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  • 8/12/2019 Congenital Hipotiroid

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    1967;40;283PediatricsMARGARET H. MACGILLIVRAY, JOHN D. CRAWFORD and JOHN S. ROBEY

    Congenital Hypothyroidism and Prolonged Neonatal Hyperbilirubinemia

    http://pediatrics.aappublications.org/content/40/2/283the World Wide Web at:

    The online version of this article, along with updated information and services, is located on

    ISSN: 0031-4005. Online ISSN: 1098-4275.

    PrintIllinois, 60007. Copyright 1967 by the American Academy of Pediatrics. All rights reserved.by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarkedPEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,

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    In M ed ic ine on e m ust p ay a tten tion n ot to p la usib le theo riz ing bu t to exp erienc e and re aso ntogether . . . . I ag ree th at th eo riz ing is to be app rov ed , p rov ide d tha t it is b ase d on facts, an dsystem atic ally m ak es its de duc tio ns from w hat is observ ed . . . . B ut co nc lusion s d raw n fromu naided reaso n c an h ard ly be serv icea b le ; on ly tho se draw n from o bse rve d fac t. H ipp ocrate s:Precep ts.

    . . .Sh ort comm unica tions o f fac tua l mate r i a l are pub lished here . C omm en ts an d cr itic ism s appear

    as Le tter s to th e Ed i tor .

    28 3

    xperien ce and eason B rie fly R ecorded

    ongen ita l ypo thy ro id ismand P ro longed N eonata l

    yperbi l i rubinemiaIn tense neon ata l jaund ice of lo ng duration is

    an un co m m o n and p uzz ling con com itan t o fcon gen ita l m y xedem a . T he assoc iatio n w aso rig inal ly do cu m e nted b y A kerren in 195 4an d con firm ed by C h ristensen in 19 56 .2

    T h is repo rt d ocum ents th e d irec t causa l re -la tion sh ip be tw een co ngen ita l m y xedem a andhv perb il irub ine m ia in a pat ien t in i tia l ly p re-sen ting in the n ew b orn per iod . T he sub se que ntreco gnitio n o f m yx ede m a an d tre atm en t w ithtriio do thy ron ine (T ,) w as associated w ithp rom pt fall in b ili rub in leve ls an d a n im prove -m ent in thyro id sta tus. A cc id en ta l w ithd raw alo f trea tm en t w as fo llo w ed by an early recur-renc e of jau ndice and m yx ede m a . R ein stitu tio no f thy ro id rep lace m e nt led o nce aga in to n or-m a l b iliru b in lev els and e u th yro id ism .

    CASE H ISTORYC . W ., an in fan t g irl, w as b orn of a fu l l-te rm ,

    firs t p regn anc y w ith a 7-ho ur labo r and b reec hvag in a l d eliv er y . E xc ep t for frequ en t upper r es -pirato ry in fec tion s, the pregn anc y w a s w itho u tinciden t. A t b irth h er w eigh t w as 6 lb , 2 oz a ndshe m e asu red 1 9 in . in len g th . H ead circum fe r-en ce w a s d isp rop ort ion ately larg e, be lon g in g inthe 90 th pe rce n ti le . O n the sec ond d ay of life ,ja un(lic c w hic h c ould not be exp lain ed on th eba s is o f a m ate rn a l-feta l b loo d group incom pati-bil ity w a s re corded . P hy sio log ic jaun dic e w as a s-s u m e d the ca use o f the icteru s and n o fu rth ers tud ies w e re pe rform e d at tha t tim e. T ota l b ill -ru b in lev el on the fo urth day of li fe w a s 2 0 m gw ith 19 .4 m g/1 00 m l u nco nju ga ted . T h e infan t as d isc ha rg ed c lin ical ly w ell o n the fifth d ay w itha b iliruh in of 17 m g /10 0 m l.

    In the fo llo w in g 3 w ee ks w hile at hom e, th erew a s inc rea sin g in ac tiv ity an d th e bab y w as de -scribed a s be ing to o goo d . Jaun dic e pe rsis ted ac -co m p anied b y s too ls of n orm al co lor , c ons istenc y ,and fre que ncy . U rine co lor w a s no rm a l. B re astm ilk fe ed ings , w hic h w ere beg un a t b irth , w erec ont inue d .

    A surv ey of th e fa m ily h is to ry reve ale d bo th pa r-en ts w ere h eal thy , an d n o rela tive ha d be en ill w ithja un dice or thyro id d ise ase .

    A t 1 m onth of a ge bec ause o f pe rsis ting jaun dic e,in crea sin g leth arg y , an d p oor fee d in g , th e in fan tw as re adm itted for further e valuation . O n p hys ica le xam ina tio n she w as in ten sely ic ter ic and rath erod d in ap pe aran ce. H e r fa ce w as sm all re la tiv e tohe ad siz e an d th ere w as an e xce ss o f lon g , stra ig h t,fin e ha ir w h ich seem ed to s tan d o n end g iv ing a porcup ine a ppe ara nce . M arked in act iv i ty andg ene ral ize d hy po ton icity w ere e v id en t. R ep eate de xposure to lou d n oises fai led to elic it s ign s ofa ud ito ry pe rce p tion . T he liv er ed ge w as palpab le2 c m be low th e r igh t cos ta l m a rg in ; the sp leenw as not en larg ed . N e uro log ic ex am inat ion d isc losedg ene ral ize d br isk ref lex es, s low m u scle re lax atio n ,an d hyp oton icity . U r ine and stoo l co lor w e re nor-m l

    B reas t m ilk feed ing s w ere co ntinue d thro ug hou tth is hosp ita l ad m is sio n and un til the in fan t w as 5m on ths of ag e.

    L a bo rato ry stu d ies sh ow ed th e fo llo w in g : h em o-g lob in , 14 .6 g m /1 00 m l; W B C , 8 ,90 0; p o ly m o rph s,4 4 % ; lymphocytes, 46% . U rin aly sis w a s no rm al.T o tal b iliru b in leve ls o n thre e oc cas ion s w e re 12 ,1 0 , an d 9 .5 m g/1 00 m l w ith d ire ct b ilirub in valuesof 0 .2 , 1 .3 , a nd 1 .4 m g, re spe ctiv ely . A lk alin e p hos -p hatase w a s 23 .3 B o dan sky u nits; tra nsa m inase w a s65 u nits pe r 1 00 m l. C e reb rosp in al flu id w as ictericb u t o th erw ise n orm al . N o in trac ere bra l calc ific ationswere seen in sk u ll film s but the su tu res w ere w idelyse pa rate d . T ox oplasm os is dy e te st w as ne gative a ndthe ele ctroen cep ha log ram w as n orm al .

    D uring th e fir st da ys of h osp ita liza tio n , the ob-P a ax m cs , V ol . 40 , N o . 2 , A ugust 1 967

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    28 4 H Y P O T H Y R O ID IS M A N D H Y P E R B IL IR U B IN E M IAserv ers bec am e pro gre ssiv ely m ore im p res sed w iththe infa n ts le tha rgy , a fain tly c ret ino us fac ia l ap -p ea r an ce , an d co oi, m o ttle d sk in . B lood sub m ittedfo r P B I a t th is tim e sh ow ed very low va lues-1 .0a nd 1 .6 psg /10 0 m l w ith a to ta l io d in e o f 4 .5 & g/10 0 m l. T he elec tro ca rd iog ram w as abn orm a l inthat the vo ltage w as reduced . X -ray of the lo ngb one s sh ow ed n ot on ly absen ce of c alcifica tio n o fa ll the carp al ep iph yse al c en ters bu t o f the d ista lfem ora l and p rox im al tib ia l ep iphy ses w hich nor-m ally c alc ify p ren atal ly .

    S inc e fu ll e ffec tiv ene ss o f U S P th yro id w ou ldn ot be at ta in ed u nti l 3 w ee ks af ter its in trod uct ion ,it w as dec ided to em ploy bo th U SP thy ro id andt r i iodo thyron ine ( T 3 ) to ge th er , th e la tter to insu ree arly retu rn to eu thyro id ism . It w a s also p lan ne dth at T 3 w ou ld be w ith dra w n gradu ally ov er th ein i tia l 3 -w e ek p erio d w hile c on tinu ing d esicca tedth yro id as dem on stra ted in F igure 1 . A ccord ing ly ,triiodo thy ron ine (T 3) w as begu n in a dose of 50g /m 2/d ay g ive n as 3 ev ery 8 h ours. W ith in4 8 hou rs there w as im p rov em ent in sk in w a rm th ,act iv i ty , and feed ing . Jaund ice appeared less s trik -in g and w ith in 2 da ys o f s tar ting T 3 the b ili rub inw as redu ced to 6 m g fro m a p re -treatm en t va lueof 1 m g /100 m l. T 3 ad m in istra t ion w as m o nito redb y an e valuat ion o f c ard iac rate p rio r to eac h do seof m ed ica tion and b y a da ily e lec trocard iogram .T he course o f th erapy w as uneven tfu l .

    F o llow ing d ischa rg e from th e hosp ital the in -fan ts m oth er m isu nd erstood ins tru ctio ns an d U S Pthy ro id w as no t adm in iste red w h ile T 3 w as grad -u ally tap ere d a nd d isco n tin ued . F igure 1 show stha t fa ilu re to g iv e ex ogenou s thy ro id w as accom -pa nie d by a n e arly re cur ren ce o f hy perb ili rub ine m iaand du rin g th is p eriod the i n f a n t a ga in m an ife ste dle tha rg y an d co o l e x t r e m i t i e s Thyro id rep lacemen tw as p rom pf ly res tarted w he n th e e rror w as d is-cov e red and aga in th ere w as a re tu rn to n orm alserum bil irub in va lues . T he pa tie n t ha s rem ain edfree o f jau nd ice and c lin ica lly eu thy ro id on treat-m e n t with 12 0 m g/m /day of US P thy ro id th ro ug h-o u t th e obse rva t ion p erio d ex ten d in g to ag e 16m o nth s. O n ex am inat ion at 6 m o nth s it w as fo un dth at she re spo nd ed to au dito ry s tim uli. H e r w eig h tw as 16 .5 lb a nd h er le ng th 23 % in . H er he ad cir-cumference w as 18 3 in . and ch est c ircu m feren cew as 16 in . H er b od y p rop ort ion s w e re norm a l forag e (upp er segm en t/lo w e r se gm ent , 1 : 1 .6 ) . S e ruman tith y ro g lob u lin an tib ody tite r w as e leva ted to1 :4 0 in the pa tie n ts m o the r a nd 1 :8 0 in th e in-fan t at 6 m o n ths .

    R e-exa m inat ion a t 16 m on ths o f ag e rev ealedthat th e p atien t w a s eu thy ro id an d tha t m o tor de -v elop m ent w as w ith in n orm al lim its . She had b eenw alk in g fro m 13 m on ths of ag e a nd w a s sa y in gtw o sin g le w ord s an d m u ch no nse nse v oca bu lary .H er w e igh t w as 21 lb and le ng th w as 3 0 in . H ea dc irc um fe renc e w as 20 in . T h e da ily dose of thy ro idw as 75 m g a t th is t im e .

    C O M M E N TT h e case desc ribed con firm s the asso cia tio n

    of co ngen ita l hypo thy ro id ism and pro longedneo na tal h yp erb ilirub in em ia. F urthe rm ore, thecausa l re latio nsh ip b etw een m y xedem a an djaun d ice w as d ocum en ted b y th e fall in se rumbilirub in w hen exo geno us thy ro id w as in itiallyin trod uced , by th e recu rren ce o f h ype rb iliru -b in em ia w h en thy ro id rep lacem en t w as acc i-d entally w ithdraw n, a nd by th e sec ond dec lin ein se rum b ilirub in w hen th y ro id w as re -in sti-tu ted .

    P ro lo nged neona ta l u ncon ju ga ted hyp erb il-i rub inemia of the so rt d isp lay ed b y th e p res-en t case is ind ica tive of a d efect in g lucuro n idefo rmation . G lucuron y l transfe rase ac tiv ity upo nw hich co n jug atio n d ep en ds m ay be absen t a sin th e perm an en t ic te rus o f th e C rig ie r-N a jja rsynd ro m e3 o r it m ay be b loc ked as in the tran -sien t ic terus due to the p regn an ed io l b reastm ilk fac to r . P re sum ab ly icte rus in th e p re s-en t case w as no t d ete rm ined by pregnaned io lin ge stio n s inc e breas t feed in g w as con tinuedth ro ugh ou t and fluc tua tion s in the b ilirub inleve l w ere c lose ly co rrela ted w ith th y ro idtreatm en t. T he m ost co m m o n and ev anescen ttype o f n eo na ta l hy pe rb ilirub inem ia , so -calledp hys io log ic jau nd ice , is a ttr ibu ted to im m a-turity of the co n jug atio n m echan ism . T hep ro long ed n eona ta l jaun d ice o f the h ypo thy -ro id in fan t has b een co nsid ered an exagg era tedv arian t o f th is la st ty pe ,5 althou gh a recen t ex -pe rim en tal a ttem pt to dem o nstra te dep res siono f g lucu ron y l tran sfe rase ac tiv ity in liv er m i-c roso m es of o ffsp ring o f p rop y lth io u rac il treat-ed rats w as unrew ard ing .6 In th is rega rd , ho w -ev e r , it m ay be pertinen t to n o te th at th e ex -p erim en ta l d es ign fa iled to te st fo r hum oralin h ib ito rs o f con juga tion . T h at the se m ay bere spo nsib le fo r the b lo ck in b ilirub in m etabo-lism in con gen ita l h ypo thy ro id ism is sugg ested th e g lucu rony l tran sfe rase inh ib ito ry capa -b ility o f a va riety o f s tero ids k now n to be p re s-en t a t h ig h leve ls in the neon a te7 as w e ll as thein flu en ce o f th y ro id h orm on es in in c rea singgen era tion of T P N H and the reby acce lera tings te ro id d eg ra da tio n.8O f add itio nal in terest in th e p resen t ca se w asthe p re sence of dea fn ess n o ted a t 1 m on th o fage w h en the pa tien t w as m ax im a lly hvp o thy -ro id and its sub sequen t d isapp ea ran ce by 6m on th s w hen the pa tien t w as eu thy ro id . T he as-soc ia tion of dea fn es s and hyp o thy ro id ism has re -cen tly been d iscussed b y H o w a rth a nd L lov dan d by d e V os1 {1 76}ho a ttribu ted revers ib le hear-

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    T 3

    E X PE R IE N C E A N D R E A S O N -B R IE F L Y R E C O R D E D 28 5

    T O T A L 5B IL l R U B INm g / lO O m I)

    0

    5 IPBI 1 6

    I I

    u . s . p T H Y R O ID 5 m gT 3 g J 6 3 i _ _ _ _ _ _ _ _ _ _L 3 V //A i A 5 _ __ __ __ __ __ __ __ __ _ I I I I ,

    0 5 3 0 4 5 60 7 5 90D A Y SF I G 1 . In flu enc e of thy ro id trea tm ent on seru m bil irub in in an in fan t w ithco nge nita l hy po thy ro id ism . N o te sh arp d ecl ine w ith b eg inn ing of tre at-m e nt, recrude sce nce of h yp erb iliru b in em ia w hen th yro id w as acc ide n ta lly( l i sc ont inue d , an d seco nda ry fall to no rm al lev els w ith resum ptio n of m ed i-

    cat ion .

    ing los s in acq uire d m yx ede m a to de fec tiv e c on-d uct ion ca used by ed em a of th e eus tach ian tub e.E dem a of the m ucosa o f th e u ppe r airw ay m aybe a pro m in en t find in g in con gen ital hyp o thy-ro id ism ; in so m e ca ses it is th e ch ief clue todiagnosis.

    T h is case em phasizes tha t p ro lon ged neona-ta l jau nd ice sho u ld b e consid ered as a p ossib lemanifesta t ion o f con gen ital h ypo thy ro id ism .W hen cre tin ism does und erlie the h ype rb iliru -b in em ia, the la tter pro m p tly sub sid es on a p-pro pria te trea tm en t w ith thyro id horm on e . It iso f no te , ho w e ver , th at t he h yp er bi lir ub in em iaof th e eu thyro id prem atu re in fan t app ears no tto be sim ilar ly rap id ly am e lio rated , if a t allin flu enc ed , b y trea tm ent w ith thyroac tiv e

    1 1 1 2

    S U MM A R YA cre tinou s in fan t exh ib ited p ro lon ged neo-

    na tal ja un dic e w h ich sub sid ed on thyro id re-p lacem en t the rapy . A cciden ta l w ithd raw al o ftreatm e nt w ith rec rud esc en ce of jau nd ice anda secon d d rop in b ilirub in o n re sto ra tion of thy -ro id trea tm en t se rv ed to docum en t th e c loseassociat ion of thyro id insu ffic iency and u ncon-ju gate d h yp erb iliru bin em ia.

    MARG ARE T H . M AC G I L L I V R A Y M . D .F orm erly , D epa rtm ent o f P ed iatricsH arvard M edical S c ho ol

    an dC lin ica l an d R esearch F ellowC hild ren s S erv iceM assach use tts G en era l H o sp ita lP re sen t A ddress:C h ild ren s H osp ita l

    Buffalo New York 4222J O l I N D . CRAWFORD M . D .

    an dJou r S . ROBEY M . D .D epa rtm en t o f P ed ia tric sH arvard M ed ica l S choo l

    an dC hild ren s S e rv iceM assachuse tts G enera l H osp ital

    Boston M assachusettsT his w ork w a s supp orted in par t b y gra n ts o f

    th e U .S . P u blic H e alth S erv ice , T I-H D -0 00 33 .H D -00 243 , an d K 3-H D -14 , 8 24 .

    REFERENCES1 . A k erren , Y . : P ro long ed ja und ice in th e ne w -

    born asso cia ted w ith co ngen ital m yxed em a.A c ta P aed ia t. (S tockh o lm ), 43 :411 , 1 9 5 4 .

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    28 6 C H IL D -R E S IS T A N T C O N T A IN E R2 . C hr is te ns en , J. F . : P ro lo nge d icte rus ne ona -

    to ru m and co ng enita l m yx ed em a. A c taP aed iat ., 4 5 :3 67 , 19 56 .

    3 . S chm id , R . : H yp erb iiru b in em ia. in Stanbury ,J. B ., W y ng aa rd en , J. B ., a nd F re de ri ck so n,D . S ., ed . : T he M etabo lic B asis o f Inhe ritedD isease. N ew Y ork : M cG raw -H ill B oo k C o rn -p a n y I n c p 2 2 6 1 9 6 0 .

    4. A rias, I. M ., G arth e r, L . M ., S e if te r, S ., an dF u rm an , M . : P ro lon ged neon ata l un co n-ju gated h yp erb ilirub inern ia w ith breas t fe ed-ing an d a ste ro id , p reg nane 3 (alp ha) , 2 0(be ta ) -d io l in m atern al m ilk that in h ib its g lu -curon id e fo rm atio n in v i tro . J . C lin . Inv es t.,43 :20 37 , 1 964 .

    5. L ees , M . H ., an d R u thv en , C . R . J. : T he e ffec to f t ri io do th yr on in e in neona ta l h yperb ilim -b in em ia . L an c et, 2 :371 1959 .

    6 . W erd er, E . A ., a nd Y affe , S . J. : Glucurony lt ran sferase ac tiv ity in e xpe rim en tal neo na talhypothyro id ism. Bio l . Neonat . , 6 :8 , 1964 . Jones , B. : G lucu ron yl tran sferase inh ib i tio nby stero id s. J . P ed ia t. , 64 :81 5 , 1 96 4 .

    8 . M cG uire , J. S ., and T o m k ins , G . M . : E ffe cts ofthy rox in adm in istra tion on the enzymatic re -duct ion o f 4 - 3- k et o st er o id s . J . B io l. C he rn .,234:791 , 1 9 5 9

    9 . H ow arth , A . E ., an d L loyd , H . E . D .: Percep-tiv e d ea fne ss in hy po thy ro id ism . B ri t. M ed .J. , 1 :431 , 195 6 .

    10 . D e V o s, J . A . : Deafness i n h yp o th y ro id is m . J.L aryng ., 77 :3 90 , 1963 .

    11 . N ajje r, S . : R esp irato ry m an ife sta t ion s in in -fan ts w ith h yp oth yro id ism . A rch . D is . C h ild .,37 :603 , 1962 .

    1 2 . S hrand , H ., and R uth ven , C . R . J. : E ffec t o ftriiodo thy ron ine on se rum-b i l i rub in leve l an dneona ta l deve lop m en t o f th e p rem a tu re in -fan t. L ance t, 2:1 274 , 19 60 .

    R es u l t s o f T e s t i n g a C h i l d r es i s t an tM e d ic in e C o n ta in e r

    A cc iden ta l po ison in g o f y oun g ch ild ren w ithits attend an t m orb id ity and m o rta lity con tin uesto attract the a tten tion o f p ed ia tric ians co n-c ern ed w ith th e p reven ta tive aspec ts o f theprob lem . D esp ite edu ca tion al and leg isla tiveprograms, the ov era ll m o rta lity h as sca rce lyd ecreased since 1 954 . A frequ en t cause o f ac-c iden ta l po iso n ing resu lts fro m th e ingestion ofm ed ic ines . R ea lizing th is , a C anad ian pharm a-ceu tical as soc ia tion he ld a con te st in 19 64 tofind an eff icien tly d esig ned , inexp en sive , ch ild -res istan t con ta ine r. T h is b rie f rep ort desc ribesthe resu lts o f tes tin g th e ab ility o f ch ild ren toop en th e con tes t-w inn ing con ta ine r.

    METHOD S AN D MATERIALSA to ta l o f 420 ch ild ren fro m th e p ed ia tr ic

    cl in ic , p ed ia tric w ards , nurse ries , an d nurse rysch oo ls at M adigan G enera l H osp ita l w eretested . A con tro l g roup of 120 ch ild ren ran gedfrom 9 m on ths to 1 1 years , w ith m ost be ing 3years of ag e o r you nge r . A te st g ro up cons istedo f 300 ch ild ren rang ing in age fro m 1 to 11years. O ne hun dred six ty -e igh t o f the 3 00 ch il-d ren w ho w ere te sted w ere und er th e age o f 5years .

    T he tw o con ta in e rs tes ted are show n in F ig -u re 1 . T he con tro l w as a snap-top , p la sticm edicine con ta ine r in genera l use by ou r phar-m acy . T h e test item w as a p las tic con ta ine rw ith a ch i ld - resista n t top , w h ich m ay beo pened by em p loy in g tw o d istin ct an d coo rd i-na ted m aneuv ers: 1 depres sion of th e capag ain st a re sis tan t fo rce o f ap prox im ate ly 5 k gan d (2 ) a coun ter-c lo ck w ise tu rn o f 4 5 degrees.T h e ch ild ren w ere g iv en a clo sed con ta ine r inw hich w as p laced a rew ard ( sa ltw ate r ta ffyw ra pp ed in b rig h tly co lo red pap er) an d w ereasked to op en th e con ta ine r . A ll age g ro upsan d sub jec ts re sp ond ed to the stim u lu s. If thech ild g av e u p , o r w as un ab le to o pen th e con -tam er in 3 m in u te s, a fa ilu re w as reco rded .T h e ex am ine r then v isua lly d em ons tra ted tothe ch ild the co rrec t m e thod of op en ing th eco n ta ine r. T h is w as don e to ap pro x im a te aco m m o n situa tion w hich occurs a t h om e , i.e .,the ch ild w ho im ita te s th e pa ren tal actio n . T hech ild w as aga in a llo w ed 3 m inu te s. If he fa iled ,a secon d dem o nstra tion w as g iv en , and th ech ild w as aga in encou raged to o pen th e co n-t am er .

    T he te st w as d iscon tin ued if the ch ild (1 )opened th e con ta ine r du ring the tes t pe r iod , o r(2 ) fa iled to op en it a fte r th e in itia l tr ia l and

    t wo d em o ns tr at io ns .RESULTS

    CONTROL GROUP : O n e hun dred n ine teen of12 0 ch ild ren stud ied w ere ab le to op en the con-tro l con tain er w ith in 3 m in u te s w ith ou t ad em onstra tion . T he on e ch ild w ho failed (age2 6 m o nths) ea sily op en ed the con ta in er a f tero ne d em on str atio n.

    TEST GROUP: O f the 300 ch ild ren tested ,2 92 w ere un ab le to o pe n the c ontain er w ith ou ta dem on stra tio n (T ab le I) . S e ven of the eig h tsu cce ssfu l ch ild ren w ere 8 y ears of a ge or o lde r.O nly on e 5 -y ea r-o ld ch ild (1 o f 55 ) succeed edw ith ou t d em o nstra tion w ith in th e 3-m inu te tes tpe riod . W ith e ithe r o ne or tw o dem o nstratio ns,

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    1967;40;283PediatricsMARGARET H. MACGILLIVRAY, JOHN D. CRAWFORD and JOHN S. ROBEY

    Congenital Hypothyroidism and Prolonged Neonatal Hyperbilirubinemia

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