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The institutional mortality and morbidity of infantile eczema
T H E I N S T I T U T I O N A L MOR, T A L I T Y A N D M O R B I D I T Y OF INFANTILE ECZEMA DOROTI~Y KOCh, M.D., AND A. B. SCHWARTZ, M.D. MILWAUKEE, WIS.
E C E N T L Y , a t t e n t i o n has again been focussed on the dangers of the i n f a n t w a r d - - i t s high m o r t a l i t y and morbidity. 1 Both are largely the result of u p p e r r e s p i r a t o r y infections and digestive disturbances universally p r e s e n t in i n f a n t wards. On this account, m a n y have come to feel with B r e n n e m a n n t h a t " n o i n f a n t should be a d m i t t e d to an i n f a n t w a r d who can with reasonable assurance be t a k e n care of in an out-patient department, or in a good home or foster h o m e . " This would restrict hospitalization of infants to emergencies and to those whose illnesses d e m a n d either f o r purposes of diagnosis or t h e r a p y a specialized technic t h a t c a n n o t be provided in a home. i n o r d e r to define more clearly the c h a r a c t e r of cases that m a y still be r e g a r d e d as eligible f o r hospitalization in an i n f a n t ward, it se~ms i m p o r t a n t to decide w h a t classes of cases should not be admitted to an i n f a n t ward. B r e n n e m a n n lists as especially to be excluded, " b o a r d e r s and infants with infections of the u p p e r respirat o r y t r a c t and gastrointestinal disorders t h a t are not immediately serious. ' ' I n a s m u c h as the m a n a g e m e n t of infantile eczema presents a problem often r e g a r d e d as more ideally t r e a t e d in a hospital, we have gone over the results obtained in the care of 103 cases of infantile eczema admitted to the Milwaukee Children's tIospita]. These 103 patients were net selected in particular', as tllat n m n b e r represents a.lt the infants and children up to two years, who were admitted from August, 1922, to April, 1931, with a diagnosis of infantile eczema. The only Cases omitted from this study a ro those who did not stay in the hospital long" enough f o r a n y conclusions to be drawn, as t h e y were t a k e n home against t h e advice of the a t t e n d i n g physician. The cases have been divided into two g r o u p s : (1) Those infants a d m i t t e d f o r treatment of eczema b u t otherwise in a p p a r e n t l y good health, (2) those infants who had miscellaneous complaints besides their eczema. A d m i t t e d for the t r e a t m e n t of eczema alone were 56 infants (Table I). Of these, 23 h a d an u n e v e n t f u l stay in the hospital, 33 developed complications, a m o r b i d i t y of 58.9 per cent. There were 10 deaths in this group, a m o r t a l i t y of 17.9 per cent a m o n g p r e v i o u s l y h e a l t h y inf a n t s admitted f o r t r e a t m e n t of eczema. Some of the infants h a d
R
F r o m the M i l w a u k e e C h i l d r e n ' s H o s p i t a l a nd D e p a r t m e n t of P e d i a t r i c s , M a r q u e t t e U n i v e r s i t y Medical School. S u b m i t t e d for p u b l i c a t i o n Aug. 6, ].932. 169
J70
TIlE JOURNAL OF PEDIATRICS TA~nE I IN~'AN'•
ADMIT'I"ED ~OR TRF~ATMEN'I' 0t~ EOZEIVIA
tXOSP. bIO.
DATE OF ADMISSION
DATE 0 F DISC:~IABA]E
26576 19483 18286 19851 20949 18181 13559
3 / 5/31 2/24/28 1/14/28 4/17/28 7/19/28 7/18/27 12/31/24
3/16/31 3 / 7/28 1/26/28 5/21/28 11/ 7/28 8/13/27
1/26/25
I 1 1 8 2 8 7
12484 12484
7/23/24 4 / 7/24
9/ 9/24 5/31/24
9 5
12314 24877
2/12/24 9/30/20
2/27/24 2/12/31
1 1
22425
6/10/29
7/16/29
6
19632
3/17/28
3/23/28
4
25914 21692
11/21/30 1/29/29
11/26/30 2/24/29
18325 18156 18145 17230
8 / 9/27 8/ 4/27 7/I3/27 1/24/27
9 / 7/27 8/10/27 8 / 4/27 3/30/27
3
11191 12024 13968 14769
8/11/22 10/22/23
9 / 5/22 12/30/23
2
15536 15585'
AGE
i I 1 5 5
3/22/26
6 3 7
2/I5/26 2/25/26
3 / 9/26 4/12/26
6
16158
7/ 2/26
7/21/26
2
19670 20360 19473 12303 ]2257
3/22/28 6/29/28 2/23/28 . 2 / 7/24 1/22/24
4 / 5/28 8 / 6/28 3/16/28 3 / 7/24 4 / 6/24
6 3 I0 1O
14829
9/15/25
11/ 1/25
3
26357
1/26/31
3 / 2/31
I
23252
10/14/29
12/ 7/29
4
17401
2/26/27
7/20/27
3
17401
8/ 2/27
9/29/27
8
17517 17529 17194
3/19/27 3/22/27 1/17/27
4/28/27 4 / 4/27 2/26/27
4 4 1
14369
6/24/25
7/17/25
5
3/23/25 12/ 4/2~
4/ 4/25
8
3
yr. yr. 2 mo. yr. 1 too. mo. mo. me. me.
C0MPLIC~TIONS COURSE
AN])
Uneventful Uneventful Uneventful Uneventful Uneventful Uneventful Diarrhea, upper respiratory infection too. Uneventful roD. Upper respiratory infe.ct/on, bronehopneumoma yr. 2 mo. Uneventful yr. Upper respiratory infection too. Upper respiratory infection, diarrhea lnO, Upper respiratory infection, diarrhea yr. 2 rod. Uneventful yr. Upper respiratory infection m0, Uneventful yr. Uneventful me. Uneventful me, Upper respiratory infection, ehiekenpox ]no, Uneventful rod. Postauricular abscess me. Uneventful me. Upper respiratory infection me. Uneventful me. Upper respiratory infection me. Upper respiratory infectio~ me. Intestinal intoxication me. Diarrhea me. Intestinal intoxication me. Uneventful me. Upper respiratory infection, mastoiditis, abscess of groin InO, Otitis media, diarrhea; intestinal intoxication yr. Upper respiratory infection n2o, Upper respiratory infection, pneumonia i310. Spasmophi]ia, upper respiratory infection, furnnenlosis, cervical adenitis ]no, Upper respiratory infection mo. Bronchopneumonia me. Bronchopneumonia yr. I0 mo Upper respiratory infection mo. Uneventful
RESULT
Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Expired Expired Expired Improved Improved Improved Improved Improved Improved
Improved Improved Improved Improved Improved Expired Improved Expired Improved Improved Improved Improved
Expired Improved Improved Improved
Improved Expired Expired hnproved Improved
I(OCI-I AND SCHWARTZ:
INFANTILE ECZEMA
171
TABLE I--CONT'D ttOSP. DATEOF DAT~EOP AGE NO. hi'MISSION DISCI-IAI~GE 6/20/26 5 1no. 7/ 9/26 16087
COMPLICATIONS AND ~OURSE [Jpper respiratory infection 8 too. Upper respiras infection 4 too. [Impetigo, pneumonia 1 yr. 4 mo. Uneventful 2 mo. Otitis media, furunculosis 2 too. Diarrhea, furunculosis upper respiratory infection 2 mo. 1 wk. Diarrhea 1 mo. Uneventful 6 mo. Upper respiratory infection 1 yr. 2 too. Uneventful 1 yr. Upper respiratory infection 2 mo. Uneventful 1 yr. I mo. Uneventful 8 too. Uneventful 3 mo. Impetigo I yr. 7 mo. Upper respiratory infection
Improved
21388
11/27/28
12/15/28
Expireit
21587 11731 23799
I/ 5/29 5/14/23 1/10/30
1/26/29 6/21/23 3/14/30
21725
2/ 5/29
4/16/29
23038 18327 11365
9/ 3/29 8/ 9/27 11/ 3/22
9/20/29 10/25/27 11/ 6/22
18368 15919
8/15/27 1/26/27
8/21/27 3/21/27
16917 11358 13309 13146 21361
11/20/26 10/31/22 10/25/24 ,9/17/24 11/21/28
12/10/26 11/29/22 11/19/24 11/20/24 1/14/29
RESUI2T
Improved Improved Improved Improved Expired Improved Improved Improved Improved Improved Improved Improved Improved Improved
~UMh{ARY OF TABL~ I NO. CASES 23 10 3 2 2 1 2 1 1 1 1 1 1
COURSE DURING It0.SPITAL STAY Uneventful Upper respiratory infection Upper respiratory infection Bronchopneumoniu Diarrhea, upper respiratory infection Diarrhea, upper respiratory infection Upper respiratory infection~ bronchopneumonia Diarrhea Diarrhea Intestinal intoxication Intestinal intoxication Upper respiratory infection, chickenpox Upper respiratory infection, mastoiditis, abscess of g r o i n Upper respiratory infection, diarrhea, furuneulosis Upper respiratory infection, spasmophilia, furuncu]osis, cervical adenitis Otitis media, diarrhea, intestinal intoxication Otitis media, furunculosis Impetigo, pneumonia Impetigo Postauriculor abscess
RESULT Improved Improved Expired Expired Expired Improved Improved Expired Improved Expired Improved Improved Improved Improved Improved Expired Improved Improved Improved Improved
m o r e t h a n one c o m p l i c a t i o n , as s h o w n in T a b l e I. D i a r r h e a o r u p p e r respiratory infection were the most common eomplieations. T h e r e w e r e 47 i n f a n t s a d m i t t e d f o r t h e t r e a t m e n t of e c z e m a i n w h o m t h e r e w a s an a d d i t i o n a l a d m i s s i o n d i a g n o s i s ( T a b l e I I ) . T h i r t y - t h r e e o f t h e s e i n f a n t s h a d a n u n e v e n t f u l course. T w e l v e i n f a n t s d e v e l o p e d n e w c o m p l i c a t i o n s , a h o s p i t a l m o r b i d i t y in t h i s g r o u p of 25.5 p e r t e n t .
]72
TtIE
JOUI%NAL
OF
PEDIATRICS
TABLE I I I N F A N T S A D M I T T E D ~FOl% T R E A T M E N T OF EOZEI~[A W I T H
HOSP. NO.
DATE O~ ADMISSION
DATE 01~ DISOHARGE
AGE
24145
3 / 5/30 3 / 2 1 / 3 0
1 yr.
24145
4/29/30
23886
1/25/30
18286
2 / 2/28
19851 19018
6/12/28 12/ 5/27
19018 19018
11/ 2/28 4 / 5/29
18106 16205
7 / 8/27 9/27/26
18185 11777 14249
7/19/27 6 / 6/23 5/27/25
26268 24877 22698 25717 25456 25456
1/13/31 6/23/30 7/17/29
10/15/30
19184 18253 18702
1 / 7/28 7/29/27 10/10/27
16773 16773
10/21/26 12/ 4/26
16782
10/23/26
16850
11/ 5/26
16938 17865 17259 17042
11/24/26
12135
12/11/23
12181
12/27/23
9 / 9/30 9/23/30
5/23/27 1/28/27 12/13/26
1 5/20/30 1 2 2/18/30 9
too. yr. too. mo.
ADMISSION DIAGNOSIS
Eczema, impetigo
ADDITIONAL COI~pLAINTS
COURSE
Uneventful
Eczema, upper respir- Diarrhea atory infection Eczema, cervical ad-! Uneventful enitis 2/21/28 1 yr. Eczema, infected fin- Uneventful 1 me. ger 6/27/28 8 mo. Eczema, otitis media Uneventful 12/22/27 I yr. Eczema, intestinal in- Otitis media 1 me. toxieation 1/21/29 2 yr. Eczema, scabies Uneventful 4/20/29 2 yr. Eczema, upper respir- Uneventful 5 me. atory infection Uneventful 8/10/27 8 too. Eczema, impetigo 11/24/27 3 mo. Eczema, furuneulosis Diarrhea, otitis media 8 / 1/27 5 too. Eczema, malnutrition Uneventful 6/20/23 11 too. Eczema, impetigo Uneventful 11/29/25 10 too. Eczema, upper respir- Uneventful atory infection 3/22/31 2 mo. Eczema, impetigo Diarrhea Uneventful 7/19/30 I yr. Eczema, clubfoot 8 / 4/29 1 yr. Eczema, nephrosis(?) Uneventful 12/20/30 2 mo. Eczema, diarrhea 9/12/30 1 yr. Eczema, otitis media Uneventful 10/ 3/30 1 yr. Eczema, otitis media Pneumonia 1 mo. Uneventful 2 / 2/28 3 too. Eczema, diarrhea 8 / 9/27 6 mo. Eczema, otitis media Uneventful 10/26/27 4 mo. Eczema, upper respir- Uneventful atory infection Uneventful 11/ 9/26 2 too. Eczema, diarrhea 12/11/26 4 too. Eczema, upper respiratory i n f e c t i o n (dating from previous d a t e of discharge from hospital) 11/10/26 1 too. Eczema, diarrhea Upper respiratory infection 11/24/26 1,_I, too. Eczema, upper respir- Uneventful atory infection 12/26/26 289 too. Eczema, diarrhea Uneventful 8 / 9/27 5 mo. Eczema, otitis media Uneventful 2 / 4/27 5 too. Eczema, pneumonia 3/21/27 6 too. Eczema, upper respir- Cervical adeniris, chickenatory infection pox ; discharged after 3 months ' stay; weight 1 lb. 10 oz. less t h a n on admission Uneventful 2 / 7/2/[ 1 yr. Eczema, asthma 3 too. 1 / 1 5 / 2 4 10 too. Eczema, upper respir- Uneventful atory infection
RESULT
Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Expired Improved Improved Expired Improved Improved Improved Improved Expired
Improved Improved Improved Improved Expired
Improved Improved
KOCIt AND SCttWARTZ:
173
INFANTILE ECZEMA
TABLE I I - - C O N T 'D IIOSP,
ADMISSION DIAGNOSIS
NO.
13238
Eczema, diarrhea Eczema, upper respiratory infection Eczema, upper respiratory infection Eczema, otitis media Eczema~ birth injury
15874
15916 14653
COURSE
RESULT
Uneventful Uneventful
Improved Improved
Uneventful
Improved
Uneventful Bronehopneumonia Eczema, cervical ad- Uneventful enitis Eczema, spasmophiHa Upper respiratory infection otitis media Eczema, upper respir- Uneventful atory infection Eczema, upper respir- Bronehopneuatory infection monia Eczema, otitis media Uneventful Eczema, upper respir- Cellulitis of atory infection face, chicken-
14400 16995 17426 17656 17391 16917 16917
Improved Improved Improved Improved Improved Expired Improved Improved
pox
17050 14994
Eczema, impetigo Eczema, upper respiratory infection Eczema, hernia Eczema, upper respiratory infection
13210 26298
Uneventful Uneventful
Improved Improved
Uneventful Uneventful
Improved hnproved
SUMMARY 0~ TABLE I I NO, 01~ CASES
1~
A~mssm~ DIAGNOSIS Eczema, upper respiratory infection
UN~VENS FUL
CO1V!PLIOATIONS
1 Cellulitis
1 t 1
Eczema, otitis media Eczema, diarrhea
1 1
Eczema, impetigo Eczema, cervical adenitis Eczema, intestinal intoxication Eczema, furuneulosis Eczema, infected finger Eczema, scabies Eczema, malnutrition Eczema, clubfoot Eczema, nephrosis Eczema, pneumonia Eczema, birth injury Eczema, spasmophilia
2 Diarrhea
Eczema, hernia Eczema, asthma
of
face
chickenpox Cervical adenitis ehiekenpox Bronehopneumonia Upper respiratory in fection dating from date of discharge previous admission to hospital Pneumonia Upper respiratory infection
l Otitis media l Diarrhea, otitis media
RESULT
Improved Improved Expired Expired
Expired Improved Improved Improved Improved
Improved Improved Improved Improved Improved Expired .Expired 1 Bronehopneumonia Improved i Upper respiratory in- Improved fection, otitis media Improved Improved
174
THE JOURNAL 01~' PEDIATRICS
There were 5 deaths in this series, 3 of which were f r o m complications incurred d u r i n g t h e i r hospital stay. The m o r t a l i t y in this series was 10.6 per cent. F o r the entire group of 103 infants, the m o r t a l i t y rate was 14.5 per cent. DISCUSSION
I n f a n t s with infantile eczema seem p a r t i c u l a r l y susceptible to those infections which are generally p r e v a l e n t in the i n f a n t s ' ward. The m o r t a l i t y rate of 17.9 per cent in uncomplicated infantile eczema here recorded is h i g h e r than the m o r t a l i t y rates r e c o r d e d b y Cutler '2 for acute appendicitis (11.4 per cent), empyema (16.6 per cent), pyloric stenosis (11.1 per cent) or f r a c t u r e of skull (10.2 per cent). Admitting the a d v a n t a g e s of a superior dermatologic technic provided in hospital care, does the increased m o r b i d i t y a~d m o r t a l i t y rate justify our jeopardizing the lives of these infants? Eezemas in infancy not only display a particular' susceptibility to r e s p i r a t o r y t r a c t infections, but their t e n d e n c y to unexplained sudden death has often been noted. Clinical review of some of these instances indicates that sudden death in eczema m a y be the result of a massive infection of the r e s p i r a t o r y t r a c t following generalized sepsis. Such infections exhibiting the symptoms of sudden collapse without striking localizing signs are not u n k n o w n to the pediatrician. I t is curious to note t h a t of 15 instances of sudden death collected by Moro, 3 13 occurred d u r i n g Febr~lary, March, and A p r i l - - m o n t h s in which u p p e r r e s p i r a t o r y infections art; m o r e com!qlOil. SUMIVs
AND CONCLUSIONS
1. Of 103 patients with infantile eczema t r e a t e d in an infant ward, 15 died, a m o r t a l i t y rate of 14.5 per cent. 2. Of the 103 cases of infantile eczema t r e a t e d in an infant ward, 45 developed one or more complications, a m o r b i d i t y r a t e of 43.6 per cent. 3. Of 56 infants with infantile eczema admitted for eczema alone, 10 died, a m o r t a l i t y rate of 17.9 per cent; 33 had complications, a morbidity rate of 58.9 per cent. 4. Infants having infantile eczema should not be admitted to an infant ward if they can possibly be treated in a home or fos.ter ho.me, supervised by an out-patient depariment, utilizing the Speedwell technic of Chapin. 5. Sudden death in infantile eczema m a y be the result of massive r e s p i r a t o r y infection of hematogenous origin. REFERENCES 1. Brennemann, 5oseph: Am. J. Dis. Child. 43: 577, 1932. 2. Cutler, G~orge David: Boston, ]~I. & S. J-. 191: 333, 1924. 3. )r E r n e s t : Ekzeraa I n f a n t u m a n 4 Dermatitis Seborrhoides, Yerlag Julius Springer, Berlin, 1932. 2018 E. Nol~z~ AVENUE.
E C E N T L Y , a t t e n t i o n has again been focussed on the dangers of the i n f a n t w a r d - - i t s high m o r t a l i t y and morbidity. 1 Both are largely the result of u p p e r r e s p i r a t o r y infections and digestive disturbances universally p r e s e n t in i n f a n t wards. On this account, m a n y have come to feel with B r e n n e m a n n t h a t " n o i n f a n t should be a d m i t t e d to an i n f a n t w a r d who can with reasonable assurance be t a k e n care of in an out-patient department, or in a good home or foster h o m e . " This would restrict hospitalization of infants to emergencies and to those whose illnesses d e m a n d either f o r purposes of diagnosis or t h e r a p y a specialized technic t h a t c a n n o t be provided in a home. i n o r d e r to define more clearly the c h a r a c t e r of cases that m a y still be r e g a r d e d as eligible f o r hospitalization in an i n f a n t ward, it se~ms i m p o r t a n t to decide w h a t classes of cases should not be admitted to an i n f a n t ward. B r e n n e m a n n lists as especially to be excluded, " b o a r d e r s and infants with infections of the u p p e r respirat o r y t r a c t and gastrointestinal disorders t h a t are not immediately serious. ' ' I n a s m u c h as the m a n a g e m e n t of infantile eczema presents a problem often r e g a r d e d as more ideally t r e a t e d in a hospital, we have gone over the results obtained in the care of 103 cases of infantile eczema admitted to the Milwaukee Children's tIospita]. These 103 patients were net selected in particular', as tllat n m n b e r represents a.lt the infants and children up to two years, who were admitted from August, 1922, to April, 1931, with a diagnosis of infantile eczema. The only Cases omitted from this study a ro those who did not stay in the hospital long" enough f o r a n y conclusions to be drawn, as t h e y were t a k e n home against t h e advice of the a t t e n d i n g physician. The cases have been divided into two g r o u p s : (1) Those infants a d m i t t e d f o r treatment of eczema b u t otherwise in a p p a r e n t l y good health, (2) those infants who had miscellaneous complaints besides their eczema. A d m i t t e d for the t r e a t m e n t of eczema alone were 56 infants (Table I). Of these, 23 h a d an u n e v e n t f u l stay in the hospital, 33 developed complications, a m o r b i d i t y of 58.9 per cent. There were 10 deaths in this group, a m o r t a l i t y of 17.9 per cent a m o n g p r e v i o u s l y h e a l t h y inf a n t s admitted f o r t r e a t m e n t of eczema. Some of the infants h a d
R
F r o m the M i l w a u k e e C h i l d r e n ' s H o s p i t a l a nd D e p a r t m e n t of P e d i a t r i c s , M a r q u e t t e U n i v e r s i t y Medical School. S u b m i t t e d for p u b l i c a t i o n Aug. 6, ].932. 169
J70
TIlE JOURNAL OF PEDIATRICS TA~nE I IN~'AN'•
ADMIT'I"ED ~OR TRF~ATMEN'I' 0t~ EOZEIVIA
tXOSP. bIO.
DATE OF ADMISSION
DATE 0 F DISC:~IABA]E
26576 19483 18286 19851 20949 18181 13559
3 / 5/31 2/24/28 1/14/28 4/17/28 7/19/28 7/18/27 12/31/24
3/16/31 3 / 7/28 1/26/28 5/21/28 11/ 7/28 8/13/27
1/26/25
I 1 1 8 2 8 7
12484 12484
7/23/24 4 / 7/24
9/ 9/24 5/31/24
9 5
12314 24877
2/12/24 9/30/20
2/27/24 2/12/31
1 1
22425
6/10/29
7/16/29
6
19632
3/17/28
3/23/28
4
25914 21692
11/21/30 1/29/29
11/26/30 2/24/29
18325 18156 18145 17230
8 / 9/27 8/ 4/27 7/I3/27 1/24/27
9 / 7/27 8/10/27 8 / 4/27 3/30/27
3
11191 12024 13968 14769
8/11/22 10/22/23
9 / 5/22 12/30/23
2
15536 15585'
AGE
i I 1 5 5
3/22/26
6 3 7
2/I5/26 2/25/26
3 / 9/26 4/12/26
6
16158
7/ 2/26
7/21/26
2
19670 20360 19473 12303 ]2257
3/22/28 6/29/28 2/23/28 . 2 / 7/24 1/22/24
4 / 5/28 8 / 6/28 3/16/28 3 / 7/24 4 / 6/24
6 3 I0 1O
14829
9/15/25
11/ 1/25
3
26357
1/26/31
3 / 2/31
I
23252
10/14/29
12/ 7/29
4
17401
2/26/27
7/20/27
3
17401
8/ 2/27
9/29/27
8
17517 17529 17194
3/19/27 3/22/27 1/17/27
4/28/27 4 / 4/27 2/26/27
4 4 1
14369
6/24/25
7/17/25
5
3/23/25 12/ 4/2~
4/ 4/25
8
3
yr. yr. 2 mo. yr. 1 too. mo. mo. me. me.
C0MPLIC~TIONS COURSE
AN])
Uneventful Uneventful Uneventful Uneventful Uneventful Uneventful Diarrhea, upper respiratory infection too. Uneventful roD. Upper respiratory infe.ct/on, bronehopneumoma yr. 2 mo. Uneventful yr. Upper respiratory infection too. Upper respiratory infection, diarrhea lnO, Upper respiratory infection, diarrhea yr. 2 rod. Uneventful yr. Upper respiratory infection m0, Uneventful yr. Uneventful me. Uneventful me, Upper respiratory infection, ehiekenpox ]no, Uneventful rod. Postauricular abscess me. Uneventful me. Upper respiratory infection me. Uneventful me. Upper respiratory infection me. Upper respiratory infectio~ me. Intestinal intoxication me. Diarrhea me. Intestinal intoxication me. Uneventful me. Upper respiratory infection, mastoiditis, abscess of groin InO, Otitis media, diarrhea; intestinal intoxication yr. Upper respiratory infection n2o, Upper respiratory infection, pneumonia i310. Spasmophi]ia, upper respiratory infection, furnnenlosis, cervical adenitis ]no, Upper respiratory infection mo. Bronchopneumonia me. Bronchopneumonia yr. I0 mo Upper respiratory infection mo. Uneventful
RESULT
Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Expired Expired Expired Improved Improved Improved Improved Improved Improved
Improved Improved Improved Improved Improved Expired Improved Expired Improved Improved Improved Improved
Expired Improved Improved Improved
Improved Expired Expired hnproved Improved
I(OCI-I AND SCHWARTZ:
INFANTILE ECZEMA
171
TABLE I--CONT'D ttOSP. DATEOF DAT~EOP AGE NO. hi'MISSION DISCI-IAI~GE 6/20/26 5 1no. 7/ 9/26 16087
COMPLICATIONS AND ~OURSE [Jpper respiratory infection 8 too. Upper respiras infection 4 too. [Impetigo, pneumonia 1 yr. 4 mo. Uneventful 2 mo. Otitis media, furunculosis 2 too. Diarrhea, furunculosis upper respiratory infection 2 mo. 1 wk. Diarrhea 1 mo. Uneventful 6 mo. Upper respiratory infection 1 yr. 2 too. Uneventful 1 yr. Upper respiratory infection 2 mo. Uneventful 1 yr. I mo. Uneventful 8 too. Uneventful 3 mo. Impetigo I yr. 7 mo. Upper respiratory infection
Improved
21388
11/27/28
12/15/28
Expireit
21587 11731 23799
I/ 5/29 5/14/23 1/10/30
1/26/29 6/21/23 3/14/30
21725
2/ 5/29
4/16/29
23038 18327 11365
9/ 3/29 8/ 9/27 11/ 3/22
9/20/29 10/25/27 11/ 6/22
18368 15919
8/15/27 1/26/27
8/21/27 3/21/27
16917 11358 13309 13146 21361
11/20/26 10/31/22 10/25/24 ,9/17/24 11/21/28
12/10/26 11/29/22 11/19/24 11/20/24 1/14/29
RESUI2T
Improved Improved Improved Improved Expired Improved Improved Improved Improved Improved Improved Improved Improved Improved
~UMh{ARY OF TABL~ I NO. CASES 23 10 3 2 2 1 2 1 1 1 1 1 1
COURSE DURING It0.SPITAL STAY Uneventful Upper respiratory infection Upper respiratory infection Bronchopneumoniu Diarrhea, upper respiratory infection Diarrhea, upper respiratory infection Upper respiratory infection~ bronchopneumonia Diarrhea Diarrhea Intestinal intoxication Intestinal intoxication Upper respiratory infection, chickenpox Upper respiratory infection, mastoiditis, abscess of g r o i n Upper respiratory infection, diarrhea, furuneulosis Upper respiratory infection, spasmophilia, furuncu]osis, cervical adenitis Otitis media, diarrhea, intestinal intoxication Otitis media, furunculosis Impetigo, pneumonia Impetigo Postauriculor abscess
RESULT Improved Improved Expired Expired Expired Improved Improved Expired Improved Expired Improved Improved Improved Improved Improved Expired Improved Improved Improved Improved
m o r e t h a n one c o m p l i c a t i o n , as s h o w n in T a b l e I. D i a r r h e a o r u p p e r respiratory infection were the most common eomplieations. T h e r e w e r e 47 i n f a n t s a d m i t t e d f o r t h e t r e a t m e n t of e c z e m a i n w h o m t h e r e w a s an a d d i t i o n a l a d m i s s i o n d i a g n o s i s ( T a b l e I I ) . T h i r t y - t h r e e o f t h e s e i n f a n t s h a d a n u n e v e n t f u l course. T w e l v e i n f a n t s d e v e l o p e d n e w c o m p l i c a t i o n s , a h o s p i t a l m o r b i d i t y in t h i s g r o u p of 25.5 p e r t e n t .
]72
TtIE
JOUI%NAL
OF
PEDIATRICS
TABLE I I I N F A N T S A D M I T T E D ~FOl% T R E A T M E N T OF EOZEI~[A W I T H
HOSP. NO.
DATE O~ ADMISSION
DATE 01~ DISOHARGE
AGE
24145
3 / 5/30 3 / 2 1 / 3 0
1 yr.
24145
4/29/30
23886
1/25/30
18286
2 / 2/28
19851 19018
6/12/28 12/ 5/27
19018 19018
11/ 2/28 4 / 5/29
18106 16205
7 / 8/27 9/27/26
18185 11777 14249
7/19/27 6 / 6/23 5/27/25
26268 24877 22698 25717 25456 25456
1/13/31 6/23/30 7/17/29
10/15/30
19184 18253 18702
1 / 7/28 7/29/27 10/10/27
16773 16773
10/21/26 12/ 4/26
16782
10/23/26
16850
11/ 5/26
16938 17865 17259 17042
11/24/26
12135
12/11/23
12181
12/27/23
9 / 9/30 9/23/30
5/23/27 1/28/27 12/13/26
1 5/20/30 1 2 2/18/30 9
too. yr. too. mo.
ADMISSION DIAGNOSIS
Eczema, impetigo
ADDITIONAL COI~pLAINTS
COURSE
Uneventful
Eczema, upper respir- Diarrhea atory infection Eczema, cervical ad-! Uneventful enitis 2/21/28 1 yr. Eczema, infected fin- Uneventful 1 me. ger 6/27/28 8 mo. Eczema, otitis media Uneventful 12/22/27 I yr. Eczema, intestinal in- Otitis media 1 me. toxieation 1/21/29 2 yr. Eczema, scabies Uneventful 4/20/29 2 yr. Eczema, upper respir- Uneventful 5 me. atory infection Uneventful 8/10/27 8 too. Eczema, impetigo 11/24/27 3 mo. Eczema, furuneulosis Diarrhea, otitis media 8 / 1/27 5 too. Eczema, malnutrition Uneventful 6/20/23 11 too. Eczema, impetigo Uneventful 11/29/25 10 too. Eczema, upper respir- Uneventful atory infection 3/22/31 2 mo. Eczema, impetigo Diarrhea Uneventful 7/19/30 I yr. Eczema, clubfoot 8 / 4/29 1 yr. Eczema, nephrosis(?) Uneventful 12/20/30 2 mo. Eczema, diarrhea 9/12/30 1 yr. Eczema, otitis media Uneventful 10/ 3/30 1 yr. Eczema, otitis media Pneumonia 1 mo. Uneventful 2 / 2/28 3 too. Eczema, diarrhea 8 / 9/27 6 mo. Eczema, otitis media Uneventful 10/26/27 4 mo. Eczema, upper respir- Uneventful atory infection Uneventful 11/ 9/26 2 too. Eczema, diarrhea 12/11/26 4 too. Eczema, upper respiratory i n f e c t i o n (dating from previous d a t e of discharge from hospital) 11/10/26 1 too. Eczema, diarrhea Upper respiratory infection 11/24/26 1,_I, too. Eczema, upper respir- Uneventful atory infection 12/26/26 289 too. Eczema, diarrhea Uneventful 8 / 9/27 5 mo. Eczema, otitis media Uneventful 2 / 4/27 5 too. Eczema, pneumonia 3/21/27 6 too. Eczema, upper respir- Cervical adeniris, chickenatory infection pox ; discharged after 3 months ' stay; weight 1 lb. 10 oz. less t h a n on admission Uneventful 2 / 7/2/[ 1 yr. Eczema, asthma 3 too. 1 / 1 5 / 2 4 10 too. Eczema, upper respir- Uneventful atory infection
RESULT
Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Improved Expired Improved Improved Expired Improved Improved Improved Improved Expired
Improved Improved Improved Improved Expired
Improved Improved
KOCIt AND SCttWARTZ:
173
INFANTILE ECZEMA
TABLE I I - - C O N T 'D IIOSP,
ADMISSION DIAGNOSIS
NO.
13238
Eczema, diarrhea Eczema, upper respiratory infection Eczema, upper respiratory infection Eczema, otitis media Eczema~ birth injury
15874
15916 14653
COURSE
RESULT
Uneventful Uneventful
Improved Improved
Uneventful
Improved
Uneventful Bronehopneumonia Eczema, cervical ad- Uneventful enitis Eczema, spasmophiHa Upper respiratory infection otitis media Eczema, upper respir- Uneventful atory infection Eczema, upper respir- Bronehopneuatory infection monia Eczema, otitis media Uneventful Eczema, upper respir- Cellulitis of atory infection face, chicken-
14400 16995 17426 17656 17391 16917 16917
Improved Improved Improved Improved Improved Expired Improved Improved
pox
17050 14994
Eczema, impetigo Eczema, upper respiratory infection Eczema, hernia Eczema, upper respiratory infection
13210 26298
Uneventful Uneventful
Improved Improved
Uneventful Uneventful
Improved hnproved
SUMMARY 0~ TABLE I I NO, 01~ CASES
1~
A~mssm~ DIAGNOSIS Eczema, upper respiratory infection
UN~VENS FUL
CO1V!PLIOATIONS
1 Cellulitis
1 t 1
Eczema, otitis media Eczema, diarrhea
1 1
Eczema, impetigo Eczema, cervical adenitis Eczema, intestinal intoxication Eczema, furuneulosis Eczema, infected finger Eczema, scabies Eczema, malnutrition Eczema, clubfoot Eczema, nephrosis Eczema, pneumonia Eczema, birth injury Eczema, spasmophilia
2 Diarrhea
Eczema, hernia Eczema, asthma
of
face
chickenpox Cervical adenitis ehiekenpox Bronehopneumonia Upper respiratory in fection dating from date of discharge previous admission to hospital Pneumonia Upper respiratory infection
l Otitis media l Diarrhea, otitis media
RESULT
Improved Improved Expired Expired
Expired Improved Improved Improved Improved
Improved Improved Improved Improved Improved Expired .Expired 1 Bronehopneumonia Improved i Upper respiratory in- Improved fection, otitis media Improved Improved
174
THE JOURNAL 01~' PEDIATRICS
There were 5 deaths in this series, 3 of which were f r o m complications incurred d u r i n g t h e i r hospital stay. The m o r t a l i t y in this series was 10.6 per cent. F o r the entire group of 103 infants, the m o r t a l i t y rate was 14.5 per cent. DISCUSSION
I n f a n t s with infantile eczema seem p a r t i c u l a r l y susceptible to those infections which are generally p r e v a l e n t in the i n f a n t s ' ward. The m o r t a l i t y rate of 17.9 per cent in uncomplicated infantile eczema here recorded is h i g h e r than the m o r t a l i t y rates r e c o r d e d b y Cutler '2 for acute appendicitis (11.4 per cent), empyema (16.6 per cent), pyloric stenosis (11.1 per cent) or f r a c t u r e of skull (10.2 per cent). Admitting the a d v a n t a g e s of a superior dermatologic technic provided in hospital care, does the increased m o r b i d i t y a~d m o r t a l i t y rate justify our jeopardizing the lives of these infants? Eezemas in infancy not only display a particular' susceptibility to r e s p i r a t o r y t r a c t infections, but their t e n d e n c y to unexplained sudden death has often been noted. Clinical review of some of these instances indicates that sudden death in eczema m a y be the result of a massive infection of the r e s p i r a t o r y t r a c t following generalized sepsis. Such infections exhibiting the symptoms of sudden collapse without striking localizing signs are not u n k n o w n to the pediatrician. I t is curious to note t h a t of 15 instances of sudden death collected by Moro, 3 13 occurred d u r i n g Febr~lary, March, and A p r i l - - m o n t h s in which u p p e r r e s p i r a t o r y infections art; m o r e com!qlOil. SUMIVs
AND CONCLUSIONS
1. Of 103 patients with infantile eczema t r e a t e d in an infant ward, 15 died, a m o r t a l i t y rate of 14.5 per cent. 2. Of the 103 cases of infantile eczema t r e a t e d in an infant ward, 45 developed one or more complications, a m o r b i d i t y r a t e of 43.6 per cent. 3. Of 56 infants with infantile eczema admitted for eczema alone, 10 died, a m o r t a l i t y rate of 17.9 per cent; 33 had complications, a morbidity rate of 58.9 per cent. 4. Infants having infantile eczema should not be admitted to an infant ward if they can possibly be treated in a home or fos.ter ho.me, supervised by an out-patient depariment, utilizing the Speedwell technic of Chapin. 5. Sudden death in infantile eczema m a y be the result of massive r e s p i r a t o r y infection of hematogenous origin. REFERENCES 1. Brennemann, 5oseph: Am. J. Dis. Child. 43: 577, 1932. 2. Cutler, G~orge David: Boston, ]~I. & S. J-. 191: 333, 1924. 3. )r E r n e s t : Ekzeraa I n f a n t u m a n 4 Dermatitis Seborrhoides, Yerlag Julius Springer, Berlin, 1932. 2018 E. Nol~z~ AVENUE.