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Vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC) are potentially severe and complex disease in its management among the various allergic eye diseases. In this regard, studies clarified the etiopathogenetic mechanisms. The workup should be multidisciplinary. The treatment includes topical and systemic medications with anti-inflammatory and immunosuppressant activity. However, a definition of nationally- and internationally-shared diagnostic protocols would also be needed and validated access to therapeutic options of proven safety and efficacy to avoid the use of galenic preparations, up to now still essential in the management of moderate-severe VKC. Finally, recognizing VKC and AKC, among rare diseases, at a national and international level would be an essential step to allow the management of VKC with adequate timings and settings within the National Health System.

The clinical spectrum of SARS‐CoV‐2 infection is mixed. It ranges from asymptomatic cases, medium‐intensity forms with mild to moderate symptoms, to severe ones with bilateral lung involvement and respiratory distress, which can require transfer to ICUs and intubation. In most cases, the clinical picture is characterized by a persistent fever, cough, dyspnoea, expectoration, myalgias, arthralgias, headache, gastrointestinal symptoms, nasal congestion, and pharyngodynia. The spread of COVID‐19 in Europe has highlighted an atypical presentation of disease involving upper airways and, above all, dysfunction of olfactory and gustatory senses. There is ample evidence that COVID‐19 is significantly less severe in children than in adults. However, due to difficulties in assessing the disorder in children, especially among very young patients, the olfaction and gustatory dysfunctions remain open issues. This article sheds light on the upper airway involvement in pediatric COVID‐19 subjects.

Background The role of allergic sensitization seems to be protective against SARS CoV2 infection. The aim of this study was to evaluate, using online surveys, the impact of COVID-19 on Italian allergic children, comparing the prevalence of AR and asthma symptoms between the first and second pandemic wave. Methods Both surveys were emailed to Italian pediatricians in April 2020 (first survey) and in March 2021 (second survey). The first one was related to the impact of COVID-19 and the most frequently reported symptoms. The second one was superimposed on the previous one, taking into account some additional aspects in the management of disease. Results A total of 99 pediatricians participated in the first survey and 267 in the second one. The first survey showed that, asthma and allergic rhinoconjunctivitis prevalence was mostly between 0 and 20% throughout the country. The second survey showed a lower prevalence of both diseases nationwide in comparison to the first one. Comparing the two surveys, statistically significant differences were reported only in the distribution of asthma prevalence in Southern Italy while no differences were highlighted in the North and in the Center. Finally regarding allergic rhinoconjunctivitis prevalence, no differences were noticed nationwide. Conclusions Allergic rhinoconjunctivitis and asthma, if under control, did not represent risk factors for the susceptibility to SARS CoV2. Therefore, it is strongly recommended to continue therapies during COVID-19 outbreak, according to the international guidelines. However, being COVID-19 a new disease, actual knowledge will undergo continuous improvements over time.

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.

More than a year and a half after the beginning of the coronavirus disease 2019 (COVID-19) pandemic, symptoms, such as loss of smell and taste (anosmia and ageusia, respectively), remain difficult to characterize and quantify, especially in children, since no validated tests to assess these disorders are available. However, these symptoms can also be seen in children, although less frequently than observed in the adult population. In this article, we present the results of a national survey that collected the responses of 267 Italian pediatricians on the presence of anosmia and ageusia in children affected by COVID-19. These data were then compared with existing literature.

The persistence of symptoms after recovery from Coronavirus 2019 (COVID-19) is defined as long COVID, an entity that had occurred among adults but which is not yet well characterized in pediatric ages. The purpose of this work was to present some of the data from a survey addressed to Italian pediatricians concerning the impact of long-COVID among children who recovered from severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. The questionnaire was designed and pre-tested in February 2021 by a working group of experts from the Italian Pediatric Society for Allergy and Immunology (SIAIP). The survey was emailed once in March 2021 to a sample of Italian pediatricians. A total 267 Italian pediatricians participated in our survey. According to most pediatricians (97.3%), the persistence of symptoms is found in less than 20% of children. Specifically, with regard to the symptoms that persist even after swab negativization, fatigue was the most mentioned one (75.6%). Long-COVID would seem to be a phenomenon of limited occurrence in pediatric ages, affecting less than 20% of children. Among all of the symptoms, the one that was most prevalent was fatigue, a pathological entity that is associated with many viral diseases.

Background There is ample evidence that COVID-19 is significantly less severe in children than in adults and asthma and allergy, the most common chronic disorders in children, are not included in the top 10 comorbidities related to COVID-19 fatalities. Nevertheless, concerns about asthma and allergy are still high.. In order to evaluate the impact of paediatric COVID-19 among Italian paediatricians, we sent a 20-questions anonymous internet-based survey to 250 Italian paediatricians with particular address to allergic symptoms and those affecting the upper airways. Methods The questionnaire was conceived and pretested in April 2020, by a working group of experts of the Italian Paediatric Society for Allergy and Immunology (SIAIP), and structured into different sections of 20 categorized and multiple choice questions. The first part included questions about epidemiological data follows by a second part assessing the way to manage a suspected COVID-19 infection and personal experiences about that. The third part concerned questions about patients’ clinical characteristics and clinical manifestations. The survey was emailed once between April and mid-May 2020. Results A total 99 participants had participated in our survey and provided responses to our electronic questionnaire. The distribution of patients reported per month varies significantly according to the geographical area (P = 0.02). Data confirmed that in the North part of Italy the rate of patients referred is higher than in the rest of Italy. Almost all respondents (98%) reported caring for up to a maximum of 10 infected children and the last 2% more than twenty. Among these patients, according to the 75% of responders, a maximum rate of 20% were affected by allergic rhino-conjunctivitis and in particular in the North of Italy while in the Centre and in the South there was a higher incidence (P = 0.09). Almost the same applies for asthma, 83% of responders declared that up to a maximum of 20% of affected children were asthmatic, from 20 to 40% for the 13,5% of responders and from 40 to 60% for the last 3,5%. As for the allergic conjunctivitis also for asthma, we found a higher incidence in the Centre and in South than in the North (P = 0.03). Conclusions This study is the first to provide a comprehensive review of COVID-19 knowledge and impact among paediatricians in Italy about allergic asthma and upper airway involvement. From our point of view, it provides important information clearly useful for improving a good practice.

Background There is ample evidence that COVID-19 is significantly less severe in children than in adults and it has been reported that asthma and allergy, the most prevalent chronic disorders in children, are not included in the top 10 comorbidities associated with COVID-19 fatalities. Nevertheless, there would seem that the concerns about asthma and the risk of disease and related outcomes are still high. In order to assess these features, we conducted a 20-question anonymous internet-based survey among Italian paediatricians. Methods The questionnaire was conceived and pretested in April 2020, by a working group of experts of the Italian Paediatric Society for Allergy and Immunology (SIAIP). The survey was emailed once between April and mid-May 2020. Participants were allowed to complete only a single survey.Results A total 99 participants had taken part in our survey and provided responses to our electronic questionnaire. The distribution of patients reported per month varies significantly according to the geographical area (P=0.02). Data confirmed that in the North part of Italy the rate of patients referred is higher than in the rest of Italy. Almost all respondents (98%) reported caring for up to a maximum of 10 infecting children and the last 2% more than twenty. Among these patients, according to the 75% of responders, a maximum rate of 20% were affected by allergic rhino-conjunctivitis and in particular in the North of Italy while in the Centre and in the South there was a higher incidence (P=0.09). Almost the same applies for asthma, 83% of responders declared that up to a maximum of 20% of affected children were asthmatic, from 20% to 40% for the 13,5% of responders and from 40% to 60% for the last 3,5%. As for the allergic conjunctivitis also for asthma, we found a higher incidence in the Centre and in South than in the North (P=0.03).Conclusions This study is the first to provide a comprehensive review of COVID-19 knowledge and perceptions among paediatricians in Italy. From our point of view, it provides important information clearly useful for improving a good practice.

Background Children with vernal keratoconjunctivitis (VKC) present symptoms that are similar to other ocular allergies, but more pronounced, and are controlled using topical steroids. To avoid excessive and prolonged use of topical steroid eye drops, over the past 20 years galenic eye drops of cyclosporine with a concentration of 1% to 2% and tacrolimus with a concentration of 0.1% have been introduced as a treatment for the severe and unresponsive forms. The main symptoms of VKC occur most frequently during the spring and tend to get worse during the summer, meaning that affected children tend to avoid exposure to sunlight. The aim of this study was to assess the most common cell types present in the conjunctiva of children with VKC, how ocular treatment can influence them, and whether affected children express a typical conjunctival pattern, which could be useful as a pathognomonic pattern of VKC, allowing us to study this rare eye disease. Method This was a cohort study of 56 children, of whom 17 were not receiving any treatment at the time of testing, 14 were using steroid eye drops or had taken them in the previous 10 days, and 25 were treated with cyclosporine eye drops or tacrolimus eye drops 0.1%. Result Children in group 1 (no topical therapy) express more epithelial cells, neutrophils, mast cells, eosinophils, and lymphocytes than the other two groups. Conclusion Given the ease of performance, when conducting further longitudinal studies, the conjunctival cytology examination could be used, on the one hand, to diagnose VKC, especially when the clinical diagnosis is uncertain, and, on the other, to follow disease evolution and monitor the response to topical treatment.

Vitamin D plays a pivotal role in the regulation of calcium-phosphorus metabolism, particularly during pediatric age when nutritional rickets and impaired bone mass acquisition may occur. Besides its historical skeletal functions, in the last years it has been demonstrated that vitamin D directly or indirectly regulates up to 1250 genes, playing so-called extraskeletal actions. Indeed, recent data suggest a possible role of vitamin D in the pathogenesis of several pathological conditions, including infectious, allergic and autoimmune diseases. Thus, vitamin D deficiency may affect not only musculoskeletal health but also a potentially wide range of acute and chronic conditions. At present, the prevalence of vitamin D deficiency is high in Italian children and adolescents, and national recommendations on vitamin D supplementation during pediatric age are lacking. An expert panel of the Italian Society of Preventive and Social Pediatrics reviewed available literature focusing on randomized controlled trials of vitamin D supplementation to provide a practical approach to vitamin D supplementation for infants, children and adolescents.

Vernal keratoconjunctivitis (VKC) is an inflammatory disease of the ocular surface. It commonly occurs in the first decade of life, has a wide geographical distribution, and usually occurs in warm, dry areas. The pathogenesis of VKC seems to have an immune, nervous, and endocrine basis. The most common eye symptoms are itching, discharge, tearing, eye irritation, redness of the eyes, and photophobia. Although VKC generally has a good prognosis, the lack of clarity regarding the origin of the disease makes treatment a challenge for pediatricians and ophthalmologists. The purpose of this review is to discuss the pathogenesis, clinical features, and diagnostic criteria in VKC, with a focus on its therapeutic management. The selection of a therapeutic scheme from the many available options is based on clinical features and the personal preferences of both physicians and patients. Due to the lack of uniform grading of disease severity, there is no worldwide consensus on first-line and second-line therapeutic approaches. The choice of treatment for long-term moderate to severe VKC includes topical cyclosporine or tacrolimus. Further data are needed to define the minimal effective concentration and the safety of these drugs in eye drops and to clarify the diagnosis of VKC in patients who require these drugs. Finally, while promising newly discovered drugs are expected to enter into clinical practice, further studies on their efficacy and safety are required.

The aim of this study was to evaluate whether the control of ocular symptoms with cyclosporine or with tacrolimus in eye drops allows to improve sun exposure and therefore serum level of vitamin D (VD; 25OHD), in the more severe forms of vernal keratoconjunctivitis (VKC). Out of 242 children followed for active VKC, 94 were treated with 1% cyclosporine or 0.1% tacrolimus eye drops, while the other 148 with mild VKC did not need to be treated with immunomodulators. VD serum levels were measured in spring and autumn in 71 children. In total, 60 of them were treated with cyclosporine eye drops (first group) and 11 (not responding to cyclosporine therapy previously) with 0.1% tacrolimus eye drops (second group) between March and November 2016. Pre-treatment median values of VD were 23.7 ng/mL in the first group and 23.8 in the second group, and post-treatment values increased up to 32.8 and 32.9 ng/mL, respectively. Before treatment, 33% presented a deficiency (25OHD

Background Allergic sensitization in children and allergic diseases arising therefrom are increasing for decades. Several interventions, functional foods, pro- and prebiotics, vitamins are proposed for the prevention of allergies and they can’t be uncritically adopted.Objective This Consensus document was developed by the Italian Society of Preventive and Social Paediatrics and the Italian Society of Paediatric Allergy and Immunology.The aim is to provide updated recommendations regarding allergy prevention in children.Methods The document has been issued by a multidisciplinary expert panel and it is intended to be mainly directed to primary care paediatricians.It includes 19 questions which have been preliminarily considered relevant by the panel. Relatively to each question, a literature search has been performed, according to the Italian National Guideline Program. Methodology, and a brief summary of the available literature data, has been provided.Many topics have been analyzed including the role of mother’s diet restriction, use of breast/formula/hydrolyzed milk; timing of introduction of complementary foods, role (if any) of probiotics, prebiotics, vitamins, exposure to dust mites, animals and to tobacco smoke.Results Some preventive interventions have a strong level of recommendation. (e.g., the dehumidifier to reduce exposure to mite allergens). With regard to other types of intervention, such as the use of partially and extensively hydrolyzed formulas, the document underlines the lack of evidence of effectiveness.No preventive effect of dietary supplementation with polyunsaturated fatty acids, vitamins or minerals has been demonstrated.There is no preventive effect of probiotics on asthma, rhinitis and allergic diseases. It has demonstrated a modest effect, but steady, in the prevention of atopic dermatitis.Conclusions The recommendations of the Consensus are based on a careful analysis of the evidence available.The lack of evidence of efficacy does not necessarily imply that some interventions may not be effective, but currently they can’t be recommended. Keywords: Allergy, Children, Prevention, Consensus

We reviewed current clinical evidence for the use of topical treatments in pediatric rhinosinusitis. Repeated Entrez PubMed searches were done using the template algorithm [rhinosinusitis AND (...)] with the settings: [Humans; English; All Child 0-18; Clinical trial; Last 10 yr] for the following comparators: steroid, irrigation, saline, antihistamine, decongestant, antibiotic, antimycotic, fungicide. The authors' clinical experience in the pediatric allergy unit of a university hospital was also drawn upon. Pediatric studies were retrieved but only one satisfied current evidence-based medicine standards for reporting clinical trials. Studies could not be systematized because of methodological, analytical, and interpretation biases. While saline irrigation, nasal decongestants, steroids, antibiotics, antihistamines and fungicides are all in widespread pediatric use, comparing studies from the literature for evidence of efficacy implied subjective appraisal, except in the case of topical steroids. Evidence for the efficacy of topical treatment for pediatric rhinosinusitis is narrative albeit this modality cannot be excluded from individualized patient protocols on the basis of the clinical literature alone. With the exception of topical steroids, no weighable evidence of effectiveness supports the premise that topical treatments actually serve the purpose for which they are widely prescribed in pediatrics.

Objective: Familial hypobetalipoproteinemia (FHBL) is autosomal codominant disorder of lipoprotein metabolism characterized by low plasma levels of total cholesterol (TC), low-density lipoproteincholesterol (LDL-C) and apolipoprotein B (apoB) below the 5 th percentile of the distribution in the population. Patients with the clinical diagnosis of homozygous FHBL (Ho-FHBL) are extremely rare and few patients have been characterized at the molecular level. Here we report the medical history and the molecular characterization of one paediatric patient with clinical features of Ho-FHBL. Methods: A one month old infant with failure to thrive, severe hypocholesterolemia and acanthocytosis was clinically and genetically characterized. Molecular characterization of the proband and her parents was performed by direct sequencing of the APOB gene and functional role of the identified mutations was assessed by the minigene methodology. Results: The proband was found carrying two novel splicing mutations of the APOB gene (c.3696þ1G > C and c.3697-1G > A). CHOK1H8 cells expressing minigenes harbouring the mutations showed that these two mutations were associated with the retention of intron 23 and skipping of exon 24, resulting in two truncated apoB fragments of approximate size of 26e28 % of ApoB-100 and the total absence of apoB. Conclusion: We describe the first case of Ho-FHBL due to two splicing mutations affecting both the donor and the acceptor splice sites of the same intron of the APOB gene occurring in the same patient. The clinical management of the proband is discussed and a review of the clinical and genetic features of the published Ho-FHBL cases is reported.

Correct management of anaphylactic manifestations in the emergency department is crucial to prevent mortality and future episodes, in particular for paediatric patients. We make here recommendations based on a critical review of the evidence for the management of anaphylaxis in emergency department with particular emphasis on children.Available information suggests that anaphylaxis must be promptly recognized keeping in mind the airway patency, breathing (ventilation and respiration), circulation and mental status and treated. The first treatment is epinephrine. After successful treatment of an anaphylactic episode, attention must be paid at prevention of early recurrences (biphasic anaphylaxis) and assessment of causes. Patients should not be discharged before prescribing self-injectable epinephrine and explain how and in under what circumstances it must be injected; giving an action plan to be communicated to their communities; inform the school about the possible occurrence of reactions and the appropriate avoidance and rescue measures; and consider the necessity of a Medic-Alert identification.As gross differences have been described in the awareness of the disease and its management between allergists and nonallergists, allergists should interact with emergency doctors to improve education in this area.

A 6-month-old girl presented referred for FPIES of difficult management. Admitted for suspected sepsis at 15 days after receiving milk thickened with cream of rice, she was hospitalized for suspected anaphylaxis at 5 months soon after her first rice-containing meal. Correctly diagnosed with rice-induced FPIES, she was challenged with maize to which she reacted with vomiting, hypotonia and bloody diarrhoea. Referred to this institution for investigation of cereal tolerance, we suspected industrial maize food contamination with rice and requested from a manufacturer a whole wheat flour which was tolerated at challenge. The girl reacted strongly to two accidental contacts with rice. A special diet was initiated in collaboration with the manufacturers who used the same rice-free flour to make pasta to which she did not react. Introduction of solids was predicated on a series of challenges, including beef, carrot, potato, pork, chicken, zucchini and spinach. Of note, after 5 symptom-free months, the girl reacted to accidental ingestion of a fragment of a sweet left over from the day before. This case report highlights how FPIES onset can be very early, though patients may respond to dietary management with cross-contaminant-free baby foods.