Disrupted Seasonality of Respiratory Viruses: Retrospective Analysis of Pediatric Hospitalizations in Italy from 2019 to 2023.

This multicenter study in Italian hospitals highlights the epidemiologic disruptions in the circulation of the 5 main respiratory viruses from 2019 to 2023. Our data reveal a resurgence of respiratory syncytial virus and influenza during the 2022-2023 winter season, with an earlier peak in cases for both viruses, emphasizing the importance of timely monitoring.

Nurturing the next generation of pediatric physician scientists: the Padova Physician Scientist Research Training for pediatric residents.

Less than 2% of physicians complete a research training (PhD) after the residency with a declining trend in those pursuing a clinical scientist pathway in pediatrics. The exposure to research methodology during the clinical training may play a role in engaging the next generations of pediatric physician scientist. Herein, we describe the experience of the Padova Physician Scientist Research Training (PPSRT) of the pediatric residency program at the University of Padova. The PPSRT was addressed to residents attending PGY2 to PGY4 of the pediatric program and consisted of two cores: a general one including in person or virtual lectures about research methodology in pediatrics including design of a clinical trial, writing of a scientific paper and statistical methods, and a subspecialties core for the discussion of research challenges in each area and the scientific writing activities. The perceived barriers to a research training and an evaluation of the program were assessed by an anonymized questionnaire. Sixty-four out 150 residents registered for the research training with 62/64 completing the two cores. The major perceived barrier to research during clinical training was the absence of protected time (89%) followed by the lack of specific funds (37%). The group activities lead to the publication of 24 papers.    Conclusion: This is the first experience in the Italian pediatric training of a dedicated research program within the frame of postgraduate medical education. Our report highlights the need for protected time to promote research interest and nurture a new generation of physician scientists. What is Known: • Training to medical research is not part of residency program. • The declining trend of physician scientists might be reverted by early exposure to research methodology and challenges during residency. What is New: • An early exposure to research training during pediatric residency increases the research engagement of pediatric residents. • The lack of protected time for research is perceived as the major barrier to research training during residency.

SIMPEDVR: using VR in teaching pediatric emergencies to undergraduate students-a pilot study.

The objective of this work was to provide pilot data on feasibility of using virtual reality (VR) to train undergraduate students in pediatric emergency scenarios. We staged VR sessions for a total of 45 medical and nursing students; in every session, each student managed two pediatric emergency virtual scenarios. At the end of the sessions, students completed a Technology Assessment Questionnaire to evaluate the perceived usefulness and perceived ease-of-use of their VR training experience and rated their perceived level of competence in managing the two clinical scenarios. The median perceived usefulness was 91.7/100 (interquartile range (IQR) 80.6-100), while the median perceived ease-of-use was 77.8/100 (IQR 63.9-88.9). The perceived level of competence increased from 2 (IQR 1-3) to 4 (IQR 3-4) on a 5-point Likert scale, for both scenarios (p < 0.001, Wilcoxon test for paired samples).       Conclusions: The staged VR sessions had a good perceived usefulness and resulted in an increase in the perceived level of competence. The results on the ease-of-use, however, show that an assumption that millennials and younger students can navigate with confidence VR hardware in a healthcare training setting should not be made; further work is required to ease the integration of VR into curricula. What is Known: • Virtual reality (VR) is a rising simulation training methodology in Pediatric Emergency Medicine (PEM), however little experience is reported about its use for undergraduate students What is New: • VR PEM trainiing was found useful by undergraduate students and its use increased their perceived level of competence, although ease-of-use received lower ratings. • Despite the young age, an assumption that millennials and younger students can navigate with confidence VR hardware in a healthcare training setting should not be made.

Palpable signs of skull fractures on physical examination and depressed skull fractures or traumatic brain injuries on CT in children.

To assess the actual presence of underlying depressed skull fractures and traumatic brain injuries (TBI) on computed tomography (CT) in children with and without palpable skull fractures on physical examination following minor head trauma. This was a secondary analysis of a prospective, observational multicenter study enrolling 42,412 children < 18 years old with Glasgow Coma Scale scores ≥ 14 following blunt head trauma. A palpable skull fracture was defined per the treating clinician documentation on the case report form. Skull fractures and TBIs were determined on CT scan by site radiologists. Palpable skull fractures were reported in 368/10,698 (3.4%) children < 2 years old, and in 676/31,613 (2.1%) of older children. Depressed skull fractures on CT were observed in 56/273 (20.5%) of younger children with palpable skull fractures and in 34/3047 (1.1%) of those without (rate difference 19.4%; 95%CI 14.6-24.2%), and in 30/486 (6.2%) vs 63/11,130 (0.6%) of older children (rate difference 5.6%; 95%CI 3.5-7.8%). TBIs on CT were found in 73/273 (26.7%) and 189/3047 (6.2%) of younger children with and without palpable skull fractures (rate difference 20.5%; 95%CI 15.2-25.9), and in 61/486 (12.6%) vs 424/11,130 (3.8%) of older children (rate difference 8.7%; 95%CI 6.1-12.0).Conclusions: Although depressed skull fractures and TBIs on CT are more common in children with palpable fractures than those without, most of these children do not have underlying depressed fractures. The discriminatory ability of the scalp examination could be enhanced by direct bedside visualization of the skull, such as through ultrasound.

A two-tiered high-flow nasal cannula approach does not increase intensive care utilization and hospital length of stay in bronchiolitis.

While concerns about high-flow nasal cannula oxygen (HFNC) overuse and associated increased use of hospital resources are rapidly spreading, a two-tiered approach in its use is recommended by recent bronchiolitis guidelines. However, data on its effects in practice have not been reported. We aimed to analyze the trends in use of HFNC, hospitalizations, length of stay (LOS), and intensive care unit (ICU) admissions for bronchiolitis in a tertiary care center using a two-tiered HFNC approach since its introduction in practice. We retrospectively included data of children < 12 months of age who presented to the Paediatric Emergency Department (PED) and were hospitalized for bronchiolitis at our institution in the epidemic season between October 1st and April 30th during the years 2012-2023 and compared the clinical data across the years. Of the 687 hospitalized children included, 79.9% required oxygen supplementation. Use of HFNC significantly increased since its implementation (from 25% in 2012-2013 to over 60% since 2019-2020, p < 0.0001) and was most frequently administered as rescue treatment (in 57.5% of patients). There was no increased trend in ICU admissions (between 1.5% and 10.0% of hospitalizations across seasons, p = 0.40), while LOS, after increasing between 2013 and 2016 (medians between 4.0 and 5.4 days), remained stable thereafter (medians between 3.8 and 4.3 days). CONCLUSIONS: The use of HFNC according to a two-tiered approach does not appear to be associated with an increase in ICU utilization or LOS. WHAT IS KNOWN: • Bronchiolitis is one of the most common reasons for hospitalization in infants. • Use high-flow nasal canulae oxygen (HFNC) has rapidly spread outside the intensive care unit (ICU) to treat infants with bronchiolitis, although increasing evidence has dampened the initial enthusiasm about their effectiveness. • Concerns nowadays are rising about HFNC overuse and associated increased use of hospital resources, including escalation of care to ICU. WHAT IS NEW: • A more selective use of HFNC according to a "two-tiered approach", intended as a second-line rescue treatment in non-severely ill children who fail standard oxygen therapy, is not associated with increased ICU and length of hospital stay.

Respective roles of non-pharmaceutical interventions in bronchiolitis outbreaks: an interrupted time-series analysis based on a multinational surveillance system.

BACKGROUND: Bronchiolitis is a major source of morbimortality among young children worldwide. Non-pharmaceutical interventions (NPIs) implemented to reduce the spread of severe acute respiratory syndrome coronavirus 2 may have had an important impact on bronchiolitis outbreaks, as well as major societal consequences. Discriminating between their respective impacts would help define optimal public health strategies against bronchiolitis. We aimed to assess the respective impact of each NPI on bronchiolitis outbreaks in 14 European countries. METHODS: We conducted a quasi-experimental interrupted time-series analysis based on a multicentre international study. All children diagnosed with bronchiolitis presenting to the paediatric emergency department of one of 27 centres from January 2018 to March 2021 were included. We assessed the association between each NPI and change in the bronchiolitis trend over time by seasonally adjusted multivariable quasi-Poisson regression modelling. RESULTS: In total, 42 916 children were included. We observed an overall cumulative 78% (95% CI -100- -54%; p<0.0001) reduction in bronchiolitis cases following NPI implementation. The decrease varied between countries from -97% (95% CI -100- -47%; p=0.0005) to -36% (95% CI -79-7%; p=0.105). Full lockdown (incidence rate ratio (IRR) 0.21 (95% CI 0.14-0.30); p<0.001), secondary school closure (IRR 0.33 (95% CI 0.20-0.52); p<0.0001), wearing a mask indoors (IRR 0.49 (95% CI 0.25-0.94); p=0.034) and teleworking (IRR 0.55 (95% CI 0.31-0.97); p=0.038) were independently associated with reducing bronchiolitis. CONCLUSIONS: Several NPIs were associated with a reduction of bronchiolitis outbreaks, including full lockdown, school closure, teleworking and facial masking. Some of these public health interventions may be considered to further reduce the global burden of bronchiolitis.

Increased risk of emergency department presentations for bronchiolitis in infants exposed to air pollution.

Air pollution has been linked to an increased risk of several respiratory diseases in children, especially respiratory tract infections. The present study aims to evaluate the association between pediatric emergency department (PED) presentations for bronchiolitis and air pollution. PED presentations due to bronchiolitis in children aged less than 1 year were retrospectively collected from 2007 to 2018 in Padova, Italy, together with daily environmental data. A conditional logistic regression based on a time-stratified case-crossover design was performed to evaluate the association between PED presentations and exposure to NO2 , PM2.5, and PM10. Models were adjusted for temperature, relative humidity, atmospheric pressure, and public holidays. Delayed effects in time were evaluated using distributed lag non-linear models. Odds ratio for lagged exposure from 0 to 14 days were obtained. Overall, 2251 children presented to the PED for bronchiolitis. Infants' exposure to higher concentrations of PM10 and PM2.5 in the 5 days before the presentation to the PED increased the risk of accessing the PED by more than 10%, whereas high concentrations of NO2 between 2 and 12 days before the PED presentation were associated with an increased risk of up to 30%. The association between pollutants and infants who required hospitalization was even greater. A cumulative effect of NO2 among the 2 weeks preceding the presentation was also observed. In summary, PM and NO2 concentrations are associated with PED presentations and hospitalizations for bronchiolitis. Exposure of infants to air pollution could damage the respiratory tract mucosa, facilitating viral infections and exacerbating symptoms.

Concussion Knowledge and Self-Reported Behaviors in Youth Rugby Players and Their Coaches: A Population-Wide Cross-Sectional Survey.

OBJECTIVE: To investigate concussion knowledge and self-reported behaviors in Italian youth rugby players and their coaches. To investigate predictors of lower concussion knowledge and association between athletes' self-reported knowledge and behavior. DESIGN: Cross-sectional, population-wide, survey study. SETTING: All rugby clubs (n = 52) of the Veneto region (Italy). PARTICIPANTS: Players and coaches of all under 15, 17 and 19 teams. Overall, 1719 athlete surveys (92.2% male; response rate, 71.1%) and 235 coach surveys (93.6% male; response rate, 93.2%) were eligible for analysis. INTERVENTION: Surveys circulated from September 20 to December 13, 2021. MAIN OUTCOME MEASURES: Knowledge scores were reported as a percentage of correct answers. Descriptive statistics were reported for all answers. The primary outcomes were concussion knowledge and self-reported behaviors. The secondary outcomes were the association between knowledge and participant individual factors and self-reported behaviors. RESULTS: Median knowledge score for athletes was 55% (IQR: 44-67) and for coaches was 60% (IQR: 52.5-69). Only 33.3% of athletes and 40% of coaches were aware of an increased risk of a second concussion after sustaining one. Athletes who had never heard of the word concussion (effect: -9.31; SE: 1.35, 95% CI: -12.0 to -6.7; P < 0.0001) and coaches with longer coaching experience (effect: -4.35; SE: 2.0, 95% CI: -8.29 to -0.41; P < 0.03) reported lower knowledge scores. There was no statistical association between knowledge scores and athlete self-reported behavior. CONCLUSION: Athletes and coaches had a similar level of concussion knowledge. Knowledge score of athletes did not predict self-reported behaviors. Although enhanced concussion education should be undertaken, interventions to ensure appropriate concussion reporting behaviors are also required.

Sepsis Prognostic Scores Accuracy in Predicting Adverse Outcomes in Children With Sepsis Admitted to the Pediatric Intensive Care Unit From the Emergency Department: A 10-Year Single-Center Experience.

OBJECTIVE: To compare the performance of several prognostic scores calculated in the first 24 hours of admission (day 1) in predicting mortality and morbidity among critically ill children with sepsis presenting to the pediatric emergency department (PED) and then admitted to the pediatric intensive care unit (PICU). METHODS: Single-center, retrospective cohort study in children with a diagnosis of sepsis visiting the PED and then admitted to the PICU from January 1, 2010 to December 31, 2019. Sepsis organ dysfunction scores-pediatric Sequential Organ Failure Assessment (pSOFA) (Schlapbach, Matics, Shime), quickSOFA, quickSOFA-L, Pediatric Logistic Organ Dysfunction (PELOD)-2, quickPELOD-2, and Pediatric Multiple Organ Dysfunction score-were calculated during the first 24 hours of admission (day 1) and their performance compared with systemic inflammatory response syndrome (SIRS) and severe sepsis-International Consensus Conference on Pediatric Sepsis(ICCPS)-derived criteria-using the area under the receiver operating characteristic curve. Primary outcome was PICU mortality. Secondary outcomes were: a composite of death and new disability (ie, change from baseline Pediatric Overall Performance Category score ≥1); prolonged PICU length of stay (>5 d); prolonged invasive mechanical ventilation (MV) (>3 d). RESULTS: Among 60 patients with sepsis, 4 (6.7%) died, 7 (11.7%) developed new disability, 26 (43.3%) experienced prolonged length of stay, and 21 (35%) prolonged invasive MV. The prognostic ability in mortality discrimination was significantly higher for organ dysfunction scores, with PELOD-2 showing the best performance (area under the receiver operating characteristic curve, 0.924; 95% confidence interval, 0.837-1.000), significantly better than SIRS 3 criteria (0.924 vs 0.509, P = 0.009), SIRS 4 criteria (0.924 vs 0.509, P < 0.001), and severe sepsis (0.924 vs 0.527, P < 0.001). Among secondary outcomes, PELOD-2 performed significantly better than SIRS criteria and severe sepsis to predict prolonged duration of invasive MV, whereas better than severe sepsis to predict "poor outcome" (mortality or new disability). CONCLUSIONS: Day 1 organ dysfunction scores performed better in predicting mortality and morbidity outcomes than ICCPS-derived criteria. The PELOD-2 was the organ dysfunction score with the best performance for all outcomes.

Presentations of children to emergency departments across Europe and the COVID-19 pandemic: A multinational observational study.

BACKGROUND: During the initial phase of the Coronavirus Disease 2019 (COVID-19) pandemic, reduced numbers of acutely ill or injured children presented to emergency departments (EDs). Concerns were raised about the potential for delayed and more severe presentations and an increase in diagnoses such as diabetic ketoacidosis and mental health issues. This multinational observational study aimed to study the number of children presenting to EDs across Europe during the early COVID-19 pandemic and factors influencing this and to investigate changes in severity of illness and diagnoses. METHODS AND FINDINGS: Routine health data were extracted retrospectively from electronic patient records of children aged 18 years and under, presenting to 38 EDs in 16 European countries for the period January 2018 to May 2020, using predefined and standardized data domains. Observed and predicted numbers of ED attendances were calculated for the period February 2020 to May 2020. Poisson models and incidence rate ratios (IRRs), using predicted counts for each site as offset to adjust for case-mix differences, were used to compare age groups, diagnoses, and outcomes. Reductions in pediatric ED attendances, hospital admissions, and high triage urgencies were seen in all participating sites. ED attendances were relatively higher in countries with lower SARS-CoV-2 prevalence (IRR 2.26, 95% CI 1.90 to 2.70, p < 0.001) and in children aged <12 months (12 to <24 months IRR 0.86, 95% CI 0.84 to 0.89; 2 to <5 years IRR 0.80, 95% CI 0.78 to 0.82; 5 to <12 years IRR 0.68, 95% CI 0.67 to 0.70; 12 to 18 years IRR 0.72, 95% CI 0.70 to 0.74; versus age <12 months as reference group, p < 0.001). The lowering of pediatric intensive care admissions was not as great as that of general admissions (IRR 1.30, 95% CI 1.16 to 1.45, p < 0.001). Lower triage urgencies were reduced more than higher triage urgencies (urgent triage IRR 1.10, 95% CI 1.08 to 1.12; emergent and very urgent triage IRR 1.53, 95% CI 1.49 to 1.57; versus nonurgent triage category, p < 0.001). Reductions were highest and sustained throughout the study period for children with communicable infectious diseases. The main limitation was the retrospective nature of the study, using routine clinical data from a wide range of European hospitals and health systems. CONCLUSIONS: Reductions in ED attendances were seen across Europe during the first COVID-19 lockdown period. More severely ill children continued to attend hospital more frequently compared to those with minor injuries and illnesses, although absolute numbers fell. TRIAL REGISTRATION: ISRCTN91495258 https://www.isrctn.com/ISRCTN91495258.

Point-of-care testing allows successful simultaneous screening of sickle cell disease, HIV, and tuberculosis for households in rural Guinea-Bissau, West Africa.

Diagnosis of noncommunicable genetic diseases like sickle cell disease (SCD) and communicable diseases such as human immunodeficiency virus (HIV) or tuberculosis (TB) is often difficult in rural areas of Africa due to the lack of infrastructures, trained staff, or capacity to involve families living in remote areas. The availability of point-of-care (POC) tests for the above diseases offers the opportunity to build joint programs to tackle all conditions. We report successful simultaneous screening of SCD, HIV, and TB utilizing POC tests in 898 subjects in Fanhe, in rural Guinea-Bissau. Adherence was 100% and all diagnosed subjects were enrolled in care programs.

Diagnostic variation for febrile children in European emergency departments.

The study aimed to explore the use of diagnostics for febrile children presenting to European emergency departments (EDs), the determinants of inter-hospital variation, and the association between test use and hospitalization. We performed a secondary analysis of a cross-sectional observational study involving 28 paediatric EDs from 11 countries. A total of 4560 children < 16 years were included, with fever as reason for consultation. We excluded neonates and children with relevant comorbidities. Our primary outcome was the proportion of children receiving testing after primary evaluation, by country and by focus of infection. Variability between hospitals and effects of blood testing on patient disposition were explored by multilevel regression analyses, adjusting for patient characteristics (age group, triage level, appearance, fever duration, focus of infection) and hospital type (academic, teaching, other). The use of routine diagnostics varied widely, mostly in the use of blood tests, ranging from 3 to 75% overall across hospitals. Age < 3 months, high-acuity triage level, ill appearance, and suspicion of urinary tract infection displayed the strongest association with blood testing (odds ratios (OR) of 8.71 (95% CI 5.23-14.53), 19.46 (3.66-103.60), 3.13 (2.29-4.26), 10.84 (6.35-18.50), respectively). Blood testing remained highly variable across hospitals (median OR of the final model 2.36, 1.98-3.54). A positive association was observed between blood testing and hospitalization (OR 13.62, 9.00-20.61). CONCLUSION: the use of diagnostics for febrile children was highly variable across European EDs, yet patient and hospital characteristics could only partly explain inter-hospital variability. Focus groups of participating sites should help define reasons for unexpected variation. WHAT IS KNOWN: • Although previous research has shown variation in the emergency department (ED) management of febrile children, there is limited information on the use of diagnostics in European EDs. • A deeper knowledge of variability and its determinants can steer optimization of care. WHAT IS NEW: • The use of diagnostics for febrile children was highly variable across European EDs, yet patient and hospital characteristics could only partly explain inter-hospital variability. • Data on between-centre comparison offer opportunities to further explore factors influencing unwarranted variation.

Oral steroids for reducing kidney scarring in young children with febrile urinary tract infections: the contribution of Bayesian analysis to a randomized trial not reaching its intended sample size.

BACKGROUND: This study aimed to evaluate the effect of oral dexamethasone in reducing kidney scars in infants with a first febrile urinary tract infection (UTI). METHODS: Children aged between 2 and 24 months with their first presumed UTI, at high risk for kidney scarring based on procalcitonin levels (≥1 ng/mL), were randomly assigned to receive dexamethasone in addition to routine care or routine care only. Kidney scars were identified by kidney scan at 6 months after initial UTI. Projections of enrollment and follow-up completion showed that the intended sample size could not be reached before funding and time to complete the study ran out. An amendment to the protocol was approved to conduct a Bayesian analysis. RESULTS: We randomized 48 children, of whom 42 had a UTI and 18 had outcome kidney scans (instead of 128 planned). Kidney scars were found in 0/7 and 2/11 patients in the treatment and control groups respectively. The probability that dexamethasone could prevent kidney scarring was 99% in the setting of an informative prior probability distribution (which fully incorporated in the final inference the information on treatment effect provided by previous studies) and 98% in the low-informative scenario (which discounted the prior literature information by 50%). The probabilities that dexamethasone could reduce kidney scar formation by up to 20% were 61% and 53% in the informative and low-informative scenario, respectively. CONCLUSIONS: Dexamethasone is highly likely to reduce kidney scarring, with a more than 50% probability to reduce kidney scars by up to 20%. TRIAL REGISTRATION NUMBER: EudraCT number: 2013-000388-10; registered in 2013 (prospectively registered) A higher resolution version of the Graphical abstract is available as Supplementary information.

SARS-CoV-2 testing and infection control strategies in European paediatric emergency departments during the first wave of the pandemic.

Between February and May 2020, during the first wave of the COVID-19 pandemic, paediatric emergency departments in 12 European countries were prospectively surveyed on their implementation of SARS-CoV-2 disease (COVID-19) testing and infection control strategies. All participating departments (23) implemented standardised case definitions, testing guidelines, early triage and infection control strategies early in the outbreak. Patient testing criteria initially focused on suspect cases and later began to include screening, mainly for hospital admissions. Long turnaround times for test results likely put additional strain on healthcare resources.Conclusion: Shortening turnaround times for SARS-CoV-2 tests should be a priority. Specific paediatric testing criteria are needed. What is Known: • WHO and public health authorities issued case definitions, testing and infection control recommendations for COVID-19 in January. • SARS-CoV-2 testing was made available across Europe in February. What is New: • Paediatric emergency departments implemented COVID-19-specific procedures rapidly, including case definitions, testing guidelines and early triage. • A third of surveyed departments waited more than 24 h for SARS-CoV-2 test to be reported, resulting in additional strain on resources.

Missed intracranial injuries are rare in emergency departments using the PECARN head injury decision rules.

PURPOSE: The PECARN head trauma (HT) prediction rules have been developed to guide computed tomography-related decision-making for children with minor HT (mHT). There are currently limited data on the rate of unscheduled revisits to emergency departments (EDs), and initially missed intracranial injuries, in children with mHT initially assessed using the PECARN rules. This study aimed to fill this gap in knowledge. METHODS: Clinical charts of children assessed for mHT over a 5-year period at two EDs that implemented the PECARN rules in Italy and France were reviewed retrospectively. Children who returned to EDs for mHT-related, or potentially related complaints, within 1 month of initial assessment were included. RESULTS: The total number of children with mHT presenting for the first time to the EDs of both sites was 11,749. Overall, 180 (1.5%) unscheduled revisits to the EDs occurred for mHT-related or potentially related complaints. Twenty-three of these 180 patients underwent neuroimaging, and seven had an intracranial injury (including one ischemic stroke). Of these, three were hospitalized and none needed neurosurgery or intensive care. CONCLUSION: Unscheduled revisits for mHT in EDs using the PECARN rules were very uncommon. Initially missed intracranial injuries were rare, and none needed neurosurgery or intensive care.

Paediatric emergencies and related mortality in Nicaragua: results from a multi-site paediatric emergency registry.

BACKGROUND: We aim to describe the characteristics and outcomes of the severe spectrum of paediatric emergency visits using a multi-site registry developed as part of an international cooperation project. METHODS: This observational registry-based study presented descriptive statistics of clinical and outcome data on urgent-emergency paediatric visits from 7 Nicaraguan hospitals, including the national referral paediatric hospital, between January and December 2017. Extensive piloting to ensure data collection feasibility, sustainability and accuracy was carried out in 2016 with substantial input and feedback from local stakeholders. RESULTS: Overall, 3521 visits of patients <15 years of age, of whom two-thirds <5 years, met predefined inclusion criteria of urgent-emergency visits. Respiratory (1619/3498; 46%), gastrointestinal (407/3498; 12%) and neurological (368/3498; 11%) complaints were the most common symptoms. Malnutrition was reported in 18% (610/3448) of presentations. Mortality was 7% (233/3521); 52% (120/233) of deaths occurred in the <1-year subgroup; 32% (71/3521) of deaths occurred within the first 24 hours of presentation. The most common immediate causes of death were septic shock (99/233; 43%), respiratory failure (58/233; 25%) and raised intracranial pressure (24/233; 10%). CONCLUSIONS: The mortality rate of urgent-emergency paediatric visits in Nicaragua is high, with younger children being most at risk and the majority of deaths being eventually caused by septic shock or respiratory failure. Our data provide useful information for the development of a Paediatric Emergency Care network to help direct training efforts, resources and logistic/organisational interventions to improve children's health in an emergency setting in Nicaragua.

Deep Neck Abscesses in Children: An Italian Retrospective Study.

BACKGROUND: Retropharyngeal and parapharyngeal abscesses (RPAs, PPAs) usually affect young children. Surgical drainage and/or antibiotic therapy are treatment of choice, but no specific guidelines exist. In order to reduce the risk of severe complications, appropriate diagnosis and therapy are necessary. The aims of the study were to review diagnosis and management of children with RPAs/PPAs and to compare surgical versus medical approach. METHODS: This is a multicenter retrospective study including all patients younger than 15 years admitted at 4 Italian pediatric hospitals of Florence, Padua, Rome, and Treviso, with International Classification of Diseases, Ninth Revision discharge diagnosis code of RPAs and PPAs, from January 1, 2008, to December 31, 2016. RESULTS: One hundred fifty-three children were included. The median age was 4.4 years, with overall male predominance. Heterogeneous signs and symptoms (fever, neck cervical, lymphadenopathy, pain, and stiff neck most frequently) and a large mixture of bacteria from pus cultures were detected. Computer tomography (66.7%) and magnetic resonance imaging (27.5%) were performed to confirm the presence of abscess. Fifty-one percent of abscesses were greater than 3 cm. Eighty-seven patients (56.9%) underwent surgery, and 66 (43.1%) were treated with antibiotics alone (mostly ceftriaxone, metronidazole, amikacin, and clindamycin) with median days of therapy of 26.5 days and length of therapy of 16.0 days of median. Median length of stay was 11 days. None had severe complications. Multivariate analysis indicated as independent predictive factors of surgery abscess of 3 cm or greater, high white blood cell count, and-most of all-the hospital of admission. CONCLUSIONS: Deep neck abscesses mostly affect patients in early childhood, with a combination of nonspecific signs and symptoms, and it still emerges as a heterogeneous approach in diagnosis and management of these infections. Thus, common shared protocols represent an essential tool in order to standardize care and improve patients' outcomes.

Preparedness and Response to Pediatric COVID-19 in European Emergency Departments: A Survey of the REPEM and PERUKI Networks.

Study objective: We aim to describe the variability and identify gaps in preparedness and response to the coronavirus disease 2019 pandemic in European emergency departments (EDs) caring for children. Methods: A cross-sectional point-prevalence survey was developed and disseminated through the pediatric emergency medicine research networks for Europe (Research in European Pediatric Emergency Medicine) and the United Kingdom and Ireland (Paediatric Emergency Research in the United Kingdom and Ireland). We aimed to include 10 EDs for countries with greater than 20 million inhabitants and 5 EDs for less populated countries, unless the number of eligible EDs was less than 5. ED directors or their delegates completed the survey between March 20 and 21 to report practice at that time. We used descriptive statistics to analyze data. Results: Overall, 102 centers from 18 countries (86% response rate) completed the survey: 34% did not have an ED contingency plan for pandemics and 36% had never had simulations for such events. Wide variation on personal protective equipment (PPE) items was shown for recommended PPE use at pretriage and for patient assessment, with 62% of centers experiencing shortage in one or more PPE items, most frequently FFP2 and N95 masks. Only 17% of EDs had negative-pressure isolation rooms. Coronavirus disease 2019-positive ED staff was reported in 25% of centers. Conclusion: We found variation and identified gaps in preparedness and response to the coronavirus disease 2019 epidemic across European referral EDs for children. A lack in early availability of a documented contingency plan, provision of simulation training, appropriate use of PPE, and appropriate isolation facilities emerged as gaps that should be optimized to improve preparedness and inform responses to future pandemics.

Dexmedetomidine for EEG sedation in children with behavioral disorders.

OBJECTIVE: To evaluate the efficacy and safety of sedation with dexmedetomidine, a highly selective α2-agonist with sedative effect, for EEG recording in children with behavioral disorders. MATERIAL AND METHODS: Prospective observational study on children with behavioral disorders undergoing EEG at the Pediatric Hospital in Padova, Italy. A 2 mcg/kg intravenous bolus of dexmedetomidine was administered, followed by a 1-2 mcg/kg/h infusion. If necessary, bolus was repeated up to 3 times to reach the target level of sedation, assessed by Pediatric Sedation State Scale. Patients were fully monitored before, during and after the procedure until complete recovery. EEG recording quality, and caregivers' satisfaction were collected. Any adverse effect was registered using SIVA score. RESULTS: For this preliminary study, 19 patients were enrolled. EEG was successfully completed in all of them. Mean total dose of dexmedetomidine was 3.7 ± 1.7 mcg/kg. Adequate sedation was achieved within 11.9 ± 8 minutes. Mean time to first awakening was 30.9 ± 36.9 minutes and time to complete recovery 113.3 ± 92.7 minutes. Adverse effects (hypotension, bradycardia) were reported in 10 patients, all classified as "minor." EEG recording quality was good or excellent. Parents' satisfaction was high in all the interviewed families. CONCLUSIONS: Intravenous dexmedetomidine as a single drug showed an excellent efficacy and good safety profile for EEG recording in children with behavioral disorders.

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.