THE LANCET, OCTOB ER
25,1975
815
In conclusion, suspicion of spurious thrombocytopenia should be aroused when a low platelet-count varies widel y on repeated occasions. All falsely low counts would be detected if confirmation by smear interpretation were sought. Studies with E.D.T.A.-anticoagulated blood can then further delineate the cause of the agglutination. Since the conditions causing spurious thrombocytopenia are benign, patients should not be treated with corticosteroids. Division s of Hsemat olo gy and Internal J\1.edici ne and of L aboratory Medicine ,
MayoClinic, Rochester, Minnesota 55901, U.S.A.
PHILIP R. GREIPP PAUL OlDISHElM MALCOLM BRIGDEN
INFANT'S UTILISATION OF IDS MILK INTAKE SIR,- The letter of Dr Ounsted and Dr Sleigh (Sept . 20 , p. 551) was very interesting. It seems, however, that the evidence to support their conclusion is not firmly based. Foman! indicated that in infants fed ad libitum during the first 6 weeks of life, caloric consumption was correlated with the caloric concentration of the milk formula . After 6 week s the infants were able to regulate their intake, so that caloric consumption was similar ir r espect ive of the caloric concentration of the milk formula, provided the caloric concentration was not 100 low. He concluded that the ability of the normal infant to adjust hi s intake volume wa s considerably greater after 6 weeks. In the infants described by Dr Ounsred and Dr Sle igh the majority of growth (ap p roxim ately two-thirds) took place during a period of diminished ability to regulate volume. It therefore seems illogical to relate the total growth 10 the volume consumed at a time when the infants had increased control over their intake. A British study" indicated that 57% of infa n t feeds were significantly overstrength. Even after the mothers had been shown how to prepare the feed s and had been warned against overstrength feeds the response was st ill d isappointing. Thi s indicates that not much reliance can be placed on the way mothers mix feeds . The preparation of the milk taken by infants studied by Dr Ounsted and Dr Sleigh was not standardised , and we do not know the precise caloric concentration befor e or after 6 weeks . The extent to which the caloric conlent of the milk influe nced both growth and the volume consumed is therefore unknown. It has been implied by Dr Ounsted and Dr Sleigh that the basal metabolism of small-for-dates babies is greater th an average-weight babies, thereby providing Jess energy for growth. Is this in fact so? In the first 2 weeks at least this doe s not appear 10 be so. Minimum rates of oxygen consumption in small-for-dates babies and average-weight babies are simi la r at th is time. 3 Department of Child Health, University of Aberdeen, Foresterhill,
AberdeenAB92ZD.
I. BI.UM ENTH AL
straighten the record on two questions of fact ? He suggests that the women I studied in Aberdeen during the 1950s probably ate unusually large amounts of fish protein. That "ain't so". He also says that my review of Stein and Susser's book on the Dutch famine was tragicomic because I failed to ponder the problem of controls. That, also, "ain't so" . Susser and Stein point out that reduction of birth-weights during the Dutch famine was followed by a sharp rise in infant mortality, especially after the first week . True; but adverse effects on perinatal mortality were surprisingly slight, and affected both the "famine" and the "control" areas. In their book (p. 230) Stein et al. I conclude that " a coherent explanation requires in teraction between famine exposure in early gestation and an unknown co-determinant", possibly maternal infection . M.R.C. Reprodu ction and Gro wth Unit, Princess Ma ry Maternity Hosp ital ,
Great North Road ,
Newcastle upon Tyne NE23BD
A. M. THOMSON
CAUTIONARY TALE OF A WANDERING TUBE SIR,-If, in a neonate, a stomach tube can be passed via the oesophagus in to the stomach, the diagnosis of eesophageal atresia can be excluded. If too small a stomach tube is used it may curl up in the upper eesophageal pouch and give the impression of having passed further on . This can be avoided by using a fairly stiff tube and checking the position radiologically. We ha ve lately encountered another diagnostic snag which is not so easil y recognised. A term baby born here was " mucusy" after birth , and an attempt to pass a tube into the stomach in the labour ward was unsuccessful. While awaiting transfer to a neonatal surgical unit the baby was moved to the neonatal special-eare unit, where th e sister in charge passed a stomach tube (admitting later that it was a little more difficult tha n usual), and the presence of the tube in the stomach was confirmed by a plain X-ray of the chest and abdomen. Becau se of hypoglycremia the baby was given intravenous dextrose by an umbilical venous catheter. After a few hours he was given a small amount of clear fluid by mouth which immediately caused respirat ory distress and cyanosis. He was therefore transferred to the Hospital for Sick Children , Great Ormond Street. Further radiological studies showed that he had oesophageal atresia , and at operation this was found to be of the common type with a fistula connecting the trach ea with the lower oesophageal pouch. There was no upper-pouch fistula. The stomach tube had passed via the trach ea, through the fistula , and then into the stomach. This must be an extremely rare event, but it should be borne in mind when a baby clinically has eesophageal atresia though a stomach tube has been successfull y pa ssed, albeit with some difficulty. J EREMY AlLGROV E West Middlesex Hospital, Isleworth, Mid d lesex. PETER H USBAND Hospital for SickChildren, Great Ormond Street, london wet.
J . A. S. DICKSON
STEROID AEROSOLS IN ASTHMA MATERNAL MALNUTRITION AND LOW BIRTH-WEIGHT SIR,-Physiologists and others have argued about maternal fetal priorities for nearly a century, and it is not astonish ing that Professor Susser and Professor Stein (Oct. 4, p. 664 ) found your annotation (Sep t. 6, p. 445 ) " sensible" , wherea s Dr Pasamanick (Oct. 11 , p. 704 ) accuses you of " ir responsibility and incompetence". You probably agree with Josh Billings: " T he trouble with people is not that the y don 't know , but that they know so much that a in 't so" . Since Pasamanick refers to me twice, ma y I attempt to 1. roman. s . J. InfantNutrition; p. 28. Philadelphia, 1974. 2. Smith. H. A. M. B. medc], t974, iv, 741 3. Bhakoo, O. N., Scopes, J. W. Archs DIS. Childh . 1974,49,583.
SIR,- The results of a multicentre trial (Sept. 13, p. 469) comparing two different inhaled corticosteroids with oral prednisone, in patients with asthma who had not previously had long-term corticosteroids, were of considerable interest . Rather unexpectedly it was found that approximately 10 % of patients with potentially re versible airways obstruction will need longer than II days on 20 mg da ily of prednisone to improve by 20 % or more. For practical purposes this would indicate that a relativel y low dose of oral steroids for a short time may give a wro ng imp ression about the potential reversibility of airways obstructive disease when oral steroids are used. The conclusions about the effect of 400 p.g of inhaled corti1. Stein , Z.] Su sser, M., Saenger , G., Marolla, F. Famine and Human Develop" merit:
the DutchHunger Winterof t944-1945 . NewYork, 1975.
25,1975
815
In conclusion, suspicion of spurious thrombocytopenia should be aroused when a low platelet-count varies widel y on repeated occasions. All falsely low counts would be detected if confirmation by smear interpretation were sought. Studies with E.D.T.A.-anticoagulated blood can then further delineate the cause of the agglutination. Since the conditions causing spurious thrombocytopenia are benign, patients should not be treated with corticosteroids. Division s of Hsemat olo gy and Internal J\1.edici ne and of L aboratory Medicine ,
MayoClinic, Rochester, Minnesota 55901, U.S.A.
PHILIP R. GREIPP PAUL OlDISHElM MALCOLM BRIGDEN
INFANT'S UTILISATION OF IDS MILK INTAKE SIR,- The letter of Dr Ounsted and Dr Sleigh (Sept . 20 , p. 551) was very interesting. It seems, however, that the evidence to support their conclusion is not firmly based. Foman! indicated that in infants fed ad libitum during the first 6 weeks of life, caloric consumption was correlated with the caloric concentration of the milk formula . After 6 week s the infants were able to regulate their intake, so that caloric consumption was similar ir r espect ive of the caloric concentration of the milk formula, provided the caloric concentration was not 100 low. He concluded that the ability of the normal infant to adjust hi s intake volume wa s considerably greater after 6 weeks. In the infants described by Dr Ounsred and Dr Sle igh the majority of growth (ap p roxim ately two-thirds) took place during a period of diminished ability to regulate volume. It therefore seems illogical to relate the total growth 10 the volume consumed at a time when the infants had increased control over their intake. A British study" indicated that 57% of infa n t feeds were significantly overstrength. Even after the mothers had been shown how to prepare the feed s and had been warned against overstrength feeds the response was st ill d isappointing. Thi s indicates that not much reliance can be placed on the way mothers mix feeds . The preparation of the milk taken by infants studied by Dr Ounsted and Dr Sleigh was not standardised , and we do not know the precise caloric concentration befor e or after 6 weeks . The extent to which the caloric conlent of the milk influe nced both growth and the volume consumed is therefore unknown. It has been implied by Dr Ounsted and Dr Sleigh that the basal metabolism of small-for-dates babies is greater th an average-weight babies, thereby providing Jess energy for growth. Is this in fact so? In the first 2 weeks at least this doe s not appear 10 be so. Minimum rates of oxygen consumption in small-for-dates babies and average-weight babies are simi la r at th is time. 3 Department of Child Health, University of Aberdeen, Foresterhill,
AberdeenAB92ZD.
I. BI.UM ENTH AL
straighten the record on two questions of fact ? He suggests that the women I studied in Aberdeen during the 1950s probably ate unusually large amounts of fish protein. That "ain't so". He also says that my review of Stein and Susser's book on the Dutch famine was tragicomic because I failed to ponder the problem of controls. That, also, "ain't so" . Susser and Stein point out that reduction of birth-weights during the Dutch famine was followed by a sharp rise in infant mortality, especially after the first week . True; but adverse effects on perinatal mortality were surprisingly slight, and affected both the "famine" and the "control" areas. In their book (p. 230) Stein et al. I conclude that " a coherent explanation requires in teraction between famine exposure in early gestation and an unknown co-determinant", possibly maternal infection . M.R.C. Reprodu ction and Gro wth Unit, Princess Ma ry Maternity Hosp ital ,
Great North Road ,
Newcastle upon Tyne NE23BD
A. M. THOMSON
CAUTIONARY TALE OF A WANDERING TUBE SIR,-If, in a neonate, a stomach tube can be passed via the oesophagus in to the stomach, the diagnosis of eesophageal atresia can be excluded. If too small a stomach tube is used it may curl up in the upper eesophageal pouch and give the impression of having passed further on . This can be avoided by using a fairly stiff tube and checking the position radiologically. We ha ve lately encountered another diagnostic snag which is not so easil y recognised. A term baby born here was " mucusy" after birth , and an attempt to pass a tube into the stomach in the labour ward was unsuccessful. While awaiting transfer to a neonatal surgical unit the baby was moved to the neonatal special-eare unit, where th e sister in charge passed a stomach tube (admitting later that it was a little more difficult tha n usual), and the presence of the tube in the stomach was confirmed by a plain X-ray of the chest and abdomen. Becau se of hypoglycremia the baby was given intravenous dextrose by an umbilical venous catheter. After a few hours he was given a small amount of clear fluid by mouth which immediately caused respirat ory distress and cyanosis. He was therefore transferred to the Hospital for Sick Children , Great Ormond Street. Further radiological studies showed that he had oesophageal atresia , and at operation this was found to be of the common type with a fistula connecting the trach ea with the lower oesophageal pouch. There was no upper-pouch fistula. The stomach tube had passed via the trach ea, through the fistula , and then into the stomach. This must be an extremely rare event, but it should be borne in mind when a baby clinically has eesophageal atresia though a stomach tube has been successfull y pa ssed, albeit with some difficulty. J EREMY AlLGROV E West Middlesex Hospital, Isleworth, Mid d lesex. PETER H USBAND Hospital for SickChildren, Great Ormond Street, london wet.
J . A. S. DICKSON
STEROID AEROSOLS IN ASTHMA MATERNAL MALNUTRITION AND LOW BIRTH-WEIGHT SIR,-Physiologists and others have argued about maternal fetal priorities for nearly a century, and it is not astonish ing that Professor Susser and Professor Stein (Oct. 4, p. 664 ) found your annotation (Sep t. 6, p. 445 ) " sensible" , wherea s Dr Pasamanick (Oct. 11 , p. 704 ) accuses you of " ir responsibility and incompetence". You probably agree with Josh Billings: " T he trouble with people is not that the y don 't know , but that they know so much that a in 't so" . Since Pasamanick refers to me twice, ma y I attempt to 1. roman. s . J. InfantNutrition; p. 28. Philadelphia, 1974. 2. Smith. H. A. M. B. medc], t974, iv, 741 3. Bhakoo, O. N., Scopes, J. W. Archs DIS. Childh . 1974,49,583.
SIR,- The results of a multicentre trial (Sept. 13, p. 469) comparing two different inhaled corticosteroids with oral prednisone, in patients with asthma who had not previously had long-term corticosteroids, were of considerable interest . Rather unexpectedly it was found that approximately 10 % of patients with potentially re versible airways obstruction will need longer than II days on 20 mg da ily of prednisone to improve by 20 % or more. For practical purposes this would indicate that a relativel y low dose of oral steroids for a short time may give a wro ng imp ression about the potential reversibility of airways obstructive disease when oral steroids are used. The conclusions about the effect of 400 p.g of inhaled corti1. Stein , Z.] Su sser, M., Saenger , G., Marolla, F. Famine and Human Develop" merit:
the DutchHunger Winterof t944-1945 . NewYork, 1975.
