Antimicrobial treatment of ENT infections.

Ear, nose and throat (ENT) or upper respiratory tract infections (URTI) are the most common infections in children and the leading causes of antibiotic prescriptions. In most cases, these infections are due to (or are triggered by) viruses and even when bacterial species are implicated, recovery is usually spontaneous. The first imperative is to refrain from prescribing antibiotics in a large number of URTIs: common cold, most cases of sore throat, laryngitis, congestive otitis, and otitis media with effusion. On the contrary, a decision to treat sore throats with antibiotics is based primarily on the positivity of the Group A Streptococcus (GAS) rapid antigen diagnostic tests. For ear infections, only (a) purulent acute otitis media in children under 2 years of age and (b) complicated or symptomatic forms of purulent acute otitis media (PAOM) in older children should be treated with antibiotics. Amoxicillin is the first-line treatment in the most cases of ambulatory ENT justifying antibiotics. Severe ENT infections (mastoiditis, epiglottitis, retro- and parapharyngeal abscesses, ethmoiditis) are therapeutic emergencies necessitating hospitalization and initial intravenous antibiotic therapy.

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.

Timeliness of routine immunization in non-preterm children less than 2 years old using electronic data capture in an ambulatory setting in France in the context of vaccine hesitancy.

OBJECTIVES: The vaccine schedule was changed in 2013 in France, which resulted in fewer vaccinations. However, to maintain disease protection, both vaccine timeliness and high coverage should be respected. In the context of growing vaccine hesitancy, we aimed to describe compliance with the immunization program according to the age recommended for each dose for non-preterm children less than 2 years old. METHODS: Between May 2013 and April 2016, we used automated electronic data capture of electronic medical records for non-preterm children less than 2 years old. Children were followed up by 92 randomly selected pediatricians from the French ambulatory pediatricians group. Delayed immunization was defined as more than 15 days after the recommended age for the primary series of diphtheria-tetanus-pertussis-polio-Haemophilus influenzae b-hepatitis B (DTaP-IPV-Hib±HB) and 13-valent pneumococcal vaccine (PCV13), 2 months for boosters, 1 month for measles-mumps-rubella (MMR)/meningococcal C conjugate (Men-C), and 6 months for the second dose of MMR. An association between delayed first dose and other doses delayed were described with odds ratios (ORs) and their 95% confidence intervals (CIs). RESULTS: Data for 22,097 children in France with 124,702 vaccinations were analyzed: 21.8%, 20.4%, and 30.7% of children had one or more delayed doses of DTaP-IPV-Hib±HB, PCV13, and MMR vaccines, respectively. For 47.6% of children, the single-dose Men-C vaccination was delayed. A delayed first dose of DTaP-IPV-Hib±HB, PCV13, and MMR was associated with a delayed second dose of the same vaccine (OR 7.5 [95% CI 6.6-8.6], 39.0 [34.1-44.8], and 23.5 [19.1-29.0], respectively) and with a third dose of DTaP-IPV-Hib±HB and PCV13 (14.7 [13.3-17.7] and 3.7 [3.1-4.5]). CONCLUSION: This large study shows that the proportion of children with delayed vaccination in France was globally high and substantial for Men-C and the first MMR vaccination. Risk of a delayed second and third dose was increased with a delayed first dose, which may reflect vaccine hesitancy.

Antimicrobial treatment of ENT infections.

ENT infections are the most common childhood infections and the leading causes of antibiotic prescriptions. These infections are mainly due to viruses and most of them (even if bacterial species are implicated) resolve spontaneously. Therefore, the first message is to not prescribe antibiotics in the following situations: common cold, non-streptococcal pharyngitis, laryngitis, non-purulent otitis media, etc. For sore throat/pharyngitis, the antibiotic treatment decision is based mainly on the use of group A streptococcus rapid diagnostic tests. For otitis media, only purulent forms occurring in children less than 2 years of age and most severe situations in older children should be treated with antibiotics. Amoxicillin is the first-line treatment for the vast majority of ENT infections requiring antibiotic treatment. Severe ENT infections (mastoiditis, epiglottitis, retro- and parapharyngeal abscesses, and ethmoiditis) are therapeutic emergencies requiring in most cases hospitalization and intravenous antibiotics.

Public health impact of Infanrix hexa™ (DTPa-HBV-IPV/Hib) reimbursement: A study programme in France. Part 2: Evolution of the acceptability of infants' vaccination against hepatitis B in general and pediatric practices - the PRALINE study.

BACKGROUND: The reimbursement of the hexavalent vaccine (Infanrix hexa™), comprising the DTPa-IPV-Hib components and the hepatitis B recombinant in a single vaccine, was approved in France in March of 2008. The impact of its reimbursement on physicians' decisions to vaccinate infants against hepatitis B was assessed in a study conducted with general practitioners and pediatricians. METHODS: The PRALINE study (NCT01777074) was a national, cross-sectional, repeated study with two measurement periods (T1 and T2) that measured the changes in physicians' acceptance of hepatitis B vaccination of infants before and for the 3 years after the approval of the hexavalent vaccine reimbursement. Two patient registers were created for each measurement period to enroll the first 15 12- to 15-month-old infants and the first 15 24- to 27-month-old children seen by the practitioners. The proportion of eligible children receiving a hepatitis B vaccine for each physician's practice was calculated. Practitioners also answered a vaccination practice questionnaire via telephone interviews. RESULTS: Across the two study periods, 418 general practitioners and 463 pediatricians were recruited and responded to the telephone interview on their vaccination practices. The overall number of children included in the study in both study periods reached almost 20,000. In the general practitioners group, there was a significant increase in the proportion of physicians "practicing hepatitis B vaccination" (i.e., at least 50% of eligible children receiving the initial hepatitis B vaccination) in children 24-27 months old (79% T2 versus 47% T1, P-value [P]<0.001). Similarly, the proportion of pediatricians initiating hepatitis B vaccination increased from 51% (T1) to 94% (T2) (P<0.0001). General practitioners offered hepatitis B vaccination to infants more systematically in the second study period (87% T2 versus 73% T1, P<0.001) and also suggested the use of the hexavalent vaccine to more patients after reimbursement (92% T2 versus 78% T1, P<0.0001). The proportion of pediatricians offering vaccination to every infant was high at T1 (94%) and remained steady (97%) with a high use of the hexavalent vaccine (94% T1 and 96% T2). CONCLUSION: The PRALINE study shows a significant and immediate change in the hepatitis B vaccination practices of general practitioners and pediatricians following hexavalent vaccine reimbursement with a significant increase in hepatitis B vaccine coverage in infants.

Public health impact of Infanrix hexa (DTPa-HBV-IPV/Hib) reimbursement: A study programme in France. Part 1: Evolution of hepatitis B vaccine coverage rates in infants aged less than 27 months, in the general population - the PopCorn study.

BACKGROUND: Reimbursement of the hexavalent vaccine (Infanrix hexa) comprising the DTPa-IPV-Hib components and the hepatitis B valence in a single vaccine was decided in March 2008 in France. The impact of its reimbursement on the hepatitis B vaccine coverage rate was assessed in a study conducted in the general population prior to and after implementation of the reimbursement policy. METHODS: The PopCorn study (NCT01782794) was a national, cross-sectional and repeated study, with four assessment periods over 3 years, from 2009 to 2012, to assess the hepatitis B vaccine coverage in 12- to 15- and 24- to 27-month-old children, vaccinated between 2007 and 2011 and selected by the quota sampling method. Face-to-face interviews were conducted at their homes and vaccination status was collected using their child's health record. Parents were also interviewed on their perceptions and acceptance of hepatitis B vaccination. Three indicators were calculated to assess hepatitis B vaccination coverage: proportions of infants with at least one dose before 6 months of age, with at least two doses before 6 months of age and with a complete schedule at 24 months of age. RESULTS: A total of 4903 children were enrolled in the study. An overall significant increase (P-value [P<0.05]) of the three indicators of interest over the four periods of time was observed for both age groups. The proportion of children receiving hepatitis B vaccination before 6 months increased from 21% at baseline (before vaccine reimbursement) to almost 75% at the last assessment period in 2012. More than 60% of 24- to 27-month-old children received a complete schedule in 2012 compared to 33% at baseline. No significant increases in the proportions of parents "favourable" and "moderately in favour" of hepatitis B vaccination were observed across the four evaluation periods (respectively, 17-22% and 48-50%, P=0.09). CONCLUSION: The rapid increase of hepatitis B vaccination coverage suggests a significant change in hepatitis B vaccination practice related to the hexavalent vaccine's reimbursement. This change was observed in a context of stability regarding parents' perceptions and acceptance of hepatitis B vaccination and of coverage rates for other infant vaccinations.

[Impact of guidelines on ambulatory pediatric antibiotic prescriptions]. / Impact des recommandations sur la prescription en consultation de ville d'antibiotiques à l'enfant.

INTRODUCTION: The emergence of antibiotics resistance as a major public health threat has led, in France as in other countries, to the establishment of "antibiotics plans" based in part on practice guidelines. The objectives of this study were to determine the structure (number, causes, distribution of compounds) of antibiotic prescriptions by infectious diseases pediatricians (belonging to a pediatric infectious diseases research group), to check their compliance with guidelines and compare their prescriptions to other French pediatricians and general practitioners (GPs). PATIENTS AND METHODS: In a survey on acute otitis media (AOM), outpatient pediatricians reported prospectively from October 2013 to February 2014 all antibiotics prescribed and the reasons for these prescriptions. These results were compared with prescription data from a panel of other pediatricians and GPs in France (IMS Health panels). RESULTS: Between October 2013 and February 2014, 27 pediatricians from the Infectious Disease Pediatricians Group conducted 54,212 visits, 10.7 % of which resulted in antibiotic prescriptions, all diseases combined, compared to 12 % for other pediatricians and 21 % for GPs in the same period. AOM was the leading cause of prescriptions for infectious disease pediatricians and panel pediatricians, and GPs (respectively, 72.6 %, 33 %, and 25 %). Amoxicillin was the most frequently prescribed antibiotic (respectively, 71.7 %, 49.9 %, and 28.2 %). Cephalosporins were prescribed in 6.4 % of cases by infectious disease pediatricians versus 19 % for panel pediatricians and 19.9 % for GPs. CONCLUSION: The prescriptions of infectious disease pediatricians are in accordance with the French guidelines. The differences with the IMS data justify the need for continuous medical training and recommendations to promote these guidelines.

Congenital dislocation of the hip: optimal screening strategies in 2014.

A prospective multi-centre nationwide study of patients with congenital dislocation of the hip (CDH) diagnosed after 3 months of age was conducted with support from the French Society for Paediatric Orthopaedics (Société Française d'Orthopédie Pédiatrique [SoFOP]), French Organisation for Outpatient Paediatrics (Association Française de Pédiatrie Ambulatoire [AFPA]), and French-Speaking Society for Paediatric and Pre-Natal Imaging (Société Francophone d'Imagerie Pédiatrique et Prénatale [SFIPP]). The results showed inadequacies in clinical screening for CDH that were patent when assessed quantitatively and probably also present qualitatively. These findings indicate a need for a communication and educational campaign aimed at highlighting good clinical practice guidelines in the field of CDH screening. The usefulness of routine ultrasound screening has not been established. The findings from this study have been used by the authors and French National Health Authority (Haute Autorité de Santé [HAS]) to develop recommendations about CDH screening. There is an urgent need for a prospective randomised multi-centre nationwide study, which should involve primary-care physicians.

[Is the new vaccination schedule recommended in France adapted to premature babies?]. / Le nouveau calendrier vaccinal est-il adapté à l'ancien prématuré ?

The French 2013 immunization schedule having a goal of simplification with comparable efficacy, has decreased the number of injections and removed the injection performed at three months of age in the general population. Apart from the prevention of invasive pneumococcal infections for which it is recommended to maintain three dose primary immunization, vaccination of premature is not addressed in this new calendar. Can the extremely preterm infants (<33 weeks of gestational age) benefit from this new schedule or should we keep them in three injections schedule? The objective of this paper is to clarify this point through the data available in the literature. Children born prematurely and especially the "extremely premature" born before 33 weeks are at high risk of infections, some of them are preventable by immunization. Although there is no clinical evidence, for pertussis, pneumococcus, Haemophilus influenzae b, hepatitis B, whatever the immunogenicity criteria, immunogenicity is significantly lower in preterm than in term newborn after 3 doses primary schedule. This lower immunogenicity raises concerns about the transition to two doses, about the ability to give short term protection and booster responses. Given these data, GPIP takes the position for maintaining a primary 3-dose vaccination at 2.3 and 4 months for premature infants less than 33 weeks.

[Plea for advancement of the age of vaccination against human papillomavirus in France: Position of the Pediatric Infections Pathology Group (GPIP) and the French Association of Ambulatory Pediatrics (AFPA)]. / Plaidoyer pour un avancement de l'âge de la vaccination contre les papillomavirus en France: Position du Groupe de Pathologie Infectieuse Pédiatrique (GPIP) et de l'Association Française de Pédiatrie Ambulatoire (AFPA).

Vaccination against human papillomavirus (HPV) is recommended in France at 14 years. The Groupe de Pathologie Infectieuse Pédiatrique de la Société Française de Pédiatrie takes a clear position for advancement of age of vaccination at 11-12 years based on the following arguments: (i) data on the long-term persistence of protective antibodies are reassuring; (ii) these vaccines can be co-administered with vaccines recommended in the current immunization schedule at this age; (iii) actually, nearly 20% of adolescents have had sexual intercourse when the vaccination schedule is finished; (iv) vaccination beyond 14 years increases the risk of occurrence of coincidental autoimmune diseases; (v) the immunogenicity of vaccines against HPV is better when they are administered before age 15; (vi) finally, especially by reducing the number of injections from 3 to 2, the immunization at 11-12 years could improve immunization coverage which is insufficient nowadays.

[Rotavirus vaccination in 2012. Position of the Pediatric Infections Pathology Group (GPIP) and the French Association of Ambulatory Pediatrics (AFPA)]. / La vaccination rotavirus en 2012. Position du Groupe de Pathologie Infectieuse Pédiatrique (GPIP) et de l'Association Française de Pédiatrie Ambulatoire (AFPA).

In 2008 and 2010, the Comité technique des vaccinations and the Haut Conseil de Santé Publique have not recommended generalized vaccination against rotavirus (RV) in France. The Groupe de Pathologie Infectieuse Pédiatrique (GPIP) and the Association Française de Pédiatrie Ambulatoire (AFPA) believes that it is time to reconsider the recommendation. Indeed, on the one hand, answers were made on the presence of circovirus in vaccines and the risk of intussusception, on the other hand, these vaccines are already implemented in vaccination programs in many developing countries or countries with income intermediate and high. Finally, independent studies have demonstrated the effectiveness in countries with widespread vaccinations (without significant genotypic changes of circulating strains). In addition, implementation would have a major impact on our health care system, changes of the epidemic curve of RV infections (delayed and shortened) to prevent the coexistence of different epidemics occurring during the fall and winter. Remains medico-economic evaluation, which is not of the competence and the responsibility of GPIP and AFPA. However, it seems surprising that developing or middle-income countries have been able to generalize this vaccination and that France can't do it.