toxins Article Acute Exposure to European Viper Bite in Children: Advocating for a Pediatric Approach Marco Marano 1 , Mara Pisani 2 , Giorgio Zampini 1 , Giuseppe Pontrelli 3 and Marco Roversi 3, *   Citation: Marano, M.; Pisani, M.; Zampini, G.; Pontrelli, G.; Roversi, M. Acute Exposure to European Viper Bite in Children: Advocating for a Pediatric Approach. Toxins 2021, 13, 330. https://doi.org/10.3390/ toxins13050330 Received: 16 April 2021 Accepted: 30 April 2021 Published: 2 May 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affil- iations. Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). 1 Pediatric Intensive Care Unit, Pediatric Clinical Toxicology Center, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; marco.marano@opbg.net (M.M.); giorgio.zampini@opbg.net (G.Z.) 2 Department of Emergency, Acceptance and General Pediatrics, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; mara.pisani@opbg.net 3 Clinical Trial Unit, Academic Department of Pediatrics, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; giuseppe.pontrelli@opbg.net * Correspondence: marcrov@outlook.it Abstract: Viper bite is an uncommon but serious cause of envenoming in Europe, especially in children. Our study aim is to better describe and analyze the clinical course and treatment of viper bite envenoming in a pediatric population. We retrospectively reviewed 24 cases of pediatric viper bites that were admitted to the Pediatric Emergency Department and the Pediatric Intensive Care Unit of the Bambino Gesù Children Hospital in Rome between 2000 and 2020. Epidemiological char- acteristics of the children, localization of the bite, clinical and laboratory findings, and treatment approaches were evaluated. The median age of the patients was 4.2 years, with male predominance. Most cases of viper bite occurred in the late summer. Most patients required admission to the ward for prolonged observation. The most common presenting signs were pain, local oedema, and swelling. Patients with a high severity score also had a significantly higher white blood cell count and an increase of INR, LDH, and CRP levels. No fatality was reported. Viper bite envenomation is a rare pediatric medical emergency in Italy but may sometimes be severe. A new pediatric severity score may be implemented in the screening of children with viper bites to favor a selective and prompt administration of antivenom. Keywords: pediatrics; children; viper bite; envenoming; severity score; antivenom administration Key Contribution: This study gives more insight on the clinical effect and management of viper bites in the fragile cohort of children. With our work, we propose a pediatric severity score for viper bites, which could prove a ready-to-use tool for all emergency pediatricians in their clinical practice. 1. Introduction Snakebite envenoming is a rare yet potentially fatal event, reported to kill between 81,000 and 138,000 people and to cause long-lasting disabilities in another 400,000 people across the world [1]. Fortunately, snakebites are less common in Europe, occurring in every 0.22 to 1.43 people every 100,000 population per year in different countries [2]. According to the epidemiologic reports, fatalities following snakebite are rare events due to both the high- standard public health systems of these countries [3] and the lower lethality of the local snakes compared to their foreign counterparts, with the species V. berus the most involved, followed by the taxa V. ammodytes and V. aspis, and, less frequently, by the taxa V. ursini, V. latastei, and V. seoanei [4]. In Italy, V. aspis is the most common snake of the Viperidae family. About a quarter of snakebites occur without venom inoculation [5], as they are meant to scare the predator away, rather than killing the prey (‘dry’ bites). Given their lower weight-to-venom ratio, children are most exposed to the potentially lethal consequences of snakebites. Although the management of viper bite is mainly supportive, the cornerstone of the treatment is represented by immunotherapy, which should be implemented according Toxins 2021, 13, 330. https://doi.org/10.3390/toxins13050330 https://www.mdpi.com/journal/toxins