BRITISH MEDICAL JOURNAL
14 OCTOBER 1978
1085
the job nearly as well, provided that the milk is expressed or pumped often enough. Infrequent expressing or pumping, like the infrequent scheduled feeding of a baby at the breast, will lead to insufficient milk production. Given that the mother's milk production can be maintained at a high level by expression or pumping I fail to see what "the very nature of the babies in a special-care baby unit" has to do with many mothers being unable to supply fresh milk for every feed. Even if the mother has to leave hospital and send in milk from home, her baby could still receive her own breast milk for every feed. Let's not emulate the hospital which replied to the mother offering to express her own milk for her premature baby with a polite but cool, "Thank you, but we have plenty of breast milk in the milk bank."
to preterm infants in special care baby units outweigh the disadvantages, care must be taken to ensure that other nutritional deficiencies do not occur and that the appropriate supplements are provided. If the examples set by Whipps Cross and King's College hospitals were followed modified human milk could be the standard preterm infant's feed in special care baby units in the future.
PENNY STANWAY
SIR,-Warnings have been given by many writers in the BMJ on the responsibilities of the medical profession to travellers returning to Britain since as far back as just after the last war. In every instance emphasis has been laid on the taking of a blood smear. Dr A P Hall in his admirable paper (23 September, p 877) has put forward some important suggestions which require further expansion. He suggests that "British airlines (and shipping companies) should be compelled to give detailed written and verbal information both before and during flights." From my own personal experience advice given by travel agents, not only in the case of prevention of malaria but of other diseases, is notoriously inaccurate and that they themselves require guidance in these matters, which should be consistent and applicable to all airlines and shipping companies and their respective travel agents, not only in Britain but throughout the world. This is not as difficult as would appear if all travel agents and shipping lines were familiar with the World Health Organisation's "Information on Malaria Risk for International Travellers."' This contains an up-todate evaluation of the malaria risks in countries and areas of countries and advice on personal protection to travellers as well as a complete list of chemoprophylactic drugs with their trade names and dosages for all ages. This publication would standardise current expert advice. The contents could also be summarised and incorporated, with achnowledgment to the WHO, in the NHS procedure manual suggested by Dr Hall. If there is to be any inquiry or blame laid for an avoidable death it should be solely on the grounds of failure to take a blood slide by medical or paramedical personnel and not necessarily because of failure to make a clinical diagnosis. Furthermore, the diagnosis from the blood smear should be made by a microscopist experienced in recognising malaria parasites. Even the taking of a thick smear by many members of our profession leaves much to be desired, a remark based on 25 years of seeing some of these efforts. The procedural manual should clearly set out the techniques for taking thick and thin smears for malaria diagnosis. Finally, under "treatment" I note there is no reference made to dexamethosone, which, given along with quinine, is mandatory in cerebral malaria and has saved many lives of patients with cerebral malaria in Thailand and other SE Asian countries in areas of chloroquine-resistant falciparum malaria. Switching to the oral route with return to consciousness
Redhill, Surrey
***There are certain features about babies on special-care baby units which make it difficult for all their mothers to provide fresh milk for every feed. Firstly, the socially disadvantaged are usually over-represented among the families with babies on such units. This limits the number of mothers who will want to breast-feed, since (currently) breastfeeding is commoner among social classes I and II than IV and V. Secondly, even the well-motivated mother who is successful in sustaining her lactation faces problems of determination and organisation if her baby remains on hourly tube feeds in the specialcare baby unit for six weeks or so (which is not uncommon among very low-birth-weight infants), especially if the family lives any distance from the hospital and does not own a car. We agree with Dr Stanway that it is possible and desirable for a mother to supply her baby with her own milk for every feed, but it is not something easily achieved by all mothers of babies on special-care baby units.-ED, BM7. SIR,-In your leading article (16 September, p 781) you express the need to show that lowbirthweight infants grow as well on banked human milk as on standard formula feeds. Physiologically, human milk is designed to meet the needs of the mature neonate, but the mineral requirements for skeletal growth in the low-birthweight preterm infant are different. In addition, there is considerable variation in the composition of human milk. The electrolyte and fat content differs in colostrum and transitional milk and also in mature milk from the beginning to the end of the feed. The figures usually quoted for the composition of human milk refer to mature hind milk, which has a lower sodium and potassium content than fore milk, transitional milk, and colostrum.1 Day et a12 have described hyponatraemia, hyperkalaemia, and reduced growth in length in very-low-birthweight infants fed with a modified cows' milk formula (SMA 27) which has concentrations of electrolytes based on human milk. Human milk collected from volunteers will usually be mature hind milk with low sodium and potassium concentrations which may be inadequate for the needs of the very-low-birthweight preterm infant. While I believe that the antimicrobial and other advantages of feeding raw human milk
ANGELA MOORE Department of Paediatrics, New Cross Hospital, Wolverhampton
Ansell, C, Moore, A, and Barrie, H, Pediatric Research, 1977, 11, 1177. 2 Day, G M, et al, Pediatric Research, 1976, 10, 522.
Preventing deaths from malaria
obviates the chances of overhydration. (Yes, I have had to take oral quinine myself.) I sincerely hope that Dr Hall's recommendations are taken seriously by the Department of Health. F R S KELLETT Northamptonshire Area Health Authority, Northampton 1 WHO Weekly Epidemiological Record, 1978, 53, 181 and 189.
SIR,-I am sure those more competent than I will answer Dr A P Hall (23 September, p 877). However, as one with some experience in the prevention and treatment of malaria and who is involved in giving advice to travellers on a regular basis I would take issue with his more major points. I would dispute that it is automatically negligent to fail to take a blood film consequent upon symptoms following a visit to the tropics. Evidence must surely be present that malaria is a possible infection and I am sure that with the present publicity most people are fully aware that this disease should be looked for, even in unlikely circumstances. If this advice is followed, then logically blanket batteries of tests should be performed on all patients seen in all clinics; this would be the thin end of a thick and potentially dangerous wedge. Many would agree that airlines and travel agents could do more to advise their passengers. However, coercion by statute is seldom the best way to gain co-operation, and appropriately worded leaflets could easily be designed for dissemination through the appropriate channels with particular reference to aircraft flying to the tropics. Bruce-Chwatt et all are probably right in saying that malaria prophylaxis is a personal responsibility. One can hardly compel healthy people to take drugs (in this case with known potential side effects) against their will. It is worth pointing out that many business travellers in my personal experience are informed (by indigenous opinion) that there is no malaria in the area in which they are travelling. This was a common problem in some large urban areas in central Africa with which I was concerned. The myth ofthe efficacy of spraying was enough to cause dangerous complacency in short-term visitors despite adequate epidemiological evidence to the contrary. For regular travellers, reinforcement of the advice is essential and this can be done and is done often by occupational physicians and company medical advisers. Much of this advice is ignored, but at least the index of suspicion is high on return from the tropics. The idea of a Malaria Prevention Act is to propose unwanted and unnecessary regulations which would be almost impossible to enforce, especially on airlines flying over international territory. I am sure that it can be left to the good sense of the profession to help prevent malaria deaths. EoIN S HODGSON Birmingham
Site Medical Officer, IMI Kynoch Ltd
Bruce-Chwatt, L J, Southgate, B A, and Draper, C C, British Medical5Journal, 1974, 4, 707.
SIR,-Having read with great interest and sympathy Dr A P Hall's eloquent plea for prevention of deaths from malaria (23 September, p 877) I cannot help feeling that his
14 OCTOBER 1978
1085
the job nearly as well, provided that the milk is expressed or pumped often enough. Infrequent expressing or pumping, like the infrequent scheduled feeding of a baby at the breast, will lead to insufficient milk production. Given that the mother's milk production can be maintained at a high level by expression or pumping I fail to see what "the very nature of the babies in a special-care baby unit" has to do with many mothers being unable to supply fresh milk for every feed. Even if the mother has to leave hospital and send in milk from home, her baby could still receive her own breast milk for every feed. Let's not emulate the hospital which replied to the mother offering to express her own milk for her premature baby with a polite but cool, "Thank you, but we have plenty of breast milk in the milk bank."
to preterm infants in special care baby units outweigh the disadvantages, care must be taken to ensure that other nutritional deficiencies do not occur and that the appropriate supplements are provided. If the examples set by Whipps Cross and King's College hospitals were followed modified human milk could be the standard preterm infant's feed in special care baby units in the future.
PENNY STANWAY
SIR,-Warnings have been given by many writers in the BMJ on the responsibilities of the medical profession to travellers returning to Britain since as far back as just after the last war. In every instance emphasis has been laid on the taking of a blood smear. Dr A P Hall in his admirable paper (23 September, p 877) has put forward some important suggestions which require further expansion. He suggests that "British airlines (and shipping companies) should be compelled to give detailed written and verbal information both before and during flights." From my own personal experience advice given by travel agents, not only in the case of prevention of malaria but of other diseases, is notoriously inaccurate and that they themselves require guidance in these matters, which should be consistent and applicable to all airlines and shipping companies and their respective travel agents, not only in Britain but throughout the world. This is not as difficult as would appear if all travel agents and shipping lines were familiar with the World Health Organisation's "Information on Malaria Risk for International Travellers."' This contains an up-todate evaluation of the malaria risks in countries and areas of countries and advice on personal protection to travellers as well as a complete list of chemoprophylactic drugs with their trade names and dosages for all ages. This publication would standardise current expert advice. The contents could also be summarised and incorporated, with achnowledgment to the WHO, in the NHS procedure manual suggested by Dr Hall. If there is to be any inquiry or blame laid for an avoidable death it should be solely on the grounds of failure to take a blood slide by medical or paramedical personnel and not necessarily because of failure to make a clinical diagnosis. Furthermore, the diagnosis from the blood smear should be made by a microscopist experienced in recognising malaria parasites. Even the taking of a thick smear by many members of our profession leaves much to be desired, a remark based on 25 years of seeing some of these efforts. The procedural manual should clearly set out the techniques for taking thick and thin smears for malaria diagnosis. Finally, under "treatment" I note there is no reference made to dexamethosone, which, given along with quinine, is mandatory in cerebral malaria and has saved many lives of patients with cerebral malaria in Thailand and other SE Asian countries in areas of chloroquine-resistant falciparum malaria. Switching to the oral route with return to consciousness
Redhill, Surrey
***There are certain features about babies on special-care baby units which make it difficult for all their mothers to provide fresh milk for every feed. Firstly, the socially disadvantaged are usually over-represented among the families with babies on such units. This limits the number of mothers who will want to breast-feed, since (currently) breastfeeding is commoner among social classes I and II than IV and V. Secondly, even the well-motivated mother who is successful in sustaining her lactation faces problems of determination and organisation if her baby remains on hourly tube feeds in the specialcare baby unit for six weeks or so (which is not uncommon among very low-birth-weight infants), especially if the family lives any distance from the hospital and does not own a car. We agree with Dr Stanway that it is possible and desirable for a mother to supply her baby with her own milk for every feed, but it is not something easily achieved by all mothers of babies on special-care baby units.-ED, BM7. SIR,-In your leading article (16 September, p 781) you express the need to show that lowbirthweight infants grow as well on banked human milk as on standard formula feeds. Physiologically, human milk is designed to meet the needs of the mature neonate, but the mineral requirements for skeletal growth in the low-birthweight preterm infant are different. In addition, there is considerable variation in the composition of human milk. The electrolyte and fat content differs in colostrum and transitional milk and also in mature milk from the beginning to the end of the feed. The figures usually quoted for the composition of human milk refer to mature hind milk, which has a lower sodium and potassium content than fore milk, transitional milk, and colostrum.1 Day et a12 have described hyponatraemia, hyperkalaemia, and reduced growth in length in very-low-birthweight infants fed with a modified cows' milk formula (SMA 27) which has concentrations of electrolytes based on human milk. Human milk collected from volunteers will usually be mature hind milk with low sodium and potassium concentrations which may be inadequate for the needs of the very-low-birthweight preterm infant. While I believe that the antimicrobial and other advantages of feeding raw human milk
ANGELA MOORE Department of Paediatrics, New Cross Hospital, Wolverhampton
Ansell, C, Moore, A, and Barrie, H, Pediatric Research, 1977, 11, 1177. 2 Day, G M, et al, Pediatric Research, 1976, 10, 522.
Preventing deaths from malaria
obviates the chances of overhydration. (Yes, I have had to take oral quinine myself.) I sincerely hope that Dr Hall's recommendations are taken seriously by the Department of Health. F R S KELLETT Northamptonshire Area Health Authority, Northampton 1 WHO Weekly Epidemiological Record, 1978, 53, 181 and 189.
SIR,-I am sure those more competent than I will answer Dr A P Hall (23 September, p 877). However, as one with some experience in the prevention and treatment of malaria and who is involved in giving advice to travellers on a regular basis I would take issue with his more major points. I would dispute that it is automatically negligent to fail to take a blood film consequent upon symptoms following a visit to the tropics. Evidence must surely be present that malaria is a possible infection and I am sure that with the present publicity most people are fully aware that this disease should be looked for, even in unlikely circumstances. If this advice is followed, then logically blanket batteries of tests should be performed on all patients seen in all clinics; this would be the thin end of a thick and potentially dangerous wedge. Many would agree that airlines and travel agents could do more to advise their passengers. However, coercion by statute is seldom the best way to gain co-operation, and appropriately worded leaflets could easily be designed for dissemination through the appropriate channels with particular reference to aircraft flying to the tropics. Bruce-Chwatt et all are probably right in saying that malaria prophylaxis is a personal responsibility. One can hardly compel healthy people to take drugs (in this case with known potential side effects) against their will. It is worth pointing out that many business travellers in my personal experience are informed (by indigenous opinion) that there is no malaria in the area in which they are travelling. This was a common problem in some large urban areas in central Africa with which I was concerned. The myth ofthe efficacy of spraying was enough to cause dangerous complacency in short-term visitors despite adequate epidemiological evidence to the contrary. For regular travellers, reinforcement of the advice is essential and this can be done and is done often by occupational physicians and company medical advisers. Much of this advice is ignored, but at least the index of suspicion is high on return from the tropics. The idea of a Malaria Prevention Act is to propose unwanted and unnecessary regulations which would be almost impossible to enforce, especially on airlines flying over international territory. I am sure that it can be left to the good sense of the profession to help prevent malaria deaths. EoIN S HODGSON Birmingham
Site Medical Officer, IMI Kynoch Ltd
Bruce-Chwatt, L J, Southgate, B A, and Draper, C C, British Medical5Journal, 1974, 4, 707.
SIR,-Having read with great interest and sympathy Dr A P Hall's eloquent plea for prevention of deaths from malaria (23 September, p 877) I cannot help feeling that his
