Conceptual and practical advances in the measurement and clinical management of lead toxicity.

The purpose of this paper is to discuss issues which relate to the risks and benefits of pharmacologic intervention in children with elevated blood lead (BPb) concentrations. In January, 1991, 2,3-dimercaptosuccinic acid (DMSA; succimer or CHEMET) was approved by the FDA for administration to children with blood lead concentrations of 45 micrograms/dl or higher. Thus, it is now considerably simpler to treat children with elevated BPb's. DMSA is orally actively, relatively safe and specific, and can, in some situations, be used on an out-patient basis. The author is concerned that the recent CDC statement on lead poisoning, whose aim is to reduce (by various means) children's BPb's below 10 micrograms/dl, may unintentionally encourage pediatricians to treat children with relatively low BPb's with DMSA, both for medical and legal reasons. Should children with BPb's of less than 45 ug/dl be treated, and why? The risks and benefits of treatment in such children are uncertain. A randomized, placebo controlled, double-blind drug intervention trial is needed (and justified) in order to more carefully assess the benefits and the risks associated with the treatment of lower BPb's.