Review

Child healthcare services offered by the State in its national territory and in extra-territorial neighboring Italian areas

Alberto Villani1, Michele Giuliani2, Massimiliano Raponi1, Saverio Ladogana2, Pierpaolo Cristalli2, Michele Sacco2, Massimo Pettoello-Mantovani2

1Ospedale Pediatrico Bambino Gesù (OPBG), SCV, Roma, 2Department of Pediatrics, Scientific Institute “Casa Sollievo della Sofferenza” SCV, San Giovanni Rotondo, Italy

Abstract Pediatric healthcare activity related to the Vatican City State is carried out at secondary and tertiary levels in the two main pediatric territorial and extra-territorial medical centers, which are administered by the Vatican: the Bambino Gesù Pediatric Hospital and the Mother and Child pediatric Department of the Casa Sollievo della Sofferenza Medical Center. Both centers are recognized by the Italian State and internationally with the formal legal status of Scientific Institutes for Clinical Research. The relations established between the , in the person of the Secretary of State, the Board of Directors, the President of the Board, and the Board of Auditors regulate the management of the two medical centers. The child healthcare and research activity of the two Vatican State administered medical centers is described in this article.

Keywords: Children, extra-territorial, healthcare

Introduction types of institutions and organizations are located, in- The Vatican City State is an independent city-state en- cluding medical centers providing public care to the clave within , Italy, which was established with the Vatican, Italian, and non-Italian population gathering , signed between the Holy See and Italy on form different parts of the world. February 11th, 1929. It is under the “full ownership, exclu- sive dominion, and sovereign authority and jurisdiction” Its status as a Sovereign Entity under international public of the Holy See. In 1964, the Vatican State was admitted at law is universally recognized [United Nations, the World the United Nations Assembly, which enables it to vote in Health Organization (WHO), and it is legally distinct various UN conferences and to participate in the General from the religious component called the “Holy See.” Assembly discussions and consensus agreements. The entire territory of the Vatican City State is placed With an area of just 44 hectares (108.7 acres), the Vati- under the protection of Convention of May can City State is the smallest independent state in the 14th, 1954, concerning the protection of cultural property world, both in terms of the number of inhabitants and in the event of armed conflict. In 1984, the Vatican City of territorial extension. Its boundaries are bordered by was included in the list of world cultural and natural walls, and on Piazza San Pietro, by a marble strip that heritage sites, referred to in the UNESCO Convention of connects the two wings of the colonnade. In addition November 16th, 1972, on the protection of this heritage. to the state’s own territory, the Vatican jurisdiction ex- There are a total 618 citizens of the State, of whom only tends in areas of Rome and beyond Rome, which enjoy 246 (including 104 members of the Swiss Guards) live the right of “extraterritoriality.” In these areas, various within the walls.

Cite this article as: Villani A, Giuliani M, Raponi M, et al. Child healthcare services offered by the Vatican City State in its national territory and in extra-territorial neighboring Italian areas. Turk Pediatri Ars 2020; 55(Suppl 1): S105–S111.

Corresponding Author: Massimo Pettoello-Mantovani E-mail: [email protected] ©Copyright 2020 by Turkish Pediatric Association - Available online at www.turkpediatriarsivi.com DOI: 10.14744/TurkPediatriArs.2020.23690 OPEN ACCESS This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. S105 Villani et al. Vatican City State child healthcare Turk Pediatri Ars 2020; 55(Suppl 1): S105–S111

About half of the citizens therefore do not reside in the Main pediatric centers administered by the Vatican City State, but in other countries, above all for reasons of ser- State vice (in particular diplomatic personnel). The acquisition The pediatric healthcare activity related to the Vatican and the loss of citizenship and various other matters, in- City State is carried out at secondary and tertiary levels cluding mother and child care, are governed by specific in two main pediatric medical centers: the Bambino Gesù provisions, mostly regulated by the 1929 Lateran Treaty, Pediatric Hospital, located in the territory of the Vatican which was signed after a long period of confrontation fol- City State, and the Mother and Child pediatric Depart- lowing the military takeover of the large territory of the ment of the Casa Sollievo della Sofferenza Medical Cen- Vatican State (11789 Km2/4555 mi2), by the Italian Kingdom ter, located extra-territorially, in Italy. Both centers are in 1870. The Vatican City State has now, therefore, the sin- recognized by the Italian State and internationally with gular characteristic of an instrument of independence of the formal legal status of Scientific Institutes for Clinical the Holy See and of the from any power Research (IRCCS) (2, 3). constituted in the rest of the world, and the structures of the Vatican State are reduced to the minimum indispens- The relations established between the Holy See, in the able for its functioning. person of the Secretary of State, the Board of Directors, the President of the Board, and the Board of Auditors reg- In 1929, the first documented medical guard in Vatican ulate the management of the two medical centers. City State was established, with a medical-surgical clin- ic attached to the Vatican (1). This is a service, Bambino Gesù Pediatric Hospital which, since 1969, has been under the direction of the The Bambino Gesù Pediatric Hospital was founded in Health Services Directorate, which is responsible for Rome in 1869 as the first royal Italian pediatric hospital, health protection in the microstate territory. The first aid on the model of the Hôpital des Enfants Malades in Par- service is provided to anyone who urgently needs it in the is, on the initiative of the Salviati dukes. In 1924, it was Vatican City territory and in the adjacent extraterritorial donated to the Holy See, becoming in effect the Hospital area and is active especially during events that attract a of the . In 1985, it was recognized as a Scientific In- large number of people. stitute for Clinical Research (IRCCS), based on its docu- mented research activity of support to medical care. In Healthcare in the Vatican City State 2006, it obtained the first accreditation by the Joint Com- Healthcare is entrusted to the “Directorate of Health and mission International (JCI), which certified the excellence Hygiene of the Vatican City State.” Public health is pro- of the Center in the quality of pediatric healthcare (4, 5). In vided through the “Healthcare Fund” (FAS) of the Vatican 2014, new research laboratories were inaugurated, which City State. FAS provides health assistance and coverage extend over 5000 square meters. They are equipped with for ecclesiastical, religious and lay staff, in-service and the most modern technologies for genetic and cellular retired, of the , of the Governorate of the surveys, with a Pharmaceutical Workshop (Cell Factory) State of Vatican City, and it is extended to bodies admin- entirely dedicated to the large-scale production of ad- istratively managed, directly, by the Apostolic See, also if vanced therapies. In 2015, the Hospital was granted the located extraterritorially. status of Academic Medical Center by the JCI for the medical and clinical training activity (6). The Fund finances the following services, both directly and indirectly: (a) medical and surgical assistance in the Healthcare provided by the Bambino Gesù pediatric cen- event of illness, including chronic or terminal forms; (b) ter is divided into 4 hospitals: the historic headquarters medical and obstetric assistance in case of pregnancy; of the Gianicolo hill, the scientific center of Saint Paul’s (c) conservative dental treatments; (d) administration of Outside the Walls, both located in the metropolitan area drugs in accordance with the handbook approved by the of Rome; and the satellite centers of Palidoro and Santa Board of Directors; (e) economic contributions for any Marinella, on the Lazio Region coast. The Bambino Gesù supplementary services. However, the Fund does not pro- pediatric hospital counts 607 beds, of which 62 are in var- vide the following related services: (a) treatment for dis- ious intensive care units, and 22 in the neonatal intensive eases intentionally contracted or aggravated; (b) medical care clinical unit. or surgical interventions with a purely aesthetic purpose. The Health Assistance Fund is used to fully cover expens- An average of 29,000 hospitalizations are provided every es from the administrative fees and contributions paid by year, over 30,000 surgical and interventional procedures, members, according to the measures approved from time 42,000 days of day hospital, and 85,000 accesses to the to time by the Cardinal Secretary of State. emergency department. The outpatient services provided

S106 Turk Pediatri Ars 2020; 55(Suppl 1): S105–S111 Villani et al. Vatican City State child healthcare annually are 2,000,000. However, the scope of the Hos- Clinical departments pital’s activity extends beyond the territory of Rome and The Directorate of Clinical Departments coordinates Lazio: 29% of hospitalized patients come from outside the clinical-assistance, organizational, and management the Region, while 15% are of foreign nationality. activities of the Departments. It coordinates the rela- tionship between the Administration and the Clinical The hospital’s care offer covers all medical specialties. Departments directed to the planning and allocation of Transplantation, genetic, and metabolic diseases, medical resources in accordance with the strategic and budget and surgical cardiology, neuroscience, oncohematology objectives and promotes the development and improve- and rehabilitation are among the sectors of care and re- ment of clinical-assistance processes. It carries out its search of absolute excellence. The Bambino Gesù Center functions in accordance with the guidelines of the Health is the only European center able to respond to all trans- Department and the Scientific Direction, as far as their plant needs of the pediatric age group: heart, marrow, respective competence is concerned. cornea, including the activity of living transplant involv- ing the liver and kidney (in 2018, in total, 324 organ, cell The Departments depending on the Directorate are as and tissue transplants were performed, including eight follows: Surgical Department, Diagnostic Imaging De- artificial heart implants). partment, Acceptance Emergency Department, Depart- ment of Laboratories, Medical Surgery Department of Clinical activity is accompanied by an intense reception Pediatric Cardiology, Department of Medical and Sur- activity for families, in particular those coming from out- gical Neonatology, Department of Neurosciences and side the region engaged in long therapeutic treatments. Neurorehabilitation, Department of Oncology and He- With the help of a network of associations, foundations matology, Cellular and Genetic Hematology and Thera- and hotel agencies, the Hospital manages to guarantee py, Specialist Pediatrics Department, University-Hospital free housing assistance to more than 4400 families, for Pediatric Department. about 96,000 nights every year. Research activity The Bambino Gesù is currently present internationally The experimental activity performed at the hospital refer with training and assistance interventions in 12 coun- to the Trials Center or directly to the U.O. competence. tries: Central African Republic, Tanzania, Ethiopia, , The Trials Center is a structure created to guarantee ex- Jordan, Cambodia, India, China, , Haiti, Ecuador cellence and quality of care through advanced pharma- and South Korea. cologic experiments; its mission is to promote the excel- lence of clinical trials in pediatrics, in accordance with Thanks to the support of the Bambino Gesù Foundation, Good Clinical Practice, to provide pediatricians with the dozens of humanitarian patients are welcomed and cared tools necessary for conducting high-quality research. for each year (in 2018, 62 humanitarian patients from 28 countries were received), children from abroad with seri- Research Areas for the 2016–2019 three-year period were: ous pathologies or war wounds, which in their own Coun- Genetics and Rare Diseases, Multifactorial Diseases and try would have no possibility of treatment. The commit- Complex Diseases, Immunology, Infectious Disease and ment to the “peripheries” of the world does not forget Development of Pediatric Drugs, Oncohematology, Clini- the city of Rome, where the Hospital of the Holy See is cal-Management, and Technological Innovations. present with a mobile health unit in the parishes and in the most disadvantaged neighborhoods (7, 8). Biobank The Biobank is a non-profit organization that, in the re- The Research Areas are organizational units consisting of spect of the rights of the participants involved and ac- the structural and/or functional aggregation of several re- cording to proven quality standards to guarantee the search projects, which are identified consistently with the complete traceability of the activities, manages the col- strategic guidelines of the hospital in the research sec- lection, processing, storage, and distribution of biologic tor. The Research Areas are divided into Research Units, material and associated data. The stored biologic samples identified with the objective of carrying out one or more can be of different types (cells, tissues, nucleic acids, bio- projects of similar content and pursuing specific objec- logic liquids and others), and are always accompanied by tives of scientific, assistance or management relevance a panel of data (clinical, scientific, epidemiologic, genetic, (9). Professionals affiliated to a specific Area express -com family, lifestyle and more) of the participant (patient or plementary skills, often transversal to different hospital healthy person), archived in full respect of ethical, legal, structures. social and privacy aspects.

S107 Villani et al. Vatican City State child healthcare Turk Pediatri Ars 2020; 55(Suppl 1): S105–S111

The samples stored in research biobanks are invaluable extra-territorial polyclinic hospitals hosted in the Italian and help to transfer conventional medicine to precision, geographical territory, and it is recognized as a leading predictive, and preventive medicine. The service provided institution in the medical and social care, as well as in by a research Biobank therefore has public value, consid- scientific research in the Center-Southern area of Italy. ering that patients, their families, and the entire society The Medical Center, including the Mother and Child are the first beneficiaries of the new diagnostic investiga- Department, is part of a Vatican Medical not-for-profit tions and innovative therapies that can be designed and Foundation, which Board is the governing body of the developed through the use of samples of the Biobank. Organization. Since 2006, the Mother and Child Depart- ment has been part of the centers of Excellence, hosting In the years following its classification as a Scientific -In the university residency training in pediatrics of the Ital- stitute for Clinical Research the Bambino Gesù Pediatric ian University of Foggia. During the last 10 years, the pe- Center was committed to the collection, for research pur- diatric team of Casa Sollievo della Sofferenza published poses, of biologic material, with particular regard to rare over 200 scientific articles in various fields of clinical -pe and complex diseases, genetic and orphan diagnosis, and diatrics, all in prestigious international scientific journals, onco-hematologic diseases. listed in PubMed and reported in Scopus.

Currently, in its research laboratories, four historical col- Pediatric healthcare professionals, working for the Casa lections are preserved, including about 100,000 samples, Sollievo della Sofferenza Medical Center, are directly en- taken from more than 45,000 subjects, which fall into 18 gaged in clinical care and offer their expertise in various different chapters of the international classification of childcare specialties. In particular, the Mother and Child Diseases and Health Problems (ICD10). Department includes four Pediatric Units: the general and polyspecialistic pediatrics unit, the pediatric hematol- From 2017, a process was started to adapt the activities ogy-oncology unit, the neonatology and high education in line with the international recommendations and best and clinical research academic unit (10). The non-medical practices for the management of biologic material and staff counts over 2700 employees. related data. The process led to the achievement of two important objectives in 2018: (1) the entry of the Research The department’s activity aims at providing high quality Biobank into the international Biobanking and BioMo- care and social assistance to all subjects in the develop- lecular Resources Research Infrastructure (BBMRI); (2) the mental age up to 16 years, suffering from the most fre- certification of Biobank activities according to the inter- quent acute and chronic pathologies and rare diseases. national quality assurance ISO 9001 by the accredited cer- During 2018, over 5000 patients were admitted in the var- tifying body Det Norske Veritas (DNV-GL). ious units of the Mother of Child Department.

The Research Biobank of the Bambino Gesù Pediatric The first pediatric unit, which began its clinical activity Hospital Center is regulated by specific criteria for the on May 5th, 1956, as part of the original medical building, evaluation of requests for conservation and use of bio- moved in 2002 to its new location in the new medical logic material and related data, taking into consideration complex called John Paul II. The children’s hospital in- the quality of the research projects. These criteria do not cludes clinical units and research sections, the ambulato- exclude third parties interested in the pediatric Center ry and day hospitals facilities, the outpatient departments, Research Biobank collections, with a view to international and the Child Neuropsychiatry Service, which are all collaboration with associations, networks, research insti- functionally aggregated to the department. tutes, and private subjects involved in translational and personalized medicine activities General pediatrics and polyspecialistic unit The general pediatrics and polyspecialistic unit counts 29 Casa Sollievo Della Sofferenza Medical Center - mother beds, of which four are dedicated to day hospital activi- and child department ties, and includes several specialty sections: diabetology, The Mother and Child Department is part of the Casa endocrinology, gastroenterology, hepatology, bronchus Sollievo della Sofferenza (Home for the Relief of Suffer- pneumology, allergology, rheumatology, nephrology, and ing) Medical Center, also known as the Hospital of Pa- urology, rare diseases. The Infant Neuropsychiatry Unit dre Pio, is formally classified as a “highly ranked religious is also part of the Pediatric Unit, and provides care for hospital.” It is administered and falls under the jurisdic- children and adolescents with neurologic pathologies, in tion of the Vatican City State. The Casa Sollievo della Sof- particular epilepsy, headache, cranial trauma, neuromus- ferenza medical center, is considered one of the largest cular diseases, and mental retardation.

S108 Turk Pediatri Ars 2020; 55(Suppl 1): S105–S111 Villani et al. Vatican City State child healthcare

Since 1986, the department has been recognized as a Re- geal reflux and esophagitis; gastroduodenitis and Helico- gional Center for the Diagnosis and Therapy of Hypoph- bacter pylori infection. yseal Nanism and the Pediatric Unit is recognized by the Puglia Region as the center of reference of the National The Gastroenterology and Digestive Endoscopy unit pro- Network of Rare Diseases and for the following diseas- vides the following tests: ph-metha esophageal continu- es: Kawasaki syndrome, neurofibromatosis, septo-optical ation; manometry; breath tests; endoscopy of the upper dystrophy, and pediatric rare liver diseases. and lower gastrointestinal tract; operative endoscopy; biopsy of the endoscopic intestinal mucosa; evaluation The Pediatric Basic Life Support-Defibrillatiom (PBLSD) of pancreatic function; cardiopulmonary resuscitation Training Center has been set up at the Pediatric Operative (CPR); positioning of percutaneous endoscopic gastros- Unit together with the First Aid and Resuscitation Unit; it tomy (PEG); echo-guided liver biopsy; and serous therapy is recognized by the Italian Resuscitation Council and is of esophageal varices. The Diagnostic Radiology section part of its national training network. provides the following diagnostic exams: cholangiogra- phy and arteriography of the celiac tripod, and the Dietary The center operates in the field of training for health per- Service performs dietary regimes in gastrointestinal pa- sonnel, offering several training courses, including PBLSD. thologies, and parental and enteral nutrition.

The clinical activity of diagnosis and treatment of pedi- Hepatology and liver transplantation section atric patients performed by these facilities is divided into This section deals with all liver and kidney diseases, fol- two macro areas of competence: General and Polyspecial- lowing up pediatric patients already transplanted or with istic Pediatrics. serious liver diseases for which there is an indication for inclusion in a transplant list. The main diseases treated The activity of the pediatric center is performed in close are neonatal cholestasis and extra-hepatic bile duct atre- coordination with the regional network of primary care sia, Wilson’s disease and metabolic hepatopathies, chron- pediatricians (11, 12). The areas of clinical excellence that ic HBV and HCV-related hepatitis, autoimmune hepatitis, characterize the pediatric center of Casa Sollievo are re- biliary calculosis, steatosis and steatohepatitis, and portal ported and briefly described below. hypertension.

Auxo-endocrinology-diabetology section Immunology, allergology, and bronchopneumology Clinical activity involves the integration of endocrinolog- section ic, dietary, and neuropsychiatric skills. In this specialized field, the activity is extended to the di- agnosis and treatment of acute and chronic respiratory The main diseases treated are insulin-dependent diabe- diseases: bronchial asthma, acute pneumopathies, chron- tes mellitus and other alterations of carbohydrate metab- ic pneumopathies, immuno-allergic disorders, atopic der- olism (D.M.type II, MODY); pituitary dysfunction; thyroid matitis, urticaria, food allergies, allergic rhinoconjunctivi- dysfunction; gonadal dysfunction and abnormalities of tis, rheumatologic pathology, recurrent arthralgias, acute sexual differentiation; adrenal dysfunctions; and eating and chronic arthritis, collagenopathies, and recurrent and disorders. periodic fevers.

The main procedures performed in the field of endocri- Nephrology and urology section nology diagnostics are dynamic tests for the evaluation This section provides diagnostic procedures and treatment of the function of endocrine glands and glucose metab- of kidney and urinary tract diseases in children and adoles- olism, which involve the infusion/administration of sub- cents. The main diseases treated are congenital nephropa- stances with stimulatory or suppressive properties and thy, acute and chronic renal failure, acute and chronic ne- peripheral blood sampling. phritis, infections, and malformations of the urinary tract

Gastroenterology section Neurocutaneous syndromes section This unit deals with all gastroenterological diseases in the Specialists here deal with the diagnosis and treatment of pediatric and adolescence years, following the young pa- patients with NF1 (neurofibromatosis type 1) and neuro- tient from the diagnostic phase to long-term follow-up. cutaneous syndrome in collaboration with the Medical The main diseases treated are malabsorption syndromes; Genetics service, and adopt specific multidisciplinary ap- celiac disease-food allergies; intractable chronic diarrhea; proaches in order to ensure complete assistance to young chronic intestinal inflammatory diseases; gastroesopha- patients.

S109 Villani et al. Vatican City State child healthcare Turk Pediatri Ars 2020; 55(Suppl 1): S105–S111

Table 1. Clinical activity of the neonatology unit* Oncohematology unit Clincal expertise The Pediatric Oncology Hematology Unit counts 20 beds and is one of the Italian Centers accredited by the Ital- Preterm and neonatal anemia ian Association of Pediatric Hematology and Oncology Preterm and neonatal apnea (AIEOP) for the diagnosis and treatment of hematologic Perinatal asphyxia and oncologic diseases of patients aged 0 to 16 years. It Neonatal convulsions is authorized to perform hematopoietic stem cell trans- Bronchopulmonary dysplasia plantation. Respiratory distress Necrotizing enterocolitis (NEC) Neonatology unit The neonatology unit includes 24 beds, of which eight are Congenital infections located in the intensive care section. The Milk Bank is Kidney failure active at this unit and provides its services to the regional Severe respiratory failure community. The clinical expertise of the unit is reported Hyperbilirubinemia in Table 1. Pulmonary hypertension Hypoglycemia and neonatal hypocalcemia Conclusions Hemorrhagic disease of the newborn Pediatric care in medical centers related and adminis- Serious and/or complex malformations tered by the Vatican City State has reached a worldwide high-quality level, widely documented by the scientific pneumothorax activity produced by medical and research personnel in Prematurity and/or low birth weight the pediatric units and related research centers. These Gastroesophageal reflux centers of excellence are able to provide top clinical care Retinopathy of prematurity (ROP) and to develop clinical studies and perform translational Sepsis and meningitis research, which contributes to the global advancement of Mechanic inhalation syndrome pediatric science (12–14). Respiratory syndrome of pulmonary hyaline membranes Conflict of Interest: The authors have no conflicts of in- Transient newborn tachypnea terest to declare. Areas of excellence Financial Disclosure: The authors declared that this study Newborns with severe respiratory failure has received no financial support. Preterm infants, including gestational age and extremely low birth weight Neonatal Transport and Emergency Service References Milk Bank 1. Stato Città del Vaticano. Sanità e igiene, Città del Vatica- *: Mother and Child Department of Casa Sollievo della no. Available at: https://www.vaticanstate.va/it/. Accessed Sofferenza Medical Center 28 October, 2019. 2. Ehrich JH, Tenore A, del Torso S, Pettoello-Mantovani M, Neuropsychiatry and psychotherapy section Lenton S, Grossman Z. Diversity of Pediatric Workforce and Education in 2012 in : A Need for Unifying This deals with all clinical disorders that involve the ner- Concepts or Accepting Enjoyable Differences? J Pediatr vous system and the psyche of children and adolescents, as 2015; 167: 471–6.e4. [CrossRef ] well as their families. Moreover, a good part of its activity, 3. Ehrich J, Namazova-Baranova L, Pettoello-Mantovani M. is conducted profitably as day and outpatient admissions, Introduction to “Diversity of Child Health Care in Eu- carrying out electroencephalography (EEG) performed with rope: A Study of the European Paediatric Association/ video recording and taking care of patients with mental re- Union of National European Paediatric Societies and As- tardation, headache, behavioral disorders, autism, specific sociations”. J Pediatr 2016; 177S: S1–10. [CrossRef ] developmental disorders, and chronic neurologic diseases. 4. World Health Organization. Global Health Observatory (GHO) data. Available at: www.who.int/gho/child_health/ The main treated diseases are epilepsy, mental retarda- en/index.html. Accessed October 12, 2019. tion, headache, behavioral disorders, autism, specific de- 5. Wolfe I, Thompson M, Gill P, et al. Health services for velopmental disorders, and chronic neurologic diseases. children in western Europe. Lancet 2013; 381: 1224–34.

S110 Turk Pediatri Ars 2020; 55(Suppl 1): S105–S111 Villani et al. Vatican City State child healthcare

6. Pettoello-Mantovani M, Ehrich J, Romondia A, Nigri L, 10. Silano M, Vincentini O, Luciani A, et al. Early tissue trans- Pettoello-Mantovani L, Giardino I. Diversity and differ- glutaminase-mediated response underlies K562(S)-cell ences of postgraduate training in general and subspe- gliadin-dependent agglutination. Pediatr Res 2012; 71: cialty pediatrics in the . J Pediatr 2014; 532–8. [CrossRef ] 165: 424–6. [CrossRef ] 11. Pettoello-Mantovani M, Campanozzi A, Maiuri L, Giardi- 7. P, Corsello G, Basile MC, Nigri L, Campanozzi A, no I. Family-oriented and family-centered care in pediat- Ehrich J, Pettoello-Mantovani M. The Economic Burden rics. Ital J Pediatr 2009; 35: 12. [CrossRef ] of Child Maltreatment in High Income Countries. J Pe- 12. Biasci P, Sanz AC, Pop TL, Pettoello-Mantovani M, D’Avi- diatr 2015; 167: 1457–9. [CrossRef ] no A, Nigri L. The State of Children’s Health in Europe. J 8. Pettoello-Mantovani M, Pop TL, Mestrovic J, et al. Foster- Pediatr 2019; 209: 260–1.e1. [CrossRef ] ing Resilience in Children: The Essential Role of Health- 13. Hojsak I, Fabiano V, Pop TL, et al. Guidance on the use care Professionals and Families. J Pediatr 2019; 205: 298–9. of probiotics in clinical practice in children with select- 9. Albenzio M, Campanozzi A, D’Apolito M, Santillo A, Pert- ed clinical conditions and in specific vulnerable groups. toello-Mantovani M, Sevi A. Differences in protein frac- Acta Paediatr 2018; 107: 927–37. [CrossRef ] tion from goat and cow milk and their role on cytokine 14. Somekh I, Somekh E, Pettoello-Mantovani M, Somech production in children with cow’s milk protein allergy. R.The Clinician Scientist, a Distinct and Disappearing Small Ruminant Research 2012; 105: 202–5. [CrossRef ] Entity. J Pediatr 2019; 212: 252–3. [CrossRef ]

S111