Optimizing Oxygen Delivery by Low-Flow Nasal Cannula to Small Infants: A Bench Study.

BACKGROUND: In infants treated with a low-flow nasal cannula (LFNC), the oxygen concentration delivered to the lungs (i.e., the effective FiO2) is difficult to estimate. The existing mathematical formulas rely on important assumptions regarding the values of respiratory parameters and, thus, may be inaccurate. We aimed to assess oxygen delivery by LFNC to small infants using realistic simulations on a mechanical breathing model. METHODS: A mechanical breathing simulator (infant upper-airway replica, single-space breathing compartment, electric motor, microcontroller) was developed. Breathing simulations (n = 1200) were performed at various tidal volume (VT), inspiratory time (Ti), and respiratory rate (RR) combinations and different cannula flows. RESULTS: Minute ventilation (MV) was the most significant predictor of effective FiO2. FiO2 was higher at lower VT and higher Ti values. Benaron and Benitz's formula underestimated the effective FiO2 at lower MV values, while Finer's formula significantly overestimated it. A set of predictive FiO2 charts was developed based on cannula flow, infant body weight, and RR. CONCLUSIONS: The effective FiO2 delivered by LFNC to small infants critically depends on VT, Ti, and RR. However, since VT and Ti values are not available in clinical practice, the existing mathematical formulas may be inaccurate. Our novel predictive FiO2 charts could assist in optimizing oxygen delivery by LFNC using easy-to-obtain parameters, such as infant body weight and RR.

Flow-resistive loading and diaphragmatic muscle function in term and preterm infants.

PURPOSE: We aimed to assess diaphragmatic function in term and preterm infants with and without history of bronchopulmonary dysplasia (BPD), before and after the application of inspiratory flow resistive loading. METHODS: Forty infants of a median (range) gestational age of 34 (25-40) weeks were studied. BPD was defined as supplemental oxygen requirement for >28 days of life. Seventeen infants were term, 17 preterm without history of BPD, and six preterm with a history of BPD. The diaphragmatic pressure-time index (PTIdi) was calculated as the mean to maximum trans-diaphragmatic pressure ratio times the inspiratory duty cycle. The PTIdi was calculated before and after the application of an inspiratory-flow resistance for 120 s. Airflow was measured by a pneumotachograph and the transdiaphragmatic pressure by a dual pressure catheter. RESULTS: The median (interquartile range [IQR]) pre-resistance PTIdi was higher in preterm infants without BPD (0.064 [0.050-0.077]) compared with term infants (0.052 [0.044-0.062], p = .029) and was higher in preterm infants with BPD (0.119 [0.086-0.132]) compared with a subgroup of preterm infants without BPD (0.062 [0.056-0.072], p = .004). The median (IQR) postresistance PTIdi was higher in preterm infants without BPD (0.101 [0.084-0.132]) compared with term infants (0.067 [0.055-0.083], p < .001) and was higher in preterm infants with BPD [0.201(0.172-0.272)] compared with the preterm subgroup without BPD (0.091 [0.081-0.108],p = .004). The median (IQR) percentage change of the PTIdi after the application of the resistance was higher in preterm infants without BPD (65 [51-92] %) compared with term infants (34 [20-39] %, p < .001). CONCLUSIONS: Preterm infants, especially those recovering from BPD, are at increased risk of diaphragmatic muscle fatigue under conditions of increased inspiratory loading.

Monocyte Chemoattractant Protein-1 (MCP-1), Activin-A and Clusterin in Children and Adolescents with Obesity or Type-1 Diabetes Mellitus.

Inflammation plays a crucial role in diabetes and obesity through macrophage activation. Macrophage chemoattractant protein-1 (MCP-1), activin-A, and clusterin are chemokines with known roles in diabetes and obesity. The aim of this study is to investigate their possible diagnostic and/or early prognostic values in children and adolescents with obesity and type-1 diabetes mellitus (T1DM). METHODS: We obtained serum samples from children and adolescents with a history of T1DM or obesity, in order to measure and compare MCP-1, activin-A, and clusterin concentrations. RESULTS: Forty-three subjects were included in each of the three groups (controls, T1DM, and obesity). MCP-1 values were positively correlated to BMI z-score. Activin-A was increased in children with obesity compared to the control group. A trend for higher values was detected in children with T1DM. MCP-1 and activin-A levels were positively correlated. Clusterin levels showed a trend towards lower values in children with T1DM or obesity compared to the control group and were negatively correlated to renal function. CONCLUSIONS: The inflammation markers MCP-1, activin-A, and clusterin are not altered in children with T1DM. Conversely, obesity in children is positively correlated to serum MCP-1 values and characterized by higher activin-A levels, which may reflect an already established systematic inflammation with obesity since childhood.

Cardiopulmonary Exercise Performance of Children Born Non-Extremely Preterm.

Data on exercise tolerance of children born non-extremely preterm are sparse. We aimed to explore the cardiopulmonary exercise testing (CPET) characteristics in this population. We studied 63 children (age 7-12 years) born at 290/7-366/7 weeks of gestation (34 were late preterm, 29 were preterm) and 63 age-matched, term-born controls. All performed spirometry and CPET (cycle ergometry). There were no differences in activity levels and spirometric parameters between the group of preterm-born children and controls. A peak oxygen uptake (VO2peak) of <80% was noted in 25.4% of the term-born and 49.2% of preterm-born children (p = 0.001). Term-born participants presented similar VO2peak to late-preterm children but higher than those born at <340/7 weeks of gestation (p = 0.002). Ventilatory limitation was noted in 4.8% of term and 7.9% of preterm participants, while only one preterm child presented cardiovascular limitation. Children born before 34 weeks of gestation had higher respiratory rates and smaller tidal volumes at maximum exercise, as well as lower oxygen uptake for the level of generated work. We conclude that school-age children born at 29-34 weeks of gestation may present decreased exercise performance attributed to an altered ventilatory response to exercise and impaired O2 utilization by their skeletal muscles rather than other cardiopulmonary limiting factors.

Diaphragmatic muscle function in term and preterm infants.

We aimed to assess the determinants of diaphragmatic function in term and preterm infants. 149 infants (56 term; 93 preterm, of whom 14 were diagnosed with bronchopulmonary dysplasia-BPD) were studied before discharge. Diaphragmatic function was assessed by measurement of the maximum transdiaphragmatic pressure (Pdimax)-a measure of diaphragmatic strength, and the pressure-time index of the diaphragm (PTIdi)-a measure of the load-to-capacity ratio of the diaphragm. The Pdimax was higher in term than preterm infants without BPD (90.1 ± 16.3 vs 81.1 ± 11.8 cmH2O; P = 0.001). Term-born infants also had lower PTIdi compared to preterms without BPD (0.052 ± 0.014 vs 0.060 ± 0.017; P = 0.006). In term and preterm infants without BPD, GA was the most significant predictor of Pdimax and PTIdi, independently of the duration of mechanical ventilation and oxygen support. In infants with GA < 32 weeks (n = 30), the Pdimax was higher in infants without BPD compared to those with BPD (76.1 ± 11.1 vs 65.2 ± 11.9 cmH2O; P = 0.015). Preterms without BPD also had lower PTIdi compared to those with BPD (0.069 ± 0.016 vs 0.109 ± 0.017; P < 0.001). In this subgroup, GA was the only significant independent determinant of Pdimax, while BPD and the GA were significant determinants of the PTIdi.  Conclusions: Preterm infants present lower diaphragmatic strength and impaired ability to sustain the generated force over time, which renders them prone to diaphragmatic fatigue. In very preterm infants, BPD may further aggravate diaphragmatic function. What is Known: • The diaphragm of preterm infants has limited capacity to undertake the work of breathing effectively. • The maximum transdiaphragmatic pressure (a measure of diaphragmatic strength) and the pressure-time index of the diaphragm (a measure of the load-to-capacity ratio of the muscle) have not been extensively assessed in small infants. What is New: • Preterm infants have lower diaphragmatic strength and impaired ability to sustain the generated force over time, which renders them prone to diaphragmatic fatigue. • In very preterm infants, bronchopulmonary dysplasia may further impair diaphragmatic function.

Post-Traumatic Stress as a Psychological Effect of Mild Head Injuries in Children.

BACKGROUND: Head trauma is one of the most common pediatric emergencies. While the psychological effects of severe head injuries are well studied, the psychological consequences of mild head injuries often go overlooked. Head injuries with a Glasgow Coma Scale score of 13-15, with symptoms such as headache, vomiting, brief loss of consciousness, transient amnesia, and absence of focal neurological signs, are defined as mild. The aim of this study is to evaluate the stress of children with mild head injuries and their parents' relevant perception during the early post-traumatic period. METHODS: This is a prospective cross-sectional study on a cohort of children with mild head injuries and their parents. Two questionnaires were implemented, the Child Trauma Screening Questionnaire (CTSQ) which was compiled by the children, and the Children's Revised Impact of Event Scale (CRIES-13), compiled by their parents. Both questionnaires are widely used and reliable. The first presents an excellent predictive ability in children with a risk of post-traumatic stress disorder, while the second is a weighted self-completed detecting instrument for the measurement of post-traumatic stress in children and adolescents, with a detailed evaluation of their reactions to the traumatic incident. The participants responded one week and one month after the traumatic event. RESULTS: A total of 175 children aged 6-14 years and 174 parents participated in the study. Stress was diagnosed in 33.7% of children after one week, and in 9.9% after one month. Parental responses suggesting stress presence in their children were 19.0% and 3.9%, respectively. These outcomes showed that mild head injuries are not so innocent. They are often underestimated by their parents and may generate a psychological burden to the children during the early post-traumatic period. CONCLUSIONS: Mild head injuries may affect the emotional welfare of children. Healthcare providers should understand the importance of the psychological effect of this overlooked type of injury. They should be trained in the psychological effect of trauma and be aware of this probability, promptly notify the parents accordingly, and provide psychological assistance beyond medical treatment. Follow-up and support are needed to avoid the possibility of future post-traumatic stress disorder. More extensive research is needed as the outcomes of this study regarded a limited population in numbers, age, and survey period. Furthermore, many children with mild head injuries do not ever visit the emergency department and stay at home unrecorded. Community-based research on the topic should therefore be considered.

Ceftriaxone Administration Associated with Lithiasis in Children: Guilty or Not? A Systematic Review.

Lithiasis is a known side effect of ceftriaxone administration in children. Sex, age, weight, dosage, and duration of intake have been reported as risk factors for the formation of calcification or stones in the bile and urine excretory systems of children who received ceftriaxone. The purpose of this systematic review is to investigate the reported effects of ceftriaxone administration in pediatric patients who were admitted to a hospital due to infection, the likelihood of gallstones, nephroliths, or precipitations in both the biliary and urinary systems, as well as investigate the relationship with their mother's history during pregnancy. Original studies and literature reviews from the PubMed database were included in the study. No time limit related to research or publication was set for the articles. The results were evaluated, aiming to understand the outcomes and identify any predisposing factors relevant to this side effect. Of the 181 found articles, 33 were appropriate for inclusion in the systematic review. The administered dose of ceftriaxone presented variability. Symptoms, such as abdominal pain and vomiting, were associated with ceftriaxone-related lithiasis in many cases. It was noted that most of the results were the outcomes of retrospective observation and not of prospective randomized research. Definitively, more randomized control studies with long-term outcomes are needed to identify the exact association between ceftriaxone and lithiasis in children.

Preterm newborns exposed to early-onset preeclampsia have altered postnatal Tumor Necrosis Factor-related apoptosis-inducing ligand trends versus controls.

BACKGROUND: Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) is a protein with anti-atherogenic and vasoprotective effects that has never been studied in newborns exposed to preeclampsia. Our aim was to examine TRAIL serum concentrations in such neonates after birth and during the transitional period. METHODS: Serum TRAIL levels were measured on the first and fifth day of life (DOL1 and DOL5, respectively) in 38 newborns exposed to early-onset preeclampsia and 38 controls born of normotensive mothers. RESULTS: TRAIL values on DOL1 and DOL5 did not differ between cases and controls. However, from DOL1 to DOL5 TRAIL levels increased in controls (from 20.54 ± 7.35 to 23.93 ± 11.02 pg/ml, p = 0.044) but decreased in those exposed to preeclampsia (from 25.58 ± 15.74 to 20.53 ± 10.72 pg/ml, p = 0.035). Overall, the relative change of TRAIL values from DOL1 to DOL5 was positively related to birth weight (beta coefficient 0.234, p = 0.042) and inversely related to preeclampsia (beta coefficient -0.241, p = 0.036). CONCLUSION: Newborns exposed to early-onset preeclampsia present a decrease in serum TRAIL levels during the transitional period. This pattern is exactly the opposite from what is observed in neonates born to normotensive mothers, and most likely points towards a defective mechanism of extrauterine adaptation related to preeclampsia exposure in utero. IMPACT: Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) levels during the transitional period do not differ between infants exposed to early-onset preeclampsia and controls The pattern of change of TRAIL levels after birth is different; TRAIL decreases in newborns exposed to preeclampsia but increases in controls The decrease of TRAIL levels during the transitional period points towards a defective mechanism of extrauterine adaptation and an altered cardiometabolic profile in newborns exposed to early-onset preeclampsia.

The Psychological Impact of COVID-19 Admission on Families: Results from a Nationwide Sample in Greece.

The aim of the present study was to assess the psychological impact of hospitalization during the COVID-19 pandemic on parents and their offspring. We performed a nationwide cross-sectional study in Greece based on an Internet questionnaire survey. A convenience sample of parents whose offspring had been hospitalized due to COVID-19 (including multisystem inflammatory syndrome in children, MIS-C), diagnosed with COVID-19 but not hospitalized, and hospitalized for another reason during the pandemic were enrolled. Parental stress was assessed using the Perceived Stress Scale (PSS) and the Revised Impact of Event Scale (IES-R) tools, and childhood mental wellbeing with the Children's Revised Impact of Event 13 (CRIES-13) scale. Out of 214 received responses, stress levels were significantly higher in parents whose children had been admitted for COVID-19 or MIS-C versus those not admitted or admitted for other reasons (p < 0.001, for PSS/IES-R). Parental and childhood stress levels were correlated. In the multivariable linear regression analysis, children's hospitalization because of COVID-19 or MIS-C, younger parental age, the existence of comorbidities, and another family member's hospitalization because of COVID-19 were independent factors for higher stress. In light of the above, stricter hospital admission criteria for COVID-19 could be implemented, and psychological support for eventually admitted families may be beneficial.

Knowledge and Attitudes of Medical and Nursing Students in Greece Regarding Child Abuse and Neglect.

Data on the knowledge and attitudes of healthcare practitioners in training regarding child abuse and neglect (CAN) are scarce. The aim of this study was to investigate the knowledge and attitudes regarding CAN of medical and nursing students in Greek universities. We performed a questionnaire-based e-survey on a convenience sample of students and recruited 609 students (366 medical and 243 nursing). An unsatisfactory level of knowledge in the field was reported overall. Most of the students (92.2%) were aware of their future responsibility to protect vulnerable children and report suspected cases of CAN; at the same time, they were willing to obtain further education. Based on the above, appropriate training in the undergraduate curriculum should be developed in order to strengthen future healthcare practitioners and boost their confidence in dealing with suspected cases of CAN and protect children's welfare.

Nutrition of Infants with Bronchopulmonary Dysplasia before and after Discharge from the Neonatal Intensive Care Unit.

Bronchopulmonary dysplasia (BPD) represents a severe sequela in neonates born very prematurely. The provision of adequate nutritional support in this high-risk population is challenging. The development of the lungs and physical growth are closely linked together in infants with BPD. Growth deficiency has been associated with pulmonary dysfunction, whereas improvement in respiratory status results in growth acceleration. Currently, there is not enough data regarding optimal nutritional strategies in this population. Nutrition in these infants should provide sufficient calories and nutrients to establish growth, avoid growth retardation and assist alveolarization of the lungs. Meticulous follow-up is mandatory during and after discharge from the Neonatal Intensive care Unit (NICU) to minimize growth retardation and improve lung function. Despite the significant literature supporting the contribution of growth and nutrition in the avoidance of BPD, there is limited research regarding interventions and management of infants with established BPD. Our aim was to review clinical strategies applied in everyday clinical practice and identify debates on the nutritional approach of newborns with BPD. Well-organized interventions and clinical trials regarding the somatic development and nutrition of infants with BPD are warranted.

Parental and Pediatricians' Attitudes towards COVID-19 Vaccination for Children: Results from Nationwide Samples in Greece.

Although many studies have examined factors associated with COVID-19 vaccination and healthcare professionals' attitudes towards vaccines, less is known about parents' and pediatricians' attitudes towards COVID-19 vaccination for children. Using two cross-sectional surveys from November to December 2021 in Greece, we aimed to assess parental intention to vaccinate their 5 to 17 years old children against COVID-19 and to evaluate pediatricians' attitudes towards children's vaccination against COVID-19. Overall, 439 parents and 135 pediatricians participated. Of them, 240 (54.7%) intended to vaccinate their children against COVID-19. The most commonly reported reasons for non-intention were the short length of clinical trials and the fear of side effects. Only 16.6% of non-intenders would vaccinate their children if the pediatrician recommended it. The factors associated with higher intention to get vaccinated were a parent's own vaccination against COVID-19, trust in official healthcare guidelines, increased trust in the state and the healthcare system during the pandemic, and older age. Of the pediatricians, 92.6% recommended children's vaccination, and 75.6% agreed with mandating the vaccine. These findings suggest the need to tailor easy-to-understand messages by well-informed pediatricians to address safety concerns, educate, and clarify misconceptions through targeted interventions among those who currently do not wish to vaccinate their children.

Exercise Limitation in Children and Adolescents with Mild-to-Moderate Asthma.

BACKGROUND: Children with uncontrolled asthma are less tolerant to exercise due to ventilatory limitation, exercise-induced bronchoconstriction (EIB), or physical deconditioning. The contribution of these factors in children with controlled mild-to-moderate asthma is unknown. OBJECTIVE: To explore the underlying mechanisms of reduced exercise capacity in children with controlled mild-to-moderate asthma. METHODS: This was a cross-sectional study of 45 children and adolescents (age 8-18 years) with controlled mild-to-moderate asthma (asthma control test score 21-25) and 61 age-matched healthy controls. All participants completed a physical activity questionnaire and performed spirometry and cardiopulmonary exercise testing (CPET; maximal incremental protocol). Spirometric indices and CPET parameters were compared between the two groups. The effect of EIB (FEV1 decrease >10% post CPET), ventilatory limitation and physical deconditioning on maximum oxygen uptake (O2peak), was assessed by multivariable linear regression. RESULTS: 62.2% of children with asthma and 29.5% of controls (P = 0.002) were categorized as inactive. Reduced exercise capacity (O2peak <80%) was noted in 53.3% of asthmatics and 16.4% of controls (P < 0.001). EIB was documented in 11.1% of participants with asthma. Physical deconditioning was noted in 37.8% of children with asthma and in 14.8% of controls (P = 0.013). Physical deconditioning emerged as the only significant determinant of O2peak, irrespective of asthma diagnosis, body mass index, ventilatory limitation and EIB. CONCLUSION: Children with controlled mild-to-moderate asthma are less tolerant to strenuous exercise than their healthy peers. The decreased exercise capacity in this population should mainly be attributed to physical deconditioning, while the contribution of ventilatory limitation and EIB is rather small.

Neonatal meningococcal disease: an update.

Purpose of the review: Neisseria meningitidis is a common cause of sepsis in the pediatric population but is only rarely observed in neonates. The true incidence of the disease in that age group remains undefined. The purpose of this review is to summarize the published data on meningococcal disease in the neonatal period.Materials and methods: All published studies reporting data on neonatal meningococcal disease were included for data extraction. Results: Published cases from around the world show that, while rare, neonatal meningococcal disease is characterized by a high mortality rate and serious neurodevelopmental complications. The initial clinical presentation is atypical and there is a rapid clinical deterioration. Predisposing factors have been described and they include immune deficiencies and maternal genitourinary tract colonization by the pathogen. Transmission can be intrauterine, intrapartum or postpartum. Intrapartum transmission has been linked to conjunctivitis, which serves as a point of entry for the pathogen. Conclusions: Neonatal meningococcal disease remains a rare but potentially fatal disease, whose true incidence is not known. Genitourinary colonization of the mother and nasopharyngeal carriage of both parents should be assessed, especially in early onset cases. N. meningitidis should be suspected in cases of neonatal sepsis and seizures, even in the absence of typical symptoms associated with meningococcemia. A high level of clinical suspicion and quick initiation of therapy are needed to improve the clinical outcome, and patients who survive require long term follow-up to detect possible neurodevelopmental sequelae. Transmission can be intrauterine, intrapartum or postpartum. Intrapartum transmission has been linked to conjunctivitis, which serves as a point of entry for the pathogen. Published case reports from around the world show that, while rare, neonatal meningococcal disease is characterized by a high mortality rate and serious neurodevelopmental complications. The initial clinical presentation is atypical and there is a rapid clinical deterioration within less than 12 h. The objective of this review is to summarize the latest literature on N. meningitidis infections in the neonatal period.

Influenza vaccination among caregivers and household contacts of children with congenital heart disease before and during COVID-19 pandemic.

AIM: We aimed to investigate the influenza immunisation status of caregivers and household contacts of children with congenital heart disease (CHD) and potential barriers to vaccine uptake. METHODS: Prospective questionnaire-based survey over two influenza seasons (2019-2020 and 2020-2021) on 161 children with CHD attending a tertiary paediatric cardiology clinic and their families. Logistic regression and factor analysis were performed to identify factors associated with influenza vaccine uptake. RESULTS: Influenza vaccination coverage of children was 65%, whereas that of their fathers and mothers was 34% and 26%, respectively. Children with unvaccinated siblings represented 43% and those with unvaccinated adults in the household 79% of our study population. No statistically significant differences were found before and during COVID-19 pandemic on vaccine uptake. Logistic regression analysis showed that higher education level, understanding the risk of contracting the disease and vaccination status of the child determined the vaccination status of parents, regardless of their age, age of their child, severity of CHD, beliefs about vaccine safety and efficacy and risk of transmission if not vaccinated. Factor analysis revealed distinct groups among unvaccinated parents (76.3% of the variation in the responses). CONCLUSIONS: Vaccination coverage of caregivers and household contacts of children with CHD is suboptimal. Influenza vaccination campaigns should take into consideration the specific characteristics of parental groups and target interventions accordingly to increase their vaccine uptake and indirectly protect children with CHD.

Anxiety levels in parents of asymptomatic neonates and young infants referred for echocardiography.

INTRODUCTION: Previous studies in children with innocent murmurs have shown that parental concern is common. METHODS: We assessed the anxiety levels among parents of asymptomatic neonates or infants up-to 6 weeks referred for cardiologic consultation because of a heart murmur. A six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI) was completed by the parents before and after consultation. RESULTS: The average STAI score decreased from 14.42 ± 4.54 on arrival to 9.69 ± 4.26 after the consultation (p < 0.001). Overall, the parents felt more calm, less tense, less upset, more relaxed, more content and less worried after the consultation (p < 0.001). Multivariable linear regression analysis showed that the STAI score prior to consultation was related to infants age (coefficient ß = - 0.172; P = 0.046) and STAI score post consultation was related to the final diagnosis (ß = 0.312; P < 0.001). CONCLUSION: In conclusion, parents of asymptomatic neonates and young infants with a murmur exhibit moderate levels of anxiety which can be ameliorated after consultation. Parental education in the field is of paramount importance and the role of both paediatric cardiologists as well as primary care physicians is crucial and decisive.

Parents under siege: the psychological impact of COVID-19 outbreak on children's caregivers.

AIMS OF THE STUDY: It is well known that parenting stress is an important but often underestimated psychosocial variable. Data regarding the impact of the corona virus disease 2019 (COVID-19) outbreak on parental psychology are currently lacking. The aim of the present study was to assess parenting stress during the COVID-19 pandemic in Greece. METHODS: An Internet e-survey was conducted adhering to CHERRIES guidelines of the EQUATOR network and released from 16 March to 22 March 2020, using the Perceived Stress Scale (PSS) and Revised Impact of Event Scale (IES-R). A convenience sample of 1105 Greek parents of children with or without chronic or severe underlying disorders was enrolled, identified by a network of collaborating paediatricians across the country, and invited via personal emails. RESULTS: The participation rate was 91.6% and the completion rate was 100%. A total of 178 (16.1%) of the participants had children with underlying disorders (198 affected children in total). Parents of children with underlying disorders had significantly higher stress levels than those of healthy children (PSS 21.22 ± 5.06 vs 19.02 ± 6.85, p <0.001; IES-R 40.71 ± 11.58 v. 35.86 ± 12.69, p <0.001), particularly those caring for children with cardiovascular or respiratory disorders, or immunodeficiencies. The presence of children with underlying disorders was a strong predictor of PSS and IES-R scores, independently of parental sex, age, education and place of residence. CONCLUSIONS: The impact of COVID-19 outbreak on parental stress is substantial, and those caring for children with underlying disorders are more profoundly affected. Pending the global socioeconomic rebooting after the pandemic, the possible short- and long-term consequences of parental stress should not be ignored. As for other vulnerable groups, accurate health information and resources for psychological support should be provided to parents, especially those caring for children with underlying disorders.

Parental Knowledge, Attitude, and Practices on Antibiotic Use for Childhood Upper Respiratory Tract Infections during COVID-19 Pandemic in Greece.

This cross-sectional study aims to assess parents' knowledge, attitude, and practices on antibiotic use for children with URTIs symptoms in Greece in the era of the COVID-19 pandemic. We distributed a questionnaire to a random sample of parents who visited primary health care centers in Patras, Greece. Out of 412 participants, 86% believed that most infections with common cold or flu symptoms were caused by viruses, although 26.9% believed that antibiotics may prevent complications. Earache was the most common symptom for which antibiotics were needed. Most of them (69%) declare being considerably anxious about their children's health during the COVID-19 pandemic. The majority (85%) knew that COVID-19 was of viral origin, yet half of them declared uncertain whether antibiotics were needed. All demographic characteristics, except for gender, were found to have a significant effect on parents' knowledge, attitude, and practices on antibiotic use for URTIs and COVID-19. Factor analysis revealed six groups of parents with common characteristics associated with misuse of antibiotics. Our findings highlight the need to decrease misconceptions regarding antibiotic use by providing relevant education for parents targeting particular characteristics, especially during the COVID-19 pandemic. Continuous education of healthcare providers in the field is also of paramount importance.

Knowledge and Attitudes of School Teachers on Vaccination in Greece.

Few studies have assessed attitudes and beliefs of school teachers on vaccination. Our cross-sectional questionnaire-based prospective survey aims to explore vaccination coverage and relevant knowledge of school teachers in Greece. Out of the 217 respondents, 93% believe that vaccines offer protection but only 69.7% were completely vaccinated as per adults' National Immunization Schedule. In multivariate analysis, female gender, being a parent, beliefs that vaccination should be mandatory and imposing penalties to vaccine refusals are the main factors that account for teachers' "behavioral" variability towards vaccination. Strengthening the training of school teachers in health promotion should become a priority in the era of the highly anticipated vaccine against severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2).