Simone Piga

Timeliness of routine immunization in a population-based Italian cohort of very preterm infants: Results of the ACTION follow-up project

BACKGROUND Although very preterm infants are recommended to receive immunizations, according to their chronological age, immunization start in these infants is often delayed. Aim To measure coverage and timeliness of routine immunizations in Italian very preterm infants and to assess determinants of delay. METHODS We followed up infants 22-31 completed weeks of gestational age discharged from intensive care. We measured the proportion of children with one dose of diphtheria-tetanus-pertussis-poliohepatitis, B-Hib vaccine (DTP-Pol-HBV-Hib), measles-mumps-rubella vaccine (MMR), conjugate pneumococcal vaccine (Pnc), conjugate meningococcal C vaccine (MenC), and varicella vaccine (Var) by 24 months. We used the Kaplan Meier method and Cox proportional hazard models to estimate the age, at immunization start and determinants of timeliness for each vaccine. RESULTS Data on 1102 (92.1%) children out of 1196 included in the cohort were analyzed. Immunization start by 24 months of age occurred in 95.9% of children for DTP-Pol-HBV-Hib; 84.0% for MMR; 49.7% for Pnc; 38.5% for MenC; and 4.1% for Var. Eighty-seven percent of participants received the first dose of DTP-Pol-HBV-Hib by 6 months of age, and 66.7% had their first MMR administered by 18 months. Hospitalization was associated with delay for all vaccines with the exception of MenC and Var. Maternal employment was associated with earlier immunization for MMR, Pnc, and MenC. DTP-Pol-HBV-Hib timeliness improved with increasing birthweight and paternal employment and decreased with a larger number of siblings in the household. MMR was delayed in children with cerebral palsy, and in those with a larger number of children in the household. Immunization for Pnc was delayed in children with larger number of siblings. CONCLUSIONS Immunization start for all vaccines was considerably delayed in many very preterm infants. Public health strategies taking into account determinants of delay should be implemented to improve coverage and timeliness of vaccination in this group of infants.

Procedural pain in neonates: the state of the art in the implementation of national guidelines in Italy

National and international guidelines have been published on pain control and prevention in the newborn, but data on compliance with these guidelines are lacking.

Corneal curvature and axial length values in children with congenital/infantile cataract in the first 42 months of life.

PURPOSE To evaluate corneal curvature (K(m)) and axial length (AL) of eyes of term-born children aged <3.5 years with uncomplicated congenital cataract and provide age-specific estimates. METHODS This was a retrospective review of patients undergoing cataract extraction from January 1994 to December 2006. Exclusion criteria were preterm birth, microphthalmia, microcornea, megalocornea, glaucoma, traumatic or complicated cataract, retinal disease. Keratometric readings were taken with an autokeratometer before surgery. Linear regression with the logarithm of the patients age as an independent variable was used to model the relationship between the patients age and biometric and keratometric readings. RESULTS All unilateral cataractous eyes (n = 69) and a randomly selected eye in bilateral cases (n = 111) were included in the analysis, for a total of 180 eyes. Mean age was 15.5 +/- 11.8 months; mean AL, 20.03 +/- 2.25 mm; mean K(m), 45.07 +/- 3.00 D. K(m) was significantly greater and AL shorter in younger children (P < 0.001). No differences according to sex were found. As a group, eyes from unilateral cataract had significantly longer AL than those from bilateral cases (P = 0.029). In a small subgroup of unilateral cataract patients for which readings from the clear lens eye were available (n = 39), K(m) of the affected eye was significantly greater than that of the fellow healthy eye (P = 0.007). CONCLUSIONS In the first 42 months of age, K(m) and AL are significantly different according to age. These findings have implications for the calculation of intraocular lens power in children.

Development of a score based on urinalysis to improve the management of urinary tract infection in children

BACKGROUND The need for reducing unnecessary antibiotic treatment is being emphasized in the management of urinary tract infections (UTI), a disease frequent in childhood. An ideal test should provide early diagnosis without the waiting times of urine culture, but even a simple test of exclusion could significantly improve patient management. METHODS We evaluated the sensitivity, specificity, negative and positive predictive value of automated microscopy IRIS iQ200 combined with the dipstick analyses in children with suspected UTI. Multivariable logistic regression analysis was used to identify the set of variables that best predict positive culture results and develop a numerical risk score. RESULTS Of 474 consecutive urine samples retrospectively analyzed, 69 were positive at urine culture with prevalence of infection of 14.6%. Parameters significantly associated with the presence of infection in multivariable analysis were age <1 year (p<0.001), leukocyte esterase ≥ 15×10^6/L (p<0.001), number of small particles (ASP) ≥ 5500 × 10^6/L (p<0.001) and bacteria ≥ 3 × 10^6/L (p=0.01). The derived score ranged from 0 to 10, with higher values indicating higher risk of UTI. The area under the score ROC curve was 79% (95% CI 0.72-0.85), and was better than those of the individual urinary chemical and microscopic analyses. CONCLUSIONS This routine method could improve the management of UTI in children by early identifying patients with low probability of infection, for whom antibiotic treatment can be withheld until the results of urine culture become available.

Parental Perception of Emotional Problems in Children and Adolescents withMixed Specific Developmental Disorder

This study examined the emotional and behavioral problems of children with Mixed Specific Developmental Disorders (MSDD) as reported by their parents (main caregiver). Forty-four children with MSDD (43% males and 57% females, mean age 10.55 yrs, SD 2.85) attending the Bambino Gesu Children’s Hospital health clinics and their parents participated in the study. They were compared with children affected by specific learning disabilities (SLD) (61 children: 56% males and 44% females, mean age 10.92 yrs, SD 2.59). Measurements included the Child Behavior Checklist (CBCL) and detailed cognitive and learning assessment. CBCL T scores indicated that 57% of the children with MSDD and 36% of those with SLD had an internalizing mental health problem (p <0.05), particularly as regard the withdrawn/depressed scale (61% MSDD versus 57% SLD, p<0.05), thought problems (59% versus 55%, p<0.01) and attention problems (64% versus 60%, p<0.05). Thus, MSDD children appeared to have a greater incidence of psychopathological traits than SLD children. In clinical settings, the assessment of learning disabilities in children with MSDD should include both cognitive and learning abilities, as well as psychological/mental health aspects.

Nationwide study of headache pain in Italy shows that pain assessment is still inadequate in paediatric emergency care

Italian national guidelines on pain management were published in 2010, but there is little information on how effective pain management is in paediatric emergency care, with other countries reporting poor levels. Using headache as an indicator, we described pain assessment in Italian emergency departments and identified predictors of algometric scale use.

Size at birth by gestational age and hospital mortality in very preterm infants: Results of the area-based ACTION project

BACKGROUND Size at birth is an important predictor of neonatal outcomes, but there are inconsistencies on the definitions and optimal cut-offs. AIMS The aim of this study is to compute birth size percentiles for Italian very preterm singleton infants and assess relationship with hospital mortality. STUDY DESIGN Prospective area-based cohort study. SUBJECTS All singleton Italian infants with gestational age 22-31 weeks admitted to neonatal care in 6 Italian regions (Friuli Venezia-Giulia, Lombardia, Marche, Tuscany, Lazio and Calabria) (n. 1605). OUTCOME MEASURE Hospital mortality. METHODS Anthropometric reference charts were derived, separately for males and females, using the lambda (λ) mu (μ) and sigma (σ) method (LMS). Logistic regression analysis was used to estimate mortality rates by gestational age and birth weight centile class, adjusting for sex, congenital anomalies and region. RESULTS At any gestational age, mortality decreased as birth weight centile increased, with lowest values observed between the 50th and the 89th centiles interval. Using the 75th-89th centile class as reference, adjusted mortality odds ratios were 7.94 (95% CI 4.18-15.08) below 10th centile; 3.04 (95% CI 1.63-5.65) between the 10th and 24th; 1.96 (95% CI 1.07-3.62) between the 25th and the 49th; 1.25 (95% CI 0.68-2.30) between the 50(h) and the 74th; and 2.07 (95% CI 1.01-4.25) at the 90th and above. CONCLUSIONS Compared to the reference, we found significantly increasing adjusted risk of death up to the 49th centile, challenging the usual 10th centile criterion as risk indicator. Continuous measures such as the birthweight z-score may be more appropriate to explore the relationship between growth retardation and adverse perinatal outcomes.

Management of children presenting with low back pain to emergency department. A 7-year retrospective study

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 ± 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.