We read with interest the recently published IAP position paper on Kawasaki disease (KD) [1]. We would like to highlight the following issues that require further consideration.

Under laboratory investigations, it is noted that serum levels of NT-pro-BNP (N-terminal pro-brain natriuretic peptide) >225 pg/mL can assist in the diagnosis of KD (86.5% sensitivity and 94.8% specificity to suggest myocardial dys-function). However, in the subsequent section, authors mention that cut-off values for NT-Pro-BNP indicative of myocardial involvement are yet to be clearly defined. The AHA statement [2] also states that this biomarker may not have sufficient discriminative ability. It is notable that during childhood, NT-Pro-BNP is known to vary with age and therefore, it has been suggested that a single cut-off value based on ROC analysis would be inappropriate [3,4].

It is mentioned that it may take 36-48 hours for the fever to subside in IVIG-responsive patients [1]. However, both this position paper and the AHA statement define IVIG resistance as persistence or recurrence of fever 36 hours after the end of IVIG infusion. Several recent studies and the Japanese Society of Pediatric Cardiology and Cardiac Surgery guidelines suggest a 48-hour time frame for the same [5]. The 36-hour cut-off, when applied strictly, could potentially lead to over-diagnosis of IVIG resistance. This is a pertinent issue that needs further exploration, considering that the time taken for IVIG infusion itself can be variable (typically 12 hours in North America and 20-24 hours in Japan) [5]. AHA recommends IVIG infusion over 10-12 hours (as opposed to 12-24 hours recommended by the authors) [1,2].

There are certain variations in the definition of recurrence. Recurrent KD is defined as a repeat episode of KD after complete resolution of the first episode [1,2]. Acute illness in KD usually lasts for 4 to 6 weeks and several Japanese surveys have classified KD as recurrent if there is an interval of at least two months from the onset of the first illness to onset of the new episode [6].

In the paper, the available Indian data has not been critically evaluated. It is imperative to consider relevant local data to bring in the much needed Indian perspective. In the process, lack of good quality data on the disease epidemiology and the importance of a national registry could have been highlighted. Finally, a conflict of interest statement by the authors is missing.

1. Shenoy B, Singh S, Ahmed MZ, et al. Indian Academy of Pediatrics Position Paper on Kawasaki Disease. Indian Pediatr. 2020;57:1040-48.

2. McCrindle BW, Rowley AH, Newburger JW, et al. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals from the American Heart Association. Circulation. 2017; 135:e927-99.

3. Albers S, Mir TS, Haddad M, Läer S. N-terminal pro brain natriuretic peptide: Evaluation of pediatric reference values including method comparison and inter-laboratory variability. Clin Chem Lab Med. 2006;44:80-85.

4. Dahdah N, Fournier A. Natriuretic peptides in Kawasaki disease: The myocardial perspective. Diagnostics (Basel). 2013; 3:1-12.

5. Research Committee of the Japanese Society of Pediatric Cardiology; Cardiac Surgery Committee for Development of Guidelines for Medical Treatment of Acute Kawasaki Disease. Guidelines for medical treatment of acute Kawasaki disease: Report of the Research Committee of the Japanese Society of Pediatric Cardiology and Cardiac Surgery (2012 revised version). Pediatr Int. 2014;56:135-58. Erratum in: Pediatr Int. 2016;58:675.

6. Hirata S, Nakamura Y, Yanagawa H. Incidence rate of recurrent Kawasaki disease and related risk factors: From the results of nationwide surveys of Kawasaki disease in Japan.　Acta Paediatr.　2001;90:40-4.