Pediatric emergency medicine trisk 3120 3120

anemia that results from a defect in hemoglobin synthesis. However, much of the
anemia seen in children with excess BLL may be caused by concurrent iron
deficiency. A moderately sensitive laboratory measure of lead effect on
hemesynthesis is the evaluation of erythrocyte protoporphyrin (EP), a heme
precursor. Moderately elevated EP levels are seen in iron deficiency, but levels
above 250 to 300 mcg/dL are almost always the result of chronic lead poisoning.
There is no safe threshold for lead exposure and the 97.5% for BLLs among
young U.S. children is 5 mcg/dL. The most important treatment for lead
poisoning is to remove the lead exposure from the child’s environment. The
asymptomatic child discovered to have a BLL in the 5 to 44 mcg/dL range,
warrants thorough environmental investigation for lead hazards, clinical and
nutritional evaluation, prudent follow-up by primary healthcare provider, and case
management to reduce lead exposure as expeditiously as possible. All
symptomatic children and those with BLL higher than 44 mcg/dL warrant urgent
treatment as outlined next.
The remainder of this discussion is addressed primarily to the early recognition
and treatment of plumbism, including acute lead encephalopathy. Though now
rare, this single manifestation of chronic childhood lead poisoning is highlighted
because it represents a true medical emergency.
The recognition of mildly symptomatic patients with lead poisoning (or
asymptomatic children with high lead levels, who are at great risk to soon become
symptomatic) requires a high index of suspicion. All children between 1 and 5
years of age are suspect if they have (i) persistent vomiting, listlessness or
irritability, clumsiness, or loss of recently acquired developmental skills; (ii)
afebrile convulsions; (iii) a strong tendency to pica, including a history of acute
exploratory ingestions or aural or nasal foreign body; (iv) a deteriorating preWorld War II house or a parent with industrial exposures; (v) a family history of
lead poisoning; (vi) iron-deficiency anemia; or (vii) evidence of child abuse or
neglect. Recent immigration is a risk factor.
The child between the ages of 1 and 5 years who comes to the ED with an
acute encephalopathy and the above-cited risk factors presents the physician with
a dilemma: lead intoxication requires urgent diagnosis, but confirmation with a

BLL is usually not available on an immediate basis. A constellation of historical
features increases the likelihood of lead poisoning. These features include (i) a
prodromal illness of several days’ to weeks’ duration (suggestive of mild
symptomatic plumbism); (ii) a history of pica; and (iii) a source of exposure to
lead. Several nonspecific laboratory findings make lead poisoning likely enough
to warrant presumptive chelation therapy until confirmation by lead levels is