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Adamiec A, Cieślik M, Mączka K, Tarnoruda J, Jensen S, Chawes B, Bønnelykke K, Konradsen JR, Söderhäll C, Makrinioti H, Camargo CA, Hasegawa K, Ambrożej D, Jartti T, Ruszczyński M, Feleszko W. A systematic review and meta-analysis on absolute eosinophil counts and the risk of asthma in preschool children with wheezing: An EAACI Task Force Report. Pediatr Allergy Immunol 2024; 35:e14078. [PMID: 38339981 DOI: 10.1111/pai.14078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 01/17/2024] [Indexed: 02/12/2024]
Abstract
Preschool children with wheezing disorders pose diagnostic and therapeutic challenges and consume substantial healthcare resources. Peripheral eosinophil blood count (EBC) has been proposed as a potential indicator for future asthma development. This review by the European Academy of Allergy and Clinical Immunology (EAACI) Preschool Wheeze Task Force aimed to provide systematic evidence for the association between increased EBC and the risk of future asthma, as well as to identify potential cutoff values. In February 2023, a search of PubMed, EMBASE, and Cochrane Library databases was conducted to identify studies comparing EBCs in preschool children with wheezing who continued to wheeze later in life and those who did not. Included observational studies focused on children aged <6 years with a wheezing disorder, assessment of their EBCs, and subsequent asthma status. No language or publication date restrictions were applied. Among the initial 3394 studies screened, 10 were included in the final analysis, involving 1225 patients. The data from these studies demonstrated that high EBC in preschool children with wheezing is associated with future asthma development, with odds ratios of 1.90 (95% CI: 0.45-7.98, p = .38), 2.87 (95% CI: 1.38-5.95, p < .05), and 3.38 (95% CI: 1.72-6.64, p < .05) for cutoff values in the <300, 300-449, and ≥450 cells/μL ranges, respectively. Defining a specific cutoff point for an elevated EBC lacks consistency, but children with EBC >300 cells/μL are at increased risk of asthma. However, further research is needed due to the limitations of the included studies. Future investigations are necessary to fully elucidate the discussed association.
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Affiliation(s)
- Aleksander Adamiec
- Department of Paediatric Pneumonology and Allergy, Medical University of Warsaw Children's Hospital, Warsaw, Poland
- Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Maja Cieślik
- Department of Paediatric Pneumonology and Allergy, Medical University of Warsaw Children's Hospital, Warsaw, Poland
| | - Katarzyna Mączka
- Department of Paediatric Pneumonology and Allergy, Medical University of Warsaw Children's Hospital, Warsaw, Poland
- Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Tarnoruda
- Department of Paediatrics, Medical University of Warsaw Children's Hospital, Warsaw, Poland
| | - Signe Jensen
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Bo Chawes
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Klaus Bønnelykke
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jon R Konradsen
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Cilla Söderhäll
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Heidi Makrinioti
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Dominika Ambrożej
- Department of Paediatric Pneumonology and Allergy, Medical University of Warsaw Children's Hospital, Warsaw, Poland
- Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Tuomas Jartti
- Department of Paediatrics, Turku University Hospital and Turku University, Turku, Finland
- PEDEGO Research Unit, Medical Research Centre, University of Oulu, Turku, Finland
- Department of Pediatrics, Oulu University Hospital, Turku, Finland
| | - Marek Ruszczyński
- Department of Paediatrics, Medical University of Warsaw Children's Hospital, Warsaw, Poland
| | - Wojciech Feleszko
- Department of Paediatric Pneumonology and Allergy, Medical University of Warsaw Children's Hospital, Warsaw, Poland
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Myklebust Å, Rae Simpson M, Valand J, Stenhaug Langaas V, Jartti T, Døllner H, Risnes K. Bronchial reactivity and asthma at school age after early-life metapneumovirus infection. ERJ Open Res 2024; 10:00832-2023. [PMID: 38259817 PMCID: PMC10801746 DOI: 10.1183/23120541.00832-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/14/2023] [Indexed: 01/24/2024] Open
Abstract
Background The association between early-life lower respiratory tract infection (LRTI) and asthma is well established. Knowledge about bronchial hyperresponsiveness (BHR) and asthma after metapneumovirus (MPV) LRTI is scarce. The aim of this study was to assess BHR and current asthma in school-aged children after hospital admission for early-life LRTI with MPV, and to compare with more well-known viruses, rhinovirus (RV) and respiratory syncytial virus (RSV), and with controls. Methods A cohort consisting of children admitted for LRTI and controls was followed-up at school age with a clinical research assessment and lung function tests, including a methacholine provocation test. Current asthma was defined based on objective variable airway obstruction and clinical symptoms. BHR and asthma were compared according to viral groups. Results 135 children (median age 9.3 years) were included (16 MPV, 34 RV, 51 RSV, 13 mixed infections and 21 controls). Compared with controls there was increased BHR after MPV and RV LRTI (provocative dose causing a 20% fall in forced expiratory volume in 1 s and dose-response slope; p<0.05). Using Kaplan-Meier statistics, BHR was increased for MPV compared with both controls and RSV (p=0.02 and p=0.01). The proportion of children with current asthma at follow-up was higher in the LRTI children compared with the controls (46% versus 24%; p=0.06). Among children who had undergone MPV and RV infection, 50% fulfilled the asthma criteria compared with 43% in the RSV group (p=0.37). Conclusion We found increased BHR and a high prevalence of asthma in school-aged children after early-life MPV infection, and findings were similar to RV, and less to RSV, compared with controls.
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Affiliation(s)
- Åsne Myklebust
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Children's Clinic, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Melanie Rae Simpson
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jonas Valand
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Tuomas Jartti
- Department of Pediatrics and Adolescent Medicine, University of Oulu, Oulu, Finland
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Henrik Døllner
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Children's Clinic, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Kari Risnes
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Children's Clinic, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Mallet MC, Pedersen ESL, Makhoul R, Blanchon S, Hoyler K, Jochmann A, Latzin P, Moeller A, Regamey N, Goutaki M, Spycher BD, Kuehni CE. Phenotypes of cough in children: A latent class analysis. Clin Exp Allergy 2023; 53:1279-1290. [PMID: 37997173 DOI: 10.1111/cea.14416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 09/29/2023] [Accepted: 10/19/2023] [Indexed: 11/25/2023]
Abstract
INTRODUCTION Distinguishing phenotypes among children with cough helps understand underlying causes. Using a statistical data-driven approach, we aimed to identify and validate cough phenotypes based on measurable traits, physician diagnoses, and prognosis. METHODS We used data from the Swiss Paediatric Airway Cohort and included 531 children aged 5-16 years seen in outpatient clinics since 2017. We included children with any parent-reported cough (i.e. cough without a cold, cough at night, cough more than other children, or cough longer than 4 weeks) without current wheeze. We applied latent class analysis to identify phenotypes using nine symptoms and characteristics and selected the best model using the Akaike information criterion. We assigned children to the most likely phenotype and compared the resulting groups for parental atopy history, comorbidities, spirometry, fractional exhaled nitric oxide (FeNO), skin prick tests and specific IgE, physician diagnoses, and 1-year prognosis. RESULTS We identified four cough phenotypes: non-specific cough (26%); non-allergic infectious and night cough with snoring and otitis (4%); chronic allergic dry night cough with snoring (9%); and allergic non-infectious cough with rhino-conjunctivitis (61%). Children with the allergic phenotype often had family or personal history of atopy and asthma diagnosis. FeNO was highest for the allergic phenotype [median 17.9 parts per billion (ppb)] and lowest for the non-allergic infectious phenotype [median 7.0 parts per billion (ppb)]. Positive allergy test results differed across phenotypes (p < .001) and were most common among the allergic (70%) and least common among the non-specific cough (31%) phenotypes. Subsequent wheeze was more common among the allergic than the non-specific phenotype. CONCLUSION We identified four clinically relevant cough phenotypes with different prognoses. Although we excluded children with current wheeze, most children with cough belonged to allergy-related phenotypes.
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Affiliation(s)
- Maria Christina Mallet
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Eva S L Pedersen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Ronny Makhoul
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Sylvain Blanchon
- Pediatric Pulmonology and Cystic Fibrosis Unit, Service of Pediatrics, Department Woman-Mother-Child, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Karin Hoyler
- Kinderpneumologie Horgen, Private Practice for Pediatric Pneumology, Horgen, Switzerland
| | - Anja Jochmann
- Department of Paediatric Pulmonology, University Children's Hospital Basel, Basel, Switzerland
| | - Philipp Latzin
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Moeller
- Department of Respiratory Medicine, University Children's Hospital Zurich and Children's Research Centre, University of Zurich, Zurich, Switzerland
| | - Nicolas Regamey
- Division of Paediatric Pulmonology, Children's Hospital, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Myrofora Goutaki
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ben D Spycher
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Carlone G, Graziano G, Trotta D, Cafagno C, Aricò MO, Campodipietro G, Marabini C, Lizzi M, Fornaro M, Caselli D, Valletta E, Aricò M. Bronchiolitis 2021-2022 epidemic: multicentric analysis of the characteristics and treatment approach in 214 children from different areas in Italy. Eur J Pediatr 2023; 182:1921-1927. [PMID: 36807514 PMCID: PMC9943040 DOI: 10.1007/s00431-023-04853-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 02/23/2023]
Abstract
Bronchiolitis causes a remarkable number of hospitalizations; its epidemiology follows that of respiratory syncytial virus (RSV), its main pathogen. The aim of this study was to evaluate the presenting features, treatment approach, and impact of medical therapy in four pediatric hospitals in Italy. Data on infants < 24 months of age hospitalized with bronchiolitis in the 2021-2022 season were collected. Between October 2021 and February 2022, 214 children were admitted. Median hospital stay was 5 days; none of the patients died. The distribution of the presenting features is largely comparable in the 33 (15.8%) RSV-negative versus the 176 (84.2%) RSV-positive children; also, no difference was observed in medical therapy provided: duration of oxygen therapy, administration of steroid, and duration of hospital stay. Systemic steroids, inhalation, or antibiotic therapy were given to 34.6%, 79.4%, and 49.1% of children respectively. Of the 214 patients with bronchiolitis, only 19 (8.8%) were admitted to ICU. Conclusion: Our data suggest that, irrespective of treatments provided, RSV-positive and RSV-negative children had a similar clinical course. The results of our retrospective study further underline the need to improve adherence to existing guidelines on bronchiolitis treatment. What is Known: • Bronchiolitis is a common diseases with seasonal peak. The outcome is usually favorable but hospitalization and even ICU admission is not exceptional. What is New: • Children with RSV associated bronchiolitis do not have a different course and outcome. The analysis of the 2021-2022 cohort, following COVID pandemic peaking, did not show a different course and outcome. • Adherence to literature recommendation, i.e. to focus on oxygen and hydration therapy while avoiding unnecessary systemic therapy with steroid and antibiotics, should be improved.
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Affiliation(s)
- Giorgia Carlone
- grid.415245.30000 0001 2231 2265S. Spirito Hospital, Azienda Sanitaria Locale Pescara, Pescara, Italy
| | - Giusi Graziano
- grid.512242.2CORESEARCH (Center for Outcomes Research and Clinical Epidemiology), Pescara, Italy
| | - Daniela Trotta
- grid.415245.30000 0001 2231 2265S. Spirito Hospital, Azienda Sanitaria Locale Pescara, Pescara, Italy
| | - Claudio Cafagno
- grid.488556.2Pediatric Infectious Diseases, Children’s Hospital Giovanni XXIII, Azienda Ospedaliero Universitaria Consorziale Policlinico di Bari, Bari, Italy
| | - Melodie O. Aricò
- grid.415079.e0000 0004 1759 989XDepartment of Pediatrics, G. B. Morgagni - L. Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Giacomo Campodipietro
- grid.6292.f0000 0004 1757 1758School of Pediatrics, University of Bologna, Bologna, Italy
| | - Claudio Marabini
- Department of Pediatrics and Neonatology, Provincial General Hospital, ASUR Marche- Area Vasta 3, Macerata, Italy
| | - Mauro Lizzi
- grid.415245.30000 0001 2231 2265S. Spirito Hospital, Azienda Sanitaria Locale Pescara, Pescara, Italy ,grid.412451.70000 0001 2181 4941School of Pediatrics, University of Chieti, Chieti, Italy
| | - Martina Fornaro
- Department of Pediatrics and Neonatology, Provincial General Hospital, ASUR Marche- Area Vasta 3, Macerata, Italy
| | - Desiree Caselli
- grid.488556.2Pediatric Infectious Diseases, Children’s Hospital Giovanni XXIII, Azienda Ospedaliero Universitaria Consorziale Policlinico di Bari, Bari, Italy
| | - Enrico Valletta
- grid.415079.e0000 0004 1759 989XDepartment of Pediatrics, G. B. Morgagni - L. Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Maurizio Aricò
- S. Spirito Hospital, Azienda Sanitaria Locale Pescara, Pescara, Italy.
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Ichinose M, Obara T, Shibata M, Kagawa T, Sakama T, Takakura H, Hirai K, Furuya H, Kato M, Mochizuki H. Clinical application of a lung sound analysis in infants with respiratory syncytial virus acute bronchiolitis. Pediatr Int 2023; 65:e15605. [PMID: 37615369 DOI: 10.1111/ped.15605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/11/2023] [Accepted: 06/09/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Objective investigation of the characteristics of acute bronchiolitis in infants is important for its diagnosis and treatment. METHODS Lung sound data of 50 patients diagnosed with respiratory syncytial virus (RSV) acute bronchiolitis (m:f = 29:21, median of age 7 months), 20 patients with RSV acute respiratory tract infections without acute bronchiolitis (m:f = 10:10, 5 months) and 38 age-matched control infants (m:f = 23:15, 8 months) were analyzed using a conventional method and compared. Furthermore, the relationships between lung sound parameters and clinical symptoms (clinical score, length of hospital stay and SpO2 level) in the bronchiolitis and the non-bronchiolitis patients were examined. RESULTS Results of lung sound analysis showed that the inspiratory sound power of patients with RSV respiratory tract infections was low and the expiratory sound power was high compared with those of the controls. When the patients with RSV respiratory tract infections were divided into the bronchiolitis and non-bronchiolitis groups, the expiratory/inspiratory ratio of the bronchiolitis patients was greater than that of the non-bronchiolitis patients. There was no difference in the clinical symptoms, clinical score and length of hospital stay between the bronchiolitis and non-bronchiolitis patients, except for the SpO2 level on admission. CONCLUSION Lung sound analysis confirmed that patients with RSV acute bronchiolitis present with marked airway narrowing. Considering these results as a characteristic of acute bronchiolitis, it would be meaningful to reflect it in the improvement of diagnosis, treatment and subsequent management.
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Affiliation(s)
- Mami Ichinose
- Department of Pediatrics, Tokai University Hachioji Hospital, Hachioji, Japan
- Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
| | - Takeru Obara
- Department of Pediatrics, Tokai University Hachioji Hospital, Hachioji, Japan
- Department of Pediatrics, Tokai University School of Medicine, Isehara, Japan
| | - Mayuko Shibata
- Department of Pediatrics, Tokai University Hachioji Hospital, Hachioji, Japan
- Department of Pediatrics, Tokai University School of Medicine, Isehara, Japan
| | - Takanori Kagawa
- Department of Pediatrics, Tokai University Hachioji Hospital, Hachioji, Japan
- Department of Pediatrics, Tokai University School of Medicine, Isehara, Japan
| | - Takashi Sakama
- Department of Pediatrics, Tokai University Hachioji Hospital, Hachioji, Japan
- Department of Pediatrics, Tokai University School of Medicine, Isehara, Japan
| | - Hiromitsu Takakura
- Department of Pediatrics, Tokai University Hachioji Hospital, Hachioji, Japan
- Department of Pediatrics, Tokai University School of Medicine, Isehara, Japan
| | - Kota Hirai
- Department of Pediatrics, Tokai University Hachioji Hospital, Hachioji, Japan
- Department of Pediatrics, Tokai University School of Medicine, Isehara, Japan
| | - Hiroyuki Furuya
- Department of Basic Clinical Science and Public Health, Tokai University School of Medicine, Isehara, Japan
| | - Masahiko Kato
- Department of Pediatrics, Tokai University Hachioji Hospital, Hachioji, Japan
- Department of Pediatrics, Tokai University School of Medicine, Isehara, Japan
| | - Hiroyuki Mochizuki
- Department of Pediatrics, Tokai University Hachioji Hospital, Hachioji, Japan
- Department of Pediatrics, Tokai University School of Medicine, Isehara, Japan
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Korppi M. Eosinophil activity in infancy predicts the outcome of infant bronchiolitis. Pediatr Pulmonol 2022; 57:1348-1349. [PMID: 35224887 DOI: 10.1002/ppul.25871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/25/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Matti Korppi
- Center for Child Health Research, University of Tampere and University Hospital, Tampere, Finland
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Bottau P, Liotti L, Laderchi E, Palpacelli A, Calamelli E, Colombo C, Serra L, Cazzato S. Something Is Changing in Viral Infant Bronchiolitis Approach. Front Pediatr 2022; 10:865977. [PMID: 35498813 PMCID: PMC9047867 DOI: 10.3389/fped.2022.865977] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/23/2022] [Indexed: 11/13/2022] Open
Abstract
Acute Viral Bronchiolitis is one of the leading causes of hospitalization in the first 12-24 months of life. International guidelines on the management of bronchiolitis broadly agree in recommending a minimal therapeutic approach, not recommending the use of bronchodilators. Guidelines, generally, consider bronchiolitis as a "unique disease" and this runs the risk of not administering therapy in some patients who could benefit from the use of bronchodilators, for instance, in those who will develop asthma later in their life and face first episode in the age of bronchiolitis. Today, there is growing evidence that bronchiolitis is not a single illness but can have different "endotypes" and "phenotypes," based on age, personal or family history of atopy, etiology, and pathophysiological mechanism. There is evidence that some phenotypes of bronchiolitis are more strongly associated with asthma features and are linked to higher risk for asthma development. In these populations, possible use of bronchodilators might have a better impact. Age seems to be the main feature to suggest a good response to a bronchodilator-trial, because, among children > 6 months old with bronchiolitis, the presence of a subset of patients with virus-induced wheezing or the first episode of asthma is more likely. While waiting for new research to define the relationship between therapeutic options and different phenotypes, a bronchodilator-trial (using short-acting β2 agonists with metered-dose inhalers and valved holding chambers) seems appropriate in every child with bronchiolitis and age > 6 months.
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Affiliation(s)
- Paolo Bottau
- Pediatric and Neonatology Unit, Imola Hospital, Imola, Italy
| | - Lucia Liotti
- Pediatric Unit, Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
| | - Eleonora Laderchi
- Postgraduate School of Pediatrics, University of Bologna, Bologna, Italy
| | - Alessandra Palpacelli
- Pediatric Unit, Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
| | | | - Carlotta Colombo
- Postgraduate School of Pediatrics, University of Bologna, Bologna, Italy
| | - Laura Serra
- Pediatric and Neonatology Unit, Imola Hospital, Imola, Italy
| | - Salvatore Cazzato
- Pediatric Unit, Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
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