ALL STEROIDS ARE NOT CREATED EQUALLY

Steroids are effective in the management of both moderate and severe croup. Rates of hospitalisation as well as revisits are reduced. The article by Sparrow and Geelhoed from Perth reminds us that not all steroids are of equivalent potency – this may be because of different glucocorticoid or mineralocorticoid effects or biological half life. They conducted a randomised, double-blind trial in which 133 children received either a single dose of 15 mg/kg of dexamethasone or 1 mg/kg of prednisolone. The rate of revisit was substantially lower in the dexamethasone group (7% vs 29%). Since they used an “equivalent” dose of prednisolone, they speculate that the half life of drug (dexamethasone (36 to 72 hours) vs prednisolone (12 to 36 hours), likely affected the outcome. This certainly makes biological and clinical sense since croup is often a 2–3 day disease. In checking my handy 2005 BNF for Children (page 407) I found that the oral form of dexamethasone is available in the UK, unfortunately it is unavailable in Australia. The lesson taught by this nicely done study—steroids are not interchangeable.
See page 580

“SPRINKLES” – A NEW WAY TO PROVIDE MICRONUTRIENTS

Parents struggle to give multivitamins to infants. Very few like giving drops and many complain about the taste of any preparation that contains iron. In resource-poor countries this issue is further complicated by cost and availability. About five years ago Dr Stanley Zlotkin and colleagues in Toronto developed small sachets, similar in size to packets of sugar or artificial sweeteners, which contain various micronutrients (http://www.supplefer.com). We are currently conducting a randomised clinical trial in which infants are assigned to either multivitamins with iron (liquid form) or multivitamins with iron (powder form). The contents of the packets are easily mixed with any foods that are introduced when infants wean. Our primary outcome is adherence with daily use of multivitamins; our secondary outcome is the rate of iron deficiency at nine months of age. In this issue of ADC, Sharieff, Bhutta, Schauer, Tomlinson, and Zlotkin report the outcome of a triple blind randomised trial in Pakistan, in which 75 children between 6 and 12 months of age at high risk for diarrhoea received packets containing zinc and micronutrients, zinc, micronutrients, and heat inactivated lactic acid bacteria (LAB), or placebo. The use of LAB, yet another probiotic, has been associated with a reduction in diarrhoea. In this trial, the prevalence of diarrhoea over the two month follow-up period was reduced in the group that received micronutrients and zinc, but not the group that also received LAB. These authors are to be congratulated for their continued work in an important area—the treatment and prevention of diarrhoea in resource-poor countries. Hopefully these packets, which parents find more acceptable that multivitamins with drops will become available around the world.
See page 573

MEDICINE IN CHILDREN

Numerous concerns have arisen over the past decade about some practices of the pharmaceutical industry, including direct to consumer advertising and inadequate reporting of clinical outcomes. An additional issue that is gaining notoriety regarding drugs is their off-label use in children. McLay et al, from the University of Aberdeen, describe the knowledge of Scottish paediatricians about this issue—over 90% of 151 respondents are aware of off-label medicines and knowingly prescribe them. Professor Imti Choonara, in an accompanying perspective, outlines the progress and politics of improving children’s medicines. One area that has received less attention is the impact of an increasingly risk adverse public on the development of drugs and vaccines. It is virtually impossible to develop drugs that have no side effects. This poses enormous problems, and potential liability, for the pharmaceutical industry. Many drug trials involve thousands of patients, but manufacturers are increasingly held liable for serious, but very rare, adverse drug events. I am not certain how to resolve this conflict. Certainly post-marketing surveillance is critical, as is rapid disclosure of potential side effects of drugs.
See pages 550 and 584

THIS MONTH IN FETAL AND NEONATAL EDITION

• Should all newborns have a cardiac echo, or can clinical examination detect critical congenital heart disease? This issue is explored in an article by Drs Patton and Hey and a perspective by Dr Onuzo. The authors and their team are to be congratulated for developing a comprehensive service that has assessed 14 752 infants, and then auditing the programme (see pages F236 and F263).

• Length of stay in hospital has not been well described for infants born between 30 and 34 weeks gestational age, even though they are the majority of infants cared for in NICUs. Investigators from the US found that length of stay was longer in the UK and Massachusetts than in a well organised and integrated managed care model in California—Kaiser Permanente Medical Care Program. Although the difference—about 4 shorter days in California—may not mean much on an individual basis, from a healthcare system perspective, this has enormous cost implications (see page F245).

• Very low birthweight (VLBW) infants are at high risk for sensory-neural hearing loss. Ari-Even Roth and colleagues from Israel describe a universal neonatal hearing screening programme that employed transient evoked otoacoustic emissions (TEOAE) as a first stage in-hospital screening tool in a cohort of 346 VLBW infants. The “pass rate” was high—87.2%, although not surprisingly, it was significantly lower compared with a full-term control group—92.2%. They suggest that TEOAE is effective (see page F257).