What is the next step in management for a 24-month-old child with developmental delay, lead level of 12 micrograms per deciliter (μg/dL), and risk factors for lead exposure?

From the Guidelines

The next step in management for this 24-month-old child with developmental delay and a blood lead level of 12 μg/dL is to retest the venous blood lead concentration within 1-3 months to verify that the lead concentration is not rising, and simultaneously, identify and eliminate the source of lead exposure in the child's environment through a home inspection and remediation of lead hazards. According to the guidelines from the American Academy of Pediatrics 1, for a blood lead level between 5-14 μg/dL, the recommended steps include retesting the venous blood lead concentration within 1-3 months, taking a careful environmental history to identify potential sources of exposures, and providing nutritional counseling related to calcium and iron. The child's developmental delay should also be addressed through comprehensive developmental assessment and appropriate interventions. It is essential to consider the potential sources of lead exposure, such as lead-based paint, contaminated soil, or water, and to take steps to reduce or eliminate these exposures, as outlined in the guidelines 1. Additionally, the child's iron sufficiency should be screened, and treatment provided per AAP guidelines, as iron deficiency can increase the absorption of lead 1. Follow-up blood lead level testing should be performed every 3 months until levels remain below 5 μg/dL for at least 6 months. The child should receive nutritional counseling to emphasize foods rich in calcium, iron, and vitamin C, which can help reduce lead absorption. Chelation therapy may be considered if the blood lead level is confirmed to be at or above 10 μg/dL, but the current guidelines do not recommend chelation therapy for a blood lead level of 12 μg/dL without confirmation of the level and assessment of the child's overall health and environmental exposure. The most recent and highest quality study on this topic is from 2016, and it emphasizes the importance of identifying and eliminating the source of lead exposure, as well as providing comprehensive care to address the child's developmental delay and nutritional needs 1.

From the Research

Developmental Delay and Lead Exposure

• The child's blood lead level is 12 μg/dL, which is above the recommended level of 10 μg/dL 2
• The child has risk factors for lead exposure and has achieved only the developmental milestone of an 18-month-old at 24 months of age

Chelation Therapy

• Chelation therapy is generally not indicated for children with blood lead concentrations of < 45 μg/dL 3, 2, 4
• Succimer, a lead chelator, has been shown to lower blood lead levels but does not improve cognitive, behavioral, or neuropsychological function in children with blood lead levels below 45 μg/dL 3, 4
• The use of chelation therapy in children with blood lead levels between 20 and 44 μg/dL has been found to have no neurodevelopmental benefits 3

Next Steps in Management

• Given the child's blood lead level of 12 μg/dL, chelation therapy may not be necessary 2
• Environmental measures to prevent exposure to lead should be taken, such as removing lead-based paint and reducing dust and soil exposure 3, 2
• The child's developmental delay should be addressed through other means, such as early intervention services and developmental therapy 3