Protocol for validation of the Global Scales for Early Development (GSED) for children under 3 years of age in seven countries

INTRODUCTION

Children's early development is affected by caregiving experiences, with lifelong health and well-being implications. Governments and civil societies need population-based measures to monitor children's early development and ensure that children receive the care needed to thrive. To this end, the WHO developed the Global Scales for Early Development (GSED) to measure children's early development up to 3 years of age. The GSED includes three measures for population and programmatic level measurement: (1) short form (SF) (caregiver report), (2) long form (LF) (direct administration) and (3) psychosocial form (PF) (caregiver report). The primary aim of this protocol is to validate the GSED SF and LF. Secondary aims are to create preliminary reference scores for the GSED SF and LF, validate an adaptive testing algorithm and assess the feasibility and preliminary validity of the GSED PF.

METHODS AND ANALYSIS

We will conduct the validation in seven countries (Bangladesh, Brazil, Côte d'Ivoire, Pakistan, The Netherlands, People's Republic of China, United Republic of Tanzania), varying in geography, language, culture and income through a 1-year prospective design, combining cross-sectional and longitudinal methods with 1248 children per site, stratified by age and sex. The GSED generates an innovative common metric (Developmental Score: D-score) using the Rasch model and a Development for Age Z-score (DAZ). We will evaluate six psychometric properties of the GSED SF and LF: concurrent validity, predictive validity at 6 months, convergent and discriminant validity, and test-retest and inter-rater reliability. We will evaluate measurement invariance by comparing differential item functioning and differential test functioning across sites.

ETHICS AND DISSEMINATION

This study has received ethical approval from the WHO (protocol GSED validation 004583 20.04.2020) and approval in each site. Study results will be disseminated through webinars and publications from WHO, international organisations, academic journals and conference proceedings.

REGISTRATION DETAILS

Open Science Framework https://osf.io/ on 19 November 2021 (DOI 10.17605/OSF.IO/KX5T7; identifier: osf-registrations-kx5t7-v1).

The creation of the Global Scales for Early Development (GSED) for children aged 0-3 years: combining subject matter expert judgements with big data

INTRODUCTION

With the ratification of the Sustainable Development Goals, there is an increased emphasis on early childhood development (ECD) and well-being. The WHO led Global Scales for Early Development (GSED) project aims to provide population and programmatic level measures of ECD for 0-3 years that are valid, reliable and have psychometrically stable performance across geographical, cultural and language contexts. This paper reports on the creation of two measures: (1) the GSED Short Form (GSED-SF)-a caregiver reported measure for population-evaluation-self-administered with no training required and (2) the GSED Long Form (GSED-LF)-a directly administered/observed measure for programmatic evaluation-administered by a trained professional.

METHODS

We selected 807 psychometrically best-performing items using a Rasch measurement model from an ECD measurement databank which comprised 66 075 children assessed on 2211 items from 18 ECD measures in 32 countries. From 766 of these items, in-depth subject matter expert judgements were gathered to inform final item selection. Specifically collected were data on (1) conceptual matches between pairs of items originating from different measures, (2) developmental domain(s) measured by each item and (3) perceptions of feasibility of administration of each item in diverse contexts. Prototypes were finalised through a combination of psychometric performance evaluation and expert consensus to optimally identify items.

RESULTS

We created the GSED-SF (139 items) and GSED-LF (157 items) for tablet-based and paper-based assessments, with an optimal set of items that fit the Rasch model, met subject matter expert criteria, avoided conceptual overlap, covered multiple domains of child development and were feasible to implement across diverse settings.

CONCLUSIONS

State-of-the-art quantitative and qualitative procedures were used to select of theoretically relevant and globally feasible items representing child development for children aged 0-3 years. GSED-SF and GSED-LF will be piloted and validated in children across diverse cultural, demographic, social and language contexts for global use.

Filmpjes voor het afnemen van de Van Wiechenkenmerken door ouders: determinanten van gebruik

Inleiding: Korte filmpjes van de Van Wiechenkenmerken zijn ontwikkeld, zodat ouders deze kenmerken met hun kind kunnen uitvoeren. Door ouders meer te betrekken bij de ontwikkeling van hun kind en het ontwikkelingsonderzoek door de jeugdgezondheidszorg (JGZ) komen ze beter voorbereid op het consult en zijn ze tijdens het consult meer gelijkwaardige gesprekspartners. Het doel van dit onderzoek is om determinanten van huidig en toekomstig gebruik van de filmpjes (wel/niet aanbieden en ervaringen) door JGZ-professionals en gebruik (ervaringen) door ouders te onderzoeken om daarmee implementatie van de filmpjes binnen de JGZ te ondersteunen.

Methode: Er is kwalitatief onderzoek met semigestructureerde interviews uitgevoerd om de belemmerende en bevorderende determinanten van het gebruik van de filmpjes zoals ervaren door JGZ-professionals (n = 14) en ouders (n = 10) in kaart te brengen. Met data (n = 4.370 ouders) uit een online tool waarin de filmpjes en vragenlijsten werden getoond, is kwantitatief onderzoek uitgevoerd, waarbij de ervaringen van de ouders met de filmpjes en de uitkomsten op de leeftijdsspecifieke kenmerken van hun kind zijn afgenomen.

Resultaten: Het kwalitatieve onderzoek liet zien dat het gebruik van de filmpjes door de meeste JGZ-professionals en ouders als positief werd ervaren. Aandachtspunten waren onder andere het beperkte bereik en gebruik van de filmpjes bij specifieke groepen (bijvoorbeeld anderstaligen), gebrek aan tijd bij sommige ouders en JGZ-professionals, ouders misten feedback direct na afname van de Van Wiechenkenmerken en uitkomsten op kenmerken kwamen niet altijd overeen tussen ouders en JGZ-professionals. Het kwantitatieve onderzoek liet zien dat ouders de filmpjes gemiddeld een 8,2 als rapportcijfer gaven en dat ongeveer de helft van de ouders zich (meer) betrokken voelde bij de ontwikkeling van hun kind en (beter) waren voorbereid op de afspraak bij de JGZ. De kenmerken werden door 96–100% van de ouders begrepen. Bij enkele kenmerken moest er gebruik worden gemaakt van materiaal dat niet aanwezig was in elk huishouden, zoals een stoof of een driewieler.

Conclusie: JGZ-professionals en ouders waren positief over het gebruik van de filmpjes. Op basis van de determinanten uit dit onderzoek is een implementatieplan ontwikkeld om JGZ-organisaties te ondersteunen als zij het gebruik van de filmpjes willen implementeren.

Evaluation of the Dutch neonatal screening for congenital adrenal hyperplasia

BACKGROUND

In 2002, a nationwide screening for congenital adrenal hyperplasia (CAH) was introduced in the Netherlands. The aim of our study is to evaluate the validity of the neonatal screening for CAH and to assess how many newborns with salt-wasting (SW) CAH have already been clinically diagnosed before the screening result was known.

METHODS

Retrospective, descriptive study. The following data of patients with positive screening results since implementation of the screening programme were collected (1 January 2002 up until 31 December 2013): gestational age, sex, diagnosis, clinical presentation and contribution of screening to the diagnosis.

RESULTS

In the evaluated period, 2 235 931 newborns were screened. 479 children had an abnormal screening result, 133 children were diagnosed with CAH (114 SW, 14 simple virilizing (SV)), five non-classic CAH. During this period, no patients with SW CAH were missed by neonatal screening (sensitivity was 100%). After exclusion of 17 cases with missing information on diagnosis, specificity was 99.98% and positive predictive value was 24.7%. Most false positives (30%) were attributable to prematurity. Of patients with SW CAH, 68% (71/104) patients were detected by neonatal screening and 33 (33/104) were clinically diagnosed. Of girls with SW CAH, 38% (14/37) were detected by neonatal screening and 62% (23/37) were clinically diagnosed.

CONCLUSION

The Dutch neonatal screening has an excellent sensitivity and high specificity. Both boys and girls can benefit from neonatal screening.

Trend in height of Turkish and Moroccan children living in the Netherlands

Objectives

To study trends in height of Turkish and Moroccan immigrant children living in The Netherlands, to investigate the association between height and background characteristics in these children, and to calculate height-for-age-references data for these groups.

Design

Nationwide cross-sectional data collection from children aged 0 to 18 years by trained professionals in 1997 and 2009. The study population consisted of 2,822 Turkish 2,779 Moroccan, and 13,705 Dutch origin children in 1997and 2,548 Turkish, 2,594 Moroccan, and 11,255 Dutch origin children in 2009. Main outcome measures: Mean height in cm, and mean height standard deviation scores.

Results

In 2009, mean height at the age of 18y was similar for Turkish and Moroccan children: 177 cm for boys and 163 cm for girls, which was 2 to 3 cm taller than in 1997. Still, Turkish and Moroccan adolescents were 5.5 cm (boys) to 7 cm (girls) shorter than their Dutch peers. No significant differences were found in mean height standard deviation scores across the educational level of the parents, geographical region, primary language spoken at home, and immigrant generation.

Conclusions

While the secular height increase in Dutch children came to a halt, the trend in Turkish and Moroccan children living in The Netherlands continued. However, large differences in height between Turkish and Moroccan children and Dutch children remain. We found no association with the background characteristics. We recommend the use of the new growth charts for children of Turkish and Moroccan origin who have a height-for-age below -2SD on the growth chart for Dutch children.

Call for early prevention: prevalence rates of overweight among Turkish and Moroccan children in The Netherlands

BACKGROUND

Monitoring overweight in risk groups is necessary. Our aim is to assess the trend in overweight and obesity in Turkish and Moroccan children in the Netherlands since 1997 and to monitor the levels of lifestyle-related behaviours in 2009.

METHODS

We selected cross-sectional data of Turkish and Moroccan children aged 2-18 years from two national Growth Studies performed in 1997 and 2009 in the Netherlands. Lifestyle-related behaviours were obtained in the 2009 study by questionnaire.

RESULTS

In 2009, 31.9% of Turkish and 26.6% of Moroccan children had overweight, whereas this was, respectively, 26.7% and 19.6% in 1997. Already at 2 years, 21.1% in Turkish and 22.7% in Moroccan children had overweight in 2009. The prevalence of obesity was above 4% from 3 years onwards. High (i.e. ≥ 25%) prevalence rates of unhealthy lifestyle-related behaviours were found for not having breakfast (26-49%) among Turkish and Moroccan adolescent (i.e. 15-18 years) girls, consuming no fruit (29-45%) and watching TV/PC ≥ 2 h (35-72%) among all Turkish and Moroccan adolescents, no walking/cycling to school/day care among preschool children (2-4 years) (28-56%) and adolescents (34-94%), drinking ≥ 2 glasses of sweet beverages (44-74%) and being <1 h physically active (29-65%) among all children.

CONCLUSION

An upward trend of overweight and obesity occurred in Turkish and Moroccan children. Already at 2 years of age, one out of five Turkish and Moroccan children had overweight, which calls for early prevention with attention to specific lifestyle-related behaviours.

Thinness in the era of obesity: trends in children and adolescents in The Netherlands since 1980

BACKGROUND

Although children both at the upper and lower tail of the body mass index (BMI) distribution are at greater health risk, relatively little is known about the development of thinness prevalence rates in developed countries over time. We studied trends in childhood thinness and assessed changes in the BMI distribution since the onset of the obesity epidemic.

METHODS

Growth data from 54 814 children aged 2-18 years of Dutch, Turkish and Moroccan origin living in The Netherlands were used. Anthropometric measurements were performed during nationwide cross-sectional growth studies in 1980 (only Dutch), 1997 and 2009. Prevalence rates of thinness grades I, II and III were calculated according to international cut-offs. BMI distributions for 1980, 1997 and 2009 were compared.

RESULTS

Since 1980, thinness (all grades combined) reduced significantly from 14.0% to 9.8% in children of Dutch origin, but the proportion of extremely thin children (grade III) remained constant. Thinness in children of Moroccan origin decreased significantly from 8.8% to 6.2% between 1997 and 2009. No significant difference was observed in children of Turkish origin (5.4% in 1997 vs. 5.7% in 2009). Thinness occurred most often in children aged 2-5 years. There were no differences between boys and girls. The BMI distribution widened since 1980, mainly due to an upward shift of the upper centiles.

CONCLUSION

Since the onset of the obesity epidemic, prevalence rates of thinness decreased. However, we found a small but persistent group of extremely thin children. More research is needed to gain insight into their health status.

Trends in a life threatening condition: morbid obesity in dutch, Turkish and Moroccan children in The Netherlands

BACKGROUND

Morbid obesity can be a life threatening condition. The aim of our study is to assess the trend in morbid obesity in The Netherlands among children of Dutch origin since 1980, and among children of Turkish and Moroccan origin since 1997.

METHODS AND FINDINGS

Cross-sectional height and weight data of children of Dutch, Turkish and Moroccan origin aged 2-18 years were selected from three national Dutch Growth Studies performed in 1980, 1997 and 2009 (n = 54,814). Extended international (IOTF) cut-offs in childhood were used to define morbid obesity (obesity class II and III combined). The morbidity index for overweight was calculated as the prevalence of morbid obesity divided by the prevalence of overweight. Our study showed that the prevalence of morbid obesity in children of Dutch origin was 0.59% in boys and 0.53% in girls in 2009. Significant upward trends occurred since 1980 and 1997. The prevalence was three to four fold higher in Turkish children compared to Dutch children. The Turkish children also had an upward trend since 1997, but this was only statistically significant in boys. The prevalence of morbid obesity in Moroccan children was two to three fold higher than in Dutch children, but it remained almost stable between 1997 and 2009. The Dutch and Turkish children showed an upward trend in morbidity index for overweight since respectively 1980 and 1997, while the Moroccan children showed a downward trend since 1997. In 2009, children of low educated parents had the highest prevalence rates of morbid obesity; 1.06% in Dutch, 2.11% in Turkish and 1.41% in Moroccan children.

CONCLUSIONS AND SIGNIFICANCE

An upward trend of morbid obesity in Dutch and Turkish children in The Netherlands occurred. Monitoring and reducing the prevalence of childhood morbid obesity is of high importance for these children, health care and the community.

The impact of height during childhood on the national prevalence rates of overweight

BACKGROUND

It is known that height and body mass index (BMI) are correlated in childhood. However, its impact on the (trend of) national prevalence rates of overweight and obesity has never been investigated. The aim of our study is to investigate the relation between height and national prevalence rates of overweight and obesity in childhood between 1980, 1997, and 2009, and to calculate which fixed value of p (2.0,2.1, …,3.0) in kg/m(p) during childhood is most accurate in predicting adult overweight.

METHODS AND FINDINGS

Cross-sectional growth data of children from three Dutch nationwide surveys in 1980, 1997, and 2009, and longitudinal data from the Terneuzen Birth Cohort and the Harpenden Growth Study were used. Relative risks (RR) and 95% confidence intervals (CI) were calculated. Our study showed that tall (>1 standard deviation (SD)) girls aged 5.0-13.9 y were more often overweight (RR = 3.5,95%CI:2.8-4.4) and obese (RR = 3.9,95%CI:2.1-7.4) than short girls (<-1 SD). Similar results were found in boys aged 5.0-14.9 y (RR = 4.4,95%CI:3.4-5.7 and RR = 5.3,95%CI:2.6-11.0). No large differences were found in the other age groups and in comparison with children with an average stature. Tall boys aged 2.0-4.9 y had a significantly higher positive trend in overweight between 1980 and 1997 compared to short boys (RR = 4.0,95%CI:1.38-11.9). For other age groups and in girls, no significant trends were found. The optimal Area Under the Curve (AUC) to predict adult overweight was found for p = 2.0.

CONCLUSIONS AND SIGNIFICANCE

Tall girls aged 5.0-13.9y and tall boys aged 5.0-14.9y have much higher prevalence rates of overweight and obesity than their shorter peers. We suggest taking into account the impact of height when evaluating trends and variations of BMI distributions in childhood, and to use BMI to predict adult overweight.

Prenatal famine, birthweight, reproductive performance and age at menopause: the Dutch hunger winter families study

STUDY QUESTION

Is there an association between acute prenatal famine exposure or birthweight and subsequent reproductive performance and age at menopause?

SUMMARY ANSWER

No association was found between intrauterine famine exposure and reproductive performance, but survival analysis showed that women exposed in utero were 24% more likely to experience menopause at any age.

WHAT IS KNOWN ALREADY

Associations between prenatal famine and subsequent reproductive performance have been examined previously with inconsistent results. Evidence for the effects of famine exposure on age at natural menopause is limited to one study of post-natal exposure.

STUDY DESIGN, SIZE, DURATION

This cohort study included men and women born around the time of the Dutch famine of 1944-1945. The study participants (n = 1070) underwent standardized interviews on reproductive parameters at a mean age of 59 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The participants were grouped as men and women with prenatal famine exposure (n = 407), their same-sex siblings (family controls, n = 319) or other men and women born before or after the famine period (time controls, n = 344). Associations of famine exposure with reproductive performance and menopause were analysed using logistic regression and survival analysis with competing risk, after controlling for family clustering.

MAIN RESULTS AND THE ROLE OF CHANCE

Gestational famine exposure was not associated with nulliparity, age at birth of first child, difficulties conceiving or pregnancy outcome (all P> 0.05) in men or women. At any given age, women were more likely to experience menopause after gestational exposure to famine (hazard ratio 1.24; 95% CI 1.03, 1.51). The association was not attenuated with an additional control for a woman's birthweight. In this study, there was no association between birthweight and age at menopause after adjustment for gestational famine exposure.

LIMITATIONS, REASON FOR CAUTION

Age at menopause was self-reported and assessed retrospectively. The study power to examine associations with specific gestational periods of famine exposure and reproductive function was limited.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings support previous results that prenatal famine exposure is not related to reproductive performance in adult life. However, natural menopause occurs earlier after prenatal famine exposure, suggesting that early life events can affect organ function even at the ovarian level.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the NHLBI/NIH (R01 HL-067914).

TRIAL REGISTRATION NUMBER

Not applicable.

Trends in menarcheal age between 1955 and 2009 in the Netherlands

AIM

To assess and compare the secular trend in age at menarche in Dutch girls (1955-2009) and girls from Turkish and Moroccan descent living in the Netherlands (1997-2009).

METHODS

Data on growth and maturation were collected in 20,867 children of Dutch, Turkish and Moroccan descent in 2009 by trained health care professionals. Girls, 9 years and older, of Dutch (n = 2138), Turkish (n = 282), and Moroccan (n = 295) descent were asked whether they had experienced their first period. We compared median menarcheal age in 2009 with data from the previous Dutch Nationwide Growth Studies in 1955, 1965, 1980 and 1997. Age specific body mass index (BMI) z-scores were calculated to assess differences in BMI between pre- and postmenarcheal girls in different age groups.

RESULTS

Median age at menarche in Dutch girls, decreased significantly from 13.66 years in 1955 to 13.15 years in 1997 and 13.05 years in 2009. Compared to Dutch girls there is a larger decrease in median age of menarche in girls of Turkish and Moroccan descent between 1997 and 2009. In Turkish girls age at menarche decreased from 12.80 to 12.50 years and in Moroccan girls from 12.90 to 12.60 years. Thirty-three percent of Turkish girls younger than 12 years start menstruating in primary school. BMI-SDS is significantly higher in postmenarcheal girls than in premenarcheal girls irrespective of age.

CONCLUSION

There is a continuing secular trend in earlier age at menarche in Dutch girls. An even faster decrease in age at menarche is observed in girls of Turkish and Moroccan descent in the Netherlands.

Prevalence of overweight in Dutch children with Down syndrome

OBJECTIVE

Prevalence of overweight in children is increasing, causing various health problems. This study aims to establish growth references for weight and to assess the prevalence rates of overweight and obesity in a nationwide sample of Dutch children with Down syndrome (DS), taking into account the influence of comorbidity.

METHODS

In 2009, longitudinal growth data from Dutch children with trisomy 21 who were born after 1982 were retrospectively collected from medical records of 25 Dutch regional specialized DS centers. "Healthy" was defined as not having concomitant disorders or having only a mild congenital heart defect. Weight and BMI references were calculated by using the LMS method, and prevalence rates of overweight and obesity by using cutoff values for BMI as defined by the International Obesity Task Force. Differences in prevalence rates were tested by multilevel logistic regression analyses to adjust for gender and age.

RESULTS

Growth data of 1596 children with DS were analyzed. Compared with the general Dutch population, healthy children with DS were more often overweight (25.5% vs 13.3% in boys, and 32.0% vs 14.9% in girls) and obese (4.2% vs 1.8%, and 5.1% vs 2.2%, respectively). Prevalence rates of overweight between DS children with or without concomitant disorders did not vary significantly.

CONCLUSIONS

Dutch children with DS have alarmingly high prevalence rates of overweight and obesity during childhood and adolescence. Health care professionals should be aware of the risk of overweight and obesity in children with DS to prevent complications.

Ethnic differences and parental beliefs are important for overweight prevention and management in children: a cross-sectional study in the Netherlands

Background

The prevalence of obesity and overweight is highest among ethnic minority groups in Western countries. The objective of this study is to examine the contribution of ethnicity and beliefs of parents about overweight preventive behaviours to their child’s outdoor play and snack intake, and to the parents’ intention to monitor these behaviours.

Methods

A cross-sectional survey was conducted among parents of native Dutch children and children from a large minority population (Turks) at primary schools, sampled from Youth Health Care registers.

Results

Native Dutch parents observed more outdoor play and lower snack intake in their child and had stronger intentions to monitor these behaviours than parents of Turkish descent. In the multivariate analyses, the parents’ attitude and social norm were the main contributing factors to the parental intention to monitor the child’s outdoor play and snack intake. Parental perceived behavioural control contributed to the child’s outdoor play and, in parents who perceived their child to be overweight, to snacking behaviour. The associations between parents’ behavioural cognitions and overweight related preventive behaviours were not modified by ethnicity, except for perceived social norm. The relationship between social norm and intention to monitor outdoor play was stronger in Dutch parents than in Turkish parents.

Conclusions

As the overweight related preventive behaviours of both children and parents did differ between the native and ethnic minority populations of this study, it is advised that interventions pay attention to cultural aspects of the targeted population. Further research is recommended into parental behavioural cognitions regarding overweight prevention and management for different ethnicities.

Perinatal factors related to negative or positive recall of birth experience in women 3 years postpartum in the Netherlands

BACKGROUND

Little research has been conducted to date on women's postnatal emotional well-being and satisfaction with the care received in the Netherlands. The aim of this study was to investigate Dutch women's views of their birth experience 3 years after the event.

METHODS

A questionnaire was mailed to all women who had given birth in 2001 and who had at least one prenatal, perinatal, or postnatal visit to the participating midwifery practice. Women who had a subsequent birth after the index birth in 2001 were not excluded. We specifically asked respondents to reflect on the birth that occurred in 2001. Women were asked to say how they felt now looking back on their labor and birth, with five response options from "very happy" to "very unhappy."

RESULTS

We received 1,309 postnatal questionnaires (response rate 44%). The sample was fairly representative with respect to the mode of delivery, place of birth, and obstetric interventions compared with the total Dutch population of pregnant women; however, the sample was not representative for ethnicity and initial caregiver. Three years after delivery, most women looked back positively on their birth experience, but more than 16 percent looked back negatively. More than 1 in 5 primiparas looked back negatively compared with 1 in 9 multiparas. Adjusted odds ratios (OR) for looking back negatively 3 years later included having had an assisted vaginal delivery or unplanned cesarean delivery (OR 2.6, 95% CI 1.59-4.14), no home birth (OR 1.4, 95% CI 1.04-1.93), referral during labor (OR 2.4, 95% CI 1.48-3.77), not having had a choice in pain relief (OR 2.9, 95% CI 1.91-4.45), not being satisfied in coping with pain (OR 4.9, 95% CI 2.55-9.40), a negative description of the caregivers (OR 2.9, 95% CI 1.85-4.40), or having had fear for the baby's life or her own life (OR 2.3, 95% CI 1.47-3.48).

CONCLUSIONS

A substantial proportion of Dutch women looked back negatively on their birth experience 3 years postpartum. Further research needs to be undertaken to understand women's expectations and experiences of birth within the Dutch maternity system and an examination of maternity care changes designed to reduce or modify controllable factors that are associated with negative recall.

A retrospective study of the success, safety and effectiveness of external cephalic version without tocolysis in a specialised midwifery centre in the Netherlands

BACKGROUND

to evaluate the effectiveness of external cephalic version (ECV) without tocolysis or epidural analgesia, the complications associated with the procedure and the association between the number of ECV attempts and cephalic presentation at birth and caesarean section.

METHODS

retrospective cohort study of all (n=924) ECVs carried out between 1996 and 2000 in a specialised midwifery centre in the Netherlands. After bivariate analysis, those variables with a p value under 0.05 were considered statistically significant and were tested in a logistic regression model using backward stepwise selection. Analyses were carried out separately for first ECV attempts and second ECV attempts.

FINDINGS

in total, 958 ECVs were analysed, 889 first attempts and 69 repeat attempts. Seventy per cent of all first ECVs were carried out before 37 weeks, but half of those were carried out between 36 and 37 weeks. The success rate for first ECV was 41% and for the second ECV 29%. Bivariate analysis showed that the success of the first ECV was positively influenced by parity, non-Dutch origin, higher birth weight, higher age and longer duration of pregnancy. After logistic regression, parity (odds ratio [OR] 2.8, 95% CI 2.1 to 3.7), non-Dutch origin (OR 1.8, 95% CI 1.2 to 2.8) and birth weight (OR 1.7, 95% CI 1.4 to 2.0) remained factors that independently influenced the success of ECV. The odds ratio for duration of pregnancy at first ECV was borderline significant: OR 1.2 (1.0 to 1.4). After an unsuccessful first ECV, only 13% of the women received a second ECV. The prevalence of cephalic presentation at birth increased with 3% after a second ECV. Three cases of complications were reported during or very shortly after the first ECV, and these did not result in serious complications. No complications were reported after a second ECV.

CONCLUSION

ECV without tocolysis is a safe procedure for pregnant women and their babies. Repeat ECV increases the number of cephalic presentations at birth and should be considered after an unsuccessful ECV.

Rationale and design of the prevention of respiratory infections and management in children (PRIMAKid) study: a randomized controlled trial on the effectiveness and costs of combined influenza and pneumococcal vaccination in pre-school children with recurrent respiratory tract infections

Health and economic burden of recurrent respiratory tract infections (RTIs) in early childhood is considerable. A systematic review of licensed influenza and pneumococcal vaccines showed substantial efficacy in children, but the health-economic impact of such vaccines among pre-school children with recurrent RTIs is unknown. We therefore, designed a double-blind randomized controlled trial to determine the effectiveness and costs of a combined influenza and pneumococcal vaccination program among a primary care based cohort of children with recurrent episodes of RTI aged between 18 and 72 months. We will enroll 690 children over three consecutive years (2003--2005) who will be randomly allocated to receive vaccinations against influenza and pneumococcal disease, influenza alone or hepatitis B in a similar schedule. Follow up by parental diaries, tympanic temperature measurements, questionnaires and interviews is planned until May 2006. Primary outcome is number of febrile RTIs. Other outcomes include duration and severity of RTI episodes, medical consumption, safety and costs.

Negative attitude of highly educated parents and health care workers towards future vaccinations in the Dutch childhood vaccination program

BACKGROUND

It is unknown whether further expansion of the Dutch childhood vaccination program with other vaccines will be accepted and whom should be targeted in educational strategies.

AIM

To determine attitudes of parents towards possible future vaccinations for their children and the behavioural determinants associated with a negative attitude.

DESIGN

Questionnaire study.

METHODS

Parents of children aged between 3 months and 5 years of day-care centres were asked to fill out a questionnaire. Determinants of a negative attitude to comply with possible future vaccinations against example diseases such as pneumonia or influenza, hepatitis B, TBC, smallpox and SARS were assessed using polytomous logistic regression analysis.

RESULTS

Of the 283 respondents, 123 (43%) reported a positive attitude towards all vaccinations, 129 (46%) reported to have a positive attitude to have their child vaccinated against some diseases and 31 (11%) had no intention to comply with any new vaccination. Determinants of a fully negative attitude were a high education of the parent (odds ratio [OR] 3.3, 95% confidence interval [95% CI]: 1.3-8.6), being a health care worker (OR 4.2, 95% CI: 1.4-12.6), absence of religion (OR 2.6, 95% CI: 1.0-6.7), perception of vaccine ineffectiveness (OR 6.9, 95% CI: 2.5-18.9) and the perception that vaccinations cause asthma or allergies (OR 82.4, 95% CI: 8.9-766.8).

CONCLUSION

Modifiable determinants for a negative attitude to comply with new vaccinations are mainly based on lack of specific knowledge. These barriers to vaccinations might be overcome by improving health education in the vaccination program, especially when targeted at educated parents and health care workers.

Cost analysis of singleton versus twin pregnancies after in vitro fertilization

OBJECTIVE

To determine the difference in costs between singleton and twin pregnancies after IVF treatment from pregnancy to 6 weeks after delivery from a health care perspective.

DESIGN

Retrospective cost analysis.

SETTING

IVF department at the University Medical Center Nijmegen, The Netherlands.

PATIENT(S)

A representative sample of singleton and twin pregnancies after IVF treatment between 1995 and 2001 at the University Medical Center Nijmegen.

INTERVENTION(S)

IVF with or without intracytoplasmic sperm injection and with or without cryopreservation.

MAIN OUTCOME MEASURE(S)

Medical costs per singleton and twin pregnancy after IVF.

RESULT(S)

In patients pregnant with twins, the incidence of hospital antenatal care, complicated vaginal deliveries, and cesarean sections was higher and was associated with more frequent and longer maternal and neonatal hospital admissions. Maternal and neonatal hospital admissions were the major cost drivers. The medical cost per twin pregnancy was found to be more than five times higher than per singleton pregnancy, 13,469 and 2,550, respectively.

CONCLUSION(S)

The medical cost per twin pregnancy was more than 10,000 higher than per singleton pregnancy. A reduction in the number of twin pregnancies by elective single ET will save substantial amounts of money. This money might be used for the additional IVF cycles that will probably be needed to achieve similar success rates between single ET and two-embryo transfer.

[Multiple pregnancies: epidemiology and management]

Since the 1980s, the percentage of multiple pregnancies in the Netherlands has increased. Nowadays, the percentage of triplets is decreasing but there is still an increase in the percentage of twin pregnancies. A major cause is that Dutch women tend to delay starting a family until an advanced age. This increases their chances of a spontaneous multiple pregnancy. Moreover, they are prone to subfertility and consequently have a greater chance of undergoing treatments involving assisted-reproduction techniques such as intra-uterine insemination (IUI) and in-vitro fertilisation. In the Netherlands, the majority of higher order multiple pregnancies result from mild ovarian hyperstimulation in combination with IUI. In case of in-vitro fertilisation, since the practice of transferring a maximum of two embryos still results in 20-25% twin pregnancies, single-embryo transfer should be advocated more often.

Meconium-stained amniotic fluid is not a risk factor for otitis media

It has recently been hypothesised that large amounts of amniotic fluid cellular content (AFCC) in the middle ear may lead to chronic inflammation and predispose young children to recurrent middle ear infections. Because children born with meconium-stained amniotic fluid (MSAF) have higher AFCC in the middle ear, we performed a retrospective cohort study to determine whether children born with MSAF had a higher risk of OM during infancy. Children born between May 1998 and April 2000 formed two groups based on the absence or presence of MSAF at birth as documented in the hospital birth records. In April 2002, home visits were made to take tympanometric measurements and administer a questionnaire on OM history and possible confounders. Logistic regression models were constructed to assess odds ratios (OR) as a measure of the effect of MSAF on OM and to adjust for potential confounders. There were no differences in the point prevalence of a type-B tympanogram at the home visit (OR 0.81; 95% confidence interval: 0.38-1.76). Also, no statistically significant association was found between the proportion of children with OM diagnosed in the 1st year of life (OR 0.86, 95% confidence interval: 0.27-2.73) and in the proportion of children that had ever been diagnosed with OM (OR 0.91, 95% confidence interval: 0.40-2.91). It can be concluded that children born with MSAF do not constitute a high-risk group for OM in early childhood. A long-term OM effect, especially in severe MSAF cases, cannot be excluded.