French national diagnostic and care protocol for Kawasaki disease.

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

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

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

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

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

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

INTRODUCTION: Good practice guidelines help clinicians to establish a suspected diagnosis of non-accidental head injury (NAHI) and help forensic experts to establish a level of certainty for the diagnosis. The objective of this study was to assess how the French Health Authority (HAS) guidelines contribute to the process of producing an expert assessment, on causation and certainty in cases of suspected NAHI. METHOD: A retrospective study was conducted of the expert assessments that were conducted by a paediatric surgeon and forensic expert attached to our local court between 2002 and 2018, with the aim of determining the causal mechanism of the lesions and express a degree of certainty regarding the diagnosis. RESULTS: In our study, we found that, despite the HAS guidelines, a number of documents deemed essential for the forensic expert were sometimes missing, and that, by applying these guidelines, the decisions reached in some expert assessments could been reclassified and certain factors formerly described as risk factors for injury could be excluded. A precise dating of the traumatic event was proposed in half of cases. CONCLUSION: Our study highlights the vital role of the HAS guidelines, not only for patient management but also to ensure high-quality expert assessments. Unfortunately, guidelines were not yet being properly adhered to by medical teams.

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

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

Severe adenovirus pneumonia with hemophagocytic syndrome and respiratory failure.

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

Non accidental repeated lithium poisoning in a child: The role of hair analysis.

Non accidental intoxication due to child abuse is rare and its frequency is likely underestimated because it is difficult to diagnose. Here, we report a case of voluntary repeated exposure to lithium in an infant, for whom the clinical manifestations were convulsions. Toxicological analysis was very helpful for documenting lithium exposure during the assumed period of time. Interpreting the results of hair analysis, a simple and minimally invasive examination, is tricky at this age, but it can facilitate the differentiation of acute versus chronic exposure. Although infrequent and underestimated, lithium should be considered as a cause of intoxication in a previously healthy child with acute seizure.

The medical and social outcome in 2016 of infants who were victims of shaken baby syndrome between 2005 and 2013.

INTRODUCTION: There are few studies that have investigated the long-term outcome of children who have been victims of shaken baby syndrome (SBS). However, the consequences appear to be significant and the data available from a social point of view are scarce. The main objective of this study was to define the medical and social outcome in 2016 of the infants who were victims of SBS and admitted to one of the Marseille university hospitals. The number of patients followed by a specialized team was evaluated along with their clinical state, living conditions, and whether a social support system such as the Child welfare system had been put into place. METHOD: The study was retrospective and descriptive. Patients under 1 year of age who were hospitalized between January 2005 and December 2013 and manifested clinical and paraclinical characteristics enabling the diagnosis of SBS were included in the study. The diagnosis was certain, probable, or possible according to the definitions given by the consensus of the 2011 shaken baby health authority conference (HAS). RESULTS: Eighty babies qualified for the study, three of whom died in intensive care. Only ten of these patients (12.9%) had regular (annual) neuropediatric check-up during the whole study period. Thirty-seven patients (48%) had an annual neuropediatric check-up during the first 2 years only following the diagnosis. Only 12 of the children (15.6%) were still being followed after the age of 6. The children were followed up on average for 2.5 years (29.6 months). In 24 cases (31%), the last medical visit revealed an abnormal neurological examination including multiple disabilities due to spastic quadriplegia and severe intellectual deficit, which led to total dependency in half of these cases. Forty-four patients (57%) had a normal neurological examination. Concerning the babies' social outcome, 50 patients (64.9%) had returned home, 12 (15.6%) benefited, from educational assistance at the patient's home (AEMO) following the ruling of a children's judge, and 19 (24.7%) were still placed in foster care (ASE). The average foster care placement lasted 34.7 months. DISCUSSION AND CONCLUSION: Long-term medical follow-up for children having sustained serious head injury as a result of abuse is inadequate. Sequelae such as multiple disabilities are less frequent than described in the literature. According to this study, a longer-term follow-up is necessary for children suffering from sequelae such as learning disabilities than what is actually possible in our center.

[Pseudomonas aeruginosa in post-piercing perichondritis: Two case reports]. / Chondrite à Pseudomonas aeruginosa après piercing chez l'adolescent : à propos de deux cas.

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

[Chest X-ray and acute bronchiolitis: Are these indications decreasing?] / Radiographie de thorax et bronchiolite aiguë : des indications en diminution ?

OBJECTIVE: A management protocol for infants hospitalized for acute bronchiolitis, established after the study conducted in our unit in 2012, recommends a chest X-ray when the clinical course is unusual or if a differential diagnosis is suspected. The goal of this study was to evaluate professional practices after the introduction of this new management protocol. STUDY DESIGN: Retrospective descriptive study in two pediatric units from October 2013 to March 2015, including infants (0-23 months) hospitalized for their first episode of acute bronchiolitis without any underlying chronic condition. RESULT: Overall, 599 infants were included (median age, 3.7 months, 54 % boys). Nearly six out of ten (n=355, 59.3 %) had at least one chest radiograph (38.5 % fewer than in 2012). It was abnormal in 96.3 % of cases, revealing distension and/or bronchial wall thickening (56.7 %), focal opacity (23.5 %), or atelectasis (19.5 %). An X-ray was performed out of the recommendations in 42.5 % of cases. The chest X-ray result led to management changes in 52 infants with prescription of antibiotics for pneumonia (86.5 %) and allowed the diagnosis of heart disease in one case (0.2 %). Management of acute bronchiolitis (X-ray and antibiotics) was statistically different between the two pediatric units. DISCUSSION: This protocol led to a significant decrease in the number of chest X-rays. However, many are still performed out of the recommendations, resulting in an increase of antibiotic use for pneumonia. CONCLUSION: The decrease in use of chest X-rays in acute bronchiolitis for hospitalized infants was significant but remains insufficient.

[Complementary exams in child abuse: A French national study in 2015]. / Explorations complémentaires face à une situation d'enfant en danger : état des lieux des pratiques en France en 2015.

INTRODUCTION: Even if there are HAS (French National Health Authority) guidelines on shaken baby syndrome, many other child abuse situations are not included in these recommendations. The aim of this study was to invent the complementary exams in cases of child abuse in France and compare the practice to existing guidelines. MATERIAL AND METHODS: This was a multicenter study by email to 128 French hospitals (35 university hospitals and 93 general hospitals) that receives children in emergency and hospitalization settings. Three child abuse clinical situations were included in a clinical case multiple-choice format concerning the further explorations. We described the main results and evaluated their adherence to the HAS protocol for case 1. RESULTS: Of 128 hospitals surveyed, 104 responded, for an 81 % response rate, which corresponded to 274 doctors. Analysis of the results showed great heterogeneity in practices. The majority of physicians (99 %) performed systematic explorations in the situation of physical abuse, while only 27 % undertook such exams in situations of serious neglect. The situation of sexual abuse was the most consensual in terms of diagnostic tests for the detection of sexually transmitted diseases, but other types of associated abuse were not sought. In the first case, the HAS guidelines were respected in less than half of the cases for all complementary exams except the eye fundus exam. Abdominal imaging was insufficiently performed (40 % of cases). Examinations that were not indicated were still prescribed. Moreover, siblings under 2 years of age were examined in only one-third of cases (n=88/274; 32 %). Practices were not influenced by the age of the child. CONCLUSION: This study illustrates the heterogeneity in the use of complementary exams in cases of child abuse in France. Common protocols throughout the country would be useful, standardizing the most relevant exams for potential medical-legal issues, and facilitating exchanges concerning practices between different centers.

[Fat overload syndrome]. / Syndrome de surcharge en lipides : un accident iatrogène rare.

We report the case of a 21-month-old child suffering from pulmonary fibrosis, who presented with acute respiratory distress and liver damage, due to an accidental overdose of intravenous lipid emulsion. This poisoning is a rare entity, whose potential severity and almost exclusive iatrogenic effect deserve to be remembered.

[Motivations for a consultation before adoption: A multicenter study]. / Étude multicentrique sur les motivations d'une consultation avant adoption.

INTRODUCTION: While the number of international adoptions in France is decreasing, adopted children are older and in poorer health than they used to be. This phenomenon has resulted in an increase in the demand for preadoption consultations over the past several years. This study analyses the reasons for these consultations. METHOD: Prospective multicenter study conducted from 1 January to 31 December 2013. RESULTS: Ten centers contributed to the study, i.e., 196 preadoption consultations. Seeking medical advice was the reason for 88% of the consultations, whether the advice was based on the study of an identified child's medical file (32%) or a country's healthcare characteristics, whether the country was identified (34%) or not (23%). In 6% of cases, the motive for preadoption consultations was social and familial, and in the last 5% it was to obtain general information about adoption and its procedures. In more than 40% of the cases, whether the child or the country identified, Russia is the subject of the consultation because of the complexity of the files and because of the dreaded but rarely mentioned fetal alcohol syndrome. CONCLUSION: The deterioration of adopted children's health is an additional worry for future adoption applicants. To provide them with the best information possible without making choices for them, specialists should have substantial experience in adoption before going into these preadoption consultations.

[Study of reports to the departmental home of disabled children placed in social assistance to children in the Bouches-du-Rhône]. / Étude des notifications à la Maison départementale des personnes handicapées chez les enfants placés à l'Aide sociale à l'enfance dans les Bouches-du-Rhône.

INTRODUCTION: By the end of 2011, 275,000 children in France were included in the Aide sociale à l'enfance (ASE, Child Welfare System). Half of these children were entrusted to public care. There is limited data on these children. The MDPH (Maison départementale des personnes handicapées) is an administrative body assisting in the care of disabled children, through material, financial, and human means. Analyzing MDPH medical records can provide medical information about these children. The aim of this study was to describe the characteristics of children left to the ASE with a record at MDPH in Bouches-du-Rhône. METHODS: We extracted administrative data from two registers, the ASE register and the MDPH register. The MDPH medical files of each patient were analyzed and their medical information was coded: gestational age, deficiencies, and pathologies. RESULTS: In Bouches-du-Rhône, 2965 children were entrusted, 506 (17%) of whom were known by the MDPH: 30.6% of the entrusted children known by MDPH were taken into foster care and 48% were in residential group homes. Half of the MDPH notifications concerned a referral to a school or medico-social institution. By analyzing the medical data, we observed an average of 2.1 deficiencies per child. The types of deficiencies were distributed as follows: 35.9% were psychological deficiencies, 26.4% were speech deficiencies, and 21.6% were intellectual cognitive deficiencies. The most common pathology was mental and behavioral disorder (71% of diagnoses). DISCUSSION: The MDPH notification rate in children entrusted to public care was seven times higher than in the general population. Overall, explaining the relation between child abuse and neglect and disability is difficult. The psychopathology of these children is complex. These results show the importance of specific medical monitoring for these children.

[Bronchiectasis revealing triple A syndrome]. / Une dilatation de bronches révélant un syndrome du triple A.

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

[Scurvy, an old disease still in the news: two case reports]. / Le scorbut, une vieille maladie toujours d'actualité: à propos de deux cas.

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

[Acute bronchiolitis and chest physiotherapy: the end of a reign]. / Bronchiolite et kinésithérapie respiratoire: un dogme ébranlé.

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

[Value of routine identification of respiratory infectious agents in children hospitalized with an acute asthma exacerbation]. / Intérêt de l'identification en routine des agents pathogènes respiratoires chez les enfants hospitalisés pour une exacerbation d'asthme.

BACKGROUND: Asthma is the most common chronic disease in childhood. With its high economic burden, it is considered a disease of major public health importance by the World Health Organization. The link between respiratory tract infections and acute exacerbation has been recognized for a long time. The aim of this retrospective study in routine care was to evaluate our practices concerning microbiological prescriptions in children hospitalized for asthma exacerbation. STUDY DESIGN: All children aged from 2 to 15 years hospitalized for asthma exacerbation between January 2010 and December 2011 in our unit were included in the study. Microbiological prescriptions, their indications, their results, and their cost were studied. RESULTS: One hundred ninety-seven children were included in the study. A potential causative agent was sought in 79.7% of the children (n=157) by immunofluorescence assay (IFA) and/or polymerase chain reaction (PCR). The main indications were upper airway infections, hypoxemia, and pneumonia. Viruses were detected in 23.8% of them (30/126). Mycoplasma pneumoniae was detected by PCR in only 3.2% of these patients (4/125). No other bacterial agent was identified. There was no correlation between the severity of asthma exacerbation and the microbiological diagnosis of infection. The results did not influence the therapy given. These prescriptions represented a substantial cost for each child. CONCLUSION: These analyses do not seem to have a real advantage for the patient except for epidemiology. It would be important to conduct a new study analyzing the role of rhinovirus, and of other viruses such as coronavirus, bocavirus, and enterovirus, not routinely investigated in our hospital, and to question the value of these costly microbiological tests.

[Infections of central venous catheters in home parenteral nutrition: a retrospective monocentric study over 2 years]. / Infections des voies veineuses centrales en nutrition parentérale à domicile : étude rétrospective monocentrique sur 2ans.

BACKGROUND AND STUDY AIMS: Infection of the central venous catheter (CVC) is the main aggravating factor of parenteral nutrition. The aim of this study was to determine the ecology of these infections in our home parenteral nutrition center and to evaluate our care protocol. PATIENTS AND METHODS: The present study was monocentric and retrospective, and was conducted in the parenteral nutrition service of the Marseille University Hospital between 1 January 2011 and 31 May 2012. During this period, all the children who presented fever and a positive hemoculture in a medical emergency were taken into account, and the characteristics of the infection were analyzed. RESULTS: After 17 months, 17 children had been subject to an infection in their central catheter: 47 bacteremia were identified, which is equivalent to 5.4 infections for 1000 days of CVC. An average 2.8 hemocultures were performed during this time. The most common bacterium was Staphylococcus hominis. The children affected by a digestive stoma or by a gastrostomy were not subject to more infections and their ecology was not different. All the children were referred to the hospital and treated with an intravenous antibiotic through the CVC. DISCUSSION: As expected during the time of the study, the infection rate was very high. This finding led us to reassess our prevention protocol. It is also very likely that the number of infections was overestimated due to the protocol for sampling in the hemocultures and their subsequent analysis. Lastly, some children relapsed easily, although no predisposing factor was found in the present study. The therapy chosen was in agreement with the best practices and the ecology recovered. CONCLUSION: The high number of infections observed during the study encourages a prospective evaluation of current practices.