How paediatric psycho‐oncology is changing during the COVID‐19 epidemic in Italy: New approaches

The city of Turin, located in Piedmont, north-west Italy, is the fourth largest city in Italy with almost 900 000 citizens in the municipality and 2 200 000 if we consider the city plus the surrounding area of its 315 municipalities. Since the end of April 2020, Piedmont and more specifically the metropolitan city of Turin, has been one of the mostly highly affected areas by the COVID-19 pandemic with more than 20 000 cases throughout Piedmont and almost 10 000 in Turin alone. It has had the fourth highest number of positive cases in the country. International research is demonstrating that this particular coronavirus mainly affects older people and therefore cannot be considered a paediatric concern as such. This is also confirmed by Italian data that estimates the incidence of positive cases among children (age 0-18) stands at around 1.2%. Nonetheless, the epidemic has a potentially devastating indirect impact on the paediatric oncology population and the family as a whole. First, in consideration of their immunodepression, young patients are weaker and less able to fight infection. Second, they are already undergoing a psychological stressful condition due to the intense treatments they are receiving on a daily basis. Third, patient and caregiver are now being forced to tolerate social and relational isolation that is much stricter than they would be required to experience under normal circumstances. Finally, offtreatment patients may suffer from feelings of anxiety if they find themselves reliving the limitations and fears they experienced during the course of treatment (fear of infection, isolation, use of extensive precautions). Located in the municipality of Turin, the Department of Paediatric Oncology of the Regina Margherita Children's Hospital is the baseline validated Hub for the entire Piedmont and Aosta Valley and one of the main centres at national level (about 8% of total diagnoses in Italy). Its Psycho-oncology Unit, manages more than 150 new diagnoses per year, providing highly-structured psychological support to child and adolescent patients and their families. Psycho-oncologists also take care of patients who have concluded their therapy (“offtherapy patients” who make up around 40 per year) as well as mediating the complex relationships: patients and their families, doctors and educational services (hospital school, social services and volunteers). The entire range of psychological activities is regulated by formalized protocols that help professionals orient their interventions which are currently organized in three levels: (1) preventive (diagnosis communication with psycho-oncologist and oncologist and preliminary interviews with patients and families), (2) diagnostic-therapeutic, (3) psycho-therapeutic, psycho-pharmacologist and psycho-social. Since February 23, when the first positive cases of Covid-19 appeared in the city of Turin, the Regina Margherita Children's Hospital implemented security procedures to prevent any possible contamination by following government directives. Visitors' access to the Hospital was interrupted and even educational and recreational activities were stopped, forcing patients to endure new trauma and the inevitable suffering that psycho-oncologists have been left to cope with. This is a historical moment in which psycho-oncology can make even more of a difference. In fact, psycho-oncologists have recognized the need for new strategies to cope with this unexpected event. A wide spectrum of services has been modified or created from scratch by psycho-oncologists who, together with doctors and nurses, are available around the clock. The major challenge observed due to Covid-19 was visiting restrictions which resulted in causing an additional burden for parents. Currently, patient assistance is limited to a single parent: the mother and father of the child or adolescent cannot take turns anymore as a result of the restrictions imposed by the Covid-19 welfare hospital rules which have led to an inevitable increase in physical and psychological stress and fatigue. These conditions are particularly critical for newly diagnosed cases in which the principal caregiver, usually the mother, is forced to experience traumatic events completely alone (eg, diagnosis communication, CVC, lumbar puncture, bone marrow Received: 9 May 2020 Revised: 26 May 2020 Accepted: 6 June 2020