Volume 119 Editorial correspondence 1 6 1 Number 1, Part 1

be dealt with in such calculations, include an infant mortality rate twice that of other developed countries; the lowest literacy rate; many times the teen pregnancy, addiction, and homicide rates; and the largest prison population.

We have been very successful as a society with our individual- ism, at least in the material sense. It seems to me that our reliance on individualism, however, has exceeded its limit and resulted in the

problems noted above, which other developed countries seem to deal with much better than the United States. Perhaps it is time to

put private charity in its place--in personal relationships and emergencies. Private, individual action may relieve our guilt but cannot get the job done.

Perhaps we need to go beyond our ideological wars and form co-

alitions that express our commitment to the new values and struc- tural changes needed. It is not obvious that we can work together, but we certainly can't do the job individually. Let's help our Acad-

emy get to work on a comprehensive solution that is big enough for the problem.

Karl W. Hess, MD 3286 Maynard Rd.

Cleveland, OH 44122

Replacement doses of glucocorticoids To the Editor:

I think a correction to the conclusion of the article by Linder et

al. (J PEDIATR 1990:1 l 7:892-6) should be made. We published se- cretion rates of cortisol in children (J Clin Endocrinol 1970;30:361), measured by the double-isotope dilution derivative technique. The secretion rate was 7.5 mg/m 2 per day in 10 subjects, establishing

a secretion rate lower than that in subsequent reports. Linder's data

corroborate older data using a different technique. Thus Linder should have cited our article.

Maria I. New, MD Professor and Chairman, Department of Pediatrics

Chief Pediatric Endocrinology Harold and Percy Uris Professor of Pediatric Endocrinology

and Metabolism Department of Pediatrics

New York Hospital-Cornell Medical Center New York, N Y 10021

Reply

To the Editor: We are pleased to learn that Dr. New agrees with our estimate

of cortisol production rate in normal children and adolescents. In the publication cited by Dr. New, she determined the cortisol pro- duction rate in three patients with congenital adrenal hyperplasia and in 10 normal subjects. Unfortunately, the article does not state the age or gender of the normal subjects studied; it is unclear whether there were any children among this control population.

Their cortisol production rates, determined by double-isotope dilu-

tion, ranged between approximately 3 and 14 mg/m 2 per day, with

a mean of 7.5. We found that the daily cortisol production rate in 33 normal children and adolescents, determined by a stable-isotope dilution technique, was 6.8 _+ 1.9 mg/m 2 per day (mean _+ SD).

A review of several pediatric and endocrine textbooks shows that they uniformly state that the cortisol production rate of normal children is approximately 12 to 15 mg/m 2 per day. I-3 This estimate

is based on several widely cited references on this topic. 4, 5 In our

view, this has led to the use of supraphysiotogic doses of glucocor-

ticoids to treat patients with adrenal insufficiency, with a resultant impaired growth in some children with this condition. Our findings

should help to correct this inaccurate estimate and provide a ratio- nal basis for glucocorticoid replacement therapy in children and adolescents.

Fernando Cassorla, MD Clinical Director

National Institute of Child Health and Human Development,

Bethesda, MD 20892

D. Lynn Loriaux, MD, PhD Professor of Medicine University of Oregon, Portland, OR 97201

REFERENCES

1. Donohue PA. The adrenal cortex. In: Oski FA, ed. Principles and practice of pediatrics. Philadelphia: JB Lippincott, 1990.

2. Forest MG. Adrenal steroid-deficient states. In: Brook CGD, ed. Clinical paediatric endocrinology. 2nd ed. Boston: Black- well Scientific Publications, 1989.

3. Bondy PK. Disorders of the adrenal cortex. In: Wilson JD, Foster DW, ads. Williams' textbook of endocrinology. 7th ed. Philadelphia: WB Saunders, 1985.

4. Kenny FM, Preeyasombat C, Migeon CJ. Cortisol production rate in normal infants, children, and adults. Pediatrics 1966;32:34-42.

5. Paterson KE. The production of cortisol and corticosterone in children. Acta Paediatr Scand 1980;281:2-38.

Clinical application of necrotizing enterocolitis theory To the Editor:

The supplement to the July 1990 issue of THE JOURNAL brought most readers up to date on the current thinking on, and research

into, the cause of necrotizing enterocolitis. More recently, Dr. Kliegman's editorial 1 attempted to bridge the basic science theory with the clinical disease process. Having trained with Dr. Clark, 2

one of the authors of the supplement. I wish to report the outcome of translating that theory into a "controlled" clinical practice.

All patients admitted to the neonatal intensive care unit at Lutheran Hospital-La Crosse for a 6-year period, starting in Au- gust 1984 and ending in August 1990, were examined. Of the 61 l patients admitted to the neonatal intensive care unit during that