Association between birth order and emergency room visits and acute hospital admissions following pediatric vaccination: a self-controlled study

Parental engagement in research on paediatric lower respiratory tract infections in Indonesia

BACKGROUND

Lower respiratory tract infections (LRTIs) in children are a major concern in Indonesia as it is the leading cause of morbidity and mortality. Therefore, research on LRTIs is crucial to improve children's health. However, clinical research in children is challenging due to parental concerns. This study aims to understand parental considerations for taking part in clinical studies on LRTI in the Indonesian context.

METHODS

A cross-sectional study using a validated online questionnaire was conducted from November 2021 to March 2022. This study included parents from two public elementary schools and two private primary schools in Semarang, Indonesia. A total of 1236 responses were analysed.

RESULTS

There was a significant association between educational attainment and willingness to participate in general health and LRTI-related research requiring specimen collection; respondents with an advanced educational level were more likely to refuse participation in research. A similar pattern was observed among respondents with smaller families and younger children against participation in LRTI research. Most respondents who indicated not to participate explained that they did not perceive the necessity to take part and expressed their concerns about endangering their child's health as a consequence of the specimen collection. Most respondents expected a personal benefit and prioritized access to the study results for their child.

CONCLUSION

Parents' educational background and family composition are important determinants of parental engagement in research on LRTI in Indonesia. Notably, parents with a lower educational level, having large families, and older children were more inclined to participate. The emphasis on concerns about potential harm and personal benefit underscores the need for a targeted communication strategy.

Factors associated with healthcare utilization for infant falls in South Korea: a cross-sectional online survey

PURPOSE

Falls are a common cause of unintentional injuries in infants. This study was conducted to examine the patterns of healthcare utilization following infant falls in South Korea.

METHODS

This cross-sectional descriptive study utilized an online survey designed to gather information regarding the general characteristics of parents and infants, fall-related variables, and healthcare use.

RESULTS

The most serious falls identified by parents occurred at an average infant age of 6.97 months. Most fall incidents took place indoors (95.7%), and many occurred under the supervision of caregivers (68.0%). Following the fall, 36.4% of the participants used healthcare services. Logistic regression analysis revealed that healthcare use following an infant fall was significantly associated with being a firstborn child (odds ratio [OR]=5.32, 95% confidence interval [CI], 2.19-15.28) and falling from a caregiver's arms (OR=4.22; 95% CI, 1.45-13.68).

CONCLUSION

To prevent and decrease the frequency of infant falls, improvements are needed in both the domestic environment and parenting approaches.

Morbidity and healthcare use among mothers of children with cancer: A population-based study

BACKGROUND

The impact of a child's cancer diagnosis on subsequent maternal physical health is unclear.

METHODS

We identified all Ontario children diagnosed less than 18 years with cancer between 1992 and 2017. Linkage to administrative databases identified mothers who were matched to population controls. We identified physical health conditions, acute healthcare use, and preventive healthcare use through validated algorithms using healthcare data, and compared them between exposed (child with cancer) and unexposed mothers. Predictors of health outcomes were assessed among exposed mothers.

RESULTS

We identified 5311 exposed mothers and 19,516 matched unexposed mothers. For exposed mothers, median age at last follow-up was 48 years, (interquartile range: 42-53). Exposed mothers had an increased risk of cancer (hazard ratio [HR] 1.2, 95% confidence interval [95% CI]: 1.0-1.5, p = .03), but not of any other adverse physical outcomes or of increased acute healthcare use. Exposed mothers were more likely to receive influenza vaccinations (odds ratio 1.4, 95% CI: 1.3-1.5, p < .0001), and underwent cancer screening at the same rate as unexposed mothers. Among exposed mothers, bereavement was associated with a subsequent increased risk of cancer (HR 1.7, 95% CI: 1.2-2.5, p = .004) and death (HR 2.2, 95% CI: 1.2-4.1, p = .01).

CONCLUSION

Mothers of children with cancer are at increased risk of developing cancer, but not of other adverse physical health outcomes, and were equally or more likely to be adherent to preventive healthcare practices. Bereaved mothers were at increased risk of subsequent cancer and death. Interventions targeting specific subpopulations of mothers of children with cancer or focused on screening for specific cancers may be warranted.

Morbidity and health care use among siblings of children with cancer: A population-based study

BACKGROUND

Childhood cancer impacts the entire family unit. We sought to investigate its impact on the long-term physical health outcomes of siblings of children with cancer.

PROCEDURE

Pediatric cancer patients diagnosed in Ontario, Canada between 1988 and 2016 were linked to biological siblings. Sibling cases were matched to population controls based on sex, age, geographic location, and number of other children in the family. After individual linkage to health services data, we compared several outcomes between sibling cases and controls: (a) physical health conditions (such as diabetes, hypertension, and death); (b) acute health care use (hospitalization, low- and high-acuity emergency department [ED] visits); and (c) preventive health care use (periodic health checkups, influenza vaccinations). Cox proportional hazards, recurrent event, or logistic regression models were used as appropriate.

RESULTS

We identified 8529 sibling cases and 30,364 matched controls (median age at index: 6 years, median age at last follow-up 17 years). Compared to controls, siblings were at increased risk of hypertension (hazard ratio [HR] 1.8; 95% confidence interval [CI] 1.1-2.9; p = .01), had higher rates of low- and high-acuity ED visits (rate ratio 1.1; 95% CI 1.1-1.2; p < .001), and increased risk of hospitalization (HR 1.1; 95% CI 1.1-1.2; p < .001). Sibling cases were also more likely to receive preventive health care (p < .05).

CONCLUSION

Increased risk of hypertension, high-acuity ED visits, and hospitalizations suggest that siblings may experience poorer health compared to controls. Counseling families about this potential increased risk and long-term follow-up of siblings to monitor their physical health may be justified.

Parental Response to Only Children: Breaking the Stereotypes

While much has been written about the relationship between only child status and parents' behavior toward children, and consequent personality and intelligence, little is known about the relationship between only child status, parental response to illness, and subsequent child illness behavior. In this study, 227 mothers of 342 children completed measures designed to assess: (a) their children's school attendance, (b) their own psychological status, and (c) their own responses to their children's expressions of stomach pain. Parents of only children were more likely to minimize their children's gastrointestinal symptoms than were parents of children with at least one sibling. In addition, only children were less likely to miss school. Parental protectiveness did not differ as a function of only child status. These findings are somewhat discrepant with commonly held beliefs about parents' patterns of responding to only children.

Receipt of routine preventive care among infant daughters and sons of immigrant mothers in Ontario, Canada: a retrospective cohort study

OBJECTIVES

To explore gender disparities in infant routine preventive care across maternal countries of birth (MCOB) and by mother tongue among infants of Indian-born mothers.

SETTING

Retrospective population-based administrative cohort in Ontario, Canada (births between 2002 and 2014).

PARTICIPANTS

350 366 (inclusive) healthy term singletons belonging to families with a minimum of one opposite gender child.

OUTCOME MEASURES

Fixed effects conditional logistic regression generated adjusted ORs (aORs) for a daughter being underimmunised and having an inadequate number of well-child visits compared with her brother, stratified by MCOB. Moderation by maternal mother tongue was assessed among children to Indian-born mothers.

RESULTS

Underimmunisation and inadequate well-child visits were common among both boys and girls, ranging from 26.5% to 58.2% (underimmunisation) and 10.5% to 47.8% (inadequate well-child visits). depending on the maternal birthplace. Girls whose mothers were born in India had 1.19 times (95% CI 1.07 to 1.33) the adjusted odds of inadequate well-child visits versus their brothers. This association was only observed among the Punjabi mother tongue subgroup (aOR: 1.26, 95% CI 1.08 to 1.47). In the Hindi mother tongue subgroup, girls had lower odds of underimmunisation than their brothers (aOR: 0.73, 95% CI 0.54 to 0.98).

CONCLUSIONS

Gender equity in routine preventive healthcare is mostly achieved among children of immigrants. However, daughters of Indian-born mothers whose mother tongue is Punjabi, appear to be at a disadvantage for well-child visits compared with their brothers. This suggests son preference may persist beyond the family planning stage among some Indian immigrants.

Treatment patterns and outcomes in adolescents and young adults with Hodgkin lymphoma in pediatric versus adult centers: An IMPACT Cohort Study

Hodgkin lymphoma (HL) is a common adolescent and young adult (AYA) cancer. While outcome disparities between pediatric vs. adult centers [locus of care (LOC)] have been demonstrated in other AYA cancers such as acute lymphoblastic leukemia, they have not been well studied in HL. We therefore compared population‐based treatment patterns and outcomes in AYA HL by LOC. The IMPACT Cohort includes data on all Ontario, Canada AYA (15‐21 years) diagnosed with HL between 1992 and 2012. Linkage to population‐based health administrative data identified late effects. We examined LOC‐based differences in treatment modalities, cumulative doses, event‐free survival (EFS), overall survival (OS), and late effects. Among 954 AYA, 711 (74.5%) received therapy at adult centers. Pediatric center AYA experienced higher rates of radiation therapy but lower cumulative doses of doxorubicin and bleomycin. 10‐year EFS did not differ between pediatric vs. adult cancer vs. community centers (83.8% ± 2.4% vs. 82.8% ± 1.6% vs. 82.7%±3.0%; P = .71); LOC was not significantly associated with either EFS or OS in multivariable analyses. Higher incidences of second malignancies in pediatric center AYA and of cardiovascular events in adult center AYA were observed, but were not significant. In conclusion, while pediatric and adult centers used different treatment strategies, outcomes were equivalent. Differences in treatment exposures are however likely to result in different late‐effect risks. Protocol choice should be guided by individual late‐effect risk.

Long-Term Mental Health Outcomes in Mothers and Siblings of Children With Cancer: A Population-Based, Matched Cohort Study

PURPOSE

Although a diagnosis of childhood cancer can have a profound effect on the entire family unit, its impact on the long-term mental health of family members is not well characterized.

METHODS

A provincial childhood cancer registry in Ontario, Canada, was linked to birth records to identify separate population-based cohorts of mothers and siblings of children diagnosed with cancer between 1998 and 2014. The mother and sibling cohorts were matched to corresponding population controls and linked to health services data. The rate of mental health-related outpatient visits (family physician, psychiatrist) and the incidence of severe psychiatric events (psychiatric emergency department visit, psychiatric hospitalization, suicide) were compared between mothers and siblings and their controls. Possible predictors of mental health outcomes were examined, including demographics, characteristics of the cancer-affected child, and cancer treatment.

RESULTS

We identified 4,773 mothers and 7,897 siblings of children diagnosed with cancer during the study period. Compared with controls, both groups experienced elevated rates of outpatient visits (mothers: rate ratio [RR], 1.4; P < .0001; siblings: RR, 1.1; P < .0001). The risk of severe psychiatric events was not increased in either cohort. Mother and sibling demographic factors associated with increased risk of adverse mental health included younger maternal age at cancer diagnosis, low socioeconomic status, and rural residence among mothers and older sibling age among siblings. Treatment-related variables pertaining to the cancer-affected child were not associated with mental health outcomes. Mental health outcomes clustered within families.

CONCLUSION

Both mothers and siblings experience elevated and prolonged need for mental health-related health care as compared with the general population. Demographic risk factors predict subpopulations at highest risk. Increased psychosocial support for family members during and after cancer therapy is warranted.

The use of relative incidence ratios in self-controlled case series studies: an overview

Background

The self-controlled case series (SCCS) is a useful design for investigating associations between outcomes and transient exposures. The SCCS design controls for all fixed covariates, but effect modification can still occur. This can be evaluated by including interaction terms in the model which, when exponentiated, can be interpreted as a relative incidence ratio (RIR): the change in relative incidence (RI) for a unit change in an effect modifier.

Methods

We conducted a scoping review to investigate the use of RIRs in published primary SCCS studies, and conducted a case-study in one of our own primary SCCS studies to illustrate the use of RIRs within an SCCS analysis to investigate subgroup effects in the context of comparing whole cell (wcp) and acellular (acp) pertussis vaccines. Using this case study, we also illustrated the potential utility of RIRs in addressing the healthy vaccinee effect (HVE) in vaccine safety surveillance studies.

Results

Our scoping review identified 122 primary studies reporting an SCCS analysis. Of these, 24 described the use of interaction terms to test for effect modification. 21 of 24 studies reported stratum specific RIs, 22 of 24 reported the p-value for interaction, and less than half (10 of 24) reported the estimate of the interaction term/RIR, the stratum specific RIs and interaction p-values. Our case-study demonstrated that there was a nearly two-fold greater RI of ER visits and admissions following wcp vaccination relative to acp vaccination (RIR = 1.82, 95 % CI 1.64–2.01), where RI estimates in each subgroup were clearly impacted by a strong healthy vaccinee effect.

Conclusions

We demonstrated in our scoping review that calculating RIRs is not a widely utilized strategy. We showed that calculating RIRs across time periods is useful for the detection of relative changes in adverse event rates that might otherwise be missed due to the HVE. Many published studies of vaccine-associated adverse events could have missed/underestimated important safety signals masked by the HVE. With further development, our application of RIRs could be an important tool to address the HVE, particularly in the context of self-controlled study designs.

Motor vehicle crashes during pregnancy and cerebral palsy during infancy: a longitudinal cohort analysis

OBJECTIVES

To assess the incidence of cerebral palsy among children born to mothers who had their pregnancy complicated by a motor vehicle crash.

DESIGN

Retrospective longitudinal cohort analysis of children born from 1 April 2002 to 31 March 2012 in Ontario, Canada.

PARTICIPANTS

Cases defined as pregnancies complicated by a motor vehicle crash and controls as remaining pregnancies with no crash.

MAIN OUTCOME

Subsequent diagnosis of cerebral palsy by age 3 years.

RESULTS

A total of 1 325 660 newborns were analysed, of whom 7933 were involved in a motor vehicle crash during pregnancy. A total of 2328 were subsequently diagnosed with cerebral palsy, equal to an absolute risk of 1.8 per 1000 newborns. For the entire cohort, motor vehicle crashes correlated with a 29% increased risk of subsequent cerebral palsy that was not statistically significant (95% CI -16 to +110, p=0.274). The increased risk was only significant for those with preterm birth who showed an 89% increased risk of subsequent cerebral palsy associated with a motor vehicle crash (95% CI +7 to +266, p=0.037). No significant increase was apparent for those with a term delivery (95% CI -62 to +79, p=0.510). A propensity score-matched analysis of preterm births (n=4384) yielded a 138% increased relative risk of cerebral palsy associated with a motor vehicle crash (95% CI +27 to +349, p=0.007), equal to an absolute increase of about 10.9 additional cases per 1000 newborns (18.2 vs 7.3, p=0.010).

CONCLUSIONS

Motor vehicle crashes during pregnancy may be associated with an increased risk of cerebral palsy among the subgroup of cases with preterm birth. The increase highlights a specific role for traffic safety advice in prenatal care.

Anthropometry, glucose homeostasis, and lipid profile in prepubertal children born early, full, or late term

To examine differences in growth and metabolism in prepubertal children born early term, full term, and late term. We retrospectively studied 294 prepubertal children aged 7.3 years (range 3.0-12.1 years). Children were separated into those born early term (37 0/7-38 6/7 weeks of gestation; n = 68), full term (39 0/7-40 6/7 weeks; n = 179), and late term (41 0/7-41 6/7 weeks; n = 47). Clinical assessments included anthropometry, DXA-derived body composition, fasting lipids, and glucose homeostasis. Statistical models accounted for important confounding factors, such as gender, age, birth weight SDS, birth order, and parental variables. When birth weight was adjusted for sex and gestational age (birth weight SDS), late terms were heavier than both early (p = 0.034) and full (p = 0.020) terms. Early term children were shorter than both full (p = 0.010) and late (p = 0.049) term children, but differences in height disappeared following correction for parents' heights. There were no differences in glucose homeostasis, BMI SDS, adiposity, or fat distribution between groups. Lipid profiles were also similar. When important confounding factors were accounted for, there were no meaningful differences in anthropometry, glucose homeostasis, and lipid profile among children born early term, full term, or late term.