- Email: [email protected]
ADVICE ABOUT MILK FOR INFANTS AND YOUNG CHILDREN
843
evaluation of medical technology? After the initial discussions, ministers met again in 1985 and 1986 when they adopted a number of resolutions. They are scheduled to meet again in May. All of this is good and to be welcomed. If health ministers do not meet to address health matters then others, less well informed or prepared, will tackle the issues for them. This is what seems to have happened with cancer, and the jingoistic ring of Europe Against Cancer is the result. The problem with cancer is its emotional potency. President Mitterand capitalised on this when introducing cancer into the discussion of heads of state at the Milan summit in June, 1985. The seeds of a European programme were sown. What is now so disturbing is not the who, when, and where of planting the seeds but what these have grown into. The answer lies in a document published by the Commission that proposes a shotgun approach of seventyfour different actions, a European Year of Cancer Information, twenty-six additional staff, and a total budget of some C16 million.3 In formulating these proposals the Commission was advised by a group of cancer experts from each of the member states of the Community. Naturally any group of experts will agree that their subject needs more money, more people, more teaching time, more recognition, and so on. As any academic knows, the only checks on such demands are the competing demands of others. In terms of
allocating scarce resources, is there a case for diverting money, manpower, and teaching resources into oncology and away from other disciplines at this time? Only oncologists could be expected to reach a unanimous verdict. Then there is the matter of information campaigns. Plans include year of
an
information week in 1988 and
an
information
1989, with media presentations, publicity, and
a
European Code Against Cancer. Whilst all of these proposals might appear self-evidently good, are they equally relevant to all member states and, more importantly, is the timing appropriate in view of current preoccupations with AIDS and drug abuse? One has to have some sympathy for the public being subjected to such an assault; but one fears even more that if there is any confusion resulting from competing campaigns then the messages will be lost and the impact lessened. Worst of all, one cannot avoid the conclusion that the technical and scientific basis of the scheme is suspect. Much of the document is taken up with a partial and misleading review of the literature, with several serious errors. Many would question the basis of public advice on the consumption of animal fats, vegetables, or salt as dietary factors causing or preventing the development of specific tumours. In dealing with cigarette smoking so uncritically the contribution of cigarettes to cardiovascular disease and the fact that a reduction in tar yield but an increase in CO intake might result in more premature deaths are
ignored.
If there is a case for mounting a major campaign against cancer now-and this is not something to be taken for granted-then the professionals and the public deserve something better. The experts have failed in not pressing on the Commission the need for scientific objectivity; the Commission has surely failed the ministers and the heads of states in putting forward such a poorly thought-out document with no indication of priorities or practicability; and the ministers of health will fail to serve both their own national interest and the longer term Community interest in 2. Cost containment in health services. Commission of the
European Communities. (84) 1652 (final), Oct 25, 1984. 3. Europe against cancer programme. Official Journal of the European Communities. OJ 87’C50’01, Feb 26, 1987. CON
health matters if they fail to dissect this plan, reject the grandiose, the irrelevant, and the misplaced, and thereby leave some five or six things to be done properly. The final evaluation cannot be left, as is proposed, in the hands of the self-same experts who have played a part in its preparation.
ADVICE ABOUT MILK FOR INFANTS AND YOUNG CHILDREN MOTHERS of young children often ask questions which health professionals find hard to answer objectively. Which formula is best? When should I change formula? When can baby take "doorstep" milk? Does it matter when solids are started? Can I give skimmed milk to a toddler? Professionals may wonder why breast feeding is not increasing more rapidly, why iron deficiency anaemia is so common,! and what advice should be given in infancy on animal fat, salt in the diet, and fibre. Community doctors and health visitors are also aware that whatever advice is given, parents are increasingly likely to make their own judgment on what is best for baby, influenced as much by "alternative" sources of information as by the health service. The latest expert pronouncement on the subject comes from the Panel on Child Nutrition. of the DHSS Advisory Committee on Medical Aspects of Food Policy (COMA), who have issued a brief statement on milk for infants and young children.2 The Panel state that the advice is issued because "the nutritional merit of unmodified,,whole cow’s milk has been questioned by some because of the high proportion of energy derived from fat (particularly saturated fatty acids), its low content of iron, and the occasional occurrence in children of milk intolerance". The advice contains certain
key points. Early infancy.-Exclusive breast feeding is best; formula should continue to six months if used; solids may be introduced from four months; soya-based formula may be used if cow’s milk formula is unsuitable. Late infancy.-Suitable milks over six months are human milk, infant formulas, "follow-up" milks, or whole pasteurised cow’s milk. Unmodified skimmed and semiskimmed milks are not recommended because of their low energy and vitamin A content. Care should be taken to ensure adequate iron and vitamin D intake, especially in babies on whole cow’s milk. Milk for young children.-Whole cow’s milk should be a staple item for pre-school children. Semi-skimmed milk may be used from two years if the overall diet is adequate, but wholly skimmed milk is not recommended below five years.
The Panel will be issuing a fuller report on infant feeding later this year, based on the 1985/86 OPCS survey on infant feeding practices. They note that, disappointingly, this survey shows no change in the breast-feeding rate since the 1980 survey,3 when 67% of babies were breast fed at some time and 14% received breast milk alone at four months. This advice does not break new ground (except on skimmed milk) and does not provide answers to the questions posed by parents and professionals. Perhaps the forthcoming report will do so. Why has the breast-feeding rate remained static? Is the profession doing enough both to promote and to protect breast-feeding? Protection means preventing adverse pressure on mothers towards formula 1 Editorial. Iron deficiency—time for a community campaign? Lancet 1987; i: 141-42. 2 CommitteeontheMedicalAspectsofFoodPolicy,PanelonChildNutrition.Milkfor infants and young children. London: DHSS, 1987. 3. Present Day Practice in Infant Feeding: 1980. London: HM Stationery Office, 1980.
844
feeding,
which is still
common
within the health
care
system.45 The World Health Organisation code of marketing of breast milk substitutes has not yet been adopted in the UK; the weaker industry-developed Food Manufacturers’ Federation code tolerates free milk samples being given to mothers through the health services, and many child care organisations are still dependent on milk company sponsorship. Both these customs increase the power of the milk companies to control the baby feeding market. The example set by the Health Visitors’ Association in developing its own code of practices based on the WHO code is welcome and should be emulated by other professional groups. For mothers who bottle feed, clearer guidance is needed on the relative value of the highly modified breast-milk "’look alikes" now being surveyed by many maternity hospitals. Anecdotal evidence from health visitors suggests that many mothers switch to a less modified milk in the early weeks because the baby wakes too often for comfort. What are the benefits of these highly modified milks? In the second half of infancy, the use of "doorstep" milk may have a place in the development of iron deficiency anaemia, whose significance is greater now it is known to be associated with delay.1 How is iron deficiency best prevented-by use of iron-fortified formula, or by another easily assimilated iron source? What is the best advice on iron sources for mothers on low income (whose babies are most at risk)? For older children, there should be clarification as to why skimmed milk is inadvisable below five years of age. Are there scientific reasons for this recommendation, or is it simply caution? Milk is unlikely to be a major energy source for most pre-school children, so the risks of skimmed milk are not immediately clear. Professionals giving advice on milk for children would do well to accept the strong feelings (and opinions) of mothers on the subject. Should not the consumer (via a parent) be represented on the Panel on Child Nutrition?
psychomotor
TRANSIENT TRAUMATIC QUADRIPLEGIA THE
governing bodies of such diverse sports as trampolining7,8 steeple-chasing, American football,9 and rugby unionl° have been prepared to alter their rules to reduce the risk of injury, and individual clinicians8--10 have made important contributions. In American football headon tackling (known as "spearing") causing axial loading with a risk of fracture dislocation of the lower cervical spine has been banned,9 while in rugby union the number of severe flexion injuries to the neck in rucks and maulsll has been reduced Now Torg and colleagues,12 in their review of what has been regarded as a bizarre collection of neurological manifestations following trauma to the neck, Bergevin Y, Dougherty C, Kramer MS. Do infant formula samples shorten the duration of breast-feeding? Lancet 1983; i: 1148-51. 5. Anon. London failing to meet WHO baby milk code. Lancet 1987; i: 398. 6. Lowe R. A code of practice to protect and promote breast feeding. Health Visitor 1986; 4.
define a distinct clinical entity-namely, neuropraxia of the cervical spinal cord with transient quadriplegia. The sensory changes include burning pain, numbness, tingling, and loss of sensation; the motor changes range from weakness to complete paralysis. The episodes are transient and complete recovery usually occurs in 10-15 min; in some patients gradual resolution occurs over 36-48 h. Except for burning paraesthesia, pain in the neck is not present at the time of injury and there is complete return of motor function and7 full, pain-free movement of the cervical spine. Blackouts, breathing difficulties,13,14 nystagmus, or visual symptoms have not been observed. Neuropraxia can be defined as trauma usually produced by pressure or direct impact, with temporary abolition of axonal function unaccompanied by neural degenerative changes. The patients described by Torg and co-workers12 were mostly, but not exclusively, American football players who had sustained forced hyperextension, hyperflexion, or axial-loading injuries to the lower cervical spine without fracture or dislocation. The common denominator was statistically significant spinal stenosis in all of the patients, by comparison with control subjects of similar age, sometimes but not always complicated by the presence of congenital fusion, instability, or intervertebral disc disease. The presence of spinal stenosis between C3 and C6 was determined by standard techniques (lateral radiographs of the neck) and by a ratio method in which the sagittal diameter of the spinal canal was compared with the antero-posterior width of the vertebral body, thereby compensating for magnification factors. Plain radiographs in flexion and extension and tomographic scanning do not provide information about the possible role of intervertebral discs or ligamentous infolding in the production of
thirty-two
neuropraxia. During hyperextension, especially, dynamic compression by the soft tissues anteriorly and posteriorly15 a can narrow the cord by 30 % of its width,16 often producing central cord syndrome with spasticity in the lower limbs and a more persistent flaccid paralysis in the upper limbs.14 Theoretically, myelography is required to confirm the presence of disc and soft tissue changes, but in practice it is probably not justifiable to use an invasive procedure for every patient. Does neuropraxia predispose to permanent neurological injury? To answer this question Torg et al 12 contacted one hundred and seventeen quadriplegic football players and found that none of them had had any episodes of transient motor paresis before they incurred their permanent lesion. are numerous reports of an association between spinal stenosis and myelopathy, 14,15,17 and this issue is not settled. Torg and co-workers suggest that patients with transient quadriplegia in association with instability of the cervical spine or acute or chronic degenerative changes should be precluded from further participation in contact sports; those who have developmental spinal stenosis or spinal stenosis in association with a congenital abnormality should be managed individually.12
However, there
59: 291. 7. 8. 9.
Torg JS, Das M Trampoline and minitrampoline injuries to the cervical spine. Clin Sports Med 1985; 4: 45-60. Clarke KS A survey of sports-related spinal cord injuries in schools and colleges. 1973-1975 J Safety Res 1977; 9: 140-45. Torg JS, Vegso JJ, Sennett B, Das M The National Football Head and Neck Injury Registry. 14-year report on cervical quadriplegia 1971 through 1984. JAMA 1985; 254: 3439-43.
10. Silver JR. Injuries of spine sustained in rugby. Br Med J 1984; 288: 37-42. 11. Scher AT. Rugby injuries to the cervical spinal cord sustained during rucks and mauls. S Afr Med J 1983; 64: 592-94. 12.
Torg JS, Pavlov H, Genuano SE, et al. Neuroraxia of the cervical spinal cord with transient quadriplegia. J Bone Joint Surg 1986; 68-A: 1354-70.
McCoy GF, Piggot J, Macafee AL, Adair IV. Injuries of the cervical spine m schoolboy rugby football. J Bone Joint Surg 1984; 66-B: 500-03 14. Moiel RH, Raso E, Waltz TA. Central cord syndrome resulting from congenital narrowness of the cervical spinal canal J Trauma 1970; 10: 502-10. 15. Ladd AL, Scranton PE. Congenital cervical stenosis presenting as transient quadriplegia in athletes- report oftwo cases. J Bone Joint Surg 1986, 68-A: 1371-74 16. Taylor AR. The mechanism of injury to the spinal cord in the neck without damage to the vertebral column. J Bone Joint Surg 1951; 33-B: 543-47 17. Payne EE, Spillane JD The cervical spine: an anatomico-pathological study of 70 specimens (using a special technique) with particular reference to the problem of cervical spondylosis. Brain 1957; 80: 571-96.
13.
evaluation of medical technology? After the initial discussions, ministers met again in 1985 and 1986 when they adopted a number of resolutions. They are scheduled to meet again in May. All of this is good and to be welcomed. If health ministers do not meet to address health matters then others, less well informed or prepared, will tackle the issues for them. This is what seems to have happened with cancer, and the jingoistic ring of Europe Against Cancer is the result. The problem with cancer is its emotional potency. President Mitterand capitalised on this when introducing cancer into the discussion of heads of state at the Milan summit in June, 1985. The seeds of a European programme were sown. What is now so disturbing is not the who, when, and where of planting the seeds but what these have grown into. The answer lies in a document published by the Commission that proposes a shotgun approach of seventyfour different actions, a European Year of Cancer Information, twenty-six additional staff, and a total budget of some C16 million.3 In formulating these proposals the Commission was advised by a group of cancer experts from each of the member states of the Community. Naturally any group of experts will agree that their subject needs more money, more people, more teaching time, more recognition, and so on. As any academic knows, the only checks on such demands are the competing demands of others. In terms of
allocating scarce resources, is there a case for diverting money, manpower, and teaching resources into oncology and away from other disciplines at this time? Only oncologists could be expected to reach a unanimous verdict. Then there is the matter of information campaigns. Plans include year of
an
information week in 1988 and
an
information
1989, with media presentations, publicity, and
a
European Code Against Cancer. Whilst all of these proposals might appear self-evidently good, are they equally relevant to all member states and, more importantly, is the timing appropriate in view of current preoccupations with AIDS and drug abuse? One has to have some sympathy for the public being subjected to such an assault; but one fears even more that if there is any confusion resulting from competing campaigns then the messages will be lost and the impact lessened. Worst of all, one cannot avoid the conclusion that the technical and scientific basis of the scheme is suspect. Much of the document is taken up with a partial and misleading review of the literature, with several serious errors. Many would question the basis of public advice on the consumption of animal fats, vegetables, or salt as dietary factors causing or preventing the development of specific tumours. In dealing with cigarette smoking so uncritically the contribution of cigarettes to cardiovascular disease and the fact that a reduction in tar yield but an increase in CO intake might result in more premature deaths are
ignored.
If there is a case for mounting a major campaign against cancer now-and this is not something to be taken for granted-then the professionals and the public deserve something better. The experts have failed in not pressing on the Commission the need for scientific objectivity; the Commission has surely failed the ministers and the heads of states in putting forward such a poorly thought-out document with no indication of priorities or practicability; and the ministers of health will fail to serve both their own national interest and the longer term Community interest in 2. Cost containment in health services. Commission of the
European Communities. (84) 1652 (final), Oct 25, 1984. 3. Europe against cancer programme. Official Journal of the European Communities. OJ 87’C50’01, Feb 26, 1987. CON
health matters if they fail to dissect this plan, reject the grandiose, the irrelevant, and the misplaced, and thereby leave some five or six things to be done properly. The final evaluation cannot be left, as is proposed, in the hands of the self-same experts who have played a part in its preparation.
ADVICE ABOUT MILK FOR INFANTS AND YOUNG CHILDREN MOTHERS of young children often ask questions which health professionals find hard to answer objectively. Which formula is best? When should I change formula? When can baby take "doorstep" milk? Does it matter when solids are started? Can I give skimmed milk to a toddler? Professionals may wonder why breast feeding is not increasing more rapidly, why iron deficiency anaemia is so common,! and what advice should be given in infancy on animal fat, salt in the diet, and fibre. Community doctors and health visitors are also aware that whatever advice is given, parents are increasingly likely to make their own judgment on what is best for baby, influenced as much by "alternative" sources of information as by the health service. The latest expert pronouncement on the subject comes from the Panel on Child Nutrition. of the DHSS Advisory Committee on Medical Aspects of Food Policy (COMA), who have issued a brief statement on milk for infants and young children.2 The Panel state that the advice is issued because "the nutritional merit of unmodified,,whole cow’s milk has been questioned by some because of the high proportion of energy derived from fat (particularly saturated fatty acids), its low content of iron, and the occasional occurrence in children of milk intolerance". The advice contains certain
key points. Early infancy.-Exclusive breast feeding is best; formula should continue to six months if used; solids may be introduced from four months; soya-based formula may be used if cow’s milk formula is unsuitable. Late infancy.-Suitable milks over six months are human milk, infant formulas, "follow-up" milks, or whole pasteurised cow’s milk. Unmodified skimmed and semiskimmed milks are not recommended because of their low energy and vitamin A content. Care should be taken to ensure adequate iron and vitamin D intake, especially in babies on whole cow’s milk. Milk for young children.-Whole cow’s milk should be a staple item for pre-school children. Semi-skimmed milk may be used from two years if the overall diet is adequate, but wholly skimmed milk is not recommended below five years.
The Panel will be issuing a fuller report on infant feeding later this year, based on the 1985/86 OPCS survey on infant feeding practices. They note that, disappointingly, this survey shows no change in the breast-feeding rate since the 1980 survey,3 when 67% of babies were breast fed at some time and 14% received breast milk alone at four months. This advice does not break new ground (except on skimmed milk) and does not provide answers to the questions posed by parents and professionals. Perhaps the forthcoming report will do so. Why has the breast-feeding rate remained static? Is the profession doing enough both to promote and to protect breast-feeding? Protection means preventing adverse pressure on mothers towards formula 1 Editorial. Iron deficiency—time for a community campaign? Lancet 1987; i: 141-42. 2 CommitteeontheMedicalAspectsofFoodPolicy,PanelonChildNutrition.Milkfor infants and young children. London: DHSS, 1987. 3. Present Day Practice in Infant Feeding: 1980. London: HM Stationery Office, 1980.
844
feeding,
which is still
common
within the health
care
system.45 The World Health Organisation code of marketing of breast milk substitutes has not yet been adopted in the UK; the weaker industry-developed Food Manufacturers’ Federation code tolerates free milk samples being given to mothers through the health services, and many child care organisations are still dependent on milk company sponsorship. Both these customs increase the power of the milk companies to control the baby feeding market. The example set by the Health Visitors’ Association in developing its own code of practices based on the WHO code is welcome and should be emulated by other professional groups. For mothers who bottle feed, clearer guidance is needed on the relative value of the highly modified breast-milk "’look alikes" now being surveyed by many maternity hospitals. Anecdotal evidence from health visitors suggests that many mothers switch to a less modified milk in the early weeks because the baby wakes too often for comfort. What are the benefits of these highly modified milks? In the second half of infancy, the use of "doorstep" milk may have a place in the development of iron deficiency anaemia, whose significance is greater now it is known to be associated with delay.1 How is iron deficiency best prevented-by use of iron-fortified formula, or by another easily assimilated iron source? What is the best advice on iron sources for mothers on low income (whose babies are most at risk)? For older children, there should be clarification as to why skimmed milk is inadvisable below five years of age. Are there scientific reasons for this recommendation, or is it simply caution? Milk is unlikely to be a major energy source for most pre-school children, so the risks of skimmed milk are not immediately clear. Professionals giving advice on milk for children would do well to accept the strong feelings (and opinions) of mothers on the subject. Should not the consumer (via a parent) be represented on the Panel on Child Nutrition?
psychomotor
TRANSIENT TRAUMATIC QUADRIPLEGIA THE
governing bodies of such diverse sports as trampolining7,8 steeple-chasing, American football,9 and rugby unionl° have been prepared to alter their rules to reduce the risk of injury, and individual clinicians8--10 have made important contributions. In American football headon tackling (known as "spearing") causing axial loading with a risk of fracture dislocation of the lower cervical spine has been banned,9 while in rugby union the number of severe flexion injuries to the neck in rucks and maulsll has been reduced Now Torg and colleagues,12 in their review of what has been regarded as a bizarre collection of neurological manifestations following trauma to the neck, Bergevin Y, Dougherty C, Kramer MS. Do infant formula samples shorten the duration of breast-feeding? Lancet 1983; i: 1148-51. 5. Anon. London failing to meet WHO baby milk code. Lancet 1987; i: 398. 6. Lowe R. A code of practice to protect and promote breast feeding. Health Visitor 1986; 4.
define a distinct clinical entity-namely, neuropraxia of the cervical spinal cord with transient quadriplegia. The sensory changes include burning pain, numbness, tingling, and loss of sensation; the motor changes range from weakness to complete paralysis. The episodes are transient and complete recovery usually occurs in 10-15 min; in some patients gradual resolution occurs over 36-48 h. Except for burning paraesthesia, pain in the neck is not present at the time of injury and there is complete return of motor function and7 full, pain-free movement of the cervical spine. Blackouts, breathing difficulties,13,14 nystagmus, or visual symptoms have not been observed. Neuropraxia can be defined as trauma usually produced by pressure or direct impact, with temporary abolition of axonal function unaccompanied by neural degenerative changes. The patients described by Torg and co-workers12 were mostly, but not exclusively, American football players who had sustained forced hyperextension, hyperflexion, or axial-loading injuries to the lower cervical spine without fracture or dislocation. The common denominator was statistically significant spinal stenosis in all of the patients, by comparison with control subjects of similar age, sometimes but not always complicated by the presence of congenital fusion, instability, or intervertebral disc disease. The presence of spinal stenosis between C3 and C6 was determined by standard techniques (lateral radiographs of the neck) and by a ratio method in which the sagittal diameter of the spinal canal was compared with the antero-posterior width of the vertebral body, thereby compensating for magnification factors. Plain radiographs in flexion and extension and tomographic scanning do not provide information about the possible role of intervertebral discs or ligamentous infolding in the production of
thirty-two
neuropraxia. During hyperextension, especially, dynamic compression by the soft tissues anteriorly and posteriorly15 a can narrow the cord by 30 % of its width,16 often producing central cord syndrome with spasticity in the lower limbs and a more persistent flaccid paralysis in the upper limbs.14 Theoretically, myelography is required to confirm the presence of disc and soft tissue changes, but in practice it is probably not justifiable to use an invasive procedure for every patient. Does neuropraxia predispose to permanent neurological injury? To answer this question Torg et al 12 contacted one hundred and seventeen quadriplegic football players and found that none of them had had any episodes of transient motor paresis before they incurred their permanent lesion. are numerous reports of an association between spinal stenosis and myelopathy, 14,15,17 and this issue is not settled. Torg and co-workers suggest that patients with transient quadriplegia in association with instability of the cervical spine or acute or chronic degenerative changes should be precluded from further participation in contact sports; those who have developmental spinal stenosis or spinal stenosis in association with a congenital abnormality should be managed individually.12
However, there
59: 291. 7. 8. 9.
Torg JS, Das M Trampoline and minitrampoline injuries to the cervical spine. Clin Sports Med 1985; 4: 45-60. Clarke KS A survey of sports-related spinal cord injuries in schools and colleges. 1973-1975 J Safety Res 1977; 9: 140-45. Torg JS, Vegso JJ, Sennett B, Das M The National Football Head and Neck Injury Registry. 14-year report on cervical quadriplegia 1971 through 1984. JAMA 1985; 254: 3439-43.
10. Silver JR. Injuries of spine sustained in rugby. Br Med J 1984; 288: 37-42. 11. Scher AT. Rugby injuries to the cervical spinal cord sustained during rucks and mauls. S Afr Med J 1983; 64: 592-94. 12.
Torg JS, Pavlov H, Genuano SE, et al. Neuroraxia of the cervical spinal cord with transient quadriplegia. J Bone Joint Surg 1986; 68-A: 1354-70.
McCoy GF, Piggot J, Macafee AL, Adair IV. Injuries of the cervical spine m schoolboy rugby football. J Bone Joint Surg 1984; 66-B: 500-03 14. Moiel RH, Raso E, Waltz TA. Central cord syndrome resulting from congenital narrowness of the cervical spinal canal J Trauma 1970; 10: 502-10. 15. Ladd AL, Scranton PE. Congenital cervical stenosis presenting as transient quadriplegia in athletes- report oftwo cases. J Bone Joint Surg 1986, 68-A: 1371-74 16. Taylor AR. The mechanism of injury to the spinal cord in the neck without damage to the vertebral column. J Bone Joint Surg 1951; 33-B: 543-47 17. Payne EE, Spillane JD The cervical spine: an anatomico-pathological study of 70 specimens (using a special technique) with particular reference to the problem of cervical spondylosis. Brain 1957; 80: 571-96.
13.