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La crise sanitaire de la Covid-19 du printemps 2020 a peu touché les enfants avec peu d’hospitalisations dans les hôpitaux pédiatriques. Le défi a été d’apporter une aide aux hôpitaux adultes avec un personnel principalement formé à la pédiatrie tout en maintenant la permanence des soins urgents pour les enfants atteints ou non de la Covid-19. À l’hôpital universitaire Armand-Trousseau, nous avons créé des unités dédiées pour les enfants atteints de la Covid-19, identifié les spécificités des enfants atteints de la Covid-19 et notamment les formes de Kawasaki like ou PIMS (paediatric multisystem inflammatory syndrome), créé une unité de réanimation adulte au pic de l’épidémie pour augmenter les capacités en lits de réanimation dans notre région, mutualisé notre centre de dépistage pour le personnel d’hôpitaux adultes. Enfin, nous avons envoyé plus de 140 personnels médicaux et paramédicaux dans les hôpitaux adultes de notre groupe hospitalier. Cette aide a pu être organisée grâce aux liens étroits établis par des cellules de crises communes avec les hôpitaux adultes de notre groupe hospitalier. Nous rapportons ainsi un retour d’expérience d’un hôpital pédiatrique au cours de la crise de la Covid-19 en Île-de-France.

Rotavirus is responsible for infantile gastroenteritis and each year causes 440 000 deaths worldwide. The virus infects the mature enterocytes of the villus tip of the small intestine and induces a watery diarrhea. Diarrhea can occur with no visible tissue damage and, conversely, the histological lesions can be asymptomatic. Rotavirus infection impairs intestinal disaccharidases and Na+-solute symports coupled to water transport. Maldigestion of carbohydrates and their accumulation in the intestinal lumen as well as malabsorption of nutriments and a concomitant inhibition of water reabsorption would lead to osmotic diarrhea. The hypothesis that the NSP4 viral enterotoxin, by mobilizing intracellular calcium, would be a secretory agonist remains to be demonstrated. In rotavirus diarrhea, Cl- reabsorption in villi is stimulated and secretion in crypt is unaffected, questioning the origin of Cl- secreted into the intestinal lumen, which possibly arises from the villus base cells. These mechanisms appear to be quite different from those used by bacterial enterotoxins that cause "pure" secretory diarrhea. The viral enterotoxin would induce mainly osmotic diarrhea, especially since NSP4 has been shown to be directly responsible for glucosegalactose malabsorption.

To describe the management of home oxygen therapy for infants with acute bronchiolitis through a home care network: Hospital at Home (HAH).A retrospective observational study was carried out during two consecutive winters from 2012 to 2014.A total of 141 patients were eligible for home oxygen therapy, and 54 were discharged on home oxygen therapy through HAH. The median age of patients was 2.5 months (0.75-13 months). The average length of hospital stay before discharge was 4.9 days (1-17 days). In total, 73% of the children received oxygen at home. There was an average of five nurse visits per patient. Each child was seen by a pediatrician during the HAH care. There were no deaths or readmissions to an intensive care unit. There were two conventional readmissions for increased respiratory distress and two emergency department visits. The median length of HAH was 6 days (1-33 days).Home oxygen for infants with acute bronchiolitis is a promising and safe alternative to reduce conventional hospitalizations. It is necessary to evaluate the cost of this treatment and its impact on nosocomial infections.

Resume Le rotavirus est la cause la plus frequente de gastro-enterite (GEA) necessitant une hospitalisation chez l’enfant. C’est un virus tres resistant et contagieux a l’origine de nombreuses GEA nosocomiales (GEAN). En France, le vaccin contre le rotavirus est disponible depuis 2006, mais il n’est pas recommande. Le but de cette etude retrospective etait de decrire les GEAN a rotavirus et d’evaluer leur incidence chez les enfants hospitalises dans le service de pediatrie generale de l’hopital Robert-Debre (Paris) entre le 1 er janvier 2009 et le 31 decembre 2013. Nous avons evalue si ces enfants auraient pu beneficier de la vaccination contre le rotavirus. Resultats Au total, 136 enfants ont presente une GEAN a rotavirus, soit une incidence de 2,5 cas pour 1000 jours d’hospitalisation. Cette incidence est restee stable entre 2009 et 2013 malgre le renforcement des mesures d’hygiene. L’âge moyen des enfants etait de 7 mois (entre 0,5 et 111 mois). Les GEAN a rotavirus etaient survenues chez des enfants hospitalises le plus souvent pour une pathologie respiratoire aigue (65 %) et necessitant une hospitalisation prolongee (mediane = 18 jours). Un quart des enfants etaient nes prematures (25 %). L’hydratation a ete orale pour 80 enfants (59 %), par perfusion intraveineuse pour 18 (13 %) et par voie intra-osseuse pour 1 enfant. La moitie des patients etait âgee de moins de 5 mois et aurait pu beneficier de la protection fournie par la vaccination. Conclusion Les GEAN rotavirus sont frequentes. La vaccination des nourrissons contre le rotavirus permettrait de diminuer les hospitalisations pour gastro-enterite communautaire a rotavirus et, indirectement, de proteger les enfants porteurs de pathologies sous-jacentes trop jeunes pour etre vaccines.

Introduction Chaque annee en France, 30 % des enfants âges de moins de deux ans sont infectes par le virus respiratoire syncitial (VRS) a l’origine d’infections respiratoires severes. Ce virus est responsable de nombreuses hospitalisations chez le nourrisson et le jeune enfant. Cette etude vise a estimer le fardeau hospitalier associe au VRS chez l’enfant âge de moins de 5 ans en France. Methodes A partir du PMSI, les enfants âges de moins de 5 ans ayant un sejour hospitalier avec un diagnostic principal ou relie en lien avec le VRS (CIM-10 : J210/J219/J121/J205/J45/R062) ont ete analyses sur huit saisons hivernales (octobre a mars) de 2010/11 et 2017/18. Resultats Entre 2010/11 et 2017/18, l’incidence des hospitalisations pour VRS a augmente de 183 a 240 pour 100 000 personne-mois Discussion/Conclusion Les hospitalisations pour VRS ont augmente sur la periode d’etude et concernent principalement les enfants âges de moins de 2 ans. Un âge

Resume Peu d’etudes decrivent l’incidence et l’evolution des dermo-hypodermites neonatales a streptocoque du groupe B (SGB). Objectifs Decrire l’incidence, les caracteristiques cliniques et evolutives de la dermo-hypodermite dans le cadre d’une infection a SGB chez le nourrisson de moins de 3 mois. Patients et methodes Les nourrissons âges de moins de 3 mois hospitalises a l’hopital Robert-Debre (Paris) et au centre hospitalier d’Orsay entre janvier 2002 et aout 2013 pour une dermo-hypodermite a SGB ont ete inclus dans une etude retrospective. Resultats Cinq nourrissons ont ete inclus. Toutes les infections etaient neonatales tardives. Le taux d’incidence parmi les infections neonatales tardives a SGB etait de 7 %. Quatre patients etaient de sexe masculin et presentaient un facteur de risque d’infection maternofœtale (prematurite–hypotrophie). Quatre enfants avaient des signes cliniques specifiques de dermo-hypodermite a l’admission associes a un tableau de choc septique. Un enfant avait une meningite et une parotidite associees. Tous avaient une hemoculture positive a SGB. Un SGB de serotype III avait ete identifie dans quatre cas. La duree de l’antibiotherapie par voie intraveineuse avait ete de 7 a 23 jours et la duree totale de traitement de 14 a 44 jours. L’evolution avait ete favorable dans tous les cas. Conclusion La dermo-hypodermite du nourrisson de moins de 3 mois est rare mais peut etre un signe precoce d’infection invasive a SGB. Une prise en charge rapide par une antibiotherapie probabiliste, puis adaptee secondairement est indispensable.

Anti-inflammatory drugs have been suspected on several occasions to have promoted development of bacterial infection among varicella patients. Some countries have not implemented childhood varicella vaccination. Three cases in our hospital suggested the predisposing role of NSAIDs in varicella patient deterioration. Open access to these drugs widely increases their use and patient information should be continually provided in the medical offices and at dispensing pharmacy counters. Taking account of the benefit/risk balance and applying the simple precautionary principle, it would be appropriate to be cautious about the use of NSAIDs in the paediatric population.

Objective: To assess the availability and source of guidelines for common infections in European paediatric hospitals and determine their content and characteristics. Design: Participating hospitals completed an online questionnaire on the availability and characteristics of antibiotic prescribing guidelines and on empirical antibiotic treatment including duration of therapy for 5 common infection syndromes: respiratory tract, urinary tract, skin and soft tissue, osteoarticular and sepsis in neonates and children. Results: 84 hospitals from 19 European countries participated in the survey of which 74 confirmed the existence of guidelines. Complete guidelines (existing guidelines for all requested infection syndromes) were reported by 20% of hospitals and the majority (71%) used a range of different sources. Guidelines most commonly available were those for urinary tract infection (UTI) (74%), neonatal sepsis (71%) and sepsis in children (65%). Penicillin and amoxicillin were the antibiotics most commonly recommended for respiratory tract infections (RTIs) (up to 76%), cephalosporin for UTI (up to 50%) and for skin and soft tissue infection (SSTI) and bone infection (20% and 30%, respectively). Antistaphylococcal penicillins were recommended for SSTIs and bone infections in 43% and 36%, respectively. Recommendations for neonatal sepsis included 20 different antibiotic combinations. Duration of therapy guidelines was mostly available for RTI and UTI (82%). A third of hospitals with guidelines for sepsis provided recommendations for length of therapy. Conclusions: Comprehensive antibiotic guideline recommendations are generally lacking from European paediatric hospitals. We documented multiple antibiotics and combinations for most infections. Considerable improvement in the quality of guidelines and their evidence base is required, linking empirical therapy to resistance rates.

An asthmatic girl was first hospitalized at age 2(9/12) years because of dyspnoea, lung consolidations and/or atelectasis, and rattling. Between ages 2(9/12) and 6(2/12) years, she required three hospitalizations in ICU out of nine hospitalizations for the same symptoms. Differential diagnosis of this difficult to treat asthma disclosed severe tracheomalacia and persistent asthma. Treatments given according to the clinical, radiological and functional findings failed to decrease frequency and severity of acute respiratory episodes. Eventually, positive pressure ventilation delivered at airway opening (via a mouthpiece) associated to active respiratory physiotherapy succeeded in removing atelectasis and quickly cured the five following acute episodes without any further hospitalization. This case report is about diagnosis procedure, intricate asthma and tracheomalacia, and open mind to unusual therapeutics that may disclose potential help.

The rotavirus is the major cause of infantile gastroenteritis. The virus infects the mature enterocytes of the villus tip of the small intestine and induces a watery diarrhea. Diarrhea can occur in the absence of histological changes in the intestine, and, conversely, the histological changes can be asymptomatic. Rotavirus decreases the activities of digestive enzymes at the apical brush border membrane and inhibits Na+ -solute cotransport systems. Accumulation of carbohydrates in the intestinal lumen as well as malabsorption of nutrients and a concomitant inhibition of water absorption can lead to a malabsorptive component of diarrhea. Since the discovery of the NSP4 enterotoxin, several hypotheses have been proposed in favour of an additional secretion component in the pathogenesis of diarrhea. Rotavirus induces a moderate net chloride secretion at the onset of the diarrhea. The mechanisms appear to different from those used by bacterial enterotoxin that cause pure secretory diarrhea. Rotavirus stimulated C1- reabsorption in villi, and failed to stimulate C1- secretion in crypt. Intestinal villi could secrete chloride as a result of rotavirus infection. The chloride secretory response is regulated by a dependant calcium signalling pathway induced by NSP4. The overall response is weak, suggesting that NSP4 may exert both secretory and subsequent antisecretory actions, hence limiting C1- secretion.

Rotavirus is the most common cause of gastroenteritis in children requiring hospitalization. It is a very resistant and contagious virus causing nosocomial gastroenteritis. In France, the vaccine against rotavirus has been available since 2006, but the vaccine is not recommended for infant vaccination. The aim of this retrospective study was to describe nosocomial rotavirus gastroenteritis (NRGE) and to assess its impact on children hospitalized in the General Pediatrics Department of Robert-Debré Hospital (Paris) between 1 January 2009 and 31 December 2013. We analyzed the demographic characteristics of children (age, term birth, underlying diseases) and the severity of the NRGE (oral or intravenous hydration), and assessed whether these children could benefit from vaccination against rotavirus.One hundred thirty-six children presented nosocomial rotavirus infection, with an incidence of 2.5 NRGE per 1000 days of hospitalization. The incidence of NRGE was stable between 2009 and 2013 despite the introduction of specific hygiene measures. The average age of the children was 7 months (range: 0.5-111 months). Most often NRGE occurred in children hospitalized for respiratory diseases (65% of cases) and requiring prolonged hospitalization (median: 18 days). One-third of children were born premature (25%). Hydration was oral in 80 patients (59%), by intravenous infusion in 18 patients (13%), and intraosseous in one patient. Half of the patients were aged less than 5 months and could benefit from the protection afforded by vaccination.NRGE are common. Rotavirus mass vaccination should have a positive impact on the incidence of NRGE by reducing the number of children hospitalized for gastroenteritis, therefore indirectly reducing the number of hospital cross-infections of hospitalized children who are too young to be vaccinated.

Resume Le dosage de l’interferon alpha (IFN-α) comme temoin d’infection virale est utile dans certaines situations cliniques. Sa validite n’est pas reconnue chez le tres jeune nourrisson. Objectif. – Determiner s’il existe une difference dans la detection d’IFN-α produit lors d’infections virales entre les enfants de moins et de plus de six mois. Methode. – Trois infections virales du nourrisson etaient choisies : la meningite a enterovirus, l’infection a virus respiratoire syncitial et la gastroenterite a rotavirus. Retrospectivement, 233 enfants ayant presente une de ces infections et ayant eu un dosage d’IFN-α etaient recenses sur trois ans. Une analyse comparative de la production qualitative et quantitative d’IFN-α etait faite entre les groupes des moins de six mois ( n = 105) et des plus de six mois ( n = 128). Un groupe de patients finalement non infectes mais ayant eu un dosage d’IFN-α etait pris comme controle ( n = 15). Resultats. – Une production d’IFN-α etait detectee aussi frequemment chez les moins de six mois (81,9 % des cas) que chez les plus âges (80,3 % des cas), quelle que soit l’infection virale en cause ( p = 0,3–0,63). Les valeurs quantitatives d’IFN-α produit n’etaient pas significativement differentes entre les deux groupes et etaient meme significativement plus elevees chez les moins de six mois admis pour une meningite a enterovirus. Aucune production d’IFN-α n’etait observee chez les controles. Conclusion. – La detection d’IFN-α lors d’infections virales chez le tres jeune nourrisson est aussi sensible que chez l’enfant plus âge. Elle peut etre utile dans des situations diagnostiques incertaines.

Introduction L’acne fulminans (AF) est definie par la survenue brutale d’une acne pustuleuse et necrotique, extensive, douloureuse, associee a une AEG febrile, un syndrome inflammatoire biologique et une atteinte osteoarticulaire dont l’expression la plus classique est l’osteomyelite multifocale chronique recurrente (OCMR). Nous rapportons une serie de 5 cas d’AF associe a une OCMR chez des adolescents. Materiel et methodes Etude retrospective multicentrique : 5 cas d’OCMR/AF pediatrique apres appel aupres des membres de la SOFREMIP et du GRSFDP ; comparaison avec les cas pediatriques d’OCMR/AF (10) et d’OCMR (464) de la litterature. Critere d’inclusion : AF associee au moins a une atteinte osseuse (IRM ou scintigraphie) patient Resultats Tableau 1 Discussion L’OCMR est un syndrome auto-inflammatoire caracterise par des foyers d’osteite aseptique, considere comme l’equivalent pediatrique du SAPHO. Chez l’adulte, l’acne est une des dermatoses frequemment associees au SAPHO, elle est plutot de type conglobata et evolue independamment des signes articulaires qui dominent le tableau rhumatologique. Au contraire, l’AF est rare au cours des OCMR de l’enfant mais semble realiser un sous-groupe specifique au sein de cette entite : specificite epidemiologique (adolescent male), rhumatologique (atteinte surtout axiale), evolutive (bonne reponse aux AINS, faible recours aux immunomodulateurs ou bisphosphonates, parallelisme avec l’evolution cutanee). L’OCMR/AF est une maladie neutrophilique cutanee et osseuse (infiltration neutrophilique aseptique necrosante) particuliere par son evolution secondairement fibrosante (cicatrices cutanees et fibrose osseuse). Il pourrait s’agir d’une reaction immunitaire inadaptee a un desequilibre de la flore cutanee (Propionibacterieum acnes), lui meme eventuellement precipite par la fragilisation des parois du follicule pilosebace par l’isotretinoine a forte dose. Le role du gene PSTPIP1 (implique dans le PAPA = Pyogenic Arthritis, Pyoderma gangrenosum and Acne et dans le modele murin d’OCMR) dans l’inflammasome NLAP3 vient renforcer cette hypothese. Conclusion L’OCMR est une complication possiblement sous-estimee de l’AF de l’adolescent de sexe masculin (interet de l’IRM corps entier ou de la scintigraphie en cas de douleurs rhumatologiques au cours d’une AF). Son pronostic au sein des OCMR sans AF semble meilleur du fait d’un diagnostic precoce et d’une bonne reponse aux AINS sous reserve d’un controle parallele de l’acne. La dose d’isotretinoine est determinante au cours de l’AF : role precipitant des fortes doses, efficacite des faibles doses prolongees associees a une courte corticotherapie generale.

Resume Le traitement conventionnel des enfants atteints de fievre typhoide ou de salmonellose severe repose sur les β-lactamines et en particulier la ceftriaxone. En raison de leur faible pouvoir de penetration intracellulaire, les β-lactamines, meme actives in vitro, sont quelquefois en situation d’echec clinique. La solution est, dans ces circonstances, d’utiliser les fluoroquinolones, qui elles ont une excellente penetration intracellulaire. L’objectif de cette etude est d’evaluer dans une etude retrospective l’efficacite et les eventuels accidents secondaires de la ciprofloxacine orale chez les patients avec une salmonellose severe en echec clinique de traitement par la ceftriaxone. Patients. – De 1995 a 2000, 215 patients avec une infection aigue a salmonelle ont ete identifies par le laboratoire de bacteriologie d’un hopital parisien (âge : 1 mois a 15 ans). Cent treize de ces enfants ont du etre hospitalises en raison de leur etat clinique. Trois ont ete exclus de l’etude. Aucune des 110 souches restantes (dont 4 S. typhi , 51 S. typhimurium et 25 S. enteritidis ) n’etaient resistantes a la ceftriaxone ou la ciprofloxacine, mais 41 souches soit 37,3 % produisaient une β-lactamase. Douze patients ont eu une guerison rapide sans traitement antibiotique et 98 (âge moyen 3,9 ans) ont ete traites (ceftriaxone chez 91 patients, amoxicilline chez 7) en raison d’un syndrome dysenterique (43 %), d’un choc (15 %), ou d’une fievre persistante avec diarrhee severe. Resultats. – Chez 72 enfants, la ceftriaxone (ou l’amoxicilline chez 5) a entraine une guerison rapide, avec disparition de la fievre (en 1,5 j en moyenne) et de la diarrhee (2,2 j en moyenne). Trois semaines apres la guerison clinique, un portage asymptomatique de salmonelles a ete observe chez 22/38 patients, soit 58 %. Chez les 26 autres patients, la ceftriaxone etait cliniquement inefficace malgre sa bonne activite in vitro, et les enfants ont recu un traitement par ciprofloxacine orale (20 mg kg –1 j –1 , 5 j) apres 2 a 7 j de fievre prolongee et de diarrhee severe. La guerison clinique des la mise sous ciprofloxacine a ete obtenue en moins de 48 h. Les souches retrouvees chez ces 26 patients incluaient 4 S. typhi et 15 S. typhimurium ( p p Conclusion. – Dans les salmonelloses severes, l’echec clinique de la ceftriaxone n’est pas rare, particulierement au cours des infections a S. typhi ou a S. typhimurium produisant une β-lactamase, et un traitement par la ciprofloxacine orale permet une guerison rapide.

Resume Objectifs – Determiner les sensibilites, specificite et valeurs predictives de la procalcitonine, comparee a la CRP, a l'IL6 et a l'interferon alpha pour differencier pneumonies communautaires bacteriennes et virales. Patients – Parmi 88 patients (deux mois–13 ans) hospitalises pour une pneumonie communautaire, 72 ont eu une identification des agents pathogenes. Vingt cinq avaient une pneumonie bacterienne apparemment primitive (dix avec hemoculture positive a pneumocoque), dix une pneumonie a mycoplasme et 37 une pneumonie virale, parmi lesquels huit avaient une surinfection bacterienne (un avec hemoculture positive). Resultats – La PCT etait superieure a 2 μg/L chez les 11 patients avec hemoculture positive et chez 1/29 avec infection virale non surinfectee. La PCT etait superieure a 1 μg/L chez 80 % de tous les patients (incluant les mycoplasmes) avec infection bacterienne. La CRP au seuil de 20 mg/L a une sensibilite comparable a celle de la PCT, mais une specificite beaucoup plus faible (40 % vs 87,5 %). Les specificite et sensibilite de numeration des leucocytes, de l'interleukine 6 et de l'interferon alpha etaient toujours plus faibles. Conclusion – La procalcitonine, au seuil de 1 μg/L, est le meilleur marqueur en salle d'urgence pour differencier l'origine bacterienne de l'origine virale dans les pneumonies communautaires de l'enfant en salle d'urgence.

The group A streptococcus (GAS) is the 5(th) responsible pathogen of invasive infections in children in France. These particularly severe diseases are dominated in children by soft tissue infection, isolated bacteremia but also osteoarthritis. Other complications are rare in France such as lung infections, necrotizing fasciitis (NF) and streptococcal toxic shock syndrome (STSS). More unusual localizations such as meningitis, neonatal infections, severe ear and throat and gastrointestinal infections and vascular disorders are also described. Based on published series, mortality ranging from 0-8 % of cases, is high but still lower than that observed in adults. Probabilistic antibiotherapy includes a β-lactam with anti-SGA but also anti-staphylococcal (predominantly methi-S in France) activity such as clavulanic acid- amoxicillin followed by amoxicillin as soon as identification of SGA is performed. The addition of an anti-toxin antibiotic such as clindamycin is recommended particularly in NF or STSS or clinical signs suggestive of toxin production by the SGA (rash, gastrointestinal signs, hemodynamic disorders). The use of intravenous polyvalent immunoglobulins must also be discussed in NF and STSS. In all cases surgery should be discussed. The prognosis of these potentially very severe infections is related to their early diagnosis and treatment. A better understanding of the pathophysiology of these infections may optimize their management but also their prevention.

To document more fully the characteristics of chronic recurrent multifocal osteomyelitis (CRMO) in pediatric patients, to collect data on the outcomes and management of the disease, and to define prognostic factors.One hundred seventy-eight patients were included (123 female patients and 55 male patients), with a mean ± SD age at diagnosis of 10.9 ± 2.9 years. Inclusion criteria were a diagnosis of CRMO, evidence of at least one lesion of osteitis confirmed by imaging, and development of the syndrome before age 18 years.Longitudinal clinical and imaging studies revealed that only 12 of 178 CRMO patients (7%) had unifocal lesions at the last medical visit. We were able to apply the clinical chronic nonbacterial osteomyelitis score to 110 of 178 patients (62%), which indicated that bone biopsy could have been avoided in 27 cases (25%). At the last medical visit, disease was in remission in only 73 of 171 patients (43%) (41% receiving therapy) after a mean ± SD of 47.9 ± 38.9 months; 44 of 171 patients (26%) experienced sequelae. Using cluster analysis, the CRMO cohort was separated into 3 homogeneous phenotypes (severe, mild, and intermediate). Patients with the severe phenotype had the worst prognosis. This group was entirely composed of male patients, most of whom had the multifocal form of CRMO and inflammatory syndrome. Patients with the mild phenotype had the best prognosis. This group was primarily composed of female patients with a unifocal form of CRMO and infrequent clavicle involvement and inflammatory syndrome. Patients with the intermediate phenotype had a good prognosis but greater reliance on treatment. This group primarily included female patients with multifocal lesions and inflammatory syndrome.This is the largest CRMO cohort described in the literature to date. Clinical evolution and imaging investigations confirmed the multifocal pattern of the disease. Three distinct subgroups of CRMO patients were distinguished, with very different prognoses.

Very few studies describe group B streptococcal dermo-hypodermitis in newborns.To describe the incidence, clinical characteristics, and course of group B streptococcal dermo-hypodermitis in infants less than 3 months old.Infants under 3 months of age, hospitalized for group B streptococcal dermo-hypodermitis at Robert Debré University Hospital, Paris, France, and at Orsay Hospital, Orsay, France, between January 2002 and August 2013, were included in a retrospective study.Five infants were included in this study. All the infections occurred late. Dermo-hypodermitis accounted for 7% of the overall late-onset group B streptococcal infections during the same period. Four patients were male and had a risk factor of maternal-fetal infection (prematurity/hypotrophy). Four patients had specific clinical signs of dermo-hypodermitis with septic shock features on admission. One patient had meningitis and associated parotitis. Group B Streptococcus was isolated from blood culture of all patients. Serotype III Streptococcus was identified in four cases. The duration of intravenous antibiotic therapy varied from 7 to 23 days and the total duration of antibiotic therapy was between 14 and 44 days. The progression was favorable for all the infants, with no recurrence.Dermo-hypodermitis in infants under 3 months of age is rare but could be an early indicator of group B streptococcal bacteremia and/or sepsis. Early diagnosis of this severe complication and appropriate antibiotic therapy are critical.

Septic arthritis has to be suspected in children with joint effusion and fever so as to perform joint aspiration, which will confirm the diagnosis by bacteriological methods, and to perform surgical treatment by joint lavage. Since development of current molecular methods, such as real-time PCR, Kingella kingae has become the first microbial agent of osteoarticular infections in young children, whereas Staphylococcus aureus is second. C-reactive protein (CRP) is an aid used to diagnose septic arthritis, but its elevation could be moderate. In a previous study, conducted at our hospital, 10% of children hospitalized for S. aureus or K. kingae septic arthritis had a CRP level10 mg/L. To determine if diagnosis of septic arthritis could be made by other parameters, we analyzed the clinical and biologic features of these patients and compared them to those of children hospitalized for septic arthritis with initial CRP ≥10 mg/L. Among the 89 children with septic arthritis, 10% (n=9) had initial CRP10 mg/L (K. kingae, n=5/63 ; S. aureus, n=4/26). Initial temperature and fibrinogen were significantly lower in the CRP10 mg/L group than in the other (37.3°C vs. 37.9°C, P=0.039 and 4.19 vs. 5.72 g/L, P=0.003, respectively). Age, symptom duration before diagnosis, as well as leukocyte and platelet counts were similar in both groups. Two children (2/89=2.2%) with S. aureus septic arthritis had no fever, CRP elevation, or fibrinogen elevation. In the CRP-negative group, three of four children with S. aureus arthritis and one of five with K. kingae arthritis had a high CRP level (34, 40, 61, and 13 mg/L, respectively) 3 days after surgery and antibiotic treatment. One child with K. kingae septic arthritis and initial CRP10 mg/L needed a second surgical drainage because of relapse of arthritis. In the S. aureus arthritis group, none of the children with initial CRP10 mg/L experienced complications, while six of those with initial CRP≥10 mg/L needed a second surgical act or hospitalization in an intensive care unit. While CRP is most often10 mg/L during septic arthritis in children, it could be negative in up to 20% of patients in different studies. However, a mild inflammatory syndrome or even a CRP10 mg/L cannot exclude diagnosis of septic arthritis. Therefore, a first episode of monoarthritis in children has to be considered as septic arthritis and treatment should not be delayed.

In children, acute mastoiditis is a classic but rare complication of otitis media. Primary treatment of mastoiditis is mainly medical with intravenous antibiotics. Surgical procedures may be necessary for complicated forms of the disease. Though, the adequacy of the initial empiric antibiotic therapy with the susceptibility of the suspected bacteria germs is essential to avoid potentially serious complications. We perform a review of the literature to provide supportive arguments for the therapeutic approach of acute mastoiditis in children worked out by the French Group for Pædiatric Infectious Diseases.

Intra or extra orbital cellulitis or abscesses are the most frequent bacterial complications of acute sinusitis. Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus (SA), and anaerobic bacteria are predominant, and more rarelyHaemophilus influenzae (especially since vaccination against type b). Because of bacterial sensitivity, PK/PD parameters of antibiotics, and depending on the classification of Chandler, different probabilistic regimens may be proposed: In class 1 by Chandler (preseptal cellulitis), amoxicillinclavulinate (80 mg/kg/d) in 2 oral doses, and ceftriaxone in intramuscular injection; in cases of class 2 to 5 by Chandler, high doses of intravenous amoxicillin-clavulinate (until 150 mg/kg/d of amoxicillin), or intravenous association of ceftriaxone (100 mg/kg/d) or cefotaxim (200 mg/kg/d), with anti-anaerobic like metronidazole (30 mg/kg/d) or clindamycine (40 mg/kg/d).

Staphylococcus aureus and Streptococcus pyogenes are the two main bacteria involved in skin infections in children. Mild infections like limited impetigo and furonculosis should preferentially be treated by topical antibiotics (mupirocine or fucidic acid). Empiric antimicrobial therapy of dermohypodermitis consists in amoxicillin-clavulanate through oral route (80 mg/kg/d) or parenteral route (150 mg/kg amoxicillin per d. in 3-4 doses) for complicated features: risk factors of extension of the infection, sepsis or fast evolution. Clindamycin (40 mg/kg/d per d. in 3 doses) should be added to the beta-lactam treatment in case of toxinic shock, surgical necrotizing soft tissues or fasciitis infections.

Neck infections in children are categorized as peritonsillar infections, latero and retroparapharyngeal infections. The clinical features and severity of these infections vary according to different pædiatric age groups, in relation to the location of the infection. In France, the antimicrobial therapy should consider meticillin sensitive S. aureus, Streptococcus pyogenes and anerobic bacteria. Empiric initial antimicrobial therapy consists in high doses of parenteral amoxicillin-clavulanate (150 mg/kg d. in 3-4 doses) during a few days then changed to oral amoxicillin-clavulanate (80 mg/kg/d). The total course of therapy should be 10 to 14 days.

The French Group of Pediatric Infectious Diseases (PID) of the French Society of Pediatrics found necessary to issue in 2011 therapeutic proposals concerning antibiotic treatment in severe ENT infections in children (acute mastoiditis, severe sinusitis, peripharyngeal abscess). They took into account, for each clinical situation, published studies and existing guidelines, the most frequently encountered bacterial species, their usual sensitivity to antibiotics, their pharmacokinetic and pharmacodynamic (PK-PD) characteristics. These propositions aim to ensure the proper use of antibiotics and to limit the development of bacterial resistance to antibiotics by minimizing the use of broadspectrum molecules, especially cephalosporins and penems. These infections are often multi microbial and respond to aerobic flora similar to that found in non severe community acquired ENT infections and soft tissue infections ( Streptococcus pyogenes or group A Streptococcus(GAS), Streptococcus pneumoniae, Staphylococcus aureus and Haemophilus influenzae). Anaerobic flora may be associated and implicated in some situations. In most cases, high-dosage of amoxicillin +/- clavulanic acid offers the best PK/PD profile and allows to avoid the overuse of injectable third-generation cephalosporins.

Scabies is a disease in steady increase in Île-de-France region. Standard treatment, Ascabiol(®) (benzyl benzoate/sulfiram), is back-order for several months and its return remains uncertain. Facing this drug shortage, French Drug Agency (ANSM) has imported a drug from Germany, Antiscabiosum 10 % (benzyl benzoate), to treat patients having contraindications for other scabicides available in France (ivermectin, esdepallethrine). However, infants less than 1 year (15 kg) and asthmatics infants have no alternative treatment. A multidisciplinary workgroup explored the various existing therapeutic alternatives in France and worldwide. From ANSM's recommendations and group's experience, a decision algorithm was proposed for treating patients. However, pediatric context implied the use of off-label drugs. Proposed treatments widely known by practitioners, prescriptions-types, dose, modalities of use and dispensation, and flyers to patients were realized to optimize treatment efficacy.

Recommendations for the use of diagnostic testing in low respiratory infection in children older than 3 months were produced by the Groupe de Recherche sur les Avancées en Pneumo-Pédiatrie (GRAPP) under the auspices of the French Paediatric Pulmonology and Allergology Society (SP(2)A). The Haute Autorité de santé (HAS) methodology, based on formalized consensus, was used. A first panel of experts analyzed the English and French literature to provide a second panel of experts with recommendations to validate. Only the recommendations are presented here, but the full text is available on the SP(2)A website.

In France, international adoption includes around to 90,000 children since 1980 and near 300,000 immigrant children were counted in 2008. This population is heterogeneous, according to age and country of origin, and its large number. It is not easy to completely and surely assess the vaccine status of the child. Due to a great variability of individual situations, it is not possible to have systematic and unchangeable rules. This article aims to give an update of catch-up vaccination of internationally adopted or refugee or migrant children in France. The vaccination status of a child who recently arrived in France is complex and has to be adapted to his country of origin. Some of them were never vaccinated whereas the vaccine status of others is uncertain or unknown. Three parameters have to be considered: the age of the child, the country of origin, and sometimes serology in the case of doubts of his vaccine status. Catch-up vaccination of foreign children has to be adapted to French vaccine recommendations, as a reference, and to vaccines already administered to the child.

Sickle cell disease is the most common monogenic hereditary hemoglobinopathy. Its course is marked by vaso-occlusive crises (VOC), episodes of acute hemolytic anemia on a background of chronic hemolytic anemia, and severe infections.A 2-year-old child with sickle cell disease presented with severe sepsis caused by Salmonella non typhi. Control of the sepsis was difficult, with multifocal osteomyelitis and arthritis, which required prolonged intravenous antibiotic therapy. Prolonged treatment was complicated by cardiorespiratory arrest and severe neurological damage, as well as nosocomial infections.Osseous articular infections caused by Salmonella non typhi are a common complication in children with sickle cell disease, which need to be promptly recognized. Management remains a great concern. The clinical case reported herein is original in its multifocal evolution. It illustrates the vulnerability of patients with sickle cell disease and the need for urgent and intensive care in the case of infection.

Bacterial meningitis (BM) is the primary etiology of acquired sensorineural hearing loss (SNHL) in children and may compromise language development. Since the 1990 s, cochlear implants (CIs) have become part of the management of children with profound SNHL with encouraging results. The aim of this study was to analyze the audiophonological performance of children before and after cochlear implantation for SNHL following bacterial meningitis.Retrospective study of all children fitted with CIs for bilateral severe to profound SNHL after bacterial meningitis in the Robert-Debré pediatric ENT department between August 1990 and March 2009. Audiophonological performance was assessed using the APCEI profile.Of the 283 children receiving implants during that period, 16 children (6%; 6 boys, 10 girls) underwent CI implantation after bacterial meningitis (Streptococcus pneumoniae in 8 cases, Neisseria meningitidis in 2 cases, and Haemophilus influenzae in 4 cases). The mean time from meningitis to SNHL was 8.3 months (median, 1.5 months; range, 1 day to 13 years). The mean time from meningitis to cochlear implantation was 2 years and 3 months (median, 7 months; range, 1 month to 13 years 3 months). Twelve children (75%) presented partial cochlear and/or vestibular ossification on presurgical CT scan. Three children received bilateral implants.Thirteen children (81%) developed early SNHL in the first 3 months, whereas 3 children developed SNHL more than 10 months after meningitis. As for the benefits of cochlear implantation, 11 children presented near to normal intelligibility and optimal use of their cochlear implant; 5 children presented partial benefits due to neurological sequelae (1), a long delay before implantation (1), technical problems (2), or a social problem in relation to low socioeconomic status (1).After bacterial meningitis, audiological evaluation must be made carefully during the first 3 months to detect early SNHL, but SNHL may also develop several years later. In case of profound SNHL and a modified signal of the labyrinth on the MRI, cochlear implantation must be performed without delay before cochlear and/or vestibular ossification. Cochlear implantation is an effective technique with good long-term audiologic results. The coexistence of neurological lesions may compromise the results, but it should not contraindicate a cochlear implantation.

Few data are available on the impact of a tuberculosis exposure on newborns in a maternity ward.To describe the screening and clinical course of infants exposed during the neonatal period to a caregiver with bacillary tuberculosis.Infants exposed during the postnatal period in a maternity unit in Paris, from March to August 2005, to a caregiver with bacillary tuberculosis were included in a standardized screening protocol. The screening performed at baseline (M0) and at 3 months (M3) included a clinical evaluation, a tuberculin skin test (TST), and a chest X-ray. A preventive treatment for tuberculosis with isoniazid and rifampicin for 3 months was systematically proposed.At M0, 182 of the 217 infants (84%) with significant exposure were evaluated. Data were available for 172 infants. The median age at M0 was 4.9 months (IQR=3.8-6.2). At M0, 4 of 172 infants (2.3%) had latent TB infection. Between M0 and M3, 19 infants (11%) were lost to follow-up and 1 on 153 developed a latent TB infection. No cases of tuberculosis disease were diagnosed. The treatment was administered properly in 83% of cases and side effects were observed in 11% of infants without any serious adverse event. Four infants received no treatment and 11 stopped their treatment prematurely.In the absence of neonatal massive exposure, although low (2.9%), the risk of latent TB infection requires close monitoring of the infants exposed. However, in the context of a mild exposure in the maternity unit, surveillance without systematic initiation of TB preventive treatment could be discussed.

The annual meeting of the Infectious Disease Society of America (IDSA) ; which brought together nearly 5000 participants from over 80 countries in Vancouver, Canada, October 21 to 24, 2010 ; provided a review of the influenza (H1N1) 2009 pandemic, evaluated vaccination programmes and presented new vaccines under development. With 12,500 deaths in the United States in 2009-2010, the influenza (H1N1) 2009 pandemic was actually less deadly than the seasonal flu. But it essentially hit the young, and the toll calculated in years of life lost is high. The monovalent vaccines, whether live attenuated or inactivated with or without adjuvants, were well tolerated in toddlers, children, adults and pregnant women. In order to protect infants against pertussis, family members are urged to get their booster shots. The introduction of the 13-valent Pneumococcal conjugated vaccine in the beginning of 2010 may solve - but for how long ? - the problem of serotype replacement, responsible for the re-increasing incidence of invasive Pneumococcal infections observed in countries that had introduced the 7-valent vaccine. The efficacy of a rotavirus vaccine has been confirmed, with a reduction in hospitalization in the United States and a reduction in gastroenteritis-related deaths in Mexico. In the United States, vaccination of pre-adolescents against human papillomavirus (HPV) has not resulted in any specific undesirable effects. Routine vaccination against chicken pox, recommended since 1995, has not had an impact on the evolution of the incidence of shingles. Vaccination against shingles, recommended in the United States for subjects 60 years and over, shows an effectiveness of 55 %, according to a cohort study (Kaiser Permanente, Southern California). Although some propose the development of personalized vaccines according to individual genetic characteristics, the priority remains with increasing vaccine coverage, not only in infants but also in adults and the elderly. Vaccine calendars that cover a whole lifetime should be promoted, since the vaccination of adults and seniors is a determining factor of good health at all ages.

Acute bacterial parotitis is a rare infectious disease in infants under 3 months of age.To describe the clinical characteristics and the course of acute bacterial parotitis in infants less than 3 months old.Infants under 3 months of age, hospitalized at Robert Debré university hospital, Paris, France, between January 2005 and December 2009 for acute bacterial parotitis, were included in a retrospective study.Five infants less than 3 months of age were included in this study, for a frequency of 2.5/1000 hospitalizations in this age group. All were born at term, 4 of 5 were male. Three of the 5 patients had specific clinical signs of parotitis on admission. One patient had septic shock on admission. The ultrasound confirmed the parotitis in all cases. No parotid abscess was demonstrated on imaging. All patients had at least one abnormal inflammatory biological test (WBC, CRP, PCT). Bacteria were identified in 4 of 5 cases: Staphylococcus aureus was isolated in the pus culture of the Stenon duct in 2 patients and a group B Streptococcus was isolated from blood culture of 2 other patients. The duration of intravenous antibiotic therapy varied from 4 to 13 days, and the total duration of antibiotic therapy was between 10 and 16 days. No surgical procedures were needed.Acute bacterial parotitis in infants under 3 months of age might be associated with localized infections due to S. aureus, but also with a more severe clinical presentation due to group B streptococcus infection. Early diagnosis and appropriate antibiotic therapy might prevent the progression to serious complications.

Evaluating the frequency and modalities of transmissible infection prevention counseling in children before a stay in tropical or subtropical areas.Description of the frequency and modalities of transmissible infection prevention counseling (except specific vaccination) given prior to travel in children attending a tertiary care center in Paris, France, for fever occurring within 3 months following a return from Africa. Data were collected retrospectively from medical observations and telephone interviews with parents.A total of 173 children were included; 98 and 75 returned from sub-Saharan Africa and North Africa, respectively. Forty-one percent were less than 2 years old. Eighty-one percent of the children had consulted before leaving. Among children who returned from North Africa, the proportion of children who had a specific preventive consultation before travel was lower than among children who returned from sub-Saharan Africa (respectively, 72.1% versus 94.7%; p0.001). In children having consulted before traveling, specific hygiene and diet advice had been given in 72% of cases but less frequently in children who traveled in North Africa compared to children who traveled to sub-Saharan Africa (respectively, 57.8% vs. 92.2%; p0.001). Among children who returned from North Africa, those who had no preventive consultation before travel had febrile gastrointestinal infection more frequently than those who had a consultation before traveling (p=0.003).Although in this study the majority of children traveling to Africa receive transmissible infection prevention counseling before the travel, prevention could be improved, particularly before a stay in North Africa.

Management of bone and joint infections in children associates early appropriate antibiotic therapy against Staphylococcus aureus and Kingella kingae and, if necessary, surgical drainage of abscess or septic arthritis. In 2007, the Paediatric Infectious Diseases Group of the French Society of Paediatrics (GPIP) proposed guidelines for antibiotherapy in acute and non-complicated cases, with an intravenous therapy during 4 to 7 days followed by oral therapy during 3 weeks.

An asthmatic girl was first hospitalized at age 2(9/12) years because of dyspnoea, lung consolidations and/or atelectasis, and rattling. Between ages 2(9/12) and 6(2/12) years, she required three hospitalizations in ICU out of nine hospitalizations for the same symptoms. Differential diagnosis of this difficult to treat asthma disclosed severe tracheomalacia and persistent asthma. Treatments given according to the clinical, radiological and functional findings failed to decrease frequency and severity of acute respiratory episodes. Eventually, positive pressure ventilation delivered at airway opening (via a mouthpiece) associated to active respiratory physiotherapy succeeded in removing atelectasis and quickly cured the five following acute episodes without any further hospitalization. This case report is about diagnosis procedure, intricate asthma and tracheomalacia, and open mind to unusual therapeutics that may disclose potential help.

International audience; Management of paediatric skeletal infections remains delicate in France due to the absence of general agreement or official recommendations from the French National Societies. However, practices have evolved since 40 years towards simplified and mostly ambulatory treatment modalities. The Paediatric Infectious Diseases Group of the French Society of Paediatrics (GPIP) has elaborated guidelines funded on the joint analysis of bacterial epidemiology, comparison of common antimicrobial spectra, pharmacokinetic and pharmacodynamic parameters and clinical studies. The aim of this article is to review the evolution of therapeutic concepts of treatment of bone and joint infections in paediatrics for 40 years with the aid of main published clinical studies.

The diagnosis of acute osteomyelitis and septic arthritis is a clinical one. Acute-phase reactants, such as white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) are useful to help the clinicians at the time of initial diagnosis. The WBC count may be normal in up to 80 % of cases and it is not a reliable indicator. The ESR is elevated in 80 % of cases. CRP is elevated more than 80 % of cases. CRP rises rapidly within 48 hours of admission and returns to normal within a week after appropriate therapy. Its rapid kinetics is useful for follow-up of the response treatment. Patients who require surgical drainage procedures have prolonged time to normalization of CRP. PCT is a useful specific marker for predicting severe infection but its sensibility to detect bone and joint infections seems to be low.

The rotavirus is the major cause of infantile gastroenteritis. The virus infects the mature enterocytes of the villus tip of the small intestine and induces a watery diarrhea. Diarrhea can occur in the absence of histological changes in the intestine, and, conversely, the histological changes can be asymptomatic. Rotavirus decreases the activities of digestive enzymes at the apical brush border membrane and inhibits Na+ -solute cotransport systems. Accumulation of carbohydrates in the intestinal lumen as well as malabsorption of nutrients and a concomitant inhibition of water absorption can lead to a malabsorptive component of diarrhea. Since the discovery of the NSP4 enterotoxin, several hypotheses have been proposed in favour of an additional secretion component in the pathogenesis of diarrhea. Rotavirus induces a moderate net chloride secretion at the onset of the diarrhea. The mechanisms appear to different from those used by bacterial enterotoxin that cause pure secretory diarrhea. Rotavirus stimulated C1- reabsorption in villi, and failed to stimulate C1- secretion in crypt. Intestinal villi could secrete chloride as a result of rotavirus infection. The chloride secretory response is regulated by a dependant calcium signalling pathway induced by NSP4. The overall response is weak, suggesting that NSP4 may exert both secretory and subsequent antisecretory actions, hence limiting C1- secretion.

Only few drugs for uncomplicated Plasmodium falciparum malaria are available in children. Atovaquone-proguanil is a recent antimalarial drug licensed in France for the uncomplicated P. falciparum malaria in adults. Few paediatric studies have evaluated atovaquone-proguanil in children for uncomplicated malaria in endemic area, but no study have evaluated this treatment for imported malaria.To evaluate treatment by atovaquone-proguanil for uncomplicated and imported P. falciparum malaria in children.We retrospectively evaluated the tolerance and the efficacy of atovaquone-proguanil in the children admitted in Robert-Debré Hospital (Paris) for a P. falciparum malaria. From January 2004 to December 2005, 48 children with a median age of 7,5 years (IQR 4-11) were treated with atovaquone-proguanil for a uncomplicated P. falciparum malaria, except for 5 children who had an isolated hyperparasitemia greater or equal to 5%.Atovaquone-proguanil was stopped for 3/48 children because of vomiting. Fever resolved in all the children between Day 3 and 7, following the beginning of the treatment. One child, with a favourable outcome, had a positive parasitemia at Day 4 equal to the initial parasitemia (0,1%). No late therapeutic failure was observed among the 24 children evaluated up to one month after starting treatment.Atovaquone-proguanil is an efficient and well-tolerated antimalarial treatment for uncomplicated P. falciparum malaria in children. The risk of vomiting should lead to a systematic initial hospitalisation of children treated with atovaquone-proguanil.

To describe the different pathways of management of intussusception (IS) in infants and children in metropolitan France and to identify paediatric emergency centres that might constitute a surveillance network for IS.A questionnaire was sent to 273 paediatric emergency centres distributed across France in 2005. Modalities of diagnosis and treatment of IS had to be precised.One hundred and sixty-seven centres (61.2%) responded. The response was given by 131 paediatricians (78.4%) and 36 surgeons (21.6%) working in 38 universitary hospitals (22.7%) and 129 general hospitals (77.2%). The mean number of IS treated in each centre in 2004 was 11+/-13.5 (extr. 0 to 70; median 6). Diagnosis of IS required a collaboration between medical and surgical teams in 51.5% of the centres, but in 40.1% the sole medical team was in charge of the diagnosis. Ultrasonography is used for diagnosis by 98.8% of the centres. Reduction with hydrostatic enema and eventually surgery was performed in the same hospital in 44.3%. Other centres systematically or frequently transferred the patients for reduction, mostly towards universitary hospitals (90%).The procedures of IS diagnosis are the same everywhere in France but the pathways of therapeutic management do vary, depending on the availability of surgeons and anaesthetists trained in paediatrics on each site. These disparities will probably change with the implementation of the new plan for sanitary organization in children and adolescents in France. Labellized paediatric emergency centres will gather more surgical patients and could eventually constitute an effective surveillance network for IS.