Martina D'Agostin

Rivista di formazione e di aggiornamento professionale del pediatra e del medico di base, realizzata in collaborazione con l'Associazione Culturale Pediatri

Recently, technological innovations have radically changed diabetes care. Insulin pumps and continuous glucose monitoring systems have significantly improved diabetes outcomes in both children and adults with Type 1 diabetes. For this reason, the major international associations recommend the use of technology in the management of Type 1 diabetes. The limitations of glycemic self-monitoring have prompted research to develop alternative techniques, favouring the expansion of continuous blood glucose monitoring systems (CGMs). CGM measures interstitial glucose through tiny sensors inserted in the subcutaneous tissue. Sensors can provide information in real time on the current glucose level and its trend. These data can be uploaded to the cloud and checked any time by doctors, patients and their caregivers. CGM can be combined with multiple daily injections (MDI) therapy or continuous subcutaneous insulin infusion (CSII). With CSII, basal insulin is supplied in the form of a continuous infusion and pre-meal bolus doses are calculated based on the meals’ carbohydrate content. A variety of insulin pumps is available, some of which can communicate with specific CGM devices, helping the patient to make better decisions about insulin dosing. This approach is known as sensor-augmented insulin pump therapy and it is the gold standard for the treatment of Type 1 diabetes in children and young adults, as recommended by the Italian Association of Paediatric Endocrinology and Diabetology. In the most recent systems, basal insulin delivery can be automatically modified through algorithms, based on CGM results, target glucose and the amount of active insulin, even though the patients still have to set the pre-meal insulin bolus manually. This system is defined as a partially hybrid closed-loop system, also known as artificial pancreas. Compared to MDI, CSII is associated with better control of blood glucose - measured by haemoglobin A1c and glycemic variability -, reduction of daily insulin requirement and an improvement of the quality of life. Psychophysical disabilities, language barriers or socio-economic disadvantage should not be considered limitations of CSII treatment as long as the caregiver is able to manage the therapy. Nowadays, MDI is recommended as first line therapy exclusively for those patients who do not want to use insulin pumps due to physical discomfort. The aim of this article is to provide updated information on the management of paediatric diabetes with modern technological devices for glucose monitoring and insulin delivery.

Nurses play a pivotal role during pediatric procedural sedation and their perspective is an important indicator for the quality of care. The aim of this study is to examine nurses’ satisfaction comparing four different pharmacological regimens used for pediatric sedation outside of the operating room. A prospective observational study was conducted in a third-level pediatric teaching hospital, involving all the nurses with experience in the field of pediatric procedural sedation. A 13-item survey was used to assess the level of nurses’ satisfaction for the quality of sedation with four different analgesic–sedative drugs. Fifty-one questionnaires were completed by pediatric nurses, with a median length of experience of 10 years. Regarding the overall quality of the sedation, the highest median satisfaction scores were observed for propofol (8, IQR 7–9), dexmedetomidine (8, IQR 6–8) and midazolam (8, IQR 7–9). Ketamine (5, IQR 3–7) displayed the lowest score. When asked to rate their level of perceived safety, nurses gave high scores to all the four drugs studied, with no statistically significant difference between them. Non-pharmacological techniques during procedural sedation were judged as important by 38 (74.5%) nurses. According to this sample of pediatric nurses, the best quality of procedural sedation in children outside of the operating room is obtained with propofol, dexmedetomidine and midazolam. During procedural sedation, nurses feel safe overall, regardless of the pharmacological regimen used. Moreover, they highlighted the relevance on non-pharmacological approaches in the preparation of the child for the procedure.

Purpose Nurses play a pivotal role during pediatric procedural sedation and their perspective is an important indicator of the quality of care. The aim of this study is to examine nurses’ satisfaction comparing four different pharmacological regimens used for pediatric sedation outside of the operating room. Methods A prospective observational study was conducted in a third level pediatric teaching hospital, involving all the nurses with experience in the field of pediatric procedural sedation. A 13-items survey was used to assess the level of nurses’ satisfaction for the quality of sedation with four different analgesic-sedative drugs. Results Fifty-one questionnaires were completed by pediatric nurses with a median length of experience of 10 years. Regarding the overall quality of the sedation, the highest median satisfaction scores were observed for propofol (8, IQR 7–9), dexmedetomidine (8, IQR 6–8) and midazolam (8, IQR 7–9). Ketamine (5, IQR 3–7) displayed the lowest score. When asked to rate their level of perceived safety, nurses gave high scores to all the four drugs studied, with no statistically significant difference between them. Non-pharmacological techniques during procedural sedation were judged as important by 38 (74.5%) nurses. Conclusions According to this sample of pediatric nurses, the best quality of procedural sedation in children outside of the operating room is obtained with propofol, dexmedetomidine and midazolam. During procedural sedation, nurses feel overall safe regardless of the pharmacological regimen used. Moreover, they highlighted the relevance on non-pharmacological approaches in the preparation of the child for the procedure.

Coeliac disease is an immune-mediated systemic disease that affects 1% of the population and it is caused by the ingestion of gluten in genetically predisposed subjects. Clinical manifestations and intestinal damage completely resolve once gluten is excluded from the diet, therefore the precocity of diagnosis is of primary relevance. Although considerable progress has been made in recent years, the wide spectrum of clinical manifestations still causes diagnostic delay. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) has recently published an update of the guidelines providing tools to optimize diagnostic skills. This work aims to summarize the main topics of the new guidelines through illustrative clinical cases.

Although the effectiveness of probiotics has only been proven in specific conditions, their use in children is massively widespread because of their perception as harmless products. Recent evidence raises concerns about probiotics’ safety, especially but not only in the paediatric population due to severe opportunistic infections after their use. This review aimed at summarising available case reports on invasive infections related to probiotics’ use in children. For this purpose, we assessed three electronic databases to identify papers describing paediatric patients with documented probiotic-derived invasive infections, with no language restrictions. A total of 49 case reports from 1995 to June 2021 were identified. The infections were caused by Lactobacillus spp. (35%), Saccharomyces spp. (29%), Bifidobacterium spp. (31%), Bacillus clausii (4%), and Escherichia coli (2%). Most (80%) patients were younger than 2 years old and sepsis was the most observed condition (69.4%). All the patients except one had at least one condition facilitating the development of invasive infection, with prematurity (55%) and intravenous catheter use (51%) being the most frequent. Three (6%) children died. Given the large use of probiotics, further studies aiming at evaluating the real incidence of probiotic-associated systemic infections are warranted.

Background and Objectives: This observational study aims to determine the correlation between glycemic control with the HbA1c value and adverse obstetric outcome in women affected by pre-gestational diabetes. Materials and Methods: A retrospective analysis has been performed at the University Hospital of Udine. Only patients with a singleton pregnancy, pre-gestational diabetes, and known level of Hb A1c throughout pregnancy were included in the study. Results: According to the HbA1c level, at the beginning of pregnancy, 49 patients with HbA1c ≤ 7.0% were compared with 45 patients with HbA1c > 7.0%. Maternal age at diagnosis of the disease was significantly higher in the group with HbA1c ≤ 7% than in the group with HbA1c > 7%, 26.00 (18.00–32.00) vs. 20.00 (12.50–27.00). Women with HbA1c ≤ 7.0% reached, at term of pregnancy, significantly lower levels of HbA1c, 5.8% (5.7–6.0) vs. 6.7% (6.3–7.3). Daily insulin units were statistically different between the two groups at the end of pregnancy (47.92 (39.00–67.30) vs. 64.00 (48.00–82.00)). Proteinuria was significantly higher in the group with HbA1c > 7.0%, who delivered at earlier gestational age (37.57 (35.57–38.00) vs. 38.14 (38.00–38.43). Moreover, women with HbA1c > 7.0% had a significantly higher prevalence of an adverse composite outcome. Of note, in multivariate logistic regression analysis, pregnancy complications were significantly correlated to pre-pregnancy HbA1c > 7.0% (OR 2.95 CI.95 1.16–7.48, p < 0.05) independently of age, insulin treatment, and type of diabetes. Conclusions: Our data, obtained from a single-center cohort study, suggest that starting pregnancy with poor glycemic control might predict more complex management of diabetes in the following trimesters.