An unusual swollen dermal lesion in a 14-month-old child.

A 14-month-old child was brought to the pediatric emergency unit in the morning, after his parents discovered inflammatory lesion on his left thigh. Three hours later, he was admitted to our unit, his vital signs were normal and his physical examination revealed a round swollen lesion of 7-8 cm in diameter with blisters on the surface and an additional inflammatory reaction of his left thigh ( Figs. 1 and 2 ). The parental interview provides the cause. The child was discharged after the lesion was dressed and a follow-up scheduled.

[Analysis of neonate admissions to the pediatric emergency department]. / Fréquentation des urgences pédiatriques par les nouveau-nés.

UNLABELLED: Neonate admissions follow the general growing concern of emergency department use. OBJECTIVE: To analyze the epidemiological characteristics of a cohort of neonates admitted to a tertiary-level pediatric emergency department. MATERIAL AND METHODS: Prospective study conducted between August 2008 and April 2009 including all neonates aged 28 days or less admitted to the pediatric emergency department. The data collected for neonates were age, sex, premature or term birth, feeding mode, mode and reason of admission, time of admission, neonatal history, length of stay, and progression. For children admitted between August and October, any later consultations were analyzed during the following 6 months. The data collected for mothers were age, number of live births, living conditions, delivery mode, length of stay in the maternity ward, and occupation. RESULTS: Descriptive analysis: 538 neonates were included, the mean age was 17 days, the male:female ratio was 1.13. Twenty-nine children were premature (5.4%), 13% had previous conditions (jaundice, maternofetal infection, gastroesophageal reflux). Half the babies were formula-fed. Medical reasons were the most frequent (90%); 8% of children were admitted after a trauma. Almost ½ the neonates were hospitalized (47%). In the group of children followed for possible later consultations, 59 children were readmitted, totalling 103 consultations mainly for the same medical reason. The mothers' average age was 30 years, 53% were primiparae, and the mean length of stay in the maternity ward was 5 days. Comparative analysis: the neonate sex-ratio and prematurity rate were similar to those of the regional area. They differed from other admissions in their higher rate of nighttime consultations (18% versus 8%, P<0.001), physician referrals (23% versus 17%, P<0.001), and a higher rate of hospitalization (relative risk [RR] equal to 3.27 [3.01-3.54], P<0.001). The medical severity responded to the all or nothing principle: they were more often admitted for simple consultation (RR=1.31 [1.19-1.45], P<0.001), and for unstable conditions (RR=2.70 [2.36-3.07], P<0.001). A higher risk of emergency department use was noted if the mother was a first-time mother, young, living alone, and in a neighborhood near a hospital, with no occupation and the neonate aged less than 15 days. CONCLUSION: Initially associated with the reduction in the length of stay in the maternity ward, the increase of neonates' admissions to the pediatric emergency department is known to have several origins and is related to neonates' vulnerability or previous medical conditions, their familial environment, and sociological factors.

[Osteoarticular tuberculosis: a differential diagnosis of idiopathic juvenile arthritis]. / Oligo-arthrite tuberculeuse : un diagnostic différentiel de l'arthrite juvénile idiopathique.

UNLABELLED: We report a case of extrapulmonary tuberculosis with oligoarthritis and synovitis in a 6-year-old girl with undiagnosed disseminated tuberculosis. CLINICAL CASE: The child, adopted from Ethiopia, was admitted to the pediatric rheumatology unit for suspected idiopathic juvenile arthritis. She presented with clinical signs of subacute arthritis of the right knee. Joint symptoms began insidiously and followed a short period of fever and pain in the right hip. Clinical examination showed voluminous cervical lymphadenitis, night sweats, and a moderate alteration of the child's general condition. The medical history revealed that since her arrival in France, 2 years before, she had had febrile subacute pneumonia. A review of the chest x-ray diagnosed primary pulmonary tuberculosis. An intradermal tuberculin test confirmed the diagnosis with a phlyctenular response and a diameter exceeding 20mm. Additional evaluation showed cervical lymphadenitis and intense synovitis of the right hip and knee joints. With an appropriate antitubercular regimen, her condition improved within a few months. After 1 year of treatment, magnetic resonance imaging (MRI) showed normalization of the impaired joints with no functional sequelae. DISCUSSION: Although the spine is a common target for osteoarticular tuberculosis (OAT), peripheral involvement in this case underlines the polymorphism of OAT in children. It illustrates a case of OAT strictly located to the synovial membranes, which usually occurs in one-third of OAT cases. In addition, MRI showed tenosynovitis of the quadriceps. The child presented with unilateral oligoarthritis instead of chronic insidious monoarthritis or symmetrical oligoarthritis as usually described in pediatric OAT. When available, MRI is the best way to evaluate OAT lesions. Mycobacterium tuberculosis can be isolated from sputum, gastric aspiration, and joint fluid or synovial biopsy. Histological lesions can reveal advanced tuberculosis with the presence of caseous follicular lesions. Rapid bacterial detection using polymerase chain reaction remains insufficiently useful in those situations. The recommended therapeutic regimen consists of 3 months with four antitubercular agents (rifampicin, isoniazid, pyrazinamide, and ethambutol) followed by 9 months of a dual therapy (isoniazid, rifampicin).

[Hair-thread tourniquet syndrome]. / Syndrome du tourniquet ou cheveu étrangleur.

OBJECTIVE: Describe the epidemiology of tourniquet syndromes and a cohort of such children admitted to the pediatric emergency department (PED), analyze the family's social situation to detect neglect behaviors, and analyze subsequent hospital admissions. PATIENT AND METHODS: From 1st January 2003 to 31st May 2009 in the PED, all patients admitted for tourniquet syndrome were included in the study. The data collected were day and time of admission, age, sex, length of stay, medical coverage, type and location of the constrictive agent, therapeutic management, progression, and complications. PED social workers in relation with child protective services (CPS) recovered information on the family's social situation. RESULTS: During the study period, 57 children were registered. The mean number of admissions per year was 8 (range: 2-15). The mean age was 5.5+/-4 months. The toe was the most frequent location (95%). The penis was injured in 2 cases and labia majora in 1 case. The constrictive agent was often a hair (95%). One case of abuse was detected. The analysis of family social situations showed that 53% had no or incomplete medical coverage, 67% were already followed by CPS with extreme poverty or lived in dilapidated housing. Insufficient hygiene or neglect was found in 67% of the families with incomplete or no social coverage. The analysis of 2003-2007 period for later admissions identified that 15 accidents in the home occurred in 12 children. Among these families, 58% were already known by CPS for neglect behavior. CONCLUSION: Although most tourniquet syndromes seem accidental, this entity is often associated with a lack of hygiene. Several and distant locations (e.g., toes and genitals), multiple and/or separated knots, constrictive agents inconsistent with a safe environment for the child, and penile location in an infant require meticulous investigation because of a higher incidence of child neglect.

[Risk of arrhythmia and domestic low-voltage electrical injury]. / Risque de trouble du rythme et électrisation par courant domestique.

AIM: Analysis of domestic low-voltage (220-240 V) electrical injury in children admitted to a pediatric emergency department to illustrate the low risk of initial or delayed risk of arrhythmia. MATERIAL AND METHODS: Retrospective study between 2001 and 2008 analyzing all children aged less than 15 years admitted for a low-voltage electrical injury. The data collected were age, sex, time and circumstances of the accident, time and day of admission, transport modalities, presence of risk factors for arrhythmia (transthoracic current, wet skin, tetany, loss of consciousness or neurological symptoms, and initial EKG abnormalities), injuries, EKG, muscular and/or cardiac enzyme values, progression and complications. For statistical analysis, data were entered in Microsoft Excel tables. Analysis was done with StatView5.1 (SAS Institute) and Epi Info 6.04fr (VF, ENSP epiconcept). In the descriptive analysis, the data are presented as mean values with SD, median and range. RESULTS: Forty-eight children were included. The mean annual number of admissions was equal to 6 (range, 3-12). The mean age was 6.2 + or - 4.3 years (median, 4.6 years). There was a male predominance: the overall sex ratio was 1.5, i.e., 3 before the age of 2 and 2.6 before the age of 10. The electrical injury occurred after contact with a wire or a connected cord or after the introduction of a metallic object in a wall socket. Ten children had risk factors of arrhythmia (mainly wet skin or thoracic pain). Twenty-nine children suffered from burns to the extremities (digits and hands, 70 %). At admission, 45 children had an EKG performed. The initial EKG was considered abnormal in 8 cases showing: sinusal tachycardia (n=4), incomplete right bundle branch block (n=4), and V(1) negative T waves (n=1). The EKG normalized within the first 12h. Hospitalization for cardiac monitoring was required for 18 children. No delayed arrhythmia occurred. In a mean time of 3.5h after the accident, a troponin dosage was given to 15 children and was normal in all cases. One child developed rhabdomyolysis and evolved without needing dialysis. CONCLUSION: After a low-voltage electrical injury, initial arrhythmia is not frequent, with often a nonspecific and transitory EKG expression; delayed arrhythmia is very rare. Children presenting to the emergency department after such an electrical accident, who are asymptomatic, without any risk factors for arrhythmia (wet skin, tetany, vertical pathway of the current, preexistent cardiological conditions, loss of consciousness) and with a normal initial EKG do not require cardiac monitoring.

[Nasal foreign body in infants]. / Corps étranger nasal chez l'enfant.

AIMS: Provide a descriptive analysis of children admitted to a tertiary care pediatric emergency department (PED) for a nasal foreign body (NFB) and describe the current knowledge and management of such accidents. MATERIAL AND METHODS: A retrospective study was conducted from January 2003 to May 2008, including all patients aged less than 15 years admitted for a NFB. The data collected were age, sex, geographic origin, time and day of admission, duration in PED, duration of NFB insertion, nostril location, symptoms and clinical signs, prehospital extraction attempts, facial x-ray, extraction mode, referral to an ENT specialist, progression, and complications. For statistical analysis, the data were entered in Microsoft Excel spreadsheets. The data were analyzed with StatView 5.1 (SAS Institute) and EpiInfo 6.04fr (VF, ENSP Epiconcept). In the descriptive analysis, the data are presented as mean values with standard deviation, median with extreme values or with 95% confidence intervals where appropriate, unless otherwise indicated. To compare qualitative variables, a chi(2) test (Mantel-Haenszel) was used and the two-tailed Fisher exact test if the expected value was 5 or less. Statistical significance was set at p<0.05. RESULTS: A total of 388 patients were included (393 NFB). The annual mean number of cases was 68. The annual distribution showed a higher number in January, March, April, and October following Christmas, Easter and Halloween celebrations, totaling 40% of all NFB admissions. The sex-ratio was 0.95. Children aged less than 4 years accounted for 71% of the studied population. The mean age was 3.5+/-1.6 years (range, 1.4-13 years). The majority of accidents occurred at home (95%). The length of time spent in the PED was 78+/-57 min. The NFB duration of insertion was unknown in one-quarter of cases, present for less than 4 h in 65% of cases. No symptoms were described in most cases (88%). When symptoms were described, bleeding, pain or nasal discomfort, and foul nasal odor were the principal symptoms. The right nostril was the predominant location (60%). This difference tended to disappear in the group of children aged less than 4 years. Five children had bilateral NFB. Nonorganic compounds accounted for 80% of the NFB: plastic beads or balls (39%), plastic or toy parts (20%), stones or pebbles (11%), and paper (6%). The extraction was instrumental in 82% of cases, and 26% of patients were referred to an ENT specialist when PED attempts were unsuccessful. One child needed hospitalization for extraction under general anesthesia of two beads located deep in the same nostril. No complication occurred. Five children had repeated accidents within an average delay of 6 months. CONCLUSION: Often benign, this frequent accident can be serious in case of batteries or neodymium magnet insertion: the extraction becomes an emergency because of risks of nasal mucosa necrosis and/or nasal septum perforation. In other cases, positive pressure techniques (the parent's kiss or its variants) could be tried first in the emergency department or at home at the time of a call to emergency services before a medical visit.

[When doors slam, fingers jam!]. / Quand les portes claquent, les doigts craquent!

AIM: Epidemiological analysis in a universitary paediatric emergency unit of children admitted after accidental injuries resulting from fingers crushed in a door. MATERIAL AND METHODS: Prospective, descriptive cohort study from September 6th, 2004 to July 1st, 2005 included all children admitted for finger injuries crushed in a non-automatic door. EXCLUSIONS: included accidents due to automatic doors, toy's or refrigerator doors, families who refused to participate to the study or families who had left the waiting area before medical examination. Collected data were patient and family characteristics, accident characteristics and its management. RESULTS: Three hundred and forty children affected by 427 digital lesions were included. The mean age was 5.5+/-3.8 years (range 4 months - 15.5 years). Male/female ratio was equal to 1.2: 1. Fifty-eight percent of patients belonged to families composed of 3 or more siblings. Ninety-three per cent of families came to hospital within the first 2 hours after the accident (mean delay 99+/-162 min, median range 54 minutes). Location of the accident was: domestic (62%, at home (64%)), at school (17%). Locations within the home were: the bedroom (33%), bathroom and toilets (21%). An adult was present in 75% of cases and responsible for the trauma in 25% of accidents, another child in 44%. The finger or fingers were trapped on the hinge side in 57% of patients. No specific safeguard devices were used by 94% of families. Among victims, 20% had several crushed digits; left and right hand were injured with an equal frequency. The commonest involved digits were: the middle finger (29%), the ring finger (23%). The nail plate was damaged in 60% of digital lesions, associated with a wound (50%), a distal phalanx fracture (P3) (12%). Six children had a partial or complete amputation of P3, 2 children a lesion of the extensor tendon, 1 child had a rupture of the external lateral ligament. Three percent of children required an admission to the paediatric orthopaedic surgery unit. Post-traumatic pain was mainly limited to the first 48 h (64%). Early complications included: 16 cases of infected injuries, 3 cases of pulpar necrosis. The total cost of hospital care was 71,500 euros, the average cost for hospitalised patient equal to 2100 euros and for ambulatory cases equal to 141 euros; the annual cost was estimated at 81,600 euros. CONCLUSION: Associated with potentially serious digital injuries, functional or inesthetic sequelae, this painful experience still remains too frequent in toddlers for a home accident that could be often prevented by the acquisition of specific protective doors devices and for a reasonable cost compared to the cost of hospital care.

[Babywalker use (baby-trot, youpala): an unsafe practice]. / Utilisation du trotteur (baby-trot, youpala): une conduite à risque.

AIM: Epidemiological analysis of accidents related to babywalker use admitted to a pediatric emergency department. METHODS: Retrospective, descriptive study of injuries related to babywalkers admitted to the pediatric emergency department between January 1st, 2003 and December 31st, 2005. RESULTS: One hundred and seventy-eight children were admitted due to an accident related to babywalker use. The sex ratio was 1.7 with a male prevalence. Mean age was 11+/-4 months. Seventy-eight percent of babywalker-related injuries were attributable to fall down a flight of stairs. The mean number of steps that a child fell down was 7 (range 1-20 steps). The repartition of accidents was bimodal: during the year, 1 peak in May and 1 in October; during the week: 54% of the cases occurred on Thursday or on the weekend; during the day (1 peak between 10 a.m. and 1 p.m. and 1 peak between 4 p.m. and 7 p.m.). Non-severe head traumas represented the most frequent injury (72%). Twenty-one children were hospitalised for concussion (N=15), cranial fractures (N=3), forearm fracture (N=1), dental subluxation (N=1) and extradural hematoma (N=1). A social problem (families with unsafe domestic practices) was identified in 26 children (15%), 16 of these situations were recognized due to the retrospective character of the study and the analysis of hospital admissions after the first accident. CONCLUSION: Stairway related falls associated with babywalker use and fall down in the stairs are very frequent in children less than 1 year-old. This resulted in babywalkers being prohibited in Canada since 2004. In several countries, advocates are working to ban babywalkers. Active or passive prevention methods have shown their limits. This unsafe and dangerous practice should be banned in France.