Predictors of clinically urgent intracranial pathology at neuroimaging in children with complex febrile seizures: a retrospective cross-sectional study.

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.

Do All Children Who Present With a Complex Febrile Seizure Need a Lumbar Puncture?

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.

Clinical course and cost assessment of infants with a first episode of acute bronchiolitis presenting to the emergency department: Data from the GUERANDE clinical trial.

INTRODUCTION: Bronchiolitis is the leading cause of hospitalization for infants but its economic burden is not well documented. Our objective was to describe the clinical evolution and to assess the 1-month cost of a first episode of acute bronchiolitis presenting to the emergency department (ED). METHODS: Our study was an epidemiologic analysis and a cost study of the cohort drawn from the clinical trial GUERANDE, conducted in 24 French pediatric EDs. Infants of 6 weeks to 12 months of age presenting at pediatric EDs with a first episode of bronchiolitis were eligible. The costs considered were collected from a societal viewpoint, according to the recommendations of the French National Health Authority. RESULTS: A total of 777 infants were included with a median age of 4 months. A total of 57% were hospitalized during the month following the first consultation in the ED, including 28 (3.6%) in an intensive care unit. The mean length of stay was 4.2 days (SD = 3.7). The average time to relief of all symptoms was 13 days (SD = 7). Average total cost per patient was €1919 (95% confidence interval: 1756-2138) from a societal perspective, mostly due to hospitalization cost. The estimated annual cost of bronchiolitis in infants was evaluated to be between €160 and €273 million in France. DISCUSSION: Bronchiolitis represent a high cost for the health care system and broadly for society, with hospitalizations costs being the main cost driver. Thus significant investments should be made to develop innovative therapies, to reduce the number of hospitalizations and length of stay.

Effect of Nebulized Hypertonic Saline Treatment in Emergency Departments on the Hospitalization Rate for Acute Bronchiolitis: A Randomized Clinical Trial.

Importance: Acute bronchiolitis is the leading cause of hospitalization among infants. Previous studies, underpowered to examine hospital admission, have found a limited benefit of nebulized hypertonic saline (HS) treatment in the pediatric emergency department (ED). Objective: To examine whether HS nebulization treatment would decrease the hospital admission rate among infants with a first episode of acute bronchiolitis. Design, Setting, and Participants: The Efficacy of 3% Hypertonic Saline in Acute Viral Bronchiolitis (GUERANDE) study was a multicenter, double-blind randomized clinical trial on 2 parallel groups conducted during 2 bronchiolitis seasons (October through March) from October 15, 2012, through April 15, 2014, at 24 French pediatric EDs. Among the 2445 infants (6 weeks to 12 months of age) assessed for inclusion, 777 with a first episode of acute bronchiolitis with respiratory distress and no chronic medical condition were included. Interventions: Two 20-minute nebulization treatments of 4 mL of HS, 3%, or 4 mL of normal saline (NS), 0.9%, given 20 minutes apart. Main Outcomes and Measures: Hospital admission rate in the 24 hours after enrollment. Results: Of the 777 infants included in the study (median age, 3 months; interquartile range, 2-5 months; 468 [60.2%] male), 385 (49.5%) were randomized to the HS group and 387 (49.8%) to the NS group (5 patients did not receive treatment). By 24 hours, 185 of 385 infants (48.1%) in the HS group were admitted compared with 202 of 387 infants (52.2%) in the NS group. The risk difference for hospitalizations was not significant according to the mixed-effects regression model (adjusted risk difference, -3.2%; 95% CI, -8.7% to 2.2%; P = .25). The mean (SD) Respiratory Distress Assessment Instrument score improvement was greater in the HS group (-3.1 [3.2]) than in the NS group (-2.4 [3.3]) (adjusted difference, -0.7; 95% CI, -1.2 to -0.2; P = .006) and similarly for the Respiratory Assessment Change Score. Mild adverse events, such as worsening of cough, occurred more frequently among children in the HS group (35 of 392 [8.9%]) than among those in the NS group (15 of 384 [3.9%]) (risk difference, 5.0%; 95% CI, 1.6%-8.4%; P = .005), with no serious adverse events. Conclusions and Relevance: Nebulized HS treatment did not significantly reduce the rate of hospital admissions among infants with a first episode of acute moderate to severe bronchiolitis who were admitted to the pediatric ED relative to NS, but mild adverse events were more frequent in the HS group. Trial Registration: clinicaltrials.gov Identifier: NCT01777347.

Risk of Bacterial Meningitis in Children 6 to 11 Months of Age With a First Simple Febrile Seizure: A Retrospective, Cross-sectional, Observational Study.

OBJECTIVES: National and international guidelines are very heterogeneous about the necessity to perform a lumbar puncture (LP) in children under 12 months of age with a first simple febrile seizure. We estimated the risk of bacterial meningitis in children aged 6 to 11 months with a first simple febrile seizure. METHODS: This multicenter retrospective study was conducted in seven pediatric emergency departments (EDs) in the region of Paris, France. Visits of patients aged 6 to 11 months for a first simple febrile seizure from January 2007 to December 2011 were analyzed. Bacterial meningitis was sequentially sought for by 1) analyzing bacteriologic data at the time of the visit, 2) looking for data from a second visit to the hospital after the index visit, and 3) phone calling the child's parents to determine the symptom evolution after the index visit. Infants lost to this follow-up were searched for in a national bacterial meningitis database. RESULTS: From a total of 1,183,487 visits in the seven pediatric EDs, 116,503 were for children 6 to 11 months of age. From these, 205 visits were for a first simple febrile seizure. An LP was performed in 61 patients (29.8%). The outcome bacterial meningitis was ascertainable for 168 (82%) visits. No bacterial meningitis was found among these patients (95% confidence interval = 0% to 2.2%). None of the 37 infants lost to our follow-up were registered in the national database as having bacterial meningitis. CONCLUSIONS: Among children between 6 and 11 months of age with a first simple febrile seizure, the risk of bacterial meningitis is extremely low. These results should encourage national and international societies to either develop or endorse guidelines limiting routine LP in these infants and contribute to widely homogenized management practices.