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Implantable cardioverter‐defibrillators (ICDs) may save the lives of some children with hypertrophic cardiomyopathy (HCM) but there are problems that remain to be solved. At three London hospitals 160 children with HCM were assessed between 1993 and February 2006 and 22 children aged 7‐16 years had ICD implantation into subpectoral pockets using transvenous lead systems (Heart 2007;93:372–4). Sixteen patients received dual chamber devices. Seventeen devices were implanted for primary prevention and five for secondary prevention of potentially fatal arrhythmias. Median follow up was 1.7 years. Four patients received 15 appropriate shocks (for ventricular tachycardia or fibrillation) and on each occasion a single shock was successful. Four patients had seven inappropriate shocks caused by sinus tachycardia or supraventricular tachycardia (three patients) or lead fracture (one patient). One patient developed acute bacterial endocarditis and the youngest child suffered from anxiety and depression attributed to ICD discharges. It is concluded that ICDs are effective in selected children with HCM. Outstanding issues include prevention of inappropriate discharges, provision of psychological support, and prevention of infection.
Despite immunoglobulin treatment about 5% of children with Kawasaki disease develop coronary aneurysms. The role of early treatment with corticosteroid is uncertain. Now a trial at eight centres in the USA and Canada (New England Journal of Medicine 2007;356:663–75; see also Perspective, ibid: 659–61) has shown no benefit from a single dose of methylprednisolone. A total of 191 children (median age 2.9 years) with Kawasaki disease were randomised within 10 days of the onset of fever to receive intravenous methylprednisolone (30 mg/kg over 2–3 hours) or placebo, followed by diphenhydramine, intravenous immunoglobulin, and oral aspirin. The outcomes (coronary dimensions at 1 and 5 weeks, number of days in hospital, duration of fever, adverse events, and rates of retreatment with immunoglobulin) were similar in the two groups.
The US Advisory Committee on Immunization Practices has recommended routine annual vaccination of children aged 6–59 months with trivalent inactivated influenza vaccine. Now inactivated and live attenuated influenza vaccines have been compared in a multinational trial (New England Journal of Medicine 2007;356:685–96; see also editorial, ibid: 729–31). A total of 8352 children aged 6–59 months were randomised to intranasal live attenuated or intramuscular inactivated vaccine, with appropriate placebos. There were significantly fewer cases of culture‐confirmed influenza in the live attenuated vaccine group (153/4179 vs 338/4173). The live attenuated vaccine showed greater efficacy against both well matched and poorly matched viruses. Among children aged 6‐11 months wheezing and hospital admission were more common after the live attenuated vaccine. It is suggested that the live attenuated vaccine might be better than the inactivated vaccine for children aged 12–59 months but the writers of the editorial insist that more thought is needed before recommending a switch in policy.
Living near to a motorway affects children's lungs. In southern California (Lancet 2007;369:571–7; see also Comment, ibid: 535–7) a total of 3677 children had annual lung function tests between the ages of 10 and 18 years. Growth in lung function was significantly less in children who lived within 500 m of a motorway than in children who lived at least 1500 m away. For forced expiratory volume in 1 second (FEV1) the mean deficit was 81 ml and for maximum midexpiratory flow rate (MMEF) it was 127 ml/sec over the 8 years of follow up. Children who lived near a motorway had, at the age of 8, a mean FEV1 of 97% of the predicted value and a mean MMEF of 93.4% of predicted.
Good housing is important for health. In New Zealand (BMJ 2007;334:460–4; see also editorial, ibid: 434–5) 1350 houses in seven communities (4407 people) were randomised to provision of house insulation or a control group. (The controls were provided with insulation at the end of the study.) Insulation reduced self‐rated fair or poor health by 50%, wheezing in the past 3 months by 43%, and number having a day off school by 57% or a day off work by 38%. Self‐reported visits to general practitioners were 37% fewer in the intervention group. A 47% reduction in hospital admissions for respiratory conditions was not statistically significant. The cost of insulation was £700 per house. The energy saving covered around half of the cost and the estimated savings in health and energy outweighed the cost by a factor of almost two.
There has been some doubt about an association between folic acid intake in pregnancy and facial clefts. Now a study in Norway, where there is no food fortification with folic acid, has shown that folic acid supplementation before pregnancy and in the first 2 months of pregnancy reduces the risk of cleft lip with or without cleft palate (BMJ 2007;334:464–7; see also editorial, ibid: 433–4). The national population‐based case‐control study of infants born between 1996 and 2001 included 377 infants with cleft lip with or without cleft palate, 196 infants with cleft palate alone, and 763 controls. Folic acid supplementation (400 μg or more daily) reduced the risk of cleft lip with or without cleft palate by 39%. A folate rich diet alone did not reduce the risk significantly but such a diet together with folic acid supplements and multivitamins reduced the risk by 64%. The risk of cleft palate alone was not reduced by folic acid supplementation. In relation to food fortification with folic acid the writer of the editorial asks, “What is Europe waiting for?”
The RESOLVE trial of drotrecogin alfa (activated) (Drot AA, recombinant human activated protein C) was carried out in children with severe sepsis because of favourable results in adults. The results in children have been disappointing (Lancet 2007;369:836–43, see also Comment, ibid: 803–4). A total of 477 children with cardiovascular and respiratory failure because of severe sepsis were randomised in 18 countries to Drot AA or placebo for 96 hours. Over the first 28 days, rates of mortality and serious bleeding were similar in the two groups although children younger than 60 days were more prone to bleed with the drug. There seems to be uncertainty about whether this is the end of the line for activated protein C in severe sepsis or whether new, more effective, forms might be found, or subgroups of patients defined in which the drug might be more effective.