Randomised trial of analgesic effects of sucrose, glucose, and pacifiers in term neonates.

OBJECTIVES: To assess and compare the analgesic effects of orally administered glucose and sucrose and pacifiers. To determine the synergistic analgesic effect of sucrose and pacifiers. DESIGN: Randomised prospective study with validated behavioural acute pain rating scale. SETTING: Maternity ward. PARTICIPANTS: 150 term newborns undergoing venepuncture randomly assigned to one of six treatment groups: no treatment; placebo (2 ml sterile water); 2 ml 30% glucose; 2 ml 30% sucrose; a pacifier; and 2 ml 30% sucrose followed by a pacifier. RESULTS: Median (interquartile) pain scores during venepuncture were 7 (5-10) for no treatment; 7 (6-10) for placebo (sterile water); 5 (3-7) for 30% glucose; 5 (2-8) for 30% sucrose; 2 (1-4) for pacifier; and 1 (1-2) for 30% sucrose plus pacifier. Mann-Whitney U test P values for comparisons of 30% glucose, 30% sucrose, pacifier, and 30% sucrose plus pacifier versus placebo (sterile water) were 0.005, 0.01, <0.0001, and <0.0001, respectively. Differences between group median pain scores for these comparisons were 2 (95% confidence interval 1 to 4), 2 (0 to 4), 5 (4 to 7), and 6 (5 to 8), respectively. P values for comparisons of 30% glucose, 30% sucrose, and 30% sucrose plus pacifier versus pacifier were 0.0001, 0.001, and 0.06, respectively. Differences between group medians for these comparisons were 3 (2 to 5), 3 (1 to 5), and 1 (0 to 2), respectively. CONCLUSION: The analgesic effects of concentrated sucrose and glucose and pacifiers are clinically apparent in newborns, pacifiers being more effective than sweet solutions. The association of sucrose and pacifier showed a trend towards lower scores compared with pacifiers alone. These simple and safe interventions should be widely used for minor procedures in neonates.

[Post-lumbar puncture headache in children. Treatment with epidural autologous blood (blood patch)]. / Céphalées post-ponction lombaire chez l'enfant. Intérêt de l'injection péridurale de sang autologue (blood patch).

UNLABELLED: Post-lumbar puncture headaches (PLPH) are uncommon in children, but when they occur treatment is challenging. PLPH in adults have been successfully treated by the use of the epidural blood patch. This treatment has been very rarely reported in children. CASE REPORT: A 13-year-old boy, weighing 64 kg, had a lumbar puncture as part of a work-up for a 4-day history of right hemithorax pain. This pain was associated with hypoesthesia; there were no cutaneous vesicles. Neurological examination revealed decreased strength in the left upper extremity. A magnetic resonance imaging of the cervicodorsolumbar spine was normal. Three hours after lumbar puncture, the patient complained of bifrontal headaches. The headaches worsened in the upright position and they prevented the boy from ambulating. Treatment with acetaminophen was unsatisfactory. On day 9, the initial symptoms that had motivated the lumbar puncture had disappeared, but PLPH persisted. Therefore, an epidural blood patch was performed (EBP). A 18-gauge 1 Perican needle was introduced into the peridural space at the L3-L4 interspace using the loss of resistance technique. Fifteen milliliters of blood were drawn in a sterile fashion and without anticoagulant from the patient's forearm and injected slowly through the epidural needle. The patient experienced immediate, complete, and definite relief of his PLPH. Follow-up did not show any complication. CONCLUSION: EBP can be useful in the treatment of PLPH lasting more than 5 days in children.

[APN: evaluation behavioral scale of acute pain in newborn infants]. / DAN: une échelle comportementale d'évaluation de la douleur aiguë du nouveau-né.

AIM: This study was designed to validate a behavioral acute pain rating scale for term and preterm neonates (APN). METHODS: From January through June 1996, neonates requiring a heel lance or a venous puncture for blood sampling at the intensive care unit and the nursery of Poissy Hospital were recruited into the study. After a pilot study, a pain rating scale was developed. The scale score pain ranged from 0 to 10 and it evaluated three items: facial expression, limb movements, and vocal expression with ratings per item ranging from 0 to 4, 0 to 3 and 0 to 3, respectively. Two observers evaluated independently each infant during a painful procedure (puncture for a blood sample) and during a dummy procedure (rubbing the thigh softly). RESULTS: Forty-two neonates born between 25 and 41 weeks gestational age were included in the study. Medians (quartiles) of gestational age, birth weight, and corrected postmenstrual age at time of investigation were 34 (29-39) weeks, 1,850 (1,055-3,093) g, and 35.5 (31-39) weeks, respectively. Ten infants were intubated. The scale showed to be sensitive because all possible scores were obtained; during painful procedures scores ranged from 1 to 10, with 95% of scores > or = 3 while during dummy procedures they ranged from 0 to 5, with 88% of scores < or = 2. The medians (95% confidence interval) of scores were for painful procedures 5 (5 to 7) and for dummy procedures 1 (0 to 1). This indicates a good specificity of the scale. High intercorrelation of items (internal consistency) was confirmed by a Cronbach's coefficient alpha of 0.88. Inter-rater agreement was high since the Krippendorff R test was 91.2. CONCLUSION: This behavioral acute pain rating scale for newborns demonstrated a good specificity and sensitivity, internal consistency and inter-rater reliability. This scale could be used to test the analgesic effects of different therapies during painful procedures.

[Evaluation of pediatric advise asked by telephone in emergency units]. / Evaluation des demandes de conseils téléphoniques pédiatriques dans un service d'urgences.

BACKGROUND: Telephone calls for advice are common in pediatric emergency departments. This study was conducted to determine the nature of these calls and the answers provided. METHODS: From 24 April through 24 July 1994, all telephone calls requesting pediatric advice in the emergency department of the Poissy Hospital were independently analysed by two pediatricians from forms prospectively filled in for each call by the resident or the attending people who answered the call. RESULTS: Of the 239 registered calls, 186 could be analysed. They represented, in number, 15.25% of the children seen at the same emergency department during the study period. Weekend and holiday calls accounted for 35.5% of calls. 7.8% of calls were received from 0.01 am to 8.00 am, 28.7% from 8.01 am to 4.00 pm, and 63.5% from 4.01 pm to 12.00 pm. Thirty-seven percent concerned children under one year of age. The caller was one of the parents in 93% of cases. The four most frequent complaints were fever (26.5%), requests for information (17.2%), rash (12.3%), and vomiting (10.2%). The review of calls by two pediatricians determined that 67% of children did not need to be seen by a physician within six hours; 28% needed to be seen within 6 hours, and 5% needed to be seen within one hour. The advice given was followed in 88% of cases; 96% of callers were satisfied with their calls management. CONCLUSIONS: Telephone advice constitutes an important part of the activity in the pediatric emergency department. Instructional programs in telephone management are necessary for physicians. These programs should include communication skills and familiarization with protocols concerning the most frequent complaints, especially those regarding children under one year of age.

[Telephonic advice by an emergency department given in a simulated pediatric case]. / Conseils téléphoniques donnés aux urgences pour un cas pédiatrique simulé.

BACKGROUND: Emergency departments (ED) are requested everyday to dispense medical telephone advice for children. To evaluate the quality of telephone management, a mock scenario simulating a febrile 4 month-old-girl with signs compatible with septicemia was used. METHODS: One hundred randomly selected French emergency departments were called on. Half of the hospitals had a pediatric department with more than 20 beds; the other half did not have a pediatric department. A research technician called and said: "My baby has got fever and I do not know what to do". Additional information was given only on request. RESULTS: Ninety-four ED gave medical advice by telephone: 65% of the cases by a physician, 24.5% by a nurse, 9.5% by a nurse technician and 1% by a secretary. In hospitals without a pediatric department, physicians took calls in 76.5% of the cases, whereas in hospitals with a pediatric department they only took calls in 53% of the cases. The mean number of questions asked per ED was 3.1. The age of the child was requested by 87.2% of the respondents. Advice was given by 36.1% of the ED without asking either the age of the patient or grade of the fever. The advice given by the respondents was: come to the ED immediately (30.9%), see a community physician immediately (51%), come to the ED tomorrow (2.1%), see a community physician tomorrow (8.5%), and manage at home (7.5%). CONCLUSIONS: This study has shown important inadequacies in pediatric telephone advice given by some ED. It suggests that the respondents do not use a protocol to handle the calls; development of such protocols to guide the histories taken and advice given for the most common telephone queries is urged.

[Inaugural acute cholestasis of Kawasaki disease]. / Cholestase aiguë inaugurale d'une maladie de Kawasaki.

BACKGROUND: Hepatic dysfunction with mild obstructive jaundice occurs occasionally in Kawasaki disease. Acute episode of cholestasis as a presenting symptom has never been reported. CASE REPORT: A 14 year-old-boy was admitted with fever and cholestasis. He subsequently developed the classical manifestations of Kawasaki disease. No signs of liver cell injury or hepatic failure were present. Bacteriological cultures and seroimmunologic markers for viral infection remained negative. There was no ultrasonic abnormality of bile ducts. The child was given intravenous gamma globulins and salicylate. The outcome was favourable without any cardiovascular complications. CONCLUSION: A persistent febrile cholestasis of unknown etiology should evoke the diagnosis of Kawasaki disease.

[Water intoxication following preparation for barium enema]. / Intoxication par l'eau après une préparation pour un lavement baryté.

BACKGROUND: Induction of water intoxication from tap water enemas was reported a few years ago. Its treatment is still debated. CASE REPORT: A 4 1/2 year-old boy was admitted because he suffered from coma grade I. A barium enema had been prescribed for fecal incontinence and the patient had been given orally about 4 liters of water during the 24 hours preceding this investigation. Blood examination showed;: Na 122 mEq/l; K 3 mEq/l; Cl 87 mEq/l. Brain CT scan was normal. The patient was placed under restriction of fluid and was given i.v. 5.8% NaCl solution (2 mM/kg) for 3 hours. Convulsions appeared despite this treatment requiring intubation and ventilation plus increasing doses of NaCl: 20% solution (2 mM/kg) for 30 minutes followed by 2 mM/kg for 3 hours, associated with mannitol and furosemide infusion. CONCLUSION: Use of hypertonic saline solutions in the treatment of water intoxication is discussed. Acute hyponatremia must be rapidly corrected using hypertonic saline solution plus restriction of fluid and diuretic.

[Intraosseous infusion in children]. / Perfusion intraosseuse chez l'enfant.

BACKGROUND: Intravenous access in critically ill patients may be very difficult to obtain. The intraosseous route is an alternate way to administer fluids and drugs. CASE REPORT: A five month old infant was brought to the emergency department in profound hypovolemia requiring immediate tracheal intubation. A peripheral venous access was established and 35 ml of colloid were rapidly infused. Unfortunately, fluid extravasated and the intravenous line had to be removed. As further attempts to gain intravenous access were unsuccessful, an intraosseous needle was inserted into the left tibia 1 cm below the tibial tuberosity, and colloid and human albumin solution were infused rapidly, followed by 1.4% sodium bicarbonate. After ninety minutes of intraosseous rehydration, 2 peripheral venous lines were inserted, and the intraosseous needle was removed. Bacteriological and viral cultures were negative. Four days after admission, the child was discharged in good condition. CONCLUSIONS: Intraosseous infusion provides safe, rapid and reliable access to the circulation for administration of fluids and drugs in the critically ill child or during cardiac arrest.

[Prenatal prevention of infant respiratory distress syndrome. 1st part: experimental data and pharmacological treatment]. / Prévention anténatale du syndrome de détresse respiratoire du prématuré. 1re Partie: Données expérimentales et moyens pharmacologiques.

Pulmonary maturation and growth are two time-related interdependent phenomena. The main regulatory mechanisms of pulmonary maturation are complex and the role of epithelial-mesenchymal interrelationship appear to be determinant in the phenomena leading to morphological growth of the lung and in cellular differentiation of the epithelium during development. At an early stage of morphological development of the fetal lung, endogenous hormones do not directly affect epithelial differentiation but modulate the expression of genes coding for surfactant. Later surfactant production responds to multihormone regulation. Some of these hormones or growth factors (steroids, oestradiol, prolactin, thyroxine, epidermal growth factor, fibroblast pneumocyte factor) are powerful stimulators, favoring biochemical development of the fetal lung. Inversely, other factors (insulin, androgens) limit the production of surfactant. Glucocorticoids play a specific role (stimulation of morphologic and biochemical development of the lung) and potentialize the stimulating effect of other factors. A good understanding of these mechanisms is essential before introducing treatments stimulating natural processes as closely as possible. Experimental results on the use of lung maturation induction, especially with glucocorticoids, have been quite promising. Combining thyroid hormones and thyrotropin-releasing hormone appears to be an interesting proposal, as is the use of growth factors such as epidermal growth factor.

[Prenatal prevention of infant respiratory distress syndrome. 2nd part: clinical applications and indications]. / Prévention anténatale du syndrome de détresse respiratoire du prématuré. 2e Partie: Applicatons cliniques et indications.

Two types of sometimes complementary therapeutic strategies can be developed to prevent infant respiratory distress syndrome antenatally. The first is to administer a treatment aimed at accelerating the maturation process of fetal lung tissue in women at risk of premature birth. This is the only strategy with a goal of antenatal treatment. The second method is to optimize neonatal care, particularly with exogenous surfactants. The use of corticosteroids during the antenatal period has been well studied and is known to be effective with a 50% reduction in the risk of the syndrome before 34 weeks gestation. Prenatal morbidity and mortality are decreased without major adverse effects. Based on a limited number of cases, TRH-corticosteroid combination probably gives better results with no predictable unfavourable neonatal consequences. The synergic action of antenatal treatments, completed with exogenous surfactants at birth, is one of the fundamental aspects of care for very premature infants (< 28 weeks gestation).

[An unusual etiology of hydramnios: prenatal cerebral vascular accident. Five cases]. / Une étiologie inhabituelle d'hydramnios: l'accident vasculaire cérébral anténatal. A propos de 5 observations.

Neurological anomalies of the fetus are classically reported as causes of hydramnios, but cerebral vascular events occurring in utero in the fetus are rarely mentioned. We observed five newborns with neurological complications during the neonatal period in which anomalies of cerebral vascularization were identified antenatally. The mothers had hydramnios during pregnancy. Several pathophysiological hypotheses have been proposed to explain the mechanism of hydramnios. Magnetic resonance imaging of the brain in the fetus has made it possible to identify such exceptional events with extremely poor prognosis and major sequelae.

[Pneumothorax revealing pneumoblastoma in an infant]. / Pneumothorax chez un nourrisson révélateur d'un pneumoblastome.

BACKGROUND: Pulmonary blastoma is a tumor with bad prognosis that is exceptionally seen before the age of 2 years. CASE REPORT: A 3 1/2 month-old infant was admitted because she suffered from tachypnea. A left pneumothorax with shift of the mediastinum was recognized that required insertion of a chest tube followed by ventilation and pleural drainage. X rays and CT scan showed a round bullous lesion in the left lung that persisted at the age of 5 months. At that time, clinical deterioration led to thoracotomy allowing excision of a bullous tumor; histological examination showed that this tumor was a pulmonary blastoma. Recurrence of this tumor, 16 months later, required chemotherapy and surgical excision. The patient is normal at the age of 4 years. CONCLUSION: Pulmonary blastoma is exceptional in infancy; it may be revealed by pneumothorax. Its bad prognosis requires aggressive therapy.

[Deficiency in medium chain acyl coA dehydrogenase manifested as febrile coma]. / Déficit en acyl-CoA déshydrogénase à chaîne moyenne révélé par un coma fébrile.

A 21-month-old infant developed coma with hypotonia during a viral infection. Acyl CoA dehydrogenase deficiency was diagnosed on the basis of results of the chromatographic study of organic acids performed on a urine specimen collected during the acute episode. However, other disorders of mitochondrial and fatty acid oxygenation can generate similar symptoms. Emphasis is put on the need for collecting urine specimens in patients who develop alterations in consciousness and hypoglycemia without ketonuria during prolonged fasting or repeated vomiting due to a viral infection. Urine chromatography can suggest which enzyme is defective, although the diagnosis should always be confirmed by a study of fatty acid oxygenation in lymphocytes or fibroblasts.

[Cerebral embolism revealing aneurysm of the interauricular septum]. / Embolie cérébrale révélatrice d'un anévrysme du septum interauriculaire.

BACKGROUND: Aneurysm of the interatrial septum is a potential cause of systemic embolism, but it is rarely responsible for a cerebral embolism in childhood. CASE REPORT: A girl, aged 14 years, presented with a sudden right hemiplegia. The coagulation factors were normal, as was the CSF. The CT scan was normal and the EEG showed some theta waves (3-4/s) on the left temporal lobe. MRI, performed 6 days later, showed ischemic lesions leading to a search for the origin of the embolism. One-dimensional echocardiography revealed no abnormality, but two-dimensional echocardiography showed an aneurysm of the interatrial septum bulging into the right atrium. The child was treated with low doses of acetylsalicylic acid, but still had a moderate degree of spastic hemiplegia one year later. CONCLUSION: Cardiopathies can be among the causes of cerebral embolism in children. An aneurysm of the interatrial septum requires treatment throughout patient's life.