33 2
3.
Editorial correspondence
Stocks J, and Godfrey S: Nasal resistance during infancy, Respir Physiol (in press).
Rq, O' To the Editor: The interesting data presented by Stocks and Godfrey suggest one mechanism .for the survival advantage of small black neonates over white infants of similar weight, gestational age, and socioeconomic status, tlowever, it seems unlikely that nasal obstruction, which with modern neonatal care must rarely contribute to death, accounts for the marked difference in mortality. We would certainly like to learn of other data or speculation regarding the reaons for this apparently racially determined survival advantage. A. Frederick North, Jr., M.D. llugh MacDonald, M.D. Department of Pediatrics and lz~idemiologo' Unirersit)' of Pittsburgh Pittsburgh, PA 15261
hlappropriate secretion of A DH in neonatal hypoxia To the Editor: Drs. Kaplan and Feigin' report an interesting observation in their paper, "Inappropriate secretion of antidiuretic hormone complicating neonatal hypoxic-ischemic encephalopathy." Although I agree with the authors that the mechanism by which this alteration in regulation of arginine vasopressin secretion occurs is unknown, the explanation may lie in the observations of Gaufin et aF in monkeys with implanted subdural balloons. These authors found that as they raised intracranial pressure, AVP secretion increased. Elevated intracranial pressure may be the precipitating event in the newborn cases described as well, particularly in the first case where cerebral edema was described at autopsy. Clinicians have limited fluids empirically in older children with head trauma and meningitis. There is now clear evidence s~ that the newborn infant is capable of AVP hypersecretion and that he requires the same individualization of his fluid prescription. Rosemary D. Leake, M.D. Chief Division of Neonatolog)' UCL.,I/Harbor General ltospital 1000 IV. Carson St. Torrance, CA 90509 REFERENCES 1. Kaplan SL, and Feigin RD: Inappropriate secretion of anti-diuretic hormone complicating neonatal hypoxicischemic encephalopathy, J P~mA'[R 92:431, 1978.
The Journal of Pediatrics August 1978
2. Gaufin L, Skowsky W, and Goodman SJ: Release of antidiuretic hormone during mass-induced elevation of intracranial pressure, J Neurosurg 46:627, 1977. 3. Kaplan SL, and Feigin RD: Inappropriate secretion of antidiuretic hormone in children with bacterial meningitis, presented to Midwest Society for Pediatric Research Meeting, November 3, 1976, Chicago, lllinois. 4. Weinberg JA, Weitzman RE, Zakauddin S, and Leake RD: Inappropriate secretion ofantidiuretic hormone in a premature infant, J PEDIATR 90:111, 1977. 5. Hadeed A J, Leake RD, Weitzman RE, and Fisher DA: Mechanism of fetal vasopressin hypersecretion during the perinatal period, Clin Res 26:199A, 1978.
On the diagnosis of I9'pothyroidism in the early neonatal period To the Editor: In the August, 1977, issue of Tile JOURNAL OF PEDIATRICS Dr. Mace reported transient elevation of thyroid-stimulating hormone (TSH) in stressed premature infants. In our screening program for the detection of congenital hypothyroidism, using radioimmunoassay of TStl in capillary blood samples taken on the fifth day of life, in the county of Vasterbotten in Sweden, many of the infants delivered by cesarean section have been found to have elevated TSH concentrations. So far 6,107 infants have been screened under this program. In 5,961 infants the TSH concentration was in the normal range ( < 20/LU/ml). In 46 infants it was increased. Two of these were infants with congenital hypothyroidism, with TSH concentrations of 87 and 200 ~U/ml at 5 days of age. In the remaining 44 infants, the TSH elevation was transient. Twenty-four of these 44 infants were delivered by cesarean section; almost all sections were planned, uncomplicated, and performed at term. Of these 24 infants, 20 had a slight-to-moderate increase of the TS}I concentration: 20 to 45/tU/ml, and four had over 45 ttU/ml. Subsequent follow-up of the 44 infants with a transient elevation of TSII showed that all were euthyroid. The cause of the transient elevation of the neonatal TStl level in the infants delivered by cesarean section is unknown, ltmight indicate a transient hypothyroidism, but more probably represents a response to a perinatal stress factor or factors associated with the cesarean section itself. We are currently making a detailed study of neonatal thyroid function in such infants, including pituitary trophic hormone levels. Sta(fan Engberg, M.D. Karl-llenrik Gustavson, 2ll.D. Department of Pediatrics L. Jacobsson. 2ll.D. Ruzena S6derstrOm. 2lLD. Department of Clinical Chemistrr Universit.r llospital 90187 Umeh, Swed,'t,
Volume 93 Number 2
Editorial correspondence
REFERENCE
I.
Mace J: On the diagnosis of hypothyroidism in the early neonatal period, J PEDtXTR 91:347, 1977.
hnportance of early mother-infant interactions To the Editor: Even in the present-day jaded world which seems increasingly desensitized to violence, the case of Ellie G. must be regarded as excessive. In this particular instance of extreme child abuse, the first baby was found dismembered; the second neonate was decapitated. With the third off-spring the mother had to be restrained, bu~ only after she had torn off the lower half of the newborn's face. This is not comparable to "normal" child abuse as Ellie G. was, in fact, a female gorilla in a major zoo in the USA. At the same time, the disrupted family life and the lack of mother-child contact in non-wild gorillas may be more comparable than seems at first apparent. Until recently, gorillas were imported into America as babies and subsequently hand-reared in captivity, without the social contact with other members of the family that would occur in natural circumstances. Parallels between this type of aberrant behavior and that of "disorders of mothering" in man cannot be overlooked, in fact, considerable problems now exist in captive gorilla populations; without the normal imprinting of early infancy, there is not only the danger of later hostile behavior, but also a lack of learned experience in relation to breast feeding and sexual behavior, making the rearing of gorillas in captivity extremely difficult. It may very well be that Ellie G. has a message for her more sophisticated fellow primates-mankind. The ill consequences of disrupting patterns of in!eraction between mother and newborn established over millennia have been too lightly put aside. Fortunately modern research, notably by Klaus and colleagues,' is making us realize that the bonding at this period in the human as well as ape can be of extreme importance to subsequent social behavior and especially to patterns of parenting. Derrick B. Jellif]'e, M.D. Professor of Public llealth and Pediatrics lh'ad, Division of Population, Famil)" and International llealth E.F. Patrice Jelliffe, M.P.IL Lecturer and Associate Researcher Dirision of Population, Famil)" and International Health School of Public llealth Universit)" of California Los Angeles, CA 90024 REFERENCE
I.
Klaus MH, and Kennell JH: Mother-infant bonding: The impact of early separation or loss on family development, St. Louis, 1976, The C. V. Mosby Company.
333
eeFO' To the Editor: Studies of animal behavior and physiology have been very helpful in attempting to understand human physiology and behavior. Obse~'ations of this kind can give us important insights on how to study and observe human beings, llowever, we must be cautious about translatingthese studies directly to the human. They do not tell us that what we see in animal mothers will occur in human beings. It would be interesting to know whether Ellie G. was born in the wild or in the zoo. Meier' studied the mother's acceptance of her own newborn after cesarean section delivery in feral and laboratory-reared monkeys. The mothers were delivered surgically and separated from their infants for two hours. None of the laboratory monkeys delivered by cesarean section accepted their babies by the third day after delivery. They would not approach, pick up, or hold the infant to their ventral surface. ttowever, three of the seven feral monkeys (captured after being raised, presumably, by their own mothers) accepted their cesarean section delivered infants on the day of delivery, and the remaining four accepted their infants on the second day. kaboiatory and feral monkeys delivered vaginally with no separation showed normal maternal behavior. Thus, not only may Ellie G. be affected by the jail-like qualities of her present living arrangements, but where she was born and how she herself was mothered. Marshall tL Klaus, M.D. Professor of Pediatrics John Kennell, M.D. Professor of Pediatrics Universit). tlospitals of Cleveland 2065 Adelbert Rd Cleveland, OH 44106 REFERENCE
I.
Meier GW: Maternal behavior of feral- and laboratoryreared monkeys following the surgical delivery of their infants, Nature 206:492, 1965.
Dosage accttrac), of chewable theoph),lline To the Editor: In his recent review of theophylline therapy for asthma, Weinberger' reminds us that flexibility of dosage and cost should be the major factors which influence product selection. Recently, a chewable theophylline tablet was made commercially available (Theophyl Chewable, Knoll Pharmaceutical Company). These 100 mg tablets have been double scored by the manufacturer to facilitate accurate dosage titration in 25 mg increments? ~ We undertook a small investigation to evaluate the accuracy of this claim by examining the weight variation and content uniformity of the quartered tablets. The tablets were hand broken by a
3.
Editorial correspondence
Stocks J, and Godfrey S: Nasal resistance during infancy, Respir Physiol (in press).
Rq, O' To the Editor: The interesting data presented by Stocks and Godfrey suggest one mechanism .for the survival advantage of small black neonates over white infants of similar weight, gestational age, and socioeconomic status, tlowever, it seems unlikely that nasal obstruction, which with modern neonatal care must rarely contribute to death, accounts for the marked difference in mortality. We would certainly like to learn of other data or speculation regarding the reaons for this apparently racially determined survival advantage. A. Frederick North, Jr., M.D. llugh MacDonald, M.D. Department of Pediatrics and lz~idemiologo' Unirersit)' of Pittsburgh Pittsburgh, PA 15261
hlappropriate secretion of A DH in neonatal hypoxia To the Editor: Drs. Kaplan and Feigin' report an interesting observation in their paper, "Inappropriate secretion of antidiuretic hormone complicating neonatal hypoxic-ischemic encephalopathy." Although I agree with the authors that the mechanism by which this alteration in regulation of arginine vasopressin secretion occurs is unknown, the explanation may lie in the observations of Gaufin et aF in monkeys with implanted subdural balloons. These authors found that as they raised intracranial pressure, AVP secretion increased. Elevated intracranial pressure may be the precipitating event in the newborn cases described as well, particularly in the first case where cerebral edema was described at autopsy. Clinicians have limited fluids empirically in older children with head trauma and meningitis. There is now clear evidence s~ that the newborn infant is capable of AVP hypersecretion and that he requires the same individualization of his fluid prescription. Rosemary D. Leake, M.D. Chief Division of Neonatolog)' UCL.,I/Harbor General ltospital 1000 IV. Carson St. Torrance, CA 90509 REFERENCES 1. Kaplan SL, and Feigin RD: Inappropriate secretion of anti-diuretic hormone complicating neonatal hypoxicischemic encephalopathy, J P~mA'[R 92:431, 1978.
The Journal of Pediatrics August 1978
2. Gaufin L, Skowsky W, and Goodman SJ: Release of antidiuretic hormone during mass-induced elevation of intracranial pressure, J Neurosurg 46:627, 1977. 3. Kaplan SL, and Feigin RD: Inappropriate secretion of antidiuretic hormone in children with bacterial meningitis, presented to Midwest Society for Pediatric Research Meeting, November 3, 1976, Chicago, lllinois. 4. Weinberg JA, Weitzman RE, Zakauddin S, and Leake RD: Inappropriate secretion ofantidiuretic hormone in a premature infant, J PEDIATR 90:111, 1977. 5. Hadeed A J, Leake RD, Weitzman RE, and Fisher DA: Mechanism of fetal vasopressin hypersecretion during the perinatal period, Clin Res 26:199A, 1978.
On the diagnosis of I9'pothyroidism in the early neonatal period To the Editor: In the August, 1977, issue of Tile JOURNAL OF PEDIATRICS Dr. Mace reported transient elevation of thyroid-stimulating hormone (TSH) in stressed premature infants. In our screening program for the detection of congenital hypothyroidism, using radioimmunoassay of TStl in capillary blood samples taken on the fifth day of life, in the county of Vasterbotten in Sweden, many of the infants delivered by cesarean section have been found to have elevated TSH concentrations. So far 6,107 infants have been screened under this program. In 5,961 infants the TSH concentration was in the normal range ( < 20/LU/ml). In 46 infants it was increased. Two of these were infants with congenital hypothyroidism, with TSH concentrations of 87 and 200 ~U/ml at 5 days of age. In the remaining 44 infants, the TSH elevation was transient. Twenty-four of these 44 infants were delivered by cesarean section; almost all sections were planned, uncomplicated, and performed at term. Of these 24 infants, 20 had a slight-to-moderate increase of the TS}I concentration: 20 to 45/tU/ml, and four had over 45 ttU/ml. Subsequent follow-up of the 44 infants with a transient elevation of TSII showed that all were euthyroid. The cause of the transient elevation of the neonatal TStl level in the infants delivered by cesarean section is unknown, ltmight indicate a transient hypothyroidism, but more probably represents a response to a perinatal stress factor or factors associated with the cesarean section itself. We are currently making a detailed study of neonatal thyroid function in such infants, including pituitary trophic hormone levels. Sta(fan Engberg, M.D. Karl-llenrik Gustavson, 2ll.D. Department of Pediatrics L. Jacobsson. 2ll.D. Ruzena S6derstrOm. 2lLD. Department of Clinical Chemistrr Universit.r llospital 90187 Umeh, Swed,'t,
Volume 93 Number 2
Editorial correspondence
REFERENCE
I.
Mace J: On the diagnosis of hypothyroidism in the early neonatal period, J PEDtXTR 91:347, 1977.
hnportance of early mother-infant interactions To the Editor: Even in the present-day jaded world which seems increasingly desensitized to violence, the case of Ellie G. must be regarded as excessive. In this particular instance of extreme child abuse, the first baby was found dismembered; the second neonate was decapitated. With the third off-spring the mother had to be restrained, bu~ only after she had torn off the lower half of the newborn's face. This is not comparable to "normal" child abuse as Ellie G. was, in fact, a female gorilla in a major zoo in the USA. At the same time, the disrupted family life and the lack of mother-child contact in non-wild gorillas may be more comparable than seems at first apparent. Until recently, gorillas were imported into America as babies and subsequently hand-reared in captivity, without the social contact with other members of the family that would occur in natural circumstances. Parallels between this type of aberrant behavior and that of "disorders of mothering" in man cannot be overlooked, in fact, considerable problems now exist in captive gorilla populations; without the normal imprinting of early infancy, there is not only the danger of later hostile behavior, but also a lack of learned experience in relation to breast feeding and sexual behavior, making the rearing of gorillas in captivity extremely difficult. It may very well be that Ellie G. has a message for her more sophisticated fellow primates-mankind. The ill consequences of disrupting patterns of in!eraction between mother and newborn established over millennia have been too lightly put aside. Fortunately modern research, notably by Klaus and colleagues,' is making us realize that the bonding at this period in the human as well as ape can be of extreme importance to subsequent social behavior and especially to patterns of parenting. Derrick B. Jellif]'e, M.D. Professor of Public llealth and Pediatrics lh'ad, Division of Population, Famil)" and International llealth E.F. Patrice Jelliffe, M.P.IL Lecturer and Associate Researcher Dirision of Population, Famil)" and International Health School of Public llealth Universit)" of California Los Angeles, CA 90024 REFERENCE
I.
Klaus MH, and Kennell JH: Mother-infant bonding: The impact of early separation or loss on family development, St. Louis, 1976, The C. V. Mosby Company.
333
eeFO' To the Editor: Studies of animal behavior and physiology have been very helpful in attempting to understand human physiology and behavior. Obse~'ations of this kind can give us important insights on how to study and observe human beings, llowever, we must be cautious about translatingthese studies directly to the human. They do not tell us that what we see in animal mothers will occur in human beings. It would be interesting to know whether Ellie G. was born in the wild or in the zoo. Meier' studied the mother's acceptance of her own newborn after cesarean section delivery in feral and laboratory-reared monkeys. The mothers were delivered surgically and separated from their infants for two hours. None of the laboratory monkeys delivered by cesarean section accepted their babies by the third day after delivery. They would not approach, pick up, or hold the infant to their ventral surface. ttowever, three of the seven feral monkeys (captured after being raised, presumably, by their own mothers) accepted their cesarean section delivered infants on the day of delivery, and the remaining four accepted their infants on the second day. kaboiatory and feral monkeys delivered vaginally with no separation showed normal maternal behavior. Thus, not only may Ellie G. be affected by the jail-like qualities of her present living arrangements, but where she was born and how she herself was mothered. Marshall tL Klaus, M.D. Professor of Pediatrics John Kennell, M.D. Professor of Pediatrics Universit). tlospitals of Cleveland 2065 Adelbert Rd Cleveland, OH 44106 REFERENCE
I.
Meier GW: Maternal behavior of feral- and laboratoryreared monkeys following the surgical delivery of their infants, Nature 206:492, 1965.
Dosage accttrac), of chewable theoph),lline To the Editor: In his recent review of theophylline therapy for asthma, Weinberger' reminds us that flexibility of dosage and cost should be the major factors which influence product selection. Recently, a chewable theophylline tablet was made commercially available (Theophyl Chewable, Knoll Pharmaceutical Company). These 100 mg tablets have been double scored by the manufacturer to facilitate accurate dosage titration in 25 mg increments? ~ We undertook a small investigation to evaluate the accuracy of this claim by examining the weight variation and content uniformity of the quartered tablets. The tablets were hand broken by a
