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Background and aims Healthcare for the increasing number of migrants in Europe, and particularly of unaccompanied minors (UMs) seeking asylum, has become a major challenge. We aimed to describe the health issues of UMs managed in a dedicated pediatric consultation service in a care center in Paris. Methods All UMs attending a dedicated migrant medical consultation service in Robert Debre Hospital, Paris, France, were included in a single-center retrospective observational study from September 1, 2017, to September 30, 2018. Results Out of the 107 UMs who were included, 87% had a health problem (n=93) and 52% had an infectious disease (n=56). The main infectious diagnoses were schistosomiasis (22%), latent tuberculosis (22%), intestinal parasitosis (16%), and chronic hepatitis B (8%). Posttraumatic stress disorder (PTSD) and overweight were common (35% and 20%, respectively). The median age was 15 years old (IQR, 14-16), the male/female ratio was 95/12. Most of the children were from sub-Saharan Africa (n=67), 46% had crossed Libya (n=49) and, when compared to the other migration routes, faced an increasing risk of violence (69%, p=0.04), imprisonment (53%, p=0.03), and forced labor (48%, p=0.02). The median duration of the trip before reaching France was 6 months (IQR, 2-13), the median time to consultation was 2 months (0-5) and was not associated with an increased risk of health problems. A total of 43 UMs were lost to follow-up. Conclusion Health problems, particularly infectious diseases and PTSD, are common among UMs and should prompt an early medical consultation with psychiatric evaluation. Follow-up is problematic and could be improved by an on-line health book.

Resumen El numero de ninos adoptados en Francia o a escala internacional ha disminuido desde 2004, con ninos caracterizados por un aumento de la edad, de los hermanos, de las experiencias de rupturas y de las patologias fisicas, de desarrollo, de comportamiento y/o psicologicas que requieren cuidados mas o menos duraderos y que preocupan a los padres adoptivos. Se puede recurrir a los medicos en la preadopcion sobre el expediente de un nino o para el asesoramiento pediatrico general. Tambien pueden evaluar a un nino recien llegado clinicamente y mediante pruebas complementarias. Tambien son preguntados por los padres cuyo hijo adoptado presenta trastornos somaticos y/o psicosociales durante o despues del periodo de transicion, y en particular durante las cuestiones de identidad de la adolescencia. El objetivo de este articulo es proporcionar un medio para comprender y tratar las situaciones que el profesional puede encontrar en la consulta de un nino adoptado. Las patologias que se observan con mas frecuencia a su llegada son las infecciones intestinales y cutaneas, la desnutricion y los trastornos psicoconductuales. Algunas infecciones e intoxicaciones potencialmente graves y poco frecuentes se examinan sistematicamente (tuberculosis, hepatitis virica, sifilis, virus de la inmunodeficiencia humana, etc.) o en funcion de los factores de exposicion al riesgo (paludismo, alcoholizacion fetal, intoxicacion por plomo, etc.). Es necesario realizar una evaluacion de la inmunidad y una posible puesta al dia en una fase temprana. Durante el seguimiento, los motivos frecuentes de consulta son la dinamica del crecimiento, la incertidumbre sobre la edad, los trastornos del desarrollo (motricidad, lenguaje, sueno y/o alimentacion), los trastornos psicoafectivos y de apego, y la pubertad avanzada. El conocimiento de los problemas actuales de la adopcion es necesario para evitar atribuir cualquier sintoma a la adopcion. En la mayoria de las regiones de Francia y en los paises de adopcion existen consultas multidisciplinares de adopcion (pediatras, psiquiatras infantiles, psicologos en conexion con una red de especialistas) que son centros de referencia para situaciones complejas.

France receives a relatively large number of international adoptions. However, little is known about the frequency and types of microaggressions experienced by adoptive parents and internationally ...

Background Sickle cell disease (SCD) children are frequent travellers to countries where yellow fever (YF) is endemic, but there are no data regarding the safety and immunogenicity of the vaccine in such children treated with hydroxyurea (HU). The main objective of this study was to compare the tolerance and immune response to YF vaccination in SCD children treated or not with HU. Method SCD children Results Among the 52 SCD children vaccinated against YF, 17 (33%) were treated with HU. Only mild adverse events, mainly fever and local reaction, were observed in the HU group with a similar frequency in the non-HU group (57 and 35%, respectively, P = 0.30). YF antibody titres were measured in 15/17 patients in the HU group and 23/35 patients in the non-HU group after a median of 6.0 months (3.5–8.5) following vaccination. The geometric mean of YF antibody titre was similar in both groups. A protective antibody level was observed in 85% of the children in the HU group vs 100% in the non-HU group (P = 0.14), suggesting a lower effectiveness of the vaccine in patients on HU similarly to what has been described in patients on immune suppressive therapy for other vaccines. Conclusion YF vaccination seems to be safe and efficient in SCD children treated with HU. Considering the potential risk of severe complications in cases of YF while travelling in Africa for those patients, the benefit-to-risk ratio argues for YF vaccination in all SCD children. Control of a protective antibody titre may also be useful to ascertain an adequate response in those treated with HU.

Background There are few data on imported schistosomiasis – especially in children. The objectives of the present study were to estimate the prevalence of imported schistosomiasis in at-risk children in the greater Paris region of France and to compare diagnostic methods. Method Children at risk of schistosomiasis who consulted or were hospitalized in four hospitals in the greater Paris region were prospectively included. Clinical and laboratory data were collected. Urine and feces samples were screened for Schistosoma spp. using microscopy, a point-of-care circulating cathodic antigen and a real-time polymerase chain reaction assay. Serum samples were screened using Western blot, ELISA, indirect hemagglutination, and immunochromatographic assays. The diagnosis was characterized as confirmed (positive microscopy analysis) and as suspected (positive ELISA and Western blot assays). The prevalence of schistosomiasis and the tests’ performances were estimated using the latent class method. Results A total of 114 children were included. Most of the children were newly arrived migrants from sub-Saharan Africa. The mean age was 13.2 years-old. There were 12 (10.5%) confirmed cases and 13 (11.4%) suspected cases. Half of the confirmed and suspected cases were asymptomatic. The prevalence was 24.3%. The ELISA and the Western blot assays presented the same sensitivity (83%) and specificity (99%). The serum immunochromatographic assay also showed good performance. Conclusions The high prevalence of imported schistosomiasis among at-risk children in the greater Paris region confirms the need for systematic screening. A serum immunochromatographic assay appears to be one of the most effective screening methods for a low cost.

AIM In the context of global changes in the epidemiology of internationally adopted children (IACs), the prevalence of infectious diseases and nutritional impairment has not been recently reviewed. Moreover, in France, these characteristics of the children according to their continents of origin and preadoption special needs (SN) status have been incompletely explored. METHODS Demographic, infectious data and anthropometric of all the newly arrived IACs seen in a specialised clinic for international adoptees in Paris, France, between 2013 and 2016 were retrospectively reviewed. RESULTS Three hundred and fifty IACs [mean age: 3.4 years (±2.7), 204 male] from 39 countries were included; 55% had SN. Ninety-nine patients had at least one infection, 42% being classified as 'serious' (chronic viral infection, tuberculosis or malaria). Chronic viral infection was diagnosed in 26 (7%) patients (HIV: 16 cases, HBV: 5, HCV: 4) and affected especially Asian children (P

Resume La dengue est l’arbovirose dont l’expansion a ete la plus massive dans les populations des regions intertropicales au cours des dernieres annees. Elle peut etre grave, son taux de letalite le plus eleve etant observe chez les enfants de moins de cinq ans. L’augmentation des cas importes et l’implantation des moustiques Aedes, vecteur competent, en France metropolitaine depuis 2004, expliquent la survenue de quelques cas de dengue autochtone et incitent a anticiper une epidemie dans la population metropolitaine non immune. A l’instar des pediatres des regions intertropicales, nous allons devoir nous familiariser avec la symptomatologie et la prise en charge des cas de dengue en France et en Europe, en etant vigilant au depistage des rares formes graves, qui peuvent mettre en jeu le pronostic vital. Les caracteristiques epidemiologiques, physiopathologiques, cliniques, diagnostiques et therapeutiques de la dengue sont presentees.

More than 700,000 children were adopted internationally between 1990 and 2014. The USA and France have been among the top receiving countries in these years. Recently, many factors, including the ratification of the Hague Convention on Inter-country Adoption, have favored domestic adoption for children in need of families. As a result, the number of inter-country adoptions has declined considerably. Concurrently, the proportion of internationally adopted children with defined special needs has risen dramatically. These special needs may be generally categorized as medical issues (such as physical disabilities), age (> 5 years), or being part of a sibling group. Additional special needs, frequently behavioral or emotional problems, are often diagnosed after evaluation in the receiving country. These changing trends have greatly modified the need for and type of pre-adoption preparation of prospective adoptive parents, as well as for post-adoption support for these families and their children. In this review, the authors comprehensively analyze pediatric and child psychiatric considerations for preparing and supporting families and children. Based on clinical and epidemiological studies, as well as parent questionnaires, the need for pediatric and child psychiatric support before and after the arrival child is confirmed. Consultations with professionals specializing in international adoption can provide needed advice, diagnosis, and treatment tailored to the origin of the child and his prior experiences. The high prevalence of behavioral and emotional problems often justifies the need for psychological and child psychiatric guidance. Thus, the changing trends in inter-country adoption emphasize the needs for comprehensive support linked to the specific needs of these children.

Résumé Les enfants voyageurs sont des millions dans le monde et sont exposés à de nombreux risques, infectieux ou non, dont les praticiens n’ont pas toujours l’expérience. La consultation d’un enfant fébrile après un voyage est de plus en plus fréquente. Ainsi, la notion d’antécédent de voyage doit être recherchée devant tout enfant fébrile. La démarche diagnostique prend en compte prioritairement des pathologies intertropicales potentiellement graves, comme le paludisme, qui exigent d’être recherchées et traitées efficacement sans délai. Rapidement sont recherchées des infections contagieuses à risque épidémique qui nécessitent la mise en place de mesures d’hygiène et de santé publique. L’interrogatoire évalue les caractéristiques de la fièvre, les vaccinations réalisées, les antécédents médico-chirurgicaux et les risques d’exposition aux infections lors du voyage d’après les données géographiques, saisonnières, environnementales, socioculturelles et épidémiologiques. Il oriente avec les données cliniques et paracliniques élémentaires certains examens complémentaires qui permettent un diagnostic étiologique et un traitement optimal dans près de 75 % des cas. La majorité des causes de fièvre des enfants au retour de voyage sont des infections cosmopolites. En cas de paludisme, le traitement antipaludique est une urgence. Cet article décrit la démarche diagnostique et la prise en charge recommandée en France devant un enfant fébrile de retour de voyage.

Introduction Both adoption status and ethnic differences may contribute to stigmatization and microaggressions experienced by adopted individuals and their families. Internationally adopted children have been increasingly recognized to have elevated rates of special needs (SN), especially learning disabilities, attention deficit hyperactivity disorder (ADHD), emotional-behavioral problems, and medical-physical issues. However, relatively little is known about the feelings, perceptions, and stigma experienced by families of internationally adopted children with SN. Methods 461 French parents responded to a questionnaire (308 on-line, 153 paper) regarding their feelings and perceptions after international adoption (feelings of difference, ease of attachment, similarities to and dissimilarities from their child), as well as their views of their child’s feelings and experiences (difference, exclusion, and prejudice). Parents were asked if their children were diagnosed by professionals as having special needs, specifically: (1) medical/physical conditions, (2) ADHD, (3) learning disabilities, or (4) emotional-behavioral difficulties. Results were compared for parents of children with or without SN. Results The children (57%M; 43%F) of the parent respondents were adopted from 47 countries. The children were age (mean ± SD) 3.19 ± 2.59 years old at arrival and 11.33 ± 5.03 years old at the time of the survey. 301 (65%) parents reported that their child had at least one SN: physical-medical SN (13% of children) were reported significantly less often than the other 3 categories (ADHD 39%, learning disabilities 36%, emotional-behavioral problems 40%). Overall, parents reported 652 distinct SN among these 301 children: 102/301 (34%) had a diagnosis in a single category, whereas 199/301 (66%) had diagnoses in at least two categories. SN diagnoses varied by continent of origin: Eastern European children had proportionally more ADHD, learning disabilities, and emotional-behavior problems, as well as more diagnoses per child. Compared with parents of non-SN children, parents of SN children (especially those with learning disabilities or emotional-behavioral problems) significantly more often endorsed feelings of difference, more difficulties attaching to their child, and fewer similarities to and more dissimilarities from their child. The SN parents also more often reported that their child experienced exclusion and/or prejudice. The more SN diagnosed in their children, the more likely their parents’ feelings and perceptions differed from parents of children without SN. These relationships remained significant after controlling for arrival age, current age, gender, and adoption visibility, and after adjusting for exclusion due to adopted status or country of origin. Conclusions Compared to adoptive parents of children without SN, parents of children with SN report differing patterns of perceptions and feelings. Child SN represent an additional burden for parents of internationally adopted children, and for their children’s feelings and experiences (difference, exclusion, and prejudice, as reported by the parents). These perceptions and feelings are present, even when the SN are not physically obvious. SN must be recognized as an increasingly common, complex, and added dimension to the issues of adoptive status and (often) ethnic differences faced by internationally adopted children and their parents.

Internationally adopted children arrive in their new countries with many infectious disease and other health risks. Physicians provide advice prior to the arrival of the child, including pretravel health and vaccine recommendations for adoptive parents. After arrival, the adoptee should be screened for infectious diseases, including parasites, tuberculosis, hepatitis A/B/C, HIV, and syphilis, and also undergo general health evaluation. Careful assessment of immunity to vaccine-preventable diseases is also required. Follow-up screening for tuberculosis, HIV, hepatitis B/C is recommended 6 or more months after arrival. Growth and developmental delays, emotional/behavioral problems, and medical special needs are often found in this population. Parent preparation is essential to facilitate the adjustment of the child to a new family.

Prevention of malaria is based on personal vector-control measures (PVCMs) to avoid mosquito bites at night and chemoprophylaxis if justified by the risk of contracting the disease. The most effective PVCM is the use of insecticide-treated mosquito nets. The decision to prescribe chemoprophylaxis, mainly to prevent Plasmodium falciparum infection, depends on the benefit-risk ratio. Overall, the risk of contracting malaria is 1,000-fold lower during a stay in the tropical regions of Asia or the Americas than in sub-Saharan Africa. For "conventional" stays (less than one month with nights spent in urban areas) in low-risk settings in tropical Asia and America, the risk of being infected with Plasmodium parasites (≤1/100,000) is equivalent or lower than that of experiencing serious adverse effects caused by chemoprophylaxis. Preventive medication is therefore no longer recommended. By contrast, in other settings and particularly in sub-Saharan Africa, chemoprophylaxis is the most effective measure against malaria. However, it is worth noting that no single preventive measure provides full protection. Regardless of the level of risk or chemoprophylaxis-related indication, protection against mosquito bites and rapid management of febrile illness after returning from an endemic area are also critical to prevent malaria. Finally, migrants of sub-Saharan origin visiting friends and relatives in their country of origin form a high-risk group who should be recommended chemoprophylaxis in the same way as any other travelers-with a preference for the least expensive molecules (doxycycline).

Since the 2007 French guidelines on imported Falciparum malaria, the epidemiology, treatment, and prevention of malaria have changed considerably requiring guidelines for all Plasmodium species to be updated. Over the past decade, the incidence of imported malaria has decreased in all age groups, reflecting the decrease in the incidence of malaria in endemic areas. The rates of severe pediatric cases have increased as in adults, but fatalities are rare. The parasitological diagnosis requires a thick blood smear (or a rapid immunochromatographic test) and a thin blood film. Alternatively, a rapid antigen detection test can be paired with a thin blood film. Thrombocytopenia in children presenting with fever is highly predictive of malaria following travel to a malaria-endemic area and, when detected, malaria should be strongly considered. The first-line treatment of uncomplicated P. falciparum malaria is now an artemisinin-based combination therapy (ACT), either artemether-lumefantrine or artenimol-piperaquine, as recommended by the World Health Organization in endemic areas. Uncomplicated presentations of non-falciparum malaria should be treated either with chloroquine or ACT. The first-line treatment of severe malaria is now intravenous artesunate which is more effective than quinine in endemic areas. Quinine is restricted to cases where artesunate is contraindicated or unavailable. Prevention of malaria in pediatric travelers consists of nocturnal personal protection against mosquitoes (especially insecticide-treated nets) combined with chemoprophylaxis according to the risk level.

SummaryBackground In erythropoietic protoporphyria (EPP), an inherited disease of porphyrin-biosynthesis, the accumulation of protoporphyrin in the skin causes severely painful phototoxic reactions. Symptom prevention was impossible until recently when afamelanotide became available. Afamelanotide-induced skin pigmentation has statistically significantly improved light-tolerance, although the clinical significance of the statistical effect was unknown. Objectives To assess clinical effectiveness by recording compliance and safety during prolonged use. Methods We report longitudinal observations of 115 ambulatory patients with EPP, who were treated with a total of 1023 afamelanotide implants over a period of up to 8 years at two porphyria centres; one in Rome, Italy, and the other in Zurich, Switzerland. Results Since the treatment first became available in 2006, the number of patients treated with 16 mg afamelanotide implants rose continuously until June 2014, when 66% of all patients with EPP known to the porphyria centres were treated. Only three patients considered afamelanotide did not meet their expectations for symptom improvement; 23% discontinued the treatment for other, mostly compelling, reasons such as pregnancy or financial restrictions. The quality of life (QoL) scores, measured by an EPP-specific questionnaire, were 31 ± 24% of maximum prior to afamelanotide treatment, rose to 74% after starting afamelanotide and remained at this level during the entire observation period. Only minor adverse events attributable to afamelanotide, predominantly nausea, were recorded. Conclusion Based on the improved QoL scores, high compliance and low discontinuation rates, we conclude that afamelanotide exhibits good clinical effectiveness and good safety in EPP under long-term routine conditions.

We investigated the knowledge of female genital mutilation (FGM) among 60 general and 52 specialized travel medicine practitioners. Less than 50% of these practitioners had adequate knowledge of FGM. Only 42.9% declared having encountered FGM. FGM is likely underestimated in health facilities. Medical education and supporting information should be developed to better address and prevent FGM.

Introduction Le vaccin de la fievre jaune (FJ) est contre-indique chez les patients ayant une immunosuppression. Malgre l’absence de donnees, les recommandations sanitaires pour le voyageur autorisent cette vaccination chez les patients drepanocytaires traites par hydroxycarbamide (HC). L’objectif de cette etude etait d’evaluer la tolerance et l’efficacite du vaccin FJ chez des enfants drepanocytaires traites ou non par HC. Materiels et methodes Il s’agit d’une etude prospective realisee entre mars 2016 et juillet 2017. Tous les enfants drepanocytaires de mois de 18 ans, traites ou non par HC et recevant un vaccin FJ dans un des 3 centres de vaccination du voyage de l’etude ont ete inclus. La tolerance a ete evaluee par un entretien telephonique a 15 jours de l’injection. L’efficacite a ete evaluee a environ 6 mois par une serologie FJ > 5 en methode PRNT80. Le test Mann–Whitney a ete utilise pour les comparaisons. Resultats Au total, 54 enfants, âge median de 7.6 ans [2,9 ; 12,4], sex-ratio M/F 0,61, ont ete inclus. Tous recevaient une primo-vaccination. Dix-sept sur 54 etaient traites par HC. Les enfants HC + etaient plus âges que les enfants HC − (6,8 vs 9,5 ans, p = 0,0015), plus souvent sous programme d’echange transfusionnel (17 vs 3 %, p = 0,006) et avaient des lymphocytes totaux plus bas (3,3 vs 4,9 G/L, p = 0,014) que les enfants HC −. Quarante-trois pourcent des enfants ont eu des effets indesirables post-vaccination, tous de grade I/II. Les plus frequents etaient une douleur au point d’injection (24 % des patients) ou une fievre (17 % des patients). Globalement, la frequence des effets indesirables etait identique dans les 2 groupes (37 % dans le groupe HC − vs 57 % dans le groupe HC + , p = 0,15). La proportion de seroconversion FJ etait plus faible dans le groupe HC + (85 %) par rapport au groupe HC − (100 %). Le titre d’anticorps median etait comparable dans les deux groupes (40 UI/mL). Conclusion La tolerance de la vaccination FJ semble satisfaisante chez les enfants traites par HC bien que la taille de notre effectif ne permette pas de conclure definitivement. Les enfants drepanocytaires sous HC ont toutefois une moins bonne reponse vaccinale. Un controle serologique est necessaire chez ces enfants afin de discuter la realisation d’une 2e dose de vaccin fievre jaune avant un nouveau depart en zone d’endemie.

La consulta pediatrica previa a un viaje tiene como objetivos evaluar la probabilidad de los riesgos sanitarios relacionados con el estado de salud del nino y con el entorno extrano, asi como proporcionar los medios para prevenir o reducir estos riesgos. Se basa en la exploracion fisica y en una anamnesis detallada de los antecedentes personales y de los lugares de estancia. Es necesario contar con conocimientos actualizados de la epidemiologia de las regiones del viaje, de las medidas y de los tratamientos preventivos o empiricos de las enfermedades que puedan aparecer durante el viaje. Las recomendaciones sanitarias indispensables engloban, en caso de exposicion, la prevencion del paludismo y de algunas enfermedades infecciosas transmitidas por vectores o prevenidas mediante vacunacion (con independencia del destino), asi como la prevencion de la diarrea, de las situaciones de riesgo de accidente y de la agravacion de una posible enfermedad cronica. Los consejos universales de prevencion primaria son validos para cualquier viajero con independencia de su edad, insistiendo especialmente en los ninos en lo referente a la higiene alimentaria, hidrica (lactancia materna, biberon), corporal y de la ropa, en la proteccion solar y contra el calor, en la vigilancia durante los banos, asi como en las medidas de seguridad durante los transportes. La evaluacion y la educacion sanitaria requieren tiempo y, en ocasiones, varias consultas para completar el calendario vacunal antes del viaje.

Dengue is the arboviral disease that has massively spread in intertropical regions these past few years. The rise in imported cases of dengue and the rapid spread of the Aedes vector mosquitoes in continental France since 2004 explain the occurrence of indigenous dengue cases among the nonimmune population and points to an epidemic risk. Severe dengue cases are rare, but lethality is highest among children under 5 years of age. Like pediatricians in tropical regions, we must learn how dengue presents in metropolitan France and how it can be managed, and pay special attention to severe and potentially fatal forms. The epidemiological, pathophysiological, clinical, diagnostic, and therapeutic characteristics of dengue are presented herein.

Use of topical insect repellent is an important component in prophylaxis of arthropod bite vector borne diseases. Topical insect repellent are used in a three part management regimen, along with impregnated clothing and mosquito netting. Parental training for efficacious and secure use of repellents for their children is essential part of a successful strategy to combat Lyme borreliosis, dengue fever, Chikungunya, West Nile virus infection and malaria, amongst children, according to local epidemiological risks. Rational repellent prescription for a child must take into account age, active substance concentration, topical substance tolerance, nature and surface of the skin to protect, number of daily applications, and the length of use in a benefit-risk ratio assessment perspective. The 4 currently repellents recommended by Whopes (Who) for their long lasting efficacy and patient tolerance are: 1) Citriodiol (PMD), 2) DEET, 3) Icaridine (KB3023), and 4) IR3535. In field trials the minimum required concentration of each four of these agents to be effective for 3 hours against most arthropods is 20% (in cream, roll-on or spray vehicle). Described side effects of these agents are mild, being limited to local irritative dermatitis and allergy. The risk of severe side effects has been related to DEET misused and neurotoxicity. The international recommendations concerning utilization of topical repellent amongst children for prophylaxis of arthropod borne diseases is concerning short term usage (several weeks). But the use of repellent is sub chronic or chronic amongst the majority of children living in subtropical regions where these vector borne diseases are endemic. And toxicity of topical repellent when used sub-chronically and chronically is not well studied in pediatric age groups. Taking into account these considerations, the current recommendations of the French Group of Tropical Paediatrics are to teach the parents of children who live in arthropod vector disease endemic regions to use topical insect repellent on their children with the recommended age related frequency in the following way: the use of topical repellent in infants above 6 months, once daily. Only in exceptional circumstances of severe arthropod exposure risk, their brief use in nursing infants as young as 2 months is acceptable, however with never more than 1 application daily. From ages 1 to 12 years, 2 applications daily may be safely used; 3 applications daily after 12 years old through adulthood.

Vector transmitted diseases are often a serious threat for child health, especially for children traveller in tropical regions. Few arthropod borne diseases are preventable by immunization or chimioprophylaxis. Prevention of most of them is based on personal protection against arthropod bites. The evidence of its efficacy has been established by the use of impregnated bed nets, impregnated clothes with permethrin or mosquito repellent which reduced significantly child malaria morbidity and mortality in endemic countries. These personal protective measures are able to minimize arthropod bites and prevent Chikungunya infection, dengue fever and Lyme disease. The choice of a repellent among the commercialised products need to be efficacy and safety evidence based. This article propose to raise this issue and to give pragmatic recommendations, with a focus to children below 30 months who are at a high toxicological risk. Severity of these diseases allowed to use potentially toxic repellents if misused.

Each year, half a million of children leave France to travel towards countries south or east of the European Union, sometimes in poor sanitary conditions. In order to propose essential or useful immunizations for these trips, the current synthesis will allow the practitioner to insure that the routine French immunization schedule has been followed, and to complete it if needed, to protect the child according to the epidemiological situation in the visited area, to try to reduce the limitations of the immunization of the traveler child. In case of emergency, or close departure, it may be useful to follow an accelerated schedule of the last minute, and, sometimes, to immunize traveler children with a chronic disease. Informations on Internet sites useful for the knowledge of current infectious risks in the destination country are also provided.

Resume Contexte et objectifs. – La France est le pays notifiant le plus de cas de paludisme d'importation a Plasmodium falciparum (1300 enfants en 2000). Trois ans apres la conference nationale de consensus sur la prise en charge du paludisme d'importation, le groupe de pediatrie tropicale a realise une enquete pour recenser les pratiques de traitement de l'acces palustre non complique de l'enfant a l'hopital en France. Methode. – Un questionnaire a ete propose aux 29 services de pediatrie de France metropolitaine ayant declare plus de dix cas de paludisme en 2000. Les questions concernaient le traitement et la surveillance des enfants atteints d'acces palustre simple en 2002. Resultats. – Vingt-six services ayant traite au total plus de 700 acces palustres de l'enfant ont repondu. L'hospitalisation des enfants impaludes etait systematique pour 22 des 26 services, avec une duree moyenne de sejour de 2,2 jours (ET ± 0,9). Le medicament antipaludique de premiere intention etait l'halofantrine dans 22 services et la mefloquine dans les quatre autres. Une seconde cure d'halofantrine a J7 etait prescrite par trois services sur 22. Aucun incident cardiaque clinique n'a ete rapporte. La quinine n'etait utilisee qu'en cas de troubles digestifs. La surveillance apres la sortie de l'hopital etait clinique et parasitologique dans 16 services, seulement parasitologique dans trois services, uniquement clinique dans deux services et non systematique dans cinq services. Des echecs therapeutiques precoces etaient rapportes par deux services avec la mefloquine, aucun avec l'halofantrine. Des echecs therapeutiques tardifs ont ete signales au moins une fois par 19 des 22 services utilisant l'halofantrine. Discussion. – L'halofantrine demeure l'antipaludique le plus prescrit dans l'acces simple de l'enfant. En depit de l'absence d'incident cardiaque clinique rapporte chez l'enfant voyageur, ce produit n'est plus guere utilise qu'en cure unique, exposant a un risque eleve de rechute. La mefloquine est trois fois plus utilisee qu'en 1997, malgre ses effets digestifs expliquant certains echecs precoces. Reservee aujourd'hui aux cas graves, la quinine est un peu moins utilisee dans l'acces simple qu'en 1997. Conclusions. – Les limites des traitements actuels de l'acces simple de l'enfant en France rendent necessaire l'amelioration des protocoles (deuxieme cure d'halofantrine systematique a dose reduite apres J7, association d'un anti-emetique a la mefloquine), un controle systematique de l'evolution clinique et parasitologique et la mise a disposition rapide des associations d'antipaludiques existantes alliant efficacite durable et bonne tolerance.

The present analysis addresses several passive tilt systems for railroad cars aiming to compensate for the cart deficiency on curved tracks. To this end, the virtual centre of suspension must be located as close as possible to the longitudinal plane of symmetry of the coach, above the mass centre level for stability reasons. On the one hand, pantograph or Peaucellier's mechanisms may achieve the correct self-compensation. On the other hand, simpler articulated systems yield the desired goal with an excellent approximation. For example, selective algorithms can be applied for designing eight-link mechanisms, to be optimized thereafter by some method of the gradient type, minimizing the mean square value of the transverse acceleration component.

We investigate the vacuum energy of a scalar massless field confined in a Casimir cavity moving in a circular equatorial orbit in the exact Kerr space-time geometry. We find that both the orbital motion of the cavity and the underlying space-time geometry conspire in lowering the absolute value of the (renormalized) Casimir energy ⟨ e vac ⟩ ren , as measured by a comoving observer, with respect to whom the cavity is at rest. This, in turn, causes a weakening in the attractive force between the Casimir plates. In particular, we show that the vacuum energy density ⟨ e vac ⟩ ren → 0 when the orbital path of the Casimir cavity comes close to the corotating or counter-rotating circular null orbits (possibly geodesic) allowed by the Kerr geometry. Such an effect could be of some astrophysical interest on relevant orbits, such as the Kerr innermost stable circular orbits, being potentially related to particle confinement (as in some interquark models). The present work generalizes previous results obtained by several authors in the weak field approximation.

Consultation of child traveler has two main objectives: to assess of health risk related to the child's health status and history and also the risk related to travel environment; to counsel and prescribe preventive measure to reduce these travel health risks. The evaluation is based on physical examination and a detailed interview including personal history and information regarding the regions of proposed travel. Up to date knowledge of the epidemiology of visited sites, preventive measures and presumptive treatment is required. Essential health recommendations include, in case of exposure, prevention of malaria, arthropod borned diseases and vaccine preventable diseases. For all destinations advice regarding prevention of diarrhea, accident risks and aggravation of preexisting chronic diseases is needed. Universal primary prevention counselling is valuable for all travellers regardless of their age. In the case of children, special attention must be given to food and water hygiene, sun and heat exposure, swimming risks and transports security measures. Evaluation of risk and health education take time and often several visits are needed to complete the immunization schedule before departure.

Use of topical insect repellent is an important component in prophylaxis of arthropod bite vector borne diseases. Topical insect repellent are used in a three part management regimen, along with impregnated clothing and mosquito netting. Parental training for efficacious and secure use of repellents for their children is essential part of a successful strategy to combat Lyme borreliosis, dengue fever, Chikungunya, West Nile virus infection and malaria, amongst children, according to local epidemiological risks. Rational repellent prescription for a child must take into account age, active substance concentration, topical substance tolerance, nature and surface of the skin to protect, number of daily applications, and the length of use in a benefit-risk ratio assessment perspective. The 4 currently repellents recommended by Whopes (Who) for their long lasting efficacy and patient tolerance are: 1) Citriodiol (PMD), 2) DEET, 3) Icaridine (KB3023), and 4) IR3535. In field trials the minimum required concentration of each four of these agents to be effective for 3 hours against most arthropods is 20% (in cream, roll-on or spray vehicle). Described side effects of these agents are mild, being limited to local irritative dermatitis and allergy. The risk of severe side effects has been related to DEET misused and neurotoxicity. The international recommendations concerning utilization of topical repellent amongst children for prophylaxis of arthropod borne diseases is concerning short term usage (several weeks). But the use of repellent is sub chronic or chronic amongst the majority of children living in subtropical regions where these vector borne diseases are endemic. And toxicity of topical repellent when used sub-chronically and chronically is not well studied in pediatric age groups. Taking into account these considerations, the current recommendations of the French Group of Tropical Paediatrics are to teach the parents of children who live in arthropod vector disease endemic regions to use topical insect repellent on their children with the recommended age related frequency in the following way: the use of topical repellent in infants above 6 months, once daily. Only in exceptional circumstances of severe arthropod exposure risk, their brief use in nursing infants as young as 2 months is acceptable, however with never more than 1 application daily. From ages 1 to 12 years, 2 applications daily may be safely used; 3 applications daily after 12 years old through adulthood.

Here we report the characterization of four novel mutations and a previously described one of the coproporphyrinogen III oxidase (CPO) gene in five Italian patients affected by Hereditary Coproporphyria (HCP). Three of the novel genetic variants are missense mutations (p.Gly242Cys; p.Leu398Pro; p.Ser245Phe) and one is a frameshift mutation (p.Gly188TrpfsX45).

Each year hundreds of thousands of children leave France to travel to developing countries where they are exposed to infectious agents that can be prevented by vaccination. During the child's pre-travel check-up, practitioners should check that all mandatory immunizations are up-to-date and provide advice on relevant vaccines in function of the epidemiological situation at the chosen destination. However various factors hinder full compliance with this approach and some vaccines are underused. Underused vaccines are referred to as neglected vaccines. In the French vaccination schedule three vaccinations can be considered as neglected. The first is the hepatitis B vaccine that has a low coverage level in France due to strong reluctance to its use despite the fact that the virus is widespread in tropical areas. The second is pneumococcal vaccine that should be administered to all infants less than 2 years of age, especially for travel to areas where pneumonia and meningitis are frequent. The third is BCG vaccine that is now at greater risk of being neglected in child travellers because its use has been downgraded from a general requirement to a recommendation only for children at risk. A serious limitation on the use of travel vaccinations is cost that can lead families to neglect some infectious risk such as hepatitis A that is a major risk for child travellers as well as for their relatives during or after the trip and typhoid fever that is essentially an imported disease. Rabies vaccine is also underused due to its cost and to poor understanding of the risk by many practitioners and families. The purpose of this article is to underline the need to improve information and access to vaccines that are all too often neglected in child travellers.