ceed the elite and British groups. In short, these apparently plump arms contained not only fat but fluid not otherwise obvious on clinical exami¬ nation. The implications of this find¬ ing in terms of bodily growth, intel¬ lectual alertness, and, above all, resistance to infection are only too obvious and are manifested in the high incidence, morbidity, and mor¬ tality from infections and the rapid¬ ity with which these children can be triggered off into clinical malnutri¬ tion syndromes. There is, then, a growing realisa¬ tion of the complex interaction be¬ tween the many factors leading to PCM. Low intake of important food factors—yes; but of itself not a suffi¬ cient explanation. Others include low general standards of living, and taboos, on feeding eggs to young chil¬ dren for instance, alleged to have de¬ veloped to ensure that the father-the worker-gets what he needs in order to do his farming. In this connection one study of rural family food con¬ sumption showed a rise in the inci¬ dence of malnutrition in the children that coincided with a sudden increase in the family total calorie intake oc¬ curring with the return to intense farming activity in anticipation of the coming rains. And then, constant infections, with the accompanying loss of appetite, poor digestion, and diminished absorption of food, are now accepted as vital factors contrib¬ uting to undernourishment and pre¬ cipitating malnutrition. Gastroenter¬ itis is undoubtedly the biggest contributor to marasmus and to in¬ fant mortality, and measles, the great villain occurs in epidemics of great severity and high mortality, and can be seen to be followed by sudden on¬ set of kwashiokor a few weeks later. Severe diarrhoea often accompanies the acute phase, and it is easy to un¬ derstand that the rash, so evident as Koplik spots in the mouth, extends down into the gut and gives rise to mucosal damage and malabsorption— and so it is. Disaccharide intolerance has been shown to be present and sometimes persists and is associated with other malabsorptions. Further¬ more, some interesting recent work at Ahmadu Bello University Hospital in Zaria, Nigeria, has pinpointed an actual positive protein-losing enteropathy of up to 4 to 5 gm daily, suffi¬ cient to give rise to oedema even in well-fed subjects with nephrotic syn¬ drome.
So, in summary the concept now ac¬ cepted is that malnutrition does not— will not—occur solely from inadequate protein or calorie intake in a healthy child, even in rural Africa, but results from the constant ill health, infec¬ tions, malabsorption, and so on that are the normal lot of mankind during the first few years of life, until some degree of immunity to a host of infec¬ tions has been achieved. But adequate immunity fails to develop in the un¬ dernourished, and infections flourish;
and so the wheel goes round and round and the end result is the sur¬ vival of the toughest and luckiest 55% to 65% of those born into the African world—natural selection. It follows, of course, that the plump, well-nourished children of the African elite and of those in the de¬ veloped world, among whom the in¬ fant and child death rates are mea¬ sured per thousand rather than per hundred as in Africa, are the product of a highly artificial, not to say un¬ natural, environment brought about by the near elimination of serious in¬ fections and the adoption of artificial dietary practices that ensure that the only form of malnutrition likely to develop is obesity. And yet, it is these children who form the basis of the charts, eg, the "Harvard Standard" and the "50th Percentile of British Children," against which the growth of African children is assessed. Wherein, then, lie the remedies? In government action, the Congress con¬ cluded, and in organised action to ap¬ ply the mass of knowledge that has accumulated for two decades and to implement recommendations reiter¬ ated at this and many previous meet¬ ings and discussions. First, to estab¬ lish widespread schemes at the rural, peasant level to improve irrigation, increase agricultural yields, and im¬ prove the quality and increase the quantity of livestock herds. Begin¬ nings have been made in some areas but are sporadic and sometimes fail for lack of continued support and sup¬ plies. Second, spread dispensaries and health centres throughout the coun¬ tryside, in which the emphasis is on hygiene, nutrition education, breast feeding, and supplementary feeding schemes, taught with the cooperation of the experienced senior mothers of the community and using locally pro¬ duced weaning foods rather than ex¬ pensive imported processed foods. Third, the extension of immunisation procedures to cover at least 80% of the
Downloaded From: http://archpedi.jamanetwork.com/ by a New York University User on 06/16/2015
population, a figure that has been shown to result in a rapid decrease in rates and intensity of infections. As these various measures spread across and infiltrate the continent, undernutrition will improve and re¬ sistance to infections will strengthen; or, one could put it, resistance will strengthen and undernutrition will improve, the two processes acting, re¬ acting, and interacting with each other to reduce infant, and partic¬ ularly toddler, mortality so that it can be measured per thousand rather than per hundred of the child popu¬ lation. But all this, as was constantly reit¬ erated at the Ibadan Congress, needs to be done at the local, community level, using what we call here inter¬ mediate technology and implements that can be handled by the farmers themselves, rather than through vast programmes of industrialised farm¬ ing and the proliferation of large hos¬ pital complexes. The great mass of the African population must be en¬ couraged to take part in and, indeed, be made responsible, with wide gov¬ ernment help, for its own nutritional salvation. RICHARD DOBBS, MD, FRCP Department of Paediatrics Ahmadu Bello University Zaria, Nigeria
Multiple Rib Fractures Due to Physiotherapy in a Neonate With Hyaline Membrane Disease
Physical therapy to the chest has been recommended as an adjunct to the treatment of hyaline membrane disease.1 Especially for babies receiving mechanical respiratory assistance, postural drainage and percussion are thought to be of value in the prevention of pulmonary atelectasis due to secretions. Also in bronchopulmonary dysplasia, the presence of mucous secretion, metaplastic changes in bronchiolar epithelium, and fibrosis2 has prompted the use of pulmonary chest therapy in many nurseries. However, the beneficial effect of such therapy has not been proved. Recently, endotracheal suctioning at birth, combined with physical therapy in the first eight hours of life, has been shown to be of value in neonates with meconium aspiration.3 No specific complication from chest
therapy has been reported to our knowledge until the present case. Report of a Case.\p=m-\Aboy weighing 2.1 kg (4.6 lb) with a gestational age of 32 weeks
admitted to the intensive care nursery of the Medical University of South Caro¬ lina with respiratory distress due to hya¬ line membrane disease. The infant did not require resuscitation at birth. Since eval¬ uation of his arterial blood gases in 100% oxygen showed a pH of 7.05, a Pao2 of 74 mm Hg, and a Paco, of 61 mm Hg, he was given mechanical respiratory assistance. At 7 days of age he developed atelectasis of the right upper and middle lobes as well as an infiltrate in the remaining lung fields. Physical therapy was then added to the regimen of antibiotics and tracheobronchial toilet that the infant was receiv¬ ing. Every two hours either percussion by hands or vibration with electric toothbrush was performed. The atelectatic areas grad¬ ually reexpanded. While receiving respira¬ tory assistance, nasogastric tube feeding of formual (Similac 20) supplemented daily by 0.6 ml of vitamins (Poly-Vi-Sol) was well tolerated. After one month the regimen was changed to continuous positive airway pressure breathing, and the patient was subsequently extubated. However, the infant had developed clini¬ cal and radiological manifestations of bronchopulmonary dysplasia. He was tachypneic with a respiratory rate varying be¬ tween 60 and 70/min, he had intercostal re¬ tractions, and he was oxygen dependent, needing 50% oxygen to maintain normal breathing. He did not have apneic spells requiring resuscitation during this period. Following a recurrence of atelectasis on the 53rd day, physical therapy and parenteral antibiotics were reinstituted. Subse¬ quent roentgenograms showed resolution of atelectasis. A roentgenogram done on the 75th day of age showed for the first time the healing fractures of the right sixth and seventh and left eighth ribs (Figure). There was also an infiltrate in the right upper lobe and herniation of the left upper lobe to the right. Roentgen¬ ograms of the rest of the skeleton were normal. Serum calcium, phosphorus, and alkaline phosphatase levels at this time were 9.3 mg/100 ml, 5 mg/100 ml, and 217 was
IU, respectively.
Comment.—Multiple rib fractures in the newborn infant can occur in os¬ teogenesis imperfecta congenita, con¬ genital hypophosphatasia, osteopetrosis, pyknodysostosis,4 and following vigorous resuscitative efforts.0 Os¬ teogenesis imperfecta was excluded since the roentgenograms of the long bones did not show hypoplasia, thin¬ ning of the cortex, and scanty spongiosis.6 Also, the roentgenograms of the skull did not disclose irregular mineralization (mosaic rarefaction),
Roentgenogram eighth ribs.
of chest demonstrates fractures of
which is of great diagnostic assist¬ ance when changes in long bones are equivocal." Other above-mentioned causes of multiple rib fractures were unlikely since the skeletal survey was normal and the infant did not require resuscitation during nursery stay. Burnard et al have reported "stress fractures" of the ribs in infants with prolonged respiratory distress.7 In the present case the fractures may partly be attributed to the stress of pro¬ longed respiratory distress; the other factor that seemed to have played a role was most likely the trauma in¬ duced by the physical therapy. In neonates, small medicine cups for percussion and an electric tooth¬ brush for vibration have been recom¬ mended for physical therapy. Besides ease of administration, these methods also tend to limit the amount of force used. In our infant, percussion was done by hand and vibration was ac¬ complished by electric toothbrush. Apparently, the force used, in spite of the technical expertise of the nursing personnel either alone or in concert with the stress due to respiratory dis¬ tress, was enough to fracture the rib cage. In the term newborn, callus forma¬ tion may become visible by roentgen¬ ogram one week after fracture.8 Thus, the fractures in the present case may
Downloaded From: http://archpedi.jamanetwork.com/ by a New York University User on 06/16/2015
right sixth and seventh and left
have occurred around 58 to 68 days of age. Had the fractures of this unin¬ tentionally battered neonate first been diagnosed following hospital discharge, he might have been labeled as a case of parental child abuse. DILIP M.
PUROHIT, MD
CANDACE CALDWELL, MD
ABNER H.
LEVKOFF, MD
Department of Pediatrics Medical University of South Carolina
80 Barre St
Charleston, SC 29401 1. Dunn D, Lewis AT: Some important aspects of neonatal nursing related to pulmonary disease and family involvement. Pediatr Clin North Am 20:481-498, 1973. 2. Northway WH Jr, Rosan RC, Porter DY: Pulmonary disease following respiratory therapy of hyaline membrane disease. N Engl J Med 276:357-368, 1967. 3. Gregory GA, Gooding AA, Phibbs RH, et al: Meconium aspiration in infants: A prospective study. J Pediatr 85:848-852, 1974. 4. Wesenberg RL: The Newborn Chest. New York, Harper & Row Publishers Inc, 1973, pp 154-156. 5. Caffey J: Pediatric X-Ray Diagnosis. Chicago, Year Book Medical Publishers Inc, 1972, vol 1, pp 279-285. 6. Caffey J: Pediatric X-Ray Diagnosis. Chicago, Year Book Medical Publishers Inc, 1972, vol 2, pp 1037-1042. 7. Burnard ED, Grattan-Smith P, Picton-Warlow CG, et al: Pulmonary insufficiency in prematurity. Aust Paediatr J 1:12-38, 1965. 8. Mechan I: Analysis of Roentgen Signs in General Radiology. Philadelphia, WB Saunders Co, 1973, vol 1, pp 167-171.
So, in summary the concept now ac¬ cepted is that malnutrition does not— will not—occur solely from inadequate protein or calorie intake in a healthy child, even in rural Africa, but results from the constant ill health, infec¬ tions, malabsorption, and so on that are the normal lot of mankind during the first few years of life, until some degree of immunity to a host of infec¬ tions has been achieved. But adequate immunity fails to develop in the un¬ dernourished, and infections flourish;
and so the wheel goes round and round and the end result is the sur¬ vival of the toughest and luckiest 55% to 65% of those born into the African world—natural selection. It follows, of course, that the plump, well-nourished children of the African elite and of those in the de¬ veloped world, among whom the in¬ fant and child death rates are mea¬ sured per thousand rather than per hundred as in Africa, are the product of a highly artificial, not to say un¬ natural, environment brought about by the near elimination of serious in¬ fections and the adoption of artificial dietary practices that ensure that the only form of malnutrition likely to develop is obesity. And yet, it is these children who form the basis of the charts, eg, the "Harvard Standard" and the "50th Percentile of British Children," against which the growth of African children is assessed. Wherein, then, lie the remedies? In government action, the Congress con¬ cluded, and in organised action to ap¬ ply the mass of knowledge that has accumulated for two decades and to implement recommendations reiter¬ ated at this and many previous meet¬ ings and discussions. First, to estab¬ lish widespread schemes at the rural, peasant level to improve irrigation, increase agricultural yields, and im¬ prove the quality and increase the quantity of livestock herds. Begin¬ nings have been made in some areas but are sporadic and sometimes fail for lack of continued support and sup¬ plies. Second, spread dispensaries and health centres throughout the coun¬ tryside, in which the emphasis is on hygiene, nutrition education, breast feeding, and supplementary feeding schemes, taught with the cooperation of the experienced senior mothers of the community and using locally pro¬ duced weaning foods rather than ex¬ pensive imported processed foods. Third, the extension of immunisation procedures to cover at least 80% of the
Downloaded From: http://archpedi.jamanetwork.com/ by a New York University User on 06/16/2015
population, a figure that has been shown to result in a rapid decrease in rates and intensity of infections. As these various measures spread across and infiltrate the continent, undernutrition will improve and re¬ sistance to infections will strengthen; or, one could put it, resistance will strengthen and undernutrition will improve, the two processes acting, re¬ acting, and interacting with each other to reduce infant, and partic¬ ularly toddler, mortality so that it can be measured per thousand rather than per hundred of the child popu¬ lation. But all this, as was constantly reit¬ erated at the Ibadan Congress, needs to be done at the local, community level, using what we call here inter¬ mediate technology and implements that can be handled by the farmers themselves, rather than through vast programmes of industrialised farm¬ ing and the proliferation of large hos¬ pital complexes. The great mass of the African population must be en¬ couraged to take part in and, indeed, be made responsible, with wide gov¬ ernment help, for its own nutritional salvation. RICHARD DOBBS, MD, FRCP Department of Paediatrics Ahmadu Bello University Zaria, Nigeria
Multiple Rib Fractures Due to Physiotherapy in a Neonate With Hyaline Membrane Disease
Physical therapy to the chest has been recommended as an adjunct to the treatment of hyaline membrane disease.1 Especially for babies receiving mechanical respiratory assistance, postural drainage and percussion are thought to be of value in the prevention of pulmonary atelectasis due to secretions. Also in bronchopulmonary dysplasia, the presence of mucous secretion, metaplastic changes in bronchiolar epithelium, and fibrosis2 has prompted the use of pulmonary chest therapy in many nurseries. However, the beneficial effect of such therapy has not been proved. Recently, endotracheal suctioning at birth, combined with physical therapy in the first eight hours of life, has been shown to be of value in neonates with meconium aspiration.3 No specific complication from chest
therapy has been reported to our knowledge until the present case. Report of a Case.\p=m-\Aboy weighing 2.1 kg (4.6 lb) with a gestational age of 32 weeks
admitted to the intensive care nursery of the Medical University of South Caro¬ lina with respiratory distress due to hya¬ line membrane disease. The infant did not require resuscitation at birth. Since eval¬ uation of his arterial blood gases in 100% oxygen showed a pH of 7.05, a Pao2 of 74 mm Hg, and a Paco, of 61 mm Hg, he was given mechanical respiratory assistance. At 7 days of age he developed atelectasis of the right upper and middle lobes as well as an infiltrate in the remaining lung fields. Physical therapy was then added to the regimen of antibiotics and tracheobronchial toilet that the infant was receiv¬ ing. Every two hours either percussion by hands or vibration with electric toothbrush was performed. The atelectatic areas grad¬ ually reexpanded. While receiving respira¬ tory assistance, nasogastric tube feeding of formual (Similac 20) supplemented daily by 0.6 ml of vitamins (Poly-Vi-Sol) was well tolerated. After one month the regimen was changed to continuous positive airway pressure breathing, and the patient was subsequently extubated. However, the infant had developed clini¬ cal and radiological manifestations of bronchopulmonary dysplasia. He was tachypneic with a respiratory rate varying be¬ tween 60 and 70/min, he had intercostal re¬ tractions, and he was oxygen dependent, needing 50% oxygen to maintain normal breathing. He did not have apneic spells requiring resuscitation during this period. Following a recurrence of atelectasis on the 53rd day, physical therapy and parenteral antibiotics were reinstituted. Subse¬ quent roentgenograms showed resolution of atelectasis. A roentgenogram done on the 75th day of age showed for the first time the healing fractures of the right sixth and seventh and left eighth ribs (Figure). There was also an infiltrate in the right upper lobe and herniation of the left upper lobe to the right. Roentgen¬ ograms of the rest of the skeleton were normal. Serum calcium, phosphorus, and alkaline phosphatase levels at this time were 9.3 mg/100 ml, 5 mg/100 ml, and 217 was
IU, respectively.
Comment.—Multiple rib fractures in the newborn infant can occur in os¬ teogenesis imperfecta congenita, con¬ genital hypophosphatasia, osteopetrosis, pyknodysostosis,4 and following vigorous resuscitative efforts.0 Os¬ teogenesis imperfecta was excluded since the roentgenograms of the long bones did not show hypoplasia, thin¬ ning of the cortex, and scanty spongiosis.6 Also, the roentgenograms of the skull did not disclose irregular mineralization (mosaic rarefaction),
Roentgenogram eighth ribs.
of chest demonstrates fractures of
which is of great diagnostic assist¬ ance when changes in long bones are equivocal." Other above-mentioned causes of multiple rib fractures were unlikely since the skeletal survey was normal and the infant did not require resuscitation during nursery stay. Burnard et al have reported "stress fractures" of the ribs in infants with prolonged respiratory distress.7 In the present case the fractures may partly be attributed to the stress of pro¬ longed respiratory distress; the other factor that seemed to have played a role was most likely the trauma in¬ duced by the physical therapy. In neonates, small medicine cups for percussion and an electric tooth¬ brush for vibration have been recom¬ mended for physical therapy. Besides ease of administration, these methods also tend to limit the amount of force used. In our infant, percussion was done by hand and vibration was ac¬ complished by electric toothbrush. Apparently, the force used, in spite of the technical expertise of the nursing personnel either alone or in concert with the stress due to respiratory dis¬ tress, was enough to fracture the rib cage. In the term newborn, callus forma¬ tion may become visible by roentgen¬ ogram one week after fracture.8 Thus, the fractures in the present case may
Downloaded From: http://archpedi.jamanetwork.com/ by a New York University User on 06/16/2015
right sixth and seventh and left
have occurred around 58 to 68 days of age. Had the fractures of this unin¬ tentionally battered neonate first been diagnosed following hospital discharge, he might have been labeled as a case of parental child abuse. DILIP M.
PUROHIT, MD
CANDACE CALDWELL, MD
ABNER H.
LEVKOFF, MD
Department of Pediatrics Medical University of South Carolina
80 Barre St
Charleston, SC 29401 1. Dunn D, Lewis AT: Some important aspects of neonatal nursing related to pulmonary disease and family involvement. Pediatr Clin North Am 20:481-498, 1973. 2. Northway WH Jr, Rosan RC, Porter DY: Pulmonary disease following respiratory therapy of hyaline membrane disease. N Engl J Med 276:357-368, 1967. 3. Gregory GA, Gooding AA, Phibbs RH, et al: Meconium aspiration in infants: A prospective study. J Pediatr 85:848-852, 1974. 4. Wesenberg RL: The Newborn Chest. New York, Harper & Row Publishers Inc, 1973, pp 154-156. 5. Caffey J: Pediatric X-Ray Diagnosis. Chicago, Year Book Medical Publishers Inc, 1972, vol 1, pp 279-285. 6. Caffey J: Pediatric X-Ray Diagnosis. Chicago, Year Book Medical Publishers Inc, 1972, vol 2, pp 1037-1042. 7. Burnard ED, Grattan-Smith P, Picton-Warlow CG, et al: Pulmonary insufficiency in prematurity. Aust Paediatr J 1:12-38, 1965. 8. Mechan I: Analysis of Roentgen Signs in General Radiology. Philadelphia, WB Saunders Co, 1973, vol 1, pp 167-171.
