- Email: [email protected]
FETAL HICCUPS AND FETAL MOVEMENT
560 MATERNAL SERUM-COPPER CONCENTRATIONS IN PREGNANCIES
BREAST FEEDING AND RICKETS
SIR,-Lakdawala and Widdowson*
WITH
that breast-fed infants do not get rickets. Although most infants in Turkey depend solely on breast feeding, rickets is still common.2-’ What grounds do Lakdawala and Widdowson have for their statement?
ANENCEPHALV AND
CONTROL PREGNANCIES.
state
Institute of Child Health,
Hacettepe University, Ankara, Turkey
SINASI OZSOYLU
Dr Widdowson’s reply follows.-En.L.
SIR,-Our statement that "breast-fed infants do not get rickets", which applies to the U.K., has also been questioned letter from Canada. Breast-fed infants of Italian women living in Toronto have been reported to suffer from rickets (1. Am. med. Ass. 1969, 207, 1269). If the lactating mother’s diet is deficient in vitamin D and she is not exposed to sunlight and has no vitamin-D stores in her liver then her milk may well contain less vitamin D sulphate than the sample we analysed. The effect of the vitamin-D status of the mother on the vitamin D sulphate of her milk has not yet been described. in
a
Department of Medicine, Addenbrooke’s Hospital, Cambridge CB2 2QQ
ELSIE M. WIDDOWSON
ADVERTISING BOTTLE FEEDING ,
I
over the acceptance of the advantages of breastfeeding over artificial bottle feeding, medical journals and other periodicals in India carry a distasteful advertisement for bottle feeding equipment. This piece of advertising will surely win over some people, to the dismay of doctors. I draw this advertisement to your attention so that those who are concerned with the problems of infant and maternal health over the world can be aware of a practice in India which has gone unchecked by any agency (medical, social, or welfare).
are
trying to get
168 South Cross
of which related to cases and which did not. The mean serumcopper concentration in the 9 cases studied was very close to that in the 36 controls (184 and 18$g/dl respectively). These data do not support the suggestion that a relative copper deficiency is a cause of anencephaly. D.H.S.S. Cancer Epidemiology and Clinical Trials Unit, Department of the Regius Professor of Medicine, Radcliffe Infirmary, Oxford OX2 6HE.
Road,
Basavanagudi, Bangalore-560004, India
LAXMIPURAM P. SRIVATSA
Department of Pediatrics, University of Colorado Medical Center, 4200 East Ninth Avenue, Denver, Colorado 80220, U.S.A.
*** Dr SriVatsa enclosed
a copy of an advertisement for ’PoopLatex and Dispersions Ltd) which, below a picture of an Indian woman breast feeding her baby, carried the words: "For a mother to feed her baby like this every four hours just isn’t convenient. Only Poop-Cee comes closest to giving your baby the kind of feeding comfort you can give."En.L
Cee’
(Bombay
MATERNAL SERUM-COPPER CONCENTRATION AND NEURAL-TUBE DEFECTS SIR,-In an analysis of 12 trace elements in drinking water from 48 areas in South Wales, the concentration of copper showed a statistically significant negative association with the incidence of neural-tube defects.l Variation in the concentration of copper in the water accounted for about 16% of the variance in the malformation rate. This result prompted us to measure serum-copper levels in pregnant women who were delivered of anencephalic infants, and compare the results with those from control women who had blood taken at the same 1. 2. 3. 4.
Lakdawala, D. R., Widdowson, E. Lancet, 1977, i, 167. Ozsoylu, S. New Engl. J. Med. 1969, 280, 1221. Ozsoylu, S., Turhan, O. Acta pœdiat. scand. 1971, 60, 338. Hanioglu, N., Ozsoylu, S. Ist. int. Symp. Magnesium Deficit
hum. Path.
1971, p. 227. 1. Morton, M.
30, 36.
S., Elwood, P. C., Abernethy, M. Br. J. prev.
soc.
Med.
1976,
I
gestational age (see accompanying table) and were delivered of unaffected infants. The sera were assayed without knowledge
SiR,-While paediatricians and obstetricians all
world
I
NICHOLAS WALD
MICHAEL HAMBIDGE
FETAL HICCUPS AND FETAL MOVEMENT
,
SIR,-We were interested to read the report by Dr Lewis and Mr Trudinger (Aug. 13, p. 355) on fetal hiccups. Realtime ultrasonic scanning allows movements of the human fetus to be "observed" in utero from a very early age.’ This is an important functional indicator of fetal maturation that until lately had been relatively unexplored. Our research on the development of the human locomotor system2-4 includes the monitoring of fetal movements in utero.5 We have monitored the movements of normal living rabbit fetuses in utero for periods of up to an hour, recorded them on videotape, and analysed spontaneous and evoked movements in the normal fetus at various stages of gestation. We hope to compare these with movements of human and other animal fetuses seen on the real-time scanner. 1. 2. 3. 4. 5.
Reinold, E. J. perinat. Med. 1973, 1, 5. Bagnall, K. M. PH.D. thesis, Loughborough University, 1976. Bagnall, K. M., Harris, P. F., Jones, P. R. M. J. Anat. 1977, 123, 777. Bagnall, K M., Harris, P. F. and Jones, P. R. M. ibid (in the press). Higginbottom, J., Bagnall, K. M., Harris, P. F., Slater, J., Porter, G. Lancet 1976, i, 719.
561
Regular thoracic and abdominal wall movements ("respiration" and "breathing" imply gaseous exchange) occur in the rabbit fetus from an early stage (17 days) as they also occur in man at a similar morphological stage (11 weeks6). These movements are complex and may involve single or rhythmical episodes, deep and shallow excursions, and opening and closing of the mouth, and they may or may not be accompanied by extension of the head and cervical spine. Not infrequently, these events are accompanied by whole-body movement. An ultrasound scan of the chest wall alone can define only one component of this complex of "respiratory" movements. We also have recordings of what we consider to be fetal hiccups,- and they closely resemble fetal "gasping". We cannot say whether hicupping involves the passage of fluid through the mouth and trachea, as would happen if "respiration" was attempted or whether they are indeed true hiccups terminating in laryngeal closure. Liley7 found that fetal hiccups could often be induced in the human by irrigating the amniotic cavity with cold solutions. Windle6 suggested that respiration is the most basic of all the mechanisms necessary for survival and, therefore, that the component movements needed for breathing develop very early in fetal life. He related the first reflexes detectable in human fetuses of 8 weeks’ gestation with the movements utilised in "gasping" and noted that after placental separation gasping is the last reflex to disappear. Our preliminary findings support this. Others have suggested8 that the fetus might "rehearse" before birth those movements which will be vital for its survival after birth. Lendon9 suggests that fetal chest wall movements, especially vigorous gasping and hiccuping, might aid circulation of blood through the placenta. Whatever their function, movements of the fetal chest are certainly varied and complex, and there is much to be learned concerning their functional significance. Dr Lewis and Mr Trudinger and also Liley’ suggest that the mother can be reassured when she feels hiccuping movements. They certainly appear to be within the normal spectrum of fetal movements, but whether or not they are "unrelated to the outcome of pregnancy" remains to be seen. Manchester M13 9PT
P. F. HARRIS K. M. BAGNALI M. MAHON
Department of Physiology, University ofManchester.
E. M. SCOTT
Department of Anatomy, University of Manchester,
ABORTION COUNSELLING
SiR,-After your Note (Aug. 13. p. 366) which outlined the D.H.S.S. circular to area health authorities about wider provision of abortion counselling, some of your readers may care to know that the British Pregnancy Advisory Service has recently made generally available its own highly developed counsellor training courses B.P.A.S. pioneered pregnancy counselling and now has 92 years’ experience of this specialised work, during which it has seen more than 125 000 women worried about an unplanned pregnancy. This experience has reinforced B.P.A.S.’s early strong belief that the first need of an unhappily pregnant woman is for a trained, sympathetic, informed, non-biased, and non-judgmental ear. The D.H.S.S. circular, which echoes much of B.P.A.S.’s philosophy, indicates that-as with family planning-what was initiated and developed on a voluntary basis by concerned private individuals later becomes an accepted part of professional and official thinking. Although the D.H.S.S. is "prepared to consider applications" for funding for training projects for this work, some individuals or non-statutory bodies may like to consider using 6.
Windle, W. F. Physiology of the Fetus. Springfield, 7. Liley, A. W. Aust. N. Z. Jl. Psychiat. 1972, 6, 99. 8. 9.
already established B.P.A.S. training courses setting up their own. Anybody who wants to
the
rather than know more
the Information Officer, British Pregnancy Wootton Wawen, Solihull, West Midlands B95 6DA.
should write
to
Advisory Service, Austy Manor,
DIANE MUNDAY, British
Pregnancy Advisory
Service
Public Relations Officer
CŒLIAC-AXIS COMPRESSION
SIR,-Mr Marston’s acerbic and entertaining letter (July 2,
32) generates more heat than light. His comments on Szilagyi’s paper’ are almost as uncritical as the paper itself was tendentious. Dr Szilagyi was not the foreman of the jury, he was leading counsel for the defence (or prosecution, depending on whose side you are on). If you say that angina (abdominal) is a necessary symptom for clinically significant coeliac-axis compression then it is easy to show that many cases are "atypical". The "typical" pain of coeliac-axis compression is not at all like the abdominal angina of mesenteric ischaemia. It seldom has a clear food relationship and dyspeptic accompaniments. And why should it, unless it were due to ischaemia of the small bowel, an organ supplied by the superior mesenteric artery? Further, if one says that everything that is less than 100% of normal calibre is stenosis or compression, then it is easy to produce an apparently ludicrously high incidence of "narrowing". If one only accepts as possibly significant degrees of compression of 70% or more, the incidence falls radically. The cceliac axis is seldom uniformly cylindrical. Pain has many mechanisms, and pain in the belly is no exception. Perhaps there are pain mechanisms that are still unrecognised. Perhaps pain originating from a compressed coeliac axis has something to do with the compression itself. There are paradoxes in other areas of medicine. Major coronary-artery disease can be present without angina and angina can be pres-
p.
without demonstrable disease of the coronary arteries. Mr Marston himself has written important work on ischxmic colitis and he must know that in a. proportion of cases no fault of the vascular supply to the gut can be demonstrated by standard arteriographic techniques. When Dr Szilagyi presented his paper all three discussants who followed (Dr Fry, Dr Ehrenhaft, and Dr Connolly) disagreed with him. Dr Fry presented evidence for impaired D-xylose absorption in some patients with coeliac-axis compression. We have found impaired pancreatic function.2 Among the hypotheses considered in the aaiology of duodenal ulceration, duodenal ischaemia is suggested as a contributing mechanism. Perhaps that is why some of our patients with coeliac-axis compression give histories of previous duodenal ulceration. Certainly there is considerable variability in the literature because there are no uniform criteria for the clinical picture of this condition. That is not a new problem for medicine and is not a reason to deny the possibilities of such a condition. Entities like gastrin got written off prematurely and took 50 years to re-emerge. There is no other site in the body where we would accept a compressed or stenosed artery as normal. Why this one? Does Mr Marston think that there is no possibility of any syndrome being associated with the coeliac axis? It is fashionable to write off patient testimony as a valid method of assessing clinical outcome. I suppose I see hundreds of patients every year with different varieties of abdominal pain, and presumably my clinical antennae are as sensitive as those of the average physician. If, therefore, when I have made all the standard diagnoses of gallbladder disease and ulcers and pancreatitis and spastic colon syndromes and gas syndromes ent
Illinois. 1971.
Davis, M. E. Potter, E. L. J. Am. med. Ass. 1936, 131, 1194. Lendon, R G. Personal communication.
1.
Szilagyi,
D. E., Riam, R. L.,
Elliot, J. P., Smith,
R. F.
Surgery, 1972, 72,
849. 2. Watson, W.
C., Sadikali, F. Ann. intern. Med. 1977, 86, 278.
BREAST FEEDING AND RICKETS
SIR,-Lakdawala and Widdowson*
WITH
that breast-fed infants do not get rickets. Although most infants in Turkey depend solely on breast feeding, rickets is still common.2-’ What grounds do Lakdawala and Widdowson have for their statement?
ANENCEPHALV AND
CONTROL PREGNANCIES.
state
Institute of Child Health,
Hacettepe University, Ankara, Turkey
SINASI OZSOYLU
Dr Widdowson’s reply follows.-En.L.
SIR,-Our statement that "breast-fed infants do not get rickets", which applies to the U.K., has also been questioned letter from Canada. Breast-fed infants of Italian women living in Toronto have been reported to suffer from rickets (1. Am. med. Ass. 1969, 207, 1269). If the lactating mother’s diet is deficient in vitamin D and she is not exposed to sunlight and has no vitamin-D stores in her liver then her milk may well contain less vitamin D sulphate than the sample we analysed. The effect of the vitamin-D status of the mother on the vitamin D sulphate of her milk has not yet been described. in
a
Department of Medicine, Addenbrooke’s Hospital, Cambridge CB2 2QQ
ELSIE M. WIDDOWSON
ADVERTISING BOTTLE FEEDING ,
I
over the acceptance of the advantages of breastfeeding over artificial bottle feeding, medical journals and other periodicals in India carry a distasteful advertisement for bottle feeding equipment. This piece of advertising will surely win over some people, to the dismay of doctors. I draw this advertisement to your attention so that those who are concerned with the problems of infant and maternal health over the world can be aware of a practice in India which has gone unchecked by any agency (medical, social, or welfare).
are
trying to get
168 South Cross
of which related to cases and which did not. The mean serumcopper concentration in the 9 cases studied was very close to that in the 36 controls (184 and 18$g/dl respectively). These data do not support the suggestion that a relative copper deficiency is a cause of anencephaly. D.H.S.S. Cancer Epidemiology and Clinical Trials Unit, Department of the Regius Professor of Medicine, Radcliffe Infirmary, Oxford OX2 6HE.
Road,
Basavanagudi, Bangalore-560004, India
LAXMIPURAM P. SRIVATSA
Department of Pediatrics, University of Colorado Medical Center, 4200 East Ninth Avenue, Denver, Colorado 80220, U.S.A.
*** Dr SriVatsa enclosed
a copy of an advertisement for ’PoopLatex and Dispersions Ltd) which, below a picture of an Indian woman breast feeding her baby, carried the words: "For a mother to feed her baby like this every four hours just isn’t convenient. Only Poop-Cee comes closest to giving your baby the kind of feeding comfort you can give."En.L
Cee’
(Bombay
MATERNAL SERUM-COPPER CONCENTRATION AND NEURAL-TUBE DEFECTS SIR,-In an analysis of 12 trace elements in drinking water from 48 areas in South Wales, the concentration of copper showed a statistically significant negative association with the incidence of neural-tube defects.l Variation in the concentration of copper in the water accounted for about 16% of the variance in the malformation rate. This result prompted us to measure serum-copper levels in pregnant women who were delivered of anencephalic infants, and compare the results with those from control women who had blood taken at the same 1. 2. 3. 4.
Lakdawala, D. R., Widdowson, E. Lancet, 1977, i, 167. Ozsoylu, S. New Engl. J. Med. 1969, 280, 1221. Ozsoylu, S., Turhan, O. Acta pœdiat. scand. 1971, 60, 338. Hanioglu, N., Ozsoylu, S. Ist. int. Symp. Magnesium Deficit
hum. Path.
1971, p. 227. 1. Morton, M.
30, 36.
S., Elwood, P. C., Abernethy, M. Br. J. prev.
soc.
Med.
1976,
I
gestational age (see accompanying table) and were delivered of unaffected infants. The sera were assayed without knowledge
SiR,-While paediatricians and obstetricians all
world
I
NICHOLAS WALD
MICHAEL HAMBIDGE
FETAL HICCUPS AND FETAL MOVEMENT
,
SIR,-We were interested to read the report by Dr Lewis and Mr Trudinger (Aug. 13, p. 355) on fetal hiccups. Realtime ultrasonic scanning allows movements of the human fetus to be "observed" in utero from a very early age.’ This is an important functional indicator of fetal maturation that until lately had been relatively unexplored. Our research on the development of the human locomotor system2-4 includes the monitoring of fetal movements in utero.5 We have monitored the movements of normal living rabbit fetuses in utero for periods of up to an hour, recorded them on videotape, and analysed spontaneous and evoked movements in the normal fetus at various stages of gestation. We hope to compare these with movements of human and other animal fetuses seen on the real-time scanner. 1. 2. 3. 4. 5.
Reinold, E. J. perinat. Med. 1973, 1, 5. Bagnall, K. M. PH.D. thesis, Loughborough University, 1976. Bagnall, K. M., Harris, P. F., Jones, P. R. M. J. Anat. 1977, 123, 777. Bagnall, K M., Harris, P. F. and Jones, P. R. M. ibid (in the press). Higginbottom, J., Bagnall, K. M., Harris, P. F., Slater, J., Porter, G. Lancet 1976, i, 719.
561
Regular thoracic and abdominal wall movements ("respiration" and "breathing" imply gaseous exchange) occur in the rabbit fetus from an early stage (17 days) as they also occur in man at a similar morphological stage (11 weeks6). These movements are complex and may involve single or rhythmical episodes, deep and shallow excursions, and opening and closing of the mouth, and they may or may not be accompanied by extension of the head and cervical spine. Not infrequently, these events are accompanied by whole-body movement. An ultrasound scan of the chest wall alone can define only one component of this complex of "respiratory" movements. We also have recordings of what we consider to be fetal hiccups,- and they closely resemble fetal "gasping". We cannot say whether hicupping involves the passage of fluid through the mouth and trachea, as would happen if "respiration" was attempted or whether they are indeed true hiccups terminating in laryngeal closure. Liley7 found that fetal hiccups could often be induced in the human by irrigating the amniotic cavity with cold solutions. Windle6 suggested that respiration is the most basic of all the mechanisms necessary for survival and, therefore, that the component movements needed for breathing develop very early in fetal life. He related the first reflexes detectable in human fetuses of 8 weeks’ gestation with the movements utilised in "gasping" and noted that after placental separation gasping is the last reflex to disappear. Our preliminary findings support this. Others have suggested8 that the fetus might "rehearse" before birth those movements which will be vital for its survival after birth. Lendon9 suggests that fetal chest wall movements, especially vigorous gasping and hiccuping, might aid circulation of blood through the placenta. Whatever their function, movements of the fetal chest are certainly varied and complex, and there is much to be learned concerning their functional significance. Dr Lewis and Mr Trudinger and also Liley’ suggest that the mother can be reassured when she feels hiccuping movements. They certainly appear to be within the normal spectrum of fetal movements, but whether or not they are "unrelated to the outcome of pregnancy" remains to be seen. Manchester M13 9PT
P. F. HARRIS K. M. BAGNALI M. MAHON
Department of Physiology, University ofManchester.
E. M. SCOTT
Department of Anatomy, University of Manchester,
ABORTION COUNSELLING
SiR,-After your Note (Aug. 13. p. 366) which outlined the D.H.S.S. circular to area health authorities about wider provision of abortion counselling, some of your readers may care to know that the British Pregnancy Advisory Service has recently made generally available its own highly developed counsellor training courses B.P.A.S. pioneered pregnancy counselling and now has 92 years’ experience of this specialised work, during which it has seen more than 125 000 women worried about an unplanned pregnancy. This experience has reinforced B.P.A.S.’s early strong belief that the first need of an unhappily pregnant woman is for a trained, sympathetic, informed, non-biased, and non-judgmental ear. The D.H.S.S. circular, which echoes much of B.P.A.S.’s philosophy, indicates that-as with family planning-what was initiated and developed on a voluntary basis by concerned private individuals later becomes an accepted part of professional and official thinking. Although the D.H.S.S. is "prepared to consider applications" for funding for training projects for this work, some individuals or non-statutory bodies may like to consider using 6.
Windle, W. F. Physiology of the Fetus. Springfield, 7. Liley, A. W. Aust. N. Z. Jl. Psychiat. 1972, 6, 99. 8. 9.
already established B.P.A.S. training courses setting up their own. Anybody who wants to
the
rather than know more
the Information Officer, British Pregnancy Wootton Wawen, Solihull, West Midlands B95 6DA.
should write
to
Advisory Service, Austy Manor,
DIANE MUNDAY, British
Pregnancy Advisory
Service
Public Relations Officer
CŒLIAC-AXIS COMPRESSION
SIR,-Mr Marston’s acerbic and entertaining letter (July 2,
32) generates more heat than light. His comments on Szilagyi’s paper’ are almost as uncritical as the paper itself was tendentious. Dr Szilagyi was not the foreman of the jury, he was leading counsel for the defence (or prosecution, depending on whose side you are on). If you say that angina (abdominal) is a necessary symptom for clinically significant coeliac-axis compression then it is easy to show that many cases are "atypical". The "typical" pain of coeliac-axis compression is not at all like the abdominal angina of mesenteric ischaemia. It seldom has a clear food relationship and dyspeptic accompaniments. And why should it, unless it were due to ischaemia of the small bowel, an organ supplied by the superior mesenteric artery? Further, if one says that everything that is less than 100% of normal calibre is stenosis or compression, then it is easy to produce an apparently ludicrously high incidence of "narrowing". If one only accepts as possibly significant degrees of compression of 70% or more, the incidence falls radically. The cceliac axis is seldom uniformly cylindrical. Pain has many mechanisms, and pain in the belly is no exception. Perhaps there are pain mechanisms that are still unrecognised. Perhaps pain originating from a compressed coeliac axis has something to do with the compression itself. There are paradoxes in other areas of medicine. Major coronary-artery disease can be present without angina and angina can be pres-
p.
without demonstrable disease of the coronary arteries. Mr Marston himself has written important work on ischxmic colitis and he must know that in a. proportion of cases no fault of the vascular supply to the gut can be demonstrated by standard arteriographic techniques. When Dr Szilagyi presented his paper all three discussants who followed (Dr Fry, Dr Ehrenhaft, and Dr Connolly) disagreed with him. Dr Fry presented evidence for impaired D-xylose absorption in some patients with coeliac-axis compression. We have found impaired pancreatic function.2 Among the hypotheses considered in the aaiology of duodenal ulceration, duodenal ischaemia is suggested as a contributing mechanism. Perhaps that is why some of our patients with coeliac-axis compression give histories of previous duodenal ulceration. Certainly there is considerable variability in the literature because there are no uniform criteria for the clinical picture of this condition. That is not a new problem for medicine and is not a reason to deny the possibilities of such a condition. Entities like gastrin got written off prematurely and took 50 years to re-emerge. There is no other site in the body where we would accept a compressed or stenosed artery as normal. Why this one? Does Mr Marston think that there is no possibility of any syndrome being associated with the coeliac axis? It is fashionable to write off patient testimony as a valid method of assessing clinical outcome. I suppose I see hundreds of patients every year with different varieties of abdominal pain, and presumably my clinical antennae are as sensitive as those of the average physician. If, therefore, when I have made all the standard diagnoses of gallbladder disease and ulcers and pancreatitis and spastic colon syndromes and gas syndromes ent
Illinois. 1971.
Davis, M. E. Potter, E. L. J. Am. med. Ass. 1936, 131, 1194. Lendon, R G. Personal communication.
1.
Szilagyi,
D. E., Riam, R. L.,
Elliot, J. P., Smith,
R. F.
Surgery, 1972, 72,
849. 2. Watson, W.
C., Sadikali, F. Ann. intern. Med. 1977, 86, 278.