EAP and ECPCP urge ban on novel nicotine- (NNCPS) and non-nicotine-containing products (NNDS) to youth.

AIM: We want to verify the correlation between the increasing use of novel nicotine-containing products (NNCPs) and non-nicotine delivery products (NNDPs) among young individuals and the escalating negative health consequences, necessitating their prohibition. METHODS: We performed a comprehensive analysis of the most relevant literature about the utilisation of NNCPs and NNDPs among young individuals and their health effects. RESULTS: Despite being initially seen as less harmful alternatives, for smokers aiming to quit, these products have become more popular due to misleading marketing claims. Teenagers using NNCPs and NNDPs, despite having no smoking history, are more likely to transition to tobacco smoking. Consistent use can lead to health issues like pulmonary damage, asthma, and cardiovascular and ocular problems. CONCLUSION: The EAP and the ECPCP endorse the WHO's appeal to outlaw these hazardous products. They urge European governments to forbid the sale of NNCPs and NNDPs to children and adolescents in order to safeguard their well-being. They also propose specific recommendations (box 4) to support this cause.

Vaccine-hesitant families are more susceptible to verbal communication messaging.

OBJECTIVES: Our survey aims to highlight parents' and healthcare workers' opinions and hesitations regarding children's vaccination, identify the main factors influencing these opinions, and assess the impact of hesitations on immunisation for children, included in the National Immunisation Programme in Lithuania. METHODS: We used the questionnaire developed by the European Academy of Paediatrics Research in Ambulatory Settings Network (EAPRASnet). This questionnaire is designed to assess attitudes toward vaccination. The study involved parents raising children aged 1-4 years and primary healthcare providers (paediatricians, family doctors and nurses). RESULTS: We analysed the completed questionnaires from a total of 329 parents (142 fathers, 187 mothers) and 386 medical personnel (150 physicians, 236 nurses). Most parents expressed positive opinions about vaccines (> 8 points out of 10 possible), with older parents exhibiting more favourable attitudes. Compared to mothers, fathers showed more criticism regarding the information provided by physicians (p = 0.04). Family doctors and paediatricians were more supportive of vaccination than nurses and homoeopaths (p < 0.001). Parents and healthcare providers with higher education showed statistically significantly stronger opinions about the benefits of vaccines than those with lower education levels (p = 0.01 for parents, p < 0.001 for physicians and nurses). The Internet was identified as the primary source of negative information for both parents (69.6%) and healthcare providers (86%). However, verbal information received from medical staff during patient consultations or informal conversations among colleagues had the greatest impact on parents' opinions (17.3%) and medical personnel (35.5%). CONCLUSIONS: Confidential conversations with physicians and nurses remain the most trustworthy sources of information and influential factors shaping opinions. The Internet serves as the primary source of inaccurate information about vaccinations for both parents and medical professionals, although verbal information from primary healthcare providers has a more significant impact on vaccination attitudes. Discrepancies in basic education and specific knowledge about vaccination within the same family can pose additional obstacles to child vaccination.

Measuring the knowledge of juvenile idiopathic arthritis among Israeli paediatricians and paediatric orthopaedic surgeons: what needs to be improved?

OBJECTIVES: Approximately 1 child in 1,000 is affected by juvenile idiopathic arthritis (JIA). Persistent, undiagnosed JIA with high disease activity interferes with daily life and carries a risk of irreversible physical and psychosocial damage. Due to its relative rarity, primary care physicians often do not recognise it. Consequently, diagnosis and referral to paediatric rheumatologists are delayed. We aimed to evaluate the knowledge of Israeli paediatricians and paediatric orthopaedic surgeons regarding the epidemiology, clinical manifestations, laboratory parameters and treatment of JIA. METHODS: An 11-item, online questionnaire regarding JIA was sent to Israeli paediatricians and paediatric orthopaedic surgeons. The questionnaire was completed by 318 paediatricians and 30 paediatric orthopaedic surgeons (total response rate 22.5%). RESULTS: The average score was 67/100 points and the pass rate was 70.1% (set at 60 points). Several factors were associated with better overall scores: paediatric residents compared to senior physicians, exposure to rheumatology during residency, and seeing more patients with JIA in the past 5 years. No significant difference was found between paediatricians and paediatric orthopaedic surgeons. The true incidence of JIA was underestimated by 40% of participants, 30-45% were not familiar with its clinical presentation (age of onset, pain characteristics, chronic uveitis symptoms), and 60% were not familiar with up-to-date treatments. CONCLUSIONS: Paediatricians and paediatric orthopaedic surgeons in Israel have gaps in knowledge regarding JIA. This could result in delayed referral and treatment, which might affect outcomes. The results of this study highlight the need for better education and exposure to a rheumatologist, to improve knowledge and recognition of JIA.

How compassionate use enabled Israel to deliver the Pfizer-BioNTech COVID-19 vaccination to vulnerable children aged 12-15 years before regulatory approval.

AIM: This paper describes the emergency, compassionate use of the COVID-19 vaccination for high-risk adolescents aged 12-15 years prior to approval by the American Food and Drugs Administration in May 2021. The target audience had underlying health conditions associated with severe disease and multisystem inflammatory syndrome in children (MIS-C) or severely immunosuppressed household members. METHODS: An orderly approval system was established in Israel for adolescents aged 12-15 years, based on a professional position paper and compassionate treatment regulations. From 12 February 2021, eligible adolescents were referred to the Israeli Ministry of Health for permission to vaccinate, via four health maintenance organisations. Data were collected about adverse events after vaccinations and the incidence of any cases of COVID-19. RESULTS: By 15 March 2021, the vaccine had been approved for 607 adolescents: 333 had received one dose, and 92 had received two doses. The median age was 14.6 years, and the major indication was obesity. Only one child tested positive for the virus, 4 days after vaccination, and no adverse effects were recorded. CONCLUSION: The emergency use of COVID-19 vaccination for 333 adolescents aged 12-15, 92 of them with 2 doses, based on a position paper and compassionate treatment regulations, did not result in any adverse effects. Since 27 July 2021, the same process was further applied in Israel among younger children, aged 5-11, preceding formal release of the clinical trial.

Mandatory vaccination: a joint statement of the Ethics and Vaccination working groups of the European Academy of Paediatrics.

Vaccinating children is amongst the most cost-effective interventions for reducing children's morbidity and mortality. Parents who choose not to vaccinate their children despite having been informed about the evidence on safety and efficacy of vaccines may seriously jeopardise the health of both their own children and others. Contemporary ethical thinking about the limits of parental decision-making over their children's healthcare treatment often considers the zone of parental discretion. However, with vaccination this is slightly less direct as the benefits are not only accumulated by an individual child but also by children as a population. Forcing parents is of course not the only solution to counteracting the fear of vaccines. Health authorities should certainly fund research and deploy resources on combatting vaccine disinformation.Conclusion: It would be preferable to achieve high rates of vaccination coverage by educating both parents and physicians without adopting any legislation for mandatory vaccination. However, in countries where vaccination uptake is low and/or outbreaks of vaccine-preventable diseases occur, the implementation of mandatory vaccination will most probably save children's lives. EAP calls for action to make all scheduled childhood vaccinations a matter of fact for all European children.

Overtesting and overtreatment-statement from the European Academy of Paediatrics (EAP).

Child health has improved considerably, partly due to increased availability of appropriate disease surveillance and treatment. Inappropriate testing and treatment may impose a risk. There is a large and unexplained variation in the use of tests and treatments for children between and within countries. This suggests that non-scientific factors determine their use. In an era of increasing availability of health services, pediatricians have an important role in balancing risks and benefits of available tests and treatments. Examples from the medical literature of overtesting and overtreatment challenge us to reconsider current practices. Antibiotic overuse, overtreatment of bronchiolitis, and non-indicated radiological procedures are found in common practice across Europe. Choosing Wisely is an initiative to improve the quality of care by reducing unnecessary testing and treatment.Conclusion: Clinicians have the challenge to find the optimal balance between too much and too little medicine-just appropriate.

Consumption of Sugar-Sweetened Beverages in Paediatric Age: A Position Paper of the European Academy of Paediatrics and the European Childhood Obesity Group.

BACKGROUND: Health risks associated with the high consumption of sugar-sweetened beverages (SSBs) include overweight or obesity and their complications such as diabetes, as well as oral and dental decay, among others. AIM: The aim of the present statement is to inform health care professionals, parents, care-givers, teachers and school head teachers, stakeholders and governing bodies about the risks associated with drinking SSBs in infants, children and adolescents. METHODS: We searched PubMed and the Cochrane databases for English language studies published from 2010 through October 1, 2018, for randomized clinical trials, meta-analyses, systematic reviews and observational studies (search terms are reported in eAppendix in the Supplement). We also manually searched the references of selected articles, reviews, meta-analyses and practice guidelines. RECOMMENDATIONS: Consumption of SSB by children and adolescents should be limited, and the consumption of water and other non-sweetened beverages should be promoted. Educational institutions such as nurseries, pre-schools and schools should offer unlimited access to drinking water, whereas the sale of SSBs should be banned.

Maternal and child health in Israel: building lives.

Israel is home to a child-oriented society that values strong family ties, universal child benefits, and free education for all children from 3 years of age to school grade 12. Alongside the universal health-care services that are guaranteed by the National Health Insurance Law and strong, community-based primary and preventive care services, these values have resulted in good maternal and child health. In 2015, infant and maternal mortality (3·1 deaths per 1000 livebirths and 2·0 deaths per 100 000 livebirths, respectively) were lower than the mean infant and maternal mortality of countries within the Organisation for Economic Co-operation and Development. Israel has already exceeded the developed regions' Sustainable Development Goal 2030 targets for maternal mortality, neonatal mortality, and mortality in children younger than 5 years in all population groups. Yet these accomplishments are marred by Israel's high prevalence of child poverty (more than 30%), particularly among Arabs (63%) and ultra-Orthodox Jews (67%). Although infant mortality has improved in all subpopulations since Israel was founded in 1948, infant mortality among Arabs is still more than twice as high as among Jews. To address these disparities in health, the Israeli Ministry of Health has created a special division and has funded an intervention programme to reduce the infant mortality among Bedouin Arabs. Other interventions include targeted and culturally appropriate health-care programmes and services for communities with a high number of at-risk children and young adults, dental health service for all children up to 15 years, and improved collaboration between health, education, and welfare services. The challenges faced by the Israeli health-care system include a growing trend towards medicalisation of prenatal care, ensuring staff are trained to treat developmental, behavioural, and psychosocial issues in children and their families, securing sustainable funding for health promotion and injury prevention programmes, expanding and improving the coordination of services for children with special needs or who are at risk, and programme assessment. Ensuring adequate funding for dedicated, preventive paediatric care and taking action on a nationwide scale to reduce child poverty are essential for maintaining health gains in children. In this Series paper, we describe the health indices, highlight disparities, and discuss the challenges in delivering and maintaining maternal and child health care in Israel.

Oral health training, knowledge, attitudes and practices of primary care paediatricians: a European survey.

Oral health is an essential component of children's general health. The aim of this study is to evaluate the training, knowledge, attitudes and practices of primary care paediatricians in oral health in Europe. Paediatricians were invited to complete a survey on the web. There was a 54.3% response rate. The oral health education of the responders was received mainly through continuing medical education and practical experience (51%) rather than in medical school or during paediatric residency training (33%). Twenty-four percent of the responders did not know that the first signs of caries were white spots on the surfaces of teeth. Although 98.8% of paediatricians check the oral health status of children, only 52% feel confident enough to identify dental caries. A large proportion of the paediatricians (43%) recommended a first dental visit for children above the age of 3 years and only 7% under 1 year of age. CONCLUSIONS: Paediatricians are familiar with some aspects of the oral health but are not confident in identifying the risk factors. The current postgraduate curriculum in Paediatrics should incorporate training on basic oral healthcare. In addition, continuous educational programmes are needed to keep the knowledge of the paediatrician up to date. What is Known: • Oral health is an essential component of general health that influences the functional, psychological and social dimensions of a child's well-being. • Paediatricians are the leading providers of primary healthcare for children. What is New: • Paediatricians are familiar with some aspects of the oral health of children but are not confident in identifying the risk factors responsible for oral disease. • The current postgraduate curriculum in Paediatrics should incorporate training on basic oral healthcare in children.

Vitamin D in European children-statement from the European Academy of Paediatrics (EAP).

Vitamin D is synthesized in human skin upon sun exposure and is also a nutrient. It regulates calcium and phosphate metabolism and is essential for the maintenance of bone health. Vitamin D supplementation during infancy, in order to prevent rickets, is universally accepted. Many human cell types carry vitamin D receptor, this being a drive for conducting studies on the possible association between vitamin D status and other diseases. Studies have affirmed that a considerable number of healthy European children may be vitamin D deficient, especially in high-risk groups (darker pigmented skin, living in areas with reduced sun exposure and other disorders). However, the definition of deficiency is unclear due to inter assay differences and due to a lack of consensus as to what is an "adequate" 25(OH)D level. Therefore, there is no justification for routine screening for vitamin D deficiency in healthy children. An evaluation of vitamin D status is justified in children belonging to high-risk groups. All infants up to 1 year of age should receive an oral supplementation of 400 IU/day of vitamin D. Beyond this age, seasonal variation of sunlight should be taken into account when considering a national policy of supplementation or fortification.

Child Health Care in Israel.

Israel is a relatively rapidly growing country with a high fertility rate and a young population. These data emphasize the importance of an efficient and appropriate pediatric service for its population. Although the pediatric service in Israel has attained several achievements, such as a relatively low infant mortality, high vaccination rates, and a primary care service that is mainly based on licensed pediatricians, several challenges, such as overcoming inequalities in health care and health indices between different regions and different populations within the country and the provision of a more organized mental and dental health care service to children, need to be addressed.

Causality Assessment of Serious Neurologic Adverse Events Following bOPV National Vaccination Campaign in Israel.

BACKGROUND: During 2013-2014 Israel experienced a continuous circulation of wild poliovirus type 1 (WPV1) but with no clinical cases. WPV1 circulation was gradually terminated following a national vaccination campaign of bivalent oral poliovirus vaccine (bOPV) for 943,587 children < 10 years. Four cases of children with neurological manifestations that appeared following bOPV vaccinations were reported during the campaign: three of Guillain-Barré syndrome (GBS) and one of acute disseminated encephalomyelitis (ADEM). OBJECTIVES: To present an analysis of these cases, the rapid response and the transparent publication of the results of this analysis. METHODS: The clinical, laboratory and epidemiological data of these four patients were available during the analysis. In addition, data regarding the incidence of GBS and ADEM during previous years, and reported cases of acute flaccid paralysis (AFP) and the incidence of Campylobacter jejuni enteritis were collected from the Epidemiology Department of the Israel Ministry of Health. RESULTS: The incidence of GBS among bOPV-vaccinated children was not higher than among bOPV-unvaccinated children. For all the cases reviewed the "incubation period" from vaccination to the event was longer than expected and other more plausible causes for the neurologic manifestations were found. There is no evidence in the literature of a causal relationship between bOPV and ADEM. CONCLUSIONS: There was no association between the bOPV vaccine and the reported neurological manifestations. We believe that our experience may assist other public health professionals when confronting a similar problem of alleged side effects during a mass medical intervention.

[NEWBORN DISCHARGE LETTER AS A COMMUNICATION DOCUMENT FOR CONTINUITY OF CARE].

AIMS: To check information items in newborn discharge letters from various delivery rooms and compare them to the expectations of community pediatricians. BACKGROUND: The newborn discharge letter is the document that supports the transition of care from the hospital stay to life at home and in the community. It usually summarizes medical information related to the baby's family, maternal pregnancies, delivery and the stay in hospital until discharge. It is primarily a communication tool between healthcare professionals. It is also a legal document that records basic anthropomorphic and physiologic measurements. METHODS: A comparison of items in discharge letters and a survey among pediatricians. RESULTS: A survey of 104 community pediatricians revealed that the most important information that is expected to appear in a discharge letter includes duration of pregnancy, mode of delivery, APGAR score, birth weight, head circumference, weight at the time of discharge, and the results of hearing screening test and red reflex in the examination of the eyes. Except for the red reflex, all this information appears in the discharge letters of the 19 hospital delivery centers that were checked. Items of information that were rated less important for the community pediatricians were history of previous pregnancies, maternal blood type, time of delivery, baby's length and size of the fontanelle. Inconsistency in the presentation of information in discharge letters was the major concern indicated by community pediatricians. There was a major difference between hospitals with regard to the detailing of instructions to parents about the baby's safety, feeding, and further follow-up in the community. CONCLUSIONS: It is desirable that newborn discharge letters from different hospitals will have more uniformity and more detailed information.

Diversity of Pediatric Workforce and Education in 2012 in Europe: A Need for Unifying Concepts or Accepting Enjoyable Differences?

OBJECTIVE: To evaluate differences in child health care service delivery in Europe based on comparisons across health care systems active in European nations. STUDY DESIGN: A survey involved experts in child health care of 40 national pediatric societies belonging both to European Union and non-European Union member countries. The study investigated which type of health care provider cared for children in 3 different age groups and the pediatric training and education of this workforce. RESULTS: In 24 of 36 countries 70%-100% of children (0-5 years) were cared for by primary care pediatricians. In 12 of 36 of countries, general practitioners (GPs) provided health care to more than 60% of young children. The median percentage of children receiving primary health care by pediatricians was 80% in age group 0-5 years, 50% in age group 6-11, and 25% in children >11 years of age. Postgraduate training in pediatrics ranged from 2 to 6 years. A special primary pediatric care track during general training was offered in 52% of the countries. One-quarter (9/40) of the countries reported a steady state of the numbers of pediatricians, and in one-quarter (11/40) the number of pediatricians was increasing; one-half (20/40) of the countries reported a decreasing number of pediatricians, mostly in those where public health was changing from pediatric to GP systems for primary care. CONCLUSIONS: An assessment on the variations in workforce and pediatric training systems is needed in all European nations, using the best possible evidence to determine the ideal skill mix between pediatricians and GPs.

Barriers and challenges to telemedicine usage among the elderly population in Israel in light of the COVID-19 era: A qualitative study.

Background: Although there may still be many challenges to its adoption, telemedicine is becoming more and more popular for helping elderly people preserve their independence and continue to live in their own homes. We intended to investigate the challenges and barriers (if any) experienced by the elderly population when using telemedicine services in Israel. Methods: Fourteen elderly people were recruited for the study and interviewed in person using a semistructured interview protocol, using a qualitative technique. Participants' replies were evaluated and analyzed thematically. The participants were questioned regarding their usage of telehealth services, the benefits they perceive in them, any potential difficulties or hurdles to use, and suggestions they had for making these services more readily available and simpler to use for the elderly. Results: Most participants recognized the advantages of telehealth services, particularly for the elderly population during pandemics and normal times. However, most of them also expressed various challenges that face the elderly population in using these services. Many participants were concerned that the quality of telemedicine sessions may not be good enough compared to in-person sessions, and expressed a lack of confidence in telemedicine services, and frustration from the absence of in-person interaction and communication. Many participants highlighted the technological challenges in the use of computers and applications in general and in the context of healthcare, in particular, in addition to physiological and literacy difficulties. Finally, the participants suggested several ways to increase the accessibility and usage of telemedicine solutions by elderly people. Conclusions: A proactive approach to identifying and resolving telehealth barriers can maximize virtual interactions for the older population and alleviate care inequities. In addition to identifying barriers that impede older patients from using telemedicine, there is a need to increase awareness of the availability, benefits, and uses of each telehealth service in comparison to in-person consultations.

European Academy of Paediatrics statement on the clinical management of children and adolescents with gender dysphoria.

Gender issues have become a polarised and political subject in modern paediatrics and indeed, in broader society. These include the management of infants with disorders of sex development and transgender sports participation, but especially recently regarding the management of gender dysphoria. The European Academy of Paediatrics (EAP) acknowledges that there are deeply held beliefs about this issue based on conscience and social norms. Several European countries, led by the UK, have recently reviewed the management of gender dysphoria in children and young people. Recognising the need for far more research into treatments such as pubertal suppression and cross-sex hormones in children and young people, we review the current ethical and legal dilemmas facing children with gender dysphoria, their families and the clinical teams caring for them. We suggest an approach that maintains the child's right to an open future whilst acknowledging that the individual child is the crucial person affected by decisions made and must receive appropriate support in decision-making and care for any associated mental health or psychological issues. Noting that national approaches to this vary and are in flux, the EAP advocates a child-centred individual rights-based analytical approach.

Over-investigation and overtreatment in pediatrics: a survey from the European Academy of Paediatrics and Japan Pediatric Society.

Introduction: Avoiding over-investigation and overtreatment in health care is a challenge for clinicians across the world, prompting the international Choosing Wisely campaign. Lists of recommendations regarding medical overactivity are helpful tools to guide clinicians and quality improvement initiatives. We aimed to identify the most frequent and important clinical challenges related to pediatric medical overactivity in Europe and Japan. Based on the results, we aim to establish a (European) list of Choosing Wisely recommendations. Methods: In an online survey, clinicians responsible for child health care in Europe and Japan were invited to rate 18 predefined examples of medical overactivity. This list was compiled by a specific strategic advisory group belonging to the European Academy of Paediatrics (EAP). Participants were asked to rate on a Likert scale (5 as the most frequent/important) according to how frequent these examples were in their working environment, and how important they were considered for change in practice. Results: Of 2,716 physicians who completed the survey, 93% (n = 2,524) came from 17 countries, Japan (n = 549) being the largest contributor. Pediatricians or pediatric residents comprised 89%, and 51% had 10-30 years of clinical experience. Cough and cold medicines, and inhaled drugs in bronchiolitis were ranked as the most frequent (3.18 and 3.07 on the Likert scale, respectively), followed by intravenous antibiotics for a predefined duration (3.01), antibiotics in uncomplicated acute otitis media (2.96) and in well-appearing newborns. Regarding importance, the above-mentioned five topics in addition to two other examples of antibiotic overtreatment were among the top 10. Also, IgE tests for food allergies without relevant medical history and acid blockers for infant GER were ranked high. Conclusion: Overtreatment with antibiotics together with cough/cold medicines and inhaled drugs in bronchiolitis were rated as the most frequent and important examples of overtreatment across countries in Europe and Japan.