HOSPITAL MILK KITCHEN

1049 21. Lischner, H.

W., Dacou, C., DiGeorge, A. M. Transplantation, 1967, 5, 555. 22. Miller, J. F. A. P., Dukor, P., Grant, G., Sinclair, N. R. St. C., Sacquet, E. Clin. exp. Immun. 1967, 2, 531. 23. Good, R. A., Gatti, R. A., Meuwissen, H. J., Stutman, O. Lancet, 1969, i, 947. 24. Rossle, R. Arch. path. Anat. 1932, 283, 41. 25. Gilmour, J. R. J. Path. Bact. 1941, 52, 213. 26. Cameron, A. H. Archs Dis. Childh. 1965, 40, 334. 27. Kalter, H., Warkany, J. Am. J. Path. 1961, 38, 1. 28. Parrot, D. M. V., DeSousa, M. A. B. J. exp. Med. 1966, 123, 191. 29. Dodson, W. E., Alexander, D., Al-Aish, M., de la Cruz, F. Lancet, 1969, i, 574. 30. Zinzar, S. N., Svet-Moldavsky, G. J. Nature, Lond. 1967, 214, 295. 31. Taylor, R. B., Wortis, H. H. ibid. 1968, 220, 927. 32. Sinclair, N. R. St. C., Elliott, E. V. Immunology, 1968, 15, 325. 33. Pinnas, J. L., Fitch, F. W. Int. Archs Allergy, 1966, 30, 217. 34. Fahey, J. L., Barth, W. F., Law, L. L. J. natn Cancer Inst. 1965, 35, 663. 35. Bealmear, P. M., Wilson, R. Cancer Res. 1967, 27, 358. 36. Siskind, G. W., Paterson, P. Y., Thomas, L. J. Immun. 1963, 90, 929. 37. Hess, M. W., Stoner, R. D. Int. Archs Allergy, 1966, 30, 37. 38. Rowley, D. A., Fitch, F. W. J. exp. Med. 1965, 121, 671. 39. Hege, J. S., Cole, L. J. J. Immun. 1967, 99, 61. 40. Laskov, R. Nature, Lond. 1968, 219, 973. 41. Many, A., Schwartz, R. S. Clin. Res. 1969, 27, 356. 42. Gershon, R. K. Fedn Proc. 1969, 28, 376.

13/4 walls and underbench cupboards along 1 wall (figs. 1 and 2). The major items of equipment are:

HOSPITAL MILK KITCHEN H. R. GAMSU

C. G. TAYLOR

Departments of Child Health and Medical Microbiology, King’s College Hospital, London S.E.5 PREPARATION of infant feeds in the hospital milk kitchen usually calls for equipment and techniques for bottle cleaning, sterilisation, and terminal sterilisation of the individual prepared feeds. This is expensive in terms of space, staff, and capital and running costs. We have designed a milk kitchen to serve a new maternity unit of 77 beds and a special baby-care unit of 20 incubators and cots. By using a sterile disposable plastic bottle incorporating a plastic teat, bottle and terminal sterilisation are no longer required, thus saving space, and reducing capital expenditure and the numbers of staff employed. DESIGN AND EQUIPMENT The milk kitchen is 121 sq. ft. in area and has

Fig.

1—General view of the milk kitchen work filling a disposable bottle.

She is sitting of prepared

showing

the mixer. To her right is feeds and the water heater. at

a

56. ibid p. 1226. 57. Dempster, W. J. ibid. 1969, i, 468. 58. Hand, T., Ceglowski, W. S., Damrongsak, D., Friedman, H. J. reticuloendoth. Soc. 1968, 5, 563. 59. Kirkpatrick, J. A., Jr., DiGeorge, A. M. Am. J. Roent, 1968, 103, 32.

top along

Methods and Devices

H. M. CAWDERY

Horiuchi, A., Gery, I., Waksman, B. H. Yale J. Biol. Med. 1968, 41, 13. 44. Law, L. W. ibid. 1966, 210, 1118. 45. Miller, J. F. A. P., Mitchell, G. F., Weiss, N. S. ibid. 1967, 214, 992. 46. Stutman, O., Good, R. A., Yunis, E. J. Fedn. Proc. 1969, 28, 376. 47. Silverstein, A. M., Parshall, C. J., Jr., Prendergast, R. A. ibid. 1969, 27, 686. 48. DeSousa, M. A. B., Parrott, D. M., Pantelouris, E. M. Clin. exp. Immun. 1969, 4, 637. 49. Tyan, M. L., Herzenberg, L. A. Proc. Soc. exp. Biol. Med. 1968, 128, 952. 50. Stutman, O., Yunis, E. J., Good, R. A. Transplantation Proc. 1969, 1, 614. 51. Miller, J. F. A. P., Block, M., Rowlands, D. T., Jr., Kind, P. Proc. Soc. exp. Biol. Med. 1965, 118, 916. 52. Osoba, D. ibid. 1968, 127, 418. 53. Wolf, B., Erb, S. in Proceedings of Fourth Leukocyte Culture Conference (edited by O. R. McIntyre) (in the press). 54. Nossal, G. J. V. Am. Rev. Med. 1967, 18, 81. 55. August, C. S., Rosen, F. S., Filler, R. M., Janeway, C. A., E. M. Markowski, B., Kay, H. Lancet, 1968, ii, 1210. 43.

a

(1) The stainless-steel water boiler (Hodgkison water boiler; A. Browne & Son, London N.W.10). Boiling water is dispensed from this via a swivelling pipe into the mixing bowl. (2) A milk food mixer (Cow & Gate, Guildford, Surrey) designed to mix milk powder and water in a stainless-steel bowl. Volumes of 14 pints (7-95 litres) and 12 pints (6-82 litres) are indicated by marks on the inner surface of the bowl. A stainlesssteel lid covers the bowl. Mixing is achieved by a stainless-steel agitator driven by the motor above, and the mixture is dispensed via a filler valve at the base of the bowl. (3) Refrigerator for milk storage. (4) Hand-washing basin. (5) Sink. (6) Double hot plate for boiling expressed breast-milk. (7) Under-bench cupboards and space for storage of milk powder, cleaning equipment, and cartons of disposable bottles. (8) Noticeboard for instructions and daily orders. (9) Sterile disposable bottles with integral plastic teat (’ Axifeed’ bottle; Smith & Nephew-Southall’s, Welwyn Garden City, Hertfordshire). The teat and its removable plastic cap are unscrewed when the bottle is filled and then replaced. The cap is removed at the beginning of the feed to expose the teat.

working-

the

nurse at

partially filled rack

Fig. 2-Floor plan and general lay-out of milk kitchen. For identification of the numbered items see Design and

Equipment.

1050 METHOD

Each morning the nurse turns on the water heater, washes her hands, and, wearing a gown, mask, and sterile gloves, attaches the previously autoclaved bowl and agitator to the mixer. 2 lb. (908 g.) of half-cream milk powder are emptied into the mixing bowl and then boiling water is added to the 14 pint (7-95 litre) mark. Mixing takes 15-20 minutes, when the temperature of the milk will have fallen to below 60°C, and the bottles can then be filled without the distortion of the plastic which occurs at higher temperatures. Milk is dispensed in 2 fl. oz. (60 ml.) and 4 fl. oz. (120 ml.) amounts. Approximately three hundred feeds are prepared daily, which requires the mixing and filling process to be done three times. The filled bottles are packed into racks of thirty-six and transferred to the ward refrigerators. Immediately before use they are briefly rewarmed in warm tap water, dried, the cap removed and the baby fed. The mixing bowl, agitator, and filler valve are dismantled and cleaned thoroughly in hot water and alkaline detergent. The filler valve is reassembled and the whole apparatus wrapped in two layers of linen and sent to the central sterile-supply department to be autoclaved. Three separate sets of bowls and agitators are needed so that a sterile set is always available. A part-time State-enrolled nurse, who is supervised by the midwifery superintendent, is employed on weekdays, and at weekends the ward personnel make the feeds. The daily process of making up the feeds takes a total of 31/2 hours. As a result of repeated bacterial cultures of the mixing bowl, the water boiler and the milk, the following precautions were found necessary: (1) the bowl, its lid, and the agitator should be autoclaved before use; (2) the water in the boiler should be boiling; (3) for assembly of the autoclaved parts, the nurse should wear a gown, cap, mask, and sterile gloves; (4) immediately after filling, the racks should be placed in the milk kitchen refrigerator and, when transferred to the wards, be kept there refrigerated until used; and (5) those feeds not used within 24 hours should be discarded. Many samples of freshly made milk and milk which had been refrigerated for 24 hours were cultured and, except for a single instance when one colony of a coagulase-negative staphylococcus was grown, all samples were free from vegetative bacteria, being either sterile or containing a few aerobic spore-bearers, never more than 10 per ml. The cost works out at iust under 8d. per feed as follows:

The most expensive item is the disposable bottle, but its has allowed economies in space and personnel since we no longer require bottle-cleaning equipment and terminal sterilisation. The cost of replacement of broken bottles and perished teats is also avoided. Though in general satisfactory, we and others1 have found that the smallest premature infants do not find the teat sufficiently resilient and may find sucking difficult. Most infants, however, experience no difficulty at all. Though there are other satisfactory methods of hospital infant-feed preparation, we have found the system that we have evolved and used for the past 15 months to be safe, simple, and economically use

practicable. We thank Prof. C. E. Stroud for his help and encouragement and Prof. A. Cunliffe for his assistance. Requests for reprints should be addressed to H. R. G., Department of Child Health, King’s College Hospital Medical School, London S.E.5. REFERENCE 1.

Michelson,

A. Nurs.

Times, Nov. 4,

1966.

Reviews of Books Physiology of the Human Kidney LAURENCE G. WESSON, M.D., head of division of nephrology, professor of medicine, Jefferson Medical College, Philadelphia, Pennsylvania, U.S.A. New York: Grune & Stratton. London: William Heinemann Medical Books. 1969. Pp. 712.$34; E15 16s.

THE author modestly states that his aim is to provide a reasonable body of reference material for the more advanced student. The book is dedicated to Homer Smith and is virtually a second edition of The Kidney. About 6500 references up to and including the year 1967 are interpolated and interpreted in the text. However, many of the current topics of renal physiology are only briefly considered. An excellent chapter on sodium clarifies the various concepts of glomerular tubular balance; yet, perhaps wisely, the postulate of a natriuretic factor is largely ignored. There is a concise summary of the factors involved in the transport and clearance of aromatic acids, but this is not enlivened by a consideration of the advantages and disadvantages of the use of radioactively labelled substitutes for the measurement of glomerular filtration-rate and renal plasma-flow. The various ideas concerning the method whereby the urine is concentrated are presented but there is no clear description and no critical account of the counter-current multiplier system. The catalogue of information about the enzyme constitution of the cells of the kidney and the description of the handling of various ions by the kidney are valuable sources of reference. A chapter on the renin-angiotensin system, contributed by Prof. P. J. Mulrow and Prof. J. A. Goffinet, which provides an introduction to a subject in which rapid advances are being made, and a chapter on the erythropoietic role of the kidney by Prof. A. J. Erslev encompass the non-excretory functions of the kidney. The photographs and line drawings are of the highest quality and beautifully illustrate the points made in the text. Industrial

Organizations and Health

Vol. I: Selected Readings. Edited by FRANK BAKER, PETER J. M. McEwAN, and ALAN SHELDON. London: Tavistock Publications. New York :Barnet and Noble. 1969. Pp.699. 90s.

collection of original papers mainly published in and psychological journals during the past ten years. The general theme is the interaction between the social environment of an organisation and the health behaviour of the individual within it. There are five sections, each introduced by editorial comment. The first consists of articles describing a variety of models of organisation! employee relationship; in the second the focus is on types of health behaviour in industrial situations; the third section deals with specific problems, such as frustration in industry, demotion, and the mental-health implications of ageing; attitudes and morale are dealt with in the fourth; and the final section describes methods of changingand modifying the environment of the organisation. The emphasis throughout is on the importance of assessing the total situation in relation to individual health and on the great contribution that is made by the interdisciplinary approach. The articles on mental health, absenteeism in industry, and industriahccidents are all of interest, especially to the industrial physician, and there is a revealing article by Bernard Goldstein, Lawrence G. Northwood, and Rhoda L. Goldstein on the scale and practice of industrial health in the United States. Unless the reader is familiar with the vocabulary and modes of expression of the sociologist and psychologist he will find this a difficult book to read and the style unduly verbose. Nevertheless many of the articles have a viewpoint which is new and challenging. THIS is

a

sociological