Breastfeeding and respiratory, ear and gastro-intestinal infections, in children, under the age of one year, admitted through the paediatric emergency departments of five hospitals.

Background: Breastfeeding is a protective factor against respiratory and intestinal infections in developing countries. In developed countries, proof of this protection is more difficult to show. The objective of the study is to compare the proportion of children breastfed during their first year in groups of children with infectious pathologies supposedly prevented by breastfeeding and children free of these infectious pathologies. Method: Questionnaires about diet, socio-demographic data and the motive for consultation were given to the parents upon arrival in the paediatric emergency departments of 5 hospitals located in Pays de Loire (France) in 2018 and 2019. Children with lower respiratory tract infections, acute gastroenteritis and acute otitis media were included in the case group (A), children admitted for other reasons were included in the same control group (B). Breastfeeding was classified as exclusive or partial. Results: During the study period, 741 infants were included, of which 266 (35.9%) in group A. In this group, children were significantly less likely to have been breastfed at the time of admission than children in group B: for example, for children under 6 months, 23.3% were currently breastfed in group A, vs. 36.6% (weaned BF or formula diet) in group B [OR = 0.53 (0.34-0.82); p = 0.004]. Similar results were found at 9 and 12 months. After taking into account the age of the patients, the same results were confirmed with an aOR = 0.60 (0.38-0.94) (p = 0.02) at 6 months, but with when considering six variables six variables, aOR was not significative aOR = 0.65 (0.40-1.05); p = 0.08), meaning that factors such as the childcare out of home, socio-professional categories, and the pacifier decrease the protective effect of breastfeeding. Sensitivity analyses (age-matching, analysis by type of infection) showed the same protection effect provided by breastfeeding when it was pursued for at least 6 months and also that the protective effect of breastfeeding is especially true against gastro-enteritis. Conclusion: Breastfeeding is a protective factor against respiratory, gastrointestinal and ear infections when pursued at least 6 months after birth. Other factors such as collective childcare, pacifiers and low parental professional status can reduce the protective effect of breastfeeding.

Do abused young children feel less pain?

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

Why children with severe bacterial infection die: a population-based study of determinants and consequences of suboptimal care with a special emphasis on methodological issues.

INTRODUCTION: Suboptimal care is frequent in the management of severe bacterial infection. We aimed to evaluate the consequences of suboptimal care in the early management of severe bacterial infection in children and study the determinants. METHODS: A previously reported population-based confidential enquiry included all children (3 months- 16 years) who died of severe bacterial infection in a French area during a 7-year period. Here, we compared the optimality of the management of these cases to that of pediatric patients who survived a severe bacterial infection during the same period for 6 types of care: seeking medical care by parents, evaluation of sepsis signs and detection of severe disease by a physician, timing and dosage of antibiotic therapy, and timing and dosage of saline bolus. Two independent experts blinded to outcome and final diagnosis evaluated the optimality of these care types. The effect of suboptimal care on survival was analyzed by a logistic regression adjusted on confounding factors identified by a causal diagram. Determinants of suboptimal care were analyzed by multivariate multilevel logistic regression. RESULTS: Suboptimal care was significantly more frequent during early management of the 21 children who died as compared with the 93 survivors: 24% vs 13% (p = 0.003). The most frequent suboptimal care types were delay to seek medical care (20%), under-evaluation of severity by the physician (20%) and delayed antibiotic therapy (24%). Young age (under 1 year) was independently associated with higher risk of suboptimal care, whereas being under the care of a paediatric emergency specialist or a mobile medical unit as compared with a general practitioner was associated with reduced risk. CONCLUSIONS: Suboptimal care in the early management of severe bacterial infection had a global independent negative effect on survival. Suboptimal care may be avoided by better training of primary care physicians in the specifics of pediatric medicine.

Suboptimal care in the initial management of children who died from severe bacterial infection: a population-based confidential inquiry.

OBJECTIVES: To study the frequency and types of suboptimal care and medical errors in children who died of severe bacterial infection as the first-stage procedure intended to improve quality of care. DESIGN: Population-based confidential inquiry. SETTING: Two adjoining administrative districts in France. PATIENTS: Children older than 3 months dead from severe bacterial infection from 2000 through 2006. INTERVENTIONS: The medical files were summarized on standardized forms and then evaluated independently by two experts, who determined whether the initial management before the patients' arrival in intensive care was or was not optimal, in comparison with current guidelines. MEASUREMENTS AND MAIN RESULTS: Of 23 deaths from severe bacterial infection, 21 could be analyzed; management was considered suboptimal in 76%. The coefficient of agreement between the experts was high, with a weighted kappa of 0.73. The types of errors identified included parental delay in seeking medical care (33%; 95% confidence interval, [12-54]), physicians' delay in administering appropriate treatment (antibiotic therapy in the case of purpura; 38%; 95% confidence interval, 16-60), insufficient doses of or failure to repeat fluid resuscitation (24%; 95% confidence interval, [9 -35]), and overall underestimation of disease severity (38%; 95% confidence interval, [16-60]). CONCLUSION: This study found a high frequency of suboptimal care in the initial management of children who died of severe bacterial infection, with four separate types of errors. Other studies are needed to assess the potential avoidability of this type of death.