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nicotine or other substances in the breast, milk of smokers could be studiied' also. With the present laudable increase in the popularity of breast-feeding, such studies could be designed' and earried' out prospectively, perhaps by a collaborative e0'orn SiR,: N'our editorial on smoking and intrauterine growth (14Sarch 10,, pl 536)'seems to discount the possible role of nutri- tional deficiencies as the major cause of intrauterine growth : retardation ([.u.G.R:). Although the totall caloria intake in B'ri- tain and the other Western countries is not deficicnt,, there could'very welllbe deficiencies in,the more expensive but essen- tial! constituents of thed'iersueh as:protein, vitamias, and'trace metals.' Even in the U.S.A. pregnant,tvomen:at'tending, a,hos' pital clinic from a low socioeconomic group ate less protein, than did! pregnant' women ini the same region from the upper aocioeconomie group who were attending a private clinic.=' Even in, the study by, Meyer; which is,the basis of your views, the babies of patients attending a private',hospitaI' had' signifi- cantly' lesser ta;1G.R: than d'id1babics of patients who attended a public hospital', for the'same amount of'smoking, In view of the effect of social inequalities on health,4 it is important to id'entify the major cause of ILti.G.R: in the poorer classes and findla practicable remedy. Data collecttd in t'his,hospital,on factors which may affect birthweight may be relevant (see tabie); The difference ia, binhweighi between babies born to smoken and nonrsmokers increased with inereasrin the social- elass'r_ur.lber. Even in social class 3 (the numbers in social classes I and 2' are too small'to permit a reliable conclusion), there is:no signi5cant difference in the proportion of small-for- , dates infants between smokers and non-smokers. However, in social class 5' (unskilled manuall workers)' this difference iss striking, nearly 1 in 4 babies being growth-retarded. Although it could easil'y, be arguedl that smoking, was the cause of', the higher incidence of'r,ti:G.R: in socialiclass 51 this argument willl be tenable only if the lack of excess t.u'.G.R. in smokers in sociall class 3 can be explained. If t:u.G:R. is ascribed'to fetal hypoxia due to maternaf smok ir.g;,why does', fet'al Ihypoxia occur in cer- tain social classes and not in others? Since soeial' class is a characteristic not, of the mother but of't'he father, the fetal- hypoxia hypothesis looks evendess convincing. The above results suggest that factors other than smoking, are involved in the atioiogv of t.u.G.RL There is abundant evi- denee for this view from perinatal mortality fie res:?nthe gri- tish, Perinatal hio-ality.'Survey,b the relat'ive,risk of smoking, (noortalitytatiofor smokers'babiesto non-smokers' babies) for social classes i' and 2 was 1'•02 whereas for social classes 3'-S it' was 1•39. In a study in the U:S.A.,r white mothers had a relative risk of 1•08 whereas for black mothers it was 1!•89. Even for white mothersa (Washington County, Maryland), if the father had' hadi a high-school' education,, the relative risk was 1• 12 whereas if he had not attained this level of education„ the relative risk was 2-1'6. Thus it seems that some important factor in the way of life in the upper social groups protects the 1. Sandstead', H. H:,A'm.1 a/in. 4rrer. 1973, 26'„ 1251. 2. Johnsan,W: C. Abs.].' Obs:cr: 6vnec.1'977,128; 29.: 3. Meyer, M. B', ibid.1978,131,,838• 4. Muvri, J. M, Ganccr, 1979,, i4 87: S: Thamson, A. Nt.,,Billcwicz,lS', 7.'.,, Hytten, F. E. Br: a; Obsrer: Gyn.rc. 1968, 75.901 6. Binllr; ti;. R., Albcrman; F. D: Perinatal protikms, Ediotburgh,1969. 7. Rush,l)., Kass,A: CI.Aia. j: Epidemio(,1972, 9/G,183'. ai t:amstock, C: OP,, Shah, F. K., Aleycr. M. B. A',m. $ Obsrrt: Gynec. 1971„ 111,53. Non-smokers Smokers 1%1;can (±s.D:)li birth+seight ($)' TI'lE LANCET„M:tY 5,,1,979 BIRTHwE1G}iT ACCORDIVG TO SOCIAL CLASS AND MATERYA4 SMOKrNG 3398±416 01 3"t 3352±564 5(7 ~) ~ 3259±527 !8 (Z ~) 3I178±496'• 95 (l5''-2'a•) 4 3101±566 ' • ' ' L9(1S'•S • r ) `Significantdifference between smokers and non-smokers, pG0 -00 L s:F.D:~Smallforthegestationat'agt,parity,andsexitfinfant.s . ~ fetuses of smoking, mothers from hypoxia and/or other factors , , which cause r.ulG.R.,, and t'his' factor seems to be missing in. lower social' classes. Factors likely to be relevant to i:u.o.tt. ` ' may be income and education. Low income could. mean less_ meat,, fruit, and, veget'ables+ in the diet, resulting in nutritionall jl~ deficiencies and!t.u.G:R.'' hbutritional'd'eficiencies could becdrrected'bydietary'supple- : ments: It seems unfair to cxhort only the poor and already un- ~ dcrprivileged' to give up smoking in pregnanry; while better-off : mothers-to-be can smoke with relative impunity in ad'dit'ion to : other luiuries that they already have. A practicable sol'utionn would be to subsid'ise the pregnant: woman from poorer fami- lies and ensure a,good diet for them throughout theirpregnan.-, cies. Morris',has suggested' that the reduction of sociallinequa- lities should start by giving equal' opportunities in childhood. This will only be possible if equal' opportunities are provided, in utero by intensive antenatal care and special attention t'o maternal nutrition. Maternity Hospital, Belishillj Lanarkshirc NtL4 3'Jhi' 71v, T33'O'-WEEI'CPOSTNfATAL F.XAJMiIIriEILZTON OF fr' ' ~ INFANTS StR,-I have read with concern the recent discussion ini The Laacet on failure to thrive due to breast-milk 'ttuul6ciency.' This s'yndrome is well knowmto pa:d'iatricians„but has:not led, to the obvious: preventive'strategy -namely, early assessment. It:has long,been the habit in the United States (and'presum- ' abiy in the,United,I:;ingdom, as well), to see an infanr fbr his' first postnatal visit at 4-6 or even 8 weeks of age. A routine ' visit,at 2'+veeks, however, migh'n allow recognition and correc- . tion' of breast underfeeding. Other common problems, such as residuall or recurrrnent, jaundice, the ana•mia ofbl'Dod-group: in- compatibility, the murmur of left-to-right cardiac shunts, and the id'enti5cation of true dislocation of the hip;,could be noted at this time permitting early treatment: , The costlbeneflt ratio of a visit, at 2.veeks of age has not ".;. been scientifically assessed';,ix should be,,for there is much to suggest its value. Children"s Hospitat', Newark, ntw~ Jersey 07107, t3:S:A. HEALTH CARE FOEt THE UN33E1Z-FINES Sttt,~-l would' like to correct an impression given in the account ofl this meeting, published in your' issue of April 28 (p. 938). The speakers were invited to reply tacomments made 9.Crosby, Vi'. Nti.Mencoft. J'., Costitoey J: Pi, Atamiesh.,M., 9andstead,ll: H., .. Jacob, R. A., McLair, N., E:, f+cobson, G:,,Rcid,,W., Burns,,G. ibia• 1977,128,,22_ among obstetricians„perinatol'ogists, and padiatricians„ aided by epidemiologists. ocial ~Niaan (±s.Da' birthw•cight &troal of Hygiene and' Publie' Healtha class No. (8) S.F.D., No. Jbhns Hopkins ttnivcrsity„ Battimore, /NSkrytand 2'1205', U.S.1.; MAR1? B': MEl?ER 11 74 3504'±450 4(5 ~) 25 2' 226 3471±502' 13 (5 74 3 496 ' 3375±528 32 (6•S'r+ 333 4 657 3452±512 42 (8>5`iJ 626 5 Ib8! I 3396±548 l4(7•1";. 271 INTRAQTD'ERII4E t1ROWTI:E ILETARIyATLOIV

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