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. A venous blood sample confirms a lead level of 35 μg/dL.  The parents are concerned about potential consequences of lead toxicity.  Which of the following complications is this child at greatest risk of developing?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c017_1057_8f63_c713d108f6c0_MD0005_00 At-risk children should be screened for lead toxicity, as most patients with toxic levels are asymptomatic. Levels as low as 10-20 μg/dL are associated with cognitive impairment and behavioral problems (eg, attention-deficit hyperactivity disorder) that may not manifest until school initiation. Cognitive deficits can persist throughout childhood and beyond adolescence. Chelation therapy has not been shown to improve neuropsychiatric outcomes in children with lead levels of 5-44 μg/dL. Therefore, primary prevention is critical in avoiding long-term complications of lead intoxication, and all parents should be given education about sources of lead exposure (eg, lead-painted surfaces, soil, old toys). (Choice A) Acute encephalopathy (eg, altered mental status, seizures) typically occurs with very severe lead toxicity (>100 μg/dL) and does not present with moderately elevated levels (as in this patient). (Choice C) Although many children with lead intoxication may have concurrent iron-deficiency anemia, hemolytic anemia is rare and typically only occurs with severe toxicity (>70 μg/dL). (Choice D) Hepatotoxicity is an adverse side effect of several chelating agents, such as succimer and edetate calcium disodium (ethylenediaminetetraacetic acid [EDTA]), used in lead poisoning treatment. Gastrointestinal complications of lead poisoning include constipation and abdominal pain. (Choice E) Decreased nerve conduction has been shown to occur at low levels, but peripheral neuropathy is an uncommon complication in otherwise healthy children. Educational objective: Any child with an elevated lead level is at risk for long-term neurobehavioral impairment. Avoidance of lead exposure (primary prevention) is the only method for preventing permanent complications. References: A clinical study of the effects of lead poisoning on the intelligence and neurobehavioral abilities of children. (http://www.ncbi.nlm.nih.gov/pubmed/23414525)

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