14 8
Clinical notes
consider lowering the age at which discussions of contraception, parenting, and venereal disease prevention and treatment are begun. The earlier onset of sexual activity documented in this high-risk population emphasizes the importance of obtaining complete sexual histories from early adolescent populations.
Karen Hein, M.D. A ssistant Professor of Pediatrics Michael L Cohen, M.D. Professor of Pediatrics Andrea Marks, M.D. Assistant Professor of Pediatrics S. Kenneth Schonberg, 3LD. Assistant Professor of Pediatrics Monica Me)er, M.D. Instructor of Pediatrics Andrew McBride, M.D. Medical Director New York State Divisionfor Youth Division of Adolescent Medicine Department of Pediatrics Montejqore llospital and Medical Center 11! East 210th St. Bronx, N Y 10467 REFERENCES
!. Zelnik M, and Kantner JF: Sexual and contraceptive experience of young unmarried women in the United States, 1976 and 1971, Family Planning Perspec:tives 9:55, 1977. 2. Roddick JW: Gynecologic disease in young, sexually active women, Am J Obstet Gynecol 126:880, 1976. Sorensen RC: Adolescent sexuality in contemporary America, New York 1973, The World Pub. Co, p 18.
Hypernatremia in seborrheic dermatitis Patients with an intact thirst mechanism and free access to water can maintain normal serum sodium concentrations during illnesses in which there is excess loss of free water. Hypernatremia may develop, however, ifa patient is too young or too i!l to adjust his water intake. This paper describes an infant who had a seyere, generalized for m ofseborrheic dermatitis. Hypernatremia developed unexpectedly and could not be explained except by invoking loss of water through the abnormal skin. This was confirmed by demonstrating that the humidity of air above the patient's skin was much higher than in carefully chosen control subjects. CASE REPORT Patient G.B., a male, was born to a 16-year-old primigravida after an uneventful pregnancy; the delivery was normal and the infant weighed 3.6 kg. At 2 weeks of age he developed a patchy, red, scaly rash in the diaper area and on the trunk. By 8 weeks the
0022-3476/78/0193-0148500.20/0 9 1978 The C.V. Mosby Co.
The Journal of Pediatrics July 1978
entire body was covered with a nonexudative, erythematous rash. There was no history of diarrhea, vomiting, or fever. "l'he parents were not consanguinous, and there was no family history of a similar condition. The infant was referred to the Montreal Children's Hospital at I 1 weeks of age for evaluation of the rash. He weighed 4.9 kg; the temperature was 37~ respiratory rate 32/minute, and pulse rate 148/minute. There was no evidence of dehydration, increased perspiration, or edema. The entire body was covered with a red, dry, scaly rash. During the next two weeks he developed generalized lymphadenopathy and hepatosplenomegaly. Laboratory investigations aimed at elucidating t h e precise nature of his disease will be reported separately (Reece E, et al [in preparation]). On admission the serum sodium concentration was 153 mEq/1, potassium 5.0 m E q / l , chloride 121 mEq/!, blood urea nitrogen 11 mg/dl, creatinine 0.8 mg/dl, glucose 172 mg/dl, total protein 5.6 gm/dl, and albumin 3.1 gm/dl. Urine specific gravity was as high as 1.026. While taking 120 to 150 ml/kg/day of a meat base formula (13.3 m E q / l of sodium), he had a second episode of hypernatremia (serum sodium concentration 153 mEq/l). The episodes of hypernatremia were accompanied by weight losses of 500 and 200 gm, respectively. There was no tachypnea, increased perspiration, fever, apparent fluid loss from weeping ski n, diarrhea, vomiting, or polyuria, or high ambient temperature. After correction of the hypernatremia and dehydration, he required more than 160 m!/kg/day of 3A strength meat base formula to prevent its recurrence. METHODS A Beckman Humi-Check hygrometer was modified by attaching a plastic cup to its sensing apparatus. The volume of the cup was about 60 co and the system was made airtight with adhesive masking tape. The 6.5 cm diameter opening of the cup was applied firmly to the anterior chest wall. Percent humidity was measured at one minute intervals for seven to ten minutes. The measurements were made in rooms with constant temperature and humidity, no circulating air, and while subjects were asleep or not active. There were no cold surfaces near the patient which could attract radiant heat. Three healthy patients of similar age and weight were also studied. Details of the patient and control subjects' age, sex, weight, body temperature, as well as the room temperature and ambient humidity are shown in Table I. The humidity increment was calculated as follows: percent humidity over the subject after five minutes minus percent humidity of the ambient air. RESULTS The humidity increment for the patient was measured on four occasions (mean 35, range 18 to 45). The mean increment in the humidity of the three control patients was 10, with a range of 7 to 13. The percentage humidity recorded at one minute intervals for 7 to 10 minutes is shown in Table I. DISCUSSION Hypernatremia occurs as a result of excessive sodium intake, marked restriction of water, or increased free water loss. Loss of water in excess of sodium can occur in conditions in which the concentrating ability of the kidney is impaired, and in patients
Volume 93 Number 1
Clinical notes
14 9
Table I. D a t a o n p a t i e n t a n d controls
Sex
Age (mo)
Weight (kg)
Body temperature (oC)
Room temperature (0 C)
Ambient humidit), (%)
Percentage humidity in the cup (min)
I/I 21 ] 4 1 5 1 6 [ zls[
l10
Patient M
3
3.3
36.4 36.5 37.4 36.7
24.5 24.5 25.5 24.5
36 46 35 64
46 51 46 67
64 65 64 73
72 72 72 77
76 75 76 80
79 78 79 81
80 80 80 82
82 82 82 83
83 83 83 83
83 83 83 84
84 84 83 84.
Controls M M F
2 2 389
4.1 3.48 4.6
36.7 37.1 37.0
26.5 26.5 23.5
39 35 60
39 35 61
41 37 62
45 41 64
48 44 64
49 46 67
52 44 68
53 45 69
55 46 70
55
56
71
85 83 85 85
Increment in humidity
Cat5rain) 44 34 45 18 13 9 7
with profuse diarrhea. Water is also lost through lungs and skin. Excess evaporative water loss has been documented in small premature infants and has caused hypernatremia dehydration when theie infants are treated with phototherapy. To our knowledge, however, hypematremia has not been shown to occur as a result of excess water loss through the skin of patients with extensive skin diseases?
Robert Jeanneau, M.D. Paul Goodyer, M.D. Bernard S. Kaplan, M.B., B.Ch., EC.P.(S.A.) Department of Nephrology Montreal Children's Hospital Montreal, Canada REFERENCE I.
MoncriefJA: Bums, N Engl J Med 288:444, 1973.
Bochdalek hernia presenting as gastric outlet obstruction Congenital diaphragmatic hernia usually presents with severe respiratory distress beginning shortly after delivery. Rarely, the presenting symptoms are due to gastrointestinal obstruction. We report a case of a 3-day-old infant who began to vomit on the third day of life and was found to have a gastric outlet obstruction due to a posterolateral diaphragmatic hernia (Bochdalek hernia). CASE REPORT A female infant was born after an uneventful pregnancy and delivery, weighing 3.3 kg. She was the first child of a young and healthy couple. Examination after delivery revealed good general condition and no signs of respiratory distress or mediastinal shift. The abdomen was soft and not scaphoid; the spleen and liver were not enlarged. On the second day of life she began to receive food orally
0022.3476/78/0193-0149500.20/0 9 1978 The C.V. MosbyCo.
Fig. I. A radiograph of the chest and abdomen showing an air fluid level in the left hemithorax, with slight displacement of the heart to the right and no air in the gastrointestinal tract. without any problems, but 24 hours later she started to vomit shortly after every feeding; the vomitus was not bile stained. There were no respiratory difficulties and physical examination was again normal. Total blood count and serum electrolyte values were normal. A radiograph of the chest and abdomen was taken (Fig. 1) and showed an air fluid level in the left hemithorax,
Clinical notes
consider lowering the age at which discussions of contraception, parenting, and venereal disease prevention and treatment are begun. The earlier onset of sexual activity documented in this high-risk population emphasizes the importance of obtaining complete sexual histories from early adolescent populations.
Karen Hein, M.D. A ssistant Professor of Pediatrics Michael L Cohen, M.D. Professor of Pediatrics Andrea Marks, M.D. Assistant Professor of Pediatrics S. Kenneth Schonberg, 3LD. Assistant Professor of Pediatrics Monica Me)er, M.D. Instructor of Pediatrics Andrew McBride, M.D. Medical Director New York State Divisionfor Youth Division of Adolescent Medicine Department of Pediatrics Montejqore llospital and Medical Center 11! East 210th St. Bronx, N Y 10467 REFERENCES
!. Zelnik M, and Kantner JF: Sexual and contraceptive experience of young unmarried women in the United States, 1976 and 1971, Family Planning Perspec:tives 9:55, 1977. 2. Roddick JW: Gynecologic disease in young, sexually active women, Am J Obstet Gynecol 126:880, 1976. Sorensen RC: Adolescent sexuality in contemporary America, New York 1973, The World Pub. Co, p 18.
Hypernatremia in seborrheic dermatitis Patients with an intact thirst mechanism and free access to water can maintain normal serum sodium concentrations during illnesses in which there is excess loss of free water. Hypernatremia may develop, however, ifa patient is too young or too i!l to adjust his water intake. This paper describes an infant who had a seyere, generalized for m ofseborrheic dermatitis. Hypernatremia developed unexpectedly and could not be explained except by invoking loss of water through the abnormal skin. This was confirmed by demonstrating that the humidity of air above the patient's skin was much higher than in carefully chosen control subjects. CASE REPORT Patient G.B., a male, was born to a 16-year-old primigravida after an uneventful pregnancy; the delivery was normal and the infant weighed 3.6 kg. At 2 weeks of age he developed a patchy, red, scaly rash in the diaper area and on the trunk. By 8 weeks the
0022-3476/78/0193-0148500.20/0 9 1978 The C.V. Mosby Co.
The Journal of Pediatrics July 1978
entire body was covered with a nonexudative, erythematous rash. There was no history of diarrhea, vomiting, or fever. "l'he parents were not consanguinous, and there was no family history of a similar condition. The infant was referred to the Montreal Children's Hospital at I 1 weeks of age for evaluation of the rash. He weighed 4.9 kg; the temperature was 37~ respiratory rate 32/minute, and pulse rate 148/minute. There was no evidence of dehydration, increased perspiration, or edema. The entire body was covered with a red, dry, scaly rash. During the next two weeks he developed generalized lymphadenopathy and hepatosplenomegaly. Laboratory investigations aimed at elucidating t h e precise nature of his disease will be reported separately (Reece E, et al [in preparation]). On admission the serum sodium concentration was 153 mEq/1, potassium 5.0 m E q / l , chloride 121 mEq/!, blood urea nitrogen 11 mg/dl, creatinine 0.8 mg/dl, glucose 172 mg/dl, total protein 5.6 gm/dl, and albumin 3.1 gm/dl. Urine specific gravity was as high as 1.026. While taking 120 to 150 ml/kg/day of a meat base formula (13.3 m E q / l of sodium), he had a second episode of hypernatremia (serum sodium concentration 153 mEq/l). The episodes of hypernatremia were accompanied by weight losses of 500 and 200 gm, respectively. There was no tachypnea, increased perspiration, fever, apparent fluid loss from weeping ski n, diarrhea, vomiting, or polyuria, or high ambient temperature. After correction of the hypernatremia and dehydration, he required more than 160 m!/kg/day of 3A strength meat base formula to prevent its recurrence. METHODS A Beckman Humi-Check hygrometer was modified by attaching a plastic cup to its sensing apparatus. The volume of the cup was about 60 co and the system was made airtight with adhesive masking tape. The 6.5 cm diameter opening of the cup was applied firmly to the anterior chest wall. Percent humidity was measured at one minute intervals for seven to ten minutes. The measurements were made in rooms with constant temperature and humidity, no circulating air, and while subjects were asleep or not active. There were no cold surfaces near the patient which could attract radiant heat. Three healthy patients of similar age and weight were also studied. Details of the patient and control subjects' age, sex, weight, body temperature, as well as the room temperature and ambient humidity are shown in Table I. The humidity increment was calculated as follows: percent humidity over the subject after five minutes minus percent humidity of the ambient air. RESULTS The humidity increment for the patient was measured on four occasions (mean 35, range 18 to 45). The mean increment in the humidity of the three control patients was 10, with a range of 7 to 13. The percentage humidity recorded at one minute intervals for 7 to 10 minutes is shown in Table I. DISCUSSION Hypernatremia occurs as a result of excessive sodium intake, marked restriction of water, or increased free water loss. Loss of water in excess of sodium can occur in conditions in which the concentrating ability of the kidney is impaired, and in patients
Volume 93 Number 1
Clinical notes
14 9
Table I. D a t a o n p a t i e n t a n d controls
Sex
Age (mo)
Weight (kg)
Body temperature (oC)
Room temperature (0 C)
Ambient humidit), (%)
Percentage humidity in the cup (min)
I/I 21 ] 4 1 5 1 6 [ zls[
l10
Patient M
3
3.3
36.4 36.5 37.4 36.7
24.5 24.5 25.5 24.5
36 46 35 64
46 51 46 67
64 65 64 73
72 72 72 77
76 75 76 80
79 78 79 81
80 80 80 82
82 82 82 83
83 83 83 83
83 83 83 84
84 84 83 84.
Controls M M F
2 2 389
4.1 3.48 4.6
36.7 37.1 37.0
26.5 26.5 23.5
39 35 60
39 35 61
41 37 62
45 41 64
48 44 64
49 46 67
52 44 68
53 45 69
55 46 70
55
56
71
85 83 85 85
Increment in humidity
Cat5rain) 44 34 45 18 13 9 7
with profuse diarrhea. Water is also lost through lungs and skin. Excess evaporative water loss has been documented in small premature infants and has caused hypernatremia dehydration when theie infants are treated with phototherapy. To our knowledge, however, hypematremia has not been shown to occur as a result of excess water loss through the skin of patients with extensive skin diseases?
Robert Jeanneau, M.D. Paul Goodyer, M.D. Bernard S. Kaplan, M.B., B.Ch., EC.P.(S.A.) Department of Nephrology Montreal Children's Hospital Montreal, Canada REFERENCE I.
MoncriefJA: Bums, N Engl J Med 288:444, 1973.
Bochdalek hernia presenting as gastric outlet obstruction Congenital diaphragmatic hernia usually presents with severe respiratory distress beginning shortly after delivery. Rarely, the presenting symptoms are due to gastrointestinal obstruction. We report a case of a 3-day-old infant who began to vomit on the third day of life and was found to have a gastric outlet obstruction due to a posterolateral diaphragmatic hernia (Bochdalek hernia). CASE REPORT A female infant was born after an uneventful pregnancy and delivery, weighing 3.3 kg. She was the first child of a young and healthy couple. Examination after delivery revealed good general condition and no signs of respiratory distress or mediastinal shift. The abdomen was soft and not scaphoid; the spleen and liver were not enlarged. On the second day of life she began to receive food orally
0022.3476/78/0193-0149500.20/0 9 1978 The C.V. MosbyCo.
Fig. I. A radiograph of the chest and abdomen showing an air fluid level in the left hemithorax, with slight displacement of the heart to the right and no air in the gastrointestinal tract. without any problems, but 24 hours later she started to vomit shortly after every feeding; the vomitus was not bile stained. There were no respiratory difficulties and physical examination was again normal. Total blood count and serum electrolyte values were normal. A radiograph of the chest and abdomen was taken (Fig. 1) and showed an air fluid level in the left hemithorax,
