Feb 21, 1981 - pathy, mononucleosis, and, often, pharyngitis ? The commonest causal agent of this ... caused by cytomegalovirus (human herpes- virus 5) and ...
BRITISH MEDICAL JOURNAL
VOLUME 282
653
21 FEBRUARY 1981
"infectious mononucleoses." This is con- Scotland, is a useful precaution against overfusing, because the term glandular fever was looking this infection later on in the disease. used to describe a clinical condition long H WiLLIAMs before any of the aetiological agents were Toxoplasma Reference identified. May we suggest that the term be Scottish Laboratory, restricted to this descriptive function for a Microbiology Laboratories, Hospital, syndrome characterised by fever, lymphadeno- Raigmore Inverness IV2 3UJ pathy, mononucleosis, and, often, pharyngitis ? The commonest causal agent of this condition 'Desmonts G, Couvreur J. Prog Clin Biol Res 1975;3: 115-32. is Epstein-Barr virus (human herpesvirus 4), 2Thorburn H, Williams Clin Path 1972;25:762-7. though clinically similar conditions can be 3Williams KAB, et al. J H.._ Infection (in press). KAB, Williams H. Br Medj 1979;i:561. caused by cytomegalovirus (human herpes- 'I Williams Beattie CP. Lancet 1980;i:873. virus 5) and Toxoplasma gondii. We would reserve the term infectious mononucleosis for glandular fever caused by Epstein-Barr virus. K E K RoWSON Collecting and banking human milk T A REES SIR,-Our paper "Collecting and banking Department of Pathology and human milk: to heat or not to heat ?" (20 Bacteriology, Institute of Laryngology and September, p 765) evidently gave rise to Otology, debate. We are pleased to recognise that, London WC1X 8EE since this was one of our intentions. Our essential conclusions were as follows. We SIR,-Your leading article (24 January, p 249) have found no data supporting the fear that is unexceptionable but fails to bring into sharp feeding donated raw human milk to infants focus the problems of toxoplasmosis in may cause ill effects. Raw milk, as opposed to pasteurised milk, resists bacterial growth. clinical medicine in the UK today. of human milk These are closely connected with the diag- Even moderate heat treatment nosis of the congenital disease, the assessment has adverse effects on the bacteriostatic value of the milk. of its incidence, and the wisdom or otherwise properties and nutritional of treating women who acquire the infection Holder pasteurisation is not a safe and during pregnancy, and their infants, with the reproducible routine method for decontaminadrugs currently available. Another set of tion of human milk. Dr David Baum (18 October, p 1066) agrees difficulties is concerned with the early diagnosis of activated or disseminated toxo- that there is no simple correct way of running a human milk bank. He opts for a simple system plasmosis in the immunosuppressed. on precise pasteurisation that can provide There are some regional differences in the based bacteriologically clean milk with a majority of its incidence of toxoplasma antibodies in antenatal bacteriostatic properties intact. He suggests that a populations in Scotland; but there is, overall, commercially available machine for holder pasteura large seronegative and therefore vulnerable isation fulfils these demands. We do not agree population. However, a small risk applied to a with Dr Baum since the essential conclusion drawn large population may be as productive of in our paper was that pasteurisation can be avoided. congenital infections as a large risk applied to Moreover, an expensive commercial machine designed for large-scale pasteurisation might not a small population,' which is the case in some be a realistic alternative in small units with countries in Europe. A number of small limited need of donated human milk. prospective surveys in Scotland carried out Dr J D Hall (15 November, p 1350) joins Dr between 1960 and 1980,2 with limited follow- Baum in his criticism and argues that our conup, and one larger one in Glasgow in 1975 clusions are based on faith rather than on science. indicate that the incidence of congenital He also claims that our warning that heat treatment toxoplasmosis in Scotland is probably not will reduce the nutritional value of the milk is much less than 1 in 2000 live births, although speculative and is in direct contradiction to studies carried out in Oxford and in other places. However, nearly all the infection is subclinical.3 About he does not present or refer to scientific data 404 new cases of toxoplasma retinitis, almost verifying his own opinion. Our opinion is based on entirely a sequel to congenital disease, are published data as reviewed in our paper. Furtherdiagnosed each year in Scotland. There has more, from these it is evident that so far this been some discussion of the cost-benefit ratio question has been embarrassingly little considered. of screening antenatal populations for toxo- Since there is no detailed knowledge about the plasma infections,5 and some of the newer composition of human milk it is impossible techniques may materially influence the to claim that the nutritional value of milk is not by denaturation of several of its conposition. Preliminary experience in this influenced In our paper we present evidence that laboratory indicates that one technician stituents. bacterial growth is poor in raw human milk supported by a computer program designed stored at 6-8°C. Thus experience from the dairy to key in and validate weekly data, report industry, referred to by Dr Hall, concerning possible seroconversions, and match records contamination of bovine milk is not relevant. (both maternal and mother-baby), could However, we agree that the dairy industry has screen an antenatal population successfully for much more knowledge about bovine milk than antibodies to rubella, cytomegalovirus, and paediatricians about human milk. In a report from the International Dairy Federation' it was stated toxoplasma on a single dilution of serum using that "in the absence detailed understanding of an ELISA technique. The long-term prog- the mechanisms whichof can occur during heating, nosis for subclinically infected infants could it is difficult to predict the behavioral patterns be affected if these screening schemes are which may be found in an individual milk sample, successfully extended, but this will require and to provide information on the basis of which much co-operation in the follow-up and the processing of the milk may be placed on a more fundamentally sound basis." We consider assessment of affected children. The diagnosis of toxoplasmosis in the this to be an equally relevant statement about the of human milk. immunosuppressed is difficult. The examina- processing Dr Hall implied that our conclusions were tion of all such patients for toxoplasma anti- based only on Swedish experience and were not bodies before treatment has begun, such as is necessarily relevant to other countries. However, carried out by a large lymphoma clinic in Dr Hilary M C Hoey and others (15 November,
p 1350) noted no ill effects by feeding raw human milk to low-birthweight babies in a London hospital. Our own experience gives support to these observations. After pasteurisation, however, contamination of human milk may occur and nosocomial infections caused by pasteurised human milk have been reported. Dr Hall also criticised our health screening of milk donors. A careful reading of our paper will reveal that strict criteria should be fulfilled by the donor, including a satisfactory chest x-ray examination. Donors are carefully instructed how to collect and store the milk. We also recommend a limited bacteriological monitoring of donated milk.
Our decision not to screen for hepatitis B virus, because it is uncommon in our region, does not imply that it should not be screened for in areas where such infections are common. Obviously the exact routine screening of donors has to be decided locally. BENGT BJORKSTEN Bo FREDRIKZON OLLE HERNELL Department of Pediatrics, University Hospital, S-901 85 Umea, Sweden
PETER DE CHATEAU Department of Paediatrics, Karolinska Institute, S-104 60 Stockholm, Sweden
Dalgleish DG. International Dairy Federation Report. F-Doc 1978;69:1-2.
***This correspondence is now closed.ED, BMJ7.
Fat content of donated breast milk
SIR,-We were very interested to read the paper by Dr S A Spencer and Professor D Hull (10 January, p 99) on the fat content of expressed breast milk donated to their neonatal unit in Nottingham. They present a strong case for quality control of donor breast milk if preterm infants are to be adequately nourished. In an earlier study we also showed a great variation in the fat concentration of individual samples of donor milk (ranging from 5-8 to 67 g/l).' However, in contrast with the Nottingham findings, the mean fat concentration was very low, 17-1 g/l compared with 31-5 g/l. This difference in fat content most likely reflects the methods of collecting milk in the two centres. In Leicester we rely mainly on "drip" milk; in Nottingham the milk was expressed. The low overall fat concentration of our milk, along with the great variability between individual samples, is worrying. Indeed, we sometimes wonder about the viability of those milk banks which depend mainly on drip milk, unless this can be modified-or unless quality control is exercised-to allow only milk of specified fat content to be given to babies. Dr Spencer and Professor Hull suggest that milk containing less than 2-34 MJ (560 Kcal) per litre (equivalent to a fat content of about 19 g/l) should be discarded. Had we followed this suggestion as many as 90% of our milk samples would have been rejected. Lucas et al have proposed that controlled amounts ofhuman milk constituents, such as fat and protein, be added to pooled milk to improve its nutritional content.2 Attractive and scientifically appealing though this suggestion might be, it is unlikely to gain universal acceptance in view of technical
