How should patients exposed to lead‑containing house paint be evaluated and managed, including screening, blood lead level thresholds, environmental remediation, chelation therapy, and special considerations for children, adults, and pregnant women?

Evaluation and Management of Lead Exposure from House Paint

For patients exposed to lead-containing house paint, immediately obtain a blood lead level (BLL) and remove the patient from the contaminated environment, particularly if the home was built before 1978, with urgent action required for children, pregnant women, and anyone with BLL ≥10 μg/dL.

Initial Evaluation

Blood Lead Level Testing

• Obtain BLL immediately for all exposed individuals, as this is the primary diagnostic test for lead toxicity 1
• Children living in pre-1978 housing require blood lead screening, with those in homes built before 1960 at highest risk (67% contain lead hazards) 2
• Homes built 1940-1959 have 39-43% lead hazard prevalence, and homes built 1960-1977 have 8-11% prevalence 3, 2

Environmental History

• Document specific renovation, repair, and painting (RRP) activities, as these are major sources of acute lead exposure 4
• Identify deteriorated lead-based paint, lead-contaminated dust (the primary exposure pathway), and contaminated soil 3, 2
• Ask about window sanding/scraping (42% of RRP cases), removal of painted materials (29%), and other disturbance activities 4, 5
• Assess occupational lead exposure of all household members 3

Additional Testing

• Measure serum creatinine to identify chronic renal dysfunction, which increases risk from lead exposure 1
• Consider abdominal radiography for children with pica behavior 1

Management Based on Blood Lead Levels

BLL <5 μg/dL

• No specific action required 6
• Provide anticipatory guidance about avoiding future exposure 6

BLL 5-9 μg/dL

• Discuss health risks and implement exposure reduction measures 6
• Pregnant women must avoid any exposure at this level 6

BLL 10-19 μg/dL

• Implement quarterly blood lead monitoring 1, 6
• Discuss health risks and decrease exposure 6
• Initiate case management services and home inspection 3

BLL 20-29 μg/dL

• Remove from exposure if repeat BLL in 4 weeks remains ≥20 μg/dL 6
• Continue monthly monitoring until levels decline 1

BLL 30-79 μg/dL

• Immediate removal from exposure required 6
• Prompt medical evaluation and consultation for BLL >40 μg/dL 6
• Monthly BLL monitoring 1

BLL ≥80 μg/dL

• Urgent medical evaluation required 6
• Consider chelation therapy if symptomatic and/or BLL ≥100 μg/dL 1, 6
• Chelation is almost always warranted for BLL ≥100 μg/dL 1

Environmental Remediation

Critical Actions

• Stop all RRP activities immediately if ongoing, as these cause acute 3-6 fold increases in lead-contaminated dust (up to 100-fold at abated sites) 5
• Do not allow resident owners or tenants to perform RRP work, as 66% of lead exposure cases involved non-professional work 4
• Arrange professional lead-safe remediation using certified contractors 3

Home Assessment

• All homes built before 1978 must be presumed to contain lead-based paint hazards unless a licensed inspector has determined otherwise 3, 2
• Request lead testing reports from landlords (federally required) 3
• Conduct dust wipe testing to identify lead-contaminated areas 3
• Focus on windows, doors, and floors, as these friction/impact surfaces are major dust sources 5

Remediation Priorities

• Target deteriorated paint, lead-contaminated dust, and contaminated soil 3
• Ensure complete abatement of window units, as windows are high sources of lead-contaminated dust 5
• Implement effective clean-up to remove lead-bearing dust 5
• Maintain lead-safe housing through proper construction work practices 3

Special Population Considerations

Children

• Peak exposure risk occurs between 6-36 months of age due to mouthing behaviors and increased lead absorption 2
• Children with BLL >45 μg/dL require chelation therapy 1
• Screen for iron deficiency, which increases lead absorption 2
• Provide developmental monitoring, as cognitive dysfunction can occur even at low levels 1, 6

Pregnant Women

• Avoid any lead exposure that would result in BLL >5 μg/dL 3, 1, 6
• Remove from any lead exposure environment during pregnancy 6
• Provide calcium supplementation, especially important for women with past lead exposure 1
• Encourage breastfeeding for most women; address high-exposure cases individually 1

Adults

• Remove from occupational exposure if single BLL ≥30 μg/dL or repeat BLL ≥20 μg/dL over 4 weeks 3, 1
• Monitor for hypertension, renal dysfunction, cognitive effects, and reproductive problems at BLL <40 μg/dL 3, 6
• Chelation indicated only for symptomatic adults with BLL ≥70 μg/dL 1

Critical Pitfalls to Avoid

• Never perform traditional abatement without proper lead-safe practices, as this causes acute increases in both dust lead levels and children's BLLs 5
• Do not use chelation therapy for asymptomatic individuals with low BLLs 1, 6
• Do not rely on chelation as substitute for source removal—environmental remediation is the primary treatment 6
• Do not overlook continued monitoring after initial intervention, as neither traditional nor modified abatement practices resulted in long-term BLL reductions without proper follow-up 5
• Do not assume intact paint is safe—deterioration can occur, and lead-contaminated dust may already be present 3

Ongoing Surveillance

• Quarterly BLL measurements for levels 10-19 μg/dL 1, 6
• Semiannual BLL measurements when sustained levels <10 μg/dL 1, 6
• Annual blood pressure monitoring 6
• Periodic renal function assessment 1, 6
• Monitor for cognitive dysfunction, hypertension, and reproductive problems 1, 6