TEXAS DEPARTMENT OF HEALTH 
GUIDELINES FOR 
THE DETECTION AND MANAGEMENT 
OF CHILDHOOD LEAD POISONING 
FOR 
PHYSICIANS AND HEALTH CARE PROVIDERS 
August 1994 GUIDELINES FOR THE DETECTION AND 
MANAGEMENT OF LEAD POISONING FOR 
PHYSICIANS AND HEALTH CARE PROVIDERS 
Texas Department of Health 
Bureau of Women and Children 
Children's Health Division 
Childhood Lead Poisoning Prevention Program TABLE OF CONTENTS 
Introduction 1 
Overview of the Effects of Lead 1 
Sources of Lead 2 
Screening 3 
Laboratory Analysis for Lead Screening 6 
Case Definition 7 
Diagnostic Evaluation 9 
Medical Management 11 
Treatment and Follow-up 16 
Community Intervention 17 
The Role of the Texas Department of Health 18 
Appendices 
A. Specimen Collection 20 
B. Parent Questionnaire 21 
C. Prevention of Lead Poisoning: Advice to Parents 26 
D. Industries With Moderate to High Priority for Occupational Lead Exposure 28 
E. Folk Remedies/Medicines Which May Be Dangerous 30 
F. Questionnaire to Providers 31 
G. CLPPP Resources 32 
Bibliography 35 INTRODUCTION 
Childhood lead poisoning is one of the most common and preventable pediatric health 
problems in the United States today. Children are particularly susceptible to lead's toxic 
effects. The Agency for Toxic Substances and Disease Registry estimated that in 1984, 17 
percent of all American preschool children had blood lead levels exceeding 15 ug/dL. 
Because of evidence showing adverse effects at low blood lead levels, new guidelines 
from the Centers for Disease Control have changed the definition of lead poisoning to 
a blood lead level greater than or equal to 10 ug/dL. 
Currently in Texas, approximately 190,000 EPSDT screenings are provided annually through the efforts of local 
health departments, private physicians and other health service providers. Approximately 15,000 patients were 
identified with elevated (> 10 ug/dL) blood lead levels in 1993. 
Lead poisoning is a public health problem of continuing importance. Our understanding of it has evolved over 
the past two decades. In the early 1970's, physicians struggled to save critically ill children with this problem. 
Some died of lead poisoning, and the survivors were left with severe mental retardation. The medical community 
responded by developing improved diagnostic tests and treatment. Public health advocates pushed for crucial 
legislation that decreased the amount of lead in gasoline, new paint, metal solder, and pipes in plumbing. As 
a result, few children suffer from the effects of lead encephalopathy, but, unfortunately, since a great deal of 
leaded paint exists in older housing, thousands are exposed to lower doses of lead which results in subtle but 
serious problems. 
OVERVIEW OF THE EFFECTS OF LEAD 
There is no biologic function or need for lead. There is no such thing as a "normal'1 
lead level, only that level which we are willing to tolerate. 
Lead is a toxic substance that injures children starting even before birth. It can damage the central nervous 
system, the peripheral nervous system, the hematopoietic system, regulation of vitamin D, and the kidneys. Very 
high levels of lead can cause seizures, coma and death. If the child survives, he/she may have severe mental 
retardation. With lower lead levels, a child may suffer from developmental delay, a lower IQ, hyperactivity, 
learning disabilities, behavioral problems, impaired hearing, and stunted growth. Much of the damage to the 
brain is irreversible. 
Recent research suggests blood lead levels as low as 10 ug/dL, which do not cause distinctive symptoms, are 
associated with decreased intelligence and slowed neurobehavioral development. Other effects may result from 
low blood lead levels. Fetal lead exposure has been shown to decrease stature and affects the ability to maintain 
steady posture. The effects of lead on decreased hearing acuity have no apparent threshold. 
Lead's impairment of the biosynthesis of the active vitamin D metabolite is detectable at blood lead levels of 10 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
TDH, Fall 1994 
ug/dL to 15 ug/dL. It has been shown that lead poisoned children have lower serum total and ionized calcium 
levels. Maternal cord blood lead levels of 10 to 15 ug/dL appear to be associated with reduced gestational age 
and reduced weight at birth. 
SOURCES OF LEAD 
Lead-based paint and lead-contaminated dusts remain the primary sources of lead exposure for children. 
Nationwide, lead remains in approximately 74 percent of all private housing units built before 1978, Housing 
built before 1950 is at even greater risk of having interior lead-based paint. Household dust may also contain 
significant amounts of lead. This lead is in a much more absorbable form. Children can swallow it by chewing 
or sucking dusty toys and fingers. Lead-burdened dust may also be inhaled. Lead in dust is increased after older 
paint has been disturbed. Children and pregnant women should never be allowed to remain in a house that 
is undergoing renovation to correct a lead problem. 
Other sources of lead are less prevalent. However, several low level sources together can accumulate 
significantly. Lead can be found in water and soil. 
Lead in water is a less frequent but significant source. Water pipes and especially the solder that connects them 
may contain lead. If lead in plumbing is suspected, water from a hot water tap should not be used for drinking 
or food preparation until the problem is eliminated. The cold water tap should be flushed for several minutes 
each morning or until there is a noticeable change in temperature of the water before any water is consumed. 
Lead in soil is also a cause of poisoning. Lead may have been deposited in soil from leaded gasoline, lead paint 
dust and industries using lead. Food grown in city gardens may be contaminated with lead from the soil. 
Children's outside play areas may be contaminated with lead from air pollution and paint from the outside of 
buildings. Outside play areas should be located away from houses and buildings and away from areas that could 
have been contaminated by heavy traffic. 
Lead in food has been dramatically reduced due to voluntary reduction of its use by food manufacturers. Lead 
solder is much less commonly used for canned foods. However, it is important to transfer the food from opened 
cans into glass or plastic containers immediately. Metal cans with dented seams should be discarded without 
opening. Recent information notes that some bread wrappers are printed with lead based paint. Bread 
wrappers/bags should not be turned inside out and reused. Other sources of lead include gasoline sniffing, poorly 
glazed ceramic dishes, and folk medicines. See Appendix E for a list of common folk medicines that contain 
lead and should not be applied onto or ingested by humans. 
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The following is a list of occupations that have been found to carry a potential for exposure to lead. Such 
exposure represents a risk not only to the worker, but to members of the worker's family as well, unless good 
hygiene is observed to avoid bringing lead dust into the home from the work place. It is important to note that 
this list is not complete. 
Lead smelting 
Battery manufacture and reclamation 
Radiator repair 
Pottery manufacture 
Automotive machine shop work 
Electronics (soldering) 
Spray painting (if using lead-based paint) 
House (or other structure) paint removal 
Firing range supervision 
Firing range work 
Gasoline refining 
Glass manufacturing using purchased glass 
Casting bullets (hobby) 
Stained glass window design (hobby) 
Printing (if involving the manufacture, use or reclamation of lead printing surfaces) 
Cable stripping 
Cable splicing 
Die casting 
Valve and pipe fittings (except brass goods) 
Plumbing fixture fittings and trim (except brass goods) 
Bridge, tunnel and elevated highway construction 
Please see Appendix D for a more comprehensive listing. 
SCREENING 
The primary goal of screening for lead poisoning is to identify symptomatic or asymptomatic lead-poisoned 
children and to intervene as quickly as possible to reduce their blood lead levels. Most cases identified will be 
asymptomatic. 
Symptomatic lead poisoning is a medical emergency. 
Screening may also be used to collect and evaluate data to target community-wide interventions in areas with 
children at high risk for lead poisoning. Medical guidelines in Texas dictate that a provider screen a child at 12 
and 24 months of age. In low-risk geographic areas at other ages, the provider may elect to ask a list of high 
risk questions, which, if all answered "no," will allow the child to skip the blood test. If the child is older than 
24 months and younger than 72 months, and has never been tested for blood lead, the child must be tested. 
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The latest CDC guidelines (October 7, 1991) change the definition of lead poisoning to a confirmed blood lead 
level greater than or equal to 10 ug/dL. Because the erythrocyte protoporphyrin level does not correlate well 
with blood lead levels below 25 ug/dL, the screening test of choice is a blood lead measurement. Capillary 
specimens may be more feasible for screening purposes. Capillary specimens can be contaminated by surface 
lead from the child's hand. Contamination of capillary specimens can be minimized if proper collection 
technique is followed. See Appendix A for information on specimen collection. Before a child undergoes lead 
treatment, a confirmatory venous blood lead measurement should be taken, even if the child was initially screened 
using a venous blood sample. Diagnostic blood lead levels must be measured on venous samples. 
ANTICIPATORY GUIDANCE AND RISK ASSESSMENT 
Anticipatory guidance helps prevent lead poisoning by educating families on ways to 
reduce lead exposure. 
Questions about housing and other factors are used to identify children at greatest risk 
for high-dose lead exposure. 
Anticipatory guidance and risk assessment should be tailored to important sources and 
pathways of lead exposure in the child’s community 
Assessment of the risk of lead poisoning should be part of routine pediatric well child care. Starting at 6 months 
of age, and at each regular office visit thereafter, each child should receive a brief assessment, to determine 
whether the child is at risk for lead exposure. The issue of lead poisoning and recommended actions to reduce 
the risk of environmental exposure should become a consistent component of anticipatory guidance routinely 
provided at well child visits. A sample questionnaire appears in Appendix B. 
Based on the assessment, children can be categorized as low or high risk for lead poisoning. If the answers to 
all questions are consistently negative, the child is considered to be at low risk for lead poisoning and should be 
screened with a blood lead test at 12 months and 24 months. If the answer to any question is positive, the child 
is potentially at high risk for lead poisoning, and a blood lead test should be obtained. For children previously 
at low risk, any history suggesting that exposure to lead has increased should be followed up with a blood lead 
test. 
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SITUATIONS THAT PLACE CHILDREN 
AT HIGH RISK FOR LEAD POISONING 
1. Children with signs and/or symptoms compatible with lead poisoning; 
such as loss of appetite, abdominal cramps, constipation, anemia, 
apathy, lethargy, or periodic vomiting. 
2. Children who have previously had an elevated lead level, even if it has 
returned to an acceptable level in the interim. 
3. Children living in a building where a lead hazard has been found. 
4. Children who live in, or are frequent visitors to, housing constructed 
before 1978 that is poorly maintained. 
5. Children who live in older housing that is being or has been renovated 
while the children are or were living or visiting there. 
6. Children who are siblings, housemates, visitors, and playmates of 
children with known lead toxicity. 
7. Children whose parents or other household members participate in a 
lead-related occupation or hobby. This includes painters and those who 
engage in jewelry making, pottery glazing, stained glass work, the 
creation of fishing weights or bullets, and soldering of metal structures. 
8. Children who live near heavy traffic areas, near hazardous waste sites or 
solid waste incinerators where lead is a major pollutant or near a lead 
smelter or processing plant. 
9. Children with pica or frequent hand-to-mouth activity, such as thumb- 
sucking. These children might also have had an incidence of an 
accidental ingestion of another hazardous substance. 
10. Children with failure to thrive. 
11. Children with a history of accidental ingestion of any non-edible item. 
12. Children who have been administered Mexican or Asian folk medicines 
such as Greta or Pay-loo-ah, or who have been exposed to cosmetics such 
as kohl. 
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Screening Schedule 
Ideally, all preschool children should be screened for lead poisoning. Those children at highest risk for lead 
poisoning, however, are the highest priority for screening. The following is the suggested screening schedule 
for children. In general, children who have capillary blood levels > 15 ug/dL should have venous 
confirmation of these levels. 
1. All children between ages of 6 and 72 months should receive, as part of routine Well Child 
care, a risk assessment to determine potential environmental exposure to lead. It is 
recommended that providers utilize a structured risk assessment process such as the 
sample questionnaire in Appendix B. 
2. Children should be screened at 12 months of age and again at 24 months. If the child is 
between 24 and 72 months of age and has never been screened, a blood lead test should be 
done. The priority placed on screening should be based on the physician's judgement 
regarding the probability of lead exposure and the risk status of the community. 
* If the blood lead level is < 10 ug/dL, the child's risk for lead exposure 
should be monitored at subsequent Well Child visits. 
* If the blood lead level is 10-14 ug/dL, the child is 
Class IIA and should be rescreened in 3-4 months. If the level has not 
increased over that time, the child's risk for lead exposure should be 
monitored at subsequent Well Child visits. 
* If the blood lead level is 15-19 ug/dL, the child is 
Class IIB and should be rescreened every three months until the lead level 
is below 15 ug/dL. 
3. Children should be screened any time risk assessment or history suggests that exposure to 
lead may have increased (i.e., child living in an old house undergoing renovation). 
Indicators of a possible high blood lead include anemia, nutritional inadequacy or 
developmental delay. 
LABORATORY ANALYSIS FOR LEAD SCREENING 
The Texas Department of Health recommends that specimens requiring analysis for lead screening be submitted 
to its Bureau of Laboratories. The State laboratory will provide the following supplies: 2 ML EDTA anti- 
coagulant tubes; 7 mg. anti-coagulant collection tubes; 7 ML plain red top vacuum tubes; EDTA anti-coagulant 
fmgerstick collectors; 22 gauge 1" vacutainer needle; needle holders in 2 ML and 7 ML; lancets; form G-401 
(EPSDT lab request form); mailing containers in small, medium and large; and mailing labels. Test results are 
mailed from the laboratory. Test results greater than 40 ug/dL are called to the submitter by the laboratory. 
CASE DEFINITION 
The Guidelines from the Centers for Disease Control provide case definitions and recommendations for follow-up 
as indicated in Table 1 and Table 2. 
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Table 1 represents the timetables for confirming screening results and determining case definition based on the 
new CDC Guidelines. 
TABLE 1. Case Classification for Confirming Blood Lead Results 
Blood lead 
Presumptive 
Time within which venous blood lead should be 
level ug/dL 
Class 
obtained 
<9 
I 
Not applicable 
10-14 
IIA 
Not applicable (capillary 
rescreen in 3-4 months) 
15-19 
IIB 
Within 1 month 
20-44 
III 
Within 1 week 
45-69 
IV 
Within 48 hours 
>70 
V 
Immediately 
Table 2 presents interpretation of blood lead test results and follow-up activities. 
GUIDELINES FOR Follow-up OF ELEVATED BLOOD LEADS 
Advised protocols for follow-up of elevated blood lead in children under six years of age: 
Blood lead <9 ug/dL (Class I); 
A child in Class I is not considered lead poisoned. 
Blood lead 10-14 ug/dL (Class IIA); 
a. The parent should be informed (face to face, by phone, or by letter) that they should make 
an appointment for the child in 3-4 months. 
b. Test every 3-4 months; yearly if two subsequent measurements are < 10 ug/dL or three 
are <15 ug/dL. 
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Blood lead 15-19 ug/dL (Class IIB); 
a. Confirm capillary results with venous blood specimen. Skin contaminants can cause 
falsely elevated results. The inter-assay variability of the blood lead assay is + or - 3 
ug/dL. Repeat venous testing should be done within a reasonable time as levels can rise 
acutely. 
b. As (b) above. Tracking should be employed to ensure follow-up. 
c. Supply parent with information concerning nutrition (adequate iron, calcium, zinc, and 
protein), house cleaning (daily damp mopping, not sweeping, using a high phosphate 
product like dishwasher detergent), handwashing, and controlling pica. 
d. Conduct an environmental assessment INTERVIEW (TDH form #M-100). This form can 
be obtained from the Texas Department of Health, Literature and Forms Division, 1100 
West 49th Street, Austin, Texas 78756-3199. This is the first step in identifying the 
source of lead. 
e. If two consecutive tests 3-4 months apart remain in this range, and the INTERVIEW fails 
to demonstrate the source of lead, a HOME VISIT may be indicated to assess water 
supply, use of pottery, condition of home paint, home medications, hobbies, etc. The local 
or regional health department may assist you in home investigations. 
f. Paint, soil, water, and house dust assays are indicated only when the INTERVIEW and 
HOME VISIT have failed to identify the source of lead. These assays can be obtained 
through the local or regional health department. If the child spends most of his/her time 
in a daycare home, daycare center or school, this location must be investigated also. 
Blood lead 20-44 ug/dL (Class HI): 
a. Steps (a)-(f) above. The repeat test (venous sample) should be done within one week. If 
confirmed to be = to or > 20: 
g. Conduct (or refer for) a complete medical evaluation: 
physical exam, including, but not limited to, growth assessment, blood 
pressure, hearing acuity, peripheral nerve function; 
developmental assessment; and 
laboratory assessment. Check for iron deficiency as it often co-exists 
with lead poisoning and can exacerbate lead toxicity. Serum iron, iron- 
binding capacity, and ferritin should be measured. Serum ferritin = to 
or < 12 ug/dL indicates iron deficiency. A blood lead > 40 ug/dL 
should prompt a serum creatinine to assess renal function. 
h. Some physicians advise oral medications if blood lead remains in this range. Call the 
Bureau of Women and Children Childhood Lead Poisoning Prevention Program for the 
name of a physician or institution willing to advise on treatment. It is inadvisable to treat 
medically without identifying and removing the source of contamination. 
i. Abatement or containment of lead source - as Texas does not require licensing of lead 
investigation or abatement firms, the quality of private firms should be evaluated. 
Improperly conducted "lead abatement" procedures may INCREASE lead in the 
environment. Other than for HUD or Farmer's Home Administration homes, there are 
no public funds for abatement activities. 
Blood lead 45-69 ug/dL (Class IV); 
(a)-(i) as above. Begin medical treatment and environmental assessment and remediation within 48 hours 
Pharmacologic treatment is indicated and should be conducted under the guidance of a physician 
experienced in the treatment of lead poisoning. 
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Blood lead >69 ug/dL (Class V): 
Considered a medical emergency. Medical treatment and environmental assessment/remediation must 
begin immediately. 
NOTE: When a child is found to have a high blood lead, it is advisable to test other children < 6 
years of age sharing the same environment. 
DIAGNOSTIC EVALUATION 
Children with a confirmatory blood lead level of > 20 ug/dL, defined as Class III or greater, should receive 
medical and developmental evaluation and follow-up. The urgency of further medical evaluation depends on the 
blood lead level (BPb) and the presence of any symptoms. 
THE SINGLE MOST IMPORTANT FACTOR IN PEDIATRIC CASE 
MANAGEMENT IS TO DRASTICALLY REDUCE THE CHILD S EXPOSURE TO 
LEAD. 
Screening tests are not diagnostic. Every child with a positive screening test should be evaluated in a timely 
manner. In cases of acute poisoning, the rise of the EP may lag behind the lead level and therefore the EP may 
be normal while the lead is acutely rising. 
Children with symptoms that suggest lead poisoning should receive immediate evaluation, regardless of their risk 
classification. Symptoms such as loss of appetite, abdominal cramps, constipation, anemia, apathy, 
lethargy, and periodic vomiting may indicate lead poisoning. Other behavioral disturbances compatible 
with lead toxicity include clumsiness, hvperirritabilitv. and loss of recently acquired developmental skills. 
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The child with an elevated blood lead level (greater than 20 ug/dL) should have a 
complete pediatric medical evaluation, giving special attention to the following: 
1. A detailed history, including the presence or absence of clinical 
symptoms; child's mouthing activities; existence of pica; nutritional 
status; dietary habits; family history of lead exposure; speech/language 
and hearing screenings; assessment of child's developmental status; and 
previous blood lead determinations. 
2. The physical examination, with particular attention to the neurologic 
examination; height and weight; developmental assessment; and language 
skills. 
3. Hematologic evaluation for iron deficiency, creatinine and urinalysis. 
4. Trends in blood lead levels (see paragraph following this chart). 
5. Detailed environmental and occupational histories concerning adults in 
the same household or other caretakers. 
Since trends are important in diagnosis and management, serial measurements of blood lead are far more valuable 
than data obtained at a single point in time. Analytical variability must be considered when interpreting blood 
lead results. Apparent changes in lead status based on successive blood lead measurements can be considered 
significant only when the net difference of results exceeds the limit of analytic variance allowed by the 
laboratory. As a general rule, trends should not be considered significant unless the magnitude of the change 
is > 5 ug/dL. 
The degree of analytical variability between laboratories, which may employ different analytic methods, exceeds 
that within a single laboratory. Therefore, a single laboratory using one analytical method should be used to best 
compare multiple blood lead results from an individual or a population. Laboratories may have a margin of error 
up to 5 ug/dL either way. This variability should be considered when interpreting results. 
In addition an erythrocyte protoporphyrin (EP) level should be obtained prior to chelation. EP levels and 
concurrent measurement of blood lead are extremely helpful in following children post-chelation. 
TESTS 
1. Calcium Disodium EDTA Mobilization (or Provocative Chelation) Test is not recommended. 
2. Assessment for Iron Deficiency 
Because iron deficiency can exacerbate lead poisoning and often coexists with it, children with 
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blood lead values greater than or equal to 20 ug/dL must be evaluated for iron deficiency. The 
hemoglobin, hematocrit, and reticulocyte count are not adequately sensitive, and the EP is not 
specific enough to diagnose iron deficiency. Ferritin is the most sensitive indicator of iron status. 
Serum iron and iron binding capacity can be used with discretion. 
3. Other Tests 
The diagnosis of acute lead encephalopathy can usually be made without lumbar puncture, which 
has considerable risk because of the increase in intracranial pressure. Flat plate of the abdomen, 
x-ray of long bones, microscopic examination of red cells for basophilic stippling, and tests of hair 
and fingernails for lead levels are not sensitive indicators for the diagnosis or clinical management 
of lead poisoning and are not components of the routine workup of a patient with suspected lead 
poisoning. However, in certain circumstances, the flat plate of the abdomen may be indicated, 
such as when there is evidence of lead ingestion. 
MEDICAL MANAGEMENT 
Pregnant Women 
At present, there is insufficient clinical knowledge or experience with any chelating regimen(s) to 
recommend treating pregnant women or women of child-bearing age who have elevated blood lead levels. 
Until further clinical research is carried out, including toxicokinetic, experimental studies of the maternal-fetal 
unit and sequential measurements of maternal bone lead concentrations during pregnancy, no recommendations 
can be made. Women of child-bearing age and pregnant women who have blood lead levels above 10 ug/dL 
should receive environmental assessments to identify and eradicate sources of excessive lead exposure. 
Breastfeeding Women 
Women who have blood lead levels greater than 10 ug/dL should be counseled regarding lead poisoning as lead 
can be passed to the infant through breastmilk. 
Children 
One of the most important factors in the management of the lead poisoned child is to remove the child from the 
source of lead or remove the source. Health care providers can play an essential role in identifying the source 
of lead exposure. A thorough environmental history and parent occupational history must be obtained for all 
lead-poisoned children. The proximity of family homes to lead industries and high traffic roadways should be 
determined. Health care providers should advise families never to carry out lead paint removal themselves in 
their homes or apartments and should warn them of the dangers of renovating or remodeling older homes. Such 
repairs are safely performed only by trained and licensed contractors. The entire family should be out of the 
home day and night as the dwelling is properly prepared pre-abatement, during the actual abatement, and until 
thorough post-abatement clean-up is completed. It is the responsibility of primary care providers to promptly 
refer children to medical facilities with experience in the prevention, care, and management of lead poisoned 
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children if they are unable to provide this care themselves. See Appendix C for advice to parents. 
General Supportive Management for Symptomatic Lead Poisoning. For children with a blood lead level 
>70 ug/dL and symptoms suggestive of lead encephalopathy, all oral intake is prohibited until the child's 
condition has significantly improved. Parenteral fluid therapy is started immediately; fluid volume is restricted 
to basal requirements plus a careful assessment of ongoing losses. Excessive intravenous fluid administration 
should be avoided. Once urine flow is established, chelation treatment, already begun with BAL alone for one 
dose, is continued with simultaneous administration of CaNa2EDTA. An adequate flow of urine must be 
established before intravenous chelation therapy with CaNa2EDTA is begun. Parenteral fluid therapy minimizes 
vomiting that may accompany administration of BAL and ensures prompt excretion of CaNa2EDTA. For 
immediate control of seizures, diazepam or paraldehyde are the preferred drugs. Barbiturate and phenytoin are 
reserved for the long-term management of recurring seizures, only after the acute encephalopathic episode is 
managed and consciousness has been fully recovered. Although it is desirable to evaluate any residual lead from 
the bowel, this must never delay the start of chelation therapy. The diagnosis of acute lead encephalopathy can 
usually be made without lumbar puncture, which has considerable risk because of the increase in intracranial 
pressure. Management of increased intracranial pressure and cerebral edema should be conducted in a pediatric 
intensive care setting. 
General Supportive Management for Asymptomatic Lead Poisoning. For a child whose blood lead is greater 
than or equal to 45 ug/dL, general supportive management should follow the guidelines recommended for 
children with symptomatic lead poisoning. 
Medical Treatment 
TREATMENT GUIDELINES FOR CHILDREN 
WITH BLOOD LEAD LEVELS >20 Ug/dL 
* The most important factor in managing childhood lead poisoning is 
reducing the child's exposure to lead. 
* Children with symptomatic lead poisoning, with and without 
encephalopathy, should be managed by a multidisciplinary team. 
* Asymptomatic children with blood lead levels > 45 ug/dL should receive 
chelation therapy. 
* Different clinical centers and programs use different protocols to 
medically manage children with blood lead levels of 25 to 44 ug/dL. 
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The following medical treatment schedule is recommended for each classification of lead level: 
Blood lead level <10 ug/dL (Class I). A blood lead level <10 ug/dL is not considered indicative of lead 
poisoning. 
Blood lead level 10 to 14 ug/dL (Class HA). Children with blood lead levels in this range are in a border zone. 
Since the laboratory tests for measuring blood lead levels are not always accurate and precise at these levels, 
many of these children's blood lead levels may, in fact, be < 10 ug/dL. Although a detailed environmental 
history should be taken since an obvious remediable source of lead may be found, it is unlikely there is a single 
predominant source of lead exposure for most of these children. Thus, a full home inspection is not 
recommended. It is, however, prudent, to try to decrease exposure to lead with some simple interventions. In 
addition, these children should receive follow-up blood lead testing in about 3-4 months. The adverse effects 
of blood lead levels of 10 to 14 ug/dL are subtle and are not likely to be recognizable or measurable in the 
individual child. It is important to make sure that these children's blood lead levels do not go up. 
Blood lead level 15 to 19 ug/dL (Class IIB). Children with venous blood lead levels 15-19 ug/dL need more 
careful follow-up. The pediatric health care provider should take a careful history, asking about sources of lead 
exposure. Parents should receive guidance about interventions to reduce blood lead levels. Children with blood 
lead levels in this range are at risk for lower than expected IQ and other subtle effects. The effects of lead at 
these levels are significant enough that the health care provider should emphasize to parents the importance of 
follow-up screening to make sure the levels have not increased. The provider should also discuss interventions 
to reduce the blood lead levels. In addition, these children should receive follow-up testing. If their blood lead 
levels persist at > 15 ug/dL, environmental investigation and remediation should be completed, if resources 
permit. In some communities, childhood lead poisoning prevention programs may be able to manage the 
environmental investigation and remediation. 
Blood lead level 20 to 24 ug/dL (Class HI). A child with confirmed blood lead of 20 to 24 ug/dL will require 
individual case management by a pediatric health care provider. The child should have a complete pediatric 
evaluation within 10 working days of the initial confirmation, with special attention to nutritional, developmental 
and iron status. Parents should receive education about lead poisoning that includes information about: 1) the 
causes and effects of lead poisoning; 2) the need for more routine blood lead testing; 3) possible sources of lead 
intake and means of reducing intake; 4) nutrition, emphasizing the need for three nutritious meals a day and two 
snacks, with a diet high in callcium and iron; and 5) resources for further information. Sequential measurements 
of blood lead along with review of the child's clinical status should be done monthly. Children with higher blood 
lead levels require referral for environmental investigation and management. The identification and eradication 
of specific sources of excessive lead exposure are essential to ensure that blood lead levels decrease. 
Blood lead level 25 to 44 ug/dL (Class HI). Many experienced lead clinics will proceed with chelation therapy 
for a child with a blood lead level 25 to 44 ug/dL. Some clinicians recommend the use of Succimer for treatment 
of children in this category. Currently FDA limits its recommendations for the use of Succimer to children with 
blood lead levels > 45 ug/dL. Clinical judgment should be used in this situation. 
Supportive management, decreasing the child's exposure to lead from all sources, nutritional interventions 
(correcting iron deficiency and maintaining adequate calcium intake), and more frequent testing to ensure blood 
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lead levels decrease are the minimum medical management for children with these blood lead levels. 
Blood lead level 45 to 69 ug/dL (Class IV). For blood lead values between 45 and 69 ug/dL, chelation 
treatment should be limited to or Succimer. Generally, Succimer would be the preferred chelation 
agent unless for compliance reasons, CaNa2EDTA must be used. 
is given for five days at a dose of 1000 mg/m2/day, preferably by continuous infusion or in divided 
doses intravenously. During treatment, evaluate renal and hepatic function and serum electrolyte levels. 
treatment should be continued for five days and no longer. Repeated courses of treatment may be 
necessary, as mobilization of lead from bone causes a rebound in semm lead level. It is prudent to allow a period 
of five to seven days before beginning a second course. 
Blood lead level >70 ug/dL (Class V). Children with blood lead levels >70 ug/dL (with or without 
symptoms) represent an acute medical emergency. If the blood lead level is >70 ug/dL, both BAL and 
CaNa2EDTA should be given, in the same doses and using the same guidelines as for treatment of symptomatic 
lead poisoning. A second course of chelation therapy with CaNa2EDTA alone may be required if the blood lead 
concentration rebounds to a level of >45 ug/dL within five to seven days after treatment. It is desirable to allow 
at least five to seven days before beginning a second course of CaNa2EDTA. 
See the following chart for recommendations concerning chelation therapy and CaNa.EDTA test. 
CHELATING AGENTS USED IN TREATING CHILDREN WITH LEAD POISONING 
Product Name 
Generic Name 
Chemical Name 
Abbreviation 
Calcium Disodium 
Versenate 
Edetate disodium 
calcium 
Calcium disodium 
ethylenediamine tetraacetate 
CaNa2EDTA 
BAL in Oil 
Dimercaprol 
2, 3-dimercapto-l-propanol 
BAL 
Chemet 
Succimer 
Meso 2,3-dimercaptosuccinic acid 
DMSA 
SUCCIMER (CHEMET). The Food and Drug Administration has approved Succimer for use in lead-poisoned 
children with blood lead levels >45 ug/dL. The use of Succimer is not indicated for use with children having 
blood lead levels 70 ug/dL or higher. Succimer (trade name: Chemet), by McNeil Consumer Products 
Company, is an approved oral chelating agent effective in the treatment of lead poisoning. The route of 
administration allows the option of outpatient management of lead intoxication. The drug's specificity for lead 
substantially reduces the risk of essential mineral depletion associated with conventional parenteral chelating 
agents. The efficacy of this drug is comparable with other treatment modalities and may be superior in some 
situations. Succimer is a more efficacious chelating agent than EDTA in addition to being available in an oral 
form which is less toxic (see bibliography article by Graziano). 
Indications and Usage 
Succimer (Chemet) is indicated for the treatment of lead intoxication in children with blood lead levels above 45 
ug/dL. The drug is not indicated for the prophylaxis of lead poisoning in areas of high-risk exposure. Use of 
14 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
TDH, Fall 1994 
Succimer (Chemet) should always be accompanied by an active ongoing lead abatement program. 
Dosage and Administration 
Dosage should begin at 10 mg/kg or 350 mg/m2 orally every 8 hours for 5 days. The dose should then be 
reduced to 10 mg/kg or 350 mg/m2 every 12 hours for an additional two weeks. The total length of a single 
treatment course is 19 days. Repeated courses may be necessary if indicated by weekly monitoring of blood lead 
concentrations. A minimum of two weeks between courses is recommended unless blood lead concentrations 
dictate the need for more prompt treatment. Succimer (Chemet) is available in capsule form (100 mg). The 
capsules may be opened and the beads inside can be sprinkled on top of and mixed with food or fruit drinks for 
young children who cannot swallow the capsule whole. The beads elicit a characteristic "rotten egg" sulfur odor 
due to the presence of the sulfhydryl moieties on the molecular structure. Doses should be rounded up or down 
to the nearest whole capsule increment when initiating therapy. 
Monitoring Parameters 
Baseline and post-chelation therapy blood lead concentrations are, of course, important parameters to follow in 
patients being treated with Succimer (Chemet). Lead level concentrations may rise following completion of 
chelation therapy due to redistribution of lead from bone stores. Succimer chelates are excreted in urine; 
therefore, adequate hydration is essential to maintain good urine flow. Serum transaminase should be obtained 
prior to initiation of treatment with Succimer (Chemet) and periodically thereafter. 
Summary 
Clinical studies indicate that Chemet (dimercaptosuccinic acid - DMSA) is a relatively 
selective and highly effective agent for the treatment of lead intoxication. Succimer 
(Chemet) reverses the metabolic effects of lead on heme synthesis while increasing 
urinary lead output. This novel orally active chelator offers the distinct advantage of 
outpatient treatment and subsequent lower health care costs for the persistent problem 
of lead poisoning. 
FUTURE TRENDS IN THE MANAGEMENT OF CHILDHOOD LEAD POISONING 
Bone Lead Measurements Using X-Ray Fluorescence (XRF) 
The development of L-line XRF techniques to measure tibial bone lead in children permits noninvasive 
assessments of skeletal lead levels and more accurately reflects the accumulated lead burden over an individual's 
lifetime. In contrast, blood lead values reflect recent lead exposure and absorption during the past one to three 
months and provide only limited information about lead toxicokinetics over time. Endogenous release of lead 
from bone occurs and is the equivalent of new exposure. Knowing the toxicokinetics associated with endogenous 
release will add a new dimension to basic and clinical research. Evaluations using XRF methods have shown 
that blood lead values may markedly underestimate the body burden of lead in lead-poisoned children. In one 
study, the majority of 59 lead-toxic children, with blood lead values between 23 and 53 ug/dl, had bone lead 
15 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
TDH, Fall 1994 
values equal to those measured in industrially exposed adults. Hence, by 7 years of age, lead-poisoned children 
may have remarkably elevated skeletal burdens of lead, which may exert profound effects on their health in later 
years. The L-line technique has also documented decreases in bone lead content sequentially following 
CaNa2EDTA treatment in lead-poisoned children. 
When considering published data concerning radiation dosimetry, counting time, minimum detection limits, and 
clinical data in lead-paint poisoned children, the L-line XRF technique appears to be the most valuable technique 
for epidemiological and clinical analyses of infants, children, pregnant women, and women of child-bearing age. 
For studies of industrial workers and post-menopausal women, the K-line XRF method appears most appropriate. 
Together, these XRF methods will be valuable tools for studying the association between bone lead concentration 
and renal disease, hypertension, and adverse effects on the central nervous system. L-line XRF, measuring lead 
over longer exposure periods, will be increasingly incorporated into management and treatment protocols. At 
present, the availability of XRF equipment is limited to a few centers in the United States and Europe. 
TREATMENT AND FOLLOW-UP 
POST CHELATION FOLLOW-UP 
Recheck blood lead levels 7 to 21 days after treatment. 
Determine if retreatment is necessary. 
Do not discharge a child from the hospital until a lead-free environment can be 
assured. 
At the end of each treatment cycle, the blood lead concentration usually declines to values <25 ug/dL. Within 
a few days, however, reequilibration among body lead compartments takes place and may result in a rebound; 
thus, the blood lead level must be rechecked 7 to 21 days after the end of treatment. 
In children who have received chelation therapy, repeated cycles are indicated if the blood lead concentration 
rebounds to within 5 ug/dL of the original pretreatment value 7 to 21 days posttreatment. In all children, 
regardless of age, with elevated blood lead values but with an excretion ratio less than 0.60 on the provocative 
chelation test, blood lead should be measured monthly. If the elevation in blood lead values persists, chelation 
therapy should be repeated. 
Any child who undergoes chelation treatment requires longterm follow-up preferably from pediatric health care 
providers, nutritionists, environmental specialists, and community outreach workers. The last group provides 
a critical bridge among hospital-based or clinic-based (outpatient) medical care, health advocacy education, and 
environmental remediation outside the hospital. A child should not be discharged from the hospital until 
appropriate alternative housing is provided while all lead hazards in his/her home or elsewhere are being 
controlled and eliminated. Lead free "safe housing" (with friends, relatives, or in designated transitional 
housing) must be arranged in which a successfully treated child can live with his/her family during the 
entire abatement process through post-abatement clean-up. With appropriate public health measures, 
16 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
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complete and safe abatement should take place during the treatment period. 
Once a child is discharged to a safe environment, frequent follow-up is mandatory. In general, depending on 
the initial blood lead value, most children who require chelation therapy must be followed closely for at least 
one year or more until the blood lead and EP concentrations reach values <25 and 35 ug/dL, respectively. All 
children undergoing chelation treatment should be seen every other week for eight weeks, then once a 
month for six months. A child treated with BAL and CaNa2EDTA should be followed more closely: every 
two weeks for six weeks, then monthly for 12 months. 
With prompt diagnosis, removal from lead sources and chelation therapy (when indicated), the toxic biochemical 
effects of lead may be reversible; the reversibility of these indices has been shown to follow different time 
courses. The return to normal EP concentrations (< 35 ug/dL) takes several weeks to several months. The 
gradual decline that should occur in EP values (with successful environmental and medical intervention) is a 
valuable parameter to follow post-treatment. 
At each clinic visit, environmental and housing information should be updated. Re-evaluation of the environment 
may be necessary (preferably by an environmental specialist from the local health department who plays a central 
role to ensure prompt, safe and technically sound abatement). Nutritionists can provide nutritional advice. 
Continued improvement in serial blood lead and EP data indicate no excessive new exposure to lead; rising blood 
lead concentrations, which may be accompanied by a rising EP level, indicate increased exposure to lead. Re- 
investigation often reveals previously undetected sources of environmental lead, inadequate abatement, or 
unsound structures in buildings. 
A comprehensive developmental evaluation, including a hearing screen, should be conducted yearly on any 
child with lead poisoning. The children need evaluation for problems such as attention deficit disorders and 
behavioral problems, as well as lowered IQ or obvious neurologic or learning problems. Appropriate early 
intervention or early childhood services and counseling of parents should be provided as necessary. Early 
intervention agencies or the early childhood programs of public school districts and Head Start programs should 
be used for developmental screening and monitoring of neurobehavioral status. 
When a child with earlier elevated blood lead concentrations approaches school age, psychometric evaluation may 
be indicated, even though the blood lead concentration at the time is <20 ug/dL. 
COMMUNITY INTERVENTION 
Local health officials who have traditionally carried out all or most of the lead poisoning prevention activities 
in a community will work in collaboration with physicians and other education, social service and housing 
agencies that have a role in community-wide primary prevention efforts. Lead poisoning prevention strategies 
will work best as part of an integrated program for creating safe and affordable housing and/or providing 
impoverished people in the community with the full range of needed social services. Local, state, and federal 
agencies dealing with health, housing, environmental, and children's issues should be identified and contacted. 
Optimally, a regular, formal mechanism should be established for communication among agencies and decision- 
making on joint prevention strategies. 
17 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
TDH, Fall 1994 
To be successful, community-level intervention will require four different types of activities: 
1. Surveillance and Risk Assessment: Determining populations at risk and areas where the most 
exposures are occurring. 
2. Outreach and Education: Informing health care providers, parents, day care providers, early 
childhood educators, property owners, and other key audiences about lead poisoning prevention. 
3. Infrastructure Building: Creating the resources needed for a successful program of risk abatement. 
4. Hazard Abatement: Abating the hazards of lead paint, dust and soil, particularly in high-risk 
buildings and neighborhoods. 
THE ROLE OF THE TEXAS DEPARTMENT OF HEALTH 
At 12 and 24 months, along with other times as prescribed by responses to the parent questionnaire, the EPSDT 
health care provider will obtain a blood sample in order to ascertain if the child has a high blood lead level. 
After obtaining the sample, the blood should be sent to the State laboratory. The laboratory usually reports the 
results by mail within four working days after specimen receipt. 
In addition to reporting results to the health care provider, the lab also sends the information to the Bureau of 
Women and Children Childhood Lead Poisoning Prevention Program (CLPPP). If the blood lead level is greater 
than or equal to 20 ug/dL, the child is entered into the CLPPP database. A child maintains active status in the 
database until the blood lead drops below 20 ug/dL. 
Six weeks after receipt of the results from the laboratory, a certified letter is sent to both the provider and 
parent/guardian of the lead poisoned child. The provider receives, along with the letter, a questionnaire which 
requests basic information regarding the child's case. See Appendix F for a sample provider questionnaire. With 
the letter, the parent/guardian is sent an informational brochure which describes sources of lead, lead's affect on 
a child's body and ways to prevent lead poisoning. The brochure is available in both English and Spanish. 
In the event that a child's blood lead is 40 ug/dL or greater, the laboratory notifies the health care provider 
immediately by phone, and also notifies the CLPPP via fax. Usually within about a week of notification, the 
CLPPP calls the provider in order to find out if the family has brought the child in for follow-up and if the 
provider needs help getting an environmental investigation or would benefit from advice on medical treatment 
of the child. If the provider cannot locate the family, the CLPPP can obtain help from EPSDT Services or 
Medicaid Eligibility in finding the family. If the provider has trouble obtaining an environmental investigation, 
the CLPPP can work with the Texas Department of Health regional offices and local health departments to 
arrange an environmental assessment. 
In addition to case management and tracking, the CLPPP also develops educational materials for parents and 
health providers. See Appendix G for a listing of resources that are presently available. These materials and 
in-service education are available on request. By tracking blood lead results, the CLPPP is able to identify areas 
18 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
TDH, Fall 1994 
of Texas with a high incidence of lead poisoning. Public health authorities in those areas are notified of the 
situation and are encouraged to initiate environmental assessment and ensure that health care providers are 
adequately educated concerning lead poisoning prevention. 
19 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
TDH, Fall 1994 
APPENDIX A 
SPECIMEN COLLECTION 
Blood lead determinations on microspecimens collected by fingerstick are usual on small children; however, 
these are subject to contamination with surface lead on the patient's finger. Special steps are used to 
minimize this contamination. These special procedures include thorough scrubbing of the hand and finger 
with soap and water prior to alcohol sterilization. 
Several types of pediatric blood collection containers (maximum volume <500 uL) exist. These containers 
are made of plastic and offer safety advantages. 
Materials used in the collection procedures also have the potential for contaminating the specimen (e.g., 
blood container, alcohol swabs, barrier spray) and must be lead-free. The State Laboratory will recommend 
or supply suitable collection materials. 
Procedure: 
(Note: This written procedure is explained in greater detail in the laboratory handbook for EPSDT. 
Illustrations are also provided in the booklet.) 
The specimen may be obtained either by venipuncture or by capillary fingerstick. Venipuncture is preferred 
since there is less chance of contaminating the specimen. If collecting the specimen by fingerstick, this 
procedure should be followed: 
1. Wash patient's hand with soap and water, dry, then wipe with alcohol. 
2. Wear gloves. 
3. Discard any dropped collection vials. 
4. Use long-point metal lancet and make collection stick. 
5. Wait for large drop to form. Hold collector container parallel to the ground to let capillary action 
pull blood in. 
6. May use the capillary top of the collection container or you may remove it and let blood drop 
directly into the tube. Cap tightly. 
7. Collection vial should be half full. More will cause the cap to dislodge due to expansion of air 
and blood in the unit. 
8. Snap specimen vial sharply 10 times to insure proper mixing while inverting several times. 
9. Do not draw blood using venipuncture tube and then pour into capillary tube. There will be 
excessive anticoagulant and test results will be invalid. 
10. Mail on the day of collection. If not possible, refrigerate, but hold no longer than two days. DO 
NOT FREEZE. 
11. Specimens should be placed in the dark immediately after collection. Falsely elevated EP values 
can occur from excessive exposure to light. 
12. Be sure vials are stored before use in ziplock bag with drying pack. 
20 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
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APPENDIX B 
PARENT QUESTIONNAIRE 
PRESCREENING QUESTIONS FOR A CHILD WHO HAS NEVER HAD A HIGH 
BLOOD LEAD 
These questions should be asked at least once a year until the child is 6 years old. "Yes" to any of the following questions 
should prompt lead testing according to the recommended periodicity schedule, REGARDLESS OF PREVIOUS BLOOD 
LEAD RESULTS. 
* 1) Do you live in or often visit a house that was built before 1978? YES NO 
* 2) Does your child live in or often visit a house that is being painted, 
remodeled, or having the paint scraped or sanded? YES NO 
* 3) Does your child eat or chew on things like paint chips or dirt? YES NO 
* 4) Have any other members of the family or your child's playmates had high 
blood leads? YES NO 
* 5) Does anyone living in your house work at a place where any of these 
things happen or have a hobby that involves these things (circle the ones 
that apply): 
radiator repair 
lead industry 
welding 
battery manufacture or repair 
house construction or repair 
smelting 
chemical preparation 
making pottery 
going to a firing range 
stained glass with lead solder 
brass/copper foundry 
valve and pipe fittings 
bridge, tunnel and elevated highway construction 
industrial machinery and equipment 
casting ammunition, fishing weights, or toy soldiers 
refmishing furniture 
burning lead-painted wood 
automotive repair shop 
Does anybody that your child spends a lot of time with (outside of your home) 
do any of these things or work at a place where these things are done? YES NO 
* 6) Does your family live near or does your child play near any of these 
21 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
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(circle the ones that apply): 
smelter 
hazardous waste site 
lead industry 
place where batteries are manufactured or repaired 
house construction site 
heavily traveled major highway 
place where cars are abandoned or repaired? 
7) Do you give your child, or have you ever given your child any of these products from another country: 
MEDICINES like greta or azarcon for empacho, alarcon, alkohl, 
bali goli, coral, ghasard liga, pay-loo-ah, or rueda? YES NO 
NUTRITIONAL SUPPLEMENTS OTHER THAN VITAMINS? YES NO 
COSMETICS like surma or kohl? YES NO 
8) Does your home's plumbing have lead pipes, lead solder or 
lead-containing holding tanks? YES NO 
9) Is imported or antique pottery used to cook or store your food? YES NO 
10) Does your child eat foods canned outside the U.S.? YES NO 
(NOTE: Asterisks by questions indicate that answers to these questions are particularly important in determining if a child may have a high 
blood lead.) 
22 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
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OUESTIONARIO A LOS PADRES PREGUNTAS PARA NINOS 
OUE NUNCA HAN TEMPO ALTOS 
NIVELES DE PLOMO EN LA SANGRE 
Estas preguntas se deben hacer por lo menos una vez al ano hasta cuando el nino tiene seis anos. En el caso 
de que una de las respuestas sea "si", se necesita hacer una prueba para determinar el nivel de plomo en la 
sangre. Esta prueba se debe hacer siguiendo el cuadro de periodicidad y a pesar de los resultados anteriores. 
*1. Hay alguien que vive en su casa que trabaja o tiene un pasatiempo en una de las actividades 
siguientes? (Haz un circuit) alrededor de las respuestas que apliquen.): 
El reparo de radiadores 
Una fabrica donde se utiliza plomo 
La soldadura 
La fabrica o reparo de baterias 
La renovacion de casas 
La fundicion de plomo, acero, cobre, o cualquier otro metal 
La preparation o mezcla de quimicas 
La alfareria 
Va a un campo de tiro 
La fabrica de vidrio con dibujos coloreados con soldadura de plomo 
La maquinaria o tuberia hecha de piezas de plomo 
La construction de puentes, tuneles, o carreteras elevadas 
La maquinaria industrial 
El moldeado de plomo para fabricar municiones, equipo para la pesca, o soldaditos de plomo 
El dar de acabado nuevo a muebles 
La quemada de madera cubierta con pintura de plomo 
El reparo de automoviles 
2. Visita su nino(a) alguien que hace una las actividades listadas arriba? 
Si No No se 
*3. Come su nino cosas por casualidad como pintura que esta pelada, o tierra? 
Si No No se 
*4. Vive su nino(a) en una casa donde la pintura se esta pelando o se esta rajada? 
Si No No se 
23 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
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*5. Visita su nino(a) una casa donde la pintura se esta pelando o se esta rajada? 
Si No No se 
*6. Vive su nino(a) en una casa donde alguien esta pintando, o lijando o quitando la pintura? 
Si No No se 
*7. Visita su nino(a) una casa donde alguien esta pintando, o lijando o quitando la pintura? 
Si No No se 
*8. Vive su nino(a) en una casa que esta en el proceso de renovacion o recientemente fue renovada? 
Si No No se 
*9. Visita su nino(a) una casa que esta en el proceso de renovacion o recientemente fue renovada? 
Si No No se 
10. Juega su nino(a) donde hay automoviles que estan abandonados o donde los reparan? 
Si No No se 
11. Le da o le ha dado a su nino uno de estos productos? (Haz un circulo alrededor de las respuestas 
que apliquen.) 
Medicinas como: greta, azarcon para empacho, alarcon, alkohl, bali goli, coral, 
ghasard, liga, pay-loo-ah, o rueda 
Vitaminas o suplementos naturales 
Cosmeticos como: surma, kohl 
12. Come su nino(a) comidas enlatadas de palses fuera de los Estados Unidos? 
Si No No se 
13. Utiliza Ud. la alferia para cocinar o guardar la comida? 
Si No No se 
24 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
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*14. Fue constmida su casa antes de 1978? 
Si No No se 
15. Esta su casa cerca de las actividades siguientes? (Haz un circulo alrededor de las respuestas que 
apliquen.) 
La fundicion 
Fabricas u otros lugares donde haya quimicas peligrosas 
Una fabrica donde se utiliza plomo 
La fabrica o reparo de baterias 
La renovacion de casas 
*16. Hay otros miembros de su familia que tienen o ban tenido altos niveles de plomo en la sangre? 
Si No No se 
* Los asteriscos que estan al lado de los numeros indican que estas preguntas son muy importantes para 
determinar si el nino tiene niveles altos de plomo en la sangre.) 
25 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
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APPENDIX C 
PREVENTION OF LEAD POISONING 
Advice to Parents 
LEAD PAINT: Intact paint is not a hazard to your child, but peeling paint and paint dust is a danger. 
Most homes built before 1950 contain lead paint and about half of houses built between 1950 and 
1980 are likely to contain lead paint. 
1. Check your home inside and out for peeling paint, looking especially around 
wooden door and window frames, where weather and friction tend to grind and 
chip painted surfaces. 
2. Clean up any peeling paint and cover peeling areas so your child cannot touch them 
until they are repaired. 
3. To prevent your children from eating dust contaminated with lead, wet mop 
wooden and tile floors, wash the toys of young children, and wash children's hands 
before they eat. 
4. You can determine if lead paint is present by using a do-it-yourself lead testing kit 
or by contacting your county or state health department to get a referral to a 
professional contractor or laboratory to test for lead. Home test kits are available 
in most hardware stores and are also sold by: 
Frandon Enterprises, 511 N. 48th St., Seattle, WA 
98103, 1-800-359-9000 
HybriBet Systems, Inc., P.O. GBHox 1210, Framingham, MA 
01701, 1 -800-262-LEAD 
5. It is very dangerous to attempt to remove lead paint yourself since you need protective 
devices to prevent inhalation of lead dust, and the home needs to be carefully sealed to 
prevent spreading of lead dust. Regular vacuums tend to spread rather than contain the 
dust. Scraping and sanding paint are dangerous, and heating lead paint with torches is very 
dangerous since it vaporizes the lead so that it is easily inhaled. For guidelines that should 
be followed in removing lead paint, contact: 
Bureau of Environmental Health 
Texas Department of Health 
1100 West 49th Street 
Austin, Texas 78756-3199 
512/834-6600 
26 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
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SOIL: Soil gets contaminated with lead from paint washed off of buildings, automobile exhaust, and emissions 
from local industry. 
1. Try to find play areas away from old painted buildings or provide your child with 
a covered sandbox. 
2. Make sure your children wash their hands before they eat after playing outside. 
DRINKING WATER: Water may be contaminated by lead solder used to connect your plumbing to the water 
main. 
The new safe standard for lead content of water is 15ppb (parts per billion). 
You can get your drinking water tested by calling the EPA's water safety hotline 
at 1-800-426A791 for a list of state-certified testing laboratories. If your water's 
lead content is more than 10 to 15 ppb, do the following: 
a. Before you draw water for drinking or cooking, run the cold water 
for 1 to 2 minutes if the taps have been turned off for more than 
six hours. Keep a pitcher of cold water in the refrigerator. 
b. Always use cold water for drinking and cooking. Hot water 
contains more lead. 
DISHWARE AND CANNED FOODS: Some of the lead in the glazes on pottery and china may not be properly 
fired during manufacture and may leak into food or solutions such as fruit juices or coffee. 
1. You can use the containers for serving, but do not use them to store foods or 
beverages. Likewise, do not store liquor in crystal decanters. 
2. Lead solder is no longer used in most tin cans made in the United States but is still 
used in canned foods from some other countries. 
NUTRITION: Iron or calcium deficiency promotes increased absorption of lead from the intestines; therefore, 
be sure your child has enough iron and calcium in the diet. More iron is absorbed on an empty stomach; 
therefore, children should eat at least three meals and two snacks daily. 
27 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
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APPENDIX D 
INDUSTRIES WITH A MODERATE PRIORITY FOR OCCUPATIONAL LEAD EXPOSURE 
NIOSH 
Industrial inorganic chemicals 
Explosives 
Printing ink 
Tires and inner tubes 
Mechanical rubber goods 
Fabricated rubber products 
Unsupported plastics film & sheets 
Unsupported plastics profile shapes 
Laminated plastics plate & sheet 
Plastics bottles 
Plastics foam products 
Custom compound purchased resins 
Pressed and blown glass 
Vitreous china table & kitchenware 
Blast furnaces & steel mills 
Gray and ductile iron foundries 
Primary copper 
Copper rolling and drawing 
Nonferrous rolling and drawing 
Nonferrous wire drawing & insulating 
Aluminum die-castings 
Aluminum foundries 
Nonferrous foundries 
Primary metal products 
Metal cans 
Hand and edge tools 
Hardware 
Metal sanitary ware 
Sheet metal work 
Miscellaneous metal work 
Screw machine products 
Crowns and closures 
Metal stamping 
Ammunition 
Misc. fabricated wire products 
Metal foil and leaf 
Refrigeration and heating equipment 
Relays and industrial controls 
Telephone and telegraph apparatus 
Primary batteries, dry and wet 
Aircraft 
Aircraft parts and equipment 
Instruments to measure electricity 
Radiotelephone communications 
Telephone communications, exc. radio 
Industrial machinery and equipment 
28 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
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INDUSTRIES W/ HIGH & VERY HIGH PRIORITY FOR OCCUPATIONAL LEAD EXPOSURE 
Very High Priority Industries are Italicized 
NIOSH 
Secondary nonferrous metals 
Plumbing fixture fittings and trim 
Storage batteries 
Inorganic pigments 
Adhesives and sealants 
Chemical preparations 
Plastic products 
Products of purchased glass 
Ceramic wall and floor tile 
Pottery products 
Primary nonferrous metals 
Nonferrous die-casting exc. aluminum 
Copper foundries 
Industrial valves 
Fluid power valves & hose fittings 
Valves and pipe fittings 
Elevators and moving stairways 
Power transmission equipment 
Radio & TV communications equipment 
Communications equipment 
Electrical equipment & supplies 
Motor vehicles and car bodies 
Truck and bus bodies 
Motor vehicle parts and accessories 
Search and navigation equipment 
Measuring & controlling devices 
Signs and advertising specialties 
Scrap and waste materials 
General automotive repair shops 
Automotive repair shops 
29 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
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APPENDIX E 
FOLK REMEDIES/MEDICINES WHICH MAY BE DANGEROUS 
Pay-loo-ah Indochinese remedy (red powder) for high fever 
prevalent in the Hmong community 
Azarcon Mexican treatment (bright orange powder) for empacho (intestinal 
illness) which is 90% lead (also known as Rueda, Coral, Maria 
Luisa, Liga, Alarcon, and Alarzon) - any amount is poisonous to 
children and adults 
Greta Mexican treatment (yellow powder) for empacho which is 90% lead 
- any amount is poisonous to children and adults 
Ghasard Asian Indian folk remedy (brown powder) administered to aid 
digestion 
Bali Goli Asian Indian folk remedy, which is a round, flat 
black bean that is dissolved in "gripe water" and used for 
stomachache 
Kandu Asian Indian folk remedy (red powder) used to treat stomachache 
Surma or Kohl Arab powder used both as a cosmetic eye make-up and applied to 
skin infections and the navel of a newborn child 
30 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
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APPENDIX F 
QUESTIONNAIRE TO PROVIDERS 
Name of child 
Birthdate Medicaid # 
Was the initial test a capillary? NO YES 
Has a venous confirmation been done? NO YES 
What were the results of the follow-up test? 
Has child moved to another residence and cannot be located? 
NO YES 
Has parent/guardian failed to bring child in for appointments? 
NO YES 
Child's current address, according to your records: 
STREET/PO BOX 
CITY, STATE, ZIP 
PHONE # 
Has child been referred to another health care provider? 
NO YES 
If yes: NAME 
ADDRESS 
CITY,STATE,ZIP 
PHONE # 
DO YOU NEED HELP GETTING AN ENVIRONMENTAL INVESTIGATION? NO YES 
NOTE: Please retain this questionnaire until the above information is available. If you have any questions about 
physician guidelines or need a referral to someone who can offer advice on the medical treatment of childhood lead 
poisoning, feel free to call Kay Randall at 512/458-7700. 
When questionnaire has been completed, please mail to: 
Bureau of Women and Children 
Childhood Lead Poisoning Prevention Program 
1100 W. 49th Street 
Austin, TX 78756-3199 
31 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
TDH, Fall 1994 
APPENDIX G 
CLPPP RESOURCES 
NUTRITION 
Nutrition and Childhood Lead Poisoning Prevention: A Quick Reference Guide for Health Professionals 
Handout for health care providers. Copy of article published by the National Center for Education in Maternal and Child 
Health. Offers information concerning lead's effect on the body and the relationship between lead contamination and diet, 
and includes a nutrition and lead bibliography. 
Nutrition and Lead Fact Sheet for Health Professionals 
Handout for health care providers. Contains information concerning lead's effect on the body, the relationship between 
nutrition and lead contamination, and sources of lead contamination. 
Iron for Strong Red Blood Cells 
Handout targeted at parents. Provides information concerning the nutritional benefits of a diet rich in iron, calcium and 
vitamin C. English only. 
♦Foods with Iron 
Handout targeted at parents. Lists foods which are rich in iron. English and Spanish. 
♦Calcium 
Handout targeted at parents. Lists foods which are rich in calcium. English only. 
LEAD-BASED PAINT 
Lead Paint Hazards Fact Sheet: Health and Safety Precautions 
Handout produced by the Texas Department of Health Bureau of Epidemiology. Provides detailed discussion of effects 
of lead on body, identification of lead paint hazards, removal of lead-based paint, and containment or clean up of lead- 
bearing dust and debris. 
National Lead Information Center: Home Repairs and Renovations, What You Should Know About Lead-Based Paint 
Handout targeted at parents. Produced by the National Lead Information Center and offers basic information for persons 
who know or suspect that their home may contain lead-based paint. English only. 
HEALTH CARE PROVIDER PROTOCOLS AND GUIDANCE IN MEDICAL MANAGEMENT OF HIGH BLOOD LEADS 
Specimen Collection for Lead Screening 
Handout for health care providers. Instruction from the State laboratory on the collection of venous and capillary 
specimens. 
EPSDT Parent Questionnaire 
Questionnaire to be administered to parent by health care provider. Negative responses to all questions on form may 
allow child to forego blood lead test. Some conditions apply. English and Spanish. 
Health Care Provider Guidelines for Follow-up of High Blood Leads 
Handout with Texas Department of Health health care provider guidelines for the management of children with elevated 
blood lead levels. 
Succimer 
Handout for health care providers. Contains basic information about succimer, an oral chelation drug used to treat 
32 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
TDH, Fall 1994 
children with very high blood lead levels. 
Physiologic Effects of Lead on Body/Medical Evaluation, Management and Treatment 
Handout for health care providers. Contains specific physician-oriented information about treatment and management 
of high blood lead levels. 
Screening Schedule for High Blood Leads 
Handout for health care providers. Contains a chart showing the instances when the health care provider may administer 
the parent questionnaire and the times when a child must receive a blood lead test. 
ENVIRONMENTAL ASSESSMENT 
List of Local Health Departments 
Handout for health care providers which lists several local health departments. Can be utilized when arranging a home 
visit or environmental investigation. 
List of Public Health Regions 
Handout for health care providers which lists the Texas Department of Health Public Health Regions. Can be utilized 
when arranging a home visit or environmental investigation. 
♦Texas Department of Health Lead Assessment Interview Tool 
Form for health care providers. To be utilized when health care provider questions parent regarding possible sources 
of lead contamination. 
Points of Contact for an Environmental Investigation 
Handout for health care providers which lists persons at the TDH regional offices who can be contacted when an 
environmental investigation is needed. 
SOURCES OF LEAD 
Folk Medicines Which May Be Dangerous to Children 
Handout for health care provider. Lists seven of the most common folk remedies and medicines that can cause lead 
contamination. 
Industries with Lead Exposure 
Handout for health care provider. Lists industries with a moderate priority for occupational lead exposure and industries 
with high priority for occupational lead exposure. May be utilized when attempting to determine source of child's lead 
contamination. 
GENERAL INFORMATION 
CDC: Preventing Lead Poisoning in Young Children (October 1991) 
Definitive statement from CDC on the prevention of childhood lead poisoning and management of a child with an elevated 
blood lead. The document offers guidance for health care professionals, public health entities and communities. This 
book may be obtained from the Department of Health and Human Services, Public Health Service, Centers for 
Disease Control, Atlanta, GA 30333. The Texas Department of Health DOES NOT stock this item. 
Getting the Lead Out of Just About Everything 
Copy of an article from FDA Consumer Magazine which provides an overview of the hazards of lead in our environment. 
33 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
TDH, Fall 1994 
Facts About Lead 
Handout targeted at parents. Provides basic information regarding lead absorption, the effects of lead on health, sources 
of lead, and preventing lead contamination. English only. 
Resources for Childhood Lead Poisoning Prevention 
Handout suitable for health care providers or parents. Lists nationwide government agencies and non-profit organizations 
which can offer assistance and information on lead-related topics. Addresses, phone numbers and names of contact 
persons are listed. English only. 
National Lead Information Hotline and Clearinghouse 
Handout suitable for health care providers or parents. Information sheet describing the services offered by the National 
Lead Information Hotline and Clearinghouse. Sheet lists toll-free phone numbers, address and hours of operation. 
English only. 
Health Effects in Children and Fetuses from Lead Exposure 
Handout targeted at parents. Chart which shows the effects of lead at various levels in a child's body. English only. 
National Lead Information Center: Questions Parents Ask About Lead Poisoning 
Handout targeted at parents. Lists several common questions that parents ask concerning childhood lead poisoning and 
offers brief answers. English only. 
EPA: Lead Poisoning and Your Children 
Brochure targeted at parents. Created by the Environmental Protection Agency and lists sources of lead, ways in which 
children get contaminated and ways to prevent lead poisoning. Health care provider may request the brochures from EPA 
and receive 50 free copies - additional copies available for nominal cost. English only. 
*What Parents Need to Know About Lead Poisoning 
Handout targeted at parents. Describes lead's effect on a child’s body, sources of lead and ways to prevent lead 
poisoning. English and Spanish. 
• Item may be obtained by writing to Literature and Forms, 1100 W. 49th Street, Austin, TX 78756-3199, and stating name of the resource, the amount needed 
and the place to which copies should be mailed. 
34 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
TDH, Fall 1994 
APPENDIX H 
BIBLIOGRAPHY 
Amitai Y, Brown MJ, Graef JW, Cosgrove E. Effects of residential deleading on the blood lead levels of 
lead poisoned children. Pediatrics 88:893-842, Nov 1991. 
Aposhian HV, Aposhian MM. Meso-2,3-dimercaptosuccinic acid: chemical, pharmacological and 
toxicological properties of an orally effective metal chelating agent. Ann Rev Pharmacol Toxicol 
1990;30:279-306. 
ATSDR (Agency for Toxic Substance and Disease Registry). The nature and extent of lead poisoning in 
children in the United States: a report to Congress. Atlanta: ATSDR, 1988. 
Bellinger D, Sloman J, Leviton A, Rabinowitz M, Needleman H, Waternaux C. Low-level exposure and 
children's cognitive function in the preschool years. Pediatrics 1991;87:219-27. 
Bornschein RL, Succop PA, Kraft KM, Clark CS, Peace B, Hammond PB. Exterior surface dust lead, 
interior house dust lead and childhood lead exposure in an urban environment. In: Hemphill D, ed. Trace 
Substances in Environmental Health. Columbia, MO: University of Missouri Press, 1986:322-32. 
Centers for Disease Control. Preventing Lead Poisoning in young children: A statement by the Centers for 
Disease Control. Atlanta: CDC, 1985; CDC report no. 99-2230. 
Preventing Lead Poisoning in Young Children: A Statement by the Centers for Disease Control. Atlanta: 
Centers for Disease Control; 1985. 
Chisolm JJ Jr. The use of chelating agents in the treatment of acute and chronic lead intoxication in 
childhood. J Pediatr 1968;73:1-38. 
Chisolm JJ Jr. Management of increased lead absorption - illustrative cases. In: Chisolm JJ Jr, O'Hara 
DM, eds. Lead Absorption in Children: Management. Clinical. Environmental Aspects. Baltimore, MD: 
Urban and Schwarzenbert, 1982:171-88. 
Chisolm JJ Jr, Mellits ED, Quaskey SA. The relationship between the level of lead absorption in children 
and the age, type and condition of housing. Environ Res 1985;38:31-45. 
Chisolm JJ Jr. Evaluation of the potential role of chelating therapy in the treatment of low to moderate lead 
exposures. Environ Health Perspect 1990;89:67-74. 
Cory-Slechta DA, Weiss B, Cox C. Mobilization and redistribution of lead over the course of calcium 
disodium ethylenediamine tetraacetate chelation therapy. J Pharmacol Exp Ther 1987;243:804-13. 
DeSilva PE, Donnan MB. Petrol vendors, capillary blood lead levels, and contamination. Med J Aust 
35 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
TDH, Fall 1994 
1977;1:794-5. 
Environmental Protection Agency. Strategy for Reducing Lead Exposures: Report to Congress. Washington, 
DC: EPA, 1991. 
Emhart CB, Wolf AW, Kennard MJ, Erhard P, Filipovich HE, Sokol RJ. Intrauterine exposure to low levels 
of lead: the status of the neonate. Arch Environ Health 1986;41:287-91. 
Farfel MR, Chisolm JJ Jr. Health and environmental outcomes of traditional and modified practices for 
abatement of residential lead-based paint. Am J Public Health 1990;80:1240-5. 
Graziano JH, Lolacono NJ, Meyer P. Dose-response study of oral 2,3-dimercaptosuccinic acid in children with 
elevated blood lead concentrations. J Pediatr 1988;113:751-7. 
Kapoor SC, Wielopolski L, Graziano JH, Lolacono NJ. Influence of 2,3-dimercaptosuccinic acid on 
gastrointestinal lead absorption and whole-body lead retention. Toxic Appl Pharmacol 1989;97:525-9. 
McElvaine MD, Orbach HG, Binder S, Blanksma LA, Maes EF, Krieg RM. Evaluation of the erythrocyte 
protoporphyrin test as a screen for elevated blood lead levels, Chicago, Illinois, 1988-1989. J Pediatr (in press) 
1991. 
Markowitz ME, Rosen JF. Assessment of lead stores in children: validation of an 8-hour CaNa2EDTA 
provocative test. J Pediatr 1984;104:337-2. 
Markowitz ME, Rosen JF, Bijur PE. Effects of iron deficiency on lead excretion in children with moderate lead 
intoxication. J Pediatr 1990;116:360-4. 
Markowitz ME, Rosen JF. Need for the lead mobilization test in children with lead poisoning. J Pediatr 
1991;119:305-10. 
Mitchell DG, Aldous KM, Ryan FJ. Mass screening for lead poisoning: capillary blood sampling and automated 
Delves-cup atomic-absorption analysis. NY State J Med 1974;74:1599-1603. 
Mushak P, Davis JM, Crochetti AF, Grant LD. Prenatal and postnatal effects of low level lead exposure: 
integrated summary of a report to the U.S. Congress on childhood lead poisoning. Environ Res 1989;50:11-36. 
Needleman HL, Gatsonis CA. Low-level lead exposure and the IQ of children. JAMA 1990;263:673-8. 
Osterloh J, Becker CE. Pharmacokinetics of CaNa2EDTA and chelation of lead in renal failure. Clin Pharm 
Ther 1986;40:686-93. 
Perlstein, MA, Attala R. Neurologic sequelae of plumbism in children. Clin Pediatr 1966;5:292-8. 
36 Guidelines for the Prevention, Detection and Management of Lead Poisoning for Health Care Providers 
TDH, Fall 1994 
Piomelli S, Corash L, Corash MB, Seaman C, Mushak P, Glover B, Padgett R. Blood lead concentrations in 
a remote Himalayan population. Science 1980;210:1135-7. 
Piomelli S, Rosen JF, Chisolm JJ Jr, Graef JW. Management of childhood lead poisoning. J Pediatr 
1984;105:523-32. 
Rabinowitz MB, Wetherill GW, Kopple ID. Magnitude of lead intake from respiration by normal man. J Lab 
Clin Med 1977;90:238-48. 
Rosen JF, Markowitz ME, Bijur PE, Jenks ST, Wielopolski L, Kalef-Ezra JA, Slatkin DN. L-line x-ray 
fluorescence of cortical bone lead compared with the CaNa2EDTA-treated lead-toxic children. Environ Health 
Perspect (in press). 
Shannon M, Graef J, Lovejoy FH Jr. Efficacy and toxicity of D-penicillamine in low-level lead poisoning. J 
Pediatr 1988;112:799-804. 
Weinberger HL, Post EM, Schneider T, Helu B, Friedman J. An analysis of 248 initial mobilization tests 
performed on an ambulatory basis. Am J Pis Child 1987;141:1266-70. 
37 Texas Department of Health 
Stock No. 1-306 12/94