- Email: [email protected]
Neonatal Infection
294
urgently needing greater output, this question is highly important ; but if nutrition continues to be regarded, as a matter for guidance exclusively by nutritionists, and for purely interdepartmental discussion, we shall not be making full use of our opportunities to get the facts. Part-time
and its Future often said that part-time
Nursing
DURING the war it was nursing had been tried but had failed. Gloucestershire has made’ it clear that the failure lay not with the part-time workers but with those seeking to use them. Those who attended the Cheltenham conference (reported elsewhere in this issue) saw hospitals, staffed almost entirely by part-timers, running smoothly and giving to chronic-sick patients a standard of care not exceeded in first-class acute
hospitals.
-_
°
number of volunteers of all kinds in a fortnight was only 930-a total which must seem meagre to those familiar with the Cockney tradition of lending a friendly hand to neighbours in difficulties. But criticisms at the conference suggest that backwardness in volunteering is also partly. attributable to the Rushcliffe rates of pay which have been adopted. On this scale intermediate assistant nurses are paid 18. 5d. an hour, which is less than the rate recommended by the National Joint Council for ward orderlies doing domestic work ; and State-registered staff nurses are offered 2s. Id., which is less than the average pay of a metropolitan charwoman. There was a strong feeling at the conference that these rates should be reconsidered. May not the part-time principle have much wider applications than at present appear ? Speakers at Cheltenham felt it opened great possibilities for mental hospitals and sanatoria, and perhaps also for special hospitals and acute general hospitals. There were doubtswhether it could be applied in training schools, but further experiment may disperse even these : it is possible to conceive of a training in which hospital part-time workers,jointly with full-time trained staff, ensure the staffing of the ward, and thus release the sister for bedside teaching and the students for learning. The long-standing coinplaint that students bear the double burden of study and hospital service could thus be relieved. Wejnust not be faint-hearted if the implications of the parttime system turn out to be much greater than we
In his full account of an experiment for which he has been largely responsible, Mr. W. A. SHEE could not help revealing how much careful and human The deliberation had gone to make it succeed. essence of the scheme has been that part-time workers, whether State-registered nurses or raw recruits with no previous experience, have been regarded from the beginning as members of the hospital team, and given responsibility appropriate to their sense and experience. The result has been to attract a new type of woman into nursing ; or rather to attract good nurses who have been compelled to resign their career, and other able women who can give some but not all of originally supposed. their time to the care of the sick. There seems little doubt that we now have in our hands a complete Neonatal Infection answer to: the staffing difficulties of the infirmaries and the old for and the Ministries and institutions ailing, IT is probably fair to say that about a fifth of all of Health and Labour are warmly encouraging local deaths in the first four weeks of life are the result of authorities to follow Gloucestershire’s lead. The infection. Rather more than half of the total infant to the conference went back convinced, mortality occurs in this first month, which in England many visitors to principles to their own areas. Medical and Wales means some 18,000 deaths ; so each officers of health were not perhaps as numerous as year 3000-4000 babies die of infection, much of it1 could have been wished, but possibly the Society of preventable, in the first few weeks of life. The report Medical Officers of .Health would contemplate inviting of a subcommittee of the Scottish Scientific Advisory Dr. KENNETH COWAN and Mr. SHEE to open a disCommittee, under the chairmanship of Sir ALEXANDERcussion on part-time nursing at one of their meetings. MACGREGOR, which has been studying the causes, The success of such schemes, experience has shown, predisposing factors, and control of neonatal infection, depends on overcoming in advance the prejudice of shows that the neonatal mortality for Scotland during those who will have to work it, and especially the 1941-43 was 35-91 per thousand live births. The prejudices of matrons ; and nobody is better placed rates for maternity units ranged from 10’I1 per for this persuasive task than the medical officer of thousand in emergency hospitals taking only normal health. The prejudices of authorities can be dimin- cases to 52-2 per thousand in teaching institutions. ished by showing the Gloucestershire balance-sheet, which admit a high proportion of abnormal cases and where expenditure of E10,000 a year on transport is have a premature-birth rate of 12-7% compared with in other ways. entirely 2’8% in the emergency hospitals. The proportion of Londoners will have noticed that a part-time scheme these deaths attributed to infection ranged around was launched on Feb. 15 for the Greater London area, 10%, but where clinical diagnosis was checked by in need. The the are L.C.C. careful greatest where hospitals post-mortem examination this proportion daily press has published lists of hospitals to which was doubled. volunteers can apply; the Ministry of Labour The principal form of fatal neonatal infection was resettlement advice offices are also taking particulars pneumonia, of which Dr. AcNES MACGREGOR has from volunteers and forwarding them to the nearest described four main varieties. The first is chieflv hospital wanting part-time workers ; and specially associated with birth asphyxia, and deaths difficult cases are being put through the London occur in the first three days of life ; its prevention Appointments Office, at 23, Portman Square, W.l, lies chiefly with the obstetrician. The second, septic which is acting as a clearing-house for the whole area. aspiration pneumonia, also most common in the first The appeal unfortunately coincided with the fuel Deaths Due to Infection. Edinburgh: H.M. Stationery crisis, and this no doubt partly explains why the 1. Neonatal Office. 1947. Pp. 43. 9d.
carry the
compensated
.
usually
295
iew days of life, is due to inhalation of milk or regurgitated stomach contents ; its prevention is dependent on care in the feeding and nursing of the infant. The
third, staphylococcal pneumonia,
is
commoner
in the
neonatal- period than at any other time of life and frequently arises in small outbreaks ; while the
fourth, bronchopneumonia similar to that in older infants, may be due to organisms, such as Bact. coli,
which are not usually associated with pneumonic infection. Many of these pneumonias, which are most common in premature infants and are often related to faults in lung function, are undetected clinically because of the absence of cough, fever, and dyspnoea ; while cyanosis, when present, may suggest asphyxia or cerebral hsemorrhage. In Scotland, in the three years covered by the report, neonatal diarrhoea was responsible for much fewer deaths than respiratory infections, and outbreaks of neonatal diarrhoea were rare, but the committee cite Prof. CHARLES McNEIL’S figures showing an incidence of diarrhoea ten times higher in premature than in full-time babies. The committee also comment on the much greater resistance to intestinal infection among breast-fed than among artificially fed infants, a point well illustrated by the figures from Cincinnati,2 where of 221 infants admitted to hospital for diarrhoea all. but3 had been bottle-fed. The .committee give sound advice on prevention. Emphasis is rightly laid on the adequacy and quality of the nursery nursing staff. They should be sufficient in number for the work to be careful and unhurried ; there should be a nucleus of permanent trained staff to ensure continuity of treatment; and a basic nursing technique should be fully understood and practised. The nursery nurse or " auxiliary worker " (who may range in age from 17 to 45 years), being a permanent member of the nursing staff, is more useful than the pupil-midwife who spends only 4-6 weeks in the nursery. The nursery should be under the charge of a, paediatrician skilled in the care of young babies, and records should be kept of the day-to-day progress of each infant so that any minor infection or loss of weight is noted and attended to early. Mothers need more instruction in the care of the infant and in breastfeeding, WALLER’Sstudies on lactation being borne in mind ; this may mean a larger staff and a longer stay in hospital, and, before the mother leaves hospital, cooperation between the health visitors and -the hospital midwives. The committee were divided in their views about keeping infant and mother together or having a separate nursery for the healthy babies. If separate nurseries are provided they should be small, containing only 4-6 cots and allowing 40 sq. ft. per cot; the cots should be properly spaced and not crowded cheek byjowl along one side of the room as they often are. A separate nursery with a number of single rooms should be provided for sick and premature infants and for infected cases requiring isolation. For premature infants the committee favour a ward unit of 4 cots kept at a temperature of 75-80° F and a relative humidity of 70%, and they recommend the nursing technique evolved by Dr. MARY CROSSE in Birmingham. Prematurity is clearly the most important predisposing factor in fatal infections. Thus in the two 2. Weihl, C., Rapoport, S., Dodd, K. J. Pediat. 1947, 30, 45. 3. Waller, H. Lancet, 1943, i, 69; Arch. Dis. Childh. 1946, 21, 105.
the death-rates 5.4 and 5-7 per thousand among mature babies but 79 and 75 per thousand among premature infants. In the four Glasgow corporation hospitals, where the proportion of abnormal cases is much smaller, death-rates from infection among full-time and premature babies were 3-4 and 29 per thousand. Of the neonatal deaths from all causes, 70% were in premature infants. The causes of but the studies prematurity require further elucidation, of BAIRD4 and SUTHERLAND 5 indicate that poverty and poor nutrition of the mother are important factors, and the remarkable reduction in the stillbirthrate and neonatal mortality during the war years is probably a reflection of better nutrition in the lowest social classes, among whom premature births are most common. A reduction in the prematurity-rate, now around 7%, must be the long-term policy in the control of neonatal mortality. Meanwhile, this report points the way to the preventive measures that should be pra.ctised in every maternity unit.
largest Scottish teaching hospitals from infection
were
Annotations DIVORCE
TiiE great argument against divorce is the-bad effect of a broken home on children. In their final report,6 the Committee on Procedure in Matrimonial Causes, whose chairman is Mr. Justice Denning, pay special attention to the child, and consider in detail possiblemeans of reconciling the parents. Reconciliation work has so far been mostly done by voluntary bodies, someof them religious. Court missionaries and probation officers have also helped estranged couples to understand each other better, and so have the Family Welfare Association, and the Sailors’, Soldiers’ and Airmen’s Families Association. Since 1937 magistrates have been officially permitted to ask a probation officer or other person to try to reconcile parties seeking separation or divorce. Under the Army and R.A.F. Legal Aid Scheme some 27,000 applicants for divorce (a quarter of all those applying) have been reconciled ; and in civilian life the Marriage Guidance Council, founded in 1938 and reconstituted in 1943, has done successful work At its centres selected people act as counsellors," interviewing those who apply and often referring them, according to their needs, to a consultant, who may be a. doctor or psychologist, an ethical or spiritual adviser, a social worker, or a lawyer. The Denning Committee find that the prospects of reconciliation are most favourable in the early stages of disharmony, and in families where there are children. For success, one of the couple must seek help of his or her own free will; and each must be sure that nothing told to the adviser will be repeated to the other partner without permission. The personal relationship with the adviser is so important that churches, voluntary societies, and individuals have a much better chance than a State institution would. Unfortunately the law relating to collusion and condonation hampers. attempts at reconciliation : fear that the divorce may be quashedmakes each partner reluctant to offer oraccept advances. Actually, the law about collusion: does not forbid discussions with a view to reconciliation, or about the future of the children, the house and furniture, maintenance, or costs. Condonation, on the otherhand, presents a more serious bar to reconciliation, because one act of sexual intercourse cancels out an "
4. Baird, D. J. Obstet. Gynæc. 1945, 52, 5. Sutherland, I. Lancet, 1946, ii, 953. 6. Cmd. 7024. H.M. Stationery Office.
339. Pp. 36.
9d.
urgently needing greater output, this question is highly important ; but if nutrition continues to be regarded, as a matter for guidance exclusively by nutritionists, and for purely interdepartmental discussion, we shall not be making full use of our opportunities to get the facts. Part-time
and its Future often said that part-time
Nursing
DURING the war it was nursing had been tried but had failed. Gloucestershire has made’ it clear that the failure lay not with the part-time workers but with those seeking to use them. Those who attended the Cheltenham conference (reported elsewhere in this issue) saw hospitals, staffed almost entirely by part-timers, running smoothly and giving to chronic-sick patients a standard of care not exceeded in first-class acute
hospitals.
-_
°
number of volunteers of all kinds in a fortnight was only 930-a total which must seem meagre to those familiar with the Cockney tradition of lending a friendly hand to neighbours in difficulties. But criticisms at the conference suggest that backwardness in volunteering is also partly. attributable to the Rushcliffe rates of pay which have been adopted. On this scale intermediate assistant nurses are paid 18. 5d. an hour, which is less than the rate recommended by the National Joint Council for ward orderlies doing domestic work ; and State-registered staff nurses are offered 2s. Id., which is less than the average pay of a metropolitan charwoman. There was a strong feeling at the conference that these rates should be reconsidered. May not the part-time principle have much wider applications than at present appear ? Speakers at Cheltenham felt it opened great possibilities for mental hospitals and sanatoria, and perhaps also for special hospitals and acute general hospitals. There were doubtswhether it could be applied in training schools, but further experiment may disperse even these : it is possible to conceive of a training in which hospital part-time workers,jointly with full-time trained staff, ensure the staffing of the ward, and thus release the sister for bedside teaching and the students for learning. The long-standing coinplaint that students bear the double burden of study and hospital service could thus be relieved. Wejnust not be faint-hearted if the implications of the parttime system turn out to be much greater than we
In his full account of an experiment for which he has been largely responsible, Mr. W. A. SHEE could not help revealing how much careful and human The deliberation had gone to make it succeed. essence of the scheme has been that part-time workers, whether State-registered nurses or raw recruits with no previous experience, have been regarded from the beginning as members of the hospital team, and given responsibility appropriate to their sense and experience. The result has been to attract a new type of woman into nursing ; or rather to attract good nurses who have been compelled to resign their career, and other able women who can give some but not all of originally supposed. their time to the care of the sick. There seems little doubt that we now have in our hands a complete Neonatal Infection answer to: the staffing difficulties of the infirmaries and the old for and the Ministries and institutions ailing, IT is probably fair to say that about a fifth of all of Health and Labour are warmly encouraging local deaths in the first four weeks of life are the result of authorities to follow Gloucestershire’s lead. The infection. Rather more than half of the total infant to the conference went back convinced, mortality occurs in this first month, which in England many visitors to principles to their own areas. Medical and Wales means some 18,000 deaths ; so each officers of health were not perhaps as numerous as year 3000-4000 babies die of infection, much of it1 could have been wished, but possibly the Society of preventable, in the first few weeks of life. The report Medical Officers of .Health would contemplate inviting of a subcommittee of the Scottish Scientific Advisory Dr. KENNETH COWAN and Mr. SHEE to open a disCommittee, under the chairmanship of Sir ALEXANDERcussion on part-time nursing at one of their meetings. MACGREGOR, which has been studying the causes, The success of such schemes, experience has shown, predisposing factors, and control of neonatal infection, depends on overcoming in advance the prejudice of shows that the neonatal mortality for Scotland during those who will have to work it, and especially the 1941-43 was 35-91 per thousand live births. The prejudices of matrons ; and nobody is better placed rates for maternity units ranged from 10’I1 per for this persuasive task than the medical officer of thousand in emergency hospitals taking only normal health. The prejudices of authorities can be dimin- cases to 52-2 per thousand in teaching institutions. ished by showing the Gloucestershire balance-sheet, which admit a high proportion of abnormal cases and where expenditure of E10,000 a year on transport is have a premature-birth rate of 12-7% compared with in other ways. entirely 2’8% in the emergency hospitals. The proportion of Londoners will have noticed that a part-time scheme these deaths attributed to infection ranged around was launched on Feb. 15 for the Greater London area, 10%, but where clinical diagnosis was checked by in need. The the are L.C.C. careful greatest where hospitals post-mortem examination this proportion daily press has published lists of hospitals to which was doubled. volunteers can apply; the Ministry of Labour The principal form of fatal neonatal infection was resettlement advice offices are also taking particulars pneumonia, of which Dr. AcNES MACGREGOR has from volunteers and forwarding them to the nearest described four main varieties. The first is chieflv hospital wanting part-time workers ; and specially associated with birth asphyxia, and deaths difficult cases are being put through the London occur in the first three days of life ; its prevention Appointments Office, at 23, Portman Square, W.l, lies chiefly with the obstetrician. The second, septic which is acting as a clearing-house for the whole area. aspiration pneumonia, also most common in the first The appeal unfortunately coincided with the fuel Deaths Due to Infection. Edinburgh: H.M. Stationery crisis, and this no doubt partly explains why the 1. Neonatal Office. 1947. Pp. 43. 9d.
carry the
compensated
.
usually
295
iew days of life, is due to inhalation of milk or regurgitated stomach contents ; its prevention is dependent on care in the feeding and nursing of the infant. The
third, staphylococcal pneumonia,
is
commoner
in the
neonatal- period than at any other time of life and frequently arises in small outbreaks ; while the
fourth, bronchopneumonia similar to that in older infants, may be due to organisms, such as Bact. coli,
which are not usually associated with pneumonic infection. Many of these pneumonias, which are most common in premature infants and are often related to faults in lung function, are undetected clinically because of the absence of cough, fever, and dyspnoea ; while cyanosis, when present, may suggest asphyxia or cerebral hsemorrhage. In Scotland, in the three years covered by the report, neonatal diarrhoea was responsible for much fewer deaths than respiratory infections, and outbreaks of neonatal diarrhoea were rare, but the committee cite Prof. CHARLES McNEIL’S figures showing an incidence of diarrhoea ten times higher in premature than in full-time babies. The committee also comment on the much greater resistance to intestinal infection among breast-fed than among artificially fed infants, a point well illustrated by the figures from Cincinnati,2 where of 221 infants admitted to hospital for diarrhoea all. but3 had been bottle-fed. The .committee give sound advice on prevention. Emphasis is rightly laid on the adequacy and quality of the nursery nursing staff. They should be sufficient in number for the work to be careful and unhurried ; there should be a nucleus of permanent trained staff to ensure continuity of treatment; and a basic nursing technique should be fully understood and practised. The nursery nurse or " auxiliary worker " (who may range in age from 17 to 45 years), being a permanent member of the nursing staff, is more useful than the pupil-midwife who spends only 4-6 weeks in the nursery. The nursery should be under the charge of a, paediatrician skilled in the care of young babies, and records should be kept of the day-to-day progress of each infant so that any minor infection or loss of weight is noted and attended to early. Mothers need more instruction in the care of the infant and in breastfeeding, WALLER’Sstudies on lactation being borne in mind ; this may mean a larger staff and a longer stay in hospital, and, before the mother leaves hospital, cooperation between the health visitors and -the hospital midwives. The committee were divided in their views about keeping infant and mother together or having a separate nursery for the healthy babies. If separate nurseries are provided they should be small, containing only 4-6 cots and allowing 40 sq. ft. per cot; the cots should be properly spaced and not crowded cheek byjowl along one side of the room as they often are. A separate nursery with a number of single rooms should be provided for sick and premature infants and for infected cases requiring isolation. For premature infants the committee favour a ward unit of 4 cots kept at a temperature of 75-80° F and a relative humidity of 70%, and they recommend the nursing technique evolved by Dr. MARY CROSSE in Birmingham. Prematurity is clearly the most important predisposing factor in fatal infections. Thus in the two 2. Weihl, C., Rapoport, S., Dodd, K. J. Pediat. 1947, 30, 45. 3. Waller, H. Lancet, 1943, i, 69; Arch. Dis. Childh. 1946, 21, 105.
the death-rates 5.4 and 5-7 per thousand among mature babies but 79 and 75 per thousand among premature infants. In the four Glasgow corporation hospitals, where the proportion of abnormal cases is much smaller, death-rates from infection among full-time and premature babies were 3-4 and 29 per thousand. Of the neonatal deaths from all causes, 70% were in premature infants. The causes of but the studies prematurity require further elucidation, of BAIRD4 and SUTHERLAND 5 indicate that poverty and poor nutrition of the mother are important factors, and the remarkable reduction in the stillbirthrate and neonatal mortality during the war years is probably a reflection of better nutrition in the lowest social classes, among whom premature births are most common. A reduction in the prematurity-rate, now around 7%, must be the long-term policy in the control of neonatal mortality. Meanwhile, this report points the way to the preventive measures that should be pra.ctised in every maternity unit.
largest Scottish teaching hospitals from infection
were
Annotations DIVORCE
TiiE great argument against divorce is the-bad effect of a broken home on children. In their final report,6 the Committee on Procedure in Matrimonial Causes, whose chairman is Mr. Justice Denning, pay special attention to the child, and consider in detail possiblemeans of reconciling the parents. Reconciliation work has so far been mostly done by voluntary bodies, someof them religious. Court missionaries and probation officers have also helped estranged couples to understand each other better, and so have the Family Welfare Association, and the Sailors’, Soldiers’ and Airmen’s Families Association. Since 1937 magistrates have been officially permitted to ask a probation officer or other person to try to reconcile parties seeking separation or divorce. Under the Army and R.A.F. Legal Aid Scheme some 27,000 applicants for divorce (a quarter of all those applying) have been reconciled ; and in civilian life the Marriage Guidance Council, founded in 1938 and reconstituted in 1943, has done successful work At its centres selected people act as counsellors," interviewing those who apply and often referring them, according to their needs, to a consultant, who may be a. doctor or psychologist, an ethical or spiritual adviser, a social worker, or a lawyer. The Denning Committee find that the prospects of reconciliation are most favourable in the early stages of disharmony, and in families where there are children. For success, one of the couple must seek help of his or her own free will; and each must be sure that nothing told to the adviser will be repeated to the other partner without permission. The personal relationship with the adviser is so important that churches, voluntary societies, and individuals have a much better chance than a State institution would. Unfortunately the law relating to collusion and condonation hampers. attempts at reconciliation : fear that the divorce may be quashedmakes each partner reluctant to offer oraccept advances. Actually, the law about collusion: does not forbid discussions with a view to reconciliation, or about the future of the children, the house and furniture, maintenance, or costs. Condonation, on the otherhand, presents a more serious bar to reconciliation, because one act of sexual intercourse cancels out an "
4. Baird, D. J. Obstet. Gynæc. 1945, 52, 5. Sutherland, I. Lancet, 1946, ii, 953. 6. Cmd. 7024. H.M. Stationery Office.
339. Pp. 36.
9d.