Cost of childhood severe pneumonia management in selected public inpatient care facilities in Bangladesh: a provider perspective

OBJECTIVE

To estimate inpatient care costs of childhood severe pneumonia and its urban-rural cost variation, and to predict cost drivers.

DESIGN

The study was nested within a cluster randomised trial of childhood severe pneumonia management. Cost per episode of severe pneumonia was estimated from a healthcare provider perspective for children who received care from public inpatient facilities. A bottom-up micro-costing approach was applied and data collected using structured questionnaire and review of the patient record. Multivariate regression analysis determined cost predictors and sensitivity analysis explored robustness of cost parameters.

SETTING

Eight public inpatient care facilities from two districts of Bangladesh covering urban and rural areas.

PATIENTS

Children aged 2-59 months with WHO-classified severe pneumonia.

RESULTS

Data on 1252 enrolled children were analysed; 795 (64%) were male, 787 (63%) were infants and 59% from urban areas. Average length of stay (LoS) was 4.8 days (SD ±2.5) and mean cost per patient was US$48 (95% CI: US$46, US$49). Mean cost per patient was significantly greater for urban tertiary-level facilities compared with rural primary-secondary facilities (mean difference US$43; 95% CI: US$40, US$45). No cost variation was found relative to age, sex, malnutrition or hypoxaemia. Type of facility was the most important cost predictor. LoS and personnel costs were the most sensitive cost parameters.

CONCLUSION

Healthcare provider cost of childhood severe pneumonia was substantial for urban located public health facilities that provided tertiary-level care. Thus, treatment availability at a lower-level facility at a rural location may help to reduce overall treatment costs.

Are children living with obesity more likely to experience musculoskeletal symptoms during childhood? A linked longitudinal cohort study using primary care records

OBJECTIVE

To assess whether there is a higher incidence of musculoskeletal consultations in general practice among children with obesity.

DESIGN

Longitudinal SETTING: 285 north-east London general practitioners (GPs).

PARTICIPANTS

63 418 (50.9% boys) Reception and 55 364 (50.8% boys) Year 6 National Child Measurement Programme (NCMP) participants, linked to GP electronic health records (EHRs).

MAIN OUTCOME MEASURE

A GP consultation with a recorded musculoskeletal symptom or diagnosis.

METHODS

We calculated proportions with a musculoskeletal consultation by ethnic-adjusted weight status (underweight <2nd; overweight ≥91st; obese ≥98th centile), sex, ethnicity, and area-level deprivation. We estimated mutually-adjusted hazard ratios (HR) and 95% confidence intervals (95% CI) using Cox's proportional regression models stratified by school year and sex.

RESULTS

We identified 1868 (3.0%) Reception and 4477 (8.1%) Year 6 NCMP participants with at least one musculoskeletal consultation. In adjusted analyses, Reception year girls with a body mass index (BMI) classified as overweight (HR 1.24, 95% CI 1.02 to 1.52) or obese (HR 1.67, 95% CI 1.35 to 2.06) were more likely to have at least one musculoskeletal consultation. Year 6 girls with obesity were more likely (HR 1.20, 95% CI 1.07 to 1.35), and boys with a BMI in the underweight range were less likely (HR 0.39, 95% CI 0.21 to 0.73), to have a musculoskeletal consultation.

CONCLUSIONS

Girls living with obesity at the start or end of primary school are more likely to attend their GP for a musculoskeletal consultation. Routine linkage of NCMP data to EHRs provides useful insights into childhood health conditions related to excess weight in early childhood. Recognition of obesity as a contributing factor for musculoskeletal symptoms may inform clinical management, particularly in girls.

Bronchopulmonary dysplasia: temporal trend from 2010 to 2019 in the Brazilian Network on Neonatal Research

OBJECTIVE

To evaluate the temporal trend of bronchopulmonary dysplasia (BPD) in preterm infants who survived to at least 36 weeks' post-menstrual age (PMA) and BPD or death at 36 weeks' PMA, and to analyse variables associated with both outcomes.

DESIGN

Retrospective cohort with data retrieved from an ongoing national registry.

SETTING

19 Brazilian university public hospitals.

PATIENTS

Infants born between 2010 and 2019 with 23-31 weeks and birth weight 400-1499 g.

MAIN OUTCOME MEASURES

Temporal trend was evaluated by Prais-Winsten model and variables associated with BPD in survivors or BPD or death were analysed by logistic regression.

RESULTS

Of the 11 128 included infants, BPD in survivors occurred in 22%, being constant over time (annual per cent change (APC): -0.80%; 95% CI: -2.59%; 1.03%) and BPD or death in 45%, decreasing over time (APC: -1.05%; 95% CI: -1.67%; -0.43%). Being male, small for gestational age, presenting with respiratory distress syndrome, air leaks, needing longer duration of mechanical ventilation, presenting with treated patent ductus arteriosus and late-onset sepsis were associated with an increase in the chance of BPD. For the outcome BPD or death, maternal bleeding, multiple gestation, 5-minute Apgar <7, late-onset sepsis, necrotising enterocolitis and intraventricular haemorrhage were added to the variables reported above as increasing the chance of the outcome.

CONCLUSION

The frequency of BPD in survivors was constant and BPD or death decreased by 1.05% at each study year. These results show some improvement in perinatal care in Brazilian units which resulted in a reduction of BPD or death, but further improvements are still needed to reduce BPD in survivors.

Staff experiences of wearing the Rainbow Badge in a paediatric hospital setting: a mixed-methods survey

OBJECTIVE

This study aimed to assess staff's experience of wearing the Health Service Executive (HSE) Rainbow Badge, a symbol of inclusion for LGBTQ+ (lesbian, gay, bisexual, transgender, queer/questioning; + signifying inclusivity of all sexual and gender identities) people, in a paediatric hospital setting.

DESIGN

This was a cross-sectional multisite observational study. Participants completed an anonymous online survey, consisting of open and closed-ended questions covering domains of: responses to the badge from staff and patients; experience and impact of wearing the badge; and further training needs.

SETTING

All five sites (four clinical and one non-clinical) pertaining to the Children's Health Ireland healthcare group.

PARTICIPANTS

All staff, clinical and non-clinical, who had signed up the HSE Rainbow Badge initiative were eligible to participate.

RESULTS

A total of 151 eligible participants across a mix of disciplines participated, 29 (19.2%) of whom were members of the LGBTQ+ community. Over half (58.9%, n=89) of respondents said they learnt something new about barriers to care for LGBTQ+ young people from the initiative. Staff reported mostly positive responses to the badge; 5.1% reported mixed/negative responses from colleagues, 4.5% reported mixed/negative responses from young people and 3.7% reported mixed/negative responses from families. Open-ended questions were analysed using a thematic analysis framework. Five themes emerged: pride, a symbol of safety and inclusion, impact on workplace culture, awareness of LGBTQ+ issues and more to do for LGBTQ+ patients.

CONCLUSIONS

This study demonstrates that the Rainbow Badge initiative increases staff awareness of LGBTQ+ issues and helps to create a safe, inclusive environment for staff, young people and families.

Clusters of 24-hour movement behavior and diet and their relationship with health indicators among youth: a systematic review

Movement-related behaviors (physical activity [PA], sedentary behavior [SB], and sleep) and diet interact with each other and play important roles in health indicators in youth. This systematic review aimed to investigate how PA, SB, sleep, and diet cluster in youth by biological sex; and to examine which cluster are associated with health indicators. This study was registered in PROSPERO (number: CRD42018094826). Five electronic databases were assessed. Eligibility criteria allowed studies that included youth (aged 19 years and younger), and only the four behaviors {PA, SB, sleep, and diet (ultra-processed foods [UPF]; fruits and vegetables [FV])} analyzed by applying data-based cluster procedures. From 12,719 articles screened; 23 were included. Of these, four investigated children, and ten identified clusters by biological sex. Sixty-six mixed cluster were identified including, 34 in mixed-sex samples, 10 in boys and 11 in girls. The most frequent clusters in mixed-sex samples were "High SB UPF Low Sleep", "Low PA High SB Satisfactory Sleep", and "High PA". The main difference in profiles according to sex was that girls' clusters were characterized by high sleep duration, whereas boys' clusters by high PA. There were a few associations found between cluster types and health indicators, highlighting that youth assigned to cluster types with low PA exhibited higher adiposity. In conclusion, the youth presented a range of clusters of behaviors, typically exhibiting at least one unhealthy behavior. Similar patterns were observed in both sexes with the biggest difference in time of sleep for girls and PA for boys. These findings underscore the importance of intervention strategies targeting multiple behaviors simultaneously to enhance health risk profiles and indicators in children and adolescents.

Novel mutation leading to splice donor loss in a conserved site of DMD gene causes Duchenne muscular dystrophy with cryptorchidism

BACKGROUND

As one of the most common congenital abnormalities in male births, cryptorchidism has been found to have a polygenic aetiology according to previous studies of common variants. However, little is known about genetic predisposition of rare variants for cryptorchidism, since rare variants have larger effective size on diseases than common variants.

METHODS

In this study, a cohort of 115 Chinese probands with cryptorchidism was analysed using whole-genome sequencing, alongside 19 parental controls and 2136 unaffected men. Additionally, CRISPR-Cas9 editing of a conserved variant was performed in a mouse model, with MRI screening used to observe the phenotype.

RESULTS

In 30 of 115 patients (26.1%), we identified four novel genes (ARSH, DMD, MAGEA4 and SHROOM2) affecting at least five unrelated patients and four known genes (USP9Y, UBA1, BCORL1 and KDM6A) with the candidate rare pathogenic variants affecting at least two cases. Burden tests of rare variants revealed the genome-wide significances for newly identified genes (p<2.5×10-6) under the Bonferroni correction. Surprisingly, novel and known genes were mainly found on X chromosome (seven on X and one on Y) and all rare X-chromosomal segregating variants exhibited a maternal inheritance rather than de novo origin. CRISPR-Cas9 mouse modelling of a splice donor loss variant in DMD (NC_000023.11:g.32454661C>G), which resides in a conserved site across vertebrates, replicated bilateral cryptorchidism phenotypes, confirmed by MRI at 4 and 10 weeks. The movement tests further revealed symptoms of Duchenne muscular dystrophy (DMD) in transgenic mice.

CONCLUSION

Our results revealed the role of the DMD gene mutation in causing cryptorchidism. The results also suggest that maternal-X inheritance of pathogenic defects could have a predominant role in the development of cryptorchidism.

Storylines of family medicine VII: family medicine across the lifespan

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VII: family medicine across the lifespan', authors address the following themes: 'Family medicine maternity care', 'Seeing children as patients brings joy to work', 'Family medicine and the care of adolescents', 'Reproductive healthcare across the lifespan', 'Men's health', 'Care of older adults', and 'Being with dying'. May readers appreciate the range of family medicine in these essays.

Parent screening questionnaires to detect cognitive and language delay at 2 years in high-risk infants: an analysis from the Victorian Infant Collaborative Study 2016-2017 cohort

OBJECTIVE

To determine the accuracy of two developmental screening questionnaires to detect cognitive or language delay, defined using the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III), in children born extremely preterm (EP: <28 weeks' gestation) or extremely low birth weight (ELBW: <1000 g).

DESIGN

Prospective cohort study.

SETTING

State of Victoria, Australia.

PATIENTS

211 infants born EP/ELBW assessed at 2 years' corrected age (mean 2.2, SD 0.2).

MAIN OUTCOME MEASURES

Cognitive and language delay (<-1 SD) on the Bayley-III. The screening questionnaires were the Parent Report of Children's Abilities-Revised (PARCA-R) and the Ages & Stages Questionnaires Third Edition (ASQ-3).

RESULTS

The PARCA-R performed better than the ASQ-3, but neither questionnaire had substantial agreement with the Bayley-III to detect cognitive delay; kappa (95% CI): PARCA-R 0.43 (0.23, 0.63); ASQ-3 0.15 (-0.05, 0.35); sensitivity (95% CI): PARCA-R 70% (53%, 84%) ASQ-3 62% (47%, 76%); specificity (95% CI): PARCA-R 73% (60%, 84%) ASQ-3 53% (38%, 68%). When both tools were used in combination (below cut-off on at least one assessment), sensitivity increased to 78% (60%, 91%) but specificity fell to 45% (29%, 62%). Similar trends were noted for language delay on the Bayley-III, although kappa values were better than for cognitive delay.

CONCLUSIONS

Neither screening questionnaire identified cognitive delay well, but both were better at identifying language delay. The PARCA-R detects delay on the Bayley-III more accurately than the ASQ-3. Sensitivity for detecting delay is greatest when the PARCA-R and ASQ-3 were used in combination, but resulted in lower specificity.

Children born to subfertile couples, how are they doing? Evidence from research

More than 10 million children have been born with assisted reproductive technology (ART) as we begin to enter the third generation of individuals conceived by ART. Here we summarise key messages from an enlarging body of literature regarding their health. Earlier research had pointed towards increases in perinatal, neonatal and neurological risks, such as preterm birth, low birth weight, congenital malformations and cerebral palsy. Many of these risks have continued to persist in most recent work but have shown reduction. Newer research proposes long-term cardiometabolic and endocrine concerns. Fortunately, most reports conclude there is little or no risk of increased childhood malignancy or abnormal neurodevelopment. Moving forward, new research may benefit from changes in comparator groups and a better understanding of infertility per se in ART, and the confounding role it probably plays in many of the known risk associations, to reliably scan the horizon for health threats for individuals born after ART.

Disease severity impacts perceived quality of life in congenital diaphragmatic hernia: a prospective observational study

BACKGROUND

While research indicates comparable quality of life (QOL) in congenital diaphragmatic hernia (CDH) and healthy populations, the effect of CDH severity on patients' health perceptions remains unexplored. We aimed to assess QOL perception in CDH, hypothesising a decline correlated with increased disease severity.

METHODS

In this prospective observational study, we analysed patients with CDH aged 5 years and above participating in a longitudinal outpatient programme. We excluded bilateral CDH, genetic/syndromic conditions, prematurity and late diagnosis. Participants self-administered the age-adapted Pediatric Quality of Life Inventory (PedsQL) survey, covering four domains (physical, emotional, social, school). After enrolment, data were collected blind to severity status (larger defects denoting significant/'severe' disease). Repeated measurements were managed using a random mixed-effects model.

RESULTS

Of 34 participants (50% males) who completed the PedsQL, 10 provided measurements at two visits. Eight required a patch (type C), while 26 had primary repairs (type A=8; type B=18). Age at first evaluation was comparable across groups (no patch: median 11 (7-16), patch: 13 (8-15) years, p=0.78). Severe CDH correlated significantly with lower PedsQL scores (adjusted β: -18%, 95% CI -28%; -7%, adjusted for age at visit and sex). Lower scores specifically occurred in walking, exercising, social and academic functioning.

CONCLUSION

Severe CDH significantly lowers QOL. This finding is crucial for resource allocation in long-term CDH health surveillance and advocates for regular inclusion of patient experiences in quality improvement efforts.

Tackling obesity while preventing obesity stigma

Obesity is a significant public health problem. Prevalence is rising in children and young people, with lifelong health impacts and implications for paediatric clinical practice. Obesity stigma is increasingly acknowledged as a problem within health services. Health professionals can inadvertently contribute to this stigma, which is harmful and in itself can promote weight gain. A complex web of factors contributes to obesity, and a simplistic approach exclusively focused on personal responsibility, diet and exercise is unhelpful. A more nuanced, sensitive and informed approach is needed, with careful use of language and non-judgemental partnership working.

Association of empiric antibiotic selection and clinical outcomes in hospitalised children with severe orbital infections: a retrospective cohort study

OBJECTIVE

To determine the association of initial empiric antibiotic regimens with clinical outcomes in hospitalised children with severe orbital infections.

DESIGN

Multi-centre observational cohort study using data from 2009 to 2018 clinical records.

SETTING

Canadian children's hospitals (7) and community hospitals (3).

PATIENTS

Children between 2 months and 18 years hospitalised for >24 hours with severe orbital infections.

INTERVENTIONS

Empiric intravenous antibiotic regimen in the first 24 hours of hospitalisation.

MAIN OUTCOME MEASURES

Length of hospital stay and surgical intervention using multivariable median regression and multivariate logistic regression, with adjustment for covariates.

RESULTS

Of 1421 patients, 60.0% were male and the median age was 5.5 years (IQR 2.4-9.9). Median length of stay was 86.4 hours (IQR 56.9-137.5) and 180 (12.7%) received surgical intervention. Patients receiving broad-spectrum empiric antibiotics had an increased median length of stay, ranging from an additional 13.8 hours (third generation cephalosporin and anaerobic coverage) to 19.5 hours (third generation cephalosporin, staphylococcal and anaerobic coverage). No antibiotic regimen was associated with a change in the odds of surgical intervention. These findings remained unchanged in sensitivity analyses restricted to more severely ill patients. There was a twofold increase in the percentage of patients receiving the broadest empiric antibiotic regimens containing both staphylococcal and anaerobic coverage from 17.8% in 2009 to 40.3% in 2018.

CONCLUSIONS

Empiric use of broad-spectrum antibiotics with staphylococci and anaerobic coverage was associated with longer length of stay and similar rates of surgery in children with orbital infections. There is an urgent need for comparative effectiveness studies of various antibiotic regimes.

Comparative analysis of primary health care attributes between children under and over 3 years of age using the primary care assessment tool

INTRODUCTION

Child health actions in Brazil have their primary focus on early childhood. A new epidemiological profile is emerging for children after the first one thousand days: an increase in non-communicable chronic diseases. This research aimed to analyze the attributes of Primary Health Care comparatively among different age groups, using three years of age as the cutoff point.

METHODS

The study design was cross-sectional and conducted in three Primary Health Care Units and three Ambulatory Medical Assistance facilities in the Western Region of São Paulo. The PCA Tool Brazil was used as the assessment instrument.

RESULTS

A total of 311 interviews were conducted with caregivers of children aged 0 to 12 years; 153 children were under three years old, and 158 were three years or older. The attributes that showed statistically significant differences between age groups (< 3 years and > 3 years) were affiliation (4.9 × 3.8), longitudinality (5.7 × 5.2), information system (7.4 × 6.3), and services provided (5.4 × 4.5). Through linear regression analysis, it was observed that there was a trend for better overall and essential scores in the evaluations of the group of children under three years old who attended Primary Health Care Units.

CONCLUSION

The comparative analysis of Primary Health Care attributes among pediatric age groups revealed a trend towards higher scores, according to caregivers' perceptions, for children under three years old. This study suggests the need for the implementation of programs that can better address the healthcare needs of children beyond early childhood.

Public health relevance of medicines developed under paediatric legislation in Europe and the USA: a systematic mapping study

BACKGROUND

Legislation in the European Union (EU) and the USA promoting the development of paediatric medicines has contributed to new treatments for children. This study explores how such legislation responds to paediatric health needs in different country settings and globally, and whether it should be considered for wider implementation.

METHODS

We searched EU and US regulatory databases for medicines with approved indications resulting from completed paediatric development between 2007 and 2018. Of 195 medicines identified, 187 could be systematically mapped to the burden of the target disease for six study countries (Australia, Brazil, Canada, Kenya, Russia, South Africa) and globally, using disability-adjusted life years (DALYs). All medicines were also screened for inclusion on the WHO Model List of Essential Medicines (EML) and the EML for children under 13 years (EMLc).

RESULTS

The studied medicines were disproportionately focused on non-communicable diseases, which represented 68% of medicines and 21% of global paediatric DALYs. On the other hand, we found 28% of medicines for communicable, maternal, neonatal and nutritional disorders, representing 73% of global paediatric DALYs. Neonatal disorders and malaria were mapped with two medicines, tuberculosis and neglected tropical diseases with none. The gap between medicines and paediatric DALYs was greater in countries with lower income. Still, 34% of medicines are included in the EMLc and 48% in the EML.

CONCLUSIONS

Paediatric policies in the EU and the USA are only partially responsive to paediatric health needs. To be considered for wider implementation, paediatric incentives and obligations should be more targeted towards paediatric health needs. International harmonisation of legislation and alignment with global research priorities could further strengthen its impact on child health and support ongoing efforts to improve access to medicines. Furthermore, efforts should be made to ensure global access to authorised paediatric medicines.

A review of dairy food intake for improving health among black infants, toddlers, and young children in the US

Adequate nutrition is paramount for proper growth and musculoskeletal, neurocognitive, and immunological development in infants, toddlers, and young children. Among breastfeeding mother-child dyads, this critical window of development, is impacted by both maternal and offspring dietary patterns. For mothers, their dietary patterns impact not only their own health and well-being, but also the nutrition of their breast milk - which is recommended as the sole source of food for the first 6 months of their infant's life, and as a complementary source of nutrition until at least 2 years of age. For infants and toddlers, the breast milk, formulas, and first foods they consume can have both short-term and long-term effects on their health and well-being - with important impacts on their taste perception, microbiome composition, and immune function. According to dietary intake data in the US, infants and young children meet a greater number of nutrient requirements than older children and adults, yet numerous disparities among socially disadvantaged racial/ethnic groups still provide significant challenges to achieving adequate nutrition during these early life stages. For example, Black children are at greater risk for disparities in breastfeeding, age-inappropriate complementary feeding patterns, nutrient inadequacies, food insecurity, and obesity relative to most other racial/ethnic groups in the US. For infants who do not receive adequate breast milk, which includes a disproportionate number of Black infants, dairy-based infant formulas are considered the next best option for meeting nutritional needs. Fermented dairy foods (e.g., yogurt, cheese) can serve as ideal first foods for complementary feeding, and cow's milk is recommended for introduction during the transitional feeding period to help meet the nutrient demands during this phase of rapid growth and development. Low dairy intake may put children at risk for multiple nutrient inadequacies and health disparities - some of which may have lifelong consequences on physical and mental health. A burgeoning body of research shows that in addition to breast milk, cow's milk and other dairy foods may play critical roles in supporting physical growth, neurodevelopment, immune function, and a healthy gut microbiome in early life. However, most of this research so far has been conducted in White populations and can only be extrapolated to Black infants, toddlers, and young children. Therefore, to better understand and support the health and development of this population, greater research and education efforts on the role of milk and dairy products are urgently needed. This review presents the current evidence on health disparities faced by Black children in the US from birth to four years of age, and the role that dairy foods can play in supporting the normal growth and development of this vulnerable population.

Biallelic PKP2 loss of function variants are associated with a lethal perinatal-onset biventricular dilated cardiomyopathy with excessive trabeculations and ventricular septal defects

Homozygous plakophilin-2 (PKP2) variants have been identified as a cause of a lethal form of dilated cardiomyopathy with excessive trabeculations (DCM-ET) in three cases. We report three more cases from two families with homozygous pathogenic PKP2 variants and perinatal-onset, lethal DCM-ET. Identification of the genetic abnormalities played a key role in decision-making and family counselling in these cases. This case series supports the published evidence that biallelic loss of function PKP2 variants cause a lethal, perinatal-onset cardiomyopathy.

Introduction of allergenic food to infants and allergic and autoimmune conditions: a systematic review and meta-analysis

OBJECTIVES

To evaluate the effects of early introduction to allergenic foods compared with late introduction and its impact on food allergy, food sensitisation and autoimmune disease risk.

DESIGN AND SETTING

The systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Four electronic databases (MEDLINE, CENTRAL, EMBASE and CINAHL) were searched from inception till 24 October 2022 using keywords and MeSH without limitations on publication's language or date. A forward and backwards citation analysis was also conducted. Risk of bias was assessed by three authors independently, in pairs using the Cochrane Risk of Bias Tool 2. Findings were narratively and quantitatively synthesised. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.

PARTICIPANTS

Randomised controlled trials (RCTs) on allergenic food introduction prior to 12 months of age that evaluated its effect on the development of allergic and autoimmune conditions.

INTERVENTION

Early introduction to allergenic foods to infants diet.

MAIN OUTCOME MEASURES

(1) Food allergy and sensitisation with main measures including oral food challenge, specific-IgE, skin prick testing, physician assessment and parental reporting. (2) Allergic and autoimmune conditions such as asthma and eczema.

RESULTS

Of the 9060 identified records, we included 12 RCTs. We found high to moderate certainty evidence suggested that early introduction of allergen-containing foods reduces the risk of multiple food allergies (4 RCTs, 3854 participants, RR 0.49, 95% CI 0.33 to 0.74), egg (8 RCTs, 5193 participants, RR 0.58, 95% CI 0.44 to 0.78), peanut (3 RCTs, 4183 participants, RR 0.31, 95% CI 0.17 to 0.54) and atopic dermatitis or eczema (4 RCTs, 3579 participants, RR 0.88, 95% CI 0.78 to 1.00). Effects on other food allergies including milk, wheat, fish; autoimmune conditions, and food sensitisation are very uncertain and informed by low and very-low certainty evidence. No important subgroup differences were observed related to baseline risk of allergy and age at introduction. Sensitivity analyses limited to low risk of bias RCTs showed similar results.

CONCLUSIONS

This systematic review and meta-analysis shows that early introduction of allergen-containing food from 4 to 12 months of age, was associated with lower risk of multiple food allergy and eczema. Further research on other allergenic foods, and their long-term impact on food allergy and autoimmune risk is essential for enhancing our understanding on development of these conditions and guiding future clinical recommendations.

PROSPERO REGISTRATION NUMBER

CRD42022375679.

Air pollution and childhood respiratory consultations in primary care: a systematic review

BACKGROUND

Outdoor air pollution is a known risk factor for respiratory morbidity worldwide. Compared with the adult population, there are fewer studies that analyse the association between short-term exposure to air pollution and respiratory morbidity in children in primary care.

OBJECTIVE

To evaluate whether children in a primary care setting exposed to outdoor air pollutants during short-term intervals are at increased risk of respiratory diagnoses.

METHODS

A search in Medline, the Cochrane Library, Web of Science and Embase databases throughout March 2023. Percentage change or risk ratios with corresponding 95% CI for the association between air pollutants and respiratory diseases were retrieved from individual studies. Risk of bias assessment was conducted with the Newcastle-Ottawa Scale (NOS) for cohort or case-control studies and an adjusted NOS for time series studies.

RESULTS

From 1366 studies, 14 were identified as meeting the inclusion criteria. Most studies had intermediate or high quality. A meta-analysis was not conducted due to heterogeneity in exposure and health outcome. Overall, studies on short-term exposure to air pollutants (carbon monoxide (CO), sulfur dioxide (SO2), nitrogen dioxide (NO2) and particulate matter ≤10 µm (PM10)) were associated with increased childhood respiratory consultations in primary care. In general, exposure to ozone was associated with a reduction in respiratory consultations.

CONCLUSIONS

The evidence suggests CO, SO2, NO2, PM10 and PM2.5 are risk factors for respiratory diseases in children in primary care in the short term. However, given the heterogeneity of the studies, interpretation of these findings must be done with caution.

PROSPERO REGISTRATION NUMBER

CRD42022259279.

Early educational attainment in children with major congenital anomaly in the UK

OBJECTIVE

To describe early educational attainment and special educational needs (SEN) provision in children with major congenital anomaly (CA) compared with peers.

DESIGN

Analysis of educational data linked to the ongoing Born in Bradford cohort study. Confounders were identified via causal inference methods and multivariable logistic regression performed.

SETTING

Children born in Bradford Royal Infirmary (BRI), West Yorkshire.

PATIENTS

All women planning to give birth at BRI and attending antenatal clinic from March 2007 to December 2010 were eligible. 12 453 women with 13 776 pregnancies (>80% of those attending) were recruited. Records of 555 children with major CA and 11 188 without were linked to primary education records.

OUTCOMES

Key Stage 1 (KS1) attainment at age 6-7 years in Maths, Reading, Writing and Science. SEN provision from age 4 to 7 years.

RESULTS

41% of children with major CA received SEN provision (compared with 14% without), and 48% performed below expected standards in at least one KS1 domain (compared with 29% without). The adjusted odds of children with CA receiving SEN provision and failing to achieve the expected standard at KS1 were, respectively, 4.30 (95% CI 3.49 to 5.31) and 3.06 (95% CI 2.47 to 3.79) times greater than their peers. Those with genetic, heart, neurological, urinary, gastrointestinal and limb anomalies had significantly poorer academic achievement.

CONCLUSIONS

These novel results demonstrate that poor educational attainment extends to children with urinary, limb and gastrointestinal CAs. We demonstrate the need for collaboration between health and education services to assess and support children with major CA, so every CA survivor can maximise their potential.

Interpretation: use of autoantibodies in children

Judicious use of autoantibodies in paediatrics can be challenging. Autoimmune conditions can present with a wide range of signs and symptoms, many of which are non-specific. In combination with clinical features and laboratory findings, autoantibodies can facilitate diagnosis and in certain cases inform prognosis. Evidence for use of autoantibodies to guide and monitor treatment is limited. Caution is necessary when interpreting adult studies. We summarise the use of autoantibodies in paediatric practice with a guide on how they may be used.

Investigating the air quality surrounding new schools in England: polluted playgrounds and school buildings are a source of avoidable harm

OBJECTIVE

To assess levels of pollutants at the sites of new schools and whether pupils are likely to be protected from associated risks.

SETTING

Air pollution causes damage to children's health by increasing respiratory tract infection rates, asthma exacerbations, allergies and childhood cancers. Further effects include poorer neurocognitive outcomes and multisystemic illness in adulthood.

DESIGN

We obtained a list of all 187 proposed new schools in England from 2017 to 2025 and found locations for 147 of them. We assessed air quality against WHO air quality targets and the air quality percentile of the location relative to pollution levels across the UK. We review relevant legislation and guidance.

RESULTS

Our analysis found 86% of new schools (126/147) exceeded all three WHO targets, and every location exceeded at least one. Nationally, 76% (112/147) of sites were in the 60th or greater pollution percentile. Within London, the median pollution percentile was the 90th, with a minimum of 76th and maximum of 99th (IQR=83 rd to 94th).

CONCLUSION

The guidance for school proposals does not include any requirement to assess air quality at the identified site. Building regulations also fail to consider how widespread poor air quality is, and significantly underestimates the levels of major air pollutants surrounding schools. Therefore it is unlikely that adequate action to reduce pupil and staff exposure is undertaken.We argue that air quality assessment should be mandatory at the proposal and planning stage of any new school building and that national guidance and legislation urgently needs to be updated.

A Data-Driven Approach to Optimizing Medical-Legal Partnership Performance and Joint Advocacy

Medical-legal partnerships connect legal advocates to healthcare providers and settings. Maintaining effectiveness of medical-legal partnerships and consistently identifying opportunities for innovation and adaptation takes intentionality and effort. In this paper, we discuss ways in which our use of data and quality improvement methods have facilitated advocacy at both patient (client) and population levels as we collectively pursue better, more equitable outcomes.

Semaglutide treatment for children with obesity: an observational study

OBJECTIVE

To assess efficacy and tolerability of semaglutide as a weight loss treatment for children living with comorbid obesity.

DESIGN

Retrospective observational study of the first 50 children from a weight management service treated with semaglutide for at least 6 months.

SETTING

A tertiary paediatric multidisciplinary weight management clinic in a UK hospital.

PATIENTS

Aged 10-18 years old with a body mass index (BMI) SD score (SDS) >2 with a weight-related comorbidity (including insulin resistance (defined as homeostatic model assessment for insulin resistance >4), type 2 diabetes, metabolic-associated fatty liver disease, obstructive sleep apnoea or hypertension).

INTERVENTIONS

Once-weekly injectable semaglutide titrated over 8 weeks to a final dose of 1 mg in addition to dietary and lifestyle advice.

MAIN OUTCOME MEASURES

Primary outcome measures were change in weight, BMI SDS and percentage body weight. Secondary outcomes were side effects and cessation of treatment.

RESULTS

After 6 months of treatment, statistically significant decreases in BMI SDS (0.32±0.27, p<0.001) and body weight (7.03±7.50 kg, p<0.001) were seen. Mean percentage total weight loss was 6.4±6.3% (p<0.001). For the 14 patients for whom 12-month data were available, statistically significant decreases were seen in mean BMI SDS (0.54±0.52, p<0.001). Mean body weight decreased by 9.7±10.8 kg (p<0.001). Percentage total weight loss at 12 months was 8.9±10.0% (p<0.001). Mild gastrointestinal side effects were common. One patient developed gallstones. Five patients discontinued treatment due to side effects.

CONCLUSION

Semaglutide appears to be a safe and effective weight loss adjunct when used in a multidisciplinary weight management clinic.

Management of cerebrospinal-fluid-related intracranial abnormalities in frontoethmoidal encephalocele using "Shunt algorithm for frontoethmoidal encephalocele" (SAFE)

A cerebrospinal-fluid-related (CSF-related) problem occurred in 25-30% of frontoethmoidal encephalocele (FEE) cases. Since there was no algorithm or guideline, the judgment to treat the CSF-related problem often relies upon the surgeon's experience. In our institution, the early shunt was preferable to treat the problem, but it added risks to the children. We developed an algorithm, "Shunt Algorithm for Frontoethmoidal Encephalocele" (SAFE), to guide the surgeon in making the most reasonable decision. To evaluate the SAFE's efficacy in reducing unnecessary early shunting for FEE with CSF-related intracranial abnormality. Medical records of FEE patients with CSF-related abnormalities treated from January 2007 to December 2019 were reviewed. The patients were divided into two groups: before the SAFE group as group 1 (2007 - 2011) and after the SAFE group as group 2 (2012 - 2019). We excluded FEE patients without CSF-related abnormalities. We compared the number of shunts and the complications between the two groups. One hundred and twenty-nine patient's medical records were reviewed. The males were predominating (79 versus 50 patients) with an average age of 58.2±7.1 months old (6 to 276 months old). Ventriculomegaly was found in 18 cases, arachnoid cysts in 46 cases, porencephalic cysts in 19 cases, and ventricular malformation in 46 cases. Group 1, with a score of 4 to 7 (19 cases), received an early shunt along with the FEE repair. Complications occurred in 7 patients of this group. Group 2, with a score of 4-7, received shunts only after the complication occurred in 3 cases (pseudomeningocele unresponsive with conservative treatment and re-operation in 2 cases; a sign of intracranial hypertension in 1 case). No complication occurred in this group. Groups 1 and 2, with scores of 8 or higher (6 and 8 cases, respectively), underwent direct shunt, with one complication (exposed shunt) in each group. The SAFE decision algorithm for FEE with CSF-related intracranial abnormalities has proven effective in reducing unnecessary shunting and the rate of shunt complications.

What is cystic fibrosis screen positive inconclusive diagnosis? And what is it not?

Since screening for cystic fibrosis (CF) was incorporated into the newborn screening program, the number of recognised variants in the CF transmembrane conductance regulator (CFTR) gene has significantly increased. This has led to the discovery of combinations of gene variants with an uncertain prognosis. One outcome is the designation of 'cystic fibrosis screen positive inconclusive diagnosis' (CFSPID). While the majority of these children are expected to be unaffected by their CFTR variants, a small proportion have been seen to develop symptoms or increasing sweat chloride levels over time, which may reflect dysfunction of the CFTR protein.As the number of children with CFSPID increases, paediatricians and those working in primary care are more likely to encounter them in their practice. It is important that professionals have an understanding of CFSPID: what it is and, importantly, what it is not (ie, they do not have CF). In this article, we hope to explore this using some example cases, illustrating the ways in which these children may present symptomatically and how to manage them.

Post-urethroplasty complications in hypospadias repair: a systematic review and meta-analysis comparing polydioxanone and polyglactin sutures

Background

Polyglactin (PG) and polydioxanone (PDS) sutures are extensively used based on the surgeon's preference. The development of post-reconstruction urethrocutaneous fistula (UCF) is variably attributed to the choice of suture material for urethroplasty. This meta-analysis compares complications of hypospadias repair using PG and PDS sutures.

Methods

The systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The authors conducted thorough searches in databases including MEDLINE, EMBASE, CENTRAL, Scopus, Google Scholar, and clinical trial registries. Outcome measures included UCF, meatal stenosis, wound infection, urethral stricture, glans dehiscence, and overall complications. Quantitative analysis was used with fixed or random-effect models to find the pooled risk ratio and I2 heterogeneity.

Results

The criteria for inclusion were met by five comparative studies with the inclusion of 1244 children altogether. Pooled analysis failed to show a statistically significant difference in the incidence of meatal stenosis, urethral stricture, wound infection, and total complications using PG and PDS sutures. However, it showed a reduction in the incidence of UCF with PDS suture hypospadias repairs (risk ratio=0.66, 95% CI 0.48 to 0.92).

Conclusions

PDS sutures are associated with decreased incidence of UCF than PG after hypospadias repair. The incidence of meatal stenosis, urethral stricture, wound infection, and total complications was not affected by the type of suture material used for repair.

Clinical implications

This meta-analysis suggests decreased incidence of UCF when PDS sutures are used for hypospadias repair which may impact the choice of suture material for repair.

PROSPERO registration number

CRD42023409710.

Artificial food additives: hazardous to long-term health

Many additives, some of which have no nutritional value, can be legally used in processed foods. They intensify colour, thicken, increase shelf life and enhance flavour. Regulatory authorities issue approvals as safe within acceptable quantitative limits. Ultra-processed foods (UPFs) contain combinations of all these additives and are particularly attractive to children.Many publications suggest that artificial colourants, benzoate preservatives, non-caloric sweeteners, emulsifiers and their degradation derivatives have adverse effects by increasing risks of mental health disorders, attention deficit hyperactivity disorder, cardiovascular disease, metabolic syndrome and potential carcinogenic effects.A systematic review has established that artificial azo dye food colourants (AFCs) and sodium benzoate preservative cause disturbed behaviour in children. AFCs and benzoates in animal models have neurotoxic properties through gut microbial generation of toxic metabolites. Observational studies show associations between high emulsifier intake and cardiovascular disease. Animal models and in vitro studies have highlighted neurotoxic, cytotoxic, genotoxic and carcinogenic effects. High intake of non-caloric sweeteners has been linked to cardiovascular disease and depression in adults and is linked to childhood obesity.Little research has focused on children who are the largest consumers of UPFs. Potentially, they are a ticking time bomb for adult obesity, metabolic syndrome, cardiovascular diseases, mental health disorders and cancers. Based on risk/benefit analysis, azo dye AFCs should be banned. Benzoates, emulsifiers and sweeteners require assessment of quantitative limits and cumulative effects of combinations. Consumers purchasing UPFs require information through ingredient health warnings and recommendations to use natural unprocessed foods which have well-described health-promoting properties.

Associations between physical activity and development in preschool-aged children born <30 weeks' gestation: a cohort study

OBJECTIVE

To investigate the effect of physical activity (PA) on development (motor, cognitive, social-emotional) in children 4-5 years old born <30 weeks' gestation, and to describe subgroups of children at risk of low PA in this cohort.

DESIGN

Longitudinal cohort study.

PATIENTS

123 children born <30 weeks were recruited at birth and assessed between 4 and 5 years' corrected age.

MAIN OUTCOME MEASURES

Development was assessed using the Movement Assessment Battery for Children, Second Edition (MABC-2), Little Developmental Coordination Disorder Questionnaire (L-DCDQ), Wechsler Preschool and Primary Scale of Intelligence (Fourth Edition; WPPSI-IV), and Strengths and Difficulties Questionnaire (SDQ). To measure PA, children wore an accelerometer and parents completed a diary for 7 days. Effects of PA on developmental outcomes, and associations between perinatal risk factors and PA, were estimated using linear regression.

RESULTS

More accelerometer-measured PA was associated with better MABC-2 aiming and catching scores (average standard score increase per hour increase in PA: 0.54, 95% CI 0.11, 0.96; p=0.013), and lower WPPSI-IV processing speed index scores (average composite score decrease per hour increase in PA: -2.36, 95% CI -4.19 to -0.53; p=0.012). Higher accelerometer-measured PA was associated with better SDQ prosocial scores. Major brain injury in the neonatal period was associated with less moderate-vigorous and less unstructured PA at 4-5 years.

CONCLUSIONS

Higher levels of PA are associated with aspects of motor, cognitive and social-emotional skill development in children 4-5 years old born <30 weeks. Those with major brain injury in the neonatal period may be more vulnerable to low PA at preschool age.

Neurosensory, cognitive and academic outcomes at 8 years in children born 22-23 weeks' gestation compared with more mature births

Despite providing intensive care to more infants born <24 weeks' gestation, data on school-age outcomes, critical for counselling and decision-making, are sparse.

OBJECTIVE

To compare major neurosensory, cognitive and academic impairment among school-aged children born extremely preterm at 22-23 weeks' gestation (EP22-23) with those born 24-25 weeks (EP24-25), 26-27 weeks (EP26-27) and term (≥37 weeks).

DESIGN

Three prospective longitudinal cohorts.

SETTING

Victoria, Australia.

PARTICIPANTS

All EP live births (22-27 weeks) and term-born controls born in 1991-1992, 1997 and 2005.

MAIN OUTCOME MEASURES

At 8 years, major neurosensory disability (any of moderate/severe cerebral palsy, IQ <-2 SD relative to controls, blindness or deafness), motor, cognitive and academic impairment, executive dysfunction and poor health utility. Risk ratios (RRs) and risk differences between EP22-23 (reference) and other gestational age groups were estimated using generalised linear models, adjusted for era of birth, social risk and multiple birth.

RESULTS

The risk of major neurosensory disability was higher for EP22-23 (n=21) than more mature groups (168 EP24-25; 312 EP26-27; 576 term), with increasing magnitude of difference as the gestation increased (adjusted RR (95% CI) compared with EP24-25: 1.39 (0.70 to 2.76), p=0.35; EP26-27: 1.85 (0.95 to 3.61), p=0.07; term: 13.9 (5.75 to 33.7), p<0.001). Similar trends were seen with other outcomes. Two-thirds of EP22-23 survivors were free of major neurosensory disability.

CONCLUSIONS

Although children born EP22-23 experienced higher rates of disability and impairment at 8 years than children born more maturely, many were free of major neurosensory disability. These data support providing active care to infants born EP22-23.

Mental health of caregivers of children with medical complexity: group-based trajectory modelling

OBJECTIVE

To describe the mental health trajectories of caregivers of children with medical complexity (CMC) and explore child characteristics associated with below-average caregiver mental health.

DESIGN

A secondary analysis of prospectively collected data from 123 caregivers of children aged <16 years with medical complexity from a multicentre randomised trial conducted from December 2016 to June 2021.

MAIN OUTCOME MEASURE

The Patient-Reported Outcomes Measurement Information System Global Mental Health Scale was used to measure caregivers' self-reported mental health well-being. Group-based trajectory analysis was used to identify clusters of caregivers with similar changes in mental health across 24 months. Logistic regression was used to identify child-related predictors of mental health among caregivers.

RESULTS

A final model with three distinct groups was selected, corresponding to caregivers with average (n=39), moderately below-average (n=65) and severely below-average (n=19) mental health scores, all with stable trajectories and high posterior probabilities (>90%). Moderately and severely below-average caregiver mental health groups, merged into one group, were associated with a greater number of child medical technology devices (adjusted OR (aOR) 1.44, 95% CI 1.01 to 2.04), gross motor difficulties (aOR 3.51, 95% CI 1.02 to 12.05) and worse child emotional (aOR 0.93, 95% CI 0.87 to 0.99) and psychological well-being (aOR 0.93, 95% CI 0.88 to 0.99).

CONCLUSION

Most caregivers of CMC reported persistently below-average mental health. The intensity of caregiving, as indicated by medical technology and child functional needs, is a potential risk factor for below-average caregiver mental health. Future design and evaluation of interventions focused on support for caregivers of CMC are warranted.

Changing contexts of child health: an assessment of unmet physical, psychological and social needs of children with common chronic childhood illness

BACKGROUND

We assessed the biopsychosocial needs and key health drivers among children living with a common chronic illness, as baseline for a cluster randomised controlled trial of a child health system strengthening intervention.

METHODS

Cross-sectional data were analysed from a large population sample of children from South London with asthma, eczema or constipation, as exemplar tracer conditions of a new integrated care service. Descriptive and regression analyses, accounting for sociodemographic factors, investigated social needs, psychosocial outcomes and quality of life associated with poor symptom control.

RESULTS

Among 7779 children, 4371 children (56%) had at least one uncontrolled physical health condition. Across the three domains of physical health, mental health and social needs, 77.5% of children (n=4304 of 5554) aged 4-15 years had at least one unmet need, while 16.3% of children had three unmet needs. Children from the most socioeconomically disadvantaged quintile had a 20% increased risk of at least one poorly controlled physical condition (risk ratio (RR)=1.20, 95% CI: 1.11 to 1.31, p<0.001) compared with those from the least disadvantaged quintile. There was an 85% increased risk of clinically important mental health needs among children with uncontrolled asthma (RR=1.85, 95% CI: 1.65 to 2.07, p<0.001), 57% for active constipation (RR=1.57, 95% CI: 1.12 to 2.20, p<0.01) and 39% for uncontrolled eczema (RR=1.39, 95% CI: 1.24 to 1.56, p<0.001). Health-related quality of life was associated with poor symptom control.

CONCLUSIONS

There is a large burden of unmet biopsychosocial needs among children with chronic illness, signalling an urgent need for prevention, early intervention and integrated biopsychosocial care.

Tubularized incised plate urethroplasty and grafted tubularized incised plate urethroplasty: systematic review, meta-analysis and trial sequential analysis

Background

Hypospadias is one of the most common genital birth defects. There are around 300 various techniques available for the repair of hypospadias. This study aims to compare the reported outcomes of Tubularized incised plate urethroplasty (TIP) and Grafted TIP (GTIP) repair in children undergoing primary hypospadias repair.

Methods

This meta-analysisadhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and we framed our research question using the population, intervention, control and outcomes format. We conducted comprehensive electronic searches across various databases, employing a Boolean search strategy with predefined search terms. Only randomized controlled trials (RCTs) were included for quantitative analysis.

Results

Totally, 10 RCTs met our inclusion criteria for quantitative analysis. The results indicated that urethrocutaneous fistula, glans dehiscence, and stricture rates were comparable between the two groups. The incidence of meatal stenosis was found to be significantly lower in the GTIP group with a relative risk (RR) of 0.32 (95% confidence interval (CI) 0.15 to 0.67).

Conclusion

The coucomes UCF, glans dehiscence, and stricture rates were comparable between the two groups. Notably, the incidence of meatal stenosis was found to be significantly lower in the grafted TIP group. In terms of operative time, our quantitative synthesis demonstrated that the TIP group had a shorter operative time than the GTIP group with significant heterogeneity.

Pain in children with Bell's palsy: secondary analysis of a randomised controlled trial

OBJECTIVE

To describe the prevalence and severity of pain experienced by children with Bell's palsy over the first 6 months of illness and its association with the severity of facial paralysis.

METHODS

This was a secondary analysis of data obtained in a phase III, triple-blinded, randomised, placebo-controlled trial of prednisolone for the treatment of Bell's palsy in children aged 6 months to <18 years conducted between 13 October 2015 and 23 August 2020 in Australia and New Zealand. Children were recruited within 72 hours of symptom onset and pain was assessed using a child-rated visual analogue scale (VAS), a child-rated Faces Pain Score-Revised (FPS-R) and/or a parent-rated VAS at baseline, and at 1, 3 and 6 months until recovered, and are reported combined across treatment groups.

RESULTS

Data were available for 169 of the 187 children randomised from at least one study time point. Overall, 37% (62/169) of children reported any pain at least at one time point. The frequency of any pain reported using the child-rated VAS, child-rated FPS-R and parent-rated VAS was higher at the baseline assessment (30%, 23% and 27%, respectively) compared with 1-month (4%, 0% and 4%, respectively) and subsequent follow-up assessments. At all time points, the median pain score on all three scales was 0 (no pain).

CONCLUSIONS

Pain in children with Bell's palsy was infrequent and primarily occurred early in the disease course and in more severe disease. The intensity of pain, if it occurs, is very low throughout the clinical course of disease.

TRIAL REGISTRATION NUMBER

ACTRN12615000563561.

Parents' understanding of medication at discharge and potential harm in children with medical complexity

OBJECTIVE

Children with medical complexity (CMC) are among the most vulnerable patient groups. This study aimed to evaluate their prevalence and risk factors for medication misunderstanding and potential harm (PH) at discharge.

DESIGN AND SETTING

Cross-sectional study at a tertiary care centre.

STUDY POPULATION

CMC admitted at Medical University of Vienna between May 2018 and January 2019.

INTERVENTION

CMC and caregivers underwent a structured interview at discharge; medication understanding and PH for adverse events were assessed by a hybrid approach.

MAIN OUTCOME MEASURES

Medication misunderstanding rate; PH.

RESULTS

For 106 included children (median age 9.6 years), a median number of 5.0 (IQR 3.0-8.0) different medications were prescribed. 83 CMC (78.3%) demonstrated at least one misunderstanding, in 33 CMC (31.1%), potential harm was detected, 5 of them severe. Misunderstandings were associated with more medications (r=0.24, p=0.013), new prescriptions (r=0.23, p=0.019), quality of medication-related communication (r=-0.21, p=0.032), low level of education (p=0.013), low language skills (p=0.002) and migratory background (p=0.001). Relative risk of PH was 2.27 times increased (95% CI 1.23 to 4.22) with new medications, 2.14 times increased (95% CI 1.10 to 4.17) with migratory background.

CONCLUSION

Despite continuous care at a tertiary care centre and high level of subjective satisfaction, high prevalence of medication misunderstanding with relevant risk for PH was discovered in CMC and their caregivers. This demonstrates the need of interventions to improve patient safety, with stratification of medication-related communication for high-risk groups and a restructured discharge process focusing on detection of misunderstandings ('unknown unknowns').

Child mask mandates for COVID-19: a systematic review

BACKGROUND

Mask mandates for children during the COVID-19 pandemic varied in different locations. A risk-benefit analysis of this intervention has not yet been performed. In this study, we performed a systematic review to assess research on the effectiveness of mask wearing in children.

METHODS

We performed database searches up to February 2023. The studies were screened by title and abstract, and included studies were further screened as full-text references. A risk-of-bias analysis was performed by two independent reviewers and adjudicated by a third reviewer.

RESULTS

We screened 597 studies and included 22 in the final analysis. There were no randomised controlled trials in children assessing the benefits of mask wearing to reduce SARS-CoV-2 infection or transmission. The six observational studies reporting an association between child masking and lower infection rate or antibody seropositivity had critical (n=5) or serious (n=1) risk of bias; all six were potentially confounded by important differences between masked and unmasked groups and two were shown to have non-significant results when reanalysed. Sixteen other observational studies found no association between mask wearing and infection or transmission.

CONCLUSIONS

Real-world effectiveness of child mask mandates against SARS-CoV-2 transmission or infection has not been demonstrated with high-quality evidence. The current body of scientific data does not support masking children for protection against COVID-19.

Trends in inequalities in childhood overweight and obesity prevalence: a repeat cross-sectional analysis of the Health Survey for England

OBJECTIVE

To examine trends in socio-economic and ethnic inequalities in childhood overweight and obesity in the England between 1995 and 2019 in survey data and to compare these to administrative data.

DESIGN

Observational repeated cross-sectional study using the Health Survey for England (HSE) and National Child Measurement Programme (NCMP).

OUTCOME

Age and sex standardised overweight, obesity and overweight including obesity.

ANALYSIS

Inequalities assessed by parental education, family structure, ethnicity (binary non-white vs white) and area-level Index of Multiple Deprivation. Estimates stratified by age and sex. Trends compared against NCMP data (age 4-5 and 10-11 years).

RESULTS

Prevalence of childhood overweight including obesity increased from 26.0% in 1995 to 31.7% in 2019, with the highest and fastest growing levels in those aged 11-15 years, rising from 29.7% to 38.0%. Despite a plateau in overall childhood obesity since 2004, differences between groups demonstrated widening inequalities over time. Inequalities widened by area-level deprivation, household educational attainment, household structure and ethnicity driven primarily by increased prevalence among socioeconomically disadvantaged children. For example, the gap between children from households with no qualifications versus degree-level qualifications increased from -1.1% to 13.2%, and the gap between single-parent households and couple households increased from 0.5% to 5.3%. HSE trends in prevalence of childhood overweight and obesity by deprivation quintile were consistent with those in NCMP.

CONCLUSION

Overall levels of child overweight and obesity increased between 1995 and 2004. Since then, increases in prevalence among less advantaged groups have driven widening of inequalities.