LETTERS TO THE EDITOR 771
month-old girl, following the accidental
inges-tion of “Lomotil” tablets.
On the morning prior to hospital admission,
the child was noted by her mother to have
in-gested about 16 “Lomotil” tablets, by
esti-mate. No medical attention was sought, and 2
hours later the child was observed to be
drowsy while eating lunch. She was put to bed
after lunch, and seven hours later she was still
sleeping, “breathing hard” and could not be
aroused. When examined at a local hospital,
the infant was described as flaccid and
unre-sponsive, with shallow, gasping respirations.
Brown material, presumably vomitus, was
found in the patient’s mouth. Fourteen hours
after ingestion of the “Lomotil” tablets, the
pa-tient was admitted to the Upstate Medical
Center.
At that time she was pale, flaccid and
coma-tose. Reflexes were diminished and she
re-sponded only to deep pain. Her pupils were
contracted to pinpoint size. Respirations were
irregular, shallow and intermittently gasping.
Heart rate was 140 per minute, with a blood
pressure of 90/65. An adequate airway was
en-sured by tracheal intubation, and 2 mg of
Nal-line
(
nalorphine)
was given intravenously.Spontaneous respiration improved markedly
following Nalline administration. Blood
chemi-cal and hematological findings were normal,
save for a leucocytosis of 17,000/eu mm and
transiently elevated blood urea nitrogen values.
Chest and skull films were unremarkable. An
electrocardiogram revealed a sinus tachycardia
with non-specific ST and T wave
abnormali-ties. An electroencephalogram was suggestive
of cortical irritability, and disturbance of deep brain function.
The patient gradually regained
conscious-ness, over a period of about 4 days. She was
moderately febnile (38#{176}C to 39#{176}C) for 6
days. During the period of recovery the patient exhibited transient hypertension (BP 150/110) with evidence of cortical blindness and marked
irritability. The degree of permanent visual
im-pairment is still being evaluated. An
intra-venous pyelogram, performed because of the
transient elevated blood urea nitrogen (as high
as 41 mg/100 ml) associated with pyuria,
showed no abnormalities. Evidence of a urinary
tract infection, secondary to Proteus mirabilis,
was documented.
“Lomotil” is advertised as a “federally
ex-ernpt narcotic,” that “may be habit forming,”
presumably because of the drug di1;:enoxylate
hydrochloride. Information concerning the
me-tabolism of this drug in infants and children, or even safe, effective therapeutic levels, does not
seem to be readily available. The value of
“Lomotil” in the therapy of juvenile diarrhea is
not established, but its toxicity may be severe
or even lethal. Reevaluation of “Lomotil” by the FDA would seem appropriate.
GERALD
J.
BARGMAN, M.D.LYTT I. GARDNER, M.D.
Department of Pediatrics
State University of New York
Upstate Medical Center
Syracuse, New York 13210
REFERENCES
1. Harnies, J. T., and Rossiter, M. : Fatal ‘Lomotil’
poisoning. Lancet, 1 : 150, 1969.
2. Henderson, W., and Psaila, A. : Lomotil
poison-ing. Lancet, 1:307, 1969.
3. Riley, I. D. : Lomotil poisoning. Lancet, 1:373,
1969.
4. Redhead, I. H. : Lomotil sensitivity? Lancet,
1:573, 1969.
5. Ament, M. E. : Diphenoxylate poisoning in
children. J. Pediat., 74:462, 1969.
Responsibility for School Problems: An Objection to “Pediatric Globalism”
To iiiE EDITOR:
At a time when our country is reviewing the
question of foreign overcommitment,
overex-tension, and priorities it may be relevant to
look at a similar problem in pediatrics.
The pediatrician is being asked to become
an expert in school problems. If not the final
expert, he is at least expected to be the
coordi-nator of the team that diagnoses and treats the
school problem. Parents want this. The schools
want this. Some prominent pediatricians seem
to want this.
The pediatrician who doesn’t attempt to
provide these services might well feel
made-quate. Parents are accustomed to turning to
him for “everything” that pertains to children. The schools pressure him for assistance because
they want confirmation of “brain damage.”
Pe-diatricians who have become subspecialists in
school problems write articles that ask the
772
LETTERS TO THE EDITORHowever, the pediatrician can find
justifica-tion for questioning his role in school problems.
First, we have our man-power problem. At
least 30% of American children are not
receiv-ing adequate physical care.’ Going from the
one extreme of personally providing all well
child care for some to another extreme of
over-involvement with a nonmedical problem,
is still a misuse of physician time. Second, the
pediatrician is not qualified to handle these
school problems (especially the learning
prob-lems)
,
except as a diagnostic dilettante. For this reason, the average pediatrician finds school problems frustrating. A nonmedicalsub-specialty problem is not a remedy for the
“pe-diatric disenchantment syndrome.” Third, the
psychologists and educators who are qualified
to manage these learning problems, resent the
pediatrician’s tendency to usurp their role.
Fourth, the pediatric housestaff is repeatedly
irritated to find referred school problems
“dumped” on them.
The following three recommendations are
offered as an alternative to becoming a school
problem subspecialist:
(
1)
The pediatrician’srole in school problems should be to rule out or
manage physical disease, neurological disease,
visual defects and hearing defects. The
pedia-tnician himself can perform the neurological
history and neurological examination necessary
to exclude a neurological handicap. Tests for
soft neurological signs are possibly best not
done, since their relevance is so conflicting.2 The pediatrician should discourage the
witch-hunt for “brain damage.” An EEC should
rarely be ordered. The pediatrician should be
willing to prescribe a therapeutic trial of
amphetamines for the child whose
hypenactiv-ity (regardless of cause) interferes with his
learning. In the child who has mental
retarda-tion or cerebral palsy, the pediatrician should
bear primary responsibility for the child’s
med-ical care and for helping the child make a
healthy emotional adaptation to his physical
handicap; but he should not be responsible for
evaluating or treating the child’s learning
handicaps. The one school problem in which
the pediatrician plays the key role is school phobia. Since it usually presents as an organic disease, he is responsible for it’s early detec-tion, convincing the parents their child is phys-ically sound, returning the child to school,
noti-fying the school nurse not to send the child
home for future psychosomatic complaints, and
forbidding homebound teaching. In nonschool
problems, the pediatrician should keep the
schools informed of any medical disorders that
may have medical repercussions at school.
Ex-amples of these are gym restrictions for some
children with chronic heart or lung disease, ap-propniate teacher response to seizures or insulin
reactions, and so on. The pediatrician should
also be available to the school to participate in
discussions concerning medical topics such as
sex education, venereal disease, and drug
abuse.
(2) The school is the proper place to solve
school problems-be they learning disorders,
classroom misbehavior, or poor attendance.
The school psychologist is the proper person to
coordinate these problems. He is unique in
being able to validly test students, delineate
their specific strengths and weakness,
under-stand the realities of school facilities, and
un-derstand behavior modification techniques. He
is the only person who can realistically design
a remedial learning program for a given child.
In the case where the school problem is caused
by an emotional disorder, the psychologist is
better trained than the pediatrician to obtain the necessary psychosocial history. He can then decide either to treat the family himself, or to
make a referral to a mental health worker. In
conclusion, the pediatrician should return the
responsibility for school problems to the
schools. He should remain the “school’s
con-science” and demand followup on his patients
with school problems. If the schools do not
ac-cept their responsibility, the pediatrician should encourage the school board by whatever
means necessary to improve their special
edu-cational facilities.
(3) The pediatrician should instead expand his knowledge base in “everyday child
psychia-try.” He should demand more instruction at both the resident and postgraduate level in an-ticipatory guidance, crisis intervention, school phobia, recurrent pain, psychosomatic prob-lems, medication refusal and emotional
reac-tions to chronic and fatal disease. These
prob-lems are unquestionably within the
pediatni-cian’s jurisdiction. These areas should receive priority in training for “comprehensive
pediat-rics.” But if one defines “comprehensive
pedi-atrics” as including the whole gamut of school
problems, the acceptance and realization of
“comprehensive pediatrics” becomes greatly
BARTON D. SCHMITT, M.D.
LETTERS
TO THE EDITOR 7735121 Pinyon Drive Littleton, Colorado
REFERENCES
1. Butler, A. : Availability, effectiveness, and econ-omy of child health services. PEDIATRICS, 43: 284, 1969.
2. Abrams, A. : Delayed and irregular maturation
versus minimal brain injury. Clin. Pediat.
7:344, 1968.
Cystic Fibrosis of Pancreas and Down’s Syndrome
To THE EDIToR:
Dr. A. Milunsky describes (PEDIATRICS,
42:501, 1968) the observation “for the first time” of cystic fibrosis of the pancreas in three
children with Down’s syndrome. I would like
to point out that such association has been
ob-served in several autopsied cases at the
De-partment of Pathology in University Medical
School of Milan. I think this association occurs
very frequently in Down’s syndrome, and I
de-scribed it in the book “Ii Mongolismo,
auxopa-tia somatopsichica caniotipica,” by E. Aldeghi
and A. Maderna, in the chapter devoted to the
pathological anatomy of the syndrome (page
69).
I am sending you a copy of this book under separate cover. I believe that this topic is won-thy of further studies in order to reach a better
understanding of the relationship between
Down’s syndrome and cystic fibrosis of the
pancreas.
Milan, Italy
DR. A. ROVESCALLI
Department of Pathology
The University Medical School of Milan
EDITOR’S Nom: See also PEDIATRICS, 43:905.
Dr. Milunsky commented on Dr. Rovescalli’s letter as follows:
I would like to thank Dr. Rovescalli for
pointing out the four or five lines in his Italian
text on mongolism in which he mentions
pa-tients with mongolism and cystic fibrosis.
Un-fortunately, no evidence for the diagnosis of
cystic fibrosis is provided (e.g. sweat test
re-suits) . The poor reproduction of the adjoining
slide of the pancreas leaves the point further
unresolved, since in this disorder the pancreas
may appear entirely normal on microscopy in
the early weeks of life.
AUBREY MILUNSEY, M.B.B.Ch., M.R.C.P. D.C.H.
Assistant Professor of Pediatrics Tufts University School of Medicine
1 71 Harrison Avenue
Boston, Massachusetts 02111
Mist Therapy Reconsidered-Humidified Tents vs. The High Humidity Room, Further Comment
To THE EDITOR:
It is gratifying that Avery and her group, in a recent paper,’ have by careful thought,
knowledge of physics, and the alchemy of
mathematics helped substantiate some of the
statements we made in the paper2 which dealt
with the size of water droplets in relation to the obstructive respiratory ills of childhood. In
their report, indicated above, these workers
deny the value of a humidified plastic tent (or
mist tent) and mention several possible
ad-verse effects when these tents are used. They do not consider the type of nebulizer and the size of water droplets it produces as being sig-nificant. They suggest a method of humidifica-tion other than by mist tent which we feel is not practical and in small children might be unsafe.
The above paragraph can become more
meaningful if we add to it an explanation of
how adequate humidification probably helps
relieve the child with an obstructive
respira-tory ill. In addition to all else the body’s water
stores are replenished, thus restoring an
opti-ma! water level in the tissues of the whole
re-spiratory tract. With this the function of these
tissues improves and helps the clearing of the
passages of the bronchial tree. Because the
nasal (and oral) passages play a very
impor-tant part in the humidifying and warming of
the inhaled air, this clearing process can be speeded if concurrently with the general
humid-ification, steps are taken to bring the mucosa
of the nose (and mouth) to a more optimal
