OBJECTIVE: We aimed to provide an evidence-supported approach to diagnose, monitor, and treat children with inflammatory bowel disease (IBD) and primary sclerosing cholangitis (PSC). METHODS: The core group formulated seven PICO-structured clinical questions. A systematic literature search from inception to December 2022 was conducted by a medical librarian using MEDLINE and EMBASE. Core messages from the literature were phrased as position statements and then circulated to a sounding board composed of international experts in pediatric gastroenterology and hepatology, histopathology, adult gastroenterology and hepatology, radiology, and surgery. Statements reaching at least 80% agreement were considered as final. The other statements were refined and then subjected to a second online vote or rejection. RESULTS: Regular screening for gamma-glutamyltransferase (GGT) is essential for detecting possible biliary disease in children with IBD. MR cholangiopancreatography is the radiological modality of choice for establishing the diagnosis of PSC. Liver biopsy is relevant in the evaluation of small duct PSC or autoimmune hepatitis. Children who do not have known IBD at the time of PSC diagnosis should undergo initial screening with fecal calprotectin for asymptomatic colitis, and then at least once yearly thereafter. Children with a cholestatic liver enzyme profile can be considered for treatment with ursodeoxycholic acid and can continue if there is a meaningful reduction or normalization in GGT. Oral vancomycin may have a beneficial effect on GGT and intestinal inflammation, but judicious use is recommended due to the lack of long-term studies. Children with PSC-IBD combined with convincing features of autoimmune hepatitis may benefit from corticosteroids and antimetabolites. CONCLUSIONS: We present state-of-the-art guidance on the diagnostic criteria, follow-up strategies, and therapeutic strategies and point out research gaps in children and adolescents with PSC-IBD.
Patrick F van Rheenen, Kaija-Leena Kolho, Richard K Russell et al.
BACKGROUND: Management of patients with food allergies is complex, especially in cases of patients with multiple and potentially severe food allergies. Although international guidelines exist for food allergy management, the role of the allergist in the decision-making process is key. OBJECTIVE: Our aim was to investigate the management patterns and educational needs of practicing allergists treating patients with food allergies. METHODS: An online survey was e-mailed to United States-based practicing allergists (N = 2833) in November-December 2021. The allergists were screened for managing 1 or more patients (including ≥25% pediatric patients) with food allergies per month. The allergists responded to questions regarding food allergy management in response to 2 hypothetical pediatric case studies, their familiarity with available guidelines and emerging treatments, and their future educational preferences. A descriptive analysis of outcomes was conducted. RESULTS: A total of 125 responding allergists (4.4%) met the eligibility criteria and completed the survey. The allergists prioritized written exposure action plans, patient-caregiver communication, prevention of serious reactions, and consideration of both food allergy severity and allergic comorbidities in the management of patients with food allergies. With regard to recommending biologics in the future, the allergists identified patient history of anaphylaxis and hospitalizations, food allergy severity, and allergic comorbidities as all being important factors to consider when deciding on appropriate treatment options. The allergists noted their ongoing educational needs, especially for current and emerging treatments for food allergies. CONCLUSION: With the treatment landscape for food allergies evolving rapidly, the decision-making priorities and continuing educational needs of allergists will be important in optimizing the management of patients with food allergies.
Aikaterini Anagnostou, Matthew Greenhawt, Jay A Lieberman et al.
BACKGROUND: Disease outbreaks significantly affect maternal and neonatal health. Variability in reporting health outcomes hinder evidence generation. We aimed to develop a core outcome set (COS) for maternal and neonatal health research and surveillance during emerging and ongoing epidemic threats and to agree on outcomes' definitions. METHODS: We conducted a systematic review of observational and experimental studies related to epidemics to identify outcomes, and a four-stage modified-Delphi consensus. 150 international stakeholders participated in online surveys, and 24 representatives in consensus meetings. The panels were diverse, with balanced representation of professional background, gender, and geography, including civil society representatives. Outcome were included if ≥ 80% of participants scored them as critically important and ≤10% rated them as not important. FINDINGS: The final COS includes seven main maternal outcomes-pregnancy outcome, maternal death, suspected symptomatic infection, confirmed infection, severe disease, preterm delivery, mode of birth; seven complementary maternal outcomes-antepartum haemorrhage, postpartum haemorrhage, hypertensive disorders of pregnancy, maternal sepsis, admission to intensive care unit/special units, respiratory support, depression and anxiety; 11 main neonatal outcomes-neonatal death, neonatal suspected symptomatic infection, confirmed infection, severe disease, vertical transmission, low birth weight, prematurity, congenital disorder, respiratory support, skin-to-skin contact, breastfeeding; and, four complementary neonatal outcomes-admission to neonatal intensive care unit/special units, respiratory failure, birth asphyxia, sepsis. INTERPRETATION: This COS could contribute to standardize maternal and neonatal outcomes selection and reporting in observational and experimental studies, facilitating efficient data comparison and timely evidence-based decision-making in the context of ongoing and emerging epidemic threats. FUNDING: Bill & Melinda Gates Foundation (grant INV-041181) and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (HQHRP2422779).
Verónica Pingray, Karen Klein, Juan Pedro Alonso et al.
BACKGROUND: Maternal vaccination and infant monoclonal antibodies are promising avenues to protect young infants from respiratory syncytial virus (RSV) infection. Successful inclusion into the UK immunization schedule depends on parental acceptability, among other factors. METHODS: An online cross-sectional survey from August to September 2023 exploring the likelihood of accepting, and preference for, either method of RSV prophylaxis, and reasons given for these. A questionnaire was distributed via social media networks to UK participants with a child under the age of 2 years and/or pregnant. RESULTS: A total of 1620 participants completed the survey. Participants' median age was 33 years [interquartile range (IQR), 31-36], 92% were of White ethnicity. Acceptability was high, but higher for a maternal vaccine than an infant monoclonal antibody (P < 0.0001). Concerns about safety, need for more information and number of vaccines given to infants already were common reasons for hesitancy. Lacking knowledge about RSV was associated with a lower likelihood of accepting either option [maternal vaccine: odds ratio (OR): 0.32, 95% confidence interval (CI): 0.16-0.68, P = 0.002; infant monoclonal antibody: OR: 0.35, 95% CI: 0.19-0.68, P = 0.002], as was identifying as Black, Black British, African or Caribbean ethnic group, or having declined the routinely recommended antenatal vaccines. CONCLUSIONS: While most parents would accept a maternal vaccine or infant monoclonal antibody to protect their infant against RSV, understanding preferences, influencing factors and concerns is essential to optimize immunization programs. This study highlights the information parents require to make an informed choice about RSV protection.
Simone Paulson, Alasdair P S Munro, Katrina Cathie et al.
INTRODUCTION: Medical students feel poorly prepared to examine pediatric patients during clerkship. Our institution's introduction to clinical skills course lacked practice with pediatrics physical examination skills. We developed a novel clinical skills curriculum to increase students' confidence in examining pediatric patients. METHODS: Ericsson's deliberate practice conceptual framework guided curriculum design. We utilized a flipped-classroom model to teach the newborn examination. Students watched a video, then practiced with manikins and patients. For the child examination, students attended a lecture and practiced with hospitalized children and facilitators. Students then participated in a Home, Education, Eating/Exercise, Activities/Employment, Drugs, Suicidality, Sexuality, Safety (HEEADSSS) didactic and role play activity. Before and after participation, students completed REDCap surveys ranking confidence in performing pediatric examinations and identifying normal examination findings on a Likert scale (1 = "Not at all confident," 4 = "Extremely confident"). We analyzed data using Wilcoxon rank sum tests. RESULTS: A total of 97 students participated in the curriculum. Respectively, 56 (58%) and 32 (30%) students completed pre- and post-participation surveys. Post-participation, students reported increased confidence in identifying normal infant (median [interquartile range]; (2 [2,2] vs 4 [3,4]; p < 0.001) and child (2 [2,2] vs 3 [3,4]; p < 0.001) examination findings as well as HEEADSSS assessment components (2 [1.5,2] vs 4 [3,4]; p < 0.001), and had significantly higher scores on confidence performing infant (2 [2,2.5] vs 4 [3,4]; p < 0.001), child (2 [2,2] vs 3 [3,4]; p < 0.001), and HEEADSSS assessment (2 [2,3] vs 4 [3,4]; p < 0.001). DISCUSSION: This multi-modal curriculum emphasizing pediatric examination skills improved students' confidence in pediatric-specific knowledge and skills prior to clerkship. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-024-02191-w.
Lindsay C Podraza, Lauren S Starnes, Joseph R Starnes et al.
Concussions are a prevalent public health concern; however, non-concussive head impacts without signs and symptoms of concussion may have a greater influence on brain health. The objective of this study was to apply components of the health belief model to perceptions of non-concussive head impacts and preventative efforts to reduce head impacts in youth American football and thematically analyze responses across parents with children participating in youth football, coaches, and organizational leaders. Parents, coaches, and organizational leaders of a local youth football league were invited to complete a one-time online anonymous survey assessing football and sport history, knowledge, beliefs, perceived susceptibility, perceived severity, self-efficacy, and demographics. Principal factor analysis was conducted prior to scoring measurements evaluated in this study. Parents perceived the susceptibility and severity of head impacts in football to be greater than coaches and organizational leaders; however, coaches and organizational leaders had greater beliefs and self-efficacy surrounding head impact safety efforts in football compared to parents. Understanding beliefs and perceptions of key stakeholders in the youth football community is critical to the development and implementation of prevention programs aimed at reducing head impact exposure in the sport.
Jillian E Urban, Justin B Moore, Lydia L Faber et al.
BACKGROUND: Asthma is a chronic airway condition with a global prevalence of 262.4 million people. Asthma education is an essential component of management and includes provision of information on the disease process and self-management skills development such as trigger avoidance. Education may be provided in various settings. The home setting allows educators to reach populations (e.g. financially poor) that may experience barriers to care (e.g. transport limitations) within a familiar environment, and allows for avoidance of attendance at healthcare settings. However, it is unknown if education delivered in the home is superior to usual care or the same education delivered elsewhere. There are large variations in asthma education programmes (e.g. patient-specific content versus broad asthma education, number/frequency/duration of education sessions). This is an update of the 2011 review with 14 new studies added. OBJECTIVES: To assess the effects of educational interventions for asthma, delivered in the home to children, their caregivers, or both, on asthma-related outcomes. SEARCH METHODS: We searched Cochrane Airways Group Trials Register, CENTRAL, MEDLINE, two additional databases and two clinical trials registries. We searched reference lists of included trials/review articles (last search October 2022), and contacted authors of included studies. SELECTION CRITERIA: We included randomised controlled trials of education delivered in the home to children and adolescents (aged two to 18 years) with asthma, their caregivers or both. We included self-management programmes, delivered face-to-face and aimed at changing behaviour (e.g. medication/inhaler technique education). Eligible control groups were usual care, waiting list or less-intensive education (e.g. shorter, fewer sessions) delivered outside or within the home. We excluded studies with mixed-disease populations and without a face-to-face component (e.g. telephone only). DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, assessed trial quality, extracted data and used GRADE to rate the certainty of the evidence. We contacted study authors for additional information. We pooled continuous data with mean difference (MD) and 95% confidence intervals (CI). We used a random-effects model and performed sensitivity analyses with a fixed-effect model. When combining dichotomous and continuous data, we used generic inverse variance, using a Peto odds ratio (OR) and fixed-effect model. Primary outcomes were exacerbations leading to emergency department visits and exacerbations requiring a course of oral corticosteroids. Six months was the primary time point for outcomes. The summary of findings tables reported on the primary outcomes, and quality of life, daytime symptoms, days missed from school and exacerbations leading to hospitalisations. MAIN RESULTS: This review includes 26 studies with 5122 participants (14 studies and 2761 participants new to this update). Sixteen studies (3668 participants) were included in meta-analyses. There was substantial clinical diversity. Participants differed in age (range 1 to 18 years old) and asthma severity (mild to severe). The context and content of educational interventions also varied, as did the aims of the studies (e.g. reducing healthcare utilisation, improving quality of life) and there was diversity in control group event rates. Outcomes were measured over various time points specified in the original studies. All studies were at risk of bias due to the nature of the intervention. It is possible that the participants/educators may not have been aware of their allocation, so all studies were judged at unclear risk for performance bias. Home-based education versus usual care, waiting list or less-intensive education programme delivered outside the home Primary outcomes Home-based education may result in little to no difference in exacerbations leading to emergency department visits at six-month follow-up compared to control, but the evidence is very uncertain (Peto OR 1.22, 95% CI 0.50 to 2.94; 5 studies (2 studies with 2 intervention arms), 855 participants; very low-certainty evidence). Home-based education results in little to no difference in exacerbations requiring a course of oral corticosteroids compared to control (mean difference (MD) -0.18, 95% CI -0.63 to 0.26; 1 study (2 intervention arms), 250 participants; low-certainty evidence). Secondary outcomes Home-based education may improve quality-of-life scores compared to control, but the evidence is very uncertain (standardised mean difference (SMD) 0.32, 95% CI 0.08 to 0.56; 4 studies, 987 participants; very low-certainty evidence). The evidence is very uncertain about the effects of home-based education on mean symptom-free days, days missed from school/work and exacerbations leading to hospitalisation compared to control (all very low-certainty evidence). Home-based education versus less-intensive home-based education for children with asthma Primary outcomes A more-intensive home-based education intervention did not reduce exacerbations leading to emergency department visits (Peto OR 1.36, 95% CI 0.35 to 5.30; 4 studies, 729 participants; low-certainty evidence) or exacerbations requiring a course of oral corticosteroids (MD 0.08, 95% CI -0.14 to 0.30; 3 studies, 605 participants; low-certainty evidence), compared to a less-intensive type of home-based education. Secondary outcomes A more-intensive home-based asthma education intervention may reduce hospitalisation due to an asthma exacerbation (Peto OR 0.14, 95% CI 0.04 to 0.55; 4 studies, 689 participants; low-certainty evidence), but not days missed from school (low-certainty evidence), compared with a less-intensive home-based asthma education intervention. A more intensive home-based education intervention had no effect on quality of life and symptom-free days (both very low certainty), compared with a less-intensive home-based asthma education intervention, but the evidence is very uncertain. AUTHORS' CONCLUSIONS: We found uncertain evidence for home-based asthma educational interventions compared to usual care, education delivered outside the home or a less-intensive educational intervention. Home-based education may improve quality of life compared to control and reduce the odds of hospitalisation compared to less-intensive educational intervention. Although asthma education is recommended in guidelines, the considerable diversity in the studies makes the evidence difficult to interpret about whether home-based education is superior to none, or education delivered in another setting. This review contributes limited information on the fundamental optimum content and setting for educational interventions in children. Further studies should use standard outcomes from this review and design trials to determine what components of an education programme are most important.
Antonia O'Connor, Maryam Hasan, Krishna Bajee Sriram et al.
BACKGROUND: Access to healthcare involves timely and affordable service availability. Barriers, such as economic and geographic factors, particularly affect low- and middle-income countries. This study analyzes the spatial distribution and socio-economic determinants of healthcare access barriers among female youths in Mozambique to inform targeted interventions. METHODS: Data from the Mozambique Demographic and Health Survey (DHS) 2022/23 on maternal and child health was analyzed. Using a stratified two-stage sampling design, 619 enumeration areas were selected, including 5,743 female youths aged 15-24. Barriers were assessed based on finances, distance, permission, and safety, with independent variables like age, education, wealth index, marital status, and community factors. Analyses included multilevel logistic regression and spatial methods (Global Moran's I, SaTScan) using Stata 17 and ArcGIS 10.7 to identify barriers and clusters. RESULTS: This study found that 49.10% (95% CI: 47.81%, 50.39%) of female youths reported barriers to healthcare access, primarily due to financial difficulties (40.69%) and distance (38.16%). Youths aged 20-24 were 15% lower odds of facing barriers (AOR = 0.85, 95% CI: 0.73, 0.99). Those with no formal education were 2.18 times more likely to face barriers (AOR = 2.18, 95% CI: 1.22, 3.88). Youths from poor and middle-wealth households were 1.9 times (AOR = 1.9, 95% CI: 1.44, 2.49) and 1.51 times (AOR = 1.51, 95% CI: 1.19, 1.92) more likely to face barriers, respectively. Married youths had a 1.22 times higher likelihood of facing barriers (AOR = 1.22, 95% CI: 1.03, 1.44), and rural residents were three times more likely to experience challenges compared to urban residents (AOR = 3.00, 95% CI: 2.24, 4.01). Spatial analysis revealed regional disparities, with hotspots in Southern Manica and Northern Zambezia. CONCLUSIONS: Female youths in Mozambique face significant barriers to healthcare access, mainly due to financial constraints and distance, with regional concentrations in Southern Manica, Southern Niassa, and Northern Zambezia. Key determinants include age, education, marital status, rural residency, and economic status. Targeted interventions should address these disparities by enhancing economic opportunities, promoting education, and improving transportation infrastructure. Policymakers must prioritize strategies to advance gender equity and health outcomes for female youths in Mozambique.
Habtu Kifle Negash, Hiwot Tezera Endale, Hailu Aragie et al.
BACKGROUND: Interstitial lung disease is rarer in children than adults, but, with increasing diagnostic awareness, more cases are being discovered. The prognosis of childhood interstitial lung disease is often poor, but increasing numbers are now surviving into adulthood. AIM: To characterise childhood interstitial lung disease survivors and identify their impact on adult interstitial lung disease centres. METHODS: This was a European study (34 adult and childhood interstitial lung disease centres) reporting incident/prevalent cases of childhood interstitial lung disease survivors from January to July 2023. Epidemiological, clinical, physiological and genetic data were collected. RESULTS: 244 patients were identified with a median (interquartile range) age at diagnosis of 12.5 years (6-16 years) and age at study inclusion of 25 years (22-33 years), with 51% male, 86% nonsmokers and a median (interquartile range) % predicted forced vital capacity of 70% (47-89%) and diffusing capacity of the lungs for carbon monoxide of 48% (32-75%). 32% were prescribed long-term oxygen and 227 (93%) were followed up in adult centres whereas 17 (7%) never transitioned. The commonest diagnoses (82%) were childhood interstitial lung disease category B1 (sarcoidosis, hemosiderosis, connective tissue disorders, vasculitis) at 35%, A4 (surfactant-related) at 21%, B2 (bronchiolitis obliterans, hypersensitivity pneumonitis) at 14% and Bz (unclassified interstitial lung disease) at 13%. Bz patients had the worst functional status. 60% of all patients were still being prescribed corticosteroids. Re-specification of diagnosis and treatment were made after transition for 9.8% and 16% of patients, respectively. Not all childhood interstitial lung disease diagnoses were recognised in adult interstitial lung disease classifications. CONCLUSION: Childhood interstitial lung disease survivors are seen in most adult interstitial lung disease centres and only a minority continue follow-up in paediatric centres. Survivors have a significant loss of lung function. The heterogeneity of their aetiologies and therapeutic requirements has a real impact on adult interstitial lung disease centres. Re-specification of diagnosis and treatment may contribute to precision and personalisation of management.
Effrosyni D Manali, Matthias Griese, Nadia Nathan et al.
INTRODUCTION: Digital health technologies have vastly improved monitoring, diagnosis, and care during pregnancy. As expectant mothers increasingly engage with social media, online platforms, and mobile applications, these innovations present valuable opportunities to enhance the quality of maternal healthcare services. OBJECTIVE: This review aims to assess the applicability, outcomes, and recent advancement of digital health modalities in antenatal care. METHOD: We conducted a scoping review by searching four electronic databases (Scopus, Web of Science, PubMed, EBSCOhost), performing manual searches of Google Scholar, and examining the references of relevant studies. Eligible studies included original research published in English between 2010 and 2024 involving the use of digital health technologies for antenatal care, complying with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review guidelines. RESULTS: One hundred twenty-six eligible articles were identified, with the majority (61.11%) conducted in high-income countries, including the United States, United Kingdom, and Australia. Digital health studies have increased over time, driven by telehealth adoption in affluent nations. Interventions predominantly focused on patient-provider consultations, remote monitoring, and health education, complementing in-person visits or as a substitute when necessary. High levels of acceptance and satisfaction were reported among users. These interventions primarily targeted general maternal care (28.57%), gestational diabetes mellitus (15.07%), and mental health (13.49%) while also addressing gestational weight management, hypertensive disorders, high-risk pregnancies and maternal education. The findings demonstrated positive outcomes in managing clinical conditions, enhancing knowledge, promoting birth preparedness, and improving antenatal care access and utilisation. Additionally, the findings revealed the cost-effectiveness of these approaches in alleviating financial burdens for patients and healthcare systems. CONCLUSION: Digital health is emerging as a pivotal tool in maternal and child care, fostering positive outcomes and high acceptance among patients and healthcare providers. Its integration into antenatal care ensures the maintenance of standard care quality, with no adverse effects reported despite limited discussions on safety and privacy concerns. As these technologies continue to evolve, they are set to redefine antenatal care by offering more accessible, efficient, and patient-centred solutions, ultimately shaping the future of maternal healthcare delivery.
