I am grateful to the Editors of Pediatric Annuls for inviting me to edit this issue devoted to Pediatric Rheumatology. The fact that we recently attracted over 400 practitioners to a one-day postgraduate pediatric rheumatology course reflects the widespread interest pediatricians have in the rheumatic diseases of childhood.
In this issue, Earl Brewer, MD and Ivonne Arroyo, MD provide us with up-to-date data on the use of nonsteroidal anti- inflammatory drugs in arthritic children. I do not know anywhere else the pediatrician can obtain this information so conveniently. We convinced the federal authorities that drugs which are not adequately studied in children should not be labeled by the FDA for use in children. This seems reasonable, until one recognizes the large number of drugs which will then be available for adults but not FDA labeled for children. That is the situation we find ourselves in today. The Pediatric Rheumatology Collaborative Drug Study Group, founded and chaired by Dr. Brewer, has for many years conducted pioneer, randomly selected, controlled studies of the use of these drugs in children. Those studies are summarized in their article. Use of these drugs to control fever in systemic Juvenile Rheumatoid Arthritis (JRA) and differentiation of spondylarthritis, in which these drugs are often most effective, from other forms of arthritis have recently been summarized elsewhere.1,2
Dr. Andrew H. Eichenfield and his colleagues in Philadelphia first called our attention to their observation that most children with Lyme disease do not have a history of tick bite or the hallmark rash, erythema chronicum migrans, which enables any pediatrician in an endemic area to diagnose this disorder. In most children, therefore, diagnosis is dependent on serologic testing. In areas like Westchester and Suffolk Counties, New York, pediatricians think of Lyme disease daily (at least in certain seasons). But more varieties of ticks are being found worldwide that can spread this spirochetal infection. Children's doctors everywhere are going to have to think about it, and serologic testing with prompt reporting is going to have to be generally available if morbidity is to be reduced. Rheumatologists have been hearing about Lyme disease for years; unfortunately, very few articles have appeared in the pediatric literature.
I was shocked to learn recently that the death rate of children in the United States with brain tumors or leukemia was many fold higher than the death rate for those diseases in academic centers in this country. Apparently, access or perceived access to the best care is not the same nationwide. I am aware, however, that the death/renal death rate in our own institution for children with SLE followed in the clinic is much higher than for private patients; Dubois reported similar data from San Francisco in adult lupus patients many years ago. Ilona Szer, MD, who recently emigrated from here to Boston, eloquently addresses the need for expert care of children with SLE.
Rosemarie Watson, MB, MRCPI, a dermatologist, studies neonatal lupus and provides a rare opportunity for pediatricians to think about fetal immunology, the potential for permanent damage to the fetus by maternal antibodies which cross the placenta, and the potential for a baby to cure himself of placentally transmitted lupus. The newborn with lupus, aside from scars such as those that cause congenital heart block, generally fully recovers from the lupus. If we could find out how that works, perhaps we could cure the mother. Meanwhile, we need to think about whether we can treat SLE in pregnant women in a way which avoids scars in the baby. Most mothers who give birth to babies with congenital heart block, the hallmark of neonatal SLE, have not been recognized as having SLE. I suspect we can do better if we try harder.
Pediatricians are recognizing Kawasaki disease these days, but most cases are identified too late to institute treatment (which is safe and available) that would prevent aneurysms. The data are not available yet, but every pediatrician sees Kawasaki disease and wants to stay abreast of new developments. I have summarized what is known about therapy of Kawasaki disease and provided references to the latest data.
1. Jacobs JC (ed): New Frontiers in Pediatric Rheumatology (1986). Morrisville, PA, Menley and James Laboratories, 1986.
2. Jacobs JC: Pediatric Rheumatology for the Practitioner. New York, Springer-Verlag. 1982.