A survey of the prevalence, management and outcome of infants with an inconclusive diagnosis following newborn bloodspot screening for cystic fibrosis (CRMS/CFSPID) in six Italian centres

OBJECTIVE

We evaluated the prevalence, Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene profile, clinical data, management and outcome for infants with a CFTR-related metabolic syndrome/CF Screen Positive, Inconclusive Diagnosis (CRMS/CFSPID) designation from six Italian centres.

METHODS

All newborn bloodspot screening (NBS) positive infants born from January 2011 to August 2018 with a CF diagnosis or a CRMS/CFSPID designation were enrolled. Data on sweat testing, genetics, clinical course and management were collected.

RESULTS

We enrolled 257 CF patientsand 336 infants with a CRMS/CFSPID designation (CF: CRMS/CFSPID ratio of 1:1.30).Blood immuno-reactive trypsinogen (IRT) was significantly lower in CRMS/CFSPID infants and the F508del variant accounted for only 20% of alleles. Children with CRMS/CFSPID showed a milder clinical course, pancreatic sufficiency compared to CF infants. Varied practice across centres was identified regarding sweat testing, chest radiograph (8-100%) and salt supplementation (11-90%). Eighteen (5.3%) CRMS/CFSPID infants converted or were reclassified to diagnosis of CF. Four infants (1.3%) developed a clinical feature consistent with a CFTR-related disorder (1.2%). Twenty-seven were re-classified as healthy carriers (8.0%) and 16 as healthy infants (4.8%).

CONCLUSIONS

We have identified considerable variability in the evaluation and management of infants with an inconclusive diagnosis following NBS across six Italian centres. CRMS/CFSPID is more regularly seen in this population compared to countries with higher prevalence of F508del.Conversion to a CF diagnosis was recorded in 18 (5.3%) of CRMS/CFSPID infants and in 16 was as a result of increasing sweat chloride concentration.

Cystic fibrosis in Tuscany: evolution of newborn screening strategies over time to the present

BACKGROUND

Cystic fibrosis (CF) is a life-threatening disease affecting about 1:3000 newborns in Caucasian populations. The introduction of newborn screening for cystic fibrosis (CF NBS) has improved the clinical outcomes of individuals with CF through early diagnosis and early treatment. NBS strategies have been implemented over time. CF NBS was introduced extensively in 1984 in Tuscany, a region with 3.7 million people, characterized by a high allelic heterogeneity of CFTR gene.

AIM AND METHODS

The aim of the study is to present the results from 34 years (1984-2018) of CF NBS, retrospectively evaluating the sensitivity, specificity and predictive values of the tests. In particular, we studied the impact of the introduction of DNA molecular analysis in NBS in a region with high allelic heterogeneity, such as Tuscany.

RESULTS

Over these 34 years, 919,520 neonates were screened, using four different NBS strategies. From 1984 to 1991, CF NBS was performed by the determination of albumin on dried meconium (sensitivity 68.75%; specificity 99.82%). Subsequently, the analysis of immunoreactive trypsinogen on a blood spot was adopted as CF NBS protocol (sensitivity 83.33%; specificity 99.77%). From 1992 to 2010, this strategy was associated with lactase meconium dosage: IRT1/IRT2 + LACT protocol (sensitivity 87.50%; specificity 99.82%). From 2011, when the existing algorithm was integrated by analysis of CF causing variants of the CFTR gene (IRT1/IRT2 + LACT + IRT1/DNA protocol), a substantial improvement in sensitivity was seen (senisitivity 96.15%; specificity 99.75%). Other improved parameters with DNA analysis in the NBS programme, compared with the previous method, were the diagnosis time (52 days vs. 38 days) and the recall rate (0.58 to 0.38%).

CONCLUSION

The inclusion of DNA analysis in the NBS was a fundamental step in improving sensitivity, even in a region with high allelic variability.

Knowledge, attitude and disinformation regarding vaccination and immunization practices among healthcare workers of a third-level paediatric hospital

Background

Vaccination represents one of the most effective means of preventing infections for the population and for the public health in general. Recently there has been a decline in vaccinations, also among healthcare workers (HCWs). The aim of the study is to detect the knowledge, skills, attitudes and barriers of HCWs regarding vaccinations in a tertiary children’s hospital in order to support clinical management in immunisation practices.

Methods

An observational study was conducted on 255 subjects over a period of 8 months. The 31-item questionnaire considered profession, level of instruction and different ages. It included questions taken from a questionnaire used for a Canadian research and one used by the Bellinzona hospital. A 4-point Likert scale and closed-ended questions were used. A confidence interval of 95%, p value ≤ 0.05, Chi-square, ANOVA and the Kruskal-Wallis test were considered.

Results

In the last 5 years less than one third of the sample were vaccinated against flu. 77.8% (n.130) of nurses and 45.8% (n.19) of doctors were not vaccinated (p < 0.0001).

As for risk perception, 51.5% of nurses and 90.6% of doctors believe that their risk of contracting influenza is greater than that of the general population.

In relation to the injection site, in all the age ranges there was a high level of knowledge except for those aged over 61 who responded incorrectly. Doctors were more prepared (p < 0.0001).

50% of the sample used internet only as a source of information for vaccines. Generally, scientific sources were used infrequently. The higher the education level, the more frequent the utilisation of trustworthy scientific resources and literature. (p = 0.0002).

Conclusions

In line with the attitude observed in recent years, nurses are not inclined to get vaccinated themselves although they agree to having their children vaccinated. HCWs have a good level of knowledge about vaccines and immunisation practices.

With the nurses we found that the higher the education level, the greater the knowledge about vaccines which leads to the conclusion that low levels of adherence are not due to a lack of knowledge, but rather, to a low perception of risks. Hence the need to strengthen the vaccination strategies inside the companies.

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 child's 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.

Effectiveness of an App for Reducing Preoperative Anxiety in Children: A Randomized Clinical Trial

IMPORTANCE

Effective methods to reduce children's preoperative anxiety (such as giving information beforehand, organizing a tour of the operating room [OR] before the intervention, and incorporating clown physicians) may be difficult to implement for some hospitals, as they are time-consuming and expensive and require hospital staff to be performed.

OBJECTIVE

To test the effectiveness of Clickamico, an app that shows clown physicians giving a comical and informative tour of the OR, for reducing preoperative anxiety in children.

DESIGN, SETTING, AND PARTICIPANTS

This unblinded randomized clinical trial included 40 children aged 6 to 11 years undergoing a planned surgical intervention at a third-level Italian pediatric hospital from December 2013 to September 2014 randomized into experimental (n = 20) and control (n = 20) groups.

INTERVENTIONS

The experimental intervention was a 6-minute video showing 2 clown physicians visiting the OR and explaining to each other what is in the OR in a joking way. The video was shown on a tablet to children in the experimental group the afternoon preceding a planned surgical procedure. The control intervention was the standard informative intervention regarding the surgical procedure the next day.

MAIN OUTCOMES AND MEASURES

The main outcome was preoperative anxiety. Preoperative anxiety was measured before the experimental and control interventions and immediately before entering the OR using the modified Yale Preoperative Anxiety Scale (m-YPAS).

RESULTS

The experimental and control groups were homogeneous with regard to age (mean [SD] age, 8.8 [2.5] vs 8.6 [2.2] years), sex (female, 11 [55.0%] vs 9 [45.0%]), parents' age (mean [SD] age, 41.8 [6.2] vs 41.3 [5.0] years), and previous surgical procedures (already underwent surgical procedure, 9 [45.0%] vs 10 [50.0%]). The initial mean (SD) m-YPAS scores were 37.3 (21.7) and 37.1 (13.8) for the experimental and control groups, respectively; the mean (SD) m-YPAS scores when entering the OR were 33.0 (18.4) and 48.6 (15.9), respectively (P = .009). The mean (SD) difference between the m-YPAS score at the first and second measurements of each participant was -2.8 (7.2) in the experimental group and 10.7 (10.8) in the control group. The 13.5-point difference between these averages was statistically significant (P = .003).

CONCLUSIONS AND RELEVANCE

The app was effective in reducing preoperative anxiety in Italian children admitted to an Italian National Health System pediatric hospital and may act as a substitute for staff-provided interventions, allowing possible reductions of hospital costs.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01688115.

[Cross-sectional study on the determinants of work stress for nurses and intention of leaving the profession]

INTRODUCTION

Occupational stress is one of the main causes of sick leaves among healthcare professionals and it determines high costs to health systems. Monitoring occupational related stress can be an important tool for policy makers. The Italian nursing research gave little attention to nurses' occupational stress. The aims of this study is to estimate the prevalence of occupational stress and evaluate risks factors among Italian nurses in order to evaluate health promotion intervention.

METHODS

Cross-sectional study on a convenience sample of nurses from three Italian public hospitals was carried out. The Nursing Stress Scale was administrated together with socio-demographic data information(age, occupational age, family structure etc). The Nursing Stress Scale includes 34 items with a score from 0 to 3. Seven areas of job related stress are investigate in the scale: conflict with physicians, inadequate training, lack of support, conflict with other nurses, workload, uncertainty about treatments, death and suffering. Scores were calculated for each item and for each area. Associations between stress scores and socio-demographic data were analyzed.

RESULTS

231 nurses participated to the study. The two stress areas with the highest scores were "workload" (1.58) and "death and suffering" (1.39). Among the 13 items that exceed the overall mean stress score (i.e. 1.07), five belong to the "workload" area. "Watching a suffering patient" is the single item with the highest mean score. Demographic data associated to higher stress scores are, female gender (p=0.03) and working with night shifts (p=0.02). Intention to leave the nursing profession is associated to higher stress scores (p=0.002). Age, occupational age, time to commute to work, number of children, having disabled relatives at home, were not correlated to higher stress scores.

CONCLUSIONS

Our study provides data regarding nurses' occupational stress that was not available before. This data may be useful for policy makers to plan preventive interventions for nurses' job related stress and to reduce nurses' intention to leave.

Transcultural validation of Activities Scale for Kids (ASK): translation and pilot test

BACKGROUND AND AIM OF THE WORK

The Activities Scale for Kids performance (ASKp) is one of the few self-assessment questionnaires in pediatric rehabilitation that measures child perception in performance of daily routine activities. ASKp is composed of 30 questions designed to explore activities and participation in children and teenagers with musculoskeletal disorders. Scores assess level of physical ability, identify appropriate treatment and monitor changes over time. We undertook this cross-cultural validation study to achieve a culturally adapted Italian version of ASKp, to be tested on Italian children.

METHODS

ASKp was converted into Italian by two independent certified translators, supported by two Italian research physiotherapists. Twelve children with musculoskeletal disorders, their parents and eleven expert pediatric physiotherapists independently assessed clarity of language and semantics of each item. Physiotherapists also evaluated content validity of each item.

RESULTS

One item out of 30 did not reach inter-rater agreement ≥80% for clarity and was modified according to suggestions given. A panel of three research physiotherapists improved clarity of some other items based on suggestions from study participants. Regarding content validity of ASKp, I-CVI was ≥0.59 for all items and overall ASKp was deemed valid (S-CVI/Ave 0.93).

CONCLUSIONS

The Italian version of ASKp is linguistically clear and culturally coherent with a high content validity. It can be extremely useful in assessing activity limitation perspectives in Italian children and adolescent ranging from five to 15 affected by musculoskeletal disorders.

Development of an algorithm for the management of cervical lymphadenopathy in children: consensus of the Italian Society of Preventive and Social Pediatrics, jointly with the Italian Society of Pediatric Infectious Diseases and the Italian Society of Pediatric Otorhinolaryngology

Cervical lymphadenopathy is a common disorder in children due to a wide spectrum of disorders. On the basis of a complete history and physical examination, paediatricians have to select, among the vast majority of children with a benign self-limiting condition, those at risk for other, more complex, diseases requiring laboratory tests, imaging and, finally, tissue sampling. At the same time, they should avoid expensive and invasive examinations when unnecessary. The Italian Society of Preventive and Social Pediatrics, jointly with the Italian Society of Pediatric Infectious Diseases, the Italian Society of Pediatric Otorhinolaryngology, and other Scientific Societies, issued a National Consensus document, based on the most recent literature findings, including an algorithm for the management of cervical lymphadenopathy in children.

METHODS

The Consensus Conference method was used, following the Italian National Plan Guidelines. Relevant publications in English were identified through a systematic review of MEDLINE and the Cochrane Database of Systematic Reviews from their inception through March 21, 2014.

RESULTS

Basing on literature results, an algorithm was developed, including several possible clinical scenarios. Situations requiring a watchful waiting strategy, those requiring an empiric antibiotic therapy, and those necessitating a prompt diagnostic workup, considering the risk for a severe underling disease, have been identified.

CONCLUSION

The present algorithm is a practice tool for the management of pediatric cervical lymphadenopathy in the hospital and the ambulatory settings. A multidisciplinary approach is paramount. Further studies are required for its validation in the clinical field.

Impact of hospitalization on the sleep patterns of newborns, infants and toddlers admitted to a pediatric ward: a cross-sectional study

AIM

Sleep is essential for children's physical and mental recovery and it is indispensable for their growth, for endocrine and for immune function, and for the development of cognitive behavioral skills. The purpose of this study is to describe the impact of hospitalization on the sleep patterns of newborns, infants and toddlers, as well as mothers' perceptions of any changes in their children's sleep patterns.

METHODS

This was a single-centre cross-sectional study. The study included children aged up to 2 years who had been hospitalized for more than two days, selected by accidental sampling. Data were collected using an anonymous questionnaire with open and closed questions administered to mothers.

RESULTS

Two hundred and one children aged on average 11.2 months (SD 10.3) were enrolled in the study. The percentage of children who at home used to sleep less than 5 hours a night increased by 4.7% in hospital, while the percentage of children sleeping 9 to 11 hours at home decreased by 5.9% in hospital. In hospital mothers put their children to bed later than at home. Indeed, the number of individuals going to bed between 9 and 10 p.m. decreased by 9.8% in hospital, while the number of children going to bed between 10 and 11 p.m. increased by 10.1%. The number of children who had 2 to 4 awakenings per night increased by 13.9% and the number of those who had 4 to 6 nocturnal awakenings increased by 4.8%; 50.5% of mothers reported that their children's sleep was interrupted by nurses to provide care. Mothers generally perceived their children's sleep as adequate, even if they noticed that their children were more restless and irritable. Mothers with only one child reported that they had more difficulty helping their children fall asleep (P=0.02).

CONCLUSION

The study highlights the need to review the routine in paediatric wards on the basis of the sleep needs of children. Further studies are needed to estimate the effectiveness of the specific measures suggested by mothers.

Actual implementation of sick children's rights in Italian pediatric units: a descriptive study based on nurses' perceptions

Background

Several charters of rights have been issued in Europe to solemnly proclaim the rights of children during their hospital stay. However, notwithstanding such general declarations, the actual implementation of hospitalized children’s rights is unclear. The purpose of this study was to understand to which extent such rights, as established by the two main existing charters of rights, are actually implemented and respected in Italian pediatric hospitals and the pediatric units of Italian general hospitals, as perceived by the nurses working in them.

Methods

Cross-sectional study. A 12-item online questionnaire was set up and an invitation was sent by email to Italian pediatric nurses using professional mailing lists and social networks. Responders were asked to score to what extent each right is respected in their hospital using a numeric scale from 1 (never) to 5 (always).

Results

536 questionnaires were returned. The best implemented right is the right of children to have their mothers with them (mean score 4.47). The least respected one is the right of children to express their opinion about care (mean 3.01). Other rights considered were the right to play (4.29), the right to be informed (3.95), the right to the respect of privacy (3.75), the right to be hospitalized with peers (3.39), the right not to experience pain ever (3.41), and the right to school (3.07). According to the majority of nurses, the most important is the right to pain relief.

Significant differences in the implementation of rights were found between areas of Italy and between pediatric hospitals and pediatric units of general hospitals.

Conclusion

According to the perception of pediatric nurses, the implementation of the rights of hospitalized children in Italian pediatrics units is still limited.

Inter-society consensus document on treatment and prevention of bronchiolitis in newborns and infants

Acute bronchiolitis is the leading cause of lower respiratory tract infection and hospitalization in children less than 1 year of age worldwide. It is usually a mild disease, but some children may develop severe symptoms, requiring hospital admission and ventilatory support in the ICU. Infants with pre-existing risk factors (prematurity, bronchopulmonary dysplasia, congenital heart diseases and immunodeficiency) may be predisposed to a severe form of the disease. Clinical diagnosis of bronchiolitis is manly based on medical history and physical examination (rhinorrhea, cough, crackles, wheezing and signs of respiratory distress). Etiological diagnosis, with antigen or genome detection to identify viruses involved, may have a role in reducing hospital transmission of the infection. Criteria for hospitalization include low oxygen saturation (<90-92%), moderate-to-severe respiratory distress, dehydration and presence of apnea. Children with pre-existing risk factors should be carefully assessed.To date, there is no specific treatment for viral bronchiolitis, and the mainstay of therapy is supportive care. This consists of nasal suctioning and nebulized 3% hypertonic saline, assisted feeding and hydration, humidified O2 delivery. The possible role of any pharmacological approach is still debated, and till now there is no evidence to support the use of bronchodilators, corticosteroids, chest physiotherapy, antibiotics or antivirals. Nebulized adrenaline may be sometimes useful in the emergency room. Nebulized adrenaline can be useful in the hospital setting for treatment as needed. Lacking a specific etiological treatment, prophylaxis and prevention, especially in children at high risk of severe infection, have a fundamental role. Environmental preventive measures minimize viral transmission in hospital, in the outpatient setting and at home. Pharmacological prophylaxis with palivizumab for RSV bronchiolitis is indicated in specific categories of children at risk during the epidemic period. Viral bronchiolitis, especially in the case of severe form, may correlate with an increased incidence of recurrent wheezing in pre-schooled children and with asthma at school age.The aim of this document is to provide a multidisciplinary update on the current recommendations for the management and prevention of bronchiolitis, in order to share useful indications, identify gaps in knowledge and drive future research.

Perception of venipuncture pain in children suffering from chronic diseases

BACKGROUND

Venipuncture pain in children results from a variety of co-factors which increase the intensity of the nociceptive stimulus. Among them, anticipatory anxiety plays an important role. Children with chronic diseases undergo invasive procedures and venipuncture more often than other children. Some healthcare professionals still believe that children who are repeatedly exposed to painful procedures, such as children with chronic diseases, gradually increase their pain tolerance and that, as a result, they have a higher pain threshold than children with no chronic diseases. The purpose of this study was to assess whether a difference exists in the perception of venipuncture pain between children with chronic diseases and children with no previous health problems nor experience of venipuncture.

METHODS

A cross-sectional study was carried out using the Wong and numeric pain scales and the Observational Scale of Behavioral Distress (OSBD) for the assessment of behavioral distress. A group of children with chronic diseases and a group of children with no previous health problems nor experience of venipuncture, aged 4 to 12 years, both boys and girls, were observed during a standardized venipuncture procedure.

RESULTS

The study included 230 children in total: 82 of them suffered from chronic diseases and had already experienced venipuncture at least once, while the remaining 148 children had no previous experience of venipuncture. The children with chronic diseases reported more pain (median pain score of 8 on the Wong or numeric scales,) and showed more signs of behavioral distress (median score of 27 on the OSBD) than non-chronic children (median pain score of 2 on the Wong/numeric scales, p = 0.00001; median OSBD score 5, p = 0.00001).

CONCLUSIONS

Our study suggests that children with chronic diseases have a lower pain threshold than children of the same sex and age who experience venipuncture for the first time.

Rational use of antibiotics for the management of children's respiratory tract infections in the ambulatory setting: an evidence-based consensus by the Italian Society of Preventive and Social Pediatrics

BACKGROUND

Several guidelines for the management of respiratory tract infections in children are available in Italy, as well as in other European countries and the United States of America. However, poor adherence to guidelines and the sustained inappropriate use of antibiotics have been reported. In the outpatient setting, almost half of antibiotics are prescribed for the treatment of common respiratory tract infections. In Italy the antibiotic prescription rate is significantly higher than in other European countries, such as Denmark or the Netherlands, and also the levels of antibiotic resistance for a large variety of bacteria are higher. Therefore, the Italian Society of Preventive and Social Paediatrics organised a consensus conference for the treatment of respiratory tract infections in children to produce a brief, easily readable, evidence-based document.

METHODS

The conference method was used, according to the National Institute of Health and the National Plan Guidelines. A literature search was performed focusing on the current guidelines for the treatment of airway infections in children aged 1 month-18 years in the ambulatory setting.

RESULTS

Recommendations for the treatment of acute pharyngitis, acute otitis media, sinusitis, and pneumonia have been summarized. Conditions for which antibiotic treatment should not be routinely prescribed have been highlighted.

CONCLUSION

This evidence-based document is intended to accessible to primary care pediatricians and general practice physicians in order to make clinical practice uniform, in accordance with the recommendations of the current guidelines.

Cross-sectional study on differences in pain perception and behavioral distress during venipuncture between italian and chinese children

Venipuncture is perhaps the scariest aspect of hospitalization for children as it causes pain and high levels of behavioral distress. Pain is a complex experience which is also influenced by social factors such as cultural attitudes, beliefs and traditions. Studies focusing on ethnic/cultural differences in pain perception and behavioral distress show controversial results, in particular with regards to children. The aim of this paper is to evaluate differences in pain perception and behavioral manifestations between Italian and Chinese children undergoing a venipuncture, through a cross-sectional study. Behavioral distress and self-reported pain were measured in Chinese and Italian outpatient children during a standardized blood-drawing procedure, using the Observational Scale of Behavioral Distress (OSBD) and pain scales. We observed 332 children: 93 Chinese and 239 Italian. Chinese children scored higher than Italians on pain scales - mean scores 5.3 (95%CI 4.78-5.81) vs. 3.2 (95%CI 2.86-3.53) - but lower mean OSBD scores - mean 4.1 (95%CI 3.04-5.15) vs. 8.1 (95%CI 7.06-9.14). Our data suggest that Chinese children experience higher levels of pain than their Italian peers, although they show more self-control in their behavioral reaction to pain when experiencing venipuncture.

Heparin solution for maintaining peripheral venous catheter patency in children: a survey of current practice in Italian pediatric units

BACKGROUND

Prolonging the duration of peripheral venous catheters (PVC) as long as possible in children is a nursing priority. However, available studies provide conflicting evidence on what kind of flush/lock solution should be used to increase the life of PVCs in children.

OBJECTIVES

To describe the clinical behavior of nurses working in Italian pediatric units with regards to PVCs flushing and locking practices.

METHODS

Cross-sectional study. Nurses were invited to participate using the network of the Italian Society of Pediatric Nursing Science. Those participating completed an online questionnaire available on a website established for this specific purpose. Results: 405 questionnaires were completed.

RESULTS

The majority of nurses reported using Normal saline solution (NS) to flush 22 gauge PVCs: 77.6% in children up to 6 months of age, 74.7% in children 6 months to 2 years, and 74.6% in children over 2 years. Nurses tend to use heparin solutions (HS) more frequently when a smaller gauge PVC is used (24 instead of 22) and when access is less frequent. The use of HS for PVC lock is more common in onco-hematology units (54.5% in children over 6 months with 24 gauge PVC), pediatric surgery units (35%), and in short-stay units (55.6%), whereas NS is used more frequently in Intensive care units (9.4%) and neonatology units (12.2%).

CONCLUSION

Although the majority of respondents use NS, we found a high variability in practices among Italian nurses. More research on the effectiveness and safety of HS in maintaining the patency of PVCs is needed.

Pediatric nursing in Italy: struggling to survive

In Italy the regulatory framework of the nursing professions presents critical aspects. While a Children Nurse cannot provide care to an adult, a newly graduated General Nurse can legally be assigned to a Neonatal Intensive Care Unit without having ever touched a newborn before. Italian general hospitals with pediatric departments almost always prefer to hire General Nurses rather than Children Nurses, because the former, albeit insufficiently prepared, make staff management easier for nursing directors. Italian Children Nurses are not only penalized by this situation, but also by the public's lack of interest in the specific wellbeing and health needs of children. In addition, they must defend themselves from a part of the Italian nursing leadership, which periodically tries to eliminate the pediatric nursing profession. In an environment that is essentially hostile to Children Nurses, the young who decide nonetheless to take up this profession have very strong and enduring motivations.