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! 2 0

Brief clinical and laborator)"

observations

concept that conversion of T4 to T~ depends upon a 5'- monodeiodinase enzyme system that is immature at birth? The 3,3'T2 is thought to be derived at least in part from the peripheral conversion of T~ and reverse T~? In this infant, the 3,3'T~ level was high at birth, and remained elevated until the twenty-sixth day; therefore, it seems likely that the enzyme or enzymes capable of forming 3,3'T~ in thyrotoxicosis are operative at birth. LATS-P was present in high concentrations-in the serum of both mother and infant, whereas LATS was measurable in both at low levels which could be consid- ered nonspecific? The high concentration of LATS-P in the infant's serum when he was hyperthyroid and its reduction to undetectable levels when he became euthy-. roid suggest a role for this thyroid-stimulating immuno- globulin in the development of neonatal thyrotoxic0sis? Although the routine measurement, in all pregnant thyr0toxic women, of the thyroid-stimulating immuno- glob.ulins LATS and LATS-P may be helpful in detecting neofmtal thyrotoxicosis, a definitive diagnosis of this disorder requires the demonstration of elevated iodothy- ronines in the infant. Although T4 and rT3 levels in cord serum are normally higher than in serum of euthyroid adults,~"~markedly elevated levels should suggest hyper- thyroidism. An elevated cord serum T3 value may be

diagnostic, since it is normally very low, ~. s

elevated cord serum 3,3'T: level also indicates overpro- duction of iodothyronines. This patient illustrates that a variety of iodothyronines are abnormally elevated in neonatal thyrotoxicosis, and supports the concept that the disorder is produced by transplacental transmission of thyroid-stimulating immu- noglobulins.

We thank Dr. David II. Solomon for his valuable advice as well as his help in performing the LATS and LATS-protector

and an

TI,e Journal of Pediatrics

July 1978

assays, and v.'e appreciate the technical assistance of Frances D. Wright, Yin-Ying Djuh, Yvonne Lukes, Francoise Smith, and the

staff of the

We also thank Janet Anastasi and Rosetta

Medical Center.

Stokes Floyd for secretarial support.

Nuclear Medicine Service, Walter Reed Army

REFERENCES

i.

White C: A foetus with congenital hereditary Graves's disease, J Obstet Gynaecol Br Emp 21:231, 1912.

2.

Sunshine P, Kusumoto H, and Kriss JP: Survival time of circulating long-acting thyroid stimulator in neonatal thyro- toxicosis: Implications for diagnosis and therapy of the disorder, Pediatrics 36:869, 1965.

3.

Dirmikis SM, and Munro DS: Placental transmission of thyroid-stimulating immunoglobulins, Br Med J 2:665,

1975.

4.

Burman KD, Read J, Dimond RC, Strum D, Wright FD, Patow W, Earll JM, and Wartofsky L: Measurements of 3,3',5'-tri-iodothyronine (reverse T3), 3,3'-L-diiodothyro- nine, T3, and T4 in human amniotic fluid and in cord and maternal serum, J Clin Endocrinol Metab 43:1351, 1976.

5.

Burman KD, Strum D, Dimond RC, Djuh Y-Y, Wright FD, Earll JM, and Wartofsky L: A radioimmunoassayfor 3,Y-L- diiodothyronine (3,3'T2), J Clin Endocrinol Metab 45:339,

1977.

6.

Chopra IJ, Solomon DH, and Limberg NP: Specific and non-specific responses in the bioassayof long-acting thyroid stimulator (LATS), J Clin Endocr 31:382, 1970.

7.

Adams DD, Fastier FN, Howie JB, Kennedy TH, Kilpat- rick JA, and Stewart RDtI: Stimulation of the human thyroid by infusions of plasma containing LATS-protector, J Clin Endocrinol Metab 39:826, 1974.

8.

Chopra IJ, Sack J, and Fisher DA: Circulating 3,Y,5'- triiodothyronine (reverse T3) in the human newborn, J Clin Invest 55:1137, 1975.

9.

Chopra IJ, Sack J, and Fisher DA: 3,3',5'-triiodothyronine (reverse T3) and 3,Y,5-triiodothyronine (T3) in fetal and adult sheep: studies of metabolic clearance rates, produc- tion rates, serum binding, and thyroidal content relative to thyroxine, Endocrinology 97:1080, 1975.

A simplified method for diagnosis ofgestational age in the newborn infant

llaroldo Capurro, M.D., Sergio Konlchezky, M.D., Daniel Fonseca, M.D., and

Roberto Caldcyro-Barcia, M.D., Montevideo,

Urttgtta)"

CERTAIN SOMATIC" :~ or neurologic findings or both have correlated well with gestational age as estimated by

From the Latin American Center of Perinatologv and Human Development (PA t10/IVItO). Reprint address: Casilla de Correo 627, Montevideo. Urugua)'.

the date of onset of amenorrhea?- ' In 1970, Dubowitz~ devised a scoring system based on 21 such somatic and neurologic signs. The advantages of this method are that it is painless, inexpensive, precise, and that quantification is possible. Its major inconvenience is its complexity for daily prac-

0022-3476/78/0193-0120500.30/0 9 1978 The C. V. Mosby Co.

Vol,,me 93

Brief clinical and laboratory observations

1 2 1

Number I

 

VARIABLES

Nipple formation

IIipplebarely

 

S

v.[slble: no / areola "/~

t:

B?

Skin texture

Thin,

 

A

gelatinous

S

O

/

M

A

T

I

C

C

Ear form

P.[nna flat &

A

shapeless /

:1

D

II

K=

Breastsize

llo breast

E

204

t.[ssue S

U

days

R

O

Plantar creases

L

I;o creases

O

/

G

I

C

A

L

K=

200

days

;/ell-def.[ned

nipple : areola~

<0.Ts/~,~

Thin

and

smooth /

Incurving of

part

of edge

Diameter

<0.5cm /

Faint

red

marks over

anterior~. '.

/

Areola stlppled |

Areola

not raised

A

raised

/

>

0.75 en

>0.75

Smooth, medium Slight thicken- Thick and

thlekness,super-

 

in~ superflc.[al parchment

f.[clalpeeling

cracking & peel- like

 

~i0

fingeet ~ hands/l~/

/20

 

Nell-deflned

Partial incurvlng of whole of upper

/

incurvlngof

pinna

pinna

/

Diameter 0.5 - 1 on

/

Diameter > 1 on

/

/i0

/is

Definite red marks Indentations over anterior 1/2, over anterlor

anteri~176

/~/

over/

1/2

Deep indentations over more than anterior 1/2W./~Q

Fig.I. Variables and assigned scores in ihe modified Dubowitz method for assessment of gestational age. A. Gestational age in days = 204 + total somatic score (for neurologically depressed infants). B, Gestational age in days = 200 + total combined somatic and neurologic score (for healthy infants).

rice, in vie`,',' of the large number of Variables to be considered. Our aim has been to simplify this method, reducing the number of variables while keeping reason- able precision.

Abbreviation used

 

GA:

gestational age

MATERIAL

AND

METHOD

Gestational age was assessed by the Dubowitz method in 115 newborn infants. The mothers were healthy; pregnancy had been controlled; the time of anaenorrhea was known, based on regular menstrual cycles; and they had not taken hormonal contraceptives for one year before becoming pregnant. The neonates were vigorous (Apgar ~ 7) at the first, fifth, and tenth minutes. No abnormal finding was discov-

ranged

ered during their stay in the

between 790 and 4,500 gm (X = 3,140) and gestational ages between 205 and 296 days (X = 272). Ten percent

hospital.

Weights

0'4 = 11) `,,,'ere small-for-date infants, 85% (N = 98) appropriate-v,,eight-for-date, and 5% (N = 6) large-for- gestational-age. The Conditions stated by Dubowitz ~ `,vere strictly followed (quiet wakefulness) two hours after feeding; cooling and sudden maneuvers during examination were avoided. All the neonates were examined at between 12 and 48 hours of life by the same neonatologist ([t.C.), who

the

corresponding score. The correlation found bet`,veen the

score obtained and the time of amenorrhea for these 115

quantified the 21 findings studied by Dubowitz :' with

infants (r = 0.91, SE

obtained by Dubowitz (r = 0.93, SE = 7). Based on these facts, we attempted to reduce the number of variables to be tested, using a multiple linear regression method. After successive analyses, those variables with a regression coefficient not significantly different from zero, at the selected significance level

(P = 0.05), `,,,'ere discarded.

=

8

days) ,,,,'as similar to that

122 Brie.f cfinical and laboratory observations

RESULTS

OF

THE

SIMPLIFICATION

OF

DUBOWITZ

METIIOD

 

Fig. 1 shows the five somatic and the two neurologic variables which, according to the method of multiple linear regression, were those of major influence in the assessment of GA. These signs correspond to those estab- lished by Dubowitz, but are scored differently, according to their respective influence on the determination of GA as demonstrated by the regression analysis. When the infant has signs of cerebral damage or dysfunction (immediately after labor or later) neurologic signs cannot be used for assessment of GA. Therefore, in these infants, we propose to use only the five somatic signs shown in Fig. !, column A (Method A). When the infant is heaithy and aged more than 12 hours after birth, we propose to use four somatic and two neurologic signs (Fig. i, column B) (Method B). Using Method A, GA (in days) is assessed simply by adding to a constant (K = 204 days), the sum of the five values of somatic findings. The adjustment of this method to our data has been as follows: correlation coefficient

(r) = 0.88, standard error of estimation (SE) = 9.2

days. Using Method B, GA (in days) is assessed by adding to

a slightly different constant (K~ = 200 days), the sum of the values of the four somatic and the two neurologic findings. The adjustment of this method with the time of amenorrhea is as follows: correlation coefficient

(r) = 0.90; standard error of estimation (SE)= 8.4

days. An example of Method B in an hypothetic newborn infant would be as follows: Skin texture, 15; ear form, 24;

The Journal of Pediatrics Jul)" 1978

breast size, 10; plantar creases, 15; scarfsign, 12; head lag, 8; K, 200 = 284 days.

DISCUSSION

The Dubowitz method with 21 variables is somewhat impractical for daily practice. Some authors '~": have tried to simplify it in order to make it easier and quicker for the clinician and the infant, yet preserving its original preci- sion. Our simplified method with only six variables has a similar correlation coefficient and error as that by Dubo- witz. Moreover, it can be used even when the infant is neurologically depressed.

REFERENCES

1. Farr V, and Mitchell RG: Estimation of gestational age in the newborn infant. Comparison between birth weight and maturity scoring in infants premature by weight, Am J Obstet Gynecol 103:380, 1969.

2. Usher R, McLean F. and Scott KE: Judgment Of fetal age. li. Clinical importance of gestational age and an objective method to value it, Pediatr Clin North Am, 835, 1966

3. Saint-Anne D'Argassies S: La maturation neurologique du pr6mature, Etud N6o-Natales 4:71, 1955.

4. Amiel-Tison C: Neurological evaluation of the maturity of newborn infants, Arch Dis Child 43:89, 1968.

5. Dubowitz LMS, Dubowitz V, and Goldberg C: Clinical assessment of gestational age in the newborn infant, J PEDtA'rR77:1, 1970.

6. Parkin JM, Hey EN, and Clowes JS: Rapid assessment of gcstational age at birth, Arch Dis Child 51:259, 1976.

7. Bailard: Mentioned in Klaus MH, and Fanaroff AA, editors: "Care of the high-risk neonate", Philadelphia. 1973, WB Saunders Company, p 47.

Pelforation of feeding tube into right renal pelvis

Rhonda S. Fogle, M.D., Wilbur L. Smith, iM.D.,* and Ed~in L. Gresham, M.D., Indianapolis, Ind.

MECHANICAL COMPLICATIONS have been reported with the use of oro/nasojejunal feeding tubes, including

retroperitoneal perforation of the second portion of duo-

portion

denum, 1- '-' intraperitoneal perforation of the third

of duodenum, -~'~and aspiration from too large a bolus of formula?

From the Department of Neonatolog), RadiologL and Pediatrics, Janws IVhitcomb Rile)' ttospital for Children, Indiana University Medical Center. *Reprint adress:Rile)'Children'sHospital Departmentof Radiology, 1100 WestMichiganSt. Indianapolis, IN 46202.

We describe an infant who had a tube perforation of the second portion of the duodenum which entered the fight renal pelvis.

OJ:

CASE REPORT

orojejunal

A one-hour-old, 936-gram boy was admitted to Riley Chil- dren's Hospital for mild respirator), distress complicated by episodes of apnea and brady-cardia. To maintain nutritional status a No. 5 Frencfi orojejunal tube made of polyvinylchloride

0022-3476/78/0193-0122500.30/0 9 1978 The C. V. Mosby Co.