Estimating the prevalence of chronic conditions in children who die in England, Scotland and Wales: a data linkage cohort study

Behavior Change Techniques Involved in Physical Activity Interventions for Children With Chronic Conditions: A Systematic Review

BACKGROUND

Behavior change techniques (BCTs) have been extensively used in physical activity interventions for children, however, no systematic reviews have synthesized their effects.

PURPOSE

The present review aimed to identify the most promising BCTs used in physical activity interventions associated with (i) increased physical activity behavior and (ii) positive psychosocial outcomes in children with chronic conditions.

METHODS

A systematic search of 6 databases identified 61 articles as eligible for inclusion. Data, including BCTs, were extracted from these studies and analyzed descriptively. Due to the heterogeneity of interventions, chronic conditions, and outcome measures, a meta-analysis was not conducted.

RESULTS

Social support (unspecified), graded tasks, generalization of target behavior, and credible source were the most commonly reported and most promising (i.e., present in 2+ studies evidencing significant effects) BCTs across all studies. These BCTs were found to be especially relevant to improving psychosocial outcomes in the short- and long-term and improving physical activity behaviors in the long-term. Meanwhile, to improve short-term physical activity behaviors, in addition to social support (unspecified), action planning, goal setting (behavior), and problem solving were found to be promising BCTs.

CONCLUSIONS

The BCTs identified in this review may be relevant to incorporate when planning future interventions to support physical activity and psychosocial outcomes for children with chronic conditions.

Evaluating the real-world implementation of the Family Nurse Partnership in England: a data linkage study

Background/objectives

The Family Nurse Partnership is an intensive home visiting programme for adolescent mothers. We aimed to evaluate the effectiveness of the Family Nurse Partnership on outcomes up to age 7 using national administrative data.

Design

We created a linked cohort of all mothers aged 13-19 using data from health, educational and children's social care and defined mothers enrolled in the Family Nurse Partnership or not using Family Nurse Partnership system data. Propensity scores were used to create matched groups for analysis.

Setting

One hundred and thirty-six local authorities in England with active Family Nurse Partnership sites between 2010 and 2017.

Participants

Mothers aged 13-19 at last menstrual period with live births between April 2010 and March 2019, living in a Family Nurse Partnership catchment area and their firstborn child(ren).

Interventions

The Family Nurse Partnership includes up to 64 home visits by a family nurse from early pregnancy until the child's second birthday and is combined with usual health and social care. Controls received usual health and social care.

Main outcome measures

Indicators of child maltreatment (hospital admissions for injury/maltreatment, referral to social care services); child health and development (hospital utilisation and education) outcomes and maternal hospital utilisation and educational outcomes up to 7 years following birth.

Data sources

Family Nurse Partnership Information System, Hospital Episode Statistics, National Pupil Database.

Results

Of 110,520 eligible mothers, 25,680 (23.2%) were enrolled in the Family Nurse Partnership. Enrolment rates varied across 122 sites (range: 11-68%). Areas with more eligible mothers had lower enrolment rates. Enrolment was higher among mothers aged 13-15 (52%), than 18-19 year-olds (21%). Indicators of child maltreatment: we found no evidence of an association between the Family Nurse Partnership and indicators of child maltreatment, except for an increased rate of unplanned admissions for maltreatment/injury-related diagnoses up to age 2 for children born to Family Nurse Partnership mothers (6.6% vs. 5.7%, relative risk 1.15; 95% confidence interval 1.07 to 1.24). Child health and developmental outcomes: there was weak evidence that children born to Family Nurse Partnership mothers were more likely to achieve a Good Level of Development at age 5 (57.5% vs. 55.4%, relative risk 1.05; 95% confidence interval 1.00 to 1.09). Maternal outcomes: There was some evidence that Family Nurse Partnership mothers were less likely to have a subsequent delivery within 18 months of the index birth (8.4% vs. 9.3%, relative risk 0.92; 95% confidence interval 0.88 to 0.97). Younger and more vulnerable mothers received higher numbers of visits and were more likely to achieve fidelity targets. Meeting the fidelity targets was associated with some outcomes.

Limitations

Bias by indication and variation in the intervention and usual care over time and between areas may have limited our ability to detect effects. Multiple testing may have led to spurious, significant results.

Conclusions

This study supports findings from evaluations of the Family Nurse Partnership showing no evidence of benefit for maltreatment outcomes measured in administrative data. Amongst all the outcomes measured, we found weak evidence that the Family Nurse Partnership was associated with improvements in child development at school entry, a reduction in rapid repeat pregnancies and evidence of increased healthcare-seeking in the mother and child.

Future work

Future evaluations should capture better measures of Family Nurse Partnership interventions and usual care, more information on maternal risk factors and additional outcomes relating to maternal well-being.

Study registration

The study is registered as NIHR CRN Portfolio (42900).

Funding

This award was funded by the National Institute of Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/99/19) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 11. See the NIHR Funding and Awards website for further award information.

Paediatric sleep diagnostics in the 21st century: the era of "sleep-omics"?

Paediatric sleep diagnostics is performed using complex multichannel tests in specialised centres, limiting access and availability and resulting in delayed diagnosis and management. Such investigations are often challenging due to patient size (prematurity), tolerability, and compliance with "gold standard" equipment. Children with sensory/behavioural issues, at increased risk of sleep disordered breathing (SDB), often find standard diagnostic equipment difficult.SDB can have implications for a child both in terms of physical health and neurocognitive development. Potential sequelae of untreated SDB includes failure to thrive, cardiopulmonary disease, impaired learning and behavioural issues. Prompt and accurate diagnosis of SDB is important to facilitate early intervention and improve outcomes.The current gold-standard diagnostic test for SDB is polysomnography (PSG), which is expensive, requiring the interpretation of a highly specialised physiologist. PSG is not feasible in low-income countries or outwith specialist sleep centres. During the coronavirus disease 2019 pandemic, efforts were made to improve remote monitoring and diagnostics in paediatric sleep medicine, resulting in a paradigm shift in SDB technology with a focus on automated diagnosis harnessing artificial intelligence (AI). AI enables interrogation of large datasets, setting the scene for an era of "sleep-omics", characterising the endotypic and phenotypic bedrock of SDB by drawing on genetic, lifestyle and demographic information. The National Institute for Health and Care Excellence recently announced a programme for the development of automated home-testing devices for SDB. Scorer-independent scalable diagnostic approaches for paediatric SDB have potential to improve diagnostic accuracy, accessibility and patient tolerability; reduce health inequalities; and yield downstream economic and environmental benefits.

Impact of Hospitalizations due to Chronic Health Conditions on Early Child Development

OBJECTIVE

To assess the impact of hospitalization for chronic health conditions on early child development and wellbeing at school start.

METHODS

We conducted a longitudinal cohort study of children starting school using population-based record linkage of routinely collected admitted hospital data and standardized assessment of early childhood development (Australian Early Developmental Census: AEDC). Developmental vulnerability (DV) was defined as children scoring <10th centile in any one of five developmental domains. Children scoring <10th centile on two or more domains were considered developmentally high-risk (DHR). Children hospitalized with chronic health conditions were compared to children without hospitalizations prior to school start.

RESULTS

Among 152,851 children with an AEDC record, 22,271 (14·6%) were hospitalized with a chronic condition. Children hospitalized with chronic health conditions were more likely to be DHR (adjusted odds ratio 1.25, 95% CI: 1.18-1.31) compared to children without hospitalizations. Children hospitalized more frequently (>7 times) or with longer duration (>2 weeks) had a 40% increased risk of being DHR (1.40, 95% CI: 1.05-1.88 and 1.40, 95% CI: 1.13-1.74, respectively). Children hospitalized with mental health/behavioral/developmental conditions had the highest risk of DHR (2.23, 95% CI: 1.72-2.90). Developmental vulnerability was increased for physical health (1.37, 95% CI: 1.30-1.45), language (1.28, 95% CI: 1.19-1.38), social competence (1.22, 95% CI: 1.16-1.29), communication (1.17, 95% CI: 1.10-1.23), and emotional maturity (1.16, 95% CI: 1.09-1.23).

CONCLUSIONS

Frequent and longer duration hospitalizations for chronic health conditions can impact early childhood development. Research and interventions are required to support future development and well-being of children with chronic health conditions who are hospitalized.

Pediatric Hospitalizations and ICU Admissions Due to COVID-19 and Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2 in England

Importance

Investigating how the risk of serious illness after SARS-CoV-2 infection in children and adolescents has changed as new variants have emerged is essential to inform public health interventions and clinical guidance.

Objective

To examine risk factors associated with hospitalization for COVID-19 or pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) among children and adolescents during the first 2 years of the COVID-19 pandemic and change in risk factors over time.

Design, Setting, and Participants

This population-level analysis of hospitalizations after SARS-CoV-2 infection in England among children and adolescents aged 0 to 17 years was conducted from February 1, 2020, to January 31, 2022. National data on hospital activity were linked with data on SARS-CoV-2 testing, SARS-CoV-2 vaccination, pediatric intensive care unit (PICU) admissions, and mortality. Children and adolescents hospitalized with COVID-19 or PIMS-TS during this time were included. Maternal, elective, and injury-related hospitalizations were excluded.

Exposures

Previous medical comorbidities, sociodemographic factors, and timing of hospitalization when different SARS-CoV-2 variants (ie, wild type, Alpha, Delta, and Omicron) were dominant in England.

Main Outcomes

PICU admission and death within 28 days of hospitalization with COVID-19 or PIMS-TS.

Results

A total of 10 540 hospitalizations due to COVID-19 and 997 due to PIMS-TS were identified within 1 125 010 emergency hospitalizations for other causes. The number of hospitalizations due to COVID-19 and PIMS-TS per new SARS-CoV-2 infections in England declined during the second year of the COVID-19 pandemic. Among 10 540 hospitalized children and adolescents, 448 (4.3%) required PICU admission due to COVID-19, declining from 162 of 1635 (9.9%) with wild type, 98 of 1616 (6.1%) with Alpha, and 129 of 3789 (3.4%) with Delta to 59 of 3500 (1.7%) with Omicron. Forty-eight children and adolescents died within 28 days of hospitalization due to COVID-19, and no children died of PIMS-TS (PIMS-S data were limited to November 2020 onward). Risk of severe COVID-19 in children and adolescents was associated with medical comorbidities and neurodisability regardless of SARS-CoV-2 variant. Results were similar when children and adolescents with prior SARS-CoV-2 exposure or vaccination were excluded.

Conclusions

In this study of data across the first 2 years of the COVID-19 pandemic, risk of severe disease from SARS-CoV-2 infection in children and adolescents in England remained low. Children and adolescents with multiple medical problems, particularly neurodisability, were at increased risk and should be central to public health measures as further variants emerge.

Causes of death in children with congenital anomalies up to age 10 in eight European countries

BACKGROUND

Congenital anomalies (CAs) increase the risk of death during infancy and childhood. This study aimed to evaluate the accuracy of using death certificates to estimate the burden of CAs on mortality for children under 10 years old.

METHODS

Children born alive with a major CA between 1 January 1995 and 31 December 2014, from 13 population-based European CA registries were linked to mortality records up to their 10th birthday or 31 December 2015, whichever was earlier.

RESULTS

In total 4199 neonatal, 2100 postneonatal and 1087 deaths in children aged 1-9 years were reported. The underlying cause of death was a CA in 71% (95% CI 64% to 78%) of neonatal and 68% (95% CI 61% to 74%) of postneonatal infant deaths. For neonatal deaths the proportions varied by registry from 45% to 89% and by anomaly from 53% for Down syndrome to 94% for tetralogy of Fallot. In children aged 1-9, 49% (95% CI 42% to 57%) were attributed to a CA. Comparing mortality in children with anomalies to population mortality predicts that over 90% of all deaths at all ages are attributable to the anomalies. The specific CA was often not reported on the death certificate, even for lethal anomalies such as trisomy 13 (only 80% included the code for trisomy 13).

CONCLUSIONS

Data on the underlying cause of death from death certificates alone are not sufficient to evaluate the burden of CAs on infant and childhood mortality across countries and over time. Linked data from CA registries and death certificates are necessary for obtaining accurate estimates.

Development and preliminary validation of the Sleep Screening for Children and Adolescents with Complex Chronic Conditions (SCAC)

Children and adolescents with complex chronic conditions, including those with life-threatening or life-limiting conditions, are a heterogeneous population. Many individuals exhibit sleep abnormalities that are measurable by proxy questionnaires. No suitable instrument to assess the wide range of different complex chronic conditions is currently available. The aim of the present study was to develop a screening tool-the Sleep Screening for Children and Adolescents with Complex Chronic Conditions-to effectively obtain sleep behaviour information in this population. Following a mixed-method design, potential items for the Sleep Screening for Children and Adolescents with Complex Chronic Conditions questionnaire were defined through literature research and expert meetings. In a pre-test with N = 60 family and professional caregivers, the items' relevance and comprehensibility as well as the instrument's overall design were assessed. For the main test, N = 315 participants were recruited in three tertiary paediatric hospitals. A principal components analysis detected the questionnaire's scales. Item analysis focused on mean values, range, difficulty and discriminatory power. Convergent validation of the Sleep Screening for Children and Adolescents with Complex Chronic Conditions was assessed via correlations between scale items. Most patients had neurological or neuromuscular diseases. Four scales ("Falling and staying asleep", "Sleep-associated respiration and arousal", "Daytime sleepiness" and "Sleep-associated movements") emerged. The item analysis showed satisfactory discriminative power. In the preliminary validation, all scales correlated positively with a child's care level and with various sleep circumstances items. Three scales additionally correlated with the number of complex chronic condition diagnoses. This newly developed questionnaire can provide clinicians with first indications of possible sleep problems in a growing paediatric population.

Trends in hospital admissions during transition from paediatric to adult services for young people with learning disabilities or autism: Population-based cohort study

Background

Transition from paediatric to adult health care may disrupt continuity of care, and result in unmet health needs. We describe changes in planned and unplanned hospital admission rates before, during and after transition for young people with learning disability (LD), or autism spectrum disorders (ASD) indicated in hospital records, who are likely to have more complex health needs.

Methods

We developed two mutually exclusive cohorts of young people with LD, and with ASD without LD, born between 1990 and 2001 in England using national hospital admission data. We determined the annual rate of change in planned and unplanned hospital admission rates before (age 10–15 years), during (16–18 years) and after (19–24 years) transition to adult care using multilevel negative binomial regression models, accounting for area-level deprivation, sex, birth year and presence of comorbidities.

Findings

The cohorts included 51,291 young people with LD, and 46,270 autistic young people. Admission rates at ages 10–24 years old were higher for young people with LD (54 planned and 25 unplanned admissions per 100 person-years) than for autistic young people (17/100 and 16/100, respectively). For young people with LD, planned admission rates were highest and constant before transition (rate ratio [RR]: 0.99, 95% confidence interval [CI] 0.98–0.99), declined by 14% per year of age during (RR: 0.86, 95% CI: 0.85–0.88), and remained constant after transition (RR: 0.99, 95% CI: 0.99–1.00), mainly due to fewer admissions for non-surgical care, including respite care. Unplanned admission rates increased by 3% per year of age before (RR: 1.03, 95% CI: 1.02–1.03), remained constant during (RR: 1.01, 95% CI: 1.00–1.03) and increased by 3% per year after transition (RR: 1.03, 95% CI: 1.02–1.04). For autistic young people, planned admission rates increased before (RR: 1.06, 95% CI: 1.05–1.06), decreased during (RR: 0.95, 95% CI: 0.93–0.97), and increased after transition (RR: 1.05, 95%: 1.04–1.07). Unplanned admission rates increased most rapidly before (RR: 1.16, 95% CI: 1.15–1.17), remained constant during (RR: 1.01, 95% CI: 0.99–1.03), and increased moderately after transition (RR: 1.03, 95% CI: 1.02–1.04).

Interpretation

Decreases in planned admission rates during transition were paralleled by small but consistent increases in unplanned admission rates with age for young people with LD and autistic young people. Decreases in non-surgical planned care during transition could reflect disruptions to continuity of planned/respite care or a shift towards provision of healthcare in primary care and community settings and non-hospital arrangements for respite care.

Funding

National Institute for Health Research Policy Research Programme.

Incidence of anxiety and depression in children and young people with life-limiting conditions

BACKGROUND

The aim of this study was to investigate the incidence of anxiety and depression in children and young people with life-limiting conditions.

METHODS

A comparative cohort study was conducted, using primary and secondary care data from the Clinical Practice Research Datalink (CPRD) in England. Anxiety and depression codes were identified using diagnostic, symptom and prescription codes. Incidence rates of anxiety and depression were compared across condition groups using Poisson regression, adjusting for sex, age, ethnicity, and deprivation status.

RESULTS

A total of 25,313 children and young people were included in the study: 5527 with life-limiting conditions, 6729 with chronic conditions, and 13,057 with no long-term conditions. The incidence of anxiety (IRR_adj: 1.39, 95% CI: 1.09-1.77) and depression (IRR_adj: 1.41, 95% CI: 1.08-1.83) was significantly higher in children and young people with life-limiting conditions, compared to children and young people with no long-term conditions.

CONCLUSIONS

The higher incidence of anxiety and depression observed among children and young people with life-limiting conditions highlights the need for psychological support in this population, including further efforts to prevent, identify, and treat anxiety and depression.

IMPACT

The analysis of primary and secondary healthcare data from England revealed that the incidence of anxiety and depression was higher among children and young people with life-limiting conditions, compared to those with no long-term conditions. This is the first study to investigate the incidence of anxiety and depression in children and young people with a wide range of life-limiting conditions. The higher incidence of anxiety and depression observed in children and young people with life-limiting conditions highlights the need for psychological support aiming to prevent, identify, and treat anxiety and depression in this population group.

Characteristics of enrolment in an intensive home-visiting programme among eligible first-time adolescent mothers in England: a linked administrative data cohort study

BACKGROUND

Intensive home visiting for adolescent mothers may help reduce health disparities. Given limited resources, such interventions need to be effectively targeted. We evaluated which mothers were enrolled in the Family Nurse Partnership (FNP), an intensive home-visiting service for first-time young mothers commissioned in >130 local authorities in England since 2007.

METHODS

We created a population-based cohort of first-time mothers aged 13-19 years giving birth in English National Health Service hospitals between 1 April 2010 and 31 March 2017, using administrative hospital data linked with FNP programme, educational and social care data. Mothers living in a local authority with an active FNP site were eligible. We described variation in enrolment rates across sites, and identified maternal and FNP site characteristics associated with enrolment.

RESULTS

Of 110 520 eligible mothers, 25 680 (23.2% (95% CI: 23.0% to 23.5%)) were enrolled. Enrolment rates varied substantially across 122 sites (range: 11%-68%), and areas with greater numbers of first-time adolescent mothers achieved lower enrolment rates. Mothers aged 13-15 years were most likely to be enrolled (52%). However, only 26% of adolescent mothers with markers of vulnerability (including living in the most deprived areas and ever having been looked after as a child) were enrolled.

CONCLUSION

A substantial proportion of first-time adolescent mothers with vulnerability markers were not enrolled in FNP. Variation in enrolment across sites indicates insufficient commissioning of places that is not proportional to level of need, with mothers in areas with large numbers of other adolescent mothers least likely to receive support.

Reductions in hospital care among clinically vulnerable children aged 0-4 years during the COVID-19 pandemic

OBJECTIVE

To quantify reductions in hospital care for clinically vulnerable children during the COVID-19 pandemic.

DESIGN

Birth cohort.

SETTING

National Health Service hospitals in England.

STUDY POPULATION

All children aged <5 years with a birth recorded in hospital administrative data (January 2010-March 2021).

MAIN EXPOSURE

Clinical vulnerability defined by a chronic health condition, preterm birth (<37 weeks' gestation) or low birth weight (<2500 g).

MAIN OUTCOMES

Reductions in care defined by predicted hospital contact rates for 2020, estimated from 2015 to 2019, minus observed rates per 1000 child years during the first year of the pandemic (March 2020-2021).

RESULTS

Of 3 813 465 children, 17.7% (one in six) were clinically vulnerable (9.5% born preterm or low birth weight, 10.3% had a chronic condition). Reductions in hospital care during the pandemic were much higher for clinically vulnerable children than peers: respectively, outpatient attendances (314 vs 73 per 1000 child years), planned admissions (55 vs 10) and unplanned admissions (105 vs 79). Clinically vulnerable children accounted for 50.1% of the reduction in outpatient attendances, 55.0% in planned admissions and 32.8% in unplanned hospital admissions. During the pandemic, weekly rates of planned care returned to prepandemic levels for infants with chronic conditions but not older children. Reductions in care differed by ethnic group and level of deprivation. Virtual outpatient attendances increased from 3.2% to 24.8% during the pandemic.

CONCLUSION

One in six clinically vulnerable children accounted for one-third to one half of the reduction in hospital care during the pandemic.

Polypharmacy in Children and Young People With Life-limiting Conditions From 2000 to 2015: A Repeated Cross-sectional Study in England

CONTEXT

Polypharmacy is often appropriate for children with life-limiting conditions but is associated with an increase in hospitalizations and inappropriate prescribing, and can affect the quality of life of children and their families as they manage complex medication schedules. Despite this, little is known about polypharmacy in this population.

OBJECTIVE

To describe the prevalence and patterns of polypharmacy in children with a life-limiting condition in a nationally representative cohort in England.

METHODS

Observational study of children (age 0-19 years) with a life-limiting condition in a national database from 2000 to 2015. Common definitions of polypharmacy were used to determine polypharmacy prevalence in each year based on unique medications and regular medications. Hierarchical regression analyses were used to explore factors associated with polypharmacy.

RESULTS

Data on 15,829 individuals were included. Each year 27%-39% of children were prescribed ≥5 unique medications and 8%-12% were prescribed ≥10. Children with a respiratory (OR 7.6, 95%CI 6.4-9.0), neurological (OR 2.8, 95%CI 2.4-3.2), or metabolic (OR 2.2, 95%CI 1.7-2.8) condition were more likely than those with a congenital condition to experience polypharmacy. Increasing age, being diagnosed with a LLC under one year of age, having >1 life-limiting or chronic condition or living in areas of higher deprivation were also associated with higher prevalence of polypharmacy.

CONCLUSION

Children with life-limiting conditions have a high prevalence of polypharmacy and some children are at greater risk than others. More research is needed to understand and address the factors that lead to problematic polypharmacy in this population.

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.

Gestational age at birth, chronic conditions and school outcomes: a population-based data linkage study of children born in England

INTRODUCTION

We aimed to generate evidence about child development measured through school attainment and provision of special educational needs (SEN) across the spectrum of gestational age, including for children born early term and >41 weeks of gestation, with and without chronic health conditions.

METHODS

We used a national linked dataset of hospital and education records of children born in England between 1 September 2004 and 31 August 2005. We evaluated school attainment at Key Stage 1 (KS1; age 7) and Key Stage 2 (KS2; age 11) and any SEN by age 11. We stratified analyses by chronic health conditions up to age 2, and size-for-gestation, and calculated population attributable fractions (PAF).

RESULTS

Of 306 717 children, 5.8% were born <37 weeks gestation and 7.0% had a chronic condition. The percentage of children not achieving the expected level at KS1 increased from 7.6% at 41 weeks, to 50.0% at 24 weeks of gestation. A similar pattern was seen at KS2. SEN ranged from 29.0% at 41 weeks to 82.6% at 24 weeks. Children born early term (37-38 weeks of gestation) had poorer outcomes than those born at 40 weeks; 3.2% of children with SEN were attributable to having a chronic condition compared with 2.0% attributable to preterm birth.

CONCLUSIONS

Children born with early identified chronic conditions contribute more to the burden of poor school outcomes than preterm birth. Evaluation is needed of how early health characteristics can be used to improve preparation for education, before and at entry to school.

Numbers, characteristics, and medical complexity of children with life-limiting conditions reaching age of transition to adult care in England: a repeated cross-sectional study [version 1; peer review: 2 approved]

Background

The number of children with life-limiting conditions in England is known to be increasing, which has been attributed in part to increased survival times. Consequently, more of these young people will reach ages at which they start transitioning to adult healthcare (14-19 years). However, no research exists that quantifies the number of young people with life-limiting conditions in England reaching transition ages or their medical complexity, both essential data for good service planning.

Methods

National hospital data in England (Hospital Episode Statistics) from NHS Digital were used to identify the number of young people aged 14-19 years from 2012/13 to 2018/19 with life-limiting conditions diagnosed in childhood. The data were assessed for indicators of medical complexity: number of conditions, number of main specialties of consultants involved, number of hospital admissions and Accident & Emergency Department visits, length of stay, bed days and technology dependence (gastrostomies, tracheostomies). Overlap between measures of complexity was assessed.

Results

The number of young people with life-limiting conditions has increased rapidly over the study period, from 20363 in 2012/13 to 34307 in 2018/19. There was evidence for increased complexity regarding the number of conditions and number of distinct main specialties of consultants involved in care, but limited evidence of increases in average healthcare use per person or increased technology dependence. The increasing size of the group meant that healthcare use increased overall. There was limited overlap between measures of medical complexity.

Conclusions

The number of young people with life-limiting conditions reaching ages at which transition to adult healthcare should take place is increasing rapidly. Healthcare providers will need to allocate resources to deal with increasing healthcare demands and greater complexity. The transition to adult healthcare must be managed well to limit impacts on healthcare resource use and improve experiences for young people and their families.

School academic performance of children hospitalised with a chronic condition

OBJECTIVE

To examine academic outcomes among children hospitalised with a chronic health condition.

DESIGN

Population-level birth cohort.

SETTING

New South Wales, Australia.

PARTICIPANTS

397 169 children born 2000-2006 followed up to 2014.

INTERVENTION/EXPOSURE

Hospitalisations with a chronic condition.

MAIN OUTCOME MEASURES

Academic underperformance was identified as 'below the national minimum standard' (BNMS) in five literacy/numeracy domains using the national assessment (National Assessment Program-Literacy and Numeracy) data. Multivariable logistic regression assessed the adjusted ORs (aORs) of children performing BNMS in each domain at each grade (grades 3, 5 and 7, respectively).

RESULTS

Of children hospitalised with a chronic condition prior to National Assessment Program-Literacy and Numeracy (NAPLAN) (16%-18%), 9%-12% missed ≥1 test, with a maximum of 37% of those hospitalised ≥7 times, compared with 4%-5% of children not hospitalised. Excluding children who missed a NAPLAN test, more children hospitalised with a chronic condition performed BNMS across all domains and grades, compared with children not hospitalised (eg, for BNMS in reading at grade 3: n=2588, aOR 1.35 (95% CI 1.28 to 1.42); for BNMS in numeracy at grade 3: n=2619, aOR 1.51 (95% CI 1.43 to 1.59)). Increasing frequency and bed-days of hospitalisation were associated with 2-3 fold increased odds of performing BNMS across all domains and grades. Children hospitalised with mental health/behavioural conditions had the highest odds of performing BNMS across all domains at each grade.

CONCLUSIONS

Children hospitalised with a chronic condition underperform academically across literacy/numeracy domains at each school grade. Health and educational supports are needed to improve these children's academic outcomes.

Febrile children with comorbidities at the emergency department - a multicentre observational study

We aimed to describe characteristics and management of children with comorbidities attending European emergency departments (EDs) with fever. MOFICHE (Management and Outcome of Fever in children in Europe) is a prospective multicentre study (12 European EDs, 8 countries). Febrile children with comorbidities were compared to those without in terms of patient characteristics, markers of disease severity, management, and diagnosis. Comorbidity was defined as a chronic underlying condition that is expected to last > 1 year. We performed multivariable logistic regression analysis, displaying adjusted odds ratios (aOR), adjusting for patient characteristics. We included 38,110 patients, of whom 5906 (16%) had comorbidities. Most common comorbidities were pulmonary, neurologic, or prematurity. Patients with comorbidities more often were ill appearing (20 versus 16%, p < 0.001), had an ED-Paediatric Early Warning Score of > 15 (22 versus 12%, p < 0.001), or a C-reactive protein > 60 mg/l (aOR 1.4 (95%CI 1.3-1.6)). They more often required life-saving interventions (aOR 2.7, 95% CI 2.2-3.3), were treated with intravenous antibiotics (aOR 2.3, 95%CI 2.1-2.5), and were admitted to the ward (aOR 2.2, 95%CI 2.1-2.4) or paediatric intensive care unit (PICU) (aOR 5.5, 95% CI 3.8-7.9). They were more often diagnosed with serious bacterial infections (aOR 1.8, 95%CI 1.7-2.0), including sepsis/meningitis (aOR 4.6, 95%CI 3.2-6.7). Children most at risk for sepsis/meningitis were children with malignancy/immunodeficiency (aOR 14.5, 8.5-24.8), while children with psychomotor delay/neurological disease were most at risk for life-saving interventions (aOR 5.3, 4.1-6.9) or PICU admission (aOR 9.7, 6.1-15.5).

CONCLUSIONS

Our data show how children with comorbidities are a population at risk, as they more often are diagnosed with bacterial infections and more often require PICU admission and life-saving interventions.

WHAT IS KNOWN

• While children with comorbidity constitute a large part of ED frequent flyers, they are often excluded from studies.

WHAT IS NEW

• Children with comorbidities in general are more ill upon presentation than children without comorbidities. • Children with comorbidities form a heterogeneous group; specific subgroups have an increased risk for invasive bacterial infections, while others have an increased risk of invasive interventions such as PICU admission, regardless of the cause of the fever.

Inequality in early childhood chronic health conditions requiring hospitalisation: A data linkage study of health service utilisation and costs

BACKGROUND

The cost of socioeconomic inequality in health service use among Australian children with chronic health conditions is poorly understood.

OBJECTIVES

To quantify the cost of socioeconomic inequality in health service use among Australian children with chronic health conditions.

METHODS

Cohort study using a whole-of-population linked administrative data for all births in Queensland, Australia, between July 2015 and July 2018. Socioeconomic status was defined by an areas-based measure, grouping children into quintiles from most disadvantaged (Q1) to least disadvantaged (Q5) based on their postcode at birth. Study outcomes included health service utilisation (inpatient, emergency department, outpatient, general practitioner, specialist, pathology and diagnostic imaging services) and healthcare costs.

RESULTS

Of the 238,600 children included in the analysis, 10.4% had at least one chronic health condition. Children with chronic health conditions in Q1 had higher rates of inpatient (6.6, 95% confidence interval [CI] 6.4, 6.7), emergency department (7.2, 95% CI 7.0, 7.5) and outpatient (20.3, 95% CI 19.4, 21.3) service use compared to children with chronic health conditions in Q5. They also had lower rates of general practitioner (37.5, 95% CI 36.7, 38.4), specialist (8.9, 95% CI 8.5, 9.3), pathology (10.7, 95% CI 10.2, 11.3), and diagnostic imaging (4.3, 95% CI 4.2,4.5) service use. Children with any chronic health condition in Q1 incurred lower median out-of-pocket fees than children in Q5 ($0 vs $741, respectively), lower median Medicare funding ($2710, vs $3408, respectively), and higher median public hospital funding ($31, 052 vs $23, 017, respectively).

CONCLUSIONS

Children of most disadvantage are more likely to access public hospital provided services, which are accessible free of charge to patients. These children are less likely to access general practitioner, specialist, pathology and diagnostic imaging services; all of which are critical to the ongoing management of chronic health conditions, but often attract an out-of-pocket fee.

Adult healthcare is associated with more emergency healthcare for young people with life-limiting conditions

BACKGROUND

Children with life-limiting conditions receive specialist paediatric care in childhood, but the transition to adult care during adolescence. There are concerns about transition, including a lack of continuity in care and that it may lead to increases in emergency hospital visits.

METHODS

A retrospective cohort was constructed from routinely collected primary and hospital care records for young people aged 12-23 years in England with (i) life-limiting conditions, (ii) diabetes or (iii) no long-term conditions. Transition point was estimated from the data and emergency inpatient admissions and Emergency Department visits per person-year compared for paediatric and adult care using random intercept Poisson regressions.

RESULTS

Young people with life-limiting conditions had 29% (95% CI: 14-46%) more emergency inpatient admissions and 24% (95% CI: 12-38%) more Emergency Department visits in adult care than in paediatric care. There were no significant differences associated with the transition for young people in the diabetes or no long-term conditions groups.

CONCLUSIONS

The transition from paediatric to adult healthcare is associated with an increase in emergency hospital visits for young people with life-limiting conditions, but not for young people with diabetes or no long-term conditions. There may be scope to improve the transition for young people with life-limiting conditions.

IMPACT

There is evidence for increases in emergency hospital visits when young people with life-limiting conditions transition to adult healthcare. These changes are not observed for comparator groups - young people with diabetes and young people with no known long-term conditions, suggesting they are not due to other transitions happening at similar ages. Greater sensitivity to changes at transition is achieved through estimation of the transition point from the data, reducing misclassification bias.

Risk factors for PICU admission and death among children and young people hospitalized with COVID-19 and PIMS-TS in England during the first pandemic year

Identifying which children and young people (CYP) are most vulnerable to serious infection due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is important to guide protective interventions. To address this question, we used data for all hospitalizations in England among 0-17 year olds from 1 February 2019 to 31 January 2021. We examined how sociodemographic factors and comorbidities might be risk factors for pediatric intensive care unit (PICU) admission among hospitalizations due to the following causes: Coronavirus Disease 2019 (COVID-19) and pediatric inflammatory multi-system syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in the first pandemic year (2020-2021); hospitalizations due to all other non-traumatic causes in 2020-2021; hospitalizations due to all non-traumatic causes in 2019-2020; and hospitalizations due to influenza in 2019-2020. Risk of PICU admission and death from COVID-19 or PIMS-TS in CYP was very low. We identified 6,338 hospitalizations with COVID-19, of which 259 were admitted to a PICU and eight CYP died. We identified 712 hospitalizations with PIMS-TS, of which 312 were admitted to a PICU and fewer than five CYP died. Hospitalizations with COVID-19 and PIMS-TS were more common among males, older CYP, those from socioeconomically deprived neighborhoods and those who were of non-White ethnicity (Black, Asian, Mixed or Other). The odds of PICU admission were increased in CYP younger than 1 month old and decreased among 15-17 year olds compared to 1-4 year olds with COVID-19; increased in older CYP and females with PIMS-TS; and increased for Black compared to White ethnicity in patients with COVID-19 and PIMS-TS. Odds of PICU admission in COVID-19 were increased for CYP with comorbidities and highest for CYP with multiple medical problems. Increases in odds of PICU admission associated with different comorbidities in COVID-19 showed a similar pattern to other causes of hospitalization examined and, thus, likely reflect background vulnerabilities. These findings identify distinct risk factors associated with PICU admission among CYP with COVID-19 or PIMS-TS that might aid treatment and prevention strategies.

Estimation of age of transition from paediatric to adult healthcare for young people with long term conditions using linked routinely collected healthcare data

Introduction

Healthcare transitions, including from paediatric to adult services, can be disruptive and cause a lack of continuity in care. Existing research on the paediatric-adult healthcare transition often uses a simple age cut-off to assign transition status. This risks misclassification bias, reducing observed changes at transition (adults are included in the paediatric group and vice versa) possibly to differing extents between groups that transition at different ages.

Objective

To develop and assess methods for estimating the transition point from paediatric to adult healthcare from routine healthcare records.

Methods

A retrospective cohort of young people (12 to 23 years) with long term conditions was constructed from linked primary and secondary care data in England. Inpatient and outpatient records were classified as paediatric or adult based on treatment and clinician specialities. Transition point was estimated using three methods based on record classification (First Adult: the date of first adult record; Last Paediatric: date of last paediatric record; Fitted: a date determined by statistical fitting). Estimated transition age was compared between methods. A simulation explored impacts of estimation approaches compared to a simple age cut-off when assessing associations between transition status and healthcare events.

Results

Simulations showed using an age-based cut-off at 16 or 18 years as transition point, common in research on transition, may underestimate transition-associated changes. Many health records for those aged <14 years were classified as adult, limiting utility of the First Adult approach. The Last Paediatric approach is least sensitive to this possible misclassification and may best reflect experience of the transition.

Conclusions

Estimating transition point from routine healthcare data is possible and offers advantages over a simple age cut-off. These methods, adapted as necessary for data from other countries, should be used to reduce risk of misclassification bias in studies of transition in nationally representative data.

Hospital admissions for stress-related presentations among school-aged adolescents during term time versus holidays in England: weekly time series and retrospective cross-sectional analysis

BACKGROUND

Schools are a potential stressor for adolescents and may contribute to emergency hospital admissions.

AIMS

We describe rates of stress-related presentations (SRPs) among school-aged adolescents (11-17 years) during school terms and holidays, and explore differences by age and gender.

METHOD

Using national administrative hospital data, we defined an SRP as an emergency hospital admission with a primary diagnosis related to pain, psychosomatic symptoms (e.g. fatigue) or mental health problems, or with self-harm indicated in any diagnostic position. We estimated incidence rate ratios for weekly SRPs in term time versus holidays from 2014-2015 to 2017-2018, using negative binomial regression models, stratified by age and gender. We estimated the cumulative incidence of any SRP between 11 and 17 years by analysing prior hospital admission histories of adolescents with an SRP in 2017-2018.

RESULTS

Over the 4-year study period, 305 491 SRPs in 171 013 school-aged adolescents accounted for 31% of emergency admissions for this group. SRPs were predominantly for mental health problems or self-harm (38%), or pain (35%). Weekly admission rates for SRPs were higher in term time than holidays for all ages (age-specific incidence rate ratios were 1.15-1.49 for girls and 1.08-1.60 for boys). Rates were highest for girls aged 14 and 15 years. The estimated cumulative incidence of any SRP between 11 and 17 years was 7.9% for girls and 4.1% for boys.

CONCLUSIONS

Hospital admissions for SRPs are common among adolescents, affecting around two girls and one boy in every classroom. Higher rates in term time than holidays suggest that school factors may contribute.

Deaths in children and young people in England after SARS-CoV-2 infection during the first pandemic year

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is rarely fatal in children and young people (CYP, <18 years old), but quantifying the risk of death is challenging because CYP are often infected with SARS-CoV-2 exhibiting no or minimal symptoms. To distinguish between CYP who died as a result of SARS-CoV-2 infection and those who died of another cause but were coincidentally infected with the virus, we undertook a clinical review of all CYP deaths with a positive SARS-CoV-2 test from March 2020 to February 2021. The predominant SARS-CoV-2 variants were wild-type and Alpha. Here we show that, of 12,023,568 CYP living in England, 3,105 died, including 61 who were positive for SARS-CoV-2. Of these deaths, 25 were due to SARS-CoV-2 infection (mortality rate, two per million), including 22 due to coronavirus disease 2019-the clinical disease associated with SARS-CoV-2 infection-and 3 were due to pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2. In total, 99.995% of CYP with a positive SARS-CoV-2 test survived. CYP older than 10 years, Asian and Black ethnic backgrounds and comorbidities were over-represented in SARS-CoV-2-related deaths compared with other CYP deaths. These results are important for guiding decisions on shielding and vaccinating children. New variants might have different mortality risks and should be evaluated in a similar way.

A study of sex difference in infant mortality in UK pediatric intensive care admissions over an 11-year period

Within the UK, child mortality from all causes has declined for all ages over the last three decades. However, distinct inequality remains, as child mortality rates are generally found to be higher in males. A significant proportion of childhood deaths in the UK occur in Paediatric Intensive Care Units (PICU). We studied the association of sex with infant mortality in PICUs. We included all infants (0 to 12 months old) admitted to UK PICUs from 01/01/2005 to 31/12/2015 using the Paediatric Intensive Care Audit Network (PICANet) dataset. We considered first admissions to PICU and fitted a cause-specific-hazard-ratio (CSHR) model, and a logistic model to estimate the adjusted association between sex and mortality in PICU. Pre-defined subgroups were children less than 56-days old, and those with a primary diagnosis of infection. Of 71,243 cases, 1,411/29,520 (4.8%) of females, and 1,809/41,723 (4.3%) of males died. The adjusted male/female CSHR was 0.87 (95%-CI 0.81 to 0.92) representing a 13% higher risk of death for females. The adjusted OR for male to female mortality is 0.86 (95%-CI 0.80 to 0.93). Analyses in subgroups yielded similar findings. In our analysis, female infants have a higher rate of PICU mortality compared to male infants.

Health of mothers of children with a life-limiting condition: a comparative cohort study

OBJECTIVE

This study aimed to quantify the incidence rates of common mental and physical health conditions in mothers of children with a life-limiting condition.

METHODS

Comparative national longitudinal cohort study using linked primary and secondary care data from the Clinical Practice Research Datalink in England. Maternal-child dyads were identified in these data. Maternal physical and mental health outcomes were identified in the primary and secondary care datasets using previously developed diagnostic coding frameworks. Incidence rates of the outcomes were modelled using Poisson regression, adjusting for deprivation, ethnicity and age and accounting for time at risk.

RESULTS

A total of 35 683 mothers; 8950 had a child with a life-limiting condition, 8868 had a child with a chronic condition and 17 865 had a child with no long-term condition.The adjusted incidence rates of all of the physical and mental health conditions were significantly higher in the mothers of children with a life-limiting condition when compared with those mothers with a child with no long-term condition (eg, depression: incidence rate ratio (IRR) 1.21, 95% CI 1.13 to 1.30; cardiovascular disease: IRR 1.73, 95% CI 1.27 to 2.36; death in mothers: IRR 1.59, 95% CI 1.16 to 2.18).

CONCLUSION

This study clearly demonstrates the higher incidence rates of common and serious physical and mental health problems and death in mothers of children with a life-limiting condition. Further research is required to understand how best to support these mothers, but healthcare providers should consider how they can target this population to provide preventative and treatment services.

Mortality in children aged <5 years with severe acute respiratory illness in a high HIV-prevalence urban and rural areas of South Africa, 2009-2013

BACKGROUND

Severe acute respiratory illness (SARI) is an important cause of mortality in young children, especially in children living with HIV infection. Disparities in SARI death in children aged <5 years exist in urban and rural areas.

OBJECTIVE

To compare the factors associated with in-hospital death among children aged <5 years hospitalized with SARI in an urban vs. a rural setting in South Africa from 2009-2013.

METHODS

Data were collected from hospitalized children with SARI in one urban and two rural sentinel surveillance hospitals. Nasopharyngeal aspirates were tested for ten respiratory viruses and blood for pneumococcal DNA using polymerase chain reaction. We used multivariable logistic regression to identify patient and clinical characteristics associated with in-hospital death.

RESULTS

From 2009 through 2013, 5,297 children aged <5 years with SARI-associated hospital admission were enrolled; 3,811 (72%) in the urban and 1,486 (28%) in the rural hospitals. In-hospital case-fatality proportion (CFP) was higher in the rural hospitals (6.9%) than the urban hospital (1.3%, p<0.001), and among HIV-infected than the HIV-uninfected children (9.6% vs. 1.6%, p<0.001). In the urban hospital, HIV infection (odds ratio (OR):11.4, 95% confidence interval (CI):5.4-24.1) and presence of any other underlying illness (OR: 3.0, 95% CI: 1.0-9.2) were the only factors independently associated with death. In the rural hospitals, HIV infection (OR: 4.1, 95% CI: 2.3-7.1) and age <1 year (OR: 3.7, 95% CI: 1.9-7.2) were independently associated with death, whereas duration of hospitalization ≥5 days (OR: 0.5, 95% CI: 0.3-0.8) and any respiratory virus detection (OR: 0.4, 95% CI: 0.3-0.8) were negatively associated with death.

CONCLUSION

We found that the case-fatality proportion was substantially higher among children admitted to rural hospitals and HIV infected children with SARI in South Africa. While efforts to prevent and treat HIV infections in children may reduce SARI deaths, further efforts to address health care inequality in rural populations are needed.

Evaluation of the incidence, characteristics, and outcomes of pediatric chronic critical illness

Our aim was to determine characteristics of children with chronic critical illness (CCI) admitted to the pediatric intensive care unit (PICU) of a tertiary care children's hospital in Turkey. The current study was a multicenter retrospective cohort study that was done from 2014 to 2017. It involved three university hospitals PICUs in which multiple criteria were set to identify pediatric CCIs. Pediatric patients staying in the ICU for at least 14 days and having at least one additional criterion, including prolonged mechanical ventilation, tracheostomy, sepsis, severe wound (burn) or trauma, encephalopathy, traumatic brain injury, status epilepticus, being postoperative, and neuromuscular disease, was accepted as CCI. In order to identify the newborn as a chronic critical patient, a stay in the intensive care unit for at least 30 days in addition to prematurity was required. Eight hundred eighty seven (11.14%) of the patients who were admitted to the PICU met the definition of CCI and 775 of them (87.3%) were discharged to their home. Of CCI patients, 289 (32.6%) were premature and 678 (76.4%) had prolonged mechanical ventilation. The total cost values for 2017 were statistically higher than the other years. As the length of ICU stay increased, the costs also increased. Interestingly, high incidence rates were observed for PCCI in our hospitals and these patients occupied 38.01% of the intensive care bed capacity. In conclusion, we observed that prematurity and prolonged mechanical ventilation increase the length of ICU stay, which also increased the costs. More work is needed to better understand PCCI.

A comparative two-cohort study of pediatric patients with long term stay in ICUs

During the last decades, the number of patients with long stay admissions (LSA) in PICU has increased. The purpose of this study was to identify factors associated with PICU LSA, assessing healthcare resources use and changes in the profile of these patients. A retrospective, observational, single-center study was carried out. Characteristics of LSA were compared between two periods (2006–2010 and 2011–2015). During the earlier period there were 2,118 admissions (3.9% of them LSA), whereas during the second period, there were 1,763 (5.4% of them LSA) (p = 0.025). LSA accounted for 33.7% PICU stay days during the first period and 46.7% during the second (p < 0.001). Higher use of non-invasive ventilation (80.2% vs. 37.8%, p = 0.001) and high-flow oxygen therapy (68.8% vs. 37.8%, p = 0.005) was observed in the 2011–2015 cohort, whereas the use of arterial catheter (77.1% vs. 92.6%, p = 0.005), continuous infusion of adrenaline (55.2% vs. 75.9%, p = 0.004), and hemoderivative transfusion (74% vs. 89.2%, p = 0.010) was less frequent. In the 2006–2010 cohort, hospital-acquired infections were more common (95.2% vs. 68.8%, p < 0.001) and mortality was higher (26.8% vs. 13.8%, p = 0.026). The number of long-stay PICU admissions have increased entailing an intensive use of healthcare resources. These patients have a high risk for complications and mortality.

Associations between pre-pregnancy psychosocial risk factors and infant outcomes: a population-based cohort study in England

BACKGROUND

Existing studies evaluating the association between maternal risk factors and specific infant outcomes such as birthweight, injury admissions, and mortality have mostly focused on single risk factors. We aimed to identify routinely recorded psychosocial characteristics of pregnant women most at risk of adverse infant outcomes to inform targeting of early intervention.

METHODS

We created a cohort using administrative hospital data (Hospital Episode Statistics) for all births to mothers aged 15-44 years in England, UK, who gave birth on or after April 1, 2010, and who were discharged before or on March 31, 2015. We used generalised linear models to evaluate associations between psychosocial risk factors recorded in hospital records in the 2 years before the 20th week of pregnancy (ie, teenage motherhood, deprivation, pre-pregnancy hospital admissions for mental health or behavioural conditions, and pre-pregnancy hospital admissions for adversity, including drug or alcohol abuse, violence, and self-harm) and infant outcomes (ie, birthweight, unplanned admission for injury, or death from any cause, within 12 months from postnatal discharge).

FINDINGS

Of 2 520 501 births initially assessed, 2 137 103 were eligible and were included in the birth outcome analysis. Among the eligible births, 93 279 (4·4%) were births to teenage mothers (age <20 years), 168 186 (7·9%) were births to previous teenage mothers, 51 312 (2·4%) were births to mothers who had a history of hospital admissions for mental health or behavioural conditions, 58 107 (2·7%) were births to mothers who had a history of hospital admissions for adversity, and 580 631 (27·2%) were births to mothers living in areas of high deprivation. 1 377 706 (64·5%) of births were to mothers with none of the above risk factors. Infants born to mothers with any of these risk factors had poorer outcomes than those born to mothers without these risk factors. Those born to mothers with a history of mental health or behavioural conditions were 124 g lighter (95% CI 114-134 g) than those born to mothers without these conditions. For teenage mothers compared with older mothers, 3·6% (95% CI 3·3-3·9%) more infants had an unplanned admission for injury, and there were 10·2 (95% CI 7·5-12·9) more deaths per 10 000 infants.

INTERPRETATION

Health-care services should respond proactively to pre-pregnancy psychosocial risk factors. Our study demonstrates a need for effective interventions before, during, and after pregnancy to reduce the downstream burden on health services and prevent long-term adverse effects for children.

FUNDING

Wellcome Trust.

Developing a national birth cohort for child health research using a hospital admissions database in England: The impact of changes to data collection practices

BACKGROUND

National birth cohorts derived from administrative health databases constitute unique resources for child health research due to whole country coverage, ongoing follow-up and linkage to other data sources. In England, a national birth cohort can be developed using Hospital Episode Statistics (HES), an administrative database covering details of all publicly funded hospital activity, including 97% of births, with longitudinal follow-up via linkage to hospital and mortality records. We present methods for developing a national birth cohort using HES and assess the impact of changes to data collection over time on coverage and completeness of linked follow-up records for children.

METHODS

We developed a national cohort of singleton live births in 1998-2015, with information on key risk factors at birth (birth weight, gestational age, maternal age, ethnicity, area-level deprivation). We identified three changes to data collection, which could affect linkage of births to follow-up records: (1) the introduction of the "NHS Numbers for Babies (NN4B)", an on-line system which enabled maternity staff to request a unique healthcare patient identifier (NHS number) immediately at birth rather than at civil registration, in Q4 2002; (2) the introduction of additional data quality checks at civil registration in Q3 2009; and (3) correcting a postcode extraction error for births by the data provider in Q2 2013. We evaluated the impact of these changes on trends in two outcomes in infancy: hospital readmissions after birth (using interrupted time series analyses) and mortality rates (compared to published national statistics).

RESULTS

The cohort covered 10,653,998 babies, accounting for 96% of singleton live births in England in 1998-2015. Overall, 2,077,929 infants (19.5%) had at least one hospital readmission after birth. Readmission rates declined by 0.2% percentage points per annual quarter in Q1 1998 to Q3 2002, shifted up by 6.1% percentage points (compared to the expected value based on the trend before Q4 2002) to 17.7% in Q4 2002 when NN4B was introduced, and increased by 0.1% percentage points per annual quarter thereafter. Infant mortality rates were under-reported by 16% for births in 1998-2002 and similar to published national mortality statistics for births in 2003-2015. The trends in infant readmission were not affected by changes to data collection practices in Q3 2009 and Q2 2013, but the proportion of unlinked mortality records in HES and in ONS further declined after 2009.

DISCUSSION

HES can be used to develop a national birth cohort for child health research with follow-up via linkage to hospital and mortality records for children born from 2003 onwards. Re-linking births before 2003 to their follow-up records would maximise potential benefits of this rich resource, enabling studies of outcomes in adolescents with over 20 years of follow-up.

Emergency paediatric critical care in England: describing trends using routine hospital data

OBJECTIVE

To determine trends in emergency admission rates requiring different levels of critical care in hospitals with and without a paediatric intensive care unit (PICU).

DESIGN

Birth cohort study created from Hospital Episode Statistics.

SETTING

National Health Service funded hospitals in England.

PATIENTS

8 577 680 singleton children born between 1 May 2003 and 31 April 2017.

OUTCOME MEASURES

Using procedure and diagnostic codes, we assigned indicators of high dependency care (eg, non-invasive ventilation) or intensive care (eg, invasive ventilation) to emergency admissions.

INTERVENTIONS

Children were followed up until their fifth birthday to estimate high dependency and intensive care admission rates in hospitals with and without a PICU. We tested the yearly trend of high dependency and intensive care admissions to hospitals without a PICU using logistic regression models.

RESULTS

Emergency admissions requiring high dependency care in hospitals without a PICU increased from 3.30 (95% CI 3.09 to 3.51) per 10 000 child-years in 2008/2009 to 7.58 (95% CI 7.28 to 7.89) in 2016/2017 and overtook hospitals with a PICU in 2015/2016. The odds of an admission requiring high dependency care to a hospital without a PICU compared with a hospital with a PICU increased by 9% per study year (OR 1.09, 95% CI 1.08 to 1.10). The same trend was not present for admissions requiring intensive care (OR 1.01, 95% CI 0.99 to 1.03).

CONCLUSIONS

Between 2008/2009 and 2016/2017, an increasing proportion of admissions with indicators of high dependency care took place in hospitals without a PICU.

Asthma and all-cause mortality in children and young adults: a population-based study

BACKGROUND

Studies suggest an increased all-cause mortality among adults with asthma. We aimed to study the relationship between asthma in children and young adults and all-cause mortality, and investigate differences in mortality rate by also having a life-limiting condition (LLC) or by parental socioeconomic status (SES).

METHODS

Included in this register-based study are 2 775 430 individuals born in Sweden between January 1986 and December 2012. We identified asthma cases using the National Patient Register (NPR) and the Prescribed Drug Register. Those with LLC were identified using the NPR. Parental SES at birth (income and education) was retrieved from Statistics Sweden. We estimated the association between asthma and all-cause mortality using a Cox proportional hazards regression model. Effect modification by LLC or parental SES was studied using interaction terms in the adjusted model.

RESULTS

The adjusted hazard rate (adjHR) for all-cause mortality in asthma cases versus non-asthma cases was 1.46 (95% CI 1.33 to 1.62). The highest increased rate appeared to be for those aged 5-15 years. In persons with asthma and without LLC, the adjHR remained increased at 1.33 (95% CI 1.18 to 1.50), but differed (p=0.002) from those with asthma and LLC, with an adjHR of 1.87 (95% CI 1.57 to 2.22). Parental SES did not alter the association (income, p=0.55; education, p=0.83).

CONCLUSION

This study shows that asthma is associated with an increased mortality in children and young adults regardless of LLC or parental SES. Further research is warranted to investigate the possible mechanisms for this association.

Interventions to improve the mental health of children and young people with long-term physical conditions: linked evidence syntheses

BACKGROUND

Although mental health difficulties can severely complicate the lives of children and young people (CYP) with long-term physical conditions (LTCs), there is a lack of evidence about the effectiveness of interventions to treat them.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of interventions aiming to improve the mental health of CYP with LTCs (review 1) and explore the factors that may enhance or limit their delivery (review 2).

DATA SOURCES

For review 1, 13 electronic databases were searched, including MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Science Citation Index. For review 2, MEDLINE, PsycINFO and CINAHL were searched. Supplementary searches, author contact and grey literature searches were also conducted.

REVIEW METHODS

The first systematic review sought randomised controlled trials (RCTs) and economic evaluations of interventions to improve elevated symptoms of mental ill health in CYP with LTCs. Effect sizes for each outcome were calculated post intervention (Cohen's d). When appropriate, random-effects meta-analyses produced pooled effect sizes (d). Review 2 located primary qualitative studies exploring experiences of CYP with LTCs, their families and/or practitioners, regarding interventions aiming to improve the mental health and well-being of CYP with LTCs. Synthesis followed the principles of metaethnography. An overarching synthesis integrated the findings from review 1 and review 2 using a deductive approach. End-user involvement, including topic experts and CYP with LTCs and their parents, was a feature throughout the project.

RESULTS

Review 1 synthesised 25 RCTs evaluating 11 types of intervention, sampling 12 different LTCs. Tentative evidence from seven studies suggests that cognitive-behavioural therapy interventions could improve the mental health of CYP with certain LTCs. Intervention-LTC dyads were diverse, with few opportunities to meta-analyse. No economic evaluations were located. Review 2 synthesised 57 studies evaluating 21 types of intervention. Most studies were of individuals with cancer, a human immunodeficiency virus (HIV) infection or mixed LTCs. Interventions often aimed to improve broader mental health and well-being, rather than symptoms of mental health disorder. The metaethnography identified five main constructs, described in an explanatory line of argument model of the experience of interventions. Nine overarching synthesis categories emerged from the integrated evidence, raising implications for future research.

LIMITATIONS

Review 1 conclusions were limited by the lack of evidence about intervention effectiveness. No relevant economic evaluations were located. There were no UK studies included in review 1, limiting the applicability of findings. The mental health status of participants in review 2 was usually unknown, limiting comparability with review 1. The different evidence identified by the two systematic reviews challenged the overarching synthesis.

CONCLUSIONS

There is a relatively small amount of comparable evidence for the effectiveness of interventions for the mental health of CYP with LTCs. Qualitative evidence provided insight into the experiences that intervention deliverers and recipients valued. Future research should evaluate potentially effective intervention components in high-quality RCTs integrating process evaluations. End-user involvement enriched the project.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001716.

FUNDING

The National Institute for Health Research (NIHR) Health Technology Assessment programme and the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

Prevalence, hospital admissions and costs of child chronic conditions: A population-based study

AIM

To determine population-based prevalence, hospital use and costs for children admitted to hospital with chronic conditions.

METHODS

We used hospital admissions data for children aged <16 years, 2002-2013 in New South Wales, Australia.

RESULTS

Of all admissions, 35% (n = 692 514) included a diagnosis of a chronic condition. In 2013, prevalence was 25.1 per 1000 children. Children with greater socio-economic disadvantage or living in regional and remote areas had lower prevalence, but a higher proportion of emergency admissions. Prevalence rates were highest for respiratory and neurological conditions (9.4, 7.4 per 1000, respectively). Mental health conditions were most common in older children. Admissions involving chronic conditions had longer length of stay (3.0 vs. 1.6 days), consumed more bed-days (50% of total) and involved 43% of total hospital costs.

CONCLUSION

Differences in prevalence and use of hospital services suggest inequities in access and need for more appropriate and equitable models of care.

Timing of paediatric orchidopexy in universal healthcare systems: international administrative data cohort study

BACKGROUND

International guidelines in 2008 recommended orchidopexy for undescended testis at 6-12 months of age to reduce the risk of testicular cancer and infertility. Using administrative data from England, Finland, Ontario (Canada), Scotland and Sweden (with data from Victoria (Australia) and Iceland in supplementary analyses), the aim of this study was to investigate compliance with these guidelines and identify potential socioeconomic inequities in the timing of surgery before 1 and 3 years.

METHODS

All boys born in 2003-2011 with a diagnosis code of undescended testis and procedure codes indicating orchidopexy before their fifth birthday were identified from administrative health records. Trends in the proportion of orchidopexies performed before 1 and 3 years of age were investigated, as were socioeconomic inequities in adherence to the guidelines.

RESULTS

Across all jurisdictions, the proportion of orchidopexies occurring before the first birthday increased over the study period. By 2011, from 7·6 per cent (Sweden) to 27·9 per cent (Scotland) of boys had undergone orchidopexy by their first birthday and 71·5 per cent (Sweden) to 90·4 per cent (Scotland) by 3 years of age. There was limited evidence of socioeconomic inequities for orchidopexy before the introduction of guidelines (2008). Across all jurisdictions for boys born after 2008, there was consistent evidence of inequities in orchidopexy by the first birthday, favouring higher socioeconomic position. Absolute differences in these proportions between the highest and lowest socioeconomic groups ranged from 2·5 to 5·9 per cent across jurisdictions.

CONCLUSION

Consistent lack of adherence to the guidelines across jurisdictions questions whether the guidelines are appropriate.

Health of mothers of children with a life-limiting condition: a protocol for comparative cohort study using the Clinical Practice Research Datalink

INTRODUCTION

There are now nearly 50 000 children with a life-limiting or life-threatening condition in the UK. These include conditions where there is no reasonable hope of cure and from which they will die, as well as conditions for which curative treatment may be feasible but can fail, for example, cancer or heart failure. Having a child with a life-limiting condition involves being a coordinator and provider of healthcare in addition to the responsibilities and pressures of parenting a child who is expected to die young. This adversely affects the health and well-being of these mothers and affects their ability to care for their child, but the extent of the impact is poorly understood.This study aims to quantify the incidence and nature of mental and physical morbidity in mothers of children with a life-limiting condition, their healthcare use and to assess whether there is a relationship between the health of the mother and the child's condition.

METHODS AND ANALYSIS

A comparative cohort study using data from the Clinical Practice Research Datalink and linked hospital data will include three groups of children and their mothers (those with a life-limiting condition, those with a chronic condition and those with no long-term health condition total=20 000 mother-child dyads). Incidence rates and incidence rate ratios will be used to quantify and compare the outcomes between groups with multivariable regression modelling used to assess the relationship between the child's disease trajectory and mother's health.

ETHICS AND DISSEMINATION

This study protocol has approval from the Independent Scientific Advisory Committee for the UK Medicines and Healthcare products Regulatory Agency Database Research. The results of this study will be reported according to the STROBE and RECORD guidelines. There will also be a lay summary for parents which will be available to download from the Martin House Research Centre website (www.york.ac.uk/mhrc).

Evaluating the real-world implementation of the Family Nurse Partnership in England: protocol for a data linkage study

INTRODUCTION

Almost 20 000 babies are born to teenage mothers each year in England, with poorer outcomes for mothers and babies than among older mothers. A nurse home visitation programme in the USA was found to improve a wide range of outcomes for young mothers and their children. However, a randomised controlled trial in England found no effect on short-term primary outcomes, although cognitive development up to age 2 showed improvement. Our study will use linked routinely collected health, education and social care data to evaluate the real-world effects of the Family Nurse Partnership (FNP) on child outcomes up to age 7, with a focus on identifying whether the FNP works better for particular groups of families, thereby informing programme targeting and resource allocation.

METHODS AND ANALYSIS

We will construct a retrospective cohort of all women aged 13-24 years giving birth in English NHS hospitals between 2010 and 2017, linking information on mothers and children from FNP programme data, Hospital Episodes Statistics and the National Pupil Database. To assess the effectiveness of FNP, we will compare outcomes for eligible mothers ever and never enrolled in FNP, and their children, using two analysis strategies to adjust for measured confounding: propensity score matching and analyses adjusting for maternal characteristics up to enrolment/28 weeks gestation. Outcomes of interest include early childhood development, childhood unplanned hospital admissions for injury or maltreatment-related diagnoses and children in care. Subgroup analyses will determine whether the effect of FNP varied according to maternal characteristics (eg, age and education).

ETHICS AND DISSEMINATION

The Nottingham Research Ethics Committee approved this study. Mothers participating in FNP were supportive of our planned research. Results will inform policy-makers for targeting home visiting programmes. Methodological findings on the accuracy and reliability of cross-sectoral data linkage will be of interest to researchers.

The match between need and use of health services among healthy under-fives in Denmark: A register-based national cohort study

OBJECTIVES

To study a potential positive association (referred to as 'a match') between the need for health service (expressed by a mortality risk score) and observed health service utilisation among healthy Danish under-fives. Further, municipal differences in the match were examined to motivate focused comparisons between the organisation of regional health services.

DESIGN

Register-based national cohort study.

PARTICIPANTS

The population of 1,246,599 Danish children born 1997-2016 who survived until date of first discharge to the home after birth without a diagnosis of severe chronic disease.

MAIN OUTCOME MEASURES

Hazard ratios (HR) for a doubling of the mortality rate were calculated for the following health services: total contacts, inpatient contacts (admission > 1 day), outpatient contacts, general practitioner contacts, specialist contacts, medication use, and vaccinations.

RESULTS

The use of total contacts, inpatient contacts (> 1 day) and general practitioner contacts as well as medication matched with the mortality risk score, HRs between 1.027 (1.026 to 1.028) and 1.111 (1.108 to 1.113), whereas outpatient and specialist contacts as well as vaccinations did not, HRs between 0.913 (0.912 to 0.915) and 0.991 (0.991 to 0.991). There were some remarkable differences among the 98 Danish municipalities.

CONCLUSIONS

We found some match between need and use for total contacts, inpatient contacts (> 1 day), contacts with general practitioner, and medication use although the associations were relatively weak. For outpatient and specialist contacts, the mismatch may be related to services not addressing potentially fatal disease whereas for vaccination there was a small mismatch. Our results indicate local discrepancies in diagnosis, and a low adjusted utilisation of hospital admissions in Aarhus compared to the other three major cities in Denmark suggests that a comparison of the organisation of services could be useful.

Phenotyping congenital anomalies in administrative hospital records

BACKGROUND

Congenital anomalies are a major cause of co-morbidity in children. Diagnostic code lists are increasingly used to identify congenital anomalies in administrative health records. Evidence is lacking on comparability of these code lists.

OBJECTIVES

To compare prevalence of congenital anomalies and prognostic outcomes for children with congenital anomalies identified in administrative health records using three different code lists.

METHODS

We developed national cohorts of singleton livebirths in England (n = 7 354 363, 2003-2014) and Scotland (n = 493 556, 2003-2011). Children with congenital anomalies were identified if congenital anomaly diagnosis was recorded at birth, during subsequent hospital admission or as cause of death before 2 years old. We used three code lists: the EUROCAT list for congenital anomaly surveillance in Europe; the Hardelid list developed to identify children with chronic conditions (including congenital anomalies) admitted to hospital in England; and the Feudtner list developed to indicate children with complex chronic conditions (including congenital anomalies) admitted to hospitals in the United States. We compared prevalence, and risks of postnatal hospital readmission and death according to each code list in England and Scotland.

RESULTS

Prevalence of congenital anomalies was highest using the EUROCAT list (4.1% of livebirths in England, 3.7% in Scotland), followed by Hardelid (3.1% and 3.0% of livebirths, respectively) and Feudtner (1.8% and 1.5% of livebirths, respectively). 67.2%-73.3% of children with congenital anomalies in England and 65.2%-77.0% in Scotland had at least one postnatal hospital admission across the three code lists; mortality ranged between 42.6-75.4 and 41.5-88.7 deaths per 1000 births in England Scotland, respectively. The risk of these adverse outcomes was highest using Feudtner and lowest using EUROCAT code lists.

CONCLUSIONS

The prevalence of congenital anomalies varied by congenital anomaly code list, over time and between countries, reflecting in part differences in hospital coding practices and admission thresholds. As a minimum, researchers using administrative health data to study congenital anomalies should report sensitivity analyses using different code lists.

Risk factors of post-discharge under-five mortality among Danish children 1997-2016: A register-based study

Objectives

Estimating associations between somatic and socioeconomic risk factors and post-discharge under-five mortality.

Design

Register-based national cohort study using multiple Cox regression.

Participants

The population of 1,263,795 Danish children live-born 1997–2016 who survived until date of first discharge to the home after birth was followed from that date until death, emigration, 5 years of age or 31 December 2016.

Main outcome measures

(A) Mortality hazard ratios (HRs) among all children, (B) mortality HRs among children without severe chronic disease, and (C) mortality HRs among children without severe chronic disease or asthma.

Main results

In the total population (1,947 deaths) severe chronic disease was associated with mortality HR = 15.28 (95% CI: 13.77–16.95). In children without severe chronic-disease (719 deaths) other somatic risk factors were immature birth HR = 3.40 (1.92–6.02), maternal smoking HR = 1.84 (1.55–2.18) and low birth weight HR = 1.74 (1.21–2.51). Socioeconomic risk factors for mortality included: maternal age < 25 years HR = 1.91 (1.38–2.64) compared to > 35 years (similar for 30–35 years and 25–29 years), lowest vs. highest family income tertile HR = 1.76 (1.23–2.51), not living with both parents HR = 1.63 (1.25–2.13), maternal unemployment HR = 1.54 (1.12–2.12), presence of siblings HR = 1.44 (1.20–1.71) and secondary vs. tertiary parental education HR = 1.33 (1.07–1.65) for fathers and HR = 1.23 (1.01–1.52) for mothers. Factors not found to be associated with child mortality in this population included presence of asthma HR = 1.29 (0.83–1.98) and non-Danish ethnicity HR = 0.98 (0.70–1.37).

Conclusions

Childhood death after discharge to the home after birth and before 5 years of age is a very rare event in Denmark. This ‘post-discharge’ mortality was heavily associated with severe chronic disease. In children without severe chronic disease, immature birth, maternal smoking and certain socioeconomic characteristics were noticeable risk factors. Mortality may possibly be decreased by focusing on vulnerable groups.

Epidemiology of Readmissions After Sepsis Hospitalization in Children

BACKGROUND AND OBJECTIVES

The decline in hospital mortality in children hospitalized with sepsis has increased the number of survivors. These survivors are at risk for adverse long-term outcomes, including readmission and recurrent or unresolved infections. We described the epidemiology of 90-day readmissions after sepsis hospitalization in children. We tested the hypothesis that a sepsis hospitalization increases odds of 90-day readmissions.

METHODS

Retrospective cohort analysis of the Nationwide Readmissions Database. We included index unplanned admissions of non-neonatal pediatric patients and described the proportion of readmissions, including those involving infection or sepsis. We performed multivariable analysis to determine the odds of readmission after a sepsis and nonsepsis admission and compared costs of readmission after sepsis and nonsepsis admissions.

RESULTS

Of 562 817 pediatric admissions, 7634 (1.4%) and 555 183 (98.6%) were discharged alive after admissions with and without sepsis. The rate of 90-day readmission after sepsis was 21.4%: 7.2% and 25.5% in previously healthy and chronically ill patients. The adjusted mean cost during readmission was $7385. Half of readmissions (52.9%) involved recurrent infection or sepsis. Sepsis admissions were associated with higher odds of readmission at 90 days compared with nonsepsis admissions (adjusted odds ratio 1.15, 95% confidence interval 1.08-1.23). The results remained unchanged for 30-day and 6-month readmissions.

CONCLUSIONS

Readmissions occur after 1 in 5 pediatric sepsis hospitalizations and increase health care costs. Sepsis hospitalization increased odds of readmission and commonly involved recurrent infection or sepsis. Clinicians caring for these patients should consider surveillance for recurrent or unresolved infection, and researchers should explore underlying mechanisms and potential interventions to reduce readmissions.

Causes of death in critically ill paediatric patients in Japan: a retrospective multicentre cohort study

OBJECTIVES

The primary objective is to clarify the clinical profiles of paediatric patients who died in intensive care units (ICUs) or paediatric intensive care units (PICUs), and the secondary objective is to ascertain the demographic differences between patients who died with and without chronic conditions.

METHODS

In this retrospective multicentre cohort study, we collected data on paediatric death from the Japanese Registry of Pediatric Acute Care (JaRPAC) database. We included patients who were ≤16 years of age and had died in either a PICU or an ICU of a participating hospital between April 2014 and March 2017. The causes of death were compared between patients with and without chronic conditions.

RESULTS

Twenty-three hospitals participated, and 6199 paediatric patients who were registered in the JaRPAC database were included. During the study period, 126 (2.1%) patients died (children without chronic illness, n=33; children with chronic illness, n=93). Twenty-five paediatric patients died due to an extrinsic disease, and there was a significant difference in extrinsic diseases between the two groups (children without chronic illness, 15 (45%); children with chronic illness, 10 (11%); p<0.01). Cardiovascular disease was the most common chronic condition (27/83, 29%). Eighty-three patients (85%) in the chronic group died due to an intrinsic disease, primarily congenital heart disease (14/93, 15%), followed by sepsis (13/93, 14%).

CONCLUSIONS

The majority of deaths were in children with a chronic condition. The major causes of death in children without a chronic illness were due to intrinsic factors such as cardiovascular and neuromuscular diseases, and the proportion of deaths due to extrinsic causes was higher in children without chronic illness.

Avoidable mortality from respiratory tract infection and sudden unexplained death in children with chronic conditions: a data linkage study

OBJECTIVE

To determine the risk of death from two potentially avoidable causes with different aetiologies: respiratory tract infection (RTI) and sudden unexplained death (SUD) in children with and without chronic conditions.

DESIGN

Whole-country, birth cohort study using linked administrative health databases from Scotland.

SETTING AND PARTICIPANTS

Children aged 2 months to less than 5 years in Scotland between 2000 and 2014.

MAIN OUTCOME MEASURES

Relative risk of death (expressed as the HR) related to RTIs or SUD, in children with and without chronic conditions. We separately analysed deaths at ages 2-11 months and at 1-4 years and adjusted for birth characteristics, socioeconomic status and vaccination uptake using Cox regression.

RESULTS

The cohort comprised 761 172 children. Chronic conditions were recorded in 9.6% (n=72 901) of live births, 82.4% (n=173) of RTI-related deaths and 17.4% (n=49) of SUDs. Chronic conditions were very strongly associated with RTI mortality (2-11 months: HR 68.48, 95% CI (40.57 to 115.60), 1-4 years: HR 38.32, 95% CI (23.26 to 63.14)) and strongly associated with SUD (2-11 months: HR 2.42, 95% CI (1.67 to 3.63), 1-4 years: HR 2.53, 95% CI (1.36 to 4.71)).

CONCLUSIONS

The very strong association with chronic conditions suggests that RTI-related mortality may sometimes be a consequence of a terminal decline and not possible to defer or prevent in all cases. Recording whether death was expected on death certificates could indicate which RTI-related deaths might be avoidable through healthcare and public health measures.

Pediatric admissions that include intensive care: a population-based study

Background

Pediatric admissions to intensive care outside children’s hospitals are generally excluded from registry-based studies. This study compares pediatric admission to specialist pediatric intensive care units (PICU) with pediatric admissions to intensive care units (ICU) in general hospitals in an Australian population.

Methods

We undertook a population-based record linkage cohort study utilizing longitudinally-linked hospital and death data for pediatric hospitalization from New South Wales, Australia, 2010–2013. The study population included all new pediatric, post-neonatal hospital admissions that included time in ICU (excluding neonatal ICU).

Results

Of 498,466 pediatric hospitalizations, 7525 (1.5%) included time in an intensive care unit – 93.7% to PICU and 6.3% to ICU in a general (non-PICU) hospital. Non-PICU admissions were of older children, in rural areas, with shorter stays in ICU, more likely admitted for acute conditions such as asthma, injury or diabetes, and less likely to have chronic conditions, receive continuous ventilatory support, blood transfusion, parenteral nutrition or die.

Conclusions

A substantial proportion of children are admitted to ICUs in general hospitals. A comprehensive overview of pediatric ICU admissions includes these admissions and the context of the total hospitalization.

Educational outcomes for children with cerebral palsy: a linked data cohort study

AIM

To identify a cohort of children with cerebral palsy (CP) from hospital data; determine the proportion that participated in standardized educational testing and attained a score within the normal range; and describe the relationship between test results and motor symptoms.

METHOD

This population-based retrospective cohort study used data from New South Wales, Australia. We linked hospital data for children younger than 16 years of age admitted between 1st July 2000 and 31st March 2014 to education data from 2009 to 2014. Hospital diagnosis codes were used to identify a cohort of children with CP (n=3944) and describe their motor symptoms. Educational outcomes in the CP cohort were compared with those among children without CP.

RESULTS

Of those with educational data (n=1770), 46% were exempt from reading assessment because of intellectual or functional disability, 7% were absent or withdrawn from testing and 47% participated in testing. About 30% of all children with educational data had test scores in the normal range. The proportion was greatest among those with hemiplegia (>40%) and lowest among those with tetraplegia (<10%).

INTERPRETATION

One-third of children with CP participated in standardized testing and achieved a result in the normal range. The proportions were lower in children with more severe motor symptoms.

WHAT THIS PAPER ADDS

From 2009 to 2014, most Australian children with cerebral palsy (CP) attended a mainstream school. The rate of disability-related exemption from standardized educational testing was almost 50%. Thirty per cent of children with CP achieved educational scores in the normal range.

Validation of the Feverkidstool and procalcitonin for detecting serious bacterial infections in febrile children

BackgroundTo validate the Feverkidstool, a prediction model consisting of clinical signs and symptoms and C-reactive protein (CRP) to identify serious bacterial infections (SBIs) in febrile children, and to determine the incremental diagnostic value of procalcitonin.MethodsThis prospective observational study that was carried out at two Dutch emergency departments included children with fever, aged 1 month to 16 years. The prediction models were developed with polytomous logistic regression differentiating "pneumonia" and "other SBIs" from "non-SBIs" using standardized, routinely collected data on clinical signs and symptoms, CRP, and procalcitonin.ResultsA total of 1,085 children were included with a median age of 1.6 years (interquartile range 0.8-3.4); 73 children (7%) had pneumonia and 98 children (9%) had other SBIs. The Feverkidstool showed good discriminative ability in this new population. After adding procalcitonin to the Feverkidstool, c-statistic for "pneumonia" increased from 0.85 (95% confidence interval (CI) 0.76-0.94) to 0.86 (0.77-0.94) and for "other SBI" from 0.81 (0.73-0.90) to 0.83 (0.75- 0.91). A model with clinical features and procalcitonin performed similar to the Feverkidstool.ConclusionThis study confirms the external validity of the Feverkidstool, with CRP and procalcitonin being equally valuable for predicting SBI in our population of febrile children. Our findings do not support routine dual use of CRP and procalcitonin.