Volume 91 Number 5

serum globulin before one year of age; (4) those who received further attenuated measles-virus vaccine with ISG in a dose intended for use with the more reactive E d m o n s t o n B vaccine; and (5) those who received live measles vaccine that had lost its potency because of exposure to excessive light or heat." A sixth indication was added in an a d d e n d u m to the article and called for consideration of revaccination in "children who received measles vaccine before their 13-month birthday . . . . " Though clearly stated by Dr. Kruginan there seems to be widespread failure to note that all patients receiving g a m m a globulin in combination with live vaccines need not be revaccinated. The Edmonston strain given after one year of age (even with g a m m a globulin) produced and has maintained a measles antibody response comparable with that of natural measles.' Only the further attenuated vaccines (such as Swartz) when wrongfully administered with g a m m a globulin are suspect. Misreading of Dr. K r u g m a n ' s statement has led to r e c o m m e n d a tions heard on local television news bulletins, in infectious disease lectures, and by state public health departments that all patients with coincidental g a m m a globulin administration should be revaccinated. Such policy m a y be justified (in light of the apparent low rate of complication associated with revaccination) whenever any doubt exists as to the strain originally used. However, it seems an injustice both to the vaccine and to the child when the vaccine is known to be Edmonston. More disturbing is the uncertainty about Dr. K r u g m a n ' s recommendations for those children vaccinated between 12 and 13 months of age. Most children were vaccinated promptly after their first birthday but before 13 months. In a J A M A editoriaF Dr. K r u g m a n notes that neither the American A c a d e m y of Pediatrics or the Advisory Committee on Immunization Practices of the United States Public Health Service recommend "the routine or systematic reimmunization" of children vaccinated at 12 months of age. Further on he says, "only those children who received measles vaccination before their 13 month birthday should be considered for revaccination." This situation takes in perhaps the majority of children, even though only one m o n t h is involved. There is very little to individualize in these particular children. Perhaps we should simply confess; we have no defense against a school health nurse who is "quoting K r u g m a n " and who wants all these children revaccinated. Could he help us out of this dilemma? Lewis B. Harden, M.D., LTC, MC, USA James W. Bass, M.D., COL, MC, USA Department of Pediatrics Walter Reed Army Medical Center Washington, DC 20012

REFERENCES I.

2.

K r u g m a n S: Present status of measles and rubella i m m u n i zation in the United States: A medical progress report, J PEDIATR 90:1, 1977. K r u g m a n S: Measles immunization: New r e c o m m e n d a tions, J A M A 237:366, 1977.

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847

Reply To the Editor: At a recent meeting the Committee on Infectious Diseases of the American A c a d e m y of Pediatrics reviewed past and present recommendations for vaccine use and outbreak control. The recommendations of the Committee were published in the Academy's June, 1977, issue of "News and C o m m e n t . " The following four comments, extracted from this report, deal with the two issues that have created the dilemma presented by Dr. Lewis B. Harden and Dr, James W. Bass: Item No. 1. The recommended age for measles immunization under usual circumstances is at or after 15 m o n t h s o f age (vaccine is available as measles alone, or measles-mumps-rubella vaccine). Item No. 3. At the time of an outbreak, children whose live measles vaccine was given at or shortly after 12 months, but before 15 months, need not be recalled for re-immunization. However, such children should not be denied vaccine if they are brought for this purpose to a physician's office or other health facility. Item No. 4. A n y child who on school entry does not have a medically documented history of natural measles or live measles vaccine administration at or after 12 months of age should receive a dose of live measles vaccine to ensure full i m m u n i z a tion. I t e m No. 5. In the past, an approved method of measles immunization involved the use of live vaccine accompanied by a calculated dose of i m m u n e serum globulin. This was discontinued with the release of the further attenuated virus vaccine. Re-immunization of children who received g a m m a globulin with live vaccine is unnecessary, unless the vaccine and g a m m a globulin were administered prior to 12 m o n t h s of age. As a Consultant to the Committee on infectious Diseases I participated in the preparation of these measles r e c o m m e n d a tions. I do hope that these comments will provide Dr. Harden and Dr. Bass with the " a m m u n i t i o n " needed to defend themselves against anybody who is "quoting K r u g m a n . " Saul Krugman, M.D. Department of Pediatrics New York University Medical Center New York, N Y 10016

Plasma renin activity in normal children To the Editor: We fully agree with the statement of Dr. Hiner a n d associates ~ on the importance of a n o m o g r a m plotting plasma renin activity (PRA) values against sodium excretion, at equilibrium o f sodium balance, in normal children of various ages. In fact one of us (G. G.) had already had the opportunity of pointing this out, at the

848

Letters to the Editor

The Journal of Pediatrics November 1977

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Fig. 1. Thirty-eight normal children (in-patients), ages from 2 months to 14 years, at constant dietary potassium (50 mEq/m'-'/24 hours) and different sodium intakes (from 10 to 160 mEq/m2/24 hours), both in the supine and upright positions, at equilibrium of sodium balance. The attainment of balance was checked by daily controls of the prescribed dietary intake and the 24-hour urinary excretion of sodium; satisfactory equilibrium (i.e., a difference between intake and output within _+ 20%) was reached after ~ 3 days in most cases. In five patients PRA values have been determined twice, i.e., at low and high Na intakes, respectively; the results fit well with those expected from the nomogram. Main technical data: kit of Cea-Cen-Sorin; BAL-IC as an inhibitor; plasma pH adjusted to 5.5. The interrogation point is related to the unexpected rising of some PRA values in the upright positions for the highest sodium intakes applied. last International Congress of Pediatrics in Buenos Aires, ~and we believe that such a nomogram constitutes the premise for the rational interpretation of PRA, especially in single cases or in different physiopathologic conditions. We have devised a nomogram (Fig. 1) and discussed its results on two occasions last year. 3. 4 In our opinion the results reinforce the aforesaid statement and permit the following conclusions (which may also be of interest in relation to the paper of Dr. Stalker and associatesS), i.e.: (1) PRA levels increase in the upright position (suckling infants seem to constitute an exception to the rule). (2) PRA decreases by increasing dietary sodium intake, both in the supine and upright positions (however, at the highest intakes, a paradoxical behavior may be observed, at least in some cases. This point may have some interest, if confirmed by further investigation). (3) In the supine position only ~ 25% of the total variance of PRA levels is accounted for by the correlation with sodium excretion (the value exceeds 60% for the parabolic correlation in the upright position). This finding, while supporting the claimed influence of age in prepuberal subjects (as described in the literature and as we have also confirmed) points out the limited value of isolated supine PRA levels for

clinical purposes, even after normalization for sodium excretion. Giorgio Giovannelli, M.D. Director Department of Pediatrics University of Parma Via Gramsci, 14 43100 Parma Italy REFERENCES

1. Hiner LB, Gruskin AB, Baluarte H J, and Cote ML: Plasma renin activity in normal children, J PEDIATR 89:258, 1976. 2. Giovannelli G, Catterina A, and Cavagni G: Our experience with the radioimmunoassay of PRA and angiotensin II in children, Acta of the XIV International Congress of Paediattics, 5:11, 1974. 3. Giovannelli G, Banchini G, and Bernasconi S: Relationship between PRA and sodium intake in normal children, Joint Meeting of ESPR, ESPE and WGMM, Rotterdam, June 2024, 1976, Abstract 172. 4. Giovannelli G, Banchini G, Ammenti A, and Bernasconi S:

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5.

Relationship between PRA plasma levels and sodium dietary intake in normal children, in the supine and upright positions, Serno Symposia, "Recent Progress in Pediatric Endocrinology," Milan, September, 1976 (in press). Stalker HP, Holland NH, Kotchen JM, and Kotchen TA: Plasma renin activity in healthy children, J PEDIATR 89:256, 1976.

Reply To the Editor: We appreciate the letter of Dr. Giovannelli and his co-workers. They were able to obtain supine and upright levels of plasma renin activity (PRA) in children whose diets were controlled for quantities of.sodium and potassium, and in whom the state of sodium balance was known with certainty. Unfortunately, as they and we have noted, the variability of PRA with age still renders the interpretation of isolated renin values difficult. The availability of a nomogram such as they have constructed is most helpful for the comparison of paired values for PRA obtained while a child is ingesting diets of differing sodium content. Linda B. Hiner, M.D. Alan B. Gruskin, M.D. St. Christopher's Hospital for Children 2600 N. Lawrence St. Philadelphia, PA 19133

Letters to the Editor

849

reasons why hydrocortisone is the drug of choice over its synthetic analogues in the treatment of CVAH, among them being its more physiologic effects on growth and bone age. Laron and Pertzelan 3 and Stempfel and associates 4 both report growth retardation in children with CVAH treated with synthetic glucocorticoids in doses just high enough to suppress urinary 17ketosteroids to normal. More specifically, Van Metre and associates5 in their work with asthmatic patients, and, more recently, Bailey and Komrower ~ in their study of children with CVAH, have demonstrated that prednisone in doses lower than those used in the present study causes growth suppression in children. Because of these other reports as well as our own experience with children with CVAH, we feel that the use of prednisone for the control of CVAH in children who have not yet attained their ultimate height should not be recommended until convincing longitudinal data are presented which demonstrate that prednisone has no greater a detrimental effect on linear growth than hydrocortisone, the current drug of choice. James M. Horner, M.D. Arni V. Thorson, M.D. Raymond L. Hintz, M.D. Department of Pediatrics Division of Endocrinology Stanford University School of Medicine Stanford, CA 94305 REFERENCES

Prednisone in the therapy of congenital adrenal hyperplasia To the Editor: In their recent article in the April issue of THE JOURNAL Huseman and associates ~ concluded that adequate control of congenital virilizing adrenal hyperplasia (CVAH) could be attained with twice daily administration of prednisone. We agree that their data show adequate chemical control of CVAH as assessed by urinary 17-ketosteroid and pregnanetriol levels and serum 17-hydroxyprogesterone levels, but seriously question whether they have documented adequate clinical control of the disease. As stated in their introduction, the effectiveness of a therapy aimed at suppression of ACTH without excessive glucocorticoid side effects is best assessed by the combined evaluation of chemical measurements, linear growth, advancement of bone age, and clinical signs of virilizing. It does not appear to us as though the authors have obtained sufficient follow-up data on their subjects to conclude that prednisone has no deleterious effects, especially in regard to linear growth, bone age advancement, and ultimate heights. This is disturbing in light of numerous reports in the literature indicating that synthetic glucocorticoids, including prednisone, have deleterious effects on linear growth and skeletal maturation in CVAH. Lawson Wilkins, as echoed by Migeon, ~ gave several

1. Huseman CA, Varma MM, Blizzard RM, and Johanson A: Treatment of congenital viritizing adrenal hyperplasia patients with single and multiple daily doses of prednisone, J PEDIATR 90:538, 1977. 2. Migeon C J: Updating the treatment of congenital adrenal hyperplasia, J PEDIATR 73:805, 1968. 3. Laron Z, and Pertzelan A: The comparative effect of 6afluoroprednisolone, 6 a-methylprednisolone, and hydrocortisone on linear growth of children with congenital adrenal virilism and Addison's disease, J PEDIATR 73:774, 1968. 4. Stempfel RS, Sheikholislam BM, Lebovitz HE, Allen E, and Franks RC: Pituitary growth hormone suppression with low-dosage long-acting corticoid administration, J PEDIATR 73:767, 1968. 5. Van Metre TE Jr, Niermann WA, and Rosen LJ: A comparison of the growth suppressive effect of cortisone, prednisone, and other adrenal cortical hormones, J Allergy 31:531, 1960. 6. Bailey CC, and K0mrower GM: Growth and skeletal maturation in congenital adrenal hyperplasia, Arch Dis Child 49:4, 1974.

Reply To the Editor." We are not in disagreement with the comments of Drs. Horner, Thorsson, and Hintz. The basis for final judgment regarding

Plasma renin activity in normal children.

Volume 91 Number 5 serum globulin before one year of age; (4) those who received further attenuated measles-virus vaccine with ISG in a dose intended...
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