Recommended Actions Based on Blood Lead Level

Summary of Recommendations for Follow-up and Case Management of Children Based on Initial Screening Capillary and Confirmed* Venous Blood Lead Levels

Initial Screening Capillary Blood Lead Level (BLL) – if the initial screening test is done using a venous sample, proceed to the next section titled, “Confirmed Venous Blood Lead Level.”

≥3.5 μg/dL micrograms per deciliter

  • Anticipatory guidance about common sources of lead exposure and how to prevent exposure
    • Common sources include paint in homes built prior to 1978, soil near sources of lead such as smelters, and take-home exposures related to adult occupations or hobbies. A full list of sources is available at Sources of Lead Exposure.
    • Exposure can be reduced by frequent washing of hands, especially before meals, and washing toys. For children living in or frequenting homes or structures built before 1978, reduce potential lead-based paint dust by wet-wiping windows and windowsills and wet-mopping floors, avoiding renovations that may create lead-based paint dust, and covering chipping or peeling paint to make it inaccessible.
  • Obtain a confirmatory venous sample for blood lead testing based on the schedule shown in Table 1, “Recommended Schedule for Obtaining a Confirmatory Venous Sample.”

Confirmed Venous Blood Lead Level (BLL) – an initial screening test using a venous sample or an initial screening capillary test followed by a venous blood sample.

< 3.5 μg/dL micrograms per deciliter

  • Anticipatory guidance about common sources of lead exposure and how to prevent exposure
  • Routine assessment of developmental milestones and nutritional status with a focus on iron and calcium intake
  • Follow-up blood lead testing at recommended intervals based on child’s age
    • All Medicaid-enrolled children are required to be tested at ages 12 and 24 months, or at age 2472 months if they have not previously been screened.
    • For children not enrolled in Medicaid, CDC recommends targeted screening efforts to focus on high-risk neighborhoods and children based on age of housing and sociodemographic risk factors. Public health and clinical professionals should collaborate to develop screening plans responsive to local conditions using local data. In the absence of such plans, universal blood lead testing is appropriate. 

3.5–19 μg/dL micrograms per deciliter

  • Follow recommendations for BLL < 3.5 μg/dL as described above.
  • Report test result to state or local health department.
  • Environmental exposure history to identify potential sources of lead
  • Environmental investigation of the home to identify potential sources of lead, as required**
  • Ensure iron sufficiency via testing and treatment per AAP guidelinesexternal icon.
  • Nutritional counseling related to calcium and iron intake and refer to supportive services, as needed (e.g., Special Supplemental Nutrition Program for Women, Infants and Children (WIC), etc.)
  • Assess development per AAP guidelinesexternal icon and refer to supportive services, as needed (e.g., developmental subspecialists, Early Intervention Program (EIP), etc.)
  • Follow-up blood lead monitoring at recommended intervals according to the schedule shown in Table 2, “Schedule for Follow-Up Blood Lead Testing”

20–44 μg/dL micrograms per deciliter

  • Follow recommendations for BLL 3.5-19 μg/dL as described above.
  • Complete history and physical exam assessing for signs and symptoms related to lead
  • Environmental investigation of the home and lead hazard reduction
  • Consider obtaining an abdominal X-ray to evaluate for lead-based paint chips and other radiopaque foreign bodies, especially in children in whom pica or mouthing of lead-contaminated surfaces is a concern; initiate bowel decontamination if indicated.
  • Contact a Pediatric Environmental Health Specialty Unit (PEHSU) or poison control center for guidance.

≥45 μg/dL micrograms per deciliter

  • Follow recommendations for BLL 20-44 μg/dL as described above.
  • Complete history and physical exam including detailed neurological exam
  • Obtain abdominal X-ray and initiate bowel decontamination if indicated.
  • If the patient exhibits signs or symptoms of lead poisoning, emergently admit them to a hospital.
  • If a lead-safe environment cannot be assured or if chelation therapy is being considered in consultation with a PEHSU or poison control center, admit the patient to a hospital.
  • Contact a Pediatric Environmental Health Specialty Unit (PEHSU) or poison control center for assistance.

μg/dL: micrograms per deciliter

*Confirmed BLL: capillary screening results equal to or greater than the BLRV should be confirmed with blood drawn by venipuncture (see Table 1 below, “Recommended Schedule for Obtaining a Confirmatory Venous Sample”). Confirmatory testing is not required when an initial screening test is performed using a venous sample.

** Environmental investigations at BLLs 3.5–19 μg/dL vary based on jurisdictional requirements and available resources.

Table 1: 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
≥3.5–9 Within 3 months*
10–19 Within 1 month*
20–44 Within 2 weeks*
≥45 Within 48 hours*

*The higher the BLL on the initial screening capillary test, the more urgent the need for confirmatory testing using a venous sample.

Table 2: 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
≥3.5–9 3 months* 6–9 months
10–19 1–3 months* 3–6 months
20–44 2 weeks–1 month 1–3 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