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Key Features

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  • Usually occurs insidiously in children younger than age 5 years

  • Most likely sources include

    • Flaking leaded paint

    • Artist's paints

    • Fruit tree sprays

    • Solder

    • Brass alloys

    • Home-glazed pottery

    • Fumes from burning batteries

    • Foreign country remedies

  • Only paint containing < 1% lead is safe for interior use (eg, furniture, toys)

  • Repetitive ingestions of small amounts of lead are far more serious than a single massive exposure

  • Toxic effects are likely to occur if more than 0.5 mg of lead per day is absorbed

  • In the United States, lead levels continue to decline and are more common abroad, so particular attention should be paid to immigrant and refugee populations or use of foreign remedies

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Clinical Findings

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  • Causes vague symptoms, including

    • Weakness

    • Irritability

    • Weight loss

    • Vomiting

    • Personality changes

    • Ataxia

    • Constipation

    • Headache

    • Colicky abdominal pain

  • Late manifestations consist of developmental delays, convulsions, and coma associated with increased intracranial pressure, which is a medical emergency

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Diagnosis

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  • Blood lead levels are used to assess the severity of exposure

  • A complete blood cell count and serum ferritin concentration should be obtained; iron deficiency increases absorption of lead

  • Glycosuria, proteinuria, hematuria, and aminoaciduria occur frequently

  • A normocytic, slightly hypochromic anemia with basophilic stippling of the red cells and reticulocytosis may be present

  • Lumbar punctures

    • Must be performed cautiously to prevent herniation

    • Cerebrospinal fluid (CSF) protein is elevated, and the white cell count usually is <100 cells/mL

    • CSF pressure may be elevated in patients with encephalopathy

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Treatment

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  • Refer to the CDC guidelines for the most up to date recommendations on lead treatment

  • Removing the source of exposure is the most important initial treatment to toxicity

  • Succimer

    • Approved for use in children and reported to be as efficacious as calcium edetate

    • Should be initiated in asymptomatic children who have blood lead levels over 45 μg/dL

    • Initial dose is 10 mg/kg (350 mg/m2) every 8 hours for 5 days.

    • Same dose is then given every 12 hours for 14 days

    • At least 2 weeks should elapse between courses

    • Blood lead levels increase somewhat (ie, rebound) after discontinuation of therapy

  • Courses of dimercaprol/BAL (300–450 mg/m2/d) and calcium sodium edetate/CaNa2EDTA (1000–1500 mg/m2/d) should be considered in symptomatic children or levels over 70 μg/dL

  • Encephalopathy associated with cerebral edema needs to be treated with standard measures; anticonvulsants may be needed

  • A high-calcium, high-phosphorus diet and large doses of vitamin D may remove lead from the blood by depositing it in the bones

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