Quality and Characteristics of Pediatric Rheumatology Content on Social Media: Toward a New Era of Education for Patients and Caregivers?

Social media platforms are an extremely common form of online interaction, with more than 4.5 billion users worldwide in 2022. According to Statista.com, there is a significant expectation that this usage will exceed 6 billion by the year 2027.

Potential Predictors of Long COVID in Italian Children: A Cross-Sectional Survey

BACKGROUND

Identifying predictive factors of long COVID syndrome (LCS) is essential to preventing and managing this condition. We investigated the prevalence, symptoms, and risk factors of LCS in a cohort of Italian children and adolescents.

METHODS

We carried out a cross-sectional survey on demographic characteristics and clinical data related to COVID-19 phase and LCS in a cohort of children and adolescents, sending a questionnaire by using the PEDIATOTEM platform.

RESULTS

The prevalence of LCS was 25% (99/396). The most frequent symptoms of LCS included nasal congestion, diarrhea, headache, and fatigue. We found no association between demographic data (gender, age, and ethnicity) and LCS. Additionally, we showed that patients with concurrent allergic rhinitis, atopic dermatitis, respiratory disease, gastrointestinal disease, and rheumatologic disease had a higher risk of LCS than patients without those comorbidities. Patients experiencing fatigue, muscle, and abdominal pain in COVID-19 showed a higher risk of LCS than patients complaining of other symptoms. We found no association between vaccination and LCS.

CONCLUSIONS

Specific comorbidities or symptoms during acute illness were identified as being risk factors for LCS. Understanding which are the risk factors for LCS could yield a clearer picture of its pathogenesis.

Lung function assessment in children with Long-Covid syndrome

INTRODUCTION

A significant percentage of patients who survived the Coronavirus Infection Disease 2019 (COVID-19) showed persistent general and respiratory symptoms even months after recovery. This condition, called Post-Acute Sequelae of COVID-19 or Long-Covid syndrome (LCS), has been described also in children with positive history for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Little is known about the pathophysiologic mechanisms underlying this syndrome. The aim of this study was to investigate any difference between children with LCS and asymptomatic peers with previous COVID-19 in terms of lung function and lung ultrasound (LUS) patterns. Secondly, we tested associations between lung function abnormalities and LUS findings with Long-Covid.

METHODS

We carried out a prospective, descriptive, observational study including 58 children aged 5-17 years: 28 with LCS compared to 30 asymptomatic children with previous COVID-19. We collected demographic data, history of asthma, allergy or smoke exposure, and acute COVID-19 symptoms. After a median period of 4.5 months (1%-95% range 2-21) since the infection, lung function was assessed by spirometry, body plethysmography, diffusion lung capacity for carbon monoxide (DLCO). Airways inflammation was investigated by fractional exhaled nitric oxide (FeNO). LUS was performed independently by two experienced clinicians.

RESULTS

We found that children with LCS were older than controls (mean (SD) 12 (4.1) vs. 9.7 (2.6); p = .04). Children with LCS complained more frequently fatigue (46.4%), cough (17.9%), exercise intolerance (14.3%) and dyspnea (14.3%). Lung function was normal and similar between the two groups. The frequency of LUS abnormalities was similar between the two groups (43.3% children with LCS vs. 56.7% controls; p = .436). Children with LCS showed lower FeNO values (log difference -0.30 (CI 95% -0.50, -0.10)), but no association of LCS with a lower lung function and abnormal LUS findings was found.

CONCLUSIONS

LCS seems to be more frequent in older age children. Lung functional and structural abnormalities were not different between children with LCS and asymptomatic subjects with previous COVID-19. In addition, children with LCS showed lower FeNO values than controls, suggesting its potential role as a marker in LCS. However, further and larger studies are needed to confirm our findings.

Serum calprotectin and joint ultrasound in the definition of disease relapse in non-systemic juvenile idiopathic arthritis: a prospective longitudinal study

OBJECTIVES

The aim of our study was to investigate the role of serum calprotectin (SC) and muscle-skeletal ultrasound (MSUS) as predictive markers of relapse in patients with juvenile idiopathic arthritis (JIA).

METHODS

Sixty non-systemic (ns) JIA patients in clinical remission were recruited to evaluate the risk of disease relapse. SC levels and JIA disease activity were assessed at every visit (3, 6, 12 and 18 months). Joint synovitis, characterised by both synovial effusion (SE) and synovial hyperplasia (SH), was measured by US score (sum of SE, SH, power Doppler and bone erosions) given to each examined joint and US ratio (US score/number of joints examined) at every visit. Associations of SC, US score and US ratio with relapse prevalence was studied longitudinally by using generalised estimating equations model.

RESULTS

Thirty-one (51.6%) patients relapsed within 18 months. Patients with higher baseline US scores showed higher risk of relapse at 6 months (OR (95% confidence interval (CI)): 1.96 (1.09-3.52)). Additionally, patients with higher SC values at baseline showed higher risk of relapse at 18 months (1.66 (1.13-2.44)). Patients with higher baseline SC values showed an increased overall odds of relapse up to 18 months of follow-up (1.21 (1.08-1.36)). Furthermore, patients with higher US scores showed an increased overall odds of relapse up to 18 months of follow-up (1.96 (1.56-2.46)). Similarly, patients with higher US ratio showed an increased overall odds of relapse up to 18 months of follow-up (16.62 (7.17-38.54)).

CONCLUSIONS

SC was able to identify JIA patients with unstable remission and increased risk of relapse. MSUS represents an interesting additional tool to the clinical evaluation, especially in predicting early relapse.

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) Syndrome: A 10-Year Retrospective Cohort Study in an Italian Centre of Pediatric Rheumatology

BACKGROUND

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) syndrome is a rare pediatric disorder consisting of a sudden onset of obsessive-compulsive disorder (OCD) and/or tics after a group A Streptococcus (GAS) infection.

METHODS

In the period between 2013 and 2023, 61 children presented to our Pediatric Rheumatology unit with a suspicion of PANDAS syndrome. Among these, a retrospective analysis was conducted, and 19 fulfilled the current classification criteria and were included in this study.

RESULTS

The male-to-female ratio was 14:5, the median age at onset was 7.0 (2.0-9.5) years, and the median age at diagnosis was 8.0 (3.0-10.4) years. The median follow-up period was 16.0 (6.0-72.0) months. Family and personal history were relevant in 7/19 and 6/19 patients. Tics were present in all patients. Details for motor tics were retrospectively available in 18/19 patients, with the eyes (11/18) and neck/head (10/18) being most often involved. Vocal tics were documented in 8/19, behavioral changes in 10/19, and OCD in 2/19. Regarding the therapeutic response, all patients responded to amoxicillin, 12/13 to benzathine benzylpenicillin, and 7/9 to azithromycin.

CONCLUSIONS

Our findings partially overlap with previous reports. Larger prospective studies are needed to improve treatment strategies and classification criteria.

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS): Myth or Reality? The State of the Art on a Controversial Disease

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) syndrome is one of the most controversial diseases in pediatric rheumatology. Despite first being described more than 25 years ago as the sudden and rapid onset of obsessive-compulsive disorder (OCD) and/or tic disorder symptoms as complications of a Group A beta-hemolytic Streptococcus (GAS) infection, precise epidemiological data are still lacking, and there are no strong recommendations for its treatment. Recent advances in the comprehension of PANDAS pathophysiology are largely attributable to animal model studies and the understanding of the roles of Ca++/calmodulin-dependent protein kinase (CaM kinase) II, disrupted dopamine release in the basal ganglia, and striatal cholinergic interneurons. The diagnosis of PANDAS should be made after an exclusion process and should include prepubescent children with a sudden onset of OCD and/or a tic disorder, with a relapsing/remitting disease course, a clear temporal association between GAS infection and onset or exacerbation of symptoms, and the association with other neurological abnormalities such as motoric hyperactivity and choreiform movements. Antibiotic medications are the primary therapeutic modality. Nonetheless, there is a paucity of randomized studies and validated data, resulting in a scarcity of solid recommendations.

Longitudinal prospective anthropometric evaluation in Caucasian prepubertal children with lactose intolerance

Introduction

The health consequences of lactose intolerance remain unclear. We studied the association of lactose intolerance with growth in children.

Methods

In this prospective case-control study, we compared Caucasian prepubertal children with lactose intolerance (LI) [n = 30, median age = 7.87 years (3.00-12.75)] to healthy controls [(n = 75, median age = 2.25 years (2.00-7.25)]. A lactose tolerance test was performed for lactose intolerance diagnosis. The gastrointestinal symptom score was administered at baseline and after a lactose-free diet for a median period of 9.0 months [range 5%-95% (6.0-24.0)]. The anthropometric parameters were measured at baseline and follow-up. All the anthropometric data were converted into standard deviation scores (SDS). A linear regression model was used to investigate the association of lactose intolerance with growth parameters.

Results

We found no difference in height velocity SDS between the LI and control groups [SDS difference (95% CI): 0.52 (-1.86 to 2.90)]. In addition, we found a significant reduction in the clinical score of the LI group after a lactose-free diet [median (5%-95%): 7.5 (4.0-15.0) and 3 (0.0-8.0); p-value <0.001].

Conclusions

The LI group exhibited no difference in height velocity compared with the control group. Nonetheless, due to the small sample size, the results on the anthropometric profile of the LI group require careful interpretation. More large-scale studies in the pediatric population are required to better understand the association of LI with anthropometric and metabolic profiles.

Long COVID in Children: A Multidisciplinary Review

Long COVID syndrome has emerged as a long-lasting consequence of acute SARS-CoV-2 infection in adults. In addition, children may be affected by Long COVID, with potential clinical issues in different fields, including problems in school performance and daily activities. Yet, the pathophysiologic bases of Long COVID in children are largely unknown, and it is difficult to predict who will develop the syndrome. In this multidisciplinary clinical review, we summarise the latest scientific data regarding Long COVID and its impact on children. Special attention is given to diagnostic tests, in order to help the physicians to find potential disease markers and quantify impairment. Specifically, we assess the respiratory, upper airways, cardiac, neurologic and motor and psychological aspects. Finally, we also propose a multidisciplinary clinical approach.

Drug-Induced Enterocolitis Syndrome in Children

Drug-Induced Enterocolitis Syndrome (DIES) is a drug-induced hypersensitivity reaction non-IgE mediated involving the gastrointestinal system that occurs 2 to 4 h after drug administration. Antibiotics, specifically amoxicillin or amoxicillin/clavulanate, represent the most frequent drugs involved. Symptoms include nausea, vomiting, abdominal pain, diarrhea, pallor, lethargy, and dehydration, which can be severe and result in hypovolemic shock. The main laboratory finding is neutrophilic leukocytosis. To the best of our knowledge, 12 cases of DIES (9 children-onset and 3 adult-onset cases) were described in the literature. DIES is a rare clinically well-described allergic disease; however, the pathogenetic mechanism is still unclear. It requires to be recognized early and correctly treated by physicians.

The Role of Nasal Cytology and Serum Atopic Biomarkers in Paediatric Rhinitis

A Nasal Provocation Test allows the differentiation of allergic and non-allergic rhinitis, but it is difficult and expensive. Therefore, nasal cytology is taking hold as an alternative. We carried out a cross-sectional study, including 29 patients with persistent rhinitis according to ARIA definition and negative skin prick tests. Nasal symptoms were scored from 0 to 5 using a visual analogue scale, and patients underwent blood tests to investigate blood cell count (particularly eosinophilia and basophilia), to analyze serum total and specific IgE and eosinophil cationic protein (ECP), and to perform nasal cytology. We performed a univariate logistical analysis to evaluate the association between total serum IgE, serum eosinophilia, basophils, and ECP and the presence of eosinophils in the nasal mucosa, and a multivariate logistic model in order to weight the single variable on the presence of eosinophils to level of the nasal mucosa. A statistically significant association between serum total IgE levels and the severity of nasal eosinophilic inflammation was found (confidence interval C.I. 1.08-4.65, odds ratio OR 2.24, p value 0.03). For this reason, we imagine a therapeutic trial with nasal steroids and oral antihistamines in patients with suspected LAR and increased total IgE levels, reserving nasal cytology and NPT to non-responders to the first-line therapy.

Case report: Increased troponin level in 125 children during COVID-19

Introduction

Increase in cardiac biomarkers during Coronavirus disease 2019 (COVID-19) was frequent regardless of the presence of myocarditis and multisystem inflammatory syndrome in children (MIS-C). Several studies described MIS-C, but few papers evaluated cardiac manifestations in children with SARS-CoV-2 infection without MIS-C and investigated the role of troponin in absence of electrocardiogram (ECG) and echocardiographic alterations. The aim of this case series is to describe the cardiac manifestations during COVID-19 in children, trying to explain the meaning of laboratory findings during COVID-19, especially of increased troponin.

Materials and methods

We conducted a retrospective case series of children aged <18 years admitted at the Department of Pediatrics, University of Chieti, for SARS-CoV-2 infection between 1st March 2020 and 31th July 2022. All patients with documented SARS-CoV-2 infection underwent a laboratory evaluation at admission. Children with increased troponin I and/or BNP underwent electrocardiographic and echocardiographic exams.

Results

125 children were admitted for SARS-CoV-2 infection to our Department of Pediatrics, of whom 17 (13.6% of cases) with different patterns of cardiac involvement. Specifically, 5 subjects (4.0% of admitted children) were diagnosed as MIS-C and 12 children (9.6%) manifested a cardiac involvement in terms of increased troponin with or without ECG and echocardiography anomalies. Troponin, C-reactive protein, procalcitonin and BNP values resulted higher in patients with MIS-C compared to patients without MIS-C. Furthermore, patients with MIS-C had higher neutrophils and lower lymphocytes compared to patients without MIS-C. ECG abnormalities were found in 4/5 patients with MIS-C and in 2/12 patients without MIS-C. Echocardiographic anomalies were found in all patients with MIS-C, especially in terms of valve regurgitation and ejection fraction reduction and in 2/12 patients without MIS-C, especially in terms of pericardial effusion. Despite high troponin levels, children presented a favorable clinical evolution.

Conclusion

The increase in troponin level in children with COVID-19 could also be due to respiratory causes or a massive inflammatory state. In our case series, patients with increased troponin associated to COVID-19 presented a favorable clinical course with clinical and laboratory remission almost always within 7 days.

Lung Involvement in Systemic Juvenile Idiopathic Arthritis: A Narrative Review

Systemic juvenile idiopathic arthritis associated with lung disorders (sJIA-LD) is a subtype of sJIA characterized by the presence of chronic life-threatening pulmonary disorders, such as pulmonary hypertension, interstitial lung disease, pulmonary alveolar proteinosis and/or endogenous lipoid pneumonia, which were exceptionally rare before 2013. Clinically, these children show a striking dissociation between the relatively mild clinical manifestations (tachypnoea, clubbing and chronic cough) and the severity of the pulmonary inflammatory process. Our review describes sJIA-LD as having a reported prevalence of approximately 6.8%, with a mortality rate of between 37% and 68%. It is often associated with an early onset (<2 years of age), macrophage activation syndrome and high interleukin (IL)-18 circulating levels. Other risk factors may be trisomy 21 and a predisposition to adverse reactions to biological drugs. The most popular hypothesis is that the increase in the number of sJIA-LD cases can be attributed to the increased use of IL-1 and IL-6 blockers. Two possible explanations have been proposed, named the “DRESS hypothesis” and the “cytokine plasticity hypothesis”. Lung ultrasounds and the intercellular-adhesion-molecule-5 assay seem to be promising tools for the early diagnosis of sJIA-LD, although high resolution computed tomography remains the gold standard. In this review, we also summarize the treatment options for sJIA-LD, focusing on JAK inhibitors.

Long-Term Ventilation in Children with Medical Complexity: A Challenging Issue

Children with medical complexity (CMCs) represent a subgroup of children who may have congenital or acquired multisystemic disease. CMCs are frequently predisposed to respiratory problems and often require long-term mechanical ventilation (LTMV). The indications for LTMV in CMCs are increasing, but gathering evidence about indications, titration, and monitoring is currently the most difficult challenge due to the absence of validated data. The aim of this review was to examine the clinical indications and ethical considerations for the initiation, continuation, or withdrawal of LTMV among CMCs. The decision to initiate long-term ventilation should always be based on clinical and ethical considerations and should be shared with the parents.

Effect of tonsillectomy in a child with obesity and obstructive sleep apnea: A case report and review of the literature

Obstructive sleep apnea (OSA) is an increasingly recognized disorder in children. Adenotonsillectomy is the primary surgical treatment for OSA in children with adenotonsillar hypertrophy (ATH). We present the case of an obese 4-year-old boy hospitalized for severe desaturation during sleep and severe ATH. Nasal steroid therapy proved ineffective with persistent symptoms. Polygraphy documented severe OSA with an apnea-hypopnea index (AHI) equal to 11. Tonsillectomy resulted in prompt symptom improvement and a substantial reduction of the AHI (2.2). In this case, tonsillectomy alone resulted effective in treating OSA, despite obesity. We concluded that the presence of obesity should not postpone/exclude surgical treatment of preschool children for whom ATH is the most important cause of OSA.

Effect of Invasive Mechanical Ventilation at Birth on Lung Function Later in Childhood

BACKGROUND

Despite recent neonatal care improvements, mechanical ventilation still remains a major cause of lung injury and inflammation. There is growing literature on short- and long-term respiratory outcomes in infants born prematurely in the post-surfactant era, but the exclusive role of mechanical ventilation at birth in lung function impairment is still unclear. The aim of this study was to assess the effect of neonatal mechanical ventilation on lung function parameters in children born ≤ 32 weeks of gestational age at 11 years of age.

MATERIALS AND METHODS

In total, 55 ex-preterm children born between January 1, 2006 and December 31, 2007 were enrolled at 11 years of age. Neonatal information was obtained from medical records. Information about family and personal clinical history was collected by questionnaires. At 11 years of age, we measured spirometry parameters, lung volumes, diffusing lung capacity, and fractional exhaled nitric oxide. In addition, an allergy evaluation by skin prick test and eosinophil blood count were performed. A multivariable linear or logistic regression analysis was performed to examine the associations of mechanical ventilation with respiratory outcomes, adjusting for confounders (maternal smoking during pregnancy, gestational age, surfactant replacement therapy, and BMI).

RESULTS

No difference in lung function evaluation between ventilated and unventilated children were found. No association was also found between mechanical ventilation with lung function parameters.

CONCLUSION

Mechanical ventilation for a short period at birth in preterm children was not associated with lung function impairment at 11 years of age in our study sample. It remains to define if ventilation may have a short-term effect on lung function, not evident at 11 years of age.

Total serum IgE levels as predictor of the acquisition of tolerance in children with food allergy: Findings from a pilot study

BACKGROUND

The gold standard to diagnose food allergy (FA) is a double-blind, placebo-controlled food challenge (OFC), even if it shows potential risk of severe allergic reactions for the patient and is time-consuming. Therefore, easier, and less invasive methods are needed to diagnose FA and predict the tolerance, changing the clinical practice.

AIM

The main aim of this study was to assess whether the total IgE values at the diagnosis of FA were associated with the duration of the tolerance acquisition and thus of the food elimination diet.

METHODS

We retrospectively analyzed the medical records of 40 patients allergic to milk or egg who performed an OFC for the reintroduction of the causal food at the Pediatric Allergy and Respiratory Unit of the University of Chieti from January 2018 to December 2020.

RESULTS

We found a positive association of total serum IgE with the elimination diet duration (β = 0.152; CI, 95% 0.04-0.27) after adjusting for age, sex, and type of allergy (milk or egg). We also showed a significant correlation (r = 0.41 and p-value = 0.007) between the total IgE values and the duration of the elimination diet and a significant correlation between the casein specific IgE values at diagnosis of FA and the severity of the clinical presentation (r = 0.66; p-value 0.009).

CONCLUSION

Total serum IgE at baseline, along with the downward trend of food-specific IgE levels (to milk or egg), may be useful in the prognostication of natural tolerance acquisition.

The Role of Breastfeeding on Respiratory Outcomes Later in Childhood

BACKGROUND

Breastfeeding is associated with a lower risk of wheezing in early childhood, but its effect later in childhood remains unclear. We investigated the association of breastfeeding and respiratory outcomes in children aged 11 years.

MATERIALS AND METHODS

We performed an observational longitudinal study including 110 prepubertal children. Information about breastfeeding duration, wheezing and asthma was collected by questionnaires. At 11 years of age, we measured spirometry parameters, lung volumes, diffusing lung capacity, and fractional exhaled nitric oxide. We used logistic and linear regression models to examine the associations of breastfeeding duration with the odds of asthma and lung function measures. All multivariable analyses were adjusted for sex, smoking during pregnancy, gestational age at birth, twins, and mode of delivery (confounder model).

RESULTS

Breastfeeding duration was associated with FEV₁ z-score [β = 0.04, CI 95% (0.02-0.09)], FEF75 z-score [β = 0.06, CI 95% (0.03-0.09)] and FEV₁/FVC z-score [β = 0.03, CI 95% (0.00-0.07)], but not with diffusing lung capacity and fractional exhaled nitric oxide. No association of breastfeeding duration with preschool wheezing, ever asthma and current asthma was documented.

CONCLUSION

We showed that children breastfed for longer time presented higher FEV₁, FEV₁/FVC, and FEF75 z-score values at 11 years of age compared to children breastfed for shorter time, suggesting a protective effect of breastfeeding on airways, and not on lung parenchyma (lung volumes and alveolar capillary membrane) or allergic airway inflammation. The positive effect of breastfeeding duration on lung function lays the foundation to promote breastfeeding more and more as effective preventive measure.

Use of lung ultrasound in school-aged children with wheezing

BACKGROUND

There is limited information available on fast and safe bedside tools that could help clinicians establish whether the pathological process underlying cases of wheezing is due to asthmatic exacerbation, asthmatic bronchitis, or pneumonia. The study's aim was to characterize Lung Ultrasound (LUS) in school-aged children with wheezing and evaluate its use for their follow-up treatment.

MATERIALS AND METHODS

We carried out a cross-sectional study involving 68 consecutive outpatients (mean age 9.9 years) with wheezing and suggestive signs of an acute respiratory infection. An expert sonographer, blinded to all subject characteristics, clinical course, and the study pediatrician's diagnosis, performed an LUS after spirometry and before BDT. The severity of acute respiratory symptoms was determined using the Pediatric Respiratory Assessment Measure (PRAM) score.

RESULTS

The LUS was positive in 38.2% (26/68) of patients [12 (46.1%) with multiple B-lines, 24 (92.3%) with consolidation, and 22 (84.6%) with pleural abnormalities]. In patients with pneumonia, asthmatic bronchitis, and asthma, the percentages of those patients with a positive LUS were 100%, 57.7%, and 0%, respectively. Of note, patients with a positive LUS were associated with an increased need for hospital admission (30.8% vs. 2.4%, p = 0.001), administration of oxygen therapy (14.6% vs. 0%, p = 0.009), oral corticosteroids (84.6% vs. 19.0%, p < 0.001), and antibiotics (88.5% vs. 11.9%, p < 0.001); and a higher median value of PRAM score (4.0 (2.0-7.0) vs. 2.0 (1.0-5.0); p < 0.001).

CONCLUSIONS

Our findings would suggest the use of LUS as a safe and cheap tool used by clinicians to define the diagnosis of school-aged children with wheezing of unknown causes.

Usefulness of Lung Ultrasound in Paediatric Respiratory Diseases

Respiratory infection diseases are among the major causes of morbidity and mortality in children. Diagnosis is focused on clinical presentation, yet signs and symptoms are not specific and there is a need for new non-radiating diagnostic tools. Among these, lung ultrasound (LUS) has recently been included in point-of-care protocols showing interesting results. In comparison to other imaging techniques, such as chest X-ray and computed tomography, ultrasonography does not use ionizing radiations. Therefore, it is particularly suitable for clinical follow-up of paediatric patients. LUS requires only 5-10 min and allows physicians to make quick decisions about the patient's management. Nowadays, LUS has become an early diagnostic tool to detect pneumonia during the COVID-19 pandemic. In this narrative review, we show the most recent scientific literature about advantages and limits of LUS performance in children. Furthermore, we discuss the major paediatric indications separately, with a paragraph fully dedicated to COVID-19. Finally, we mention potential future perspectives about LUS application in paediatric respiratory diseases.

Biologic Therapy and Severe Asthma in Children

Severe asthma is a heterogeneous, complex and chronic disease widespread in the pediatric population. According to the recent findings about the different endotypes of asthma in children, each one characterized by specific intracellular molecular pathways, several innovative biologic therapies have been developed. Due to their precise ability to target specific inflammatory type 2 mediators, biologics have revolutionized the care of chronic allergic diseases in the pediatric and adult population. In this review, we aim to provide the latest evidence about the use, indications, efficacy and safety of biologic therapies to treat severe asthma in children and adolescents.

Virome in the Lungs: The Role of Anelloviruses in Childhood Respiratory Diseases

More recently, increasing attention has been directed to exploring the function of the global virome in health and disease. Currently, by new molecular techniques, such as metagenomic DNA sequencing, the virome has been better unveiled. By investigating the human lung virome, we could provide novel insights into respiratory diseases. The virome, as a part of the microbiome, is characterized by a constant change in composition related to the type of diet, environment, and our genetic code, and other incalculable factors. The virome plays a substantial role in modulating human immune defenses and contributing to the inflammatory processes. Anelloviruses (AVs) are new components of the virome. AVs are already present during early life and reproduce without apparently causing harm to the host. The role of AVs is still unknown, but several reports have shown that AVs could activate the inflammasomes, intracellular multiprotein oligomers of the innate immune system, which show a crucial role in the host defense to several pathogens. In this narrative revision, we summarize the epidemiological data related to the possible link between microbial alterations and chronic respiratory diseases in children. Briefly, we also describe the characteristics of the most frequent viral family present in the lung virome, Anelloviridae. Furthermore, we discuss how AVs could modulate the immune system in children, affecting the development of chronic respiratory diseases, particularly asthma, the most common chronic inflammatory disease in childhood.

Evaluation of sleep quality and anxiety in Italian pediatric healthcare workers during the first wave of COVID-19 pandemic

OBJECTIVE

The aim of this study was to evaluate sleep quality and psychological effects on pediatric healthcare workers during the first wave of COVID-19 epidemic in Italy and to evaluate differences between primary and secondary care operators. Pediatric healthcare workers were involved in an online survey to assess sleep quality, stress and anxiety level, self-efficacy and social support in Italian pediatric healthcare workers during COVID-19 pandemic.

RESULTS

We found that 67.4% of our sample suffered from sleep disturbance and 19.4% of subjects suffered from anxiety. Lower values of anxiety and social support were found in primary care staff compared to secondary care one. The associations between healthcare professional figures (being primary or secondary care operators) and mental health outcomes were not statistically significant. However, sex, age and having a SARS-CoV-2 infected relative/friend had an independent effect on mental health outcomes. It is crucial to provide social and psychological support to pediatric healthcare workers. A tailored psychological screening would be desirable for female healthcare workers and for those who have a SARS-CoV-2 infected relative/friend.

Evaluation of sleep quality and anxiety in Italian pediatric healthcare workers during the first wave of COVID-19 pandemic

OBJECTIVE

The aim of this study was to evaluate sleep quality and psychological effects on pediatric healthcare workers during the first wave of COVID-19 epidemic in Italy and to evaluate differences between primary and secondary care operators. Pediatric healthcare workers were involved in an online survey to assess sleep quality, stress and anxiety level, self-efficacy and social support in Italian pediatric healthcare workers during COVID-19 pandemic.

RESULTS

We found that 67.4% of our sample suffered from sleep disturbance and 19.4% of subjects suffered from anxiety. Lower values of anxiety and social support were found in primary care staff compared to secondary care one. The associations between healthcare professional figures (being primary or secondary care operators) and mental health outcomes were not statistically significant. However, sex, age and having a SARS-CoV-2 infected relative/friend had an independent effect on mental health outcomes. It is crucial to provide social and psychological support to pediatric healthcare workers. A tailored psychological screening would be desirable for female healthcare workers and for those who have a SARS-CoV-2 infected relative/friend.

Coaggregation of Asthma and Type 1 Diabetes in Children: A Narrative Review

Asthma and type 1 diabetes mellitus (T1DM) are two of the most frequent chronic diseases in children, representing a model of the atopic and autoimmune diseases respectively. These two groups of disorders are mediated by different immunological pathways, T helper (Th)1 for diabetes and Th2 for asthma. For many years, these two groups were thought to be mutually exclusive according to the Th1/Th2 paradigm. In children, the incidence of both diseases is steadily increasing worldwide. In this narrative review, we report the evidence of the potential link between asthma and T1DM in childhood. We discuss which molecular mechanisms could be involved in the link between asthma and T1DM, such as genetic predisposition, cytokine patterns, and environmental influences. Cytokine profile of children with asthma and T1DM shows an activation of both Th1 and Th2 pathways, suggesting a complex genetic-epigenetic interaction. In conclusion, in children, the potential link between asthma and T1DM needs further investigation to improve the diagnostic and therapeutic approach to these patients. The aim of this review is to invite the pediatricians to consider the potential copresence of these two disorders in clinical practice.

Emergency Department Visits for allergy related-disorders among children: experience of a single Italian hospital during the first wave of the COVID-19 pandemic

Introduction: The aim of this study was to compare the number of the Pediatric Emergency Department (PED) visits for young allergic patients with respiratory or cutaneous symptoms during the first wave of the coronavirus disease 19 (COVID-19) pandemic in 2020 with the same period in 2019, evaluating the percentage of positive cases to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). We carried out a retrospective analysis using data from young patients who visited the PED with cutaneous or respiratory symptoms in the period from 20^th February to 12^th May of the years 2020 and 2019. Data on allergy and COVID-19 nasal swab were also collected. We observed eleven (28.2%) PED visits for allergic patients with respiratory or cutaneous symptoms for the period from 20^th February to 12^th May of the year 2020 and ninety-three (31.8%) PED visits for the same time frame of the year 2019 (p=0.645). Only a two-month-old child out of 39 patients with non-allergic respiratory or cutaneous symptoms resulted positive for SARS-CoV-2. Specifically, we found for all the PED visits: 21 (7.2%) in 2019 vs 2 (5.1%) in 2020 for patients with urticaria/angioedema or atopic dermatitis (p=0.634); 3 (1.0%) in 2019 vs 3 (7.7%) in 2020 for patients with anaphylaxis (p=0.003); 19 (6.5%) in 2019 vs 2 (5.1%) in 2020 for those with asthma (p=0.740); 11(3.8%) in 2019 vs 1(2.6%) in 2020 for those with lower respiratory diseases, excluding asthma (p=0.706); 39(13.4%) in 2019 vs 3 (7.7%) in 2020 for those with upper respiratory diseases (URDs) (p=0.318). We also showed a substantial decrease (~80%) in all PED visits compared with the same time frame in 2019 (absolute number 263 vs 1,211, respectively). Among all the PED visits a significant reduction was mostly found for URDs [155 (12.8%) in 2019 vs 17 (6.5%) in 2020; p=0.045)]. The total number of PED visits for allergic patients with respiratory or cutaneous symptoms dropped precipitously in 2020. It is very tricky to estimate whether it was a protective action of allergy or the fear of contagion or the lockdown or a reduction in air pollution that kept children with allergy from visiting the PED. Further studies are needed to better understand the impact of underlying allergies on COVID-19 susceptibility and disease severity.

Pulmonary Outcomes in Children Born Extremely and Very Preterm at 11 Years of Age

Background: There is increasing evidence of prematurity being a risk factor for long-term respiratory outcomes regardless the presence of bronchopulmonary dysplasia (BPD). Aim: To assess the effect of prematurity on respiratory outcomes in children born ≤32 weeks of gestational age at 11 years of age. Materials and Methods: Fifty five ex-preterm children (≤ 32 weeks of gestational age), born in Chieti between January 1, 2006 and December 31, 2007, performed lung function and diffusing capacity test (DLCO) at 11 years of age. Furthermore, allergy evaluation by skin prick test (SPT), eosinophil blood count and assessment of eosinophilic airways inflammation by exhaled nitric oxide (FeNO) were performed. The ex-preterm group was compared to an age- and sex-matched group of term children. Results: No difference for atopic and respiratory medical history was found between ex-preterm children and term controls, except for preschool wheezing that resulted more frequent in ex-preterm children. No difference neither in school-aged asthma frequency nor in lung function assessment at 11 years of age was found between the two groups. Lower DLCO values in ex-preterm children compared to term controls regardless the presence of BPD were found; furthermore, we showed a positive association between DLCO and gestational age. Eosinophil blood count, positive SPTs and FeNO values were similar between the two groups. Conclusions: Diffusing lung capacity was decreased in ex-preterm children at 11 years of age in the absence of lung function impairment and eosinophil airway inflammation, suggesting a non-eosinophilic pattern underlying pulmonary alterations. It could be desirable to include the diffusing capacity assessment in follow-up evaluation of all ex-preterm children.

Inpatient Care during the COVID-19 Pandemic: A Survey of Italian Physicians

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a potentially fatal disease that is of great global public health concern.

OBJECTIVE

We explored the clinical management of inpatients with COVID-19 in Italy.

METHODS

A self-administered survey was sent by email to Italian physicians caring for adult patients with COVID-19. A panel of experts was selected according to their clinical curricula and their responses were analyzed.

RESULTS

A total of 1,215 physicians completed the survey questionnaire (17.4% response rate). Of these, 188 (15.5%) were COVID-19 experts. Chest computed tomography was the most used method to detect and monitor COVID-19 pneumonia. Most of the experts managed acute respiratory failure with CPAP (56.4%), high flow nasal cannula (18.6%), and non-invasive mechanical ventilation (8%), while an intensivist referral for early intubation was requested in 17% of the cases. Hydroxychloroquine was prescribed as an antiviral in 90% of cases, both as monotherapy (11.7%), and combined with protease inhibitors (43.6%) or azithromycin (36.2%). The experts unanimously prescribed low-molecular-weight heparin to patients with severe COVID-19 pneumonia, and half of them (51.6%) used a dose higher than standard. The respiratory burden in patients who survived the acute phase was estimated as relevant in 28.2% of the cases, modest in 39.4%, and negligible in 9%.

CONCLUSIONS

In our survey some major topics, such as the role of non-invasive respiratory support and drug treatments, show disagreement between experts, likely reflecting the absence of high-quality evidence studies. Considering the significant respiratory sequelae reported following COVID-19, proper respiratory and physical therapy programs should be promptly made available.

C hlamydia trachomatis during pregnancy and childhood asthma-related morbidity: a population-based prospective cohort

INTRODUCTION

Chlamydia trachomatis is the most commonly reported sexually transmitted disease and although infection during pregnancy is associated with neonatal complications, long-term respiratory consequences are unknown. We aimed to determine whether C. trachomatis infection during pregnancy is associated with asthma-related symptoms across childhood METHODS: This study among 2475 children and their mothers was embedded in a population-based prospective cohort study. Maternal urine samples were tested for C. trachomatis infection during pregnancy. Questionnaires provided information on childhood physician-attended lower respiratory tract infections and wheezing, and current asthma at age 10 years. Lung function was measured by spirometry at age 10 years.

RESULTS

The prevalence of C. trachomatis infection during pregnancy was 3.2% (78 out of 2475). C. trachomatis infection during pregnancy was not associated with lower respiratory tract infections until age 6 years, but was associated with a higher odds of wheezing in children until age 10 years (OR 1.50 (95% CI 1.10-2.03)). C. trachomatis infection during pregnancy was associated with an increased odds of asthma (OR 2.29 (95% CI 1.02-5.13)), and with a lower forced expiratory volume in 1 s/forced vital capacity and forced expiratory flow at 75% of forced vital capacity (z-score difference -0.28 (95% CI -0.52- -0.04) and -0.24 (95% CI -0.46- -0.01), respectively) in children at age 10 years. The observed associations were only partly explained by mode of delivery, gestational age at birth or birthweight.

CONCLUSIONS

C. trachomatis infection during pregnancy is associated with increased odds of wheezing, asthma and impaired lung function. The causality of the observed associations and potential underlying mechanisms need to be explored.

Lung function in children with juvenile idiopathic arthritis: A cross-sectional analysis

AIM

We measured respiratory parameters in children with juvenile idiopathic arthritis (JIA) without clinical signs of respiratory involvement and assessed the influence of methotrexate (MTX) treatment and disease activity on lung function.

METHODS

In 49 JIA children and 70 controls lung volumes by spirometry and body plethysmography, and lung diffusion for carbon monoxide (DLCO) with single-breath technique were evaluated.

RESULTS

DLCO was significantly different between JIA children and controls (P = .01), whereas no differences were found in flow expiratory volume in 1 second (FEV ₁ ), forced vital capacity (FVC), forced expiratory flow at 25% to 75% of FVC (FEF _25-75 ), peak expiratory flow, total lung capacity, and residual volume. After dividing study JIA patients according to MTX treatment, a significant difference in DLCO was found among JIA patients treated with MTX and those treated with other drugs and controls (P < .001). A significant difference in DLCO was also found among JIA patients with active disease and those with inactive disease and controls (P = .003). Analysis of covariance showed a weak independent effect of MTX therapy on DLCO after adjusting for sex and height (P = .04). Furthermore, a negative correlation of DLCO with MTX cumulative dose and MTX treatment duration (r = -.58, P = .006; r = -.68, P = .001, respectively) was found, whereas there was no correlation between DLCO and disease activity (r = -.10; P = .51).

CONCLUSIONS

In JIA children MTX treatment seems to have a dose-dependent effect on lung function. For this reason in these patients, a regular assessment of lung function, especially with DLCO evaluation, is recommended.

Insulin resistance and lung function in obese asthmatic pre-pubertal children

BACKGROUND

Recent findings have supposed that the underlying association between the increased prevalence of both asthma and obesity may be insulin resistance (IR).

METHODS

Insulin and glucose serum levels were analyzed to calculate the homeostatic model assessment of insulin resistance (HOMA-IR) for IR in 98 pre-pubertal children. Lung function and allergy status evaluation were performed. The study population was divided into four groups: (1) obese asthmatic children (ObA); (2) normal-weight asthmatic children (NwA); (3) normal-weight non-asthmatic children (Nw) and (4) obese non-asthmatic children (Ob).

RESULTS

Forced expiratory volume in 1 s (FEV1) was slightly lower in obese subjects compared with normal-weight subjects and forced vital capacity (FVC) appeared lower in asthmatics, whereas between non-asthmatics subjects, it was lower in the obese group than in the normal-weight one. The post hoc analysis revealed a statistically significant reduction in FEV1, peak expiratory flow (PEF), forced expiratory flows (FEF) between 50% and 25% of the FVC (FEF50 and FEF25) between ObA and Nw and in FEV1, FVC, PEF, FEF50 and FEF25 between NwA and Nw, but no statistically significant differences of lung function parameters were observed between ObA and NwA. We found an inverse relationship between HOMA-IR and all spirometric parameters, although without any statistical significance. We also observed a significantly lower FVC in insulin-resistant children (HOMA-IR>95th percentile) (p=0.03).

CONCLUSIONS

This study suggests that lung function could be early altered in obese children, already in pre-pubertal age. Although IR should not manifest its effects on lungs in pre-pubertal obese children, the prevention or treatment of obesity in the pre-pubertal period may prevent definitive negative effects on lungs.

An underestimated cause of chronic cough: The Protracted Bacterial Bronchitis

Chronic cough in childhood is associated with a high morbidity and decreased quality of life. Protracted bacterial bronchitis (PBB) seems to be the second most common cause of chronic cough in children under 6 years of age. Its main clinical feature is represented by wet cough that worsens when changing posture and improves after the introduction of antibiotics. Currently, the mainstay of PBB treatment is a 2-week therapy with a high dose of antibiotics, such as co-amoxiclav, to eradicate the infection and restore epithelial integrity. It is very important to contemplate this disease in a child with chronic cough since the misdiagnosis of PBB could lead to complications such as bronchiectasis. Clinicians, however, often do not consider this disease in the differential diagnosis and, consequently, they are inclined to change the antibiotic therapy rather than to extend it or to add steroids. Data sources of this review include PubMed up to December 2016, using the search terms “child,” “chronic cough,” and “protracted bacterial bronchitis.”

Usefulness of molecular diagnosis in egg allergic children

INTRODUCTION

Egg allergy is one of the most common food allergies in children. Egg white, including ovomucoid (OVM or Gal d 1) and ovalbumin (OVA or Gal d 2), is the major source of allergens. The aim of this study was to assess the role of Gal d 1 and Gal d 2 in predicting the risk of anaphylaxis caused by eggs in children, and to compare this new diagnostic tool with established methods of allergen-specific IgE detection.

MATERIAL AND METHODS

One hundred and forty-eight children were divided into 2 groups according to a positive (group A, 33 children) or negative (group B, 115 children) history of anaphylaxis after ingestion/contact with eggs. All patients underwent an allergological evaluation by measurements of specific IgE against egg white: Gal d 1 and Gal d 2.

RESULTS

Higher levels of Gal d 1, Gal d 2 and IgE against egg white were detected in group A compared to group B (p < 0.001). Although the area under the curve was similar for Gal d 1 and Gal d 2, egg white specific IgE showed a better sensitivity (85%) for a cut-off value ≥ 0.975 kUA/l, while Gal d 1 and Gal d 2 demonstrated a better specificity (90% and 80%, respectively) for cut-off values ≥ 1.460 kUA/l and ≥ 2.310 kUA/l, respectively.

CONCLUSIONS

Egg white specific IgE showed a similar ability as Gal d 1 and Gal d 2 in differentiating children at risk for egg anaphylaxis, although Gal d 1 and Gal d 2 showed a better specificity.

Asthma in childhood

Several topics on childhood asthma were addressed in the Paediatric Clinical Year in Review session at the 2015 European Respiratory Society International Congress. With regard to the relationship between lower respiratory tract infections and asthma, it emerges that is the number of respiratory episodes in the first years of life, but not the particular viral trigger, to be associated with later asthma development. Understanding which characteristics of individual patients are associated with an increased risk for asthma exacerbation is a critical step to implement strategies preventing these seasonal events. Recent data suggest the possibility that exhaled volatile organic compounds may qualify as biomarkers in detecting early signs of asthma. Adding information of exhaled volatile organic compounds and expression of inflammation genes to a clinical tool significantly improves asthma prediction in preschool wheezy children. Personal communication with children and adolescents is likely more important than the tools actually used for monitoring asthma. Systemic corticosteroids do not affect the long-term prognosis in children with first viral-induced wheezing episode and should be used cautiously during acute episodes. Finally, stress and a polymorphism upstream of a specific gene are both associated with reduced bronchodilator response in children with asthma.

Influence of inhaled corticosteroids on pubertal growth and final height in asthmatic children

BACKGROUND

Controversial data exist on the possibility that inhaled corticosteroids (ICs) affect growth in children with mild-to-moderate asthma. We assessed whether ICs affect growth and final height (FH) in asthmatic children compared to controls.

METHODS

A retrospective study was conducted on 113 asthmatic children compared with 66 control children. Asthmatic children presented with mild-to-moderate asthma and had exclusive ICs. Anthropometric data of four specific time-points were collected for both groups (pre-puberty, onset and late puberty, and FH) and converted to standard deviation scores (SDS). Growth trajectories were assessed as follows: (i) in puberty, using peak height velocity (PHV) and pubertal height gain SDS (PHG-SDS); (ii) until FH achievement, using FH-SDS and FH gain SDS (FHG-SDS). Repeated measurement analysis was performed across longitudinal study visits. A general linear model (GLM) was performed in asthmatic group evaluating the effect of corticosteroid type, treatment duration, and cumulative dose on FH corrected for multiple variables.

RESULTS

At pre-puberty, height and weight SDS were similar between the groups (p > 0.05). Height SDS progressively declined over the study period in asthmatic patients from pre-puberty to FH (p-trend < 0.05), whereas it did not change over time in controls (p-trend > 0.05), in both boys and girls. Asthmatic children had exclusive ICs [budesonide (n = 36) vs. fluticasone (n = 43) vs. mometasone (n = 34)] for a mean period of 6.25 ± 1.20 years and a mean cumulative dose of 560.07 ± 76.02 mg. They showed decreased PHG-SDS and lower PHV compared to controls (all p < 0.05). FH-SDS and FHG-SDS were significantly reduced in asthmatic group compared to controls. FH in asthmatic patients was 2.5 ± 2.89 cm lower in boys and 2.0 ± 2.03 cm lower in girls than controls. The GLM showed that FH achievement was dependent on the type of ICs, duration of the treatment, and cumulative dose (p < 0.05).

CONCLUSIONS

ICs affect pubertal growth determining reduced final height in asthmatic children compared to controls, in a dose- and duration-dependent manner.

Bronchial hyperresponsiveness to mannitol, airway inflammation and Asthma Control Test in atopic asthmatic children

INTRODUCTION

The aim of this study was to evaluate the relationship between airway hyperresponsiveness (AHR) to mannitol and bronchial inflammation measured as exhaled nitric oxide (FeNO) and to assess whether asthma control correlates with AHR to mannitol and FeNO in atopic asthmatic children.

MATERIAL AND METHODS

Allergy evaluation, the mannitol challenge test, FeNO levels and the Asthma Control Test (ACT) questionnaire were assessed in 40 children with intermittent and mild persistent allergic asthma.

RESULTS

All the subjects showed positive AHR to mannitol. Pearson's correlation test revealed a significant inverse correlation between AHR (mannitol PD15) and FeNO (p = 0.020). There was also a significant positive correlation between ACT and PD15 (p = 0.020) and a significant negative correlation between ACT and FeNO levels (p = 0.003). The study population was divided into two groups according to FeNO levels (group A ≥ 16 ppb vs. group B < 16 ppb). In group A mannitol PD15 was significantly lower (p = 0.040) and ACT score values were significantly lower (p = 0.001) compared to group B. In group A, the ACT showed that 13.3% of subjects had well-controlled asthma, 80% had partially controlled asthma and 6.7% had uncontrolled asthma. In group B, the ACT showed that 72% of subjects had well-controlled asthma and 28% had partially controlled asthma.

CONCLUSIONS

Our findings indicate that the degree of AHR to mannitol correlates with the degree of airway inflammation in asthmatic atopic children; moreover, better control of asthma correlates with a lower degree of AHR to both mannitol and FeNO.

Critical appraisal of Timothy grass pollen extract GRAZAX in the management of allergic rhinitis

Allergic rhinitis is one of the most common diseases of adult and pediatric age, associated with grass pollen (GP) allergy in >50% cases, with a consistent impact on quality of life of affected patients. A grass allergen tablet, containing standardized extract derived from Timothy grass (Phleum pratense) pollen and ~15 μg major allergen P. pratense (rPhl p 5), may be the future of allergen-specific immunotherapy (IT) for GP allergy. The aim of this review was to critically evaluate the role of Timothy GP extract IT for the management of allergic rhinitis. For this purpose, we have tried to analyze potential mechanisms of action at the basis of Timothy GP extract, we have reviewed efficacy studies to establish potential benefits and clinical response, and we have also evaluated safety and tolerability profiles and patient focus perspective, such as quality of life, satisfaction and acceptability, and compliance to this IT.

Airway hyper-responsiveness to mannitol provides a good evaluation of atopy in childhood asthma

AIM

The relationship between airway hyper-responsiveness (AHR) and atopy has been previously investigated, but there are still some issues to be clarified. The aim of this study was to assess the link between AHR and mannitol and atopy in asthmatic children.

METHODS

We evaluated 44 children with asthma, aged 6-16 years of age, using skin prick tests (SPTs), serum total and specific immunoglobulin E (IgE) levels and the mannitol challenge test (MCT).

RESULTS

We found a good correlation between AHR to mannitol and specific IgE against Dermatophagoides pteronissinus (r = -0.66, p < 0.001) and a weak correlation with specific IgE against dog dander (r = -0.33, p = 0.01) and Aspergillus fumigatus (r = -0.23, p = 0.02). Furthermore, we found a weak correlation between AHR to mannitol and serum total IgE (r = -0.30; p = 0.03), the sum of specific IgE to aeroallergens (r = -0.37, p = 0.01) and the number of positive SPTs (r = -0.31, p = 0.02).

CONCLUSION

Measuring AHR with MCT might provide an accurate evaluation of the degree of atopy in children. The patients with a higher degree of atopy were significantly more reactive to mannitol. In clinical practice, these results indicate that children with asthma who are more atopic may require more intensive treatment strategies to reduce AHR.

Usefulness of Atopy Patch Test on a child with milk protein-induced enterocolitis syndrome: a case report

We describe the case of a child affected by milk-protein induced enterocolitis, in which oral challenge with corn was performed without symptoms after a negative specific Atopy Patch Test. Food protein-induced enterocolitis syndrome (FPIES) is an uncommon nonIgE-mediated gastrointestinal food hypersensitivity of infancy, characterized by severe vomiting and diarrhea arising within 1 to 3 hours after ingestion of the causative food. Little is known about the pathophysiology of FPIES. The absence of food-specific IgE as demonstrated by negative skin prick tests suggests that the disease is not caused by an early onset IgE-mediated reaction. Atopy Patch Test has been described as sensitive and predictive in this syndrome. The hypothesis on the immunological pathogenesis has been discussed on the basis of literature data.

Mycoplasma pneumoniae infection with rhabdomyolysis in a child

We report the history of a seven year-old male boy with cough and fever, who developed rhabdomyolysis concomitant with Mycoplasma pneumoniae infection. The association between this organism and the muscular injury is rarely described in paediatric patients. This case then thus emphasizes that even seemingly mild M. pneumoniae airway infections may be complicated by invalidating neuromuscular sequelae.

Usefulness of nBos d 4, 5 and nBos d 8 Specific IgE Antibodies in Cow's Milk Allergic Children

PURPOSE

The aim of study was to assess the value of recombinants in predicting the degree of symptoms in children with and without anaphylaxis to cow's milk.

METHODS

The study included 79 children (70±40 months) referred to the Allergological Unit of the Pediatric Department between the years 2008-2012. Group A was composed of 17 children (78±49.6 months) with anaphylaxis after ingestion of milk. Group B was composed of 62 children (73.1±38.6 months) without a history of anaphylaxis, but with less severe symptoms (gastrointestinal and/or skin symptoms). All patients from Group B had a positive open challenge with cow's milk. All patients underwent an allergic evaluation and blood samples were collected to test for IgE to recombinans of milk (nBos d 4, 5, 8).

RESULTS

A significant difference in nBos d 8 emerged with higher levels in Group A (median [IQR]=2.80 [0.91-16.1]) than B (0.65 [0.24-1.67]; P=0.006), whereas there were no statistically significant differences for nBos d 4 and 5. The recombinants' sum was higher in Group A than B: 8.39 [2.72-41.39] vs 3.04 [1.85-7.31] kUA/L; P=0.044. The recombinant nBos d 8 was superior to the other recombinants in identifying children at risk for anaphylaxis, with an area under the curve of 0.718 (95% CI, 0.57-0.86, P=0.006). Considering a cutoff of 1.8 kUA/L, nBos d 8 had the most favorable sensitivity and specificity ratio (sensitivity=0.65, specificity=0.77) with an odd ratio of 6.02 (95% C.I: 1.89-19.23).

CONCLUSIONS

This study suggested 2 phenotypes of allergic children, "high-anaphylaxis-risk" and "milder-risk". These types can be differentiated through measuring the level of IgE to nBos d 8.

Evaluation of association between airway hyperresponsiveness, asthma control test, and asthma therapy assessment questionnaire in asthmatic children

Background: Achieving asthma control is a major challenge in children, otherwise symptoms perception remain poor especially at this age. The aim of this study is to evaluate the relationship between Asthma Control Test (ACTTM), Asthma Therapy Assessment Questionnaire (ATAQTM) and exercise-induced bronchospasm (EIB). Methods: We studied 80 asthmatic children. Airways hyperresponsiveness (AHR) was assessed by exercise-induced bronchospasm (Balke Protocol). Asthma control was evaluated using two questionnaires in all subjects: ACT (composed by Childhood-ACT and ACT) and ATAQ. In addition the use of short acting beta 2 agonist agents (SABAs) was assessed for each patient. Non-parametric variables were compared by Chi Square Test. Binomial logistic regression was performed to estimate the two questionnaires Odds Ratio (OR) in finding AHR. Results: We have found that ATAQ has a sensitivity and a specificity of 0.72 and 0.45 respectively; instead, ACT has a sensitivity and a specificity of 0.5 and 0.39 respectively in evaluating AHR. Patients with uncontrolled asthma according to ATAQ revealed a significant higher percentage of AHR compared with ACT (72% vs 50%, p < 0.01). Confirming this finding, patients declaring uncontrolled asthma to ATAQ have a significantly higher percentage (34%) of frequent SABAs use than the group with uncontrolled asthma to ACT (21%) (p <0.01). Binomial logistic regression shows how a test revealing uncontrolled asthma is associated with the increasing odds of having AHR according to ATAQ (OR = 3.8, p = 0.05), not to ACT (OR = 0.2, p = 0.1). Conclusions: Our results show that ATAQ reflects AHR and asthma control better than ACT. Children with uncontrolled asthma according to ATAQ have higher odds of having AHR and use of rescue medications (SABAs) compared to patients declaring uncontrolled asthma according to ACT. However both questionnaires are not sufficient alone to fully evaluate asthma control in children and it is always necessary to perform functional tests and investigate patients lifestyle, drug use and other important data that a simple questionnaire is not able to point out

Evaluation of association between airway hyperresponsiveness, asthma control test, and asthma therapy assessment questionnaire in asthmatic children

Background

Achieving asthma control is a major challenge in children, otherwise symptoms perception remain poor especially at this age. The aim of this study is to evaluate the relationship between Asthma Control Test (ACT^TM), Asthma Therapy Assessment Questionnaire (ATAQ^TM) and exercise-induced bronchospasm (EIB).

Methods

We studied 80 asthmatic children. Airways hyperresponsiveness (AHR) was assessed by exercise-induced bronchospasm (Balke Protocol). Asthma control was evaluated using two questionnaires in all subjects: ACT (composed by Childhood-ACT and ACT) and ATAQ. In addition the use of short acting beta 2 agonist agents (SABAs) was assessed for each patient. Non-parametric variables were compared by Chi Square Test. Binomial logistic regression was performed to estimate the two questionnaires Odds Ratio (OR) in finding AHR.

Results

We have found that ATAQ has a sensitivity and a specificity of 0.72 and 0.45 respectively; instead, ACT has a sensitivity and a specificity of 0.5 and 0.39 respectively in evaluating AHR. Patients with uncontrolled asthma according to ATAQ revealed a significant higher percentage of AHR compared with ACT (72% vs 50%, p < 0.01).

Confirming this finding, patients declaring uncontrolled asthma to ATAQ have a significantly higher percentage (34%) of frequent SABAs use than the group with uncontrolled asthma to ACT (21%) (p <0.01).

Binomial logistic regression shows how a test revealing uncontrolled asthma is associated with the increasing odds of having AHR according to ATAQ (OR = 3.8, p = 0.05), not to ACT (OR = 0.2, p = 0.1).

Conclusions

Our results show that ATAQ reflects AHR and asthma control better than ACT. Children with uncontrolled asthma according to ATAQ have higher odds of having AHR and use of rescue medications (SABAs) compared to patients declaring uncontrolled asthma according to ACT. However both questionnaires are not sufficient alone to fully evaluate asthma control in children and it is always necessary to perform functional tests and investigate patients lifestyle, drug use and other important data that a simple questionnaire is not able to point out