Pediatric Primary Care (122 page)

b.  Iron chelation therapy—transfusions can lead to a build up of iron in the blood.

•  Deferoxamine—liquid given slowly under the skin with a pump; takes time and is often painful and side effects include loss of vision and hearing.

•  Deferasirox—pill taken once a day; side effects include headache, nausea, vomiting, diarrhea, joint pain, and fatigue.

c.  Folic acid supplements—a B vitamin that helps build healthy RBCs.

d.  Bone marrow/stem cell transplant—only cure for thalassemia.

I.  Follow up.

1.  Well-child physical as indicated.

2.  Vaccines as scheduled.

3.  Follow with hematology physicians on routine basis.

J.  Complications.

1.  Heart disease—caused by iron overload from the transfusions.

2.  Heart attack.

3.  Arrhythmias.

4.  Heart failure.

5.  Liver disease—also caused by iron overload and damage to the organ.

6.  Infection—risk of infection higher in persons whose spleen has been removed.

7.  Osteoporosis.

K.  Education.

1.  Follow the treatment plan as outlined by the doctor/clinic.

a.  Blood transfusions as needed.

b.  Chelation medications to be taken as prescribed.

c.  Take your folic acid supplements.

2.  Routine maintenance.

a.  Yearly well child checks (WCC).

•  Height and weight.

•  Test for iron build up in the liver.

•  Vision and hearing tests.

b.  Monthly CBCs.

c.  Quarterly tests for iron build up in the blood.

3.  Measures to stay healthy.

a.  Healthy eating.

b.  Vaccinations as scheduled.

c.  Watch for signs of infection.

d.  Wash hands.

e.  Avoid crowds during cold and flu season.

f.  Call clinic/doctor if develop fever.

4.  Support groups—parents and children.

III.  LEAD POISONING

A.  Most common, widespread environmental health concern, especially for children younger than 6 years of age. Can cause decrease in gestational weight and age; may increase possibility of stillbirths and miscarriages.

B.  Etiology.

1.  Increased lead levels in children occur by exposure to deteriorating paint, household dust, bare soil, air, drinking water, food, ceramics, home remedies, hair dyes, other cosmetics. Usually exposure is in child's own home.

2.  Manufacture, use, disposal of modern products containing lead results in fine lead particles that release into environment. Lead particles enter air, water, food; also contaminate soil, dust.

3.  Lead containing toys, crayons, soft vinyl lunch boxes.

C.  Occurrence.

1.  Estimated at least 400,000 children younger than 6 years of age have too much lead in their bodies.

2.  Questions for assessing risk of lead poisoning:

a.  Live in, regularly visit, or have lived in a place with peeling or chipping paint built before 1960?

•  Includes daycare, preschools, homes of babysitters, relatives.

•  Houses with recent, ongoing, planned renovation or remodeling.

b.  Brother or sister, housemate, playmate being followed or treated for lead poisoning (blood level > 15 mcg/dL)?

c.  Live with adult whose job or hobby involves exposure to lead?

•  Ceramics, furniture refinishing; stained glass work; construction workers.

d.  Taking home remedies such as azarcon and greta?

e.  Live near active smelter, battery-recycling plant, other industry likely to release lead into air?

3.  Lead toxicity is decreasing in the United States but approximately 25% of children still live in housing with deteriorating lead-based paint.

D.  Clinical manifestations.

1.  Many symptoms resemble common childhood complaints: headache, stomachache, irritability, tiredness, poor appetite.

2.  Other subtle symptoms: poor attention span and memory, sleep disorders.

3.  All of these can lead to coma and death because not noticed until brain damage has already occurred. Once organ systems are damaged, damage often irreversible.

E.  Physical findings.

1.  Weight loss, decreased growth.

2.  Muscular weakness (diminished reflexes).

3.  Seizures (signs of anemia).

4.  Loss of visual motor coordination.

5.  Irritability.

6.  Constipation, abdominal pain.

7.  Learning difficulties/cognitive impairment.

F.  Diagnostic tests.

1.  CBC.

2.  Lead blood levels: < 10 mcg/dL. Screening tests as recommended by Centers for Disease Control and Prevention (CDC)
(
Table 32-2
).

3.  Free erythrocyte protoporphyrin (FEP): elevated.

Table 32-2
CDC Recommendations for Follow-Up Lead Blood Level Measurements

Source:
Data from Centers for Disease Control and Prevention. Recommendations for follow-up lead blood level measurements. Retrieved March 2004, from:
www.cdc.gov
; Cohen, S. (2001). Lead poisoning: A summary of treatment and prevention.
Pediatric Nursing
, 27, 125.

G.  Differential diagnosis.

1.  Neurologic problems (unexplained seizures, behavioral disorders).

2.  IDA.

3.  Unexplained abdominal pain.

H.  Treatment.

1.  Lead blood level determines treatment (
Table 32-2
).

2.  Alteration in environment; stop unusual exposure to lead.

3.  Good nutrition.

4.  Chelation therapy.

a.  British anti-Lewisite (BAL).

b.  Edetate calcium disodium (CaNa2EDTA).

c.  Dimercaptosuccinic acid (DMSA) or Succimer.

d.  
D
-Penicillamine.