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Objectives The aim of this study was to describe severe forms of novel coronavirus disease 2019 in children, including patient characteristics, clinical, laboratory, and imaging findings, as well as the disease management and outcomes. Methods This was a retrospective, single-center, observational study conducted in a pediatric intensive and high-dependency care unit (PICU, HDU) in an urban hospital in Paris. All patients, aged from 1 month to 18 years, admitted for confirmed or highly suspected SARS-CoV-2 were included. Results We analyzed the data of 27 children. Comorbidities (n = 19, 70%) were mainly neurological (n = 7), respiratory, (n = 4), or sickle cell disease (n = 4). SARS-CoV-2 PCR results were positive in 24 children (nasopharyngeal swabs). The three remaining children had a chest CT scan consistent with COVID-19. Respiratory involvement was observed in 24 patients (89%). Supportive treatments were invasive mechanical ventilation (n = 9), catecholamine (n = 4), erythropheresis (n = 4), renal replacement therapy (n = 1), and extracorporeal membrane oxygenation (n = 1). Five children died, of whom three were without past medical history. Conclusion This study highlighted the large spectrum of clinical presentation and time course of disease progression as well as the non-negligible occurrence of pediatric life-threatening and fatal cases of COVID-19 mostly in patients with comorbidities. Additional laboratory investigations are needed to further analyze the mechanism underlying the variability of SARS-Cov-2 pathogenicity in children.

BackgroundHealthcare workers (HCWs) have paid a heavy toll during the coronavirus disease 2019 (COVID-19) outbreak. Routes of transmission remain to be fully understood.MethodsThis prospective study compared a 1500-bed adult and 600-bed pediatric setting of a tertiary-care university hospital located in central Paris. From 24 February until 10 April 2020, all symptomatic HCWs were screened for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on a nasopharyngeal swab. HCWs screened positive were questioned on their profession, symptoms, and occupational and nonoccupational exposures to SARS-CoV-2.ResultsAmong 1344 HCWs tested, 373 were positive (28%) and 336 (90%) corresponding questionnaires were completed. Three hospitalizations and no deaths were reported. Most HCWs (70%) had patient-facing occupational activities (22% in COVID-19 dedicated units). The total number of HCW cases peaked on 23 March, then decreased slowly, concomitantly with a continuous increase of compliance to preventive measures (including universal medical masking and personal protective equipment [PPE] for direct care to COVID-19 patients). Attack rates were of 3.2% and 2.3% in the adult and pediatric settings, respectively (P = .0022). In the adult setting, HCWs more frequently reported exposure to COVID-19 patients without PPE (25% vs 15%, P = .046). Report of contacts with children attending out-of-home care facilities dramatically decreased over the study period.ConclusionsUniversal masking, reinforcement of hand hygiene, and PPE with medical masks for patients’ care allowed protection of HCWs and containment of the outbreak. Residual transmissions were related to persistent exposures with undiagnosed patients or colleagues and not to contacts with children attending out-of-home care facilities.

Background: From the start of the pandemic, health-care workers (HCW) have paid a heavy toll to the coronavirus desease-19 (COVID-19) outbreak. Routes of transmission however remain to be fully understood. Methods: This prospective study compared two settings of a tertiary-care university hospital located in central Paris: a 1,500-bed adult and a 600-bed paediatric setting, accounting for a total of 13,278 employees. From February 24th until April 10th, 2020, all symptomatic HCW were screened for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) on a nasopharyngeal swab. HCW screened positive were prospectively questioned by phone on their profession, symptoms, occupational and non-occupational exposures to SARS-CoV-2. Findings: Among 1344 symptomatic HCW tested, 373 were positive (28%) and 336 (90%) corresponding questionnaires were completed. Three hospitalizations and no death have been reported. Most HCW (70%) had patient-facing occupational activities and 22% in COVID-19 dedicated units. The total number of HCW cases peaked on week 13 (March 23rd, 2020) then decreased slowly until April 10th, concomitantly with a continuous increase of compliance to preventive measures (including universal medical masking for all hospital staff and personal protective equipment (PPE) for direct care to COVID-19 patients). Attack rates were of 3 · 2% and 2 · 3% in the adult and paediatric settings, respectively (p=0 · 0022). In the adult setting, HCW more frequently reported exposure to COVID-19 patients without PPE (25% versus 15%, p=0 · 046). In both settings, report of contacts with children attending out-of-home care facilities dramatically decreased all over the study period. Interpretation: In central Paris, implementation of universal masking, reinforcement of hand hygiene, social distancing and PPE with medical masks for patients’ care allowed protection of HCW and containment of the outbreak. Residual transmissions were related to persistent exposures with undiagnosed patients or colleagues and not to contacts with children attending out-of-home care facilities. Funding Statement: None. Declaration of Interests: AC reports personal fees and non-financial support from Janssen Cilag, outside the submitted work. RG reports personal fees and other from Sanofi, personal fees from MSD, personal fees from Eumedica, personal fees from Pfizer, personal fees from Frezenius, personal fees from Cubist, personal fees from Correvio, personal fees from Astellas, outside the submitted work. PF reports personal fees and nonfinancial support from MSD France, personal fees from ViiV Healthcare, non-financial support from Gilead Science, personal fees and non-financial support from Janssen Cilag, personal fees from Medtronic SAS, non-financial support from Astellas, non-financial support from GSK, outside the submitted work. MLV reports non-financial support from Biomerieux, non-financial support from Diasorin, outside the submitted work. OL reports personal fees from Pfizer, personal fees from Astellas, personal fees from MSD, personal fees from Gilead, outside the submitted work. SK reports research grants from bioMerieux, personal fees from Accelerate Diagnostics, bioMerieux, MSD and Menarini, and travel expenses from bioMerieux, Astellas, MSD and Pfizer, outside the submitted work. All other authors declare no conflict of interests. Ethics Approval Statement: This study was approved by the Ethical Review Committee for publications of the Cochin university Hospital (CLEP) (N°: AAA-2020-08012). According to French policy, a non-opposition statement was obtained for all participants, meaning that all had received written detailed information on the objectives of the study and were free to request withdrawal of their consent for participation at any time.

La neurofisiologia del movimento e dell’apprendimento motorio occupa un ampio campo scientifico. Le basi fondamentali dell’elaborazione centrale del movimento si inseriscono in strutture cerebrali molto specifiche sul piano anatomico e funzionale, ma anche riccamente interconnesse, formando insiemi neuronali gerarchici e dinamici. L’obiettivo principale di questo articolo e di introdurre le basi generali dell’apprendimento motorio, ottenute attraverso esperimenti a partire da modelli animali elementari, per integrarle progressivamente a comportamenti motori piu complessi. Le basi delle oscillazioni neuronali e dell’apprendimento motorio, che coinvolgono il potenziamento e la depressione a lungo termine, e i meccanismi che risiedono nella membrana dei neuroni cosi come quelli che attivano il materiale genetico neuronale sono considerati nel loro contesto sperimentale iniziale, prima di essere descritti in comportamenti motori piu complessi negli esseri umani. Si propone una visione aggiornata dei diversi sistemi corticali e subcorticali alla base della neurofisiologia del movimento e della sua plasticita. La struttura dinamica proposta incorpora le aree corticali coinvolte nell’organizzazione del movimento volontario e dell’orientamento sensoriale, cosi come il ruolo dei gangli della base e del cervelletto. Infine, la descrizione dei neuroni specchio e del modello interno dovrebbe permettere di capire meglio la dinamica generale dell’apprendimento del gesto motorio portato dall’attivita oscillatoria del cervello.

La neurofisiologia del movimiento y del aprendizaje motor abarca un campo cientifico muy amplio. Las bases fundamentales de la elaboracion central del movimiento se inscriben en estructuras cerebrales muy especificas desde los puntos de vista anatomico y funcional, pero tambien profusamente interconectadas, formando conjuntos neuronales jerarquizados y dinamicos. El objetivo principal de este articulo consiste en presentar las bases generales del aprendizaje motor obtenidas a partir de los experimentos con modelos animales elementales, con el fin de integrarlas progresivamente en comportamientos motores mas complejos. Antes de describirlos como parte de conductas motoras mas complejas en seres humanos, se consideraran, en su entorno experimental inicial, las bases de las oscilaciones neuronales y del aprendizaje motor, que involucran la potenciacion y la depresion a largo plazo, asi como los mecanismos que se localizan en la membrana de las neuronas y los que activan el material genetico neuronal. Se propone una vision actualizada de los diferentes sistemas corticales y subcorticales, que se encuentran en la base de la neurofisiologia del movimiento y de su plasticidad. La estructura dinamica propuesta integra las areas corticales implicadas en la organizacion del acto voluntario y de la orientacion sensorial, asi como el papel de los nucleos de la base y del cerebelo. Finalmente, la descripcion de las neuronas espejo y del modelo interno deberia permitir comprender mejor la dinamica general del aprendizaje del acto motor que sustenta la actividad oscilatoria del cerebro.

Les traumatismes crâniens (TC) de l’enfant sont frequents et benins dans leur grande majorite. Les formes graves, definies par un score de Glasgow (GCS) < 9, restent la 1ere cause de deces accidentel des l’âge d’un an. Leur gravite reside dans la survenue de lesions intracrâniennes (LIC) mises en evidence par la tomodensitometrie cerebrale. Les TC graves relevent de mesures therapeutiques protocolisees dans un centre pediatrique specialise. L’objectif est de prevenir les lesions cerebrales secondaires. La reanimation precoce debute sur les lieux de l’accident par le maintien des fonctions vitales. La prise en charge optimale de la multitude d’enfants consultant pour un TC mineur (GCS : 13–15) reste a definir. Elle repose sur l’evaluation de la gravite potentielle du TC qui seule determine l’indication d’une tomodensitometrie. L’urgentiste doit mettre en balance le risque de manquer une LIC neurochirurgicale avec celui de malignite future liee aux radiations ionisantes. La valeur predictive de LIC d’une fracture du crâne, d’un cephalhematome, d’une perte de connaissance initiale, d’une amnesie, d’une convulsion immediate, de vomissements, de cephalees, d’une cinetique elevee et d’un âge < 2 ans est controversee. Les regles de decision clinique publiees permettent d’identifier les rares LIC avec une excellente sensibilite mais au prix d’un nombre eleve de tomodensitometries cerebrales normales. Le recours a une breve periode d’observation des enfants dont la benignite du TC ne peut etre affirmee des l’evaluation clinique initiale est une alternative de choix.

I traumi cranici del bambino sono frequenti e hanno un’incidenza bimodale: prima dell’eta di 5 anni e all’adolescenza. La loro gravita risiede nella comparsa di lesioni intracraniche (ematoma, lesioni assonali, edema cerebrale). Inizialmente e gia in fase preospedaliera, la gestione terapeutica consiste nel mantenere le funzioni vitali. I disturbi di coscienza, dei segni di destrutturazione o di focalizzazione, una frattura del cranio e l’eta (

Los traumatismos craneoencefalicos pediatricos son frecuentes y su incidencia es bimodal: antes de los 5 anos y en la adolescencia. Su gravedad se debe a la aparicion de lesiones intracraneales (hematoma, lesiones axonales, edema cerebral). El tratamiento inicial (ya desde la fase prehospitalaria) consiste en mantener las funciones vitales. Los trastornos de la conciencia, los signos de desestructuracion o de focalizacion, las fracturas del craneo y la edad (

Postnatally diagnosed congenital diaphragmatic hernias (CDH) are rare and have a better prognosis than those diagnosed prenatally. Postnatal symptoms can be respiratory, digestive, or mixed. Gastric volvulus can reveal CDH. Symptoms are pain, abdominal distension, and/or vomiting. Upper gastrointestinal barium X-ray radiography provides the diagnosis. Prognosis is related to early surgical management in complicated forms with intestinal occlusion or sub-occlusion. We report on an infant who presented with vomiting, which revealed gastric volvulus associated with a CDH. Progression was favorable after surgical treatment.

Sedation and analgesia in emergency structure. Reactualization 2010 of the Conference of Experts of Sfar of 1999 B. Vivien *, F. Adnet , V. Bounes , G. Cheron , X. Combes , J.-S. David , J.-F. Diependaele , J.-J. Eledjam , B. Eon , J.-P. Fontaine , M. Freysz , P. Michelet , G. Orliaguet , A. Puidupin , A. Ricard-Hibon , B. Riou , E. Wiel , J.-E. de La Coussaye o,4,** a Samu de Paris, departement d’anesthesie-reanimation, hopital Necker–Enfants-Malades, universite Paris Descartes–Paris-5, 149, rue de Sevres, 75730 Paris cedex 15, France b EA 3409, Samu 93, hopital Avicenne, universite Paris-13, 125, rue de Stalingrad, 93009 Bobigny, France c Samu 31, pole de medecine d’urgences, hopitaux universitaires, universite de Toulouse, 1, avenue Jean-Poulhes, place du Dr.Baylac, 31059 Toulouse cedex 9, France d Departement des urgences pediatriques, hopital Necker–Enfants-Malades, universite Paris Descartes–Paris-5, 149, rue de Sevres, 75730 Paris cedex 15, France e Departement d’anesthesie-reanimation-urgences, centre hospitalier Lyon-Sud, hospices civils de Lyon, 69493 Pierre-Benite, France f Smur pediatrique regional de Lille, centre hospitalier regional universitaire de Lille, universite Lille-2, Nord-de-France, 5, avenue Oscar-Lambret, 59037 Lille cedex, France g Structure des urgences, hopital Lapeyronie, universite 1, 191, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France h Pole reanimation urgence, service d’aide medicale urgente hyperbarie (RUSH), reanimation des urgences, CHU de SainteMarguerite, 270, boulevard Sainte-Marguerite, 13009 Marseille, France i Service d’accueil des urgences, hopital Saint-Louis, universite Paris-7, 1, avenue Claude-Vellefaux, 75010 Paris, France j Samu 21, departement d’anesthesie-reanimation, centre hospitalier universitaire de Dijon, faculte de medecine, 3, rue du Faubourg-Raines, BP 1519, 21033 Dijon cedex, France Annales Francaises d’Anesthesie et de Reanimation 31 (2012) 391–404

L’arret cardiorespiratoire (ACR) de l’enfant est dans la majorite des cas l’ultime consequence d’une insuffisance respiratoire et/ou circulatoire. L’hypoxie etant la premiere cause, la prise en charge de l’ACR de l’enfant a des specificites: manoeuvres de reanimation pendant une minute avant l’appel des secours, ratio 15/2 des compressions thoraciques et des insufflations chez l’enfant prepubere. Les troubles du rythme cardiaque, responsables de l’arret, les plus frequents sont l’asystolie et l’activite electrique sans pouls. Les defibrillateurs automatiques externes (DAE) sont utilisables a partir de l’âge d’un an, si possible avec un attenuateur pediatrique. La survie a un an des arrets cardiaques reste tres faible, grevee de sequelles neurologiques. La reconnaissance et la prise en charge precoce des defaillances respiratoires et circulatoires, surtout en milieu hospitalier, est la seule prevention de l’arret cardiaque. La formation des professionnels de sante est indispensable et represente un immense probleme.

La neurofisiologia del movimento e dell’apprendimento motorio ricopre un campo scientifico molto vasto. Le basi fondamentali dell’elaborazione centrale del movimento si inscrivono in alcune strutture cerebrali molto specifiche sul piano anatomico e funzionale ma anche riccamente interconnesse, che formano degli insiemi neuronali gerarchizzati e dinamici. L’obiettivo principale di questo capitolo consiste nell’introdurre le basi generali dell’apprendimento motorio ottenute grazie alle esperienze realizzate a partire da modelli animali elementari, per integrarle gradualmente a comportamenti motori piu complessi. Le basi dell’apprendimento neuronale che coinvolgono il potenziamento e la depressione a lungo termine e i meccanismi che hanno sede a livello della membrana dei neuroni, cosi come quelli che attivano il materiale genetico neuronale, sono considerati nel loro contesto sperimentale iniziale, prima di essere descritti all’interno di comportamenti motori piu complessi che coinvolgono in particolare la motricita umana. E proposta una visione aggiornata dei differenti sistemi corticali e sottocorticali alla base della neurofisiologia del movimento e della sua plasticita. La struttura dinamica proposta integra le aree corticali implicate nell’organizzazione del gesto volontario e della guida sensoriale, cosi come il ruolo dei nuclei della base e del cervelletto. Infine, la descrizione dei neuroni specchio e del modello interno dovrebbe permettere di afferrare meglio la dinamica generale del gesto motorio e del suo apprendimento.

Resume Nous rapportons le cas d’un enfant de 3 ans atteint de la fievre boutonneuse mediterraneenne. Cet enfant avait ete mordu par une tique au cours d’une promenade en foret en region parisienne. Un traitement par azithromycine a entraine une amelioration des symptomes. La fievre boutonneuse mediterraneenne n’est pas exceptionnelle et il faut savoir l’evoquer devant une eruption febrile avec une escarre meme en dehors des zones traditionnelles d’infestation.

Reanimation medicale et toxicologique, hopital Lariboisiere, 2, rue Ambroise-Pare, 75010, Paris cedex, France b Service de reanimation, hopital de Montfermeil, 10, rue du General-Leclerc, 93370 Montfermeil cedex, France Unite de reanimation pediatrique, hopital Charles-Nicolle, 1, rue de Germont, 76031 Rouen cedex, France Centre d’urgences–diagnostic rapide, hopital Necker–Enfants-Malades, 49, rue de Sevres, 75015 Paris cedex, France e Service de reanimation medicale, hopital Antoine-Beclere, 157, rue de la Porte-de-Trivaux, 92140 Clamart cedex, France

The study reported here prospectively evaluated the time-to-diagnosis of imported Plasmodium falciparum malaria in children in seven French pediatric emergency departments during a 1-week period. For the 29 patients included, the mean patient, doctor and total delays were 3.1, 1.5 and 4.7 days, respectively. The late medical diagnosis for 11 patients was mainly due to the treating physician's failure to consider malaria, despite having been informed that the child had been in an endemic area, and erroneously making a diagnosis of viral infection. The five patients who were diagnosed correctly without delay had higher mean platelet counts than the others (206,000 vs 118,541/mm(3); p=0.008). The results indicate that greater awareness of the risk of malaria in returning travelers may help reduce delays in diagnosis and its consequences.

Laryngeal papillomatosis is a rare, potentially severe cause of recurrent laryngeal dyspnea. It should be known as a cause of laryngeal dyspnea resistant to the usual treatments. We report on two pediatric cases of severe laryngeal papillomatosis with respiratory distress and failure. These observations illustrate the importance of early adequate treatment.

Pyelonephritis is a common bacterial disease in young children and is a serious infection because of its potential to produce renal scarring. One of the concerns of physicians is therefore the diagnosis of uropathy at risk for recurrence of pyelonephritis, especially high-grade reflux. There are no French recommendations on imaging evaluation after a first episode of pyelonephritis. Voiding cystography was systematically proposed years ago and recommended by the American Academy of Pediatrics until 1999. This systematic strategy exposed all children to a painful, irradiating exam, and exposed them to urinary tract infection. The American recommendations changed in 2011 and cystography is now only proposed to children with recurrence of pyelonephritis or with ultrasound abnormalities. A collaborative review of the literature involving the Pediatric Emergency, Nephrology and Surgery Departments at Necker-Enfants-Malades Hospital led us to propose an algorithm for imaging after the first episode of pyelonephritis in children. This algorithm was based on data from the past medical history (results of prenatal ultrasonography or recurrence of pyelonephritis), the results of the ultrasound exam at the time of diagnosis, and the procalcitonin concentration, to limit the indications for voiding cystography, limiting risk for delaying high-grade reflux diagnosis. Children with low risk for high-grade reflux can be followed up with an ultrasound exam 6 months after acute infection.

Xanthogranulomatous pyelonephritis is a rare form of chronic pyelonephritis observed in only a few cases in children. Symptoms are mild, which explains the delay in diagnosis. Diagnosis is based on histology but can be suspected on CT. The treatment is medical and often surgical, with an uncertain renal prognosis. It is therefore imperative to diagnose early. We report the case of a 4-year-old child who presented with xanthogranulomatous pyelonephritis caused by Pseudomonas aeruginosa, which evolved into pyonephrosis, due to inadequate antibiotic therapy. This highlights the importance of understanding this disease and not treating urinary tract infections blindly.

Neurological causes are common diagnoses for apparent life-threatening events in infants. The objective of this study was to evaluate the relevancy of electroencephalography performed after an apparent life-threatening event.A retrospective study was conducted in a children's hospital over a 1-year period. The charts of infants under 2 years of age who were admitted following an apparent life-threatening event were reviewed. Clinical and biological data were collected and electroencephalograms - divided into normal and abnormal - were reviewed. To evaluate the follow-up state of the patients, parents were invited to complete an evaluation form an average 13 months after the event. The yield for electroencephalography was established according to the ratio of positive results contributing to the diagnosis of the cause of the apparent life-threatening event.A total of 47 patients met the inclusion criteria. Fifteen had had an EEG, 32 had not. The rate of abnormal neurological signs described by parents during the apparent life-threatening event was higher in the EEG group compared to the group without EEG (53% vs. 22%, P=0.05). In the follow-up, 35% of the children presented a second event, which was described as being similar or less impressive and occurred in the 1st month after the event (91%). Of the eight abnormal electroencephalograms, six had no specific abnormalities and two contributed to the diagnosis of epileptic seizure. Therefore, the diagnostic yield of electroencephalography in this study was 13% (2/8).The yield of electroencephalography performed after an apparent life-threatening event is low. Neurological history and repeated physical examinations still remain the major diagnostic tools before resorting to electroencephalography.

We report the case of a 3-year-old patient with Mediterranean spotted fever (MSF). The patient was infected through a tick bite in the forests surrounding Paris. Treatment with azithromycin was started with good results. MSF is not exceptional and should be considered in patients with fever, rash, and eruptions even outside the usual infested areas.

Background. - Brainstem dysfunction in newborns (BDN) is an association of symptoms originally described in the Pierre-Robin sequence. BDN is thought to result from a deficiency of the sucking and swallowing embryonic organization. Population and methods. - Between 1983 to 1993, 48 infants without cleft polate were referred for suck and swallow abnormalities. They were considered to have BDN because they presented three of the four following criteria: neonatal suck and swallow difficulties: pharyngeo-oesophageat uncoordination with abnormal oesophageal mutometria; upper airway obstruction, either clinically obvious or detected on laryngoscopy; vagal overactivity, either clinically obvious or detected during Holter recording with ocular compression. Results. - Among these 48 infants, 30 were affected with polymalformative syndrome often involving embryonic fields derived from the neural crest. Three infants had a conotruncal cardiac malformation and 15 had no associated malformation. These latter 15 infants presented with facial dysmorphic features including reciding chin, glossoptosis. U-shape polate and a vertical tongue. From birth or the first weeks of life, they had suck and swallow difficulties with various functional symptoms: slow babybottle intake, cough or velo-pharyngeal incoordination, upper airway obstruction or apparent life threatening events (ALTE). Diagnosis was confirmed by both clinical observation and three simple investigations namely: laryngoscopy, vesoplungeal monometria and Holter recording with ocular compression. Ten children were nasogastric tube or gastrostomy fed, one had a tracheostomy and one had a nightly O2 supplementation. While the overall functional prognosis was good whatever the initial symptoms. 50% of these children had mental retardation, most moderate. Conclusion. - Examination of short-term follow-up in these children has stressed that BDN requires a specific management of both nutritional and respiratory troubles. Finally, BDN should lead to the active search of an underlying polymalformative syndrome and to an accurate neurologic evalution.

Cocaine and its principal metabolite were isolated from the urine, confirmed by urine chromatographic analysis, in a 25-month-old girl who had unsteady gait and a third fever seizure. She was premature, had intrauterine growth restriction (IUGR), and a psychomotor delay. The hair examination confirmed prolonged cocaine exposure. The concentration was significant and showed that she had been intoxicated for the 10 previous months. Passive cocaine inhalation may have caused and contributed to these symptoms.