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Background/objective Endotracheal suction is one of the most common and harmful procuedres performed on mechanically ventilated children. The aim of the study was to establish the feasibility of a randomised controlled trial (RCT) examining the effectiveness of normal saline instillation (NSI) and a positive end-expiratory pressure recruitment manoeuvre (RM) with endotracheal suction in the paediatric intensive care unit. Methods Pilot 2 × 2 factorial RCT. The study was conducted at a 36-bed tertiary paediatric intensive care unit in Australia. Fifty-eight children aged less than 16 years undergoing tracheal intubation and invasive mechanical ventilation. (i) NSI or no NSI and (ii) RM or no RM with endotracheal suction . The primary outcome was feasibility; secondary outcomes were ventilator-associated pneumonia (VAP), change in end-expiratory lung volume assessed by electrical impedance tomography, dynamic compliance, and oxygen saturation-to-fraction of inspired oxygen (SpO2/FiO2) ratio. Results/Findings Recruitment, retention, and missing data feasibility criteria were achieved. Eligibility and protocol adherence criteria were not achieved, with 818 patients eligible and 58 enrolled; cardiac surgery was the primary reason for exclusion. Approximately 30% of patients had at least one episode of nonadherence. Children who received NSI had a reduced incidence of VAP; however, this did not reach statistical significance (incidence rate ratio = 0.12, 95% confidence interval = 0.01–1.10; p = 0.06). NSI was associated with a significantly reduced SpO2/FiO2 ratio up to 10 min after suction. RMs were not associated with a reduced VAP incidence (incidence rate ratio = 0.31, 95% confidence interval = 0.05–1.88), but did significantly improve end-expiratory lung volume at 2 and 5 min after suction, dynamic compliance, and SpO2/FiO2 ratio. Conclusion RMs provided short-term improvements in end-expiratory lung volume and oxygenation. NSI with suction led to a reduced incidence of VAP; however, a definitive RCT is needed to test statistical differences. A RCT of study interventions is worthwhile and may be feasible with protocol modifications including the widening of participant eligibility.

Objectives Traffic-related air pollution (TRAP) negatively impacts children's health. Self-protective measures are available, but population uptake is variable. It is essential to understand human beliefs and behaviours related to air pollution in order to understand the lack of self-protection in communities. As a prelude to undertaking a comprehensive assessment of children's attitudes and beliefs on the health effects of TRAP exposure, we sought to develop and validate an appropriate instrument. Study design This study used exploratory sequential mixed methods. Methods This instrument, based on the constructs of the health belief model (HBM), aimed to determine factors predicting wearing a mask to protect against TRAP exposure. An initial literature-based questionnaire was modified using in-depth interviews, focus group discussions, and a quantitative survey pilot. This study included 121 school students and nine professional experts in Vietnam. The questionnaire was tested for content validity, agreement, test-retest reliability, and internal consistency. Results The concordance of questionnaire items between two repeated assessments ranged from 47.2% to 78.3%, intraclass correlation coefficients ranged from 0.16 to 0.87 and Cronbach's internal reliability coefficient for the instrument was 0.60. Conclusion The self-administered instrument, based on the HBM, is suitable to understand health attitudes and beliefs related to self-protective behaviours to reduce TRAP exposure.

Background and aims Shift workers face an increased risk of cardiovascular disease (CVD), type-2 diabetes and obesity. Eating during the night is a likely contributing factor, as it coincides with the time at which postprandial metabolism is least efficient. In this pilot randomised crossover trial, we examine the effects of a short overnight fast on CVD risk markers (primarily postprandial triglyceride and glucose response) of night shift workers. Methods and results Night shift workers with abdominal obesity underwent 4-week intervention and control periods, separated by ≥ 2 weeks washout. In the intervention period, an overnight fast (0100 h–0600 h) was implemented, by redistributing 24-h energy intake. Usual dietary habits were followed in the control period. Outcomes between intervention and control were compared using mixed effects linear regression models. Nineteen adults completed the trial [13 females, mean (±SD) age 41 ± 10 years, BMI 30.7 ± 5.7 kg/m2]. Postprandial triglyceride and glucose response post intervention were not different to post control. The overnight fast was well-tolerated by participants with an adherence rate of 95%, assessed by weekly 24-h dietary recalls. Exploratory analysis indicates lower mean body weight post intervention compared to post control (mean difference: −0.9 kg, 95% CI: −1.3 to −0.4). Conclusions Night shift workers who habitually ate during their night shifts were able to rearrange their meal times to maintain a small overnight fast, which may have promoted small weight changes. This warrants further investigation into the role of meal timing in mitigating the metabolic consequences of night shift work. Trial registration Australian New Zealand Clinical Trials Registry (http://anzctr.org.au/) registered on the 30th May 2017 (ACTRN12617000791336).

IntroductionNusinersen is used in spinal muscular atrophy (SMA) to improve peripheral muscle function; however, respiratory effects are largely unknown.AimTo assess the effects of nusinersen on respiratory function in paediatric SMA during first year of treatment.MethodsA prospective observational study in paediatric patients with SMA who began receiving nusinersen in Queensland, Australia, from June 2018 to December 2019. Outcomes assessed were the age-appropriate respiratory investigations: spirometry, oscillometry, sniff nasal inspiratory pressure, mean inspiratory pressure, mean expiratory pressure, lung clearance index, as well as polysomnography (PSG) and muscle function testing. Lung function was collected retrospectively for up to 2 years prior to nusinersen initiation. Change in lung function was assessed using mixed effects linear regression models, while PSG and muscle function were compared using the Wilcoxon signed-rank test.ResultsTwenty-eight patients (15 male, aged 0.08–18.58 years) were enrolled: type 1 (n=7); type 2 (n=12); type 3 (n=9). The annual rate of decline in FVC z-score prior to nusinersen initiation was −0.58 (95% CI −0.75 to −0.41), and post initiation was −0.25 (95% CI −0.46 to −0.03), with a significant difference in rate of decline (0.33 (95% CI 0.02 to 0.66) (p=0.04)). Most lung function measures were largely unchanged in the year post nusinersen initiation. The total Apnoea–Hypopnoea Index (AHI) was reduced from a median of 5.5 events/hour (IQR 2.1–10.1) at initiation to 2.7 events/hour (IQR 0.7–5.3) after 1 year (p=0.02). All SMA type 1% and 75% of SMA types 2 and 3 had pre-defined peripheral muscle response to nusinersen.ConclusionThe first year of nusinersen treatment saw reduced lung function decline (especially in type 2) and improvement in AHI.

Evaluate the validity of the Clinical Test of Sensory Integration of Balance (CTSIB) scored using Kids-Balance Evaluation Systems Test (Kids-BESTest) criteria compared to laboratory measures of postural control. Participants were 58 children, 7–18 years, 17 with ambulant cerebral palsy (CP) (GMFCS I–II), and 41 typically developing (TD). Postural control in standing was assessed using CTSIB items firm and foam surfaces, eyes open (EO) then closed (EC). Face validity was evaluated comparing clinical Kids-BESTest scores between groups. Correlating force plate centre-of-pressure (CoP) data and clinical scores allowed evaluation of concurrent and content validity. Face validity: TD children scored higher for all CTSIB conditions when compared to children with CP. Concurrent validity: the agreement between clinical and CoP derived scores was poor to excellent (Firm-EO = 76%, Firm-EC = 76%, Foam-EO = 59%, Foam-EC = 94%). Clinical scores of “2-unstable” and “3-stable” were not distinguished reliably by force plate measures. Content validity: significant correlations were found between clinical scores and CoP data for the two intermediate conditions (Firm-EC: rs −0.40 to −0.72; Foam-EO: rs −0.12 to −0.50), but not the easier (Firm-EO: rs −0.41 to −0.36) or harder conditions (Foam-EC: rs −0.25 to −0.27). Face validity of Kids-BESTest CTSIB criteria was supported. Content and concurrent validity were partially supported. Improved Kids-BESTest scoring terms were recommended to describe postural characteristics of “2-unstable.”IMPLICATIONS FOR REHABILITATIONFace validity of the Kids-BESTest criteria for the CTSIB was confirmed.The Kids-BESTest criteria for the CTSIB can identify children with atypical postural control.Concurrent validity and content validity were partially supported, since children with CP resorted to a range of different balance strategies when “unstable.”To improve CTSIB Kids-BESTest criteria, new terms were recommended to better describe postural characteristics of “2-unstable.” Face validity of the Kids-BESTest criteria for the CTSIB was confirmed. The Kids-BESTest criteria for the CTSIB can identify children with atypical postural control. Concurrent validity and content validity were partially supported, since children with CP resorted to a range of different balance strategies when “unstable.” To improve CTSIB Kids-BESTest criteria, new terms were recommended to better describe postural characteristics of “2-unstable.”

To examine interrater agreement and validity of the Functional Communication Classification System (FCCS) for young children with cerebral palsy (CP) aged 2 or 3 years.Speech-language pathologist (SLP) and parent FCCS ratings for 31 children with CP (aged 2y, n=16; aged 3y, n=15; 18 males, 13 females) were examined for interrater agreement using a weighted Cohen's kappa statistic. Relationships between FCCS (SLP) ratings and: (1) concurrent validity with the Language Use Inventory, a standardized pragmatic assessment for children aged 18 to 47 months, (2) gross motor and fine motor function, (3) associated impairments (visual and intellectual), and (4) primary expressive communication mode were examined using Spearman's correlation coefficients.Almost perfect interrater agreement between SLP and parent FCCS ratings were found (kThe FCCS has excellent interrater agreement and validity for communication classification of children with CP aged 2 or 3 years and is highly suitable for surveillance and research purposes. What this paper adds The Functional Communication Classification System (FCCS) is a valid instrument for children with cerebral palsy (CP) aged 2 or 3 years. Excellent agreement exists between speech-language pathologist and parent FCCS ratings. The FCCS has excellent correlation with intelligence, pragmatic function, and primary expressive mode. Stronger correlations with the Gross Motor Function Classification System and vision exist for children aged 2 or 3 years. Weaker correlations with manual ability exist when compared to older children with CP.

Respiratory syncytial virus (RSV) is the most common virus identified in children hospitalised with acute respiratory infections. However, less is known about RSV in community settings. This report describes RSV epidemiology in the community, including acute illness episodes, healthcare burden, and risk factors in Australian children during the first 2-years of life. A community-based, birth cohort from Brisbane, Australia, followed children until their second birthday. Parents completed daily respiratory symptom and illness-burden diaries. Weekly parent-collected nasal swabs were analysed for RSV by real-time polymerase chain reaction assays. Serum RSV-neutralising antibodies were assayed at age 3 years. Overall, 158 children provided 11,216 swabs, of which 104 were RSV-positive (85 incident episodes). RSV incidence in the first 2 years of life was 0.46 (95% CI = 0.37-0.58) episodes per child-year. Incidence increased with age and formal childcare attendance and was highest in autumn. Of 82 episodes linked with symptom data, 60 (73.2%) were symptomatic, 28 (34.1%) received community-based medical care, and 2 (2.4%) led to hospitalisation. Viral load was higher in symptomatic than asymptomatic infections. In 72 children, RSV-specific antibody seroprevalence was 94.4% at age 3 years.Conclusion: RSV incidence increased after age 6-months with approximately three-quarters of infections symptomatic and most infections treated in the community. What is known •RSV is a major cause of hospitalisation for acute lower respiratory infections in infants and young children, especially in the first 6 months of life. •However, limited data exist on the overall burden in young children at the community level. What is new •RSV incidence in the community increases after age 6 months, and by 3 years, most children have been infected. •About one-quarter of RSV infections were asymptomatic in children aged < 2 years, and approximately 60% of children with RSV-related symptoms had a healthcare contact of any kind with most managed within the community.

Background We explored the nasal microbiota in Indigenous Australian children in relation to ear and nasal health. Methods In total, 103 Indigenous Australian children aged 2–7 years (mean 4.7 years) were recruited from 2 Queensland communities. Children’s ears, nose, and throats were examined and upper respiratory tract (URT) swabs collected. Clinical histories were obtained from parents/medical records. URT microbiota were characterized using culturomics with Matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) identification. Real-time PCR was used to quantify otopathogen (Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis) loads and detect respiratory viruses. Data were analyzed using beta diversity measures, regression modeling, and a correlation network analysis. Results Children with historical/current otitis media (OM) or URT infection (URTI) had higher nasal otopathogen detection and loads and rhinovirus detection compared with healthy children (all P < .04). Children with purulent rhinorrhea had higher nasal otopathogen detection and loads and rhinovirus detection (P < .04) compared with healthy children. High otopathogen loads were correlated in children with historical/current OM or URTI, whereas Corynebacterium pseudodiphtheriticum and Dolosigranulum pigrum were correlated in healthy children. Conclusions Corynebacterium pseudodiphtheriticum and D. pigrum are associated with URT and ear health. The importance of the main otopathogens in URT disease/OM was confirmed, and their role relates to co-colonization and high otopathogens loads.

Background Following high influenza activity in 2017, the state of Queensland, Australia, funded a quadrivalent inactivated influenza vaccination program for children aged 6 months to Methods A matched case-control study was conducted. Cases were identified using Queensland 2018 influenza notification data among children age-eligible for funded vaccination. Controls were drawn from Australian Immunisation Register records of Queensland resident children age-eligible for funded influenza vaccine. Up to 10 controls per case were matched for location and birthdate. First dose vaccination was valid if received ≥14 days prior to specimen collection; a second dose was valid if received ≥28 days after first dose receipt. VE was calculated for vaccine doses and adherence to national recommendations for two doses in the first season (schedule completeness) and adjusted (VEadj) for sex and First Nations status. Results There were 1,125 cases and 10,645 matched controls analysed. Overall VEadj against laboratory-confirmed influenza was 51% (95% confidence interval (CI) 41–60). VEadj was 60% (95% CI 46–70) for children who received two doses in 2018, and 60% (95% CI 48–69) for children vaccinated appropriately according to schedule completeness. VE increased with age. Conclusions Moderate vaccine effectiveness was observed for children eligible for the funded program in Queensland in 2018, adding to the sparse evidence for influenza vaccine use in Australian children. Adhering to the national first season two dose schedule for influenza vaccine receipt in children ensures maximum protection.

Nutrition assessment is multidimensional; however, much of the literature examining the nutritional status of children with cerebral palsy (CP) focuses on a single dimension.The aim of the study was to evaluate nutritional status in children and adolescents with CP by comparing results from the Pediatric Subjective Global Nutrition Assessment (SGNA) with results from traditional anthropometric measures.This study was a cross-sectional observational study.This study was conducted in a tertiary hospital outpatient setting in Brisbane, Australia, from February 2017 to March 2018. A total of 89 children (63 boys) with CP aged between 2 and 18 years of age were included. All Gross Motor Function Classification System levels were observed. The majority of children were in Gross Motor Function Classification System I and II (57, 64%) compared with Gross Motor Function Classification System III to V (32, 36%). Children with feeding tubes and those acutely unwell or hospitalized were excluded.Children were classified as well nourished, moderately malnourished, or severely malnourished by dietitians using the SGNA. Weight, height, body mass index (BMI), triceps skinfold thickness, subscapular skinfold thickness, and mid upper arm circumference were measured and converted to z scores to account for age and sex differences. Moderate malnutrition was defined by z scores -2.00 to -2.99 and severe malnutrition as ≤-3.00 z scores.Multinomial logistic analyses were used to compare results from the SGNA and each single measurement. Continuous outcomes were transformed into z scores. Agreement was assessed with 2 categories: not malnourished and malnourished. Comparison statistics included percent agreement, sensitivity, and specificity.More children were classified as moderately or severely malnourished by SGNA than any of the anthropometric z score cutoffs. The majority of children were well nourished (n = 63) with 20 (22%) moderately malnourished and 6 (7%) severely malnourished by SGNA. The SGNA classified 11 children as malnourished that were not classified as malnourished by BMI. Children with moderate or severe malnutrition by SGNA had lower weight (P.001, P.001), BMI (P.001, P.001), mid upper arm circumference (P.001, P.001), triceps skinfold thickness (P = .01, P = .007), and subscapular skinfold thickness (P = .005, P = .02) z scores than well-nourished children.The SGNA identified more potentially malnourished children including children classified as well nourished by the single measurements such as BMI, height, and weight. The SGNA provided a clinically useful multidimensional approach to nutrition assessment for children with CP.

Respiratory syncytial virus (RSV) is an important cause of early life acute respiratory infections. Potentially pathogenic respiratory bacteria, including Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae are frequently detected during RSV infections and associated with increased illness severity. However, the temporal dynamics of bacterial colonization associated with RSV infection remain unclear. We used weekly nasal swab data from a prospective longitudinal birth cohort in Brisbane, Australia, to investigate bacterial colonization patterns within children aged less than 2 years in the 4-week period before and after an RSV infection. During 54 RSV infection episodes recorded in 47 children, both S. pneumoniae and M. catarrhalis were detected frequently (in 33 [61.1%] and 26 [48.1%] RSV infections, respectively). In most cases, S. pneumoniae and M. catarrhalis colonization preceded the viral infection, with the nasal load of each increasing during RSV infection. Generally, the dominant serotype of S. pneumoniae remained consistent in the 1 to 2 weeks immediately before and after RSV infection. Little evidence was found to indicate that prior colonization with either bacteria predisposed participants to developing RSV infection during the annual seasonal epidemic. Possible coacquisition events, where the bacteria species was first detected with RSV and not in the preceding 4 weeks, were observed in approximately 20% of RSV/S. pneumoniae and RSV/M. catarrhalis codetections. Taken together our results indicate that RSV generally triggered an outgrowth, rather than a new acquisition, of S. pneumoniae and M. catarrhalis from the resident microbial community.

Objective: The longer-term effectiveness of silicone and pressure burn scar interventions was evaluated at 12-months postburn. Design: Parallel group, randomised trial. Setting: Hospital outpatient clinics, research centre. Participants: Children referred for burn scar management following grafted or spontaneously healed acute burn injuries or scar reconstruction surgery. Interventions: Participants were randomised to: (1) topical silicone gel only, (2) pressure garment only, or (3) combined topical silicone gel and pressure garment. Main measures: Primary outcomes were scar thickness (blinded ultrasound measurement) and itch intensity (caregiver proxy-report, numeric rating scale). Results: Of 153 participants randomised who received the interventions (silicone n = 51, pressure garment n = 49, combined n = 53), 86 were followed-up at 12-months postburn ( n = 34, n = 28, n = 24). No differences were identified for the primary outcomes using intention-to-treat analysis. Scar thickness mean difference (95% confidence interval) = 0.00 cm (−0.04, 0.05); −0.03 cm (−0.07, 0.02); 0.03 cm (−0.02, 0.08) and scar itch = 0.09 (−0.88, 1.06); −0.21 (−1.21, 0.79); 0.30 (−0.73, 1.32) for silicone vs pressure; silicone vs combined and combined vs pressure respectively. No serious adverse effects occurred. Conclusion: Similar to short-term results, the combined intervention offered no statistically or clinically significant benefit for improving the primary outcomes compared to each intervention alone. No differences in the primary outcomes were identified between the silicone and pressure alone groups.

Recurrent vulvovaginal candidiasis (RVVC) is a subtype of vulvovaginal candidiasis, with debilitating effects on physical and emotional well-being affecting up to 10% of Australian women. Current evidence suggests that the induction and maintenance approach for RVVC is not particularly effective with post-treatment relapse rates as high as 57%. Frequently accessed Australasian RVVC prescribing resources and guidelines were examined showing a variety of adaptations of current evidence-based induction and maintenance therapies, making it difficult to select best treatment in clinical practice. The ways to introduce more clarity and consistency into these guidelines are outlined.

IntroductionUsing patient-reported outcome measures (PROMs) with children have been described as ‘giving a voice to the child’. Few studies have examined the routine use of these measures as potentially therapeutic interventions. This study aims to investigate: (1) the effectiveness of feedback using graphical displays of information from electronic PROMs (ePROMs) that target health-related quality of life, to improve health outcomes, referrals and treatment satisfaction and (2) the implementation of ePROMs and graphical displays by assessing acceptability, sustainability, cost, fidelity and context of the intervention and study processes.Methods and analysisA hybrid II effectiveness-implementation study will be conducted from February 2020 with children with life-altering skin conditions attending two outpatient clinics at a specialist paediatric children’s hospital. A pragmatic randomised controlled trial and mixed methods process evaluation will be completed. Randomisation will occur at the child participant level. Children or parent proxies completing baseline ePROMs will be randomised to: (1) completion of ePROMs plus graphical displays of ePROM results to treating clinicians in consultations, versus (2) completion of ePROMs without graphical display of ePROM results. The primary outcome of the effectiveness trial will be overall health-related quality of life of children. Secondary outcomes will include other health-related quality of life outcomes (eg, child psychosocial and physical health, parent psychosocial health), referrals and treatment satisfaction. Trial data will be primarily analysed using linear mixed-effects models; and implementation data using inductive thematic analysis of interviews, meeting minutes, observational field notes and study communication mapped to the Consolidated Framework for Implementation Research.Ethics and disseminationEthical approval was obtained from Children’s Health Queensland Human Research Ethics Committee (HREC/2019/QCHQ/56290), The University of Queensland (2019002233) and Queensland University of Technology (1900000847). Dissemination will occur through stakeholder groups, scientific meetings and peer-reviewed publications.Trial registration numberAustralian New Zealand Clinical Trials Registry (ACTRN12620000174987).

IntroductionPeripherally inserted central catheters (PICCs) are vital for the delivery of medical therapies, but up to 30% of PICCs are associated with complications such as deep vein thrombosis or infection. The integration of antimicrobial and hydrophobic catheter materials, and pressure-activated valves, into polyurethane PICCs are innovations designed to prevent infective and/or thrombotic complications.Methods and analysisA multicentre, parallel group, superiority randomised controlled trial with two experimental arms ((1) hydrophobic PICC (with pressure-activated valve); (2) chlorhexidine gluconate-impregnated PICC (with external clamp)) and one control group ((3) conventional polyurethane PICC (with external clamp)). Recruitment of 1098 adult and paediatric patients will take place over 2 years at three tertiary-referral hospitals in Queensland, Australia. Patients are eligible for inclusion if their PICC is to be inserted for medical treatment, with a vascular size sufficient to support a 4-Fr PICC or larger, and with informed consent. The primary outcome is PICC failure, a composite of thrombotic (venous thrombosis, breakage and occlusion) and infective complications (PICC-associated bloodstream infection and local infection). Secondary outcomes include: all-cause PICC complication; thrombotic complications; infective complications; adverse events (local or systemic reaction); PICC dwell time; patient/parent satisfaction; and healthcare costs. Differences between both intervention groups and the control group will be compared using Cox proportional hazards regression. Effect estimates will be presented as HRs with corresponding 95% CI.Ethics and disseminationEthical approval from Queensland Health (HREC/QCHQ/48682) and Griffith University (Ref. No. 2019/094). Results will be published.Trial registration numberACTRN12619000022167.

BACKGROUND: Longitudinal data on medication use in adults with intellectual disability (ID) are scarce. We describe the longitudinal use of and factors associated with psychotropic medication prescribing in adults with ID living in the Australian community. METHODS: Longitudinal data were obtained from adults with ID in the community in Queensland, Australia, between 1999 and 2015. Participant characteristics and medication use information were extracted from baseline questionnaires and health check booklets. Logistic regression was used to investigate the associations between participant characteristics and psychotropic medication use, commencement or cessation. RESULTS: Longitudinal data were available for 138 participants on 697 reviews. The proportion of participants prescribed psychotropic medications increased from 43% to 54% between 1999 and 2015. The rates of commencement and cessation of psychotropic medications between consecutive time periods ranged from 9% to 18% and 7% to 15%, respectively. Challenging behaviour was associated with psychotropic medication use (adjusted odds ratio = 4.1; 95% confidence interval: 2.1-7.9). Presence of challenging behaviour, either consistent or newly identified, was positively associated with ongoing use or commencement of psychotropic medications. CONCLUSIONS: Psychotropic medications are commonly prescribed to adults with ID. Challenging behaviour is positively associated with ongoing use and commencement.

Summary Background Bronchiectasis guidelines recommend antibiotics for the treatment of acute respiratory exacerbations, but randomised placebo-controlled trials in children are lacking. We hypothesised that oral amoxicillin–clavulanate and azithromycin would each be superior to placebo in achieving symptom resolution of non-severe exacerbations in children by day 14 of treatment. Methods In this multicentre, three-arm, parallel, double-dummy, double-blind, randomised placebo-controlled trial at four paediatric centres in Australia and New Zealand, we enrolled children aged 1–18 years with CT-confirmed bronchiectasis unrelated to cystic fibrosis, who were under the care of a respiratory physician and who had had at least two respiratory exacerbations in the 18 months before study entry. Participants were allocated (1:1:1) at exacerbation onset to receive oral suspensions of amoxicillin–clavulanate (45 mg/kg per day) plus placebo azithromycin, azithromycin (5 mg/kg per day) plus placebo amoxicillin–clavulanate, or both placebos for 14 days. An independent statistician prepared a computer-generated, permuted-block (size 2–8) randomisation sequence, stratified by centre, age, and cause. Participants, caregivers, study coordinators, and investigators were masked to treatment assignment until data analysis was completed. The primary outcome was the proportion of children with exacerbation resolution by day 14 in the intention-to-treat population. Treatment groups were compared using generalised linear models. Statistical significance was set at p

Background: Pregnant women and infants

Vertical transmission from mother-to-child is an important mode of hepatitis B virus (HBV) infection, accounting for up to half of all incident cases globally. We evaluated the uptake of HBV neonatal vaccination and immunoglobulin delivery in Queensland, Australia, between 2001 and 2013. We identified HBV-positive mothers using linked notifiable conditions, hospitalisation, and perinatal administrative data. Perinatal receipt of monovalent HBV vaccine and hepatitis B immunoglobulin were examined. Of 710,859 live births, with 5753 infants (0.81%) born to identified HBV-positive mothers; 91.7% received HBV neonatal vaccine. Immunoglobulin uptake was 20.0% in 2012 and 36.6% in 2013. Uptake was higher when the mother's HBV-positive status was recorded in perinatal records (69.6% if maternal HBV status recorded on perinatal data collection vs 9.5% otherwise). Delivery of neonatal HBV vaccination in Queensland was high. Improved identification and documentation of HBV-positive mothers' status during the antenatal period was associated with increased immunoglobulin administration.

Objective To evaluate the reproducibility, including reliability and agreement, of the Kids Balance Evaluation Systems Test (Kids-BESTest) and the short form of Kids-BESTest (Kids-Mini-BESTest) for measuring postural control in school-aged children with cerebral palsy. Design Psychometric study of intrarater, interrater, and test-retest reliability and agreement. Setting Clinical laboratory and home. Participants Convenience sample of children (N=18) aged 8 to 17 years with ambulant cerebral palsy (CP) (Gross Motor Function Classification System I-II) with spastic or ataxic motor type. Intervention Not applicable. Main Outcome Measures Postural control was assessed using the Kids-BESTest and the Kids-Mini-BESTest. An experienced physiotherapist assessed all children in real time and the testing session was videotaped. The same physiotherapist viewed and scored the video twice, at least 2 weeks apart, to assess intrarater reproducibility. Another experienced physiotherapist scored the same video to determine interrater reproducibility. Thirteen children returned for a repeat assessment with the first physiotherapist within 6 weeks and their test-retest performance was rated in real time and with video. Results Excellent reliability was observed for both the Kids-BESTest (intraclass correlation coefficient [ICC] 0.96-0.99) and Kids-Mini-BESTest (ICC 0.79-0.98). The smallest detectable change was good to excellent for all Kids-BESTest agreement analyses (5%-9%), but poor to good for Kids-Mini-BESTest analyses (9%-16%). Conclusion The Kids-BESTest shows an excellent ability to discriminate postural control abilities of school-aged children with CP and it has a low smallest detectable change, suitable for use as a preintervention and postintervention outcome measure. Although the Kids-Mini-BESTest is 5 to 10 minutes shorter to administer, it has poorer reproducibility and focuses only on falls-related balance, which excludes 2 domains of postural control.

Aim To develop and validate a screening tool for feeding/swallowing difficulties and/or undernutrition in children with cerebral palsy (CP). Method This cross‐sectional, observational study included 89 children with CP (63 males, 26 females; median age 6y 0mo; interquartile range 4y 0mo–8y 11mo), across all Gross Motor Function Classification System levels. Children with feeding tubes were excluded. Children were classified as well‐nourished or moderately to severely undernourished, using the paediatric Subjective Global Nutrition Assessment. Eating and drinking abilities were classified using the Eating and Drinking Ability Classification System (EDACS) from mealtime observation and videofluoroscopic swallow studies when indicated. Parents/caregivers answered 33 screening questions regarding their child's feeding/swallowing abilities and nutritional status. The diagnostic ability of each question for identifying children with feeding/swallowing difficulties and undernutrition was calculated and the combination of questions with the highest sensitivity and specificity identified. Results Feeding difficulties impacted on swallow safety in 26 children (29%) and 26 children (29%) were moderately or severely undernourished. The 4‐item final tool had high sensitivity and specificity for identifying children with feeding/swallowing difficulties (81% and 79% respectively) and undernutrition (72% and 75% respectively). The tool successfully identified 100 per cent of children with severe undernutrition and 100 per cent of those classified as EDACS level IV or V. Interpretation Screening for feeding/swallowing difficulties and undernutrition will enable early identification, assessment, and management for those children in need. What this paper adds A screening tool with high sensitivities and specificities for identifying children with feeding/swallowing difficulties and undernutrition.The tool identified 100 per cent of children with severe undernutrition.The tool identified 100 per cent of children in Eating and Drinking Ability Classification System levels IV or V., What this paper adds A screening tool with high sensitivities and specificities for identifying children with feeding/swallowing difficulties and undernutrition.The tool identified 100 per cent of children with severe undernutrition.The tool identified 100 per cent of children in Eating and Drinking Ability Classification System levels IV or V. This article's abstract has been translated into Spanish and Portuguese. Follow the links from the http://onlinelibrary.wiley.com/doi/10.1111/dmcn.14220/abstract to view the translations.

Survey research frequently involves missing cases attributable to refusals to participate, lack of success in accessing all potential respondents or loss to follow-up in longitudinal studies. There is concern that those not recruited or those lost are a select group whose absence from a study may bias the findings of the study. This study provides a test of the extent to which selective loss to follow-up in a longitudinal study may lead to biased findings. The Mater-University Study of Pregnancy collected baseline information for 7718 pregnant women. Follow-ups occurred five years, 14 years, 21 years and 27 years after the birth, for 6753 eligible women. Participants at baseline were partitioned according to follow-up status for each follow-up. We compare baseline (at recruitment) measures of association, with these same measures of association for those retained in the study (Group A) and those lost to follow-up (Group B) at each phase of data. Using univariate logistic regression we compared the strength of association between maternal mental health and various baseline socio-demographic factors for different rates of loss to follow-up. Estimates of association at baseline, and at each follow-up are similar irrespective of the rate of loss to follow-up and whether the comparison is with those retained in the study or those lost to follow-up. There were no statistically significant differences in 90.8% of baseline comparisons with Group A, and 96.9% of comparisons with Group B measures of association. We conclude that differential loss to follow-up rarely affects estimates of association. We suggest that loss to follow-up may produce misleading findings only in circumstances where loss to follow-up is combined with a number of other sources of bias.

Background Aboriginal and Torres Strait Islander (Indigenous) Australians have high rates of invasive pneumococcal disease (IPD), with repeat doses of 23-valent polysaccharide pneumococcal vaccine (PPV23) recommended. We report the relative effectiveness of revaccination using a cohort from linked administrative data. Methods All resident North Queensland Indigenous adults who received any PPV23 vaccination between 2000 and 2012 were identified and linked with IPD cases. IPD rates were compared for individuals revaccinated >five years after initial PPV23 dose against individuals not revaccinated. Results Analysed data included 12,809 individuals and 89,612 person-years. Revaccinated adults had similar rates of IPD as non-revaccinated adults, after adjusting for potential confounders (HR = 0.92; 95%CI: 0.35–2.42). Findings were similar for vaccine-specific serotypes (HR = 1.32; 95%CI: 0.32–5.43). Conclusions Benefits of PPV23 revaccination against IPD in this high-risk population were not demonstrated, although estimates were imprecise. Findings should be validated in other high-risk cohorts, and against all-cause pneumonia as an outcome.

Background There is a limited body of literature exploring referral relationships between general dental practitioners and periodontists. Clinical and non-clinical factors associated with the referral process are rarely considered however a better understanding of these will improve the general dentist practitioner and periodontal specialist relationship and benefit patient management. This study investigated which non-clinical factors have an association with the referral of patients by general dental practitioners to periodontists in Tasmania, Australia. Methods A questionnaire was emailed to registered general dental practitioners in Tasmania, Australia and information collected on demographics, referral patterns, and potential factors which may influence referral. Results Response rate was 44.5%. Non-clinical factors that influenced referral were previous treatment by a periodontist (70.8%), a complex medical history (56.8%), the patient's reluctance to undergo periodontal treatment, medico-legal reasons, patient awareness of periodontal disease (47.3%), and lack of training (43.2%). Patients frequently declined periodontal referral due to cost (66.2%), oral health not being a priority (55.4%), or inconvenience (46.6%). The most important periodontist qualities were their reputation (84.0%), patient feedback (81.3%), ease of communication (72.0%), report quality (68.0%), and location (62.7%). Conclusion Non-clinical factors, such as practice type-, general dental practitioner-, patient-, periodontist-related factors are associated with referral by general dental practitioners to periodontists for periodontal management.

Background Most acute respiratory infection (ARI) research focuses on severe disease and overlooks the burden of community-managed illness. For community-based studies, home-based specimen collection by parents could be a resource-saving alternative to collection by healthcare workers (HCWs). In this study, we compared parent and HCW groups for their likelihood to collect specimens and the timeliness and quality of such collection. Methods In this unblinded randomized controlled trial, parents from Brisbane, Australia, were taught to identify new ARI episodes in their children aged, Parents and HCWs obtained samples in similar proportions of ARI episodes, but the parents collected the samples fewer days after ARI onset and with a resulting higher likelihood of pathogen identification.

To examine the stability over time of the Manual Ability Classification System (MACS) levels in children with cerebral palsy (CP) aged 18 to 60 months.This was a prospective longitudinal population-based study of 252 Australian children (160 males [63%] 92 females [37%]; mean age [SD] 41.7mo [14], range 17.2mo-69.2mo) with CP. Children were classified at 18 months (n=70), 24 months (n=131), 30 months (n=173), 36 months (n=209), 48 months (n=226), and 60 months (n=221) of age. Stability of the MACS was examined using the proportion of specific positive agreement and transition proportions, which are measures of agreement.There were 1030 unique observations, with each of the 252 participants seen between two and six occasions (median=4). Average specific positive agreement over the study period was 76% for MACS level I, 67% for level II, 50% for level III, 51% for level IV, and 83% for level V. MACS levels I and V have the highest degree of stability, while levels III and IV have the lowest. We show how this may be explained by the proportion of children in each MACS level.Using measures of agreement rather than measures of reliability provides accurate information when measuring stability over time of an ordinal classification system. The relative stability of MACS levels can be explained by the proportion of children in each level.Children classified in Manual Ability Classification System (MACS) levels III and IV change levels at next assessment about 50% of the time. Children should be assessed with the MACS regularly, particularly those in levels III and IV. Stability within ordinal classification level categories can be predicted using a measurement error model. Transition proportions or specific agreement is recommended for reporting stability of ordinal classification systems.Estabilidade do Sistema de Classificação da Habilidade Manual (MACS) em crianças jovens com paralisia cerebral OBJETIVO: Examinar a estabilidade ao longo do tempo dos níveis do Sistema de Classificação da Habilidade Manual (MACS) em crianças com paralisia cerebral (PC) com idade entre 18 e 60 meses. MÉTODO: Este foi um estudo prospectivo de caráter longitudinal, com amostra baseada no estudo da população de 252 crianças Australianas (160 meninos [63%], 92 meninas [37%]; idade média [desvio padrão] de 41,7 meses [14], variação de 17, 2 a 69, 2 meses de idade]) com PC. As crianças foram classificadas aos 18 meses (n = 70), 24 meses (n = 131), 30 meses (n = 173), 36 meses (n = 209), 48 meses (n = 226), e aos 60 meses (n = 221) de idade. A estabilidade do MACS foi examinada utilizando a proporção de concordância positiva específica e proporções de transição, sendo estas as medidas de concordância. RESULTADOS: Foram realizadas um total de 1.030 observações com os 252 participantes, os quais foram avaliados individualmente entre dois e seis momentos (média = 4). A média de concordância específica positiva durante o estudo foi de 76% para MACS nível I, 67% para nível II, 50% para nível III, 51% para nível IV, e 83% para nível V. Os classificados com MACS nível I e V tiveram os maiores graus de estabilidade, enquanto os classificados com os níveis III e IV tiveram os menores graus de estabilidade. Estes resultados podem ser explicados pela proporção de crianças classificadas em cada nível do MACS. INTERPRETAÇÃO: A utilização de medidas de concordância ao invés de medidas de confiabilidade proporciona informações mais precisas quando se mensura estabilidade ao longo do tempo com um sistema de classificação ordinal. A estabilidade relativa dos níveis do MACS pode ser explicada pela proporção de crianças classificadas em cada nível.Estabilidad del Sistema de Clasificación de Habilidad Manual (MACS) en niños pequeños con parálisis cerebral OBJETIVO: Examinar la estabilidad en el tiempo de los niveles del Sistema de Clasificación de Habilidad Manual (MACS) en niños con parálisis cerebral (PC) de 18 a 60 meses. MÉTODO: Este fue un estudio prospectivo longitudinal basado en la población de 252 niños australianos (160 [63%] hombres, 92 mujeres [37%]; edad media [DE] 41.7mo [14], rango 17.2mo-69.2mo]) con PC. Los niños se clasificaron a los 18 meses (n = 70), 24 meses (n = 131), 30 meses (n = 173), 36 meses (n = 209), 48 meses (n = 226) y 60 meses (n = 221) de edad. La estabilidad del MACS se examinó utilizando la proporción de acuerdo positivo específico y las proporciones de transición, que son medidas de acuerdo. RESULTADOS: Con cada uno de los 252 participantes vistos entre dos y seis ocasiones (mediana = 4) hubo 1030 observaciones únicas. La concordancia positiva específica promedio durante el período de estudio fue de 76% para MACS nivel I, 67% para nivel II, 50% para nivel III, 51% para nivel IV y 83% para nivel V. Los niveles I y V de MACS son los más altos de estabilidad, mientras que los niveles III y IV tienen los más bajos. Mostramos cómo esto puede explicarse por la proporción de niños en cada nivel de MACS. INTERPRETACIÓN: El uso de medidas de acuerdo - en lugar de medidas de confiabilidad - proporciona información precisa cuando se mide la estabilidad en el tiempo de un sistema de clasificación ordinal. La estabilidad relativa de los niveles de MACS puede explicarse por la proporción de niños en cada nivel.

Background Most respiratory bacterial carriage studies in children are based on cross‐sectional samples or longitudinal studies with infrequent sampling points. The prospective Observational Research in Childhood Infectious Diseases birth cohort study intensively evaluated the community‐based epidemiology of respiratory viruses and bacteria during the first 2‐years of life. Here we report the bacteriologic findings. Methods Pregnant women in Brisbane, Australia were recruited between September 2010 and October 2012, and their healthy newborn children were followed for the first 2‐years of life. Parents kept a daily symptom diary for the study child, collected a weekly anterior nose swab and completed an illness burden diary when their child met pre‐defined illness criteria. Specimens were tested for respiratory bacteria by real‐time polymerase chain reaction (PCR) assays and those containing human genomic DNA, deemed as high‐quality, were analyzed. Results Altogether 8100 high‐quality nasal swab specimens from 158 enrolled children were analyzed. Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae were detected in 42.4%, 38.9%, and 14.8% of these samples, respectively. Concomitant detection of bacteria was common. In contrast, Bordetella pertussis, B. parapertussis, Mycoplasma pneumoniae, Chlamydia pneumoniae, and Simkania negevensis were rarely identified. The prevalence of the three major bacteria was higher with increasing age and in the winter and spring months. Siblings and childcare attendance were the other risk factors identified. Conclusions We confirmed the feasibility of frequent nasal swabbing by parents for studying bacterial colonization. PCR detected the major respiratory tract bacteria with expected high frequencies, but atypical bacteria were found rarely in this cohort.

Background Burns are a painful and traumatic experience, particularly in children. Reduced pain and anxiety positively influences re-epithelialisation rates in paediatric burn patients, however current literature fails to fully explain the effects of pain and anxiety and their links with wound healing. This study will determine if Burnaid® hydrogel dressing is an effective treatment for reducing pain in the acute period of a burn injury. It is hypothesised that a reduction in pain will then improve re-epithelialisation time in comparison to plastic wrap, which is standard practice at our institution — a metropolitan tertiary paediatric hospital located in Brisbane, Australia. Methods/design A randomised controlled trial will be conducted to assess the effectiveness of Burnaid® as an analgesic adjunct to cold running water first aid for the treatment of paediatric burns. Participants will include children aged between 0 and 16 years with an acute thermal burn injury (total burn surface area

Background Otitis media (OM) imposes a great burden of disease in indigenous populations around the world, despite a variety of treatment and prevention programs. Improved understanding of the pathogenesis of OM in indigenous populations is required to advance treatment and reduce prevalence. We conducted a systematic review of the literature exploring the upper airway and middle ear microbiota in relation to OM in indigenous children. Methods Papers targeting microbiota in relation to OM in children

To describe longitudinal development of self-care and its relationship to manual ability in children with cerebral palsy (CP) aged 18 months to 5 years across all functional abilities.This was a prospective longitudinal population-based study of 290 children with CP (178 [61%] males, 112 [39%] females). Self-care was assessed using the Pediatric Evaluation of Disability Inventory (PEDI). At 60 months (n=242), children were classified using the Manual Ability Classification System (MACS); 113 in level I (47%), 61 in MACS level II (25%), 24 in MACS level III (10%), 14 in MACS level IV (6%), and 30 in MACS level V (12%). Measures were taken at 18 months, 24 months, 30 months, 36 months, 48 months, and 60 months of age. Longitudinal analyses were performed using mixed-effects linear regression models.Self-care development achieved by 60 months was negatively associated with the severity of manual ability impairment. Distinct self-care developmental trajectories were found with estimated changes in PEDI self-care scaled scores per month: 0.61 for MACS level I, 0.46 for MACS levels II, 0.31 for MACS level III, 0.16 for MACS level IV, and 0.03 for MACS level V. Children classified in MACS level V had the lowest level of self-care skills at 18 months and showed no progress in self-care development.This study reports rate of self-care development in preschool children with CP. Self-care performance was highest in children with greatest manual ability. Clinicians may use rates of change to predict or monitor self-care performance. PEDI trajectories inform goal setting in discussions with families regarding expected levels of independence in self-care.Distinct self-care developmental trajectories in children with cerebral palsy were found according to Manual Ability Classification System (MACS) levels. Children in MACS levels IV and V with epilepsy did not show any significant change in self-care. Children in MACS levels IV and V without epilepsy demonstrated small yet significant gains in self-care performance.AUTOCUIDADO Y HABILIDAD MANUAL EN NIÑOS PREESCOLARES CON PARÁLISIS CEREBRAL: UN ESTUDIO LONGITUDINAL: OBJETIVO: Describir el desarrollo longitudinal del autocuidado en niños con parálisis cerebral (PC) de edades comprendidas entre los 18 meses y los 5 años de edad en todas las habilidades funcionales y su relación con la habilidad manual. MÉTODO: Se trata de un estudio prospectivo longitudinal basado en una población de 290 niños con PC (178 [61%] niños, 112 [39%] niñas). El autocuidado se evaluó utilizando el Inventario de Evaluación Pediátrica de Discapacidad (Pediatric Evaluation of Disability Inventory, PEDI). A los 60 meses (n=242), los niños se clasificaron usando el Sistema de Clasificación de la Habilidad Manual (Manual Ability Classification System, MACS); 113 en el nivel I (47%), 61 en el nivel MACS II (25%), 24 en el nivel MACS III (10%), 14 en el nivel MACS IV (6%), y 30 en el nivel MACS V (12%). Las mediciones se tomaron a los 18 meses, 24 meses, 30 meses, 36 meses, 48 meses, y 60 meses de edad. Los análisis longitudinales se realizaron utilizando modelos de regresión lineal de efectos mixtos. RESULTADOS: El desarrollo del autocuidado logrado a los 60 meses se asoció negativamente a la severidad de la alteración de la habilidad manual. Se encontraron trayectorias del desarrollo del autocuidado distintas con cambios estimados de los puntajes escalados del autocuidado de PEDI por mes: 0,61 para el nivel MACS de I, 0,46 para el nivel MACS de II, 0,31 para el nivel MACS de III, 0,16 para el nivel MACS de IV, y 0,03 para el nivel MACS de V. Los niños clasificados con el nivel MACS de V tuvieron el nivel más bajo de las destrezas de autocuidado a los 18 meses y no mostraron progreso en el desarrollo del autocuidado. INTERPRETACIÓN: Este estudio informa sobre la tasa de desarrollo del autocuidado en niños preescolares con PC. El desempeño del autocuidado fue mayor en niños con la mayor habilidad manual. Los profesionales podrian utilizar las tasas de cambio para predecir o monitorizar el desempeño del autocuidado. Las trayectorias de PEDI informan el establecimiento de objetivos, mediante un dialogo con las familias, basados en los niveles de independencia esperados en el autocuidado.AUTO-CUIDADO E HABILIDADE MANUAL EM CRIANÇAS PRÉ-ESCOLARES COM PARALISIA CEREBRAL: UM ESTUDO LONGITUDINAL: OBJETIVO: Descrever o desenvolvimento longitudinal do auto-cuidado em crianças com paralisia cerebral (PC) com idades entre 18 meses e 5 anos em todos os níveis de capacidade funcional e sua relação com a habilidade manual. MÉTODO: Este estudo populacional com desenho prospectivo e longitudinal incluiu 290 crianças com PC (178 [61%] do sexo masculino, 112 [39%] do sexo feminino). O auto-cuidado foi avaliado usando o Inventário pediátrico de avaliação da disfunção (PEDI). Aos 60 meses (n=242), as crianças foram classificadas usando o Sistema de Classificação da Habilidade Manual (MACS); 113 no nível I (47%), 61 no nível MACS II (25%), 24 no nível MACS III (10%), 14 no nível MACS level IV (6%), e 30 no nível MACS V (12%). As medidas foram realizadas aos 18, 24, 30, 36, 48 e 60 meses de idade. RESULTADOS: O desenvolvimento do auto-cuidado atingido aos 60 meses foi negativamente associado com a severidade do comprometimento da habilidade manual. Trajetórias distintas do desenvolvimento do auto-cuidado foram encontradas com mudanças estimadas nos scaled escores de auto-cuidado do PEDI por mês: 0,61 para nível MACS I, 0.46 para nível MACS II, 0,31 para nível MACS III, 0,16 para nível MACS IV, e 0,03 para nível MACS V. Crianças classificadas no nível MACS V tiveram o menor nível de habilidades de auto-cuidado aos 18 meses e não mostraram nenhum progresso no desenvolvimento do auto-cuidado. INTERPRETAÇÃO: Este estudo relata a taxa do desenvolvimento do auto-cuidado em crianças pré-escolares com PC. O desempenho do auto-cuidado foi o mais alto em crianças com maior habilidade manual. Clínicos podem usar as taxas de mudança para predizer ou monitorar o desempenho do auto-cuidado. As trajetórias do PEDI informam o estabelecimento de objetivos nas discussões com as famílias com relação aos níveis esperados de independência no auto-cuidado.

The aim of the study was to determine if a Beacon model of integrated care utilising general practitioners (GPs) with special interests could achieve similar clinical outcomes to a hospital-based specialist diabetes outpatient clinic. This pragmatic non-inferiority multisite randomised controlled trial assigned individuals with complex type 2 diabetes to care delivered by a Beacon clinic or to usual care delivered by a hospital outpatient department, in a 3:1 ratio. Owing to the nature of the study, researchers were only blinded during the allocation process. Eligible participants were aged 18 or over, had been referred by their usual GP to the hospital central referral hub with type 2 diabetes and had been triaged to be seen within 30 or 90 days. The intervention consisted of diabetes management in primary care by GPs with a special interest who had been upskilled in complex diabetes under the supervision of an endocrinologist. The primary outcome was HbA1c at 12 months post-recruitment. The non-inferiority margin was 4.4 mmol/mol (0.4%). Both per-protocol and intention-to-treat analyses are reported. Between 27 November 2012 and 14 July 2015, 352 individuals were recruited and 305 comprised the intention-to-treat sample (71 in usual care group and 234 in the Beacon model group). The Beacon model was non-inferior to usual care for both the per-protocol (difference −0.38 mmol/mol [95% CI −4.72, 3.96]; −0.03% [95% CI −0.43, 0.36]) and the intention-to-treat (difference −1.28 mmol/mol [95% CI −5.96, 3.40]; −0.12% [95% CI −0.55, 0.31]) analyses. Non-inferiority was sustained in a sensitivity analysis at 12 months. There were no statistically or clinically significant differences in the secondary outcomes of BP, lipids or quality of life as measured by the 12 item short-form health survey (SF-12v2) and the diabetes-related quality of life (DQoL-Brief) survey. Safety indicators did not differ between groups. Participant satisfaction on the eight-item client satisfaction questionnaire (CSQ-8) was good in both groups, but scores were significantly higher in the Beacon model group than the usual care group (mean [SD] 28.4 [4.9] vs 25.6 [4.9], respectively, p

Summary Background Although amoxicillin–clavulanate is the recommended first-line empirical oral antibiotic treatment for non-severe exacerbations in children with bronchiectasis, azithromycin is also often prescribed for its convenient once-daily dosing. No randomised controlled trials involving acute exacerbations in children with bronchiectasis have been published to our knowledge. We hypothesised that azithromycin is non-inferior to amoxicillin-clavulanate for resolving exacerbations in children with bronchiectasis. Methods We did this parallel-group, double-dummy, double-blind, non-inferiority randomised controlled trial in three Australian and one New Zealand hospital between April, 2012, and August, 2016. We enrolled children aged 1–19 years with radiographically proven bronchiectasis unrelated to cystic fibrosis. At the start of an exacerbation, children were randomly assigned to oral suspensions of either amoxicillin–clavulanate (22·5 mg/kg, twice daily) and placebo or azithromycin (5 mg/kg per day) and placebo for 21 days. We used permuted block randomisation (stratified by age, site, and cause) with concealed allocation. The primary outcome was resolution of exacerbation (defined as a return to baseline) by 21 days in the per-protocol population, with a non-inferiority margin of −20%. We assessed several secondary outcomes including duration of exacerbation, time to next exacerbation, laboratory, respiratory, and quality-of-life measurements, and microbiology. This trial was registered with the Australian/New Zealand Registry (ACTRN12612000010897). Findings We screened 604 children and enrolled 236. 179 children had an exacerbation and were assigned to treatment: 97 to amoxicillin–clavulanate, 82 to azithromycin). By day 21, 61 (84%) of 73 exacerbations had resolved in the azithromycin group versus 73 (84%) of 87 in the amoxicillin–clavulanate group. The risk difference showed non-inferiority (−0·3%, 95% CI −11·8 to 11·1). Exacerbations were significantly shorter in the amoxicillin–clavulanate group than in the azithromycin group (median 10 days [IQR 6–15] vs 14 days [8–16]; p=0·014). Adverse events were attributed to the trial medication in 17 (21%) of 82 children in the azithromycin group versus 23 (24%) of 97 in the amoxicillin–clavulanate group (relative risk 0·9, 95% CI 0·5 to 1·5). Interpretation By 21 days of treatment, azithromycin is non-inferior to amoxicillin–clavulanate for resolving exacerbations in children with non-severe bronchiectasis. In some patients, such as those with penicillin hypersensitivity or those likely to have poor adherence, azithromycin provides another option for treating exacerbations, but must be balanced with risk of treatment failure (within a 20% margin), longer exacerbation duration, and the risk of inducing macrolide resistance. Funding Australian National Health and Medical Research Council.

Children with cerebral palsy (CP) have lower habitual physical activity (HPA) than their typically developing peers. There are limited studies of HPA in young children with CP under the age of 5 years.To investigate the relationships between HPA, sedentary time, motor capacity and capability in children with CP aged 4-5 years.Sixty-seven participants were classified using Gross Motor Function Classification System (GMFCS), assessed for motor capacity using Gross Motor Function Measure (GMFM) and wore accelerometers for three days to measure HPA and sedentary time. Motor capability was assessed using parent-reported Pediatric Evaluation of Disability Inventory (PEDI) functional skills of mobility domain. Mixed-effects regression models were used for analyses.GMFM was positively associated with HPA (mean difference (MD) = 19.6 counts/min; 95%CI = 16.6 to 22.7, p 0.001) and negatively associated with sedentary time (MD = -0.6%; 95%CI = -0.7 to -0.5, p 0.001). The PEDI was also positively associated with HPA (MD = 16.0 counts/min; 95%CI = 13.1 to 18.8, p 0.001) and negatively associated with sedentary time (MD = -0.5%; 95%CI = -0.6 to -0.4, p 0.001). After stratification for ambulatory status, GMFM and PEDI were associated with HPA and sedentary time in ambulant participants but not in non-ambulant participants.Gross motor capacity and motor capability are related to HPA and sedentary time in ambulant children with CP aged 4-5 years.

Objectives Point-of-care ultrasound (POCUS) diagnosis of distal forearm fractures relies on the identification of buckling or breach of hyperechoic bone cortex. We describe the pronator quadratus hematoma (PQH) formation visualized on POCUS, the PQH sign, as it may aid diagnosis of pediatric distal forearm cortical breach fractures. Methods A prospective cohort of children presenting to an emergency department with isolated, clinically non-angulated distal forearm injuries received POCUS by an expert emergency physician sonologist who identified the presence or absence of the PQH sign. They secondarily recorded the difference between the size of the pronator quadratus (PQ) muscle on both the affected and non-affected forearms (PQ delta thickness). Children received an x-ray subsequent to POCUS and were diagnosed based on an x-ray reported by a radiologist masked to POCUS findings. Results Thirty-eight children were recruited. All 22 patients with cortical breach fracture had PQH sign present (100%; 95%CI: 85-100%), while all 16 patients without cortical breach fracture had PQH sign absent (100%; 95%CI: 79-100%). PQ delta thickness ranged from 2.1 to 10.2 mm in cortical breach fractures, 0.0 to 1.1 mm in buckle fractures, and 0.2 to 0.8 mm in patients without fracture. Conclusions The PQH sign correctly distinguished all children with, and without, cortical breach fractures. All PQ delta thicknesses were ≧2.1 mm when cortical breach fracture was present and ≦1.1 mm when cortical breach fracture was absent. The PQH sign and PQ delta thickness are promising measurements to identify pediatric distal forearm cortical breach fractures, and their utility should be confirmed in larger studies with sonologists of different abilities.

Background: Peripheral intravenous catheters (PIVCs) are medical devices used to administer intravenous therapy but can be complicated by soft tissue or bloodstream infection. Monitoring PIVC safety and quality through clinical auditing supports quality infection prevention however is labour intensive. We sought to determine the optimal patient ‘number’ for clinical audits to inform evidence-based surveillance. Methods: We studied a dataset of cross-sectional PIVC clinical audits collected over five years (2015–2019) in a large Australian metropolitan hospital. Audits included adult medical, surgical, women's, cancer, emergency and critical care patients, with audit sizes of 69–220 PIVCs. The primary outcome was PIVC complications for one or more patient reported symptom/auditor observed sign of infection or other complications. Complication prevalence and 95% confidence interval (CI) were calculated. We modelled scenarios of low (10%), medium (20%) and high (50%) prevalence estimates against audit sizes of 20, 50, 100, 150, 200, 250, and 300. This was used to develop a decision-making tool to guide audit size. Results: Of 2274 PIVCs evaluated, 475 (21%) had a complication. Complication prevalence per round varied from 7.8% (95% CI, 4.2–12.9) to 39% (95% CI, 32.0–46.4). Precision improved with larger audit size and lower complication rates. However, precision was not meaningfully improved by auditing >150 patients at a complication rate of 20% (95% CI 13.9%–27.3%), nor >200 patients at a complication rate of 50% (95% CI 42.9%–57.1%). Conclusion: Audit sizes should be 100 to 250 PIVCs per audit round depending on complication prevalence.

Approximately 80% of patients admitted to acute hospitals have at least one peripheral intravenous catheter inserted during their admission, for the administration of fluids and medicines, and/or diagnostic tests, so the failure rate is concerning. New technology may decrease these rates even when used by inexperienced inserters. The choice of insertion site for an intravenous catheter is a known predictor of catheter failure. Therefore, the objective for this study was to evaluate the utility of vessel locating devices for novice clinicians to select catheter insertion sites in the forearm.An inter-subject incomplete counterbalanced research design was employed with healthy volunteers. Novice clinicians used either a vessel locating device using light or sound waves or they used palpation to identify relatively superficial veins in the forearm. This was compared to site selection performed by an expert clinician using palpation method only. Measurements of differences were analysed from photos of chosen sites. Bland-Altman agreement analysis was used to plot novice expert agreement. The STROBE checklist was followed in reporting this study (Techniques to select site of insertion for a peripheral intravenous catheter with vessel locating devices (Appendix S1)).A total of 32 novice clinicians used three vessel locating devices and a palpation technique. Novice clinicians did not choose more veins for optimum catheter placement when assisted with vessel locating devices compared to palpation techniques. All methods had a similar mean difference between novice and expert measurements and a similar percentage difference in distance from the expert choice. Bland-Altman agreement analysis did not identify any advantage for the novice with vessel locating devices over palpation.Vessel locating devices do not enhance the ability of novice clinicians any greater than palpation when selecting suitable forearm veins. If vessel locating device approaches are to be adopted in clinical practice to support better insertion outcomes then current PIVC teaching techniques should include structured vessel locating devices theory and practice.Successful insertion of a peripheral intravenous catheter (PIVC) on the first attempt is a challenging procedure for nurses. Careful consideration of the selected site of insertion could modify this risk factor for catheter failure. The choice of PIVC insertion site by a novice clinician compared to an expert does not necessarily improve with the use of vein locating technology. While there is a range of technological devices available to assist with locating vessels, there needs to be more emphasis from educators on how to select an appropriate insertion site for intravenous therapy.

AIM To determine the predictors of magnitude of change in response to a participation-focused leisure-time physical activity intervention in children with cerebral palsy (CP) using the ParticiPAte CP protocol. METHOD We included 33 children (16 males, 17 females) aged 8 to 12 years (mean age=10y, SD=1y 6mo) with CP with pre/postintervention data from a wait-list randomized trial. The hypothesized linear predictors of change in primary outcomes (Canadian Occupational Performance Measure [COPM]-performance and COPM-satisfaction, Belief in Goal Self-Competence Scale (BiGSS), and minutes per day moderate-to-vigorous physical activity [MVPA]) were: age; Gross Motor Function Classification System level; comorbid autism spectrum disorder (ASD); Goal Attainment Scaling T score; Problems in Schools Questionnaire; Physical Activity Climate Questionnaire; Motives for Physical Activities Measure-Revised; and stage of behaviour change. Multivariable models were selected using the Bayesian information criterion. RESULTS Overcoming barriers to participation, age, and comorbid ASD explained 49% of the variance in change in COPM-performance. Being motivated by interest and/or enjoyment and age explained 32% of the variance in change in COPM-satisfaction. Being motivated by physical activity competence or appearance (extrinsic motivation) explained 24% of the variance in change in BiGSS. Parental autonomy supportiveness, overcoming barriers to participation, appearance motivation, and baseline MVPA explained 59% of the variance in change in MVPA. INTERPRETATION These findings support a behaviour paradigm for conceptualizing physical activity in children with CP. WHAT THIS PAPER ADDS Children who met their treatment goals showed a greater increase in physical activity participation. Children who were more intrinsically motivated by physical activity at baseline improved more. Being older and having a comorbid diagnosis of autism spectrum disorder were associated with an attenuated effect of the therapy.

Background Psychotropic medications are sometimes used off-label and inappropriately. This may cause harm to adolescents with intellectual disability. However, few studies have analysed off-label or inappropriate prescribing to this group. Aims To examine the appropriateness of psychotropic prescribing to adolescents with intellectual disability living in the community in south-east Queensland, Australia. Method Off-label medication use was determined based on whether the recorded medical condition treated was approved by the Australian Therapeutic Goods Administration. Clinical appropriateness of medication use was determined based on published guidelines and clinical opinion of two authors who specialise in developmental disability medicine (J.N.T. and D.H.). Results We followed 429 adolescents for a median of 4.2 years. A total of 107 participants (24.9%) were prescribed psychotropic medications on at least one occasion. Of these, 88 (82.2%) were prescribed their medication off-label or inappropriately at least once. Off-label or inappropriate use were most commonly associated with challenging behaviours. Conclusions Off-label or inappropriate use of psychotropic medications was common, especially for the management of challenging behaviours. Clinical decision-making accounts for individual patient factors and is made based on clinical experience as well as scientific evidence, whereas label indications are developed for regulatory purposes and, although appropriate at a population level, cannot encompass the foregoing considerations. Education for clinicians and other staff caring for people with intellectual disability, and a patient-centred approach to prescribing with involvement of families should encourage appropriate prescribing. The effect of the National Disability Insurance Scheme on the appropriateness of psychotropic medication prescribing should be investigated.

BACKGROUND AND OBJECTIVES: The coronavirus (CoV) disease 2019 pandemic has drawn attention to the CoV virus family. However, in community settings, there is limited information on these viruses in healthy children. We explored the epidemiology of the 4 endemic (non–severe acute respiratory syndrome CoV 2) human coronaviruses (HCoVs) by species, including acute illness episodes, risk factors, and health care burden in Australian children in the first 2 years of life. METHODS: The Observational Research in Childhood Infectious Diseases community-based cohort was a prospective study of acute respiratory illnesses in children from birth until their second birthday. Parents recorded daily symptoms, maintained an illness-burden diary, and collected weekly nasal swabs, which were tested for 17 respiratory viruses, including HCoVs, by real-time polymerase chain reaction assays. RESULTS: Overall, 158 children participating in Observational Research in Childhood Infectious Diseases provided 11 126 weekly swabs, of which 168 were HCoV-positive involving 130 incident episodes. HCoV-NL63 and HCoV-OC43 were most commonly detected, accounting for two-thirds of episodes. Whereas 30 children had different HCoVs detected on different occasions, 7 were reinfected with the same species. HCoV incidence in the first 2 years of life was 0.76 episodes per child-year (95% confidence interval [CI] 0.63 to 0.91), being greatest in the second year (1.06; 95% CI 0.84 to 1.33) and during winter (1.32; 95% CI 1.02 to 1.71). Fifty percent of HCoV episodes were symptomatic, and 24.2% led to health care contact. CONCLUSIONS: In children, HCoV infections are common, recurrent, and frequently asymptomatic. In future studies, researchers should determine transmission pathways and immune mechanisms.

Background Children frequently present to the emergency department (ED) with forearm injuries and often have x-rays to determine if there is a fracture. Bedside ultrasound, also known as point-of-care ultrasound (POCUS), is an alternative diagnostic test used to rapidly diagnose a fracture at the time of examination, without exposing children to ionising radiation. Prospective studies have demonstrated high agreement between POCUS and x-ray findings. However, whether the initial imaging modality affects the patient’s medium-term physical function is unknown. Methods This is a multicentre, open-label, non-inferiority randomised controlled trial conducted in Australian EDs. Recruitment will continue until 112 children with distal forearm injuries (including 48 buckle fractures) per trial arm have achieved the primary outcome measure. Patients aged 5–15 years presenting with an isolated, acute, clinically non-angulated, distal forearm injury with suspected fracture will have their initial diagnostic approach randomised to either POCUS, performed by a credentialled practitioner, or x-ray imaging. If a cortical breach fracture is identified on POCUS, the patient will receive x-rays and have usual care. If a buckle fracture is identified, the patient will have their forearm placed in a splint and be discharged home. Patients will be followed up at 1, 4 and 8 weeks. The primary outcome is upper limb physical function at 4 weeks, as determined by the Pediatric Upper Extremity Short Patient-Reported Outcomes Measurement Information System (PROMIS) tool. Secondary outcomes include healthcare costs, satisfaction, pain, complications, rates of imaging, ED length of stay and diagnostic accuracy. Discussion If POCUS is non-inferior to x-ray in terms of patient’s medium-term physical function, it may have an effect on overall health care resource use, including the number of x-ray performed and earlier ED discharge. Although prospective studies have confirmed the accuracy of POCUS, this will be the first RCT to assess non-inferiority of functional outcomes of POCUS to diagnose non-angulated paediatric distal forearm injuries, compared to x-ray. POCUS may be of particular importance in settings where access to x-ray imaging can be limited either during or after-hours, as it can aid the triaging and management of patients. Trial registration Prospectively registered with the ANZCTR on 29 May 2020 (ACTRN12620000637943).

This study aimed to identify which MRI and clinical assessments, alone or in combination, from (i) early (32 weeks postmenstrual age, PMA), (ii) term equivalent age (TEA) and (iii) 3 months corrected age (CA) are associated with motor or cognitive outcomes at 2 years CA in infants born31 weeks gestation.Prospective cohort study of 98 infants who underwent early and TEA MRI (n = 59 males; median birth gestational age 28 + 5 weeks). Hammersmith Neonatal Neurological Examination (HNNE), NICU Neonatal Neurobehavioural Scale and General Movements Assessment (GMs) were performed early and at TEA. Premie-Neuro was performed early and GMs, Test of Infant Motor Performance and visual assessment were performed at TEA and 3 months CA. Neurodevelopmental outcomes were determined using Bayley Scales of Infant and Toddler Development 3rd edition.The best combined motor outcome model included 3-month GMs (β = -11.41; 95% CI = -17.34, -5.49), TEA MRI deep grey matter score (β = -6.23; 95% CI = -9.47, -2.99) and early HNNE reflexes (β = 3.51; 95% CI = 0.86, 6.16). Combined cognitive model included 3-month GMs (β = -10.01; 95% CI = -15.90, -4.12) and TEA HNNE score (β = 1.33; 95% CI = 0.57, 2.08).Early neonatal neurological assessment improves associations with motor outcomes when combined with term MRI and 3-month GMs. Term neurological assessment combined with 3-month GMs improves associations with cognitive outcomes.We present associations between 32- and 40-week MRI, comprehensive clinical assessments and later 2-year motor and cognitive outcomes for children born31 weeks gestation. MRI and clinical assessment of motor, neurological and neurobehavioural function earlier than term equivalent age in very preterm infants is safe and becoming more available in clinical settings. Most of these children are discharged from hospital before term age and so completing assessments prior to discharge can assist with follow up. MRI and neurological assessment prior to term equivalent age while the child is still in hospital can provide earlier identification of children at highest risk of adverse outcomes and guide follow-up screening and intervention services.

Volatile organic compound (VOC) breath testing of lung and head and neck squamous cell carcinoma (SCC) has been widely studied, however little is known regarding VOC profiles of in-situ SCC. A prospective study of VOC in patients with histologically proven SCC, either in-situ or advanced, and controls. Breath samples were analysed using the E-nose Cyranose ®320 and by gas chromatography/mass spectroscopy. Predictive models were developed using bootstrap forest using all 32 sensors. Data from 55 participants was analysed: 42 SCC cases comprising 20 bronchial (10 in-situ, 10 advanced) and 22 laryngeal (12 in-situ, 10 advanced), and 13 controls. There were 32 (76%) male SCC cases with mean age 63.6 (SD = 9.5) compared with 11 (85%) male controls with mean age 61.9 (SD = 10.1). Predictive models for in situ cases had good sensitivity and specificity compared to controls (overall, 95% and 69%; laryngeal, 100% and 85%; bronchial, 77% and 80%). When distinguishing in-situ and advanced tumours, sensitivity and specificity 82% and 75% respectively. For different tumour types (bronchial versus advanced laryngeal) sensitivity and specificity were 100% and 80% respectively. VOCs isolated from in-situ cancers included some previously demonstrated in advanced cancers and some novel VOCs. In-situ bronchial and laryngeal cancer can be detected by VOC analysis. Distinction from normal controls and between the two tumour types could allow screening in high risk groups for these curable lesions.

Objectives:To confirm the factor validity of the Compassionate Engagement and Action Scales (CEAS), as set out in the original development study, when used with a sample of family carers of older adults.Design:A series of confirmatory factor analyses were undertaken to test the previously proposed factor solutions of each scale.Setting:As part of a larger cross-sectional survey, the scales were completed online or via hard copy between July and December 2019.Participants:An international sample of 171 family carers of adults aged 65 years or older.Measurements:The CEAS are three measures that individually assess Compassion for Self, Compassion to Others, and Compassion from Others. All scales measure two aspects, “engagement” and “actions” (two-factor solution), and Compassion for Self also measures two further dimensions within engagement: “sensitivity to suffering” and “engagement with suffering” (three-factor solution).Results:Results were largely consistent with the two-factor solutions proposed for the three orientations of compassion, with acceptable fit and good internal reliability. There was some support for the three-factor solution of Compassion for Self; however, despite model fit comparable to the two-factor solution, internal reliability of the delineated “engagement” dimensions was low, and there was a weak factor loading for item 5 that measured distress tolerance.Conclusions:Use of the CEAS with family carers of older adults is promising. Further research is recommended with larger samples and to explore distress tolerance as a competency within conceptualization and measurement of compassion.

Objective: Evaluate the validity of the Kids-Balance Evaluation Systems Test (Kids-BESTest) clinical criteria for the Functional Reach Test (FRT) forward and lateral with laboratory measures of postural control in children with cerebral palsy (CP). Design: Psychometric study of face, concurrent, and content validity. Setting: Clinical laboratory. Participants: Children (N=58) aged 7-18 years (ambulant CP n=17, typically developing [TD] n=41). Intervention: Not applicable. Main Outcome Measures: Stability limits in standing were assessed using the Kids-BESTest items for FRT forwards (FRTFORWARD), FRT lateral preferred (FRTLATERAL(P)), and FRT lateral nonpreferred (FRTLATERAL(NP)). Force platforms and kinematic markers were used to collect information on center of pressure (CoP) and joint movement during reach. Analyses included face validity (Kids-BESTest scores compared between CP and TD groups), concurrent validity (agreement between Kids-BESTest scores and digitally derived scores), and content validity (relations between Kids-BESTest scores with kinematic and CoP data). Results: Face validity of Kids-BESTest criteria was demonstrated with lower scores for CP compared to TD groups for FRTFORWARD (P

BackgroundPaediatric distal forearm fractures are a common ED presentation. They can be diagnosed with point-of-care ultrasound (POCUS) as an alternative to X-rays. Given that ED nurse practitioners (NPs) are relied on for the diagnosis of paediatric fractures, it is important to describe the diagnostic accuracy of NP-conducted POCUS versus X-ray.MethodsThis prospective diagnostic study was conducted in a tertiary paediatric hospital in Queensland, Australia, between February 2018 and April 2019. Participants were children aged 4–16 years with a clinically non-angulated, suspected distal forearm fracture. Diagnosis from 6-view NP-administered POCUS of the distal radius and ulna was compared against the reference standard of 2-view X-ray. Each patient received both imaging modalities. Overall forearm diagnosis was classified as ‘no’, ‘buckle’ or ‘other’ fracture for both modalities. The primary outcome was diagnostic accuracy for ‘any’ fracture (‘buckle’ and ‘other’ fractures combined). Secondary outcomes included diagnostic accuracy for ‘other’ fractures versus ‘buckle’ and ‘no’ fractures combined, and pain, imaging duration and preference for modality.ResultsOf 204 recruited patients, 129 had X-ray-diagnosed forearm fractures. The sensitivity and specificity for NP-administered POCUS were 94.6% (95% CI 89.2% to 97.3%) and 85.3% (95% CI 75.6% to 91.6%), respectively. ‘Other’ fractures (mostly cortical breach fractures), when compared with ‘buckle’/ ‘no’ fractures, had sensitivity 81.0% (95% CI 69.1% to 89.1%) and specificity 95.9% (95% CI 91.3% to 98.1%). Pain and imaging duration were clinically similar between modalities. There was a preference for POCUS by patients, parents and NPs.ConclusionsNP-administered POCUS had clinically acceptable diagnostic accuracy for paediatric patients presenting with non-angulated distal forearm injuries. This included good sensitivity for diagnosis of ‘any’ fracture and good specificity for diagnosis of cortical breach fractures alone. Given the preference for POCUS, and the lack of difference in pain and duration between modalities, future research should consider functional outcomes comparing POCUS with X-ray in this population in a randomised controlled trial.

There is a strong association between access to early intervention (EI) services by 6 months of age and improved speech and language outcomes for children with permanent hearing loss (PHL)....

Estimates of acute gastroenteritis (AGE) burden are difficult to compare between studies because of inconsistent definitions describing this illness. AGE definitions used in prospective, community-based childhood cohort studies were identified by searching databases for studies that collected daily observations of AGE symptoms. Disease definitions and refractory periods were extracted. Data from the Australian community-based Observational Research in Childhood Infectious Diseases birth cohort were used to calculate AGE incidence and duration using identified AGE definitions, and the World Health Organization definition for diarrhoea. Eight distinct AGE definitions were identified. All included loose stools and 7 included vomiting as symptoms. The refractory period separating episodes ranged from 1 to 21 days. When applied to the Observational Research in Childhood Infectious Diseases dataset, AGE incidence ranged from 0.8 to 2.6 episodes per child-year-at-risk, a 3-fold relative difference. Direct comparisons of rates from different cohorts can only be undertaken if a standard definition for AGE is adopted.

EDITOR–A recent letter by Hastings‐Ison and Graham1 considered three randomized controlled trials (RCTs) that report the outcome of botulinum neurotoxin A (BoNT‐A) injections in children with cerebral palsy (CP), and asserted that they were not effectively blinded. This assertation is made because, at follow‐up, parents and researchers were able to identify which group (BoNT‐A or placebo) the child was allocated to. However, a question such as ‘Do you think your child received BoNT‐A or placebo?’ can only be used to assess the effectiveness of blinding if it is answered before any effect due to the treatment occurs. If the same question is asked after the treatment has taken effect, then it becomes an outcome measure – a measure of the parent's expectation of the intervention's success.

No randomized controlled trial has investigated the efficacy of hypnosis for reducing pain and improving wound-healing in children with burns. This randomized controlled trial aimed to investigate whether hypnosis decreases pain, anxiety, and stress and accelerates wound-healing in children undergoing burn wound procedures. Children (4-16 years) with acute burns presenting for their first dressing change were randomly assigned to a Hypnosis Group who received hypnosis plus standard care or a Standard Care Group who received standard pharmacological and nonpharmacological intervention. Repeated measures of pain intensity, anxiety, stress, and wound-healing were taken at dressing changes until ≥95% wound re-epithelialization. Data for 62 children were analyzed on an intent-to-treat basis using Generalized Estimating Equations (n = 35 Standard Care Group; n = 27 Hypnosis Group). An effect on the primary outcomes of pain and wound healing was not supported {self-reported pain intensity largest Mean Difference [MD] = -0.85 (95% confidence interval [CI]: -1.91 to 0.22), P = 0.12; MD for re-epithelialization = -0.46 [95% CI: -4.27 to 3.35], P = 0.81}. Some support was found for an effect on the secondary outcomes of preprocedural anxiety (MD = -0.80 [95% CI: -1.50 to -0.10], P = 0.03 before the second dressing change) and heart rate as a measure of stress (MD = -15.20 [-27.20 to -3.20], P = 0.01 and MD = -15.39 [-28.25 to -2.53], P = 0.02 before and after the third dressing change). Hypnosis may be effective for decreasing preprocedural anxiety and heart rate in children undergoing repeated pediatric wound care procedures but not for reducing pain intensity or accelerating wound healing.

Introduction Injury is the leading cause of mortality and morbidity in adolescents worldwide, and injury rates have been shown to be higher among youth with intellectual disability. Despite this, injury among adolescents with intellectual disability remains poorly investigated. This study aimed to identify characteristics associated with injury among adolescents with intellectual disability living in the community. Methods A cohort of adolescents with intellectual disability living in southern Queensland, Australia was investigated prospectively between January 2006 and June 2010. Personal characteristics were collected via postal questionnaire. Injury information, including mechanism and location of injury, was extracted from general practitioner records. The association between demographic, social and clinical characteristics of participants and episodes of injury was investigated using negative binomial regression. Results A total of 289 injuries were recorded from 432 participants over 1627.3 years of study-time. The overall annual injury incidence was 17.5 (95%CI 14.7, 20.9) per 100 person years. Presence of ADHD and less severe disability was associated with increased risk of injury. Down syndrome and reduced verbal communication capacity were associated with decreased risk of injury. Falls accounted for the highest single mechanism of injury (19.0%) with the majority (73.2%) of injuries involving either upper or lower limbs. Conclusions ADHD is a co-morbidity that increases risk of injury among adolescents with intellectual disability. A critical component of injury prevention is avoidance of the great variety of environmental risk factors for injury relevant to this population.