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Indian Pediatrics 1999;36: 1191-1194 |
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o Corticosteroids are considered to be contraindicated during the acute phase of Kawasaki disease based on unfavorable results in early studies. However, a recent study does not seem to agree with this. The medical records of 299 children with Kawasaki disease treated with one of the 4 regimens were reviewed retrospectively. Regimen 1 consisted of aspirin, dipyridamole, and propranolol, regimen 2 was regimen 1 plus prednisolone, regimen 3 was regimen 1 plus intravenous-globulin (IVGG); and regimen 4 was regimen 1 plus both prednisolone and IVGG. The study found the duration of fever and incidence of coronary aneursyms to be lesser with prednisolone use, though not as much with IVGG use. Multiple regression analysis showed significant reductions of fever and coronary aneurysm incidence with predniso-lone. The Study concluded that there is a possible role of corticosteroids in the treatment of the acute phase of Kawasaki disease (J Pediatr 1999; 135:465). o Body Mass Index, well established as a measure of relative fatness in adults may not be a very useful index of obesity in children. A study of the weight for height relations in the Wessex growth study suggests that children of different heights show different relations of height to weight. The study found that using body mass index to assess weight for height in the community may identify a disproportion-ate number of tall, apparently overweight children, while short overweight children will be harder to detect. The authors suggested those children with diverging height and weight centiles should be referred rather than waiting for body mass index to cross an arbitrary threshold (BMJ 1999; 319:1103). o A selective protocol on indomethacin administration in pretern with PDA using echocardiographic flow pattern as a guide associated with a reduction in the total dose administered. In this study on neonates weighing <1500g, infants were randomly assigned to receive conventional indomethacin treatment and given an initial dose of 0.2 mg/kg, followed by 0.1 or 0.2 mg/kg, 12 hourly for two further doses, and were eligible for a second course. Those randomly assigned to the ductal flow pattern assessment (ECHO group) received further doses of indomethacin after 24 hours, only if their flow pattern was pulsatile or growing. There was no difference in the closure rates between the two groups. Moreover, there was a significantly lower incidence of hypoglycemia, impaired urine output, and gastrointestinal bleeding following use of the study protocol (Arch Dis Child Fetal Neonatal Ed 1999; 91:F197). o In addition to a positive effect on hyper-bilirubinemia, phototherapy has an effect on the immune system also. The capacity of peripheral blood mononuclear cells (PBMC) to produce interleukins and tumor necrosis factor was examined in 20 term newborns with those from 30 untreated neonates. Photo-therapy caused a 70% increase in IL-2 secretion, whereas the spontaneous secretion of IL-lbeta was reduced by 43%. In the control grpup there was no increase in secretion of these cytokines. The synthesis of IL-3 and IL-6 did not change significantly in both the groups. On the other hand, lipopolysaccharide induced TNF alpha production was higher on the second day in both groups irrespective of phototherapy. The study concluded that in addition to the well-known positive effect of phototherapy on the neonate serum bilirubin level, this treatment affects the function of the immune system in newborns via alterations in cytokine production (Eur J Ped 1999; 158: 910). o Procalcitonin has been advocated as a diagnostic marker of bacterial infection. Pro-calcitonin, C reactive protein, and leukocyte count were measured in 175 children, with median age of 16 months, on admission to the PICU. A Procalcitonin concentration >2 ng/ml identified all patients with bacterial meningitis or septic sock and was more specific and sensitive than CRP or leukocyte count. The study concluded that a procalcitonin con-centration of 2 ng/ml might be useful in differentiating severe bacterial disease in infants and children and could be a better diagnostic marker of infection than C reactive protein or leukocyte count (Arch Dis Child 1999; 81: 417). o Hydroxyurea, a new therapeutic modality in sickle cell anemia, was evaluated for its side effects. Data were collected on 101 children and adolescents with sickle cell disease, treated for a median of 22 months, with 36 having been treated for more than three years. Thirteen children were younger than 5 years of age at inclusion. Hydroxyurea was stopped for medical reasons in 11 patients: 6 failures, one each due to cutaneous rash, leg ulcer, lupus and pregnancy. Acute lymphoblastic leukemia occured in a girl treated for 1.5 months with hydroxyurea, this short interval arguing against a causative association. One 17-year-old boy had paraparesis after 8 years of treatment. The study concluded that there were no major short or medium term toxicity related to hydroxyurea in this cohort. However, the number of children treated for more than 3 years is too few to make firm conclusions on the long term tolerance of this drug, cautioned the authors (Arch Dis Child 1999, 81: 437). o Walker, supposed to be an aid to early walking are not only a hazard but also cause for a dealy in development. A study on 109 children has found that about half had never been put in a walker, one-third had newer-style walkers with large trays that blocked the children's view of their feet, and the rest had been using smaller, older-style walkers that allowed them to see their feet and grab at objects around them. The children who used walkers to sit, crawl, and walk later, scored lower on early tests of mental and physical development than other infants. The newer-style walkers, which have large trays that prevent infants from seeing their moving feet and from grasping objects around them were found to cause greater delays in physical and mental development (J Dev Behav Pediatr 1999, 20: 355). o The association of breastfeeding with future asthma has been the topic of much study. In a study to investigate this association, 2187 children were followed up till the age of 6 years. The introduction of milk other than breast milk before 4 months of age was found to be a significant risk factor for all asthma and atopy related outcomes in children aged 6 years. Moreover a significant reduction in the risk of childhood asthma at age 6 years occured if exclusive breast feeding was continued for at least the 4 months after birth. The authors suggested that public health interventions to optimize breastfeeding may help to reduce the community burden of childhood asthma and its associated traits (BMJ 1999; 319:815). o The effect of antenatal glucocorticoid therapy on the occurrence of cystic periventri-cular leukomalacia, a major cause of cerebral palsy, remains a mystery. A retrospective study was carried out on a cohort of 883 live-born infants, with gestational ages ranging from 24 to 31 weeks. The rate of cystic periventricular leukomalacia was 4.4% among the infants whose mothers had received beta-methasone, 11.0% among the infants whose mothers had received dexamethasone, and 8.4% among the infants whose mothers had not received a glucocorticoid. The study con-cluded that antenatal exposure to betametha-sone but not dexamethasone was associated with a decreased risk of cystic periventricular leukomalacia among very premature infants (N Engl J Med 1999, 341:1190). A related editorial suggests that, in addition, antibiotics should be given to women in preterm labor, prolonged labor, and those with clinical chorioamnionitis to interrupt the link between chorioamnionitis and periventricular leuko-malacia (New Engl J Med 1999; 341:1229). o It may not be safe for children younger than 2 years to share bed with parents. A retrospective review and analysis of data collected by the US Consumer Product Safety Commission in a 8 year period found a total of 515 deaths of children younger than 2 years who were placed to sleep on adult beds. Of these deaths, 121 were reported to be due to overlying of the child by a parent, other adult, or sibling sleeping in bed with the child and 394 were due to entrapment in the bed structure. Most of these deaths seem to have resulted from suffocation or strangulation caused by entrapment of the child's head in various structures of the bed. The study concluded that parents and caregivers should be altered to these avoidable hazards including overlying by a parent sharing the bed; entrap-ment or wedging of the child between the mattress and another object; and suffocation on waterbeds (Arch Pediatr Adolesc Med 1999, 153:1019). o The use of pacifiers has many an adverse effect, among which is an effect on the duration of breast feeding. The influence of thumb sucking and pacifier use on breast- feeding patterns, the duration of exclusive breastfeeding, and on the total breastfeeding duration was studied on 506 mother-infant pairs. Pacifier use was associated with fewer feeds and shorter total breastfeeding duration compared with no pacifier use. These associa-tions however, were not found for thumb sucking. More frequent use of a pacifier was associated with shorter breastfeeding duration, even among a group of mothers who were highly motivated to breastfeed (Pediatrics 1999; 104:e50). o Steroids are the mainstay of treatment in nephrotic syndrome. Hoever, the adverse reaction of steroids include effects on the child's behavior. Ten children with steroid repsonsive nephrotic syndrome underwent behavioral assessment using the Child Behavior Checklist at baseline and during high dose prednisone therapy for relapse. Five of these children experienced serious problems with anxiety, depression, and increased aggression during high-dose prednisone therapy for relapse, with the behavioral changes occuring almost exclusively at predni-sone doses of 1 mg/kg every 48 hours or more. The study concluded that prednisone dose was a strong predictor of abnormal behavior, especially aggression (Pediatrics 1999; 104:e51). o The use of nitric oxide in preterm neonates with hypoxemia continues to evoke interest. Two studies on inhaled nitric oxide were carried out. In the first study, preterm neonates and near-term neonates treated with or without nitric oxide were compared, and in the second, preterm neonates receiving nitric oxide were compared with preterm neonates receiving no nitric oxdide. The studies concluded that inhaled nitric oxide did improve oxygenation, but survival, adverse events, and benefits were similar in all groups. A related commentary suggests that until issues are clarified, nitric oxide should be thought of as an experimental treatment and its use confined to clinical studies (Lancet 1999; 354, 1047, 1061). o The evidence on adverse effects of smoking during pregnancy continues to accu-mulate. A follow up study on the association between smoking during pregnancy and hospitalization of the child before 8 months of age was carried out on around two thousand children. Overall, 8% of these children were hospitalized during the first 8 months of life. Compared with children whose mothers did not smoke during pregnancy, children with mothers who smoked 1 to 14 cigarettes per day had no increased risk of being hospitalized, whereas children whose mothers smoked 15 or more cigarettes per day had twice as high a risk of being hospitalized. The study concluded that if all pregnant women smoking 15 or more cigarettes per day stopped smoking, 5% of all admissions to hospitals before 8 months of age could have been avoided (Pediatrics 1999; 104:e46). o Ibuprofen appears to be a safe analgesic/antipyretic for use in children. In a comparative study, the serious adverse clinical events among children <2 years old given ibuprofen and acetaminophen to control fever was studied. A total of 27, 065 febrile children were randomized to receive acetaminophen (12 mg/kg), ibuprofen (5 mg/kg), or ibuprofen (10 mg/kg). The rates of hospitalization for acute gastrointestinal bleeding, acute renal failure, anaphylaxis, Reye's syndrome, asthma, bronchiolitis, and vomiting/gastritis were compared in the three groups. The study reported that the risk of serious adverse clinical events among children <2 years old receiving short-term treatment with either acetaminophen or ibuprofen suspension was small and did not vary by choice of medication (Pediatrics 1999; 104:e39). C. Vidyashankar, |
