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doi:10.1111/jpc.12842
Letters to the Editor Dear Editor, MYOSITIS AS A PRESENTING FEATURE OF SYSTEMIC ONSET JUVENILE IDIOPATHIC ARTHRITIS Myositis is a condition of varied aetiology often encountered in paediatric practice. We present the unusual case of a previously well 13-year-old boy of mixed Melanesian/Caucasian background with a constellation of symptoms including predominant bilateral calf myositis. The patient had been admitted to a peripheral hospital 4 weeks earlier with a short history of sore throat, fever, unilateral hip and knee pain as well as markedly elevated inflammatory markers. Magnetic resonance imaging (MRI) demonstrated inflammatory changes of the hip joint. Treatment for acute rheumatic fever was commenced and follow-up echocardiogram was normal. The patient represented with substantial myalgia, quotidian fevers, macular evanescent rash, polyarthritis and difficulty mobilising. Inflammatory markers were significantly elevated. C-reactive protein was 200 mg/L, erythrocyte sedimentation rate 125 mm/h and serum ferritin 510 μg/L. Antinuclear antibodies and vasculitis markers were negative. There was serological evidence of recent streptococcal infection, although no organism was able to be isolated. Extensive infectious tests including blood cultures were unremarkable. Doppler ultrasound excluded deep vein thrombosis. Chest X-ray and abdominal ultrasound were unremarkable. Contrast MRI confirmed significant myositis of the superior posterior compartments of both lower limbs as well as a left knee effusion with associated synovitis (Fig. 1). Creatinine kinase remained normal despite radiological evidence of active myositis. The pattern of fever, rash and arthritis was suggestive of systemic onset juvenile idiopathic arthritis (SoJIA) and the diagnostic criteria were met.1 Treatment was commenced with a short course of high-dose methylprednisolone and then continued with oral prednisolone and methotrexate. Myalgia rapidly improved and the patient quickly achieved remission of other symptoms. He remained symptom free at a 4-month review. Myositis is a common paediatric problem and often has a self-limiting course. This case demonstrates that myositis has a wide differential and rheumatic conditions including SoJIA that should be considered. This presentation of SoJIA with prominent myositis, normal muscle enzymes and prompt response to treatment is unusual but has been previously reported.2,3 Dr William Renton1 Dr Ben Whitehead2 2 1 Paediatric Registrar, Paediatric Rheumatologist, Rheumatology Department, Royal Children’s Hospital, Brisbane, Queensland, Australia
Conflict of interest: The authors have declared no conflict of interest.
Fig. 1 Magnetic resonance imaging (MRI) short tau inversion recovery (STIR) sequence image demonstrating bilateral myositis and left knee synovitis.
References 1 Petty RE, Southwood TR, Manners P et al. International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: second revision. J. Rheumatol. 2004; 31: 390–2. 2 Kitcharoensakkul M, White AJ, French AR, Cooper MA, Baszis KW. Localized myositis as a manifestation of systemic-onset juvenile idiopathic arthritis: a case series from a tertiary-care hospital. Arthritis Rheumatol. 2014; 66 (Suppl. 1): 11. 3 Lindehammar H, Lindvall B. Muscle involvement in juvenile idiopathic arthritis. Rheumatology 2004; 43: 1546–54.
Dear Editor, ROUTINE ULTRASONOGRAPHY IS NOT STERNOMASTOID TUMOURS IN INFANTS
INDICATED
FOR
The instructive case by Skelton and Howlett1 describes an infant presenting at 24 days of age with ultrasonographic features of a sternomastoid tumour. The history and clinical features alone were sufficient to make a clinical diagnosis with certainty. This raises the question as to whether ultrasonography was really indicated. The other differential diagnoses cited in the article included cervical lymphadenopathy, lymphoma, lymphangioma and branchial cysts, none of which are likely when the key clinical feature is a thickened and shortened STM (it is this which causes the predictable head position and limitation in head movement) in a child of this age. In these days of limited resources, there may be an argument for the avoidance of Conflict of interest: None.
Journal of Paediatrics and Child Health 51 (2015) 233–235 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
233
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Letters to the Editor
unnecessary investigations, but this requires that children presenting with torticollis at this age are seen by clinicians familiar with the likely pathologies and who can interpret the signs correctly. Professor Spencer W Beasley1,2 1 Clinical Director Department of Paediatric Surgery Christchurch Hospital 2 Professor of Paediatric Surgery Departments of Surgery and Paediatrics University of Otago Christchurch, Canterbury New Zealand
Reference 1 Skelton E, Howlett D. Fibromatosis colli: the sternomastoid tumour of infancy. J. Paediatr. Child Health 2014; 50: 833–5.
Dear Editor, RESPONSE TO ‘SLEEPING LIKE A BABY? INFANT SLEEP: IMPACT ON CARE GIVERS AND CURRENT CONTROVERSIES’ The Annotation ‘Sleeping like a baby?’ suggests it may be unethical to deny parents a ‘behavioural management’ approach for infant sleep problems in the first 6 months of life.1 We disagree with this interpretation of the scientific literature. ‘First wave behavioural approach’ (FWBA) is a more accurate term for the cluster of parenting strategies described as ‘behavioural management’, because behavioural psychology has advanced beyond the mid-20th century lens that continues to be applied to parent–infant sleep. The Annotation claims that four randomised controlled trials (RCTs) have shown modest success in improving infant sleep duration when FWBAs are applied in the first 6 months, particularly in infants who feed >11 times in 24 h. It is also claimed that FWBAs reduce post-natal depression symptoms. However, the modest decrease in night-time waking, which we estimate from the literature to be the equivalent of one less episode of waking every second night, is not associated with better maternal mental health or improved sleep habits in later childhood, as is assumed. For example, breastfeeding mothers, who wake more often during the night, also have more sleep, and the Victorian Infant Sleep Study showed no improvement in sleep habits in older children who received FWBAs in infancy. Edinburgh Postnatal Depression Scale (EPDS) scores should not be equated with clinical diagnoses of depression, and higher scores are not associated with increased numbers of night-wakings but with poor maternal sleep efficiency. Improved EPDS scores after residential stays can be attributed to multiple aspects of a complex intervention and should not be assumed to result from FWBAs.
Conflict of interest: Pamela Douglas and Koa Whittingham are both authors of the Possums Sleep Intervention (0–6 months), a program written for the non-profit organisation Possums for Mothers and Babies.
234
In the recent Baby Business RCT, the focus upon improvements in crying and day-time sleeping problems in a subgroup of participants, the frequent feeders, is a distraction from the main results: this large FWBA study was unsuccessful in its aim of reducing crying or sleeping problems for the cohort as a whole. The program did not help parents identify feeding problems, and the improvement in this subset could have a variety of explanations – these findings do not prove that FWBAs are appropriate for frequent feeders. Our systematic review investigating FWBAs in this age-group finds FWBAs do not improve outcomes for the baby or mother and risk unintended consequences. The 43 selected studies, including RCTs, often conflate the older infant with the baby less than 6 months of age; fail to take into account the effects of unidentified feeding problems on parent–infant sleep in the first 6 months; and apply simplistic interpretations to complex data.2 For complex primary care problems, such as parent–infant sleep difficulty, evidence-based medicine requires much more than just RCTs: for example, it requires systematic literature reviews that interpret RCT findings in light of the broader science.3 We have developed a new paradigm for optimising parent– infant sleep in the first 6 months, which avoids simplistic and divisive framing. Our model integrates strategies to resolve factors that disrupt healthy parent–infant sleep with strategies from the psychology of applied functional contextualism (a third-wave behaviourism).4 This theoretically rigorous, evidence-based model now requires evaluation. Dr Pamela Douglas1,2 Dr Koa Whittingham3,4 1 Associate Professor (Adjunct) Centre for Health Practice Innovation Griffith University 2 Senior Lecturer Discipline of General Practice The University of Queensland 3 Research Fellow Queensland Cerebral Palsy and Rehabilitation Research Centre The University of Queensland 4 Hononary Research Fellow School of Psychology The University of Queensland Brisbane, Queensland Australia Possums for Mothers and Babies (http://www.possumsonline.com)
References 1 Hiscock H, Fisher J. Sleeping like a baby? Infant sleep: impact on caregivers and current controversies. J. Paediatr. Child Health 2014. doi: 10.1111/jpc.12752. 2 Douglas P, Hill PS. Behavioural sleep interventions in the first six months of life do not improve outcomes for mothers or infants: a systematic review. J. Dev. Behav. Pediatr. 2013; 34: 497–507. 3 Greenhalgh T, Howick J, Maskrey N. Evidence based medicine: a movement in crisis? BMJ 2014; 348: g3725. 4 Whittingham K, Douglas PS. Optimizing parent-infant sleep from birth to 6 months: a new paradigm. Infant Ment. Health J. 2014. doi: 10.1002/imhj.21455.
Journal of Paediatrics and Child Health 51 (2015) 233–235 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
Copyright of Journal of Paediatrics & Child Health is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
doi:10.1111/jpc.12842
Letters to the Editor Dear Editor, MYOSITIS AS A PRESENTING FEATURE OF SYSTEMIC ONSET JUVENILE IDIOPATHIC ARTHRITIS Myositis is a condition of varied aetiology often encountered in paediatric practice. We present the unusual case of a previously well 13-year-old boy of mixed Melanesian/Caucasian background with a constellation of symptoms including predominant bilateral calf myositis. The patient had been admitted to a peripheral hospital 4 weeks earlier with a short history of sore throat, fever, unilateral hip and knee pain as well as markedly elevated inflammatory markers. Magnetic resonance imaging (MRI) demonstrated inflammatory changes of the hip joint. Treatment for acute rheumatic fever was commenced and follow-up echocardiogram was normal. The patient represented with substantial myalgia, quotidian fevers, macular evanescent rash, polyarthritis and difficulty mobilising. Inflammatory markers were significantly elevated. C-reactive protein was 200 mg/L, erythrocyte sedimentation rate 125 mm/h and serum ferritin 510 μg/L. Antinuclear antibodies and vasculitis markers were negative. There was serological evidence of recent streptococcal infection, although no organism was able to be isolated. Extensive infectious tests including blood cultures were unremarkable. Doppler ultrasound excluded deep vein thrombosis. Chest X-ray and abdominal ultrasound were unremarkable. Contrast MRI confirmed significant myositis of the superior posterior compartments of both lower limbs as well as a left knee effusion with associated synovitis (Fig. 1). Creatinine kinase remained normal despite radiological evidence of active myositis. The pattern of fever, rash and arthritis was suggestive of systemic onset juvenile idiopathic arthritis (SoJIA) and the diagnostic criteria were met.1 Treatment was commenced with a short course of high-dose methylprednisolone and then continued with oral prednisolone and methotrexate. Myalgia rapidly improved and the patient quickly achieved remission of other symptoms. He remained symptom free at a 4-month review. Myositis is a common paediatric problem and often has a self-limiting course. This case demonstrates that myositis has a wide differential and rheumatic conditions including SoJIA that should be considered. This presentation of SoJIA with prominent myositis, normal muscle enzymes and prompt response to treatment is unusual but has been previously reported.2,3 Dr William Renton1 Dr Ben Whitehead2 2 1 Paediatric Registrar, Paediatric Rheumatologist, Rheumatology Department, Royal Children’s Hospital, Brisbane, Queensland, Australia
Conflict of interest: The authors have declared no conflict of interest.
Fig. 1 Magnetic resonance imaging (MRI) short tau inversion recovery (STIR) sequence image demonstrating bilateral myositis and left knee synovitis.
References 1 Petty RE, Southwood TR, Manners P et al. International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: second revision. J. Rheumatol. 2004; 31: 390–2. 2 Kitcharoensakkul M, White AJ, French AR, Cooper MA, Baszis KW. Localized myositis as a manifestation of systemic-onset juvenile idiopathic arthritis: a case series from a tertiary-care hospital. Arthritis Rheumatol. 2014; 66 (Suppl. 1): 11. 3 Lindehammar H, Lindvall B. Muscle involvement in juvenile idiopathic arthritis. Rheumatology 2004; 43: 1546–54.
Dear Editor, ROUTINE ULTRASONOGRAPHY IS NOT STERNOMASTOID TUMOURS IN INFANTS
INDICATED
FOR
The instructive case by Skelton and Howlett1 describes an infant presenting at 24 days of age with ultrasonographic features of a sternomastoid tumour. The history and clinical features alone were sufficient to make a clinical diagnosis with certainty. This raises the question as to whether ultrasonography was really indicated. The other differential diagnoses cited in the article included cervical lymphadenopathy, lymphoma, lymphangioma and branchial cysts, none of which are likely when the key clinical feature is a thickened and shortened STM (it is this which causes the predictable head position and limitation in head movement) in a child of this age. In these days of limited resources, there may be an argument for the avoidance of Conflict of interest: None.
Journal of Paediatrics and Child Health 51 (2015) 233–235 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
233
bs_bs_banner
Letters to the Editor
unnecessary investigations, but this requires that children presenting with torticollis at this age are seen by clinicians familiar with the likely pathologies and who can interpret the signs correctly. Professor Spencer W Beasley1,2 1 Clinical Director Department of Paediatric Surgery Christchurch Hospital 2 Professor of Paediatric Surgery Departments of Surgery and Paediatrics University of Otago Christchurch, Canterbury New Zealand
Reference 1 Skelton E, Howlett D. Fibromatosis colli: the sternomastoid tumour of infancy. J. Paediatr. Child Health 2014; 50: 833–5.
Dear Editor, RESPONSE TO ‘SLEEPING LIKE A BABY? INFANT SLEEP: IMPACT ON CARE GIVERS AND CURRENT CONTROVERSIES’ The Annotation ‘Sleeping like a baby?’ suggests it may be unethical to deny parents a ‘behavioural management’ approach for infant sleep problems in the first 6 months of life.1 We disagree with this interpretation of the scientific literature. ‘First wave behavioural approach’ (FWBA) is a more accurate term for the cluster of parenting strategies described as ‘behavioural management’, because behavioural psychology has advanced beyond the mid-20th century lens that continues to be applied to parent–infant sleep. The Annotation claims that four randomised controlled trials (RCTs) have shown modest success in improving infant sleep duration when FWBAs are applied in the first 6 months, particularly in infants who feed >11 times in 24 h. It is also claimed that FWBAs reduce post-natal depression symptoms. However, the modest decrease in night-time waking, which we estimate from the literature to be the equivalent of one less episode of waking every second night, is not associated with better maternal mental health or improved sleep habits in later childhood, as is assumed. For example, breastfeeding mothers, who wake more often during the night, also have more sleep, and the Victorian Infant Sleep Study showed no improvement in sleep habits in older children who received FWBAs in infancy. Edinburgh Postnatal Depression Scale (EPDS) scores should not be equated with clinical diagnoses of depression, and higher scores are not associated with increased numbers of night-wakings but with poor maternal sleep efficiency. Improved EPDS scores after residential stays can be attributed to multiple aspects of a complex intervention and should not be assumed to result from FWBAs.
Conflict of interest: Pamela Douglas and Koa Whittingham are both authors of the Possums Sleep Intervention (0–6 months), a program written for the non-profit organisation Possums for Mothers and Babies.
234
In the recent Baby Business RCT, the focus upon improvements in crying and day-time sleeping problems in a subgroup of participants, the frequent feeders, is a distraction from the main results: this large FWBA study was unsuccessful in its aim of reducing crying or sleeping problems for the cohort as a whole. The program did not help parents identify feeding problems, and the improvement in this subset could have a variety of explanations – these findings do not prove that FWBAs are appropriate for frequent feeders. Our systematic review investigating FWBAs in this age-group finds FWBAs do not improve outcomes for the baby or mother and risk unintended consequences. The 43 selected studies, including RCTs, often conflate the older infant with the baby less than 6 months of age; fail to take into account the effects of unidentified feeding problems on parent–infant sleep in the first 6 months; and apply simplistic interpretations to complex data.2 For complex primary care problems, such as parent–infant sleep difficulty, evidence-based medicine requires much more than just RCTs: for example, it requires systematic literature reviews that interpret RCT findings in light of the broader science.3 We have developed a new paradigm for optimising parent– infant sleep in the first 6 months, which avoids simplistic and divisive framing. Our model integrates strategies to resolve factors that disrupt healthy parent–infant sleep with strategies from the psychology of applied functional contextualism (a third-wave behaviourism).4 This theoretically rigorous, evidence-based model now requires evaluation. Dr Pamela Douglas1,2 Dr Koa Whittingham3,4 1 Associate Professor (Adjunct) Centre for Health Practice Innovation Griffith University 2 Senior Lecturer Discipline of General Practice The University of Queensland 3 Research Fellow Queensland Cerebral Palsy and Rehabilitation Research Centre The University of Queensland 4 Hononary Research Fellow School of Psychology The University of Queensland Brisbane, Queensland Australia Possums for Mothers and Babies (http://www.possumsonline.com)
References 1 Hiscock H, Fisher J. Sleeping like a baby? Infant sleep: impact on caregivers and current controversies. J. Paediatr. Child Health 2014. doi: 10.1111/jpc.12752. 2 Douglas P, Hill PS. Behavioural sleep interventions in the first six months of life do not improve outcomes for mothers or infants: a systematic review. J. Dev. Behav. Pediatr. 2013; 34: 497–507. 3 Greenhalgh T, Howick J, Maskrey N. Evidence based medicine: a movement in crisis? BMJ 2014; 348: g3725. 4 Whittingham K, Douglas PS. Optimizing parent-infant sleep from birth to 6 months: a new paradigm. Infant Ment. Health J. 2014. doi: 10.1002/imhj.21455.
Journal of Paediatrics and Child Health 51 (2015) 233–235 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
Copyright of Journal of Paediatrics & Child Health is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
