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Case Study 2

A 5 year-old boy presents to your clinic with his mother complaining of headaches. His mother complains that he has been hyperactive within the last few months and that his kindergarten teacher related to her that he is having trouble concentrating.

Family members have no history of headaches. His last visit to your office was 3 months ago for a pre-kindergarten physical. All results were documented as normal, except hearing acuity, which was below normal. He has NKA, is up to date on his immunizations and is not taking any medications. Physical exam in your office today is normal. Lab tests show a diminished hematocrit at 30%. There is no evidence of blood loss and occult blood is negative.

What are the relevant questions in the exposure history for this child?

Answer:

Testing:
Blood lead testing was ordered due to the client’s possible exposure from the paint removal and his mother’s hobby. The physician also ordered lead testing on his mother and younger sister.

Results were as follows:
5 year-old boy 18 ug/dL
Mother 16 ug/dL
1 year-old sister 20 ug/dL

Both the children and their mother have lead levels, which may be associated with adverse health effects. Testing for anemia is also appropriate.

Treatment:
The first step in treatment includes removing the children from the exposure (in this case the home) while cleaning up the source of the lead exposure. The source of the lead exposure (i.e. lead pipes, lead paint, hobbies, occupational exposure) will determine the course of action in resolving/reducing the exposure. The Lincoln-Lancaster County Health Department’s Childhood Lead Poisoning Prevention Program (CLPPP) can advise your client/client’s family on appropriate clean-up/abatement measures.

Children are more susceptible to lead toxicity than adults. Children’s unique physiology and behavior can influence the extent of their exposure. Health effects that have been associated with lead exposures during infancy or childhood include: anemia, renal impairment, colic, impaired metabolism of vitamin D, delays in the development of the neurological system, neurological impairment (i.e. encephalopathy), neurobehavioral deficits including IQ deficits, growth retardation, low birth weight and low gestational age. Damage from exposure to lead can begin in utero, in infancy or during childhood but may not be evident until a later stage of development.

Diet is important in the prevention of lead toxicity. A diet with adequate amounts of calcium, zinc, and iron may decrease the absorbed dose of lead. Children from lower socioeconomic means can be at particularly high risk for nutritional deficiencies and lead toxicity. Methods for reducing the toxicity of absorbed lead at high levels include the injection or oral administration of chelating agents such as British Anti-Lewisite (or BAL), CaNa2-EDTA (or EDTA), and 2,3-Dimercaptosuccinic acid (or Succimer). The preferred chelating agent and the treatment regimen depend on the nature of the intoxication (i.e., the symptomology present and the blood lead level). A physician experienced in chelation therapy should be consulted. Case management and retesting is recommended based on initial blood lead levels and exposure history. The Lincoln-Lancaster County Health Department’s Childhood Lead Poisoning Prevention Program (CLPPP) provides medical case management, outreach/follow-up, education, referral, and can advise your client/client’s family on timelines for retesting blood lead levels according to their specific risk/prior blood lead level.

Further information can be accessed on the worldwide web at http://www.cdc.gov/nceh/lead/guide/guide97.htm. Chapter four of this PDF file is entitled “Roles of Child Health-Care Providers in Childhood Lead Poisoning Prevention”.

References:
Environmental Health in Family Medicine on CD-ROM. Available from the International Joint Commission 234 Laurier Ave. W. 22nd Fl., Ottawa K1P 6K6 or by email request to: houstononj@ottawa.ijc.org

Agency for Toxic Substances and Disease Registry. (1999). Toxicological profile for lead. [On-Line]. Available: http://www.atsdr.cdc.gov/toxprofiles/tp13.pdf.

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