Riccardo Longhi

Acute otitis media: From diagnosis to prevention. Summary of the Italian guideline

Acute otitis media (AOM) is the most common disease occurring in infants and children and has major medical, social and economic effects. If we consider the Italian pediatric population and the incidence rates in different age ranges it can be calculated that almost one million cases of AOM are diagnosed in Italy every year. Various attempts have been made internationally to clarify the most appropriate ways in which AOM should be managed. In Italy, this has been done at local or regional level but there have so far been no national initiatives. The objective of this guideline is to provide recommendations to pediatricians, general practitioners and otolaryngologists involved in the clinical management of acute otitis media in healthy children aged 2 months to 12 years. After a systematic review and grading of evidences from the literature, the document was drafted by a multidisciplinary panel with identified key clinical questions related to diagnosis, treatment of the acute episode, management of complications and prevention.

Management of fever in children: Summary of the Italian pediatric society guidelines

OBJECTIVE This article summarizes the Italian Pediatric Society guideline on the management of the signs and symptoms of fever in children, prepared as part of the National Guideline Program (NGLP). METHODS Relevant publications in English and Italian were identified through searches of MEDLINE and the Cochrane Database of Systematic Reviews from their inception through December 31, 2007. Based on the consensus of a multidisciplinary expert panel, the strength of the recommendations was categorized into 5 grades (A-E) according to NGLP methodology. SUMMARY In the health care setting, axillary measurement of body temperature using a digital thermometer is recommended in children aged <4 weeks; for children aged > or =4 weeks, axillary measurement using a digital thermometer or tympanic measurement using an infrared thermometer is recommended. When body temperature is measured at home by parents or care-givers, axillary measurement using a digital thermometer is recommended for all children. Children who are afebrile when seen by the clinician but are reported to have had fever by their caregivers should be considered febrile. In special circumstances, high fever may be a predictive factor for severe bacterial infection. Use of physical methods of reducing fever is discouraged, except in the case of hyperthermia. Use of antipyretics-paracetamol (acetaminophen) or ibuprofen-is recommended only when fever is associated with discomfort. Combined or alternating use of antipyretics is discouraged. The dose of antipyretic should be based on the childs weight rather than age. Whenever possible, oral administration of paracetamol is preferable to rectal administration. Use of ibuprofen is not recommended in febrile children with chickenpox or dehydration. Use of ibuprofen or paracetamol is not contraindicated in febrile children with asthma. There is insufficient evidence to form any recommendations concerning fever in children with other chronic conditions, but caution is advised in cases of severe hepatic/renal failure or severe malnutrition. Newborns with fever should always be hospitalized because of the elevated risk of severe disease; paracetamol may be used, with the dose adjusted to gestational age. Use of paracetamol or ibuprofen is not effective in preventing febrile convulsion or the adverse effects of vaccines.

Update of the 2009 Italian Pediatric Society Guidelines about management of fever in children.

BACKGROUND In 2009, the Italian Pediatric Society developed national guidelines for management of fever in children for health care providers and parents/caregivers; an update of these guidelines was scheduled after 2 years. OBJECTIVE This article summarizes the update of Italian guidelines on managing fever in children, focusing specifically on measuring body temperature and using antipyretic agents. METHODS Relevant publications in English and Italian were identified through searches of MEDLINE and the Cochrane Database of Systematic Reviews from January 1, 2008, to May 1, 2012. On the basis of consensus of a multidisciplinary expert panel, evidence levels and strength of recommendations were reviewed. RESULTS Axillary temperature measurement using a digital thermometer is recommended in children younger than 4 weeks. In the hospital or ambulatory care setting, axillary temperature measurement using a digital or infrared thermometer (tympanic or skin contact or nocontact) is recommended in children older than 4 weeks. Paracetamol and ibuprofen are the only antipyretic drugs recommended for use in children; however, combined or alternating use of these agents is not recommended. CONCLUSIONS Recent scientific evidence mainly supports previous recommendations. The aim of the present article was to support pediatric knowledge and stimulate application of guidelines in daily clinical practice.

Performance of non-contact infrared thermometer for detecting febrile children in hospital and ambulatory settings

AIMS To assess the performance of the non-contact infrared thermometer compared with mercury-in-glass thermometer in children; to assess the diagnostic accuracy of non-contact infrared thermometer for detecting children with fever; to compare the discomfort caused by the two procedures in children aged > one month. BACKGROUND Non-contact infrared thermometer is a quick and non-invasive method to measure body temperature, not requiring sterilisation or disposables. It is a candidate for temperature recording in children. DESIGN Prospective multicenter study. METHODS Body temperature readings were taken from every child consecutively admitted to the Pediatric Emergency Departments or Pediatric Clinics participating in the study. Two bilateral axillary temperature measurements using the mercury-in-glass thermometers and three mid-forehead temperature measurements using the non-contact infrared thermometer were performed. RESULTS Two hundred and fifty-one children were enrolled in the study. Mean body temperature obtained by mercury-in-glass thermometer and non-contact infrared thermometer was 37.18 (SD 0.96) °C and 37.30 (SD 0.92) °C, respectively (p = 0.153). Non-contact infrared thermometer clinical repeatability was 0.108 (SD 0.095) °C, similar to that of the mercury-in-glass thermometer (0.11 SD 01 °C; p = 0.517). Bias was 0.0150 (SD 0.09) °C. The proportion of outliers >1 °C was 4/251 children (1.59%). A significant correlation between temperature values obtained with the two procedures was observed (r(2) = 0.84; p < 0.0001). The limits of agreement, by the Bland and Altman method, were -0.62 (95% CI: -0.47 to -0.67) and 0.76 (95% CI: 0.61-0.91). No significant correlation was evidenced between the difference of the body temperature values recorded by the two methods and age (p = 0.226), or room temperature (p = 0.756). Calculating the receiver operating characteristic curve to determine the best threshold for axillary temperature >38.0 °C, for a non-contact infrared thermometer temperature = 37.98 °C the sensitivity was 88.7% and the specificity 89.9%. Mean distress score (on a 5-point scale) was significantly lower using the non-contact infrared thermometer than using the mercury-in-glass thermometer (1.92 SD 0.56 and 2.40 SD0.93, respectively; p < 0.0001). CONCLUSION Non-contact infrared thermometer showed a good performance in our study population, has the advantage of measuring body temperature in two seconds and is comfortable for children. RELEVANCE TO CLINICAL PRACTICE Non-contact infrared thermometer may be taken into consideration when assessing body temperature in children aged > one month in hospital or ambulatory.

2016 Update of the Italian Pediatric Society Guidelines for Management of Fever in Children.

Objective To review new scientific evidence to update the Italian guidelines for managing fever in children as drafted by the panel of the Italian Pediatric Society. Study design Relevant publications in English and Italian were identified through search of MEDLINE and the Cochrane Database of Systematic Reviews from May 2012 to November 2015. Results Previous recommendations are substantially reaffirmed. Antipyretics should be administered with the purpose to control the childs discomfort. Antipyretics should be administered orally; rectal administration is discouraged except in the setting of vomiting. Combined use of paracetamol and ibuprofen is discouraged, considering risk and benefit. Antipyretics are not recommended preemptively to reduce the incidence of fever and local reactions in children undergoing vaccination, or in attempt to prevent febrile convulsions in children. Ibuprofen and paracetamol are not contraindicated in children who are febrile with asthma, with the exception of known cases of paracetamol‐ or nonsteroidal anti‐inflammatory drug‐induced asthma. Conclusions Recent medical literature leads to reaffirmation of previous recommendations for use of antipyretics in children who are febrile.

In-hospital management of children with bacterial meningitis in Italy

BackgroundOver the years 2009-2013, we conducted a prospective study within a network established by the Italian Society of Pediatrics to describe the in-hospital management of children hospitalized for acute bacterial meningitis in 19 Italian hospitals with pediatric wards.MethodsHospital adherence to the study was voluntary; data were derived from clinical records. Information included demographic data, dates of onset of first symptoms, hospitalization and discharge; diagnostic evaluation; etiology; antimicrobial treatment; treatment with dexamethasone; in-hospital complications; neurological sequelae and status at hospital discharge. Characteristics of in-hospital management of patients were described by causative agent.ResultsEighty-five patients were identified; 49.4% had received an antimicrobial treatment prior to admission. Forty percent of patients were transferred from other Centers; the indication to seek for hospital care was given by the primary care pediatrician in 80% of other children. Etiological agent was confirmed in 65.9% of cases; the most common infectious organism was Neisseria meningitidis (34.1%), followed by Streptococcus pneumoniae (20%). Patients with pneumococcal meningitis had a significant longer interval between onset of first symptoms and hospital admission. Median interval between the physician suspicion of meningitis and in-hospital first antimicrobial dose was 1 hour (interquartile range [IQR]: 1-2 hours). Corticosteroids were given to 63.5% of cases independently of etiology; 63.0% of treated patients received dexamethasone within 1 hour of antibiotic treatment, and 41.2% were treated for ≤4 days. Twenty-nine patients reported at least one in-hospital complication (34.1%). Six patients had neurological sequelae at discharge (7.1%). No deaths were observed.ConclusionsWe observed a rate of meningitis sequelae at discharge similar to that reported by other western countries. Timely assistance and early treatment could have contributed to the favorable outcome that was observed in the majority of cases. Adherence to recommendation for corticosteroid adjunctive therapy seems suboptimal, and should be investigated in further studies. Most meningitis cases were due to N. meningitidis and S. pneumoniae. Reaching and maintaining adequate vaccination coverage against pneumococcal and meningococcal invasive infections remains a priority to prevent bacterial meningitis cases.

The Italian Pediatric Network

The Italian Pediatric Network is now 8 years old. The number of pediatric Departments has increased from the 19 that in 2006 began a feasibility study of the project, to the 129 of today. The objectives of the network are: scientific research, surveillance of rare events, monitoring of complex phenomena, standardization of diagnostic criteria and therapeutic processes, creation of a hospital network capable of allowing a fast and profitable exchange of informations, evaluation of the degree of implementation of clinical Guide Lines. The Network was created by the Working Group for the Accreditation and Quality Improvement (GSAQ) of the Italian Society of Pediatrics Clinical. Date are recorded at the time of discharge by a single operator for each hospital and loaded into anonymous electronic case report forms, different for each pathology, prepared with the help of subspecialty Scientific Societies and available in the Pediatric Network website [http://networkpediatrico.sip.it]. It is not possible to report here all the results obtained from the analysis of the data concerning the first four pathologies investigated (idiopathic trombocytopenic purpura, diabetes at onset, bacterial meningitis after the neonatal period, acute asthma after the second year of life). We will present just a few data on the fifth pathology: acute gastroenteritis in children below 5 years of age. 31 centers filled 612 case report forms in 7 months. It is interesting to compare the diagnostic and therapeutic policies of the partecipating units with the indications of the ESPGHAN Guide Lines. The appropriateness of admissions was rather low, beeing only 42,5% altogether, and minimal for patients admitted under pressure from the family, 2%. Appropriateness of treatments: only 2/3 of the patiens have been correctly treated showing complete or almost complete adherence to the recommendations (no more than 2 major violations or one major and two minor). Major violations were considered those that might negatively affect the course of the disease, unnecessarely increase the cost of treatment or any violation to high grade recommendations, minor violations those that did not change the course of the disease, even if not appropriate and all interventions in contrast with low grade recommendations. The most frequent violations were: microbiological studies, wrong diet prescriptions, use of unrecommended antidiarrhoeal drugs or of probiotics lacking evidence of efficacy, prescription of antibiotics. Two other report forms, concerning bronchiolitis and ALTE, will be officialy presented at this meeting and are ready to be launched in the network.