Management of Childhood Lead Poisoning: A Survey

Published recommendations (1985) for the management of childhood lead poisoning suggest the use of ethylenediaminetetraacetic acid (EDTA)provocation testing and chelation as the mainstay of treatment for blood lead levels between 25 and 55 μg/dL. Since 1985 evidence has accumulated indicating that (1) levels of blood lead less than 25 μg/dL are detrimental to cognitive development, (2) EDTA provocation testing may result in potentially harmful shifts in the body lead burden, and (3) oral agents such as penicillamine and 2,3-dimercaptosuccinic acid are effective in reducing elevated lead levels. To determine how this evidence impacts on the management of childhood lead poisoning, the authors surveyed the lead poisoning clinics of pediatric departments in the cities estimated by the United States Public Health Service to have the largest number of children affected by lead poisoning. Thirty (70%) of 43 surveys were completed. Respondents indicated that the lowest blood lead level for which they would use a chelating agent to reduce the lead burden was as follows: 50 μg/dL (3%), 45 μg/dL (3%), 40μg/dL (13%) 35 μg/dL (3%), 30 μg/dL (27%), 25 μg/dL (47%) and 20μg/dL (3%). For all blood lead levels from 20 through 55 μg/dL, EDTA was the most frequently recommended chelating agent (chelation and provocation testing). Fifteen percent of responding lead clinics do not use the provocation test under any circumstances. For a child with a negative EDTA provocation test, the percentage of respondents recommending the use of any chelation therapy ranged from 16% for blood lead levels of 25 through 29μg/dL to 66% for levels of 50 through 55 μg/dL. Orally active chelating agents are used by fewer than one third of the responding lead clinics and were selected as the chelating agent of choice at all blood lead levels from 25 through 55 μg/dL by at least one respondent. The results of this survey indicate the following: (1) There is a wide range of blood lead levels for which chelation therapy is recommended. (2) The majority of children with elevated lead burdens are managed using EDTA. (3) The EDTA provocation test continues to be widely used. (4) The majority of children with blood lead levels of 25 through 44 μg/dL with negative provocation tests do not receive chelation therapy. (5) Orally active chelating agents are used in the minority of lead clinics. (6) No common approach for the treatment of lead toxicity appears to exist. (7) In the majority of pediatric centers, current management of blood lead elevation does not appear to reflect new information regarding the effects and treatment of lead poisoning.