16 4
Letters to the Editor
The Journal of Pediatrics January 1977
Table I
Cone Hospital Births Meconium stained "Sick" "Sick" with pneumothorax Ventilatory assistance Deaths
2,268 148 (6.6%) 15 (9.9%) 0 1 0
Gregory and associates 1,000 88 (8.8%) 16 (18.2%) p-NS 2 p-NS 0 0
p-N S
had their airways cleared by DeLee traps or small suction catheters. The results compared to those of Gregory and associates are in Table I. At our hospital, all infants born meconium stained or with meconium-stained amniotic fluid are observed in a special care nursery for at least 24 hours. A house officer or pediatrician examines each child admitted to the nursery within one hour from birth. All patients were evaluated by me or another faculty member within 24 hours. "Sick" infants were those noted to have respiratory difficulty other than clinical hyaline membrane disease during the course of their hospital stay. The incidence of meconium staining is similar in the two groups. Without using endotracheal aspiration, the incidence of "sick" infants in our hospital is no different than that reported by Gregory and associates. The technique of tracheal suctioning used by Gregory and associates is an excellent one. What is unclear to me is which neonates need it.
Robert G. Dillard, M.D. Assistant Professor of Pediatrics UNC School of Medicine Neonatologist Moses H. Cone Memorial Hospital Greensboro, N.C. 27401
REFERENCE
1. Gregory GA, Gooding CA, Phibbs RH, and Tooley H: Meconium aspiration in infants-a prospective study, J PEDIATR 85:848, 1974.
What is good diabetic control?
that the metabolic state of the children would vary so much from day to day. This is especially true when the children are trying to emotionally adjust to a new situation. More important than the specifics of the paper, and also of Dr. Drash's editorial, is the message they convey. The prevailing attitude about diabetes has been that good control was unimportant, but more and more evidence to the contrary is accumulating. Simply reading through the abstracts o f the current American Diabetes Association meeting should be convincing. The current attitude is that since good control is so difficult to achieve, it should not be strived for. It is as if good control is "pie in the sky" and that no human effort can attain it. This is an unfortunate attitude because these children, however few, who might achieve good control, deserve the opportunity to do so; otherwise they are probably condemned to the complications of the disease. We do not hesitate to spend tens of thousands of dollars to save the life of one newborn infant. Yet many of us are unwilling to mobilize ourselves to provide the medical, psychologic, and social support our thousands of young diabetic patients need. Dr. Drash refers to the confusion in trying to sort out the effects of good control. The confusion arises from what one strives to achieve. If one believes, as does Dr. Drash, that good control consists of having urines that are always 1% (glucosuria), one probably will see no difference between controlled and noncontrolled diabetic children. A 1% glucosuria means having a blood sugar value of 200 mg/dl, and any value over 200 mg/dl cannot reflect a normal metabolic state. The psychologic effects of good control are cited by many. I believe that whatever psychologic harm is done results from being a diabetic and having a life-long illness. Even under the freest of regimens, the diabetic child is different from others. He takes shots, goes to the hospital at times, and must be careful about his activities. In a psychiatric study of our children here, those in the best control had a lower incidence of psychiatric disorders than even the control population, indicating that they were a well-adjusted group of children. Certainly, children with pre-existing psychologic weaknesses will have these worsened, but this will occur no matter how the illness is handled. We need a cure for diabetes, but one is not yet available. After working with our 200 diabetic children here for a year, after seeing children who maintain themselves in the best possible control, I cannot say that it is easy or even always possible to achieve good control. But it can be done. For the sake of these children who may be able to achieve good control, i hope more doctors will not adopt the attitude that, because it is difficult, it is not worth the effort.
Edward Holland, M.D. Fellow Pediatric Endocrinology Department of Child Health University of Missouri Columbia, MO 65201
To the Editor: Concerning the article by Malone and associates' about diabetic control: I seriously question the use of a summer camp with 220 children as a rigid, or even a stable, environment in which to study the problem. The authors do not make clear how much and what kind of insulin was given to the children or if any care was taken to control food intake and variations in exercise. Without controlling these variables, it would hardly be surprising
REFERENCE
1. Malone Jl, Hellrung JM, Malphus EW, Rosenbloom AL, Grgic A, and Weber FT: Good diabetic c o n t r o l - a study in mass delusion, J PEDIATR 88:943, 1976.
Letters to the Editor
The Journal of Pediatrics January 1977
Table I
Cone Hospital Births Meconium stained "Sick" "Sick" with pneumothorax Ventilatory assistance Deaths
2,268 148 (6.6%) 15 (9.9%) 0 1 0
Gregory and associates 1,000 88 (8.8%) 16 (18.2%) p-NS 2 p-NS 0 0
p-N S
had their airways cleared by DeLee traps or small suction catheters. The results compared to those of Gregory and associates are in Table I. At our hospital, all infants born meconium stained or with meconium-stained amniotic fluid are observed in a special care nursery for at least 24 hours. A house officer or pediatrician examines each child admitted to the nursery within one hour from birth. All patients were evaluated by me or another faculty member within 24 hours. "Sick" infants were those noted to have respiratory difficulty other than clinical hyaline membrane disease during the course of their hospital stay. The incidence of meconium staining is similar in the two groups. Without using endotracheal aspiration, the incidence of "sick" infants in our hospital is no different than that reported by Gregory and associates. The technique of tracheal suctioning used by Gregory and associates is an excellent one. What is unclear to me is which neonates need it.
Robert G. Dillard, M.D. Assistant Professor of Pediatrics UNC School of Medicine Neonatologist Moses H. Cone Memorial Hospital Greensboro, N.C. 27401
REFERENCE
1. Gregory GA, Gooding CA, Phibbs RH, and Tooley H: Meconium aspiration in infants-a prospective study, J PEDIATR 85:848, 1974.
What is good diabetic control?
that the metabolic state of the children would vary so much from day to day. This is especially true when the children are trying to emotionally adjust to a new situation. More important than the specifics of the paper, and also of Dr. Drash's editorial, is the message they convey. The prevailing attitude about diabetes has been that good control was unimportant, but more and more evidence to the contrary is accumulating. Simply reading through the abstracts o f the current American Diabetes Association meeting should be convincing. The current attitude is that since good control is so difficult to achieve, it should not be strived for. It is as if good control is "pie in the sky" and that no human effort can attain it. This is an unfortunate attitude because these children, however few, who might achieve good control, deserve the opportunity to do so; otherwise they are probably condemned to the complications of the disease. We do not hesitate to spend tens of thousands of dollars to save the life of one newborn infant. Yet many of us are unwilling to mobilize ourselves to provide the medical, psychologic, and social support our thousands of young diabetic patients need. Dr. Drash refers to the confusion in trying to sort out the effects of good control. The confusion arises from what one strives to achieve. If one believes, as does Dr. Drash, that good control consists of having urines that are always 1% (glucosuria), one probably will see no difference between controlled and noncontrolled diabetic children. A 1% glucosuria means having a blood sugar value of 200 mg/dl, and any value over 200 mg/dl cannot reflect a normal metabolic state. The psychologic effects of good control are cited by many. I believe that whatever psychologic harm is done results from being a diabetic and having a life-long illness. Even under the freest of regimens, the diabetic child is different from others. He takes shots, goes to the hospital at times, and must be careful about his activities. In a psychiatric study of our children here, those in the best control had a lower incidence of psychiatric disorders than even the control population, indicating that they were a well-adjusted group of children. Certainly, children with pre-existing psychologic weaknesses will have these worsened, but this will occur no matter how the illness is handled. We need a cure for diabetes, but one is not yet available. After working with our 200 diabetic children here for a year, after seeing children who maintain themselves in the best possible control, I cannot say that it is easy or even always possible to achieve good control. But it can be done. For the sake of these children who may be able to achieve good control, i hope more doctors will not adopt the attitude that, because it is difficult, it is not worth the effort.
Edward Holland, M.D. Fellow Pediatric Endocrinology Department of Child Health University of Missouri Columbia, MO 65201
To the Editor: Concerning the article by Malone and associates' about diabetic control: I seriously question the use of a summer camp with 220 children as a rigid, or even a stable, environment in which to study the problem. The authors do not make clear how much and what kind of insulin was given to the children or if any care was taken to control food intake and variations in exercise. Without controlling these variables, it would hardly be surprising
REFERENCE
1. Malone Jl, Hellrung JM, Malphus EW, Rosenbloom AL, Grgic A, and Weber FT: Good diabetic c o n t r o l - a study in mass delusion, J PEDIATR 88:943, 1976.
