BMJ Paediatrics Open最新文献

Background: The cause of acute paediatric hepatitis of unknown aetiology (2022) has not been established despite extensive investigation.

Objective: To summarise the evidence for and against a causal role for human adenovirus (HAdv), adeno-associated virus 2 (AAV-2) and SARS-CoV-2 in outbreaks of paediatric hepatitis in 2022.

Methods: We appraised and summarised relevant evidence for each of the Bradford Hill criteria for causality using quantitative (statistical modelling) and qualitative (narrative coherence) approaches. Each team member scored the evidence base for each criterion separately for HAdv, AAV-2 and SARS-CoV-2; differences were resolved by discussion. We additionally examined criteria of strength and temporality by examining the lagged association between SARS-CoV-2 positivity, respiratory HAdv positivity, positive faecal HAdv specimens and excess A&E attendances in 1-4 years for liver conditions in England.

Results: Assessing criteria using the published literature and our modelling: for HAdv three Bradford Hill criteria (strength, consistency and temporality) were partially met; and five criteria (consistency, coherence, experimental manipulation, analogy and temporality) were minimally met. For AAV-2, the strength of association criterion was fully met, five criteria (consistency, temporality, specificity, biological gradient and plausibility) were partially met and three (coherence, analogy and experimental manipulation) were minimally met. For SARS-CoV-2, five criteria (strength of association, plausibility, temporality, coherence and analogy) were fully met; one (consistency) was partially met and three (specificity, biological gradient and experimental manipulation) were minimally met.

Conclusion: Based on the Bradford Hill criteria and modelling, HAdv alone is unlikely to be the cause of the recent increase in hepatitis in children. The causal link between SARS-CoV-2, and to a lesser degree AAV-2, appears substantially stronger but remains unproven. Hepatitis is a known complication of multisystem inflammatory syndrome in children following COVID-19, and SARS-CoV-2 has been linked to increased susceptibility to infection post-COVID-19, which may suggest complex causal pathways including a possible interaction with AAV-2 infection/reactivation in hosts that are genetically susceptible or sensitised to infection.

Background: The aetiology of congenital heart disease (CHD) is multifactorial. Environmental risk factors have emerged as an important modifiable determinant of several congenital cardiac conditions. Previous studies have shown a strong relationship between CHD and air pollution. Much less is known about the influence of ambient temperature on CHD. The primary objective of this meta-analysis was to examine the association between exposure to extreme heat events (EHE) during pregnancy and CHD in the offspring.

Methods: comprehensive literature search was conducted using electronic databases such as Scopus and PubMed, along with a review of secondary references. This process yielded eight studies that met the inclusion criteria: four from the USA, two from China, one from Israel and one from Canada. The risk of bias was assessed using the Newcastle Ottawa scale. Mixed-effect regression was used to pool the estimates of individual studies. Heterogeneity was measured by I². Results were visualised by a forest plot, a Baujat plot and an albatross plot. Subgroup analyses were performed for climate zones, exposure definitions and the study region. As a sensitivity analysis, a leave-one-out meta-analysis was performed to assess the robustness of the estimates.

Results: Exposure to EHE during pregnancy increased the risk for CHD in the offspring (OR=1.12, 95% CI 1.04 to 1.34). Studies from the USA observed the smallest effect (OR=1.01, 95% CI 0.91 to 1.13), studies in the continental climate zone observed a slightly larger effect (OR=1.07, 95% CI 0.97 to 1.19), and studies from the temperate climate zone observed the largest effect (OR=1.35, 95% CI 1.23 to 1.48). Subgroup analysis was conducted with respect to exposure, effect definition and region. The residual heterogeneity measures were 88% (exposure), 61% (effect definition) and 38% (Region).

Conclusion: The association between prenatal EHE exposure and future risk of CHD has important implications for pregnant mothers, infant health and health policy. Future studies should explore the additional burden of CHD contributed by current trends in global ambient temperature in other parts of the world.

Prospero registration number: CRD42023455934.

Objective: Lack of physical activity (PA) and sedentary behaviour (SB) have emerged as critical global health concerns in children and are believed to be associated with functional constipation (FC). The present study aims to explore this potential association.

Design: A comprehensive search of PubMed, Scopus, Web of Science, Embase, Cochrane Library and PsycInfo databases was conducted through 2023 using terms related to constipation and PA and SB in ages 0-18 years. Titles and abstracts were screened against eligibility criteria. Constipation was diagnosed using Rome (II-IV) criteria. Full-text reviews were reviewed, and data were extracted. Risk of Bias in Non-randomized Follow-up Studies of Exposure quality assessment tool was used to evaluate the risk of bias of studies.

Main outcome measures: We assessed the association between lack of PA/SB and FC.

Results: A total of 2170 titles were screened. Nine studies encompassing 3849 children from six countries were included. Of these, four were community/school-based studies, one was a birth cohort, three were case series and two were hospital-based case-controlled studies. All 10 studies assessed the association between PA and FC. Only three showed an association between lack of PA and FC. Five studies evaluated the effects of SB on FC, and only two reported a positive association. The methods used to assess PA/SB differed across the studies. All nine studies included in the systematic review were rated as having high risk of bias.

Conclusions: Despite numerous studies suggesting a link between insufficient PA/SB and FC, this systematic review did not uncover compelling evidence supporting such an association.

Objective: Children with special healthcare needs (SHCN) due to a chronic health condition perform more poorly at school compared with their classmates. We aimed to estimate the effects of past, current, transient, emerging and persistent SHCN on school performance in primary school children.

Methods: Data from the German population-based prospective cohort study ikidS were used. The children withSHCN screener was administered before school entry (T1) and at the end of first (T2) and third grade (T3). Grades for German, maths and science (range: 1 (Very Good) to 6 (Failure)) were obtained at the end of third grade (age 8-9 years), and an average grade was calculated. Associations between the timing of SHCN and average grade were estimated by mixed linear regression models adjusted for potential confounding variables.

Results: 751 children were included, and 21% had ever SHCN. Children with ever SHCN had poorer school performance than children with never SHCN (adjusted mean difference in average grade [95% CI]: 0.17 [0.06; 0.28]). SHCN in the third year were associated with a poorer average grade (0.29 [0.16; 0.41]) compared with healthy children. Only emerging (0.31 [0.15; 0.48]) and persistent (0.25 [0.07; 0.43]) SHCN were associated with average grade.

Conclusions: This study demonstrates the negative effect of current, emerging and persistent SHCN on academic performance in primary school children. Consequently, students should be regularly assessed for SHCN during school age. Timely interventions may help reduce the adverse effects of chronic health conditions on academic achievements in childhood.

Introduction: Whether the manikin should die in simulation training is a controversial area, with some educators stating that manikin death is essential in providing realistic training, while others state that the psychological burden of manikin death could derail learning and impair psychological safety. This scoping review aims to explore the existing literature regarding death of the manikin in paediatric and neonatal simulation education.

Methods: The literature was searched for publications regarding paediatric and/or neonatal manikin death in simulation training. The same search strategy was used across MEDLINE (OVID), Embase (OVID), CINAHL (EBSCO) and PsycInfo (OVID) databases. Articles were screened against predefined inclusion and exclusion criteria.

Results: 810 articles were identified. 807 were excluded (duplicates/did not meet criteria). Three articles were suitable for inclusion in the final review. Included studies were analysed using an inductive thematic analysis approach.

Conclusions: There is a paucity of research in this important area of simulation training. From the limited research available, the following themes were identified: death of the paediatric manikin can increase scenario realism; participation in paediatric manikin death scenarios was not more stressful than participating in standard simulation; and the debrief has a crucial role in mitigating the potentially negative impacts of paediatric manikin death for learners.Death of the paediatric and neonatal manikin can provide a beneficial educational experience for participants but requires considered and experienced facilitation.

Background: Melatonin is widely used to promote sleep in both normally developing children and adolescents and those with neurodevelopmental disorders. It has an evidence base as both hypnotic and chronobiotic although the optimum dose and timing remain unclear. There are now a wide variety of different preparations of melatonin both immediate and prolonged release. We reviewed annual national and regional prescribing data and undertook a detailed review of one year of melatonin prescriptions issued to those under 18 within one of the UK's dedicated paediatric hospitals, this included a cost analysis. This was to understand whether prescribing was appropriate, whether behavioural therapies had been recommended first and whether there had been consideration of other causes of poor sleep, such as sleep apnoea.

Methods: Between November 2020 and October 2021, 220 patients under 18 had one or more melatonin prescriptions issued to treat poor sleep. The audit assessed whether prescriptions were issued in accordance with local Melatonin Shared Care Guidance standards that emphasise: an initial behavioural approach, fixed timing, use of licensed preparations and review of benefit. This included a detailed review of electronic patient care records. A cost analysis of the different preparations was also made.Results adherence to the audit were not met for any of the audit standards, only 9% had a prior behavioural intervention, and only 15% had another sleep disorder considered. Community prescribers were more likely to give advice on timing and review any subsequent benefit. The total costs of prescriptions were £13 299 of which £8736 was issued as off licence, liquid suspension.

Conclusion: The audit highlighted a lack of knowledge about appropriate melatonin prescribing and led to a trust-wide sleep education programme. It additionally highlighted the cost and potential risk of inappropriate prescribing and a clear need for better access to effective behavioural interventions.

Background: Conflict is prevalent across healthcare settings but is especially common in paediatrics, where high emotional stakes and parental expectations often intensify disagreements. Conflict can lead to negative outcomes for hospitals, staff and patients. Effective conflict management training can mitigate these impacts, but evaluating such training programmes remains challenging due to a lack of standardised tools and best practices.

Methods: This qualitative study aimed to explore healthcare decision-makers' perspectives on what key areas should be evaluated in conflict management training programmes in paediatric healthcare settings, employing Patton's utilisation-focused evaluation approach. Semi-structured interviews were conducted with 13 healthcare decision-makers and key stakeholders from various healthcare and charitable organisations. Interviews were analysed using reflexive thematic analysis by Braun and Clarke to identify key themes for evaluation.

Results: Four primary themes were generated regarding the key areas that healthcare decision-makers believe should be evaluated in conflict management training. These were experience of training sessions, staff competency and well-being, patient/family experiences of conflict and impact on staff time and on clinical resources. Interviewees identified that the evaluation of training sessions should focus on participant engagement and satisfaction. Codes relating to staff competency and well-being included the acquisition and long-term retention of conflict management skills. Codes relating to patient/family experience focused on the quality of communication and support during conflicts. The theme of resource utilisation included codes relating to the time and cost implications of conflict.

Conclusion: The study identified essential evaluation areas that align with and expand on Kirkpatrick's framework, suggesting the need for both qualitative and quantitative data and long-term follow-up. Tailoring evaluation frameworks to specific programme contexts can enhance their relevance and utility, contributing to improved conflict management in both paediatric and wider healthcare settings.

Objective: This study compared the differences in the rates of maltreatment and homicide deaths between children and young adults with and without a life-limiting condition (LLC) and determined whether this affects the likelihood of receiving specialised palliative care (SPC) services before death.

Design: A nationwide retrospective observational study.

Setting: Taiwan.

Patients: Children and young adults aged 0-25 years with LLCs and maltreatment were identified within the Health and Welfare Data Science Centre by International Classification of Diseases codes. Deaths were included within the Multiple Causes of Death Data if they occurred between 2016 and 2017.

Main outcome measures: Rates of maltreatment, homicide deaths and SPC referrals.

Results: Children and young adults with underlying LLCs experienced a similar rate of maltreatment (2.2 per 10 000 vs 3.1 per 10 000) and had a 68% decrease in the odds of homicide death (19.7% vs 80.3%, OR, 0.32; 95% CI 0.18 to 0.56) than those without such conditions. Among those with LLCs who experienced maltreatment, 14.3% (2 out of 14) had received SPC at least 3 days before death. There was no significant difference in SPC referrals between those who experienced maltreatment and those who did not.

Conclusions: The likelihood of being referred to SPC was low with no significant statistical differences observed between children and young adults with maltreatment and without. These findings suggest a need for integrating SPC and child protection services to ensure human rights are upheld.