Document RaeoO8OK8YLkjMXO7QV91ymBz

LEAD INDUSTRIES ASSOCIATION I O KA*T ASM* arHIKT w*w row* it . k .t . txs* Sit, 19$9 LEAD fflBim and sx/wrKjmnr ToTTD------------ To the Hceten of the Load Industrie# AsaoelaUont two quit* disparate aeeloauree com to you with this bulletin. A UVXER LOOKS IT nOMBZSlfi Botable anong tba eddreese* dallrerad at oar 1959 Annual Meeting wa* that with tba abora titla by lhaodora C. Witara, Esq., an attorn*/ with wide experience la iadustrial liability practice. In this, Mr, Vatari aought to point out tba obligation* to thair workers and to tba public, la tars* of baaltb aad safety, lapoaed oo employers by federal, atata end mnlclpel etatutee, aad tba potantial ooata larolrad la neglect of tbair prorlelone. It will baar earaful reading. l e a s roisorao n c h u d r eb i d u o k o b t x c csram* Though a problaa of only Indirect oooeequenoe to aany of oar a--*it i, load poisoning la children la a eource of nor* adversa publicity to our induatriaa than ara all other ferae of pluafclan eoabinad. Baring found that tba diagnosis of such cases was often on a aost inaccurate basis, resulting In frequent falsa allegations of lead poisoning, our organisation recently teased up with tba Rational Paint, Tarnish and Lacquer Association to occurs tba creation of a radical ocanlttee whoa# actiritlaa bar* born* fruit in tba isauanc* of our aacood enclosure by the 0.3, Public Health Carries, It is hoped that these criteria will hare general acceptance throughout the oountry. Manured Bowditch Director of Health and Safety LEAD INDUSTRIES ASSOCIATION 00 CAST U STSSST NSW YO*K 17, M.T. A U*TER LOOKS AT FUMBISM* Theodore C, Voters klle# & Otocldarldge In addressing sjniU to the exaootlres of jroor Ajaodatlon X wish to call yrvr attention to two phu m of potential legal liabil ity of nanageaent - (1) tha liability to eaployeee who Mjr bo exposed to the hatard rf plusbles during th* eourso of oparatinn*, and (2) tbo liability of sashar eospaniee to tbo constating pcblio la satorlals that are add containing load. In this enlightened age Z do nH Wlm it Is nsossssry to labor * tbo responsibility of managesent In tbo two oategorlas to which X haws Joat referred. Too tro aware of yew responsibility to fire to j o br ^ esplcyses a sofa place In which to work and sofa tods wltb wfcloh to -** - "* work] certainly wltb roapoet to tbo ecnetislng public yon are charged with tbs responsibility that tbo matorlals which yon prodnoo and sarket oontaln toxle substances. fr<-m tbo standpoint of tbo lntentlon of namgwant, you recognlte year obligation aod tbo industry's obligation to protoot tbo oonsutlng public fres any potential dosage that any reault frot the use cf ynur product*. for the orderly proaontatloc of ay aubjeot, X bars broken It down Into tbs olaselflca tione Jnat nsntlonad, and truat that ay rasarka say bo of lntoroat * Presented at the 31st Annual Meeting of the toad Industries Association, Chicago, 111.. April 82-23. 1959 N 360.01 t . o. unn -z- a uvtt l o c k s a t h imb is n and uiliUnci to you in tha conduot of your operatloni. FIRST. The liability to aeploreat who ay bo expoaed to the htaard of plvcblM during the court# of operation#. Coopenaatlon law# are new i WmUm la all atat at of tbt union, to gether with all oar tarrltorlaa and fadaral Jurladlctlm*. 1bay ara tha raoult of aoelal naad to renova froa tba flald of ecaaon law liti gation dlaputea arialnc batvaan aaployara and eaplayaca with raapaot to lnduatrlal iejurlaa arialnc out of and la tha courta of aagdaynast. They lapoao upon tba oaployara tba liability of an lnaurer for tbcaa Iejurlaa aada cwpenaahle undar tba varleua atatutea and ataura to tba Injured workauw a Mthod fpr tba prompt datarnlnatlon of hit claim tor Injury *th aa lnaurad obligation for tba paymar.t of that liability. Tba lava of our raapaotlva atataa ara not calfora, thay dlffar ,, v-,.. t >.. -.r, with raapaot to coverage, requirements of inauraeea, lnjurita cwpeo abla, banaflta payable, and adelnlatratlva acaaolaa to which la a*> tlgnad tba adalnlatratloa of tha lava, Howrrer, thair baalo purpooa la almilar and with raapaot to the Injury ao ecmpenaabla, tbay provide tha exclusive remedy of tba oaplayaa for compensation for tuoh Injury. Slnoa tbalr oriflral enactment, thaaa lava have been rapaatadly wended and aaob legislative yaar eouatleea billa ara lntroduood Into our raapaotlva legislatures for tba purpoaa of effeotli^ auch amendMata, Tha ganaral tanor and trend of auch legislation la to llberalita tha lava extending thair banaflta, Increasing an employer'* liability not only vlth roapaot to Brnatary payaocta, but with raapaot to th ooroapt of the lnjurita mad* eonpaneable undar tba atatutaa. For example, tha original purpoae aid objaotlra of thla legialatlon T. C. WATERS -3- A UtfOU LOOKS AT fLUlBISK t u to provldo oau.wnotti n for traunatlo injuries, but by saerxfcont and Interpretation, w* nns find that benefits he vs boon extended to cocpensatlon for occupetli~nal diseases In *11 states except two (l)e. Again, vo find differences with respect to tbo dlaouo* that ro nado eoopeneable under too statutes. tighteen states (2)o provide *o-eall*d schedule coverage defining tbo tor* oecupatlcnal disease" tgr specific reference to tbo dlooaoo ooa eneahle as, for example, tho tom load poisoning." Twenty-cins outoo (3)*, tbo tlotrlot of Colubla and fodoral Jurtediotl'-na prorldo so-called general coverage vblob makes ooaponoablo any and *11 occupational dlooaoo* arising out of and la tbo couroo of oapXegrwst, * Ha/ Z dlroet *X oessent for * few sonant* to tbo subject of tbo Imposition upon Industry for tbo payment of ooaponoatlon for all indus trial injuria*, lncludli* occupational diseases, arising Out of and la tbo oour** of seploymeDt. Z tauw that In this enlightened age every member coopery of jrcur Association doolre* to prorldo ooaponoatlon for 5' *nx trul/ industrial Injury that your employees may sustain. It 1* yrur responsibility a* oaploy*r to provide for your aaployooa a aafa plao* in which to work and aaft tools with which to work. Tour eaplayooa are justly dslanding aaft, sanitary and dean working conditions. (1) o Mississippi and Wyoming. (2) * Althaea, Arlscr-a, C-lorado, Georgia, Idaho, Iowa, Kansas, - Louisiana, Mid r*>, Montana, How Hanpshlre, Maw Mexico. Korth CaroUra, Oklahoma, South Dakota, Tennessee, Texas, Vsraont. ()) Alaska, Arkaraas, California, Connecticut, Delaware, fiord.da, Illinois, Ir.dlana, Kentucky, Maryland, Massachusetts, Mlohlgar., Mlrr.esote, Missouri, Nebraska, Nevada, Now jersey. Mo* Tork, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Utah, Virginia, Washington, West Virginia, Vlsoor.sln, T.c.wmw -l - a urns l o o k s at rumis* Rownr, tha purpoit of ccnptnaatlcn statutaa La to prorlda oaspanaatlon for th''* lnjurl#* truly occupational In naturs and net to nalca consptnsablt tha ilia of ordinary Ufa unralattd to soployMnt, Horrtr, tba trand rf eooptnsatlen lagislatton and declaims of ourta and coanlaalcna In oonstrulrg auoh li ia to traat all lnjurlaa rialng out of and In tha oouraa of aa jloyaant aa btlng eoapanaabla ... whether or wt they ara ooeaalonad fcy aeoldant and ohathar or not tha particular diaaaaa for whioh condensation ia sought la charaotarlatio of or paculiar to tho lnduatiy wherein it arlaaa. In thia connection, Z wish to atraaa tha iapcrtance to y~ur induatry of tha rola of tha industrial physician and engineer in effecting control of haaardoua . ' eondltlrna within jr* plente, Tina doaa not pamit a datallad discussion of tha progressist - lagialatlv* tronda Increasing nonatary benefits and libsnallilng le cislatirs prorialona providing eaapanaatlon for injured workxen. Oar general standard of living has naterlally improved, Tha eort of living la higfcer than srtr before, wages ara higher and industry will ba not by tha continuing demand of a 'kssrnen for labor to ralato au>natary benefits undar tha occpanaation acts to auoh inertasad sohadula of wages, Industry must adjust Itself to such reasonable deiandj and prioa its product to make prcrlsioia for tha inertasad coat ineidant to tho payment of induatrial lnjurlaa. Z fttl etrtain that no ora irould disagree with tha general statentnta Just mada and iasedlately there arlaaa tha question as to what, If anything, oan ba dona ly aenagesent to affaot proper oor.trol* and protection for employees against haaarda paoullar to your Industry. ii T.o. w at er s -5- a u w ix r l o o k s at puaoisw Thl* Li a oattar that li th* aubjaot of tb* r**p'sn#lbility tbit lUu frc* top nanigetant. Shew si th* top axacutir# wh' concern* hiaielf ldth thl health, walfir* ind protection of hli aaploye* froa lnduitrlll lnjurlee, nd I will ahow /on Ac leduitrill orginlaatlon whr# ooapanaa- tioo ooata at * At a kinixsa raaultlng froa th* prtrentlrn And eoctroi of injurl**. Zt la aoeewhat ia i; for untgiwant to adopt alofioa for tbi aifty And protection of aaployaaa, peeling on to aubordlnite* tha job of exe cuting auch program; hut Z aay that tha raiponaibllity of mnijj**ant doaa not and with tha preoulfatloa of auch plica, but In cirrying out thalr axtoutlcn, Thoae of you wV do ao will find that thil la good bualnaia, not rely la Birin* yruraalfth* ooat rf eoopanaatlcn, but la winning tha confidence, raapaot and affoetlm of your aaplojaai la tfaaonatratlcg your paraonal inter*at la thair walfart. ^ Z hara asada rafaranea to tha rola of tha Induatrial physician and tb* engineer with raipaot to tha control rf hatardou* baalth condition* , in your plant*. Thalr affactiva uaa la th* ultloat* answer to coop*ela tion coot1 and eoopanaatlcn prohlaaa. If you bar* well-daralopad aadleal and tnglntarii* ooctroi method# than th* eonpanaatlon ooata arlalng undar the different atatutoa will baooe* ainisuo. Turthernora, it la alaply (rod bual a and good induitrial ralitloca for aanagaoaat ' to oonoarn ltaalf with th* baalth and walfano of employe#*. In hi* rola, th* lnduatrial phyalelan nay bacooa on# of th* noat affaotlr* aganolea for tha promotion of good relitIona between canaga- nant and It* employee*. Zt nay b* that In aoot of tha plant* th* anploycmt of a full-tin* phyalelan la not juitlflad, Bowarar, thar* >* I.C, WATEM A UnSt LOCKS AT FUMBXSM t available to awry sawbar oaapany th# #rrle* of pert-tls# physician* and unl#* and until an affective aadloal control* progras la eetabllahed you ar laply not going to know the ooodltiro of the health of ywr asployaa* and ara not going to has* Intelligent raoorda that anabla you to evaluate eoapenaatioa eoata, . Tha fact la that an Industrial physician, If ha properly fulfill* tha utlpart that la given to Ha, say wall ba th* "fatbar oonfaaaor* to tha enployee* la tha plant that ha la oallsd open to aana. This should not ha Halted to tha asployea hlaaelf but should also extend to his faslly ao that be say bacon* facdllar with tha problasa that are : - Incident to th* fasily llfa of the aaployee. It la naadlass to rape* that asnagenant ahruld conduct pra-eaplcyaent and poat-asploysatt physical axaalnatloaa, X knew of naty eonpaniaa that haYe oaxa to , praclata th* value of the phyalelan who renders aarrlca to th* eaplcy *** of those cocparda*. feUav* m, they ara real, and X * certain / that through their effort* many natters of industrial relation* ara resolved before they reach th* stage of compensation. Th* salntanano* of sadleal reoordj la lrrraluabl*, particularly with raapaot to th* ultinat* trial and disposition of oospanaatloa elals*, X si not g~ing to asfcarraaa you by asking how sany of th* cospanlea bar* preaant are following a constructive nodical prograa, . 'Cy but as cartain that thar* la such rocs for laprovaasnt. froatlsa to tin* I have heard oritloisa of rising ccspansatlon eoata but until top sanagmont baooews convinced of tha need for ocopatant sadloal anrico and oontrol you will ba facad with rising coats for coopenta- tlon Which say *m to you to ba out of reason. Therefore, let us stop -m ; ' * %*; : V*. - . 4 " :%/ '.I: ' T.O. WARM -7- A uma LOOKS AT FLCKHS* talking about thla phut of our problaa and do aroathlng about It. Thara ara otbara in attendance at thla seating who ara battar abla to adrlaa with raapaot to the datelle of auch aarrloaa than X at. Z honestly believe that If affaotlva progress ara developed you will not only raallta tha banaflt of decreasing coata for oaapensatlon but will anjqy a wueh sors satisfactory ralatlroahlp with your asploywas. With raapaot to engineering ooctroi, baar in wind that you ara daallnc *lth a toodo Material and tha existence of axpoaura to that aatarlal In your plana way wall tend to indict tha oowpany aa beinf reaponalbla for health hazards that nay arlee therein. It ia certd nly naoaaoary to have engineering control with tha aaintenaooa cf raaorda that indicate axpoaura. However, phase records should be primarily tot tha purpoaa of indicating tha particular parts of tha operation where hazards axist. In other words, they should be used by tha caapany to affect nathods of control. Tton the standpoint of bain* offootlro in' dafanaa in conpamation easas on trial, X aust eonfaas that they do not have auoh value uniats it can ba shown tint thara is actually no injurious axpoaura. Tbs fact la that If an enpleyaa testifies to Ms axpoaura to an atnoaphara eontaininf a toxic aatarlal, imadiatoly tha compensation ccmieaion aooapta thla taatlsony aa indicating a potaatial injurious axpoaura. 7ou aust eoaa to accept thla and to do everythlnc you ean to oUalnata any possible axpoaura in your planta. SECOND. The liability of goober cocuanles to tha aonaxalng publlo In material* that ara aold containing lead. Tha nanufaoturara and producars of lead alao hava a potential liability under labelling law* and regulation* enacted and promulgated by govermental agenolaa dealgned to protect tho general publlo froa " ~~ - 0*. *v 3 T.C. HATERS 4- A UUTTM UUK3 AT PUMBXSX haaards Involved la the use of toodo mate rial a, Orly recently, the Coonittae oa Toxicology of the Aaerioen Medical Association has reccanended the enaoteant of a Oniforw Hasardous Subetanoea Aat la tba oral states. While X do not wish to present any argunent of tba proa and eona of this propoaad legislation, iCla of iteelf a warning to those ooooaroad with tba production and nanufaatura of load that they nay be required to catply with tba requlrenents of that Aet If It should be paaaad la tba several atataa. Thara ar* already In axlatanoa various ordlnanoaa and regulations acactad In various Jurisdictions having aa their objective tba sane purpose aa tba legislative ohanges rafarrad to, Thaaa ordlnanoaa and regulations ar* net ttnlfom and industry nay be eonfrontad with one type of ordlnanoe or regulation In a (Ires Juriediotlon aid an entirely different type of ordlnanoe or regulation In another furladlotlon. It la needless to ay that tba obligation raata upon tba canufacturar and producer to cceply with any (Ivan ordlnanoe or regula tion In the Jurisdiction whara such products are add. Violation thereof would lxpoae the liability provided by the ordinance or regulation with resulting prejudicial publicity. The reaporalblllty of aesber cenpanlea of thla Aaaoolatlon axtanda to the general public which purohasaa or ocnaucea the products which you produoe and sell, Xour responsibility enhrwceatie potential injury to those who nay not be infonaed as to the torlo features of your nota rial* that nay oauae injury to aoae parson not aware of their hatard, Hera the nanufaeturer, producer or user nay be eubjeot not only to punishnent for violation of a given ordlnanoe or regulation affective in the Jurisdiction where the product le sold but nay also ba aubjeot t .c . mxzja -9- a ura* l o o k s at Ptosis* to tba potlbUlty of the lnatltution of a careen la* notion for duMge* to an injured party arlairg out of th* failure to ooapJy with tha rdlnanoe or regulation effective in tho particular Jari*dietloo In which the product 1* told. Action# at coreoa low arc typical 4iM|* aulta filed In law court# where a Jury la empowered to award aooh damages aa nay be juetlfled In Ita discretion, provided, brwevar, that tha In jured party aatebUahM tha foot that failure of tha manufacturer to dledoae tha toxlo or haaardoua aubatanoa of tha aatarlal ao aold oaoaod tha Injury that la tha aubjed of complaint, Zt la aoeawhat ldla for me to tall you of tha aarluanaaa of thda tyja of litigation. Complaint! ara baaed upon tba a11a(ad negligenoa rf tha aanufaoturar or uaar In apedfying or requiring tha uaa of paints or cthar aatarlal# in tha manner which randarad It unaafa or hareful baoauaa It contained an *x- eaaalTO amount of dalatarloua auhatancaa aueh aa lead, and falling to warn tha Injured party of tha dalatarloua nature in order that protective clothing or appliance# could ba uaed by the person ao ualng tha aatarlal. Aaaixlog that thare haa been a violation of aona atatute or ragulatiea e with reaped to tha labelling of tha torlo aubatanoa, than tba manufno- turer aayba legally reeponelble for reaultlng Injuries providing there la a direct oauaal relation*hip between exposure to tha toxic rub*taooe and tha lnddonoa of Injury. , , r . ' Xrebora of thia Aaaodatlrn are fully advlaad with reaped to tha particular ordinance or regulation that aay axiat within tha Jurladio- ticna <rt*ra you aell your product* and I will not attempt to dlaouaa this phaa* of tha matter In any <Wtdll. However, there la a continuing concern on tha part cf tha publlo and public health agenda# to aeo T.C. VAICT3 -10- A urns LOOKS a t p u k h is m that tha paiblio 1* fully protected against Mgr unknown haaard inoldant to the uae of tojdo substancea. Tour tcs'-ciatloo, through your Direotor of Health tad Sifity, bes dons an excellent job la apprising you of rules and regulations snaetad or effective la ths vari-ue Jurisdic tion* whom your products ars sold. However, tbsrs Is a cootlnulnf nssd for this tyys of ssnrlos not only to ths and that you say b proparly advised of ths status of ths lav under which you say be garr* oraed, but also to ocnsult with and adriss governaental agenoias about ths details of statutes, <-rdinances or ragulatlons which say bs ths sub ject of onactoent. Tou people and yrur Association bars sore information about this subject than ary govermental agency could possibly obtain and it is sulEittad that you reccgnita your responsibility in this con nection. On ths other hard, uuy vell-lntentionad govermsotal agenoias not having ths bcnsfit cf the infontatiec which ym hare, ney frequently oorjldar ill-advised, lneffeetire or unnecessary lsglslatlon which say bo highly prejudicial to your industry and to the public that uaas your produets. Therefore, tty I suggest a progrm for your Association in volving continued and Increased concern tdsallng with the possible' enaotsent of statutes, ordinances, miss or regulations relating to tfao labeling of your products, to ths end that suoh legislation upon beooaing effective nay aocoaplish the objectives for which it was designed without tbs imposition upon your Industry of unnecessary, unwise or unjust burdens. National Clearinghouse /or ^Poison Control Centers ** * .* iTi.' cVnviVit ' of tSUlTH, IDUC ATICN AW WflfiK ftbllt M*UW Strvltt VitkU|iM li, I.C May 199 LEAD POKOMWC M CHILDRQfc tXAGHOSTlC OBTEJBA As A* tsa--ar soil Am mm, it is rss--eble It tcptcl iaerssM it A* mW W cnn si ItW poisoning it dtlArsi is ony Ivgt cities Antflittl At NtHit. This nwttJ incidence bes As m wtnltly noted is iWfitf Iks ttiitaitiogf sf cbllAMd fla^iia.t.1.3 TWo Is c Ims rtlusH to llxs itcttiij mm ItciAta tittt>ytl(l fittA Incxooled Isod tdwrwptioa cntW by tditic ttfi el lbs mm see* sad Uatttid beet tl Am h mm lwAi| ts dob) Astist tttt ittt togpooled.* Byers* foils Aet At h m iecid--co is e nfltditg si As peer dmct tl ntown Is lend ftttl as As part si children ploying ewtdoers. as cnaiparod ts indoors. Tbs ssssossl eerieti-- la At scnsTsacs si ibis d tiers tbotll hoop physicians sisrt ts tlgts si lead ptlltaisg is children la As mb b w . That iatarsst la ibis At--ts iacraasea As tadAsses si Atjttiil sad up tried castt bas bs-- bents svt lm As srptri--ce si cilitt teeb as Cbioft, Oacis--H, Bsiliasts, sad Haw Yocb where deterest sad strarwMtt csscsrsisg childhood lead poiteaiog a-- high. Where sscb iatarsst dess ast exist cases asy be fregaendy --race gal tad. A seed for accsrste diagnosis ia childhood lead poisoning exists. Prognosis aad lesA lo tion at proper Imtnstt day--d ts s grist exteat ea tbs early sad sccsrsts Atoattls si ibis disease. Criteria ier diopoiiiog cases el childhood plewblf bass base Itr--lotod, Tke perposa el Ais ca--aeaicati-- is la priseet aad disarms Asms criteria. Dtigastric Criteria la repairing a greep ar canid--ties el conditions be prsssat to sola a diegat sis af a specific disease, (bars Is s risk of miming wet esses or eiroeooesiy di eg--ting As --tity hi sons cases is which it is absent, dap--Aeg -- As eiteat sad specificity el A# criteria set forth. Tbe criteria listed below ms based -- selected coiled!re sspsri1 sacs wi A cbilAood lead peisowing sad ere designed to detect a mini-- al Mm past* Are aed Mm safeties cases. After a reasonable period of carefully Mlewsd wt As m criteria will be revised, if --canary. A irm < * trr-tBV tww tMM at t--Ml IW Im-w m. Sm at fce# trMi irr.^aj . --^ 1. Olaleof gad Laboratory Critgrfa 2- A. Gottroiafattiaol Uoalfottorioag On* or mot* of 4>* fallowing: I) Awnli 2 IflNnwtHnt vo wiling 9 AMowfnaf h h 4) Contha*i** -. 1 B. Control Norvovt Syotoai UanifoototlOM _ Ox w it Mlnhf t) Irritability 2 DrowtiwaOt 4) hCMfiiWlM S Canwitinn* 6) Comm 7) *Amh mr ywdyoi* 8) Hygartantiaa C Hnwleltjic ifaoifotatio*g 0n of M *4 4m liHntny 1) H|*KtiiMlt Microcytic Bull 2 A ilyiilicwl dogma 4 )ni4iillc I) PydlWnt 10) Pwdytit of on* or a*ra crwti 4 MnH II) Oavarad ttrmbrompimJ Raid grata!* oniwi 12 CmbtufM^ iaid glaacytttio 12 BmiW tiri>ni>m) Avid (MM* Am rad Hand wilt 0. Erauln Cofnr)k|rriMri < , E. Urinary finding* Ow w b*4 mi4m (Htf ' - I) Giycaawrfa ' 'z * ----** - i&CZfjs, . ' ~r -J'*', - > i. F. Tk# dawonttration of Inemotad radiologic dtnsify at tb* awtapky*** of long bonag. 2. Criteria for Land Abtorgtioa Tka following finding* present evidence hf obtorption af laad ia quantities tfcot or* kaowa to ka copcbla of inducing iatoaicotioa. A. The finding af a concentration allood in 4m Wood, a* datawninad by a walked af known kigk tantitivity and BKitiM,! af 0.08 . gar 12 gw. of who)* blwf of |na. Voluat af 0.06 0.08 mg. gar 100 gw. of wkol* Woodwa indicative of abnoraMl absorption of la4 but aftan Mt a dagra* af absorption wklck It cgabla af inducing tymgtowt af inloiicatiaa. Rapaaf datarwinatlon* ora preferred. . 8. Tka finding af urinary aacretion af land, a* datonnlnad by aadafi af anWytla af knaam High tantitivity and precision,7 In MOvnli af 0.08 wp. or am pmt JfJwwAI in pariant* naf receiving tfaoiwant la increase laad accretion. Repeat detenwlnotlona art preferred. 3. Exposura to a Load Source A confirmed history, by ckemlccl Identification af 4m touroa, of a^otwra I* laad af tuck severity and af tuck duration ot to ka Indicativt of a dongereet degree of absorption. The child who I* pel ionrd by lood will hove toVen lit end absorbed dongeraus owounti of teed. Tbe presence o( clinical end laboratory manifestations In such child enables a diagnosis of lead poisoning to be mode. C/inicei end LeSerefery Criteria * Manifestations included under clinical end laboratory criteria ora non-specific, since ony of these con be found in other illnesses. Even the Increased redie-opoauo oreas or lines et the ejetophyses of the long bones ere net spe cific indications of leod absorption, for these rodio-epogu* lines ere seen with ether diseases, e.g., abnormal absorption end storage of other heavy metals end hooting richefs. Such lines ere not indicative of illness, but ere so frequent in their occurrence in small children who ore absorbing abnormal amounts of leod as to serve as warning. A child exhibiting this manifestation should be investigated corofully, with respect to the extent of his absorption of lead. When any two of the criteria listed under clinical ond loborotory criteria occur together with oae of the criteria far leod absorption, e diognosis of feed poisoning may be mode. Two or more of the clinical end laboratory criteria listed may be used to moVe e pre sumptive diagnosis ef plumbism in children with eorly manifestations of increased Introcranial pressure; such children require removal from the source ef lead end emergency treatment. A delay in treatment while a blood or urine analysis for lead is being per formed may be bexordous. Edathomil calcium disodium (calcium EDTA or edothemil) therapy con be instituted while blood or urine determinations ere being performed. Treat ment con be stopped if repeated leod analyses shew the provisionol diagnosis to be le tffOfe The central nervous System is frepventfy involved in children with lead poisoning. Whom involvement 1$ such that abnormal cerebrospinal fluid findings (most commonly elevation el protein content} become manifest, the diagnosis ef teed poisoning with encephalopathy may be mode.* Excessive coproporphyrinerla is e constant finding In acuta episodes ef lead intaxlcetien, end con be demonstrated by a relatively simple qualitative test on freshly voided urine. Briefly, the urine is acidified to pH4 with acetic acid. Ceproporphyrin fs extracted immediately from the acidified urine into ether end then from the other into 1.5 N. hydrachloric acid. Intense rad fluorescence ef the hydrochloric odd loyer when viewed under e Wood's light is indicative of on increased amount of coproporphyria. Quantitative copra- porphyrin determinations on 24-hour urine collections con else be performed.^ These 4 may be helpful ia long-term management of patients. I The coptoporphyrinutlo encountered in leod poisoning Is incompletely understood, but derangement ie hemoglobin synthesis and Interference In praphyrio metabolism In tissues othet then blood ore probobly underlying factors.^ ' Criteria for Lead AIteration Once the suspicion of food pel sonlna Is oraused, the most Important single consideration in the differential diognosis is whether or not leod has bean absorbed in puentitits sufficient to induce Illness. This cue best be demonstrated * 4 br determining the lead content of iho Mood. TKo threshold value cited obove, 4.01 mg. of load pot fw gm. of whole blood, ) o critical on*. Lead concentrations between 0.06 end 0.01 mg. per 100 gm. of whole blood art indicative of abnormal obtotption of leed, but ofton not of o dogroo of absorption which is copoblo of Inducing symptoms of intoxlcation. Extensive studios bavt boon modo 00 tho variability of tho concontrotlons of food in tbo blood ond urine of odolts ond children, both under erdinorp circvmstoncet ond undor eon* ditions of obmoonol xposute to lood.6,11*1] In a group of children botwoon tho ogos of sis months ond four poors, in whom thorn wos no evidence of obnormoi infoho ond ab sorption of food, tho OTorogo blood lood coneoatratloa wos 0.027 mg. por 100 gm. of blood. 11 In o rocoat popor tho uppor normal limit of blood lood concontrolioa in young childron is stotod to bo 0.0S mg. por 100 gm. of bleod.13 Tbo appraisal of tho significance of food absorption bp moons of analpsls of tho urino Is much more difficult and much loss effective than thot of enalpiis of tho blood, ospociollp with childron. In poang childron there is o wide phpsiotogic variation in 24-hogr urinary volume. Factor* such os dohpdratisn end ocidesis, ofton occomponping ths ocvta episodo of lood poisoning in children, can of tor urinary lood output in tho untreated patient, so thot tho amount excreted mop foil within tho normal range. Tho colloctioo of on unconteainoted somplo of urino from a poung child for the purpose of lood analpsis is suollp difficult, ostramu precautions being required to provont contamination of tho urino with lood.6 Administration of calcium EDTA to patients who hovo obnormol amount* of lood in their tissues is followed bp a rise in urinary accretion of food. '* This increased lood os* cration following odoihomit administration has boon suggested os tho basis for o diog* ' nostic tost.14 Potionts receiving odothomil thoropp should osooto 1.5 mg. or more of food in tho erine on any one of the first throe doys of treatment. This tost, while by no moons as satisfactory os thot of tho determination of the level of tho urlnory excretion of lood prior to any thoropp, atop bo mare practical than the collection ond onolpsi* of a 24hour urino specimen from on untreated patient io those instances where o delay lo therapy Is heiordeus. Different methods for analysing blood end urino for lood ora ovoilobto. A simplified pro cedure for the determination of lood in smoll samples of urino ond blood has boon re ported." This procedurt requires only 2 ml. el blood whore most determinations requirt 10 ml. Ths requirement of a tmollat volume of blood Is odvontageous whan working with children. Certain other analytical procedures art described in articles listed in a mono graph published bp the Awericon Public Heo/th Association. 7 Glassware ond other equipment used In the collection ond onalpslt of blood and urine samples con ond should bo rendered free of onp possible contaminating food bp rinsing with worm 20 percent nitric ocid, followed bp thorough rinsing in "load-free" distilled water. Other special precautions mutt bo taken in the laboratory to prevent contamina tion of tho temples from load-containing olrborno sources during ashing ond onolysit. Exposure e e Leed Source Childhood load poisoning Is, In gentraj, a disease of poverty,'4 almost olwops found In eroos of old, run-down housing, the source of food :v;:-.''r-. ,\. ^.r.iry-^;..Vr; l .5. I* utuolly leod pigment paint oppliod and re-applied eorly I* this century, to wolls and fixture* which more recently have been neglected and allowed ta (all into disrepair. These coot* may be buried baaaolh other coot* of paint, covered with wollpoper, or may cover wollpoper or ploitar. With neglect th# point ond pointed wollpoper pool, and th# painted plotter crumbles. Porliclts may then bo picked ond ingetted by yovng children. Lead point in good condition hot been chtwed off of surfaces alto. An odegvot* taf* substitute indoor point wot not mod* eveilobl* entil about 1940. Lead point applied to outside surfaces hot alto been reported to be the source of lead In catet of childhood pfembitm. * Children** toy* ond fumitur# ore not tignificent toercet ef food oalett repainted with leod pigment paint. Since 19SS the American Standard* Attociation hot recommended tbot only point* with a leod content of on* percent or let* may be ceetidertd tof* for eta on children's toy*, furniture and in boating interior*.!* Other sources of leod theuld be kept in mind. Nomerovt cat** of poitoning bar* occoned in both children and odoltt from inhalation of lead fumat3 and exposure I* ethos3* resulting from tht burning of leod ttorog* battery casings for fwad, a proctica sometimes retorted to by destitute families. Other sources of leod involved in childhood poisoning con be found in the medical literature, bat in this country these sources ploy a relotirtly unimportont rolt. References to theta are listed.33'34 la most cases ef childhood leod poisoning, pica, the abnormal appetite for eon-adibt* substances, it responsible (or load being taken into the body. Children, usually bitwioo the dg*s ef one and five yeors, mast often eshibit this abnormal oppetit* which may re sult from emotional disorder34 or nutritional deficiency.33 It hot been shown that lead I* retained in small omounts in th* tissues of on odult with a daily intake of 1 of soluble load in addition to the normal daily dietary inloka (0.2-0.4 mg. of leod).3* Since load pigment-containing point peelings may contain 100 mg. or more of lead, the repeated Ingestion of smell amounts of thtse peelings is compatible with absorption and retentioa of dangerous goontities ol lead ft the tissues. This will eventually result in clinical aianifostations of poisoning if the exposure i* net interrupted. A history of Ingesting point chips or chewing on walls or woodwork may or mar not be obtained. Often such octivlty goes unnoticed or the amount ingested is considered in significant by th* porents. Th* history moy be obscure, incomplete or fregmentory. Th* possibility of th* existence of leod poisoning, therefor*, must occur to th dinlcion from th* nature of th* illness itself, ond he must be prepored to moke a presumptive diagnosis in on acutely ill child without on elicited history of leod ingestion. Diagnosis (on* therapy) must not be deloyed becouse a source of lead is not rtodily demonstrable. Th* axplonotion of th* origin of th* disease, if it turns out to be leod poisoning, is often found after the foct. A positive history of pico for point and a roentgenogram ef th* abdomen demonstrating rodio-opoqu* mottrlol in th* Intestinol troct or* voluobl* clues to th* Ingestion of feed. In New York City, blood leod analyses are performed on all children under th* ogt of sit yeors enrolled in the City Well Baby Clinics with e history of pico; young housohald siblings of these children ora olso examined in this monner.W The absence of these clues does not rule out th* possibility of leod poisoning. 6- Exposure to a load source may be confirmed by demonstrating that the source contains leod in itciil el recommended limits. In children the history el lead exposure may usually be established by onelyfino paint particles (alien from the environment el the child end demonstroting excessive lead concentrations. The enolyticol procedure need thould be an accepted one end ehewld be performed by competent end experienced pereannet. Ctexifirefien a/ fiW Oiepeeele la making a final dtognosla involving a child exposed to lead, the following classification far diagnosis la recommended: A. Asymptemotlc Increaeed Leod AbaorpHaa TVi i r*Wi H 4m ^m Am rri 4mf f ynm<> U 4*9 Miwtt AM7ttn ( AfMradlf mt W In ^ W (m it A ftovec* #4 I **4, tl ied and 4o* CINM< fdutqfic W4phyl #f t*f WmI MO* W AmiXiA 8. L#od latoxSecfiM 1. Ld Ulou cation Vithovt Encopbolopotky * Two mu of diiiird andldmeur) oiiwleerdudm coned nerveut eyetem menifettebemx ecteme enled by ebnxrmW cerebra pined Held (Medinge, evidence lor Aearplten el lead in dmyrnvl Oieiiitiet, and demonstration ef e lead tource enable Ml degnexfs e be made. 2. Leod Intocitation with Encephatepelbf Two or wore ef Me dimed endleboioeery crilerie Indvdiny canud nervoua eyetem menltertotieni eccempanled by ebnermbl crbre spinel fluid hadngt, evidence fer ebtoipHen ef leed in dwigeravl fieitinet, mid domonstratien el a teed eewree enable Ihie diegneeia te be mode. This cerogery may be subdkvidoA an the betie el am verity ef encmbdopwiiy, into leod poisoning widt nilf and leed pei toning wifti eevore enenphdepodiy. The letter group ibevld fcp elude ihete patients ed>e convulse and/or edie ere cemateee lev 24 heere er longer. I The long-term progneaia of childhood plumblsm (with reference to mentoI end nevrolealcol function) moy depend upon the severity of the ocvtg aymptomotic eplaoda. Therefore thle cloaailicotion should be of prognoatic volue. The above diognostlc cleaaiflcoHon la olao auggeated In order that children who ora ingesting abnormolly lores quantities af leod ond children with lead poisoning without ancepholopethy will not be overlooked. Eorly diognoaia la essential for a good progna* ala In thia diaaaaa. Removal from leod exposure ond thoropy with calcium EDTA'* will mart olten raault in o fovorobla outcome ll Instituted eorly. Therapy with calcium EOTA la net oe effective once acute leod encepholopothy has occurred. This drug has net slgnllicontly reduced the JO 15 percent mortality rate from leod poisoning In childroo i 9 .?: . '.......... i`` if-. f: b ond Ml to bo oo k o t o effoctlso thon oldor moosvret io terminating lb# ocvto episode of encephalopathy.** However, there It mo evidence suggesting that neurologic end mantel tequeloo associated with childhood plo*blt-m, o*d especially with encepho* lopothy may bo reduced by tho woo of calcium EDTA.50.JI Thete communitieo with octlvo programs for tho control of childhood lood poltoning, whoro only com of lood encepho!opolhy and dootb pro being reported, oro undoubtedly witting numbers of oorly CO tot. Dotochon of thoto early cotot it on importont octirity which should bo under token by physicians, public boolth workers and poison control contort in communities whet# sources of food may exist. Tho Public Hoolth Service offort Contvltati on torvlcot ond tochnlcal ottlttonco to any community with o childhood lood poitonlng problem. Cato finding ond proironNoo OCtivl- Hot together with tho Institution of adequate diognottic sorriest oro ottontiai for con* trolling this problem. * For more details contact tho Notional Oooringhouoo for Poison Control Contort, U. S. Public Hoolth Sorrico, Washington 25, 0. C. Sonwory CHtoria to bo utod In diognotlng lood poisoning in chitdron boro boon presented. Qini* cal ond laboratory criteria. critorio for lood absorption, ond exposure to a lood towreo or* tho throo orsot under whidi ths diognottic critorio foil. Two or moro d inicol ond lobono* tory critorio cowplod with ono or both critorio for lood absorption onoblo o diognotitof food poisoning to bo soda. Although chemical Idontificotion of tho lood toorc* involved . it importont in orriving at final diognooit, treatment must not bo dalayod if tho tourco is not roodily demonstrated. A classification for final diagnosis concoming ths sxposuro of a child to lood is rnesm ' mended. Tho Impotlonco of rocagnizing oorly cotot of lood Intoxication ond nvoa oarllnr -v, osymptomotic cotot In which increased food absorption occurs Is ootphosltod by the * classification. Use of this elottiheotion should aid in ostablishing a long*tom prog a# nosis. Eorly diagnosis is accessory to reduce sequelae end mortality from lood poison* ing in children. -*1 Acknowledgment Wo with to fhonlt tho following physicians for tholr ottlttonco in tho preparation of ibis communication; Robert H. Alwoy, Eliton L. Bolknop, Somwol P. Bossmon, Rondolph K. Byars, J. Julian Chisolm, Jr., John Foul got, Leonard J. Goldwotor, Harold Jocobzlrvor, Robert A. Kohoo, May R. Mayors, Edword Prttt, Hugo D. Smith, Lewis W. Spolyor, Goorgo M. Whsotley, ond Mitchell R. Zovoa. ti > ". .y' '.* }' ' V t il . %, -; '*'I :1 I j ; > % V.3 'I Rotorone* 1. CMh Ii^ X X, Jr., ond Harrlaon, H. E.i PrilrWtl H:941 1936. 2. Villlm, K, Kiflv ., Coochoun, C , flrvd Sayan, R. R.i PA Hoolth Rif 0|U% 1932. X Jonhini. C. 0. and Moillna. R. B.: AM.A An*. Hoarol. 1 Ptychlot. 77:7% 1937. A IW, M., and Rubin, M. L: A*. J. On. Chill 6U4S, 1941 X tHoclMn, X X, Jr.: Bail. Jdn Hoohlnt HaOf. 61:1, 1937, X Brora, R. 1C: Podtotrici 23:363, 1939. 7. MoAodo tar Dotornlnlng Load la Air atd in Biological Matoriola. Hoar YaA, Aaarittr PU( HoolA Aaaoclorion, lac., 193X X Bran. R. X. Malool C C i4 Caohnan. Hi Aon. X Oil. ChlU. 67:546, 1934. 9. Sdirati, X, Zlm L, and Wrfion. C. Xi X Lab. an4 Ot*. IU. 37:60, 1931. IX CKlula, X X, Jr., a4 Harrioaa, H. E.: i Ola. Invart 33:1131, 1956. (L,IX Robinoon, M. X, KoryinaU, F. E., a4 Briogor, H.: Podiatrier 21:793, K5A 12. Bra4Iar. j. El Powoll. A. Niomaut, V., McGrady, K. aod Kaplan, E.: X Podia*. 49: X 1936. IX CholoV. X. aa4 Bnahach. K: X Matt. Mr* 3X47, 1941 14. Rabin, It, Solan90, G., Booaaan. X P. nt BoIVnoa, E. L.: Sclaaca J I745t, 1931 IX Boaoaan. X P., Rabin. R. o*A Laibon, X: PaXatrica 14:201. 1934. IX Albahary, C, TruhoaV R-, and Bovdana, C: Arch. MataX PiotaaaioanaHaa 19:122, 19SX 17. Boaoaan, X P.ai Loyna, E. C: X lab X Clin. Mol 43:139, I93X IX Bradlor, X E* an4 X P.: PA HoolA Rf 7X467, 193X 19. Onarioan SanM SprcIlKrtbni la Miofanlto Hajordo to Children baa RootAiol Surteco Cooling Motorialo, 266-1 - 193X Nro YoA. Aaoricon Standard* AaaaciaUaa, 193X 20. Editorial: Internal Mol Diport. 63:1201 1931 21. Trovon, E^ Randla start, X, and Horvoy, C Cl Loncot 2.111 I93X 21 Vara*. R., Albohory, C, and ScMwaborgor, H. G.: Proata Mol 65:177, 1937, 21 Danilaaic, V.: Britfoh Mol X 3061, 27, I93X 21 Oooidaoa, V. X : late** 2:1094, 1937. 21 Loomed, A H, and lynch, G.: Calllaatl* Mol 94:414, 195X 2X Mllican. F.. Levri*. R. X. td tayaon. E. M.: A*. X Dio. Chill 91:14< 19JX 27. Caaaar, R: PICA. Soring*oil C. C. Thoaoo, 1957. 2X Kohaa, R. A, atal.: X InduaL Hyf. 22:341, 194& 29. Grambarf M., Jacobtinar, K, McLaughlin, M. C, Fweroi, K. T., *4 PotilfOeri, Ay Padiatrica 22:731 193X 30. Oiaoln, X X, and Harrlaon, K E.: Podialrica 192, 1937, 31 Bradley, X E^ and Bowngartnor, R. Xl X Podia*. 53211, 1931 JljUKuii )>1(U>W4\ Howard M. Conn, M. 0., Dinetor Hanry L. Varhulat,Aailitant Ditoetor