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Breast-feeding and social circumstances
PUBLIC HEALTH, March, 1949
118
BREAST-FEEDING AND SOCIAL CIRCUMSTANCES tion of Accidents' suggestions for accident prevention. He thought the difficulty in this subject was to get evidence about the non-fatal B y R. M . DYKES, M.A., M.B., D.P.H., accidents which might stimulate effort in small populations where the accident death roll was not so high. Deputy Medical O~eer of Health, Borough of Luton Dr. A. S. Hebblethwaite (M.O.H., Sunderland) asked whether F e w s u b j e c t s are o f g r e a t e r i n t e r e s t to h e a l t h d e p a r t m e n t s electrical b u r n s were commoner in the U.S.A., with its bigger ratio of electrification. H e suggested that there might be a free repair t h a n i n f a n t feeding, a n d few illustrate so well t h e g u l f b e t w e e n scheme for electrical apparatus. H e asked also for information w h a t we s h o u l d like to k n o w a n d w h a t we d o k n o w . about cases of suffocation due to overcrowding, and of gas poisoning T h e r e is, h o w e v e r , n o scarcity o f p a p e r s a n d c o m m e n t a r i e s by children turning on gas taps. o n b r e a s t - f e e d i n g a n d its significance for c h i l d h e a l t h . E v e r y Dr. Boucher said that figures had been sought from the United m e d i c a l officer is f a m i l i a r w i t h the s t a t e m e n t s r e p e a t e d t i m e a n d States b u t had not yet arrived. Gas. poisoning figures had not yet again o n d i f f e r e n t aspects of t h e subject. W e are told, for been analysed. Regarding information of non-fatal accidents, he thought the hospital almoner would be found most co-operative in instance, t h a t t h e b r e a s t - f e d b a b y e n j o y s m a n y a d v a n t a g e s giving M.O.H.s the details. Regarding deaths, coroners' reports o v e r t h e b o t t l e fed, a n d t h a t b r e a s t - f e e d i n g h a s d e c l i n e d d u r i n g were now under analysis and should produce further information. t h e last 25 years. W e h a v e also b e e n told t h a t t h e b r e a s t Dr. A. A. E. Newth (S.M.O., Nottingham) asked for information f e e d i n g of b a b i e s b o r n i n h o s p i t a l is less successful t h a n t h a t about accidents arising from children climbing. H e was also in- of b a b i e s b o r n at h o m e . F e w s u c h s t a t e m e n t s , h o w e v e r , are terested in home accidents to epileptics, and he drew attention to the s o u n d l y b a s e d o n fact. O p i n i o n a n d u n s u p p o r t e d assertions juvenile suicides where expressed intentions were sometimes not are c o m m o n ; verified d a t a relatively rare. T h e s i t u a t i o n is, taken seriously but where deaths could be prevented by psychological indeed, s u c h t h a t a r e c e n t r e p o r t t w h i c h d e p l o r e d " t h e lack treatment. Dr. C. Metealfe Brown (M.O.H., Manchester C.B.) pointed out the of satisfactory statistical i n f o r m a t i o n " a b o u t b r e a s t - f e e d i n g dangers of the two-pin plug from which children could get shocks can h a v e c a u s e d little s u r p r i s e a n d m o s t of us w o u l d b e ready by inserting small objects. He made a plea for the universal pro- to a d m i t t h a t t h e s u p e r i o r i t y of b r e a s t - f e e d i n g o v e r artificial vision of three-pin plugs. He asked whether there was any way of f e e d i n g is still m a i n l y conjectural. preventing accidental death from gas escaping from fires connected T h e r e are m a n y q u e s t i o n s still to b e a n s w e r e d conclusively. with penny- or shiUing-in-the-slot gas meters. For educational W h a t is t h e p r o p o r t i o n o f m o t h e r s w h o fail to e s t a b l i s h b r e a s t purposes there was no doubt that health visitors would be the most feeding ? W h a t is t h e d u r a t i o n of b r e a s t - f e e d i n g generally ? tmportant agents by keeping their eyes open when they visited the W h a t are t h e differences in different social g r o u p s a n d family homes, and he thought also that the local B.B.C. would be of service. sizes ? W h a t are t h e reasons for failures ? H o w are the Dr. Boueher said regarding broadcasting that prevention of accidents had been mentioned in the " W o m a n ' s H o u r , " which was p h y s i q u e , t h e n u t r i t i o n a l state a n d t h e sickness experience o f extensively listened to. Regarding electrical plugs, he agreed, in i n f a n t s affected b y t h e i r feeding ? Q u e s t i o n s of this k i n d regard to the dangers of the two-pin plug, and said that it had also suggest at once t h a t t h e r e are m a n y gaps in o u r knowledge. been under consideration whether plugs need be at ground level T h e c o n t r i b u t i o n we are able to m a k e in this p a p e r is a m o d e s t at all and should not be placed higher where they were out of reach one ; a n d u n f o r t u n a t e l y o u r data are n o t generally comparable. of young children. w i t h t h o s e o f m o s t o t h e r r e c e n t surveys. T h e w e a n i n g rate Dr. Miriam Florentin (Senior A.M.O.H., West H a m C.B.) was m o n t h b y m o n t h u p to n i n e m o n t h s is rarely g i v e n in p u b l i s h e d convinced that overcrowding was the main factor in many home accidents. She thought it was a mistake in the overcrowding legis- papers, a n d m o s t of t h e g r o u p s investigated are selected, i.e., lation that babies were not reckoned in computing the n u m b e r of i n f a n t s in n u r s e r i e s a n d hospitals o r a t t e n d i n g welfare eentres. T h e p r i m a r y p u r p o s e o f t h e survey s f r o m w h i c h t h e data dwellers and children under five only reckoned as half unit. T h e chairman asked if there was any authoritative view about the for t h i s p a p e r were d r a w n was to estimate t h e a m o u n t a n d dangers of pillows for babies. H e pointed out one danger of suffoca- n a t u r e o f infantile s i c k n e s s ; i n f o r m a t i o n a b o u t feeding tion by babies getting their heads between the bars of cots and histories was, therefore, incidental. N o a t t e m p t was m a d e to thought that the distance between bars was a n important point. He investigate i n f a n t feeding i n detail, n o r to assess t h e causes of mentioned one unusual accident where a baby had been suffocated a failure to b r e a s t - f e e d at different ages. T h e h i s t o r y dealt by a plastic bib which blew over its face. Regarding loose gas taps, he mentioned a device by which a tap was self-locking and had to be o n l y w i t h t h e age i n m o n t h s a t w h i c h b r e a s t - f e e d i n g ceased completely. N e v e r t h e l e s s , we feel justified i n r e p o r t i n g o u r lifted to turn on. I n regard to the danger of a coin-in-the-slot meter, he suggested that a small pilot light on the gas fire might obviate findings because legitimacy a n d h o u s i n g c o n d i t i o n s , social class a n d f a m i l y size, w e r e all investigated, a n d it was, t h e r e this danger. Finally, in moving a hearty vote of thanks to Dr. Boucher, h e " fore, possible to relate f e e d i n g h i s t o r y to t h e s e factors. M o r e regretted the small attendance b u t said that the value of the paper over, t h e s u r v e y g r o u p (1,498) h a s t h e a d v a n t a g e o f relating and the discussion would be appreciated b y all m e m b e r s when they to all t h e b a b i e s b o r n i n 1945 in a t o w n o f t i 0 , 0 0 0 i n h a b i t a n t s , read it in the journal. a n d n o t to a selected g r o u p (for example, welfare b a b i e s or babies b o r n i n hospital). T h e m a i n f i n d i n g s are as follows : COUNTY BOROUGH M.O.H. GROUP Under the presidency of Dr. R. M. Galloway (Bolton), the County Borough M.O.H. Group will hold their Annual Meeting and Conference at "Low Wood," Windermere, from May 6th to 9th, 1949. The programme includes a talk on " The Working of the National Health Service Act, 1946," by Dr. C. Metcalfe Brown, Medical Officer of Health of Manchester, and Dr. F. Hall, County Medical Officer, Lancashire, on " Maternity and Child Welfare " by Mrs. Baker, formerly Matron, St. Mary's Hospital, Manchester, on " M e n t a l Health Service responsibilities of Part III Authorities under the Health Service Act, t946" by Dr. W. Rees Thomas, Ministry of Health, on " T h e Care of the Deaf in the Community " by Drs. A. W. G. and Irene Ewing, University of Manchester, on " The Training of Health Visitors " by Professor I. G. Davies, Leeds University, and on " Medicine--Social and Anti-Social--in West Africa " by Professor Andrew Topping, University of Manchester. The Hon. Secretary is Dr. J. Greenwood Wilson, Cardiff. An announcement by the University of London of the By~ott studentships tenable at the London School of Hygiene and Troptcal Medicine appears on p. x of this issue. Copies of the Index of Volume 61 of PUBLIC HEALTH are now available free of charge on request to the Executive Secretary.
Age of Weaning T h e s u r v e y s h o w e d t h a t f o r t h e w h o l e g r o u p (1,498 infants) t h e p e r c e n t a g e o f i n f a n t s n o l o n g e r b r e a s t fed a t different m o n t h s of age was B r e a s t - f e e d i n g n o t e s t a b l i s h e d o r lasting less t h a n 10 days . . . . . . . . . . . . . . . 20~o Off breast completely : 1 month . . . . . . . . . . . . . . . 26% 2 months . . . . . . . . . . . . . . . 35% 3 . . . . . . . . . . . . . . . . . 43% 4 . . . . . . . . . . . . . . . . . 5t% 5
. . . . . . . . . . . . . . . . .
5~%
6
. . . . . . . . . . . . . . . . .
GI%
7
. . . . . . . . . . . . . . . . .
73%
8
. . . . . . . . . . . . . . . . .
79%
9
.
.
.
.
.
.
.
.
-.
.
.
.
.
.
84%
I t will b e n o t e d t h a t a b o u t a q u a r t e r o ( ' t h e i n f a n t s were n o l o n g e r o n t h e b r e a s t at t h e age of o n e m o n t h , a n d t h a t above this age i n f a n t s were t a k e n off t h e b r e a s t at a fairly s t e a d y rate u p to t h e age o f six m o n t h s . A t t h e age o f six m o n t h s 39~to o f i n f a n t s were still b r e a s t - f e d a n d 16~o were still h a v i n g one or m o r e b r e a s t - f e e d s at t h e age of n i n e m o n t h s . T h a t is to say,
PUBLIC HEALTH, March, 1949
119
of the 585 infants still wholly or partly on the breast at six months, 247 were still having breast-feeds at nine months. Hospital and Home
TABLE I
AGE AT W H I C H BREAST FEEDING CEASED FOR ALL
Confinement
LEGITIMATE INFANTS BY F A M I L Y SIZE
When the whole group of infants is divided into two subgroups, i.e., those born in hospitals (or maternity homes) and those born at home, it is found that babies born in hospital (1,026) had a slight advantage as regards breast-feeding over those born at home (397). It is noteworthy that other investigators have demonstrated the same fact elsewhere. Hughes, s for example, found that 32% of babies delivered at home by midwives were weaned by the end of two weeks as against 20% of those delivered in hospital. One of the findings of the recently published report, " Maternity in Great Britain, ''4 was that there was n o significant difference in the proportions of babies born in hospital and born at home who were bottle-fed at eight weeks. I f anything, the b a l a n c e ~ i n terms of breastfeeding~was slightly in favour of the hospital group. T h e graph illustrates the percentage rate of weaning for the two sub-groups. T h e curves for hospital and home confinement groups do not include illeg;timate babies in whom the reasons for weaning are more often compelling social a n d economic circumstances. If, however, they were included the s t a t e m e n t that hospital-born babies have a small advantage would not be invalidated. T h e percentage of illegitimate infants weaned during the first ten days of life is very much higher than for legitimate babies, though the rate of weaning after ten days is much the same.
Age in months
On/y
4
child (0) Sibship
or more children
2 3 Not children children (3, 4, 5, stated (1) (2) arm 6)
8
360 22.29%
2
122 8.57%
--
1 t7 8.22%
11 6-83%
I
117 8.22%
24 9 4.89?/o 4.04%
10 6.21%
2
74 5.20%
24 4-88%
5 3.11%
2
67 4.70%
--
170 11-94%
16 9-94%
1
155 10.89%
0oX
9 +- months 90 82 43 22 (9) 17.0~:% 16"703o 19-28% 13'66%
3
240 16.86%
toT.
Not stated
i
1
20
1,423
d
Under 1 month (1)
128 24.24%
1-2 months (2)
48 9-12%
45 9.16%
14 6.28%
13 8-07%
2-3 months (3)
46 8.71%
45 9.16%
18 8.07%
8 4'97?/o
3-4 months (4)
37 7-0%
46 9.37%
22 9-87%
4-5 months (5)
29 5.49%
5-6 months (6)
26 4-92%
10 4-48%
6-7 months (7)
57 63 10"79% 12.83%
7-9 months (8)
67 56 15 12.68% 11.41% 6-73%
Total
TaX
106 65 53 21.58% 29.15% 32.92%
All
. ...
528
.
27 23 12.11% 14"29%
. 491
. 223
• 161
/I /
~oX Breast-Feeding
////
sag ¢o'L mY. ao't. tax O
II •
---.
t
1
~rr~
s
#
•
o~tt
4
7
m m ~
t
9
....
ta ~ J ~ s
pxtr.mM~ o ~
NOTES.--(1) There is a high initial incidence of failure to establish breast-feeding, or to maintain breast-feeding for more than ten days. (2) Illegitimate babies are more likely to be weaned in the first t e n days than legitimate babies. (3) After the tenth day the rate of weaning of all babies is about 8% per month up to six months, accelerates to 12% in the seventh month, and finally slows down to 6% per month up to nine months. (4) Babies born in hospitals or maternity homes have a small consistent advantage over those born at home. Breast-Feeding
and Family
Size
It has been suggested from time to time that family size may influence breast-feeding. Thus, it is argued, the first baby is more likely to be breast-fed because the mother has more time to devote to an only child. Conversely, it has also been argued that the mother may be less anxious about breast feeding, and may establish it more easily for the second or later ehildren. T h e Luton survey shows that (for Luton at all events) family size has little influence. Table I shows dearly that the only child does not enjoy a n o t a b l e advantage over later children at any age up to n i n e "months.
and Social Class
Overcrowding in the home and general lack of privacy have been given as possible contributory causes of early weaning. I f this is so, it should be reflected by social class and housing circumstances, though it is possible, of course, that changed circumstances of life affecting all groups of the community in 1945 may mask any differences which existed before the war. T h e number of infants born into families living in unfit houses* numbered only 58. T h e percentage weaned at each month of age compared favourably with those infants in fit houses. Table II (overleaf) gives the percentage of infants weaned at each month of age in two social groups. Discussion
No attempt has been made to determine reasons for failures to establish or maintain breast-feeding. T h a t there is a high proportion of babies weaned for no ascertained reason has been shown by a number of investigators. Robinson ~, in an investigation of 1,100 consecutive cases of premature weaning in the infant welfare centres at Norris Green, found that 40% of the women could give no reason at all. O f the remaining 60%, 23% were attributed to maternal ill-health, 12% to infantile conditions, 8% to environment and 17% to other causes. Social and environmental factors believed to influence breastfeeding adversely have, however, been investigated in the Luton survey, and it is demonstrated clearly that social circumstances have no particular influence. Hughes a has shown over the period 1941--45 that 29% of infants were weaned by the end of two weeks, and 39-5% by the end of the first month. These are rather higher than the Luton figures and confirm that a high proportion of failures occur in the first ten days or so. * According to Housing Act standards.
120
PUBLIC HEAI.TH, March, 1949
As we have pointed out, it has often been stated that breastfeeding is more successful among babies born in hospital, and reasons have been adduced to explain this difference between TABLE II AOE AT WHICH BREAST-FEEDINGCEASEDFOR LEGITIMATE INFANTS BY SOCIAL CLASS~t
Age in months
Under 1 month (1) 1-2 mths. (2) 2-8 mths. (3) 3-4mths. (4) 4-5 mths. (5) 5-6 mths. (6) 6-7mths. (7) 7-9mths. (8) 9 mths. and over (9) Not stated Total
Group (1) Social classes I, I I ~ 111
Group (2) Social classes IV & V
No. 220
% 25
No. 97
% 24
No. 43
No. 360
% 25
70 73 70 46 44 103 106 158
8 8 8 5 5 11 12 18
41 29 40 23 18 57 38 67
10 7 10 6 4 14 9 16
11 15 7 5 5 10 11 15
122 117 117 74 67 170 155 240
9 8 8 5 5 12 11 17
1
1
123
1,423
. 890
.
. 100
. 410
100
Not stated
All classes
-100
* Social class according to Registrar-General's classification. N O T E . - Infants born into Group I have no demonstrable advantage. hospital born babies and babies born at home. It has been said, for instance, that in hospital and maternity homes attention by nursing staff is circumscribed by hospital r o u t i n e - - t h e infant is presented to the mother at fixed intervals and the mother suffers anxiety when the child is taken away between feeds. Hospital wards, it has been said, moreover, have not an atmosphere which encourages breast-feeding. T h e Luton enquiry shows (so far as Luton is concerned) that there is no difference to explain.
Conclusions (1) Breast-feeding is not established at all, or ceases within 10 days, in about 200/9 of all births. (2) T h e rate of weaning thereafter is about 8% per month up to six months, then accelerates to 12% in the seventh month, and finally slows down to 6% per month up to nine months. (3) Family size, social class and standard o f housing do not exert any material influence on breast-feeding. (4) A high proportion of illegitimate babies are weaned during the first ten days, but the rate of weaning after ten days is almost the same as for legitimate babies. (5) Babies born in hospital have a slight advantage over babies born at home. REFERENCES 1 MINISTRY OF HEALTH. Reports on Public Health and Medical Subjects, no. 91. " Illness in Early Childhood in the Borough." Annual Report of the Medical Officer of Health, Borough of Luton. 1948. a HUGHES, ENID L. (1948). Study of Breast-Feeding in a Mining Town. Brit. med. J., 2. • " Maternity in Great Britain." Joint Committee of the Royal College of Obstetricians and Gynaecologists and the Population Investigation Committee. London: Oxford University Press. 1948. 5 ROmNSON, MnaOA~T. (1943). " Failing Lactation." Lancet, 1, 66.
SOME P U B L I C
HEALTH PROBLEMS OF SEASIDE RESORTS
By W. S. PARKER, M.B., CH.B., M.R.C.S., L.R.C.P., D.P.H., D.I.H., Medical Officer of Health, Cromer and Sheringham Urban Districts T h e public health problems of a seaside resort are mainly those caused by seasonal fluctuations of population and the provision of amenities for visitors. T h e health department can do much to maintain the reputation of the town and thus the very essential goodwill of holiday makers. T h e special needs of the resort must be constantly under survey and an effort must be made to combine improvements in hygiene with the necessity of attracting and impressing those who provide the main industry of the town. It is not sufficient to conduct public health administration without any liaison to make necessary tasks appear in the most acceptable form. T h e basic industry of a holiday resort is to achieve the maxim u m income for the year from a season lasting only a few summer months. T h a t income has to be earned by attracting the largest number of visitors and satisfying their demand for accommodation and amusement while maintaining the greatest possible economy. Health points demanding attention are food and drink hygiene, sanitation and the control of infectious disease.
Hotels and Boarding Houses Little is heard of work carried out by public health departments in the improvement of hotel and boarding-house accommodation. In the better class of establishment there is no cause for complaint as these cater for a discriminating clientele. Some of the cheaper accommodation is of a more questionable standard and merely consists of the cramming together of the maximum number of sleeping places often with very little in the way of public rooms. In fine weather, with all the windows open, the situation is not bad but it is a different story in inclement weather when visitors have to remain indoors, with the windows closed, with no drying space and, in the smaller resorts, often with no amusements available under cover elsewhere in the town. A case of diphtheria or similar infectious disease in such a boarding-house can be a minor nightmare to the medical officer of health. Staff accommodation, even in the biggest hotels, is too often of a low standard. Attic bedrooms furnished with an assortment of cast-off furniture and with poor window space cannot be expected to attract the best type of catering staff. Many hotels are nearly 50 years old and not all have been modernised in those parts which do not catch the eye of the visitor. It is interesting to note that passenger ships, which in many ways can be compared to large hotels, have been remodelled since the war almost without exception so as to pro.vide better crew (i.e., staff) accommodation and amenities. Visitors, whose stay is brief, are likely to be out of doors most of the time whereas hotel staffs have hard indoor w9rk f.)r the whole of the summer and this increases with the success of the season. T h e i r task is often forgotten and so is their need for adequate personal accommodation. In this connection an ever-recurring staff problem is that of the catering worker who has suffered from a " weak chest " during the winter and who takes a summer job by the sea in the hope of improvement; after placing his workmates at risk for much longer than necessary, he is there diagnosed as a case of pulmonary tuberculosis by the seaside general practitioner who has learnt to expect such cases. Hygiene of Catering Establishments No general standard of washing-up has yet been specified for catering establishments or for public-houses. A visit to a crowded public-house in the rush hour provides much of interest to the observer. Elementary hygiene demands are the provision of double sinks of adequate size t3 p~rmit c~mplete washing and rinsing, of proper drying facilities and of a sufficient supply of drinking vessels in prop)rtion to the number of customers to be expected. S)me immediate improvement could be made if water were supplied to catering establishments and public-houses at a fixed annual charge and "
118
BREAST-FEEDING AND SOCIAL CIRCUMSTANCES tion of Accidents' suggestions for accident prevention. He thought the difficulty in this subject was to get evidence about the non-fatal B y R. M . DYKES, M.A., M.B., D.P.H., accidents which might stimulate effort in small populations where the accident death roll was not so high. Deputy Medical O~eer of Health, Borough of Luton Dr. A. S. Hebblethwaite (M.O.H., Sunderland) asked whether F e w s u b j e c t s are o f g r e a t e r i n t e r e s t to h e a l t h d e p a r t m e n t s electrical b u r n s were commoner in the U.S.A., with its bigger ratio of electrification. H e suggested that there might be a free repair t h a n i n f a n t feeding, a n d few illustrate so well t h e g u l f b e t w e e n scheme for electrical apparatus. H e asked also for information w h a t we s h o u l d like to k n o w a n d w h a t we d o k n o w . about cases of suffocation due to overcrowding, and of gas poisoning T h e r e is, h o w e v e r , n o scarcity o f p a p e r s a n d c o m m e n t a r i e s by children turning on gas taps. o n b r e a s t - f e e d i n g a n d its significance for c h i l d h e a l t h . E v e r y Dr. Boucher said that figures had been sought from the United m e d i c a l officer is f a m i l i a r w i t h the s t a t e m e n t s r e p e a t e d t i m e a n d States b u t had not yet arrived. Gas. poisoning figures had not yet again o n d i f f e r e n t aspects of t h e subject. W e are told, for been analysed. Regarding information of non-fatal accidents, he thought the hospital almoner would be found most co-operative in instance, t h a t t h e b r e a s t - f e d b a b y e n j o y s m a n y a d v a n t a g e s giving M.O.H.s the details. Regarding deaths, coroners' reports o v e r t h e b o t t l e fed, a n d t h a t b r e a s t - f e e d i n g h a s d e c l i n e d d u r i n g were now under analysis and should produce further information. t h e last 25 years. W e h a v e also b e e n told t h a t t h e b r e a s t Dr. A. A. E. Newth (S.M.O., Nottingham) asked for information f e e d i n g of b a b i e s b o r n i n h o s p i t a l is less successful t h a n t h a t about accidents arising from children climbing. H e was also in- of b a b i e s b o r n at h o m e . F e w s u c h s t a t e m e n t s , h o w e v e r , are terested in home accidents to epileptics, and he drew attention to the s o u n d l y b a s e d o n fact. O p i n i o n a n d u n s u p p o r t e d assertions juvenile suicides where expressed intentions were sometimes not are c o m m o n ; verified d a t a relatively rare. T h e s i t u a t i o n is, taken seriously but where deaths could be prevented by psychological indeed, s u c h t h a t a r e c e n t r e p o r t t w h i c h d e p l o r e d " t h e lack treatment. Dr. C. Metealfe Brown (M.O.H., Manchester C.B.) pointed out the of satisfactory statistical i n f o r m a t i o n " a b o u t b r e a s t - f e e d i n g dangers of the two-pin plug from which children could get shocks can h a v e c a u s e d little s u r p r i s e a n d m o s t of us w o u l d b e ready by inserting small objects. He made a plea for the universal pro- to a d m i t t h a t t h e s u p e r i o r i t y of b r e a s t - f e e d i n g o v e r artificial vision of three-pin plugs. He asked whether there was any way of f e e d i n g is still m a i n l y conjectural. preventing accidental death from gas escaping from fires connected T h e r e are m a n y q u e s t i o n s still to b e a n s w e r e d conclusively. with penny- or shiUing-in-the-slot gas meters. For educational W h a t is t h e p r o p o r t i o n o f m o t h e r s w h o fail to e s t a b l i s h b r e a s t purposes there was no doubt that health visitors would be the most feeding ? W h a t is t h e d u r a t i o n of b r e a s t - f e e d i n g generally ? tmportant agents by keeping their eyes open when they visited the W h a t are t h e differences in different social g r o u p s a n d family homes, and he thought also that the local B.B.C. would be of service. sizes ? W h a t are t h e reasons for failures ? H o w are the Dr. Boueher said regarding broadcasting that prevention of accidents had been mentioned in the " W o m a n ' s H o u r , " which was p h y s i q u e , t h e n u t r i t i o n a l state a n d t h e sickness experience o f extensively listened to. Regarding electrical plugs, he agreed, in i n f a n t s affected b y t h e i r feeding ? Q u e s t i o n s of this k i n d regard to the dangers of the two-pin plug, and said that it had also suggest at once t h a t t h e r e are m a n y gaps in o u r knowledge. been under consideration whether plugs need be at ground level T h e c o n t r i b u t i o n we are able to m a k e in this p a p e r is a m o d e s t at all and should not be placed higher where they were out of reach one ; a n d u n f o r t u n a t e l y o u r data are n o t generally comparable. of young children. w i t h t h o s e o f m o s t o t h e r r e c e n t surveys. T h e w e a n i n g rate Dr. Miriam Florentin (Senior A.M.O.H., West H a m C.B.) was m o n t h b y m o n t h u p to n i n e m o n t h s is rarely g i v e n in p u b l i s h e d convinced that overcrowding was the main factor in many home accidents. She thought it was a mistake in the overcrowding legis- papers, a n d m o s t of t h e g r o u p s investigated are selected, i.e., lation that babies were not reckoned in computing the n u m b e r of i n f a n t s in n u r s e r i e s a n d hospitals o r a t t e n d i n g welfare eentres. T h e p r i m a r y p u r p o s e o f t h e survey s f r o m w h i c h t h e data dwellers and children under five only reckoned as half unit. T h e chairman asked if there was any authoritative view about the for t h i s p a p e r were d r a w n was to estimate t h e a m o u n t a n d dangers of pillows for babies. H e pointed out one danger of suffoca- n a t u r e o f infantile s i c k n e s s ; i n f o r m a t i o n a b o u t feeding tion by babies getting their heads between the bars of cots and histories was, therefore, incidental. N o a t t e m p t was m a d e to thought that the distance between bars was a n important point. He investigate i n f a n t feeding i n detail, n o r to assess t h e causes of mentioned one unusual accident where a baby had been suffocated a failure to b r e a s t - f e e d at different ages. T h e h i s t o r y dealt by a plastic bib which blew over its face. Regarding loose gas taps, he mentioned a device by which a tap was self-locking and had to be o n l y w i t h t h e age i n m o n t h s a t w h i c h b r e a s t - f e e d i n g ceased completely. N e v e r t h e l e s s , we feel justified i n r e p o r t i n g o u r lifted to turn on. I n regard to the danger of a coin-in-the-slot meter, he suggested that a small pilot light on the gas fire might obviate findings because legitimacy a n d h o u s i n g c o n d i t i o n s , social class a n d f a m i l y size, w e r e all investigated, a n d it was, t h e r e this danger. Finally, in moving a hearty vote of thanks to Dr. Boucher, h e " fore, possible to relate f e e d i n g h i s t o r y to t h e s e factors. M o r e regretted the small attendance b u t said that the value of the paper over, t h e s u r v e y g r o u p (1,498) h a s t h e a d v a n t a g e o f relating and the discussion would be appreciated b y all m e m b e r s when they to all t h e b a b i e s b o r n i n 1945 in a t o w n o f t i 0 , 0 0 0 i n h a b i t a n t s , read it in the journal. a n d n o t to a selected g r o u p (for example, welfare b a b i e s or babies b o r n i n hospital). T h e m a i n f i n d i n g s are as follows : COUNTY BOROUGH M.O.H. GROUP Under the presidency of Dr. R. M. Galloway (Bolton), the County Borough M.O.H. Group will hold their Annual Meeting and Conference at "Low Wood," Windermere, from May 6th to 9th, 1949. The programme includes a talk on " The Working of the National Health Service Act, 1946," by Dr. C. Metcalfe Brown, Medical Officer of Health of Manchester, and Dr. F. Hall, County Medical Officer, Lancashire, on " Maternity and Child Welfare " by Mrs. Baker, formerly Matron, St. Mary's Hospital, Manchester, on " M e n t a l Health Service responsibilities of Part III Authorities under the Health Service Act, t946" by Dr. W. Rees Thomas, Ministry of Health, on " T h e Care of the Deaf in the Community " by Drs. A. W. G. and Irene Ewing, University of Manchester, on " The Training of Health Visitors " by Professor I. G. Davies, Leeds University, and on " Medicine--Social and Anti-Social--in West Africa " by Professor Andrew Topping, University of Manchester. The Hon. Secretary is Dr. J. Greenwood Wilson, Cardiff. An announcement by the University of London of the By~ott studentships tenable at the London School of Hygiene and Troptcal Medicine appears on p. x of this issue. Copies of the Index of Volume 61 of PUBLIC HEALTH are now available free of charge on request to the Executive Secretary.
Age of Weaning T h e s u r v e y s h o w e d t h a t f o r t h e w h o l e g r o u p (1,498 infants) t h e p e r c e n t a g e o f i n f a n t s n o l o n g e r b r e a s t fed a t different m o n t h s of age was B r e a s t - f e e d i n g n o t e s t a b l i s h e d o r lasting less t h a n 10 days . . . . . . . . . . . . . . . 20~o Off breast completely : 1 month . . . . . . . . . . . . . . . 26% 2 months . . . . . . . . . . . . . . . 35% 3 . . . . . . . . . . . . . . . . . 43% 4 . . . . . . . . . . . . . . . . . 5t% 5
. . . . . . . . . . . . . . . . .
5~%
6
. . . . . . . . . . . . . . . . .
GI%
7
. . . . . . . . . . . . . . . . .
73%
8
. . . . . . . . . . . . . . . . .
79%
9
.
.
.
.
.
.
.
.
-.
.
.
.
.
.
84%
I t will b e n o t e d t h a t a b o u t a q u a r t e r o ( ' t h e i n f a n t s were n o l o n g e r o n t h e b r e a s t at t h e age of o n e m o n t h , a n d t h a t above this age i n f a n t s were t a k e n off t h e b r e a s t at a fairly s t e a d y rate u p to t h e age o f six m o n t h s . A t t h e age o f six m o n t h s 39~to o f i n f a n t s were still b r e a s t - f e d a n d 16~o were still h a v i n g one or m o r e b r e a s t - f e e d s at t h e age of n i n e m o n t h s . T h a t is to say,
PUBLIC HEALTH, March, 1949
119
of the 585 infants still wholly or partly on the breast at six months, 247 were still having breast-feeds at nine months. Hospital and Home
TABLE I
AGE AT W H I C H BREAST FEEDING CEASED FOR ALL
Confinement
LEGITIMATE INFANTS BY F A M I L Y SIZE
When the whole group of infants is divided into two subgroups, i.e., those born in hospitals (or maternity homes) and those born at home, it is found that babies born in hospital (1,026) had a slight advantage as regards breast-feeding over those born at home (397). It is noteworthy that other investigators have demonstrated the same fact elsewhere. Hughes, s for example, found that 32% of babies delivered at home by midwives were weaned by the end of two weeks as against 20% of those delivered in hospital. One of the findings of the recently published report, " Maternity in Great Britain, ''4 was that there was n o significant difference in the proportions of babies born in hospital and born at home who were bottle-fed at eight weeks. I f anything, the b a l a n c e ~ i n terms of breastfeeding~was slightly in favour of the hospital group. T h e graph illustrates the percentage rate of weaning for the two sub-groups. T h e curves for hospital and home confinement groups do not include illeg;timate babies in whom the reasons for weaning are more often compelling social a n d economic circumstances. If, however, they were included the s t a t e m e n t that hospital-born babies have a small advantage would not be invalidated. T h e percentage of illegitimate infants weaned during the first ten days of life is very much higher than for legitimate babies, though the rate of weaning after ten days is much the same.
Age in months
On/y
4
child (0) Sibship
or more children
2 3 Not children children (3, 4, 5, stated (1) (2) arm 6)
8
360 22.29%
2
122 8.57%
--
1 t7 8.22%
11 6-83%
I
117 8.22%
24 9 4.89?/o 4.04%
10 6.21%
2
74 5.20%
24 4-88%
5 3.11%
2
67 4.70%
--
170 11-94%
16 9-94%
1
155 10.89%
0oX
9 +- months 90 82 43 22 (9) 17.0~:% 16"703o 19-28% 13'66%
3
240 16.86%
toT.
Not stated
i
1
20
1,423
d
Under 1 month (1)
128 24.24%
1-2 months (2)
48 9-12%
45 9.16%
14 6.28%
13 8-07%
2-3 months (3)
46 8.71%
45 9.16%
18 8.07%
8 4'97?/o
3-4 months (4)
37 7-0%
46 9.37%
22 9-87%
4-5 months (5)
29 5.49%
5-6 months (6)
26 4-92%
10 4-48%
6-7 months (7)
57 63 10"79% 12.83%
7-9 months (8)
67 56 15 12.68% 11.41% 6-73%
Total
TaX
106 65 53 21.58% 29.15% 32.92%
All
. ...
528
.
27 23 12.11% 14"29%
. 491
. 223
• 161
/I /
~oX Breast-Feeding
////
sag ¢o'L mY. ao't. tax O
II •
---.
t
1
~rr~
s
#
•
o~tt
4
7
m m ~
t
9
....
ta ~ J ~ s
pxtr.mM~ o ~
NOTES.--(1) There is a high initial incidence of failure to establish breast-feeding, or to maintain breast-feeding for more than ten days. (2) Illegitimate babies are more likely to be weaned in the first t e n days than legitimate babies. (3) After the tenth day the rate of weaning of all babies is about 8% per month up to six months, accelerates to 12% in the seventh month, and finally slows down to 6% per month up to nine months. (4) Babies born in hospitals or maternity homes have a small consistent advantage over those born at home. Breast-Feeding
and Family
Size
It has been suggested from time to time that family size may influence breast-feeding. Thus, it is argued, the first baby is more likely to be breast-fed because the mother has more time to devote to an only child. Conversely, it has also been argued that the mother may be less anxious about breast feeding, and may establish it more easily for the second or later ehildren. T h e Luton survey shows that (for Luton at all events) family size has little influence. Table I shows dearly that the only child does not enjoy a n o t a b l e advantage over later children at any age up to n i n e "months.
and Social Class
Overcrowding in the home and general lack of privacy have been given as possible contributory causes of early weaning. I f this is so, it should be reflected by social class and housing circumstances, though it is possible, of course, that changed circumstances of life affecting all groups of the community in 1945 may mask any differences which existed before the war. T h e number of infants born into families living in unfit houses* numbered only 58. T h e percentage weaned at each month of age compared favourably with those infants in fit houses. Table II (overleaf) gives the percentage of infants weaned at each month of age in two social groups. Discussion
No attempt has been made to determine reasons for failures to establish or maintain breast-feeding. T h a t there is a high proportion of babies weaned for no ascertained reason has been shown by a number of investigators. Robinson ~, in an investigation of 1,100 consecutive cases of premature weaning in the infant welfare centres at Norris Green, found that 40% of the women could give no reason at all. O f the remaining 60%, 23% were attributed to maternal ill-health, 12% to infantile conditions, 8% to environment and 17% to other causes. Social and environmental factors believed to influence breastfeeding adversely have, however, been investigated in the Luton survey, and it is demonstrated clearly that social circumstances have no particular influence. Hughes a has shown over the period 1941--45 that 29% of infants were weaned by the end of two weeks, and 39-5% by the end of the first month. These are rather higher than the Luton figures and confirm that a high proportion of failures occur in the first ten days or so. * According to Housing Act standards.
120
PUBLIC HEAI.TH, March, 1949
As we have pointed out, it has often been stated that breastfeeding is more successful among babies born in hospital, and reasons have been adduced to explain this difference between TABLE II AOE AT WHICH BREAST-FEEDINGCEASEDFOR LEGITIMATE INFANTS BY SOCIAL CLASS~t
Age in months
Under 1 month (1) 1-2 mths. (2) 2-8 mths. (3) 3-4mths. (4) 4-5 mths. (5) 5-6 mths. (6) 6-7mths. (7) 7-9mths. (8) 9 mths. and over (9) Not stated Total
Group (1) Social classes I, I I ~ 111
Group (2) Social classes IV & V
No. 220
% 25
No. 97
% 24
No. 43
No. 360
% 25
70 73 70 46 44 103 106 158
8 8 8 5 5 11 12 18
41 29 40 23 18 57 38 67
10 7 10 6 4 14 9 16
11 15 7 5 5 10 11 15
122 117 117 74 67 170 155 240
9 8 8 5 5 12 11 17
1
1
123
1,423
. 890
.
. 100
. 410
100
Not stated
All classes
-100
* Social class according to Registrar-General's classification. N O T E . - Infants born into Group I have no demonstrable advantage. hospital born babies and babies born at home. It has been said, for instance, that in hospital and maternity homes attention by nursing staff is circumscribed by hospital r o u t i n e - - t h e infant is presented to the mother at fixed intervals and the mother suffers anxiety when the child is taken away between feeds. Hospital wards, it has been said, moreover, have not an atmosphere which encourages breast-feeding. T h e Luton enquiry shows (so far as Luton is concerned) that there is no difference to explain.
Conclusions (1) Breast-feeding is not established at all, or ceases within 10 days, in about 200/9 of all births. (2) T h e rate of weaning thereafter is about 8% per month up to six months, then accelerates to 12% in the seventh month, and finally slows down to 6% per month up to nine months. (3) Family size, social class and standard o f housing do not exert any material influence on breast-feeding. (4) A high proportion of illegitimate babies are weaned during the first ten days, but the rate of weaning after ten days is almost the same as for legitimate babies. (5) Babies born in hospital have a slight advantage over babies born at home. REFERENCES 1 MINISTRY OF HEALTH. Reports on Public Health and Medical Subjects, no. 91. " Illness in Early Childhood in the Borough." Annual Report of the Medical Officer of Health, Borough of Luton. 1948. a HUGHES, ENID L. (1948). Study of Breast-Feeding in a Mining Town. Brit. med. J., 2. • " Maternity in Great Britain." Joint Committee of the Royal College of Obstetricians and Gynaecologists and the Population Investigation Committee. London: Oxford University Press. 1948. 5 ROmNSON, MnaOA~T. (1943). " Failing Lactation." Lancet, 1, 66.
SOME P U B L I C
HEALTH PROBLEMS OF SEASIDE RESORTS
By W. S. PARKER, M.B., CH.B., M.R.C.S., L.R.C.P., D.P.H., D.I.H., Medical Officer of Health, Cromer and Sheringham Urban Districts T h e public health problems of a seaside resort are mainly those caused by seasonal fluctuations of population and the provision of amenities for visitors. T h e health department can do much to maintain the reputation of the town and thus the very essential goodwill of holiday makers. T h e special needs of the resort must be constantly under survey and an effort must be made to combine improvements in hygiene with the necessity of attracting and impressing those who provide the main industry of the town. It is not sufficient to conduct public health administration without any liaison to make necessary tasks appear in the most acceptable form. T h e basic industry of a holiday resort is to achieve the maxim u m income for the year from a season lasting only a few summer months. T h a t income has to be earned by attracting the largest number of visitors and satisfying their demand for accommodation and amusement while maintaining the greatest possible economy. Health points demanding attention are food and drink hygiene, sanitation and the control of infectious disease.
Hotels and Boarding Houses Little is heard of work carried out by public health departments in the improvement of hotel and boarding-house accommodation. In the better class of establishment there is no cause for complaint as these cater for a discriminating clientele. Some of the cheaper accommodation is of a more questionable standard and merely consists of the cramming together of the maximum number of sleeping places often with very little in the way of public rooms. In fine weather, with all the windows open, the situation is not bad but it is a different story in inclement weather when visitors have to remain indoors, with the windows closed, with no drying space and, in the smaller resorts, often with no amusements available under cover elsewhere in the town. A case of diphtheria or similar infectious disease in such a boarding-house can be a minor nightmare to the medical officer of health. Staff accommodation, even in the biggest hotels, is too often of a low standard. Attic bedrooms furnished with an assortment of cast-off furniture and with poor window space cannot be expected to attract the best type of catering staff. Many hotels are nearly 50 years old and not all have been modernised in those parts which do not catch the eye of the visitor. It is interesting to note that passenger ships, which in many ways can be compared to large hotels, have been remodelled since the war almost without exception so as to pro.vide better crew (i.e., staff) accommodation and amenities. Visitors, whose stay is brief, are likely to be out of doors most of the time whereas hotel staffs have hard indoor w9rk f.)r the whole of the summer and this increases with the success of the season. T h e i r task is often forgotten and so is their need for adequate personal accommodation. In this connection an ever-recurring staff problem is that of the catering worker who has suffered from a " weak chest " during the winter and who takes a summer job by the sea in the hope of improvement; after placing his workmates at risk for much longer than necessary, he is there diagnosed as a case of pulmonary tuberculosis by the seaside general practitioner who has learnt to expect such cases. Hygiene of Catering Establishments No general standard of washing-up has yet been specified for catering establishments or for public-houses. A visit to a crowded public-house in the rush hour provides much of interest to the observer. Elementary hygiene demands are the provision of double sinks of adequate size t3 p~rmit c~mplete washing and rinsing, of proper drying facilities and of a sufficient supply of drinking vessels in prop)rtion to the number of customers to be expected. S)me immediate improvement could be made if water were supplied to catering establishments and public-houses at a fixed annual charge and "