Weaning from noninvasive ventilatory support in infants with severe bronchiolitis: An observational study.

BACKGROUND: The aim of the study was to analyze the weaning success, the type of weaning procedures, and weaning duration in consecutive infants hospitalized in a pediatric intensive care unit over a winter season. METHODS: A retrospective observational study was conducted in a pediatric intensive care unit in a tertiary center. Infants hospitalized for severe bronchiolitis were included and the weaning procedure from continuous positive airway pressure (CPAP), noninvasive ventilation (NIV), or high-flow nasal cannula (HFNC) was analyzed. RESULTS: Data from 95 infants (median age, 47 days) were analyzed. On admission, 26 (27%), 46 (49%), and 23 (24%) infants were supported with CPAP, NIV, and HFNC, respectively. Weaning failed in one (4%), nine (20%), and one (4%) infants while supported with CPAP, NIV, or HFNC, respectively (p = 0.1). In infants supported with CPAP, CPAP was stopped directly in five patients (19%) while HFNC was used as an intermediate ventilatory support in 21 (81%). The duration of weaning was shorter for HFNC (17 h, [IQR: 0-26]) than for CPAP (24 h, [14-40]) and NIV (28 h, [19-49]) (p < 0.01). CONCLUSIONS: The weaning phase corresponds to a large proportion of noninvasive ventilatory support duration in infants with bronchiolitis. The weaning procedure following a "step-down" strategy may lead to an increase in the duration of weaning.

Implementation of a nutritional supplementation program in a population of Cambodian children and its impact on statural growth.

BACKGROUND: Stunting is a major health problem in low-income countries. We aimed to describe the implementation of a lipid-based nutrient supplement (LNS) program in a rural neighborhood in Cambodia and to assess its impact on statural growth. METHOD: This was a before-after comparative study. The program was promoted by the Pédiatres du Monde (PDM) organization between 2011 and 2019 in six villages in a rural area in Cambodia. The supplementation program consisted of daily administration of LNS during the third semester of pregnancy for the mothers and then between 6 and 24 months of age for the toddlers. Anthropometric data of the children were recorded during PDM visits before and after the program implementation, which allowed us to compare child growth in the two groups: control and intervention groups. Primary outcome was height-for-age between 24 and 35 months of age. RESULTS: Overall, 198 data were collected for children between 24 and 35 months of age in the control group. A total of 347 pregnant women were enrolled in the intervention phase. A total of 188 data were collected for children between 24 and 35 months of age in the intervention group. The mean height-for-age z-score in the population receiving LNS was higher than in the control group (-1.14 vs. -1.60, p < 0.001). There was no significant difference between the two groups regarding the weight-for-height z-score (WHZ; -1.11 vs. -1.26, p = 0.18) and children in the intervention group had a higher middle upper-arm circumference z-score (MUACZ; -0.75 vs.. -1.1, p < 0.001). CONCLUSION: LNS supplementation significantly and increased the HAZ between 24 and 35 months of age. However, the fight against malnutrition is complex and needs intervention on multiple levels.

Organization of trauma management in French level-1 pediatric trauma centers: A cross-sectional survey.

BACKGROUND: Due to the lack of available evidence on pediatric trauma care organization, no French national guideline has been developed. This survey aimed to describe the management of pediatric trauma patients in France. METHODS: In this cross-sectional survey, an electronic questionnaire (previously validated) was distributed to intensive care physicians from tertiary hospitals via the GFRUP (Groupe Francophone de Réanimation et Urgences Pédiatriques) mailing list. RESULTS: We collected 37 responses from 28 centers with available data, representing 100% of French level-1 pediatric trauma centers. Most of the pediatric centers (n = 21, 75%) had a written local protocol on pediatric trauma care. In most centers (n = 17, 61%), patients with severe trauma could be admitted in various locations, including the adult or pediatric emergency department or the intensive care unit. Usually, the location of the trauma room depended on the patients' age and/or severity of trauma. In 12 centers in which trauma could be managed by adult physicians (n = 12/18, 70%), a physician with pediatric expertise (anesthesiologist or intensive care physician) could be called according to the patient's age or severity of trauma. The cut-off patient age for considering pediatric expertise was mainly 3-5 years (n = 10, 83%). CONCLUSION: Although most French level-1 pediatric trauma centers have a local protocol for pediatric trauma management, organization is very heterogeneous in France. Guidelines should focus on collaboration between professionals and hospital facilities in order to improve outcomes of children with trauma.

Ultrasound assessment of gastric contents in children before general anaesthesia for acute appendicitis.

There is increasing evidence that a minority of adults with acute appendicitis have gastric contents, posing an increased risk of pulmonary aspiration. This study aimed to evaluate the proportion of children with acute appendicitis who have gastric contents considered to pose a higher risk of pulmonary aspiration. We analysed point-of-care gastric ultrasound data routinely collected in children before emergency appendicectomy in a specialist paediatric hospital over a 30-month period. Based on qualitative and quantitative antral assessment in the supine and right lateral decubitus positions, gastric contents were classified as 'higher-risk' (clear liquid with calculated gastric fluid volume > 0.8 ml.kg-1 , thick liquid or solid) or 'lower-risk' of pulmonary aspiration. The 115 children studied had a mean (SD) age of 11 (3) years; 37 (32%; 95%CI: 24-42%) presented with higher-risk gastric contents, including 15 (13%; 95%CI: 8-21%) with solid/thick liquid contents. Gastric contents could not be determined in 13 children as ultrasound examination was not feasible in the right lateral decubitus position. No cases of pulmonary aspiration occurred. This study shows that gastric ultrasound is feasible in children before emergency appendicectomy. This technique showed a range of gastric content measurements, which could contribute towards defining the risk of pulmonary aspiration.

Aminoglycoside prescription: compliance with national guidelines in a pediatric hospital.

OBJECTIVE: Our study aimed to describe the use of aminoglycosides (AGs) in the pediatric population in acute settings and to assess its compliance with the most recent national recommendations. METHODS: A single-center retrospective study conducted over a 5-month period. Pediatric patients who received at least one dose of AGs in emergency or intensive care unit were included. Compliance with the 2011 French recommendations was assessed. RESULTS: A total of 153 AG prescriptions (120 with gentamicin and 33 with amikacin) for 139 patients (median age of patients = 10 months [IQR: 3-36]) were analyzed. Most of the AG prescriptions were initiated in the emergency department (n = 117, 76%) and, overall, compliance with national guidelines was met in half (n = 77) of the prescriptions. In the emergency department, cases of misuse concerned the indication, mostly for patients with pyelonephritis. In the pediatric intensive care unit setting, the misuse concerned underdosing and a low rate of pharmacological monitoring. CONCLUSION: AGs are still misused in pediatric acute settings. In order to limit drug resistance and to be more efficacious, higher doses should be used and monitoring should be performed, in particular in pediatric intensive care units. In the emergency department, more objective criteria should be used to initiate AGs.

Upper limb compartment syndrome after a viper bite in a child: A case report.

The occurrence of compartment syndrome after a viper bite is a rare phenomenon and its treatment remains controversial. We report the case of an 11-year-old boy who developed compartment syndrome of the right upper limb following a viper bite. Decompression by fasciotomy was performed urgently with a good outcome. Surgical decompression for compartment syndrome following a viper bite is not a common treatment according to the literature. Fast access to care and antivenom administration seem to be effective at treating the compartment syndrome without recourse to fasciotomy.

Has the introduction of high-flow nasal cannula modified the clinical characteristics and outcomes of infants with bronchiolitis admitted to pediatric intensive care units? A retrospective study.

BACKGROUND: This study aimed to assess how the emergence of high-flow nasal cannula (HFNC) has modified the demographic and clinical characteristics as well as outcomes of infants with bronchiolitis admitted to a pediatric intensive care unit (PICU). METHODS: This was a single-center retrospective study including infants aged 1 day to 6 months with bronchiolitis requiring HFNC, noninvasive ventilation (NIV), or invasive ventilation on admission. RESULTS: A total of 252 infants (mean age 53±36 days) were included in the study. The use of HFNC increased from 18 (21.4%) during 2013-2014 to 53 infants (55.2%) during 2015-2016. The length of stay in the PICU decreased over time from 4.7±2.9 to 3.5±2.7 days (P<0.01) but the hospital length of stay remained similar (P=0.17). On admission, patients supported by HFNC as the first-line therapy were older. The PICU length of stay was similar according to the type of respiratory support (P=0.16), but the hospital length of stay was longer for patients supported by HFNC (P=0.01). CONCLUSION: The distribution of respiratory support has significantly changed over time for patients with bronchiolitis and HFNC is increasingly used. The demographic and clinical characteristics of the have not changed over time. However, the PICU length of stay decreased significantly.

Endogenous endophthalmitis as a severe complication following a Streptococcus pyogenes infection.

The diagnosis of endogenous endophthalmitis is challenging. We report a pediatric case of endogenous endophthalmitis due to Streptococcus pyogenes angina. A previously healthy 33-month-old child presented to the emergency department with a history of fever and fatigue related to bacterial angina. On physical examination, an opalescent cornea was noticed and the diagnosis of endogenous endophthalmitis was confirmed by the pediatric ophthalmologist. Streptococcus pyogenes was found in blood culture and in the anterior chamber fluid. There was an adverse outcome with posterior vitrectomy and eye atrophy. Since endogenous endophthalmitis can lead to a poor visual outcome, urgent therapeutic management is necessary.

Transcranial Doppler as a useful tool in the detection of cervical steno-occlusive arteriopathy in infants.

OBJECTIVE: The early detection of cervical steno-occlusive arteriopathy is essential to rapidly initiate appropriate treatment and to potentially improve neurological outcome. To accurately confirm the diagnosis, cerebral imaging is the gold standard, but it cannot be performed if the patient is unstable or if the facility is unavailable. CASES: Here we report our experience of using transcranial Doppler (TCD) ultrasound as a readily available, easy-to-use bedside tool to guide the rapid screening and management of cervical steno-occlusive arteriopathy in infants. DISCUSSION AND CONCLUSION: Children with traumatic cervical steno-occlusive arteriopathy, TCD is a potentially useful tool for early diagnosis.

[Non-invasive ventilation in children: Do we need more evidence?] / Intérêt de la ventilation non invasive en réanimation pédiatrique : doit-on espérer un autre niveau de preuve ?

Respiratory failure is the leading cause of hospital admissions in the pediatric intensive care unit (PICU) and is associated with significant morbidity and mortality. Mechanical ventilation, preferentially delivered by a non-invasive route (NIV), is currently the first-line treatment for respiratory failure since it is associated with a reduction in the intubation rate. This ventilatory support is increasingly used in the PICU, but its wider use contrasts with the paucity of studies in this field. This review aims to describe the main indications of NIV in acute settings: (i) bronchiolitis; (ii) postextubation respiratory failure; (iii) acute respiratory distress syndrome; (iv) pneumonia; (v) status asthmaticus; (vi) acute chest syndrome; (vii) left heart failure; (viii) exacerbation of chronic respiratory failure; (ix) upper airway obstruction and (x) end-of-life care. Most of these data are based on descriptive studies and expert opinions, and few are from randomized trials. While the benefit of NIV is significant in some indications, such as bronchiolitis, it is more questionable in others. Monitoring these patients for the occurrence of NIV failure markers is crucial.

[Intrapartum asphyxia: Risk factors and short-term consequences]. / Asphyxie perpartum à terme : facteurs de risque de survenue et conséquences à court terme. À propos de 82 cas.

UNLABELLED: Intrapartum asphyxia is a rare yet serious complication during labor with immediate consequences and possible long-term neurological impairment. The international Cerebral Palsy Task Force established criteria that attribute a cerebral palsy to intrapartum asphyxia: metabolic acidemia measured at birth with pH<7 and base deficit≥12mmol/L. OBJECTIVE: To determine the risk factors of an intrapartum asphyxia occurring in term live births, to evaluate the short-term consequences. METHODS: Our retrospective study included all births between 2002 and 2010 in a level 3 maternity of a university hospital center. Inclusion criteria were those of the Cerebral Palsy Task Force associated with a gestational age≥34weeks of gestation. We studied the conventional markers of intrapartum asphyxia: Apgar score at 5minutes, abnormal cardiotogographic recordings whether they occurred after a sentinel hypoxic event or not before and during labor. The duration of expulsive efforts, the amniotic fluid aspects, the delivery mode as well as the preexisting pregnancy pathologies were also evaluated. On the other hand, we studied the short-term consequences at the newborns: death, multiorgan failure and especially the occurring of a neonatal encephalopathy using Sarnat and Sarnat staging. RESULTS: One hundred and twenty-nine newborns (0.43%) out of 29,416 live births had a pH<7 of whom only 82 (0.27%) presented a real intrapartum asphyxia and were included in this study. A preexisting pregnancy pathology was found in 22% of the women. Hypoxic events were noted in only 9/82 of the cases. Abnormal cardiotocographic recordings were present in 97.6% of the cases. The duration of expulsive efforts as well as the amniotic fluid aspects did not interfere with the occurring of a metabolic acidemia. Caesarean rate was at 46.3% and instrumental extraction rate was at 34.1%. Thity-eight newborns (46.3%) were admitted in neonatal intensive care in which we noted 3 deaths (3.65%), 2 multiorgan failures (2.4%) and 17 neonatal encephalopathy (20.7%). The pH value seemed to influence the occurring of an encephalopathy: 50% when pH<6.9 vs. 13.6% when pH≥6.9 (P=0.0013), as well as for the base deficit: 50% when BD<-18 vs. 15.7% when BD≥-18 (P=0.0068). Apgar score at 5minutes also seemed predictive for a neonatal encephalopathy: 100% when<4, 46% between 4 and 6 and 11% when>6 (P<0.001). CONCLUSIONS: Our results showed an intrapartum asphyxia rate half the one widely recorded of 0.5% of total live births. Our study also validates the commonly used markers to evaluate a high risk of an early neonatal encephalopathy. This study should be continued with the evaluation of hypoxia long-term consequences on the psychomotor development of these kids and especially the occurring of cerebral palsy.

[Clowns in the pediatric intensive care unit in France]. / Les clowns en réanimation pédiatrique : état des lieux en France.

INTRODUCTION: In recent years, in children's hospitals, clowns are involved in pediatric intensive care units (PICUs), at the bedside of the most severely ill children. This study is the first that addresses the work of professional clowns in the PICU. Its aim is to describe this practice in French hospitals. METHODS: This study is a descriptive and prospective study conducted in December 2013 involving all the pediatric PICUs in French hospitals. A survey was emailed to all the PICU department heads in France. RESULTS: Questionnaires were sent to 32 PICUs (21 pediatric and neonatal intensive care units and 11 pediatric intensive care units). The response rate was 81.2% (26 questionnaires completed). Among the 26 units that responded to the survey, clowns intervened in 13 of them (50%). Eight had an exclusive pediatric activity and five had both pediatric and neonatal activities. The clown visit was twice a week in six units and once in seven (missing data: one unit). The head doctor was satisfied or very satisfied in 92.3% of the cases (n=12/13). Medical clowns were trained and professional artists in all of the units. They worked in duo in most units (n=12/13) and solo in one unit. The clown rounds were preceded by a meeting with a healthcare worker in 12 of the 13 PICUs in which the clowns worked. They dialogued with a doctor in four and a nurse (or head nurse) in eight. DISCUSSION: Prior to implementation, the clowns' work should be understood, accepted, and supported by each PICU team, to be validated in the overall care plan for each child. CONCLUSION: Despite the severity of the situations met in the PICU, the instability of patients and the technical environment, clowning in PICUs appears to be a common and worthwhile practice in most French pediatric hospitals.

[Winter viral ecology in a pediatric intensive care unit: a prospective study]. / Étude prospective de l'écologie virale hivernale dans un service de réanimation pédiatrique.

INTRODUCTION: Viral respiratory infections are common in children, most of which are due to a virus. They can lead to serious infections, and these children may require treatment in a pediatric intensive care unit (PICU). This prospective study evaluated the epidemiology of respiratory viruses and associated illnesses among children hospitalized in a PICU during the three winter months of 2012-2013. METHODS: All the children admitted to the PICU, University Hospital of Caen, France, were included. Nasal swabs were collected and specimens were tested using a single real-time PCR (polymerase chain reaction). RESULTS: Of the 105 patients admitted to the PICU during the study period, 84 fulfilled the inclusion criteria. The "respiratory group" included 37 patients with respiratory symptoms at admission while the "nonrespiratory group" included 47 patients with no respiratory symptoms. The 84 nasal swabs collected included 54 that were considered positive (64.3%) and 70 viruses were detected. The most commonly detected virus was RSV (n=28; 40.0% positive samples), followed by HRV (n=24; 34.3%). Viruses were more frequently detected in the respiratory (86.5%) than in the nonrespiratory (42.6%) group (P<0.001). Statistical analysis by subgroups revealed that RSV infections were significantly more frequent in the respiratory group (54.1%) than in the nonrespiratory group (6.4%) (P<0.001). There was no difference for HRV (32.4% and 27.7%) or for the other viruses. No difference in duration of hospitalization or duration of mechanical ventilation was demonstrated depending on the virus detected. DISCUSSION: The use of the very sensitive multiplex PCR technique increased virus detection rates in both symptomatic and asymptomatic subjects. CONCLUSION: We have confirmed the frequency of RSV infections in a PICU and found that many patients without respiratory symptoms have respiratory infections caused by viruses. The impact of these infections on patient outcome should now be analyzed in order to demonstrate the role played by respiratory viruses.

[Measles in France]. / Rougeole : que retenir de l'année 2011 ?

Measles is one of the most contagious diseases implicated in an outbreak in Western Europe for a few years. In France, the outbreak began in 2008, especially in the southern regions. Most of the cases are mild but deleterious effects can occur in infants, during the pregnancy, or in immunosuppressive patients. Pneumonia and encephalitis are the major complications in these patients. Measles illness during pregnancy results in a higher risk of premature labor, spontaneous abortion, and low-birthweight infants. Death from measles was reported in approximately 0.3% of cases. The National Reference Center for measles and paramyxoviridae is implicated in biological confirmation of cases and epidemiologic surveillance. Virologic diagnosis consists in a direct detection of viral RNA (real time PCR), or indirect detection of the immune response (IgM and IgG) in saliva samples. The measles genotype is determined by sequencing a 450 nucleotids fragment of the N gene, as the World Health Organization (WHO) recommendation. This molecular analysis helps determine the geographic origin of the virus and the viral strains circulating in the country. In 2011, 3105 specimens were received. PCR was positive for 1990 patients (64%), with a large majority of children younger than 2 years of age and young adults. The most important cause of measles resurgence is low vaccination coverage. The role of pediatricians is important in order to achieve the goal of 95% of vaccination coverage established by the WHO.