Search

The aim of the study was to investigate the burden of mental health problems in children and adolescents admitted to a pediatric ward with physical complaints. We conducted a retrospective study, considering all patients admitted to the pediatric ward of the IRCCS Burlo Garofolo, Trieste, Italy, between January 2015 and September 2016. We selected all patients, from 5 to 17 years old, who were admitted with physical complaints and were discharged with a diagnosis suggestive of a mental health problem: somatic symptom disorder, anxiety disorder, depressive disorder, factious disorders. For every patient, we collected demographic features, medical characteristics, health care services utilization, length of hospital stay, and after discharge referral. We selected 1456 patients; of these, 101 (6.9%) revealed a mental health problem. The median duration of symptoms was 5 months (IQR 1.5-12), and pain was the main reported symptom (69%). Of the 101 patients, 23 (23%) were affected by a previously documented chronic organic disease. Somatic symptom disorder was the most common diagnosis. In 69/78 patients (88%), a loss of social contacts emerged; 49/95 patients frequenting school (51%) had chronic school absenteeism in the previous school year.Conclusion: A considerable proportion of patients admitted to a pediatric ward with physical complaints have mental health problems. What is Known: • It has been suggested that mental health problems in children and adolescents are increasing and frequently burden on pediatric healthcare services, but how they impact on a general pediatric ward is not clear. What is New: • Among 1456 patients admitted to a general pediatric ward with physical symptoms, 101 patients (6.9%) had a mental health problem. Among them, pain was the most commonly reported symptom and somatic symptom disorder was the commonly reported diagnosis.

Intervista al prof. Francesco Emma Nefrologia e Dialisi, Ospedale Pediatrico “Bambino Gesù” IRCCS, Roma

To estimate the incidence and describe the spectrum of inflammatory and autoimmune diseases linked to SARS-CoV-2 infection and COVID-19 vaccination in children from two neighbouring south central European countries.We performed a multi-centre prospective cohort study of children under 18 years diagnosed with inflammatory/autoimmune diseases linked to SARS-CoV-2 infection or COVID-19 vaccination, who were admitted to the paediatric tertiary care hospitals in Slovenia and Friuli Venezia Giulia, Italy, from January 1, 2020, to December 31, 2021. Disease incidence was calculated based on laboratory-confirmed cases only.Inflammatory and autoimmune diseases linked to SARS-CoV-2 were diagnosed in 192 children (127 laboratory-confirmed), of whom 112 had multisystem inflammatory syndrome (MIS-C), followed by vasculitis, neurological and cardiac diseases. Calculated risk of MIS-C was 1 in 860 children after SARS-CoV-2 infection and cumulative incidence of MIS-C was 18.3/100,000 of all children. Fifteen children had severe COVID-19. Two patients with MIS-C and a patient with myositis presented after COVID-19 vaccination. All 3 had at presentation also a serologically proven recent SARS-CoV-2 infection. After MIS-C, nine patients were vaccinated against COVID-19 and 25 patients had a SARS-CoV-2 reinfection, without recurrence of MIS-C.Autoimmune diseases following SARS-CoV-2 infection in children were 8.5 times as common as severe COVID-19. MIS-C was the most common manifestation and its incidence in this predominantly white population was higher than previously reported. MIS-C does not seem to recur after SARS-CoV-2 reinfection or COVID-19 vaccination. Autoimmune diseases were much more common after SARS-CoV-2 infection than after COVID-19 vaccination.

Complex regional pain syndrome of the foot in a girl with post-SARS-CoV-2 chilblains

Background In recent years, several studies have been published on the prognosis of children with congenital solitary kidney (CSK), with controversial results, and a worldwide consensus on management and follow-up is lacking. In this consensus statement, the Italian Society of Pediatric Nephrology summarizes the current knowledge on CSK and presents recommendations for its management, including diagnostic approach, nutritional and lifestyle habits, and follow-up. Summary of the recommendations We recommend that any antenatal suspicion/diagnosis of CSK be confirmed by neonatal ultrasound (US), avoiding the routine use of further imaging if no other anomalies of kidney/urinary tract are detected. A CSK without additional abnormalities is expected to undergo compensatory enlargement, which should be assessed by US. We recommend that urinalysis, but not blood tests or genetic analysis, be routinely performed at diagnosis in infants and children showing compensatory enlargement of the CSK. Extrarenal malformations should be searched for, particularly genital tract malformations in females. An excessive protein and salt intake should be avoided, while sport participation should not be restricted. We recommend a lifelong follow-up, which should be tailored on risk stratification, as follows: low risk: CSK with compensatory enlargement, medium risk: CSK without compensatory enlargement and/or additional CAKUT, and high risk: decreased GFR and/or proteinuria, and/or hypertension. We recommend that in children at low-risk periodic US, urinalysis and BP measurement be performed; in those at medium risk, we recommend that serum creatinine also be measured; in high-risk children, the schedule has to be tailored according to kidney function and clinical data.

The first Covid-19 pandemic affected the epidemiology of several diseases. A general reduction in the emergency department (ED) accesses was observed during this period, both in adult and pediatric contexts.This retrospective study was conducted on the behalf of the Italian Society of Pediatric Nephrology (SINePe) in 17 Italian pediatric EDs in March and April 2020, comparing them with data from the same periods in 2018 and 2019. The total number of pediatric (age 0-18 years) ED visits, the number of febrile urinary tract infection (UTI) diagnoses, and clinical and laboratory parameters were retrospectively collected.The total number of febrile UTI diagnoses was 339 (73 in 2020, 140 in 2019, and 126 in 2018). During the first Covid-19 pandemic, the total number of ED visits decreased by 75.1%, the total number of febrile UTI diagnoses by 45.1%, with an increase in the UTI diagnosis rate (+ 121.7%). The data collected revealed an increased rate of patients with two or more days of fever before admission (p = 0.02), a significant increase in hospitalization rate (+ 17.5%, p = 0.008) and also in values of C reactive protein (CRP) (p = 0.006). In 2020, intravenous antibiotics use was significantly higher than in 2018 and 2019 (+ 15%, p = 0.025). Urine cultures showed higher Pseudomonas aeruginosa and Enterococcus faecalis percentages and lower rates of Escherichia coli (p = 0.02).The first wave of the Covid-19 pandemic had an essential impact on managing febrile UTIs in the ED, causing an absolute reduction of cases referring to the ED but with higher clinical severity. Children with febrile UTI were more severely ill than the previous two years, probably due to delayed access caused by the fear of potential hospital-acquired Sars-Cov-2 infection. The possible increase in consequent kidney scarring in this population should be considered.

Most of primary immunodeficiencies with hypogammaglobulinemia are associated with reduced memory B cells. T cell development may be interesting as well, but increased recent thymic emigrants are rarely reported in these patients. We report the case of a family (mother and her two sons) diagnosed with common variable immunodeficiency 10 due to a mutation in the NFKB2 gene. Laboratory findings showed that all three patients presented hypogammaglobulinemia, reduced memory B cells and elevated naïve T lymphocytes and recent thymic emigrants. This feature, in the absence of glucocorticoid deficiency, may suggest a primary thymic dysfunction. Interestingly, the mother presented the worst immune phenotype, as regards both antibody production and NK function, indicating that immune function may deteriorate in the course of time. We conclude that close monitoring of immune functions may widen the knowledge on the CVID10 and improve the patients’ care.

A 12-year-old boy presented with a 1-year history of painful swelling of the left ankle.

Fasting before procedural sedation is a hot topic in everyday medical life with the main concern regarding pulmonary aspiration. Fasting guidelines before procedural sedation have always been the same as those used for general anaesthesia. However, procedural sedation and general anaesthesia differ in terms of invasiveness, drugs, duration and patient characteristics. This results in lower risk of pulmonary aspiration during procedural sedation, when compared to general anaesthesia. Moreover, a large case series of sedations performed in the emergency department with no respect for the proper fasting times showed no association between fasting duration and any type of adverse event with the latter occurring also in patients that properly fasted. The type of procedure (with the need of airway management) and characteristics of the patient seem to matter more. Furthermore, prolonged fasting is uncomfortable and has been associated with hypoglycaemia and dehydration. For this reason, fasting guidelines before procedural sedation should be adapted on the presence of risk factors, such as ASA score, need for airway management, comorbidities, type of procedure and drug used.

not available

Background The need for dialysis after kidney allograft failure (DAGF) is among the top five reasons for dialysis initiation, making this an important topic in clinical nephrology. However, data are scarce on dialysis choice after transplantation and clinical outcomes for DAGF in children. Methods Patients receiving chronic dialysis < 18 years were recorded from January 1991 to January 2019 by the Italian Registry of Pediatric Chronic Dialysis (IRPCD). We investigated factors influencing choice of dialysis modality, patient outcome in terms of mortality, switching dialysis modality, and kidney transplantation. Results Among 118 patients receiving DAGF, 41 (35%) were treated with peritoneal dialysis (PD), and 77 (65%) with haemodialysis (HD). Significant predictors for treatment with PD were younger age at dialysis start (OR 0.85 per year increase [95%CI 0.72–1.00]) and PD use before kidney transplantation (OR 8.20 [95%CI 1.82–37.01]). Patients entering DAGF in more recent eras (OR 0.87 per year increase [95%CI 0.80–0.94]) and with more than one dialysis modality before kidney transplantation (OR 0.56 for being treated with PD [0.12–2.59]) were more likely to be initiated on HD. As compared to patients on HD, those treated with PD exhibited increased but non-significant mortality risk (HR 2.15 [95%CI 0.54–8.6]; p = 0.28) and higher prevalence of dialysis-related complications during DAGF (p = 0.002) Conclusions Patients entering DAGF in more recent years are more likely to be initiated on HD. In this specific population of children, use of PD seems associated with a more complicated course. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information

Background: This study investigated whether performing kidney ultrasound (KUS) only in children presenting either a pathogen other than E. coli at their first febrile urinary tract infection (fUTI) or experiencing fUTI recurrence would increase missed diagnoses of kidney anomalies. Methods: Patients aged 2–36 months with fUTI who underwent KUS evaluation from 2 January 2013 to 31 June 2018 were enrolled. Cystourethrography was performed after pathological KUS or recurring fUTIs. Thereafter, we retrospectively assessed the detection rate of kidney anomalies through performing KUS only in patients with atypical pathogen at first fUTI or with recurring fUTIs. Results: In 263 patients included, the isolated pathogen was E. coli in 223 cases (84.8%) and atypical in 40 cases (15.2%). KUS detected kidney anomalies in 14/223 (6.3%) of fUTIs caused by E. coli and in 11/40 (27.5%) of fUTIs caused by an atypical pathogen (OR 5.5, 95%CI 2.5–14.5). Cystourethrography was performed in 40 patients and vesicoureteral reflux (VUR) found in 20 cases. None of the high grade VUR diagnoses or other kidney anomalies would have been lost through a different diagnostic protocol that required the presence of an atypical pathogen at the first fUTI or a fUTI recurrence to perform the KUS. Conclusions: A diagnostic protocol that requires presence of an atypical pathogen at the first fUTI or a second episode of fUTI to perform the KUS would allow a reduction in the number of negative ultrasounds with a negligible risk of missed diagnoses of kidney anomalies.

N/A

Background and Aims An increasing number of patients are returning to dialysis after kidney allograft failure (KAF). These patients are at higher risk of complications and mortality compared with incident ESKD patients.. In the pediatric population these data are missing and outcomes have never been investigated before in a nationally representative sample. The aim of this study was to describe the characteristics and hard outcomes of children entering dialysis after KAF in a large population of pediatric dialysis patients. Method We retrospectively reviewed the files of patients receiving chronic dialysis at Results After KAF, 45 (35.7 %) patients were treated with PD and 81 (64,3%) with HD. Prior to kidney transplantation (Ktx), 74 (58.7%) were on PD, 45 (35.7%) on HD, and 7 on conservative care (5.5%). Compared with PD patients, those on HD were older (median age of 14.8 years [IQR 11.4-17.5] vs. 10.8 [IQR 2-6.5] vs.; p=0.002), had a longer transplant vintage ([55.2 months [13.2-100.3]) vs. 33 [5.1-82.2], and reentered dialysis in more recent calendar years (2013 [2007-2017] vs. 2004 [2001-2009]). Significant predictors for being treated with PD after KAF were a younger age at dialysis start (OR 0.83 per year increase [95%CI 0.72-0.94]) and a history of PD use before Ktx (OR 12.74 [2.2-74.6]). Patients returning to dialysis in more recent eras (OR 0.87 per year increase [0.81-0.94]) and those who were treated with more than one dialysis modality before Ktx (OR 0.15 for being treated with PD [0.04-0.63]) were more likely to be initiated on HD. Over the observation period, 6 PD (13.6%) and 3 HD (4.2%) patients died. After adjustment for several covariates, patients on PD exhibited an increased risk for mortality compared with HD (HR 4.65 [1.12-19.30], while the difference for modality failure and access to renal transplantation did not reach statistical significance (Fig.1) Conclusion Patients returning to dialysis after KAF in more recent years are more likely to be initiated on HD rather than PD. According to our registry data, the use of PD is associated with a lower survival among patients initiating dialysis after KAF. Fig.1 Cumulative incidences for the competing events, death, transplant and other techniques (solid line: PD, dash line: HD)

BackgroundThe study aimed to investigate if the behaviours suggestive of ADHD were more frequent in a population of children attending the Emergency Department (ED) for injuries, rather than for other causes.MethodsA cross-sectional study was carried out. Patients, aged 6 to 17 years, attending the ED for acute injuries and other causes were considered cases and controls, respectively. We used a questionnaire, which investigates the presence in the child of inattention, hyperactivity, and impulsivity. The primary outcome was the number of children with behaviours suggestive of ADHD in cases and controls.ResultsFive hundred forty-five children were enrolled, 251 with injuries and 294 with other complains. Twenty two out of two hundred fifty one (9%) children visited for injuries, and 30 out of 294 (10%) visited for other causes had behaviours suggestive of ADHD (p = 0.661). Among these cases, children with evocative ADHD scores had a higher probability (OR 4.52; 95% CI 1.45–14.04;p = 0.009) of having had more than five previous ED accesses due to injury, compared to the others.ConclusionsThis study did non shown a difference in behaviours suggestive of ADHD between cases and controls, but identified a population of children with behaviours suggestive of ADHD who more frequently access the ED for injuries.

The COVID-19 pandemic challenged health care systems to balance high standards of care with patients' needs and health care workers' safety.1 Pediatric sedation poses multiple potential contagion risks: aerosol generating procedures such as bag-valve mask ventilation and oro-pharyngeal suctioning2 , close proximity of the sedationist to the patient's airway, the need for airway manipulation or insertion of airway devices and the risk of patient vomiting and coughing. Although COVID risk mitigation to providers is achieved for elective procedures that allow for pre-sedation COVID-19 testing, it is important to recognize that there are still false negatives, with sensitivity cited to be as low as 73.3%3 . For this reason, thoughtful consideration should be directed to means of lowering the healthcare providers' risk of COVID-19 exposure during pediatric procedural sedation.

N/A

N/A

­ A 3-year-old toddler was admitted for a 5-day history of worsening painful limping on his left leg. History was remarkable only for a minor trauma 2 days before the onset of symptoms; the boy fell on his buttocks but was walking normally in the following days. No fever was reported. Pain was also present at night, with no response to oral ibuprofen. On physical examination, the patient refused to stand on his left leg, palpation of the left buttock evoked pain, and exorotation and abduction of the left hip were only moderately limited, without local signs of inflammation such as redness, swelling or skin warming. Blood tests showed elevated erythrocyte sedimentation rate (ESR) (98 mm/hour, normal value 9/L, haemoglobin was 127 g/L and PLT was 430 x 109/L. Creatine kinase values were within the normal range. An X-ray of the pelvis was unremarkable. An ultrasound of the left hip showed a 2 mm articular effusion. Questions Based on the clinical picture and laboratory tests, what is the most likely diagnosis? Perthes disease. Pyomyositis. Septic arthritis. Bone fracture. Leukaemia. What test could confirm the diagnosis? Bone scintigraphy. CT. Bone marrow aspirate. MRI. Intra-articular puncture. What is the mainstay of management of this condition? Wait and see. Surgical excision. Antibiotic course. Antineoplastic treatment. Answers can be found on page 2.

N/A

The diagnosis of late-onset Adenosine deaminase deficiency (ADA) deficiency should be suspected in progressive lymphopenia associated with hypereosinophilia and moderately high IgE level

Aim Acute abdominal pain is a frequent complaint in children attending emergency departments. The aim of this study was to investigate the pain score reductions when children with acute abdominal pain received medication sublingually. Methods We carried out a multicentre randomised controlled trial in three children's hospitals in Italy between March 2015 and June 2017. Children from four to 18 years of age with acute abdominal pain were recruited if their self-reported pain was at least six on a scale from 0-10. The children were randomised to receive ketorolac 0.5 mg/kg (n = 70) or tramadol 2 mg/kg (n = 70) sublingually or a melt in the mouth powder of 20 mg/kg paracetamol (n = 70). The main study outcome was the pain scores for the three drugs after two hours. Results The 210 children (58.6% girls) had a median age of 12 years with an interquartile range of 9-14.3. The median pain scores at two hours were not significantly different between ketorolac 2.0 (interquartile ranges, IQR 0.0-4.3) and tramadol 3.0 (IQR 1.0-5.0) vs paracetamol 3.0 (IQR 0.8-5.0). The median pain reductions were all 5.0 points. Conclusion Delivering analgesia sublingually was a suitable option for pain relief in children with acute abdominal pain in the emergency department.

A 15-year-old girl presented with left ear pain and vertigo, exacerbated by head movements. She described vertigo as a sensation of motion of the environment. Physical examination showed hyperaemia and oedema of the auricle and of the external auditory canal. Persistent, spontaneous, horizontal, grade II right-beating nystagmus, under Frenzel’s glasses, was noted. Bedside examination of vestibulospinal reflexes (Romberg test, past pointing test, tandem, walking and stepping tests) showed a shifting towards the left, indicating a static imbalance. Oral therapy with ciprofloxacin at 20 mg/kg in two doses was started. Three days later, ear pain and vertigo persisted and worsened. On re-evaluation, a painful vesicular and crusty rash in the left auditory canal and auricle was noted (figure 1). Figure 1 Vesicular and crostous lesions of the auditory canal and concha, with oedema and hyperaemia of the ear, pathognomonic of varicella zoster virus reactivation. Which of the …

Unarousable child with short bowelA 4-year-old boy was admitted with progressive lethargy of a few hours’ duration and no other symptoms. His medical history was relevant for short bowel syndrome (SBS), following neonatal volvulus, with residual bowel length of 23 cm and intact ileocecal valve. He had similar self-limiting episodes in the past, after weaning parenteral nutrition, especially after eating large meals. The day before, he had consumed a large amount of apples.Arterial blood gas (ABG) analysis showed metabolic acidosis with normal lactacidaemia (pH 7.09, pCO2 19 mm Hg, pO2 101 mm Hg, HCO3 5.8 mmol/L, BE −24, anion gap 29.4, chloride 116 mmol/L, L-lactate level 4 mmol/L).On admission, the child could be awakened, but he was confused with slurred speech (Glasgow Coma Scale 14), with a body temperature of 37 C°, a heart rate of 125 beats/min and a respiratory rate of 38 breaths/min. The abdomen was distended, without guarding and with normal bowel sounds. Blood glucose levels were normal, as well as white blood cell count, liver and kidney function test and C reactive protein. An abdominal ultrasound ruled out an intussusception. An abdominal X-ray was performed too (see figure 1).Figure 1Abdominal distension with gas and bloating.QuestionsWhich is the most likely diagnosis?EncephalitisD-lactic acidosisDehydration with third space fluid collection and acidosisHereditary fructose intolerance.How is this diagnosis confirmed?D lactic dosageBreath test for bacterial overgrowthUrine organic acid dosageSearch for reductive substances in the stools.How should this patient be managed?Intravenous fluids to facilitate D-lactic excretionRestrict carbohydrates in the dietIntravenous bicarbonatesAntibiotic treatment to reduce bowel bacterial overgrowth.Answers can be found on page 2.

Background Peripheral blood access and venipuncture are a stressful and painful experience in pediatric patients; moreover, it is estimated that more than one attempt is required to achieve the procedure in about one third of children. For this reason, we investigated if Near-infrared light technology routinely used, could give an advantage to venipuncture in a pediatric blood center setting. Methods We conducted an open, pseudo-randomized controlled trial with two parallel arms, in the blood-drawing center, with enrolment of 115 patients between 0 and 18 years, in 14 consecutive working days. Fifty-three subjects were enrolled in group 1 (VeinViewer®) and 62 in group 2 (control group). We divided patients into three subgroups considering their age ( 10 years). The primary study outcome was to assess if the use of VeinViewer® was associated with a reduction of time to perform blood sampling. The secondary outcome was to analyze VienViewer®‘s impact on first attempt success rate in blood sampling. Results No difference was found regarding the duration of blood sampling between the two groups, even after stratifying the patients into the three age subgroups. There was no difference between the two groups in the success at the first attempt in blood sampling. Conclusions Routine use of VeinViewer® is not useful to reduce time of the procedure during venipuncture. Trial registration The study was registered with ClinicalTrials.gov, with number NCT03277092, on September 8, 2017.

Based on its phosphatidylinositol 3-kinase-delta (PI3Kd) inhibitory properties, theophylline was administered to a young girl with activated PI3Kd syndrome (APDS). We report reduced frequency of infections, decreased lymphoproliferation, and noticeable changes in immunophenotype, encouraging further trials with theophylline in children with APDS.

Not available

N/A

Estroprogestins with "natural oestrogen" has represented a new option in terms of combined hormonal contraception. So, the aim of this study is to investigate how estroprogestins with natural estrogen may modify the vaginal niche. In literature, very few studies focused on the interaction between hormonal contraception and vaginal milieu. This is a prospective comparative study. We enrolled 60 women from January 2013 to September 2013, 30 of them were administered estradiol valerate dienogest (E2V+DNG - Klaira®) in a quadriphasic regimen, while the other 30 women were administered 17-β estradiol with nomestrol acetate (EV+NOMAC - Zoely®) in a monophasic regimen. After a baseline study of vaginal milieu at recruitment of patients (Gram stain with Nugent score, vaginal pH, vaginal wet mount for the quantification of leukocytes, Lactobacilli and/or presence of Candida), we performed the same follow-up after six months of estroprogestin therapy. Our results showed that the women treated with E2V+DNG had a trend of an improvement of vaginal health in terms of increase of lactobacillar flora and reduction of vaginal pH in place of women treated with EV+NOMAC that showed a reduction of cervical mucus. Finally, our data about the effects on vaginal flora exerted by two estroprogestin pills (EPs) containing a natural estrogen suggest slight, but interesting differences in terms of vaginal ecology. These differences could be related to the type of estrogen, type of progestin, regimen of administration and, after all, to the net balance between estrogenic and progestin component of the EPs.