AIM:To compare the outcomes of home-based and conventional hospital-based care for children newly diagnosed with type 1 diabetes mellitus.METHODS:A descriptive study was conducted of all children newly diagnosed with diabetes mellitus at the Timone Hospital in Marseille, France, between November 2017 and July 2019. The patients received either home-based or in-patient hospital care. The primary outcome was the length of initial hospital stay. The secondary outcome measures were glycemic control in the first year of treatment, families' diabetes knowledge, the effect of diabetes on quality of life, and overall quality of care.RESULTS:A total of 85 patients were included, 37 in the home-based care group and 48 in the in-patient care group. The initial length of hospital stay was 6 days in the home-based care group versus 9 days in the in-patient care group. Levels of glycemic control, diabetes knowledge and quality of care were comparable in the two groups despite a higher rate of socioeconomic deprivation in the home-based care group.CONCLUSION:Home-based care for children with diabetes is safe and effective. This new healthcare pathway provides good overall social care, especially for socioeconomically deprived families.

In France, units called "Healthcare Access Centers" (Permanences d'Accès aux Soins de Santé; PASS) improve access to the healthcare system for deprived outpatients in hospitals. This study aimed to describe child care in PASS in mainland France in 2019. PASS receive a growing number of children: 23.9% of all newly admitted patients. However, only 6.6% of children receiving care were seen by pediatricians. Social deprivation would receive better attention in pediatric care through the close partnership between PASS and pediatricians or through the direct intervention of the latter in PASS. This improvement also starts with the implementation of wide screening for social vulnerability during the routine medical follow-up of children.

Background: Deprivation generates many health inequalities. This has to be taken in account to enhance appropriate access to care. This study aimed to develop and validate a pediatric individual-level index measuring deprivation, usable in clinical practice and in public health. Methods: The French Individual Child Deprivation Index (FrenChILD-Index) was designed in four phases: item generation then reduction using the literature review and expert opinions, and index derivation then validation using a cross-sectional study in two emergency departments. During these last two phases, concordance with a blinded evaluation by an expert enabled us to determine thresholds for two levels of moderate and severe deprivation. Results: The generation and reduction phases retained 13 items. These were administered to 986 children for the derivation and validation phases. In the validation phase, the final 12 items of the FrenChILD-Index showed for moderate deprivation (requiring single specific care for deprived children) a sensitivity of 96.0% [92.6; 98.7] and specificity of 68.3% [65.2; 71.4]. For severe deprivation (requiring a multidisciplinary level of care), the sensitivity was 96.3% [92.7; 100] and specificity was 91.1% [89.2; 92.9]. Conclusions: The FrenChILD-Index is the first pediatric individual-level index of deprivation validated in Europe. It enables clinical practice to address the social determinants of health and meet public health goals.

Environmental influence on intelligence quotient (IQ) is poorly understood in developing countries. We conducted the first cross-sectional investigation to assess the role of socio-economic and environmental factors on schoolchildren’s IQ in Jalalabad, Afghanistan. A representative sample of 245 schoolchildren aged 7–15 was randomly selected in five schools. Children’s records included: non-verbal IQ TONI-1 scale, body mass index, socio-economic status, and further environmental indicators (water supply, proximity to a heavy-traffic road, use of surma traditional cosmetics). The mean age of the children was 11.7 years old (±2.0 years), and 70.2% and 29.8% were male and female, respectively. The children’s mean IQ was 83.8 (±12.6). In total, 37 (14.9%) of the children were overweight, 78 (31.5%) were living below the USD 1.25 poverty line, 133 (53.6%) used tap water supply, 76 (30.6%) used surma, and 166 (66.9%) were exposed to heavy road traffic. The children’s IQ was significantly and independently lowered by tap water use (−3.9; 95% CI [−7.1; −0.6]) and by aging (−1.4; 95% CI [−2.2; −0.6]), as revealed in multivariate analysis, independently of gender, socio-economic status, exposure to heavy road traffic, overweight status, and surma use. Lower IQ among older children is possibly attributed to chronic stress experienced by adolescents due to living conditions in Afghanistan. While using tap water prevents fecal peril, it may expose children to toxic elements such as lead which is known to lower their intellectual development.

Many children with poor access to healthcare are finally admitted in emergency departments. This study describes the knowledge, attitudes, and practice of 161 pediatricians caring for these children. Among the pediatricians, 84 (52.8%) felt under-informed about the performance of the various health insurances, 107 (68.6%) lacked systematic information on the health insurance cover of the children they cared for, and many were unaware of appropriate local resources. Admission to emergency departments can be a way of linking up the healthcare pathway, once provided: systematic assessment of children's access to healthcare, better information and coordination of healthcare professionals' interventions, and several partnerships including social support.

Abstract Purpose Deprivation is a known risk factor for many diseases. But the fact it is progressive and multidimensional must be taken in account to assess its impact on health and enhance appropriate access to care. This study aimed to develop and validate a pediatric individual-level index measuring deprivation, usable in clinical practice and in public health. Methods The French Individual Child Deprivation Index (FrenChILD-Index) was designed in 4 phases: items generation then reduction using literature review, expert interviews, and a steering committee; index derivation then validation using a cross-sectional study in two emergency departments. During these last two phases, a blinded evaluation was performed between an expert opinion and FrenChILD-Index to assess its concordance and determine thresholds for two levels of moderate and severe deprivation. Results Generation and reduction phases retained 13 items to be tested. They were administered to 986 children for derivation and validation phases. In the validation phase, the final 12 items FrenChILD-Index showed for moderate deprivation (requiring single specific care for deprived children): sensitivity of 96.0% [92.6; 98.7] and specificity of 68.3% [65.2; 71.4]. For severe deprivation (requiring a multidisciplinary level of care) sensitivity was 96.3% [92.7; 100] and specificity was 91.1% [89.2; 92.9]. FrenChILD-Index met the Terwees validity criterion for screening instruments. Conclusions FrenChILD-Index is the first pediatric individual-level index of deprivation, methodologically validated in Europe. It enables individual appropriate referral of deprived children. Thus, FrenChILD-Index enables clinical practice to meet public health goals by taking into account the social determinants of health.

Abstract The purpose of this study was to develop and validate a pediatric individual-level index for deprivation, usable in clinical practice and in public health. The index had a 4 phases development: items generation with literature review and experts interviews, items reduction with steering committee consensus, index derivation with multivariate analysis, and index validation with psychometric and Pearson analysis. French Child Individual-Level Deprivation Index (FrenChILD-Index) was addressed by untrained healthcare professionals in a cross-sectional multicentric study. The deprivation burden was blindly evaluated in every domain of lifestyle by an expert. Children in need of one specific type of healthcare for deprived children were: moderately deprived. Children in need of referral to a socio-medical unit for access to healthcare were: severely deprived. The main outcome measure was the agreement between FrenChILD-Index results and expert evaluation.Development phases produced a 12-item instrument. Validation phases were carried out in a 986 children sample. FrenChILD-Index fulfilled the Terwee validity criterion for screening instruments. For moderate deprivation, sensitivity was 96.0% [92.6; 98.7] and specificity 68.3% [65.2; 71.4]. For severe deprivation, sensitivity was 96.3% [92.7; 100] and specificity 91.1% [89.2; 92.9]. It correlated with the number of lifestyle deprived domains 0.80 [0.77; 0.83] and the amount of specific healthcare for children 0.86 [0.83; 0.88].Conclusions: FrenChILD-Index is the first pediatric individual-level index of deprivation, methodologically validated in Europe. FrenChILD-Index enables individual appropriate referral for deprived children. It enables considering social determinants of health into account in epidemiological adjustment, patient sample stratification and program impact measurement. (NCT03640715, 21/08/2018)

Abstract Background Removing lead sources is the main measure against child lead poisoning. Medical treatment is ineffective for most mild cases and particularly against long-term complications in neurological development. However, the effectiveness of interventions to eliminate sources of lead exposure has not been fully established, mainly because of the diversity of situations. The objective of this study was to determine the influence of several interventions (housing counselling, rehabilitation and relocation) on blood lead levels in two situations (stable unhealthy housing with old flaked lead paints, slums with family recycling practices by incineration). Methodology A historical cohort of lead poisoning in children has been established in Marseille, France. Medical follow-up followed national guidelines. Environmental interventions followed legal procedures, where available. In slums, counselling was adapted to the exposure. A generalized mixed model was developed to study the kinetics of blood lead levels after the interventions. Results 151 children were included; age = 5.4 (SD = 7.8) years; 85 (56%) lived in stable unhealthy housing, others lived in slums. Medical follow-up included 492 blood lead levels. For children living in stable unhealthy housing, blood lead level decrease was significantly associated with every intervention: housing counselling, rehabilitation and relocation (respectively p < 0.005; p < 0.05 and p < 0.005). For children living in slums, blood lead level decrease was only associated with relocation in a stable housing (p < 0.005). Conclusions Several interventions are effective to decrease blood lead levels in unhealthy housing. In slums, access to a stable housing first is a prerequisite for any intervention against child lead poisoning, even when related to family practices. Key messages In stable unhealthy housing, several interventions against lead exposure can be effective to raise a strategy. But, environmental health and access to housing first needs to be addressed for their implementation.

Screening for social vulnerability is emphasized improve access and quality and of healthcare. In pediatrics although some specific tools exist, a global screening tool for social vulnerability and access to healthcare was missing. A Vulnerable Child Scale (VUCHIS) was developed with expert focus groups. It included short evaluation about several issues: medical follow-up, health assurance, children schooling, housing, close entourage, comorbidities, recent migration, language comprehension and food insecurity. Fifteen items were addressed in a short and easy to translate interview. The aim of this study was to validate this tool. This multicenter study was conducted in two pediatric emergency departments in France. VUCHIS questionnaire was completed by the emergency department caregiver. Another blinded interview with a social worker, expert in social vulnerabilities diagnosis, was conducted to assess the need for care in a clinic for socially vulnerable children. Clinical exam was recorded. The main criteria for this study was the clinimetric properties of VUCHIS compared to the expert caregiver opinion. 480 children were included. Their mean age was 8.3 years (SD = 3.8); 264 (55.0 %) were boys. The expert evaluation identified 57 (11.9 %) children with social vulnerabilities. VUCHIS ranged from 0 to 79 (mean = 6.9; SD = 14.7). ROC curve area was 0.83 (SD = 0.04). The selected diagnostic threshold was 10. This showed sensitivity = 0.70; 95% confidence interval (CI) = [0.56; 0.81]; specificity = 0.89; CI = [0.86; 0.92]; positive likelihood ratio = 6.60; CI = [4.77; 9.12] and negative likelihood ratio = 0.33; CI = [0.22; 0.50]. VUCHIS has good clinimetric qualities that will promote the screening of social vulnerability in pediatric clinical practice. Pediatricians need global and easy-to-use tools to implement social vulnerabilities in their clinical routine, especially in emergency departments. Implementing tool-mediated screening for social vulnerabilities in pediatrics prevent inappropriate orientation and prescriptions and poor therapeutic adherence.

Background. A 13-valent pneumococcal conjugate vaccine (PCV13) seems to be associated with a reduction of community-acquired pneumonia (CAP) in children. Methods. To explore the link between PCV13 implementation and children' visits in emergency departments (EDs) for pneumonia, we analyzed mandatory Electronics Emergency Department Abstracts (EEDA), in 7 EDs, located in southern France, from 2009 to 2014. Diagnosis related to visits were coded using International Classification Diseases-10 codes. All codes available for EEDA were used to define bacterial pneumonia (BP), viral pneumonia (VP), and nonspecific pneumonia (NSP). For adjustment, we also used codes related to influenza and bronchiolitis. Comparisons between periods (pre-PCV13, transitional, early post-PCV13, and late post-PCV13) were made by logistic regression. On daily aggregated data, a general linear model was constructed with daily proportion of BP as dependent variable, period as fixed factor, and daily proportion of viral respiratory infections (flu plus bronchiolitis) as covariate. Results. Among 718 758 visits, 7284 were coded as CAP. A significant decline in CAP was noted only for children between 2 and 5 years of age. In contrast, the proportion of BP was dramatically reduced: 2.49 vs 5.17/1000 visits (odds ratio, 0.48; 95% confidence interval, 0.42-0.55), whereas the proportion of VP was similar and NSP increased. After adjustment on influenza plus bronchiolitis, the decrease of BP remained significant. Conclusions. Electronics Emergency Department Abstracts analysis confirms an important reduction in children ED visits for BP after PCV13 implementation. The EEDA also allow a real-time surveillance of pneumonia and an adjustment on confounding factors, such as viral respiratory infections.

The provision of medical care for minors can be complicated. On the one hand, the pattern of the traditional family has changed and many parents are separated while retaining parental authority, which can make the pursuit of parental consent even more complex. In addition, French law, in line with international law, has modified the place of minors in the healthcare relationship, acknowledging the importance of seeking their consent. Such consent is sometimes even required for certain medical procedures. This consent from minors may even allow care to be provided to them without the consent of their parents.

La vaccination conjuguée pneumococcique 13-valente (PCV13), recommandée en France depuis 2010, semble réduire l’incidence des pneumonies graves.

Tropheryma whipplei was detected in preliminary studies in faeces of young children with diarrhoea and also in faeces of asymptomatic persons, not only in Europe but also in Africa. In this study, the link between this bacterium and the presence of acute diarrhoea was evaluated in a large group of children. From December 2009 to January 2013, rectal swabs collected from 3796 children in the emergency departments of university hospitals in Marseille, France, were analysed: 555 children (245 female and 310 male, from 6 days to 6 years old) with acute diarrhoea defined as at least three loose stools per day for <1 week and 3241 children (1444 female and 1797 male, from 22 days to 6 years old) without diarrhoea. Specific quantitative real-time PCR was performed to detect the presence of T. whipplei and of two enteric pathogens Clostridium difficile and Giardia duodenalis. Tropheryma whipplei was significantly more common in children with diarrhoea (22/555, 4%) than without (56/3241, 1.7%; p 0.001). Neither C. difficile nor G. duodenalis showed this association. For C. difficile, 39 of 531 (7.3%) children with diarrhoea were positive versus 184 of 3119 (5.9%) of children without diarrhoea (p 0.25). For G. duodenalis, 2 of 529 (0.37%) children with diarrhoea were positive versus 5 of 3119 (0.16%) children without diarrhoea (p 0.26). Tropheryma whipplei was found more commonly in autumn. Tropheryma whipplei is significantly associated with diarrhoea in children, suggesting that the bacterium may be a cause of acute diarrhoea.

To the Editors: A full-term born 18-day-old baby boy was admitted in a tertiary pediatric emergency department for fever (40°C) lasting for 4 hours. His brother reported vomiting the previous days. On admission, the newborn appeared highly irritable and whining. Pallor, tachycardia 210/min and hypotony were present. Blood analysis showed white blood cell count 6.44 G/L, lymphocytes 1.70 G/L and C-reactive protein >90 mg/L. Cerebrospinal fluid (CSF) analysis noted glucose <1.11 mmol/L, protein 2.13 g/L and white blood cell count 1.76 G/L (neutrophils 79% and lymphocytes 6%). Salmonella enterica serotype arizonae, susceptible in vitro to amoxicillin and ciprofloxacin, was isolated from blood and CSF cultures. Intravenous fluids and antibiotics (amoxicillin 200 mg/kg/d + amikacin 15 mg/kg/d + cefotaxime 200 mg/kg/d) were given immediately. Ciprofloxacin (10 mg/kg × 2/d) was added when direct examination of CSF revealed a Gram-negative bacillus. The parents reported having a corn snake (Pantherophis guttatus) as an exotic pet at home. They claimed that the snake had never been in contact with the baby. However, Salmonella enterica subsp. arizonae was isolated from snake’s feces. The newborn slowly recovered. Antibiotics were given for 21 days, and a CSF control culture at day 21 was sterile. Cerebral magnetic resonance imaging and a long-term neurologic follow-up were planned. Reptile-associated salmonellosis (RAS) is due to contact with turtles, exotic reptiles and amphibians, or ingestion of snake-based products. In the United States, 74,000 RAS cases were annually reported in the late 1990s.1 Human cases are related to the 50–90% of carriage of Salmonella species by reptiles. Gastrointestinal symptoms are observed in 69–78% of RAS, invasive diseases in 15% and meningitis in 5–14%. Salmonella enterica subsp. enterica (or subspecies I) is recovered in 78–90% of RAS. Salmonella enterica subsp. arizonae, formerly named Salmonella dar-essalaam, Arizona hinshawii, Salmonella arizonae or Salmonella choleraesuis subsp. arizonae, is uncommon (5–9%2,3). It mainly causes gastroenteritis, but is also isolated in pleuritis, peritonitis, osteomyelitis or bacteremia. Only 2 Salmonella enterica subsp. arizonae meningitis have been previously reported.4,5 This is the second neonatal case. Reptile owners should be informed that reptiles, turtles and amphibians may carry Salmonella species and have to be kept out of households with young children. These animals should also be banned in day-care centers or schools. Emilie Briard, MD Pediatric Emergency Karine Retornaz, MD Pediatric Department Sophie Miramont, MD Pediatric Emergency Aurélie Sapet, MD Pediatric Department Rémi Laporte, MD Philippe Minodier, MD Pediatric Emergency CHU Nord, Chemin des Bourrely Marseille, France

Radial nerve injuries continue to challenge hand surgeons. The course of the nerve and its intimate relationship to the humerus place it at high risk for injury with humerus fractures. We present a review of radial nerve injuries with emphasis on their etiology, workup, diagnosis, management, and outcomes.

Malgré une faible incidence de la tuberculose en France, il existe de grandes variations à l’échelle communale : certains quartiers de Marseille présentent ainsi une incidence annuelle supérieure à 30/100 000. Le but de notre étude était d’évaluer la couverture vaccinale par le vaccin de Calmette et Guérin (BCG) des enfants à risque âgés de moins de 5 ans consultant dans un service d’urgences pédiatriques.