Archives of Disease in Childhood

Background: Children born prematurely (before 37 weeks) or admitted to the neonatal unit (NNU) are at increased risk of adverse long-term physical health outcomes. It is also recognised that there is an association with later academic performance and special educational needs, however it is not clear whether these broad risk factors could be used as stand-alone heuristics to identify children who may benefit from additional support in educational settings. We aimed to examine the associations between neonatal unit (NNU) admission and educational attainment in mid-childhood. Methods and Findings: Pregnancy data from a prospective birth cohort (Pregnancy Outcome Prediction Study, Cambridge, United Kingdom, 2008-2012) were linked to national educational outcomes (Department for Education, United Kingdom). Multivariable regression models adjusted for maternal, child, and socioeconomic factors were used to evaluate associations between (i) all NNU admissions, (ii) at term NNU admissions >48 hours, (iii) preterm birth without ongoing physical health needs, and educational outcomes at ages 5-11 years. Children who required any NNU care were more likely not to meet expected educational standards across multiple ages and domains in early and mid-childhood: age 5 early year foundation (aOR 1.64, 95% CI 1.19-2.27, p=0.003), phonics at age 6 (aOR 2.43, 95% CI 1.72-3.57, p<0.001), and at age 7 (here assessments were divided into multiple domains): reading (aOR 1.67, 95% CI 1.18-2.38, p=0.004), writing (aOR 1.72, 95% CI 1.25-2.38, p<0.001), mathematics (aOR 1.56, 95% CI 1.09-2.22, p=0.020), and science (aOR 1.85, 95% CI 1.22-2.78, p=0.003). Similar patterns were observed among both at term-born infants who stayed >48hrs in NNU (phonics assessment at age 6 aOR 2.26, 95% CI 1.51-3.36, p<0.001) and in children born preterm without long-term physical health sequelae (phonics assessment at age 6 aOR 3.07, 95% CI 1.96-4.81, p<0.001). These associations were robust to adjustment for demographic, perinatal, and socio-economic factors. By age 11, differences in academic attainment were attenuated and no longer clearly distinguishable across all exposure groups. However, there was an increased likelihood of special educational needs (SEN) at age 11 associated with any NNU admission (aOR 1.78, 95% CI 1.15-2.73, p=0.009), at term NNU admission for >48hrs (aOR 1.88, 95% CI 1.19-3.00, p=0.007), and children born preterm without long-term physical health sequelae (aOR 1.50, 95% CI 1.00-2.25, p=0.049). Predictive performance of any NNU admission for SEN at age 11 was moderate (AUC 0.70, 95% CI: 1.14-2.65, p=0.010), with balanced sensitivity and specificity and high negative predictive value. Conclusions: NNU admission, for both term and preterm infants, is associated with poorer educational outcomes and an increased likelihood of special educational needs in mid-childhood.

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.

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.

BackgroundDuring the COVID-19 pandemic children and young people (CYP) mortality in England reduced to the lowest on record, but it is unclear if the mechanisms which facilitated a reduction in mortality had a longer lasting impact, and what impact the pandemic, and its social restrictions, have had on deaths with longer latencies (e.g. malignancies). The aim of this analysis was to quantify the relative risk of childhood deaths, in England, before, during, and after the COVID pandemic and its social changes. Methods and FindingsMortality for each analysis year was calculated per 1,000,000 person years. Poisson regression was used to test for an overall trend across the time period, and tested if trends differed between April 2019 to March 2021 (Period 1)) and April 2021 to March 2023 (Period 2). This was then repeated for each category of death and demographic group. The underlying population profile was obtained from 2021 ONS Census data. 12,828 deaths were included in the analysis. 59.4% of deaths occurred under 1 year of age. Mortality rate (per 1,000,000 CYP per year) dropped from 272.2 (264.8-283.8) in 2019-20, to 242.2 (233.4-251.2) in 2020-21, increasing to 296.1 (286.3-306.1) in 2022-23. Overall, death rate reduced in Period 1 (RR 0.96 (0.92-0.99)) and then increased in Period 2 (RR 1.12 (1.08-1.16)). Asian (p<0.001), Black (p-0.012), and Other (p=0.003) ethnic groups, and those in more deprived areas (p<0.001), had evidence of an initial reduction mortality, and then a subsequent increase. Death rates for children from White (p=0.601) or Mixed (p=0.823) ethnic backgrounds, or those in the least deprived areas, did not change over the study period. ConclusionsDifferent temporal profiles were seen across cause of death categories, with reassuring trends in deaths from Suicide and Intrapartum deaths (after pandemic peaks). However, for all other causes of death, rates are either static, or increasing. Overall child mortality in England is now higher than before the pandemic. In addition, any reductions in health inequalities seen moving into, and during, the pandemic have now disappeared.

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.

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.

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

BackgroundPreterm birth (PTB) is a leading cause of atypical brain development and cognitive impairment, however, there are sparse data on its impact on statutory educational assessments. We aimed to describe school readiness at 5 years and educational attainment at 6-7 years of children born preterm in England and identify the early life factors that associate with attainment. MethodsWe created a novel record linkage between the National Neonatal Research Database and the National Pupil Database for all babies born <32 weeks gestation in England (2008-2012) who survived to neonatal discharge. We used logistic regression to investigate associations between clinical and demographic variables and performance in six statutory school-age assessments. FindingsData from 15,857 children were analysed (53.3% boys). Fifty-seven percent did not meet the school readiness level at age 5, 51% did not meet expected attainment at ages six to seven in writing, maths (48%), reading (42%), and science (36%). Children born at 23-24 weeks had two to three times higher odds of not meeting expected levels compared to those born at 31 weeks (age 5: adjusted odds ratio 2.86, 95% CI 2.19-3.73). Children born in the most deprived areas at birth had 1 7 to 2-fold the risk of under-attainment compared to those in the least deprived. In adjusted models, male sex and season of birth conferred increased risk, alongside several potentially mutable risks: smoking during pregnancy, exposure to ante-or postnatal corticosteroids, severe acquired neonatal brain injuries, co-morbidities of PTB, nutrition during neonatal care, and childhood deprivation. InterpretationPTB poses a substantial risk for educational under-attainment at ages 5 through 7 years, particularly when combined with socioeconomic deprivation. Addressing neighbourhood-and family-level social inequalities should be given similar priority as reducing medical complications of PTB for improving the educational attainment of children born preterm. FundingUKRI Medical Research Council RESEARCH IN CONTEXTO_ST_ABSEvidence before this studyC_ST_ABSWe searched PubMed from October 1st, 2015, to October 1st, 2025, with no language restrictions for publications using the terms (("preterm" OR "premature" OR "gestational age") AND "socioeconomic" AND ("school" OR "education")) in the title/abstract. Our search identified 20 relevant peer-reviewed studies, including one narrative systematic review that examined how socioeconomic inequalities and preterm birth interact to modify health and education outcomes. Three studies were conducted in the UK and used linked data to investigate educational outcomes for preterm-born children. The remainder were conducted in Scandinavian countries, Canada, Australia, and the Netherlands. Collectively, these studies have consistently shown that children born preterm have lower educational attainment compared with those born at term: a well-established dose-response relationship exists between gestational age and educational outcomes, with lower gestational age associated with progressively poorer attainment across all stages of education. However, most existing linkage studies did not capture the clinical heterogeneity of the preterm-born population underlying this gradient, as these data are rarely available in population-level datasets linked to education records. Whilst some studies included measures of socioeconomic status as a covariate, their independent effects have seldom been investigated, particularly relative to neonatal risk factors. Added value of this studyThe present study addresses these gaps through a novel linkage of population-level neonatal clinical data with national statutory educational assessments. We describe the high prevalence of low attainment among very preterm children (<32 weeks gestation) at ages 5 through 7 years in England. The linkage enables a granular characterisation of how maternal and neonatal conditions, exposures and treatments, and neighbourhood-and family-level measures of social disadvantage explain educational performance of children born <32 weeks gestation. The findings show a dose effect of low GA on low attainment and that the adverse effects of socioeconomic deprivation at birth persist through early school age. The effect of family-level deprivation at the start of school age is comparable in magnitude to that of severe neonatal brain injury, however, impacts a greater proportion of the population. As such, this study provides a more holistic understanding of the pathways underlying educational risk in this population. Implications of all the available evidenceImproving the educational attainment of very preterm children is likely to require a reduction in social inequalities in pregnancy and early childhood, alongside care practices and research to minimise comorbidities of preterm birth. Furthermore, the identification of modifiable exposures, including maternal non-smoking, antenatal or postnatal corticosteroid exposure, breastfeeding, and deferred school entry or targeted additional support for very preterm children born in the summer months, offers practical targets for parents, clinicians, teachers and school leaders and educators, that could facilitate long-term educational attainment for children born preterm.

ObjectivesThe aim of this analysis is to identify and report the patterns of social deprivation in relation to childhood mortality; and identify potential points where public health, social and education interventions or health policy may be best targeted. DesignDecile of deprivation and underlying population distribution was derived using Office for National Statistics (ONS) data. The risk of death was then derived using a Poisson regression model, calculating the increasing risk of death for each increasing deprivation decile. SettingEngland Participants2688 childhood deaths in England reviewed between the April 2019 and March 2020. Main Outcome MeasuresThe relationship between deprivation and risk of death; for deaths with, and without modifiable factors. ResultsThere was evidence of increasing mortality risk with increase in deprivation decile (RR 1.08 (1.07 to 1.10)), with the gradient of risk stronger in children who died with modifiable factors than those without (RR 1.12 (1.09 to 1.15)) vs (RR 1.07 (1.05 to 1.08)). Deprivation sub-domains of Employment, Adult Education, Barriers to Housing and Services, and Indoor Living Environments appeared to be the most important predictors of child mortality ConclusionsThere is a clear gradient of increasing child mortality across England as measures of deprivation increase; with a striking finding that this varied little by area, age or other demographic factor. Over a fifth of all child deaths may be avoided if the most deprived half of the population had the same mortality as the least deprived. Children dying in more deprived areas may have a greater proportion of avoidable deaths. Adult employment and education, and improvements to housing, may be the most efficient place to target resources to reduce these inequalities.

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.

ImportanceWhole genome sequencing (WGS) is increasingly used to diagnose severely ill children, yet the long-term impact of a genetic diagnosis on healthcare utilization and resource allocation remains poorly understood. ObjectiveTo determine the influence of a genetic diagnosis via WGS on long-term healthcare utilization metrics in severely ill children. DesignA retrospective cohort study using data from the Next Generation Children study (2016-2020) with record linkage and analysis of primary care records conducted between 2022 and 2024. SettingA multicenter study involving primary care and hospital records linked via the UK National Health Research Institute (NIHR) Rare Disease Bioresource, Cambridge, UK. ParticipantsA referred sample of 270 severely ill children who underwent WGS. Exposure(s)Receipt of a genetic diagnosis (87/270; 32%) compared to those who remained undiagnosed (183/270; 68%) following WGS. Main Outcome(s) and Measure(s)Comparison of 36 healthcare utilization parameters, including hospitalizations, primary care prescriptions, and diagnostic tests. ResultsAmong the 270 children analyzed, those receiving a genetic diagnosis (n=87) exhibited significantly higher overall healthcare utilization compared to undiagnosed peers (n=183). This included increased hospital admissions and outpatient visits, particularly for neurodevelopmental and seizure-related conditions. Diagnosed children received a higher volume of neurological, gastrointestinal, and nutritional prescriptions. The most pronounced differences in utilization were observed in children initially diagnosed in neonatal (NICU) or pediatric (PICU) intensive care settings. While genetic diagnosis was not associated with reduced healthcare costs during the study period, it was linked to more targeted, condition-specific medical care. Conclusions and RelevanceWGS diagnosis facilitates the integration of specialist care and the alignment of healthcare resources with the specific needs of children with complex disorders. These findings suggest that while costs may not decrease immediately, a diagnosis enables more precise and targeted clinical management. Key PointsO_ST_ABSQuestionC_ST_ABSDoes a genetic diagnosis through whole genome sequencing influence long-term healthcare utilization in severely ill children? FindingsIn this cohort study of 270 children, those who received a genetic diagnosis demonstrated significantly greater overall healthcare utilization, including more hospitalizations and targeted prescriptions, compared with undiagnosed children. MeaningA genetic diagnosis facilitates the integration of specialized, condition-specific care, helping to align healthcare resources with the individual needs of children with complex disorders.

Using data from 4678 children participating in VirusWatch, a household cohort study, we estimated the prevalence of persistent symptoms lasting [&ge;]4 weeks as 1.7%, and 4.6% in children with a history of SARS-CoV-2 infection. Persistent symptom prevalence was higher in girls, teenagers and children with long-term conditions.

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.

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.

A long-acting monoclonal antibody against Respiratory Syncytial Virus (RSV), given as a one-off injection shortly after birth, is likely to be introduced soon. We hypothesised that carer acceptance of intra-muscular (IM) vitamin K, another injection given shortly after birth, might serve as a proxy indicator of likely acceptance of any such anti-RSV intervention, given previous associations described between IM vitamin K acceptance and subsequent non-immunisation. Using a national dataset of all postnatal health visitor visits in Scotland from 2018-2021 we explored demographic variables associated with non-acceptance of IM vitamin after birth. We found that in the time period 2019-2021 over 95.5% of carers were documented as consenting to this intervention, with only 1.1% requesting oral vitamin K and 0.9% refusing vitamin K altogether. Infant ethnicity, use of English as a first language at home, socio-economic position and maternal age were not associated with reduced uptake of IM vitamin K. We therefore did not identify any groups that might require increased engagement prior to the roll-out of a long-acting monoclonal antibody for RSV.

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.

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.

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.

Background: Socioeconomic deprivation is associated with childhood morbidity, but nationwide evidence on critical illness and death in a health system with universal insurance coverage is scarce. We assessed the association between area-level deprivation and the population-level incidence of hospital admission, complex intensive care treatment (CICT), and CICT-related mortality in German children, and changes over time. Methods: Population-based analysis of complete German hospital discharge data, 2016 to 2023, covering all cases aged > 28 days to < 18 years. Cases were linked to the German Index of Socioeconomic Deprivation (GISD) via the municipality of residence and grouped into quintiles (Q1 least, Q5 most deprived). Incidence rates were calculated per 100,000 child years. Negative binomial regression adjusted for calendar year, with population as offset, yielded adjusted incidence rate ratios (aIRR) per one-quintile increase in deprivation; sensitivity analyses additionally adjusted for age group. Excess cases were estimated by applying Q1 incidence rates to Q2 to Q5. Results: Of 8,890,103 pediatric cases, 140,509 (1.6 %) received CICT and 3,386 (2.40 %) of these died. Incidence rose with deprivation from Q1 to Q5: admissions 6,191 to 9,255 per 100,000 child years, CICT 97 to 128, mortality 2.54 to 2.96. Each one-quintile increase was associated with higher risk of admission (aIRR 1.10, 95 % CI 1.10-1.11), CICT (1.07, 1.05-1.08), and mortality (1.04, 1.01-1.06); estimates were unchanged after age adjustment. Relative to Q1 rates, Q2 to Q5 accounted for 1,295,896 excess admissions (20.8 %), 11,254 excess CICT cases (12.6 %), and 194 excess deaths (8.7 %). Case fatality among CICT cases was lower in more deprived quintiles (2.35 % in Q5 versus 2.64 % in Q1), as were organ dysfunction and chronic conditions. Disparities in admission and CICT narrowed over time, whereas the mortality gradient persisted. Conclusions: Universal health insurance did not eliminate socioeconomic inequalities in pediatric critical illness. Deprivation increased the population burden of admission, intensive care, and death, but did not worsen outcomes once intensive care had begun, indicating that inequalities arise before pediatric intensive care and that prevention upstream in the care continuum is the primary target.

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.