Archives of Disease in Childhood

ObjectiveTo compare hospital activity, patient casemix and medication prescribing and administration before and during the COVID-19 emergency. DesignRetrospective observational study SettingA specialist childrens hospital in the UK PatientsInpatients aged 25 and younger treated at a specialist childrens hospital between 29 April 2019 and 6 September 2020 ResultsThere were 21,471 day cases and inpatients treated during the 16 month study period. Day cases (no overnight stay) dropped by around 37% per week. Both admissions and discharges for inpatients (at least one overnight stay) decreased leading to a small reduction in hospital bed days but no reduction in hospital bed nights. The effect on hospital activity on different patient groups varied substantially with some groups such as medical oncology day cases increasing by 13%. As a result, the patient case mix in the hospital was very different during the pandemic. Overall weekly medication administrations decreased for day cases and inpatients, but weekly medication administrations per bed day increased by 10% for day cases and 6% for inpatients. ConclusionsDespite not being badly affected by the disease itself, specialist paediatric hospital services have been greatly affected by the pandemic. The average number of medications per inpatient bed day increased, likely reflecting changes to the patient population, with only those children with severe conditions being treated during the pandemic. These data demonstrate the complex pattern of implications on specialist services and provide evidence for planning the impact of future emergencies and resolution strategies.

BackgroundThe epidemiological transition and medical innovations have led to changes in causes of ill-health and disability by children and young people (CYP) in many wealthy countries over the past two decades. However this has not been systematically examined at a national level in the UK. Here we examined changes in disability-adjusted life-years (DALYs) by cause for 0-24 year olds by age-group. MethodsWe used data on DALYS by cause, sex and age-group for the UK from 1998 to 2017 from the 2017 Global Burden of Disease (GBD) study. We modified the GBD cause-hierarchy to be more relevant to paediatrics. We assessed current causes of burden in 2017 and change at cause-level for 1998-2007 and 2008-2017 by age. We then used Holt-Winters doubly exponentiated time-series models to forecast change in DALYs by age to 2040. ResultsIn 2017, neonatal and congenital disorders were the main causes of DALYS across 0-24 year olds, with other the other large causes being anxiety and depression, endocrine and immune disorders, and lower respiratory tract infections. Total DALYS were highest amongst neonates and lowest amongst 1-9 year olds, rising with age amongst 10-24 year olds. Between 1998-2017, total DALYs fell in each age-group, with the largest falls in infants. The greatest changes in DALYS from 2008 to 2017 were falls in neonatal and congenital causes amongst infants, falls in infectious diseases and injuries in older age-groups, and rises in neonatal causes, mental health, acne and somatic symptoms in all age-groups other than infants. These patterns were forecast to continue to 2040. ConclusionsWe forecast falls in causes that have historically dominated disease in CYP, particularly congenital disorders, infectious diseases, cancers and injuries, representing falls in the prevalence of many infectious diseases and improvements in road safety and also improvements in survival from cancer and many congenital conditions. Forecast increases in DALYS from mental health problems, other adolescent health issues and the consequences of neonatal survival, such as neuro-disability and epilepsy, have potential implications for the training of paediatricians and workforce needs over the next two decades. The impact of the COVID-19 pandemic, climate change and changes in child poverty require further research.

BackgroundBronchiolitis (most frequently caused by Respiratory Syncytial Virus; RSV) is a common winter disease predominantly affecting children under one year of age. It is a common reason for presentations to an Emergency Department (ED) and frequently results in hospital admission, contributing to paediatric units approaching or exceeding capacity each winter. During the SARS-CoV-2 pandemic, the circulation of RSV was dramatically reduced in the United Kingdom and Ireland. Evidence from the Southern Hemisphere and other European countries suggests that as social distancing restrictions for SARS-CoV-2 are relaxed, RSV infection returns, causing delayed or even summer epidemics, with different age distributions. Study questionThe ability to track, anticipate and respond to a surge in RSV cases is critical for planning acute care delivery. There is an urgent need to understand the onset of RSV spread at the earliest opportunity. This will influence service planning, to inform clinicians whether the population at risk is a wider age range than normal, and whether there are changes in disease severity. This information is also needed to inform decision on the timing of passive immunisation of children at higher risk of hospitalisation, intensive care admission or death with RSV infection, which is a public health priority. Methods and likely impactThis multi-centre prospective observational cohort study will use a well-established research network (Paediatric Emergency Research in the UK and Ireland, PERUKI) to report in real time cases of RSV infection in children aged under two years, through the collection of essential, but non-identifying patient information. Forty centres will gather initial data on age, index of multiple deprivation quintile, clinical features on presentation, and co-morbidities. Each case will be followed up at 7 days to identify treatment, viral diagnosis and outcome. Information be released on a weekly basis and used to support clinical decision making.

BackgroundLong COVID remains incompletely understood in children and adolescents with scant Australian data available. We aimed to assess the impacts of the 2021 Delta variant of SARS-CoV-2 outbreak on symptoms and functioning 12 weeks post-acute infection in a cohort of children and adolescents. MethodsThe parents (or next of kin) of 11864 children and adolescents from a population catchment who had mandatory contact with Sydney Childrens Hospital Network facilities during acute SARS-CoV-2 infection (confirmed by PCR) were contacted by email or text message. Findings1731 (17.7%) responded to an online survey assessing symptoms, functional impairment. 203 of the responders (11.7%) gave answers that were consistent with continued symptoms and/or functional impairment and were flagged for clinical review. Of the 169 subsequently clinically reviewed, many had already recovered (n=63, 37.3%) or had a pre-existing condition exacerbated by COVID-19 (18, 10.7%); 64 (37.9%) were diagnosed with a Post COVID Condition (PCC). Of these, a minority we considered to have features compatible with the United Kingdom consensus cases definition for Long COVID (n=21). InterpretationDuring an outbreak of the Delta variant of SARS-CoV-2 an online questionnaire with clinical review follow-up provided evidence that a majority of children with COVID-19 had complete recovery at 12 weeks post infection, but those with persisting symptoms demonstrated a wide spectrum of severity and phenotype that comprises a likely significant burden that warrants attention for individuals and at a population level. FundingNew South Wales Health COVID-19 Emergency Response Priority Research Funding.

Childrens attendances in paediatric emergency departments have fallen precipitously in North East England and elsewhere in recent months. We analysed data from 3 hospitals to understand which children were not being brought during the COVID-19 lockdown. In our population there is no evidence of a disproportionate impact on children belonging to vulnerable sociodemographic groups and no obvious change in illness acuity among those children still attending. However we noted a marked reduction in infectious disease presentations which might reflect one positive impact of enhanced social distancing on child health. More granular data describing the collateral damage of the COVID-19 pandemic to childrens clinical services are needed to plan for the mitigation of its continuing effects. What is known on this topicO_LIPresentations to paediatric emergency departments in Europe and the United States have reduced dramatically during the COVID-19 pandemic lockdown. C_LI What this paper adds boxO_LIThis is the first paper to show that reduced attendance was proportionate across different deprivation and ethnicity groups. C_LIO_LIWe show that presentations of children with infectious diseases reduced more than those with other conditions or trauma. C_LIO_LIThere was no change in admission rates, taken as a broad indicator of illness acuity at presentation among the population still attending paediatric emergency departments. C_LI

Special Educational Needs (SEN) provision for school children provides extra support and reasonable adjustments for children and young people with additional educational, behavioural or health needs to ensure equal education opportunities; for example those born with a healthcare need such as cleft lip and palate may be provided SEN to aid with challenges in communications. However, there is limited knowledge of whether SEN provisions impact academic or health outcomes in such a population and conducting a randomised controlled trial to establish this evidence is not plausible. In lieu of randomised controlled trials, target trial emulation methods can be used in attempt to answer causal questions using observational data whilst reducing confounding and other biases likely to arise with such data. The Education and Child Health Insights from Linked Data (ECHILD) dataset could be used as part of trial emulation methods to understand the impact of SEN provisions on academic and healthcare outcomes. ECHILD is the first dataset to hold longitudinal school, health and social care data on all pupils in England, obtained by linking the National Pupil Database (NPD) with Hospital Episode Statistics (HES). In this protocol, we describe how the ECHILD dataset could be used to explore and conduct a target trial emulation to evaluate whether children who were born with cleft lip and palate would have different unplanned hospital utilisation if they received or did not receive SEN provisions by Year 1 (specifically by January in their second year of school) when they are aged 5 or 6. MethodsFocussing on the population of children who are identified as having been born with cleft lip and palate, an intervention of varying levels of SEN provision (including no SEN provision) by January of the second year of school, and an outcome of unplanned hospital utilisation, we apply a trial emulation design to reduce confounding when using observational data to investigate the causal impact of SEN on unplanned hospital admissions. Our target population is children born 2001-2014 who had a recording of cleft lip and palate in HES and who started their second year of primary school (Year 1) in a state school between 2006 and 2019; children with a first recording of cleft lip and palate after Year 1 were excluded (these were pupils who likely immigrated to England after birth). We intend to use a time window of SEN provision assignment between the start of school (reception) and by the January school census in Year 1. Using target trial emulation, we aim to estimate the average treatment effect of SEN provision on the number of unplanned hospital admissions (including admissions to accident and emergency) between the January school census in Year 1 and Year 6 (the end of primary school, when children are 10-11 years old). Ethics and disseminationPermissions to use linked, de-identified data from Hospital Episode Statistics and the National Public Database were granted by DfE (DR200604.02B) and NHS Digital (DARS-NIC-381972). Ethical approval for the ECHILD project was granted by the National Research Ethics Service (17/LO/1494), NHS Health Research Authority Research Ethics Committee (20/EE/0180) and UCL Great Ormond Street Institute of Child Healths Joint Research and Development Office (20PE06). Stakeholders (academics, clinicians, educators and child/young people advocacy groups) will consistently be consulted to refine populations, interventions and outcomes of studies that use the ECHILD dataset to conduct target trial emulation. Scientific, lay and policy briefings will be produced to inform public health policy through partners in the Department of Education and the Department of Health and Social Care.

BackgroundThere is evolving evidence of significant differences in severity and outcomes of coronavirus disease 2019 (COVID-19) in children compared to adults. Underlying medical conditions associated with increased risk of severe disease are based on adult data, but have been applied across all ages resulting in large numbers of families undertaking social shielding (vulnerable group). We conducted a retrospective analysis of children with suspected COVID-19 at a Specialist Childrens Hospital to determine outcomes based on COVID-19 testing status and underlying health vulnerabilities. MethodsRoutine clinical data were extracted retrospectively from the Institutions Electronic Health Record system and Digital Research Environment for patients with suspected and confirmed COVID-19 diagnoses. Data were compared between Sars-CoV-2 positive and negative patients (CoVPos / CoVNeg respectively), and in relation to presence of underlying health vulnerabilities based on Public Health England guidance. FindingsBetween 1st March and 15th May 2020, 166 children (<18 years of age) presented to a specialist childrens hospital with clinical features of possible COVID-19 infection. 65 patients (39.2%) tested positive for SARS-CoV-2 virus. CoVPos patients were older (median 9 [0.9 - 14] years vs median 1 [0.1 - 5.7.5] years respectively, p<0.001). There was a significantly reduced proportion of vulnerable cases (47.7% vs 72.3%, p=0.002), but no difference in proportion of vulnerable patients requiring ventilation (61% vs 64.3%, p = 0.84) between CoVPos and CoVNeg groups. However, a significantly lower proportion of CoVPos patients required mechanical ventilation support compared to CoVNeg patients (27.7 vs 57.4%, p<0.001). Mortality was not significantly different between CoVPos and CoVNeg groups (1.5 vs 4% respectively, p=0.67) although there were no direct COVID-19 related deaths in this highly preselected paediatric population. InterpretationCOVID-19 infection may be associated with severe disease in childhood presenting to a specialist hospital, but does not appear significantly different in severity to other causes of similar clinical presentations. In children presenting with pre-existing COVID-19 vulnerable medical conditions at a specialist centre, there does not appear to be significantly increased risk of either contracting COVID-19 or severe complications, apart from those undergoing chemotherapy, who are over-represented.

Recent evidence has shown a substantial RSV burden in healthy term-born children, but there is less data quantifying the relative burden compared to those with co-morbidity or prematurity. There is also limited primary care and emergency department (ED) data due to the lack of routine pathogen detection. These data are important for the development of RSV immunisation strategies. A prospective surveillance study of children < 3 years old, presenting with lower respiratory infection and a sub-study in primary care of upper respiratory infection was conducted. The primary endpoint was RSV prevalence by healthcare setting. Secondary endpoints included proportion of hospitalisations, level of ventilatory support and admission to higher levels of care. An economic analysis assessing the costs associated with healthcare utilisation was also conducted. The primary analysis revealed RSV prevalence was 50.4% in children admitted to hospital, 36.3% in ED discharges, 36.5% in primary care and 12.8% in primary care children with upper respiratory infection. Healthy term-born children accounted for 73.3% of medically-attended RSV cases and 70.1% of hospitalisations. Risk factors for severe disease included any level of prematurity, age < 3 months and congenital cardiac disease. RSV positive cases incurred a higher mean cost than RSV negative cases (mean = {pound}1,706; incremental = {pound}683) per illness. The findings revealed a substantial burden associated with RSV. Even moderate prematurity was a risk factor for severe disease, and these children may not benefit from the full maternal immune response to vaccination and would not be eligible for Nirsevimab under UK guidance, we therefore recommend broadening eligibility to include these children. What is already known on this topicRecent cohort studies have revealed a substantial healthcare and economic RSV burden from previously healthy term-born children which has supported the implementation of a maternal RSV vaccination programme in the UK, providing protection for infants from birth up to 6 months old. What this study addsWe have shown that children born prematurely, including moderately preterm children, are at increased risk of severe RSV disease. These children may not benefit from full protection by maternal RSV vaccination, and may not be eligible for Nirsevimab, the long-acting monoclonal antibody, which is currently reserved for only the most high-risk children in the UK. How this study might affect research, practice or policyThis data supports broadening eligibility for Nirsevimab, to include preterm children, who were born before full maternal protection from RSV vaccination may have developed, and to infants born to mothers not receiving maternal vaccination.

ObjectiveTo support integrated health and education approaches by assessing differences in educational attainment between primary school children with and without a range of neurodisabilities. DesignPopulation-based cohort study. MethodsWe derived a national birth cohort of 2,351,589 children born in England between 01/09/2003-31/08/2008 enrolled in state-funded primary schools in Reception (age 4-5) using linked health and education records. Neurodisability was identified from hospital admission records. We described differences in primary school educational attainment for children with and without neurodisability. Results2.2% of children had a recorded neurodisability before starting Reception. These children consistently underperformed in national assessments, with fewer than half meeting nationally expected levels in Maths and English at every time point. By the end of primary school (age 10/11), 31% of children with neurodisability did not participate in national assessments despite being enrolled in school. Among children with neurodisability, educational attainment was lowest for children with Down syndrome and highest for children with perinatal conditions. ImplicationsSubstantial attainment gaps exist between children with and without neurodisability. By the end of primary school, many children with neurodisability are excluded from being formally assessed, highlighting the need for more personalised, functional outcome measures to ensure the meaningful evaluation of their educational development. KEY MESSAGESWhat is already known on this topic Children with neurodisability face functional challenges that can disrupt their success in school. There is limited understanding of their participation in national assessments and academic attainment throughout primary school on a population level in England. What this study adds: Large attainment gaps exist between children with neurodisability and their peers. Most (70% of) children with neurodisability who enter Year 1 are not school ready. A third of children with neurodisability are excluded from assessments at the end of primary school despite being enrolled in school. How this study might affect research, practice or policy: Health records can identify children with neurodisability early, supporting timely special educational needs and disability (SEND) assessments before school starts. Joint support provided by health and education systems may reduce the burden of neurodisability on school outcomes.

BackgroundAlthough individually rare, collectively rare diseases are more common than diabetes mellitus. The diagnostic odyssey for rare diseases is typically prolonged. AimWe aimed to hear the voice of rare disease stakeholders to provide evidence for strategies to improve rare disease care in Tasmania, Australia. MethodsMixed methods research with surveys, focus groups, and interviews captured the voice of healthcare consumers with rare disease, their families, and their caregivers, as well as consumer advocates, community reference group, rare disease researchers, and healthcare professionals. ResultsWe undertook 1,014 stakeholder consultations. Participants described elements of the diagnostic pathway that worked well, as well as barriers to diagnosis. Those affected by rare disease and their caregivers emphasised the need for healthcare providers to listen and respond to consumer concerns. Collectively, stakeholders reported that challenges in rare disease diagnosis in Tasmania include difficulties accessing timely primary and specialist health care, low awareness of rare disease among health professionals in Tasmania (including how to identify people with possible rare disease and what to do next), difficulty in accessing diagnostic testing, cost and geographic barriers in accessing diagnostic care, a lack of epidemiologic information on rare disease in Tasmania and the breakdown in care and support from the health system when transitioning from paediatric to adult services. DiscussionMany participant concerns that fall under the system responsibility of the Tasmanian Government could be addressed by establishing a Tasmanian Rare Care Centre. The centre could adopt principles from cancer care, such as patient-centred care, safe and quality care, multidisciplinary care, supportive care, care coordination, communication, and research and clinical trials. Other concerns, such as the equitable implementation of emerging diagnostic technologies and the education and training of non-genetics practitioners, will require national leadership and interjurisdictional cooperation to address. O_TEXTBOXSUMMARY BOXThe Known Rare diseases are a global health priority. The diagnostic odyssey is often prolonged, affecting rare disease care. The New Stakeholder consultation revealed that individuals affected by rare diseases and their families and caregivers often feel that they are not listened to, that their care is fragmented, and that non-genetics healthcare providers have limited awareness and understanding of rare disease. The Implications Many concerns raised by rare disease stakeholders could be addressed by establishing a Tasmanian Rare Care Centre. C_TEXTBOX

BackgroundPediatric emergency departments (PEDs) often face high volumes of low-acuity visits, reflecting gaps in primary care access and socio-economic disparities. We investigated how neighborhood socio-economic vulnerability, pediatrician availability, and proximity to the PED jointly influence PED utilization in Geneva, Switzerland. MethodsIn this retrospective ecological study (Jan 2023-Dec 2024), we aggregated all PED visits for children aged 0-16 years by neighborhood and Canadian Triage Acuity Scale (CTAS) level. Neighborhood visit incidence (unique patients per child population) was modeled using mixed-effects regression against a composite socio-economic vulnerability index (NSVI), pediatrician density within a 2 km radius, and distance to the PED, incorporating an exponential decay function for distance and postal code as a random intercept. ResultsThere were 68,482 PED visits by 35,994 children (35.1% of Geneva under-16 population). Low-acuity visits (CTAS 4-5) comprised [~]50% of encounters. Both distance and socio-economic vulnerability showed clear dose-response relationships, with stronger effects observed for lower-acuity visits, and no interaction effect between them. Overall, proximity accounted for up to 20.8% of non-urgent PED use, while neighborhood socio-economic vulnerability explained up to 19.7% of low acuity visits across Geneva. Pediatrician density showed a modest inverse association for low-acuity visits only. ConclusionsBoth proximity and socio-economic vulnerability are independent determinants of non-urgent PED use. Policies focusing only on primary care access risk missing key drivers of PED use, highlighting the need for locally tailored strategies such as community outreach near hospitals or programs to strengthen health literacy among families. SummaryProximity and socio-economic vulnerability each explain up to 20% of non-urgent pediatric emergency visits, highlighting major contextual drivers of avoidable care use. Whats Known on This SubjectPediatric emergency department crowding, often driven by low-acuity visits, has been linked to socio-economic disadvantage, poor primary care access, and proximity. Yet, few studies have jointly examined these factors or compared their impact within a universal healthcare setting. What This Study AddsThis study disentangles the effects of distance, socio-economic vulnerability, and pediatrician density on PED use. Proximity and disadvantage each explain [~]20% of low-acuity visits, while pediatrician density has limited impact, highlighting the need for targeted, locally adapted interventions.

BackgroundIncreasing hospital use in the past decade has placed considerable strain on children and young peoples (CYP) health services in England. Greater integration of healthcare may reduce these increases. We projected CYP healthcare activity out to 2040 and examined the potential impact of integrated care systems on projected activity. MethodsWe used routine administrative data (Hospital Episode Statistics (HES)) on emergency department (ED) attendances, emergency admissions and outpatient (OP) attendances for England by age-group for 0-24 year olds from 2007 to 2017. Bayesian projections of future activity used projected population and ethnicity and future child poverty rates. Cause data were used to identify ambulatory-care-sensitive-conditions (ACSC). FindingsED attendances, emergency admissions and OP attendances increased in all age groups from 2007 to 2017. ED and OP attendances increased 60-80% amongst children under 10 years. ACSC and neonatal causes drove the majority of increases in emergency admissions. Activity was projected to increase by 2040 by 50-145% for ED attendances, 20-125% for OP attendances and 4-58% for total admissions. Scenarios of increasing or decreasing child poverty resulted in small changes to forecast activity. Scenarios in which 50% of ACSC were seen outside hospital in integrated care reduced estimated activity in 2040 by 21.2-25.9% for admissions and 23.5-30.1% for ED attendances across poverty scenarios amongst infants. InterpretationThe rapid increases in CYP healthcare activity seen in the past decade may continue for the next decade given projected changes in population and child poverty, unless some of the drivers of increased activity are addressed. Contrary to these pessimistic scenarios, our findings suggest that development of integrated care for CYP at scale in England has the potential to dramatically reduce or even reverse these forecast increases FundingNil funding obtained. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSThere has been marked increases in hospital use (inpatient, outpatient and emergency department (ED)) by children and young people (CYP). Search of the PubMed database using the search terms: ((((("child"[MeSH Major Topic]) OR ("adolescent"[MeSH Major Topic])) OR ("infant"[MeSH Major Topic]))) AND ((healthcare use[Text Word])) OR (emergency admission[Text Word])) AND (united kingdom[Text Word]). Drivers of increased activity include population growth and sociodemographic factors, help-seeking behaviour, growth in medical knowledge and capability, and by factors within the health system. Additional factors in child health include increased survival of premature neonates and those with congenital conditions and rising parental expectations of modern medicine. Previous studies have shown that ambulatory-care-sensitive-conditions (ACSC) are responsible for much of the increase in CYP emergency activity in England and Scotland. Added value of this studyThis is the first study to use existing data to project possible future scenarios for CYP healthcare activity out to 2030 and 2040 in any country. Our future scenarios are based upon authoritative projections for population, ethnic diversity and child poverty in England and allow us to estimate the potential impact of integrated care scenarios in which ACSC are treated outside hospital. We show that future projected CYP activity is very high if mitigations such as integrated care are not instituted in England. Implications of all the available evidenceHealthcare activity has grown dramatically over the last decade in CYP, largely due to ACSC and the consequences of premature delivery. Projections to 2040 suggest that similar increases are likely over the next 2 decades without action to reduce child poverty and implementation of integrated care at scale in the NHS.

BackgroundInterventions introduced in 2020 to reduce the spread of SARS-CoV-2 led to a widespread reduction in childhood infections, including respiratory syncytial virus (RSV), in the subsequent year. However, from the spring of 2021 onwards the United Kingdom and Ireland began to experience an unusual out of season epidemic of childhood respiratory disease. MethodsWe conducted a prospective observational cohort study (BronchStart), enrolling children aged 0-23 months presenting with clinician-diagnosed bronchiolitis, lower respiratory tract infection or first episode of wheeze in 59 Emergency Departments (ED) across England, Scotland and Ireland from 1 May 2021 to 30 April 2022. We collected baseline data on patient demographics and clinical presentation, and follow-up data at 7 days. We used high-granularity BronchStart clinical data together with national English and Scottish admission datasets to infer the impact of RSV disease in a typical year before the Covid-19 pandemic, and to provide an up-to-date estimate of the annual impact of disease to inform implementation of anti-RSV interventions. FindingsThe BronchStart study collected data on 17,899 ED presentations for 17,179 children. Of these, 6,825 (38.1%) were admitted to hospital for further observation or treatment, 458 (2.6%) required care in a high dependency unit (HDU), and 154 (0.9%) were admitted to a paediatric intensive care unit (PICU). Of the 5,788 children admitted and tested for RSV, 41.8% of the overall study cohort, and 48.7% of those 0-11 months of age, were positive. Risk factors for hospital admission included prematurity and congenital cardiac disease. Patients with these risk factors were also more likely to receive oxygen therapy, or be admitted to a HDU or PICU. However, 84.5% of those admitted to an observation unit, 78.1% of those admitted to a ward, 67.7% of those admitted to HDU and 50.0 % of those admitted to PICU had no identified comorbidity. Using admissions data for England and Scotland we estimate that every year 12,167 infants with RSV infection receive low flow oxygen, 4,998 high flow oxygen and 6,198 a course of antibiotic therapy in secondary care. InterpretationAlthough RSV was the major pathogen in this cohort, 51.3% of admissions for serious respiratory viral infections in those aged <1 year of age were not associated with the virus. Whilst prematurity and congenital cardiac disease were risk factors for admission to hospital, HDU and PICU, the majority of these admissions, for all levels of care except PICU, were in previously healthy term born infants.

BackgroundMajor congenital anomalies (CAs) occur in 2.3% of livebirths and are associated with lower educational attainment in affected children. Understanding how attainment changes throughout primary school would inform parents, schools and organisations and help plan support. ObjectivesWe compared school enrolment and attainment at ages 5, 7 and 11 in children with different CAs and their peers in England using linked administrative hospital and education data in the ECHILD database. MethodsWe included all singleton children born in NHS-funded hospitals from September 2003 to August 2008 who enrolled in state-funded schools at age 4-5. CAs were identified from hospital diagnoses, procedures or death records. We described school enrolment, school-readiness, the percentages of children who sat curriculum assessments and who achieved expected levels in English and Maths at three ages. We estimated risk ratios of children with CAs achieving expected levels compared with peers, adjusting for sociodemographic factors. ResultsOf 2,351,589 singleton children enrolled at age 5, 78,847 (3.5%) had CAs. At age 11, 88.7% of enrolled children with CAs sat assessments versus 97.2% of peers. Proportionally fewer children with CAs (45.7%) were school-ready at age 5 versus peers (57.0%). For English, 56.9%, 55.4% and 65.3% of children with CAs achieved expected levels at ages 5, 7 and 11 respectively, consistently 11%-12% fewer than peers; similar gaps persisted for Maths. Children with CAs were on average less likely than peers to achieve expected levels [adjusted risk ratio, aRR (95%CI): 0.86 (0.85,0.86)] but this varied substantially across CA subgroups [aRR (95%CI) range: 0.01 (0.01,0.02) to 1.04 (0.96,1.12)]. ConclusionThe attainment gap between children with CAs and peers remained unchanged across subjects and ages, with proportionally fewer sitting assessments at age 11. Better monitoring and support for these children from school entry could help optimise learning experiences and fulfil their academic potential. SYNOPSISO_ST_ABSStudy questionC_ST_ABSWhat are the patterns of educational attainment in children with major congenital anomalies (CAs) throughout primary school? What is already knownStudies of regional or registry-specific cohorts of children with CAs showed that proportionally fewer achieve expected attainment relative to peers at single stages of national assessments. There is limited evidence on childrens participation in assessments and how attainment gaps change throughout primary school at a population level. What the study addsLongitudinal analysis of whole-population cohorts from ages 4 to 11 found that attainment gaps between children with and without CAs remained largely constant across ages. Over half of children with CAs were assessed as not school-ready at age 5. Whilst almost all children with CAs remained enrolled in school at age 11, one in nine did not participate in assessments.

BackgroundThe comparative efficacy and safety of intravenous rehydration (IVR) and oral rehydration (OR) strategies in children with severe acute malnutrition (SAM) remains uncertain. MethodsWe systematically reviewed randomized clinical trials (RCTs) comparing the use of IVR and oral rehydration (standard of care) in children with SAM hospitalized with severe dehydration secondary to gastroenteritis. The primary outcome was in-hospital mortality. Secondary outcomes included fluid overload events, development of shock requiring intravenous boluses, development of neurological complications; severe electrolyte abnormalities at 24 hours and day 28 mortality. FindingsWe identified 3 RCTs, comprising 484 participants with severe malnutrition including 72 children with the kwashiorkor phenotype: (2 some risk of bias; 1 low risk of bias). The risk ratio (RR) for in-hospital mortality with IVR versus OR was 0.71 (95% confidence interval [CI], 0.46-1.10; I2=0.0%) with moderate certainty of evidence. No fluid overload events were reported, pooled RR 0.99 (95% CI 0.10-9.35). Pooled RR of severe hyponatremia at 24 hours (grouped by threshold (sodium < 125 or <130mmol/L)) was 0.66 (95% CI 0.44-0.99). Only one trial reported RR for shock development; hypernatremia (sodium >145mmol/l) and 28-day mortality with IVR versus OR RRs of 0.56 (95% CI 0.21-1.48); 2.05 (95% CI 0.50-8.58) and 0.85 (95% CI 0.44-1.65) respectively. Subgroup analyses for in-hospital mortality were carried out for region and risk of bias rating giving p=0.85 and p=0.54 for heterogeneity respectively. ConclusionThe estimated effect of using IVR versus OR in children with SAM with severe dehydration ranges from a 54% relative reduction to a 10% relative increase in the risk of death with IVR resulting in fewer adverse events. (PROSPERO number, CRD42025637956.) Key QuestionsO_ST_ABSWhat is already known on this topicC_ST_ABSInternational guidelines advise against giving intravenous rehydration to children with severe acute malnutrition due to concerns about fluid overload. Evidence to support this recommendation is weak, specifically in children in African with severe dehydration due to diarrhoea What this study addsWe systematically reviewed evidence comprising of 484 children in 3 randomised trials, and estimated that intravenous rehydration resulted in a 54% relative reduction to a 10% relative increase in the risk of death No evidence of fluid overload or cardiac failure was reported in any trial How might this study affect research, practice or policyThe guidance on intravenous rehydration should be reconsidered in light of the findings of this review and considering the safety of intravenous rehydration Simplification of the rehydration guidelines for severe dehydration to remove the distinction between malnourished and non-malnourished children would facilitate ease of implementation.

Background & ObjectiveCOVID-19 has caused significant shifts in healthcare utilization, including pediatric emergency departments (EDs). We describe variations in visits made to two large pediatric EDs during the first three months of the COVID-19 pandemic, compared to a historical control period. MethodsWe performed a retrospective cohort study of children presenting to two academic pediatric EDs in Quebec, Canada. We compared the number of ED visits during the first wave of COVID-19 pandemic (March-May 2020) to historical controls (March-May 2015-2019), using Poisson regression, adjusting for site and the underlying baseline trend. Secondary analyses examined variations in ED visits by acuity, disposition, and disease categories. ResultsFrom 2015 to 2019, the two EDs had a median of 1,632 visits per week [interquartile range (IQR) 1,548; 1,703]; in 2020, this number decreased to 536 visits per week [IQR 446; 744]. In multivariable analyses, this represent a 53.3% (95%CI: 52.1, 54.4) reduction in the number of ED visits. The reduction was larger among visits triage categories 4 and 5 (lower acuity) than categories 1, 2 and 3 (higher acuity): -54.2% vs. -42.0% (p<0.001). A greater proportion of children presenting to these sites were hospitalized during the COVID period than in pre-COVID period: 11.8% vs. 5.5% (p<0.001). ConclusionsDuring the early stages of the COVID-19 pandemic, there was a large decrease in visits to pediatric EDs. Patients presented with higher acuity at triage and the proportion of patients requiring hospitalization increased.

ImportanceInternationally, there are gaps in data to monitor both early childhood development (ECD) and progress in closing the inequality gap. The unequal impact of the COVID-19 pandemic, and any differential impact on ECD domains is also not poorly understood. ObjectiveTo examine time trends and area-level socioeconomic inequalities in ECD at 2 2.5 years in England between 2019 and 2024 DesignCross-sectional and longitudinal ecological analysis Setting149 local authorities in England Participants143 local authorities (662 annual observations, publishable quality data and at least 75% coverage of eligible children) ExposureYear of assessment, area-level socioeconomic conditions (Index of Multiple Deprivation 2019, Income Deprivation Affecting Children Index (IDACI)) assessed as the Slope Index of Inequality (SII) and Relative Index of Inequality (RII)) Main outcomesAges and Stages Questionnaire 3, rate per 100 not developmentally on track (Five domains of development: Communication, Gross Motor, Fine Motor, Personal Social, or Problem Solving; and any domain) ResultsRate per 100 children not developmentally on track in any domain increased progressively from 2019 (16[95%CI: 14.2; 16.9]), and was highest in 2023 (20.6[18.9; 22.4]) and 2024 (19.8[18.2; 21.4]). Compared to 2019 rates, the largest absolute increase was in 2023 (4.9[3.6; 6.3]), largest for Communication (4.3[3.5; 5.2], followed by similar increases for Personal Social (3.3[2.5; 4]) and Problem Solving (2.9[2.2; 3.5]), and smaller increases for Fine Motor (1.4[0.6; 2]) and Gross Motor (0.9[0.2; 1.6]). All rates except Gross Motor remained elevated in 2024. On average, 21.3[19.5; 23.0] per 100 children were not on track in any domain for the most income-deprived quintile compared to 16.2[14.7;17.8] for the least income-deprived (SII: 2.9[1.8; 3.9]; RII: 23%[14%; 32%]). Inequalities were largest in Communication (SII: 2.8[2.0; 3.6]; RII: 36%[25%; 49%]). Year by area-level socioeconomic conditions interaction effects were not statistically significant. Conclusions and RelevanceIn England, ECD worsened during the pandemic, more so for children exposed for longer, or from a younger age. Children born after the pandemic continue to be affected. Area-level inequalities were striking but did not worsen during this period. Pandemic-recovery efforts need to consider the potentially enormous economic and societal cost of disruption to ECD. Key pointsO_ST_ABSQuestionC_ST_ABSWhat are the time trends and area-level socioeconomic inequalities in early childhood development at 2 to 2.5 years in England around the time of the COVID-19 pandemic? FindingsEarly childhood development at 2 to 2.5 years in England worsened in the wake of the COVID-19 pandemic. Stark socioeconomic inequalities were observed throughout the period of 2019 to 2024. MeaningPolicy makers need to prioritise early years and children services in pandemic recovery efforts to improve early developmental outcomes, especially for children from socioeconomically deprived backgrounds.

BackgroundWheezing in the pre-school aged group (under 5 years) is a common presentation and significant healthcare burden. It is a heterogenous presentation representing a spectrum of phenotypes and although the causes may be multifactorial, viral infection is the most common trigger, with rhinovirus and Respiratory Syncytial Virus (RSV) being the most commonly detected. Rigorous evidence-based guidance for the acute management of preschool wheeze (PW) with respect to which children likely to benefit from oral corticosteroid therapy (OCS), is lacking. RCTs of OCS use in PW have not adequately assessed the impact of respiratory virus testing in the management of PW. To address the hypothesis that OCS response may be determined by the specific virus, the feasibility of performing POC respiratory virus tests prior to randomisation in an acute paediatric ED setting needs to be ascertained. MethodsThe PRECISE Study will be a single centre, randomised, open-label, feasibility trial. Children aged 24-59 months with acute wheeze will be eligible if the clinician is uncertain if there is a role for oral corticosteroid therapy or not. At enrolment, participants will undergo a nasal swab for rapid respiratory virus testing. Children will be randomised in a 1:1 ratio to receive oral dexamethasone or not, based on their RSV result. Participants will continue to be managed by the clinician according to local guidance. They will be invited for clinical review at 72 hours where a repeat nasal swab may be performed. There will be a telephone follow up at one month and parents will be invited for extended telephone interviews within a further month. Comprehensive screening logs will address the primary outcome of recruitment and timeliness until enrolment. Remaining timeliness and adherence outcomes will be recorded in individual participant records and described using CONSORT diagrams. Acceptability will be measured using a mixed method qualitative approach based on the theory of acceptability framework. DiscussionThis pragmatically designed trial will address key feasibility points needed to inform a future, definitive multi-centre RCT prospectively testing the role of respiratory virus testing to randomise children with PW to receive oral corticosteroids or not. Trial registrationNCT06580600 (clinicaltrials.gov)

BackgroundLinked administrative data covering whole populations are fundamental resources for longitudinal studies of children with rare conditions (cases) and unaffected peers (comparators). Data minimisation regulations sometimes limit the number of comparators per case (sampled comparators, SC), with unknown impact on study findings. MethodsUsing Monte Carlo draws, we simulated 100 000 children with and without an exemplar condition, congenital hypothyroidism (CHT), with covariates (sex and comorbidity). Three outcomes (Y: Maths tests z-score, age 11 years; L: achieving expected Maths attainment (binary); T: months to neurodevelopmental disorder diagnosis) were modelled as linear combinations of CHT, sex and comorbidity. Varying parameters (comorbidity prevalence; comorbidity-CHT association; CHT effect on Y/L/T) factorially produced 36 data-generating mechanisms (DGMs). We used regression coefficients (CHT effect), standard errors (SEs) and p-values from 1000 simulations to evaluate power, precision and bias, comparing SCn (n=5/10/15/25/50/100) versus full cohort (FC). ResultsMean p-values and SEs for SC25 generally deviated [&le;]5% versus FC with medium effects (z-score difference=0.3; odds/hazard ratios[&ge;]2), and [&le;]2% for large effects (z-score difference[&ge;]0.6; odds/hazard ratios[&ge;]5). For all outcomes, no SC nor FC had sufficient power (>80% of p-values[&le;]0.05) with small or medium effects, whilst all SC had sufficient power with large effects. Compared with FC, precision loss for SC25 was 2.0-4.3%, 5.0-8.9%, 6.7-15.5% for Y, L, T respectively. SC was not associated with bias. ConclusionSC25 provided comparable performance as FC for rare disease studies under several scenarios, but small effects posed challenges, notwithstanding sampling. This approach generates cost-effective recommendations for study design and data minimisation. Key messagesWhat is the minimum ratio of children without disease (comparators) to children with disease (cases) needed to reliably quantify differences in health and educational outcomes, if whole population data were not accessible? Sampling 25 comparators per case would generally provide comparable inferences as whole population data for typical scenarios likely to be encountered in longitudinal studies involving children with rare diseases. Decreasing sample sizes helps studies to fulfil data minimisation principles, guides negotiations with data providers and facilitates approvals by research governance bodies, without compromising the quality of research findings.

UK Lockdown measures introduced in March 2020 aimed to mitigate the spread of Covid-19. Although seeking healthcare was still permitted within restrictions, paediatric emergency department attendances reduced dramatically and led to concern over risks caused by delayed presentation. Our aim was to gain insight into healthcare decisions faced by parents during the first wave of the Covid-19 pandemic and to understand if use of urgent healthcare, self-care, and information needs differed during lockdown as well as how parents perceived risks of Covid-19. We undertook qualitative telephone interviews with a purposive sample of parents living in the North East of England recruited through online advertising. We used a semi-structured topic guide to explore past and current healthcare use, perceptions of risk and the impact of the pandemic on healthcare decisions. Interviews were transcribed and analysed using Thematic Analysis. Three major themes were identified which concerned (i) how parents made sense of risks posed to, and by their children, (ii) understanding information regarding health services and (iii) attempting to make the right decision. These themes contribute to the understanding of the initial impact of Covid-19 and associated restrictions on parental decisions about urgent healthcare for children. These findings are important to consider when planning for potential future public health emergencies but also in the wider context of encouraging appropriate use of urgent healthcare.