Table 1.

Sources, Health Effects, and Laboratory Testing For Common Metals of Public Health Significance: Arsenic, Lead, and Mercury^a

Metal	Common Sources of Exposure in Children	Health Effectsb	Laboratory testing for patients with history and/or physical exam symptoms consistent with metal toxicityc
Arsenic (inorganic)	Contaminated soil or water Pressure-treated wood containing chromated copper arsenate (CCA) Rice products (low levels)	Chronic exposure can lead to gastrointestinal upset, cytopenias, liver dysfunction, cardiac conduction disturbance, peripheral neuropathy, skin changes (hyperkeratosis and dyspigmentation)	Preferred method: Timed (or spot) urine with speciation Speciation delineates between organic arsenic (less toxic, found in seafood) and inorganic arsenic
Lead	Paint (homes built before 1978) Contaminated soil and house dust Contaminated drinking water Folk remedies Imported spices Imported cosmetics or religious powders Imported glazed ceramics Parent occupations and hobbies	Low levels of lead exposure (BLL <10 μg/dL) have been linked to cognitive deficits, behavioral issues, decreased hearing, reduced postnatal growth Moderate levels of lead exposure can lead to anemia and gastrointestinal symptoms Severely elevated BLLs (> 70 μg/dL) can lead to severe effects including seizures, coma	Blood lead level Notes: -Current reference level for further action is 5 μg/dL -Elevated capillary BLL should be confirmed with a venous level -All children aged 12 months and 24 months who are at high-risk for lead exposure should be routinely screened
Mercury	Elemental (inhalation of vapor): thermometers, sphygmomanometers, dental amalgams, certain religious/cultural practices Inorganic: skin lightening creams and soaps Organic: large predatory fish such as shark, some tuna, tile fish, swordfish	Elemental: neurologic symptoms including tremor, insomnia, personality changes, photophobia; fever, sweating fatigue, rash (palms/soles), “Acrodynia” or “Pink Disease” Inorganic: ingestion can lead to gastrointestinal hemorrhage, acute renal toxicity Organic: neurologic toxicity	Elemental/Inorganic Mercury: Timed (24 hour) urine; spot urine also acceptable Organic: Whole blood

^aInformation in Table 3 adapted from Pediatric Environmental Health, 4^th Edition (Chapters 22, 32, 33)

^bHealth effects from exposure to a toxicant depends on dose, route of exposure, genetics, underlying medical conditions, nutritional status, age, etc

^cThe Pediatric Environmental Health Specialty Unit (PEHSU) is available to assist clinicians with ordering or interpreting results of environmental toxicant testing.

BLL = Blood Lead Level