UMEM Educational Pearls

Lead is a ubiquitous metal in the environment partly due to decades of using leaded gasoline (organic lead) and lead-based paint (inorganic lead). Outside of occupational exposure, children are disproportionately affected from environmental lead exposure.


Common route of exposure are:

  1. Ingestion (common in children): soil, water, lead-based paint chips, toys, certain folk remedies.
    • Absorption: adult: 3 – 10% vs. children: 40 – 50%
  2. Inhalation (mostly occupational exposure): lead dust
    • Absorption: 30 – 40%
  3. Dermal (minor): cosmetic products
    • Absorption: < 1%


Majority of the absorbed lead are stored in bone (years) > soft tissue (months) > blood (30-40 days) (half-life). Thus blood lead level does not accurately reflect the true body lead burden.


Incidence of elevated blood lead level (EBLL > 5 microgram/dL) in children increased from 2.9 to 4.9% in Flint, MI before and after water source change. In the area with the highest water lead level, the incidence increased by 6.6%.


Clinical manifestation in children

Clinical severity

Typical blood lead level (microgm/dL)


  • CNS: encephalopathy (coma, seizure, altered sensorium, ataxia, apathy, incoordination, loss of developmental skills, cranial nerve palsy, signs of increased ICP
  • GI: persistent vomiting
  • Heme: anemia

> 70 – 100

Mild to moderate

  • CNS: hyperirritable behavior, intermittent lethargy, decrease interest in play, “difficult” child
  • GI: intermittent vomiting, abdominal pain, anorexia

50 – 70


  • CNS: impaired cognition, behavior, balance, fine-motor coordination
  • Misc: impaired hearing or growth

> 10


Evaluation for lead poisoning

  1. Blood lead level (BLL)
  2. CBC: hypochromic microcytic anemia, basophilic stippling
  3. Imaging: abdominal XR – check for foreign bodies in GI tract; long-bone XR – lead lines


Management of children with EBLL

  1. Removal from exposure
  2. Environmental investigation/intervention (BLL: 15 - 44 ug/dL)
  3. Chelation
    • Asymptomatic (BLL: 45 – 69 ug/dL): Succimer (PO)
    • Symptomatic (BLL: > 70 ug/dL): Dimercaprol (IM) and CaNa2EDTA (IV)


  1. Dapul H, Laraque D. Lead poisoning in children. Advances in pediatrics 2014;61:313-333.
  2. Hanna-Attisah M. et al. Elevated blood lead levels in children associated with the Flint drinking water crisis: a spatial analysis of risk and public health response. AM J Public Health 2016;106:283-290.
  3. Goldfrank's Toxicologic Emergencies 10th ed.