- Email: [email protected]
Dosage of aspirin
956
Editorial correspondence
7.
Steele RW, Limas C, Thurman G, Schuelein M, Bauer H, and Bellatin J: Familial thymic aplasia, N Engl J Med 287:787, 1972. 8. Shepard MK, Linman SK, and Cavazos A: Familial thymic aplasia with intrauterine growth retardation and fetal death: A new syndrome or a variant o f DiGeorge syndrome, Birth Defects 12:123, 1976. 9. Cohen MM, Jichsek JE, Guzman RT, Gorlin RG, and Peterson MQ: Holoprosencephaly and .facial dysmorphia: Nosology, etiology and pathogenesis, Birth Defects 7:125, 1971. 10. Shen SC, Fall( RE, and Swanson VL: Coexistence of Kallman syndrome and DiGeorge syndrome, Clin Res 27:119A, 1979 (abstr). 11. Kretschmer R, Say B, Brown D, and Rosen F: Congenital aplasia of the thymus gland (DiGeorge syndrome), N Engl J Med 279:1295, 1968.
The Journal of Pediatrics May 1980
Table. C T scans s h o w i n g d i l a t e d ventricles plus w i d e sulci in i n f a n t s v~ith m a c r o c r a n i a Subdural collections* Meningitis Malformationst Achondroplasia Unknown Total
REFERENCES
2.
To the Editor: The ventricular enlargement and wide sulci described by Robertson et al, 1 as indicating benign subdural collections was found on computed tomographic (CT) scans of 12 o f the last 65 infants we evaluated for macrocrania. Ages ranged from 1 month to 5 years, including nine infants less than 8 months. Etiologies are listed in the Table. Of our patients who had subdural collections, one was proven by xanthochromic fluid obtained on subdural puncture, and the other had subdural membranes visualized at craniotomy for coexisting optic glioma. In the patient who had Arnold-Chiari malformation, the widened sulci were seen only along the frontal pole and interhemispheric fissure; at autopsy this area of brain showed polymicrogyria. Two of the infants with unknown etiology had negative subdural taps and the other two were twins. We have also seen this CT scan appearance in patients without macrocrania, including patients with Haemophilus influenzae meningitis as noted by Snyder, 2 and, of course, in patients whose histories were consistent with atrophic processes. This small series shows that this CT abnormality occurs in a diverse group of diseases. However, it is interesting to note that, with the exception of patients who had brain malformations, our other nine patients all had mild macrocrania and only three of these underwent shunting procedures. Therefore, with respect to the benignity of the CT findings, we are in general agreement with Robertson and his associates. Jane F. Donat, M.D. Assistant Professor of Neurology and Pediatrics Louisiana State University Medical Center Shreveport, LA 71130
12
*One patient also had optic glioma. tOne patient each with Amold-Chiari malformation and meningomyelocele; porencephaly and occipital encephalocele; agenesis of the corpus callosum and Dandy-Walker anomaly.
1.
Significance of CT scans showing enlarged ventricles and sulci
2 2 3 1 4
Robertson WC, Chun RWM, Orrison WW, and Sackett JF: Benign subdural collections o f infancy, J PEOIATR 94:382, 1979. Snyder RD: Benign "subdural" collections J PEDIAXR 95:499, 1979 (letter).
Reply To the Editor: We did not intend to imply that one can make a diagnosis of subdural fluid from CT scan alone. We agreed previously with Dr. Snyder's observations that one can see the combination of ventricular enlargement, wide cerebral sulci, and decreased radio density over the cerebral hemispheres in several conditions. The CT scan can only provide a visual image of various levels of the central nervous system and may not tell us what is responsible for the specific pathological abnormalities that we are visualizing. The purpose of our article was to indicate that there may be a group of infants who have accumulations of subdural fluid from a benign or unknown cause; this group of infants may have a benign course and not require any aggressive therapy. We certainly would not take issue with Dr. Donat that a particular CT picture may result frorfi a variety of diseases. William C. Robertson, M.D. Assistant Professor in Neurology Albert B. Chandler Medical Center University of Kentucky Lexington, K Y 40506
Dosage of aspirin To the Editor: In the October, 1979, issue Done et al' discuss the various dosage schedules for aspirin, an area that has long needed clarification and conclusions based on the pharmacokinetics of the drug.
Volume 96 Number 5
Editorial correspondence
I am concerned about the revised dosage schedule as it appears in the package insert of commercial aspirin for children. Done et al have stressed that age alone is not sufficient for prescribing aspirin. They state that the revised dosage schedule "is based on the previously suggested dosage of 10 to 15 mg/kg of body weight:" The resulting dosage schedule at various ages is "based upon the mean and the tenth to the ninetieth percentile weights for age." Indeed the pediatric aspirin manufacturers have incorporated this schedule in the package insert, but the chart is Useful only if the child's age and weight in pounds coincides with the ranges given. What dosage is recommended for the child whose weight for age falls outside these limits? The instructions offer no directions for computing dosage in this situation. I would assume that most parents would use age as the determining factor. The problem is that the resulting dosage is no longer basedon the 10 to 15 mg/kg of body weight as suggested by the authors. To ensure the dosage suggested by Done et al, it seems appropriate to supplement the package insert directions with a statement specifying that if a child's weight falls outside the range for his age, dosage should be given according to weight, not age. Donna L. Wong, R.N., M.N. 34 Stanford Ct. Totowa, NJ 07512 REFERENCE
I.
Done AK, Yaffe SJ, and Clayton JM: Aspirin dosage for infants and children, J PEDIATR 95:617, 1979.
Reply To the Editor w e intended to recommend that for children who fell outside the listed, weight limits for age, weight should be used in computing dose, but this was inadvertently deleted. We recommend that the substance of such recommendations be included in the labeling of aspirin for pediatric use. Alan K. Done, M.D. Director of Clinical Pharmacology and Toxicology Children's Hospital of Michigan 390l Beaubien Blvd. Detroit, M I 48201
Relationship of diapers to diaper rashes To the Editor: I wish to comment on the recent paper by Dr. Wiener I titled "The relationship of diapers to diaper rashes in the onemonth-old infant." Data from our own extensive clinical diaper testing program over the past 12 years do not support Dr.
9 57
Wiener's conclusions. Dr. Wiener points out that a one-week study is inadequate as a basis for determining the effects of a diaper on skin condition of the infant's diaper area. i agree. However, his series of consecutive single observations over a one-year period on an unselected but highly stratified (onemonth-old) infant population also fails to provide such a basis. A comparison based on such observations, which we presume were not balanced for the various diaper systems during any given period, could not have taken into account the influence of important factors such as mothers' diapering habits, state of health of the infants, weather, or factors that may have influenced the choice of diapering systems. I have conducted an extensive program of controlled studies i periods of test diaper usage have ranged from four to 12 weeks. In each test, detailed examination of the diaper region of each infant was made by two or more trained investigators, who graded the infants' skin conditions for diaper rash on a quantitative numerical scale. Each investigator made independent observations and was unaware of the identity of the diaper that the infant was using. The numerical grading scale was developed with the aid of pediatricians and dermatologists; it considers the type and severity of lesions and the areas covered by them in the assignment of the grade. Results of these tests, involving variously from more than 150 to 400 infants ranging in age from newborn infants to 24-month-old children and conducted in the United States, Japan, and Germany in various seasons of the year, indicate that incidence, types, and severity of rash do not differ significantly between infants diapered in cloth and those diapered in Pampers (registered trademark of the Procter & Gamble Company for disposable diapers). Results of microbiologic examinations fail to show differences in numbers or species of microorganisms associated with the type of diaper, cloth or disposable, used by the infant. Marples 2 reported that application of moisture-proof films directly to the skin for extended periods of time results in a sharp rise in the microbial population of the occluded area, due to the favorable temperature and accumulation of transpired skin moisture. In our tests, introduction of moisture-absorbent disposable diaper core material beneath the film prevents this rise in bacterial population until the moisture content approaches 2.5 times the weight of the absorbent material. I interpret this to mean that wearing of a diaper covered with, or enclosed by, a moistureproof barrier will not result in more favorable growth conditions for skin bacteria, provided wetted diapers (cloth or disposable) are changed with reasonable promptness. Control of diaper rash is largely in the hands of those responsible for the routine daily care of the infant. Careful attention to diaper change frequency and thorough cleansing of the diaper area at each change will control incidence and severity of rash among most infants, regardless of the diapering system used. William E. Jordan, Ph.D. Paper Products Division The Procter & Gamble Company Winton Hill Technical Center 6100 Center Hill R d CincinnatL OH 45224
Editorial correspondence
7.
Steele RW, Limas C, Thurman G, Schuelein M, Bauer H, and Bellatin J: Familial thymic aplasia, N Engl J Med 287:787, 1972. 8. Shepard MK, Linman SK, and Cavazos A: Familial thymic aplasia with intrauterine growth retardation and fetal death: A new syndrome or a variant o f DiGeorge syndrome, Birth Defects 12:123, 1976. 9. Cohen MM, Jichsek JE, Guzman RT, Gorlin RG, and Peterson MQ: Holoprosencephaly and .facial dysmorphia: Nosology, etiology and pathogenesis, Birth Defects 7:125, 1971. 10. Shen SC, Fall( RE, and Swanson VL: Coexistence of Kallman syndrome and DiGeorge syndrome, Clin Res 27:119A, 1979 (abstr). 11. Kretschmer R, Say B, Brown D, and Rosen F: Congenital aplasia of the thymus gland (DiGeorge syndrome), N Engl J Med 279:1295, 1968.
The Journal of Pediatrics May 1980
Table. C T scans s h o w i n g d i l a t e d ventricles plus w i d e sulci in i n f a n t s v~ith m a c r o c r a n i a Subdural collections* Meningitis Malformationst Achondroplasia Unknown Total
REFERENCES
2.
To the Editor: The ventricular enlargement and wide sulci described by Robertson et al, 1 as indicating benign subdural collections was found on computed tomographic (CT) scans of 12 o f the last 65 infants we evaluated for macrocrania. Ages ranged from 1 month to 5 years, including nine infants less than 8 months. Etiologies are listed in the Table. Of our patients who had subdural collections, one was proven by xanthochromic fluid obtained on subdural puncture, and the other had subdural membranes visualized at craniotomy for coexisting optic glioma. In the patient who had Arnold-Chiari malformation, the widened sulci were seen only along the frontal pole and interhemispheric fissure; at autopsy this area of brain showed polymicrogyria. Two of the infants with unknown etiology had negative subdural taps and the other two were twins. We have also seen this CT scan appearance in patients without macrocrania, including patients with Haemophilus influenzae meningitis as noted by Snyder, 2 and, of course, in patients whose histories were consistent with atrophic processes. This small series shows that this CT abnormality occurs in a diverse group of diseases. However, it is interesting to note that, with the exception of patients who had brain malformations, our other nine patients all had mild macrocrania and only three of these underwent shunting procedures. Therefore, with respect to the benignity of the CT findings, we are in general agreement with Robertson and his associates. Jane F. Donat, M.D. Assistant Professor of Neurology and Pediatrics Louisiana State University Medical Center Shreveport, LA 71130
12
*One patient also had optic glioma. tOne patient each with Amold-Chiari malformation and meningomyelocele; porencephaly and occipital encephalocele; agenesis of the corpus callosum and Dandy-Walker anomaly.
1.
Significance of CT scans showing enlarged ventricles and sulci
2 2 3 1 4
Robertson WC, Chun RWM, Orrison WW, and Sackett JF: Benign subdural collections o f infancy, J PEOIATR 94:382, 1979. Snyder RD: Benign "subdural" collections J PEDIAXR 95:499, 1979 (letter).
Reply To the Editor: We did not intend to imply that one can make a diagnosis of subdural fluid from CT scan alone. We agreed previously with Dr. Snyder's observations that one can see the combination of ventricular enlargement, wide cerebral sulci, and decreased radio density over the cerebral hemispheres in several conditions. The CT scan can only provide a visual image of various levels of the central nervous system and may not tell us what is responsible for the specific pathological abnormalities that we are visualizing. The purpose of our article was to indicate that there may be a group of infants who have accumulations of subdural fluid from a benign or unknown cause; this group of infants may have a benign course and not require any aggressive therapy. We certainly would not take issue with Dr. Donat that a particular CT picture may result frorfi a variety of diseases. William C. Robertson, M.D. Assistant Professor in Neurology Albert B. Chandler Medical Center University of Kentucky Lexington, K Y 40506
Dosage of aspirin To the Editor: In the October, 1979, issue Done et al' discuss the various dosage schedules for aspirin, an area that has long needed clarification and conclusions based on the pharmacokinetics of the drug.
Volume 96 Number 5
Editorial correspondence
I am concerned about the revised dosage schedule as it appears in the package insert of commercial aspirin for children. Done et al have stressed that age alone is not sufficient for prescribing aspirin. They state that the revised dosage schedule "is based on the previously suggested dosage of 10 to 15 mg/kg of body weight:" The resulting dosage schedule at various ages is "based upon the mean and the tenth to the ninetieth percentile weights for age." Indeed the pediatric aspirin manufacturers have incorporated this schedule in the package insert, but the chart is Useful only if the child's age and weight in pounds coincides with the ranges given. What dosage is recommended for the child whose weight for age falls outside these limits? The instructions offer no directions for computing dosage in this situation. I would assume that most parents would use age as the determining factor. The problem is that the resulting dosage is no longer basedon the 10 to 15 mg/kg of body weight as suggested by the authors. To ensure the dosage suggested by Done et al, it seems appropriate to supplement the package insert directions with a statement specifying that if a child's weight falls outside the range for his age, dosage should be given according to weight, not age. Donna L. Wong, R.N., M.N. 34 Stanford Ct. Totowa, NJ 07512 REFERENCE
I.
Done AK, Yaffe SJ, and Clayton JM: Aspirin dosage for infants and children, J PEDIATR 95:617, 1979.
Reply To the Editor w e intended to recommend that for children who fell outside the listed, weight limits for age, weight should be used in computing dose, but this was inadvertently deleted. We recommend that the substance of such recommendations be included in the labeling of aspirin for pediatric use. Alan K. Done, M.D. Director of Clinical Pharmacology and Toxicology Children's Hospital of Michigan 390l Beaubien Blvd. Detroit, M I 48201
Relationship of diapers to diaper rashes To the Editor: I wish to comment on the recent paper by Dr. Wiener I titled "The relationship of diapers to diaper rashes in the onemonth-old infant." Data from our own extensive clinical diaper testing program over the past 12 years do not support Dr.
9 57
Wiener's conclusions. Dr. Wiener points out that a one-week study is inadequate as a basis for determining the effects of a diaper on skin condition of the infant's diaper area. i agree. However, his series of consecutive single observations over a one-year period on an unselected but highly stratified (onemonth-old) infant population also fails to provide such a basis. A comparison based on such observations, which we presume were not balanced for the various diaper systems during any given period, could not have taken into account the influence of important factors such as mothers' diapering habits, state of health of the infants, weather, or factors that may have influenced the choice of diapering systems. I have conducted an extensive program of controlled studies i periods of test diaper usage have ranged from four to 12 weeks. In each test, detailed examination of the diaper region of each infant was made by two or more trained investigators, who graded the infants' skin conditions for diaper rash on a quantitative numerical scale. Each investigator made independent observations and was unaware of the identity of the diaper that the infant was using. The numerical grading scale was developed with the aid of pediatricians and dermatologists; it considers the type and severity of lesions and the areas covered by them in the assignment of the grade. Results of these tests, involving variously from more than 150 to 400 infants ranging in age from newborn infants to 24-month-old children and conducted in the United States, Japan, and Germany in various seasons of the year, indicate that incidence, types, and severity of rash do not differ significantly between infants diapered in cloth and those diapered in Pampers (registered trademark of the Procter & Gamble Company for disposable diapers). Results of microbiologic examinations fail to show differences in numbers or species of microorganisms associated with the type of diaper, cloth or disposable, used by the infant. Marples 2 reported that application of moisture-proof films directly to the skin for extended periods of time results in a sharp rise in the microbial population of the occluded area, due to the favorable temperature and accumulation of transpired skin moisture. In our tests, introduction of moisture-absorbent disposable diaper core material beneath the film prevents this rise in bacterial population until the moisture content approaches 2.5 times the weight of the absorbent material. I interpret this to mean that wearing of a diaper covered with, or enclosed by, a moistureproof barrier will not result in more favorable growth conditions for skin bacteria, provided wetted diapers (cloth or disposable) are changed with reasonable promptness. Control of diaper rash is largely in the hands of those responsible for the routine daily care of the infant. Careful attention to diaper change frequency and thorough cleansing of the diaper area at each change will control incidence and severity of rash among most infants, regardless of the diapering system used. William E. Jordan, Ph.D. Paper Products Division The Procter & Gamble Company Winton Hill Technical Center 6100 Center Hill R d CincinnatL OH 45224