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Covid-19 causedhospitalizations, severe disease and deaths in any age, including in the youngest children. The aim of this multicenter national study is to characterize the clinical and the prognostic role of lung ultrasound (LUS) in children with Covid-19. We enrolled children between 1 month and 18 years of age diagnosed with SARS-CoV2 infection and whounderwenta lung ultrasound within 6 hours from firstmedical evaluation. A total of 213 children were enrolled, 51.6%were male, median age was2 years and 5 months (IQR 4mm- 11 yearsand4 months).One hundred and fortyeight (69.4%) children were admitted in hospital, 9 (6.1%) in pediatric intensive care unit.We found an inverse correlation between the LUS score and the oxygen saturationatthe clinical evaluation (r = −0.16; p = 0.019). Moreover, LUS scores were significantly higher in patients requiring oxygen supplementation (8 (IQR 3 - 19) vs 2 (IQR 0 - 4); p= 0.001). Among LUS pathological findings, irregular pleural line, sub-pleural consolidations and pleural effusions were significantly more frequentin patients whoneeded oxygen supplementation (p = 0.007; p = 0.006 andp = 0.001, respectively). This multicentric study confirmed that LUS is able to detect Covid-19 low respiratory tract involvement, which is characterized by pleural line irregularities, vertical artifacts and subpleural consolidations. Notably, children with higher LUS score have an higher risk of hospitalization or need for oxygen supplementation, supporting LUS as a valid and safe point-of-care first level tool for the clinical evaluation of children with Covid-19.

The soft scalp hematoma is one of the clinical markers used as a predictor for the presence of intracranial injury in children with a head trauma. We evaluated the significance of time presentation in the management of these patients.We conducted a retrospective study of children and adolescents aged 0 to18 years by comparing the clinical, radiological, and epidemiological features in those presenting within 24 hours with those presenting greater than 24 hours after a head injury.We identified 188 and 98 patients with early presentation and late presentation, respectively. The percentage of children aged 0 to6 months was lower in those with late presentation (6.12%) than those with early presentation (20.21%) with a significant difference (P.001). Likewise, the percentage of children aged ≥24 months was lower in children with late presentation (7.14%) than those with early presentation (34.04%) with a significant difference (P.001). The severe mechanism rate was more elevated in early presentation (38.83%) with a significant difference (-14.34%; 95% confidence interval [CI], -25.34% to -3.34%; P = .015). The symptom rate resulted higher in early presentation (14.36%) with a significant difference (-11.30%; 95% CI, -17.36% to 5.22%; P = .003). The parietal scalp hematoma occurred mostly in children with late presentation (85.71%) with a significant difference (19.76%; 95% CI, 10.07% to 29.45%; P.001). The occipital scalp hematoma rate was higher in early presentation with a significant difference (-17.50%; 95% CI, -22.99% to -12.12%; P.001). There was no significant difference in the prevalence of different types of intracranial injury, and the only 5 patients needing a neurosurgical intervention were exclusively children with an early presentation.Although children with soft scalp hematoma presenting to the emergency department greater than 24 hours after a head injury may have pathological findings on computed tomography, all of them had a good short- and long-term outcomes, and no neurological deterioration aroused the medical attention on follow-up. For this subset of patients that does not experience red flags (neurological symptoms, focal signs on examination, or severe injury mechanism), a wait-and-see approach might be more appropriate rather than neuroimaging.

Point-of-care ultrasound (POCUS) is a growing interesting tool in the emergency setting. Its usefulness in diagnostic and therapeutic pathway of patients with respiratory distress in addition to clinical evaluation is well established in adult emergency medicine while paediatric specific data, although growing, remain limited. We report a case series of paediatric patients presenting with respiratory distress successfully diagnosed with cardiac dysfunction following POCUS evaluations. Lung POCUS, in combination with cardiac POCUS, is a very useful supplementary diagnostic tool to assess the breathless child and to rapidly identify life-threatening primary etiologies or secondary physiologies. Thus, fast echocardiography is a desirable aid for paediatric emergency physicians and should be supported in all paediatric emergency settings following an adequate training that is mandatory regarding image acquisition and data interpretation.

Objectives The study aimed to evaluate the emergency department (ED) presentation of children with a diagnosis of osteomyelitis, septic arthritis, or both. Methods A retrospective single-center study was conducted on all children aged between 1 month and 18 years evaluated in the ED over a 7-year period and having a final diagnosis of osteoarticular infection. One hundred seventeen patients were enrolled. Results Only 39.3% of patients were admitted after the first evaluation, and only 45.3% had a proper diagnosis of admission. Pain was the only symptom reported by all. White cell count, C-reactive protein level, and erythrocytes sedimentation rate were normal in 49.5%, 21.4%, and 17.1% of children, respectively. X-ray findings were unremarkable in 48% of cases. Clinical and bone structural sequelae were described in 19.23% and 56.86% of all cases. No statistically significant differences were found among osteomyelitis, arthritis, and the combination of both regarding all considered variables, except for structural outcomes resulting more significant in the third group. Significant differences were evident in clinical manifestations, blood examinations, and findings of osteolysis between patients diagnosed within and after 1 week since the disease onset. Finally, questionable differences between white blood cells and C-reactive protein level were found among patients younger than 5 years and older ones, whereas a history of trauma was more often reported in the second group. Conclusions The difficulty in recognizing osteoarticular infection in a pediatric ED can be due to the possible lack of the classic signs and symptoms, and the absence of specific laboratory and radiologic findings.

Background: To date, there are no data regarding the systematic application of Point-of-Care Lung Ultrasound (PoC-LUS) in children with Multisystem Inflammatory Syndrome in Children (MIS-C). The main aim of this study is to show the role of Point-of-Care Lung Ultrasound as an additional aid in the diagnosis of COVID-19-related Multisystem Inflammatory Syndrome in Children (MIS-C). Methods: Between April 2020 and April 2021, patients aged 0–18 years referred to our emergency department for fever, and later hospitalized without a specific diagnosis, underwent PoC-LUS. Ultrasound images of patients with a final diagnosis of MIS-C were retrospectively evaluated. Results: Ten patients were enrolled. All were described to have pleural irregularities and B-lines. In particular: 8/10 children presented with isolated B-lines in at least half of the lung areas of interest; 8/10 presented with multiple B-lines and 3/8 had them in at least 50% of lung areas; 5/10 had a white lung appearance in at least one lung area and 1/5 had them in half of the areas of interest. Pleural effusion was described in 9/10. Conclusions: During the ongoing COVID-19 pandemic, we suggest performing PoC-LUS in febrile patients with high levels of inflammatory indices and clinical suspicion of MIS-C, or without a certain diagnosis; the finding of many B-lines and pleural effusion would support the diagnosis of a systemic inflammatory disease.

Introduction Understanding how the use of hoverboards (HBs) can affect a child’s safety is crucial. We describe the characteristics of HB related injuries and provide key messages about child prevention when using these leisure devices. Methods This was a retrospective study at an emergency department (ED) of a level-III-trauma center from 2016 to 2019. We tested the differences in children presenting for injury associated with HBs between 2016-2017 and 2018-2019 to better describe the temporal trend of the phenomenon. Results The rate of Injury associated with HBs / Total injury per 1,000 increased from 0.84 in 2016 to 7.7 in 2017, and then there was a gradual decline. The likelihood of injury was more common in younger children, increasing by 17% with decreasing age in 2018-2019 compared with 2016-2017 (OR: 0.83; 95%CI: 0.71-0.97; p = 0.021). The occurrence of injury in the April-June period was over twice as common in 2018-2019 (OR: 2.05; 95%CI: 1.0-2.05; p = 0.05). Patients were over 4 times more likely to have injured the lower extremity during the 2018-2019 period rather than other body regions (OR: 4.58; 95%CI: 1.23-4.58; p = 0.02). The odds of the indoor injury were more than twice as high in 2018-2019 (OR: 2.04; 95%CI: 1.077-2.04; p = 0.03). Conclusion Despite a decrease in the frequency of HB related injuries after 2017, during the 2018-2019 period, the younger the children, the more they were exposed to injury risk, in addition to a greater occurrence of indoor injuries from HBs compared with 2016-2017. The enhancement of preventive measures is necessary to ensure child safety when using HBs.

Background: The aim of this study was to analyze the lung ultrasound (LUS) patterns in combination with clinical-laboratory profiles of children hospitalized for COVID-19 infection in relation to temporal trend of the Italian epidemic. Methods: This was a retrospective study conducted at a pediatric tertiary referral hospital from 15th March 2020 to 15th March 2021. We compared the characteristics of two periods of the pandemic outbreak, the first one in spring and summer (15th March-30th September 2020) and the second one in autumn and winter (1st October 2020-15th March 2021). Results: 28 patients (53.85%) were in the first period, 24 patients (46.15%) were in the second period. The disease severity score was significantly higher in the second period (p=0.02). We observed that the occurrence of the irregular pleural line was seen more frequently in the second period (87.5% vs 60.71%; p=0.03). The B-lines were significantly more frequent in children in the second period (87.5% vs 60%; p=0.03). The several but not-coalescent B-lines were significantly more frequent in the second period (80% vs 41.7%; p=0.05). The LUS score correlated significantly with the disease severity score with a strong relationship (r=0.51, p=0.002). The second phase of the COVID-19 epidemic outbreak had a higher disease severity score than the first phase with a moderate correlation (r= 0.42; p=0.01). Conclusion: The LUS plays an important role in the evaluation of pulmonary involvement in children affected by COVID-19 during different periods of the pandemic in combination with clinical-laboratory findings.

Understanding how the use of hoverboards (HBs) can affect a child’s safety is crucial. We describe the characteristics of HB related injuries and provide key messages about child prevention when using these leisure devices. This was a retrospective study at an emergency department (ED) of a level-III-trauma center from 2016 to 2019. We tested the differences in children presenting for injury associated with HBs between 2016–2017 and 2018–2019. The rate of injury associated with HBs / Injury per 1,000 increased from 0.84 in 2016 to 7.7 in 2017, and then there was a gradual decline. The likelihood of injury was more common in younger children, increasing by 17% with decreasing age in 2018–2019 compared with 2016–2017 (OR: 0.83; 95%CI: 0.71–0.97; p = 0.021). The occurrence of injury in the April-June period was over twice as common in 2018–2019 (OR: 2.05; 95%CI: 1.0-2.05; p = 0.05). Patients were over 4 times more likely to have injured the lower extremity during the 2018–2019 period rather than other body regions (OR: 4.58; 95%CI: 1.23–4.58; p = 0.02). The odds of the indoor injury were more than twice as high in 2018–2019 (OR: 2.04; 95%CI: 1.077–2.04; p = 0.03). Conclusion: Despite a decrease in the frequency of HB related injuries after 2017, during the 2018–2019 period, the younger the children, the more they were exposed to injury risk, in addition to a greater occurrence of indoor injuries from HBs compared with 2016–2017. The enhancement of preventive measures is necessary to ensure child safety when using HBs.

Point-of-care lung ultrasound is a widely used tool in the diagnosis and management of patients with pulmonary diseases and now with SARS-CoV-2 infection. We describe two cases of pneumothorax which are, as far as we know, among the first reported in COVID-19 patients younger than 18 years. The diagnostic and monitoring role of point-of-care lung ultrasound has been extremely useful in the management of patients.

Objectives- We prospectively analyzed children with acute chest pain and clinical suspicion of pneumothorax (PNX) evaluated at the pediatric Emergency Department. Methods- After clinical examination and before Chest X-Ray, children underwent LUS to evaluate the presence of PNX. We enrolled 70 children, 13 (18,57%) received a final diagnosis of PNX. Results- In all 13 (100%) patients LUS showed the “bar-code sign”, the absence of lung sliding and the absence of B lines while in 12 (92,3%) there was the lung point, giving a diagnosis of PNX. All cases had PNX features on CXR. The “bar-code sign”, the absence of lung sliding and the absence of B lines had a sensitivity of 100% and a specificity of 100%. The “bar-code sign” had a positive predictive value of 100% and a negative predictive value of 100% for the detection of PNX. Conclusions- LUS is highly accurate in detecting or excluding pneumothorax in children with acute chest pain evaluated in the pediatric emergency department.

Leukemia is the most common childhood malignancy, and it is often characterized by pallor, fatigue, cytopenia, and organomegaly; sometimes musculoskeletal symptoms, mainly characterized by diffuse bone pain in the lower extremities, are the onset clinical characteristics of the disease. In these cases, the disease may initially be misdiagnosed as reactive arthritis, osteomyelitis, or juvenile idiopathic arthritis delaying appropriate diagnosis and management. Even if leukopenia, thrombocytopenia, and a history of nighttime pain are reported to be the most important predictive factors for a pediatric leukemia, blood examinations can sometimes be subtle or within normal limits, and this represents a further diagnostic difficulty. Radiological findings of leukemic bone involvement are described in patients with musculoskeletal symptoms of acute lymphoblastic leukemia and often appear before hematologic anomalies, but they are not specific for the disease. However, they could be helpful to get the right diagnosis if integrated with other features; thus, it is important knowing them, and it is mandatory for the multidisciplinary comparison to talk about dubious cases even in an emergency setting. We describe 4 patients visited in the emergency department for musculoskeletal complaints and having radiological lesions and a final diagnosis of acute lymphoblastic leukemia, in whom the onset of the manifestations could mimic orthopedic/rheumatologic diseases.

Mild encephalopathy with a reversible splenial lesion (MERS) is an uncommon clinico-radiological entity characterized by magnetic resonance imaging (MRI) findings of a reversible lesion in the splenium of corpus callosum associated with a significant neurological manifestation of encephalopathy. The majority of reported cases involve the Asiatic population and are closely associated with infection. We report the case of an adolescent with an HHV6-related MERS presenting with hyponatremia and urinary and fecal retention. To our knowledge, urinary retention is not a constant aspect of the disease and has rarely been described, while fecal retention has never been reported before. Despite the self-limiting nature of the disease, it is mandatory to suspect it for a faster diagnosis and it might be useful to know its rare occurrences in order to better understand its etiopathogenetic mechanisms.

Background Acute cerebellitis (AC) and acute cerebellar ataxia (ACA) are the principal causes of acute cerebellar dysfunction in childhood. Nevertheless. there is no accepted consensus regarding the best management of children with AC/ACA: the aim of the study is both to assess clinical, neuroimaging and electrophysiologic features of children with AC/ACA and to evaluate the correlation between clinical parameters, therapy and outcome. Methods A multicentric retrospective study was conducted on children ≤ 18 years old admitted to 12 Italian paediatric hospitals for AC/ACA from 01/01/2003 to 31/12/2013. A score based on both cerebellar and extracerebellar signs/symptoms was computed for each patient. One point was given for each sign/symptom reported. Severity was divided in three classes: low, moderate, severe. Results A total of 124 children were included in the study. Of these, 118 children received a final diagnosis of ACA and 6 of AC. The most characteristic finding of AC/ACA was a broad-based gait disturbance. Other common symptoms included balance disturbances, slurred speech, vomiting, headache and fever. Neurological sequelae were reported in 6 cases (5%) There was no correlation among symptoms, cerebrospinal fluid findings, clinical outcome. There was no correlation between clinical manifestations and clinical score on admission and length of hospital stay, sex, age and EEG findings with sequelae (P > 0.05). Children with pathological magnetic resonance imaging (MRI) or computed tomography (CT) had a higher probability of having clinical sequelae. Treatment was decided independently case by case. Patients with a higher clinical score on admission had a higher probability of receiving intravenous steroids. Conclusions We confirmed the literature data about the benign course of AC/ACA in most cases but we also highlighted a considerable rate of patients with neurological sequelae (5%). Pathological MRI or CT findings at admission correlate to neurological sequelae. These findings suggest the indication to perform an instrumental evaluation in all patients with AC/ACA at admission to identify those at higher risk of neurological outcome. These patients may benefit from a more aggressive therapeutic strategy and should have a closer follow-up. Randomized controlled trials are needed to confirm these observations. The ultimate goal of these studies could be to develop a standardized protocol on AC/ACA. The MRI/CT data, associated with the clinical manifestations, may allow us to define the class risk of patients for a neurological outcome.

Clostridium difficile infection (CDI) is increasingly found in children worldwide, but limited data are available from children living in southern Europe. A 6-year retrospective study was performed to investigate the epidemiology, clinical features, treatment, and risk of recurrence in Italy. Data of children with community- and hospital-acquired CDI (CA-CDI and HA-CDI, respectively) seen at seven pediatric referral centers in Italy were recorded retrospectively. Annual infection rates/10,000 hospital admissions were calculated. Logistic regression was used to investigate risk factors for recurrence. A total of 177 CDI episodes was reported in 148 children (83 males, median age 55.3 months), with a cumulative infection rate of 2.25/10,000 admissions, with no significant variability over time. The majority of children (60.8 %) had CA-CDI. Children with HA-CDI (39.2 %) had a longer duration of symptoms and hospitalization (p = 0.003) and a more common previous use of antibiotics (p = 0.0001). Metronidazole was used in 70.7 % of cases (87/123) and vancomycin in 29.3 % (36/123), with similar success rates. Recurrence occurred in 16 children (10.8 %), and 3 (2 %) of them presented a further treatment failure. The use of metronidazole was associated with a 5-fold increase in the risk of recurrence [odds ratio (OR) 5.18, 95 % confidence interval (CI) 1.1-23.8, p = 0.03]. Short bowel syndrome was the only underlying condition associated with treatment failure (OR 5.29, 95 % CI 1.17-23.8, p = 0.03). The incidence of pediatric CDI in Italy is low and substantially stable. In this setting, there is a limited risk of recurrence, which mainly concerns children treated with oral metronidazole and those with short bowel syndrome.

The occurrence of hospital-acquired acute gastroenteritis (AGE) is a major concern for public health. RotavirusA (RVA) and norovirus (NoV) are common causes of viral AGE in the pediatric population, and their role in nosocomial infections has been proven, remaining poorly investigated. To investigate RVA and NoV in hospital-acquired AGE, 55 stool samples from children with nosocomial AGE were collected between May 2014 and May 2015. To evaluate virus spreading routes, 51 environmental swabs were collected from staff and patients' rooms. Stools were tested for both RVA and NoV RNA by reverse-transcription-PCR. Nucleotide sequencing and phylogenetic analysis were performed to characterize the viruses. Forty-seven of 55 cases analyzed resulted positive for RVA. The predominant genotype was G4P[8] (18/55) followed by G1P[8] (14/55). Mixed RVA infections were also detected (7/55). Twenty-two samples were positive for NoV, and GII.4 was revealed to be the predominant genotype. Seventeen samples were positive for both RVA and NoV. This study aimed to evaluate the burden of norovirus and rotavirus nosocomial AGE, contributing to identify the environment source of infections and to activate effective strategies for intervention. The reduction in nosocomial AGE cases is an important aspect, considered the worsened disease course in transplant, cancer, and intensive care unit inpatients.

Background Anorexia Nervosa is a Psychiatric eating disorder of adolescence age with a high morbidity and mortality. Case Presentation We describe a common case of anorexia nervosa (AN) in a female adolescent complicated by less known conditions related to refeeding syndrome. At admission, the girl showed a mild hypercholesterolemia with progressive normalization of the values. The initial low hypertransaminasemia worsened after refeeding until very high levels and hypophosphoremia was also described. Only a controlled caloric intake and a specific electrolyte supplementation led to the improvement of hematologic values and the clinical condition of the patient. Conclusions Refeeding complications must be always suspected because of life-threatening risk. More attention should be paid not only to the acute state of the disease but also to the prevention and the management of refeeding-related manifestations.

Tuberculosis (TB) is one of the leading causes of death worldwide. Over the last decades, TB has also emerged in the pediatric population. Epidemiologic data of childhood TB are still limited and there is an urgent need of more data on very large cohorts. A multicenter study was conducted in 27 pediatric hospitals, pediatric wards, and public health centers in Italy using a standardized form, covering the period of time between 1 January 2010 and 31 December 2012. Children with active TB, latent TB, and those recently exposed to TB or recently adopted/immigrated from a high TB incidence country were enrolled. Overall, 4234 children were included; 554 (13.1%) children had active TB, 594 (14.0%) latent TB and 3086 (72.9%) were uninfected. Among children with active TB, 481 (86.8%) patients had pulmonary TB. The treatment of active TB cases was known for 96.4% (n = 534) of the cases. Overall, 210 (39.3%) out of these 534 children were treated with three and 216 (40.4%) with four first-line drugs. Second-line drugs where used in 87 (16.3%) children with active TB. Drug-resistant strains of Mycobacterium tuberculosis were reported in 39 (7%) children. Improving the surveillance of childhood TB is important for public health care workers and pediatricians. A non-negligible proportion of children had drug-resistant TB and was treated with second-line drugs, most of which are off-label in the pediatric age. Future efforts should concentrate on improving active surveillance, diagnostic tools, and the availability of antitubercular pediatric formulations, also in low-endemic countries.

This retrospective study was conducted to analyze clinical and laboratoristic parameters to individuate specific differences and facilitate differential diagnosis between Measles and Kawasaki Disease (KD) at first evaluation in a emergency room. We found similar clinical features as duration of fever and number of KD criteria (p >0.5) but significant differences in white blood cell count, neutrophils, CRP and LDH levels (p < 0.001). LDH value ≥ 800 mg/dl had sensibility of 89% and specificity of 90% for Measles while CRP ≥ 3 mg/dl had sensibility 89% and specificity of 85% for KD. The combined use of CRP, LDH and AST showed accuracy of 86.67%.

We report the case of a two-month-old immunocompetent girl affected by Staphylococcus aureus sepsis complicated with pneumonia and pleural effusion, spondylodiscitis and endophthalmitis treated with linezolid. She developed a S. aureus sepsis in the neonatal period antibiotically treated with clinical resolution. Ten days after therapy discontinuation, the infant experienced a new S. aureus sepsis complicated by pneumonia with pleural effusion. Due to the presence of dorsal swelling, a pulmonary computer tomography was performed that showed a dorsal D5-D6 spondylodiscitis. Since the sepsis was scarcely responsive to several appropriate antibiotics, we finally decided to treat the patient with linezolid. A few weeks after changing antibiotics, the child underwent an ophthalmologic visit. Due to the finding of ocular lesions, imaging examinations were performed. The diagnosis was compatible with retinoblastoma, such that the eye was enucleated. Nevertheless, histological and microbiological investigations did not confirm the tumour hypothesis, but revealed a S. aureus abscess with retinal detachment. The child completed antibiotic therapy with linezolid and was visited periodically at the Infectious Disease Unit for a follow-up. She underwent progressive resolution of discitis and did not present any further flare of sepsis. Nevertheless, she still has a replacement device in her right eye and a D5-D6 severe kyphosis with spinal fusion.

Introduction PERTINENT is a pilot active surveillance system of infants hospitalised with pertussis in six European Union/European Economic Area countries (37 hospitals, seven sites). Aim This observational study aimed to estimate annual pertussis incidence per site from 2016 to 2018 and respective trends between 2017 and 2018. Pertussis cases were described, including their severity. Methods We developed a generic protocol and laboratory guidelines to harmonise practices across sites. Cases were hospitalised infants testing positive for Bordetella pertussis by PCR or culture. Sites collected demographic, clinical, laboratory data, vaccination status, and risk/protective factors. We estimated sites’ annual incidences by dividing case numbers by the catchment populations. Results From December 2015 to December 2018, we identified 469 cases (247 males; 53%). The median age, birthweight and gestational age were 2.5 months (range: 0–11.6; interquartile range (IQR): 2.5), 3,280 g (range: 700–4,925; IQR: 720) and 39 weeks (range: 25–42; IQR: 2), respectively. Thirty cases (6%) had atypical presentation either with cough or cyanosis only or with absence of pertussis-like symptoms. Of 330 cases with information, 83 (25%) were admitted to intensive care units including five deceased infants too young to be vaccinated. Incidence rate ratios between 2018 and 2017 were 1.43 in Czech Republic (p = 0.468), 0.25 in Catalonia (p = 0.002), 0.71 in France (p = 0.034), 0.14 in Ireland (p = 0.002), 0.63 in Italy (p = 0.053), 0.21 in Navarra (p = 0.148) and zero in Norway. Conclusions Incidence appeared to decrease between 2017 and 2018 in all but one site. Enhanced surveillance of hospitalised pertussis in Europe is essential to monitor pertussis epidemiology and disease burden.