- Email: [email protected]
CORTICOSTEROIDS, CORTICOTROPHIN, AND CHILDREN'S GROWTH
907
irreversible. It is fair to add, however, that re-anastomosis is being achieved with an increasing measure of success by an
regimens have been rather different. In the light of experience we should like to make the following points:
increasing number of surgeons. The Trust is carrying out a follow-up inquiry on men who have been sterilised. It is hoped that the inquiry on the first hundred cases will be complete early next year. Simon Population Trust, 64 Sloane Street, London S.W.1.
L. N.
1. Certain children with severe asthma have stunted growth before steroids are given. 2. Some children grow normally on corticosteroids and others do not, but also some children show " stunting " on corticotrophin. 3. We agree that often growth accelerates when steroids are decreased or stopped, but this may occur whether or not corticotrophin treatment replaces corticosteroids. 4. Growth suppression usually depends on the dose of corticosteroid given-large doses often suppress growth, whereas small doses such as 5 mg. or 7-5 mg. prednisolone daily usually do not, even though doses of this order are reputed to cause adrenal suppression and may be ineffective in controlling the asthma.12 5. That growth velocity does not depend on the intact adrenal gland can be shown by the following case: 3 A boy with Cushing’s disease due to adrenal hyperplasia completely stopped growing for 2 years (from 9 to 11) on account of the disease, which causes an overproduction of corticosteroids. After total adrenalectomy, he grew 20 cm. (8 in. in a year), during which time he was on maintenance cortisone therapy (10-15 mg.
JACKSON
Hon. Director.
FAMILY-PLANNING ADVICE SIR,—Iwas interested to read Mr. Steele’s article (Oct. 1, p. 742) and Dr. Pasmore’s letter last week (p. 860). For just over a year I have been running an intrauterine-device (I.U.D.) clinic in a large maternity department in hospital, and although this does not fully cover the recommendations of Mr. Steele I feel that it is doing very useful work. Since this clinic is under the N.H.S. only those patients for whom a further pregnancy would be detrimental to health can be seen, but this ruling can be interpreted in its widest sense. Patients coming to see me fall roughly into two groups. The first group consists of women, often of low intelligence and poor socioeconomic background, who have had too many or too frequent pregnancies and for whom any other method of contraception is impossible, because of poor motivationfor them the l.u.D. is the only possible method, and most accept it very well. It seems that these women are the most likely to become pregnant with the device in situ, but even so it reduces their fertility to a very significant extent. The second group are those who have some disease which would make a further pregnancy dangerous, and in view of the failure-rate (about 25 per 100 woman-years of use) it seems at first sight doubtful whether this is a safe enough method to recommend. Sometimes these patients will not consent to sterilisation, however, and the more efficient oral contraceptives may be contraindicated for medical reasons in many cases. In hospital practice many of these patients could not be relied upon to use conventional methods of birth control effectively, and the l.u.D., despite its failure-rate, may still be the method of choice. Although I do not see patients in the wards, the medical and nursing staff discuss contraception with them before they leave hospital and give them an appointment to see me. Unfortunately those in the greatest need of advice do not always attend, but it is my impression, after working for many years in Family Planning Association clinics, that far more of them will come back to the hospital that they already know than go to an F.P.A. clinic which is strange to them. Another advantage of a clinic in hospital is that, much more than in the past when these patients had to be referred elsewhere, it gives medical students and student nurses the impression that the giving of contraceptive advice is a normal part of the care of women who have recently had a baby or miscarriage. The last patient whom I fitted with an l.u.D. was a married woman with a grown-up family who was referred after treatment in hospital for the fifth miscarriage which she had herself induced after failure of more conventional contraceptive methods. London W.1. MARY POLLOCK
CORTICOSTEROIDS, CORTICOTROPHIN, AND CHILDREN’S GROWTH SIR Over the past 10 years we have been investigating in detail the natural history of children with asthma. In the treatment of severe intractable cases we have had to resort occasionally to the use of corticosteroids or corticotrophin for long periods. Thus we were interested in the article by Dr. Friedman and Dr. Strang (Sept. 10, p. 568). Our observations on the growth of such children are slightly different from theirs, probably because our steroid and corticotrophin
our
cortisone daily). 6. When we consider prolonged corticosteroids to be indicated, it has been our practice to give corticotrophin initially, and at the same time to assess the adrenal function by the assay of urinary 17-hydroxycorticosteroids. Later, oral corticosteroids are given if daily corticotrophin injections become impracticable, but corticosteroids are seldom given for more than 6 months, after which the child is usually switched back to corticotrophin, when the adrenal function can be reassessed. We agree that if prolonged treatment is necessary corticotrophin is preferable to corti-
costeroids. we should like to emphasise that continuous longsteroid or corticotrophin therapy is only rarely necessary in childhood asthma. Many cases of severe asthma show a seasonal pattern and once this pattern has been identified short courses control the condition effectively, if given at the appropriate time, without disturbance to growth or other ill effects. Such children require regular surveillance and
Finally,
term
assessment, however, not only to determine the appropriate times for treatment, but also during and after the withdrawal
of treatment. Department of Respiratory Physiology, City General Hospital, Stoke-on-Trent.
M. C. S. KENNEDY D. C. THURSBY-PELHAM.
PROTEIN DEFICIENCIES AND CALORIE DEFICIENCIES have SIR,-We only recently had the opportunity of reading the interesting article by Professor McCance and Dr. Widdowson (July 16, p. 158), and subsequent correspondence from Professor Platt (July 30, p. 283) and Dr. Ghosh (Oct. 8, p. 798). It is timely that attention should be focused on the value of greater exactitude in the diagnosis of clinical malnutrition in young children, and therefore on the need for more precision in nomenclature. There is no doubt that deficiencies in protein and calories can be more sharply analysed in animals, because their dietary intake is so finely controllable. The classical experiments described have shed considerable light on clinical malnutrition, and elements of these clearly-defined, experimentallyinduced syndromes can be picked out in any individual malnourished child. Especially is this true in the polar case where there are a fairly clear history and syndrome. As Professor McCance and Dr. Widdowson point out, however, " proteincalorie malnutrition " (r.c.M.) is not a diagnosis for the individual malnourished child, and can have an adverse blanket effect, suppressing attempts at a more precise diagnosis. But with this possible abuse in mind, the term has still a great deal in its favour for two reasons: 1. 2. 3.
Kennedy, M. C. S., Thursby-Pelham, D. C. Br. med. J. 1956, i, Thursby-Pelham, D. C., Kennedy, M. C. S. ibid. 1958, i, 243. Thursby-Pelham, D. C., Crowe, G. G. ibid. 1961, ii, 1536.
1511.
irreversible. It is fair to add, however, that re-anastomosis is being achieved with an increasing measure of success by an
regimens have been rather different. In the light of experience we should like to make the following points:
increasing number of surgeons. The Trust is carrying out a follow-up inquiry on men who have been sterilised. It is hoped that the inquiry on the first hundred cases will be complete early next year. Simon Population Trust, 64 Sloane Street, London S.W.1.
L. N.
1. Certain children with severe asthma have stunted growth before steroids are given. 2. Some children grow normally on corticosteroids and others do not, but also some children show " stunting " on corticotrophin. 3. We agree that often growth accelerates when steroids are decreased or stopped, but this may occur whether or not corticotrophin treatment replaces corticosteroids. 4. Growth suppression usually depends on the dose of corticosteroid given-large doses often suppress growth, whereas small doses such as 5 mg. or 7-5 mg. prednisolone daily usually do not, even though doses of this order are reputed to cause adrenal suppression and may be ineffective in controlling the asthma.12 5. That growth velocity does not depend on the intact adrenal gland can be shown by the following case: 3 A boy with Cushing’s disease due to adrenal hyperplasia completely stopped growing for 2 years (from 9 to 11) on account of the disease, which causes an overproduction of corticosteroids. After total adrenalectomy, he grew 20 cm. (8 in. in a year), during which time he was on maintenance cortisone therapy (10-15 mg.
JACKSON
Hon. Director.
FAMILY-PLANNING ADVICE SIR,—Iwas interested to read Mr. Steele’s article (Oct. 1, p. 742) and Dr. Pasmore’s letter last week (p. 860). For just over a year I have been running an intrauterine-device (I.U.D.) clinic in a large maternity department in hospital, and although this does not fully cover the recommendations of Mr. Steele I feel that it is doing very useful work. Since this clinic is under the N.H.S. only those patients for whom a further pregnancy would be detrimental to health can be seen, but this ruling can be interpreted in its widest sense. Patients coming to see me fall roughly into two groups. The first group consists of women, often of low intelligence and poor socioeconomic background, who have had too many or too frequent pregnancies and for whom any other method of contraception is impossible, because of poor motivationfor them the l.u.D. is the only possible method, and most accept it very well. It seems that these women are the most likely to become pregnant with the device in situ, but even so it reduces their fertility to a very significant extent. The second group are those who have some disease which would make a further pregnancy dangerous, and in view of the failure-rate (about 25 per 100 woman-years of use) it seems at first sight doubtful whether this is a safe enough method to recommend. Sometimes these patients will not consent to sterilisation, however, and the more efficient oral contraceptives may be contraindicated for medical reasons in many cases. In hospital practice many of these patients could not be relied upon to use conventional methods of birth control effectively, and the l.u.D., despite its failure-rate, may still be the method of choice. Although I do not see patients in the wards, the medical and nursing staff discuss contraception with them before they leave hospital and give them an appointment to see me. Unfortunately those in the greatest need of advice do not always attend, but it is my impression, after working for many years in Family Planning Association clinics, that far more of them will come back to the hospital that they already know than go to an F.P.A. clinic which is strange to them. Another advantage of a clinic in hospital is that, much more than in the past when these patients had to be referred elsewhere, it gives medical students and student nurses the impression that the giving of contraceptive advice is a normal part of the care of women who have recently had a baby or miscarriage. The last patient whom I fitted with an l.u.D. was a married woman with a grown-up family who was referred after treatment in hospital for the fifth miscarriage which she had herself induced after failure of more conventional contraceptive methods. London W.1. MARY POLLOCK
CORTICOSTEROIDS, CORTICOTROPHIN, AND CHILDREN’S GROWTH SIR Over the past 10 years we have been investigating in detail the natural history of children with asthma. In the treatment of severe intractable cases we have had to resort occasionally to the use of corticosteroids or corticotrophin for long periods. Thus we were interested in the article by Dr. Friedman and Dr. Strang (Sept. 10, p. 568). Our observations on the growth of such children are slightly different from theirs, probably because our steroid and corticotrophin
our
cortisone daily). 6. When we consider prolonged corticosteroids to be indicated, it has been our practice to give corticotrophin initially, and at the same time to assess the adrenal function by the assay of urinary 17-hydroxycorticosteroids. Later, oral corticosteroids are given if daily corticotrophin injections become impracticable, but corticosteroids are seldom given for more than 6 months, after which the child is usually switched back to corticotrophin, when the adrenal function can be reassessed. We agree that if prolonged treatment is necessary corticotrophin is preferable to corti-
costeroids. we should like to emphasise that continuous longsteroid or corticotrophin therapy is only rarely necessary in childhood asthma. Many cases of severe asthma show a seasonal pattern and once this pattern has been identified short courses control the condition effectively, if given at the appropriate time, without disturbance to growth or other ill effects. Such children require regular surveillance and
Finally,
term
assessment, however, not only to determine the appropriate times for treatment, but also during and after the withdrawal
of treatment. Department of Respiratory Physiology, City General Hospital, Stoke-on-Trent.
M. C. S. KENNEDY D. C. THURSBY-PELHAM.
PROTEIN DEFICIENCIES AND CALORIE DEFICIENCIES have SIR,-We only recently had the opportunity of reading the interesting article by Professor McCance and Dr. Widdowson (July 16, p. 158), and subsequent correspondence from Professor Platt (July 30, p. 283) and Dr. Ghosh (Oct. 8, p. 798). It is timely that attention should be focused on the value of greater exactitude in the diagnosis of clinical malnutrition in young children, and therefore on the need for more precision in nomenclature. There is no doubt that deficiencies in protein and calories can be more sharply analysed in animals, because their dietary intake is so finely controllable. The classical experiments described have shed considerable light on clinical malnutrition, and elements of these clearly-defined, experimentallyinduced syndromes can be picked out in any individual malnourished child. Especially is this true in the polar case where there are a fairly clear history and syndrome. As Professor McCance and Dr. Widdowson point out, however, " proteincalorie malnutrition " (r.c.M.) is not a diagnosis for the individual malnourished child, and can have an adverse blanket effect, suppressing attempts at a more precise diagnosis. But with this possible abuse in mind, the term has still a great deal in its favour for two reasons: 1. 2. 3.
Kennedy, M. C. S., Thursby-Pelham, D. C. Br. med. J. 1956, i, Thursby-Pelham, D. C., Kennedy, M. C. S. ibid. 1958, i, 243. Thursby-Pelham, D. C., Crowe, G. G. ibid. 1961, ii, 1536.
1511.