Long-term outcome in patients with juvenile dermatomyositis: a cross-sectional follow-up study.

OBJECTIVE: To evaluate a group of 53 patients with juvenile dermatomyositis (JDM), on average 13.9 years after disease onset, in order to describe the long-term disease outcome and to identify disease-related parameters associated with poor disease outcome. METHODS: Baseline information at disease onset was obtained from medical records. Disease status at follow-up was evaluated by physical examination. The Myositis Damage Index (MDI) and the Myositis Disease Damage by Visual Analogue Scale (MYODAM-VAS) were used to describe disease damage. RESULTS: Disease damage was seen in 60.4% of patients. The most common damage was cutaneous scarring (39.6%) and muscle dysfunction (34%). Calcinosis was found in 20%, lipodystrophy in 13%, and severe damage affecting more than two organ systems in 24.5% of patients. A disease duration > 4 years increased the risk of damage based on: MDI score [adjusted odds ratio (AOR) 8.3, 95% confidence interval (CI) 1.7-41.7], MYODAM-VAS score (AOR 26.2, 95% CI 3.1-223.7), and number of affected organs (AOR 16.3, 95% CI 1.1-232.4). Disease onset age ≥ 7.4 years increased the risk of more than two affected organs (AOR 15.8, 95% CI 1.9-129.4). Disease duration ≥ 4 years increased the risk of calcinosis (OR 4.8, 95% CI 1.1-20.9) and continuous muscle dysfunction (OR 4.2, 95% CI 1.1-17.3). CONCLUSION: In a long-term follow-up study, 60% of JDM patients had disease damage at a mean of 14 years after disease onset. Longer disease duration was the most important predictor of damage, calcinosis, and impaired muscle function, and higher age at disease onset predicted more organs involved at follow-up.

Orofacial pain, jaw function, and temporomandibular disorders in women with a history of juvenile chronic arthritis or persistent juvenile chronic arthritis.

OBJECTIVES: We sought to study the long-term outcome of juvenile chronic arthritis (JCA) in the temporomandibular joint (TMJ). STUDY DESIGN: Temporomandibular disorders, including TMJ involvement, were assessed in 42 women with pauciarticular or polyarticular JCA--on average 25.8 years from disease onset--and compared with those found in matched control subjects. Disease-related parameters associated with temporomandibular disorders were identified. RESULTS: The TMJ was involved in 66.7% of the patients, most severely in extended pauciarticular JCA. Temporomandibular disorders were more frequent in the patients than in the control subjects, especially in those with persistent disease. The TMJ involvement was positively correlated with disease duration and negatively correlated with jaw opening and occlusal support. Duration of active JCA and history of functional pain were identified as predictors of present TMJ involvement. CONCLUSION: In a long-term follow-up, TMJ involvement proved frequent in the studied patients and was associated with long disease duration and previous pain on jaw opening. The findings suggest that patients with JCA should undergo orofacial evaluation on a regular basis.

The Danish version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ).

We report herein the results of the cross-cultural adaptation and validation into the Danish language of the parent's version of two health related quality of life instruments. The Childhood Health Assessment Questionnaire (CHAQ) is a disease specific health instrument that measures functional ability in daily living activities in children with juvenile idiopathic arthritis (JIA). The Child Health Questionnaire (CHQ) is a generic health instrument designed to capture the physical and psychosocial well-being of children independently from the underlying disease. The Danish CHAQ-CHQ were fully validated with 3 forward and 3 backward translations. A total of 139 subjects were enrolled: 76 patients with JIA (25% systemic onset, 30% polyarticular onset, 19% extended oligoarticular subtype, and 26% persistent oligoarticular subtype) and 63 healthy children. The CHAQ clinically discriminated between healthy subjects and JIA patients, with the systemic, polyarticular and extended oligoarticular subtypes having a higher degree of disability, pain, and a lower overall well-being when compared to their healthy peers. Also the CHQ clinically discriminated between healthy subjects and JIA patients, with the systemic onset, polyarticular onset and extended oligoarticular subtypes having a lower physical and psychosocial well-being when compared to their healthy peers. In conclusion the Danish version of the CHAQ-CHQ is a reliable, and valid tool for the functional, physical and psychosocial assessment of children with JIA.

Refraction in juvenile chronic arthritis: a long-term follow-up study, with emphasis on myopia.

OBJECTIVE: Assessment of refraction anomalies in juvenile chronic arthritis (JCA) on a long-term follow-up basis. MATERIAL AND METHODS: Sixty-five adults, 52 females and 13 males, with a history of active JCA had a complete ophthalmic evaluation including subjective refractioning on average 26.4 years after JCA onset. The age range was 22-49 years. RESULTS: The refraction ranged from -8.12 D to +6.5 D with a mean (SD) of -0.64 (2.16) D. The mean refraction in the JCA group was significantly more towards myopia than that of a coeval adult hospital-based sample used as controls (p = 0.008). Twenty-eight out of the 65 (43%) had a negative refractive value of at least 0.37 D. Myopia onset age ranged from 8 to 31 years. In those able to specify their myopia onset by first purchase of spectacles (n = 25) the JCA onset had preceded the myopia, with a mean (SD) interval of 10.1 (5.4) years. CONCLUSION: The elevated myopia figure of 43% among JCA patients suggests an association between myopia and JCA. In lack of more precise indicators and in accordance with older literature, an explanation might be a weakening effect of chronic inflammation on scleral connective tissue.

[Diseases among refugee and immigrant children]. / Sygdomme hos flygtninge- og indvandrerbørn.

Foreign adopted children and children of asylum applicants and refugees, newly arrived in Denmark, often have lived under conditions that make the following diagnostic considerations relevant: scabies, lice, impetigo and fungal skin infections, nutritional iron deficiency or bleeding, anaemia caused by hook worms in the gastrointestinal tract, malaria, tuberculosis, hepatitis B, HIV infection and various intestinal parasites. Haemoglobinopathies including sickle cell anaemia and talassaemia should also be kept in mind in anaemia. Immigrant children are admitted to hospital approximately twice as frequently as Danish children but with the same diagnoses apart from some increased frequency of psychological and behavioural disturbances and talassaemia.

Juvenile chronic arthritis into adulthood: a long-term follow-up study.

OBJECTIVE: To evaluate a group of 65 adults with a history of or persistent juvenile chronic arthritis (JCA), on average, 26.4 yr after disease onset. METHODS: Disease status at the time of the study included an evaluation of disease-related parameters assessed by the patient and the investigator. RESULTS: Active disease was present in 37% of the study participants, of which 80% had either extended pauciarticular or polyarticular JCA. Eleven per cent of the study subjects were in Steinbrocker functional classes III and IV and 22% had undergone JCA-related major surgery. The pain visual analogue scale, health assessment questionnaire, erythrocyte sedimentation rate and C-reactive protein (CRP) were significantly increased in those participants who had active JCA at the time of the study. Disease duration proved to be the parameter most strongly associated with an unfavourable disease outcome. CONCLUSIONS: Although the study group was biased towards the more severe cases, the data suggest that the long-term functional outcome in JCA is, in more than one-third, associated with active disease persisting into adulthood, increasing residua and the need for surgery.

Development of ARI case management at primary and secondary level in southern Vietnam.

In southern Vietnam it is not uncommon that children under 5 years of age die from pneumonia. Reduction of severity and mortality has to rely on proper case management by mothers and health workers on both grass root level and referral level. The responsibility of training of clinical skills of ARI case management in the southern provinces of Vietnam has been delegated to Pediatric Hospital N1 (PHN1) Ho Chi Minh City (HCMC) by Ministry of Health. A pilot project was carried out by the Danish-Vietnamese Study Group. The immediate objects were: to provide basic epidemiological information about ARI in southern Vietnam, to develop training modules and case management intervention modules at primary and secondary level in order to enable mothers, village workers, health post staff and district hospital emergency department staff to treat moderate and severe pneumonia and acute bronchitis in accordance with the WHO management guide for ARI and to evaluate the effect of those modules after implementation in a limited number of communes. The modules were developed at PHN1. Ten commune health stations were carefully selected. The purpose of the project and the conditions for taking part had been explained to the health workers. The doctors and other commune health workers from the 10 commune health stations and doctors from the connected district hospitals attended the training courses at PHN1, HCMC and also at the belonging provincial hospitals. Essential equipment was provided and a pharmacy with essential drugs established. The registered health statistics was collected yearly during on site visits. The local doctors and commune health workers gave seminars for mothers in the villages of the 10 project communes. The mothers' knowledge, attitude and practice (KAP) was tested in interviews before and two months after the seminars had taken place. The spread of KAP was measured by random interviews of mothers six month later. In the interviews information on social conditions was obtained. The mothers' KAP had risen by 25% two months after attending the seminars. A further increase of KAP by 5-10% within the untrained group appeared in a survey 4-6 months later. It was not possible to obtain reliable statistics on morbidity or mortality of ARI in the project area.

Epidemiology of juvenile chronic arthritis: risk dependent on sibship, parental income, and housing.

OBJECTIVE: We studied the socioeconomic background of children with juvenile chronic arthritis (JCA) diagnosed during the years 1988-91 in Denmark. The working hypothesis is that JCA may be triggered by one or several different infectious agents and that the amount of exposure to infectious agents in infancy and childhood affects the risk of JCA. METHODS: In this case-control study, we investigated socioeconomic variables prior to disease onset from national registers, primarily the Fertility Database of Statistics Denmark, in a national cohort of all 220 known cases of JCA fulfilling the EULAR criteria incident during the years 1988-91, identified from national and local diagnosis registers. There were 4 controls per case, matched for sex, age, and county of residence. Socioeconomic variables as risk factors were quantified by odds ratios, which are equivalent to relative risks of contracting JCA if exposed to a risk factor. RESULTS: Three socioeconomic variables were significantly and mutually independently associated with the risk of developing JCA during the following year. An only child had a risk of JCA 1.6 times that of a child with siblings. Children whose parents had a high income had a relative risk of 1.9. Children living in an urban flat had a risk 2.7 times that of children living on a farm. We found no space-time clustering of cases and no cyclical variations of incidence rates. CONCLUSION: The absence of clustering and of seasonal variation does not support a theory of triggering by infection. The hitherto unreported effects of the socioeconomic variables on the risk of JCA are of the same order of magnitude as reported for certain HLA alleles. Our findings do not lend full support to either of the 2 mechanisms, that growing up under either hygienic or unhygienic conditions increases the risk of JCA, and lack an obvious biological explanation.

Assessment of bone mineral density in adults with a history of juvenile chronic arthritis: a cross-sectional long-term followup study.

OBJECTIVE: To assess bone mineral density (BMD) and bone turnover in adults with a history of juvenile chronic arthritis (JCA) or persistent JCA, and to identify predictors of reduced BMD. METHODS: Sixty-five white patients (mean age 32.2 years) with a history of JCA and 65 age-, sex-, height-, and weight-matched healthy control subjects participated in the study. Densitometry of the left hip and the lumbar spine was performed, and osteocalcin (bone formation marker) and crosslinks (bone resorption marker) were measured. In addition, bone-related clinical parameters were assessed in the JCA group. RESULTS: BMD in the hip and lumbar spine was significantly lower in the JCA group than in the controls. Levels of osteocalcin and crosslinks were significantly increased in the JCA group. According to WHO definitions, significantly more subjects in the JCA group had "osteopenia" and "osteoporosis" than would be expected in a normal population sample. Active disease at the time of the study (1996-1997), baseline erosions evaluated in 1979, Steinbrocker functional class in 1996-1997, polyarticular course of JCA, and history of systemic steroid treatment for more than 1 year were significantly associated with reduced BMD. In linear regression analysis including both the JCA and control groups, presence of JCA proved to be the factor most strongly associated with reduced BMD, explaining approximately 20% of its variation. CONCLUSION: Reduced BMD and evidence of increased bone turnover suggest that JCA patients may be at risk of developing premature osteoporosis and associated fractures later in life. The data are consistent with the concept that BMD in JCA is determined by many factors.

The etiology of bacterial pneumonia and meningitis in Vietnam.

BACKGROUND: To date no studies on the incidence of Haemophilus influenzae type b (Hib) disease, Hib carrier rates in infants and children or the proportion of bacterial meningitis cases caused by Hib in Vietnam have been performed. The availability of safe and highly effective Hib vaccines makes such information important. METHODS: The bacterial etiology of a sample of infants and children with pneumonia and meningitis seen at Pediatric Hospital No. 1 in Ho Chi Minh City was studied by culture and latex agglutination of blood, cerebrospinal fluid, urine and pleural fluid. The carriage rate of pneumococci and Hib was studied in a sample of outpatient children. RESULTS: Hib caused 53% of 34 culture-proven bacterial meningitis cases and pneumococci caused 18%. Of 31 meningitis cases diagnosed by latex agglutination, 39% were caused by Hib and 55% by pneumococci. Ninety percent of cases of Hib meningitis occurred in children <1 year of age. Fifty percent of meningitis cases were associated with acute respiratory infection. In 213 bacteremic pneumonia cases 92.5% of blood cultures grew Streptococcus pneumoniae and only 1% grew Hib. The carrier rate of Hib in outpatients <5 years of age with upper respiratory tract infection increased from 2% to 7.6% between 1993 and 1996. CONCLUSION: Hib is the most frequent cause of meningitis in infants and children admitted to hospitals in South Vietnam. Ninety percent of Hib meningitis cases occur in patients < 1 year of age. Bacteremic Hib pneumonia in Vietnam is rare. The results suggest that Hib is the major cause of meningitis in Vietnam but do not permit conclusions regarding its true incidence. The carrier rate of Hib in children <5 years of age in Vietnam has increased to approximately 7% since 1993.

[Randomized comparison of intravenous immunoglobulin and methylprednisolone pulse therapy in children with newly diagnosed idiopathic thrombocytic purpura. The Danish ITP Study Group]. / Randomiseret sammenligning af intravenøs immunglobulin og methylprednisolon-pulsterapi hos børn med nydiagnosticeret idiopatisk trombocytopenisk purpura. The Danish ITP Study Group.

Forty three children with newly diagnosed idiopathic thrombocytopenic purpura (ITP), platelet count (pl.c.) below 20 x 10(9)/l, and either clinically significant bleeding or failure to show a spontaneous platelet rise within three days of admission were randomly allocated to treatment with intravenous infusions of either immunoglobulin (IVIG) 1 g/kg or methylprednisolone (MPPT) 30 mg/kg on two consecutive days. Prompt induction of partial remission with pl.c. > 50 x 10(9)/l after 72 hours was seen in 21/23 given IVIG versus 10/20 given MPPT (exact p = 0.003); mean pl.c.s after 72 hours were 188 versus 77 x 10(9)/l (2p < 0.001). Poor responders were then given the alternative infusions in addition. After six days, complete remission with pl.c. > 150 x 10(9)/l was achieved in 16/23 versus 10/20 (p = 0.16). During six months follow-up, there were no significant differences regarding relapse rates or chronic course. Eleven children with relapse were crossed over to the alternative treatment arm: the estimated treatment effect in pl.c. after 72 hours was 134 x 10(9)/l in favour of IVIG. These results indicate that IVIG infusions may be preferable to high-dose corticosteroids as initial treatment for children with ITP.

High dose vitamin A supplementation in the course of pneumonia in Vietnamese children.

We carried out a randomized, placebo-controlled, double-blinded trial to evaluate the effect on morbidity of high dose oral vitamin A, given on hospital admission to 592 children aged 1-59 months with moderate and severe pneumonia. Severely underweight children were not included, but 45% were moderately underweight. The vitamin A and placebo groups were comparable in baseline characteristics. Four patients died. Among all of the surviving children, no differences were found regarding mean time for normalization of fever, respiratory rate and time of hospitalization. Stratification for moderate malnutrition, degree of pneumonia, age and sex revealed moderately malnourished vitamin A-supplemented children to have a shorter time of hospitalization (p = 0.04), due to an effect in females aged > 12 months (p = 0.02) and females with very severe pneumonia (p = 0.048). This study indicates that, in developing countries like Vietnam, supplementation with vitamin A in children with pneumonia could shorten the recovery rate in the ones that are undernourished, especially females > 1 y old.

Interleukin-1 receptor antagonist in neonates, children and adults, and in patients with pauci- and polyarticular onset juvenile chronic arthritis.

OBJECTIVE: The production of interleukin (IL) -1 alpha IL-1 beta and IL-1 receptor antagonist (IL-1ra) by blood mononuclear cells (MNC), as well as the corresponding serum levels of IL-1ra were examined in blood samples from umbilical cords (n = 11), children (n = 40) and adults (n = 20), and in 42 patients with juvenile chronic arthritis (JCA) of the pauci- or polyarticular onset type. RESULTS: IL-1ra serum levels were found to differ significantly between the three age groups, being higher in neonates (569 pg/ml) than in children (70 pg/ml) and adults (177 pg/ml). IL-1ra production in E. coli lipopolysacharide (LPS) stimulated-cultures of MNC was also significantly higher in neonates (median 2451 pg/ml) than in children (1526 pg/ml), but similar to that in adults (2107 pg/ml). IL-1ra levels in the sera of both subgroups of JCA patients were significantly elevated (median 257 pg/ml), but did not reflect paraclinical or clinical disease parameters. In samples of synovial fluid the IL-1ra levels tended to be fairly high, up to approximately 2 ng/ml, but they did not reflect the serum levels of IL-1ra. CONCLUSION: These findings suggests that the upregulation of IL-1ra production forms part of the immunoregulatory response in JCA patients, and that the insufficient production of IL-1ra is unlikely to contribute to the pathogenesis of JCA.

Randomized trial comparing intravenous immunoglobulin with methylprednisolone pulse therapy in acute idiopathic thrombocytopenic purpura. Danish I.T.P. Study Group.

Forty-three children with newly diagnosed idiopathic thrombocytopenic purpura (ITP), platelet count (PC) below 20 x 10(9)l-1, and either continued bleeding or failure to show a spontaneous rise in the PC after a 3 day observation period were randomized to treatment with either intravenous immunoglobulin (IVIG) infusions 1 g kg-1 (n = 23) or intravenous methylprednisolone pulse therapy (MPPT) 30 mg kg-1 (n = 20) on two consecutive days. After 72 h, IVIG had induced greater platelet responses (mean PC 188 x 10(9) versus 77 x 10(9)l-1, 2p < 0.001) and raised the PC to a haemostatically safe level above 50 x 10(9)l-1 more frequently (91 versus 50%, one-sided exact p = 0.003). Children responding poorly were then given the alternative treatment in addition. After 6 days, a normal PC of over 150 x 10(9)l-1 had been obtained more frequently in the group given first-line IVIG (70 versus 50%, p = 0.16). The relapse rates during 6 months of follow-up were not significantly different (26 versus 40%, p = 0.26). Cross-over treatment in 11 children with relapse confirmed the superior response to IVIG. The treatment given was restricted to the two initial infusions more often in the IVIG group (70 versus 35%, p = 0.05). These results indicate that IVIG may be preferable to MPPT as the initial treatment for ITP.

In vitro cytokine production and phenotype expression by blood mononuclear cells from umbilical cords, children and adults.

Age related differences in immunological reactions include variations in the in vitro functions of blood mononuclear cells (MNC). In an attempt to understand the mechanism behind these differences we examined age related differences in the phenotype profiles of MNC in parallel with the in vitro production of interleukin IL-6, tumour necrosis factor alpha (TNF alpha) and interferon gamma (IFNg) in neonates, children and adults. In cultures without added polyclonal activators IL-6 and TNF alpha levels in children were 3-6 times higher than those of umbilical cords and adults. However, using optimal in vitro stimulation (E. coli lipopolysaccharide (LPS), phytohaemmagglutinin or pokeweed mitogen (PWM)) no significant differences in the levels of these cytokines were observed. The levels of IFNg in PWM driven cultures followed a different pattern with comparable levels in children and adults, and unmeasurable levels in cord blood MNC. Flow cytometry analysis of the phenotypic distribution of MNC revealed age related differences in the expression of CD3, CD4, CD8, CD14, CD19, CD45RA, CD45R0, CD2, LFA-1, ICAM-1 and LFA-3. Correlation studies did not indicate that the observed differences in cytokine production could be ascribed to differences in the frequency of monocytes, T cells or B cells. The TNF alpha levels in suboptimally stimulated cultures correlated negatively with the expression of LFA-3 and positively with CD45RA, while IFNg correlated positively with CD2, LFA-1, CD45R0 and CD8. In conclusion, the study provides evidence of age related differences in the production of TNF alpha, IL-6 and IFNg among neonates, children and adults. These differences may to some extent be caused by differences in the expression of cell surface molecules involved in cellular interactions and signalling.

Autoantibodies to IL-1 alpha in sera from umbilical cords, children, and adults, and from patients with juvenile chronic arthritis.

Antibodies against interleukin-1 alpha (aAb-IL-1 alpha) have previously been demonstrated in sera of healthy adults and in patients with inflammatory diseases. In the present investigation the occurrence of aAb-IL-1 alpha was examined by second antibody precipitation technique in sera from umbilical cords (n = 11), children (n = 45), and adults (n = 20), as well as in 51 patients with juvenile chronic arthritis (JCA) of pauciarticular (n = 34), polyarticular (n = 8), or systemic onset type (n = 9). RESULTS. The frequency of positive sera was significantly lower in children than in cord blood and adults as were the levels of aAb-IL-1 alpha (p < 0.0001). In the non-neonatal group of individuals the levels of aAb-IL-1 alpha correlated positively with age (r = 0.394, p = 0.0015). The frequency of sera positive for aAb-IL-1 alpha was higher in the JCA patients, as were the levels (p < 0.005), and correlated positively with disease activity as evaluated by joint score and visual analogue score.

[Kawasaki disease. Incidence in Denmark during the period 1981-1990]. / Kawasaki's sygdom. Forekomst i Danmark i perioden 1981-1990.

The aim of the study was to estimate the incidence of Kawasaki's disease and to describe the clinical manifestations and the prognosis of the disease in children in Denmark during the period 1981-1990. In a register of all hospital admissions in Denmark, 99 patients were registered as having Kawasaki's disease. Of those, 89 patients fulfilled the clinical diagnostic criteria. The mean incidence of the ten year period was 1.0 per 100,000 children per year. The incidence of the disease decreased in the age group from zero to seven years after which it was rarely observed. Typical laboratory findings were hypersedimentation, leucocytosis and thrombocytosis. Eight children had cardiomegaly and three had electrocardiographic changes. Echocardiography was performed in 66 patients showing coronary artery aneurysms in nine patients (14%) (six boys and three girls). No further cardiac complications were found.

[HIV antibody positive children in Denmark]. / Børn med HIV-antistoffer i Danmark.

The AIDS-committee of The Danish Society of Paediatrics has done a nation-wide study among infants and children under the age of 15 with AIDS or HIV-antibodies in preparation for planning prevention and treatment. Clinical data have been collected from the Departments of Paediatrics and Infectious Diseases, Haemophilia, Dermatology and Internal Medicine up to 1 March 1993. The study includes 44 infants with a risk of vertical transmission from the mother and 16 children with haemophilia. No cases were found to be infected by blood-transfusion. Twenty of the 44 infants with congenital HIV-antibodies were HIV-infected. Seven of them died from AIDS, 10 currently have AIDS and three are asymptomatic. Seventeen infants are well and HIV-antibody negative after the age of 18 months. Seven infants still have unclarified status, but all are well. Three of the patients with haemophilia are dead. The 13 others do not have AIDS. It is surprising that most of the infected infants' mothers were not known to be infected before the infants got sick. Thus infected infants exist in families who are not suspected to be HIV-infected. The AIDS-committee of The Danish Society of Paediatrics has proposed recommendations for HIV-testing of infants and children. HIV-infected families need comprehensive psychosocial care. The risk-factor from blood-transfusion is now eliminated, but vertical transmission will continue to be a risk-factor. The size of the problem in Denmark will not be known until an epidemiological study of pregnant women has been conducted.

A comparison between nebulized terbutaline, nebulized corticosteroid and systemic corticosteroid for acute wheezing in children up to 18 months of age.

One hundred and twenty-three children, aged 1.5-18 months, participated in a randomized, double-blind, placebo-controlled multicentre study comparing different treatments for acute wheezing. The children were admitted to one of five participating paediatric departments. They were randomized into one of four treatment groups: (1) soluble prednisolone+placebo inhalation+terbutaline inhalation; (2) soluble placebo+budesonide inhalation+terbutaline inhalation; (3) soluble placebo+placebo inhalation+terbutaline inhalation; and (4) soluble placebo+placebo inhalation+normal saline inhalation. On admission, measurements of temperatures, respiratory rate and heart rate were made and once-a-day thereafter. Wheezing, accessory respiratory muscle use, prolonged expiration and general condition were scored on a scale ranging from 0 to 3. Significantly more treatment failures were recorded in the placebo group. Children from both steroid groups were discharged earlier than children from the terbutaline group. Compared with children from the placebo group, children from all three treatment groups had a greater improvement in symptom score, but this was significant for the budesonide group only.