Francesca Benedetti

N-acetylcysteine (NAC) is widely used for its mucolytic, antioxidant, anti-inflammatory and synergistic antibacterial properties in the treatment of respiratory diseases. NAC and other mucolytics and mucoactive medications are frequently employed in the adult population and in paediatric settings to improve mucus clearance in conditions such as cystic fibrosis, bronchiolitis, pneumonia, and both chronic and acute bronchitis, with varying degrees of success. This narrative review evaluates the efficacy and safety of NAC in paediatric acute and chronic respiratory diseases, synthesizing data from clinical trials, observational studies and real-world evidence, with a particular focus on optimizing dosing based on patient-specific characteristics. Numerous studies indicate that oral NAC doses of 20 mg/kg/day for acute conditions and 200 mg three times daily for chronic conditions are generally effective and well tolerated in children. However, most participants in these studies were older than 9 years, resulting in a lack of literature-based evidence for the optimal dosing in younger children over 2 years of age. Given the significant weight variations within this age group, weight-based dosing is recommended to ensure appropriate drug exposure and optimize treatment benefits. Weight-based dosing adjustments and patient monitoring may help optimize treatment outcomes and reinforce the overall positive safety and tolerability profile in paediatric settings. NAC is a valuable therapeutic agent for paediatric respiratory diseases, particularly in older children. In younger patients, weight-adjusted dosing and careful monitoring for potential adverse effects may help maximize efficacy and maintain its favourable tolerability profile.

Pediatric palliative care (PPC) aims to enhance the quality of life of children with life-limiting conditions and their families through individualized, interdisciplinary support. Among this population, children with neurological diseases represent a substantial and growing group, often facing prolonged disease courses, cognitive impairment, and high prognostic uncertainty. Effective communication is central to PPC; however, it remains deeply influenced by cultural, religious, and spiritual frameworks that shape family perceptions of illness, suffering, and decision-making. This narrative review explores communication strategies in PPC, with a specific focus on children with neurological conditions, highlighting conceptual foundations, cross-cultural variations, and emerging best practices. Key findings highlight the importance of culturally humble approaches, family-centered communication models, and structured tools, such as co-designed advance care planning and dignity therapy, to enhance communication. Additionally, the review highlights the presence of ethical and interdisciplinary challenges, particularly in neonatal and neurology settings, where misaligned team messaging and institutional hesitancy may compromise trust and timely referral to palliative care. Future research, policy, and clinical education priorities should advocate for models that are inclusive, ethically grounded, and tailored to the unique trajectories of neurologically ill children. Integrating cultural competence, team alignment, and family voices is essential for delivering equitable and compassionate PPC across diverse care settings.

Pediatric palliative care (PPC) aims to enhance the quality of life for children with life-limiting conditions and their families through individualized, interdisciplinary support. Among this population, children with neurological diseases represent a substantial and growing group, often facing prolonged disease courses, cognitive impairments, and high prognostic uncertainty. Effective communication is central to PPC, yet it remains deeply influenced by cultural, religious, and spiritual frameworks that shape family perceptions of illness, suffering, and decision-making. This narrative review explores communication strategies in PPC with a specific focus on children with neurologic conditions, highlighting conceptual foundations, cross-cultural variations, and emerging best practices. We examine how culturally humble approaches, family-centered models, and structured tools such as co-designed advance care planning and dignity therapy can enhance communication. Additionally, we address ethical and interdisciplinary challenges—particularly in neonatal and neurology settings—where misaligned team messaging and institutional hesitancy may compromise trust and timely referral to palliative care. Finally, we identify future priorities in research, policy, and clinical education, advocating for models that are inclusive, ethically grounded, and tailored to the unique trajectories of neurologically ill children. Integrating cultural competence, team alignment, and family voice is essential to delivering equitable and compassionate PPC across diverse care settings.

Background: The death of a child due to complex congenital heart disease (CCHD) in pediatric intensive care units profoundly affects families, often resulting in lasting grief and emotional distress. Despite advancements in pediatric palliative care (PPC), significant gaps persist in communication and end-of-life (EoL) planning. This study explores the experiences and perceptions of bereaved parents to identify areas for improvement in PPC delivery. Methods: A qualitative phenomenological design was used to analyze the lived experiences of 18 bereaved parents whose children died from CCHD at a tertiary cardiac center. Semi-structured telephone interviews were conducted, incorporating five open-ended questions. Data were analyzed inductively using Colaizzi’s method to identify recurring themes and subthemes. Results: Four key thematic areas emerged: communication issues, the parental role, child care, and bereavement support. Parents highlighted inconsistent communication, lack of preparedness for EoL decisions, and emotional isolation as major challenges. Positive experiences often involved compassionate healthcare providers and structured psychological support. A significant proportion of parents identified family support and faith as key coping mechanisms, while others expressed dissatisfaction with post-mortem follow-up and the absence of long-term bereavement care. Conclusions: Bereaved parents’ experiences underscore the need for improved communication strategies, greater parental involvement in care, and enhanced bereavement support. Integrating structured decision-making pathways early in the care trajectory may help mitigate parental distress and improve the quality of EoL experiences for children with CCHD.

Background: The death of a child due to complex congenital heart disease (CCHD) in pediatric intensive care units profoundly affects families, often resulting in lasting grief and emotional distress. Despite advancements in pediatric palliative care (PPC), significant gaps persist in communication and end-of-life (EoL) planning. This study explores the experiences and perceptions of bereaved parents to identify areas for improvement in PPC delivery. Methods: A qualitative phenomenological design was used to analyze the lived experiences of 18 bereaved parents whose children died from CCHD at a tertiary cardiac center. Semi-structured telephone interviews were conducted, incorporating five open-ended questions. Data were analyzed inductively using Colaizzi’s method to identify recurring themes and subthemes. Results: Four key thematic areas emerged: communication issues, the parental role, child care, and bereavement support. Parents highlighted inconsistent communication, lack of preparedness for EoL decisions, and emotional isolation as major challenges. Positive experiences often involved compassionate healthcare providers and structured psychological support. A significant proportion of parents identified family support and faith as key coping mechanisms, while others expressed dissatisfaction with post-mortem follow-up and absence of long-term bereavement care. Conclusions: Bereaved parents’ experiences underscore the need for improved communication strategies, greater parental involvement in care, and enhanced bereavement support. Integrating structured decision-making pathways early in the care trajectory may help mitigate parental distress and improve the quality of EoL experiences for children with CCHD.

Background: Pediatric palliative care (PPC) is defined as the prevention and relief from suffering of families and children with life-limiting (LLDs) or life-threatening diseases (LTDs). These patients often experience pain, with morphine being the most widely used drug to treat it. Few studies investigated the role of methadone in PPC patients, although it is considered among the most effective and underutilized drugs in PPC. Objectives: Our aim was to evaluate the efficacy, safety, and dosage of methadone in PPC. Methods: Between August and October 2021 PubMed, Scopus and the Cochrane Library were searched for studies on the use of methadone in children with LLDs and LTDs. Articles were included if they met the following criteria: published in the last 10 years, English language, patients aged 0–23 years; children enrolled in a PPC center or receiving declared support from a PPC service; reporting of specific data on methadone in interventional trials, observational studies, or case series on >10 patients. The reporting of the article was guided by the PRISMA guidelines, and a critical appraisal of the included studies was performed using the JBI-tool. Results: After duplicates removal and full-text assessment, four studies were included and another one was added after checking the references of the retrieved papers. All were retrospective, and the literature is concordant in documenting the lack of evidence. A total of 116 children received methadone in PPC. From our review emerges the poor quality of data collection: in only one study pain was assessed with standardized scales. All studies documented the effectiveness of methadone in treating complex pain, either nociceptive or neuropathic. No serious adverse events were reported, with no cases of cardiac arrhythmias. Conclusion: Our results suggest that methadone could represent a suitable strategy for treating pain in PPC. However, the evidence base is insufficient, and further research is warranted.