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Background: We report a case of geometrical skin lesions in a teenage patient., Case: A previously healthy 14-year-old boy presented in our pediatric emergency department with unusual skin lesions on his left forearm. The patient said the lesions started 2 weeks earlier following a spider bite. His physical examination revealed an otherwise healthy child with no medical history with raised square lesions of the left forearm. The lesions were in different stages of healing and resembled second-degree burns. Examination showed no other lesions. Vital signs were normal. The patient was discharged after the lesions were dressed with antibiotic ointment. A follow-up consultation was scheduled a week later, but the patient did not attend the follow-up consultation. A senior emergency physician called the family and learned that the lesions were progressively healing and no other lesions appeared. The teen admitted he played the "salt and ice challenge.", Discussion: The salt and ice challenge involves putting salt on the skin and then applying and/or pressing ice cubes on top of the salt. The challenge is to resist the pain consecutive to frostbite for as long as possible. The result is often second-degree burns and possible partial third-degree burns., Conclusions: Because of the current popularity of this practice, emergency or family physicians, pediatricians, dermatologists, and burn or orthopedic surgery units might encounter these injuries. When young patients present with geometrical burn injuries and unexplained or bizarre circumstances, self-inflicted burn "challenges" should be considered., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Minoxidil hair formulation is commonly used for the treatment of male or female androgenic alopecia. This over-the-counter product is wrongly considered safe. The ingestion of a few milliliters by a child can lead to significant intoxication. We report a case of significant intoxication after the ingestion of topical minoxidil (Alopexy; Pierre Fabre Laboratoires, SA, Switzerland). A 7-year-old girl, who accidentally ingested a teaspoon of minoxidil hair solution, presented to the pediatric emergency department for emesis. At admission, she had a blood pressure of 86/56 mm Hg and a pulse of 149 beats per minute. Hypotension lasted 40 hours with the lowest value 24 hours after ingestion (79/33 mm Hg). She presented electrocardiogram changes (sinus tachycardia and flattening T-waves) but normal cardiac enzymes. Infusion of 20 mL/kg of normal saline fluid had no hemodynamic effect. Her blood pressure normalized on day 2. Minoxidil topical solution is an unsafe product for children. This formulation should be strictly kept out of reach of children and manufacturers should enhance child-resistance security of packaging. The over-the-counter availability must be questioned.

Objectives: Cannabis intoxication in toddlers is rare and mostly accidental. Our objectives were to focus on the characteristics and management of children under the age of 6 years who were admitted to our emergency department with cannabis poisoning reported as accidental by parents, and to point out the need to consider accidental cannabis ingestions as an indicator of neglect., Methods: The medical records of children hospitalized for cannabis poisoning in a pediatric emergency department from January 2007 to November 2012 were retrospectively evaluated. Data collected included age, sex, drug ingested, source of drug, intentional versus accidental ingestion, pediatric intensive care unit or hospital admission, treatment and length of hospital stay, toxicology results, and rate of child protectives services referral., Results: Twelve toddlers (4 boys and 8 girls; mean age, 16.6 months) were included. All had ingested cannabis. Their parents reported the ingestion. Seven children experienced drowsiness or hypotonia. Three children were given activated charcoal. Blood screening for cannabinoids, performed in 2 cases, was negative in both, and urine samples were positive in 7 children (70%). All children had favorable outcomes after being hospitalized from 2 to 48 hours. Nine children were referred to social services for further assessment before discharge., Conclusions: Cannabis intoxication in children should be reported to child protection services with the aim of prevention, to detect situations of neglect and at-risk families. Legal action against the parents may be considered. Accidental intoxication and caring parents should be no exception to this rule.

Background: Viper bites and subsequent evolution to severe envenomations are more frequent in children., Aim: The aims of this study were to describe the clinical, biological, and therapeutic characteristics of children bitten by vipers in France and to identify risk factors associated with severe envenomations., Methods: A retrospective study was conducted between 2001 and 2009 in the pediatric emergency department of a tertiary-level children hospital. Collected data were age and sex of children; day and time of admission; day, time, and circumstances of the accident; snake identification; bite location; envenomation severity; presence of fang marks; prehospital care; use of specific immunotherapy and associated treatments; length of stay; and hospital course., Results: Fifty-eight children were included (43 boys, 15 girls). The mean age was 7.8 ± 4.1 years. Bites were most often located on the lower extremities (77%). The classification of envenomation was: 83% low grade (absence or minor envenomation) and 17% high-grade (moderate to severe envenomations). All high-grade envenomations received specific immunotherapy (Viperfav). Being bitten on an upper extremity (P < 0.001), during the afternoon (P = 0.025), feeling violent pain (P = 0.037), and high initial glucose level (P = 0.016) were associated with a significant risk of high-grade envenomation. In the multivariate analysis, 3 factors remained significant: upper-extremity location (relative risk [RR], 60.5 [3.5-1040]; P = 0.005), immediate violent pain (RR, 21.5 [1.3-364.5]; P = 0.03), and female sex (RR, 17.5 [0.9-320.3]; P = 0.053)., Conclusions: A certain number of criteria seem related to more significant risk of progression to high-grade envenomation. Bites to the upper extremities should be carefully observed because of the risk of evolution to a high-grade envenomation.

Aim: This study aimed to report a rare clinical course of pandemic influenza A(H1N1) infection, ischemic stroke, in a 9 month-old child., Case: A 9-month-old girl with no previous medical problem presented to our pediatric emergency department with high fever (39°C/102°F) lasting for 48 hours. Soon after admission, she started generalized tonic-clonic seizures that ceased after 2 injections of diazepam. Six hours later, she presented 2 short episodes of partial clonic seizures of the right arm followed by monoplegia. Lumbar puncture was normal. Noncontrast computed tomographic imaging of the brain was performed and revealed an acute infarct in the left middle cerebral artery territory with no mass effect. Electroencephalogram revealed important slowing in the left hemisphere. A magnetic resonance imaging was performed the next day and confirmed an ischemic stroke in the left posterior middle cerebral artery region. Nasal swab polymerase chain reaction was positive for influenza A(H1N1) and polymerase chain reaction detection negative in cerebrospinal fluid. She fully recovered her right-arm function on day 3 and was discharged on day 10 without sequelae., Comments: Seasonal influenza is known to cause neurological complications in children. Influenza increases the stroke risk especially in adults at high risk. This is a rare event in childhood, and we believe this is the first report associated with H1N1 new variant., Conclusions: Acute viral infection, notably influenza, is associated with increased susceptibility to stroke, and vaccination against influenza may reduce the risk of stroke.

Objective: Describe the epidemiology of a pediatric resuscitation room (PRR)., Methods: A prospective study was performed in a pediatric emergency department (PED) from June 17, 2004 to March 19, 2006. Collected data were date and time of admission in the unit and, in the PRR, age and sex, geographical origin, mode of transportation, PED referral mode, diagnosis, evolution, and resuscitation techniques. Statistical analysis included a univariate analysis of hypothetical links between variables and their relation to the risk of death or transfer to the pediatric intensive care unit, then a multivariate analysis by logistical regression where the dependant variable was this risk., Results: Three hundred sixty-one patients totaled 370 admissions. The male-female ratio was 1.3. Mean (SD) age was 5.5 (5.2) years. A quarter of the population was recommended for admission by a physician. Main causes were cardiocirculatory (32%), neurological (26%), respiratory (23%), and traumas (18%), and 17% were hospitalized in an intensive care unit and 4 died. Sixteen technical resuscitation procedures were performed. Children from 0 to 2 years old were more often admitted for cardiocirculatory insufficiency (P < 0.001). The children who were at higher risk for pediatric intensive care unit transfer or death were children from 0 to 2 years old (P < 0.001), an admission for respiratory insufficiency (P < 0.001), and an arrival by medicalized transport (P = 0.003)., Conclusions: In addition to national guidelines for PRR management, the teaching and knowledge of the different diagnosis admitted in the PRR and their resuscitation technical procedures warranty a serener approach of those stressful situations.

Background: Saddleback caterpillar sting has been very rarely reported in European countries. We report a French case of a stung toddler., Case: A 2-year-old girl was brought to the pediatric emergency department after being stung by a caterpillar in a furniture store. The emergency department physical examination revealed an inflammatory edema of the stung finger, normal vital signs, and no fever. Three hours after presentation, she was discharged with local ointment prescription. The caterpillar brought in by the parents was unusual compared to common French caterpillar species. The regional poison center was unable to identify it. With the help of the Internet, we succeeded in its identification as a saddleback caterpillar. Tracing its transatlantic importation was the most difficult., Conclusions: Saddleback caterpillars can be imported to France and carried across the Atlantic Ocean on house or garden plants especially Areca trees. French garden store owners should be informed about this risk and should check and treat host plants (especially Areca trees) at the arrival time.

Background: Evaluate, by radiographic analysis, tibial growth after an intraosseous infusion (IOI) in a pediatric population., Methods: We performed a prospective simple blind study, between January 1, 1994, and July 1, 2001, which included pediatric patients who needed an intraosseous trocar in emergency situations. During the follow-up, roentgenographs were performed. On each radiologic view, different measurements were carried out: anterior and lateral tibial length, anterior and lateral width at 2 diaphyseal levels. We compared the anterior length values to those published in the Anderson et al tables. When only one tibia was punctured, the mean measurements were compared with the control leg measurements using a paired t test., Results: The initial population included 78 patients. Of these 78 subjects, 42 died, 10 families could not be contacted, and one refused to participate. Two children were excluded because they had other conditions that could influence tibial growth. The study included 23 children. The puncture site was the proximal tibia. The mean age was 18.6 months at the time of IOI, the mean time of infusion was 5 hours, and the mean perfused volume was 225 mL. The mean radiologic follow-up time was 29.2 months. When compared with the Anderson et al tables, all the anterior length values were within the 95% confidence interval. For the other measurements, the statistical analysis showed no significant difference between punctured and control legs., Conclusion: There is no long-term effect on tibial growth after an IOI when the IO trocar is properly placed.