Document e720JqzE7bO5JRrbBKz5m1gNe

r JCF/AC 24 August 1989 The British Plastics Federation 5 Belgrave Square London SW1X 8PD 01-235 9483 Telex 8951528 Plated G Fax 01-235 8045 Status and publication details of the Laboratory of the Government Chemist research Into the allegations made by Mr Richardson 1 The BPF has been advised to liaise directly with Dr Raymond Cooke of the LGC every 2 months (links have already been established) and it is anticipated that the LGC work will take approximately 4 months to complete. It is likely that the research will be described in an article in Chase Bulletin however, no conclusions will be drawn. Conclusions will only be made available to the DTI 'a CSU directly and will not be made public. The CSO may well retain a statement in its files which could, for instance, be used to respond to Parliamentary questions. Details of the research may also appear in the house journal of the LGC, published quarterly. This information is then passed on to the DTI, the Government Research Establishment and other academic/research bodies. If an industry has been closely involved in a particular issue being researched by the LGC then it is usual for them to be consulted before details of the report are finalised. It is therefore probable that the BPF will have 3ight of the LGC's draft report. It is the current view of the CSU and Department of Health that Mr Richards reports is very much a 'dead-letter' with little, if any, foundation on fact. Jacky Freer Group Executive e o to s j-e s L Director - D R Jones A company limited by guarantee Registered in England No. 282883 T BFG21129 in '  ______ 224& ) 11 0 1 TUESDAY,JUNE, 1989 -- IJi oenzoga rR0M Hvfl 5hgK8e"2CS62 BRITISH rustics reo 0t-235<w 7-'9' 91,1 ~) /---------------- /f L ' L - n*\ ^ V. fl if iff '" The British Plastics Federation 5 Belgrtva Square condon SW1X 8P0 01-235 9483 T*lx 8951528 PlafJG Fax 01-235 8045 *N |M>** 4 0/bv . AL Kbx^ 4s&*^k-uk_ * I'jfay sUJjz^uJ- JlsA && 'ns*A jJb i^yU-i**jLx & (j-^j f I^KjM) ZOTUSt'ZZ Olr#f:tR .HO' BFG21131 T'J Ths British Plasties Fadsratlon S Belgravo Sguara * Lonoon $W1 X8PD 01-235 9483 - Tela* 8981521 Plafad Q Pax 01 -235 8045 Ths British Plastics Fsdaratlon it twin of thi rsssareh raport that hts bain produced which links ths Incldanca of Suddsn Infant Oatth Syndroms ("cot diaths") with eartain additIves'applied to PVC used in ths manufacture of ehildrsn't Mfloing. Ths BPf Is obviously concsrnsd md hu rsqusstid In indsptndant itsasamant of ths report's findings as wall aa obtaining its own experts' opinion, Aftsr initial raiding, ths rsport sppttrs not to Involvt PVC dirsctly with thus trigidlss. An inmsdlits appraiaal of the material* ua4 it balng earrisd out with ths minufaeturiri. In ths miantlms concirnad psrsnts should follow ths quits normal hygisns procaduras whan dialing with infanta and if in any doubt leek medical advics. For moro information Philip Law feritjah Plasties Fodaration I Belgrave square London im IPH Engl and Toll (01)23$ 948) M Oiceior -OR BFG21132 8 0 T 0 8 &Z 39M>-85v4g**8 BRITISH PLPSTICS TED 0l-235-8fl|};f, Ths British Plasties Psdsratlon 5 Balgrav# Square - London SW1X 0PH 01-235 9483 Telex 6951528 Plated G Ml............................................. NO. OF PAGES (INCLUDING FUCTVFJ; IF ANY DIFFICULTIES ARB ENCOUNTERED DURING TRANSMISSION. OUR FAX NIM3ER IS: 01-335 804$ MESSAGE: BGH21133 fc o to &HZ& -SOM HvffilJ0^l5??Nj|j?s49 BRITISH PLASTICS TED 0r-735rW4S------------------------(lTOin 6. 3.'89 1 31 84 NO. 288288281*^ "pfl#* J jjx/vs* Lul^v Gvv^CfcCJ /\*. (" ^W-VVVSJU^ ^ -fife* 3T. ' y>-i ^ OU. OLV*. (vvvL L^jt(dUl*s Cj>{" (|-jCfk, 4 DvJ^ CjUL^. C V. AA.^W't" S! nysf*-i *yt't\Jk-r.I t-w * ji-. /2fc /it (> **-**AjLr^ tvim. t(juW* ~tL**b ^ (xaJcCsZcjI ffc ^ Cy{~ tUjJErJUwOLn ^Co-t rvi-e. * &aaa%Wow ^ 'fr co or Pti< oq /u,J>U* 9 Art;* <um. {hts*t . AA^VjL-A tf* *ip ^Sv>y^KA-a^ k/W * h^Jjrl^ ** ^Xtciri^M CoO H* o a ^ko/(L^lXUikJ W ~\/7 PROM 19 BRITISH RUSTICS FTI) ssr 3. '39 13103 NO. 20828628`l2,%B8t 3 ^dljl^Xr 1A** 'iff*1. t xdi h*Jh fa* fa Cav^ ^ ifcAJLfcJl \ y\M OUv^ h**- (aO+*JL. l%JUb^ c*-t ^J>|rL c(joh>. ev QxJ-^J' _ rj 1*u f,c f! ffytsuo^Lvl t fa Aavo. Oid^jj ^nKaX ^aJ^XkJI $AjJ[- (vm_ Lou*. fV^^v'Vv^-AJl iy A/*/~ ` 9 oT O S >2:2 BFG21135 FVC lurne linktol;; cot deaths dismissed By Pearce Wright Science Editor A theory that cot deaths are linked to poisonous fumes released from PVC plastic cot mattresses has been widely dismissed by experts. The Department of Health says there is "no adequate validation" for the idea, which has caused alarm among many parents. The scientific advisory co mmittee to the Foundation for the Study of Infant Deaths, which has spent 4 million in the past 17 yean on research, says the hypothesis contra dicts the findings of painstak ing investigations into factors that may trigger the deaths. {The British Medical Journal ;slso rejected the theory. - Dr John Grange, consultant bacteriologist at the Brampton 1Hospital, west London, said in ja devastating assessment of |the report for The Time*, 'which was circulated this 'week, that more detailed studlies were needed to provide mote definitive answer. The controversy centres on the details of a report by Mr Barry Richardson, director of a scientific consultancy ser vice, which describes the lab oratory experiments on which the suggestions about cot deaths are based. Dr Orange described the ex perimental methods at "using crude equipment, lacking an obvious control experiment that would reveal ffows and irrelevant as a representation ofa cot mattress". Mr Richardson maintains that a particular type ofmicro: organism common in homes can react with traces ofchemi cals used in the manufacture of PVC to generate poisonous fumes. A key to the process is mattresses must also have a protein content on which the micro-organisms thrive. The laboratory experiments involved placingstrips'ofPVC ! and organisms on a rich i nutrient mixture ofsoya flour 1 and malt Dr Orange said that that bore no relation to mat tress conditions and traces of protein it might contain. Moreover, advanced in struments would be needed to identify the type and amount of gases generated. The report contains no figures of the quantity of gases which came from heating those cultures.' Dr Grange said they could have been generated from the nutrient mixture rather than the PVC He suggested that Mr Richardson had con ducted for the best ofmotives a completely irrelevant O C4 00 5 o* +c-/s* G <u Oh Bo o 43 cn Son mra- 3 to oo _1 S>-LS ,3 0 00 3 us a e <u its 2U ~J ,0> .op 8 H $ I II S S IX 3o *o 03 w9 jPa b*Jo 3 OC 1awS e ft. * 5 2 Quo, -- -------------- * a c Ih BFG21136 iri TELLEK REPORTTHE BROADCAST REPORTING SERVICE PVC - LINKS WITH COT DEATHS / For : Prog: BRITISH PLASTICS FEDERATION KEITH HANMAN HARALD FUCHS Service : BBC SHROPSHIRE Serial : 066232/JD HnDate : 8.6.89 Time: 12oo Duration : 3 minutes 10 seconds 36 Paradise Street, Birmingham B1 2AJ Telephone: 021-643 4177 BFG21137 HARALD FUCHS: 'i PVC mattresses could be the cause of cot deaths, according to a British research company. Penarth Research Laboratory tested twenty one mattresses, including some from Shropshire, on whichccot deaths occurred. Jonathan Beale asked the Tech nical Director of ^the company, Barry Richardson, what his investigations had revealed. BARRY RICHARDSON: Our research was part of a programme of investigating deterioration of PVC fabric and we became aware that a particular fungus might infect fabric and might attack some of the additives that are commonly put into the fabric:as preservatives and fire retardents (sic) . And this fungus would then cause toxic gases to be produced from the fabric. JONATHAN BEALE: So what would actually happen to the baby then'lying on the bed? B.R: Well in the case of the cot mattresses investigations that we did we found that the infection is always naturally present underneath the baby. It develops after a few months. The... depending upon how long a baby is left on the mattresses actually, and it only develops just beneath the baby where the mattress is warm and moist from perspiration. The gas, we find, is always produced from the in...from infected mattresses. Every one that we have examined is producing this gas when we incubate it. That means we put it in conditions that are i similar to cot conditions. The gas is produced, the main one is called dibean* and it's exceedingly toxic., A thousand times more toxic than carbon monoxide. So I'm afraid I'm not talking about anything that is mildly toxic or anything like that. We're talking about one of the most toxic gases we know. What we actually have is the babies who are dying are generally sleeping apparently in the face down position,' and they're generally quite heavily wrapped during cool weather. J.B: (Phrase inaudible)... to the incidence of cot death, particularly in relation to Shropshire? fiotO SfrZ; Phonetic spelling rT,yfTr.yT?P.^vwrr!!-:,!,;rr/-rr.r`r.,u.?xvt.VfrfiPt-?^^ Lev- tanrw? BFG21138 B.R: t\ ?I When deaths have occurred some of the cor1 oners offices who have heard of our work have asked the parents whether they could provide us with the mattresses on which the infants were I lying. We've received mattresses, including mattresses from Shropshire. -- i J.B: What's your_reaction to people who've actually disclaimed this theory? For example, the Foundation for the Study of Infant Deaths.says that your work is'unproven., What's your reaction to that? __ B.R; - __ The work that I have done on the generation of the gas from plastic is quite fdimly proven. What is unproven is_the significance that this work may have, or this poisoning may have in relation to actual dot deaths. That's not my job. I'm i afraid the medical people must take my work into account and " see whether it does relate to the cot deaths that they're investigating. J.B: ~ - ----------r What precautions can" parents take? B.R: _ _ Well I think in the long term, of course, parents will have to replace~inattresies with safe mattresses. There's no objections to PVC, I'must emphasise that. The problem lies with the additives that are used in current PVC. So obviously the mattress manufacturers will producing safe mattresses I imagine quite shortly. H.F: Barry Richardson of Penarth Research Laboratory talking about his investigations into cot deaths. 2Z480H0 ** ** BFG21139 T ITT '89-06-09 10!23 BRITISH PLflSTICS FED 01-235-8045 PU/14. r The British Plastics Federation 5 Bslgrave Square London SW1X8PD 01-235 9483 Telex 8951528 Plated G i i Fax 01-235 8045 i i i to : . .. .CiU5^cr5> FROM: . rGftz&nT.. . iI i j DATE: i NO. OF PAOES (INCLUDING FRONT): . . S-frlT. IP ANY DIFFICULTIES ARE ENCOUNTERED DURING TRANSMISSION CUR PAX NUMBER IS: 01r235 80M5 MESSAGE: J. 1*T. ........... .*lb. .wOa-4 .... .Vwrfefc*... ACtoeTCr... :+*** : j*aeA .r..:*rhf%. ..*... .\.............. N lQ SbZ: Director - D H Jones A company by guarantee -'' sleree in England No. 282983 BFG21140 89-0S-S9 10:24 BRITISH PLASTICS 7S 01-235-0045 P.Z/14T P.JR.X.I-. TSCHNlCAk fSRVlfilt PENARTH RESEARCH INTERNATIONAL LIMITED P.O. Box 142, St. Pater Port Guernsey, Channal Islands REPORT COT MATTRESS BIODETERIOHATION AND SODDEN INPANT-fiBATE Barry A Richardson PI Tuns 1989 zno8W & BFG21141 '89-06-09 10:24 BRITISH PLfiSTICS FED 01-235-0045 P.3/14 nd COT MATTRESS BIODETERIORATION AND SUDDEN INFANT DEATH Barry A. Richardson _ Introduction Suddan Infant daathr commonly dascribad as cot death, accounts for a significant proportion of postnaonotal_ mortalitiaa, usually involving infanta which art not obaarvably ill prior_to deaths Tha cauaaa remain unexplained daspita extensive research,--many raeant studies- concantrating on statistical interpretations of tha circumataneaa of death as obvious explanations saam to hava baan eliminated. It has baan ganarally aatabliahad that auddan infant daath ayndroma ia tha -commonest causa of -daath between 1 and 12 montha, and accounts for about 2 deaths par 1,000 live births in tha Unitad Kingdom, 2 to 4 par 1,000 ganarally irr waatam countries, and about 6 par 1,000 in Now Zealand, but only about 0.3 par 1,000 In Kong Kong, and vary' low incidence in Russia, China, India and Africa, and amongst Infanta of African--or ~&elan origin in England and Ualas (172,3,4,9,6). Tha vary- high daath rata in Naw Zaaland is dua to exceptional-rates of about 11.S par 1,000 amongst Maori infanta, tha rata for _ -Caucasian infanta at-about 1.6 par .1,000 being lowar^ than moat wastam countries<7>. Daatha occur unexpectedly during alaap, 6011 of tha deaths -- affecting Infanta batyaan 1 and S months, Thara are proportionally mors daatha In tha winttr and mors at waekanda, with boya mors at risk in countrlaa whsra high daath rataa occur. Tha risk-la hlghar with pramatura births at low birth wsighta, twins, smoking mothara, unamployad fethars, slngla mothara and poor housing conditions, psrhapa bacausa all thaaa factors tend to result in Infanta with lowar weights than normal for thalr age. Daatha sometimes follow observations of general malalae whan Infants hava digaatlva diaordara, rafusa to faad or era difficult to wake- Racant hypotheses have concentrated on tha upper respiratory tract. It has baan noted that thara has baan a threefold increase in auddan infant daatha in Tha Netherlands from 0.46 par 1,000 for 1969-71 to about 1.31 par 1,000 tinea 1976(8). Tha obvious explanation for this increase la that auddan infant daath ayndroma la now recognised statistically, but this increase has baan attributed instead to tha general adoption of a prone or face-down alaaping position following recommendations that it was preferable at a paediatric conference in 1971. It has baan auggastsd that tlaaplng in tha pront position presents mors risk of obstruction of tha upper respiratory tract (9,10). Viral and bacterial infections have also baan reported, and may be aaeociatad with tha prone alaaping position (11,12). In a recant review it was pointed out that sleeping in tha euplna position may avoid these problems but craata others<13). It haa also baan suggested that tha prona position might result in hyperthermia as tha face la tha moat important cooling aurfaea and tamparatura control alamant, particularly in Infants protacted In tha winter by extra coverInga (14,19). P.R.X.L.. Page i *3 I? BFG21142 '89-06-09 10:25 BRITISH PLASTICS FED 01-235-6045 P.4/14 1/ C*% r****r>s*i *fvci **'"* Infant ***** Another possibility with heavy bed coverings and cote with high impermeable Ides Is that the Infant Is affected by accumulations of an heaviar-than-alr gas, the prona positIsn aggravating exposure. The most obvious gas Is carbon dioxide generated by the infant itself. High carbon dioxide concentrations would normally stimulate hyperventilation, although Infants at risk may suffer longer attacks of apnoea and may not bs able to hyperventilate to e sufficient extent to clear tha accumulating gaa from a cot and bedclothes reservoir <16,17). In euch circumstances ths carbon dloxlda would ba convsrtad avantually to toxic carbon monoxlda, such a convsrslon parhapa explaining why suddan infant daatha are particularly aasocistad with week-ends whan an Infant may ramaln unehackad In tha cot for a longar psriod<6>. - Carbon monoxlda poisoning has not baan reported and la unlikaly as this gas is llghtar than air and likaly to dlaparaa, but such an explanation would ba consistent with tha slow ralaaaa or formation of a toxic heaviar-than-alr gaa. Reesnt Investigations by Panarth Research International Limited Into blodeterloretlon of tho plasticisers In polyvinyl chloride indicated that three extremely toxic hoavlor-then-eir gaaoa phosphine, arsine and stlblne might ba generated, and this report therefore considers the possibility that these toxic gases from mattress covers, cot aides and nappy pants might ba a causa of suddan Infant death. Phosphine, arsine and stlblne Group V/Vb elements form gaseous trlhydridee. Nitrogen trlhydrlde is best known as ammonia, but phosphorus, arsenic and antimony similarly form phosphine, arsine and stlblne geaaa which are 1.17, 2.69 end 4.29 times heavier than air respectively. The threshold limit voluoo for phosphine, arsine end etlblne are usually quoted as 0.3, 0.06 and O.lpps respectively, about 300, 2000 and 1000 times mors toxic than carbon monoxlda which has a TLV of lOOppm. AH throe gates are colourless. Phosphine has e 'dead fish' or 'garlic' odour, aralno Is more distinctly 'garlic', and stlblne odour is usually described only as 'very unpleasant') with aralne tha garlic odour, which may ba aasocistad with tha formation of alkyl compounds, la only detectable at concentrations wall In excess of tha TLV. Armine The typical symptoms of acuta aralne poisoning in adults, which usually develop between 2 and 24 hours after exposure, art headache and dizziness with general weeknees and malalaa, followed by thirst, nausea, vomiting, diarrhoea and abdominal pain, often with a burning sensation of tha face and ehast discomfort accompanying dyspnea and pulmonary oedema<18>. Red urine mey develop 4 to 6 hours after exposure, followed by oliguria, anuria and anaemia. Hepatomegaly end jaundice follow after 24 to 46 hours. Polyneuropathy and encephalopathy have also been reported. Chronic exposure la usually reported to have a cumulative affect. This la not strictly correct as aralne la eliminated by conversion and excretion in tha urine, but anaemia caused by chronic exposure obviously beeomee prograsalvaly more severr, at vary low air concentrations poisoning la characterised by ahortnaaa of breath and general weakness resulting from this anaemia. Tha mode of poisoning Includes erythrocyte haemolysis through glutathione reduction which continues after exposure eaaaaa, followed by haemorrhagic hepatitis and Taaftnirml SiPvteem P&gO 2 VTTM ttZ BFG21143 I '09-06-09 10:26 BRITISH PLASTICS FED 01-235-8045 P.5/14 f'j C*% tom '*!** tear* loi-a ticm and w<a<ar\ U*irtt<fe nephritie with tubular nacroalt. Araine 1 a dapraaaant of tha cantral narvoua system, and prolonged exposure may affact th* bona marrow. Expoaura to lOppm for 1 minuta or 3ppn for 30 mlnutas is aufflelant to causa fatal or tavare toxic reactions, and Ippm for long parlods can be exceedingly dangerous. Arslna poisoning Is usually dlegnosad through acuta haamolitlc anaamla with ghost arythrocytaa and Incraassd plasma haemoglobin. Arsanlc in tha urlna usually excaads 0.0Smg/l In acuta poisoning, although in chronic poisoning continuous elimination usually maans that tha arsanie concentration doss not axeaad normal ambisnt lavala- It has long baan advlaad that casaa of 'toxic Jaundice' and 'haemolytic anaamla' should ba investigated for possible arslna poisoning (19). Mild chronic arslns poisoning may ba easily missed and attributed to food poisoning (20). This description of arslna poisoning la baaad on observations in adults. Young Infanta can be expected to be more susceptible bacauaa of their low body weight but there may be other physiological factors which may further Increase susceptibly such ea sluggish respiration and blood circulation In deeply alaaping infanta, and which may causa local rather than general anaemia in cases of acute poisoning. Phoaphina and atibina Phosphorus trlhydrlda or phosphine end antimony trlhydrlde or etiblne ere not ee well known as arslna, but thay are exceedingly poisonous heavier-then-air gaaaa with tha aama mode of action and symptoms as arslna. Tha main differences are eaaoclatad only with differences in density and toxicity. Phosphine, arsine and etiblne from plasticised polyvinyl chlorids Phosphine, arslna end etiblne can be generated by blodeterioratlon of organic and Inorganic phosphorus, arsenic end antimony compounds) alkyl compounds may also be produced which ere also exceedingly toxic gases. Seopulariopala fungi are usually involved but Patciloayeas species and soma wood destroying fungi auch as Lantinua aquamoaua and soma bacteria can also act in this way (32-62). Published reports refer only to arslna generation but phoaphlne and stlbine can be similarly formed. Micro-organisms can only convert phosphorus, arsenic and antimony compounds to hydrides if an adequate nutrient source is alto available which will provide tha necessary energy. Scopulariopaia Pravicaulia, also known aa Panlcllllum bravlcaula, is tha fungus spades which la most frequently reported as generating arsine In this way In domestic situations. It is usually described ea protein tolerant but It la actually protein dependant, and was usually identified in tha peat on silk, a protein fibre. Several classical cases of orslne poisoning hove been attributed to thle fungus causing blodeterioratlon of old wallpaper printed with Seheela'a green or Paris green arsenical pigments. Napoleon's death and a mystery Illness suffsrsd s fsw ysars sgo by ths US Ambassadress to Italy hava both been attributed to chronic orslne poisoning caused in this way, and this could be an explanation for some of tha unexplained sudden Infant deaths reported In tha 19th century. Although thle fungus Is usually associated in reference books with blodeterioratlon of ailk, it actually occurs in normal domestic air and will P.R.X.L. i.'vu.i Page 3 BFG21144 cTTnak^ 1T1 89-06-09 10:27 BRITISH PLfiSTICS P.6^1<P cat li.atriorttQn *ni mucirtitn fnfrrft develop on any suitable protein sourca, such at wool In carpets on damp floors or clothing atorad In damp wardrobes, aa wall aa on laathar <53-38>. Scopulariopaia bravicaulia can davalop on polyvinyl chlorida cot mattrass _ covarlnga If adaquata moiatura and protain ara praaant, paraplratlon uaually providing that# requirements. Othar fungi and bactarla can datarlorata PVC plaaticiaara, particularly Atparglllu* nigar which cauaaa gray dlaeolouration and Straptanycaa rubriraticuli which eauaao bright pink staining; thaaa organiama heva no toxic affact but thalr praaanca indicataa that conditions ara auitabla for tha development of S. bravicaulia and other organiama that can ganarsta phoaphina, araina and atibina<23*24,25.28.27,31). Tha araanic source In-- plaaticiaad PVC la uaually 10,10'-oxybiaphanoxyaraina (OBPA), a blocida that -ia incorporatad to pravant biodatarioration- of tha plaatlclaar in tantaga and-similar PVC fabric exposed to tha wssthar, although It ia also sometimes used-in PVC furnitura covarlnga for hospitals aa a sanitizing agant. OBPA will control moat organisms at normal biocidal uaa concantrationa but it ia slightly volatlla and it la also dtgradad by ultra violet light, concantrationa typically dacraaalng prograaslvaly until colonisation by arsanlc-raalatant organiama such aa S. bravicaulia bacomas poatlbla. Tha antimony sourca la uaually antimony trioxlda, a whlta plgmant which la addad to PVC to improve firs ratardancy aa It acta with tha chlorine In tha PVC as a flams suppressant by formation of antimony chlorldasi but It appears that soma manufacturers era now uflng antimony trioxlda aa a filler plgmant at concantrationa wall above those required for firs ratardancy. Antimony trioxlda le~7Tot significantly biocidal and atlbina can be ganarated If conditions ara -- ~ otherwise auitabla for microbial davalopmant. Tha phosphorus sourca la uaually a phosphate plaatlclaar, uaad in preference to phthalete and elmilar compound# - whan firs -ratardancy-la required. Regulations Introduced In tha United Kingdom In March 1969 raquirt PVC for nuretry purposes to be fire retardant and this mesne that all cot PVC contain*- antimony trioxlda and phoaphata plaaticiaara) this is an unfortunate response to fira risk as firm rarely initiates In PVC items, and fira retardant PVC heated by*fira from another source will ganarsta much more toxic smoke than ordinary PVC. Investigations Phosphine, arsine and atlbina generation by Scopulariopait bravicaulia can be demonstrated in tha laboratory. This fungus la protein dependent and will not develop strongly in tha absence of a protain nutrient source. A convenient culture medium can be prepared by stirring 5X soya flour Into 5% malt agar, although tha soya flour can ba replaced by other nitrogen aourcaa such aa ammonium citrate. Incubation should ba at about 23*C. If a phosphorus, araanic or antimony sourca la addad to tha medium or aa a patch of material such aa impregnated filter paper or fabric, generation of phosphine, araina or atlbina will occur. Thaaa gaaea are reducing agents and can ba detected by darkening of silver nitrate; phosphine initially forma a lemon yellow complex, and araina and atlbina form brown complexes before black silver deposits ara formed at higher coneentrationa. If greater sensitivity is required tha culture air can ba circulated through silver dlathyldlthlocarbemate reagent, producing a brown or orange colour for phoaphina and rad colours for araina and atlbina (21). f3. R.X.JL. fvt.M Page 4. BFG21145 9TT08I-2Z in- '89-06-03 10:28 BRITISH PLASTICS FED 01-235-0045 P.7/14 l<sr*4tn *nd Mtrcurie chloride or bromide will react with ereine to produce yellow to rod complexes, depending on concentration, but phosphlno and otlblno do not produco coloured product*- with thooo reagents. Tho moot convaniant mathod of datactlon of thoaa gaaaa from Petri dloh eulturaa la to usa two small strips of dstoctlon -- paper tucked over tha adga of aach dloh eftar tha growth haa become strongly established, a silver nitrate paper which will turn Initially yallow with phosphine and brown with arsine or stlblne and eventually black with all three gaaas, and e- mercuric chlorlda or bromide papers which will turn yallow or rad If arsine la present. Sliver nitrate paper la prepared by soaking fUtsr psper In s 5% aqueous solution and marcurie chlorlda or' bromida papar la proparad by aoaklng filter paper In a 5% alcohol solution. PVC is ofton naturally- infected and detariersted by organisms, particularly Anpargillut nigar end Sfraptomycaa rubriratieuli, end laboratory experiments have demonstrated that thee* Infections can develop if the arsenical biocide OBPA ls'preeant at an inadequate concentration and even if antimony trloxide ia present at high concentrations, provided that a suitable nutrient source Is ovallabla axtarnally or within tha PVC as plasticiser. It has also bean demonstrated in laboratory experiments that the fungus Scopulariopaim ^bravicaullt can develop on tha earns PVC semplas In similar conditions, a high protein nutrient source being necessary, a soye/melt agar medium being the most convaniant way to Introduce an external protein source In routine laboratory experiments. Exposing small discs of PVC fabric to Sr~ bravlcaulia Petri dish cultures on soys /malt agar with silver nitrate end marcurie ehlorld*' psper detection is e simple means for checking whether samples contain phosphorus, arsenic or antimony eourcee which might cause toxle hydride gee generation under appropriate blodetarloration conditions. Checking PVC involved in sudden Infant death to 'confirm whether toxle gee generation wee probable can Involve e similar technique but without Inoculation, relying upon the natural Infection on th# febrlc. -- Initial cot Investigations wars on PVC fabric from a new mattress which did not contain any biocide, according to the manufacturer. Semplse were Inoculated with S. bravicaulia and generated gas gave a brown colour with silver nitrate end a faint yellow colour with mercuric chloride, indicating a reducing gee, probably etlbln* from antimony trloxide, with some arsine, probably from the arsenic contamination that la usually present in antimony trloxide. A doctor who had lost an Infant then provided the mattress on which it had died. Tha mattress wee a Vialvent carry cot type mattress comprising foam with th* lower two-third* covered with PVC and tha upper third covered only with a net. The mattress had been ueed for a previous Infant but wee in excellent clean condition. The PVC fabric wee sampled and placed on aoya/malt plate*, producing the normal Renlcllllum, AapmrgHlua end other fungal cultures that are normal from domestic articles, but heavy growth of Scopulariopaia bravtcaull* also developed, generating gee causing brown or black colouration with silver nitrate but no detectable colouration with marcurie chloride, probably stlblne from antimony trloxide. Foem was sampled under the net, thet 1* under the head of tha Infant, giving heavy S. bravicaulia Infection but no colour change with sliver nitrate) eeverel other mlcro-orgenlema were also found on the foam, Including Straptoayeaa rubriraticuii which la a pink staining organism which Is often associated with deterioration of plasticised PVC. P.R.X.L*. * m'vi.m Page 5 BFG21146 m osm T II '99-06-09 10:28 BRITISH PLASTICS FED 01-235-8043 P.8/14 O Cot mas-b-fcra*** twfont et**H Tha Initial invaatigatione Included 21 mattraeeae from sudden Infant death lncldenta, including one cotton covered mattreea but ell othera involving PVC and aome with exposed foam areas coverad only by net. All PVC covers were Infected with S. bravlcaulia which was particularly heavy at stitching, although also always present in the PVC covering immediately beneath the infant) all samples Infected with S. bravicoulia also generated gas which caused brown or blaek colouration with silver nitrate, probably stiblne from antimony trloxlde. Some samples ware also infected by S. rvbriraticult, although the characteristic pink stain was not always visible) In one case on a mattress only 2 years old the pink stain had clearly formed under the Infant and followed the body shape. Foam samples from arses covered only by net were heevily Infected with e number of fungi, including S. brmvieaulia although gas ganaretlon was not detected) the foam does not contain aultable sources of phosphorus, arsenic or antimony. It was observed thst some of the fungi on the foam produce spores which are wall known at cauaea of allarglc reactions and which might causa fatal asthmatic attacks in sensitized infante (53,57,89-64). Phosphine, arsine or stiblne gas generation through biodeterleretion of plastleer in polyvinyl chloride fabric it a possible explanation for sudden infant death, particularly if infants are In doted cote or heevily wrapped. Toxic poisoning In this way Is conslstsnt with the reported circumstances of sudden Infant death eyndroae. A prone sleeping position, heavy coverings in cool weather, and longer undisturbed periods in the cot at week-ends all increase the risk of chronic poisoning from a heavlar-than-alr gee. The Increasing incidence over the last 20 to 30 years it consistent with the Increasing use of plasticised PVC in nursery products, and algnlfleantly lower incidence in some countries such as Russia may be associated with lack of uae of PVC products In this way. The fraquently reported malaise, digestive disorders and anersxls prior to daath are consistent with chronic poisoning; it might bs expected thst some darkening of the urine would be reported In such circumstances but It it possible that daath occurs before it develops. The risk le least with new cote and aattreeeee as they are less likely to be supporting Infection. The symptoms of phosphine, arsine and stiblns poisoning have been generally reported for adults with the cautions that poisoning is not easily auapacted or diagnosed <18,19 >. Infants are more susceptible because of their lower body weight) in en accident on the Tharnopylla, a ship carrying grain fumigated with phosphine, 29 crew and 2 children wars affected but it was a child that dlad (22 >. Infanta with low birth welghta might bs expected to be particularly suecaptlbla, whatever the cause of their low birth weight, because of their lower weight in relation to age during subsequent development. The high incidence at last than 12 months Is probably associated with low body weight coupled with minimal ventilation due to lack of body disturbance during sleep, but the peak incidence between 1 and 5 months might ba associated with physiological blood or respiration features associated with that age group. Hydride formation by micro-organisms is well known. Sulphate reducing bacteria such as Daaulfovibrla species can convert sulphates to sulphur dlhydrlds, mors commonly known as hydrogen sulphide, but only usually in anaerobic conditions in which the becterle utilises sulphate as a source of oxygen) hydrogen aulphlde Is R.X. I_. Pega 6 mnmzz BFG21147 T TTI '89-0S-09 10:29 BRITISH PLASTICS FED 01-235-8045 P.9^14 . C4it Blad* r trva audcton mfrtni generated In faeces in this way. Nitrogen trihydride or ammonia can be ganaratad from nitrogen sources such as nitrates and urea by a variety of bacteria such as Thiobacillu* danitrificanm, some acting In aerobic situations; ammonia Is generated In this wey from urine soilage of nappies and clothing. Some bacteria are capable of converting suitable arsenic sources Into the trlhydrlde arsine (28,29,30). In all esses these bacteria also require a suitable nutrient carbon source. Fungi can also generate phosphine, arsine and stlblne, Patcilomyca* and particularly Seopulariopaia species being the most likely cause In domestic nursery situations In which the protein-dependent S, bravicaulia Is likely to be present as an Infection of damp wool carpeting or clothing. Infection of plasticised PVC Is apparently dependant on perspiration end * develops mainly on the area immediately beneath the Infant, Infection being followed by toxic gee generation if suitable sources of phosphorus, arsenic or antimony are present; stlblne formed from antimony trioxide aeams to be the moot eommonly generated gae. The risk of Infection on PVC In this way Is higher on older materials which are mors likely to be affected by established infections, although en infection will only generate significant amounts of gas when It la particularly active, perhaps not until several weeks after the mattress Is first used. vented mattreseee In which the foam at tha haad and la covarad only with a net eupport maeeive mixed fungal infections which produce spores which can cause allsrgic reactions, Including ssvsre asthmatic attacks in sensitized Infante. Conclusions Phosphine, arsine and stlblne gee generation through blodetarloratlon of plasticised PVC is a possible cause of sudden Infant death. Infants ere more susceptible then adults becausa of thalr low body weight which makes it sealer to accumulate a lathal doaa and particularly if slaeping In tha prona poaitlon with the face close to the gae accumulating on the mattress. Poisoning la difficult to detect, as the phosphorus, arsenic or antimony introduced Into the body through phosphine, arsine or stlblne poisoning would not Increase levels beyond normal ranges. Investigations should Involve Incubation of samples of PVC mattress coverings at about 23C on high protaln agar plates, such as 5% malt agar with tha addition of 5% soya flour. Positive Identification of organisms is not essential, but it Is necessary to confirm whether en Infection le present which may ba generating phosphine, arsine or atlblne, most conveniently by Incubating tha samples on Pstrl dish plates with silver nltrata end mercuric chloride or bromide test paper strips tucked over the adgs of each dish whan an active Infection has developedisllver nitrate paper changes Initially to yellow with phosphine and brown for arsine and atlblne, and subsequently to black with all three gasas, aralne also causing yellow or red colouration of mercuric chloride or bromide paper. It should ba appreciated that heavy fungal Infections on exposed foam In vented mattraesaa may produce spores that can causa allergic raactlone, Including savers asthmatic attacks in sensitized Infanta. P.R.X.L. Mnuaa Page 7 BFG21148 '89-06-09 10:30 BRITISH PLASTICS FED 01-235-0045 P.10/14 C** >ii04atri4rtian nwOMn Recommendations Sudden infsnt death investigators ahould recognise phosphine, erslns and stibine_ poisoning from PVC biodeterioretion, and asthmatic reactions to fungal spores, as possible causae of death. PVC mattress coverings should ba checked for fungal Infections ~snd. gas generation, and exposed foam and porous mattress fabrics -should be checked for fungal Infections. PVC used In mattress coverings, cot sides and nappy covers should be resistant to fungal and bacterial infections. Resistance can be achieved most reliably and permanently by using resistant plasticisers, rather than by adding biocides. Components contain ing'-phoaphorua, arsenic and antimony must not be used) the present limits for arsenic and antimony In British Standard BS 1877:Part 10:1982 Domestic bidding/--Part f0r Specification for mattresees for children'* cot*, paramboiatora and similar .dmaatic articla* are too high and there ere_no limits for phosphorus. Exposed foam mattrassas should not be used. ~ Temporary protection against gas and spare generation can ba achieved by wrapping mattresses in clear polythene sheet, aacured on the underside using ~adhesive tape. Carry cot mattresees can be replaced with a folded large sheet. Acknowledgements These Investigations are an extsnslon of a series of projects on biodeterioretion of plasticised PVC. 1 an particularly grateful to Mr P R Mitchell *4 Mitchell Marquees who, when warned that arsine generation might oeeur in stored tentage containing OBPA, prompted these Investigations by enquiring whether sudden Infant daath might ba caused in this wsy. My assistant Mrs S A R Kelly was responsible for the mycologlcal work, and Mr T R G Cox advised on chemical mattare. Dr D Allsopp of the CAB International Mycology Institute at Kew supplied the original sample of Scopulariopaia bravicauli* which enabled ue to eeteblleh thet phoephlne, areine end etibine could ba generated through biodatariotalon of plasticised polyvinyl chloride fabric. References 1. Golding J, Limerick S A MacFarlane A. Sudden infant daath; pattama, puzxla* and probiemrShepton Mallet: Open Book Publishing, 1985. 2. Becroft D M 0 & Mltchall E A. Trends in unexpected Infant deaths. Lancat 1989;B639:G73. . 3. Lee N N Y, Chan Y F, Davies D P, Lan E * Yip D C P. Sudden lnfent death syndrome In Hong Kong) confirmation of low incidence Br Mad X 1989)298:721. 4. Gordon R R. Trends In unexpected deaths In Sheffield Lancat 1989)8629:106 Page 8 22480120 BFG21149 T TTr '89-06-09 10:31 BRITISH PLPSTICS FED 01-235-0045' P.11/14. y ii i C** 5> Balarajan R, Sonl Ralaigh V k Botting 8. Suddan Infant death eyndrome and poatnaonatal mortality In Immigrants In England and Walee. Br Mad 7 _ 1989;298:746-720. 6. Morris J A. Increased risk of sudden Infant death syndrome In older Infants at weekends. BrJMad 7 1986;293:566. 7. Mitchell E A, Haseell IBS Becroft D M Or Poatnaonatal mortality review In Auckland; two years experience. NZ Mad 7 1987; 100(269-272 6. de Tonga 0 A, Engelberts--A C, Koomen-Lieftlng ATMS Kostanse P T. Cot death and prone sleeping position In The Netherlands. Sr Mad 7 1989;298:722. ~ 9. Beel S. Prone-or euplna~for pre-term babies? Lancat 1988;llt512. 10. Southall D P, Croft C, Stabblns V, at al. Detection of sleep associated dysfunctional pharyngeal obstruction In Infants. ffur 7 Padiatr 1989; 148(353-9. "'ll. __ Morris T A. Haran D S Smith A. Hypothesis; Common bacterial toxins are a possible cause of the sudden Infant death syndrome. Mad Hypothaaaa 1987;22:211-222. 12. Morris J A. Suddsn lnfsnt dssth syndroms. Sr Mad 7 1989|298t958. 13. Mllntr AO.8 Rugglns N. Suddsn lnfsnt dssth syndroms. Br Mad 7 1009; "298(689-690. .- 14.-- Nslson-E A 9, Ttylor B T k Wsethsrall I L. Sleeping position end lnfsnt death bedding may predispose to hyperthermia and the Sudden Infant Death Syndrome Lancet 1989;ii 199-200. 15. Stanton A N, Scott D T k Downham M A P S, Is ovsrhsating a factor in aoraa unsxpactsd infant daatha? Lancat 1989ili 1084-7. 16. Kally D H, Oolub H, Carlay D k Shannon 0. Pnaumograma in Infants who ubaequantly dlad of Suddsn Infant Daeth Syndroms. 7 Padiatr 1986; 109:249254. 17. Kahn A, Blum 0, Rabuffat, at ol. Polyeomnogrephic etudiee of Infante who subsequently died of Sudden lnfsnt Death Syndrome. Padiatrica 1986;S2i721727. 16. Kleinfeld M T. Arsine poisoning 7 o M 1980;22:820. 19. Dolg A T. Lancat 1954;11:88-92. 20. Hunter 0. Pharm 7 1936;137;5H-15. 21. Anon. Arsine Mathoda for tha detection of toxic aubatancma in air; Booklet No 9, Ministry of Labour, H M Factory Inapectorata; London, HMS0, 1966. Paga 9 BFG21150 W H iQ H Z ITT '99-06-09 10:31 BRITISH PLASTICS FED 01-235-9045 P. 12/14-J Col tkl*da*+r ior*tiwn dHPt uddn 4fMrtfn 22. Wileon R, Lovejoy F H, Jaeger R I I Lendrigan P L. Acute phoephine poiaoning abroad a grain freighter. JAMA 244:148-ISO. 23. Klausmeier R E. Reeulta of the second Interlaboratory experiment In blodeterioratlon of plaeUc*. Int Biodat Bull 1972)8(11:3-7. 24. Yeager C C. Pink etalning in polyvinylchloride. Plaatica World 1962)20:14. 25. Yeager C C. Laboratory and aervlce teete for PVC. Proc fat Int Biodat Synp 1960)151-161. 26. Klauemeier R E 6 Jonea W A. Mieroblal degradation of plaetlcizere. Dav Tnd Microbiol 1961)2:47-53. 27. Klauemeier R E. The effect of axtraneoue nutriente on the blodeterioratlon of plaetlca. Monograph S3, Soc Cham ihdl 966)232-243. 26. Stainer R Y, Doudoroff M 6 Adelber B A. Oanaral Microbiology, London,Macmillan, 2nd edition, 1971. 29. Bergey. Manual of Datarainativa Bacteriology, 8th edition, 1976. 30. Engvell A-Q. Ammonium releeee at the eedlaent-water interfacet in eitu atudlea of a Baltic eedlmant during negative redox turnover. Microbial Oaocham 1978;2:1-39. 31. Hollo 1 6 Kollar-Volgyeei M. Reeletance of plaetlca to microbiological corroaion. Bioch Exp Biel 1875;! 1:163-173. 32. Smith 0. An introduction to Induatrial Mycology. London,Edward Arnold, 6th edition, 1969. 33. Morton F ] I Smith 0. The genere Seopulariopaia Balner, Microaacva Zukel, and Doratomycaa Gorge. Mycol Paper 66, 1963. 34. Rlehardeon B A. Wood Praaarvation. London, Conetruction Praaa 6 Longmana, 1976. 35. Broaaa van Qroanou H, Rlachan HULt van dan Barga J. Wood Praaarvation during tho laat 30 yaora. Leiden, Sijthoffe, 1952. 36. Hamilton A. industrial Poiaona in tha United States. Haw York, 1925. 37. Bub-Bodmer P A Tilger B. Dia Konaarviarung daa Holzaa in Thaoria und Praxis. Berlin, 1922. 38. Qoelo B. Azione dl alcune muffa aul compoetl fleal d'eraenico. Riv d'lgiano a San Publ 3,201-230, 261-273, 1892. 39. Qoelo B. Action de quelquea moieieeurea eur lea compoaaa fixes d'areenic, Arch Ital Biol 18,253-265,1893. P.-R.T.I.. Page 10 BFG21151 '89-06-09 10:32 BRITISH PLASTICS FED 01-235-8043 ch r*\*nd uddn infnl 40. Goalo B. Zur Fraga, wodurch dlt Oiftigkelt areenhaltigar Tapeten bedingt wlrd. Bar Deuta Cham Gaa 30, 1024-1026,1897, 41. Schmidt H F. Ubar verachimmelta Tapatan. Diaa Brlangan, 1899. 42. Thom C A Rapar 1C B. Tha araanic fungi of Goaio, Scianca 76, 548-550,1932. 43. Mahlke F 8 Troachel E. Handbuch dar Holikonaarviarung. Barlin, 1928 44. Bargs 7 van dan. Baoordaallng van da wsarda van funglclda stoffan voor houteonstrvaaring, Diaa Dalft, 1934. CTaating tha aultability of fungicldaa for wood praaarvation Publ Int Adv Off Wood Praa, Tha Hague). 45. Anon. Oaaaoua araanic from wall-plastar. Tha Analyat 57,163-184,1932. 46. larrlgoA F. Tha biological mathod far tha datactlon of araanic. Tha Analyat 57,155-158,1932. 47. Sangar C R. On tha formation of volatile compounde of areanical wall papara. Proc Am Acad Aria 4 Set 21)112-147,1694. 48. Sangar C R. On chronic araanlcal poleoning from wall papers and fabrics. Proc Am Acad Arta 3 Set 21,148-177,1894. 49. Biginalll P. Compositions a costltuslone chlmlca dal gas arsenicsla dalle tappazaria. Atti R Accad Uncat Randle Cl Sc Fie Math a Rat, 9,210-214,242249,1900. 50. Maaaan A. Dia blologlacha Mathoda Ooaio'a sum Nachwaia daa Araana und die Blldung organltchar Arsen-, Solan- and Tallurvarblndungan durch Schlmmalpilze und Baktarian. Arb a d kaiaarl Oaaundh ambt, 16,478-469,1902. 51. Hues K. Zur Konutnia dar. biologischan Zarastzung von Araanverblndungen. Z f Hyg u Tnfakt krankh, 76,381-406,1914. 52. Lagge T K. Araanic poisoning. Ann Rap Chiaf Trap Fad Vorkah Or Brit, 6768,1916. 53. Milberg P. Mlkroorganlamor 1 byggnadar, an litterarurstudla over artar, forakomst och miljokrav. Sv Lantbrukauniv, Tnat f virkaalara, Uppaats 164, 1987. 54. Davlaa RR. Viable moulds in house dust. Tirana Brit Mye Soc, 43,617630,1960. 55. Oravaaan S. Identification and quantification of Indoor airborne microfungi during 12 months from 44 Danish homes. Acta allargologica, 27, 337354,1972. 56. Oravaaan S. Identification and pravalanca of eulturabla mesophllle microfungi in housa dust from 100 Danish homes. Allergy, 33,268-272,1978. P.R.X-L. |,,v,,,i Page 11 BFG21152 T IF 2Z4 8 0 1 Z3 'S9-0E-39 10:33 BRITISH PLASTICS FED 01-235-8045 Co % ro 4trtt4li if/ftvlon ond auddan dctat Vn 57. Holmbarg K. Halaoaffaktar ov mogalkontaminaring 1 avanaka boatidar. Byggforakningaredat rapport R36.99a.198B. 5&_ Morton LJi 0 t Eggina HOW. Tha af fact of moietura contant In wood on tha aurfaca growth and panatratlon of fungi. Miat u Org, 11.279-294,1878. -- 59. Anon. Mogal 1 byggnadar; an kunakapaovaraikt. Soclelatyralaan radoviaar, 11,37a, 1984. ~- 60. Gravaaan S. Fungi aa a cauaa of ellargle diaaaaa. Allergy, 34,139-194,1979. 61. Holabarg K 8 KalUngt--L-O. Allarglak alvaolit oraakad av mogal och tarmoflla aktinomyeatar. Lakertidnlngan, 77,39-44, 1980. 62. Sundin B. Fukt och mogal i byggnadar. Medlcineka affaktars -WS och anargt, 12,43-46,1983.-- 63- 8arr ARM, Hutchana M E 4 David 7, Mycotoxinaj a potantlal hazard to haalth indomaatlc dwallinga. J Inat Wood Set, 10,120-121,1985. 64. Croft W A, Jarvla B B & Yatawara C S. Alrboma outbraak of Trichothacana toxlcoaii. Atmoa Env, 20.549-552,1986. bK tO & W S P.R.X.L. Paga 12 BFG21153 T- ITT ioxic gas*4 theory on THE mystery cot"Geth syndroms may be caused by Al&n Massam- - by babies breathing toxic eases generated from PVC mattress coverings, scientists now believe. ing by gas heavier than air . accumulating in bedding. Infants usually dlad fact A team o( researcher*---down when they were have come up with the ex* heavily wrapped against the planatkm lor sudden infant cold. death syndrome, which UUs 3000 babies each year in Bri tain. Deaths often occurred on mattresses which were not new and In which fungi or*- The discovery was an ganlsms could have become nounced today by Guernsey* - established. *- based Penartb Research In* temational. But Britain's lsading research body into tha problem. The Founds; lion lor the Study of Infant v Deaths, condemned it be* cause It was "only an un* proven hypothesis'. "We have bean inundated with csHt from worried par* anta/nrspokaswoman said. Mattresses supplied by parents who had recently lost babies were eontami*. nated with tbe fungus seopuimbpsls brevicauUs. par* Ucularly in stitching. Tha researchers also con sidered that, foam coverings of the top hall of mattresses supported fungai infections which could provoke aller* Penarth claim that mat gie reactions. tresses tested included The Foundation for the - those only half covered with* Study of Infant Deaths * PVC. It was found that they' `stressed that epidemiologi were likely to harbour fungi cal evidence did not support c which were capable of giv tbe Penartb claims because - ing off gases like arsenic cot deaths occurred long be*.. trichloride when they re fora PVC was used on mat* -a acted with the plasticisers tresses. used to make PVC Oexlbile. t The Penarth research is ~ Tha company .believed .- supported by Dr PetCr Plem- - that the usual eireum*... Ing of Bristol. Maternity . stances of sudden cot deaths Hospital's Department of ;wera ooosixto&t with poises* ChUdHealth.. ------ f will be examined By OerHealtli Services SUfF ' . Health oAcials are "taking serf* ouslv** a theory that some cot deaths may he caused by-PVC in mattresses emitting -heavier* tban-air noxious gases.' The Department of Health said yesterday that the claim, by a Guernsey, research, company, weald be evaluated scicatift* rally, hut a spokesman added; ''Current thinking is that cof deatlu arc due te mere than ena cause and the possible expUna. tion that has been put forward is just another possibility." - -..r--3>bOT deaths bring - trsfedy . to thousands .of .parents every Cyear. They are ill the more dls--: stressing for being shrouded la such'* Tinystery. . Heaearehers ara not sura whetherthey stem-from one cause or many/ All of which dots nothing to r-------millions of anxious mothers. Moreover the mystery helps create suspicion in the-minos. ox outsid ers -- thus increasing the sgonyr-of -* tha grieving parents. - For those reason*'the prospect of major breakthrough into tbe causa of * cot death ts armatter forTejoieihg. If'r tha rasaarch^.taam on- the.- Chennai. Islands really has cores up with the ,., answer.- they.. will : deserve allourthanks..-** - >< '* COT DEATH.-* Is' one of-Urn-meet i, a -- - -- eu, ba so devastating :tbol* i have born driven, to. poison * '** r.vrtfdli at Death Syndrome *(3X08) Is very welt ,-Ttoe findings show that tbe FVCeov ___ mattress on the cot Itself could bo I nepomlbla *>-. *. ! lmfc - Research by BarTy fclctaerdsod-of. Pern * ^ artb Rassareh Intamattenal -In; Guernsey.:. Idesafad yesterday, suggests cot dsathrter time maybe being literally geesid by thatt ewtf ebts as fungi, growing on-FVC.etad mb tressaa. give off toxic fumes. Tbe fungi cam to cot ? not be kifiod by ordinary disinfectant and are paturally present in the home, especially in woms. It is a terrible bony that many parents ibeve Switched to PVC covered ................... to deaths*** best ether pcaslbls causes e< oet death. ;. Cot death atm remalnaaa anlgma. Dr Elk ' sabstb Tayiec. senior lecturer in.. community paediatrics at Shef* - - V Sy MARK VOUIS Said Utoversttjr, is one *f Ui* foremost researcbers In theMO. She says: -Cot death la. THE DAY MY BABY DIED BRITISH* scientists*. claimed yesterday to v . Risk /.- have 'tracked down n He advised ntfrents fo. major cause - of .ool death; which kills more than 1,000 babies a year. Researchers m ithe Channel Islands hlivcdff* covered a fungus wMeh throw away all fYQ eopr. ered maUreagea. an replace them:; 1 fetdad coUan sf j ; aMWr. t'R^fichard Hacks PVC .mattress - covers, giving o(t a cock* tall of deadly gates. The scientists saM the . amount of poisonous gas has Increased because af ' chemicals added to PVC-.- to comply . with recent fire laws.. Laboratory lasts on 31 - -mattresses on which babies died were carried., out lijr Penarth Research.. International ,ln Quern-. ey. Twenty had 1*VC cover ings and each of these had ' fungal. -Infections ' which.were generating the lethal gases- arsine. nd stlbinC. ; I The . scientists said mere Investigation: was1' needed, but research-; wbere they `ara ctos* 10 '* the liberated gas."' -`; /f -The news eausad pgnlc'. bmong parents after Mr... Richardson was Inter viewed on Radio Ptvr'i.J Today |programme:- Hunddrreodss Jammed' llnat to ths Poun* ' datkm far the Study of ' Infant Deaths pleading (or.help on how lb pro*, tact their babies. Many callers ware In tears. * The Department of Health promised an Investigation -- and . probably due to a lot of factors which corns together and then hk a baby who is already vulner able. Wa ve get to look at every* Cot death was only oCOetai>y' ,cmlamie.dra..s..a..c.a..u.s.e...o.f..d.e..a.t.h..in . . although there waa e slight tatiec. Uan af the hang. ..,. *Om ef the worst things after* i?. wards Is tha fUt yau fed.* Sue says. Sue. 31. and Graham. 33. are ' new expecting a new baby, doe In ' October.- They're thrilled but war* 1 L ani wtll neve a manlier tfi iht Vulnerability _ . : I't see Pavid_ ai -fcrtaihlng la interrupted.-The baby ; the severs. Soe wfu alaa steep In their ream. * it la* now thought that about * ***** . IW* mm ManaalliML conU .OHO in SOO babies die from cot ' death.. Two thirds^ of >ihese ---------- >!* month sasnsaHatlan*^Alaaandra mParags. Was-ton:nmer-^_; , daatha occur in babies of four to ' II weeks old. and slighty more _ knm^h^avtd Mart. Uf P3-eJl3J3. or MJS- t #13333 or on their. 24 hour fte^ikne ; boys ara vietiras than girls. Research bee shown that M par . cant of all eot deaths happen B..;guhl Tha post mortem eaM Mothers * was natblwg wring with David ROSCMARt CARPCMTtn -between October and March.. : The high winter rates have ted - ___ __________ _ IBIOomsbury. wrrrtlter researchers to boeluieevveetuhisaitoovveerr*- ------- ~_ urv uruvice SunOiM f t ntaur mpm . DDeebboorraahh JJaacckkseoonn mmyyisi Uisl heating may be a cause, or even By JANET MENZIES tonr tract InfecllOJL Oia flrat year, of Ufa. a baby s -suftoeatloo: because of over* . - 1 " - xm Tajkif confirms:' "Bradb . breathing bv* from 17 fo wrapped babies. Children under ____y(,, |(ym -Important. The - around-17 breaths per mlmrtCj . thresmentha old have ditOcutty inund^S iiiiLhiidf~ wtombeontrola.tha.:. "And between two..and tour In regulating their tempereturo-. J**J*p*,'e*B.**"found In {j^wg braalhtng can be bUo aaonthet the time wh*n.*b*fTht? control nMCbaniam. But the ****b vr '* SSLS Soma d my researeh changing breathing patterns. !^ raaearehiTS came to a halt when- . A common tbemy la ^ > SSpaiahfolab*eMM*o(raapi- ; la moat suaeeptlble t* SIDS. ; . ktokfoc at Older vtctima., * . babY* oiwn "JPPW "r*Ky ntecUon. Allergy hae , Sleeping next to an adult ran The new. research links the* *> "5?,?*?J?* .^.AWimenoutlorwcrd.aaapeeel atlmulele regular breathing In a tnddenea of chlldreor lying laeeX*^*>7,^- "" ----^ ' v. V-- hehvt--------------- -- downwards ' and swaddledcovers with their Increased vul*-t * Or ICsvtoFersytk,blIk#Mbi suscepdbi*. neraMttty to fumes accumulate-. luto of ChPd Health In London, -.. Inc ki the PVC bedding. * has conducted a nirvey.which fears: litleJy eertvlneal' he luu. discovered one o( the causes of ,cot deitth. .' - advised parents not to start ripping elf PVC maUrnss covers. , ` Ptatbar support lor- the the*; . ^.^ti^I**_^toTW*faIetorr*HtI ocy appears to eome-Crora Hew , Infeetipn. as ..**?tsr. .l* Zealand, which has one of the highest cot death rates to,the ______ ^.InLrS rfSy . lent to take the next breath."! AfriaT: SiSaSd-.. with their mothers display dli, world. The custom there ts.to * r*?trr0!7 j- tbt baby face down oar-a *. Six bablee died wwiuig. ae Unkedto thebSy fei*. ferant breathing pettyrntrog s sleeping alone. In fac^ sheepskin rug covered with blankets -- and the: micro-or* S^^^ichwron^lnrte hours In the Hofoe Counties in January thla year. Researchers fell That It wee caused by a King 22480125. mother's.breathing pattern*. . -^In her hook Three I*A*Bedr ' g would appear that the child t breathing follows the mother s BFG21154 Mothercare rap boffin -- If SUM ACFOUTM t P scigntlst Undid In a row last night w. ti cuimed to hava dltcovtrcd on# ol the main causes of cot deaths. Or Barry Richardson said mattressts covered by PVC were to blame for many of the.cot trafcdiet which have baffled research- en for yean. But bum ef (he fiant Mothercare store ehain, which stocks a range ef , PVC-coverad foam met* tresses, were furious. ) don't want parents te worry about something that Is net proven.** Makers i Dr Richardson, SI, heed of a rosoaich Amt In Guernsey, said he found that M mattress covers on which babies had died wort affected by a fungus : giving off isdc gases. Mothercare WILL, dfs- ; cuss his findings with ' mattress makers. The Little Ones cot death charity said! **Wa remain acepucafc** Qy0j uavaiaou'wj vuvw* -------- - claiming, to liave discovereda major caus^trf the; mysterious''" cot death- syndrome..;' -tTM " ; - The. Mothercare chain was besieged by calls from parents anxious-.about the report that FVC-covered mattresses might be to blame. ; ~ Doctors woe furious tint the iwMicbs had lumped tht gun. sad rsrmled (Mr.findings a advance of mere siilngsul torts.trr. But 'lartaighttba dm.br d Peaarth Research International > By Ut B1MU I bv .Ma. data of a. possible breabthongh la the V xyudiema which kUb one' baby in retry $00. Mr Barry Wdarijm txpijflniU ' researchfiDte fabrtm *' the Ttrtirthreport' hrt been rarflaoecrcrisdemntaellyws-tnumttbMledt fals -am aereea a r vtS^sMdM?the^StWt Modkoi jeurual whma a la brtnjg eanpal fungus la PVC-coverad uiimmn by- * r_a_f_o_o_m_ _-to-..dacM If it Ja whfefc gives oU highly uade sUbtee. ,m>abdtat ifar uliuubbMHmrtbinme . m*rgas when In Sf the PTC.. mntast with tbrnaa ...,, iettetF.I:t-WS---B--Ooll*a""fu The mattresses ^i! "'*SLiaSLI5t-- *teClmsi then rtudMs** hpve rtndkdthe^- wea found that the gas. which * ~ urifein'wi hypotna Tine iihalVmsh Indy tlmsrlcb . .Ur^hSnkS thkwMrtaam unaubetaaUated shoal* not he moeast tht wtila #b very- w'im Oo OmthjSt Man , SSmm' ' IMUal'wiwrt.^M, ottel mrtM <m tkM Mn heye ihn^gum dta to ei a <;? as*i____ egm of two m haw bmA M> C !. bo wot tied pamta, but we en teOh thorn tbms b no ha1 a spofcaan* mid. j-- -- *Our FTC Is supplied by a laadb our msttreasaT7celt 'itrlsf?i legulrtmrtits relating to totortty/ Mr Richardson mid:. T faead to whotbn to b Theories add to grief, say mothers -sr; _ loot and im, and It W> only around 1#7 that une plained. Infant^ deetl leeched such* e-tawi thi the- The fact that etd Bren wlth Onto beta node we found the mttrtn lUiTiiutd ? P^Cfume link to; cokdeaths dismissed Dr Grange described the ex By Pearce Wright .'j ' ScienceCdiler A theory ihal col deaths ere perimental methods as "using crude equipment, tacking an obvious..control, experiment that would reveal flawy and linked ( poisonous flimet irrelevant as a .representation release# from PVC plastic col of a cot mattress'*. maittcsses ` has been widely Mr Richardson maintains dismissed by experts. The Deperimcni-of Health that a particular type ofrnioW organism.common in homes says there is **no adequate can react with traces ofchemi validation"for(heides, which cals used in the manufacture Ms caused alarm among of PVC to generate poisonous many parents. fumes. ( -^ - . The scientific advisory co A key to the process . U mmittee (o the Foundation for mattresses must also have, a the Study of Infant Deaths, protein content on which the which has spent 4 million in micro-organisms thrive.: the past IT years on research, .says the -hypothesis contra ; The laboratory experiments involved piecing strips ofFVC- dicts ihe findings of painstak ing tdvesiifatieM into factors snd . organisms on 1 g.ricb nutriehl.mixture of soya Dour that may trigger the deaths. and mall Dr Gra. je said that, The Briilsh- Medkml Journal that bore no relation to mat also rejected the theory. tress conditions and (races of [ Dr`John Grange, consultant protein it might contain. Ibacteriologist at the Drompton Moreover, advanced in 'Hospital; west London, said in struments would be needed to, la devastating assessment of identify the type and amodml jthc report for Th* Timts, of gases generated. The report; 'which* wis circulated this contains ho figures of the' Iweek, that more detailed stud- quantity of gases which came, lies were needed.to provide a from heating (hose cultures. 1 'more definitive answer.. ' Dr Grange said they could The controversy centres on have been generated from the the*details-of a report by Mr nutrient mixture rather than; Barry Richardson, director of the PVG He suggested that1 a scientific consultancy ser Mr Richardson had con-' vice,-which describes (he lain ducted for the best of motives! oratory experiments on which a completely irrelevant the suggestions about cot experiment. | 22480126deaths are batea. BFG21155 'll.1) hit?'. As a ;7- TJ is.. I had to. mi cot link.. as a father I had to warn mw.vV3P' THE scientist death panic la at the cent--re of "the cot a factual!; precise, mild- PET: ntaniMretTman, not given to dramatic or emotional statements. But whan Barr; Richardson .discovered that tangos artmins on PVC' mattresses lcoaous*eodvecro.-t deaths. Us Instincts as a parent "Von can hnaahte the attaadm I m in," ha ears. *1 had a tenfhls SUeasia. IhaaM 1 gt ea as a actenMet and remplololy prove a Hah I wee oartain extend or should I were paonlgT I sdll didn't hive proof, ham Mber and potential ~c3 ..~T>|ll meant theta be- SVSJ2" non. the trsntfutwr l nelliid I hed tv M people knee. Hvedredt ef seal*. . atrlckea nothere Jaaeaud a hale hadtae SyfCtiTrWAIBt *r MrtUariaa l -------- auadMawaaetas- e^h -m s m 1 knew lhare eUjM PVC cat daatk <ea>. ka a peak totI aaowt trewMe we udhri " " JSV**V}ehhywar froie Meaea haakete, ** * JjT" acwaael ^wn Mee * apnradnaat,doMohtar.acaat tryrvyacaaae(e . lethal A coueottaot and r ulm nf g?i.Lh.. 0bQiyrrl?nlyfrflfi is V* RCMNMI QHI AWBOVr wad In January tfcae a (rT-nomenKnMfaaniMiaihhnikdl ihaisS- Ola to PVC lealfrawia la ptadnca lha yaa rtfhkw a Mm ------ IdM UdWEE Vp* potoMMun dsn carton h^tii nwliwo haSi ... . ** h gnki as Me HtefeceherIdnaaWnlnmchaalelaeair.<Mwr ana* awtruin Beda waa Snalef hr the par- e< ekHmM 1W da eMEilE WEE dtadb hJiTs iT ' ------- ww^ar. TVaU umid thenne rhandnl eat not eaad w .... . -w _ H dR MEndl IEI CEVs v *StSSl?* of pradoLi's!^ Aad to Mtafoino hto theory to toctod up by tattotfcp. "Cot deaths tomw more noticeable la IVML They had increated vary rapidly darlnc the prevtoue ten Mn. wtMm PVC bcpm to to and n mattress toyofinf.* Ha also points out that SUM, which affect* betwan two and tour bebtoo par thousand, to a purely Western phe* la Kuaato anrf China, whara cotton mattrtnoa areueed, the syndrome la nod raeocntoad. AHtoapi the Found* tton tor the Study of Mfcnt Daatha has not aaoapted Mr Richard* sari's ftndincs. ha insists tho results speak tor inlv aQirnoaimnywcrolnatgro--lrma-o--* aar Itkhard Mark* aMU *M to a vary dan XEfuoo sfalw--rt to rtp"t-IatMttmfeokrtiwoa^WaMoaiet triaidpnalrefsdVApwsC&aslfdtornatgraovaf*ahdy.iD. eaw9aaatTaattIbadmna"yoahsnlaapa--iHrdtooattnhoEoeldWo.rwefdpporoafooor*-ttrvV*mSw*j**^n*jS*o-^?r.l4o>*TofS*n*!yTp*"Str?a*o'"J*w.*.Wi'" IrthS by * iia^ai? la a pude,* - tolled rmwrh". --aw--*. I5 % i mm U yPilSltfifli'sulsSi nii\ OOrS'S 1 OS'- villi' is: si tPil irJSI U BFG21156 irr ' Ncwacur/Apcvr TODAY Mr * Mothers panto over mattress link to cot deaths Freni Pgflgl "la lh* cm of a larger drop* Bided col. the mattress iliouM be covered in a ilrthen* siwot and weurely taped." Parents must also ensure that tibia1 rooms are well ventilated. But caution was urged oy Peter Fleming of Bristol Maternity Hospital, coo* ddared octa of (ha country's leading poodlotrtctem Ha saM? "Tha awre posit biHty that (Ms has occurred, whan all (he products hare bean tested for safety, dearly gives us couee tor concern. "The testa were carded out under controlled Ishm elury oondltions and there is we hard tvldanra that (Mo oa* am fa the eel. ~We must be cautious. U would be foolish for mothers to (brow away PVC mat' trmm or changg (ha way they attend to ihetr chW- One T Ih hjggeet retailere. MurtWRanr, announced an Immediate investigation. ham paid: "The foam mattrees has been bt our range since the (MO* and we hare no record of any cot death attributed to the use of PVC the Tho Foundation for (he Study of Intent Doniho ad mittad M had Known about tha research for a month. hypothmia that col deaths might ho caused by the reteaae of from PVC cat i __________ _ been carefully rmubhrud by --r Scientific Advisory Com -It must remain as yet a cwipitady unproven hypwhcsla which One* not m wHh what b known of rnnkhm intent death syndrome." There have been many the ories to expiate cot death since It was first identified more than 30 years age. with more bays dying than gbls. The mortality rate oars during the winter months. ing ensyme. * lung maitencthm. a deficiency of sleep hormone or abnormal rad Mood calk. Panes tireatfieinltiller gas A SLICKPIM; baby meld. mir. Vwunc.lH', lilng tarr bo --n ed drnth hy a S Amp mv sretxrd of nt- h--mrhald fun- pro u limp divp. Ihr Mi- mm rending with (he PVC enlist* - utiMi i an cut bedding. llsssfwtwm itr a* SdcMhh M Penarth (leeeureh Imwrnwtlnnef m Guernsey stumbled on the mmh re kill <ilT *hr funpun . during ptuduriiMn. liul this drlrriuran-s with breakthrough accld* totally. Daring team on the dotsrterattan of PVC tebrfoe Tfco potential bao grown unre Atarrh when a flre-relardant % antimony Irion* Introduced intn ended with The bug can gtvo dl throe lethal grow, all at -which arc header Hum The tenge* rends Hh rbrmfccl I* produce * Ibe hfoMy male gas Uibine. Keeeertb hue director Iterry fUchardron said: "Hi- lirtiiitl ail w uM tllr lillMtUv -Sllhim* i- I.'iW Murt Crwlb than ratten* NttHMiHlr and aitwrks iln- ivd UnmI n-lh n-iidriiiic tlirn unnhlv t uhswt W v ygen. -The rxatl isiim* itl death nnutd he anaemia. -The n%k In infants is very high. It h ufllv a hypethnifo, ten r hr- Have It to he a.grrci step forward In nrrd of greater research." MatImm with team inll<** headpieers rwuld als cause asllunas attach*, pay doctors. sztosyz-z BFG2U57 05/17/90 MARKETING THELANCET MARCH 17,19KT Cot mttrm biod;erioration and SIDS St*,--In 1988, various (VirigJ wen identilied in industrial pUiUcited polyvinyl chloride (7VQ despite the pnwnct of ih preservative 10,10'-ox>MphflVSxyartirie (OBl'A). Warning* were given that the PVC might atoo become infected by arscnic-iderent orginisms which miglu.convert OBPA to toxic mine gat. Mr P. R. Mitchell, a client ofour company, inquired whether mine generation through biodeterioration ofnich covarings might bet caviar ofludden infant death lvndrome (SIRS). 50 mattresses utod in fony-tiv* SIDS incidents were outlined, including 1 cotton covered, 26 PVC covered, IS PVC covered with exposed foam at one or both ends, and 8 exposed Idem; in five modem* 2 mituascs had been used. Ail menratMt contained Scopvlariepas hwicaulii, but only tn the area beneath the infant affected by warmth and perspiration. Incubated sample* of the infected materials All generated toxic trihydnde gases. PVC covering* usually generate itibine (SbHJ from a Are retardant additive, antimony triotdde, but also phosphine (PH) from the phoaphatc plasddacn that arc used when fire resistance ia required. Although OBPA Is not generally uaed in cot maun** PVC, tena indicated arsine (AsH,) generation when it was used; and snail amount* of arsine were sometime* identified when it sat not, presumably hum rnenkal impurities in antimony <rioxide. Mixtures ofgun were often detected. Phosphine gensretion from PVC wss sometimes associated with the development of a pink Stain, usually in the shape of the sleeping infant, apparently mined by liberation of phenol cumpounds from decomposition of phenyl phosphate pbstkiam, Only phosphine wee generated from infected Cuttun and feem samples, apperendy through biodetedontivn of phosphate fire-retardant treatments. Foam samples and the I mono sample were also infected by various other ftmgl, especially in the area affected by dribble; many of these fungi produce aathmatic reaction*. The generation uf highly toxic trihydrlde gasea flora COi maureeaee is a serious threat to health. The gases are heavier than dr, and infimts most at risk are thosewho remain for long periods in ' their outs, sleep prone In csny-oxi, or arc heavily wrapped suds thatthey ere in long and dot* breathing contactwith wninuilatiam atgas. Heavy wrapping also induces hyperthermia, which prompts an increase in pi groendon. Some Infant* probably survive because thefirst symptuRiofpoisoning isheadache,which results in irritability, dislodgncnt of bedding, and improved vsutiletigoj infants oflow weight cwmot dislodge bedding, SIDS oocuit mainly in in&nts up ro age 9 months who sleap prone with heavy wrapping and have indications of hyperthermia. SIDS is only reported In westtra*siyle oummunities where foam and PVC covered oof mattresses are used, andhaa only been recognised sinceabout I960, following introduction ofthese materials during the previous 10-15 years. It has been reported that SIDS is lesa likely to occur in first bora children, perhaps because mature*** arc new arid do not become infected whtls the infant k young and most at risk. 5 first children were involved in ihe 45 (ndtknts farvcatfptcd. 2 died cm previously used mntrcMo; 1 of these 2 slept nn a maztresa immediately after use by anotdsrchild. I inftmt died one new foam raanrast that wu goentfog phetphkia and 2 died on new PVC mattresaet which were affected by exceptionally active ftmgus and ware gmenting phosphine; two ether new matures** wot implicated, both of whkh wan similariy afiketed. Infactiun by StrnieauHt is not readily visible in PVC. Seven deterioration, usually associated with phosphate pfatiriacra, results in brittleness sivd tpUnliig. In the heme the fongtia is usually loixad in protein-containing tubstaaces such as cheese and mast, and in damp wool and laaihen however, its extracellular enxymes out convert a wide rung* uf compound* containing the elements nitrogm, phosphorus, arsenic, and antimony into the trihydridat ammonia, phosphine, arsine, and ttibinc. The preferential development ofthis Aingui in cot mattresses should be etlributsd to the pretence of nitrogen compounds in the perspiration. The generation of ininc in this way )us been recognised fbr about 100 years since Cosio1 discovered that death in children and iHore*** in dult* we** sometimei caused by arsine generated by the action of S Prnkliuhs an arsenical wallpaper pigments, although it to now known that arsine could be similarly generated from the horse-hoof trie thet was commonly used at that time endwhich contained white arsenic to discourage redan damage.' Phosphine, arsine, and itibine ere exceedingly toxic with threshold limit values of 0-3, O S and 0-1 ppm, respectively, compared with 1QQ ppm for carbon monoxide. Relatively high ambient level* prevent the detection of phosphorus, araank, and antimony residues at nacropty. However, tome pbiologist* have commented that they usually associate SIDS with abnormal lung colour; this could be associated with local erythrocyte haemolysis due tu exposure to these trOiydride pun ftasith Itaeweh inMriuiienal. SO *(*} St r*r pon. OueiMSr. Channel Winds B. A. RlQtAJlDSON 1. tlAdtiH. AAnU< a*.Mirwi(biiei WRitwd Anid'uiaiic*. 8a*^(rww< aw ia*3| kaOI>30.MI>71. 2, Thua C, Rarer KJ. Tlx inaic funp of Gove- inn lfU.Miwa.ie. VA Oovcmmant Inquiry, prompted by there flndkigs, was announced on March 9, The inquiry will be chaired by Prof Paul Tum. Acute rtonal failure ftr colloidal bismuth subcitrate overdose Six,--Nephropathy due to acute and chronic use ofbismuth salt* i* well recognised,1 but uni ingestion ofcolloidal bismuth Is said to be safe since it i* lew readily absorbed than other salts.' IX'e report a auc uf acute renal failure associated with an overdose of colloidal bismuth tubeitrste. A 76-ye&/-oW nun who had been taking tripotassium didtrambtomuthatt fDe-Nol*) fur four weeks for haemorrhagic gastritis and duodenitis wes sdmitied having taken an overdose of6 'Dorado' Cutracycline hydrochloride 113-4 mg, chlonetraeydine hydrochloride J13-4 mg, and demedoeydinc hydrochloride 092 iibl Pr tablet) and 80 de-aot tablets 4 h earlier. `Hvc only other presaibed drug htgested In the month before admission was fluoxetine. His puts* rare was 84 per min and blood pressure was 17Q/90 mm Hg, He hod mild epigastric tenderness and was Slightly confuted. Fhtscw creatinine wes 145 pmol/l, scrum sodium 137 mmul/I, serum potassium 3 4 mmol/1 (hacnxtiyted sample), hoonugluban OV g/dl, white cell count 23-8 * 10*/], and platelet count 212 * IC/I. Bismuth was detectable in tho blood (1600 jtg/1). An abdominal X-ray film showed opacification of the cuk by ingested bismuth and a chest X*ray film showed no evidence offree gas wider the dieplinqpn- Since the patient had vomited profusely at home wxi in the aoeidmt sod emergency department, gastric lavigvwasout dune. After admission asthe wardhe wa* raxed so be oiigurie end few hours liter began passing bloody stools, but no source was seen st sigmoMoseopy. He was started un ranitidine end regular sntaetd, ind magnesium sulphat* enenu* were prescribed topurgchheokri Ofbismuth. Hehade briefcpinxieofhypotension (80/35 mm Hg toting ebuut 3 min) I2h after admission, but mean blood pranura was 149^0 mm 1 (< with venous eentral prewre of S 10 cm water. 11 was UuaAaed with two units oi blood though his beonugkibin never dropped below 11-3 g/dl. After 48 h of oliguria ptosma ereatinkK was516 pmoi/l and senira potassium was 8-1 mmol/l and he was dialysed foe 3 days, during whidt time he oontlnued to pres bloody stools and needed Airtiwr transfusion. Acute abdominal pain then developed with absent bowat sounds but be was lodged unfit for surgery end died 4 day* liter. Necropsy revealed e perforated duodenal ulcer end "pale kidneys" whichCO proved to contain bismuth (11 mg/g and 16 mg/g). This pedant had toxic scrum bismuth concentrations 4 h eftcr*^*. ingestion of 80 dc-ttol tablet* and bismuth proved to hev*QQ accumulated in his renal tissue. Bismuth nephropathy probably ^ contributed to acute renal failure, although there was the additional insult of gastrointestinal bleeding. W* ere swore of only an*V\ previouely rwueded cue ofsent* ratal failure secondary to eolloidal bianuth subdtrite ingestion,1 in which s 27-yeer-old man recovered following colonic purging ind haemodialysis. Ouunie BFG21158