Archives of Disease in Childhood

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.

Importance: Preschool children in care are at high risk for psychosocial health concerns. Population-based evidence is limited. Objective: Estimate prevalence of psychosocial health concerns in children in care and not in care, and assess care-status differences stratified by deprivation. Design: Population-based cross-sectional study using 27-30 Month Health Review data from April 2013 to March 2023. Setting: Universal health review program in Scotland. Participants: 7887 children in care and 445 547 children not in care. Exposures: Care status at review, classified as in care or not. Main Outcomes and Measures: Four outcome categories (emotional, behavioral, and/or attentional; personal and/or social; speech, language, and/or communication; and other developmental concerns) plus an aggregate indicator of any of the four. We estimated adjusted odds ratios between children in care and not in care, including variation with deprivation. Models adjusted for sex, age, ethnicity, and deprivation. Results: Psychosocial health concerns were more common in children in care (2290; 29.0%) than children not in care (77 836; 17.5%; relative risk 1.66). Concerns were more common in children in care across all outcomes. The adjusted odds ratio comparing children in care with children not in care for any recorded concern was 1.86 (95% CI, 1.77-1.96). Adjusted odds ratios varied by outcome from 1.57 (95% CI, 1.49-1.66) for speech, language, and/or communication concerns to 2.49 (95% CI, 2.34-2.66) for emotional, behavioral, and/or attentional concerns. Relative inequities between children in care and not in care decreased with increasing deprivation from aOR of 1.58 (95% CI, 1.45-1.72) in the most deprived fifth of areas to 2.61 (95% CI, 2.25-3.03) in the least deprived fifth. Prevalence of any recorded concern increased with deprivation in both care groups. The relative risk comparing the most deprived with least deprived fifth of areas was 1.46 (95% CI, 1.29-1.66) among children in care and higher at 2.34 (95% CI, 2.29-2.40) among children not in care. Conclusions and Relevance: Psychosocial health inequities are evident at an early age between children in care and not in care, and vary with deprivation. Support for children in care and children living in more deprived areas should be prioritized.

Background: Gender-affirming medical care (GAMC) for children and adolescents in Australia has become increasingly politicized, despite care being provided in accordance with latest evidence-based international guidelines. Critics of GAMC claim that current assessment and deliberation processes are insufficient, and that too many young people are accessing medical interventions, no longer identifying as trans, and expressing treatment regret. These claims have led to widespread bans on the provision of paediatric GAMC, despite growing evidence regarding harms caused by such bans. Aim: This study sought to describe the care journeys of the young people attending Australia's largest paediatric gender service, with a focus on reporting the rates at which young people commenced medical interventions, re-identified with their birth-assigned sex, and expressed regret about their treatment. Methods: The Royal Children's Hospital Gender Service (RCHGS) is a statewide service that provides individualised multidisciplinary care to trans and gender diverse young people in Victoria, Australia. An initial extended triage appointment explores the needs and goals of the young person and their family. Some proceed to receive individualised multidisciplinary care (MDC) at RCHGS which can include psychosocial assessment and management, family support, and medical interventions including pubertal suppression (PS) and gender-affirming hormonal therapy (GAHT). We undertook a retrospective file audit of all patients who had attended at least one RCHGS appointment and been discharged between 1/1/2017-31/12/2024. For each person, key data were extracted from their electronic medical record and recorded in REDCap. Results: 1,391 patients were discharged over the 8-year study period and many different care trajectories were observed. 814 (58.5%) did not access ongoing MDC. Of the remaining 577, 353 (25.4% of total cohort) started a medical intervention ((PS: n=64/1391 (4.6%); estradiol: n=97/1391 (7.0%); testosterone: n=244/1391 (17.5%)). For those who started these medical interventions, the median duration and number of sessions from first appointment until commencement of medications was 530 (IQR: 371-693) days and 9 (IQR: 7-13) sessions. 346 of these patients (98.0%) had data on gender identity at discharge and subsequent care pathways. 7 (2.0%) re-identified with their birth-registered sex and stopped treatment: 4 did so after commencing PS (4/61=6.6% of those starting PS), 2 did so after commencing testosterone, and 1 did so after commencing estradiol (3/341=0.9% of those starting GAHT). Just one of these patients, who had been on estradiol for 1 month, expressed treatment regret given concerns about initial breast budding and future fertility. Conclusion: This study highlights varied trajectories of those referred to paediatric gender services, directly challenges claims used to justify restrictions on paediatric GAMC and underscores the importance of a person-centred approach to care.

Abstract Background: Having a usual source of care (USC) supports continuity and access to health services. Recent national trends among U.S. children have not been comprehensively characterized. We examined changes in USC prevalence, subgroup heterogeneity, and reported reasons for not having a USC using the 2015-2024 Medical Expenditure Panel Survey. Methods: We analyzed the 2015-2024 Medical Expenditure Panel Survey Household Full-Year Consolidated Data. Annual prevalence rates were estimated for children aged 0 to 17 years overall and by sex, age group, race and ethnicity, and insurance status. The reported reasons for not having a USC were grouped to low perceived need, preference or self-management, access or continuity barrier, and other reasons. The distribution of grouped reasons was analyzed for each study year. Temporal differences in yearly estimates were evaluated using two-sample z-tests between 2015 and 2019 and between 2015 and 2024, and average annual changes were estimated using generalized linear regression. Results: Overall USC prevalence declined from 92.9% (95% confidence interval [CI], 91.9%, 93.8%) in 2015 to 87.2% (95% CI, 85.1%, 89.2%) in 2024. The estimated average annual change was -0.8 percentage points (95% CI, -1.0 to -0.6). Declines were observed across most subgroups and were largest among uninsured children, whose prevalence decreased from 78.4% to 53.6%. Low perceived need remained the most common reported reason for not having a USC, while the proportion reporting access or continuity barriers decreased and the proportion classified as other reasons increased. Conclusions: Estimates based on the Medical Expenditure Panel Survey indicated a substantial decline in the prevalence of having a USC among U.S. children, with notable heterogeneity by insurance status and race and ethnicity. Further research is needed to determine whether the decline reflects changing access, organization and use of pediatric care, survey measurement, or a combination of these factors.

Background Hospital outpatient departments (OPDs) deliver specialist care at scale, under close scrutiny over waiting times. Interruptions are common in this setting and are linked to error. Little is known about how they cause harm, for whom, and under what conditions. Methods Qualitative study using focus groups and interviews with 42 doctors working in UK National Health Service OPDs (19 sessions, September to November 2025). Participants were purposively sampled by clinical experience and self-reported patient complexity. Data were analysed using the Framework Method, informed by Cognitive Load Theory and Social Identity Theory, with independent double coding of 10% of transcripts (kappa = 0.97) and participant validation. Results We developed four themes. (1) Interruptions as a structural and increasingly ambiguous feature of clinical work. Interruptions were a normal part of clinical coordination, but new communication channels lacked shared norms about urgency, so each doctor had to judge what mattered. (2) The hidden cognitive cost of interruptions. The main cost came from returning to the interrupted task. This cost grew with complexity and was only partly offset by experience. (3) The social fabric of interruption burden. Transient teams weakened the norms that regulate interrupting, and approachability and hierarchy concentrated the burden on particular doctors. (4) The social amplification of cognitive burden. Understaffing multiplied cognitive costs. Doctors used familiarity and track record to decide which requests deserved attention, so concerns from junior or unfamiliar colleagues risked being discounted. Conclusions Interruptions are structural, and their impact depends on cognitive and social conditions. Reducing interruption frequency alone may miss the main risk. Interventions should support task resumption, protect capacity at busy times, rebuild shared communication norms and take account of the receiver's capacity when designing escalation.

Background Respiratory infections remain the leading infectious cause of death among children and adolescents, yet the share of these deaths that could be averted with currently feasible care is not routinely quantified. Existing amenable-mortality frameworks rely on cause lists and population-level mortality benchmarks and do not exploit information on how many episodes occur. We propose an episode-fatality-ratio (EFR) frontier approach and apply it to lower respiratory infections (LRI), whooping cough (pertussis) and upper respiratory infections (URI) in 204 countries, 1990-2023. Methods For each cause, country and year we computed EFR = deaths/incident episodes using Global Burden of Disease (GBD) 2023 estimates for ages 0-19 years. The frontier was defined as the 10th-percentile country EFR within each GBD super-region, cause and year; avoidable deaths = max(0, deaths - episodes x frontier EFR). Primary estimates are deterministic; 95% uncertainty intervals (UIs) come from 2,000 Monte Carlo draws. Sensitivity analyses varied the frontier percentile, applied an aspirational global frontier, constructed pertussis counterfactuals, and recomputed all estimates within the single under-5 age band. Results In 2023, 333,803 childhood deaths from lower respiratory infections (95% UI 289,123-417,460; 46.9% of LRI deaths) were avoidable. Summing the three causes deterministically gives 391,034 avoidable deaths (46.5% of 840,444); the combined figure is a deterministic sum, and a UI is available for the LRI component only. The pertussis (43,958; 39.0%) and URI (13,273; 81.0%) estimates are secondary: their deterministic point values fall below their own Monte Carlo intervals and the underlying death estimates carry very wide uncertainty (global pertussis UI 12,545-321,874). Avoidable deaths fell from 1,050,468 (44.9%) in 1990, but between 2019 and 2023 the avoidable share for LRI+URI barely moved (48.7% to 47.7%) while absolute avoidable deaths fell 14.5%, a pattern consistent with stalled convergence to the frontier. Sub-Saharan Africa plus South Asia held 73.1% of avoidable deaths in 2023 versus 41.8% in 1990; ten countries accounted for 59.1%. Conclusion Nearly half of childhood respiratory-infection deaths remain avoidable relative to within-region best practice, and the residual burden is increasingly concentrated in low-income settings. In the pertussis counterfactual, most countries kept pace with their regional frontier, so further gains require advancing the frontier itself through quality-of-care improvements.

Background While overall application volume by ethnic minority doctors into UK postgraduate medical training has expanded significantly, workforce diversity varies substantially across specialties. Previous reports have suggested that doctors from certain ethnic backgrounds and international medical graduates (IMGs) experience lower likelihoods of securing training posts, but granular longitudinal evaluations across all specialty training levels and recruitment stages remained limited. Therefore, this study evaluates longitudinal trends in self-reported ethnicity and country of qualification across postgraduate medical training in England between 2021 and 2025, maps specialty representation, and tests the hypothesis that recruitment success rates differ significantly between ethnic minority and White baseline applicants. Methods We conducted a retrospective national longitudinal analysis of mandatory NHS specialty recruitment data across England from 2021 to 2025, encompassing over 300,000 applications across ST1/CT1 (entry-level) and ST3+ (higher specialty) pathways. Applicants were categorised into census-aligned broad and granular ethnic groups, alongside IMG classifications. Unadjusted odds ratios (ORs) with 95% confidence intervals were calculated using White graduates and internal sub-ethnic baselines as comparators. Specialty-level ecological correlations (Spearman's rho) were performed to evaluate whether international workforce reliance moderated ethnic recruitment disparities. Results Between 2021 and 2025, applicant volume expanded rapidly, with ethnic minority applicants and IMGs comprising numerical majorities. However, Asian and Black applicants experienced substantially lower odds of receiving training offers compared to White baseline applicants across multiple high-volume specialties (e.g., emergency medicine and anaesthetics at ST1, where Black applicants faced multi-fold reductions in success odds: OR 0.03 to 0.05, p<0.001). Granular analyses revealed notable intra-ethnic heterogeneity, including lower success among Pakistani and Bangladeshi applicants compared to Indian applicants. Furthermore, UK graduates maintained higher offer success than IMGs across most specialties. Ecological correlations demonstrated that higher international applicant reliance was moderately and significantly associated with wider recruitment disparities at higher training levels for Black applicants {rho}=-0.43, p=0.019). Conclusions Centralised medical recruitment in England exhibits some persistent ethnic and international qualification disparities despite rising application diversity. The findings highlight the necessity of disaggregating ethnic groups and addressing subjective evaluation vulnerabilities within multi-stage recruitment processes to foster equity. Trial registration: Not applicable

Background: Short birth intervals are a well-documented, modifiable risk factor for child death in low- and middle-income countries, yet nationally representative evidence from Ghana's most recent Demographic and Health Survey has not been fully examined. This study assessed the association between the preceding birth interval and under-five mortality using the 2022 Ghana Demographic and Health Survey. Methods: The analysis used the complete birth history reported by women aged 15-49 years. The cohort comprised births occurring 60-119 completed months (5-10 years) before the survey, which allowed a complete five-year observation window for under-five survival (n = 8,418; 397 deaths). Spacing models were restricted to second-or-higher-order births with a defined preceding interval (n = 6,340; 282 deaths), categorised as under 18, 18-23, 24-35 (reference), 36-47, and 48 or more months. Crude and adjusted odds ratios were estimated using survey-weighted, Taylor-linearised logistic regression, adjusting for birth order, child sex, plurality, maternal age, residence, region, maternal education, wealth quintile, and marital status. Results: Weighted under-five mortality in the cohort was 45.4 per 1,000 live births (4.54%). Among second-or-higher-order births, weighted mortality fell from 9.3% after intervals of under 18 months and 8.0% after 18-23 months to 4.2%, 3.2%, and 3.5% after 24-35, 36-47, and 48 or more months, respectively. Relative to 24-35 months, the adjusted odds of death were higher after intervals of under 18 months (adjusted odds ratio [AOR] 2.58, 95% confidence interval [CI] 1.48-4.49, p < 0.001) and 18-23 months (AOR 2.09, 95% CI 1.33-3.29, p = 0.001); longer intervals did not differ from the reference. Multiple birth (AOR 2.48, 95% CI 1.33-4.63) and having a mother who was never in union (AOR 3.25, 95% CI 1.29-8.17) were also associated with higher odds of death, and marked regional variation persisted after adjustment. Conclusion: A short preceding birth interval, particularly one of under 18 months, was independently associated with an approximately two- to two-and-a-half-fold increase in the odds of under-five death in this nationally representative sample. The findings support continued investment in postpartum family planning to help women space births at least 24 months apart, alongside closer attention to multiple births, unmarried mothers, and the regions carrying the greatest burden.

Objective. This systematic review and meta-analysis synthesised the global prevalence of overweight and obesity in people with Down syndrome (DS) across the lifespan, characterised determinants of excess adiposity, and examined associations with adverse cardiometabolic outcomes. Methods. Six databases were searched without date or language restriction. Two independent reviewers screened studies, extracted data, and assessed quality using the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies. Prevalence was pooled using a random-effects logit model. A pre-specified subgroup analysis by age band was conducted. Publication bias was assessed with Egger's test and certainty of evidence with Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results. Twenty-six studies (7,840 individuals; 14 countries) were included. The pooled prevalence was 18% (95% CI 15-22%) in children and adolescents, 36% (95% CI 26-47%) in adults, and 30% (95% CI 20-43%) in mixed-age cohorts; the test for subgroup differences was significant. The overall pooled prevalence was 22% (95% CI 18-26%; prediction interval 7-53%; I^2 = 95.3%). No publication bias was detected (Egger's t = 0.39, p = 0.6964). DS-specific growth charts yielded estimates 14-37 percentage points lower than general-population references applied to the same cohorts. Obesity more than doubled obstructive sleep apnea risk (RR 2.4; 95% CI 1.34-4.34) and non-alcoholic fatty liver disease was present in 82% of obese versus 45% of non-obese children with DS. GRADE certainty was Moderate for prevalence estimates. Conclusions. Overweight and obesity in DS are highly prevalent, age-progressive, and substantially exceed general-population rates at every life stage. Roughly one in five people with DS is affected overall, rising to more than one in three adults. The reference chart applied is the single largest source of heterogeneity in reported estimates. Cardiometabolic surveillance, adapted lifestyle interventions, and primary prevalence research from low- and middle-income countries are the highest-priority gaps.

Purpose: Outcome consequences of critically ill children treated outside of pediatric intensive care units (PICU) are unknown. We assessed case fatality of children receiving complex intensive care treatment (CICT) by treating department in Germany and explored reasons for admission to adult intensive care units (AICU). Methods: Retrospective study using the German nationwide hospital discharge dataset 2016 to 2023. Cases aged [&ge;] 28 days and < 18 years receiving CICT were classified as PICU, AICU, or interdisciplinary by department codes. Odds ratios (OR) for in-hospital case fatality were estimated in generalized linear mixed models with the hospital as random effect, adjusted for age, acute organ dysfunction, and chronic conditions. Excess deaths were estimated and a survey among pediatric and adult intensivists was analyzed qualitatively. Results: Of 143,034 cases, 67.8 % were treated in PICUs, 14.0 % in AICUs, and 18.2 % were interdisciplinary. The crude OR for death in PICUs versus AICUs was 1.14 (95 % CI 1.03 to 1.26), reversing to 0.73 (0.63 to 0.84) after adjustment. For PICU and interdisciplinary cases combined versus AICU, the fully adjusted OR was 0.61 (0.54 to 0.70). Estimated excess deaths across the study period were 100, rising to 191 when interdisciplinary cases counted as pediatric. Capacity constraints, organizational factors, and clinical expertise were the main domains underlying AICU admissions. Conclusions: Children treated outside of PICUs had higher risk-adjusted case fatality, while crude figures pointed in the opposite direction. The findings support treating critically ill children in settings with routine pediatric intensive care experience.

BACKGROUND: We used anthropometric data from electronic health records (EHRs) of Swiss childrens hospitals to evaluate growth references and estimate centile curves. METHODS: We received EHRs extracted from seven Swiss childrens hospitals and analysed two samples: all children with a height, weight, body mass index (BMI), or head circumference recording, and a subsample restricted to children without diseases potentially affecting growth, weighted to represent the general population. We calculated mean z-scores based on the World Health Organization growth references adopted for Switzerland in 2011 (CH-WHO 2011) and current Swiss growth references (Swiss 2026). We estimated sex-specific centile curves in the subsample using generalised additive models for location, scale, and shape. RESULTS: We included 213,868 children with height, 448,002 with weight, 209,244 with BMI, and 67,397 with head circumference recordings. Mean z-scores in the all children sample were (CH-WHO 2011; Swiss 2026): height (0.10; -0.19), weight (0.16; -0.09), BMI (0.04; -0.07), head circumference (-0.28, -0.28); and in the subsample: height (0.34; 0.00), weight (0.27; 0.01), BMI (0.18; 0.05), and head circumference (0.04; 0.01). The 50th height, weight, BMI, and head circumference centiles of girls and boys in the subsample closely followed those of Swiss 2026, with slightly wider 3rd and 97th centiles in infancy and adolescence. CONCLUSION: Height, weight, BMI, and head circumference centiles aligned well with the Swiss 2026 growth references in Switzerland, demonstrating that hospital EHRs could contribute to future growth references.

Background Interruptions are common in hospital outpatient departments (OPDs) and are linked to error. Many are clinically necessary, so the aim is to regulate them. Most interventions target the individual clinician. Little is known about how doctors manage interruptions in practice or what makes their strategies work. Methods Qualitative study using focus groups and interviews with 42 doctors working in UK National Health Service OPDs (19 sessions, September to November 2025). Participants were purposively sampled by clinical experience and self-reported patient complexity. Data were analysed using Framework Analysis, informed by Cognitive Load Theory and Social Identity Theory. Results We developed four themes. (1) Pre-emptive protection of attention. Doctors withdrew, signalled unavailability and set thresholds for interrupting. These depended on colleagues learning and sharing the norm, which staff rotation eroded. (2) Sharing the burden through team coordination. Designated roles and time-limited rotas moved interruptions to colleagues with capacity set aside for them and made interrupting legitimate. (3) Real-time cognitive repair. Doctors asked interrupters to wait while they secured the task, and rebuilt the consultation on return, sometimes with the patient's help. Asking a colleague to wait depended on seniority or team membership; some trainees described difficulty doing this with senior colleagues. (4) Organisational recognition as the precondition for sustainable regulation. Where supervision was built into job plans, the interruptions it generated were expected and doctors held capacity in reserve for them. Advice, vetting and telephone queries were rarely counted as work. Conclusions Each strategy served a cognitive purpose, and social and organisational conditions decided whether it was perceived to work. Interventions could make norms shared and roles explicit, count interruption work in job plans and keep routes open for junior staff to raise concerns. Evaluations should ask who is able to use them.

Objectives To examine the prevalence of interruptions during UK secondary care outpatient consultations, their association with clinician mental workload, and the strategies clinicians use to manage them. Design Nationwide cross-sectional online survey. Setting Secondary care outpatient clinics, United Kingdom. Participants A sample of 465 UK secondary care doctors across a range of grades and specialties, recruited through a medical defence organisation's network. Primary and secondary outcome measures Mental workload (NASA Task Load Index, Raw-TLX); interruption frequency; perceived cognitive impact of interruptions; task resumption difficulty; perceived social effects on colleague interactions and team cohesion; and interruption-management strategy use. Results 61.1% of clinicians reported being interrupted often or very often, and mean overall workload was high (Raw-TLX 66.2, SD 11.5). Interruption frequency, patient complexity and perceived cognitive impact were each associated with higher workload across multiple NASA-TLX subscales. In fully adjusted models, interruption frequency retained independent associations with overall workload (beta = 1.79, p = 0.004) and temporal demand (beta = 0.94, p < 0.001). Task resumption difficulty was associated with worse perceived performance (beta = -0.59, p = 0.014), while perceiving interruptions as socially positive was associated with better performance (beta = 0.75, p = 0.003) and lower frustration (beta = -1.16, p < 0.001). Years of experience showed only small effects, and self-reported strategy use (38.7%) was not consistently associated with lower workload. Exploratory natural language processing of open-text descriptions identified three strategy clusters; cognitive offloading, anticipating and preparing, and blunt responses, with distinct emotional profiles. Conclusions Interruptions were commonly reported during UK secondary care outpatient consultations and were associated with measurable cognitive and temporal burden. The perceived social framing of interruptions was independently associated with frustration and self-rated performance. Binary strategy use showed no consistent workload association, indicating a need for system-level approaches addressing interruption frequency, task resumption support and the social context of interruptions rather than reliance on individual coping.

Background Gambling harm is a significant public health concern that is systematically under-recognised in clinical practice. Despite the recent inclusion of gambling disorder in the General Medical Council's Medical Licensing Assessment content map, gambling harm has been largely absent from undergraduate medical education in the United Kingdom, and structured evaluations of gambling harm teaching delivered to medical students have not, to our knowledge, been reported. Methods A single-group, pre-post study of a teaching session on gambling harm was conducted across three sequential cohorts of Year 4 medical students at King's College London during the 2025-2026 academic year. Outcome measures were collected immediately after the teaching with no follow-up. The session was delivered online by Gambling Harm UK, a registered UK charity, and comprised lived experience testimony and teaching with public health and clinical components. Self-reported confidence across six domains was assessed pre- and post-session on a five-point scale, alongside nine post-session attitudinal statements. Paired confidence data were analysed using the Wilcoxon signed-rank test with Hodges-Lehmann estimates of the median paired difference, with a Bonferroni-corrected significance threshold of p < 0.008 applied within each cohort. Results Sixty-eight paired responses were analysed (completion rates of 28%, 24%, and 32%). Statistically significant improvements in self-reported confidence were observed across all six domains in each cohort. Median confidence rose from 'slightly confident' before the session to 'quite confident' afterwards, with median paired improvements of 1.5 to 2.5 points (all p [&le;] 0.001). Post-session attitudinal responses were positive across all nine items, with lived experience the most strongly endorsed. Conclusions A single online teaching session on gambling harm was associated with significant and consistent improvements in self-reported confidence in recognising and responding to gambling harm across three cohorts of medical students. Whether these gains translate into changes in clinical behaviour requires longer-term, multi-site evaluation with behavioural outcome measures. Medical schools should consider how gambling harm teaching might fit within their curricula and evaluate its introduction, with the aim of normalising asking about gambling in routine social history taking alongside alcohol and smoking.

Background Congenital heart disease is the most common congenital anomaly and a major public health concern. No single cause has been identified, and its aetiology is most likely to be multifactorial, determined by a combination of genetic and environmental factors. Congenital heart disease can have a significant and lasting impact on childrens health and development with well documented neurodevelopmental difficulties experienced by some children with CHD. However, evidence linking early environmental factors to developmental outcomes remains limited, despite growing recognition of their importance. The Northern Ireland BabyHearts 2 Study provides an opportunity to investigate these relationships in a longitudinal cohort with extensive prospectively collected preconceptional and antenatal data. Aim To investigate the associations between preconceptional and antenatal environmental factors and the birth outcomes, physical health, neurodevelopment and academic achievement of children with and without congenital heart disease. Methods This is a longitudinal matched cohort follow-up study of children with and without congenital heart disease recruited to the NI BabyHearts 1 case-control study (2014-2017), with controls matched 1:1 by age and sex. Data sources include the existing NI BabyHearts 1 dataset of prospectively collected preconceptional and antenatal environmental exposures, together with linked routine maternity and prescribing data. Follow-up data collected at 8-11 years of age include parental questionnaires assessing child executive function and behavioural development, standardised child-completed assessments of neurodevelopment, language and educational attainment, and clinical information. Impact This study will provide evidence on the long-term health and developmental outcomes in children born with and without congenital heart disease and improve understanding of how early environmental factors influence these outcomes. Findings will inform clinical care and service provision for children with congenital heart disease, strengthen preconception and antenatal guidance, and contribute to public health policy aimed at improving long-term outcomes for children living with congenital heart disease.

Background Under-five mortality remains a major public health challenge in Zambia despite substantial reductions over recent decades. Demographic and Health Survey (DHS) data are commonly analysed using Cox proportional hazards models; however, violations of the proportional hazards assumption and unobserved cluster-level heterogeneity may compromise inference. This study compared advanced survival modelling approaches to determine the most appropriate framework for analysing under-five mortality using pooled Zambia DHS data. Methods We conducted a pooled secondary analysis of the 2018 and 2024 Zambia Demographic and Health Survey child recode datasets. The analysis included 9,982 children, among whom 266 died before their fifth birthday. A survey-weighted Cox proportional hazards model was fitted as the reference model and assessed using Schoenfeld residual diagnostics. To address identified methodological limitations, an extended Cox model, a shared-frailty model, and a Bayesian survival model were subsequently fitted. Model performance, assumptions, and the consistency of adjusted hazard ratio estimates were compared across modelling approaches. Results The global Schoenfeld test indicated violation of the proportional hazards assumption ({chi}2=51.26, p=0.002). In the adjusted extended Cox model, male children had higher mortality risk than females (aHR 1.95, 95% CI 1.40-2.73), while children with gestation [&ge;]9 months had lower mortality risk than those with shorter gestation (aHR 0.21, 95% CI 0.14-0.32). Average and large birth size were associated with lower mortality compared with small birth size (aHR 0.47, 95% CI 0.34-0.66 and aHR 0.57, 95% CI 0.39-0.84, respectively). Newborn health checks before discharge were associated with lower mortality (aHR 0.50, 95% CI 0.38-0.66), as was any antenatal care (aHR 0.25, 95% CI 0.09-0.75). A high-risk fertility pattern involving fourth or higher births with an interval [&ge;]24 months was also associated with lower mortality (aHR 0.57, 95% CI 0.41-0.80). The shared-frailty model produced similar estimates, including increased mortality among male children (aHR 1.39, 95% CI 1.08-1.78) and twins or multiple births (aHR 2.74, 95% CI 1.36-5.53). Bayesian estimates were broadly consistent with the extended Cox model. Conclusions Advanced survival models provided a more robust analytical framework than the conventional Cox model for evaluating under-five mortality in nationally representative DHS data. While the extended Cox model accommodated time-varying effects, the shared-frailty model captured unobserved cluster-level heterogeneity, and the Bayesian model confirmed the stability of parameter estimates. Incorporating these complementary approaches can improve the validity of survival analyses and strengthen evidence for child survival research and policy in low- and middle-income settings.

Introduction: The TREOCAPA (Prophylactic TREatment Of the duCtus Arteriosus in Preterm infants by Acetaminophen) trial was a pan-European, multi-centre, phase II/III trial investigating the impact of prophylactic paracetamol (also known as acetaminophen) given during the first 5 days of life for children born before 29 weeks' gestational age (GA) on survival to 36 weeks' post-menstrual age without severe neonatal morbidities. However, due to time restrictions, long-term follow-up was not planned as part of the initial trial despite recommendations for neonatal trials to include endpoints measuring efficacy after discharge from the neonatal unit and on-going debate about the long-term effects of paracetamol in the neonatal period. This protocol describes a study to follow-up participants in the TREOCAPA trial at 2 years corrected age initiated after the trial's onset. Methods and analysis: The TREOCAPA Long Term (TREOCAPA-LT) study population consists of all children included in the TREOCAPA phase III trial in centres in countries participating in the follow-up study who are aged between 23.5 and 27.5 months corrected age during the study period. Families are contacted by the clinical teams and a parent or guardian is invited to complete an internet-based (online) questionnaire. The primary outcome is cognition, as measured by the non-verbal Cognitive Scale standard score from the Parent Report of Children's Abilities-Revised (PARCA-R) questionnaire. Secondary outcomes are moderate to severe neurodevelopment, health service use and costs. Data will be analysed according to the study groups to which children were randomised in the original TREOCAPA RCT. Ethics and Dissemination: The TREOCAPA-LT protocol was first approved by ethics' committees in France (the study's sponsor) and subsequently by all participating countries. Results from TREOCAPA-LT will be published in open access journals in accordance with the funder's regulations. Registration: https://clinicaltrials.gov/study/NCT06064825

Objective: to estimate reconsultation risk and trajectories after a new episode of musculoskeletal pain in children and young people (CYP), and to determine routinely recorded prognostic factors associated with reconsultation. Design: Population based retrospective cohort study. Setting: Clinical Practice Research Datalink (CPRD) Aurum, 2005-2021. Participants: CYP aged 8-18 years consulting primary care for a new musculoskeletal pain episode (no musculoskeletal consultation in prior 12-months). Main Outcome Measures: Musculoskeletal pain reconsultation within 12-months, and 3-year musculoskeletal reconsultation trajectories derived using latent class growth analysis. Prognostic factors selected from a literature search and two-year symptom histories (sample prevalence >1%) were examined using regression models (conditional logistic; multinomial). Results: Among 313,830 CYP with >12 months' follow-up, 32% reconsulted for musculoskeletal pain within 12 months. Among 240,384 CYP with >3 years' follow-up, three trajectories were observed: single episode (62%), early reconsultation (18%), and persistent reconsultation (20%). Older age; female gender; hip, knee, multisite and back pain on index; previous headache; previous abdominal pain; and analgesic prescribing were associated with higher reconsultation risk. Asian or Black ethnicity, and residing in more deprived areas, were associated with lower recorded reconsultation. Conclusion: Most CYP had no further recorded consultation, but 38% followed early or persistent reconsultation trajectories. Routinely recorded prognostic factors, particularly index pain side and prior pain/symptom history, may differentiate groups who could benefit from proactive follow-up. Lower recorded reconsultation among Asian and Black individuals, and living in more deprived areas, should not imply lower need and warrants equity-sensitive monitoring of access, health-seeking, and coding.

Background. Designing high-quality Objective Structured Clinical Examination (OSCE) stations is a time-consuming process. Generative artificial intelligence (AI) represents a promising path to accelerate content creation by automating the generation of scenarios. A growing number of AI tools is now available for this purpose. Objective. To assess the variability between generative AI models in their ability to produce OSCE stations in the field of paediatrics. Methods. A structured prompt was developed based on the French national OSCE guidelines for medical education. Five distinct AI models were provided with this prompt, alongside the neonatal jaundice chapter from the French pediatric reference textbook, to generate 6 complete OSCE stations. Results. Prompt compliance was high for ChatGPT 5.1, ChatGPT 5.2, Gemini 3.0 Pro, and Claude Opus 4.5, while it was lower for Grok 4.1. Expert-rated quality was generally high, with few factual errors or missing information across models. However usability differed significantly between models. This was also true for several quality dimensions such as checklist clarity, embedding of checklist answers within vignettes, and ease of standardized patient formation. ChatGPT 5.1 required the most revisions and Gemini most often rated usable as is. Significant inter-model differences were observed in diagnostics, only with ChatGPT 5.1 sampling all three neonatal jaundice categories. Contextual variables showed systematic narrowing across models. Clinical grid density was consistent (10-12 items per station), but thematic distribution differed markedly. Soft skills coverage varied significantly across models (p=0.002), none of them consistently representing all communication competency domains. Conclusion. Large language models can generate structurally compliant OSCE stations, but surface compliance conceals substantive inter-model differences in diagnostic coverage, contextual diversity, and soft skills representation, that compromise content validity. No model currently meets the criteria for unsupervised deployment in a summative assessment bank. The choice of model carries pedagogical implications and expert curation remains essential before integration into high-stakes assessment workflows.

Background: Early identification of Autism Spectrum Disorder (ASD) is critical for optimizing developmental outcomes, yet community-based screening remains underutilized in Tanzania due to systemic, cultural, and logistical barriers. Purpose: This study explores stakeholder perceptions of the acceptability, feasibility, and potential implementation strategies for culturally adapted autism screening tools in community-based early childhood settings in the Kilimanjaro region, Tanzania. Methods: A phenomenological qualitative study guided by the Socioecological Model (SEM) was conducted across preschools, daycare centers, and rehabilitation facilities in Moshi Municipality and Hai District. Multi-stakeholder participants included daycare center directors, kindergarten teachers, healthcare providers, and parents and guardians of children with ASD and policymakers (10 in-depth interviews, 3 focus group discussions). Data were collected through usability assessments, cognitive debriefing, and semi-structured discussions, and were thematically analyzed using NVivo 15 aligned with SEM domains. Results: Participants reported high perceived acceptability of utilizing the tools, driven by the tools Swahili adaptation, perceived clinical usefulness, and cultural relevance. Key anticipated feasibility enablers included private administration of the tools to mitigate stigma, trained non-specialist screeners, and structured caregiver psychoeducation. Primary barriers included questionnaire length, caregiver stress, and initial resistance. Multi-level implementation strategies emerged: standardized training, consistent home school communication, multidisciplinary care coordination, task-shifting to Community Health Workers, engagement of local and faith leaders, and integration into digital and policy frameworks. Conclusion: Culturally adapted ASD screening tools are feasible and acceptable in Tanzanian community settings when deployed with attention to linguistic accessibility, confidentiality, staff capacity, and cross-sectoral partnerships. Embedding screening within existing early childhood and community health infrastructure, supported by policy alignment and digital outreach, offers a scalable model for improving early ASD identification in low-resource contexts