The American Heart Association (AHA) has released a new guideline, endorsed by the American Academy of Pediatrics, which focuses on the prevention of rheumatic fever (RF) and on diagnosis and treatment of acute group A streptococcal (GAS) pharyngitis. Also included in the scientific statement are prophylaxis recommendations for recurrent RF and bacterial endocarditis and discussion of poststreptococcal reactive arthritis and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. Although much of the information is not new, the report confirms many recommendations in the AAP Committee on Infectious Diseases’ Red Book. Highlights of the report include the following:
— One third of acute RF episodes result from streptococcal infections that are not evident.
— GAS pharyngitis primarily affects children between ages 5 and 15 years. Infants with GAS infections might present with excoriated nares or purulent nasal discharge. Acute RF is rare in children younger than 3 years.
— Microbiological confirmation is necessary to differentiate GAS pharyngitis from pharyngitis caused by other pathogens. Neither rapid antigen tests nor traditional throat culture can differentiate between people who have GAS infection and those who are carriers.
— Antigen tests are very specific, but sensitivity is unacceptably low. If a patient has a negative rapid test but the clinician has a high index of suspicion for GAS pharyngitis, a culture should be performed.
— Treatment is indicated for patients with acute pharyngitis and either a positive antigen test or a positive culture. In general, follow-up cultures are not recommended.
— Recommended treatments for primary prevention of RF are the following:
Penicillin V (250 mg for children 27 kg or 500 mg for children >27 kg 2 to 3 times/day for 10 days)
Amoxicillin (50 mg/kg once daily [maximum, 1 g] for 10 days)
Benzathine penicillin G (1 dose of 600,000 U for children 27 kg or 1,200,000 U for patients >27 kg)
— Recommended treatments for patients allergic to penicillin are the following:
Clindamycin (20 mg/kg/day divided in 3 doses [maximum, 1.8 g/day] for 10 days)
Azithromycin (12 mg/kg/day [maximum dose, 500 mg/day] for 5 days)
Clarithromycin (15 mg/kg/day divided in 2 doses [maximum, 250 mg twice per day] for 10 days)
— Repeated courses of antibiotics are rarely indicated in asymptomatic children who continue to be culture positive for GAS.

Published in Journal Watch Pediatrics and Adolescent Medicine April 1, 2009

Small-scale studies have documented low vitamin D levels in children and adolescents, even as evidence mounts about the role of this vitamin in maintaining health and preventing disease. Three studies further our understanding of vitamin D status in children.
One study was based on data from 6275 children and adolescents who participated in the 2001–2004 National Health and Nutrition Examination Survey (NHANES). Overall, 9% of respondents (representing 7.6 million children and adolescents) were vitamin D deficient (serum 25 hydroxyvitamin D [25(OH)D] <15 ng/mL), and 61% (representing 50.8 million) were vitamin D insufficient (serum 25[OH]D, 15–29 ng/mL). Only 4% of participants reported taking 400 IU of vitamin D daily during the past 30 days. Among those aged 13–21 years, vitamin D deficiency was detected in 3% and 5% of white boys and girls, 43% and 59% of non-Hispanic black boys and girls, and 7% and 20% of Mexican American boys and girls. Deficiency rates were generally lower in children aged 7–12 years and lowest in children aged 1–6 years. Risk factors associated with deficiency were obesity (odds ratio, 1.9), drinking milk less than once per week (OR, 2.9), and television /video/computer use for more than 4 hours per day (OR, 1.6). Reported use of daily vitamin D supplements reduced the risk for deficiency (OR, 0.4). Compared with participants with vitamin D levels 30 ng/mL, those with deficiency had higher parathyroid hormone (PTH) levels and systolic blood pressure (BP) and lower HDL and serum calcium levels.
Other investigators used the same dataset to examine the effects of low serum 25(OH)D levels in 3577 fasting adolescents (age range, 12–19 years). In analyses that were adjusted for sociodemographic factors and physical activity, 25(OH)D levels were inversely associated with systolic BP and plasma glucose concentrations. Compared with children with vitamin D levels in the highest quartile (>26 ng/mL), those with levels in the lowest quartile (<15 ng/mL) had adjusted ORs of 2.36 for hypertension, 2.54 for fasting hyperglycemia (glucose 100 mg/dL), and 3.88 for metabolic syndrome.
In the third study, investigators examined the relation between serum 25(OH)D levels and insulin and glucose dynamics in 51 black adolescents (mean body-mass index, 43.3 kg/m2) at a hospital-based weight-management clinic. After controlling for BMI and PTH levels, the investigators found no metabolic differences between children with 25(OH)D levels <20 ng/mL and those with levels >20 ng/mL. However, insulin sensitivity was significantly lower and insulin resistance was higher among those with 25(OH)D levels <15 ng/mL compared with those with levels 15 ng/mL.

Published in Journal Watch Pediatrics and Adolescent Medicine November 4, 2009