French national diagnostic and care protocol for Kawasaki disease

Kawasaki disease (KD) is an acute vasculitis with a particular tropism for the coronary arteries. KD mainly affects male children between 6 months and 5 years of age. The diagnosis is clinical, based on the international American Heart Association criteria. It should be systematically considered in children with a fever, either of 5 days or more, or of 3 days if all other criteria are present. It is important to note that most children present with marked irritability and may have digestive signs. Although the biological inflammatory response is not specific, it is of great value for the diagnosis. Because of the difficulty of recognising incomplete or atypical forms of KD, and the need for urgent treatment, the child should be referred to a paediatric hospital as soon as the diagnosis is suspected. In the event of signs of heart failure (pallor, tachycardia, polypnea, sweating, hepatomegaly, unstable blood pressure), medical transfer to an intensive care unit (ICU) is essential. The standard treatment is an infusion of IVIG combined with aspirin (before 10 days of fever, and for a minimum of 6 weeks), which reduces the risk of coronary aneurysms. In case of coronary involvement, antiplatelet therapy can be maintained for life. In case of a giant aneurysm, anticoagulant treatment is added to the antiplatelet agent. The prognosis of KD is generally good and most children recover without sequelae. The prognosis in children with initial coronary involvement depends on the progression of the cardiac anomalies, which are monitored during careful specialised cardiological follow-up.

A rare chest tumor in a 7-year old girl with a neurodegenerative disease

We report the case of a 7-year-old girl with a history of San Filippo disease who presented with gingivitis and painful chest tumefaction. Microbiology of this tumefaction identified Aggregatibacter actinomycetemcomitans (AA), a slowly growing, commensal, Gram negative bacillus that is a very unusual cause of thoracic infection. We discuss this case in the light of available literature of pediatric cases of AA thoracic infection. Conclusion: a tumor-like chest mass in a patient with multiple disabilities should evoke an invasive AA infection.

Real-life requests for Bordetella polymerase chain reaction testing in children presenting to hospital

From 2015 to 2017, 3197 interpretable Bordetella polymerase chain reaction (PCR) tests were performed for 2760 children presenting to our tertiary university hospital. Requests mainly came from the emergency department (62%) and for children older than 1 year (68%). Only 32 PCR (1%) results were positive, mainly in children younger than 1 year (n = 29/32, 90.6%; p<0.001). When focusing on the PCR indications in 2017, we found the requests were mainly based on nonspecific respiratory symptoms and were clinically unjustified in 383 cases (39%). Pediatricians overused Bordetella PCR in clinical practice. They should reserve their requests for cases of young children with symptoms suggestive of respiratory illness and/or incomplete pertussis immunization.

Judicial handling of cases of non-accidental head trauma in infants: Review and analysis of expert assessments

INTRODUCTION

Good practice guidelines help clinicians to establish a suspected diagnosis of non-accidental head injury (NAHI) and help forensic experts to establish a level of certainty for the diagnosis. The objective of this study was to assess how the French Health Authority (HAS) guidelines contribute to the process of producing an expert assessment, on causation and certainty in cases of suspected NAHI.

METHOD

A retrospective study was conducted of the expert assessments that were conducted by a paediatric surgeon and forensic expert attached to our local court between 2002 and 2018, with the aim of determining the causal mechanism of the lesions and express a degree of certainty regarding the diagnosis.

RESULTS

In our study, we found that, despite the HAS guidelines, a number of documents deemed essential for the forensic expert were sometimes missing, and that, by applying these guidelines, the decisions reached in some expert assessments could been reclassified and certain factors formerly described as risk factors for injury could be excluded. A precise dating of the traumatic event was proposed in half of cases.

CONCLUSION

Our study highlights the vital role of the HAS guidelines, not only for patient management but also to ensure high-quality expert assessments. Unfortunately, guidelines were not yet being properly adhered to by medical teams.

Real-life study of the role of high-flow nasal cannula for bronchiolitis in children younger than 3 months hospitalised in general pediatric departments

We aimed to describe the real-life role of high-flow nasal cannula (HFNC) for bronchiolitis in infants under 3 months of age admitted to three general pediatric departments during the 2017-2018 epidemic period. We retrospectively assessed the clinical severity (Wang score) for every 24-h period of treatment (H0-H24 and H24-H48) according to the initiated medical care (HFNC, oxygen via nasal cannula, or supportive treatments only), the child's discomfort (EDIN score), and transfer to the pediatric intensive care unit (PICU). A total of 138 infants were included: 47±53 days old, 4661±851.9 g, 70 boys (50.7%), 58 with hypoxemia (42%), Wang score of 6.67±2.58, 110 (79.7%) staying for 48 consecutive hours in the same ward. During the H0-H24 period, only patients treated with HFNC had a statistically significant decrease in the severity score (n=21/110; -2 points, P=0.002) and an improvement in the discomfort score (n=15/63; -3.8 points, P<0.0001). There was no difference between groups during the H24-H48 period. The rate of admission to the PICU was 2.9% for patients treated for at least 24 h with HFNC (n=34/138, 44% with oxygen) versus 16.3% for the others (P=0.033). Early use of HFNC improves both clinical status and discomfort in infants younger than 3 months admitted for moderately severe bronchiolitis, whatever their oxygen status.

Severe adenovirus pneumonia with hemophagocytic syndrome and respiratory failure

We report the case of an 18-month-old infant with severe serotype 3 adenovirus pneumonia, exceptionally associated with hemophagocytic syndrome. Treatment included cidofovir and mechanical ventilation for 13 days. The child developed chronic respiratory insufficiency due to bronchiectasis and bronchiolitis obliterans.

[Pseudomonas aeruginosa in post-piercing perichondritis: Two case reports]

The frequency of body piercing has increased in France over the past few years, particularly among teenagers. Piercing can be performed at different sites on the body, especially in the cartilage of the ears. We relate two cases of Pseudomonas aeruginosa chondritis. A 10-year retrospective study at the Marseille University Hospital found no additional pediatric cases. These infectious complications can sometimes be necrotizing. It is therefore important to inform the medical staff on the hygiene measures that need to be respected and the patients on the treatment to follow after the piercing as well as the signs to watch for, possibly indicating chondritis. The esthetic consequences depend on early diagnosis.

[Complementary exams in child abuse: A French national study in 2015]

INTRODUCTION

Even if there are HAS (French National Health Authority) guidelines on shaken baby syndrome, many other child abuse situations are not included in these recommendations. The aim of this study was to invent the complementary exams in cases of child abuse in France and compare the practice to existing guidelines.

MATERIAL AND METHODS

This was a multicenter study by email to 128 French hospitals (35 university hospitals and 93 general hospitals) that receives children in emergency and hospitalization settings. Three child abuse clinical situations were included in a clinical case multiple-choice format concerning the further explorations. We described the main results and evaluated their adherence to the HAS protocol for case 1.

RESULTS

Of 128 hospitals surveyed, 104 responded, for an 81 % response rate, which corresponded to 274 doctors. Analysis of the results showed great heterogeneity in practices. The majority of physicians (99 %) performed systematic explorations in the situation of physical abuse, while only 27 % undertook such exams in situations of serious neglect. The situation of sexual abuse was the most consensual in terms of diagnostic tests for the detection of sexually transmitted diseases, but other types of associated abuse were not sought. In the first case, the HAS guidelines were respected in less than half of the cases for all complementary exams except the eye fundus exam. Abdominal imaging was insufficiently performed (40 % of cases). Examinations that were not indicated were still prescribed. Moreover, siblings under 2 years of age were examined in only one-third of cases (n=88/274; 32 %). Practices were not influenced by the age of the child.

CONCLUSION

This study illustrates the heterogeneity in the use of complementary exams in cases of child abuse in France. Common protocols throughout the country would be useful, standardizing the most relevant exams for potential medical-legal issues, and facilitating exchanges concerning practices between different centers.

[Motivations for a consultation before adoption: A multicenter study]

INTRODUCTION

While the number of international adoptions in France is decreasing, adopted children are older and in poorer health than they used to be. This phenomenon has resulted in an increase in the demand for preadoption consultations over the past several years. This study analyses the reasons for these consultations.

METHOD

Prospective multicenter study conducted from 1 January to 31 December 2013.

RESULTS

Ten centers contributed to the study, i.e., 196 preadoption consultations. Seeking medical advice was the reason for 88% of the consultations, whether the advice was based on the study of an identified child's medical file (32%) or a country's healthcare characteristics, whether the country was identified (34%) or not (23%). In 6% of cases, the motive for preadoption consultations was social and familial, and in the last 5% it was to obtain general information about adoption and its procedures. In more than 40% of the cases, whether the child or the country identified, Russia is the subject of the consultation because of the complexity of the files and because of the dreaded but rarely mentioned fetal alcohol syndrome.

CONCLUSION

The deterioration of adopted children's health is an additional worry for future adoption applicants. To provide them with the best information possible without making choices for them, specialists should have substantial experience in adoption before going into these preadoption consultations.

[Study of reports to the departmental home of disabled children placed in social assistance to children in the Bouches-du-Rhône]

INTRODUCTION

By the end of 2011, 275,000 children in France were included in the Aide sociale à l'enfance (ASE, Child Welfare System). Half of these children were entrusted to public care. There is limited data on these children. The MDPH (Maison départementale des personnes handicapées) is an administrative body assisting in the care of disabled children, through material, financial, and human means. Analyzing MDPH medical records can provide medical information about these children. The aim of this study was to describe the characteristics of children left to the ASE with a record at MDPH in Bouches-du-Rhône.

METHODS

We extracted administrative data from two registers, the ASE register and the MDPH register. The MDPH medical files of each patient were analyzed and their medical information was coded: gestational age, deficiencies, and pathologies.

RESULTS

In Bouches-du-Rhône, 2965 children were entrusted, 506 (17%) of whom were known by the MDPH: 30.6% of the entrusted children known by MDPH were taken into foster care and 48% were in residential group homes. Half of the MDPH notifications concerned a referral to a school or medico-social institution. By analyzing the medical data, we observed an average of 2.1 deficiencies per child. The types of deficiencies were distributed as follows: 35.9% were psychological deficiencies, 26.4% were speech deficiencies, and 21.6% were intellectual cognitive deficiencies. The most common pathology was mental and behavioral disorder (71% of diagnoses).

DISCUSSION

The MDPH notification rate in children entrusted to public care was seven times higher than in the general population. Overall, explaining the relation between child abuse and neglect and disability is difficult. The psychopathology of these children is complex. These results show the importance of specific medical monitoring for these children.

[Bronchiectasis revealing triple A syndrome]

We report on the case of a 3-year-old child presenting bilateral bronchiectasis due to recurrent pneumonia with esophageal achalasia. The final diagnosis was triple A syndrome. This presentation is particularly atypical and rare at this age.

[Acute bronchiolitis and chest physiotherapy: the end of a reign]

Every winter, numerous infants are hospitalized for acute bronchiolitis. The severity criteria and symptomatic treatment are well known, with chest physiotherapy codified in 2000 by the French Health Authority (HAS) consensus conference (with techniques varying from one country to another) and becoming nearly systematic for the treatment of bronchial obstruction in infants. However, is this treatment really effective and legitimate for acute bronchiolitis? The objective of this study was to review the main studies on this subject. Few studies are available and most have a low level of evidence. However, they all tend to agree that chest physiotherapy does not change the natural history of the disease and most particularly the duration of hospitalization. Therefore, it does not seem that the prescription of chest physiotherapy in infant acute bronchiolitis is recommended.

[Scurvy, an old disease still in the news: two case reports]

Scurvy is the clinical manifestation of a deficiency in vitamin C, which is present in fresh fruits and vegetables. It is historically linked to the era of great maritime expeditions. Manifestations are misleading in children, in contrast with adults: bone disease and hemorrhagic syndrome are the earliest and most frequent manifestations due to a collagen biosynthesis defect. Scurvy is an old, potentially fatal disease but is easily curable with ascorbic acid. It can be prevented with vitamin C treatment in pediatric populations with unusual eating habits. We describe two cases of pediatric scurvy in two 7-year-old boys who had dietary restrictions stemming from developmental disorders.

[Value of routine identification of respiratory infectious agents in children hospitalized with an acute asthma exacerbation]

Introduction

Chez l’enfant les exacerbations d’asthme sont le plus souvent déclenchées par une infection respiratoire. L’objectif de cette étude était d’évaluer l’intérêt de l’identification des pathogènes respiratoires chez les enfants hospitalisés pour une exacerbation d’asthme.

Patients et méthodes

Il s’agit d’une étude rétrospective incluant tout enfant hospitalisé pour une exacerbation d’asthme dans notre unité entre janvier 2010 et décembre 2011 et analysant la prescription des examens microbiologiques, leurs indications, leur rendement, leur impact sur la prise en charge médicale et leur coût.

Résultats

Cent quatre-vingt-dix-sept enfants ont été inclus. Une recherche d’agent pathogène respiratoire avait été réalisée chez 157 enfants (79,7 %), surtout en cas d’infection oto-rhino-laryngologique (ORL), d’hypoxémie ou de pneumonie. Un virus avait été identifié chez 30 (23,8 %) des 126 enfants prélevés. Les analyses bactériologiques avaient eu un rendement faible puisque seulement 3,2 % des analyses par amplification génique (PCR) pour Mycoplasma pneumoniae avaient été positives (n = 4/125). Aucune autre bactérie n’avait été identifiée. Aucun lien n’a pu être établi entre les résultats microbiologiques et la gravité de l’exacerbation. La prise en charge thérapeutique avait été peu modifiée par ces résultats. Le coût global avait été de plus de 40 400 euros pour les 2 ans d’étude.

Conclusion

D’après nos résultats la recherche de pathogènes respiratoires au cours des exacerbations d’asthme a un intérêt modéré en dehors de l’aspect épidémiologique. L’impact du rhinovirus, du coronavirus, du bocavirus et de l’entérovirus, non recherchés en routine hospitalière, reste cependant à préciser.

[Infections of central venous catheters in home parenteral nutrition: a retrospective monocentric study over 2 years]

BACKGROUND AND STUDY AIMS

Infection of the central venous catheter (CVC) is the main aggravating factor of parenteral nutrition. The aim of this study was to determine the ecology of these infections in our home parenteral nutrition center and to evaluate our care protocol.

PATIENTS AND METHODS

The present study was monocentric and retrospective, and was conducted in the parenteral nutrition service of the Marseille University Hospital between 1 January 2011 and 31 May 2012. During this period, all the children who presented fever and a positive hemoculture in a medical emergency were taken into account, and the characteristics of the infection were analyzed.

RESULTS

After 17 months, 17 children had been subject to an infection in their central catheter: 47 bacteremia were identified, which is equivalent to 5.4 infections for 1000 days of CVC. An average 2.8 hemocultures were performed during this time. The most common bacterium was Staphylococcus hominis. The children affected by a digestive stoma or by a gastrostomy were not subject to more infections and their ecology was not different. All the children were referred to the hospital and treated with an intravenous antibiotic through the CVC.

DISCUSSION

As expected during the time of the study, the infection rate was very high. This finding led us to reassess our prevention protocol. It is also very likely that the number of infections was overestimated due to the protocol for sampling in the hemocultures and their subsequent analysis. Lastly, some children relapsed easily, although no predisposing factor was found in the present study. The therapy chosen was in agreement with the best practices and the ecology recovered.

CONCLUSION

The high number of infections observed during the study encourages a prospective evaluation of current practices.

[Children and air travel: national survey results]

Airplanes are widely used by families and their children and pediatricians are increasingly asked to answer questions on this subject. The main purpose of this study was to evaluate the knowledge of pediatricians in this field except for medical transportation. Pediatricians belonging to the AFPA, the SFP, the SNPEH, or the SP2A were emailed a questionnaire on the physiological particularities of airborne transportation, contraindications to flight related to diseases (infections, diabetes, sickle-cell anemia, respiratory diseases, etc.) and the possible medication intake on board. Among the 232 responders, 82.3% had an exclusive hospital practice and 65% were specialized in more than one area of medicine. Regarding contraindications to flying, the rate of correct answers varied from 14 to 84% with divided opinions regarding respiratory and hematological pathologies. However, contraindications related to infections were well known. Items related to oxygen therapy raised questions as 35-68% of pediatricians stated that they could not answer. On the whole, this work demonstrated very fragmented knowledge on this topic.

[Clustered cases of intrafamily invasive Streptococcus pyogenes infection (or group A streptococcus)]

Streptococcus pyogenes or group A streptococcus (GAS) is responsible for serious invasive infections with a risk of secondary infection in patients with more contact than in the general population. Regardless of clustering, few intrafamilial invasive infections have been reported despite a recent increase in the incidence of invasive GAS disease. We report the cases of two brothers, one a boy of 8.5 years with toxic shock syndrome with no bacteria identified and the second, 1 week later, his 14.5-year-old brother in hospital for sepsis due to GAS. The occurrence of a confirmed case of invasive GAS and a probable case within such a short period met the definition of clustered cases. Both brothers showed no risk factors for invasive disease and no gateway including skin was found. Antibiotic therapy was initiated in the family as recommended by the French Higher Council of Public Hygiene.

[Amanita proxima poisoning in a child]

Mushroom intoxication due to Amanita proxima poisoning is characterized by moderate gastrointestinal symptoms, followed by severe acute renal failure and sometimes by hepatic cytolysis. This syndrome was described in the 1990s in the southeast of France; we report here the first pediatric case, requiring dialysis but achieving complete recovery. The mother of this 11-year-old boy, who had eaten the same mushrooms but in smaller quantities, had only biological renal and hepatic involvement.

Management of young children in contact with an adult with drug-resistant tuberculosis, France, 2004-2008

SETTING

Drug-resistant tuberculosis (DR-TB) is increasing worldwide and may be a source of diagnostic and therapeutic problems in young exposed children. In France exposed children are systematically treated with 3-month isoniazid-rifampicin prophylaxis.

OBJECTIVE

To describe the characteristics and management of children aged <2 years in contact with an adult case of DR-TB in France over a 5-year period (2004-2008).

METHODS

Children were retrospectively identified by sending questionnaires to all the members of the Paediatric Infectious Diseases Group and the Paediatric Pulmonology Group of the French Paediatric Society.

RESULTS

Ten children, all infants, in contact with an adult case of DR-TB were identified: six cases of DR-TB (mean age 4.6 months), one case of TB infection and three cases of exposure (mean age 3.1 months). The children were mainly in contact with poly- or multidrug-resistant TB. Time to initiation of appropriate treatment was 39 days for TB disease and 58 days for TB infection or exposure. One child with TB infection developed TB disease due to failure to adapt prophylaxis. Treatment was variable and centre-dependent. Short-term follow-up showed complete recovery of all children.

CONCLUSION

Management of young children in contact with adult DR-TB requires rapid identification of the drug resistance profile. Molecular techniques should be used to reduce delays in initiating appropriate treatment.

[Respiratory complications of accidental drownings in children]

Accidental drownings are severe and sometimes mortal events in children. Our study aims to better clarify the epidemiology and the respiratory complications of these accidents in our hospital. We led a retrospective study over 10 years concerning the children hospitalized for accidental drowning in our hospital centre. Age at the moment of the accident, sex, history of accident, hospitable care, thoracic imaging and neurological outcome of the children were studied. In total, 83 children were hospitalized (5 years on average, 70% being boys). The drowning especially took place in fresh water (71%), particularly in swimming pools (51.8%). Stages III and IV of drowning concerned 40.9% of the population. The coverage was the following one: admittance in ICU 57.8%, mechanical ventilation 34.9%, oxygen therapy 16.9%, antibiotics 87.9%. A normal chest x-ray was present in 45.7% of the cases. Drowning in fresh water, especially in contaminated fresh water (canal, WC, etc.), induced atelectasis (10.8%), whereas drowning in sea water induced diffuse infiltrates (8.4%). Aspiration pneumonia (33.7%) was present in both cases and a pulmonary oedema (6%) was only noticed during stage IV drowning. The secondary infections were rare (1 case was suspected and another probable). A child presented a secondary acute respiratory distress syndrome (1.2 %). Finally, 7 deaths (8.4%) and 1 case with severe neurological sequelae (1.2%) were noted. Accidental drowning causes important consequences in children. The long-term respiratory outcomes have not been properly studied. Prevention of such accidents is based on parental vigilance during their child's bathe.

[Pneumonia with empyema during varicella]

Chicken pox is usually considered a benign viral affection; however, possible infectious complications are observed. Although cutaneous infections are well described, bacterial pneumonia with empyema is more exceptionally reported.

PURPOSE

To describe the clinical characteristics of bacterial pneumonia with empyema associated with chicken pox.

METHODS

This descriptive multicenter retrospective study was based on a questionnaire sent by Internet to 30 French pediatric and pediatric respiratory hospital wards.

RESULTS

We found 4 cases of children (mean age, 19 months) presenting during the chicken pox eruption concomitant bacterial pneumonia with empyema. The average time of diagnosis was 4.5 days after the beginning of the eruption. All the children were febrile and had an average pulsed oxygen saturation of 87%. The inflammatory syndrome was constant with a mean C reactive protein of 253 mg/l. Group A Streptococcus was identified in 3 cases out of 4. Admission to an intensive care unit was necessary for 3 children, 1 of them requiring mechanical ventilation. No clinical or radiological sequelae were observed during the complete year of follow-up.

CONCLUSION

Bacterial pneumoniae with empyema are not current complications of chicken pox but have to be sought when prolonged fever and/or alteration of the health status occurs during chicken pox eruption.

[The effects of tobacco on children]

INTRODUCTION

Smoking remains an important topic. It is estimated that at present half the children born in France have been, or will be, exposed to the toxic effects of passive smoking. This paper aims to review the evidence of the effects of passive smoking, both intra and extra-uterine.

STATE OF THE ART

Extra-uterine passive smoking is implicated in numerous respiratory (asthma, allergy, infections...) and non respiratory diseases (neoplastic, dental, ophthalmic, digestive, cardio-vascular and infective). Intra-uterine exposure is even more dangerous and leads to abnormalities of the pregnancy (placental abnormalities, prematurity...), of the foetus (behavioural problems, malformations) and long term problems for the unborn child. Passive smoking is responsible for pulmonary morphological abnormalities (pulmonary hypoplasia, reduction in elasticity, increased deposition of collagen and alteration of alveolar structure) and functional disorders (reduced compliance, increased airways resistance, bronchial hyperreactivity). Finally it causes a disturbance of respiratory control, promoting all the factors responsible for sudden cot death.

CONCLUSIONS

The ill effects of passive smoking fully justify efforts to inform and persuade the medical profession of its duty to fight this scourge.

[Nebulized drugs: the evolution?]

The revival of nebulization as a drug delivery route is real. The current delivery systems respond to the new European norms, the new mesh-vibrating nebulizers allow delivering drugs more quickly, other nebulizers, more performant because of less drug losses and of a better lung deposition of the drug, are in progress. Only 12 drugs are commercialized for nebulization. All are available in dispensaries, some requiring a first prescription by a physician working in a hospital (cystic fibrosis drugs), others requiring a prescription from only some specialists as paediatricians or pulmonologists (bronchodilators). Works are in progress concerning the diameter and shape of the drug particles (nanotechnology) and also concerning the use of nebulized drugs for a systemic effect (vaccines, insulin, cyclosporine, anticancerous agents, etc.).