LETTERS

LETTERS

Editor's note

The authors of "Managing acute diarrhea: What every pediatricianneeds to know" (February) have pointed out that the toddler whose photowe used on the first page of their article might appear to be drinking grapejuice or soda. In fact the child in the photo is holding a cup of grape-flavoredoral rehydration solution (Pedialyte). The article emphasized that sweetenedfruit drinks and soft drinks are not appropriate beverages for a child withdiarrhea because of their high osmolarity.

Cathy Brown

More about the pediatric hip

I very much enjoyed "Get a grip on the pediatric hip" (November).As a pediatric rheumatologist I have several additional comments that maybe helpful for pediatricians who are evaluating hips.

• The referral patterns of hip joint pain include not only the anterior knee, but the anterior thigh and the groin--in the area where femoral arterial and venous punctures are performed. A patient with true hip joint pain often will talk about having groin pain or even abdominal pain, not hip pain.
• The authors discussed examining the hip joint in several positions, which is certainly an excellent point because it allows the examiner to differentiate among different sources of pain. In addition to examining the child in the supine position, as the authors describe, I find it extremely useful to examine a hip while the patient is lying prone. You can check for flexion contracture by seeing if the patient can get the anterior pelvis flat down to the examining surface or if he or she holds it off the examining position with one buttock up in the air. If there is no significant hip flexion contracture, this is the best position to assess for asymmetry in internal rotation. The patient lies flat in the prone position, flexing the knees 90° and keeping the knees together. He then drops both feet laterally at the same time, providing an excellent view of hip internal rotation.

This is also a good position in which to check for leg length. If thepatient is lying prone with no hip flexion contracture and the knees aretogether and bent 90°, one can look for asymmetry in the femur or thelower part of the legs. If one knee extends farther on the exam table thanthe other, the child may have some femoral length asymmetry or hip jointsubluxation. If one heel extends farther up into the air than the other,there may be some asymmetry in the tibia/fibular component of the leg length.It is important to be sure that the lower legs are perpendicular to theexamining surface.

• It should be noted than an AP radiograph will rarely show a hip effusion. If you suspect a hip effusion, despite a normal plain film, have an ultrasound performed.
• With regard to sacroiliitis, described in the table on diseases of the hip, the authors suggest treatment with corticosteroids, but nonsteroidal anti-inflammatory drugs are more likely to be the mainstay of therapy for this condition. The ophthalmology consult they recommend is needed only if the eye is symptomatic. Finally, obtaining radiographs of the sacroiliac joint, as suggested, may not be instructive because the sacroiliac joints often look abnormal in normal adolescents.

Gail D. Cawkwell
St. Petersburg, FL

The authors reply: Dr. Cawkwell's thoughtful comments regarding our articleon the pediatric hip are much appreciated.

We agree that referred pain from the hip joint may produce symptoms inthe area between the knee and the groin. Referred pain from the hip is mostcommonly localized to the mid-shaft of the anterior thigh or the medialaspect of the knee (Thompson et al: The hip, in Nelson Textbook of Pediatrics,ed 15).

Dr. Cawkwell states that an AP radiograph of the hip rarely will showa hip effusion. This obviously depends on the severity and size of the effusionand the experience of the pediatric radiologist who is reading the X-rays.We agree, however, that an ultrasound should be requested if plain filmsare normal and there are clinical reasons to suspect an effusion.

With regard to sacroiliitis, nonsteroidal anti-inflammatory drugs arecertainly a mainstay of therapy for sacroiliitis associated with juvenilechronic arthritis, psoriatic arthritis, and other spondyloarthropathies.Local sacroiliitis and recalcitrant enthesitis may be treated with localinjections of corticosteroids, however (Khan MA: Ankylosing spondylitis,in Primer on the Rheumatic Diseases, ed 11).

Finally, we agree with Dr. Cawkwell that radiographic examination ofthe sacroiliac joint in adolescence may be difficult to read. We believethat a high-quality single AP view of the pelvis can provide an adequatescreening examination of the sacroiliac joints and minimizes radiation exposure.Many pediatric radiologists and rheumatologists prefer stereoscopic angulated(30°) or oblique views to evaluate the sacroiliac joints, however. Sacroiliacjoint films are not simple to evaluate. The interested reader can consultthe detailed description of the radiologic abnormalities in sacroiliac jointdisease provided by Cassidy and Petty in the third edition of their Textbookof Pediatric Rheumatology (pages 236­237).

Douglas J. Barrett, MD
Ellyn Palermo Theophilopoulos, MD
Gainesville, FL

Cautions about oil in the ear

In my opinion, the Clinical Tip suggesting warm cooking oil to relieveear pain (January) should have included some cautions, such as not to usethis technique if there is a chronic perforation, ear tubes, or acute eardischarge. In addition, a trade-off of using oil in the ear canal is thatit interferes with the otoscopic exam on the following day. Finally, I'mnot sure if cooking oil, olive oil, or baby (mineral) oil is the betterchoice.

Barton D. Schmitt, MD
Denver, CO

A timely reminder

This summer, I gave my 2-year-old nephew a bath and he happily playedwith several plastic objects. Being a rambunctious little boy, he suddenlyjumped up, then slipped and fell. He cried with pain and only Mother couldcomfort him. I looked him over, but saw nothing but a small red mark. Thenext day he had a significant purple bruise measuring about 2.5 cm by 3cm. I remarked to my brother and his wife that I was grateful for witnessingthis incident because it showed me that contrary to what I had thought,a lesion like this one is not necessarily caused by abuse.

I especially enjoyed "Skin lesions that mimic abuse" (January)because one of its authors, Dr. Sara Sinal, was one of my favorite attendingswhen I was a resident in the Wake Forest program. I appreciate the reminderfrom her and her colleagues that what appears to be abuse may be somethingelse.

T. Rita Browning, MD
Jacksonville, FL