- Email: [email protected]
Pediatric hospital discharge summary
324
Letters to the Editor
has been observed and confirmed by roentgenograms during the active process in.a parent and child. Other reported familial cases have occurred in siblings, or with parental involvement suggested by history and/or the presence of residual bony deformities. William H. Langewisch, M.D. Rockford School of Medicine 1601 Parkview A re. Rockford, IlL 61101 REFERENCES 1. R6ske G: Eine eigenartige Knocheuerkrankung im Saulingsalter, Monnatsschr Kinderheilk 47:385, 1930. 2. Valler K, and Taur A: Zur ~tiologie der infantilen Kortikalen hyperostose (Caffey-Syndrom), Fortschr Geb ROntgenstr 79:446, 1953. 3. Clemett AR, and Williams JH: The familial occurrence of infantile cortical hyperostosis, Radiology 80:409, 1963. 4. Pajewski M, and Vure E: Late manifestations of infantile cortical hyperostosis (Caffey's disease), Br J Radiol 40:90, 1967. 5. Sherman MS, and Hellyer DT: Infantile cortical hyperostosis; review of literature and report of five cases, Am J Roentgenol Rad Ther 63:212, 1950.
Withdrawal symptoms in a neonate associated with maternal pentazocine abuse To the Editor: Two recent case reports in THE JOURNAL have suggested a relationship between maternal pentazocine (Talwin) abuse and neonatal withdrawal symptoms?. : A third case with toxicologic studies of maternal urine and serum is presented.
The Journal of Pediatrics August 1975
taken other medication in excess but this was unsubstantiated. The mother admitted taking 50 mg of pentazocine as often as every 4 hours during the pregnancy, but she denied taking other drugs. Neonatal pentazocine withdrawal was suspected. Paragoric was given to the infant for 48 hours after which time she was markedly improved. No signs suggestive of withdrawal were noted after 72 hours of onset. Antibiotics were discontinued after five days and the infant discharged at 7 days of age. Follow-up evaluation at 3 weeks and 6 months of age was unremarkable. Urine and serum were obtained from the mother 12 hours after onset of the infants symptoms (two days after delivery). The mother had received 50 mg doses of pentazocine five and 12 hours after delivery but none thereafter. Toxicologic studies on these specimens were negative, except pentazocine was detected in the serum and urine by radioimmunoassay at a concentration of 13 and 400 ng/ml, respectively. DISCUSSION The infant's course is most consistent with withdrawal? The presence of pentazocine in the maternal urine and serum may reflect primarily postnatally administered drug, but the absence of other drugs in these specimens and the history of pentazocine abuse support the previously suspected association between maternal pentazocine abuse and neonatal withdrawal symptoms. Thomas O. Reeds, M.D., F.A.A.P. Kootenai Memorial Hospital Coeur d'Alene, Idaho 83814 REFERENCES 1. Goetz RL, and Bain RV: Neonatal withdrawal symptoms associated with maternal use of pentazocine, J PED1ATR 84:887, 1974. 2. Scanlon JW: Pentazocine and neonatal withdrawal symptoms, J PEDIAXR85:735, 1974. 3. Rothsteim P, and Gould JB: Born with a habit, Infants of drug addicted mothers, Pediatr Clin North Am 21:307, 1974.
CASE REPORT A 24-year-old white female was admitted to the hospital at 37 weeks' gestation in active labor; she had a temperature of 104 ~ F and meconium-stained amniotic fluid. She delivered a normal appearing 2,254-gm female infant 4 hours later. After cultures were obtained, intramuscular kanamycin and ampicillin were administered to the infant. The infant's course was unremarkable until 11/2 days of age when the following appeared: jitteriness, intermittent rapid respirations, eye blinking, liquid stools, vomiting, fist chewing, clusters of yawning and sneezing, and abdominal distention. Complete blood count, electrolytes, fiat plate of the abdomen, and serial calcium and glucose determinations were within normal limits. Cultures done at the time of delivery indicated over 100,000 colonies of Escherichia coli in the mother's urine. Infant and maternal blood cultures were negative and surface cultures of the infant were unremarkable as was microscopic examination of the placenta. The mother was known to many physicians in the local area because of her frequent requests for pentazocine for pain apparently related to injuries in a motorcycle accident two years previously. Physical dependence on pentazocine was suspected by these physicians. A relative suspected that the mother had
Pediatric hospital discharge summary To the Editor: We read with interest the description by Swender and associates 1 of the pediatric discharge summary utilized in their institution. We agree that this is a natural outgrowth of the problem-oriented medical record. We have developed a form with a similar purpose (Figs. 1 and 2). In addition, we have included other information and data which relate to immunizations, screening tests, and pediatric counseling. The form may be used as a teaching tool calling attention to areas of pediatric care which are considered essential, although not necessarily related to the acute problems which precipitated the hospitalization. Discharge forms are completed by the intern and/or students and reviewed by the attending pediatrician. The pertinent data can be
Volume 87 Number 2
Letters to the Editor
PEDIATRIC D~SCPARGE SUMMARY N~e: Where P r i o r y Care Previously Received:
Discharge Date:
PLAN (INCLUDING M~DICATIONS WITH DOSES)
RETURN CLINIC APPOINTMENT: Clinic (s)
I]~dUN IZATIONS
Date (~)
Doctor (s)
_ _
(d~tes)
:
DPT
~
Polio
M%m%pe
, TET, TOX.
_ _ Rubella
Ruhe~lla
Other~ (~peel fy) (record d a t e a n d result When applicahle):
SCREENING PROCEDURES Grc~vth ~
Heigh~ - -
Nematocrit -
-
PKU
Weight
Sickle screen D
d
P
{cad Circumference He
........
9 U/A
D
VDRL Dental ~ealth check
Blood pressure T B screen Development (indicate method u s e d for screen) FEEDING (children under 24 months): Milk (type and quantity) Dther foods Known allergies
Fig. 1.
Dep~rtment of Pediatrics j&=kson MemoriK1 Hospit~l Miami, Flo~id~
SOCIAL EVALUATION C~act
R=lationship _
(his=orlan)
Contact with mother?
Quality o f contact
Conzacs with father? significa~t 5ome prohle~
Q ~ l i t y of contact
Overall eval~tio~ of the f a m i l y ~it:
Parental appreciation o f disefi~rge plans : fully P~s Soeiai S e m i t e been contacted for this ~atie~t? If "yes", what is the di~posltion
-
-
COUNSELING: (Check those areas i~ ~hlch pacient or family n~ed specific teaseling or advice; circle those areas already r Feeding Sensory sti~latlon RX of minor illnes Poisoning prevent Accident prevent W a t e r esfety Bicycle smfety l~=nunizetions Bottle ~eaning ToileL =ralnin s Enuresis R X of impetigo
Sickle Cell Anemia GdPD colic Need for affection B~havior modification Discipline appropriateness Dsntal Bare School Prohle~ Sex~lity a=d contraception llen@truation Adolescent adjustments - - .
SPECIAL EERVIGES REQUIRED (describe dlsposition) Protective Services Ce=etlc Couns~lln E OT}~R SPECIAL FAMILY P~Z%LTH OR O T ~
TEAI~ S IGJ~!ATUR>~S : Student ~esident Attending
Fig. 2.
~ i l m a ~ Center Oth%r (specify) PROBLemS REQUIRING FL~T.~R ASSISTANCE OK }i%~EAGE~NI':
DAT~
325
326
Letters to the Editor
collected rapidly and may be useful as an alternative to the discharge summary form described by Swender and associates. Irwin E. Redlener, M.D. Assistant Professor, Pediatrics and Family Medicine William W. Cleveland, M.D. Professor and Chairman Department o f Pediatrics Jackson Memorial Hospital University of Miami Miami, Fla. 33152 REFERENCE 1. Swender PT, Schneider AJ, and Oski FA. A functional hospital discharge summary, J PEDIATR 86:97, 1975.
Trisomies 21 and 18 in two sibs; another case To the Editor: In some families chromosomal errors resulting from nondisjunction tend to accumulate. A rare event of two different chromosomal anomalies in one family are trisomies 21 and 18. Six cases of these two trisomies in siblings have been described? It has been known that certain chromosomal rearrangements and variants in parents increase the probability of chromosomal aberration in progeny~; however, in only three cases was it possible to examine the chromosomes of both parents. We had the opportunity to study another case, which is interesting because the trisomy 18 patient has survived to an unusual age of 16 years. Only a few cases surviving the first decade of life have been described?. 4 We examined the chromosomes of family members using QM fluorescence method. Father (born 1917), mother (1916), and son (1942, married, with one daughter) are in good health. The chromosomes of parents were normal, with brightly fluorescent short arms in one No. 14 (mother) and fluorescent satellites in one No. 22 (father). Both variants are very common, without any predictive value regarding the trisomies in their children. The elder daughter (1944) has typical symptoms of Down syndrome and her chromosomal examination revealed standard trisomy 21. The younger daughter (born 1958, died 1974) had trisomy 18 in all examined cells (lymphocytes and fibroblasts). Identity of extra This study was assisted under Grant No. 267-69 C o f the Ontario Mental Health Foundation.
The Journal of Pediatrics August 1975
chromosomes in both sisters was confirmed by QM fluorescence and Giemsa trypsin banding. The birth weight of the girl with trisomy 18 was 1.93 kg. She was in an incubator for 5 weeks, tube fed through the nose for 4 months, and fed with a spoon until 10 months. She did not cry as an infant. She sat alone at 5 years, but this deteriorated, and later she was able to sit only with support. She never stood or walked alone, and never used words; her only vocal communication were isolated sounds. She was confined to a wheelchair and had to be fed, clothed, and toileted. Psychically she was in a profoundly retarded range. She was at home until three years ago when she became a patient in a hospital for the mentally retarded. Since an early age she frequently suffered from respiratory infections, and her general health deteriorated during the last months. She was slowly losing weight; her hemoglobin and hematocrit values increased. One day in August, 1974, she was found dead in bed. Her family did not give permission for necropsy. The weight and height (1971) of this girl was 18 kg amd 124 cm, respectively. There was cyanosis of lips, tongue, fingers, toes, and nose; micrognathia, prominent epicanthus, and microcephalus; short and webbed neck, minor degree of contractures of extremities; enlarged and protruding tongue; and webbing of all five fingers on both hands and webbing of toes on both feet. She had scoliotic thoracic spine which made the left anterior thorax appear more prominent than the right. Auscultation and chest roentgenograms were compatible with the diagnosis of tetralogy of Fallot. An electrocardiogram showed evidence of right ventricular hypertrophy. An electroencephalogram given while awake was normal: the sleep record was only slightly dysrhythmic. Dermatoglyphs disclosed that both hands and feet had all digits with arch pattern. Dushan Soudek, M.D. Ontario Mental Health Foundation Research Associate Bruce McCreary, M.D. Assistant Professor Parvaneh Laraya, B.Sc. Cytogenetics Laboratory Queen's University and L. S. Penrose Centre Kingston, Ontario, Canada REFERENCES 1. Crandall BF, and Ebbin A J Trisomy 18 and 21 in two siblings, Clin Genet 4:517, 1973. 2. Grell RF: Distributive pairing in man? Ann Genet 14:165, 1971. 3. Stoll C, Levy JM, and Terrade E: Les survies prolong6es dans la trisomie 18, Ann Pediatr 21:185, 1974. 4. Weber WW: Survival and the sex ratio in trisomy 17-18, Am J Human Genet 19:369, 1967.
Letters to the Editor
has been observed and confirmed by roentgenograms during the active process in.a parent and child. Other reported familial cases have occurred in siblings, or with parental involvement suggested by history and/or the presence of residual bony deformities. William H. Langewisch, M.D. Rockford School of Medicine 1601 Parkview A re. Rockford, IlL 61101 REFERENCES 1. R6ske G: Eine eigenartige Knocheuerkrankung im Saulingsalter, Monnatsschr Kinderheilk 47:385, 1930. 2. Valler K, and Taur A: Zur ~tiologie der infantilen Kortikalen hyperostose (Caffey-Syndrom), Fortschr Geb ROntgenstr 79:446, 1953. 3. Clemett AR, and Williams JH: The familial occurrence of infantile cortical hyperostosis, Radiology 80:409, 1963. 4. Pajewski M, and Vure E: Late manifestations of infantile cortical hyperostosis (Caffey's disease), Br J Radiol 40:90, 1967. 5. Sherman MS, and Hellyer DT: Infantile cortical hyperostosis; review of literature and report of five cases, Am J Roentgenol Rad Ther 63:212, 1950.
Withdrawal symptoms in a neonate associated with maternal pentazocine abuse To the Editor: Two recent case reports in THE JOURNAL have suggested a relationship between maternal pentazocine (Talwin) abuse and neonatal withdrawal symptoms?. : A third case with toxicologic studies of maternal urine and serum is presented.
The Journal of Pediatrics August 1975
taken other medication in excess but this was unsubstantiated. The mother admitted taking 50 mg of pentazocine as often as every 4 hours during the pregnancy, but she denied taking other drugs. Neonatal pentazocine withdrawal was suspected. Paragoric was given to the infant for 48 hours after which time she was markedly improved. No signs suggestive of withdrawal were noted after 72 hours of onset. Antibiotics were discontinued after five days and the infant discharged at 7 days of age. Follow-up evaluation at 3 weeks and 6 months of age was unremarkable. Urine and serum were obtained from the mother 12 hours after onset of the infants symptoms (two days after delivery). The mother had received 50 mg doses of pentazocine five and 12 hours after delivery but none thereafter. Toxicologic studies on these specimens were negative, except pentazocine was detected in the serum and urine by radioimmunoassay at a concentration of 13 and 400 ng/ml, respectively. DISCUSSION The infant's course is most consistent with withdrawal? The presence of pentazocine in the maternal urine and serum may reflect primarily postnatally administered drug, but the absence of other drugs in these specimens and the history of pentazocine abuse support the previously suspected association between maternal pentazocine abuse and neonatal withdrawal symptoms. Thomas O. Reeds, M.D., F.A.A.P. Kootenai Memorial Hospital Coeur d'Alene, Idaho 83814 REFERENCES 1. Goetz RL, and Bain RV: Neonatal withdrawal symptoms associated with maternal use of pentazocine, J PED1ATR 84:887, 1974. 2. Scanlon JW: Pentazocine and neonatal withdrawal symptoms, J PEDIAXR85:735, 1974. 3. Rothsteim P, and Gould JB: Born with a habit, Infants of drug addicted mothers, Pediatr Clin North Am 21:307, 1974.
CASE REPORT A 24-year-old white female was admitted to the hospital at 37 weeks' gestation in active labor; she had a temperature of 104 ~ F and meconium-stained amniotic fluid. She delivered a normal appearing 2,254-gm female infant 4 hours later. After cultures were obtained, intramuscular kanamycin and ampicillin were administered to the infant. The infant's course was unremarkable until 11/2 days of age when the following appeared: jitteriness, intermittent rapid respirations, eye blinking, liquid stools, vomiting, fist chewing, clusters of yawning and sneezing, and abdominal distention. Complete blood count, electrolytes, fiat plate of the abdomen, and serial calcium and glucose determinations were within normal limits. Cultures done at the time of delivery indicated over 100,000 colonies of Escherichia coli in the mother's urine. Infant and maternal blood cultures were negative and surface cultures of the infant were unremarkable as was microscopic examination of the placenta. The mother was known to many physicians in the local area because of her frequent requests for pentazocine for pain apparently related to injuries in a motorcycle accident two years previously. Physical dependence on pentazocine was suspected by these physicians. A relative suspected that the mother had
Pediatric hospital discharge summary To the Editor: We read with interest the description by Swender and associates 1 of the pediatric discharge summary utilized in their institution. We agree that this is a natural outgrowth of the problem-oriented medical record. We have developed a form with a similar purpose (Figs. 1 and 2). In addition, we have included other information and data which relate to immunizations, screening tests, and pediatric counseling. The form may be used as a teaching tool calling attention to areas of pediatric care which are considered essential, although not necessarily related to the acute problems which precipitated the hospitalization. Discharge forms are completed by the intern and/or students and reviewed by the attending pediatrician. The pertinent data can be
Volume 87 Number 2
Letters to the Editor
PEDIATRIC D~SCPARGE SUMMARY N~e: Where P r i o r y Care Previously Received:
Discharge Date:
PLAN (INCLUDING M~DICATIONS WITH DOSES)
RETURN CLINIC APPOINTMENT: Clinic (s)
I]~dUN IZATIONS
Date (~)
Doctor (s)
_ _
(d~tes)
:
DPT
~
Polio
M%m%pe
, TET, TOX.
_ _ Rubella
Ruhe~lla
Other~ (~peel fy) (record d a t e a n d result When applicahle):
SCREENING PROCEDURES Grc~vth ~
Heigh~ - -
Nematocrit -
-
PKU
Weight
Sickle screen D
d
P
{cad Circumference He
........
9 U/A
D
VDRL Dental ~ealth check
Blood pressure T B screen Development (indicate method u s e d for screen) FEEDING (children under 24 months): Milk (type and quantity) Dther foods Known allergies
Fig. 1.
Dep~rtment of Pediatrics j&=kson MemoriK1 Hospit~l Miami, Flo~id~
SOCIAL EVALUATION C~act
R=lationship _
(his=orlan)
Contact with mother?
Quality o f contact
Conzacs with father? significa~t 5ome prohle~
Q ~ l i t y of contact
Overall eval~tio~ of the f a m i l y ~it:
Parental appreciation o f disefi~rge plans : fully P~s Soeiai S e m i t e been contacted for this ~atie~t? If "yes", what is the di~posltion
-
-
COUNSELING: (Check those areas i~ ~hlch pacient or family n~ed specific teaseling or advice; circle those areas already r Feeding Sensory sti~latlon RX of minor illnes Poisoning prevent Accident prevent W a t e r esfety Bicycle smfety l~=nunizetions Bottle ~eaning ToileL =ralnin s Enuresis R X of impetigo
Sickle Cell Anemia GdPD colic Need for affection B~havior modification Discipline appropriateness Dsntal Bare School Prohle~ Sex~lity a=d contraception llen@truation Adolescent adjustments - - .
SPECIAL EERVIGES REQUIRED (describe dlsposition) Protective Services Ce=etlc Couns~lln E OT}~R SPECIAL FAMILY P~Z%LTH OR O T ~
TEAI~ S IGJ~!ATUR>~S : Student ~esident Attending
Fig. 2.
~ i l m a ~ Center Oth%r (specify) PROBLemS REQUIRING FL~T.~R ASSISTANCE OK }i%~EAGE~NI':
DAT~
325
326
Letters to the Editor
collected rapidly and may be useful as an alternative to the discharge summary form described by Swender and associates. Irwin E. Redlener, M.D. Assistant Professor, Pediatrics and Family Medicine William W. Cleveland, M.D. Professor and Chairman Department o f Pediatrics Jackson Memorial Hospital University of Miami Miami, Fla. 33152 REFERENCE 1. Swender PT, Schneider AJ, and Oski FA. A functional hospital discharge summary, J PEDIATR 86:97, 1975.
Trisomies 21 and 18 in two sibs; another case To the Editor: In some families chromosomal errors resulting from nondisjunction tend to accumulate. A rare event of two different chromosomal anomalies in one family are trisomies 21 and 18. Six cases of these two trisomies in siblings have been described? It has been known that certain chromosomal rearrangements and variants in parents increase the probability of chromosomal aberration in progeny~; however, in only three cases was it possible to examine the chromosomes of both parents. We had the opportunity to study another case, which is interesting because the trisomy 18 patient has survived to an unusual age of 16 years. Only a few cases surviving the first decade of life have been described?. 4 We examined the chromosomes of family members using QM fluorescence method. Father (born 1917), mother (1916), and son (1942, married, with one daughter) are in good health. The chromosomes of parents were normal, with brightly fluorescent short arms in one No. 14 (mother) and fluorescent satellites in one No. 22 (father). Both variants are very common, without any predictive value regarding the trisomies in their children. The elder daughter (1944) has typical symptoms of Down syndrome and her chromosomal examination revealed standard trisomy 21. The younger daughter (born 1958, died 1974) had trisomy 18 in all examined cells (lymphocytes and fibroblasts). Identity of extra This study was assisted under Grant No. 267-69 C o f the Ontario Mental Health Foundation.
The Journal of Pediatrics August 1975
chromosomes in both sisters was confirmed by QM fluorescence and Giemsa trypsin banding. The birth weight of the girl with trisomy 18 was 1.93 kg. She was in an incubator for 5 weeks, tube fed through the nose for 4 months, and fed with a spoon until 10 months. She did not cry as an infant. She sat alone at 5 years, but this deteriorated, and later she was able to sit only with support. She never stood or walked alone, and never used words; her only vocal communication were isolated sounds. She was confined to a wheelchair and had to be fed, clothed, and toileted. Psychically she was in a profoundly retarded range. She was at home until three years ago when she became a patient in a hospital for the mentally retarded. Since an early age she frequently suffered from respiratory infections, and her general health deteriorated during the last months. She was slowly losing weight; her hemoglobin and hematocrit values increased. One day in August, 1974, she was found dead in bed. Her family did not give permission for necropsy. The weight and height (1971) of this girl was 18 kg amd 124 cm, respectively. There was cyanosis of lips, tongue, fingers, toes, and nose; micrognathia, prominent epicanthus, and microcephalus; short and webbed neck, minor degree of contractures of extremities; enlarged and protruding tongue; and webbing of all five fingers on both hands and webbing of toes on both feet. She had scoliotic thoracic spine which made the left anterior thorax appear more prominent than the right. Auscultation and chest roentgenograms were compatible with the diagnosis of tetralogy of Fallot. An electrocardiogram showed evidence of right ventricular hypertrophy. An electroencephalogram given while awake was normal: the sleep record was only slightly dysrhythmic. Dermatoglyphs disclosed that both hands and feet had all digits with arch pattern. Dushan Soudek, M.D. Ontario Mental Health Foundation Research Associate Bruce McCreary, M.D. Assistant Professor Parvaneh Laraya, B.Sc. Cytogenetics Laboratory Queen's University and L. S. Penrose Centre Kingston, Ontario, Canada REFERENCES 1. Crandall BF, and Ebbin A J Trisomy 18 and 21 in two siblings, Clin Genet 4:517, 1973. 2. Grell RF: Distributive pairing in man? Ann Genet 14:165, 1971. 3. Stoll C, Levy JM, and Terrade E: Les survies prolong6es dans la trisomie 18, Ann Pediatr 21:185, 1974. 4. Weber WW: Survival and the sex ratio in trisomy 17-18, Am J Human Genet 19:369, 1967.