Initial Check


This Initial Check will help you assess your current knowledge about lead toxicity. To take the Initial Check, read the case below, and then answer the questions that follow.

Case Study

A father brings his 2-year-old boy into a pediatrician’s office for a routine well-child visit. The boys lives with his parents and an older sister in a rented apartment.

The pediatrician examines the boy and finds no abnormalities. The boy’s growth and development indicators are within normal limits for his age.

Three years later, concerned that her child is hyperactive, the mother brings the same child, now 5 years old, to your office (his previous pediatrician recently retired).

At a parent-teacher conference last week, the kindergarten teacher said that the boy seems impulsive and has trouble concentrating. They recommended evaluation by a physician as well as by the school psychologist. The mother states that her son has always seemed restless and easily distracted, but that these first 6 months in kindergarten have been especially difficult.

He has also complained recently of frequent intermittent abdominal pains and constipation. The mother gave him acetaminophen for stomach pains with little change. She has also been giving him a fiber laxative, which has reduced the frequency and severity of constipation. She wonders if the change to attending kindergarten has played a role in his increased complaints.

Family history reveals that the boy’s parents are divorced. He lives with his older sister, mother, and maternal grandparents in an older suburb of your community. The parents divorced when the boy was three years old. The father works in retail at a local shopping center. The child visits with his father one weekend a month, which is working out fine. However, he seems to be fighting more with his sister, who has been diagnosed with attention deficit hyperactivity disorder (ADHD) and is repeating first grade. Since the mother moved in with her parents after her divorce 2 years ago, she has worked with the grandfather in an automobile radiator repair shop, where her children often come to play after school. She has recently been laid off and has expressed worry about increasing financial dependence on her parents as the children grow older. She also worries that the grandfather, who has gout and complains increasingly of abdominal pain, may become even more irritable when he learns that she is pregnant from the father of her son. Her third child is due in 61/2 months. The father has no lead exposure risk factors.

When you inquire about the home, she explains that it was built in the 1960s. Her father bought it 30 years ago at a good price, as it is on a busy street close to the center of town. She has no idea of the type of pipes they have or the source of drinking water. They don’t use any kind of water filtration system. The yard is bare. She doesn’t see her father doing any improvements to the house due to his economic situation.

You ask about smoking habits and learn that the mother smokes up to a pack of cigarettes a day, sometimes in front of the children at home. The grandfather also smokes, but seldom in front of the children.

On chart review, you see that the previous pediatrician examined the boy for his preschool physical 1 year ago. A note describes a very active 4 year old who could dress himself without help but could not correctly name the primary colors. His vision was normal, but hearing acuity was below normal according to a hearing test administered for his preschool physical. The previous doctor noted that the boy’s speech and language abilities were slightly delayed. Immunizations are up to date.

Further history on last year’s visit indicated adequate diet, with no pica behavior. Hemoglobin 10 g/dL and low ferritin. Hematocrit was diminished at 30%. Peripheral blood smear showed hypochromia and microcytosis. There was no evidence of blood loss, and stool examination was negative for occult blood. The diagnosis was “mild iron deficiency anemia,” and elemental iron 5 milligrams/kilograms (mg/kg) per 24 hours (divided 3 times daily without food) was prescribed. The family failed to keep several follow-up appointments, but the child did apparently complete the prescribed 3-month course of iron supplements. He received no medications and had no known allergies. No psychological studies, learning, speech or behavioral evaluations were performed.

On physical examination today, you note that the boy is in the bottom 10th percentile for height and weight. The previous year he was plotted at the 20th percentile. His attention span is very short, making him appear restless. He has difficulty following simple instructions. Except for hearing acuity below normal, slightly delayed language, and social skills, the boy has reached most important developmental milestones.