Archives ofDisease in Childhood 1991; 66: 227-231

Handwashing and cohorting in prevention ofhospital acquired infections with respiratorysyncytial virus

David Isaacs, Harriet Dickson, Chris O'Callaghan, Richard Sheaves, Andrew Winter,E Richard Moxon

AbstractHospital acquired infections with respiratorysyncytial virus are a major problem. The virusis spread predominantly by infected nasal sec-

retions and we investigated whether we couldreduce its incidence by cohorting babies on

each ward into designated areas andencouraging staff and parents to wash theirhands.We examined the incidence of hospital

acquired infection due to respiratory syncytialvirus in ali children <2 years old and in thosewith congenital heart disease. In 1986-7,before any intervention, 18 (4-2%) of 425 hos-pitalised children <2 years old developed hos-pital acquired infection due to respiratory syn-cytial virus. In 1987-8, after intervention, five(0-6%) of 840 children developed hospitalacquired infection but there were fewer wardadmissions with community acquired infec-tions due to the virus. In 1988-9, when therewere more community acquired infectionsthan 1986-7, six (1-1%) of 552 children develo-ped hospital acquired infection. In 1986-7,eight (34-8%) of 23 children <2 years old withcongenital heart disease developed hospitalacquired infection due to respiratory syncytialvirus; ali eight were among 11 children withcongenital heart disease hospitalised for morethan 14 days. In 1987-8, one (3.3%) of 30 chil-dren with congenital heart disease developedhospital acquired infection due to respiratorysyncytial virus and in 1988-9 there was one(2.1%) case out of 47 children with congenitalheart disease.Handwashing and cohorting significantly

reduce the incidence of nosocomial respira-tory syncytial virus infection.

Infectious Diseases Unit,Department ofPaediatrics,John Radcliffe Hospital,OxfordDavid IsaacsHarriet DicksonChris O'CallaghanRichard SheavesAndrew WinterE Richard MoxonCorrespondence and requestsfor reprints to:Dr David Isaacs,Department of Immunologyand Infectious Diseases,The Children's Hospital,Pyrmont Bridge Road,Camperdown,NSW 2050,Australia.Accepted 16 August 1990

Respiratory syncytial virus is a major cause ofmorbidity and mortality in children worldwide.' Children's services in hospital present a

particular problem as not only are large num-

bers of infants admitted from the communityeach year with bronchiolitis and other infectionscaused by respiratory syncytial virus but there isa subpopulation of hospitalised children whoare at relatively high risk from infection. Chil-dren at increased risk from respiratory syncytialvirus infection include those with congenitalheart disease, particularly if they have pulmon-ary hypertension,2 babies who are born pretermand have chronic lung disease such as broncho-pulmonary dysplasia,2 immunocompromisedchildren,3 and those with cystic fibrosis.4

Respiratory syncytial virus spreads readilywithin hospitals to infect children and staff.5

Gloves and gowns6 and even goggles7 have beenfound by some authors to be of value in decreas-ing the incidence of hospital acquired (nosoco-mial) infections but others have been uncon-vinced by the efficacy of gowns and masks.8 It isnow widely accepted in neonatal units thathandwashing is an important way of preventingnosocomial infections, but this has been lessfirmly emphasised on general paediatric wards,at least in the United Kingdom, and its efficacyin preventing respiratory syncytial virus infec-tion has not been evaluated. In an effort todecrease the incidence of nosocomial respiratorysyncytial virus infections we introduced cohort-ing of babies with suspected or proved respira-tory syncytial virus infection and mounted aneducational programme to emphasise theimportance of handwashing to staff and rela-tives.

Patients and methodsIn order to assess the importance of nosocomialrespiratory syncytial virus infection we retro-spectively collected data on all children withrespiratory syncytial virus infection on any ofthe paediatric medical wards in the winter of1986-7. Infection by the virus was diagnosed byindirect immunofluorescence on nasopharyn-geal secretions using a bovine antiserumagainst respiratory syncytial virus (Central Pub-lic Health Laboratory, Colindale) and a fluores-cein conjugated antibovine antiserum (Well-come) and/or by culture of secretions on MRC-5fibroblasts and HeLa cells.

In order to define a population at risk ofdeveloping respiratory syncytial virus infectionwe determined the number of children under 2years of age hospitalised on the two paediatricmedical wards (one 17 and one 19 bed) and the(six bed) paediatric intensive care unit and thenumber of days they spent in hospital. Eachmedical ward contained six single rooms. Toexamine a group at high risk for severe respira-tory syncytial virus infection the records werereviewed of all children under 2 years of agewith congenital heart disease admitted to thepaediatric medical wards over the period of the1986-7 outbreak, from the first reported caseuntil the last case had been discharged or was nolonger infectious. In our hospital cardiacpatients are admitted onto one of the generalpaediatric medical wards. Cases were classifiedas having either community acquired infectionif they were admitted with a respiratory illnessand had not been in hospital in the 10 daysbefore developing symptoms or hospitalacquired infection if they had previously been in

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this hospital in the preceding 10 days. All chil-dren with hospital acquired infection had in factpreviously been in this hospital within five daysof developing symptoms; that is the averageincubation period of infection with the virus.6Follow up after discharge to identify late onsethospital acquired infection was not routinelyperformed. Children who acquired their respir-atory syncytial virus infection at another hos-pital were considered to have communityacquired infections for the purpose of thisstudy. Children, not previously hospitalised,admitted with a non-respiratory condition butdeveloping a respiratory illness due to respira-tory syncytial virus within five days of admis-sion were deemed to have community acquiredinfection, although no such cases actually occur-red in the study period. Children were definedas having recurrences of infection with the virusif their symptoms recurred more than 30 daysafter their initial infection and respiratory syn-cytial virus could again be isolated.The severity of the infection, both hospital

and community acquired, was assessed using a

clinical grading.9 Grade 1: children toleratedoral feeds, grade 2: required nasogastric tubefeeds, grade 3: required nasogastric tube feedsand supplemental oxygen, grade 4: requiredintravenous fluids and supplemental oxygen,and grade 5: required artificial ventilation.

For the next two winters (1987-8 and 1988-9)the same data were prospectively collected.In addition some interventions were made to tryto reduce the incidence of hospital acquiredrespiratory syncytial virus infection. Becausethe medical wards alternate in taking emergencyadmissions it was not practicable to have a ward

*Your baby is in hospital with a condition called Stop Bronchiolitis:-bronchiolitia.

*This is caused by a virus called respiratorysyncytial virus (RSV).

*The virus is usually caught from a brother, or Xsister or parent who has a cold or chestiness. .

Thediseaseisveryinfectiousandispassedonbyinfected nasalsecretionscarriedonhandsortoysbut not usually by coughing. The secretions are

rubbed into the nose or eyes to cause infections.

*The best way of preventing spread of RSV infec-

tion is, therefore, by washing your hands after _ /7handling your baby. If you have a cold yourselftry to wash your hands before handling otherchildren. Please

Manychildrenontheward haveconditionssuch 4A1as heart disease which can be made much worse l W ash*byRSV infection. To prevent these childrenbeinginfected please wash your hands. Ifyou have an yOUrolder child with a cold do not let them play in theplay areas on the ward until they are better. handsThank you

Information leaflet given to parents.

dedicated to children with the infection. A sixbedded area in each of the two paediatric medi-cal wards including two single rooms was,therefore, cordoned off by screens and designa-ted the 'respiratory syncytial virus area'. Chil-dren admitted with suspected respiratory syncy-tial virus infection were nursed in this area untilthe result of an indirect immunofluorescentstain of nasopharyngeal secretions was avail-able. If this proved negative they were movedinto the rest of the ward. Children on the warddeveloping respiratory symptoms were nottransferred to this area unless they proved to bepositive for the virus by indirect immuno-fluorescence. Where possible nurses whodeveloped a respiratory illness were cohorted tocare for babies in the respiratory syncytial virusarea, but no formal attempt was made todiagnose the virus in staff. It was not possible tocohort babies on the paediatric intensive care

unit. It has been hospital policy for nursing butnot medical staff to wear gowns when handlinginfants under 1 year old, and change thesebetween each infant, and this policy was notchanged. Alcohol based hand rubs (Amphisept90, Goldschmidt Ltd) were placed on each sink.Staff were instructed on the importance ofhandwashing and this was reinforced on wardrounds. A leaflet was prepared for parents(figure) detailing the way respiratory syncytialvirus infection is spread, asking them to washtheir hands and to keep older siblings with coldsaway from the play areas. A leaflet was given tothe parents of every child admitted with theinfection.

Statistical analysis was by Student's t test tocompare means and by x2 or Fisher's exact testto compare incidence and severity of infection.

ResultsIn 1986-7 (9 December to 26 March), beforeany intervention, there were 122 isolates ofrespiratory syncytial virus from study children.Altogether 101 isolates were from communityacquired infections, 18 children had hospitalacquired infections, and three with hospitalacquired infection had recurrences. In 1987-8(12 September to 11 April) there were 55 admis-sions with community and five with hospitalacquired infection. In 1988-9 (18 October to 16February) there were 115 admissions with com-

munity and six with hospital acquired infection(table 1).

During the first study period (1986-7) therewere 425 children admitted to or present on thepaediatric wards, excluding children admittedwith respiratory syncytial virus infection, thelatter not being considered at risk of acquiringthe virus. The children stayed in hospital for a

Table I Occurrence of community acquired infections and hospital acquired infections of respiratory syncytial virus

Year Total admissions No (%) with Remainder (at nrsk of No (%) withduring epidemic community acquired hospital acquired hospital acquired

infection infection) infection

1986-7 526 101 (19) 425 18 (4-2)*1987-8 895 55 (6) 840 5 (06)*1988-9 667 115 (17) 552 6 (1 1)*

*1986-7 v 1987-8, X2=19.0, p<0 001; 1986-7 v 1988-9, X2=8-7, p<0-01; 1987-8 v 1988-9, X2=-.5, p=05.

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Handwashing and cohorting in prevention ofhospital acquired infections with respiratory syncytial virus

Table 2 Duration of hospital stay for children withcommunity acquired infection due to respiratory syncytialvirus

Year Total days Mean (SD) stay Median stayin hospital in days* in days

1986-7 414 5-24 (427) 41987-8 259 4-71 (4-29) 31988-9 487 4-24 (4-25) 3

*No significant difference between years.

total of 1731 days within the study period, amean (SD) stay of 405 (3-16) days with amedian of 2 days. In the second study period(1987-8), which was a much longer outbreak,there were 840 such admissions for 3749 days, amean (SD) stay of 4-46 (3-92) days and a medianof 2 days. In the third study period (1988-9)there were 552 admissions for 2082 days, mean(SD) was 3-77 (3-69) days and median 2 days.Thus in the first study period 18 of 425 (4 2%)children exposed developed respiratory syncy-tial virus infection compared with five of 840(0-6%) in the second period and six of 552(1-1%) in the third period (X2=24-3, 2df,p<0001). The difference between the first andsecond periods (x2= 19-0, ldf, p<0 001) andbetween the first and third periods (x2= 8X7, ldf,p<001) was significant, but not between thesecond and third periods (X2=0 55 ldf, p=0 5).

Children infected in the community withrespiratory syncytial virus were hospitalised fora similar mean duration in each study period(table 2). The total duration of hospitalisationof children with community acquired infectionwas similar in 1986-7 and 1988-9, but was con-siderably less in 1987-8.There was an increasing number of children

under 2 years old admitted with congenitalheart disease over the three year study period,concomitant with the appointment of a secondcardiologist. In 1986-7 none of 12 children <2years with congenital heart disease (excludingbabies with community acquired infection dueto respiratory syncytial virus) admitted for lessthan 14 days, but eight of 11 (72-7%) admittedfor more than 14 days were infected with thevirus in hospital (table 3). In 1987-8 one of 30(3 3%) children with congenital heart diseasebecame infected in hospital compared witheight of 23 (34-8%) in 1986-7 (p<0008,Fisher's exact test). In 1988-9 one of 47 (2- 1%)became infected in hospital (p<0-0008 com-pared with 1986-7).Three children with congenital heart disease

were admitted with community acquired infec-tion due to respiratory syncytial virus in 1986-

Table 3 Number of children <2 years old with congenitalheart disease admitted to paediatric wards during respiratorysyncytial virus season (number who developed a hospitalacquired infection with the virus)

Year Duration of hospital stay (days)1-7 8-14 >14 Total

1986-7 7 (0) 5 (0) 11 (8) 23 (8)*1987-8 19 (0) 5 (0) 6 (1) 30(1)*1988-9 26 (0) 9 (1) 12 (0) 47 (1)*

Children with congenital heart disease admitted with respiratorysyncytial virus infection have been excluded.*X2=24-3, 2df, p<0001.

Table 4 Severity of community acquired infections withrespiratory syncytial vwrus

Year Grade of severity Total1 2 3 4 5

1986-7 49 20 8 21 3 1011987-8 30 10 8 2 5 551988-9 62 26 20 6 1 115

x2= 164, 6df, p<002.

7, none in 1987-8, and seven in 1988-9. Threeof the children with respiratory syncytial virusinfection in 1986-7 had pulmonary hyperten-sion, none in 1987-8, and four in 1988-9. Therewere no deaths attributable to infection with thevirus. The mean (SD) duration of hospital stayof children under 2 years with congenital heartdisease (excluding babies with communityacquired infection) was not significantly diffe-rent in the three study years: 33-6 (33 1) days in1986-7, 33-7 (16-1) days in 1987-8, and 31-0(18-2) days in 1988-9. The median stay was 21,28, and 23 days respectively. Thus childrenwith congenital heart disease were equally likelyto be exposed to respiratory syncytial virusinfection, other factors being equal, in each ofthe three years.The median duration of hospital stay of chil-

dren with congenital heart disease before theydeveloped respiratory syncytial virus infectionwas 14 days (range 8-114).

In 1986-7, four babies with chronic lung dis-ease due to bronchopulmonary dysplasiadeveloped respiratory syncytial virus infection(three infections acquired in hospital) and oftwo children with cystic fibrosis who developedthe virus one infection was hospital acquired.In 1987-8 one baby with bronchopulmonarydysplasia became infected with the virus in hos-pital. In 1988-9 two babies with bronchopul-monary dysplasia were infected (one hospitalacquired) and one child with cystic fibrosis hada community acquired infection.The severity of infection acquired in the com-

munity in each of the study years is shown intable 4. A x2 analysis (combining grades 4 and 5because of small numbers in these cells) showedthat the severity of infection was not the same ineach of the three years. There was no significantdifference in severity between 1986-7 and1987-8 (X2=4 05 3df, p>02), but infectionwith the virus was significantly more severe in1986-7 than 1988-9 (x2=15*8, 3df, p<0c01). In1988-9 three babies with congenital heart dis-ease and respiratory syncytial virus infectionwere treated with nebulised ribavirin, but riba-virin was not used for children in previous yearsnor for any other children in 1988-9.

DiscussionNosocomial infections with respiratory syncy-tial virus are a major problem within hospitals,5particularly as children with serious underlyingdisorders who are at risk of severe infection maybecome infected. In one study the mortality forinfants with congenital heart disease and respir-atory syncytial virus was 37%, and 73% if theyhad pulmonary hypertension,2 although subse-

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quent studies including the current one wouldsuggest the mortality has fallen substantially.The risk of nosocomial infection with the virushas previously been shown to rise with increas-ing duration of hospital stay.2

Prevention of hospital acquired respiratorysyncytial virus infection depends on under-standing how the infection is spread. Babiesshed large quantities of virus for prolongedperiods.'0 Adults can readily be reinfected, byrubbing infected secretions into their nose oreyes,"I and act as a reservoir for the infection,which is probably important in infecting babies.Babies are most likely to be infected by con-taminated nasal secretions, which have comefrom another infected baby or infected memberof staff and are carried on the hands of staff.'2Other possible mechanisms of spread includefomites, as respiratory syncytial virus canremain viable on environmental surfaces forseveral hours. 13 Respiratory droplet spread,however, is probably an unusual route oftransmission. 12 This evidence suggests that effi-cient handwashing might be an effective way ofpreventing infections both in staff and babies. Ithas been recommended that gowns be wornwhen soiling of clothes with respiratory secre-tions is likely,'4 but we found an unacceptablyhigh level of nosocomial respiratory syncytialvirus infection despite following this sugges-tion. We do not have sufficient isolation roomsto isolate all infected babies, as has also beensuggested.'4 Various interventions have beenevaluated. Leclair and colleagues found thatglove and gown isolation precautions werehighly effective in preventing nosocomialrespiratory syncytial virus infections,6 butothers have found gowns and masks to beineffective.8 Eye-nose goggles prevent staffinfections over a short period but are unaccept-able to staff.7 There are obvious advantages tousing handwashing and cohorting as the mainmethods for preventing infections. Manystudies have shown that handwashing practises,even in intensive care units, are suboptimal andwe have previously observed handwashing to beextremely poorly performed on paediatricwards. We did not formally examine com-pliance with handwashing, but feel the reduc-tion in nosocomial respiratory syncytial virusinfection is strong evidence that compliance wasgood.

In order to show convincingly that our inter-ventions were effective in reducing nosocomialinfection with the virus we need to show thatthere was comparable exposure in the threestudy winters. In 1987-8 the epidemic wasmuch smaller and more drawn out than in theother two years, and children on the wards wereless exposed to the virus. Thus the fall in theincidence of hospital acquired infection in1987-8 alone cannot be attributed to our inter-ventions. In 1988-9 there were more childrenadmitted with community acquired infectionthan in 1986-7 over a similar period of time,however, and the total number of infections inthe two winters was virtually the same. We didnot evaluate duration of viral shedding in chil-dren with respiratory syncytial virus infection,but they were hospitalised for a comparable

length of time each year. Leclair and colleaguesestimated that children would shed virus forseven days, and calculated exposure on thisbasis.6 On the other hand children often shedvirus for much longer,9 and neither they nor weformally examined this. As children with hospi-tal acquired infection often remain in hospitalbecause of their underlying illness they willexpose other children, leading to a cascade effectif infections are not prevented. Another con-sideration is that the severity of the annual epi-demics may vary from year to year, possibly as aresult of different subgroups of respiratory syn-cytial virus being prevalent,'5 and more severeinfections might be more contagious. We didnot look at subgroups of the virus but we didexamine severity by a clinical grading and foundthat respiratory syncytial virus infection wasless severe in 1988-9 than in the two previousyears. Despite this the number of admissionswith community acquired infection due to thevirus in 1988-9, and reports to the Communic-able Disease Surveillance Centre for the threeyears, would suggest the respiratory syncytialvirus epidemic was at least as large in 1988-9 asthe two previous years and the virus no less con-tagious. We did not formally examine nursinglevels, which might have influenced spread ofinfection. However these certainly did notimprove between 1986-7 and 1988-9.Our observations are not based on an ideal

study design, as the data on the incidence ofnosocomial respiratory syncytial virus infectionsbefore intervention were not collected prospec-tively. Our rate of nosocomial infection with thevirus was unacceptably high, however, and wefelt ethically constrained to intervene and thenattempt to evaluate our intervention. Cases ofrespiratory syncytial virus infection were identi-fied by positive viral cultures and the techni-ques used for identification did not change overthe study period. Children were classified ashaving hospital or community acquired infec-tion on strict criteria not amenable to bias.Nasopharyngeal aspirates are routinely takenfrom all children <2 years admitted with respir-atory illness and from those hospitalised chil-dren who develop respiratory symptoms. Biasmight have been introduced by failure to iden-tify children with hospital acquired infectiondue to the virus after intervention, but we feelthat increased awareness of respiratory syncytialvirus infection generated by the study is morelikely to have resulted in more rather than fewercases of hospital acquired infection being identi-fied.We showed a reduction of at least 66% in the

number of hospital acquired infections due torespiratory syncytial virus in the two wintersafter emphasising the importance of handwash-ing and simple cohorting of babies. Further-more, despite comparable lengths of stay eachyear, we showed that the proportion of babieswith congenital heart disease hospitalised formore than 14 days who acquired the infectionfell from 73% to less than 4%. We acknowledgethat we cannot prove that the decrease in inci-dence of infection with the virus was due to ourinterventions, but feel we have provided con-vincing circumstantial evidence to this effect.

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Handwashing and cohorting in prevention of hospital acquired infections with respiratory syncytial virus 231

One minor problem with cohorting was thatbabies could not remain in the accident andemergency department until a diagnosis ofrespiratory syncytial virus infection was virolo-gically confirmed. Hence they were cohorted onthe basis of a clinical diagnosis of bronchiolitis.In 1988-9 one baby with congenital heart dis-ease and clinical bronchiolitis was cohorted inthe respiratory syncytial virus area and subse-quently shown to be negative for the virus.Despite being moved within 24 hours to themain ward and discharged home shortly there-after the baby was readmitted within five dayswith respiratory syncytial virus positive bron-chiolitis. This problem might be overcome if amore rapid antigen detection test for respiratorysyncytial virus infection was available, and onehour tests are currently being evaluated.Handwashing is simple, cheap, and highly

effective in preventing nosocomial respiratorysyncytial virus infections. We should makeevery effort to reinforce this message to staffand parents on the general paediatric wards aswell as in the neonatal unit.DI was funded by the Welicome Trust. We should like to thankparents and staff for washing their hands and Doctors Archer,Bower, Dunger, Gardiner, Moncrieff, and Ostman-Smith forallowing us to study their patients. We also thank the virologydepartment for performing antigen detection and virus isolation;the department of medical illustration for preparing the leaflet;Christine Hatton and Virginia Butler of the information centre,Manor House, for ward statistics; and Gail Davies and BettyNicholson for secretarial assistance.

1 Hall CB. Respiratory syncytial virus. In: Feigin RD, CherryJD, eds. Textbook of pediatric infectious diseases. 2nd Ed.Philadelphia: WB Saunders, 1987:1653-76.

2 MacDonald NE, Hall CB, Suffin SC, Alexson C, Harris PJ,Manning JA. Respiratory syncytial virus infection ininfants with congenital heart disease. N Engl Med1982;307:397-400.

3 Hall CB, Power KR, MacDonald NE, et al. Respiratory syn-cytial viral infection in children with compromised immunefunction. N EnglJ Med 1986;315:77-81.

4 Abman SH, Ogle JW, Butler-Simon N, Rumack CM,Accurso FJ. Role of respiratory syncytial virus in early hos-pitalizations for respiratory distress of young infants withcystic fibrosis. J Pediatr 1988;113:826-30.

5 Hall CB, Douglas RG Jr, Geiman JM, Messner MK. Nosoco-mial respiratory syncytial virus infections. N Engl J Med1975;293:1343-6.

6 Leclair JM, Freeman J, Sullivan BF, Crowley CM, Gold-mann DA. Prevention of nosocomial respiratory syncytialvirus infections through compliance with glove and gownisolation precautions. N EnglJ Med 1987;317:329-34.

7 Gala CL, Hall CB, Schnabel KC, et al. The use of eye-nosegoggles to control nosocomial respiratory syncytial virusinfection.JAMA 1986;256:2706-8.

8 Hall CB, Douglas RG Jr. Nosocomial respiratory syncytialvirus infections: should gowns and masks be used? Am JDis Child 1981;135:521-5.

9 Isaacs D, Bangham CRM, McMichael AJ. Cell-mediatedcytotoxic response to respiratory syncytial virus in infantswith bronchiolitis. Lancet 1987;ii:769-71.

10 Hail CB, Douglas RG Jr, Geiman JM. Respiratory syncytialvirus infections in infants: quantitation and duration ofshedding. J Pediatr 1976;89:11-5.

11 Hendley JO, Wenzel RP, Gwaltney JM Jr. Transmission ofrhinovirus colds by self-inoculation. N Engl J Med1973;288:1361-4.

12 Hail CB, Douglas RG Jr. Modes of transmission of respira-tory syncytial virus. J Pediatr 1981;99:100-3.

13 Hall CB, Douglas RG Jr, Geiman JM. Possible transmissionby fomites of respiratory syncytial virus. J Infect Dis1980;141:98-102.

14 Garner JS, Simmons BP. Guidelines for isolation precautionsin hospitals. Infect Control 1983;4:suppl 245-325.

15 Taylor CE, Morrow S, Scott M, Young B, Toms GL. Compa-rative virulence of respiratory syncytial virus subgroups Aand B. Lancet 1989;i:777-8.

Infant care at the Appeal CourtA very premature baby needed ventilator treatment for a monthand two further periods of ventilation when he collapsed off theventilator. At 4 months postnatal age he was breathing indepen-dently but was cyanosed when crying and prone to periods ofapnoea. Ultrasound scans had shown 'very severe brain damage'.The child was a ward of court and a judge had agreed with thedoctors' view that ventilation should be withheld if the child col-lapsed again. The Official Solicitor appealed on the child's behalfand the case went to the Court of Appeal on 19 October. (TheDaily Telegraph, Law reports, 25 October 1990).The Master of the Rolls, Lord Donaldson, with Lords Justice

Balcombe and Taylor, upheld the judge's decision. Lord Donald-son said that, while there was a very strong presumption in favourof a course of action that would prolong life, the quality of life andthe pain and suffering that the child would experience if life wasprolonged also had to be taken into account. In the end therewould be cases where the answer would be that it was not in thechild's interests to subject it to treatment which would causeincreased suffering and produce no commensurate benefit.

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