available These findings include (i) microcytic anemia; (ii) elevated EP level, especially if higher than 250 mcg/dL (conversely, a normal or minimally elevated EP level, less than 50 mcg/dL, would make lead encephalopathy caused by chronic lead paint exposure unlikely); (iii) basophilic stippling of peripheral erythrocytes or, if feasible, of red blood cell precursors on bone marrow examination; (iv) glycosuria; (v) aminoaciduria; (vi) radiopaque flecks on abdominal radiographs; and (vii) dense metaphyseal bands on radiographs of knees and wrists (lead lines— Fig 102.11 ) Abnormalities on examination of cerebrospinal fluid (CSF) are also indicative of lead encephalopathy, including a lymphocytic pleocytosis, elevated protein level, and increased pressure The treatment of lead poisoning involves relocation of the child to a lead-free environment, consideration of chelation therapy, and appropriate supportive care Symptomatic patients are at risk of developing encephalopathy with subsequent death or neurologic sequelae In addition, asymptomatic patients with high BLL (especially higher than 100 mcg/dL) are also at significant risk for developing CNS involvement and might require urgent treatment Routine chelation is not indicated for children with BLL less than 45 mcg/dL The specific chelating drugs commonly used for symptomatic lead intoxication are edetate calcium disodium (CaNa2 EDTA) and 2,4-dimercaptopropanol (British Anti-Lewisite [BAL]; Table 102.16 ) Side effects of CaNa2 EDTA include local reactions at injection sites, fever, hypercalcemia, and renal dysfunction manifested by rising BUN and abnormal urine sediment with proteinuria, hematuria, and/or epithelial cells The major side effects of BAL include nausea and vomiting, so for the first day or two of BAL therapy, it is prudent to maintain the patient on IV fluids and clear liquids or nothing by mouth BAL is formulated in peanut oil, is given only by IM injection, and also induces hemolysis in patients with G6PD deficiency Its use is hazardous if the patient has severe hepatic dysfunction, and it forms a toxic complex if given concurrently with iron Succimer (dimercaptosuccinic acid [DMSA]) has been approved for pediatric use in cases in which BLL exceeds 45 mcg/dL ( Table 102.16 ) This water-soluble analog of BAL may be taken orally, and several studies have found such use to be as effective as CaNa2 EDTA given parenterally