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Child abuse is a major health problem that can lead to physical and psychological issues. Its diagnosis can be difficult and sensitive. Physicians are submitted by law to inform the parents when they report to child welfare services or judicial authorities, unless otherwise in the minor's interest. This exercise is destabilizing for both patients and physicians. The physician must be trained to detect and announce a possible diagnosis of child abuse. To facilitate and increase those reports, we have developed guidelines for the physicians to help the exercise of announcement. These guidelines were based on pre-existing recommendations about how to announce bad news. We have also planned to put into practice these guidelines with a communication skills training program based on standardized patients. We propose the acronym PROTECT; P for plural: never stay alone in such situations, R for remaining a caregiver and not becoming an investigator or judge, O for obligation to protect minors, T for time, to take enough time to inform the parents and the child but in a limited time frame, E for explaining to the parents what preoccupy the professionals; C for centring ourselves on the child, his or her symptoms, needs and pain; T for total care of the child that should integrate physical, psychological, and social child health, through a global and interdisciplinary approach in collaboration with child welfare services, and should involve also the child in the process. This tool will be applied by simulation in child welfare training with standardized patients. The evaluation of this tool and its application would need further study.

Minor offenders are at risk for medico-psycho-social vulnerability, that impacts global health, schooling, professional future, and socio-familial environment; moreover, minors who are victims of violence and neglect are at greater risk of becoming offenders and minor offenders are at greater risk of suffering violence. Few data are currently available regarding global health and vulnerability factors for minors (i.e. those aged under 18) who have been placed in police custody. This study aimed to describe the judicial and social characteristics of these minors, their medical and psychological health status, with the hypothesis that most minors placed in police custody can be considered as abused or neglected, by presenting factors of vulnerability. We carried out a prospective study, including consecutive minors aged of 13 to 18 years old, who had been detained in custody at the Central Police Station of Nantes (France), from October 2012 to May 2013. The sociodemographic characteristics, scores for global health and the data collected from the welfare and judiciary services were analyzed, to identify abused or neglected minors. Ninety-nine teenagers were included: 78 males and 11 females (mean age±standard deviation: 16.5 years±1.01), who had been placed in custody for robbery, with a remarkable proportion of recidivist minors. Our study has highlighted several worrying characteristics of minors in police custody reflecting their vulnerability, as living conditions (no schooling, no fixed address) and irregular or absent medical follow-up; however their scores for global health were not different from the general population. While 49 minors (49.5 %) had already been identified by the welfare services, our study find that 35 added minors of this population should nonetheless be considered as being abused and/or neglected, based on a very high rate of minors already followed by child protection services and/or already penalized. Systematic health screening in custody could help to detect abused and/or neglected minors, in order to provide them access to appropriate medical and social cares. They could be referring to psychiatric or rehabilitation cares, and to the relevant welfare and judiciary services in order to assess if a specific protection measure is needed.

The educational and social benefits provided by school far outweigh the risks of a possible COVID-19 contamination of children in school environments or in daycare centers. Following summer break, the back-to-school period in France is taking place in the context of an increasing viral spread and requires strict adherence to health measures to limit the risk of outbreaks in communities. Based on a critical update of the role of children in the transmission of the infection, and of children's susceptibility to infection, the French Pediatric Society published practical guidelines for school re-entry and the management of COVID-19 infections in schools.

Resume Les infections liees a l’herpes virus humain (HSV), au virus de la varicelle et du zona (VZV) et au virus de la grippe (Influenza A et B) sont tres frequentes en pediatrie et sont le plus souvent benignes avec une guerison spontanee. L’utilisation des antiviraux antigrippaux (inhibiteurs de neuraminidase) a ete etudiee dans de larges essais randomises et fait l’objet de recommandations nationales et internationales. Celle des anti-HSV et anti-VZV n’a pas fait l’objet d’etudes de la meme ampleur et de ce fait, leur prescription est plus discutee avec des benefices moins bien definis et variables (a l’exception des infections neonatales et/ou neuro-meningees). L’objectif de cette mise au point est donc de proposer une synthese des donnees disponibles dans la litterature concernant les indications des antiviraux en pratique de ville pour les infections liees a l’HSV (gingivostomatite, herpes recurrent, faux panaris herpetique), au VZV (varicelle, zona) et a la grippe.

This study aimed to describe the impact of the first COVID-19 lockdown in France on the activity of a Child Advocacy Center.This cross-sectional, observational study included all children involved in the activity of the CAC during the first lockdown, from March 16 to May 10, 2020 and the next 3 months and the corresponding periods in 2018 and 2019. Cases were considered severe when a hospitalization, social alert and/or judicial report to the prosecutor was decided.Data for 1583 children were analyzed. During the lockdown, the global center activity decreased with 26.4 consultations per 100.000 children in 2018, 46 in 2019 and 20.7 in 2020 (p 0.001). Judicial activity decreased (forensic examinations and child forensic interview recordings), whereas assessment consultations increased. Cases were more severe during the lockdown than in 2019 and 2018 (12.3, 9.4 and 6.04/100.000 children, respectively, p 0.0001). The global activity of the center increased in the 3 months after the lockdown as compared with during the lockdown (38.2/100.000 versus 20.7/100.000, respectively, p 0.001) but did not differ from activity in 2018 and 2019. Severe cases were more frequent in the 3 months after the lockdown than the previous years (13.7/100.000 in 2020, 9.62 in 2019 and 8.17 in 2018, p = 0.0002).The CAC activity decreased during the lockdown in France but the increase in incidence of severe abuse cases during the lockdown and the next 3 months confirm the need for optimal screening, care and support of child abuse and neglect victims even in the context of health crisis.

Background and objectives The role of schools in the spread of SARS-CoV-2 infections in the community is still controversial. The objective of our study was to describe the epidemiology of SARS-CoV-2 infections in different pediatric age groups during the first 2 months of the fall back-to-school period, in the context of increasing viral transmission in France. Methods Weekly epidemiological data provided by Sante Publique France and the Ministry of National Education were analyzed according to the age groups defined by the different school levels. Weeks (W) 34–42 were considered for analysis. Results The PCR positivity rate and incidence rate increased in all age groups during the study period, in an age-dependent manner. At W42, with adults being considered as reference, the risk ratio for a positive PCR test was 0.46 [95% CI: 0.44–0.49] and 0.69 [0.68–0.70] for children aged 0–5 years and 6–17 years, respectively. Similarly, the incidence rate ratio was 0.09 [0.08–0.09], 0.31 [0.30–0.32], 0.64 [0.63–0.66], and 1.07 [1.05–1.10] for children aged 0–5 years, 6–10 years, 11–14 years, and 15–17 years, respectively. Children and adolescents accounted for 1.9% of the newly hospitalized patients between W34 and W42, and for 1.3% of new intensive care admissions. No death was observed. Among infected children and adolescents, the percentage of asymptomatic individuals was 57% at W34 and 48% at W42. The number of schools closed remained low, less than 1% throughout the study period. The number of confirmed cases among school staff was consistent with the data measured in the general population. Conclusion In the context of increasing viral transmission in the population, the spread among children and adolescents remained lower than that observed among adults, despite keeping schools open. However, the impact was age-dependent, with data in high schools close to those observed in adults.

Objective The aim of this study was to characterize conventional pediatric care capacities in French public hospitals and identify the main difficulties in guiding upcoming health policies. The secondary objective was to assess the quality of care by the implementation of the European Charter of the Rights of Children in Hospital. Method Multicenter cross-sectional study using a questionnaire survey sent by e-mail to the heads of conventional pediatric departments in four French regions identified on the French Hospital Federation's website. The survey was conducted between 25 September and 25 October 2018. Results Fifty-six of 113 heads of departments participated in the survey. The mean annual number of admissions per unit in 2017 was 2066 (SD, 1433), with a median length of stay of 2.7 days (range, 1–10). Children were admitted up to age 18 years in 76% of the departments, and 83% of the departments had an individualized pediatric emergency department. The nurse care load was very high, specifically during the night shift (9.5 patients/nurse). Inpatient education and academic teaching were unavailable in 38% of the departments. Overall, 89% of department heads declared knowing the European Charter of the Rights of Children in Hospital, and a copy of it was posted in all units in 57% (95% confidence interval, 44–70) of the services/departments. At all times and in all departments, parents were allowed to be with their children, and for 34% (95% CI, 21–47) of the departments, an accommodation for parents was available close to the hospital. Conclusion Public hospital pediatric departments lack sufficient medical and nonmedical caregivers. Department heads were well aware of the European Charter, and it was well disseminated but should be updated to address today's challenges in pediatrics. An area of improvement would be to include parents in their child's care more effectively.

International audience; Background: Infectious diseases are still an important cause of morbidity and mortality in high-income countries and may preferentially affect predisposed children, especially immunocompromised children. We aimed to evaluate the frequency of recommended immunological tests in children with communityonset severe bacterial infection (COSBI) admitted to a pediatric intensive care unit. We also assessed the frequency and described the typology of diagnosed primary immune deficiency (PID). Methods: We conducted a retrospective observational epidemiological study in six university hospitals in western France. All children from 1 month to 16 years of age admitted to hospital for bacterial meningitis, purpura fulminans, or meningococcal disease between August 2009 and January 2014 were included. We analyzed the frequency, type, and results of the immunological tests performed on children with meningitis, purpura fulminans, or a meningococcemia episode. Results: Among the 143 children included (144 episodes), 84 (59%) and 60 (41%) had bacterial meningitis and purpura fulminans or meningococcemia, respectively: 72 (50%) had immunological tests and 8% had a complete immunological investigation as recommended. Among the 72 children examined for PID, 11 (15%) had at least one anomaly in the immunological test results. Two children had a diagnosis of PID (one with C2 deficit and the other with C8 deficit) and seven other children had possible PID. Thus, the prevalence of a definite or possible diagnosis of PID was 12% among the children examined. Conclusion: PID is rarely investigated after COSBI. We raise awareness of the need for immunological investigations after a severe infection requiring PICU admission. (C) 2021 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.

In the era of intrapartum chemoprophylaxis to reduce GBS, rates of early onset bacterial infection have declined in term newborns. New guidelines have been written in order to adapt our current practices to this epidemiological evolution and limit excessive exams and antibiotic administrations. The main point of these new guidelines consists in a clinical systematic surveillance in maternity for well appearing newborns instead of the current empiric antibiotic treatment. Advised biological exams are also detailed.

Resume Introduction Les adolescents admis dans les services d’accueil des urgences pediatriques (SAUP) pour agitation sont de plus en plus nombreux. Leur agitation, multifactorielle, survient dans un parcours souvent « complexe ». Ils mettent en difficulte les structures hospitalieres d’accueil parfois inadaptees et depassees par ces moments de crises. L’objectif de cette etude etait de recenser et decrire la population admise dans un centre hospitalier universitaire (CHU) pour agitation au cours d’une annee, et de discuter la problematique de leur prise en charge. Materiel et methodes Etude retrospective de tous les adolescents admis pour agitation, au SAUP du CHU de Nantes, en 2015. Resultats Quatre-vingt-dix-neuf adolescents avaient consulte 182 fois pour agitation. Parmi eux, 85 % avaient des antecedents d’agitation, 70 % avaient un suivi psychologique en cours et 56 %, suivis par l’aide sociale a l’enfance, avaient un parcours « complexe ». La majorite des crises etait survenue au domicile parental et etait de type hetero-agressif. A l’arrivee au SAUP, 90 % etaient calmes. La duree moyenne de sejour au SAUP avait ete de 3 h 42 minutes et par la suite 31 % avaient ete hospitalises en pediatrie generale, 14 % en pedopsychiatrie et 8 % en psychiatrie pour adultes. Conclusion La proportion de parcours complexes parmi les adolescents admis aux SAUP etait importante. Ces adolescents en souffrance, au parcours complexe, illustrent le lien entre violences subies et violences agies. Le developpement d’unites d’hospitalisation de courte duree semble une solution pertinente pour permettre une mise a distance et une evaluation pluridisciplinaire, somatique, psychique et sociale de ces patients vulnerables.

Rational use of antibiotic has become a national and international health priority to fight against the emergence of multiresistant bacteria. Neonates are particularly exposed to antibiotic treatments because of their high susceptibility to severe infection and the lack of specificity of sepsis signs that make diagnosis difficult. This population is also particularly susceptible to microbiota disruption due to antibiotic treatment. Implementation of antibiotic stewardship in neonate is then an urgent need. According to a literature review, principles of antibiotic stewardship implementation in neonate are based on: (i) a multidisciplinary team comprising infectious disease specialists and aware of neonatal specificities (diagnosis, bacterial epidemiology, pharmacology) ; (ii) clear and easy-to-evaluate goals discussed a priori with neonatologists ; (iii) short-term assessment of the impact on antibiotic consumption and antimicrobial resistance ; (iv) enablement of the healthcare professionals within the ward to enhance the sustainability and (v) support from the institution.

Acute hematogenous bone and joint infections (osteomyelitis, septic arthritis, osteoarthritis, and spondylodiscitis) affect more frequently children younger than 5 years of age. Early diagnosis and prompt treatment are needed to limit the risk of complications. Children with suspected bone and joint infections (BJI) should be hospitalized at the beginning of treatment. Surgical drainage is indicated in patients with septic arthritis and in those with periosteal abscess. Staphylococcus aureus is involved in BJIs in children at all ages; Kingella kingae is a very common causative pathogen in children under 4 years of age. The French Pediatric Infectious Disease Group recommends in children > 3 months of age empirical antibiotic therapy with appropriate coverage against methicillin-sensitive S. aureus with high doses (150mg/kg/day) of intravenous amoxicillin-clavulanate, cefuroxime or cefazoline. In most children with uncomplicated BJI, short intravenous antibiotic therapy for 3 days can be followed by oral therapy. The minimum total duration of antibiotic therapy should be 10 days for septic arthritis and 3 weeks for osteomyelitis.

Background Central venous catheters (CVCs) provide a great comfort for hospitalized children. However, CVCs increase the risk of severe infection. As there are few data regarding pediatric epidemiology of catheter-related infections (CRIs), the main objective of this study was to measure the incidence rate of CRIs in our pediatric university hospital. We also sought to characterize the CRIs and to identify risk factors. Materials and methods We conducted an epidemiological prospective monocentric study including all CVCs, except Port-a-Caths and arterial catheters, inserted in children from birth to 18 years of age between April 2015 and March 2016 in the pediatric University Hospital of Nantes. Our main focus was the incidence rate of CRIs, defined according to French guidelines, while distinguishing between bloodstream infections (CRBIs) and non-bloodstream infections (CRIWBs). The incidence rate was also described for each pediatric ward. We analyzed the association between infection and potential risk factors using univariate and multivariate analysis by Cox regression. Results We included 793 CVCs with 60 CRBIs and four CRIWBs. The incidence rate was 4.6/1000 catheter-days, with the highest incidence rate occurring in the neonatal intensive care unit (13.7/1000 catheter-days). Coagulase-negative staphylococci were responsible for 77.5% of the CRIs. Factors independently associated with a higher risk of infection in neonates were invasive ventilation and low gestational age. Conclusions The incidence of CRIs in children hospitalized in our institution appears to be higher than the typical rate of CRIs reported in the literature. This was particularly true for neonates. These results should lead us to reinforce preventive measures and antibiotic stewardship but they also raise the difficulty of diagnosing with certainty CRIs in neonates.

We wanted to determine the diagnostic performance of a rapid influenza diagnostic test (RIDT) used bedside in a pediatric emergency department (PED). This was a prospective study over four consecutive winters (2009-2013), comparing the results of a RIDT (QuickVue®) with RT-PCR in children admitted to a PED. Among the 764 children included, we did not observe any significant differences in the diagnostic performance of RIDT except during the H1N1 pandemic. The overall sensitivity of the test was 0.82; the specificity 0.98; the positive and negative likelihood ratios 37.8 and 0.19. The positive and negative post-test probabilities of infection were 98% and 17%. The diagnostic performance was increased for influenza B cases (P = 0.03). RIDTs are suitable for use every winter with few differences in its diagnostic value, except during specific pandemic periods. This test could limit unnecessary complementary exams and guide the prescription of antivirals during influenza epidemic periods in PEDs.

Background In light of the pending update of the French guidelines for the management of neonatal infections, knowing the current epidemiology of early-onset neonatal infection (EONI) is essential. Objectives The aim of this study was to assess the current epidemiology of a French administrative district population of proven EONI, including umbilical cord blood procalcitonin levels. Methods We conducted a retrospective population-based study in the Nantes metropolitan area. We included all infants treated for proven EONI in the maternity, neonatology, and intensive care wards between 1 January 2006 and 31 December 2015 in the Nantes University Hospital. Results Among the 140,502 children born during the study period, 61 cases of EONI were documented. The overall incidence of confirmed EONI was 0.43/1000 live births, with 0.23/1000 GBS (group B streptococcus) infections and 0.08/1000 Escherichia coli infections. The majority of infected newborns were full-term or late-preterm infants (67% were ≥ 34 weeks of gestation), 88% had symptoms of EONI in the first 24 h of life, most of which were respiratory. The mortality rate was 8% (in premature infants). Available in 51% of the population, the cord blood PCT value could contribute to an earlier diagnostic screening in 10% of cases but with a very low sensitivity. Conclusions The incidence of confirmed EONI is low in this French district. The diagnostic value of PCT umbilical blood cord should be assessed based on further studies before confirming its value. We suggest that a national registry of these rare but serious cases of EONI could contribute to monitoring the epidemiological progression as well as to optimizing our diagnostic and therapeutic strategies.

Resume Des criteres d’hospitalisation pour la bronchiolite aigue du nourrisson ont ete etablis lors de la conference de consensus de 2000. Cette etude avait pour objectif d’evaluer leur impact sur l’hospitalisation dans les services d’accueil des urgences pediatriques (SAUP). Materiel et methodes Il s’est agi d’une enquete observationnelle multicentrique un jour donne dans 66 SAUP repartis sur l’ensemble du territoire. Le questionnaire portait sur la structure evaluee et etudiait le parcours de soin, l’etat clinique, la prise en charge et le devenir de chaque nourrisson presentant un premier episode de dyspnee sifflante. Une question ouverte permettait de detailler sur quel(s) critere(s) l’hospitalisation etait decidee. Le modele de regression logistique a ete utilise pour identifier des criteres cliniques independants conduisant a l’hospitalisation. Les donnees ont ete comparees par le test t de Student ou le test de Chi 2 . Resultats Pour 338 enfants inclus, 145 ont ete hospitalises (45,1 %). Les criteres ayant le plus de poids dans le choix d’hospitalisation ont ete un aspect toxique (OR: 3 [IC 95 %: 1,0–8,5], p = 0,04), une frequence respiratoire superieure a 60/minute (OR: 3,4 [IC 95 %: 1,3–8,8], p = 0,02), un âge inferieur a 6 semaines (OR: 29,8 [IC 95 %: 7,0–125,4], p p p p = 0,007). Conclusion Les criteres cliniques de gravite de la conference de consensus de 2000 influencent la decision d’hospitalisation. Cependant d’autres criteres sont retenus dans pres de 1/3 des cas.

Bacterial skin and soft tissues infections are common in children and frequently do not require systemic antibiotics, especially if lesions are superficial. Careful washing is always indicated in superficial lesions and is often sufficient. Careful evaluation of symptoms (which may be difficult despite the accessibility of the lesions) should be performed before prescription. Therefore, the need for drainage (spontaneous or surgical) should be assessed considering that antibiotics are mostly useless if purulent lesions are drained. Presence of toxinic symptoms (i.e., generalized cutaneous rash, diarrhea, hypotension) are strongly associated with enhanced severity. The bacterial targets for antibiotics are mainly Staphylococcus aureus (SA) and Streptococcus pyogenes. Considering the low incidence of methicillin-resistant SA in France, the French Pediatric Infectious Disease Group recommends the use of amoxicillin + clavulanate as the first-line antibiotic in most children suffering from severe skin infections requiring antibiotic treatment. In patients presenting toxinic symptoms and signs, the adjunction of an antibiotic with antitoxin properties such as clindamycin should be considered.

We present a prospective, observational study evaluating the incidence of medication errors (ME) in a university hospital pediatric emergency department and describe their characteristics and determinants. A systematic analysis of the handwritten prescriptions was conducted by a clinician and pharmacist. Of 11,573 consecutively studied prescriptions in children under 15 years of age, the ME incidence was 0.9% (n = 102). The incidence of errors found was statistically significantly higher in children older than 5 years (OR = 2.05; P = 0.026). There was no significant difference regarding the time of admission (P = 0.544), the day of the week (P = 0.940), or the affluence of people in attendance at the emergency department. The errors observed were all prescription errors. Most errors were related to analgesic (51%) and antibiotic (30%) treatments. No serious errors were reported. Conclusion We found a low incidence of medication errors in this study. The validation of prescriptions by a senior multidisciplinary staff could contribute to limited medication errors. Measures should be continued to further reduce the incidence of drug errors by calling the attention of prescribers to the most common situations at risk of ME.

The aim of this study was to create a specific tool and evaluate its impact on the knowledge of primary care physicians (PCPs) in reporting child abuse to child protective services (CPS).Prospective "before/after" study assessing the knowledge of general practitioners (GPs) registered at the medical board in a French administrative area through anonymous questionnaires. The tool was adapted from the guidelines published in 2014 by the French Health authorities. The main criterion was the median score (/100) calculated for each questionnaire before (Q1) and after (Q2) the dissemination of the tool. These median scores were compared and associations between scores and some PCPs' characteristics were tested through multiple linear regression.A total of 279 GPs answered the first questionnaire (Q1) and 172 answered the second (Q2). PCPs who answered were mainly women (68% and 74%), were between 30 and 50 years old (61% and 66%), practiced in association with other physicians (82% and 84), and had 15-30% children in their patient population. For Q1, the general median was 65 [IQR: 40-81] versus 82 [IQR: 71-91] for Q2 (P0.001). The PCPs' characteristics leading to significant variations in the scores for Q1 were age older than 50 years, being female, and having been trained in diagnosis and management of child abuse, with the β coefficient at -16.4 [95% CI: -31.1; -1.69], +8.93 [95% CI: 2.58; 15.27] and +12 [95% CI: 6.33; 17.73], respectively.This study confirms the significant impact of this new tool on PCPs' knowledge concerning reporting suspected child abuse to the CPS.Wider dissemination of this tool could increase PCPs' awareness and comprehension of when and how to make a report to the CPS.

Teenagers admitted to the emergency room for a violent attacks episode are increasingly numerous. The source of agitation is multifactorial for these teenagers, often with a complex course. They jeopardize hospital wards, which are often ill-suited for and overwhelmed during these outbursts. This study aims to identify and describe all the teenagers admitted to the hospital over 1 year for a violent outburst and discuss their management.Retrospective and descriptive study of teenagers admitted to the pediatric emergency department of the Nantes University Hospital for a violent outburst in 2015.During this 1-year study, 99 teenagers out of a total of 182 consultations were admitted for a violent outburst. We noted that 85% of them had a previous history of a violent outburst, 70% of them were seeing a psychologist, and 56% were followed by the child welfare services. Most of the outbursts took place at home and were hetero-aggressive. Upon arrival at the pediatric emergency ward, 90% of the teenagers had calmed down. The mean time spent in the emergency ward was 3h42min. Finally, 31% of the teenagers were hospitalized in the general pediatric unit, 14% in the children's psychiatric department, and 8% in the adult psychiatry ward.We observed a high proportion of complex cases in the teenagers admitted to our emergency department for a violent outburst. These teenagers in distress, with a complex previous history, illustrated the relation between violence against themselves and their own violent behavior toward others. Developing short-stay units for a temporary isolation could be an advantageous multidisciplinary approach to allow somatic, psychological, and social evaluation of these vulnerable patients.

Resume Objectifs La pratique pediatrique est un exercice difficile ou il faut apprendre a distinguer parmi une multitude de recours pour des motifs benins des situations cliniques rares mais potentiellement graves. Notre but etait d’evaluer les connaissances des etudiants entrant en 3e cycle de medecine generale sur ces situations. Methodes Cent trois etudiants ont ete evalues sur les « feux tricolores » sous forme de 103 questions a choix multiple (QCM) a 2 modalites (vrai/faux). Ces feux tricolores avaient ete definis par des praticiens pediatriques du centre hospitalier universitaire (CHU) et des enseignants de medecine generale de Nantes comme des fondamentaux de la pediatrie : situations pieges, diagnostiques ou therapeutiques a ne pas manquer. Le degre d’urgence etait defini par la couleur, le rouge correspondant aux urgences vitales immediates. Resultats Trente-six pour cent des QCM (n = 103) ont eu un taux de bonnes reponses inferieur a 75 %. Trente-deux pour cent des QCM concernant des situations avec urgence vitale (« feux rouges ») (n = 37) ont eu un taux de bonnes reponses inferieur a 75 %. Quinze pour cent des questions (n = 103) ont eu un taux de bonnes reponses inferieur a 50 %, la moitie concernant des « feux rouges » (meningite, decouverte de diabete, choc). Les questions concernant les nourrissons (n = 24) ont eu significativement moins de bonnes reponses (taux de bonnes reponses inferieur a 50 % de 29 % versus 10 %, p = 0,047) Conclusions Certaines situations d’urgence ou concernant les nourrissons ne sont pas maitrisees par la majorite des etudiants. Il est donc indispensable de mener une reflexion sur l’optimisation de l’enseignement de la pediatrie au second cycle.

Pneumococcal serotypes 1, 3, 5, 7F, and 19A were the most implicated in community-acquired pneumonia (CAP) after implementation of 7-valent pneumococcal conjugate vaccine (PCV7). In France, the switch from PCV7 to 13-valent pneumococcal conjugate vaccine (PCV13) occurred in June 2010. An active surveillance network was set up to analyze the impact of PCV13 on CAP.An observational prospective study performed in 8 pediatric emergency departments from June 2009 to May 2012 included all children between 1 month and 15 years of age with chest radiography-confirmed pneumonia. Three 1-year periods were defined: pre-PCV13, transitional, and post-PCV13.During the 3-year study period, among the 953 274 pediatric emergency visits, 5645 children with CAP were included. CAP with pleural effusion and documented pneumococcal CAP were diagnosed in 365 and 136 patients, respectively. Despite an increase (4.5%) in number of pediatric emergency visits, cases of CAP decreased by 16% (2060 to 1725) between pre- and post-PCV13 periods. The decrease reached 32% in infants in the same periods (757 to 516; P.001). Between pre- and post-PCV13 periods, the proportion of CAP patients with a C-reactive protein level120 mg/dL decreased from 41.3% to 29.7% (P.001), the number of pleural effusion cases decreased by 53% (167 to 79; P.001) and the number of pneumococcal CAP cases decreased by 63% (64 to 24; P = .002). The number of additional PCV13 serotypes identified decreased by 74% (27 to 7).Our data suggest a strong impact of PCV13 on CAP, pleural effusion, and documented pneumococcal pneumonia, particularly cases due to PCV13 serotypes.

Resume Introduction Faute de score clinico-biologique sensible et specifique, tout nouveau-ne symptomatique est considere comme « suspect d’infection neonatale jusqu’a preuve du contraire ». Ainsi aujourd’hui en France, 30 a 50 % des nouveau-nes sont suspects d’infection materno-fœtale (IMF) dont une proportion importante fait l’objet d’un bilan biologique et parfois d’une antibiotherapie probabiliste dont l’impact n’est pas sans consequence. L’objectif de cette etude etait d’evaluer la valeur diagnostique des differents criteres de suspicion d’IMF recommandes par l’Agence nationale d’accreditation en sante (Anaes) depuis 2002 ; et celle du dosage de la procalcitonine (PCT) au cordon, utilise en routine dans notre maternite. Patients et methode Etude retrospective monocentrique au centre hospitalier universitaire (CHU) de Nantes sur 4 ans incluant tous les nouveau-nes suspects d’IMF hospitalises. Les nouveau-nes ont ete classes a posteriori comme infectes ou non infectes, a l’aveugle du resultat du dosage de la PCT. La valeur diagnostique de chaque critere a ete etudiee en utilisant la sensibilite, la specificite, la valeur predictive et le rapport de vraisemblance. Resultats Deux mille cent cinquante et un nouveau-nes suspects d’IMF ont ete inclus. Pour un nouveau-ne symptomatique, le risque relatif d’etre infecte etait de 12,2 (IC95 % : 4,9–30,2 : p 0,6 ng/L qui entrainait un risque relatif a 291,6 (IC95 % : 70,7–1214,0, p Conclusion Les criteres cliniques d’adaptation a la vie extra-uterine sont plus predictifs d’IMF que les criteres anamnestiques. Le dosage de la PCT au cordon semble etre un marqueur interessant dans la prediction de l’IMF qui pourrait etre integre dans un nouvel algorithme decisionnel de prise en charge des nouveau-nes suspects d’IMF.

Introduction La couverture vaccinale est insuffisante en France, exposant au risque de reapparition des maladies. La mefiance envers les vaccins est en augmentation et met en difficulte les medecins generalistes. Ceux-ci sont dans l’ensemble favorables a la vaccination mais expriment un besoin de formation sur le sujet. L’e-learning est un outil recent qui a montre son efficacite seul ou en complement des formations presentielles. Materiels et methodes Nous avons realise une etude descriptive non interventionnelle aupres de medecins generalistes. L’objectif principal etait d’evaluer la faisabilite et l’interet d’une evaluation formative en ligne sur le theme de la vaccination. Le critere de jugement principal etait le taux de reponses aux cas cliniques termines en entier, evalue en pourcentage ; et la satisfaction des praticiens, evaluee par une note sur 10. L’objectif secondaire etait d’evaluer les connaissances des medecins generalistes sur la vaccination. Nous avons mis en place un e-learning compose de 12 cas cliniques dont le lien a ete diffuse par mail a 357 medecins generalistes. Il etait realisable au choix en une seule fois ou en plusieurs etapes. Un questionnaire d’evaluation et sur le profil des participants etait joint. Resultats Trois mois apres la diffusion, il y avait 75 reponses competes soit un taux de 21 % et 146 reponses partielles soit un taux de 41 %. La moyenne de la note de satisfaction du e-learning etait de 7,8 sur 10. Les participants comportaient 88 % de femmes et 12 % d’hommes. L’âge moyen etait de 40,3 ans. La proportion de pediatrie dans leur activite etait consideree moyennement importante pour 56 % d’entre eux et tres importante pour 33 %. L’e-learning a ete realise en une seule fois par 71 % des participants et en plusieurs fois par 29 %. Les raisons evoquees pour une realisation en plusieurs fois etaient le manque de temps, une organisation personnelle plus pratique, une meilleure assimilation des connaissances. Apres participation, 100 % des medecins declaraient avoir acquis des donnees nouvelles et 92 % d’entre eux envisageaient une modification de leurs pratiques. Les cas cliniques ayant pose le plus de difficultes etaient ceux concernant les prematures, les migrants, l’allergie a l’œuf, la vaccination contre la varicelle, les contre-indications vaccinales, la pharmacovigilance des vaccins. Conclusion L’e-learning propose permettait l’acquisition de nouvelles connaissances pour l’ensemble des medecins participants. Cette methode d’apprentissage semblait interesser pres de la moitie des medecins contactes mais avec un fort taux d’abandon en cours. Les perspectives de cette etude sont de realiser un post-test a partir des themes ayant pose des difficultes afin d’evaluer la progression des participants et d’inscrire l’e-learning dans un programme de DPC.

Resume Objectif Etablir un protocole interregional actualise de prise en charge de la bronchiolite aigue du nourrisson de moins de 1 an. Methode Un groupe de travail compose de pediatres et d’urgentistes des hopitaux universitaires du Grand Ouest (HUGO) s’est reuni autour de l’analyse des donnees recentes de la litterature. Les recommandations issues de ce travail ont ensuite ete soumises et validees par les pediatres des HUGO. Resultats Apres avoir etabli des criteres permettant de distinguer un asthme debutant du nourrisson d’une bronchiolite aigue virale, les indications d’examens complementaires ainsi que les prescriptions d’antibiotiques et de kinesitherapie respiratoire ont ete precisees et reservees a des situations tres limitees. De meme, des modalites de prescription de l’oxygenotherapie et du support nutritionnel ont ete proposees. Enfin, d’autres therapeutiques comme les nebulisations de serum sale hypertonique ont ete jugees prometteuses mais leur place dans la prise en charge de la bronchiolite aigue du nourrisson reste encore a preciser. Conclusion Alors que la prise en charge de la bronchiolite aigue du nourrisson en France est actuellement guidee par la conference de consensus de la Haute Autorite de sante (HAS) qui date de 2000 et que nos confreres europeens et nord-americains ont recemment mis a jour leurs recommandations, ce travail a permis d’actualiser les modalites de prise en charge de cette affection et d’homogeneiser les pratiques au sein des HUGO.

Resume Introduction La Conference de Consensus de 2000 recommandait un traitement symptomatique systematique des bronchiolites aigues du nourrisson, notamment par desobstruction rhinopharyngee et encourageait la kinesitherapie respiratoire, depuis remise en cause par differentes etudes. L’objectif principal de cette etude etait d’evaluer la concordance des prises en charge therapeutiques des bronchiolites aigues, en medecine generale, par rapport aux recommandations de la Conference de Consensus. Patients et methodes Ont ete inclus les nourrissons de 0 a 24 mois, presentant une bronchiolite, consultant un medecin generaliste, en Vendee ou en Loire-Atlantique, de novembre 2011 a avril 2012 et dont les parents ont accepte la participation a l’etude. Le critere de jugement principal etait la concordance des prises en charge therapeutiques par rapports aux recommandations (traitements instaures, orientation vers les urgences pediatriques). Les donnees ont ete recueillies via des questionnaires remplis par les medecins generalistes participants. Resultats Sur les 1236 questionnaires distribues, 134 ont ete remplis et 118 prises en charge therapeutiques ont pu etre analysees. Au total, 52,5 % de prises en charge therapeutiques etaient concordantes au regard des recommandations et 57,5 % en cas de premieres bronchiolites. Cinquante pour cent des nourrissons avec un critere imposant une hospitalisation selon la Conference de Consensus, ne l’ont pas ete, ce qui montre probablement l’interet de nouvelles recommandations, avec mise en exergue des criteres d’hospitalisation.

Resume La chirurgie osteo-articulaire de l’enfant comporte certaines specificites qui justifient des recommandations propres (chirurgie de rachis, reconstruction post-tumorectomie). Les enfants les plus a risque d’infection du site operatoire sont ceux atteints de comorbidites ou subissant des chirurgies longues. Les germes cibles de l’antibioprophylaxie sont ceux de la flore cutanee avec en chef de file le staphylocoque dore. La cefazoline est l’antibiotique de choix pour les chirurgies osteo-articulaires. Le depistage et la decontamination du staphylocoque dore notamment resistant a la meticilline peuvent se discuter notamment dans les centres a forte incidence d’infection postoperatoire a SARM. L’adaptation de l’antibioprophylaxie a la flore urinaire des patients atteints de pathologie neuromusculaire peut egalement se justifier au cas par cas avant les chirurgies de rachis.

Resume Introduction Le diagnostic et la prise en charge precoce de l’infection neonatale precoce (INP) sont urgents du fait de la gravite de cette affection. Aucun signe clinique ni biologique n’est assez sensible ni specifique pour etablir a lui seul le diagnostic. De ce fait, et en depit d’une incidence d’INP devenue faible, de nombreux nouveau-nes suspects d’INP font l’objet de bilans biologiques ou d’une antibiotherapie probabiliste a large spectre. Plusieurs etudes recentes soulignent l’interet du dosage de la procalcitonine (PCT) pour differencier les maladies inflammatoires et les infections virales des infections bacteriennes. Joram montre qu’il est possible de s’affranchir du pic physiologique de la PCT les premiers jours de vie, de par le dosage de la PCT au sang du cordon. Notre etude visait a evaluer la valeur diagnostique d’un nouvel algorithme de prise en charge des nouveau-nes integrant la procalcitonine (PCT) au cordon dans le but d’identifier plus precisement les nouveau-nes justifiant une antibiotherapie. Patients et methode Tous les nouveau-nes suspects d’INP nes du 1er mars au 16 novembre 2011 ont ete inclus. Le statut infecte des enfants a ete defini selon les criteres de l’Agence nationale d’accreditation et d’evaluation en sante et leur evolution clinique. Le critere de jugement principal etait la valeur diagnostique du nouvel algorithme. Les criteres de jugements secondaires etaient le recours aux examens biologiques et l’impact medico-economique. Resultats Mille deux cent soixante-sept nouveau-nes suspects d’INP ont ete inclus. Le nouvel algorithme etait d’une valeur diagnostique semblable a l’algorithme actuel (p = 0,5) avec respectivement une sensibilite de 87,5 % (IC95 % [52–98]) versus 100 % (IC95 % [87–100]) et une specificite 87,3 % (IC95 % [85–90]) versus 83,1 % (IC95 % [81–86]). Le nombre de bilans serait significativement diminue selon le nouvel algorithme 13,1 % (IC95 % [11–16]) versus 42,2 % (IC95 % [39–45]) permettant une diminution des couts de 64,2 %. La prescription des antibiotiques serait significativement plus faible avec le nouvel algorithme 13,1 % (IC95 % [11–16]) versus 16,7 % (IC95 % [14–19]). Conclusion Le dosage au cordon de la PCT semble presenter une valeur diagnostique discriminante lorsqu’il est integre a un algorithme prenant en compte l’aspect symptomatique ou non du nouveau-ne. Ces resultats devront etre confirmes par une etude prospective et multicentrique menee a partir d’une plus grande cohorte de nouveau-nes suspects d’INP.