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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.

Acute bronchiolitis is one of the most common health burdens in infants worldwide and leads to frequent hospitalisation, morbidity and mortality (1). Children have been relatively spared by the COVID-19 pandemic, but reports of multisystem inflammatory syndrome (2) and probable long-term COVID (3) effects in children have started to emerge. One major concern was whether the overlap of the pandemic and seasonal bronchiolitis would put substantial pressure on healthcare systems. Bronchiolitis has a predictable seasonal pattern, primarily in autumn and winter, and in France this is between October and February. The second COVID-19 wave in France led to a two-week night curfew from 17 October 2020, followed by a full lockdown on 30 October. However, day care centres and primary and secondary schools remained open.

International audience; Objective: To evaluate the association of early continuous infusions of opioids and/or midazolam with survival and sensorimotor outcomes at age 2 years in very premature infants who were ventilated.Study: design This national observational study included premature infants born before 32 weeks of gestation intubated within 1 hour after birth and still intubated at 24 hours from the French EPIPAGE 2 cohort. Infants only treated with bolus were excluded. Treated infants received continuous opioid and/or midazolam infusion started before 7 days of life and before the first extubation. Naive infants did not receive these treatments before the first extubation, or received them after the first week of life, or never received them. This study compared treated (n = 450) vs naive (n = 472) infants by using inverse probability of treatment weighting after multiple imputation in chained equations. The primary outcomes were survival and survival without moderate or severe neuromotor or sensory impairment at age 2 years.Results: Survival at age 2 years was significantly higher in the treated group (92.5% vs 87.9%, risk difference, 4.7%; 95% CI, 0.3-9.1; P =.037), but treated and naive infants did not significantly differ for survival without moderate or severe neuromotor or sensory impairment (86.6% vs 81.3%; risk difference, 5.3%; 95% CI -0.3 to 11.0; P =.063). These results were confirmed by sensitivity analyses using 5 alternative models.Conclusions: Continuous opioid and/or midazolam infusions in very premature infants during initial mechanical ventilation that continued past 24 hours of life were associated with improved survival without any difference in moderate or severe sensorimotor impairments at age 2 years.

* Abbreviation: COVID-19 — : coronavirus disease Acute bronchiolitis, a viral seasonal infection of the lower respiratory tract, affects nearly 20% of all children and leads to the hospitalization of 2% to 3% of all children younger than 12 months every year.1,2 Approximately 2% to 6% of hospitalized children require admission to the PICU.1 Acute bronchiolitis may account for as much as 13% of PICU admissions,3 and it is responsible for the death of ∼3 of 100 000 children under 12 months each year4 (eg, nearly 20 and 100 infants annually in England4 and the United States,5 respectively). Bronchiolitis epidemic has a predictable seasonal pattern, and in France, it starts in September, peaks in November to December, and ends in February. Although children have been relatively spared by the coronavirus disease (COVID-19) pandemic, the impact that the overlap of the second wave of this pandemic and of the associated public measures have … Address correspondence to Ricardo Carbajal, MD, PhD, Pediatric Emergency Department, APHP Hopital Armand Trousseau, 26, av du Dr Netter, 75012 Paris, France. E-mail: ricardo.carbajal{at}aphp.fr

To describe the frequency and nature of premedication practices for neonatal tracheal intubation (TI) in 2011; to identify independent risk factors for the absence of premedication; to compare data with those from 2005 and to confront observed practices with current recommendations. Data concerning TI performed in neonates during the first 14 days of their admission to participating neonatal/pediatric intensive care units were prospectively collected at the bedside. This study was part of the Epidemiology of Procedural Pain in Neonates study (EPIPPAIN 2) conducted in 16 tertiary care units in the region of Paris, France, in 2011. Multivariate analysis was used to identify factors associated with premedication use and multilevel analysis to identify center effect. Results were compared with those of the EPIPPAIN 1 study, conducted in 2005 with a similar design, and to a current guidance for the clinician for this procedure. One hundred and twenty-one intubations carried out in 121 patients were analyzed. The specific premedication rate was 47% and drugs used included mainly propofol (26%), sufentanil (24%), and ketamine (12%). Three factors were associated with the use of a specific premedication: nonemergent TI (Odds ratio (OR) [95% CI]: 5.3 [1.49-20.80]), existence of a specific written protocol in the ward (OR [95% CI]:4.80 [2.12-11.57]), and the absence of a nonspecific concurrent analgesia infusion before TI (OR [95% CI]: 3.41 [1.46-8.45]). No center effect was observed. The specific premedication rate was lower than the 56% rate observed in 2005. The drugs used were more homogenous and consistent with the current recommendations than in 2005, especially in centers with a specific written protocol. Premedication use prior to neonatal TI was low, even for nonemergent procedures. Scientific consensus, implementation of international or national recommendations, and local written protocols are urgently needed to improve premedication practices for neonatal intubation.

International audience; Aim: This study determined the influence of the COVID-19 pandemic on the occurrence of multisystem inflammatory syndrome in children (MIS-C) and compared the main characteristics of MIS-C and Kawasaki disease (KD).Methods: We included patients aged up to 18 years of age who were diagnosed with MIS-C or KD in a paediatric university hospital in Paris from 1 January 2018 to 15 July 2020. Clinical, laboratory and imaging characteristics were compared, and new French COVID-19 cases were correlated with MIS-C cases in our hospital.Results: There were seven children with MIS-C, from 6 months to 12 years of age, who were all positive for the virus that causes COVID-19, and 40 virus-negative children with KD. Their respective characteristics were as follows: under 5 years of age (14.3% vs. 85.0%), paediatric intensive care unit admission (100% vs. 10.0%), abdominal pain (71.4% vs. 12.5%), myocardial dysfunction (85.7% vs. 5.0%), shock syndrome (85.7% vs. 2.5%) and mean and standard deviation C-reactive protein (339 ± 131 vs. 153 ± 87). There was a strong lagged correlation between the rise and fall in MIS-C patients and COVID-19 cases.Conclusion: The rise and fall of COVID-19 first wave mirrored the MIS-C cases. There were important differences between MIS-C and KD.

Resume L’assistance respiratoire et circulatoire extracorporelle (ECMO), hors situation postoperatoire d’une cardiotomie, correspond a l’ensemble des techniques de reanimation utilisees chez le nouveau-ne comme chez l’enfant, ayant pour objectif la suppleance cardiaque et pulmonaire. L’ECMO comprend differentes modalites techniques selon le type de defaillance d’organe pris en charge. Les principales indications des ECMO sont a la fois respiratoires (syndrome de detresse respiratoire aigu, asthme aigu grave, pleuropneumopathie hypoxemiante, inhalation meconiale et hypertension arterielle pulmonaire) et hemodynamiques (choc cardiogenique, choc septique refractaire, arret cardiorespiratoire refractaire). Les principales contre-indications sont la prematurite

In the present work, nanocomposites-based 3XXX series Al alloy with three different types of hard nanoparticles, including TiO2, C, and CeO2, were produced employing two techniques such as mechanical milling and stir-casting method in order to evaluate the viability of integration of the reinforcement in the Al matrix. The integration and dispersion capability of the reinforcement into the Al alloy (3xxx Series) matrix was evaluated, using a phase angle difference and surface roughness analyses by atomic force microscopy operated in both the contact mode (CM-AFM) and tapping mode (TM-AFM), respectively. The distribution profile of both rugosity and the phase angle shift was used to statically quantify the integration and dispersion of the reinforcement into the extruded samples, by using the root mean square (RMS) parameter and phase shift coupled with the events number (EN) parameter. Results from Atomic Force Microscopy (AFM) analyses were corroborated by X-ray diffractometry and scanning electron microscopy (SEM) and transmission electron microscopy (TEM). Microhardness tests were conducted to identify the mechanical properties of the composites in the extruded condition and their correlation with the microstructure. A close relationship was found between the microstructure obtained from the AFM and X-ray diffractometry (XRD) analyses and mechanical properties. Among all, the C reinforcement produced the major changes in the microstructure as well as the best integration and dispersion into the Al-alloy coupled with the best mechanical properties.

ObjectivesPremedication practices for neonatal tracheal intubations have not yet been described for neonatal transport teams. Our objective is to describe the use of sedation/analgesia (SA) for tracheal intubations and to assess its tolerance in neonates transported by medical transport teams in France.SettingThis prospective observational study was part of the EPIPPAIN 2 project and collected around-the-clock data on SA practices in neonates intubated by all five paediatric medical transport teams of the Paris region during a 2-month period. Intubations were classified as emergent, semiemergent and non-emergent. Sedation level and conditions of intubation were assessed with the Tonus, Reactivity, Awareness and Conditions of intubation to Help in Endotracheal intubation Assessment (TRACHEA score). The scores range from 0 to 10 representing an increasing ladder from adequate to inadequate sedation, and from excellent to very poor conditions of intubation.Participants40 neonates intubated in 28 different centres.ResultsThe mean (SD) age was 34.9 (3.9) weeks, and 62.5% were intubated in the delivery room. 30/40 (75%) of intubations were performed with the use of SA. In 18/30 (60.0%) intubations performed with SA, the drug regimen was the association of sufentanil and midazolam. Atropine was given in 19/40 intubations. From the 16, 21 and 3 intubations classified as emergent, semiemergent and non-emergent, respectively, 8 (50%), 19 (90.5%) and 3 (100%) were performed with SA premedication. 79.3% of intubations performed with SA had TRACHEA scores of 3 or less. 22/40 (55%) infants had at least one of the following adverse events: muscle rigidity, bradycardia below 100/min, desaturation below 80% and nose or pharynx–larynx bleeding. 7/24 (29.2%) of those who had only one attempt presented at least one of these adverse events compared with 15/16 (93.8%) of those who needed two or more attempts (pConclusionSA premedication is largely feasible for tracheal intubations performed in neonates transported by medical transport teams including intubations judged as emergent or semiemergent.Trial registration numberNCT01346813; Results.

How to cite this article: Rambaud J, Allioux C, Jean S, Guilbert J, Guellec I, Demoulin M, et al. Nosocomial Infections in Neonates Supported by Extracorporeal Membrane Oxygenation: First French Retrospective Study. Indian J Crit Care Med 2019;23(9):392–395.

Pediatric lumbar puncture : indications, execution and complications. Lumbar puncture (LP) is a commonly performed procedure with specific indications and technical considerations in pediatrics. The principal indication is for the diagnosis of central nervous system infection, but in case of meningitis in infants, nuchal rigidity may be absent and the clinical picture is more likely to be marked by axial hypotonia associated with abnormal behavior and/or a bulging fontanel. Pharmacological agents and non-pharmacological techniques (reassuring approach, distraction, presence of a parent) should be used whenever possible, to create successful environmental conditions for the completion of the LP procedure in childhood. During the procedure, the LP needle should be moved forward slightly and perpendicularly to the patient's back, and the stylet should be removed regularly to check CSF reflux, as resistance related to the spinal ligaments and dura mere are often absent in young children. In children, post-LP headaches may be prevented by the use of atraumatic and/or the smallest LP needle, and the replacement of the stylet prior to needle removal.La ponction lombaire chez l'enfant : indications, réalisation et complications. La ponction lombaire est un acte diagnostique et thérapeutique dont les indications ainsi que la procédure du geste présentent des spécificités chez l’enfant. L’indication principale est celui du diagnostic d’une méningite, mais chez le jeune nourrisson une raideur de nuque est souvent absente et le tableau clinique est marqué par une hypotonie axiale associée à des anomalies du comportement et/ou une fontanelle bombée. L’information de la famille et la mise en condition de l’enfant visant à créer les conditions environnementales propices à la réussite du geste est indispensable et comprend des moyens non médicamenteux et médicamenteux. Au cours du geste, l’aiguille de ponction doit être enfoncée perpendiculairement au plan vertical du dos du patient et le stylet doit être régulièrement retiré pour visualiser un reflux de liquide céphalorachidien, le ressaut indiquant le passage du ligament jaune et de la dure-mère étant souvent manquant chez le jeune enfant. Enfin, la prévention des céphalées post-ponction lombaire chez l’enfant repose principalement sur l’utilisation d’aiguilles plus fines ou atraumatiques et le replacement du stylet en fin de geste.

Acute gingivostomatitis is relatively frequent in children; of viral origin, its diagnosis is usually straightforward. Acute gingivostomatitis is very painful and for many years, codeine, whose use was restricted in 2013, was widely employed in this context. The aim of this study was to ascertain the prevalence of acute stomatitis in pediatric emergency care, to evaluate the pain caused by stomatitis, and to determine the analgesic resources deployed both in the emergency department and at discharge, over the 5-year period preceding restriction of the use of codeine. Methods This was a retrospective study conducted in a pediatric emergency department (PED) of a university hospital between August 2008 and June 2013. Results A total of 702 children (372 herpetic gingivostomatitis [HGS], 149 herpangina [H], 181 hand, foot, and mouth disease [HFMD]) were included. Over the 5 years, one case of gingivostomatitis was identified for 303 visits to the PED. A total of 548 (78.1%) children were aged less than 36 months and the median age was 22 months. For 501 of 702 (71.4%) children, parents reported pain and/or feeding difficulties; in the HGS group, 314 of 372 (84.4%) patients had these symptoms. Of the 702 children, 48 (6.8%) were admitted to hospital. Overall, 457 (65.1%) of 702 children were given codeine before the PED visit, during the PED visit, or as a medication to take after discharge. The corresponding figures were 314 of 372 (84.4%) for the HGS group, 67 of 149 (45.0%) for the H group, and 76 of 181 (42.0%) for the HFMD group, P Conclusions Acute gingivostomatitis is a relative frequent reason for PED visits, and the pain and feeding difficulties that it elicits are a real challenge. Before codeine restriction, this medication played a major role in the analgesic strategy for this disease. It is essential that analgesic regimens at least as effective as codeine replace it. Morphine combined with paracetamol or the association of ibuprofen with paracetamol are options that are recommended by the French National Health Authority (HAS).

Aim To assess the prevalence of clinically urgent intracranial pathology (CUIP) in children visiting the emergency department with a complex febrile seizure (CFS). Methods Retrospective cohort review. We analysed the visits of patients for a CFS from January 2007 to December 2011 in seven paediatric emergency departments. Our main outcomes were the proportions of CUIP diagnosed between day 0 and 1 and within 30 days after the index visit. Results From 1 183 487 visits, 839 were for a CFS and 130 (15.5%) of these had a neuroimaging performed within 30 days (CT scan for 75 visits [8.9%], MRI for 30 visits [3.6%] and both for 25 visits [3.0%]). Three CUIP were diagnosed between day 0 and 1 (0.4% [CI-95%: 0.1-1.3]), 5 within 30 days after the index visit (0.7% [CI-95%: 0.2-1.7]) but none among the 630 visits of children presenting with a normal neurological clinical examination (0% [95% CI: 0.0-0.7]), nor among the 468 presenting only with multiple seizure (0% [95% CI: 0.0-1.0]). Conclusion In children with a CFS, CUIP is rare event in the subgroup of children with a normal neurological clinical examination and in those with brief generalised multiple seizures.

Shisha smoking has spread to many countries since the 1990s and is now a global phenomenon among adolescents. Notwithstanding the connotations of conviviality of shisha smoking, it is in fact highly dangerous since the smoke inhaled contains toxic substances. Carbon monoxide (CO) poisoning carries a high risk of neurological and neuropsychological sequelae such as memory loss, impaired concentration, mood disorders, and various other symptoms. We report a case of severe CO poisoning in a 13-year-old boy after smoking shisha that caused loss of consciousness and seizure. To our knowledge, there have as yet been no reports of cases involving children. We present some epidemiological data on shisha smoking in adolescents as well as on CO intoxication.

International audience; Background Parents of preterm neonates wish greater involvement in pain management; little is known about factors associated with this involvement. We aim to describe perceived maternal information on infants’ pain during hospitalization (PMIP), to study associations between PMIP and mothers’ attitudes during painful procedures, and to identify individual and contextual factors associated with PMIP. Methods Analyses of questionnaires from the French national cohort study of preterm neonates, EPIPAGE-2. PMIP was derived from mothers’ answers to questions about information perceived on both pain assessment and management. Results Among 3056 eligible neonates born before 32 weeks, 1974, with available maternal reports, were included in the study. PMIP was classified as “sufficient,” “little, not sufficient,” or “insufficient, or none” for 22.7, 45.9, and 31.3% of neonates, respectively. Mothers reporting PMIP as “sufficient” were more frequently present and more likely comforting their child during painful procedures. Factors independently associated with “sufficient” PMIP were high maternal education, gestational age

Introduction: Clinical scales are currently the best method to assess pain in the neonate, given the impossibility of self-report in this age group. A study is designed with the aim of determining the current practices as regards the clinical assessment of pain in Spanish Neonatal Units and the factors associated with the use of clinical scales. Methods: A prospective longitudinal observational study was conducted. A total of 30 Units participated and 468 neonates were included. Results: Only 13 Units (43.3%) had pain assessment protocols. Pain was evaluated with a scale in 78 neonates (16.7%, 95% CI; 13.1–20.1) and the mean number of pain assessments per patient and per day was 2.3 (Standard Deviation; 4.8), with a median of 0.75. Of the total number of 7189 patient-days studied, there was at least one pain assessment in 654 (9.1%). No pain assessment was performed with a clinical scale on any patient in 20 (66.7%) Units. Among those that did, a wide variation was observed in the percentage of patients in whom pain was assessed, as well as in the scales used. The CRIES (C-Crying; R-Requires increased oxygen administration; I-Increased vital signs; E-Expression; S-Sleeplessness) scale was used in most Units. In the multivariate analysis, only invasive mechanical ventilation was associated with receiving a pain assessment with a scale (OR 1.46, P = .042). Discussion: The majority of neonates admitted into Intensive Care in Spain do not receive a pain assessment. Many units still do not routinely use clinical scales, and there is a wide variation between those that do use them. These results could serve as a basis for preparing national guidelines as regards pain in the neonate. Resumen: Introducción: Las escalas clínicas son hoy en día el mejor método para evaluar el dolor en el neonato, dada la imposibilidad de autorreporte en este grupo de edad. Se diseñó un estudio con el objetivo de determinar las prácticas actuales en relación con la valoración clínica del dolor en España y los factores asociados al uso de escalas clínicas. Métodos: El estudio es de tipo observacional, longitudinal y prospectivo. Participaron 30 unidades y se reclutó a 468 neonatos. Resultados: Solo 13 unidades (43,3%) disponían de protocolos de valoración del dolor. Se evaluó el dolor con una escala en 78 neonatos (16,7%, IC del 95%, 13,1-20,1) y el número medio de valoraciones del dolor por paciente y día de estancia fue de 2,3 ± 4,8, con una mediana de 0,75. Del total de 7.189 días-paciente estudiados, 654 (9,1%) conllevaron al menos una valoración del dolor. Veinte unidades (66,7%) no realizaron evaluación del dolor con una escala clínica en ningún paciente. Entre las que sí lo hicieron, se observó una gran variabilidad en el porcentaje de pacientes en los que se evaluó el dolor y en las escalas utilizadas. La escala CRIES (C-Crying; R-Requires increased oxygen administration; I-Increased vital signs; E-Expression; S-Sleeplessness) fue la que se usó en más unidades. En el análisis multivariante solo la ventilación mecánica invasiva se asoció a recibir valoración del dolor con una escala (OR 1,46, p = 0,042). Discusión: La mayoría de los neonatos ingresados en cuidados intensivos en España no recibe una valoración del dolor. Muchas unidades todavía no utilizan rutinariamente las escalas clínicas y entre las que las utilizan existe una gran variabilidad. Estos resultados pueden servir de base para la elaboración de guías nacionales al respecto del dolor en el neonato.

Background Heelstick is the most frequently performed skin-breaking procedure in the neonatal intensive care units (NICUs). There are no large multicenter studies describing the frequency and analgesic approaches used for heelsticks performed in NICUs. Objectives To describe the frequency of heelsticks and their analgesic management in newborns in the NICU. To determine the factors associated with the lack of specific preprocedural analgesia for this procedure. Design EPIPPAIN 2 (Epidemiology of Procedural PAin In Neonates) is a descriptive prospective epidemiologic study. Setting All 16 NICUs in the Paris region in France. Participants All newborns in the NICU with a maximum corrected age of 44 weeks +6 days of gestation on admission who had at least one heelstick during the study period were eligible for the study. The study included 562 newborns. Methods Data on all heelsticks and their corresponding analgesic therapies were prospectively collected. The inclusion period lasted six weeks, from June 2, 2011 to July 12, 2011. Newborns were followed from their admission to the 14th day of their NICU stay or discharge, whichever occurred first. Results The mean (SD) gestational age was 33.3 (4.4) weeks and duration of participation was 7.5 (4.4) days. The mean (SD; range) of heelsticks per neonate was 16.0 (14.4; 1–86) during the study period. Of the 8995 heelsticks studied, 2379 (26.4%) were performed with continuous analgesia, 5236 (58.2%) with specific preprocedural analgesia. Overall, 6764 (75.2%) heelsticks were performed with analgesia (continuous and/or specific). In a multivariate model, the increased lack of preprocedural analgesia was associated with female sex, term birth, high illness severity, tracheal or noninvasive ventilation, parental absence and use of continuous sedation/analgesia. Conclusions Heelstick was very frequently performed in NICUs. Although, most heelsticks were performed with analgesia, this was not systematic. The high frequency of this procedure and the known adverse effects of repetitive pain in neonates should encourage the search of safe and effective strategies to reduce their number.

Newborns in intensive care units (ICUs) undergo numerous painful procedures including venipunctures. Skin-breaking procedures have been associated with adverse neurodevelopment long-term effects in very preterm neonates. The venipuncture frequency and its real bedside pain management treatment are not well known in this setting.To describe venipuncture frequency, its pain intensity, and the analgesic approach in ICU newborns; to determine the factors associated with the lack of preprocedural analgesia and with a high pain score during venipuncture.Further analysis of EPIPPAIN 2 (Epidemiology of Procedural Pain In Neonates), which is a descriptive prospective epidemiologic study.All 16 neonatal and pediatric ICUs in the Paris region in France.All newborns in the ICU with a maximum corrected age under 45 weeks of gestation on admission who had at least one venipuncture during the study period.Data on all venipunctures, their pain score assessed with the DAN scale and their corresponding analgesic therapies were prospectively collected. The inclusion period lasted six weeks, from June 2, 2011, to July 12, 2011. Newborns were followed from their admission to the 14th day of their ICU stay or discharge, whichever occurred first.495 newborns who underwent venipunctures were included. The mean (SD) gestational age was 33.0 (4.4) weeks and duration of participation was 8.0 (4.5) days. A total of 257 (51.9%) neonates were very preterm (33 weeks). The mean (SD; range) number of venipunctures per neonate during the study period was 3.8 (2.8; 1-19) for all neonates and 4.1 (2.9; 1-17) for neonates33 weeks. Of the 1887 venipunctures, 1164 (61.7%) were performed successfully in one attempt, 437 (23.2%) with continuous analgesia, 1434 (76.0%) with specific preprocedural analgesia. In multivariate models, lack of preprocedural analgesia was associated with higher disease-severity score, intrauterine growth retardation, invasive or noninvasive ventilation, venipuncture performed on the first day of hospitalization or at nighttime, and the use of continuous sedation/analgesia. High pain scores were significantly associated with absence of parents during procedures, surgery during the study period, and higher number of attempts.Venipuncture is very frequent in preterm and term neonates in the ICUs. 76% were performed with preprocedural analgesia. Strategies to reduce the number of attempts and to promote parental presence seem necessary.

Resume Objectifs Decrire une population voyageant avec des enfants au depart de France vers un pays hors d’Europe ; evaluer la proportion des familles qui avait beneficie de conseils de prevention et leur application ; connaitre la morbidite et la prise en charge des pathologies sur place pour essayer d’ameliorer la prevention. Materiel et methode Etude retrospective dans trois centres hospitaliers d’Ile de France. Des questionnaires anonymes ont ete proposes d’aout a octobre aux familles des enfants consultant aux services d’accueil des urgences et qui avaient voyage hors d’Europe dans l’annee. Resultats Pour les 166 enfants inclus, 78 % des familles avaient beneficie de conseils, majoritairement aupres de leur medecin traitant. Les enfants etaient originaires du pays de destination (76 %) et avaient voyage pour rendre visite a leurs familles (80 %), le plus souvent a destination de l’Afrique (68 %). Ils avaient ete vaccines contre la fievre jaune mais le vaccin anti-hepatite A avait ete neglige. Les mesures de prevention avaient ete difficilement realisables en pratique. Sur place, 54 % des enfants avaient eu des problemes de sante (39 % de la diarrhee, 29 % des vomissements, 31 % de la fievre et 13 % d’acces palustre en zone endemique) a l’origine de consultations medicales (28 %), d’hospitalisations (5 %) et de retours anticipes (4 %). Conclusion Les conseils de prevention (hygieno-dietetiques, vaccination) sont a ameliorer. La pediatrie preventive du voyage est un enjeu de sante publique pour fournir des conseils clairs, compris et applicables.

BACKGROUND Ventilator-associated pneumonia (VAP) is a severe intensive complication and remains under estimated in neonatal intensive care unit (NICU). Center for Disease Control defined criteria for adults and pediatrics without neonatal criteria. The objective of this article was to evaluate the rate, the risks factors and the outcome of neonates suffering from ventilator-associated pneumonia in a French NICU. METHODS We conducted a prospective observational study within a one-year period in our NICU. Three hundred and eighty-one neonates under 28 days of age were included. Data analyses were performed using Fischer exact-test, Kolgomorov analysis, Mann-Whitney test and logistic regression. RESULTS Seventeen patients were diagnosed with ventilator-associated pneumonia. Incidence rate of VAP was 8.8 per 1000 invasive mechanical ventilator days. The median age at diagnosis was 20 days (range: 4-45). Extremely low birth weight (under than 1000 grams) were significantly associated with VAP (OR=4.31 [95% CI: 1.38-13.39]). Newborns suffering from VAP had a significantly longer duration of invasive ventilation (median: 16 days [range 4-75] versus 3 days [range 1-28], P

ObjectiveAs the results from epidemiological studies about the impact of outdoor air pollution on asthma in children are heterogeneous, our objective was to investigate the association between asthma exacerbation in children and exposure to air pollutants.MethodsA database of 1 264 585 paediatric visits during the 2010–2015 period to the emergency rooms from 20 emergency departments (EDs) of ‘Assistance Publique Hôpitaux de Paris (APHP)’, the largest hospital group in Europe, was used. A total of 47 107 visits were classified as asthma exacerbations. Concentration of air pollutants (nitrogen dioxide, ozone, fine particulate matter (PM) with an aerodynamic diameter smaller than 10 µm (PM10) and 2.5 µm (PM2.5)), as well as meteorological data, evolution of respiratory syncytial virus infection and pollen exposition, were collected on an hourly or daily basis for the same period using institutional databases. To assess the association between air pollution and asthma, mixed-effects quasi-Poisson regression modelling was performed.ResultsThe only compound independently associated with ED visits for asthma was PM2.5 (P−4). The association between asthma exacerbation and PM2.5 was not linear, and a sigmoid function described the relationshipsatisfactorily. PM2.5 concentration, which gives half the maximum effect, was estimated at 13.5 µg/m3.ConclusionsWe found an association between daily asthma exacerbation in paediatric visits to the ED and fine particulate air pollutants.

L’asthme de l’enfant est une des premieres causes de consultation aux urgences pediatriques. L’evaluation de la gravite de la crise, le choix du traitement et l’orientation du patient ameliorent le devenir a court terme des enfants asthmatiques. Apres un traitement adequat, certains pourront rentrer au domicile, d’autres necessiteront d’etre hospitalises. Les protocoles de soins permettent d’aider a la decision afin d’optimiser la prise en charge aux urgences. L’efficacite de ces protocoles depend entre autres de l’evaluation de la gravite de la crise, de la qualite du protocole et de son implementation en pratique. L’utilisation des scores cliniques simples peut etre une aide a l’evaluation de l’enfant des l’admission. L’objectif de cet article est de proposer un protocole de soins base sur l’experience et les pratiques d’une equipe multidisciplinaire a la lecture des dernieres publications. Le traitement des exacerbations et leurs applications en pratique clinique a fait l’objet de nombreuses publications recentes. Les β2-agonistes administres par voie inhalee constituent dans tous les cas le traitement prioritaire. Lorsqu’elle est indiquee, la corticotherapie orale doit etre administree precocement.

Diagnostic and therapeutic skin-breaking procedures have become ubiquitous in current medical practice and neonatology does not constitute an exception. One of the main sources of neonatal pain is procedure-induced pain. It has recently become clear that pain prevention must be a health care priority. Non-pharmacological approaches constitute a first option for the analgesia of common procedures performed in neonatology. This article reviews the non-pharmacological treatments most frequently used in this context: swaddling, tucking, containment, sweet solutions, non-nutritive sucking (NNS), breastfeeding analgesia, breast milk and music. In practice, the dose of 1 to 2mL of 24% or 30% sucrose solution or 30% glucose solution immediately followed by NNS can be given for minor painful procedures in term neonates or those weighing more than 2500g. In the preterm, 0.3mL of a sweet solution (sucrose or glucose) can be given for infants weighing less than 1500g and 0.5mL for those weighing between 1500 and 2500g. The synergistic effect of sweet solutions and NNS has been clearly shown and thus their association is largely justified in practice. For breast-fed term neonates, breastfeeding can be given to sooth procedure-induced pain. All these non-pharmacological options can be effective to relieve pain from minor or moderate procedures. However, when more painful procedures are performed, stronger analgesics must be used.

Refractory severe hemodynamic or respiratory failure may require extracorporeal membrane oxygenation (ECMO). Since some patients are too sick to be transported safely to a referral ECMO center on conventional transportation, mobile ECMO transport teams have been developed. The experiences of some ECMO transport teams have already been reported, including air and international transport. We report the first French pediatric international ECMO transport by aircraft. This case shows that a long distance intervention of the pediatric ECMO transport team is feasible, even in an international setting. Long distance ECMO transportations are widely carried out for adults, but remain rare in neonates and children.

ObjectiveTo compare the effectiveness of sedation by intranasal administration of midazolam (nMDZ) or ketamine (nKTM) for neonatal intubation.DesignA multicentre, prospective, randomised, double-blind study.SettingDelivery rooms at four tertiary perinatal centres in France.PatientsPreterm neonates with respiratory distress requiring non-emergent endotracheal intubation for surfactant instillation.InterventionsTreatment was randomly allocated, with each neonate receiving a bolus of 0.1 mL/kg in each nostril, corresponding to 0.2 mg/kg for nMDZ and 2 mg/kg for nKTM. The drug was repeated once 7 min later at the same dose if adequate sedation was not obtained.Main outcome measuresSuccess was defined by adequate sedation before intubation and adequate comfort during the procedure. Intubation features, respiratory and cardiovascular events were recorded.ResultsSixty newborns, with mean (SD) gestational age and birth weight of 28 (3) weeks and 1100 (350) g, were included within the first 20 min of life. nMDZ was associated with a higher success rate (89% vs 58%; RR: 1.54, 95% CI 1.12 to 2.12, pNumber of attempts, time to intubation, mean arterial blood pressure measures over the first 12 hours after birth and length of invasive ventilation were not different.ConclusionsnMDZ was more efficient than nKTM to adequately sedate neonates requiring intubation in the delivery room. The haemodynamic and respiratory effects of both drugs were comparable.Clinical trialThis clinical trial was recorded on the National Library of Medicine registry (NCT01517828).

Background We aimed to examine current bedside analgesia/sedation (A/S) and pain assessment (PA) practices in Italian neonatal intensive care units (NICUs) in relation to the findings of an epidemiological European study and recently-introduced national guidelines. Methods We analyzed the Italian data from the EUROPAIN (EUROpean-Pain-Audit-In-Neonates) prospective observational study on A/S practices that involved 6680 newborns admitted to tertiary-level NICUs in 18 European countries. Demographics, type of assisted ventilation, type and mode of A/S administration and PA were analyzed. Multivariate linear regression models were used to identify factors predicting A/S and PA practices. Results From October 1st, 2012 to June 30th, 2013, thirty Italian NICUs gathered data on 422 newborn: 131 on invasive ventilation (IV); 150 on noninvasive ventilation (NIV); and 141 on spontaneous ventilation (SV). A/S was documented for 35.3% of all infants admitted (86.3% IV; 17.3% NIV; 7.1% SV [p = 0.0001]), and varied considerably between NICUs (as reported in other European countries). Strong analgesics were used in 32.5% of cases, sedatives in 10.2%, mild analgesics in 3.8%. Fentanyl was used in 78.6% of cases, morphine in 8.4%, neuromuscular blockers in 5.3%, midazolam in 22.1%. The performance of PA was documented in 67.5% of all newborn (85.5% IV; 67.3% NIV; 51.1% SV [p = 0.001]). Illness severity, type of ventilation, bedside PA, and number of NICU beds were all factors associated with A/S use on multivariate analysis, while gestational age ≤ 32 weeks, and type of ventilation and presence of a pain team were associated with PA. Conclusions We documented a generally widespread, but still highly variable use of A/S and PA at Italian NICUs, despite the diffusion of national guidelines. There is an urgent need to improve routine PA to enable customized pain and stress control (and prevention) in all infants. Trial registration Clinical Trials.gov # NCT01694745. Electronic supplementary material The online version of this article (doi:10.1186/s13052-017-0343-2) contains supplementary material, which is available to authorized users.

Objectives Extracorporeal membrane oxygenation support is indicated in severe and refractory respiratory or circulatory failures. Neurological complications are typically represented by acute ischemic or hemorrhagic lesions, which induce higher morbidity and mortality. The primary goal of this study was to assess the prognostic value of cerebral tissue oxygen saturation (StcO2) on mortality in neonates and young infants treated with ECMO. A secondary objective was to evaluate the association between StcO2 and the occurrence of cerebral lesions. Study design This was a prospective study in infants < 3 months of age admitted to a pediatric intensive care unit and requiring ECMO support. Measurements The assessment of cerebral perfusion was made by continuous StcO2 monitoring using near-infrared spectroscopy (NIRS) sensors placed on the two temporo-parietal regions. Neurological lesions were identified by MRI or transfontanellar echography. Results Thirty-four infants

Resume La bronchiolite aigue due au virus respiratoire syncytial (VRS) peut se compliquer d’atteintes extra-pulmonaires et notamment d’une hyponatremie severe. Cette hyponatremie est due a une secretion augmentee d’hormone antidiuretique et peut etre aggravee par l’utilisation de solutes de perfusion hypotoniques. Nous rapportons trois cas de jeunes nourrissons hospitalises pour une bronchiolite a VRS ayant eu une hyponatremie severe avec des crises convulsives. Nous decrivons la correction de l’hyponatremie et analysons les conditions de perfusion qui ont pu aggraver l’hyponatremie. Nous rappelons les principes de prise en charge hydroelectrolytique des bronchiolites.

The treatment of acute hematogenous osteomyelitis has evolved in recent years to a shorter parenteral treatment with an early switch to the oral route. Current publications recommend a 2- to 4-day parenteral treatment before the oral switch. We retrospectively analyzed a series of 45 children aged 1 to 11 years and treated in our department for acute osteomyelitis without severity criterion. Nineteen of 45 patients were treated by an exclusive ambulatory oral treatment by amoxicillin and clavulanic acid. Twenty six of 45 patients had a 2- to 4-day parenteral treatment before the oral switch. The minimum follow-up was 6 months. The primary endpoint was a clinical, radiographic, and biologic healing, 6 months after the beginning of the treatment. The secondary endpoints evaluated were the length of hospitalization, the total duration of treatment, and the type of antibiotic used. On the primary endpoint, we did not find any significant difference between the 2 treatments (P = 0.38). On the duration of treatment, we found a significant difference (P = 0.049) in favor of oral treatment. The ambulatory oral treatment by amoxicillin and clavulanic acid seems to be a valid alternative to the classical parenteral then oral sequence in the treatment of acute hematogenous osteomyelitis in children without severity criterion.

Study objective We assess the prevalences of bacterial meningitis and herpes simplex virus meningoencephalitis (HSV-ME) in children with a complex febrile seizure and determine these prevalences in the subgroup of children with a clinical examination result not suggestive of meningitis or encephalitis. Methods This multicenter retrospective study was conducted in 7 pediatric emergency departments (EDs) in the region of Paris, France. Visits of patients aged 6 months to 5 years for a complex febrile seizure from January 2007 to December 2011 were analyzed. We defined a subgroup of patients whose clinical examination result was not suggestive of meningitis or encephalitis. Bacterial meningitis and HSV-ME were sequentially sought for by analyzing bacteriologic and viral data at the visit, looking for data from a second visit to the hospital after the index visit, and telephoning the child's parents. Results From a total of 1,183,487 visits in the 7 pediatric EDs, 839 patients presented for a complex febrile seizure, of whom 260 (31.0%) had a lumbar puncture. The outcomes bacterial meningitis and HSV-ME were ascertainable for 715 (85%) and 657 (78.3%) visits, respectively, and we found 5 cases of bacterial meningitis (0.7% [95% confidence interval [CI] 0.2% to 1.6%]) and no HSV-ME (0% [95% CI 0% to 0.6%]). Among the 630 visits of children with a clinical examination result not suggesting meningitis or encephalitis, we found no bacterial meningitis (0% [95% CI 0% to 0.7%]) and no HSV-ME (0% [95% CI 0% to 0.8%]). Conclusion In children with a complex febrile seizure, bacterial meningitis and HSV-ME are unexpected events when the clinical examination after complex febrile seizure is not suggestive of meningitis or encephalitis.

[Resumen] Introducción. Las escalas clínicas son hoy en día el mejor método para evaluar el dolor en el neonato, dada la imposibilidad de autorreporte en este grupo de edad. Se diseñó un estudio con el objetivo de determinar las prácticas actuales en relación con la valoración clínica del dolor en España y los factores asociados al uso de escalas clínicas. Métodos. El estudio es de tipo observacional, longitudinal y prospectivo. Participaron 30 unidades y se reclutó a 468 neonatos. Resultados. Solo 13 unidades (43,3%) disponían de protocolos de valoración del dolor. Se evaluó el dolor con una escala en 78 neonatos (16,7%, IC del 95%, 13,1-20,1) y el número medio de valoraciones del dolor por paciente y día de estancia fue de 2,3±4,8, con una mediana de 0,75. Del total de 7.189 días-paciente estudiados, 654 (9,1%) conllevaron al menos una valoración del dolor. Veinte unidades (66,7%) no realizaron evaluación del dolor con una escala clínica en ningún paciente. Entre las que sí lo hicieron, se observó una gran variabilidad en el porcentaje de pacientes en los que se evaluó el dolor y en las escalas utilizadas. La escala CRIES (C-Crying; R-Requires increased oxygen administration; I-Increased vital signs; E-Expression; S-Sleeplessness) fue la que se usó en más unidades. En el análisis multivariante solo la ventilación mecánica invasiva se asoció a recibir valoración del dolor con una escala (OR 1,46, p=0,042). Discusión. La mayoría de los neonatos ingresados en cuidados intensivos en España no recibe una valoración del dolor. Muchas unidades todavía no utilizan rutinariamente las escalas clínicas y entre las que las utilizan existe una gran variabilidad. Estos resultados pueden servir de base para la elaboración de guías nacionales al respecto del dolor en el neonato. [Abstract] Introduction. Clinical scales are currently the best method to assess pain in the neonate, given the impossibility of self-report in this age group. A study is designed with the aim of determining the current practices as regards the clinical assessment of pain in Spanish Neonatal Units and the factors associated with the use of clinical scales. Methods. A prospective longitudinal observational study was conducted. A total of 30 Units participated and 468 neonates were included. Results. Only 13 Units (43.3%) had pain assessment protocols. Pain was evaluated with a scale in 78 neonates (16.7%, 95% CI; 13.1-20.1) and the mean number of pain assessments per patient and per day was 2.3 (Standard Deviation; 4.8), with a median of 0.75. Of the total number of 7,189 patient-days studied, there was at least one pain assessment in 654 (9.1%). No pain assessment was performed with a clinical scale on any patient in 20 (66.7%) Units. Among those that did, a wide variation was observed in the percentage of patients in whom pain was assessed, as well as in the scales used. The CRIES (C-Crying; R-Requires increased oxygen administration; I-Increased vital signs; E-Expression; S-Sleeplessness) scale was that used in most Units. In the multivariate analysis, only invasive mechanical ventilation was associated with receiving a pain assessment with a scale (OR 1.46, P=.042). Discussion. The majority of neonates admitted into Intensive Care in Spain do not receive a pain assessment. Many units still do not routinely use clinical scales, and there is a wide variation between those that do use them. These results could serve as a basis for preparing national guidelines as regards pain in the neonate.

To describe the incidence and the characteristics of neonatal cholestasis in a cohort of patients with known risk factors and to investigate additional risk factors.A prospective observational study conducted between April 2008 and 2009 involved all neonates admitted in the neonatal ward. They were divided into high- and low-risk groups for cholestasis. The high-risk group included preterm birth34 weeks of gestation, small for gestational age (SGA), parenteral nutrition (PN)7 days, abdomino-pelvic or thoracic surgery. Bilirubinemia was weekly measured in the high-risk group.Of the 460 newborns studied, 234 were included in the high-risk group and 226 in the low-risk group. Cholestasis developed in 32 patients (13.7%) in the high-risk group at mean (SD) age of 14.7 (12.9) days; all were receiving PN. None of the patients in the low-risk group developed cholestasis. An analysis was carried out in the 207 patients in the high-risk group who received PN. The odds ratio (OR) for developing cholestasis was 2.3 [1.1-5.0] and 5.6 [2.5-12.5] for SGA or surgical patients, respectively. Cholestasis was associated with neonatal severe conditions, longer PN duration, and more intravenous macronutrients' intakes. In multivariate analysis, SGA and neonatal surgery were strong independent risk factors for cholestasis, with OR (95% confidence interval [95% CI]) of 4.4 [1.6-12.5] and 4.6 [1.7-12.3], respectively.Transient neonatal cholestasis is a complication of PN. SGA and neonatal surgery are additional risk factors. There is no evidence to limit intravenous protein intakes in preterm.

The suture, when possible, is the best method to close a simple wound. It must be preceded by debridement and performed with great care. A rigorous technique applied in the best possible environment is necessary but not always sufficient to achieve a good cosmetic result.

Enterocolitis is the most serious complication of Hirschsprung disease. Early management of these patients can decrease the severity of this complication. Hirschsprung disease is more common in patients with trisomy 21 than in the general population. Furthermore, the risk of developing enterocolitis is higher in this population. We report on an infant with trisomy 21 who developed enterocolitis as a complication of Hirschsprung disease that was diagnosed late when the infant presented with septic shock leading to death of the patient.

La specialite de pediatrie doit se structurer autour d’un « tronc commun » de pediatrie generale suivi d’une surspecialite pediatrique, comme la pediatrie d’urgence, dont l’enseignement recommande est respectivement de trois et de deux ans au niveau europeen. La specialite de medecine d’urgence a ete recemment reconnue par l’Union europeenne des medecins specialistes (UEMS) comme une specialite medicale dont l’enseignement recommande est de cinq ans. Ces recommandations europeennes doivent tenir compte de la diversite des systemes de sante au sein des 27 pays de l’Union europeenne. Ainsi, en France, le futur DES de medecine d’urgence comportera six mois obligatoires de pediatrie d’urgence et six mois de stage libre qui peut etre en pediatrie. Le referentiel metier-competences pour la specialite de pediatrie d’urgence a ete recemment soumis a la Commission nationale de l’internat et du postinternat (CNIPI) dans le but d’obtenir la creation d’un DESC de type I de pediatrie d’urgence qui viendrait completer les deux formations specifiques de pediatrie et de medecine d’urgence, afin d’ameliorer grandement les connaissances, les competences et les gestes techniques des medecins et des internes qui travaillent dans les structures d’urgences pediatriques et generalistes.

BACKGROUND: A previous audit performed at a tertiary/quaternary pediatric hospital in Toronto, Ontario, demonstrated suboptimal assessment and treatment of children’s pain. Knowledge translation (KT) initiatives (education, reminders, audit and feedback) were implemented to address identified care gaps; however, the impact is unknown.OBJECTIVES: To determine the impact of KT initiatives on pain outcomes including process outcomes (eg, pain assessment and management practices) and clinical outcomes (eg, pain prevalence and intensity); and to benchmark additional pain practices, particularly opioid administration and painful procedures.METHODS: Medical records at The Hospital for Sick Children (Toronto, Ontario) were reviewed on a single day in September 2007. Pain assessment and management practices, and pain prevalence and intensity in the preceding 24 h were recorded on a standardized data collection form. Where possible, pain outcomes were compared with previous audit results.RESULTS: Records of 265 inpatients were audited. Sixty-three per cent of children underwent a documented pain assessment compared with 27% in an audit conducted previously (PCONCLUSIONS: Following KT initiatives, significant improvements in pain processes (pain assessment documentation and pain management interventions) and clinical outcomes (pain prevalence, pain intensity) were observed. Further improvements are recommended, specifically with respect to procedural pain practices and opioid utilization patterns.