{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T10:18:47Z","timestamp":1788430727848,"version":"build-2803163510"},"reference-count":43,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T00:00:00Z","timestamp":1788393600000},"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>Background: Bronchiolitis is a leading cause of hospitalization in infants, with respiratory syncytial virus (RSV) as the main etiological agent. The clinical relevance of respiratory pathogen co-infections and the role of emerging preventive strategies, including nirsevimab immunoprophylaxis, remain under investigation. Methods: We conducted two complementary observational analyses within the pediatric healthcare network of Western Sicily. The first was a retrospective study including 580 children younger than 24 months hospitalized for bronchiolitis between 2019 and 2025 at the \u201cGiovanni Di Cristina\u201d Hospital in Palermo, Italy, to investigate respiratory pathogen detection patterns and their clinical correlates. Patients were classified according to microbiological findings as single-virus infections or viral\u2013viral\/viral\u2013bacterial co-detections. The second was a separate observational cohort of 458 newborns from two birth centers in Western Sicily during the 2024\u20132025 RSV season, established to evaluate the implementation, safety, and respiratory outcomes associated with nirsevimab prophylaxis. Results: Viral\u2013viral and\/or viral\u2013bacterial co-detections were identified in 45.5% of hospitalized infants and were associated with longer hospital stay (8.86 vs. 6.35 days, p &lt; 0.001) and a higher frequency of complications (18.6% vs. 8.5%, p &lt; 0.001), without differences in age, sex, or respiratory support requirements. RSV remained the predominant pathogen throughout the study period. In the complementary observational subgroup analysis, the observed safety findings were reassuring, with only mild and self-limiting events reported during follow-up; however, the sample size and observational design limit the ability to assess rare or delayed adverse events. Among infants undergoing clinically indicated respiratory testing, RSV was detected in 7\/9 (77.8%) non-prophylaxed infants and 5\/24 (20.8%) prophylaxed infants. Among hospitalized infants, complications were less frequently observed among those who had received nirsevimab (3.5% vs. 26.9%, p &lt; 0.001), although substantial baseline differences between groups precluded causal interpretation of this finding. Conclusions: Viral\u2013viral and viral\u2013bacterial co-detections are frequent in hospitalized bronchiolitis and are associated with increased clinical complexity, mainly through prolonged hospitalization and higher occurrence of complications. The observational nirsevimab analysis showed a favorable safety profile and a lower proportion of RSV detection among clinically tested prophylaxed infants. However, because respiratory testing was performed according to clinical indication and differed substantially between groups, these findings cannot be interpreted as estimates of RSV incidence or as definitive evidence of nirsevimab effectiveness. The observed difference in complications should also be interpreted cautiously because of substantial baseline differences between prophylaxed and non-prophylaxed infants. Prospective studies with systematic respiratory testing are warranted.<\/jats:p>","DOI":"10.3390\/children13091189","type":"journal-article","created":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T09:20:43Z","timestamp":1788427243000},"page":"1189","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Respiratory Pathogen Co-Detection in Hospitalized Infants with Bronchiolitis and Implementation of Universal Nirsevimab Immunoprophylaxis: A Six-Year Observational Study"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2918-9826","authenticated-orcid":false,"given":"Gregorio","family":"Serra","sequence":"first","affiliation":[{"name":"Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties \u201cG. D\u2019Alessandro\u201d, University of Palermo, Via Alfonso Giordano 3, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"validation","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Chiara","family":"Martorana","sequence":"additional","affiliation":[{"name":"Children\u2019s Hospital \u201cGiovanni Di Cristina\u201d, Azienda di Rilievo Nazionale e Alta Specializzazione Civico Di Cristina Benfratelli, Via dei Benedettini, 1, 90134 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"validation","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"}]},{"given":"Giovanni","family":"Barbera","sequence":"additional","affiliation":[{"name":"Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties \u201cG. D\u2019Alessandro\u201d, University of Palermo, Via Alfonso Giordano 3, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"}]},{"given":"Mariavalentina","family":"Catania","sequence":"additional","affiliation":[{"name":"Children\u2019s Hospital \u201cGiovanni Di Cristina\u201d, Azienda di Rilievo Nazionale e Alta Specializzazione Civico Di Cristina Benfratelli, Via dei Benedettini, 1, 90134 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"supervision","vocabulary":"credit"},{"role":"resources","vocabulary":"credit"}]},{"given":"Domenico","family":"Cipolla","sequence":"additional","affiliation":[{"name":"Children\u2019s Hospital \u201cGiovanni Di Cristina\u201d, Azienda di Rilievo Nazionale e Alta Specializzazione Civico Di Cristina Benfratelli, Via dei Benedettini, 1, 90134 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"resources","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3245-9396","authenticated-orcid":false,"given":"Claudia","family":"Colomba","sequence":"additional","affiliation":[{"name":"Children\u2019s Hospital \u201cGiovanni Di Cristina\u201d, Azienda di Rilievo Nazionale e Alta Specializzazione Civico Di Cristina Benfratelli, Via dei Benedettini, 1, 90134 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"resources","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3412-0399","authenticated-orcid":false,"given":"Piero","family":"Farruggia","sequence":"additional","affiliation":[{"name":"Unit of Pediatrics, Salvatore Cimino Hospital, Palermo Provincial Health Authority (ASP 6), Via Salvatore Cimino, 2, 90018 Termini Imerese, Italy"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"supervision","vocabulary":"credit"},{"role":"resources","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9576-1635","authenticated-orcid":false,"given":"Mario","family":"Giuffr\u00e8","sequence":"additional","affiliation":[{"name":"Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties \u201cG. D\u2019Alessandro\u201d, University of Palermo, Via Alfonso Giordano 3, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"resources","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]},{"given":"Giulia","family":"La Malfa","sequence":"additional","affiliation":[{"name":"Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties \u201cG. D\u2019Alessandro\u201d, University of Palermo, Via Alfonso Giordano 3, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"data-curation","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"}]},{"given":"Martina","family":"Greco","sequence":"additional","affiliation":[{"name":"Children\u2019s Hospital \u201cGiovanni Di Cristina\u201d, Azienda di Rilievo Nazionale e Alta Specializzazione Civico Di Cristina Benfratelli, Via dei Benedettini, 1, 90134 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"validation","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"}]},{"given":"Giovanni","family":"Corsello","sequence":"additional","affiliation":[{"name":"Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties \u201cG. D\u2019Alessandro\u201d, University of Palermo, Via Alfonso Giordano 3, 90127 Palermo, Italy"},{"name":"Children\u2019s Hospital \u201cGiovanni Di Cristina\u201d, Azienda di Rilievo Nazionale e Alta Specializzazione Civico Di Cristina Benfratelli, Via dei Benedettini, 1, 90134 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"project-administration","vocabulary":"credit"},{"role":"conceptualization","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,3]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e1474","DOI":"10.1542\/peds.2014-2742","article-title":"Clinical practice guideline: The diagnosis, management, and prevention of bronchiolitis","volume":"134","author":"Ralston","year":"2014","journal-title":"Pediatrics"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"946","DOI":"10.1016\/S0140-6736(17)30938-8","article-title":"Global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in young children in 2015: A systematic review and modelling study","volume":"390","author":"Shi","year":"2017","journal-title":"Lancet"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"700","DOI":"10.1001\/archpediatrics.2011.1669","article-title":"Prospective multicenter study of viral etiology and hospital length of stay in children with severe bronchiolitis","volume":"166","author":"Mansbach","year":"2012","journal-title":"Arch. Pediatr. Adolesc. Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"268","DOI":"10.1016\/j.jcv.2008.03.012","article-title":"Multiple simultaneous viral infections in infants with acute respiratory tract infections in Spain","volume":"42","author":"Calvo","year":"2008","journal-title":"J. Clin. Virol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"111","DOI":"10.1111\/j.1553-2712.2007.00034.x","article-title":"Prospective multicenter study of the viral etiology of bronchiolitis in the emergency department","volume":"15","author":"Mansbach","year":"2008","journal-title":"Acad. Emerg. Med."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Cebey-L\u00f3pez, M., Herberg, J.A., Pardo-Seco, J., G\u00f3mez-Carballa, A., Martin\u00f3n-Torres, N., Salas, A., Martin\u00f3n-S\u00e1nchez, J.M., Justicia, A., Rivero-Calle, I., and Sumner, E. (2016). Does viral co-infection influence the severity of acute respiratory infection in children?. PLoS ONE, 11.","DOI":"10.1371\/journal.pone.0152481"},{"key":"ref_7","first-page":"363","article-title":"Single and multiple respiratory virus infections and severity of respiratory disease: A systematic review","volume":"15","author":"Goka","year":"2014","journal-title":"Paediatr. Respir. Rev."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1301","DOI":"10.1016\/j.jaci.2014.02.030","article-title":"Detection of pathogenic bacteria during rhinovirus infection is associated with increased respiratory symptoms and asthma exacerbations","volume":"133","author":"Kloepfer","year":"2014","journal-title":"J. Allergy Clin. Immunol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e341","DOI":"10.1542\/peds.2013-0303","article-title":"Respiratory syncytial virus-associated hospitalizations among children less than 24 months of age","volume":"132","author":"Hall","year":"2013","journal-title":"Pediatrics"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"837","DOI":"10.1056\/NEJMoa2110275","article-title":"Nirsevimab for prevention of RSV in healthy late-preterm and term infants","volume":"386","author":"Hammitt","year":"2022","journal-title":"N. Engl. J. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2425","DOI":"10.1056\/NEJMoa2309189","article-title":"Nirsevimab for prevention of hospitalizations due to respiratory syncytial virus in infants","volume":"389","author":"Drysdale","year":"2023","journal-title":"N. Engl. J. Med."},{"key":"ref_12","unstructured":"Sicilian Regional Health Department (2024). Campagna di Immunoprofilassi con Nirsevimab per la Prevenzione del VRS nei Neonati\u2014Stagione 2024\/2025, Sicilian Regional Health Department. Circular No. 30834."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1186\/s41479-025-00160-4","article-title":"Prevention of respiratory syncytial virus disease across the lifespan in Italy","volume":"17","author":"Manzoni","year":"2025","journal-title":"Pneumonia"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1186\/s13052-022-01392-6","article-title":"UPDATE\u20142022 Italian guidelines on the management of bronchiolitis in infants","volume":"49","author":"Manti","year":"2023","journal-title":"Ital. J. Pediatr."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Bosch, A.A.T.M., Biesbroek, G., Trzcinski, K., Sanders, E.A.M., and Bogaert, D. (2013). Viral and bacterial interactions in the upper respiratory tract. PLoS Pathog., 9.","DOI":"10.1371\/journal.ppat.1003057"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1056\/NEJMra1413456","article-title":"Viral bronchiolitis in children","volume":"374","author":"Meissner","year":"2016","journal-title":"N. Engl. J. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1016\/j.jcv.2016.04.019","article-title":"Respiratory viral coinfection and disease severity in children: A systematic review and meta-analysis","volume":"80","author":"Scotta","year":"2016","journal-title":"J. Clin. Virol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1061","DOI":"10.1002\/ppul.24699","article-title":"Viral strategies predisposing to respiratory bacterial superinfections","volume":"55","author":"Rossi","year":"2020","journal-title":"Pediatr. Pulmonol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"273","DOI":"10.3201\/eid2802.211727","article-title":"Viral Interference between Respiratory Viruses","volume":"28","author":"Piret","year":"2022","journal-title":"Emerg. Infect. Dis."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Morris, D.E., Cleary, D.W., and Clarke, S.C. (2017). Secondary bacterial infections associated with influenza pandemics. Front. Microbiol., 8.","DOI":"10.3389\/fmicb.2017.01041"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"318","DOI":"10.1186\/s13052-025-02155-9","article-title":"SARS-CoV-2 infection during pregnancy and necrotizing enterocolitis: Case report and review of the literature","volume":"51","author":"Serra","year":"2025","journal-title":"Ital. J. Pediatr."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"631","DOI":"10.1002\/jmv.24994","article-title":"Acute bronchiolitis: Influence of viral co-infection in infants hospitalized over multiple epidemic seasons","volume":"90","author":"Petrarca","year":"2018","journal-title":"J. Med. Virol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"211","DOI":"10.1016\/S0140-6736(16)30951-5","article-title":"Viral bronchiolitis","volume":"389","author":"Florin","year":"2017","journal-title":"Lancet"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"175","DOI":"10.1186\/s13052-024-01738-2","article-title":"Group B streptococcus colonization in pregnancy and neonatal outcomes: A three-year monocentric retrospective study during and after the COVID-19 pandemic","volume":"50","author":"Serra","year":"2024","journal-title":"Ital. J. Pediatr."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"e113533","DOI":"10.1136\/bmjopen-2025-113533","article-title":"Uptake and predictors of newborn respiratory syncytial virus (RSV) immunisation with nirsevimab in Ireland\u2019s national pilot programme: A cross-sectional study","volume":"16","author":"Masukume","year":"2026","journal-title":"BMJ Open"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"102986","DOI":"10.1016\/j.eclinm.2024.102986","article-title":"Acceptance and safety of the RSV-preventive treatment of newborns with nirsevimab in the maternity department: A prospective longitudinal cohort study in France","volume":"79","author":"Testard","year":"2025","journal-title":"eClinicalMedicine"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1186\/s13052-022-01334-2","article-title":"Quality of life improving after propranolol treatment in patients with Infantile Hemangiomas","volume":"48","author":"Pensabene","year":"2022","journal-title":"Ital. J. Pediatr."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"152","DOI":"10.1186\/s13052-019-0751-6","article-title":"Perinatal and newborn care in a two years retrospective study in a first level peripheral hospital in Sicily (Italy)","volume":"45","author":"Serra","year":"2019","journal-title":"Ital. J. Pediatr."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"American Academy of Pediatrics Committee on Infectious Diseases, and Bronchiolitis Guidelines Committee (2014). Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. Pediatrics, 134, 415\u2013420.","DOI":"10.1542\/peds.2014-2783"},{"key":"ref_30","unstructured":"European Medicines Agency (2023). Beyfortus (Nirsevimab): EPAR\u2014Product Information."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"892","DOI":"10.1056\/NEJMc2112186","article-title":"Safety of nirsevimab for RSV in infants with heart or lung disease or prematurity","volume":"386","author":"Domachowske","year":"2022","journal-title":"N. Engl. J. Med."},{"key":"ref_32","first-page":"2400046","article-title":"Early estimates of nirsevimab immunoprophylaxis effectiveness against hospital admission for respiratory syncytial virus lower respiratory tract infections in infants, Spain, October 2023 to January 2024","volume":"29","year":"2024","journal-title":"Eurosurveillance"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"e13311","DOI":"10.1111\/irv.13311","article-title":"Nirsevimab Effectiveness Against Cases of Respiratory Syncytial Virus Bronchiolitis Hospitalised in Paediatric Intensive Care Units in France, September 2023-January 2024","volume":"18","author":"Paireau","year":"2024","journal-title":"Influenza Other Respir. Viruses"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2400033","DOI":"10.2807\/1560-7917.ES.2024.29.4.2400033","article-title":"Impact of nirsevimab prophylaxis on paediatric respiratory syncytial virus (RSV)-related hospitalisations during the initial 2023\/24 season in Luxembourg","volume":"29","author":"Ernst","year":"2024","journal-title":"Eurosurveillance"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"106624","DOI":"10.1016\/j.jinf.2025.106624","article-title":"Sustained clinical and epidemiological impact of respiratory syncytial virus (RSV) in young infants exposed to universal immunization with nirsevimab at birth: An Italian multicenter, retrospective, cohort study 2024\/25","volume":"91","author":"Manzoni","year":"2025","journal-title":"J. Infect."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"2348135","DOI":"10.1080\/21645515.2024.2348135","article-title":"Assessment of effectiveness and impact of universal prophylaxis with nirsevimab for prevention of hospitalizations due to respiratory syncytial virus in infants. The NIRSE-GAL study protocol","volume":"20","author":"Mallah","year":"2024","journal-title":"Hum. Vaccines Immunother."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"180","DOI":"10.1016\/S2352-4642(22)00321-2","article-title":"Efficacy of nirsevimab against respiratory syncytial virus lower respiratory tract infections in preterm and term infants, and pharmacokinetic extrapolation to infants with congenital heart disease and chronic lung disease: A pooled analysis of randomised controlled trials","volume":"7","author":"Madhi","year":"2023","journal-title":"Lancet Child Adolesc. Health"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"209","DOI":"10.15585\/mmwr.mm7309a4","article-title":"Early estimate of nirsevimab effectiveness for prevention of respiratory syncytial virus-associated hospitalization among infants entering their first respiratory syncytial virus season\u2014New Vaccine Surveillance Network, October 2023\u2013February 2024","volume":"73","author":"Moline","year":"2024","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_39","unstructured":"World Health Organization (2025). WHO position paper on immunization to protect infants against respiratory syncytial virus disease, May 2025. Wkly. Epidemiol. Rec., 100, 193\u2013218."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"15","DOI":"10.1186\/s13052-025-02184-4","article-title":"Efficacy and safety of a single dose of nirsevimab against respiratory syncytial virus infection in infants: A meta-analysis and time-to-event analysis","volume":"52","author":"Sayed","year":"2025","journal-title":"Ital. J. Pediatr."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"524","DOI":"10.1080\/08998280.2025.2488211","article-title":"Efficacy and safety of nirsevimab for preventing respiratory syncytial virus infection in infants: An updated systematic review and meta-analysis encompassing 11,001 participants","volume":"38","author":"Tanashat","year":"2025","journal-title":"Bayl. Univ. Med. Cent. Proc."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"415","DOI":"10.1056\/NEJMoa1913556","article-title":"Single-dose nirsevimab for prevention of RSV in preterm infants","volume":"383","author":"Griffin","year":"2020","journal-title":"N. Engl. J. Med."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"920","DOI":"10.15585\/mmwr.mm7234a4","article-title":"Use of nirsevimab for the prevention of respiratory syncytial virus disease among infants and young children: Recommendations of the Advisory Committee on Immunization Practices\u2014United States, 2023","volume":"72","author":"Jones","year":"2023","journal-title":"MMWR. Morb. Mortal. Wkly. Rep."}],"container-title":["Children"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2227-9067\/13\/9\/1189\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T09:51:13Z","timestamp":1788429073000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2227-9067\/13\/9\/1189"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,3]]},"references-count":43,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["children13091189"],"URL":"https:\/\/doi.org\/10.3390\/children13091189","relation":{},"ISSN":["2227-9067"],"issn-type":[{"value":"2227-9067","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,3]]}}}