Reply to "Keeping us on our toes!"

}i: i i

~,

r}: {[i ~i;

{i I}i 6

N

}i ! [

iii*

ii

!i{ i?i} *

}) ~i+ ~ ,

}: !

~i{

~

Keeping us on our toes! To the Editor: Although I concede the probability of an association of toe walking with various developmental disabilities, no such conclusion can be made on the basis of the study by Shulman et al.1 Their study group, consisting solely of minority children, some of whom appear to have a history of intrauterine drug or alcohol exposure, was selected from a group of children already at high risk for developmental problems. Without a control group, it is impossible to say whether the incidence of developmental difficulties is higher in toe-walking children than in a similar group of minority children with similar backgrounds. Are creatine kinase levels, nerve conduction studies, and electromyograms a necessary part of the evaluation of toewalking children? With reports of as many as 24% of children toe walking during some part of their life,2 this would suggest that toe walking is most frequently a normal developmental variant for most of these children, and the above tests represent diagnostic overkill. Finally, I disagree with the recommendation that all children with toe walking be referred for developmental evaluation. With 24% of the population being toe walkers, I am not sure there are enough developmental specialists available to evaluate such a large number of children. Instead, I would suggest that children with toe walking and no other abnormality on physical examination, who have normal strength, tone, reflexes, and sensation, be given a standard developmental screening test b y their primary care provider. A decision to refer the child for further evaluation should be based on the results of this screening and parental concerns. This is really no different than the recommendation for the care of children who are not toe walkers.

Robert D. Cunningbam Jr., MD 50 GreenwaySquare Apartment 34-31 Dover, DE 19904 9/35/84616

i

,

ili

i

i

i

~i

i

}

~ i

References 1. Shulman LH, Sala DA, Chu MLY, McCaul PR, Sandler BJ. Developmental implications of idiopathic toe walking. J Pediatr 1997;130:541-6. 2. Accardo E Morrow J, Heaney MS, Whitman B, TomazicT. Toe walldng and language development. Clin Pediatr 1992;31:158-60.

Reply To the Editor: I would like to clarify several points. First, the population of children whom we studied were persistent toe walkers. As noted in the article, this was not a transitory issue but rather the chief complaint for which the parents sought medical intervention at an orthopedic hospital. Over half the children walked on their toes at all times, and the majority of the children demonstrated ankle contractures of some degree. This is not a common condition. The statistic cited of "as many as 24% of children toe walking during some part of their life "1 was elicited with much less stringent conditions, namely, a recalled "history of previous toe walking of more than one month's duration." By our estimation, the prevalence of persistent toe walking beyond 1 month's duration is significantly lower. Certainly, the presence of contractures is much rarer. Second, we did not choose to address the issue of recommended workup for this population. The nerve conduction velocity studies and electromyograms were performed in the small group in this study because of the severity of the problem. The negative findings permit us to characterize the children in the study group as idiopathic toewalkers. Clinical examination and history should guide pediatricians as to the extent of a required evaluation for these children. Creatine kinase levels, however, in our estimate, are an inexpensive means of ruling out myopathies and should be considered. The point made regarding the high-risk nature of the study group is valid and acknowledged in the article itself. Clearly, a larger, more varied population would shed light on the possible contributions

!

i~

i

macle by intrauterine teratogen exposure. However, it is important to note that the prevalence of in utero teratogen exposure seen in the study group does exceed that in the general population of the pediatric orthopedic clinic from which the referrals originated. Lastly, on the issue of developmental screening by the pediatrician versus referral: if this article encourages pediatricians to more carefully survey the developmental milestones of children displaying similar findings and screen these children with a standardized developmental test, then we have succeeded in making our point. Referrals for additional developmental evaluation and services should be on a selected basis if significant developmental problems are suspected.

Lisa Sbulman, MD Children5 Evaluation and Rebabi[itation Center Rose E Kennedy Center University Affiliated Program Albert Einstein Co[[ege(Medicine Brmwc,N Y 10461 9/35/84617

Reference 1. Accardo P, Morrow J, Heaney MS, Whitman B, TomazicT. Toe walking and language development. Ctin Pediatr 1992;31:158-60.

Estimation of body composition by bioelectrical impedance in HIV-infected children To the Editor: We read with interest the article by Arpadi et al.1 and the related editorial2 on the use of bioelectrical impedance (BIA) in HIV-infectecl children. Both reports are suitably cautious in their conclusions with respect to the validity of BIA. The conclusion that it is necessary to develop BIA prediction equations that are specific to HIV-infected children is perhaps premature. BIA prediction equations are