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Multisystemic inflammatory syndrome in children (mis-c) Asociated with covid Although children are less susceptible to sars-cov-2 and less symptomatic than adults with low mortality, clusters of Septic shock associated with elevated cardiac biomarkers and unusual vasoplegia have been recently described and Treated by inotropes, vasopressors, and fluid loading. Both clinical symptoms (i.e., high and persistent fever, gastrointestinal Disorders, skin rash, conjunctivitis and dry cracked lips) and biological signs (e.g., elevated crp/procalcitonin, high Levels of ferritinemia) resembled kawasaki disease. In most instances, intravenous immunoglobin therapy with glucosteroids Improved the cardiac function and led to full recovery within a few days. However, adjunctive biotherapy (e.g., Anti-il-1ra, anti-il-6 monoclonal antibodies) was sometimes necessary. Although almost all children fully recovered Within a few days, some of them developed late coronary artery dilation or aneurysm. Thus, a new "multisystem inflammatory Syndrome in children" (mis-c) associated with sars-cov-2 has been identified, and its pathophysiology better Understood., Competing Interests: Les auteurs déclarent n’avoir aucun lien d’intérêts.

SARS-CoV-2 pandemics is characterized by a high level of infectivity and a high mortality among adults at risk (older than 65 years, obesity, diabetes, systemic hypertension). Following a common viral pneumonia, a multisystem inflammatory syndrome sometimes occurs, including an Acute Respiratory Distress Syndrome (ARDS) carrying a high mortality. Unlike most common respiratory viruses, children seem less susceptible to SARS-CoV-2 infection and generally develop a mild disease with low mortality. However, clusters of severe shock associated with high levels of cardiac biomarkers and unusual vasoplegia requiring inotropes, vasopressors and volume loading have been recently described. Both clinical symptoms (i.e., high and persistent fever, gastrointestinal disorders, skin rash, conjunctivitis and dry cracked lips) and biological signs (e.g., elevated CRP/PCT, hyperferritinemia) resembled Kawasaki disease. In most instances, intravenous immunoglobin therapy improved the cardiac function and led to full recovery within a few days. However, adjunctive steroid therapy and sometimes biotherapy (e.g., anti-IL-1Ra, anti-IL-6 monoclonal antibodies) were often necessary. Although almost all children fully recovered within a week, some of them developed coronary artery dilation or aneurysm. Thus, a new 'Multisystem Inflammatory Syndrome associated with SARS-CoV-2' has been recently described in children and helps to better understand Kawasaki disease pathophysiology., (© 2021 l'Académie nationale de médecine. Published by Elsevier Masson SAS. All rights reserved.)

Competing Interests: Les auteurs déclarent n’avoir aucun lien d’intérêts.

The vast majority of medicines have been developed for adults. Consequently, the prescribing of medicines for children must take into account their pharmacodynamic characteristics and must be calculated individually according to the degree of prematurity, the age, the weight or body area and the clinical condition. Medication errors are the most common type of medical errors, notably in children, due to dosage errors or prescribtion of inappropriate medicines. The best way to avoid them lies in the use of prescribing software, the involvement of pharmacists in care units, and proper communication between prescribing doctors, caregivers, pharmacists and families., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Suicide attempts (SA) in children are often considered rare and poorly studied. The aim of this study was to explore the clinical characteristics of SA in children under 12 years of age. A retrospective assessment was conducted in 30 consecutive SAs reported in children under 12 years of age admitted to the emergency department at the Robert-Debré University Hospital (Paris, France) from 2007 to 2010 and the Regional University Hospital (Besançon, France) from 2000 to 2008. All suicide attempters were directly assessed at the somatic and psychiatric level. Patients were 8-11 years old (mean, 10.2±0.8). The sex ratio was 0.9 boys for 1 girl. The leading SA methods were poisoning by medication (53.3%), hanging or strangulation (23.3%), jumping from a height (16.7%), poisoning by chemicals (3.3%), and lesions inflicted by sharp objects (3.3%). In addition, SAs were characterized by high lethality (43.7%) contrasting with their low to moderate suicidal intentionality (43.8% and 56.2%, respectively). In conclusion, we reported that SA in children differs from those of adolescents by their greater lethality related to the methods used, but contrasting with the low intentionality mentioned by these patients., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Every year, epidemics of viral bronchiolitis and gastroenteritis occur with a significant increase in the number of visits (by a factor 1.8) and hospitalisations that can over-exceed bed capacity leading to transfer sick children to other hospitals. This kind of hospital 'crisis' is not limited to paediatrics, big cities or western nations. It is a worldwide worrying problem. Because our hospital sits in the Northern districts of Paris where a large community of m.ncants lives in poverty, our number of visits is high (mean 250 per day), and winter epidemics further jeopardise the difficult equilibrium achieved between quality management and waiting times. Thus, we have taken various initiatives in terms of organisation of the paediatric emergency department and other wards, including a "fast track" clinic, the opening of beds dedicated to winter epidemics, the institution of a "bed manager" in order to more easily find a bed, and a larger use of home hospitalisations. Furthermore, we created a specific committee which may decide on various indicators of tension whether it is necessary to cancel programmed hospitalisations or surgery.in order to resolve the emergency crisis. This kind of organisation can serve as a model for other hospitals facing winter epidemics crises.

Objectives: Evaluating the frequency and modalities of transmissible infection prevention counseling in children before a stay in tropical or subtropical areas., Methods: Description of the frequency and modalities of transmissible infection prevention counseling (except specific vaccination) given prior to travel in children attending a tertiary care center in Paris, France, for fever occurring within 3 months following a return from Africa. Data were collected retrospectively from medical observations and telephone interviews with parents., Results: A total of 173 children were included; 98 and 75 returned from sub-Saharan Africa and North Africa, respectively. Forty-one percent were less than 2 years old. Eighty-one percent of the children had consulted before leaving. Among children who returned from North Africa, the proportion of children who had a specific preventive consultation before travel was lower than among children who returned from sub-Saharan Africa (respectively, 72.1% versus 94.7%; p<0.001). In children having consulted before traveling, specific hygiene and diet advice had been given in 72% of cases but less frequently in children who traveled in North Africa compared to children who traveled to sub-Saharan Africa (respectively, 57.8% vs. 92.2%; p<0.001). Among children who returned from North Africa, those who had no preventive consultation before travel had febrile gastrointestinal infection more frequently than those who had a consultation before traveling (p=0.003)., Conclusion: Although in this study the majority of children traveling to Africa receive transmissible infection prevention counseling before the travel, prevention could be improved, particularly before a stay in North Africa., (Copyright © 2011. Published by Elsevier SAS.)

With the advent of prenatal steroids, postnatal exogenous surfactant and less aggressive respiratory support, premature infants can develop chronic lung disease without even acute respiratory distress. This "new bronchopulmonary dysplasia" could be the result of impaired postnatal growth. Several experimental studies have suggested a possible role of the vascular endothelial growth factor/nitric oxide (VEGF/NO) pathway in restoring pulmonary angiogenesis and enhancing distal lung growth. The results of the clinical studies are, however, inconclusive, and it is currently unclear which subsets of premature infants might benefit from inhaled nitric oxide. Besides, severe intracranial haemorrhage and/or cystic periventricular leukomalacia may affect the most immature babies, many of whom are spared from severe initial respiratory disease. Recently, inhaled nitric oxide was shown to significantly decrease the incidence of these neurological events, and to improve the long-term outcome in a few clinical trials. At times neuroprotective, at times neurotoxic, nitric oxide is capable of divergent effects depending upon the extent of cerebral damage, the redox state of the cell, and the experimental model used. Recently, inhaled nitric oxide had recognized to have dramatic remote effects including angiogenesis and maturation on the developing brain in rodent pups. Therefore, the developmental consequences of inhaled NO should be further investigated to ensure its safety on the developing brain and to test its potential neurprotective effect.

Bacterial meningitis is a medical emergency requiring prompt recognition and evaluation and urgent initiation of appropriate antibacterial therapy. However, early recognition of severe bacterial infection including bacterial meningitis is a challenge in infants. Two clinical forms are basically observed in infants and young children: firstly, clinical meningitis which is characterized by fever, usually greater than 39 degrees C, and poorly specific gastrointestinal signs such as refusal of feeding and/or vomiting; irritability, abnormal crying, bulging fontanel, unusual generalized seizures occurring before six months of age and lasting more than 10 min should draw the clinician's attention and lead him/her to perform a lumbar puncture and initiate antibiotics; secondly, severe sepsis which is characterized by tachycardia, cold and/or mottled limbs and sometimes leg pain which should suggest a meningococcal disease; it is quite urgent to administer rapid fluid loading and antibiotic treatment while postponing lumbar puncture before the septic cascade evolves towards septic shock, extensive hemorrhagic rash, and ischemic limbs. Given the relative frequency of viral self-limiting diseases and rarity of serious bacterial infections, guidelines were published to guide the clinician's decision when dealing with a febrile infant. However, an alternative to these guidelines was recently suggested with a more clinically oriented decision-making attitude appearing as efficient while limiting hospitalizations.

Despite significant progress in intensive care medicine, the mortality of septic shock has not changed in recent years. Early recognition of subtle signs in favor of meningococcal sepsis, early antibiotic treatment, and aggressive hemodynamic support remains the cornerstone of therapy of severe meningococcal shock in children. Recent work has emphasized the role of genetic polymorphisms in various systems to explain the most severe cases: anti-inflammatory cytokine profile IL-10/TNF-alpha, elevated levels of plasminogen activator inhibitor type-1, variants of the gene for mannose-binding lectin complement pathway. This may explain the disillusionment of pediatric intensivists, and the general failure of immunotherapy for sepsis. Reasonable hope lies upon new meningococcal vaccines.

Unlabelled: New issues have arisen in pediatric intensive care units, especially concerning long-stay patients. The aims of the present study were to describe the etiologic factors of these long-stay patients and to recognize the comorbidities., Material and Methods: Ninety-five patients who had a total of 100 hospitalizations of more than 30 days were admitted to the pediatric intensive care unit at Robert-Debre Hospital during a 3-year period (1993-1995); this accounted for 9.1% of total admissions. We retrospectively reviewed these 100 long-stay hospitalizations., Results: Most of these patients were newborns (65%). Patients with severe congenital anomalies (44 patients) and very premature infants (26 patients) constituted the majority of long-stay patients. The mean duration of mechanical ventilation for the 95 patients was 110 days (ranges 17-789 days). Two factors of comorbidity were found: gastroesophageal reflux (41% of cases) and nosocomial infections (89% of cases)., Conclusion: In order to prevent long stays, pediatric intensive care units must be directed toward these factors.

Despite major insights into the pathogenesis and pathophysiology of congenital diaphragmatic hernia, and despite the availability of an antenatal diagnosis and continuous progress in neonatal intensive care, little improvement has been obtained in the prognosis of this malformation. Thus obstetricians, neonatologists and pediatric surgeons are still facing a several dilemma: dilemma before birth to predict the prognosis, i.e., to evaluate the severity of the associated pulmonary hypoplasia in order to decide whether or not to interrupt pregnancy; dilemma after birth in case of severe respiratory failure to decide how far to go in life support. Based on a review of the literature and their own experience, the authors attempt to recapitulate the perinatal management and outcome of this severe malformation.

Described for the first time in 1848 by Bochdalek, congenital diaphragmatic hernia is still a hot topic. How can it be that a simple defect of the diaphragm still has a mortality rate reaching 50% in 1997, and this despite continuous progress in neonatal intensive care? If some problems remain unsolved, experimental studies over the past 30 years have raised some questions concerning the pathogenesis, and have shed some light into the pathophysiology of congenital diaphragmatic hernia. This article reviews the recent knowledge about the aetiology, pathogenesis and pathophysiology of this complex malformation.

Fetal pulmonary circulation is characterized by high resistance and low pulmonary blood flow. Right-to-left shunting through the foramen ovale and/or patent ductus arteriosus is necessary to perfuse the placenta and insure fetal life. At birth, pulmonary arterial blood flow increases immediately by 8- to 10-fold, and allows pulmonary gas exchange and postnatal life. In some circumstances, this adaptation to extra-uterine life is inadequate, because of persistent high pulmonary resistance (PPHN). Due to the lack of a selective pulmonary vasodilator, the treatment of this syndrome remained purely symptomatic using high oxygen levels and barotraumatic mechanical hyperventilation. When this medical treatment failed, the only alternative was extracorporeal membrane oxygenation (ECMO). The discovery of the major role of various endothelium-derived factors including nitric oxide (NO) in the control of vascular reactivity led to dramatic switches in the concepts of severe neonatal respiratory failure and the therapeutic approach of PPHN. It was shown, first in experimental animals then in a few infants with hypoxemic respiratory failure, that NO inhalation selectively vasodilated the vasoconstricted pulmonary vessels, and reversed right-to-left shunting and refractory hypoxemia. Whether inhaled NO also reduces mortality and/or morbidity in hypoxic infants remains to be proven by appropriate randomized clinical trials. However, not only PPHN is associated with pulmonary diseases of various etiologies and underlying pathophysiologic mechanisms, but also inhaled NO is used in conjunction with other validated therapeutic strategies including ante- or postnatal steroids, exogenous surfactants, and high-frequency oscillatory ventilation. Thus, the relevant primary endpoint might be not only crude survival but the most physiological and economical way of obtaining it.

Pulmonary vascular endothelium synthesizes and releases two groups of vasoactive substances, namely the endothelium-derived relaxing and contracting factors. Among the former, the effects of nitric oxide (NO), formerly known as endothelium-derived relaxing factor (EDRF), and those of the so-called endothelium-derived hyperpolarizing factor (EDHF) have been extensively investigated. Among the latter, endothelin is probably one of the most potent endogenous vasoconstrictors. NO is a free radical which can be readly inactivated by hemoglobin. NO has all the characteristics of a gas, whereas its pharmacological properties are consistent with those of an endogenous nitrovasodilator. Therefore, inhalation of the gas NO is now considered as one of the most promising means to treat persistent pulmonary hypertension of the newborn. EDHF relaxes vascular smooth muscle through activation of ATP-dependent potassium channels. Both the chemical nature and the physiological role of EDHF are still unclear. The pharmacological properties of endothelin are far from being unequivocal. It is a potent vasoconstrictor, when it directly acts on vascular smooth muscle. However, it can also induce the release of NO and EDHF, hence causing vasorelaxation. These effects of endothelin are mediated by various transduction pathways. Activations of ET-B receptors located on endothelium on the one hand, and ET-A receptors located on smooth muscle on the other hand, are responsible for relaxation and constriction of vascular smooth muscle, respectively. Such highly complex cellular mechanisms highlight the need for further insight into the physiology of the cell related to the pulmonary circulation. This, in turn, will help to better define the target upon which one can try to correct the abnormal function of the cell underlying the pathophysiological processes.

Background: Neonates with classic maple syrup urine disease (MSUD) undergo rapid neurological deterioration by the end of the first week of life. Exchange transfusion and peritoneal dialysis are the usual emergency treatment. Continuous arteriovenous hemofiltration (CAVHF) appears to be safe and more rapidly effective., Case Report: Martin was born at the 37th week from a normal pregnancy. Abnormal movements of legs and lethargy appeared on the 7th day of life. Progressive brain dysfunction with coma led to intubation on the 13th day. A diagnosis of MSUD was immediately made and CAVHF was initiated and continued for 19 hours. The plasma leucine, valine and isoleucine levels fell from 2,248 to 275, 640 to 91 and 298 to 13 mumol/l, respectively. Neurologic improvement was dramatic, except for moderate hypertonia which lasted for the 2 following days., Conclusion: CAVHF is an appropriate treatment for very young patients with inborn errors of metabolism. It appears safer and more rapidly effective for eliminating branched-chain amino acids than other techniques, such as peritoneal dialysis with or without exchange transfusions. It also permits more rapid introduction of the specific diet.

Seventy-two patients with congenital diaphragmatic hernia (CDH) diagnosed in the first 12 hours of live have been reviewed retrospectively. Forty-eight patients born before 1985 (group I) were compared to 24 patients born between 1985 and 1989 (group II). The management was different for the 2 groups. Group I was operated on immediately. For group II, delayed surgery after stabilization was preferred. For this group, stability was sought before, during and after surgery. Therapy was first aimed at optimizing ventilation and oxygenation by way mechanical ventilation. Pharmacologic agents were used in an attempt to decrease pulmonary vascular resistance and improve cardiac output. The survival rate was 37.5% before 1985, 62.5% after 1985 (P less than 0.01). Main prognostic factors were Apgar score, paCO2, pH, ventilation index, alveolar-arterial difference in oxygen and oxygenation index. The stabilization before surgery improved the survival rate.

The choice of antibiotics for the treatment of hospital-acquired infections in children is a rational choice based on the child's general condition, on the site of infection, on the most probable pathogens and on their current sensitivity to antibiotics. The antibiotic chosen must reach bactericidal concentrations at the site of infection for rapid reduction or the inoculum and to limit the systemic spread of infection, thereby decreasing the risk of a rapidly expanding infectious process in the younger children. The optimal antibiotic is selected on the basis of what is known about bacterial resistance. General therapeutic rules must be adjusted to the epidemiological situation prevailing in each hospital department.

Cardiac arrest in infants and children is usually not unexpected. All efforts, therefore, should be made to recognize a high risk situation soon enough and to apply the emergency therapeutic measures that are mandatory. When the drama occurs, cardiopulmonary resuscitation (CPR) must be instituted at once according to a well-defined sequence: first, elementary CPR performed by any occasional rescuer, including 1. clearing of the airways, 2. mouth-to-mouth breathing, and 3. closed cardiac massage (CCM); then, medical CPR applied by a professional rescuer pursuing the same objectives and consisting of 1. tracheal intubation, 2. manual or mechanical ventilation with pure oxygen, 3. controlled efficacy CCM, and 4. intratracheal, then intravenous or intraosseous injection of adrenaline. As this sequence cannot be improvised, no effort should be spared to teach and organize CPR outside and within hospitals.

A one-month old infant whose mother had been treated with erythromycin during pregnancy exhibited signs of severe congenital syphilis with collapse requiring admission to an intensive care unit. Erythromycin has low placental transfer and other treatments would have probably been more adequate. Some authors advocate the use of the latest tetracyclines and doxycycline could also be administered. The WHO's recommendations that all children born of mothers who were not treated with penicillin should receive this antibiotic after birth is still valid.

We report the case of a 6 year-old boy with rhabdomyolysis involving only the inferior limbs. It was complicated by renal failure with anuria and intravenous coagulopathy and associated with encephalitis. Virologic investigations showed a recent infection due to Coxsackie B5 virus. Full recovery was observed after symptomatic treatment with peritoneal dialysis, exchange transfusion and heparin therapy.

The amino acid sequence of porcine and human caseinomacropeptides (CMP), the C-terminal glycopeptide released from kappa-casein by chymosin at the initial step of milk coagulation, have been investigated. The complete amino acid sequence of porcine CMP and that of the first 59 amino acid residues of human CMP have been determined. Porcine and human CMPs contain 71 and likely 65 amino acid residues respectively. The extra hexapeptide 38-43 found in porcine CMP arises obviously from the duplication of the DNA fragment coding for the 6 preceding amino acids.

A case of intestinal obstruction and enterocolitis, probably as a consequence of inappropriate use of thickened feedings, is reported. Products which thicken feedings take an important part in the treatment of gastro-oesophageal reflux in infants. In order to thicken feedings, pectin and silicium have been added to milk. However, they may lead to an obstructive medication bezoar. Thus, it is necessary to limit their use to 3-5% of feeding and to clearly explain their potential hazards to the family.

The authors report two cases of febrile pancytopenia of tuberculous origin. In both cases specific antibiotic treatment led to disappearance of the clinical and blood signs. These cases, together with 65 others, found in the world literature were then analysed. In most cases (54), death occurred owing to lack of early diagnosis and treatment, whilst in 14 cases, cure was obtained when the treatment was not started to late. The authors emphasize the necessity of liver biopsy to make the diagnosis of tuberculosis in any case of unexplained pancytopenia with fever.

Rapid bactericidal effect is essential for therapy of severe Staphylococcus aureus infections in children. The in vitro activity of clinically achievable levels of vancomycin and its combinations with gentamicin, amikacin and rifampin plus amikacin was studied with the time-kill curve method at 2.5, 4, 6, 24 and 48 hours against 20 strains of Staphylococcus aureus isolated from children with severe staphylococcal infection. Vancomycin alone exerted a bactericidal effect at 48 hours. However, with the combinations vancomycin plus gentamicin, vancomycin plus amikacin and vancomycin plus amikacin plus rifampin a bactericidal effect was respectively observed at 24, 6 and 4 hours. Most rapid killing was achieved with vancomycin plus rifampin plus amikacin. Thus this antibiotic combination seems the most appropriate for initial treatment of severe staphylococcal infections in children.

Toxic shock syndrome (TSS) is reported in 2 children. TSS occurred 10 days after an accidental injury of the fore foot in one case and 5 days following surgery for severe uretero-vesical reflux in the other. The clinical illness was defined by the case definition formulated for epidemiologic studies (CDC, 1982). The diagnosis was confirmed by isolation of a Staphylococcus aureus strain producing TSST, at the infected site. Toxin-induced mediators such as interleukin I and Tumor Necrosis Factor have been incriminated in septic shock with multivisceral involvement. As in our 2 cases, the syndrome may be delayed or even absent.

The complete amino acid sequence of Italian water buffalo (Bubalus arnee) caseinomacropeptide, the C-terminal fragment released from kappa-casein by chymosin, has been determined. It contains 64 amino acid residues including one phosphoserine and differs from its bovine (Bos taurus) B counterpart by 10 amino acid substitutions. The sequence of the last 11 amino acid residues of para-kappa-casein is also reported. In relation to the Ala148/Asp substitution which is responsible for the different electrophoretic behaviour of bovine kappa-caseins B and A, water buffalo kappa-casein is homologous to the bovine variant B. It is suggested that a variant Thr136-Ala148 might be the wild type of the Bos genus.

A child is described with a portal cavernoma and marked growth retardation who was found to have intestinal lymphangiectasia. It is proposed that the lymphangiectasia may be secondary to portal hypertension. This suggestion is supported by the improvement in lymphopenia after a splenorenal shunt cavernome.