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L’arret cardiaque en pediatrie est rare et son pronostic gravissime. Il est le plus souvent l’ultime complication d’une hypoxie ou d’une insuffisance circulatoire. Il s’agit de rythmes non defibrillables (asystolie, activite electrique sans pouls), plus rarement le fait de troubles du rythme ventriculaire (15 %). Les recommandations de prise en charge actualisees en 2015 precisent la duree (1 sec) des insufflations, l’intensite des compressions thoraciques (le tiers du diametre du thorax), renouvellent les algorithmes des rythmes choquables et non choquables d’arret, rappellent l’importance du monitorage post-arret (normothermie, normoxie / normocapnie, normoglycemie, dysfonction myocardique). L’effort doit porter sur sa prevention c’est-a-dire la reconnaissance des situations de detresse a risque de decompensation, l’evaluation hemodynamique des etats septiques et/ou febriles. La formation et l’entrainement par la simulation des equipes a des prises en charge coordonnees autour d’un leader sont des points d’amelioration potentielle tres importants.

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

Objectif Confirmer qu’une antibiotherapie orale d’emblee est aussi efficace qu’une antibiotherapie sequentielle intraveineuse puis orale pour prevenir les cicatrices renales chez des enfants de 1 a 36 mois ayant un premier episode de pyelonephrite aigue (PNA).

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

Circumcision is the most common surgical procedure in boys. Even if the procedure is frequent, circumcision can have tragic complications. We report the cases of six children, seen over 1 year at the emergency department for bleeding complication or mutilation after ritual home circumcision. To avoid such complications, it is recommended that circumcision should be performed by doctors trained in this procedure. Parents have to be cautioned about the risks of possible complications after this procedure.

Resume Position du probleme Le traitement des crises d’asthme aux urgences repose sur l’administration de β2 mimetiques inhales. Nous avons compare l’efficacite des β2 mimetiques selon qu’ils etaient administres en nebulisation ou par une chambre d’inhalation lors des crises d’asthme severes et potentiellement severes. Methode Des enfants âges de 4 a 15 ans, traites aux urgences pour une crise d’asthme severe ou potentiellement severe ont ete randomises, sans insu. Ils recevaient soit 6 nebulisations de 0,15 mg/kg de salbutamol (sous O2), soit 6 aerosols de 50 μg/kg de salbutamol (ou 125 μg/kg de terbutaline) en aerosol doseur couple a une chambre d’inhalation. La chambre et la molecule etaient choisies en fonction du traitement anterieur de l’enfant. Les familles etaient suivies par telephone aux 10e et 30e jours. Les criteres de jugement etaient le taux d’hospitalisation, la variation du score de Bishop, la SaO2, la frequence respiratoire (FR), la frequence cardiaque (FC) et le debit expiratoire de pointe (DEP)/valeur attendue, les effets secondaires, le temps necessaire a la realisation du traitement, le taux de rechute. Resultats Soixante-dix-neuf enfants (groupe nebulisation n = 40 vs groupe chambre n = 39) d’âge moyen 9 ans vs 9,4 ont ete inclus. Les DEP des enfants de plus de 6 ans etaient de 48,3 ± 16,0 et 55,7 ± 25,0 % des valeurs theoriques. Il y avait respectivement 20 et 14 crises severes avec des DEP de 40,8 ± 13,9 % et 44,5 ± 28,2 % (NS). Les deux groupes differaient pour la duree de leur gene respiratoire avant l’arrivee aux urgences (p Conclusion L’efficacite en terme d’hospitalisation des β2 mimetiques inhales au cours des crises d’asthme severes et potentiellement severes n’etant pas differente selon qu’ils sont administres par nebulisation ou avec une chambre d’inhalation, l’usage en premiere intention de la chambre pourrait etre plus frequent et procurer un gain de temps soignant destine a l’education de l’enfant asthmatique.

Objective To compare treatment with beta 2 agonist delivered either by a spacer device or a nebulizer in children with severe or potentially severe acute asthma. Methods In this randomized trial, children 4 to 15 years, cared for in the emergency department for severe or potentially severe acute asthma, received 6 times either nebulizations of salbutamol (0.15mg/kg) or puffs of a beta 2 agonist (salbutamol 50 microg/kg or terbutaline 125 microg/kg). The primary outcome was the hospitalization rate. Secondary outcomes included percentage improvement in Bishop score, in PEF, SaO(2), respiratory and heart rates, side effects, length of stay and relapses 10 and 30 days later. Results Groups did not differ for baseline data. There were no significant differences between the 2 groups (nebulizer N=40, spacer N=39) for baseline characteristics before emergency department consultation except for length of acute asthma in the spacer group. Clinical evolution after treatment, hospitalization rate, relapse were similar including the more severe subgroup. In the spacer group, tachycardia was less frequent (P Conclusions The administration of beta 2 agonist using a metered-dose inhaler with spacer is an effective alternative to nebulizers for the treatment of children with severe or potentially severe acute asthma in the emergency department. Time gained can be used for asthma education.

Resume Objectif. – Etudier la conformite de prescription, l'efficacite et les effets secondaires de la morphine orale lors de son utilisation aux urgences pediatriques dans les douleurs post-traumatiques de l'enfant. Methode. – L'etude prospective a ete conduite dans le service des urgences pediatriques, entre le 1er octobre 2002 et le 1er septembre 2003. Les enfants âges de six mois a 16 ans ayant une douleur mesuree superieure a 70 sur l'EVA ou une deformation post-traumatique de membre, recevaient de la morphine par voie orale (0,5 mg/kg). Une evaluation de la douleur etait faite toutes les 30 minutes a l'aide de deux echelles : echelle des visages utilisee en heteroevaluation et Objective Pain Scale (OPS) pour les enfants âges de moins de cinq ans, echelle des visages en heteroevaluation et echelle visuelle analogique (EVA) pour les plus de cinq ans. La conformite de la prescription de morphine, l'evolution de la douleur dans le temps et la survenue d'eventuels effets secondaires etaient etudiees. Resultats. – Quatre-vingt-onze enfants ont recu de la morphine et 74 dossiers ont ete etudies. La prescription etait conforme dans 70 % des cas. Chez les enfants de moins de cinq ans, tous evalues en heteroevaluation, la diminution de la douleur etait rapide en 30 minutes et satisfaisante (reduction de 79 et 84 % a la sortie). Chez les enfants de plus de cinq ans, la reduction de la douleur etait plus importante et plus rapide en heteroevaluation qu'en autoevaluation au cours de la premiere heure (reduction de 58,2 et 36,1 %). A la sortie du service les pourcentages de reduction de la douleur obtenus en hetero- et autoevaluation ne differaient pas (74 et 64 %). Aucun effet secondaire majeur n'a ete note. Conclusion. – L'utilisation de la morphine orale aux urgences est simple, associee a un nombre peu important d'effets secondaires, tous mineurs. Son efficacite est satisfaisante dans un delai de 30 a 60 minutes.

Resume La douleur concerne plus de 50 % des enfants consultant aux urgences. Presente, elle doit etre evaluee et traitee sans delai par des moyens medicamenteux adaptes a son intensite et a son etiologie. La douleur residuelle doit faire l’objet d’un ajustement therapeutique. L’objectif est de permettre a l’enfant de reprendre ses activites. Lorsqu’un geste douloureux a visee diagnostique ou therapeutique est programme, une sedation analgesie preventive peut etre necessaire. Pour ce type de prise en charge, les antalgiques, en monotherapie comme en association, doivent etre administrables aisement et sans douleur, avoir une action rapide et previsible, une demi-vie courte, une bonne efficacite et etre depourvus d’effets secondaires. Une telle gamme de molecules n’existe pas et toute sedation-analgesie comporte un risque d’hypoxemie. Neanmoins, au prix d’un investissement humain et materiel, un service d’urgences doit etre capable d’assurer une prise en charge antalgique efficace dans des conditions de securite identiques a celles d’une anesthesie. La qualite de ce type d’organisation se mesure par l’identification des enfants pour lesquels une anesthesie generale est d’emblee preferable.

Resume Position du probleme. – Le traitement des diarrhees aigues repose sur une (re)hydratation adaptee et une reprise precoce de lˈalimentation. Inhibiteur des enkephalinases, le racecadotril reduit le poids des selles au cours des 48 premieres heures et la duree des troubles digestifs. Le travail avait pour objectif de mesurer lˈeffet sur le recours secondaire aux soins de l'administration du racecadotril au cours dˈune diarrhee aigue du nourrisson et de lˈenfant. Methode. – Lˈetude etait randomisee, ouverte et comparait le nombre de visites medicales pour un meme episode de diarrhee chez des enfants âges de trois mois a trois ans, au cours de la premiere semaine suivant le passage aux urgences. Le racecadotril etait administre des le debut de la rehydratation quˈelle soit orale ou intraveineuse et lˈalimentation etait reprise a la sixieme heure. Le nombre de selles des deux premiers jours et la duree de la diarrhee etaient des criteres secondaires de jugement. Resultats. – Cent soixante-six enfants ont ete inclus. Les deux groupes ne differaient ni pour lˈâge, ni pour le degre de deshydratation, ni pour la duree dˈevolution avant la consultation. Le nombre de visites medicales (p Conclusion. – Au cours des diarrhees aigues, le racecadotril administre des le debut de la rehydratation orale ou intraveineuse reduit la duree des troubles et le nombre de visites medicales sollicitees par les parents au cours dˈun meme episode diarrheique.

Background: To determine if the addition of ipratropium bromide in the emergency department (ED) for the treatment of childhood asthma reduces rates of hospitalization and relapses for moderate and severe exacerbations. Methods: Patients were given an oral corticosteroid treatment (2 mg/kg) and received every 20 minutes either three nebulizations with albuterol (0.15 mg/kg) and ipratropium bromide (250 micrograms) or six nebulizations with albuterol alone (control group). The primary end point was the need for hospitalization, additional nebulizations or a relapse during the following week. Secondary end point included the effect of age. Results: One hundred and forty three children, two to 15 years old, were randomized to ipratropium or control groups and 121 were evaluated on day seven. As a whole, the control group was less often hospitalized or in relapse than those treated with three nebulizations of albuterol and ipratropium (17.5% vs 37.9%, p < 0.02). The ipratropium group reached the same result after three additional albuterol nebulizations. The benefit of anticholinergic therapy was observed for children less than six years of age who had a similar rate of success (73.5 vs 75.7%). Conclusion: The association of ipratropium bromide to the first three doses of the albuterol protocol for acute asthma did not act as well as six nebulizations of albuterol alone. The effect was age dependent and two to six years old children needed more attention. Nevertheless the hospitalization rate did not support the use of ipratropium compared with repeated albuterol nebulizations.

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

Resume Position du probleme. – Un quart des enfants âges de moins de deux ans a chaque annee une premiere bronchiolite a virus respiratoire syncytial (VRS). Sa morbidite sur des terrains a risque et son eventuel role dans la survenue dˈun asthme conduisent a envisager des mesures preventives dont le rapport cout/efficacite nˈest pas connu. Le travail avait pour objectif de mesurer les couts dˈun premier episode de bronchiolite. Methode. – Les couts directs et indirects (journees de productivite perdues) ont ete mesures sur la base des tarifs conventionnels pour les enfants de moins de deux ans examines aux urgences. Les comorbidites, la nature de la prise en charge (hospitalisation contre ambulatoire), le suivi a 15 jours pour les enfants qui ne sont pas hospitalises et les modes de garde ont ete analyses. Resultats. – Cent quatre-vingt-trois enfants ont ete inclus. La duree moyenne de sejour (DMS) des 40 hospitalises etait de 7,6 ± 4,3 j. Les couts directs etaient de 37 200 ± 22 000 F pour un sejour hospitalier, et de 1 286 ± 633 F pour un traitement ambulatoire. Les couts indirects pour les 113 enfants suivis qui nˈont pas ete admis etaient de 49 journees de productivite perdues. Mode de garde et taux de chomage de lˈechantillon etaient similaires aux donnees de lˈInstitut national de la statistique et des etudes economiques (INSEE). Conclusion. – La variabilite du taux dˈhospitalisation ne permet pas de mesurer a partir de cette etude lˈensemble des couts de lˈepidemie. Pour le gestionnaire de sante la plus grande partie de couts est le fait des enfants qui ne sont pas hospitalises. Dˈautres etudes devront mesurer le cout du premier episode de bronchiolite afin de determiner la valeur economique de mesures preventives.

Resume Le syndrome de Munchausen par procuration est une forme de sevices a enfants d’individualisation recente et encore mal connue, correspondant a une maladie produite ou simulee par un parent, la mere dans la tres grande majorite des cas. Il est difficile a diagnostiquer car il se manifeste par une symptomatologie variee constituant un tableau clinique trompeur et souvent inhabituel pour le medecin, par ailleurs place en situation d’erreur par des parents d’attitude apparemment normale. L’acharnement diagnostique et therapeutique du medecin peut entretenir ou meme aggraver les sevices et contribuer aussi a la mortalite non negligeable du syndrome. Il convient donc d’evoquer le syndrome de Munchausen dans chaque situation ambigue et de prendre les mesures necessaires pour proteger l’enfant des le diagnostic etabli.

Ingestion of foreign body has often no consequence. We report on a case in an 11-month-old girl who was referred for mild hematemesis and anorexia. Upper digestive tract endoscopy found a small metallic foreign body in the gastric antrum. After its removal, all symptoms disappeared. It is usually recommended to remove foreign bodies by endoscopy when they are in esophageal position, or are more than 3 to 5 cm long, or have a shape that may hurt the gut mucosa. Although rare, a gastric foreign body should be searched for in face of an upper gastrointestinal bleeding in an infant.

OBJECTIVE: To confirm whether oral antibiotic treatment is as efficacious as sequential intravenous/oral antibiotic treatment in the prevention of renal scarring in children with acute pyelonephritis and scintigraphy-documented acute lesions. METHODS: In a prospective multicenter trial, children aged 1 to 36 months with their first case of acute pyelonephritis, a serum procalcitonin concentration ≥0.5 ng/mL, no known uropathy, and a normal ultrasound exam were randomized into 2 treatment groups. They received either oral cefixime for 10 days or intravenous ceftriaxone for 4 days followed by oral cefixime for 6 days. Patients with acute renal lesions detected on early dimercaptosuccinic acid scintigraphy underwent a follow-up scintigraphy 6 to 8 months later. RESULTS: The study included 171 infants and children. There were no significant differences between the 2 groups in any clinical characteristic. Initial scintigraphy results were abnormal for 119 children. Ninety-six children were measured for renal scarring at the follow-up scintigraphy (per protocol analysis population). The incidence of renal scarring was 30.8% in the oral treatment group and 27.3% for children who received the sequential treatment. CONCLUSIONS: Although this trial does not statistically demonstrate the noninferiority of oral treatment compared with the sequential treatment, our study confirmed the results of previously published reports and therefore supports the use of an oral antibiotic treatment of primary episodes of acute pyelonephritis in infants and young children.

To compare treatment with beta 2 agonist delivered either by a spacer device or a nebulizer in children with severe or potentially severe acute asthma.In this randomized trial, children 4 to 15 years, cared for in the emergency department for severe or potentially severe acute asthma, received 6 times either nebulizations of salbutamol (0.15mg/kg) or puffs of a beta 2 agonist (salbutamol 50 microg/kg or terbutaline 125 microg/kg). The primary outcome was the hospitalization rate. Secondary outcomes included percentage improvement in Bishop score, in PEF, SaO(2), respiratory and heart rates, side effects, length of stay and relapses 10 and 30 days later.Groups did not differ for baseline data. There were no significant differences between the 2 groups (nebulizer N=40, spacer N=39) for baseline characteristics before emergency department consultation except for length of acute asthma in the spacer group. Clinical evolution after treatment, hospitalization rate, relapse were similar including the more severe subgroup. In the spacer group, tachycardia was less frequent (P0.02). The overall length of stay in the emergency department was significantly shorter (148+/-20 vs 108+/-13 min, P10(-9)).The administration of beta 2 agonist using a metered-dose inhaler with spacer is an effective alternative to nebulizers for the treatment of children with severe or potentially severe acute asthma in the emergency department. Time gained can be used for asthma education.

To study the compliance of prescription, the efficacity and the adverse events of oral morphine used in the pediatric emergency department (ED) in traumatic pains.This prospective study was conducted in the ED from october 2002 to september 2003. Children aged six months to 16 years with a visual analogic scale (VAS) score higher than 70 or with a traumatic member deformation received oral morphine (0,5 mg/kg). Pain was assessed every 30 minutes using two scales: behavioral observation by the faces scale and objective pain scale (OPS) for children less than five years, behavioral observation by the faces scale and self-report by VAS for children older than five years. The compliance of prescription, the pain scores and the adverse events were studied.Ninety-one children received oral morphine and seventy-four children were studied. Seventy per cent of prescriptions were in accordance with the recommendations. For patients younger than five years a rapid decrease of pain was observed in thirty minutes. The pain's reduction was respectively 79 and 84% with faces scale and OPS when they left ED. For children older than five years, pain's reduction was more important and more rapid when pain assessment was made by nurses than when it was self-reported in the first hour (pain reduction 58,2 and 36,1%). When leaving, pain reduction was the same with the two different assessments. No major adverse event was noted.Use of oral morphine in ED is simple, with a few numbers of adverse events. None was severe. Efficiency is correct after 30 to 60 minutes.

Pain concerns more than 50% of the children cared in the emergency unit. After evaluation, it has to be cured with drugs adapted to its level and its origin. Residual pain needs therapeutic adjustment. The goal is to allow the child to restart his activities. A preventive sedation analgesia is necessary when a painful exam is to be performed, either for diagnosis or therapeutic purpose. For this goal ideal analgesics, either for monotherapy or associated, are easily and painlessly administered. They have rapid onset of action, brief half-life, predictable, effective analgesic properties without side effects and they are quickly reversible. These drugs do not exist and every sedation procedure has a risk of hypoxemia. With the human and equipment's investment an emergency department should be able to ensure that procedures are performed in children under sedation with a standard of safety that is similar to general anaesthesia. The main drawback in a well-organised system should be a significant children's rate for which general anaesthesia is preferred.

Ingestion of foreign body has often no consequence. We report on a case in an 11-month-old girl who was referred for mild hematemesis and anorexia. Upper digestive tract endoscopy found a small metallic foreign body in the gastric antrum. After its removal, all symptoms disappeared. It is usually recommended to remove foreign bodies by endoscopy when they are in esophageal position, or are more than 3 to 5 cm long, or have a shape that may hurt the gut mucosa. Although rare, a gastric foreign body should be searched for in face of an upper gastrointestinal bleeding in an infant.

The clinical presentation, treatment, and outcome of steroid-sensitive nephrotic syndrome (SSNS) during childhood have been extensively studied. Conversely, few data regarding the outcome in adulthood of childhood SSNS have been published previously. We undertook to conduct a retrospective study of the outcome in adulthood of a large cohort of patients diagnosed with an SSNS during childhood.We identified all children born between 1970 and 1975 who had been admitted to our institution for an SSNS. Data regarding the outcome in adulthood of these patients were obtained through mailed questionnaires or phone calls to patients and/or their parents or through attending physicians.One hundred seventeen patients were identified. Data regarding the outcome of SSNS in adulthood were available for 102 patients (87.2%). Forty-three patients (42.2%) experienced at least one relapse of nephrotic syndrome in adulthood. By univariate analysis, young age at onset (6 years) and more severe disease in childhood, indicated by a greater number of relapses (12.9 for adulthood relapsers versus 5.4 for adulthood nonrelapsers; P0.0001) and more frequent use of immunosuppressors (74.4% versus 31.6%; P0.0001) or cyclosporine (42.9% versus 7.3%; P0.0001) were predictive of the occurrence of SSNS relapse in adulthood. Conversely, relapse rate in the first 6 months of disease was not predictive of further relapses in adulthood. By multivariate analysis, only number of relapses during childhood was predictive of adulthood relapses (P0.0058). Long-term side effects of steroids were found in 44.2% of adulthood relapsers; the most frequent were osteoporosis and excess weight.The incidence of childhood SSNS relapses in adulthood was relatively high in our study. Further studies are required to assess long-term complications in adults with relapses and a history of prolonged steroid and immunosuppressor use.

The treatment of diarrhoea relies on the maintenance or restoration of hydration with maintenance of an adequate nutritional intake. Racecadotril has been shown to reduce the stools output during acute diarrhoea. The present work was aimed at measuring the number of emergency department visits for acute diarrhoea either the children received racecadotril or not.Racecadotril and rehydration were compared with rehydration alone in children aged three months to three years who had acute diarrhoea and were evaluated in the emergency department (ED). The primary end point was the number of medical exams during the week after starting treatment. Secondary end points were the number of stools during the first 48 hours, the duration of the diarrhoea and the weight on day 7.One hundred and sixty-six children were alternatively randomized to the treated and the control groups. There was no difference for age, degree of dehydration and length of illness before the first visit between the groups. Whatever type of rehydration (oral or i.v.), the treated group had a significant lower number of stools (p0.001) and a faster recovery (p10(-9)). The children receiving racecadotril needed less additional ED visits for the same episode (p0.05). There was no difference for the weight-gain on day 7.This study demonstrates the efficacy of racecadotril as adjuvant therapy to oral and i.v. rehydration in the treatment of acute diarrhoea and a fewer emergency department second visit before recovery.

To determine if the addition of ipratropium bromide in the emergency department (ED) for the treatment of childhood asthma reduces rates of hospitalization and relapses for moderate and severe exacerbations.Patients were given an oral corticosteroid treatment (2 mg/kg) and received every 20 minutes either three nebulizations with albuterol (0.15 mg/kg) and ipratropium bromide (250 micrograms) or six nebulizations with albuterol alone (control group). The primary end point was the need for hospitalization, additional nebulizations or a relapse during the following week. Secondary end point included the effect of age.One hundred and forty three children, two to 15 years old, were randomized to ipratropium or control groups and 121 were evaluated on day seven. As a whole, the control group was less often hospitalized or in relapse than those treated with three nebulizations of albuterol and ipratropium (17.5% vs 37.9%, p0.02). The ipratropium group reached the same result after three additional albuterol nebulizations. The benefit of anticholinergic therapy was observed for children less than six years of age who had a similar rate of success (73.5 vs 75.7%).The association of ipratropium bromide to the first three doses of the albuterol protocol for acute asthma did not act as well as six nebulizations of albuterol alone. The effect was age dependent and two to six years old children needed more attention. Nevertheless the hospitalization rate did not support the use of ipratropium compared with repeated albuterol nebulizations.

Drugs for pediatric emergencies are useful for respiratory (croup, asthma), cardiologic (hypertensive crisis, acute congestive heart failure, arrhythmias, hypoxic spells), neurologic (seizures), metabolic (dehydration, hypoglycaemia), infectious (meningococcemia) or allergic (anaphylaxis) distresses. Pain management is always important whether to relieve or to prevent the discomfort which would happen during diagnosis or therapeutic procedures.

Each year, a quarter of the children younger than 24 months has respiratory syncytial virus bronchiolitis. The morbidity among high-risk infants and the possible association with the development of asthma lead to propose preventive measures whose cost-effectiveness relationship is unknown. The present work was aimed at measuring costs of a first attack of bronchiolitis.For children less than two years visited in the emergency department, direct and indirect costs were measured according to the 'Sécurité Sociale' prices. Associated morbidity, the management of care (inpatient versus outpatient), outpatients' outcome two weeks after the visit, socioeconomic data were recorded.One hundred eighty three children have been studied. The length of stay for 40 hospitalizations was 7.6 +/- 4.3 days. Direct costs were 37,200 +/- 22,000 FF for inpatients, and 1286 +/- 633 F for outpatients. For 113 outpatients' families, indirect costs were 49 working days lost. The way the child was looked after and the unemployment rate in the study were similar to data provided by the National Institute of Statistics and Economic Studies.Because of the variability of the hospitalization rate from one setting to another, overall costs of the epidemic cannot be evaluated. For the policymaker, the greatest costs come from the outpatient care. Others studies will be necessary to evaluate the price of future preventive measures.

Munchausen syndrome by proxy is a form of child abuse presenting as a disease produced or simulated by a parent, the mother in most cases. Its diagnosis is uneasy because of its miscellaneous and unusual clinical presentation and of the misleading apparently normal attitude of the parents. Physicians may participate in the abuse by insistently looking for diagnostic and therapeutic measures, therefore contributing to the significant mortality of the syndrome. It is therefore important that physicians consider Munchausen syndrome in any ambiguous situation in order to protect the child by an early diagnosis.

Nous avons compare l’efficacite lors d’une premiere pyelonephrite chez l’enfant d’un traitement oral (PO) (cefixime) et d’un traitement sequentiel intraveineux (ceftriaxone) puis oral (cefixime) (IV/PO) sur le risque de cicatrice renale. Cent soixante et onze enfants de 1 mois a 3 ans ont ete inclus. Apres une scintigraphie au DMSA pathologique a la phase aigue, l’efficacite du traitement etait evaluee sur la presence d’une cicatrice renale sur une scintigraphie a 6 mois. Resultats : En intention de traiter, le risque de cicatrice renale n’etait pas significativement different entre les 2 groupes : 25/61(41 %) enfants traites PO versus 26/58 (44,8 %) enfants traites IV/PO. Dans l’analyse per protocole, le risque de cicatrice n’etait pas non plus significativement different: 16/52 (30,8 %) enfants traites PO et 12/44 enfants (27,3 %) traites IV/PO. Le delai d’apyrexie, l’incidence de reflux ne differaient pas dans les 2 groupes. Conclusion : Un traitement oral donne des resultats comparables a un traitement sequentiel sur le risque de cicatrice renale a distance apres une premiere pyelonephrite chez l’enfant de 1 mois a 3 ans. Ces resultats sont similaires a ceux rapportes precedemment [1-3] .