Perception and Management of COVID-19 Among Allergic Children: An Italian Survey.


 Background There is ample evidence that COVID-19 is significantly less severe in children than in adults and it has been reported that asthma and allergy, the most prevalent chronic disorders in children, are not included in the top 10 comorbidities associated with COVID-19 fatalities. Nevertheless, there would seem that the concerns about asthma and the risk of disease and related outcomes are still high. In order to assess these features, we conducted a 20-question anonymous internet-based survey among Italian paediatricians. Methods The questionnaire was conceived and pretested in April 2020, by a working group of experts of the Italian Paediatric Society for Allergy and Immunology (SIAIP). The survey was emailed once between April and mid-May 2020. Participants were allowed to complete only a single survey.Results A total 99 participants had taken part in our survey and provided responses to our electronic questionnaire. The distribution of patients reported per month varies significantly according to the geographical area (P=0.02). Data confirmed that in the North part of Italy the rate of patients referred is higher than in the rest of Italy. Almost all respondents (98%) reported caring for up to a maximum of 10 infecting children and the last 2% more than twenty. Among these patients, according to the 75% of responders, a maximum rate of 20% were affected by allergic rhino-conjunctivitis and in particular in the North of Italy while in the Centre and in the South there was a higher incidence (P=0.09). Almost the same applies for asthma, 83% of responders declared that up to a maximum of 20% of affected children were asthmatic, from 20% to 40% for the 13,5% of responders and from 40% to 60% for the last 3,5%. As for the allergic conjunctivitis also for asthma, we found a higher incidence in the Centre and in South than in the North (P=0.03).Conclusions This study is the first to provide a comprehensive review of COVID-19 knowledge and perceptions among paediatricians in Italy. From our point of view, it provides important information clearly useful for improving a good practice.


Background
In March 2020, the World Health Organization (WHO) has declared the COVID-19 pandemic. The novel coronavirus, SARS-CoV-2, a top threat to global health, emerged in Wuhan (China) in December last year and rapidly spread worldwide [1].
Globally, the total con rmed cases of COVID-19 have reached over 8,975,000, with over 468,000 deaths and daily data shows continuous increases in new COVID-19 cases [1].
In Italy, we have experienced serious outbreaks linked to the rst cluster, in South Lombardy, with about 300000 con rmed cases and more than 30000 deaths [1].
Every age may be affected but childhood seems to be safeguarded by severe COVID-19, due to comorbidities associated with lethal COVID-19 infection (obesity, diabetes and chronic heart disease).
It has been reported that asthma and allergy, the most prevalent chronic disorders in children, are not included in the top 10 comorbidities associated with COVID-19 fatalities [6].
Nevertheless, there would seem that the concerns about asthma and the risk of disease and related outcomes are still high.
Actually, data on COVID-19 in Italian children are limited and almost certainly underestimated, since they are frequently asymptomatic or presenting mild or moderate infection, similar to common cold.
In order to assess these features, we conducted a 20-question anonymous internet-based survey among Italian paediatricians, with available email addresses.

Methods
The questionnaire was conceived and pretested in April 2020, by a working group of experts of the Italian Paediatric Society for Allergy and Immunology Finally, the last part focused on the knowledge in the eld and educational priorities of participants.
The language of the questionnaire was the national one.
The reported time to complete the survey was approximately 10 min.
The survey was emailed once between April and mid-May 2020. Participants were allowed to complete only a single survey, duplicate entries were avoided and responses were scrupulously monitored.
Informed consent was not obtained, given that the participation was voluntary. No nancial incentive was offered.
The Ethics Committee, was contacted and no special permission was deemed to be required because the study design satis ed the criteria of an activity audit.
Once the questionnaire results were obtained, they were processed statistically.
Answers were converted in different categorical variables. Differences in categorical variables were evaluated with Chi square and Fisher exact tests as appropriate.
SAS® University Edition (Cary, NC: SAS Institute Inc) was used for all analyses. Data are expressed as percentage, p < 0.05 were considered statistically signi cant.

Results
A total 99 participants had taken part in our survey and provided responses to our electronic questionnaire by 27 April 2020. The characteristics of the survey participants are detailed in Table 1. Among responders, 52% practiced in a place where there is not a Children Hospital dedicated to COVID care. 86% of respondents reported that in a month referring up to 10 patients for suspected SARS-CoV-2 and up to 20 for the 11% (more than 20 just for the 3%), starting from February 2020 according the majority of them (86%). In particular, the distribution of patients reported per month varies signi cantly according to the geographical area (P = 0.02). Data con rmed that in the North part of Italy the rate of patients referred is higher than in the rest of Italy. Moreover, we found that only the infectious disease specialist reported that in a month referring more than 20 patients for suspected SARS-CoV-2 (P < 0.0001).
The diagnosis of COVID-19 is made once a month according to 34% of participants, once a week for 23% of participants, once in two months for 19%, once in three months for 10%, and once a day for 9% of participants. Almost all respondents (98%) reported caring for up to a maximum of 10 infecting children and the last 2% more than twenty. Among these patients, according to the 75% of responders, a maximum rate of 20% were affected by allergic rhino-conjunctivitis and in particular in the North of Italy while in the Centre and in the South there was a higher incidence (P = 0.09).
Almost the same applies for asthma, 83% of responders declared that up to a maximum of 20% of affected children were asthmatic, from 20-40% for the 13,5% of responders and from 40-60% for the last 3,5%. As for the allergic conjunctivitis also for asthma, we found a higher incidence in the Centre and in South than in the North (P = 0.03).
On average, these children are ≤ 3 years old according to 24% of participants, from ≤ 4 to 6 years old for the 25% of responders as well from ≤ 7 to 10 years old, until 15 years old for the 21% and more than 16 years old for the last 5%.
Of the respondents, 90% agreed immediately isolation in a proper place and to alert the public health service system was the rst step in case of a suspected infection, 13% declared to suggest just the isolation. Eleven percent of respondents would refer out patients to the emergency department and the last 10% leading to an emergency call. However, 45% of participants clari ed that con rmed cases of SARS-CoV-2 infection had nasopharyngeal and oropharyngeal swab sampling, 32% reported that it was not performed in suspected cases and not yet for 23% of responders. In particular, we found that the rate of not performed nasopharyngeal and oropharyngeal swab sampling is higher in the Centre and in the South than in the North (P = 0.02).
Finally, the majority of Italian paediatricians (85%) declared to have a good knowledge about COVID-19, however they'd all be interested to increase knowledge about the impact of COVID-19 on Italian children.

Discussion
There was a good response rate for this survey, re ecting signi cant interest about the ndings of the disease among Italian paediatricians. A good level of knowledge in the eld is linked to a successful practice. So that, evaluating knowledge, attitude and practice among paediatricians is of considerable practical importance.
Responders' knowledge of COVID-19 was fair and balanced. It should be noted that responders were allocated evenly among Italy in order to guaranteed information from all Italian regions. In addition, no signi cant difference has been identi ed with regard to management of a suspected COVID-19 case among Italy.
Regarding signs and symptoms suggestive of COVID-19, our results showed that in children, unlike adults, olfactory and gustatory dysfunctions are not prevalent. These ndings are in line with a recent meta-analysis which included research performed in China (just one clinical case in Singapore) [7].
Allergic rhino-conjunctivitis and asthma, according to our data, seem not to be a risk factor to developing more severe COVID-19. However, since the role of asthma in increasing the severity of COVID-19 is still unclear, it remains a great concern for patients and paediatricians.
The diagnosis and management of COVID-19 in children is still di cult due to the mild or moderate clinical course. Moreover, asymptomatic infections were not infrequent [8] with the risk of uncon rmed disease. This seems to be a frequent problem in daily clinical practice.
Nevertheless, our data showed that Italian children have good chances to be tested for SARS-CoV-2, indicating the importance of an accurate diagnosis, which will facilitate appropriate treatment options and preventive measures.
Our study shows some limitations. Although almost 100 participants completed our survey, only those with access to the Internet and only those with available email addresses were recruited. Other limitations are related to our pilot survey and include the use of a non-standardised questionnaire. However, to the best of our knowledge, standardised and validated surveys on this issue are not available. Some selection bias includes the recruitment methodology; those who felt more interested about COVID-19 may have been more inclined to complete the survey.

Conclusions
This study is the rst to provide a comprehensive review of COVID-19 knowledge and perceptions among paediatricians in Italy. From our point of view, it provides important information clearly useful for improving a good practice.

Declaration Session
Ethics approval and consent to participate Not applicable Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.