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The Study Group on Accreditation and Quality Improvement of the Italian Society of Pediatrics has developed an observational study about the hospital management of pediatric patients affected by severe asthma, in order to evaluate how the Guidelines for severe asthma in childhood are applied in the daily practice.This study included patients between 2 and 17 years, hospitalized or under short intensive observation for acute asthma. The data collection was carried out through the compilation of on-line forms. The statistical technique used was the Chi Square test.409 forms were filled in by 32 Italian Centers. 17% of the patients showed severe asthma, 59% moderate and 24% mild. On arrival at the Emergency Room the oximetry was measured in 95% of the patients, the respiratory rate in 64% while the heart rate in 88% of them. 48% of the children were exposed to chest X-ray. More than half of the children received oxygen therapy, 98.5% received short-acting beta-2 agonists and systemic steroid therapy was given to 82% of children, mainly orally. At discharge only half of the children were provided with written instructions for the management of any subsequent asthmatic episode. The analysis of the collected data highlights that not all the children had their oxygen saturation measured, although this parameter is one of the main indicators of disease severity, as well as the respiratory rate, which was detected in a minimal percentage of cases. The frequency of chest X-ray was extremely high, even though it does not have any indication in the majority of asthma cases. The evaluation of the therapeutic treatment denotes an adequate use of the oxygen therapy according to the oximetry values found on arrival, but an abuse of steroid therapy. Critical issues emerge at discharge: children are not always educated about the home management of the disease and the self-evaluation of the illness seriousness.The pediatric network has become an excellent system of monitoring of the clinical management of asthmatic children, highlighting strengths and weaknesses on which to focus actions of improvement.

AIM: The aim of the study was to assess the quality of clinical practice guidelines (CPGs) using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument, a validated international tool. MATERIALS AND METHODS: CPGs were identified by searching MEDLINE (1966-January 2009) and Embase (1988-January 2009), CPG databases, and relevant Web sites of agencies and organizations that produce and/or endorse guidelines. Included in the study were CPGs in English that addressed the management of acute gastroenteritis in children. Retrieved CPGs were evaluated with the AGREE instrument for quality assessment by 6 independent reviewers. AGREE consists of 6 domains for a total of 23 items. RESULTS: Nine CPGs were identified. Four were evidence based (EB) and 2 of these included tables of evidence. Eight CPGs (88%) scored

Recent studies found a difference in body composition determined by skinfold thickness measurements between breast-fed and formula-fed infants in the first year of life. We therefore investigated the body composition of 79 infants at 12 months measured by total body electrical conductivity (TOBEC) and compared with early feeding mode (breast-feeding for at least 6 months versus formula-feeding or breast-feeding or for ≤2 months). Lower weight, stature and cranial circumference were associated with breast-feeding when the variables were compared using an ANOVA model. The groups did not significantly differ in terms of fat-free mass, but body-fat mass was lower among breast-fed infants. Multiple regression analysis showed a significant correlation between body fat mass and duration of breast-feeding and lower amounts of body fat correlated with a longer period of breast-feeding. Copyright © 1996 Elsevier Science Inc.

We report on the ability of a food frequency questionnaire (FFQ) to estimate the mean nutrient intake at population level for an Italian pediatric population. Three-hundred and twenty-three healthy, fourth grader school children (158 females, 165 males) were enrolled (mean age = 9.3 years, range 8.1–10.6). Data collected from the FFQ was compared with a 24-hour dietary recall that is known to yeald good estimates of group mean nutrient intake. The 24-hour dietary recall was compiled by trained personnel who interviewed the children's mothers. Nutrient intakes were calculated using the Italian National Institute for Nutrition nutrient composition data base. The FFQ was designed according to Block 's procedure. Data were expressed as nutrient densities to adjust for caloric intake. The comparison between the two methods of nutrient intake evaluation was assessed separately for males and females by Student's t-test for paired samples. Energy intake was found to be higher among both males and in females. For females, protein (−9%) and cholesterol (−11%) were found to be significantly lower with FFQ than with 24-hour dietary recall. For all other nutrients the mean difference was

We designed a food frequency questionnaire [FFQ] for Northern Italian school-children and tested its validity for the assessment of individual nutrient intake. Eighty-eight healthy children (49 females, 39 males — age range 9–12) were investigated. The FFQ we designed consists of 116 food items selected for their common use among our target population (food items found to provide up to 90 % of the following nutrients: energy, total lipids, saturate [SFA], polyunsaturate [PUFA] and monounsaturate [MUFA] fatty acids, carbohydrates, proteins, cholesterol, vitamins A, B1, B2, B6, C, D, E, calcium, iron, soluble and non-soluble fibres). To test the validity of the FFQ we collected data from a seven-day dietary record for comparison at the beginning of the study and six months later. The FFQ was distributed to parents several days before the collection of the second diary. The validity of the FFQ in the categorizing of individual children at the extreme quintiles was evaluated with contingency tables; the validity of the individual evaluations of nutrient intake was assessed by Pearson's correlation coefficient. The estimated energy intake is greater with the use of the FFQ. The intake of most nutrients is comparable, but there is a significant difference for proteins, PUFA, MUFA, cholesterol, vitamins B1, C, B6, E and for fibres. The greatest difference was found for vitamins B1 and C. The degree of correlation for most nutrients was within the 0.30 and 0.58 range. For most nutrients, the calculation of the nutrient density increased the correlation coefficient, while proteins, carbohydrates and MUFA decreased it. For some nutrients (vitamins A and B6) the coefficient of correlation was found to be low. The contingency analysis of absolute nutrient intake shows gross misclassification above all for MUFA and vitamin B1. The use of nutrient density removes the misclassification for MUFA but not for vitamin B1. Proteins are classified with less consistency when expressed as nutrient density. The comparison between a standard measurement methodology and the FFQ yields a higher consistency for individual estimates than for other paediatric populations but lower than that reported in adult populations.

The calcium intakes of 35 072 Italian schoolchildren aged 7 – 10 years were investigated as part of a nation-wide survey of nutritional patterns. The Friuli, Piedmont, Latium and Sicily regions of Italy were selected as representative of the nation's north–south and east–west socio-economic divisions. A food-frequency questionnaire was used to assess the nutritional intakes of the whole sample. The validity of the food-frequency questionnaire method was assessed in a sub-sample of children by traditional methods: 24-h dietary recall and a weighted food diary. The data indicate that the mean calcium intakes of girls were below the recommended daily intake of 800 mg in all of the regions except Sicily, and that the calcium intakes of boys were above the recommended daily intake in all of the regions except Friuli. These results suggest that there may be deficiencies in the calcium intakes of this age-group in the wider population, particularly in girls. Food-frequency questionnaires are potentially valuable as part of a multi-method approach in large-scale nutritional monitoring.

Summary. Diet variability influences the accuracy of the assessment of the relationship between nutrient intake and disease. The present study investigates intra- and inter-individual variability in an infant population at 12 months. The mothers of 79 infants completed a 7-day weighted food record. No significant difference in nutrient intake was observed between males and females. For some nutrients an intra-/inter-individual variability ratio < 1 was found. Adjustment for total calorie intake slightly altered the intra-/inter-individual variability ratio of many nutrients. An error margin of 10% or less for calories can be expected within an 18-day study. Most nutrients however would need to be studied for over 30 days to give an error margin ≤10%. For dietary cholesterol, vitamins A, B6, C, and E, bracketing the error within the 10% margin would require an unrealistic time frame. Adjustments for calorie intake reduced the number of days in the dietary record for some nutrients. A lower intra/inter-individual variability ratio was seen when data for adults and older infants were compared.

An analysis of LDL-receptor gene was performed on an Italian patient with heterozygous familial hypercholesterolemia. Restriction enzyme analysis showed that the proband was heterozygous for a deletion of 4.5 kb spanning the 5' end of exon 13 (45 nucleotide residues) to intron 15. Amplification of genomic DNA, using polymerase chain reaction (PCR), followed by direct sequencing, showed that this deletion was identical to the one reported by Lehrman et al. (1986. Proc. Natl. Acad. Sci. 83: 3679-3683). As only the normal LDL-receptor mRNA was detectable in proband fibroblasts by Northern blot, we used reverse transcription-PCR to amplify the mutant mRNA using primers complementary to exon 6 (sense) and exon 18 (antisense). The amplification of control cDNA resulted in a single fragment of 1725 nucleotides containing the normal sequence. The amplification of cDNA from the proband produced the 1725-nucleotide fragment (as in the control) and three additional fragments (F1, F2, and F3) of smaller size. The direct sequence showed that in the F1 fragment exon 12 was joined to exon 16; in the F2 fragment exon 12 was joined to exon 17; and in the F3 fragment exon 11 was joined to exon 16. Thus, the deletion-bearing allele generated three mRNAs, two of which resulted from alternative splicings leading to the skipping of exons 16 and 12, respectively. It is expected that the translation of these mutant mRNAs will generate three aberrant proteins, the synthesis of which should be negligible in view of the very low content of the corresponding mRNAs.

Summary The association between lipids and apoproteins and indices of fat patterning was assessed in a sample of school-age children of both sexes. The study included 361 children between 6 and 15 years of age in two urban centers in the Milan area. Ages, weights, and skin folds were recorded, and percentages of overweight and body mass index were derived. Total cholesterol (TC), high-density lipoprotein cholesterol (C-HDL), triglycerides (TRIGL), apoprotein A-I (apoA-I), and apoprotein B (apoB) were assayed. Low-density lipoprotein cholesterol (C-LDL) was calculated. The obese boys had significantly higher levels of TRIGL and apoB than nonobese boys. The obese girls had significantly higher TC, TRIGL, C-LDL, and apoB levels than the nonobese girls, but lower C-HDL. The LDL/apoB ratio was lower in obese than normal-weight boys. The subscapular/tricipital fold ratio (S/T) was correlated positively with TRIGL and inversely with C-HDL in boys, while in girls it was correlated with TRIGL and apoB. The subscapular/iliac fold ratio (S/I) was correlated with the C-LDL/ apoB ratio only in girls. These data underline the importance of anthropometric parameters and indices of fat patterning in determining early cardiovascular risk factors.

Dyslipidemia is a major risk factor for atherosclerosis in adults and children. This study investigated the levels of lipoproteins in a northern Italian pediatric population, in relation to nutritional and familial factors. We studied 650 children on the basis of a 3-day dietary record; 361 of these children had their lipid levels [total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and triglycerides] measured by a dry, multilayer method and apoprotein A-I and B by an immunonephelometric method. Familial history of cardiovascular disease and dyslipidemia was recorded. Anthropometric variables were taken for each child. Mean TC and low-density lipoprotein cholesterol (LDL-C) were high compared with southern Italian data, but similar to those of other Western countries. Family history of cardiovascular disease could not identify children with higher levels of atherogenic lipoprotein. Nutritional factors affected lipoprotein levels. The most important finding was a higher TC/HDL-C ratio in the lower quartile of polyunsaturated fatty acid intake. Obese children had higher levels of ApoB, triglycerides, TC and LDL-C, and lower levels of HDL-C; figures were higher for obese boys than for obese girls. Our study confirms a high prevalence of elevated levels of atherogenic lipoproteins among the northern Italian pediatric population and an association with nutritional factors and weight.

An analysis of LDL-receptor gene was performed on an Italian patient with heterozygous familial hypercholesterolemia. Restriction enzyme analysis showed that the proband was heterozygous for a deletion of 4.5 kb spanning the 5' end of exon 13 (45 nucleotide residues) to intron 15. Amplification of genomic DNA, using polymerase chain reaction (PCR), followed by direct sequencing, showed that this deletion was identical to the one reported by Lehrman et al. (1986. Proc. Natl. Acad. Sci. 83: 3679-3683). As only the normal LDL-receptor mRNA was detectable in proband fibroblasts by Northern blot, we used reverse transcription-PCR to amplify the mutant mRNA using primers complementary to exon 6 (sense) and exon 18 (antisense). The amplification of control cDNA resulted in a single fragment of 1725 nucleotides containing the normal sequence. The amplification of cDNA from the proband produced the 1725-nucleotide fragment (as in the control) and three additional fragments (F1, F2, and F3) of smaller size. The direct sequence showed that in the F1 fragment exon 12 was joined to exon 16; in the F2 fragment exon 12 was joined to exon 17; and in the F3 fragment exon 11 was joined to exon 16. Thus, the deletion-bearing allele generated three mRNAs, two of which resulted from alternative splicings leading to the skipping of exons 16 and 12, respectively. It is expected that the translation of these mutant mRNAs will generate three aberrant proteins, the synthesis of which should be negligible in view of the very low content of the corresponding mRNAs.

The levels of atherogenic lipid fractions are higher in children with a family history of ischemic cardiovascular disease (CD). This study was designed to examine this relationship in neonates. A total of 1276 newborns were investigated; 400 cord blood samples were collected for measurement of triglycerides (TG), total cholesterol (TC), LDL cholesterol (LDL-C) and HDL cholesterol (HDL-C); on day 4, 1200 capillary samples were taken for TC and TG measurements. Male newborns with a positive history of CD had higher concentrations of cord blood TC (P less than 0.04) and LDL-C (P less than 0.02). On day 4 this difference in TC was no longer detectable (LDL-C not determined). A coronary heart disease (CHD) risk factor family history is sensitive (0.87) in predicting high cord blood concentrations of LDL-C, the specificity being 0.46 and the positive predicting value 0.08.

From January 1st, 1983 to March 31st, 1988, 66 children with GER were tested with barium esophagogram, esophageal pH monitoring and esophagoscopy. A medical therapy was given to 49 children and 46 had a clinical improvement; 13 were operated. Early diagnosis is very important to prevent complications: in fact our data show that older children have the worst complications, while infants with GER and severe esophageal pH monitoring have only I-II grade esophagitis.

An investigation of the nutrient intake of a large-scale sample ( n = 35 072), drawn from the Italian school-age population (7 – 10 years) was carried out in a nationwide survey of nutritional patterns. Friuli, the Piedmont, Latium and Sicily regions were selected as representative of the nation's north-south and east-west socio-economic divisions. A food frequency questionnaire was used to assess nutritional intake. Traditional methods of 24-h dietary recall and a weighted food diary were used in sub-samples to assess the’ validity of the food frequency questionnaire. Our data suggest that the average diet of Italian schoolchildren is rich in protein (especially animal proteins) and lipids (prevalently saturated fatty acids), but that carbohydrate and fibre intakes remain generally low. The relatively low calcium intake among girls and a widespread, more than adequate iron intake are also noteworthy. The food and nutrient intakes assessed suggest a dietary pattern with several positive points, but also reveal potential hazards for a wider population spectrum. The type of large-scale nutritional monitoring with a multimethod approach can be used in Italy and elsewhere to describe the dietary trends of a school-age population.

The Italian Pediatric Network is now 8 years old. The number of pediatric Departments has increased from the 19 that in 2006 began a feasibility study of the project, to the 129 of today. The objectives of the network are: scientific research, surveillance of rare events, monitoring of complex phenomena, standardization of diagnostic criteria and therapeutic processes, creation of a hospital network capable of allowing a fast and profitable exchange of informations, evaluation of the degree of implementation of clinical Guide Lines. The Network was created by the Working Group for the Accreditation and Quality Improvement (GSAQ) of the Italian Society of Pediatrics Clinical. Date are recorded at the time of discharge by a single operator for each hospital and loaded into anonymous electronic case report forms, different for each pathology, prepared with the help of subspecialty Scientific Societies and available in the Pediatric Network website [http://networkpediatrico.sip.it]. It is not possible to report here all the results obtained from the analysis of the data concerning the first four pathologies investigated (idiopathic trombocytopenic purpura, diabetes at onset, bacterial meningitis after the neonatal period, acute asthma after the second year of life). We will present just a few data on the fifth pathology: acute gastroenteritis in children below 5 years of age. 31 centers filled 612 case report forms in 7 months. It is interesting to compare the diagnostic and therapeutic policies of the partecipating units with the indications of the ESPGHAN Guide Lines. The appropriateness of admissions was rather low, beeing only 42,5% altogether, and minimal for patients admitted under pressure from the family, 2%. Appropriateness of treatments: only 2/3 of the patiens have been correctly treated showing complete or almost complete adherence to the recommendations (no more than 2 major violations or one major and two minor). Major violations were considered those that might negatively affect the course of the disease, unnecessarely increase the cost of treatment or any violation to high grade recommendations, minor violations those that did not change the course of the disease, even if not appropriate and all interventions in contrast with low grade recommendations. The most frequent violations were: microbiological studies, wrong diet prescriptions, use of unrecommended antidiarrhoeal drugs or of probiotics lacking evidence of efficacy, prescription of antibiotics. Two other report forms, concerning bronchiolitis and ALTE, will be officialy presented at this meeting and are ready to be launched in the network.