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the patients whose treatment was started in hospital. Sputum another, "stronger" antibiotic when they have real concern

specimens from 46 patients were examined; however, a third that respiratory infection is present. If this is the case, then
of these specimens were obtained after antibiotic treatment the patient may be being deprived of an excellent drug when
had been started. An agent, thought by the medical he needs it because he is being prescribed it when he does not
microbiologist to be causal, was isolated from the sputum of require it-a case of losing both on the swings and on the
13 patients. All these specimens were taken before antibiotic roundabouts.
therapy was given. Blood cultures were done in 27 cases. This review of antibiotic use for lower respiratory tract
Streptococcus pneumoniae was isolated from 1 patient. In 1 infection suggests that the quality of antibiotic prescribing is
patient pleural fluid yielded non-haemolytic streptococci unlikely to be improved by microbiological and
which were thought to be causal. pharmacological guidelines. The introduction of a more
restrictive antibiotic policy would not be a solution. It is the
DISCUSSION development of a more critical diagnostic approach which
should be the first concern of all those who want to improve
Unlike other antibiotic surveys which have discussed the
the quality of antibiotic prescribing. The onus of this task
quality of antibiotic use,2-5 this analysis has been limited to belongs as much to the clinician, surgical or medical, as to the
the treatment of infection at one site and is based on
information derived from a larger survey which included an microbiologist and infectious disease consultant. We suggest
that by considering the evidence of infection by a method
interview with the prescriber. It is, therefore, possible to
similar to the scoring technique outlined in this paper,
gain a greater and more precise insight into the reasoning of
the prescriber and to the sources of error in antibiotic prescribers might derive a useful index of the probability of
infection and, as a consequence, improve the quality of
prescribing. antibiotic prescribing.
The index of infection was constructed to include not only
features associated with bacterial pneumonia but also features We thank the senior and junior medical staff of the Central Middlesex
associated with infective exacerbations of chronic bronchitis Hospital for their cooperation; Miss M. Fielding, Miss A. Etherington, and
Miss J. Steward for secretarial services; and Miss V. Musgrove for retrieval of
and asthma, which are more difficult to define. We believe chest X-rays. F. M. was in receipt of a grant from the C.M.H. Research and
that the index does reflect the presence of bacterial infection Teaching Fund.
of the lower respiratory tract: of the 13 patients from whom F. M.
Requests for reprints should be addressed to
an organism with a very high probability of having a causal
role was isolated, only 1 had an index of <2. The mean index 1. Moss FM, McNichol MW, McSwiggan DA, Miller DL. Survey of antibiotic pre-
of the remainder was 4-6, and antibiotic therapy, according scribing in a district general hospital I: The pattern of use. Lancet 1981; ii: 349-52.
2. Roberts AW, Visconti JA. The rational and irrational use of systemic antibiotics. Am J
to the criteria outlined, was considered justified in all of these Hosp Pharm 1972; 29: 829-34.
Scheckler WE, Bennett JV. Antibiotic usage in seven community hospitals. JAMA
patients. 3.
1970; 213: 264-67.
If the index of infection is accepted as an objective method 4. Kumn CM, Tupasi T, Craig WA. Use of antibiotics: a brief exposition of the problems
of assessing the justification for antibiotic therapy, the use of and some tentative solutions. Ann Intern Med 1973; 79: 555-60.
5. Meiring P de C, Briscoe RJN. A survey of systemic antibiotics prescribed in a general
antibiotics seems to have been justifiable in 49% and hospital: a step towards medical audit. S Afr Med J 1968; 42: 836-39
questionable or unjustifiable in 51% of the patients. The
single most frequent error was the misinterpretation of chest
X-rays. 13 of the 33 patients with an index of 0 or 1 were
diagnosed as having a chest infection on the basis of
misinterpretation of radiological findings; many of these Child Health
X-rays showed pulmonary oedema, which explains why a
higher proportion of antibiotics prescribed to older patients
than to younger patients was considered unjustifiable. In the BREASTFEEDING AND HOSPITAL MORTALITY
remainder, the diagnosis appeared to have been made on very IN CHILDREN IN RWANDA
tenuous clinical evidence, probably influenced by the view
that to omit to prescribe antibiotics is a more serious sin than PHILIPPE LEPAGE CHRISTOPHE MUNYAKAZI
to prescribe them unnecessarily. The fact that only one of PHILIPPE HENNART
these prescriptions was subsequently altered by the Paediatric Department, Centre Hospitalier de Kigali, Rwanda;
consultant staff suggests that such a view may be widely Centre Scientifique et M&eacute;dical de lUniversit&eacute; Libre de Bruxelles dans
shared. ses Actions de Coop&eacute;ration (CEMUBAC); and Department of

There is an apparent contrast between the prescribers poor Epidemiology and Social Medicine, University of Brussels, Brussels,
ability to diagnose chest infection and their apparently good Belgium
choice of antibiotic. This probably reflects the hospitals
Summary The relation between breastfeeding and
antibiotic policy. It seems likely that limiting the extent of
among 2339 children under two
mortality
reporting of bacterial antibiotic sensitivities has modified the
years old and admitted to hospital with measles, diarrhoeal
pattern of antibiotic use. The limited use of cephalosporins, a
disease, or acute lower respiratory disease was analysed over a
group of drugs which is not included in the reports of
bacterial sensitivities routinely issued to prescribers, suggests two-year period in Kigali, Rwanda. Case fatality rates were
that this method is effective. The widespread use of significantly lower in the breastfed than in the completely
weaned children for all three diseases. This advantage held
ampicillin for chest infection would at first seem to confirm for all six month age groups.
the usefulness of such a policy. However, ampicillin-like
drugs were prescribed to a significantly higher proportion of INTRODUCTION
patients for whom we found the use of antibiotics to be
unjustified than for those for whom we found it to be acute lower respiratory
MEASLES, diarrhoeal disease, and
justified. It is tempting to speculate that where an antibiotic is tractdisease (ALRD) are among the leading causes of illness
used "routinely", the prescribers feel that they have to use and death in children in developing countries. In 1977 and
410

1978 measles was the commonest cause of hospital admission


to the paediatric department of the Centre Hospitalier de
Kigali. 30-40% of admissions
20%.
were for measles and the case
Diarrhoeal
1:1 Breast-fed
fatality rate was about disease and ALRD
were, with acute upper respiratory tract infections, the major E2 Weaned
reasons for consultation and the second and third causes,
respectively, of hospital admission for children in Kigali.3
The crucial role of breastfeeding-principally by its
nutritional and anti-infective properties-on the
development of the young child is well established.4
However, the relation between childrens hospital mortality
and breastfeeding does not seem to have been analysed. We
have studied the outcome in Rwandese children under two
years of age admitted to hospital with measles, diarrhoeal
disease, or ALRD to see if children who are weaned run a
higher risk of dying than those still breastfed and, if human
milk does have a protective effect, up to what age it acts.

PATIENTS AND METHODS

Background V-J BJ!)I )-t// )U.U

Age (in months)


Kigali, the capital of Rwanda, Central Africa, is a city of about
100 000 inhabitants. It is 1500 m above sea level and its climate is Distribution of case fatality rates according to feeding mode by age
periods of 6 months.
temperate, with two rainy and two dry seasons. The Centre
Hospitalier Kigali is the only hospital. About 3000 children under Case fatality rates for children with measles, diarrhoeal disease, or ALRD, by
fifteen years old are admitted each year to the paediatric
age. The numbers are:
department. Patients come from the city (60%) and from the
crowded rural communes (40%) surrounding Kigali. Data on age,
sex, month of admission, geographical origin, diet, medical history,
immunisation, anthropometric measures, physical examination,
basic laboratory findings, diagnosis, length of stay, and outcome are
recorded for each child admitted.
Breastfeeding versus weaning. -Children were defined as breastfed
Patients if, on the day of admission, they were still sucking, with or without
Between Jan. 1, 1977, and Dec. 31, 1978, 2724 Rwandese additional food.
children under 2 years of age, all of whom had full case records, were
admitted to the paediatric department. Patients from the RESULTS
department of neonatology were not included. There were 1035 As shown in the table, the case fatality rates among children
measles, 849 diarrhoeal disease, and 455 ALRD cases. Thus, the under two years of age with measles, diarrhoea, and ALRD
three diseases accounted for 86% (2339) of all admission of children
were significantly higher when the children had been weaned
under two years of age.
than when they were still being breastfed. Ih older children
case fatality rates were lower.
Definitions
The superior survival rate in breastfed children holds true
Measles.-All cases were diagnosed clinically by a physician. 92%
of these children had one or more of the following complications: for successive six month age groupings (see figure). The
difference in mortality for breastfed versus weaned is
pulmonary infection, diarrhoea, and laryngitis.
Diarrhoeal disease.-The diarrhoea, with or without vomiting, significant for children under one year of age (p<0 - 001) and
was severe enough to require hospital admission. Patients with for those aged twelve to twenty-three months (p<0-001).
measles diarrhoea were not included.
ALRD.-All cases of pneumonia, bronchiolitis and DISCUSSION
laryngotracheobronchitis were diagnosed clinically and/or by
X-ray. Pulmonary complications of measles were not included. The protection provided by breastfeeding against
infections and death in the young child5 has been confirmed
both for underdevelopedb-8 and for industrialised
FEEDING METHOD AND CASE FATALITY RATES AMONG CHILDREN
:ountries.9,1O Hospital admission for diarrhoeal disease and
ADMITTED TO HOSPITAL IN KIGALI, RWANDA 1977-78
ALRD is much more common in weaned infants.1l-14 We
have shown that, for patients less than two years old, the case
fatality rate is significantly higher among the weaned children
:table), and this held true for measles, diarrhoeal disease and
ALRD, case fatality rates being 1-5, 3-3, and 2.1times
higher, respectively, among patients who had been weaned.
This protective effect was not limited to the first 6 or 12
months of life (figure). In a survey in Bangladesh, Hoyle et
11. 1found that breastfeeding, continued during episodes of
lcute diarrhoea, protected the child against reduction in
protein and caloric consumption during the illness, and
*Case fatality rates significantly worse in weaned group than in breastfed group (p<0 - . 001;
l; mman milk seemed to provide a positive nutritional effect
test). mtil the third year of life.
411

In the paediatric department of the Centre Hospitalier INTRODUCTION

Kigali, mothers are allowed into the hospital with their Huntingtons chorea (HC) is one of the most serious
children and the nurses encourage them to continue to genetic disorders of adult life. The prevalence in most parts of
breastfeed. Thus, the better prognosis among our breastfed Europe and North America is between 2 and 9 per 100 000
patients can be attributed to better nutritional state on population, a value of 7 6 per 100 000 having been estimated
admission and/or to a higher nutrient intake while in hospital. for South Wales! The late onset of clinical features and the
We thank Prof. H. L. Vis for his support. absence of predictive tests of proven value cause particular
difficulties in genetic counselling and mean that for every
Requests for reprints should be addressed to P. H., Department of
Paediatrics, Hopital St Pierre, rue Haute 320, Brussels 1000, Belgium. overt case of the disease there are at high risk numerous
relatives whose lives may be seriously affected, even though
REFERENCES
they may never develop the disorder.
1 Walsh JA, Warren KS. Selective primary health care: An interim strategy for disease There is no evidence that HC has declined in recent years,
control in developing countries. N Engl J Med 1979; 301: 967-74.
2 Lepage P, De Mol P. Measles mortality in Rwanda. Lancet 1979; ii: 1133-34. despite enhanced awareness of the disorder and greater
3. Lepage P Aspect clinique et biologique des gastroent&eacute;rites au Centre Hospitalier de availability of genetic counselling. Indeed, some studies have
Kigali, Rwanda 1977-1978. Revue M&eacute;d Rwandaise 1979; 35: 10-15. shown increased reproductive fitness of HC patients,2
4 Jelliffe DB, Jelliffe EFP. Breast is best: Modern meaning. N Engl J Med 1977; 297:
912-15 suggesting that the prevalence might be rising.
5 Jelliffe DB, Jelliffe EFP. Human milk in the modern world. London: Oxford To attempt to answer the question of whether changes in
University Press 1978;: 197-99.
6 Scrimshaw NS Taylor CE, Gordon JE. Interaction of nutrition and infection Geneva: the incidence of HC were happening at present or would do
WHO 1968. so in the future, a prospective study of the disorder was
7 Plank SJ, Milanesi ML. Infant feeding and infant mortality in rural Chile. Bull Wld
Hlth Org 1973; 48: 203-10.
undertaken in South Wales: the initial results have already
8 Puffer RR, Serrano CV. Patterns of mortality in childhood. PAHO scientific been reported. 1,3 This paper presents data on trends observed
publication no 262. Washington DC: Pan American Health Organization; 1973. since the initial study and attempts to relate them to
9 Cunningham AS. Morbidity in breast-fed and artificially fed infants. J Pediatr 1977;
90: 726-29. influences to which the subjects may have been exposed.
10 Cunningham AS. Morbidity in breastfed and artificially fed infants II. J Pediatr 1979;
95: 685-89
11 Kannaaneh H The relationship of bottle feeding to malnutrition and gastroenteritis in SUBJECTS AND METHODS
a pre-industrial setting. J Trop Pediatr 1972; 18: 302-06.
12 Larsen Jr SA, Homer DR Relation of breast versus bottle feeding to hospitalization for The form of the initial study has been described previously.1,3
gastroenteritis m a middle-class US population. J Pediatr 1978; 92: 417-18. Complete ascertainment was attempted in the counties of Gwent
13 Glezen WP, Denny FW. Epidemiology of acute lower respiratory disease in children. and Glamorgan (comprising South, West, and Mid Glamorgan),
N Engl J Med 1973; 288: 498-505. South Wales; it is likely that ascertainment was close to complete,
14 Downham MAPS, Scott R, Sims DG, Webb JKB, Gardner PS. Breastfeeding protects
against respiratory syncytial virus infections. Br Med J 1976; ii: 274-76. since no further established cases of HC have been found during
15 Hoyle B, Yunus M, Chen LC. Breastfeeding and food intake among children with
acute diarrhoeal disease. Am J Clin Nutr 1980; 33: 2365-71.
subsequent years: new cases detected were either in families already
known to us, or in families without living affected members, or in
families who had come from outside the area.
The risk of the disorder developing was estimated for all family
members by means of a life table.4 Those for whom the risk was
greater than 1 in 10 (986 individuals in 458 family units) were
Preventive Medicine followed prospectively by means of annual home visits by an
experienced nurse. During visits data on births, deaths, and other
relevant events were collected; subjects who showed possible
features of the disorder were referred for neurological assessment at
DECLINE IN THE PREDICTED INCIDENCE OF
HUNTINGTONS CHOREA ASSOCIATED WITH
hospital. 724 subjects (74%) were visited personally in this way;
information on most of the remainder who did not wish to maintain
SYSTEMATIC GENETIC COUNSELLING AND regular contact was obtained indirectly through other family
FAMILY SUPPORT members and through family doctors. It proved impossible to obtain
any accurate information subsequent to that recorded in the initial
PETER S. HARPER AUDREY TYLER study in only 3% (32 subjects).
SUE SMITH PAT JONES Genetic counselling was given in several ways. General
information on genetic risks was given during the initial survey
Section of Medical Genetics, Department of Medicine, Welsh
visit; when family members were at or approaching reproductive
National School of Medicine
age, further and more detailed information was given at the genetics
clinic. The annual home visits provided opportunities both to
ROBERT G. NEWCOMBE VALERIE MCBROOM initiate such clinic visits, particularly in those reaching adulthood,
and to check that information given at the clinic had been correctly
Department of Medical Statistics, Welsh National School of understood. Genetic counselling was not directive, but an attempt
Medicine
was made to ensure that the subjects understood the nature of the

Summary Prospective study of relatives at high risk of disorder, as well as the risk of their developing and transmitting it.
The clinic visit was backed up by availability of contraceptive
Huntingtons chorea (HC) in a previously advice, sterilisation, and termination of pregnancy, where
documented1 South Wales population with a high incidence indicated.
of the disorder has shown a pronounced fall in the number of
births at risk and in the predicted future incidence of the
RESULTS
disease, contrasting with relatively stable levels before the
introduction of our programme of systematic genetic The figure shows the trend in predicted incidence of births
counselling and family support. Although the reasons for the heterozygous for HC in our study population (curve B)
reduction in births at risk are probably complex, it appears expressed as five-year moving averages and compared with
that genetic counselling, even in the absence of effective the general population birth-rate (curve A). The data are for
predictive and prenatal diagnostic tests, may be helpful in the the same kindreds and are expressed in the same way as
long-term prevention of HC in this population. reported previously, but figures for the ten-year period