consulted for chelation. Chelation medications bind to and release lead and other essential minerals from bone and other tissues. Lead can be stored by the bones for many years. [Family: 2022] The blood lead level may drop immediately after chelation treatment but usually increases about two weeks after treatment. [Centers: 2010] [Family: 2022] Blood lead levels may remain high for years even after chelation therapy, particularly if there has been longstanding exposure, and chelation may not affect long-term neurodevelopmental outcomes in children. [Cantor: 2018] In pregnant women, the loss of other minerals from the therapy may increase risks of complications for the fetus. [Centers: 2010]

Recommendations for chelation therapy include: [Centers: 2010]

  • Infants (0-6 months of age) with a confirmed BLL of ≥45 μg/dL should be considered as candidates for chelation in consultation with an expert in pediatric lead chelation therapy.
  • Chelation therapy must occur in a lead-safe environment; therefore, prior to initiating chelation therapy, the patient should be removed from further lead exposure.
  • Children should not return to an environment where lead hazards are present and continued exposure is likely following chelation.

Chelating agents used to treat lead poisoning include: [Centers: 2010]

  • Calcium edetate
    • Administered IM or IV, inpatient only
    • Always use with calcium
  • Succimer
    • Administered PO
    • Does not lower BLL with single course of treatment
  • Dimercaprol (British anti-Lewisite (BAL))
    • Administered IM, inpatient only
    • Used with calcium edetate
  • D-penicillamine
    • Administered PO

Services and Referrals

Public Health Services (see NM providers [9])
After blood lead levels are identified, local health department and other experts will perform important roles depending upon the source of the lead exposure.

Developmental - Behavioral Pediatrics (see NM providers [2])
After blood lead levels are identified, an expert in lead poisoning should be consulted for chelation. [Centers: 2010] See the section above, Medications Used to Treat Lead Exposure, for details on chelation.

Pediatric Hematology/Oncology (see NM providers [3])
A pediatric hematology/oncology specialist may provide consultation for diagnosis and treatment of lead poisoning.

ICD-10 Coding

Z77.011, Contact with and (suspected) exposure to lead
R78.71, Abnormal lead level in blood
Z13.88, Encounter for screening for disorder due to exposure to contaminants
See ICD-10 related to lead exposure (icd10data.com) for further coding details.

Resources

Information & Support

For Professionals

Recommendations on Medical Management of Childhood Lead Exposure and Poisoning (AAP) (PDF Document 133 KB)
Table of recommendations for testing, management, and anticipatory guidance for various blood lead levels from the Pediatric Environmental Health Specialty Units (PEHSU) of the American Academy of Pediatrics (AAP).

Where We Stand: Lead Screening (AAP)
List of resources for lead screening and prevention for providers and parents from HealthyChildren.org, American Academy of Pediatrics.

Sample Management Guidelines on Childhood Lead Poisoning for Health Care Providers (PDF Document 659 KB)
Guidelines with detailed table of evaluation, testing, and management at higher blood lead levels from the California Department of Public Health.

Guide For States Interested in Transitioning to Targeted Blood Lead Screening for Medicaid-Eligible Children (PDF Document 669 KB)
Detailed guidance for state Medicaid officials.

Practice Guidelines

Centers for Disease Control and Prevention.
Guidelines for the Identification and Management of Lead Exposure in Pregnant and Lactating Women.
Center for Disease Control and Prevention; (2010) https://www.cdc.gov/nceh/lead/publications/leadandpregnancy2010.pdf. Accessed on 3/24/2023.

Curry SJ, Krist AH, Owens DK, Barry MJ, Cabana M, Caughey AB, Doubeni CA, Epling JW Jr, Kemper AR, Kubik M, Landefeld CS, Mangione CM, Pbert L, Silverstein M, Simon MA, Tseng CW, Wong JB.
Screening for Elevated Blood Lead Levels in Children and Pregnant Women: US Preventive Services Task Force Recommendation Statement.
JAMA. 2019;321(15):1502-1509. PubMed abstract / Full Text

Patient Education

Blood Lead Levels in Children (CDC) (PDF Document 292 KB)
Fact sheet with information for parents about blood lead levels, treatment, and action steps, from the Centers for Disease Control and Prevention.

Blood Lead Levels in Children (AAP)
Website with information for parents about blood lead levels and links to more resources, from HealthyChildren.org, American Academy of Pediatrics.

Tools

Mission Unleaded: How to test children for lead with maximum accuracy (CDC)
18-minute training video for clinical staff who test children's lead levels; Centers for Disease Control.

Recommended Actions Based on Blood Lead Level (CDC)
Recommendations on how to screen and test lead levels in children and follow up recommendations for elevated levels.

Services for Patients & Families in New Mexico (NM)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: January 2019; last update/revision: April 2023
Current Authors and Reviewers:
Author: Alfred N. Romeo, RN, PhD
Funding: Developed by the Organization of Teratology Information Specialists / MotherToBaby in collaboration with and funding from the Association of Maternal & Child Health Programs (AMCHP) Cooperative Agreement #UJ9MC31105, U.S. Department of Health and Human Services’ Health Resources and Services Administration, Maternal and Child Environmental Health (MCEH) Collaborative Improvement and Innovation Network (CoIIN) for $849,999. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by, HRSA, HHS or the US government.
Authoring history
2018: first version: Beth Conover, MS, APRN, LCGCR; Stanley Schaffer, MD, MS, FAAPR
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

Advisory Committee on Childhood Lead Poisoning Prevention.
Guidelines for Measuring Lead in Blood Using Point of Care Instruments.
Centers for Disease Control and Prevention; (2013) https://www.cdc.gov/nceh/lead/ACCLPP/20131024_POCguidelines_final.pdf. Accessed on 4/4/2023.

American Academy of Pediatrics.
Lead Exposure: Steps to Protect Your Family.
(2021) https://www.healthychildren.org/English/safety-prevention/all-around/P.... Accessed on 4/1/2023.

Atkinson RL.
Human adenovirus-36 and childhood obesity.
Int J Pediatr Obes. 2011;6 Suppl 1:2-6. PubMed abstract

Cantor A, Hendrickson R, Blazina I, Griffin J, Grusing S, McDonagh M.
Screening for Elevated Blood Lead Levels in Children: A Systematic Review for the U.S. Preventive Services Task Force.
Agency for Healthcare Research and Quality. 174; October 2018. / https://www.uspreventiveservicestaskforce.org/Home/GetFile/1/16900/lea...

Center for Disease Control.
Blood Lead Levels in Children.
Center for Disease Control and Prevention; (2018) https://www.cdc.gov/nceh/lead/docs/lead-levels-in-children-fact-sheet-.... Accessed on 4/4/2023.

Centers for Disease Control and Prevention.
Guidelines for the Identification and Management of Lead Exposure in Pregnant and Lactating Women.
Center for Disease Control and Prevention; (2010) https://www.cdc.gov/nceh/lead/publications/leadandpregnancy2010.pdf. Accessed on 3/24/2023.

Centers for Disease Control and Prevention.
Blood lead levels in children aged 1-5 years - United States, 1999-2010.
MMWR Morb Mortal Wkly Rep. 2013;62(13):245-8. PubMed abstract / Full Text

Centers for Medicaid & CHIP Services.
CMCS Informational Bulletin: Coverage of Blood Lead Testing for Children Enrolled in Medicaid and the Children’s Health Insurance Program.
Centers for Medicare & Medicaid Services; (2018) https://www.medicaid.gov/federal-policy-guidance/downloads/cib113016.p.... Accessed on 4/4/2023.

Centers for Medicare & Medicaid Services.
Guide For States Interested in Transitioning to Targeted Blood Lead Screening for Medicaid - Eligible Children.
Centers for Medicare & Medicaid Services; (2012) https://www.medicaid.gov/medicaid/benefits/downloads/targetedleadscree.... Accessed on 4/4/2023.

Committee on Obstetric Practice.
Committee opinion No. 533: Lead screening during pregnancy and lactation.
Obstet Gynecol. 2012;120(2 Pt 1):416-20. PubMed abstract / Full Text
American College of Obstetricians and Gynecologists Committee Opinion.

Council on Environmental Health AAP.
Prevention of Childhood Lead Toxicity.
Pediatrics. 2016;138(1). PubMed abstract / Full Text
See correction for this article at PMID 28771419.

Council on Environmental Health AAP.
Prevention of Childhood Lead Toxicity.
Pediatrics. 2017;140(2). PubMed abstract / Full Text
Correction for the article "Prevention of Childhood Lead Toxicity" PMID 27325637.

Curry SJ, Krist AH, Owens DK, Barry MJ, Cabana M, Caughey AB, Doubeni CA, Epling JW Jr, Kemper AR, Kubik M, Landefeld CS, Mangione CM, Pbert L, Silverstein M, Simon MA, Tseng CW, Wong JB.
Screening for Elevated Blood Lead Levels in Children and Pregnant Women: US Preventive Services Task Force Recommendation Statement.
JAMA. 2019;321(15):1502-1509. PubMed abstract / Full Text

Daneshparvar M, Mostafavi SA, Zare Jeddi M, Yunesian M, Mesdaghinia A, Mahvi AH, Akhondzadeh S.
The role of lead exposure on attention-deficit/ hyperactivity disorder ‎in children: A systematic review.
Iran J Psychiatry. 2016;11(1):1-14. PubMed abstract / Full Text

Dickman J.
Children at Risk: Gaps in State Lead Screening Policies.
Safer Chemicals, Healthy Families; (2017) https://saferchemicals.org/wp-content/uploads/2017/01/saferchemicals.o.... Accessed on 11/15/2018.

Family Resources.
Lead Poisoning: Chelation Therapy.
Nationwide Childrens'; (2022) https://www.nationwidechildrens.org/family-resources-education/health-.... Accessed on 4/4/2023.

Kosnett MJ, Wedeen RP, Rothenberg SJ, Hipkins KL, Materna BL, Schwartz BS, Hu H, Woolf A.
Recommendations for medical management of adult lead exposure.
Environ Health Perspect. 2007;115(3):463-71. PubMed abstract / Full Text

Pediatric Environmental Health Specialty Units.
Recommendations on Medical Management of Childhood Lead Exposure and Poisoning.
American Academy of Pediatrics; (2013) https://www.pehsu.net/_Library/facts/medical-mgmnt-childhood-lead-expo.... Accessed on 4/4/2023.
PEHSU recommendations from the AAP