EDITORIAL C O R R E S P O N D E N C E
Editorial correspondence or letters to the Editor relative to articles published in ThE JOURNAL or to topics ofcurrent interest are subject to critical review and to current editorial policy in respect to publication in part or in full.
Depilation treatment of hypertrichosis To the Editor: I read with interest, "Minoxidil therapy in children with severe hypertension" by Pennisi et al.' Apparently the children in their ~eries experienced similar degrees of hypertrichosis as the women ~ve reported, z All five women achieved complete removal of the unwanted hair with judicious use of Surgex, enabling continuation of Minoxidil. This readily available depilatory, if applied appropriately, effectively deals with this adverse reaction and permits continued treatment with a very valuable antihypertensire. Robert N. Earhart, M.D. Baton Rouge Clinic 8415 Goodwood Blvd. Baton Rouge, LA 70806
dedicated to Dr. Smith, who often entertains by playing the harmonica. When a'baby starts to cry The muscle that shortens the eye Is said to be the oris But the face then before us Should look puckered, whistling, and wry. For the squinting muscle you see Is the orbicularis oculi; An otis contraction Produces the action That plays harmonica on or off key. Roland D. Eave); 3LD. Resident Physician, DeiTartment o f Surger), Kaiser Fo,mdation Hospital 2425 Geary Blvd. San Francisco, CA 94115 REFERENCES
REFERENCES Pennisi A J, Takahashi M, Bernstein BH, Singsen BIt, Uittenbogaarl C, Ettenger RB. Malekzadeh MIt, Hanson V, and Fine RN: Minoxidil therapy in children with severe hypertension, J PEDIATR 90:813, 1977. 2. Earhart RN, Ball J, Nuss D, et al: Minoxidil-induced hypertrichosis: Treatment v,'ith calcium thioglycolate depilatory, South Med J 70:442, 1977. I.
Ocular~oral muscle mix-up To the Editor: A brief article recently published by Jones, ttanson, and Smith' contains a small ocular/oral muscle mix-up. The article states that "'... contraction of the orbicularis otis muscle leads to shortening of the palpebral fissure." However, it is the orbicularis oculi muscle, not the orbicularis otis, that acts as " . . . the sphincter muscle of the eyelids. ''2 The orbicularis oris muscle instead acts to bring the lips together and to purse them? To illustrate this poit~t, the following piece is kindheartedly
I. Jones KL, Hanson JW, and Smith DW: Palpebral fissure size in newborn infants. J PEDIXrR 92:787, 1978. 2. Warv,'ick R, and Williams P: Gray's ana!omy, ed 35, Philadelphia, 1973, WB Saunders Company, pp 497, 500. In reply, Dr Smith stated that his orbicularis otis was mute[ J.M.G.
More on the diving reflex and supraventricular tachycardia To the Editor: I recently attempted t'o invoke the "diving reflex" in a neonate experiencing a recurrence of supraventricular tachycardia while on maintenance digoxin therapy. Being more timid about immersion of an infant's head in cold water than Whitman et al, 1 I simply applied a cold, wet cloth to the infant's face. The tachycardia, which had persisted for over five minutes, promptly reverted to normal sinus rhythm. I have just had a second successful experience with relieving this arrhythmia. This patient was a female infant who first
The Journal of P E D 1 A T R I C S
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722
Editorial correspondence
developed supraventricular tachycardia at 4 months of age, which was treated by digitalization over a 16-hour period, intravenous propranolol 0.9 mg (0.15 mg/kg) ten hours after admission, and finally converted to normal sinus rhythm 15 hours after the hospital admission following D-C counter shock (10 watt-seconds). She was maintained on digoxin 0.05 mg/day (0.008 mg/kg/day). Supraventricular tachycardia recurred six weeks later and I attempted to relieve the arrhythmia with the application of a cold facecloth. She promptly converted to normal sinus rhythm. The arrhythmia recurred again 12 and 14 hours later while the infant was being monitored in hospital. On both occasions, the arrhythmia was promptly relieved by the use of a wet faceeloth applied by the attending nursing staff. This latter case appears to confirm my initial impression that this may be an effective means of relieving this arrthymia, and has the advantage that it can be easily applied by nursing personnel; indeed, the parents of this last child feel less apprehensive about her problem since they can apply this method at home if necessary, tlowever, a colleague of mine (Dr. A. Gaal) tried this method as initial treatment in a newborn infant who developed a supraventricular tachycardia-unsuccessfully. The arrhythmia resolved two and one-half hours after the first dose of digoxin. A. Ciastko, 3LD., ER.C.P.(C) Irving Clinic 74 Se)'mour St. West gumloops. B.C., Canada V2C IE2
REFERENCE 1. Whitman V, Friedman Z, Berman W Jr, and Maisels M J: Supraventricular tach)'cardia in newborn infants; an approach to therapy, J PEOJAT~ 91:304, 1977.
Pyloric atresia To the Editor In the April, 1977, issue of THE Jouay^l., a case of pyloric atresia associated with epidermolysis bullosa is presented*; the authors state that this is the first such association to be reported. In 1972, we reported the same finding, z Subsequently, another publication appeared in our country, demonstrating the concurrence of both anomalies in the same subject. C. Arrabal Terhn Jefe del Servicio de Recien Nacidos Hospital Clinico Planta 6. Ala Sur (Oudad Uni~'ersitaria) Madrid 3~ Spain
REFERENCES I.
Korber JS, and Glasson MJ. Pyloric atresia associated with epidermolysis bullosa, J PrDl^'rR 90:600, 1977. Arrabal Ter,4n C et al: Atresia de piloro e n u n recien naeido
The Journal of Pediatrics October 1978
con epidermolisis ampollosa, Boletin de la Catedra de Pediatria-Madrid, 16:47, 1972.
Editorial note This association now seems firmly established as a syndrome. The following additional references are relevant: (I) Pedersen PV, and Hertel J: Pyloric atresia and epidermolysis bullosa (letter), J PEDIATR91:852, 1977; and (2) DeGroot WG, Postuma R, and Hunter AGW: Familial pyloric atresia associated with epidermolysis bullosa, J PEDI^'rR 92:429, 1978. J.I~LG
Removal of aspirated tracheal foreign bodies To the Editor: I read with disappointment and frustration "Asphyxia secondary to massive dirt aspiration" by Bergeson and associates.' While this is a remarkable and worthwhile case report, the discussion fails to emphasize its most important aspects. The authors surmise, probably correctly, that the extensive impaction of the tracheobronchial tree was the result of dislodgement of foreign material from the hypopharynx during attempted resuscitation. They also conclude that bronchoscopy was the only productive means of removing the enormous amount of particulate matter. While this may be true, prevention of impaction would have been far more desirable. As suggested by the authors, it appears that the initial rescuer and the paramedics failed to follow the cardinal rules and sequence of basic life support (ABC's-airway, breathing, and circulation) and to recognize upper airway obstruction. Upon establishing the airway, they should have determined the obstruction and proceeded to relieve it according to standard protocols. ~~ The child should have immediately been placed with his head in the dependent position, and four (4) sharp back blows delivered between the scapula. This should have dislodged a large portion of the debris. Only if this occurred should ventilation have been attempted. If this procedure was unsuccessful, four (4) manual thrusts and then digital removal of foreign material should have been attempted. Although the latter step is presently recommended in children as well as adults, it may be more hazardous and further impact foreign material', and in this case it would appear justifiable. The sequence should have then been repeated -until effective ventilation was established. If this was not possible, the only remaining prehospital procedures are crieothyrotomy and transtracheal ventilation, techniques rarely approved for use in adults let alone children. Immediate cricothyroid membrane puncture with a 14-gauge needle would have probably been effective in establishing an airway, ~ since foreign material would not have been impacted past the vocal cords. It is my experience that well-trained, competent paramedics often fail to follow standardized prehospital protocols ",,,'hen confronted with a critically ill child. The reasons for this are
Editorial correspondence or letters to the Editor relative to articles published in ThE JOURNAL or to topics ofcurrent interest are subject to critical review and to current editorial policy in respect to publication in part or in full.
Depilation treatment of hypertrichosis To the Editor: I read with interest, "Minoxidil therapy in children with severe hypertension" by Pennisi et al.' Apparently the children in their ~eries experienced similar degrees of hypertrichosis as the women ~ve reported, z All five women achieved complete removal of the unwanted hair with judicious use of Surgex, enabling continuation of Minoxidil. This readily available depilatory, if applied appropriately, effectively deals with this adverse reaction and permits continued treatment with a very valuable antihypertensire. Robert N. Earhart, M.D. Baton Rouge Clinic 8415 Goodwood Blvd. Baton Rouge, LA 70806
dedicated to Dr. Smith, who often entertains by playing the harmonica. When a'baby starts to cry The muscle that shortens the eye Is said to be the oris But the face then before us Should look puckered, whistling, and wry. For the squinting muscle you see Is the orbicularis oculi; An otis contraction Produces the action That plays harmonica on or off key. Roland D. Eave); 3LD. Resident Physician, DeiTartment o f Surger), Kaiser Fo,mdation Hospital 2425 Geary Blvd. San Francisco, CA 94115 REFERENCES
REFERENCES Pennisi A J, Takahashi M, Bernstein BH, Singsen BIt, Uittenbogaarl C, Ettenger RB. Malekzadeh MIt, Hanson V, and Fine RN: Minoxidil therapy in children with severe hypertension, J PEDIATR 90:813, 1977. 2. Earhart RN, Ball J, Nuss D, et al: Minoxidil-induced hypertrichosis: Treatment v,'ith calcium thioglycolate depilatory, South Med J 70:442, 1977. I.
Ocular~oral muscle mix-up To the Editor: A brief article recently published by Jones, ttanson, and Smith' contains a small ocular/oral muscle mix-up. The article states that "'... contraction of the orbicularis otis muscle leads to shortening of the palpebral fissure." However, it is the orbicularis oculi muscle, not the orbicularis otis, that acts as " . . . the sphincter muscle of the eyelids. ''2 The orbicularis oris muscle instead acts to bring the lips together and to purse them? To illustrate this poit~t, the following piece is kindheartedly
I. Jones KL, Hanson JW, and Smith DW: Palpebral fissure size in newborn infants. J PEDIXrR 92:787, 1978. 2. Warv,'ick R, and Williams P: Gray's ana!omy, ed 35, Philadelphia, 1973, WB Saunders Company, pp 497, 500. In reply, Dr Smith stated that his orbicularis otis was mute[ J.M.G.
More on the diving reflex and supraventricular tachycardia To the Editor: I recently attempted t'o invoke the "diving reflex" in a neonate experiencing a recurrence of supraventricular tachycardia while on maintenance digoxin therapy. Being more timid about immersion of an infant's head in cold water than Whitman et al, 1 I simply applied a cold, wet cloth to the infant's face. The tachycardia, which had persisted for over five minutes, promptly reverted to normal sinus rhythm. I have just had a second successful experience with relieving this arrhythmia. This patient was a female infant who first
The Journal of P E D 1 A T R I C S
72!
722
Editorial correspondence
developed supraventricular tachycardia at 4 months of age, which was treated by digitalization over a 16-hour period, intravenous propranolol 0.9 mg (0.15 mg/kg) ten hours after admission, and finally converted to normal sinus rhythm 15 hours after the hospital admission following D-C counter shock (10 watt-seconds). She was maintained on digoxin 0.05 mg/day (0.008 mg/kg/day). Supraventricular tachycardia recurred six weeks later and I attempted to relieve the arrhythmia with the application of a cold facecloth. She promptly converted to normal sinus rhythm. The arrhythmia recurred again 12 and 14 hours later while the infant was being monitored in hospital. On both occasions, the arrhythmia was promptly relieved by the use of a wet faceeloth applied by the attending nursing staff. This latter case appears to confirm my initial impression that this may be an effective means of relieving this arrthymia, and has the advantage that it can be easily applied by nursing personnel; indeed, the parents of this last child feel less apprehensive about her problem since they can apply this method at home if necessary, tlowever, a colleague of mine (Dr. A. Gaal) tried this method as initial treatment in a newborn infant who developed a supraventricular tachycardia-unsuccessfully. The arrhythmia resolved two and one-half hours after the first dose of digoxin. A. Ciastko, 3LD., ER.C.P.(C) Irving Clinic 74 Se)'mour St. West gumloops. B.C., Canada V2C IE2
REFERENCE 1. Whitman V, Friedman Z, Berman W Jr, and Maisels M J: Supraventricular tach)'cardia in newborn infants; an approach to therapy, J PEOJAT~ 91:304, 1977.
Pyloric atresia To the Editor In the April, 1977, issue of THE Jouay^l., a case of pyloric atresia associated with epidermolysis bullosa is presented*; the authors state that this is the first such association to be reported. In 1972, we reported the same finding, z Subsequently, another publication appeared in our country, demonstrating the concurrence of both anomalies in the same subject. C. Arrabal Terhn Jefe del Servicio de Recien Nacidos Hospital Clinico Planta 6. Ala Sur (Oudad Uni~'ersitaria) Madrid 3~ Spain
REFERENCES I.
Korber JS, and Glasson MJ. Pyloric atresia associated with epidermolysis bullosa, J PrDl^'rR 90:600, 1977. Arrabal Ter,4n C et al: Atresia de piloro e n u n recien naeido
The Journal of Pediatrics October 1978
con epidermolisis ampollosa, Boletin de la Catedra de Pediatria-Madrid, 16:47, 1972.
Editorial note This association now seems firmly established as a syndrome. The following additional references are relevant: (I) Pedersen PV, and Hertel J: Pyloric atresia and epidermolysis bullosa (letter), J PEDIATR91:852, 1977; and (2) DeGroot WG, Postuma R, and Hunter AGW: Familial pyloric atresia associated with epidermolysis bullosa, J PEDI^'rR 92:429, 1978. J.I~LG
Removal of aspirated tracheal foreign bodies To the Editor: I read with disappointment and frustration "Asphyxia secondary to massive dirt aspiration" by Bergeson and associates.' While this is a remarkable and worthwhile case report, the discussion fails to emphasize its most important aspects. The authors surmise, probably correctly, that the extensive impaction of the tracheobronchial tree was the result of dislodgement of foreign material from the hypopharynx during attempted resuscitation. They also conclude that bronchoscopy was the only productive means of removing the enormous amount of particulate matter. While this may be true, prevention of impaction would have been far more desirable. As suggested by the authors, it appears that the initial rescuer and the paramedics failed to follow the cardinal rules and sequence of basic life support (ABC's-airway, breathing, and circulation) and to recognize upper airway obstruction. Upon establishing the airway, they should have determined the obstruction and proceeded to relieve it according to standard protocols. ~~ The child should have immediately been placed with his head in the dependent position, and four (4) sharp back blows delivered between the scapula. This should have dislodged a large portion of the debris. Only if this occurred should ventilation have been attempted. If this procedure was unsuccessful, four (4) manual thrusts and then digital removal of foreign material should have been attempted. Although the latter step is presently recommended in children as well as adults, it may be more hazardous and further impact foreign material', and in this case it would appear justifiable. The sequence should have then been repeated -until effective ventilation was established. If this was not possible, the only remaining prehospital procedures are crieothyrotomy and transtracheal ventilation, techniques rarely approved for use in adults let alone children. Immediate cricothyroid membrane puncture with a 14-gauge needle would have probably been effective in establishing an airway, ~ since foreign material would not have been impacted past the vocal cords. It is my experience that well-trained, competent paramedics often fail to follow standardized prehospital protocols ",,,'hen confronted with a critically ill child. The reasons for this are
