Growth Monitoring in Children as an Early Detection Test

La surveillance de la croissance des enfants est une activité quasi-universelle visant principalement à repérer des affections graves chez des enfants apparemment sains. Il existe des preuves empiriques que les performances de cette surveillance sont faibles, ce qui pourrait s’expliquer par l’absence de consensus sur trois questions clés et interdépendantes : quelles sont les affections à cibler en priorité ? comment définir une croissance anormale ? et quelles sont les courbes de croissance à utiliser ?Nous avons montré qu’il existait une grande hétérogénéité des pratiques de surveillance de la croissance en Europe et que les sept algorithmes proposés pour définir une croissance anormale avaient des performances et/ou un niveau de validation faible. Nous avons réalisé une étude de validation externe et une comparaison face-à-face de ces algorithmes et démontré que la règle de Grote avait les meilleures performances. Nous avons montré que la croissance des enfants français contemporains était plus proche des courbes de l’OMS que des courbes de référence françaises, excepté dans les six premiers mois de vie, et que l’introduction des courbes de l’OMS augmenterait la sensibilité des algorithmes au détriment de leurs spécificités. Nous avons obtenu un consensus d’experts internationaux sur la typologie des affections cibles prioritaires et un consensus national sur une liste réduite de huit affections cibles prioritaires des algorithmes de surveillance de la croissance.Ces connaissances nouvelles permettront très probablement de proposer des outils plus valides pour la surveillance de la croissance et de standardiser les pratiques pour améliorer la santé des enfants.Growth monitoring in children is a worldwide health activity which aims at early detection of serious underlying disorders of apparently healthy children. Existing empirical evidence shows that growth-monitoring performance were low, this can be explained by a lack of consensus on three key and interconnected questions: which conditions should be targeted? how should abnormal growth be defined? and which growth charts should be used?We showed that there is a large heterogeneity in growth-monitoring practices in Europe and that the seven algorithms proposed for defining an abnormal growth had low performance and/or a level of validation. We performed an external validation study and head-to-head comparison of these seven algorithms and demonstrated that the Grote clinical rule had the best performance. We found that the growth of contemporary French children were closer to the WHO than French growth charts, except during the first six month of life. The introduction of WHO growth charts would increase the sensitivity at the expense of their specificity. We obtained an international consensus on the typology of priority target conditions and national consensus on a short list of eight priority target conditions of growth-monitoring algorithms.This new knowledge will most likely allow developing validated tools for growth monitoring and standardizing practices for improving child outcomes

Survey highlights important discrepancies between definitions of paediatric abnormal growth taught to medical students in 23 European countries.

This study compared the definitions of abnormal growth that are taught across Europe to explain previously reported variations in growth-monitoring practices.info:eu-repo/semantics/publishe

Serum (1 → 3)‐β‐D‐glucan could be useful to rule out invasive candidiasis in neonates with an adapted cut‐off

International audienceAim We assessed the diagnostic accuracy of serum (1 -> 3)-beta-D-glucan (BDG) for neonatal invasive candidiasis (NIC) using the recommended cut-off usually used in adults for detecting invasive candidiasis and searched for an optimal cut-off for ruling out NIC.Methods We conducted a prospective cross-sectional study at Nantes University medical centre from January 2017 to July 2018. All consecutive newborn infants of less than 28 days of corrected age, with clinically suspected NIC, who underwent BDG assay, were included. Sensitivity and specificity were calculated by using the recommended cut-off of 80 pg/mL. Receiver operating characteristic curve analysis was used to identify an optimal cut-off value.Results We included 55 newborn infants with 61 episodes of suspected NIC. Their median gestational and chronological ages were 28.0 weeks (interquartile range [IQR] 26.4-34.1) and 10.0 days (IQR 6.0-22.0), respectively. Of 61 episodes, seven revealed NIC. Sensitivity and specificity were 85.7% (95% confidence interval [CI] 42.1%-99.6%) and 51.9% (37.8%-65.7%) with the recommended cut-off, respectively. An optimal cut-off of 174 pg/mL offered the same sensitivity but higher specificity 77.8% (64.4%-88.0%).Conclusion The recommended cut-off of 80 pg/mL was probably too low for ruling out NIC. A higher cut-off might have been more appropriate

Impact of routine S100B protein assay on CT scan use in children with mild traumatic brain injury

International audienceAbstract Objectives To evaluate the impact of implementing a modified Pediatric Emergency Care Applied Research Network (PECARN) rule including the S100B protein assay for managing mild traumatic brain injury (mTBI) in children. Methods A before-and-after study was conducted in a paediatric emergency department of a French University Hospital from 2013 to 2015. We retrospectively included all consecutive children aged 4 months to 15 years who presented mTBI and were at intermediate risk for clinically important traumatic brain injury (ciTBI). We compared the proportions of CT scans performed and of in-hospital observations before (2013–2014) and after (2014–2015) implementation of a modified PECARN rule including the S100B protein assay. Results We included 1,062 children with mTBI (median age 4.5 years, sex ratio [F/M] 0.73) who were at intermediate risk for ciTBI: 494 (46.5%) during 2013–2014 and 568 (53.5%) during 2014–2015. During 2014–2015, S100B protein was measured in 451 (79.4%) children within 6 h after mTBI. The proportion of CT scans and in-hospital observations significantly decreased between the two periods, from 14.4 to 9.5% (p=0.02) and 73.9–40.5% (p<0.01), respectively. The number of CT scans performed to identify a single ciTBI was reduced by two-thirds, from 18 to 6 CT scans, between 2013–2014 and 2014–2015. All children with ciTBI were identified by the rules. Conclusions The implementation of a modified PECARN rule including the S100B protein assay significantly decreased the proportion of CT scans and in-hospital observations for children with mTBI who were at intermediate risk for ciTBI

Early growth according to protein content of infant formula: Results from the EDEN and ELFE birth cohorts

International audienceBACKGROUND: In several systematic reviews, rapid weight gain in early life has been related to increased risk of later obesity. In line with this finding, the "early protein hypothesis" suggests that reducing early protein intake is a potential lever for obesity prevention. OBJECTIVE: To determine whether the variability of protein content of infant formula used in France over the period 2003-2012 is significantly associated with early growth in children. METHODS: A pooled sample of infants from the EDEN (Etude des Determinants pre et postnatals de la sante et du developpement de l'Enfant) mother-child cohort (born in 2003-2006) and the ELFE (Etude Longitudinale Francaise depuis l'Enfance) birth cohort (born in 2011) (ntotal = 5846) was used. Protein content of the infant formula received at 4 months was classified into five groups. Associations between protein content (or breastfed status) at 4 months and weight-, length- and BMI-for-age z-scores at 6, 12 and 18 months were analysed by multivariable linear regression. RESULTS: This analysis showed a positive association between protein content and weight-, length- and BMI-for-age z-scores at 6 months and only for weight-for-age at 12 months. At 6 months, as compared with the intermediate protein-content group (2.1-2.5 g/100 kcal), infants receiving very-high protein content (>2.8 g/100 kcal) had higher BMI-for-age z-score and those from the very-low protein-content group (<2.0 g/100 kcal) had lower BMI-for-age z-score. Exclusively breastfed infants had lower length and weight z-scores than formula-fed infants at any age. CONCLUSIONS: Our findings show a positive association, under real conditions of use, between protein contents in infant formula still on the market and weight-, length- and BMI-for-age z-scores from 6 to 18 months

Supplementary data to: Algorithms to define abnormal growth in children: external validation and head-to-head 3 comparison 4 5

Suplemental Tables 1, 2 and 3. Supplemental Fig.1 and Fig.2 Article published in J Clin Endocrinol Metab. 2018 Aug 20. doi: 10.1210/jc.2018-0072

Non-immunization associated with increased risk of sudden unexpected death in infancy: A national case–control study

International audienceObjective: In the context of vaccine scepticism, our study aimed to analyse the association between immunization status and the occurrence of sudden unexpected death in infancy (SUDI). Study design: A multi-centre case–control study was conducted between May 2015 and June 2017 with data from the French national SUDI registry (OMIN) for 35 French regional SUDI centres. Cases were infants under age 1 year who died from SUDI and who were registered in OMIN. Controls, matched to cases by age and sex at a 2:1 ratio, were infants admitted to Nantes University Hospital. All immunization data for diphtheria (D), tetanus (T), acellular pertussis (aP), inactivated poliovirus (IPV), Haemophilus influenzae b (Hib), hepatitis B (HB) and 13-valent pneumococcal conjugate vaccine (PCV13) were collected by a physician. Cases and controls were considered immunized if at least one dose of vaccine was administered. Results: A total of 91 cases and 182 controls were included. The median age was 131 days (interquartile range 98–200.0) and the sex ratio (M/F) was about 1.1. For all vaccines combined (D-T-aP-IPV-Hib and PCV13), 22 % of SUDI cases versus 12 % of controls were non-immunized, which was significantly associated with SUDI after adjustment for potential adjustment factors (adjusted odds ratio 2.01 [95 % confidence interval 1.01–3.98, p = 0,047]). Conclusions: Non-immunization for D-T-aP-IPV-Hib-HB and PCV13 was associated with increased risk of SUDI. This result can be used to inform the general public and health professionals about this risk of SUDI in case of vaccine hesitancy

Algorithms to define abnormal growth in children: external validation and head-to-head comparison

International audienceBackground: Growth monitoring of apparently healthy children aims at early detection of serious conditions by use of both clinical expertise and algorithms that define abnormal growth. The seven existing algorithms provide contradictory definitions of growth abnormality and have a low level of validation. Objective: An external validation study with head-to-head comparison of the seven algorithms combined with study of the impact of use of the World Health Organization (WHO) versus national growth charts on algorithm performance. Study design: With a case-referent approach, we retrospectively applied all algorithms to growth data for children with Turner syndrome, growth hormone deficiency, or celiac disease (n= 341) as well as apparently healthy children (n=3,406). Sensitivity, specificity, and theoretical reduction in time to diagnosis for each algorithm were calculated for each condition by using the WHO or national growth charts. Results: Among the two algorithms with high specificity (> 98%), the Grote clinical decision rule had higher sensitivity than the Coventry consensus (4.6% to 54% vs 0% to 8.9%, p<0.05) and offered better theoretical reduction in time to diagnosis (median 0.0 to 0.9 years vs 0 years, p<0.05). Sensitivity values were significantly higher with the WHO than national growth charts at the expense of specificity. Conclusion: The Grote clinical decision rule had the best performance for early detection of the three studied diseases, but its limited potential for reducing time to diagnosis suggests the need for better-performing algorithms based on appropriate growth charts

Priority target conditions for algorithms for monitoring children's growth: Interdisciplinary consensus

<div><p>Background</p><p>Growth monitoring of apparently healthy children aims at early detection of serious conditions through the use of both clinical expertise and algorithms that define abnormal growth. Optimization of growth monitoring requires standardization of the definition of abnormal growth, and the selection of the priority target conditions is a prerequisite of such standardization.</p><p>Objective</p><p>To obtain a consensus about the priority target conditions for algorithms monitoring children's growth.</p><p>Methods</p><p>We applied a formal consensus method with a modified version of the RAND/UCLA method, based on three phases (preparatory, literature review, and rating), with the participation of expert advisory groups from the relevant professional medical societies (ranging from primary care providers to hospital subspecialists) as well as parent associations. We asked experts in the pilot (n = 11), reading (n = 8) and rating (n = 60) groups to complete the list of diagnostic classification of the <i>European Society for Paediatric Endocrinology</i> and then to select the conditions meeting the four predefined criteria of an ideal type of priority target condition.</p><p>Results</p><p>Strong agreement was obtained for the 8 conditions selected by the experts among the 133 possible: celiac disease, Crohn disease, craniopharyngioma, juvenile nephronophthisis, Turner syndrome, growth hormone deficiency with pituitary stalk interruption syndrome, infantile cystinosis, and hypothalamic-optochiasmatic astrocytoma (in decreasing order of agreement).</p><p>Conclusion</p><p>This national consensus can be used to evaluate the algorithms currently suggested for growth monitoring. The method used for this national consensus could be re-used to obtain an international consensus.</p></div