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!


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Sean M. Fox
Sean M. Fox
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