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La sincope è una perdita di coscienza improvvisa, completa, di breve durata, con o senza prodromi e a risoluzione spontanea, che rappresenta una causa frequente di accesso in Pronto Soccorso pediatrico o presso l’ambulatorio del pediatra di famiglia. Nella maggior parte della popolazione pediatrica la sincope è vaso-vagale, condizione benigna per cui è necessaria solo terapia comportamentale. Sebbene più rara, nell’ambito della valutazione va sempre esclusa la sincope di origine cardiogena, ricercando la presenza o meno delle cosiddette bandierine rosse per sincope non vaso-vagale.

A four-year old girl is evaluated for 8 recurrent episodes of perineal bleeding of undefined origin appeared six months before. Physical examination is normal except for a small anal fissure and a mild congestion of external haemorrhoids during Valsalva manoeuvre. Different diagnostic hypotheses and treatment options are discussed.

Anomalous aortic origin of coronary artery (AAOCA) is a rare condition and the second cause of sudden cardiac death among young athletic patients. Suspicion should arise in the presence of exertional syncope without prodrome, chest pain and/or dyspnea. An accurate transthoracic echocardiogram with Doppler colour flow mapping is the best and first method to identify AAOCA, followed by cardiac CT or MRI to define the coronary anatomy that could benefit from corrective cardiac surgery.

Background Although children with special health care needs (CSHCN) represent a minority of the population, they go through more hospitalizations, more admissions to the Emergency Department (ED), and receive a major number of medical prescriptions, in comparison to general pediatric population. Objectives of the study were to determine the reasons for admission to the ED in Italian CSHCN, and to describe the association between patient’s demographic data, clinical history, and health services requirements. Methods Ad hoc web site was created to collect retrospective data of 3479 visits of CSHCN to the ED in 58 Italian Hospitals. Results Seventy-two percent of patients admitted to ED were affected by a previously defined medical condition. Most of the ED admissions were children with syndromic conditions (54%). 44.2% of the ED admissions were registered during the night-time and/or at the weekends. The hospitalization rate was of 45.6% among patients admitted to the ED. The most common reason for admission to the ED was the presence of respiratory symptoms (26.6%), followed by gastrointestinal problems (21.3%) and neurological disorders (18.2%). 51.4% of the access were classified as ‘urgent’, with a red/yellow triage code. Considering the type of ED, 61.9% of the visits were conducted at the Pediatric EDs (PedEDs), 33.5% at the Functional EDs (FunEDs) and 4.6% at the Dedicated EDs (DedEDs). Patients with more complex clinical presentation were more likely to be evaluated at the PedEDs. CSHCN underwent to a higher number of medical procedures at the PedEDs, more in comparison to other EDs. Children with medical devices were directed to a PedED quite exclusively when in need for medical attention. Subjects under multiple anti-epileptic drug therapy attended to PedEDs or FunEDs generally. Patients affected by metabolic diseases were more likely to look for medical attention at FunEDs. Syndromic patients mostly required medical attention at the DedEDs. Conclusions Access of CSHCN to an ED is not infrequent. For this reason, it is fundamental for pediatricians working in any kind of ED to increase their general knowledge about CHSCN and to gain expertise in the management of such patients and their related medical complexity.

A fourteen-year-old girl presented with a history of intermittent bilateral swelling in her ankles associated with moderate but progressively worsening pain that lasted for two years. The patient had been previously investigated and ankle X-rays, US and MRI, echocardiogram, blood and urine tests were negative. Physical examination highlighted bilateral non-pitting oedema. A scintigraphy was performed. The present paper discusses different diagnostic hypotheses and treatment options.

Ognuno di noi ha avuto o avrà prima o poi a che fare con la spirometria. Che si tratti di richiederla, eseguirla o interpretarla è importante avere ben presente quale sia il ruolo di questo esame (per quale paziente lo richiedo? Cosa voglio sapere?), quali le modalità di eseguirlo (ho ottenuto un risultato attendibile? Ci sono errori che devo evitare?), cosa vado a misurare (cosa mi può dire la curva di questo bambino?). Solo se consapevoli delle risposte a queste domande potremo sfruttare al meglio questa risorsa, interpretandone i risultati con spirito critico. A tale scopo questo articolo si rivolge ai “non addetti ai lavori”, cercando di percorrere i punti principali e fornendo i trucchi del mestiere attraverso i casi clinici vissuti più comuni.

A three-month-old infant was referred to the emergency department with fever and a right cervical abscess. Nasopharyngeal swab was positive for SARSCoV- 2 infection. Main causes of infectious abscess and immunodeficiency disorders were ruled out. After a surgical drainage and an antibiotic therapy, clinical conditions of the infant improved, and Staphylococcus Aureus was found in the wound drainage culture. This is a possible, not yet described in infant patients, concurrent clinical manifestation of SARS-CoV-2 infection.

Background In Italy, as in many European countries, Pediatric Emergency Medicine is not formally recognized as a pediatric subspecialty, hindering nation-wide adoption of standards of care, especially in the field of procedural sedation and analgesia (PSA) in the Emergency Department (ED). For this reason PSA in Italy is mostly neglected or performed very heterogeneously and by different providers, with no reference standard. We aimed to describe the procedures and results of the first multidisciplinary and multi-professional Consensus Conference in Italy on safe and effective pediatric PSA in Italian EDs. Methods The preparation, organization and conduct of the Consensus Conference, held in Florence in 2017, followed the recommended National methodological standards. Professionals from different specialties across the country were invited to participate. Results Overall 86 recommendations covering 8 themes (pre-sedation evaluation, pharmacologic agents, monitoring, equipment and discharge checklists, training, non-pharmacologic techniques, the adult ED setting, impact on hospitalizations) were developed, taking into account the Italian training system and healthcare organization characteristics. Conclusion The results of the first multidisciplinary and multi-professional Consensus Conference in Italy are meant to provide up-to-date national guidance to improve the standard of care of children undergoing painful and stressful procedures in the ED. The recommendations will be periodically updated as new relevant evidence is published.

This article corrects the Guidelines by Green SM, Leroy PL, Roback MG, Irwin MG, Andolfatto G, Babl FE, Barbi E, Costa LR, Absalom A, Carlson DW, Krauss BS, Roelofse J, Yuen VM, Alcaino E, Costa PS, Mason KP on behalf of the International Committee for the Advancement of Procedural Sedation, ‘An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children’ [1]. The authors thank a careful reader who identified that a study from this table by Rajasekaran et al should have been excluded, as it included fewer than 5000 patients. The corrected table without this study is shown below, and this change does not alter our other findings and conclusions. An author and corresponding affiliation were omitted and is now revised as follows: 1 Table Literature estimates of aspiration risk during procedural sedation* (Table presented.) * To include just the largest studies we display those with 5,000 or more patients. We also exclude studies which report duplicate sub-sets of patients.

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Hidradenitis suppurativa (HS) is a chronic and recurrent skin disease affecting apocrine gland-bearing regions. Typical lesions are nodules and abscesses that result in sinus tracts, fistulas and eventually scarring. Prepubertal onset of HS is quite rare, representing only 2% of all HS cases, which are frequently expression of genetic forms, hormonal imbalances or systemic autoinflammatory diseases. Therapy is severity-tailored ranging from topical antibiotics to monoclonal antibodies, saving surgery for unresponsive cases. Early diagnosis and prompt treatment are fundamental to arrest disease progression to milder stages, giving children the opportunity to keep a good quality of life without getting stuck on this condition.

Hyphema refers to an accumulation of red blood cells within the anterior chamber of the eye and is more frequently a consequence of trauma. Particularly, blunting trauma due to plastic projectiles is increasingly reported as its cause. Isolated low-grade hyphema does not represent an emergency, but deferred urgency. The paper reports the case of a 17-year-old boy who presented with a hyphema after blunt ocular trauma and highlights important teaching points for the Emergency Room paediatricians.

Pain is a frequent symptom in paediatric population, especially in the emergency setting; nevertheless pain is poorly managed in clinical practice. The present paper aims to give an up-to-date analysis concerning paediatric pain in emergency units, as regards epidemiology, assessment, measurement and treatment, through a detailed systematic revision of the literature and an on-going clinical trial assessment carried out by analysing the relevant data available until March 2018. Among the many paediatric pain scales for different ages and situations and according to their efficacy and efficiency, FLACC scale, Wong-Baker scale and FLACC-r or NCCPC-R scale are proposed. Moreover, pharmacological and non-pharmacological strategies should always be considered; innovative strategies, new molecules and route of administration allow adequate therapies to be performed in many clinical situations. Emerging data suggest the need to carry out more research on pain prophylaxis, increase opioid drugs prescription in case of severe pain and reduce primary analgesia time. Therefore, an adequate management of pain in paediatric population in the emergency setting is still a goal to achieve. So, innovative organisational arrangements, training strategies addressed to health professionals, information and research are the instruments to imprint a real change in paediatric pain management in emergency units.

Paediatric palliative care (PPC) aims to ensure the control of symptoms and the best possible quality of life for patients whose underlying disease, characterised by an unstoppable evolution and negative prognosis, no longer responds to specific treatments. The Italian Medicines Agency (Agenzia Italiana del Farmaco - AIFA) and the Italian Society of Palliative Care (Società Italiana di Cure Palliative - SICP), within a dedicated working group, wrote a document that collects the scientific evidence available to support the offlabel drugs that are more frequently used in adult and PPC. The goal is to certify the consolidated off-label use of these drugs (under the Law 648/96), in the absence of data from its pivotal clinical trials. The paper reports the conditions for this important work and presents the 10 drugs that are usually used off-label in PPC and in pain therapy. At present they are included in Law 648/96 and deemed essential to resolve, at least in part, the unavailability of medicines approved for use in this specific setting.

At the moment alterations of SHOX gene, located in the pseudoautosomal region of sex chromosomes, are considered the most frequent genetic defects associated with short stature. Pathogenic mutations leading to SHOX deficiency involve not just exons, but also enhancer regions (affected in almost half of the cases) and follow an autosomal dominant inheritance pattern. Independently of the mutation, clinical severity varies between genders and ranges from idiopathic short stature to severe mesomelic skeletal dysplasia. Growth hormone is a valid treatment option to promote growth in this condition. In this article, current knowledge on manifestations, diagnosis and treatment of SHOX deficiency in children is summarised by a clinical case.

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Functional and somatic disorders are common in childhood and can become long-lasting and disabling. This study showed a 6.9% prevalence of children with emotional distress and/or mental disorders among children admitted to a third level paediatric ward for physical symptoms. Most cases were characterised by long-lasting symptoms, “doctor shopping”, school absenteeism and functional disability. A psychiatric disorder, mostly an anxious-depressive status, was observed in 21% of cases. At a two-year followup, the symptoms and the disability were still present in 34% of cases in spite of a declared exclusion of any organic disease and the activation of a multidisciplinary therapeutic approach aimed to reduce symptoms and disability. Functional and somatic disorders are frequent in children admitted to hospital for physical complaints. The prognosis of these cases is still unacceptably poor. Paediatricians should improve their skills in facing this emerging problem.