Despite decades of environmental reform, legacy lead is a persistent health hazard within communities. Secondary prevention with screening for childhood lead exposure typically occurs at the 12-month and 24-month well visits, and early identification of toxicity is of vital importance to reduce morbidity and mortality. Over the past few years, there have been multiple challenges impacting the management of lead toxicity, including the coronavirus disease 2019 pandemic, a national shortage of the chelation agent CaNa2EDTA, and housing-related concerns that may result in re-exposure of lead before lead abatement. This report identifies the importance of lead screening and limitations that a pandemic has placed on health care while emphasizing access to care and community resources needs to be a priority.

Providers and public health officials continue to advocate for increased effort to identify and eliminate sources of lead in communities to reduce toxicity and prevent exposure.1,2 Nationwide, children from racial and ethnic minorities are disproportionately affected and 2 to 3 times more likely to have high blood lead levels.3 Our report illustrates the challenges with adequately managing lead toxicity during the coronavirus disease 2019 (COVID-19) pandemic. Our institution, a free-standing pediatric tertiary care facility in Northeast Ohio, features a multidisciplinary lead clinic where patients receive collaborative care from a pediatrician, pharmacologist-toxicologist, and neuropsychologist, as well as support from social work and legal aid.

A 30-month-old, former full-term female with sickle cell trait presented to her pediatrician for her 2-year well-child visit in 2022 during the COVID-19 pandemic. No concerns were noted regarding the patient’s development and overall health. Previous capillary lead levels had been high (5 mcg/dL at her 12-month visit and 7 mcg/dL at her 18-month visit); the patient’s pediatrician ordered a venous blood lead level (BLL) and discussed the importance of this confirmatory laboratory with the child’s caregiver; however, the venous sample was never collected. A capillary lead level was repeated at this 2-year visit and resulted the following day as >120 mcg/dL. The caregiver was advised to take the patient to the emergency department. In the emergency department, she was neurologically appropriate. Her workup included venous BLL, a complete blood count pertinent for microcytic anemia (hemoglobin 10.4 g/dL, mean corpuscular volume 61.4, red cell distribution width 15.7%), and a complete metabolic panel that was unremarkable. In addition, zinc protoporphyrin was ordered and resulted several days later as 582 mcg/dL (reference range <60 mcg/dL). An abdominal x-ray identified radiopaque densities concerning for ingested lead paint chips. The patient was admitted to the hospitalist service for a nasogastric cleanout to remove the particulate matter. Her venous BLL resulted as >120 mcg/dL the following morning and chelation was initiated.

Typically, screening for lead toxicity occurs at 12 and 24 months of age with additional testing based on the risk.1 There is no safe BLL; however, in 2021, the Centers of Disease Control and Prevention lowered the blood lead reference value to 3.5 mcg/dL.4 Our institution performs universal screening at 12 months of age, risk-based screening at 24 months of age, and catch-up screening for children at high risk between 12 months to 6 years of age,5 which is assisted by electronic health records clinical decision support tools.6 Electronic tools also alert providers when patients need follow-up levels because of previously high BLL. Blood is drawn during office visits and sent to the centralized laboratory within our hospital system; however, this process is not always available in all health care systems, and there have been recalls of testing equipment.7 Scheduled well-child visit care was disrupted during the pandemic, significantly impacting the structure of screening children for lead toxicity.7 

Historically, patients with BLL 70 mcg/dL or greater are treated with dual chelation therapy consisting of CaNa2EDTA and dimercaprol.8 However, the CaNa2ETDA was unavailable nationally during the patient’s admission and the pharmaceutical shortage resulted in deviation from the standard therapy. For this patient, dimercaprol intramuscular injections were administered and succimer was started on day 2 of therapy. The patient’s BLL showed a dramatic decrease to 35.8 mcg/dL following completion of 3 days of dimercaprol and 1 day of succimer. Succimer was continued at discharge to complete a 19-day course, and she was to follow-up with the lead clinic.

Drug shortages impacting medication options are unfortunately a common occurrence in health care and have affected all 3 primary lead chelators.9,10 In 2021, the oral option of succimer was on shortage for close to 9 months,11 whereas the drug shortage of calcium disodium versenate injection only recently resolved in 2023 after not being available for over 2 years.11 Dimercaprol injection is part of the regimen for BLL 70 mcg/dL or greater; however, the company manufacturing this drug filed for bankruptcy in 2023, so this drug is not available.11 Adapting to the chelator shortages adds to the complexity of adequately treating lead toxicity.12 Even if the chelator is available, cost can be a barrier for quickly obtaining the drug for patients.12 

This patient lived in a home owned by her grandparents that was built in 1916. In addition to being over a century old, a construction project was started in the home approximately 1 month before admission. Although the patient’s mother had not observed any of her children ingesting paint or dust, she later found peeling paint in the bathroom. The patient’s siblings were also tested for lead, and 2 were found to have high BLL. The family then stayed with a relative for approximately 2 weeks while their home was evaluated by the health department. Sources of lead were identified, and abatement was planned for the following month. The health department permitted the family to stay in the home in the interim. Once abatement started, the family relocated to a hotel. However, high zinc protoporphyrin (1325 mcg/dL) and BLL (62.4 mcg/dL) drawn 6 weeks after chelation suggest that re-exposure may have occurred before abatement.

Seeking alternative housing for families adds an additional challenge to an already stressful situation. Finding new housing may seem theoretically feasible but requires time, expense, and physical resources. Families must pay the landlord a security deposit and first month’s rent, and this alone may be prohibitively expensive. Unfortunately, there is little financial assistance available to help with those costs. There are programs that provide aid for moving expenses and security deposits; however, those funds are limited in size and availability. The short-term influx of COVID-related rental assistance only highlighted the long-term need for housing-related financial help.

Nationwide, 49% of homes were built before 1980, whereas in Ohio, 64% of homes were built before 1980. The communities served by our institution, which provides care across 33 counties in Ohio, include many old architecture and residences. There are a number of similar communities spread throughout the United States. In Summit County, where our institution is based, 68% of occupied homes were built before 1980,13 and 71% percent of occupied rental homes were built before 1980.14 In Akron, Summit’s county seat, the numbers are even higher, with 85% of occupied homes built before 1980. As a result, the children who live in Akron are particularly at risk for lead exposure. Public policy can be an additional challenge for families looking to relocate since it is rare to find both safe and affordable housing. For families fortunate enough to have a housing voucher, landlords in most Ohio communities can refuse to rent to the family simply because of the voucher. Affordable housing is often located in areas of less opportunity, which creates short- and long-term issues for families, particularly children. Attempts to build safe and affordable housing in areas of higher opportunity often face community opposition based on inaccurate beliefs of how that housing will affect the surrounding neighborhoods.15 Many families are left with limited options and are faced with the difficult decision of staying in the home that is poisoning their child or relocating to a suboptimal environment and circumstances.

This patient has remained asymptomatic from a gross neurologic perspective despite requiring multiple courses of chelation therapy; however, the neurocognitive effects may not manifest until she is older. Although neurodevelopmental and eventual neuropsychological evaluations could serve to identify deficits and any need for interventions and services, and to provide psychoeducation for the family and school teams, no neurodevelopmental evaluation has been completed with the presented patient because of a lack of concerns. Patients like this should continue to be closely monitored and referred for baseline neuropsychological evaluations.

For many years, research has suggested an increased risk for developmental and later cognitive deficits in children exposed to lead, including decreased processing speed, visuo-spatial skills, fine motor skills, attention, and executive functioning (ie, skills needed to accomplish a goal).16 Factors also impacting the relationship between lead exposure and neurodevelopmental outcomes include age of exposure, duration of exposure, severity of exposure, gender, nutrition, level of stimulation provided within the child’s environment, and other effect modifiers (eg, iron deficiency).17 Most lead research has focused on neurodevelopmental impact on the basis of peak BLL alone; however, an alternate theory for examining risk of deficits has been proposed.18 Nie et al18 identified that a “Cumulative Blood Lead Index” (a formula arrived at by collecting blood lead levels over an extended period of time) was a better predictor of neurodevelopmental concerns than individual acute readings or levels. This finding suggests that early identification is imperative in the prevention of later deficits, regardless of peak BLL, so that longer periods of exposure can be avoided.18 Further, the fact that lead at any level increases the risk for neurodevelopmental deficits has become widely accepted. Recent research has accordingly shifted its focus to identify biomarkers for the relationship between lead and neurodevelopmental delay, as well as genetic factors that could increase one’s vulnerability to lead toxicity.19–21 Future research could perhaps help to determine how certain patients could exhibit seemingly no clinically overt pathology despite significantly high levels for an extended period.

When a high blood lead level is the result of the child’s housing, several immediate problems arise. The most immediate issue is relocating the family to lead safe housing, particularly when the lead abatement work begins. In some situations, a landlord has lead safe housing available. More often, however, the family needs to move into less-than-ideal housing, such as a hotel. There has been some success with having a landlord pay for a hotel, however, the local health department or a nonprofit often steps in to pay. The next issue is paying for the lead abatement work. Lead abatement grants are generally available throughout the country from state and local governments; however, there can be a shortage in the supply of contractors who are certified to abate houses.

Increasing the availability of multidisciplinary clinics, similar to our clinic, to address lead toxicity would be advantageous for families. This allows for multiple needs to be addressed at 1 appointment, which eases the burden for families in an already stressful situation. It also facilities connecting providers and enhancing communication to address patient specific needs.

The longer-term issue is why we use children as a way to see if a house has accessible sources of lead. In Ohio, 2 cities – Cleveland and Toledo – have passed laws requiring inspections for some rental houses. However, both cities have faced legal challenges from landlords that have slowed the inspection process. Until those laws are fully implemented and there is enough data to show the positive effects of preventive inspections, other jurisdictions are less likely to adopt similar laws.

Northeast Ohio, like many regions in the United States, continues to face difficulties in adequately addressing lead exposure and managing toxicity as depicted with this patient. Management of her lead toxicity was impacted by obstacles, including the COVID19 pandemic, drug shortages, and housing-related issues. Developing multidisciplinary lead toxicity teams is one approach to allow for different needs to be addressed during 1 appointment, which could improve patient care. Health care providers will need to continue educating families on the danger of lead, question about personal risk factors, screen children up to the age of 6 years based on risk factors, and provide them with guidance on ways to minimize exposure until primary prevention strategies are prioritized.

Drs Dreher and Blackford provided direct patient care to the patient depicted in this case, conceptualized the paper, wrote the original manuscript, and revised the final manuscript; Drs Davidson, Schneider, and Printy, and Mr Neuhauser critically reviewed and revised the manuscript; Dr Besunder supervised and interpreted the data and critically reviewed and revised the case; and all authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the information presented.

BLL

blood lead level

ED

emergency department

1
Council on Environmental Health
.
Prevention of childhood lead toxicity
.
Pediatrics
.
2016
;
138
(
1
):
e20161493
2
Schuch
L
,
Curtis
A
,
Davidson
J
.
Reducing lead exposure risk to vulnerable populations: a proactive geographic solution
.
Annals of the American Association of Geographers
.
2017
;
107
(
3
):
606
624
3
Yeter
D
,
Banks
EC
,
Aschner
M
.
Disparity in risk factor severity for early childhood blood lead among predominantly African-American Black children: the 1999 to 2010 US NHANES
.
Int J Environ Res Public Health
.
2020
;
17
(
5
):
1552
4
Centers for Disease Control and Prevention
.
Recommended actions based on blood lead level
. Available at: https://www.cdc.gov/lead-prevention/hcp/clinical-guidance/?CDC_AAref_Val=https://www.cdc.gov/nceh/lead/advisory/acclpp/actions-blls.htm. Accessed October 10, 2023
5
Ruckart
PZ
,
Jones
RL
,
Courtney
JG
, et al
.
Update of the blood lead reference value - United States, 2021
.
MMWR Morb Mortal Wkly Rep
.
2021
;
70
(
43
):
1509
1512
6
Davidson
JR
,
Karas
DR
,
Bigham
MT
.
Improving lead screening rates in a large pediatric primary care network
.
Pediatr Qual Saf
.
2021
;
6
(
5
):
e478
7
Woolf
AD
,
Brown
MJ
.
Old adversary, new challenges: childhood lead exposure and testing
.
Pediatrics
.
2022
;
149
(
5
):
e2021055944
8
Markowitz
M
.
Lead poisoning: an update
.
Pediatr Rev
.
2021
;
42
(
6
):
302
315
9
Fox
ER
,
McLaughlin
MM
.
ASHP guidelines on managing drug product shortages
.
Am J Health Syst Pharm
.
2018
;
75
(
21
):
1742
1750
10
Shachar
C
,
Gruppuso
PA
,
Adashi
EY
.
Pediatric drug and other shortages in the age of supply chain disruption
.
JAMA
.
2023
;
329
(
24
):
2127
2128
11
ASHP
.
Drug shortages list
. Available at: https://www.ashp.org/drug-shortages/current-shortages/drug-shortages-list?page=All. Accessed October 10, 2023
12
Mazer-Amirshahi
M
,
Fox
ER
,
Routsolias
JC
,
Johnson-Arbor
K
,
Mycyk
MB
.
How can we “get the lead out” without chelators?
J Med Toxicol
.
2021
;
17
(
4
):
330
332
13
United States Census Bureau
.
Year structure built
. Available at: https://data.census.gov/table/ACSDT1Y2021.B25034?q=housing+year+built+summit+county,+ohio. Accessed October 10, 2023
14
United States Census Bureau
.
Tenure by year structure built
. Available at: https://data.census.gov/table/ACSDT1Y2021.B25036?q=rental+housing+year+built+summit+county,+ohio. Accessed October 10, 2023
15
Brian
YA
,
Jakabovics
A
,
Liu
J
, et al
.
Factors affecting spillover impacts of low-income housing tax credit developments: an anaylsis of Los Angeles
.
Cityscape
.
2023
;
25
(
2
):
309
363
16
Chiodo
LM
,
Jacobson
SW
,
Jacobson
JL
.
Neurodevelopmental effects of postnatal lead exposure at very low levels
.
Neurotoxicol Teratol
.
2004
;
26
(
3
):
359
371
17
Bellinger
DC
.
Very low lead exposures and children’s neurodevelopment
.
Curr Opin Pediatr
.
2008
;
20
(
2
):
172
177
18
Nie
LH
,
Wright
RO
,
Bellinger
DC
, et al
.
Blood lead levels and cumulative blood lead index (CBLI) as predictors of late neurodevelopment in lead poisoned children
.
Biomarkers
.
2011
;
16
(
6
):
517
524
19
Bellinger
DC
,
Malin
A
,
Wright
RO
. Chapter one - the neurodevelopmental toxicity of lead: history, epidemiology, and public health implications. In:
Advances in Neurotoxicology
.
Vol 2
.
Elsevier
;
2018
:
1
26
20
Sanders
T
,
Liu
Y
,
Buchner
V
,
Tchounwou
PB
.
Neurotoxic effects and biomarkers of lead exposure: a review
.
Rev Environ Health
.
2009
;
24
(
1
):
15
45
21
Gundacker
C
,
Forsthuber
M
,
Szigeti
T
, et al
.
Lead (Pb) and neurodevelopment: a review on exposure and biomarkers of effect (BDNF, HDL) and susceptibility
.
Int J Hyg Environ Health
.
2021
;
238
:
113855

Competing Interests

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose.