!

20

Brief clinical and laborator)" observations

concept that conversion of T4 to T~ depends upon a 5'monodeiodinase enzyme system that is immature at
birth? The 3,3'T2 is thought to be derived at least in part
from the peripheral conversion of T~ and reverse T~? In
this infant, the 3,3'T~ level was high at birth, and
remained elevated until the twenty-sixth day; therefore, it
seems likely that the enzyme or enzymes capable of
forming 3,3'T~ in thyrotoxicosis are operative at birth.
LATS-P was present in high concentrations-in the
serum of both mother and infant, whereas LATS was
measurable in both at low levels which could be considered nonspecific? The high concentration of LATS-P in
the infant's serum when he was hyperthyroid and its
reduction to undetectable levels when he became euthy-.
roid suggest a role for this thyroid-stimulating immunoglobulin in the development of neonatal thyrotoxic0sis?
Although the routine measurement, in all pregnant
thyr0toxic women, of the thyroid-stimulating immunoglob.ulins LATS and LATS-P may be helpful in detecting
neofmtal thyrotoxicosis, a definitive diagnosis of this
disorder requires the demonstration of elevated iodothyronines in the infant. Although T4 and rT3 levels in cord
serum are normally higher than in serum of euthyroid
adults, ~"~ markedly elevated levels should suggest hyperthyroidism. A n elevated cord serum T3 value may be
diagnostic, since it is normally very low, ~. s and an
elevated cord serum 3,3'T: level also indicates overproduction of iodothyronines.
This patient illustrates that a variety of iodothyronines
are abnormally elevated in neonatal thyrotoxicosis,
and supports the concept that the disorder is produced by
transplacental transmission of thyroid-stimulating immunoglobulins.
We thank Dr. David II. Solomon for his valuable advice as
well as his help in performing the LATS and LATS-protector

TI,e Journal of Pediatrics

July 1978

assays, and v.'e appreciate the technical assistance of Frances D.

Wright, Yin-Ying Djuh, Yvonne Lukes, Francoise Smith, and the
staff of the Nuclear Medicine Service, Walter Reed Army
Medical Center. We also thank Janet Anastasi and Rosetta
Stokes Floyd for secretarial support.
REFERENCES
i. White C: A foetus with congenital hereditary Graves's
disease, J Obstet Gynaecol Br Emp 21:231, 1912.
2. Sunshine P, Kusumoto H, and Kriss JP: Survival time of
circulating long-acting thyroid stimulator in neonatal thyrotoxicosis: Implications for diagnosis and therapy of the
disorder, Pediatrics 36:869, 1965.
3. Dirmikis SM, and Munro DS: Placental transmission of
thyroid-stimulating immunoglobulins, Br Med J 2:665,
1975.
4. Burman KD, Read J, Dimond RC, Strum D, Wright FD,
Patow W, Earll JM, and Wartofsky L: Measurements of
3,3',5'-tri-iodothyronine (reverse T3), 3,3'-L-diiodothyronine, T3, and T4 in human amniotic fluid and in cord and
maternal serum, J Clin Endocrinol Metab 43:1351, 1976.
5. Burman KD, Strum D, Dimond RC, Djuh Y-Y, Wright FD,
Earll JM, and Wartofsky L: A radioimmunoassay for 3,Y-Ldiiodothyronine (3,3'T2), J Clin Endocrinol Metab 45:339,
1977.
6. Chopra IJ, Solomon DH, and Limberg NP: Specific and
non-specific responses in the bioassay of long-acting thyroid
stimulator (LATS), J Clin Endocr 31:382, 1970.
7. Adams DD, Fastier FN, Howie JB, Kennedy TH, Kilpatrick JA, and Stewart RDtI: Stimulation of the human
thyroid by infusions of plasma containing LATS-protector,
J Clin Endocrinol Metab 39:826, 1974.
8. Chopra IJ, Sack J, and Fisher DA: Circulating 3,Y,5'triiodothyronine (reverse T3) in the human newborn, J Clin
Invest 55:1137, 1975.
9. Chopra IJ, Sack J, and Fisher DA: 3,3',5'-triiodothyronine
(reverse T3) and 3,Y,5-triiodothyronine (T3) in fetal and
adult sheep: studies of metabolic clearance rates, production rates, seru m binding, and thyroidal content relative to
thyroxine, Endocrinology 97:1080, 1975.

A simplified method for diagnosis ofgestational age in

the newborn infant
llaroldo Capurro, M.D., Sergio Konlchezky, M.D., Daniel Fonseca, M.D., and
Roberto Caldcyro-Barcia, M.D., Montevideo, Urttgtta)"

S O M A T I C " :~ or neurologic findings or both

have correlated well with gestational age as estimated by
CERTAIN

From the Latin American Center of Perinatologv and

Human Development (PA t10/IVItO).
Reprint address: Casilla de Correo 627, Montevideo.
Urugua)'.

the date of onset of amenorrhea?- ' In 1970, Dubowitz ~

devised a scoring system based on 21 such somatic and
neurologic signs.
The advantages of this method are that it is painless,
inexpensive, precise, and that quantification is possible.
Its major inconvenience is its complexity for daily prac-

0022-3476/78/0193-0120500.30/0 9 1978 The C. V. Mosby Co.

Vol,,me 93
Number I

Brief clinical and laboratory observations

12 1

VARIAB LES
Nipple formation
S

IIipple barely
v.[slble: no /
areola "/ ~

;/ell-def.[ned
Areola stlppled |
nipple : areola~ not raised
A

Thin,
gelatinous

Thin

<0.Ts/~,~

>

0.75 en

Areola
raised

>0.75

t:

B?

Skin texture
A

S
O
M
A
T
I
C

/
C
Ear form

P.[nna flat &

shapeless

A
:1
D
II
E
U
R
O
L
O
G
I
C
A
L

and
smooth

K=
Breast size
204
days

Plantar creases

llo breast
t.[ssue

S
/

I;o creases

Smooth, medium
thlekness,superf.[clal peeling
~i0

Incurving of
part of edge

Partial incurvlng
of whole of upper
pinna
/

Diameter

Diameter
0.5 - 1 on

<0.5 cm /

/i0
Faint

red

marks

over

anterior~. '.

Definite red m a r k s
over anterior 1/2,
anteri~176
over/

Slight thicken- Thick and

in~ superflc.[al parchment
cracking & peel- like
fing
eet ~ hands/l~/

/20

Nell-deflned
incurvlngof
pinna
/

Diameter
> 1 on
/

/is
Indentations
over anterlor
1/2
/~/

Deep indentations
over more than
anterior 1/2W./~Q

K=
200
days

Fig.I. Variables and assigned scores in ihe modified Dubowitz method for assessment of gestational age. A. Gestational
age in days = 204 + total somatic score (for neurologically depressed infants). B, Gestational age in days = 200 + total
combined somatic and neurologic score (for healthy infants).
rice, in vie`,',' of the large n u m b e r of Variables to be
considered. Our aim has been to simplify this method,
reducing the n u m b e r of variables while keeping reasonable precision.
Abbreviation used
GA:
gestational age
MATERIAL

AND METHOD

Gestational age was assessed by the Dubowitz method

in 115 newborn i n f a n t s . The mothers were healthy;
pregnancy had been controlled; the time of anaenorrhea
was known, based on regular menstrual cycles; and they
had not taken hormonal contraceptives for one year
before becoming pregnant.
The neonates were vigorous (Apgar ~ 7) at the first,
fifth, and tenth minutes. No abnormal finding was discovered during their stay in the__hospital. Weights ranged
b e t w e e n 790 and 4,500 gm (X = 3,140) and gestational
ages between 205 and 296 days (X = 272). Ten percent

0'4 = 11) `,,,'ere small-for-date infants, 85% (N = 98)

appropriate-v,,eight-for-date, and 5% (N = 6) large-forgestational-age.
The Conditions stated by Dubowitz ~ `,vere strictly
followed (quiet wakefulness) two hours after feeding;
cooling and sudden maneuvers during examination were
avoided.
All the neonates were examined at between 12 and 48
hours of life by the same neonatologist ([t.C.), who
quantified the 21 findings studied by Dubowitz :' with the
corresponding score. The correlation found bet`,veen the
score obtained and the time of amenorrhea for these 115
infants (r = 0.91, SE = 8 days) ,,,,'as similar to that
obtained by Dubowitz (r = 0.93, SE = 7).
Based on these facts, we attempted to reduce the
n u m b e r of variables to be tested, using a multiple linear
regression method. After successive analyses, those
variables with a regression coefficient not significantly
different from zero, at the selected significance level
(P = 0.05), `,,,'ere discarded.

122

Brie.f cfinical and laboratory observations

RESULTS OF THE SIMPLIFICATION

DUBOWITZ METIIOD

The Journal of Pediatrics

Jul)" 1978

OF

Fig. 1 shows the five somatic and the two neurologic

variables which, according to the method o f multiple
linear regression, were those of major influence in the
assessment of GA. These signs correspond to those established by Dubowitz, but are scored differently, according
to their respective influence on the determination of GA
as demonstrated by the regression analysis.
When the infant has signs o f cerebral damage or
dysfunction (immediately after labor or later) neurologic
signs cannot be used for assessment of GA. Therefore, in
these infants, we propose to use only the five somatic signs
shown in Fig. !, column A (Method A). When the infant is
heaithy and aged more than 12 hours after birth, we
propose to use four somatic and two neurologic signs (Fig.
i, column B) (Method B).
Using Method A, GA (in days) is assessed simply by
adding to a constant (K = 204 days), the sum of the five
values of somatic findings. The adjustment o f this method
to our data has been as follows: correlation coefficient
(r) = 0.88, standard e r r o r of estimation (SE) = 9.2
days.
Using Method B, GA (in days) is assessed by adding to
a slightly different constant (K~ = 200 days), the sum of
the values of the four somatic and the two neurologic
findings. The adjustment of this method with the time of
amenorrhea is as follows: correlation coefficient
(r) = 0.90; standard error of estimation ( S E ) = 8.4
days.
An example of Method B in an hypothetic newborn
infant would be as follows: Skin texture, 15; ear form, 24;

breast size, 10; plantar creases, 15; scarfsign, 12; head lag,
8; K, 200 = 284 days.
DISCUSSION
The Dubowitz method with 21 variables is somewhat
impractical for daily practice. Some authors '~": have tried
to simplify it in order to make it easier and quicker for the
clinician and the infant, yet preserving its original precision.
Our simplified method with only six variables has a
similar correlation coefficient and error as that by Dubowitz. Moreover, it can be used even when the infant is
neurologically depressed.

REFERENCES
1. Farr V, and Mitchell RG: Estimation of gestational age in
the newborn infant. Comparison between birth weight and
maturity scoring in infants premature by weight, Am J
Obstet Gynecol 103:380, 1969.
2. Usher R, McLean F. and Scott KE: Judgment Of fetal age.
li. Clinical importance of gestational age and an objective
method to value it, Pediatr Clin North Am, 835, 1966..
3. Saint-Anne D'Argassies S: La maturation neurologique du
pr6mature, Etud N6o-Natales 4:71, 1955.
4. Amiel-Tison C: Neurological evaluation of the maturity of
newborn infants, Arch Dis Child 43:89, 1968.
5. Dubowitz LMS, Dubowitz V, and Goldberg C: Clinical
assessment of gestational age in the newborn infant, J
PEDtA'rR 77:1, 1970.
6. Parkin JM, Hey EN, and Clowes JS: Rapid assessment of
gcstational age at birth, Arch Dis Child 51:259, 1976.
7. Bailard: Mentioned in Klaus MH, and Fanaroff AA,
editors: "Care of the high-risk neonate", Philadelphia. 1973,
WB Saunders Company, p 47.

Pelforation of feeding tube into right renal pelvis

Rhonda S. Fogle, M.D., Wilbur L. Smith, iM.D.,* and Ed~in L. Gresham, M.D., Indianapolis, Ind.

MECHANICAL COMPLICATIONS have been reported

with the use of oro/nasojejunal feeding tubes, including
retroperitoneal perforation of the second portion of duodenum, 1- '-' intraperitoneal perforation of the third portion
of duodenum, -~'~ and aspiration from too large a bolus of
formula?

We describe an infant who had a tube perforation of

the second portion of the duodenum which entered the
fight renal pelvis.

OJ:

orojejunal

CASE R E P O R T
From the Department of Neonatolog), RadiologL and
Pediatrics, Janws IVhitcomb Rile)' ttospital for
Children, Indiana University Medical Center.
*Reprint adress: Rile)' Children's Hospital Department of
Radiology, 1100 West Michigan St. Indianapolis, IN 46202.

A one-hour-old, 936-gram boy was admitted to Riley Children's Hospital for mild respirator), distress complicated by
episodes of apnea and brady-cardia. To maintain nutritional
status a No. 5 Frencfi orojejunal tube made of polyvinyl chloride
0022-3476/78/0193-0122500.30/0 9 1978 The C. V. Mosby Co.