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Despite being a standard of care for children undergoing stressful procedures, little data exist on parental perception of pediatric sedation.This study aimed to investigate recovery characteristics and parental satisfaction for pediatric sedations performed with four widely used sedative regimens.A prospective observational study was conducted at the Institute for Maternal and Child Health of Trieste, Italy, enrolling children undergoing procedural sedation with one of the following pharmacological regimens: propofol, propofol + midazolam, ketamine + propofol, and dexmedetomidine + midazolam. A questionnaire was used to assess the occurrence of symptoms upon recovery from sedation and the following day, and the caregivers' satisfaction for both the recovery pattern and the overall sedation experience, according to a numerical rating scale (0-10). Answers were collected through a telephone survey. The primary outcome was the difference in the quality of the recovery as perceived by caregivers; the secondary and tertiary outcomes were the perceived quality of the overall sedation experience and the frequency of sedation-related adverse events, respectively.Data from 655 patients, 149 receiving propofol, 245 propofol + midazolam, 134 ketamine + propofol, and 127 dexmedetomidine + midazolam, were analyzed. The level of parents' satisfaction for both the recovery and the sedation experience was overall high and increased with the patients' age in all the pharmacological groups (Spearman's rank correlation, ρ .083, p = .033, and ρ .087, p = .026, respectively), with no statistically significant differences between groups when adjusting for age. The occurrence of irritability, prolonged sleepiness, hyperactivity, unsteadiness, hallucinations, emesis, and respiratory distress at any moment negatively affected parental satisfaction.In this study, caregivers' satisfaction with pediatric sedation was high, regardless of the regimen used. Lower parental satisfaction was associated with younger age, irritability after sedation, prolonged sleepiness, hyperactivity, unsteadiness, hallucinations, emesis, and respiratory distress.

According to the Italian national statistical institute, severe bacterial infections (SBI) in Italy are responsible for 1.7% of mortality under 5 years of age and their recognition is often challenging, especially in the first stages of the disease. We tried to estimate the prevalence of SBI in our target population and to identify signs and symptoms that could guide in the initial evaluation of a child with a possible SBI.We designed a prospective, multicentre study and enrolled patients aged 0-14 years at the first evaluation to the emergency department with an acute illness lasting a maximum of 5 days. The presence of variables suggestive of SBI was collected for every enrolled patient. One week after the enrolment, every patient was followed up by telephone.SBI is more likely to be detected with the 'gut feeling' in both univariate and multivariate models (univariate OR: 7.16, 95% CI: 4.08-12.56; multivariate OR: 5.34, 95% CI: 2.78-10.25), while abnormal breathing pattern resulted significative only in univariate model (OR 3.83, 95% CI: 1.98-7.40). Nevertheless, their associated sensitivity is low.SBI is uncommon in the absence of paediatricians' gut feeling and abnormal respiratory pattern.

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.

The authors present the case of a 3-year-old child with severe diarrhoea, hypoalbuminaemia, hypogammaglobulinaemia and anaemia eventually diagnosed as coeliac. The clinical features of the so-called coeliac crisis are discussed.

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.

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

Children with intellectual disability frequently undergo needle-related procedures for diagnosis or treatment. Nevertheless, only a few studies deal with pain and distress management during the procedure in this population of children. This study aimed to investigate the number of anxiety and pain management techniques performed during needle procedure in children with intellectual disability (cases) compared to a population of children without intellectual disability (controls). This multicenter cohort study was performed from July 2016 to January 2018 in the pediatric ward of four urban hospitals in Italy. Eligible subjects were children with and without intellectual disability, from 4 to 17 years old, who needed venipuncture or intravenous cannulation for diagnosis or treatment. Use of topical anesthesia, distraction techniques, and physical or verbal comfort during procedures were recorded. Pain and anxiety scores were also recorded. Forty-seven cases and 94 controls were recruited. Three pain- and anxiety-relieving techniques were performed during the procedure in 12 (25%) cases and in 10 controls (11%); two techniques were performed in 23 (50%) cases and in 26 (28%) controls; 12 (25%) cases and 52 (55%) controls received only one.Conclusion: In this series, children with intellectual disability received significantly more relieving techniques, but experienced more pain and anxiety when compared to children without intellectual disability. What is Known: • Children with intellectual disability experience more episodes of pain than cognitively healthy ones, and almost 10% of these episodes are due to medical procedures. What is New: • Children with intellectual disability despite receiving more relieving techniques during a needle-related procedure experienced more pain and anxiety when compared to healthy children.

BACKGROUND: To prevent malnutrition and food aspiration in children with chronic neuromuscular problems, enteral nutrition provided by gastrostomy is recommended. Long-term follow-up data about surgical and medical complications of PEG are available, but few papers have addressed all of the issues in the same series. METHODS: This retrospective study enrolled patients under 18 years who had a gastrostomy tube placed at our institution between 2003 and 2017. The aim is to evaluate outcomes after gastrostomy placement, focusing both on surgical complications (early and late), and its effect on their nutritional status, on the prevention of pulmonary infections, and their parents&rsquo, opinion. RESULTS: Eighty-four gastrostomies were placed in total (35 F, 49 M). Seventy-seven patients had a severe neurocognitive impairment (GMFCS 5). The principal indication for gastrostomy was severe dysphagia (53.3%). No gastrostomy-related death was observed. Early surgical complications were observed in five of 84 (5,9%) patients, late complications were observed in 15 of 84 (17.8%) patients. Twenty-two patients were diagnosed with subsequent gastroesophageal reflux, five patients developed dumping syndrome (6%). Complete medical follow-up data were available for 45 patients. A progressive improvement of nutritional status was observed in 29 patients, and 11 maintained the same percentile, the occurrence of respiratory infections and need for hospitalization decreased. In 90% of cases, parents were fully satisfied with the g-tube. CONCLUSION: This study confirms the positive nutritional outcomes of gastrostomy-tube with an associated small risk of surgical complications and a reduction in the number of respiratory infections, with most parents scoring their experience as positive.

We have read with interest the original article by Picarelli et al. [1] describing metabolic control and selected hemocoagulative/anticoagulant parameters in patients with isolated type 1 diabetes mellitus (T1DM) and in those affected by celiac disease (CD) too. According to our experience at Pediatric Endocrinology Unit of Trieste, we respectfully disagree with Picarelli’s conclusion and otherwise support the importance of a gluten-free diet (GFD). Picarelli et al. emphasize a better metabolic and glycolipidic control in patients with both DM1 and CD not following a GFD and suggest a protective role of CD in the prothrombotic state of DM1. In our opinion, their study has three critical points. First, all patients presented a glycosylated hemoglobin level (HbA1c)\7.5%. These inclusion criteria could be a selection bias that could influence the results. Second, in accord with literature, we believe that a single variable (glycosylated hemoglobin) is not sufficient to evaluate glycemic control: daily insulin dosages, hypoglycemia frequency, and glycemic variability should be also considered. Glycemic variability, specially, is considered an independent risk factor for complications [2]. Third, they do not analyze the effect of CD on the anthropometric variables nor investigate the presence of other autoimmunities. We followed up 74 patients with diabetes to evaluate the prevalence of celiac disease (CD) in a cohort of children with type 1 diabetes (T1DM) and to investigate the influence of CD on growth and metabolic control, before and after gluten-free diet (GFD). A total of 17 celiac-positive subjects (group 1) and 57 celiac-negative subjects (group 2) were examined. Data on growth and metabolic control were collected retrospectively at three different moments (diabetes diagnosis, CD diagnosis, and 6–12 months after a GFD was started). Prevalence of CD accounts for 13% of our cohort, which is comparable with prevalence in Picarelli’s cohort (13.8%). In most of cases (70%), screening test led to the diagnosis. In 70% of CD-positive patients, HbA1c levels were\8% before GFD (vs 54% of CD negative), but only in 42% of them after GFD. In CD-positive cases, good HbA1c levels were often associated with glycemic variability (65%) before GFD, while quite rarely after 6–12 months of diet (28.5%). These results allow us to suppose that before GFD was started, metabolic control was apparently good, but it really improved after GFD (reduction in glycemic variability). Besides, in our cohort, we observed that the co-occurrence of both disease compromises growth, and meanwhile, it improves after that GFD is started (BMI of CD-positive subjects rises from 46 percentile before GFD, to 54 after GFD, P \ 0.05). In our cohort, CD remains asymptomatic in the most of cases (70%), and then, the diagnosis would have been missed if the screening had not been performed, as confirmed by Picarelli’s study too. This result accords with literature [3–10] and supports importance of serological screening in diabetic population. In conclusion, we believe that serological screening is useful for diagnosing asymptomatic CD and GFD in CDpositive diabetic patients can allow growth and diabetes control comparable with patients with T1DM alone. P. Pascolo (&) E. Faleschini G. Tonini A. Ventura Institute for Child Health IRCCS Burlo Garofolo, Trieste, Italy e-mail: paolapascolo@gmail.com