Children under 6 years with acute headache in Pediatric Emergency Departments. A 2-year retrospective exploratory multicenter Italian study.

BACKGROUND: Preschool age (i.e. children under six years of age) represents a red flag for requiring neuroimaging to exclude secondary potentially urgent intracranial conditions (PUIC) in patients with acute headache. We investigated the clinical characteristics of preschoolers with headache to identify the features associated with a greater risk of secondary "dangerous" headache. METHODS: We performed a multicenter exploratory retrospective study in Italy from January 2017 to December 2018. Preschoolers with new-onset non-traumatic headache admitted to emergency department were included and were subsequently divided into two groups: hospitalized and discharged. Among hospitalized patients, we investigated the characteristics linked to potentially urgent intracranial conditions. RESULTS: We included 1455 preschoolers with acute headache. Vomiting, ocular motility disorders, ataxia, presence of neurological symptoms and signs, torticollis and nocturnal awakening were significantly associated to hospitalization. Among the 95 hospitalized patients, 34 (2.3%) had potentially urgent intracranial conditions and more frequently they had neurological symptoms and signs, papilledema, ataxia, cranial nerves paralysis, nocturnal awakening and vomiting. Nevertheless, on multivariable logistic regression analysis, we found that only ataxia and vomiting were associated with potentially urgent intracranial conditions. CONCLUSION: Our study identified clinical features that should be carefully evaluated in the emergency department in order to obtain a prompt diagnosis and treatment of potentially urgent intracranial conditions. The prevalence of potentially urgent intracranial conditions was low in the emergency department, which may suggest that age under six should not be considered an important risk factor for malignant causes as previously thought.

Relationship between viral load and symptoms in children infected with SARS-CoV-2.

BACKGROUND: The purpose of this study is to evaluate the association between SARS-CoV-2 viral load in respiratory secretions of infected children and signs/symptoms of COVID-19. METHODS: We reported the clinical characteristics of SARS-CoV-2-infected children during the study period. We compared viral load for several clinical variables, performed a predictive linear regression analysis to identify signs and symptoms significantly associated with viral load, and searched for discriminant viral load thresholds for symptomatic versus asymptomatic infections based on receiver-operating characteristics. RESULTS: A total of 570 patients were included. The median age was 4.75 years. Comparison of CT values by dichotomous variable showed higher viral loads in children with fever, respiratory symptoms, and previous exposure to SARS-CoV-2. The linear regression analysis confirmed a significant relationship between the CT value with these variables and with age, other symptoms, and asymptomaticity. In particular, infants with fever and SARS-CoV-2 exposure had higher viral loads. No viral load cut-offs were found to distinguish symptomatic from asymptomatic patients. CONCLUSION: Our study shows that fever, SARS-CoV-2 exposure, and respiratory symptoms are associated with higher viral load in children, especially infants, while age, presence of nonrespiratory symptoms, or absence of any symptoms are associated with lower viral load. IMPACT: Key message: the clinical variables that best predict viral load in infected children are history of previous exposure to a SARS-CoV-2-infected person and presence of fever and respiratory symptoms (higher viral load). Added value to the current literature: this is the first article to prove this point. IMPACT: SARS-CoV-2 viral load should not be used as a measure of clinical severity of COVID-19 in the pediatric population; however, lower viral load appears to be associated with asymptomatic COVID-19 in older children.

Frequency and type of domestic injuries among children during COVID-19 lockdown: what changes from the past? An Italian multicentre cohort study.

Accidents are the main cause of injury in children, more than half events happen at home. Aims of this study were to assess if SARS-CoV-2 lockdown influence emergency department (ED) visits due to children domestic accident (DAs) and to identify factors associated with hospitalization. This was a multicentre, observational, and retrospective cohort study involving 16 EDs in Italy and enrolling children (3-13 years) receiving a visit in ED during March-June 2019 and March-June 2020. Risk factors for hospitalization were identified by logistic regression models. In total, 8860 ED visits due to domestic accidents in children occurred before (4380) and during (4480) lockdown, with a mean incidence of DA of 5.6% in 2019 and 17.9% in 2020 (p < 0.001) (IRR: 3.16; p < 0.001). The risk of hospitalization was influenced by the type of occurred accident, with fourfold higher for poisoning and twofold lower risk for stab-wound ones. In addition, a higher risk was reported for lockdown period vs 2019 (OR: 1.9; p < 0.001), males (OR: 1.4; p < 0.001), and it increased with age (OR: 1.1; p < 0.001).    Conclusions: The main limitation of this study is the retrospective collection of data, available only for patients who presented at the hospital. This does highlight possible differences in the total number of incidents that truly occurred. In any case, the COVID-19 lockdown had a high impact on the frequency of DAs and on hospitalization. A public health campaign aimed at caregivers would be necessary to minimize possible risks at home. What is Known: • In Italy, domestic accidents are the second leading cause of paediatric mortality after cancer. • During the first SARS-CoV-2 lockdown in 2020, a sharp decrease in the total number of Emergency Departments visits for all causes was observed, both in children and in adults. What is New: • During the first SARS-CoV-2 lockdown in 2020, domestic accidents involving children increased threefold from the previous year. • Higher risk of hospitalization was showed in minors accessing during 2020 vs 2019, in males than in females and it increased with advancing age. Considering the type of injury, a significant higher risk of hospitalization for poisoning was observed.

Diagnosis of COVID-19 in children guided by lack of fever and exposure to SARS-CoV-2.

BACKGROUND: The objective of this study is to test how certain signs and symptoms related to COVID-19 in children predict the positivity or negativity of the SARS-CoV-2 nasopharyngeal swab in children. METHODS: We review the data of children who were tested for SARS-CoV-2 for a suspected infection. We compared the clinical characteristics of the subjects who tested positive and negative, including the sensibility, positive and negative predictive value of different combination of signs and symptoms. RESULTS: Of all the suspected infected, 2596 tested negative (96.2%) and 103 tested positive (3.8%). The median age was 7.0 and 5.3 years for the positive and negative ones, respectively. The female to male ratio was ~1:1.3. Fever and respiratory symptoms were mostly reported. Most positive children had a prior exposure to SARS-CoV-2-infected subjects (59.2%). A total of 99.3% of patients without fever nor exposure to the virus proved negative to the SARS-CoV-2 test. CONCLUSIONS: Our study suggests that a child without fever or contact with infected subjects is SARS-CoV-2 negative. If this were to be confirmed, many resources would be spared, with improved care of both COVID-19 and not COVID-19-affected children. IMPACT: Key message: lack of fever and exposure to SARS-CoV-2-infected people highly predicts a negative results of the SARS-CoV-2 nasopharyngeal swab in the paediatric population. Added value to the current literature: this is the first article to prove this point. IMPACT: reduction of emergency department accesses of children with suspected SARS-CoV-2 infection; increased outpatient management of children with cough or other common respiratory symptoms of infancy; sparing of many human and material health resources.

Children With a Soft Scalp Hematoma Presenting to the Emergency Department More Than 24 Hours After a Head Injury.

OBJECTIVES: The soft scalp hematoma is one of the clinical markers used as a predictor for the presence of intracranial injury in children with a head trauma. We evaluated the significance of time presentation in the management of these patients. METHODS: We conducted a retrospective study of children and adolescents aged 0 to <18 years by comparing the clinical, radiological, and epidemiological features in those presenting within 24 hours with those presenting greater than 24 hours after a head injury. RESULTS: We identified 188 and 98 patients with early presentation and late presentation, respectively. The percentage of children aged 0 to <6 months was lower in those with late presentation (6.12%) than those with early presentation (20.21%) with a significant difference (P < .001). Likewise, the percentage of children aged ≥24 months was lower in children with late presentation (7.14%) than those with early presentation (34.04%) with a significant difference (P < .001). The severe mechanism rate was more elevated in early presentation (38.83%) with a significant difference (-14.34%; 95% confidence interval [CI], -25.34% to -3.34%; P = .015). The symptom rate resulted higher in early presentation (14.36%) with a significant difference (-11.30%; 95% CI, -17.36% to 5.22%; P = .003). The parietal scalp hematoma occurred mostly in children with late presentation (85.71%) with a significant difference (19.76%; 95% CI, 10.07% to 29.45%; P < .001). The occipital scalp hematoma rate was higher in early presentation with a significant difference (-17.50%; 95% CI, -22.99% to -12.12%; P < .001). There was no significant difference in the prevalence of different types of intracranial injury, and the only 5 patients needing a neurosurgical intervention were exclusively children with an early presentation. CONCLUSION: Although children with soft scalp hematoma presenting to the emergency department greater than 24 hours after a head injury may have pathological findings on computed tomography, all of them had a good short- and long-term outcomes, and no neurological deterioration aroused the medical attention on follow-up. For this subset of patients that does not experience red flags (neurological symptoms, focal signs on examination, or severe injury mechanism), a wait-and-see approach might be more appropriate rather than neuroimaging.

Reduction of Waiting Times and Patients Leaving Without Being Seen in the Tertiary Pediatric Emergency Department: A Comparative Observational Study.

OBJECTIVES: Analyze the effectiveness of an intervention to reduce waiting time and patients leaving without being seen in the pediatric emergency department. METHODS: A comparative observational study was carried out from November 2018 to April 2019.Patients aged 3 months to 17 years were included. The new organizational model consisted of a dedicated outpatients' clinic for nonurgent codes and a fast track for traumatic and surgical emergency cases. RESULTS: The comparative group included 14,822, and the intervention group included 15,585 patients. The new organizational model significantly reduced the numbers of patients who left the ED without being seen from 12.9% to 5.9%. CONCLUSIONS: This new organizational model in the pediatric emergency department could be successfully used to reduce overcrowding, waiting time, and the numbers of patients leaving without being seen. However, more needs to be done by the pediatric services in the community to reduce nonurgent accesses to the emergency department.

Hypoglycemia in a Pediatric Emergency Department: Single-Center Experience on 402 Children.

OBJECTIVES: This study aimed to establish the rate, etiology, and short-term outcome of hypoglycemia in infants and children accessing an emergency department of a tertiary care pediatric hospital. METHODS: The study was retrospectively conducted on the clinical records of children with hypoglycemia aged 15 days to 17 years who were admitted consecutively to the emergency department during a 6-year period for various clinical conditions. Hypoglycemia was defined as a venous plasma glucose level lower than 45 mg/dL. RESULTS: Hypoglycemia was detected in 402 patients (female-to-male ratio, 1.26; mean age, 2.6 ± 1.8 years), with a rate of 0.99 per 1000 children. Plasma glucose levels ranged from 3 to 45 (mean, 37.48 ± 7.44) mg/dL. Hypoglycemia was associated with gastroenteritis or other infectious diseases causing protracted fasting in 86.32% of cases, whereas hypoglycemia related to a different etiology (HDE) was observed in 13.68% of hypoglycemic children. Most HDE patients had a final diagnosis of ketotic hypoglycemia, whereas metabolic defects were a rare (1.49%) but nonnegligible etiologic cause. A severe triage code was more frequent in the HDE group (P < 0.001). Factors significantly and independently associated with HDE were impaired level of consciousness, assessed with the AVPU scale (A, alert; V, responding to verbal; P, responding to pain; U, unresponsive; adjusted odds ratio, 2.50; P = 0.025) and clinical onset within 12 hours (adjusted odds ratio, 3.98; P < 0.001). CONCLUSIONS: In a nonnegligible number of critically ill children, hypoglycemia can be detected. In a minority of cases, hypoglycemia was due to metabolic disorders that should be suspected on the basis of the severity of hypoglycemia, and the recent onset and the presence of neuroglycopenic symptoms.

Early echocardiographic evaluation of children admitted to the emergency department for anorexia nervosa during the COVID-19 pandemic.

PURPOSE: Anorexia nervosa (AN) is the most frequent eating disorder (ED), whose cardiac complications may have life-threatening consequences for both the physical and psychological health of affected children. In this study, we reported and analysed the echocardiographic anomalies found in pediatric patients diagnosed with AN. METHODS: We reported the demographic and clinical characteristics of children aged 8 to 18 years, who were diagnosed with AN and underwent a complete cardiological evaluation at the Emergency Department of the Bambino Gesù Children's Hospital, IRCCS, Rome between the 1st January 2021 and the 30th June 2021. Furthermore, we compared the patients according to the presence of pericardial effusion and a BMI (body mass index) cut-off 14.5 kg/m2. RESULTS: Forty-nine patients were included in the study. The mean age was 15.1 years. Most patients were female (89.8%). The mean length of hospitalization was 18 days. The mean BMI at admission was 14.8 kg/m2, with a median weight loss of 9 kg in the last year. Eleven patients (22.4%) presented with cardiovascular signs or symptoms at admission. Most patients had pericardial effusion on heart ultrasound, with a mean thickness of 6 mm (SD ± 4). The LV (left ventricle) thickness over age was significantly higher in patients with pericardial effusion, with a Z score of -2.0 vs -1.4 (p = 0.014). The administration of psychiatric drugs was significantly more frequent in patients with a lower BMI (37.5% vs 12%, p = 0.038). CONCLUSION: Our study suggests that a non-urgent baseline echocardiographic evaluation with focus on left-ventricular wall thickness and mass in children with anorexia nervosa is advisable. LEVEL III: Evidence obtained from cohort or case-control analytic studies.

Psychiatric comorbidities and dehydration are more common in children admitted to the emergency department for eating disorders in the COVID-19 era.

PURPOSE: Since the beginning of COVID-19 pandemic, social distancing and home confinement had a significant impact on children, especially on those with eating disorders (ED). The primary objective of this retrospective study was to describe and analyze the demographic and clinical profiles of children presenting with ED during the COVID-19 pandemic. METHODS: We conducted a retrospective review of clinical charts of patients with ED younger than 18 years who accessed the emergency department of the Bambino Gesù Children's Hospital, Rome, between March 2019 and March 2021. Of these, we reported and compared the demographic, clinical and laboratory data before and after the COVID-19 pandemic and looked for predictors of ED severity. RESULTS: A total of 211 admissions for ED were recorded. The patients, mostly females (86.3%) were on average 14.1 years old. The mean weight loss on admission was 11 kg. Bradycardia was observed in 31.3% of the study sample. 16.6% of patients had an associated psychiatric disorder and 60.2% required psychotropic drugs. 68.7% of the patients required hospitalization. Respectively, 96 and 115 patients were admitted before and during the COVID-19 pandemic. The latter were hospitalized more (78.3 vs 57.3%; p = 0.001), yet for less time (19 vs 26 days; p = 0.004), had a higher mean serum creatinine (0.68 vs 0.47; p < 0.001) and were more frequently diagnosed with an associated psychiatric disorder (23.5 vs 8.3%; p = 0.003). CONCLUSION: Our study shows a significant increase of hospitalizations of children with ED during the COVID-19 pandemic, along with a shorter length of stay, more psychiatric comorbidities, and some distinctive features at the laboratory work-up, such as an increase of serum creatinine and/or a reduction of serum albumin. LEVEL OF EVIDENCE: III, evidence obtained from well-designed cohort or case-control analytic studies.

The Osteoarticular Infection in a Pediatric Emergency Setting: A Challenging Diagnosis.

OBJECTIVES: The study aimed to evaluate the emergency department (ED) presentation of children with a diagnosis of osteomyelitis, septic arthritis, or both. METHODS: A retrospective single-center study was conducted on all children aged between 1 month and 18 years evaluated in the ED over a 7-year period and having a final diagnosis of osteoarticular infection. One hundred seventeen patients were enrolled. RESULTS: Only 39.3% of patients were admitted after the first evaluation, and only 45.3% had a proper diagnosis of admission. Pain was the only symptom reported by all. White cell count, C-reactive protein level, and erythrocytes sedimentation rate were normal in 49.5%, 21.4%, and 17.1% of children, respectively. X-ray findings were unremarkable in 48% of cases. Clinical and bone structural sequelae were described in 19.23% and 56.86% of all cases. No statistically significant differences were found among osteomyelitis, arthritis, and the combination of both regarding all considered variables, except for structural outcomes resulting more significant in the third group. Significant differences were evident in clinical manifestations, blood examinations, and findings of osteolysis between patients diagnosed within and after 1 week since the disease onset. Finally, questionable differences between white blood cells and C-reactive protein level were found among patients younger than 5 years and older ones, whereas a history of trauma was more often reported in the second group. CONCLUSIONS: The difficulty in recognizing osteoarticular infection in a pediatric ED can be due to the possible lack of the classic signs and symptoms, and the absence of specific laboratory and radiologic findings.

Point-of-care lung ultrasound in infants with bronchiolitis in the pediatric emergency department: a prospective study.

Bronchiolitis is the most common cause of hospitalization of children in the first year of life. The lung ultrasound is a new diagnostic tool which is inexpensive, non-invasive, rapid, and easily repeatable. Our prospective study was conducted in the emergency department and all patients underwent a routine clinical evaluation and lung ultrasound by the pediatricians who defined the clinical and the ultrasound score. We enrolled 76 infants (median age 90 days [IQR 62-183], 53.9% males). In nasopharyngeal aspirates, the respiratory syncytial virus was isolated in 33 patients. Considering the clinical score, children with higher score had a higher probability of requiring respiratory support (p 0.001). At the ultrasound evaluation, there was a significant difference on ultrasound score between those who will need respiratory support or not (p 0.003). Infants who needed ventilation with helmet continuous positive airway pressure had a more severe ultrasound score (p 0.028) and clinical score (p 0.004), if compared with those who did not need it.Conclusion: Our study shows that lung ultrasound in the bronchiolitis may be a useful method to be integrated with the clinical evaluation to better define the prognosis of the individual patient. Multicenter studies on larger populations are necessary to confirm our data. What is Known: • Bronchiolitis is the main cause of lower respiratory tract infection in children younger than 24 months. • Ultrasound can evaluate the lung parenchyma without ionizing radiations. What is New: • Lung ultrasound may be a useful diagnostic tool to define the prognosis of the infants affected by bronchiolitis if performed at the first assessment in the emergency department. • The score obtained at the ultrasound evaluation is higher in those who will need oxygen therapy during admission for more time and in those who will need respiratory support with helmet continuous positive airway pressure.

Management of children presenting with low back pain to emergency department.

OBJECTIVE: We aimed to describe characteristics, etiology and health care use in children with low back pain (LBP) presenting to pediatric emergency department (ED) and to develop an algorithm to design a diagnostic approach. METHODS: We conducted a 7-year cohort study of children admitted to ED with a primary complaint of LBP. They were classified into diagnostic groups: visceral LBP; traumatic LBP; non-visceral/non-traumatic LBP. To identify high-risk factors (red flags) associated with severe prognosis conditions (SPCs), we analyzed the non-visceral/non-traumatic group comparing the SPC children with those children without SPCs. RESULTS: Our population comprised 140 females (52.6%) and 126 males (47.4%), with a median age of 10.5 years. Eighty children (30.3%) were hospitalized, with an average length of stay of 8.53 ±â€¯9.84 days. SPCs accounted for 28 patients (18.9%) of overall 148 with non-traumatic/non-visceral LBP. In this group, SPCs presented with earlier onset and longer duration of symptoms than non-SPCs. The presence of red flags was more significant in the SPCs group, 28 vs 18; 100% vs 15% (p < 0.001); sensitivity 100%, specificity 85%. Among SPCs, 78.6% were hospitalized vs non-SPC (16.8%) (p < 0.001); within SPC group 2 patients returned because of onset of red flags. CONCLUSION: Our study identified significative high-risk factors (red flags) associated with serious outcomes (SPC group) compared to the non-SPC group, thereby ensuring specific treatment. We developed an algorithm based on previous literature and the findings of our study, which will need to be validated by future prospective research.

Vertigo/dizziness in pediatric emergency department: Five years' experience.

BACKGROUND: Vertigo/Dizziness in childhood is not a rare cause of visits to the emergency department (ED). We analyzed a selected group with vertigo/dizziness to identify signs and symptoms that may help to guide the diagnostic approach and management. METHODS: A total of 616 children admitted for vertigo to the ED over a five-year period were retrospectively reviewed. Their medical history, clinical characteristics, laboratory and neuroimaging tests, final diagnoses and management were analyzed. RESULTS: Migraine and syncope were the most frequent causes. Two patients were affected by life-threatening cardiac syncope, while structural life-threatening central nervous system diseases were found in 15 patients, none of whom presented with vertigo as an isolated clinical finding. CONCLUSIONS: Most cases of vertigo/dizziness in childhood that consist mainly of migraine and syncope are of benign origin. The prompt identification of neurological or cardiological signs or symptoms associated with vertigo in children is mandatory to rule out life-threatening conditions.

Inflatable bouncer-related injuries to children: increasing phenomenon in pediatric emergency department, 2002-2013.

UNLABELLED: A sharp uptrend in emergency department (ED) visits for injuries associated with inflatable bouncers (IBs) has been observed recently. The aim of this study is to describe the epidemiology and features of injuries resulting from the use of IBs at an Italian pediatric ED. We collected data of 521 children from GIPSE (regional software for management of admission at ED) in the period of 2002-2013. The injuries were slightly more frequent in males than females (52.4 vs 47.6 %). Preschooler children were the most commonly injured (45.7 %). The occurrence of injuries increased by year (eight cases in 2002 and 90 cases in 2013), and a seasonal variability was reported (207 cases in the period of April-June). The most common body region injured was the upper extremity (52.4 %). Children with fractures were 126 times more likely to have injured the upper extremity rather than other body regions compared with patients with no fracture (p < 0.05). Humerus and radius/ulna fractures occurred most commonly in preschooler children (p < 0.05). Fractures were 43 times more likely to be hospitalized than children with no fracture (p < 0.05). CONCLUSION: Injuries associated with IBs increased over time. Preschooler children were most injured, and this means there is insufficient adherence to existing recommendations concerning an age limit. WHAT IS KNOWN: • Along with the skyrocketing popularity of IBs among children, the number of children presenting to ED with injuries from these plays has also been increasing at an alarming rate; • The European literature about this phenomenon is scarce and no specific legislations exist for safety of these devises in European Union (EU). What is New: • This is the first study in EU that examines trends for pediatric inflatable bouncer-related injuries at ED over an 11-year period. • Although American Academy of Pediatrics recommends restrictions of attendance to IBs under 6 years old, injuries and fractures continue to occur more frequently under this age.

Myeloid Sarcoma Presenting as Low Back Pain in the Pediatric Emergency Department.

BACKGROUND: Low back pain is a common symptom in the pediatric population; approximately half of all children present with at least one episode of low back pain. The majority of cases are due to nonspecific causes such as musculoskeletal trauma with spontaneous regression. On some occasions, however, life-threatening diseases have to be considered. CASE REPORT: A 15-year-old girl presented to the Pediatric Emergency Department for a history of continuous 2-day duration of low back pain and transient paresthesia of the right gluteal area. Low back pain was diagnosed and nonsteroidal anti-inflammatory treatment combined with rest were prescribed. After 7 days, worsening of the clinical conditions was observed with bilateral gluteus paresthesia. A corset was recommended, and magnetic resonance imaging (MRI) and rheumatological evaluation were prescribed on an outpatient basis. After 5 days she was hospitalized due to urinary incontinence and persistence of pain. Blood tests revealed neutrophil leukocytosis associated with mild anemia, thrombocytopenia, hyperuricemia, and increased lactate dehydrogenase. MRI examination of the spine demonstrated a mass involving the sacral canal and the presacral region, extending through the sacral foramina, along the nerve roots. Similar tissue was found at multiple levels in the spine and in the right orbit. Bone marrow aspiration and biopsy highlighted the presence of myeloid blasts and myeloid dysplasia, consequently, myeloid sarcoma was diagnosed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case demonstrates the importance of prompt identification of diagnostic "red flags" in childhood low back pain, indicating the need for diagnostic investigations such as MRI and blood tests.

The availability and the adherence to pediatric guidelines for the management of syncope in the Emergency Department.

OBJECTIVE: To evaluate the impact of the 2009 Italian pediatric clinical guidelines on the management of syncope. STUDY DESIGN: A retrospective study of patients who presented to the Emergency Department (ED) of Bambino Gesù Children's Hospital with syncope during the 2 years before and then for 2 years after the establishment of the Italian pediatric clinical guidelines. Implementation of the clinical guidelines included educational seminars, additional training of health care workers, and the availability of clinical guidelines and its algorithms on ED examination rooms. RESULTS: We studied a population of 1073 patients (n = 470 vs n = 603). Most patients had neurocardiogenic syncope with a greater increase in postimplementation period (n = 241, 51.3% vs n = 454, 49.8%); we also noticed a parallel reduction of the number of patients with undefined syncope (30% vs 8.3%). We observed an increase in electrocardiogram (n = 328, 69.8% vs n = 512, 85.1%; P < .001), a reduction in electroencephalogram (n = 54, 11.5% vs n = 25, 4.1%; P < .001), and computed tomography scan/magnetic resonance imaging utilization (n = 26, 5.5% vs n = 8, 1.3%; P < .001). In addition, there was a significant reduction of hospital admission rates (n = 195; 41.5% vs n = 116, 19.2%; P < .001). The time period was significantly associated with improvements in all procedures at the multivariate analysis. CONCLUSIONS: Providing practitioners in the ED with age-oriented clinical guidelines increased the efficiency of clinical management of pediatric syncope. Our study demonstrated that the implementation of pediatric clinical guidelines on syncope improve diagnosis, reduce hospital admissions, and decrease the use of unnecessary diagnostic tests.

Children accessing accident and emergency department for non-urgent consultations: A cross-sectional study about parents' use of primary care services.

INTRODUCTION: Parents often take their children to the Paediatric Accident and Emergency Department (A&E) for non-urgent consultations rather than using community-based primary care services. This study describes the use of primary care services in parents taking their children to the A&E for non-urgent consultations. METHODS: A cross-sectional study was conducted from July 2018 to June 2019, in a second-level Italian paediatric A&E of a tertiary-level children's academic research and hub hospital. Parents of children aged between 3 months and 6 years assigned with a white code at the triage were asked to complete a paper-and-pencil 40-item questionnaire after accessing the A&E for a non-urgent consultation. RESULTS: The questionnaire was completed by the parents of 237 children (males 58 %; median age = 2.3 years). Overall, 48.1 % (n = 114) of the parents reported consulting 'often/always' the primary care paediatrician, mainly when their child was sick and for check-ups (n = 182, 76.8 %). However, only 7.2 % (n = 17) of the parents 'often/always' used any other health service in the community. Most of them (n = 191, 82 %) did not even know where the community health centre was located. CONCLUSION: Parents accessing the A&E for non-urgent consultations should be better informed/educated on how to use community health services.

Urgent Psychiatric Consultations for Suicidal Ideation and Behaviors in Italian Adolescents during Different COVID-19 Pandemic Phases.

Access to the emergency department (ED) for acute psychiatric problems, especially for suicide attempts (SA), has increased in the last decade. This increase has exceptionally accelerated after the COVID-19 pandemic. The aim of this project was to study the increase in acute psychiatric care demand of children and adolescents in the short and medium term after the pandemic, in relation to public health measures and in comparison with a pre pandemic reference period. We retrospectively studied 5445 child psychiatric (CP) consultations requested for any reason and for suicide attempt (SA), suicidal ideation (SI) and non-suicidal self-injury (NSSI) in a pediatric ED during three different pandemic periods in Italy (from March 2020 to May 2022) and compared them to a pre-pandemic reference period (from January 2018 to February 2020). Monthly CP consultations for any reason increased significantly by 2.2 times from 70.9 in 2018 to 157 in 2022 (p < 0.001). During the pandemic, monthly CP consultations for any reason increased significantly from 75/month in the first lockdown to 153/month in the second lockdown, remaining stable in the following year. CP consultations for SA increased significantly from 5/month in the first lockdown to 16/month in the second. Consultations for SI increased gradually but significantly from the pre-pandemic period to the end of the pandemic. Juveniles evaluated for SA during the pandemic vs. pre-pandemic more frequently attempted suicide by self-poisoning and less frequently by precipitation, and they were more likely to be diagnosed with a major depressive disorder. CP consultations for any reason and for suicide attempts significantly increased in the decade before the pandemic and peaked in the second lockdown period in Italy.