{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T04:10:44Z","timestamp":1788408644806,"version":"build-2803163510"},"reference-count":57,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2026,2,26]],"date-time":"2026-02-26T00:00:00Z","timestamp":1772064000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Children"],"abstract":"<jats:p>Vernal keratoconjunctivitis (VKC) represents far more than a typical allergic eye disease. It is a distinct and often underestimated chronic inflammatory condition that primarily affects children during critical stages of physical and emotional development. Though frequently grouped with seasonal allergic conjunctivitis, VKC differs significantly in its immunopathology, clinical presentation, and long-term implications. Its intense ocular symptoms and its potential for corneal damage and substantial psychosocial burden require, rather than symptom control, coordinated and multidisciplinary management. This narrative review explores VKC from every angle, with a particular focus on its implications for pediatric care. VKC, in fact, represents a genuine clinical challenge: as its symptoms can mimic milder forms of conjunctivitis, its course is often unpredictable, and its treatment requires balancing efficacy and safety in vulnerable age groups. We examined the immunological mechanisms that make it a model of localized Th2 inflammation, the diagnostic pitfalls that delay recognition, and the evolving treatment landscape, from conventional therapies like cyclosporine A and tacrolimus to innovative agents such as omalizumab and dupilumab. We also highlighted the role of emerging biomarkers, the influence of environmental and microbiome factors, and the urgent need for standardized care pathways. As research continues to expand our understanding, VKC is emerging as a prime example of how personalized medicine and translational science can intersect to address complex immune-mediated diseases in children. For the ones treating pediatric allergic disorders, VKC is no longer a rare curiosity: it is a clinical challenge worth understanding deeply.<\/jats:p>","DOI":"10.3390\/children13030335","type":"journal-article","created":{"date-parts":[[2026,2,26]],"date-time":"2026-02-26T13:58:03Z","timestamp":1772114283000},"page":"335","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Pediatric Vernal Keratoconjunctivitis (VKC): Current State and Future Directions\u2014A Narrative Review of Clinical Features, Diagnostic Strategies, and Emerging Therapies"],"prefix":"10.3390","volume":"13","author":[{"given":"Elia","family":"Pignataro","sequence":"first","affiliation":[{"name":"Department of Experimental Medicine, La Sapienza University, 00161 Rome, Italy"},{"name":"Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5059-6082","authenticated-orcid":false,"given":"Giulia","family":"Brindisi","sequence":"additional","affiliation":[{"name":"Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-9211-6829","authenticated-orcid":false,"given":"Alessandra","family":"Gori","sequence":"additional","affiliation":[{"name":"Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giorgio","family":"Colletti","sequence":"additional","affiliation":[{"name":"Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paola","family":"Moraca","sequence":"additional","affiliation":[{"name":"Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1268-5038","authenticated-orcid":false,"given":"Bianca Laura","family":"Cinicola","sequence":"additional","affiliation":[{"name":"Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alberto","family":"Spalice","sequence":"additional","affiliation":[{"name":"Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9607-8632","authenticated-orcid":false,"given":"Caterina","family":"Anania","sequence":"additional","affiliation":[{"name":"Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna Maria","family":"Zicari","sequence":"additional","affiliation":[{"name":"Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,2,26]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"119","DOI":"10.2147\/OPTH.S129552","article-title":"Vernal Keratoconjunctivitis","volume":"12","author":"Addis","year":"2018","journal-title":"Clin. Ophthalmol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1157","DOI":"10.1016\/S0161-6420(00)00092-0","article-title":"Vernal Keratoconjunctivitis Revisited","volume":"107","author":"Bonini","year":"2000","journal-title":"Ophthalmology"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1016\/j.survophthal.2023.10.008","article-title":"Management of Vernal Keratoconjunctivitis: Navigating a Changing Treatment Landscape","volume":"69","author":"Ali","year":"2024","journal-title":"Surv. Ophthalmol."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Sacchetti, M., Plateroti, R., Bruscolini, A., Giustolisi, R., and Marenco, M. (2021). Understanding Vernal Keratoconjunctivitis: Beyond Allergic Mechanisms. Life, 11.","DOI":"10.3390\/life11101012"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1097","DOI":"10.1136\/bjo.2007.117812","article-title":"Prevalence of Vernal Keratoconjunctivitis: A Rare Disease?","volume":"92","author":"Donadieu","year":"2008","journal-title":"Br. J. Ophthalmol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1167\/iovs.64.10.37","article-title":"Air Pollution and Meteorological Conditions Significantly Associated With Vernal Keratoconjunctivitis Exacerbations","volume":"64","author":"Levanon","year":"2023","journal-title":"Investig. Ophthalmol. Vis. Sci."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1111\/aos.15212","article-title":"Prevalence of Allergic Sensitization with Vernal Keratoconjunctivitis: A Systematic Review with Meta-analyses","volume":"101","author":"Rasmussen","year":"2023","journal-title":"Acta Ophthalmol."},{"key":"ref_8","first-page":"e2021517","article-title":"Vernal Keratoconjunctivitis: State of Art and Update on Treatment","volume":"92","author":"Brindisi","year":"2021","journal-title":"Acta Biomed. Atenei Parm."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e2023-0054","DOI":"10.5935\/0004-2749.2023-0054","article-title":"Translation, Adaptation, and Psychometric Properties of the Brazilian-Portuguese Version of the Quality of Life in Children with Vernal Keratoconjunctivitis Questionnaire","volume":"87","author":"Ferreira","year":"2024","journal-title":"Arq. Bras. Oftalmol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"282","DOI":"10.1016\/j.jtos.2020.10.005","article-title":"Management of Corneal Complications in Vernal Keratoconjunctivitis: A Review","volume":"19","author":"Feizi","year":"2021","journal-title":"Ocul. Surf."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1016\/j.jtos.2020.09.009","article-title":"Conjunctival Transcriptome Analysis Reveals the Overexpression of Multiple Pattern Recognition Receptors in Vernal Keratoconjunctivitis","volume":"19","author":"Leonardi","year":"2021","journal-title":"Ocul. Surf."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"9672082","DOI":"10.1155\/2016\/9672082","article-title":"Quiescent and Active Tear Protein Profiles to Predict Vernal Keratoconjunctivitis Reactivation","volume":"2016","author":"Micera","year":"2016","journal-title":"BioMed Res. Int."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"907","DOI":"10.1016\/j.survophthal.2021.03.010","article-title":"The Ocular Microbiome and Microbiota and Their Effects on Ocular Surface Pathophysiology and Disorders","volume":"66","author":"Aragona","year":"2021","journal-title":"Surv. Ophthalmol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"3589","DOI":"10.2147\/OPTH.S370414","article-title":"Efficacy and Safety of 0.1% Cyclosporine versus 2% Cyclosporine in the Treatment of Severe Vernal Keratoconjunctivitis in Children","volume":"16","author":"Bourcier","year":"2022","journal-title":"Clin. Ophthalmol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"308","DOI":"10.1007\/s11882-013-0345-0","article-title":"Use of Cyclosporine A and Tacrolimus in Treatment of Vernal Keratoconjunctivitis","volume":"13","author":"Vichyanond","year":"2013","journal-title":"Curr. Allergy Asthma Rep."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"100788","DOI":"10.1016\/j.waojou.2023.100788","article-title":"Vernal Keratoconjunctivitis: Current Immunological and Clinical Evidence and the Potential Role of Omalizumab","volume":"16","author":"Doan","year":"2023","journal-title":"World Allergy Organ. J."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e13899","DOI":"10.1111\/cts.13899","article-title":"Dupilumab: Mechanism of Action, Clinical, and Translational Science","volume":"17","author":"McCann","year":"2024","journal-title":"Clin. Transl. Sci."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1111\/j.1755-3768.2008.01347.x","article-title":"Vernal Keratoconjunctivitis: A Major Review","volume":"87","author":"Kumar","year":"2009","journal-title":"Acta Ophthalmol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1243","DOI":"10.1016\/j.ophtha.2024.01.038","article-title":"Burden of Vernal Keratoconjunctivitis in the United States: A Retrospective Claims Database Analysis","volume":"131","author":"Koo","year":"2024","journal-title":"Ophthalmology"},{"key":"ref_20","first-page":"58","article-title":"Corneal Complications And Visual Impairment In Vernal Keratoconjunctivitis Patients","volume":"29","author":"Arif","year":"2017","journal-title":"J. Ayub Med. Coll. Abbottabad"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"100855","DOI":"10.1016\/j.waojou.2023.100855","article-title":"Vernal Keratoconjunctivitis and Eosinophilic Esophagitis: A Rare Combination?","volume":"17","author":"Artesani","year":"2024","journal-title":"World Allergy Organ. J."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"2828","DOI":"10.1177\/11206721211022153","article-title":"Vernal Keratoconjunctivitis: An Update","volume":"31","author":"Ghiglioni","year":"2021","journal-title":"Eur. J. Ophthalmol."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Tariq, F. (2024). Allergic Conjunctivitis: Review of Current Types, Treatments, and Trends. Life, 14.","DOI":"10.3390\/life14060650"},{"key":"ref_24","first-page":"1007","article-title":"Reserve Drug as First-Line Management: Topical Interferon \u03b1-2b for Vernal Keratoconjunctivitis","volume":"72","author":"Haral","year":"2024","journal-title":"Indian J. Ophthalmol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"110","DOI":"10.4103\/IJO.IJO_24_24","article-title":"Tear Film Parameters and Meibography in Eyes of Children with Vernal Keratoconjunctivitis","volume":"73","author":"Gupta","year":"2025","journal-title":"Indian J. Ophthalmol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"173","DOI":"10.1016\/j.jtos.2024.07.009","article-title":"Unraveling the Complexity\u2014Insights and Interventions of Refractory Vernal Keratoconjunctivitis","volume":"34","author":"Agarwal","year":"2024","journal-title":"Ocul. Surf."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"S109","DOI":"10.1097\/ICL.0000000000000688","article-title":"Potential Biomarkers for Allergic Conjunctival Diseases","volume":"46","author":"Roy","year":"2020","journal-title":"Eye Contact Lens Sci. Clin. Pract."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1016\/j.lfs.2015.01.040","article-title":"A Comprehensive Review on Vernal Keratoconjunctivitis with Emphasis on Proteomics","volume":"128","author":"Pattnaik","year":"2015","journal-title":"Life Sci."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"277","DOI":"10.1007\/s12016-023-08970-4","article-title":"Vernal Keratoconjunctivitis: A Systematic Review","volume":"65","author":"Bruschi","year":"2023","journal-title":"Clin. Rev. Allergy Immunol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1007\/s10792-019-01149-x","article-title":"Relationship between Tear Eotaxin-2 and MMP-9 with Ocular Allergy and Corneal Topography in Keratoconus Patients","volume":"40","author":"Mutlu","year":"2020","journal-title":"Int. Ophthalmol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1007\/978-981-13-6657-4_12","article-title":"Periostin in Eye Diseases","volume":"Volume 1132","author":"Kudo","year":"2019","journal-title":"Periostin"},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Syed, N.H., Shahidan, W.N.S., Shatriah, I., and Zunaina, E. (2022). MicroRNA Profiling of the Tears of Children With Vernal Keratoconjunctivitis. Front. Genet., 13.","DOI":"10.3389\/fgene.2022.847168"},{"key":"ref_33","first-page":"250","article-title":"Biomarkers of Ocular Allergy and Dry Eye Disease","volume":"67","author":"Mihail","year":"2023","journal-title":"Rom. J. Ophthalmol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1111\/pai.13382","article-title":"Is Oxidative Stress Involved in Vernal Keratoconjunctivitis? Results from a Pilot Study in Children","volume":"31","author":"Zicari","year":"2020","journal-title":"Pediatr. Allergy Immunol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"796","DOI":"10.1016\/j.ajo.2012.11.018","article-title":"Vernal Keratoconjunctivitis-like Disease in Adults","volume":"155","author":"Leonardi","year":"2013","journal-title":"Am. J. Ophthalmol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"436","DOI":"10.1097\/ACI.0b013e3282efb726","article-title":"Clinical Grading of Vernal Keratoconjunctivitis","volume":"7","author":"Bonini","year":"2007","journal-title":"Curr. Opin. Allergy Clin. Immunol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"5053","DOI":"10.1007\/s00431-024-05776-0","article-title":"Seeing Eye to Eye: A Modified Delphi Method-Based Multidisciplinary Expert Consensus on the Diagnosis and Treatment of Vernal Keratoconjunctivitis","volume":"183","author":"Ghiglioni","year":"2024","journal-title":"Eur. J. Pediatr."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1207","DOI":"10.1007\/s40123-023-00665-5","article-title":"Novel Insights in the Management of Vernal Keratoconjunctivitis (VKC): European Expert Consensus Using a Modified Nominal Group Technique","volume":"12","author":"Bonini","year":"2023","journal-title":"Ophthalmol. Ther."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"6","DOI":"10.3928\/01913913-20220328-01","article-title":"Management of Vernal Keratoconjunctivitis in Children in the United Kingdom: A Review of the Literature and Current Best Practice Across Six Large United Kingdom Centers","volume":"60","author":"Ghauri","year":"2023","journal-title":"J. Pediatr. Ophthalmol. Strabismus"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"347","DOI":"10.1007\/s40272-016-0185-1","article-title":"An Update on the Therapeutic Approach to Vernal Keratoconjunctivitis","volume":"18","author":"Esposito","year":"2016","journal-title":"Pediatr. Drugs"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"364","DOI":"10.3341\/kjo.2024.0048","article-title":"Health-Related Quality of Life in Children with Vernal Keratoconjunctivitis in Malaysia","volume":"38","author":"Lai","year":"2024","journal-title":"Korean J. Ophthalmol."},{"key":"ref_42","first-page":"1077","article-title":"Local Allergic Rhinitis\u2014A Narrative Review","volume":"28","author":"Manole","year":"2024","journal-title":"Eur. Rev. Med. Pharmacol. Sci."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1657","DOI":"10.1111\/all.13200","article-title":"Non-allergic Rhinitis: Position Paper of the European Academy of Allergy and Clinical Immunology","volume":"72","author":"Hellings","year":"2017","journal-title":"Allergy"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1002\/iid3.278","article-title":"Role of Ocular Cytology in Vernal Keratoconjunctivitis","volume":"8","author":"Bruschi","year":"2020","journal-title":"Immun. Inflamm. Dis."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"671","DOI":"10.1016\/j.ophtha.2018.12.027","article-title":"A Randomized, Controlled Trial of Cyclosporine A Cationic Emulsion in Pediatric Vernal Keratoconjunctivitis","volume":"126","author":"Leonardi","year":"2019","journal-title":"Ophthalmology"},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Ghiglioni, D.G., Martino, P.A., Bruschi, G., Vitali, D., Osnaghi, S., Corti, M.G., and Beretta, G. (2020). Stability and Safety Traits of Novel Cyclosporine A and Tacrolimus Ophthalmic Galenic Formulations Involved in Vernal Keratoconjunctivitis Treatment by a High-Resolution Mass Spectrometry Approach. Pharmaceutics, 12.","DOI":"10.3390\/pharmaceutics12040378"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"2320","DOI":"10.1038\/s41433-022-02342-6","article-title":"Topical Cyclosporine A Cationic Ophthalmic Emulsion in Paediatric Vernal Keratoconjunctivitis: Pooled Analysis of Randomised NOVATIVE and VEKTIS Trials","volume":"37","author":"Leonardi","year":"2023","journal-title":"Eye"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1444","DOI":"10.1097\/ICO.0000000000000918","article-title":"Tacrolimus in Corticosteroid-Refractory Vernal Keratoconjunctivitis","volume":"35","author":"Chatterjee","year":"2016","journal-title":"Cornea"},{"key":"ref_49","first-page":"25158414231173532","article-title":"Comparision of Efficacy and Safety of 0.03% and 0.1% Tacrolimus Ointment in Children with Vernal Keratoconjunctivitis","volume":"15","author":"Saha","year":"2023","journal-title":"Ther. Adv. Ophthalmol."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"375","DOI":"10.1097\/ICO.0000000000001200","article-title":"Comparative Evaluation of Tacrolimus Versus Interferon Alpha-2b Eye Drops in the Treatment of Vernal Keratoconjunctivitis: A Randomized, Double-Masked Study","volume":"36","author":"Zanjani","year":"2017","journal-title":"Cornea"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"268","DOI":"10.1159\/000508031","article-title":"Vernal Keratoconjunctivitis: A Case of Anti-IgE Treatment with Short-Lasting Remission","volume":"11","author":"Gatta","year":"2020","journal-title":"Case Rep. Ophthalmol."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"e13856","DOI":"10.1111\/pai.13856","article-title":"Diagnosis and Management of Food Allergy-associated Gastroesophageal Reflux Disease in Young Children\u2014 EAACI Position Paper","volume":"33","author":"Meyer","year":"2022","journal-title":"Pediatr. Allergy Immunol."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1016\/j.alit.2020.01.004","article-title":"Roles of Omalizumab in Various Allergic Diseases","volume":"69","author":"Okayama","year":"2020","journal-title":"Allergol. Int."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"1061","DOI":"10.1007\/s40123-024-00909-y","article-title":"A Patient-Centered Approach to Vernal Keratoconjunctivitis (VKC): A Podcast","volume":"13","author":"Larsen","year":"2024","journal-title":"Ophthalmol. Ther."},{"key":"ref_55","doi-asserted-by":"crossref","unstructured":"Alenezi, H., Parnell, G., Schibeci, S., Ozkan, J., Willcox, M., White, A.J.R., and Carnt, N. (2024). Ocular Surface Immune Transcriptome and Tear Cytokines in Corneal Infection Patients. Front. Cell. Infect. Microbiol., 14.","DOI":"10.3389\/fcimb.2024.1346821"},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"496","DOI":"10.1016\/j.alit.2020.05.003","article-title":"Ocular Allergy Test and Biomarkers on the Ocular Surface: Clinical Test for Evaluating the Ocular Surface Condition in Allergic Conjunctival Diseases","volume":"69","author":"Shoji","year":"2020","journal-title":"Allergol. Int."},{"key":"ref_57","doi-asserted-by":"crossref","unstructured":"Altman, J., Jones, G., Ahmed, S., Sharma, S., and Sharma, A. (2023). Tear Film MicroRNAs as Potential Biomarkers: A Review. Int. J. Mol. Sci., 24.","DOI":"10.3390\/ijms24043694"}],"container-title":["Children"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2227-9067\/13\/3\/335\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,4]],"date-time":"2026-03-04T05:17:56Z","timestamp":1772601476000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2227-9067\/13\/3\/335"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,26]]},"references-count":57,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,3]]}},"alternative-id":["children13030335"],"URL":"https:\/\/doi.org\/10.3390\/children13030335","relation":{},"ISSN":["2227-9067"],"issn-type":[{"value":"2227-9067","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,26]]}}}