498
Editorial correspondence
be important when outcomes utilizing these experimental therapies are compared.
Mitchell S. Cairo, MD Director, Hematology/Oncology Research and Bone Marrow Transplantation Children's Hospital of Orange County Orange, CA 92668 REFERENCES
1. Cairo MS, Rucker R, Bennetts GA, et al. Improved survival of newborns receiving leukocyte transfusion for sepsis. Pediatrics 1984;74:887. 2. Cairo MS, Worcester C, Rucker RW, et al. Role of circulating complement and polymorphonuclear leukocyte transfusion in treatment and outcome in critically ill neonates with sepsis. J PED~ATR 1987;110:935-41.
"Parental nose blowing": Another oropharyngeal custom To the Editor: Steinkuller et al. (J PEDIATR1992; 120:563-4) rightly pointed out the infectious hazards of parental prechewing of food. We report another oropharyngeal custom also fraught with potential problems: that of "parental nose blowing." Having witnessed in our urban clinic setting a mother forcefully blowing a breath into her infant's mouth to clear the child's nose of mucus, we conducted a small survey to get a sense of the frequency of this previously unreported practice. A series of 39 consecutive parents bringing infants less than 1 year of age to the clinic were asked whether they had ever used the method described above to clear their child's nose; 16 (41%) answered affirmatively. Although all but one of those using the method believed the method effective, 37% of these parents reported that afterward the child had vomited, seemed more irritable, or had tachypnea. Practitioners of parental nose blowing most often cited parents or friends as their examples. Surprisingly, one reported that a "delivery room nurse" had suggested the technique at a prenatal visit. Some parents voluntarily reported "sucking" the child's nose as an additional technique. Beside the potential for the spread of infection inherent in both methods, the forceful insufflation of parental nose blowing could precipitate:otitis media (through the introduction of organisms via positive eustachian tube pressure), lower respiratory tract infections, or barotrauma. Future studies of otitis media may wish to inquire about this apparently common practice. Pending more definitive studies, prudence dictates that parents be explicitly questioned about, and advised against, using this technique for clearing mucus from a child's nose.
~ Neil Izenberg, MD Department of Pediatrics Albert Einstein Medical Center Philadelphia, PA 19141
The Journal of Pediatrics September 1992
Screening for high serum cholesterol concentrations in children To the Editor: Stuhldreher et al. I recently reported on tracking of serum cholesterol measurements in the Beaver County Lipid Study. They found correlations of 0.51 in women and 0.38 in men between total cholesterol measurements that had been made at ages 11 to 14 and additional measurements made 16 years later--similar to those reported in other studies. 2, 3 The authors stated that "although some subjects were misclassifted as a result of childhood screening, some of this misclassification was associated with adopting changes that a screening and intervention program would be designed to promote." However, the comparisons that they reported do not allow them to assess whether any such association was present. To show that misclassification was associated with life-style changes, the authors would have had to compare life-style changes in those who were misclassified with life-style changes in those who were correctly classified. This analysis was not reported. The authors concluded that the results "support the value of screening for hypercholesterolemia in childhood on a population basis." Because there was no control group (children who were not screened), the study does not provide evidence that any changes in life-style that did occur could be attributed to the screening. In fact, because only 7% of the children with high cholesterol levels recalled having been told to change their diet, and only 2.5% reported having done so, the study results suggest that any observed dietary changes may have occurred without screening. Finally, even if screening leads to "beneficial" changes in diet, this would not be sufficient to justify a childhood screening program. Such a decision must be based on a careful consideration of the costs, risks, and benefits. 4 The many unanswered questions about possible adverse effects of efforts to lower cholesterol levels in adults should make us reluctant to embark on a population-wide screening program in children.5
Thomas B. Newman, MD, M P H Warren S. Browner, MD, M P H Stephen B. Hulley, MD, M P H Departments of J~aboratory Medicine, Pediatrics, Medicine, and Epidemiology and Biostatistics University of California San Francisco School of Medicine San Francisco, CA 94143 REFERENCES
1. Stuhldreher WL, Orchard T J, Donahue RP, et al. Cholesterol screening in childhood: sixteen-year Beaver County Lipid Study experience. J PEDIATR 1991;119:551-6. 2. Lauer RM, Clarke WR. Use of cholesterol measurements in childhood for the prediction of adult hypercholesterolemia:the Muscatine Study. JAMA 1990;264:3034-8. 3. Wynder EL, Berenson GS, Strong WB, Williams C, eds. Coronary artery disease prevention: cholesterol, a pediatric perspective. Prey Med 1989;18:323-409.
Volume 121 Number 3
E d i t o r i a l correspondence
4. N e w m a n TB, Browner WS, Hulley SB. The case against childhood cholesterol screening. J A M A 1990;264:3039-43. 5. N e w m a n TB, Browner WS, Hulley SB. Childhood cholesterol screening: contraindicated. J A M A 1992;267:100-1.
Reply To the Editor." W e urge Drs. Newman, Browner, and Hulley to review our article again to clarify misinterpretation of the data presented. In response to their claim that life-style changes should be compared between those correctly classified and those misclassified to show that misclassification was associated with life-style change, we refer them to the data in Tables IV and V, which show life-style factors by classification status. When the data are taken as a whole, no differences were seen between those correctly and those incorrectly classified, but this is a meaningless conclusion because misclassification is bidirectional. Life-style factors of patients misclassifted because of false-positive results would be expected to differ (and indeed did differ) from life-style factors of those misclassified because of false-negative results. W e agree that the change in lifestyle that we report cannot be attributed to the screening. However, the important point to be made is the powerful effect of dietary and other hygienic changes observed without planned intervention. Just think how much greater the effects might be if intervention were planned and promoted! Finally, we agree there are concerns about cost and safety of childhood intervention to lower serum cholesterol values. For this reason, we believe that it important to screen patients as part of routine pediatric care and focus intervention on those at greatest risk (e.g., familial hypercholesterolemia). 1
Wendy L. Stuhldreher, PhD Trevor J. Orchard, MBBCh, MMedSci Allan L. Drash, MD Lewis H. Kuller, MD, DrPH Richard P. Donahue, PhD Department o f Epidemiology University o f Pittsburgh Graduate School of Public Health Pittsburgh, PA 15261 REFERENCE
1. Stuhldreher WL, Orchard TJ. Use of routine cholesterol testing in childhood to classify risk status. Curr Opin Pediatr 1991;3:681-7.
Multiple-lumen umbilical venous catheters To the Editor: W e read with interest the article by Pinheiro and Fisher (J PEO~ATR 1992;120:624-6). We wish to share our experience with
499
double-lumen catheters, first presented at the Western Conference on Perinatal Research, Palm Springs, Calif., in January 1991. Between January 1989 and December 1990, Becton Dickinson Careflow double-lumen or Gesco Umbilical Cath II single-lumen catheters (Becton Dickinson Critical Care Monitoring, Sandy, Utah; Gesco International, Inc., San Antonio, Tex.) were inserted in critically ill infants as clinically indicated. The type of catheter was determined by the attending physician on the basis of severity of illness. Catheters (41 double, 132 single) were placed in 173 neonates with birth weights ranging from 470 to 4725 gm and gestational ages ranging from 22 to 40 weeks, The double-lumen group was significantly smaller and more premature. There was no difference between the groups in mean number of days with a catheter in place. The incidence of catheter-related sepsis did not differ significantly (two per group), and sepsis occurred only in infants with catheters in place more than 10 days. Two babies had mechanical complications (pericardial effusions); both had singlelumen catheters. A few triple-lumen catheters were inserted, but their use was discontinued because the third lumen, 2 cm proximal to the tip, was intrahepatic, and two lumina were found to be adequate. Reliable and painless angioaccess can be critical to the overall care and outcome of sick neonates. Multilumen catheters are an attractive option. Review of our 2-year experience showed that both single- and double-lumen umbilical venous catheters entail similar low risks. We continue to monitor the use of both catheters in our neonatal intensive care unit.
Pramela Ramachandran, MD Ronald S. Cohen, MD Eun H. Kim, MD Division o f Neonatology Department o f Pediatrics Santa Clara Valley Medical Center San Jose, CA 95128 To the Editor." Pinheiero and Fisher t recently reported their experience with the use of a triple-lumen catheter for umbilical venous access in neonates. They stated that a literature search using M E D L I N E revealed no reported use of multiple-lumen catheters in conjunction with the umbilical venous route. Because their report Was accepted for publication in November 1991, they may have missed our report of the use of double-lumen umbilical catheters in critically ill neonates. 2 W e reported the relative efficacy and complications associated with the use of double- versus single-lumen umbilical venous catheters in critically ill neonates in a prospective, randomized trial. W e found that double-lumen umbilical venous catheters were well tolerated for short-term use, decreased the need for additional venous catheters in critically ill neonates, and did not significantly increase the risk of mechanical complications when compared with single-lumen umbilical venous catheters. I designed both the double-lumen umbilical venous catheter used in this study and also a triple-lumen umbilical venous catheter ( C - D U C O , C - T U C O 5.0-30, Cook Criticai Care, Bloomington, Ind.) specifically for umbilical venous use. Both lumina have distal openings at
Editorial correspondence
be important when outcomes utilizing these experimental therapies are compared.
Mitchell S. Cairo, MD Director, Hematology/Oncology Research and Bone Marrow Transplantation Children's Hospital of Orange County Orange, CA 92668 REFERENCES
1. Cairo MS, Rucker R, Bennetts GA, et al. Improved survival of newborns receiving leukocyte transfusion for sepsis. Pediatrics 1984;74:887. 2. Cairo MS, Worcester C, Rucker RW, et al. Role of circulating complement and polymorphonuclear leukocyte transfusion in treatment and outcome in critically ill neonates with sepsis. J PED~ATR 1987;110:935-41.
"Parental nose blowing": Another oropharyngeal custom To the Editor: Steinkuller et al. (J PEDIATR1992; 120:563-4) rightly pointed out the infectious hazards of parental prechewing of food. We report another oropharyngeal custom also fraught with potential problems: that of "parental nose blowing." Having witnessed in our urban clinic setting a mother forcefully blowing a breath into her infant's mouth to clear the child's nose of mucus, we conducted a small survey to get a sense of the frequency of this previously unreported practice. A series of 39 consecutive parents bringing infants less than 1 year of age to the clinic were asked whether they had ever used the method described above to clear their child's nose; 16 (41%) answered affirmatively. Although all but one of those using the method believed the method effective, 37% of these parents reported that afterward the child had vomited, seemed more irritable, or had tachypnea. Practitioners of parental nose blowing most often cited parents or friends as their examples. Surprisingly, one reported that a "delivery room nurse" had suggested the technique at a prenatal visit. Some parents voluntarily reported "sucking" the child's nose as an additional technique. Beside the potential for the spread of infection inherent in both methods, the forceful insufflation of parental nose blowing could precipitate:otitis media (through the introduction of organisms via positive eustachian tube pressure), lower respiratory tract infections, or barotrauma. Future studies of otitis media may wish to inquire about this apparently common practice. Pending more definitive studies, prudence dictates that parents be explicitly questioned about, and advised against, using this technique for clearing mucus from a child's nose.
~ Neil Izenberg, MD Department of Pediatrics Albert Einstein Medical Center Philadelphia, PA 19141
The Journal of Pediatrics September 1992
Screening for high serum cholesterol concentrations in children To the Editor: Stuhldreher et al. I recently reported on tracking of serum cholesterol measurements in the Beaver County Lipid Study. They found correlations of 0.51 in women and 0.38 in men between total cholesterol measurements that had been made at ages 11 to 14 and additional measurements made 16 years later--similar to those reported in other studies. 2, 3 The authors stated that "although some subjects were misclassifted as a result of childhood screening, some of this misclassification was associated with adopting changes that a screening and intervention program would be designed to promote." However, the comparisons that they reported do not allow them to assess whether any such association was present. To show that misclassification was associated with life-style changes, the authors would have had to compare life-style changes in those who were misclassified with life-style changes in those who were correctly classified. This analysis was not reported. The authors concluded that the results "support the value of screening for hypercholesterolemia in childhood on a population basis." Because there was no control group (children who were not screened), the study does not provide evidence that any changes in life-style that did occur could be attributed to the screening. In fact, because only 7% of the children with high cholesterol levels recalled having been told to change their diet, and only 2.5% reported having done so, the study results suggest that any observed dietary changes may have occurred without screening. Finally, even if screening leads to "beneficial" changes in diet, this would not be sufficient to justify a childhood screening program. Such a decision must be based on a careful consideration of the costs, risks, and benefits. 4 The many unanswered questions about possible adverse effects of efforts to lower cholesterol levels in adults should make us reluctant to embark on a population-wide screening program in children.5
Thomas B. Newman, MD, M P H Warren S. Browner, MD, M P H Stephen B. Hulley, MD, M P H Departments of J~aboratory Medicine, Pediatrics, Medicine, and Epidemiology and Biostatistics University of California San Francisco School of Medicine San Francisco, CA 94143 REFERENCES
1. Stuhldreher WL, Orchard T J, Donahue RP, et al. Cholesterol screening in childhood: sixteen-year Beaver County Lipid Study experience. J PEDIATR 1991;119:551-6. 2. Lauer RM, Clarke WR. Use of cholesterol measurements in childhood for the prediction of adult hypercholesterolemia:the Muscatine Study. JAMA 1990;264:3034-8. 3. Wynder EL, Berenson GS, Strong WB, Williams C, eds. Coronary artery disease prevention: cholesterol, a pediatric perspective. Prey Med 1989;18:323-409.
Volume 121 Number 3
E d i t o r i a l correspondence
4. N e w m a n TB, Browner WS, Hulley SB. The case against childhood cholesterol screening. J A M A 1990;264:3039-43. 5. N e w m a n TB, Browner WS, Hulley SB. Childhood cholesterol screening: contraindicated. J A M A 1992;267:100-1.
Reply To the Editor." W e urge Drs. Newman, Browner, and Hulley to review our article again to clarify misinterpretation of the data presented. In response to their claim that life-style changes should be compared between those correctly classified and those misclassified to show that misclassification was associated with life-style change, we refer them to the data in Tables IV and V, which show life-style factors by classification status. When the data are taken as a whole, no differences were seen between those correctly and those incorrectly classified, but this is a meaningless conclusion because misclassification is bidirectional. Life-style factors of patients misclassifted because of false-positive results would be expected to differ (and indeed did differ) from life-style factors of those misclassified because of false-negative results. W e agree that the change in lifestyle that we report cannot be attributed to the screening. However, the important point to be made is the powerful effect of dietary and other hygienic changes observed without planned intervention. Just think how much greater the effects might be if intervention were planned and promoted! Finally, we agree there are concerns about cost and safety of childhood intervention to lower serum cholesterol values. For this reason, we believe that it important to screen patients as part of routine pediatric care and focus intervention on those at greatest risk (e.g., familial hypercholesterolemia). 1
Wendy L. Stuhldreher, PhD Trevor J. Orchard, MBBCh, MMedSci Allan L. Drash, MD Lewis H. Kuller, MD, DrPH Richard P. Donahue, PhD Department o f Epidemiology University o f Pittsburgh Graduate School of Public Health Pittsburgh, PA 15261 REFERENCE
1. Stuhldreher WL, Orchard TJ. Use of routine cholesterol testing in childhood to classify risk status. Curr Opin Pediatr 1991;3:681-7.
Multiple-lumen umbilical venous catheters To the Editor: W e read with interest the article by Pinheiro and Fisher (J PEO~ATR 1992;120:624-6). We wish to share our experience with
499
double-lumen catheters, first presented at the Western Conference on Perinatal Research, Palm Springs, Calif., in January 1991. Between January 1989 and December 1990, Becton Dickinson Careflow double-lumen or Gesco Umbilical Cath II single-lumen catheters (Becton Dickinson Critical Care Monitoring, Sandy, Utah; Gesco International, Inc., San Antonio, Tex.) were inserted in critically ill infants as clinically indicated. The type of catheter was determined by the attending physician on the basis of severity of illness. Catheters (41 double, 132 single) were placed in 173 neonates with birth weights ranging from 470 to 4725 gm and gestational ages ranging from 22 to 40 weeks, The double-lumen group was significantly smaller and more premature. There was no difference between the groups in mean number of days with a catheter in place. The incidence of catheter-related sepsis did not differ significantly (two per group), and sepsis occurred only in infants with catheters in place more than 10 days. Two babies had mechanical complications (pericardial effusions); both had singlelumen catheters. A few triple-lumen catheters were inserted, but their use was discontinued because the third lumen, 2 cm proximal to the tip, was intrahepatic, and two lumina were found to be adequate. Reliable and painless angioaccess can be critical to the overall care and outcome of sick neonates. Multilumen catheters are an attractive option. Review of our 2-year experience showed that both single- and double-lumen umbilical venous catheters entail similar low risks. We continue to monitor the use of both catheters in our neonatal intensive care unit.
Pramela Ramachandran, MD Ronald S. Cohen, MD Eun H. Kim, MD Division o f Neonatology Department o f Pediatrics Santa Clara Valley Medical Center San Jose, CA 95128 To the Editor." Pinheiero and Fisher t recently reported their experience with the use of a triple-lumen catheter for umbilical venous access in neonates. They stated that a literature search using M E D L I N E revealed no reported use of multiple-lumen catheters in conjunction with the umbilical venous route. Because their report Was accepted for publication in November 1991, they may have missed our report of the use of double-lumen umbilical catheters in critically ill neonates. 2 W e reported the relative efficacy and complications associated with the use of double- versus single-lumen umbilical venous catheters in critically ill neonates in a prospective, randomized trial. W e found that double-lumen umbilical venous catheters were well tolerated for short-term use, decreased the need for additional venous catheters in critically ill neonates, and did not significantly increase the risk of mechanical complications when compared with single-lumen umbilical venous catheters. I designed both the double-lumen umbilical venous catheter used in this study and also a triple-lumen umbilical venous catheter ( C - D U C O , C - T U C O 5.0-30, Cook Criticai Care, Bloomington, Ind.) specifically for umbilical venous use. Both lumina have distal openings at
