BMJ

Towards Fewer Handicapped ChildrenAuthor(s): John H. SmithSource: The British Medical Journal, Vol. 280, No. 6209 (Jan. 26, 1980), pp. 252-253Published by: BMJStable URL: http://www.jstor.org/stable/25438611 .

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252 BRITISH MEDICAL JOURNAL 26 JANUARY 1980

(caused by anxiety, inappropriate, or paroxys

mal) but even more so if it is of ventricular

origin. The commonest cause of ventricular

tachycardia is acute cardiac infarction, and

the differentiation at the bedside between a

paroxysm of ventricular tachycardia and one

of supraventricular origin is by no means

easy. Both usually give a heart rate of 160 or

more beats a minute and one of the few

differences is that in ventricular tachycardia

spacing of the beats may be irregular and this

may be clinically perceptible. Your expert, who recommends intravenous digoxin for a

heart rate that "becomes fast and irregular," could easily convert what might be a ventricu

lar tachycardia into ventricular fibrillation.

Nor am I happy with the routine use of

lignocaine to prevent primary ventricular

fibrillation. This is a longstanding controversy but there is increasing opinion today not

only that it may be of no use but that it may

actually be harmful. Pantridge1 in 1970

found lignocaine to be ineffective against ventricular ectopic beats occurring in the

first hour of the clinical onset of acute myo cardial infarction. In 1971 Chopra et al2

showed that both ectopics of R on T type and multifocal ectopics were resistant to

lignocaine, and that the only ectopics which

were easily abolished were those occurring in

diastole?and these in any case are considered

relatively benign and unlikely to produce

primary ventricular fibrillation. Darby et al3

in 1972 found that ventricular tachycardia and fibrillation occurred no less frequently in the group treated with lignocaine than in

the control group. Lie et al* in 1974 in

400 successive patients with acute cardiac

infarction found that 5% developed primary ventricular fibrillation in the lignocaine treated group as opposed to 4-3% in the

control group. Moreover, Bleifeld5 showed

that ectopic beats, sinus bradycardia, and

second-degree atrioventricular block were

more common in the lignocaine-treated group than in the control group; and concluded

that lignocaine should not be used routinely in acute cardiac infarction.

Furthermore, your expert does not mention

that it is necessary whenever one gives

lignocaine intravenously to give it very slowly

?taking at least two minutes to administer

100 mg of a 1% solution; otherwise toxic

effects of lignocaine, such as bradycardia and

hypotension, are apt to occur. This is

particularly important in the elderly, where

following its administration many authors6-8 have reported sinus bradycardia, ectopic beats, sinoatrial block, and even cardiac arrest.

Incidentally, I am sure that your expert is

referring to dipyridamole and not disopyra mide in connection with antiplatelet aggre

gation action.

I agree that your expert was attempting to

"oversimplify" the problem, but I hope not

at the expense of creating new problems.

Alan A Morgan Honorary Clinical Assistant

in Chest Diseases

University College Hospital, London WC1E 6AU

1 Pantridge JF. In: Scott DB, Julian DG, eds. Lidocaine

in the treatment of ventricular arrhythmia. Edin burgh: Livingstone, 1971:77-81. 2

Chopra MP, Thadam U, Portal RW, Aber CP. Br MedJ 1971;iii:668-70. 3

Darby S, Cruickshank JC, Bennett MA, Pentecost BL. Lancet 1972 ;i:817-9. 4 Lie KI, Wellens HJ, D?rrer D. Eur J Cardiol 1974;1 : 379-84.

8 Bleifeld W, Merx W, Heinrich KW, Eifert S. Eur J Clin Pharmacol 1973;6:119-26. 6

Lippestad CT, Forfang K. Br MedJ 1971;i:537. 7 Jeresaty RM, Kahn AH, Landey AB. Chest 1972 ;61:

683-5. 8 Cheng TO, Wadhawa J.JAMA 1973;223:790-2.

%*With regard to the first point, we regret that we printed disopyramide rather than

dipyridamole. The similarity between these two names presents a recurring problem. Dr

Morgan points out that intravenous lignocaine must be given slowly. Of course, no drug

should be given fast intravenously, and

lignocaine is no exception. There are indeed

papers suggesting that this drug may not be

useful but at least it rarely seems to do harm.

If the heart is beating very fast and the

patient is hypotensive it must be slowed.

Clearly an electrocardiogram, correctly in

terpreted, is desirable but we live in an im

perfect world. We do not agree that ventricular

tachycardia and rapid atrial fibrillation would

often be confused. The irregularity of ventri

cular tachycardia is obvious on paper but

usually slight compared with that of atrial

fibrillation. The rate of atrial fibrillation can

be slowed by a beta-blocker or by verapamil but we would not regard these as safer than

digoxin in this hypothetical emergency.?

Ed, BMJ.

Effects of naloxone on pethidine-induced neonatal depression

Sir,?We report a follow-up on children included in a neonatal study of the effects

of naloxone on pethidine-induced depression of respiration, feeding, and measures of

behaviour.1

Nineteen of 29 infants included in the origi nal trial attended for examination when aged 10-16 months. At birth nine of the infants had

received placebo (normal saline) and 10

naloxone hydrochloride 200 /xg intramuscu

larly. At follow-up all were rated on the Cardiff

standardisation of the Denver developmental

screening test2 and were neurologically examined. No differences were found between

the placebo and naloxone groups of children.

Of the nine children in the placebo group one

had delayed gross motor and two had delayed fine motor development. Two of the children

in the naloxone group had delayed gross motor achievements.

These findings complement the results of the

original trial, which indicated that 200 /?g intramuscular naloxone at birth seemed to reverse the undesirable effects of pethidine up to 48 hours after birth. We conclude that

naloxone did not disproportionately affect

development. P C Wiener

Sheila Wallace Department of Anaesthetics, University Hospital of Wales, Cardiff CF4 4XW

1 Wiener PC, Hogg MPJ, Rosen M. Br MedJ 1977; ii:228-31. 2

Bryant GM, Davies KJ, Newcombe RG. Develop Med Child Neurol 1979;21:353-64.

Resuscitation of the newborn

Sir,?Dr A R J Bosley (15 December, p 1590) is incorrect in stating that the Penlon bag was

not designed for use with an endotracheal

tube. Mushin and Hillard mentioned such an

application in their original description.1 The

ability of the device to create airway pressures

up to 80 cm H20 was also noted. In using a

leak hole in the inflating valve (instead of an

ordinary blow-off valve with a preset pressure

limit) the authors found that as pulmonary

compliance increased (with inflation of the

lungs) the maximum pressure obtainable would

fall. This variable blow-off effect was justified

by pointing out that the inflation pressure needed for totally airless lungs2 may often be

80 cm H20, so it was illogical to use a blow-off valve preset at a lower figure. Nevertheless, in

another study, which compared the Penlon

bag with the Ambu neonatal bag, which uses

an equally novel mechanism, again not depen dent on a blow-off valve, it was found3 that

both gave maximum pressures of about 85 cm

H20 with either a high or a low resistance.

However, the Penlon created a maximum

pressure of 175 cm H20 in a closed system

compared with only 85 cm H20 with the Ambu bag.

Despite these comments, these "flat" babies will not survive without someone inflating the

lungs with one of a multitude of devices at his

disposal. The fact that they all carry risks of

pneumothorax, which may prove fatal, does not alter the situation. Endotracheal intubation

of the neonate is often difficult to perform and to teach4 but may be life saving. With the

appalling UK perinatal mortality statistics, can we afford to limit the resuscitation abilities

of the obstetric team ?

M J Boscoe

Department of Anaesthetics, University Hospital of Leiden, Leiden, The Netherlands

1 Mushin WW, Hillard EK. Br MedJ 1967;i:416-7. 2 Rosen M, Laurence KM. Lancet 1965;ii:721-2. 3 Rondio Z, Rawicz M. Anaesth Resus Intensive Therap 1976;4:273-9. 4 Rosen M, Mushin WW. Lancet 1968 ;i: 1307.

Towards fewer handicapped children

Sir,?Your recent leading article "Towards

fewer handicapped children" (8 December,

p 1458) mentions the relation between severe

handicap, low birth weight (<2500 g), and

low socioeconomic group and suggests that

researchers might best employ themselves by

identifying which particular components of

socioeconomic deprivation result in an in

creased incidence of handicap. Surely part of

this research has already been done.

Improved maternal nutrition during preg

nancy in low socioeconomic groups is known

to increase average birth weight, reduce the

incidence of low-birth-weight babies ( < 2500

g), and reduce perinatal mortality. Thus in

Guatemala1 adequate maternal dietary supple mentation during pregnancy in village dwellers

resulted in an average fall from 30% to 9% in the incidence of low-birth-weight babies.

Similar findings are demonstrated in developed countries. In Montreal2 reduction in the

incidence of low-birth-weight babies ( < 2500 g) and a decrease in both perinatal and neonatal

mortality was shown in a high-risk, low

socioeconomic study group subjected to

"intensive nutritional care" (counselling and

dietary supplementation) throughout preg

nancy. With such improvements in birth weight and

reduction in perinatal and neonatal mortality can one not expect an attendant reduction in

morbidity, including mental and physical

handicap ? While attention is focused sharply on perinatal intensive care, could we not

reduce perhaps the size of the perinatal

problem by instituting "intensive nutritional

care," including dietary supplementation

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BRITISH MEDICAL JOURNAL 26 JANUARY 1980 253

where necessary, throughout the antenatal

period, especially in low socioeconomic

groups ?

John H Smith

Rotunda Hospital, Dublin, Eire

1 Lechtig A, Habicht JP, Delgado H, Klein RE,

Yarbrough C, Martorell R. Pediatrics 1975 ;56: 508-20.

2 Primrose T, Higgins A. J Reprod Med 1971 ;7: 257-64.

Monitoring blood glucose

Sir,?Mary Warner (15 December, p 1581) and Dr R D Eastham (12 January, p 116) have

both quite rightly cautioned us on the indis

criminate and unsupervised use of blood

glucose meters and one has to agree with many of the points made. The biochemistry labora

tory should indeed be able to produce the more

accurate results, and results from meters in

some clinical situations, operated by a variety of personnel, may at times be suspect. How

ever, even with all the limitations of interpre tation of the single clinic blood glucose estima

tion, it is far more valuable if the result is

available at the time of the consultation; and

this in many hospitals and outlying clinics

can be provided only by a meter and strip

system. The responsibility for such a system must lie with the clinician, who should be

constantly checking quality control with the

assistance of his biochemical colleagues. With regard to self-monitoring by the

patient, one fundamental question is in danger of being overlooked?who needs to know the

blood glucose results ? The answer is that it is

the patient who needs the result and he or she

needs it at the time of the test, not two or three

days later. The patient must be trained to react

to abnormal patterns of results by making sen

sible changes of treatment. If this is not done

then the full potential of self-monitoring is not

being realised. Thus filter paper strips sent to

the laboratory, as described by Dr R Paisey and others (8 December, p 1509), provide only a

partial self-monitoring system. A coefficient

of variation of less than 10% is adequate for

day-to-day diabetic management and may be

achieved by suitably trained patients using meters and strip tests at home.1 Quality control

is important with self-monitoring even if more

difficult to organise than in the hospital. The

clinician must be satisfied that the patient is

well trained, maintains good technique, and

responds appropriately to the results. The

blood glucose meters and strip systems must

be kept under critical review and must be

shown to live up to the manufacturers' speci fications when put into the hands of the

trained patient.

Self-monitoring of blood glucose may be a

real advance for many patients. Producing inaccurate results will give it a bad name but so

will limiting its potential by giving the result

to the doctor in preference to the patient.

A H Knight

Stoke Mandeville Hospital, Aylesbury, Bucks HP21 8AL

1 Webb DJ, Lovesay JM, Ellis A, Knight AH. Br MedJ In press.

Sir,?We read with interest the paper by Dr I Peacock and others on self-monitoring of blood glucose during diabetic pregnancy

(24 November, p 1333).

Our own experience using the Ames

Dextrostix-Eyetone reflectance meter system is very similar in a series of 24 un

selected consecutive patients (21 established

diabetics ? duration of insulin therapy nine

years, range 0-5 to 26 years ? and three

gestational diabetics on insulin). However, our

patients made three to four measurements of

preprandial blood glucose daily and were

taught and encouraged to modify their own

insulin doses to achieve optimal diabetic

control. We have found that in many patients there are abrupt changes in insulin dose

requirements, particularly towards the end of

the second trimester. Weekly profiles, no

matter how detailed, do not yield enough information in such patients. Furthermore,

postprandial measurements of blood glucose do not appear to be particularly helpful in that

high concentrations after breakfast seem to be

predictable from the value before breakfast.

We are, however, in agreement with the

authors' comments about the dangers of

nocturnal hypoglycaemia, although we have

not found it necessary to advise a third injec tion for this reason.

Collection of blood samples at home for

processing in the laboratory (Dr R B Paisey and others, 8 December, p 1509) may be a

useful method of checking on the correctness

of patients' measurements but does not have

the same educational value as true self

monitoring of blood glucose. In addition, surveillance can be improved by unheralded

visits from a health visitor or specialist nurse.

Measurement of glycosylated haemoglobin concentrations in the pregnant diabetic is too

insensitive a method to detect any but the

more gross forms of aberration in diabetic

control. In our hands normal haemoglobin

Ai concentrations (measured by the micro

column method) can be achieved even when

blood glucose is normal. Hb A1 estimations

give no clue about the swings of blood glucose

(either hyperglycaemia or hypoglycaemia).

By involving the patients in their own dia

betic control motivation and understanding of

the aims of diabetic treatment are greatly enhanced. Although shortening of the period of

hospitalisation was not our prime aim, we

found this easy to achieve save in women with

established diabetes of 10 years or more. In

this group the maternal course during preg

nancy was frequently complicated despite

good control of blood glucose, although the

fetal outcome was as good as in the group with

duration of maternal diabetes of less than 10

years. This method of blood glucose surveil

lance and diabetic control was acceptable to all

our patients and no problems arose as a result

of the frequent capillary blood sampling.

TET West E E Edwards

Royal Shrewsbury Hospital, Shrewsbury, Shropshire

Clara Lowy

S L Judd St Thomas's Hospital, London SEI 7EH

Sir,?As Dr R D Eastham states (12 January,

p 116), the days of the single clinic blood

glucose estimation for assessment of treatment

of diabetes mellitus are numbered. Glyco

sylated haemoglobin may become a better

measure of general diabetic control at inter

mittent clinic visits. However, frequent blood

glucose estimations are required to provide

the up-to-date information necessary for rational adjustment of insulin dosage.

Home monitoring of blood glucose levels is a practical procedure1 and, given the current

mode of insulin administration, exact glucose levels as provided by a clinical chemistry laboratory are unnecessary for this purpose.

Blood glucose levels may be estimated with

glucose oxidase-peroxidase test strips using a

colour comparison scale without the need to

purchase a reflectance meter.2 We have not

found these newer test strips liable to varia tion. Clearly the laboratory estimation of

plasma glucose remains essential for glucose tolerance tests and for management of patients during intercurrent illness and in diabetic

emergencies (and for the calibration of blood

glucose meters). But diabetic patients who have achieved better diabetic control through home monitoring3 should not abandon the

method because it has not yet reached the

precision expected of laboratories.

C M Kesson

Paul Lawson

John T Ireland

Department of Medicine, Southern General Hospital,

Glasgow G51 4TF

1 S?nksen PH, Judd SL, Lowy C. Lancet 1978;i:729-32. 2 Lawson PM, Kesson CM, Ireland JT. Lancet 1979; ii:742.

3 Tattersall RB. Diabetologia 1979;16:71-4.

Postoperative analgesia

Sir,?Dr P C Rutter and others (5 January, p 12) have clearly shown that continuous

intravenous opiate analgesia following abdo

minal surgery produces better analgesia for

less opiate. Vital capacity and peak expiratory flow rate are improved and pulmonary com

plications are fewer with this regimen than

with the two more commonly employed alternatives.

It would be interesting to know the arterial

blood oxygen and carbon dioxide tensions and

pH in the three patient groups during treat

ment, for these findings would have implica tions for the postoperative management of

patients who have preoperative impairment of

pulmonary function. Analgesia is often given

reluctantly to such patients on the grounds that it may cause or exacerbate respiratory failure. If the patients in groups B and C

were more hypoxic and hypercapnic than those

in group A this might suggest that adequate

analgesia by infusion of opiates is more likely to secure optimal pulmonary function even

in patients at risk of respiratory failure because

of lung disease. Postoperative pain resulting from a reluctance to prescribe opiates for these

patients may be more likely to cause respiratory failure than adequate opiate analgesia.

A G Leitch

Department of Respiratory Medicine, City Hospital, Edinburgh EH10 5SB

***We sent a copy of this letter to the authors,

and Professor H A F Dudley's reply on behalf

of his colleagues is printed below.?Ed, BMJ.

Sir,?Dr Leitch is quite right in saying that

the reluctance to give opiates to patients with

borderline respiratory function when they suffer the additional embarrassment of pain

may not be soundly based. However, we cannot

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