Develop. Med. Child Nelwol. 1975, 17, 277-278
EDITORIAL CHANGING CONCEPTS OF RISK LIFEholds many hazards for infants and young children, but the main focus of anxiety about the risks has gradually altered. In the forties and early fifties the concern was with risk of death. Obstetric practice was poor by present-day standards and intensive neonatal care as we know it did not exist. In Britain, 70 or more of every thousand babies died in infancy. There have been great advances since then and the infant mortality rate in Britain has fallen to 17 or 18, yet this rate has been overtaken by other countries. In 1960, the infant mortality rate in England and Wales was 22 per thousand, in France it was 27 and in Japan 31 : ten years later, the rates were England and Wales 18, France 15 and Japan 13. Clearly we have not learned the lesson that low death-rates depend on well-organised health services. There are still too many areas in Britain, including some large cities, where obstetric and paediatric services leave much to be desired. In 1972, the infant mortality rate in Aberdeen was 13, yet in Glasgow it was 25. There is still far to go before standards are uniformly good throughout Britain and there is little indication that progress will be rapid. The problem of maldistribution of services is one shared by Britain, the United States’ and many other countries where effort is needed to make good mortality statistics better. During the late fifties, interest began to turn from death to the quality of life for survivors. In 1955, LILIENFELD and PASAMANICK~ introduced the phrase “a continuum of reproductive casualty” to indicate that events which kill some fetuses and infants cause neurodevelopmental disability i n others, of any degree from severe mental and physical handicap to scarcely measurable loss of potential intelligence. Obstetricians began to ask, “What kind of babies are we producing?” and turned to paediatricians for a quick answer. When it was realised that we cannot be sure about a child’s abilities for seven years or more, the idea of trying to predict them began to take root. It seemed as though concentration on the known obstetric antecedents of perinatal mortality, with close follow-up of surviving babies, might lead to earlier recognition of future disability. However, the limitations of ‘at risk’ registers soon became apparent3 and the enthusiasm with which they were started was diverted to developmental screening of all infants at set intervals from birth onwards-a practice now widely established in Britain, though as yet of unproven value. Another way of prophesying abnormality during this period, which some believed to hold great promise, was the diagnosis of future neurological status from neonatal behaviour. Much was learned by studying the reflexes of the 277
DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.
1975, 17
newborn infant and relating them to his subsequent progress, but it is fair to say that this approach proved disappointing, for it requires much time and greater expertise than was at first believed and the predictive value is relatively low. Even of newborn infants showing well-defined abnormal neurological signs, only a small proportion are abnormal later4?5. Although it is thus still difficult to give accurate information quickly enough to the obstetric team to allow responsive changes in their methods, there is much evidence that modern clinical practice has materially reduced the frequency and severity of later disability6-8. A new phase in the ‘at risk‘ concept is now developing-the risk of environmental disadvantage. We have always believed that the child born into a poor home has a less favoured start in life than one born ‘with a silver spoon in his mouth’, but popular misconception nurtured on tales of Abraham Lincoln and Andrew Carnegie has fostered the idea that children readily overcome initial adversity. Studies such as Born to Failg show clearly that, for the vast majority of children, early cultural deprivation means permanent educational and social disability just as great as the more obvious physical disabilities that follow perinatal insult. So we begin to ask “What kind of home is this infant born into? Is he at risk from disturbed family interrelationships? Is he even at risk of ill-treatment or death at the hands of his parents?” Growing concern about child abuse in all its ugliness-physical assault, mental cruelty and neglect-is iiicreasing pressure for early identification of the ‘at risk‘ situation. How can we recognize potential child abuse? How can we identify the mother who may inflict injury on her infant in the future? Can we show that enriching the child’s environment will favour development ? Studies progressing at Denver, Aberdeen and elsewhere may one day give us the answers but we cannot yet assess the practical value of such forecasting. Will it go the way of the ‘at risk‘ register and prediction by neonatal reflexes, or will it become a major new perinatal activity? Our readers will watch developments in this field with interest and anticipation. Ross G. MITCHELL REFERENCES 1. Kerr, L. E. (1975) ‘The poverty of affluence.’ American Journal of Public Health, 65, 17. 2. Lilienfeld, A. M., Pasamanick, B. (1955) ‘Association of maternal and fetal factors with development of cerebral palsy and epilepsy.’ American Journal of Obstetrics and Gynecology, 70, 93. 3. Rogers, M. G. H. (1971) ‘The early recognition of handicapping disorders in childhood.’ Developmental Medicine and Child Neurology, 13, 88. 4. De Souza, S. W., Milner, R. D. G. (1974) ‘Clinical and CSF studies in newborn infants with neurological abnormalities.’ Archives of Disease in Childhood, 49, 351. 5. Drillien, C. M. (1972) ‘Abnormal neurologic signs in the first year of life in low-birthweight infants: possible prognostic significance.’ Developmental Medicine and Child Neurology, 14, 515. 6. Rawlings, G . , Reynolds, E. 0. R., Stewart, A., Strang, L. B. (1971) ‘Changing prognosis for infants of very low birthweight.’ Lancet, i, 516. 7. Dinwiddie, R., Mellor, D. H.. Donaldson, S. H. C., Tunstall, M. E., Russell, G. (1974) ‘Quality of survival after artificial ventilation of the newborn.’ Archives of Disease in Childhood, 49, 703. 8 . Davies, P. A., Tizard, J. P. M. (1975) ‘Very low birthweight and subsequent neurological defect’ Developniental Medicine and Child Neurology, 17, 3 . 9. Wedge, P., Prosser, H. (1973) Born to Fail. London: National Children’s Bureau.
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EDITORIAL CHANGING CONCEPTS OF RISK LIFEholds many hazards for infants and young children, but the main focus of anxiety about the risks has gradually altered. In the forties and early fifties the concern was with risk of death. Obstetric practice was poor by present-day standards and intensive neonatal care as we know it did not exist. In Britain, 70 or more of every thousand babies died in infancy. There have been great advances since then and the infant mortality rate in Britain has fallen to 17 or 18, yet this rate has been overtaken by other countries. In 1960, the infant mortality rate in England and Wales was 22 per thousand, in France it was 27 and in Japan 31 : ten years later, the rates were England and Wales 18, France 15 and Japan 13. Clearly we have not learned the lesson that low death-rates depend on well-organised health services. There are still too many areas in Britain, including some large cities, where obstetric and paediatric services leave much to be desired. In 1972, the infant mortality rate in Aberdeen was 13, yet in Glasgow it was 25. There is still far to go before standards are uniformly good throughout Britain and there is little indication that progress will be rapid. The problem of maldistribution of services is one shared by Britain, the United States’ and many other countries where effort is needed to make good mortality statistics better. During the late fifties, interest began to turn from death to the quality of life for survivors. In 1955, LILIENFELD and PASAMANICK~ introduced the phrase “a continuum of reproductive casualty” to indicate that events which kill some fetuses and infants cause neurodevelopmental disability i n others, of any degree from severe mental and physical handicap to scarcely measurable loss of potential intelligence. Obstetricians began to ask, “What kind of babies are we producing?” and turned to paediatricians for a quick answer. When it was realised that we cannot be sure about a child’s abilities for seven years or more, the idea of trying to predict them began to take root. It seemed as though concentration on the known obstetric antecedents of perinatal mortality, with close follow-up of surviving babies, might lead to earlier recognition of future disability. However, the limitations of ‘at risk’ registers soon became apparent3 and the enthusiasm with which they were started was diverted to developmental screening of all infants at set intervals from birth onwards-a practice now widely established in Britain, though as yet of unproven value. Another way of prophesying abnormality during this period, which some believed to hold great promise, was the diagnosis of future neurological status from neonatal behaviour. Much was learned by studying the reflexes of the 277
DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY.
1975, 17
newborn infant and relating them to his subsequent progress, but it is fair to say that this approach proved disappointing, for it requires much time and greater expertise than was at first believed and the predictive value is relatively low. Even of newborn infants showing well-defined abnormal neurological signs, only a small proportion are abnormal later4?5. Although it is thus still difficult to give accurate information quickly enough to the obstetric team to allow responsive changes in their methods, there is much evidence that modern clinical practice has materially reduced the frequency and severity of later disability6-8. A new phase in the ‘at risk‘ concept is now developing-the risk of environmental disadvantage. We have always believed that the child born into a poor home has a less favoured start in life than one born ‘with a silver spoon in his mouth’, but popular misconception nurtured on tales of Abraham Lincoln and Andrew Carnegie has fostered the idea that children readily overcome initial adversity. Studies such as Born to Failg show clearly that, for the vast majority of children, early cultural deprivation means permanent educational and social disability just as great as the more obvious physical disabilities that follow perinatal insult. So we begin to ask “What kind of home is this infant born into? Is he at risk from disturbed family interrelationships? Is he even at risk of ill-treatment or death at the hands of his parents?” Growing concern about child abuse in all its ugliness-physical assault, mental cruelty and neglect-is iiicreasing pressure for early identification of the ‘at risk‘ situation. How can we recognize potential child abuse? How can we identify the mother who may inflict injury on her infant in the future? Can we show that enriching the child’s environment will favour development ? Studies progressing at Denver, Aberdeen and elsewhere may one day give us the answers but we cannot yet assess the practical value of such forecasting. Will it go the way of the ‘at risk‘ register and prediction by neonatal reflexes, or will it become a major new perinatal activity? Our readers will watch developments in this field with interest and anticipation. Ross G. MITCHELL REFERENCES 1. Kerr, L. E. (1975) ‘The poverty of affluence.’ American Journal of Public Health, 65, 17. 2. Lilienfeld, A. M., Pasamanick, B. (1955) ‘Association of maternal and fetal factors with development of cerebral palsy and epilepsy.’ American Journal of Obstetrics and Gynecology, 70, 93. 3. Rogers, M. G. H. (1971) ‘The early recognition of handicapping disorders in childhood.’ Developmental Medicine and Child Neurology, 13, 88. 4. De Souza, S. W., Milner, R. D. G. (1974) ‘Clinical and CSF studies in newborn infants with neurological abnormalities.’ Archives of Disease in Childhood, 49, 351. 5. Drillien, C. M. (1972) ‘Abnormal neurologic signs in the first year of life in low-birthweight infants: possible prognostic significance.’ Developmental Medicine and Child Neurology, 14, 515. 6. Rawlings, G . , Reynolds, E. 0. R., Stewart, A., Strang, L. B. (1971) ‘Changing prognosis for infants of very low birthweight.’ Lancet, i, 516. 7. Dinwiddie, R., Mellor, D. H.. Donaldson, S. H. C., Tunstall, M. E., Russell, G. (1974) ‘Quality of survival after artificial ventilation of the newborn.’ Archives of Disease in Childhood, 49, 703. 8 . Davies, P. A., Tizard, J. P. M. (1975) ‘Very low birthweight and subsequent neurological defect’ Developniental Medicine and Child Neurology, 17, 3 . 9. Wedge, P., Prosser, H. (1973) Born to Fail. London: National Children’s Bureau.
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