- Email: [email protected]
Elevation of TSH during the early neonatal period
1030
Editorial correspondence
(y = 2.01 + 1.41 x height in SD)]. In most children, the skeietal age, as determined by the Tanner-Whitehouse method,' was several years advanced. Height in SD was als0 significantly related to the advance in skeletal age (r = 0.58; P < 0.001). These data confirm the clinical impression that both advanced skeletal maturation and advanced height for age may be important diagnostic tools in the diagnosis of exogenous overalimentation obesity in childhood. J.-P. G. M. Van Biervliet, M.D. University Children's Hospital Het Wilhelmina Kinderziekenhuis Utrecht, Netherlands J. F. de Wijn, M.D. Central Institute of Nutrition and Food Research T.N.O. Zeist, Netherlands REFERENCES
1. Forbes GB: Nutrition and growth, J PEDIATR 91:40, 1977. 2. Van Biervliet J-P GM and de Wijn JF: Blood lipids in childhood obesity, Acta Paediatr Belg (in press). 3. van Wieringen JC: Lengte' en gewicht surveys 1964-1966 in Nederland in historisch perspectief, Thesis, Leiden, 1973. 4. Tanner JM, Whitehouse RH, Marshall WA, Healy MJR; and Goldstein H: Assessment of skeletal maturity and prediction of adult height, London, 1975, Academic Press. Inc.
Elevation of TSH during the early neonatal period To the Editor: In the August, 1977, issue of TrIE JOURNAL of Pediatrics, Dr. Mace I reported transient elevation of TSH in stressed premature infants. In our screening program for the detection of congenital hypothyroidism, using radioimmun0assay of thyroid-stimulating hormone (TSH) in capillary blood samples taken on the fifth day of life, in th e county of V/isterbotten 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/zU/ml). In 46 infants it was increased. Two of these were infants with congenital hypothyroidism, with TSH concentrations of 87 and 200 #U/ml, respectively at 5 days of age. In the remaining 4 infants the TSH elevation was transient. Twentyfour 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 TSH concentration (20 to 45/~U/ml) and four had over 45 /~U/ml. Subsequent follow-up of the 44 infants with a transient elevation of TSH showed that all were euthyroid. The cause of the transient elevation of the neonatal TSH level
The Journal ofPediatrics June 1978
in the infants delivered by cesarean section is unknown. It might 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 the neonatal thyroid function in such children, including pituitary trophic hormone levels. Staffan Engberg, M.D. Karl-Henrik Gustavson, M.D. Department o f Pediatrics Lennart Jacobsson, M.D. Ruzena SOderstrOm, M.D. Department o f Clinical Chemistry University Hospital, 90198 Umed, Sweden REFERENCE
1. Mace J: On the diagnosis of hypothyroidism in the early neonatal period, J PEDIATR 9!:347, 1977.
Reply To the Editor: I am pleased to see that Drs. Eugberg and Jacobsson have also seen elevation in TSH without subsequent documentation of hypothyroidism. Their letter further underscores the observation that while TSH may serve as a screening tool for healthy, term neonates, stressed premature neonates may well have elevated TSH levels and not be hypothyroid. Their observation underscores the need for further study as to the mechanisms of TSH elevation in stressed neonates either prior to delivery or immediately after. John Mace, M.D. Professor and Chairman Department of Pediatrics School o f Medicine Loma Linda University Loma Linda, CA 92350
Treatment of giant hemangioma To the Editor: I wish to comment on the article in the September, 1977, issue of THE JOURNAL, entitled "Giant hemangioma with consumption coagulopathy. Sustained response to heparin and radiotherapy." Several statements require rebut!al. Prednis0ne was started but it is not clear when the prednisone was stopped, although the Fig. 1 suggests that this was approximately 20 days; if so, the course of prednisone therapy was shorter than that usually recommended. The statement, [Radio]therapy was given over a period of 80 days. This resulted in normalization of the coagulation indices and disappearance of the hemangioma in four months" may be true, but spontaneous involution may have occurred. More
Editorial correspondence
(y = 2.01 + 1.41 x height in SD)]. In most children, the skeietal age, as determined by the Tanner-Whitehouse method,' was several years advanced. Height in SD was als0 significantly related to the advance in skeletal age (r = 0.58; P < 0.001). These data confirm the clinical impression that both advanced skeletal maturation and advanced height for age may be important diagnostic tools in the diagnosis of exogenous overalimentation obesity in childhood. J.-P. G. M. Van Biervliet, M.D. University Children's Hospital Het Wilhelmina Kinderziekenhuis Utrecht, Netherlands J. F. de Wijn, M.D. Central Institute of Nutrition and Food Research T.N.O. Zeist, Netherlands REFERENCES
1. Forbes GB: Nutrition and growth, J PEDIATR 91:40, 1977. 2. Van Biervliet J-P GM and de Wijn JF: Blood lipids in childhood obesity, Acta Paediatr Belg (in press). 3. van Wieringen JC: Lengte' en gewicht surveys 1964-1966 in Nederland in historisch perspectief, Thesis, Leiden, 1973. 4. Tanner JM, Whitehouse RH, Marshall WA, Healy MJR; and Goldstein H: Assessment of skeletal maturity and prediction of adult height, London, 1975, Academic Press. Inc.
Elevation of TSH during the early neonatal period To the Editor: In the August, 1977, issue of TrIE JOURNAL of Pediatrics, Dr. Mace I reported transient elevation of TSH in stressed premature infants. In our screening program for the detection of congenital hypothyroidism, using radioimmun0assay of thyroid-stimulating hormone (TSH) in capillary blood samples taken on the fifth day of life, in th e county of V/isterbotten 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/zU/ml). In 46 infants it was increased. Two of these were infants with congenital hypothyroidism, with TSH concentrations of 87 and 200 #U/ml, respectively at 5 days of age. In the remaining 4 infants the TSH elevation was transient. Twentyfour 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 TSH concentration (20 to 45/~U/ml) and four had over 45 /~U/ml. Subsequent follow-up of the 44 infants with a transient elevation of TSH showed that all were euthyroid. The cause of the transient elevation of the neonatal TSH level
The Journal ofPediatrics June 1978
in the infants delivered by cesarean section is unknown. It might 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 the neonatal thyroid function in such children, including pituitary trophic hormone levels. Staffan Engberg, M.D. Karl-Henrik Gustavson, M.D. Department o f Pediatrics Lennart Jacobsson, M.D. Ruzena SOderstrOm, M.D. Department o f Clinical Chemistry University Hospital, 90198 Umed, Sweden REFERENCE
1. Mace J: On the diagnosis of hypothyroidism in the early neonatal period, J PEDIATR 9!:347, 1977.
Reply To the Editor: I am pleased to see that Drs. Eugberg and Jacobsson have also seen elevation in TSH without subsequent documentation of hypothyroidism. Their letter further underscores the observation that while TSH may serve as a screening tool for healthy, term neonates, stressed premature neonates may well have elevated TSH levels and not be hypothyroid. Their observation underscores the need for further study as to the mechanisms of TSH elevation in stressed neonates either prior to delivery or immediately after. John Mace, M.D. Professor and Chairman Department of Pediatrics School o f Medicine Loma Linda University Loma Linda, CA 92350
Treatment of giant hemangioma To the Editor: I wish to comment on the article in the September, 1977, issue of THE JOURNAL, entitled "Giant hemangioma with consumption coagulopathy. Sustained response to heparin and radiotherapy." Several statements require rebut!al. Prednis0ne was started but it is not clear when the prednisone was stopped, although the Fig. 1 suggests that this was approximately 20 days; if so, the course of prednisone therapy was shorter than that usually recommended. The statement, [Radio]therapy was given over a period of 80 days. This resulted in normalization of the coagulation indices and disappearance of the hemangioma in four months" may be true, but spontaneous involution may have occurred. More