Alcohol consumption during pregnancy and infants ... - Europe PMC

Alcohol consumption during pregnancy and infants' development SIR,-In their study Dr F Forrest and colleagues tried to find a relation between alcohol intake during pregnancy and infants' development.' Other factors, however, had to be taken into consideration, such as maternal smoking. Using the Bayley scales of infant development, the authors showed that the mental index was lower (-6 units) for children whose mothers smoked 10-19 cigarettes a day and (-3 units) for those whose mothers smoked .'20 cigarettes a day. What I would have liked to know is the clinical importance or consequence of this lower score and whether a child with the lower score is within or outside the normal range for age. If she or he is outside the normal range does this constitute impairment, disability, or handicap? The previous study of the cohort had the same problem.' For example, it showed a positive correlation between alcohol intake of : 120 g/week and shorter gestational age (-2-0 weeks) and a lower Apgar score at 5 minutes (0 2). Alcohol intake of 100-1 19 g/week was significantly related to smaller head size (-12 mm). Apgar scores are a rather unreliable and controversial index, particularly when the difference is very small and the observations are made by more than one person. Measurements of head circumference have the same problem, and we also know that head size as such is of no clinical importance. A shorter gestational age of - 2 0 weeks means that the child is born at 38 weeks, which is considered to be term and, to my knowledge, of no clinical importance. To summarise, the two papers have shown theoretical rather than practical points and have failed to show any clinical importance. Consequently, I would have thought that any conclusions and advice on the consumption of alcohol during pregnancy could not be substantiated. M M MADLOM

Community Child Health Department, West Lane Hospital,

Cleveland TS5 4EE I Forrest F, Florey Cdu%', Taylor D, McPherson F, Young JA. Reported social alcohol consumption during pregnancy and infants' development at 18 months. B.MJ7 1991;303:22-6.

(6 July.) 2 Sulaiman ND, Florev CduV', 'Taylor DG, Ogston SA. Alcohol consumption in Dundee primigravidas and its effect on outcome of pregnancy. BMJ 1988;2%:1500-3.

The health of the nation SIR,-Dr Jacky Chambers's letter' attacking our response2 to The Health of the Nation3 is bedevilled by the confusion of which she accuses us but gives us an opportunity to clarify our political position and reinforce some points that we made in our article. Our name is Radical Statistics Health Group, not Radical Health Statistics Group, as in Dr Chambers's letter. Her suggestion that "one could almost accuse the group of being party political" is untrue. Radical Statistics, of which we are part, has never been affiliated to any political party or other organisation apart from the now defunct British Society for Social Responsibility in Science. Our first publications criticised misleading use of statistics in documents produced by the last Labour government.4" Since 1979 we have criticised misuse of statistics by Conservative governments.6 7 We will continue to criticise any political party that uses statistics misleadingly in government or in opposition, irrespective of whether some people within our group support its political aims. On the other hand, the view that statistics is a branch of political science is not new. It was held

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by the social and sanitary reformers who in the 1830s founded the Statistical Society of London, later to become the Royal Statistical Society. Their aim of "ascertaining and bringing together of those 'facts which are calculated to illustrate the condition and prospects of society' . with the view to determine those principles on which the well-being of society depends"' contrasts with the narrow focus on "individuals and their families" that underpins current political policy in general and the green paper in particular. Our critique of the green paper arose from a dissatisfaction with the avalanche of articles written by people who, in their enthusiasm to welcome an opportunity for health promotion, failed to balance this with a critical analysis of what The Health of the Nation actually contained. We could not on this occasion put forward positive alternatives and this was not in the brief given to us by the BMJ7, and we knew that a further 20 articles had been commissioned to do just that. We are interested in alternative approaches, and these a're on the agenda of the conference that we are holding on 21 September jointly with the Public Health Alliance. Anyone who wants to debate the issues seriously will be welcome. We reject Dr Chambers's allegation that we "do not understand that 'health' is a multidimensional concept." A rereading will show that this was made explicit in our article and that we pointed to the need for action outside the NHS. This action should go beyond the limited range of activity proposed and cannot be achieved simply, as Dr Chambers suggests, by health authorities purchasing "a range of NHS and non-NHS services."' Far from ignoring the sections of the green paper that referred briefly to inequalities in health and the need for better data, we pointed out that they were not prominently placed in the document and did not explore the problems in any depth. We are mystified by Dr Chambers's accusation that our arguments, supported by references, "are no more than a collection of value judgments or half truths" and find it strange that of the three of our 49 references that she cites to support this view, two come from her own organisation. Our critique of The Health of the Nation is not a dismissal of the need to promote health but an analysis of its lack of proposals for "effective action." Dr Chambers suggests that this should not deter those "who have a heart to help" from putting their weight behind it. We are unconvinced. As statisticians, epidemiologists, and public health doctors we do not hesitate to criticise suggestions from clinicians that, in the absence of effective remedies, ineffective or unproved remedies should be applied. So why should we tolerate this in our own area of public health? RADICAL STATISTICS HEALTH GROUP I Chambers J. '[he health of the nation. BMJ 1991;303:520. (31 August.) 2 Radical Statistics Health Group. Missing: a strategy for the health of the nation. BMJ 1991;303:299-302. (3 August.) 3 Department of Health. The health of the natton. London: HMSO, 1991. 4 Radical Statistics Health Group. Whose priorities? A critique of "Priorities for Health and Personal Social Services in England." London: Radical Statistics, 1976. 5 Radical Statistics Health Group. RAW(P) deals. A critique of "Sharing resources for health in England." London: Radical Statistics, 1977. 6 Radical Statistics Health Group. Unsafe in thetr hands. London: Radical Statistics, 1985. 7 Radical Statistics Health Group. Facing the figures: what reallys is happening to the National Health Service? London: Radical Statistics, 1987. 8 Introduction. Journal of ihe Statistical Societv of Loondon. 1839;1: 1-5.

SIR,-It is encouraging that The Health of the Nation recognises rehabilitation as an area in which there is clear scope for improvement.' It also recognises the importance of multisectoral

influences: "health is determined by a wide range . family and social circumof influences from stances to the physical and social environment." As someone with a disability, I find this the right sort of talk. People with disabilities have on average lower incomes than the rest of the population. Many buildings, leisure facilities, and public transport are inaccessible. Two thirds of disabled people aged under 65 are unemployed.2 Much support at home is inadequate, and there is a shortage of appropriate housing. Improvements in these aspects have the potential to improve health much more than medical services alone. Though medical services offering rehabilitation should not be neglected and there are things to be welcomed in the green paper, the concern for a multisectoral approach does not extend to disability. Professor D L McLellan begins to touch on this by setting targets such as increasing employment and by recognising that work with social services, housing, etc, is required.4 It is to be hoped that this is built into the consultation. To improve the lot of disabled people, however, the wider dimensions of health need more emphasis. Especially at national level, where the aim should be to effect multisectoral change, policies are required across departments, coordinating legislation. Targets might include reducing the number of people in residential accommodation against their will by 75% (in coordination with community care policies and local authorities); ensuring that all public transport is accessible; increasing the proportion of disabled people in employment, as Professor McLellan suggested4; introducing legislation

against discrimination, making it impossible to discriminate against the disabled in employment, for example; and alleviating poverty among the disabled (perhaps with a disability income). Above all, the approach must encompass the realisation that disability is not about people with problems but about a society that can't or won't adapt to a substantial minority. Pie in the sky? It shouldn't be if as a society we believe that people with disabilities ought to be treated as equals. IAN BASNETT

London E l 9BE 1 Secretary of State for Health. The health of'the nation, London: HMSO, 1991. (Cm 1523.) 2 Martin J, White A. 7he financial circumstances oJ'disabled adulis living in private households. London: HMSO, 1988. (Office of Population Censuses and Surveys report 2.) 3 Greater London Association for the Disabled. A consumer study of public transport handicap in Greater London. London: GLAD, 1986. 4 McLellan DL. Rehabilitation. BMj 1991;303:355-7.

(10 August.)

SIR,-In common with others we have been considering our response to the government's paper The Health of the Nation.' As part of this process we have looked at the applicability, at district health authority level, of the document's suggested mortality targets. Because of the very small numbers involved, problems of interpretation of infant mortality trends at district health authority level have long been recognised; there is, however, a temptation to assume that the greater number of deaths in adults at district level, at least for the major causes, make chance variation less likely and so make the analysis of mortality trends statistically robust. If true this would facilitate the direct translation of the mortality targets suggested in The Health of the Nation into district targets. Although not explicitly recommended in the government's paper, this approach to measuring changes in health is appealing because such district based data are routinely available. Nevertheless, calculating the mortality trends for the major causes of adult death in our own health authority has shown thai, even though the numerator for the rates may be larger than for

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infant mortality, the denominator is also increased. The effect of this is to again render even quite large percentage changes in mortality over time liable to chance variation. For example, there was an apparent decrease of 12 1% in deaths from coronary heart disease from 1981 to 1989 for men aged 35-64 in Hull. However, the 95% confidence intervals for this change in mortality are wide (-2 7x 10 4 to 12x 10 3) and allow the possibility either of no change or of an increase in the true mortality for men of this age. Indeed, the same uncertainty is true of the district mortality trends for all the conditions suggested in The Health of the Nation. We suggest, therefore, that changes in death rates are a statistically inappropriate method of measuring variations over time in the health of a district population. This is a further argument for the need to develop measures of health that are not based on mortality for use at district level. SUE IBBOTSON IAN WATT

Department of Public Health Medicine, Hull Health Authority, Hull HU2 8TD 1 Secretary of State for Health. The health of the nation. London: HMSO, 1991.

SIR,-Dr S Bingham, in her article on dietary aspects of a health strategy for England, recognises that health education on its own is insufficient as a policy for dietary change.' National food culture, food advertising, and nutrition labelling are appropriately highlighted as areas in need of public attention. The green paper and Dr Bingham's response to it neglect the crucial economic dimensions of personal income, food prices, and fiscal policy in agriculture. Low income is an obstacle to healthy eating. The Department of Health's recent dietary survey shows that those in receipt of welfare benefits have comparatively low intakes of vitamins C, D, and E as well as calcium and magnesium.2 Foods providing dietary fibre and micronutrients, such as oranges and wholemeal bread, are expensive sources of food energy. For example, two custard cream biscuits at 3p and 1 lb of carrots at 20p each provides 0-42 MJ.3 Healthy eating is a luxury for the increasing number of those below or on the margins of poverty in Britain. In 1988, 11 8 million people, including 25% of the nation's children, were dependent on incomes of less than 50% of the average wage.4 Financial hardship tends also to limit access to food. Those without a car may not be able to reach good supermarkets or to shop cheaply in bulk.3 Those without a well equipped kitchen are unable to store and prepare food in the most appropriate ways.' There is therefore certainly a case for reviewing current levels of welfare benefit to make a healthy diet at least potentially accessible for the whole nation.5 E J BRUNNER

Department of Community Medicine, University College London, London WC I E 6EA 1 Bingham S. Dietary aspects of a health strategy for England. BMJ 1991;303:353-5. (10 August.) 2 Gregory J, Foster K, Tyler H, Wiseman M. The dietarv and nutrttional survoy of British adults. London: HMISO, 1990. 3 Cole-Hamilton I, Lobstein TJ. Poverty and nutn'tion surves. London: National Children's Homes, 1991. 4 House of Commons Social Security Committee. Low income statistics: households below average income. London: HMSO, 1991. 5 Radical Statistics Health Group. Facing the figures. London: Radical Statistics, 1987.

Leprosy in reaction SIR,-Mr A W Fowler concludes' that because the patient described by Dr A S Malin and colleagues

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had developed a plantar neurotrophic ulcer2 there must have been a lesion of the posterior tibial nerve. Section of the trunk of a peripheral nerve does not, however, lead to the severe trophic ulcers, mutilation, and Charcot's joints that are such a characteristic feature of leprosy. More probably this patient had developed a sensory polyneuritis with a "glove and stocking" distribution, the features of which were described by Monrad-Krohn nearly 70 years agog and confirmed by me in Nigerian patients.4 This purely sensory polyneuritis can occur on its own or be associated with the more commonly described mononeuritis multiplex. This sensory polyneuritis can be acute in onset and affect the arms and legs simultaneously, but the nerves are not necessarily tender or even enlarged and skin lesions need not be inflamed. The cardinal sign is oedema of the hands, feet, and face.4 Although surgical decompression to prevent protective loss of sensation would not be indicated, Mr Fowler is right to emphasise the importance of compression, which is due not so much to enlarged nerves but to soft tissue swelling and particularly affects the median nerve at the wrist, the deep branch of the ulnar nerve, and the zygomatic and temporal branches of the facial nerve as they cross the zygomatic arch. Steroids should be given not in standardised regimens but in doses sufficient to reduce the oedema and so prevent the compression neuropathies and also to ensure the return of the sensation of pain in the hands and feet. As the syndrome is self limiting the steroids can then be tailed off. C L CRAWFORD Department of Anatomy, Charing Cross and Westminster Medical School, London W6 8RF I Fowler AW. Leprosy in reaction. BMJ, 1991;303:124. (13 July.) 2 Malin AS, Waters MFR, Shehade SA, Roberts MM. Leprosy in reaction: a medical emergency. BMJ 1991;302:1324-6. 1 June.) 3 Monrad-Krohii GH. 7he neurological aspect of leprosv. Christiana: Jacob Dybwad, 1923. 4 Crawford CL. NeuLrological lesions in leprosy. Lepr Rev 1968;39:9- 13.

Kala-azar in France SIR,-In reporting their study of kala-azar in France Dr D Jeannel and colleagues remark on the difficulty in diagnosing the disease.' They also state that "regarding the clinical signs no particular association was apparent." While I was serving in the Indian army during the second world war the most striking feature of early kala-azar that I observed was the absence of malaise despite the patient having a high temperature. Ifthe temperature chart showed a reading of 40°C and the patient was out of his bed socialising with other patients in the ward kala-azar was the most probable diagnosis. No other tropical fever has such a noticeable absence of malaise. M D INNIS

Greensloopes Repatriation Hospital, Brisbane, Australia I Jeannel D, Tuppin P, Brucker G, Danis M, Gentilini M. Imported and autochthonous kala-azar in France. B.MJ 1991;303:336-8. (10 August.)

Papaveretum in women of childbearing potential SIR,-We, the consultant anaesthetists of West Berkshire Health Authority, are astounded by the recommendation of the Committee on Safety of Medicines that all products containing papaveretum should be contraindicated in women of

childbearing potential.' This seems to have been made solely on the basis of in vitro experiments, for which no reference is given. We believe that most anaesthetists use papaveretum as their first choice for a strong analgesic during pregnancy. This is because in the United Kingdom it is the agent of which we have the greatest experience, and there is no clinical evidence of harm to pregnancy or fetus. Unless the recommendation is withdrawn newer analgesics without this proved record of efficiency and safety may be used with consequences for the fetus yet to be discovered. S ALLEN A MARSHALL BARR JANE BIRD P J BROCK M C EWART RACHEL HALL Royal Berkshire Hospital, Reading, Berkshire RGI 5AN

R JAGO M RIMMER T SMITH C VERGHESE C WALDMANN E YOUNG

1 Committee on Safety of Medicines. Genotoxicity of papavereturn and noscapine. Current Problems 1991 June;No 30.

SIR,-After reviewing published reports concerning the genotoxic effects of noscapine,' 2 the Committee on Safety of Medicines has been prompted into action. It has made several recommendations, including that papaveretum should be contraindicated in women of childbearing potential.' Papaveretum has been one of the mainstays of perioperative analgesia in the United Kingdom for the past 20 years. It consists of the hydrochlorides of opium alkaloids and contains the equivalent of anhydrous morphine 47 5-52 5%, anhydrous codeine2-5-5%, noscapine 16-22%, andpapaverine 2 5-7%.4 Pure noscapine hydrochloride (C22H23 NO7, HCI, H2O; molecular weight 467 9) consists of colourless crystals freely soluble in water whose pharmacological actions are mainly as a centrally acting cough suppressant and smooth muscle relaxant. To review the implication of the recommendations made by the Committee on Safety of Medicines, we conducted a postal survey concerning the use of this drug. We distributed 228 questionnaires to anaesthetists of all grades throughout the anaesthetic departments of Wessex health region. We had received 149 replies (65%) within three weeks, when results were assessed. Only one anaesthetist was unaware of the Committee on Safety of Medicines' recommendations, and 144 had previously used papaveretum in women of childbearing potential. Two anaesthetists still prescribed papaveretum in this group of patients despite being aware of the guidelines, but 143 anaesthetists had had to alter their practice. The guidelines have thus had widespread effect. Of interest is the variable interpretation that the guidelines have produced. One hundred and nine anaesthetists still prescribed papaveretum to men, 83 to male children, but only 34 to female children. A discrepancy thus exists concerning the prescription of papaveretum to male and female children. The committee's guideline concerning women of childbearing potential refers to the potential of a woman to bear a child at the present time (Committee on Safety of Medicines, personal communication). The genotoxic effects of noscapine have been shown on diploid mammalian cell lines in vitro, and the rapidly dividing cells of the newly fertilised ovum are considered to be most at risk. As yet there is no work concerning genotoxicity in haploid cells, and so the interference of noscapine in gametogenesis is purely speculative. Thus the committee's recommendation does not extend to female children, although many anaesthetists have interpreted the guidelines to include this group. 647