pregnancy reported to the Communicable Disease ... immigrated to Britain after the age at which rubella ... necrotising fasciitis, and antibiotics are not effective.
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Congenital rubella in the Asian community in Britain SIR, -We have previously reported that susceptibility to rubella was nearly threefold higher in Asian than in non-Asian pregnant women screened during 1984, and that this was associated with a 2 3-fold excess of congenital rubella among babies born to Asian women compared with those born to non-Asian women.' In recent years the Department of Health, the Health Education Authority, and charitable organisations such as the National Rubella Council have tried to promote rubella immunisation in the Asian communities in Britain. We repeated our earlier survey to assess the response to these campaigns. Data on rubella susceptibility according to age, parity, and ethnic group were obtained for pregnant women screened by Leeds, Luton, and Manchester public health laboratories between July 1988 and June 1989. Of the 3946 Asian women identified, 133 (3 4%) were susceptible compared with 808 (1-2%) of 68252 non-Asian women (p' A previously fit 40-year old man presented to the accident and emergency department profoundly hypovolaemic, feverish, anaemic, and jaundiced. He had had a painful right sided otorrhoea for
three weeks. Culture of the discharge showed group A fi haemolytic streptococcus. He was unresponsive to oral co-amoxicular and Audicort (neomycin, triamcinolone, and benzocaine) ear drops. Two days before he attended our department he had sprained his right ankle. The pain and swelling from this had progressively worsened and spread to affect his lower leg and foot. On examination his lower leg was erythematous with haemorrhagic bullae to the level of the knee. Foot pulses were absent and the skin over the toes was numb. New lesions developed over his shoulders and right thigh over the following three hours. After resuscitation he was started on parenteral penicillin, multiple longitudinal skin incisions were made for debridement of necrotic tissue. His foot was amputated above the ankle, and this was revised later. All wounds were packed with proflavine dressings. Two further debridements were necessary, and his wounds were closed by delayed primary closure and split skin grafting over the next three weeks. Cultures of blood and all wounds grew group A f haemolytic streptococcus. Necrotising fasciitis is often misdiagnosed or initially diagnosed as cellulitis,26 the true nature and extent of the condition being apparent only at operation. Hence a high degree of clinical suspicion is necessary in patients presenting with toxic shock and what may seem like minimal skin changes; skin changes appear only when there is thrombosis of the perforating nutrient vessels.2 The exact mechanism of the streptococcal toxic shock is still uncertain but will probably be found to be multifactorial.' 210-12 Until this has been further elucidated treatment should consist of appropriate resuscitation, loading with intravenous penicillin and possibly flucloxacillin, and early diagnostic linear incisions with radical excision of necrotic tissue. This is the only sure way of
minimising mortality. J A McGLASHAN
Guy's Hospital, London SE1 9RT I Sanderson P. Do streptococci cause toxic shock? BMJ 1990; 301:1006-7. (3 November.) 2 Roberts JO, Fenton OM, Peters JL. Necrotizing fasciitis.
Hospital Update 1985;Nov:829-42.
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3 Dellinger EP. Severe necrotizing soft-tissue infectionsmultiple disease entities requiring a common approach. 7AMA 1981,246:1717-21. 4 Tehrani MA, Ledingham IMcA. Necrotizing fasciitis. Postgrad Medj 1977;53:237-42. 5 Janevicius RV, Sang-Erk Hann, Batt MD. Necrotizing fasciitis. Surg Gvnecol Obstet 1982;154:97-102. 6 Stamenkovic I, Lew PD. Early recognition of potentially fatal necrotizing fasciutis-the use of frozen-section biopsy. N Engl JMed 1984;310:1689-93. 7 Cruickshank JG, Hart RJC, George M, Feest TG. Fatal streptococcal septicaemia. BAf7 1981;282:1944-5. 8 Cone LA, Woodard DR, Schlievert PM, Tomory GS. Clinical and bacteriologic observations of a toxic shock-like syndrome due to Streptococcus pyogenes. N Engl J Med 1987;317: 146-9. 9 Strasberg SM, Silver MS. Hemolytic streptococcus gangrenean uncommon but frequently fatal infection in the antibiotic era. Am3'Surg 1968;115:763-8. 10 Stevens DL, Tanner HM, Winship J, et al. Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A. N Engl J Med 1989; 321:1-7. 11 Kim YB, Watson DW. A purified group A streptococcal pyrogenic exotoxin -physicochemical and biological properties including the enhancement of susceptibility to endotoxin lethal shock. JExpMed 1970;131:611-28. 12 Wannamaker LW. Streptococcal toxins. Rev Infect Dis 1983;5 (suppl 4):S723-32.
Milk for babies and children SIR,-Professor Brian Wharton's advice for feeding infants cannot be applicable to the babies and children in the Third World. ' Moreover, in my opinion, it is also inappropriate for the best nutrition of babies and children in developed countries. Professor Wharton ignores the unique position of human milk for babies and infants. Mothers throughout the world, irrespective of whether they come from poor or rich nations, should breast feed their infants for 'two years or more. Exclusive breast feeding should be practised for four to six months. Then the baby should be weaned on to locally available, home made, additional food. Breast feeding alone provides for infants optimum nuturition up to 4 to 6 months of age, immunological protection, and bonding between mother and infant, it is also economical and provides a contraceptive effect for the mother as well as safeguarding against breast and ovarian cancer." Commercial interests rather than nutritional ones have dominated the production of various kinds of milk powders throughout the world; in Bangladesh, for example, about 500 million takas ($15m) worth of milk powders are imported a year. About 50 different brands are available in the country from all over the world, including about 10 varieties of infant formula (Consumer Association of Bangladesh, unpublished data).2 About six brands ofpowder milk are soya based and popularly sold for treating diarrhoea. One European brand even boasts of being suitable for treating acute diarrhoea. There is aggressive marketing of the powdered tinned milk throughout the country both in towns and rural areas. As Bangladesh is poor and the literacy rate is 32% (22% among women) mothers' perception is that any powdered milk is a breast milk substitute. Due to ignorance and poverty these powdered milks, particularly the infant formulas, are prepared dilute and in second hand, dirty bottles. As a result children who receive this mixture get diarrhoea and become malnourished. Secondhand bottles are easily available and the teat is cheap, but mothers cannot clean them because there is no safe water and fuel is scarce. In Brazil it was found that infants who were not breast fed at all had 14 2 and 3-6 times greater risk of death from diarrhoea and respiratory infections respectively compared with infants who were breast fed and receive no milk supplements." Infants who received both breast milk and formula or cows' milk were 4-2 and 1 6 times more likely to die from diarrhoea and respiratory infections than those who were exclusively breast fed.7 The BMJ is read not only in Britain, Europe, and North America but by the medical profession
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throughout the world. Western based education still has a deep root in the medical colleges and among the professionals of the Third World, and this kind of article will certainly influence many doctors in the developing countries when they give feeding advice to mothers for their infants. Although this article is directed at developed countries, it could be disastrous for many children and families in the Third World. MQ-K TALUKDER Institute of Postgraduate Medicine and Research, Dhaka- 1 200, Bangladesh 1 Wharton B. Milk for babies and children. BMJ 1990;301:774-5. (6 October.) 2 United States Agency for International Development. Breast feeding for child survival strategy. Washington, DC: USAID, 1990. (Report 20523.) 3 Layde PM, Webster LA, Bangham AL, et al. The independent associations of parity, age at first full-term pregnancy, and duration of breast feeding with the risk of breast cancer. J Clin
learns to chew, to feed himself by hand, and to increase his experience of tastes and textures. There is little to be gained by postponing this developmental milestone. Why are follow on milks being recommended? The cost difference between follow on formula and cows' milk is not negligible. Calculating the difference in weekly household expenditure, and using the weight and energy data from Fomon's hypothetical infants' I estimate the additional weekly cost of one follow on formula compared with cows' milk to be £1.88 and £1.43 at 6 and 10 months respectively. Because of their distinct formulation follow on milks may also escape the legal strictures of the World Health Organisation's international code of marketing with regard to advertising of breast milk substitutes. If the spectre of protein malnutrition slips its bony toe in the door in Britain, how much more vulnerable will the mothers of the Third World be to persuasion?
Epidemiol 1989;42:%3-73. 4 Yuan JM, Yu MC, Ross RK, et al. Risk factors for breast cancer in Chinese women in Shanghai. Cancer Res 1988;48:1949-53. 5 McTiernan A, Thomas DB. Evidence for a protective effect of lactation on risk of breast cancer in young women. Am J Epidemiol 1986;124:353-8. 6 Byers T, Grahams S, Rzepka T, Marshal J. Lactation and breast cancer: evidence for a negative association in premenopausal women. Amy Epidemiol 1985;121:664-74. 7 Victoria CG, Vaughan JP, Lombardi C, et al Evidence for protection by breast feeding against infant deaths from infectious diseases in Brazil. Lancet 1987;i:319-21.
SIR,-Professor Brian Wharton proposed that follow on milks offer advantages for older infants and toddlers. ' Little evidence exists to support this claim, and the implicit suggestion that a high protein milk might compensate for impoverished weaning diets is to be deplored. Available evidence indicates that the protein energy requirements of an infant will be met by breast or formula milk provided that sufficient volume is taken to meet energy needs. If the safe level of protein intake falls from 1-86 g protein/kg body weight to 1-48 g/kg and the energy requirements fall from 485 kJ/kg to 423 kJ/kg between 6 and 12 months of age2 protein needs during this period will be met by an energy adequate diet in which the percentage of protein energy falls from 6-4% to 5 9%. The percentage of protein energy in breast milk is 7-4%; formula milks range from 8-6% to 11-3% and follow on milks from 11-9% to 17 8% (calculated from Professor Wharton's data). Fomon et al calculated that the protein needs of hypothetical 6 and 10 month old infants will be met by a mixture of formula milk and weaners and question whether the follow on milks available in the United States (also high in protein) are "designed to meet the special needs of the older infant."3 Even if we accept the unlikely postulate of a weaning diet that is virtually free of protein, the addition of nonprotein dietary energy will improve the rate of nitrogen retention "until the response reaches a plateau which represents the limitations imposed by the dietary protein level."2 The regular weaning diet is high in protein3 and in Western countries usually offers a higher energy density than milk. Iron deficiency, especially in Asian babies is a more important nutritional problem in Britain than that of protein energy.45 The weaning diet of 100 Asian toddlers, which included a large contribution from formula milk and was adequate in protein and energy, failed to meet the recommended dietary intake for iron (M B Duggan and L Harbottle unpublished results). The possible risks of intestinal blood loss due to early feeding with cows' milk should also be seen in context. Infants in the study cited by Professor Wharton had been fed on pasteurised cows' milk that had not been heat treated, and the authors noted that in Finnish studies heat treatment of cows' milk prevented intestinal blood loss.6 The bioavailability of the iron in formula milks is uncertain, and they are often given by bottle. During weaning the infant
MAUREEN B DUGGAN
Centre for Human Nutrition, Sheffield S10 2TN 1 Wharton B. Milk for babies and children. BMJ 1990;301:774-5. (6 October.) 2 World Health Organisation energy and protein requirements. WHO Tech Rep Ser 1985;724. 3 Fomon S, Sanders KD, Ziegler EE. Formulas for older infants. J Pediatr 1990;116:690-6. 4 Erhardt P. Iron deficiency in young Bradford children from different ethnic groups. BMJf 1986;292:90-3. 5 Grindulis H, Scott PH, Belton NR, Wharton BA. Combined deficiency of iron and vitamin D in Asian toddlers. Arch Dis Child 1986;61:843-8. 6 Zeigler EE, Fomon SJ, Nelson SE, et al. Cow milk feeding in infancy: further observations on blood loss from the gastrointestinal tract.J Pediatr 1990;116:11-8.
AUTHOR'S REPLY,-Having cut my nutritional teeth in a developing country (Uganda), I share many of Dr Talukder's concerns. I did, however, state that the editorial was looking at the question of "what advice should be given to mothers living in developed countries." Dr Talukder emphasises the value of breast feeding; I quoted the study showing that even in Scotland babies who had been breast fed for 13 weeks or more had fewer gastrointestinal upsets and fewer admissions to hospital. Many aspects of medical care, preventive and curative, differ because ofthe genetic characteristics of the population, the age and the development of the individual, and the environment in which he or she lives: microbiological, cultural, socioeconomic, etc. What is good for Europe is not necessarily good elsewhere-nor did I suggest that it was. I am a great supporter of breast feeding, but bottle fed babies have rights too. Dr Duggan is mainly concerned with follow on milks, particularly their higher protein *content when compared with infant formula and their higher cost when compared with whole cows' milk. Cows' milk contains even more protein than a follow on milk. Presumably she therefore agrees with my advice to mothers who are bottle feeding to continue with an infant formula, but if a mother insists on changing, as some do, then rather than cows' milk she would favour follow on milk because it has a lower protein content. Her opinion is not clear because in the later comparisons she compares the cost of a follow on formula with cows' milk for a 6 and 10 month old child-is she really advocating using whole cows' milk despite her concern about protein intakes at this age quite apart from its other disadvantages? Pasteurised cows' milk is by definition heat treated. Dr Duggan has taken most exception to the possible use of a follow on formula between 12 and 24 months. I agree that this is controversial. What does she recommend for the liquid part of the diet at this age? Skimmed and semiskimmed milks have a high protein to energy ratio. Whole cows' milk certainly is acceptable, and I mentioned it first, but follow on milks are worth considering
BMJ VOLUME 301
15 DECEMBER 1990
