An 18-month-old boy is brought to the office for a well-child visit. The family relocated to the area 5 months ago. The patient speaks 15-20 words and runs well. His diet has variety and includes whole milk, fruits, vegetables, and meat. He has no fatigue, vomiting, constipation, or abdominal pain. The patient has no chronic medical conditions and takes no daily medications. Vaccinations are up to date. He lives with his parents and 5-month-old sister in a home built in 1938 that is currently undergoing renovations. A lead level performed at age 12 months was 4 μg/dL (normal:

Question

An 18-month-old boy is brought to the office for a well-child visit. The family relocated to the area 5 months ago. The patient speaks 15-20 words and runs well. His diet has variety and includes whole milk, fruits, vegetables, and meat. He has no fatigue, vomiting, constipation, or abdominal pain. The patient has no chronic medical conditions and takes no daily medications. Vaccinations are up to date. He lives with his parents and 5-month-old sister in a home built in 1938 that is currently undergoing renovations. A lead level performed at age 12 months was 4 μg/dL (normal: <5). Examination shows a playful and active boy. Cardiac, pulmonary, and abdominal examinations are unremarkable. Capillary blood sample shows a hemoglobin level of 12 mg/dL and lead level of 35 μg/dL. Item 1 of 2 Which of the following is the best next step in management of this patient?

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Explanation: Lead toxicity is a preventable environmental hazard. Young children are particularly susceptible to lead intoxication due to oral exploration and greater propensity for absorption. Although the incidence of toxicity has declined since the 1970s due to lead removal from gasoline/paint and laboratory screening, homes that were built prior to 1978 still pose a risk (eg, lead-based paint, dust). Other risk factors include history of pica, low socioeconomic status, and foreign-born children. Screening at-risk children is commonly performed by capillary (fingerstick) testing, but elevated capillary results must be confirmed by a venous lead level due to the risk of contamination of capillary samples (eg, inadequate cleansing of the child's finger). Children with asymptomatic, mild intoxication (<45 μg/dL) require extensive counseling (eg, source identification, developmental testing) and close follow-up of lead levels. Chelation therapy (eg, succimer) is typically recommended for patients with a lead level >45 μg/dL (Choice A). (Choices B and E) A peripheral blood smear may show basophilic stippling (blue cytoplasmic granules within red blood cells) in patients with lead poisoning. In addition, because lead is stored in bone, x-ray may reveal an increased opacity at the metaphyseal growth plate ("lead lines"). Neither study is routinely indicated in the evaluation of lead poisoning, and the diagnosis should first be confirmed with a venous lead level. basophilic stippling ("lead lines") (Choice D) After venous blood confirmation of an elevated lead level, x-ray of the abdomen can be considered to evaluate for ingestion of radiopaque foreign bodies containing lead flecks. X-ray of the abdomen is unnecessary for an asymptomatic child with mild intoxication and without pica. Educational objective: Positive screening of an elevated lead level on capillary testing should be confirmed by a venous lead level. References: Lead poisoning in children. (http://www.ncbi.nlm.nih.gov/pubmed/20229974)

An 18-Month-Old Boy Is Brought to the Office for a Well-Child