Clinical Predictors and Biomarkers in Children With Sepsis and Bacterial Meningitis.

OBJECTIVES: Sepsis and meningitis in children may present with different clinical features and a wide range of values of inflammatory markers. The aim of this study was to identify the prognostic value of clinical features and biomarkers in children with sepsis and bacterial meningitis in the emergency department (ED). METHODS: We carried out a single-center, retrospective, observational study on 194 children aged 0 to 14 years with sepsis and bacterial meningitis admitted to the pediatric ED of a tertiary children's hospital through 12 years. RESULTS: Among epidemiological and early clinical features, age older than 12 months, capillary refill time greater than 3 seconds, and oxygen blood saturation lower than 90% were significantly associated with unfavorable outcomes, along with neurological signs ( P < 0.05). Among laboratory tests, only procalcitonin was an accurate and early prognostic biomarker for sepsis and bacterial meningitis in the ED, both on admission and after 24 hours. Procalcitonin cut-off value on admission for short-term complications was 19.6 ng/mL, whereas the cut-off values for long-term sequelae were 19.6 ng/mL on admission and 41.9 ng/mL after 24 hours, respectively. The cut-off values for mortality were 18.9 ng/mL on admission and 62.4 ng/mL at 24 hours. CONCLUSIONS: Procalcitonin, along with clinical evaluation, can guide the identification of children at higher risk of morbidity and mortality, allowing the most appropriate monitoring and treatment.

Infantile idiopathic intracranial hypertension: case report and review of the literature.

BACKGROUND: Idiopathic intracranial hypertension is an infrequent condition of childhood, and is extremely rare in infants, with only 26 cases described. The etiology is still unknown. Typical clinical manifestations change with age, and symptoms are atypical in infants, thus the diagnosis could be late. This is based on increased opening pressure at lumbar puncture, papilloedema and normal cerebral MRI. The measurement of cerebrospinal fluid opening pressure in infants is an issue because many factors may affect it, and data about normal values are scanty. The mainstay of treatment is acetazolamide, which allows to relieve symptoms and to avoid permanent visual loss if promptly administered. CASE PRESENTATION: We report the case of an 8-month-old infant admitted because of vomit, loss of appetite and irritability; later, also bulging anterior fontanel was observed. Cerebral MRI and cerebrospinal fluid analysis resulted negative and after two lumbar punctures he experienced initial symptom relief. Once the diagnosis of idiopathic intracranial hypertension was made, he received oral acetazolamide, and corticosteroids, with progressive symptom resolution. CONCLUSIONS: Infantile idiopathic intracranial hypertension is extremely rare, and not well described yet. Bulging anterior fontanel in otherwise healthy infants with normal neuroimaging should be always considered suggestive, but can be a late sign, while irritability and anorexia, especially if associated with vomiting, may represent an early sign. In such cases, lumbar puncture should be always done, hopefully with cerebrospinal fluid opening pressure measurement, which is among coded diagnostic criteria, but whose threshold is controversial in infants. Early diagnosis, timely treatment and strict follow-up help to prevent vision loss or death of affected infants.

Can we trust in Sars-CoV-2 rapid antigen testing? Preliminary results from a paediatric cohort in the emergency department.

BACKGROUND: Rapid identification of Covid-19 in the paediatric emergency department is critical; Antigen tests are fast but poorly investigated in children. AIMS: To investigate Sars-CoV-2 antigen rapid test in children. METHODS: We compare the performance of LumiraDx with molecular tests in a paediatric emergency department. RESULTS: A retrospective cohort of 191 patients with AT and PCR tests performed in the same episode was analysed; 16% resulted positive for Sars-CoV-2. Using the PCR test as the gold standard, we calculated antigen testing overall sensitivity of 94.1%, specificity of 91.9%, and NPV of 99.4%. Only one false-negative test was found. CONCLUSIONS: AT may be helpful in the initial screening of patients at PED.

First diagnosis of multisystem inflammatory syndrome in children (MIS-C): an analysis of PoCUS findings in the ED.

Children with multisystem inflammatory syndrome (MIS-C) tend to develop a clinical condition of fluid overload due both to contractile cardiac pump deficit and to endotheliitis with subsequent capillary leak syndrome. In this context, the ability of point-of-care ultrasound (PoCUS) to simultaneously explore multiple systems and detect polyserositis could promote adequate therapeutic management of fluid balance. We describe the PoCUS findings in a case-series of MIS-C patients admitted to the Emergency Department. At admission 10/11 patients showed satisfactory clinical condition without signs and symptoms suggestive for cardiovascular impairment/shock, but PoCUS showed pathological findings in 11/11 (100%). In particular, according to Rapid Ultrasound in SHock (RUSH) protocol, cardiac hypokinesis was detected in 5/11 (45%) and inferior vena cava dilatation in 3/11 (27%). Peritoneal fluid was reported in 6/11 cases (54%). Lung ultrasound (LUS) evaluation revealed an interstitial syndrome in 11/11 (100%), mainly localized in posterior basal lung segments. We suggest PoCUS as a useful tool in the first evaluation of children with suspected MIS-C for the initial therapeutic management and the following monitoring of possible cardiovascular deterioration.

Pediatric admissions to emergency departments of North-Western Italy during COVID-19 pandemic: A retrospective observational study.

BACKGROUND: COVID-19 pandemic caused huge decrease of pediatric admissions to Emergency Department (ED), arising concerns about possible delays in diagnosis and treatment of severe disorders. METHODS: Impact of COVID-19 on Pediatric Emergency Room (ICOPER) was a retrospective multicentre observational study including 23 Italian EDs.All the children <18 years admitted, between March 9th and May 3rd 2020 stratified by age, priority code, cause of admission and outcome have been included and compared to those admitted in the same period of 2019.Our objectives were to assess the characteristics of pediatric admissions to EDs since COVID-19 outbreak until the end of lockdown, and to describe the features of critical children. FINDINGS: 16,426 children were admitted in 2020, compared to 55,643 in 2019 (-70·48%). Higher reduction was reported in hospitals without Pediatric Intensive Care Unit (PICU) (-73·38%) than in those with PICU (-64·08%) (P<0·0001). Admissions with low priority decreased more than critical ones (-82·77% vs. 44·17% respectively; P<0·0001). Reduction of discharged patients was observed both in hospitals with (-66·50%) and without PICU (-74·65%) (P<0·0001). No difference in the duration of symptoms before admission was reported between 2019 and 2020, with the majority of children accessing within 24 h (55·08% vs. 57·28% respectively; P = 0·2344). INTERPRETATION: Admissions with low priority decreased significantly more than those with high priority; we suppose that the fear of being infected in hospital maybe overcame the concerns of caregivers. Compared to 2019, no significant referral delay by caregivers was reported. Our data suggest the need of adaptation of EDs and primary care services to different needs of children during COVID-9 pandemic.

Impact of the COVID-19 Pandemic on Child and Adolescent Psychiatric Emergencies.

OBJECTIVE: By forcing closure of schools, curtailing outpatient services, and imposing strict social distancing, the COVID-19 pandemic has abruptly affected the daily life of millions worldwide, with still unclear consequences for mental health. This study aimed to evaluate if and how child and adolescent psychiatric visits to hospital emergency departments (EDs) changed during the pandemic lockdown, which started in Italy on February 24, 2020. METHODS: We examined all ED visits by patients under 18 years of age in the 7 weeks prior to February 24, 2020, and in the subsequent 8 weeks of COVID-19 lockdown at two urban university hospitals, in Turin and Rome, Italy. ED visits during the corresponding periods of 2019 served as a comparison using Poisson regression modeling. The clinician's decision to hospitalize or discharge home the patient after the ED visit was examined as an index of clinical severity. RESULTS: During the COVID-19 lockdown, there was a 72.0% decrease in the number of all pediatric ED visits (3,395) compared with the corresponding period in 2019 (12,128), with a 46.2% decrease in psychiatric visits (50 vs 93). The mean age of psychiatric patients was higher in the COVID-19 period (15.7 vs 14.1 years). No significant changes were found in hospitalization rate or in the prevalence distribution of the primary reason for the psychiatric ED visit (suicidality, anxiety/mood disorders, agitation). CONCLUSIONS: In the first 8 weeks of the COVID-19-induced social lockdown, the number of child and adolescent psychiatric ED visits significantly decreased, with an increase in patient age. This decrease does not appear to be explained by severity-driven self-selection and might be due to a reduction in psychiatric emergencies or to the implementation of alternative ways of managing acute psychopathology.

Accuracy of Point-of-Care Ultrasound in Detecting Fractures in Children: A Validation Study.

This study sought to compare point-of-care ultrasound (POCUS) and conventional X-rays for detecting fractures in children. This was a prospective, non-randomized, convenience-sample study conducted in five medical centers. It evaluated pediatric patients with trauma. POCUS and X-ray examination results were treated as dichotomous variables with fracture either present or absent. Descriptive statistics were calculated in addition to prevalence, sensitivity, specificity, positive predictive value and negative predictive value, including 95% confidence intervals (CIs). The Cohen κ coefficient was determined as a measurement of the level of agreement. A total of 554 examinations were performed with POCUS and X-ray. On physical examination, swelling, localized hematoma and functional limitation were found in 66.73%, 33.78% and 53.74% of participants, respectively. The most-studied areas were limbs and hands/feet (58.19% and 38.27%), whereas the thorax was less represented (3.54%). Sensitivity of POCUS was 91.67% (95% CI, 76.41-97.82%) for high-skill providers and 71.50 % (95% CI, 64.75-77.43%) for standard-skill providers. Specificity was 88.89% (95% CI, 73.00-96.34%) and 82.91% (95% CI, 77.82-87.06%) for high- and standard-skill providers, respectively. Positive predictive value was 89.19% (95% CI, 73.64-96.48%) and 75.90% (95% CI, 69.16-81.59%) for high- and standard-skill providers, respectively. Negative predictive value was 91.43% (95% CI, 75.81-97.76%) and 79.44% (95% CI, 74.21-83.87%) for high- and standard-skill providers, respectively. The Cohen κ coefficient showed very good agreement (0.81) for high-skill providers, but moderate agreement (0.54) for standard-skill providers. We noted good diagnostic accuracy of POCUS in evaluating fracture, with excellent sensitivity, specificity, and positive and negative predictive value for high-skill providers.

[Non pharmacologic interventions for pain associated to venipuncture in children: a literature review]. / Tecniche non farmacologiche per il contenimento del dolore associato a venipuntura nel bambino: revisione della letteratura.

. Non pharmacologic interventions for pain associated to venipuncture in children: a literature review. INTRODUCTION: Venipuncture is one of the most common painful procedures performed on children. Pain prevention and control are essential in childhood, because the earlier is the nociceptive experience, the more it affects the response to subsequent painful events. OBJECTIVE: To analyse the literature on non-pharmacological methods of pain management in children undergoing venipuncture. METHOD: The review was carried out between May and July 2019 by consulting the PubMed and Cochrane Database, combining Mesh terms and free text. The references reported in the articles found in the first part of the research were also analyzed, to identify further relevant studies. RESULTS: A total of 20 articles were included in this review (8 randomized clinical trials, 10 systematic reviews, 1 meta-analysis and 1 pilot study), on a total population of almost 20,086 children aged 1-18 years. The settings considered by the studies were pediatric wards, pediatric outpatient, and Emergency Department. Non-pharmacological interventions can be classified in 4 categories: supportive or environmental therapies; physical therapies; cognitive-behavioral therapies; and non-nutritive suction for newborns and infants. The strength of evidence ranged from high to low or extremely low. DISCUSSION: Most non-pharmacological methods are simple, cheap, easily acquired, and do not need excessive application time. They allow pain control and support the comfort and cooperation of children undergoing venipuncture, alone or combined to pharmacological treatment.

Children with special health care needs attending emergency department in Italy: analysis of 3479 cases.

BACKGROUND: Although children with special health care needs (CSHCN) represent a minority of the population, they go through more hospitalizations, more admissions to the Emergency Department (ED), and receive a major number of medical prescriptions, in comparison to general pediatric population. Objectives of the study were to determine the reasons for admission to the ED in Italian CSHCN, and to describe the association between patient's demographic data, clinical history, and health services requirements. METHODS: Ad hoc web site was created to collect retrospective data of 3479 visits of CSHCN to the ED in 58 Italian Hospitals. RESULTS: Seventy-two percent of patients admitted to ED were affected by a previously defined medical condition. Most of the ED admissions were children with syndromic conditions (54%). 44.2% of the ED admissions were registered during the night-time and/or at the weekends. The hospitalization rate was of 45.6% among patients admitted to the ED. The most common reason for admission to the ED was the presence of respiratory symptoms (26.6%), followed by gastrointestinal problems (21.3%) and neurological disorders (18.2%). 51.4% of the access were classified as 'urgent', with a red/yellow triage code. Considering the type of ED, 61.9% of the visits were conducted at the Pediatric EDs (PedEDs), 33.5% at the Functional EDs (FunEDs) and 4.6% at the Dedicated EDs (DedEDs). Patients with more complex clinical presentation were more likely to be evaluated at the PedEDs. CSHCN underwent to a higher number of medical procedures at the PedEDs, more in comparison to other EDs. Children with medical devices were directed to a PedED quite exclusively when in need for medical attention. Subjects under multiple anti-epileptic drug therapy attended to PedEDs or FunEDs generally. Patients affected by metabolic diseases were more likely to look for medical attention at FunEDs. Syndromic patients mostly required medical attention at the DedEDs. CONCLUSIONS: Access of CSHCN to an ED is not infrequent. For this reason, it is fundamental for pediatricians working in any kind of ED to increase their general knowledge about CHSCN and to gain expertise in the management of such patients and their related medical complexity.

Where have the children with epilepsy gone? An observational study of seizure-related accesses to emergency department at the time of COVID-19.

PURPOSE: The COVID-19 pandemic and related lockdown measures drastically changed health care and emergency services utilization. This study evaluated trends in emergency department (ED) access for seizure-related reasons in the first 8 weeks of lockdown in Italy. METHODS: All ED accesses of children (<14 years of age) at two university hospitals, in Turin and Rome, Italy, between January 6, 2020 and April 21, 2020, were examined and compared with the corresponding periods of 2019. RESULTS: During the COVID-19 lockdown period (February 23-April 21, 2020), there was a 72 % decrease in all pediatric ED accesses over the corresponding 2019 period (n = 3,395 vs n = 12,128), with a 38 % decrease in seizure-related accesses (n = 41 vs n = 66). The observed decrease of seizure-related ED accesses was not accompanied by significant changes in age, sex, type of seizure, or hospitalization rate after the ED visit. CONCLUSION: The COVID-19 lockdown was accompanied by a sudden decrease in seizure-related hospital emergency visits. School closure, social distancing, reduced risk of infection, and increased parental supervision are some of the factors that might have contributed to the finding.

COVID-19 in 17 Italian Pediatric Emergency Departments.

BACKGROUND: Variability in presentation of children with coronavirus disease 2019 (COVID-19) is a challenge in emergency departments (EDs) in terms of early recognition, which has an effect on disease control and prevention. We describe a cohort of 170 children with COVID-19 and differences with the published cohorts. METHODS: Retrospective chart reviews on children (0-18 years) evaluated in 17 Italian pediatric EDs. RESULTS: In our cohort (median age of 45 months; interquartile range of 4 months-10.7 years), we found a high number of patients <1 year with COVID-19 disease. The exposure happened mainly (59%) outside family clusters; 22% had comorbidities. Children were more frequently asymptomatic (17%) or with mild diseases (63%). Common symptoms were cough (43%) and difficulty feeding (35%). Chest computed tomography, chest radiograph, and point-of-care lung ultrasound were used in 2%, 36%, and 8% of cases, respectively. Forty-three percent of patients were admitted because of their clinical conditions. The minimal use of computed tomography and chest radiograph may have led to a reduced identification of moderate cases, which may have been clinically classified as mild cases. CONCLUSIONS: Italian children evaluated in the ED infrequently have notable disease symptoms. For pediatrics, COVID-19 may have rare but serious and life-threatening presentations but, in the majority of cases, represents an organizational burden for the ED. These data should not lower the attention to and preparedness for COVID-19 disease because children may represent a source of viral transmission. A clinically driven classification, instead of a radiologic, could be more valuable in predicting patient needs and better allocating resources.

COnsensus on Pediatric Pain in the Emergency Room: the COPPER project, issued by 17 Italian scientific societies.

In the pediatric setting, management of pain in the emergency department - and even in common care - is a challenging exercise, due to the complexity of the pediatric patient, poor specific training of many physicians, and scant resources.A joint effort of several Italian societies involved in pediatrics or in pain management has led to the definition of the PIPER group and the COPPER project. By applying a modified Delphi method, the COPPER project resulted in the definition of 10 fundamental statements. These may represent the basis for improving the correct management of children pain in the emergency department.

Characteristic of COVID-19 infection in pediatric patients: early findings from two Italian Pediatric Research Networks.

Detailed data on clinical presentations and outcomes of children with COVID-19 in Europe are still lacking. In this descriptive study, we report on 130 children with confirmed COVID-19 diagnosed by 28 centers (mostly hospitals), in 10 regions in Italy, during the first months of the pandemic. Among these, 67 (51.5%) had a relative with COVID-19 while 34 (26.2%) had comorbidities, with the most frequent being respiratory, cardiac, or neuromuscular chronic diseases. Overall, 98 (75.4%) had an asymptomatic or mild disease, 11 (8.5%) had moderate disease, 11 (8.5%) had a severe disease, and 9 (6.9%) had a critical presentation with infants below 6 months having significantly increased risk of critical disease severity (OR 5.6, 95% CI 1.3 to 29.1). Seventy-five (57.7%) children were hospitalized, 15 (11.5%) needed some respiratory support, and nine (6.9%) were treated in an intensive care unit. All recovered.Conclusion:This descriptive case series of children with COVID-19, mostly encompassing of cases enrolled at hospital level, suggest that COVID-19 may have a non-negligible rate of severe presentations in selected pediatric populations with a relatively high rates of comorbidities. More studies are needed to further understand the presentation and outcomes of children with COVID-19 in children with special needs. What is Known: • There is limited evidence on the clinical presentation and outcomes of children with COVID-19 in Europe, and almost no evidence on characteristics and risk factors of severe cases. What is New: • Among a case series of 130 children, mostly diagnosed at hospital level, and with a relatively high rate (26.2%) of comorbidities, about three-quarter had an asymptomatic or mild disease. • However, 57.7% were hospitalized, 11.5% needed some respiratory support, and 6.9% were treated in an intensive care unit.

Childhood acute poisoning in the Italian North-West area: a six-year retrospective study.

BACKGROUND: Data about acute poisoning in Italian pediatric patients are obsolete or absent. This study would partially fill this exiting gap and compare the scene with others around the world. METHODS: A retrospective evaluation was performed on a 2012-2017 data registry of the Children's Emergency Department at the Regina Margherita Hospital of Turin, where 1030 children under age 14 were accepted with a diagnosis of acute intoxication. RESULTS: The median age of the patients was 2.2 years (IQR 2.3) and 55% were male. Events occurred mostly in children aged 1-4 years (n = 751, 72.9%). Six hundred and eight patients (59%) were exposed to Nonpharmaceutical agents, the household cleaning products being the more frequent (n = 298, 49%). Exposure to Pharmaceuticals were 422 (41%); the most common Pharmaceuticals were analgesics (n = 88, 20.8%), psychotropics (n = 77, 18.2%) and cardiovascular (n = 53, 12.6%) drugs. The 85% of the intoxications occurred accidentally, the 10.6% as therapeutic error, the 2.3% as suicide attempts and the 1.5% for recreational purposes. No patient died. CONCLUSIONS: Despite acute poisoning being a relevant problem in pediatric emergency, our results would seem to paint a less worrying picture if compared to other countries, mainly when considering the children hospitalized in the pediatric intensive care unit and the number of deaths. Nevertheless, our study might represent a tool for public health authorities to program incisive interventions.

Differential diagnosis between physical maltreatment and cupping practices in a suspected child abuse case.

Physical maltreatment is one of the most common forms of child abuse. Cutaneous injuries often raise the suspicion of child maltreatment. Nevertheless, among health professionals there is still uncertainty in the evaluation of such injuries. In the literature, there are few indications about the most important factors that allow the differentiation of physical abuse findings from signs/lesions that are caused by "folk medicine practices" with similar presentations. We report the case of two brothers who were brought to the Emergency Department of a pediatric hospital by their father because each of them showed one painful, circular and red-purple bruise on their back. Suspecting child abuse, the emergency physicians reported the case to a multidisciplinary unit (dedicated to child abuse). After a careful physical examination, psychological interviews, as well as the evaluation of their medical history, the operators pointed out that the lesions were the result of cupping practices (a form of folk medicine). This case highlights the need for a multidisciplinary approach and demonstrates the importance of a careful evaluation of the cultural background of the family.

Pain management in children has significantly improved in the Italian emergency departments.

AIM: Pain in children is often poorly assessed and treated in Italian emergency departments (EDs) as found in a survey conducted among the centres of the "Pain in Pediatric Emergency Room (PIPER)" Study Group in 2010. Our aim was to evaluate the changes in pain management in Italian EDs in the last years. METHOD: A structured questionnaire about pain assessment, protocols, use of local anaesthetics before venipuncture, opioids and adjuvants was mailed to 46 Italian EDs between November 2017 and April 2018. RESULTS: Pain was always assessed at triage in 34 centres (73.9%). Algometric scales were used in over 90% of EDs. Triage protocols were available in 37 centres (80.4%). Local anaesthetics before venipuncture were always used in six centres (13.0%). Protocols included opioids and adjuvants in 73.0% and 47.2%, respectively. Triage pain assessment was always done in 91.0% of the centres joining the PIPER Study Group up to 2015 and 56.5% in ones that joined the Group after 2015 (P = .017). Local anaesthetics before venipuncture were given in 39.1% of the centres joining until up to 2015 and 13.0% in ones that joined the Group after 2015 (P = .003). CONCLUSION: Paediatric pain management has significantly improved in Italian EDs in the last 8 years. The centres joining the PIPER Study Group for longer time have shown better results for the indicators considered in the survey.

[Premature departure from pediatric emergency department: retrospective analysis and preventive strategies.] / Abbandoni spontanei in pronto soccorso pediatrico: analisi retrospettiva e possibili strategie preventive.

. Premature departure from pediatric emergency department: retrospective analysis and preventive strategies. INTRODUCTION: The overcrowding of Emergency Departments (EDs) is a major cause of increased waiting time for the medical evaluation and dissatisfaction of children and their families, who often decide to leave before the visit is completed. AIM: To describe the characteristics of children who leave a second-level Pediatric ED before the medical examination. METHODS: Retrospective descriptive analysis of children who leave before the medical evaluation at the ED of the Regina Margherita Children's Hospital of Turin, Italy between June and November 2018. Data were obtained from the Hospital's informatic registry. RESULTS: 1351 children left the ED during the study period (6.7% of total visits); 9 of them (0.7%) had received a high triage priority code. The highest leaving rate was recorded in November, on the evening-slot and in children ageing 1-10 years. The average and median waiting time of those who left the ED before the medical examination were respectively 131 and 124 minutes. Fever and gastrointestinal problems were the most frequent reasons of access. Overall, 19.8% of children received nursing care during the triage. The revolving door rate was 6.0%. CONCLUSION: Low priority of urgency, long waiting times, access during periods of increased influx and the age between 1 and 10 years were major factors leading to leave Pediatric ED before the medical evaluation. Further studies are needed to investigate how many early leavings are due to ineffective nursing in the triage setting.