V. Hue

Increased detection rate of Kawasaki disease using new diagnostic algorithm, including early use of echocardiography.

OBJECTIVE To determine the incidence of Kawasaki disease (KD) in Northern France by using new American Heart Association (AHA) criteria. STUDY DESIGN A 1-year prospective multicenter cohort study was performed in all pediatric departments. Patients <18 years old, who were admitted for prolonged but initially unexplained fever or suspected KD were included. All patients received the standard treatment considered appropriate by their physicians. A descriptive analysis and comparison of patients with complete and incomplete forms of KD were performed. The incidence of confirmed cases of KD (complete and incomplete forms) was calculated. RESULTS Seventy-seven children were included (39 in whom KD was diagnosed). Of the patients with KD, 26 (67%) met the classic AHA case definition, and 7 (18%) had incomplete KD. Cardiac ultrasound scanning was helpful in the diagnosis of 6 of 7 patients with incomplete KD (86%). The final incidence of confirmed KD was 9 of 100,000 children <5 years of age. In 6 children (15%) the diagnosis of KD was uncertain, but they were successfully treated for it. Coronary disease was identified in 48% of patients with confirmed KD. CONCLUSION The incidence of KD is higher than previously reported, in part because earlier reports did not include incomplete forms. New AHA criteria (laboratory tests and early echocardiography) were helpful for the diagnosis of incomplete forms of KD.

Paediatric skin disorders encountered in an emergency hospital facility: a prospective study.

To determine the frequency of skin disorders encountered in a paediatric emergency care unit and to evaluate the benefits of advice from a dermatologist, we prospectively recorded data of children admitted with skin disorders to the emergency care unit during a 5-month period. Diagnostic agreement between paediatricians and dermatologists evaluating the patients separately was assessed. Three hundred and ninety-five children (median age 3 years; interquartile 1-6) were included. Skin disorders represented 4% of all paediatric emergency care unit visits. Visits were considered as appropriate in 19-30% of cases according to different criteria. Six diseases accounted for 57% of cases: viral exanthema, urticaria, atopic dermatitis, varicella, diaper dermatitis and herpetic gingivostomatitis. The dermatologist modified the diagnosis in 42% of cases and the treatment in 30%. Greater emphasis on teaching the skin disorders encountered in this setting and efforts to provide easy access to advice from dermatologist would improve the quality of care.

Spondylodiscitis and mediastinitis after esophageal perforation owing to a swallowed radiolucent foreign body

A 6-year-old boy with aphagia presented with a radiolucent foreign body, esophageal perforation, mediastinitis, and a C6-C7 spondylodiscitis. A rigid plastic gear wheel was removed via thoracotomy, and the mediastinal abscess was drained through the esophagomediastinal fistula. Treatment included antibiotics as well as nonsurgical orthopedic management of the spondylodiscitis. The recovery period was uneventful, and the patient has remained asymptomatic for 2 years. Physicians must be aware of radiolucent foreign bodies. Computed tomography is very helpful in establishing the diagnosis of radiolucent foreign body, mediastinal abscess, and spondylodiscitis.

Impact de la conférence de consensus sur le traitement ambulatoire des bronchiolites du nourrisson: Étude sur 3 années dans le département du Nord

Resume Objectifs Mesurer l’impact des recommandations de la conference de consensus de septembre 2000 sur la prise en charge ambulatoire de la bronchiolite aigue du nourrisson. Methodes L’etude etait prospective, multicentrique, dans 4 hopitaux du departement du Nord, pendant 3 periodes epidemiques: l’hiver precedant la Conference et les 2 hivers suivants. Etaient inclus les enfants âges de 30 jours a 2 ans se presentant en urgence pour un premier ou deuxieme episode de bronchiolite. Etaient recueillis les principales caracteristiques des enfants et les traitements ambulatoires prescrits. Resultats Six cent trente-huit enfants etaient inclus: 169 avant et 469 apres la conference. Soixante-dix-sept pour cent avaient consulte precedemment et 77 % de ces enfants avaient eu une prescription. Il n’existait aucune difference dans la frequence de prescription des medicaments et de la kinesitherapie entre les 3 periodes. Apres la conference, les s2mimetiques inhales restaient prescrits dans 21 % des cas, les corticoides inhales dans 15 %, les corticoides oraux dans 34 %, les antibiotiques dans 53 %, et les mucolytiques dans 54 %. La kinesitherapie etait prescrite chez 58 % des nourrissons. Conclusion Deux annees apres la conference, le traitement ambulatoire des bronchiolites n’etait pas modifie, corticoides, s2mimetiques, antibiotiques et mucolytiques restant trop prescrits. Il convient de reevaluer, dans quelques annees, l’application de ces recommandations tant en ambulatoire qu’a l’hopital.

The Value of Body Weight Measurement to Assess Dehydration in Children

Dehydration secondary to gastroenteritis is one of the most common reasons for office visits and hospital admissions. The indicator most commonly used to estimate dehydration status is acute weight loss. Post-illness weight gain is considered as the gold-standard to determine the true level of dehydration and is widely used to estimate weight loss in research. To determine the value of post-illness weight gain as a gold standard for acute dehydration, we conducted a prospective cohort study in which 293 children, aged 1 month to 2 years, with acute diarrhea were followed for 7 days during a 3-year period. The main outcome measures were an accurate pre-illness weight (if available within 8 days before the diarrhea), post-illness weight, and theoretical weight (predicted from the child’s individual growth chart). Post-illness weight was measured for 231 (79%) and both theoretical and post-illness weights were obtained for 111 (39%). Only 62 (21%) had an accurate pre-illness weight. The correlation between post-illness and theoretical weight was excellent (0.978), but bootstrapped linear regression analysis showed that post-illness weight underestimated theoretical weight by 0.48 kg (95% CI: 0.06–0.79, p<0.02). The mean difference in the fluid deficit calculated was 4.0% of body weight (95% CI: 3.2–4.7, p<0.0001). Theoretical weight overestimated accurate pre-illness weight by 0.21 kg (95% CI: 0.08–0.34, p = 0.002). Post-illness weight underestimated pre-illness weight by 0.19 kg (95% CI: 0.03–0.36, p = 0.02). The prevalence of 5% dehydration according to post-illness weight (21%) was significantly lower than the prevalence estimated by either theoretical weight (60%) or clinical assessment (66%, p<0.0001).These data suggest that post-illness weight is of little value as a gold standard to determine the true level of dehydration. The performance of dehydration signs or scales determined by using post-illness weight as a gold standard has to be reconsidered.

Consensus in diagnostic definitions for bone or joint infections in children by a Delphi method with European French-speaking experts.

Aim:  Various diagnostic criteria have been proposed for bone or joint infection. This study used a Delphi process to determine the consensual definitions for arthritis, osteomyelitis and bone or joint infections in general in children.

Simultaneous tracheal and oesophageal pH monitoring during mechanical ventilation.

OBJECTIVE: To simultaneously record tracheal and oesophageal pH in mechanically ventilated children to determine: (1) the feasibility and safety of the method; (2) the incidence of gastro-oesophageal reflux (GOR) and pulmonary contamination; and (3) their associated risk factors. DESIGN: Prospective study. SETTING: Paediatric intensive care unit in a university hospital. PATIENTS: Twenty mechanically ventilated children (mean age 6.7 years) who met the following inclusion criteria: endotracheal tube with an internal diameter of 4 mm or more (cuffed or uncuffed), mechanical ventilation for an acute disease, no treatment with antiacids, prokinetics, or H2-receptor blockers, and no nasogastric or orogastric tube. METHODS: The tracheal antimony pH probe was positioned 1 cm below the distal end of the endotracheal tube. The oesophageal antimony pH probe was positioned at the lower third of the oesophagus. pH was recorded on a double channel recorder and analysed with EsopHogram 5.01 software and by examination of the trace. The following definitions were used: GOR index, percentage of time pH < 4; pathological GOR, GOR index > 4.8%; tracheal reflux, fall in tracheal pH < 4, 4.5, or 5, or a decrease of one unit from baseline, in both cases preceded by an episode of GOR. The results were analysed statistically by Fishers exact and the Kruskal-Wallis test. RESULTS: The procedure was well tolerated and the median duration of analysable recording was 6 hours (range 5-22.6). Pathological GOR was observed in eight (40%) children. GOR was more frequent with an uncuffed endotracheal tube than with a cuffed one (p = 0.01). Tracheal reflux (pH < 4) was observed in four children (20%) without clinical evidence of pulmonary aspiration. Episodes of tracheal reflux were associated with a GOR index > 10% (p < 0.01) and were more frequent with a maximal inspiratory pressure of < 25 cm H2O (p = 0.03), but were not related to the indication for mechanical ventilation, whether the endotracheal tube was cuffed or not, age, or drug treatment. CONCLUSIONS: Simultaneous tracheal and oesophageal pH monitoring was feasible in the setting of this study. Tracheal reflux can occur without pathological GOR, and GOR may occur without tracheal reflux. Further prospective studies in larger groups of patients are now justified.

Utilité d’une unité d’hospitalisation de courte durée aux urgences pédiatriques

Resume Les unites d’hospitalisation de courte duree (UHCD) aux urgences evitent des hospitalisations traditionnelles mais peuvent generer des HCD pour des enfants qu’on aurait laisses sortir en l’absence d’UHCD. Notre objectif etait de mesurer ces deux effets et d’evaluer les missions de l’HCD. Methodes. – Etude prospective incluant du 4 septembre au 31 octobre 2001 tous les enfants d’une UHCD medico-chirurgicale de 10 lits. Le medecin indiquant l’HCD notait des l’admission quelle aurait ete sa decision en l’absence d’UHCD et quel etait le motif de l’HCD. Resultats. – Cinq cent neuf enfants (mediane d’âge = 4 ans, affections chroniques : 26 %, traumatismes : 34 %), representant 15 % des passages aux urgences, ont eu une HCD d’une duree moyenne de 14 ± 8 h. La decision en l’absence d’HCD aurait ete : hospitalisation traditionnelle (77 %), transfert dans un autre hopital en l’absence de place (7 %), retour au domicile (10 %), attente dans le secteur de soins externes aux urgences (4 %), ne sait pas ou non precisee (2 %). Le motif de l’HCD etait souhaitable dans 81 % des cas : hospitalisation previsible de moins de 24 h (65 %) ou une orientation incertaine de l’enfant (16 %). Les indications de l’HCD etaient discutables dans 13 % des cas et inappropriees dans 6 % des cas. Les enfants repartaient au domicile dans 66 % des cas. Conclusion. – L’UHCD genere beaucoup plus d’economies d’hospitalisations qu’elle ne provoque d’HCD et s’avere particulierement adaptee aux affections de l’enfant. Les indicateurs proposes doivent permettre des comparaisons inter-services.

Risk of bacterial meningitis in young children with a first seizure in the context of fever: a systematic review and meta-analysis.

Background Of major concern in any febrile child presenting with a seizure is the possibility of bacterial meningitis (BM). We did a systematic review to estimate the risk of BM among various subgroups of young children with a first seizure in the context of fever, and to assess the utility of routine lumbar puncture (LP) in children with an apparent first FS. Methods/Principal Findings MEDLINE, INIST, and the COCHRANE Library databases were searched from inception to December 2011 for published studies, supplemented by manual searches of bibliographies of potentially relevant articles and review articles. Studies reporting the prevalence of BM in young children presenting to emergency care with a first: i) “seizure and fever”, ii) apparent simple FS, and iii) apparent complex FS were included. Fourteen studies met the inclusion criteria. In children with a first “seizure and fever”, the pooled prevalence of BM was 2.6% (95% CI 0.9–5.1); the diagnosis of BM might be suspected from clinical examination in 95% of children >6 months. In children with an apparent simple FS, the average prevalence of BM was 0.2% (range 0 to 1%). The pooled prevalence of BM among children with an apparent complex FS was 0.6% (95% CI 0.2–1.4). The utility of routine LP for diagnosis of CNS infections requiring immediate treatment in children with an apparent first FS was low: the number of patients needed to test to identify one case of such infections was 1109 in children with an apparent first simple FS, and 180 in those with an apparent first complex FS. Conclusion The values provided from this study provide a basis for an evidence-based approach to the management of different subgroups of children presenting to emergency care with a first seizure in the context of fever.

Les décès par déshydratation aiguë du jeune enfant : les leçons de l’analyse d’une base de données de société d’assurances

Une revue générale récente de la littérature nous a montré que les seules études publiées des plaintes médicolégales en pédiatrie étaient nord-américaines [1]. Cela nous a conduit à proposer une étude en collaboration avec le Groupe Sou médical–Mutuelle d’assurances du corps de santé français (MACSF) qui assure en responsabilité civile professionnelle environ 66 % des pédiatres libéraux, 49 % de l’ensemble des pédiatres et 60 % des généralistes français. Nous avons ainsi pu analyser les 228 déclarations de plaintes à l’encontre de pédiatres ou de médecins généralistes assurés du groupe Sou médical MACSF (GAMM), concernant des enfants âgés de 1 mois à 18 ans, et intervenues entre janvier 2003 et décembre 2007. Dans 41 % des cas, il s’agissait de nourrissons âgés de 1 à 24 mois. Les erreurs diagnostiques étaient les causes alléguées de plaintes les plus fréquentes (47 %), suivies par les accidents ou les erreurs liées aux médicaments (19 %). Les déshydratations représentaient la seconde affection en cause après les méningites avec 13 cas (soit 6,6 % des plaintes pour lesquelles une affection pouvait être identifiée), dont 12 décès (92 %) et 1 enfant n’ayant pas présenté de séquelle. L’âge moyen était de 15 12 mois : 4 enfants dans le 1er semestre de vie, 3 dans le 2nd semestre, 2 dans la 2e année de vie et 4 dans la 3e année. Le sex-ratio était de 0,86. Trois enfants étaient décédés au cours de leur hospitalisation, et ce en dehors d’un contexte de simple choc hypovolémique : un présentait une hyperplasie des surrénales et 2 présentaient un tableau de défaillance multiviscérale évoquant une éventuelle maladie métabolique (non démontrée). Les 9 autres étaient décédés à domicile (n = 7) ou à leur arrivée aux urgences (n = 2) du fait d’un choc hypovolémique sur déshydratation majeure et ne présentaient aucune affection sous-jacente. Sept des 9 enfants avaient eu au moins une consultation préalable (3 par un médecin généraliste, 1 par un pédiatre, et 3 aux urgences), dans un délai moyen de 20 11 h (extrêmes : 9 à 34 h) par rapport à l’heure du décès. Quatre