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Infant feeding and its relation to the health of the school child
3o6
PUBLIC HEALTH.
AucuST,
I n f a n t F e e d i n g and its R e l a t i o n t o t h e H e a l t h o f t h e S c h o o l Child. By J. GREENWOOD WILSON, M.D., M.R.C.P., D.P.H., Medical Officer of Health, Dewsbury. This investigation, although it relates to a limited area and a comparatively small number of cases, elicited a considerable amount of useful information and permitted Dr. Greenwood Wilson to draw conclusions that will be found interesting to consider. The paper was read at a meeting of the Yorkshire Sub-Group of the Maternity and Child Welfare Group at York on May 20th, 1933. HIS investigation was undertaken, while I T was working in an industrial area of SouthEast Lancashire, in an attempt to show :-(1) The proportion of infants in the area who were breast fed during the years 1929 and 1930. (2) Whether the proportion was less in those years than formerly. (3) The causes of early weaning and to what extent they are preventable. (4) To what extent the health of the school child is influenced by the method of feeding (artificial or breast) in infancy. The figures for parts (1) and (3) of the investigation were obtained from the case record cards of the infants who attended two child welfare centres in South-East Lancashire during the years 1929 and 1930. Notes were taken only from those cards which had a reasonably complete record of the infant's progress from birth to the time of weaning. T h e total number of cards from which notes were taken was 407 ; 210 males and 197 females. Results are shown in Table I. The figures for parts (2), (3) and (4) were taken from notes of statements by mothers of children brought to the minor ailments clinic, or marked down for treatment at visits to schools within the period September, 1930, to February, 1931, inclusive. The mother of each child was asked what illnesses the child had had, at what age in infancy it was weaned, and the reason for doing so (if the weaning was early). When she had made her statement her memory was assisted by leading questions. Next, a full examination was made of each child, and a record made of its general condition together with any local defect found. On going through the records afterwards it was found that the data so obtained could be grouped under the following heads, which are set out in Table VI :--(a) General condition good ; (b) general condition fair ; (c) condition delicate ; (d) diseased tonsils and adenoids; (e) rachitic deformities; (f) organic heart disease. The
group " delicate " follows the definition of the Board of Education, and inchtdes pre- or latent tuberculosis, malnutrition, debility, anaemia, etc. The group " fair " includes all border-line cases whose general condition was far from " good," yet they were not bad enough to label " delicate." They were in a state of sub- rather than mal-nutrition. Altogether 315 school children between the ages of five and fourteen (inclusive) were examined, and their histories recorded in respect of infant feeding, age of weaning, cause of early weaning, and past illnesses. There were 167 boys and 148 girls, and slightly more than half of the total (165) were between the ages of eight and fourteen years. The figures obtained from the histories of these children with regard to ages of weaning, and causes thereof, may be compared with those obtained from the welfare centre cards. PART I . - - T h e proportion of infants in the area breast fed during the years 1929 and 1930. It will be observed that only 24 per cent. males and 22 per cent. females were fed to nine months, and that 50 per cent. or more of both sexes had been weaned by the end of the third month. Yet all authorities on infant feeding are agreed that the majority of mothers are capable of breast feeding: Sir F. Truby King 1 puts the figure as high as 95 per cent. It may be objected that the mothers who come to the welfare centres only come because they are in difficulties over breast feeding, and want to get advice on artificial feeding, and, still more, to purchase the dried milks supplied at the centres ; whilst those mothers who stay away may be assumed to be feeding their babies on the breast successfully. In a word, it may be contended that an investigation into methods of infant feeding not confined to the section of the population attending welfare centres, but extended to the entire population of the district, would give results showing a higher percentage of infants breast fed at all ages. Confirmation of this argument is suggested by Table III, the
1933.
PUBLIC HEALTH.
357
TABLE I. The
f o l l o w i n g figures
were
obtained
from
the
welfare
centre
cards.
O f t h e 210 m a l e i n f a n t s : Per cent. 10 were artificially fed from birth. 90 were breast fed for one week. 86.2 ,, two weeks. 78 three weeks. 72.9 four weeks. 64.7 six weeks. 59.5 two months. 51.4 two and a half months. 49.5 three months. 41.4 three and a half months. 40 four months. 36.6 four and a half months 36.6 five months. 32.8 five and a half months. 32.8 six months. 3O six and a half months. 29.5 seven months. 26.6 seven and a half months. 26.2 eight months. 24.76 eight and a half months. 24.2 nine months. 13.3 nine and a half months. 12.8 ten months. 9 ten and a half months. 8.57 eleven months. 4-2 twelve months. .95 thirteen and a half months. .95 fourteen months. .4 sixteen months.
O f t h e 197 f e m a l e i n f a n t s : - Per cent. 12.2 were artificially fed from birth. 87.8 were breast fed for one week. 81.7 ,, two weeks. 71.1 ,, three weeks. 66.5 four weeks. 60 -4 . . . . six weeks. 53.2 ,, two months. 47.2 . . . . two and a half months. 44 -6 ,, three months. 39.6 . . . . three and a half months. 38.6 . . . . four months. 35 -0 four and a half months. 32.99 . . . . five months. 29.44 . . . . five and a half months. 28.93 . . . . six months. 28.43 . . . . six and a half months. 27.41 seven months. 26.39 seven and a half months. 25 -88 eight months. 24.87 ,, eight and a half months. 22.84 nine months. 15.73 nine and a half months. 14.72 ten months. 11-16 ten and a half months. 9.13 eleven months. 6.09 eleven and a half months. 4.56 twelve months. 2.03 thirteen months. .5 fifteen months.
figures o f w h i c h w e r e o b t a i n e d f r o m h i s t o r i e s t a k e n at r a n d o m i n t h e d i s t r i c t , i r r e s p e c t i v e o f w h e t h e r the infants had attended welfare c e n t r e s o r not. T h i s does s h o w a h i g h e r p e r c e n t a g e o f b r e a s t f e d i n f a n t s i n b o t h sexes, w h i c h also m i g h t be a c c o u n t e d f o r b y t h e fact t h a t m a n y o f t h e m w e r e r e a r e d at a t i m e w h e n t h e i n d u s t r i a l d e p r e s s i o n was n o t so s e v e r e as it is n o w , a n d t h e s t a n d a r d o f l i v i n g was c o r r e s pondingly higher, favouring better nourishment amongst the mothers. F u r t h e r l i g h t is s h e d o n t h e p r o b l e m b y a c o m p a r i s o n , in T a b l e I I , o f b o t h sets o f
L a n c a s h i r e figures w i t h statistics d r a w n in t h e U n i t e d States o f A m e r i c a , b y M a n n i n g * , o f 1,000 cases in p r i v a t e p r a c t i c e , a n d b y M i t c h e l l 8, o f 1,819 cases in t h e h o s p i t a l class. I t will be o b s e r v e d t h a t t h e r e is a f a i r l y close r e s e m b l a n c e b e t w e e n t h e statistics d r a w n b y M a n n i n g ( U . S . A . ) f r o m his 1,000 p r i v a t e cases, and those drawn from the Lancashire welfare cases o n t h e o n e h a n d ; whilst, on the other h a n d , t h e r e is n o t a m a r k e d d i f f e r e n c e b e t w e e n t h e figures r e p r e s e n t i n g t h e o t h e r L a n c a s h i r e cases a n d t h o s e c o m p i l e d b y M i t c h e l l ( U . S . A . ) f r o m his 1,819 cases of t h e h o s p i t a l class.
.
.
.
.
.
.
.
.
.
.
.
.
,,
,,
TABLE II. Breast fed. Not at all.
Welfare centre cases (both sexes) Other Lancashire cases (both sexes) . . . . . . . . Manning (U.S.A.). Private cases (both sexes) .. Mitchell (U.S.A.). __ Hospital cases (both sexes) . .
One week.
Three months,
Six months,
Nine months,
One year.
Per cent. Per cent, Per cent. 47.0 11.1 88-9
Per cent. 30.8
Per cent. Per cent 4.35 23 "5
Eighteen. months. Per cent.
17.0
F 79-5
63.5
54.5
50.5
28.5
5.0
8.1
91-9
64.0
41.0
26.0
11.8
1.6
20.0
800
55.0
42.0
34.0
27 '0
9"0
:~S
PUBLIC HEALTH.
T h e s e resemblances suggest that the analysis of the welfare centre records does not present an unjustifiably pessimistic picture of the state of affairs with regard to breast feeding amongst m o d e r n infants, and further, that the failure to reach ideal standards in this respect is neither recent nor a p h e n o m e n o n peculiar to SouthEast Lancashire. T h e figures also indicate that poverty is not in itself a bar to successful breast feeding, because after the first three months the per-
AUGUST,
centages of " hospital class " m o t h e r s who continue breast feeding are higher t h a n those of the private cases. PART I I . - - W h e t h e r the p r o p o r t i o n of infants breast fed in 1929 and 1930 is less than formerly. T h e figures taken f r o m the histories of the 315 school children show that in the districts of S o u t h - E a s t Lancashire u n d e r consideration, the proportion is less than it was five to fourteen years ago. T h e figures are shown in T a b l e I I I .
TAB LE I I I . O f the 167 school boys : Per cent. 21 were not breast fed at all. 78 were breast fed for one week. 76 ,, two weeks. 69 three weeks. 67 four weeks. 65 ,, six weeks. 64 ,, two months. 60 . . . . three months. 55 . . . . four months. 51 . . . . five months. 48 . . . . six months. 43 . . . . seven months. 41 nine months. 31 . . . . ten months. 23 . . . . eleven months. 21 . . . . twelve months. 7 "8 . . . . thirteen months. 7"0 . . . . fourteen months. 4 "0 ,, fifteen months. 2.9 . . . . sixteen months.
O f the 148 school girls : Per cent. 13 were not breast fed at all. 81 were breast fed for one week. 79 two weeks. 75 three weeks. 71 five weeks. 69 two months. 67 three months. 63 four months. 62 five months. 61 six months. 60 nine months. 42 ten months. 34 eleven months. 30 twelve months. 12 thirteen months. 11 fourteen months. 9 ,, fifteen months. 6 sixteen months. 5 seventeen months. 5 eighteen months.
PART I I I . - - T h e causes of early weaning and to what extent they are preventable. T h e causes of early weaning in the welfare centre cases are classified u n d e r headings and groups in T a b l e IV. Space does not p e r m i t a reproduction of all the figures but a detailed analysis of these gives the " g r o u p percentages " s h o w n in the table. T h e large G r o u p " J " (34 per cent. of all causes of early weaning) represents an unfortunate gap in the i n f o r m a t i o n available. Here no reason is noted on the card, because either the m o t h e r had not been in to see the medical officer between the time of weaning and the time of collecting the statistics, or the reason given was considered too inadequate to be recorded. T h e vagueness of the statements made in these cases suggests that in most of t h e m early weaning m i g h t have been avoided had the m o t h e r so desired. I n G r o u p " H " (22 per cent.) most of the first three causes (" infant not satisfied, . . . . no
milk " and " milk left ") could be placed in the same category of " reason too indefinite to r e c o r d . " A large p r o p o r t i o n of these is preventable. It m a y be that in some mothers, e . g . those who were exhausted by a difficult labour, the milk s u p p l y really did fail to a p p e a r or continue, but more often the m o t h e r ' s s t a t e m e n t was noted d o w n without c o m m e n t because it was too long after the event to diagnose the real reason. Unfortunately, the average m o t h e r ignores all causes for a b a b y ' s crying except hunger, and p r o m p t l y weans her b a b y as soon as it becomes fretful or gets colic, acting on the a s s u m p t i o n that " it is not satisfied " ; whereas the trouble is most likely to be overfeeding, which could have been regulated b y timely advice at the welfare centre. Nos. 4 and 5 (" long interval since previous p r e g n a n c y " and " elderly p r i m i p a r a ") need no special c o m m e n t . I n t h e m long disuse of the lactating function has led to its atrophy. I n G r o u p " G " ( 6 per cent.) bad m a n a g e m e n t
PUBLIC HEALTH.
1933.
359
TABLE I V . Totals of various causes for early w e a n i n g . Group percentages (approx.)
Reasons for Bottle Feeding.
A.--lll-health associated with pregnancy or parturition-1. T o x ~ e m i a s o f p r e g n a n c y . . . . 2. E c l a m p s i a . . . . . . . . 3. Difficult l a b o u r .. . . . . 4. P o s t - p a r t u m h ~ e m o r r h a g e . . . . 5. P u e r p e r a l m a n i a . . . . . . 6. P u e r p e r a l f e v e r . . . . . . . . 7. P u e r p e r a l h ~ e m o r r h a g e .. .. 8. P h l e g m a s i a alba d o l e n s ( " w h i t e leg " ) .. 9. A l b u m i n u r i a .. . . . . . . . . . . . . 10. T i r e d m u l t i p a r a . . . . . . . . '. .. 11. M o t h e r to c o n t i n u e r a d i u m t r e a t m e n t f o r c a n c e r o f c e r v i x e
6
O
5
~
1 7 6
1 4 ° .
•
6 4
°
. °
1
. °
B . - - I l l - h e a h h not directly associated w i t h p r e g n a n c y or p a r t u r i t i o n - 1. I n f l u e n z a a n d p l e u r i s y j u s t b e f o r e c o n f i n e m e n t . . . . 2. E n c e p h a l i t i s l e t h a r g i c a five w e e k s b e f o r e c o n f i n e m e n t .. 3. T u b e r c u l o u s s p i n e . . . . . . . . . . . . 4. H e a r t disease . . . . . . . . . . . . . . 5. R h e u m a t i c f e v e r t w o y e a r s b e f o r e . . . . . . . . 6. C h r o n i c colitis . . . . 7. D e l i c a t e - - " n o t s t r o n g e n o u g h '~ f o r b r e a s t f e e d i n g .. 8. D i a b e t e s m e l l i t u s . . . . . . . . 9. Q u i n s y . . . . . . . . . . . . 10. P n e u m o n i a . . . . . . . . . . 11. J a u n d i c e . . . . . . . . . . . . 12. I n f l u e n z a .. . . . . . . . . 13. G a s t r o - e n t e r i t i s . . . . . . . . .
1 •
1
•
1 1 1 1 9 per cent.
•
•
. °
4
C.--Ill-health of infants-1. P y l o r i c s t e n o s i s . . . . . . . . . . . . . . . . 2. T o o w e a k to s u c k l e . . . . . . . . . . . . . . . . 3. N a s a l o b s t r u c t i o n - - p r e v e n t i n g s u c k l i n g . . . . . . . . . . 4. C o n g e n i t a l h e a r t disease . . . . . . . . . . . . . 5. C a v e r n o u s na~vus o f l i p - - w e a ~ e d o n a d m i s s i o n to h o s p i t a l f o r o p e r a t i o n 6. W h o o p i n g c o u g h a n d m e a s l e s . . . . . . . . . . . . D.--Diseases of Breast-1. C a n c e r .. . . . . . . . . . . . . . 2. R e t r a c t e d n i p p l e s . . . . . . . . . . . . . 3. M a s t i t i s . . . . . . •. . . . . . . . . . . 4. B r e a s t a b s c e s s . . . . . . . . . . . . . . .
. . . .
. . . .
1 1 ]
. . . .
7 per cent.
4 p e r cent•
F.--Worry-1. O v e r o p e r a t i o n f o r " t o n g u e - t i e " at t w o d a y s o l d 2. U n j u s t i f i a b l y , t h a t i n f a n t n o t g e t t i n g e n o u g h . . 3. A b o u t o t h e r c h i l d , w h o is m e n t a l l y defective . . management-Overfeeding . . . . . . . Irregular feeding . . . . . Infantile dyspepsia . . . . . Careless mother Interference from grandmother and
.
. . .
. .
. . .
. . .
J.--No
reason noted
.
.
.
.
.
.
.
. . .
.
.
.
.
. . . .
.
.
. .
. . .
. . .
2 per cent.
. . .
6 per cent,
.
.
. .
.
. . . .
. . .
. . . . . . . . . . . . . . . .
. .
. . . . .
neighbours
H.--Other reasons-1. I n f a n t s " n o t satisfied " . . . . . . . 2. " N o m i l k " .. . . . . . . . . . 3. " M i l k w e n t " . . . . .. . . . . 4. L o n g i n t e r v a l since p r e v i o u s p r e g n a n c y . . 5. E l d e r l y p r i m i p a r a . . . . . . . . .
.
. .
.
.
. .
. .
3
.
11 11
. .
22 p e r c e n t .
. . . . . . . . . . . . . . . . . . .
.
4 p e r cent•
1
E.--Economic causes-1. M o t h e r w e n t to w o r k as s o o n as s t r o n g e n o u g h 2. M o t h e r i n s u f f i c i e n t l y n o u r i s h e d - - p o v e r t y . . . .
G.--Bad 1. 2. 3. 4. 5.
12 p e r c e n t .
1 1
.
.
. •.
.
.
1 104
.
Total
..
306
34 p e r cent•
360
PUBLIC HEALTH.
and overfeeding lead to " infantile dyspepsia." T h e mother concludes that her milk disagrees and the infant is weaned. " Irregular feeding " either operates in the same way, or the irregular stimulus to the breast leads to a failure of lactation. T h e " careless mother " combines neglect of personal hygiene with overfeeding, or irregular feeding, or b o t h ; and so the infant gets diarrhma, and is weaned, or her milk supply fails. Alternatively, she may wean the child deliberately because she cannot be " bothered " with breast feeding. " Interference from grandmother or neighbours " leads the mother to think that her milk supply is insufficient or unsuitable. She may, even against her better judgment, be made to wean her child because her adviser (grandmother or neighbour) has reared a family of her own. T h e belief that a woman who has reared a family of her own is therefore qualified to give expert advice on all matters pertaining to infant welfare is widely held by the general public, and is one of the chief obstacles in the way of their education in infant management. In Group " F , " " w o r r y " (2 per cent.), depends largely on the t e m p e r a m e n t of the individual. W h e n it concerns matters other than the weaning of the infant, e.g. about other children in the family, or about financial difficulties, little can be done. Unnecessary worry over the infant's progress, induced by interference f r o m ignorant advisers, has been discussed under the previous heading. W h e n the mother is of the worrying type, it is difficult to help. In one case, weaned after four months, both nurse and doctor waged a losing battle all the way through to keep the infant at the breast, on which it was making excellent progress. At four months the mother had her way, and weaned the infant, but she stayed away from the welfare centre for some months afterwards. G r o u p " E " (" economic causes " - - 4 per cent.) is difficult to remedy. A mother cannot be made to give up her work to stay at home and feed her baby. Often she is the only breadwinner in the family. It is cheaper for her to work and buy artificial food for her infant than to stay at home and feed it. Only exceptionally strong women are able both to go out to work and to feed their babies as well. T h e other economic cause of failure to breast feed is illnourishment through poverty. In these cases, early weaning is probably the better policy to pursue in the interests both of mother and child. Matters are often further complicated by the worry of striving to make both ends meet.
AUGUST,
G r o u p " D " - - " Diseases of the breast " (7 per cent.). With the exception of cancer, the diseases mentioned indicate a failure of antenatal care. Either the mother was too busy (e.g. managing a large family and unemployed husband) or too careless to carry out the necessary regimen ; or for both of these reasons, plus ignorance, she failed to obtain ante-natal advice. M a n y women do not book either doctor or midwife till the last minute. T h e county nurses help when they become aware of cases in their districts, but their advice is not sought very frequently. T h e n u m b e r of mothers who come voluntarily to the clinic for advice is negligible. G r o u p " C " - - I l l - h e a l t h of the infant (4 per cent.) as a cause of bottle feeding is mostly unavoidable, but those who were too weak' to suckle might have been born stronger if the mothers had received ante-natal care, which might have improved their health during pregnancy and prevented the difficult confinements that are often responsible for the birth of weak babies. Of those weaned for nasal obstruction, one was subsequently admitted to hospital for removal of adenoids. T h e other two had chronic nasal catarrh and " snuffles." G r o u p " B " (9 per cent.). These are all unavoidable causes of weaning except, perhaps, those classified under " delicate." Some of the " delicate " mothers may have been persuaded by themselves or their friends and relatives that they were not strong enough to breast feed their infants. G r o u p " A " (12 per cent.). W h e n discussing the prevention of breast diseases the need for more ante-natal supervision was emphasised and some of the reasons for its lack were mentioned. T h e whole question of ante-natal care is discussed so fully in the reports of the Maternal Mortality Committee that there is no need to elaborate here, but it is evident that G r o u p " A " represents a mass of pre and post-partum morbidity which might have been prevented. A table similar to Table IV was prepared to show the causes assigned by the mothers of the school children for failure of breast feeding. T h e causes and their classification are so similar to those given in Table IV that there is no need to reproduce them, but one point deserves special mention. Of the school children u n d e r consideration, 159 were born towards the end of the Great War, yet only two of their mothers attributed failure of breast feeding to war rationing. In a further Table (V) both sets of figures
361
PUBLIC HEALTH.
1933.
TABLE
V.
Welfare centre cases (Table IV).
Group " A " - Pre- or post-partum morbidity . . . . Group " B " Ill-health not directly associated with pregnancy or parturition .... Group " C " Ill-health of infant .. -" Group " D " Diseases of the breast • . Group " E " Economic causes .. • . Group " F " . . Worry .... Group " G " Bad management.. .. Group " H " .. Other reasons .. Group " J " .. No reason noted .. Totals
..
School children.
Unavoidable.
Preventable.
Unavoidable.
Preventable.
(Percentages)
(Percentages)
(Percentages)
(Percentages)
6
6
8
7
7
2
18
?
3
1
2
1
1
6
i
i
None
4
4
None
11
None
2
None
None
3
None
6
None
2
I
16
6
4
20
]
17
17
10
10
!
56
44
53
47
i
(welfare centre cases and school children) have been analysed f r o m the view-point of prevention. F o r example, if it be a d m i t t e d that in T a b l e IV, G r o u p D (" Diseases of the breast ") all the causes of failure to breast feed except cancer are preventable, it m a y be said that 6 per cent. of the total causes of failure to breast feed listed in T a b l e I V are preventable. T h o s e causes of failure not considered preventable are classed as " unavoidable." T a b l e V shows that in both series of cases (welfare centre and school children) nearly half (44 to 47 per cent.) the failures to breast feed for the full period were preventable. Dr. H. W. Pooler 4, M a t e r n i t y and Child Welfare Medical Officer to the D e r b y s h i r e County Council, who analysed one h u n d r e d cases of failure to continue breast-feeding up to the end of the first m o n t h , concludes that eighty ( i . e . , 80 per cent.) were preventable. Before leaving the subject of early weaning and its prevention, m e n t i o n m u s t be made of the influence of the welfare centre in this respect. T h e difficulty is that the majority of the mothers do not give the workers at the centre the o p p o r t u n i t y to advise t h e m soon enough. O f the 407 welfare centre babies under consideration, only 40 per cent. had been b r o u g h t to the centre b y t h e time they were four
weeks old. Of the remaining 60 per cent., who were b r o u g h t at subsequent ages u p to seven months, 54 per cent. had been already weaned before their first visit to the centre. M a n y of the mothers who join late a d m i t frankly that they have come because they have heard f r o m a neighbour that dried milk can be obtained cheaply f r o m the centre. Unfortunately, enthusiasm to learn mothercraft is not yet as widespread as could be desired. PART I V . - - T o what extent the health of the school child is influenced b y the m e t h o d of feeding (artificial or breast) in infancy. T h e m e t h o d of obtaining the statistics for this part of the investigation is explained at the beginning of the article. T h e y are set out in T a b l e VI. I n it the past medical histories and " present condition " of 315 school children are correlated with the histories of their feeding in infancy. F o r example, of those weaned at six m o n t h s of age, 60 per cent. were in good general condition when they reached school age, and 40 per cent. were delicate. It has been explained already that the meaning attached to the word " delicate " is the definition of the Board of Education, namely, a condition of " pre- or latent tuberculosis, malnutrition, debility, anmmia, e t c . " T h e group " fair " includes all border-line cases, whose general condition was
PUBLIC HEALTH.
362
AUGUST,
TABLE VI. PERCENTAGES OF SCHOOL CHILDREN BETWEEN THE AGES OF S YEARS AND 14 YEARS, BOTTLE FED FROM : - -
Birth.
2 Weeks•
nil 5 9 2 2 2 2 2 nil
Per cent. 79 37 2O 16 12 37 29 nil 29 nil nil 8 4 8 4 nil 4 nil nil nil nil nil 4
29 21 50 6 17 nil
Past history (illnesses)-Measles Whooping cough .. Scarlet fever .. Diphtheria . . . . Mumps .... Chicken pox .. Bronchitis f O n c e .. k ~viore than once fOnce .... Pneumonia ~More than once Chronic nasal catarrh .. Tonsillitis Tonsils and adenoids removed Cervical adenitis (non-tuberculous . . . . fabdominal Glandular ruoercmosls-~ cervical .. Otitis media . . . . . . . . Rheumatic fever Rheumatism (including chorea) .. Acute poliomyelitis . . . . . . Meningitis . . . . . . . . Septic~emia . . . . . . . , Osteomyelitis . . . . . . Condition on examination-General condition good .... General condition fair .... Delicate Rachitic deformities Diseased tonsils and adenoids .. Organic heart disease (except " congenital ") . . . . . .
4 Weeks• Per
cent• 72 39 nil
9 12 6 18 5 to 12 Weeks• Months. Months. Months. Months. Per cent. 85 54 27
Per cen
100 5O nil 8 20 58 37 nil 29
Per cent• 87 43 11 4 17 41 38 nil 20 2 5 S nil nil nil 22 nil nil 2 2 nil nil
Per cent. 72 51 22 4 13 44 30 2 19 4 2 8 4 nil nil 6 16 1 6 1 1 nil nil
Per
cent. 96 4O nil nil II 29 22
nil 18 nil
3 nil nil nil nil
nil 12 12 nil nil nil nil 8 nil 16 nil 4 nil nil
40 19 41 4 20
28 22 50 nil 27
60 nil 40 nil 16
57 nil 43 nil 20
62 7 31 6 20
62 14 24 nil 22
ail
nil
nil
4
nil
nil
far from good, yet they were not bad enough to label " delicate." T h e y were in a state of subrather than real-nutrition. T h e claim is c o m m o n l y put forward that the breast-fed infant not only scores during babyhood, but that he carries into life a greater resistance to disease, and that he may reasonably expect to achieve a higher degree of general health and stamina than one artificially fed. T h a t the infant mortality rate during the first few weeks of life is higher amongst the artificially fed than the breast-fed, no one would deny ; but is it true that the survivors amongst artificially fed infants carry with them into the succeeding years a lowered resistance to disease and an inferior standard of general health as compared with the breast-fed ? Table VI does not support this conclusion. With the exception of diphtheria, it does not show that artificially fed infants suffered more from illness in childhood than the breast-fed.
4
8
16 nil
nil nil 4 22
nil nil nil nil nil nil
Some illnesses, indeed ( e . g . , otitis media, chronic coryza, tonsillitis, and the exanthemata) seem to have had a markedly greater incidence u p o n those weaned late than u p o n those weaned early• Perhaps the greater incidence of pharyngeal diseases and otitis media amongst the breast-fed is attributable partly to the t e n d e n c y of breast-fed babies to be more fretful than the artificially fed, with the result that they are given the n o t o r i o u s " d u m m y " m o r e frequently. T h e figures grouped u n d e r " condition on examination " do give some s u p p o r t for the theory that breast feeding in infancy may influence favourably the general health in childhood, for the percentage of those in good general health is maintained at about 60 per cent. in those who were breast-fed from birth to between six and eighteen months ; whilst of those fed at the breast for shorter periods, only 28 to 40 per cent. enjoyed good health. Similarly, the percentage of " fair " and " delicate " children
1933.
PUBLIC HEALTH.
steadily falls as the period of breast feeding increases. It is noticeable that the rise in percentage of those in good health and the decline in percentage of those in poor health does not occur to any great extent until the six months column is reached, indicating the logical conclusion that for a method of infant feeding to have any permanent effect at all it must be continued for a long period. When all this has been said, it cannot be claimed that the figures in Table VI support the view that the health of the school child can be predetermined by the method of feeding during infancy alone. It is here submitted that there is on the part of medical practitioners, and of the general public, a tendency to feel that if only the infant can be piloted safely through the first year it will look after itself in the succeeding years. Even the forces of preventive medicine have been so concentrated upon the reduction of infant mortality (admittedly with striking success) on the one hand, and upon the health of the school child on the other, that the intervening period of the child's life has suffered a comparative neglect. True, the welfare centre is there to give advice on the management of children over one year, but most of the mothers cease to attend regularly after the baby's first birthday, either because attendance has been made difficult by the occurrence of another pregnancy, or--and this is the chief reason-because they fail to realise the necessity for doing so. No better example could be found of the general neglect of child welfare after the first year than in the figures in Table VI to the effect that the percentage (6 per cent.) of rachitic deformities is as high amongst the children who were breast-fed to 12 months, as amongst those who had no breast milk at all. In recent years the Chief Medical Officer to the Board of Education, in his annual reports, has pointed out from year to year that the mass of minor defects and crippling amongst school children remains unreduced despite the long sustained efforts of the school medical service. He thus deduces that the attention of the preventive service should be directed more to the care of the child from one to five years of age, so that its health may be maintained through the pre-school years, and the child delivered into the hands of the school medical service at a higher level of general health than heretofore, free from defects that are difficult or impossible to cure. The statistics given in Table VI, although working from the other end of the scale, lend themselves to the same conclusion.
363
I am indebted to Dr. J. J. Butterworth, County Medical Officer of Health, Lancashire, for permission to publish this paper. CONCLUSIONS.
(1) Of the infants attending two child welfare centres in South-East Lancashire during 1929 and 1930, only 50 per cent. were breast-fed to three months, 30 per cent. to six months, and 25 per cent. to nine months. (2) In at least 40 per cent. of those weaned prematurely, breast feeding could have been maintained if the mothers had been willing to seek advice before and after the birth of the child. (3) The breast-fed infant is not more resistant to disease in childhood than the artificially fed infant, and the general health of the school child cannot be pre-determined by the method of feeding (breast or artificial) during infancy. REFERENCES.
1Sir F. Truby King. Natural Feeding of Infants. 2Manning. Arch. Ped., Vol. XXXVII, No. 4, 1920. aAmer, flour. Obstet., 1912. 4Pooler, H. W. Annual Report, County Medical Officer of Health, Derbyshire, 1930. Hill, Practical Infant Feeding. W.B. Saunders Co., Philadelphia and London. Thomson. Clinical Study and Treatment of Sick Children. Oliver and Boyd, Edinburgh and London. Pearson and Wyllie. Recent Advances in Diseases of Children. J. and A. Churchill, London. Myers. Modern Infant Feeding. Jonathan Cape, London. The Annual Reports of the Chief Medical Officer of the Board of Education.
THE Third Biennial Conference on Mental Health will be held at Caxton Hall, Westminster, London, S.W.1, from November 22nd to 24th, 1933. The Conference will be opened by H.R.H. Prince George, K.G., and the subjects to be discussed include the following: " The Place of Mental Health in the Life of the Nation " ; " The Working of the Mental Treatment Act, 1930 . . . . . Sex Problems of Adolescence " ; " Suicide and Society " ; " The Neurotic " ; " Punishment or Treatment ? " ; " The Gambling Spirit as a National Problem " ; and " The Medical Attitude to Crime." Full information regarding the Conference may be obtained from the Secretary, National Council for Mental Hygiene, 78, Chandos House, Palmer Street, London, S.W.1.
PUBLIC HEALTH.
AucuST,
I n f a n t F e e d i n g and its R e l a t i o n t o t h e H e a l t h o f t h e S c h o o l Child. By J. GREENWOOD WILSON, M.D., M.R.C.P., D.P.H., Medical Officer of Health, Dewsbury. This investigation, although it relates to a limited area and a comparatively small number of cases, elicited a considerable amount of useful information and permitted Dr. Greenwood Wilson to draw conclusions that will be found interesting to consider. The paper was read at a meeting of the Yorkshire Sub-Group of the Maternity and Child Welfare Group at York on May 20th, 1933. HIS investigation was undertaken, while I T was working in an industrial area of SouthEast Lancashire, in an attempt to show :-(1) The proportion of infants in the area who were breast fed during the years 1929 and 1930. (2) Whether the proportion was less in those years than formerly. (3) The causes of early weaning and to what extent they are preventable. (4) To what extent the health of the school child is influenced by the method of feeding (artificial or breast) in infancy. The figures for parts (1) and (3) of the investigation were obtained from the case record cards of the infants who attended two child welfare centres in South-East Lancashire during the years 1929 and 1930. Notes were taken only from those cards which had a reasonably complete record of the infant's progress from birth to the time of weaning. T h e total number of cards from which notes were taken was 407 ; 210 males and 197 females. Results are shown in Table I. The figures for parts (2), (3) and (4) were taken from notes of statements by mothers of children brought to the minor ailments clinic, or marked down for treatment at visits to schools within the period September, 1930, to February, 1931, inclusive. The mother of each child was asked what illnesses the child had had, at what age in infancy it was weaned, and the reason for doing so (if the weaning was early). When she had made her statement her memory was assisted by leading questions. Next, a full examination was made of each child, and a record made of its general condition together with any local defect found. On going through the records afterwards it was found that the data so obtained could be grouped under the following heads, which are set out in Table VI :--(a) General condition good ; (b) general condition fair ; (c) condition delicate ; (d) diseased tonsils and adenoids; (e) rachitic deformities; (f) organic heart disease. The
group " delicate " follows the definition of the Board of Education, and inchtdes pre- or latent tuberculosis, malnutrition, debility, anaemia, etc. The group " fair " includes all border-line cases whose general condition was far from " good," yet they were not bad enough to label " delicate." They were in a state of sub- rather than mal-nutrition. Altogether 315 school children between the ages of five and fourteen (inclusive) were examined, and their histories recorded in respect of infant feeding, age of weaning, cause of early weaning, and past illnesses. There were 167 boys and 148 girls, and slightly more than half of the total (165) were between the ages of eight and fourteen years. The figures obtained from the histories of these children with regard to ages of weaning, and causes thereof, may be compared with those obtained from the welfare centre cards. PART I . - - T h e proportion of infants in the area breast fed during the years 1929 and 1930. It will be observed that only 24 per cent. males and 22 per cent. females were fed to nine months, and that 50 per cent. or more of both sexes had been weaned by the end of the third month. Yet all authorities on infant feeding are agreed that the majority of mothers are capable of breast feeding: Sir F. Truby King 1 puts the figure as high as 95 per cent. It may be objected that the mothers who come to the welfare centres only come because they are in difficulties over breast feeding, and want to get advice on artificial feeding, and, still more, to purchase the dried milks supplied at the centres ; whilst those mothers who stay away may be assumed to be feeding their babies on the breast successfully. In a word, it may be contended that an investigation into methods of infant feeding not confined to the section of the population attending welfare centres, but extended to the entire population of the district, would give results showing a higher percentage of infants breast fed at all ages. Confirmation of this argument is suggested by Table III, the
1933.
PUBLIC HEALTH.
357
TABLE I. The
f o l l o w i n g figures
were
obtained
from
the
welfare
centre
cards.
O f t h e 210 m a l e i n f a n t s : Per cent. 10 were artificially fed from birth. 90 were breast fed for one week. 86.2 ,, two weeks. 78 three weeks. 72.9 four weeks. 64.7 six weeks. 59.5 two months. 51.4 two and a half months. 49.5 three months. 41.4 three and a half months. 40 four months. 36.6 four and a half months 36.6 five months. 32.8 five and a half months. 32.8 six months. 3O six and a half months. 29.5 seven months. 26.6 seven and a half months. 26.2 eight months. 24.76 eight and a half months. 24.2 nine months. 13.3 nine and a half months. 12.8 ten months. 9 ten and a half months. 8.57 eleven months. 4-2 twelve months. .95 thirteen and a half months. .95 fourteen months. .4 sixteen months.
O f t h e 197 f e m a l e i n f a n t s : - Per cent. 12.2 were artificially fed from birth. 87.8 were breast fed for one week. 81.7 ,, two weeks. 71.1 ,, three weeks. 66.5 four weeks. 60 -4 . . . . six weeks. 53.2 ,, two months. 47.2 . . . . two and a half months. 44 -6 ,, three months. 39.6 . . . . three and a half months. 38.6 . . . . four months. 35 -0 four and a half months. 32.99 . . . . five months. 29.44 . . . . five and a half months. 28.93 . . . . six months. 28.43 . . . . six and a half months. 27.41 seven months. 26.39 seven and a half months. 25 -88 eight months. 24.87 ,, eight and a half months. 22.84 nine months. 15.73 nine and a half months. 14.72 ten months. 11-16 ten and a half months. 9.13 eleven months. 6.09 eleven and a half months. 4.56 twelve months. 2.03 thirteen months. .5 fifteen months.
figures o f w h i c h w e r e o b t a i n e d f r o m h i s t o r i e s t a k e n at r a n d o m i n t h e d i s t r i c t , i r r e s p e c t i v e o f w h e t h e r the infants had attended welfare c e n t r e s o r not. T h i s does s h o w a h i g h e r p e r c e n t a g e o f b r e a s t f e d i n f a n t s i n b o t h sexes, w h i c h also m i g h t be a c c o u n t e d f o r b y t h e fact t h a t m a n y o f t h e m w e r e r e a r e d at a t i m e w h e n t h e i n d u s t r i a l d e p r e s s i o n was n o t so s e v e r e as it is n o w , a n d t h e s t a n d a r d o f l i v i n g was c o r r e s pondingly higher, favouring better nourishment amongst the mothers. F u r t h e r l i g h t is s h e d o n t h e p r o b l e m b y a c o m p a r i s o n , in T a b l e I I , o f b o t h sets o f
L a n c a s h i r e figures w i t h statistics d r a w n in t h e U n i t e d States o f A m e r i c a , b y M a n n i n g * , o f 1,000 cases in p r i v a t e p r a c t i c e , a n d b y M i t c h e l l 8, o f 1,819 cases in t h e h o s p i t a l class. I t will be o b s e r v e d t h a t t h e r e is a f a i r l y close r e s e m b l a n c e b e t w e e n t h e statistics d r a w n b y M a n n i n g ( U . S . A . ) f r o m his 1,000 p r i v a t e cases, and those drawn from the Lancashire welfare cases o n t h e o n e h a n d ; whilst, on the other h a n d , t h e r e is n o t a m a r k e d d i f f e r e n c e b e t w e e n t h e figures r e p r e s e n t i n g t h e o t h e r L a n c a s h i r e cases a n d t h o s e c o m p i l e d b y M i t c h e l l ( U . S . A . ) f r o m his 1,819 cases of t h e h o s p i t a l class.
.
.
.
.
.
.
.
.
.
.
.
.
,,
,,
TABLE II. Breast fed. Not at all.
Welfare centre cases (both sexes) Other Lancashire cases (both sexes) . . . . . . . . Manning (U.S.A.). Private cases (both sexes) .. Mitchell (U.S.A.). __ Hospital cases (both sexes) . .
One week.
Three months,
Six months,
Nine months,
One year.
Per cent. Per cent, Per cent. 47.0 11.1 88-9
Per cent. 30.8
Per cent. Per cent 4.35 23 "5
Eighteen. months. Per cent.
17.0
F 79-5
63.5
54.5
50.5
28.5
5.0
8.1
91-9
64.0
41.0
26.0
11.8
1.6
20.0
800
55.0
42.0
34.0
27 '0
9"0
:~S
PUBLIC HEALTH.
T h e s e resemblances suggest that the analysis of the welfare centre records does not present an unjustifiably pessimistic picture of the state of affairs with regard to breast feeding amongst m o d e r n infants, and further, that the failure to reach ideal standards in this respect is neither recent nor a p h e n o m e n o n peculiar to SouthEast Lancashire. T h e figures also indicate that poverty is not in itself a bar to successful breast feeding, because after the first three months the per-
AUGUST,
centages of " hospital class " m o t h e r s who continue breast feeding are higher t h a n those of the private cases. PART I I . - - W h e t h e r the p r o p o r t i o n of infants breast fed in 1929 and 1930 is less than formerly. T h e figures taken f r o m the histories of the 315 school children show that in the districts of S o u t h - E a s t Lancashire u n d e r consideration, the proportion is less than it was five to fourteen years ago. T h e figures are shown in T a b l e I I I .
TAB LE I I I . O f the 167 school boys : Per cent. 21 were not breast fed at all. 78 were breast fed for one week. 76 ,, two weeks. 69 three weeks. 67 four weeks. 65 ,, six weeks. 64 ,, two months. 60 . . . . three months. 55 . . . . four months. 51 . . . . five months. 48 . . . . six months. 43 . . . . seven months. 41 nine months. 31 . . . . ten months. 23 . . . . eleven months. 21 . . . . twelve months. 7 "8 . . . . thirteen months. 7"0 . . . . fourteen months. 4 "0 ,, fifteen months. 2.9 . . . . sixteen months.
O f the 148 school girls : Per cent. 13 were not breast fed at all. 81 were breast fed for one week. 79 two weeks. 75 three weeks. 71 five weeks. 69 two months. 67 three months. 63 four months. 62 five months. 61 six months. 60 nine months. 42 ten months. 34 eleven months. 30 twelve months. 12 thirteen months. 11 fourteen months. 9 ,, fifteen months. 6 sixteen months. 5 seventeen months. 5 eighteen months.
PART I I I . - - T h e causes of early weaning and to what extent they are preventable. T h e causes of early weaning in the welfare centre cases are classified u n d e r headings and groups in T a b l e IV. Space does not p e r m i t a reproduction of all the figures but a detailed analysis of these gives the " g r o u p percentages " s h o w n in the table. T h e large G r o u p " J " (34 per cent. of all causes of early weaning) represents an unfortunate gap in the i n f o r m a t i o n available. Here no reason is noted on the card, because either the m o t h e r had not been in to see the medical officer between the time of weaning and the time of collecting the statistics, or the reason given was considered too inadequate to be recorded. T h e vagueness of the statements made in these cases suggests that in most of t h e m early weaning m i g h t have been avoided had the m o t h e r so desired. I n G r o u p " H " (22 per cent.) most of the first three causes (" infant not satisfied, . . . . no
milk " and " milk left ") could be placed in the same category of " reason too indefinite to r e c o r d . " A large p r o p o r t i o n of these is preventable. It m a y be that in some mothers, e . g . those who were exhausted by a difficult labour, the milk s u p p l y really did fail to a p p e a r or continue, but more often the m o t h e r ' s s t a t e m e n t was noted d o w n without c o m m e n t because it was too long after the event to diagnose the real reason. Unfortunately, the average m o t h e r ignores all causes for a b a b y ' s crying except hunger, and p r o m p t l y weans her b a b y as soon as it becomes fretful or gets colic, acting on the a s s u m p t i o n that " it is not satisfied " ; whereas the trouble is most likely to be overfeeding, which could have been regulated b y timely advice at the welfare centre. Nos. 4 and 5 (" long interval since previous p r e g n a n c y " and " elderly p r i m i p a r a ") need no special c o m m e n t . I n t h e m long disuse of the lactating function has led to its atrophy. I n G r o u p " G " ( 6 per cent.) bad m a n a g e m e n t
PUBLIC HEALTH.
1933.
359
TABLE I V . Totals of various causes for early w e a n i n g . Group percentages (approx.)
Reasons for Bottle Feeding.
A.--lll-health associated with pregnancy or parturition-1. T o x ~ e m i a s o f p r e g n a n c y . . . . 2. E c l a m p s i a . . . . . . . . 3. Difficult l a b o u r .. . . . . 4. P o s t - p a r t u m h ~ e m o r r h a g e . . . . 5. P u e r p e r a l m a n i a . . . . . . 6. P u e r p e r a l f e v e r . . . . . . . . 7. P u e r p e r a l h ~ e m o r r h a g e .. .. 8. P h l e g m a s i a alba d o l e n s ( " w h i t e leg " ) .. 9. A l b u m i n u r i a .. . . . . . . . . . . . . 10. T i r e d m u l t i p a r a . . . . . . . . '. .. 11. M o t h e r to c o n t i n u e r a d i u m t r e a t m e n t f o r c a n c e r o f c e r v i x e
6
O
5
~
1 7 6
1 4 ° .
•
6 4
°
. °
1
. °
B . - - I l l - h e a h h not directly associated w i t h p r e g n a n c y or p a r t u r i t i o n - 1. I n f l u e n z a a n d p l e u r i s y j u s t b e f o r e c o n f i n e m e n t . . . . 2. E n c e p h a l i t i s l e t h a r g i c a five w e e k s b e f o r e c o n f i n e m e n t .. 3. T u b e r c u l o u s s p i n e . . . . . . . . . . . . 4. H e a r t disease . . . . . . . . . . . . . . 5. R h e u m a t i c f e v e r t w o y e a r s b e f o r e . . . . . . . . 6. C h r o n i c colitis . . . . 7. D e l i c a t e - - " n o t s t r o n g e n o u g h '~ f o r b r e a s t f e e d i n g .. 8. D i a b e t e s m e l l i t u s . . . . . . . . 9. Q u i n s y . . . . . . . . . . . . 10. P n e u m o n i a . . . . . . . . . . 11. J a u n d i c e . . . . . . . . . . . . 12. I n f l u e n z a .. . . . . . . . . 13. G a s t r o - e n t e r i t i s . . . . . . . . .
1 •
1
•
1 1 1 1 9 per cent.
•
•
. °
4
C.--Ill-health of infants-1. P y l o r i c s t e n o s i s . . . . . . . . . . . . . . . . 2. T o o w e a k to s u c k l e . . . . . . . . . . . . . . . . 3. N a s a l o b s t r u c t i o n - - p r e v e n t i n g s u c k l i n g . . . . . . . . . . 4. C o n g e n i t a l h e a r t disease . . . . . . . . . . . . . 5. C a v e r n o u s na~vus o f l i p - - w e a ~ e d o n a d m i s s i o n to h o s p i t a l f o r o p e r a t i o n 6. W h o o p i n g c o u g h a n d m e a s l e s . . . . . . . . . . . . D.--Diseases of Breast-1. C a n c e r .. . . . . . . . . . . . . . 2. R e t r a c t e d n i p p l e s . . . . . . . . . . . . . 3. M a s t i t i s . . . . . . •. . . . . . . . . . . 4. B r e a s t a b s c e s s . . . . . . . . . . . . . . .
. . . .
. . . .
1 1 ]
. . . .
7 per cent.
4 p e r cent•
F.--Worry-1. O v e r o p e r a t i o n f o r " t o n g u e - t i e " at t w o d a y s o l d 2. U n j u s t i f i a b l y , t h a t i n f a n t n o t g e t t i n g e n o u g h . . 3. A b o u t o t h e r c h i l d , w h o is m e n t a l l y defective . . management-Overfeeding . . . . . . . Irregular feeding . . . . . Infantile dyspepsia . . . . . Careless mother Interference from grandmother and
.
. . .
. .
. . .
. . .
J.--No
reason noted
.
.
.
.
.
.
.
. . .
.
.
.
.
. . . .
.
.
. .
. . .
. . .
2 per cent.
. . .
6 per cent,
.
.
. .
.
. . . .
. . .
. . . . . . . . . . . . . . . .
. .
. . . . .
neighbours
H.--Other reasons-1. I n f a n t s " n o t satisfied " . . . . . . . 2. " N o m i l k " .. . . . . . . . . . 3. " M i l k w e n t " . . . . .. . . . . 4. L o n g i n t e r v a l since p r e v i o u s p r e g n a n c y . . 5. E l d e r l y p r i m i p a r a . . . . . . . . .
.
. .
.
.
. .
. .
3
.
11 11
. .
22 p e r c e n t .
. . . . . . . . . . . . . . . . . . .
.
4 p e r cent•
1
E.--Economic causes-1. M o t h e r w e n t to w o r k as s o o n as s t r o n g e n o u g h 2. M o t h e r i n s u f f i c i e n t l y n o u r i s h e d - - p o v e r t y . . . .
G.--Bad 1. 2. 3. 4. 5.
12 p e r c e n t .
1 1
.
.
. •.
.
.
1 104
.
Total
..
306
34 p e r cent•
360
PUBLIC HEALTH.
and overfeeding lead to " infantile dyspepsia." T h e mother concludes that her milk disagrees and the infant is weaned. " Irregular feeding " either operates in the same way, or the irregular stimulus to the breast leads to a failure of lactation. T h e " careless mother " combines neglect of personal hygiene with overfeeding, or irregular feeding, or b o t h ; and so the infant gets diarrhma, and is weaned, or her milk supply fails. Alternatively, she may wean the child deliberately because she cannot be " bothered " with breast feeding. " Interference from grandmother or neighbours " leads the mother to think that her milk supply is insufficient or unsuitable. She may, even against her better judgment, be made to wean her child because her adviser (grandmother or neighbour) has reared a family of her own. T h e belief that a woman who has reared a family of her own is therefore qualified to give expert advice on all matters pertaining to infant welfare is widely held by the general public, and is one of the chief obstacles in the way of their education in infant management. In Group " F , " " w o r r y " (2 per cent.), depends largely on the t e m p e r a m e n t of the individual. W h e n it concerns matters other than the weaning of the infant, e.g. about other children in the family, or about financial difficulties, little can be done. Unnecessary worry over the infant's progress, induced by interference f r o m ignorant advisers, has been discussed under the previous heading. W h e n the mother is of the worrying type, it is difficult to help. In one case, weaned after four months, both nurse and doctor waged a losing battle all the way through to keep the infant at the breast, on which it was making excellent progress. At four months the mother had her way, and weaned the infant, but she stayed away from the welfare centre for some months afterwards. G r o u p " E " (" economic causes " - - 4 per cent.) is difficult to remedy. A mother cannot be made to give up her work to stay at home and feed her baby. Often she is the only breadwinner in the family. It is cheaper for her to work and buy artificial food for her infant than to stay at home and feed it. Only exceptionally strong women are able both to go out to work and to feed their babies as well. T h e other economic cause of failure to breast feed is illnourishment through poverty. In these cases, early weaning is probably the better policy to pursue in the interests both of mother and child. Matters are often further complicated by the worry of striving to make both ends meet.
AUGUST,
G r o u p " D " - - " Diseases of the breast " (7 per cent.). With the exception of cancer, the diseases mentioned indicate a failure of antenatal care. Either the mother was too busy (e.g. managing a large family and unemployed husband) or too careless to carry out the necessary regimen ; or for both of these reasons, plus ignorance, she failed to obtain ante-natal advice. M a n y women do not book either doctor or midwife till the last minute. T h e county nurses help when they become aware of cases in their districts, but their advice is not sought very frequently. T h e n u m b e r of mothers who come voluntarily to the clinic for advice is negligible. G r o u p " C " - - I l l - h e a l t h of the infant (4 per cent.) as a cause of bottle feeding is mostly unavoidable, but those who were too weak' to suckle might have been born stronger if the mothers had received ante-natal care, which might have improved their health during pregnancy and prevented the difficult confinements that are often responsible for the birth of weak babies. Of those weaned for nasal obstruction, one was subsequently admitted to hospital for removal of adenoids. T h e other two had chronic nasal catarrh and " snuffles." G r o u p " B " (9 per cent.). These are all unavoidable causes of weaning except, perhaps, those classified under " delicate." Some of the " delicate " mothers may have been persuaded by themselves or their friends and relatives that they were not strong enough to breast feed their infants. G r o u p " A " (12 per cent.). W h e n discussing the prevention of breast diseases the need for more ante-natal supervision was emphasised and some of the reasons for its lack were mentioned. T h e whole question of ante-natal care is discussed so fully in the reports of the Maternal Mortality Committee that there is no need to elaborate here, but it is evident that G r o u p " A " represents a mass of pre and post-partum morbidity which might have been prevented. A table similar to Table IV was prepared to show the causes assigned by the mothers of the school children for failure of breast feeding. T h e causes and their classification are so similar to those given in Table IV that there is no need to reproduce them, but one point deserves special mention. Of the school children u n d e r consideration, 159 were born towards the end of the Great War, yet only two of their mothers attributed failure of breast feeding to war rationing. In a further Table (V) both sets of figures
361
PUBLIC HEALTH.
1933.
TABLE
V.
Welfare centre cases (Table IV).
Group " A " - Pre- or post-partum morbidity . . . . Group " B " Ill-health not directly associated with pregnancy or parturition .... Group " C " Ill-health of infant .. -" Group " D " Diseases of the breast • . Group " E " Economic causes .. • . Group " F " . . Worry .... Group " G " Bad management.. .. Group " H " .. Other reasons .. Group " J " .. No reason noted .. Totals
..
School children.
Unavoidable.
Preventable.
Unavoidable.
Preventable.
(Percentages)
(Percentages)
(Percentages)
(Percentages)
6
6
8
7
7
2
18
?
3
1
2
1
1
6
i
i
None
4
4
None
11
None
2
None
None
3
None
6
None
2
I
16
6
4
20
]
17
17
10
10
!
56
44
53
47
i
(welfare centre cases and school children) have been analysed f r o m the view-point of prevention. F o r example, if it be a d m i t t e d that in T a b l e IV, G r o u p D (" Diseases of the breast ") all the causes of failure to breast feed except cancer are preventable, it m a y be said that 6 per cent. of the total causes of failure to breast feed listed in T a b l e I V are preventable. T h o s e causes of failure not considered preventable are classed as " unavoidable." T a b l e V shows that in both series of cases (welfare centre and school children) nearly half (44 to 47 per cent.) the failures to breast feed for the full period were preventable. Dr. H. W. Pooler 4, M a t e r n i t y and Child Welfare Medical Officer to the D e r b y s h i r e County Council, who analysed one h u n d r e d cases of failure to continue breast-feeding up to the end of the first m o n t h , concludes that eighty ( i . e . , 80 per cent.) were preventable. Before leaving the subject of early weaning and its prevention, m e n t i o n m u s t be made of the influence of the welfare centre in this respect. T h e difficulty is that the majority of the mothers do not give the workers at the centre the o p p o r t u n i t y to advise t h e m soon enough. O f the 407 welfare centre babies under consideration, only 40 per cent. had been b r o u g h t to the centre b y t h e time they were four
weeks old. Of the remaining 60 per cent., who were b r o u g h t at subsequent ages u p to seven months, 54 per cent. had been already weaned before their first visit to the centre. M a n y of the mothers who join late a d m i t frankly that they have come because they have heard f r o m a neighbour that dried milk can be obtained cheaply f r o m the centre. Unfortunately, enthusiasm to learn mothercraft is not yet as widespread as could be desired. PART I V . - - T o what extent the health of the school child is influenced b y the m e t h o d of feeding (artificial or breast) in infancy. T h e m e t h o d of obtaining the statistics for this part of the investigation is explained at the beginning of the article. T h e y are set out in T a b l e VI. I n it the past medical histories and " present condition " of 315 school children are correlated with the histories of their feeding in infancy. F o r example, of those weaned at six m o n t h s of age, 60 per cent. were in good general condition when they reached school age, and 40 per cent. were delicate. It has been explained already that the meaning attached to the word " delicate " is the definition of the Board of Education, namely, a condition of " pre- or latent tuberculosis, malnutrition, debility, anmmia, e t c . " T h e group " fair " includes all border-line cases, whose general condition was
PUBLIC HEALTH.
362
AUGUST,
TABLE VI. PERCENTAGES OF SCHOOL CHILDREN BETWEEN THE AGES OF S YEARS AND 14 YEARS, BOTTLE FED FROM : - -
Birth.
2 Weeks•
nil 5 9 2 2 2 2 2 nil
Per cent. 79 37 2O 16 12 37 29 nil 29 nil nil 8 4 8 4 nil 4 nil nil nil nil nil 4
29 21 50 6 17 nil
Past history (illnesses)-Measles Whooping cough .. Scarlet fever .. Diphtheria . . . . Mumps .... Chicken pox .. Bronchitis f O n c e .. k ~viore than once fOnce .... Pneumonia ~More than once Chronic nasal catarrh .. Tonsillitis Tonsils and adenoids removed Cervical adenitis (non-tuberculous . . . . fabdominal Glandular ruoercmosls-~ cervical .. Otitis media . . . . . . . . Rheumatic fever Rheumatism (including chorea) .. Acute poliomyelitis . . . . . . Meningitis . . . . . . . . Septic~emia . . . . . . . , Osteomyelitis . . . . . . Condition on examination-General condition good .... General condition fair .... Delicate Rachitic deformities Diseased tonsils and adenoids .. Organic heart disease (except " congenital ") . . . . . .
4 Weeks• Per
cent• 72 39 nil
9 12 6 18 5 to 12 Weeks• Months. Months. Months. Months. Per cent. 85 54 27
Per cen
100 5O nil 8 20 58 37 nil 29
Per cent• 87 43 11 4 17 41 38 nil 20 2 5 S nil nil nil 22 nil nil 2 2 nil nil
Per cent. 72 51 22 4 13 44 30 2 19 4 2 8 4 nil nil 6 16 1 6 1 1 nil nil
Per
cent. 96 4O nil nil II 29 22
nil 18 nil
3 nil nil nil nil
nil 12 12 nil nil nil nil 8 nil 16 nil 4 nil nil
40 19 41 4 20
28 22 50 nil 27
60 nil 40 nil 16
57 nil 43 nil 20
62 7 31 6 20
62 14 24 nil 22
ail
nil
nil
4
nil
nil
far from good, yet they were not bad enough to label " delicate." T h e y were in a state of subrather than real-nutrition. T h e claim is c o m m o n l y put forward that the breast-fed infant not only scores during babyhood, but that he carries into life a greater resistance to disease, and that he may reasonably expect to achieve a higher degree of general health and stamina than one artificially fed. T h a t the infant mortality rate during the first few weeks of life is higher amongst the artificially fed than the breast-fed, no one would deny ; but is it true that the survivors amongst artificially fed infants carry with them into the succeeding years a lowered resistance to disease and an inferior standard of general health as compared with the breast-fed ? Table VI does not support this conclusion. With the exception of diphtheria, it does not show that artificially fed infants suffered more from illness in childhood than the breast-fed.
4
8
16 nil
nil nil 4 22
nil nil nil nil nil nil
Some illnesses, indeed ( e . g . , otitis media, chronic coryza, tonsillitis, and the exanthemata) seem to have had a markedly greater incidence u p o n those weaned late than u p o n those weaned early• Perhaps the greater incidence of pharyngeal diseases and otitis media amongst the breast-fed is attributable partly to the t e n d e n c y of breast-fed babies to be more fretful than the artificially fed, with the result that they are given the n o t o r i o u s " d u m m y " m o r e frequently. T h e figures grouped u n d e r " condition on examination " do give some s u p p o r t for the theory that breast feeding in infancy may influence favourably the general health in childhood, for the percentage of those in good general health is maintained at about 60 per cent. in those who were breast-fed from birth to between six and eighteen months ; whilst of those fed at the breast for shorter periods, only 28 to 40 per cent. enjoyed good health. Similarly, the percentage of " fair " and " delicate " children
1933.
PUBLIC HEALTH.
steadily falls as the period of breast feeding increases. It is noticeable that the rise in percentage of those in good health and the decline in percentage of those in poor health does not occur to any great extent until the six months column is reached, indicating the logical conclusion that for a method of infant feeding to have any permanent effect at all it must be continued for a long period. When all this has been said, it cannot be claimed that the figures in Table VI support the view that the health of the school child can be predetermined by the method of feeding during infancy alone. It is here submitted that there is on the part of medical practitioners, and of the general public, a tendency to feel that if only the infant can be piloted safely through the first year it will look after itself in the succeeding years. Even the forces of preventive medicine have been so concentrated upon the reduction of infant mortality (admittedly with striking success) on the one hand, and upon the health of the school child on the other, that the intervening period of the child's life has suffered a comparative neglect. True, the welfare centre is there to give advice on the management of children over one year, but most of the mothers cease to attend regularly after the baby's first birthday, either because attendance has been made difficult by the occurrence of another pregnancy, or--and this is the chief reason-because they fail to realise the necessity for doing so. No better example could be found of the general neglect of child welfare after the first year than in the figures in Table VI to the effect that the percentage (6 per cent.) of rachitic deformities is as high amongst the children who were breast-fed to 12 months, as amongst those who had no breast milk at all. In recent years the Chief Medical Officer to the Board of Education, in his annual reports, has pointed out from year to year that the mass of minor defects and crippling amongst school children remains unreduced despite the long sustained efforts of the school medical service. He thus deduces that the attention of the preventive service should be directed more to the care of the child from one to five years of age, so that its health may be maintained through the pre-school years, and the child delivered into the hands of the school medical service at a higher level of general health than heretofore, free from defects that are difficult or impossible to cure. The statistics given in Table VI, although working from the other end of the scale, lend themselves to the same conclusion.
363
I am indebted to Dr. J. J. Butterworth, County Medical Officer of Health, Lancashire, for permission to publish this paper. CONCLUSIONS.
(1) Of the infants attending two child welfare centres in South-East Lancashire during 1929 and 1930, only 50 per cent. were breast-fed to three months, 30 per cent. to six months, and 25 per cent. to nine months. (2) In at least 40 per cent. of those weaned prematurely, breast feeding could have been maintained if the mothers had been willing to seek advice before and after the birth of the child. (3) The breast-fed infant is not more resistant to disease in childhood than the artificially fed infant, and the general health of the school child cannot be pre-determined by the method of feeding (breast or artificial) during infancy. REFERENCES.
1Sir F. Truby King. Natural Feeding of Infants. 2Manning. Arch. Ped., Vol. XXXVII, No. 4, 1920. aAmer, flour. Obstet., 1912. 4Pooler, H. W. Annual Report, County Medical Officer of Health, Derbyshire, 1930. Hill, Practical Infant Feeding. W.B. Saunders Co., Philadelphia and London. Thomson. Clinical Study and Treatment of Sick Children. Oliver and Boyd, Edinburgh and London. Pearson and Wyllie. Recent Advances in Diseases of Children. J. and A. Churchill, London. Myers. Modern Infant Feeding. Jonathan Cape, London. The Annual Reports of the Chief Medical Officer of the Board of Education.
THE Third Biennial Conference on Mental Health will be held at Caxton Hall, Westminster, London, S.W.1, from November 22nd to 24th, 1933. The Conference will be opened by H.R.H. Prince George, K.G., and the subjects to be discussed include the following: " The Place of Mental Health in the Life of the Nation " ; " The Working of the Mental Treatment Act, 1930 . . . . . Sex Problems of Adolescence " ; " Suicide and Society " ; " The Neurotic " ; " Punishment or Treatment ? " ; " The Gambling Spirit as a National Problem " ; and " The Medical Attitude to Crime." Full information regarding the Conference may be obtained from the Secretary, National Council for Mental Hygiene, 78, Chandos House, Palmer Street, London, S.W.1.