TO CORTICOTROPHIN AND CORTISONE IN THE NEWBORN INFANT

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1 THE EVALUATION OF THE EOSINOPENIC RESPONSE TO CORTICOTROPHIN AND CORTISONE IN THE NEWBORN INFANT BY JAMES W. FARQUHAR From the Deprtment of Child Life wd Helth, University of Edinburgh (RECEVED ro PuucAnoN ocromt 4, 1954) The eosinopenic response to stress hs been recognized since Zppert (1893) described its occurrence m certin infections, nd in recent yers it hs been included mong the phenomen of the lrm rection (Selye, 1949). It ws lso shown tht decrese in the number of circulting eosinophils followed the injection of corticotrophin or cortisone, nd Hills, Forshm nd Finch (1948) concluded tht sts induced eosinopeni by the relese of these hormones. Thorn, Forshm, Prunty nd Hills (1948) demonstrted tht the secretion of the drenl cortex ws essentil if eosinopeni were to be produced, nd from this devised the Thorn test. Following the determintion of the bsolute eosinophil count n dult receives 25 mg. of corticotrophin nd the percentge decrese in four hours is found. Thorn et l. believed tht decrement of 5% or more should occur in the presence of helthy drenl cortex. The si nce of the results is dependent upon the stbility of the eosinophil count in norml people over similr time intervl, nd it hs been shown by Swnson, Buer nd Ropes (1952) from review of the literture nd from smll but crefully studied series of their own tht spontneous vntions of this mgnitude my in fct occur t certin periods of the 24 hours in dults. The test hs been employed lso in newborn infnts, but no creful study of hourly chnges in the bsolute eosinophil level t tht ge cn be found. It ws decided, therefore, to undertke n evlution of the test in the neontl period by determining the nture of the spontneous vrition over four-hour intervl nd to note ny reltionship tht might exist between eosinophil chnge nd disturbnce of the bby. The second prt of the investigtion ws plnned to determine wht responses could be obtined by 133 the injection of vrying doses of corticotrophin nd cortisone. Finlly it ws hoped to determine whether the mgnitude of the response vried with the ge of the infnt. METHODS Prt I Three groups of newborn infnts, conformin to the criteri of normlity previously employed (Frquhr, 1954), were selce t rndom. The first- nd third-dy groups ech contined 15 infnts nd there were 16 in the tenth-dy group. Six hours were llowed to elpse before studying infnts on the first dy in order to void the rpid eosinophil chngs previously described s occrring in tht priod. The first count ws crried out t 9.3 m. in the mjority, but t 1.3 m. in few, nd therefter t intervls of one hour until 3.3 p.m. The infnts were fed t 9.45 m. nd 1.45 p.m. so tht ll were fed on in the first four hours, or just before strting in few, nd twice in the six hours. The infnt's rection to the pin of heel-stbbing ws lso noted nd grded s follows: (1) Cried when stbbed nd for some time therefter; (2) cried when stbbed; (3) restls nd whimpered when stbbed; (4) no response. The technique of eosinophil counting ws tht described by McArthur, Smrt, McL chln. Terry, Hrting, Gutier, Godly, Swllow, Simeone, Zygmuntowicz, Christo, Crepeuw, Point nd Benson (1954), nd employed in previous work (Frquhr, 1954). pnrt I Vrying dosges of corticotrophin nd cortisone were injected into different groups of norml newborn infnts t 9.3 m. nd the percentge chnge induced in the eosmophil count ws detmind The infnts in some of the groups were given the sme dosge of the hormone on the first, third nd tenth dys, so providing seril studies of response in individuls. Lest the response to third injection fter the intervl of week might be influed by the infnt's hving Arch Dis Child: first published s /dc on 1 April Downloded from on 23 July 218 by guest. Protected by

2 134 reeved two injections previously, seprte groups were given the sme dose on dys one nd three nd on dys three nd ten. Both the corticotrophin nd cortisone were fresh nd tken from the sme btches. The corticotrophin ws lter checked fvourbly ginst nother btch by the sme mnufcturer nd further btch by nother mnufcturer. A tuberculin syringe ws employed for the injection of cortisone in order to chieve more ccurte dosge. 7 DAY LD 9 bo 6 5 E 4 - z CM -. ARCHIVES OF DISEASE IN CHILDHOOD RESULTS N=-_ i TiGp1 FIG. 1. MY 3 -zs.~ Nrl~ ~ i I I M TIME Fic Prt I It my be seen (Figs. 1-3) tht there ws little spontneous chnge in the eosinophil counts of individuls during the sme six-hour period on the first, third nd tenth dys of life. Of the 15 cses studied on the first dy there ws insifnt hourly vrition in 1, moderte downwrd trend in three, slight downwrd trend in one nd the count fluctuted little in one. Only six of the 15 infnts studied on the third dy hd very stble eosinophil counts. Four showed slight nd two moderte downwrd tend, two slight upwrd trend nd some fluctution occurred On the tenth dy the count ws stble in in one. 11 of the 16 infnts, two showed slight nd one moderte downwrd trend nd in two there ws little fluctution. -I 7 z Z DAY oo_ *~~~~~~~~~~~~~~~~~~~~, n I I I I P. M WO GAR TIME FIG. 3. FMG 1, 2 nd 3.-Hourly observtions on tise cosinophil counts of norml infnts on Dys 1, 3 nd 1. follows grde I response follows grde H respone fouowsgdemresponse... follows grde IV response Arch Dis Child: first published s /dc on 1 April Downloded from on 23 July 218 by guest. Protected by

3 / 1 CHANGE I icit x 3cI xx. x 1X of Xkk y ~~~~ix I 5 DAY I DAY 3 DAYIO FiG. 4,4Eosinophil klvels of newborn infnts, showing spontneou chng in four hours on Dys 1, 3 nd 1 of life. CHANGE -5o so / 6 3 so 9I o ;:%? & x o CORTICOTROPHI COT1SoME 8 ~ te o~~~~1 X~ A At A& l o A 'W -- '--.I.Zg.~...-..". 1 ACTH ACTHTH ACTH C c FIG. 5. FIGs. 5, 6 nd 7,-Percentge chnge in eosinophil cotmts of norml infnts on Dys 1, 3 nd 1 of life occurring four hours fter vrying doses Of ortcotrophin nd cortisone. o A CoHA CHANG so 4, 3 2 I E t * CORTcoTRoPHIN &CORTISONE ft 2 os " 3 CP 3~~~~ 4& o.so 5 A A 6- o ~~~ o 8 A K)c i K ofki -. A lug u_ ukrmg *-g.- - MTII #ctll XMI ACrm c c Fuo 6. I O 3 c v 8 8 * CRflc3ROP4 * CORIoSO A Z' 4 bg"--.sm Sin Omm 2 ACTN ACTh ACT" ACTh c c FIG. 7. 4mA Arch Dis Child: first published s /dc on 1 April Downloded from on 23 July 218 by guest. Protected by

4 136 In 35 of the 46 infnts the spontneous chnge in four hours ws either n increse or decrese of less thn 1%. In only two of the 46 did the derese exceed 2% (see Fig. 4). It my lso be seen from Figs. 1-3 tht there ws no correltion between the rection of the bby to the tking of blood nd the chnge in the eosinophil count over the next hour, nor were the chnges relted to the time of feeds. Induced (luge by Cwricorophin. The sctter of chnges (expressed s percentges) in the eosinophil counts of the infnts studied on the first, third nd tenth dys of life s the result of injecting 1, 2-5 or 5 mg. of corticotrophin is shown in Figs Two groups were given 1 mg. of corticotrophin, one receiving it on the first nd third dys nd the other on dys three nd ten, nd s the results on dy three were lmost identicl in the two groups, the figures for tht dy from the first group were used in Figs Similrly, two groups were given 5 mg. corticotrophin in ddition to the seril study nd gin there ws little difference between them in the response on the third dy. EoINopmuc RESPO1s. The injection of 1 mg. of corticotrophin resulted in substntil increse in the number of circulting eosinophils in four of the 15 cses the first dy nd smll increse occurred in further two. One of the infnts given 1 mg. on the third dy lso showed n increse in eosinophils. ARCHIVES OF DISEASE IN CHILDHOOD The injection of 2-5 mg. provoked n incresed eosinophil count in different cses on dys one, three nd ten, wheres only one smll increment followed the injection of 5 mg. in bigger series nd none t ll fter the giving of 1 mg. EosnioPENIc REsPONsES. The eosinopenic responses to the different doses of corticotrophin my be seen in Figs The sctter of response to ech dose is considerble on ech dy, but from the grphs nd from the frequency distribution tble Prt I (Tble 1), which tkes into considertion lrger groups of infnts, it my be seen tht in generl the greter the dose of corticotrophin the greter the fll in the eosinophil count. The men percentge chnges with the vrying doses re recorded in Tble 2, but when these mens re re-clculted fter the removl of the lrge positive vlues on dy one it my be seen from Fig. 8 tht the regression lines of the mens indicte tht rough rithmetic reltionship existed between the degree of chnge nd the dose of corticotrophin injected. The sctter of response to the vrying doses overlps widely, however, nd by compring Fig. 4 with Figs. 5-7 it my be seen tht n pprecible number of the helthy infnts studied hd spontneous eosinolysis in four hours s gret s tht which in some followed the injection of corticotrophin. Certinly, with doses of 2-5 mg. or less, so mny of the eosinopenic responses ly within -2 % tht such result would hve no siii in individul cses. With 5 mg. minority of TABLE 1 FREQUENCY DISTRIBUTION OF EOSINOPHIL RESPONSES Negtive Response ( No. of Stimulus Dose Dy Positive Infnts (mg.) >5 Studied Nil Corticotrophin Arch Dis Child: first published s /dc on 1 April Downloded from on 23 July 218 by guest. Protected by

5 EOSINOPENIC RESPONSE TO CORTICOTROPHIN AND CORTISONE 137 the responses ws less thn -2%, biut only with individul vrition in eosinopenic response, nd 1 mg. ws there lmost universl response beyond over the four-hour intervl the response of the tht figure. cortisone group s whole ws pprecibly less thn From the groups studied no significnt evidence the response of the groups receiving hlf the dosge cn be found to indicte tht the responsse to cortico- (by weight) of corticotrophin. trophin ws ny more or less efficient on ny of the It my be seen lso tht the responses of the group three dys. receiving 2 mg. of cortisone were on the whole smller thn those of the group receiving 1 mg. D 3 The men chnge on the third dy with the greter /,X dosge is in fct lrger, but this is due to the influence - on the men of four decrements which fll well below the min sctter of responses. Ar citktur NW FIG. 8.-Averge percentge decreses induced by c norml infnts on Dys 1, 3 nd 1. io DISCUSSION AND INFERENCES Spontneous vritions sufficiently gret to invlidte the Thorn test were described by Rud (1947) in dults, but he used n cetone stin which hs been recognized s being cpble of introducing error into eosinophil counting. Swnson et l. (1952) undertook creful study of the hourly spontneous chnges in dult bsolute eosinophil vlues, nd substntited tht diurnl vrition did occur nd tht it ws sufficiently gret in the mornings to invlidte the test if crried out.. then. They concluded, however, tht the eosinop phil count ws sufficiently stble in the fternoons to justify Thorn testing even lthough spontneous Induced s by Cortsone. The results of decrements of up to 4% were found. It ws injecting cortisone my be seen lso: in Figs. 5-7 postulted tht the stress of wkening nd the relxtion of sleep might exert n importnt effect on the nd in Tbles I nd 2. Only one significnt eosinophilic rn esponse ws number of circulting eosinophils nd would explin obtined, nd unlike those from cortiicotrophin it why the spontneous chnges re commoner nd occurred on the tenth dy. greter in the morning Tti nd Ogw (1951) As with corticotrophin there ws ( considerble studied norml sedentry dults nd found tht the stimu}is TABLE 2 MEANS OF EOSINOPHIL CHANGES */.~~ Chng in Four Hoursl Dy I Dy 3 Dy 1 C ino. of Infnts in Group Nil (i.e.'spontnous chnge').j Corticotrophi mg. I Seril study mg. 2-5 Seril study mg. 5 Seril study Comprtive groups mg. 1 Comprtive groups CorrLse Seril study mg. 1I. Comprtive groups mg. 2 Comprtive groups Arch Dis Child: first published s /dc on 1 April Downloded from on 23 July 218 by guest. Protected by

6 138 bsolute eosinophil count ws mximum t night during sleep nd minimum in the wking dylight hours. Following the djustments mde by the infnt to the strt of extr-uterine life he is subjected to fewer stresses thn the dult nd his dy is not divided into the sme comprtments of stress nd relxtion. Much of his 24 hours is spent sleep protected from sudden chnges in environmentl temperture nd with the sole disturbnce of regulr feeding. It ws importnt, therefore, to determine whether the diurnl vrition obtining in dults occurred in newborn infnts nd whether feeding, with the ssocited processes of weighing nd chnging, or the pinful stimulus occsioned by the tking of blood, were ble to induce eosinophil decrements greter thn 5%. Leucocyte counts t 15-minute intervls over three or four hours following bottle feeds were crried out by Mitchell (1915), nd vritions in the number of white cells were found. No prticulr ttention ws pid to eosinophils nd there ws no proof tht the process of digestion ws relly responsible for the fluctutions. Wshburn (1934) performed seril totl white cell nd differentil counts on infnts over the intervl 9 m. to 5 p.m. nd filed to find ny pronounced vrition in the totl number of leucocytes. Those which did occur were produced lrgely by lymphocytic chnges nd were not relted to ingestion, digestion, sleep, incresed ctivity, or minor externl disturbnce. No bsolute figures for eosinophils were given in the pper but the line of the hourly eosinophil vlues is depicted on the grphs of severl infnts, nd, lthough they pper firly stble, they re close to the bse-line nd the smll fluctutions which do pper my mount to decrements of 3% or more. In the present groups studied on the first, third nd tenth dys of life considerble stbility of the eosinophil count over the sme six hours in individul infnts ws found. Prticulr ttention ws pid to such spontneous chnges s might occur in the time intervl zero to four hours for comprison with the eosinopenic responses to corticotrophin nd cortisone. Usully t four hours the eosinophil count fell within the rnge ±I1% of the originl vlue; in only two of the 46 individuls (4%) were the decrements in excess of 2% nd in neither did they mount to 3%. Frquhr (1954), in personl series nd from review of the literture, observed trend towrd higher eosinophil vlues on the third dy thn t ny other time in the first 1 dys with the exception of birth. The evidence suggesting under-ctivity of the drenl cortex following upon the immedite ARCHIVES OF DISEASE IN CHILDHOOD response to the stress of birth ws reviewed, but no correltion between dy-to-dy eosinophil nd blood ghlcose chnge ws found to substntite the suggestion (Frquhr, 1954; Tlbot, SobeL McArthur nd Crwford, 1952) tht the explntion of the group trend towrd rising eosinophil counts nd flling blood glucose levels in the first few dys might be tht the production of oxycorticosteroids ws depressed t tht time. White nd Sutton (195) observed the eosinopenic responses of infnts to dreline, ccepted decrements of 35 % or greter s implying norml drenocorticl response nd regrded nything less thn 3% decrese s bnorml. Employing these criteri they concluded tht the pituitry-drenl response in helthy, full-term infnts ws norml, but no ttention ws pid to the ge of the subject in dys. Since the publiction of their pper, however, the use of drenline in the test hs fllen into disrepute in view of such inconsistent results s those demonstrted by Krk nd Muehrcke (1952) mong others. The Thorn test employing corticotrophin hs been shown to be of vlue in the ssessment of the efficiency of the pituitry-drenl mechnism in dults, provided it is remembered tht 'it is subject to the limittions common to most lbortory tests' (de Mowbry nd Bishop, 1953), nd provided tht the test is crried out in the fternoon to void the greter spontneous vritions occurring in the morning, Klein nd Hnson (195) employed corticotrophin in the Thorn test on older children nd seldom induced decrements much greter thn 37 %. Employing this s their stndrd of normlity they crried out the test on newborn infnts. The infnts of one group were tested once in the first three dys nd gin in the second week with much better nd more consistent flls in the ltter. Two other groups were studied, one in the first week nd the other in the second, with similr results. With 1 mg. or less of corticotrophin fewer 'positive' Thorn tests were obtined thn when the dose ws incresed to 2-12 mg. nd the 1 mg. dose ws considered to be the more sensitive in demonstrting drenocorticl hypofunction. Venning (195), however, employed much lrger doses of corticotrophin in smll series nd induced greter eosinophil responses in the second thn in the first week. In the present study doses of 2-5 mg, or less of corticotrophin were indequte to provoke eosinopenic responses beyond the rnge of spontneous chnge nd ppered in some cses to induce n eosinophili. The injection of 5 mg, ws followed by n eosinopeni beyond the spontneous rnge in Arch Dis Child: first published s /dc on 1 April Downloded from on 23 July 218 by guest. Protected by

7 EOSINOPENIC RESPONSE TO CORTICOTROPHIN AND CORTISONE the mjority of cses, but only with 1 mg. ws such response consistently obtined. In the groups studied, therefore, the dose of corticotrophin required to provoke eosinopenic responses greter thn 2% in newborn infnts ws two-fifths s gret s tht required to induce decrese of over 5% in the norml dult lthough the body weight of the infnt ws only bout onetwentieth of the dult weight. Furthermore, even with this reltively high dose of corticotrophin decrements of 5 % or greter occurred in bout hlf the subjects only. The mgnitude of the response ws roughly proportionte to the dose given, but the dosges were so high reltive to body weight tht impotence of the prticulr btch of corticotrophin might be suspected hd it not been excluded by comprison with others. These observtions provide furiher suggestive evidence tht reltive inefficiency of the drenocorticl response to corticotrophin exists t this ge. White nd Sutton (195) found tht drenline ws reltively ineffective in provoking eosinopeni in premture infnts, nd, in order to exclude the possibility tht this might be due not to functionl under-ctivity of the drenl but to bnorml resistnce of the eosinophils to cortisone, they injected six infnts with whole drenl corticl extrct nd obtined n dequte eosinopenic response in ll. They concluded tht there ws inbility on the prt of the premture infnt to elborte sufficient mounts of drenl corticl hormone in response to corticotrophin. Klein nd Hnson (195) injected whole drenl extrct into 11 infnts in the first two dys of life with view to excluding eosinophil resistnce nd obtined eosinopenic responses greter thn 37% in eight of them in four hours. In the present study cortisone ws employed in preference to lipo-drenl extct nd proved to be less effective in inducing eosinopeni thn hlf the dose by weight of corticotrophin. This t first ppers to suggest eosinophil resistnce. Evidence in fvour of the suppression of dreno-corticl function by cortisone ws published by McIntosh nd Holmes (1951), nd the more likely explntion of the poorer response to 2 mg. is tht the injection of cortisone depressed endogenous dreno-corticl function nd the resulting totl of vilble cortisone ws less thn would hve followed smller dose of corticotrophin. The bsolute eosinophil levels in Prt I of this investigtion were rther higher on the tenth thn on the third dy nd so differed from the figures lredy published (Frquhr, 1954) nd the figures from which the eosinopenic responses were clcu- 139 lted in Prt H of this study, both of which series were lrger nd showed higher bsolute vlues on the third dy. It hd been considered possible tht pplying the Thorn test to newborn infnts on the third dy would show tht the eosinopenic responses indicted reltive degree of drenl corticl hypofunction compred with those induced on the first nd tenth. The comprison of the group responses to corticotrophin on the three dys, however, shows no signifint difference between them, nd if there is ny doubtful trend t ll it is towrd rther better responses on the third dy. The Thorn test is of little vlue in the ssesment of the helth of the pituitry-drenl xis in newborn infnts becuse, unlike in dults where the gret diurnl vrition is the hndicp, the response to reltively gret doses of corticotrophin is so poor tht it my be within the rnge of spontneous vrition. In these conditions it is lmost impossible to define wht the norml eosinopenic response of norml newborn infnt to corticotrophin should be, but from the experience of this study it ppers tht the criteri might be decrement of 3% or greter when 1 mg. re injected. SUMMARY AND CONCLUSIONS The literture referring to the Thorn test in dults nd newborn infnts is briefly reviewed. The evlution of the test in the newborn infnt depends upon () the rnge of spontneous eosinophil chnge, nd (b) the rnge of eosinopenic response to vrying doses of corticotrophin. Seril hourly studies of eosinophils in helthy infnts showed considerble stbility of bsolute levels, nd such fluctutions s did occur were unrelted to feeding nd minor upsets. Inresing doses of corticotrophin induced proportionte increse in the men eosinopenic response. There ws, however, considerble rnge of response to ech dose on ech dy, nd 1 mg. of corticotrophin were required to induce decrements greter thn 3% consistently. There ws no significnt difference in the nture of the response to the vrying doses on the first, third nd tenth dys of life. The Thorn test t this ge is of little vlue becuse the poor eosinopenic responses to corticotrophin my fll within the rnge of spontneous chnge. A norml response might be defined s decrement of 3(% or greter when 1-mg. dose is injected. I wish to cknowledge my grtitude to Professor R. W. B. Ellis for his encourgement nd dvice, to 1 Arch Dis Child: first published s /dc on 1 April Downloded from on 23 July 218 by guest. Protected by

8 14 ARCHIVES OF DISEASE IN CHILDHOOD Dr. E. C. Fhmy for permission to crry out these investigtions in his obstetric unit, to Professor R. J. Kellr for lbortory spce, to Professor D. M. Dunlop for supplies of corticotrophin nd cortisone, nd to Sister E. S. Somerville for invluble help. Finlly, I should like to py tribute to Miss Pt Steven for her meticulous technicl work in the lbortory. Prt of the work ws crried out during the tenure of the George Guthrie Reserch Fellowship in Child Helth. REFEW2* Frquhr, J. W. (1954). Archives of Disese in Chikdood, 29, 519. Hills, A. G., Forshm, P. H. nd Finch, C. A. (1948). Blood, 3, 755. Krk, R. M. nd Muchrcke, R. C. (1952). Lwcet, 1, Klein, R. nd Hnson, J. (195). Pedirics, 6, 192. McArthur, J. W., Smrt, G. A., McLchln, F. A., Terry, M. L., Hrting, D., Gutier, E., Godly, A., Swllow, K. A, Simeone, F. A., Zygmuntowicz, A., Christo, E., Crepeux, J., Point, W. W. nd Benson, J. A. (1954). J. cin. Invest., 33,42. McIntosh, H. W. nd Holmes, C. B. (1951). Lncet, 2, 161. Mitchell, A. G. (1915). Amer. J. Dis. Chid., 9, 358. Mowbry, R. R. de nd Bishop, P. M. F. (1953). Brit. med. J., 1, 17. Rud, F. (1947). Act psychit. Kbh., Suppl. 4, p. 1. Selye, H. (1949). Textbook of Endocrinology, 2nd ed. Montrel. Swnson, J. N., Buer, W. nd Ropes, M. (1952). Lcet, 1, 129. Tlbot, N. B., Sobel, E. H., McArthur, J. W. nd Crwford, J. D. (1952). Fuctionl Endocrinology from Birth Through Adolescence. Cmbridge, Mss. Tti, K. nd Ogw, S. (1951). Jp. J. Physiol., 1, 328. Thorn, G. W., Forshm, P. H., Prunty, F. T. G. nd Hills, A. G. (1948). J. Amer. med. Ass., 137, 15. Venning, E. (195). Proceedings of the First Cliwicl ACTH Conference, ed. Mote, J. R., p. 25. London. Wshburn, A. H. (1934). Amer. J. Dis. Child., 47, 993. White, F. P. nd Sutton, L. E. (195). Peditrics, 5, 876. Zppert, J. (1893). Z. klin. Med., 23, 227. Arch Dis Child: first published s /dc on 1 April Downloded from on 23 July 218 by guest. Protected by