Suboptimal care was frequent in severe child physical abuse cases and was mainly related to delayed diagnoses and ineffective secondary prevention.

AIM: Our aim was to assess suboptimal care before a diagnosis of severe child physical abuse in western France. METHODS: A confidential inquiry was carried out, based on children under 6 years of age who were hospitalised in the Nantes regional university hospital from 2016 to 2018. Two researchers retrospectively reviewed the medical records of all the children who were reported to the authorities for suspected severe child physical abuse. Two experts determined the optimality of care and identified the main categories of suboptimal care. RESULTS: The median age of the 94 children included in the study was 8 months. A fifth of them had intra-cranial injuries and a quarter had fractures. One child died and a third had severe sequelae at hospital discharge. Included children frequently (37%) received suboptimal care before the diagnosis of severe CPA and this fell into two categories: delayed diagnosis was experienced by 17% and ineffective secondary prevention by 22%. CONCLUSION: Suboptimal care for severe child physical abuse was frequent and fell into two categories: delayed diagnosis and ineffective secondary prevention. These results can help us to design corrective actions.

[How to detect and what to do with child abuse?]. / Repérage et conduite á tenir face à un enfant en danger.

Child abuse is a major public health problem. The consequences including death, but also physical injuries and psychological troubles. To know and recognize the possibility of child abuse is essential for all doctors. This diagnostic hypothesis must be considered alongside all pathologies in varied clinical presentations. The practitioner must keep in mind that an unusual location, incoherent mechanism, a health seeking delay, no painful expression are warning signs and particularly a traumatic injury unexplained in an infant who does not move. To overcome the denial that surrounds these situations, the health professional should emphasize teamwork and not hesitate in doubt to be hospitalized children or at least contact a specialized team.

Progressive polyepiphyseal dysplasia with arthropathy: a distinct disorder from idiopathic juvenile arthritis and pseudorheumatoid dysplasia?

Juvenile idiopathic arthritis is an inflammatory disease with various onset-forms which can sometimes be difficult to distinguish from genetic inflammatory/rheumatoid-like osteoarthropathies. In this report, we describe two boys with severe chronic arthralgia, stiffness and swelling of joints, motor weakness and joints contractures evolving despite immunosuppressive treatments and for whom all biological and molecular exams failed to identify a prompt diagnosis. Some findings also overlap with pseudorheumatoid dysplasia but WISP3 gene molecular analysis failed to identify any mutation for both patients. Therefore, we propose that these boys show a clinical entity distinct from the actually known genetic inflammatory/rheumatoid-like osteoarthropathies.

Mycophenolate mofetil in juvenile dermatomyositis: a case series.

The objective of this study was to report the use of Mycophenolate Mofetil (MMF) in Juvenile Dermatomyositis (JDM). A retrospective chart review of children diagnosed with JDM having received MMF was performed. Response was evaluated 3 months after the onset of MMF by comparing muscle strength and steroid dosage before and after treatment. A good response was defined by global improvement concerning weakness and fatigability as evaluated subjectively by the physician along with a gain of at least 4 points on each of 2 muscle testings (Manual Muscle Testing, MMT and Childhood Myositis Assessment Score, CMAS) and/or a decrease of >15% of the corticosteroid dosage. Eight patients were identified. Except for one, all had received MMF secondary to an initial therapy of conventional immunosuppressants. Six patients showed good response by our predefined criteria. Changes of muscle testing scores ranged between +0 to +21 points (mean = +10.6) for the MMT and between +3 and +11 (mean = +7) for the CMAS. Corticosteroid tapering varied from 0 to 50%, with a mean of 18%. In most cases, follow-up was available for many months (up to 26); overall, we observed only one complication: a transient neutropenia in a patient concurrently receiving another immunosuppressant. This small series is the first published report on the use of MMF in JDM and suggests it is safe. Prospective larger studies are required to further elucidate the use of MMF in JDM.

[Recognizing clinical signs suggesting child abuse in young children]. / Repérage des signes cliniques evocateurs de maltraitance chez le petit enfant.

It is difficult to diagnose child abuse. Any injury to a child should raise the essential question as to its plausibility. Any incompatibility between the nature of the lesion and the child's age, or the explanations given, should suggest intentional injury. The presence of a bruise on an infant too young to move about is a serious warning sign. Any fractures before the infant is able to walk should raise the suspicion of intentional injury. Regardless of the type of abuse noted for an infant, it must be hospitalized. Supplementary examinations, in association with a psychosocial evaluation, will enable exploration for other lesions and the elimination of differential diagnoses. This allows the child to be protected, while including the family in the treatment process.

[Vaccination of adolescents]. / Vaccination des adolescents.

In 1999 the WHO alerted on vaccination coverage of adolescents in the world. In France, the vaccination coverage is low in this age. One third of teenagers has received all the recommended vaccines. The situation is particularly worrying for pertussis, measles mumps and rubella vaccines, and for the vaccine against hepatitis B. French coverage is considerably lower than figures published in the USA and Belgium. Vaccine strategies are specific to adolescence with regard to the location of vaccines, the vaccination decision, the vaccinator. The GP is the principal actor in the vaccine. Teenagers have largely favorable opinion about vaccination. The schedule is simple in adolescence. Recent innovations are: introduction of the vaccine HPV (Human Papillomavirus), generalization of the vaccine against meningococcal group C and simplification of the vaccination against hepatitis B. Six recommendations are proposed to improve vaccination of adolescents.

[The tired child]. / L'enfant fatigué.

THE TIRED CHILD. Child fatigue is difficult to define and evaluate. This is a common reason for parental concern and consultation. The expressions of fatigue are variable according to age. An organic origin must be sought. It is rarely found when the symptom is isolated. Most often the origin of child and adolescent fatigue is environmental, related to living conditions. The analysis should focus on family constraints, sleep conditions, use of screens, school and activities. A psychological origin must be sought especially a depressive syndrome.

L'ENFANT FATIGUÉ. La fatigue de l'enfant est difficile à définir et évaluer. C'est un motif fréquent d'inquiétude parentale et de consultation. Les expressions de la fatigue sont variables selon les âges. Une origine organique doit être recherchée. Elle est rarement retrouvée lorsque le symptôme est isolé. Le plus souvent, l'origine de la fatigue de l'enfant et de l'adolescent est environnementale, liée aux conditions de vie. L'analyse doit porter sur les contraintes familiales, les conditions de sommeil, l'utilisation des écrans, les activités scolaires et extrascolaires. Une origine psychologique doit être recherchée, particulièrement un syndrome dépressif.

Distribution of serum measles-neutralizing antibodies according to age in women of childbearing age in France in 2005-2006: impact of routine immunization.

Measles antibody titers were measured in 210 French women. Ninety-four percent had protective values (>120 mIU/mL). Geometric mean titers were significantly different (P < 0.001) between women born before and after 1983, when measles vaccination was recommended (731 and 1358 mIU/mL, respectively). geometric mean titers in 4 age cohorts decreased significantly (P < 0.001) with increasing birth year. These data may help identify the appropriate age for infant vaccination.

Chronically ill adolescents are also incompletely vaccinated: A cross-sectional study in France.

BACKGROUND: Adolescent vaccination coverage tends to be suboptimal, leading to resurgent infectious pathologies and vulnerability to various pathogens. The low frequency of medical consultations and missed opportunities for vaccination are often used to explain the low rate of vaccination. The aim of this study was to assess if the vaccination coverage rate is higher in chronically ill adolescents (CIA) who require a close pediatric specialized follow-up versus the rate in healthy adolescents (HA). METHODS: A monocentric cross-sectional study was conducted in the Nantes University Hospital. We included 114 CIA and 266 HA. The vaccination coverage rate and the up-to-date immunization status were compared between ill versus healthy adolescents for each of the following vaccines: diphtheria, tetanus, acellular pertussis, inactivated poliovirus (DTaP/IPV), measles-mumps-rubella (MMR), hepatitis B (HepB), meningococcal C conjugate (MnC), human papillomavirus (HPV) and composite combinations (e.g. DTaP/IPV-MMR-HepB-MnC). RESULTS: The overall immunization rate for DTaP/IPV-MMR-HepB-MnC was very low, with no significant difference between CIA and HA (9.6% versus 13.5%; p=0.28). Most of the investigated vaccines exhibited similar immunization patterns for the two groups: DTaP/IPV (77.2vs. 76.7%; p=0.97), MMR (92.1vs. 95.9%; p=0.14), HepB (51.8vs. 48.5%; p=0.51) with the exception of the MnC (18.4vs. 27.8%; p=0.05) and HPV (28.6vs. 16.1%; p=0.04). CONCLUSION: Despite undergoing specialized and close medical follow-up, we found that the vaccination coverage rate for the CIA remained suboptimal. This indicates that pediatricians need to check the vaccination status and, when required, ensure that the vaccination schedules for these fragile patients are up-to-date.

Do abused young children feel less pain?

The objective of this study was to investigate whether acute pain in abused children was under recognized by doctors and nurses compared to children evaluated for accidental injuries. We hypothesize that an abused child's reaction to physical pain could be an additional symptom of this challenging diagnosis. For the observational prospective case control study in an emergency department, children were eligible when: younger than six years old, the reported trauma occurred within the previous seven days, the trauma comprised a bone injury or burn, and the child was able to express his or her pain. The case group comprised children for whom the medical team reported their abuse suspicions and supporting information to a court, and whose cases of abuse were subsequently confirmed. The control group consisted of children with a plausible cause for their injury and no obvious signs of abuse. The children were matched according to their age and type of trauma. The pain was assessed by doctors and nurses before analgesic administration using a certified pain scale. Among the 78 included children, pain was significantly less recognized in the abused children vs. the controls (relative risk=0.63; 95% CI: 0.402-0.986; p=0.04). We observed a discrepancy between the nurses' and doctors' scores for the pain assessments (Kappa coefficient=0.59, 95% CI: 0.40-0.77). Our results demonstrate that pain expression in abused children is under recognized by medical staff. They also suggest that abused children may have reduced pain expression after a traumatic event. Paying particular attention to the pain of abused children may also optimize the analgesic treatment.

[Self-cutting in adolescents: when to worry?]. / Les scarifications chez l'adolescent : quand s'inquiéter ?

Self-cutting in adolescents: when to worry?. Self-cutting, the most part of the nonsuicidal self-harming behaviours, seems becoming quite common among adolescents. Nevertheless, assessment and follow up are always required with at least three aims: to assess globally the adolescent' situation, and his or her to psychological distress - to look for a passed trauma (i.e sexual abuse) behind the self- harm behaviour - to recognize psychiatric disorders beside self-harming and to recognize patients to refer to the mental health services.

Les scarifications chez l'adolescent : quand s'inquiéter ?. Les scarifications semblent aujourd'hui devenues banales chez l'adolescent. Elles doivent cependant toujours susciter une inquiétude médicale et conduire à une évaluation globale et à une proposition de suivi, en raison du mal-être dont elles témoignent et des éventuels antécédents traumatiques (par exemple des abus sexuels) qu'elles peuvent révéler. Cette évaluation permet également d'identifier les situations plus rares dans lesquelles les scarifications ne sont qu'un élément de troubles psychiatriques plus graves nécessitant d'emblée une expertise et une prise en charge en santé mentale.

Frequency and characteristics of infectious diseases in internationally adopted children: a retrospective study in Nantes from 2010 to 2012.

BACKGROUND AND AIMS: Internationally adopted children are more susceptible to developing and carrying acute or chronic infectious diseases. Specialized consultations exist in the main French cities; however, specialized consultation with a pediatrician is not mandatory. The main objective of this study was to determine the frequency and characteristics of infections (bacterial, viral, and parasitic) among a group of international adoptees in Nantes over a 3-year period. METHODS: A retrospective chart review was conducted of internationally adopted children who went through the Medical Guidance for Adopted Children Consultation between 2010 and 2012. RESULTS: A total of 133 children were included in the study. Of these, 55% had an infectious disease; 8% were severe infections. We found a frequency of 38% [confidence interval (CI) 95% 30-46] for parasitic intestinal and 35% (CI 95% 27-43) for dermatologic infections. African children were more likely to have infections that required hospitalization [odds ratio (OR) = 12, p = 0.004, CI 95% 1.3-113.7] and more likely to carry extended-spectrum ß-lactamase-producing bacteria. CONCLUSION: The frequency of infectious diseases, and sometimes severe diseases, found among our cohort of internationally adopted children highlights the need for systematic, specialized medical care.

Prevalence of anti-varicella-zoster virus antibodies in French infants under 15 months of age.

Varicella is a widespread disease of childhood resulting from primary infection with varicella-zoster virus (VZV). The objective of this study was to determine the kinetics of the decline of maternal anti-VZV antibodies in French infants between birth and the age of 15 months in order to estimate the duration of passively acquired maternal anti-VZV immunoglobulin G (IgG). This prospective multicenter study was conducted between October 2005 and January 2007 in the pediatric wards and/or pediatric emergency units of seven French hospitals scattered throughout the country. The level of anti-VZV IgG antibodies in serum was measured by a time-resolved fluorescence immunoassay (TRFIA) (the threshold considered positive is 150 mIU/ml). A total of 345 infants were included. Seventy-seven percent of mothers reported a history of varicella. A rapid decline in the prevalence of anti-VZV antibodies was observed during the first few months of life, with the mean antibody titer decreasing from 536 mIU/ml at birth and through 1 month to below the 150-mIU/ml threshold at 3 to 4 months. The half-life of passively acquired maternal immunoglobulins was around 6 weeks. Based on a large number of subjects, this study clearly demonstrated, for the first time in France, high levels of passively acquired maternal antibodies during the neonatal period, and it allowed us to estimate the duration of passively acquired maternal anti-VZV IgG in French infants. After 4 to 5 months, infants had very low levels of maternal anti-VZV IgG, below the 150-mIU/ml cutoff of the VZV IgG TRFIA.

Kinetics of decline of maternal measles virus-neutralizing antibodies in sera of infants in France in 2006.

The optimal age for measles vaccination is an important health issue, since maternal antibodies may neutralize the vaccine antigen before a specific immune response develops, while delaying vaccination may increase the risk of complicated diseases in infants. However, measles vaccination impacts the duration of protection afforded by transplacental transfer of maternal antibodies: vaccination-induced maternal antibodies disappear faster than disease-induced antibodies. In order to maintain protection against measles in infants, it is important to monitor the dynamics of this phenomenon in vaccinated populations. To assess the current situation in France, a multicenter, prospective seroepidemiological study was conducted in seven French hospitals between October 2005 and January 2007. Maternal measles antibody concentrations from 348 infants 0 to 15 months old were measured using the plaque reduction neutralization assay. Geometric mean concentrations and the percentage of infants with maternal measles antibody concentrations above the protection threshold (>or=120 mIU/ml) were assessed according to age. Results show that after more than 20 years of routine measles vaccination in France, maternal measles-neutralizing antibodies decrease dramatically in French infants by 6 months of age, from 1,740 mIU/ml for infants 0 to 1 month old to 223 mIU/ml for infants 5 to 6 months old, and that 90% of infants are not protected against measles after 6 months of age. Infant protection against measles could be optimized both by increasing herd immunity through an increased vaccine coverage and by lowering the age of routine vaccination from 12 to 9 months.

Contribution of procalcitonin to occult bacteraemia detection in children.

We conducted a prospective study in 215 children, 3 to 36 months of age, presenting with fever > or = 39 degrees C without obvious origin, in order to evaluate the diagnostic value of procalcitonin (PCT) in detection of occult bacteraemia. PCT associated with white blood cell count constitutes an efficient screening method with sensitivity 100%, specificity 61.9% and positive and negative likelihoods ratios of 2.62 and 0, respectively.