ADEQUACY OF BREAST-FEEDING

691 and fetal infection in women who had HAI antibodies but no NT antibodies.7-9 However, Grillner’° has shown that NT antibodies are significantly lower 2 years after vaccination with Cendehill than after RA27/3. Using tests carried out in RK13 cells we have found NT antibodies in all our volunteers before challenge, but the presence or titre of these antibodies

associated with protection. However, Schluederberg et at." have shown that the results of NTs in rabbit cells differ from those done in Vero cells. Although it is encouraging that Andre et al. detect NT antibodies for up to 10 years after Cendehill vaccination they do not give details of the tests they used and it is therefore not possible to assess the protective role of these particular antibodies. Effective long-term protection which may need to extend for more than 20 years is essential if congenitally acquired rubella is to be prevented; we no longer feel that we can justify giving Cendehill vaccine to our susceptible hospital staff. was not

Department of Virology, St. Thomas’ Hospital and Medical School, London SE1 7EH

JENNIFER M. BEST GILLIAN C. HARCOURT SIOBHAN O’SHEA J. E. BANATVALA

ISOPRINOSINE IN TREATMENT OF ACUTE VIRAL ENCEPHALITIS

SIR, -Since the beginning of 1977 we have treated 27 acute viral encephalitis patients with isoprinosine, an immunostimulant and antiviral agent. The most common symptoms of encephalitis were clinical signs of cerebral distress with disturbance of awareness and consciousness, infection, increased total proteins and gammaglobulins in cerebrospinal fluid, changes in electroencephalograph pattern with major, diffuse, predominantly focal abnormalities, and cutaneous and/or biological signs of more or less severe immunodepression. By tomography, which appears to be the best means of determining diagnosis and prognosis, provided it is repeated and correlated with clinical findings, 13 patients with necrotising acute encephalitis (NAE) were identified. 10 had focal or pseudofocal, largely unilateral encephalitis, and 3 had multi-focal and bilateral encephalitis with cedematous lamination of the basal ventricular system and basal temporo-frontal or temporo-parietal-occipital necrotic lesions. In 7 NAE was herpetic in origin. In addition, 14 patients with acute diffuse viral encephalitis with disseminated or multifocal tomographic lesions not fitting NAE criteria were identified. The lesions were discrete and disseminated in tomography, with a variable tendency toward spontaneous regression. In 5, the illness was severe (1 reovirus encephalitis) and in 9 it was benign, either meningoencephalitis with lymphocytic reaction (5) or encephalitis with raised CSF gammaglobulins (4).

Isoprinosine (100 mg per kg per day) was given discontinuously (except in 2 cases) for 8-10 days with 8 days between courses (1-3 courses for benign forms, either 2-6 or 9 courses for severe forms). Treatment was by mouth but in 8 of the most seriously ill patients treatment was started i.v. Associated treatments were limited to anti-epileptic therapy and control of oedema (glyHolm SE, Hermodsson S, Norrby R, Lycke E. Case of apparent reinfection with rubella. Lancet 1970; i: 240-41. 8. Eilard T, Strannegård O. Rubella reinfection in pregnancy followed by

7. Strannegård O,

transmission to the fetus. J Infect Dis 1974; 129: 594-96. 9. Forsgren M, Carlström, G, Strangert K. Congenital rubella after maternal reinfection. Scand J Infect Dis 1979; 11: 81-83. 10. Grillner L. Neutralising antibodies after rubella vaccination of newly delivered women: A comparison between three vaccines. Scand. J Infect Dis

1975; 7: 169-72. 11.

Schluederberg A, Horstmann DM, Andiman WA, Randolph MF. Neutralizing and hemagglutination inhibiting antibodies to rubella virus as indicators of protective immunity in vaccinees and naturally immune individuals.J Infect Dis 1978; 138: 877-83.

cerol, with

a

synthetic corticostimulant in 2 patients)

and anti-

biotics.

Isoprinosine was generally well tolerated, although 3 comapatients vomited when treated via gastric tube and a few other patients vomited at the beginning of an oral course. 23 of the 27 patients (11 NAE, 12 DAE) recovered, 19 (8 NAE, 11 DAE) without sequela;. One of the 4 patients who died had NAE of herpetic origin and on the 15th day had received a single 5-day course of isoprinosine at 50 mg/kg/day, which was probably too low. The second, who showed a clear but transitory improvement, received a single course of isoprinosine but at a high and especially prolonged level (200 mg/kg/day for 3 months, continuously). The third, aged 73, recovered from coma and aphasia but died accidentally after an acute deglutition problem. The fourth was profoundly immunodepressed and had been on dialysis for several years after double nephrectomy ; this patient recovered from encephalitis but had septic shock with bilateral pulmonary atelectasis and irreversible hypoxia at the end of the fifth week. Treatment of severe forms of viral encephalitis with isoprinosine should be started as early as possible. For the benign acute forms, the purpose ot the treatment is prevention of the aggravation which sometimes may occur. On isoprinosine, these patients generally improve between the sixth and sixteenth day, with restored immunoreactivity and tomodensitotose

metric evidence of recovery. For all forms of the disorder, discontinuous administration at moderate dose-levels yields the best results. Immunostimulants in continuous therapy, and/or at excessively high dose-levels, may enhance proliferation of suppressor T lymphocytes, yielding results opposite to those

sought.

Clinique Neurologique, Hôpital de la Salpêtrière, Paris, France

A. BUGE G. RANCUREL J. METZGER A. PICARD B. LESOURD D. GARDEUR

ADEQUACY OF BREAST-FEEDING

SIR,-The paper by Professor Waterlow and Dr Thomson (Aug. 4, p. 238) has three main errors: Validity of recommended dietary allowances (RDA).-Far from being "generally accepted", the recommended dietary allowances for early infancy (0-6 months) are highly tenuous. As Waterlow and Thomson note, they are largely based on S. J. Fomon’s studies on intakes observed in North American infants fed various milks-in fact, cow’s milk based formula:, soy milk preparations and pasteurised pooled human milk fed by bottle ad libitum. Such studies only indicate the approximate use of energy and protein from these preparations when given by bottle. Their relevance to babies breast-fed with fresh human milk on demand is conjectural. Human milk in its natural state is a complex biological system whose interacting components should not be considered in isolation. For example, the presence of active lipase and more digestible fatty acids will influence the utilisation of energy. The protein content, too, is more different from that of cow’s milk than has previously been recognised. These nutritional issues are only now being explored. By contrast, "host resistance factors" in breast milk are well recognised. To compare the absorption and utilisation from fresh human milk in its natural cycle from breast to baby with bottle-fed pasteurised human milk makes as much sense as comparing circulating blood with black pudding. Still, Western man seems most culturally secure when swaddled with numbers, however doubtful their meaning. The limited significance and arbitrariness of RDAs is nowhere better indicated than by the recent halving of energy needs for lactating women, as a result of studies by Thomson and others.’ RDAs 12. Thomson AM, et al.

Br J Nutr 1970; 24: 565.

692 for early infancy among the breast fed will be very difficult, if not impossible, to ascertain. What we can say is that they are likely to be more variable than previously believed and that extrapolation from older children, as Waterlow and Thomson have done, is inappropriate. Balance between intake and requirements.-Theoretical extrapolations lead Waterlow and Thomson to conclude that breast-feeding alone after 3 months cannot be adequate mathematically, and, therefore, that this must be so. This is an extraordinary conclusion, as anyone with practical experience will realise from simple observation. Paediatric texts have long recognised that breast-feeding alone sustains babies well for 5-6 months (or more). This is the preferred advice given in Nelson’s Textbook of Pediatrics (1975) and in China,2 the Soviet Union,3 and elsewhere. In legal jargon, it would be a case of res ipsa loquitur. In addition, more precise information is now emerging: 96 exclusively breast-fed babies remained above the 25th centile of the National Centre for Health Statistics standard for up to 9-10 months.4 Frequency of weight faltering.-Weight faltering is not "common at 3 months in developing countries". The early "tropical peediatricians" recognised that growth of breast-fed babies was excellent for the first 6 months or SO.5-7 Field surveys confirm this. For example, a village survey in Haiti in 1959 involving 2343 children showed no young infants (0-6 months) with Gomez third-degree underweight and only 2% with second degree, compared with 3% and 17% in older infants (7-12 months).8 More recent investigations confirm that solely breast-fed babies grow well for 5-6 months in developing countries (in Chile,9 in Australian aborigines,lo in New Guinea," in rural Thailand,12 in drought-ridden Niger,’3 and in the rural Ivory CoastI4). It is true that some recent studies show that output of breast milk can be sufficient by itself for less than 6 months-for example, in Karachi.ls However, in evaluating this problem we need to know about traditional and/or Western imported practices which may be interfering with the prolactin or let-down reflexes and about maternal illhealth, including malnutrition, infection, and stress. The danger in Waterlow and Thomson’s paper is that, unwittingly, it is tailor-made for the promotional campaigns of the formula companies. Primary health care is the major concern of developing countries, and breast-feeding, for as long as it is nutritionally valuable, is a major aspect of practical, affordable primary health care. In most of the Third World, the nutritional, antiinfective, and child-spacing effects of breast-feeding are maximal when the practice is continued alone for about 6 months. The introduction of semisolids from 4-6 months seems a reasonable compromise. Where breast-feeding on its own seems adequate for a shorter period, emphasis needs to be given to the mother’s health and nutrition in what we term "maternalchannelled infant feeding". 16

FREE SCHOOL MEALS AND HEIGHT OF WELSH SCHOOLCHILDREN

SiR,-We would like Welsh

8, p.

DERRICK B. JELLIFFE E. F. PATRICE JELLIFFE

University of California, Los Angeles, California, U.S.A.

Moscow:

Foreign Language Publishing

House, 1965. 4. Ahn CH, MacLean WC. Pediatrics (in press). 5. Trowell HC, et al. Kwashiorkor. London: Edward Arnold, 1954. 6. Welbourn HF. J Trop Pediat 1955; 1: 98. 7. Gopalan C. J Trop Pediat 1958; 20: 149. 8. Jelliffe DB, Jelliffe EFP. Acta Tropica 961; 15: 4. 9. Mönckenberg F. Proceedings of Western Hemisphere Nutrition Conference II. Puerto Rico, 1969. 10. Cox JW. J Biosoc Sci 1978; 10: 429. 11. Lambert J, Basford J. Papua New Guinea Med 1977; 20: 175. 12. Khanjanasthiti P, Dhanamitta S. J Med Assoc Thailand 1978; 61: 341. 13. Murray J, Murray AB. Am J Clin Nutr 1979; 31: 737. 14. Lauber E, Reinhardt M. Am J Clin Nutr 1979; 32: 1159. 15. Lindblad BS, et al. Food and immunology. Stockholm: Alqvist and Wiksell, 1977: 125. 16.

111M

1&11

IV&V

Social class Mean height of eight-year-old Welsh schoolchildren class and % provision of free school meals.

by social

the socioeconomic circumstances of families assessed in a standard manner according to criteria laid down by the Department of Education. The figure shows mean heights of over 900 eight-year-old children in the sample by father’s social class and according to the upper and lower strata of percentage provision of free school meals. For all classes of manual workers mean heights of these children are 1-1.5cm less in schools receiving the higher percentage of free school meals. As in England and Scotland, free school meals are being provided more commonly to children who are short. Proof of benefit to growth by the provision of free school meals will

on

require an experimental approach. I. A. BAKER P.C. ELWOOD P. M. SWEETNAM

M.R.C. Epidemiology Unit, Cardiff CF2 3AS

DOES SEXUAL INTERCOURSE CAUSE FETAL DISTRESS?

and International Health Division, School of Public Health,

Chin Med J 1978; 4: 85. Koltypin A, et al. Children’s diseases.

support, with information from

English and Scottish children. For purposes of growth surveillance we took a random sample of primary schools in Mid-Glamorgan stratified by percentage of their pupils receiving free school meals. Eligibility to receive free school meals depends

Population, Family,

2. 3.

to

children, the findings of Dr Rona and colleagues (Sept. 534), concerning attained height and school meals in

Jelliffe DB, Jelliffe EFP. FAO Food Nutr (in press).

SIR,-Considerable information is available on sexual attitudes and behaviour patterns during and after pregnancy.1-4 There is general agreement that the frequency of sexual intercourse decreases as pregnancy progresses, and that this is associated with a decline in libido, a fear of harming the fetus, and physical discomfort or fatigue. However, information on sexual activity in the final weeks of pregnancy in relation to pregnancy outcome is not available. 70 married primiparous women were interviewed four to eight days after delivery and before discharge from the postnatal ward at St Bartholomew’s Hospital. Women were selected 1. Masters WH,

Johnson VE. Human sexual response. Boston: Little Brown,

1966: 141-68. 2.

Kenny JA. Sexuality of pregnant Behav 1973; 2: 215-22.

and

breastfeeding

women.

Arch Sexual

3. Tolor A, DiGrazia PV. Sexual attitudes and behaviour patterns during and following pregnancy. Arch Sexual Behav 1976; 5: 539-51. 4. Lumley J. Sexual feelings in pregnancy and after childbirth. Aust NZ J

Obstet Gynæcol 1978; 18: 114-17.