Publications by authors named "Alberto Villani"

175 Publications

During the COVID-19 pandemic where has respiratory syncytial virus gone?

Pediatr Pulmonol 2021 Jul 17. Epub 2021 Jul 17.

Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy.

The diffusion of the SARS-CoV-2 virus and the implementation of restrictive measures led to a drastic reduction of respiratory syncytial virus (RSV) diffusion. Few RSV cases have been detected worldwide, even after the removal of the restrictions. We review the current literature and present possible explanations on why there has been a significant reduction of RSV detection during the COVID-19 pandemic. We also hypothesize what may happen when RSV begins to circulate again. The increase of an immunologically naïve population, with infants born from mothers who have not reinforced their immunity to RSV, could lead to greater RSV epidemics in the coming seasons. It is crucial to prepare the scientific community and to keep RSV surveillance active to avoid dramatic consequences.
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http://dx.doi.org/10.1002/ppul.25582DOI Listing
July 2021

Pediatric nurses in pediatricians' offices: a survey for primary care pediatricians.

BMC Fam Pract 2021 Jun 29;22(1):136. Epub 2021 Jun 29.

Italian Pediatric Society, Rome, Italy.

Background: The role played by nurses in caring for children in pediatricians' officies in the community is crucial to ensure integrated care. In Italy, pediatricians are responsible for the health of children aged 0-14 years living in the community. This study aimed to describe Italian primary care pediatricians' opinions about the usefulness of several nursing activities that pediatric nurses could perform in pediatricians' offices.

Methods: An online survey with pediatricians working in primary care in Italy was conducted between April-December 2018. A 40-item questionnaire was used to assess four types of nursing activities: clinical care, healthcare education, disease prevention, and organizational activities. The answers ranged from 1 (not useful at all) to 6 (very useful). Moreover, three open-ended questions completed the questionnaire.

Results: Overall, 707 pediatricians completed the online survey. Participants were mainly female (63%), with a mean age of 57.74 (SD = 6.42). The presence of a pediatric nurse within the pediatrician's office was considered very useful, especially for healthcare education (Mean 4.90; SD 1.12) and disease prevention (Mean 4.82; SD 1.11). Multivariate analysis confirmed that pediatricians 'with less working experience', 'having their office in a small town', and 'collaborating with a secretary and other workers in the office' rated the nurse's activities significantly more useful.

Conclusions: A pediatric nurse in the pediatrician's office can significantly contribute to many activities for children and their families in the community. These activities include clinical care, healthcare education, disease prevention, and the organizational processes of the office. Synergic professional activity between pediatricians and pediatric nurses could ensure higher health care standards in the primary care setting.
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http://dx.doi.org/10.1186/s12875-021-01457-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8243477PMC
June 2021

Late congenital diaphragmatic hernia: is a significant challenge? A case series and review from literature.

Minerva Pediatr (Torino) 2021 Jun 21. Epub 2021 Jun 21.

Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.

Background: Late-presenting congenital diaphragmatic hernia (L-CDH) diagnosis is a challenge for its clinical various presentation. In literature radiologic misdiagnosis is up to 62%. The aim of this study is analyze clinical findings about our cases series in a particular setting of Pediatric Emergency Department (PED) and review of literature.

Methods: We retrospectively analyzed the medical records of children older than 1 month, operated for L-CDH from November 2009 to December 2019 presented to PED, with a total of 20 children (5 Morgagni and 15 Bochdaleck).

Results: The median age at diagnosis was 1,48 years. 50% patients had a history of previouses symtptoms with a mean duration of 243,75 days. In 30 % of cases associated anomalies were presented, mainly cardiovascular. 25% of patients had undergone to chest X-ray in past history with misdiagnosis of pneumonia, microganulia and broncovascular thickening. Misdiagnosis are manly among left sided Bochdaleck hernia. Respiratory distress alone or associated with vomiting is commonest acute symptom refered to PED. Respiratory symptoms were more common in younger children, while gastrointestinal ones in older children (not statistically differences p=0,8769). Post-operative recurrence were frequent only in cases of right sided CDH and comparing with left ones, there is a difference statistically significant (p=0.0476).

Conclusions: L-CDH should be suspected in cases of unexplained acute respiratory distress and vomiting, particulary when children are affected to associate cardiovascular malformation. In cases of patients with long previouses symptoms and various accesses to PED is important to emphasize history of respiratory distress, dysphagia and failure to thrive and should be considered a chest X-ray.
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http://dx.doi.org/10.23736/S2724-5276.21.06329-1DOI Listing
June 2021

Diagnosis of COVID-19 in children guided by lack of fever and exposure to SARS-CoV-2.

Pediatr Res 2021 Jun 11. Epub 2021 Jun 11.

Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.

Background: The objective of this study is to test how certain signs and symptoms related to COVID-19 in children predict the positivity or negativity of the SARS-CoV-2 nasopharyngeal swab in children.

Methods: We review the data of children who were tested for SARS-CoV-2 for a suspected infection. We compared the clinical characteristics of the subjects who tested positive and negative, including the sensibility, positive and negative predictive value of different combination of signs and symptoms.

Results: Of all the suspected infected, 2596 tested negative (96.2%) and 103 tested positive (3.8%). The median age was 7.0 and 5.3 years for the positive and negative ones, respectively. The female to male ratio was ~1:1.3. Fever and respiratory symptoms were mostly reported. Most positive children had a prior exposure to SARS-CoV-2-infected subjects (59.2%). A total of 99.3% of patients without fever nor exposure to the virus proved negative to the SARS-CoV-2 test.

Conclusions: Our study suggests that a child without fever or contact with infected subjects is SARS-CoV-2 negative. If this were to be confirmed, many resources would be spared, with improved care of both COVID-19 and not COVID-19-affected children.

Impact: Key message: lack of fever and exposure to SARS-CoV-2-infected people highly predicts a negative results of the SARS-CoV-2 nasopharyngeal swab in the paediatric population. Added value to the current literature: this is the first article to prove this point.

Impact: reduction of emergency department accesses of children with suspected SARS-CoV-2 infection; increased outpatient management of children with cough or other common respiratory symptoms of infancy; sparing of many human and material health resources.
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http://dx.doi.org/10.1038/s41390-021-01585-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8193603PMC
June 2021

Cytokine expression patterns in hospitalized children with Bordetella pertussis, Rhinovirus or co-infection.

Sci Rep 2021 May 26;11(1):10948. Epub 2021 May 26.

Multifactorial Disease and Complex Phenotype Research Area, Bambino Gesù Children's Hospital (IRCCS), Piazza S. Onofrio, 4, 00165, Rome, Italy.

Mechanisms of interaction between Bordetella pertussis and other viral agents are yet to be fully explored. We studied the inflammatory cytokine expression patterns among children with both viral-bacterial infections. Nasopharyngeal aspirate (NPA) samples were taken from children, aged < 1 year, positive for Rhinovirus, Bordetella pertussis and for Rhinovirus and Bordetella pertussis. Forty cytokines were evaluated in NPA by using human cytokine protein arrays and a quantitative analysis was performed on significantly altered cytokines. Forty cytokines were evaluated in NPA by using human cytokine protein arrays and a quantitative analysis was performed on significantly altered cytokines. Our results show that co-infections display a different inflammatory pattern compared to single infections, suggesting that a chronic inflammation caused by one of the two pathogens could be the trigger for exacerbation in co-infections.
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http://dx.doi.org/10.1038/s41598-021-89538-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8154898PMC
May 2021

Inter-society consensus for the use of inhaled corticosteroids in infants, children and adolescents with airway diseases.

Ital J Pediatr 2021 Apr 21;47(1):97. Epub 2021 Apr 21.

Pediatric Unit, Department of Mother and Child, AUSL-IRCCS, Reggio Emilia, Italy.

Background: In 2019, a multidisciplinary panel of experts from eight Italian scientific paediatric societies developed a consensus document for the use of inhaled corticosteroids in the management and prevention of the most common paediatric airways disorders. The aim is to provide healthcare providers with a multidisciplinary document including indications useful in the clinical practice. The consensus document was intended to be addressed to paediatricians who work in the Paediatric Divisions, the Primary Care Services and the Emergency Departments, as well as to Residents or PhD students, paediatric nurses and specialists or consultants in paediatric pulmonology, allergy, infectious diseases, and ear, nose, and throat medicine.

Methods: Clinical questions identifying Population, Intervention(s), Comparison and Outcome(s) were addressed by methodologists and a general agreement on the topics and the strength of the recommendations (according to the GRADE system) was obtained following the Delphi method. The literature selection included secondary sources such as evidence-based guidelines and systematic reviews and was integrated with primary studies subsequently published.

Results: The expert panel provided a number of recommendations on the use of inhaled corticosteroids in preschool wheezing, bronchial asthma, allergic and non-allergic rhinitis, acute and chronic rhinosinusitis, adenoid hypertrophy, laryngitis and laryngospasm.

Conclusions: We provided a multidisciplinary update on the current recommendations for the management and prevention of the most common paediatric airways disorders requiring inhaled corticosteroids, in order to share useful indications, identify gaps in knowledge and drive future research.
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http://dx.doi.org/10.1186/s13052-021-01013-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8058583PMC
April 2021

Recommendations for neonatologists and pediatricians working in first level birthing centers on the first communication of genetic disease and malformation syndrome diagnosis: consensus issued by 6 Italian scientific societies and 4 parents' associations.

Ital J Pediatr 2021 Apr 19;47(1):94. Epub 2021 Apr 19.

Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University of Palermo, Palermo, Italy.

Background: Genetic diseases are chronic conditions with relevant impact on the lives of patients and their families. In USA and Europe it is estimated a prevalence of 60 million affected subjects, 75% of whom are in developmental age. A significant number of newborns are admitted in the Neonatal Intensive Care Units (NICU) for reasons different from prematurity, although the prevalence of those with genetic diseases is unknown. It is, then, common for the neonatologist to start a diagnostic process on suspicion of a genetic disease or malformation syndrome, or to make and communicate these diagnoses. Many surveys showed that the degree of parental satisfaction with the methods of communication of diagnosis is low. Poor communication may have short and long-term negative effects on health and psychological and social development of the child and his family. We draw up recommendations on this issue, shared by 6 Italian Scientific Societies and 4 Parents' Associations, aimed at making the neonatologist's task easier at the difficult time of communication to parents of a genetic disease/malformation syndrome diagnosis for their child.

Methods: We used the method of the consensus paper. A multidisciplinary panel of experts was first established, based on the clinical and scientific sharing of the thematic area of present recommendations. They were suggested by the Boards of the six Scientific Societies that joined the initiative: Italian Societies of Pediatrics, Neonatology, Human Genetics, Perinatal Medicine, Obstetric and Gynecological Ultrasound and Biophysical Methodologies, and Pediatric Genetic Diseases and Congenital Disabilities. To obtain a deeper and global vision of the communication process, and to reach a better clinical management of patients and their families, representatives of four Parents' Associations were also recruited: Italian Association of Down People, Cornelia de Lange National Volunteer Association, Italian Federation of Rare Diseases, and Williams Syndrome People Association. They worked from September 2019 to November 2020 to achieve a consensus on the recommendations for the communication of a new diagnosis of genetic disease.

Results: The consensus of experts drafted a final document defining the recommendations, for the neonatologist and/or the pediatrician working in a fist level birthing center, on the first communication of genetic disease or malformation syndrome diagnosis. Although there is no universal communication technique to make the informative process effective, we tried to identify a few relevant strategic principles that the neonatologist/pediatrician may use in the relationship with the family. We also summarized basic principles and significant aspects relating to the modalities of interaction with families in a table, in order to create an easy tool for the neonatologist to be applied in the daily care practice. We finally obtained an intersociety document, now published on the websites of the Scientific Societies involved.

Conclusions: The neonatologist/pediatrician is often the first to observe complex syndromic pictures, not always identified before birth, although today more frequently prenatally diagnosed. It is necessary for him to know the aspects of genetic diseases related to communication and bioethics, as well as the biological and clinical ones, which together outline the cornerstones of the multidisciplinary care of these patients. This consensus provide practical recommendations on how to make the first communication of a genetic disease /malformation syndrome diagnosis. The proposed goal is to make easier the informative process, and to implement the best practices in the relationship with the family. A better doctor-patient/family interaction may improve health outcomes of the child and his family, as well as reduce legal disputes with parents and the phenomenon of defensive medicine.
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http://dx.doi.org/10.1186/s13052-021-01044-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8054427PMC
April 2021

Clinical characteristics of children infected with SARS-CoV-2 in Italy.

Ital J Pediatr 2021 Apr 15;47(1):90. Epub 2021 Apr 15.

Biomarkers Unit, Center for Gender-Specific Medicine, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy.

Background: Since December 2019 coronavirus disease (COVID-19) emerged in Wuhan and spread rapidly worldwide. Despite the high number of people affected, data on clinical features and prognostic factors in children and adolescents are limited. We propose a retrospective study aimed to evaluate clinical characteristics of children infected with SARS-CoV-2 in Italy.

Methods: A pediatric population admitted with COVID-19 to Bambino Gesù Children's Hospital of Rome (Italy) in the period from the end of February to July 2020 has been studied. Medical history, comorbidities, symptoms and laboratory findings were obtained from patients' electronic medical records.

Results: In 66 patients (35 males and 31 females) we found that: i) fever and cough were the dominant symptoms, while vomit and convulsions were rare symptoms; and ii) all ages of childhood were susceptible to COVID-19. Furthermore, we found that, compared to females, males with COVID-19, although not significantly, had higher values of inflammatory markers such as C-reactive protein (CRP) and ESR. Conversely, we found that COVID-19 positive females were older than males and required more days of hospitalization. Both males and females COVID-19 positives had procalcitonin values within the normal range and D-Dimer values slightly higher than the normal range. With regard to this latter marker, the value measured in females, although not significant, was higher than that measured in males. Interestingly, the presence of leukopenia was found in both sexes.

Conclusions: Compared to the adults we found that COVID-19 infection in children is a non-severe inflammatory disease in both males and females. In any case, many detailed studies should be conducted.
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http://dx.doi.org/10.1186/s13052-021-01045-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8047584PMC
April 2021

Children and Adolescent's Perception of Media Device Use Consequences.

Int J Environ Res Public Health 2021 03 16;18(6). Epub 2021 Mar 16.

The Italian Pediatric Society, via Gioberti 60, 00165 Rome, Italy.

Media device (MD) use is increasing worldwide among children. Adolescents and young children spend a lot of time using MD, Internet, and social networks. The age of initial use is getting lower to 12 years old. The aim of this research is to study children's use and perception of MD. The Italian Paediatric Society (SIP) conducted a Survey on Italian children in collaboration with Skuola.net using an online questionnaire. A total of 10,000 questionnaires were completed. Children admitted they spend more than 3 h (41%), more than 2 h (29%), more than 1 h (21%) and less than 1 h (9%) daily. Problematic MD use has been found with children using MD before sleeping (38%), during school (24%), and at wake up in the morning (21%). Addiction was documented in 14% of adolescents. Among the reported consequences, low academic outcomes, and reduced concentration (24%), neck and back pain (12%), insomnia (10%), and mood disturbances (7%) were referred. Adolescents may have a low perception of the risks related to excessive MD. The duration of time spent using media devices is a main risk factor. In this context, parents should strongly discourage excessive MD use, mainly during school, at bedtime, and wake-up. Additionally, parents should be informed and start conversations with their children on the potential negative effects of prolonged MD use.
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http://dx.doi.org/10.3390/ijerph18063048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8002029PMC
March 2021

Epidemiology, Clinical Features and Prognostic Factors of Pediatric SARS-CoV-2 Infection: Results From an Italian Multicenter Study.

Front Pediatr 2021 16;9:649358. Epub 2021 Mar 16.

Universitarian-Hospital Department, Ospedale Bambino Gesù IRCCS, Rome, Italy.

Many aspects of SARS-CoV-2 infection in children and adolescents remain unclear and optimal treatment is debated. The objective of our study was to investigate epidemiological, clinical and therapeutic characteristics of pediatric SARS-CoV-2 infection, focusing on risk factors for complicated and critical disease. The present multicenter Italian study was promoted by the Italian Society of Pediatric Infectious Diseases, involving both pediatric hospitals and general pediatricians/family doctors. All subjects under 18 years of age with documented SARS-CoV-2 infection and referred to the coordinating center were enrolled from March 2020. As of 15 September 2020, 759 children were enrolled (median age 7.2 years, IQR 1.4; 12.4). Among the 688 symptomatic children, fever was the most common symptom (81.9%). Barely 47% of children were hospitalized for COVID-19. Age was inversely related to hospital admission ( < 0.01) and linearly to length of stay ( = 0.014). One hundred forty-nine children (19.6%) developed complications. Comorbidities were risk factors for complications ( < 0.001). Viral coinfections, underlying clinical conditions, age 5-9 years and lymphopenia were statistically related to ICU admission ( < 0.05). Complications of COVID-19 in children are related to comorbidities and increase with age. Viral co-infections are additional risk factors for disease progression and multisystem inflammatory syndrome temporarily related to COVID-19 (MIS-C) for ICU admission.
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http://dx.doi.org/10.3389/fped.2021.649358DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8007917PMC
March 2021

Pediatric routine vaccinations in the COVID 19 lockdown period: the survey of the Italian Pediatric Society.

Ital J Pediatr 2021 Mar 24;47(1):72. Epub 2021 Mar 24.

Pediatric and Infectious Diseases Unit, Bambino Gesù Children's Hospital, IRCCS, Rome-The Italian Pediatric Society, Rome, Italy.

Background: COVID-19 pandemic was responsible for disrupting routine immunization activities all over the world. Aim of the study was to investigate the reduced adherence to the national children vaccination schedule during the lockdown period in Italy.

Materials And Methods: Through social channels, the Italian Pediatric Society conducted a survey among Italian families on children vaccination during lockdown period.

Results: In the study period, 1474 responders were collected. More than one third (34%) of them skipped the vaccine appointment as they were afraid of SARS-CoV-2-virus (44%), vaccination services postponed the appointment (42%) or was closed to public (13%).

Discussion: Reduction in routine immunization coverage may represent a serious life-threating problem for unvaccinated or under-vaccinated children.

Conclusions: Information on national and local preventive measures including physical distancing, handwashing, and proper coughing/sneezing hygiene should be spread among families in order to contrast vaccine hesitancy and maintain adequate coverage levels during COVID19 pandemic period.
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http://dx.doi.org/10.1186/s13052-021-01023-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7988631PMC
March 2021

Prognostic factors and predictors of outcome in children with autism spectrum disorder: the role of the paediatrician.

Ital J Pediatr 2021 Mar 18;47(1):67. Epub 2021 Mar 18.

Institute of Ortofonologia (IdO), Via Tagliamento 25, 00198, Rome, Italy.

Background: Autism spectrum disorder is a complex condition with wide variation in type and severity that involves persistent challenges in social interaction, speech and nonverbal communication, restricted/repetitive behaviours and adaptive behaviours. In recent years, research has deepened the study of the predictive factors of optimal outcome, intended as indicators of positive trajectory in children with a previous diagnosis of autism who, after a therapeutic path, show a significant reduction in the "core" symptoms of autism and a positive evolution in social, adaptive, affective, and relational skills.

Methods: The study included 40 children aged 21 to 66 months, enrolled between 2015 and 2016 for an autism spectrum disorder clinical suspicious. Children were re-evaluated after at least 2 years of therapy and they were divided into two groups: the ASD-ASD group included children with a confirmed diagnosis of ASD, and the ASD-OO comparison group included children who no longer met the criteria for an autism classification. The aim of this retrospective study was to investigate the presence of cognitive, emotional and relational predictors capable of predicting the presence of optimal outcome in with a diagnosis of autism; the predictors taken into consideration were the intelligence quotient, the play, the emotional contagion and the understanding of other's intentions. In this way, it is possible to support clinicians in defining a more complete diagnostic framework of autism, using assessment tools that can be administered quickly and therefore suitable for short observation sessions in paediatric patients.

Results: The findings showed that 15 out of 40 children, after at least for 2 years, no longer fell into the diagnostic ASD category based on the ADOS-2, DSM-5 and clinical criteria. The children in the ASD-OO group initially had a higher IQ than those in the ASD-ASD group, lower severity of autistic symptoms, greater understanding of intentions, more emotional contagion, and better quality of play. The results suggest that the initial coexistence of skills in these areas at the time of the first diagnostic assessment may allow us to predict the possibility of achieving optimal outcome after 2 years of therapy.

Conclusions: The data of this study highlight the importance of considering, during assessment, intelligence quotient, play, emotional contagion, and understanding of the intentions of others as potential prognostic predictors that can become useful tools for clinicians and paediatricians. This allows us to focus attention, in both the diagnostic and prognostic phases, on emotional-relational variables that can support the clinician in defining a more complete diagnostic framework and in planning a more personalized therapeutic path.
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http://dx.doi.org/10.1186/s13052-021-01008-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7977604PMC
March 2021

Defining Kawasaki disease and pediatric inflammatory multisystem syndrome-temporally associated to SARS-CoV-2 infection during SARS-CoV-2 epidemic in Italy: results from a national, multicenter survey.

Pediatr Rheumatol Online J 2021 Mar 16;19(1):29. Epub 2021 Mar 16.

University of Trieste, Piazzale Europa, 2, Trieste, Italy.

Background: There is mounting evidence on the existence of a Pediatric Inflammatory Multisystem Syndrome-temporally associated to SARS-CoV-2 infection (PIMS-TS), sharing similarities with Kawasaki Disease (KD). The main outcome of the study were to better characterize the clinical features and the treatment response of PIMS-TS and to explore its relationship with KD determining whether KD and PIMS are two distinct entities.

Methods: The Rheumatology Study Group of the Italian Pediatric Society launched a survey to enroll patients diagnosed with KD (Kawasaki Disease Group - KDG) or KD-like (Kawacovid Group - KCG) disease between February 1st 2020, and May 31st 2020. Demographic, clinical, laboratory data, treatment information, and patients' outcome were collected in an online anonymized database (RedCAP®). Relationship between clinical presentation and SARS-CoV-2 infection was also taken into account. Moreover, clinical characteristics of KDG during SARS-CoV-2 epidemic (KDG-CoV2) were compared to Kawasaki Disease patients (KDG-Historical) seen in three different Italian tertiary pediatric hospitals (Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste; AOU Meyer, Florence; IRCCS Istituto Giannina Gaslini, Genoa) from January 1st 2000 to December 31st 2019. Chi square test or exact Fisher test and non-parametric Wilcoxon Mann-Whitney test were used to study differences between two groups.

Results: One-hundred-forty-nine cases were enrolled, (96 KDG and 53 KCG). KCG children were significantly older and presented more frequently from gastrointestinal and respiratory involvement. Cardiac involvement was more common in KCG, with 60,4% of patients with myocarditis. 37,8% of patients among KCG presented hypotension/non-cardiogenic shock. Coronary artery abnormalities (CAA) were more common in the KDG. The risk of ICU admission were higher in KCG. Lymphopenia, higher CRP levels, elevated ferritin and troponin-T characterized KCG. KDG received more frequently immunoglobulins (IVIG) and acetylsalicylic acid (ASA) (81,3% vs 66%; p = 0.04 and 71,9% vs 43,4%; p = 0.001 respectively) as KCG more often received glucocorticoids (56,6% vs 14,6%; p < 0.0001). SARS-CoV-2 assay more often resulted positive in KCG than in KDG (75,5% vs 20%; p < 0.0001). Short-term follow data showed minor complications. Comparing KDG with a KD-Historical Italian cohort (598 patients), no statistical difference was found in terms of clinical manifestations and laboratory data.

Conclusion: Our study suggests that SARS-CoV-2 infection might determine two distinct inflammatory diseases in children: KD and PIMS-TS. Older age at onset and clinical peculiarities like the occurrence of myocarditis characterize this multi-inflammatory syndrome. Our patients had an optimal response to treatments and a good outcome, with few complications and no deaths.
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http://dx.doi.org/10.1186/s12969-021-00511-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7962084PMC
March 2021

Neonatal osteomyelitis: an Italian multicentre report of 22 cases and comparison with the inherent literature.

J Perinatol 2021 Jun 8;41(6):1293-1303. Epub 2021 Mar 8.

Paediatric and Infectious Disease Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.

Objective: The primary objective of this study is to report and compare our data with the most relevant literature of the past decade about neonatal osteomyelitis.

Study Design: We retrospectively review the data of 22 subjects aged 35 days or less who were admitted to three different sites in Italy with a radiological diagnosis of osteomyelitis. The inherent literature was searched and reviewed: five studies were considered for comparison with our data.

Results: All the neonates, except three (two pre-term and one post-term), were born at term. The male to female ratio was 1.75 (14 males and 8 females). The mean age at presentation was 19.5 days. The most common presenting signs of the infection were local swelling and reduced mobility of the affected segment. The most common sites of infection were the femur, humerus, and tibia. The mean duration of intravenous antibiotic therapy was 29.5 days. In most neonates the diagnosis was prompt and the antibiotic treatment immediate. A low rate of sequelae was reported. All infants survived through follow up. The data from the inherent literature showed a wide variability, probably owing to the setting and the historical period of the different studies.

Conclusion: Neonatal osteomyelitis is an alarming yet poorly understood disease. Nonetheless, our report suggests that a quick diagnosis and treatment can be easily achieved, with good outcome on the remarkably plastic structure of neonatal bones.
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http://dx.doi.org/10.1038/s41372-021-00956-4DOI Listing
June 2021

Breastfeeding and COVID-19 vaccination: position statement of the Italian scientific societies.

Ital J Pediatr 2021 Feb 27;47(1):45. Epub 2021 Feb 27.

Department of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.

The availability of a COVID-19 vaccine has raised the issue of its compatibility with breastfeeding. Consequently, the Italian Society of Neonatology (SIN), the Italian Society of Pediatrics (SIP), the Italian Society of Perinatal Medicine (SIMP), the Italian Society of Obstetrics and Gynecology (SIGO), the Italian Association of Hospital Obstetricians-Gynecologists (AOGOI) and the Italian Society of Infectious and Tropical Diseases (SIMIT) have made an ad hoc consensus statement. Currently, knowledge regarding the administration of COVID-19 vaccine to the breastfeeding mother is limited. Nevertheless, as health benefits of breastfeeding are well demonstrated and since biological plausibility suggests that the health risk for the nursed infant is unlikely, Italian scientific societies conclude that COVID-19 vaccination is compatible with breastfeeding.
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http://dx.doi.org/10.1186/s13052-021-00998-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7912459PMC
February 2021

Lifestyle Modifications to Help Prevent Headache at a Developmental Age.

Front Neurol 2020 2;11:618375. Epub 2021 Feb 2.

Department of Pediatrics, Department of Neuroscience, Mental Health & Sense Organs (NESMOS), Faculty of Medicine & Psychology, c/o Sant'Andrea Hospital, Sapienza University, Rome, Italy.

Headache is the world's seventh most significant cause of disability-adjusted-life in people aged between 10 and 14 years. Therapeutic management is based on pharmacological approaches and lifestyle recommendations. Many studies show associations between each migraine-promoting lifestyle, behavioral triggers, frequency, and intensity of headaches. Nevertheless, the overall aspects of this topic lack any definitive evidence. Educational programs advise that pediatric patients who suffer from migraines follow a correct lifestyle and that this is of the utmost importance in childhood, as it will improve quality of life and assist adult patients in avoiding headache chronicity, increasing general well-being. These data are important due to the scarcity of scientific evidence on drug therapy for prophylaxis during the developmental age. The "lifestyle recommendations" described in the literature include a perfect balance between regular sleep and meal, adequate hydration, limited consumption of caffeine, tobacco, and alcohol, regular physical activity to avoid being overweight as well as any other elements causing stress. The ketogenic diet is a possible new therapeutic strategy for the control of headache in adults, however, the possible role of dietary factors requires more specific studies among children and adolescents. Educational programs advise that the improvement of lifestyle as a central element in the management of pediatric headache will be of particular importance in the future to improve the quality of life of these patients and reduce the severity of cephalalgic episodes and increase their well-being in adulthood. The present review highlights how changes in different aspects of daily life may determine significant improvements in the management of headaches in people of developmental age.
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http://dx.doi.org/10.3389/fneur.2020.618375DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884344PMC
February 2021

Inhaled corticosteroids use in childhood respiratory diseases: an italian survey on pediatricians' prescription habits.

Ital J Pediatr 2021 Feb 15;47(1):34. Epub 2021 Feb 15.

Pediatrics and Neonatology Unit, "Sapienza" University, Latina, Italy.

Background: A national consensus document on inhaled corticosteroids (ICS) use in childhood, produced by the main Italian pediatric scientific societies, has been recently released. The aim of this study was to gather information on the current pediatricians' ICS prescription habits in Italy for the management of the most common pediatric respiratory diseases, namely allergic rhinitis (AR), asthma, preschool wheezing and laryngitis.

Methods: From the 1st October 2018 to the 31st January 2019 a link to an online questionnaire was sent monthly through a newsletter to the members of the Italian Society of Pediatrics. The questionnaire included 18 items on ICS use in the most common pediatric respiratory diseases. Data collection and reporting was based on STROBE Statement Checklist for cross-sectional studies.

Results: One thousand-two questionnaires were returned from primary care pediatricians (39.1%), hospital pediatricians (38.7%), private practicers (16.4%), university pediatricians (3.1%) and Pediatrics residents (2.7%). We found a good adherence to the international guidelines on AR, with prevalent use of oral antihistamine (60.6%) in the secretive phenotype and nasal ICS in the obstructive phenotype (64.8%). In asthma exacerbations ICS are not used in 53.4% of cases, but they are used at high dose in 27.9% and at low dose in 18.7% of cases. In intermittent asthma, ICS are not chosen as a daily controller therapy in 54.1% of cases, while they are chosen as a low dose daily therapy in 44.5% of cases (high dose in 1.4%). In children with persistent asthma, ICS are chosen as a daily low dose therapy in 67.4% of cases and as a daily high dose therapy in 31%. In the management of preschool wheezing, when a long-term treatment is needed, ICS are chosen both alone and in association with antileukotrienes in 71.4% of cases. Children affected by recurrent asthma exacerbations and wheezing are closely followed up, in particular by their primary care pediatricians. The preference for certain molecules in the treatment of different respiratory diseases also emerged.

Conclusions: Pediatricians' ICS prescription habits in Italy should be improved, especially in the management of asthma. Future surveys on a more numerous sample will be useful to analyze differences in prescription habits on the basis of pediatricians' work settings and geographical distribution.
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http://dx.doi.org/10.1186/s13052-021-00988-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885514PMC
February 2021

Childhood multisystem inflammatory syndrome associated with COVID-19 (MIS-C): a diagnostic and treatment guidance from the Rheumatology Study Group of the Italian Society of Pediatrics.

Ital J Pediatr 2021 Feb 8;47(1):24. Epub 2021 Feb 8.

Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini and DINOGMI, Università di Genova, Via Gerolamo Gaslini 5, 16147, Genoa, Italy.

Background: Italy was the first Western country to be hit by the SARS-CoV-2 epidemic. There is now mounting evidence that a minority of children infected with SARS-CoV2 may experience a severe multisystem inflammatory syndrome, called Multisystem inflammatory Syndrome associated with Coronavirus Disease 2019 (MIS-C). To date no universally agreed approach is available for this disease. MAIN BODY: as Italy is now facing a second hity of COVID-19 cases, we fear a recrudescence of MIS-C cases. We have, therefore, decided to prepare a report that will help clinicians to face this novel and challenging disease. We propose a diagnostic algorithm, to help case definition and guide work-up, and a therapeutic approach. MIS-C should be promptly recognized, based on the presence of systemic inflammation and specific organ involvement. Early treatment is crucial, and it will be based on the combined use of corticosteroids, high-dose immunoglobulins and anti-cytokine treatments, depending on the severity of the disease. Ancillary treatments (such as. aspirin and thrombo-profilaxis) will be also discussed.

Conclusions: we propose a document that will help physicians to diagnose and treat MIS-C patients. Given the level of evidence available and the methodology used, this document should not be interpreted as a guideline; the final decision about the optimal management should still be taken by the caring physician, on an individual basis.
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http://dx.doi.org/10.1186/s13052-021-00980-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7868856PMC
February 2021

Respiratory Syncytial Virus Bronchiolitis in Infancy: The Acute Hospitalization Cost.

Front Pediatr 2020 18;8:594898. Epub 2021 Jan 18.

Pediatric and Infectious Diseases Unit, Bambino Gesù Children Hospital, Rome, Italy.

Respiratory syncytial virus (RSV) bronchiolitis is among the leading causes of hospitalization in infants. Prophylaxis with palivizumab may reduce RSV infection, but its prescription is restricted to high-risk groups. The aim of the study is to retrospectively determine acute hospitalization costs of bronchiolitis. Infants aged 1 month-1 year, admitted to Bambino Gesù Children Hospital, Rome, Italy, with a diagnosis of bronchiolitis from January 1 till December 31, 2017, were included in the study. A total of 531 patients were enrolled in the study, and the mean age was 78.75 days. The main etiologic agent causing bronchiolitis was RSV, accounting for 58.38% of infections. The total cost of bronchiolitis hospitalization was 2,958,786 euros. The mean cost per patient was significantly higher in the case of RSV (5,753.43 ± 2,041.62 euros) compared to other etiology (5,395.15 ± 2,040.87 euros) ( = 0.04). The study confirms the high hospitalization cost associated with bronchiolitis. In detail, in the case of RSV etiology, the cost was higher compared to other etiology, which is likely due to the longer hospitalization and the more frequent admission to the intensive cure department. This study highlights that bronchiolitis is an important cost item even in a tertiary hospital and that cost-effective interventions targeting RSV are increasingly urgent.
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http://dx.doi.org/10.3389/fped.2020.594898DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7848214PMC
January 2021

Follow-up evaluation of the immunological status of children admitted for acute cerebral nervous system infections: a retrospective study.

Ital J Pediatr 2021 Feb 2;47(1):22. Epub 2021 Feb 2.

University/Hospital Department of Pediatrics, Pediatric and Infectious Diseases Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.

Background: Acute Cerebral Nervous System Infections (ACNS) may cause death or severe complications even to promptly treated children. The role of the immune system in influencing the course and the outcome of meningitis has been studied but it is not yet completely understood. The aim of the research is to ascertain whether children who experienced ACNS infection had a normal immune system.

Methods: Patients under 18 years of age admitted at Bambino Gesù Children from January 2006 till June 2016 for meningitis were asked to participate to the follow-up study. The immune status was evaluated both clinically and by laboratory investigations.

Results: Most of the patients over 3 years at follow up had at least one immunological alteration at follow-up evaluation (74%). Considering ACNS infection etiology, certain pathogens were almost exclusive of patients affected by some immunological alteration, regardless of their age.

Discussion: Our preliminary results indicate that sub-clinical immunological defects may be associated to ACNS pediatric infections. Moreover, to the best of our knowledges, this is the first study correlating pathogens to immune evaluation in ACNS infections. It is, however, important to underline the high frequency of persistent immunological alterations in the analyzed patients. Further studies are needed to confirm our conclusions.

Conclusions: We recommend an immunological assessment at follow up evaluation in children who experienced an ACNS infection.
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http://dx.doi.org/10.1186/s13052-021-00973-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7851811PMC
February 2021

School in Italy: a safe place for children and adolescents.

Ital J Pediatr 2021 Feb 2;47(1):23. Epub 2021 Feb 2.

Microbiology Unit, Bambino Gesù Children Hospital, IRCCS, Rome, Italy.

Background: During the first SARS-CoV-2 pandemic phase, the sudden closure of schools was one of the main measures to minimize the spread of the virus. In the second phase, several safety procedures were implemented to avoid school closure. To evaluate if the school is a safe place, students and staff of two school complexes of Rome were monitored to evaluate the efficacy of prevention measures inside the school buildings.

Methods: Oral secretions specimens were collected from 1262 subjects for a total of 3431 samples, collected over a 3 months period. Detection of Coronavirus SARS-CoV-2 was performed by real-time PCR. Target genes were represented by E gene, RdRP/S gene and N gene.

Results: Among the 3431 samples analyzed, just 16 sample resulted as positive or low positive: 1 sample in the first month, 12 samples in the second month and 3 in the third month. In each period of evaluation, all positive children attended different classes.

Conclusions: Even if the school has the potential for spreading viruses, our preliminary results show the efficacy of the implementations undertaken in this setting to minimize virus diffusion. Our evidence suggests that school does not act as an amplifier for transmission of SARS-CoV-2 and can be really considered a safe place for students.
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http://dx.doi.org/10.1186/s13052-021-00978-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7851807PMC
February 2021

Impact of the COVID-19 pandemic on the Emergency Department of a tertiary children's hospital.

Ital J Pediatr 2021 Jan 29;47(1):21. Epub 2021 Jan 29.

Medical Direction, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.

Background: Italy was the first country in Europe affected by COVID-19: the emergency started on February 20, 2020, culminating with national lockdown on March 11, which terminated on May 4, 2020. We describe how the pandemic affected Emergency Department (ED) accesses in a tertiary children's hospital, composed by two different pediatric centers, one located in Rome's city center and the second, Palidoro (regional COVID-19 center), in its surrounding metropolitan area, both in the Lazio region, analyzing the profile of admitted patients during the pandemic period in terms of their general characteristics (at presentation in the ED's) and urgent hospitalizations compared to prepandemic period.

Methods: The study compare the period between the 21st of February and the 30th of April 2020, covering the three phases of the national responses (this period will be referred to as the pandemic period) with the same period of 2019 (prepandemic period). The study analyzes the number of ED visits and urgent hospitalizations and their distribution according to selected characteristics.

Results: The reduction of ED visits was 56 and 62%, respectively in Rome and Palidoro centers. The higher relative decline was encountered for Diseases of Respiratory System, and for Diseases of the Nervous System and Sense Organs. A doubling of the relative frequency of hospitalizations was observed, going from 14.2 to 24.4% in Rome and from 6.4 to 10.3% in Palidoro. In terms of absolute daily numbers the decrease of urgent hospitalizations was less sharp than ED visits. For pathologies such as peritonitis, tumors or other possible life-treathening conditions we did not observe a significative increase due to delayed access.

Conclusions: In the pandemic period there was a general reduction in the number of children referred to ED, such reduction was greater in low-acuity levels. The reduction for respiratory tract infections and other communicable diseases during school closure and the national lockdown must make us reflect on the possible impact that these conditions may have on the health system, in particular the ED, at the reopening of schools. The major problem remains the fear for possible diagnostic delays in life-threatening or crippling diseases; our study doesn't demonstrate an increase in number or significant delay in some serious conditions such as tumors, peritonitis, diabetic ketoacidosis, ileo-colic intussusception and testis/ovary torsion. A continuous, deep re-organizational process step by step of the ED is nececessary in the present and upcoming pandemic situation.
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http://dx.doi.org/10.1186/s13052-021-00976-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7844808PMC
January 2021

Impact of the COVID-19 pandemic on the Emergency Department of a tertiary children's hospital.

Ital J Pediatr 2021 Jan 29;47(1):21. Epub 2021 Jan 29.

Medical Direction, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.

Background: Italy was the first country in Europe affected by COVID-19: the emergency started on February 20, 2020, culminating with national lockdown on March 11, which terminated on May 4, 2020. We describe how the pandemic affected Emergency Department (ED) accesses in a tertiary children's hospital, composed by two different pediatric centers, one located in Rome's city center and the second, Palidoro (regional COVID-19 center), in its surrounding metropolitan area, both in the Lazio region, analyzing the profile of admitted patients during the pandemic period in terms of their general characteristics (at presentation in the ED's) and urgent hospitalizations compared to prepandemic period.

Methods: The study compare the period between the 21st of February and the 30th of April 2020, covering the three phases of the national responses (this period will be referred to as the pandemic period) with the same period of 2019 (prepandemic period). The study analyzes the number of ED visits and urgent hospitalizations and their distribution according to selected characteristics.

Results: The reduction of ED visits was 56 and 62%, respectively in Rome and Palidoro centers. The higher relative decline was encountered for Diseases of Respiratory System, and for Diseases of the Nervous System and Sense Organs. A doubling of the relative frequency of hospitalizations was observed, going from 14.2 to 24.4% in Rome and from 6.4 to 10.3% in Palidoro. In terms of absolute daily numbers the decrease of urgent hospitalizations was less sharp than ED visits. For pathologies such as peritonitis, tumors or other possible life-treathening conditions we did not observe a significative increase due to delayed access.

Conclusions: In the pandemic period there was a general reduction in the number of children referred to ED, such reduction was greater in low-acuity levels. The reduction for respiratory tract infections and other communicable diseases during school closure and the national lockdown must make us reflect on the possible impact that these conditions may have on the health system, in particular the ED, at the reopening of schools. The major problem remains the fear for possible diagnostic delays in life-threatening or crippling diseases; our study doesn't demonstrate an increase in number or significant delay in some serious conditions such as tumors, peritonitis, diabetic ketoacidosis, ileo-colic intussusception and testis/ovary torsion. A continuous, deep re-organizational process step by step of the ED is nececessary in the present and upcoming pandemic situation.
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http://dx.doi.org/10.1186/s13052-021-00976-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7844808PMC
January 2021

Management of pediatric post-infectious neurological syndromes.

Ital J Pediatr 2021 Jan 25;47(1):17. Epub 2021 Jan 25.

Italian Pediatric Society, Florence, Italy.

Background: Post-Infectious Neurological Syndromes (PINS) are heterogeneous neurological disorders with post or para-infectious onset. PINS diagnosis is complex, mainly related to the absence of any recognized guidelines and a univocal definition.

Aim Of The Study: To elaborate a diagnostic guide for PINS.

Materials And Methods: We retrospectively analysed patients younger than 14 years old admitted to Bambino Gesù Children's Hospital in Rome for PINS from December 2005 to March 2018. Scientific literature using PubMed as research platform was analysed: the key words "Post-Infectious Neurological Syndromes" were used.

Results: A polysymptomatic presentation occurred in a percentage of 88% of the children. Motor signs and visual disturbances the most observed symptoms/signs were the most detached, followed by fever, speech disturbances, sleepiness, headache and bradipsychism. Blood investigations are compatible with inflammation, as a prodromal illnesses was documented in most cases. Normal cerebral spinal fluid (CSF) characteristics has been found in the majority of the study population. Magnetic resonance imaging (MRI) was positive for demyelinating lesions. Antibiotics, acyclovir and steroids have been given as treatment.

Discussion: We suggest diagnostic criteria for diagnosis of PINS, considering the following parameters: neurological symptoms, timing of disease onset, blood and CSF laboratory tests, MRI imaging.

Conclusions: We propose criteria to guide clinician to diagnose PINS as definitive, probable or possible. Further studies are required to validate diagnostic criteria.
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http://dx.doi.org/10.1186/s13052-021-00968-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7836589PMC
January 2021

Revised recommendations of the Italian Society of Pediatrics about the general management of Kawasaki disease.

Ital J Pediatr 2021 Jan 25;47(1):16. Epub 2021 Jan 25.

Bambino Gesù Children's Hospital, Rome, Italy.

Aim of these revised recommendations for the general management of Kawasaki disease is to encourage its prompter recognition and warrant the most appropriate therapy, based on ascertained scientific data, raising awareness of the complications related to misdiagnosis or delayed treatment. A set of 20 synthetic operative statements is herein provided, including the definition of Kawasaki disease, its protean presentations, clinical course and seminal treatment modalities of all disease phases. The application of these recommendations should improve prognosis of Kawasaki disease and prevent the progression to permanent vascular abnormalities, thereby diminishing morbidity and mortality.
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http://dx.doi.org/10.1186/s13052-021-00962-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7830049PMC
January 2021

Lung ultrasound in the diagnosis and monitoring of 30 children with coronavirus disease 2019.

Pediatr Pulmonol 2021 05 12;56(5):1045-1052. Epub 2021 Jan 12.

Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.

Background: The coronavirus disease 2019 (COVID-19) has caused a new global pandemic and is responsible for millions of infections and thousands of deaths in the world. The lung ultrasound (LUS) is a noninvasive and easily repeatable tool and can be carried out by the pediatrician at the bedside of children with a consequent reduction in the risk of transmission of the virus.

Objective: We hypothesized that ultrasound findings in these patients would (1) be associated with their disease severity and (2) change over time in alignment with clinical outcome.

Methods: The study was made in the emergency department (ED) in a tertiary level pediatric hospital. All patients with swab-confirmed COVID-19 infection were subjected to a LUS within 6 h from admission and after 96 h.

Results: Among a total of 30 children, 18 (60%) were males, 4 reported exertional dyspnea, and only 1 chest pain. The mean oxygen saturation was 98.8 ± 1.0% in ambient air in the ED and no patient needed oxygen therapy during hospitalization. Children with moderate disease presented more B line (p = .03). After 96 h, we had observed ultrasound abnormality only in 20% of the children. We found a statistically significant reduction in pleural irregularities (30% vs. 16.7; p = .001) and in B lines (50% vs. 20%; p = .008).

Conclusions: The LUS is a useful, feasible, and safe tool for the clinician to complement the clinical evaluation and to monitor the evolution of lung disease in children with COVID-19.
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http://dx.doi.org/10.1002/ppul.25255DOI Listing
May 2021

Global Measles Epidemic Risk: Current Perspectives on the Growing Need for Implementing Digital Communication Strategies.

Risk Manag Healthc Policy 2020 3;13:2819-2826. Epub 2020 Dec 3.

Pediatric Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.

A safe vaccine against measles has been available and globally recommended since 1974. The World Health Organization established measles elimination as a goal for 2020 but, unfortunately, this objective has not been achieved yet and outbreaks still occur. Herd immunity, ie, a population immunity higher than 95%, is required to stop the measles virus transmission. Communication plays a crucial role in immunization strategy to obtain high coverage levels, as it helps to fight barriers against vaccination. Delay and refusal of measles vaccination have become widespread due to misinformation, fake news and barriers to effective communication. This phenomenon has been defined as "vaccine hesitancy" and is considered as one of the top ten risks for global health. The alleged association between measles vaccination and autism has caused a sharp decline in vaccination rates. In this current situation, mass communication integrated into public health policies is fundamental to sway people's positive attitudes toward vaccination. Digital communication strategies based on social media and other internet platforms may represent useful tools to promote immunization and discourage skepticism and complement information provided by health-care professionals who have been considered as the most credible source on risk/benefits on vaccines for families. Digital communication strategies that may help supporting the measles elimination strategy include monitoring information needs online, integrating digital communication into immunization programs, involving a multidisciplinary group in communication, developing content that balances facts with positive messaging, using multiple communication channels. Further research activities should be promoted in the field of effective communication for immunization.
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http://dx.doi.org/10.2147/RMHP.S201279DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7725071PMC
December 2020
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