Repercussions of the COVID-19 pandemic on child and adolescent mental health: A matter of concern-A joint statement from EAP and ECPCP.

COVID-19 pandemic and the consequent rigid social distancing measures implemented, including school closures, have heavily impacted children's and adolescents' psychosocial wellbeing, and their mental health problems significantly increased. However, child and adolescent mental health were already a serious problem before the Pandemic all over the world. COVID-19 is not just a pandemic, it is a syndemic and mentally or socially disadvantaged children and adolescents are the most affected. Non-Communicable Diseases (NCDs) and previous mental health issues are an additional worsening condition. Even though many countries have responded with decisive efforts to scale-up mental health services, a more integrated and community-based approach to mental health is required. EAP and ECPCP makes recommendations to all the stakeholders to take action to promote, protect and care for the mental health of a generation.

Migrant children's health problems, care needs, and inequalities: European primary care paediatricians' perspective.

BACKGROUND: Primary care paediatricians' perception of migrant children's health in Europe has not been explored before. Our aim was to examine European paediatricians' knowledge on migrant children's health problems, needs, inequalities, and barriers to access health care. METHODS: European primary care paediatricians were invited by the European Academy of Paediatrics Research in Ambulatory Setting Network country coordinators to complete a web-based survey concerning health care of migrant children. A descriptive analysis of all variables was performed. RESULTS: The survey was completed by 492 paediatricians. Sixty-three per cent of the respondents reported that the general health of migrant children is worse than that of nonmigrants, chronic diseases cited by 66% of the respondents as the most frequent health problem. Sixty-six per cent of the paediatricians reported that migrant children have different health needs compared to nonmigrant children, proper oral health care mentioned by 86% of the respondents. Cultural/linguistic factors have been reported as the most frequent barrier (90%).to access health care. However, only 37% of providers have access to professional interpreters and cultural mediators. Fifty-two per cent and 32% do not know whether one or more of the family members are undocumented and whether they are refugees/asylum seekers, respectively. Updated guidelines for care of migrant children are available for only 35% of respondents, and 80% of them have not received specific training on migrant children's care. CONCLUSIONS: European primary care paediatricians recognize migrant children as a population at risk with more frequent and specific health problems and needs, but they are often unaware of their legal state. Lack of interpreters augments the existing language barriers to access proper care and should be solved. Widespread lack of guidelines and specific providers' training should be addressed to optimize health care delivery to migrant children.

Use of electronic health records by child primary healthcare providers in Europe.

BACKGROUND: There is limited data on the use and functionality level of electronic health records (EHRs) supporting primary child health care in Europe. Our objective was to determine European primary child healthcare providers' use of EHRs, and functionality level of the systems used. METHODS: European primary care paediatricians, paediatric subspecialists and family doctors were invited by European Academy of Paediatrics Research in Ambulatory Setting Network (EAPRASnet) country coordinators to complete a web-based survey on the use of EHRs and the systems' functionalities. Binomial logistic analysis has been used to evaluate the effect of specialty and type of practice on the use of EHRs. RESULTS: The survey was completed by 679 child primary healthcare providers (response rate 53%). Five hundred and fifty four responses coming from 10 predominant countries were taken for further analysis. EHR use by respondents varied widely between countries, all electronic type use ranging between 7% and 97%. There was no significant difference in EHR use between group practice and solo practitioners, or between family doctors and primary care paediatricians. History and physical examination can be properly recorded by respondents in most countries. However, growth chart plotting capacity in some countries ranges between 22% and 50%. Vaccination recording capacity varies between 50% and 100%, and data exchange capacity with immunization databases is mostly limited, ranging between 0% and 54%. CONCLUSIONS: There is marked heterogeneity in the use and functionalities of EHRs used among child primary child healthcare providers in Europe. More importantly, lack of critical paediatric supportive functionalities like growth tracking and vaccination status has been documented in some countries. There is a need to explore the reasons for these findings, and to develop a cross European paediatric EHR standards.

European Academy of Paediatrics Research in Ambulatory Setting network (EAPRASnet): a multi-national general paediatric research network for better child health.

BACKGROUND: In 2008, the European Academy of Paediatrics launched a paediatric-based research network - EAPRASnet (European Academy of Paediatrics Research in Ambulatory Setting network). The network has recruited primary care and general paediatricians from European and Mediterranean countries. METHODS: Every paediatrician joining the network has been asked to complete a recruitment survey. The aims of the survey were to characterize paediatrician's demographics, practice arrangements and patient's demographics, to define main incentives for research, and to learn what paediatricians view as unsolved issues that need to be studied. RESULTS: A total of 156 paediatricians from 19 countries were recruited with 144 completing the questionnaire (92%). Majority of respondents (89%) were general paediatricians for more than half of their time. Practice arrangement of 47% of paediatricians was solo practice, with 40% in group practice. Electronic medical records were being used by 72% of respondents. Over 70% of the paediatricians had more than 1000 patients under their clinical care, and patients younger than 6 years old contributed nearly half of the patient population. Areas of most interest for research were: quality of care indicators, communication with parents, obesity, attention deficit hyperactivity disorder and effective well child care. Main incentives for participation in a research project were interest in the topic (81%) and effort to improve quality of care (71%). Lack of time was the leading reported obstacle for research activity (72%). EAPRASnet is growing, and the network's structure, operation and funding are described. Methods for joining the network and the process of study development are presented. CONCLUSION: A core group of EAP general paediatricians are committed to research in their practices. The information gathered will serve for future planning of research projects in the EAPRASnet to harmonize and optimize the care given to children in the primary care setting in Europe.

Primary care pediatrics in Italy: eighteen years of clinical care, research, and teaching under a national health service system.

This article reviews how Italian National Health Service (NHS) pediatricians have tried to fulfill the obligations of modern primary care providers in a managed care environment, with special reference to the experience of the Veneto region in Italy and compares this situation with the present changes of the health system in the United States. Italian NHS primary care pediatricians work independently in their offices, providing acute and chronic patients to all children 0 to 14 years old: NHS primary care physicians, including 7000 pediatricians, contract directly with the government for the care of patients through a capitated reimbursement system. Twenty-nine independent associations of community pediatricians have been formed with the primary goal to pursue research and education in primary care pediatrics, in addition to traditional care. Several multicenter collaborative research studies at the national level have been organized and four university residency programs are training their residents in community-based pediatricians' offices also, giving priority to activities specific to ambulatory practice and follow the suggestion of an Italian work group on ambulatory pediatric training. The NHS has allowed the Italian pediatrician to focus on patient care and education rather than business. Computerization has been applied to the practice of medicine through the development of electronic medical records, particularly in the Veneto region. This technology allows combining effective clinical care with outcome researches and facilitates continuing medical education and residents' training programs. Italian primary care NHS pediatricians have tried to identify and address patient's needs as well as the needs of a primary care provider in a managed care system. Recent and possible future modifications in the health system in the United States and in Italy need to be examined to learn from similarities and differences.

Tricuspid atresia versus other complex lesions. Comparison of results with a modified Fontan procedure.

Several modifications of the Fontan principle are currently applied to the treatment of tricuspid atresia with low mortality. The use of these modifications in other malformations has most frequently been associated with less satisfactory results. At our institution, from June 1977 to October 1986, 35 consecutive patients, whose ages ranged from 8 months to 20 years (median age 3.4 years), underwent a modified Fontan procedure. Twenty patients with a median age of 3.2 years (group I) having tricuspid atresia (16 patients) or hypoplastic right heart syndrome (four patients) were treated by means of a right atrium-pulmonary artery anastomosis (12 patients) or right atrium-subpulmonary chamber connection (eight patients). Fifteen patients (group II) with a median age of 3.6 years, having a single left ventricle (10 patients), left atrioventricular valve hypoplasia or atresia (three patients), or double-outlet right ventricle (two patients), underwent right atrium-pulmonary artery anastomosis, together with a repositioning of the atrial septum to the right of the right atrioventricular valve, which thus left intact the inlet to the ventricle(s). The operative mortality rate was 25% in group I and 0% in group II. One patient in group I and one in group II died late postoperatively. All the 28 survivors are free of symptoms 3 months to 9 years after correction. According to our results, low risk can be associated with modified Fontan procedures in the treatment of complex heart malformations other than tricuspid or pulmonary atresia. Preserving the integrity of the entire inlet to the ventricle(s) by repositioning the interatrial septum, as done in group II malformations, might be helpful in improving the quality of the repair.

Radionuclide evaluation of lung perfusion after the Fontan procedure.

Lung perfusion was evaluated in 19 patients in whom a Fontan operation had been performed at a mean age of 3.7 years. First pass and equilibrium data were acquired during the lung particle perfusion scan 0.5 to 7.9 years (mean 3.7 years) following the Fontan procedure. Abnormalities of lung perfusion were documented in 8 patients. Minimal underperfusion of small areas of either right or left lung were noted in 4 patients, while the remaining 4 had evidence of major perfusion defects, involving both lungs. The perfusion defects were localized, in the majority of cases, on the side where a palliative procedure had been performed before the Fontan operation: it is of note that all our patients without palliative procedures did not show abnormalities in lung perfusion. Major abnormalities of lung perfusion seemed related to possible intimal thrombosis or emboli due to prolonged polycythemia or to pulmonary vessel distortion due to long-standing shunts.

Evaluation of aortic valve prolapse in ventricular septal defect.

Angiographic criteria for the recognition of aortic valve prolapse in isolated ventricular septal defect were based on the degree of aortic cusp deformity and the presence or absence of aortic regurgitation. Ninety eight consecutive patients with isolated perimembranous or infundibular ventricular septal defects who were catheterised and had aortography performed were reviewed. They included five with postoperative ventricular septal defects and three with additional mild right ventricular outflow tract obstruction. Eighteen were found to have aortic valve prolapse. Although eight of the 18 were noted to have aortic regurgitation angiographically, only three had an early diastolic murmur. Only eight of the 18 patients had cross sectional echocardiographic findings suggestive of prolapse. All of these had at least moderate prolapse angiographically. Cross sectional echocardiography was found to be insensitive in diagnosing mild degrees of aortic valve prolapse. A trend towards a decreasing left to right shunt was noted as the degree of aortic valve prolapse increased. Spontaneous decrease in the size of a ventricular septal defect may be due to unrecognised aortic valve prolapse without clinical evidence of aortic regurgitation.

Non-invasive assessment of pulmonary blood supply after staged repair of pulmonary atresia.

Radionuclide studies were performed to determine pulmonary blood flow in six children who had undergone surgery for pulmonary atresia, ventricular septal defect, and hypoplastic pulmonary arteries with or without major aortopulmonary collateral arteries. Lung blood flow was assessed from both particle perfusion lung scans and the pulmonary and systemic phase of a radionuclide dynamic flow study. Five patients had perfusion defects identified on the particle perfusion lung scan. In three of these, abnormal areas were perfused only during the systemic phase of the flow study, a combination of findings that indicate the presence of perfusion by collateral arteries. In one patient no systemic perfusion was noted and in one an initial particle perfusion study indicated the presence of a lung segment perfused by a collateral artery. In this last patient the particle perfusion scan after total correction showed a reduction in the size of the lung perfusion defect and no evidence of lung perfusion during the systemic phase of the flow study. The particle perfusion lung scan in the sixth patient showed pronounced asymmetry in blood flow to the lungs with no segmental perfusion defect on the particle perfusion scan and no abnormalities on the systemic flow study. It is concluded that radionuclide lung perfusion and flow studies provide useful information on lung perfusion and merit further evaluation to define their role in the management of these patients.

Radionuclide assessment of ventricular contraction at rest and during exercise following the Fontan procedure for either tricuspid atresia or single ventricle.

Ventricular contraction was evaluated in 18 patients studied at a mean of 2.6 years after Fontan repair. The diagnosis was tricuspid atresia in 9 patients and single ventricle in 9. Gated first-pass and gated equilibrium radionuclide ventriculography were performed at rest and during exercise. Abnormally low ventricular ejection fraction (EF) at rest was present in 8 of 18 patients by the gated equilibrium technique and 6 of 13 technically adequate gated first-pass studies. An abnormal response to exercise (failure of EF to increase less than or equal to 5% from rest to maximal exercise) was found in 10 of 16 patients by the gated equilibrium technique and in 8 of 12 by the gated first-pass technique. Only 2 patients by each radionuclide technique had both normal EF at rest and normal exercise response. Thus, this study confirms the frequent presence of abnormalities in ventricular contraction after the Fontan procedure at rest or during exercise or both despite absence of symptoms. Both EF response and the hemodynamic response during exercise were more abnormal in the presence of an atriopulmonary than an atrioventricular connection.

Successful repair of symptomatic cor triatriatum dexter in infancy.

Cor triatriatum dexter is a rare cardiac malformation, usually diagnosed incidentally at operation or necropsy. We report the case of a 5-month-old infant, severely symptomatic, who underwent correction of a highly obstructive cor triatriatum dexter, with multiple anomalies of the systemic venous return and a large interatrial communication. This appears to be the first case of successful repair of this anomaly during infancy.

Right lung agenesis. A case report.

This report describes a combination of a ventricular septal defect and partial anomalous pulmonary venous drainage in an infant with right lung agenesis. Unilateral agenesis of the lung has been rarely described. Although this condition is compatible with long survival, morbidity and mortality are increased by the associations with other malformations both intra- and extracardiac. In unilateral lung agenesis although there is a compensatory increase in volume of the single lung, there is a reduction in the number of branches of the pulmonary artery and the whole right ventricular output passes through a reduced vascular bed. In isolated unilateral agenesis of the lung, pulmonary hypertension is present in about 19% of cases, while in patients with additional left to right shunt the incidence is 88%. The basic condition of increased pulmonary blood flow (single lung) and the undiagnosed partial anomalous pulmonary venous drainage may explain why the early closure of the ventricular septal defect did not prevent the progressive pulmonary vascular disease. We discuss shortly Tolazoline as pulmonary vasodilator.

[Digitalis toxicity and digoxin blood levels in children (author's transl)]. / Tossicita' digitalica e digitalemia in eta' pediatrica.

Digoxin serum levels in 41 children with clinical and/or ECG symptoms of digitoxicity were determined by radioimmunoassay and compared to the normal values. 54% of the cases showed a good relationship between clinical and/or ECG signs of toxicity and digoxin levels; on the contrary, 29% of patients exhibited only clinical and/or ECG signs of toxicity with normal digoxin levels and 17% of patients had high digoxin levels without signs of toxicity. The significance and possible causes of this relative discrepancy are discussed.

Anatomy of aortic atresia. Cases presenting with a ventricular septal defect.

The anatomy of 58 specimens of aortic outflow tract atresia was studied. All cases had situs solitus and levocardia, 37 had atrioventricular (AV) concordance, two had common inlet to a right ventricle and 19 had mitral atresia. The great arteries were normally interrelated in all cases. Fifty-one cases had an intact ventricular septum, while seven presented with a ventricular septal defect (VSD). Of the seven with VSD, in two it was associated with a common AV orifice draining exclusively into the right ventricle in the presence of a rudimentary left ventricular chamber. In one case a small VSD accompanied combined mitral and aortic atresia. In the other four cases the left ventricles and mitral valves were fairly normal in size; the VSD was subpulmonary in three cases, due to infundibuloventricular malalignment, and perimembranous in one. These last four cases are of particular interest since they could be amenable to surgical correction. Possible approaches to surgical treatment and morphologic features pertinent to them are described and discussed.

[Serum digoxin levels in the pediatric age (author's transl)]. / Determinazione dei livelli sierici di digitale in età pediatrica

Serum digoxin levels during maintenance therapy in children of four different age groups were determined by a radioimmunoassay technique. For each patient, three determinations, at the peak level, at the plateau and at the final phase, were done. The newborn group showed in all three phases serum digoxin levels significantly higher than those found in the other groups, in spite of an only slightly higher dosage of digoxin used in comparison to the other groups.