409
the patients whose treatment was started in hospital. Sputum
specimens from 46 patients were examined; however, a third
of these specimens were obtained after antibiotic treatment
had been started. An agent, thought by the medical
microbiologist to be causal, was isolated from the sputum of
13 patients. All these specimens were taken before antibiotic
therapy was given. Blood cultures were done in 27 cases.
Streptococcus pneumoniae was isolated from 1 patient. In 1
patient pleural fluid yielded non-haemolytic streptococci
which were thought to be causal.
DISCUSSION
Unlike other antibiotic surveys which have discussed the
quality of antibiotic use,2-5 this analysis has been limited to
the treatment of infection at one site and is based on
information derived from a larger survey which included an
interview with the prescriber. It is, therefore, possible to
gain a greater and more precise insight into the reasoning of
the prescriber and to the sources of error in antibiotic
prescribing.
The index of infection was constructed to include not only
features associated with bacterial pneumonia but also features
associated with infective exacerbations of chronic bronchitis
and asthma, which are more difficult to define. We believe
that the index does reflect the presence of bacterial infection
of the lower respiratory tract: of the 13 patients from whom
an organism with a very high probability of having a causal
role was isolated, only 1 had an index of <2. The mean index
of the remainder was 4-6, and antibiotic therapy, according
to the criteria outlined, was considered justified in all of these
patients.
If the index of infection is accepted as an objective method
of assessing the justification for antibiotic therapy, the use of
antibiotics seems to have been justifiable in 49% and
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
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
remainder, the diagnosis appeared to have been made on very
tenuous clinical evidence, probably influenced by the view
that to omit to prescribe antibiotics is a more serious sin than
to prescribe them unnecessarily. The fact that only one of
these prescriptions was subsequently altered by the
consultant staff suggests that such a view may be widely
shared.
There is an apparent contrast between the prescribers poor
ability to diagnose chest infection and their apparently good
choice of antibiotic. This probably reflects the hospitals
antibiotic policy. It seems likely that limiting the extent of
reporting of bacterial antibiotic sensitivities has modified the
pattern of antibiotic use. The limited use of cephalosporins, a
group of drugs which is not included in the reports of
bacterial sensitivities routinely issued to prescribers, suggests
that this method is effective. The widespread use of
ampicillin for chest infection would at first seem to confirm
the usefulness of such a policy. However, ampicillin-like
drugs were prescribed to a significantly higher proportion of
patients for whom we found the use of antibiotics to be
unjustified than for those for whom we found it to be
justified. It is tempting to speculate that where an antibiotic is
used "routinely", the prescribers feel that they have to use
another, "stronger" antibiotic when they have real concern
that respiratory infection is present. If this is the case, then
the patient may be being deprived of an excellent drug when
he needs it because he is being prescribed it when he does not
require it-a case of losing both on the swings and on the
roundabouts.
This review of antibiotic use for lower respiratory tract
infection suggests that the quality of antibiotic prescribing is
unlikely to be improved by microbiological and
pharmacological guidelines. The introduction of a more
restrictive antibiotic policy would not be a solution. It is the
development of a more critical diagnostic approach which
should be the first concern of all those who want to improve
the quality of antibiotic prescribing. The onus of this task
belongs as much to the clinician, surgical or medical, as to the
microbiologist and infectious disease consultant. We suggest
that by considering the evidence of infection by a method
similar to the scoring technique outlined in this paper,
prescribers might derive a useful index of the probability of
infection and, as a consequence, improve the quality of
antibiotic prescribing.
We thank the senior and junior medical staff of the Central Middlesex
Hospital for their cooperation; Miss M. Fielding, Miss A. Etherington, and
Miss J. Steward for secretarial services; and Miss V. Musgrove for retrieval of
chest X-rays. F. M. was in receipt of a grant from the C.M.H. Research and
Teaching Fund.
F. M.
Requests for reprints should be addressed to
1. Moss FM, McNichol MW, McSwiggan DA, Miller DL. Survey of antibiotic pre-
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
Hosp Pharm 1972; 29: 829-34.
Scheckler WE, Bennett JV. Antibiotic usage in seven community hospitals. JAMA
3.
1970; 213: 264-67.
4. Kumn CM, Tupasi T, Craig WA. Use of antibiotics: a brief exposition of the problems
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
hospital: a step towards medical audit. S Afr Med J 1968; 42: 836-39
Child Health
BREASTFEEDING AND HOSPITAL MORTALITY
IN CHILDREN IN RWANDA
PHILIPPE LEPAGE CHRISTOPHE MUNYAKAZI
PHILIPPE HENNART
Paediatric Department, Centre Hospitalier de Kigali, Rwanda;
Centre Scientifique et M&eacute;dical de lUniversit&eacute; Libre de Bruxelles dans
ses Actions de Coop&eacute;ration (CEMUBAC); and Department of
Epidemiology and Social Medicine, University of Brussels, Brussels,
Belgium
Summary The relation between breastfeeding and
among 2339 children under two
mortality
years old and admitted to hospital with measles, diarrhoeal
disease, or acute lower respiratory disease was analysed over a
two-year period in Kigali, Rwanda. Case fatality rates were
significantly lower in the breastfed than in the completely
weaned children for all three diseases. This advantage held
for all six month age groups.
INTRODUCTION
acute lower respiratory
MEASLES, diarrhoeal disease, and
tractdisease (ALRD) are among the leading causes of illness
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
temperate, with two rainy and two dry seasons. The Centre
Hospitalier Kigali is the only hospital. About 3000 children under
fifteen years old are admitted each year to the paediatric
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.
Patients
Between Jan. 1, 1977, and Dec. 31, 1978, 2724 Rwandese
children under 2 years of age, all of whom had full case records, were
admitted to the paediatric department. Patients from the
department of neonatology were not included. There were 1035
measles, 849 diarrhoeal disease, and 455 ALRD cases. Thus, the
three diseases accounted for 86% (2339) of all admission of children
under two years of age.
Definitions
Measles.-All cases were diagnosed clinically by a physician. 92%
of these children had one or more of the following complications:
pulmonary infection, diarrhoea, and laryngitis.
Diarrhoeal disease.-The diarrhoea, with or without vomiting,
was severe enough to require hospital admission. Patients with
measles diarrhoea were not included.
ALRD.-All cases of pneumonia, bronchiolitis and
laryngotracheobronchitis were diagnosed clinically and/or by
X-ray. Pulmonary complications of measles were not included.
FEEDING METHOD AND CASE FATALITY RATES AMONG CHILDREN
ADMITTED TO HOSPITAL IN KIGALI, RWANDA
*Case fatality rates significantly worse in weaned group than in breastfed group (p<0 - . 001;
test).
Distribution of case fatality rates according to feeding mode by age
periods of 6 months.
Case fatality rates for children with measles, diarrhoeal disease, or ALRD, by
age. The numbers are:
Breastfeeding versus weaning. -Children were defined as breastfed
if, on the day of admission, they were still sucking, with or without
additional food.
RESULTS
As shown in the table, the case fatality rates among children
under two years of age with measles, diarrhoea, and ALRD
were significantly higher when the children had been weaned
than when they were still being breastfed. Ih older children
case fatality rates were lower.
The superior survival rate in breastfed children holds true
for successive six month age groupings (see figure). The
difference in mortality for breastfed versus weaned is
significant for children under one year of age (p<0 - 001) and
for those aged twelve to twenty-three months (p<0-001).
DISCUSSION
The protection provided by breastfeeding against
infections and death in the young child5 has been confirmed
both for underdevelopedb-8 and for industrialised
:ountries.9,1O Hospital admission for diarrhoeal disease and
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
l; mman milk seemed to provide a positive nutritional effect
mtil the third year of life.

In the paediatric department of the Centre Hospitalier
Kigali, mothers are allowed into the hospital with their
children and the nurses encourage them to continue to
breastfeed. Thus, the better prognosis among our breastfed
patients can be attributed to better nutritional state on
admission and/or to a higher nutrient intake while in hospital.
We thank Prof. H. L. Vis for his support.
Requests for reprints should be addressed to P. H., Department of
Paediatrics, Hopital St Pierre, rue Haute 320, Brussels 1000, Belgium.
REFERENCES
1 Walsh JA, Warren KS. Selective primary health care: An interim strategy for disease
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.
3. Lepage P Aspect clinique et biologique des gastroent&eacute;rites au Centre Hospitalier de
Kigali, Rwanda 1977-1978. Revue M&eacute;d Rwandaise 1979; 35: 10-15.
4 Jelliffe DB, Jelliffe EFP. Breast is best: Modern meaning. N Engl J Med 1977; 297:
912-15
5 Jelliffe DB, Jelliffe EFP. Human milk in the modern world. London: Oxford
University Press 1978;: 197-99.
6 Scrimshaw NS Taylor CE, Gordon JE. Interaction of nutrition and infection Geneva:
WHO 1968.
7 Plank SJ, Milanesi ML. Infant feeding and infant mortality in rural Chile. Bull Wld
Hlth Org 1973; 48: 203-10.
8 Puffer RR, Serrano CV. Patterns of mortality in childhood. PAHO scientific
publication no 262. Washington DC: Pan American Health Organization; 1973.
9 Cunningham AS. Morbidity in breast-fed and artificially fed infants. J Pediatr 1977;
90: 726-29.
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
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
gastroenteritis m a middle-class US population. J Pediatr 1978; 92: 417-18.
13 Glezen WP, Denny FW. Epidemiology of acute lower respiratory disease in children.
N Engl J Med 1973; 288: 498-505.
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.
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.
Preventive Medicine
DECLINE IN THE PREDICTED INCIDENCE OF
HUNTINGTONS CHOREA ASSOCIATED WITH
SYSTEMATIC GENETIC COUNSELLING AND
FAMILY SUPPORT
PETER S. HARPER AUDREY TYLER
SUE SMITH PAT JONES
Section of Medical Genetics, Department of Medicine, Welsh
National School of Medicine
ROBERT G. NEWCOMBE VALERIE MCBROOM
Department of Medical Statistics, Welsh National School of
Medicine
Summary Prospective study of relatives at high risk of
Huntingtons chorea (HC) in a previously
documented1 South Wales population with a high incidence
of the disorder has shown a pronounced fall in the number of
births at risk and in the predicted future incidence of the
disease, contrasting with relatively stable levels before the
introduction of our programme of systematic genetic
counselling and family support. Although the reasons for the
reduction in births at risk are probably complex, it appears
that genetic counselling, even in the absence of effective
predictive and prenatal diagnostic tests, may be helpful in the
long-term prevention of HC in this population.
411
INTRODUCTION
Huntingtons chorea (HC) is one of the most serious
genetic disorders of adult life. The prevalence in most parts of
Europe and North America is between 2 and 9 per 100 000
population, a value of 7 6 per 100 000 having been estimated
for South Wales! The late onset of clinical features and the
absence of predictive tests of proven value cause particular
difficulties in genetic counselling and mean that for every
overt case of the disease there are at high risk numerous
relatives whose lives may be seriously affected, even though
they may never develop the disorder.
There is no evidence that HC has declined in recent years,
despite enhanced awareness of the disorder and greater
availability of genetic counselling. Indeed, some studies have
shown increased reproductive fitness of HC patients,2
suggesting that the prevalence might be rising.
To attempt to answer the question of whether changes in
the incidence of HC were happening at present or would do
so in the future, a prospective study of the disorder was
undertaken in South Wales: the initial results have already
been reported. 1,3 This paper presents data on trends observed
since the initial study and attempts to relate them to
influences to which the subjects may have been exposed.
SUBJECTS AND METHODS
The form of the initial study has been described previously.1,3
Complete ascertainment was attempted in the counties of Gwent
and Glamorgan (comprising South, West, and Mid Glamorgan),
South Wales; it is likely that ascertainment was close to complete,
since no further established cases of HC have been found during
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
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
hospital. 724 subjects (74%) were visited personally in this way;
information on most of the remainder who did not wish to maintain
regular contact was obtained indirectly through other family
members and through family doctors. It proved impossible to obtain
any accurate information subsequent to that recorded in the initial
study in only 3% (32 subjects).
Genetic counselling was given in several ways. General
information on genetic risks was given during the initial survey
visit; when family members were at or approaching reproductive
age, further and more detailed information was given at the genetics
clinic. The annual home visits provided opportunities both to
initiate such clinic visits, particularly in those reaching adulthood,
and to check that information given at the clinic had been correctly
understood. Genetic counselling was not directive, but an attempt
was made to ensure that the subjects understood the nature of the
disorder, as well as the risk of their developing and transmitting it.
The clinic visit was backed up by availability of contraceptive
advice, sterilisation, and termination of pregnancy, where
indicated.
RESULTS
The figure shows the trend in predicted incidence of births
heterozygous for HC in our study population (curve B)
expressed as five-year moving averages and compared with
the general population birth-rate (curve A). The data are for
the same kindreds and are expressed in the same way as
reported previously, but figures for the ten-year period