- Email: [email protected]
Swallowing reflex in the night
cephalometry as part of another study. Ethical approval was obtained. lateral
control families returned 352 SAHS family members questionnaires (p=0.1) covering and 408 control family members. 10 deaths at less than 1 year old were reported in SAHS families and 1 in control families. 2 SAHS family deaths had identified causes (pneumonia and congenital heart disease) and the control death was due to rhesus incompatibility. Thus there were 8 unexpected and unexplained infant deaths in the SAHS families and none in the control families (p<0005, x2-test). 2 SAHS families each had 2 such deaths, including one pair of twins. Cephalometric data were available from 4 of the 6 SAHS families reporting SIDS and from matched controls. These 4 SAHS+SIDS family members had retroposed maxillae (angle at nasion between sella and maximal indentation on maxilla: SIDS families 82° [SE 2]; controls 91° [SE 1], p=0-04). Our results suggest that SIDS and adult SAHS are associated and that both could result from obstructive apnoeas due to facial structure narrowing the upper airway. Obstructive apnoeas would produce the associated bradycardia observed in SIDS.’ 29
SAHS families and 35
the underlying cause of death in countries where doctors have difficulty with western medical terminology and the language of International Classification of Diseases and Causes of Death. The combined average rate of suffocation and SIDS in Taiwan between 1988 and 1991 was 1-0 per 1000 live births, a value more similar to the death rate from SIDS found in western countries. Harald H
Knöbel, Wen-Shan Yang, Chien-Jen Chen
Institute of Biomedical Sciences and Sun-Yat-Sen Institute of Social Sciences and Philosophy, Academia Sinica, Taipei 11529, Taiwan; and Institute of Epidemiology, School of Public Health, National Taiwan University, Taipei
1 2
Wilson E. Sudden infant death syndrome in China. Lancet 1990; 336: 1199-200. Lee NN, Chan YP, Davies DP, Lau E, Yip DC. Sudden infant death syndrome in Hong Kong: confirmation of the low incidence. BMJ
1989, 298: 721. 3
4
5
Knöbel HH, Yang WS, Ho MS. Urban-rural and regiona differences in infant mortality in Taiwan. Soc Sci Med 1994; 39: 815-22. Bunai Y, Ohya I, Brinkmann B. Pathological approaches to SIDS I. Special emphasis on the histopathological differences between SIDS and asphyxia. Jpn J Legal Med 1992; 46: 405-06. Leadbetter S, Knight B. Sudden infant death and suffocation. BMJ
1989; 299: 455.
R Mathur, N J Douglas Respiratory Medicine Unit, University of Edinburgh, EH3 9YW. UK
Swallowing reflex in 1
2
3 4
5
Meny RG, Carroll JL, Carbone MT, Kelly DH. Respiratory recordings from infants dying suddenly and unexpectedly at home. Pediatrics 1994; 93: 44-49. Guilleminault C, Heldt G, Powell N, Riley R. Small upper airway in near-miss sudden infant death syndrome infants and their families. Lancet 1986; i: 402-07. Peterson DR, Chinn NM, Fisher LD. Sudden infant death syndrome: repetition in families. J Pediatr 1980; 97: 265-67. Mathur R, Douglas NJ. A prospective case control study of the inheritance of the sleep apnoea/hypopnoea syndrome. Am Rev Respir Dis 1993; 147: A233. Douglas NJ, Thomas S, Jan MA. Clinical value of polysomnography. Lancet 1992; 339: 347-50.
Sudden infant death Chinese
syndrome among
SIR-Sudden infant death syndrome (SIDS) has been described as a very rare event in China (and in Hong Kong).1,2 New evidence from Taiwan suggests that SIDS may not be as rare among Chinese as previously thought. Taiwan records accidental suffocation among infants at a 50% higher rate than it records SIDS.3 The epidemiological features of accidental suffocation in Taiwan were found to be those described for SIDS-namely, an age distribution with a peak at 2-3 months, a distinct winter seasonality, and more male than female deaths.3 In a case-control study in progress on SIDS and suffocation in northern and central Taiwan, interviewed mothers described no previous illnesses and no food pieces or objects obstructing respiration that would have warranted the diagnosis of suffocation. The diagnosis was based on the presence of vomitus or regurgitated milk or the infant being found face down in the bedding or covered with bedding. These findings suggest that those deaths recorded as suffocation in Taiwan would have been recorded
as
SIDS in
western
countries. Such
diagnostic practices might also prevail in mainland China. In most countries sudden and unexplained deaths of infants were generally recorded as suffocation, before SIDS was established as a distinct diagnosis. Pathologists have pointed out
that
suffocation even at
if suffocation
were
820
and
SIDS are very difficult to necropsy.1,5 It should not be surprising to be preferred to SIDS as a diagnosis of
differentiate,
the
night
SIR-Feeding and swallowing problems can occur at any age but are especially prevalent in the elderly. The elderly are more likely to develop disorders of the central nervous system and aspiration is more commonly associated with debilitation, dementia, and depression than specific neuromuscular disorders.’ In healthy people, the frequency of swallowing during sleep is slightly less than when awake.2 However, the influence of sleep on the swallowing reflex has not been studied in elderly patients at risk of aspiration. We examined the swallowing reflex during day and night in elderly patients with cerebral thrombosi or dementia due to cerebral arterial sclerosis, and compared the results with those in age-matched healthy controls. The 25 patients, mean age 76 (SE 2) years, had varying degrees of cerebral atrophy and lacunar infarction revealed by computed tomography. The 10 controls, mean age 78 (2) years, were healthy volunteers and led an active daily life. done at 1300 h and 0100 h both in the supine Each position. subject refrained from taking ethanol, or sedatives, drugs that affected the autonomic nervous for at least 72 h before the study. For the study system the during night, a nasal catheter was inserted into the and at 2200 h the catheter was connected to pharynx polyethylene tubing that was about 120 cm in length. The proximal end of the tubing was fitted with a three-way stopcock and taped to an intravenous drip stand a metre or so away from the subject’s head. 10 mL of distilled water was injected into the tubing through the stopcock and flushed with air until the water just reached the distal end of the nasal catheter. The stopcock was then closed. The catheter was secured in place and the subject was allowed to retire for the night. At 0100 h 1 mL of air was injected into the tubing via the stopcock. This manoeuvre delivered 1 mL of the distilled water into the subject’s pharynx. Swallowing was identified by submental electromyographic (EMG) activity.3 EMG activity was recorded from surface electrodes on the chin. The swallowing reflex was evaluated by the latency of response, which was timed from the injection to the onset of swallowing.3 The subject’s apparent depth of sleep and response to the injection were carefully observed and recorded. Studies during the daytime were done in a similar fashion.
Studies
were
Values
are mean (range). *S)gn!ficant within-group change (p<0001). tNo significant difference between treatment group, p=0145; repeated
measures
of
variance.
Table:
Haemoglobin at beginning and end of a 9-week supplementation period in two groups of women receiving daily versus weekly iron
.
-
Figure:
Latent time
during day and night in
controls and
patients *Significant
difference between patients in
day and night (p<001).
The latency of response was longer in patients than in controls during the daytime (4-1 [0’5] vs 2-8 [0.4] s, p<005). Although the latency of response did not differ between day and night in the controls, the response in the patients was delayed in the night (figure). Severe delay of the response (>5 s) in the night compared with that in the day was observed in 14 patients (56%) with multiple lacunar infarctions in bilateral basal ganglia lesions. We conclude that night-time might be an important risk factor for the development of aspiration pneumonia in elderly patients with cerebrovascular disease.
comes to improving iron status, an animal study has indicated that twice weekly supplementation is just as effective as daily supplementation.We studied whether daily doses of iron supplements are really necessary in anaemic non-pregnant female employees of a cigarette factory in middle Java, Indonesia. Haemoglobin concentration was measured in all 380 female workers by use of blood from a fingerprick. The haemoglobin concentration was distributed normally in this surveyed population. 94 of the 380 women were anaemic with a haemoglobin below 120 g/L. Of these anaemic women, 86 entered the experimental supplementation study (8 women were pregnant). Each of the 86 women was allocated at random to one of two iron supplementation schemes. At the end of the trial, only 80 women remained; the others were forced to drop out when they moved or developed disease. Of these 80 women, 42 had taken one tablet per day containing 200 mg dehydrated ferrous sulphate (60 mg elemental iron) and 250 µg folic acid. 38 had received the same tablet at an interval of once a week. The total duration of the supplementation period was 9 weeks. Tablet distribution and compliance was supervised. At the end of the supplementation period, haemoglobin was again determined by the cyanomethaemoglobin method by use of a Compur Minilab
(Bayer Diagnostic, Germany). Arthur Pinto, Masaru Yanai, Takuma Kiyohisa Sekizawa, Hidetada Sasaki
Nakagawa,
Department of Geriatric Medicine, Tohoku University School of Medicine, Sendai 980, Japan
1 Feinberg MJ, Knebl J, Tully J, Segall L. Aspiration and the elderly. Dysphagia 1990; 5: 61-71. 2 3
Miller AJ. Deglutition. Physiol Rev 1982; 62: 129-84. Nishino T, Takizawa K, Yokokawa N, Hiraga K. Depression of the swallowing reflex during sedation and/or relative analgesia produced inhalation of 50% nitrous oxide in oxygen. Anesthesiology 1987; 67: 995-98.
Treatment of anaemia with
by
weekly iron
supplementation SIR-Iron-deficiency anaemia is an important public health problem in most developing countries. To address this problem, intervention programmes have been initiated in which iron tablets are distributed through the primary health care
take
system.’ Anaemic individuals
Haemoglobin values in both groups were similar at the of the supplementation. As shown in the table, the haemoglobin in both groups increased significantly after There was no significant difference in treatment (p<0001). the average change of haemoglobin between the two groups (p=0-145). We conclude that supplementation on a weekly basis with a relatively low dose of medicinal iron is as effective as daily supplementation in improving the iron status of individuals start
or
with moderate anaemia. There is an urgent need for similar studies among different anaemic risk groups, such as pregnant women and schoolchildren. R Gross, W Schultink, Juliawati Regional South East Asian Ministries of Education Organisation, Center for Community Nutrition at the University of Indonesia, PO Box 3852, 10038, Jakarta, Indonesia; and Deutsche Gesellschaft fur Technische Zusammenarbeit, (GTZ) GmbH, Eschborn, Germany
1
DeMaeyer EM, Dallman P, Gurney JM, Hallberg L, Sood SK, Srikantia SG. Preventing and controlling iron deficiency anaemia through primary health care. Geneva: WHO, 1989.
2
United Nations ACC/SCN. Controlling iron deficiency. ACC/SCN state-of-the-art series. Nutrition policy discussion paper No 9, Geneva: United Nations Administrative Committee on Coordination: Subcommittee on Nutrition, 1991. Bonnar J, Goldberg A, Smith JA. Do pregnant women take their iron? Lancet 1969; i: 457-58. Schultink W, van der Ree M, Matulessi P, Gross R. Low compliance with an iron supplementation program: a study among pregnant women in Jakarta, Indonesia. Am J Clin Nutr 1993; 57: 135-39. Wright AJA, Southon S. The effectiveness of various ironsupplementation regimens in improving the iron status of anaemic rats. Br J Nutr 1990; 63: 579-85.
those at risk should
daily dose of medicinal iron for 2-3 months. However, despite large scale programmes, little success has been achieved during the past decade, since the prevalence of anaemia among pregnant women and preschool children remains high. Factors such as low a
coverage rates, insufficient tablet distribution, and low compliance among subjects all contribute to the reduced efficiency of supplemental iron programmes.2 Tablet distribution and compliance are negatively influenced by a lengthy duration of required daily ingestion.3,4 When it
3 4
5
821
control families returned 352 SAHS family members questionnaires (p=0.1) covering and 408 control family members. 10 deaths at less than 1 year old were reported in SAHS families and 1 in control families. 2 SAHS family deaths had identified causes (pneumonia and congenital heart disease) and the control death was due to rhesus incompatibility. Thus there were 8 unexpected and unexplained infant deaths in the SAHS families and none in the control families (p<0005, x2-test). 2 SAHS families each had 2 such deaths, including one pair of twins. Cephalometric data were available from 4 of the 6 SAHS families reporting SIDS and from matched controls. These 4 SAHS+SIDS family members had retroposed maxillae (angle at nasion between sella and maximal indentation on maxilla: SIDS families 82° [SE 2]; controls 91° [SE 1], p=0-04). Our results suggest that SIDS and adult SAHS are associated and that both could result from obstructive apnoeas due to facial structure narrowing the upper airway. Obstructive apnoeas would produce the associated bradycardia observed in SIDS.’ 29
SAHS families and 35
the underlying cause of death in countries where doctors have difficulty with western medical terminology and the language of International Classification of Diseases and Causes of Death. The combined average rate of suffocation and SIDS in Taiwan between 1988 and 1991 was 1-0 per 1000 live births, a value more similar to the death rate from SIDS found in western countries. Harald H
Knöbel, Wen-Shan Yang, Chien-Jen Chen
Institute of Biomedical Sciences and Sun-Yat-Sen Institute of Social Sciences and Philosophy, Academia Sinica, Taipei 11529, Taiwan; and Institute of Epidemiology, School of Public Health, National Taiwan University, Taipei
1 2
Wilson E. Sudden infant death syndrome in China. Lancet 1990; 336: 1199-200. Lee NN, Chan YP, Davies DP, Lau E, Yip DC. Sudden infant death syndrome in Hong Kong: confirmation of the low incidence. BMJ
1989, 298: 721. 3
4
5
Knöbel HH, Yang WS, Ho MS. Urban-rural and regiona differences in infant mortality in Taiwan. Soc Sci Med 1994; 39: 815-22. Bunai Y, Ohya I, Brinkmann B. Pathological approaches to SIDS I. Special emphasis on the histopathological differences between SIDS and asphyxia. Jpn J Legal Med 1992; 46: 405-06. Leadbetter S, Knight B. Sudden infant death and suffocation. BMJ
1989; 299: 455.
R Mathur, N J Douglas Respiratory Medicine Unit, University of Edinburgh, EH3 9YW. UK
Swallowing reflex in 1
2
3 4
5
Meny RG, Carroll JL, Carbone MT, Kelly DH. Respiratory recordings from infants dying suddenly and unexpectedly at home. Pediatrics 1994; 93: 44-49. Guilleminault C, Heldt G, Powell N, Riley R. Small upper airway in near-miss sudden infant death syndrome infants and their families. Lancet 1986; i: 402-07. Peterson DR, Chinn NM, Fisher LD. Sudden infant death syndrome: repetition in families. J Pediatr 1980; 97: 265-67. Mathur R, Douglas NJ. A prospective case control study of the inheritance of the sleep apnoea/hypopnoea syndrome. Am Rev Respir Dis 1993; 147: A233. Douglas NJ, Thomas S, Jan MA. Clinical value of polysomnography. Lancet 1992; 339: 347-50.
Sudden infant death Chinese
syndrome among
SIR-Sudden infant death syndrome (SIDS) has been described as a very rare event in China (and in Hong Kong).1,2 New evidence from Taiwan suggests that SIDS may not be as rare among Chinese as previously thought. Taiwan records accidental suffocation among infants at a 50% higher rate than it records SIDS.3 The epidemiological features of accidental suffocation in Taiwan were found to be those described for SIDS-namely, an age distribution with a peak at 2-3 months, a distinct winter seasonality, and more male than female deaths.3 In a case-control study in progress on SIDS and suffocation in northern and central Taiwan, interviewed mothers described no previous illnesses and no food pieces or objects obstructing respiration that would have warranted the diagnosis of suffocation. The diagnosis was based on the presence of vomitus or regurgitated milk or the infant being found face down in the bedding or covered with bedding. These findings suggest that those deaths recorded as suffocation in Taiwan would have been recorded
as
SIDS in
western
countries. Such
diagnostic practices might also prevail in mainland China. In most countries sudden and unexplained deaths of infants were generally recorded as suffocation, before SIDS was established as a distinct diagnosis. Pathologists have pointed out
that
suffocation even at
if suffocation
were
820
and
SIDS are very difficult to necropsy.1,5 It should not be surprising to be preferred to SIDS as a diagnosis of
differentiate,
the
night
SIR-Feeding and swallowing problems can occur at any age but are especially prevalent in the elderly. The elderly are more likely to develop disorders of the central nervous system and aspiration is more commonly associated with debilitation, dementia, and depression than specific neuromuscular disorders.’ In healthy people, the frequency of swallowing during sleep is slightly less than when awake.2 However, the influence of sleep on the swallowing reflex has not been studied in elderly patients at risk of aspiration. We examined the swallowing reflex during day and night in elderly patients with cerebral thrombosi or dementia due to cerebral arterial sclerosis, and compared the results with those in age-matched healthy controls. The 25 patients, mean age 76 (SE 2) years, had varying degrees of cerebral atrophy and lacunar infarction revealed by computed tomography. The 10 controls, mean age 78 (2) years, were healthy volunteers and led an active daily life. done at 1300 h and 0100 h both in the supine Each position. subject refrained from taking ethanol, or sedatives, drugs that affected the autonomic nervous for at least 72 h before the study. For the study system the during night, a nasal catheter was inserted into the and at 2200 h the catheter was connected to pharynx polyethylene tubing that was about 120 cm in length. The proximal end of the tubing was fitted with a three-way stopcock and taped to an intravenous drip stand a metre or so away from the subject’s head. 10 mL of distilled water was injected into the tubing through the stopcock and flushed with air until the water just reached the distal end of the nasal catheter. The stopcock was then closed. The catheter was secured in place and the subject was allowed to retire for the night. At 0100 h 1 mL of air was injected into the tubing via the stopcock. This manoeuvre delivered 1 mL of the distilled water into the subject’s pharynx. Swallowing was identified by submental electromyographic (EMG) activity.3 EMG activity was recorded from surface electrodes on the chin. The swallowing reflex was evaluated by the latency of response, which was timed from the injection to the onset of swallowing.3 The subject’s apparent depth of sleep and response to the injection were carefully observed and recorded. Studies during the daytime were done in a similar fashion.
Studies
were
Values
are mean (range). *S)gn!ficant within-group change (p<0001). tNo significant difference between treatment group, p=0145; repeated
measures
of
variance.
Table:
Haemoglobin at beginning and end of a 9-week supplementation period in two groups of women receiving daily versus weekly iron
.
-
Figure:
Latent time
during day and night in
controls and
patients *Significant
difference between patients in
day and night (p<001).
The latency of response was longer in patients than in controls during the daytime (4-1 [0’5] vs 2-8 [0.4] s, p<005). Although the latency of response did not differ between day and night in the controls, the response in the patients was delayed in the night (figure). Severe delay of the response (>5 s) in the night compared with that in the day was observed in 14 patients (56%) with multiple lacunar infarctions in bilateral basal ganglia lesions. We conclude that night-time might be an important risk factor for the development of aspiration pneumonia in elderly patients with cerebrovascular disease.
comes to improving iron status, an animal study has indicated that twice weekly supplementation is just as effective as daily supplementation.We studied whether daily doses of iron supplements are really necessary in anaemic non-pregnant female employees of a cigarette factory in middle Java, Indonesia. Haemoglobin concentration was measured in all 380 female workers by use of blood from a fingerprick. The haemoglobin concentration was distributed normally in this surveyed population. 94 of the 380 women were anaemic with a haemoglobin below 120 g/L. Of these anaemic women, 86 entered the experimental supplementation study (8 women were pregnant). Each of the 86 women was allocated at random to one of two iron supplementation schemes. At the end of the trial, only 80 women remained; the others were forced to drop out when they moved or developed disease. Of these 80 women, 42 had taken one tablet per day containing 200 mg dehydrated ferrous sulphate (60 mg elemental iron) and 250 µg folic acid. 38 had received the same tablet at an interval of once a week. The total duration of the supplementation period was 9 weeks. Tablet distribution and compliance was supervised. At the end of the supplementation period, haemoglobin was again determined by the cyanomethaemoglobin method by use of a Compur Minilab
(Bayer Diagnostic, Germany). Arthur Pinto, Masaru Yanai, Takuma Kiyohisa Sekizawa, Hidetada Sasaki
Nakagawa,
Department of Geriatric Medicine, Tohoku University School of Medicine, Sendai 980, Japan
1 Feinberg MJ, Knebl J, Tully J, Segall L. Aspiration and the elderly. Dysphagia 1990; 5: 61-71. 2 3
Miller AJ. Deglutition. Physiol Rev 1982; 62: 129-84. Nishino T, Takizawa K, Yokokawa N, Hiraga K. Depression of the swallowing reflex during sedation and/or relative analgesia produced inhalation of 50% nitrous oxide in oxygen. Anesthesiology 1987; 67: 995-98.
Treatment of anaemia with
by
weekly iron
supplementation SIR-Iron-deficiency anaemia is an important public health problem in most developing countries. To address this problem, intervention programmes have been initiated in which iron tablets are distributed through the primary health care
take
system.’ Anaemic individuals
Haemoglobin values in both groups were similar at the of the supplementation. As shown in the table, the haemoglobin in both groups increased significantly after There was no significant difference in treatment (p<0001). the average change of haemoglobin between the two groups (p=0-145). We conclude that supplementation on a weekly basis with a relatively low dose of medicinal iron is as effective as daily supplementation in improving the iron status of individuals start
or
with moderate anaemia. There is an urgent need for similar studies among different anaemic risk groups, such as pregnant women and schoolchildren. R Gross, W Schultink, Juliawati Regional South East Asian Ministries of Education Organisation, Center for Community Nutrition at the University of Indonesia, PO Box 3852, 10038, Jakarta, Indonesia; and Deutsche Gesellschaft fur Technische Zusammenarbeit, (GTZ) GmbH, Eschborn, Germany
1
DeMaeyer EM, Dallman P, Gurney JM, Hallberg L, Sood SK, Srikantia SG. Preventing and controlling iron deficiency anaemia through primary health care. Geneva: WHO, 1989.
2
United Nations ACC/SCN. Controlling iron deficiency. ACC/SCN state-of-the-art series. Nutrition policy discussion paper No 9, Geneva: United Nations Administrative Committee on Coordination: Subcommittee on Nutrition, 1991. Bonnar J, Goldberg A, Smith JA. Do pregnant women take their iron? Lancet 1969; i: 457-58. Schultink W, van der Ree M, Matulessi P, Gross R. Low compliance with an iron supplementation program: a study among pregnant women in Jakarta, Indonesia. Am J Clin Nutr 1993; 57: 135-39. Wright AJA, Southon S. The effectiveness of various ironsupplementation regimens in improving the iron status of anaemic rats. Br J Nutr 1990; 63: 579-85.
those at risk should
daily dose of medicinal iron for 2-3 months. However, despite large scale programmes, little success has been achieved during the past decade, since the prevalence of anaemia among pregnant women and preschool children remains high. Factors such as low a
coverage rates, insufficient tablet distribution, and low compliance among subjects all contribute to the reduced efficiency of supplemental iron programmes.2 Tablet distribution and compliance are negatively influenced by a lengthy duration of required daily ingestion.3,4 When it
3 4
5
821