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Riassunto La “morte inattesa del neonato” (MIN), definita come “il decesso improvviso di un bambino di eta compresa tra 1 mese e 1 anno, fino ad allora in buona salute mentre nulla, nei suoi antecedenti conosciuti o nella storia dei fatti, poteva lasciarlo prevedere”, e la principale causa di mortalita infantile nei paesi sviluppati; il 70% dei decessi si verifica prima che il bambino compia i sei mesi. Al termine di una valutazione eziologica esaustiva comprendente un’autopsia per scopi scientifici, questa MIN puo essere attribuita a un’origine medica, malformativa, genetica, infettiva, accidentale o traumatica. E solo in assenza di una spiegazione (circa il 50% dei casi) che una MIN puo essere classificata come sindrome della morte improvvisa del neonato (SIDS). A volte, si trova una combinazione di diversi fattori causali. Viene regolarmente avanzato il modello del “triplo rischio”, che associa: un bambino vulnerabile alla nascita (prematurita, basso peso alla nascita, predisposizione genetica, ecc.), un periodo critico del suo sviluppo compreso tra 0 e 6 mesi in cui predomina un’immaturita neurologica, autonomica, respiratoria e cardiaca, e un’esposizione a fattori di “stress” esterni o ambientali (decubito ventrale o laterale, fumo passivo, riposo su una superficie non idonea, oggetti nel letto, infezioni, ecc.). Tuttavia, non c’e spazio per la fatalita di fronte a questi tragici eventi. Gli studi scientifici devono continuare a ricercare una particolare vulnerabilita. Attualmente, e stimato che il 50% delle MIN sarebbe evitabile se si seguissero le semplici raccomandazioni di un di riposo in posizione dorsale stretta e di ambiente sicuro. La prevenzione e fragile ma efficace, anche se il suo successo rende meno visibile il problema che combatte, con il rischio di pensare che sia scomparso.

Resumen La «muerte inesperada del lactante» (MIL), que se define como «la muerte subita de un nino de entre 1 mes y 1 ano de edad, que hasta el momento gozaba de buena salud, sin que existiese nada en sus antecedentes conocidos ni en el relato de los hechos que permitiera preverla», es la principal causa de mortalidad infantil en los paises desarrollados; el 70% de las muertes se produce antes de los 6 meses del nino. Despues de un estudio etiologico exhaustivo que incluya una autopsia cientifica, esta MIL podra atribuirse a una causa medica, malformativa, genetica, infecciosa, accidental o traumatica. Solo si no existe una explicacion (aproximadamente en el 50% de los casos), una MIL puede clasificarse como muerte subita del lactante (MSL). A veces se encuentra una combinacion de diferentes factores causales. Se menciona normalmente el modelo del «triple riesgo», que asocia: nino vulnerable debido a su nacimiento (prematuridad, bajo peso al nacer, predisposicion genetica, etc.); periodo critico de su desarrollo entre los 0-6 meses, cuando predomina la inmadurez neurologica, autonoma, respiratoria y cardiaca, y exposicion a factores externos o ambientales de «estres» (decubito ventral o lateral, tabaquismo pasivo, colchon sobre una superficie inadecuada, objetos en la cama, infecciones, etc.). Sin embargo, no hay lugar para la fatalidad frente a estos tragicos acontecimientos. Los trabajos cientificos deben continuar buscando una vulnerabilidad particular. Se estima actualmente que el 50% de las MIL seria evitable si se respetasen las sencillas recomendaciones sobre acostar al nino en posicion dorsal estricta y en un entorno seguro. La prevencion es fragil pero eficaz, aunque su exito hace que sea menos visible el problema que combate, a riesgo de pensar que no existe.

We describe here changes in the bacterial causes of pleural empyema before and after implementation of the 13-valent pneumococcal conjugate vaccine (PCV13) program in France (2009–2017). For 220 (39.3%) of 560 children, a bacterial cause was found. The frequency of pneumococcal infection decreased during the study from 79.1% in 2009 to 36.4% in 2017 (P < .001). Group A streptococcus is now the leading cause of documented empyema (45.5%).

Many countries have observed an early and strong impact of implementation of the 13-valent pneumococcal conjugate vaccine (PCV13) on community-acquired pneumonia (CAP). High levels of C-reactive protein (CRP) and procalcitonin (PCT) are considered biomarkers of bacterial infection (particularly infection due to pneumococcus); therefore, PCV13 implementation should have different effectiveness on CAP depending on the levels of these two biomarkers. To demonstrate this assumption, we analyzed the evolution of number of CAP cases seen in pediatric emergency departments in France after PCV13 implementation (in 2010) by levels of these two biomarkers.From June 2009 to May 2015, 8 pediatric emergency units prospectively enrolled all children (1month to 15years) with radiologically confirmed CAP.A cohort of 9586 children with CAP was enrolled (median age 3years). CAP with pleural effusion (PE-CAP) and proven pneumococcal pneumonia (PP-CAP) accounted for 5.5% and 2.0% of cases. During the study period, the number of cases of overall CAP decreased by 25.4%, hospitalized CAP by 30.5%, PE-CAP by 63.4%, CAP with CRP level≥100mg/L by 50.9%, CAP with PCT level≥4ng/L by 60.4% and PP-CAP by 86.4%. We found no change in number of cases of CAP with low levels of CRP (20 or40mg/L) or PCT (0.5ng/mL). The number of cases of CAP overall increased (20.0%) in the last year of the study as compared with the preceeding year but not cases with CRP level≥100mg/L and/or PCT level≥4ng/mL.PCV13 implementation has had a strong impact on number of CAP cases with high levels of CRP and/or PCT in children but no impact on that with low levels of these two biomarkers. Five years after PCV13 implementation, a sustained reduction in CAP cases is observed.

Objectifs Les MIN sont la premiere cause de mortalite en France chez les enfants de moins de 1 an. En 2015, sous l’impulsion de l’association des centres referents de la MIN (Ancremin) et le CHU de Nantes l’Observatoire national des Morts Inattendues du Nourrisson (OMIN) a ete cree. Il regroupe 35 des 37 centres de reference MIN (DROM inclus) francais. Les objectifs de l’OMIN sont de (1) creer une base de donnees standardisee, (2) denombrer de maniere exhaustive les cas de MIN en France et surveiller leur evolution dans le temps (donnees epidemiologiques), (3) d’identifier les mecanismes impliques dans les MIN, (4) d’identifier de nouveaux facteurs de risque et (5) de reunir un groupe d’experts multidisciplinaires pour coordonner et developper la recherche sur les MIN nationalement et internationalement. Pour identifier les causes du deces, la Haute-Autorite de sante (HAS) recommande un examen clinique complet, des examens biologiques, des examens radiologiques, une imagerie cerebrale ainsi que la proposition systematique d’une autopsie. Des resultats toxicologiques positifs peuvent etre evocateurs de maltraitance ainsi qu’etre un facteur participant a la MIN. L’objectif principal de l’etude etaient d’analyser la prevalence des analyses toxicologiques dans les morts inattendues du nourrisson (MIN). Les objectifs secondaires etaient de comparer les caracteristiques des enfants avec des resultats positifs (TOX + ) et negatifs (TOX-) ainsi que l’association de ces resultats avec des facteurs connus des MIN et le niveau socio-economique des parents. Methode Il s’agit d’une etude nationale retrospective observationnelle multicentrique realisee de 2015 a 2018 a partir des donnees de l’OMIN incluant les donnees de tous les enfants de moins de 2 ans pris en charge dans l’un des 35 centres de reference MIN (CRMIN). Les analyses toxicologiques etaient realisees sur le sang, les urines, le liquide gastrique, la bile et les cheveux avec racines (HAS 2007). Resultats Entre mai 2015 et decembre 2018, 624 MIN ont ete enregistrees dans l’OMIN. Des analyses toxicologiques ont ete realisees chez 398 enfants (62 %). Trente-six analyses (9 %) etaient positives pour des toxiques attendus (molecules de reanimation ou traitement habituel) (53 %) et pour des produits inattendus (47 %). Les matrices positives etaient le sang (32 %), le liquide gastrique (27 %), les cheveux (25 %) et les urines (21 %). Les molecules inattendues etaient les opiaces (n = 8), le cannabis (n = 4), la cocaine (n = 3), la cotinine (n = 2), le monoxyde de carbone (n = 2), la cafeine (n = 1), l’alcool (n = 1) et le GHB (n = 1). La distribution des patients TOX+ et TOX- etaient significativement differente. Les conditions socioeconomiques etaient plus souvent precaires dans le groupe TOX+. Ces memes enfants etaient moins souvent seuls dans le lit lors du deces et leur couchage plus souvent constate inadapte. L’examen du corps retrouvait une hygiene plus souvent decrite comme insuffisante. L’anamnese familiale retrouvait plus souvent un antecedent de prise de psychotropes ou de consommation de drogues illicites chez la mere. Conclusion Malgre les recommandations de la HAS, les analyses toxicologiques n’etaient pas realisees dans plus d’1/3 des cas. Pourtant, la prevalence de resultats toxicologiques positifs impose de rappeler le caractere systematique de ce type d’analyse lors d’une MIN. Les enfants TOX+ pour des molecules inattendues sont issus de milieux plus precaires et avec un historique de consommation de molecules sur prescription ou illicites. Les familles identifiees dans ces categories doivent etre mieux reperees en maternite et pourraient beneficier d’un programme de prevention avec un suivi regulier.

Importance In several countries, 5 years after 13-valent pneumococcal conjugate vaccine (PCV13) implementation, serotype replacement has been reported for invasive pneumococcal disease, which raises concerns about the long-term outcome of PCV13 implementation. The long-term effect of vaccination on community-acquired pneumonia (CAP) remains unknown. Objective To assess the long-term outcome of PCV13 implementation on CAP in children. Design, Setting, and Participants This quasi-experimental, population-based, interrupted time-series analysis was based on a prospective multicenter study conducted from June 2009 to May 2017 in 8 French pediatric emergency departments. All patients 15 years and younger with chest radiography–confirmed CAP were included. Exposures Community-acquired pneumonia. Main Outcomes and Measures The number of CAP cases per 1000 pediatric emergency department visits over time, analyzed usingasegmented regression model, adjusted for influenza-like illness syndromes. Results We enrolled 12 587 children with CAP, including 673 cases of CAP with pleural effusion (5.3%), 4273 cases of CAP requiring hospitalization (33.9%), 2379 cases of CAP with high inflammatory biomarkers (18.9%), and 221 cases of proven pneumococcal CAP (1.8%). The implementation of PCV13 in 2010 was followed by a sharp decrease in the frequency of CAP (−0.8% per month [95% CI, −1.0% to −0.5% per month]), from 6.3 to 3.5 cases of CAP per 1000 pediatric emergency department visits until May 2014, then a slight increase since June 2014 (0.9% per month [95% CI, 0.4%-1.4% per month]), until 3.8 cases of CAP per 1000 pediatric emergency department visits in May 2017. There were marked immediate decreases in cases of CAP with pleural effusion (−48% [95% CI, −84% to −12%]), CAP requiring hospitalization (−30% [95% CI, −56% to −5%]), and CAP with high inflammatory biomarkers (−30% [95% CI, −54% to −6%]), without any rebound thereafter. Conclusions and Relevance The changes associated with PCV13 use 7 years after implementation remain substantial, especially for CAP with pleural effusion, CAP requiring hospitalization, and CAP with high inflammatory biomarkers. Emerging non-PCV13 serotypes may be less likely involved in severe CAP than invasive pneumococcal disease.

Misuse of antibiotics is largely responsible for the emergence of bacterial resistance. Children represent a subset of the population who frequently receive antibiotics. The objectives were to calculate the frequency of antibiotic prescriptions that do not comply with best practice recommendations in paediatrics primary care and to examine the thoughts and feelings of physicians and parents about antibiotic prescription and recommendations from the national health authorities. We included children admitted at the paediatric emergency room (PER) of the NANTES university hospital between June 2011 and October 2012 and who were under antibiotic drugs. Two independent experts evaluated the compliance with the national recommendations. Parents and general practitioner (GP) who prescribed the antibiotic before admission to PER were called to collect their thoughts and feeling about antibiotic prescription. The median age of the 88 included children was 2.8 years. The upper respiratory tract infection motivated the prescription of antibiotic in 59%. Seventy-six per cent of the prescriptions analysed were inappropriate, 72% of the antibiotics had a too broad spectrum, and one-third was not indicated. Ninety-one per cent of the interviewed parents thought that the antibiotic prescribed to their child was adequate. Among the 77 prescribing GP who were called, 33% agreed that they lacked time during consultation to explain to parents that no antibiotics were required. Antibiotic prescriptions were too often inadequate in this sample of children admitted in a French PER. Efforts have to be made with physicians and general public to optimize the antibiotic drug use.

International audience; Objective: To study recent epidemiologic trends of sudden unexpected death in infancy (SUDI) in Western Europe. Study design: Annual national statistics of death causes for 14 Western European countries from 2005 to 2015 were analyzed. SUDI cases were defined as infants younger than 1 year with the underlying cause of death classified as “sudden infant death syndrome,” “unknown/unattended/unspecified cause,” or “accidental threats to breathing.” Poisson regression models were used to study temporal trends of SUDI rates and source of variation. Results: From 2005 to 2015, SUDI accounted for 15 617 deaths, for an SUDI rate of 34.9 per 100 000 live births. SUDI was the second most common cause of death after the neonatal period (22.2%) except in Belgium, Finland, France, and the UK, where it ranked first. The overall SUDI rate significantly decreased from 40.2 to 29.9 per 100 000, with a significant rate reduction experienced for 6 countries, no significant evolution for 7 countries, and a significant increase for Denmark. The sudden infant death syndrome/SUDI ratio was 56.7%, with a significant decrease from 64.9% to 49.7% during the study period, and ranged from 6.1% in Portugal to 97.8% in Ireland. We observed between-country variations in SUDI and sudden infant death syndrome sex ratios. Conclusions: In studied countries, SUDI decreased during the study period but remained a major cause of infant deaths, with marked between-country variations in rates, trends, and components. Standardization is needed to allow for comparing data to improve the implementation of risk-reduction strategies.

Minor head trauma is a common reason for consultation in pediatric emergency departments. In 2009, the Pediatric Emergency Care Applied Research Network (PECARN) published a clinical decision rule for its management. It aimed to help clinicians identify children with a very low risk of developing intracranial lesions, so that unnecessary cranial computed tomography (CCT) scan radiation could be avoided, as such exposure is associated with a rising risk of cancer in this young population. In the meantime, the serum S100β neuroprotein showed encouraging results, with a 30% potential decrease in CCTs for the management of minor head traumas in adults and children. The aim of this study was to determine if the serum S100β neuroprotein, associated with the PECARN clinical decision rule, could safely reduce the use of CCTs. We included children who were examined at the pediatric emergency department for minor head trauma, who underwent a CCT, whose blood samples were analyzed to determine the level of the serum S100β protein. They were managed according to the PECARN clinical decision rule. We afterward assessed the potential decrease in the number of CCTs, according to a modified PECARN clinicobiological decision rule, had we taken into account the result of the blood tests. One hundred nine children were included, and nine of them had clinically important traumatic brain injury. Four of them had a negative S100β value but were classified as high risk of developing intracranial lesion according to the PECARN clinical decision rule. Had we taken into account the modified PECARN clinicobiological decision rule, none of them would have been missed. However, there were 32 true negatives of the rule, allowing a potential decrease in CCTs rated at 29% (95% confidence interval, 21-38). Integrating the serum S100β neuroprotein assessment in the PECARN clinical decision rule could avoid deleterious exposure to CCT radiation, with the condition of using a clinicobiological rule to avoid missing clinically important traumatic brain injuries. Those results have yet to be confirmed relying on a large multicentric study.

In France, nearly 500 infants still die unexpectedly every year. In 2009, the French Institute for Public Health Surveillance published a survey showing great heterogeneity in the management of sudden unexpected infant death (SUID) cases. The aim of this study was to evaluate the actual diagnostic approach to SUID in the different reference centers in France and to determine the degree to which the 2007 recommendations of the French National Authority for Health (Haute Autorite de sante [HAS]) are applied. We conducted a multicenter cross-sectional epidemiological study by email sent to the 36 SIDS reference centers with questions on examinations usually performed in SIDS cases. We also submitted six SUID test cases for death classification to the different reference physicians. Twenty-nine of 36 centers (80.5%) responded. Among the recommended tests, only blood cultures, analysis of cerebrospinal fluid, and a proposal to autopsy are done in 100% of the centers. Other investigations are not carried out systematically: skeleton radiography (65.5%), cranial CT scan (58%), eye fundus (20.7%), metabolic analysis (65.5%), and blood toxicology (62%). The main reasons for non-completion of these tests were hospital practices, lack of resources, technical difficulties, cost of tests, and difficulty in interpreting results (50% reported not knowing the postmortem biological standards). None of the institutions apply the HAS recommendations entirely. The classification of causes-of-death test cases also varied between the centers, with a maximum of 62% concordance in their responses. In 2013, in France, there is still substantial heterogeneity in the diagnostic set-up of SUIDS, a non-exhaustive implementation of the recommendations of the French National Authority for Health, and an unsatisfactory SUIDS classification tool because of considerable discordance between physicians. These results explain the current difficulties in obtaining reliable epidemiological data, because many teams do not use all the investigations recommended to find the cause of death. Therefore, the establishment of a national registry would provide accurate and up-to-date epidemiological, environmental, medical, and biological data to identify the events causing death and propose appropriate means of prevention.

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.

Minor head trauma is a common cause for pediatric emergency department visits. In 2009, the Pediatric Emergency Care Applied Research Network (PECARN) published a clinical prediction rule for identifying children at very low risk of clinically important traumatic brain injuries (ciTBI) and for reducing CT use because of malignancy induced by ionizing radiation. The prediction rule for ciTBI was derived and validated on 42,412 children in a prospective cohort study. The Societe Francaise de Medecine d'Urgence (French Emergency Medicine Society) and the Groupe Francophone de Reanimation et Urgences Pediatriques (French-Language Pediatric Emergency Care Group) recommend this algorithm for the management of children after minor head trauma. Based on clinical variables (history, symptoms, and physical examination findings), the algorithm assists in medical decision-making: CT scan, hospitalization for observation or discharge, according to three levels of ciTBI risk (high, intermediate, or low risk). The prediction rule sensitivity for children younger than 2 years is 100 % [86.3-100] and for those aged 2 years and older it is 96.8 % [89-99.6]. Our aim is to present these new recommendations for the management of children after minor head trauma.

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.

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.

International audience; The objective of this study was to investigate whether acute pain in abused children was under recognized by doctors and nurses compared to children evaluated for accidental injuries. We hypothesize that an abused child's reaction to physical pain could be an additional symptom of this challenging diagnosis. For the observational prospective case control study in an emergency department, children were eligible when: younger than six years old, the reported trauma occurred within the previous seven days, the trauma comprised a bone injury or burn, and the child was able to express his or her pain. The case group comprised children for whom the medical team reported their abuse suspicions and supporting information to a court, and whose cases of abuse were subsequently confirmed. The control group consisted of children with a plausible cause for their injury and no obvious signs of abuse. The children were matched according to their age and type of trauma. The pain was assessed by doctors and nurses before analgesic administration using a certified pain scale. Among the 78 included children, pain was significantly less recognized in the abused children vs. the controls (relative risk=0.63; 95% CI: 0.402-0.986; p=0.04). We observed a discrepancy between the nurses' and doctors' scores for the pain assessments (Kappa coefficient=0.59, 95% CI: 0.40-0.77). Our results demonstrate that pain expression in abused children is under recognized by medical staff. They also suggest that abused children may have reduced pain expression after a traumatic event. Paying particular attention to the pain of abused children may also optimize the analgesic treatment.

Background Lower respiratory tract infection is a common cause of consultation and antibiotic prescription in paediatric practice. The misuse of antibiotics is a major cause of the emergence of multidrug-resistant bacteria. The aim of this study was to evaluate the frequency, changes over time, and determinants of non-compliance with antibiotic prescription recommendations for children admitted in paediatric emergency department (PED) with community-acquired pneumonia (CAP). Methods We conducted a prospective two-period study using data from the French pneumonia network that included all children with CAP, aged one month to 15 years old, admitted to one of the ten participating paediatric emergency departments. In the first period, data from children included in all ten centres were analysed. In the second period, we analysed children in three centers for which we collected additional data. Two experts assessed compliance with the current French recommendations. Independent determinants of non-compliance were evaluated using a logistic regression model. The frequency of non-compliance was compared between the two periods for the same centres in univariate analysis, after adjustment for confounding factors. Results A total of 3034 children were included during the first period (from May 2009 to May 2011) and 293 in the second period (from January to July 2012). Median ages were 3.0 years [1.4–5] in the first period and 3.6 years in the second period. The main reasons for non-compliance were the improper use of broad-spectrum antibiotics or combinations of antibiotics. Factors that were independently associated with non-compliance with recommendations were younger age, presence of risk factors for pneumococcal infection, and hospitalization. We also observed significant differences in compliance between the treatment centres during the first period. The frequency of non-compliance significantly decreased from 48 to 18.8 % between 2009 and 2012. The association between period and non-compliance remained statistically significant after adjustment for confounding factors. Amoxicillin was prescribed as the sole therapy significantly more frequently in the second period (71 % vs. 54.2 %, p

Introduction Malgre les campagnes nationales de promotion du couchage sur le dos, la Mort inattendue du nourrisson (MIN) reste aujourd’hui la principale cause de mortalite postnatale dans les pays developpes. Depuis 2015, l’Observatoire national des Morts inattendues du nourrisson (OMIN) collige des donnees epidemiologiques prospectives afin de proposer des strategies de prevention optimisees et de developper des recherches innovantes dans ce domaine. Alors qu’environ 50 % des MIN restent inexpliquees, l’origine infectieuse est souvent mentionnee lorsqu’une etiologie est retrouvee. C’est dans le contexte actuel de scepticisme vaccinal entrainant une couverture vaccinale suboptimale en France, que cette etude cas-temoins multicentrique prospective nationale vient analyser l’influence du statut vaccinal sur la survenue de la MIN. Materiels et methodes Tous les enfants de moins de 2 ans admis pour une MIN dans l’un des 30 centres de reference (CR) de l’OMIN entre mai 2015 et janvier 2017 ont ete inclus prospectivement. Deux temoins par cas ont ete apparies sur l’âge et le sexe. Grâce a la notion de « retard vaccinal potentiellement dangereux » introduite par Gras et al. en 2016, le statut vaccinal a ete defini comme « a jour », ou « en retard » si l’injection avait lieu au moins 15 jours apres la date recommandee pour les vaccins pneumocoque conjugue (PCV) et hexavalent. Resultats Entre mai 2015 et janvier 2017, 91 cas et 182 temoins vivants ont ete inclus dans 22 CR de l’OMIN. Le retard vaccinal etait associe significativement a une augmentation du risque de MIN pour les vaccins PCV et hexavalent (OR 1,9 [1,2–2,6] et OR 1,8 [1,1–2,5] respectivement) apres ajustement sur les principaux facteurs de risque. Le faible poids de naissance (3,3 [2,1–4,5]), le tabagisme maternel (1,8 [1,1–2,6]), l’utilisation d’une couverture (1,9 [1–2,8]), l’utilisation d’un oreiller (4,7 [3,6–5,9]), l’absence de partage de la chambre (3,9 [3,1–4,8]) et un niveau socioeconomique faible (4,1 [2,6–5,7]) ont ete confirmees comme des facteurs de risque de la MIN. L’analyse microbiologique des echantillons post-mortem s’est averee positive dans 62 % (n = 164) des cas (36 % (n = 66) de prelevements viraux, 46 % (n = 98) de prelevements bacteriens). Respectivement, 88 % (n = 58) et 65 % (n = 64) des echantillons viraux et bacteriens positifs provenaient des voies aeriennes superieures. Conclusion Cette etude tend a souligner que le retard vaccinal pour les vaccins PCV et hexavalent est associe a une augmentation significative du risque de MIN. Ces resultats sont en faveur de la participation de l’infection, notamment respiratoire, dans la physiopathologie de la MIN et incitent a poursuivre la recherche sur les mecanismes infectieux impliques dans la survenue de la MIN a partir des donnees epidemiologiques et biologiques collectees dans l’OMIN.

In France, nearly 500 infants still die unexpectedly every year. In 2009, the French Institute for Public Health Surveillance published a survey showing great heterogeneity in the management of sudden unexpected infant death (SUID) cases. The aim of this study was to evaluate the actual diagnostic approach to SUID in the different reference centers in France and to determine the degree to which the 2007 recommendations of the French National Authority for Health (Haute Autorité de santé [HAS]) are applied. We conducted a multicenter cross-sectional epidemiological study by email sent to the 36 SIDS reference centers with questions on examinations usually performed in SIDS cases. We also submitted six SUID test cases for death classification to the different reference physicians. Twenty-nine of 36 centers (80.5%) responded. Among the recommended tests, only blood cultures, analysis of cerebrospinal fluid, and a proposal to autopsy are done in 100% of the centers. Other investigations are not carried out systematically: skeleton radiography (65.5%), cranial CT scan (58%), eye fundus (20.7%), metabolic analysis (65.5%), and blood toxicology (62%). The main reasons for non-completion of these tests were hospital practices, lack of resources, technical difficulties, cost of tests, and difficulty in interpreting results (50% reported not knowing the postmortem biological standards). None of the institutions apply the HAS recommendations entirely. The classification of causes-of-death test cases also varied between the centers, with a maximum of 62% concordance in their responses. In 2013, in France, there is still substantial heterogeneity in the diagnostic set-up of SUIDS, a non-exhaustive implementation of the recommendations of the French National Authority for Health, and an unsatisfactory SUIDS classification tool because of considerable discordance between physicians. These results explain the current difficulties in obtaining reliable epidemiological data, because many teams do not use all the investigations recommended to find the cause of death. Therefore, the establishment of a national registry would provide accurate and up-to-date epidemiological, environmental, medical, and biological data to identify the events causing death and propose appropriate means of prevention.

Minor head trauma is a common cause for pediatric emergency department visits. In 2009, the Pediatric Emergency Care Applied Research Network (PECARN) published a clinical prediction rule for identifying children at very low risk of clinically important traumatic brain injuries (ciTBI) and for reducing CT use because of malignancy induced by ionizing radiation. The prediction rule for ciTBI was derived and validated on 42,412 children in a prospective cohort study. The Société Française de Médecine d'Urgence (French Emergency Medicine Society) and the Groupe Francophone de Réanimation et Urgences Pédiatriques (French-Language Pediatric Emergency Care Group) recommend this algorithm for the management of children after minor head trauma. Based on clinical variables (history, symptoms, and physical examination findings), the algorithm assists in medical decision-making: CT scan, hospitalization for observation or discharge, according to three levels of ciTBI risk (high, intermediate, or low risk). The prediction rule sensitivity for children younger than 2 years is 100 % [86.3-100] and for those aged 2 years and older it is 96.8 % [89-99.6]. Our aim is to present these new recommendations for the management of children after minor head trauma.

The Haute autorité de santé released clinical practice guidelines in 2000 to assist in the management of bronchiolitis. These guidelines emphasized supportive care with nasal suctioning and encouraged chest physiotherapy. The aim of this study was to examine the adherence to the french guidelines for the management of bronchiolitis by general practitioners.The study included infants less than 24 months of age with bronchiolitis, consulting a general practitioner in Vendée or in Loire-Atlantique, from November 2011 to April 2012 and whose parents accepted to participate to the study. The primary endpoint was the concordance of therapeutic practice with the french guidelines (administrated treatments, refer to pediatric emergencies). Data were collected through questionaires completed by general practitioners.Of the 1236 questionnaires distributed, 134 were completed and 118 therapeutic practice were analyzed. A total of 52.5% of therapeutic practice were concordant with guidelines and 57.5% in case of first bronchiolitis. 50% of infants with a hospitalization criteria according to the guidelines, have not been, which probably shows the interest of new guidelines, with highlighting of hospitalization criteria.

While our European and North American colleagues have recently updated their recommendations, the 2000 Consensus Conference remains the main guideline on management of acute viral bronchiolitis in France. We aimed to establish an updated inter-regional protocol on management of acute viral bronchiolitis in infants.Pediatricians, pediatric pulmonologists, and emergency physicians of the Grand Ouest University Hospitals (France) gathered to analyze the recent data from the literature.Criteria to distinguish childhood asthma from acute viral bronchiolitis were established, then prescriptions of diagnostic tests, antibiotics, and chest physiotherapy were defined and reserved for very limited situations. Similarly, the modalities of oxygen therapy prescription and nutritional support were proposed. Finally, other therapeutics such as nebulized hypertonic saline seem promising, but their place in the treatment of acute bronchiolitis in infants remains unclear.This work has provided new proposals for management of acute viral bronchiolitis and helped standardize practices within the Grand Ouest University Hospitals. This local organization could lay the keystone for working toward guidelines initiated by learned societies at the national level.

Pediatric practice is a difficult task requiring physicians to discriminate potentially serious situations among a variety of benign situations. The goal of this study was to assess the knowledge of students beginning their residency in family medicine on these situations.One hundred and three students were evaluated on pediatric "traffic lights" using 103 true/false questions. Pediatric and family medicine teachers of the Nantes University Hospital defined "traffic lights" as the fundamentals of pediatrics, misleading situations, and diagnosis and treatment that should not to be missed. Emergency levels were defined by colors, with "red light" corresponding to life-threatening emergencies.Thirty-six percent of the questions (n=103) had a correct response rate below 75%. Thirty-two percent of the questions on emergency situations ("red lights") (n=37) had a response rate below 75%. Fifteen percent of the questions (n=103) had a correct response rate below 50%, half of which were "red light" (e.g., on meningitis, diabetic acidocytosis, or shock). Questions concerning infants (n=24) had significantly fewer correct answers (correct response rate below 50%: 29% versus 10%; P=0.047). All the students answered seven questions correctly. The students' mean score (percentage of good answers) was 76% (±6%). No student had 100% or less than 50% good answers.Some life-threatening situations or situations concerning infants had not been mastered by most of the students. It is therefore essential to optimize the teaching of pediatrics during the second cycle of medical studies.

L’utilisation des biomarqueurs en pediatrie est une pratique ancienne et courante. En effet, le manque de specificite des signes cliniques chez l’enfant, en particulier d’âge preverbal, rend parfois peu informatif l’examen clinique. Les notions de cephalees, photophobies, douleurs lombaires, thoraciques ou encore de courbatures par exemple sont autant d’elements d’orientation precieux chez le sujet adulte, mais qui font defaut chez le jeune enfant. Il est classique de constater que la semiologie est d’autant moins evidente que l’enfant est jeune, l’examen dans les premiers mois de vie etant particulierement difficile. On concoit dans ce contexte l’importance que peuvent revetir les biomarqueurs, qui sont utilises comme des « complements » diagnostiques de l’examen clinique et apportent au clinicien au lit du malade une aide precieuse au quotidien.

La prise en charge des morts inattendues du nourrisson (MIN) a fait l’objet de recommandations de la Haute Autorite de Sante (HAS) en 2007 mais restait tres heterogene en France en 2009 d’apres l’InVS. Nous avons realise une enquete par courriel aupres des 36 centres referents pour la MIN, des procedures diagnostiques alleguees en 2013 et verifie leur adequation aux recommandations de la HAS. Parmi les 29 centres (81%) ayant repondu, seuls hemocultures, ponction lombaire, proposition d’autopsie sont pratiques par 100%. Les autres explorations ne sont pas realisees systematiquement : radiographies de squelette 65%, toxicologie sanguine 62%, scanner cerebral 58%, fond d’œil 21%. Les motifs de non realisation etaient: habitude locale, difficultes techniques, cout des examens, difficultes d’interpretation des resultats (50% declaraient meconnaitre les normes biologiques post portem). La classification des causes de deces de dossiers tests variait aussi selon les centres. La persistance d’une grande heterogeneite des prises en charge des MIN, l’application non exhaustive des recommandations, un outil de classification des causes de deces non concordant incitent a mettre en place un registre national pour optimiser les pratiques a partir de donnees epidemiologiques fiables et actualisees

Objectifs Le traumatisme crânien leger (TCL) de l’enfant est un motif frequent de consultation. La SFMU recommande l’algorithme de Kuppermann pour identifier les enfants a bas risque de lesions intracrâniennes (LIC) et limiter les scanners cerebraux. Par ailleurs, le dosage de la proteine S100B permet une diminution de 30% du nombre de scanner cerebral dans le TCL de l’adulte. Le but de l’etude etait de determiner si la proteine S100B integree a la regle de Kuppermann permettrait une reduction supplementaire des scanners cerebraux chez les enfants presentant un TCL. Methode Ont ete inclus les enfants admis aux urgences pour TCL qui avaient un scanner cerebral et un dosage de la proteine S100B dans les 6h suivant le TCL. On evaluait a posteriori la diminution potentielle de scanners selon les resultats du biomarqueur. Resultats 87 enfants ont ete inclus, 49 presentaient un haut risque de LIC, 37 un risque intermediaire. 11 avaient une LIC. La reduction significative estimee de TDM etait de 31% (IC95 21–41 p Conclusion L’integration de la proteine S100B a l’algorithme de Kuppermann permettrait une diminution consequente du nombre des scanners cerebraux.

L’objectif principal de cette etude prospective multicentrique controlee etait de demontrer que les enfants maltraites ont des scores de douleur plus faibles que les enfants non maltraites ; l’objectif secondaire d’evaluer la concordance entre les scores d’evaluation de douleur medicaux et infirmiers. Les enfants inclus avaient moins de six ans, presentaient un traumatisme recent (brulure ou fracture). A l’accueil, une infirmiere et un medecin evaluaient la douleur. Les enfants cas avaient au moins un signe suspect de maltraitance et l’absence de cause plausible au traumatisme. Les enfants temoins n’avaient aucun signe de maltraitance et une cause plausible du traumatisme. 78 enfants ont ete inclus et apparies sur l’âge et le type de traumatisme. Dans le groupe cas, la douleur etait significativement moins reconnue pas les medecins (RR= 0.63 IC95% [0.402-0.986] p=0.04). Il existait une discordance entre les scores de douleur des medecins et ceux des infirmieres (Kappa:0.59, IC 95%% [0.40-0.77]). Notre etude confirme que les enfants maltraites ont une douleur non reconnue des soignants aux urgences

Le traumatisme crânien leger est frequent, les lesions intracrâniennes y sont (LIC) rares. L’identification des enfants relevant d’un TDM cerebral est difficile. En 2009 Kuppermann et al ont propose une regle de decision clinique (PECARN) diminuant les indications de TDM en evitant les faux negatifs. L’objectif etait d’etudier la faisabilite de l’algorithme et son impact sur les TDM et hospitalisations par rapport aux pratiques habituelles. Du 1/04/11 au 30/04/12, 562 enfants ont ete pris en charge par l’equipe medicale aux urgences pediatriques du CHU de Nantes selon cette regle (groupe1), 1370 par l’equipe chirurgicale selon le protocole habituel (groupe2); les familles etaient interrogees a 1mois sur l’existence de complications. Des LIC ont ete identifiees chez 8% des enfants (0,53% groupe1 vs 0,58% groupe2 p>0,30). Une bonne faisabilite etait observee dans le groupe1 avec une diminution significative d’hospitalisations (25,3% vs 39,4% p La regle de decision clinique est compatible avec le fonctionnement d’urgences pediatriques et permettrait meme la diminution d’hospitalisations et TDM. Une etude de validation externe de forte puissance est a mener pour confirmer les performances diagnostiques de l’algorithme.

Le traumatisme crânien leger (TCL) est un motif frequent de consultation aux urgences pediatriques. En 2009, le Pediatric Emergency Care Applied Research Network publiait une regle de decision clinique pour la prise en charge du TCL avec pour objectif d’identifier les enfants a bas risque de developper des lesions intracrâniennes cliniquement severes (LICcs) afin d’eviter le recours au scanner et l’exposition inutile a des radiations ionisantes. Cet algorithme construit et valide a partir d’une cohorte multicentrique et prospective de 42 412 enfants americains est depuis 2012 celui recommande par la Societe Francaise de Medecine d’Urgence et le Groupe Francophone de Reanimation et Urgences Pediatriques (GFRUP). L’arbre decisionnel propose permet sur des elements anamnestiques et cliniques de guider la decision medicale pour la realisation d’un scanner cerebral, la surveillance hospitaliere ou le retour a domicile en classant l’enfant en 3 niveaux de risque de LICcs (haut, intermediaire ou faible). La sensibilite de cet algorithme est chez le moins de 2 ans de 100% IC95% [86,3–100] et chez le plus de 2 ans de 96,8% IC95% [89–99,6]. L’objectif de cette communication est de presenter au nom du GFRUP ces nouvelles recommandations pour la prise en charge du TCL de l’enfant.

Introduction Alors que la France traverse une periode de scepticisme vaccinal globalement prejudiciable a la couverture vaccinale, un observatoire national des morts inattendues du nourrisson (OMIN) collige de nouvelles donnees prospectives concernant la couverture vaccinale et le role potentiel d’agent infectieux dans ces deces, dans le but de mieux en comprendre la physiopathologie et de proposer des pistes de prevention adaptees. Materiels et methodes Etude sur 2 ans (2015–2016), prospective, observationnelle, incluant toutes les MIN, admises dans l’un des 21 centres de reference de la mort inattendue du nourrisson (CRMIN). Le statut vaccinal des nourrissons est defini comme « a jour » ou avec un « retard vaccinal potentiellement dangereux » selon les delais definis par Dubos et al., ou « non vaccine », ou « non en âge d’etre vaccine ». Les prelevements bacteriologiques et virologiques des voies respiratoires ont ete realises lors de l’admission en CRMIN et caracterises par le site du prelevement (aspirations nasales, poumons, plevres) et l’existence d’un germe potentiellement pathogene. Resultats Les 127 nourrissons inclus avaient un âge median au jour du deces de 103 jours (IC ± 22,5). Sex-ratio de 1,4 (H/F). Pour le vaccin pentavalent, le vaccin anti-hepatite B et le vaccin antipneumococcique, le statut vaccinal moyen est « a jour » pour 46 % ( n = 59 ± 0), « non vaccine » pour 13 % ( n = 16 ± 3), « retard potentiellement dangereux » pour 1,8 % ( n = 2,3 ± 0,4), « non en âge d’etre vaccine » pour 31 % ( n = 40 ± 0) Les donnees sont inconnues pour 8,2 % ( n = 10 ± 0,1) des cas. Les prelevements respiratoires virologiques sont positifs chez 26 % ( n = 33) des cas. Les 48 prelevements respiratoires positifs identifient 44 % ( n = 21) de rhinovirus, 15 % ( n = 7) de bocavirus, 8 % ( n = 4) de coronavirus et d’enterovirus, 6 % ( n = 3) de VRS. Les prelevements respiratoires bacteriologiques sont positifs dans 32 % ( n = 41) des cas. Les 58 prelevements respiratoires positifs rapportent 43 % ( n = 25) d’enterobacteries, 14 % ( n = 8) d’ Haemophilus spp., 12 % ( n = 7) de Staphylococcus aureus , 10 % ( n = 6) de Streptococcus pneumoniae , 7 % ( n = 4) de Bordetella spp. Conclusion Ces premiers resultats chez des enfants admis pour MIN montrent une couverture vaccinale insuffisante (46 %) comparable aux donnees deja rapportees dans cette population mais inferieure a celle de la population generale (60 % selon Vennemann et al.). La notion de « retard vaccinal potentiellement dangereux » permet d’introduire une notion de delai dans l’analyse de la vaccination correspondant mieux au processus d’immunisation. La presence de bacterie ou virus dans les voies aerienne est frequente (respectivement 32 % et 26 %), leur implication dans la survenue du deces merite d’etre investiguee car certains sont accessibles a une prevention vaccinale. Le role potentiel protecteur de la vaccination dans la MIN pourrait faire l’objet d’une etude cas-temoins.