Exposure to Lead
Publication Date: October 27, 2021
Last Updated: March 14, 2022
Blood lead concentration that should initiate clinical intervention
In all cases of suspected or confirmed lead exposure the patient or carer should be given information about potential sources of lead exposure, methods for reducing continuing exposure and the importance of good nutrition, in particular adequate dietary intake of iron and calcium. (GPS)
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For an individual with a blood lead concentration ≥ 5 μg/dL, the source(s) of lead exposure should be identified and appropriate action taken to reduce and terminate exposure. (S)
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Gastrointestinal decontamination after ingestion of a lead foreign body or other lead-containing material
Take measures to remove solid lead objects, such as a bullets, lead pellets, jewellery, fishing or curtain weights, that are known to be in the stomach. (S)
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Consider whole bowel irrigation (WBI) for removing solid lead objects, such as a bullets, lead pellets, jewellery, fishing or curtain weights, that are known to have passed through the stomach. (C)
Remarks
If WBI fails, i.e. the object or objects are not removed, and there is evidence of lead absorption, e.g. an increasing blood lead concentration or features of lead toxicity, consider endoscopic or surgical removal.
If WBI fails, i.e. the object or objects are not removed, and there is evidence of lead absorption, e.g. an increasing blood lead concentration or features of lead toxicity, consider endoscopic or surgical removal.
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Consider surgical removal of solid lead objects, such as a bullets or lead pellets, that are known to be in the appendix if the patient shows clinical signs of appendicitis or an increasing blood lead concentration.
(C)
(C)
Remarks
If the patient is clinically well, surgical removal is not necessary, but the blood lead concentration should be measured periodically to check for lead absorption. Treatment options should be reviewed if the patient becomes symptomatic or if the blood lead concentration starts rising.
If the patient is clinically well, surgical removal is not necessary, but the blood lead concentration should be measured periodically to check for lead absorption. Treatment options should be reviewed if the patient becomes symptomatic or if the blood lead concentration starts rising.
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Consider WBI for removing liquid or solid lead-containing substances, such as paint chips, lead-containing complementary or alternative medicines, or ceramic glaze, when this material is known to be dispersed in the gut. (C)
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Nutritional interventions in children and pregnant and lactating women exposed to lead
Children ≤ 10 years of age
For a child (≤ 10 years) with a blood lead concentration ≥ 5 μg/dL who has, or is likely to have, inadequate calcium intake, administration of calcium supplementation is recommended. (S)
Remarks
The dose should be sufficient to ensure that the total calcium intake meets the national age-appropriate recommended nutrient intake value.
The dose should be sufficient to ensure that the total calcium intake meets the national age-appropriate recommended nutrient intake value.
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For a child (≤ 10 years) with a blood lead concentration of ≥ 5 μg/dL who has, or is likely to have iron-deficiency, administration of iron supplementation is recommended. (S)
Remarks
The dose should be in line with WHO guidelines (22, 23) or standard clinical practice.
The dose should be in line with WHO guidelines (22, 23) or standard clinical practice.
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Pregnant women
For a pregnant woman with a blood lead concentration of ≥ 5 μg/dL, who has, or is likely to have, inadequate calcium intake, administration of calcium supplementation is recommended.
(S)
(S)
Remarks
The dosage should be sufficient to bring the total calcium intake to national guidelines for calcium in pregnant women or to the WHO/FAO recommended nutrient intake value (1.2 g) (24). This should be given as soon as the pregnancy is recognized, for the duration of the pregnancy.
The dosage should be sufficient to bring the total calcium intake to national guidelines for calcium in pregnant women or to the WHO/FAO recommended nutrient intake value (1.2 g) (24). This should be given as soon as the pregnancy is recognized, for the duration of the pregnancy.
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Lactating women
Initiation or continuation of calcium supplementation is suggested for lactating women who have a blood lead concentration of ≥ 5 μg/dL. This should be for the duration of lactation. (C)
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Chelation therapy in individuals exposed to lead
Children ≤ 10 years of age
For a child (≤ 10 years) with a blood lead concentration ≥ 45 μg/dL, oral or parenteral chelation therapy is recommended. (S)
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For a child (≤ 10 years) with a blood lead concentration of 40–44 μg/dL, when there is doubt about the accuracy of the measurement, a persistently elevated blood lead concentration in spite of measures to stop exposure or significant clinical features of lead poisoning, oral chelation therapy should be considered. (C)
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For a child ≤ 10 years with a blood lead concentration ≥ 70 μg/dL, there should be close monitoring for signs of clinical deterioration, including regular neurological assessments, during and after chelation therapy while the concentration remains high. (GPS)
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For a child (≤ 10 years) with lead encephalopathy, urgent hospital admission and parenteral chelation therapy are recommended. (S)
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Non-pregnant adolescents (11–18 years) and adults (≥ 19 years) with blood lead concentration 45–70 μg/dL
For a non-pregnant adolescent girl or woman of child-bearing age who has a blood lead concentration of 45–70 μg/dL but who does not show clinical features of lead poisoning, oral chelation therapy should be considered. (C)
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For a male patient aged ≥ 11 years or a woman who is no longer of child-bearing age who has a blood lead concentration of 45–70 μg/dL but who does not show clinical features of lead poisoning, chelation therapy is not indicated. The patient should, however, be re-evaluated within 2–4 weeks to ensure that the blood lead concentration is decreasing and the patient remains well. (C)
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For a non-pregnant adolescent or adult with a blood lead concentration of 45–70 μg/dL and who has mild–moderate clinical features of lead poisoning (such as abdominal pain, constipation, arthralgia, headache, lethargy), chelation therapy is suggested. (C)
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Non-pregnant adolescents (11–18 years) and adults (≥ 19 years) with blood lead concentrations of > 70–100 μg/dL
An adolescent or an adult with a blood lead concentration > 70–100 μg/dL should be closely monitored for signs of clinical deterioration, regardless of whether chelation therapy is given. (GPS)
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For a non-pregnant adolescent or an adult with a blood lead concentration > 70–100 μg/dL but who does not show significant neurological features of toxicity, chelation therapy is suggested. (C)
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For a non-pregnant adolescent or adult with a blood lead concentration > 70–100 μg/dL and with significant neurological features of lead toxicity (e.g. irritability, drowsiness, ataxia, convulsions, coma) or lead encephalopathy, urgent parenteral chelation therapy is recommended. (S)
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Pregnant women
For a pregnant woman with lead encephalopathy, regardless of trimester, urgent chelation therapy is recommended. The preferred chelating agent depends on the stage of the pregnancy and available data on safety of use in pregnancy. (S)
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For a pregnant woman with a blood lead concentration ≥ 45 μg/dL, with or without clinical features of lead poisoning, but without lead encephalopathy:
i. in the first trimester: the guideline development group could not make a recommendation because of an uncertain balance of risks and benefits. (U)
i. in the first trimester: the guideline development group could not make a recommendation because of an uncertain balance of risks and benefits. (U)
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For a pregnant woman with a blood lead concentration ≥ 45 μg/dL, with or without clinical features of lead poisoning, but without lead encephalopathy: in the second or third trimester: chelation therapy is recommended. (S)
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Recommendation Grading
Overview
Title
Exposure to Lead
Authoring Organization
World Health Organization
Publication Month/Year
October 27, 2021
Last Updated Month/Year
April 1, 2024
Document Type
Guideline
Country of Publication
US
Document Objectives
The purpose of the WHO Guideline for clinical management of exposure to lead is to assist physicians in making decisions about the diagnosis and treatment of lead exposure for individual patients and in mass poisoning incidents.
Inclusion Criteria
Male, Female, Adolescent, Adult, Child, Infant, Older adult
Health Care Settings
Ambulatory, Emergency care, Hospital
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management, Prevention
Diseases/Conditions (MeSH)
D011041 - Poisoning, D007855 - Lead Poisoning, D000075322 - Heavy Metal Poisoning
Keywords
lead, lead exposure, mass poisoning
Source Citation
WHO guideline for clinical management of exposure to lead [Internet]. Geneva: World Health Organization; 2021. PMID: 34787987.