[Atopic dermatitis aggravates the allergic airways inflammation in acute viral bronchiolitis]. / La dermatite atopique aggrave l'inflammation allergique dans la bronchiolite aiguë virale.

INTRODUCTION: Exhaled nitric oxide (FeNO) is a putative non-invasive marker of eosinophilic airway inflammation with a good predictive value for allergic asthma in preschool children. The aim of the present study was to compare FeNO after acute viral bronchiolitis (AVB) in children aged less than 2 years without atopic dermatitis (AD) vs those with atopic dermatitis, as well as children with AD without any history of AVB. METHODS: Forty-two children (mean age +/- SD: 12.3 +/- 5.2 months; range 5.0-23.5; sex-ratio M: F=1.3: 1) were included in this prospective study, > 8 wks after an episode of AVB. The patients' atopic status was assessed both by clinical phenotype and IgE- mediated response to inhaled and/or food allergens. FeNO (ppb) was measured off-line by the chemoluminescence method on samples obtained from gas collected in a balloon during tidal breathing. RESULTS: There was a significant difference between the AVB/AD (23.4 +/- 14.3 ppb, n=15) vs the AVB without AD group (13.5 +/- 10. 1 ppb, n=13) or the AD without AVB group (11.0 +/- 8.3 ppb, n=14). Maternal feeding for more than 2 months decreased FeNO by 50%. CONCLUSION: Atopic children below 2 years with AD produce more NO after AVB than non-atopic children or atopic children without any history of AVB. Maternal feeding decreases FeNO.

[Central catheters and pericardial effusion: results of a multicentric retrospective study]. / Cathéters centraux et épanchements péricardiques en période néonatale: étude rétrospective multicentrique.

OBJECTIVE: To evaluate the use of neonatal central venous catheters (CVC) in 38 french neonatal units and occurrence of pericardial effusion (PCE) over the past 5 years. MATERIALS AND METHODS: We surveyed 38 units with a questionnaire and studied the cases of PCE in five units. RESULTS: Response rate was 89% (34/38). Accepted CVC tip positions were: junction of right atrium (RA) and vena cava (VC) 76%, VC 58%, RA 11%. Fifty percent of the centers had been exposed to PCE. 16 cases of PCE were studied. Median gestational age was 31 weeks (range: 26.1 to 40 weeks). Median time from insertion: 3.2 days (range: 0.4-13.5). In all cases CVC tip was intracardiac at insertion with inadequate withdrawing in 13 cases. Sudden cardiac collapse was reported in eight cases, and unexplained cardiorespiratory instability in six cases. Echography showed PCE in 14 cases. One diagnosis was post-mortem. CVC was withdrawn in 12 patients and 13 underwent pericardiocentesis. Four patients died and two had neurological sequelae. CONCLUSION: PCE was associated with intracardiac CVC tip. The CVC tip should be controlled with radiography or echography outside the cardiac silhouette. PCE diagnosis must be considered in face of unexplained cardiovascular decompensation of neonate with CVC.

Pulmonary mechanics in ventilated preterm infants with respiratory distress syndrome after exogenous surfactant administration: a comparison between two surfactant preparations.

The effects of two surfactant preparations on lung mechanics have been studied on 24 ventilated premature infants with respiratory distress syndrome (RDS): 13 were given artificial surfactant (Exosurf Neonatal, Burroughs-Wellcome) and 11 natural porcine surfactant (Curosurf, Laboratoire Serono France). Measurements of respiratory system compliance (Cdyn, Crs) and resistance (Rrs) were performed immediately before surfactant administration and repeated 6, 18, 24, 48, and 72 hours later. With Exosurf treatment, 6 hours after surfactant administration inhaled O2 concentration (FlO2) could be lowered from (0.72 +/- 0.20, to 0.62 +/- 0.33; P < 0.05), whereas Crs did not change (0.37 mL/cmH2O/kg, +/- 0.14 vs. 0.39 +/- 0.12, NS). After 24 hours and during the following days a significant increase in Crs occurred (24 hours post-Exosurf: 0.51 +/- 0.18, P < 0.05). With Curosurf treatment, the improvement in oxygenation was greater and FlO2 could be lowered much more after 6 hours (from FlO2, 0.78 +/- 0.23 to 0.34 +/- 0.11, P < 0.01). This was associated with an increase in Crs (from 0.39 +/- 0.09 to 0.59 +/- 0.17, P < 0.05). During the following days, Crs was significantly higher in the group treated with Curosurf. Resistance was not altered by the type of surfactant preparation used except after 72 hours, when Rrs increased in the group treated with Exosurf. In conclusion, Curosurf appears to be more effective than Exosurf with regard to immediate pulmonary changes in ventilator treated premature infants with RDS. A rapid increase in Crs after Curosurf treatment indicates that recruitment of new functional areas of the lung is likely to be associated with a stabilization of small airways and alveolar units.

Congenital idiopathic chylothorax in neonates: chemical pleurodesis with povidone-iodine (Betadine).

Chylothorax is defined as an accumulation of chyle in the pleural space. This condition usually occurs after an operation, the congenital idiopathic form being rare (1/15000 births). Recovery is observed within four to six weeks of diagnosis in most cases. Treatment is either conservative or surgical. Four cases are reported of congenital chylothorax (three idiopathic, one accompanied by diffuse lymphangectasia) managed by chemical pleurodesis (intrapleural injection of povidone-iodine). Tolerance was satisfactory: unaltered thyroid function in the three cases explored; one case of transient generalised oedema. Treatment was deemed successful in three of the four cases. One child died from renal failure (unrelated to the chemical pleurodesis). Pleurodesis by povidone-iodine appears to be well tolerated and may represent a good alternative to mechanical abrasion or surgery for congenital idiopathic chylothorax. Its use for refractory chylothorax may also decrease the morbidity related to prolonged hospital stay.

Neonatal Noonan syndrome with a molluscoid cutaneous excess over the scalp.

The Noonan syndrome is a multiple congenital anomalies syndrome with variable expressivity and autosomal dominant inheritance. We report an observation of a newborn with Noonan syndrome and an unusual molluscoid cutaneous excess over the scalp that might represent a new skin manifestation in Noonan Syndrome rather than a consequence of lymphatic dysplasia.

Abdominal lymphatic dysplasia and 22q11 microdeletion.

We report the case of a child with 22q11 microdeletion who presented with abdominal lymphatic dysplasia resulting in exsudative enteropathy. This primitive and localized lymphatic malformation is consistent with the vascular theory in the velocardiofacial syndrome.

Epidemiology of poisoning in children: a 7-year survey in a paediatric emergency care unit.

Acute poisoning in children is still a major public health problem, and represents a frequent cause of admission in emergency departments. We carried out an epidemiological study of poisonings leading to admission to a paediatric emergency care unit (PECU). We analysed data from 2988 children who were admitted to the PECU of Bordeaux, France with acute poisoning from 1989 through 1995. During the 7-year period, the poison exposure numbers decreased slightly from 490 to 382 (6% vs. 3% of total medical emergencies). This represented a mean annual incidence of 1.4 poison exposures per 1000 children younger than 18 years of age and living in Bordeaux and its surroundings. Characteristics of the study population, circumstances of poisoning and substances involved were similar to those previously described. Eighty per cent of children were younger than 5 years of age, presented with a benign course. Forty per cent were not treated and 75% were discharged home either immediately or within 24 hours of admission. Only 1.5% of cases, mainly adolescent girls who attempted suicide, were admitted to a paediatric intensive care unit. Overall mortality rate was 0.33/1000. In children, most cases of acute poisoning are accidental, benign, and mainly attributed to the ingestion of a non-toxic substance. This points to the need for better information of the population on availability of poison control centre calling facilities, in order to decrease the number of admissions to the PECU. Patients suspected of having ingested a potentially dangerous substance can be managed in short-stay observation units, thus avoiding unnecessarily prolonged hospitalization. Acute poisoning in children remains a frequent problem, highlighting the need to develop an education programme on primary prevention in our region.

[Severe community-acquired pneumonia in immunocompetent children]. / Pneumopathies communautaires graves chez l'enfant non immunodéprimé.

Severe community-acquired pneumonia (CAP) is still a serious disease with a high mortality rate, especially in developing countries. Children under 5 years are more prone to severe CAP. In this article, the authors review the definition and clinical criteria used in the initial evaluation and decision to hospitalize patients. The diagnosis approach requires only a limited number of laboratory tests before initiating the supportive measures and wide spectrum antimicrobial therapy. If the patient fails to respond favorably 48-72 hours after initiating therapy, more invasive investigations are indicated. After resolution, an immunological evaluation is warranted.

[Adverse effects of ketoprofen after intrauterine exposure. Value of plasma determination]. / Les effets secondaires du kétoprofène après exposition intra-utérine. Intérêt du dosage plasmatique.

BACKGROUND: Prostaglandin synthetase inhibitors have been used to prevent the onset of premature labor. But a small number of newborn infants have been reported with premature closure of the ductus arteriosus, pulmonary hypertension and/or oliguria. POPULATION AND METHODS: Eleven neonates from seven pregnancies were admitted because they suffered from adverse effects of ketoprofen given to their mothers before delivery. The plasma ketoprofen level was measured in 6 of the neonates. RESULTS: Ten of the 11 neonates had renal dysfunction which was lethal in three; two of the 11 developed cardiopulmonary complications, lethal in one. The ketoprofen concentration in plasma was high in the first few hours of life in three patients. CONCLUSION: In the absence of precise risk factors for prognosis, repeated drug measurements in the maternal plasma before delivery and in their babies after birth could be a predictive factor.

[Intrapleural fibrinolytic treatment and infectious pleuresies: three pediatric cases]. / Traitement fibrinolytique intrapleural et pleurésies infectieuses: à propos de trois observations pédiatriques.

UNLABELLED: Intrapleural instillation of fibrinolytic agents has been proposed for the treatment of loculated pleural effusions, or whenever the biochemical characteristics of the pleural fluid (pH, glucose level, LDH) indicate the risk of a complicated outcome due to a pleural effusion with complications and the possible development of empyema. At present, there is no consensus regarding the use of intrapleural fibrinolytic agents in children. CASE REPORTS: In this study, the successful treatment by fibrinolytic agents and standard drainage are successfully performed in three children with a pleural effusion due to an infection. CONCLUSION: The clinical utility, in terms of the reduction of the duration of hospitalization and additional surgical treatment, should be assessed in prospective studies.

[Acute severe asthma in children. Epidemiological, physiopathological and clinical aspects]. / Asthme aigu grave de l'enfant. Aspects épidémiologiques, physiopathologiques et cliniques.

Therapy for asthma is being prescribed more frequently. However, asthma mortality remains high in many countries. Fatal outcome is not always related to inadequate follow-up. In this article we report that children with mild to moderate symptoms may present a fatal attack. Many factors are responsible for such an outcome: asphyxia +3 due to ventilation/perfusion mismatch and/or bronchospasm, cardiac failure, cardiac arrhythmia, intrinsic positive expiratory pressure, or metabolic disturbances (hypokalemia, for example). Such problems can occur in predisposed patients: it has been shown that the chemosensitivity to hypoxia and the perception of dyspnoea are altered in certain patients with near-fatal asthma. It is very important to identify children at risk of severe asthma and to organize care so as to optimize the management of such children.

[Neonatal nonbacterial thrombotic endocarditis]. / Les endocardites thrombotiques néonatales non bactériennes.

UNLABELLED: Nonbacterial thrombotic endocarditis is not widely known in neonates. CASE REPORTS: We report three new cases which illustrate some specific aspects of this pathology. Respiratory distress with severe pulmonary hypertension, systemic hypotension and disseminated intravascular coagulopathy in a full-term newborn were characteristic findings. CONCLUSION: An early echocardiography should lead to accurate diagnosis. Hypoxemia and genetic factors could be determining factors in its pathogenesis.

[Increasing frequency and diagnostic difficulties in intestinal stenosis after necrotizing enterocolitis]. / Fréquence accrue et difficultés diagnostiques des sténoses intestinales après entérocolite ulcéronécrosante.

BACKGROUND: Stenosis after necrotizing enterocolitis (NEC) has increased from 15 to 57% over the last 10 years in our unit. The aim of this study is to point out the difficulty of diagnosis and treatment, and search for factors explaining this increase. PATIENTS AND METHODS: From 1986 to 1991, 42 newborns had NEC, followed by intestinal strictures in 19 of them (57% of the 33 survivors). Data from these 19 patients were compared with those of the 14 without intestinal strictures. The 33 survivors were also compared with those of an earlier study including 25 NEC seen from 1979 to 1986. RESULTS: After medical treatment (n = 12), intestinal stenosis led to occlusion after three weeks, was located to both small and large intestine and was short and tight. After surgical treatment (n = 7), stenosis was shown by opacification before digestive anastomosis (n = 5) or revealed by occlusion (n = 2); it stayed on the colon, was long or multiple, requiring extensive resections. No difference could be found between data from patients with or without stenosis. Although newborns were actually more premature, the risk of stenosis was more frequent when newborns of same gestational ages and/or weights were compared. CONCLUSIONS: Intestinal stenosis is a frequent complication after NEC; its diagnosis is often difficult and requires extensive digestive resections. No clinical or therapeutic factor could be found to explain the actual increase in frequency.

[Severity of ingestion of caustic substance in children]. / Gravité des ingestions de produits caustiques chez l'enfant.

BACKGROUND: Caustic ingestion is frequent in children, sometimes leading to esophageal stricture. PATIENTS AND METHODS: Between 1988 and 1994, esogastroscopy was performed in 65 children after caustic ingestion. The children were classified in three groups: no lesion (group A), minimal lesions (group B) and severe lesions (group C). Nature of the caustic substance, clinical signs and evolution were compared in the three groups. RESULTS: Median age was 2 years for the 65 children (24 girls, 41 boys). Ingestion occurred at home (94%) during meal periods. Substances were dishwater detergents (n = 14), oven cleaner (n = 10), bleach (n = 9), washing powder (n = 4), others (n = 20), more often in a liquid form (n = 37) than solid (n = 28). Children had no symptoms (57%), presented emesis (n = 20) or abdominal pain (n = 10) not correlated to endoscopic findings, and hematemesis (n = 3) or respiratory distress (n = 4), both symptoms seen only in group C. Buccal lesions (41%) were not correlated to endoscopic findings. After endoscopy, 28 children (43%) were classified into group A and 20 children (31%) in group B. Among the 17 children (26%) of the group C, eight developed an esophageal stricture: seven long strictures requiring replacement of the esophagus, one short stricture requiring repeated dilations. CONCLUSION: Esophageal stricture is still a severe complication after caustic ingestion. These data stress the interest of controlled studies to confirm the preventive role of high dose corticosteroids, and the importance of the prevention of accidental caustic ingestions in children.

[Superior sagittal sinus thrombosis in children during the first year of life: clinical aspects, imaging and development]. / Thromboses du sinus longitudinal supérieur chez l'enfant au cours de la première année de vie: aspects cliniques, imagerie et évolution.

BACKGROUND: Thrombosis of the intracranial sinuses and veins may be septic or aseptic, and in the latter case are often due to alteration in hemodynamics. It may also be seen in young babies without known predisposing factors. PATIENTS: From 1988 to 1994, 11 children had cerebral venous thrombosis (longitudinal sinus) in the first year of their life. Their ages ranged from two days to 11 months. Transient seizures, lethargy, pseudo tumor cerebri were the first clinical symptoms. The presence of longitudinal sinus thrombosis was suggested by unenhanced CT scan, confirmed by colour doppler flow imaging and magnetic resonance angiography, with absence of blood flow in the longitudinal sinus. Repeated doppler flow imaging showed thrombus resolution within 3 weeks. Thrombosis was associated with predisposing factors in seven cases and appeared idiopathic in the four others. CONCLUSION: Diagnosis of longitudinal sinus thrombosis can be made more accurately and noninvasively by colour doppler flow and angio-MRI. Treatment with anticoagulants appears unnecessary and dangerous in idiopathic forms.

[Sacrococcygeal teratomas in antenatal diagnosis]. / Tératomes sacro-coccygiens de diagnostic anténatal.

The authors report eight cases of antenatal diagnosis of sacro-coccygeal teratoma (SCT) in five girls and three boys in whom the diagnosis was made between the 19th and 34th week of amenorrhea (mean = 27 weeks). The ultrasound pictures taken antenatally of the SCT assist in the discovery of a mass that is usually heterogenous, attached to the distal end of the sacrum, and the discovery is usually made fortuitously or because the height of the uterus is too great. A different series of antenatal diagnoses for SCT have made it possible to work out certain criteria of seriousness to be able to predict intra-uterine death: the presence of anasarca or of hydramnios, the discovery of the lesion before the 30th week of amenorrhoea, the relative weight of the teratoma as against the weight of the fetus being above 50%. We think from our experience that it is important to add the scale of the antenatal growth of the teratoma. A rapid growth of the SCT will lead to a tumour mass which is great as compared to the size of the fetus. Similarly in certain cases the vascular bed will increase in size, and intratumour haemorrhages can occur and give rise to fetal heart failure and also to fetal anaemia, hypoproteinaemia and the appearance of anasarca or of hydramnios. The child dies in utero or immediately after birth because of prematurity from the haemorrhagic state or from cardiac insufficiency. Furthermore accelerated growth of the tumour is nearly always in the immature tumour cells and that means that the child, if it is born alive, should be followed up for a long time because there is a risk of it becoming locally malignant. In practice the monitoring of SCT and the antenatal discovery of the condition should be carried out very seriously in order, in some cases, if it is viable to produce a living child in conditions where the rapid growth of tumour would make it likely that the child would die in utero.

[Malaise in infants]. / Les malaises du nourrisson.

Near-miss is the term used by English-speaking authors to define a sudden accident suggestive of imminent infant death. This is one of the most worrying problems, due to its frequency and its multiple possible causes, the most common of which are gastro-oesophageal reflux and vagal hypertonia. These accidents occur in the same age-group as the sudden infant death syndrome and in similar circumstances, even though they more often occur during waking. Near-miss therefore may constitute an abortive form of sudden infant death syndrome, which would make its study a good way for understanding the syndrome. Yet one should wait before making this assimilation as it might induce unwarranted medical procedures. The risk of recurrence (about 10%), sometimes lethal, exists, but is must be discussed after full investigation in search of a cause and a possible treatment. Electronic home monitoring is only one of the possible preventive measures; it must be decided upon and applied by a specialized medical team.