1186 different corticosteroids and different patients or disease Aerosol steroids should be assessed in the same way. University of Western Ontario, Victoria Hospital, London, Ontario, Canada
states.
J. H. TOOGOOD
ORAL REHYDRATION AND MORTALITY FROM DIARRHŒA IN BANGLADESHI VILLAGES
SIR,-Oral rehydration in hospital effectively combats dehydration due to diarrhoea, but it is much more difficult to test this technique in the community. Dr Rahaman and colleagues (Oct. 20, p. 809) are to be congratulated on seizing the opportunity to examine the effect of oral rehydration on mortality from diarrhoea when an isolated community specifically ask for such a service. There are many potential problems in such studies-the effect of surveillance on normal practices, ethical considerations relating to the control therapy, and comparability of the populations. It could be argued that, because one of the two villages asked for help, it was intrinsically different from the other. However, the rapid increase in the use of oral rehydration salt packets by the people of the control village of Bordil during 1978, suggests that they also recognised a good thing when they saw it. I hope the study is continuing for a further period with the introduction of community distribution of rehydration salt packets in the control village. If the diarrhoea mortality in the second village falls to a level similar to that in the first, Rahaman et al. will have even stronger support for their hypothesis. INCIDENCE OF DIARRHGEA IN SECOND YEAR OF
LIFE, PER 1000
CHILDREN
from diarrhoea were supports the observations of many clinicians from Africa and Asia.’It is a pity that those with measles were not reported as a separate group, even though the numbers would be small. It appears encouraging that, during the period when measles was prevalent, the difference in case-fatality rates between the two villages was maintained. If measles affected both populations to a similar extent, this suggests that oral rehydration therapy is beneficial even in measles, a condition which is known to damage the smallbowel mucosa. The suggestion that fatality rates higher during an outbreak of measles
The definition and identification of diarrhoea in this study fairly standard; three or more water stools in 24 h, and surveillance by home visits every 10 days and recall of any illness. However, the incidence of diarrhoea in young children in both these Bangladeshi villages was very low (323 and 277 per 1000 infant years, and 226 and 241 per 1000 toddler years). These figures indicate that less than 1 in 3 infants and 1 in 4 toddlers had an episode of diarrhoea in a year. It is interesting to compare the incidence of diarrhoea in the second year of life from a number of longitudinal studies in different countries (see table). Admittedly the second year is the peak age for diarrhoea in most tropical countries and the Bangladesh figures are either for the first or the subsequent four years, but the difference is striking. The table also indicates how wide are the variations between different countries and studies. are
Edinburgh University, Department of Child Life and Health,
Edinburgh
SIR,-In his comments (Oct. 27, p. 898) on our Oct. 6 paper Dr Baum wonders if bacteria present in unheated milk might harm the baby. He points out that a baby exposed to his own mother’s bacterial flora is very different from a baby exposed to the same bacteria in donor milk from other breast-feeding mothers. The suggestion that there is a feedback mechanism from baby to mother enabling her to manufacture appropriate antibodies1 supports Baum’s argument. However, the ill low birthweight baby to whom much of our bank milk is given is not a suckling baby. We know of no evidence that bacteria in milk differ in pathogenicity whether they are present in the baby’s own mother’s milk or in that of a donor mother. The problem is given a further twist by the fact that a baby on a neonatal unit might be fed heated donor milk until such time as it can be suckled by its own mother. In which case the milk on one day is bacteriologically "safe", yet on the next day the milk may contain an abundance of bacteria. How clean should donor milk be before giving it to low birthweight babies? Our paper was an attempt to answer that question. We believe that human milk is better than milk formult as a food for certain categories of baby cared for on the neonatal unit. Presumably, these advantages rest in the immunological, nutritional, or other physiological properties of human milk. Unfortunately, even precise heat treatment may alter some of the immunological and nutritional properties of milk, and it is most likely that any advantages of breast milk over infant milk formula? will be demonstrated if human milk is given in its least modified form. A study of the safety and practicalities of feeding unheated donor milk using the criteria proposed in our paper is being undertaken in Leicester. Departments of Pædiatrics and Microbiology, Royal Infirmary, Leicester LE1 5WW
1963; 245: 345-77.
L. CARROLL M. OSMAN D. P. DAVIES A. S. MCNEISH
VITAMIN E FOR PREMATURITY
J Clin Nutr 1977; 30: 1215-27.
5. Parkin JM. A longitudinal study of village children in Uganda: pattern of illness during the second year of life. In Owor R, Ongom VL, Kirya BG, eds. The child in the African environment: Growth, development and survival. Nairobi East Africa Literature Bureau, 1975: 193-95. 6. Mitler FJW, Court SDM, Walton WS, Knox EG. Growing up in Newcastleupon-Tyne. London: Oxford University Press, 1960.
WILLIAM A. M. CUTTING
BACTERIOLOGY OF RAW BREAST MILK
1. Morley DC. Severe measles in the tropics. Br Med J 1969; i: 363-65. 2. Mata LJ, Kromal RA, Urrutia JJ, Garcia B. Effect of infection on food intake and the nutrition state: perspectives as viewed from the village. Am 3. Fullerton P. Malnutrition and infection: an examination of the effects of diarrhœal disease and other infections on the growth of children up to three years of age (utilising unpublished data from Morley DC and Woodland M). Dissertation for DTPH, University of London, 1978. 4. Gordon JE, Chitkara ID, Wyon JB. Weanling diarrhoea. Am J Med Sci
EH9 1UW
to
SIR,-The practice of giving vitamin E (tocopherol) routinely premature infants has spread from the United States to Eur-
ope. Vitamin E reduces the hxmolysis in vitro of neonatal erythrocytesbut its efficacy in reducing the fall in haemoglobin leading to the anxmia of prematurity has not been consistently demonstrated. Furthermore acute haemolysis in the LA, Ahlsted S, Carlsson B, et al. New knowledge immunoglobulins. Acta Pædiat Scand 1978; 67: 577-82.
1. Hanson
in human milk
2. Graeber JE, Williams ML, Oski FA. The use of intramuscular vitamin E the premature infant. J Pediat 1977; 90: 282.
in
states.
J. H. TOOGOOD
ORAL REHYDRATION AND MORTALITY FROM DIARRHŒA IN BANGLADESHI VILLAGES
SIR,-Oral rehydration in hospital effectively combats dehydration due to diarrhoea, but it is much more difficult to test this technique in the community. Dr Rahaman and colleagues (Oct. 20, p. 809) are to be congratulated on seizing the opportunity to examine the effect of oral rehydration on mortality from diarrhoea when an isolated community specifically ask for such a service. There are many potential problems in such studies-the effect of surveillance on normal practices, ethical considerations relating to the control therapy, and comparability of the populations. It could be argued that, because one of the two villages asked for help, it was intrinsically different from the other. However, the rapid increase in the use of oral rehydration salt packets by the people of the control village of Bordil during 1978, suggests that they also recognised a good thing when they saw it. I hope the study is continuing for a further period with the introduction of community distribution of rehydration salt packets in the control village. If the diarrhoea mortality in the second village falls to a level similar to that in the first, Rahaman et al. will have even stronger support for their hypothesis. INCIDENCE OF DIARRHGEA IN SECOND YEAR OF
LIFE, PER 1000
CHILDREN
from diarrhoea were supports the observations of many clinicians from Africa and Asia.’It is a pity that those with measles were not reported as a separate group, even though the numbers would be small. It appears encouraging that, during the period when measles was prevalent, the difference in case-fatality rates between the two villages was maintained. If measles affected both populations to a similar extent, this suggests that oral rehydration therapy is beneficial even in measles, a condition which is known to damage the smallbowel mucosa. The suggestion that fatality rates higher during an outbreak of measles
The definition and identification of diarrhoea in this study fairly standard; three or more water stools in 24 h, and surveillance by home visits every 10 days and recall of any illness. However, the incidence of diarrhoea in young children in both these Bangladeshi villages was very low (323 and 277 per 1000 infant years, and 226 and 241 per 1000 toddler years). These figures indicate that less than 1 in 3 infants and 1 in 4 toddlers had an episode of diarrhoea in a year. It is interesting to compare the incidence of diarrhoea in the second year of life from a number of longitudinal studies in different countries (see table). Admittedly the second year is the peak age for diarrhoea in most tropical countries and the Bangladesh figures are either for the first or the subsequent four years, but the difference is striking. The table also indicates how wide are the variations between different countries and studies. are
Edinburgh University, Department of Child Life and Health,
Edinburgh
SIR,-In his comments (Oct. 27, p. 898) on our Oct. 6 paper Dr Baum wonders if bacteria present in unheated milk might harm the baby. He points out that a baby exposed to his own mother’s bacterial flora is very different from a baby exposed to the same bacteria in donor milk from other breast-feeding mothers. The suggestion that there is a feedback mechanism from baby to mother enabling her to manufacture appropriate antibodies1 supports Baum’s argument. However, the ill low birthweight baby to whom much of our bank milk is given is not a suckling baby. We know of no evidence that bacteria in milk differ in pathogenicity whether they are present in the baby’s own mother’s milk or in that of a donor mother. The problem is given a further twist by the fact that a baby on a neonatal unit might be fed heated donor milk until such time as it can be suckled by its own mother. In which case the milk on one day is bacteriologically "safe", yet on the next day the milk may contain an abundance of bacteria. How clean should donor milk be before giving it to low birthweight babies? Our paper was an attempt to answer that question. We believe that human milk is better than milk formult as a food for certain categories of baby cared for on the neonatal unit. Presumably, these advantages rest in the immunological, nutritional, or other physiological properties of human milk. Unfortunately, even precise heat treatment may alter some of the immunological and nutritional properties of milk, and it is most likely that any advantages of breast milk over infant milk formula? will be demonstrated if human milk is given in its least modified form. A study of the safety and practicalities of feeding unheated donor milk using the criteria proposed in our paper is being undertaken in Leicester. Departments of Pædiatrics and Microbiology, Royal Infirmary, Leicester LE1 5WW
1963; 245: 345-77.
L. CARROLL M. OSMAN D. P. DAVIES A. S. MCNEISH
VITAMIN E FOR PREMATURITY
J Clin Nutr 1977; 30: 1215-27.
5. Parkin JM. A longitudinal study of village children in Uganda: pattern of illness during the second year of life. In Owor R, Ongom VL, Kirya BG, eds. The child in the African environment: Growth, development and survival. Nairobi East Africa Literature Bureau, 1975: 193-95. 6. Mitler FJW, Court SDM, Walton WS, Knox EG. Growing up in Newcastleupon-Tyne. London: Oxford University Press, 1960.
WILLIAM A. M. CUTTING
BACTERIOLOGY OF RAW BREAST MILK
1. Morley DC. Severe measles in the tropics. Br Med J 1969; i: 363-65. 2. Mata LJ, Kromal RA, Urrutia JJ, Garcia B. Effect of infection on food intake and the nutrition state: perspectives as viewed from the village. Am 3. Fullerton P. Malnutrition and infection: an examination of the effects of diarrhœal disease and other infections on the growth of children up to three years of age (utilising unpublished data from Morley DC and Woodland M). Dissertation for DTPH, University of London, 1978. 4. Gordon JE, Chitkara ID, Wyon JB. Weanling diarrhoea. Am J Med Sci
EH9 1UW
to
SIR,-The practice of giving vitamin E (tocopherol) routinely premature infants has spread from the United States to Eur-
ope. Vitamin E reduces the hxmolysis in vitro of neonatal erythrocytesbut its efficacy in reducing the fall in haemoglobin leading to the anxmia of prematurity has not been consistently demonstrated. Furthermore acute haemolysis in the LA, Ahlsted S, Carlsson B, et al. New knowledge immunoglobulins. Acta Pædiat Scand 1978; 67: 577-82.
1. Hanson
in human milk
2. Graeber JE, Williams ML, Oski FA. The use of intramuscular vitamin E the premature infant. J Pediat 1977; 90: 282.
in
