Develop. Med. Child Neurol. 1977, 19, 123-125

Letters to the Editor

0 Felix Culpa! SIR-Between our correction of the proofs and your publication of our paper’, our r6les were reversed. Margaret Lynch became a social worker and Jacqueline Roberts a paediat- rician.

An early paediatric neurologist2 showed that such slips are highly significant (although his work lacks the benefit of x2). We interpret your happy error as both endorsing the notion of the generic social worker and as upholding the even more necessary concept of the paediatrician as so unspecialised a professional that not even a medical qualification is needed.

Human Development Research Unit, Park Hospital for Children, Old Road, Headington, Oxford OX3 7LQ.

MARGARET ROBERTS JACQUELINE A. LYNCH

(Children’s Persons)

REFERENCES I . Lynch, M. A., Roberts, J., Gordon, M. (1976). ‘Child abuse: early warning in the maternity hospital.’

2. Freud, S. (1914) The Psyrhopaihology oj’Everyday Life. (Trans. A. A. Brill.) London: T. Fisher Unwin. Developmental Medicine and Child Neurology, 18, 759-166.

‘Prevention as an Imperative’ SIR-Though few will question the need for greater emphasis on prevention in paediatrics Ross Mitchell’s editorial ( D M C N , 18, 703) begs many questions. He suggests that we require political commitment to a national policy of the kind that has been pursued in France. But why should we choose the French model? There are several other European countries which have lower perinatal mortality rates than Britain or the United States, and it would be equally logical to follow their pattern. For instance we might emulate the Dutch and try to reduce our hospital confinement rate to about 50 per cent. This line of reasoning could be supported by British evidence that areas with higher rates of home confinements have lower perinatal mortality’. Or, with equal logic, we could follow the Swedes and centralise deliveries in a small number of large hospitals.

Comparisons of perinatal mortality rates from different countries appear to be becoming a major concern to the Department of Health in Britain, and international ‘league tables’ figure prominently in their publications. However, the lessons these rates provide are quite other than the ones usually derived from them. What they do show is that the way in which medical services are provided, the kind of services created and the amount of money spent on them are not at all closely related to perinatal mortality rates. Certainly the low rates that have been recorded in some European countries show that it is likely that a further reduction is possible in Britain and the United States, but they do not provide us with a

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direct model of how we may achieve an improvement. It has yet to be shown convincingly what effect, if any, the French plan has had on their rates of mortality and morbidity.

Perinatal mortality and morbidity are influenced by many factors beyond the quality and quantity of medical care provided. In order to create an effective policy for perinatal care, we need to assess the impact of current practice. The first step is to standardise perinatal mortality rates for ‘non-medical’ factors. This is very difficult to do for inter- national statistics, but is feasible for time series from one country where one can allow for factors such as changes in maternal age, birth interval, parity and height. One can also break down the figures into important components such as low birthweight and congenital malformation. Standardised figures of this kind, rather than international comparisons, allow some assessment of progress (or otherwise). It would be interesting to see the result of such standardisation on the figures that Ross Mitchell quotes from Dundee.

Standardised perinatal mortality rates can also provide a rough assessment of past chsnges in policy and innovation, though for a reliable evaluation we would require the results from well-designed, multi-centre, randomised controlled trials. Without information of this kind we do not know what laws should be passed, where funds should be allocated, or what programmes to plan. So before we ask for new initiatives or more money, we require much more evidence for the effectiveness of current practice. What evidence we have is far from encouraging, as is shown by three examples from the perinatal field.

The first is that in Britain about 40 per cent of labours are induced2. Judging by the reported case-histories, about 150 babies pel year die from the direct effects of induction (artificial rupture of the membranes followed by oxytocin to augment labour). An assessment of the admittedly incomplete evidence suggests that gains from induction are outweighed by losses when the rate rises above 10 to 20 per cent3. Therefore about half the infant deaths related to induction are avoidable. The evidence suggests that, nationally, induction policies are rather non-selective, so that many cases in which the technique would be of value are being missed3.

The second example is that analysis of regional variations in Britain in rates of admission to special care units and the policies of selected units suggests that many babies are being admitted unnecessarily and that there is an over-provision of these resources4* 5. Perhaps the risks to a baby of an unnecessary stay in a special care unit are less than those of an unnecessary induction and accelerated labour, but at the very least these admissions rep- resent a waste of expensive resources and a source of avoidable worry to parents.

Thirdly, a recent evaluation of the measures that have been introduced in Britain to prevent haemolytic disease of the newborn indicates the reduction in mortality from this disease, far from being the success story of preventive medicine described by the Department of HealthR, is largely attributable to demogiaphic changes in the population and to a general rise in the standards of medical services’.

Undoubtedly mortality and handicap can be reduced by improvements in standards of obstetric and paediatric care, but if we wish to follow the French (01 anyone else) in this aim, the political commitment we require is to policies which ensure that existing medicai practice is effective and that innovation is guided by better evaluation than has sometimes been the case in the past. Too often we have only been wise after the event.

MARTIN RICHARDS Medical Psychology Unit, University of Cambridge, Station Road, Cambridge CBl 250.

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REFERENCES 1 . Ashford, J. R . (1977) ‘Policies for maternity care in England and Wales. Too fast and too far? In

Kitzinger, S . , Davis, J . (Eds.) The Place of Birth. Oxford: O.U.P. (In press.) 2. Department of Health and Social Security statistics. 3. Richards, M. P. M. (1977) ‘The induction and acceleration of labour. Some benefits and complications.’

Early Hitinan Devc~lopinent. (In press.) 4. Richards, M . P. M., Roberton, N. R. C. (1977) ‘Admission and discharge policies for special care baby

units.’ In Brimblecombe, F. S. W., Richards, M. P. M. (Eds.) Early Separation and Special Care Units. London: Spastics International Medical Publications/Heinemann Medical; Philadelphia: Lippincott. (In press.)

5. Chamberlain, R . , Chamberlain, G., Howlett, B., Clamaux, A. (1975) British Births 1970, Vol. 1 . London: Heinemann Medical.

6. Prevention and Health: Everybody’s Business. A consultative document prepared jointly by the Health Departments of Great Britain and Northern Ireland, 1976. London: H.M.S.O.

7. Knox, E. G. (1976) ‘Control of haemolytic disease of the newborn.’ British Journal of Preventive and Soc ial Medicine, 30, 163-1 69.

Control of Anti-epileptic Drug Treatment SIR-The comments of Dr. Samuel Livingston and his colleagues on this subject were most interesting and pertinent (DMCN, 18,820). I would like to raise one point for further consideration. They state that if there is a recurrence of seizures during or after withdrawal of treatment, the patient should be restarted immediately on the same dose of medication that had previously controlled the seizures, and possibly continue this at full dosage for the rest of their lives.

Do we know enough about the long-term effects of anti-epileptic treatment, especially in childhood, ever to recommend its use for more than a limited period, a t least without renewed attempts to stop it after several years freedom from fits, with the accepted risk that in a significant number of people there will be a recurrence?

Also, however slowly the treatment is reduced, may not the occurrence of a fit while this is being done occasionally be a ‘withdrawal symptom’? If this is so, it may still be possible to stop the treatment without any long-term risk of further seizures. In this situation timing may be all-important, and the doctor’s decision on the correct course may be a matter of delicate judgement, balancing the potential risks of long-term treatment against the possibilities of recurrent fits. It is a responsibility which does seem to have been taken too lightly in the past. Booth Hall Children’s Hospital, Blackley, Manchester M9 2AA.

NEIL GORDON

Special Clinics for Epilepsy SIR-I would like whole-heartedly to endorse Dr. Keith Brown’s excellently presented arguments for establishing special clinics for people with epilepsy (DMCN, 18, 809). After hearing this matter discussed on a number of occasions, particularly with reference to adults, I feel there is one point that needs to be spelt out. The immediate reaction is often that such clinics are ‘diagnostic’, which few would advocate. The possible aetiologies of this particular symptom embrace most of medicine, and their diagnosis needs the resources of the medical services as a whole. The failure lies in the management of the person whose seizures are of unknown or irremedial cause. If long-term medical, social and educational help is needed for these people, those with the necessary expertise, and time to practise it, must work together as a team if an efficient service is to be provided. Booth Hall Children’s Hospital, Blackley, Manchester M9 2AA.

NEIL GORDON

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