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Objectives: This study developed predictive models for one-week acute and six-month persistent pain following root canal treatment (RCT). An additional aim was to study the gain in predictive efficacy of models containing clinical factors only, over models containing sociodemographic characteristics., Methods: A secondary data analysis of 708 patients who received RCTs was conducted. Three sets of predictors were used: (1) combined set, containing all predictors in the data set; (2) clinical set and (3) sociodemographic set. Missing data were handled by multiple imputation using the missing indicator method. The multilevel least absolute selection and shrinkage operator (LASSO) regression was used to select predictors into the final multilevel logistic models. Three measures, the area under the receiver operating characteristic curve (AUROC) and precision-recall curve (AUPRC) and calibration curves, were used to assess the predictive performance of the models., Results: The selected-in factors in the final models, using LASSO regression, are related to pre- and intra-treatment clinical symptoms and pain experience. Predictive performance of the models remained the same with the inclusion (exclusion) of the socio-demographic factors. For predicting one-week outcome, the model built with combined set of predictors yielded the highest AUROC and AUPRC of 0.85 and 0.72, followed by the models built with clinical factors (AUROC = 0.82, AUPRC = 0.66). The lowest predictive ability was found in models with only sociodemographic characteristics (AUROC = 0.68, AUPRC = 0.40). Similar patterns were observed in predicting six-month outcome, where the AUROC for models with combined, clinical and sociodemographic sets of predictors were 0.85, 0.89 and 0.66, respectively, and the AUPRC were 0.48, 0.53 and 0.22, respectively., Conclusions: Clinical factors such as the severity and experience of pre-operative and intra-operative pain were discovered important to the subsequent development of pain following RCTs. Adding sociodemographic characteristics to the models with clinical factors did not change the models' predictive performance or the proportion of explained variance., (© 2022 The Authors. Community Dentistry and Oral Epidemiology published by John Wiley & Sons Ltd.)

Objective: Screen time guidelines recommend no screens under two years due to the potential negative impacts on development. While current reports suggest many children exceed this, research relies on parent reports of their children's screen exposure. We objectively assess screen exposure during the first two years and how it differs by maternal education and gender., Methods: This Australian prospective cohort study used speech recognition technology to understand young children's screen exposure over an average day. Data collection occurred every six months when children were 6, 12, 18 and, 24 months old (n = 207). The technology provided automated counts of children's exposure to electronic noise. Audio segments were then coded as screen exposure. Prevalence of screen exposure was quantified, and differences between demographics examined., Results: At six months, children were exposed to an average of 1hr, 16 min (SD = 1hr, 36 min) of screens per day, increasing to an average of 2 h, 28 min (SD = 2 h, 4 min) by 24-months. Some children at six months were exposed to more than 3 h of screen time per day. Inequalities in exposure were evident as early as six months. Children from higher educated families were exposed to 1hr,43 min fewer screens per day, 95%CI (-2hr, 13 min, -1hr, 11 min) compared to lower educated households, with this difference remaining consistent as children age. Girls were exposed to an additional 12 min of screens 95%CI (-20 min, 44 min) per day compared to boys at six months, but this difference reduced to only 5 min by 24-months., Conclusion: Using an objective measure of screen exposure, many families exceed screen time guidelines, the extent increasing with child's age. Furthermore, substantial differences between maternal education groups emerge as young as six months old. This highlights the need for education and supports for parents around screen use in the early years, balanced within the realities of modern life., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Background: Populations willing to participate in randomized trials may not correspond well to policy-relevant target populations. Evidence of effectiveness that is complementary to randomized trials may be obtained by combining the 'target trial' causal inference framework with whole-of-population linked administrative data., Methods: We demonstrate this approach in an evaluation of the South Australian Family Home Visiting Program, a nurse home visiting programme targeting socially disadvantaged families. Using de-identified data from 2004-10 in the ethics-approved Better Evidence Better Outcomes Linked Data (BEBOLD) platform, we characterized the policy-relevant population and emulated a trial evaluating effects on child developmental vulnerability at 5 years (n = 4160) and academic achievement at 9 years (n = 6370). Linkage to seven health, welfare and education data sources allowed adjustment for 29 confounders using Targeted Maximum Likelihood Estimation (TMLE) with SuperLearner. Sensitivity analyses assessed robustness to analytical choices., Results: We demonstrated how the target trial framework may be used with linked administrative data to generate evidence for an intervention as it is delivered in practice in the community in the policy-relevant target population, and considering effects on outcomes years down the track. The target trial lens also aided in understanding and limiting the increased measurement, confounding and selection bias risks arising with such data. Substantively, we did not find robust evidence of a meaningful beneficial intervention effect., Conclusions: This approach could be a valuable avenue for generating high-quality, policy-relevant evidence that is complementary to trials, particularly when the target populations are multiply disadvantaged and less likely to participate in trials., (© The Author(s) 2022. Published by Oxford University Press on behalf of the International Epidemiological Association.)

Problem: The majority of South Australian pregnant women who smoke do not quit during pregnancy. Additionally, the prevalence of smoking is higher among pregnant women living in socially disadvantaged areas., Background: Understanding challenges in midwives' provision of smoking cessation care can elucidate opportunities to facilitate women's smoking cessation., Aim: We aimed to understand midwives' perspectives on current practices, perceived barriers and facilitators to delivery of smoking cessation care, and potential improvements to models of smoking cessation care., Methods: An exploratory qualitative research methodology and thematic analysis was used to understand the perspectives of midwives in five focus groups., Findings: Four themes were generated from the data on how midwives perceived their ability to provide smoking cessation care: Tensions between providing smoking cessation care and maternal care; Organisational barriers in the delivery of smoking cessation care; Scepticism and doubt in the provision of smoking cessation care; and Opportunities to enable midwives' ability to provide smoking cessation care., Discussion: A combination of interpersonal, organisational and individual barriers impeded on midwives' capacities to approach, follow-up and prioritise smoking cessation care. Working with women living with disadvantage and high rates of smoking, the midwife's role was challenging as it balanced delivering smoking cessation care without jeopardising antenatal care., Conclusion: Providing midwives with resources and skills may alleviate the sense of futility that surrounds smoking cessation care. Provision of routine training and education could also improve understandings of the current practice guidelines., Competing Interests: Conflict of Interests There are no conflicts of interest to declare., (Copyright © 2023 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Importance: Intergenerational welfare contact is a policy issue because of the personal and social costs of entrenched disadvantage; yet, few studies have quantified the burden associated with intergenerational welfare contact for health., Objective: To examine the proportion of individuals who experienced intergenerational welfare contact and other welfare contact types and to estimate their cause-specific hospital burden., Design, Setting, and Participants: This cohort study used a whole-of-population linked administrative dataset of individuals followed from birth to age 20 years using deidentified data from the Better Evidence Better Outcomes Linked Data platform (Australian Government Centrelink [welfare payments], birth registration, perinatal birth records, and inpatient hospitalizations). Participants included individuals born in South Australia from 1991 to 1995 and their parents. Analysis was undertaken from January 2020 to June 2022., Exposures: Using Australian Government Centrelink data, welfare contact was defined as 1 or more parents receiving a means-tested welfare payment (low-income, unemployment, disability, or caring) when children were aged 11 to 15 years, or youth receiving payment at ages 16 to 20 years. Intergenerational welfare contact was defined as welfare contact occurring in both parent and offspring generations. Offspring were classified as: no welfare contact, parent-only welfare contact, offspring-only welfare contact, or intergenerational welfare contact., Main Outcomes and Measures: Hospitalization rates and cumulative incidence were estimated by age, hospitalization cause, and welfare contact group., Results: A total of 94 358 offspring (48 589 [51.5%] male) and 143 814 parents were included in analyses. The study population included 32 969 offspring (34.9%) who experienced intergenerational welfare contact. These individuals were more socioeconomically disadvantaged at birth and had the highest hospitalization rate (133.5 hospitalizations per 1000 person-years) compared with individuals with no welfare contact (46.1 hospitalizations per 1000 person-years), individuals with parent-only welfare contact (75.0 hospitalizations per 1000 person-years), and individuals with offspring-only welfare contact (87.6 hospitalizations per 1000 person-years). Hospitalizations were frequently related to injury, mental health, and pregnancy. For example, the proportion of individuals with intergenerational welfare contact who had experienced at least 1 hospitalization at ages 16 to 20 years was highest for injury (9.0% [95% CI, 8.7%-9.3%])., Conclusions and Relevance: In this population-based cohort study, individuals who experienced intergenerational welfare contact represented one-third of the population aged 11 to 20 years. Compared with individuals with parent-only welfare contact, individuals with intergenerational welfare contact were more disadvantaged at birth and had 78% higher hospitalization rates from age 11 to 20 years, accounting for more than half of all hospitalizations. Frequent hospitalization causes were injuries, mental health, and pregnancy. This study provides the policy-relevant estimate for what it could mean to break cycles of disadvantage for reducing hospital burden.

Objective: We described development, health and justice system outcomes for children in contact with child protection and public housing., Design: Descriptive analysis of outcomes for children known to child protection who also had contact with public housing drawn from the South Australian (SA) Better Evidence Better Outcomes Linked Data (BEBOLD) platform., Setting: The BEBOLD platform holds linked administrative records collected by government agencies for whole-population successive birth cohorts in SA beginning in 1999., Participants: This study included data from birth registrations, perinatal, child protection, public housing, hospital, emergency department, early education and youth justice for all SA children born 1999-2013 and followed until 2016. The base population notified at least once to child protection was n=67 454., Primary Outcome Measure: Contact with the public housing system., Secondary Outcome Measures: Hospitalisations and emergency department presentations before age 5, and early education at age 5, and youth justice contact before age 17., Results: More than 60% of children with at least one notification to child protection had contact with public housing, and 60.2% of those known to both systems were known to housing first. Children known to both systems experienced more emergency department and hospitalisation contacts, greater developmental vulnerability and were about six times more likely to have youth justice system contact., Conclusions: There is substantial overlap between involvement with child protection and public housing in SA. Those children are more likely to face a life trajectory characterised by greater contact with the health system, greater early life developmental vulnerability and greater contact with the criminal justice system. Ensuring the highest quality of supportive early life infrastructure for families in public housing may contribute to prevention of contact with child protection and better life trajectories for children., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Low Apgar scores are associated with neonatal morbidity and mortality, but effects of Apgar scores of 0-5, 6, 7, 8 and 9 (compared with 10) on longer-term neurodevelopmental outcomes are less clear., Aim: To examine the associations between Apgar scores of 0-5, 6, 7, 8 and 9 (compared with 10) and children's educational outcomes as measured by the Australian National Assessment Program-Literacy and Numeracy (NAPLAN) tests at age eight., Materials and Methods: We merged perinatal data including all children born in South Australia from 1999 to 2008 with school assessment data (NAPLAN). School assessments included five learning areas (domains)-reading, writing, spelling, grammar and numeracy. Each domain was categorised according to performing at or below National Minimum Standards (≤NMS). Effects were estimated using Augmented Inverse Probability Weighting (AIPW) accounting for a range of maternal, perinatal and sociodemographic characteristics., Results: Risk differences comparing five-minute Apgar scores of 0-5 with Apgar scores of 10 for children performing ≤NMS for each domain were: reading (0.07 (95% CI -0.16 to 0.29)), writing (0.27 (95% CI -0.14 to 0.68)), spelling (0.15 (95% CI -0.10 to 0.40)), grammar (0.04 (95% CI -0.21 to 0.29)) and numeracy (0.21 (95% CI -0.04 to 0.45)). Risk differences for children performing ≤NMS were also evident when Apgar score of 6 was compared with Apgar score of 10., Conclusions: Children with five-minute Apgar scores of 0-5 and 6, compared with Apgar score of 10, are at higher risk of scoring at/below the NMS on the NAPLAN assessments at eight years., (© 2020 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Aim: To quantify the frequency of emergency department (ED) presentations and profile the socio-demographic, health and presentation characteristics of paediatric ED frequent presenters., Methods: A population-based data linkage study of 55 921 children in the South Australian Early Childhood Data Project aged 0-12 years with 100 976 presentations to public hospital EDs in South Australia. For each child, the total number of recurrent ED presentations during a 364-day period post-index presentation was calculated. Frequent presenters were children who experienced ≥4 recurrent ED presentations. We determined the socio-demographic, health and presentation characteristics by number of recurrent presentations., Results: Children with ≥4 recurrent presentations (4.4%) accounted for 15.4% of all paediatric ED presentations and 22.5% of subsequent admissions to hospital during the 12-month study period. Compared to children with no recurrent ED presentation, frequent presenters had higher proportions of socio-economic and health disadvantage at birth. One in two (49.3%) frequent presenters had at least one injury presentation and one (21.3%) in five had at least one presentation related to a chronic condition., Conclusions: Children with ≥4 presentations do not represent the majority of ED users. Nevertheless, they represent a disproportionate burden accounting for 15% of all paediatric ED presentations in a 12-month period. Frequent presenters were characterised by early socio-economic and health disadvantage, and childhood injury. Strategies targeting social disadvantage and childhood injury may reduce the burden of ED presentations., (© 2020 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Background: Policies to increase Australian Indigenous children's participation in preschool aim to reduce developmental inequities between Indigenous and non-Indigenous children. This study aims to understand the benefits of preschool participation by quantifying the association between preschool participation in the year before school and developmental outcomes at age five in Indigenous and non-Indigenous children., Methods: We used data from perinatal, hospital, birth registration and school enrolment records, and the Australian Early Development Census (AEDC), for 7384 Indigenous and 95 104 non-Indigenous children who started school in New South Wales, Australia in 2009/2012. Preschool in the year before school was recorded in the AEDC. The outcome was developmental vulnerability on ≥1 of five AEDC domains, including physical health, emotional maturity, social competence, language/cognitive skills and communication skills/general knowledge., Results: 5051 (71%) Indigenous and 68 998 (74%) non-Indigenous children attended preschool. Among Indigenous children, 33% of preschool attenders and 44% of the home-based care group were vulnerable on ≥1 domains, compared with 17% of preschool attenders and 33% in the home-based care group among non-Indigenous children. In the whole population model, the adjusted risk difference for developmental vulnerability among preschool attenders was -7.9 percentage points (95% CI, -9.8 to -6.1) in non-Indigenous children and -2.8 percentage points (95% CI -4.8 to -0.7) in Indigenous children, compared with Indigenous children in home-based care., Conclusions: Our findings suggest a likely beneficial effect of preschool participation on developmental outcomes, although the magnitude of the benefit was less among Indigenous compared with non-Indigenous children., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Every year more than 200 million children under-five years fail to achieve their full developmental potential in low- and middle-income countries (LMICs). Although women´s empowerment has been associated with improved child health and development outcomes, this is a topic little studied in LMICs. We investigated the associations between women´s empowerment and early childhood development among a sample population of 84537 children aged 36-59 months from national health surveys of 26 African countries., Methods: We used data from Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) ranging from 2010 to 2018. Four developmental domains were assessed among children using the Early Childhood Development Index: literacy-numeracy, physical, learning and socioemotional. Women's empowerment in attitude to violence, social independence and decision-making was evaluated using the SWPER global, a validated survey-based index. We reported effect sizes for each country and a combined estimate of the association. The study covers all countries with surveys in the region and uses a novel approach for measuring women's empowerment, the SWPER., Results: Across all countries, 15.1% of the children were on track in the literacy-numeracy domain, 92.3% in physical, 81.3% in learning and 67.8% in socio-emotional. The odds of a child being on track in literacy-numeracy increased by 34% (odds ratio (OR) = 1.34; 95% confidence interval (CI) = 1.31-1.37), 88% (OR = 1.88; 95% CI = 1.85-1.91) and 34% (OR = 1.34; 95% CI = 1.29-1.39), with a one standard deviation increase in the scores of attitudes to violence, social independence and decision-making domains of empowerment, respectively. No effect of empowerment was observed for the other domains of child development., Conclusions: Our results show a consistent positive effect of empowerment on the literacy-numeracy domain of child development cross-nationally in Africa and this was particularly evident for the social independence domain of the SWPER. Programs and interventions may also consider addressing the reduction of gender inequalities to improve child development., Competing Interests: Competing interests: The authors completed the ICMJE Unified Competing Interest form (available upon request from the corresponding author), and declare no conflicts of interest., (Copyright © 2020 by the Journal of Global Health. All rights reserved.)

Background: To investigate whether time spent in educational activities at 2-3 years and developmental outcomes at school entry differ among children from different socioeconomic backgrounds., Methods: Participants were from the Longitudinal Study of Australian Children (n=4253). Time spent in educational activities was collected using 24-hour time-use diaries. Income was measured using parent self-report. Receptive vocabulary was assessed using the Peabody Picture Vocabulary Test, and problem behaviours were measured by the Strengths and Difficulties Questionnaire. Marginal structural models were used to test whether the effects of educational activities on outcomes differed by income., Results: Children exposed to both <30 min/day in educational activities and being in a low-income household were at greater risk of poorer outcomes at school entry than the simple sum of their independent effects. Compared with children who spent ≥30 min/day in educational activities from high-income households, children who experienced <30 min/day in educational activities from low-income households had a 2.30 (95% CI 1.88 to 2.80) higher risk of having a receptive vocabulary score in the lowest quartile at school entry. The Relative Excess Risk due to Interaction of 0.15 (95% CI -0.38 to 0.67) was greater than 0, indicating a super-additive effect measure modification by income. These patterns were similar for behavioural outcomes., Conclusions: Our findings suggest that if there was an intervention of sufficient dose to increase the amount of time spent in educational activities to at least 30 min/day for children in the lower-income group, the risk of children having sub-optimal receptive vocabulary would be reduced by 45% and the risk of teacher-reported conduct and hyperactivity problems reduced by 67% and 70%, respectively., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

This study aims to demonstrate the use of the tree-based machine learning algorithms to predict the 3- and 5-year disease-specific survival of oral and pharyngeal cancers (OPCs) and compare their performance with the traditional Cox regression. A total of 21,154 individuals diagnosed with OPCs between 2004 and 2009 were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Three tree-based machine learning algorithms (survival tree (ST), random forest (RF) and conditional inference forest (CF)), together with a reference technique (Cox proportional hazard models (Cox)), were used to develop the survival prediction models. To handle the missing values in predictors, we applied the substantive model compatible version of the fully conditional specification imputation approach to the Cox model, whereas we used RF to impute missing data for the ST, RF and CF models. For internal validation, we used 10-fold cross-validation with 50 iterations in the model development datasets. Following this, model performance was evaluated using the C-index, integrated Brier score (IBS) and calibration curves in the test datasets. For predicting the 3-year survival of OPCs with the complete cases, the C-index in the development sets were 0.77 (0.77, 0.77), 0.70 (0.70, 0.70), 0.83 (0.83, 0.84) and 0.83 (0.83, 0.86) for Cox, ST, RF and CF, respectively. Similar results were observed in the 5-year survival prediction models, with C-index for Cox, ST, RF and CF being 0.76 (0.76, 0.76), 0.69 (0.69, 0.70), 0.83 (0.83, 0.83) and 0.85 (0.84, 0.86), respectively, in development datasets. The prediction error curves based on IBS showed a similar pattern for these models. The predictive performance remained unchanged in the analyses with imputed data. Additionally, a free web-based calculator was developed for potential clinical use. In conclusion, compared to Cox regression, ST had a lower and RF and CF had a higher predictive accuracy in predicting the 3- and 5-year OPCs survival using SEER data. The RF and CF algorithms provide non-parametric alternatives to Cox regression to be of clinical use for estimating the survival probability of OPCs patients.

Aims/hypothesis: Evidence of an association between maternal smoking during pregnancy (prenatal smoking) and childhood type 1 diabetes is mixed. Previous studies have been small and potentially biased due to unmeasured confounding. The objectives of this study were to estimate the association between prenatal smoking and childhood type 1 diabetes, assess residual confounding with a negative control design and an E-value analysis, and summarise published effect estimates from a meta-analysis., Methods: This whole-of-population study (births from 1999 to 2013, participants aged ≤15 years) used de-identified linked administrative data from the South Australian Early Childhood Data Project. Type 1 diabetes was diagnosed in 557 children (ICD, tenth edition, Australian Modification [ICD-10-AM] codes: E10, E101-E109) during hospitalisation (2001-2014). Families not given financial assistance for school fees was a negative control outcome. Adjusted Cox proportional HRs were calculated. Analyses were conducted on complete-case (n = 264,542, type 1 diabetes = 442) and imputed (n = 286,058, type 1 diabetes = 557) data. A random-effects meta-analysis was used to summarise the effects of prenatal smoking on type 1 diabetes., Results: Compared with non-smokers, children exposed to maternal smoking only in the first or second half of pregnancy had a 6% higher type 1 diabetes incidence (adjusted HR 1.06 [95% CI 0.73, 1.55]). Type 1 diabetes incidence was 24% lower (adjusted HR 0.76 [95% CI 0.58, 0.99]) among children exposed to consistent prenatal smoking, and 16% lower for exposure to any maternal smoking in pregnancy (adjusted HR 0.84 [95% CI 0.67, 1.08]), compared with the unexposed group. Meta-analytic estimates showed 28-29% lower risk of type 1 diabetes among children exposed to prenatal smoking compared with those not exposed. The negative control outcome analysis indicated residual confounding in the prenatal smoking and type 1 diabetes association. E-value analysis indicated that unmeasured confounding associated with prenatal smoking and childhood type 1 diabetes, with a HR of 1.67, could negate the observed effect., Conclusions/interpretation: Our best estimate from the study is that maternal smoking in pregnancy was associated with 16% lower childhood type 1 diabetes incidence, and some of this effect was due to residual confounding.

Objective: To compare admission rate, cumulative incidence and social distribution of potentially preventable hospitalisations (PPHs) among children according to the current Australian adult definition, and the child definition developed in New Zealand., Design, Setting, Participants: Deidentified, linked public hospital, births registry and perinatal data of children aged 0-10 years born 2002-2012 in South Australia (n=1 91 742)., Main Outcome Measures: PPH admission rates among 0-10 year olds and cumulative incidence by age 5 under the adult and child definitions. Cumulative incidence was assessed across indicators of social and health disadvantage., Results: PPH admission rates among 0-10 year olds were 25.6 (95% CI 25.3 to 25.9) and 59.9 (95% CI 59.5 to 60.4) per 1000 person-years for the adult and child definitions, respectively. Greater absolute differences in admission rates between definitions were observed at younger ages (age <1 difference: 75.6 per 1000 person-years; age 10 difference: 1.4 per 1000 person-years). Cumulative incidence of PPHs among 0-5 year olds was higher under the child (25.0%, 95% CI 24.7 to 25.2) than the adult definition (12.8%, 95% CI 12.6 to 13.0). Higher PPH incidence was associated with social and health disadvantage. Approximately 80% of the difference in admission rate between definitions was due to five conditions., Conclusions: Respiratory conditions and gastroenteritis were key contributors to the higher PPH admission rate and cumulative incidence among children when calculated under the child definition compared to the adult definition. Irrespective of definition, higher PPH cumulative incidence was associated with social and health disadvantage at birth., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: There is evidence that parents from more socioeconomically disadvantaged backgrounds engage in fewer verbal interactions with their child than more advantaged parents. This leads to the so-called, '30 million-word gap'. This study aims to investigate the number of words children hear and the number of vocalizations children produce in their first year of life and examines whether these aspects of the early language home environment differ by maternal education., Methods: Mothers were recruited into a five-year prospective cohort study and categorized into either high or low maternal education groups. Data was derived from the first two waves of the study, when the children were six and twelve months old. At both waves, children were involved in day-long audio recordings using the Language Environment Analysis software that provided automatic counts of adult words spoken to the child, child vocalizations and conversational turns. Descriptive results are presented by maternal education groups., Results: There was large variation within each maternal education group, with the number of adult words spoken to the child ranging from 2958 to 39,583 at six months and 4389 to 45,849 at twelve months. There were no meaningful differences between adult words, child vocalizations or conversational turns across maternal education groups at either wave of data collection., Conclusions: These results show that a word gap related to maternal education is not apparent up to twelve months of age. The large variability among both maternal education groups suggests that universal interventions that encourage all parents to talk more to their child may be more appropriate than interventions targeted towards disadvantaged families during the first year of life.

Avin et al (2005) showed that, in the presence of exposure-induced mediator-outcome confounding, decomposing the total causal effect (TCE) using standard conditional exchangeability assumptions is not possible even under a nonparametric structural equation model with all confounders observed. Subsequent research has investigated the assumptions required for such a decomposition to be identifiable and estimable from observed data. One approach was proposed by VanderWeele et al (2014). They decomposed the TCE under three different scenarios: (1) treating the mediator and the exposure-induced confounder as joint mediators; (2) generating path-specific effects albeit without distinguishing between multiple distinct paths through the exposure-induced confounder; and (3) using so-called randomised interventional analogues where sampling values from the distribution of the mediator within the levels of the exposure effectively marginalises over the exposure-induced confounder. In this paper, we extend their approach to the case where there are multiple mediators that do not influence each other directly but which are all influenced by an exposure-induced mediator-outcome confounder. We provide a motivating example and results from a simulation study based on from our work in dental epidemiology featuring the 1982 Pelotas Birth Cohort in Brazil., (© 2019 John Wiley & Sons, Ltd.)

Objective: To examine the changing temporal association between caesarean birth and neonatal death within the context of Ethiopia from 2000 to 2016., Design: Secondary analysis of Ethiopian Demographic and Health Surveys., Setting: All administrative regions of Ethiopia with surveys conducted in 2000, 2005, 2011 and 2016., Participants: Women aged 15-49 years with a live birth during the 5 years preceding the survey., Main Outcome Measures: We analysed the association between caesarean birth and neonatal death using log-Poisson regression models for each survey adjusted for potential confounders. We then applied the 'Three Delays Model' to 2016 survey to provide an interpretation of the association between caesarean birth and neonatal death in Ethiopia., Results: The adjusted prevalence ratios (aPR) for neonatal death among neonates born via caesarean section versus vaginal birth increased over time, from 0.95 (95% CI: 0.29 to 3.19) in 2000 to 2.81 (95% CI: 1.11 to 7.13) in 2016. The association between caesarean birth and neonatal death was stronger among rural women (aPR (95% CI) 3.43 (1.22 to 9.67)) and among women from the lowest quintile of household wealth (aPR (95% CI) 7.01 (0.92 to 53.36)) in 2016. Aggregate-level analysis revealed that an increased caesarean section rates were correlated with a decreased proportion of neonatal deaths., Conclusions: A naïve interpretation of the changing temporal association between caesarean birth and neonatal death from 2000 to 2016 is that caesarean section is increasingly associated with neonatal death. However, the changing temporal association reflects improvements in health service coverage and secular shifts in the characteristics of Ethiopian women undergoing caesarean section after complicated labour or severe foetal compromise., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Vaginal instrumental delivery is a common obstetrical intervention, but its effect on children's later development is not well known., Aims: To determine if vaginal instrumental delivery is associated with adverse neurodevelopment as measured by school achievement., Material and Methods: We performed a whole-of-population study involving linkage of routinely collected perinatal data with school assessments among children born in South Australia from 1999 to 2008. Participants were singleton children born by forceps (n = 5494), ventouse (n = 6988), or normal delivery (n = 80 803). School achievement was measured through performance on the National Assessment Program in Literacy and Numeracy (NAPLAN), at around eight years of age. This assessment involved five domains and scores were categorised according to performing at or above National Minimum Standards (NMS). Effects of instrumental versus normal vaginal delivery were analysed via augmented inverse probability weighting (AIPW), taking into account a variety of maternal, perinatal and sociodemographic characteristics., Results: In unadjusted analyses, instrumental delivery was not associated with poor NAPLAN scores. AIPW analyses also suggested that instrumental delivery had minimal adverse effect on NAPLAN scores, with the largest difference being lower spelling scores among forceps-delivered children (-0.022 (95% CI -0.0053-0.009)) compared with spontaneous vaginal births. The findings were consistent among exploratory subgroup analyses involving births in the absence of prolonged labour, with APGAR ≥ 9, and among normotensive and non-diabetic mothers., Conclusion: In singleton children born at term, instrumental delivery does not have an adverse effect on neurodevelopment as measured by NAPLAN performance at age eight., (© 2019 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Objective: To provide insights into complexities of seeking access to state and federal cross-jurisdictional data for linkage with the Australian Childhood Immunisation Register (ACIR). We provide recommendations for improving access and receipt of linked datasets involving Australian Government-administered data., Methods: We describe requirements for linking eleven federal and state data sources to establish a national linked dataset for safety evaluation of vaccines. The required data linkage methodology for integrating cross-jurisdictional data sources is also described., Results: Extensive negotiation was required with 18 different agencies for 21 separate authorisations and 12 ethics approvals. Three variations of the 'best practice' linkage model were implemented. Australian Government approval requests spanned nearly four years from initial request for data, with a further year before ACIR data transfer to the linkage agency., Conclusions: Integration of immunisation registers with other data collections is achievable in Australia but infeasible for routine and rapid identification of vaccine safety concerns. Lengthy authorisation requirements, convoluted disparate application processes and inconsistencies in data supplied all contribute to delayed data availability. Implications for public health: Delayed data access for safety surveillance prevents timely epidemiological reviews. Poor responsiveness to safety concerns may erode public confidence, compromising effectiveness of vaccination programs through reduced participation., (© 2019 The Authors.)

Objective: To examine the impact of caesarean section on breastfeeding indicators-early initiation of breastfeeding, exclusive breastfeeding under 6 months and children ever breastfed (at least once)-in sub-Saharan Africa., Design: Secondary analysis of Demographic and Health Surveys (DHS)., Setting: Thirty-three low-income and middle-income countries with a survey conducted between 2010 and 2017/2018., Participants: Women aged 15-49 years with a singleton live last birth during the 2 years preceding the survey., Main Outcome Measures: We analysed the DHS data to examine the impact of caesarean section on breastfeeding indicators using the modified Poisson regression models for each country adjusted for potential confounders. For each breastfeeding indicator, the within-country adjusted prevalence ratios (aPR) were pooled in random-effects meta-analysis., Results: The within-country analyses showed, compared with vaginal birth, caesarean section was associated with aPR for early initiation of breastfeeding that ranged from 0.24 (95% CI 0.17 to 0.33) in Tanzania to 0.89 (95% CI 0.78 to 1.00) in South Africa. The aPR for exclusive breastfeeding under 6 months ranged from 0.58 (95% CI 0.34 to 0.98) in Angola to 1.93 (95% CI 0.46 to 8.10) in Cote d'Ivoire, while the aPR for children ever breastfed ranged from 0.91 (95% CI 0.82 to 1.02) in Gabon to 1.02 (95% CI 0.99 to 1.04) in Gambia. The meta-analysis showed caesarean section was associated with a 46% lower prevalence of early initiation of breastfeeding (pooled aPR, 0.54 (95% CI 0.48 to 0.60)). However, meta-analysis indicated little association with exclusive breastfeeding under 6 months (pooled aPR, 0.94 (95% CI 0.88 to 1.01)) and children ever breastfed (pooled aPR, 0.98 (95% CI 0.98 to 0.99)) among caesarean versus vaginally born children., Conclusions: Caesarean section had a negative influence on early initiation of breastfeeding but showed little difference in exclusive breastfeeding under 6 months and children ever breastfed in sub-Saharan Africa., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: To evaluate the effect of a 2-year post-natal nurse home visiting (NHV) programme delivered in routine clinical practice to socially disadvantaged mothers on children's development at 5 years., Methods: The study was a natural experiment resulting from progressive rollout of NHV (2008-2012). Children of three groups of mothers, all eligible for NHV, were compared: (i) mothers receiving NHV in a metropolitan region (n = 197); (ii) mothers in a rural region prior to NHV being available (n = 94); and (iii) mothers receiving NHV in the rural region after it became available (n = 84). Outcomes were evaluated using the Child Behaviour Checklist, Child-Parent Relationships Scale, Behaviour Inventory of Executive Functioning and Australian Early Development Index., Results: Analyses were conducted using augmented inverse probability weighting accounting for differences in the groups' baseline characteristics. While some differences were observed in the range of 8-12% between the intervention and comparison groups (albeit with wide confidence intervals, e.g. 31% less likely to 4% more likely to be experiencing poor outcomes). For the majority of outcomes, however, there were no differences observed between the intervention and comparison groups., Conclusions: Post-natal NHV provided as a part of routine service delivery did not improve children's outcomes at 5 years. It may be that in the Australian context a NHV intervention, as offered in this study, does not provide additional benefits over standard care., (© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Objective: The objective of this study was to assess the prevalence and sociodemographic characteristics of cesarean section in Ethiopia., Methods: We used data collected for Ethiopia Demographic and Health Surveys (DHS) conducted in 2000, 2005, 2011, and 2016. A two-stage, stratified, clustered random sampling design was used to gather information from women who gave birth within the 5-year period before each of the surveys. We analyzed the data to identify sociodemographic characteristics associated with cesarean section using log-Poisson regression models., Results: The national cesarean section rate increased from 0.7% in 2000 to 1.9% in 2016, with increases across seven of the eleven administrative regions of Ethiopia. Addis Ababa had the highest cesarean section rate (21.4%) in 2016 and the greatest increase since 2000. In the adjusted analysis, women who gave birth in private health facility had a 78.0% higher risk of cesarean section (adjusted prevalence ratio (aPR) (95% CI) 1.78 (1.22, 2.58)) compared with women who gave birth in public health facility. Having four or more births was associated with a lower risk of cesarean section compared with first births (aPR (95% CI) 0.36 (0.16, 0.79))., Conclusions: The Ethiopian national cesarean section rate is about 2%, but the rate varies widely among administrative regions, suggesting unequal access. Cesarean sections were highest among urban mothers, first births, births to women with higher education, and births to women from the richest quintile of household wealth.

Objectives: To quantify emergency department (ED) presentations by individuals within vulnerable populations compared with other adults and the extent to which these are potentially preventable., Design: Period prevalence study from 2005-2006 to 2010-2011., Setting: Person-linked, ED administrative records for public hospitals in South Australia., Participants: Adults aged 20 or more in South Australia's metropolitan area presenting to ED and categorised as Refugee and Asylum Seeker Countries of birth (RASC); Aboriginal; those aged 75 years or more; or All others., Main Outcome Measures: Unadjusted rates of ambulatory care sensitive condition (ACSC), general practitioner (GP)-type presentations and associated direct ED costs among mutually exclusive groups of individuals., Results: Disparity between RASC and All others was greatest for GP-type presentations (423.7 and 240.1 persons per 1000 population, respectively) with excess costs of $A106 573 (95% CI $A98 775 to $A114 371) per 1000 population. Aboriginal had highest acute ACSC presenter rates (125.8 against 51.6 per 1000 population) with twice the risk of multiple presentations and $A108 701 (95% CI $A374 to $A123 029) per 1000 excess costs. Those aged 75 or more had highest chronic ACSC presenter rates (119.7vs21.1 per 1000), threefold risk of further presentations (incidence rate ratio 3.20, 95% CI 3.14 to 3.26) and excess cost of $A385 (95% CI $A178 160 to $A184 609) per 1000 population., Conclusions: Vulnerable groups had excess ED presentations for a range of issues potentially better addressed through primary and community healthcare. The observed differences suggest inequities in the uptake of effective primary and community care and represent a source of excess cost to the public hospital system., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Postnatal depression adversely affects many mothers and infants with good evidence that caregiving difficulties associated with depressive symptoms play a key role in later adverse childhood outcomes. In many countries, there is only limited support available for women who experience symptoms of depression during the postnatal period, particularly those experiencing subthreshold symptom levels. Furthermore, mental health services and community family health services in many countries tend to focus primarily on providing help for depressive symptoms or maternal caregiving, respectively, despite these problems commonly being comorbid. Group-based nurse-led interventions delivered over the Web through mobile phone "apps" have the potential to be a cost-effective method of providing a large number of mothers with easy access to integrated support for both maternal depressive symptoms and caregiving difficulties., Objective: This paper describes the protocol for a pragmatic randomized controlled trial of a 4-month group-based nurse-led intervention delivered over the Web when infants were 2-6 months. The primary aims of the trial are to determine whether the intervention (1) reduces levels of maternal depressive symptoms and (2) improves the quality of maternal caregiving when infants are 8-12 months of age., Methods: The trial aimed to recruit and randomize 160 mothers of infants aged 2-8 weeks to either the intervention (eMums plus) or standard care. Assessments were completed when infants were aged 1-2 (preintervention), 8, and 12 months. The primary outcomes were the level of maternal depressive symptoms and the quality of maternal caregiving assessed when infants were aged 12 months. The intervention provided specific support for problems with mood and problems with caregiving. The intervention was delivered by community health nurses as a part of routine service delivery to mothers via a mobile phone app., Results: Participant recruitment was carried out from March to July 2017. Follow-up data collection was completed in mid-2018. Data analysis has commenced., Conclusions: In the past, many mothers participated in nurse-led face-to-face groups postnatally. However, mothers' groups held in clinics can be difficult for busy mothers to attend. The eMums intervention was delivered over the Web by nurses, allowing easy access by mothers early in an infant's life. The intervention was evaluated while delivered as part of the routine service practice by community child health nurses. The advantage of evaluating the effectiveness of the intervention in the routine service practice is that if it is found to be effective, it can be more easily adopted by the service provider than if it had been assessed in an efficacy trial., International Registered Report Identifier (irrid): RR1-10.2196/11549., (©Alyssa CP Sawyer, Amy L Kaim, Christy E Reece, Denise McDonald, Huynh-Nhu Le, Jennifer Clark, John W Lynch, Michael G Sawyer. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 16.01.2019.)

Objective: To determine whether differences in combination DTaP vaccine types at 2, 4 and 6 months of age were associated with mortality (all-cause or non-specific), within 30 days of vaccination., Design: Observational nationwide cohort study., Setting: Linked population data from the Australian Childhood Immunisation Register and National Death Index., Participants: Australian infants administered a combination trivalent, quadrivalent or hexavalent DTaP vaccine (DTaP types) between January 1999 and December 2010 at 2, 4 and 6 months as part of the primary vaccination series. The study population included 2.9, 2.6, & 2.3 million children in the 2, 4 and 6 month vaccine cohorts, respectively., Main Outcome Measures: Infants were evaluated for the primary outcome of all-cause mortality within 30 days. A secondary outcome was non-specific mortality (unknown cause of death) within 30 days of vaccination. Non-specific mortality was defined as underlying or other cause of death codes, R95 'Sudden infant death syndrome', R96 'Other sudden death, cause unknown', R98 'Unattended death', R99 'Other ill-defined and unspecified cause of mortality' or where no cause of death was recorded., Results: The rate of 30 day all-cause mortality was low and declined from 127.4 to 59.3 deaths per 100,000 person-years between 2 and 6 month cohorts. When compared with trivalent DTaP vaccines, no elevated risk in all-cause or non-specific mortality was seen with any quadrivalent or hexavalent DTaP vaccines, for any cohort., Conclusion: Use of routine DTaP combination vaccines with differing disease antigens administered during the first six months of life is not associated with infant mortality., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

In the workplace, employees must choose what personal information they share with others. Employees with concealable stigmas (e.g., sexual orientation, mental illness, and certain religious beliefs) face the added pressure of having to carefully manage information about a potential social liability. Yet it remains unclear how managing a concealable stigma may influence colleagues' perceptions and reactions. Using theory about impression management and social cognition, we investigated how employees strategically manage information about their concealable stigmas and the impact of these behaviors on colleague reactions. Based on a multiple-time, multiple-source study of 196 employees, we compared 4 specific strategies for managing concealable stigmas: assimilating, decategorizing, integrating, and confirming. Consistent with our theorizing, these strategies had unique effects in how they influenced the treatment that an employee received from others. These findings have implications for research about stigmas, social cognition, and impression management, as well as for practices focused on creating diverse and supportive work environments. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Success in school and the labour market relies on more than high intelligence. Associations between "non-cognitive" skills in childhood, such as attention, self-regulation, and perseverance, and later outcomes have been widely investigated. In a systematic review of this literature, we screened 9553 publications, reviewed 554 eligible publications, and interpreted results from 222 better quality publications. Better quality publications comprised randomised experimental and quasi-experimental studies (EQIs), and observational studies that made reasonable attempts to control confounding. For academic achievement outcomes there were 26 EQI publications but only 14 were available for meta-analysis with effects ranging from 0.16 to 0.37SD. However, within sub-domains effects were heterogeneous. The 95% prediction interval for literacy was consistent with negative, null and positive effects (-0.13 to 0.79). Similarly heterogeneous findings were observed for psychosocial, cognitive and language, and health outcomes. Funnel plots of EQIs and observational studies showed asymmetric distributions and potential for small study bias. There is some evidence that non-cognitive skills associate with improved outcomes. However, there is potential for small study and publication bias that may over-estimate true effects, and heterogeneity of effect estimates spanned negative, null and positive effects. The quality of evidence from EQIs under-pinning this field is lower than optimal and more than a third of observational studies made little or no attempt to control confounding. Interventions designed to develop children's non-cognitive skills could potentially improve outcomes. The inter-disciplinary researchers interested in these skills should take a more strategic and rigorous approach to determine which interventions are most effective., Competing Interests: Competing interests The authors declare no competing interests.

Introduction: Traumatic injury is a leading contributor to the global disease burden in children and adolescents, but methods used to estimate burden do not account for differences in patterns of injury and recovery between children and adults. A lack of empirical data on postinjury disability in children has limited capacity to derive valid disability weights and describe the long-term individual and societal impacts of injury in the early part of life. The aim of this study is to establish valid estimates of the burden of non-fatal injury in children and adolescents., Methods and Analysis: Five longitudinal studies of paediatric injury survivors <18 years at the time of injury (Australia, Canada, UK and USA) and two whole-of-population linked administrative data paediatric studies (Australia and Wales) will be analysed over a 3-year period commencing 2018. Meta-analysis of deidentified patient-level data (n≈2,600) from five injury-specific longitudinal studies (Victorian State Trauma Registry; Victorian Orthopaedic Trauma Outcomes Registry; UK Burden of Injury; British Columbia Children's Hospital Longitudinal Injury Outcomes; Children's Health After Injury) and >1 million children from two whole-of-population cohorts (South Australian Early Childhood Data Project and Wales Electronic Cohort for Children). Systematic analysis of pooled injury-specific cohort data using a variety of statistical techniques, and parallel analysis of whole-of-population cohorts, will be used to develop estimated disability weights for years lost due to disability, establish appropriate injury classifications and explore factors influencing recovery., Ethics and Dissemination: The project was approved by the Monash University Human Research Ethics Committee project number 12 311. Results of this study will be submitted for publication in internationally peer-reviewed journals. The findings from this project have the capacity to improve the validity of paediatric injury burden measurements in future local and global burden of disease studies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Academic achievement varies according to gestational age but it is unclear whether achievement varies within 'term' (37-41 weeks gestation) or for 'post-term' births (≥42 weeks). We examined gestational age from preterm to post-term against a national minimum standard for academic achievement in population data., Design: Literacy and numeracy data of 8-year-old South Australian grade 3 children in 2008-2010 were linked to routinely collected perinatal data (N=28 155)., Results: Longer gestation from 23 to 45 weeks was associated with lower risk of poor literacy and numeracy. Adjusted relative risks for being at or below national minimum standard ranged from 1.12 (95% CI 1.03 to 1.22) for 'late preterm' (32-36 weeks) for numeracy, to 1.84 (95% CI 1.48 to 2.30) for 'early preterm' (23-31 weeks) for writing. Within term, every additional week of gestational age was associated with small decreased risks of poor literacy and numeracy (eg, relative risks for poor numeracy 1.10, 95% CI 1.01 to 1.20 for 37 weeks). Population-attributable fractions for poor achievement were highest among children born 'early term' (37-39 weeks) due to their higher population prevalence., Conclusions: Shorter gestational age was associated with increased risk of poor literacy/numeracy. While children born 'early term' experience only between 1% and 10% increased risk, they constitute a larger proportion of children with poor educational achievement than preterm children, and thus are important to consider for supportive interventions to improve population-level achievement gains. The seemingly lower risk for post-term children showed large error estimates and warrants further consideration within even larger populations., Competing Interests: Competing interests: JWL is funded by a National Health and Medical Research Council of Australia Partnership Project Grant (1056888) and Centre of Research Excellence (1099422)., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: The Sustainable Development Goals strongly focus on equity. Goal 5 explicitly aims to empower all women and girls, reinforcing the need to have a reliable indicator to track progress. Our objective was to develop a novel women's empowerment indicator from widely available data sources, broadening opportunities for monitoring and research on women's empowerment., Methods: We used Demographic and Health Survey data from 34 African countries, targeting currently partnered women. We identified items related to women's empowerment present in most surveys, and used principal component analysis to extract the components. We carried out a convergent validation process using coverage of three health interventions as outcomes; and an external validation process by analysing correlations with the Gender Development Index., Findings: 15 items related to women's empowerment were selected. We retained three components (50% of total variation) which, after rotation, were identified as three dimensions of empowerment: attitude to violence, social independence, and decision making. All dimensions had moderate to high correlation with the Gender Development Index. Social independence was associated with higher coverage of maternal and child interventions; attitude to violence and decision making were more consistently associated with the use of modern contraception., Interpretation: The index, named Survey-based Women's emPowERment index (SWPER), has potential to widen the research on women's empowerment and to give a better estimate of its effect on health interventions and outcomes. It allows within-country and between-country comparison, as well as time trend analysis, which no other survey-based index provides., Funding: Bill & Melinda Gates Foundation., (Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Internet-based interventions moderated by community nurses have the potential to improve support offered to new mothers, many of whom now make extensive use of the Internet to obtain information about infant care. However, evidence from population-based randomized controlled trials is lacking., Objective: The aim of this study was to test the non-inferiority of outcomes for mothers and infants who received a clinic-based postnatal health check plus nurse-moderated, Internet-based group support when infants were aged 1-7 months as compared with outcomes for those who received standard care consisting of postnatal home-based support provided by a community nurse., Methods: The design of the study was a pragmatic, preference, non-inferiority randomized control trial. Participants were recruited from mothers contacted for their postnatal health check, which is offered to all mothers in South Australia. Mothers were assigned either (1) on the basis of their preference to clinic+Internet or home-based support groups (n=328), or (2) randomly assigned to clinic+Internet or home-based groups if they declared no strong preference (n=491). The overall response rate was 44.8% (819/1827). The primary outcome was parenting self-competence, as measured by the Parenting Stress Index (PSI) Competence subscale, and the Karitane Parenting Confidence Scale scores. Secondary outcome measures included PSI Isolation, Interpersonal Support Evaluation List-Short Form, Maternal Support Scale, Ages and Stages Questionnaire-Social-Emotional and MacArthur Communicative Development Inventory (MCDI) scores. Assessments were completed offline via self-assessment questionnaires at enrolment (mean child age=4.1 weeks, SD 1.3) and again when infants were aged 9, 15, and 21 months., Results: Generalized estimating equations adjusting for post-randomization baseline imbalances showed that differences in outcomes between mothers in the clinic+Internet and home-based support groups did not exceed the pre-specified margin of inferiority (0.25 of a SD) on any outcome measure at any follow-up assessment, with the exception of MCDI scores assessing children's language development at 21 months for randomized mothers, and PSI Isolation scores at 9 months for preference mothers., Conclusion: Maternal and child outcomes from a clinic-based postnatal health check plus nurse-moderated Internet-based support were not inferior to those achieved by a universal home-based postnatal support program. Postnatal maternal and infant support using the Internet is a promising alternative to home-based universal support programs., Trial Registration: Australian New Zealand Clinical Trials Registry Number (ANZCTR): ACTRN12613000204741; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363712&isReview=true (Archived by WebCite at http://www.webcitation.org/6rZeCJ3k1)., (©Michael G Sawyer, Christy E Reece, Kerrie Bowering, Debra Jeffs, Alyssa C P Sawyer, Murthy Mittinty, John W Lynch. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 24.07.2017.)

Background: Associations of parental feeding techniques with adiposity are mixed and largely rely on cross-sectional studies. We examined associations between parental food-choice control and using food to soothe at 3.5 years on adiposity at 7 and 15 years., Methods: Participants were from the Avon Longitudinal Study of Parents and Children (n = 7312). Food-choice control was assessed using the item 'how much choice do you allow him/her in deciding what foods he eats at meals?'. Use of food to soothe was reported by mothers on the item 'how often do you use sweets or other foods to stop his/her crying or fussing?'. BMI at 7 and 15 years was converted to sex- and age-adjusted z-scores. Fat mass was assessed at 15 years using dual energy X-ray absorptiometry., Results: In fully-adjusted models, children given the least choice had 0.08 lower BMI z-score at age 7 years and 0.12 lower BMI z-score,1.46 kg lower fat mass at 15 years than children with the most choices. There was no evidence of an association between using food to soothe and adiposity., Conclusions: Contrary to some studies, higher parental control over food choice was associated with lower adiposity, but use of food to soothe was not associated with adiposity at ages 7 and 15., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: South Korea has experienced rapid economic development and a substantial increase in life expectancy in an extremely short period. Whether this rapid development has been able to adequately address inequalities in health in South Korea may have important policy implications. This paper explores long-term trends in inequalities in mortality related to education in South Korea between 1970 and 2010., Methods: We used secondary data on population size and deaths in 1970 and 1980 from a previously published study, and census and death certificate data from Statistics Korea from 1990, 1995, 2000, 2005 and 2010. Trends in age-standardised mortality rates for men and women aged 25-64 according to education, as well as the rate ratio (RR), rate difference (RD), relative index of inequality (RII) and slope index of inequality (SII), were examined over the period 1970-2010., Results: Despite overall mortality declines of 70-80% in the past 4 decades, educational inequalities have increased or been stagnant. There was minimal decline in mortality since 1970 in South Koreans with only a primary or lower level of education. The RR and RD between tertiary education and primary or lower education increased over the study period, while the RII and the SII in both genders remained stable., Conclusions: The South Korean experience over the past 40 years suggests that plummeting mortality rates and huge advances in education at the population level do not translate into reduced educational inequalities in mortality., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Socio-economic inequalities in academic achievement emerge early in life and are observed across the globe. Cognitive ability and "non-cognitive" attributes (such as self-regulation) are the focus of many early years' interventions. Despite this, little research has compared the contributions of early cognitive and self-regulation abilities as separate pathways to inequalities in academic achievement. We examined this in two nationally representative cohorts in the UK (Millennium Cohort Study, n = 11,168; 61% original cohort) and Australia (LSAC, n = 3028; 59% original cohort). An effect decomposition method was used to examine the pathways from socio-economic disadvantage (in infancy) to two academic outcomes: 'low' maths and literacy scores (based on bottom quintile) at age 7-9 years. Risk ratios (RRs, and bootstrap 95% confidence intervals) were estimated with binary regression for each pathway of interest: the 'direct effect' of socio-economic disadvantage on academic achievement (not acting through self-regulation and cognitive ability in early childhood), and the 'indirect effects' of socio-economic disadvantage acting via self-regulation and cognitive ability (separately). Analyses were adjusted for baseline and intermediate confounding. Children from less advantaged families were up to twice as likely to be in the lowest quintile of maths and literacy scores. Around two-thirds of this elevated risk was 'direct' and the majority of the remainder was mediated by early cognitive ability and not self-regulation. For example in LSAC: the RR for the direct pathway from socio-economic disadvantage to poor maths scores was 1.46 (95% CI: 1.17-1.79). The indirect effect of socio-economic disadvantage through cognitive ability (RR = 1.13 [1.06-1.22]) was larger than the indirect effect through self-regulation (1.05 [1.01-1.11]). Similar patterns were observed for both outcomes and in both cohorts. Policies to alleviate social inequality (e.g. child poverty reduction) remain important for closing the academic achievement gap. Early interventions to improve cognitive ability (rather than self-regulation) also hold potential for reducing inequalities in children's academic outcomes., (Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: To identify factors predicting use, adherence and attrition with a nurse-moderated web-based group intervention designed to support mothers of infants aged 0-6 months., Design: 9-Month observational study., Setting: Community maternal and child health service., Participants: 240 mothers attending initial postnatal health checks at community clinics who were randomly assigned to the intervention arm of a pragmatic preference randomised trial (total randomised controlled trial, n=819; response rate=45%)., Intervention: In the first week (phase I), mothers were assisted with their first website login by a research assistant. In weeks 2-7 (phase II), mothers participated in the web-based intervention with an expectation of weekly logins. The web-based intervention was comparable to traditional face-to-face new mothers' groups. During weeks 8-26 (phase III), mothers participated in an extended programme at a frequency of their choosing., Primary Outcome Measures: Number of logins and posted messages. Standard self-report measures assessed maternal demographic and psychosocial characteristics., Results: In phase II, the median number of logins was 9 logins (IQR=1-25), and in phase III, it was 10 logins (IQR=0-39). Incident risk ratios from multivariable analyses indicated that compared to mothers with the lowest third of logins in phase I, those with the highest third had 6.43 times as many logins in phase II and 7.14 times in phase III. Fifty per cent of mothers logged-in at least once every 30 days for 147 days after phase I and 44% logged-in at least once in the last 30 days of the intervention. Frequency of logins during phase I was a stronger predictor of mothers' level of engagement with the intervention than their demographic and psychosocial characteristics., Conclusions: Mothers' early use of web-based interventions could be employed to customise engagement protocols to the circumstances of individual mothers with the aim of improving adherence and reducing attrition with web-based interventions., Trial Registration Number: ACTRN12613000204741; Results., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Caesarean birth is one of the most frequently performed major obstetrical interventions. Although there is speculation that caesarean at term may have consequences for children's later health and development, longer-term studies are needed., Aim: We aimed to evaluate risks to poor school achievement among children born by caesarean section compared with spontaneous vaginal birth., Materials and Methods: This population-based observational study involved linkage of routinely collected perinatal data with children's school assessments. Perinatal data included all children born in South Australia from 1999 to 2005. Participants were children born by elective caesarean (exposed, n = 650) or vaginal birth (unexposed, n = 2959), to women who previously had a caesarean delivery. School assessments were reported via a standardised national assessment program for children attending grade three (at ~eight years of age). Assessments included reading, writing, spelling, grammar and numeracy and were categorised according to performing at above or ≤National Minimum Standards (NMS). Statistical analyses involved augmented inverse probability weighting (apiw) and accounted for a range of maternal, perinatal and sociodemographic characteristics., Results: Children performing ≤NMS for vaginal birth versus caesarean section were as follows: reading 144/640 (23%) and 688/2921 (24%), writing 69/636(11%) and 351/2917 (12%), spelling 128/646 (20%) and 684/2937 (23%), grammar 132/646 (20%) and 655/2937 (22%), and numeracy 151/634 (24%) and 729/2922 (25%). Both the raw data and the aipw analyses suggested little differences in school achievement between children born by caesarean versus vaginal birth., Conclusion: Analyses that carefully controlled for a wide range of confounders suggest that caesarean section does not increase the risk of poor school outcomes at age eight., (© 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Cognitive development might be influenced by parenting practices and child temperament. We examined whether the associations between parental warmth, control and intelligence quotient (IQ) may be heightened among children in difficult temperament. Participants were from the Avon Longitudinal Study of Parents and Children (n = 7,044). Temperament at 6 months was measured using the Revised Infant Temperament Questionnaire and classified into 'easy' and 'difficult'. Parental warmth and control was measured at 24 to 47 months and both were classified into 2 groups using latent class analyses. IQ was measured at 8 years using the Wechsler Intelligence Scale for Children and dichotomized (<85 and ≥85) for analyzing effect-measure modification by temperament. Linear regression adjusted for multiple confounders and temperament showed lower parental warmth was weakly associated with lower IQ score [β = -0.52 (95% CI 1.26, 0.21)], and higher parental control was associated with lower IQ score [β = -2.21 (-2.95, -1.48)]. Stratification by temperament showed no increased risk of having low IQ in temperamentally difficult children [risk ratio (RR) = 0.97 95% CI 0.65, 1.45)] but an increased risk among temperamentally easy children (RR = 1.12 95% CI 0.95, 1.32) when parental warmth was low. There was also no increased risk of having low IQ in temperamentally difficult children (RR = 1.02 95% CI 0.69, 1.53) but there was an increased risk among temperamentally easy children (RR = 1.30 95% CI 1.11, 1.53) when parental control was high. For both parental warmth and control, there was some evidence of negative effect-measure modification by temperament on the risk-difference scale and the risk-ratio scale. It may be more appropriate to provide parenting interventions as a universal program rather than targeting children with difficult temperament.

The aim of this study was to determine whether the extent of improvement in self-regulation achieved between ages 4 and 6 years is associated with the level of behavioral problems later in childhood. Participants were 4-year-old children (n = 510) attending preschools in South Australia. Children's level of self-regulation was assessed using the parent-completed Devereux Early Childhood Assessment when children were aged 4, 5, and 6. Children's level of behavioral problems was assessed using total, internalizing, and externalizing scores on parent- and teacher-rated Strengths and Difficulties Questionnaires (SDQs) when children were 6 years old. Random effects regression was used to describe the changes to children's self-regulation between 4 and 6 years. Linear regression models were then used to determine the strength of the association between the extent of self-regulation improvement and level of behavioral problems. Greater improvement in self-regulation, adjusted for family characteristics and baseline self-regulation scores, was associated with lower levels of parent- (B = -3.57, 95% confidence interval [CI] [-4.49, -2.65]) and teacher-rated SDQ total difficulties scores at 6 years (B = -2.42, 95% CI [-3.50, -1.34]). These effects remained after adjustment for level of parent-rated behavioral problems at 4 years. Similar effects were found for internalizing and externalizing scores at age 6 years. The results highlight the importance of improvements in self-regulation from 4-6 years for childhood behavioral problems during the early school years. Children with lower levels of improvement in self-regulation early in life are at risk for higher levels of behavioral problems both at home and at school., ((c) 2015 APA, all rights reserved).)

The original norms for the Revised Infant Temperament Questionnaire (RITQ) were published in 1978 and were based on a small sample from the US. The aim of this study is to compare temperament scores from the original RITQ against scores from a large population-based cohort of infants from the UK. This study consists of 10,937 infants from the Avon Longitudinal Study of Parents and Children (ALSPAC) born between April 1991 and December 1992 in the southwest of England. Infant temperament at 6 months of age was reported by parents using the adapted RITQ. Responses were scored according to the RITQ manual and then categorized into temperament groups (easy, intermediate low, intermediate high, and difficult) using either the RITQ norms or norms derived from the data. The scores for each temperament subscale and the proportion of children in each temperament group were compared across the two methods. Subscale scores for the ALSPAC sample were higher (more "difficult") than the RITQ norms for rhythmicity, approach, adaptability, intensity, and distractibility. When RITQ norms were applied, 24% infants were categorized as difficult and 25% as easy, compared with 15% difficult and 38% easy when ALSPAC norms were used. There are discrepancies between RITQ norms and the ALSPAC norms which resulted in differences in the distribution of temperament groups. There is a need to re-examine RITQ norms and categorization for use in primary care practice and contemporary population-based studies., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Debate about the extent of breast cancer over-diagnosis due to mammography screening has continued for over a decade, without consensus. Estimates range from 0 to 54%, but many studies have been criticized for having flawed methodology. In this study we used a novel study design to estimate over-diagnosis due to organised mammography screening in South Australia (SA). To estimate breast cancer incidence at and following screening we used a population-based, age-matched case-control design involving 4,931 breast cancer cases and 22,914 controls to obtain OR for yearly time intervals since women's last screening mammogram. The level of over-diagnosis was estimated by comparing the cumulative breast cancer incidence with and without screening. The former was derived by applying ORs for each time window to incidence rates in the absence of screening, and the latter, by projecting pre-screening incidence rates. Sensitivity analyses were undertaken to assess potential biases. Over-diagnosis was estimated to be 8% (95%CI 2-14%) and 14% (95%CI 8-19%) among SA women aged 45 to 85 years from 2006-2010, for invasive breast cancer and all breast cancer respectively. These estimates were robust when applying various sensitivity analyses, except for adjustment for potential confounding assuming higher risk among screened than non-screened women, which reduced levels of over-diagnosis to 1% (95%CI 5-7%) and 8% (95%CI 2-14%) respectively when incidence rates for screening participants were adjusted by 10%. Our results indicate that the level of over-diagnosis due to mammography screening is modest and considerably lower than many previous estimates, including others for Australia., (© 2014 UICC.)

Randomized controlled trial evidence shows that interventions before age 5 can improve skills necessary for educational success; the effect of these interventions on socioeconomic inequalities is unknown. Using trial effect estimates, and marginal structural models with data from the Avon Longitudinal Study of Parents and Children (n = 11,764, imputed), simulated effects of plausible interventions to improve school entry academic skills on socioeconomic inequality in educational achievement at age 16 were examined. Progressive universal interventions (i.e., more intense intervention for those with greater need) to improve school entry academic skills could raise population levels of educational achievement by 5% and reduce absolute socioeconomic inequality in poor educational achievement by 15%., (© 2014 The Authors. Child Development published by Wiley Periodicals, Inc. on behalf of Society for Research in Child Development.)

Background: This longitudinal study classified groups of children experiencing different trajectories of student-teacher relationship quality over the transition from preschool into school, and determined the strength of the association between different student-teacher relationship trajectories and childhood mental health problems in the second year of primary school., Methods: A community sample of 460 Australian children were assessed in preschool (age 4), the first school year (age 5), and second school year (age 6). Teachers at all three assessments reported on student-teacher relationship quality with the Student Teacher Relationship Scale. When the children were at preschool and in their second school year, parents and teachers rated children's mental health problems using the Strengths and Difficulties Questionnaire., Results: Latent-class growth modelling identified two trajectories of student-teacher relationship quality: (1) a stable-high student-teacher relationship quality and (2) a moderate/declining student-teacher relationship quality trajectory. Generalised linear models found that after adjusting for family demographic characteristics, having a stable high quality student-teacher relationship trajectory was associated with fewer parent-rated and teacher-rated total mental health problems, and fewer conduct, hyperactivity, and peer problems, and greater prosocial behaviour at age 6. A stable high quality trajectory was also associated with fewer teacher-rated, but not parent-rated emotional symptoms. These effects remained after adjustment for levels of mental health problems at age 4., Conclusions: Findings suggest that early intervention and prevention strategies that focus on building stable high quality student-teacher relationships during preschool and children's transition into formal schooling, may help reduce rates of childhood mental health problems during the early school years.

Background: There is limited longitudinal data from high-income countries on the sequelae of anaemia during pregnancy. The aim of this study is to examine whether anaemia of pregnancy is associated with adverse perinatal outcomes and with children's developmental vulnerability., Methods: We conducted a population-based study to link routinely collected government administrative data that involved all live births in the state of South Australia 1999-2005 (n = 124 061) and a subset for whom developmental data were collected during a national census of children attending their first year of school in 2009 (n = 13 654). Perinatal outcomes were recorded by midwives using a validated, standardised form. Development was recorded by schoolteachers using the Australian Early Development Index (AEDI). Children in the lowest 10% of AEDI scores are indicative of developmental vulnerability., Results: There were 8764/124 061 (7.1%) cases of anaemia. After adjustment for a range of potentially confounding factors, anaemia of pregnancy was associated with a higher risk of fetal distress [incident rate ratio (IRR) 1.20 [95% CI 1.13, 1.27]] and preterm birth <37 weeks gestation (IRR 1.23 [1.15, 1.31]), slightly higher birthweight [14 g (2, 26)] and newborns were less likely to require resuscitation (IRR 0.94 [0.91, 0.097]). Anaemia of pregnancy was not associated with children's developmental vulnerability after adjustment for maternal, obstetric and sociodemographic covariables, either in complete case analyses (n = 11 949) or after imputation for missing data (n = 13 654)., Conclusions: Anaemia of pregnancy is associated with perinatal complications but not with children's developmental vulnerability at school entry., (© 2014 John Wiley & Sons Ltd.)

To examine whether items comprising a preschool well-child check for use by family doctors in Australia with 4-5-year old children predicts health and academic outcomes at 6-7 years. The well-child check includes mandatory (anthropometry, eye/vision, ear/hearing, dental, toileting, allergy problems) and non-mandatory (processed food consumption, low physical activity, motor, behaviour/mood problems) items. The predictive validity of mandatory and non-mandatory items measured at 4-5 years was examined using data from the Longitudinal Study of Australian Children. Outcomes at 6-7 years included overweight/obesity, asthma, health care/medication needs, general health, mental health problems, quality of life, teacher-reported mathematics and literacy ability (n = 2,280-2,787). Weight or height >90th centile at 4-5 years predicted overweight/obesity at 6-7 years with 60% sensitivity, 79% specificity and 40% positive predictive value (PPV). Mood/behaviour problems at 4-5 predicted mental health problems at 6-7 years with 86% sensitivity, 40% specificity and 8% PPV. Non-mandatory items improved the discrimination between children with and without mental health problems at 6-7 years (area under the receiver operating characteristic curve 0.75 compared with 0.69 for mandatory items only), but was weak for most outcomes. Items used in a well-child health check were moderate predictors of overweight/obesity and mental health problems at 6-7 years, but poor predictors of other health and academic outcomes.

Every 3 years, the Australian Government conducts a developmental census across the entire population of children in their first year of full-time schooling (median age 5 years). The first developmental census was conducted in 2009, including 261,147 children, and in 2012 data were collected on 289,973 children-representing 97.5% and 96.5% of the estimated eligible population, respectively. The questionnaire is completed by teachers on the basis of at least 1 month's knowledge of the child, including aspects of physical, social, emotional, language and cognitive development, as well as data on special needs. Teachers are also asked to include details of the child's care arrangements and attendance in early education programmes in the years preceding school. Demographic and geographical data are recorded at the individual and area levels., (© The Author 2014; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association.)

Objective: To assess the screening accuracy of information obtained from parents of 4-5-year-old children for the purpose of identifying the children who have teacher-reported mental health problems when they are aged 6-7 years., Method: The study used data from the Longitudinal Study of Australian Children (LSAC) obtained when children were aged 4-5 years and 6-7 years. The level of children's mental health problems was assessed using the Strengths and Difficulties Questionnaire (SDQ) completed by parents when children were aged 4-5 years and by teachers when children were aged 6-7 years (n=2163). When children were aged 4-5 years, parenting skills were assessed using three questionnaires developed for the parent-completed LSAC questionnaire and maternal mental health was assessed using the Kessler Psychological Distress Scale (K6)., Results: When the level of parent-reported childhood mental health problems at 4-5 years old was used to identify children with teacher-reported mental health problems (i.e. a score in the "abnormal" range of the teacher-reported SDQ Total Difficulties Scale) when the children were aged 6-7 years, sensitivity was 26.8%, positive predictive value was 22.8%, and specificity was 92.9%. The addition of further information about the characteristics of children and their parents made only a small improvement to screening accuracy., Conclusions: Targeted interventions for preschool children may have the potential to play an important role in reducing the prevalence of mental health problems during the early school years. However, current capacity to accurately identify preschoolers who will experience teacher-reported mental health problems during the early school years is limited., (© The Royal Australian and New Zealand College of Psychiatrists 2013.)