[Acute osteomyelitis and septic arthritis in children: one year experience]

To describe bacteriologic epidemiology of bone and joint infections, a total of 52 osteomyelitis, 52 arthritis and 20 osteoarthritis of children aged one month to 15 years during a one-year period (2001) were included in a retrospective unicentric review. The mean age was 3,9 +/-3,6 years. Fever and pain were the most common clinical symptoms. The site of infection was single in 95%, involving lower extremities in 80%. Bone scintigraphy was abnormal in 71% of osteomyelitis. Positive cultures was obtained in 29% of all cases (blood cultures: 20%, aspiration cultures: 29%), but in 42% of cases which have both blood and aspiration cultures. Thirty-six bacteria were identified: 19 Staphylococcus (14 aureus), ten Streptococcus (four pneumoniae), three Salmonella, three Kingella kingae, one Moraxella. All the isolates were susceptible to the empiric antibiotic therapy. Outcome was good in 100% of osteomyelitis and in 96% of arthritis.

[Oral morphine administration for children's traumatic pain]

OBJECTIVES

To study the compliance of prescription, the efficacity and the adverse events of oral morphine used in the pediatric emergency department (ED) in traumatic pains.

METHOD

This prospective study was conducted in the ED from october 2002 to september 2003. Children aged six months to 16 years with a visual analogic scale (VAS) score higher than 70 or with a traumatic member deformation received oral morphine (0,5 mg/kg). Pain was assessed every 30 minutes using two scales: behavioral observation by the faces scale and objective pain scale (OPS) for children less than five years, behavioral observation by the faces scale and self-report by VAS for children older than five years. The compliance of prescription, the pain scores and the adverse events were studied.

RESULTS

Ninety-one children received oral morphine and seventy-four children were studied. Seventy per cent of prescriptions were in accordance with the recommendations. For patients younger than five years a rapid decrease of pain was observed in thirty minutes. The pain's reduction was respectively 79 and 84% with faces scale and OPS when they left ED. For children older than five years, pain's reduction was more important and more rapid when pain assessment was made by nurses than when it was self-reported in the first hour (pain reduction 58,2 and 36,1%). When leaving, pain reduction was the same with the two different assessments. No major adverse event was noted.

CONCLUSION

Use of oral morphine in ED is simple, with a few numbers of adverse events. None was severe. Efficiency is correct after 30 to 60 minutes.

[Treatment of exacerbation of asthma: what are today's issues?]

During past decades, major progress has been accomplished in the management of acute asthma. Most recent recommendations include evidence-based rationale. The improved quality of clinical guidelines makes them efficient models for medical education. The pediatric pharmacopoeia provides a great variety of choices of drugs as well as for asthma medical devices. These innovations dramatically facilitated the medical management of asthmatic children, but they did not solve all problems. Physicians now use higher doses of salbutamol, but the early prescription of systemic glucocorticoids for moderate exacerbation of asthma is still underused, given the most recent clinical guidelines and meta-analysis. Furthermore, repeated emergency department visits to the wards and lack of primary care physician should systematically be appraised when evaluating severity, as they are both major risk factors for severe exacerbations, even though they are not considered in acute asthma severity scores. Finally, initiating (or reinforcing) patient education at the time of exacerbation also presents important challenges, as emergency visits are a favorable moment to commence the therapeutic education of the child and his family. Indeed, framing the controller medications and educating families about how to manage the disease and to improve their domestic environment are the genuine tools available for the prevention of asthma exacerbations, and particularly those most severe.

Hématémèse chez un enfant de 11 mois : un mode de révélation rare d'un corps étranger intragastrique

Ingestion of foreign body has often no consequence. We report on a case in an 11-month-old girl who was referred for mild hematemesis and anorexia. Upper digestive tract endoscopy found a small metallic foreign body in the gastric antrum. After its removal, all symptoms disappeared. It is usually recommended to remove foreign bodies by endoscopy when they are in esophageal position, or are more than 3 to 5 cm long, or have a shape that may hurt the gut mucosa. Although rare, a gastric foreign body should be searched for in face of an upper gastrointestinal bleeding in an infant.

[Central nervous system tumor: an unusual etiology for limb pain]

Limb pain in children is one of the most frequent reasons to refer to the emergency unit. Most often it suggests an orthopaedic, a muscular, a peripheral neurologic or a spinal affection. We report two cases of recurrent limb pains revealing a central nervous system tumor.

Impotence fonctionnelle post-traumatique du membre inférieur de l’enfant

Injuries to the lower extremity are frequent. They present as pain, reduction of joint function, alteration in gait. Most of the orthopaedic emergencies for teenagers are related to trauma. For younger children, a history of recent fall is prevalent but the non traumatic orthopaedic conditions are especially important to investigate when the reported injury is minor or when onset of symptoms is delayed.

Recommandations concernant la mise en place, la gestion, l’utilisation et l’évaluation d’une salle d’accueil des urgences vitales pédiatriques

The pediatric resuscitation room is the place where children suffering from vital distress are cared for in the emergency unit. Recommendations for its organization, functioning and evaluation have been ruled on by experts from six medical societies involved in these emergencies. They concern all the hospital's physicians, nurses and administrative directors.

Analgésie aux urgences pédiatriques

Pain concerns more than 50% of the children cared in the emergency unit. After evaluation, it has to be cured with drugs adapted to its level and its origin. Residual pain needs therapeutic adjustment. The goal is to allow the child to restart his activities. A preventive sedation analgesia is necessary when a painful exam is to be performed, either for diagnosis or therapeutic purpose. For this goal ideal analgesics, either for monotherapy or associated, are easily and painlessly administered. They have rapid onset of action, brief half-life, predictable, effective analgesic properties without side effects and they are quickly reversible. These drugs do not exist and every sedation procedure has a risk of hypoxemia. With the human and equipment's investment an emergency department should be able to ensure that procedures are performed in children under sedation with a standard of safety that is similar to general anaesthesia. The main drawback in a well-organised system should be a significant children's rate for which general anaesthesia is preferred.

[Angelman syndrome: clinical and genetic model]

Angelman syndrome is a neurogenetic disorder characterized by developmental delay, absence of speech, motor impairment, epilepsy and a peculiar behavioural phenotype associated with abnormalities of chromosome 15q11-13. Precise diagnosis carries clinical and genetic counseling implications. However, many clinicians still seem unfamiliar with it despite the severity and typical aspects of presentation. Beyond individual situations, Angelman syndrome can serve as a model opening broad questioning of genetic and epigenetic influences in neurology, as well as of several concepts such as psychomotor development, cerebral palsy, behavioural phenotypes and epileptic syndromes. Recent advances in molecular biology and animal models of the syndrome provide new data which must be included in our interpretation of Angelman syndrome.

[Smoking and sudden infant death syndrome]

Assessment of the causation relationship between two phenomena requires the demonstration of an epidemiological association, a temporal and asymmetric sequence, and a biological gradient and identification of the biological mechanism(s). All epidemiological studies on sudden infant death syndrome (SIDS) and smoking have encountered major bias and difficult data interpretation but they all have estimated that maternal smoking caused a 2 to 3-fold increased risk of SIDS. Nicotine may interact with non-neuronal nicotinic receptors in the lung, peripheral nicotinic cholinergic and adrenergic chemoreceptors, and brainstem nuclei and has been largely studied. More accurate knowledge concerning the biochemistry and specific features of nicotinic receptors will be useful to explain the way nicotine alters breathing at rest and during hypoxia. Uncertainty about the casual relationship in no way means the fight against smoking is not warranted.

[Mucolytic agents for acute respiratory tract infections in infants: a pharmacoepidemiologic problem?]

OBJECTIVE

To study the use of mucolytics agents, i.e. acetylcystein and carbocystein, in infants. To evaluate their efficacy and safety for their main indications.

METHODS

A prospective one-day survey of prescriptions among 95 office-based pediatricians. A systematic review of the literature.

RESULTS

Among 1327 prescriptions regarding infants, 4.3% were mucolytics agents. Main indications were rhinopharyngitis, isolated cough, and acute bronchitis. Our review did not identify any study of rigorous methodological quality that supported the efficacy or safety of mucolytics agents in infants for their in-label (isolated cough, acute bronchitis) and off-label (rhinopharyngitis) indications. Six cases of infants, aged less than eight months, presenting paradoxical bronchial congestion during a treatment with mucolytics agents, have been reported to the French pharmacovigilance system. No causal relationship was established from these cases because of a possible protopathic bias.

DISCUSSION

Our results concerning mucolytics agents use are similar to those reported by the French Health Care Funds. In addition to the lack of studies on efficacy, no studies on the dose-response relationship were available, leading to suggested dose regimens in the French license of acetylcystein ranging from 44.4 to 16.4 mg kg-1 j-1 between one to 24 months. These dose regimens could predispose to overdosing in the youngest infants as it seems observed in the six reported cases.

CONCLUSION

In infants, mucolytics agents efficacy has never been demonstrated and some elements suggest poor safety (paradoxical bronchial congestion).

[Effect of racecadotril in the management of acute diarrhea in infants and children]

BACKGROUND

The treatment of diarrhoea relies on the maintenance or restoration of hydration with maintenance of an adequate nutritional intake. Racecadotril has been shown to reduce the stools output during acute diarrhoea. The present work was aimed at measuring the number of emergency department visits for acute diarrhoea either the children received racecadotril or not.

METHOD

Racecadotril and rehydration were compared with rehydration alone in children aged three months to three years who had acute diarrhoea and were evaluated in the emergency department (ED). The primary end point was the number of medical exams during the week after starting treatment. Secondary end points were the number of stools during the first 48 hours, the duration of the diarrhoea and the weight on day 7.

RESULTS

One hundred and sixty-six children were alternatively randomized to the treated and the control groups. There was no difference for age, degree of dehydration and length of illness before the first visit between the groups. Whatever type of rehydration (oral or i.v.), the treated group had a significant lower number of stools (p < 0.001) and a faster recovery (p < 10(-9)). The children receiving racecadotril needed less additional ED visits for the same episode (p < 0.05). There was no difference for the weight-gain on day 7.

CONCLUSIONS

This study demonstrates the efficacy of racecadotril as adjuvant therapy to oral and i.v. rehydration in the treatment of acute diarrhoea and a fewer emergency department second visit before recovery.

[Benefits of ipratropium bromide in the management of asthmatic crises in the emergency department]

BACKGROUND

To determine if the addition of ipratropium bromide in the emergency department (ED) for the treatment of childhood asthma reduces rates of hospitalization and relapses for moderate and severe exacerbations.

METHODS

Patients were given an oral corticosteroid treatment (2 mg/kg) and received every 20 minutes either three nebulizations with albuterol (0.15 mg/kg) and ipratropium bromide (250 micrograms) or six nebulizations with albuterol alone (control group). The primary end point was the need for hospitalization, additional nebulizations or a relapse during the following week. Secondary end point included the effect of age.

RESULTS

One hundred and forty three children, two to 15 years old, were randomized to ipratropium or control groups and 121 were evaluated on day seven. As a whole, the control group was less often hospitalized or in relapse than those treated with three nebulizations of albuterol and ipratropium (17.5% vs 37.9%, p < 0.02). The ipratropium group reached the same result after three additional albuterol nebulizations. The benefit of anticholinergic therapy was observed for children less than six years of age who had a similar rate of success (73.5 vs 75.7%).

CONCLUSION

The association of ipratropium bromide to the first three doses of the albuterol protocol for acute asthma did not act as well as six nebulizations of albuterol alone. The effect was age dependent and two to six years old children needed more attention. Nevertheless the hospitalization rate did not support the use of ipratropium compared with repeated albuterol nebulizations.

[Drugs for pediatric emergencies]

Drugs for pediatric emergencies are useful for respiratory (croup, asthma), cardiologic (hypertensive crisis, acute congestive heart failure, arrhythmias, hypoxic spells), neurologic (seizures), metabolic (dehydration, hypoglycaemia), infectious (meningococcemia) or allergic (anaphylaxis) distresses. Pain management is always important whether to relieve or to prevent the discomfort which would happen during diagnosis or therapeutic procedures.

[Assessing the cost of the first episode of bronchiolitis]

BACKGROUND

Each year, a quarter of the children younger than 24 months has respiratory syncytial virus bronchiolitis. The morbidity among high-risk infants and the possible association with the development of asthma lead to propose preventive measures whose cost-effectiveness relationship is unknown. The present work was aimed at measuring costs of a first attack of bronchiolitis.

METHOD

For children less than two years visited in the emergency department, direct and indirect costs were measured according to the 'Sécurité Sociale' prices. Associated morbidity, the management of care (inpatient versus outpatient), outpatients' outcome two weeks after the visit, socioeconomic data were recorded.

RESULTS

One hundred eighty three children have been studied. The length of stay for 40 hospitalizations was 7.6 +/- 4.3 days. Direct costs were 37,200 +/- 22,000 FF for inpatients, and 1286 +/- 633 F for outpatients. For 113 outpatients' families, indirect costs were 49 working days lost. The way the child was looked after and the unemployment rate in the study were similar to data provided by the National Institute of Statistics and Economic Studies.

CONCLUSION

Because of the variability of the hospitalization rate from one setting to another, overall costs of the epidemic cannot be evaluated. For the policymaker, the greatest costs come from the outpatient care. Others studies will be necessary to evaluate the price of future preventive measures.

Off label and unlicensed drug use among French office based paediatricians

AIMS

To determine the extent of off label and unlicensed drug use in French office based paediatric practice.

METHODS

A prospective one day survey of all written prescriptions, for patients under 15 years, among 95 office based paediatricians in the Paris, France metropolitan area. Main outcome measures were: comparison of the use of each drug with its product licence for age, indication, dose, and route of administration.

RESULTS

A total of 2522 prescriptions were administered to 989 patients; 844 (33%) were used either in an unlicensed (4%) or an off label (29%) manner. A total of 550 (56%) paediatric patients received one or more off label prescriptions.

CONCLUSIONS

Off label prescriptions (that is, outside the terms of the Summary of Product Characteristics) are widespread in office based paediatric practice, while unlicensed drug use is rare in our study. New regulations in the licensing process in Europe are needed to allow children to receive drugs that have been fully evaluated in their specific age group.

[Infant diseases]

Apparent life-threatening events in an infant require: 1/ to determine the seriousness of the event; 2/ to identify its etiology; 3/ to evaluate the risk of recurrence and the need for appropriate preventive measures. Management mainly depends upon the determination of the etiology and the understanding of the pathogenetic mechanism. Gastroesophageal reflux is the main etiology. Therefore whenever symptoms of gastroesophageal reflux are present, this has to be considered as the first etiological hypothesis. Other etiologies will be searched for if orientating symptoms or anamnesis information is present, leading to specific investigations.