Distraction Using Buzzy or Handheld Computers During Venipuncture.

OBJECTIVES: Venipuncture is one of the most frequently performed painful procedures in children. The aim of this study was to investigate the effectiveness of 2 analgesic strategies for venipuncture in children in a specific setting like a blood-drawing center. METHODS: This was a prospective randomized controlled trial. It was conducted in the blood-drawing center of a tertiary level children's hospital in Italy, between November 2014 and February 2015. Eligible patients were children aged from 4 to 12 years referred to the blood-drawing center for venipuncture. Enrolled children were randomized to be distracted by Buzzy device or by playing with a handheld computer. The procedural pain was measured with the faces pain scale-revised by children aged from 4 to 7 years and with a numerical rating scale by children aged from 8 to 12 years. RESULTS: Two hundred children with a median age of 8 years were enrolled in the study. The self-reported procedural pain was not statistically different between the Buzzy group and the handheld computer group: median (interquartile range) = 3.0 (1.0-4.8) and 2.0 (1.0-4.8), respectively (P = 0.72). Children reported significant pain in 25% of cases with both distraction strategies. The procedural success rate at the first attempt was not significantly different in the 2 groups. CONCLUSIONS: Analgesia provided by Buzzy or by a handheld computer was not significantly different in children undergoing venipuncture in a blood-drawing center, with the great proportion of them reporting no or mild pain during procedure.

Somatic symptom disorder was common in children and adolescents attending an emergency department complaining of pain.

AIM: The aim of this study was to quantify the prevalence of somatic pain in a paediatric emergency department (ED). METHODS: We conducted a prospective observational study using patients admitted to the ED of an Italian children's hospital between December 2014 and February 2015. We enrolled children aged 7-17 who turned up at the ED complaining of pain. Patients and parents were asked to fill in a questionnaire to allow the analysis of the patients' medical history and provide contact details for follow-up. We divided the enrolled patients into four groups: post-traumatic pain, organic pain, functional pain and somatic pain. The questionnaire was used to define pain characteristics and to generate an impairment score. RESULTS: Of the 713 patients who met inclusion criteria, 306 (42.9%) were enrolled in the study. Of these, 135 (44.0%) suffered from post-traumatic pain, 104 (34.0%) from organic pain, 41 (13.4%) from functional pain and 26 (8.6%) from somatic pain. Somatic pain patients had endured pain longer, had missed more school days and had suffered severe functional impairment. CONCLUSION: This study highlighted that somatic pain was a significant contributor to paediatric emergency room visits and should be suspected and diagnosed in children reporting pain.

Risk of hospitalisation after early-revisit in the emergency department.

AIM: Early-revisits are frequent in the paediatric emergency department (ED) setting, but few data are available about early-revisited patients. The aim of this study was to investigate the hospitalisation rate of a population of early-revisited patients and to detect if an early-revisited patient was at risk of a more severe disease. METHODS: Between June 2014 and January 2015, we conducted a retrospective cohort study, considering all patients presented to the ED of a tertiary level children's hospital in Italy. We selected all patients who were revisited within 72 h from the initial visit (study cohort), while all other patients accessed in the same period were considered the control cohort. The two cohorts were compared for age, gender, triage category, hospitalisation rate, diagnosis at admission and hospital length of stay. RESULTS: In the study period, we reviewed 10 750 visits, of which 430 (4%) were unplanned revisits for the same chief complaint within 72 h from the initial visit. Hospitalisation rate of early-revisited patients was significantly higher compared to control patients (8.4 vs. 2.9%). Hospitalisation rate increases in parallel with the number of revisits, but in many cases, it was not directly related to a worst triage category, neither to a longer hospital length of stay. CONCLUSION: Early revisited patients in the ED had a significantly higher risk of hospitalisation, but this risk was only partially related to their clinical conditions.

A quasi randomized-controlled trial to evaluate the effectiveness of clowntherapy on children's anxiety and pain levels in emergency department.

UNLABELLED: The aim of the study is to investigate if the presence of medical clowns during painful procedures in the emergency department (ED) affects children's anxiety and pain. Forty children (4-11 years) admitted to the ED with the need of painful procedures were prospectively enrolled. They were randomly assigned to the clown group, where children interacted with clowns or to the control group in which they were entertained by parents and ED nurses. The children's anxiety was assessed by the Children's Anxiety and Pain Scales; pain was evaluated with the Numerical Rating Scale and Wong-Backer Scale, according to the children's age. Staff and clown's opinions were evaluated by means of dedicated questionnaires. Children's anxiety levels in the clown group were significantly lower than those compared with the control group, while children's pain levels did not change between the two groups. CONCLUSION: The presence of clowns in the ED before and during painful procedures was effective in reducing children's anxiety. WHAT IS KNOWN: • Anxiety and fear caused by medical procedures exacerbate children's pain and may interfere with the procedure. • To reduce anxiety, fear, and pain and to facilitate patient's evaluation, different non-pharmacological approaches have been proposed and positive effects of laughter and humor have been reported. What is New: • The presence of clowns in the waiting room and in the ED during medical evaluation and painful procedures helps to reduce children's anxiety.

Increased bronchiolitis burden and severity after the pandemic: a national multicentric study.

BACKGROUND: The coronavirus 2019 (COVID-19) related containment measures led to the disruption of all virus distribution. Bronchiolitis-related hospitalizations shrank during 2020-2021, rebounding to pre-pandemic numbers the following year. This study aims to describe the trend in bronchiolitis-related hospitalization this year, focusing on severity and viral epidemiology. METHODS: We conducted a retrospective investigation collecting clinical records data from all infants hospitalized for bronchiolitis during winter (1st September-31th March) from September 2018 to March 2023 in six Italian hospitals. No trial registration was necessary according to authorization no.9/2014 of the Italian law. RESULTS: Nine hundred fifty-three infants were hospitalized for bronchiolitis this last winter, 563 in 2021-2022, 34 in 2020-2021, 395 in 2019-2020 and 483 in 2018-2019. The mean length of stay was significantly longer this year compared to all previous years (mean 7.2 ± 6 days in 2022-2023), compared to 5.7 ± 4 in 2021-2022, 5.3 ± 4 in 2020-2021, 6.4 ± 5 in 2019-2020 and 5.5 ± 4 in 2018-2019 (p < 0.001), respectively. More patients required mechanical ventilation this winter 38 (4%), compared to 6 (1%) in 2021-2022, 0 in 2020-2021, 11 (2%) in 2019-2020 and 6 (1%) in 2018-2019 (p < 0.05), respectively. High-flow nasal cannula and non-invasive respiratory supports were statistically more common last winter (p = 0.001 or less). RSV prevalence and distribution did not differ this winter, but coinfections were more prevalent 307 (42%), 138 (31%) in 2021-2022, 1 (33%) in 2020-2021, 68 (23%) in 2019-2020, 61 (28%) in 2018-2019 (p = 0.001). CONCLUSIONS: This study shows a growth of nearly 70% in hospitalisations for bronchiolitis, and an increase in invasive respiratory support and coinfections, suggesting a more severe disease course this winter compared to the last five years.

Under pressure.

Physical urticaria is a rare but challenging subset of chronic urticaria. Wheals of pressure urticaria are typically delayed in appearance. A pressure test can easily be done to confirm the diagnosis.

Galinstan thermometer is more accurate than digital for the measurement of body temperature in children.

BACKGROUND: The mercury thermometer (MT) was considered the reference standard for the evaluation of body temperature; however, since April 2009, it has no longer been available in Italy. OBJECTIVE: This study aimed to evaluate the accuracy of digital thermometer (DT) and galinstan thermometer (GT) in comparison with the MT. METHODS: We prospectively recruited 284 children (age, 1 month to 17 years; mean, 8.5 years) seen in the emergency department of a tertiary pediatric hospital between November and December 2010. For each patient, body temperature was measured sequentially in the right axilla in a randomized fashion using DT, GT, and MT. Fever was defined as an axillary temperature of 37.5°C or greater. The temperature readings with DT and GT were compared statistically with those of MT (reference standard). RESULTS: No statistically significant difference in mean temperature was found between MT and GT in pairwise comparison (P = 0.06), whereas significant differences were found between MT and DT (P < 0.001) and between GT and DT (P < 0.001). Sensitivity and specificity of DT were 67.5% and 98.0%, respectively. When considering children with a temperature of 39°C or higher, the false-negative rate was 65.4% with DT and 30.8% with GT. CONCLUSIONS: Although both DT and GT had good specificity and positive predictive value compared with MT, GT had higher sensitivity and a lower rate of false-negative rates. Galinstan thermometer is more accurate in the measurement of body temperature compared with DT or MT.

SARS-CoV-2-related bronchiolitis: a multicentre international study.

BACKGROUND: Bronchiolitis is the main acute lower respiratory tract infection in infants. Data regarding SARS-CoV-2-related bronchiolitis are limited. OBJECTIVE: To describe the main clinical characteristics of infants with SARS-CoV-2-related bronchiolitis in comparison with infants with bronchiolitis associated with other viruses. SETTING, PATIENTS, INTERVENTIONS: A multicentre retrospective study was conducted in 22 paediatric emergency departments (PED) in Europe and Israel. Infants diagnosed with bronchiolitis, who had a test for SARS-CoV-2 and were kept in clinical observation in the PED or admitted to hospital from 1 May 2021 to 28 February 2022 were considered eligible for participation. Demographic and clinical data, diagnostic tests, treatments and outcomes were collected. MAIN OUTCOME MEASURES: The main outcome was the need for respiratory support in infants testing positive for SARS-CoV-2 compared with infants testing negative. RESULTS: 2004 infants with bronchiolitis were enrolled. Of these, 95 (4.7%) tested positive for SARS-CoV-2. Median age, gender, weight, history of prematurity and presence of comorbidities did not differ between the SARS-CoV-2-positive and SARS-CoV-2-negative infants. Human metapneumovirus and respiratory syncytial virus were the viruses most frequently detected in the group of infants negative for SARS-CoV-2.Infants testing positive for SARS-CoV-2 received oxygen supplementation less frequently compared with SARS-CoV-2-negative patients, 37 (39%) vs 1076 (56.4%), p=0.001, OR 0.49 (95% CI 0.32 to 0.75). They received less ventilatory support: 12 (12.6%) high flow nasal cannulae vs 468 (24.5%), p=0.01; 1 (1.0%) continuous positive airway pressure vs 125 (6.6%), p=0.03, OR 0.48 (95% CI 0.27 to 0.85). CONCLUSIONS: SARS-CoV-2 rarely causes bronchiolitis in infants. SARS-CoV-2-related bronchiolitis mostly has a mild clinical course.

Prevalence of SARS-CoV-2 positivity in infants with bronchiolitis: a multicentre international study.

BACKGROUND: Bronchiolitis is the leading acute respiratory tract infection in infants during the winter season. Since the beginning of the SARS-CoV-2 pandemic, a reduction in the number of bronchiolitis diagnoses has been registered. OBJECTIVE: The present study aimed to describe the incidence and clinical features of bronchiolitis during the 2020-2021 winter season in a large cohort of children in Europe and Israel, and to clarify the role of SARS-CoV-2. SETTING, PATIENTS, INTERVENTIONS: We conducted a multicentre observational cross-sectional study in 23 paediatric emergency departments in Europe and Israel. Clinical and demographic data about all the cases of infants diagnosed with bronchiolitis from 1 October 2020 to 30 April 2021 were collected. For each enrolled patient, diagnostic tests, treatments and outcomes were reported. MAIN OUTCOME MEASURES: The main outcome was the prevalence of SARS-CoV-2-positive bronchiolitis. RESULTS: Three hundred and fourteen infants received a diagnosis of bronchiolitis during the study period. Among 535 infants who tested positive for SARS-CoV-2, 16 (3%) had bronchiolitis. Median age, male sex predominance, weight, history of prematurity and presence of comorbidities did not differ between the SARS-CoV-2-positive and SARS-CoV-2-negative groups. Rhinovirus was the most common involved pathogen, while respiratory syncytial virus (RSV) was detected in one case. SARS-CoV-2 bronchiolitis had a mild clinical course, with one patient receiving oxygen supplementation and none requiring paediatric or neonatal intensive care unit admission. CONCLUSIONS: During the SARS-CoV-2 pandemic, a marked decrease in the number of bronchiolitis diagnoses and the disappearance of the RSV winter epidemic were observed. SARS-CoV-2-related bronchiolitis was rare and mostly displayed a mild clinical course.

Impact and Sustainability of Antibiotic Stewardship in Pediatric Emergency Departments: Why Persistence Is the Key to Success.

Antibiotic stewardship programs proved to be effective in improving prescribing appropriateness. This multicenter quasi-experimental study, aimed to assesses the stewardship impact on antibiotics prescribing in different semesters from 2014 to 2019 in three pediatric emergency departments (Center A, B, and C) in Italy. All consecutive patients diagnosed with acute otitis media or pharyngitis were evaluated for inclusion. Two different stewardship were adopted: for Center A and B, clinical pathways were implemented and disseminated, and yearly lectures were held, for Center C, only pathways were implemented. Broad-spectrum prescription rates decreased significantly by 80% for pharyngitis and 29.5 to 55.2% for otitis after the implementation. In Center C, rates gradually increased from the year after the implementation. Amoxicillin dosage adjusted to pharyngitis recommendations in Center C (53.7 vs. 51.6 mg/kg/die; p = 0.011) and otitis recommendations in Center A increasing from 50.0 to 75.0 mg/kg/die (p < 0.001). Days of therapy in children < 24 months with otitis increased from 8.0 to 10.0 in Center A, while in older children decreased in Center A (8.0 vs. 7.0; p < 0.001) and Center B (10.0 vs. 8.0; p < 0.001). Clinical pathways combined with educational lectures is a feasible and sustainable program in reducing broad-spectrum antibiotic prescribing with stable rates over time.

Sedation and analgesia in children with cerebral palsy: a narrative review.

BACKGROUND: Patients with cognitive impairment due to cerebral palsy experience pain more often than healthy peers and frequently require diagnostic and therapeutic painful procedures. Analgesia and procedural sedation outside the operating room are often required, but they may not adequately be provided because of the inability to accurately recognize and classify the state of pain and for the perceived higher risk of complications. DATA SOURCES: We reviewed the available literature to highlight the specific risk factors and area of criticism, that should be further improved. We searched the Cochrane Library, Medline, Pubmed from 1987 to September 2018 using key words such as 'cerebral palsy and children and pain' or 'sedation and cerebral palsy and children'. RESULTS: While different pain scales are useful in recognizing pain expressions, anxiety scales are not available. Moreover, studies on non-pharmacological techniques do not always have comparable results. Several risk factors, from anatomic abnormalities to liver and kidney functioning, should be kept in mind before proceeding with sedation. CONCLUSIONS: Large trials are needed to assess the impact of non-pharmacological techniques and to evaluate which pain control strategy (pharmacological and non-pharmacological) should be used in different settings.

Impact of near infrared light in pediatric blood drawing Centre on rate of first attempt success and time of procedure.

BACKGROUND: Peripheral blood access and venipuncture are a stressful and painful experience in pediatric patients; moreover, it is estimated that more than one attempt is required to achieve the procedure in about one third of children. For this reason, we investigated if Near-infrared light technology routinely used, could give an advantage to venipuncture in a pediatric blood center setting. METHODS: We conducted an open, pseudo-randomized controlled trial with two parallel arms, in the blood-drawing center, with enrolment of 115 patients between 0 and 18 years, in 14 consecutive working days. Fifty-three subjects were enrolled in group 1 (VeinViewer®) and 62 in group 2 (control group). We divided patients into three subgroups considering their age (< 5 years, 6-10 years, > 10 years). The primary study outcome was to assess if the use of VeinViewer® was associated with a reduction of time to perform blood sampling. The secondary outcome was to analyze VienViewer®'s impact on first attempt success rate in blood sampling. RESULTS: No difference was found regarding the duration of blood sampling between the two groups, even after stratifying the patients into the three age subgroups. There was no difference between the two groups in the success at the first attempt in blood sampling. CONCLUSIONS: Routine use of VeinViewer® is not useful to reduce time of the procedure during venipuncture. TRIAL REGISTRATION: The study was registered with ClinicalTrials.gov, with number NCT03277092 , on September 8, 2017.

Children with cancer: a survey on the experience of Italian primary care pediatricians.

BACKGROUND: Cancer is the second cause of death in children and its diagnosis can be difficult, due to the presence of vague and non-specific symptoms. The primary care pediatrician is often involved in the diagnostic process, but no longer in child care once the treatment started. Care models involving both primary care pediatricians and oncologic referral centre highlighted a higher family satisfaction when they worked together. We conducted a survey on primary care pediatricians involved in childhood cancer in order to describe the actual situation. METHODS: We conducted a retrospective survey enrolling primary care pediatricians from a north-eastern area of Italy. They received a questionnaire that consisted in two parts: the first one aimed to assess the physician's seniority and experience and the second one pertained to each case of cancer and explored the relationship between the pediatrician, the family and the referral centre, and pediatricians degree of satisfaction and emotional impact. RESULTS: We obtained data from 79 pediatricians who described 150 cancer cases. In 99 cases the primary care pediatrician had visited the child at the onset of symptoms and had referred him to the hospital. In 89 cases, he understood the severity of the disease. In 53.3% of cases the pediatrician was informed by the referral centre. The relationship between the pediatrician and child's family improved in 38% of cases and this was related with their participation to the multidisciplinary meetings on child health. CONCLUSIONS: Primary pediatricians' sharing in the management of their patients with cancer was not satisfactory. Development of specific protocols targeted to an integrated care is needed to increase primary pediatricians' involvement and families' satisfactions.

Sirolimus Therapy in Congenital Hyperinsulinism: A Successful Experience Beyond Infancy.

Congenital hyperinsulinism (CHI) due to diffuse involvement of the pancreas is a challenging and severe illness in children. Its treatment is based on chronic therapy with diazoxide and/or octreotide, followed by partial pancreatectomy, which is often not resolutive. Sirolimus, a mammalian target of rapamycin inhibitor, was reported to be effective in treating CHI in infants. We report here the case of an 8-year-old boy affected by a severe form of CHI due to a biallelic heterozygous ABCC8 mutation who responded to sirolimus with a dramatic improvement in his glucose blood level regulation and quality of life, with no serious adverse events after 6 months of follow-up. To the best of our knowledge, this is the first report of a successful intervention in an older child. It provides a promising basis for further studies comparing sirolimus with other treatments, particularly in older children.