Publications by authors named "Egidio Barbi"

296 Publications

Summertime skin rash.

J Paediatr Child Health 2021 Jun;57(6):960

Pediatric Department, University of Trieste, Trieste, Italy.

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http://dx.doi.org/10.1111/jpc.1_15251DOI Listing
June 2021

Prevalence of SARS-CoV-2 infection in Italian pediatric population: a regional seroepidemiological study.

Ital J Pediatr 2021 Jun 5;47(1):131. Epub 2021 Jun 5.

Italian National Institute of Health, Rome, Italy.

Background: Data on the effective burden of the SARS-CoV-2 pandemic in pediatric population are very limited, mostly because of the higher rate of asymptomatic or paucisymptomatic cases among children. Updated data on COVID-19 prevalence are needed for their relevance in public health and for infection control policies. In this single-centre cross-sectional study we aimed to assess prevalence of SARS-CoV-2 infection through IgG antibodies detection in an Italian pediatric cohort.

Methods: The study was conducted in January 2021 among both inpatients and outpatients referring to Research Institute for Maternal and Child Health "Burlo Garofolo" in Trieste, Friuli Venezia-Giulia, Italy, who needed for blood test for any reason. Collected samples were sent to Italian National Institute of Health for analysis through chemiluminescent immunoassay (CLIA).

Results: One hundred sixty-nine patients were included in the study, with a median age of 10.5 ± 4.1 years, an equal distribution for sex (49.7% female patients), and a 55.6% prevalence of comorbidities. Prevalence of anti-SARS-CoV-2 trimeric Spike protein IgG antibodies was 9.5% (n = 16), with a medium titre of 482.3 ± 387.1 BAU/mL. Having an infected cohabitant strongly correlated with IgG positivity (OR 23.83, 95% CI 7.19-78.98, p < 0.0001), while a cohabitant healthcare worker wasn't associated with a higher risk (OR 1.53, 95% CI 0.4-5.86, p 0.46). All of the 5 patients who had previously tested positive to a nasopharyngeal swab belonged to the IgG positive group, with a 3-month interval from the infection at most.

Conclusion: We assessed a 9.5% SARS-CoV-2 seroprevalence in a pediatric cohort from Friuli Venezia-Giulia region in January 2021, showing a substantial increase after the second peak of the pandemic occurred starting from October 2020, compared to 1% prevalence observed by National Institute of Statistics (ISTAT) in July 2020.
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http://dx.doi.org/10.1186/s13052-021-01074-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8179691PMC
June 2021

Uncommon urticaria.

Arch Dis Child Educ Pract Ed 2021 Jun 3. Epub 2021 Jun 3.

Pediatric Department, Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy.

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http://dx.doi.org/10.1136/archdischild-2021-321828DOI Listing
June 2021

Enteral bleeding in a former preterm girl with short bowel syndrome: Do not miss the diagnosis.

J Paediatr Child Health 2021 May 28. Epub 2021 May 28.

University of Trieste, Trieste, Italy.

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http://dx.doi.org/10.1111/jpc.15593DOI Listing
May 2021

Adolescent Male With Severe Renal Trauma.

Ann Emerg Med 2021 Jun;77(6):592-630

Institute for Maternal and Child Health IRCCS "Burlo Garofolo," (Barbi) Trieste, Italy.

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http://dx.doi.org/10.1016/j.annemergmed.2020.12.005DOI Listing
June 2021

Effects of Intraoperative Auditory Stimulation on Pain and Agitation on Awakening After Pediatric Adenotonsillectomy: A Randomized Clinical Trial.

JAMA Otolaryngol Head Neck Surg 2021 May 20. Epub 2021 May 20.

University of Trieste School of Medicine, Trieste, Italy.

Importance: Severe pain on awakening (POA) and emergence delirium (ED) are common following pediatric adenotonsillectomy. Effective preventive interventions are lacking.

Objective: To determine the effects of intraoperative auditory stimulation on reduction of POA and ED after pediatric adenotonsillectomy.

Design, Setting, And Participants: Single-center, double-blinded, 4-armed, randomized clinical trial of children undergoing adenotonsillectomy from March 2018 to May 2019 at a tertiary care pediatric referral center.

Interventions: Children were randomized to 1 of the following groups: auditory stimulation with music, auditory stimulation with noise, ambient noise insulation with masking earplugs, and a control group receiving no intervention. Ear inserts were placed in the operating room once general anesthesia was administered. Stimulation parameters were based on the preoperative audiological evaluation and the appropriate fitting of the transduction system, including ambient noise level monitoring.

Main Outcomes And Measures: The primary outcome was POA levels measured on 10-point scales according to age-appropriate validated tools. The secondary outcome was ED levels assessed according to the Pediatric Anesthesia Emergence Delirium 20-point scale.

Results: A total of 104 consecutive healthy children (median [interquartile range] age at surgery, 5.0 [3.8-6.4] years) were included in the analysis. Music had a large effect size on POA (0.63; 98% CI, 0.43-0.84) and a medium effect size on ED (0.47; 98% CI, 0.21-0.75), while noise had a medium effect size on POA (0.47; 98% CI, 0.22-0.73) and a large effect size on ED (0.63; 98% CI, 0.44-0.85) compared with controls. The earplugs group showed a small effect size on POA and ED. Considering a clinically meaningful threshold of greater than 4 for POA and 10 or greater for ED at dichotomized analysis, a large effect size was achieved by music (1.39; odds ratio [OR], 0.08; 98% CI, 0.02-0.29; and 0.84; OR, 0.22; 98% CI, 0.06-0.75, respectively) and noise (0.97; OR, 0.17; 98% CI, 0.05-0.6; and 1.48; OR, 0.07; 98% CI, 0.02-0.26, respectively), while earplugs resulted in a small effect size.

Conclusions And Relevance: In this randomized clinical trial, children undergoing adenotonsillectomy who received intraoperative auditory stimulation demonstrated a clinically meaningful decrease in POA and ED in the immediate postoperative period. Further research is needed to assess whether intraoperative auditory stimulation may decrease POA and ED in children undergoing other types of surgical procedures.

Trial Registration: ClinicalTrials.gov Identifier: NCT04112979.
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http://dx.doi.org/10.1001/jamaoto.2021.0870DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8138746PMC
May 2021

We are not ready to use breast milk eye drops for infants with eye discharges.

Acta Paediatr 2021 May 19. Epub 2021 May 19.

Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.

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http://dx.doi.org/10.1111/apa.15944DOI Listing
May 2021

Early introduction oral immunotherapy for IgE-mediated cow's milk allergy: A follow-up study confirms this approach as safe and appealing to parents.

Immun Inflamm Dis 2021 May 18. Epub 2021 May 18.

Department of Pediatrics, Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy.

Introduction: Early introduction oral immunotherapy (E-OIT) in the first year of life can be a safe treatment for infants with cow's milk allergy (CMA). Once the protocol is completed, doubts remain whether children achieve tolerance or remain desensitized. According to current guidelines, this is determined by an avoidance period followed by a re-exposure to the food allergen during an in-hospital oral food challenge (OFC). In real life, this approach can be complicated, time-consuming, and anxiety-provoking for parents. We assessed the long-term safety of E-OIT for CMA in a cohort of children who switched to an unrestricted diet without testing the achievement of tolerance at the end of the OIT protocol.

Materials And Methods: We performed a descriptive analysis of the clinical follow-up of a cohort of children diagnosed with IgE-mediated CMA and undergoing E-OIT protocol in their first year of life. In a previous publication, the same cohort of patients had been studied to assess the feasibility of E-OIT for CMA. In the present study, we reported the results of a telephone survey, carried out through a questionnaire to their families enquiring about milk consumption and other ongoing atopic conditions of children.

Results: After an average of 4 years from the start of E-OIT, 62/73 patients (85% of the historical cohort) participated in the survey. Among them, all 56 patients who had previously successfully completed the protocol reported an unrestricted cow's milk intake. Ninety-three percent of these children did not experience any further allergic reactions, while the remaining 7% described only mild and transitory reactions until the 6-month period after the end of the protocol.

Conclusions: This study confirmed the long-term safety of E-OIT for CMA and challenged the paradigm of the need for allergen food withdrawal to discern between desensitization and tolerance. It could be a starting point for planning future trials on this issue.
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http://dx.doi.org/10.1002/iid3.447DOI Listing
May 2021

New Tools for Congenital Hyperinsulinism.

Clin Pediatr (Phila) 2021 Jul 10;60(8):336-340. Epub 2021 May 10.

Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy.

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http://dx.doi.org/10.1177/00099228211013648DOI Listing
July 2021

A young asymptomatic soccer player with a 'chaise long' spirogram.

J Paediatr Child Health 2021 Mar 17. Epub 2021 Mar 17.

Department of Pediatrics, Università degli Studi di Trieste, Trieste, Italy.

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http://dx.doi.org/10.1111/jpc.15324DOI Listing
March 2021

A child without kneecaps.

J Paediatr Child Health 2021 May 7. Epub 2021 May 7.

Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy.

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http://dx.doi.org/10.1111/jpc.15519DOI Listing
May 2021

Lipoblastoma as a cause of secondary omental torsion in children: report of the first case.

J Surg Case Rep 2021 Apr 30;2021(4):rjab151. Epub 2021 Apr 30.

Department of Paediatric Surgery and Urology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", 34137 Trieste, Italy.

Acute abdominal pain remains a major diagnostic challenge to date. Omental torsion is an infrequent cause of abdominal pain in children, which usually presents with non-specific symptoms. Herein, we report a case of persistent abdominal pain after a minor abdominal trauma. A solid mass was found in the lower abdomen at ultrasound imaging evaluation. Surgical exploration demonstrated an omental torsion secondary to a rare neoplasm of childhood.
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http://dx.doi.org/10.1093/jscr/rjab151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8087459PMC
April 2021

Hyperpigmented pityriasis versicolor misdiagnosed as acanthosis nigricans.

Arch Dis Child 2021 Apr 30. Epub 2021 Apr 30.

University of Trieste, Trieste, Italy.

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http://dx.doi.org/10.1136/archdischild-2021-322030DOI Listing
April 2021

Topical clobetasol: an overlooked cause of Cushing syndrome.

Endocr Metab Immune Disord Drug Targets 2021 Apr 26. Epub 2021 Apr 26.

Institute for maternal and child health IRCCS 'Burlo Garofolo', Trieste, Italy.

We describe the case of an 11-year-old boy affected by chronic granulomatous disease complicated by a Crohn's like colitis needing prolonged treatment with oral corticosteroids. His therapy for the control of severe oral mucositis was based on topical clobetasol, which did not decrease once the steroids were discontinued. Two years after the oral interruption of the steroids, cushingoid characteristics persisted, the cause of which, after a thorough investigation, was found to be the persistence of the topical clobetasol oral gel. Several studies investigated the efficacy of topical clobetasol for immuno-related mucositis, but little is known about its pharmacokinetics and side effects. In this report, we have reviewed the literature, defining a maximum putative dose of clobetasol mucosal gel to avoid Cushing syndrome.
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http://dx.doi.org/10.2174/1871530321666210426131423DOI Listing
April 2021

A Real-time Cerebral Bleeding in an Extremely Preterm Newborn.

J Pediatr 2021 Apr 22. Epub 2021 Apr 22.

Neonatal Intensive Care Unit, Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy.

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http://dx.doi.org/10.1016/j.jpeds.2021.04.033DOI Listing
April 2021

Correlation between Bispectral Index and EEG: a pediatric case series.

Minerva Anestesiol 2021 Apr 14. Epub 2021 Apr 14.

Department of Pediatric Anesthesia, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy.

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http://dx.doi.org/10.23736/S0375-9393.21.15703-7DOI Listing
April 2021

Characteristics and risk factors for SARS-CoV-2 in children tested in the early phase of the pandemic: a cross-sectional study, Italy, 23 February to 24 May 2020.

Euro Surveill 2021 04;26(14)

Department of Pediatrics, Latisana-Palmanova, ASUFC, Udine, Italy.

BackgroundVery few studies describe factors associated with COVID-19 diagnosis in children.AimWe here describe characteristics and risk factors for COVID-19 diagnosis in children tested in 20 paediatric centres across Italy.MethodsWe included cases aged 0-18 years tested between 23 February and 24 May 2020. Our primary analysis focused on children tested because of symptoms/signs suggestive of COVID-19.ResultsAmong 2,494 children tested, 2,148 (86.1%) had symptoms suggestive of COVID-19. Clinical presentation of confirmed COVID-19 cases included besides fever (82.4%) and respiratory signs or symptoms (60.4%) also gastrointestinal (18.2%), neurological (18.9%), cutaneous (3.8%) and other unspecific influenza-like presentations (17.8%). In multivariate analysis, factors significantly associated with SARS-CoV-2 positivity were: exposure history (adjusted odds ratio (AOR): 39.83; 95% confidence interval (CI): 17.52-90.55; p < 0.0001), cardiac disease (AOR: 3.10; 95% CI: 1.19-5.02; p < 0.0001), fever (AOR: 3.05%; 95% CI: 1.67-5.58; p = 0.0003) and anosmia/ageusia (AOR: 4.08; 95% CI: 1.69-9.84; p = 0.002). Among 190 (7.6%) children positive for SARS-CoV-2, only four (2.1%) required respiratory support and two (1.1%) were admitted to intensive care; all recovered.ConclusionRecommendations for SARS-CoV-2 testing in children should consider the evidence of broader clinical features. Exposure history, fever and anosmia/ageusia are strong risk factors in children for positive SARS-CoV-2 testing, while other symptoms did not help discriminate positive from negative individuals. This study confirms that COVID-19 was a mild disease in the general paediatric population in Italy. Further studies are needed to understand risk, clinical spectrum and outcomes of COVID-19 in children with pre-existing conditions.
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http://dx.doi.org/10.2807/1560-7917.ES.2021.26.14.2001248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8034058PMC
April 2021

Should Pediatric Endocrinologists Consider More Carefully When to Perform a Stimulation Test?

Front Endocrinol (Lausanne) 2021 22;12:660692. Epub 2021 Mar 22.

Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy.

Introduction: Pediatric endocrinology rely greatly on hormone stimulation tests which demand time, money and effort. The knowledge of the pattern of pediatric endocrinology stimulation tests is therefore crucial to optimize resources and guide public health interventions. Aim of the study was to investigate the distribution of endocrine stimulation tests and the prevalence of pathological findings over a year and to explore whether single basal hormone concentrations could have saved unnecessary stimulation tests.

Methods: Retrospective study with data collection for pediatric endocrine stimulation tests performed in 2019 in a tertiary center.

Results: Overall, 278 tests were performed on 206 patients. The most performed test was arginine tolerance test (34%), followed by LHRH test (24%) and standard dose Synachthen test (19%), while the higher rate of pathological response was found in insulin tolerance test to detect growth hormone deficiency (81%), LHRH test to detect central precocious puberty (50%) and arginine tolerance test (41%). No cases of non-classical-congenital adrenal hyperplasia were diagnosed. While 29% of growth hormone deficient children who performed an insulin tolerance test had a pathological peak cortisol, none of them had central adrenal insufficiency confirmed at low dose Synacthen test. The use of basal hormone determinations could save up to 88% of standard dose Synachthen tests, 82% of arginine tolerance + GHRH test, 61% of LHRH test, 12% of tests for adrenal secretion.

Conclusion: The use of single basal hormone concentrations could spare up to half of the tests, saving from 32,000 to 79,000 euros in 1 year. Apart from basal cortisol level <108 nmol/L to detect adrenal insufficiency and IGF-1 <-1.5 SDS to detect growth hormone deficiency, all the other cut-off for basal hormone determinations were found valid in order to spare unnecessary stimulation tests.
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http://dx.doi.org/10.3389/fendo.2021.660692DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021019PMC
March 2021

Severe hyponatremia in children: a review of the literature through instructive cases.

Minerva Pediatr (Torino) 2021 Apr 2. Epub 2021 Apr 2.

Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy.

Hyponatriemia is the most common electrolyte disorder in the paediatric population. Symptoms are related to the time in which hyponatriemia has developed. The acute presentation could be dramatic, with neurological symptoms like headache, seizure, impaired mental status and even coma. It is essential for the physician to be aware of the possible causes of hyponatremia in the child in order to start a prompt treatment.
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http://dx.doi.org/10.23736/S2724-5276.21.05856-4DOI Listing
April 2021

Do Not Simply Pull a Dislocated Finger.

J Pediatr 2021 Apr 2. Epub 2021 Apr 2.

Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy; Institute for Maternal and Child Health, Italian Research Hospital "Burlo Garofolo", Trieste, Italy.

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http://dx.doi.org/10.1016/j.jpeds.2021.03.065DOI Listing
April 2021

'Starry sky' rash in a child.

J Paediatr Child Health 2021 Apr;57(4):589

Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy.

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http://dx.doi.org/10.1111/jpc.1_15166DOI Listing
April 2021

Prevalence of children born small for gestational age with short stature who qualify for growth hormone treatment.

Ital J Pediatr 2021 Apr 1;47(1):82. Epub 2021 Apr 1.

Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Via dell'Istria 65/1, 34137, Trieste, Italy.

Background: Recombinant human growth hormone (rhGH) is approved in Europe as a treatment for short children born small for gestational age (SGA) since 2003. However, no study evaluated the prevalence of SGA children with short stature who qualify for rhGH in Europe so far. This study aimed to investigate in an Italian population the prevalence of children born SGA, of short stature in children born SGA, and of SGA children who qualify for rhGH treatment at 4 years of age.

Methods: We conducted a population-based study on primary care pediatricians' databases in Trieste, Italy. Data was collected on 3769 children born between 2004 and 2014. SGA was defined as birth weight and/or birth length ≤ - 2 SDS. Data on height and weight were registered at the closest well-being visit to 1, 2, 3, 4 years of age. Short stature was defined as height ≤ - 2 SDS. Short children born SGA who qualify for rhGH treatment were identified according to Note AIFA #39 criteria (age ≥ 4 years; height ≤ - 2.5 SDS; growth velocity < 50th percentile).

Results: Full data at birth were available for 3250 children. The SGA prevalence was 3.6% (0.8% SGA for weight, 2.2% SGA for length, 0.6% SGA for both weight and length). The prevalence of short stature among SGA children was 9% at 1 year of age, 6% at 2 years (significantly higher in preterm in the first 2 years), 4% at 3 years, 3% at 4 years (all born at term). At 4 years of age, median height SDS was - 0.52. One child born SGA was eligible for GH treatment (0.8% among SGA children).

Conclusions: The prevalence in a general pediatric population of children born SGA who qualify for GH treatment was 1:3250. Although the prevalence of SGA in our population was similar to previous studies, catch-up growth was recorded earlier in our sample compared to previous reports, and term babies had late catch-up. Height SDS of children born SGA at 4 years of age was lower than expected (- 0.52 SDS).
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http://dx.doi.org/10.1186/s13052-021-01026-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8015030PMC
April 2021

The first Italian COVID-19 lockdown reduced births and voluntary terminations by just under a fifth.

Acta Paediatr 2021 Mar 29. Epub 2021 Mar 29.

Neonatology Unit, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy.

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http://dx.doi.org/10.1111/apa.15862DOI Listing
March 2021

'Starry sky' rash in a child.

J Paediatr Child Health 2021 Mar 16. Epub 2021 Mar 16.

Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy.

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http://dx.doi.org/10.1111/jpc.15166DOI Listing
March 2021

How to recognize and manage psychosomatic pain in the pediatric emergency department.

Ital J Pediatr 2021 Mar 25;47(1):74. Epub 2021 Mar 25.

Paediatric Palliative Care - Pain Service Department of Women's and Children's Health, University of Padua, Padua, Italy.

Aim: Children and adolescents affected by somatization and somatic symptom disorder commonly refer to emergency services. Due to the absence of specific guidelines for the emergency setting and to a possible lack of knowledge, these patients are at risk of being unrecognized and mismanaged. This study aims at proposing a clinical practice to approach and manage these patients and their families in the emergency setting.

Methods: This manuscript derived from the work of a research group of italian pediatric emergency physicians and anesthesiologists, with an expertise in pain management, members of the PIPER group. The research group reviewed the literature about psychosomatic pain and somatic symptom disorder and developed a clinical practice specific for the pediatric emergency setting.

Results: The manuscript provides information about the main clinical features shared by patients with psychosomatic pain and about current diagnostic criteria and appropriate management in the emergency setting. Furthermore, it highlights the possible pitfalls in which the emergency physician may run into dealing with these patients.

Conclusion: This clinical practice should be seen as a starting point toward a better understanding of patients with psychosomatic pain and a standardization of care in the pediatric emergency setting.
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http://dx.doi.org/10.1186/s13052-021-01029-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7992953PMC
March 2021

Sudden diffuse target blisters.

J Paediatr Child Health 2020 12;56(12):1987

Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy.

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http://dx.doi.org/10.1111/jpc.1_15045DOI Listing
December 2020

Boy with crackling neck.

J Paediatr Child Health 2021 01;57(1):163

Pediatrics, Institute for Maternal and Child Health IRCCS Burlo Garofolo, via dell'Istria 65/1, Trieste, Italy.

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http://dx.doi.org/10.1111/jpc.1_15085DOI Listing
January 2021

Boy with cerebral palsy and severe malnutrition: Do not miss the mealtime!

J Paediatr Child Health 2021 Mar 24. Epub 2021 Mar 24.

Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy.

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http://dx.doi.org/10.1111/jpc.15449DOI Listing
March 2021

Definition and prevalence of familial short stature.

Ital J Pediatr 2021 Mar 9;47(1):56. Epub 2021 Mar 9.

Institute for Maternal and Child Health - IRCCS "Burlo Garofolo" - Trieste, Via dell'Istria 65/1, 34137, Trieste, Italy.

Objective: To verify the prevalence of novel definitions of familial short stature on a cross-sectional cohort of children referred for short stature when their height and that of both parents were measured.

Methods: We consecutively enrolled 65 individuals referred for short stature when both parents were present. We defined "target height-related short stature" (TH-SS) when child's height is ≤ - 2 SDS and included in the range of target height; suspected "autosomal dominant short stature" (AD-SS) when child height and at least one parent height are ≤ - 2 SDS; "constitutional familial short stature" (C-FSS) when a child with TH-SS does not have any parents with height ≤ - 2 SDS.

Results: Of 65 children referred for SS, 48 individuals had a height ≤ - 2 SDS. Based on the parents' measured heights, 24 children had TH-SS, 16 subjects AD-SS, and 12 individuals C-FSS. If we had considered only the parents' reported height, 3 of 24 children with TH-SS, 9 of 16 with AD-SS, and 10 of 12 with C-FSS would have been lost.

Conclusion: We suggest novel definitions to adequately detect and approach the cases of FSS since C-FSS (25%) might not need any specific investigation, while on the contrary, AD-SS (33%) should undergo genetic evaluation. Moreover, this study underlines that adequate measurement and consideration of children's and parents' heights (individually and together) are crucial in the clinical evaluation of every child with short stature.
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http://dx.doi.org/10.1186/s13052-021-01018-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7941953PMC
March 2021