Identifying serious underlying diagnoses among patients with brief resolved unexplained events (BRUEs): a Canadian cohort study.

OBJECTIVE: To describe the demographics and clinical outcomes of infants with brief resolved unexplained events (BRUE). DESIGN: A retrospective cohort study. SETTING: 11 centres within the Canadian Paediatric Inpatient Research Network. PATIENTS: Patients presenting to the emergency department (ED) following a BRUE (2017-2021) were eligible, when no clinical cause identified after a thorough history and physical examination. MAIN OUTCOME MEASURES: Serious underlying diagnosis (requiring prompt identification) and event recurrence (within 90 days). RESULTS: Of 1042 eligible patients, 665 were hospitalised (63.8%), with a median stay of 1.73 days. Diagnostic tests were performed on 855 patients (82.1%), and 440 (42.2%) received specialist consultations. In total, 977 patients (93.8%) were categorised as higher risk BRUE per the American Academy of Pediatrics guidelines. Most patients (n=551, 52.9%) lacked an explanatory diagnosis; however, serious underlying diagnoses were identified in 7.6% (n=79). Epilepsy/infantile spasms were the most common serious underlying diagnoses (2.0%, n=21). Gastro-oesophageal reflux was the most common non-serious underlying diagnosis identified in 268 otherwise healthy and thriving infants (25.7%). No instances of invasive bacterial infections, arrhythmias or metabolic disorders were found. Recurrent events were observed in 113 patients (10.8%) during the index visit, and 65 patients had a return to ED visit related to a recurrent event (6.2%). One death occurred within 90 days. CONCLUSIONS: There is a low risk for a serious underlying diagnosis, where the majority of patients remain without a clear explanation. This study provides evidence-based risk for adverse outcomes, critical information to be used when engaging in shared decision-making with caregivers.

Low caregiver health literacy is associated with non-urgent pediatric emergency department use.

OBJECTIVE: Caregivers with low health literacy are more likely to overestimate illness severity and have poor adherence with health-promoting behaviors. Our primary objective was to relate caregiver health literacy to the urgency of emergency department (ED) utilization. The secondary objective was to explore the relationship between social and demographic characteristics, health literacy, and urgency of ED use. METHODS: This sub-study was a descriptive cross-sectional survey with health record review. Data were collected from ten Canadian pediatric EDs. Study variables included demographics, visit details, and the Newest Vital Sign measurement of health literacy. ED visits were classified as urgent or non-urgent based on the resource utilization method. RESULTS: The response rate was 97.6% (n = 2005). Mean (SD) caregiver age was 37.0 (7.7) years, 74.3% (n = 1950) were mothers, 72.6% (n = 1953) spoke English as a primary language, 51.0% (n = 1946) had a university degree, and 45.1% (n = 1699) had a household income greater than $100,000. The mean (SD) age of the children was 5.9 (5.0) years and 48.1% (n = 1956) were female. 43.7% (n = 1957) of caregivers had low health literacy. Being a caregiver with a child < 2 years old [aOR 1.83 (1.35, 2.48)] and low health literacy [aOR 1.56 (1.18, 2.05)] were associated with greater non-urgent pediatric ED use. Interprovincial variation was evident: Quebec caregivers were less likely to use the pediatric ED for non-urgent presentations compared to Alberta, while those in Nova Scotia, Manitoba, British Columbia, and Ontario were more likely compared to Alberta. CONCLUSION: Almost half of caregivers presenting to Canadian pediatric EDs have low health literacy, which may limit their ability to make appropriate healthcare decisions for their children. Low caregiver health literacy is a modifiable factor associated with increased non-urgent ED utilization. Efforts to address this may positively influence ED utilization.

RéSUMé: OBJECTIF: Les soignants ayant une faible littératie en santé sont plus susceptibles de surestimer la gravité de la maladie et d'avoir un manque d'adhésion aux comportements favorisant la santé. Notre objectif principal était de faire le lien entre la littératie en santé des soignants et l'urgence d'utiliser les services d'urgence (SU). L'objectif secondaire était d'explorer la relation entre les caractéristiques sociales et démographiques, la littératie en santé et l'urgence de l'utilisation du traitement. MéTHODES: Cette sous-étude était une enquête transversale descriptive avec examen du dossier de santé. Les données ont été recueillies auprès de dix ED pédiatriques canadiens. Les variables étudiées comprenaient la démographie, les détails des visites et la mesure du dernier signe vital de la littératie en santé. Les visites de DS ont été classées en urgence ou non selon la méthode d'utilisation des ressources. RéSULTATS: Le taux de réponse était de 97,6 % (n=2005). L'âge moyen des aidants naturels était de 37,0 (7,7) ans, 74,3 % (n=1950) étaient des mères, 72,6 % (n=1953) parlaient l'anglais comme langue principale, 51,0 % (n=1946) avaient un diplôme universitaire et 45,1 % (n=1699) avaient un revenu familial supérieur à 100 000 $. L'âge moyen (SD) des enfants était de 5,9 (5,0) ans et 48,1 % (n=1956) étaient des femmes. 43,7 % (n=1957) des aidants avaient une faible littératie en santé. Le fait d'être un aidant naturel avec un enfant de moins de 2 ans [aOR 1,83 (1,35, 2,48)] et une faible littératie en santé [aOR 1,56 (1,18, 2,05)] étaient associés à une utilisation plus importante de l'ES pédiatrique non urgente. La variation interprovinciale était évidente : les aidants naturels du Québec étaient moins susceptibles d'utiliser le DE pédiatrique pour des présentations non urgentes comparativement à l'Alberta, tandis que ceux de la Nouvelle-Écosse, du Manitoba, de la Colombie-Britannique et de l'Ontario étaient plus susceptibles d'utiliser le DE pédiatrique pour des présentations non urgentes. CONCLUSION: Près de la moitié des aidants naturels qui se présentent aux ÉE pédiatriques au Canada ont une faible littératie en santé, ce qui peut limiter leur capacité à prendre les décisions appropriées en matière de soins de santé pour leurs enfants. Le faible niveau de connaissances en santé des aidants est un facteur modifiable associé à une utilisation accrue de l'ES non urgente. Les efforts déployés pour remédier à cette situation peuvent influencer positivement l'utilisation de la DE.

Management of Anaphylaxis Following Pre-Hospital Epinephrine Use in Children with Food-induced Anaphylaxis.

BACKGROUND: Previous guidelines recommend prompt epinephrine administration, followed by observation in the emergency department (ED). The need for transfer in all cases of anaphylaxis has recently been challenged. OBJECTIVE: We aimed to evaluate the need for additional ED treatment among children with anaphylaxis who received pre-hospital epinephrine. METHODS: Between 2011-2023, data were collected on symptoms, triggers, comorbidities, and pre-hospital and in-hospital management from children (<18 years) with food-induced anaphylaxis who received at least one dose of pre-hospital epinephrine presenting at 7 pediatric EDs. Multivariable logistic regression assessed factors associated with the usage of two or more pre-hospital EAI, epinephrine use in the ED, and hospital admission. RESULTS: Of 1127 children (mean 8.1 +/-5.3 years; 60.6% male) with food-induced anaphylaxis who used at least one EAI pre-hospital, the most common trigger was peanuts (25.3%). 209 (18.5%) received additional epinephrine in the ED, the majority of whom (88.0%) received one dose. 30 (2.7%) patients were admitted to hospital. Among all patients, severe reactions (cardiovascular instability/ cyanosis/ loss of consciousness) (adjusted odds ratio [aOR] 1.22; 95% confidence interval [CI] 1.12-1.33) and reactions to tree nuts (aOR 1.09; 95% CI 1.03-1.16) were associated with increased odds of in-hospital epinephrine use. Pre-hospital inhaled beta-agonists (aOR 1.08; 95% CI 1.01-1.16) use and severe reactions (aOR 1.13; 95% CI 1.05-1.22) were associated with the use of 2 or more EAI pre-hospital. CONCLUSION: A minority of anaphylaxis cases that used pre-hospital EAIs required additional treatment, supporting that shared decision making about transfer to ED works for the vast majority of patients.

Screen time and sleep in children.

QUESTION: I continue to hear concerns from parents in my practice about the frequent use of light-emitting devices by their children. I have also found that many children suffer from sleep disturbances. What are the effects of screen time on sleep, and what are some best practices for sleep hygiene and screen use among children? ANSWER: Screen time is higher now than before the onset of the COVID-19 pandemic, and knowledge about the effects of screen time is evolving. Spending time in front of a screen may replace sleep time or sleep-promoting activities such as exercise, and the engaging content and social interactions on screens interfere with falling asleep. Evidence exists on the disruption of the circadian rhythm by light emitted by screens. Advice to families should include sleep hygiene activities as well as elimination of screen use at least 1 hour before sleep.

A national survey of children's experiences and needs when attending Canadian pediatric emergency departments.

BACKGROUND: Optimizing a child's emergency department (ED) experience positively impacts their memories and future healthcare interactions. Our objectives were to describe children's perspectives of their needs and experiences during their ED visit and relate this to their understanding of their condition. METHODS: 514 children, aged 7-17 years, and their caregivers presenting to 10 Canadian pediatric EDs completed a descriptive cross-sectional survey from 2018-2020. RESULTS: Median child age was 12.0 years (IQR 9.0-14.0); 56.5% (290/513) were female. 78.8% (398/505) reported adequate privacy during healthcare conversations and 78.3% (395/504) during examination. 69.5% (348/501) understood their diagnosis, 89.4% (355/397) the rationale for performed tests, and 67.2% (338/503) their treatment plan. Children felt well taken care of by nurses (90.9%, 457/503) and doctors (90.8%, 444/489). Overall, 94.8% (475/501) of children were happy with their ED visit. Predictors of a child better understanding their diagnosis included doctors talking directly to them (OR 2.21 [1.15, 4.28]), having someone answer questions and worries (OR 2.51 [1.26, 5.01]), and older age (OR 1.08 [1.01, 1.16]). Direct communication with a doctor (OR 2.08 [1.09, 3.99]) was associated with children better understanding their treatment, while greater fear/ 'being scared' at baseline (OR 0.59 [0.39, 0.89]) or at discharge (OR 0.46 [0.22, 0.96]) had the opposite effect. INTERPRETATION: While almost all children felt well taken care of and were happy with their visit, close to 1/3 did not understand their diagnosis or its management. Children's reported satisfaction in the ED should not be equated with understanding of their medical condition. Further, caution should be employed in using caregiver satisfaction as a proxy for children's satisfaction with their ED visit, as caregiver satisfaction is highly linked to having their own needs being met.

The acute care burden of asthma in children was profoundly reduced during the COVID-19 pandemic: A multi-centre Canadian retrospective study.

Objectives: Asthma is a chronic lung condition that can be exacerbated when triggered by viruses. Pandemic public health restrictions aimed to reduce COVID-19 transmission indirectly effected other circulating viruses. This study assessed the impact of the pandemic and associated public health measures on acute paediatric asthma across four tertiary sites in three Canadian provinces. We queried whether pandemic-related changes would impair preventive care and delay presentation to care, increasing asthma exacerbation severity. Methods: This retrospective study compared the frequency of acute care access and severity of presentation to emergency departments (ED) for acute asthma to four tertiary care children's hospitals during the COVID-19 pandemic (from March 17, 2020 to June 30, 2021) to a pre-lockdown control period (July 1, 2018 to March 16, 2020). Data was subjected to interrupted time series and Chi-square analysis. Results: Our study included 26,316 acute asthma visits to ED. Sites experienced a 63% to 89% reduction in acute asthma visits during the pandemic, compared with pre-lockdown controls, and a 17% to 85% reduction in asthma, that is out of proportion as a fraction of all-cause ED visits. For asthma, there was no difference in severity measured by rate of ward admission or rate of Paediatric Intensive Care Unit (PICU) admission. Conclusions: Public health measures appear to have resulted in a specific protective association on acute asthma with reduced acute care utilization over and above the reduction in all-cause presentations, without an increase in severity upon presentation. Our study indicates an importance to antiviral public health and engineering strategies to reduce viral transmission and thereby asthma morbidity.

Should you test for urinary tract infection in children with respiratory symptoms?

QUESTION: An 8-month-old boy presented to our clinic with a 3-day history of fever. He has had a cough and rhinorrhea since the onset of the fever, and his 4-year-old sibling has recently had cough and cold symptoms. I have heard that the presence of respiratory symptoms means that urinary tract infection (UTI) is less likely. In infants with fever and respiratory symptoms, who should have a sample collected for urinalysis for UTI? ANSWER: The approach to diagnosing febrile infants who have respiratory symptoms varies by age. Urinalysis should be done for all febrile infants younger than 2 months of age, regardless of whether they have respiratory symptoms. Clinicians should assess risk factors for UTI in every infant between 2 and 24 months of age and should not exclude the diagnosis of UTI based on respiratory symptoms alone. Use of a predictive tool to estimate the pretest probability of UTI would aid decision making about patients in this population.

Clinical characteristics and management of pediatric egg-induced anaphylaxis: A cross-sectional study.

BACKGROUND: Egg is the third most common food allergy in children; however, data on pediatric egg-induced anaphylaxis are sparse. OBJECTIVE: To describe the clinical characteristics, management, and outcomes of pediatric egg-induced anaphylaxis. METHODS: Children presenting with anaphylaxis were recruited from 13 emergency departments as part of the Cross-Canada Anaphylaxis Registry, from which data on anaphylaxis triggered by egg were extracted. Multivariate logistic regression was used to determine factors associated with prehospital epinephrine autoinjector (EAI) use and to compare anaphylaxis triggered by egg with other triggers of food-induced anaphylaxis (FIA). RESULTS: We recruited 302 children with egg-induced anaphylaxis. The mean age was 2.6 years (SD = 3.6), and 55.3% were male. Only 39.4% had previously been diagnosed with an egg allergy. Prehospital EAI use was 32.1%, but this was not significantly lower than in other triggers of FIA (P = .26). Only 1.4% of patients required hospital admission. Relative to other triggers of FIA, patients with egg-induced anaphylaxis were significantly younger (P < .001) and exhibited more vomiting (P = .0053) and less throat tightness (P = .0015) and angioedema (P < .001). CONCLUSION: To the best of our knowledge, this is the largest published cohort of pediatric egg-induced anaphylaxis. In this cohort, prehospital EAI use was very low. In addition, we identified certain symptoms that distinguish egg-induced from other triggers of FIA. Taken together, high suspicion is crucial in identifying egg-induced anaphylaxis, given the younger patient demographic and frequent lack of FIA history.

Milk-induced anaphylaxis among children presenting to Canadian emergency departments.

BACKGROUND: Cow's milk is one of the most common and burdensome allergens in pediatrics, and it can induce severe anaphylactic reactions in children. However, data on cow's milk-induced anaphylaxis are sparse. OBJECTIVE: To describe the epidemiology of pediatric cow's milk-induced anaphylaxis and to determine risk factors for repeat emergency department (ED) epinephrine administration. METHODS: Between April 2011 and May 2023, data were collected on children with anaphylaxis presenting to 10 Canadian EDs. A standardized form documenting symptoms, triggers, treatment, and outcome was used. Multivariate logistic regression was used. RESULTS: Of 3118 anaphylactic reactions, 319 milk-induced anaphylaxis cases were identified (10%). In the prehospital setting, 54% of patients with milk-induced anaphylaxis received intramuscular epinephrine. In those with milk-induced anaphylaxis, receiving epinephrine before presenting to the ED was associated with a reduced risk of requiring 2 or more epinephrine doses in the ED (adjusted odds ratio, 0.95 [95% CI, 0.90-0.99]). Children younger than 5 years of age were more likely to experience a mild reaction compared with that in older children, who experienced a moderate reaction more often (P < .0001). Compared with other forms of food-induced anaphylaxis, children presenting with milk-induced anaphylaxis were younger; a greater proportion experienced wheezing and vomiting, and less experienced angioedema. CONCLUSION: Prehospital epinephrine in pediatric milk-induced anaphylaxis is underused; however, it may decrease risk of requiring 2 ED epinephrine doses. Milk-induced anaphylaxis in children younger than 5 years of age may be less severe than in older children. Wheezing and vomiting are more prevalent in milk-induced anaphylaxis compared with that of other foods.

Treatment Delay of Febrile Urinary Tract Infections Among Infants With Respiratory Symptoms.

OBJECTIVE: To evaluate whether antibiotic treatment of febrile urinary tract infection (UTI) is delayed in febrile infants with respiratory symptoms compared with those without. STUDY DESIGN: Data of infants 2-24 months of age diagnosed with UTI from March 1, 2012 to May 31, 2023 were collected from our hospital's medical charts and triage records. Patients with known congenital anomalies of the kidney and urinary tract or a history of febrile UTI were excluded. Patients were classified as having respiratory symptoms if they had any of the following symptoms or clinical signs: cough, rhinorrhea, pharyngeal hyperemia and otitis media. Time to first antibiotic treatment from fever onset was compared between patients with and without respiratory symptoms. A Cox regression model was constructed to adjust for potential confounders. RESULTS: A total of 214 patients were eligible for analysis. The median age of the eligible patients was 5.0 months (interquartile range: 3.0-8.8) and 118 (55%) were male. There were 104 and 110 patients in the respiratory symptom and no respiratory symptom groups, respectively. The time to first antibiotic treatment was significantly longer in the group with respiratory symptoms (51 hours vs. 21 hours). Respiratory symptoms were significantly associated with a longer time to first treatment after adjustment for age and sex in the Cox regression model (hazard ratio = 0.63, 95% confidence interval: 0.47-0.84). CONCLUSIONS: Treatment of febrile UTI infants with respiratory symptoms tends to be delayed. Pediatricians should not exclude febrile UTI even in the presence of respiratory symptoms.

Management of acute supraventricular tachycardia in children.

QUESTION: Recently, a 3-year-old patient in my practice urgently needed to go to the emergency department. The patient was found to have supraventricular tachycardia (SVT) and needed immediate treatment with adenosine. What evidence is currently available for management of SVT in children? ANSWER: Supraventricular tachycardia is a common cardiac condition in the pediatric population that manifests as a narrow QRS complex tachycardia on electrocardiography. Symptoms may range from palpitations, poor feeding, and irritability to more substantial hemodynamic instability. Patients who are hemodynamically stable can benefit from interventions such as vagal maneuvers, which can be done in the office. Such maneuvers include the Valsalva maneuver, stimulation of the diving reflex (for infants), and unilateral carotid sinus massage. Other children may need pharmacologic therapies to restore normal heart rhythm, which usually consists of a rapid intravenous injection of adenosine under monitoring. For patients who are hemodynamically unstable, emergency cardioversion may be needed.

Prise en charge de la tachycardie supraventriculaire aiguë chez les enfants.

QUESTION: Récemment, un patient âgé de 3 ans que je voyais en cabinet a dû être rapidement transporté au service d'urgence. On lui a diagnostiqué une tachycardie supraventriculaire (TSV), et de l'adénosine lui a été immédiatement administrée. De quelles données probantes disposons-nous relativement à la prise en charge de la TSV chez les enfants? RÉPONSE: La tachycardie supraventriculaire est un trouble cardiaque courant chez les patients pédiatriques. Elle se manifeste par une diminution de l'amplitude des complexes QRS sur l'électrocardiogramme. Les symptômes vont des palpitations, du manque d'appétit et de l'irritabilité à une instabilité hémodynamique plus significative. Les patients stables sur le plan hémodynamique peuvent bénéficier d'interventions comme les manœuvres vagales, qui peuvent être effectuées en cabinet. Ces manœuvres comprennent la manœuvre de Valsalva, la stimulation du réflexe de plongée (chez les enfants) et la compression unilatérale du sinus carotidien. Chez certains enfants, le rétablissement du rythme cardiaque normal peut demander un traitement pharmacologique consistant en de rapides injections intraveineuses d'adénosine administrées sous surveillance. Les patients présentant une instabilité hémodynamique pourraient nécessiter une cardioversion d'urgence.

Managing anaphylaxis: Epinephrine, antihistamines, and corticosteroids: More than 10 years of Cross-Canada Anaphylaxis REgistry data.

BACKGROUND: Epinephrine is the first-line treatment for anaphylaxis but is often replaced with antihistamines or corticosteroids. Delayed epinephrine administration is a risk factor for fatal anaphylaxis. Convincing data on the role of antihistamines and corticosteroids in anaphylaxis management are sparse. OBJECTIVE: To establish the impact of prehospital treatment with epinephrine, antihistamines, and/or corticosteroids on anaphylaxis management. METHODS: Patients presenting with anaphylaxis were recruited prospectively and retrospectively in 10 Canadian and 1 Israeli emergency departments (EDs) between April 2011 and August 2022, as part of the Cross-Canada Anaphylaxis REgistry. Data on anaphylaxis cases were collected using a standardized form. Primary outcomes were uncontrolled reactions (>2 doses of epinephrine in ED), no prehospital epinephrine use, use of intravenous fluids in ED, and hospital admission. Multivariate regression was used to identify factors associated with primary outcomes. RESULTS: Among 5364 reactions recorded, median age was 8.8 years (IQR, 3.78-16.9); 54.9% of the patients were males, and 52.5% had a known food allergy. In the prehospital setting, 37.9% received epinephrine; 44.3% received antihistamines, and 3.15% received corticosteroids. Uncontrolled reactions happened in 250 reactions. Patients treated with prehospital epinephrine were less likely to have uncontrolled reactions (adjusted odds ratio [aOR], 0.955 [95% CI, 0.943-0.967]), receive intravenous fluids in ED (aOR, 0.976 [95% CI, 0.959-0.992]), and to be admitted after the reaction (aOR, 0.964 [95% CI, 0.949-0.980]). Patients treated with prehospital antihistamines were less likely to have uncontrolled reactions (aOR, 0.978 [95% CI, 0.967-0.989]) and to be admitted after the reaction (aOR, 0.963 [95% CI, 0.949-0.977]). Patients who received prehospital corticosteroids were more likely to require intravenous fluids in ED (aOR, 1.059 [95% CI, 1.013-1.107]) and be admitted (aOR, 1.232 [95% CI, 1.181-1.286]). CONCLUSION: Our findings in this predominantly pediatric population support the early use of epinephrine and suggest a beneficial effect of antihistamines. Corticosteroid use in anaphylaxis should be revisited.

Antibiotic treatment duration for community-acquired pneumonia in children.

QUESTION: A 4-year-old child was seen in our clinic with a clinical presentation consistent with community-acquired pneumonia (CAP). He was prescribed oral amoxicillin and a colleague asked about the duration of treatment. What is the current available evidence for treatment duration for uncomplicated CAP in an outpatient setting? ANSWER: Previously the recommended duration of antibiotic treatment of uncomplicated CAP was 10 days. Recent evidence from several randomized controlled trials suggests that a 3- to 5-day duration is noninferior to a longer treatment course. In an effort to prescribe the shortest effective duration of antibiotics to minimize the risk of antimicrobial resistance associated with prolonged antibiotic use, family physicians should offer 3 to 5 days of appropriate antibiotics and monitor the recovery of children with CAP.

Durée d'une antibiothérapie pour une pneumonie acquise dans la communauté chez l'enfant.

QUESTION: Un enfant de 4 ans est venu à notre clinique, présentant un tableau clinique conforme à une pneumonie acquise dans la communauté (PAC). On lui a prescrit de l'amoxicilline par voie orale, et un collègue s'est demandé quelle devrait être la durée du traitement. Quelles sont les données probantes actuelles concernant la durée du traitement pour une PAC sans complication en milieu ambulatoire? RÉPONSE: La durée d'une antibiothérapie auparavant recommandée pour une PAC sans complication était de 10 jours. Des données probantes récentes tirées de quelques essais randomisés contrôlés indiquent qu'une durée de 3 à 5 jours n'est pas inférieure à un régime thérapeutique plus long. Dans un effort pour prescrire la durée efficace la plus courte afin de minimiser le risque d'une résistance antimicrobienne liée à une utilisation prolongée d'antibiotiques, les médecins de famille devraient offrir de 3 à 5 jours d'antibiotiques appropriés et surveiller le rétablissement des enfants souffrant d'une PAC.

Anterior cutaneous nerve entrapment syndrome in children.

QUESTION: I frequently see adolescents with recurrent abdominal pain in my family medicine clinic. While the diagnosis frequently is a benign condition such as constipation, I recently heard that after 2 years of recurrent pain, an adolescent was diagnosed with anterior cutaneous nerve entrapment syndrome (ACNES). How is this condition diagnosed? What is the recommended treatment? ANSWER: Anterior cutaneous nerve entrapment syndrome, first described almost 100 years ago, is caused by entrapment of the anterior branch of the abdominal cutaneous nerve as it pierces the anterior rectus abdominis muscle fascia. The limited awareness of the condition in North America results in misdiagnosis and delayed diagnosis. Carnett sign-in which pain worsens when using a "hook-shaped" finger to palpate a purposefully tense abdominal wall-helps to confirm if pain originates from the abdominal viscera or from the abdominal wall. Acetaminophen and nonsteroidal anti-inflammatory drugs were not found to be effective, but ultrasound-guided local anesthetic injections seem to be an effective and safe treatment for ACNES, resulting in relief of pain in most adolescents. For those with ACNES and ongoing pain, surgical cutaneous neurectomy by a pediatric surgeon should be considered.

Le syndrome de compression du nerf cutané antérieur chez l'enfant.

QUESTION: À ma clinique de médecine familiale, je vois souvent des adolescents souffrant de douleur abdominale récurrente. Le diagnostic est fréquemment un problème bénin comme la constipation, mais j'ai récemment entendu dire qu'un adolescent, après 2 ans de douleur récurrente, avait reçu un diagnostic de syndrome de compression du nerf cutané antérieur (ACNES). Comment ce problème est-il diagnostiqué, et quel est le traitement recommandé? RÉPONSE: Le syndrome de compression du nerf cutané antérieur, décrit initialement il y a près de 100 ans, est causé par la compression de la branche antérieure du nerf cutané abdominal qui empiète sur le fascia du muscle grand droit antérieur de l'abdomen. La connaissance limitée de ce problème en Amérique du Nord entraîne des diagnostics erronés et un retard dans le diagnostic réel. Le signe de Carnett, selon lequel la douleur s'aggrave lors de la palpation de la paroi abdominale intentionnellement tendue avec un doigt « en forme de crochet ¼, aide à confirmer si la douleur provient des viscères abdominaux ou de la paroi abdominale. L'acétaminophène et les anti-inflammatoires non stéroïdiens ne se sont pas révélés efficaces, mais des injections locales d'anesthésiques guidées par échographie semblent un traitement sûr et efficace pour l'ACNES, et elles entraînent un soulagement de la douleur chez la plupart des adolescents. Pour ceux dont l'ACNES et les douleurs persistent, il y a lieu d'envisager une neurectomie cutanée par un chirurgien pédiatrique.