- Email: [email protected]
Treatment of giant hemangioma
1030
Editorial correspondence
(y = 2.01 + 1.41 x height in SD)]. In most children, the skeietal age, as determined by the Tanner-Whitehouse method,' was several years advanced. Height in SD was als0 significantly related to the advance in skeletal age (r = 0.58; P < 0.001). These data confirm the clinical impression that both advanced skeletal maturation and advanced height for age may be important diagnostic tools in the diagnosis of exogenous overalimentation obesity in childhood. J.-P. G. M. Van Biervliet, M.D. University Children's Hospital Het Wilhelmina Kinderziekenhuis Utrecht, Netherlands J. F. de Wijn, M.D. Central Institute of Nutrition and Food Research T.N.O. Zeist, Netherlands REFERENCES
1. Forbes GB: Nutrition and growth, J PEDIATR 91:40, 1977. 2. Van Biervliet J-P GM and de Wijn JF: Blood lipids in childhood obesity, Acta Paediatr Belg (in press). 3. van Wieringen JC: Lengte' en gewicht surveys 1964-1966 in Nederland in historisch perspectief, Thesis, Leiden, 1973. 4. Tanner JM, Whitehouse RH, Marshall WA, Healy MJR; and Goldstein H: Assessment of skeletal maturity and prediction of adult height, London, 1975, Academic Press. Inc.
Elevation of TSH during the early neonatal period To the Editor: In the August, 1977, issue of TrIE JOURNAL of Pediatrics, Dr. Mace I reported transient elevation of TSH in stressed premature infants. In our screening program for the detection of congenital hypothyroidism, using radioimmun0assay of thyroid-stimulating hormone (TSH) in capillary blood samples taken on the fifth day of life, in th e county of V/isterbotten in Sweden, many of the infants delivered by cesarean section have been found to have elevated TSH concentrations. So far 6,107 infants have been screened under this program. In 5,961 infants the TSH concentration was in the normal range ( < 20/zU/ml). In 46 infants it was increased. Two of these were infants with congenital hypothyroidism, with TSH concentrations of 87 and 200 #U/ml, respectively at 5 days of age. In the remaining 4 infants the TSH elevation was transient. Twentyfour of these 44 infants were delivered by cesarean section; almost all sections were planned, uncomplicated, and performed at term. Of these 24 infants, 20 had a slight to moderate increase of the TSH concentration (20 to 45/~U/ml) and four had over 45 /~U/ml. Subsequent follow-up of the 44 infants with a transient elevation of TSH showed that all were euthyroid. The cause of the transient elevation of the neonatal TSH level
The Journal ofPediatrics June 1978
in the infants delivered by cesarean section is unknown. It might indicate a transient hypothyroidism, but more probably represents a response to a perinatal stress factor or factors associated with the cesarean section itself. We are currently making a detailed study of the neonatal thyroid function in such children, including pituitary trophic hormone levels. Staffan Engberg, M.D. Karl-Henrik Gustavson, M.D. Department o f Pediatrics Lennart Jacobsson, M.D. Ruzena SOderstrOm, M.D. Department o f Clinical Chemistry University Hospital, 90198 Umed, Sweden REFERENCE
1. Mace J: On the diagnosis of hypothyroidism in the early neonatal period, J PEDIATR 9!:347, 1977.
Reply To the Editor: I am pleased to see that Drs. Eugberg and Jacobsson have also seen elevation in TSH without subsequent documentation of hypothyroidism. Their letter further underscores the observation that while TSH may serve as a screening tool for healthy, term neonates, stressed premature neonates may well have elevated TSH levels and not be hypothyroid. Their observation underscores the need for further study as to the mechanisms of TSH elevation in stressed neonates either prior to delivery or immediately after. John Mace, M.D. Professor and Chairman Department of Pediatrics School o f Medicine Loma Linda University Loma Linda, CA 92350
Treatment of giant hemangioma To the Editor: I wish to comment on the article in the September, 1977, issue of THE JOURNAL, entitled "Giant hemangioma with consumption coagulopathy. Sustained response to heparin and radiotherapy." Several statements require rebut!al. Prednis0ne was started but it is not clear when the prednisone was stopped, although the Fig. 1 suggests that this was approximately 20 days; if so, the course of prednisone therapy was shorter than that usually recommended. The statement, [Radio]therapy was given over a period of 80 days. This resulted in normalization of the coagulation indices and disappearance of the hemangioma in four months" may be true, but spontaneous involution may have occurred. More
Volume 92 Number 6
importantly, the prednisone may have hastened the period o f involution. Most importantly, the 20-year effects of x-ray therapy to the back and shoulder of this infant may well result in severe atrophy, particularly of bony growth due to radiation damage of the secondary ossification centers. Nordberg and Sundberg, 2 showed severe atrophy and growth defects in children who were irradiated 15 to 20 years previously. Lampe and Latourette 3 pointed out the potential and proven ill effects from radiotherapy over a long-term period in infants and children. In view o f our 20 years' experience with management of hemangiomas in over 450 patients, in which most hemangiomas of the involuting type have spontaneously involuted over a five to seven-year period, we feel strongly that this article does a disfavor to the present literature. In addition, the conclusion by the authors that the treatment of giant hemangioma with consumptive coagulopathy must be carefully planned and that radiotherapy rather than surgery is the first choice for the defimtive cure, is not entirely correct. We would much prefer to try prednisone therapy a n d / o r compression, and then surgery before considering radiotherapy. A. M. Margileth, M.D. Director, OPD Children's Hospital National Medical Center 111 Michigan Ave, N. IV. Washington, DC 20010 REFERENCES
1.
2.
3.
Carnelli V, Bellini F, Ferrari M, Rossi E, and Masera G: Giant hemangioma with consumption coagulopathy: Sustained response to heparin and radiotherapy, J PBDIATR 9:504, 1977. Nordberg UB, and Sundberg J: Indications and methods for radiotherapy of cavernous hemangiomas, Acta Radiol 1:257, 1963. Lampe I, and Latourette HB: Management of cavernous hemangiomas in infants, Pediatr Clin North Am 6:511, 1959.
Re#y To the Editor: We thank Dr. Margileth who, by his critical remarks, allowed us to reconsider some aspects of our case report. We would like to stress that our data and conclusions concern only giant angiomas with consumption coagulopathy. In these rare cases, the patient is at high risk and a long wait for a favorable development is to be avoided. In a recent work Hagerman et al' in a similar case followed the same course of therapy, that is, heparin, prednisone, and radiotherapy, believing tha t "when consumption coagulopathy renders hemostasis inadequate, surgery can be catastrophic." These same authors turned to surgery only after the failure of all therapeutic attempts. We agree that in angiomas the best policy is usually to wait, but we reported a case of giant angioma with consumption coagulopathy, life threatening, in which a prompt treatment was mandatory and surgery could have been "catastrophic."
Editorial correspondence
103 1
As to the risks of radiotherapy, no author (not even those quoted by Dr. Margileth) asserts openly t h a t - a t the recommended doses-it is advisable to avoid this treatment in these severe angiomas. Moreover, Norberg et al ~ in their case reports never observed bone damage with skin doses up to 1,800 rads. Ossification is not disturbed with doses, directly administered to the tissue, up to 300 rads, though it could be with over 400 rads. The dose we administered (focal distance 50 mm HVL 13 ram) was of 120 rads at the proximal nucleus o f humerus, well below the range quoted. As to skin damage, Norberg et al ~ administered skin doses up to 1,000 fads both with radium and contact roentgen therapy, independently of the technique employed (single or combined). The dose we administered was less than half in every field considered. Lampe and Latourette ~ simply mention the possible late damage of irradiation with which we are all well acquainted. Furthermore, steroid therapy was extended for 25 days, a period within which a favorable development is usually to be expected. It is unadvisable to prolong this therapy for a longer time in severe cases without a prompt response. V. Carnelli F. Bellini G. Masera E. Rossi M. Ferrari Clinica Pediatria University of Milan Via Commenda, 9 20122 Milan Italy REFERENCES
1. Hagerman L J, Czapek EE, Donnellan WL, and Schwartz AD: Giant hemangioma with consumption coagulopathy, J PEDIATR 87:766, 1975, 2. Nordberg UB, and Sundberg J: Indications and methods for radiotherapy of cavernous hemangiomas, Acta Radiol 1:257, 1963. 3. Lampe I, and Latourette HB: Management of cavernous hemangiomas in infants, Pediatr Clin North Am 6:511, 1959.
Management of narcotic withdrawal in neonates To the Editor: I have read with interest the article, "Neonatal seizures associated with narcotic withdrawal" by Herzlinger et al. 1 Besides diazepam and phenobarbital, paregoric alone or in combination with phenobarbital or diazepam or both was used as therapy. The authors recommended, "careful utilization of paregoric, supplemented by phenobarbital if required for management of intractable seizures, in the treatment of neonatal narcotic withdrawal."
Editorial correspondence
(y = 2.01 + 1.41 x height in SD)]. In most children, the skeietal age, as determined by the Tanner-Whitehouse method,' was several years advanced. Height in SD was als0 significantly related to the advance in skeletal age (r = 0.58; P < 0.001). These data confirm the clinical impression that both advanced skeletal maturation and advanced height for age may be important diagnostic tools in the diagnosis of exogenous overalimentation obesity in childhood. J.-P. G. M. Van Biervliet, M.D. University Children's Hospital Het Wilhelmina Kinderziekenhuis Utrecht, Netherlands J. F. de Wijn, M.D. Central Institute of Nutrition and Food Research T.N.O. Zeist, Netherlands REFERENCES
1. Forbes GB: Nutrition and growth, J PEDIATR 91:40, 1977. 2. Van Biervliet J-P GM and de Wijn JF: Blood lipids in childhood obesity, Acta Paediatr Belg (in press). 3. van Wieringen JC: Lengte' en gewicht surveys 1964-1966 in Nederland in historisch perspectief, Thesis, Leiden, 1973. 4. Tanner JM, Whitehouse RH, Marshall WA, Healy MJR; and Goldstein H: Assessment of skeletal maturity and prediction of adult height, London, 1975, Academic Press. Inc.
Elevation of TSH during the early neonatal period To the Editor: In the August, 1977, issue of TrIE JOURNAL of Pediatrics, Dr. Mace I reported transient elevation of TSH in stressed premature infants. In our screening program for the detection of congenital hypothyroidism, using radioimmun0assay of thyroid-stimulating hormone (TSH) in capillary blood samples taken on the fifth day of life, in th e county of V/isterbotten in Sweden, many of the infants delivered by cesarean section have been found to have elevated TSH concentrations. So far 6,107 infants have been screened under this program. In 5,961 infants the TSH concentration was in the normal range ( < 20/zU/ml). In 46 infants it was increased. Two of these were infants with congenital hypothyroidism, with TSH concentrations of 87 and 200 #U/ml, respectively at 5 days of age. In the remaining 4 infants the TSH elevation was transient. Twentyfour of these 44 infants were delivered by cesarean section; almost all sections were planned, uncomplicated, and performed at term. Of these 24 infants, 20 had a slight to moderate increase of the TSH concentration (20 to 45/~U/ml) and four had over 45 /~U/ml. Subsequent follow-up of the 44 infants with a transient elevation of TSH showed that all were euthyroid. The cause of the transient elevation of the neonatal TSH level
The Journal ofPediatrics June 1978
in the infants delivered by cesarean section is unknown. It might indicate a transient hypothyroidism, but more probably represents a response to a perinatal stress factor or factors associated with the cesarean section itself. We are currently making a detailed study of the neonatal thyroid function in such children, including pituitary trophic hormone levels. Staffan Engberg, M.D. Karl-Henrik Gustavson, M.D. Department o f Pediatrics Lennart Jacobsson, M.D. Ruzena SOderstrOm, M.D. Department o f Clinical Chemistry University Hospital, 90198 Umed, Sweden REFERENCE
1. Mace J: On the diagnosis of hypothyroidism in the early neonatal period, J PEDIATR 9!:347, 1977.
Reply To the Editor: I am pleased to see that Drs. Eugberg and Jacobsson have also seen elevation in TSH without subsequent documentation of hypothyroidism. Their letter further underscores the observation that while TSH may serve as a screening tool for healthy, term neonates, stressed premature neonates may well have elevated TSH levels and not be hypothyroid. Their observation underscores the need for further study as to the mechanisms of TSH elevation in stressed neonates either prior to delivery or immediately after. John Mace, M.D. Professor and Chairman Department of Pediatrics School o f Medicine Loma Linda University Loma Linda, CA 92350
Treatment of giant hemangioma To the Editor: I wish to comment on the article in the September, 1977, issue of THE JOURNAL, entitled "Giant hemangioma with consumption coagulopathy. Sustained response to heparin and radiotherapy." Several statements require rebut!al. Prednis0ne was started but it is not clear when the prednisone was stopped, although the Fig. 1 suggests that this was approximately 20 days; if so, the course of prednisone therapy was shorter than that usually recommended. The statement, [Radio]therapy was given over a period of 80 days. This resulted in normalization of the coagulation indices and disappearance of the hemangioma in four months" may be true, but spontaneous involution may have occurred. More
Volume 92 Number 6
importantly, the prednisone may have hastened the period o f involution. Most importantly, the 20-year effects of x-ray therapy to the back and shoulder of this infant may well result in severe atrophy, particularly of bony growth due to radiation damage of the secondary ossification centers. Nordberg and Sundberg, 2 showed severe atrophy and growth defects in children who were irradiated 15 to 20 years previously. Lampe and Latourette 3 pointed out the potential and proven ill effects from radiotherapy over a long-term period in infants and children. In view o f our 20 years' experience with management of hemangiomas in over 450 patients, in which most hemangiomas of the involuting type have spontaneously involuted over a five to seven-year period, we feel strongly that this article does a disfavor to the present literature. In addition, the conclusion by the authors that the treatment of giant hemangioma with consumptive coagulopathy must be carefully planned and that radiotherapy rather than surgery is the first choice for the defimtive cure, is not entirely correct. We would much prefer to try prednisone therapy a n d / o r compression, and then surgery before considering radiotherapy. A. M. Margileth, M.D. Director, OPD Children's Hospital National Medical Center 111 Michigan Ave, N. IV. Washington, DC 20010 REFERENCES
1.
2.
3.
Carnelli V, Bellini F, Ferrari M, Rossi E, and Masera G: Giant hemangioma with consumption coagulopathy: Sustained response to heparin and radiotherapy, J PBDIATR 9:504, 1977. Nordberg UB, and Sundberg J: Indications and methods for radiotherapy of cavernous hemangiomas, Acta Radiol 1:257, 1963. Lampe I, and Latourette HB: Management of cavernous hemangiomas in infants, Pediatr Clin North Am 6:511, 1959.
Re#y To the Editor: We thank Dr. Margileth who, by his critical remarks, allowed us to reconsider some aspects of our case report. We would like to stress that our data and conclusions concern only giant angiomas with consumption coagulopathy. In these rare cases, the patient is at high risk and a long wait for a favorable development is to be avoided. In a recent work Hagerman et al' in a similar case followed the same course of therapy, that is, heparin, prednisone, and radiotherapy, believing tha t "when consumption coagulopathy renders hemostasis inadequate, surgery can be catastrophic." These same authors turned to surgery only after the failure of all therapeutic attempts. We agree that in angiomas the best policy is usually to wait, but we reported a case of giant angioma with consumption coagulopathy, life threatening, in which a prompt treatment was mandatory and surgery could have been "catastrophic."
Editorial correspondence
103 1
As to the risks of radiotherapy, no author (not even those quoted by Dr. Margileth) asserts openly t h a t - a t the recommended doses-it is advisable to avoid this treatment in these severe angiomas. Moreover, Norberg et al ~ in their case reports never observed bone damage with skin doses up to 1,800 rads. Ossification is not disturbed with doses, directly administered to the tissue, up to 300 rads, though it could be with over 400 rads. The dose we administered (focal distance 50 mm HVL 13 ram) was of 120 rads at the proximal nucleus o f humerus, well below the range quoted. As to skin damage, Norberg et al ~ administered skin doses up to 1,000 fads both with radium and contact roentgen therapy, independently of the technique employed (single or combined). The dose we administered was less than half in every field considered. Lampe and Latourette ~ simply mention the possible late damage of irradiation with which we are all well acquainted. Furthermore, steroid therapy was extended for 25 days, a period within which a favorable development is usually to be expected. It is unadvisable to prolong this therapy for a longer time in severe cases without a prompt response. V. Carnelli F. Bellini G. Masera E. Rossi M. Ferrari Clinica Pediatria University of Milan Via Commenda, 9 20122 Milan Italy REFERENCES
1. Hagerman L J, Czapek EE, Donnellan WL, and Schwartz AD: Giant hemangioma with consumption coagulopathy, J PEDIATR 87:766, 1975, 2. Nordberg UB, and Sundberg J: Indications and methods for radiotherapy of cavernous hemangiomas, Acta Radiol 1:257, 1963. 3. Lampe I, and Latourette HB: Management of cavernous hemangiomas in infants, Pediatr Clin North Am 6:511, 1959.
Management of narcotic withdrawal in neonates To the Editor: I have read with interest the article, "Neonatal seizures associated with narcotic withdrawal" by Herzlinger et al. 1 Besides diazepam and phenobarbital, paregoric alone or in combination with phenobarbital or diazepam or both was used as therapy. The authors recommended, "careful utilization of paregoric, supplemented by phenobarbital if required for management of intractable seizures, in the treatment of neonatal narcotic withdrawal."