Multimorbidity in Early Childhood and Socioeconomic Disadvantage: Findings From a Large New Zealand Child Cohort

Case identification of non-traumatic brain injury in youth using linked population data

BACKGROUND

Population-level administrative data provides a cost-effective means of monitoring health outcomes and service needs of clinical populations. This study aimed to present a method for case identification of non-traumatic brain injury in population-level data and to examine the association with sociodemographic factors.

METHODS

An estimated resident population of youth aged 0-24 years was constructed using population-level datasets within the New Zealand Integrated Data Infrastructure. A clinical consensus committee reviewed the International Classification of Diseases Ninth and Tenth Editions codes and Read codes for inclusion in a case definition. Cases were those with at least one non-traumatic brain injury code present in the five years up until 30 June 2018 in one of four databases in the Integrated Data Infrastructure. Rates of non-traumatic brain injury were examined, both including and excluding birth injury codes and across age, sex, ethnicity, and socioeconomic deprivation groups.

RESULTS

Of the 1 579 089 youth aged 0-24 years on 30 June 2018, 8154 (0.52%) were identified as having one of the brain injury codes in the five-years to 30 June 2018. Rates of non-traumatic brain injury were higher in males, children aged 0-4 years, Māori and Pacific young people, and youth living with high levels of social deprivation.

CONCLUSION

This study presents a comprehensive method for case identification of non-traumatic brain injury using national population-level administrative data.

Subpopulations of children with multiple chronic health outcomes in relation to chemical exposures in the ECHO-PATHWAYS consortium

A multimorbidity-focused approach may reflect common etiologic mechanisms and lead to better targeting of etiologic agents for broadly impactful public health interventions. Our aim was to identify clusters of chronic obesity-related, neurodevelopmental, and respiratory outcomes in children, and to examine associations between cluster membership and widely prevalent chemical exposures to demonstrate our epidemiologic approach. Early to middle childhood outcome data collected 2011-2022 for 1092 children were harmonized across the ECHO-PATHWAYS consortium of 3 prospective pregnancy cohorts in six U.S. cities. 15 outcomes included age 4-9 BMI, cognitive and behavioral assessment scores, speech problems, and learning disabilities, asthma, wheeze, and rhinitis. To form generalizable clusters across study sites, we performed k-means clustering on scaled residuals of each variable regressed on study site. Outcomes and demographic variables were summarized between resulting clusters. Logistic weighted quantile sum regressions with permutation test p-values associated odds of cluster membership with a mixture of 15 prenatal urinary phthalate metabolites in full-sample and sex-stratified models. Three clusters emerged, including a healthier Cluster 1 (n = 734) with low morbidity across outcomes; Cluster 2 (n = 192) with low IQ and higher levels of all outcomes, especially 0.4-1.8-standard deviation higher mean neurobehavioral outcomes; and Cluster 3 (n = 179) with the highest asthma (92 %), wheeze (53 %), and rhinitis (57 %) frequencies. We observed a significant positive, male-specific stratified association (odds ratio = 1.6; p = 0.01) between a phthalate mixture with high weights for MEP and MHPP and odds of membership in Cluster 3 versus Cluster 1. These results identified subpopulations of children with co-occurring elevated levels of BMI, neurodevelopmental, and respiratory outcomes that may reflect shared etiologic pathways. The observed association between phthalates and respiratory outcome cluster membership could inform policy efforts towards children with respiratory disease. Similar cluster-based epidemiology may identify environmental factors that impact multi-outcome prevalence and efficiently direct public policy efforts.

Preterm birth and the risk of multimorbidity in adolescence: a multiregister-based cohort study

BACKGROUND

Multimorbidity affects people of all ages, but the risk factors of multimorbidity in adolescence are unclear. The aim of this study was to examine preterm birth (<37 weeks) as a shared risk factor for multiple health outcomes and the role of gestational age (degree of prematurity) in the development of increasingly complex multimorbidity (two, three, or four health outcomes) in adolescence (age 10-18 years).

METHODS

We used population-wide data from Finland (1 187 610 adolescents born 1987-2006) and Norway (555 431 adolescents born 1998-2007). Gestational age at birth was ascertained from medical birth registers and categorised as 23-27 weeks (extremely preterm), 28-31 weeks (very preterm), 32-33 weeks (moderately preterm), 34-36 weeks (late preterm), 37-38 weeks (early term), 39-41 weeks (term, reference category) and 42-44 weeks (post-term). Children who died or emigrated before their 10th birthday, and those with missing or implausible data on gestational age, birthweight, or covariates, were excluded. Health outcomes at age 10-18 years were ascertained from specialised health care and mortality registers. We calculated hazard ratios (HRs) and population attributable fractions (PAFs) with 95% CIs for multiple health outcomes during adolescence.

FINDINGS

Individuals were followed up from age 10 to 18 years (mean follow-up: 6 years, SD: 3 years). Preterm birth was associated with increased risks of 20 hospital-treated malignant, cardiovascular, endocrinological, neuropsychiatric, respiratory, genitourinary, and congenital health outcomes, after correcting for multiple testing and ignoring small effects (HR <1·2). Confounder-adjusted HRs comparing preterm with term-born adolescents were 2·29 (95% CI 2·19-2·39) for two health outcomes (PAF 9·0%; 8·3-9·6), and 4·22 (3·66-4·87) for four health outcomes (PAF 22·7%; 19·4-25·8) in the Finnish data. Results in the Norwegian data showed a similar pattern. We observed a consistent dose-response relationship between an earlier gestational age and elevated risks of increasingly complex multimorbidity in both datasets.

INTERPRETATION

Preterm birth is associated with increased risks of diverse multimorbidity patterns at age 10-18 years. Adolescents with a preterm-born background could benefit from diagnostic vigilance directed at multimorbidity and a multidisciplinary approach to health care.

FUNDING

European Union Horizon 2020, Academy of Finland, Foundation for Pediatric Research, Sigrid Jusélius Foundation, Signe and Ane Gyllenberg Foundation.

State-Level Anti-Immigrant Sentiment and Policies and Health Risks in US Latino Children

BACKGROUND

Although systemic inequities, broadly defined, are associated with health disparities in adults, there is a dearth of research linking contextual measures of exclusionary policies or prejudicial attitudes to health impairments in children, particularly among Latino populations. In this study, we examined a composite measure of systemic inequities in relation to the cooccurrence of multiple health problems in Latino children in the United States.

METHODS

Participants included 17 855 Latino children aged 3 to 17 years from the National Survey of Children's Health (2016-2020). We measured state-level systemic inequities using a factor score that combined an index of exclusionary state policies toward immigrants and aggregated survey data on prejudicial attitudes toward immigrants and Latino individuals. Caregivers reported on 3 categories of child health problems: common health difficulties in the past year, current chronic physical health conditions, and current mental health conditions. For each category, we constructed a variable reflecting 0, 1, or 2 or more conditions.

RESULTS

In models adjusted for sociodemographic covariates, interpersonal discrimination, and state-level income inequality, systemic inequities were associated with 1.13 times the odds of a chronic physical health condition (95% confidence interval: 1.02-1.25) and 1.24 times the odds of 2 or more mental health conditions (95% confidence interval: 1.06-1.45).

CONCLUSIONS

Latino children residing in states with higher levels of systemic inequity are more likely to experience mental health or chronic physical health conditions relative to those in states with lower levels of systemic inequity.

Children and adolescents are not small adults: towards a better understanding of multimorbidity in younger populations

Multimorbidity is of increasing importance for the health of both children and adults but research has hitherto focused on adult multimorbidity. Hence, public awareness, practice and policy lack vital information about multimorbidity in childhood and adolescence. We convened an international and interdisciplinary group of experts from six nations to identify key priorities supported by published evidence to strengthen research for children and adolescent with multimorbidity. Future research is encouraged 1) To develop a conceptual framework to capture unique aspects of child and adolescent multimorbidity - including definitions, characteristic patterns of conditions for different age groups, its dynamic nature through childhood and adolescence and understanding of severity and trajectories for different clusters of multiple chronic conditions, 2) To define new indices to classify the presence of multimorbidity in children and adolescents, 3) To improve the availability and linkage of data across countries, 4) To synthesize evidence on the global phenomenon of multimorbidity in childhood and adolescence as well as health inequalities, 5) To involve children and adolescents in research relevant to their health.

Theoretical explanations for socioeconomic inequalities in multimorbidity: a scoping review

OBJECTIVE

To document socioepidemiological theories used to explain the relationship between socioeconomic disadvantage and multimorbidity.

DESIGN

Scoping review.

METHODS

A search strategy was developed and then applied to multiple electronic databases including Medline, Embase, PsychInfo, Web of Science, Scielo, Applied Social Sciences, ERIC, Humanities Index and Sociological Abstracts. After the selection of studies, data were extracted using a data charting plan. The last search was performed on the 28 September 2021. Extracted data included: study design, country, population subgroups, measures of socioeconomic inequality, assessment of multimorbidity and conclusion on the association between socioeconomic variables and multimorbidity. Included studies were further assessed on their use of theory, type of theories used and context of application. Finally, we conducted a meta-narrative synthesis to summarise the results.

RESULTS

A total of 64 studies were included in the review. Of these, 33 papers included theories as explanations for the association between socioeconomic position and multimorbidity. Within this group, 16 explicitly stated those theories and five tested at least one theory. Behavioural theories (health behaviours) were the most frequently used, followed by materialist (access to health resources) and psychosocial (stress pathways) theories. Most studies used theories as post hoc explanations for their findings or for study rationale. Supportive evidence was found for the role of material, behavioural and life course theories in explaining the relationship between social inequalities and multimorbidity.

CONCLUSION

Given the widely reported social inequalities in multimorbidity and its increasing public health burden, there is a critical gap in evidence on pathways from socioeconomic disadvantage to multimorbidity. Generating evidence of these pathways will guide the development of intervention and public policies to prevent multimorbidity among people living in social disadvantage. Material, behavioural and life course pathways can be targeted to reduce the negative effect of low socioeconomic position on multimorbidity.

Preterm birth and the risk of chronic disease multimorbidity in adolescence and early adulthood: A population-based cohort study

BACKGROUND

People who were born prematurely have high risks of many individual diseases and conditions in the early part of the life course. However, our knowledge of the burden of multiple diseases (multimorbidity) among prematurely born individuals is limited. We aimed to investigate the risk and patterns of chronic disease multimorbidity in adolescence and early adulthood among individuals born across the spectrum of gestational ages, comparing preterm and full-term born individuals.

METHODS AND FINDINGS

We used individual-level data from linked nationwide registers to examine the associations of gestational age at birth with specialised healthcare records of ≥2 chronic diseases (multimorbidity) in adolescence (age 10-17 years) and early adulthood (age 18-30 years). Our study population comprised 951,116 individuals (50.2% females) born alive in Finland between 1st January 1987 and 31st December 2006, inclusive. All individuals were followed from age 10 years to the onset of multimorbidity, emigration, death, or 31 December 2016 (up to age 30 years). We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for multimorbidity using flexible parametric survival models. During 6,417,903 person-years at risk (median follow-up: 7.9 years), 11,919 individuals (1.3%) had multimorbidity in adolescence (18.6 per 10,000 person-years). During 3,967,419 person-years at risk (median follow-up: 6.2 years), 15,664 individuals (1.7%) had multimorbidity in early adulthood (39.5 per 10,000 person-years). Adjusted HRs for adolescent multimorbidity, comparing preterm to full-term born individuals, were 1.29 (95% CI: 1.22 to 1.36) and 1.26 (95% CI: 1.18 to 1.35) in females and males, respectively. The associations of preterm birth with early adult multimorbidity were less marked, with the adjusted HRs indicating 1.18-fold risk in females (95% CI: 1.12 to 1.24) and 1.10-fold risk in males (95% CI: 1.04 to 1.17). We observed a consistent dose-response relationship between earlier gestational age at birth and increasing risks of both multimorbidity outcomes. Compared to full-term born males, those born at 37-38 weeks (early term) had a 1.06-fold risk of multimorbidity in adolescence (95% CI: 0.98 to 1.14) and this risk increased in a graded manner up to 6.85-fold (95% CI: 5.39 to 8.71) in those born at 23-27 weeks (extremely premature), independently of covariates. Among females, the same risks ranged from 1.16-fold (95% CI: 1.09 to 1.23) among those born at 37-38 weeks to 5.65-fold (95% CI: 4.45 to 7.18) among those born at 23-27 weeks. The corresponding risks of early adult multimorbidity were similar in direction but less marked in magnitude, with little difference in risks between males and females born at 36-37 weeks but up to 3-fold risks observed among those born at 23-27 weeks.

CONCLUSIONS

Our findings indicate that an earlier gestational age at birth is associated with increased risks of chronic disease multimorbidity in the early part of the life course. There are currently no clinical guidelines for follow-up of prematurely born individuals beyond childhood, but these observations suggest that information on gestational age would be a useful characteristic to include in a medical history when assessing the risk of multiple chronic diseases in adolescent and young adult patients.

Do social inequalities persist in the distribution of dental caries in adolescents from Maranhão? Contributions of a population-based study

This study aimed to analyze the association of socioeconomic factors with the prevalence of dental caries in adolescents from São Luís, Maranhão, Brazil, to answer whether social inequalities persist in distributing this disease. This is a cross-sectional study nested in a prospective cohort. We included 2,413 adolescents aged 18-19 years evaluated in the 2016 second follow-up. The outcome was teeth with untreated dental caries (yes or no) assessed by the DMFT index. Socioeconomic and demographic characteristics were the independent variables. Descriptive statistical and Poisson regression analyses were performed, calculating crude and adjusted prevalence ratios (PRs) (alpha=5%). Belonging to economic classes C (PR=1.23; 95% CI: 1.11-1.37) or D-E (PR=1.48; 95% CI: 1.32-1.65), being married/living with a partner (PR=1.22; 95% CI: 1.07-1.39), having separated parents (PR=1.11; 95% CI 1.03-1.19) and a greater number of people in the household (PR=1.05; 95% CI: 1.03-1.07) were associated with a higher prevalence of dental caries. Social inequalities in adolescent oral health persist despite the implementation of the National Oral Health Policy. The current health care model should seek to reorient health education strategies, targeting them at vulnerable populations.

Identifying multimorbidity patterns of non-communicable diseases in paediatric inpatients: a cross-sectional study in Shanghai, China

OBJECTIVES

To enhance the understanding of non-communicable disease (NCD) multimorbidity in children who are inpatients by delineating the characteristics of and identifying patterns among paediatric inpatients with multimorbidity in China.

DESIGN

Cross-sectional study.

SETTING

Paediatric wards (n=17) in Pudong New Area, Shanghai, China.

PARTICIPANTS

A total of 193 432 paediatric inpatients in the electronic health record systems of 17 hospitals from 2011 to 2016 participated in the study, and 91 004 children with NCDs were extracted and classified based on International Classification of Diseases, 10th version codes.

MAIN OUTCOME MEASURES

Number of the NCDs and multimorbidity patterns of the paediatric inpatients.

RESULTS

In total, 47.05% (95% CI 46.83 to 47.27) of the paediatric inpatients had one or more chronic diseases, and 16.30% (95% CI 16.14 to 16.46) had multimorbidity. Congenital anomalies accounted for 19.43% (95% CI 19.25 to 19.61) of the principal diagnoses among the paediatric inpatients. Five common multimorbidity patterns were identified: a neurological-respiratory cluster, a neurological-respiratory-ear cluster, a cardiovascular-circulatory cluster, a genitourinary cluster (boy group) and a musculoskeletal-connective cluster (10-18 years age group).

CONCLUSIONS

Multimorbidity in paediatric inpatients suggests that decisions about reasonable allocation of paediatric inpatient resources should be fully considered. Multimorbidity patterns in paediatric inpatients revealed that prevention, including innovative treatments targeting children, should be further studied.

Timing of Co-occurring Chronic Conditions in Children With Neurologic Impairment

BACKGROUND

Children with neurologic impairment (NI) are at risk for developing co-occurring chronic conditions, increasing their medical complexity and morbidity. We assessed the prevalence and timing of onset for those conditions in children with NI.

METHODS

This longitudinal analysis included 6229 children born in 2009 and continuously enrolled in Medicaid through 2015 with a diagnosis of NI by age 3 in the IBM Watson Medicaid MarketScan Database. NI was defined with an existing diagnostic code set encompassing neurologic, genetic, and metabolic conditions that result in substantial functional impairments requiring subspecialty medical care. The prevalence and timing of co-occurring chronic conditions was assessed with the Agency for Healthcare Research and Quality Chronic Condition Indicator system. Mean cumulative function was used to measure age trends in multimorbidity.

RESULTS

The most common type of NI was static (56.3%), with cerebral palsy (10.0%) being the most common NI diagnosis. Respiratory (86.5%) and digestive (49.4%) organ systems were most frequently affected by co-occurring chronic conditions. By ages 2, 4, and 6 years, the mean (95% confidence interval [CI]) numbers of co-occurring chronic conditions were 3.7 (95% CI 3.7-3.8), 4.6 (95% CI 4.5-4.7), and 5.1 (95% CI 5.1-5.2). An increasing percentage of children had ≥9 co-occurring chronic conditions as they aged: 5.3% by 2 years, 10.0% by 4 years, and 12.8% by 6 years.

CONCLUSIONS

Children with NI enrolled in Medicaid have substantial multimorbidity that develops early in life. Increased attention to the timing and types of multimorbidity in children with NI may help optimize their preventive care and case management health services.

A Scoping Review of the Risk Factors Associated with Anaemia among Children Under Five Years in Sub-Saharan African Countries

Background/Purpose: Globally, anaemia is a severe public health condition affecting over 24% of the world’s population. Children under five years old and pregnant women are the most vulnerable to this disease. This scoping review aimed to evaluate studies that used classical statistical regression methods on nationally representative health survey data to identify the individual socioeconomic, demographic and contextual risk factors associated with developing anaemia among children under five years of age in sub-Saharan Africa (SSA). Methods/Design: The reporting pattern followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. The following databases were searched: MEDLINE, EMBASE (OVID platform), Web of Science, PUBMED, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Scopus, Cochrane library, African Journal of online (AJOL), Google Scholar and Measure DHS. Results: The review identified 20 relevant studies and the risk factors for anaemia were classified as child-related, parental/household-related and community- or area-related factors. The risk factors for anaemia identified included age, birth order, sex, comorbidities (such as fever, diarrhoea and acute respiratory infection), malnutrition or stunting, maternal education, maternal age, mother’s anaemia status, household wealth and place of residence. Conclusion: The outcome of this review is of significant value for health policy and planners to enable them to make informed decision that will correct any imbalances in anaemia across socioeconomic, demographic and contextual characteristics, with the view of making efficient distributions of health interventions.

Demographic and psychosocial factors associated with hair cortisol concentrations in preschool children

BACKGROUND

Early life stress has enduring effects on physical and mental health. Hair cortisol concentrations (HCCs) reflect exposures to contextual stressors in early life, but are understudied in preschool children.

METHODS

Hair samples from children (N = 693) during clinic visits (CVs) scheduled at 1-4 years (CV1-CV4) were measured using validated assay methods for HCC.

RESULTS

HCCs were highest at CV1 and decreased at CV2-CV4, with no sex differences. Black children had higher HCC than White/other children; these differences persisted even after adjusting for socioeconomic factors. Bivariable analyses showed significant effects on HCC for Black race, with specific demographic and psychosocial factors at different ages. Multivariable analyses showed that higher HCC at CV1 were associated with Black race and male sex; at CV2 with Black race, lower maternal self-esteem, socioeconomic adversity, and the child's risk for developmental delay; at CV3 with Black race; at CV4 with maternal depression and the child's prior HCC values.

CONCLUSIONS

HCCs were higher in Black children than White/other races; differences were related to maternal factors, socioeconomic adversity, and the child's risk for developmental delay. Public health measures to reduce disparities between Blacks and other races must also consider the long-term effects of chronic stress in early life.