1010
Letters to the Editor
tions. 1 Since these are both situations in which binding affinity or capacity is decreased when compared with fresh adult sera, it is reasonable t o assume that the break in the curve is related to changes in binding affinity and capacity rather than to bilirubin concentrations independent of binding. The authors wish to apologize to Dr. Krasner for not having made mention o f his direct bilirubin fluorescence method for binding estimation, w e chose to comment only on those binding methods currently enjoying clinical application. There are, indeed, a number of other methods which have been proposed for estimation of bilirubin binding, and we did not comment on all of them. The development of new concepts for measurement of bilirubin binding, whether clinical or basic scientific application, can only serve to enrich our understanding of bilirubin chemistry and physiology. New knowledge may at first appear to confuse but ultimately it clarifies. We also wish to take issue with the final sentence in Drs. Krasner and Chignell's letter. "Direct" methods are not inherently any more accurate or simple to interprete than "indirect" methods. In fact, modern scientific knowledge in nearly all fields is based, to a very great extent, on the use of "indirect" methods. Lawrence M. Gartner, M.D. Kwang-sun Lee, M.D. Department o f Pediatrics Rose F. Kennedy Research Center Albert Einstein College of Medicine Bronx, N. Y. 10461 REFERENCE
1.
Gartner LM, and Lee KS: Bilirubin binding, free fatty acids and a new concept for the pathogenesis of kernicterus, Proceedings of the International Symposium on Bilirubin Metabolism in the Newborn, Jerusalem, Israel, April, 1974, The National Foundation (in press).
Screening for congenital hypothyroidism To the Editor." There are two minor errors in the "Editor's column," of the May issue of THE JOURNAL OF PEDIATRICS. 1 The first error, in the first paragraph, line 16, I think Dr. D. Fisher meant: " . . . during the early days and weeks of extrauterine life" (and not intrauterine). The second error is on page 823, second paragraph, line 1: "The detection o f T S H deficiency in the immediate post natal p e r i o d . . . " should read: "thyroid deficiency," because the defect is in the thyroid gland and certainly not in the hypothalamus or pituitary .gland.
The Journal of Pediatrics December 1975
The values of TSH concentration are actually very high in congenital hypothyroidism as is shown in Ref. 2 and other reports. Alfredo O. Santesteban. M.D. 2701-17th St. Rock Island, Ill. 61201 REFERENCES
1. Fisher DA: Neonatal detection of hypothyroidism, J P~DIATR 86:822, 1975. 2. Klein A, Agusfin AV, and Foley TP: Successful laboratory screening for congenital hypothyroidism, Lancet 2:77, 1974.
Rep To the Editor: Dr. Santesteban's comments are correct, and I thank him for his letter. Delbert A. Fisher, M.D. UCLA School of Medicine Harbor General Hospital Campus 1000 West Carson St. Torrance, Calif. 90509
Prevention of ulceration of neck by CPAP head box To the Editor: We note with interest the article, "Severe neck ulceration from CPAP head box," by Krauss and Marshall? We have treated 21 babies suffering from hyaline membrane disease in the "Gregory box" make of CPAP head box, and initially used the Velcro strip supplied by the distributors to fasten the plastic hood, but we too found soreness at the nape of the neck developed easily, possibly aggravated by skin edema or even fat necrosis. We found this could be avoided by using an inflated length of Paul's 1-inch colostomy tubing, attached to tapes at each end. (Fig. 1) The length of tubing was approximately 24 cm--according to the size of the infant. This proved more satisfactory than cotton gauze tissue which would become hard when compressed and tended to allow air leakage. The tapes are tied with a single tie anteriorly, which is held in place over the baby's sternum by the ballooned hood overlying it, ie, not constricting the child's neck and thereby risking raised jugular venous pressure and possibly cerebral hemorrhage. We think that the "Gregory box" method of applying CPAP has proved of significant value in treatment of hyaline membrane disease, and it is well worth overcoming such practical difficulties which might otherwise deter the neonatal staff from using it.
Letters to the Editor
tions. 1 Since these are both situations in which binding affinity or capacity is decreased when compared with fresh adult sera, it is reasonable t o assume that the break in the curve is related to changes in binding affinity and capacity rather than to bilirubin concentrations independent of binding. The authors wish to apologize to Dr. Krasner for not having made mention o f his direct bilirubin fluorescence method for binding estimation, w e chose to comment only on those binding methods currently enjoying clinical application. There are, indeed, a number of other methods which have been proposed for estimation of bilirubin binding, and we did not comment on all of them. The development of new concepts for measurement of bilirubin binding, whether clinical or basic scientific application, can only serve to enrich our understanding of bilirubin chemistry and physiology. New knowledge may at first appear to confuse but ultimately it clarifies. We also wish to take issue with the final sentence in Drs. Krasner and Chignell's letter. "Direct" methods are not inherently any more accurate or simple to interprete than "indirect" methods. In fact, modern scientific knowledge in nearly all fields is based, to a very great extent, on the use of "indirect" methods. Lawrence M. Gartner, M.D. Kwang-sun Lee, M.D. Department o f Pediatrics Rose F. Kennedy Research Center Albert Einstein College of Medicine Bronx, N. Y. 10461 REFERENCE
1.
Gartner LM, and Lee KS: Bilirubin binding, free fatty acids and a new concept for the pathogenesis of kernicterus, Proceedings of the International Symposium on Bilirubin Metabolism in the Newborn, Jerusalem, Israel, April, 1974, The National Foundation (in press).
Screening for congenital hypothyroidism To the Editor." There are two minor errors in the "Editor's column," of the May issue of THE JOURNAL OF PEDIATRICS. 1 The first error, in the first paragraph, line 16, I think Dr. D. Fisher meant: " . . . during the early days and weeks of extrauterine life" (and not intrauterine). The second error is on page 823, second paragraph, line 1: "The detection o f T S H deficiency in the immediate post natal p e r i o d . . . " should read: "thyroid deficiency," because the defect is in the thyroid gland and certainly not in the hypothalamus or pituitary .gland.
The Journal of Pediatrics December 1975
The values of TSH concentration are actually very high in congenital hypothyroidism as is shown in Ref. 2 and other reports. Alfredo O. Santesteban. M.D. 2701-17th St. Rock Island, Ill. 61201 REFERENCES
1. Fisher DA: Neonatal detection of hypothyroidism, J P~DIATR 86:822, 1975. 2. Klein A, Agusfin AV, and Foley TP: Successful laboratory screening for congenital hypothyroidism, Lancet 2:77, 1974.
Rep To the Editor: Dr. Santesteban's comments are correct, and I thank him for his letter. Delbert A. Fisher, M.D. UCLA School of Medicine Harbor General Hospital Campus 1000 West Carson St. Torrance, Calif. 90509
Prevention of ulceration of neck by CPAP head box To the Editor: We note with interest the article, "Severe neck ulceration from CPAP head box," by Krauss and Marshall? We have treated 21 babies suffering from hyaline membrane disease in the "Gregory box" make of CPAP head box, and initially used the Velcro strip supplied by the distributors to fasten the plastic hood, but we too found soreness at the nape of the neck developed easily, possibly aggravated by skin edema or even fat necrosis. We found this could be avoided by using an inflated length of Paul's 1-inch colostomy tubing, attached to tapes at each end. (Fig. 1) The length of tubing was approximately 24 cm--according to the size of the infant. This proved more satisfactory than cotton gauze tissue which would become hard when compressed and tended to allow air leakage. The tapes are tied with a single tie anteriorly, which is held in place over the baby's sternum by the ballooned hood overlying it, ie, not constricting the child's neck and thereby risking raised jugular venous pressure and possibly cerebral hemorrhage. We think that the "Gregory box" method of applying CPAP has proved of significant value in treatment of hyaline membrane disease, and it is well worth overcoming such practical difficulties which might otherwise deter the neonatal staff from using it.
