688
Letters to the Editor
The Journa ! of Pediatrics October 1977
T a b l e I. D a t a o f five infants with H. influenzae buccal cellulitis
Isolation ] of H. influenzae
eB Patient No. ~
Cheek involved
Temt~erature Co~r
l
Throat and I nose 1
(R)
Therapy
1
6.5
F
Lefl
Violaceous
40.4~
19.7
73
Yes
No
Ampicillin
2
6.5
M
Right
Red
39.4~
19.9
57
Yes
No
Cephalosporin
3
2.0
M
Right
Violaceous
39.2~
12.8
68
Yes
No
Ampicillin
4
6.0
F
Left
Violaceous
40.2~
18.4
53
Yes
No
Ampicillin
5
7.0
F
Left
Red
39.9~
18.8
82
Yes
No
Ampicillin
Coupe Afebrile in hours Afebrile in hours Afebrile in hours Afebrile in hours Afebrile in hours
24 24 24 24 24
R = Rectal; WBC = white blood count; PMN = polym0rphonuclear leukocytes. speculate that a strain with propensity to cause buccai infection caused "a mini-epidemic" in our community. In that regard, a limited inquiry established that the patients had no contact with one another prior to hospitalization and that all five patients lived in different parts of the city.
Wajid H. Siddiqi, M.D. Thomas D. Reed, M.D. Children "s Medical Center 1735 Chapel St. Dayton, OH 45404 REFERENCES 1. Green M, and Fousek M: Hemophilus influenzae type B cellulitis, Pediatrics 19:80, 1957. 2. Feingold M, and Gellis S: Cellulitis due to Hemophilus influenzae type B, N Engl J Med 272:788, 1965. 3. Granoff DM, and Nankervis GA: Cellulitis due to Hemophilus influenzae type B, Am J Dis Child 130:1211, 1976. 4. Nelson JD, and Ginsburg CM: An hypothesis on the pathogenesis of H. influenzae buccal cellulitis, J PEDIATR 88:709, 1976.
Pulmonary sequelae in low-birthweight infants To the Editor: Recently, Coates and associates I did pulmonary function tests in a small group of children who had survived prematurity with and without respiratory distress syndrome (RDS). Standard spirometry and plethysmography demonstrated essentially normal lung function. Coates and associates did notice differences in flow rates measured from flow volume curves in the study patients compared to a group of control children. In evaluating the data, the patients with prematurity with and
without RDS had statistically significant lower mean total lung capacity per second (TLC/s) at 50 and 25% of the vital capacity (VC) compared to the controls. Also, the mean volume at point of identical flow (VisoV) was found elevated in the patients with RDS. There are a number of points that deserve mentioning. As noted, the values for TLC/s at 50% VC were higher in the controls compared to values reported by Zapletal and associates? At 25% VC, the TLC(s in the controls were similar to the data of Zapletal and associates. Not noted was that the TLC/s at 50% VC for the premature children with and without RDS were identical to those values reported by Zapletal and colleagues. Zapletal and associates argued that the TLC/s corrected flow rates making them independent of height. When we reviewed his data, only 11 subjects between 110 to 140 cm in height were studied. At different heights and under 40% of the total lung capacity (TLC), there was a wide variation in the TLC/s. The TLC/s might be a reliable measurement in detecting small airway abnormalities in adult patients, .but there is so little data in the young child that one should be careful in its interpretation. The heights of the children with RDS and prematurity (i29.1 ___4.8 cm) were significantly lower than those of the control group .(135.3 _+ 6.6) (t = 2.06, dF = 12, P < 0.05). The height of the children with just prematurity was also Significantly lower than that Of the control group, When comparing the ages of the members of the three groups, the mean age was also lower in the patients with RDS and prematurity and simple prematurity Compared to those of the control groups. These differences did not quite reach Statistical significance, they might account for the abnormalities seen in TLC/s at 25% VC. Finally, normal ranges for the volume at the point of identical flow (VisoV), a relatively new measurement , have not yet been developed for children 3.4 A higher mean VisoV in Seven children With RDS compared to seven controls does not necessarily mean that these are abnormalities in Small airway resistance in survivors of RDS. Two of the normal control children reported by Coates and colleagues had elevated VisoV similar to the patients with RDS. Normal standards for children with the Viso'r by
Volume 91 Number 4
necessity, should be determined before we interpret this measurement. Michael L. Loren, M.D. Lawrence S. Mihalas, M.D. National Asthma Center Division of Medicine 1999 Julian St. Denver, CO 80204
REFERENCES 1.
2.
3.
4.
Coates AL, Bergsteinsson H, D e s m o n d K, Outerbridge EW, and Beaudry PH: Long-term pulmonary sequelae of premature birth with and without idiopathic respiratory distress syndrome, J PEDIATRICS 90:611, 1977. Zapletal A, M o t o y a m a EK, Van de Woestijne K D , et al: M a x i m u m expiratory flow volume curves a n d airway conductance in children and adolescents, J Appl Physiol 26:308, 1969. Fox WM, Bureau MA, Taussig LM, et al: Helium flow volume curves in the detection of early small airway disease, Pediatrics 54:293, 1974. Zeck RT, Solliday NH, and Cugell DW: Variability of the volume of Isoflow (abstract), A m Rev Resp Dis 115:392, 1977.
Repty To the Editor: The first point raised by Drs. Loren and Mihalas concerns our values of flow rates in air and those of Zapletal and associates.' While developing our techniques, we noticed that supposedly normal children who had a "family history of asthma, hay fever, allergic rhinitis, or other allergy ''~ tended to have lower flow rates than other normal children without such a family history. As a result, any child with a positive family history in any of the three groups was excluded from the study. Zapletal and associates do not define their selection of "normal" children and we assume that children wi.th no symptoms or history of respiratory disease were considered normal regardless of family history. Hence, we are not surprised that our "normal" values in air tend to be slightly higher than those o f Zapletal and associates and our selection criteria should be taken into consideration by any one who considers our children as representative of a n o r m a l population. Our interpretation of flow rates in air at lung volumes below 40% of TLC was that "the lower flow rates in air in each group of premature children suggest that they have either an increase in total airway resistance, most of which is made up by the large
Letters to the Editor
689
airways, or a decrease in elastic recoil." We did not suggest that these data represented abnormalities in small airways, and, with Loren and Mihalas, we would be very cautious in giving such an interpretation to these findings in y o u n g children. If the slight differences in the heights and ages of both groups of prematurely born children and n o r m a l children were a reason for the differences in flow rates in air which have been normalized for the size of each child's lung and hence expressed in total lung capacities per second (TLC/s), one would expect that there would be a trend to higher flow rates with increasing height or age. A plot of all the data from all the children of flow rates in T L C / s versus either height or age shows that this is clearly not the case. Hence we conclude that such differences a m o n g the three groups are not related to height or age. As to the variability of the volume of isoflow (Viso'~), our experience has shown that m u c h of the variability is due to the influence of small differences in vital capacity (VC) of the curves compared. To minimize these, as we have stated in the paper, we converted all data to flows in T L C / s at a percent of VC a n d replotted this normalized data from both the air and HeO~ curves in order to determine the Viso'~. This method yields a m e a n variation of less than 5% in three of the children of the study whom we studied more than once. This normalization of volume was not done by Zeck and associates, ~ the reference cited as to the variation of the Visor In conclusion, while we do not feel that there is e n o u g h information to give a firm definition of normal values of VisoV in all age ranges, we do feel that the differences we noted a m o n g the three groups are not due to differences in heights or ages nor are they due to differences in experimental technique. Allan L. Coates H. Bergsteinsson K. Desmond E. W. Outerbridge P. H. Beaudry Montreal Children's Hospital 2300 Tupper St. Montreal H3H 1P3, Canada, P.Q.
REFERENCES 1.
2.
3.
Zapletal A, M o t o y a m a EK, Van De Woestijne K D , et al: M a x i m u m expiratory flow volume curves and airway conductance in children and adolescents, J Appl Physiol 26:308, 1969. Coates AL, Bergsteinsson H, D e s m o n d K, Outerbridge EW, and Beaudry PH: Long-term p u l m o n a r y sequelae of premature birth with and without idiopathic respiratory distress syndrome, J PEDIATR 90:611, 1977. Zeck RT, Solliday NH, and Cugell DW: Variability of the volume of Isoflow (abstract), A m Rev Resp Dis 115:392, 1977.
Letters to the Editor
The Journa ! of Pediatrics October 1977
T a b l e I. D a t a o f five infants with H. influenzae buccal cellulitis
Isolation ] of H. influenzae
eB Patient No. ~
Cheek involved
Temt~erature Co~r
l
Throat and I nose 1
(R)
Therapy
1
6.5
F
Lefl
Violaceous
40.4~
19.7
73
Yes
No
Ampicillin
2
6.5
M
Right
Red
39.4~
19.9
57
Yes
No
Cephalosporin
3
2.0
M
Right
Violaceous
39.2~
12.8
68
Yes
No
Ampicillin
4
6.0
F
Left
Violaceous
40.2~
18.4
53
Yes
No
Ampicillin
5
7.0
F
Left
Red
39.9~
18.8
82
Yes
No
Ampicillin
Coupe Afebrile in hours Afebrile in hours Afebrile in hours Afebrile in hours Afebrile in hours
24 24 24 24 24
R = Rectal; WBC = white blood count; PMN = polym0rphonuclear leukocytes. speculate that a strain with propensity to cause buccai infection caused "a mini-epidemic" in our community. In that regard, a limited inquiry established that the patients had no contact with one another prior to hospitalization and that all five patients lived in different parts of the city.
Wajid H. Siddiqi, M.D. Thomas D. Reed, M.D. Children "s Medical Center 1735 Chapel St. Dayton, OH 45404 REFERENCES 1. Green M, and Fousek M: Hemophilus influenzae type B cellulitis, Pediatrics 19:80, 1957. 2. Feingold M, and Gellis S: Cellulitis due to Hemophilus influenzae type B, N Engl J Med 272:788, 1965. 3. Granoff DM, and Nankervis GA: Cellulitis due to Hemophilus influenzae type B, Am J Dis Child 130:1211, 1976. 4. Nelson JD, and Ginsburg CM: An hypothesis on the pathogenesis of H. influenzae buccal cellulitis, J PEDIATR 88:709, 1976.
Pulmonary sequelae in low-birthweight infants To the Editor: Recently, Coates and associates I did pulmonary function tests in a small group of children who had survived prematurity with and without respiratory distress syndrome (RDS). Standard spirometry and plethysmography demonstrated essentially normal lung function. Coates and associates did notice differences in flow rates measured from flow volume curves in the study patients compared to a group of control children. In evaluating the data, the patients with prematurity with and
without RDS had statistically significant lower mean total lung capacity per second (TLC/s) at 50 and 25% of the vital capacity (VC) compared to the controls. Also, the mean volume at point of identical flow (VisoV) was found elevated in the patients with RDS. There are a number of points that deserve mentioning. As noted, the values for TLC/s at 50% VC were higher in the controls compared to values reported by Zapletal and associates? At 25% VC, the TLC(s in the controls were similar to the data of Zapletal and associates. Not noted was that the TLC/s at 50% VC for the premature children with and without RDS were identical to those values reported by Zapletal and colleagues. Zapletal and associates argued that the TLC/s corrected flow rates making them independent of height. When we reviewed his data, only 11 subjects between 110 to 140 cm in height were studied. At different heights and under 40% of the total lung capacity (TLC), there was a wide variation in the TLC/s. The TLC/s might be a reliable measurement in detecting small airway abnormalities in adult patients, .but there is so little data in the young child that one should be careful in its interpretation. The heights of the children with RDS and prematurity (i29.1 ___4.8 cm) were significantly lower than those of the control group .(135.3 _+ 6.6) (t = 2.06, dF = 12, P < 0.05). The height of the children with just prematurity was also Significantly lower than that Of the control group, When comparing the ages of the members of the three groups, the mean age was also lower in the patients with RDS and prematurity and simple prematurity Compared to those of the control groups. These differences did not quite reach Statistical significance, they might account for the abnormalities seen in TLC/s at 25% VC. Finally, normal ranges for the volume at the point of identical flow (VisoV), a relatively new measurement , have not yet been developed for children 3.4 A higher mean VisoV in Seven children With RDS compared to seven controls does not necessarily mean that these are abnormalities in Small airway resistance in survivors of RDS. Two of the normal control children reported by Coates and colleagues had elevated VisoV similar to the patients with RDS. Normal standards for children with the Viso'r by
Volume 91 Number 4
necessity, should be determined before we interpret this measurement. Michael L. Loren, M.D. Lawrence S. Mihalas, M.D. National Asthma Center Division of Medicine 1999 Julian St. Denver, CO 80204
REFERENCES 1.
2.
3.
4.
Coates AL, Bergsteinsson H, D e s m o n d K, Outerbridge EW, and Beaudry PH: Long-term pulmonary sequelae of premature birth with and without idiopathic respiratory distress syndrome, J PEDIATRICS 90:611, 1977. Zapletal A, M o t o y a m a EK, Van de Woestijne K D , et al: M a x i m u m expiratory flow volume curves a n d airway conductance in children and adolescents, J Appl Physiol 26:308, 1969. Fox WM, Bureau MA, Taussig LM, et al: Helium flow volume curves in the detection of early small airway disease, Pediatrics 54:293, 1974. Zeck RT, Solliday NH, and Cugell DW: Variability of the volume of Isoflow (abstract), A m Rev Resp Dis 115:392, 1977.
Repty To the Editor: The first point raised by Drs. Loren and Mihalas concerns our values of flow rates in air and those of Zapletal and associates.' While developing our techniques, we noticed that supposedly normal children who had a "family history of asthma, hay fever, allergic rhinitis, or other allergy ''~ tended to have lower flow rates than other normal children without such a family history. As a result, any child with a positive family history in any of the three groups was excluded from the study. Zapletal and associates do not define their selection of "normal" children and we assume that children wi.th no symptoms or history of respiratory disease were considered normal regardless of family history. Hence, we are not surprised that our "normal" values in air tend to be slightly higher than those o f Zapletal and associates and our selection criteria should be taken into consideration by any one who considers our children as representative of a n o r m a l population. Our interpretation of flow rates in air at lung volumes below 40% of TLC was that "the lower flow rates in air in each group of premature children suggest that they have either an increase in total airway resistance, most of which is made up by the large
Letters to the Editor
689
airways, or a decrease in elastic recoil." We did not suggest that these data represented abnormalities in small airways, and, with Loren and Mihalas, we would be very cautious in giving such an interpretation to these findings in y o u n g children. If the slight differences in the heights and ages of both groups of prematurely born children and n o r m a l children were a reason for the differences in flow rates in air which have been normalized for the size of each child's lung and hence expressed in total lung capacities per second (TLC/s), one would expect that there would be a trend to higher flow rates with increasing height or age. A plot of all the data from all the children of flow rates in T L C / s versus either height or age shows that this is clearly not the case. Hence we conclude that such differences a m o n g the three groups are not related to height or age. As to the variability of the volume of isoflow (Viso'~), our experience has shown that m u c h of the variability is due to the influence of small differences in vital capacity (VC) of the curves compared. To minimize these, as we have stated in the paper, we converted all data to flows in T L C / s at a percent of VC a n d replotted this normalized data from both the air and HeO~ curves in order to determine the Viso'~. This method yields a m e a n variation of less than 5% in three of the children of the study whom we studied more than once. This normalization of volume was not done by Zeck and associates, ~ the reference cited as to the variation of the Visor In conclusion, while we do not feel that there is e n o u g h information to give a firm definition of normal values of VisoV in all age ranges, we do feel that the differences we noted a m o n g the three groups are not due to differences in heights or ages nor are they due to differences in experimental technique. Allan L. Coates H. Bergsteinsson K. Desmond E. W. Outerbridge P. H. Beaudry Montreal Children's Hospital 2300 Tupper St. Montreal H3H 1P3, Canada, P.Q.
REFERENCES 1.
2.
3.
Zapletal A, M o t o y a m a EK, Van De Woestijne K D , et al: M a x i m u m expiratory flow volume curves and airway conductance in children and adolescents, J Appl Physiol 26:308, 1969. Coates AL, Bergsteinsson H, D e s m o n d K, Outerbridge EW, and Beaudry PH: Long-term p u l m o n a r y sequelae of premature birth with and without idiopathic respiratory distress syndrome, J PEDIATR 90:611, 1977. Zeck RT, Solliday NH, and Cugell DW: Variability of the volume of Isoflow (abstract), A m Rev Resp Dis 115:392, 1977.
