Inappropriate Antidiuretic
Hormone Secretion Sir.\p=m-\Weread with interest the report by Mor et al in the January issue of the Journal (129:133, 1975), describing an infant with pneumonia who developed the syndrome of inappropriate secretion of antidiuretic hormone and hyponatremia. In this case, it was not until three days after hospitalization for pneumonia that the child developed hyponatremia and seizures. We would like to report the cases of two children who had status
epilepticus secondary to hyponatremia, probably resulting from clinically occult pneumonias. In addition, we wish to comment on the use of hypertonic saline in such cases. Report of Cases.\p=m-\Case1.\p=m-\An8-month\x=req-\ old girl developed bilateral tonicoclonic seizures after being seen earlier in the day with otitis media. Seizures were terminated with administration of diazepam, phenobarbital, and paraldehyde. The child was comatose with a temperature of 36.5 C (97.7 F) and blood pressure of 80/60 mm Hg; weight was 8 kg (18 lb). Tympanic membranes were erythematous; fundi were normal. Auscultation of the chest disclosed bilateral rales. Serum sodium level was 117 mEq/liter, with a urine sodium concentra¬ tion of 103 mEq/liter. Serum potassium level was 3.3 mEq/liter; glucose level, 174 mg/100 ml; and blood urea nitrogen (BUN) level, 10 mg/100 ml. Cerebrospinal fluid (CSF) showed no red blood cells (RBCs) and two mononuclear white blood cells (WBCs) per cubic millimeter; protein level was 16 mg/100 ml and glucose level was 103 mg/100 ml; cultures were negative. Chest roentgenogram showed bilateral in¬ filtrates. Blood culture yielded a Strepto¬ coccus. The hyponatremia was successfully treated with an initial infusion of 25 millimols of hypertonic saline (3 millimols/kg body weight), administered during a 20minute period, followed by fluid restriction at calculated half-maintenance levels. The pneumonia responded to treatment with antibiotics, and the patient had no subse¬ quent seizures. Case 2.—An 8-month-old black boy was well except for rhinorrhea, for which he was given aspirin and fluids, until he de¬ veloped opisthotonos and bilateral toni¬ coclonic seizures. Seizures transiently responded to treatment with diazepam and paraldehyde, but the patient subsequently had a respiratory arrest requiring intuba¬ tion and artificial ventilation. After initial laboratory data had disclosed hyponatre¬ mia, recurrent seizures were terminated with administration of hypertonic sa¬ line, 36 millimols during 15 minutes (4.2 millimols/kg body weight). Examination showed an obtunded child with a tempera¬ ture of 35.5 C (95.9 F) and blood pressure of 90/50 mm Hg; weight was 8.5 kg (18.7
lb). Auscultation of the chest showed bilat¬ eral rales and rhonchi; optic fundi were
normal. Initial serum sodium level was 119 mEq/liter, with a urinary sodium concen¬ tration of 93 mEq/liter. Serum potassium level was 3.8 mEq/liter, glucose level was 100 mg/100 ml, and BUN level was 7 mg/100 ml. The CSF showed 180 RBCs and seven mononuclear WBCs per cubic mil¬ limeter; protein level was 44 mg/100 ml and glucose level was 79 mg/100 ml; cul¬ tures were negative. Sickle cell prepara¬ tion was negative. Chest roentgenogram showed a right lower lobe infiltrate. Blood cultures yielded coagulase-positive Staphy¬ lococcus. Serum sodium level rose to 126 mEq/liter with the initial saline infusion, and stabilized at 138 mEq/liter with fluid restriction. The pneumonia responded to antibiotic treatment, and the patient had no further seizures.
Comment-In each of these cases, the cause of the seizures was probably hyponatremia. In one, seizures termi¬ nated with administration of hyper¬ tonic saline; in both, the serum so¬ dium level rose and the clinical condition improved with fluid restric¬ tion. The hyponatremia in the face of high urinary sodium level, normal re¬ nal function, normal serum potassium level, absence of dehydration or edema, and good respone to fluid re¬ striction are all supportive of the diagnosis of inappropriate antidiuretic hormone secretion. Both patients had seizures without prior respiratory symptoms other than otitis and rhinorrhea. In neither case was pneumonia clinically appar¬ ent, although initial roentgenograms showed impressive pulmonary infil¬ trates and blood cultures yielded pathogenic organisms. These cases support the concept that pneumonia can be complicated by severe and symptomatic hyponatremia, and that inappropriate antidiuretic hormone secretion is the likely mechanism. In the absence of meningitis or other central nervous system insults, oc¬ cult pneumonias should be carefully searched for. One further word must be said about the efficacy of hypertonic sa¬ line. Mor et al reported that saline in¬ fusion was unsuccessful, although the precise quantity employed and rate of administration were not stated. Cer¬ tainly, the appropriate treatment is water restriction. However, when the patient is comatose or convulsing, ad¬ ministration of hypertonic saline is potentially lifesaving. We have used a solution of 4.4% sodium chloride (750 millimols/liter), given during a 15-
minute
period.
This
provides
an
ade¬
quate amount of sodium without a large fluid excess, and avoids too rapid
shift in serum osmolality. The total dose of sodium chloride is determined by multiplying the desired rise in se¬ rum sodium level, generally 5 mEq/ liter, by the patient's estimated total body water (although sodium is large¬ ly extracellular, it is osmotically ac¬ tive throughout the total body water). Thus, in case 1, the patient received 25 millimols of sodium chloride, or ap¬ proximately 5 millimols/liter of total body water; patient 2 received ap¬ proximately 7 millimols of sodium chloride per liter of total body water. Although the elevation in serum so¬ dium level is transient, unless rein¬ forced with fluid restriction, we have found hypertonic saline to be both ef¬ fective and safe. RON G. ROSENFELD, MD MICHAEL J. REID, MD Department of Pediatrics Stanford University Medical Center Stanford, CA 94305 a
Malignant Hypertension Sir.\p=m-\Iam case
in Children
writing concerning
the
report and review by Dr. Siegler,
which appeared in the December issue of the Journal (128:853,1974). He described the unsuccessful treatment of malignant hyperreninemic hypertension in an 11-year-old girl who subsequently underwent bilateral nephrectomy and allograft transplantation. It is an excellent summary of the subject but leaves unsaid several important points concerning this fortunately rarely encountered problem in pediatric practice. Bilateral nephrectomy for hypertension is a procedure of last resort when all other means for control of high-renin hypertension have failed. Nephrectomy is irrevocable and imposes the need for dialysis and transplantation with their many problems and less-than-ideal survival rates. We have at our disposal an alternative. Contrary to Dr. Siegler's statement, there have been positive, though not widely reported, results with minoxidil therapy in children.1-3 This potent, orally administered vasodilator is now available (though it probably was not when Dr. Siegler's patient was treated) for use in an emergency setting and has been strikingly suc¬ cessful in avoiding the need for ne¬ phrectomy in three of our patients. Two of these children were under-
Downloaded From: http://archpedi.jamanetwork.com/ by a Michigan State University User on 06/18/2015
going chronic hemodialysis and were refractory to very large doses of orally administered antihypertensive agents. The third child is a 7-year-old girl who had hypertensive encepha¬ lopathy and azotemia at age 6. She was found to have bilateral hypoplastic kidneys and high renal-vein renin levels, and she was refractory to all antihypertensives and diuretics used except diazoxide, which she required frequently. Minoxidil was given, and she has remained an outpatient for 20 months with satisfactory control of blood pressure, slight improvement of renal function, continuing growth, and full participation in school and play activities. Minoxidil is usually used with one or more antihypertensive, beta-adrenergic blocking or diuretic agents. Its major side-effect is rather striking hypertrichosis. Though unfortunate,
this side-effect is tolerable consid¬ ering the rehabilitation that is achieved. It should also be noted that reduction of blood pressure occurs in patients with or without elevated re¬ nin levels. It is possible that with control of hypertension Dr. Siegler's patient would have had healing of the renal hypertensive arteriolitis and im¬ provement of renal function. With the use of minoxidil and other potent
antihypertensives, nephrectomy may be necessary in very few patients and hopefully never in those with ade¬ quate residual renal function. ANDREW J. ARONSON, MD Department of Pediatrics The University of Chicago La Rabida Children's Hospital East 65th Street at Lake Michigan
Chicago, IL 60649
1. Aronson AJ, Kallen JR: The efficacy of minoxidil in the outpatient management of accelerated nephropathic hypertension, abstracted. Presented in program of the Midwest Society for Pediatric Research Meeting, Pittsburgh, 1973. 2. Makker S: Treatment of high renin refractory hypertension in children with minoxidil: A new hypertensive drug not previously used in children, abstracted. Pediatr Res 8:458, 1974. 3. Chandra M, Exeni M, McVicar N: Minoxidil control of high renin refractory hypertension in a child. Read before the Third International Symposium of Pediatric Nephrology, Washington, DC, 1974.
In Reply.\p=m-\Thepoints raised in the letter of Dr. Aronson are certainly important and deserve emphasis. Bilateral nephrectomy is undeniably a drastic measure and should only be considered for those whose hyperreninemic hypertension is re-
fractory to medical management. I certainly wish that we had had minoxidil to use for our patient. Since then, pediatric experience with minoxidil has increased, though the total number of published cases is still relatively small. I, too, have recently used this experimental agent to successfully treat two pediatric patients with refractory hypertension. One patient had chronic interstitial nephritis from vesicoureteral reflux and the other had experienced a recurrence of the
In addition, those patients who have ingested large amounts and those for whom follow-up care or home surveil¬ lance is inadequate, even if asympto¬
matic, should also be admitted for ob¬ servation and early detection of pulmonary or cardiac complications.2 Therefore, to send this child home on a regimen of antibiotics, in the face of verified pulmonary involvement, was, I
standard
Medical Center 50 N Medical Dr Salt Lake City, UT 84132
Pneumatoceles
Following Hydrocarbon Ingestion
Sir.\p=m-\Thearticle by Bergeson et al, which appeared in the January issue of the Journal (129:49, 1975), was a fine discussion of the stated problem.
The management of their first case however, suboptimal in my opinion. This 20-month-old boy ingested lighter fluid. He choked, coughed, vomited after ingestion, and was seen in the emergency room that night. He was sent home after a normal chest roentgenogram had been obtained. He was seen in the outpatient clinic the next day with fever, "harsh breath sounds," and "right middle lobe and left lower lobe infiltrates." At this point he should have been admitted to the hospital. Instead, he was given ampicillin sodium and sent home. The authors themselves point out that "pleural effusion, pneumothorax, pneumomediastinum, subcutaneous emphysema, and pneumopericardium have been encountered as complications of hydrocarbon ingestion" (p 51). Others have reported serious cardiac complications following hydrocarbon ingestion.1 Most poison control experts suggest that all children who are symptomatic from hydrocarbon ingestion be admitted to the hospital. was,
Downloaded From: http://archpedi.jamanetwork.com/ by a Michigan State University User on 06/18/2015
manage¬ not be construed as
care.
CHRIS HOLMES, MD
hemolytic-uremic syndrome.
Even so, I doubt that minoxidil will turn out to be a hypertensive panacea. I suspect, therefore, that bilateral nephrectomy will still have to be considered for the occasional patient. But hopefully, the need for such an extreme measure will be rare indeed now that minoxidil is available. RICHARD L. SIEGLER, MD Department of Pediatrics University of Utah
think, inappropriate
ment, and should
Taylor Ave Ogden, UT 84403
3021
1. James FW, Kaplan S, Benzing G III: Cardiac complications following hydrocarbon ingestion. Am J Dis Child 121:431-433, 1971. 2. Temple A, Veltri J: Interesting intoxications. Bull Intermountain Regional Poison Control Center 2:8, 1974.
In
Reply.\p=m-\Inresponse to Dr. Holmes' pertinent observations, let us say that
agree that the management of the first case was suboptimal. This points up the fact that in a large hospital with hundreds of attending physicians and dozens of house officers, a uniform approach to any selected disease rarely exists. The article, however, was not published on the pretense of describing the subtleties of therapy of hydrocarbon ingestion and never implied that the therapeutics described were to be "construed as standard care." The article makes no claim outside of reviewing the pertinent data on one selected aspect of the disease. Nevertheless, we disagree that "all children who are symptomatic from hydrocarbon ingestion [should] be admitted to the hospital" (italics ours). This would imply that any child with slight fever or cough should be admitted regardless of time since ingestion, reliability of parents, access to medical care, or other important factors taken into consideration. This is cookbook medicine and denies the physician any freedom of choice to fit the individual situation. We should all refuse to practice medicine in this fashion. PAUL S. BERGESON, MD STEPHEN W. HALES, MD Good Samaritan Hospital 1033 E McDowell Rd Phoenix, AZ 85006 HERMAN W. LIPOW, MD University of California School of Medicine San Francisco we
Hormone Secretion Sir.\p=m-\Weread with interest the report by Mor et al in the January issue of the Journal (129:133, 1975), describing an infant with pneumonia who developed the syndrome of inappropriate secretion of antidiuretic hormone and hyponatremia. In this case, it was not until three days after hospitalization for pneumonia that the child developed hyponatremia and seizures. We would like to report the cases of two children who had status
epilepticus secondary to hyponatremia, probably resulting from clinically occult pneumonias. In addition, we wish to comment on the use of hypertonic saline in such cases. Report of Cases.\p=m-\Case1.\p=m-\An8-month\x=req-\ old girl developed bilateral tonicoclonic seizures after being seen earlier in the day with otitis media. Seizures were terminated with administration of diazepam, phenobarbital, and paraldehyde. The child was comatose with a temperature of 36.5 C (97.7 F) and blood pressure of 80/60 mm Hg; weight was 8 kg (18 lb). Tympanic membranes were erythematous; fundi were normal. Auscultation of the chest disclosed bilateral rales. Serum sodium level was 117 mEq/liter, with a urine sodium concentra¬ tion of 103 mEq/liter. Serum potassium level was 3.3 mEq/liter; glucose level, 174 mg/100 ml; and blood urea nitrogen (BUN) level, 10 mg/100 ml. Cerebrospinal fluid (CSF) showed no red blood cells (RBCs) and two mononuclear white blood cells (WBCs) per cubic millimeter; protein level was 16 mg/100 ml and glucose level was 103 mg/100 ml; cultures were negative. Chest roentgenogram showed bilateral in¬ filtrates. Blood culture yielded a Strepto¬ coccus. The hyponatremia was successfully treated with an initial infusion of 25 millimols of hypertonic saline (3 millimols/kg body weight), administered during a 20minute period, followed by fluid restriction at calculated half-maintenance levels. The pneumonia responded to treatment with antibiotics, and the patient had no subse¬ quent seizures. Case 2.—An 8-month-old black boy was well except for rhinorrhea, for which he was given aspirin and fluids, until he de¬ veloped opisthotonos and bilateral toni¬ coclonic seizures. Seizures transiently responded to treatment with diazepam and paraldehyde, but the patient subsequently had a respiratory arrest requiring intuba¬ tion and artificial ventilation. After initial laboratory data had disclosed hyponatre¬ mia, recurrent seizures were terminated with administration of hypertonic sa¬ line, 36 millimols during 15 minutes (4.2 millimols/kg body weight). Examination showed an obtunded child with a tempera¬ ture of 35.5 C (95.9 F) and blood pressure of 90/50 mm Hg; weight was 8.5 kg (18.7
lb). Auscultation of the chest showed bilat¬ eral rales and rhonchi; optic fundi were
normal. Initial serum sodium level was 119 mEq/liter, with a urinary sodium concen¬ tration of 93 mEq/liter. Serum potassium level was 3.8 mEq/liter, glucose level was 100 mg/100 ml, and BUN level was 7 mg/100 ml. The CSF showed 180 RBCs and seven mononuclear WBCs per cubic mil¬ limeter; protein level was 44 mg/100 ml and glucose level was 79 mg/100 ml; cul¬ tures were negative. Sickle cell prepara¬ tion was negative. Chest roentgenogram showed a right lower lobe infiltrate. Blood cultures yielded coagulase-positive Staphy¬ lococcus. Serum sodium level rose to 126 mEq/liter with the initial saline infusion, and stabilized at 138 mEq/liter with fluid restriction. The pneumonia responded to antibiotic treatment, and the patient had no further seizures.
Comment-In each of these cases, the cause of the seizures was probably hyponatremia. In one, seizures termi¬ nated with administration of hyper¬ tonic saline; in both, the serum so¬ dium level rose and the clinical condition improved with fluid restric¬ tion. The hyponatremia in the face of high urinary sodium level, normal re¬ nal function, normal serum potassium level, absence of dehydration or edema, and good respone to fluid re¬ striction are all supportive of the diagnosis of inappropriate antidiuretic hormone secretion. Both patients had seizures without prior respiratory symptoms other than otitis and rhinorrhea. In neither case was pneumonia clinically appar¬ ent, although initial roentgenograms showed impressive pulmonary infil¬ trates and blood cultures yielded pathogenic organisms. These cases support the concept that pneumonia can be complicated by severe and symptomatic hyponatremia, and that inappropriate antidiuretic hormone secretion is the likely mechanism. In the absence of meningitis or other central nervous system insults, oc¬ cult pneumonias should be carefully searched for. One further word must be said about the efficacy of hypertonic sa¬ line. Mor et al reported that saline in¬ fusion was unsuccessful, although the precise quantity employed and rate of administration were not stated. Cer¬ tainly, the appropriate treatment is water restriction. However, when the patient is comatose or convulsing, ad¬ ministration of hypertonic saline is potentially lifesaving. We have used a solution of 4.4% sodium chloride (750 millimols/liter), given during a 15-
minute
period.
This
provides
an
ade¬
quate amount of sodium without a large fluid excess, and avoids too rapid
shift in serum osmolality. The total dose of sodium chloride is determined by multiplying the desired rise in se¬ rum sodium level, generally 5 mEq/ liter, by the patient's estimated total body water (although sodium is large¬ ly extracellular, it is osmotically ac¬ tive throughout the total body water). Thus, in case 1, the patient received 25 millimols of sodium chloride, or ap¬ proximately 5 millimols/liter of total body water; patient 2 received ap¬ proximately 7 millimols of sodium chloride per liter of total body water. Although the elevation in serum so¬ dium level is transient, unless rein¬ forced with fluid restriction, we have found hypertonic saline to be both ef¬ fective and safe. RON G. ROSENFELD, MD MICHAEL J. REID, MD Department of Pediatrics Stanford University Medical Center Stanford, CA 94305 a
Malignant Hypertension Sir.\p=m-\Iam case
in Children
writing concerning
the
report and review by Dr. Siegler,
which appeared in the December issue of the Journal (128:853,1974). He described the unsuccessful treatment of malignant hyperreninemic hypertension in an 11-year-old girl who subsequently underwent bilateral nephrectomy and allograft transplantation. It is an excellent summary of the subject but leaves unsaid several important points concerning this fortunately rarely encountered problem in pediatric practice. Bilateral nephrectomy for hypertension is a procedure of last resort when all other means for control of high-renin hypertension have failed. Nephrectomy is irrevocable and imposes the need for dialysis and transplantation with their many problems and less-than-ideal survival rates. We have at our disposal an alternative. Contrary to Dr. Siegler's statement, there have been positive, though not widely reported, results with minoxidil therapy in children.1-3 This potent, orally administered vasodilator is now available (though it probably was not when Dr. Siegler's patient was treated) for use in an emergency setting and has been strikingly suc¬ cessful in avoiding the need for ne¬ phrectomy in three of our patients. Two of these children were under-
Downloaded From: http://archpedi.jamanetwork.com/ by a Michigan State University User on 06/18/2015
going chronic hemodialysis and were refractory to very large doses of orally administered antihypertensive agents. The third child is a 7-year-old girl who had hypertensive encepha¬ lopathy and azotemia at age 6. She was found to have bilateral hypoplastic kidneys and high renal-vein renin levels, and she was refractory to all antihypertensives and diuretics used except diazoxide, which she required frequently. Minoxidil was given, and she has remained an outpatient for 20 months with satisfactory control of blood pressure, slight improvement of renal function, continuing growth, and full participation in school and play activities. Minoxidil is usually used with one or more antihypertensive, beta-adrenergic blocking or diuretic agents. Its major side-effect is rather striking hypertrichosis. Though unfortunate,
this side-effect is tolerable consid¬ ering the rehabilitation that is achieved. It should also be noted that reduction of blood pressure occurs in patients with or without elevated re¬ nin levels. It is possible that with control of hypertension Dr. Siegler's patient would have had healing of the renal hypertensive arteriolitis and im¬ provement of renal function. With the use of minoxidil and other potent
antihypertensives, nephrectomy may be necessary in very few patients and hopefully never in those with ade¬ quate residual renal function. ANDREW J. ARONSON, MD Department of Pediatrics The University of Chicago La Rabida Children's Hospital East 65th Street at Lake Michigan
Chicago, IL 60649
1. Aronson AJ, Kallen JR: The efficacy of minoxidil in the outpatient management of accelerated nephropathic hypertension, abstracted. Presented in program of the Midwest Society for Pediatric Research Meeting, Pittsburgh, 1973. 2. Makker S: Treatment of high renin refractory hypertension in children with minoxidil: A new hypertensive drug not previously used in children, abstracted. Pediatr Res 8:458, 1974. 3. Chandra M, Exeni M, McVicar N: Minoxidil control of high renin refractory hypertension in a child. Read before the Third International Symposium of Pediatric Nephrology, Washington, DC, 1974.
In Reply.\p=m-\Thepoints raised in the letter of Dr. Aronson are certainly important and deserve emphasis. Bilateral nephrectomy is undeniably a drastic measure and should only be considered for those whose hyperreninemic hypertension is re-
fractory to medical management. I certainly wish that we had had minoxidil to use for our patient. Since then, pediatric experience with minoxidil has increased, though the total number of published cases is still relatively small. I, too, have recently used this experimental agent to successfully treat two pediatric patients with refractory hypertension. One patient had chronic interstitial nephritis from vesicoureteral reflux and the other had experienced a recurrence of the
In addition, those patients who have ingested large amounts and those for whom follow-up care or home surveil¬ lance is inadequate, even if asympto¬
matic, should also be admitted for ob¬ servation and early detection of pulmonary or cardiac complications.2 Therefore, to send this child home on a regimen of antibiotics, in the face of verified pulmonary involvement, was, I
standard
Medical Center 50 N Medical Dr Salt Lake City, UT 84132
Pneumatoceles
Following Hydrocarbon Ingestion
Sir.\p=m-\Thearticle by Bergeson et al, which appeared in the January issue of the Journal (129:49, 1975), was a fine discussion of the stated problem.
The management of their first case however, suboptimal in my opinion. This 20-month-old boy ingested lighter fluid. He choked, coughed, vomited after ingestion, and was seen in the emergency room that night. He was sent home after a normal chest roentgenogram had been obtained. He was seen in the outpatient clinic the next day with fever, "harsh breath sounds," and "right middle lobe and left lower lobe infiltrates." At this point he should have been admitted to the hospital. Instead, he was given ampicillin sodium and sent home. The authors themselves point out that "pleural effusion, pneumothorax, pneumomediastinum, subcutaneous emphysema, and pneumopericardium have been encountered as complications of hydrocarbon ingestion" (p 51). Others have reported serious cardiac complications following hydrocarbon ingestion.1 Most poison control experts suggest that all children who are symptomatic from hydrocarbon ingestion be admitted to the hospital. was,
Downloaded From: http://archpedi.jamanetwork.com/ by a Michigan State University User on 06/18/2015
manage¬ not be construed as
care.
CHRIS HOLMES, MD
hemolytic-uremic syndrome.
Even so, I doubt that minoxidil will turn out to be a hypertensive panacea. I suspect, therefore, that bilateral nephrectomy will still have to be considered for the occasional patient. But hopefully, the need for such an extreme measure will be rare indeed now that minoxidil is available. RICHARD L. SIEGLER, MD Department of Pediatrics University of Utah
think, inappropriate
ment, and should
Taylor Ave Ogden, UT 84403
3021
1. James FW, Kaplan S, Benzing G III: Cardiac complications following hydrocarbon ingestion. Am J Dis Child 121:431-433, 1971. 2. Temple A, Veltri J: Interesting intoxications. Bull Intermountain Regional Poison Control Center 2:8, 1974.
In
Reply.\p=m-\Inresponse to Dr. Holmes' pertinent observations, let us say that
agree that the management of the first case was suboptimal. This points up the fact that in a large hospital with hundreds of attending physicians and dozens of house officers, a uniform approach to any selected disease rarely exists. The article, however, was not published on the pretense of describing the subtleties of therapy of hydrocarbon ingestion and never implied that the therapeutics described were to be "construed as standard care." The article makes no claim outside of reviewing the pertinent data on one selected aspect of the disease. Nevertheless, we disagree that "all children who are symptomatic from hydrocarbon ingestion [should] be admitted to the hospital" (italics ours). This would imply that any child with slight fever or cough should be admitted regardless of time since ingestion, reliability of parents, access to medical care, or other important factors taken into consideration. This is cookbook medicine and denies the physician any freedom of choice to fit the individual situation. We should all refuse to practice medicine in this fashion. PAUL S. BERGESON, MD STEPHEN W. HALES, MD Good Samaritan Hospital 1033 E McDowell Rd Phoenix, AZ 85006 HERMAN W. LIPOW, MD University of California School of Medicine San Francisco we
