From the accidental ingestion of grandma’s blood pressure medication to novel drug exposures in adolescents, the Washington University toxicology service cared for many patients at the bedside in 2020. Although many patients with an acute ingestion may require referral to a healthcare facility, there are many toxic exposures including exposure to lead which can be effectively managed in the outpatient setting in the majority of cases. To better treat kids with a toxic exposure, Washington University and St. Louis Children’s Hospital established the Pediatric Toxicology and Lead Clinic in September 2020.
Dr. Jason Devgun joins the show to discuss some of the more common exposures children experience and the services offered by the pediatric toxicology clinic.
Selected Podcast
Pediatric Toxicology and Lead Clinic
Featured Speaker:
Jason Devgun, MD
Dr. Devgun is an Assistant Professor of Emergency Medicine and board certified in emergency medicine and medical toxicology. Transcription:
Melanie Cole, MS (Host): From the accidental ingestion of blood pressure medication to novel drug exposure in adolescents, there are many toxic exposures including exposure to lead which can be effectively managed in the outpatient setting. You're listening to Radio Rounds, the podcast series from Washington University pediatric specialists at St. Louis Children’s Hospital. I'm Melanie Cole, and I invite you to listen in as we discuss the pediatric toxicology and lead clinic at St. Louis Children’s Hospital. Joining me is Dr. Jason Devgun. He’s a pediatric medical toxicologist at St. Louis Children’s Hospital and an assistant professor in emergency medicine at Washington University School of Medicine. Dr. Devgun, it’s a pleasure to have you with us today. Let’s start with what you're seeing in the trends for toxic exposures. What are some of the more common toxic exposures that you see in our youth?
Jason Devgun, MD (Guest): Well, thank you for having me. From the inpatient side, it depends on the age range. In our pre 18 month children, unfortunately, the cases we’re seeing are iatrogenic drug exposures. So namely from the home environment or care providers in the home. We’re frequently called to interpret results of urine drug testing from outside hospitals as well as our own drug testing here at St. Louis Children’s which goes directly to a targeted mass spec. In the top of range are most common calls for exploratory ingestions. So typically older care providers, grandparents, great aunt, great uncles have their medications stored in pill providers and are more likely to have a stray pill that children can easily get into. We actually tend to see less consults in the four to twelve year age range outside of snake envenomations, which are certainly common around here in the summer months. In our adolescents, we see consults similar to our adult populations. So a whole range of ingestion of analgesics or antidepressants, and then of course recreational and novel psychoactive substances to keep us on our toes. As far as the outpatient setting, this is relatively new for this group. We envision the majority of our patients comprising lead exposed patients and post-discharged follow-ups for our snake envenomations.
Host: Well thank you for that doctor. So tell us about the pediatric toxicology and lead clinic. Why was it established? How did it come about? Why did you see this need?
Dr. Devgun: Right. So actually in our area there isn’t another resource that provides this service. So there's a dedicated lead clinic in Chicago through Lurie Children’s, and at least I recall from my time in fellowship out there, there's also one in Children’s Mercy Kansas City. To my knowledge, there's no outpatient toxicology clinic between those areas. We saw this as an opportunity to provide services not only in the St. Louis metropolitan area, but hopefully through virtual visits to cover that need throughout Missouri and southern Illinois.
Host: Well then tell us about the services you provide Dr. Devgun. Tell us about any lab or physician services. What's it like?
Dr. Devgun: Sure. So for our follow up patients, we’re able to coordinate through the St. Louis Children outpatient lab getting outpatients blood levels. If there's a question of potential leaded foreign body, they can get an x-ray for that. We’re mostly focused on the chronic lead exposed child and follow up. So this clinic isn’t for acute exposures or what would normally be reported to the poison center, but frequently a child with an elevated lead level will have an elevated lead level for some period of time perhaps even despite treatment. We’re able to take a lot of the burden that would be on normal pediatrician’s offices to follow up on environmental assessments by say the local public health department and sort of trend and follow those lead levels, including potentially if they need treatment with chelation.
Host: Well, let’s expand a little more on lead exposure Dr. Devgun. Are there warning signs for pediatricians that you would like them to be aware of? What are some of the long term effects that you’ve seen of lead exposure and children’s health effects based on blood lead levels? What happens if they're left untreated?
Dr. Devgun: So thankfully lead exposure and lead toxicity is on the radar for most outpatient pediatricians. So certainly the number one risk factor is living in an area that has older housing and exposure to lead paint. So typically this is done by screening either based on high risk areas by zip code or by screening questionnaires would be the most common reasons why a child would have a blood level drawn. So thankfully severe lead poisoning is rare these days. At the same time, over the last 20 years or so our understanding of lead as a neurotoxin and what constitutes the level of concern has changed. So our current CDC recommendations for a potential level of concern if five micrograms per deciliter. It used to be higher for that. With lowering that level of concern, they’ve also recommended more targeted screening. So, as I mentioned, high risk areas and screening questionnaires. The effects of lead in children—So even at the five microgram per deciliter, current evidence has suggested even lower than that where children can have neurotoxic effects. The unfortunate problem is our medications and our available treatment for lowering lead level at that low level exposure is limited. So chelation such as succimer, which is an oral medication, or calcium disodium EDTA are typically reserved for children with much higher lead levels exceeding 45 micrograms per deciliter. As far as warning signs, certainly anemia and behavioral changes are the most common signs. Unfortunately in the age group that we typically see lead poisoning, in toddlers, these are also common complaints. So it can make it challenging to pick up on perhaps a low level lead exposure.
Host: Is this clinic for acute exposures Dr. Devgun? How are your services different than the poison center?
Dr. Devgun: Right. So that’s a great question. So our clinic isn’t necessarily meant to replace the poison center or an inpatient toxicology service. So this is mainly meant for subacute or chronic exposures. That being said, we’re actually already fielding many of these calls through the Children’s Direct transfer line from pediatrician’s offices that have an elevated level and they're looking for advice on how frequently to check labs, treatment options. So we find that this is a service that hasn’t been available previously and can certainly help the community.
Host: Now, do you very often have to admit treatment if they have this lead exposure? Speak about that. If they are admitted, tell us about discharge planning. How do you help them with some home hazard reduction measures?
Dr. Devgun: Right. So thankfully there are not many lead exposed children that we have had admit to the hospital. Probably the most common reason for that would be an acute ingestion of a leaded foreign body. So lead paint. We’ve seen occasionally small toys or trinkets that have lead in them, lead sinkers. So those would all be potential reasons, or an elevated lead level that may require treatment to be started in the hospital. In terms of large part of inpatient hospitalization is focused on discharge planning and ensuring that the home environment is safe. Probably the most important interventions are preventing exposure, especially because our treatments at the levels that can cause potential neurologic problems are imperfect. So communicating with the local health department, having an environmental assessment of the home. In some cases, that may require the child temporarily housing with a relative or instituting some temporary lead abatement in the home itself.
Host: When should a physician refer to the clinic Dr. Devgun? Do you need a physician referral? Can patients call themselves? Please give us the indications for a referral and why it’s so important for early referral.
Dr. Devgun: We’re currently taking patients referred through a primary pediatrician office. We’re happy to see any child with an elevated lead level. So it’s usually five microgram per deciliter or more that the pediatrician would like assistance in managing. Certainly, we’re interested in patients with chronically elevated lead levels or those certainly that have a potentially treatable lead level. So greater than 45 microgram per deciliter or more, we’re definitely interested in seeing those patients, but we’re happy to see any lead exposed patients. With regards to some of the other services that we would offer including follow up post snake envenomation, a lot of those patients are actually referred from outside hospitals to us at St. Louis Children’s. So usually we’re able to see them, and thankfully most of our snake envenomations in the Missouri area are milder than in the southwest where rattlesnakes are more predominant. Occasionally we do get people that have persistent swelling or pain and would like or need follow up.
Host: As we wrap up Dr. Devgun, please let other providers know what you would like them to know about the pediatric toxicology and lead clinic at St. Louis Children’s Hospital, and just give us your best advice about lead exposure.
Dr. Devgun: Certainly, we want to let pediatricians know that this service is available. We have ability to see children both in person and virtually in Missouri as well as virtual visits in Illinois. We do have an inpatient toxicology service. We’re here through Children’s Direct for transfers that come to St. Louis Children’s. Through Children’s Direct, especially for our Children’s affiliated pediatricians, are able to take any information or referrals. Although we started the pediatric toxicology clinic as telehealth only, we’ve recently had the ability to schedule in person visits for all age ranges here on the Wash U St. Louis Children’s campus.
Host: Dr. Devgun, what an informative episode. Thank you so much. To refer a patient to the pediatric toxicology and lead clinic at St. Louis Children’s Hospital, please call the Children’s Direct physician access line at 1-800-678-HELP or you can visit stlouischildrens.org to get connected with one of our providers. That concludes this episode of Radio Rounds, the podcast series from Washington University pediatric specialists at St. Louis Children’s Hospital. Please remember to subscribe, rate, and review this podcast and all the other St. Louis Children’s podcasts. I'm Melanie Cole.
Melanie Cole, MS (Host): From the accidental ingestion of blood pressure medication to novel drug exposure in adolescents, there are many toxic exposures including exposure to lead which can be effectively managed in the outpatient setting. You're listening to Radio Rounds, the podcast series from Washington University pediatric specialists at St. Louis Children’s Hospital. I'm Melanie Cole, and I invite you to listen in as we discuss the pediatric toxicology and lead clinic at St. Louis Children’s Hospital. Joining me is Dr. Jason Devgun. He’s a pediatric medical toxicologist at St. Louis Children’s Hospital and an assistant professor in emergency medicine at Washington University School of Medicine. Dr. Devgun, it’s a pleasure to have you with us today. Let’s start with what you're seeing in the trends for toxic exposures. What are some of the more common toxic exposures that you see in our youth?
Jason Devgun, MD (Guest): Well, thank you for having me. From the inpatient side, it depends on the age range. In our pre 18 month children, unfortunately, the cases we’re seeing are iatrogenic drug exposures. So namely from the home environment or care providers in the home. We’re frequently called to interpret results of urine drug testing from outside hospitals as well as our own drug testing here at St. Louis Children’s which goes directly to a targeted mass spec. In the top of range are most common calls for exploratory ingestions. So typically older care providers, grandparents, great aunt, great uncles have their medications stored in pill providers and are more likely to have a stray pill that children can easily get into. We actually tend to see less consults in the four to twelve year age range outside of snake envenomations, which are certainly common around here in the summer months. In our adolescents, we see consults similar to our adult populations. So a whole range of ingestion of analgesics or antidepressants, and then of course recreational and novel psychoactive substances to keep us on our toes. As far as the outpatient setting, this is relatively new for this group. We envision the majority of our patients comprising lead exposed patients and post-discharged follow-ups for our snake envenomations.
Host: Well thank you for that doctor. So tell us about the pediatric toxicology and lead clinic. Why was it established? How did it come about? Why did you see this need?
Dr. Devgun: Right. So actually in our area there isn’t another resource that provides this service. So there's a dedicated lead clinic in Chicago through Lurie Children’s, and at least I recall from my time in fellowship out there, there's also one in Children’s Mercy Kansas City. To my knowledge, there's no outpatient toxicology clinic between those areas. We saw this as an opportunity to provide services not only in the St. Louis metropolitan area, but hopefully through virtual visits to cover that need throughout Missouri and southern Illinois.
Host: Well then tell us about the services you provide Dr. Devgun. Tell us about any lab or physician services. What's it like?
Dr. Devgun: Sure. So for our follow up patients, we’re able to coordinate through the St. Louis Children outpatient lab getting outpatients blood levels. If there's a question of potential leaded foreign body, they can get an x-ray for that. We’re mostly focused on the chronic lead exposed child and follow up. So this clinic isn’t for acute exposures or what would normally be reported to the poison center, but frequently a child with an elevated lead level will have an elevated lead level for some period of time perhaps even despite treatment. We’re able to take a lot of the burden that would be on normal pediatrician’s offices to follow up on environmental assessments by say the local public health department and sort of trend and follow those lead levels, including potentially if they need treatment with chelation.
Host: Well, let’s expand a little more on lead exposure Dr. Devgun. Are there warning signs for pediatricians that you would like them to be aware of? What are some of the long term effects that you’ve seen of lead exposure and children’s health effects based on blood lead levels? What happens if they're left untreated?
Dr. Devgun: So thankfully lead exposure and lead toxicity is on the radar for most outpatient pediatricians. So certainly the number one risk factor is living in an area that has older housing and exposure to lead paint. So typically this is done by screening either based on high risk areas by zip code or by screening questionnaires would be the most common reasons why a child would have a blood level drawn. So thankfully severe lead poisoning is rare these days. At the same time, over the last 20 years or so our understanding of lead as a neurotoxin and what constitutes the level of concern has changed. So our current CDC recommendations for a potential level of concern if five micrograms per deciliter. It used to be higher for that. With lowering that level of concern, they’ve also recommended more targeted screening. So, as I mentioned, high risk areas and screening questionnaires. The effects of lead in children—So even at the five microgram per deciliter, current evidence has suggested even lower than that where children can have neurotoxic effects. The unfortunate problem is our medications and our available treatment for lowering lead level at that low level exposure is limited. So chelation such as succimer, which is an oral medication, or calcium disodium EDTA are typically reserved for children with much higher lead levels exceeding 45 micrograms per deciliter. As far as warning signs, certainly anemia and behavioral changes are the most common signs. Unfortunately in the age group that we typically see lead poisoning, in toddlers, these are also common complaints. So it can make it challenging to pick up on perhaps a low level lead exposure.
Host: Is this clinic for acute exposures Dr. Devgun? How are your services different than the poison center?
Dr. Devgun: Right. So that’s a great question. So our clinic isn’t necessarily meant to replace the poison center or an inpatient toxicology service. So this is mainly meant for subacute or chronic exposures. That being said, we’re actually already fielding many of these calls through the Children’s Direct transfer line from pediatrician’s offices that have an elevated level and they're looking for advice on how frequently to check labs, treatment options. So we find that this is a service that hasn’t been available previously and can certainly help the community.
Host: Now, do you very often have to admit treatment if they have this lead exposure? Speak about that. If they are admitted, tell us about discharge planning. How do you help them with some home hazard reduction measures?
Dr. Devgun: Right. So thankfully there are not many lead exposed children that we have had admit to the hospital. Probably the most common reason for that would be an acute ingestion of a leaded foreign body. So lead paint. We’ve seen occasionally small toys or trinkets that have lead in them, lead sinkers. So those would all be potential reasons, or an elevated lead level that may require treatment to be started in the hospital. In terms of large part of inpatient hospitalization is focused on discharge planning and ensuring that the home environment is safe. Probably the most important interventions are preventing exposure, especially because our treatments at the levels that can cause potential neurologic problems are imperfect. So communicating with the local health department, having an environmental assessment of the home. In some cases, that may require the child temporarily housing with a relative or instituting some temporary lead abatement in the home itself.
Host: When should a physician refer to the clinic Dr. Devgun? Do you need a physician referral? Can patients call themselves? Please give us the indications for a referral and why it’s so important for early referral.
Dr. Devgun: We’re currently taking patients referred through a primary pediatrician office. We’re happy to see any child with an elevated lead level. So it’s usually five microgram per deciliter or more that the pediatrician would like assistance in managing. Certainly, we’re interested in patients with chronically elevated lead levels or those certainly that have a potentially treatable lead level. So greater than 45 microgram per deciliter or more, we’re definitely interested in seeing those patients, but we’re happy to see any lead exposed patients. With regards to some of the other services that we would offer including follow up post snake envenomation, a lot of those patients are actually referred from outside hospitals to us at St. Louis Children’s. So usually we’re able to see them, and thankfully most of our snake envenomations in the Missouri area are milder than in the southwest where rattlesnakes are more predominant. Occasionally we do get people that have persistent swelling or pain and would like or need follow up.
Host: As we wrap up Dr. Devgun, please let other providers know what you would like them to know about the pediatric toxicology and lead clinic at St. Louis Children’s Hospital, and just give us your best advice about lead exposure.
Dr. Devgun: Certainly, we want to let pediatricians know that this service is available. We have ability to see children both in person and virtually in Missouri as well as virtual visits in Illinois. We do have an inpatient toxicology service. We’re here through Children’s Direct for transfers that come to St. Louis Children’s. Through Children’s Direct, especially for our Children’s affiliated pediatricians, are able to take any information or referrals. Although we started the pediatric toxicology clinic as telehealth only, we’ve recently had the ability to schedule in person visits for all age ranges here on the Wash U St. Louis Children’s campus.
Host: Dr. Devgun, what an informative episode. Thank you so much. To refer a patient to the pediatric toxicology and lead clinic at St. Louis Children’s Hospital, please call the Children’s Direct physician access line at 1-800-678-HELP or you can visit stlouischildrens.org to get connected with one of our providers. That concludes this episode of Radio Rounds, the podcast series from Washington University pediatric specialists at St. Louis Children’s Hospital. Please remember to subscribe, rate, and review this podcast and all the other St. Louis Children’s podcasts. I'm Melanie Cole.