| No level of lead in the blood is safe. In 2021, the CDC established a new "reference value" for BLLs (3.5 mcg/dL [0.17 micromol/L]), thereby lowering the level at which evaluation and intervention are recommended. |
| Lead level | Recommendation* |
| <3.5 mcg/dL | - Review lab results with family/caregivers. For reference, the geometric mean BLL for children 1 to 5 years old is less than 1 mcg/dL (0.05 micromol/L).
- Repeat the BLL in 6 to 12 months if the child is at high risk or risk changes during the timeframe. Ensure levels are done at 1 and 2 years of age.
- For children screened at age <12 months, consider retesting in 3 to 6 months because lead exposure may increase as mobility increases.
- Perform routine health maintenance including assessment of nutrition, physical and mental development, and iron deficiency risk factors.
- Provide anticipatory guidance on common sources of environmental lead exposure (eg, paint in homes built prior to 1978, lead-contaminated tap water, soil near roadways or other sources of lead, take-home exposures related to adult occupations, imported spices, cosmetics, folk remedies, and cookware).
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| 3.5 to 14 mcg/dL | - Perform steps as described above for levels <3.5 mcg/dL (0.17 micromol/L).
- Re-test venous BLL within 1 to 3 months to ensure the lead level is not rising. If it is stable or decreasing, retest the BLL in 3 months. Refer patient to local health authorities if such resources are available. In the United States, most jurisdictions require elevated BLLs be reported to the state health department. Contact the CDC at 800-CDC-INFO (800-232-4636), the National Lead Information Center at 800-424-LEAD (5323), or the national PEHSU network for resources regarding lead poisoning prevention and local childhood lead poisoning prevention programs.
- Take a careful environmental history to identify potential sources of exposures (see #5 above) and provide preliminary advice about reducing/eliminating exposures. Take care to consider other children who may be exposed.
- Provide nutritional counseling related to calcium and iron. In addition, recommend having fruit at every meal as iron absorption quadruples when taken with Vitamin C-containing foods. Encourage the consumption of iron-enriched foods (eg, cereals, meats). Some children may be eligible for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) or other nutritional counseling.
- Ensure iron sufficiency with adequate laboratory testing (CBC, Ferritin, CRP) and treatment per AAP guidelines.
- Perform structured developmental screening evaluations at child health maintenance visits, as lead's effect on development may manifest over years.
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| 15 to 44 mcg/dL | - Perform steps as described above for levels 3.5 to 14 mcg/dL (0.17 to 0.68 micromol/L).
- Confirm the BLL with repeat venous sample within 1 to 2 weeks or more rapidly for higher levels.
- Additionally, specific evaluation of the child (eg, a plain abdominal radiograph) should be considered based on the environmental investigation and history (eg, pica for paint chips, mouthing behaviors). Gut decontamination using whole-bowel irrigation is suggested if leaded foreign bodies are visualized on radiograph. Any treatment for BLLs in this range should be done in consultation with an expert.
- Contact local PEHSU or PCC for guidance.
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| >44 mcg/dL | - Follow guidance for BLL 15 to 44 mcg/dL (0.72 to 2.13 micromol/L) as listed above.
- Confirm the BLL with repeat venous lead level. Timing of repeat BLL is determined by whether symptoms of lead poisoning are present and the height of the initial BLL.
- Perform chelation therapy (managed with the assistance of an experienced provider). Hospitalize patients in whom lead-safe housing cannot be assured and all patients with BLL >69 mcg/dL (3.33 micromol/L). Safety of the home with respect to lead hazards, isolation of the lead source, family social situation, and chronicity of the exposure are factors that may influence management. Contact your regional PEHSU or PCC for assistance.
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