Abstract INTRODUCTION: Current chemotherapy protocols for treatment of embryonal brain tumors in infants recommend administration of intrathecal chemotherapy either by a lumbar tap or via an Ommaya reservoir. Children with concurrent hydrocephalus and shunts may have sub-therapeutic levels of chemotherapy in the CSF due to constant CSF drainage to extra-CNS compartments. We present our experience in delivery of chemotherapy to young children via programmable valves. RESULTS: A retrospective analysis of infants with CNS malignancies and hydrocephalus treated with a shunt and a programmable valve (CERTAS™ Plus Programmable Valves - Integra Life Sciences) was conducted. Five infants 1.1-3 years of age (mean 2) were included. Pathologies included atypical teratoid rhabdoid tumor (ATRT N=2), medulloblastoma (N=2), and metastatic rhabdomyosarcoma(N=1). Intrathecal injections were conducted in an outpatient setting unless hospitalization was required for other reasons. Only one child required sedation due to noncompliance. A total of 61 chemotherapeutic administrations were performed directly through the valve while set on an extremely high opening pressure for several hours( 35 with hydrocortisone and cytarabine, 26 with topotecan). There were no infections, leaks or major complications. One child required a wound revision due to exposure of the proximal catheter related to extremely thin skin, one child developed somnolence and fever which were not related to a shunt malfunction or infection, and one child had clinical and radiological shunt over-drainage solved by increasing of valve settings. CONCLUSIONS: Programmable ventriculoperitoneal valves appear to a safe method for delivery of chemotherapy in infants with malignant CNS tumors .This technique may potentially have an added value for children with concurrent shunts, and may also obviate the need for an additional ventricular access device .
Abstract Background Health System Performance Assessment (HSPA) is a tool to monitor and evaluate the performance of health systems and to inform evidence-based policymaking. For the first time, a country specific HSPA is currently being piloted for Germany. Methods The HSPA is based on a newly developed conceptual framework including nine dimensions (e.g., access, quality, efficiency, population health). Indicators were selected based on a systematic search of (inter)national studies and HSPA initiatives. Where possible, indicators were analysed in their development over time (2000-2020), in comparison to eight European countries (e.g., Austria, Denmark, France), and along up to seven equity dimensions (e.g., sex, age, income, education, region). Results Overall, 90 indicators were included in the HSPA. Trend and equity analyses were possible for almost all and country comparisons for most indicators. A few indicators could not be analysed at all due to missing data. The overall HSPA provides an in-detail picture of Germany's health system. Access, for example, can be rated as good in Germany compared to the other countries, as insurance coverage and physician density are high, and unmet needs and waiting times for elective surgery are low. Results for quality are not as good, e.g., cancer survival rates, but most indicators show a positive trend. While population health outcomes are average in country comparison (e.g., fetal and infant mortality), resource input is comparatively high. Consequently, overall efficiency can still be improved (e.g., amenable mortality per total health expenditure). Conclusions This first HSPA for Germany allows new insights to the performance of the German health system which are important for policy and research. While the pilot benefitted a lot from previous HSPA initiatives, data availability remains one of the biggest challenges.
Background China's sustained fertility decline has intensified population contraction and ageing. Following the rollout of the three-child policy, clarifying fertility intentions among the childbearing-age population and their determinants is crucial for effective policy design and fertility promotion. Methods We conducted a systematic search of PubMed, Embase, the Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang, China Science and Technology Journal Database, and Chinese Biomedical Literature Database. We included in the analysis studies published from 31 May 2021 to 10 May 2025 that examined third-child fertility intention (TCFI) and its determinants among the childbearing-age population in China. We used the Joanna Briggs Institute Critical Appraisal Checklist for cross-sectional studies to assess the quality of studies. Further, we estimated pooled prevalence with random-effects models. Results A total of 37 studies were included in the analysis (n = 113 009 participants). The pooled prevalence of TCFI and willingness to have another child (WHAC) were 7.6% and 12.7%. Factors associated with higher TCFI included age >35 years, male sex, education at or below high school level, monthly personal income >CNY 2000, ethnic minority status, having at least one non-only-child spouse, and having no pension insurance. For WHAC, remarriage and good self-assessed health were significant determinants. Conclusions Both TCFI and WHAC remain low in China's childbearing-age population. Enhancing childcare subsidies, strengthening medical security, and addressing core economic constraints such as housing and education may help raise fertility intentions. Registration PROSPERO: CRD420251036086.
BACKGROUND: This study was conducted during the implementation period of China’s recent fertility policies, a context in which the management of cesarean section (CS) rates faces evolving challenges. This study evaluated temporal trends in CS practices using the modified Robson Classification System (RCS) at a coastal Chinese secondary maternal and child health(MCH) hospital. METHODS: We analyzed 11,755 deliveries (2019–2023) using electronic medical records categorized via the modified RCS. Statistical analyses included trend tests and regression models. RESULTS: Annual deliveries declined by 24.5% from 2019 to 2023, while maternal age increased significantly (p < 0.001). The overall CS rate was 41.4% (4,865/11,755). Most CSs were associated with nulliparous term singleton vertex pregnancies (R1; 40.7% of CSs) and women with a previous CS (R3; 35.9% of CSs), together constituting 76.6% of all CSs. The CS rate in R1 showed a significant upward trend (p < 0.001). CONCLUSION: This descriptive study of a secondary MCH hospital identifies notable obstetric practice and demographic trends against the backdrop of evolving fertility policies, with a high overall cesarean section rate driven predominantly by two patient groups. Annual delivery volumes see a substantial cumulative decline over the five-year study period, while maternal age rises significantly across the cohort. The overall cesarean section rate remains high, with the majority of cesarean procedures occurring in nulliparous women with term singleton vertex pregnancies and women with a prior cesarean section, who together account for the vast majority of all cesarean deliveries. The cesarean section rate for nulliparous women with term singleton vertex pregnancies also exhibits a marked upward trend during the study period. These trends indicate the need for targeted clinical interventions for key patient groups, including standardized labor management for nulliparous women and the promotion of vaginal birth after cesarean. Notably, this analysis coincides with national demographic and fertility policy shifts, but no causal relationship between the policies and the observed trends is established.
Background Caesarean section (CS) rates are rising across low- and middle-income countries (LMICs), frequently exceeding levels considered medically necessary. While CS can be lifesaving, emerging evidence from high-income settings suggests that delivery by CS may increase children's susceptibility to respiratory infections. However, population-based evidence from LMICs remains limited. We investigated the association between mode of delivery and acute respiratory infection (ARI) among children younger than five years across diverse LMIC settings. Methods We analysed nationally representative Demographic and Health Surveys data from 47 LMICs collected between 2015 and 2024, including 534,423 singleton live births. Mode of delivery (caesarean section vs. vaginal birth) was the exposure. ARI was defined as maternal report of cough with rapid or difficult breathing in the preceding two weeks before each survey. Country-specific adjusted prevalence ratios (aPRs) were estimated using modified Poisson regression models accounting for sociodemographic, maternal, perinatal, and environmental factors. Country-specific estimates were then pooled using random-effects meta-analysis, including subgroup analyses by national income level and caesarean section rate. Results The prevalence of caesarean section ranged from 1.3% in Chad to 44.9% in Bangladesh. The prevalence of ARI ranged from < 1% in Mozambique, Cote d'Ivoire, the Philippines, and the Maldives to 14% in Pakistan. In pooled analyses, children born by caesarean section had a higher prevalence of ARI than those born vaginally (pooled aPR 1.11; 95% CI 1.02-1.20), with low between-country heterogeneity (I² = 9.62%). The association was stronger in low- and lower-middle-income countries and in countries with very low caesarean section rates (< 10%), where caesarean birth was associated with a 17% higher prevalence of ARI. Conclusions Across 47 LMICs, caesarean birth was associated with a modestly higher prevalence of acute respiratory infection in children younger than five years. While this finding is consistent with existing evidence, it should be interpreted with caution given the potential for residual confounding, including confounding by indication. These findings highlight the importance of reducing non-medically indicated caesarean sections while ensuring access to life-saving obstetric care. Strengthening evidence-based decision-making around mode of delivery may contribute to reducing preventable childhood respiratory morbidity in resource-limited settings.
Purpose Epileptic spasms are the predominant seizure type in infantile epileptic spasms syndrome (IESS). The pathophysiology of IESS, including blood-brain barrier (BBB) function involvement, remains unclear. To address this issue, we evaluated the serum matrix metallopeptidase-9 (MMP-9) and tissue inhibitor of metalloproteinase-1 (TIMP-1) levels in patients with IESS before and after initiating vigabatrin therapy. Methods IESS was defined as epileptic spasms occurring within 2 years after birth. We prospectively assessed serum MMP-9 and TIMP-1 levels before and after initiating vigabatrin therapy in patients with IESS who attended Saitama Children's Medical Center between February 2019 and December 2024 (n = 12; 5 boys) and compared them with those in age-matched controls (n = 14; 8 boys). Results The median ages at epileptic spasm onset and vigabatrin therapy initiation were 3.5 (1-11) and 8 (3-13) months, respectively. Serum MMP-9 levels were higher in patients with IESS than in the controls (p < 0.001). Serum MMP-9 and MMP-9/TIMP-1 ratios decreased significantly after vigabatrin therapy (MMP-9: 308 [160-664] ng/mL vs. 220 [112-367] ng/mL, p < 0.01; MMP-9/TIMP-1 ratio: 1.48 [0.61-8.14] vs. 1.11 [0.31-1.92], p < 0.05). MMP-9 levels decreased in 9 of 11 patients whose epileptic spasms had disappeared by the time of the last measurement. Conclusion Decreased MMP-9 levels after the initiation of vigabatrin therapy suggested an improvement in BBB dysfunction. Our findings shed light on the role of the BBB in IESS and the role of vigabatrin in the recovery of this function.
This study examines how caretakers perceive the effects of parental migration on left-behind children in Kyrgyzstan. Drawing from interviews with 33 caretakers in southern Kyrgyzstan, this study examines the "impossible" dilemma of parental labour migration and its effects on the children that are left behind. We find that parental migration is perceived to impact children in five main ways: financial, migration ambitions, educational, behavioural, and emotional. We find the financial benefits from migration are perceived to improve children's economic conditions, but parental absence can also lead to negative behavioural and emotional outcomes. This study contributes to literature on left-behind children through a qualitative analysis of caretakers' perceptions and the community's lived experiences. Findings can inform policies and initiatives aimed at improving the living conditions of children and supporting economies in high out-migration communities.
Background Bangladesh has the second highest burden of child labour in South Asia. The informal sector employs most of the children however, data on health including injuries and place of work for children are limited. As the deadline for the Sustainable Development Goals to end child labour is upon us, it is paramount to document the impact of child labour on health. This study aims to contribute to this knowledge gap by presenting medical data from occupational health clinics (OHCs) set up by Médecins Sans Frontières (MSF) in a peri-urban area of Dhaka, Bangladesh. Methods We did a retrospective analysis of health care records of children attending MSF OHCs between February 2014 and December 2023. We stratified the analysis by sex and age (< 14 years and ≥ 14- < 18 years). We looked at morbidities according to type of factory, whether children reported working with machinery, and examined nutritional and mental health (2018-2023) status. Results Over the study period, there were 10,200 occupational health consultations among children < 18 years, of which 4945 were new/first time consultations. The average age of children attending their first consultation was 14.7 years, of which 61% were male. Fifteen percent reported living inside the factory. Children worked in all prohibited categories of the informal sector. Almost all children reported operating machinery. Musculoskeletal (26%) and dermatological (20%) were the most identified conditions, and 7.5% of consultations were for work-related injuries. A higher proportion of male children had injuries (11% vs 2.5% in girls). Children working in metal factories accounted for most injuries (65%). Mood-related disorders accounted for 86% of the 51 mental health consultations. Half of all children were malnourished with higher levels in boys and those < 14 years. Conclusions Findings suggest that children face hazardous realities; engaged in the worst form of labour, bearing important morbidity and injury burden, with vulnerabilities varying by sex and age. Despite their economic contributions to the informal sector, they remain largely invisible and exploited. This study highlights the urgent need for child rights-based research and cross-sectoral approaches that actively involve children to develop sustainable, targeted solutions to eliminate child labour.
Background Preterm birth rates may have been affected during the COVID-19 pandemic but the impact of this on perinatal morbidity is unknown. Aim To review the impact of the COVID-19 pandemic on rates of preterm birth and perinatal mortality. Methods Medline, Embase, and online pre-prints were searched from Jan 2020 to Oct 2022. Case-control, cohort studies and reports comparing rates of preterm birth, stillbirth and neonatal death before and during the COVID-19 pandemic period were included. The pooled odds ratio (OR) for preterm birth, stillbirth and neonatal death was calculated using a random effects model. The primary outcome was the rate of preterm birth, stillbirth and neonatal death in the pre-pandemic and pandemic periods. Results 100 studies were included. Compared with pre-pandemic periods, there was a decrease in preterm births during the pandemic period: OR 0.95 (95% CI 0.94-0.97) I 2 = 0.93, with the greatest reduction for births < 28 weeks' gestation in high-income countries: OR 0.92 (95% CI 0.88-0.96), I 2 = 0.46. There was a reduction in neonatal deaths in high-income countries: OR 0.78 (95% CI 0.64-0.95), I 2 = 0.4. In low- and middle-income countries the stillbirth rate increased during the pandemic compared with the pre-pandemic period: OR 1.18 (95% CI 1.02-1.36), I 2 = 0.86. Conclusion The COVID-19 pandemic was associated with a reduction in preterm births and neonatal deaths. Further research is needed to investigate the mechanisms underlying these findings. Stillbirth rates increased in low- and middle-income countries where access to healthcare may have been restricted and strategies to address this in future pandemics are warranted.
Decisions about how and where they deliver their baby are extremely important to pregnant women. There are very strong ethical norms that women's autonomy should be respected, and that plans around birth should be personalised. However, there appear to be profound challenges in practice to respecting women's choices in pregnancy and labour. Choices carry risks and consequences-to the woman and her child; also potentially to her caregivers and to other women.What does it mean for women's autonomy to be respected in obstetrics? How should health professionals respond to refusals of treatment or requests for care outside normal guidelines? What are the ethical limits to autonomy? In this clinical ethics round table, service users, midwives, obstetricians, philosophers and ethicists respond to two hypothetical cases drawn from real-life scenarios.
