*Brief Report* **Trauma in Children during Lockdown for SARS-CoV-2 Pandemic. A Brief Report**

**Daniela Dibello 1, \*, Marcella Salvemini 1 , Carlo Amati 1 , Antonio Colella 1 , Giusi Graziano 2 , Giovanni Vicenti 2 , Biagio Moretti <sup>2</sup> and Federica Pederiva 3**


**Abstract:** Purpose: The national lockdown established by the Italian government began on the 11th of March 2020 as a means to control the spread of SARS-CoV-2 infections. The purpose of this brief report is to evaluate the effect of the national lockdown on the occurrence and characteristics of trauma in children during lockdown. Methods: All children admitted to our paediatric orthopaedic unit with a diagnosis of fracture or trauma, including sprains and contusions, between 11 March 2020 and 11 April 2020, were retrospectively reviewed. Their demographic data, type of injury, anatomical location and need for hospitalisation were compared with the equivalent data of children admitted for trauma in the same period of 2018 and 2019. Results: Sixty-nine patients with trauma were admitted in 2020, with a significant decrease in comparison with 2019 (*n* = 261) and 2018 (*n* = 289) (*p* < 0.01). The patients were significantly younger, and the rate of fractures significantly increased in 2020 (*p* < 0.01). Conclusions: Home confinement decreased admissions to the emergency department for trauma by shutting down outdoor activities, schools and sports activities. However, the rate of fractures increased in comparison with minor trauma, involved younger children and had a worse prognosis.

**Keywords:** trauma; children; lockdown; pandemic; SARS-Co-V-2

#### **1. Introduction**

The vast majority of paediatric injuries in emergency rooms are fractures, which are common during childhood [1,2] and are mostly caused by trauma while practising sports or playing [2]. Such injuries have a great impact on the child's and family's daily life and carry significant social and economic consequences, both in the short- and long term [1].

In an attempt to counteract the fast spread of the infection caused by SARS-CoV-2, the Italian government declared a national lockdown on the 9 March 2020 with consequent closure of schools, gymnasiums and all commercial and industrial activities, except for those deemed essential [3,4].

This is a brief report outlining the effects of the national lockdown on the occurrence and characteristics of trauma seen in children, comparing first aid access in our hospital from 11 March to 11 April in 2018, 2019 and 2020 (the hardest restriction period). Data in the same period for 2016 and 2017 were actually under investigation. Our main hypothesis was that the lockdown drastically reduced the total number of fractures in children and that only major traumas were brought to our attention at our second-level paediatric trauma centre.

**Citation:** Dibello, D.; Salvemini, M.; Amati, C.; Colella, A.; Graziano, G.; Vicenti, G.; Moretti, B.; Pederiva, F. Trauma in Children during Lockdown for SARS-CoV-2 Pandemic. A Brief Report. *Children* **2021**, *8*, 1131. https://doi.org/10.3390/ children8121131

Academic Editor: Vito Pavone

Received: 29 September 2021 Accepted: 18 November 2021 Published: 4 December 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**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/).

#### **2. Methods**

After approval was received from the Institutional Research Committee, all children who came to our paediatric orthopaedic unit with a diagnosis of fracture or trauma, including sprains and contusions, between 11 March and 11 April 2020, were retrospectively reviewed. Demographic data, type of injury, anatomical location and the need for hospitalisation were recorded. Patients with polytrauma or with associated neurological impairment were excluded. Children admitted for fracture or trauma in the same interval of time in 2018 and 2019 were used as controls. The diagnosis was confirmed in all cases by physical examination and plain radiograph, without the need to perform a CT scan or MRI. The results were expressed as percentages or as means ± SD, and both groups were compared by nonparametric Mann–Whitney, chi-squared or Fisher tests, as appropriate, with a threshold of significance at *p* < 0.05. The analyses were performed using R software (version 3.5.2).

#### **3. Results**

Sixty-nine children (30 female and 39 male) presented during the study period in 2020 with a trauma involving the upper limb in 68%(*n =* 47), the lower limb in 28% (*n* = 19) and the spine in 4% (*n* = 3) of the cases. In the correspondent period in 2019, 260 children (100 female and 160 male) were treated for trauma of the upper limb in 55% (*n* = 143) of the cases, the lower limb in 36% (*n* = 94) and the spine in 9% (*n* = 23). In 2018, 289 children (112 female and 177 male) were treated for trauma of the upper limb in 57% (*n* = 165) of the cases, the lower limb in 35% (*n* = 101) and the spine in 8% (*n* = 23). The mean age of the patients treated in the emergency department in 2020 (6.83 ± 4.06) was significantly lower when compared with 2019 (10.84 ± 4.23) and 2018 (9.95 ± 4.42; *p* < 0.001). In all cases, the number of patients admitted to our emergency room in 2020 was significantly lower than in 2019 and 2018 (*p* < 0.001).

In 2020, the number of fractures (29) was significantly higher in percentage in comparison with 2019 (67) and 2018 (68) when contusions and sprains were the most common lesions (*p* < 0.01) (Figure 1). On the other hand, although the need to admit the patient to the ward was similar across all years, the prognosis (as estimated by the orthopaedic surgeon who treated the patient in the emergency room) for the trauma was significantly worse in 2020 (*p* < 0.05) (Figure 2). While pain or functional diseases not related to trauma decreased in our paediatric orthopaedic unit, major trauma with complicated wounds, tendon involvement and other injuries that required a multidisciplinary evaluation increased ("other" in Figure 1). Nevertheless, the total number of trauma and injuries in 2020 decreased compared to 2019 and 2018.

**Figure 1.** Comparison between 2018, 2019 and 2020 in terms of type of injury and need for hospitalization (in percentages).

**Figure 2.** Comparison between 2018, 2019 and 2020 in terms of prognosis of the trauma.

In 2020, the trauma occurred mostly at home (83.6% *n* = 58) and sport-related injuries were significantly lower (16.4% *n* = 11) in comparison with 2019 (28.7% *n* = 75) and 2018 (29.8% *n* = 87). In 2019 and 2018, the trauma more frequently happened away from home and was not sport-related (42.7% *n* = 111 and 42.9% *n* = 124, respectively) but due to play-related activities. Of the remaining cases for 2019 and 2018, half occurred at home (28.7% *n* = 75 and 29.7% *n* = 86, respectively) and the other half (28.6% *n* = 74 and 27.3% *n* = 79, respectively) were sport-related (Figure 3). However, no significant differences were found when comparing 2018 and 2019 in terms of the type of injury, prognosis and location of the trauma.

**Figure 3.** Comparison between 2018, 2019 and 2020 in terms of place in which trauma occurred (in percentages).

#### **4. Discussion**

Twelve percent of the admissions per year to the paediatric emergency department are due to musculoskeletal injuries [2,5]. The vast majority of these injuries are skeletal fractures, which cause significant morbidity to children and are an expensive public health issue. The overall rate of fractures is increasing despite the implementation of guidelines to prevent injuries and the campaign to raise parents' awareness of the subject [2,6,7].

The Italian national lockdown from the 11 March 2020 meant children spent most of their time indoors and were not allowed to practice outdoor sports or activities. The first outcome of the stay-at-home order was a significant decrease in admissions (76% less in comparison with 2019, and 77% in comparison with 2018) to the emergency department for trauma. Moreover, trauma usually happening at school or practising sports almost disappeared during the lockdown. Most of the trauma in 2020 occurred at home, while in 2019 and 2018, they mostly happened outdoor while playing. This result highlights how significantly sports and play impact the incidence of fractures in children.

The patients treated in 2020 were significantly younger than the ones seen in 2019 and 2018. One explanation is that the lockdown eliminated all the trauma occurring during school time or related to sports. During this time, older children, now staying at home, spent more time playing videogames, watching TV or following lessons online, whereas preschool-aged children did not change their activities at home, such as running or jumping up and down from couches and beds. This could explain why the percentage of the age of trauma is inversed in 2020 in comparison to 2019 and 2018.

The rate of fractures increased in percentage in 2020 and the prognosis using days of hospitalisation worsened. This data could be explained by the fact that parents preferred to treat minor traumas at home without visiting a hospital for diagnosis and treatment. The distribution of the site of fractures was not modified by the lockdown, and upper limb fractures continued to be the most usual ones at both endpoints. Forearm fractures are the most common ones in children, accounting for 40–50% of all fractures during childhood [1,8–10]. The distal third of the forearm, including the radius and/or ulna, is involved in 75% of the cases [11,12] because of the increased body mass during their growth and development together with decreased bone mineral content [5,6,9,11].

Our results were consistent with the finding of other groups [13–22], although only a few of them analysed a paediatric population. Our study, in fact, demonstrates how a lockdown could differently affect children according to the age group.

These data lead to several considerations: as previously said, during the lockdown, a lot of minor traumas were likely treated at home without reaching a hospital or calling for medical care. In this scenario, a hypothesis is that many children were treated with only analgesics and rest at home. In the future, to limit the access to a second-level trauma care hub, children with minor trauma (e.g., the frequent torus fractures of the distal radius) could be treated in a first-level emergency spot where alternatives to a plaster cast treatment could be used (especially if an orthopaedic specialist is not available). In this way, we are conducting a study about the efficacy of treating children with torus distal radius fractures with an easy-to-use 3D-printed splint in place of the classic plaster cast usually moulded by an orthopaedic specialist and a dedicated nurse. Results collected to date showed faster treatment in the emergency room, improved childhood activities during recovery and high satisfaction for parents and children without any complication or delay in the healing process as seen for splints in previous studies [23,24]. As we can easily expect new epidemic waves in the near future, changing medical care modalities for minor trauma in children (at the moment, the least vaccinated population) could improve our attempts to limit the spread of the virus.

Another consideration that could be extrapolated from these data is related to our experience in orthopaedic fast-tracking: in our hospital, in fact, after the nursing triage in the emergency room, children with uncomplicated monosegmental trauma are sent directly to our unit. Next, an orthopaedic surgeon evaluates the case, visits the child, requires radiographs and eventually CT scans and then decides for immobilisation or hospitalisation. In the first case, the patient is discharged directly home. This consolidated pathway, already described in the literature [25], demonstrates a shorter stay in the hospital, virtually no waiting time in an emergency room (where otherwise healthy children could be exposed to those with fevers, coughs or colds) and higher satisfaction for parents and

children. In these months of worldwide strategies for containment efficiency and spread control for the COVID-19 pandemic, in our opinion, every attempt to reduce the risk of contagion should be pursued.

Notably, these considerations have limitations. First, we do not have data about a delay in treatment of fractures that do not reach a hospital soon after the trauma accident, and we did not collect data from other hospitals in our region that usually treat children from 12 to 18 years old, probably losing much of the data about fractures and treatments in this age range. We also did not consider weather patterns (March and April are usually lower-fracture-rate months compared to July or August), nor did we collect data about rainfalls and sunny days in 2018, 2019 and 2020. Lastly, we only considered rates of accidental trauma, which did not include any form of abuse, during the lockdown period.

#### **5. Conclusions**

In conclusion, home confinement decreased admissions to the emergency department for trauma by shutting down outdoor activities, schools and sports activities. The volume of paediatric patients seen for trauma during the lockdown decreased by about 75% from two years prior. Moreover, the patients who were seen during the lockdown were significantly younger children, probably because only children with major trauma were brought to the hospital by their parents to avoid exposure to the virus, whereas children with contusions and sprains were treated conservatively at home. This study finally demonstrates how a lockdown could differently affect children according to the age group.

**Author Contributions:** Study conception and design: D.D., F.P.; Data acquisition: M.S., A.C., C.A.; Analysis and data interpretation: M.S., A.C., C.A., G.G.; Drafting of the manuscript: D.D., F.P., C.A.; Critical revision: F.P., G.V., B.M. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

**Informed Consent Statement:** Informed consent was obtained from all individual participants included in the study.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


### *Review* **Sports and Children with Hemophilia: Current Trends**

**Lorenzo Moretti 1 , Davide Bizzoca 2, \* , Claudio Buono 1 , Teresa Ladogana 1 , Federica Albano <sup>1</sup> and Biagio Moretti 1**


**Abstract:** Hemophilia is a sex-linked recessive disorder characterized by a lack of blood factors necessary for clotting. This review aims to investigate the benefits of sports activities in children with hemophilia in terms of both physical and psychological wellness. Sports activity is necessary for children with hemophilia to preserve joints' range of motion, reduce joint bleeding, improve muscle mass and strength, enhance proprioception and prevent secondary chronic diseases. In the past, high-impact sports were usually forbidden in children with hemophilia because of their high bleeding risk. Recent studies, however, have shown that prophylaxis therapy can allow a hemophilic child to take part in vigorous activities or high-impact sports. The benefits of sports activity in children with hemophilia are expressed by a better muscular trophism and an improved bone mineral density. Moreover, physical activity has a positive impact on children's psychosocial well-being. Due to prophylaxis therapy, the quality of life of children with hemophilia is similar to their peers, and this has allowed an improvement in sports participation, including team sports.

**Keywords:** hemophilia; children; sport; prophylaxis; high-impact sports; physical activity; psychological wellness

#### **1. Introduction**

Hemophilia is a sex-linked recessive disorder characterized by a lack of blood factors necessary for clotting [1].

This disease mainly occurs in males and the deficit may be in factor VIII (hemophilia type A or classic type) or factor IX (type B) [2]. Patients with severe plasma protein deficit can have recurrent muscular and especially joint bleeding episodes, which may lead to musculoskeletal pain and physical and functional ability reduction, thus finally compromising their quality of life [3].

Consequently, it is reported that hemophilic children tend to be more sedentary compared with non-hemophilic peers because of the difficulties they may experience during physical activity [4].

This review aims to investigate the benefits of sports activities in children with hemophilia in terms of both physical and psychological wellness.

#### **2. Materials and Methods**

The first step consisted of a scoping literature search performed by three reviewers, CB, TL and FA, supervised by DB, using the PubMed database to select an initial pool of potentially relevant papers, originally designed to investigate the feasibility of physical activity in children with hemophilia.

The search strategy included the following terms: ((hemophilia [MeSH Terms] OR "hemophilic patient" [All Fields]) OR (hemophilic child [MeSH Terms] OR "children

**Citation:** Moretti, L.; Bizzoca, D.; Buono, C.; Ladogana, T.; Albano, F.; Moretti, B. Sports and Children with Hemophilia: Current Trends. *Children* **2021**, *8*, 1064. https://doi.org/ 10.3390/children8111064

Academic Editor: Vito Pavone

Received: 26 August 2021 Accepted: 16 November 2021 Published: 19 November 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**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/).

with hemophilia" [All Fields])) AND ("sport" [MeSH Terms] OR (sport [All Fields]) OR "physical activity").

The second step consisted of revising the literature review to identify papers dealing with physical activity in children with hemophilia.

Inclusion criteria were: human studies in which the authors considered the role of sports activity in children affected by hemophilia; English language; studies about children with hemophilia.

A total of 42 articles [1,3–43] were finally included in the present review.

#### **3. Hemophilia and Sports Participation**

Sports activity is necessary for children with hemophilia to preserve joints' range of motion, reduce joint bleeding, improve muscle mass and strength, enhance proprioception and prevent secondary chronic diseases (i.e., cardiovascular disease, diabetes, cancer) [44]. To prevent joint and muscle bleeding, parents put their children with hemophilia through various exercise programs [5]. Muscle atrophy, instability and restriction of motion are the first visible signs of sedentarism [6], whereas early subclinical symptoms such as tender ligaments are found even in clinically healthy young people [1]. This leads to a lack of physical activity and exercise that results in a poor physical condition with diminished muscle strength, aerobic/anaerobic power, proprioception and flexibility [7]. Furthermore, sports activity can improve bone mineral density, which is lower in children with hemophilia than in healthy peers [8]. In the past, because of bleeding risk, sports activity was discouraged in children with chronic disease [9]. However, nowadays, due to new improvements in medical treatment, the participation of children with hemophilia in sport has improved [44].

However, even if an increase in participation in sports has been observed in children with hemophilia, aerobic activity is less practiced. This phenomenon may be explained considering that children with chronic diseases (such as cystic fibrosis or hemophilia) might have a decline in pulmonary function, which finally leads to less exercise tolerance [10]. Sports and exercise help to develop fundamental abilities, such as coordination, strength, endurance and flexibility. The muscle-to-fat ratio is improved, and, in the long term, joints are protected and bleeding episodes avoided [11].

Prophylaxis is effective to maintain a minimum level of clotting factor activity and to permit regular sports participation in children with hemophilia [12]. However, prophylaxis alone is insufficient to protect from bleeding and joint damage [13]. In fact, in children with hemophilia, it is important to maintain weight within a healthy range to prevent an overload of the joints, especially the knees and ankle [14]. Furthermore, sports exercise increases factor VIII levels and could modify coagulation parameters in mild/moderate hemophilia [15]. It is therefore reported that an increased plasmatic lactate concentration, secondary to anaerobic exercises, for instance, may affect FVIII clearance, thus improving the patient's coagulation [1].

In the past, high-impact sports were usually prohibited in children with hemophilia due to the high risk of bleeding injuries [16]. In the 1970s, it was a common practice to discourage any type of sports because of the risk of bleeding episodes, but today, the participation in sports activities by hemophilic patients has improved, and physical activity is considered healthy for this type of patient [17] even if high-impact sports are still not recommended. Nowadays, on the other hand, different guidelines are available to regulate hemophilic patients' sports participation; hemophilia type and severity play a key role in the correct sports activity choice [18,19]. According to some hemophilia centers, the choice of activities should reflect individual basis such as: preference/interest, ability, physical condition and resources [7]. Participation in non-contact sports (swimming, running and walking) should always be promoted, but high-impact sports (rugby, boxing, football and basketball) or sports such as motocross (endowed with a higher injury risk) are often discouraged even on good prophylactic therapy [7,11].

In the United States, the National Hemophilia Foundation (NHF) proposes the stratification of activities into safe, safe-to-moderate, moderate, moderate-to-dangerous and dangerous risk groups. The safe through moderate categories can be routinely recommended with the proper preparation [20]. Another stratification in high-impact and low-impact sport was proposed by Ross and Goldenberg in 2009: high-impact sports include soccer, basketball, baseball, bowling, gymnastics, field hockey, running, skiing, snowboarding, soccer, softball, tennis and track and field, while low-impact activities include weight training, cycling, Frisbee, golf, swimming and walking/hiking [21].

However, is it right to forbid children with hemophilia to participate in high-impact sports even if they are on prophylactic treatment?

According to some authors, prophylactic therapy can allow a hemophilic child to engage in vigorous activities or high-impact sports [44]. An article by Ross et al. [21] showed that children with hemophilia on prophylaxis could participate without any increased risk of joint bleedings.

The American Academy of Pediatrics (AAP) Committee on Sports Medicine and Fitness has divided childhood activities according to risks and formulated guidelines for sports participation [22]. The AAP has recommended that children should engage in trampoline activities only in professionally supervised settings due to the high risk of fractures, hospitalization and risk of bruises and other injuries [23]. For the same reason, no children should participate in boxing because this activity encourages injuries especially to the head and neck [24]. Additionally, the dangers of concussion related to US football and soccer have recently received attention, with recommendations for carefully monitoring children after an event [25]. Nonetheless, the AAP recommends participation in sports activities for children with bleeding disorders [21].

In 2017, the National Hemophilia Foundation (NHF) proposed some guidelines for athletic participation by patients with a bleeding disorder [20]. Therefore, a minimum of 60 min of exercise per day, with appropriate supervision, is recommended for children after receiving prophylaxis.

#### **4. Treatment of Sports Injuries in Children with Hemophilia**

Significant bleeding episodes in hemophilic patients are typically treated with the administration of missing clotting factors (factor VIII or IX), whereas they could be managed by bypassing agents or antifibrinolytic medication [1]. Missing factors should be administrated to permit regular sports activities in children with hemophilia with a severe deficiency (when the factors activity is lower than 10–20%) [27]. The high adherence in young children is related to the benefits of sports activity also without parents' supervision [26,45–49]. Non-adherence to prophylaxis could be responsible for an increase in joint bleeding, reduced quality of life and absence from school. Children should receive regular infusions to reduce the risk of bleeding to preserve joint wellness [28]. An alternative treatment, in the case of minor bleeding episodes, is the use of desmopressin (intravenously or intranasally) [1]. A study published in 1980 showed that desmopressin also increases factor VII plasma concentrations through the release of VWF (Von Willebrand Factor) [29]. The main complication after treatment with clotting factor concentrates is the development of inhibiting antibodies directed against some parts of factor VIII/IX, and these are the cause of a reduction in its coagulant activity [30]. Usually, inhibitors are produced in children within the first 50 days of treatment and they are the cause of an increase in the risk of bleeding episodes [31]. In the past, the usage of plasma, containing clotting factors, from unscreened donors made the transmission of blood viruses easier (HBV, HCV and HIV). Nowadays, donors are tested before blood donation [1].

#### **5. Bleeding Prevention in Hemophilic Children**

In children with lower (5% or less) factor levels, a higher bleeding risk has been observed during sports activity. It is reported that an increase of 1% in the factor level with treatment before sport correlates with a decreased bleeding risk by 2% [32,38–43]. Assessments of joint and muscle function before sport selection in children with hemophilia are required [33]. In addition, they require a complete evaluation, which should include: an analysis of balance and coordination, aerobic capacity and body fat content [23]. Although the risk of injury cannot be eliminated, protective measures can be taken to reduce the risk of injury: the use of helmets, facemasks, shin guards, kneepads, wrist and forearm guards according to the type of sports activity [34]. The risk of serious bleeding and the number of hemorrhages can be radically decreased with the use of prophylaxis with factor VIII and IX concentrates [21].

A higher factor level at the time of injury is a predictive factor of bleeding events. These observations offer the opportunity to minimize bleeding risks during participation in sports [35,50–53]. A way to reduce the risk of bleeding is to divide the dose of the prophylactic factor by the number of days per week and concerning sports participation [23]. In such a way, the factor level at the time of collision may be increased, reducing the risk of bleeding episodes [12,25,54–56].

Newer longer-acting clotting factors may improve the maintenance of a factor level enough to prevent bleeding. In addition, strengthening and warming up before sports participation may reduce the rate of sports injuries. The risk of participation in collision sports is only moderately increased in hemophilic boys in prophylactic therapy, so the risk of sports injuries in hemophilia becomes similar to that of their healthy peers [36,37].

#### **6. Psychosocial Well-Being and Sports Activity**

The positive impact of sports activity on psychosocial well-being is well known, and some studies have recently investigated the relationship between physical activity and the psychosocial dimension in hemophilic patients.

Von Macksen et al. [57], in a multicenter, cross-sectional study, have recently described the impact of sport on health-related quality of life (HRQoL), physical performance and clinical outcomes in adult patients affected by hemophilia. The authors recruited fifty hemophilic patients with mild (*n* = 12), moderate (*n* = 10) or severe (*n* = 28) hemophilia A (70%) or B (30%). Among the recruited patients, 36% of participants reported not participating in any sport, mainly because of their physical condition, whereas the remaining 64% of participants reported undertaking sporting activity, including high-impact sports. The authors showed that patients participating in more sport reported significantly better HRQoL than those participating in less sport (*p* < 0.005).

Similar findings were reported by Sondermann et al. [47] in hemophilic children. These authors showed that the increase in physical activity did not correlate with an increase in bleeding events in the recruited children. Moreover, a positive impact on the children's quality of life and participation in social/school activities was observed.

#### **7. Conclusions**

The benefits of sports activity in children with hemophilia are expressed by a better muscular trophism and an improved bone mineral density. Moreover, physical activity has a positive impact on children's psychosocial well-being.

Due to prophylaxis therapy, the quality of life of children with hemophilia is similar to their peers and this has allowed an improvement in sports participation, including team sports. While in the past, due to the high risk of injuries, participation especially in team sports had been discouraged, nowadays sports activity has been promoted to achieve better physical and social wellness.

**Author Contributions:** Conceptualization, L.M., D.B. and B.M.; validation, L.M., D.B. and B.M.; data curation, C.B., T.L. and F.A.; writing—original draft preparation, C.B., T.L. and F.A.; writing review and editing, D.B.; visualization, L.M.; supervision, D.B.; project administration, B.M.; funding acquisition, B.M. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was supported by the University of Bari "Aldo Moro".

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** Not applicable.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**

