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Background Quarantine and isolation measures during COVID-19 pandemic may have caused additional stress and challenged the mental health of the youth. Aim of the study is to investigate the COVID-19 pandemic impact on neuropsychological disorders (NPD) of Italian children and adolescents to provide general pediatric recommendations. Material and methods A retrospective multicenter observational study was planned by the Italian Pediatric Society (SIP) to explore the impact of COVID-19 on the access of children to pediatric Emergency Departments (pED) for the evaluation of neuropsychological symptoms, collecting the classification codes of diagnoses between March 1, 2019 and March 2, 2021. The period study was split into two sub-periods: a pre COVID-19 period (from March 1 2019 to March 1, 2020) and a COVID-19 period (from March 2, 2020 to March 2, 2021). As additional information, data on NPD hospitalizations in any pediatric department of the involved centers were recorded. Results During the study period, a total of 533,318 children were admitted to the pED involved in the study. Despite a 48.2% decline of pED admissions, there was a significant increase (83.1%) in patient admissions for NPD. The most frequent NPD conditions which increased during the COVID-19 pandemic were suicidal ideation (+ 147%), depression (+ 115%), eating disorder (+ 78.4%), and psychosis (+ 17.2%). During the pandemic period, a 39.5% increase in NPD hospitalizations was observed as well. The NPD disorders that mostly required hospitalizations were suicidal ideation (+ 134%), depression (+ 41.4%), eating disorder (+ 31.4%), and drug abuse (+ 26.7%). COVID-19 pandemic had a major impact on children's health, mainly on their NPD development. Neuropsychological assessment should be required at the primary level, in the pediatrician's office, to facilitate early capture of the sign of impairment and provide an adequate treatment. Conclusion SIP underlines the psychological consequences of COVID 19 pandemic on the youngest and recommends an early identification of NPD in the pediatric population to avoid other serious consequences for children's physical and mental health.

The restrictive measures required to face the recent outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may impact patterns of healthcare utilization. Our aim was to provide an insight into the change in the use of a pediatric emergency department (ED) during the SARS-CoV-2 pandemic. The medical records of the children seen in our pediatric ED during March and April 2020 were retrospectively reviewed. Consequently, these were compared to the medical records of 2018 and 2019 from the same time period and from other control periods (January–February 2019 and 2020, and July–August 2018 and 2019). The total number of ED visits declined by 73% from 2019 to 2020 (3051 vs 818). Significant variations were observed in the distribution of children between triage categories: the proportion of patients who was given a green-code showed a 0.59-fold decrease in comparison to 2019 (95% CI 0.5–0.69), while a relative increase in the proportion of yellow codes was observed (OR 1.46, 95% CI 1.2–1.78). Conclusion: Quarantine measures significantly impacted on the total number of patients and on the reasons for visiting them in our pediatric ED. This substantial decrease in pediatric care may either be due to lower rates of acute infections because of social distancing, or to parents’ or caregivers’ reticence to risk exposure to SARS-CoV-2 in a health-care setting.What is known:• A recent outbreak of a novel coronavirus responsible for a severe acute respiratory syndrome is spreading globally.• Restrictive measures may impact patterns of healthcare utilization, as observed in other previous outbreaks.What is new:• This study shows significant variations in the distribution of children among triage categories during the COVID-19 pandemic.• Discharge diagnosis was significantly different as well, in particular a relative increase in the proportion of children presenting with traumatic injuries and a decrease of viral infections were observed. Supplementary Information The online version contains supplementary material available at 10.1007/s00431-020-03909-9.

Object: Hydrocephalus is one of the main complications of brain tumors in children, being present in about 50% of cases at the time of the tumor diagnosis and persisting up to 10–40% of cases after surgical resection. This is a single-institution retrospective study on the variables that may predict the need for treatment of persistent hydrocephalus in pediatric patients presenting with a brain tumor. Methods: Retrospective case note review of 43 newly diagnosed brain tumors in children referred between April 2012 and January 2018 to our regional pediatric neuro-oncology service was carried out. Diagnosis of hydrocephalus was carried out using both preoperative and postoperative MRI to determine Evans’ index (EI) and the fronto-occipital horn ratio (FOHR) from each scan. Simple logistic regression was used to analyze categorical variables as appropriate. A p value Results: Forty-three children were analyzed, 26 males and 17 females with a median age at diagnosis 10.4 years (IQR: 5.2–13.5). Hydrocephalus was present in 22/43 children (51%) preoperatively; in 8/22 children (36%) with hydrocephalus undergoing tumor resection, hydrocephalus persisted also in the postoperative period. An EI >0.34 (p = 0.028) and an FOHR >0.46 (p = 0.05) before surgery were associated with a higher prevalence of persistent hydrocephalus and therefore to the need for a cerebrospinal fluid drain device in the postoperative phase. Conclusion: Preoperative identification of children at risk for developing persistent hydrocephalus would avoid delays in planning the permanent cerebrospinal fluid drain devices. This study finds that an EI >0.34 and an FOHR >0.46 at diagnosis could impact on the therapeutic management of children with hydrocephalus associated with brain tumors. Prospective and larger-scale studies are needed to standardize this approach.

ObjectiveTo evaluate the acceptability and safety profile of nocturnal long-term oxygen therapy (LTOT) in children with sickle cell disease (SCD) and chronic hypoxaemia.DesignRetrospective cohort study.Patients, setting and interventionChildren with SCD who started LTOT from 2014 to early 2019 in two tertiary hospitals in London, UK were retrospectively enrolled. Patients who started disease-modifying therapies Main outcome measuresMinor and major adverse events during LTOT were reported. Laboratory and clinical data, transcranial Doppler (TCD) scans and overnight oximetry studies performed at steady state within 12 months before and after starting LTOT were compared.ResultsNineteen children (10 males; median age 12 years, range 6–15) were included. Nearly half of them (9/19; 47%) were on hydroxyurea at baseline. No child discontinued LTOT because of intolerance or poor adherence. No major adverse events were reported. Laboratory data did not show significant changes in haemoglobin and reticulocyte count after 1 year of follow-up. No statistically significant change in the incidence of vaso-occlusive pain events was noted (median annual rate from 0.5 to 0 episode per patient/year; p=0.062). Overnight oximetry tests performed while on LTOT showed improvements in all oxygen saturation parameters (mean overnight and nadir SpO2, % of time spent with SpO2 ConclusionLTOT is a safe and feasible treatment option for children with SCD and chronic hypoxaemia.

A recent outbreak of a novel Coronavirus responsible for a Severe Acute Respiratory Syndrome (SARS-CoV-2) is spreading globally. The aim of this study was to systematically review main clinical characteristics and outcomes of SARS-CoV-2 infections in pediatric age. An electronic search was conducted in PubMed database. Papers published between 1 January and 1 May 2020 including children aged 0–18 years were selected. Sixty-two studies and three reviews were included, with a total sample size of 7480 children (2428/4660 males, 52.1%; weighted mean age 7.6 years). Patients showed mainly mild (608/1432, 42.5%) and moderate (567/1432, 39.6%) signs of the infection. About 2% of children were admitted to the pediatric intensive care unit. The most commonly described symptoms were fever (51.6%) and cough (47.3%). Laboratory findings were often unremarkable. Children underwent a chest CT scan in 73.9% of all cases, and 32.7% resulted normal. Overall, the estimated mortality was 0.08%. A higher proportion of newborns was severely ill (12%) and dyspnea was the most common reported sign (40%). Conclusion: SARS-CoV-2 affects children less severely than adults. Laboratory and radiology findings are mainly nonspecific. Larger epidemiological and clinical cohort studies are needed to better understand possible implications of COVID-19 infection in children.What is Known:• A novel Coronavirus has been recently identified as responsible for a new Severe Acute Respiratory Syndrome (SARS-CoV-2) spreading globally.• There is limited evidence on SARS-CoV2 infection in children.What is New:• Systematically reviewed available evidence showed that children with SARS-CoV-2 infection may have a less severe pattern of disease in comparison to adults.• Blood tests and radiology findings are mainly nonspecific in children but may help to identify those who are severely ill. Electronic supplementary material The online version of this article (10.1007/s00431-020-03684-7) contains supplementary material, which is available to authorized users.

Children with cognitive impairment (CI) are at risk of experiencing pain. Several specific pain rating scales have been developed to date. Thus, the aim of this meta-analysis was to estimate the degree of reliability of different pain assessment scales for the postoperative pain in children with CI.PubMed, Scopus and Web of Science databases were approached: all studies validating and/or using pain assessment tool in children (0-20 years) with CI published in English from the 1st of January 2000 to the 1st of January 2022 were included. Only studies reporting the interclass correlation coefficient (ICC) to evaluate the concordance between caregivers' and external researchers' scores were eligible.Twelve studies were included (586 children with CI, 60% males; weighted mean age 9.9 years - range 2-20). Five of them evaluated the Non-Communicating Children's Pain Checklist-Postoperative Version (NCCPC-PV) scale whereas four the original and revised Face, Legs, Activity, Cry, Consolability (FLACC) scale. The analysis showed an overall ICC value of 0.76 (0.74-0.78) for the NCCPC-PV scale, with a high heterogeneity index (IThe NCCPC-PV and FLACC pain rating scales showed the strongest evidence for validity and reliability for assessing postoperative pain in children with CI. However, due to the high heterogeneity of the studies available, these results should not be considered conclusive.This review is focused on the assessment of pain in children with CI in the postoperative period. Simplified observation-based pain assessment tools that rely on evaluating non-verbal expressions of pain should be recommended for children with difficulties to communicate their feelings. Even if there is a high degree of heterogeneity in clinical presentations among youth with CI, two tools (NCCPC-PV and FLACC) have emerged as reliable and valid in this population.

Children with sickle cell disease (SCD) have an increased risk of sleep disordered breathing (SDB) compared with the general pediatric population. There has been a growing research interest on this field in recent years, yet many questions regarding risk factors and clinical implications of SDB remain unclear. The aim of this review is to provide a concise narrative and systematic synthesis of the available evidence on the epidemiology, clinical presentation, complications and management, of SDB in children with SCD. An electronic search was conducted on studies published from the 1st of January 2000 to the 31st of December 2020 in PubMed/Medline, Scopus and Cochrane databases. All studies focusing on SDB in children with SCD aged from 0 to 20 years were included. Studies were eligible for inclusion if available in the English language. A quantitative synthesis of the included studies was performed. Only studies focusing on specific treatment outcomes were included in a meta-analytic process. A total of 190 papers were initially identified. After screening the title and abstract, 112 articles were evaluated for eligibility. At the end of the selection process, 62 studies were included in the analysis. Sleep-disordered breathing is associated with worse neurological, neurocognitive and cardiological outcomes, whereas the association with frequency or severity of vaso-occlusive pain events and acute chest syndrome was not clarified. Therapeutic interventions like adenotonsillectomy or oxygen supply may result in a significant increase in mean nocturnal oxygen saturation but effective clinical implications remain still unclear.

BackgroundNo study has described factors associated with COVID-19 diagnosis in children.AimDescribe characteristics and risk factors for COVID-19 diagnosis in children tested in 20 pediatric centers across Italy.MethodsCases aged 0-18 years tested for SARS-CoV-2 between February 23 and May 24 2020 were included. Our primary analysis focused on children tested because of COVID-19 suggestive symptoms.ResultsAmong 2494 children tested for SARS-CoV-2, 2148 (86.1%) had symptoms suggestive of COVID-19. Clinical presentation of SARS-CoV-2 included - beside fever (82.4%) and respiratory signs or symptoms (60.4%) – also gastrointestinal (18.2%), neurological (18.9%), cutaneous (3.8%) and other flu-like presentations (17.8%). In multivariate analysis, factors significantly associated with SARS-CoV-2 were: exposure history (adjusted OR 39.83 95%CI 17.52-90.55 pConclusionRecommendations for SARS-CoV-2 testing in children should be updated based on the evidence of broader clinical features. Exposure history, fever, and anosmia/ageusia are strong risk factors for COVID-19 in children, while other symptoms don’t seem helping discriminating in between the SARS-CoV-2 positive and the negative cases. This study confirm that COVID-19 is a mild disease in the general population of children in Italy. Further studies are needed to understand the risk, clinical spectrum and outcomes of COVID-19 in children with specific preexisting conditions.

Objective The aims of the present study were: (1) to review the literature on long-lasting cognitive sequelae in children treated for Posterior Fossa Tumor and (2) to investigate anatomic functional relations in a case series of 7 children treated for PFT using magnetic resonance imaging (MRI) post-processing methods. Methods We retrospectively analyzed MRIs of children who underwent complete surgical resection of PFT and performed extensive neuropsychological evaluation. Tumor, ventricular volumes, and VPS insertion site were drawn on T1 volumetric MRI scans and normalized to a pediatric template. Children showed worse performances on tasks tapping executive functions, memory, visuo-motor precision, and expressive language. Results Volumes of interest related to these functions showed a maximum overlap on the left vermis and the lateral ventricle enlargement, except for impaired narrative fluency –which was associated with left lateral ventricle enlargement– and narrative memory –which was related to the right vermis and the enlarged fourth ventricle. Conclusion Results suggest that anatomic functional relations in children treated for PFT are related to a combination of different pathophysiological factors.

Background Very few studies describe factors associated with COVID-19 diagnosis in children. Aim We here describe characteristics and risk factors for COVID-19 diagnosis in children tested in 20 paediatric centres across Italy. Methods We included cases aged 0–18 years tested between 23 February and 24 May 2020. Our primary analysis focused on children tested because of symptoms/signs suggestive of COVID-19. Results Among 2,494 children tested, 2,148 (86.1%) had symptoms suggestive of COVID-19. Clinical presentation of confirmed COVID-19 cases included besides fever (82.4%) and respiratory signs or symptoms (60.4%) also gastrointestinal (18.2%), neurological (18.9%), cutaneous (3.8%) and other unspecific influenza-like presentations (17.8%). In multivariate analysis, factors significantly associated with SARS-CoV-2 positivity were: exposure history (adjusted odds ratio (AOR): 39.83; 95% confidence interval (CI): 17.52–90.55; p Conclusion Recommendations for SARS-CoV-2 testing in children should consider the evidence of broader clinical features. Exposure history, fever and anosmia/ageusia are strong risk factors in children for positive SARS-CoV-2 testing, while other symptoms did not help discriminate positive from negative individuals. This study confirms that COVID-19 was a mild disease in the general paediatric population in Italy. Further studies are needed to understand risk, clinical spectrum and outcomes of COVID-19 in children with pre-existing conditions.

Tonsillectomy and adenoidectomy (T&A) is frequently performed in children with sickle cell disease (SCD). Our aim was to evaluate the impact of this surgery on overnight oxygenation and rates of complications in these patients. Children with SCD who underwent T&A between 2008 and 2014 in two tertiary hospitals were retrospectively evaluated. Overnight oximetry and admission rates due to vaso-occlusive pain episodes (VOEs) and acute chest syndrome (ACS) in the year preceding and following the surgery were compared. 19 patients (10 males, 53%) with a median age of 6 years (range 3.5–8) were included. A significant increase of mean overnight arterial oxygen saturation measured by pulse oximetry (SpO2) (from 93±3.6% to 95.3±2.8%, p=0.001), nadir SpO2 (from 83.0±7.1% to 88±4.1%, p=0.004) and a reduction of 3% oxygen desaturation index (from a median value of 5.7 to 1.8, p=0.003) were shown. The mean annual rate of ACS decreased from 0.6±1.22 to 0.1±0.2 events per patient-year (p=0.003), while the mean cumulative rate of hospitalisations for all causes and the incidence of VOEs were not affected. T&A improved nocturnal oxygenation and was also associated with a reduction in the incidence of ACS at 1-year follow-up after surgery., In children with SCD, this retrospective analysis suggests that tonsillectomy and adenoidectomy may have a beneficial effect on nocturnal oxygenation level and the rate of ACS. This finding will need further confirmation in prospective and larger studies. https://bit.ly/3gL6gaU

Background Cerebellar tumor survivors often exhibit neuropsychological deficits that could be related to alterations in cerebro-cerebellar networks. This is a pilot study designed to understand if diffusion tensor imaging (DTI)-based tractography is able to identify possible correlations between cerebellar white matter structure and cognitive outcome in children on long-term follow-up for posterior fossa (PF) tumors who were thoroughly assessed for neuropsychological functioning. Methods DTI-based tractography was performed in pediatric patients with PF tumors. Fractional anisotropy (FA) and volumetric measurements of spinocerebellar, dentorubrothalamocortical and corticopontocerebellar tracts were analyzed. Cognitive and neuropsychological functioning was assessed by the Wechsler Intelligence Scale for Children-IV Edition (WISC-IV) and the Developmental Neuropsychological Assessment (NEPSY II). The associations between Full-Scale Intelligence Quotient (FSIQ), NEPSY-II scores, and fiber tracts were tested by the Spearman rank correlation coefficient. Results Seven patients (median age at diagnosis five years, range, 3-13) treated for medulloblastoma (2/7; 29%) and pilocytic astrocytoma (5/7; 71%) were retrospectively evaluated. All children had complete surgery. The median FSIQ was 84 (range, 67-93). Patients presented with several deficits on many NEPSY-II tasks; in particular, memory was impaired in nearly half of them. FSIQ and neurocognitive tasks significantly correlated with specific corticopontocerebellar tracts. Conclusion Children on follow-up for PF tumor showed scattered cognitive impairments, including deficits in long-term and immediate memory. Tractography allowed us to describe a possible association between the integrity of cerebellar pathways and neurocognitive performance, suggesting that the myelinization of these fibers may represent an indicator for the development of long-term cognitive sequelae.

Objective: Despite a substantial consistency in recommendations for the management of children with acute gastroenteritis (AGE), a high variability in clinical practice and a high rate of inappropriate medical interventions persist in both developing and developed countries. The aim of this study was to develop a set of clinical recommendations for the management of nonseverely malnourished children with AGE to be applied worldwide. Methods: The Federation of International Societies of Pediatric Gastroenterology, Hepatology, and Nutrition (FISPGHAN) Working Group (WG) selected care protocols on the management of acute diarrhea in infants and children aged between 1 month and 18 years. The WG used a 3-step approach consisting of: systematic review and comparison of published guidelines, agreement on draft recommendations using Delphi methodology, and external peer-review and validation of recommendations. Results: A core of recommendations including definition, diagnosis, nutritional management, and active treatment of AGE was developed with an overall agreement of 91% (range 80%–96%). A total of 28 world experts in pediatric gastroenterology and emergency medicine successively validated the set of 23 recommendations with an agreement of 87% (range 83%–95%). Recommendations on the use of antidiarrheal drugs and antiemetics received the lowest level of agreement and need to be tailored at local level. Oral rehydration and probiotics were the only treatments recommended. Conclusions: Universal recommendations to assist health care practitioners in managing children with AGE may improve practitioners’ compliance with guidelines, reduce inappropriate interventions, and significantly impact clinical outcome and health care-associated costs.

Background There is no reliable marker for detecting early renal disease in early children with sickle cell disease (SCD). Estimation of glomerular filtration rate (eGFR) as derived from the height/plasma creatinine formula is dependent on the accuracy of the creatinine analytical method used. The aim of this study was to evaluate different equations for eGFR. Methods Children aged 5–16 years recruited. mGFR was obtained using plasma disappearance of Inutest/Iohexol, serum creatinine (SCr) was measured either by standard laboratory method or by tandem mass spectrometry (MSMS). Estimated GFR was then calculated either by “Bedside Schwartz method” or by the full-age spectrum (FAS) equation. Findings A total of 79 patients (mean age 9.8 ± 4.0 years). A revised eGFR constant was calculated for Schwartz equation from the slope of the plot of height/plasma creatinine versus mGFR. Mean values for mGFR (132.7 ± 32.1 ml/min/1.73m2) and eGFR methods compared: eGFR from standard SCr was significantly higher (144.2 ± 37.3 ml/min/1.73m2, p = 0.008). The MSMS eGFR showed the lowest SD (SD = 27.5), while both FAS eGFR and FAS-height eGFR showed the highest correlation coefficient (r = 0.67). Interpretation eGFR calculation based on height and SCr determined with MSMS traceable creatinine is more reliable than Schwartz formula using jaffe/enzymatic methods in SCD children.

Background: No study has described factors associated with COVID-19 diagnosis in children. Methods: Cases aged 0-18 years tested for SARS-CoV-2 between 23rd February and 24th May 2020 in 20 pediatric centers across Italy were analyzed. Our primary analysis aimed to explore sociodemographic and clinical characteristics and risk factors for SARS-CoV-2 in children tested because of suggestive symptoms. Findings: Among 2494 children tested for SARS-CoV-2, 2148 (86.1%) had symptoms suggestive of COVID-19, the remaining were asymptomatic children tested because of COVID-19 contact or children tested through hospital screenings. Clinical presentation of SARS-CoV-2 included -beside fever (82.4%) and respiratory signs or symptoms (60.4%) - gastrointestinal (18.2%), neurological (18.9%), cutaneous (3.8%) and other flu-like presentations (17.8%). In multivariate analysis, factors significantly associated with SARS-CoV-2 were: exposure history (adjusted OR 39.83 95%CI 17.52-90.55 p

Experimental evidence from animal models and epidemiology studies has demonstrated that nutrition affects lung development and may have a lifelong impact on respiratory health. Chronic restriction of nutrients and/or oxygen during pregnancy causes structural changes in the airways and parenchyma that may result in abnormal lung function, which is tracked throughout life. Inadequate nutritional management in very premature infants hampers lung growth and may be a contributing factor in the pathogenesis of bronchopulmonary dysplasia. Recent evidence seems to indicate that infant and childhood malnutrition does not determine lung function impairment even in the presence of reduced lung size due to delayed body growth. This review will focus on the effects of malnutrition occurring at critical time periods such as pregnancy, early life, and childhood, on lung growth and long-term lung function.

Disclosure of the HIV status to infected children is often delayed due to psychosocial problems in their families. We aimed at improving the quality of life in families of HIV-infected children, thus promoting disclosure of the HIV status to children by parents. Parents of 17 HIV-infected children (4.2-18 years) followed at our Center for pediatric HIV, unaware of their HIV status, were randomly assigned to the intervention group (8 monthly sessions of family group psychotherapy, FGP) or to the control group not receiving psychotherapy. Changes in the Psychological General Well-Being Index (PGWB-I) and in the Short-Form State-Trait Anxiety Inventory (Sf-STAI), as well as the HIV status disclosure to children by parents, were measured. Ten parents were assigned to the FGP group, while 7 parents to the controls. Psychological well-being increased in 70% of the FGP parents and none of the control group (p=0.017), while anxiety decreased in the FGP group but not in controls (60% vs. 0%, p=0.03). HIV disclosure took place for 6/10 children of the intervention group and for 1/7 of controls. Family group psychotherapy had a positive impact on the environment of HIV-infected children, promoting psychological well-being and the disclosure of the HIV status to children.

Objective: Acute gastroenteritis (AGE) is a major cause of child mortality and morbidity. This study aimed at systematically reviewing clinical practice guidelines (CPGs) on AGE to compare recommendations and provide the basis for developing single universal guidelines.Methods: CPGs were identified by searching MEDLINE, Cochrane-Library, National Guideline Clearinghouse and Web sites of relevant societies/organizations producing and/or endorsing CPGs.Results: The definition of AGE varies among the 15 CPGs identified. The parameters most frequently recommended to assess dehydration are skin turgor and sunken eyes (11/15, 73.3%), general appearance (11/15, 66.6%), capillary refill time, and mucous membranes appearance (9/15, 60%). Oral rehydration solution is universally recognized as first-line treatment. The majority of CPGs recommend hypo-osmolar (Na+ 45–60 mmol/L, 11/15, 66.6 %) or low-osmolality (Na+ 75 mmol/L, 9/15, 60%) solutions. In children who fail oral rehydration, most CPGs suggest intravenous rehydration (66.6%). However, nasogastric tube insertion for fluid administration is preferred according by 5/15 CPGs (33.3%). Changes in diet and withdrawal of food are discouraged by all CPGs, and early refeeding is strongly recommended in 13 of 15 (86.7%). Zinc is recommended as an adjunct to ORS by 10 of 15 (66.6%) CPGs, most of them from low-income countries. Probiotics are considered by 9 of 15 (60%) CPGs, 5 from high-income countries. Antiemetics are not recommended in 9 of 15 (60%) CPGs. Routine use of antibiotics is discouraged.Conclusions: Key recommendations for the management of AGE in children are similar in CPGs. Together with accurate review of evidence-base this may represent a starting point for developing universal recommendations for the management of children with AGE worldwide.

Background Despite consistent recommendations by all Public Health Authorities in support of annual influenza vaccination for at-risk categories, there is still a low uptake of influenza vaccine in these groups including health care workers (HCWs). Aim of this observational two-phase study was to estimate the immunization rates for influenza in four subsequent seasons and for pandemic H1N1 influenza in HCWs of a University Hospital, and to investigate its distribution pattern and the main determinants of immunization. Phase 1 data collection was performed in 2009–2010, during the peak of H1N1 pandemic. Phase 2 data collection, aimed to investigate seasonal influenza vaccination coverage in the three seasons after pandemic, was performed in 2012–2013. Methods The overall H1N1 vaccination rate was derived by the Hospital immunization registry. In 2010, the personnel of three Departments (Infectious Diseases, Pediatrics and Gynecology/Obstetrics) completed a survey on influenza. A second-phase analysis was performed in 2012 to investigate influenza vaccination coverage in three consecutive seasons. Results The first-phase survey showed a low coverage for influenza in all categories (17 %), with the lowest rate in nurses (8.1 %). A total of 37 % of health care workers received H1N1 vaccine, with the highest rate among physicians and the lowest in nurses. H1N1 vaccination was closely related to the Department, being higher in the Department of Infectious Diseases (53.7 %) and Pediatrics (42.4 %) than in Gynecology/Obstetrics (8.3 %). The second-phase survey showed the lowest rate of influenza vaccination in 2012/13 season. The main reasons for not being vaccinated were “Unsure of the efficacy of vaccine” and “Feel not at-risk of getting influenza or its complications”. Despite recommendations, influenza vaccine uptake remains poor. Conclusion Immunization is largely perceived as a personal protection rather than a measure needed to prevent disease spreading to at-risk patients. Compulsory vaccination against influenza should be considered as a possible strategy, at least in health institutions where at-risk patients are admitted. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-1090-x) contains supplementary material, which is available to authorized users.

summary Background and aims: Short bowel syndrome is the major cause of intestinal failure. Patients often require parenteral nutrition for a variable period of time to survive, but there is no consensus on the optimal feeding formula during the weaning from parenteral nutrition. Aim of this study was to retrospectively analyze the development of food allergy in children with short bowel syndrome weaned with a hydrolyzed or an amino acid-based formula. Methods: Clinical data were recorded for each patient. We also collected results of allergy tests of patients who had allergic reactions. Results: Forty-seven children with intestinal failure (26 males; mean age of 4.53 ± 3.85 years), followedup at the Department of Pediatrics since 2000, were retrospectively evaluated. Thirty-eight of 47 children (80%) had residual bowel < 100 cm requiring a mean duration of 17.36 ± 6.7 months of parenteral nutrition. In this group 22/38 children were weaned from parenteral nutrition with amino acid-based formula and 16 with hydrolyzed formula. Adverse events were reported in 16/38 children and 10 of these, all weaned with hydrolyzed formula, received diagnosis of cow's milk allergy. None of the 22 children weaned with amino acid-based formula developed allergic reactions. Conclusions: Children weaned with hydrolyzed formula have an increased risk of developing cow's milk allergy in comparison to those weaned with amino acid-based formula and its use may have a role in the prevention of food allergies. The reduced length intestinal residual (

Background An increased but unpredictable risk of malnutrition is associated with hospitalization, especially in children with chronic diseases. We investigated the applicability of Screening Tool for Risk of Impaired Nutritional Status and Growth (STRONGkids), an instrument proposed to estimate the risk of malnutrition in hospitalized children. We also evaluated the role of age and co-morbidities as risk for malnutrition. Methods The STRONGkids consists of 4 items providing a score that classifies a patient in low, moderate, high risk for malnutrition. A prospective observational multi-centre study was performed in 12 Italian hospitals. Children 1–18 years consecutively admitted and otherwise unselected were enrolled. Their STRONGkids score was obtained and compared with the actual nutritional status expressed as BMI and Height for Age SD-score. Results Of 144 children (75 males, mean age 6.5 ± 4.5 years), 52 (36%) had an underlying chronic disease. According to STRONGkids, 46 (32%) children were at low risk, 76 (53%) at moderate risk and 22 (15%) at high risk for malnutrition. The latter had significantly lower Height for Age values (mean SD value -1.07 ± 2.08; p = 0.008) and BMI values (mean SD-values -0.79 ± 2.09; p = 0.0021) in comparison to other groups. However, only 29 children were actually malnourished. Conclusions The STRONGkids is easy to administer. It is highly sensitive but not specific. It may be used as a very preliminary screening tool to be integrated with other clinical data in order to reliably predict the risk of malnutrition.

Introduction: Parenteral nutrition has significantly improved the prognosis of children with intestinal failure, but it has an inevitable impact on their lives. The aim of the present study was to assess the psychosocial well-being of these patients and their families. Materials and methods: Two groups of children (cases and controls) were enrolled with their families. Patients with primary intestinal failure aged 2-18 years who required or had previously required parenteral nutritional and healthy controls were included. We used four tests to investigate their quality of life, three administered to parents and one to children. Results: Sixteen children with primary intestinal failure (12 males; mean age 7.2 ± 4.8 years) and 12 healthy controls (6 males; mean age 9.3 ± 4.9 years) were enrolled. The International Classification of Functioning, Disability and Health, Children and Youth Version showed that specific environmental factors were perceived as barriers by patients’ caregivers (44% vs 0%; p=0.01) and 5/16 (31%) of them had medium-high levels of anxiety according to the State-Trait Anxiety Inventory. Conclusions: The quality of life of children on parenteral nutrition was only slightly impaired. Parents, instead, showed more anxious behavior related to their children’s parenteral nutrition.

The increasing incidence and severity of Clostridium difficile infection (CDI) is becoming a major issue in public health. The identification of new therapeutic options able to control severe cases and reduce the risk of recurrence is a research priority. Toxins A (TcdA) and B (TcdB) and host immune response are the major determinants of CDI pathogenesis and may be a possible target for new therapies. The aim of this review was to critically describe the evidence available on the effect of monoclonal antibodies (MAbs) on CDI, putting them into clinical context and highlighting possible advantages and barriers to their use. Experimental animal studies revealed the potential of MAbs to protect against CDI progression and recurrence, especially when a combination of anti-TcdA and anti-TcdB is used. Only one clinical trial confirmed that this combined approach is well tolerated and effective in controlling CDI recurrences in at-risk subjects with refractory CDI. Other clinical trials are currently ongoing and explore alternative molecules. Toxin-targeted MAbs are one of the most promising approaches and at-risk subjects and those experiencing recurrence are the ideal targets for this second-line treatment. However, CDI epidemiology is rapidly changing and MAbs may also represent a powerful option for other patients.

s / Digestive and Liver Disease 45 (2013) e263–e311 e267 Mean serum amylase level was 205.3±91.5 (median 196, range 61–413 IU/L) and mean serum lipase level was 526.8±598.8 (median 299, range 37–2565 IU/L). Ten (37%) patients underwent imaging ultrasound scan, 8 (29.6%) patients had magnetic resonance cholangiopancreatography and 2 (7.4%) patients had a computed tomography scan. Pancreatic pathological findings were found in all subjects with AP; in one patient primary sclerosing cholangitis was diagnosed. The mean lag time period between the diagnosis of IBD and the PI was 12.1 months (median 7, range 0–65). Five patients out of 27 (18.5%) showed PI at diagnosis of IBD. Twenty-four out of 27 (88.8%) had colonic disease [10 CD, 12 UC (8 pancolitis) and 2 IBDU]. Comparing with the patients with an exclusive hyperamylasemia and/or hyperlipasemia, the onset of AP was significantly associated with female gender (p=0.018), whereas type of IBD, ongoing treatments, activity and extension of disease did not result significant risk factors. Seven out of 11 (63.6%) patients with AP needed therapeutic measures including AZT and/or ASA withdrawal, compared to only 4 (25%) patients out of 16 with serum hyperamylasemia and/or hyperlipasemia (p=0.06). Conclusions: To the best of our knowledge this is the first pediatric registry-based study evaluating the prevalence of pancreatic involvement in IBD. Our study suggests that prevalence of AP in children was similar to that reported in adults. Female gender appears to be a risk factor for developing AP in pediatric IBD. In contrast to previous study, PI was not associated with any type of IBD.

s / Digestive and Liver Disease 45 (2013) e263–e311 e289 Conclusions: Vit D levels did not significantly differ between celiac patients with active disease and those on GFD; no differenceswere observed between Vit D levels of overweight/obese and normal weight celiac; no differences were observed between Vit D levels between different age groups; statistically significant differences were observed through seasons, thereby confirming the importance of the exposition to sunlight. Deficiency/insufficiency Sufficiency N 201 n % Mean value n % Mean value Celiac 14 12 85.7 20.09 2 14.3 45 On GFD 187 162 86.6 18.97 25 13.4 40.19 p=0.9227 p=0.5279 p=0.9227 p=0.6121 Overweight/obese 32 28 87.5 19.7 4 12.5 44.95 Normal weight 169 145 85.8 18.84 24 14.2 39.37 p=0.7988 p=0.4844 p=0.7988 p=0.4186 Summer–autumn 84 66 78.6 21.66 18 21.4 42.74 Winter–Spring 117 108 92.3 17.45 9 7.7 36.14 p=0.0049 p=0.0006 p=0.0049 p=0.2043

history of respiratory distress and ab ingestis bronchial-pneumonia and at 2 years old, he underwent surgical intervention for ultra-short Hirshproung Disease. After the exclusion of neurological and otolaryngological causes, he underwent upper endoscopy, which showed two Mallory-Weiss bleeding tears of about 1.5 cm each. He was immediately admitted and received intravenous treatment with Omeprazole and Ampicillin/Sulbactam. After one week of hospitalization a control upper endoscopy showed superficial erosions till the middle oesophagus, improved over the last. Besides the oesophagus presented a “trachealized” aspect, suspicious for eosinophilic oesophagitis and an hyperaemic gastropathy at the body and at the antrum. However the histological report defined an eosinophilic gastritis. He, also, underwent a ileocolonoscopy that described a linfoid nodular hyperplasia and an severe inflammation of ileo-caecal valve, left-colon and sigmoid-rectum tract to complete the diagnosis. The eosinophilic infiltrate was also significant at the colic level. Finally, chest X-ray, brain RNM and abdominal ultrasound resulted negative while allergic test were positive to many allergens (kiwi, hazelnuts). Faecal research of bacterial and parasites were negative; the peripheral blood smear was negative for blasts. Between biochemical parameters, eosinophils were increased (12.6%) as well as ECP (200 μg/l) and triptase (3 μg/l). According to the allergologist, the child begin a steroid therapy at full dose, a diet restriction and stopped the assumption of Montelukast, because of the possible increasing of eosinophilia. At the moment, his clinical conditions are improved: he no longer vomits, his biochemical parameters are normalizing (eosinophils: 8.2%; ECP: 86 μg/l; triptase: 2.47 μg/l), the last upper endoscopy was showed no lesions and at the histology the eosinophilic infiltrate is decreasing. Discussion: EGIDs are a group of emerging disease, which manifestations can be unspecific and chronic, but also, like in this case, severe and sudden. More studies are needed to evaluate if there were conditions that could trigger the disease (eg. drugs -Montelukast-). Finally, we report this case because of the Mallory-Weiss Syndrome is a rarely complication of EGIDs.

Background Rotavirus (RV) is a major agent of gastroenteritis and an important cause of child death worldwide. Immunization (RVI) has been available since 2006, and the Federation of International Societies of Gastroenterology Hepatology and Nutrition (FISPGHAN) identified RVI as a top priority for the control of diarrheal illness. A FISPGHAN working group on acute diarrhea aimed at estimating the current RVI coverage worldwide and identifying barriers to implementation at local level. Methods A survey was distributed to national experts in infectious diseases and health-care authorities (March 2015–April 2016), collecting information on local recommendations, costs and perception of barriers for implementation. Results Forty-nine of the 79 contacted countries (62% response rate) provided a complete analyzable data. RVI was recommended in 27/49 countries (55%). Although five countries have recommended RVI since 2006, a large number (16, 33%) included RVI in a National Immunization Schedule between 2012 and 2014. The costs of vaccination are covered by the government (39%), by the GAVI Alliance (10%) or public and private insurance (8%) in some countries. However, in most cases, immunization is paid by families (43%). Elevated cost of vaccine (49%) is the main barrier for implementation of RVI. High costs of vaccination (rs = −0.39, p = 0.02) and coverage of expenses by families (rs = 0.5, p = 0.002) significantly correlate with a lower immunization rate. Limited perception of RV illness severity by the families (47%), public-health authorities (37%) or physicians (24%) and the timing of administration (16%) are further major barriers to large- scale RVI programs. Conclusions After 10 years since its introduction, the implementation of RVI is still unacceptably low and should remain a major target for global public health. Barriers to implementation vary according to setting. Nevertheless, public health authorities should promote education for caregivers and health-care providers and interact with local health authorities in order to implement RVI.