Children and adolescents hospitalized for somatic symptoms: a retrospective cohort study

Children and adolescents hospitalized for somatic symptoms: a retrospective cohort study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Children and adolescents hospitalized for somatic symptoms: a retrospective cohort study Michela Orlandi, Chiara Rubino, Alessandra Montemaggi, Giuseppe Indolfi, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8521476/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Somatic symptoms (SS) are physical manifestations associated with clinically significant distress that is disproportionate to or inconsistent with the history, physical examination, and other objective findings; they represent a notable reason for hospitalization in pediatric patients. The present study aimed to describe a cohort of pediatric patients hospitalized for SS. Methods We conducted a retrospective cohort study of children and adolescents hospitalized for SS in the Pediatrics Unit of Meyer Children’s Hospital IRCCS in Florence, Italy, from 2015 to 2024. Results One hundred and twenty-eight patients (male/female ratio 1/2.2; mean age 12 years) were hospitalized with SS over the study period, with a peak in annual prevalence in 2020–2021, corresponding to the COVID-19 pandemic. The most frequent manifestations at admission were musculoskeletal (40%), gastrointestinal (30%), and neurological (23%). Nearly half (49%) experienced symptoms involving multiple systems. The mean duration of hospitalization was 8 days. Magnetic resonance imaging was performed in 55% of patients, and computed tomography in 11%. Almost all (97%) received at least one consultation with a medical specialist, while 86% were assessed by a psychologist, psychiatrist, or both. Biopsychosocial risk factors (such as stressful family events and school absenteeism) were identified in 62%. Conclusion SS are common in children and adolescents and represent a frequent cause of hospitalization. Although awareness of SS is low among healthcare professionals, pediatricians play a key role in detecting and managing SS through a patient-centered approach and a multidisciplinary clinical pathway involving the psychologist and the psychiatrist. Somatic symptoms hospitalization retrospective study multidisciplinary approach Figures Figure 1 What is Known – What is New Somatic symptoms (SS) are physical manifestations associated with clinically significant distress that is disproportionate or inconsistent with the history, physical examination and other objective findings. Through the retrospective analysis of 128 children and adolescents hospitalized for SS over a 10-year period, the study highlights prevalence trends, multisystem involvement, extensive diagnostic use, and the central role of multidisciplinary management. INTRODUCTION Somatic symptoms (SS) are physical manifestations characterized by their association with significant distress that is disproportionate or inconsistent with the history, physical examination and other objective findings. SS account for a spectrum of conditions, ranging from mild, self-limiting symptoms to persistent and disabling conditions leading to impairment in social, occupational, or other areas of functioning[ 1 , 2 ]. Such symptoms have been defined under broad terms, such as psychosomatic disorders, functional complaints, and medically unexplained symptoms. While often transient and benign, SS can persist, particularly in the presence of predisposing or perpetuating factors. Continued symptoms presentation becomes a disorder when it is impairing and meets specific criteria, outlined by the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM 5th [ 3 ]introduced the category of somatic symptom and related disorders (SSRD), which includes somatic symptom disorder (SSD), illness anxiety disorder, functional neurological symptom disorder, psychological factors affecting medical conditions, and factitious disorder (Table 1 ). According to SSD definition, physical symptoms may or may not be justified by a medical condition[ 4 , 5 ]. Compared with earlier diagnostic definitions, this term shifts the emphasis from the absence of a medical explanation to the presence of excessive thoughts, feelings, or behaviors related to somatic symptoms. Table 1 Diagnostic and Statistical Manual of Mental Disorders, 5th Edition diagnostic criteria of SSRD 3 Somatic Symptom Disorders and Related Disorders (SSRD) 1. Somatic Symptom Disorder - One or more somatic symptoms - Excessive thoughts, feelings, or behaviors related to the symptoms (e.g., disproportionate thoughts about seriousness, anxiety, time/energy devoted) - Symptoms are persistently symptomatic (typically ≥ 6 months) Specifiers : - with predominant pain - persistent - mild - moderate - severe 2. Illness Anxiety Disorder - Preoccupation with having or acquiring an illness - Somatic symptoms are absent or mild - High level of anxiety about health - Excessive health-related behaviors or maladaptive avoidance - Preoccupation ≥ 6 months (specific illness may change over time) Specifiers : - Care-seeking type - Care-avoidant type 3. Functional Neurologic Symptom Disorder (Conversion Disorder) - At least one symptom of altered voluntary motor or sensory function - Clinical findings incompatible with clinical presentation Specifiers : - with weakness/paralysis - with abnormal movement - with swallowing symptoms - with speech symptom - with attacks/seizures - with anesthesia/sensory loss - with special sensory symptom - with mixed symptom - acute episode ( 6 months) - with psychological stressor, without psychological stressor 4. Psychological Factors affecting General Medical Condition - Presence of medical condition - Psychological/behavioral factors negatively affect the medical condition by: 1) Interfering with treatment 2) Increasing health risk 3) Influencing pathophysiology 4) Close temporal association with symptom exacerbation Specifiers : mild, moderate, severe, extreme 5. Factitious Disorder - Falsification of physical/psychological signs or symptoms - Presents self (or another) as ill - Deceptive behavior is evident, even without obvious external rewards Specifiers : single episode, recurrent episode, imposed on self or imposed on other Shared Features : - Not better explained by another mental disorder or physical health condition - Symptoms cause significant impairment and/or distress Both in adult and children’s hospital settings, the burden of SS is increasing. According to a 2023 systematic review, the global prevalence of SS in children and adolescents is 31%[ 6 ]. Prevalence estimates range from 25% to 50% among visits in primary care pediatric settings and from approximately 5% to 13% in inpatient pediatric settings[ 7 ]. The costs for hospitalized patients with SS account for up to 20% of the annual healthcare expenditures in the United States[ 8 – 10 ]. SS constitute a broad range of manifestations, within which disorders classified under SSRD are included. Early recognition of their onset through the identification of predisposing factors could enable the implementation of intervention strategies aimed at preventing their pathological progression into SSRD. Children and adolescents with SS primarily seek medical assistance from their general pediatrician, primary care physician, or specialist, up to the hospital and the Emergency Department (ED). However, SS are often poorly recognized, with significant delays in identification: their presence is frequently considered only after repeated ED visits, hospitalizations, consultations, and investigations. This is due to a lack of standardization and proactive approaches to SS identification, evaluation, and management. Limited pediatric cohorts have been described; therefore, the scientific evidence on SS and SSRD management in pediatric settings is still limited, and pediatricians often have inadequate knowledge of these conditions[ 8 ]. There is a risk of disproportionate medicalization with excessive blood exams, extensive and sometimes invasive investigations, and ineffective drugs, which may lead to false positive results or side effects, furthering the medical evaluation. Inadequate and inconclusive medical care may sustain or even worsen the symptoms, setting off a vicious cycle, as patients’ and parents’ frustration leads to continuous seeking different medical consultations in search of a solution. Early identification and intervention are therefore critical to prevent the development of SSRD and to promote better psychological and physical outcomes in affected children and adolescents. We conducted a retrospective analysis of a cohort of children and adolescents hospitalized for SS in a tertiary pediatric hospital. Our aim was to characterize the clinical and sociodemographic profile of these patients by investigating their epidemiological and clinical data, quantifying health service utilization, and identifying potential psychosocial risk factors. MATERIALS AND METHODS We retrospectively evaluated children and adolescents hospitalized for SS in the Pediatric Unit of our Hospital between 1st January 2015 and 31st December 2024. We included ICD-9 codes for somatoform disorder (30081), hypochondriasis (3007), undifferentiated somatoform disorder (30082), conversion disorder (30011), unspecified psychophysiological disorder (306.9), complex regional pain syndrome (7337), chronic pain (3384), psychogenic pain syndrome (30780), other pain disorders (30789), unspecified non-psychotic psychic disorders (3009), unspecified psychophysiological dysfunctions (3069), musculoskeletal dysfunctions (3060), gastrointestinal dysfunction (3064), abdominal pain of unspecified location (78900), arthralgia (71949), headache (7840), tension headache (30781), myalgia (7291), other convulsions (78039), other extrapyramidal and movement disorders, not otherwise classified (33399), abnormal involuntary movements (781), syncope and collapse (7802), chest pain, unspecified (78650), pharyngeal or chest pain (7841). The patients’ electronic or paper medical records were reviewed by four authors (MO, CR, AM, ST) to include only patients with a final diagnosis of SS. We analyzed the distribution of cases over the study period. Data collected included epidemiological characteristics, comorbidities, clinical presentation, medical investigations, and interventions including the number of ED visits and hospital admissions, diagnostic tests, and specialist consultations. All treatments including pharmacological therapy and physiotherapy were recorded. When available, the psychologist or psychiatrist assessment was specified. Furthermore, data on personal and family medical history, as well as other environmental risk factors such as lack of friendships, school absenteeism, sports, or stressful life events, were collected. All the aforementioned data had been collected and registered in the medical records as part of routine clinical practice during their hospitalization (for which parental consent had already been obtained). These data were analyzed anonymously for the study. Therefore, specific approval by the ethics committee was not required. Results were summarized as mean and standard deviation (SD) for continuous variables, and percentages for nominal variables. Fisher exact test was performed to evaluate differences between categorical variables. A P < 0.05 was considered statistically significant. Statistical analysis was performed using Prism software (v10 for Macintosh; GraphPad Inc., San Diego, CA). RESULTS There were 128 patients with SS admitted to our pediatric ward over the study period. The baseline epidemiological and clinical characteristics of the sample are reported in Table 2. The male/female ratio was 1:2.2. Mean age at admission was 12 years ± 2 SD (range 8–17 years). Most patients (107, 84%) were Italian, 13 (10%) were from Eastern Europe, and 7 (6%) were from Northern and Sub-Saharan Africa. Medical comorbidities were present in 25 (20%) cases. Most admissions occurred in winter (42%) and spring (34%). A peak of annual prevalence was observed in 2020–2021, corresponding to the COVID-19 pandemic (Fig. 1 ). However, when comparing prevalence among the three-year intervals of our period of study (2015-17 vs. 2018-20 vs. 2021-23), no significant differences were observed (P = 0.8). Clinical presentation was heterogeneous with symptoms at admission mostly related to the musculoskeletal (40%), gastrointestinal (30%), or neurological system (23%) (Table 3 ). A significant proportion of patients (49%) experienced symptoms involving multiple systems. Table 2 Sociodemographic and clinical characteristics of our cohort Total Males Females Patients 128 39 (30.5%) 89 (69.5%) Mean age (years) 12 12 13 Country : Italy Albania Romania Senegal Tunisia Costa Rica Egypt Morocco Russia Poland Togo 107 (83.6%) 5 (3.9%) 6 (4.7%) 2 (1.6%) 2 (1.6%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 18 0 2 1 1 1 0 0 0 1 1 89 5 4 1 1 1 0 1 1 0 0 Comorbidities allergic asthma precocious puberty cystic fibrosis Chiari malformation Crohn disease Ehlers-Danlos syndrome gastroesophageal reflux disease hepatitis b hydrocephalus neurofibromatosis type 1 scoliosis vitiligo ADHD SLD endometriosis enuresis 6 (4.5%) 3 (1.8%) 2 (1.6%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 2 0 1 1 1 0 0 0 1 0 0 0 0 1 0 0 4 3 1 0 0 1 1 1 0 1 1 1 1 0 1 1 The musculoskeletal complaints included musculoskeletal pain (31%), especially localized in the lower limbs, back pain (10%), and altered gait (7%). During hospitalization, pain amplification syndrome (PAS) was identified in 35 patients (27%). Four patients were diagnosed with Complex Regional Pain Syndrome. Regarding gastrointestinal manifestations, patients reported abdominal pain (27%), nausea or emesis (2%), and constipation (1%). Neurological complaints included headache (20%), syncope (4%), dizziness (2%), and paresthesia (1%). Other reported complaints at admission low-grade fever, dyspnea, chest pain, diplopia, bruise-like lesions and deficit in left eye opening. Additionally, 42 patients (33%) experienced sleep problems, with 16 (14%) experiencing frequent nighttime awakenings. The mean interval between symptom onset and hospital admission was 230 days (range 5-1483). The mean duration of hospitalization was 8 days (± 3.1 SD), ranging from 2 to 27 days. Forty-eight patients (38%) were previously evaluated in the ED, of whom 23 (18%) had been seen twice or more. Fifty-seven patients (44%) had been previously admitted to a hospital ward due to SS, and 17 (13%) were hospitalized twice or more. During hospitalization, 100% of the patients underwent laboratory investigations. In most cases, several radiological exams were performed: one or more abdominal ultrasounds were performed in 70 patients (55%), magnetic resonance imaging in 71 (55%), X-ray studies in 57 (44%), and computed tomography in 14 cases (11%). Fifty-eight patients (45%) underwent other instrumental investigations, such as gastrointestinal endoscopy, upper gastrointestinal series, bone scintigraphy, electromyography, and electroneurography. Table 4 summarizes the laboratory and instrumental tests performed during the diagnostic work-up. Table 3 Clinical manifestations at admission Total Males Females Musculoskeletal symptoms - Musculoskeletal pain - Pain amplification syndrome - Back pain - Altered gait 51 (39.8%) 40 (31.3%) 35 (27%) 13 (10.2%) 9 (7.0% 17 14 3 3 34 26 9 6 Gastrointestinal symptoms - Abdominal pain - Emesis/nausea - Constipation 39 (30.4%) 35 (27.3%) 3 (2.3%) 1 (0.8%) 10 8 2 0 29 27 1 1 Neurological symptoms - Headache - Syncope - Dizziness - Paresthesia 30 (23.4%) 26 (20.3%) 5 (3.9%) 2 (1.6%) 1 (0.8%) 10 9 1 0 0 20 17 4 2 1 Other symptoms - Low-grade persistent fever - Dyspnea - Chest pain - Diplopia - Painful bruise-like lesions - Deficit in left eye opening 7 (5.4%) 2 (1.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 1 0 0 0 0 0 1 6 2 1 1 1 1 0 Psychiatric disorders 48 (37.5%) 12 36 - SSDR Somatic Symptom Disorder Factitious Disorder 22 (17.2%) 21 1 7 15 - Anxiety disorder - Depression - Eating disorder - Functional neurological symptom disorder - Obsessive-compulsive disorder - Dissociative disorder 19 (14.8%) 2 (1.6%) 2 (1.6%) 1 (0.8%) 1 (0.8%) 1 (0.8%) 2 1 1 1 0 0 17 1 1 0 1 1 Table 4 Laboratory tests, instrumental investigations, and therapeutic interventions Patients N (%) Laboratory tests 128 (100%) Stool tests 25 (19.5%) Instrumental investigations - MRI - Abdominal ultrasound - X-ray study - CT scan - Upper GI series 71 (55.4%) 70 (54.6%) 57 (44.5%) 14 (10.9%) 1 (0.8%) EKG/Echocardiogram 17 (13.3%) EEG 8 (6.3%) Others (i.e., ENG, GI endoscopy, biopsy, scintigraphy) 32 (25.0%) Therapeutic intervention - Paracetamol - NSAIDs - Benzodiazepines - Antidepressants - Physical therapy 29 (22.6%) 9 (7.0%) 7 (5.4%) 6 (4.7%) 50 (39.0%) Other medical specialists, mainly neurologists, rheumatologists, and gastroenterologists, examined almost all patients (97%); most cases (78%) received multiple specialist consultations during the same admission. One-hundred and ten patients (86%) underwent evaluation by a psychologist, a neuropsychiatrist, or both. These specialists diagnosed psychiatric comorbidity in 48 (38%) patients (Table 3 ). Particularly, 22 (17%) patients were diagnosed with SSD, 19 (15%) with anxiety, two with depression, and two with an eating disorder. The prevalence of psychiatric disorders did not significantly different among females and males with SS (P = 0.3); however, anxiety was more frequent in females (P = 0.05). Pharmacological treatment for pain included paracetamol in 29 patients (23%) and nonsteroidal anti-inflammatory drugs in nine cases (7%). Based on psychiatric prescriptions ordered, seven (6%) required benzodiazepines for anxiety disorders, and six patients (5%) received antidepressants for depressive disorder (5%). Fifty patients (39%) were prescribed physical therapy (exercises and physiotherapy). All therapeutic interventions adopted in our cohort are summarized in Table 4 . Notably, six patients (5%) inappropriately underwent surgical intervention; all presented at admission with gastrointestinal symptoms as the main complaint, accounting for 15% of patients with this presentation. Two patients underwent exploratory laparoscopy and four appendectomy. None had a condition requiring surgical intervention. Biopsychosocial risk factors were identified in 79 (61.7%) patients. Familial stressful events were found in a quarter of our cases: maternal illness in 27% of cases, severe diseases, or death in other family members in 16%, and parental conflicts or divorce in 11%. Furthermore, 15% of the patients had a lack of friends and 3% reported bullying. No history of abuse or violence was declared. A significant number of patients had a history of social withdrawal due to symptoms: in particular, 40% of patients had abandoned sports practice and 39% reported scholastic absenteeism. At discharge, most patients (89%) were referred for follow-up care, most commonly with a psychologic or neuropsychiatric specialist (66%), and/or with a physiotherapist (51%). DISCUSSION Our study described a cohort of 128 patients hospitalized for SS over 10 years, encompassing the COVID-19 pandemic. The mean age of our cohort (12 years) was lower compared to most SSRD pediatric cohorts, ranging from 13.5 to 14.6 years[ 2 , 9 – 13 ]. The prevalence of SS is similar between sexes until puberty, after which females exhibit a higher risk[ 14 ]. This difference is thought to be due to females’ tendency toward a more internalizing or ruminative coping style compared to males. Our results confirm the gender trend observed in other studies[ 2 , 9 , 15 ] showing a higher prevalence in females. In our cohort, 20% of patients had known medical comorbidities at admission. This percentage is much lower than reported in other cohorts: 48% by Bujoreanu et al. , and 65% by Wiggings et al . Notably, in these cohorts, SS potentially overlapped with symptoms due to the patient’s medical conditions[ 9 , 13 ]. We observed a prevalence peak of hospitalization in 2020–2021, although not statistically significant. This is consistent with literature showing the consequences of the COVID-19 pandemic on the mental health of children and adolescents[ 16 , 17 ]. Aligned with our findings, a 2023 Italian study documented a rise in pediatric ED admissions for SS during the pandemic[ 18 ]. As reported in other cohorts, we found the most frequent clinical manifestations were musculoskeletal, gastrointestinal and neurological[ 2 , 9 , 10 , 13 ]. Approximately half of our patients had more than one manifestation involving multiple systems. This proportion was comparable to the cohorts described by Bujoreanu et al. (53%)[ 9 ] and by Wiggings et al. (41%)[ 13 ]. The occurrence of multiple symptoms across different organs as well as some characteristics of the complaints (vague and disproportionate) are highly suggestive of SS[ 19 ]. Pain is a frequent symptom reported in adolescents, particularly chronic musculoskeletal pain defined as ongoing pain in the bones, joints, or muscles persisting for more than 3 months. The most common form of chronic musculoskeletal pain in children and adolescents include PAS, which can be localized or diffuse, resulting in a complete inability to walk, muscle weakness, atrophy, and contractures[ 20 ]. In our cohort, musculoskeletal complaints were the most frequent and mostly localized in the lower limbs, often associated with altered gait. PAS was diagnosed in approximately a quarter of our cases. As noted in the literature[ 11 , 21 ], abdominal pain was the most frequent gastrointestinal manifestation, observed in more than a quarter of our cases, followed by emesis and constipation. Headache, followed by dizziness and, more rarely, serious neurological disturbances (e.g., non-epileptic seizures, sensory impairment, and tinnitus) are the neurological manifestations typically reported[ 20 , 22 , 23 ]. Accordingly, in our cohort, neurological manifestations represented the third most frequent complaint, with headache being the most common. A range of manifestations, including fatigue, difficulty breathing, chronic cough, chest pain, and lower urinary tract symptoms, is less frequently described in the literature[ 2 ], as in our cohort. The mean duration of hospitalization was 7 days, longer than previously reported lengths of stay, ranging from 3 to 5 days[ 9 – 12 ]. Our patients had a long duration of symptoms before the hospitalization: over half of our cases had a previous hospitalization for SS, and one-quarter had been evaluated in an ED at least twice. The re-hospitalization rate in our cohort was higher than those reported in other studies (14% by Bujoreanu et al. and 30% by Wigging et al. )[ 9 , 13 ]. The overmedicalization of these patients is confirmed by the results of previous studies reporting that patients with SS have several medical consultations before hospitalization, mostly with general practitioners and/or medical specialists[ 2 , 11 ]. During hospitalization, our patients received several investigations, which were more frequently requested compared to other cohorts of inpatients with SSRD, ranging from 65% to 86%[ 10 , 11 , 13 ]. As described in other studies[ 2 , 13 ], non-SSRD psychiatric comorbidity was diagnosed in 20% of cases. Research on pharmacological interventions for SSRD in children and adolescents is limited, and there is no high-quality evidence in recommend medications in this population[ 8 , 19 ]. Comorbid psychopathologies (depression and anxiety) respond to antidepressants as adjunctive treatment in the overall management of SS. Only a small proportion of our patients were treated either with benzodiazepines, or other antidepressants. Although the effectiveness of physiotherapy in the management of SS in children and adolescents is supported by few studies[ 24 , 25 ], physiotherapy seems to play a considerable role in clinical practice as physical activity has been shown to improve mental health, alleviate chronic fatigue syndrome, and address various musculoskeletal impairments[ 26 ]. Accordingly, approximately half of the patients in our study received physiotherapy. Nonpharmacological treatment of SSRD mainly relies on cognitive behavioral therapy, which should be tailored to the individual needs of each patient and his or her family. Recognizing biopsychosocial risk factors is essential for the successful assessment and management of SS[ 19 ], with the collaboration of neuropsychiatrists and psychologists with pediatricians. Risk factors may be distinguished into individual (temperament, poor coping skills, borderline intellectual functioning, and underlying psychiatric illness), family-related (medical or psychiatric disease of a close family member, substance abuse, communication and attitude of family members towards the child/adolescent), and environmental ones (bullying, academic/sports stress, peer relationships, traumatic experiences)[ 19 , 27 ]. As acknowledged by several studies, at least one of these risk factors is present in most children and adolescents with SSRD[ 28 – 32 ]. In addition, school absenteeism is significantly associated with SSRD[ 33 ]. According to a 2021 study by Vassilopoulos et al. , patients with SSRD and severe school absenteeism (> 1 month) were more likely to have higher somatization and functional disability scores, higher rates of suicidal ideation and/or attempts, greater psychotropic medication use and psychiatry sessions during hospitalization, and greater rates of discharge to higher level of psychiatric care[ 34 ]. Recent studies have demonstrated the efficacy of a multidisciplinary clinical pathway for hospitalized patients suspected of having SSRD[ 12 , 35 , 36 ]. The clinical evaluation should require the early involvement of consultants from medical specialties, including psychologists and psychiatrists, and tailored diagnostic tests to rule out any medical issues, thereby avoiding unnecessary, invasive, time-consuming, and expensive procedures. Over-testing can suggest that the SSRD diagnosis is uncertain and makes it difficult to reassure patients and families that an unrecognized physical disease is unlikely. Conversely, regular but short clinical check-ins can monitor important changes that may require follow-up and other investigations[ 37 ]. Early involvement of psychologists and psychiatrists is essential to assess the presence of the above-mentioned risk factors and to reach a positive diagnosis of an SSRD, which is not an exclusion diagnosis. The patients and their families should be involved in the diagnostic process and receive the diagnosis of an SSRD. This approach is still difficult to implement in most settings, due to limited knowledge and training of pediatricians on SSRD and the poor liaison between hospital pediatricians, primary care physicians, psychologists, and psychiatrists. Many primary care pediatricians or hospital doctors lack experience with SS and SSRD and consider diagnosis and management challenging[ 38 ]. Our study demonstrates that SS have an increasing burden on children and adolescents and that the approach to SS is still difficult for primary care and hospital pediatricians, as demonstrated by the number of ED evaluations, the duration of hospitalization, the rate of re-hospitalization, and by the number of requested investigations and specialist consultations. Early identification of patients with SS by hospital as well as primary care pediatricians, would allow timely involvement of mental health professionals and prompt implementation of appropriate interventions, thereby avoiding prolonged or repeated hospitalizations before reaching a correct diagnosis. We acknowledge the limitations of this study. First, its retrospective nature could underestimate the number of cases hospitalized for SS and SSRD diagnoses; moreover, as a single-center study conducted in a tertiary care hospital, our sample may not accurately reflect the true prevalence in the general pediatric population. Second, we analyzed a cohort of patients with SS, which is not fully comparable to literature cohorts of SSRD: the lack of standardized terminology hampers comprehensive comparisons, as patient populations are not classified consistently. The strength of this study lies in the analysis of a substantial cohort of children and adolescents hospitalized for SS in a single Pediatric Unit. In conclusion, SS are a frequent cause of hospitalization, particularly in preadolescents and adolescents. The most frequent manifestations are musculoskeletal, gastrointestinal, and neurological. Early and close collaboration with psychologists and psychiatrists is essential for a comprehensive medical and psychological assessment, tailored medical tests and ultimately achieving a positive diagnosis of SSRD. Abbreviations DSM Diagnostic and Statistical Manual of Mental Disorders ED Emergency Department PAS pain amplification syndrome SD standard deviation SS Somatic symptoms SSD somatic symptom disorder SSRD somatic symptom and related disorders Declarations Funding/Support: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript . Competing Interests: The authors have no relevant financial or non-financial interests to disclose Author Contributions: All authors contributed to the study conception and design. Sandra Trapani, Alessandra Montemaggi, Chiara Rubino, and Michela Orlandi designed the data collection instruments, collected data, carried out the initial analyses. Michela Orlandi, Chiara Rubino and Alessandra Montemaggi wrote the first draft, Sandra Trapani and Giuseppe Indolfi critically reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. Ethics approval: Ethical review and approval were not required for this study in accordance with institutional and national regulations, as it was an observational study based exclusively on data routinely collected and recorded in medical records during hospitalization (for which parental consent had already been obtained). References O’Connell C, Shafran R, Bennett S (2020) A systematic review of randomised controlled trials using psychological interventions for children and adolescents with medically unexplained symptoms: A focus on mental health outcomes. 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J Paediatr Child Health 51:159–167. https://doi.org/10.1111/jpc.12630 Sartori R, Tessitore A, Della Torca A, Barbi E (2022) Efficacy of physiotherapy treatments in children and adolescents with somatic symptom disorder and other related disorders: systematic review of the literature. Ital J Pediatr 48:127. https://doi.org/10.1186/s13052-022-01317-3 Stinson J, Connelly M, Kamper SJ et al (2016) Models of Care for addressing chronic musculoskeletal pain and health in children and adolescents. Best Pract Res Clin Rheumatol 30:468–482. https://doi.org/10.1016/j.berh.2016.08.005 Shraim M, Mallen CD, Dunn KM (2013) GP consultations for medically unexplained physical symptoms in parents and their children: a systematic review. Br J Gen Pract 63:e318–325. https://doi.org/10.3399/bjgp13X667178 Bonvanie IJ, Rosmalen JGM, van Rhede CM et al (2015) Short report: Functional somatic symptoms are associated with perfectionism in adolescents. J Psychosom Res 79:328–330. https://doi.org/10.1016/j.jpsychores.2015.07.009 Chaudhry HA, Okonkwo CC, Inban P et al (2023) Factors in the Development of Somatoform Disorders Among Children: A Case-Control Study. Cureus 15:e43238. https://doi.org/10.7759/cureus.43238 Elliott LC, Stager LM, Long D et al (2022) Somatic Symptoms in Adolescents With an Ill Parent. Psychosom Med 84:421–428. https://doi.org/10.1097/PSY.0000000000001063 Fernandez A, Askenazy F, Zeghari R et al (2024) Somatic and Posttraumatic Stress Symptoms in Children and Adolescents in France. JAMA Netw Open 7:e247193. https://doi.org/10.1001/jamanetworkopen.2024.7193 Gini G, Pozzoli T (2013) Bullied children and psychosomatic problems: a meta-analysis. Pediatrics 132:720–729. https://doi.org/10.1542/peds.2013-0614 Console K, Cozzi G, Caiffa G et al (2024) School Absenteeism Longer Than Two Weeks Is a Red Flag of Somatic Symptom and Related Disorders in Hospitalised Children and Adolescents: A Matched Cohort Study. Child (Basel) 11:613. https://doi.org/10.3390/children11060613 Vassilopoulos A, Poulopoulos L, Ibeziako N P (2021) School absenteeism as a potential proxy of functionality in pediatric patients with somatic symptom and related disorders. Clin Child Psychol Psychiatry 26:342–354. https://doi.org/10.1177/1359104520978462 Kullgren KA, Klein EJ, Sturza J et al (2020) Standardizing Pediatric Somatic Symptom and Related Disorders Care: Clinical Pathway Reduces Health Care Cost and Use. Hosp Pediatr 10:867–876. https://doi.org/10.1542/hpeds.2020-0004 Ibeziako P, Brahmbhatt K, Chapman A et al (2019) Developing a Clinical Pathway for Somatic Symptom and Related Disorders in Pediatric Hospital Settings. Hosp Pediatr 9:147–155. https://doi.org/10.1542/hpeds.2018-0205 Geist R, Weinstein M, Walker L, Campo JV (2008) Medically unexplained symptoms in young people: The doctor’s dilemma. Paediatr Child Health 13:487–491 Broekhuijsen-van Henten DM, Luitse GHJ, Knottnerus AC, van den Heuvel M (2015) Exploring Self-Efficacy and Attitudes Among Pediatricians in Managing Medically Unexplained Physical Symptoms. Clin Pediatr (Phila) 54:1391–1393. https://doi.org/10.1177/0009922815570624 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8521476","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":574584774,"identity":"badfc2f4-9053-4749-8764-f14400535e1c","order_by":0,"name":"Michela Orlandi","email":"","orcid":"","institution":"University of Florence","correspondingAuthor":false,"prefix":"","firstName":"Michela","middleName":"","lastName":"Orlandi","suffix":""},{"id":574584775,"identity":"78b1d448-a79d-4261-97be-3e2cbf8ce08e","order_by":1,"name":"Chiara Rubino","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYDACCcYGJEYFVDSBeC1nYFrw6ZFAZjC2wXh4tPDPbm78XFHDkG9wu7ntwcd52+QMjvc+YHj4A48ldw42S545xmC54c7BdsOZ224bG5w5boDXYQYSiQ2SDWwMBgY3EtukebfdTtxwIw2/X4Bamn82/INpmXO7fsP9ZwS1tEk2tsG0NNxOMLjBhl+LBFClZWOfhIHknYNtkjOO3TaceSaN4UBCGm4t/DPSH99s+GZjwHe7/ZnEh5rb8nzHjzE+/GGDWwvMMgRT4QADwwGCGlCAfANp6kfBKBgFo2D4AwBdeFaL5L+pwAAAAABJRU5ErkJggg==","orcid":"","institution":"Meyer Children’s Hospital IRCSS","correspondingAuthor":true,"prefix":"","firstName":"Chiara","middleName":"","lastName":"Rubino","suffix":""},{"id":574584776,"identity":"e99aa9de-e9cb-42d8-a6e1-19f4b74719a0","order_by":2,"name":"Alessandra Montemaggi","email":"","orcid":"","institution":"Meyer Children’s Hospital IRCSS","correspondingAuthor":false,"prefix":"","firstName":"Alessandra","middleName":"","lastName":"Montemaggi","suffix":""},{"id":574584777,"identity":"988b550a-28de-47ef-948b-e6aa6cc0afe8","order_by":3,"name":"Giuseppe Indolfi","email":"","orcid":"","institution":"Meyer Children’s Hospital IRCSS","correspondingAuthor":false,"prefix":"","firstName":"Giuseppe","middleName":"","lastName":"Indolfi","suffix":""},{"id":574584778,"identity":"e5453572-1b45-4e9f-8637-2dfb943c0d15","order_by":4,"name":"Sandra Trapani","email":"","orcid":"","institution":"Meyer Children’s Hospital IRCSS","correspondingAuthor":false,"prefix":"","firstName":"Sandra","middleName":"","lastName":"Trapani","suffix":""}],"badges":[],"createdAt":"2026-01-05 12:39:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8521476/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8521476/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100412321,"identity":"2c19a6ca-c78c-41c3-9e67-5c1141cc8284","added_by":"auto","created_at":"2026-01-16 13:14:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":13472,"visible":true,"origin":"","legend":"\u003cp\u003ePrevalence of hospital admissions for somatic symptoms per year over study period\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8521476/v1/df7430d7380ca0a31aee0a37.png"},{"id":100546295,"identity":"3a552878-a235-4fa3-989f-50c57814c5af","added_by":"auto","created_at":"2026-01-19 08:05:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1039954,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8521476/v1/25b7e17c-5d05-48a2-8e7d-5a26f604bf53.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Children and adolescents hospitalized for somatic symptoms: a retrospective cohort study","fulltext":[{"header":"What is Known – What is New","content":"\u003cp\u003eSomatic symptoms (SS) are physical manifestations associated with clinically significant distress that is disproportionate or inconsistent with the history, physical examination and other objective findings. Through the retrospective analysis of 128 children and adolescents hospitalized for SS over a 10-year period, the study highlights prevalence trends, multisystem involvement, extensive diagnostic use, and the central role of multidisciplinary management.\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eSomatic symptoms (SS) are physical manifestations characterized by their association with significant distress that is disproportionate or inconsistent with the history, physical examination and other objective findings. SS account for a spectrum of conditions, ranging from mild, self-limiting symptoms to persistent and disabling conditions leading to impairment in social, occupational, or other areas of functioning[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Such symptoms have been defined under broad terms, such as psychosomatic disorders, functional complaints, and medically unexplained symptoms. While often transient and benign, SS can persist, particularly in the presence of predisposing or perpetuating factors. Continued symptoms presentation becomes a disorder when it is impairing and meets specific criteria, outlined by the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM 5th [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]introduced the category of somatic symptom and related disorders (SSRD), which includes somatic symptom disorder (SSD), illness anxiety disorder, functional neurological symptom disorder, psychological factors affecting medical conditions, and factitious disorder (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). According to SSD definition, physical symptoms may or may not be justified by a medical condition[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Compared with earlier diagnostic definitions, this term shifts the emphasis from the absence of a medical explanation to the presence of excessive thoughts, feelings, or behaviors related to somatic symptoms.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDiagnostic and Statistical Manual of Mental Disorders, 5th Edition diagnostic criteria of SSRD\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSomatic Symptom Disorders and Related Disorders (SSRD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Somatic Symptom Disorder\u003c/p\u003e \u003cp\u003e- One or more somatic symptoms\u003c/p\u003e \u003cp\u003e- Excessive thoughts, feelings, or behaviors related to the symptoms (e.g., disproportionate thoughts about seriousness, anxiety, time/energy devoted)\u003c/p\u003e \u003cp\u003e- Symptoms are persistently symptomatic (typically\u0026thinsp;\u0026ge;\u0026thinsp;6 months)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eSpecifiers\u003c/em\u003e:\u003c/p\u003e \u003cp\u003e- with predominant pain\u003c/p\u003e \u003cp\u003e- persistent\u003c/p\u003e \u003cp\u003e- mild\u003c/p\u003e \u003cp\u003e- moderate\u003c/p\u003e \u003cp\u003e- severe\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Illness Anxiety Disorder\u003c/p\u003e \u003cp\u003e- Preoccupation with having or acquiring an illness\u003c/p\u003e \u003cp\u003e- Somatic symptoms are absent or mild\u003c/p\u003e \u003cp\u003e- High level of anxiety about health\u003c/p\u003e \u003cp\u003e- Excessive health-related behaviors or maladaptive avoidance\u003c/p\u003e \u003cp\u003e- Preoccupation\u0026thinsp;\u0026ge;\u0026thinsp;6 months (specific illness may change over time)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eSpecifiers\u003c/em\u003e:\u003c/p\u003e \u003cp\u003e- Care-seeking type\u003c/p\u003e \u003cp\u003e- Care-avoidant type\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. \u003cb\u003eFunctional Neurologic Symptom Disorder (Conversion Disorder)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e- At least one symptom of altered voluntary motor or sensory function\u003c/p\u003e \u003cp\u003e- Clinical findings incompatible with clinical presentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eSpecifiers\u003c/em\u003e:\u003c/p\u003e \u003cp\u003e- with weakness/paralysis\u003c/p\u003e \u003cp\u003e- with abnormal movement\u003c/p\u003e \u003cp\u003e- with swallowing symptoms\u003c/p\u003e \u003cp\u003e- with speech symptom\u003c/p\u003e\u003cp\u003e- with attacks/seizures\u003c/p\u003e\u003cp\u003e- with anesthesia/sensory loss\u003c/p\u003e\u003cp\u003e- with special sensory symptom\u003c/p\u003e\u003cp\u003e- with mixed symptom\u003c/p\u003e \u003cp\u003e- acute episode (\u0026lt;\u0026thinsp;6 months), persistent (\u0026gt;\u0026thinsp;6 months)\u003c/p\u003e\u003cp\u003e- with psychological stressor, without psychological stressor\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. \u003cb\u003ePsychological Factors affecting General Medical Condition\u003c/b\u003e\u003c/p\u003e \u003cp\u003e- Presence of medical condition\u003c/p\u003e \u003cp\u003e- Psychological/behavioral factors negatively affect the medical condition by:\u003c/p\u003e \u003cp\u003e\u0026nbsp;1) Interfering with treatment\u003c/p\u003e \u003cp\u003e\u0026nbsp;2) Increasing health risk\u003c/p\u003e \u003cp\u003e\u0026nbsp;3) Influencing pathophysiology\u003c/p\u003e \u003cp\u003e\u0026nbsp;4) Close temporal association with symptom exacerbation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eSpecifiers\u003c/em\u003e:\u003c/p\u003e \u003cp\u003emild, moderate, severe, extreme\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. \u003cb\u003eFactitious Disorder\u003c/b\u003e\u003c/p\u003e \u003cp\u003e- Falsification of physical/psychological signs or symptoms\u003c/p\u003e \u003cp\u003e- Presents self (or another) as ill\u003c/p\u003e \u003cp\u003e- Deceptive behavior is evident, even without obvious external rewards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eSpecifiers\u003c/em\u003e:\u003c/p\u003e \u003cp\u003esingle episode, recurrent episode, imposed on self or imposed on other\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eShared Features\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e- Not better explained by another mental disorder or physical health condition\u003c/p\u003e \u003cp\u003e- Symptoms cause significant impairment and/or distress\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBoth in adult and children\u0026rsquo;s hospital settings, the burden of SS is increasing. According to a 2023 systematic review, the global prevalence of SS in children and adolescents is 31%[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Prevalence estimates range from 25% to 50% among visits in primary care pediatric settings and from approximately 5% to 13% in inpatient pediatric settings[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The costs for hospitalized patients with SS account for up to 20% of the annual healthcare expenditures in the United States[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. SS constitute a broad range of manifestations, within which disorders classified under SSRD are included. Early recognition of their onset through the identification of predisposing factors could enable the implementation of intervention strategies aimed at preventing their pathological progression into SSRD.\u003c/p\u003e \u003cp\u003e Children and adolescents with SS primarily seek medical assistance from their general pediatrician, primary care physician, or specialist, up to the hospital and the Emergency Department (ED). However, SS are often poorly recognized, with significant delays in identification: their presence is frequently considered only after repeated ED visits, hospitalizations, consultations, and investigations. This is due to a lack of standardization and proactive approaches to SS identification, evaluation, and management. Limited pediatric cohorts have been described; therefore, the scientific evidence on SS and SSRD management in pediatric settings is still limited, and pediatricians often have inadequate knowledge of these conditions[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. There is a risk of disproportionate medicalization with excessive blood exams, extensive and sometimes invasive investigations, and ineffective drugs, which may lead to false positive results or side effects, furthering the medical evaluation. Inadequate and inconclusive medical care may sustain or even worsen the symptoms, setting off a vicious cycle, as patients\u0026rsquo; and parents\u0026rsquo; frustration leads to continuous seeking different medical consultations in search of a solution. Early identification and intervention are therefore critical to prevent the development of SSRD and to promote better psychological and physical outcomes in affected children and adolescents.\u003c/p\u003e \u003cp\u003eWe conducted a retrospective analysis of a cohort of children and adolescents hospitalized for SS in a tertiary pediatric hospital. Our aim was to characterize the clinical and sociodemographic profile of these patients by investigating their epidemiological and clinical data, quantifying health service utilization, and identifying potential psychosocial risk factors.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eWe retrospectively evaluated children and adolescents hospitalized for SS in the Pediatric Unit of our Hospital between 1st January 2015 and 31st December 2024.\u003c/p\u003e \u003cp\u003eWe included ICD-9 codes for somatoform disorder (30081), hypochondriasis (3007), undifferentiated somatoform disorder (30082), conversion disorder (30011), unspecified psychophysiological disorder (306.9), complex regional pain syndrome (7337), chronic pain (3384), psychogenic pain syndrome (30780), other pain disorders (30789), unspecified non-psychotic psychic disorders (3009), unspecified psychophysiological dysfunctions (3069), musculoskeletal dysfunctions (3060), gastrointestinal dysfunction (3064), abdominal pain of unspecified location (78900), arthralgia (71949), headache (7840), tension headache (30781), myalgia (7291), other convulsions (78039), other extrapyramidal and movement disorders, not otherwise classified (33399), abnormal involuntary movements (781), syncope and collapse (7802), chest pain, unspecified (78650), pharyngeal or chest pain (7841).\u003c/p\u003e \u003cp\u003eThe patients\u0026rsquo; electronic or paper medical records were reviewed by four authors (MO, CR, AM, ST) to include only patients with a final diagnosis of SS. We analyzed the distribution of cases over the study period. Data collected included epidemiological characteristics, comorbidities, clinical presentation, medical investigations, and interventions including the number of ED visits and hospital admissions, diagnostic tests, and specialist consultations. All treatments including pharmacological therapy and physiotherapy were recorded. When available, the psychologist or psychiatrist assessment was specified. Furthermore, data on personal and family medical history, as well as other environmental risk factors such as lack of friendships, school absenteeism, sports, or stressful life events, were collected. All the aforementioned data had been collected and registered in the medical records as part of routine clinical practice during their hospitalization (for which parental consent had already been obtained). These data were analyzed anonymously for the study. Therefore, specific approval by the ethics committee was not required. Results were summarized as mean and standard deviation (SD) for continuous variables, and percentages for nominal variables. Fisher exact test was performed to evaluate differences between categorical variables. A P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Statistical analysis was performed using Prism software (v10 for Macintosh; GraphPad Inc., San Diego, CA).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThere were 128 patients with SS admitted to our pediatric ward over the study period. The baseline epidemiological and clinical characteristics of the sample are reported in Table\u0026nbsp;2. The male/female ratio was 1:2.2. Mean age at admission was 12 years\u0026thinsp;\u0026plusmn;\u0026thinsp;2 SD (range 8\u0026ndash;17 years). Most patients (107, 84%) were Italian, 13 (10%) were from Eastern Europe, and 7 (6%) were from Northern and Sub-Saharan Africa. Medical comorbidities were present in 25 (20%) cases.\u003c/p\u003e\n\u003cp\u003eMost admissions occurred in winter (42%) and spring (34%). A peak of annual prevalence was observed in 2020\u0026ndash;2021, corresponding to the COVID-19 pandemic (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). However, when comparing prevalence among the three-year intervals of our period of study (2015-17 \u003cem\u003evs.\u003c/em\u003e 2018-20 \u003cem\u003evs.\u003c/em\u003e 2021-23), no significant differences were observed (P\u0026thinsp;=\u0026thinsp;0.8).\u003c/p\u003e\n\u003cp\u003eClinical presentation was heterogeneous with symptoms at admission mostly related to the musculoskeletal (40%), gastrointestinal (30%), or neurological system (23%) (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). A significant proportion of patients (49%) experienced symptoms involving multiple systems.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSociodemographic and clinical characteristics of our cohort\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMales\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (30.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89 (69.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean age (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e: Italy\u003c/p\u003e\n \u003cp\u003eAlbania\u003c/p\u003e\n \u003cp\u003eRomania\u003c/p\u003e\n \u003cp\u003eSenegal\u003c/p\u003e\n \u003cp\u003eTunisia\u003c/p\u003e\n \u003cp\u003eCosta Rica\u003c/p\u003e\n \u003cp\u003eEgypt\u003c/p\u003e\n \u003cp\u003eMorocco\u003c/p\u003e\n \u003cp\u003eRussia\u003c/p\u003e\n \u003cp\u003ePoland\u003c/p\u003e\n \u003cp\u003eTogo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e107 (83.6%)\u003c/p\u003e\n \u003cp\u003e5 (3.9%)\u003c/p\u003e\n \u003cp\u003e6 (4.7%)\u003c/p\u003e\n \u003cp\u003e2 (1.6%)\u003c/p\u003e\n \u003cp\u003e2 (1.6%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eallergic asthma\u003c/p\u003e\n \u003cp\u003eprecocious puberty\u003c/p\u003e\n \u003cp\u003ecystic fibrosis\u003c/p\u003e\n \u003cp\u003eChiari malformation\u003c/p\u003e\n \u003cp\u003eCrohn disease\u003c/p\u003e\n \u003cp\u003eEhlers-Danlos syndrome\u003c/p\u003e\n \u003cp\u003egastroesophageal reflux disease\u003c/p\u003e\n \u003cp\u003ehepatitis b\u003c/p\u003e\n \u003cp\u003ehydrocephalus\u003c/p\u003e\n \u003cp\u003eneurofibromatosis type 1\u003c/p\u003e\n \u003cp\u003escoliosis\u003c/p\u003e\n \u003cp\u003evitiligo\u003c/p\u003e\n \u003cp\u003eADHD\u003c/p\u003e\n \u003cp\u003eSLD\u003c/p\u003e\n \u003cp\u003eendometriosis\u003c/p\u003e\n \u003cp\u003eenuresis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (4.5%)\u003c/p\u003e\n \u003cp\u003e3 (1.8%)\u003c/p\u003e\n \u003cp\u003e2 (1.6%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe musculoskeletal complaints included musculoskeletal pain (31%), especially localized in the lower limbs, back pain (10%), and altered gait (7%). During hospitalization, pain amplification syndrome (PAS) was identified in 35 patients (27%). Four patients were diagnosed with Complex Regional Pain Syndrome. Regarding gastrointestinal manifestations, patients reported abdominal pain (27%), nausea or emesis (2%), and constipation (1%). Neurological complaints included headache (20%), syncope (4%), dizziness (2%), and paresthesia (1%). Other reported complaints at admission low-grade fever, dyspnea, chest pain, diplopia, bruise-like lesions and deficit in left eye opening. Additionally, 42 patients (33%) experienced sleep problems, with 16 (14%) experiencing frequent nighttime awakenings.\u003c/p\u003e\n\u003cp\u003eThe mean interval between symptom onset and hospital admission was 230 days (range 5-1483). The mean duration of hospitalization was 8 days (\u0026plusmn;\u0026thinsp;3.1 SD), ranging from 2 to 27 days. Forty-eight patients (38%) were previously evaluated in the ED, of whom 23 (18%) had been seen twice or more. Fifty-seven patients (44%) had been previously admitted to a hospital ward due to SS, and 17 (13%) were hospitalized twice or more.\u003c/p\u003e\n\u003cp\u003eDuring hospitalization, 100% of the patients underwent laboratory investigations. In most cases, several radiological exams were performed: one or more abdominal ultrasounds were performed in 70 patients (55%), magnetic resonance imaging in 71 (55%), X-ray studies in 57 (44%), and computed tomography in 14 cases (11%). Fifty-eight patients (45%) underwent other instrumental investigations, such as gastrointestinal endoscopy, upper gastrointestinal series, bone scintigraphy, electromyography, and electroneurography. Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e summarizes the laboratory and instrumental tests performed during the diagnostic work-up.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eClinical manifestations at admission\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMales\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMusculoskeletal symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- Musculoskeletal pain\u003c/p\u003e\n \u003cp\u003e- Pain amplification syndrome\u003c/p\u003e\n \u003cp\u003e- Back pain\u003c/p\u003e\n \u003cp\u003e- Altered gait\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51 (39.8%)\u003c/p\u003e\n \u003cp\u003e40 (31.3%)\u003c/p\u003e\n \u003cp\u003e35 (27%)\u003c/p\u003e\n \u003cp\u003e13 (10.2%)\u003c/p\u003e\n \u003cp\u003e9 (7.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGastrointestinal symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- Abdominal pain\u003c/p\u003e\n \u003cp\u003e- Emesis/nausea\u003c/p\u003e\n \u003cp\u003e- Constipation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (30.4%)\u003c/p\u003e\n \u003cp\u003e35 (27.3%)\u003c/p\u003e\n \u003cp\u003e3 (2.3%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeurological symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- Headache\u003c/p\u003e\n \u003cp\u003e- Syncope\u003c/p\u003e\n \u003cp\u003e- Dizziness\u003c/p\u003e\n \u003cp\u003e- Paresthesia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (23.4%)\u003c/p\u003e\n \u003cp\u003e26 (20.3%)\u003c/p\u003e\n \u003cp\u003e5 (3.9%)\u003c/p\u003e\n \u003cp\u003e2 (1.6%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e- Low-grade persistent fever\u003c/p\u003e\n \u003cp\u003e- Dyspnea\u003c/p\u003e\n \u003cp\u003e- Chest pain\u003c/p\u003e\n \u003cp\u003e- Diplopia\u003c/p\u003e\n \u003cp\u003e- Painful bruise-like lesions\u003c/p\u003e\n \u003cp\u003e- Deficit in left eye opening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (5.4%)\u003c/p\u003e\n \u003cp\u003e2 (1.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychiatric disorders\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- SSDR\u003c/p\u003e\n \u003cp\u003eSomatic Symptom Disorder\u003c/p\u003e\n \u003cp\u003eFactitious Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (17.2%)\u003c/p\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e- Anxiety disorder\u003c/p\u003e\n \u003cp\u003e- Depression\u003c/p\u003e\n \u003cp\u003e- Eating disorder\u003c/p\u003e\n \u003cp\u003e- Functional neurological symptom disorder\u003c/p\u003e\n \u003cp\u003e- Obsessive-compulsive disorder\u003c/p\u003e\n \u003cp\u003e- Dissociative disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (14.8%)\u003c/p\u003e\n \u003cp\u003e2 (1.6%)\u003c/p\u003e\n \u003cp\u003e2 (1.6%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eLaboratory tests, instrumental investigations, and therapeutic interventions\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePatients\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLaboratory tests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e128 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStool tests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (19.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInstrumental investigations\u003c/p\u003e\n \u003cp\u003e- MRI\u003c/p\u003e\n \u003cp\u003e- Abdominal ultrasound\u003c/p\u003e\n \u003cp\u003e- X-ray study\u003c/p\u003e\n \u003cp\u003e- CT scan\u003c/p\u003e\n \u003cp\u003e- Upper GI series\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71 (55.4%)\u003c/p\u003e\n \u003cp\u003e70 (54.6%)\u003c/p\u003e\n \u003cp\u003e57 (44.5%)\u003c/p\u003e\n \u003cp\u003e14 (10.9%)\u003c/p\u003e\n \u003cp\u003e1 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEKG/Echocardiogram\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEEG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers (i.e., ENG, GI endoscopy, biopsy, scintigraphy)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (25.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTherapeutic intervention\u003c/p\u003e\n \u003cp\u003e- Paracetamol\u003c/p\u003e\n \u003cp\u003e- NSAIDs\u003c/p\u003e\n \u003cp\u003e- Benzodiazepines\u003c/p\u003e\n \u003cp\u003e- Antidepressants\u003c/p\u003e\n \u003cp\u003e- Physical therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (22.6%)\u003c/p\u003e\n \u003cp\u003e9 (7.0%)\u003c/p\u003e\n \u003cp\u003e7 (5.4%)\u003c/p\u003e\n \u003cp\u003e6 (4.7%)\u003c/p\u003e\n \u003cp\u003e50 (39.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eOther medical specialists, mainly neurologists, rheumatologists, and gastroenterologists, examined almost all patients (97%); most cases (78%) received multiple specialist consultations during the same admission. One-hundred and ten patients (86%) underwent evaluation by a psychologist, a neuropsychiatrist, or both. These specialists diagnosed psychiatric comorbidity in 48 (38%) patients (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Particularly, 22 (17%) patients were diagnosed with SSD, 19 (15%) with anxiety, two with depression, and two with an eating disorder. The prevalence of psychiatric disorders did not significantly different among females and males with SS (P\u0026thinsp;=\u0026thinsp;0.3); however, anxiety was more frequent in females (P\u0026thinsp;=\u0026thinsp;0.05).\u003c/p\u003e\n\u003cp\u003ePharmacological treatment for pain included paracetamol in 29 patients (23%) and nonsteroidal anti-inflammatory drugs in nine cases (7%). Based on psychiatric prescriptions ordered, seven (6%) required benzodiazepines for anxiety disorders, and six patients (5%) received antidepressants for depressive disorder (5%). Fifty patients (39%) were prescribed physical therapy (exercises and physiotherapy). All therapeutic interventions adopted in our cohort are summarized in Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eNotably, six patients (5%) inappropriately underwent surgical intervention; all presented at admission with gastrointestinal symptoms as the main complaint, accounting for 15% of patients with this presentation. Two patients underwent exploratory laparoscopy and four appendectomy. None had a condition requiring surgical intervention. Biopsychosocial risk factors were identified in 79 (61.7%) patients. Familial stressful events were found in a quarter of our cases: maternal illness in 27% of cases, severe diseases, or death in other family members in 16%, and parental conflicts or divorce in 11%. Furthermore, 15% of the patients had a lack of friends and 3% reported bullying. No history of abuse or violence was declared.\u003c/p\u003e\n\u003cp\u003eA significant number of patients had a history of social withdrawal due to symptoms: in particular, 40% of patients had abandoned sports practice and 39% reported scholastic absenteeism.\u003c/p\u003e\n\u003cp\u003eAt discharge, most patients (89%) were referred for follow-up care, most commonly with a psychologic or neuropsychiatric specialist (66%), and/or with a physiotherapist (51%).\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOur study described a cohort of 128 patients hospitalized for SS over 10 years, encompassing the COVID-19 pandemic.\u003c/p\u003e \u003cp\u003eThe mean age of our cohort (12 years) was lower compared to most SSRD pediatric cohorts, ranging from 13.5 to 14.6 years[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10 CR11 CR12\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The prevalence of SS is similar between sexes until puberty, after which females exhibit a higher risk[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This difference is thought to be due to females\u0026rsquo; tendency toward a more internalizing or ruminative coping style compared to males. Our results confirm the gender trend observed in other studies[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] showing a higher prevalence in females. In our cohort, 20% of patients had known medical comorbidities at admission. This percentage is much lower than reported in other cohorts: 48% by Bujoreanu \u003cem\u003eet al.\u003c/em\u003e, and 65% by Wiggings \u003cem\u003eet al\u003c/em\u003e. Notably, in these cohorts, SS potentially overlapped with symptoms due to the patient\u0026rsquo;s medical conditions[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe observed a prevalence peak of hospitalization in 2020\u0026ndash;2021, although not statistically significant. This is consistent with literature showing the consequences of the COVID-19 pandemic on the mental health of children and adolescents[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Aligned with our findings, a 2023 Italian study documented a rise in pediatric ED admissions for SS during the pandemic[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs reported in other cohorts, we found the most frequent clinical manifestations were musculoskeletal, gastrointestinal and neurological[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Approximately half of our patients had more than one manifestation involving multiple systems. This proportion was comparable to the cohorts described by Bujoreanu \u003cem\u003eet al.\u003c/em\u003e (53%)[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and by Wiggings \u003cem\u003eet al.\u003c/em\u003e (41%)[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The occurrence of multiple symptoms across different organs as well as some characteristics of the complaints (vague and disproportionate) are highly suggestive of SS[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePain is a frequent symptom reported in adolescents, particularly chronic musculoskeletal pain defined as ongoing pain in the bones, joints, or muscles persisting for more than 3 months. The most common form of chronic musculoskeletal pain in children and adolescents include PAS, which can be localized or diffuse, resulting in a complete inability to walk, muscle weakness, atrophy, and contractures[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our cohort, musculoskeletal complaints were the most frequent and mostly localized in the lower limbs, often associated with altered gait. PAS was diagnosed in approximately a quarter of our cases.\u003c/p\u003e \u003cp\u003eAs noted in the literature[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], abdominal pain was the most frequent gastrointestinal manifestation, observed in more than a quarter of our cases, followed by emesis and constipation. Headache, followed by dizziness and, more rarely, serious neurological disturbances (e.g., non-epileptic seizures, sensory impairment, and tinnitus) are the neurological manifestations typically reported[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Accordingly, in our cohort, neurological manifestations represented the third most frequent complaint, with headache being the most common. A range of manifestations, including fatigue, difficulty breathing, chronic cough, chest pain, and lower urinary tract symptoms, is less frequently described in the literature[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], as in our cohort.\u003c/p\u003e \u003cp\u003eThe mean duration of hospitalization was 7 days, longer than previously reported lengths of stay, ranging from 3 to 5 days[\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Our patients had a long duration of symptoms before the hospitalization: over half of our cases had a previous hospitalization for SS, and one-quarter had been evaluated in an ED at least twice. The re-hospitalization rate in our cohort was higher than those reported in other studies (14% by Bujoreanu \u003cem\u003eet al.\u003c/em\u003e and 30% by Wigging \u003cem\u003eet al.\u003c/em\u003e)[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The overmedicalization of these patients is confirmed by the results of previous studies reporting that patients with SS have several medical consultations before hospitalization, mostly with general practitioners and/or medical specialists[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDuring hospitalization, our patients received several investigations, which were more frequently requested compared to other cohorts of inpatients with SSRD, ranging from 65% to 86%[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. As described in other studies[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], non-SSRD psychiatric comorbidity was diagnosed in 20% of cases. Research on pharmacological interventions for SSRD in children and adolescents is limited, and there is no high-quality evidence in recommend medications in this population[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Comorbid psychopathologies (depression and anxiety) respond to antidepressants as adjunctive treatment in the overall management of SS. Only a small proportion of our patients were treated either with benzodiazepines, or other antidepressants. Although the effectiveness of physiotherapy in the management of SS in children and adolescents is supported by few studies[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], physiotherapy seems to play a considerable role in clinical practice as physical activity has been shown to improve mental health, alleviate chronic fatigue syndrome, and address various musculoskeletal impairments[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Accordingly, approximately half of the patients in our study received physiotherapy. Nonpharmacological treatment of SSRD mainly relies on cognitive behavioral therapy, which should be tailored to the individual needs of each patient and his or her family.\u003c/p\u003e \u003cp\u003eRecognizing biopsychosocial risk factors is essential for the successful assessment and management of SS[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], with the collaboration of neuropsychiatrists and psychologists with pediatricians. Risk factors may be distinguished into individual (temperament, poor coping skills, borderline intellectual functioning, and underlying psychiatric illness), family-related (medical or psychiatric disease of a close family member, substance abuse, communication and attitude of family members towards the child/adolescent), and environmental ones (bullying, academic/sports stress, peer relationships, traumatic experiences)[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. As acknowledged by several studies, at least one of these risk factors is present in most children and adolescents with SSRD[\u003cspan additionalcitationids=\"CR29 CR30 CR31\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In addition, school absenteeism is significantly associated with SSRD[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. According to a 2021 study by Vassilopoulos \u003cem\u003eet al.\u003c/em\u003e, patients with SSRD and severe school absenteeism (\u0026gt;\u0026thinsp;1 month) were more likely to have higher somatization and functional disability scores, higher rates of suicidal ideation and/or attempts, greater psychotropic medication use and psychiatry sessions during hospitalization, and greater rates of discharge to higher level of psychiatric care[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecent studies have demonstrated the efficacy of a multidisciplinary clinical pathway for hospitalized patients suspected of having SSRD[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The clinical evaluation should require the early involvement of consultants from medical specialties, including psychologists and psychiatrists, and tailored diagnostic tests to rule out any medical issues, thereby avoiding unnecessary, invasive, time-consuming, and expensive procedures. Over-testing can suggest that the SSRD diagnosis is uncertain and makes it difficult to reassure patients and families that an unrecognized physical disease is unlikely. Conversely, regular but short clinical check-ins can monitor important changes that may require follow-up and other investigations[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEarly involvement of psychologists and psychiatrists is essential to assess the presence of the above-mentioned risk factors and to reach a positive diagnosis of an SSRD, which is not an exclusion diagnosis. The patients and their families should be involved in the diagnostic process and receive the diagnosis of an SSRD. This approach is still difficult to implement in most settings, due to limited knowledge and training of pediatricians on SSRD and the poor liaison between hospital pediatricians, primary care physicians, psychologists, and psychiatrists. Many primary care pediatricians or hospital doctors lack experience with SS and SSRD and consider diagnosis and management challenging[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Our study demonstrates that SS have an increasing burden on children and adolescents and that the approach to SS is still difficult for primary care and hospital pediatricians, as demonstrated by the number of ED evaluations, the duration of hospitalization, the rate of re-hospitalization, and by the number of requested investigations and specialist consultations. Early identification of patients with SS by hospital as well as primary care pediatricians, would allow timely involvement of mental health professionals and prompt implementation of appropriate interventions, thereby avoiding prolonged or repeated hospitalizations before reaching a correct diagnosis.\u003c/p\u003e \u003cp\u003eWe acknowledge the limitations of this study. First, its retrospective nature could underestimate the number of cases hospitalized for SS and SSRD diagnoses; moreover, as a single-center study conducted in a tertiary care hospital, our sample may not accurately reflect the true prevalence in the general pediatric population. Second, we analyzed a cohort of patients with SS, which is not fully comparable to literature cohorts of SSRD: the lack of standardized terminology hampers comprehensive comparisons, as patient populations are not classified consistently. The strength of this study lies in the analysis of a substantial cohort of children and adolescents hospitalized for SS in a single Pediatric Unit.\u003c/p\u003e \u003cp\u003eIn conclusion, SS are a frequent cause of hospitalization, particularly in preadolescents and adolescents. The most frequent manifestations are musculoskeletal, gastrointestinal, and neurological. Early and close collaboration with psychologists and psychiatrists is essential for a comprehensive medical and psychological assessment, tailored medical tests and ultimately achieving a positive diagnosis of SSRD.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDSM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDiagnostic and Statistical Manual of Mental Disorders\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eED\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency Department\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epain amplification syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003estandard deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSomatic symptoms\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esomatic symptom disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSSRD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esomatic symptom and related disorders\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding/Support:\u0026nbsp;\u003c/strong\u003eThe authors declare that no funds, grants, or other support were received during the\u0026nbsp;preparation of this manuscript\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003eThe authors have no relevant financial or non-financial interests to disclose\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003e\u003cem\u003eAll authors contributed to the study conception and design. Sandra Trapani, Alessandra Montemaggi, Chiara Rubino, and Michela Orlandi designed the data collection instruments, collected data, carried out the initial analyses. Michela Orlandi, Chiara Rubino and Alessandra Montemaggi wrote the first draft, Sandra Trapani and Giuseppe Indolfi critically reviewed and revised the manuscript.\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003cem\u003eAll authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.\u003c/em\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e\u0026nbsp;Ethical review and approval were not required for this study in accordance with institutional and national regulations, as it was an observational study based exclusively on data routinely collected and recorded in medical records during hospitalization (for which parental consent had already been obtained).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eO\u0026rsquo;Connell C, Shafran R, Bennett S (2020) A systematic review of randomised controlled trials using psychological interventions for children and adolescents with medically unexplained symptoms: A focus on mental health outcomes. 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Paediatr Child Health 13:487\u0026ndash;491\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBroekhuijsen-van Henten DM, Luitse GHJ, Knottnerus AC, van den Heuvel M (2015) Exploring Self-Efficacy and Attitudes Among Pediatricians in Managing Medically Unexplained Physical Symptoms. Clin Pediatr (Phila) 54:1391\u0026ndash;1393. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0009922815570624\u003c/span\u003e\u003cspan address=\"10.1177/0009922815570624\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Somatic symptoms, hospitalization, retrospective study, multidisciplinary approach","lastPublishedDoi":"10.21203/rs.3.rs-8521476/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8521476/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003ePurpose\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSomatic symptoms (SS) are physical manifestations associated with clinically significant distress that is disproportionate to or inconsistent with the history, physical examination, and other objective findings; they represent a notable reason for hospitalization in pediatric patients. The present study aimed to describe a cohort of pediatric patients hospitalized for SS.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWe conducted a retrospective cohort study of children and adolescents hospitalized for SS in the Pediatrics Unit of Meyer Children\u0026rsquo;s Hospital IRCCS in Florence, Italy, from 2015 to 2024.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOne hundred and twenty-eight patients (male/female ratio 1/2.2; mean age 12 years) were hospitalized with SS over the study period, with a peak in annual prevalence in 2020\u0026ndash;2021, corresponding to the COVID-19 pandemic. The most frequent manifestations at admission were musculoskeletal (40%), gastrointestinal (30%), and neurological (23%). Nearly half (49%) experienced symptoms involving multiple systems. The mean duration of hospitalization was 8 days. Magnetic resonance imaging was performed in 55% of patients, and computed tomography in 11%. Almost all (97%) received at least one consultation with a medical specialist, while 86% were assessed by a psychologist, psychiatrist, or both. Biopsychosocial risk factors (such as stressful family events and school absenteeism) were identified in 62%.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSS are common in children and adolescents and represent a frequent cause of hospitalization. Although awareness of SS is low among healthcare professionals, pediatricians play a key role in detecting and managing SS through a patient-centered approach and a multidisciplinary clinical pathway involving the psychologist and the psychiatrist.\u003c/p\u003e","manuscriptTitle":"Children and adolescents hospitalized for somatic symptoms: a retrospective cohort study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 11:23:53","doi":"10.21203/rs.3.rs-8521476/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d9a7ad5e-0c5f-4eec-80d4-9648c4d756ba","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-16T11:23:53+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 11:23:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8521476","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8521476","identity":"rs-8521476","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}