[Assessment of pediatric practice in Lebanon, treatment and prevention of bronchiolitis]

Introduction: This study is the first of its kind in Lebanon to probe the management of bronchiolitis by pediatricians and family physicians. The American Academy of Pediatrics [APP] guidelines and standard global meta-analyses guided the comparison of patterns of medication treatment in Lebanon with clinical practices elsewhere. The aim of the study is to create a guideline that can assist with the establishment of a protocol for treatment, prevention and public education of the disease

Materials and Methods: A survey was conducted based on the clinical practice recommendations of the 2000 French consensus conference for acute viral bronchiolitis management. The survey included 80 pediatricians and general practitioners representing different regions of Lebanon

Results: The study showed inconsistency in the approach to diagnose and treat bronchiolitis in Lebanon. Results showed that 98.57% of the Lebanese pediatricians confirm the diagnosis clinically, however 41.18% of them do chest X-rays, 48.28% order a blood test and 72.86% search for viral etiology. Concerning the treatment, while all Lebanese pediatricians seemed to be convinced that the treatment of bronchiolitis is supportive [hydration, splitting meals, proclive position at 30 degrees, nasal decongestion], almost 57% said they prescribe bronchodilators, 30% opt for inhaled or oral corticosteroids, and 10% order antibiotics for prevention. When the patient is admitted, more than 80% of the practitioners reported the use of respiratory physiotherapy, while 60% said they make use of inhaled bronchodilators. Nebulized epinephrine is chosen by 65 percent of those surveyed; nebulized hypertonic saline is used by less than 40%, while more than half of the practitioners prefer nebulized physiologic saline. Concerning the administration of palivizumab, significant dissimilarity was detected among the pediatricians: 27.45% said they prescribe three doses as immunoprophylaxis, while 72.55% said they respect the five-dose rule

Conclusion: The management of bronchiolitis in Lebanon remains far from being standardized, with every pediatrician having his or her personal approach. This has led us to carry out the first ever national study to outline a regimen that is clear and based on international standards, which should be validated by the Lebanese Pediatric Society and disseminated to pediatricians and hospitals around the country. We also recommend further studies comparing the cost effectiveness of palivizumab injections with the cost of hospitalization for bronchiolitis on social security systems and health insurance schemes

Supravalvular aortic stenosis with and without coronary lesions in pediatrics

This study aims to analyze several parameters concerning the supravalvular aortic stenosis [SVAS] in children such as age of diagnosis, place of residence, the existence of a metabolic disorder or dysmor-phic syndrome and possible damage to the coronary ostia, the means of diagnosis and outcome of these patients. A large group of patients [2868] with congenital heart disease enrolled between 1 May 1999 and 30 April 2010 at the National Register of Pediatric and Congenital Heart Disease, Lebanese Society of Cardiology. SVAS were found in 14 patients [0.5%] aged 8.5 months to 15 years. The Williams Beuren syndrome was the most common etiology [6 cases] without ostial stenosis, asymptomatic and not treated, followed by forms without dysmorphic syndrome [5 cases] and without ostial stenosis, one patient was operated because of severe SVAS ; finally, 3 cases of homozygous familial hypercholesterolemia treated differently: a patient had a successful liver transplantation at age of 4.5 years but has developed, despite the normalization of cholesterol level, a SVAS associated with severe ostial lesions 10 years after transplantation, another treated by coronary artery bypass graft surgery and the latter treated medically. SVAS is a very rare disease, but its discovery must lead to search for coronary lesions especially in presence of homozygous familial hypercholesterolemia. The ultrasound monitoring is mandatory and is designed to detect this anomaly and early coronary lesions. The slightest suspicion should carry out more extensive explorations to detect ostial stenosis

[Successful familial kidney transplant in an infant weighing less than 10 kg : case report and review of the literature]

We report the case of a Lebanese infant born by normal delivery at 40 weeks of gestation. Weight and height at birth were 3200 grams and 49 cm respectively. Serum creatinine in the first week of life was 323 mmol/l [normal value for age is less than 20 mmol/L]. Kidney ultrasound confirmed diagnosis of hypoplastic small kidneys. Conservative treatment of renal failure was initiated from the first days of life. Conservative management of renal failure included careful attention to fluid balance, maintenance of adequate nutrition and correction of hyperkalemia, acidosis, hyperphosphatemia and prevention of renal osteodystrophy by the use of dietary phosphate binders and vitamin D analogs. After a slight decrease of serum creatinine in the first three months of life, creatininemia increased progressively despite conservative treatment associated to hyperkalemia and severe pruritis due to hyperphosphatemia. Faced with the progression of renal failure, we decided to start automated peritoneal dialysis at seven months of life. Weight and height were respectively 6200 g and 63 cm. Serum creatinine was 432 mmol/L. Pruritis improved after starting peritoneal dialysis as well as appetite. At 20 months of life and a weight of 9.7 kg, a familial kidney transplant was performed. Immunosuppressive treatment included Simulect[Registered sign], on day 1 and day 4, associated to mycophenolate mofetil, tacrolymus and prednisolone. The immediate post-transplant period was complicated by urinay tract infection due to BSLE E. coli. After four episodes of urinary tract infection due to resistant E. coli associated to a non obstructive stone of 15 mm in the allograft kidney, we performed two sessions of lithotripsy and placed a double J stent. Biochemical urinary analysis did not reveal any causes for lithiasis. Stone disappeared as well as infection after lithotripsy. Renal function is normal for age one year after the kidney transplant. To our knowledge, this is the first reported case of a successful kidney transplant in a Lebanese infant with kidney failure since birth with kidney transplant performed at less than 10 kg of weight on the transplant day. Peritoneal dialysis is the treatment of choice for infants with chronic kidney failure. Familial or cadaveric kidney transplant should be encouraged and performed even in infants weighing less than 10 kg allowing them to have normal growth as well as social and school integration

[Cardiogenic shock revealing heart disease in infancy and childhood]

Diagnosis, initial workup and immediate prognosis in congenital or acquired heart diseases revealed by cardiogenic shock [CS] in a Lebanese paediatric multicentric study. During a six-year period [is. January 1999 to 31 December 2004], 56 paediatric patients aged between 0 and 7 years have been admitted to the emergency departments or neonatal and intensive care units in ten different Lebanese hospitals, for high degree of CS suspicion with underlying cardiac disease. All diagnoses were confirmed by echocardiography.All children were initially in a critical condition with signs of CS. Congenital heart diseases [CHD], specially left obstructive diseases [coarctation of the aorta, critical aortic stenosis, hypoplastic left heart syndrome] were the main etiologies found in newborns, followed by dilated cardiomyopathies in infants and children. Mortality was higher in the following two groups of patients : intubation, no diuresis after the first hour of admission despite therapeutic measures [prostaglandines in newborns, dopamine, dobutamine and furosemide]. Beside those pathologies necessitating specific treatment, all the CHD [excluding hypoplastic left heart syndrome, one case of critical aortic coarctation and one case of congenital mitral regurgitation] were transferred to the catheterization laboratory or to surgery in a good hemodynamic condition. CS remains a notable medical problem observed in the emergency and paediatric intensive care units in Lebanon. Immediate prognosis is related to : immediate recognition of the CS, nature of the car-diopathy and initial response to therapeutic procedures such as rapid improvement of respiratory status and rapid diuresis. Echocardiography is a reliable, quick and non-invasive procedure for initial diagnosis

Fermeture percutanee des communications interauriculaires par la prothese Amplatzer

Percutaneous closure of an atrial septal detect [ASD] was undertaken in 10 patients aged from 3 to 33 years. The Amplatxer device was introduced intravenously and positioned under fluoroscopic and echographic control. the size of the ASD varied from 13 to 20 mm and that of the devices from 15 to 32 mm. one patient was operated for the removal of an improperly positioned device and closure of the ASD. All the other patients were discharged 24 hours after the procedure with successfull closure of the ASD. Complications were benign: spontaneously regressive arrhythmias [1 case] and migraines [2 cases]. our series reflects the experience of others, showing the faisability and efficiency of the procedure. tridimensionnal or intracardiac echocardiography may improve this technique in the future

echocardiographie set une technique utile dans un service de soins intensifs neonatals: experience Libanaise

To study the role of Doppler Echocardiography [DE], its indications and results in multiple neonatal intensive care units [NICU]. materials and methods: Over a period of 12 months, starting November 1st, 2001, till October 31st, 2002, 1105 newborns were admitted to six different NICU centers in the city of Beirut and its southern suburb. DE was requested in 159 patients [14.4%] mainly for the suspicion of hemodynamic disorders [congenital cardiopathy [cc], pulmonary hypertension [PHT], un-explained respiratory distress, shock and cardio-respiratory arrest. Through this examination, the following were investigated [search for cc; study of the cardiac contractility; search and study of the blood flow through the foramen ovale [FO] and the ductus arteriosus [DA] if patent; detection of mitral and tricuspid regurgitation [MR, TR]; measure, if possible, of the systolic pulmonary artery pressure, and eventual estimation of the systolic pressure in the aorta], Congenital heart disease was diagnosed in 53 newborns [33.3%], secondary PHT in 14 [8.8%], ischemic cardiomyopathy in 4, persistent fetal circulation in 3. DE was normal in 81 patients [50.9%]. In 123 completely documented cases, a FO was constantly patent, TR was found in 52% allowing the-measure of pulmonary artery pressure, a patent DA in 49%; the systemic arterial pressure was estimated in 35% and MR was noted in 5% of the cases. Not to consider the cc, DE is indicated in numerous situations. This technique permits precise study of the cardiovascular functions, mainly in critical situations; it allows the follow-up of the hemodynamic modifications instantaneously under treatment. Actually, the neonatal resuscitation and the critical modifications necessary in the workup of newborns mandate the presence of a DE machine in the NICU. Furthermore, DE knowledge should be incorporated in the future training programs of physicians specializing in neonatal resuscitation

Fermeture percutanee du canal arteriel chez l'enfant une premiere serie au Liban

Percutaneous closure of the patent ductus arteriosus [PDA] has become an efficient and safe technique in children. We report the first Lebanese series of 8 children who had their PDA closed percutaneously with a coil or an Amplatxer Duct Occluder. Patients median age was 3.2 years [range 1.2 to 12 years]. The median minimal diameter of the PDA was 2.1 mm [1.2 to 4 mm]. A coil was used in 4 children and an Amplatxer occluder in the 4 other patients. The device was chosen according to the diameter of The PDA The results were excellent in all patients. A trivial shunt present in 3 cases, disappeared within 8 weeks. No complication were noted in this series. Percutaneous closure of the PDA in children, using interventional radiology, is a simple and reproducible technique. It is now the treatment of choice in most pediatric cardiac centers worldwide

childhood asthma crisis in emergencies Investigation of 96 cases

Throughout a 2-year period, children who presented at Hotel-Dieu de France emergency department [ED] with acute asthma were analyzed prospectively and data on their environment, family and personal history as well as treatment were recorded. Treatment delivered at the ED, response and further outcome were analyzed. Out of 2024 children aged less than 15 years, 96 [5%] had acute asthma attack. Their median age was 4 years and M/F ratio was 2:1. Median age at onset of asthma was 2 years. Only 66 patients were recognized as asthmatics and 20% were given regular inhaled daily treatment. Current attack was mild in 45%, moderate in 45% and severe in 10% of cases. Home treatment before ED admission was often inadequate. Nine patients required hospital admission after failure of treatment at the ED. Within a median follow-up of 12 months, half of the patients experienced further attacks sometimes requiring ED care [27%] or hospital admission [8%]. These data highlight the fact that asthma in our country is still largely under recognized and inadequately treated

Corps etrangers de voies respiratoires chez l'enfant Etude retrospective de 100 cas

Foreign body inhalation is a universal problem, most common cause of death from domestic accident in children aged five years and less. Over 15 years one hundred children aged less than six years were evaluated in hotel dieu de france; findings are comparable to previous data, with one avoidable death; boys are chiefly concerned [64%]; mean age is 22.5 months circumstances are often hazy [65%]; vegetables are prominently responsible [90%] especially peanuts and pistachios [48%]; foreign bodies are seldom radiopaque [1%]; automnal predominance is noted. Inhalation is not reported in 25% of cases; immediate risk is subglottic impaction; the child survives if the foreign body is expelled one way or another. The most frequent site is the bronchial system [87%] with a slight right predominance [49%]; symptoms include: dyspnea, persistent cough, and in case of bronchial obstruction: wheezing and asymmetry of breath sounds; 15% of children are free of symptoms. Delay before hospital care is long [21.5 days], mostly because diagnosis is misread particularly in case of bronchial foreign body; pulmonary distension is a frequent finding [45%]. In case of asphyxia, first aid resuscitation is performed immediately: in fact it is rarely useful, sometimes harmful. Extraction is mandatory with the stiff bronchoscope; otherwise, bronchopulmonary infection and destruction is the usual outcome [25%]. Management is revisited, and prevention is recalled

Accidents chez l'enfant. Etude epidemiologique retrospective de 1671 observations recueillies a l'hotel-Dieu de Beyrouth

Injuries are the first cause of death in children after the neonatal age; their prevention is still critical in Lebanon. At Hotel-Dieu de France Hospital, 1671 children aged less than 18 years have had their files reviewed in the emergency department. Minor traumas represent less than half the cases. Though most of the injuries were light, in 5% of cases primary care was necessary, and 11% were admitted [10% in the Pediatric Intensive Care Unit]; 0.5% of the children died upon arrival. Moreover, 15% of our Pediatric Intensive Care Unit population are admitted for accidents. Boys are more frequently affected [69%] toddlers, small children and adolescents are risky populations. After minor traumas, the most frequent accidents are falls [21.3%], traffic road accidents [8.9%], poisoning [5.7%] and burns [5%]. Firearms injuries seem rare [2.8%] but are, in this study, the first cause of mortality. Foreign body inhalation are very rare [< 1%] but are a significant source of morbidity. The analysis is compared to published data, and allows accurate and general recommendations for injuries prevention in children

Intoxications aux hydrocarbures chez l'enfaurt

Carbohydrate poisoning is among serious children intoxications, made possible by inadequate stocking; boys, one to five years old, are particularly at risk in a series of 43 children examined and admitted in Hotel-Dieu de France hospital over a 10 year period. Outcome is constantly good after a short hospital care; clinical exam and chest x-ray are of particular value on admission. Some cases may need home care, whereas others should undertake hospital day care; treatment is discussed and long-term follow-up is being stressed on

Anorexie nerveuse du nourrisson

Infantile anorexia nervosa is different from anorexia nervosa of the adolescent; it occurs early in life, more often since the use of milk powder. The main pathway is the dyadic unit " mother and child "; the author reports two female cases of unequivalent severities, with 6 months back-up. Various presentations are discussed and focused on the struggle and duality between the mother and the child as a major element in the genesis of infantile anorexia nervosa; no organic illness was found, preventive attitude is proposed