for the Efficacy of 3% Hypertonic Saline in Acute Viral Bronchiolitis (GUERANDE) Study Group IMPORTANCE Acute bronchiolitis is the leading cause of hospitalization among infants. Previous studies, underpowered to examine hospital admission, have found a limited benefit of nebulized hypertonic saline (HS) treatment in the pediatric emergency department (ED).OBJECTIVE To examine whether HS nebulization treatment would decrease the hospital admission rate among infants with a first episode of acute bronchiolitis. DESIGN, SETTING, AND PARTICIPANTSThe Efficacy of 3% Hypertonic Saline in Acute Viral Bronchiolitis (GUERANDE) study was a multicenter, double-blind randomized clinical trial on 2 parallel groups conducted during 2 bronchiolitis seasons (October through March) from October 15, 2012, through April 15, 2014, at 24 French pediatric EDs. Among the 2445 infants (6 weeks to 12 months of age) assessed for inclusion, 777 with a first episode of acute bronchiolitis with respiratory distress and no chronic medical condition were included.INTERVENTIONS Two 20-minute nebulization treatments of 4 mL of HS, 3%, or 4 mL of normal saline (NS), 0.9%, given 20 minutes apart. MAIN OUTCOMES AND MEASURESHospital admission rate in the 24 hours after enrollment. RESULTSOf the 777 infants included in the study (median age, 3 months; interquartile range, 2-5 months; 468 [60.2%] male), 385 (49.5%) were randomized to the HS group and 387 (49.8%) to the NS group (5 patients did not receive treatment). By 24 hours, 185 of 385 infants (48.1%) in the HS group were admitted compared with 202 of 387 infants (52.2%) in the NS group. The risk difference for hospitalizations was not significant according to the mixed-effects regression model (adjusted risk difference, -3.2%; 95% CI, -8.7% to 2.2%; P = .25). The mean (SD) Respiratory Distress Assessment Instrument score improvement was greater in the HS group (-3.1 [3.2]) than in the NS group (-2.4 [3.3]) (adjusted difference, -0.7; 95% CI, -1.2 to -0.2; P = .006) and similarly for the Respiratory Assessment Change Score. Mild adverse events, such as worsening of cough, occurred more frequently among children in the HS group (35 of 392 [8.9%]) than among those in the NS group (15 of 384 [3.9%]) (risk difference, 5.0%; 95% CI, 1.6%-8.4%; P = .005), with no serious adverse events.CONCLUSIONS AND RELEVANCE Nebulized HS treatment did not significantly reduce the rate of hospital admissions among infants with a first episode of acute moderate to severe bronchiolitis who were admitted to the pediatric ED relative to NS, but mild adverse events were more frequent in the HS group. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01777347

The objective of this study was to investigate the accuracy of renal point of care ultrasound (POCUS) for the detection of hydronephrosis in children with a urinary tract infection (UTI). We prospectively included all patients with a final diagnosis of UTI who visited our pediatric emergency department between November 2009 and April 2011. Emergency physicians were encouraged to perform a renal POCUS during these visits, and a follow-up renal ultrasonography was performed by a radiologist who was blinded to the results of POCUS. We calculated the accuracy of POCUS to detect hydronephrosis (renal pelvis enlargement ≥10 mm). We included 433 UTI visits, and 382 (88.2%) POCUS were performed. The sensitivity and the specificity were 76.5% (95% confidence interval: 58.1-94.6%) and 97.2% (95.2-99.2%), respectively. The positive and the negative predictive values were 59.1% (36.4-79.3%) and 98.8% (97.7-99.9%), respectively. Renal POCUS might be used to rule out hydronephrosis in pediatric UTI.

Les traumatismes crâniens (TC) de l'enfant sont fréquents et bénins dans leur grande majorité. Les formes graves, définies par un score de Glasgow (GCS) < 9, restent la 1 ère cause de décès accidentel dès l'âge d'un an. Leur gravité réside dans la survenue de lésions intracrâniennes (LIC) mises en évidence par la tomodensitométrie cérébrale. Les TC graves relèvent de mesures thérapeutiques protocolisées dans un centre pédiatrique spécialisé. L'objectif est de prévenir les lésions cérébrales secondaires. La réanimation précoce débute sur les lieux de l'accident par le maintien des fonctions vitales. La prise en charge optimale de la multitude d'enfants consultant pour un TC mineur (GCS : 13-15) reste à définir. Elle repose sur l'évaluation de la gravité potentielle du TC qui seule détermine l'indication d'une tomodensitométrie. L'urgentiste doit mettre en balance le risque de manquer une LIC neurochirurgicale avec celui de malignité future liée aux radiations ionisantes. La valeur prédictive de LIC d'une fracture du crâne, d'un céphalhématome, d'une perte de connaissance initiale, d'une amnésie, d'une convulsion immédiate, de vomissements, de céphalées, d'une cinétique élevée et d'un âge < 2 ans est controversée. Les règles de décision clinique publiées permettent d'identifier les rares LIC avec une excellente sensibilité mais au prix d'un nombre élevé de tomodensitométries cérébrales normales. Le recours à une brève période d'observation des enfants dont la bénignité du TC ne peut être affirmée dès l'évalua-tion clinique initiale est une alternative de choix. Mots clés Traumatisme crânien · Scanner cérébral · Fracture du crâne · Maltraitance · EnfantAbstract Head trauma in children is common and overwhelmingly benign. Severe forms, defined by a Glasgow Coma Scale (GCS) < 9, are the leading cause of death in children aged more than one year. Severity is related to the intracranial injuries identified by computed tomography (CT)-scan. Management of severe traumatic brain injuries (TBI) based on standardized critical care strategy in paediatric trauma centers aims to prevent secondary brain injuries. Early resuscitation starts on the scene and first need to stabilize main functions. Optimal management of the multitude of children with mild blunt head trauma (GCS: 13-15) remains to define. It relies on prognosis evaluation that determines the need for CT-scan. Emergency physicians must balance the possibility of missing a clinically significant TBI, especially those needing acute neurosurgery and the risks of future malignancies associated with ionizing radiation. The predictive values for TBI of skull fracture, scalp hematoma, loss of consciousness, amnesia, seizure, vomiting, rapid kinetics as well as age less than 2 years are controversial. Clinical decision rules identify TBI with an excellent sensitivity but with a high rate of obtaining normal CT-scans. The short observation of children for whom the benignity of head trauma cannot be definitively assessed based on the initial clinical evaluation seems to be ben...

Introduction: Bronchiolitis is the leading cause of hospitalization for infants but its economic burden is not well documented. Our objective was to describe the clinical evolution and to assess the 1-month cost of a first episode of acute bronchiolitis presenting to the emergency department (ED).Methods: Our study was an epidemiologic analysis and a cost study of the cohort drawn from the clinical trial GUERANDE, conducted in 24 French pediatric EDs. Infants of 6 weeks to 12 months of age presenting at pediatric EDs with a first episode of bronchiolitis were eligible. The costs considered were collected from a societal viewpoint, according to the recommendations of the French National Health Authority.Results: A total of 777 infants were included with a median age of 4 months. A total of 57% were hospitalized during the month following the first consultation in the ED, including 28 (3.6%) in an intensive care unit. The mean length of stay was 4.2 days (SD = 3.7). The average time to relief of all symptoms was 13 days (SD = 7). Average total cost per patient was €1919 (95% confidence interval: 1756-2138) from a societal perspective, mostly due to hospitalization cost. The estimated annual cost of bronchiolitis in infants was evaluated to be between €160 and €273 million in France.Discussion: Bronchiolitis represent a high cost for the health care system and broadly for society, with hospitalizations costs being the main cost driver. Thus significant investments should be made to develop innovative therapies, to reduce the number of hospitalizations and length of stay.