Croup—the bark is worse than the bite

Steroids for mild croup
 
Although steroids are clearly beneficial for children with moderate-to-severe croup, their role in mild disease remains controversial. In a randomized trial in four Canadian pediatric emergency departments, investigators enrolled 708 children with mild croup (onset within 72 hours and score of points on a validated 17-point measure). The children received a single oral dose of dexamethasone (0.6 mg/kg) or placebo.
Children in the steroid group were significantly less likely to return for care within 7 days than were placebo recipients (7.3% vs. 15.3%). Clinical scores, as assessed by telephone interview, were significantly lower in the steroid group than in the placebo group on days 1 and 2 of follow-up; however, by day 3, scores were similar in both groups. Children in the steroid group lost significantly less sleep than did those in the placebo group (2.9 vs. 4.2 hours). Both health care costs and family costs were significantly lower in the steroid group.
Steroids win again. These findings extend steroids’ indication in the treatment of croup to mild disease. As an editorialist notes, the benefits of steroid treatment are small but important for children with mild croup and their families. However, I do remain concerned that this will become the “steroid generation” for many diseases.
(Howard Bauchner, MD, published in Journal Watch Pediatrics and Adolescent Medicine October 12, 2004)

Pharmacokinetics of intravenously administered Azithromycin.

The objective of this study was to characterize the pharmacokinetics and tolerance of a single intravenous (IV) azithromycin dose in children.
Methods:
Subjects were stratified into 4 age groups: 0.5-2 years; >2-<6 years; 6-<12 years; and 12-<16 years. Each subject received a single 10 mg/kg dose (500 mg maximum) infused in 1 hour. Serial venous blood samples were obtained for a 168-hour period, and laboratory safety evaluations were performed immediately preceding azithromycin administration and at the conclusion of the study. Serum azithromycin concentrations were quantified with a validated high performance liquid chromatography method with mass spectrometric detection. Pharmacokinetic indices were calculated for each subject by non compartmental techniques.
Results:
 Thirty-two subjects (6.7 +/- 5.0 years, 11 boys) participated. Mean serum concentration-time data were comparable for the 4 age groups. For all subjects with evaluable data, the mean area under the curve from 0 to 72 hours (AUC0-72) was 8.2 [mu]g [middle dot] h/mL (n = 26), the maximum concentration (Cmax) was 2.4 [mu]g/mL and the elimination half-life (t1/2) was 65.2 hours (n = 25). The AUC0-72 and Cmax were not associated with age. The dose was well-tolerated with no serious adverse events.
Conclusion:
The disposition of azithromycin after a single 10-mg/kg IV dose (maximum labeled adult dose of 500 mg) is comparable in pediatric patients between 0.5 and 16 years of age. These pharmacokinetic data can be used to guide dose selection for future therapeutic trials of IV azithromycin in pediatric patients.
(Pediatric Infectious Disease Journal. 24(1):34-39, January 2005.)

Bronchodilator treatment and deaths from asthma

Objective
 To investigate the association between bronchodilator treatment and death from asthma.
Participants
532 patients under age 65 who died from asthma and 532 controls with a hospital admission for asthma matched for period, age, and area.
Main outcome measures
Odds ratios for deaths from asthma associated with prescription of bronchodilators and other treatment, with sensitivity analyses adjusting for age at onset, previous hospital admissions, associated chronic obstructive lung disease, and number of other drug categories.
Results
 After full adjustment, there were no significant associations with drugs prescribed in the 4-12 months before the index date. For prescriptions in the 1-5 years before, mortality was positively associated with inhaled short acting agonists (odds ratio 2.05, 95% confidence interval 1.26 to 3.33) and inversely associated with antibiotics (0.59, 0.39 to 0.89). The former association seemed to be confined to those aged 45-64, and the association with antibiotics was more pronounced in those under 45. Significant age interactions across all periods suggested inverse associations with oral steroids confined to the under 45 age group. An inverse association with long acting agonists and a positive association with methylxanthines in the 1-5 year period were non-significant.
Conclusion
There was no evidence of adverse effects on mortality with medium to long term use of inhaled long acting agonist drugs. The association with short acting agonists has several explanations, only one of which may be a direct adverse effect.
(BMJ  2005;330:117 (15 January)

Catching and treating congenital hypothyroidism early: Not Enough!

Catching and treating congenital hypothyroidism early is thought to produce a favourable outcome, but a study in Pediatrics (2005; 115: e52-7) shows that even when there are similarities in genes and environment, children treated for congenital hypothyroidism don’t do as well as their siblings. In long term follow up, affected and non-affected children were tested at the same time and given the same tests. In the past, critics have pointed to disparities in testing as being the cause of any differences found.

Risk of bacterial infection in previously healthy RSV infected young children

Objective: To evaluate the risk of bacterial infection and use of antibiotics in otherwise healthy children infected with respiratory syncytial virus (RSV) admitted to the intensive care unit (ICU).
Conclusions: In otherwise healthy infants admitted to the ICU with RSV infection, bacteremia, urinary tract infection and meningitis are uncommon. Although bacterial pneumonia in this cohort may be more prevalent, overdiagnosis is common.
(Pediatric Infectious Disease Journal. 23(11):990-994, November 2004.)
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