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DRIED-MILK INFANT FEEDS
421
argued that some mothers presenting this type of feeding problem lack the necessary motivation to carry on breast-feeding. For these the advice to give complementary foods which seem to hasten the termination of breast-feeding might be what they really wish. On the other hand, there must be many mothers who are eager to carry on breast-feeding but who are depressed, and have their confidence lowered, by a continually fretful baby. For these, consistent and sympathetic management is essential if breast-feeding is to continue. Most important is the understanding of an essential principle of breast-feeding physiology-namely, that the stimulus of milk demand by the baby through suckling creates the response of milk production by the mother. If breast-feeding is to be successful, this law of supply and demand must be met. Breast-fed infants who cry excessively are most likely hungry, and since hunger is an important stimulus for milk production through increased suckling, it seems logical initially to encourage mothers who think they have insufficient milk to feed their babies more often. Milk production has been shown to increase with greater frequency of breast-feeding.13 Unfortunately, we found that all too often the first advice is to complement breast-feeding with milk formula or solid foods. In some instances this helps, but usually these dietary changes can only hinder the normal course of lactation by filling the baby to the point that its demand for milk is decreased. Milk tension in the It
can
be
breast will rise, afferent stimulation will be less, and milk production will diminish. With the baby continuing to express displeasure by crying, a vicious circle develops which will lead the mother understandably, and in desperation, to stop breast-
feeding. The widespread practice of indiscriminately introducing complementary feeds to breast-fed babies in the first few months should be discouraged. However, this will only happen if nurses and doctors acquire a better working knowledge of the natural laws governing lactation. If these are intelligently and sympathetically applied this might help to halt the rapid decline of breast-feeding in the early months after birth. Department of Child Health, Welsh National School of Medicine, University Hospital of Wales,
D. P. DAVIES
Cardiff CF4 4XW. South Glamorgan Area Health Authority.
C. THOMAS
DRIED-MILK INFANT FEEDS
SIR,-Because of the recent publicity concerning unmodified dried-milk infant feeds, we would like to present preliminary findings of a survey of the sodium content and volume
SODIUM CONTENT
(MEAN
±
S.D.) AND ESTIMATED
INFANTS AGE
5-7
SODIUM LOAD IN
,
Bna)y5ts of
72
WEEKS
I
showed that the difference in calculated sodium load ’t,t4een the unmodified dned-milk powders, the other dried-rmlk powders, and tc reaJy-to-feed formulas was highly significant: F 33-6, P<0.0001. vanance
of feeds given to an infant population. We have studied infants born in Farnborough Hospital, whose mothers live in the London Borough of Bromley. Samples of a feed were obtained 13 Egli, G E ,
Egli,
N. S.,
Newton, M. Pediatrics, 1961, 27, 314.
when the infants were aged 5-7 weeks and at the same time the mothers were asked what volume of feed they gave to the infant. The sodium content was analysed by ashing and spectrophotometry. The accompanying table shows that unmodified milk powders have a higher sodium concentration and that they tend to be given in greater volume. Thus the calculated sodium load from the unmodified milk feeds was at least 40% greater than that from the remaining feeds. If a high sodium load is harmful to infants, our data support the view that these feeds are unsuitable for use in infants.Department of Pædiatrics, Queen Charlotte’s Maternity Hospital,
L. V. COOPER
London W6 0XG. Cardiothoracic Institute,
M.
Brompton Hospital,
DE
SWIET
M.R.C. Tuberculosis and Chest Diseases Unit,
Brompton Hospital,
P. FAYERS
London SW3 6HP.
INTENSIVE ANTENATAL PLASMAPHERESIS IN SEVERE RHESUS ISOIMMUNISATION
SiR,—The paper by Dr Fraser and his colleagues (Jan. 3,
6) is interesting but unconvincing. In 1967 we carried out 36 double plasmaphereses of a highly isoimmunised Rh-negative woman with a previous history of stillbirth.’ 46 1 of plasma, 10 1 more than the maximum removed by Fraser et al., was removed in the 10-week period between 15 and 2weeks’ gestation. Her albumin/Rh antibody titre (more specific quantitative methods were not available to us at that time) of 1/256 remained unchanged throughout the plasmapheresis period. Amniotic-fluid optical-density measurements begun at 20t weeks indicated impending hyd2 rops by 24zweeks’ gestation. Three fetal transfusions were carried out between 24 weeks 6 days and 29 weeks 5 days. Gross ascites, indicating early fetal hydrops, was noted at the
p.
time of the second intrauterine transfusion (i.u.T.) at 26 weeks 2 days. The ascites was no longer noted at the time of the third I. U. T. Reversal of the hydrops may have been effected by instillation of digoxin intraperitoneally at the second l.U.T. and administration of digoxin and a diuretic to the mother. The infant, born at 34 weeks, was severely affected but no longer hydropic. His cord-haemoglobin was 9.4g/dl, of which 7.2g was donor in origin. He required three exchange-transfusions and is an intact survivor. We believed that plasmapheresis had little if anything to do with the happy outcome and abandoned this very time-consuming procedure. Dr Fraser and his colleagues suggest that plasmapheresis made a major contribution to their improved survival-rate following I.U.T. in severe hmmolytic .disease (33% with I.U.T. alone, 61% with both plasmapheresis and l.U.T.). Could other factors such as improved skill and experience with the procedure and earlier institution of i.u.T. have been more important? Our improvement in survival-rates with LU.T. witnout plasmapheresis, which we attribute to the latter factors, parallels that of Fraser and his associates: 30% survival in the two-year period 1964-65 (12 of 40 fetuses transfused), 60% survival in the four-year period 1966-69 (62 of 104 fetuses transfused), and 70% survival in the six-year period 1970-75 (69 of 99 fetuses transfused). The survival figures given for plasmapheresis alone are also not convincing. As the authors point out, plasmapheresis started before 16 weeks or between 17 and 27 weeks without accompanying l.U.T. yields very poor survival-rates-20% and 29% respectively. Although plasmapheresis begun at 28-34 weeks is said to be very successful (29 surviving out of 40 [73%]), our own figures for i.u.T. without plasmapheresis in 1.
Bowman, J. M., Peddle, L. J., Anderson, C. Vox
sang.
1968, 15, 272.
argued that some mothers presenting this type of feeding problem lack the necessary motivation to carry on breast-feeding. For these the advice to give complementary foods which seem to hasten the termination of breast-feeding might be what they really wish. On the other hand, there must be many mothers who are eager to carry on breast-feeding but who are depressed, and have their confidence lowered, by a continually fretful baby. For these, consistent and sympathetic management is essential if breast-feeding is to continue. Most important is the understanding of an essential principle of breast-feeding physiology-namely, that the stimulus of milk demand by the baby through suckling creates the response of milk production by the mother. If breast-feeding is to be successful, this law of supply and demand must be met. Breast-fed infants who cry excessively are most likely hungry, and since hunger is an important stimulus for milk production through increased suckling, it seems logical initially to encourage mothers who think they have insufficient milk to feed their babies more often. Milk production has been shown to increase with greater frequency of breast-feeding.13 Unfortunately, we found that all too often the first advice is to complement breast-feeding with milk formula or solid foods. In some instances this helps, but usually these dietary changes can only hinder the normal course of lactation by filling the baby to the point that its demand for milk is decreased. Milk tension in the It
can
be
breast will rise, afferent stimulation will be less, and milk production will diminish. With the baby continuing to express displeasure by crying, a vicious circle develops which will lead the mother understandably, and in desperation, to stop breast-
feeding. The widespread practice of indiscriminately introducing complementary feeds to breast-fed babies in the first few months should be discouraged. However, this will only happen if nurses and doctors acquire a better working knowledge of the natural laws governing lactation. If these are intelligently and sympathetically applied this might help to halt the rapid decline of breast-feeding in the early months after birth. Department of Child Health, Welsh National School of Medicine, University Hospital of Wales,
D. P. DAVIES
Cardiff CF4 4XW. South Glamorgan Area Health Authority.
C. THOMAS
DRIED-MILK INFANT FEEDS
SIR,-Because of the recent publicity concerning unmodified dried-milk infant feeds, we would like to present preliminary findings of a survey of the sodium content and volume
SODIUM CONTENT
(MEAN
±
S.D.) AND ESTIMATED
INFANTS AGE
5-7
SODIUM LOAD IN
,
Bna)y5ts of
72
WEEKS
I
showed that the difference in calculated sodium load ’t,t4een the unmodified dned-milk powders, the other dried-rmlk powders, and tc reaJy-to-feed formulas was highly significant: F 33-6, P<0.0001. vanance
of feeds given to an infant population. We have studied infants born in Farnborough Hospital, whose mothers live in the London Borough of Bromley. Samples of a feed were obtained 13 Egli, G E ,
Egli,
N. S.,
Newton, M. Pediatrics, 1961, 27, 314.
when the infants were aged 5-7 weeks and at the same time the mothers were asked what volume of feed they gave to the infant. The sodium content was analysed by ashing and spectrophotometry. The accompanying table shows that unmodified milk powders have a higher sodium concentration and that they tend to be given in greater volume. Thus the calculated sodium load from the unmodified milk feeds was at least 40% greater than that from the remaining feeds. If a high sodium load is harmful to infants, our data support the view that these feeds are unsuitable for use in infants.Department of Pædiatrics, Queen Charlotte’s Maternity Hospital,
L. V. COOPER
London W6 0XG. Cardiothoracic Institute,
M.
Brompton Hospital,
DE
SWIET
M.R.C. Tuberculosis and Chest Diseases Unit,
Brompton Hospital,
P. FAYERS
London SW3 6HP.
INTENSIVE ANTENATAL PLASMAPHERESIS IN SEVERE RHESUS ISOIMMUNISATION
SiR,—The paper by Dr Fraser and his colleagues (Jan. 3,
6) is interesting but unconvincing. In 1967 we carried out 36 double plasmaphereses of a highly isoimmunised Rh-negative woman with a previous history of stillbirth.’ 46 1 of plasma, 10 1 more than the maximum removed by Fraser et al., was removed in the 10-week period between 15 and 2weeks’ gestation. Her albumin/Rh antibody titre (more specific quantitative methods were not available to us at that time) of 1/256 remained unchanged throughout the plasmapheresis period. Amniotic-fluid optical-density measurements begun at 20t weeks indicated impending hyd2 rops by 24zweeks’ gestation. Three fetal transfusions were carried out between 24 weeks 6 days and 29 weeks 5 days. Gross ascites, indicating early fetal hydrops, was noted at the
p.
time of the second intrauterine transfusion (i.u.T.) at 26 weeks 2 days. The ascites was no longer noted at the time of the third I. U. T. Reversal of the hydrops may have been effected by instillation of digoxin intraperitoneally at the second l.U.T. and administration of digoxin and a diuretic to the mother. The infant, born at 34 weeks, was severely affected but no longer hydropic. His cord-haemoglobin was 9.4g/dl, of which 7.2g was donor in origin. He required three exchange-transfusions and is an intact survivor. We believed that plasmapheresis had little if anything to do with the happy outcome and abandoned this very time-consuming procedure. Dr Fraser and his colleagues suggest that plasmapheresis made a major contribution to their improved survival-rate following I.U.T. in severe hmmolytic .disease (33% with I.U.T. alone, 61% with both plasmapheresis and l.U.T.). Could other factors such as improved skill and experience with the procedure and earlier institution of i.u.T. have been more important? Our improvement in survival-rates with LU.T. witnout plasmapheresis, which we attribute to the latter factors, parallels that of Fraser and his associates: 30% survival in the two-year period 1964-65 (12 of 40 fetuses transfused), 60% survival in the four-year period 1966-69 (62 of 104 fetuses transfused), and 70% survival in the six-year period 1970-75 (69 of 99 fetuses transfused). The survival figures given for plasmapheresis alone are also not convincing. As the authors point out, plasmapheresis started before 16 weeks or between 17 and 27 weeks without accompanying l.U.T. yields very poor survival-rates-20% and 29% respectively. Although plasmapheresis begun at 28-34 weeks is said to be very successful (29 surviving out of 40 [73%]), our own figures for i.u.T. without plasmapheresis in 1.
Bowman, J. M., Peddle, L. J., Anderson, C. Vox
sang.
1968, 15, 272.