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Background: Migraine is one of the most frequent primary headaches in childhood. The role of thrombotic predisposition in its pathogenesis is debated. Our aim was to analyse the cardiovascular risk factors and family history of major thrombotic events in children with migraine. Methods: A retrospective, single-centre study was performed over 12 years. Our headache centre record database was screened for migraine with aura (MA) and migraine without aura (MO) on the basis of the ICHD-II (until 2013) and III criteria. A control group of otherwise healthy children was recruited. Descriptive and multivariate analyses are provided; significance was set at p < 0.05. Results: Migraine was diagnosed in 930 children (24.7% MA); 73.3% were 9–14 years old. Children with MA were older (p < 0.001). A family history of cerebral ischemic events at ≤50 years old was more commonly reported by children with MA than those with MO (p < 0.001) and those in the control group (p = 0.001). Children with MA showed a higher risk of a family history of cerebral ischemic events at ≤50 years old than children with MO (OR: 2.6) and those in the control group (OR: 3.1). When comparing the family history of DVT, we observed a significantly increased risk for MA vs. MO (OR: 2.9). Conclusion: A family history of cerebral ischemic events at ≤50 years old leads to an increased risk of MA. Further studies are needed to explore such an association.

Multiple investigators have described an increased incidence of thromboembolic events in SARS-CoV-2-infected individuals. Data concerning hemostatic complications in children hospitalized for COVID-19/multisystem inflammatory syndrome in children (MIS-C) are scant.To share our experience in managing SARS-CoV-2-associated pro-coagulant state in hospitalized children.D-dimer values were recorded at diagnosis in children hospitalized for SARS-CoV-2-related manifestations. In moderately to critically ill patients and MIS-C cases, coagulation and inflammatory markers were checked at multiple time points and median results were compared. Pro-thrombotic risk factors were appraised for each child and thromboprophylaxis was started in selected cases.Thirty-five patients were prospectively enrolled. D-dimer values did not discriminate COVID-19 of differing severity, whereas were markedly different between the COVID-19 and the MIS-C cohorts. In both cohorts, D-dimer and C-reactive protein levels increased upon clinical worsening but were not accompanied by decreased fibrinogen or platelet values, with all parameters returning to normal upon disease resolution. Six patients had multiple thrombotic risk factors and were started on pharmacological thromboprophylaxis. No deaths or thrombotic or bleeding complications occurred.COVID-19 pediatric patients show mildly altered coagulation and inflammatory parameters; on the other hand, MIS-C cases showed laboratory signs of an inflammatory driven pro-coagulant status. Universal anticoagulant prophylaxis in hospitalized children with SARS-CoV-2-related manifestations is not warranted, but may be offered to patients with other pro-thrombotic risk factors in the context of a multi-modal therapeutic approach.

Background: Kawasaki disease (KD) is an acute, self-limited febrile illness of unknown cause, that predominantly affects children < 5 years of age. The diagnosis is merely clinic, based on the identification of principal clinical findings and the exclusion of other clinically similar entities. Patients who do not fulfill the complete diagnostic criteria for KD are referred to as incomplete form. Lymphadenopathy is the least common symptom in patients with KD. The rate of cervical lymphadenopathy occurring as the initial presenting symptom is only approximately 12%. As a result, KD could be initially diagnosed as bacterial lymphadenitis and treated improperly with antibiotics.Case presentation: we describe the case of a 5 years-old girl of African origin presented to our emergency department with a two-day history of fever and left unilateral lymph node swelling. Persistent fever, unresponsiveness to broad-spectrum antibiotics therapy, the evidence on computerized-tomography (CT) scan of para-pharyngeal abscesses-like lesion and the onset of other characteristic clinical features that emerged gradually, provided support for a diagnosis of incomplete KD. The excellent response within 24 hours after administration of intravenous immunoglobulin (IVIG) and the rapid resolution of fever, confirmed the correct diagnosis of incomplete KD.Conclusions: from this case we need to realize that para-pharyngeal involvement with edema, cellulitis and abscess-like lesions is a rare, but possible initial manifestation of KD. To avoid delayed diagnosis, clinicians have to be alert to identifying head and neck manifestations as a possible early presentation of KD and include it as a routine differential diagnosis for suspected parapharyngeal abscesses.

Methemoglobinemia (MetHb) is a rare inherited or acquired cause of cyanosis in children. Owing to its rarity, case reports and case series are mostly available in the current literature. This study reports data on a large sample of children with acquired MetHb.Data on patients admitted for acquired MetHb between January 2007 to December 2020 was extracted from the databases of five Italian pediatric emergency departments (EDs). Demographical and clinical characteristics was reported and discussed.Nineteen cases of acquired MetHb were evaluated. Ten patients (52.6%) were male and 9 (47.4%) were female. The median age was 8.23 months. The median time from trigger to symptom onset was 6 hours. Mostly, the intoxication presumptively occurred by home ingestion of contaminated food, mainly badly preserved vegetable broth. All patients were cyanotic at admission, most patients also presented tachycardia and/or tachypnea, and two patients were comatose. Antidotal therapy with methylene blue was given in 14 patients (73.7%). The median hospital stay was 2 days. All patients survived.As MetHb leads to the pathognomonic brown blood discoloration, blood gas analysis is mandatory immediately upon hospital arrival of a cyanotic patient. A correct medical history is crucial to identify the trigger and remove it. In our sample, the age onset was much lower than in the previous literature, and MetHb mainly due to ingestion of contaminated vegetable broth. Methylene blue led to a rapid recovery in all patients. Oxygen therapy may well lead to complete recovery when methemoglobin levels do not exceed 30% in asymptomatic and 20% in mildly symptomatic patients.The diagnosis and management of acquired MetHb in the emergency setting requires acknowledgment of this condition as a cause of cyanosis in the weaning child. Indeed, when promptly recognized and treated, this severe condition rapidly resolves with no significant acute sequelae.

Purpose - Child abuse and neglect (CAN) is a worldwide issue due to its biological, psychological, and social effects. Research in this field is particularly useful to understand CAN aspects which are still unknown and to define updated intervention strategies. Until now, there are no clear indications about the possible effects determined by the SARS-CoV-2 pandemic on CAN. For these reasons, the authors of the present manuscript propose a study in which they compared quantitative and qualitative variables of pre-pandemic and pandemic cases evaluated at an Italian ambulatory specialized in diagnosis and management of CAN. The main aims were to: define if there was a reduction or an increase of cases referred for CAN during SARS-CoV-2 pandemic; evaluate if there were statistically significant differences of variables’ distributions between pre-pandemic and pandemic periods. Methods - The study included children 0 - 18 years of age who were referred to the specialized ambulatory during the first 13 months of the SARS-COV-2 pandemic in Italy: March 2020 - March 2021. As control group (Group B - GB), the authors chose children 0 - 18 years of age evaluated by the healthcare professionals of the same ambulatory from March 2018 to March 2019. Ages and main qualitative variables were compared between the two samples throughout statistical tests. Results - The analysis yielded no statistical differences for age distributions and for the most part of qualitative variables. The study pointed out a reduction of the distribution of the number of cases. Conclusions - In this study, the comparison of frequencies’ distribution of the most part of variables between pre and post pandemic samples did not differ. The most important result of the present analysis is that in the pandemic period the volume of observed CAN cases decreased. This allows us to confirm the indications of the scientific literature. We cannot exclude that the decrease was due to a negative impact of the pandemic on the child protection system. The afore-mentioned data will be useful to program corrective interventions, also for future pandemic and disasters.

OBJECTIVE: By forcing closure of schools, curtailing outpatient services, and imposing strict social distancing, the COVID-19 pandemic has abruptly affected the daily life of millions worldwide, with still unclear consequences for mental health. This study aimed to evaluate if and how child and adolescent psychiatric visits to hospital emergency departments (EDs) changed during the pandemic lockdown, which started in Italy on February 24, 2020. METHODS: We examined all ED visits by patients under 18 years of age in the 7 weeks prior to February 24, 2020, and in the subsequent 8 weeks of COVID-19 lockdown at two urban university hospitals, in Turin and Rome, Italy. ED visits during the corresponding periods of 2019 served as a comparison using Poisson regression modeling. The clinician's decision to hospitalize or discharge home the patient after the ED visit was examined as an index of clinical severity. RESULTS: During the COVID-19 lockdown, there was a 72.0% decrease in the number of all pediatric ED visits (3,395) compared with the corresponding period in 2019 (12,128), with a 46.2% decrease in psychiatric visits (50 vs 93). The mean age of psychiatric patients was higher in the COVID-19 period (15.7 vs 14.1 years). No significant changes were found in hospitalization rate or in the prevalence distribution of the primary reason for the psychiatric ED visit (suicidality, anxiety/mood disorders, agitation). CONCLUSIONS: In the first 8 weeks of the COVID-19-induced social lockdown, the number of child and adolescent psychiatric ED visits significantly decreased, with an increase in patient age. This decrease does not appear to be explained by severity-driven self-selection and might be due to a reduction in psychiatric emergencies or to the implementation of alternative ways of managing acute psychopathology.

Background Rapid identification of Covid-19 in the paediatric emergency department is critical; Antigen tests are fast but poorly investigated in children. Aims To investigate Sars-CoV-2 antigen rapid test in children. Methods We compare the performance of LumiraDx with molecular tests in a paediatric emergency department. Results A retrospective cohort of 191 patients with AT and PCR tests performed in the same episode was analysed; 16% resulted positive for Sars-CoV-2. Using the PCR test as the gold standard, we calculated antigen testing overall sensitivity of 94.1%, specificity of 91.9%, and NPV of 99.4%. Only one false-negative test was found. Conclusions AT may be helpful in the initial screening of patients at PED.

Some aspects of the management of caustic ingestion in children are still debated. We aimed to determine the predictive value of epidemiological and clinical features of caustic ingestion, and to define guidelines adherence. This is a retrospective study on children ≤18 years referred to our Emergency Department over 6 years because of caustic ingestion. Statistical significance at p

The rapid spread of the novel coronavirus (severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)) in Italy forced a prompt hospital reorganisation in the past 2 months. Every clinic has been divided into two separate departments, based on the detection of SARS-CoV-2 in the nasopharyngeal swab.1 In children, three main variables complicate this: first, the not optimal sensitivity of nasopharyngeal swabs, mainly due to technical difficulties2; second, the need of a caregiver during the hospital stay; finally, the high number of paediatric diseases manifesting with fever or cough, thus sharing symptoms of COVID-19, which cause about 25% of emergency department (ED) admissions.3 All these elements make the paediatric testing strategy more challenging. We performed an observational study at Regina Margherita Children’s Hospital of Turin. Two cohorts of patients were collected: cohort A included all the children admitted to the ED from 2 March 2020 through 22 April 2020, with COVID-19-related symptoms; cohort B was composed of patients …

Background Data about acute poisoning in Italian pediatric patients are obsolete or absent. This study would partially fill this exiting gap and compare the scene with others around the world. Methods A retrospective evaluation was performed on a 2012–2017 data registry of the Children’s Emergency Department at the Regina Margherita Hospital of Turin, where 1030 children under age 14 were accepted with a diagnosis of acute intoxication. Results The median age of the patients was 2.2 years (IQR 2.3) and 55% were male. Events occurred mostly in children aged 1–4 years (n = 751, 72.9%). Six hundred and eight patients (59%) were exposed to Nonpharmaceutical agents, the household cleaning products being the more frequent (n = 298, 49%). Exposure to Pharmaceuticals were 422 (41%); the most common Pharmaceuticals were analgesics (n = 88, 20.8%), psychotropics (n = 77, 18.2%) and cardiovascular (n = 53, 12.6%) drugs. The 85% of the intoxications occurred accidentally, the 10.6% as therapeutic error, the 2.3% as suicide attempts and the 1.5% for recreational purposes. No patient died. Conclusions Despite acute poisoning being a relevant problem in pediatric emergency, our results would seem to paint a less worrying picture if compared to other countries, mainly when considering the children hospitalized in the pediatric intensive care unit and the number of deaths. Nevertheless, our study might represent a tool for public health authorities to program incisive interventions.

Background COVID-19 pandemic caused huge decrease of pediatric admissions to Emergency Department (ED), arising concerns about possible delays in diagnosis and treatment of severe disorders. Methods Impact of COVID-19 on Pediatric Emergency Room (ICOPER) was a retrospective multicentre observational study including 23 Italian EDs. All the children

IntroductionLimited data exist on epidemiology, clinical presentation and management of acute hyperkinetic movement disorders (AHMD) in paediatric emergency departments (pED).MethodsWe retrospectively analysed a case series of 256 children (aged 2 months to 17 years) presenting with AHMD to the pEDs of six Italian tertiary care hospitals over a 2-year period (January 2012 to December 2013).ResultsThe most common type of AHMD was tics (44.5%), followed by tremors (21.1%), chorea (13.7%), dystonia (10.2%), myoclonus (6.3%) and stereotypies (4.3%). Neuropsychiatric disorders (including tic disorders, psychogenic movement disorders and idiopathic stereotypies) were the most represented cause (51.2%). Inflammatory conditions (infectious and immune-mediated neurological disorders) accounted for 17.6% of the cases whereas non-inflammatory disorders (including drug-induced AHMDs, genetic/metabolic diseases, paroxysmal non-epileptic movements and idiopathic AHMDs) accounted for 31.2%. Neuropsychiatric disorders prevailed among preschoolers and schoolers (51.9% and 25.2%, respectively), non-inflammatory disorders were more frequent in infants and toddlers (63.8%), whereas inflammatory conditions were more often encountered among schoolers (73.3%). In 5 out of 36 Sydenham’s chorea (SC) cases, tics were the presentation symptom on admission to emergency department (ED), highlighting the difficulties in early diagnosis of SC. Inflammatory disorders were associated with a longer hospital stay and a greater need of neuroimaging test compared with other disorders.ConclusionsThis study provides the first large sample of paediatric patients presenting to the ED for AHMDs, helping to elucidate the epidemiology, aetiology and clinical presentation of these disorders.

Background Acute diplopia (AD) is an uncommon and distressing symptom of numerous ocular and neurological conditions, with potentially serious sequelaes. No data are present in pediatrics on the presentation and management of AD. Aim This study investigated characteristics, etiology and health care utilization of the pediatric population with AD accessed to pediatric Emergency Departments (ED), trying to identify “red flags” associated with potentially life -threatening (LT) conditions. Methods We conducted a cohort multicenter study on children with AD in ten Italian hospitals. Patients were classified into diagnostic categories, comparing children with and without LT disease. Results 621 children presented AD at a rate of 3.6 per 10.000. The most frequent diagnosis among no-LT conditions (81.2%) were headache, ocular disorders and minor post-traumatic disease, while LT conditions (18.8%) were represented by brain tumors, demyelinating conditions, idiopathic intracranial hypertension and major post-traumatic diseases. The LT group showed a significantly higher age, with the odds increased by 1% for each month of age. Monocular diplopia occurred in 16.1%, but unlike adult one-fifth presented LT conditions. Binocular diplopia, associated ocular manifestations or extraocular neurological signs were significantly more common in the LT group. At regression logistic analysis strabismus and ptosis were associated with LT conditions. Conclusion The majority of children presented no-LT conditions and more than one-fourth of patients had headache. Monocular diplopia in the LT group was never isolated but associated with other signs or symptoms. Our study was able to identify some specific ocular disturbances or neurologic signs potentially useful for ED physician to recognize patients with serious pathologies.

Purpose of review Endocrine dysfunctions have been increasingly recognized following traumatic brain injury. Ever more numerous studies on acute head-injured adults have also raised concern about this risk in children and adolescents who have experienced head injury. The current review of the pediatric literature summarizes recent findings on acute-phase dysfunction and traumatic brain injury-associated hypopituitarism. Recent findings The pathophysiologic mechanisms underlying acute-phase hyponatremic and hypernatremic disorders have been elucidated. Prospective studies on traumatic brain injury-associated hypopituitarism in pediatric patients are ongoing and preliminary data are available. Summary Traumatic brain injury, a 'silent epidemic' that carries a considerable burden of disabilities, leads to a variety of endocrine dysfunctions in 28-69% of adult acute head-injured patients. In the acute posttraumatic phase, adrenal insufficiency and electrolyte disorders are critical conditions. Neurosurgical patients, particularly those prone to neurological damage, require prompt diagnosis. Hypopituitarism may be diagnosed months or years after a traumatic brain injury event. Since growth hormone and gonadotropin secretion are most frequently compromised, careful follow-up of growth and pubertal development is mandatory in children hospitalized for traumatic brain injury.

Familial Combined Hyperlipidemia is an inherited disorder affecting cholesterol and triglycerides metabolism, well known myocardial infarction risk factors. The FCHL clinical presentation is usually silent until the third decade although children can be affected, and the more recent opinion is that precocious diagnosis is mandatory in preventing complications. Aim of this study is to examine the effectiveness of the diet therapy (Step-One-Diet) in a group of 13 children affected by Familial Combined Hyperlipidemia.The patients have been submitted to a normocaloric diet, 30% fat of the total caloric daily intake according with the Dietary Intervention Study in Children (Step-One-Diet). The patients then have been submitted to a two year-follow-up and lipoprotein levels (total cholesterol, LDL-cholesterol, triglycerides and apolipoprotein B), nutritional status (macro- and micro-nutrients) as well as anthropometric data (height, weight, BMI) have been monitored.Results showed a 10% total cholesterol and 30% triglycerides decrease, Iron and Calcium intake show increased levels approaching to the normal ones after controlled diet, while cholesterol intake was correct on both regimen. The growth parameters show a decrease in weight only in two obese and two overweight patients.The present study confirmed the effectiveness and safety of the Step-One-Diet in children patients, allowing triglycerides normalization in 60% of the patients, and a 10% cholesterol decrease, in agreement with the complex genetic inheritance of the disease.