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?

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In adults a randomised study,¹ ongoing work,² review, and meta-analysis^3,4 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 …