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An erroneous assumption—news to grow by!
Population-based study of course and morbidity of idiopathic thrombocytopenic purpura This population-based study of the course and complications of idiopathic thrombocytopenic purpura in children in Nordic countries serves as important groundwork for studies that focus on intervention. Although not perfect in case ascertainment, exclusion of underlying conditions or control of interventions, a reassuring picture emerges. The condition resolves in two-thirds of patients within one month of onset, and in 90% within three months. Hemorrhage leading to transfusion occurred in 3% of children and no intracranial hemorrhage occurred. Observations on associations of age, sex, and clinical presentation with likelihood of chronicity also are made. The fine editorial by de Alarcon puts this study into the context of current knowledge and debate. —Sarah S. Long, MD Page 302
Coronary artery lesions in Kawasaki disease Some patients with Kawasaki disease develop coronary artery aneurysms, and others do not. The reasons for this difference are not known, but it has been suggested that some children may have a genetic susceptibility. In this issue of The Journal, Nishimura et al report on the evaluation of a potential candidate gene. It has been reported that adults who are homozygous for the TT genotype at CD14/-159 are at higher risk for coronary artery disease. Persons who are homozygous for the TT genotype have higher serum levels of soluble CD14 than those with the CC genotype. It is also known that the number of soluble CD14, CD14+ macrophages, and CD14+ neutrophils are increased with Kawasaki disease. Nishimura et al found that among patients with Kawasaki disease, those with the TT genotype at CD14/-159 had higher levels of C-reactive protein and vascular endothelial growth factor than those with CT or CC genotypes. They also found that abnormalities of the coronary arteries in patients with the TT genotype. If these results are borne out by future studies, they may lead to better understanding of the development of coronary artery aneurysms in patients with Kawasaki disease. It may become possible to predict which patients are at particularly increased risk for aneurysm formation. —Stephen R. Daniels, MD, PhD Page 357
2A
September 2003
An erroneous assumption—News to grow by! Oral prednisolone has become a common glucocorticoid for treating children who are unable to use prednisone tablets. Prednisone has a 5:1 ratio when compared with hydrocortisone in terms of growth-retarding effects. In the absence of data for prednisolone, it has often been assumed that the same ratio applies. In the current issue of The Journal, Punthakee et al from Montreal provide important new information questioning this assumption. They report their experience in switching nine children with various endocrine disorders (mainly congenital adrenal hyperplasia) from hydrocortisone to prednisolone, providing 1.0 mg prednisolone for every 5 mg hydrocortisone. Eight of these children exhibited a drop in growth velocity coincident with this change. This was reversed with a reduction in dose. Based on this experience, the authors recommend a 15:1 ratio as more appropriate from the standpoint of growth suppression. As the authors point out, the increasing use of oral glucocorticoid preparations, such as prednisolone for asthma, demands careful attention to complications such as growth impairment. Although this study needs to be replicated with a larger, longer-term investigation, the recommendations of these workers provide a reasonable starting point for dosing children today. —Thomas R. Welch, MD Page 402
Adjunctive corticosteroid or antihistamine therapy for acute otitis media Wow! A randomized, double-blind, placebo-controlled trial of antihistamine, corticosteroid, both or neither for acute otitis media—with universal adherence to a single antibiotic treatment (all received ceftriaxone intramuscularly) and longterm follow-up. Plus, a bonus of bacterial and viral microbiologic data on nasopharyngeal specimens taken from the whole study group! Although no otitis media study is perfect, this one can change a few questions into declarative sentences. Five-day treatment with antihistamine or corticosteroid in addition to antibiotic for acute otitis media did not improve outcomes. Antihistamine use may have prolonged the duration of middle ear effusion. As physicians consider withholding antibiotic therapy in selected children with otitis media, they should not substitute other therapies (such as an antihistamine) to satisfy an urge to ‘‘do something.’’ —Sarah S. Long, MD Page 377
The Journal of Pediatrics
Coronary artery lesions in Kawasaki disease Some patients with Kawasaki disease develop coronary artery aneurysms, and others do not. The reasons for this difference are not known, but it has been suggested that some children may have a genetic susceptibility. In this issue of The Journal, Nishimura et al report on the evaluation of a potential candidate gene. It has been reported that adults who are homozygous for the TT genotype at CD14/-159 are at higher risk for coronary artery disease. Persons who are homozygous for the TT genotype have higher serum levels of soluble CD14 than those with the CC genotype. It is also known that the number of soluble CD14, CD14+ macrophages, and CD14+ neutrophils are increased with Kawasaki disease. Nishimura et al found that among patients with Kawasaki disease, those with the TT genotype at CD14/-159 had higher levels of C-reactive protein and vascular endothelial growth factor than those with CT or CC genotypes. They also found that abnormalities of the coronary arteries in patients with the TT genotype. If these results are borne out by future studies, they may lead to better understanding of the development of coronary artery aneurysms in patients with Kawasaki disease. It may become possible to predict which patients are at particularly increased risk for aneurysm formation. —Stephen R. Daniels, MD, PhD Page 357
2A
September 2003
An erroneous assumption—News to grow by! Oral prednisolone has become a common glucocorticoid for treating children who are unable to use prednisone tablets. Prednisone has a 5:1 ratio when compared with hydrocortisone in terms of growth-retarding effects. In the absence of data for prednisolone, it has often been assumed that the same ratio applies. In the current issue of The Journal, Punthakee et al from Montreal provide important new information questioning this assumption. They report their experience in switching nine children with various endocrine disorders (mainly congenital adrenal hyperplasia) from hydrocortisone to prednisolone, providing 1.0 mg prednisolone for every 5 mg hydrocortisone. Eight of these children exhibited a drop in growth velocity coincident with this change. This was reversed with a reduction in dose. Based on this experience, the authors recommend a 15:1 ratio as more appropriate from the standpoint of growth suppression. As the authors point out, the increasing use of oral glucocorticoid preparations, such as prednisolone for asthma, demands careful attention to complications such as growth impairment. Although this study needs to be replicated with a larger, longer-term investigation, the recommendations of these workers provide a reasonable starting point for dosing children today. —Thomas R. Welch, MD Page 402
Adjunctive corticosteroid or antihistamine therapy for acute otitis media Wow! A randomized, double-blind, placebo-controlled trial of antihistamine, corticosteroid, both or neither for acute otitis media—with universal adherence to a single antibiotic treatment (all received ceftriaxone intramuscularly) and longterm follow-up. Plus, a bonus of bacterial and viral microbiologic data on nasopharyngeal specimens taken from the whole study group! Although no otitis media study is perfect, this one can change a few questions into declarative sentences. Five-day treatment with antihistamine or corticosteroid in addition to antibiotic for acute otitis media did not improve outcomes. Antihistamine use may have prolonged the duration of middle ear effusion. As physicians consider withholding antibiotic therapy in selected children with otitis media, they should not substitute other therapies (such as an antihistamine) to satisfy an urge to ‘‘do something.’’ —Sarah S. Long, MD Page 377
The Journal of Pediatrics