Letters to the Editor Albuterol Asthma
Dosage and Acute
To The Editor: The treatment protocol presented in the October 1991 issue of Clinical Pediatrics appeared to be an effective tool for the management of acute asthma in pediatric patients.’ The protocol appeared to offer fairly aggressive therapy, and there was an admission rate similar to that in previously published studies. However, the recommended maximum dose of nebulized albuterol sulfate did not appear to reflect the recent pediatric literature. Schuh et al2 demonstrated the superior effectiveness of high doses (0.15 mg/kg of body weight per dose, to a maximum of 5 mg per dose) as compared with low doses (0.05 mg/kg of body weight per dose, with a maximum of 2.5 mg per dose). The pediatric patients with acute asthma who received the high-dose therapy of nebulized albuterol every 20 minutes had significantly greater improvement in forced expiratory volume in one second (FEVI) and forced vital capacity (FVC), a decreased wheeze score, and a decreased hospitalization rate. In addition, there were no significant differences between the incidence of side effects in the two groups. In a subsequent study, Schuh et all compared a higher dose of nebulized albuterol (0.30 mg/kg of body weight, with a maximum dose of 10 mg) with a &dquo;standard&dquo; dose (0.15 mg/kg of body weight, with a maximum dose of 5 mg) in pediatric patients with moderate-tosevere acute asthma. Again, the higher dose demonstrated a sig-
702
and steady imin FEVI. The lower provement dose group, after the second dose, demonstrated a plateauing effect in the improvement of FEVI. Although the high-dose group had significantly higher serum albuterol levels, there was no demon-
nificantly greater
strated relationship between side effects and albuterol serum levels. In addition, there was no difference in the occurrence of side effects between the two groups. Inhaled beta2 agonists, such as albuterol, continue to be the medication of choice for the treatment of acute exacerbations of asthma. Higher doses of inhaled albuterol are needed during these acute exacerbations secondary to the decreased delivery of the medication to the involved airways.’ Therefore, until further recommendations are provided, it would appear to be prudent to follow the recommendations of the National Institutes of Health5 for the treatment of acute exacerbations of asthma in children, which state the albuterol nebulized dosage to be 0.1-0.15 mg/kg/dose, up to 5 mg, every 20 minutes for one to two hours. James A. Waler, M.D. Palm Beach Gardens, Florida
Lipkind R. A treatment with protocol of the acute asthma patient in a pediatric emergency department.
1.
Press S,
2.
Schuh S, Parkin P,
Clin Pediatr. versus
1991;30:573-577.
Rajan A, et al. Highlow-dose, frequently adminis-
tered, nebulized albuterol in children with severe,
acute
asthma. Pediatrics.
1989;83:513-518. 3.
Schuh S, Reider M. Canny G, et al. Nebulized albuterol in acute childhood asthma: comparison of two doses. Pediatrics. 1990;86:509-513.
4.
Newhouse M, Dolovich M. Control of asthma by aerosols. N Engl J Med.
5.
National Asthma Education Program expert panel report. Guidelines for the Diagnosis and Management of Asthma : Executive Summary. Bethesda, MD: US Dept of Health and Human Services publication NIH 91-3042A; 1991.
1986;315:870-874.
reply: We are in total with Dr. Waler. that agreement there is superior effectiveness of higher doses of albuterol (0.15 mg/kg of body weight per dose). Since our study in 1989, we have used the higher doses of inhaled albuterol with no significant side effects. The recommendations of the National Institutes of Health appeared in 1991, two years after The authors
study. We feel that they are appropriate for practitioners to follow. Shirley Press, M.D. Reina Lipkind, M.D. University of Miami our
Miami, Florida
A Question on
Nail-Biting
To The Editor: In their interesting review of nail-biting, Leung and Robson’ refer to data suggesting a genetic basis for this problem. Alternate explanations, such as copying, will always cloud the question in a behavior as common as nail-biting, however. Even twin studies may be hard to interpret unless care is taken to study only twins raised apart. Teleologically, it is hard to see why evolution would waste DNA for such a complex but biologically unimportant behavior. Recently, during a routine wellchild visit, I heard the following story. A 21/2-year-old child always
sucked the fingers of her left hand while petting an animal or &dquo;mak-
ing nice&dquo; to her infant brother. The finger-sucking was done in a characteristic manner, which was not reproduced except while petting. The maternal grandmother indicated that my patient’s mother had done exactly the same thing as a child. Although I recognize the limitations of retrospective anecdotal material, I can think of no reasonable explanation aside from heredity for the remarkable similarity between the behaviors of mother and child. Since this is a very unusual and highly specific behavior, neither coincidence nor copying is an acceptable explanation. If we permit ourselves to accept the possibility that behaviors like nail-biting, hair-twirling, and suckingpetting are genetic, we are faced with a number of fascinating questions for speculation. Can &dquo;one gene, one protein&dquo; explain the genetic mechanism? Is there a more efficient way to code for such complexity that would be less expensive in DNA? Perhaps there is a way to code for a set of iterative actions to create both structural and behavioral patterns the way a relatively simple fractal command can trace the outline of a complex fern. Meanwhile, I still have little success in helping people to stop biting their nails. WL. Lupatkin, M.D. Clinical Assistant Professor Columbia University College of Physicians and Surgeons New York, New York Attending Pediatrician Morristown Memorial Hospital
that monozygotic twins are concordant for the habit of nail-biting with approximately twice the frequency of dizygotic twins’ suggests some degree of hereditability. Actual estimation requires the
population incidence, monozygous and dizygous concordance rates, and a zygosity determination. It is estimated that 75% to 95% of infants2 and 30% to 45% of preschool children’ suck their thumbs.
sidered
1990:29;690-692.
The authors reply: We appreciate the opportunity to respond to the letter by Dr. Lupatkin. The fact
con-
a
To The Editor: The article &dquo;Varicella pneumonia as the presenting manifestation of immunodeficiency&dquo; is good and has clinical teaching value. But did I miss something? What were the HIV test results in the two cases presented? Please convey to Dr. Saulsbury how much I appreciated this well-presented paper. Gary Gorlick, M.D. Los Angeles, California
replies: I, in turn, apDr. Gorlick’s kind compreciate ments. Patient 1 was not tested for HIV before being lost to follow-up. Neither of her parents, however, had any risk factors for HIV infection. Patient 2 is HIV seronegative. Frank T. Saulsbury, M.D. The author
Associate Professor
Department of Pediatrics University of Virginia Health Sciences Center Children’s Medical Center
activities.’ Alexander K.C. Leung, M.B.B.S.,
typed movements
or
F.R. C.P. (C), F.R. C.P. (Edin) William Lane M. Robson, M.D., F.R. C.P. (C) D. Ross McLeod, M.D., F.R. C.P. (C)
Department of Pediatrics University of Calgary Alberta Children’s Hospital Calgary, Alberta, Canada 1.
Bakwin H, Bakwin RM. Behavior Disorders in Children. Philadelphia, PA:W.B. Saunders Co; 1972:510.
2.
Larsson EF, Dahlin KG. The prevalence and the etiology of the initial dummyand finger-sucking habit. Am J Orthod.
3.
Baalack IB, Frisk A. Finger-sucking in children: a study of incidence and occlusal condition. Acta Odontol Scand.
4.
Leung AK, Robson WL. Thumb-sucking. Am Fam Physician. In press. Comings DE, Comings BG. A controlled study of Tourette syndrome. IV. Obsessions, compulsions, and schizoid behaviors. Am J Hum Genet. 1987; 41:782-803.
1985;87:432-435.
1971;29:499-512.
Leung AKC, Robson WLM. Nail-biting. Clin Pediatr.
be
is
normal stage of development which, in some children, becomes a habit.4 Although there may be a genetic predisposition to thumb-sucking, the wide prevalence of this habit makes the study of its heredity difficult. Dr. Lupatkin’s observation of the 21/2-year-old child and her mother with coincidental finger-sucking and animal-petting is fascinating. Although a causal relationship cannot be established based on a single case report, genetic factors have been associated with other stereo-
Morristown, New Jersey 1.
Thumb-sucking to
HIV Status in Varicella Pneumonia
5.
Charlottesville, Virginia
Protein-Losing Enteropathy Associated with Rubella To The Editor: Dr. Belamarich and colleagues suggested that varicella infection can incite protein-losing enteropathy (PLE) .’ We would like to report a patient in whom there was a close association between the development of PLE and the onset of rubella. An 11-year-old female was referred to Sasebo Kyosai Hospital because of abdominal pain, vomiting, and diarrhea in May 1987, when rubella was epidemic in Sasebo, Japan.9 For the preceding few days, she had had fever and a morbilliform rash. There was no past medical history of rubella or
significant gastrointestinal problems.
Her
initial
examination
703
Dosage and Acute
To The Editor: The treatment protocol presented in the October 1991 issue of Clinical Pediatrics appeared to be an effective tool for the management of acute asthma in pediatric patients.’ The protocol appeared to offer fairly aggressive therapy, and there was an admission rate similar to that in previously published studies. However, the recommended maximum dose of nebulized albuterol sulfate did not appear to reflect the recent pediatric literature. Schuh et al2 demonstrated the superior effectiveness of high doses (0.15 mg/kg of body weight per dose, to a maximum of 5 mg per dose) as compared with low doses (0.05 mg/kg of body weight per dose, with a maximum of 2.5 mg per dose). The pediatric patients with acute asthma who received the high-dose therapy of nebulized albuterol every 20 minutes had significantly greater improvement in forced expiratory volume in one second (FEVI) and forced vital capacity (FVC), a decreased wheeze score, and a decreased hospitalization rate. In addition, there were no significant differences between the incidence of side effects in the two groups. In a subsequent study, Schuh et all compared a higher dose of nebulized albuterol (0.30 mg/kg of body weight, with a maximum dose of 10 mg) with a &dquo;standard&dquo; dose (0.15 mg/kg of body weight, with a maximum dose of 5 mg) in pediatric patients with moderate-tosevere acute asthma. Again, the higher dose demonstrated a sig-
702
and steady imin FEVI. The lower provement dose group, after the second dose, demonstrated a plateauing effect in the improvement of FEVI. Although the high-dose group had significantly higher serum albuterol levels, there was no demon-
nificantly greater
strated relationship between side effects and albuterol serum levels. In addition, there was no difference in the occurrence of side effects between the two groups. Inhaled beta2 agonists, such as albuterol, continue to be the medication of choice for the treatment of acute exacerbations of asthma. Higher doses of inhaled albuterol are needed during these acute exacerbations secondary to the decreased delivery of the medication to the involved airways.’ Therefore, until further recommendations are provided, it would appear to be prudent to follow the recommendations of the National Institutes of Health5 for the treatment of acute exacerbations of asthma in children, which state the albuterol nebulized dosage to be 0.1-0.15 mg/kg/dose, up to 5 mg, every 20 minutes for one to two hours. James A. Waler, M.D. Palm Beach Gardens, Florida
Lipkind R. A treatment with protocol of the acute asthma patient in a pediatric emergency department.
1.
Press S,
2.
Schuh S, Parkin P,
Clin Pediatr. versus
1991;30:573-577.
Rajan A, et al. Highlow-dose, frequently adminis-
tered, nebulized albuterol in children with severe,
acute
asthma. Pediatrics.
1989;83:513-518. 3.
Schuh S, Reider M. Canny G, et al. Nebulized albuterol in acute childhood asthma: comparison of two doses. Pediatrics. 1990;86:509-513.
4.
Newhouse M, Dolovich M. Control of asthma by aerosols. N Engl J Med.
5.
National Asthma Education Program expert panel report. Guidelines for the Diagnosis and Management of Asthma : Executive Summary. Bethesda, MD: US Dept of Health and Human Services publication NIH 91-3042A; 1991.
1986;315:870-874.
reply: We are in total with Dr. Waler. that agreement there is superior effectiveness of higher doses of albuterol (0.15 mg/kg of body weight per dose). Since our study in 1989, we have used the higher doses of inhaled albuterol with no significant side effects. The recommendations of the National Institutes of Health appeared in 1991, two years after The authors
study. We feel that they are appropriate for practitioners to follow. Shirley Press, M.D. Reina Lipkind, M.D. University of Miami our
Miami, Florida
A Question on
Nail-Biting
To The Editor: In their interesting review of nail-biting, Leung and Robson’ refer to data suggesting a genetic basis for this problem. Alternate explanations, such as copying, will always cloud the question in a behavior as common as nail-biting, however. Even twin studies may be hard to interpret unless care is taken to study only twins raised apart. Teleologically, it is hard to see why evolution would waste DNA for such a complex but biologically unimportant behavior. Recently, during a routine wellchild visit, I heard the following story. A 21/2-year-old child always
sucked the fingers of her left hand while petting an animal or &dquo;mak-
ing nice&dquo; to her infant brother. The finger-sucking was done in a characteristic manner, which was not reproduced except while petting. The maternal grandmother indicated that my patient’s mother had done exactly the same thing as a child. Although I recognize the limitations of retrospective anecdotal material, I can think of no reasonable explanation aside from heredity for the remarkable similarity between the behaviors of mother and child. Since this is a very unusual and highly specific behavior, neither coincidence nor copying is an acceptable explanation. If we permit ourselves to accept the possibility that behaviors like nail-biting, hair-twirling, and suckingpetting are genetic, we are faced with a number of fascinating questions for speculation. Can &dquo;one gene, one protein&dquo; explain the genetic mechanism? Is there a more efficient way to code for such complexity that would be less expensive in DNA? Perhaps there is a way to code for a set of iterative actions to create both structural and behavioral patterns the way a relatively simple fractal command can trace the outline of a complex fern. Meanwhile, I still have little success in helping people to stop biting their nails. WL. Lupatkin, M.D. Clinical Assistant Professor Columbia University College of Physicians and Surgeons New York, New York Attending Pediatrician Morristown Memorial Hospital
that monozygotic twins are concordant for the habit of nail-biting with approximately twice the frequency of dizygotic twins’ suggests some degree of hereditability. Actual estimation requires the
population incidence, monozygous and dizygous concordance rates, and a zygosity determination. It is estimated that 75% to 95% of infants2 and 30% to 45% of preschool children’ suck their thumbs.
sidered
1990:29;690-692.
The authors reply: We appreciate the opportunity to respond to the letter by Dr. Lupatkin. The fact
con-
a
To The Editor: The article &dquo;Varicella pneumonia as the presenting manifestation of immunodeficiency&dquo; is good and has clinical teaching value. But did I miss something? What were the HIV test results in the two cases presented? Please convey to Dr. Saulsbury how much I appreciated this well-presented paper. Gary Gorlick, M.D. Los Angeles, California
replies: I, in turn, apDr. Gorlick’s kind compreciate ments. Patient 1 was not tested for HIV before being lost to follow-up. Neither of her parents, however, had any risk factors for HIV infection. Patient 2 is HIV seronegative. Frank T. Saulsbury, M.D. The author
Associate Professor
Department of Pediatrics University of Virginia Health Sciences Center Children’s Medical Center
activities.’ Alexander K.C. Leung, M.B.B.S.,
typed movements
or
F.R. C.P. (C), F.R. C.P. (Edin) William Lane M. Robson, M.D., F.R. C.P. (C) D. Ross McLeod, M.D., F.R. C.P. (C)
Department of Pediatrics University of Calgary Alberta Children’s Hospital Calgary, Alberta, Canada 1.
Bakwin H, Bakwin RM. Behavior Disorders in Children. Philadelphia, PA:W.B. Saunders Co; 1972:510.
2.
Larsson EF, Dahlin KG. The prevalence and the etiology of the initial dummyand finger-sucking habit. Am J Orthod.
3.
Baalack IB, Frisk A. Finger-sucking in children: a study of incidence and occlusal condition. Acta Odontol Scand.
4.
Leung AK, Robson WL. Thumb-sucking. Am Fam Physician. In press. Comings DE, Comings BG. A controlled study of Tourette syndrome. IV. Obsessions, compulsions, and schizoid behaviors. Am J Hum Genet. 1987; 41:782-803.
1985;87:432-435.
1971;29:499-512.
Leung AKC, Robson WLM. Nail-biting. Clin Pediatr.
be
is
normal stage of development which, in some children, becomes a habit.4 Although there may be a genetic predisposition to thumb-sucking, the wide prevalence of this habit makes the study of its heredity difficult. Dr. Lupatkin’s observation of the 21/2-year-old child and her mother with coincidental finger-sucking and animal-petting is fascinating. Although a causal relationship cannot be established based on a single case report, genetic factors have been associated with other stereo-
Morristown, New Jersey 1.
Thumb-sucking to
HIV Status in Varicella Pneumonia
5.
Charlottesville, Virginia
Protein-Losing Enteropathy Associated with Rubella To The Editor: Dr. Belamarich and colleagues suggested that varicella infection can incite protein-losing enteropathy (PLE) .’ We would like to report a patient in whom there was a close association between the development of PLE and the onset of rubella. An 11-year-old female was referred to Sasebo Kyosai Hospital because of abdominal pain, vomiting, and diarrhea in May 1987, when rubella was epidemic in Sasebo, Japan.9 For the preceding few days, she had had fever and a morbilliform rash. There was no past medical history of rubella or
significant gastrointestinal problems.
Her
initial
examination
703
