Analysis of mandibular jaw movements to assess ventilatory support management of children with obstructive sleep apnea syndrome treated with positive airway pressure therapies

BACKGROUND

The polysomnography (PSG) is the gold-standard for obstructive sleep apnea (OSA) syndrome diagnosis and assessment under positive airway pressure (PAP) therapies in children. Recently, an innovative digital medicine solution, including a mandibular jaw movement (MJM) sensor coupled with automated analysis, has been validated as an alternative to PSG for pediatric application.

OBJECTIVE

This study aimed to assess the reliability of MJM automated analysis for the assessment of residual apnea/hypopnea events during sleep in children with OSA treated with noninvasive ventilation (NIV) or continuous PAP (CPAP).

METHODS

In this open-label prospective non-randomized multicentric trial, we included children aged from 5 to 18 years with a diagnosis of severe OSA. The children underwent in-laboratory PSG with simultaneous MJM monitoring and at-home recording with MJM monitoring 3 months later. Agreement between PSG and MJM analysis in measuring the residual apnea-hypopnea index (AHI) was evaluated by the Bland-Altman method. The treatment effect on residual AHI was estimated for both PSG and MJM analysis.

RESULTS

Fifteen (60% males) children were included with a median age of 12 years [interquartile range 8-15]. Two (17%) were ventilated with NIV and 13 (83%) with CPAP. There was a good agreement between MJM-AHI and PSG-AHI with a median bias of -0.25 (95% CI: -3.40 to +2.04) events/h. The reduction in AHI under treatment was consistently significant across the three measurement methods: in-laboratory PSG and MJM recordings in the laboratory and at home.

CONCLUSION

Automated analysis of MJM is a highly reliable alternative method to assess residual events in a small population treated with PAP therapies.

High-dose intravenous immunoglobulin versus albumin 4% in paediatric toxic shock syndrome: a randomised controlled feasibility study

PURPOSE

Toxic shock syndrome (TSS) is a rare disease responsible for significant morbidity and mortality. Intravenous immunoglobulin (IG) therapy in paediatric TSS could improve shock and organ failure, but more consistent efficacy and safety data are needed. Our objective was to determine whether a randomised clinical trial (RCT) assessing intravenous IG in TSS in children is feasible.

METHODS

We performed a multicentre, feasibility, double-blind RCT assessing efficacy of high-dose intravenous IG versus albumin 4% (control group) within the first 12 hours of shock onset. Included patients were aged above 1 month and below 18 years with suspected TSS and septic shock. Feasibility was assessed by measuring inclusion rate, protocol compliance and missing data regarding death and the Pediatric Logistic Organ Dysfunction-2 (PELOD-2) Score. Other secondary clinical outcomes were evaluated during hospital stay, at 60 day and 1 year.

RESULTS

28 patients, admitted in 6 paediatric intensive care units during 36 consecutive months and followed for 1 year, received the allocated treatment: 13 in intravenous IG group, 15 in control group. The median age was 10.6 years and the sex ratio was 1. Inclusion rate was above 50%, protocol deviations were below 30% and missing data regarding death and PELOD-2 Score below 10%. No difference concerning secondary clinical outcomes between groups was observed, and more adverse events were reported in the control group.

CONCLUSION

It seems to be feasible to conduct an RCT assessing intravenous IG efficacy and safety in paediatric TSS but must be realised internationally, with choice of a clinically relevant endpoint and a specific design in order to be realistic.

TRIAL REGISTRATION NUMBER

NCT02219165.

Weaning from noninvasive respiratory support in children in acute settings: Expert consensus statement using modified Delphi methodology

OBJECTIVE

To reach a consensus on the definition and modalities of weaning from noninvasive ventilation in acute settings.

DESIGN

A modified Delphi survey using closed and open-ended questions.

SETTING

Three rounds of consensus determination were sent via electronic mail survey to 33 experts. The survey questionnaire had four sections: definition of weaning, definition of weaning failure, criteria to initiate weaning, and modalities of weaning. Questions where agreement had been reached on round 1 were no longer part of the survey in rounds 2 and 3.

SUBJECTS

Twenty-five international experts from 10 countries.

MEASUREMENT AND MAIN RESULTS

Overall, this survey generated positive consensus from experts for 19/35 statements (9 with strong agreement and 10 with weak agreement) about weaning from noninvasive respiratory support. No negative consensus could be identified.

CONCLUSION

The clinical practice statements issued address important aspects of definition of weaning, definition of weaning failure, criteria to initiate weaning, and modalities of weaning in acute settings.

Medical management of vegetarian and vegan children in France: Medical practices and parents' perceptions

OBJECTIVES

Despite a significant increase in the prevalence of vegetarianism and veganism in children in France, data on the care pathway of these children are scarce. This study aimed to describe the characteristics of the medical follow-up of vegan/vegetarian children, to evaluate the medical practices, and to analyze the perceptions of parents.

MATERIALS AND METHODS

This was a double cross-sectional survey. One questionnaire was sent to parents of vegetarian/vegan children, and the other to French doctors (pediatricians or general practitioners).

RESULTS

A total of 241 vegetarian families responded to the study and nearly one quarter (n = 67, 28 %) were unsatisfied with the medical follow-up of their child. Parents considered that their child's diet was responsible for refusing a medical consultation in 11 % (n = 27) of cases. In almost one third of cases (n = 70, 29 %), participants declared that the doctor was unaware of their child's diet. Vitamin B12 supplementation was commonly used (n = 195, 81 %), mainly by self-medication, and laboratory testing was performed for 30 % (n = 72) of children. Regarding the questionnaire for doctors, most of the participants (n = 318/501, 63 %) reported having vegetarian/vegan children in their cohort. A few of them (n = 70, 14 %) declared they did not systematically screen for meat and fish consumption during consultations. Doctors caring for vegetarian/vegan children had 27 % correct answers to questions regarding the nutrition guidelines. Overall, 36 % of them (n = 117) systematically referred the child to a specialist.

CONCLUSION

The medical follow-up of vegetarian/vegan children in France is very heterogeneous. Parents and doctors alike stressed the need to develop reliable sources of knowledge. A systematic screening of the diet and a referral to a specialist could help to improve the management of vegetarian/vegan children.

ROX (Respiratory rate-OXygenation) index to predict early response to high-flow nasal cannula therapy in infants with viral bronchiolitis

INTRODUCTION

High-flow nasal cannula (HFNC) is commonly used as first step respiratory support in infants with moderate-to-severe acute viral bronchiolitis (AVB). This device, however, fails to effectively manage respiratory distress in about a third of patients, and data are limited on determinants of patient response. The respiratory rate-oxygenation (ROX) index is a relevant tool to predict the risk for HFNC failure in adult patients with lower respiratory tract infections. The primary objective of this study was to assess the relationship between ROX indexes collected before and 1 h after HFNC initiation, and HFNC failure occurring in the following 48 h in infants with AVB.

METHOD

This is an ancillary study to the multicenter randomized controlled trial TRAMONTANE 2, that included 286 infants of less than 6 months with moderate-to-severe AVB. Collection of physiological variables at baseline (H0), and 1 h after HFNC (H1), included heart rate (HR), respiratory rate (RR), fraction of inspired oxygen (FiO2 ), respiratory distress score (modified Wood's Clinical Asthma Score [mWCAS]), and pain and discomfort scale (EDIN). ROX and ROX-HR were calculated asSpO 2 FiO 2 RR $\frac{\left(\frac{{\mathrm{SpO}}_{2}}{{\mathrm{FiO}}_{2}}\right)}{\mathrm{RR}}$ and100 × ROX HR $100\times \frac{\mathrm{ROX}}{\mathrm{HR}}$ , respectively. Predefined HFNC failure criteria included increase in respiratory distress score or RR, increase in discomfort, and severe apnea episodes. The accuracies of ROX, ROX-HR indexes and clinical variable to predict HFNC failure were assessed using receiver operating curve analysis. We analyzed predictive factors of HFNC failure using multivariate logistic regressions.

RESULT

HFNC failure occurred in 111 of 286 (39%) infants, and for 56 (50% of the failure) of them within the first 6 h. The area under the curve of ROX indexes at H0 and H1 were, respectively, 0.56 (95% confidence interval [CI] 0.48-0.63, p = 0.14), 0.56 (95% CI 0.49-0.64, p = 0.09). ROX-HR performances were better but remained poorly discriminant. HFNC failure was associated with higher mWCAS score at H1 (p < 0.01) and lower decrease in EDIN scale during the first hour of HFNC delivery (p = 0.02). In the multivariate analyses, age and mWCAS score were were found to be independent factors associated with HFNC failure at H0. At H1, weight and mWCAS were associated factors.

CONCLUSION

In this study, neither ROX index, nor physiological variables usually collected in infants with AVB had early discriminatory capacity to predict HFNC failure.

What altitude is safe for infants? An expert panel survey

AIM

To assess advice given to parents who wish to travel to high altitudes with an infant and to provide guidance on this topic.

METHOD

Using an anonymous self-report survey online, we collected information on the advice provided by practitioners, who practice in mountain environments, to parents who wish to travel to altitude with an infant. General practitioners and pediatricians working in the French Alps were asked about the maximum allowable altitude for different ages and the specific recommendations given.

RESULTS

A total of 104 practitioners (39% general practitioners) responded to the study. Overall, to spend 1 day at altitude, practitioners recommended a median altitude of 1200, 1500, 1600, and 2000 m for infants under 1, 3, 12, and 24 months, respectively. Their main recommendations for infant protection focused on cold protection, increased hydration, and increased humidity level in the ambient air. Prevention of sudden infant death syndrome was essential according to the respondents. For infants with upper airway infection, most of the participants (90%, n = 94) recommended against traveling to altitude.

CONCLUSION

This survey revealed a certain consensus about the maximum travel altitude to be recommended for infants.

Carbapenem prescriptions: Compliance with guidelines in a pediatric hospital

BACKGROUND

This study aimed to describe the use of carbapenems in a pediatric tertiary center and to assess its compliance with national and local guidelines.

METHODS

This retrospective study focused on children who received at least one dose of carbapenems in a tertiary university hospital over a 1-year period (2019). The appropriateness of each prescription was assessed.

RESULTS

In total, 96 prescriptions were collected for 75 patients (median age 3 years [interquartile range, IQR: 0-9]). Most prescriptions were empirical (n = 77, 80%) and mainly concerned nosocomial infections (n = 69, 72%). At least one risk factor for extended-spectrum beta-lactamases was found in 48% (n = 46) of cases. The median duration of treatment with carbapenems was 5 days and it was over 7 days in 38% (n = 36) of cases. The use of carbapenems was considered appropriate in 95% (18/19) and 70% (54/77) of cases when therapy was guided by culture results or was empirical, respectively. De-escalation of carbapenem treatment within 72 h occurred in 31% (n = 30) of cases.

CONCLUSION

The use of carbapenems can be optimized in the pediatric population, even when the initial prescription for a carbapenem is considered appropriate.

Weaning from noninvasive ventilatory support in infants with severe bronchiolitis: An observational study

BACKGROUND

The aim of the study was to analyze the weaning success, the type of weaning procedures, and weaning duration in consecutive infants hospitalized in a pediatric intensive care unit over a winter season.

METHODS

A retrospective observational study was conducted in a pediatric intensive care unit in a tertiary center. Infants hospitalized for severe bronchiolitis were included and the weaning procedure from continuous positive airway pressure (CPAP), noninvasive ventilation (NIV), or high-flow nasal cannula (HFNC) was analyzed.

RESULTS

Data from 95 infants (median age, 47 days) were analyzed. On admission, 26 (27%), 46 (49%), and 23 (24%) infants were supported with CPAP, NIV, and HFNC, respectively. Weaning failed in one (4%), nine (20%), and one (4%) infants while supported with CPAP, NIV, or HFNC, respectively (p = 0.1). In infants supported with CPAP, CPAP was stopped directly in five patients (19%) while HFNC was used as an intermediate ventilatory support in 21 (81%). The duration of weaning was shorter for HFNC (17 h, [IQR: 0-26]) than for CPAP (24 h, [14-40]) and NIV (28 h, [19-49]) (p < 0.01).

CONCLUSIONS

The weaning phase corresponds to a large proportion of noninvasive ventilatory support duration in infants with bronchiolitis. The weaning procedure following a "step-down" strategy may lead to an increase in the duration of weaning.

Risk of admission to the pediatric intensive care unit for SARS-CoV-2 delta and omicron infections

BACKGROUND

The severity of SARS-CoV-2-related diseases in children remains unclear. This study aimed to describe the incidence of French pediatric intensive care units (PICUs) admissions with acute COVID-19, incidental positive SARS-CoV-2 test result, and multisystem inflammatory syndrome in children (MIS-C) during the delta and omicron variant periods.

METHODS

This study used the French PICU registry to obtain data on all patients admitted to 41 French PICUs diagnosed with acute COVID-19, incidental positive SARS-CoV-2 test result, or MIS-C between August 30, 2021, and April 20, 2022. Data regarding the total number of positive SARS-CoV-2 polymerase chain reaction results according to the type of variants were obtained from the French National Public Health Agency.

RESULTS

Of 745 children, 244 (32·8%) were admitted for acute COVID-19, 246 (33·0%) for incidental positive SARS-CoV-2 test results, and 255 (34·2%) for MIS-C. The incidence of each group was higher with delta than with omicron. The incidence rate ratios with the delta variant were 7·47 (95% CI, 4·22-13·26) for acute COVID-19, 4·78 (95% CI, 2·30-9·94) for incidental positive SARS-CoV-2 test results, and 10·46 (95% CI, 5·98-18·31) for MIS-C compared to the omicron variant. The median age was 66 (7·7-126·8) months; 314 (42%) patients had comorbidities. Patients with acute COVID-19 and incidental positive SARS-CoV-2 test results had similar proportions of comorbidities. No patient with MIS-C died, whereas the mortality rates in the acute COVID-19 and incidental positive SARS-CoV-2 test results groups were 6·8% and 3·8%, respectively.

CONCLUSIONS

The incidence of acute COVID-19, incidental positive SARS-CoV-2 test results, and MIS-C admitted to the PICU were significantly higher with the delta variant than with the omicron variant.

Post traumatic cerebral sinovenous thrombosis in children: A retrospective and multicenter study

CONTEXT

Cerebral sinovenous thrombosis (CSVT) is a rare but life-threatening condition in the pediatric population and there is no pediatric guidelines regarding anticoagulation for post traumatic CSVT.

OBJECTIVE

This study aims to describe a cohort of children with post traumatic CSVT and the use of anticoagulant therapy in this population.

METHODS

A multicenter retrospective study. Patients admitted with post traumatic CSVT in the six participating Pediatric Intensive Care Unit were included.

RESULTS

Overall, 29 patients (median age 8.2 years [IQR 4.8-14.6], n = 22 (76%) males) were included in the study (Table 1). CSVT was observed within the first 24 h after admission for a half of the patients (n = 14, 50%). Anticoagulation was initiated in 18 patients (62%). No patient received thrombolytic therapy or endovascular treatment. The presence of epidural hematoma was associated with the absence of anticoagulation (n = 0 versus n = 10, p = 0.003). One patient (3%) died of extracranial injury (not related with adverse event of anticoagulation) and in survivors, median Pediatric Overall Performance Category Outcome (POPC) score at discharge from PICU was 2 [IQR 2-4] (i.e., mild disability). Regarding the outcomes of patients, we found no association according to the anticoagulation status (p = 1). Overall, 23 patients (79%) had a follow-up cerebral imaging with a median delay of 42 days [IQR 6-63] after admission. CSVT was still seen in 9 patients (31%). We found no difference regarding the persistence of CSVT between patients according to the anticoagulation status (p = 0.36). The median duration of anticoagulant treatment was 58 days [IQR 44-91] and one patient (3%) experienced adverse event related to anticoagulation.

CONCLUSION

There were minimal adverse events in patients with post traumatic CSVT treated with therapeutic anticoagulation. However, the effect of anticoagulation on outcomes needs to be confirmed in further studies.

Systemic corticosteroids for the treatment of acute episodes of rhabdomyolysis in lipin-1-deficient patients

Mutations in the LPIN1 gene constitute a major cause of severe rhabdomyolysis (RM). The TLR9 activation prompted us to treat patients with corticosteroids in acute conditions. In patients with LPIN1 mutations, RM and at-risk situations that can trigger RM have been treated in a uniform manner. Since 2015, these patients have also received intravenous corticosteroids. We retrospectively compared data on hospital stays by corticosteroid-treated patients vs. patients not treated with corticosteroids. Nineteen patients were hospitalized. The median number of admissions per patient was 21 overall and did not differ when comparing the 10 corticosteroid-treated patients with the 9 patients not treated with corticosteroids. Four patients in the non-corticosteroid group died during a RM (mean age at death: 5.6 years). There were no deaths in the corticosteroid group. The two groups did not differ significantly in the number of RM episodes. However, for the six patients who had RM and occasionally been treated with corticosteroids, the median number of RM episodes was significantly lower when intravenous steroids had been administered. The peak plasma creatine kinase level and the area under the curve were or tended to be higher in patients treated with corticosteroids-even after the exclusion of deceased patients or focusing on the period after 2015. The median length of stay (10 days overall) was significantly longer for corticosteroid-treated patients but was similar after the exclusion of deceased patients. The absence of deaths and the higher severity of RM observed among corticosteroid-treated patients could suggest that corticotherapy is associated with greater survival.

Clinical practice guidelines: management of severe bronchiolitis in infants under 12 months old admitted to a pediatric critical care unit

PURPOSE

We present guidelines for the management of infants under 12 months of age with severe bronchiolitis with the aim of creating a series of pragmatic recommendations for a patient subgroup that is poorly individualized in national and international guidelines.

METHODS

Twenty-five French-speaking experts, all members of the Groupe Francophone de Réanimation et Urgence Pédiatriques (French-speaking group of paediatric intensive and emergency care; GFRUP) (Algeria, Belgium, Canada, France, Switzerland), collaborated from 2021 to 2022 through teleconferences and face-to-face meetings. The guidelines cover five areas: (1) criteria for admission to a pediatric critical care unit, (2) environment and monitoring, (3) feeding and hydration, (4) ventilatory support and (5) adjuvant therapies. The questions were written in the Patient-Intervention-Comparison-Outcome (PICO) format. An extensive Anglophone and Francophone literature search indexed in the MEDLINE database via PubMed, Web of Science, Cochrane and Embase was performed using pre-established keywords. The texts were analyzed and classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. When this method did not apply, an expert opinion was given. Each of these recommendations was voted on by all the experts according to the Delphi methodology.

RESULTS

This group proposes 40 recommendations. The GRADE methodology could be applied for 17 of them (3 strong, 14 conditional) and an expert opinion was given for the remaining 23. All received strong approval during the first round of voting.

CONCLUSION

These guidelines cover the different aspects in the management of severe bronchiolitis in infants admitted to pediatric critical care units. Compared to the different ways to manage patients with severe bronchiolitis described in the literature, our original work proposes an overall less invasive approach in terms of monitoring and treatment.

Factors associated with poor neurological outcome in children after abusive head trauma: A multicenter retrospective study

BACKGROUND

Abusive Head Trauma (AHT) remains the leading cause of brain injury in infants.

OBJECTIVE

This study aims to describe a cohort of patients with AHT and identify early risk factors associated with poor neurological outcome.

PARTICIPANTS AND SETTING

Children under one year old admitted to a Pediatric Intensive Care Unit (PICU) with a suspected or confirmed diagnosis of AHT were included. Neurological outcome was assessed by the Pediatric Overall Performance Category score (POPC) at discharge from the hospital and at two years of follow-up.

METHODS

A multicentre retrospective study was conducted over 8 years (from January 2012 to December 2020).

RESULTS

A total of 117 patients (mean age 4.3 (+/- 2.5) months, 61 % boys) from three PICUs were included. A total of 99 (85 %) patients completed a 2-year follow-up. Sixty-one (52 %) and 47 (40 %) children with AHT had a POPC (pediatric overall performance category) score ≥ 2 at discharge from ICU and discharge from hospital, respectively (meaning they had at least a moderate disability). Fifty-one (44 %) had a POPC score ≥ 2 at 2-year follow-up, including 19 patients (19 %) with severe disabilities. The main neurological disabilities were neurodevelopmental (n = 38, 35 %), hyperactivity disorder (n = 36, 33 %) and epilepsy (n = 34, 31 %). After analysis according to the hierarchical model, the occurrence of a cardiorespiratory arrest and a low Glasgow Coma Score at admission stand out as factors of poor neurological outcome.

CONCLUSION

This study highlights the wide range of neurological disabilities in children with AHT. Early and multidisciplinary follow-up is crucial to limit the impact of neurological disability.

Implementation of a nutritional supplementation program in a population of Cambodian children and its impact on statural growth

BACKGROUND

Stunting is a major health problem in low-income countries. We aimed to describe the implementation of a lipid-based nutrient supplement (LNS) program in a rural neighborhood in Cambodia and to assess its impact on statural growth.

METHOD

This was a before-after comparative study. The program was promoted by the Pédiatres du Monde (PDM) organization between 2011 and 2019 in six villages in a rural area in Cambodia. The supplementation program consisted of daily administration of LNS during the third semester of pregnancy for the mothers and then between 6 and 24 months of age for the toddlers. Anthropometric data of the children were recorded during PDM visits before and after the program implementation, which allowed us to compare child growth in the two groups: control and intervention groups. Primary outcome was height-for-age between 24 and 35 months of age.

RESULTS

Overall, 198 data were collected for children between 24 and 35 months of age in the control group. A total of 347 pregnant women were enrolled in the intervention phase. A total of 188 data were collected for children between 24 and 35 months of age in the intervention group. The mean height-for-age z-score in the population receiving LNS was higher than in the control group (-1.14 vs. -1.60, p < 0.001). There was no significant difference between the two groups regarding the weight-for-height z-score (WHZ; -1.11 vs. -1.26, p = 0.18) and children in the intervention group had a higher middle upper-arm circumference z-score (MUACZ; -0.75 vs.. -1.1, p < 0.001).

CONCLUSION

LNS supplementation significantly and increased the HAZ between 24 and 35 months of age. However, the fight against malnutrition is complex and needs intervention on multiple levels.

Prevalence and risk factors of discomfort in infants with severe bronchiolitis

AIM

The aim of this study was to assess the prevalence of discomfort in infants with severe bronchiolitis supported by noninvasive ventilation and to identify its potential risk factors.

METHODS

A single-centre retrospective observational study. Discomfort was assessed using the EDIN (Echelle de Douleur et d'Inconfort du Nouveau-né) scale.

RESULTS

Ninety-one infants (median age 34 days [Interquartile IQR 19-55], 52 (57%) boys) were included in our study. Overall, no patient had a mean EDIN score higher than 8 on Days 1, 2 and 3. On Days 1 and 2, patients supported by bilevel positive airway pressure (BiPAP) had a higher EDIN score compared with other patients (3.3 [SD 2.5] versus 2.6 [SD 2.2] on Day 1 and 2.9 (SD 2.1) versus 2.3 (SD 2.2) on Day 2, both p < 0.001).

CONCLUSION

Patients with severe bronchiolitis and supported by any type of noninvasive ventilation had a low degree of discomfort during the first 3 days of ICU stay. Patients requiring bilevel noninvasive ventilation appeared to have a higher degree of discomfort, while we found no correlation between the level of discomfort and the degree of respiratory distress.

Ultrasound assessment of gastric contents in children before general anaesthesia for acute appendicitis

There is increasing evidence that a minority of adults with acute appendicitis have gastric contents, posing an increased risk of pulmonary aspiration. This study aimed to evaluate the proportion of children with acute appendicitis who have gastric contents considered to pose a higher risk of pulmonary aspiration. We analysed point-of-care gastric ultrasound data routinely collected in children before emergency appendicectomy in a specialist paediatric hospital over a 30-month period. Based on qualitative and quantitative antral assessment in the supine and right lateral decubitus positions, gastric contents were classified as 'higher-risk' (clear liquid with calculated gastric fluid volume > 0.8 ml.kg^-1 , thick liquid or solid) or 'lower-risk' of pulmonary aspiration. The 115 children studied had a mean (SD) age of 11 (3) years; 37 (32%; 95%CI: 24-42%) presented with higher-risk gastric contents, including 15 (13%; 95%CI: 8-21%) with solid/thick liquid contents. Gastric contents could not be determined in 13 children as ultrasound examination was not feasible in the right lateral decubitus position. No cases of pulmonary aspiration occurred. This study shows that gastric ultrasound is feasible in children before emergency appendicectomy. This technique showed a range of gastric content measurements, which could contribute towards defining the risk of pulmonary aspiration.

Impact of the French National Lockdown on Admissions to 14 Pediatric Intensive Care Units During the 2020 COVID-19 Pandemic-A Retrospective Multicenter Study

Background: After the COVID-19 pandemic reached France in January 2020, a national lockdown including school closures was officially imposed from March 17, 2020, to May 10, 2020. Pediatric intensive care units (PICUs) admit critically ill infants, children and teenagers with severe acute conditions, in particular infectious and traumatic diseases. We hypothesized that PICU admissions would be considerably modified by the lockdown. Aims: The objectives of the study were to describe the type of admissions to French PICUs and to compare the occupation of PICU beds according to local epidemic conditions during the French national lockdown period, compared with the same period the previous year. Methods: We conducted a retrospective multicenter study in 14 French PICUs. All children aged from 7 days to 18 years admitted to one of the 14 participating PICUs over two 3-month period (March 1, 2020, to May 31, 2020 and March 1, 2019, to May 31, 2019) were included. Analysis was based on data extracted from the medicalized information systems program (a national database used in all French hospitals, into which all admissions and their diagnoses are coded for the purpose of calculating hospital funding). Each main diagnosis was reclassified in 13 categories, corresponding to normal PICU admissions. Results: We analyzed a total of 3,040 admissions, 1,323 during the 2020 study period and 1,717 during the same period in 2019. Total admissions decreased by 23% [incidence rate ratio (IRR) 0.77, 95% CI 0.71-0.83, p < 0.001], in particular for viral respiratory infections (-36%, IRR 0.64, 95% CI 0.44-0.94, p = 0.001). Admissions for almost all other diagnostic categories decreased, except intoxications and diabetes which increased, while admissions for cardiac and hemodynamic disorders were stable. Patient age and the sex ratio did not differ between the two periods. Median length of stay in the PICU was longer in 2020 [4 (IQR 2-9) vs. 3 (IQR 1-8) days, p = 0.002] in 2019. Mortality remained stable. Conclusions: In this large national study, we showed a decrease in the number of PICU admissions. The most severe patients were still admitted to intensive care and overall mortality remained stable.

Assessing gastric contents in children before general anesthesia for acute extremity fracture: An ultrasound observational cohort study

STUDY OBJECTIVE

Children with acute extremity fractures are commonly considered to be at risk of pulmonary aspiration of gastric contents during the induction of anesthesia. This study aimed to evaluate the proportion of such children with high-risk gastric contents using preoperative gastric ultrasound.

DESIGN

Prospective observational cohort study.

SETTING

Specialist pediatric center over a 30-month period.

PATIENTS

Children undergoing surgery within 24 h of an acute extremity fracture.

INTERVENTIONS

None.

MEASUREMENTS

According to preoperative qualitative and quantitative ultrasound analysis of the antrum in the supine and right lateral decubitus positions, gastric contents were classified as high-risk (clear liquid with calculated gastric fluid volume > 0.8 mL.kg^-1, thick liquid, or solid) or low-risk. Factors associated with high-risk gastric contents were identified by multivariable analysis.

MAIN RESULTS

Forty-one children (37%; 95% CI: 28-47) of the 110 studied (mean(SD) age: 10(3) years) presented with high-risk gastric contents, including 26 (24%; 95% CI: 16-33) with solids/thick liquid contents. Scanning in the supine position alone allowed a diagnosis of high-risk gastric contents in 23 children out of the 63 for whom right lateral decubitus positioning was unfeasible. Gastric contents remained undetermined in 41 children, including one with a non-contributory gastric US (antrum non-visualized). Proximal limb fractures (OR: 2.5; 95% CI: 1.0-6.2), preoperative administration of opioids (OR: 3.9; 95% CI: 1.1-13), and the absence of bowel sounds (OR: 8.0; 95% CI: 1.4-44) were associated with high-risk gastric contents. Performing surgery the day following the trauma was a protective factor (OR: 0.1; 95% CI: 0.0-0.6). No cases of pulmonary aspiration occurred.

CONCLUSIONS

At least one-third of children with an acute isolated extremity fracture had preoperative gastric contents identified as high risk for pulmonary aspiration. Although preoperative history can guide anesthetic strategy in this population, ultrasound allowed clear stratification of the risk of aspiration in most cases.

Cerebral vasospasm in children with subarachnoid hemorrhage: frequency, diagnosis, and therapeutic management

BACKGROUND

The present study explores the frequency, diagnostic approach, and therapeutic management of cerebral vasospasm in a cohort of children with moderate-to-severe traumatic and nontraumatic subarachnoid hemorrhage (SAH).

METHODS

This was a single-center retrospective study performed over a 10-year period, from January 2010 to December 2019. Children aged from one month to 18 years who were admitted to the pediatric or adult intensive care unit with a diagnosis of SAH were eligible. Cerebral vasospasm could be suspected by clinical signs or transcranial Doppler (TCD) criteria (mean blood flow velocity > 120 cm/s or an increase in mean blood flow velocity by > 50 cm/s within 24 h) and then confirmed on cerebral imaging (with a reduction to less than 50% of the caliber of the cerebral artery).

RESULTS

Eighty patients aged 8.6 years (3.3-14.8 years, 25-75th centiles) were admitted with an initial Glasgow Coma Scale score of 8 (4-12). SAH was nontraumatic in 21 (26%) patients. A total of 14/80 patients (18%) developed cerebral vasospasm on brain imaging on day 6 (5-10) after admission, with a predominance of nontraumatic SAH (12/14). The diagnosis of cerebral vasospasm was suspected on clinical signs and/or significant temporal changes in TCD monitoring (7 patients) and then confirmed on cerebral imaging. Thirteen of 14 patients with vasospasm were successfully treated using a continuous intravenous infusion of milrinone. The Pediatric Cerebral Performance Category score at discharge from the intensive care unit was comparable between children with vasospasm (score of 2 [1-4]) vs. children without vasospasm (score of 4 [2-4]) (p = 0.09).

CONCLUSIONS

These findings indicate that cerebral vasospasm exists in pediatrics, particularly after nontraumatic SAH. The use of TCD and milrinone may help in the diagnostic and therapeutic management of cerebral vasospasm.

Traumatic brain injury in children with thoracic injury: clinical significance and impact on ventilatory management

PURPOSE

This study aims to describe the epidemiology and management of chest trauma in our center, and to compare patterns of mechanical ventilation in patients with or without associated moderate-to-severe traumatic brain injury (TBI).

METHODS

All children admitted to our level-1 trauma center from February 2012 to December 2018 following chest trauma were included in this retrospective study.

RESULTS

A total of 75 patients with a median age of 11 [6-13] years, with thoracic injuries were included. Most patients also had extra-thoracic injuries (n = 71, 95%) and 59 (79%) had TBI. A total of 52 patients (69%) were admitted to intensive care and 31 (41%) were mechanically ventilated. In patients requiring mechanical ventilation, there was no difference in tidal volume or positive end-expiratory pressure in patients with moderate-to-severe TBI when compared with those with no-or-mild TBI. Only one patient developed Acute Respiratory Distress Syndrome. A total of 6 patients (8%) died and all had moderate-to-severe TBI.

CONCLUSION

In this small retrospective series, most patients requiring mechanical ventilation following chest trauma had associated moderate-to-severe TBI. Mechanical ventilation to manage TBI does not seem to be associated with more acute respiratory distress syndrome occurrence.

NLRC4 GOF Mutations, a Challenging Diagnosis from Neonatal Age to Adulthood

The NLRC4 inflammasome is part of the human immune innate system. Its activation leads to the cleavage of pro-inflammatory cytokines IL-1β and IL-18, promoting inflammation. NLRC4 gain-of-function (GOF) mutations have been associated with early-onset recurrent fever, recurrent macrophagic activation syndrome and enterocolitis. Herein, we describe two new patients with NLRC4 mutations. The first case presented with recurrent fever and vasoplegic syndrome, gut symptoms and urticarial rashes initially misdiagnosed as a severe protein-induced enterocolitis syndrome. The second case had recurrent macrophage activation syndrome (MAS) and shock, suggesting severe infection. We identified two NLRC4 mutations, on exon 4, within the nucleotide-binding protein domain (NBD). After a systematic review of NLRC4 GOF mutations, we highlight the wide spectrum of this disease with a limited genotype-phenotype correlation. Vasoplegic shock was only reported in patients with mutation in the NBD. Diagnosing this new entity combined with gastrointestinal symptoms and vasoplegic shocks is challenging. It mimics severe allergic reaction or sepsis. The plasma IL-18 level and genetic screening are instrumental to make a final diagnosis.

Clinical applications of transcranial Doppler in non-trauma critically ill children: a scoping review

BACKGROUND

Many applications of transcranial Doppler (TCD) as a diagnosis or monitoring tool have raised interest in the last decades. It is important that clinicians know when and how to perform TCD in this population, what parameter to assess and monitor and how to interpret it.

OBJECTIVE

This review aims to describe the emerging clinical applications of TCD in critically ill children excluding those suffering from trauma.

METHODS

Databases Web of Science, Cochrane and PubMed were searched in May 2020. We considered all publications since the year 2000 addressing the use of TCD as a prognostic, diagnostic or follow-up tool in children aged 0 to 15 years admitted to intensive care or emergency units, excluding neonatology and traumatic brain injury. Two independent reviewers selected 82 abstracts and full-text articles from the 2011 unique citations identified at the outset.

RESULTS

TCD provides crucial additional information at bedside about cerebrovascular hemodynamics. Many clinical applications include the diagnosis and management of various medical and surgical neurologic conditions (central nervous system infections, arterial ischemic stroke, subarachnoid hemorrhage and vasospasm, brain death, seizures, metabolic disease, hydrocephalus) as well as monitoring the impact systemic conditions on brain perfusion (hemodynamic instability, circulatory assistance).

CONCLUSION

To conclude, TCD has become an invaluable asset for non-invasive neuromonitoring in critically ill children excluding those suffering from trauma. However, the scope of TCD remains unclearly defined yet and reference values in critically ill children are still lacking.

Effect of under triage on early mortality after major pediatric trauma: a registry-based propensity score matching analysis

Background

Little is known about the effect of under triage on early mortality in trauma in a pediatric population. Our objective is to describe the effect of under triage on 24-h mortality after major pediatric trauma in a regional trauma system.

Methods

This cohort study was conducted from January 2009 to December 2017. Data were obtained from the registry of the Northern French Alps Trauma System. The network guidelines triage pediatric trauma patients according to an algorithm shared with adult patients. Under triage was defined by the number of pediatric trauma patients that required specialized trauma care transported to a non-level I pediatric trauma center on the total number of injured patients with critical resource use. The effect of under triage on 24-h mortality was assessed with inverse probability treatment weighting (IPTW) and a propensity score (Ps) matching analysis.

Results

A total of 1143 pediatric patients were included (mean [SD], age 10 [5] years), mainly after a blunt trauma (1130 [99%]). Of the children, 402 (35%) had an ISS higher than 15 and 547 (48%) required specialized trauma care. Nineteen (1.7%) patients died within 24 h. Under triage rate was 33% based on the need of specialized trauma care. Under triage of children requiring specialized trauma care increased the risk of death in IPTW (risk difference 6.0 [95% CI 1.3–10.7]) and Ps matching analyses (risk difference 3.1 [95% CI 0.8–5.4]).

Conclusions

In a regional inclusive trauma system, under triage increased the risk of early death after pediatric major trauma.

Transcranial Doppler Use in Non-traumatic Critically Ill Children: A Multicentre Descriptive Study

Background: The use and perceived value of transcranial Doppler (TCD) scope in paediatric critical care medicine has not been extensively documented. Objective: To describe the use of TCD to assess non-traumatic brain injury in patients admitted to four paediatric intensive care units (PICUs) in France. Methods: We prospectively included all children (aged under 18) assessed with inpatient TCD between November 2014 and October 2015 at one of the four PICUs. The physicians completed a questionnaire within 4 h of performing TCD. Results: 152 children were included. The primary diagnosis was neurological disease in 106 patients (70%), including post ischemic-anoxic brain insult (n = 42, 28%), status epilepticus (n = 19, 13%), and central nervous system infection/inflammation (n = 15, 10%). TCD was the first-line neuromonitoring assessment in 110 patients (72%) and was performed within 24 h of admission in 112 patients (74%). The most common indications for TCD were the routine monitoring of neurological disorders (n = 85, 56%) and the detection of asymptomatic neurological disorders (n = 37, 24). Concordance between the operator's interpretation of TCD and the published normative values was observed for 21 of the 75 (28%) TCD abnormal findings according to the published normative values. The physicians considered that TCD was of value for the ongoing clinical management of 131 (86%) of the 152 patients. Conclusion: TCD is commonly used in French PICUs and tends to be performed early after admission on patients with a broad range of diseases. The physicians reported that the TCD findings often helped their clinical decision making. In view of the subjectivity of bedside interpretation, true TCD contribution to clinical care remains to be determined. Objective studies of the impact of TCD on patient management and clinical outcomes are therefore warranted.

Use of bilevel positive pressure ventilation in patients with bronchiolitis

RATIONAL

This study aims at describing the use of bilevel positive airway pressure (BiPAP) in infants with severe bronchiolitis.

WORKING HYPOTHESIS

The use of BiPAP in infants with bronchiolitis may be associated with a worst outcome.

STUDY DESIGN

A single-center retrospective study performed from October 2013 to April 2016.

METHODOLOGY

All infants from 1 day to 6 months of age admitted in the pediatric intensive care unit (PICU) were included if they had a clinical diagnosis of bronchiolitis and if they required any type of noninvasive ventilation (NIV), including high flow nasal cannula, continuous positive airway pressure and BiPAP at admission in PICU. There was no local written protocol regarding the ventilator management during the study.

RESULTS

Overall, 252 infants (median age 45 (26-72) days) were included in the study and 110 infants (44%) were supported by BiPAP at admission. More infants were born preterm in the group of patients supported by BiPAP at admission. No complication related to NIV occurred. Patients in the BiPAP group had a longer duration of noninvasive support as well as a longer PICU length of stay. However, hospital length of stay did not differ according to the type of respiratory support at admission.

CONCLUSION

The use of BiPAP was not associated with endotracheal intubation, however it was associated with increased PICU length of stay and increased duration of NIV.

Weaning from noninvasive ventilation and high flow nasal cannula in bronchiolitis: A survey of practice

RATIONAL

This study aims to describe the current weaning practices from any type of noninvasive support in infants with bronchiolitis, in terms of weaning procedures, weaning initiation and weaning failure criteria.

WORKING HYPOTHESIS

No information regarding the weaning practices is currently available and there may be a wide variability of strategies.

STUDY DESIGN

A cross-sectional electronic survey.

METHODOLOGY

The survey was distributed to physicians from five French-speaking countries with key roles in pediatric intensive care units (PICUs).

RESULTS

Responses were obtained from 29 PICUs from five French-speaking countries. A written weaning protocol was available in three pediatric centers (10%) and nurses had a key role in the weaning process in 72% of centers. The sudden weaning was the most commonly used procedure, no matter the type of noninvasive ventilatory (NIV) support. The most commonly used criteria for weaning initiation and weaning failure were the degree of respiratory distress, the occurrence of apneas and the fraction of inspired oxygen (FiO₂ ). The thresholds commonly used for weaning initiation criteria were (a) none or a slight use of accessory muscles; (b) FiO₂ less than equal to 40%, (c) respiratory rate less than 60 per minute, (d) no apnea, (e) blood pH more than 7.30, and (f) partial pressure of venous carbon dioxide less than equal to 50 mm Hg.

CONCLUSION

In infants with bronchiolitis requiring NIV support, the sudden weaning procedure was the most commonly used strategy. We observed a certain consensus on criteria for weaning initiation. These findings should help in building nurse-driven weaning protocols, but prospective studies remain needed to assess the best weaning strategy in infants with bronchiolitis-related acute respiratory failure.

Epidemiology of severe paediatric trauma following winter sport accidents

AIM

This study describes the epidemiology of severe injuries related to winter sports (skiing, snowboarding and sledding) in children and assesses potential preventive actions.

METHODS

A single-centre retrospective study performed at Pediatric or Adult Intensive Care Unit in the French Alps. All patients less than 15 years old, admitted to the Intensive Care Unit following a skiing, snowboarding or sledding accident from 2011 to 2018, were included.

RESULTS

We included 186 patients (mean age 10.6 years and 68% were male); of which 136 (73%), 21 (11%) and 29 (16%) had skiing, snowboarding and sledding accidents, respectively. The average ISS (injury severity score) was 16. The major lesions were head (n = 94 patients, 51%) and intra-abdominal (n = 56 patients, 30%) injuries. Compared to skiing/snowboarding, sledding accidents affected younger children (7 vs 11 years, P < .001); most of whom did not wear a helmet (89% vs 8%, P < .001). Severity scores were statistically different amongst winter sports (ISS = 16 (IQR 9-24) for skiing, 9 (IQR 4-16) for snowboarding and 16 (IQR 13-20) for sledding accident, P = .02).

CONCLUSION

Winter sports can cause severe trauma in children. Sledding accidents affect younger children that may benefit from wearing protective equipment.

Upper limb compartment syndrome after a viper bite in a child: A case report

The occurrence of compartment syndrome after a viper bite is a rare phenomenon and its treatment remains controversial. We report the case of an 11-year-old boy who developed compartment syndrome of the right upper limb following a viper bite. Decompression by fasciotomy was performed urgently with a good outcome. Surgical decompression for compartment syndrome following a viper bite is not a common treatment according to the literature. Fast access to care and antivenom administration seem to be effective at treating the compartment syndrome without recourse to fasciotomy.

Prise en charge de l’exacerbation sévère d’asthme

Contexte : La Société Française de Médecine d’Urgence, la Société de Réanimation de Langue Française et le GroupeFrancophone de Réanimation et d’Urgences Pédiatriques ont émis des recommandations sur la prise en charge del’exacerbation sévère d’asthme (ESA) chez l’enfant et l’adulte.Résultats : Les recommandations ont concerné 5 champs : diagnostic, traitement pharmacologique, modalités d’oxygénothérapie et de ventilation, orientation du patient, spécifi cités de la femme enceinte. L’analyse de la littérature et laformulation des recommandations ont été conduites selon la méthode GRADE (Grade of Recommendation Assessment,Development and Evaluation). Une recherche bibliographique portant sur les publications indexées dans les bases dedonnées PubMed™ et Cochrane™ a été réalisée.Sur les 21 recommandations formalisées obtenues, 4 avaient un niveau de preuve élevé (GRADE 1+/-) et 7 un niveaude preuve faible (GRADE 2 +/-). Pour 10 recommandations, la méthode GRADE n’a pas pu être appliquée, résultanten un avis d’experts. Un accord fort a été obtenu pour toutes les recommandations.Conclusion : Le travail conjoint de 36 experts issus de 3 sociétés savantes a permis d’obtenir 21 recommandations formalisées pour aider à la prise en charge aux urgences et en soins intensifs des patients adultes et pédiatriques avec une ESA.

Transcranial Doppler as a useful tool in the detection of cervical steno-occlusive arteriopathy in infants

OBJECTIVE

The early detection of cervical steno-occlusive arteriopathy is essential to rapidly initiate appropriate treatment and to potentially improve neurological outcome. To accurately confirm the diagnosis, cerebral imaging is the gold standard, but it cannot be performed if the patient is unstable or if the facility is unavailable.

CASES

Here we report our experience of using transcranial Doppler (TCD) ultrasound as a readily available, easy-to-use bedside tool to guide the rapid screening and management of cervical steno-occlusive arteriopathy in infants.

DISCUSSION AND CONCLUSION

Children with traumatic cervical steno-occlusive arteriopathy, TCD is a potentially useful tool for early diagnosis.

Management of severe asthma exacerbation: guidelines from the Société Française de Médecine d'Urgence, the Société de Réanimation de Langue Française and the French Group for Pediatric Intensive Care and Emergencies

BACKGROUND

The French Emergency Medicine Society, the French Intensive Care Society and the Pediatric Intensive Care and Emergency Medicine French-Speaking Group edited guidelines on severe asthma exacerbation (SAE) in adult and pediatric patients.

RESULTS

The guidelines were related to 5 areas: diagnosis, pharmacological treatment, oxygen therapy and ventilation, patients triage, specific considerations regarding pregnant women. The literature analysis and formulation of the guidelines were conducted according to the Grade of Recommendation Assessment, Development and Evaluation methodology. An extensive literature research was conducted based on publications indexed in PubMed™ and Cochrane™ databases. Of the 21 formalized guidelines, 4 had a high level of evidence (GRADE 1+/-) and 7 a low level of evidence (GRADE 2+/-). The GRADE method was inapplicable to 10 guidelines, which resulted in expert opinions. A strong agreement was reached for all guidelines.

CONCLUSION

The conjunct work of 36 experts from 3 scientific societies resulted in 21 formalized recommendations to help improving the emergency and intensive care management of adult and pediatric patients with SAE.

Disaster preparedness in French paediatric hospitals 2 years after terrorist attacks of 2015

OBJECTIVE

We aimed to determine paediatric hospital preparedness for a mass casualty disaster involving children in both prehospital and hospital settings. The study findings will serve to generate recommendations, guidelines and training objectives.

DESIGN AND SETTING

The AMAVI-PED study is a cross-sectional survey. An electronic questionnaire was sent to French physicians with key roles in specialised paediatric acute care.

RESULTS

In total, 81% (26 of 32) of French University Hospitals were represented in the study. A disaster plan AMAVI with a specific paediatric emphasis was established in all the paediatric centres. In case of a mass casualty event, paediatric victims would be initially admitted to the paediatric emergency department for most centres (n=21; 75%). Paediatric anaesthesiologists, paediatric surgeons and paediatric radiologists were in-house in 20 (71%), 5 (18%) and 12 (43%) centres, respectively. Twenty-three (82%) hospitals had a paediatric specialised mobile intensive care unit and seven (25%) of these could provide a prehospital emergency response. Didactic teaching and simulation exercises were implemented in 20 (71%) and 22 (79%) centres, respectively. Overall, physician participants rated the level of readiness of their hospital as 6 (IQR: 5-7) on a 10-point readiness scale.

CONCLUSION

Paediatric preparedness is very heterogeneous between the centres. Based on the study findings, we suggest that a national programme must be defined and guidelines generated.

Impact of Spontaneous Breathing Trial on Work of Breathing Indices Derived From Esophageal Pressure, Electrical Activity of the Diaphragm, and Oxygen Consumption in Children

BACKGROUND

The present study aimed to characterize the behavior of 3 components of respiratory muscle function during mechanical ventilation weaning in children to better understand the respective impact of a spontaneous breathing trial on ventilatory mechanical action (esophageal pressure [P_es], ventilatory demand (electrical activity of the diaphragm [EA_di]), and oxygen consumption.

METHODS

This was a prospective single-center study. All children > 1 months and <18 y old who were intubated and on mechanical ventilation, and who were hospitalized in the pediatric ICU were eligible. Subjects considered as ready to extubate were included. Simultaneous recordings of oxygen consumption, P_es, and EA_di were performed during 3 steps: before, during, and after the spontaneous breathing test.

RESULTS

Twenty subjects (median age, 5.5 mo) were included. Half of them were admitted for a respiratory cause. The increase in P_es swings and esophageal pressure-time product during the spontaneous breathing trial was not significant (P = .33 and P = .75, respectively), and a similar trend was observed with peak EA_di (P = .06). Oxygen consumption obtained by indirect calorimetry was stable in the 3 conditions (P = .98).

CONCLUSIONS

In these children who were critically ill, a spontaneous breathing trial induced a moderate and nonsignificant increase in work of breathing, as reflected by the respiratory drive with EA_di and respiratory mechanics with P_es. However, indirect calorimetry did not seem to be a sensitive tool to assess respiratory muscle function during the weaning phase in children who were on mechanical ventilation, especially when work of breathing was slightly increased.