BMJ Paediatrics Open

Objective: To compare the characteristics, management and outcomes of neurodivergent (ND) children with neurotypical (NT) children attending a chronic pain clinic. Design: An audit of all patients attending the clinic from 2010-2025 using electronic patient records. Setting: A tertiary pain centre in Scotland. Patients: 724 patients were included in the analysis, 193 (26%) were neurodivergent. Patients were included if they had a documented referral to the pain clinic and attendance to at least one clinic appointment. Patients were excluded if no pain clinic letter could be found on their records. Results: There was a significant increase in the percentage of children with neurodiversity attending the chronic pain clinic compared to neurotypical children (p = 0.004) accounting for over a third of children last seen in the period of 2023-2025. ND children were most likely to present with musculoskeletal pain compared with NT children (p = 0.033) representing over half of all ND children's presentations with pain. ND children were more likely to report being bedbound (18% ND, 13% NT, p = 0.0352) or needing a walking aid (40% ND, 25% NT, p = 0.000) due to chronic pain and had a higher number of referrals (ND median = 18.4, 1QR, NT median = 12.44, IQR10.28 p = 0.000). ND children were more likely to live in areas of deprivation (Cochran-Armitage test, Z -2.15, p = 0.0315). Conclusions: Children with neurodiversity are overrepresented in the chronic pain clinic, and more often present to tertiary services with musculoskeletal pain. They are more likely to have multiple referrals, spend longer with the pain service and less likely to be discharged due to pain improvement. These findings highlight the need for focused strategies to address chronic pain in neurodivergent children. Services should consider how best to identify and support children with neurodiversity and chronic pain. Key Messages {middle dot} What is already known on this topic: While there has been research regarding the role of neurodiversity in pain perception, there are gaps in knowledge regarding the influence of neurodiversity on the development and persistence of chronic pain in children. {middle dot} What this study adds: A growing proportion of neurodiverse children attended the pain clinic. Neurodiverse children presented with more severely impactful pain, they spent a longer duration of time within the pain clinic and were less likely to be discharged due to pain improvement. {middle dot} How this study might affect research, practice or policy: Identifying neurodiverse children as a patient group with distinct requirements may prompt adaptations in chronic pain management practices. This audit provides an initial framework for subsequent research.

Purpose: To assess maternal knowledge of preterm infant care in Gaza and identify clinically actionable education priorities in a resource-constrained neonatal setting. Methods: A cross-sectional survey was conducted among 170 mothers of premature infants admitted to neonatal departments in four government hospitals. A 30-item interviewer-administered questionnaire assessed knowledge across thermoregulation, feeding, phototherapy, and infection and skin care. Bivariate analyses, ordinal logistic regression, adjusted predicted probabilities, and exploratory clinical-priority gap analyses were conducted. Results: Overall knowledge was moderate, with a mean score of 64.1% (SD 22.3). Knowledge was classified as poor in 53 mothers (31.2%), good in 41 (24.1%), and excellent in 76 (44.7%). Knowledge differed across domains (p<0.001), with feeding weakest (53.6%) and infection and skin care strongest (73.8%). Not receiving specialist premature-care antenatal follow-up was independently associated with lower odds of higher knowledge (adjusted OR 0.34, 95% CI 0.15-0.80, p=0.013). Mothers without specialist follow-up also had a higher adjusted probability of poor knowledge than those who received it (37.4% vs 18.1%) and more clinical-priority gaps (IRR 1.28, 95% CI 1.04-1.57, p=0.019). Among the 10 lowest-scoring items, 110 mothers (64.7%) had five or more gaps. Conclusion: Maternal knowledge was uneven, with clinically important gaps in practical care domains. Domain-specific education checklists may strengthen antenatal counselling, bedside teaching, and discharge preparation in similar constrained neonatal settings.

Background Sierra Leones neonatal mortality rate is among the highest in the world. Koidu Government Hospital opened a Special Care Baby Unit (SCBU) in 2020. To increase knowledge of the SCBU health care providers (HCPs), a neonatal curriculum was implemented to facilitate HCP education on management of neonatal conditions. The aim of this study was to understand the effect of the curriculum on knowledge acquisition and the perception of the teaching methodologies among participating HCPs. Methods US-based mentors facilitated a two-phase, flipped classroom, virtual neonatal medicine curriculum between October 2024 and April 2025, followed by one-week in-person education sessions with SCBU HCPs. With each phase, participants completed pre- and post-test educational assessments. At the end of the curriculum, they completed a subjective assessment to capture perceptions related to the quality of teaching methodologies integrated within the curriculum. Wilcoxon signed rank test was used to assess pre- versus post-test change. Descriptive statistics were used to analyse the subjective assessment. Results Thirty-eight participants completed the educational assessments, 30 (79%) took all four pre- and post-tests; 25/38 (65.8%) were female, 27 (71.1%) were nurses. Median correct answers for both phases increased from the pre- to post-test for individual learners [Phase 1, pre-test 14/27 (51.9%), post-test 23/27 (85.2%), p<0.001], [Phase 2, pre-test 14/25 (56.0%), post-test 23/25 (92.0%), p <0.001]. Thirty-one participants completed the subjective assessment, of whom 96.8% (30/31) rated the curriculum to be "very effective." All 31 participants indicated that the in-person instruction was "very helpful." Through open text responses, they offered valuable insight into challenges, strengths, and next steps. Conclusion This neonatal curriculum resulted in significantly increased knowledge and was well regarded. Adapting this curriculum or similar curricula show promise to improve the quality of care for small and/or sick neonates in low resource settings.

Objectives To explore caregiver and clinicians perspectives on implementing mental health conversations and supports for caregivers of children with chronic conditions in paediatric outpatient clinics. Specifically, views were sought on (a) screening approaches and measures (phase 1) and (b) how feedback and support could be provided to caregivers experiencing mental health difficulties (phase 2). Methods Caregivers and clinicians from two outpatient clinics (neuromuscular and diabetes) at a tertiary paediatric hospital in Melbourne, Australia participated in online focus groups in July and August 2024. Caregivers were recruited from outpatient clinics and clinicians were recruited via email. Both groups were combined for phase 1 before separating into breakout rooms for phase 2. Two authors conducted reflexive thematic analysis of transcripts using NVivo. Results Sixteen participants (caregivers n = 8; and clinicians n = 8) took part in in two semi-structured focus groups. Analysis generated two overarching domains, each comprising multiple themes. Domain 1, Addressing caregiver mental health, captured themes of overwhelm and invisibility, diverse caregiving roles, and the need for time and resources to support wellbeing conversations. Domain 2, Housing the mental health conversation, encompassed themes of screening preferences, caregiver agency in confidentiality, delivery of feedback, and access to tailored supports. Conclusions Caregivers and clinicians support routine caregiver mental health discussions in paediatric outpatient settings. Caregivers favour screening at diagnosis and key transitions, with clear, and actionable feedback delivered away from the child. Questions about record-keeping warrant further exploration, as do the perspectives of fathers.

Background: 48,XXYY syndrome is a rare sex chromosome aneuploidy (SCA) characterized by neurodevelopmental deficits and medical comorbidities. The limited information available in the literature is almost exclusively limited to postnatally diagnosed cases. This study aims to describe the early medical and developmental features of prenatally identified 48,XXYY infants, with comparisons to 47,XYY, 47,XXY cohorts, and typical populations, as well as previously reported postnatally diagnosed 48,XXYY cases. Methods: The eXtraordinarY Babies Study prospectively follows children prenatally identified to be at high risk for SCA with annual medical and neurodevelopmental evaluations. Data presented herein include the prevalence of medical conditions, developmental milestones, developmental and adaptive functioning assessment scores, and therapy utilization in participants confirmed to have 48,XXYY. Comparisons were made between this cohort and the typical population, infants with 47,XYY and 47,XXY also enrolled in the eXtraordinarY Babies Study, and a 2008 cohort of individuals postnatally identified 48,XXYY. Results: Infants with 48,XXYY exhibited a range of early medical features, including high rates of feeding and GI disorders (breastfeeding difficulties, gastroesophageal reflux, and eosinophilic esophagitis), allergic disorders (food allergies and environmental allergies), and hypotonia. Developmental and adaptive functioning scores indicated delays in motor, communication, and social domains, with nearly all infants receiving speech therapy, physical and/or occupational therapy. Comparisons with the 47,XYY and 47,XXY cohorts revealed more medical and developmental challenges in the 48,XXYY group, however there was variability and some overlap with both the general population and sex chromosome trisomy conditions. Additionally, comparison to the 2008 postnatally identified 48,XXYY cohort indicated that while prenatal diagnosis allowed for earlier intervention, developmental outcomes in the first years of life were similar between the two groups. Conclusions: 48,XXYY diagnosed prenatally facilitates early monitoring, anticipatory guidance, and proactive referrals for medical evaluations and intervention, given developmental delays and medical challenges are more common in infancy and early childhood compared to the general population and trisomy SCAs. These findings provide valuable insights for genetic counselors and healthcare providers, emphasizing the spectrum of medical and developmental findings and importance of early and proactive care to support individual outcomes. Prospective study of this prenatally identified cohort will provide important natural history and phenotypic variability in XXYY, as well as identification of predictors of health and developmental outcomes.

ObjectivesThe Australian Children of the Digital Age (ACODA) study is a longitudinal cohort study investigating the digital lives of Australians during early childhood. This paper presents a comprehensive description of the study protocol and overview of childrens digital technology use in the home at the first wave of data collection. MethodsCaregivers of children aged 6-months to 5-years completed a survey that captured the availability and use of digital technology within the home, and child- and caregiver-related factors that may influence childrens digital technology use. ResultsA total of 3,388 caregivers from across all Australian states and territories completed the survey. Majority (98%) of children had digital technology and internet access within their homes. Most children (93%) used at least one device in the last year, with televisions, tablets, and mobile phones most frequently used (89%, 47%, 42%, respectively). Digital technology use started early, with 61% of children aged <1-year having used a television. A greater proportion of older children used devices, and for longer durations than younger children. Across all ages, daily time was longest on televisions (M = 1:20, SD = 1:14), tablets (M = 1:06, SD = 1:36), and mobile phones (M = 0:30, SD = 1:05). Digital technology was used most for entertainment and learning activities, and was used typically with a caregiver and in lounge/living rooms. ConclusionsThe ACODA study is the first longitudinal study to describe the digital technology use of Australians during early childhood and the context of this use. Data indicated that Australian children frequently used digital technology for entertainment and with their caregivers. Also, older children used digital technology more than younger children. Future waves allow for exploration of changes in childrens digital technology use over time, and associations with factors that may influence childrens digital technology use.

Background Early onset obesity in children, almost always accompanied by significant health complications, may be driven by rare genetic variants that influence appetite, metabolism, and nutrient absorption. Traditional treatment approaches are usually insufficient for those with monogenic obesity of this type. Glucagon-like peptide-1 (GLP-1) receptor agonists, such as semaglutide, and related drugs such as melanocortin 4 receptor agonists, have emerged as promising first-line treatments for severe obesity. There is no established protocol or pathway in England for identifying children with monogenic obesity who could benefit from these and similar treatments Methods We undertook early economic modelling to examine the cost-effectiveness, from a health service perspective, of implementing a new pharmacotherapeutic care pathway for the identification and treatment of monogenic obesity in children. We modelled a hypothetical population of children with hyperphagia and body mass index (BMI) three standard deviations above mean values for age and sex. We evaluated the clinical decision to initiate the pathway using a decision tree model with patient quality-adjusted life years (QALYs) and NHS healthcare costs 12 months from an initial clinic visit as outcomes, and calculated incremental cost effectiveness ratios and a cost-effectiveness acceptability curve. Results Both costs and QALYs were higher under further investigation (GBP3,247 and 0.47 QALYs) compared to no further investigation (GBP1,589 and 0.24 QALYs). The incremental cost-effectiveness ratio in the base case was GBP7,133 per QALY. Further examination of these children was therefore likely to be cost effective in this model. Conclusion A decision-tree model suggested that further investigation of severely obese children potentially eligible for treatment with semaglutide is likely to be cost-effective for the NHS. However, this result is associated with uncertainty arising from a lack of evidence for many key model parameters.

Background: Complicated acute appendicitis carries a higher risk of postoperative morbidity relative to uncomplicated cases. It remains unclear whether surgical timing (night vs. day; weekend vs. weekday) or surgeon seniority influence short-term outcomes in this high-risk population. Methods: This was a retrospective analysis of the RIFT Turkey dataset restricted to histologically confirmed cases of complicated appendicitis who had undergone laparoscopic appendectomy. Primary exposures were surgical timing (day [n=92] vs. night [n=123]; weekday [n=172] vs. weekend [n=43]) and surgeon seniority (trainee [n=89] vs. consultant [n=126]). The primary outcome was unplanned readmission and/or reintervention within 60 days. Secondary outcomes were conversion to open surgery and length of stay (LOS) >3 days. Propensity score matching (PSM) using RIPASA score (caliper 0.05, SMD <0.1) was performed as a pre-specified sensitivity analysis for each comparison. Results: Night-time surgery was associated with higher frequencies of unplanned readmission / reintervention (12.2% vs. 6.5%; OR 1.99 [95% CI 0.74-5.35], p=0.166) and surgical conversion (9.8% vs. 3.3%; OR 3.21 [0.88-11.72], p=0.064) compared with daytime surgery, neither reaching significance. Trainee surgeons had significantly higher readmission/reintervention rates than consultants (15.7% vs. 5.6%; OR 0.32 [0.12-0.82], p=0.013). PSM-adjusted results also showed similar relationships: night vs. day (readmission OR 2.45 [0.85-7.03], p=0.09; conversion OR 2.84 [0.73-11.1], p=0.13), weekend vs. weekday (readmission OR 1.53 [0.24-9.72], p=0.65), and trainee vs. consultant (readmission OR 0.25 [0.08-0.79], p=0.013). Conclusion: Surgical timing was not significantly associated with short-term outcomes in complicated appendicitis, though night-time surgery showed a consistent trend towards higher complication rates. Surgeon seniority was the only factor independently and significantly associated with unplanned readmission and reintervention in both primary and PSM analyses, indicating the need for senior supervision during out-of-hours procedures. Keywords: complicated appendicitis; surgical timing; night surgery; weekend effect; surgeon seniority; propensity score matching; RIFT Turkey

Aim: To systematically evaluate evidence on the effects of post-discharge early developmental intervention programs (EI) on behavioral development, quality of life, participation, executive functioning, parent-child interaction, and use of medical services from infancy through adolescence in children born preterm. Method: Four bibliographic databases and one trial registry were systematically searched for randomized controlled trials up to April 23, 2024. Two reviewers independently screened studies and extracted data. In clinically and methodologically comparable studies, random-effects meta-analysis were performed. Risk of bias was assessed with the Cochrane RoB 2 tool, and certainty of evidence with the GRADE approach. Results: Twenty-six studies met inclusion criteria, eleven studies including 2,315 preterm born infants reported relevant outcomes, and seven contributed to meta-analyses. Most reported results showed some concerns or high risk of bias; certainty of evidence ranged from very low to moderate across outcomes. EI may offer small benefits for selective attention, behavioral problems and parent-child interaction. Little to no effect was found for special educational needs, language skills, executive functioning and the use of medical services. No included studies evaluated the effect of EI on ADHD, quality of life, or participation related to mobility or leisure activities. Interpretation: EI may improve problems typically seen in preterm children and should be offered especially to those with additional medical or social risk factors. High-quality, contemporary trials are needed to establish reliable clinical recommendations regarding EI strategies and complementary interventions throughout childhood.

Mental health problems, including emotional problems, are linked to adverse educational outcomes among children and adolescents. This study examines the association between early onset of mental health problems generally, and emotional problems specifically, at ages 5-14, and outcomes from the General Certificate of Secondary Education (GCSE), a secondary education qualification, at age 16 for 4,783 students in England, using the Millennium Cohort Study dataset linked to the National Pupil Database. We found that the onset of mental health problems at ages 5, 7, 11 and 14 had a significant and negative association with all GCSE outcomes. We also found negative associations between early onset emotional problems and GCSE outcomes, although results were most stark for emotional problems that onset at age 11, with statistically significant negative associations with all GCSE outcomes. School absence was identified as a potential mediator of the negative association. Furthermore, this study found that the potential loss of productivity related to mental health problems in general and emotional problems in particular was over 23,000 sterling and 11,000 sterling per affected individual, respectively, which could translate into approximately 2.57 billion sterling and 1.6 billion sterling, respectively at the population level for England. These findings highlight the importance of early intervention for children and adolescents with mental health problems to improve educational and future outcomes.

Background Complicated appendicitis (CA) increases morbidity and resource use.[1,2] In the emergency setting, risk stratification must rely on rapidly available data. Procalcitonin (PCT) is frequently obtained, but its incremental value beyond basic preoperative indicators remains uncertain.[5] We aimed to quantify PCTs incremental predictive value and develop a practical bedside score with temporal validation. Methods We conducted a retrospective cohort study of consecutive laparoscopic appendectomy patients (January 2023-December 2024). CA was defined by postoperative pathology (gangrene/necrosis, perforation, or peri-appendiceal inflammation/abscess; worst-category rule). We compared a base logistic model (age, WBC, neutrophil percentage, fever, symptom-to-surgery interval, shock index) with an extended model adding log-transformed PCT. Discrimination (AUC) and calibration were assessed. Temporal validation used 2023 for development and 2024 for testing. We also created a simple bedside score using pre-specified cutoffs and evaluated CA risk across score strata in 2024. Results In the overall complete-case cohort (n=1,792), 397 patients (22.2%) had CA. Adding PCT modestly improved discrimination in the full cohort (AUC 0.673 to 0.685). For temporal validation, 2023 included 870 patients (CA 26.9%) and 2024 included 921 patients (CA 17.7%); one otherwise eligible patient lacked a usable admission year. In the 2024 test set, discrimination was 0.662 (base) vs 0.673 (base+PCT) with a non-significant AUC difference (DeLong p=0.116); calibration slopes were near 1.0. A 7-item bedside score stratified 2024 CA risk: 9.1% (score 0-1), 14.7% (2-3), and 34.2% [&ge;]4). Using [&ge;]4 points identified a higher-risk subgroup (PPV 34.2%, NPV 87.5%, sensitivity 46.0%, specificity 81.0%). Conclusions PCT adds modest predictive information beyond simple preoperative indicators in the full cohort, but temporal validation suggests that this incremental gain is smaller and not statistically significant in later patients. A pragmatic bedside score can support CA risk stratification and prioritization in emergency care, whereas the role of routine PCT testing may be best reserved for selected situations in which uncertainty remains after initial assessment.

Background: Apnoea of prematurity is common and may cause desaturation and/or bradycardia. There is marked variability in infants cardiorespiratory responses to apnoea, despite standardised clinical thresholds. Factors influencing apnoea-related cardiorespiratory instability and whether instability can be predicted warrant investigation. Methods: 181,511 apnoeas >5 seconds were identified from continuous physiological recordings from 146 preterm infants <37 weeks postmenstrual age. Cardiorespiratory instability was defined as bradycardia (>30% heart rate reduction) and/or oxygen desaturation (<85%). Mixed-effects models assessed clinical, demographic and dynamic modulators of the relationship between apnoea duration and cardiorespiratory instability. Machine learning (XGBoost) was used to train models to predict apnoea-related cardiorespiratory instability. Results: Longer duration apnoeas were associated with increased instability, although variability was substantial and 3.6% of apnoeas <10 seconds were associated with cardiorespiratory instability, while 61.2% of apnoeas [&ge;]20 seconds were not. Multiple clinical/demographic (postmenstrual and gestational age, sex, weight z-score, and ventilation mode) and dynamic (baseline heart rate, oxygen saturation, and recent apnoea clustering) factors were associated with increased instability risk. Apnoea-related cardiorespiratory instability could be predicted with a balanced test accuracy of 75.8% when incorporating all features, while a model using only clinical/demographic features achieved 66.0%. Conclusions: Multiple factors influence cardiorespiratory responses to apnoea. Predictive modelling may enable personalised apnoea definitions, improving individualised care.

Summary- In a cross-sectional study, we calculated direct and indirect costs incurred by people prior to starting tuberculosis (TB) treatment in primary healthcare facilities in KwaZulu-Natal, South Africa. We related the total costs to patient income to explore the economic impact of TB care-seeking and contribute to the literature by exploring differences between those with and without TB symptoms. Background- Patient costs during tuberculosis (TB) treatment in South Africa are high. There are fewer data about the costs incurred prior to starting treatment. We measured pre-TB treatment costs for people in rural KwaZulu-Natal, South Africa. Design/methods- In the context of a TB case-contact study, we interviewed people starting TB treatment at primary healthcare facilities in rural South Africa. We estimated total direct and indirect costs incurred by respondents and their households in the three months prior to starting TB treatment. We estimated other coping costs, such as selling productive assets, as well as the value of any loans taken. Results- Among 98 participants (52 female, median age 36 years), 86/98 (88%) reported one or more symptoms from the WHO 4-symptom TB screening tool prior to starting treatment. The median total pre-treatment cost for TB affected households was USD 10.78 (IQR: [4.13 -- 20.23]). Total, pre-treatment costs for those with TB symptoms were USD 10.78 (IQR: [4.83 -- 20.23]) compared to USD 8.91 (IQR: [1.27 -- 22.19]) for those without TB symptoms. Conclusions- Whilst TB testing and care is free in South African public health facilities, patients still face costs that are burdensome. Our results indicate people affected by TB, including patients and their families, also face an economic burden. Our study highlights the need for further consideration of social protection policies to reduce the economic effects of asymptomatic TB.

Background School stress and psychosomatic complaints are linked and increase in high-income countries, with differences between countries. Evidence of how these parameters develop in Italy, particularly through combined parental and self-reported perspectives across age and gender, is limited. Methods A population-based online survey investigated school stress and psychosomatic complaints in children and adolescents aged 6-19 years, analyzing proxy- and self-reported data based on standardized validated instruments. Data was stratified by gender and age for children (6-10), early adolescents (11-14), and late adolescents (15-19). Results For early and late adolescents, the gender gap was evident, with higher levels of stress and health complaints in late adolescent girls. In this group, 56% of the girls self-reported rather/high school stress, and 43% of the boys. Parents perceived school stress and psychosomatic problems of their children as less severe than adolescents themselves. Parents stated a higher effect of parental help with school problems, and a lower effect of physical activity and digital media use on their childrens psychosomatic problems. Physical activity was related to fewer psychosomatic complaints, especially in girls. Conclusions This study identified late adolescent girls as vulnerable group, underscoring the critical need for gender-specific early prevention strategies starting in childhood, particularly for families with lower socioeconomic status. Parental perspectives may underestimate adolescents stress levels and psychosomatic well-being. In early adolescence, less digital media use may prevent psychosomatic problems, in late adolescence, physical activity may be a preventive method. Further longitudinal investigations should put a special focus on self- and proxy-reported perspectives.

Background: Sexual violence is a global human rights issue and a significant public health concern. Prevention of sexual violence requires addressing the structural and social norms that perpetuate it. Schools are promising settings for primary prevention interventions, as early socialisation experiences can shape attitudes and behaviours that enable sexual violence. However, evidence on effective school-based interventions is limited. The objective of this pilot study is to assess the feasibility and preliminary effectiveness of an Australian sexual violence primary prevention program, the Schools Education Program, on student sexual violence knowledge, attitudes and behavioural intentions. Methods/design: A two-arm, parallel pilot cluster randomised controlled trial will be conducted with Year 9 students (aged 13-15) in 12 secondary schools across one Australian state. Ten schools will be randomly allocated to the SEP intervention (n=6) or a waitlist control (n=4); an additional two schools are pre-assigned to the waitlist control group. The SEP comprises three student education modules, parent and staff education, and the recruitment of School Student Champions. The primary outcome is sexual violence knowledge. Secondary outcomes include attitudes, behavioural intentions, and implementation factors. Quantitative data will be collected at baseline, immediately post-intervention, and at 6-month follow-up. Analysis will use linear mixed-effects models to provide preliminary estimates of effect and estimate key parameters for a future definitive trial. The trial is embedded within a concurrent realist evaluation that includes qualitative methods to explore the mechanisms and contextual conditions shaping these outcomes. Discussion: This study is the first pilot trial to evaluate a sexual violence primary prevention intervention in Australian secondary schools. In addition to the trial focused on sexual violence prevention outcomes, its integration with realist evaluation methodology will advance knowledge about how, when, and for whom these outcomes occur. The study findings will inform adaptability and scalability for secondary schools nationally and internationally.

Introduction: Newborn babies frequently encounter acute respiratory failure requiring assisted ventilation. Acute respiratory failure in infants commonly present in a form of respiratory distress syndrome. There are several studies that documented factors associated with CPAP failure rates among preterm newborns worldwide. However, they were either statistically underpowered or defined by overt design errors. The proposed study will estimate incidence rate and predictors of Continuous Positive Airway Pressure (CPAP) failure among preterm newborns delivered at representative hospitals in a typical urban area of Africa. Methods and analysis: a prospective longitudinal cohort observational, analytical study will be conducted at neonatal and emergency units of all Dar es Salaam public regional referral hospitals from March to (and including) August 2026. Newborns with CPAP failure will be the target population. Newborns without CPAP failure will be the control group. Follow up for each child will commence from the moment the child is subjected to CPAP until CPAP failure is clinically evident or day seven of life, whichever comes first. Interval assessment of the SAS scores (for CPAP potency) will be done using Silverman-Anderson score sheet in 4-6 hours intervals (unless otherwise dictated by the child clinical situation). The main outcome/dependent variable will be proportion of new CPAP failure per newborn-time of follow up. A multivariable linear model will be used to account for independent predictors of CPAP failure. Unless otherwise stated, an alpha-level of 5% will be used as a limit of type 1 error in findings. Ethics and Dissemination process: The study has received an IRB certificate (IRB reference: KU/IREC/27/10/639) from the Institutional Research Ethics Committee of KU. Permission to recruit the affected children has been sought from Municipals based hospitals directors of Amana, Mwananyamala and Temeke regional referral hospitals respectively. Written informed consent will be sought from mothers of all recruited newborn babies.

Background Unplanned hospital admissions in Inflammatory Bowel Diseases (IBD) account for nearly three-quarters of IBD inpatient stays in the United Kingdom. Although costly to services and distressing for patients, research exploring experiences and potential drivers of admissions is limited. We undertook a qualitative study to explore the healthcare experiences and access needs of people with IBD who had unplanned admissions, along with their caregivers and clinicians. Methods Semi-structured interviews with 25 participants from a single tertiary IBD service in England (17 people with IBD, 3 informal caregivers, 5 clinicians) were conducted. We applied thematic framework analysis, guided by the Candidacy Framework, and worked with 2 patient and public contributors to generate final themes. Results We identified four themes: 1) Difficulties in Identifying flares and asserting severity before admission, summarised the prevailing uncertainty in identifying a flare and access to timely IBD care. 2) Navigating a disjointed healthcare system, highlighted how lack of care plans and systemic barriers can delay access. 2) Emergency care access challenges highlighted the gaps in emergency and inpatient care during flares. Whilst 4) fighting for care and individual advocacy needs, described the persistent assertion for care that may disproportionally impact access to vulnerable groups, also highlighting the importance of positive interpersonal relationships. Conclusions Individual, interpersonal and healthcare factors across the patient pathway were perceived to shape access to care in unplanned IBD admissions. Potentially reducing admissions requires proactive strategies, including the integration of patient education, monitoring tools, establishment of specialist rapid-access pathways, and formal psychological support to address barriers to access.

Introduction Access to quality early childhood development (ECD) services remains limited for families working in economic settings in many low-and middle-income countries. This study examined the associations between participation in integrated ECD centres of integrated ECD centres located in market and cross-border communities in Rwanda and childcare access, child nutrition, caregiving practices, and developmental outcomes. Methods A repeated cross-sectional pre-post evaluation without a comparison group was conducted between 2023 and 2025 across eight markets and cross-border ECD centres in Rwanda. Quantitative data were analyzed with logistic regression models adjusted for socio-demographic characteristics, while qualitative data were analysed thematically. University of Rwanda College of Medicine and Health Sciences Institution review board approved the study (No.366/CMHS IRB/2023). Results The proportion of children aged 6-23 months who achieved minimum meal frequency increased from 26.6% to 57% (AOR=2.35; 95% CI: 1.01-5.49), and those meeting minimum acceptable diet increased from 15.4% to 51.4% (AOR=4.51; 95% CI: 1.77-11.45). Stunting declined from 32.6% to 15.7% (AOR=0.45; 95% CI: 0.32-0.63) and underweight from 9.3% to 4.3% (AOR=0.55; 95% CI: 0.32-0.97). The proportion of children aged 24-59 months who were developmentally on track increased from 77.9% to 93.8% (AOR=3.85; 95% CI: 2.23-6.65). Households reported higher income at endline, and the centres generated strong demand for childcare services. However, reports of scolding and physical punishment increased between surveys. Conclusions Integrated ECD centres in market and cross-border settings were associated with improved child feeding practices, nutritional status, and developmental outcomes among children from vulnerable working families in Rwanda. Place-based childcare models may represent a promising strategy for expanding access to integrated ECD services while supporting womens economic participation in economic settings.

Background Since July 2022, Australian National Cervical Screening Guidelines have recommended anyone eligible for cervical screening be offered the choice between having their sample collected by a clinician with a speculum, or self-collection using a vaginal swab. Method We recruited screen-eligible people to an online survey between December 2023 and April 2024, via a paid social media (Meta) campaign, and stakeholder and community networks. Using binary logistic regression, we assessed demographic and screening history factors associated with having previously heard of self-collection. In participants screened since July-2022, we assessed factors associated with being offered a choice between self-collection and clinician-collection; choosing self-collection (among those offered choice); and using self-collection (among all recently screened participants). Results Of the 9,928 participants, 70.2% had heard of self-collection. Among those screened since July 2022, 36.1% were offered a choice in screening method. Awareness was associated with increasing age (p-trend <0.001), with participants aged >65 years most likely to have heard of self-collection (adjusted odds ratio (aOR): 1.69, 95% confidence interval (95%CI): 1.31-2.18). Compared to participants who self-reported regularly attending cervical screening, both not-regular and never screeners (based on self-reported screening history, frequency, age and sexual history) were less likely to have heard of self-collection (aOR:0.80 [95%CI:0.72-0.89] and aOR:0.73 [95%CI:0.56-0.96], respectively; p<0.001). Participants who attended a specialised womens/sexual health clinic were more likely to have heard of self-collection (aOR:1.32 (95%CI:1.06-1.64), p;<0.001), and to report being offered choice (aOR:1.62 (95%CI 1.22-2.14), p<0.001) at their last cervical screen. Half of the participants who were offered a choice opted for self-collection (N=803/1,617; 49.7%). Not-regular screeners were twice as likely (aOR:2.31 (95%CI:1.74-3.07), p<0.001) to choose self-collection as regular-screeners. Conclusion Given almost 50% of women nationally are now choosing self-collection, these findings imply national uptake might be close to plateauing overall. In high income settings where a choice in screening methods is introduced with the aim of improving screening equity, resources, adequate training, and health promotion tools should be provided prior to program launch to support healthcare providers in offering choice and facilitate improved participation in screening programs. Raising community awareness of screening options is important and needs to reach under-screened groups.

Objective: Lyme disease diagnosis in children is challenging due to atypical presentations and testing limitations. We sought to evaluate the association between Lyme disease and socio-geographic risk factors in children. Materials and methods: We enrolled children undergoing evaluation for acute Lyme disease at one of eight Pedi Lyme Net pediatric emergency departments located in high Lyme disease incidence states over a ten-year period (2015-2024). We defined a case of Lyme disease with an erythema migrans (EM) lesion or a positive two-tier serology result in a child with signs and/or symptoms of acute disease. We linked each childs primary residential county to the following factors: urban-rural residence, socioeconomic status, population-level disease incidence, wildland-urban interface, and "Lyme disease" Google searches. We performed a multi-level logistic regression analysis to evaluate associations between Lyme disease and county factors after adjusting for individual demographics. Results: Among 5,529 children enrolled, 1,396 (25.2%) had Lyme disease: 101 (7.2%) with early-localized disease, 584 (41.8%) with early-disseminated disease, and 711 (50.9%) with late-disseminated disease. Rural residence (aOR 1.9, 95% CI 1.3-2.9), higher socioeconomic advantage (aOR 1.3, 95% CI 1.1-1.4), more "Lyme disease" Google searches (aOR 1.1, 95% CI 1.0-1.2), and higher wildland urban interface (aOR 1.2, 95% CI: 1.0-1.4) were independently associated with Lyme disease. Conclusion: Incorporating socio-geographic factors alongside clinical data may augment diagnostic risk assessment in children with suspected Lyme disease. However, these factors should be incorporated carefully to ensure clinical assessments are not based on a childs geographic location alone.