Use of POCUS for the assessment of dehydration in pediatric patients-a narrative review

In pediatric practice, POCUS (point-of-care ultrasound) has been mostly implemented to recognize lung conditions and pleural and pericardial effusions, but less to evaluate fluid depletion. The main aim of this review is to analyze the current literature on the assessment of dehydration in pediatric patients by using POCUS. The size of the inferior vena cava (IVC) and its change in diameter in response to respiration have been investigated as a tool to screen for hypovolemia. A dilated IVC with decreased collapsibility (< 50%) is a sign of increased right atrial pressure. On the contrary, a collapsed IVC may be indicative of hypovolemia. The IVC collapsibility index (cIVC) reflects the decrease in the diameter upon inspiration. Altogether the IVC diameter and collapsibility index can be easily determined, but their role in children has not been fully demonstrated, and an estimation of volume status solely by assessing the IVC should thus be interpreted with caution. The inferior vena cava/abdominal aorta (IVC/AO) ratio may be a suitable parameter to assess the volume status in pediatric patients even though there is a need to define age-based thresholds. A combination of vascular, lung, and cardiac POCUS could be a valuable supplementary tool in the assessment of dehydration in several clinical scenarios, enabling rapid identification of life-threatening primary etiologies and helping physicians avoid inappropriate therapeutic interventions.   Conclusion: POCUS can provide important information in the assessment of intravascular fluid status in emergency scenarios, but measurements may be confounded by a number of other clinical variables. The inclusion of lung and cardiac views may assist in better understanding the patient's physiology and etiology regarding volume status. What is Known: • In pediatric practice, POCUS (point-of-care ultrasound) has been mostly implemented to recognize lung conditions (like pneumonia and bronchiolitis) and pleural and pericardial effusions, but less to evaluate fluid depletion. • The size of the IVC (inferior vena cava) and its change in diameter in response to respiration have been studied as a possible screening tool to assess the volume status, predict fluid responsiveness, and assess potential intolerance to fluid loading. What is New: • The IVC diameter and collapsibility index can be easily assessed, but their role in predicting dehydration in pediatric age has not been fully demonstrated, and an estimation of volume status only by assessing the IVC should be interpreted carefully. • The IVC /AO(inferior vena cava/abdominal aorta) ratio may be a suitable parameter to assess the volume status in pediatric patients even though there is a need to define age-based thresholds. A combination of vascular, lung, and cardiac POCUS can be a valuable supplementary tool in the assessment of intravascular volume in several clinical scenarios.

Acute Pupillary Disorders in Children: A 10-Year Retrospective Study of 101 Patients

BACKGROUND

To date, no study has specifically examined children with acute-onset pupillary motility disorders (APMD). Especially in the Emergency Department (ED), it is crucial to distinguish benign and transient conditions from life-threatening or urgent conditions (UCs). The aim of the study is to describe the clinical characteristics of children with APMD and their association with an increased risk of UCs.

METHODS

We conducted a pediatric retrospective study of APMD referred to ED over a 10-year period. We described the characteristics in the overall sample and in two subgroups divided according to urgency of the underlying condition. Furthermore, we applied a logistic regression model to identify the variables predictive of LT condition.

RESULTS

We analyzed 101 patients. In 59.4%, the APMD was isolated. In patients with extra-ocular involvement, the most frequently associated features were altered consciousness, headache, and vomiting. Exposure to toxic agents was reported in 48.5%. Urgent conditions occurred significantly more frequently in older children, presenting bilateral APMD and/or other ocular or extra-ocular manifestations.

CONCLUSIONS

Our study shows that UCs most commonly occur in patients presenting with bilateral APMD and other associated features. In unilateral/isolated APMD ophthalmological examination, exclusion of toxic exposure and observation until resolution of symptoms should be recommended.

Aggregatibacter actinomycetemcomitans infection in a 15-year-old boy with pulmonary empyema: a case report and review of literature

BACKGROUND

Aggregatibacter actinomycetemcomitans (Aa), previously known as Actinobacillus actinomycetemcomitans, is a slow-growing Gram-negative coccobacillus, member of the HACEK group of bacteria colonizing oral flora. Besides causing infectious diseases in the oral cavity such as dental caries and periodontitis, it is responsible for severe extra-oral infections secondary to hematogenous spread or aspiration, such as endocarditis, soft tissue abscesses and osteomyelitis. The diagnosis depends on prolonged bacterial culture of biological material obtained through biopsy. Aa is susceptible to most antibiotics but complete eradication often requires a long term treatment.

CASE PRESENTATION

We report the case of a 15-year-old previously healthy boy diagnosed with both pulmonary empyema and subphrenic chest wall abscess caused by Aa. He was admitted to our Pediatric Emergency department for evaluation of a right mass associated with marked asthenia and dry cough. After radiological findings etiological diagnosis was made by culture of fluid drainage of pleural empyema. He started empirical antibiotic therapy with intravenous piperacillin/tazobactam, whose sensibility was confirmed by the antibiogram, then, for occurrance of hepatopathy it was switched to ciprofloxacin: the patient almost completely recovered after 6-month therapy.

CONCLUSIONS

Extra-oral infections caused by Aa are extremely rare, especially in children, and not well described yet. To our knowledge, there is only another similar case described in literature. However, the case described in our manuscript represents the only one presenting with pulmonary empyema without involvement of lung parenchyma in children. We also conducted a brief review of published cases of Aa infection in the pediatric population. This case report reminds us the importance of an accurate inspection of the oral cavity during the examination of pediatric patients.

Respective roles of non-pharmaceutical interventions in bronchiolitis outbreaks: an interrupted time-series analysis based on a multinational surveillance system

BACKGROUND

Bronchiolitis is a major source of morbimortality among young children worldwide. Non-pharmaceutical interventions (NPIs) implemented to reduce the spread of severe acute respiratory syndrome coronavirus 2 may have had an important impact on bronchiolitis outbreaks, as well as major societal consequences. Discriminating between their respective impacts would help define optimal public health strategies against bronchiolitis. We aimed to assess the respective impact of each NPI on bronchiolitis outbreaks in 14 European countries.

METHODS

We conducted a quasi-experimental interrupted time-series analysis based on a multicentre international study. All children diagnosed with bronchiolitis presenting to the paediatric emergency department of one of 27 centres from January 2018 to March 2021 were included. We assessed the association between each NPI and change in the bronchiolitis trend over time by seasonally adjusted multivariable quasi-Poisson regression modelling.

RESULTS

In total, 42 916 children were included. We observed an overall cumulative 78% (95% CI -100- -54%; p<0.0001) reduction in bronchiolitis cases following NPI implementation. The decrease varied between countries from -97% (95% CI -100- -47%; p=0.0005) to -36% (95% CI -79-7%; p=0.105). Full lockdown (incidence rate ratio (IRR) 0.21 (95% CI 0.14-0.30); p<0.001), secondary school closure (IRR 0.33 (95% CI 0.20-0.52); p<0.0001), wearing a mask indoors (IRR 0.49 (95% CI 0.25-0.94); p=0.034) and teleworking (IRR 0.55 (95% CI 0.31-0.97); p=0.038) were independently associated with reducing bronchiolitis.

CONCLUSIONS

Several NPIs were associated with a reduction of bronchiolitis outbreaks, including full lockdown, school closure, teleworking and facial masking. Some of these public health interventions may be considered to further reduce the global burden of bronchiolitis.

Are Lung Ultrasound Features More Severe in Children Diagnosed with Bronchiolitis after the COVID-19 Lockdown Period?

The non-pharmacological measures implemented during the SARS-CoV-2 pandemic disrupted the usual bronchiolitis seasonality. Some authors have speculated that, after the lock down period, there would be an increase in the number and severity of respiratory infections due to the re-introduction of respiratory viruses. We collected clinical, microbiological and lung ultrasound data using the classification of the Italian Society of Thoracic Ultrasound (ADET) in children with bronchiolitis during the pandemic compared to the pre-pandemic period, with the aim of assessing whether the epidemic of bronchiolitis during the pandemic was characterized by a more severe lung involvement documented by lung ultrasound. We enrolled 108 children with bronchiolitis (52 pre-pandemic and 56 COVID-19 period), with a median age of 1.74 months (interquartile range, IQR 1-3.68) and 39.8% were females. Rhinovirus detection and high-flow nasal cannula usage were both increased during the COVID-19 period, although overall need of hospitalization and pediatric intensive care unit admissions did not change during the two periods. Lung ultrasound scores were similar in the two cohorts evaluated. Conclusions: our study suggests that, despite changes in microbiology and treatments performed, lung ultrasound severity scores were similar, suggesting that that bronchiolitis during the pandemic period was no more severe than pre-pandemic period, despite children diagnosed during the pandemic had a higher, but it was not statistically significant, probably, due to small sample size, probability of being admitted.

Children at risk of domestic accidents when are locked up at home: the other side of COVID-19 outbreak lockdown

Background

We proposed to analyze thoroughly the impact of the COVID-19 lockdown (CL) in changes of profiles and in trend of the domestic accidents (DAs) in children.

Methods

This was a single experience, cross-sectional study conducted at the emergency department (ED) of III trauma center. We enrolled children under 18 years admitted to ED with a diagnosis of DAs comparing the CL period from 10^th March 2020 to 4^th May 2020 with the same period of the previous year,10^th March 2019 to 4^th May 2019.

Results

In CL period, the cumulative incidence of ED visits for DAs increased from 86.88 to 272.13 per 1,000 children and the cumulative incidence of hospitalizations for DAs increased from 409.72 to 534.48 per 1,000 children. We reported in CL a decrease in the severity of ED presentation assessed by proxy measures: the level of priority ED visits reduced by 67% in CL period (OR: 0.33; 95%CI 0.22–0.48; p < 0.001); the likelihood of delayed time of presentation to ED increased by 65% in case of domestic injuries occurring in CL period (OR: 1.65; 95% CI: 1.17–2.34; p = 0.004); the odds of transfer from other hospital decreased by 78% in CL (OR: 0.15–0.33; p < 0.001). Children were more at risk of poisoning (OR:3.35–106.11; p = 0.001), of body foreign ingestion (OR: 1.83–14.39; p = 0.002) and less at risk of animal bite trauma (OR:0.05–0.35; p < 0.001).

Conclusion

Although the need to stay home has made a decisive breakthrough on the spread of COVID-19, the experience from this study underlines how this preventive measure has also had a downside in term of increased cumulative incidence of ED visits and of hospitalizations for DA.

Prognostic Role of Lung Ultrasound in Children with Bronchiolitis: Multicentric Prospective Study

There is increasing recognition of the role of lung ultrasound (LUS) to assess bronchiolitis severity in children. However, available studies are limited to small, single-center cohorts. We aimed to assess a qualitative and quantitative LUS protocol to evaluate the course of bronchiolitis at diagnosis and during follow-up. This is a prospective, multicenter study. Children with bronchiolitis were stratified according to clinical severity and underwent four LUS evaluations at set intervals. LUS was classified according to four models: (1) positive/negative; (2) main LUS pattern (normal/interstitial/consolidative/mixed) (3) LUS score; (4) LUS score with cutoff. Two hundred and thirty-three children were enrolled. The baseline LUS was significantly associated with bronchiolitis severity, using both the qualitative (positive/negative LUS p < 0.001; consolidated/normal LUS pattern or mixed/normal LUS p < 0.001) and quantitative models (cutoff score > 9 p < 0.001; LUS mean score p < 0.001). During follow-up, all LUS results according to all LUS models improved (p < 0.001). Better cut off value was declared at a value of >9 points. Conclusions: Our study supports the role of a comprehensive qualitative and quantitative LUS protocol for the identification of severe cases of bronchiolitis and provides data on the evolution of lung aeration during follow-up.

One Year of Lung Ultrasound in Children with SARS-CoV-2 Admitted to a Tertiary Referral Children's Hospital: A Retrospective Study during 2020-2021

During the COVID-19 pandemic, the lung ultrasound (LU) turned out to be a pivotal tool to study the lung involvement in the adult population, but the same was not well evaluated in children. We detected the LU patterns through an integrated approach with clinical−laboratory features in children hospitalized for COVID-19 in relation to the temporal trend of the Italian epidemic. We conducted a retrospective study which took place at a pediatric tertiary hospital from 15 March 2020 to 15 March 2021. We compared the characteristics of the initial phase of the first COVID-19 year—in the spring and summer (15 March−30 September 2020)—and those of the second phase—in the autumn and winter (1 October 2020−15 March 2021). Twenty-eight patients were studied both in the first and in the second phase of the first COVID-19 year. The disease severity score (DSS) was significantly greater in the second phase (p = 0.015). In the second phase of the first COVID-19 year, we detected a more significant occurrence of the following LU features than in the first phase: the irregular pleural line (85.71% vs. 60.71%; p = 0.035), the B-lines (89.29% vs. 60%; p = 0.003) and the several but non-coalescent B-lines (89.29% vs. 60%; p = 0.003). The LU score correlated significantly with the DSS, with a moderate relationship (r = 0.51, p < 0.001). The combined clinical, laboratory and ultrasound approaches might be essential in the evaluation of pulmonary involvement in children affected by COVID-19 during different periods of the pandemic.

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.

Trend of hoverboard related injuries at a pediatric emergency department

INTRODUCTION

Understanding how the use of hoverboards (HBs) can affect a child's safety is crucial. We describe the characteristics of HB related injuries and provide key messages about child prevention when using these leisure devices.

METHODS

This was a retrospective study at an emergency department (ED) of a level-III-trauma center from 2016 to 2019. We tested the differences in children presenting for injury associated with HBs between 2016-2017 and 2018-2019 to better describe the temporal trend of the phenomenon.

RESULTS

The rate of Injury associated with HBs / Total injury per 1,000 increased from 0.84 in 2016 to 7.7 in 2017, and then there was a gradual decline. The likelihood of injury was more common in younger children, increasing by 17% with decreasing age in 2018-2019 compared with 2016-2017 (OR: 0.83; 95%CI: 0.71-0.97; p = 0.021). The occurrence of injury in the April-June period was over twice as common in 2018-2019 (OR: 2.05; 95%CI: 1.0-2.05; p = 0.05). Patients were over 4 times more likely to have injured the lower extremity during the 2018-2019 period rather than other body regions (OR: 4.58; 95%CI: 1.23-4.58; p = 0.02). The odds of the indoor injury were more than twice as high in 2018-2019 (OR: 2.04; 95%CI: 1.077-2.04; p = 0.03).

CONCLUSION

Despite a decrease in the frequency of HB related injuries after 2017, during the 2018-2019 period, the younger the children, the more they were exposed to injury risk, in addition to a greater occurrence of indoor injuries from HBs compared with 2016-2017. The enhancement of preventive measures is necessary to ensure child safety when using HBs.

Ten Years of Pediatric Lung Ultrasound: A Narrative Review

Lung diseases are the most common conditions in newborns, infants, and children and are also the primary cause of death in children younger than 5 years old. Traditionally, the lung was not thought to be a target for an ultrasound due to its inability to penetrate the gas-filled anatomical structures. With the deepening of knowledge on ultrasound in recent years, it is now known that the affected lung produces ultrasound artifacts resulting from the abnormal tissue/gas/tissue interface when ultrasound sound waves penetrate lung tissue. Over the years, the application of lung ultrasound (LUS) has changed and its main indications in the pediatric population have expanded. This review analyzed the studies on lung ultrasound in pediatrics, published from 2010 to 2020, with the aim of highlighting the usefulness of LUS in pediatrics. It also described the normal and abnormal appearances of the pediatric lung on ultrasound as well as the benefits, limitations, and possible future challenges of this modality.

Lung Ultrasound to Detect Pneumothorax in Children Evaluated for Acute Chest Pain in the Emergency Department: An Observational Pilot Study

BACKGROUND

Spontaneous pneumothorax is a relatively uncommon and poorly studied condition in children. While several protocols have been developed to evaluate the use of lung ultrasound for dyspneic adult patients in the emergency department, no specific guidelines are present for pediatric emergency physicians.

OBJECTIVES

We prospectively analyzed children with acute chest pain and clinical suspicion of pneumothorax evaluated at the pediatric emergency department.

METHODS

We consecutively enrolled children aged 5-17 years presenting to the pediatric emergency department with clinically suspected pneumothorax based on sudden onset of acute chest pain. After clinical examination, all children underwent lung ultrasound followed by chest X-ray (reference standard). We enrolled 77 children, of which 13 (16.9%) received a final diagnosis of pneumothorax.

RESULTS

The lung point had a sensitivity of 92.3% (95% CI 77.8-100) and a specificity of 100% (95% CI 94.4-100) for the detection of pneumothorax. The "barcode sign" had a sensitivity of 100% (95% CI 75.3-100) and a specificity of 100% (95% CI 94.4-100) for the detection of pneumothorax.

CONCLUSION

Lung ultrasound is highly accurate in detecting or excluding pneumothorax in children with acute chest pain evaluated in the pediatric emergency department. If pneumothorax is suspected, but the lung point is not visible, the barcode sign should always be sought as it could be a form of massive pneumothorax.

Point-of-Care Ultrasound Training Programs Across Italian Pediatric Residency Schools: A National Survey

INTRODUCTION

The role of point-of-care ultrasound (POCUS) in routine clinical practice is rapidly growing, whereas adult specialties have already included training programs regarding this topic; pediatric residency schools are still late on this topic, particularly in Italy.

METHODS

We performed an online anonymous survey to Italian residents. The online survey has been submitted to the resident representatives of each pediatric residency school in Italy by the Italian Observatory of Pediatric Residents; each representative in turn distributed it to the pediatric residents of his own school.

RESULTS

Three sixty-one residents responded to the survey. Only 7.8% of residents declared that in their residency school, an official training program on POCUS exists, although more than 95% of respondents declared that such a training would be of primary importance for their future practice. Most residents do not know how to use an ultrasound machine nor the differences between different probes.

CONCLUSIONS

Our results demonstrate that POCUS training is still missing in Italy. Given the growing number of evidences of the benefits from including POCUS in clinical practice and patient evaluation, efforts are needed to fill this gap, in Italy and, probably, in most European countries. Such a training will definitely help the new generation of pediatricians improve their curriculum and, therefore, child health.

Lung ultrasound in the diagnosis and monitoring of 30 children with coronavirus disease 2019

BACKGROUND

The coronavirus disease 2019 (COVID-19) has caused a new global pandemic and is responsible for millions of infections and thousands of deaths in the world. The lung ultrasound (LUS) is a noninvasive and easily repeatable tool and can be carried out by the pediatrician at the bedside of children with a consequent reduction in the risk of transmission of the virus.

OBJECTIVE

We hypothesized that ultrasound findings in these patients would (1) be associated with their disease severity and (2) change over time in alignment with clinical outcome.

METHODS

The study was made in the emergency department (ED) in a tertiary level pediatric hospital. All patients with swab-confirmed COVID-19 infection were subjected to a LUS within 6 h from admission and after 96 h.

RESULTS

Among a total of 30 children, 18 (60%) were males, 4 reported exertional dyspnea, and only 1 chest pain. The mean oxygen saturation was 98.8 ± 1.0% in ambient air in the ED and no patient needed oxygen therapy during hospitalization. Children with moderate disease presented more B line (p = .03). After 96 h, we had observed ultrasound abnormality only in 20% of the children. We found a statistically significant reduction in pleural irregularities (30% vs. 16.7; p = .001) and in B lines (50% vs. 20%; p = .008).

CONCLUSIONS

The LUS is a useful, feasible, and safe tool for the clinician to complement the clinical evaluation and to monitor the evolution of lung disease in children with COVID-19.

Lung Ultrasound in Congenital Cardiac Abnormality: ALCAPA

Anomalous origin of left coronary artery from the pulmonary artery (ALCAPA) is a life-threatening ischemic congenital cardiac disease, resulting in myocardial dysfunction and heart failure within the first year of life. The authors report the case of a 1-mo-old infant with a radiological diagnosis of pneumonia handled with point-of-care lung ultrasound (POCUS) due to the persistence of dyspnea, despite a week of antibiotic therapy. Lung ultrasound showed a non-univocal interpretation of the lesion and gave indication to the second level instrumental diagnostics that confirmed the presence of ALCAPA. There is no case of lung ultrasound aiding to the early diagnosis of ALCAPA and no indirect ecographic signs of ALCAPA that have been described in literature yet.

Impact of the COVID-19 pandemic on the Emergency Department of a tertiary children's hospital

BACKGROUND

Italy was the first country in Europe affected by COVID-19: the emergency started on February 20, 2020, culminating with national lockdown on March 11, which terminated on May 4, 2020. We describe how the pandemic affected Emergency Department (ED) accesses in a tertiary children's hospital, composed by two different pediatric centers, one located in Rome's city center and the second, Palidoro (regional COVID-19 center), in its surrounding metropolitan area, both in the Lazio region, analyzing the profile of admitted patients during the pandemic period in terms of their general characteristics (at presentation in the ED's) and urgent hospitalizations compared to prepandemic period.

METHODS

The study compare the period between the 21st of February and the 30th of April 2020, covering the three phases of the national responses (this period will be referred to as the pandemic period) with the same period of 2019 (prepandemic period). The study analyzes the number of ED visits and urgent hospitalizations and their distribution according to selected characteristics.

RESULTS

The reduction of ED visits was 56 and 62%, respectively in Rome and Palidoro centers. The higher relative decline was encountered for Diseases of Respiratory System, and for Diseases of the Nervous System and Sense Organs. A doubling of the relative frequency of hospitalizations was observed, going from 14.2 to 24.4% in Rome and from 6.4 to 10.3% in Palidoro. In terms of absolute daily numbers the decrease of urgent hospitalizations was less sharp than ED visits. For pathologies such as peritonitis, tumors or other possible life-treathening conditions we did not observe a significative increase due to delayed access.

CONCLUSIONS

In the pandemic period there was a general reduction in the number of children referred to ED, such reduction was greater in low-acuity levels. The reduction for respiratory tract infections and other communicable diseases during school closure and the national lockdown must make us reflect on the possible impact that these conditions may have on the health system, in particular the ED, at the reopening of schools. The major problem remains the fear for possible diagnostic delays in life-threatening or crippling diseases; our study doesn't demonstrate an increase in number or significant delay in some serious conditions such as tumors, peritonitis, diabetic ketoacidosis, ileo-colic intussusception and testis/ovary torsion. A continuous, deep re-organizational process step by step of the ED is nececessary in the present and upcoming pandemic situation.

Lung Ultrasound Pattern in Healthy Infants During the First 6 Months of Life

OBJECTIVES

Lung ultrasound (LUS) has gained a primary role in the diagnosis and management of pleuropulmonary disorders in pediatric practice. However, normal and pathologic patterns are translated from adult studies and have never been specifically studied in children, particularly in infants. This was a prospective observational pilot study aiming to define the normal LUS pattern in healthy infants during the first 6 months of life.

METHODS

We recruited healthy neonates at 7 to 10 days of life, and these were followed until the sixth month of life (times: 7-10 days, 1 month, 3 months, and 6 months). We excluded neonates with a gestational age before 33 weeks and neonates with cardiac or lung abnormalities or diseases, immune deficiencies, metabolic or genetic conditions, and acute or chronic respiratory diseases. A LUS evaluation was performed by a single certified pediatrician. The chest wall was examined in 18 areas, addressing A-lines, short and long B-lines, pleural abnormalities, and subpleural consolidations.

RESULTS

Thirty-seven neonates were enrolled and followed until the sixth month of life, 27 (73%) of whom were born at term (≥37 weeks) and 10 (27%) of whom were born preterm (33-36 weeks). Most of the patients at 7 to 10 days showed multiple B-lines (long and short) with a progressive normalization toward a normal A pattern at 6 months (P < .00001; 95% confidence interval, 13.75-23.24). No infants showed subpleural consolidations or pleural abnormalities.

CONCLUSIONS

This study has implications for the interpretation of LUS during the first 6 months of life. Most healthy infants show a diffuse pattern of vertical artifacts (B-lines), and the LUS pattern tends to be similar to the physiologic pattern (A-lines) after the sixth month of life. The only pathologic LUS findings were pleural irregularities and effusion and subpleural consolidations, which have never been described in healthy infants.

COVID-19 in 17 Italian Pediatric Emergency Departments

BACKGROUND

Variability in presentation of children with coronavirus disease 2019 (COVID-19) is a challenge in emergency departments (EDs) in terms of early recognition, which has an effect on disease control and prevention. We describe a cohort of 170 children with COVID-19 and differences with the published cohorts.

METHODS

Retrospective chart reviews on children (0-18 years) evaluated in 17 Italian pediatric EDs.

RESULTS

In our cohort (median age of 45 months; interquartile range of 4 months-10.7 years), we found a high number of patients <1 year with COVID-19 disease. The exposure happened mainly (59%) outside family clusters; 22% had comorbidities. Children were more frequently asymptomatic (17%) or with mild diseases (63%). Common symptoms were cough (43%) and difficulty feeding (35%). Chest computed tomography, chest radiograph, and point-of-care lung ultrasound were used in 2%, 36%, and 8% of cases, respectively. Forty-three percent of patients were admitted because of their clinical conditions. The minimal use of computed tomography and chest radiograph may have led to a reduced identification of moderate cases, which may have been clinically classified as mild cases.

CONCLUSIONS

Italian children evaluated in the ED infrequently have notable disease symptoms. For pediatrics, COVID-19 may have rare but serious and life-threatening presentations but, in the majority of cases, represents an organizational burden for the ED. These data should not lower the attention to and preparedness for COVID-19 disease because children may represent a source of viral transmission. A clinically driven classification, instead of a radiologic, could be more valuable in predicting patient needs and better allocating resources.

Lung ultrasound findings in pediatric community-acquired pneumonia requiring surgical procedures: a two-center prospective study

BACKGROUND

Lung ultrasound (US) in the evaluation of suspected pediatric pneumonia is increasingly used and has a recognized role in evaluating pleural effusions, although there are no detailed studies specifically addressing its use in the pediatric population.

OBJECTIVES

To define lung US findings of severe pediatric community-acquired pneumonia that required surgical procedures during admission.

MATERIALS AND METHODS

Our prospective case-control study compared lung US findings in patients ages 1 month to 17 years admitted with community-acquired pneumonia that required surgical procedures from findings those who did not. Lung US was performed at admission and always before surgical procedures. Medical treatment, laboratory and microbiological findings, chest X-ray, computed tomography scan and surgical procedures are described.

RESULTS

One hundred twenty-one children with community-acquired pneumonia were included; of these, 23 underwent surgical intervention. Compared with the control group, children requiring a surgical procedure had a significantly higher rate of large consolidations (52.2%; 95% confidence interval [CI]: 30.6% to 73.2%), larger and complicated pleural effusions (100%; 95% CI: 85.2% to 100%), and both liquid and air bronchograms (73.9%; 95% CI: 51.6% to 89.8%).

CONCLUSION

Larger consolidations, larger and more complicated pleural effusions, and liquid and air bronchograms were associated with surgical treatment.

Lung Ultrasound in Children with COVID-19: Preliminary Findings

Recent evidence indicates the usefulness of lung ultrasound (LUS) in detecting coronavirus disease 19 (COVID-19) pneumonia. However, no data are available on the use of LUS in children with COVID-19 pneumonia. In this report, we describe LUS features of 10 consecutively admitted children with COVID-19 in two tertiary-level pediatric hospitals in Rome. LUS revealed signs of lung involvement during COVID-19 infection. In particular, vertical artifacts (70%), pleural irregularities (60%), areas of white lung (10%) and subpleural consolidations (10%) were the main findings in patients with COVID-19. No cases of pleural effusions were found. According to our experience, the routine use of LUS in the evaluation of children with suspected or confirmed COVID-19, when performed by clinicians with documented experience in LUS, was useful in diagnosing and monitoring pediatric COVID-19 pneumonia, reducing unnecessary radiation/sedation in children and exposure of health care workers to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Characteristic of COVID-19 infection in pediatric patients: early findings from two Italian Pediatric Research Networks

Detailed data on clinical presentations and outcomes of children with COVID-19 in Europe are still lacking. In this descriptive study, we report on 130 children with confirmed COVID-19 diagnosed by 28 centers (mostly hospitals), in 10 regions in Italy, during the first months of the pandemic. Among these, 67 (51.5%) had a relative with COVID-19 while 34 (26.2%) had comorbidities, with the most frequent being respiratory, cardiac, or neuromuscular chronic diseases. Overall, 98 (75.4%) had an asymptomatic or mild disease, 11 (8.5%) had moderate disease, 11 (8.5%) had a severe disease, and 9 (6.9%) had a critical presentation with infants below 6 months having significantly increased risk of critical disease severity (OR 5.6, 95% CI 1.3 to 29.1). Seventy-five (57.7%) children were hospitalized, 15 (11.5%) needed some respiratory support, and nine (6.9%) were treated in an intensive care unit. All recovered.Conclusion:This descriptive case series of children with COVID-19, mostly encompassing of cases enrolled at hospital level, suggest that COVID-19 may have a non-negligible rate of severe presentations in selected pediatric populations with a relatively high rates of comorbidities. More studies are needed to further understand the presentation and outcomes of children with COVID-19 in children with special needs. What is Known: • There is limited evidence on the clinical presentation and outcomes of children with COVID-19 in Europe, and almost no evidence on characteristics and risk factors of severe cases. What is New: • Among a case series of 130 children, mostly diagnosed at hospital level, and with a relatively high rate (26.2%) of comorbidities, about three-quarter had an asymptomatic or mild disease. • However, 57.7% were hospitalized, 11.5% needed some respiratory support, and 6.9% were treated in an intensive care unit.

The Use of Lung Ultrasound to Monitor the Antibiotic Response of Community-Acquired Pneumonia in Children: A Preliminary Hypothesis

Community-acquired pneumonia (CAP) is associated with high morbidity and mortality among children worldwide. Over the last 10 years, lung ultrasound (US) has been widely studied as an alternative diagnostic tool for adult and pediatric CAP with excellent results. In this case series, we describe clinical and laboratory results as well as detailed lung US findings in 6 children with CAP, showing the potential use of lung US in monitoring the response to antibiotic therapy.

Lung ultrasound features of children with complicated and noncomplicated community acquired pneumonia: A prospective study

OBJECTIVE

The purpose of this study was to describe lung ultrasound (LUS) findings at baseline and 48 hours after the beginning of treatment and evaluate how they correlate with outcome DESIGN: We prospectively analyzed patients from 1 month to 17 years of age with community acquired pneumonia (CAP) evaluated at a tertiary level pediatric hospital. At baseline and 48 hours after the beginning of treatment, history, clinical examination, laboratory testing, chest X-ray, and LUS were performed.

RESULTS

One hundred one children were enrolled in the study (13 with complicated CAP). At baseline those who developed complications presented a larger size of the subpleural pulmonary parenchymal lesions (P = .001) often associated with a complex pleural effusion (63.6%, P = .013). Those with an uncomplicated CAP presented an air, arboriform, superficial and dynamic bronchogram, as opposed to complicated CAP which had an air and liquid bronchogram, deep, fixed (P = .001). At the 48-hour control in the noncomplicated CAP group, bronchogram was more frequently superficial and dynamic (P = .050). Pleural effusion disappeared in half cases (P = .050). In all patients, neutrophilic leucocytosis with increased C-reactive protein was detected and decreased at control (P = .001). The linear regression analyses showed the switch from a deep to a superficial bronchogram as the only explanatory variable (r = 0.97, R²  = 0.94, P = .001, t = 10.73).

CONCLUSIONS

Our study describe early LUS features of CAP that might be able to predict the development of complicated CAP.

Lung ultrasound in infants with bronchiolitis

Lung ultrasound (LUS) is nowadays a fast-growing field of study since the technique has been widely acknowledged as a cost-effective, radiation free, and ready available alternative to standard X-ray imaging. However, despite extensive acoustic characterization studies and documented medical evidences, a lot is still unknown about how ultrasounds interact with lung tissue. One of the most discussed lung artifacts are the B-lines [in all ages] and the subpleural consolidations (in young infants). Recently, LUS has been claimed to be able to detect pneumonia in infants with bronchiolitis, although this can be an overestimation due to the peculiar physiology of small peripheral airways of the pediatric lung (particularly in neonate/infants). Distinguishing consolidations from atelectasis in young infants with bronchiolitis can be challenging and those criteria well defined for adults and older children (size and bronchogram) cannot easily translated in this specific subset. Therefore, if decades of studies clearly defined the low risk of SBI in bronchiolitis, we need to be careful before stating that LUS may confirm pneumonia in such a high number of cases and, importantly, new and promising techniques such as LUS should give us new insights bringing us to improvements and not back to overuse of antibiotics. More studies are surely need on this topic.

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.

Point-of-Care Ultrasound for the Diagnosis of Skull Fractures in Children Younger Than Two Years of Age

OBJECTIVES

To determine the accuracy of skull point-of-care ultrasound (POCUS) for identifying fractures in children younger than 2 years of age with signs of head trauma, and the ability of POCUS to identify the type and depth of fracture depression.

STUDY DESIGN

This was a multicenter, prospective, observational study of children younger than 2 years of age with nontrivial mechanisms of injury and signs of scalp/skull trauma. Patients were enrolled if they underwent computed tomography (CT). Patients underwent clinical evaluation, in addition to a cranial POCUS in the emergency department (ED). From the POCUS examinations, we documented whether fractures were present or absent, their location, characteristics, and depth. POCUS and CT findings were compared to calculate the diagnostic accuracy.

RESULTS

We enrolled a convenience sample of 115 of 151 (76.1%) eligible patients. Of the 115 enrolled, 88 (76.5%) had skull fractures. POCUS had a sensitivity of 80 of 88 (90.9%; 95% CI 82.9-96.0) and a specificity of 23 of 27 (85.2%; 95% CI 66.3-95.8) for identifying skull fractures. Agreement between POCUS and CT to identify the type of fracture as linear, depressed, or complex was 84.4% (97 of 115) with a kappa of 0.75 (95% CI 0.70-0.84).

CONCLUSIONS

POCUS performed by emergency physicians may identify the type and depth of fractures in infants with local physical signs of head trauma with substantial accuracy. Emergency physicians should consider POCUS as an adjunct to clinical evaluation and prediction rules for traumatic brain injuries in children younger than 2 years of age.

Repeated vaccinations do not improve specific immune defenses against Hepatitis B in non-responder health care workers

Hepatitis B is a major infectious occupational hazard for health care workers and can be prevented with a safe and effective vaccine. The serum titer of anti-HBsAg antibodies is the most commonly used correlate of protection and post-vaccination anti-HBsAg concentrations of ≥ 10 mIU/ml are considered protective. Subjects with post-vaccination anti-HBsAg titers of <10 mIU/ml 1-6 months post-vaccination, who tested negative for HBsAg and anti-HBc, are defined as non-responders. The question of whether non-responders should be repeatedly vaccinated is still open. The aim of the study was to (i) evaluate the distribution of lymphocyte subpopulations and the percentage of HBsAg-specific memory B cells in responders and non-responders (ii) assess whether non-responders can be induced to produce antibodies after administration of a booster dose of vaccine (iii) determine whether booster vaccination increases the number of specific memory B cells in non-responders. Combining flow-cytometry, ELISPOT and serology we tested the integrity and function of the immune system in 24 health care workers, confirmed to be non-responders after at least three vaccine injections. We compared the results with those obtained in 21 responders working in the same institution. We found that the great majority of the non-responders had a functional immune system and a preserved ability to respond to other conventional antigens. Our most important findings are that the frequency of HBsAg-specific memory B cells is comparable in non-responders and controls and that booster immunization does not lead either to antibody production or memory B cell increase in non-responders.

Familial recurrence of nonsyndromic interrupted aortic arch and truncus arteriosus with atrioventricular canal

BACKGROUND

Multifactorial inheritance is probably involved in most cases of nonsyndromic conotruncal heart defects (CHDs), but Mendelian transmission is often suspected.

RESULTS

We report on a family with recurrence of nonsyndromic CTHD in two double first cousins; i.e., two brothers married two sisters. One of the cousins (case 1) had interrupted aortic arch (IAA) type B, while the other one (case 2) had truncus arteriosus (TA) with atrioventricular canal defect (AVCD).

CONCLUSIONS

Our family further supports monogenic inheritance of CTHDs. In addition, the presence of TA associated with AVCD in one of the patients confirms the higher occurrence of CTHD in families with complex TA. The absence of 22q11 microdeletion (del22q11) in our patients, as in several literature reports of familial CTHDs, supports the existence of genes different to those located on chromosome 22q11 which could be implicated in the pathogenesis of CTHDs.

Echocardiographic diagnosis of totally anomalous pulmonary venous connection to the azygos vein

Totally anomalous pulmonary venous connection to the azygos vein is a rare congenital heart malformation in which all the pulmonary venous blood returns anomalously to the azygos vein. Among 111 consecutive patients with totally anomalous pulmonary venous connection undergoing surgical correction at our institution between June 1982 and September 1997, this malformation was present in seven cases. By echocardiography, using a subxyphoid short-axis view at the atrial level and a modified suprasternal sagittal view, the malformation was diagnosed when the pulmonary venous confluence was traced posteriorly and superiorly relative to the right pulmonary artery and right bronchus, finally reaching reach the superior caval vein. Totally anomalous pulmonary venous connection to the azygos vein was misdiagnosed in the first two patients, both by echocardiography and angiocardiography. In the subsequent five patients, a precise diagnosis was obtained by echocardiography. Echocardiography, therefore, can be considered an accurate diagnostic tool permitting recognition of totally anomalous pulmonary venous connection to the azygos vein, and permitting corrective surgery without recourse to catheterization and angiography.