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Recommended Actions Based on Blood Lead Level

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

Blood Lead Level (BLL)

<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

Anticipatory guidance about common sources of lead exposure

Follow-up blood lead testing at recommended intervals based on child’s age

Routine assessment of nutritional and developmental milestones

Environmental assessment** including detailed history to identify potential sources of lead exposure

 

Nutritional counseling related to calcium and iron intake

Follow-up blood lead testing at recommended intervals based on child’s age

Routine assessment of nutritional and developmental milestones

Environmental investigation** including home visit to identify potential sources of lead exposure

Nutritional  counseling related to calcium and iron intake; consider lab work to assess iron status

Follow-up blood lead monitoring at recommended intervals

Complete history and physical exam

Neurodevelopmental assessment

Environmental investigation and lead hazard reduction

Lab work:

  • Iron status
  • Hemoglobin or hematocrit

Abdominal X-ray (with bowel decontamination if indicated)

Follow-up blood lead monitoring at recommended intervals

Complete history and physical exam

Complete neurological exam including neuro-developmental assessment

Environmental investigation and lead hazard reduction

Lab work:

  • Iron status
  • Hemoglobin or hematocrit

Abdominal X-ray with bowel decontamination if indicated

Oral chelation therapy; consider hospitalization, if lead-safe environment cannot be assured

Follow-up blood lead monitoring at recommended intervals

Hospitalize and commence chelation therapy in conjunction with consultation with a medical toxicologist or a pediatric environmental health specialty unit

Proceed with additional actions according to interventions for BLLs between 45-69 μg/dL

μg/dL: micrograms per deciliter

*Confirmed BLL: One venous blood test or two capillary blood lead tests drawn within 12 weeks of each other (see Recommended Schedule for Obtaining a Confirmatory Venous Sample below).

** Environmental assessments and investigations vary according to local conditions based on jurisdictional requirements and available resources

 

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

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
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