840

Letters to the Editor

peared, but the areola was still enlarged. Inspite of a bone age of 14 years, pubertal development did not yet start (testes 3 ml, pubic hair stage 3, no axillary hair). DISCUSSION This is our only case of CAH with gynecomastia. In a series of 105 cases of CAH due to 21-hydroxylase deficiency and in two other cases o f 11-fl-hydroxylase deficiency, we have never seen this phenomenon, although plasma estrogens were high in all cases in which they were studied. In our opinion, gynecomastia in this case cannot be considered as pubertal, since it was present for several years before examination and since spontaneous puberty did not yet start under treatment. Neither can it be simply explained by increased estrogen levels, since cases of 21-hydroxylase deficiency do not develop gynecomastia in the presence of high estrogens. Conceivably, the different pattern of accumulated steroid precursors in l l-fl-hydroxylase deficiency modifies the metabolism of estrogens and/or their effectiveness at a cellular level. Milo Zachmann, M.D. Andrea Prader, M.D. Department of Pediatrics University of Zurich, Kinderspital 8032 Zurich, Switzerland REFERENCE 1. Maclaren NK, Migeon C J, and Raiti S: Gnecomastia with congenital virilizing adrenal hyperplasia (11-fl-hydroxylase defldency), J PEDIATR 86:579, 1975.

Iris pattern in patients with the Williams syndrome To the Editor: Jones and Smith' reported what they described as a "stellate" pattern in the iris of children with the Williams syndrome. We have examined three children with this syndrome since learning

Fig. 1.

The Journal of Pediatrics November 1975

of this finding. All three patients had blue eyes and two of them had an unusual iris pattern which we would describe as "lacy" rather than stellate (Fig. 1). The mother of the patient whose eye is illustrated was also blue eyed, but did not have this unusual iris pattern. The patient whose iris pattern we considered to be normal had a radial pattern. In our experience the clinical diagnosis of patients with the Williams syndrome is more difficult when they are infants than when they are older. Features such as the unusual iris pattern may be helpful in alerting the clinician to the possibility of the diagnosis. M. Preus, Ph.D. Department of Medical Genetics The Montreal Children's Hospital Montreal, P. Q., Canada H3H 1P3 REFERENCE i.

Jones KL, and Smith DW: The Williams elfin facies syndrome, J PEDIATR 86:718, 1975.

More on the prophylactic dose of fluoride To the Editor: In "Fluoridated water supplies; An inadequate source of fluoride for children" in the May issue of ThE JOURNAL/ Drs. Schwab and Schwartz ask if fluoridated water provides the amount of fluoride recommended for medicinal administration in the first two years. Using a questionnaire, they found that fluoridated water intake does not supply this amount, and recommend additional fluoride supplementation. I believe their argument is ill founded, ignoring the whole epidemiologic basis of fluoride use. The efficacy o f fluoride in decreasing dental caries was discovere d by Studying the effect of fluoridated water; a long series of investigations established one part per million of fluoride as the level associated with maximum caries prevention attainable without significant dental fluorosis (mottled enamel)? Thereafter, interest arose in attempting to duplicate this effect with medicinal fluoride administration. The doses recommended-0.5 rag/day until age 3 and 1.0 rag/day until adolescence were based on a paper by McClure ~ in which he attempted to quantify fluoride intake from fluoridated water. Because he lacked accurate observational data, McCiure used an estimate of water requirement of 1 ml/kcal/day, guessed that 2533% of this would be supplied by drinking water and thereby obtained the figures for the amount of fluoride which he thought would be ingested by children in optimally fluoridated areas. His estimates of water use, and therefore of optimal fluoride intake, have been shown to be too high by a number o f investigators who

Volume 87 Number 5

Letters to the Editor

84 1

Rep y To the Editor:

Fig. 1. actually measured real water use. 4-7 Schwab and Schwartz's data confirm this fact. It follows that children who actually receive the full recommended medicinal fluoride dose regularly throughout childhood are at greater risk of developing dental fluorosis than children drinking fluoridated water; I have now seen several such cases of mottled enamel from this cause. The labial surfaces o f the incisors are streaked with chalky white (Fig. 1). The balance between these two effects of fluoride--caries prevention and mottled enamel is q u i t e p r e c i s e / If more fluoride is given to children in a fluoridated area, as Schwab and Schwartz suggest, the increase in protection from caries will be minimal, but the incidence of mottled enamel will be unacceptable. I urge the authors to reconsider their recommendation.

Elmer R. Grossman, M.D. Berkeley Pediatric Medical Group 1650 Walnut St. Berkeley, Califi 94709 REFERENCES Schwab JG, and Schwartz AD: Fluoridated water supplies: An inadequate source of fluoride for children, J Pediatr 86:735, 1975. 2. McClure F J, editor: Fluoride drinking waters, Public Health Service Publication No. 825, 1962. 3. McClure FJ: Ingestion of fluoride and dental caries-quantitative relations based on food and water requirements of children 1 to 12 years old, A m J Dis Child 66:362, 1943. 4. Galagan D J, Vermillion JR, Nevitt GA, Stadt ZM, and Dart RE: Climate and fluid intake, Pub Health Rep 72:484, 1957. 5. Crosby ND, and Shepherd PA: Studies on patterns o f fluid intake, water balance and fluoride retention, Med J Aust August 31. p 305, 1957. 6. Margolis FJ: The physician's role in the fluoride program, 9 exhibit, A M A Annual Meeting Chicago, June, 1962. 7. Walker JS, Margolis FJ, Luten HL Jr, Weil ML, and Wilson HL: Water intake of normal children, Science 140:890, 1963. 8. Hodge HC: The concentration of fluorides in drinking Water to give the point of m i n i m u m caries with m a x i m u m safety, J A m Dent Assoc 40:436, 1950. 1.

Dr. Grossman's point is an important one; that is, that the therapeutic dose of fluoride r e c o m m e n d e d to prevent dental caries is not a great deal lower than the a m o u n t of fluoride known to cause dental fluorosis. Thus the overzealous physician m a y possibly contribute to an increased incidence of tooth mottling by prescribing supplemental fluoride t o the child who is already receiving a significant a m o u n t of fluoride in his diet, presumably from its addition to c o m m u n i t y water supplies. Dr. G r o s s m a n also points out that the optimal intake of fluoride presently recommended m a y be too high because it is based on the observations of water intake by McCture, now shown to be an overestimate. After reviewing our article, we must agree that we m a y have overstated our case since all children did not need fluoride supplements. We studied only children under age two years, and 32% ingested 0.5 m g / d a y or more o f fluoride. Those receiving less than 0.5 m g / d a y could easily be identified and are the ones who we believe should receive added fluoride. According to the Committee on Nutrition of the American Academy of Pediatrics, a degree o f tooth mottling is observed when the ingestion of fluoride exceeds 3 m g daily, and detrimental effects on tooth structure do not appear with intakes up to 5 mg daily? If the child under age three years is by history ingesting less than 0.5 m g in his diet, the addition of 0.5 mg supplemental fluoride should not increase the incidence of dental fluorosis. The use of fluoride supplements in older children has been suggested when intake from water is less than 1.0 m g daily.-' Also it must be pointed out that mottled enamel occurs spontaneously and is no more c o m m o n in communities in temperate climates with drinking water containing 1 p p m fluoride than in those with only traces of fluoride in the water supplies.:' Therefore one can not assume that tooth mottling is always due to excess fluoride intake. One interesting study published this year compared the incidence of caries in a n u m b e r of groups of children including infants from one to four m o n t h s treated with 0.5 mg of fluoride living in a community with nonfluoridated water, and those of the same age from a c o m m u n i t y with fluoridated water? The group who received 0.5 m g / d a y had 67.8% with no caries in deciduous teeth and 66.1% with no caries in p e r m a n e n t teeth in this ten-year prospective study. Those from the fluoridated water community had 51,9% with no caries in deciduous teeth and 43.4% with no caries in p e r m a n e n t teeth. One possible explanation for these results is that a n u m b e r of children in the fluoridated water c o m m u n i t y did not ingest enough water to give optimal denial protection.

Allen D. Schwartz, M.D. University of Maryland School of Medicine Baltimore, M d Joel G. Schwob, M.D. Children's Memorial Hospital 2300 Children's Plaza Chicago, Ill.

Letter: More on the prophylactic dose of fluoride.

840 Letters to the Editor peared, but the areola was still enlarged. Inspite of a bone age of 14 years, pubertal development did not yet start (test...
812KB Sizes 0 Downloads 0 Views