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Summary: Introduction: Dehydration is an important complication for sick children. The Clinical Dehydration Scale for children (CDS) measures dehydration based on 4 clinical signs: general appearance, eyes, saliva, and tears. Objective: To validate the association between the CDS and markers of dehydration in children aged 1 month to 5 years visiting emergency departments (EDs) for vomiting and/or diarrhea. Method: An international prospective cohort study conducted in 3 university-affiliated EDs in 2009. Participants were a convenience sample of children aged 1–60 months presenting to the ED for acute vomiting and/or diarrhea. Following triage, a research nurse obtained informed consent and evaluated dehydration using the CDS. A few days after recovery, another research assistant weighed participants at home. The primary outcome was the percentage of dehydration calculated by the difference in weight at first evaluation and after recovery. Secondary outcomes included proportion of blood test measurements, intravenous use, hospitalization, and inter-rater agreement. Results: During the study period, 264 children were recruited and data regarding weight and dehydration scores were complete for 219 (83%). According to the CDS, 88 had no dehydration, 159 some dehydration, and 15 moderate or severe dehydration. A Chi-square test showed a statistical association between CDS and weight gain, the occurrence of blood tests, intravenous rehydration, hospitalization, and abnormal plasmatic bicarbonate. Good inter-rater correlation was found among participants (linear weighted Kappa score of 0.65; (95% CI, 0.43–0.87). Conclusion: CDS categories correlate with markers of dehydration for young children complaining of vomiting and/or diarrhea in the ED. [Copyright &y& Elsevier]

Abstract: The coping capacity of the children during dental care depends on different factors such as age, cognitive development, personal history and social background. A good knowledge and understanding of child developmental stages will help the dentist to treat them successfully. Parental presence during treatment has been largely discussed in pediatrics and pediatric dentistry. Dentists often let parents stay in the office during the first consultation but prefer them to be in the waiting room during treatment. Depending on the case, parental presence may be needed, essential, or advised against. Parental presence during child treatment must be analyzed, but the ultimate decision is the dentist''s. [Copyright &y& Elsevier]

Summary: Aims: Analyze the epidemiology and the distribution of judo injuries in a pediatric population. Patients and methods: A retrospective study was conducted from May 2006 to May 2008, including all patients aged less than 15 years admitted to a tertiary-level pediatric emergency unit. The data collected were age, sex, geographic origin, time and day of admission, duration in the pediatric emergency department, body weight, type and location of injuries, and progression. For statistical analysis, data were entered in Microsoft Excel tables. In the descriptive analysis, data are presented as mean values with SD. To compare qualitative variables, a χ2 test was used and the two-tailed Fisher exact test if the expected value was lesser or equal to 5. Statistical significance was considered at P <0.05. Results: During the study period, 173 patients were included, with a male:female ratio of 2.46. The mean age was 10.6±2.4 years. Most children were admitted during the weekend (59 %). The distribution of lesions was contusions (44 %), fractures (31 %), sprains (19 %), dislocations (3 %), and wounds (3 %). The upper extremities were more frequently affected than the lower extremities (46 % vs. 25 %), with a significant male prevalence (78 %) (P <0.0001), dominated by fractures (54 %), especially clavicle fractures (72 %). Compared to the other injuries, the male population had a significantly higher risk of fractures (P =0.04). Thirteen children required hospitalization for surgical repair of fractures. Conclusion: Frequent and often benign, judo accidents in children are different from adult injuries in their mechanisms and injury distribution. There is also an additional risk of growth plate damage. Risk factors have been attributed to an increased injury incidence: body weight loss over 5 % or overweight, age and judo experience, and male gender. During competition and training sessions, the evaluation and prevention of these factors could decrease the occurrence of such injuries. [Copyright &y& Elsevier]

Abstract: Aim: Epidemiological analysis in a universitary paediatric emergency unit of children admitted after accidental injuries resulting from fingers crushed in a door. Material and Methods: Prospective, descriptive cohort study from September 6th, 2004 to July 1st, 2005 included all children admitted for finger injuries crushed in a non-automatic door. Exclusions: included accidents due to automatic doors, toy''s or refrigerator doors, families who refused to participate to the study or families who had left the waiting area before medical examination. Collected data were patient and family characteristics, accident characteristics and its management. Results: Three hundred and forty children affected by 427 digital lesions were included. The mean age was 5.5±3.8 years (range 4 months - 15.5 years). Male/female ratio was equal to 1.2: 1. Fifty-eight percent of patients belonged to families composed of 3 or more siblings. Ninety-three per cent of families came to hospital within the first 2 hours after the accident (mean delay 99±162 min, median range 54 minutes). Location of the accident was: domestic (62%, at home (64%)), at school (17%). Locations within the home were: the bedroom (33%), bathroom and toilets (21%). An adult was present in 75% of cases and responsible for the trauma in 25% of accidents, another child in 44%. The finger or fingers were trapped on the hinge side in 57% of patients. No specific safeguard devices were used by 94% of families. Among victims, 20% had several crushed digits; left and right hand were injured with an equal frequency. The commonest involved digits were: the middle finger (29%), the ring finger (23%). The nail plate was damaged in 60% of digital lesions, associated with a wound (50%), a distal phalanx fracture (P3) (12%). Six children had a partial or complete amputation of P3, 2 children a lesion of the extensor tendon, 1 child had a rupture of the external lateral ligament. Three percent of children required an admission to the paediatric orthopaedic surgery unit. Post-traumatic pain was mainly limited to the first 48 h (64%). Early complications included: 16 cases of infected injuries, 3 cases of pulpar necrosis. The total cost of hospital care was 71500 euros, the average cost for hospitalised patient equal to 2100 euros and for ambulatory cases equal to 141 euros; the annual cost was estimated at 81600 euros. Conclusion: Associated with potentially serious digital injuries, functional or inesthetic sequelae, this painful experience still remains too frequent in toddlers for a home accident that could be often prevented by the acquisition of specific protective doors devices and for a reasonable cost compared to the cost of hospital care. [Copyright &y& Elsevier]

Abstract: Objectives: To refine and to re-validate the best current tool (the Nigrovic rule: ‘‘outpatient management may be considered for children without seizure, blood neutrophil count≥10,000/mm3, positive cerebrospinal fluid –CSF– Gram-staining, CSF protein≥80 mg/dl, or CSF neutrophil count≥1,000/mm3’’) proposed to distinguish between aseptic meningitis (AM) and bacterial meningitis (BM) in the emergency department. Methods: Children hospitalized for BM between 1995 and 2004, or AM between 2000 and 2004 were included, and randomly divided into derivation (111 children, 14 BM) and internal validation (57 children, 7 BM) sets. The Nigrovic rule was refined on the derivation set, introducing new variables (purpura, toxic appearance and high serum procalcitonin), changing variables thresholds (CSF protein) and withdrawing some variables (blood neutrophil count, CSF neutrophil count), according to previous results, with the aim to obtain 100% sensitivity user friendly tool. The refined rule was then applied on the internal validation set, stayed blinded during the derivation process. Results: The refined rule was: start antibiotics in case of seizure, purpura, toxic appearance, procalcitonin≥0.5 ng/ml, positive CSF Gram-staining, or CSF protein≥50 mg/dl. The refined rule had 100% sensitivity on the derivation and the internal validation sets (95% confidence interval 78–100, and 65–100, respectively) with 62 and 51% specificity, respectively. Conclusion: The refined rule (called Meningitest®) was a highly sensitive, specific and user friendly tool that could allow to safely avoid>50% a posteriori unuseful antibiotic treatments for patients with AM. [Copyright &y& Elsevier]

Abstract: Objectives. – To describe the different pathways of management of intussusception (IS) in infants and children in metropolitan France and to identify paediatric emergency centres that might constitute a surveillance network for IS. Material and Methods. – A questionnaire was sent to 273 paediatric emergency centres distributed across France in 2005. Modalities of diagnosis and treatment of IS had to be precised. Results. – One hundred and sixty-seven centres (61.2%) responded. The response was given by 131 paediatricians (78.4%) and 36 surgeons (21.6%) working in 38 universitary hospitals (22.7%) and 129 general hospitals (77.2%). The mean number of IS treated in each centre in 2004 was 11±13.5 (extr. 0 to 70; median 6). Diagnosis of IS required a collaboration between medical and surgical teams in 51.5% of the centres, but in 40.1% the sole medical team was in charge of the diagnosis. Ultrasonography is used for diagnosis by 98.8% of the centres. Reduction with hydrostatic enema and eventually surgery was performed in the same hospital in 44.3%. Other centres systematically or frequently transferred the patients for reduction, mostly towards universitary hospitals (90%). Conclusion. – The procedures of IS diagnosis are the same everywhere in France but the pathways of therapeutic management do vary, depending on the availability of surgeons and anaesthetists trained in paediatrics on each site. These disparities will probably change with the implementation of the new plan for sanitary organization in children and adolescents in France. Labellized paediatric emergency centres will gather more surgical patients and could eventually constitute an effective surveillance network for IS. [Copyright &y& Elsevier]

Abstract: Objective. – Fever is a common cause of children visits to emergency units. Clinical evaluation does not always eliminate a bacterial infection. Among blood markers, several publications showed the interest of CRP. This study was undertaken to evaluate correlation between two techniques of CRP, one by usual technique at the laboratory and the other by a rapid test, and to evaluate the impact of this rapid test for febrile children at the emergency room, when a hospitalization was not immediately decided. Material and methods. – The study was undertaken in 2004–2005 in eight emergency paediatric units in Ile-de-France concerning febrile children during two periods. In period A, children had at the same time a CRP dosage through two methods, whereas in period B, only a rapid CRP test was first managed. The test used was NycoCard® CRP Single test (Progen Biotechnique). Results. – Between September 2004 and June 2005, 572 children were included, 268 in period A and 304 in period B. Comparison of CRP results by the two methods showed for 247 children (93%) a fairly good linear correlation (r: 0.929). Blood cell count was the most often prescribed test (99.4 vs 10.5%). Conversely to chest radiography, blood culture, fibrinogen and urinary test were significantly most frequent in period A. The average cost of the additional examinations was 2.6 times more important during the first period. Duration of children management in the units was approximately two times shorter when rapid CRP test was used (199.7±92.8 vs 103.5±98.6 min). Conclusion. – This study shows the interest of rapid CRP test for febrile children in the emergency units, and has to be confirmed in ambulatory paediatric practice. [Copyright &y& Elsevier]

Abstract: Objective. – To compare treatment with beta 2 agonist delivered either by a spacer device or a nebulizer in children with severe or potentially severe acute asthma. Methods. – In this randomized trial, children 4 to 15 years, cared for in the emergency department for severe or potentially severe acute asthma, received 6 times either nebulizations of salbutamol (0.15mg/kg) or puffs of a beta 2 agonist (salbutamol 50 μg/kg or terbutaline 125 μg/kg). The primary outcome was the hospitalization rate. Secondary outcomes included percentage improvement in Bishop score, in PEF, SaO2, respiratory and heart rates, side effects, length of stay and relapses 10 and 30 days later. Results. – Groups did not differ for baseline data. There were no significant differences between the 2 groups (nebulizer N =40, spacer N =39) for baseline characteristics before emergency department consultation except for length of acute asthma in the spacer group. Clinical evolution after treatment, hospitalization rate, relapse were similar including the more severe subgroup. In the spacer group, tachycardia was less frequent (P <0.02). The overall length of stay in the emergency department was significantly shorter (148±20 vs 108±13 min, P <10−9). Conclusions. – The administration of beta 2 agonist using a metered-dose inhaler with spacer is an effective alternative to nebulizers for the treatment of children with severe or potentially severe acute asthma in the emergency department. Time gained can be used for asthma education. [Copyright &y& Elsevier]

With the increasing number of emergency paediatric consultations, two surveys “on a given day” were performed in the “Communaute´ Urbaine de Lyon”, with the aim of analyzing the causes, circumstances, and relevance of these unplanned consultations, as well as a better understanding of the itinerary of these patients.Methods. – Unplanned consultations concerned children less than 18 years old seen in consultation on Saturday April 21, and Thursday December 13, 2001, in all medical facilities capable of delivering emergency paediatric care. Data collection was performed by filling out a questionnaire given to the family and the physicians (general practitioner who were chosen randomly, or paediatricians volunteering for the study), working in general medicine sectors, at the outpatient emergency consultation of the “Groupement des Pe´diatres du Lyonnais”, and in all the emergency departments to which children could be addressed (public hospitals and private clinics). “SOS Me´decins” did not participate in this study but communicated its activity a posteriori. Six hundred and eighty three consultations on the Saturday and 1183 on the Thursday were analyzed.Results. – An estimation of the total number of consultations was performed taking into account the proportion of practitioners participating in the survey, with a total number of 1813 consultations on the Saturday and 4576 on the Thursday. Consultations in the private setting (by practitioners or organized emergency centers) accounted for 82% on the Saturday (general practitioners 70%, paediatricians 12%) and 93% on the Thursday (general practitioners 75%, paediatricians 18%), public hospitals 13% and 4% and private clinics 5% and 2%, respectively. Parents considered the problem to be serious in 10–40% of the cases, depending on the setting. The reason justifying consultation was generally medical (pain or discomfort, fear of complication, less frequently feeling of imminent danger). Non-medical reasons (proximity of the week-end, personal reasons, absence or unavailability of usual practitioner) concerned a fourth of the Thursday consultations and up to half of the Saturday consultations. An urgent consultation was estimated not be justified in 13% of the cases according to the physicians. The main reason for going to a hospital was that “everything would be available on site”. On Saturday the absence of the usual practitioner was the most cited reason. The global itinerary was deemed satisfactory by the physicians in 82% of the cases.Conclusion. – Unplanned consultations are found in three situations: routine and accepted activity of medical office (consultation without an appointment), urgent medical problem (or estimated to be urgent), and the result of a dysfunction between the medical possibilities of the health care system and its use by the parents. This last point opens two possibilities of action which are the information and education of families and the networking of physicians involved in emergency consultations with the aim of reducing hospital consultations by 15–20% [Copyright &y& Elsevier]

Background. – To determine if the addition of ipratropium bromide in the emergency department (ED) for the treatment of childhood asthma reduces rates of hospitalization and relapses for moderate and severe exacerbations.Methods. – Patients were given an oral corticosteroid treatment (2 mg/kg) and received every 20 minutes either three nebulizations with albuterol (0.15 mg/kg) and ipratropium bromide (250 μg) or six nebulizations with albuterol alone (control group). The primary end point was the need for hospitalization, additional nebulizations or a relapse during the following week. Secondary end point included the effect of age.Results. – One hundred and fourty three children, two to 15 years old, were randomized to ipratropium or control groups and 121 were evaluated on day seven. As a whole, the control group was less often hospitalized or in relapse than those treated with three nebulizations of albuterol and ipratropium (17.5% vs 37.9%, p <0.02). The ipratropium group reached the same result after three additional albuterol nebulizations. The benefit of anticholinergic therapy was observed for children less than six years of age who had a similar rate of success (73.5 vs 75.7%).Conclusion. – The association of ipratropium bromide to the first three doses of the albuterol protocol for acute asthma did not act as well as six nebulizations of albuterol alone. The effect was age dependent and two to six years old children needed more attention. Nevertheless the hospitalization rate did not support the use of ipratropium compared with repeated albuterol nebulizations. [Copyright &y& Elsevier]