Indian Pediatrics 2008; 45:943-944
Guidelines on Acute Rheumatic Fever
A. Drugs for treatment of pharyngitis and secondary prophylaxis: Dose and interval of Benzathine Penicillin
1. Instead of keeping two intervals (15 days for <27kg and 21days for >27kg) it is better to take interval of 3 weeks(2) and cut off weight to 20 kg or give the adult dose irrespective of weight. (More variable parameters create more confusion).
2. Dose of oral cephalexin 15-20mg/kg bd is inadequate. Minimum of 50mg/kg per day in four-divided dose should be given for eradication of pharyngeal streptococci.
3. Time tested Sulpha used for prophylaxis is not mentioned at all.
4. Erythromycin frequency of dosing not mentioned.
5. Is there a need to mention the adult dosing of penicillin in the pediatric guidelines.
B. Diagnostic criteria
The following doubts regarding diagnostic criteria need further clarification
1. Rheumatic chorea: One should rule our chorea due to other causes.
2. Definition of recurrence: Manifestation after a period of 8 weeks "following stopping complete treatment". If it is an irregular treatment, clinical manifestations may not represent a recurrence.
3. Arthralgia and ECG changes should not be considered as minor criteria if arthritis or carditis is a major criteria.
4. Why age-dependent cutoffs are provided for only Anti DNase B and not for ASO?
5. Polymorphonuclear leucocytosis is very nonspecific criteria and not included now in minor criteria.
6. Criteria for mild, moderate and severe carditis is not mentioned.
7. Indication for other NSAIDS is very unclear.
8. There is yet no uniform consensus on use of methylprednisolone in severe carditis. Recommendations advice is for 3 days which is inadequate.
9. Atrial fibrillation in a child even with established valvular lesion should be taken as active carditis. Mere treatment of atrial fibrillation is not enough in a child. This we feel is a totally misleading message.
Overall, these recommendations should have been very clear. It should help practicing pediatrician and not confuse him. Hope that we will get right modification from concerned body.
TM Ananda Kesavan,