A 2-year-old girl is brought to the office by her parents for a routine well-child visit. The patient speaks 100 words and can use 2-word phrases. She can go up and down stairs and draw a line. The patient takes no medications and has no allergies. Immunizations are up to date. She lives with her parents, grandparents, and 5-year-old brother in a home built in 2003. Height and weight are in the 50th percentile. Physical examination is normal. She is playing with brightly-painted wooden dolls on the floor of the examination room, and her mother says, "These dolls actually used to be her grandmother's when she was a child." Capillary blood collection shows a hemoglobin level of 11 g/dL and a lead level of 11 µg/dL (normal:

Question

A 2-year-old girl is brought to the office by her parents for a routine well-child visit.  The patient speaks >100 words and can use 2-word phrases.  She can go up and down stairs and draw a line.  The patient takes no medications and has no allergies.  Immunizations are up to date.  She lives with her parents, grandparents, and 5-year-old brother in a home built in 2003.  Height and weight are in the 50th percentile.  Physical examination is normal.  She is playing with brightly-painted wooden dolls on the floor of the examination room, and her mother says, "These dolls actually used to be her grandmother's when she was a child."  Capillary blood collection shows a hemoglobin level of 11 g/dL and a lead level of 11 µg/dL (normal: <5).  A venous lead level of 12 µg/dL is confirmed the next day.  In addition to education about lead exposure and toxicity prevention, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c017_ac98_8f63_0d6690bb47ad_MD0005_00 Risk factors for lead toxicity include pica, foreign-born children, homes built prior to 1978, and low socioeconomic status. Painted toys and decorations manufactured before 1976 or outside of the United States may be overlooked sources of lead, as seen in this case. Screening should be performed for all at-risk children. A child with an elevated capillary (finger-stick) lead level requires confirmatory venous sampling. Lead poisoning is diagnosed when the venous blood lead level is ≥5 µg/dL. A detailed environment history should be obtained to identify all potential lead sources (eg, paint, soil, old toys), and the local and state public health departments should be notified. This child should also have an abdominal x-ray to evaluate for lead-containing objects/flecks given her exposure to painted toys. Once sources of exposure are removed, children with mild toxicity (5-44 µg/dL) should have a repeat venous blood level within 1 month. (Choice A) Chelation therapy (eg, calcium disodium edetate [EDTA], meso-2,3-dimercaptosuccinic acid [DMSA, succimer]) does not improve clinical outcomes at lead levels <45 µg/dL and is therefore not indicated for this child. (Choice C) Repeating a lead level in 1 year is appropriate for at-risk children with levels <5 µg/dL. This child's level is elevated and should be followed closely. (Choice D) A repeat blood level in 2 days is unnecessary as levels will not change significantly during this brief time. (Choice E) In patients with moderate lead toxicity (45-69 µg/dL), lead deposition on metaphyses of long bones may appear as "lead lines" (red arrows) on x-ray. Imaging is not routinely indicated as this finding does not change management. In addition, this patient only has mild lead toxicity. "lead lines" Educational objective: After identification and removal of lead sources, children with mild lead toxicity (5-44 µg/dL) should have a repeat venous blood lead level within 1 month to confirm that the value is not increasing. References: Lead poisoning in children. (http://www.ncbi.nlm.nih.gov/pubmed/25037135) Lead poisoning in children. (http://www.ncbi.nlm.nih.gov/pubmed/20229974)

A 2-Year-Old Girl Is Brought to the Office by Her