Stickler, Gunnar B.

Radioisotope renograms with orthoiodohippurate-I131 were obtained for 41 children who had known renal or renovascular disorders. (Two patients had hypertension but no evidence of renal disease.) Values determined for various components of the renogram curves were considered abnormal when they exceeded two standard deviations from the mean values for normal children of similar body surface area or when time B (from injection to the point of maximal radioactivity) exceeded 6.5 minutes or differed from the contralateral kidney by more than 1 minute. The renogram was clearly abnormal in all 17 patients who had unilateral or predominantly unilateral renal disorders. Abnormalities associated with bilateral renal disorders varied with the disease and its severity. The clinical severity of impairment of renal function could be estimated from the renogram. The isotope renogram proved to be a simple, reproducible technique for determination of function of the separate kidneys.

Isotope renograms (ortho-iodohippurate-I were obtained from 30 children who had no evidence of renal disease. Determinations were made by a standardized technique with the subjects in a state of relative dehydration; in 15 children the renogram was repeated under conditions of hydration (14 children) or further dehydration (1 child). Values for the point of initial peak (point A), point of maximal radioactivity (point B), and the differences between these points (B-A) were calculated. These values were plotted arithmetically against surface area to obtain regression lines and estimates of the variability of the observations about the line. The time from appearance of radioactivity to peak radioactivity was calculated and found to fall into a relatively narrow range. Similar attempts to correlate mathematically the height of timed segments of the decreasing slope of the renogram with surface area were successful in children with a body surface area of 1.15 m2 or greater. The state of hydration appeared to influence the excretory slope of the renogram; this effect was most pronounced in children whose total body surface area was less than 1.15 m2.

The purpose of this study was to re-affirm our clinical impression that non-institutionalized children whose head circumference was below minus 2 standard deviations were mentally subnormal and frequently had growth failure. A group of 134 children with a head circumference below minus 2 standard deviations from the mean were studied, and all but one were mentally subnormal. The most severe mental retardation was noted in the group of children with a head circumference of minus 4 standard deviations or below. We found, as have others, that children with mental retardation have height and weights below the expected norm and that children with a head circumference below minus 2 standard deviations have even lower mean heights and weights. The head circumference of 31 children with growth failure and normal intelligence was normal for age and sex, therefore disproving the concept that the abnormally small child has a proportionally small head. In the child with growth failure, should the head be proportionally small (below minus 2 standard deviations), mental subnormality should be suspected. We feel that the head circumference measurement has taken on new clinical significance in that our data support its use in suspecting the association of mental subnormality in children with growth failure and a head circumference of below minus 2 standard deviations from the mean for age and sex.

Replying to Dr. I. Krieger's letter to the editor poses difficulties. In using this communication for submission of her own data for publication, she has not felt the need to provide the careful documentation that would allow critical analysis. For example, her statement that "small stature, small head size, and mental subnormality are frequently associated" is true on the basis of our experience but is not supported by her recorded data. No psychometric test results are noted in the text or in the illustrations accompayning her letter.

The case records of 44 patients less than 15 years of age seen at the Mayo Clinic from 1945 to May, 1957, who had the syndrome of recurrent vomiting, were studied. A questionnaire sent at the time of this study—from 2 to 14 years after the original examination—to determine if possible the prognosis and cause, elicited a response from 38 patients or their parents. Of the 38 patients, 30 had no cyclic vomiting at the time of follow-up. Of the remaining 8 patients, there was less than a 5-year follow-up in 7. The cause of the syndrome of recurrent vomiting, while possibly psychogenic, is not known definitely. It usually terminates before puberty. There may be some relationship to migraine which also may be a syndrome and not a definite disease entity. Electroencephalographic study of 15 of the patients did not suggest any relationship to a convulsive disorder.

Much of clinical medicine is still based on empiricism, particularly the approach to diagnosis. One aspect of diagnosis that is talked about is the intuition of the experienced clinician. Most physicians working in a referral center have developed certain guidelines for themselves and have adopted suggestions from their teachers and colleagues. Some of these rules are recorded in books and essays, and others are passed by word of mouth from one generation of physicians to the next. It should not be necessary to emphasize that these are rules and not laws. Indeed, exceptions occur, and if there are not too many, they tend to prove the validity of a rule. I want to suggest some of the rules I have found useful. It is impossible to state who was the author of them, even if I might claim that most of them are my own. I hope they generate responses and discussion, which perhaps will lead to deletions, additions, and refinements. 1. Determine the true "chief complaint" and do not accept previous diagnoses as the chief complaint. For example, if a patient presents because of urinary frequency and painful urination, he or she is not complaining of a "urinary tract infection." The chief complaint should be listed in simple English as what the patient or parent states as the reason for consulting the physician and not as a previous diagnosis. 2. Listen to the mother or the primary caretaker; these persons are the best observers and describe the situation well.

After reading the article by Jakobsson and Lindberg "Cow's Milk Proteins Cause Infantile Colic in Breast-Fed Infants: A Double-Blind Crossover Study" (Pediatrics 1983;71:268-271), I am wondering a little bit what is happening to the review process. The study supposedly shows experience with 66 breast-fed infants. However, the critical double-blind crossover trial was completed successfully only with ten. It is not clear why the article was published including 50 children who were not studied objectively. I do believe a paper of this sort will cause a great deal of alarm on data based on much to small a sample.

In Reply.— Dr Deinard's opinion about the growth pattern of children from Southeast Asia is of interest and hopefully will hold up. Just looking around the Rochester soccer fields, this is doubtful. His opinion is in contrast to that repeatedly misquoted information about the Japanese who migrated to California. It is true that earlier studies showed better growth in California in comparison to those Japanese born in Japan, but this did not prove to be true with remeasurements in 1971.

In Reply.— Lildholdt's comments are perplexing. He is the author of an extensive prospective study of tympanotomy in 150 children with primary secretory otitis.1 He inserted a ventilation tube into one ear and left the other tympanic membrane intact. His patients were children ranging in age from 1 to 10 years with a mean age of 3.9 years. He noted suppuration in 25% of the ears with ventilation tubes in the follow-up period which averaged 3.2 years.

Smith and Berenberg wrote a commentary, "The Concept of Failure to Thrive," in these pages in 1970.1 After recounting the history of the term, they added: "We hope that as a label it will not become indistinct or obscured by uncertainty as to its past, current, or future diagnostic implications." Their warning was appropriate, but numerous authors have failed to accept their concern. Failure to thrive is assigned as a diagnosis to many children. To some physicians, it means that a child fails to gain weight; others intend it to include failure to grow. It is widely assumed that a failure to gain entails inevitably a failure to grow.