Immune suppressive treatment in paediatric myocarditis: still awaiting the evidence

Is immune suppressive treatment for myocarditis in the paediatric patient helpful? Paediatric and adult cardiological practices are dominated by (respectively) congenital and atheromatous heart disease. Some diseases are common to both specialities, an example being myocarditis. It is a paradox that a 15 year old child may be given potent immune suppressive treatment for myocarditis but a 16 year old on the adult cardiology ward with the same diagnosis will not. What is the evidence for this conundrum? In adults a randomised study,1 ongoing work,2 review, and meta-analysis3,4 have shown that immune suppression is not helpful. The paediatric literature is scant. There are five paediatric case series with less than 10 treated cases of myocarditis in each.5–9 There are two case series from Toronto,10,11 the more recent including 34 treated cases without controls. The largest paediatric study with controls12 had some degree of randomisation, but has been criticised in meta-analysis for methodological flaws.3 Furthermore, this study was set in an area where Chagas disease was endemic and the results are unlikely to apply to European and North American populations where entero-, adeno- and parvovirus infections predominate as causes of paediatric myocarditis. The paediatric case series have varied clinical and/or histological entry criteria and immune suppressant agents …