Childhood epidermal necrolysis and erythema multiforme major: a multicentre French cohort study of 62 patients.

INTRODUCTION: The distinction between epidermal necrolysis [EN; including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) and overlap syndrome] and erythema multiforme major (EMM) in children is confusing. We aimed to better describe and compare these entities. MATERIALS AND METHODS: This French retrospective multicentre study included children ≤18 years old referred for EN or EMM between 1 January 2008 and 1 March 2019. According to pictures, children were reclassified into TEN/overlap, SJS or EMM/unclassified (SJS/EMM) groups and compared for epidemiological and clinical data, triggers, histology and follow-up. RESULTS: We included 62 children [43 boys, median age 10 years (range 3-18)]: 16 with TEN/overlap, 11 SJS and 35 EMM. The main aetiologies were drugs in EN and infections (especially Mycoplasma pneumoniae) in EMM (P < 0.001), but 35% of cases remained idiopathic (TEN/overlap, 47%; SJS, 24%; EMM, 34%). The typical target lesions predominated in EMM (P < 0.001), the trunk was more often affected in EN (P < 0.001), and the body surface area involved was more extensive in EN (P < 0.001). Mucosal involvement did not differ between the groups. Two patients with idiopathic TEN died. Histology of EMM and EN showed similar features. The recurrence rate was 42% with EMM, 7% with TEN/overlap and 0 with SJS (P < 0.001). Sequelae occurred in 75% of EN but involved 55% of EMM. CONCLUSION: Clinical features of EN and EMM appeared well demarcated, with few overlapping cases. Idiopathic forms were frequent, especially for EN, meaning that a wide and thorough infectious screening, repeated if needed, is indicated for all paediatric cases of EN/EMM without any trigger drug. We propose a comprehensive panel of investigations which could be a standard work-up in such situation. Sequelae affected both EN and EMM.

Early Recruitment of Cerebral Microcirculation by Neuronal Nitric Oxide Synthase Inhibition in a Juvenile Ischemic Rat Model.

BACKGROUND: The development of collateral circulation is proposed as an inherent compensatory mechanism to restore impaired blood perfusion after ischemia, at least in the penumbra. We have studied the dynamic macro- and microcirculation after ischemia-reperfusion in the juvenile rat brain and evaluated the impact of neuronal nitric oxide synthase (nNOS) inhibition on the collateral flow. METHODS: Fourteen-day-old (P14) rats were subjected to ischemia-reperfusion and treated with either PBS or 7-nitroindazole (7-NI, an nNOS inhibitor, 25 mg/kg). Arterial blood flow (BF) was measured using 2D-color-coded pulsed ultrasound imaging. Laser speckle contrast (LSC) imaging and sidestream dark-field videomicroscopy were used to measure cortical and microvascular BF, respectively. RESULTS: In basal conditions, 7-NI reduced BF in the internal carotids (by ∼ 25%) and cortical (by ∼ 30%) BF, as compared to PBS. During ischemia, the increased mean BF velocity in the basilar trunk after both PBS and 7-NI demonstrated the establishment of collateral support and patency. Upon re-flow, BF immediately recovered to basal values in the internal carotid arteries under both conditions. The 7-NI group showed increased collateral flow in the penumbral tissue during early re-flow compared to PBS, as shown with both LSC imaging and side-stream dark-field videomicroscopy. The proportion of perfused capillaries was significantly increased under 7-NI as compared to PBS when given before ischemia (67.0 ± 3.9 vs. 46.8 ± 8.8, p < 0.01). Perfused capillaries (63.1 ± 17.7 vs. 81.1 ± 20.7, p < 0.001) and the BF index (2.4 ± 0.6 vs. 1.3 ± 0.1, p < 0.001) significantly increased under 7-NI given at the re-flow onset. CONCLUSIONS: Collateral support in the penumbra is initiated during ischemia, and may be increased during early re-flow by neuronal NOS inhibition (given in pre- and post-treatment), which may preserve brain tissue in juvenile rats.

Sudden deaths in adult-worn baby carriers: 19 cases.

Soft infant carriers such as slings have become extremely popular in the west and are usually considered safe. We report 19 cases of sudden unexpected death in infancy (SUDI) linked to infant carrier. Most patients were healthy full-term babies less than 3 months of age, and suffocation was the most frequent cause of death. CONCLUSION: Infant carriers represent an underestimated cause of death by suffocation in neonates. WHAT IS KNOWN: • Sudden unexpected deaths in infancy linked to infant carrier have been only sparsely reported. WHAT IS NEW: • We report a series of 19 cases strongly suggesting age of less than 3 months as a risk factor and suffocation as the mechanism of death.

A pilot study comparing two polymethylpentene extracorporeal membrane oxygenators.

OBJECTIVE: We compared two polymethylpentene oxygenators being used in our unit: the Maquet Quadrox-iD paediatric and the Medos Hilite 800LT. STUDY DESIGN: A mono-centric, prospective pilot study was conducted on ten consecutive newborn patients who had been admitted to our hospital service for extracorporeal circulation (EC) treatment. We examined the rate of oxygen transfer, the CO2 removal capacity and the average sweep gas flow required to produce this result. We also assessed the disturbances of haemostasis, the need for labile blood products and the membrane oxygenator lifetime and cost of use. CONCLUSIONS: According to our study, it seems to us that Medos Hilite 800LT membrane oxygenators demonstrate greater oxygen transfer and CO2 removal capacity than Maquet Quadrox-iD paediatric membrane oxygenators, at a similar cost. These results lead us to conclude that it is reasonable to continue using Medos Hilite 800LT membrane oxygenators. A broader comparison study would be necessary in order to support these initial results.

[Particularities of ECMO in acute respiratory distress syndrome in pediatrics]. / Particularités de l'ECMO pour le syndrome de détresse respiratoire aiguë en pédiatrie.

Since the 80's, extracorporeal techniques have been used in pediatrics for the most severe acute respiratory distress syndromes. In 2012, data from the International Register of the Extracorporeal Life Support Organization revealed that more than 5,000 children had undergone extracorporeal membrane oxygenation (ECMO) with an increase in the number of annual cases since the epidemics of 2009. The survival rate (56%) is stable while the number of children with comorbidities increases due to the improvements in the equipment. Although there are no randomized studies, results encourage considering ECMO in pediatric ARDS. If veno-venous ECMO should be preferred in respiratory diseases, veno-arterial ECMO may be necessary and is still used frequently in children (50% of cases). In pediatrics, the technical features are first related to the physiological characteristics of the child and secondly to the technical limitations of the available equipment in the different ages. ECMO is a technique requiring specific expertise and specialized pediatric teams due to children's particularities.

Two pediatric cases of multisystem inflammatory-like syndrome following COVID-19 vaccination.

Multisystem inflammatory syndrome in children (MIS-C) is a novel post-infectious disease occurring in the context of SARS-CoV2 infection. COVID-19 vaccines have been authorized since December 2020, and adverse events including myocarditis have been reported following vaccination. We describe the cases of two pediatric patients presenting with clinical and laboratory features suggestive of MIS-C a few days after receiving their first dose of the Pfizer BNT162b2 vaccine. The outcome was favorable for both patients (after corticosteroid and immunoglobulin administration for one patient). These cases suggest an association between the COVID-19 vaccine and the occurrence of MIS-C.

Therapeutic approach to pediatric patients with acute chest syndrome: national multicenter survey of non invasive ventilation (NIV) and transfusion.

BACKGROUND: Intensive care units (ICUs) have seen a spike in the use of noninvasive ventilation (NIV) for many medical conditions. We sought to investigate the attitudes and clinical practice regarding the management of acute chest syndrome (ACS) with a focus on NIV in pediatric ICUs. METHOD: Members of the French Group for Pediatric Intensive Care Emergencies (GFRUP) were asked to complete an online survey on physicians' attitudes toward children with ACS admitted to the PICU during 2015. RESULTS: The survey was answered by teams from 17 PICUs (240 beds). In total, 15 centers (88%) had a local transfusion unit and 14 (82%) worked in connection with a sickle cell disease (SCD) reference center. During 2015, 360 patients with SCD were managed (median: 7 per center; 21) of whom 137 (38%) for an ACS (median: 4 ACS per center; 8). The median length of PICU stay for ACS was 5 days (3.1). Among the 137 patients who presented with ACS, 73 (53%) received simple blood transfusion and 16 (12%) received exchange transfusion. For patients who required noninvasive ventilatory support, NIV with bilevel pressure (BiPAP) was the most frequent method (n = 68, 50%), followed by continuous positive airway pressure (CPAP) (n = 23, 17%) and high-flow oxygen (n = 21, 15%). The proportion of patients on BiPAP was up to 71% in the centers most frequently managing ACS patients. CONCLUSION: BiPAP is commonly used in PICUs for SCD patients with ACS, especially in trained centers. Future physiological studies and randomized controlled trials might help to choose the best ventilatory support for ACS.

Simple actions to support breastfeeding can avoid unwanted weaning in infants younger than 6 months hospitalized for bronchiolitis: A before/after study (Bronchilact II).

BACKGROUND: Admission to hospital with bronchiolitis may adversely affect breastfeeding. Correct advice and support have been pointed out as a determining factor. OBJECTIVES: We conducted a telephone survey to evaluate a set of actions to promote breastfeeding during hospitalization for acute bronchiolitis. METHODS: Population: All patients 6 months of age or younger hospitalized with acute bronchiolitis and receiving at least partial breastfeeding were eligible for the study. Patients discharged home whose parents accepted to be contacted by phone were also included. INTERVENTION: We established a set of actions to promote breastfeeding (posters, flyers, staff training, and equipment) in all pediatric wards attending to these patients. COMPARISON: This was a cross-sectional study conducted during two epidemic seasons of bronchiolitis in a tertiary care hospital. Data on continued breastfeeding at 3 months (0.5-6; median, range) postdischarge were collected by telephone and compared with the same set of data collected from patients with bronchiolitis in the same setting the year before the intervention. OUTCOME: We conducted a telephone survey to evaluate whether some actions regarding breastfeeding might diminish the risk of unwanted weaning during hospitalization for bronchiolitis. The primary outcome was the proportion of stopped or reduced breastfeeding at discharge. Secondary objectives were to evaluate whether there were factors associated with breastfeeding modification. RESULTS: The results of the evaluation before intervention (phase 1) are published by Heilbronner et al. In Phase 1 of our study, 84 patients were included and 43 mothers (51%) reported that breastfeeding was modified by hospitalization of their child: 20.4% stopped, 14% switched to partial breastfeeding, and 16.6% reduced breastfeeding. These mothers stated that causes of breastfeeding disturbances were lack of support and advice (63%), followed by severity of the child's respiratory disease (32%), logistical hospital difficulties (30%), and personal organizational issues (9.3%). The intervention took place in September. After the intervention, 50 patients could be included in the study between October 1and December 31, 2016. Among them, 40 (80%) mothers kept breastfeeding as before, four (8%) stopped, four (8%) switched to partial breastfeeding, and two (4%) reduced breastfeeding without stopping. Bronchiolitis was more severe among patients with altered breastfeeding in terms of ventilatory support. CONCLUSION: Bronchiolitis is a high-risk event for breastfeeding disruption but interventions to promote breastfeeding might help to prevent the risk of unwanted weaning. More severe bronchiolitis probably poses the highest risk of weaning and the need for supplementary nutrition.

Population pharmacokinetics of cefazolin in critically ill children infected with methicillin-sensitive Staphylococcus aureus.

OBJECTIVES: Cefazolin is one of curative treatments for infections due to methicillin-sensitive Staphylococcus aureus (MSSA). Both growth and critical illness may impact the pharmacokinetic (PK) parameters. We aimed to build a population PK model for cefazolin in critically ill children in order to optimize individual dosing regimens. METHODS: We included all children (age < 18 years, body weight (BW) > 2.5 kg) receiving cefazolin for MSSA infection. Cefazolin total plasma concentrations were quantified by high-performance liquid chromatography. A data modelling process was performed with the software MONOLIX. Monte Carlo simulations were used in order to attain the PK target of 100% fT > 4 ×MIC. RESULTS: Thirty-nine patients with a median (range) age of 7 (0.1-17) years and a BW of 21 (2.8-79) kg were included. The PK was ascribed to a one-compartment model, where typical clearance and volume of distribution estimations were 1.4 L/h and 3.3 L respectively. BW, according to the allometric rules, and estimated glomerular filtration rate (eGFR) on clearance were the two influential covariates. Continuous infusion with a dosing of 100 mg/kg/day to increase to 150 mg/kg/day for children with a BW < 10 kg or eGFR >200 mL/min/1.73m2 were the best schemes to reach the PK target of 100% fT> 4 ×MIC. CONCLUSIONS: In critically ill children infected with MSSA, continuous infusion seems to be the most appropriate scheme to reach the PK target of 100 % fT > 4 ×MIC in children with normal and augmented renal function.

Diagnostic evaluation and management of seizures and status epilepticus in children with known epilepsy or new-onset seizures: A retrospective and comparative analysis.

OBJECTIVES: The purpose of this study was to describe and compare the initial management, including clinical/biological investigation and treatment, of new-onset seizures and status epilepticus (SE) in children versus seizures and SE in those with known epilepsy. METHODS: This was a retrospective, single-center, observational study conducted in an urban pediatric hospital in Paris. All patients, aged from 1 month to 18 years, admitted to the pediatric intensive care unit, the high-dependency care unit, and those who required hospitalization in the short-term unit of the emergency department between January 1 and December 31, 2014 for seizures and/or SE were included. RESULTS: We analyzed the data of 190 children: new-onset seizures (N=118; group A) versus those with known epilepsy (N=72; group B). At least one diagnostic test was performed on 156 patients (82.1%) (group A, N=104, 88.1%; group B, N=52, 72.2%; P=0.05). In group B, blood levels of antiepileptic drugs were measured in 14 of the 38 patients with SE, of whom six were under dosed. Treatments were: first line, diazepam (group A, 80%; group B, 46%; P<0.001); second line, diazepam (group A, 56%; group B, 34%; P=0.02) or clonazepam (group A, 24%; group B, 46%; P=0.001); third line, phenytoin (group A, 54%; group B, 22%; P<0.001) or clonazepam (group A, 18%; group B, 61%; P<0.001). CONCLUSION: Diagnostic evaluation and treatment should be individualized for children with known epilepsy.

Management of 35 critically ill hyperammonemic neonates: Role of early administration of metabolite scavengers and continuous hemodialysis.

Neurological involvement is frequent in inherited metabolic disease of the intoxication type. Hyperammonemic coma related to these diseases may cause severe neurological sequelae. Early optimal treatment is mandatory combining metabolite scavengers (MS) and sometimes continuous veno-venous hemodialysis (CVVHD). We aimed to describe the therapeutic management of hyperammonemia in neonates upon diagnosis of their metabolic disease and to compare neonates managed with MS alone or with both MS and CVVHD. We conducted a retrospective study including all neonates admitted for initial hyperammonemia to the pediatric intensive care unit of a Reference Center of Inherited Metabolic Diseases, between 2001 and 2012. The study included 35 neonates. Before admission, MS were initiated for 11 neonates. At admission, the median ammonia levels were 391 µmol/L and were significantly lower in neonates who received MS before admission. At admission, ammonia levels were 644 µmol/L in dialyzed and 283 µmol/L in non-dialyzed neonates. The median time to reach a 50% decrease of the initial ammonia levels was significantly shorter in dialyzed neonates; however, the normalization of ammonia levels was similar between dialyzed and non-dialyzed neonates. Hemodynamic disorders were more frequent in dialyzed neonates. CONCLUSION: MS represent an effective treatment for hyperammonemia and should be available in all pediatric units to avoid the need for CVVHD. Although CVVHD enhances the kinetics of toxic metabolite decrease, it is associated with adverse hemodynamic effects.

Severe and fatal forms of COVID-19 in children.

OBJECTIVES: The aim of this study was to describe severe forms of novel coronavirus disease 2019 in children, including patient characteristics, clinical, laboratory, and imaging findings, as well as the disease management and outcomes. METHODS: This was a retrospective, single-center, observational study conducted in a pediatric intensive and high-dependency care unit (PICU, HDU) in an urban hospital in Paris. All patients, aged from 1 month to 18 years, admitted for confirmed or highly suspected SARS-CoV-2 were included. RESULTS: We analyzed the data of 27 children. Comorbidities (n=19, 70%) were mainly neurological (n=7), respiratory, (n=4), or sickle cell disease (n=4). SARS-CoV-2 PCR results were positive in 24 children (nasopharyngeal swabs). The three remaining children had a chest CT scan consistent with COVID-19. Respiratory involvement was observed in 24 patients (89%). Supportive treatments were invasive mechanical ventilation (n=9), catecholamine (n=4), erythropheresis (n=4), renal replacement therapy (n=1), and extracorporeal membrane oxygenation (n=1). Five children died, of whom three were without past medical history. CONCLUSION: This study highlighted the large spectrum of clinical presentation and time course of disease progression as well as the non-negligible occurrence of pediatric life-threatening and fatal cases of COVID-19 mostly in patients with comorbidities. Additional laboratory investigations are needed to further analyze the mechanism underlying the variability of SARS-Cov-2 pathogenicity in children.

Report of severe accidental baclofen intoxication in a healthy 4-year-old boy and review of the literature.

The number of reports on baclofen intoxication has increased in recent years. Here we report the case of a 4-year-old boy in deep coma who was referred to the pediatric intensive care unit. The patient was intubated and mechanically ventilated. A computerized tomography scan without contrast showed a collapsed appearance of the ventricular system suggesting diffuse cerebral edema. A multichannel electroencephalogram registered 6 h after admission showed a very slow and ample continuous pattern, without structure, nonreactive to stimulations, expressing diffuse and severe nonspecific cerebral pain. A targeted analysis to determine the baclofen plasma levels was performed. Test results of plasma samples were highly positive for baclofen (2009 ng/mL). Following 36 h of mechanical ventilation, the patient rapidly regained consciousness and recovered normal neurological behavior. The present case demonstrates the importance of considering baclofen overdosage in cases of deep coma with areflexia, and emphasizes the importance of warning parents about the potential toxicity of baclofen when prescribing the drug to a family member. A review of the literature on pediatric baclofen overdose is included.

The role of the neuropediatrician in pediatric intensive care unit: Diagnosis, therapeutics and major participation in collaborative multidisciplinary deliberations about life-sustaining treatments' withdrawal.

BACKGROUND: In Pediatric Intensive Care Unit (PICU) two types of population require the intervention of neuropediatricians (NP): chronic brain diseases' patients who face repetitive and prolonged hospitalizations, and patients with acute brain failure facing the risk of potential neurologic sequelae, and both conditions may result in a limitation of life-sustaining treatments (LLST) decision. OBJECTIVE: To assess NP's involvement in LLST decisions within the PICU of a tertiary hospital. METHOD: Retrospective study of medical reports of patients hospitalized during 2014 in the Necker-Hospital PICU. Patients were selected using keywords ("cardiorespiratory arrest", "death", "withdrawal of treatment", "palliative care", "acute brain failure", or "chronic neurological disease"), and/or if they were assessed by a NP during the hospitalization. Demographic and medical data were analysed, including the NP's assessment and data about Collaborative Multidisciplinary Deliberation (CMD) to discuss potential LLST. RESULTS: Among 1160 children, 274 patients were included and 142 (56%) were assessed by a NP during their hospitalization for diagnosis (n = 55) and/or treatment (n = 95) management. NP was required for 59%-100% of patients with neurological acute failure, and for 14-44% of patients with extra neurological failure. A LLST decision was taken after a CMD for 27 (9.8%) of them, and a NP was involved in 19/27 (70%) of these decisions that occurred during the hospitalization (n = 19) or before (n = 8).12 patients died thereafter the LLST decision (40% of the 30 dead patients). CONCLUSION: NP are clearly involved in the decision-process of LLST for patients admitted in PICU, claiming for close collaboration to improve current practices and the quality of the care provided to children.

[Streptococcus B meningitis in infants older than 3 months]. / Méningites à streptocoque du groupe B chez le nourrisson de plus de 3 mois.

OBJECTIVE: Bacterial meningitis is a major cause of morbitidy and mortality in childhood. It can be responsible for deafness, mental retardation, epilepsy or behavioural disorders. Group B Streptococcus (GBS) is the leading cause of sepsis and meningitis in newborn. Although clinical features of neonatal SGB meningitis occurring in the first days of life have been well documented, little is known about GBS meningitis occurring in pediatric patients after this period. This study presents the epidemiology of GBS meningitis in France and compares their clinical presentation and evolution with S. pneumoniae (PNC) meningitis, main germ responsible for bacterial meningitis in children less than 2 years old. METHODS: From January 2001 to December 2005, clinical and biological data were recorded by ACTIV/GPIP, a nationwide active surveillance network. The medical files of meningitis of SGB were reviewed. RESULTS: Seventeen cases of meningococcal SGB were compared with all cases of meningococcal PNC occurred in the same age group (n=60). Univariate analysis showed that gestational age was significantly lower in the GBS group compared with PNC group (respectively 36.6 weeks vs 38.6 weeks, p =0.035). The neurological complications were significantly more frequent in the PNC meningitis group. The seizures after the begining of treatment were reported in 58 % of cases of PNC meningitis vs 17.6 % (p=0.004) and coma in 37.3 % of cases of PNC meningitis vs 6 % (p=0.013). No significant difference was assessed between the two groups for the usual blood tests (blood count, biochemistry and cytology CSF) and case fatality rate. The predominant GBS serotype was serotype III (70 %). CONCLUSION: This cohort of GBS meningitis in infants over 3 months is the largest published until now. These meningitis appear less severe than the pneumococcal meningitis occurring in the same age group.

Anti-flatulence treatment and status epilepticus: a case of camphor intoxication.

We describe a case of a young child who lived in Hong Kong who presented with a severe epilepticus status after a return flight to Paris. Routine laboratory tests failed to establish a cause. Upon further questioning, the parents reported that the nanny had given an abdominal massage to the child with an unlabelled solution reported to have anti-flatulence effects. Toxicological analysis of this solution revealed the presence of camphor. Although the highly toxic effects of camphor have long been established, the present case illustrates that camphor continues to be a source of paediatric exposure. This case highlights the importance of systematic questioning and recalls the extreme danger associated with camphor even when administered transcutaneously.

[Newborn infants supported by extracorporeal membrane oxygenation: survival and clinical outcome]. / Survie et devenir clinique des nouveau-nés mis en assistance respiratoire extracorporelle.

OBJECTIVES: To assess the prognosis of newborn infants with refractory hypoxemia who required extracorporeal membrane oxygenation (ECMO). METHODS: Eighty-nine newborn infants treated by ECMO during more than 24 hours over a 8-year period (1996-2003) were included in this observational cohort study with a 9-month and 24-month evaluation. RESULTS: Respiratory failure mainly resulted from meconium aspiration syndrome (MAS, 43%), congenital diaphragmatic hernia (CDH, 15%) and sepsis (15%). Overall survival at hospital discharge was 67%. Infants with MAS had the best survival rate (82%) and those with CDH had the worst (46%). Of the remaining 60 survivors, 53% remained oxygen dependent at 28 days and 33% at 45 days. At the age of 2 years, only 1 infant remained oxygen dependent (but did not required oxygen at 3 years) and only 3 infants had significant neurodevelopmental problems. CDH group was associated with a prolonged duration in supplementary oxygen (P<0.001) and a prolonged duration for tube feeding (P=0.01) as compared with other diagnoses. Regarding neurologic outcome, CDH infants had the poorer neurological acquisition rate at 9 months but a very good evolution by the time of the 24-month evaluation. CONCLUSIONS: Morbidity in ECMO survivors is low considering the severity of illness in the newborn period, mainly related to pulmonary and feeding dysfunctions during the first months, in particular for the CDH group. Outcome at the age of 2 years of CDH infants is most often favourable regarding growth and neurodevelopmental evolution.

[Which sedation scale should be used in the paediatric intensive care unit? A comparative prospective study]. / Quelle échelle de sédation analgésie utiliser en réanimation pédiatrique? Etude comparative prospective.

OBJECTIVES: To compare pain and sedation assessments by nurses undertaken with the Objective Pain Scale (OPS) and a Visual Analogue Scale (VAS) to the current reference scale for paediatric intensive care that is the COMFORT scale. To compare the unmodified COMFORT scale to a COMFORT "behaviour" scale which does not include physiologic items. To evaluate the ease of use of these scales. METHODS: This prospective observational comparative study was carried out in children aged 1 year or older who were admitted in an intensive care unit. At 2 to 3 time points within 24 hours, a pain sedation assessment was carried out by the nurse in charge of the child with COMFORT scale, OPS and VAS. Correlation tests were used to compare the scores of each scale. RESULTS: Nurses recorded 55 assessments in 20 children. Correlation studies showed a poor correlation between OPS, VAS and the COMFORT scale (Spearman's r=0.54 and 0.53 respectively) and a strong correlation between the COMFORT scale and the COMFORT "behaviour" scale (Spearman's r=0.96). The COMFORT behaviour scale was the most frequently fully completed scale. CONCLUSION: Among the 3 scales compared to the COMFORT scale in this study, the COMFORT "behaviour" scale was the only one to show a strong correlation and it also seemed to be the easiest to use.

[How to discuss death with a dying child: a story can help?]. / Comment parler de la mort à un enfant en fin de vie: un conte peut-il être une aide?

Is it necessary - and possible - to discuss death with a child in palliative phase? How should one approach the subject? A recent Swedish study demonstrated the benefits for parents who discussed with their child his or her imminent death, and raised the question of the role nursing can play to help parents. The mother of one child treated in our unit recently wrote a story 48 hours before the child's death. The story served to broach a number of recurrent questions often raised by dying children and their families: fear of the unknown, of being replaced, the inevitability of death, grief, and fear of being forgotten... The story was given to 13 families with dying children. In order to evaluate the story's impact on families and to determine whether a document which stimulates dialogue should continue to be given to parents, we asked that they fill out a questionnaire. Fifty-five percent of parents answered, and confirmed that the story was experienced as a positive thing and helped parents to talk with their children. This study raises many questions and should be part of a global accompaniment strategy. A review of medical, general and children's literature, as well the results of our study, lead us to conclude that the medical body should lend its full support to families who wish to engage in this dialogue with their children.

[Contribution of fetal middle cerebral artery peak systolic velocity in the management of non-immune hydrops]. / Apport de la mesure du pic des vitesses systoliques dans l'artère cérébrale moyenne pour la discussion étiologique des anasarques foetaux.

Hydrops fetalis is associated with a wide variety of fetal and maternal disorders. Among these disorders, cases with anemia may benefit from a specific treatment. The authors report on two cases of hydrops fetalis with increased middle cerebral artery peak systolic velocity and discussed the contribution of this finding in the management of fetuses with hydrops.