542 10-12 h is difficult and it should be tailored to the individual baby’s needs. It seems sensible, however, to encourage the breast-feeding mother to wake her baby for a feed when she goes to bed to see whether some milk can be taken. Hospitals have an important role in getting breastfeeding off to a good start. In one study 10-15 min suckling immediately after birth significantly prolonged the duration of breast-feeding.6Lactation is also established sooner in hospital and continued for longer at home with 2-hourly feeding in the early post-partum period followed by demand feeding.’ The sooner lactation is established the greater will be the mother’s confidence in her ability to breast-feed and this is likely to improve further her production of milk. Community health workers (particularly clinic health visitors and doctors) must become aware that breastfeeding does not exempt babies from being underfed. By paying careful attention to breast-feeding mothers who attend clinics and who might be particularly vulnerable (e.g., those who are breast-feeding for the first time) the problem might be anticipated and, with appropriate counsel, prevented. Monitoring weight-gain in clinics could also be helpful (although great care must be taken not to make mothers over anxious. Provided that babies are weighed with a minimum of clothes and individual weights are plotted on centile charts any downward shift can be noted. Although this does not always indicate failure to thrive, it should nonetheless be an indication at least to examine the baby for signs of poor nutrition, to take careful details of breast-feeding management, and to arrange further clinic visits to review the pattern of weight-gain.
Diagnosis Underfeeding at the breast must be recognised as a likely diagnosis in breast-fed infants who are failing to thrive. A careful feeding history with details of times, length, and vigour of breast-feeding and the baby’s overall behaviour must be taken. The diagnosis is usually confirmed when test weighing over a 24-48 h period indicates that less than adequate amounts of breast-milk are being taken. However, illness in a baby might be responsible for poor feeding and vomiting, and investigation for infection (e.g., urinary tract) and other causes of vomiting (e.g., pyloric stenosis) should be considered. TREATMENT
,
For the contented underfed baby it is sometimes worthwhile trying to increase the frequency of breastfeeding (provided that this is what the mother wishes and that she is able to stay in hospital with her baby). If increasing the frequency of feeding does not produce satisfactory weight-gain and test feeds confirm that this failure is due to insufficient breast-milk, complementary or total bottle-feeds will be needed. For the fretful underfed baby possible reasons for poor milk production must be considered. The baby should be carefully examined for oral and perianal thrush which can often cause restlessness. Worry or over-zealousness by the mother or a poor feeding technique might be responsible. The naturally nervous baby who is often a difficult feeder poses difficulties but chloral hydrate (30-60 mg) given 10 min before the feed
be of great value in calming these infants to allow proper feeding.’ It is also important to check that the breast is empty after each feed, if necessary by artificial expression. If these various faults can be corrected a successful breast-feeding pattern may be established. However, if all these approaches fail, complementary or total bottle-feeding will again be needed to make the baby thrive. In my experience very few mothers whose breastfed babies are admitted to hospital because of failure to thrive continue to breast-feed satisfactorily. can
CONCLUSION
Many doctors and nurses brought up in a tradition of bottle-feeding are not familiar with the practical aspects of the management of breast-feeding. A view has been expressed that drawing attention to the failure of breastfeeding will not help to encourage breast-feeding.8 However, I believe that we must learn as much as we can about such failure. Far from being discouraging, a better understanding might lead to an increase in the number of babies who can be breast-fed successfully. REFERENCES
1. Pearson, W. J., Wylie, W. G. Recent Advances in Diseases of Children, p. 61. London, 1930. 2. Newton, M., Newton, N. R. J. Am. med. Ass 1962, 181, 206. 3. Applebaum, R. M. Pediat. Clins N. Am. 1970, 17, 203. 4. Davies, D. P., Evans, T. J. Lancet, 1977, ii, 1194. 5. Evans, T. J., Davies, D. P. Archs Dis. Childh. 1977, 52, 974. 6. de Chateau, P., Winberg, J. J. mat. Child Hlth, 1978, 3, 392. 7. Salariya, E. M., Easton, P. M., Cater, J. I. Lancet, 1978, ii, 1141. 8. Frantz, K. B., Magnus, P. D. Archs Dis. Childh. 1978, 53, 967.
Points of View NOW LET ME SEE R. A. WEALE
Department of Visual Science, Institute of Ophthalmology, London WC1 9QS MUCH visual disability in developing countries is preventable. The expenditure required need not be large, for vast benefits can flow from small investment in eye problems. Health authorities in developing countries must be made to see that these benefits are not only humanitarian but can be economic. Compared with the problems caused by diseases of poverty, in which lack of hygiene, malnutrition, or infection are aided by habit, tradition, religious belief, and ignorance, the problems of ametropia may seem superficial. But this is wrong, as a special W.H.O.-sponsored meeting at the London School of Hygiene and Tropical Medicine last September made clear. If a farmer is provided with gear enabling him to mechanise agriculture and multiply his output, the investment will be wasted if severe astigmatism stops him from deciphering the instructions for use. If an enlightened country wishes to sponsor adult literacy schemes, the effort may come to naught if the grown-up scholars cannot get the print into focus. People with presbyopia need spectacles. To provide them in a developing country, much of the basic approach familiar in developed countries may have to be abandoned. A country-wide attempt to plan the provi-
543 sion of spectacle corrections seems to need answers to the following questions: (1) what is the country’s agedistribution ? (2) what is the distribution of its ametropia ? (3) what means are there for testing eyesight? (4) what facilities are there for getting spectacles to the patient ? (5) what is the incidence of cataract?
(1) is needed because presbyopia is universal though its onset varies widely.If the lifein a given region is, say, 31 years, and the expectancy is population small, presbyopia is unlikely to be a problem. But while half the population is aged less than 15 in both Malawi and Mexico, the population of Mexico An
answer to
last May. It is also one of the action programmes of the W.H.O. It seems curious that the relief of ametropia in general, and of presbyopia in particular, has barely been considered. Although these disorders are less urgent on humanitarian grounds than preventable blindness, treating them offers quicker economic returns, especially as the life-span in developing countries lengthens.
even
REFERENCES 1. Weale, R. A. The Aging Eye. 2. W.H.O Chronicle, 32, 299.
is 66 million and will therefore demand more resources than will the people of Malawi (4 million). It is clear, therefore, that life-expectancy and population tables are needed for a rational world-wide approach to the problem of presbyopia. One need hardly add that the return on such an investment-the prolongation, or at least the improvement, of the individual’s average working life-would dwarf the investment needed to achieve it.
Round the World
From
How refractive errors are distributed with age and region is little known. Hypermetropia prevails in the west and myopia in Japan. Emmetropia appears, anecdotally, to be widespread in central East Africa but no reliable figure is available. Before a crash programme for the provision of spectacles could be mounted, a prudent manufacturer would want such figures. This applies also to aphakic corrections.
Facilities for testing
eyesight in developing countries Western standards, but this is hardly relevant. Until 1958 it was possible in the U.K. to select acceptable spectacles from baskets on store counters. Even though it lacks the precise refractive measurement now regarded as necessary in this country, this approach has obvious attractions where professional ophthalmic service is expensive, scarce, or absent. In Malawi, distributing (discarded) glasses in this way relieved a great deal of eyestrain. It has to be recognised2 that health centres, schools, and perhaps churches could mediate between suppliers and patients. are
poor
by
brings us to the matter of cost. Although "faulty" glasses are unpleasant and may be uncomfortable, no one has been able to show that they can cause organic damage. Self-selection of spectacles with a limited range of pre-determined dioptric values appears to be safe and certainly offers the speediest help to the largest number of ametropes. Yet patients in poor countries cannot afford to pay the prices charged for a pair of glasses. This problem was put to Malawi’s Minister of This
Health but his chief concern was with the scourge of river-blindness. Was there no vaccine to deal with the disease? Nor a chemical way of treating presbyopia? Here is the problem of communication between developed and developing countries in a nutshell. River-blindness can be dealt with by improving hygiene but this means interfering with time-honoured habits. On the other hand, the solution to the problem of ametropia has no traditional barriers to surmount but the condition itself has no political impact. The stamping out of preventable blindness within the decade was made one of the objectives of the 23rd International Ophthalmological Congress held in Kyoto next
London, 1963.
our
Correspondents
United States THE
PRESIDENT’S
PLANS FOR HEALTH CARE
THE Administration’s budget proposals are, as expected, rousing criticism from all sides. The sums allotted to medical and basic research are slightly augmented, the grants to medical schools will fall (to give deans fresh headaches), and the social services are also to be cut, marginally. Under attack from all sides, the President is stoutly defending his proposals and contending, not unreasonably, that inflation is our biggest problem and that rising costs affect the poor and the retired on fixed incomes more than the rich. Inflation has been particularly severe on health costs, and the lack of any specific proposals here has brought criticism from Senator Kennedy and the liberal wing of the Democratic party, who do not like the cuts in social-service programmes as a whole. Still presenting evidence of monstrous health bills which have bankrupted some U.S. families hit by catastrophic illness, Senator Kennedy and various columnists have been drawing comparisons with Canada, where bills seemingly equally monstrous have been paid by the national health insurance scheme. All this is much aggravated by the inadequacies of Medicare and Medicaid, especially when these agencies are unwilling to pay the fees the physicians ask.
Amidst all this, the President has not abandoned consideranew health proposals and Mr Califano, Secretary for Health, Education and Welfare, has been busy drafting proposals for implementation by stages of a national health programme. Details of the proposals are, as is usual, leaking out to the Press. It is reported that in the first phases Medicare coverage for the aged would be expanded and Medicaid extended to low-income prospective mothers and their children. There would also be insurance against catastrophic illness to protect against medical bills of more than$50 000. All these could no doubt be readily implemented without serious opposition. tion of
But the first phase would set strict limits on hospital costs and it would also require doctors to accept uniform negotiated fees rather than being allowed to set their own rates. This too sounds reasonable and acceptable-provided that it is accepted by other suppliers of goods and services to physicians. Consideration of my own grocery, meat, fuel, utility, and domestic bills, let alone the medical costs, malpraxis insurance, stationery, and equipment, and to speak of postage and gasoline have all shown enormous increases of recent years. If I am forced to accept a uniform negotiated fee will all those who provide me with goods and services accept uniform negotiated
Diagnosis Underfeeding at the breast must be recognised as a likely diagnosis in breast-fed infants who are failing to thrive. A careful feeding history with details of times, length, and vigour of breast-feeding and the baby’s overall behaviour must be taken. The diagnosis is usually confirmed when test weighing over a 24-48 h period indicates that less than adequate amounts of breast-milk are being taken. However, illness in a baby might be responsible for poor feeding and vomiting, and investigation for infection (e.g., urinary tract) and other causes of vomiting (e.g., pyloric stenosis) should be considered. TREATMENT
,
For the contented underfed baby it is sometimes worthwhile trying to increase the frequency of breastfeeding (provided that this is what the mother wishes and that she is able to stay in hospital with her baby). If increasing the frequency of feeding does not produce satisfactory weight-gain and test feeds confirm that this failure is due to insufficient breast-milk, complementary or total bottle-feeds will be needed. For the fretful underfed baby possible reasons for poor milk production must be considered. The baby should be carefully examined for oral and perianal thrush which can often cause restlessness. Worry or over-zealousness by the mother or a poor feeding technique might be responsible. The naturally nervous baby who is often a difficult feeder poses difficulties but chloral hydrate (30-60 mg) given 10 min before the feed
be of great value in calming these infants to allow proper feeding.’ It is also important to check that the breast is empty after each feed, if necessary by artificial expression. If these various faults can be corrected a successful breast-feeding pattern may be established. However, if all these approaches fail, complementary or total bottle-feeding will again be needed to make the baby thrive. In my experience very few mothers whose breastfed babies are admitted to hospital because of failure to thrive continue to breast-feed satisfactorily. can
CONCLUSION
Many doctors and nurses brought up in a tradition of bottle-feeding are not familiar with the practical aspects of the management of breast-feeding. A view has been expressed that drawing attention to the failure of breastfeeding will not help to encourage breast-feeding.8 However, I believe that we must learn as much as we can about such failure. Far from being discouraging, a better understanding might lead to an increase in the number of babies who can be breast-fed successfully. REFERENCES
1. Pearson, W. J., Wylie, W. G. Recent Advances in Diseases of Children, p. 61. London, 1930. 2. Newton, M., Newton, N. R. J. Am. med. Ass 1962, 181, 206. 3. Applebaum, R. M. Pediat. Clins N. Am. 1970, 17, 203. 4. Davies, D. P., Evans, T. J. Lancet, 1977, ii, 1194. 5. Evans, T. J., Davies, D. P. Archs Dis. Childh. 1977, 52, 974. 6. de Chateau, P., Winberg, J. J. mat. Child Hlth, 1978, 3, 392. 7. Salariya, E. M., Easton, P. M., Cater, J. I. Lancet, 1978, ii, 1141. 8. Frantz, K. B., Magnus, P. D. Archs Dis. Childh. 1978, 53, 967.
Points of View NOW LET ME SEE R. A. WEALE
Department of Visual Science, Institute of Ophthalmology, London WC1 9QS MUCH visual disability in developing countries is preventable. The expenditure required need not be large, for vast benefits can flow from small investment in eye problems. Health authorities in developing countries must be made to see that these benefits are not only humanitarian but can be economic. Compared with the problems caused by diseases of poverty, in which lack of hygiene, malnutrition, or infection are aided by habit, tradition, religious belief, and ignorance, the problems of ametropia may seem superficial. But this is wrong, as a special W.H.O.-sponsored meeting at the London School of Hygiene and Tropical Medicine last September made clear. If a farmer is provided with gear enabling him to mechanise agriculture and multiply his output, the investment will be wasted if severe astigmatism stops him from deciphering the instructions for use. If an enlightened country wishes to sponsor adult literacy schemes, the effort may come to naught if the grown-up scholars cannot get the print into focus. People with presbyopia need spectacles. To provide them in a developing country, much of the basic approach familiar in developed countries may have to be abandoned. A country-wide attempt to plan the provi-
543 sion of spectacle corrections seems to need answers to the following questions: (1) what is the country’s agedistribution ? (2) what is the distribution of its ametropia ? (3) what means are there for testing eyesight? (4) what facilities are there for getting spectacles to the patient ? (5) what is the incidence of cataract?
(1) is needed because presbyopia is universal though its onset varies widely.If the lifein a given region is, say, 31 years, and the expectancy is population small, presbyopia is unlikely to be a problem. But while half the population is aged less than 15 in both Malawi and Mexico, the population of Mexico An
answer to
last May. It is also one of the action programmes of the W.H.O. It seems curious that the relief of ametropia in general, and of presbyopia in particular, has barely been considered. Although these disorders are less urgent on humanitarian grounds than preventable blindness, treating them offers quicker economic returns, especially as the life-span in developing countries lengthens.
even
REFERENCES 1. Weale, R. A. The Aging Eye. 2. W.H.O Chronicle, 32, 299.
is 66 million and will therefore demand more resources than will the people of Malawi (4 million). It is clear, therefore, that life-expectancy and population tables are needed for a rational world-wide approach to the problem of presbyopia. One need hardly add that the return on such an investment-the prolongation, or at least the improvement, of the individual’s average working life-would dwarf the investment needed to achieve it.
Round the World
From
How refractive errors are distributed with age and region is little known. Hypermetropia prevails in the west and myopia in Japan. Emmetropia appears, anecdotally, to be widespread in central East Africa but no reliable figure is available. Before a crash programme for the provision of spectacles could be mounted, a prudent manufacturer would want such figures. This applies also to aphakic corrections.
Facilities for testing
eyesight in developing countries Western standards, but this is hardly relevant. Until 1958 it was possible in the U.K. to select acceptable spectacles from baskets on store counters. Even though it lacks the precise refractive measurement now regarded as necessary in this country, this approach has obvious attractions where professional ophthalmic service is expensive, scarce, or absent. In Malawi, distributing (discarded) glasses in this way relieved a great deal of eyestrain. It has to be recognised2 that health centres, schools, and perhaps churches could mediate between suppliers and patients. are
poor
by
brings us to the matter of cost. Although "faulty" glasses are unpleasant and may be uncomfortable, no one has been able to show that they can cause organic damage. Self-selection of spectacles with a limited range of pre-determined dioptric values appears to be safe and certainly offers the speediest help to the largest number of ametropes. Yet patients in poor countries cannot afford to pay the prices charged for a pair of glasses. This problem was put to Malawi’s Minister of This
Health but his chief concern was with the scourge of river-blindness. Was there no vaccine to deal with the disease? Nor a chemical way of treating presbyopia? Here is the problem of communication between developed and developing countries in a nutshell. River-blindness can be dealt with by improving hygiene but this means interfering with time-honoured habits. On the other hand, the solution to the problem of ametropia has no traditional barriers to surmount but the condition itself has no political impact. The stamping out of preventable blindness within the decade was made one of the objectives of the 23rd International Ophthalmological Congress held in Kyoto next
London, 1963.
our
Correspondents
United States THE
PRESIDENT’S
PLANS FOR HEALTH CARE
THE Administration’s budget proposals are, as expected, rousing criticism from all sides. The sums allotted to medical and basic research are slightly augmented, the grants to medical schools will fall (to give deans fresh headaches), and the social services are also to be cut, marginally. Under attack from all sides, the President is stoutly defending his proposals and contending, not unreasonably, that inflation is our biggest problem and that rising costs affect the poor and the retired on fixed incomes more than the rich. Inflation has been particularly severe on health costs, and the lack of any specific proposals here has brought criticism from Senator Kennedy and the liberal wing of the Democratic party, who do not like the cuts in social-service programmes as a whole. Still presenting evidence of monstrous health bills which have bankrupted some U.S. families hit by catastrophic illness, Senator Kennedy and various columnists have been drawing comparisons with Canada, where bills seemingly equally monstrous have been paid by the national health insurance scheme. All this is much aggravated by the inadequacies of Medicare and Medicaid, especially when these agencies are unwilling to pay the fees the physicians ask.
Amidst all this, the President has not abandoned consideranew health proposals and Mr Califano, Secretary for Health, Education and Welfare, has been busy drafting proposals for implementation by stages of a national health programme. Details of the proposals are, as is usual, leaking out to the Press. It is reported that in the first phases Medicare coverage for the aged would be expanded and Medicaid extended to low-income prospective mothers and their children. There would also be insurance against catastrophic illness to protect against medical bills of more than$50 000. All these could no doubt be readily implemented without serious opposition. tion of
But the first phase would set strict limits on hospital costs and it would also require doctors to accept uniform negotiated fees rather than being allowed to set their own rates. This too sounds reasonable and acceptable-provided that it is accepted by other suppliers of goods and services to physicians. Consideration of my own grocery, meat, fuel, utility, and domestic bills, let alone the medical costs, malpraxis insurance, stationery, and equipment, and to speak of postage and gasoline have all shown enormous increases of recent years. If I am forced to accept a uniform negotiated fee will all those who provide me with goods and services accept uniform negotiated
