Recommended Actions Based on Blood Lead Level

Blood Lead Level (BLL)
Summary of Recommendations for Follow-up and Case Management of Children Based on Confirmed* Blood Lead Levels
<5 μg/dL 5–9 μg/dL 10–19 μg/dL 20–44 μg/dL 45–69 μg/dL ≥70 μg/dL
Routine assessment of nutritional and developmental milestones Routine assessment of nutritional and developmental milestones Routine assessment of nutritional and developmental milestones Complete history and physical exam with neurodevelopmental assessment Complete history and physical exam with neurodevelopmental assessment and complete neurological exam

 

Hospitalize and commence chelation therapy in conjunction with consultation with a medical toxicologist or a pediatric environmental health specialty unit
Anticipatory guidance about common sources of lead exposure Environmental exposure history to identify potential sources of lead -and-

environmental investigation of the home to identify potential sources of lead, as required**

Environmental exposure history to identify potential sources of lead-and-

environmental investigation of the home to identify potential sources of lead

Environmental investigation of the home and lead hazard reduction Environmental investigation of the home and lead hazard reduction

 

Environmental investigation of the home and lead hazard reduction; child receiving chelation therapy should not return to home until lead hazard remediation is completed
Follow-up blood lead testing at recommended intervals based on child’s age according to schedule below Follow-up blood lead monitoring at recommended intervals according to schedule below Follow-up blood lead monitoring at recommended intervals according to schedule below Follow-up blood lead monitoring at recommended intervals according to schedule below Follow-up blood lead monitoring at recommended intervals according to schedule below Follow-up blood lead monitoring at recommended intervals according to schedule below
Nutritional counseling related to calcium and iron intake Nutritional counseling related to calcium and iron intake; consider lab work to assess iron status Lab work:
‒ Iron status
‒ Hemoglobin or hematocrit
Lab work:
‒ Iron status
‒ Hemoglobin or hematocrit
Lab work:
‒ Iron status
‒ Hemoglobin or hematocrit
Abdominal X-ray (with bowel decontamination if indicated) Abdominal X-ray (with bowel decontamination if indicated) Abdominal X-ray (with bowel decontamination if indicated)
Oral chelation therapy may be considered in consultation with a medical toxicologist or a pediatric environmental health specialty unit; consider hospitalization, if lead-safe home environment cannot be assured

μg/dL: micrograms per deciliter

*Confirmed BLL: elevated capillary screening results should be confirmed with blood drawn by venipuncture
(see Recommended Schedule for Obtaining a Confirmatory Venous Sample below).

References:

  1. Binns HJ, Campbell C, Brown MJ, for the Advisory Committee on Childhood Lead Poisoning Prevention. Interpreting and Managing Blood Lead Levels of Less Than 10 µg/dL in Children and Reducing Childhood Exposure to Lead: Recommendations of the Centers for Disease Control and Prevention Advisory Committee on Childhood Lead Poisoning Prevention. Pediatrics 2007 Nov;120(5): e1285. www.pediatrics.org/cgi/doi/10.1542/peds.2005-1770external icon
  2. Caldwell KL, Cheng PY, Jarrett JM, Makhmudov A, Vance K, Ward CD, Jones RL, Mortensen ME. Measurement Challenges at Low Blood Lead Levels. Pediatrics 2017 Aug;140(2): e0272. www.pediatrics.org/cgi/doi/10.1542/peds.2017-0272external icon
  3. The Clinical & Laboratory Standards Institute (CLSI) Guidelines #C40: Measurement Procedures for the Determination of Lead Concentrations in Blood and Urine, 2nd Edition (October 2013). https://clsi.org/standards/products/clinical-chemistry-and-toxicology/documents/c40/external icon

** Environmental investigations at BLLs 5–19 μg/dL vary according to local conditions based on jurisdictional requirements and available resources

Recommended Schedule for Obtaining a Confirmatory Venous Sample

Recommended Schedule for Obtaining a Confirmatory Venous Sample
Blood Lead Level (μg/dL) Time to Confirmation Testing
≥5–9 1–3 months
10–44 1 week–1 month*
45–59 48 hours
60–69 24 hours
≥70 Urgently as emergency test

*The higher the BLL on the screening test, the more urgent the need for confirmatory testing.

Schedule for Follow-Up Blood Lead Testinga

Schedule for Follow-Up Blood Lead Testing
Venous Blood lead Levels (µg/dL) Early follow up testing (2-4 tests after identification) Later follow up testing after BLL declining
≥5–9 3 months* 6–9 months
10–19 1–3 months* 3–6 months
20–24 1–3 months* 1–3 months
25–44 2 weeks–1 month 1–months
≥45 As soon as possible As soon as possible

aSeasonal variation of BLLs exists and may be more apparent in colder climate areas. Greater exposure in the summer months may necessitate more frequent follow ups.
*Some case managers or healthcare providers may choose to repeat blood lead tests on all new patients within a month to ensure that their BLL level is not rising more quickly than anticipated.

References:

The following actions are NOT recommended at any BLL:

  • Searching for gingival lead lines
  • Testing of neurophysiologic function
  • Evaluation of renal function (except during chelation with EDTA)
  • Testing of hair, teeth, or fingernails for lead
  • Radiographic imaging of long bones
  • X-ray fluorescence of long bones