Management of Childhood Lead Poisoning

Objectives. No consensus exists regarding the preferred treatment of childhood lead poi soning. The authors used decision analysis to compare the clinical impacts and cost-ef fectiveness of four management strategies for childhood lead poisoning, and to investigate how effective chelation therapy must be in reducing neuropsychologic sequelae to warrant its use. Methods. The model was based on a 2-year-old child with moderate lead poisoning [blood lead level 1.21 to 1.88 μmol/L (25 to 39 μg/dL)]. The following strategies were compared: 1) no treatment; 2) EDTA provocation testing, followed by chelation if testing is positive (PROV); 3) penicillamine chelation with crossover to EDTA provocation testing if toxicity occurs (PCA); 4) EDTA provocation testing with crossover to penicillamine chelation if testing is negative (EDTA). Results. The EDTA and PCA strategies prevented 22.5% of the cases of reading disability and resulted in an increase of 1.02 quality-adjusted life years compared with no treatment. When the costs of outpatient EDTA testing and chelation are considered, the EDTA strategy is more cost-effective than the PCA strategy; when inpatient costs are considered, the PCA strategy becomes more cost-effective. When costs of remedial education are considered, all strategies are cost-saving compared with no treatment if che lation reduces the risk of lead-induced reading disability by more than 20%. Conclusions. Treatment strategies for childhood lead poisoning vary in clinical impact, cost, and cost- effectiveness. Chelation of the 1.4% of United States preschoolers whose blood lead levels are 1.21 μmol/L (25 μg/dL) or higher could prevent more than 45,000 cases of reading disability, and save more than $900 million per year in overall costs when the costs of remedial education are considered. Key words: lead poisoning; decision analysis; cost anal ysis ; chelation. (Med Decis Making 1995;15:13-24)