BMJ Paediatrics Open最新文献

Background: Paediatric head injury is a common reason for emergency calls. While most cases are mild, a small proportion deteriorates rapidly. Paramedics are often the first point of clinical contact, yet the absence of paediatric-specific tools, infrequent exposure and emotionally charged environments contributes to uncertainty. Paramedic perspectives in this context remain under-represented in the literature.

Objective: To explore paramedics' experiences, challenges and decision-making in the prehospital assessment of children with suspected head injuries and explore perceptions of existing hospital-based clinical decision rules and their potential use in out-of-hospital care.

Methods: A qualitative study, guided by an interpretivist approach, was conducted with 37 paramedics from the North West Ambulance Service NHS Trust, United Kingdom. Purposive sampling captured a range of clinical grades and experience levels. Semistructured virtual interviews explored clinical assessment, decision-making, communication with families and views on current guidelines and clinical decision rules. The Paediatric Emergency Care Applied Research Network and the Children's Head Injury Algorithm for the Prediction of Important Clinical Events were presented after participants described their usual practice. Interviews were audio-recorded, transcribed verbatim, anonymised and analysed inductively using reflexive thematic analysis.

Results: Four inter-related themes captured the clinical, emotional and systemic realities of paediatric head injury assessment. Paramedics described the challenges in treating children, as developmental differences, limited communication and subtle or delayed symptoms required vigilance and adaptation. These were compounded by the paramedic's own challenges, including low confidence from limited exposure, training gaps and the emotional and ethical pressures of safeguarding. Participants showed frustration over adult-oriented tools, rigid guidelines and remote decision-making that undermined autonomy. The role of clinical decision rules was seen positively for structure and defensibility, but with caution about safeguarding, compensatory physiology, contextual risk and their limited relevance to non-conveyance decisions in out-of-hospital care.

Conclusions: Prehospital paediatric head injury assessment is shaped by intersecting clinical, emotional and systemic pressures. Improving care requires paediatric-specific decision tools, integrated training and system changes that support rather than professional judgement.

Introduction: Kenya's 2021 neonatal mortality rate was 18.42 per 1000 live births, far exceeding the Sustainable Development Goal of 12 per 1000 live births. Helping Babies Breathe (HBB) was developed to equip birth attendants with necessary skills for neonatal resuscitation in low-resource settings. This study aims to evaluate the implementation and impact of HBB training in Migori County, Kenya.

Methods: This single-group pretest-posttest study was conducted at 26 healthcare centres in Migori County, Kenya. Preimplementation neonatal health data were collected between January 2022 and June 2023. HBB training was conducted in June 2023, and postimplementation neonatal health data were collected from then until January 2024. To evaluate providers' retention of knowledge and skills, validated Knowledge Checks and Objective Structured Clinical Examination (OSCEs) were conducted immediately following training, at 4 months and at 9 months following training.

Results: The proportion of neonates not breathing and not receiving bag and mask ventilation within 1 min of birth decreased significantly following HBB training (12.73% pretraining vs 6.90% post-training, p=0.01). However, in-facility neonatal mortality did not decrease significantly when a trained HBB provider was present (86.73% survival without a provider vs 87.92% with, p=0.64). Providers' knowledge and hands-on skills deteriorated significantly within 9 months following initial training despite quarterly follow-up trainings (Knowledge Check score average 97.24% immediately post-training vs 92.67% at 9 months, p=0.01; OSCE B average 92.48% immediately post-training vs 87.10% at 9 months, p=0.04).

Conclusions: HBB training significantly improved providers' knowledge of HBB initially, but quarterly follow-up trainings were insufficient to sustain knowledge and resuscitation skills. No significant reduction in in-facility neonatal mortality was observed following implementation of HBB, although the study was not powered to detect this change. There was an increase in the appropriate use of bag and mask ventilation. As HBB training is expanded across Kenya, more frequent refresher trainings and provider engagement strategies are recommended to sustain providers' knowledge and skills.

Background: Failure to recognise and respond to early signs of critical illness contributes to preventable deaths in the UK, particularly among medically complex children. Critical care outreach teams (CCOTs) are multidisciplinary teams that manage deteriorating patients and support early care escalation. While well-established in adult services, Paediatric CCOTs (PCCOTs) remain under-researched. This study presents the first national evaluation of PCCOT provision and characteristics across tertiary paediatric centres in the UK and Ireland.

Methods: A cross-sectional questionnaire, developed from literature, patient and public involvement and peer-reviewed for validity, was distributed via Bristol Online Survey to healthcare professionals in 29 tertiary paediatric centres. Recruitment used convenience sampling through social media and professional networks. Eligible participants gave electronic consent. Data was collected over 7 weeks (August-October 2022) and used descriptive analysis. Ethical approval was obtained from the University of Birmingham.

Results: The response rate was 93% (27/29 centres). Of these, 41% reported having a PCCOT, predominantly nurse-led with notable growth since 2013. Team composition, size, funding models and training varied widely. Education and formal competencies were inconsistent, and many PCCOTs operated within incomplete governance systems often lacking process improvement functions. Commonly collected metrics included cardiorespiratory arrest rates, inpatient mortality and unplanned paediatric intensive care unit admissions.

Conclusions: PCCOTs remain underdeveloped, with limited 24/7 coverage, inconsistent training and fragmented governance in comparison with adult CCOTs. Despite their critical role, most lack sustainable funding and robust evaluation frameworks. Newly developed paediatric-specific education standards now require implementation and impact assessment. National leadership, investment and standardisation are needed to ensure PCCOTs can deliver safe, effective and equitable care across the UK and Ireland.

Background: Digital peer support apps can assist with mental ill health. We present an early economic evaluation of Tellmi, a related and novel app for children and young people (CYP).

Methods: Tellmi users were surveyed; healthcare resource use over 3 months was captured. Data informed the development of an early cost-comparison model, capturing cost and resource use differences (CYP using Tellmi vs standard care). A 1-year time horizon was used, and the model was built from a National Health Service (NHS) perspective. Deterministic sensitivity analysis highlighted key driving parameters.

Results: There were 283 responses. Tellmi use for more than 1 month resulted in significantly fewer accident and emergency, general practitioner and school nurses/counsellor visits (vs standard care). An early cost calculator model estimated that Tellmi use led to an NHS cost saving of £214 per person (excluding service cost).

Conclusions: Tellmi has the potential to be cost saving to the NHS. Further evidence is needed.

Background: Burnout is increasingly identified as a factor affecting physician welfare, and subsequently patient care. Surgeons are known to experience higher rates of burnout compared with the general population. No review has focused exclusively on burnout prevalence among paediatric surgeons. This systematic review and meta-analysis aims to determine the prevalence of burnout among paediatric surgeons, alongside identifying and analysing potential influences.

Methods: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines, following our published PROSPERO protocol (CRD42025640570), 719 records were identified from inception through 13 January 2025. Included studies produced primary data reporting paediatric surgeon burnout prevalence, using validated burnout metrics. Main exclusion criteria were: study or population irrelevance, study type and duplicates. All available data were extracted; authors were contacted for original data. Random-effects meta-analysis with restricted maximum likelihood estimation estimation was conducted to estimate a pooled burnout prevalence, further subgroup analyses and meta-regressions were performed.

Results: Meta-analysis of 15 studies (2757 paediatric surgeons) revealed a pooled burnout prevalence of 29.4% (95% CI 20.3% to 40.5%), with substantial heterogeneity (I²=96.4%). Burnout rates ranged from 7.8% to 73.7%. Studies using the Maslach Burnout Inventory (MBI) reported significantly lower burnout (22.4%) compared with non-MBI tools (44.9%; p=0.025). No publication bias was detected. Study quality and measurement tool choice explained 35.3% and 24·5% of heterogeneity, respectively.

Conclusions: This study establishes that nearly one in three paediatric surgeons experience burnout, with a pooled prevalence of 29.4% (95% CI 20.3% to 40.5%). This rate, while concerning, is notably lower than other surgical disciplines. Strong personal accomplishment, resulting from emotionally rewarding work with children, appears protective, alongside structurally embedded practices such as family-centred care and multidisciplinary collaboration. Personality traits associated with increased agreeableness, conscientiousness and emotional stability may further reduce susceptibility to burnout. Specialty-specific interventions, supported by structured mentorship, are critical to sustainable well-being throughout paediatric surgical practice.

Background: The first thousand days, the period from the conception to the second year of life, play a fundamental role in establishing the foundation of a newborn's health, growth and neurological development, finally impacting its entire life. Reading interventions during this period produce numerous positive outcomes for the infants, such as their language skills and development, as well as enhancing the relationship between caregivers and children, supporting the importance of studying the effectiveness of shared reading groups in this period among children without pathologies and their caregivers. This research aims to systematically review evidence on shared group activity in the first thousand days, including also their caregivers, exploring the following outcomes: children's language skills, cognitive development, prosocial behaviour, parent-child relationship, reading habits, health literacy, quality of life and empowerment.

Methods: We conducted a systematic review and meta-analysis based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eight experimental studies met the inclusion criteria: shared group reading intervention involving children up to 24 months with their caregivers (especially parents, but also other caregivers). These interventions typically consisted of 6-12 group sessions led by trained facilitators in community settings.

Results: The results showed no clear conclusions. Both the narrative synthesis and meta-analysis suggested improvements on children's language skills (comprehension), only the narrative analysis suggested positive changes in cognitive development and prosocial behaviour, alongside improved parent-child relationship and enhanced parental skills following the intervention. However, evidence was limited and inconsistent.

Conclusions: These findings highlighted the importance of evidence-based interventions in supporting infant development, particularly in disadvantaged contexts addressing inequalities, and the promising role of shared reading as an integral part of such interventions. However, further studies are needed to confirm the effectiveness of these early interventions in fostering optimal developmental outcomes during the critical first thousand days.

Objective: We aimed to examine the associations between family adversity in infancy and subsequent daytime soiling at primary school age. We also examined factors on the causal pathway between family adversity and soiling, specifically the child's emotional/behaviour problems and constipation.

Design: This prospective cohort study included children from the Avon Longitudinal Study of Parents and Children (N=10 033) with data on the Family Adversity Index (FAI; birth to age 2), daytime soiling at age 7.5, emotional/behaviour problems at age 4, and constipation at age 6. We examined the relationships between the FAI, soiling, emotional/behaviour problems and constipation. We then evaluated the mediating effects of emotional/behaviour problems and constipation. All analyses were adjusted for child and family-related confounders.

Results: Daytime soiling occurred in 7% of children. A one-unit increase in infancy FAI was associated with increased odds of 12% for daytime soiling at age 7.5 (OR 1.12, 95% CI 1.07 to 1.17), emotional/behaviour problems score at age 4 (beta 0.52, 95% CI 0.47 to 0.58) and increased odds of constipation at age 6 (OR 1.07, 95% CI 1.03 to 1.11). The presence of constipation at age 6 was strongly associated with increased odds of soiling at age 7.5 (OR 3.34, 95% CI 2.68 to 4.16). There was weak evidence that the associations between FAI and daytime soiling were mediated by emotional/behaviour problems and constipation (OR_{natural_indirect_effect} 1.03, 95% CI 0.99 to 1.07).

Conclusions: Clinicians should be aware that exposure to family adversity in the early years places children at greater risk of subsequent constipation and soiling.

Background: The AVENIR cluster-randomised trial evaluated whether biannual mass drug administration (MDA) of azithromycin improved childhood mortality among infants in Niger, a high-mortality, high-malnutrition setting.

Methods: Weight-for-age z-score (WAZ) was a prespecified secondary outcome of the trial. In this analysis, 2880 communities in the Dosso and Tahoua regions and 51 687 infants with two sequential weight measurements were included. Weight was assessed at baseline and 6 months post treatment, and WAZ was calculated using WHO standards. To include two subsequent measures of WAZ, infants at baseline were 1-5 months old. Linear mixed-effects models compared mean WAZ between azithromycin and placebo arms, with additional analyses examining community-level means, categorical underweight outcomes and predefined subgroups.

Results: At follow-up, mean WAZ was -1.39 in the azithromycin arm and -1.38 in the placebo arm, with no detectable difference (mean difference 0.00, 95% CI -0.05 to 0.04, p=0.94). Odds of moderate-to-severe or severe underweight also did not differ between groups. Subgroup analyses by baseline nutritional status, age, sex, community size and distance to health centres showed consistent null effects, though a small, non-significant improvement in WAZ was observed in infants treated during the rainy season compared with the dry season.

Conclusion: These findings align with prior large-scale trials that demonstrated mortality benefits but no sustained effects of azithromycin on growth. Taken together, the results suggest that while azithromycin MDA reduces childhood mortality, it is unlikely to provide medium-term improvements in weight gain, highlighting the need for complementary nutritional interventions to address undernutrition in similar settings.

Objectives: To evaluate the association between corticosteroid use and clinical outcomes in children hospitalised with severe orbital infections, and to describe practice patterns of systemic corticosteroid use.

Design: Multi-site observational cohort study using hospital data from 2009 to 2018.

Setting: Canadian children's hospitals (7) and community hospitals (3).

Patients: Children 2 months and 18 years hospitalised with severe orbital infections.

Interventions: Systemic corticosteroids at any time MAIN OUTCOME MEASURES: Length of hospital stay and surgical intervention using time-to-event Cox proportional hazards multivariable regression models to account for potential differences in timing of corticosteroid use (early, ≤24 hours or late, >24 hours after admission), with adjustment for covariates.

Results: Of the 1479 hospitalised children, 876 (59.2%) were male and median age was 5.3 years (IQR 2.2 to 9.8). Of the 65 (4.4%) who received corticosteroids, over half (53.8%) received them early. Median length of stay was 75.9 hours (IQR 47.1 to 130.4) and 98 (6.6%) underwent surgical intervention. Corticosteroid use was associated with delayed discharge and prolonged hospitalisation, as reflected by a HR of 0.73 (95% CI 0.55 to 0.96) in adjusted analyses. However, systemic corticosteroids had no association with surgical intervention (HR 0.82, 95% CI 0.36 to 1.88).

Conclusion: In a large cohort of hospitalised children with severe orbital infections, corticosteroids were used infrequently, and when used, were not associated with improved clinical outcomes. Further high-quality trial evidence is needed to determine if routine corticosteroids are safe and effective.