Aggett P, et al. Arch Dis Child 1980;55:547-550. deficiencyor possiblya medical condition that interfered with
Bilinski DL, et al. Arch DermatoI1987;123:1221-1224.
zinc absorption or utilization? Moreover,there is no discus-
Buehning LJ, Goltz RW. JAm AcadDermatoI1993;28:499-501.
Heinen F, et al. Eur J Pediatr 1995;154:71-75. sion about the mother's nutritional status duringpregnancy.
Speculation that the marginal zinc status of the mother may
Editor's comment: Zinc deficiencyis rare without a predis- have contributed to the baby's congenital abnormalities is
posing disease such as acrodermatitisenteropathica. How- appropriate. In animal models,zinc deficiency during ges-
ever,it must be consideredin the premature infant who may tation has resulted in teratogenic fetal abnormalities,includ-
have less than normal zinc absorption. This particularcase ing neural tube defects. Epidemiologic data also link
was complicatedby prematurityand maternalzinc deficiency. maternal zinc deficiency and CNS malformations in the fe-
He respondedreally wellto therapy. Interestingly, authors
the tus. Women with acrodermatitisenteropathica have a high
point out that if zinc oxidepaste is usedfor diaperrash,the zinc incidence of spontaneous abortions and fetal alterations,
may be absorbed transcutaneously from theanogenitalarea. including skeletal abnormalities and anencephaly.
Zinc needs of growing infants may be best met by breast
Judith G. Ha", MD milk even when there is intestinal malabsorption. However,
low-birth-weight infants may be at risk for zinc deficiency
2nd Editor's comment: Zinc deficiencyin premature,breast- and for these infants, the quality of the breast milk must be
fed infantshas been previouslydescribedin the literature. It is considered. Zinc content of human milk normally falls as
not apparent whythe authorsstate that thiscase is an example lactation progresses. Thus, banked human milk may con-
of a "distinctform of zinc deficiencysyndrome." The infant de- tain less zinc than the mother's own milk and should be ana-
scribed received markedlyinadequatezinc intake from day 4 lyzed and supplemented with breast milk fortifier before use
through 21 of life by being treated parenterally without zinc in feeding premature infants. Providing parenteral nutrition
supplementation.Thezinc content of thebreastmilk also was to a premature infant without zinc supplementation is inap-
poor: <50% of the usual zinc contentof human milk. No infor- propriate medical care. Current recommendations call for
mation waspresentedregardingthe amount of breast milk that 400 mg/kg/d of zinc in total parenteral nutrition solutions.
the baby was receiving. Since the infant was failing to thrive, Poor nutrition during gestation will have a great impact on
energy requirements theinfant may not have been metsec-
of the health of the baby, and knowledge of the mother's nutri-
ondary to inadequatebreast milk feedings. tional health will assist in treating the infant appropriately.
No information was given to explain why the mother was
zinc deficient. Did she have a genetic disposition to zinc Fima Lifshitz, MO
Adrenal Insufficiency and BronchopulmonaryDysplasia in Low Birth Weight Infants
The causes of bronchopulmonary dysplasia are not clear, reactions can be excessive and damage repair progresses
but it has been associated with injuries due to mechanical very slowly.
ventilation. However, chronic lung disease and bronchopul- Some studies done in animal models have shown that in
monary dysplasia can develop in small premature infants the first few hours of life the response to adrenocorticotro-
who show little initial respiratory distress and who have never pic hormone (ACTH) may be absent (Guillet et al; and Walker
needed respiratory assistance. et al). Studies in humans show that in the first hours of life
Glucocorticoids produced by the adrenal glands play an im- some low-birth-weight neonates may also lack the appropriate
portant role in the resolution of inflammation and the response response mediated by the hypothalamic-pituitary-adrenal
to stress. The trigger for the release of glucocorticoids from axis. This has been called the neonatal stress "nonrespon-
the adrenal glands is the hypothalamic-pituitary-adrenal axis. sive" or "hyporesponsive" period. During this period the ad-
If this axis is functioning normally, inflammatory reactions renal gland shows a diminished or absent response to ACTH.
are easily resolved and the damage repaired. However, if This nonresponsiveness is thought to resolve within the first
the axis is not functioning properly, impaired inflammatory week of life.
A recent study by Watterberg and Scott suggested that
some premature infants may not recover from the neonatal
stress nonresponsive period as fast as expected and are
thus predisposed to greater damage from inflammatory re-
actions. In order to confirm this, they tested the cortisol re-
sponse to ACTH by measuring blood cortisol secretion levels
in a population of very-iow-birth-weight infants.
At the end of the first week of life, the infants who had
higher blood cortisol levels recovered without broncho-
pulmonary dysplasia while the infants with lower cortisol lev-
els eventually developed bronchopulmonary dysplasia and
3 Vol. 1995
GGH 11. No.4-December
remained dependent on oxygen supplementation. Watterberg Editor's comment: These observationscould have impor-
and Scott concluded that the infants in the latter group may not tant ramificationsforpreventive therapyin premature infants.
be able to secrete an adequate amount of cortisol in response Bronchopulmonarydysplasia is a very crippling disorder and
to stress and thus inflammation goes unchecked and renders its prevention would cel1ainly be welcome. The observa-
them susceptible to long-term lung injuries. tions need to be confirmed. An appropriate method of
screening and trial of therapy could then lead to prevention
Guillet C, et al. Endocrinology 1980;106:991-994. of this dreaded complication of prematurity.
Walker CD, et al. Endocrinology 1986;118:1445-1451.
Watterberg KL, Scott SM. Pediatrics 1995;95:120-125. JudithG. Hall,MD
Reduced Growth Honnone Secretion With Maintained Periodicity Following Cranial
Irradiation in Children With Acute Lymphoblastic Leukaemia
Lannering et al obtained growth hormone (GH) determina- 24 hours was withinthe normal rangefor both boys and girls.
tions every 20 minutes for 24 hours in a group of 34 children Beforepubertya broad range of cyclesper 24 hourswas seen;
with acute lymphoblastic leukemia (ALL) who had received thesesynchronized 1
during pubertyto approximately every 3
cranial irradiation with 18to 24 Gy. These children (12 boys to 4 hours. Lowerpeakamplitudes were observedinlhe irradi-
and 22 girls) had been diagnosed 4 to 10 years previously; ated children. There was no correlationbetweentime from di-
their mean age at diagnosiswas 3.9 years. Fourteen(5 boys agnosisand GH secretionor the maximalGH level duringthe
and 9 girls) were prepubertal at the time of the study (using 24-hourperiod. There were no obvious influencesof the time
Tanner staging). Heightwas expressedas standarddeviation of diagnosison GH secretion. Children who were still prepu-
scores (SOS)in comparison with Swedish reference values bertalat the time ofthe studyhad lostan average of 0.2 SOS.
for healthy children. A control group of 208 children was Childrenwho had enteredpuberty lostan average of 1.0SOS.
utilized. The GH profiles were analyzed using the Pulsar The authorsstate that their resultsindicatenot only that cra-
pulse detection program and Fourier time-series analysis. in
nial irradiation the range of20 to 24 Gy altersGH secretion
The estimated GH secretion rate in all irradiatedALL chil- (as determinedby Moell et ai, 1988), but also that irradiation
drenwas belowthe median ofthat of controlsfor pubertal stage with 18 Gy both beforeand duringpuberty reducesGH secre-
and sex. The difference betweenpatients and controls was tion. Specifically,therewas lowerpulseamplitudein the irradi-
more pronounced latepubertythan beforepuberty.GH secre- ated patients, a GH
suggesting physiologic insufficiency.Height
tion as expressed the areaunderthecurvewasalsoreduced in of the childrenat a meanfollow-upage of 7 yearsfell withinthe
irradiatedchildren. However,the number of GH peaksover normalrange for the Swedishpopulation. Final heightswere
not reachedin a majorityofpatients. The authorsfurtherstate
thatthe impairment observedin growth issmall beforepuberty.
The recommendation madethatALL patientsshouldbe stud-
ied repeatedlyas adults to evaluate the effects of decreased
GH secretionon organsotherthan the growthplate.
Lannering B, et al. Clin Endocrinol 1995;42:153-159.
Editor's comment: More and more information regarding
the effects of cranial irradiation on pituitary function is be-
coming known. Although most pediatric endocrinologists
recognize that irradiation with 24 Gy could be expected to
be associated with pituitary dysfunction,it is not generally
felt that lower dosages will be detrimental. However, few
investigatorshave performed the carefultype of analysis that
Lannering and coworkers presented. Their data suggest
that there are indeed significant reductions in GH secretion
with smaller doses of radiation that may not be clinically ob-
servable (no obvious reduction in stature) until puberty, and
that there is little difference between the effects of 18 and
24 Gy. It will be interesting to review final heights in the
patients reported in this study. One may then be able to
better counsel families whose children have received even
modest doses of cranial irradiation.
GGHVol. 11. No.4-December 1995 4