Search

Background: Plasmodium falciparum hyperparasitemia (over or equal to 10%), isolated or associated with other severity criteria, should be managed in a pediatric intensive care unit according to the French pediatric guidelines. The main objective of our study was to describe the management and course of these special cases., Population and Methods: We conducted a retrospective study in eight French hospital facilities from January 2007 to December 2014. We reviewed the management of non-immune children aged 0-15 years, assessing the following: clinical and paraclinical data, type of care unit, treatment initiated, initial and long-term course. Data were analyzed for the whole population and for two groups according to the place of first-line management: group A (in pediatric intensive care unit), and group B (other places)., Results: A total of 61 children were included, 14 (23%) of whom were initially admitted to the intensive care unit (group A), all with neurological or hemodynamic disorders. Only 23 children (38%) overall received intravenous antimalarial treatment and the other patients received exclusively oral treatment. No deaths were reported. Median parasitemia was comparable in the two groups. In group B (n = 47/61, 77%), isolated hyperparasitemia, jaundice, and renal failure were predominant. The children who underwent initial intravenous treatment (n = 5/47, 11%) all progressed favorably, as did 92% of the children who received oral treatment (n = 42/47, 89%)., Conclusion: A majority of children with Plasmodium falciparum hyperparasitemia were managed outside the pediatric intensive care unit via the oral route, against the French pediatric guidelines except when neurologic or hemodynamic disorders were present. Initial clinical evaluation and hospital supervision are essential for the best management of these patients., Competing Interests: Conflicts of interest None., (Copyright © 2022 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.)

Acute gingivostomatitis is relatively frequent in children; of viral origin, its diagnosis is usually straightforward. Acute gingivostomatitis is very painful and for many years, codeine, whose use was restricted in 2013, was widely employed in this context. The aim of this study was to ascertain the prevalence of acute stomatitis in pediatric emergency care, to evaluate the pain caused by stomatitis, and to determine the analgesic resources deployed both in the emergency department and at discharge, over the 5-year period preceding restriction of the use of codeine., Methods: This was a retrospective study conducted in a pediatric emergency department (PED) of a university hospital between August 2008 and June 2013., Results: A total of 702 children (372 herpetic gingivostomatitis [HGS], 149 herpangina [H], 181 hand, foot, and mouth disease [HFMD]) were included. Over the 5 years, one case of gingivostomatitis was identified for 303 visits to the PED. A total of 548 (78.1%) children were aged less than 36 months and the median age was 22 months. For 501 of 702 (71.4%) children, parents reported pain and/or feeding difficulties; in the HGS group, 314 of 372 (84.4%) patients had these symptoms. Of the 702 children, 48 (6.8%) were admitted to hospital. Overall, 457 (65.1%) of 702 children were given codeine before the PED visit, during the PED visit, or as a medication to take after discharge. The corresponding figures were 314 of 372 (84.4%) for the HGS group, 67 of 149 (45.0%) for the H group, and 76 of 181 (42.0%) for the HFMD group, P<0.001., Conclusions: Acute gingivostomatitis is a relative frequent reason for PED visits, and the pain and feeding difficulties that it elicits are a real challenge. Before codeine restriction, this medication played a major role in the analgesic strategy for this disease. It is essential that analgesic regimens at least as effective as codeine replace it. Morphine combined with paracetamol or the association of ibuprofen with paracetamol are options that are recommended by the French National Health Authority (HAS)., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Shisha smoking has spread to many countries since the 1990s and is now a global phenomenon among adolescents. Notwithstanding the connotations of conviviality of shisha smoking, it is in fact highly dangerous since the smoke inhaled contains toxic substances. Carbon monoxide (CO) poisoning carries a high risk of neurological and neuropsychological sequelae such as memory loss, impaired concentration, mood disorders, and various other symptoms. We report a case of severe CO poisoning in a 13-year-old boy after smoking shisha that caused loss of consciousness and seizure. To our knowledge, there have as yet been no reports of cases involving children. We present some epidemiological data on shisha smoking in adolescents as well as on CO intoxication., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

The Groupe de Pédiatrie Générale (General Pediatrics Group), a member of the Société française de pédiatrie (French Pediatrics Society), has proposed guidelines for families and doctors regarding children's use of digital screens. A number of guidelines have already been published, in particular by the French Academy of Sciences in 2013 and the American Academy of Pediatrics in 2016. These new guidelines were preceded by an investigation into the location of digital screen use by young children in France, a survey of medical concerns on the misuse of digital devices, and a review of their documented benefits. The Conseil Supérieur de l'Audiovisuel (Higher Council on Audiovisual Technology) and the Union Nationale de Associations Familiales (National Union of Family Associations) have taken part in the preparation of this document. Five simple messages are proposed: understanding without demonizing; screen use in common living areas, but not in bedrooms; preserve time with no digital devices (morning, meals, sleep, etc.); provide parental guidance for screen use; and prevent social isolation., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Few studies are available on pediatricians' experience with announcing bad news. Announcing bad news is an important component of medical practice and is even more complex in pediatrics because parents must be associated. We had 20 hospital pediatricians complete a questionnaire containing 30 questions about their own experience announcing bad news to a child or a teenager. In spite of their experience and the time they have spent practicing medicine, there are many limitations stemming from different factors concerning children, teenagers, their families, and themselves. The difficulties encountered by pediatricians are mainly related to the timing of the announcement, the location, the choice of the words used, and the poor understanding of children and families, due to intellectual, cultural, or psychological limitations. Pediatricians question their own capacity to make such an announcement, wondering if the information has actually been well understood. They indicate that they are themselves affected. Most of them develop and implement strategies to refute the emotional instability caused by the announcement of bad news. Yet many of them feel weak, even talking about a deep sense of loneliness and guilt., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Extracorporeal membrane oxygenation is used as a last resort during neonatal and pediatric resuscitation in case of refractory circulatory or respiratory failure under maximum conventional therapies. Different types of ECMO can be used depending on the initial failure. The main indications for ECMO are refractory respiratory failure (acute respiratory distress syndrome, status asthmaticus, severe pneumonia, meconium aspiration syndrome, pulmonary hypertension) and refractory circulatory failure (cardiogenic shock, septic shock, refractory cardiac arrest). The main contraindications are a gestational age under 34 weeks or birth weight under 2kg, severe underlying pulmonary disease, severe immune deficiency, a neurodegenerative disease and hereditary disease of hemostasis. Neurological impairment can occur during ECMO (cranial hemorrhage, seizure or stroke). Nosocomial infections and acute kidney injury are also frequent complications of ECMO. The overall survival rate of ECMO is about 60 %. This survival rate can change depending on the initial disease: from 80 % for meconium aspiration syndrome to less than 10 % for out-of-hospital refractory cardiac arrest. Recently, mobile ECMO units have been created. These units are able to perform ECMO out of a referral center for untransportable critically ill patients., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Unlabelled: International travel is growing, but few data exist on prevention for children traveling. The aim of this study was to describe a population of children traveling from France to countries outside Europe and to evaluate the quality of prevention and healthcare services provided for these travelers., Materials and Methods: We conducted a retrospective epidemiological study in three pediatric emergency departments in Paris from August to October 2009 and 2012. Data were collected retrospectively from anonymous questionnaires proposed to families consulting emergency services, irrespective of their reason, who had recently traveled (in the year preceding travel outside the European Union)., Results: Of the 166 children included, who for the most part had traveled to visit relatives and friends in Sub-Saharan Africa and North Africa, 76% of their families were from the destination countries, 78% had received prevention counseling, mostly with their doctor. They had been vaccinated against yellow fever, but the hepatitis A vaccine was neglected. The preventive measures had been difficult to achieve in practice. During travel, 54% of children had health problems (39% diarrhea, 29% vomiting, 31% fever) prompting medical care in 28%, 5% were admitted to a hospital, and 4% had return to France earlier than planned. In epidemic areas, 13% of children had malaria., Conclusion: There is poor counseling on basic prevention (hygiene, diarrhea, malaria, immunization). Time constraints in pediatricians and competing priorities could explain this problem. The challenge for healthcare providers to reduce these pathologies is to provide services of sufficient quality and clarity. All medical stakeholders have an important role to play., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Background: Neonates who are in pain or are stressed during care in the intensive care unit (ICU) are often given sedation or analgesia. We investigated the current use of sedation or analgesia in neonatal ICUs (NICUs) in European countries., Methods: EUROPAIN (EUROpean Pain Audit In Neonates) was a prospective cohort study of the management of sedation and analgesia in patients in NICUs. All neonates admitted to NICUs during 1 month were included in this study. Data on demographics, methods of respiration, use of continuous or intermittent sedation, analgesia, or neuromuscular blockers, pain assessments, and drug withdrawal syndromes were gathered during the first 28 days of admission to NICUs. Multivariable linear regression models and propensity scores were used to assess the association between duration of tracheal ventilation (TV) and exposure to opioids, sedatives-hypnotics, or general anaesthetics in neonates (O-SH-GA). This study is registered with ClinicalTrials.gov, number NCT01694745., Findings: From Oct 1, 2012, to June 30, 2013, 6680 neonates were enrolled in 243 NICUs in 18 European countries. Mean gestational age of these neonates was 35.0 weeks (SD 4.6) and birthweight was 2384 g (1007). 2142 (32%) neonates were given TV, 1496 (22%) non-invasive ventilation (NIV), and 3042 (46%) were kept on spontaneous ventilation (SV). 1746 (82%), 266 (18%), and 282 (9%) neonates in the TV, NIV, and SV groups, respectively, were given sedation or analgesia as a continuous infusion, intermittent doses, or both (p<0.0001). In the participating NICUs, the median use of sedation or analgesia was 89.3% (70.0-100) for neonates in the TV group. Opioids were given to 1764 (26%) of 6680 neonates and to 1589 (74%) of 2142 neonates in the TV group. Midazolam was given to 576 (9%) of 6680 neonates and 536 (25%) neonates of 2142 neonates in the TV group. 542 (25%) neonates in the TV group were given neuromuscular blockers, which were administered as continuous infusions to 146 (7%) of these neonates. Pain assessments were recorded in 1250 (58%) of 2138, 672 (45%) of 1493, and 916 (30%) of 3017 neonates in the TV, NIV, and SV groups, respectively (p<0.0001). In the univariate analysis, neonates given O-SH-GA in the TV group needed a longer duration of TV than did those who were not given O-SH-GA (mean 136.2 h [SD 173.1] vs 39.8 h [94.7] h; p<0.0001). Multivariable and propensity score analyses confirmed this association (p<0.0001)., Interpretation: Wide variations in sedation and analgesia practices occur between NICUs and countries. Widespread use of O-SH-GA in intubated neonates might prolong their need for mechanical ventilation, but further research is needed to investigate the therapeutic and adverse effects of O-SH-GA in neonates, and to develop new and safe approaches for sedation and analgesia., Funding: European Community's Seventh Framework Programme., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Diagnostic and therapeutic skin-breaking procedures have become ubiquitous in current medical practice and neonatology does not constitute an exception. One of the main sources of neonatal pain is procedure-induced pain. It has recently become clear that pain prevention must be a health care priority. Non-pharmacological approaches constitute a first option for the analgesia of common procedures performed in neonatology. This article reviews the non-pharmacological treatments most frequently used in this context: swaddling, tucking, containment, sweet solutions, non-nutritive sucking (NNS), breastfeeding analgesia, breast milk and music. In practice, the dose of 1 to 2mL of 24% or 30% sucrose solution or 30% glucose solution immediately followed by NNS can be given for minor painful procedures in term neonates or those weighing more than 2500g. In the preterm, 0.3mL of a sweet solution (sucrose or glucose) can be given for infants weighing less than 1500g and 0.5mL for those weighing between 1500 and 2500g. The synergistic effect of sweet solutions and NNS has been clearly shown and thus their association is largely justified in practice. For breast-fed term neonates, breastfeeding can be given to sooth procedure-induced pain. All these non-pharmacological options can be effective to relieve pain from minor or moderate procedures. However, when more painful procedures are performed, stronger analgesics must be used., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Acute bronchiolitis due to respiratory syncytial virus (RSV) can present with extrapulmonary manifestations, notably severe hyponatremia. Hyponatremia is caused by excess secretion of antidiuretic hormone and can be exacerbated by intravenous infusion of hypotonic solutions. We report three cases of infants admitted for acute bronchiolitis and hyponatremia leading to acute seizures. We describe how hyponatremia was corrected and analyze the management aspects that might have worsened the magnitude of hyponatremia. We underline the basic principles of water and electrolyte management of bronchiolitis., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Suppurative parotidis is an uncommon disease in newborns, with limited information available on its pathogenesis and management: approximately 50 cases have been reported in the literature. Diagnosis is based on clinical signs. The predominant organism is Staphylococcus aureus. The administration of empiric antimicrobial therapy is an essential part of the management in very young patients. Prognosis is good and recurrence of the disease is unusual. We describe a 21-day-old newborn who presented with fever and unilateral swelling of the parotid region, and provide a literature review., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Enterocolitis is the most serious complication of Hirschsprung disease. Early management of these patients can decrease the severity of this complication. Hirschsprung disease is more common in patients with trisomy 21 than in the general population. Furthermore, the risk of developing enterocolitis is higher in this population. We report on an infant with trisomy 21 who developed enterocolitis as a complication of Hirschsprung disease that was diagnosed late when the infant presented with septic shock leading to death of the patient., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

The suture, when possible, is the best method to close a simple wound. It must be preceded by debridement and performed with great care. A rigorous technique applied in the best possible environment is necessary but not always sufficient to achieve a good cosmetic result., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Context: The Standards, Options and Recommendations (SOR) project, started in 1993, is a collaboration between the Federation of French Cancer Centres (FNCLCC), the 20 French cancer centres, and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery., Objectives: To establish the Standards, Options and Recommendations clinical practice guidelines for the management of procedure related pain (lumbar puncture, bone marrow aspiration or biopsy, blood sampling) in children oncology patients. To define, on the basis of the critical appraisal of the best available evidence and expert agreement, the clinical situations in which a pain preventive strategy should be implemented., Methods: MEDLINE was searched using specific search strategies from January 1966 to August 2004. Literature monitoring was performed to identify controlled clinical trials published in 2005., Results: A total of 57 references were identified. Clinical guidelines have been defined for each invasive procedure.

Pain causes numerous physiological changes in neonates. All invasive procedures induce undesirable stress responses; theses responses can, however, be eliminated or reduced by a judicious use of analgesia. Even though a large number of analgesics and sedatives are currently available, most of them have not been studied in the neonate. At present, a precise understanding of the pharmacological mechanisms of analgesics is difficult because many interactions still remain unknown in the term and premature neonate. This article describes the main analgesics and sedative agents used in the neonate: morphine, fentanyl, sufentanil, alfentanil, nalbuphine, ketamine, midazolam, propofol, acetaminophen, and Emla cream. After a review of the literature regarding these drugs, some practical advices and suggestions for the treatment of procedure-induced pain, and background sedation/analgesia for ventilated neonates are given. It is also stated in this article that the best way to soothe pain in neonates is to combine non pharmacological and pharmacological strategies. At the national level, written guidelines should be prepared in order to improve pain management in the neonate.

Objectives: To compare pain and sedation assessments by nurses undertaken with the Objective Pain Scale (OPS) and a Visual Analogue Scale (VAS) to the current reference scale for paediatric intensive care that is the COMFORT scale. To compare the unmodified COMFORT scale to a COMFORT "behaviour" scale which does not include physiologic items. To evaluate the ease of use of these scales., Methods: This prospective observational comparative study was carried out in children aged 1 year or older who were admitted in an intensive care unit. At 2 to 3 time points within 24 hours, a pain sedation assessment was carried out by the nurse in charge of the child with COMFORT scale, OPS and VAS. Correlation tests were used to compare the scores of each scale., Results: Nurses recorded 55 assessments in 20 children. Correlation studies showed a poor correlation between OPS, VAS and the COMFORT scale (Spearman's r=0.54 and 0.53 respectively) and a strong correlation between the COMFORT scale and the COMFORT "behaviour" scale (Spearman's r=0.96). The COMFORT behaviour scale was the most frequently fully completed scale., Conclusion: Among the 3 scales compared to the COMFORT scale in this study, the COMFORT "behaviour" scale was the only one to show a strong correlation and it also seemed to be the easiest to use.

It has taken a staggering amount of time for the medical community to realize that new-borns are able to feel pain. The treatment of neonatal pain during procedures has become mandatory, not only for humanitarian reasons which could alone justify the soothing of pain in these infants but also because repeated and prolonged pain may have long-term consequences in neonates. Nonpharmacological interventions which comprise environmental and behavioral interventions have a wide applicability for neonatal pain management alone or in combination with pharmacological treatments. These interventions are not necessarily substitutes or alternatives for pharmacological interventions but are complimentary. Nonpharmacological interventions can reduce neonatal pain indirectly by reducing the total amount of noxious stimuli to which infants are exposed and directly, by blocking nociceptive transduction or transmission or activation of descending inhibitory pathways or by activating attention and arousal systems that modulate pain. This article describes prevention, environmental interventions, and behavioral strategies. Within the behavioral strategies, sweet solutions, especially sucrose and glucose, with or without non-nutritive sucking, skin to skin contact, and breastfeeding during procedures have been studied and their analgesic efficacy has been shown. A practical approach is described hereafter. Give 1-2 ml of oral sucrose or glucose 30% at 2 min before a minor painful procedures in term neonates or neonates weighing more than 2500 g. The analgesic efficacy of sucrose and glucose seems similar. For preterm neonates weighing less than 2500 g, give 0.5 ml of oral sucrose or glucose 30%, and for those weighing less than 1500 g, 0.3 ml of oral sucrose or glucose 30%. Since a synergistic effect has been shown for the association of sweet solutions and pacifiers, give a pacifier together with sweet solutions. For term neonates that are breastfed, consider breastfeeding during procedures. These nonpharmacological interventions are suitable for minor procedures. They should not constitute the sole analgesic when performing more invasive procedures.

Unlabelled: Peritoneal tuberculosis is an uncommon presentation of extra-pulmonary tuberculosis in children. It usually presents as ascites, abdominal pain, anorexia and weight loss., Cases Report: We report two adolescent patients who presented with ascites, fever, weight loss and abdominal distension. In one case, the diagnosis was late, and confirmed by ascites culture. In the second case, a laparoscopy was performed and showed whitish nodules involving the entire abdominal cavity, compatible with peritoneal tuberculosis, later confirmed bacteriologically., Conclusion: Peritoneal tuberculosis presents with nonspecific symptoms. Because laboratory investigations may not be helpful, diagnosis may be difficult. Peritoneal-fluid adenosine deaminase (ADA) determination and coelioscopy seem to be the best way to make a rapid diagnosis.

Background: Opioid analgesia is commonly used during neonatal intensive care. We undertook the Neurologic Outcomes and Pre-emptive Analgesia in Neonates (NEOPAIN) trial to investigate whether pre-emptive morphine analgesia decreases the rate of a composite primary outcome of neonatal death, severe intraventricular haemorrhage (IVH), and periventricular leucomalacia (PVL) in preterm neonates., Methods: Ventilated preterm neonates (n=898) from 16 centres were randomly assigned masked placebo (n=449) or morphine (n=449) infusions. After a loading dose (100 microg/kg), morphine infusions (23-26 weeks of gestation 10 microg kg(-1) h(-1); 27-29 weeks 20 microg kg(-1) h(-1); 30-32 weeks 30 microg kg(-1) h(-1)) were continued as long as clinically justified (maximum 14 days). Open-label morphine could be given on clinical judgment (placebo group 242/443 [54.6%], morphine group 202/446 [45.3%]). Analyses were by intention to treat., Findings: Baseline variables were similar in the randomised groups. The placebo and morphine groups had similar rates of the composite outcome (105/408 [26%] vs 115/419 [27%]), neonatal death (47/449 [11%] vs 58/449 [13%]), severe IVH (46/429 [11%] vs 55/411 [13%]), and PVL (34/367 [9%] vs 27/367 [7%]). For neonates who were not given open-label morphine, rates of the composite outcome (53/225 [24%] vs 27/179 [15%], p=0.0338) and severe IVH (19/219 [9%] vs 6/189 [3%], p=0.0209) were higher in the morphine group than the placebo group. Placebo-group neonates receiving open-label morphine had worse rates of the composite outcome than those not receiving open-label morphine (78/228 [34%] vs 27/179 [15%], p<0.0001). Morphine-group neonates receiving open-label morphine were more likely to develop severe IVH (36/190 [19%] vs 19/219 [9%], p=0.0024)., Interpretation: Pre-emptive morphine infusions did not reduce the frequency of severe IVH, PVL, or death in ventilated preterm neonates, but intermittent boluses of open-label morphine were associated with an increased rate of the composite outcome. The morphine doses used in this study decrease clinical signs of pain but can cause significant adverse effects in ventilated preterm neonates.

Pasteurella multocida is usually responsible for local infections occurring after animal bites. It can also be responsible for meningitis in infants. A three-month old infant was admitted to hospital with a diagnosis of bacterial meningitis and hip osteitis. Cultures of cerebrospinal fluid, blood and joint liquid were positive to Pasteurella multocida. Licking from the family dog was the transmission mode in this case. Despite initial neurological complications, clinical evolution was favourable after three weeks of intravenous antibiotic therapy followed by an oral administration for three months. Pasteurella multocida meningitis is rare in infants. It can be associated with arthritis, osteitis and septicaemia. Besides animal bites, licking is also a mode of contamination.

Background: Early interventions, such as occlusive wrapping of very low birth weight infants at delivery reduce postnatal temperature fall. This new intervention was implemented in our hospital on January 2000. The aim of this study was to investigate retrospectively the effect of polyethylene wrap, applied immediately at birth, on thermoregulation., Patients and Methods: Matched pair analysis was conducted for 60 infants delivered inborn at less than 33 weeks' gestation and 60 premature infants who were born during the second half of 1999 fulfilling the same criteria. The only difference in the management (medical and environmental) was wrapping with a polyethylene bag in the delivery room. Rectal temperature and other vital parameters were taken, after removal of wraps, on admission to NICU., Results: The perinatal characteristics of both groups were comparable. Use of wrapping resulted in a significantly higher admission rectal temperature (difference in means = 0.8 degree C, p < 0.0001), this difference was also significant in infants < 30 weeks. The incidence of hypothermia (< 35.5 degrees C) was less frequent in infants enclosed in plastic bags (8.3% vs 55%). No side effects (skin burns, infection or hyperthermia) were attributable to the intervention. The heart rate was higher in the wrapping group (163 +/- 16 vs 150 +/- 17 b/min, p < 0.01), as well as the capillary glycemia (62 +/- 26 vs 45 +/- 30 mg/dl, p < 0.01). There was no significant difference on arterial pressure., Conclusion: Occlusive wrapping with a polyethylene bag at birth prevented low rectal temperature in premature infants in the immediate postnatal period. This method is easy, practical and effective, and does not interfere with current practice for resuscitation.

Jargon, the specialized vocabulary and idioms, is frequently used by people of the same work or profession. The neonatal intensive care unit (NICU) makes no exception to this. As a matter of fact, NICU is one place where jargon is constantly developing in parallel with the evolution of techniques and treatments. The use of jargon within the NICU is very practical for those who work in these units. However, this jargon is frequently used by neonatologists in medical reports or other kinds of communication with unspecialized physicians. Even if part of the specialized vocabulary can be decoded by physicians not working in the NICU, they do not always know the exact place that these techniques or treatments have in the management of their patients. The aim of this article is to describe the most frequent jargon terms used in the French NICU and to give up-to-date information on the importance of the techniques or treatments that they describe.

Nitrous oxide is a gas that has been used to provide analgesia to patients for more than a century. Its modern use started in the late sixties when a mixture of 50% nitrous oxide/50% oxygen was prepared. Nitrous oxide/oxygen provides analgesia within 3 minutes of inhalation and this analgesic effect disappears in less than 4 minutes after cessation. Its administration is very easy and a complete or partial pain relief is observed in 75 to 81% of patients. The gas mixture has been found to be safe with few side effects and no significant adverse reactions. Diffusion hypoxia which could lead to hypoxemia was reported in 1955, but recent work does not confirm this complication. Nitrous oxide/oxygen mixture constitutes an excellent drug to control procedure-related pain in children. This articles describes the history, the pharmacology, and the clinical uses of nitrous oxide/oxygen in children.

Unlabelled: Post-lumbar puncture headaches (PLPH) are uncommon in children, but when they occur treatment is challenging. PLPH in adults have been successfully treated by the use of the epidural blood patch. This treatment has been very rarely reported in children., Case Report: A 13-year-old boy, weighing 64 kg, had a lumbar puncture as part of a work-up for a 4-day history of right hemithorax pain. This pain was associated with hypoesthesia; there were no cutaneous vesicles. Neurological examination revealed decreased strength in the left upper extremity. A magnetic resonance imaging of the cervicodorsolumbar spine was normal. Three hours after lumbar puncture, the patient complained of bifrontal headaches. The headaches worsened in the upright position and they prevented the boy from ambulating. Treatment with acetaminophen was unsatisfactory. On day 9, the initial symptoms that had motivated the lumbar puncture had disappeared, but PLPH persisted. Therefore, an epidural blood patch was performed (EBP). A 18-gauge 1 Perican needle was introduced into the peridural space at the L3-L4 interspace using the loss of resistance technique. Fifteen milliliters of blood were drawn in a sterile fashion and without anticoagulant from the patient's forearm and injected slowly through the epidural needle. The patient experienced immediate, complete, and definite relief of his PLPH. Follow-up did not show any complication., Conclusion: EBP can be useful in the treatment of PLPH lasting more than 5 days in children.

Aim: This study was designed to validate a behavioral acute pain rating scale for term and preterm neonates (APN)., Methods: From January through June 1996, neonates requiring a heel lance or a venous puncture for blood sampling at the intensive care unit and the nursery of Poissy Hospital were recruited into the study. After a pilot study, a pain rating scale was developed. The scale score pain ranged from 0 to 10 and it evaluated three items: facial expression, limb movements, and vocal expression with ratings per item ranging from 0 to 4, 0 to 3 and 0 to 3, respectively. Two observers evaluated independently each infant during a painful procedure (puncture for a blood sample) and during a dummy procedure (rubbing the thigh softly)., Results: Forty-two neonates born between 25 and 41 weeks gestational age were included in the study. Medians (quartiles) of gestational age, birth weight, and corrected postmenstrual age at time of investigation were 34 (29-39) weeks, 1,850 (1,055-3,093) g, and 35.5 (31-39) weeks, respectively. Ten infants were intubated. The scale showed to be sensitive because all possible scores were obtained; during painful procedures scores ranged from 1 to 10, with 95% of scores > or = 3 while during dummy procedures they ranged from 0 to 5, with 88% of scores < or = 2. The medians (95% confidence interval) of scores were for painful procedures 5 (5 to 7) and for dummy procedures 1 (0 to 1). This indicates a good specificity of the scale. High intercorrelation of items (internal consistency) was confirmed by a Cronbach's coefficient alpha of 0.88. Inter-rater agreement was high since the Krippendorff R test was 91.2., Conclusion: This behavioral acute pain rating scale for newborns demonstrated a good specificity and sensitivity, internal consistency and inter-rater reliability. This scale could be used to test the analgesic effects of different therapies during painful procedures.

Pulse oximetry has become the leading technique for monitoring hemoglobin oxygen saturation whenever a risk of hypoxia exists. It is based upon the principle of light absorbance of pulsatile arterial blood. Since it uses 2 wavelengths, it can only measure oxyhemoglobin and reduced hemoglobin. Thus, in case of increased methemoglobin or carboxyhemoglobin, pulse oximetry values are not reliable. Low tissue perfusion can also be responsible for inaccurate values. Nevertheless pulse oximetry is a reliable and easy-to-use technique in most of the clinical situations. This article reviews the physical basis, the reliability, the pediatric aspects, and the limitations of the technique.

Background: Telephone calls for advice are common in pediatric emergency departments. This study was conducted to determine the nature of these calls and the answers provided., Methods: From 24 April through 24 July 1994, all telephone calls requesting pediatric advice in the emergency department of the Poissy Hospital were independently analysed by two pediatricians from forms prospectively filled in for each call by the resident or the attending people who answered the call., Results: Of the 239 registered calls, 186 could be analysed. They represented, in number, 15.25% of the children seen at the same emergency department during the study period. Weekend and holiday calls accounted for 35.5% of calls. 7.8% of calls were received from 0.01 am to 8.00 am, 28.7% from 8.01 am to 4.00 pm, and 63.5% from 4.01 pm to 12.00 pm. Thirty-seven percent concerned children under one year of age. The caller was one of the parents in 93% of cases. The four most frequent complaints were fever (26.5%), requests for information (17.2%), rash (12.3%), and vomiting (10.2%). The review of calls by two pediatricians determined that 67% of children did not need to be seen by a physician within six hours; 28% needed to be seen within 6 hours, and 5% needed to be seen within one hour. The advice given was followed in 88% of cases; 96% of callers were satisfied with their calls management., Conclusions: Telephone advice constitutes an important part of the activity in the pediatric emergency department. Instructional programs in telephone management are necessary for physicians. These programs should include communication skills and familiarization with protocols concerning the most frequent complaints, especially those regarding children under one year of age.

Background: Emergency departments (ED) are requested everyday to dispense medical telephone advice for children. To evaluate the quality of telephone management, a mock scenario simulating a febrile 4 month-old-girl with signs compatible with septicemia was used., Methods: One hundred randomly selected French emergency departments were called on. Half of the hospitals had a pediatric department with more than 20 beds; the other half did not have a pediatric department. A research technician called and said: "My baby has got fever and I do not know what to do". Additional information was given only on request., Results: Ninety-four ED gave medical advice by telephone: 65% of the cases by a physician, 24.5% by a nurse, 9.5% by a nurse technician and 1% by a secretary. In hospitals without a pediatric department, physicians took calls in 76.5% of the cases, whereas in hospitals with a pediatric department they only took calls in 53% of the cases. The mean number of questions asked per ED was 3.1. The age of the child was requested by 87.2% of the respondents. Advice was given by 36.1% of the ED without asking either the age of the patient or grade of the fever. The advice given by the respondents was: come to the ED immediately (30.9%), see a community physician immediately (51%), come to the ED tomorrow (2.1%), see a community physician tomorrow (8.5%), and manage at home (7.5%)., Conclusions: This study has shown important inadequacies in pediatric telephone advice given by some ED. It suggests that the respondents do not use a protocol to handle the calls; development of such protocols to guide the histories taken and advice given for the most common telephone queries is urged.

Background: Hepatic dysfunction with mild obstructive jaundice occurs occasionally in Kawasaki disease. Acute episode of cholestasis as a presenting symptom has never been reported., Case Report: A 14 year-old-boy was admitted with fever and cholestasis. He subsequently developed the classical manifestations of Kawasaki disease. No signs of liver cell injury or hepatic failure were present. Bacteriological cultures and seroimmunologic markers for viral infection remained negative. There was no ultrasonic abnormality of bile ducts. The child was given intravenous gamma globulins and salicylate. The outcome was favourable without any cardiovascular complications., Conclusion: A persistent febrile cholestasis of unknown etiology should evoke the diagnosis of Kawasaki disease.

This article describes the most current and effective means for providing sedation and analgesia for the pediatric patient. Three basic levels for sedation can be defined: conscious sedation, deep sedation and general anesthesia. Treatment of pain is also established according to an analgesic ladder. Providing safe and effective sedation and analgesia to children requires appropriate selection of drugs and dosage, proper monitoring, knowledge of potential side effects, and adequate airway management equipment and personnel. Agents available for sedation and analgesia of children and therapeutic options according to different clinical situations are described.

Background: Induction of water intoxication from tap water enemas was reported a few years ago. Its treatment is still debated., Case Report: A 4 1/2 year-old boy was admitted because he suffered from coma grade I. A barium enema had been prescribed for fecal incontinence and the patient had been given orally about 4 liters of water during the 24 hours preceding this investigation. Blood examination showed;: Na 122 mEq/l; K 3 mEq/l; Cl 87 mEq/l. Brain CT scan was normal. The patient was placed under restriction of fluid and was given i.v. 5.8% NaCl solution (2 mM/kg) for 3 hours. Convulsions appeared despite this treatment requiring intubation and ventilation plus increasing doses of NaCl: 20% solution (2 mM/kg) for 30 minutes followed by 2 mM/kg for 3 hours, associated with mannitol and furosemide infusion., Conclusion: Use of hypertonic saline solutions in the treatment of water intoxication is discussed. Acute hyponatremia must be rapidly corrected using hypertonic saline solution plus restriction of fluid and diuretic.

Background: Intravenous access in critically ill patients may be very difficult to obtain. The intraosseous route is an alternate way to administer fluids and drugs., Case Report: A five month old infant was brought to the emergency department in profound hypovolemia requiring immediate tracheal intubation. A peripheral venous access was established and 35 ml of colloid were rapidly infused. Unfortunately, fluid extravasated and the intravenous line had to be removed. As further attempts to gain intravenous access were unsuccessful, an intraosseous needle was inserted into the left tibia 1 cm below the tibial tuberosity, and colloid and human albumin solution were infused rapidly, followed by 1.4% sodium bicarbonate. After ninety minutes of intraosseous rehydration, 2 peripheral venous lines were inserted, and the intraosseous needle was removed. Bacteriological and viral cultures were negative. Four days after admission, the child was discharged in good condition., Conclusions: Intraosseous infusion provides safe, rapid and reliable access to the circulation for administration of fluids and drugs in the critically ill child or during cardiac arrest.

Neurological anomalies of the fetus are classically reported as causes of hydramnios, but cerebral vascular events occurring in utero in the fetus are rarely mentioned. We observed five newborns with neurological complications during the neonatal period in which anomalies of cerebral vascularization were identified antenatally. The mothers had hydramnios during pregnancy. Several pathophysiological hypotheses have been proposed to explain the mechanism of hydramnios. Magnetic resonance imaging of the brain in the fetus has made it possible to identify such exceptional events with extremely poor prognosis and major sequelae.

A case of Noonan syndrome associated with hydrops fetalis has been reported; it is recalled that morphological anomalies common to both Turner and Noonan syndromes depend on similar lymphatic anomalies. In the present case it is therefore proposed that the malformations of Noonan syndrome and hydrops fetalis proceed from the same lymphatic anomalies.