Ingested Lead Foreign Bodies: Not a Typical FB

Foreign Bodies (FBs) are so commonly encountered in the Peds ED, sometimes it seems like they are not so “foreign.” FBs end up everywhere we look: in the Nose, Ear, Skin, Esophagus and Airway! Often they are relatively “easy” to manage; however, there are some unique FB’s that deserve specific consideration and may cause alterations in plans. Most notably, the Button Battery is a unique FB that requires special contemplation. Another unique FB is a pair of Magnets. While these two unique FBs readily come to mind, let’s take a minute to review another important one – Ingested Lead Foreign Bodies:

Bullets & Lead Poisoning

  • While the notion of high ballistic missiles (AKA bullets) leading to Lead Poisoning is often joked about… it is an actual concern.
    • Obviously, firearm safety (or lack of) is a completely different topic…
    • And penetrating trauma will take priority over toxicology concerns, but…
    • Patients shot by lead bullets have been found to have elevated lead levels! [McQuirter, 2003]
  • Ingestion leads to greater Lead exposure.
    • In firearm victims: [McQuirter, 2003]
      • Lead levels were higher if lead fragments entered the GI tract!
      • Lead levels rose more rapidly if fragments were in the GI tract.
    • Lead exposure can also occur in hunted animals and those who eat them. [Pain, 2010; Hunt, 2009]
      • I’ll let the irony sink in… …
      • Some nations are advocating using “lead-free” bullets as a way to diminish lead in our food chain. [Kanstrup, 2016]
      • Children are particularly at risk.

Lead Poisoning: Kids are at Greater Risk

  • Toddlers and infants like to put things in the mouths.
  • Children of all ages can have Pica… and ingest inedible materials containing lead.
  • Children absorb more lead through their GI tract than adults.
    • Children absorb ~30-50% of the ingested lead. [Rozier, 2018]
    • Adults absorb ~10% of ingested lead. [Rozier, 2018]
  • Lead can cross the child’s immature blood-brain barrier more easily than adults.

Ingested Lead Foreign Bodies

  • Obviously, more common lead exposures are due to Lead-based paints and unregulated Toys.
  • Ingestion of other lead-containing objects also warrant concern for rapid lead exposure:
    • Bullets
      • Buckshot ammunition is >95% lead.
    • Pellets (BBs) [Rozier, 2018]
    • Fishing Weights [Mowad, 1998]
    • Jewelry
  • Factors that influence lead absorption:
    • Age – children absorb more than adults (see above)
    • Particle size of lead FB [Rozier, 2018]
      • Smaller => higher absorption
      • Lead dust has highest absorption.
    • Large Surface Area => higher absorption [Rozier, 2018]
      • Lead in BBs, buckshot, lead pellets is more readily absorbed than that from a single bullet or fishing line weight.
    • GI Motility [Rozier, 2018]
      • Slow movement => ongoing and increased absorption

Ingested Lead Foreign Body: Management

  • Management should not be based solely on symptoms.
    • Acute ingestion does NOT necessarily cause acute lead poisoning symptoms!
    • Acute symptoms, however, may include:
      • Vomiting
      • Abdominal Pain
      • Chronic exposure affects numerous systems!
  • Get an X-ray! [Rozier, 2018]
    • If there is concern for possible lead FB, get an X-ray!
    • No FB… no lead.
    • If FB in STOMACH: [Rozier, 2018]
      • Consider endoscopic removal (especially larger item that may not move out of stomach)
      • Consider pro kinetic therapies.
      • Consider Polyethylene glycol 3350!
      • Obtain Lead Level (yes, even in this acute setting).
      • Consult Toxicology / Poison Control
    • If FB PAST stomach: [Rozier, 2018]
      • Start Polyethylene glycol 3350.
      • Check Lead Level.
      • Consult Toxicology / Poison Control
  • Monitor movement of FB. [Rozier, 2018]
    • If no passage of FB noted, repeat X-ray within 72 hours.
    • May require, although rarely, removal if still retained in intestines.
  • Acute Chelation Therapy
    • No lead level is “safe”
      • Lead should not be in human bodies.
      • Some argue this means there should be a low threshold for chelation.
    • Lead levels >44 mcg/dL -> start chelation
    • Lead levels >70 mcg/dL -> hospitalize and start chelation therapy.

Moral of the Morsel

  • Bullets are bad! Just in general… but also if children eat them!
  • Not all FBs are created equal. Know which ones warrant different considerations (ex, Button Batteries, Magnets) and put Lead Foreign Bodies on that list.
  • Lead FB in the stomach isn’t the same as a coin in the stomach. Lead levels can rise quickly!
  • Check that Xray! Look for the Lead!
  • Check the Lead Level! Yes… it can increase acutely… particularly in kids!

References

Rozier B, Liebelt E. Lead Pellet Ingestion in 3 Children: Another Source for Lead Toxicity. Pediatr Emerg Care. 2018 Aug 8. PMID: 30095594. [PubMed] [Read by QxMD]
Kanstrup N1, Thomas VG2, Krone O3, Gremse C4. The transition to non-lead rifle ammunition in Denmark: National obligations and policy considerations. Ambio. 2016 Sep;45(5):621-8. PMID: 27040101. [PubMed] [Read by QxMD]
Pain DJ1, Cromie RL, Newth J, Brown MJ, Crutcher E, Hardman P, Hurst L, Mateo R, Meharg AA, Moran AC, Raab A, Taggart MA, Green RE. Potential hazard to human health from exposure to fragments of lead bullets and shot in the tissues of game animals. PLoS One. 2010 Apr 26;5(4):e10315. PMID: 20436670. [PubMed] [Read by QxMD]
Hunt WG1, Watson RT, Oaks JL, Parish CN, Burnham KK, Tucker RL, Belthoff JR, Hart G. Lead bullet fragments in venison from rifle-killed deer: potential for human dietary exposure. PLoS One. 2009;4(4):e5330. PMID: 19390698. [PubMed] [Read by QxMD]
Gorospe EC1, Gerstenberger SL. Atypical sources of childhood lead poisoning in the United States: a systematic review from 1966-2006. Clin Toxicol (Phila). 2008 Sep;46(8):728-37. PMID: 18608287. [PubMed] [Read by QxMD]
McQuirter JL1, Rothenberg SJ, Dinkins GA, Norris K, Kondrashov V, Manalo M, Todd AC. Elevated blood lead resulting from maxillofacial gunshot injuries with lead ingestion. J Oral Maxillofac Surg. 2003 May;61(5):593-603. PMID: 12730839. [PubMed] [Read by QxMD]
McNutt TK1, Chambers-Emerson J, Dethlefsen M, Shah R. Bite the bullet: lead poisoning after ingestion of 206 lead bullets. Vet Hum Toxicol. 2001 Oct;43(5):288-9. PMID: 11577935. [PubMed] [Read by QxMD]
Mowad E1, Haddad I, Gemmel DJ. Management of lead poisoning from ingested fishing sinkers. Arch Pediatr Adolesc Med. 1998 May;152(5):485-8. PMID: 9605033. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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