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

OBJECTIVE

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

DESIGN

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

PARTICIPANTS

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

MAIN OUTCOME MEASURE

A GP consultation with a recorded musculoskeletal symptom or diagnosis.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Is obesity more likely among children sharing a household with an older child with obesity? Cross-sectional study of linked National Child Measurement Programme data and electronic health records

BACKGROUND/OBJECTIVES

We identified household members from electronic health records linked to National Child Measurement Programme (NCMP) data to estimate the likelihood of obesity among children living with an older child with obesity.

METHODS

We included 126 829 NCMP participants in four London boroughs and assigned households from encrypted Unique Property Reference Numbers for 115 466 (91.0%). We categorised the ethnic-adjusted body mass index of the youngest and oldest household children (underweight/healthy weight <91st, ≥91st overweight <98th, obesity ≥98th centile) and estimated adjusted ORs and 95% CIs of obesity in the youngest child by the oldest child's weight status, adjusting for number of household children (2, 3 or ≥4), youngest child's sex, ethnicity and school year of NCMP participation.

RESULTS

We identified 19 702 households shared by two or more NCMP participants (% male; median age, range (years)-youngest children: 51.2%; 5.2, 4.1-11.8; oldest children: 50.6%; 10.6, 4.1-11.8). One-third of youngest children with obesity shared a household with another child with obesity (33.2%; 95% CI: 31.2, 35.2), compared with 9.2% (8.8, 9.7) of youngest children with a healthy weight. Youngest children living with an older child considered overweight (OR: 2.33; 95% CI: 2.06, 2.64) or obese (4.59; 4.10, 5.14) were more likely to be living with obesity.

CONCLUSIONS

Identifying children sharing households by linking primary care and school records provides novel insights into the shared weight status of children sharing a household. Qualitative research is needed to understand how food practices vary by household characteristics to increase understanding of how the home environment influences childhood obesity.

Clustering long-term health conditions among 67728 people with multimorbidity using electronic health records in Scotland

There is still limited understanding of how chronic conditions co-occur in patients with multimorbidity and what are the consequences for patients and the health care system. Most reported clusters of conditions have not considered the demographic characteristics of these patients during the clustering process. The study used data for all registered patients that were resident in Fife or Tayside, Scotland and aged 25 years or more on 1st January 2000 and who were followed up until 31st December 2018. We used linked demographic information, and secondary care electronic health records from 1st January 2000. Individuals with at least two of the 31 Elixhauser Comorbidity Index conditions were identified as having multimorbidity. Market basket analysis was used to cluster the conditions for the whole population and then repeatedly stratified by age, sex and deprivation. 318,235 individuals were included in the analysis, with 67,728 (21·3%) having multimorbidity. We identified five distinct clusters of conditions in the population with multimorbidity: alcohol misuse, cancer, obesity, renal failure, and heart failure. Clusters of long-term conditions differed by age, sex and socioeconomic deprivation, with some clusters not present for specific strata and others including additional conditions. These findings highlight the importance of considering demographic factors during both clustering analysis and intervention planning for individuals with multiple long-term conditions. By taking these factors into account, the healthcare system may be better equipped to develop tailored interventions that address the needs of complex patients.

Effect on life expectancy of temporal sequence in a multimorbidity cluster of psychosis, diabetes, and congestive heart failure among 1·7 million individuals in Wales with 20-year follow-up: a retrospective cohort study using linked data

BACKGROUND

To inform targeted public health strategies, it is crucial to understand how coexisting diseases develop over time and their associated impacts on patient outcomes and health-care resources. This study aimed to examine how psychosis, diabetes, and congestive heart failure, in a cluster of physical-mental health multimorbidity, develop and coexist over time, and to assess the associated effects of different temporal sequences of these diseases on life expectancy in Wales.

METHODS

In this retrospective cohort study, we used population-scale, individual-level, anonymised, linked, demographic, administrative, and electronic health record data from the Wales Multimorbidity e-Cohort. We included data on all individuals aged 25 years and older who were living in Wales on Jan 1, 2000 (the start of follow-up), with follow-up continuing until Dec 31, 2019, first break in Welsh residency, or death. Multistate models were applied to these data to model trajectories of disease in multimorbidity and their associated effect on all-cause mortality, accounting for competing risks. Life expectancy was calculated as the restricted mean survival time (bound by the maximum follow-up of 20 years) for each of the transitions from the health states to death. Cox regression models were used to estimate baseline hazards for transitions between health states, adjusted for sex, age, and area-level deprivation (Welsh Index of Multiple Deprivation [WIMD] quintile).

FINDINGS

Our analyses included data for 1 675 585 individuals (811 393 [48·4%] men and 864 192 [51·6%] women) with a median age of 51·0 years (IQR 37·0-65·0) at cohort entry. The order of disease acquisition in cases of multimorbidity had an important and complex association with patient life expectancy. Individuals who developed diabetes, psychosis, and congestive heart failure, in that order (DPC), had reduced life expectancy compared with people who developed the same three conditions in a different order: for a 50-year-old man in the third quintile of the WIMD (on which we based our main analyses to allow comparability), DPC was associated with a loss in life expectancy of 13·23 years (SD 0·80) compared with the general otherwise healthy or otherwise diseased population. Congestive heart failure as a single condition was associated with mean a loss in life expectancy of 12·38 years (0·00), and with a loss of 12·95 years (0·06) when preceded by psychosis and 13·45 years (0·13) when followed by psychosis. Findings were robust in people of older ages, more deprived populations, and women, except that the trajectory of psychosis, congestive heart failure, and diabetes was associated with higher mortality in women than men. Within 5 years of an initial diagnosis of diabetes, the risk of developing psychosis or congestive heart failure, or both, was increased.

INTERPRETATION

The order in which individuals develop psychosis, diabetes, and congestive heart failure as combinations of conditions can substantially affect life expectancy. Multistate models offer a flexible framework to assess temporal sequences of diseases and allow identification of periods of increased risk of developing subsequent conditions and death.

FUNDING

Health Data Research UK.

Implementation of a quality improvement programme using the Active Patient Link call and recall system to improve timeliness and equity of childhood vaccinations: protocol for a mixed-methods evaluation

INTRODUCTION

Call and recall systems provide actionable intelligence to improve equity and timeliness of childhood vaccinations, which have been disrupted during the COVID-19 pandemic. We will evaluate the effectiveness, fidelity and sustainability of a data-enabled quality improvement programme delivered in primary care using an Active Patient Link Immunisation (APL-Imms) call and recall system to improve timeliness and equity of uptake in a multiethnic disadvantaged urban population. We will use qualitative methods to evaluate programme delivery, focusing on uptake and use, implementation barriers and service improvements for clinical and non-clinical primary care staff, its fidelity and sustainability.

METHODS AND ANALYSIS

This is a mixed-methods observational study in 284 general practices in north east London (NEL). The target population will be preschool-aged children eligible to receive diphtheria, tetanus and pertussis (DTaP) or measles, mumps and rubella (MMR) vaccinations and registered with an NEL general practice. The intervention comprises an in-practice call and recall tool, facilitation and training, and financial incentives. The quantitative evaluation will include interrupted time Series analyses and Slope Index of Inequality. The primary outcomes will be the proportion of children receiving at least one dose of a DTaP-containing or MMR vaccination defined, respectively, as administered between age 6 weeks and 6 months or between 12 and 18 months of age. The qualitative evaluation will involve a 'Think Aloud' method and semistructured interviews of stakeholders to assess impact, fidelity and sustainability of the APL-Imms tool, and fidelity of the implementation by facilitators.

ETHICS AND DISSEMINATION

The research team has been granted permission from data controllers in participating practices to use deidentified data for audit purposes. As findings will be specific to the local context, research ethics approval is not required. Results will be disseminated in a peer-reviewed journal and to stakeholders, including parents, health providers and commissioners.

Impact of the COVID-19 pandemic on timeliness and equity of measles, mumps and rubella vaccinations in North East London: a longitudinal study using electronic health records

OBJECTIVES

To quantify the effect of the COVID-19 pandemic on the timeliness of, and geographical and sociodemographic inequalities in, receipt of first measles, mumps and rubella (MMR) vaccination.

DESIGN

Longitudinal study using primary care electronic health records.

SETTING

285 general practices in North East London.

PARTICIPANTS

Children born between 23 August 2017 and 22 September 2018 (pre-pandemic cohort) or between 23 March 2019 and 1 May 2020 (pandemic cohort).

MAIN OUTCOME MEASURE

Receipt of timely MMR vaccination between 12 and 18 months of age.

METHODS

We used logistic regression to estimate the ORs (95% CIs) of receipt of a timely vaccination adjusting for sex, deprivation, ethnic background and Clinical Commissioning Group. We plotted choropleth maps of the proportion receiving timely vaccinations.

RESULTS

Timely MMR receipt fell by 4.0% (95% CI: 3.4% to 4.6%) from 79.2% (78.8% to 79.6%) to 75.2% (74.7% to 75.7%) in the pre-pandemic (n=33 226; 51.3% boys) and pandemic (n=32 446; 51.4%) cohorts, respectively. After adjustment, timely vaccination was less likely in the pandemic cohort (0.79; 0.76 to 0.82), children from black (0.70; 0.65 to 0.76), mixed/other (0.77; 0.72 to 0.82) or with missing (0.77; 0.74 to 0.81) ethnic background, and more likely in girls (1.07; 1.03 to 1.11) and those from South Asian backgrounds (1.39; 1.30 to 1.48). Children living in the least deprived areas were more likely to receive a timely MMR (2.09; 1.78 to 2.46) but there was no interaction between cohorts and deprivation (Wald statistic: 3.44; p=0.49). The proportion of neighbourhoods where less than 60% of children received timely vaccination increased from 7.5% to 12.7% during the pandemic.

CONCLUSIONS

The COVID-19 pandemic was associated with a significant fall in timely MMR receipt and increased geographical clustering of measles susceptibility in an area of historically low and inequitable MMR coverage. Immediate action is needed to avert measles outbreaks and support primary care to deliver timely and equitable vaccinations.

Are children living with obesity more likely to consult their general practitioner for knee pain? Longitudinal analysis of linked primary care and National Child Measurement Programme (NCMP) records

ObjectivesMore than one in four 11-year-old children in England are living with obesity. The implications for future musculoskeletal health remain unclear. We assessed whether general practitioner consultations for knee pain were more likely among children with obesity, and how this varied by sex, ethnic background, and area-level deprivation. ApproachOf 61,478 11-year-old NCMP participants (2013-19), we linked 60,723 (98.8%) to their primary care records. 58,761 children (50.9% male) had no recorded knee pain consultation (including arthralgia and Osgood-Schlatter’s disease) prior to the NCMP measurement date. We calculated the proportion with a consultation for knee pain by ethnic-adjusted weight status (underweight<2nd; overweight≥91st; obese≥98th centile), sex, ethnic background and Index of Multiple Deprivation quintile. We studied time to first general practitioner consultation for knee pain after the NCMP date by fitting Cox proportional hazards models, estimating mutually-adjusted hazard ratios (aHRs) and 95% confidence intervals (CI) for boys and girls separately. ResultsWe identified 2503 (4.3%) children with at least one consultation for knee pain after the NCMP date. Boys were more likely to consult than girls (mean difference 1.5%; 95% CI: 1.2,1.9). Median time to first knee pain consultation was 1.88 years (IQR: 0.94,2.93). In adjusted analyses, boys with underweight (aHR 0.16; 95% CI: 0.05,0.51), from South Asian ethnic backgrounds (0.80; 0.69,0.92) and living in less deprived areas (Wald test statistic: 11.41; p-value=0.0223) were less likely, and those from Black ethnic backgrounds (1.31; 1.13,1.51) more likely, to consult with knee pain. Girls from South Asian ethnic backgrounds (0.70; 0.59,0.84) and those living in less deprived areas (15.44; p-value=0.0039) were less likely, and those with a BMI considered obese (1.30; 1.10,1.54) more likely to do so. ConclusionAdolescent girls, but not boys, living with obesity are more likely to consult their general practitioner with knee pain. Ethnic differences in knee pain consultations merit further study. Linkage of primary care and NCMP records enables greater understanding of health service utilisation by children by weight status and demographic characteristics.

Who lives in overcrowded households in north-east London? Cross-sectional study of linked electronic health records and Energy Performance Certificate register data

ObjectivesHousehold overcrowding is associated with adverse health outcomes, including increased risk of infectious diseases, mental health problems, and poor educational attainment. We investigated inequalities in overcrowding in an urban, ethnically diverse, and disadvantaged London population by pseudonymously linking electronic health records (EHR) to Energy Performance Certificates (EPC) data. ApproachWe used pseudonymised Unique Property Reference Numbers to link EHRs for 1,066,156 currently registered patients from 321,318 households in north-east London to EPC data. We measured household occupancy and derived the bedroom standard overcrowding definition (number of rooms relative to occupants’ sex and ages) to estimate overcrowding prevalence. We examined associations with: household composition (adults only, single adult+children, ≥2 working-age adults+children, ≥1 retirement-age adults+children, three-generational household); ethnic background (White, South Asian, Black, Mixed, Other, missing); and Index of Multiple Deprivation (IMD) quintile. We used multivariable logistic regression to estimate the adjusted odds (aOR) and 95% Confidence Intervals (CI) of overcrowding. ResultsOverall, 243,793 (22.9%) people were overcrowded. People living in households with children, or three-generational households were more likely (aOR [95% CI] 3.79 [3.74 - 3.84]; 6.53 [6.41 - 6.66] respectively), and single adults or retirement age adults with children less likely (0.36 [0.35 - 0.38]; 0.36 [0.23 - 0.57] respectively), to be overcrowded. Overcrowding was more likely among people from Asian or Black ethnic backgrounds (1.24 [1.22 - 1.25] and 1.17 [1.15 - 1.19] respectively). There was a dose-response relationship between IMD quintile and overcrowding: OR 0.20 [0.20 - 0.21] in the least deprived compared to most deprived quintile. ConclusionOne in five people in north-east London live in overcrowded households with marked inequalities by ethnicity, household generational composition, and deprivation. Up-to-date estimates of household overcrowding can be derived from linked housing and health records and used to evaluate the impact of economic policies on health and housing inequalities.

Linking cohort data and Welsh routine health records to investigate children at risk of delayed primary vaccination

BACKGROUND

Delayed primary vaccination is one of the strongest predictors of subsequent incomplete immunisation. Identifying children at risk of such delay may enable targeting of interventions, thus decreasing vaccine-preventable illness.

OBJECTIVES

To explore socio-demographic factors associated with delayed receipt of the Diphtheria, Tetanus and Pertussis (DTP) vaccine.

METHODS

We included 1,782 children, born between 2000 and 2001, participating in the Millennium Cohort Study (MCS) and resident in Wales, whose parents gave consent for linkage to National Community Child Health Database records at the age seven years contact. We examined child, maternal, family and area characteristics associated with delayed receipt of the first dose of the DTP vaccine.

RESULTS

98.6% received the first dose of DTP. The majority, 79.6% (n = 1,429) received it on time (between 8 and 12 weeks of age), 14.2% (n = 251) received it early (prior to 8 weeks of age) and 4.8% (n = 79) were delayed (after 12 weeks of age); 1.4% (n = 23) never received it. Delayed primary vaccination was more likely among children with older natural siblings (risk ratio 3.82, 95% confidence interval (1.97, 7.38)), children admitted to special/intensive care (3.15, (1.65, 5.99)), those whose birth weight was > 4Kg (2.02, (1.09, 3.73)) and boys (1.53, (1.01, 2.31)). There was a reduced risk of delayed vaccination with increasing maternal age (0.73, (0.53, 1.00) per 5 year increase) and for babies born to graduate mothers (0.27, (0.08, 0.90)).

CONCLUSIONS

Although the majority of infants were vaccinated in a timely manner, identification of infants at increased risk of early or delayed vaccination will enable targeting of interventions to facilitate timely immunisation. This is to our knowledge the first study exploring individual level socio-demographic factors associated with delayed primary vaccination in the UK and demonstrates the benefits of linking cohort data to routinely-collected child health data.

Are children with obesity at school entry more likely to have a diagnosis of a musculoskeletal condition? Findings from a systematic review

BACKGROUND

Children with obesity at school entry are at increased risk of persistent obesity throughout childhood and adulthood. Little is known about associations with adverse health outcomes with onset during childhood including those affecting the musculoskeletal system. We examined the association between obesity present at school entry and adverse musculoskeletal diagnoses with onset during childhood.

METHODS

We searched three electronic databases to identify longitudinal studies published in English between January 2000 and June 2022 assessing associations between obesity measured at school entry (around age 5 years) and musculoskeletal diagnoses made before age 20 years. Two reviewers screened titles, abstracts and full-text using EPPI-Reviewer software. Bias and quality of eligible studies were appraised using The Quality Assessment tool for Observational Cohort and Cross-sectional studies and findings synthesised.

RESULTS

We identified four eligible studies from 291 unique records, three conducted in Spain and one in Scotland. These studies reported on 1 232 895 children (available data: 51.4% boys; none reported ethnic distribution) with study sample sizes ranging from <2000 to 600 000 and length of follow-up from 2 to 13 years. Quantitative synthesis of findings across these four studies was not possible due to differences in outcomes and effect sizes reported. Children with obesity at school entry were more likely to receive diagnoses of slipped capital femoral epiphysis, back pain, fractures and musculoskeletal complaints made in primary care settings. Included studies were assessed as of 'fair' to 'good' quality.

CONCLUSION

There is good to fair evidence to suggest children with obesity at school entry are more likely to receive a diagnosis of a musculoskeletal condition during childhood. Further research is needed to replicate these findings in ethnically diverse populations and to investigate whether these are causal associations. The implications of this for children's mobility and quality of life and future musculoskeletal health warrants further assessment.

The association between childhood hearing loss and self-reported peer victimisation, depressive symptoms, and self-harm: longitudinal analyses of a prospective, nationally representative cohort study

BACKGROUND

Childhood hearing loss (HL) predicts poor mental health and is associated with a higher risk of communication difficulties. The relationship of childhood HL with specific types of poor mental health (such as depressive symptoms or self-harm) and peer victimisation remains unclear.

METHODS

We analysed data from the Millennium Cohort Study (MCS), a prospective observational cohort study of children living in the UK at age 9 months and born between 2000 to 2002. Data were available on the children and their families at ages 9 months, then at 3, 5, 7, 11, and 14 years. Participants were 10,858 singleton children with self-reported data on peer victimisation, depressive symptoms, and self-harm at age 14 years. Multivariable logistic regression models were fitted to estimate odds ratios (OR) for HL with peer victimisation, depressive symptoms, and self-harm. HL presence was examined in terms of any HL between ages 9 months and 14 years, as well as by HL trajectory type (defined by onset and persistence). Analyses were adjusted for potential sources of confounding, survey design, and attrition at age 14 years. Interactions between sex and HL were examined in each model and multiple imputation procedures used to address missing data.

RESULTS

Children with any HL had increased odds of depressive symptoms (OR: 1.32, 95% CI: 1.09-1.60), self-harm (1.41, 1.12-1.78) and, in girls only, peer victimisation (girls: 1.81, 1.29-2.55; boys: 1.05, 0.73-1.51), compared to those without HL. HL with later age at onset and persistence to age 14 years was the only trajectory associated with all outcomes.

CONCLUSIONS

Childhood HL may predict peer victimisation (in girls), depressive symptoms, and self-harm. Further research is needed to identify HL trajectories and methods to facilitate good mental health in children with HL.

Early-life respiratory tract infections and the risk of school-age lower lung function and asthma: a meta-analysis of 150 000 European children

Background

Early-life respiratory tract infections might affect chronic obstructive respiratory diseases, but conclusive studies from general populations are lacking. Our objective was to examine if children with early-life respiratory tract infections had increased risks of lower lung function and asthma at school age.

Methods

We used individual participant data of 150 090 children primarily from the EU Child Cohort Network to examine the associations of upper and lower respiratory tract infections from age 6 months to 5 years with forced expiratory volume in 1 s (FEV₁), forced vital capacity (FVC), FEV₁/FVC, forced expiratory flow at 75% of FVC (FEF_75%) and asthma at a median (range) age of 7 (4–15) years.

Results

Children with early-life lower, not upper, respiratory tract infections had a lower school-age FEV₁, FEV₁/FVC and FEF_75% (z-score range: −0.09 (95% CI −0.14– −0.04) to −0.30 (95% CI −0.36– −0.24)). Children with early-life lower respiratory tract infections had a higher increased risk of school-age asthma than those with upper respiratory tract infections (OR range: 2.10 (95% CI 1.98–2.22) to 6.30 (95% CI 5.64–7.04) and 1.25 (95% CI 1.18–1.32) to 1.55 (95% CI 1.47–1.65), respectively). Adjustment for preceding respiratory tract infections slightly decreased the strength of the effects. Observed associations were similar for those with and without early-life wheezing as a proxy for early-life asthma.

Conclusions

Our findings suggest that early-life respiratory tract infections affect development of chronic obstructive respiratory diseases in later life, with the strongest effects for lower respiratory tract infections.

This meta-analysis of 150 000 children suggests that mostly lower respiratory tract infections are associated with an increased risk of asthma and lower lung function. This is independent from preceding respiratory tract infections or early-life asthma.https://bit.ly/3weE62I

Evaluation of the ASSIGN open-source deterministic address-matching algorithm for allocating unique property reference numbers to general practitioner-recorded patient addresses

INTRODUCTION

Linking places to people is a core element of the UK government's geospatial strategy. Matching patient addresses in electronic health records to their Unique Property Reference Numbers (UPRNs) enables spatial linkage for research, innovation and public benefit. Available algorithms are not transparent or evaluated for use with addresses recorded by health care providers.

OBJECTIVES

To describe and quality assure the open-source deterministic ASSIGN address-matching algorithm applied to general practitioner-recorded patient addresses.

METHODS

Best practice standards were used to report the ASSIGN algorithm match rate, sensitivity and positive predictive value using gold-standard datasets from London and Wales. We applied the ASSIGN algorithm to the recorded addresses of a sample of 1,757,018 patients registered with all general practices in north east London. We examined bias in match results for the study population using multivariable analyses to estimate the likelihood of an address-matched UPRN by demographic, registration, and organisational variables.

RESULTS

We found a 99.5% and 99.6% match rate with high sensitivity (0.999,0.998) and positive predictive value (0.996,0.998) for the Welsh and London gold standard datasets respectively, and a 98.6% match rate for the study population.The 1.4% of the study population without a UPRN match were more likely to have changed registered address in the last 12 months (match rate: 95.4%), be from a Chinese ethnic background (95.5%), or registered with a general practice using the SystmOne clinical record system (94.4%). Conversely, people registered for more than 6.5 years with their general practitioner were more likely to have a match (99.4%) than those with shorter registration durations.

CONCLUSIONS

ASSIGN is a highly accurate open-source address-matching algorithm with a high match rate and minimal biases when evaluated against a large sample of general practice-recorded patient addresses. ASSIGN has potential to be used in other address-based datasets including those with information relevant to the wider determinants of health.

Which young women are not being vaccinated against HPV? Cross-sectional analysis of a UK national cohort study

OBJECTIVES

HPV vaccination is highly effective in preventing HPV-associated disease, including cervical cancer, which disproportionately affects women from disadvantaged and minority ethnic backgrounds. We examined inequalities in initiation of the HPV vaccination schedule among young women in the UK and reasons given by their parents for non-initiation.

DESIGN

Cross sectional analyses of a prospective nationally representative cohort study.

SETTING

Four UK countries.

PARTICIPANTS

5,695 young women (39.9% from households in lowest income quintiles, 5.1% ever excluded from school, 0.5% not attending school) whose parents (14.3% from minority ethnic backgrounds; 54.1% with no stated religious faith) took part in interviews conducted when their daughters were 14 years old.

MAIN OUTCOME MEASURES

Parent-reported initiation of HPV vaccination and reasons for non-initiation. The adjusted odds (aORs) and 95% Confidence Intervals (CI) of initiating HPV vaccination were estimated using logistic regression after mutual adjustment for household income, school exclusion, school attendance and parental ethnic background and religious faith.

RESULTS

92.3% (5265) had initiated HPV vaccination at time of interview. Initiation was less likely among those living in the poorest households (aOR; 95% CI: 0.44; 0.30 to 0.64 for those in lowest household income quintile), who did not attend school (0.11; 0.04 to 0.33), had ever been excluded from school (0.47; 0.29 to 0.76), or whose parents were from Black African (0.49; 0.26 to 0.95) or Any Other (0.34; 0.17 to 0.66) ethnic backgrounds. A reason consistent with a conscious or practical decision was reported by 53.3% (219) and 24.1% (90) parents respectively.

CONCLUSIONS

Although most young women are immunised, marked social inequalities in access to HPV vaccination initiation remain. Practical steps to address this are possible and should be implemented to reduce inequalities in primary prevention of cancers and to ensure equitable access to this important public health intervention.

Completeness and representativeness of body mass index in children's electronic general practice records: Linked cross-sectional study in an ethnically-diverse urban population in the United Kingdom

OBJECTIVE

To assess completeness and accuracy of children's body mass index (BMI) recorded in general practice electronic health records (GP-EHRs).

METHODS

We linked National Child Measurement Programme (NCMP) records from 29 839 5-year-olds and 26 660 11-year-olds attending state schools in inner London to GP-EHRs (95% linked; 49.1% girls). We estimated adjusted odds (aOR) of at least one GP-BMI record by sex, ethnic background, area-level deprivation, weight-status and long-term conditions. We examined within-child BMI differences and compared obesity prevalence from these sources.

RESULTS

10.5% (2964/28330) and 26.0% (6598/25365) of 5- and 11-year-olds respectively had at least one GP-BMI record. Underweight (aOR;95% CI:1.71;1.34,2.19), obesity (1.45;1.27,1.65), South Asian background (1.55;1.38,1.74), presence of a long-term condition (8.15;7.31,9.10), and residence in deprived areas (Wald statistic 38.73; P-value<0.0001) were independently associated with at least one GP-BMI record. NCMP-BMI and GP-BMI differed by +0.45(95% Limits of Agreement -1.60,+2.51) and + 0.16(-2.86,+3.18) in 5- and 11-year-olds, respectively. The prevalence of obesity based on GP-BMI was 18.2%(16.1,20.5) and 35.9%(33.9,38.0) in 5- and 11-year-olds respectively, compared to 12.9%(12.5,13.3) and 26.9%(26.4,27.4) based on NCMP-BMI.

CONCLUSION

Child BMI is not comprehensively recorded in urban general practice. Linkage to school measurement records is feasible and enables assessment of health outcomes of obesity.

Is child weight status correctly reported to parents? Cross-sectional analysis of National Child Measurement Programme data using ethnic-specific BMI adjustments

Background

BMI underestimates and overestimates body fat in children from South Asian and Black ethnic groups, respectively.

Methods

We used cross-sectional NCMP data (2015–17) for 38 270 children in three inner-London local authorities: City & Hackney, Newham and Tower Hamlets (41% South Asian, 18.8% Black): 20 439 4–5 year-olds (48.9% girls) and 17 831 10–11 year-olds (49.1% girls). We estimated the proportion of parents who would have received different information about their child’s weight status, and the area-level prevalence of obesity—defined as ≥98th centile—had ethnic-specific BMI adjustments been employed in the English National Child Measurement Programme (NCMP).

Results

Had ethnic-specific adjustment been employed, 19.7% (3112/15 830) of parents of children from South Asian backgrounds would have been informed that their child was in a heavier weight category, and 19.1% (1381/7217) of parents of children from Black backgrounds would have been informed that their child was in a lighter weight category. Ethnic-specific adjustment increased obesity prevalence from 7.9% (95% CI: 7.6, 8.3) to 9.1% (8.7, 9.5) amongst 4–5 year-olds and from 17.5% (16.9, 18.1) to 18.8% (18.2, 19.4) amongst 10–11 year-olds.

Conclusions

Ethnic-specific adjustment in the NCMP would ensure equitable categorization of weight status, provide correct information to parents and support local service provision for families.

Protocol for the development of the Wales Multimorbidity e-Cohort (WMC): data sources and methods to construct a population-based research platform to investigate multimorbidity

INTRODUCTION

Multimorbidity is widely recognised as the presence of two or more concurrent long-term conditions, yet remains a poorly understood global issue despite increasing in prevalence.We have created the Wales Multimorbidity e-Cohort (WMC) to provide an accessible research ready data asset to further the understanding of multimorbidity. Our objectives are to create a platform to support research which would help to understand prevalence, trajectories and determinants in multimorbidity, characterise clusters that lead to highest burden on individuals and healthcare services, and evaluate and provide new multimorbidity phenotypes and algorithms to the National Health Service and research communities to support prevention, healthcare planning and the management of individuals with multimorbidity.

METHODS AND ANALYSIS

The WMC has been created and derived from multisourced demographic, administrative and electronic health record data relating to the Welsh population in the Secure Anonymised Information Linkage (SAIL) Databank. The WMC consists of 2.9 million people alive and living in Wales on the 1 January 2000 with follow-up until 31 December 2019, Welsh residency break or death. Published comorbidity indices and phenotype code lists will be used to measure and conceptualise multimorbidity.Study outcomes will include: (1) a description of multimorbidity using published data phenotype algorithms/ontologies, (2) investigation of the associations between baseline demographic factors and multimorbidity, (3) identification of temporal trajectories of clusters of conditions and multimorbidity and (4) investigation of multimorbidity clusters with poor outcomes such as mortality and high healthcare service utilisation.

ETHICS AND DISSEMINATION

The SAIL Databank independent Information Governance Review Panel has approved this study (SAIL Project: 0911). Study findings will be presented to policy groups, public meetings, national and international conferences, and published in peer-reviewed journals.

Allocating Unique Property Reference Numbers to Patient Addresses Using A Deterministic Address-Matching Algorithm: Evaluation of Accuracy, Match Rate and Bias

IntroductionRepresenting patient-registered addresses as pseudonymised Unique Property Reference Numbers (UPRNs) enables linkage of environmental and household information to electronic health records (EHRs). However, the accuracy and potential biases in address-matching algorithm results applied to patient addresses is unknown. Objectives and ApproachTo investigate accuracy, match rate, and biases in assigning UPRNs to general practitioner (GP)-registered patient addresses for a geographically-defined UK population, using a bespoke deterministic address-matching algorithm comprising 213 rules applied in rank order of minimising false-positives, developed for the Discovery Data Service. We ran this algorithm to match 906,220 adult patient GP-registered addresses (48% female, 47% non-White, 89% 20-64) sampled in mid-2018 from 159 GP practices in four London boroughs to Ordnance Survey’s AddressBase Premium database. We evaluated the error rates using a gold-standard dataset. We used binary logistic regression to estimate the likelihood (Odds Ratio [OR]; 95% Confidence Intervals [CI]) of no UPRN match according to and adjusting for patient age, sex, ethnic background, deprivation, residential mobility and multiple GP registrations. Results96% of patient addresses were successfully assigned a UPRN. Algorithm sensitivity, specificity, positive and negative predictive-values and F-measure were, respectively: 0.993, 0.019, 0.914, 0.204, and 0.9516. After mutual adjustment, UPRN assignment was less likely for: men (OR: 0.87; 95%CI: 0.83,0.91); adolescents and the elderly (15-19 years: 0.57;0.43,0.77; ≥90 years: 0.39;0.18,0.84); those from Chinese ethnic backgrounds (0.87;0.8,0.91), living in the least deprived areas (0.25;0.21,0.31), or with two or more distinct UPRNs across multiple registrations (0.37;0.28,0.49); and more likely for: those from Bangladeshi ethnic backgrounds (1.79;1.61,2.00), registered before 2018 (5.10;4.42,5.87), or with multiple GP registrations (2.36;1.82,3.05). Conclusion / ImplicationsThe Discovery open-source algorithm achieves a high accurate match rate and quantifies the demographic groups that may be under-represented among those successfully matched. This is the first time that bias in matching rates for an address-matching algorithm has been evaluated using patient-registered addresses.

Identifying Patterns of Comorbidities with Cancers of the Colon and Rectum, as Related to age at Diagnosis

IntroductionMulti-morbidity is a widely recognised but poorly understood global issue that appears to be increasing in prevalence, according to the UK’s Academy of Medical Sciences (AMS) report in 2018. Disease clustering, their determinants and consequences are poorly researched. Better understanding would help drive prevention and improved clinical care, services and patient outcomes. Objectives and ApproachDevelopment of two comprehensive population-wide e-cohorts, derived utilising data linkage techniques and including multi-sourced anonymised routine health and demographic data held within the SAIL Databank. The objective is to characterise multi-morbidity and its clustering, determinants and outcomes and compare methods using a) prospective cohort design using multiple data sources in Wales and b) retrospective cohort design to examine household level and environment clustering using GP data in demographically diverse populations (Wales and North East London). The prospective e-cohort focuses on adults living in Wales on 1 st January 2000 and followed up to 2020, including data from the NHS population register, deaths, inpatients, outpatients, Emergency Department, GP, disease registries, laboratory data, and population surveys with QoL measures. This e-cohort will be harmonised with other sites across the UK. The retrospective e-cohort is designed to harmonise with a North East London e-cohort, including all individuals living in Wales on 24 th April 2018 and registered with a GP. Results2.8 and 2.2 million individuals have been included in the prospective and retrospective cohorts respectively, with 43.6 million person years of follow up. Established comorbidity indices and published phenotypes from libraries are being applied to the data to create initial prevalence and incidence estimates for further analysis. Important clusters will be determined by associations with mortality and excess healthcare utilisation. Conclusion/ImplicationsBuilding the e-cohorts has involved multiple disciplines across organisations. Multi-morbidity prevalence estimates and study designs will be compared prior to statistical analyses and machine learning methods to evaluate clustering and determinants.

Behavioural difficulties in early childhood and risk of adolescent injury

OBJECTIVE

To evaluate long-term associations between early childhood hyperactivity and conduct problems (CP), measured using Strengths and Difficulties Questionnaire (SDQ) and risk of injury in early adolescence.

DESIGN

Data linkage between a longitudinal birth cohort and routinely collected electronic health records.

SETTING

Consenting Millennium Cohort Study (MCS) participants residing in Wales and Scotland.

PATIENTS

3119 children who participated in the age 5 MCS interview.

MAIN OUTCOME MEASURES

Children with parent-reported SDQ scores were linked with hospital admission and Accident & Emergency (A&E) department records for injuries between ages 9 and 14 years. Negative binomial regression models adjusting for number of people in the household, lone parent, residential area, household poverty, maternal age and academic qualification, child sex, physical activity level and country of interview were fitted in the models.

RESULTS

46% of children attended A&E or were admitted to hospital for injury, and 11% had high/abnormal scores for hyperactivity and CP. High/abnormal or borderline hyperactivity were not significantly associated with risk of injury, incidence rate ratio (IRR) with 95% CI of the high/abnormal and borderline were 0.92 (95% CI 0.74 to 1.14) and 1.16 (95% CI 0.88 to 1.52), respectively. Children with borderline CP had higher injury rates compared with those without CP (IRR 1.31, 95% CI 1.09 to 1.57).

CONCLUSIONS

Children with high/abnormal hyperactivity or CP scores were not at increased risk of injury; however, those with borderline CP had higher injury rates. Further research is needed to understand if those with difficulties receive treatment and support, which may reduce the likelihood of injuries.

Risk factors for permanent childhood hearing impairment

OBJECTIVE

While several perinatal risk factors for permanent childhood hearing impairment (PCHI) are known, association with gestational length remains unclear. We hypothesised that shorter gestational length predicts higher PCHI risk.

DESIGN

19 504 participants from the UK Millennium Cohort Study (born 2000-2002, prior to newborn screening).

METHODS

Multivariable discrete-time survival analysis to examine associations between parent-reported PCHI by age 11 years and gestational length, plus other prespecified factors.

RESULTS

PCHI affected 2.1 per 1000 children (95% CI 1.5 to 3.0) by age 11; however, gestational length did not predict PCHI risk (HR, 95% CI 1.00, 0.98 to 1.03 per day increase). Risk was increased in those with neonatal illness, with or without admission to neonatal care (6.33, 2.27 to 17.63 and 2.62, 1.15 to 5.97, respectively), of Bangladeshi or Pakistani ethnicity (2.78, 1.06 to 7.31) or born to younger mothers (0.92, 0.87 to 0.97 per year).

CONCLUSION

Neonatal illness, rather than gestational length, predicts PCHI risk. Further research should explore associations with ethnicity.

Quantifying multi-morbidity in an ethnically-diverse inner city population: the health burden of households

Background with rationaleNew insights into the wider demographic context of multimorbidity has been prioritised, notably among disadvantaged and ethnically-diverse populations with a high disease burden. We propose an innovative approach to quantify health burden and disease clustering at household level, to enable predictors of household multimorbidity to be investigated and understood. Main AimTo quantify multi-morbidity at the household level using general practitioner (GP) electronic health records (EHRs) in a geographically-defined ethnically-diverse inner city population. MethodsWe extracted clinical and patient address data from GP EHRs from four east London boroughs (Tower Hamlets, Newham, Waltham Forest and City & Hackney). We included currently registered patients aged ≥18 years as at July 2018, and excluded those with duplicate or complex registrations, new registrations in the previous 12 months, or registrations without historical clinical data or occurring prior to 1948, as well as inactive patients with no recorded EHR activity in varying years depending on age and gender. We defined multimorbidity using 16 long-term condition Read codesets defined in the Quality and Outcomes Framework. We grouped patients into households, defined as those sharing the same home address on their GP registration, represented by a pseudonymised Unique Property Reference Number. ResultsProvisional data are presented. We identified 737,920 patients (51% female) eligible for this study out of a total population of 1,171,483 currently registered patients. Of these, 23% aged <20, 69% aged 20-64, 8% aged >=65, 38% White ethnicity, 3% Mixed, 30% Asian, 14% Black, 5% Other and 12% Not Stated/Null. We identified 312,582 shared households among 737,920 patients. Analyses to derive household-level summary characteristics and relate these to multimorbidity burden are in progress and will be presented. ConclusionHousehold-level multi-morbidity can be quantified using clinical and patient address data in GP electronic health records.

Allocating Unique Property Reference Numbers (UPRNs) to general practitioner-recorded patient addresses using a deterministic address-matching algorithm: evaluation of representativeness and bias in an ethnically-diverse inner city population

Background with rationalePseudonymised UPRNs based on patient addresses can be used to link environmental information to electronic health records (EHRs), however the representativeness and potential demographic or health-related biases in linkage using existing address-matching algorithms have not been evaluated using patient addresses. Main AimTo evaluate representativeness and bias in assigning UPRNs using an address-matching algorithm based on general practitioner (GP)-recorded patient addresses for a geographically-defined multi-ethnic inner city population. MethodsWe evaluated the Discovery Programme deterministic address-matching algorithm, comprising 213 rules applied, in rank order of minimising false positives, to the GP-recorded address of 879,286 (48% female) patients currently registered with all GP practices in four boroughs in inner east London. We used logistic regression to estimate the adjusted odds (aOR) of an address not being linked to a UPRN by: age band (reference group: <1 year), sex (female), ethnic group (White British), Index of Multiple Deprivation (IMD) quintile (most deprived), number of long-term conditions (none); and timing of GP registration (most recent quartile). We evaluated the linkage and algorithm error rates in an independent validated NHS address dataset using best practice linkage reporting standards. Results99% of patients had a UPRN assigned. Men (aOR;95%CI:0.87;0.8,0.91), and patients aged 15-19 (0.51;0.39,0.68), 20-24 (0.67;0.51,0.89), or ≥90 years (0.35;0.83,0.91), of Chinese ethnic background (95% CI; 0.50; 0.45,0.56), or living in the least deprived IMD quintile (0.24; 0.20,0.30) were less likely, and those with a GP-registration preceding mid-2016 (p-value0.00) more likely, to have a UPRN assigned. The sensitivity, specificity, positive and negative predictive-values and F-measure of the algorithm were, respectively: 0.993, 0.019, 0.914, 0.204, and 0.9516. ConclusionWe have demonstrated, for the first time, a high GP-address UPRN match rate and quantified error rates and biases for users. Further work is needed to investigate addresses in patients with more complex address histories.

How complete, representative and accurate is recording of child BMI in electronic general practice records? A record linkage study

Background with rationaleGeneral practitioner (GP) electronic health records (EHRs) are a potentially valuable, but unevaluated, source of child BMI measurements to inform clinical practice and research. Main AimTo assess representativeness and accuracy of child GP-BMI records. MethodsWe linked school National Child Measurement Programme (NCMP) records from 29,839 five-year-olds (49.1% girls) and 26,660 11-year-olds (49.1% girls) in City & Hackney (2013-17), Newham (2014-17) and Tower Hamlets (2015-17) to GP EHRs using pseudonymised NHS numbers (94.9% and 95.1% linked, respectively) and identified GP-BMI measurements using Read code “22K..”. We estimated adjusted odds ratios (aOR) of at least one GP-BMI by: sex (reference category: male); ethnic background (White); area-level deprivation (most deprived Index of Multiple Deprivation quintile); weight status (healthy weight; clinical UK1990); and long-term condition (none). We estimated mean BMI difference (NCMP-BMI minus GP-BMI kg/m2) and 95% Limits of Agreement (LoA; Bland and Altman method). ResultsWe identified at least one GP-BMI in 10.5% (2,964/28,330) and 26.0% (6,598/25,365) of 5- and 11-year-olds respectively. Five-year-old children who were underweight (aOR; 95% CI: 1.70; 1.28,2.25) or obese (1.45; 1.28,1.65), from South Asian backgrounds (1.63; 1.45,1.80) and with long-term conditions (9.58; 8.13,11.28) were more likely, and girls (0.88; 0.81,0.95) and those from less deprived areas (Wald statistic; p-value: 40.06; <0.0001) less likely, to have at least one GP-BMI measurement recorded. Findings among 11-year-olds were similar. We identified GP-BMI measurements made within one month of NCMP-BMI in 5.4% (160/2,964) of 5-year-olds and 4.0% (263/6,598) of 11-year-olds. There was poor agreement between NCMP-BMI and GP-BMI: mean difference (95% LoA): +0.55 (-2.49,+3.58) and +0.16 (-2.85,+3.18) in five- and 11-year-olds respectively. ConclusionChild BMI is not comprehensively recorded in UK GP settings. Access to BMI school measurements in GP settings could support discussions about child weight status between children, their families and general practitioners.

Does parental concern about their child's future risk of overweight vary by their ethnic background? Cross-sectional analysis of a national cohort study

OBJECTIVES

Children from South Asian ethnic backgrounds are at increased risk of obesity and its associated future health risks; however, evidence is lacking as to whether parental concern about their child's future overweight risk varies by ethnic background. We hypothesised that parents of 5-year-old children from South Asian backgrounds would be more likely to express such concerns.

DESIGN

Cross-sectional.

SETTING

UK.

PARTICIPANTS

15 039 singleton 5-year-old Millennium Cohort Study participants (48.9% girls; 86.7% White).

PRIMARY OUTCOME MEASURE

Parent-reported concern (some/none) about future overweight risk.

METHODS

We estimated the adjusted ORs (aORs) of some parental concern (ranging from a little to very concerned) by child's ethnic background (reference group: White), adjusted for parent and child weight status, and child sex.

RESULTS

Parents of girls from Pakistani (aOR 0.4; 95% CI 0.2 to 0.5), Bangladeshi (0.3; 0.2 to 0.5), Black African (0.5; 0.3 to 0.7) and Mixed (0.7; 0.5 to 0.99) ethnic backgrounds and of boys from Pakistani ethnic backgrounds (0.6; 0.4 to 0.9) were less likely to report concern about their child's future overweight risk than parents of White girls and boys, respectively. Overweight (2.5; 2.2 to 2.8) and obesity (6.7; 5.7 to 7.9) in children, and overweight (1.4; 1.2 to 1.5) and obesity (1.9; 1.7 to 2.2) in parents, were associated with increased likelihood of concern.

CONCLUSIONS

Parents of children from South Asian ethnic backgrounds express less concern about their child's future overweight risk. Qualitative studies are needed to understand the concerns of parents from different ethnic backgrounds to inform weight-management interventions in ethnically diverse populations.

Physical activity among children with asthma: Cross-sectional analysis in the UK millennium cohort

BACKGROUND

Although beneficial for health and well-being, most children do not achieve recommended levels of physical activity. Evidence for children with asthma is mixed, with symptom severity rarely considered. This paper aimed to address this gap.

METHODS

We analyzed cross-sectional associations between physical activity and parent-reported asthma symptoms and severity for 6497 UK Millennium Cohort Study 7-year-old participants (3321, [49%] girls). Primary outcomes were daily moderate-to-vigorous physical activity (MVPA, minutes) and proportion of children achieving recommended minimum daily levels of 60 minutes of MVPA. Daily steps, sedentary time, and total activity counts per minute (cpm) were recorded, as were parent-reported asthma symptoms, medications, and recent hospital admissions. Associations were investigated using quantile (continuous outcomes) and Poisson (binary outcomes) regression, adjusting for demographic, socioeconomic, health, and environmental factors.

RESULTS

Neither asthma status nor severity was associated with MVPA; children recently hospitalized for asthma were less likely to achieve recommended daily MVPA (risk ratio [95% confidence interval [CI]]: 0.67 [0.44, 1.03]). Recent wheeze, current asthma, and severe asthma symptoms were associated with fewer sedentary hours (difference in medians [95% CI]: -0.18 [-0.27, -0.08]; -0.14 [-0.24, -0.05]; -0.15, [-0.28, -0.02], respectively) and hospital admission with lower total activity (-48 cpm [-68, -28]).

CONCLUSION

Children with asthma are as physically active as their asthma-free counterparts, while those recently hospitalized for asthma are less active. Qualitative studies are needed to understand the perceptions of children and families about physical activity following hospital admission and to inform support and advice needed to maintain active lifestyles for children with asthma.

Are children with clinical obesity at increased risk of inpatient hospital admissions? An analysis using linked electronic health records in the UK millennium cohort study

BACKGROUND

Few studies have examined health service utilization of children with overweight or obesity by using linked electronic health records (EHRs).

OBJECTIVE/METHODS

We analysed EHRs from 3269 children (1678 boys; 51.3% [weighted]) participating in the Millennium Cohort Study, living in Wales or Scotland at age seven whose parents consented to record linkage. We used height and weight measurements at age five to categorize children as obese (>98th centile) or overweight (>91st centile) (UK1990 clinical reference standards) and linked to hospital admissions, up to age 14 years, in the Patient Episode Database for Wales and Scottish Morbidity Records. Negative binomial regression models compared rates of inpatient admissions by weight status at age five.

RESULTS

At age five, 11.5% and 6.7% of children were overweight or obese, respectively; 1221 (38%) children were subsequently admitted to hospital at least once. Admissions were not increased among children with overweight or obesity (adjusted rate ratio [RR], 95% confidence interval [CI]: 0.87, 0.68-1.10 and 1.16, 0.87-1.54, respectively).

CONCLUSIONS

In this nationally representative cohort of children in Wales and Scotland, those with overweight or obesity at entry to primary school did not have increased rates of hospital admissions in later childhood and early adolescence.

Record linkage to enhance consented cohort and routinely collected health data from a UK birth cohort

Background

In longitudinal health research, combining the richness of cohort data to the extensiveness of routine data opens up new possibilities, providing information not available from one data source alone. In this study, we set out to extend information from a longitudinal birth cohort study by linking to the cohort child’s routine primary and secondary health care data. The resulting linked datasets will be used to examine health outcomes and patterns of health service utilisation for a set of common childhood health problems. We describe the experiences and challenges of acquiring and linking electronic health records for participants in a national longitudinal study, the UK Millennium Cohort Study (MCS).

Method

Written parental consent to link routine health data to survey responses of the MCS cohort member, mother and her partner was obtained for 90.7% of respondents when interviews took place at age seven years in the MCS. Probabilistic and deterministic linkage was used to link MCS cohort members to multiple routinely-collected health data sources in Wales and Scotland.

Results

Overall linkage rates for the consented population using country-specific health service data sources were 97.6% for Scotland and 99.9% for Wales. Linkage rates between different health data sources ranged from 65.3% to 99.6%. Issues relating to acquisition and linkage of data sources are discussed.

Conclusions

Linking longitudinal cohort participants with routine data sources is becoming increasingly popular in population data research. Our results suggest that this is a valid method to enhance information held in both sources of data.

Newborn Screening for Primary Congenital Hypothyroidism: Estimating Test Performance at Different TSH Thresholds

CONTEXT

Active surveillance of primary congenital hypothyroidism (CH) in a multiethnic population with established newborn bloodspot screening.

OBJECTIVE

To estimate performance of newborn screening for CH at different test thresholds and calculate incidence of primary CH.

DESIGN

Prospective surveillance from June 2011 to June 2012 with 3-year follow-up of outcomes. Relative likelihood ratios (rLRs) estimated to compare bloodspot TSH test thresholds of 6 mU/L and 8 mU/L, with the nationally recommended standard of 10 mU/L for a presumptive positive result.

SETTING

UK National Health Service.

PATIENTS

Clinician notification of children aged <5 years investigated following clinical presentation or presumptive positive screening result.

MAIN OUTCOME MEASURE(S)

Permanent primary CH status determined by clinician report of continuing T4 requirement at 3-year follow-up.

RESULTS

A total of 629 newborns (58.3% girls; 58.7% white ethnicity) were investigated following presumptive positive screening result and 21 children (52.4% girls; 52.4% white) after clinical presentation; 432 remained on treatment at 3-year follow-up. Permanent CH incidence was 5.3 (95% CI, 4.8 to 5.8) per 10,000 infants. With use of locally applied thresholds, sensitivity, specificity, and positive predictive value were 96.76%, 99.97%, and 66.88%, respectively. Compared with a TSH threshold of 10 mU/L, positive rLRs for 8 mU/L and 6 mU/L were 1.20 (95% CI, 0.82 to 1.75) and 0.52 (95% CI, 0.38 to 0.72), and negative rLRs were 0.11 (95% CI, 0.03 to 0.36) and 0.11 (95% CI, 0.06 to 0.20), respectively.

CONCLUSIONS

Screening program performance is good, but a TSH threshold of 8 mU/L appears superior to the current national standard (10 mU/L) and requires further evaluation. Further research should explore the implications of transient CH for screening policy.

Analysis of factors associated with changing general practice in the first 14 years of life in Wales using linked cohort and primary care records: implications for using primary care databanks for life course research

IntroductionPrimary care electronic health records (pcEHRs) are a valuable resource for life course research, however loss to follow up due to changing practices has received little attention. We investigated factors associated with changes in registration and record continuity in the Secure Anonymised Information Linkage (SAIL) databank, with ~80% practice coverage. Objectives and ApproachWe analysed linked pcEHRs for 1834 (882 girls) Millennium Cohort Study (MCS) participants, resident in Wales and with parental consent to health record linkage at the age seven MCS interview. We studied time from first to next general practice (GP) registration in Wales by fitting Cox proportional hazards models, and estimated mutually-adjusted hazard ratios (aHRs) for the following factors: child (sex, ethnicity, mode of delivery, gestation, birthweight, neonatal illness, wheeze, longstanding illness); maternal (age, education, lone parent status); household (income, housing tenure, residential mobility, urban/rural residence); GP type (SAIL-contributing/-non-contributing). Analyses were weighted for survey design (Stata: Release 15; StataCorp LP). ResultsThere were 3065 Welsh GP registrations for 1834 children. By age 5 years, 25% of children changed GP at least once, with 1070 (58.3%), 477 (26.0%) and 287 (15.7%) registered with 1, 2, 3+ GPs respectively up to 14 years of age. Children with older mothers (aHRs; 95% CI: 0.96; 0.95, 0.98; per year) or those residing in rural areas (0.75;0.56,0.99) were less likely, and those whose first registration was not with a SAIL contributing GP (2.16;1.60,2.93), whose mothers had no educational qualifications (1.40;1.15,1.71), or had recently changed address (1.62;1.21,2.16) more likely, to change GP. 305 (16.6%) children had never registered with a SAIL-contributing GP. Of 403 children initially registered with a SAIL contributing GP who then changed GP, 66.7% re-registered with a SAIL contributing GP. Conclusion/ImplicationsGeographically contiguous primary care databanks, such as the SAIL databank, enable a high proportion of children to be reliably followed over time despite changing GP. Similar analyses of databases based on geographically disparate volunteer GPs are needed to quality assure their suitability for life course epidemiology research.

Harmonising data from different sources to conduct research using linked survey and routine datasets

IntroductionHarmonization of different data sources from various electronic health records across systems enhances the potential scope and granularity of data available to health data research, providing more opportunities for research by improving the generalizability and effective sample size of a range of outcome metrics. Objectives and ApproachThis study describes data harmonisation for a UK longitudinal birth cohort, the Millennium Cohort Study (MCS) which was linked to routine inpatient and emergency department, and, where available, general practice and child health records for 1838 Welsh and 1431 Scottish consenting MCS participants. Datasets requiring harmonisation were: from Wales, Patient Episode Dataset for Wales (PEDW) and Emergency Department Data Set (EDDS) data and from Scotland, Scottish Medical Record 01 (SMR01) and Accident and Emergency dataset (A&E2). Heterogeneous variables were created by transforming variable names, concepts, codes to improve scope for analysis. ResultsA harmonized dataset of 2166 participants and 5747 hospital admissions were derived of cohort members who had at least 1 hospital inpatient or A&E event before their 14th birthday. Harmonisation included: dealing with date granularity by generating random dates of birth; standardising periods of data collection; identifying inconsistencies and then mapping and bridging differences in definitions of periods of care and levels of diagnostic and operational coding across countries and datasets. Conclusion/ImplicationsHeterogeneous variables from different data sources were pooled and converted into standardised data for research, extending existing harmonisation work, including curation of a population based anonymously linkable longitudinal cohort. [AA1] These methods are reproducible and can be utilised by other researchers and projects applying to use these routine data sources.

Integrating electronic health records from different sources across the UK: lessons from a record linkage study

BackgroundHarmonisation of different data sources from various electronic health records (EHRs) across systems enhances the potential scope and granularity of data available to health data research. ObjectiveTo describe data harmonisation of routine electronic healthcare records in Wales and Scotland linked to a UK longitudinal birth cohort, the Millennium Cohort Study (MCS). MethodsComparable secondary care data was linked, with parental consent, to MCS information for 1838 and 1431 children participating in MCS and residing in Wales and Scotland, by assigning, respectively, unique Anonymised Linkage Fields to personbased records in the privacy protecting Secure Anonymised Information Linkage (SAIL) databank at Swansea University, and by the National Health Service (NHS) Information Standards Division. Survey and non-response weights were created to account for the clustered sample, sample attrition and consent to linkage. Heterogeneous variables from the Patient Episode Dataset for Wales, Emergency Department Data Set for Wales, Scottish Medical Record 01 and Accident and Emergency dataset for Scotland were harmonised enabling data to be pooled and standardised for research. FindingsOverall linkage to harmonised health care data was achieved for 98.9% (99.9% for Wales and 97.6% for Scotland) of consented MCS participants. 66% of children experienced at least one hospital admission (total 5747 hospital admissions) up totheir 14th birthday, while 60% attended A&E departments at least once (total 5221 attendances) between their 9th and 14th birthday. We managed date granularity by generating random dates of birth, standardising periods of data collection,identifying inconsistencies and then mapping and bridging differences in definitions of periods of care across countries and datasets. ConclusionsCombining and harmonising data from multiple sources and linking them to information from a longitudinal cohort create useful resources for population health research. These methods are reproducible and can be utilised by other researchersand projects.

Analysis of factors associated with changing general practice in the first 14 years of life in Wales using linked cohort and primary care records: implications for using primary care databanks for life-course research

Background Databanks of primary care electronic health records (pcEHRs) are a valuable resource for life course research, however loss to follow up due to changing general practice has received little attention. ObjectiveWe investigated factors associated with changing general practice (GP) in early life and continuity of participation in the Secure Anonymised Information Linkage (SAIL) databank, to which approximately 80% of Welsh practices contribute. MethodsWe analysed linked pcEHRs for 1834 (882 girls) Millennium Cohort Study participants, resident in Wales, with consent to health record linkage. We studied time from first to next practice registration using Cox proportional hazards models, and estimated mutually-adjusted hazard ratios (aHRs) for child, household and practice factors. FindingsThere were 3065 Welsh GP registrations for 1834 children. By age 5 years, 25% changed practice at least once, with 1070 (58.3%), 477 (26.0%), 287 (15.7%) registered with 1, 2, or 3+ GPs respectively by age 14 years. Changing practice was related to maternal age (aHRs; 95% CI: 0.96; 0.95,0.98), living in rural areas (0.75;0.56,0.99), initial registration with a non-SAIL-practice (2.16;1.60,2.93), recent address change (1.62;1.21,2.16), and no maternal educational qualifications (1.40;1.15,1.71). Overall, 305 (16.6%) children had never registered with a SAIL practice. Of 403 children initially registered with a SAIL practice who then changed practice, 66.7% re-registered with a SAIL practice. ConclusionsIn a nationally representative sample of Welsh children, the majority remained registered with the same practice up to age 14 years, with change in practice varying by maternal and household factors. Continuity of participation in the Welsh SAIL databank over early life is high, reflecting the high proportion of practices contributing, and the high proportion of children registered with them. Geographically contiguous primary care databanks, such as SAIL, enable a high proportion of children to be followed over time despite changing general practice.

Childhood asthma prevalence: cross-sectional record linkage study comparing parent-reported wheeze with general practitioner-recorded asthma diagnoses from primary care electronic health records in Wales

Introduction

Electronic health records (EHRs) are increasingly used to estimate the prevalence of childhood asthma. The relation of these estimates to those obtained from parent-reported wheezing suggestive of asthma is unclear. We hypothesised that parent-reported wheezing would be more prevalent than general practitioner (GP)-recorded asthma diagnoses in preschool-aged children.

Methods

1529 of 1840 (83%) Millennium Cohort Study children registered with GPs in the Welsh Secure Anonymised Information Linkage databank were linked. Prevalences of parent-reported wheezing and GP-recorded asthma diagnoses in the previous 12 months were estimated, respectively, from parent report at ages 3, 5, 7 and 11 years, and from Read codes for asthma diagnoses and prescriptions based on GP EHRs over the same time period. Prevalences were weighted to account for clustered survey design and non-response. Cohen’s kappa statistics were used to assess agreement.

Results

Parent-reported wheezing was more prevalent than GP-recorded asthma diagnoses at 3 and 5 years. Both diminished with age: by age 11, prevalences of parent-reported wheezing and GP-recorded asthma diagnosis were 12.9% (95% CI 10.6 to 15.4) and 10.9% (8.8 to 13.3), respectively (difference: 2% (−0.5 to 4.5)). Other GP-recorded respiratory diagnoses accounted for 45.7% (95% CI 37.7 to 53.9) and 44.8% (33.9 to 56.2) of the excess in parent-reported wheezing at ages 3 and 5 years, respectively.

Conclusion

Parent-reported wheezing is more prevalent than GP-recorded asthma diagnoses in the preschool years, and this difference diminishes in primary school-aged children. Further research is needed to evaluate the implications of these differences for the characterisation of longitudinal childhood asthma phenotypes from EHRs.

Measuring the timeliness of childhood vaccinations: Using cohort data and routine health records to evaluate quality of immunisation services

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Most children received the first dose of primary vaccines on time.

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Timeliness of vaccination decreased with vaccine dose.

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Most children had appropriate intervals between doses; marked variation occurred.

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The quality of routine vaccination records in Wales is high.

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Parental report of MMR status is reliable.

Background

To achieve full benefits of vaccination programmes, high uptake and timely receipt of vaccinations are required.

Objectives

To examine uptake and timeliness of infant and pre-school booster vaccines using cohort study data linked to health records.

Methods

We included 1782 children, born between 2000 and 2001, participating in the Millennium Cohort Study and resident in Wales, whose parents gave consent for linkage to National Community Child Health Database records at the age seven year contact. We examined age at receipt, timeliness of vaccination (early, on-time, delayed, or never), and intervals between vaccine doses, based on the recommended schedule for children at that time, of the following vaccines: primary (diphtheria, tetanus, pertussis (DTP), polio, Meningococcal C (Men C), Haemophilus influenzae type b (Hib)); first dose of measles, mumps and rubella (MMR); and pre-school childhood vaccinations (DTP, polio, MMR). We compared parental report with child health recorded MMR vaccination status at age three years.

Results

While 94% of children received the first dose of primary vaccines early or on time, this was lower for subsequent doses (82%, 65% and 88% for second and third doses and pre-school booster respectively). Median intervals between doses exceeded the recommended schedule for all but the first dose with marked variation between children. There was high concordance (97%) between parental reported and child health recorded MMR status.

Conclusions

Routine immunisation records provide useful information on timely receipt of vaccines and can be used to assess the quality of childhood vaccination programmes. Parental report of MMR vaccine status is reliable.

Self-Reported Health Experiences of Children Living with Congenital Heart Defects: Including Patient-Reported Outcomes in a National Cohort Study

BACKGROUND

Understanding children's views about living with congenital heart defects (CHDs) is fundamental to supporting their successful participation in daily life, school and peer relationships. As an adjunct to a health and quality of life outcomes questionnaire, we asked school-age children who survived infant heart procedures to describe their experiences of living with CHDs.

METHODS

In a UK-wide cohort study, children aged 10 to 14 years with CHDs self-completed postal questionnaires that included an open question about having a 'heart problem'. We compared the characteristics of children with more and less severe cardiac diagnoses and, through collaborative inductive content analysis, investigated the subjective experiences and coping strategies described by children in both clinical severity groups.

RESULTS

Text and/or drawings were returned by 436 children (246 boys [56%], mean age 12.1 years [SD 1.0; range 10-14]); 313 had less severe (LS) and 123 more severe (MS) cardiac diagnoses. At the most recent hospital visit, a higher proportion of the MS group were underweight (more than two standard deviations below the mean for age) or cyanosed (underweight: MS 20.0%, LS 9.9%; cyanosed: MS 26.2%, LS 3.5%). Children in the MS group described concerns about social isolation and feeling 'different', whereas children with less severe diagnoses often characterised their CHD as 'not a big thing'. Some coping strategies were common to both severity groups, including managing health information to avoid social exclusion, however only children in the LS group considered their CHD 'in the past' or experienced a sense of survivorship.

CONCLUSIONS

Children's reported experiences were not dependent on their cardiac diagnosis, although there were clear qualitative differences by clinical severity group. Children's concerns emphasised social participation and our findings imply a need to shift the clinical focus from monitoring cardiac function to optimising participation. We highlight the potential for informing and evaluating clinical practice and service provision through seeking patient-reported outcomes in paediatric care.

Objectively measured physical activity and sedentary time: cross-sectional and prospective associations with adiposity in the Millennium Cohort Study

OBJECTIVE

To examine whether physical activity (PA) and sedentary time (ST) in primary school-aged children are associated with adiposity at the start of secondary school, and whether these associations differ by sex or ethnic group.

DESIGN

Nationally representative prospective cohort study.

SETTING

Children born across the UK, between 2000 and 2002.

PARTICIPANTS

6497 singleton children.

OUTCOME MEASURES

Measures of adiposity (body mass index (BMI), fat mass index (FMI) and fat free mass index (FFMI))--obtained at 7 and 11 years.

EXPLANATORY MEASURES

Total daily PA (mean counts per minute (cpm)); minutes of moderate-to-vigorous PA (MVPA); and ST. All assessed at 7 years using accelerometers.

RESULTS

In cross-sectional analyses, total PA was inversely associated with FMI (3.7% (95% CI 2.7% to 4.7%) reduction per 150 cpm increase), as was MVPA (4.2% (CI 3.2% to 5.2%) reduction per 20 min/day increase). Associations were stronger in black and South Asian ethnic groups. Total PA and MVPA were not associated with FFMI. ST was positively associated with FMI (1.3% (CI 0.2% to 2.3%) increase per 50 min/day increase) and inversely associated with FFMI (0.5% (CI 0.2% to 0.7%) reduction per 50 min/day increase). Longitudinally, MVPA at age 7 years remained inversely associated with FMI at age 11 years (1.5% (CI 0.4% to 2.6%) reduction per 20 min/day increase). No association was found between total PA and ST and any of the later adiposity measures.

CONCLUSIONS

7-year-old children who are more physically active are less likely to be obese at that age and at age 11 years. These associations were particularly evident in children from black or South Asian ethnicity at age 7 years and in boys at age 11 years. Measurements of fat mass provide valuable insights into ethnic differences in associations between adiposity and activity.

Modelling survival and mortality risk to 15 years of age for a national cohort of children with serious congenital heart defects diagnosed in infancy

BACKGROUND

Congenital heart defects (CHDs) are a significant cause of death in infancy. Although contemporary management ensures that 80% of affected children reach adulthood, post-infant mortality and factors associated with death during childhood are not well-characterised. Using data from a UK-wide multicentre birth cohort of children with serious CHDs, we observed survival and investigated independent predictors of mortality up to age 15 years.

METHODS

Data were extracted retrospectively from hospital records and death certificates of 3,897 children (57% boys) in a prospectively identified cohort, born 1992-1995 with CHDs requiring intervention or resulting in death before age one year. A discrete-time survival model accounted for time-varying predictors; hazards ratios were estimated for mortality. Incomplete data were addressed through multilevel multiple imputation.

FINDINGS

By age 15 years, 932 children had died; 144 died without any procedure. Survival to one year was 79.8% (95% confidence intervals [CI] 78.5, 81.1%) and to 15 years was 71.7% (63.9, 73.4%), with variation by cardiac diagnosis. Importantly, 20% of cohort deaths occurred after age one year. Models using imputed data (including all children from birth) demonstrated higher mortality risk as independently associated with cardiac diagnosis, female sex, preterm birth, having additional cardiac defects or non-cardiac malformations. In models excluding children who had no procedure, additional predictors of higher mortality were younger age at first procedure, lower weight or height, longer cardiopulmonary bypass or circulatory arrest duration, and peri-procedural complications; non-cardiac malformations were no longer significant.

INTERPRETATION

We confirm the high mortality risk associated with CHDs in the first year of life and demonstrate an important persisting risk of death throughout childhood. Late mortality may be underestimated by procedure-based audit focusing on shorter-term surgical outcomes. National monitoring systems should emphasise the importance of routinely capturing longer-term survival and exploring the mechanisms of mortality risk in children with serious CHDs.

Patient-reported quality of life outcomes for children with serious congenital heart defects

OBJECTIVE

To compare patient-reported, health-related quality of life (QoL) for children with serious congenital heart defects (CHDs) and unaffected classmates and to investigate the demographic and clinical factors influencing QoL.

DESIGN

Retrospective cohort study.

SETTING

UK National Health Service.

PATIENTS

UK-wide cohort of children with serious CHDs aged 10-14 years requiring cardiac intervention in the first year of life in one of 17 UK paediatric cardiac surgical centres operating during 1992-1995. A comparison group of classmates of similar age and sex was recruited.

MAIN OUTCOME MEASURES

Child self-report of health-related QoL scores (Pediatric Quality of Life Inventory, PedsQL) and parental report of schooling and social activities.

RESULTS

Questionnaires were completed by 477 children with CHDs (56% boys; mean age 12.1 (SD 1.0) years) and 464 classmates (55%; 12.0 (SD 1.1) years). Children with CHDs rated QoL significantly lower than classmates (CHDs: median 78.3 (IQR 65.0-88.6); classmates: 88.0 (80.2-94.6)) and scored lower on physical (CHDs: 84.4; classmates: 93.8; difference 9.4 (7.8 to 10.9)) and psychosocial functioning subscales (CHDs: 76.7, classmates: 85.0; difference 8.3 (6.0 to 10.6)). Cardiac interventions, school absence, regular medications and non-cardiac comorbidities were independently associated with reduced QoL. Participation in sport positively influenced QoL and was associated with higher psychosocial functioning scores.

CONCLUSIONS

Children with serious CHDs experience lower QoL than unaffected classmates. This appears related to the burden of clinical intervention rather than underlying cardiac diagnosis. Participation in sports activities is positively associated with increased emotional well-being. Child self-report measures of QoL would be a valuable addition to clinical outcome audit in this age group.

Quality control methods in accelerometer data processing: identifying extreme counts

BACKGROUND

Accelerometers are designed to measure plausible human activity, however extremely high count values (EHCV) have been recorded in large-scale studies. Using population data, we develop methodological principles for establishing an EHCV threshold, propose a threshold to define EHCV in the ActiGraph GT1M, determine occurrences of EHCV in a large-scale study, identify device-specific error values, and investigate the influence of varying EHCV thresholds on daily vigorous PA (VPA).

METHODS

We estimated quantiles to analyse the distribution of all accelerometer positive count values obtained from 9005 seven-year old children participating in the UK Millennium Cohort Study. A threshold to identify EHCV was derived by differentiating the quantile function. Data were screened for device-specific error count values and EHCV, and a sensitivity analysis conducted to compare daily VPA estimates using three approaches to accounting for EHCV.

RESULTS

Using our proposed threshold of ≥ 11,715 counts/minute to identify EHCV, we found that only 0.7% of all non-zero counts measured in MCS children were EHCV; in 99.7% of these children, EHCV comprised < 1% of total non-zero counts. Only 11 MCS children (0.12% of sample) returned accelerometers that contained negative counts; out of 237 such values, 211 counts were equal to -32,768 in one child. The medians of daily minutes spent in VPA obtained without excluding EHCV, and when using a higher threshold (≥19,442 counts/minute) were, respectively, 6.2% and 4.6% higher than when using our threshold (6.5 minutes; p<0.0001).

CONCLUSIONS

Quality control processes should be undertaken during accelerometer fieldwork and prior to analysing data to identify monitors recording error values and EHCV. The proposed threshold will improve the validity of VPA estimates in children's studies using the ActiGraph GT1M by ensuring only plausible data are analysed. These methods can be applied to define appropriate EHCV thresholds for different accelerometer models.

Late clinical presentation of congenital adrenal hyperplasia in older children: findings from national paediatric surveillance

OBJECTIVES

To describe the clinical presentation and sequelae, including salt-wasting crises of newly-diagnosed congenital adrenal hyperplasia (CAH) in children aged over 1 year in a contemporary population without screening. To appraise the potential benefit of newborn screening for late-presenting CAH.

DESIGN

Active national surveillance undertaken in Great Britain prospectively from 2007-2009 through the British Paediatric Surveillance Unit.

SETTING

England, Wales and Scotland.

PATIENTS

Children first presenting aged 1-15 years with clinical features of CAH and elevated 17-hydroxyprogesterone.

RESULTS

Fifty-eight children (26 [45%] boys) aged 1-15 years were reported; 50 (86%) had 21-hydroxylase deficiency. Diagnosis was precipitated by secondary sexual characteristics (n=38 [66%]; median age 5.8 [IQR] 4.8, 7.6) years, genital virilisation (8 girls; 3.2 [IQR 1.3, 7.3] years) or an affected sibling (n=8; 10.0 [IQR 7.4, 13.3] years). At least 33 (57%) children had advanced bone age and 13 (30%) were obese (body mass index ≥ 95 th centile). No child had experienced a salt-wasting crisis.

CONCLUSIONS

In Great Britain, 30 children aged 1-15 years present annually for the first time with CAH. Older children frequently manifest prematurely advanced epiphyseal and pubertal maturation and genital virilisation, which are often irreversible and likely to have long-lasting consequences for adult health and wellbeing. Almost one-third of affected children are obese before commencing steroid therapy. Newborn screening offers the potential to avoid serious clinical manifestations in older children with unrecognised CAH; however, it may also detect some children who would otherwise remain asymptomatic and for whom the benefit from treatment is uncertain.

Modelling survival and mortality risk to 15 years of age for a national cohort of children with serious congenital heart defects diagnosed in infancy

BACKGROUND

Congenital heart defects (CHDs) are a significant cause of death in infancy. Although contemporary management ensures that 80% of affected children reach adulthood, post-infant mortality and factors associated with death during childhood are not well-characterised. Using data from a UK-wide multicentre birth cohort of children with serious CHDs, we observed survival and investigated independent predictors of mortality up to age 15 years.

METHODS

Data were extracted retrospectively from hospital records and death certificates of 3,897 children (57% boys) in a prospectively identified cohort, born 1992-1995 with CHDs requiring intervention or resulting in death before age one year. A discrete-time survival model accounted for time-varying predictors; hazards ratios were estimated for mortality. Incomplete data were addressed through multilevel multiple imputation.

FINDINGS

By age 15 years, 932 children had died; 144 died without any procedure. Survival to one year was 79.8% (95% confidence intervals [CI] 78.5, 81.1%) and to 15 years was 71.7% (63.9, 73.4%), with variation by cardiac diagnosis. Importantly, 20% of cohort deaths occurred after age one year. Models using imputed data (including all children from birth) demonstrated higher mortality risk as independently associated with cardiac diagnosis, female sex, preterm birth, having additional cardiac defects or non-cardiac malformations. In models excluding children who had no procedure, additional predictors of higher mortality were younger age at first procedure, lower weight or height, longer cardiopulmonary bypass or circulatory arrest duration, and peri-procedural complications; non-cardiac malformations were no longer significant.

INTERPRETATION

We confirm the high mortality risk associated with CHDs in the first year of life and demonstrate an important persisting risk of death throughout childhood. Late mortality may be underestimated by procedure-based audit focusing on shorter-term surgical outcomes. National monitoring systems should emphasise the importance of routinely capturing longer-term survival and exploring the mechanisms of mortality risk in children with serious CHDs.

How active are our children? Findings from the Millennium Cohort Study

OBJECTIVE

To describe levels of physical activity, sedentary time and adherence to Chief Medical Officers (CMO) physical activity guidelines among primary school-aged children across the UK using objective accelerometer-based measurements.

DESIGN

Nationally representative prospective cohort study.

SETTING

Children born across the UK, between 2000 and 2002.

PARTICIPANTS

6497 7-year-old to 8-year-old singleton children for whom reliable accelerometer data were available for at least 10 h a day for at least 2 days.

MAIN OUTCOME MEASURES

Physical activity in counts per minute (cpm); time spent in sedentary and moderate-to-vigorous intensity physical activity (MVPA); proportion of children meeting CMO guidelines (≥60 min/day MVPA); average daily steps.

EXPLANATORY MEASURES

Gender, ethnicity, maternal current/most recent occupation, lone parenthood status, number of children in the household and country/region of residence.

RESULTS

The median daily physical activity level was 595 cpm (IQR 507, 697). Children spent a median of 60 min (IQR 47-76) in MVPA/day and were sedentary for a median of 6.4 h/day (IQR 6-7). Only 51% met CMO guidelines, with girls (38%) less active than boys (63%). Children took an average of 10 229 (95% CI (8777 to 11 775)) steps each day. Children of Indian ethnicity were significantly less active overall than all other ethnic groups. Children of Bangladeshi origin and those living in Northern Ireland were least likely to meet CMO guidelines.

CONCLUSIONS

Only half of 7-year-old children in the UK achieve recommended levels of physical activity, with significant gender, ethnic and geographic variations. Longitudinal studies are needed to better understand the relevance of these (in)activity patterns for long-term health and well-being. In the meantime population-wide efforts to boost physical activity among young people are needed which are likely to require a broad range of policy interventions.