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As factors influencing the health and well-being of children are complex and cross-sectoral, integrated interventions are required to improve child health and hence address the Sustainable Development Goals. This paper explores linkages between environmental factors, feeding practices and potential infection pathways in India. The PANChSHEEEL project is a participatory interdisciplinary study, designed to explore HEEE (Health, Education, Engineering and Environment) factors influencing Infant and Young Child Feeding practices. This study uses data from observational transect walks and 445 household interviews from nine villages in Banswara district in India. Using the socio-ecological model, this study demonstrates how the lack of access to and quality of water resources, poor access to sanitation and hygiene practices, access to cooking fuels and flooding can influence feeding practices. The study finds that access to water, sanitation and cooking fuels can affect the preparation of food, contaminate water and food and place added time burden on caregivers. For infants, insufficient and contaminated water can lead to a higher risk of infection, diarrhoea and ultimately malnutrition. Recommendations include efforts to address waterlogging, promote safe storage of water, establish a water quality regime with stakeholders and develop appropriate, affordable and acceptable sanitation solutions. HIGHLIGHTS The use of observational transect walks to better capture linkages between environment and feeding practices.; The socio-ecological framework is used to map links between built environment and feeding practices at the village, household and individual level.; Opportunities to improve child health through linkages to SDG 2 (Hunger), SDG 3 (Health), SDG 6 (Baby WASH) and SDG 7 (Energy).

In March 2020, the outbreak of COVID‐19 was officially declared a global pandemic by the World Health Organization. Given the novelty of the virus, and hence, lack of official guidance on effective containment strategies, individual countries opted for different containment approaches ranging from herd immunity to strict lockdown. The opposing strategies followed by the United Kingdom and its former colony, Malaysia, stand exemplary for this. Real‐time polymerase chain reaction was implemented for testing in both counties. Malaysia acted with strict quarantining rules and infection surveillance. The United Kingdom followed an initially lenient, herd‐immunity approach with strict lockdown only enforced weeks later. Although based on the same health‐care structure historically, Malaysia developed a more unified health system compared with the United Kingdom. We suggest that this more centralized structure could be one possible explanation for why Malaysia was able to react in a more timely and efficient manner, despite its closer geographic proximity to China. We further explore how the differences in testing and quarantining strategy, as well as political situation and societal compliance could account for the discrepancy in the United Kingdom's versus Malaysia's relative success of COVID‐19 containment., Key Points 1.Different countries employed a range of strategies toward the COVID‐19 pandemic, with varying levels of success.2.Malaysia's strict rule enforcement were reflected both in quantitative and qualitative terms.3.Despite the closer geographical proximity to the source of the outbreak, Malaysia fared better than the United Kingdom in its response to the pandemic, suggesting that there are valuable lessons to be learned for the developed from developing, limited‐resource countries.

Purpose Children with Down’s syndrome (DS) are prone to respiratory tract infections (RTIs) due to anatomical variation, immune system immaturity and comorbidities. However, evidence on RTI-related healthcare utilisation, especially in primary care, is incomplete. In this retrospective cohort study, we use routinely collected primary and secondary care data to quantify RTI-related healthcare utilisation in children with DS and matched controls without DS. Methods Retrospective cohort study of 992 children with DS and 4874 matched controls attending English general practices and hospitals as identified in Clinical disease research using LInked Bespoke studies and Electronic health Records (CALIBER) from 1997 to 2010. Poisson regression was used to calculate consultation, hospitalisation and prescription rates, and rate ratios. Wald test was used to compare risk of admission following consultation. The Wilcoxon rank–sum test was used to compare length of stay by RTI type and time-to-hospitalisation. Results RTI-related healthcare utilisation is significantly higher in children with DS than in controls in terms of GP consultations (adjusted RR 1.73; 95% CI 1.62–1.84), hospitalisations (adjusted RR 5.70; 95% CI 4.82–6.73), and antibiotic prescribing (adjusted RR 2.34; 95% CI 2.19–2.49). Two percent of children with DS presenting for an RTI-related GP consultation were subsequently admitted for an RTI-related hospitalisation, compared to 0.7% in controls. Conclusions Children with DS have higher rates of GP consultations, hospitalisations and antibiotic prescribing compared to controls. This poses a significant burden on families. Further research is recommended to characterise healthcare behaviours and clinical decision-making, to optimise care for this at risk group.

The laboratory diagnosis of SARS-CoV-2 infection comprises the informational cornerstone in the effort to contain the infections. Therefore, the ability to leverage laboratories' capacity in diagnostic testing and to increase the number of people being tested are critical. This paper reviews the readiness of Indonesian laboratories during the early months of the pandemic. It discusses the success of cross-sectoral collaboration among previously siloed national and sub-national government institutions, international development agencies, and private sector stakeholders. This collaboration managed to scale-up the COVID-19 referral laboratory network from one Ministry of Health NIHRD laboratory in the capital to 685 laboratories across 34 provinces. However, this rapid growth within 12 months since the first Indonesian case was discovered remained insufficient to cater for the constantly surging testing demands within the world's fourth most populous country. Reflecting on how other countries built their current pandemic preparedness from past emergencies, this paper highlights challenges and opportunities in workforce shortage, logistic distribution, and complex administration that need to be addressed.

Infections are the leading cause of mortality in children worldwide. Amongst those, respiratory infections and gastrointestinal diseases are the most prevalent. The health effects of these infections are exacerbated by increasing levels of antimicrobial resistance (AMR) due to poor antibiotic governance, particularly in developing nations, where rates of antibiotic consumption and resistance are highest. The aim of Childhood Infections and Pollution Consortium (CHIP) is to reduce the burden of childhood infections and AMR through the co-production of integrated, low-cost behavioural and slum-upgrading interventions using a One Health and technology-enabled Citizen Science approach. As a …

Objective:To systematically review the literature with the primary aim of identifying behavioural interventions to improve vitamin D stores in children from at-risk ethnic groups.Design:Review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PROSPERO registration number: CRD42017080932. Health Behaviour Model and Behaviour Change Wheel framework constructs used to underpin evaluation of interventions. Methodological quality evaluated using Cochrane Risk of Bias, Cochrane ROBINS-I and NHLBI tools.Setting:Databases Cochrane Library, MEDLINE, EMBASE, CINAHL with secondary search of Google Scholar. No country limits set. Papers between January 1990 and February 2018, published in English included. Anticipating study heterogeneity, outcome measures not pre-specified and identified from individual full papers. Updated literature search November 2020.Participants:Patient or population including pregnant women, newborns and children aged under 18 years, from Asian or African ethnic groups.Results:Of 10 690 articles screened, 298 underwent full-text review, with 24 ultimately included for data extraction. All identified studies conducted a vitamin D pharmacological supplementation intervention, with two also incorporating a behavioural intervention strategy. No study explicitly defined a primary aim of evaluating a behavioural intervention, undertaken to study its effect on vitamin D supplement uptake.Conclusions:There is a need to address the paucity of data in ethnic at-risk children on how behavioural interventions ideally developed and co-produced with the community under study, affect and help improve vitamin D uptake, within the antenatal and pregnancy phase as well as during childhood.

Background Respiratory Tract Infections (RTIs) and Gastro-Intestinal (GI) infections are the leading causes of child mortality and morbidity. This study investigates the associations between the individual, household and slum-level determinants of children’s health and vulnerability to RTIs and GI infections in peri-urban slums in India; an area of research interest at the Childhood Infections and Pollution Consortium. Methods The 2015–16 Indian National Family Health Survey was used for data analysis on children aged 0–5 years. NFHS-4 includes data on slums in eight Indian cities, including Delhi, Meerut, Kolkata, Indore, Mumbai, Nagpur, Hyderabad, Chennai. The outcome variables, having fever and cough (FeCo) and diarrhoea in the last two weeks, were used to define the phenotype of infections; for this analysis fever and cough were measures of RTIs and diarrhoea was used to measure GI infections. Exposures considered in this study include variables at the individual, household and slum level and were all informed by existing literature. Multilevel models were used to estimate the association between exposures and outcomes variables; a prior of Cauchy distribution with a scale of 2.5 was selected when building the multilevel logistic models. Results The total sample size of the number of children included in the analysis was n = 1,424. Data was imputed to account for missingness, and the original and imputed sample showing similar distributions. Results showed that diarrhoea and FeCo were both found to be more present in younger children than older children by a few months. In fixed effects, the odds of developing FeCo were higher if the mother perceives the child was born smaller than average (AOR 4.41, 1.13–17.17, Polder (AOR 0.97, 0.96–0.98, Ppublic tap or standpipe (AOR 0.54, 0.31–0.96, P Conclusion The determinants of health, both social and related to health care, at all levels demonstrated linkages to child morbidity in RTIs and GI infections. The empirical evidence highlights the need for contextualised ideas at each level, including one health approach when designing interventions to improve child health.

Purpose: Infectious diseases are one of the leading causes of death among children under five (U5s) both in India and globally. This is worse in slum environments with poor access to water, sanitation and hygiene (WASH), good nutrition and a safe built environment. Globally, a One Health (i.e. human, animal and environment) approach is increasingly advocated for by the WHO-FAO-OIE tripartite to reduce infections and antimicrobial resistance. As under-5s living in peri-urban slums are exposed to household- and community-owned companion and livestock animals and pests, the CHIP consortium hypothesised that employing a One Health approach to co-produce behavioural change and slum upgrading interventions may reduce this burden where other WASH and nutrition interventions have failed. This study aimed to assess the feasibility of employing a One Health approach to assess under-5 infection and risk factor prevalence in Jaipurs peri-urban slums, prior to undertaking prospective cohort studies involving culture and culture-independent sampling of under-5s and animals across our study sites in Jaipur (Rajasthan, India), Jakarta (Indonesia) and Antofagasta (Chile). Methods: We administered a rapid household survey to 25 purposively selected households across six slums in Jaipur. The questionnaire used evaluated infection prevalence, healthseeking behaviours, the built environment, the presence of companion and livestock animals and pests, and individual- and household-level demographics. We displayed the correlations between infection incidence and a range of factors in our sample, and displayed the portion of children under 5 who experienced one or multiple episodes of ill health, categorised by a range of One Health factors. Results: Parents reported at least one recent episode of ill health for a large portion (40%) of under-5s within the last 30 days. 80% of under-5s had no access to safe drinking water; every household reported the presence of at least one kind of pest within the respondents own home; and 20% of under-5s feeding equipment was cleaned with water only. Only one household reported owning a companion or livestock animal, potentially reflecting confusion about the definition of these animals. The incidence of infection appeared to be related to WASH and socio-economic factors as expected. Conclusion: Safe drinking water, pest control and behavioural change surrounding the cleaning of under-5 feeding equipment should be given consideration in future research in this locale. Future studies should not rely solely on parent reporting of childrens symptoms cross referencing symptom reporting from multiple household members should be combined with culture and culture-independent sampling. Where possible, researchers should measure the presence of companion and livestock animals directly to avoid misinterpretation and to observe practices rather than relying on reporting alone.

Aim During humanitarian emergencies, women and children are particularly vulnerable to health complications, and neonatal mortality rates rise. Additionally, health cluster partners face challenges in coordinating referrals from communities and camps to health facilities, and between different levels of health facilities. The purpose of this review was to identify the primary referral needs among neonates during humanitarian emergencies, current gaps and barriers, and effective mechanisms for overcoming these barriers. Methods A systematic review was performed using 4 electronic databases (CINAHL, EMBASE, Medline, and Scopus) and multiple grey literature sources between June and August 2019. Title, abstract, and full text screening were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The target population was neonates born during humanitarian emergencies. Studies from high-income countries and prior to 1991 were excluded. The STROBE checklist was used to assess for risk of bias. Results A total of 35 articles were included in the analysis; these were mainly qualitative, field-based studies. The primary needs identified were referrals from homes to health facilities before and during labour, and inter-facility referrals after labour to more specialised services. Some of the main barriers included a lack of roads and infrastructure for transport, a deficiency of specialised equipment for complications, staff shortages – especially among more specialised services, and a lack of knowledge among healthcare workers for identifying neonatal referral issues. Effective mechanisms for addressing these needs and gaps included establishing pre- or post-natal home visits by Community Health Workers or Traditional Birth Attendants; standardised, inter-facility referral checklists and procedures for healthcare staff; and staff training programmes for identification of neonatal complications. The severity and issues varied significantly between different countries and emergencies. Conclusion This review benefited from a strong consensus among selected studies but was limited in the quality of data and types of data that were reported. Based on the above findings, the following recommendations were compiled: Recruit community healthcare workers to raise awareness and reduce pressure on health facilities. Establish contextualised programmes that address local needs and draw on local resources. Continue to train healthcare workers to provide timely, appropriate and quality care during humanitarian emergencies.

Aims To explore optimal nutritional care practices and their drivers within the British Bangladeshi population as an exemplar to inform a tailored, co-adapted intervention design. Methods Qualitative community based participatory research. Multiple recruitment strategies were used to purposively sample the British Bangladeshi population. Community facilitators were an active partner in this study and worked as a bridge to the community. A total of 145 participants completed the study and were recruited to 12 focus groups and 45 semi-structured interviews, including; British Bangladeshi mothers, fathers, grandmothers and grandfathers of infants and young children aged 6–23 months; key informants and lay community members from the British Bangladeshi population and health professionals. Transcripts were then checked and were analysed using framework analysis. Results Two overarching themes were identified during interviews and group discussions: (1) modifiable infant feeding practices that participants suggested could be targeted in order to optimise infant feeding and (2) socio-ecological factors believed by participants to influence these modifiable feeding practices. Participants discussed several infant feeding practices that may restrict dietary diversity, override infant satiety and encourage dependence on sugary or sweetened foods and impact on broader care practices such as sleeping and physical activity. Specifically, four modifiable infant feeding and care practices were highlighted: untimely introduction of semi- and solid foods, overfeeding, prolonged parent-led feeding and feeding to ‘fill the belly’. These practices were driven by factors at all socio-ecological levels, categorised as: society, culture and religion, physical and local environment and information and awareness. Conclusions Parenting interventions need to be culturally sensitive to populations of diverse ethnicity and recognise the social and cultural norms that inform complementary feeding practices. Further, the infant feeding environment requires better regulation of marketing of foods for infant and young children. More evidence is needed to inform effective early years interventions.

Background Since 2013, the number of violent crimes and offences by sharp instruments have increased continually, following a previous decrease, with majority of cases occurring among young people and in London. There is limited understanding surrounding the drivers influencing this change in trends, with mostly American-based research identifying risk factors. Methods The aim of this review is to identify and synthesise evidence from a range of literature to identify risk factors associated with weapon-related crime, for young people (aged 10–24 years) within the UK. A search strategy was generated to conduct a systematic search of published and grey literature within four databases (EMBASE, Medline, PsycINFO, and OpenGrey), identifying papers within a UK-context. Abstracts and full texts were screened by two independent reviewers to assess eligibility for inclusion, namely study focus in line with the objectives of the review. Weight of Evidence approach was utilised to assess paper quality, resulting in inclusion of 16 papers. Thematic analysis was conducted for studies to identity and categorise risk factors according to the WHO ecological model. Results No association was found between gender or ethnicity and youth violence, contrasting current understanding shown within media. Multiple research papers identified adverse childhood experiences and poor mental health as positively associated with youth and gang violence. It was suggested that community and societal risk factors, such as discrimination and economic inequality, were frequently linked to youth violence. A small number of studies were included within the review as this is a growing field of research, which may have led to a constrained number of risk factors identified. Due to heterogeneity of studies, a meta-analysis could not be conducted. As many studies displayed positive results, publication bias may be present. Conclusions Several risk factors were identified, with evidence currently heterogeneous with minimal high-quality studies. However, findings highlight key areas for future research, including the link between poor mental health and knife-crime, and the trajectory into gangs. Risk factors should help identify high-risk individuals, targeting them within mitigation strategies to prevent involvement within crime. This should contribute to efforts aimed at reducing the rising crime rates within UK. Systematic review registration number CRD42019138545. Registered at PROSPSERO: 16/08/2019.

Introduction We explored how different chronic diseases, risk factors, and protective factors highly associated with cardiovascular diseases (CVD) are associated with dementia or Mild Cognitive Impairment (MCI) in Korean elders, with a focus on those that manifest in mid-life. Methods A CVD-free cohort (n = 4289) from the Korean Longitudinal Study of Aging was selected to perform Cox mixed-effects proportional hazard regressions. Eighteen control variables with strong associations to CVD were chosen as explanatory variables, and Mini-Mental State Examination (MMSE) score cut-off for dementia and MCI were used as outcome variables. Results The statistically significant (P Conclusion In lieu of the protective factor of MCI and dementia, implementing regular exercise routine well before mid-life and cognitive decline is significant, with adjustments made for those suffering from health conditions, so they can continue exercising despite their morbidity. Further attention in diabetes care and management is needed for patients who already show decline in cognitive ability as it is likely that their MCI impacts their ability to manage their existing chronic conditions, which may adversely affect their cognitive ability furthermore.

ObjectivesTo explore optimal infant feeding and care practices and their drivers within the British-Bangladeshi population of East London, UK, as an exemplar to inform development of a tailored, coadapted participatory community intervention.DesignQualitative community-based participatory research.SettingCommunity and children’s centres and National Health Service settings within Tower Hamlets, London, UK.Participants141 participants completed the community study including: British-Bangladeshi mothers, fathers, grandmothers and grandfathers of infants and young children aged 6–23 months, key informants and lay community members from the British-Bangladeshi population of Tower Hamlets, and health professionals working in Tower Hamlets.Results141 participants from all settings and generations identified several infant feeding and care practices and wider socioecological factors that could be targeted to optimise nutritional outcomes. Our modifiable infant feeding and care practices were highlighted: untimely introduction of semi and solid foods, overfeeding, prolonged parent-led feeding and feeding to ‘fill the belly’. Wider socioecological determinants were highlighted, categorised here as: (1) society and culture (e.g. equating ‘chubby baby’ to healthy baby), (2) physical and local environment (e.g. fast food outlets, advertising) and (3) information and awareness (e.g. communication with healthcare professionals around cultural norms).ConclusionsParenting interventions should be codeveloped with communities and tailored to recognise and take account of social and cultural norms and influence from different generations that inform infant feeding and care practices and may be of particular importance for infants from ethnically diverse communities. In addition, UK infant feeding environment requires better regulation of marketing of foods for infants and young children if it is to optimise nutrition in the early years.

BACKGROUND: Children with Down Syndrome (DS) are at high risk of respiratory tract infections (RTIs) due to anatomical variations, comorbidities and immune system immaturity. Evidence on interventions to reduce this risk is incomplete. This study aims to quantify the effect of antibiotics prescribed for RTIs in primary care on the subsequent risk of RTI-related hospitalisation for children with DS versus controls. METHODS: We conducted a retrospective cohort study of 992 children with DS and 4,874 controls managed by UK National Health Service (NHS) General Practitioners (GPs) and hospitals as identified in CALIBER (Clinical disease research using LInked Bespoke studies and Electronic health Records), 1997-2010. Univariate and multivariate logistic regression were undertaken. RESULTS: In children with DS, the prescription of antibiotics following an RTI-related GP consultation did not significantly reduce the risk of RTI-related hospitalisation in the subsequent 28 days (Risk with antibiotics 1.8%; without 2.5%; Risk Ratio (RR) 0.699, 95% Confidence Interval (CI) 0.471-1.036). Subgroup analyses showed a risk reduction only in infants with DS, after adjustment for covariates. There was no reduction in risk for controls, overall or across subgroups. CONCLUSIONS: In conclusion, whilst prescription of antibiotics following RTI-related GP consultations were effective for infants with DS in reducing subsequent RTI-related hospitalisation, this was not the case for older children with DS. We would encourage further high-quality cohort and randomised controlled trials to interrogate this finding, and to examine the impact of antibiotics on other endpoints, including symptom duration. This article is protected by copyright. All rights reserved.

Purpose: The Ebola Virus Disease (EVD) epidemic was one of the most severe public health emergencies in modern times. The economic impact of epidemics has mostly been analysed at the macroeconomic level. Conversely, we aimed to estimate the economic costs of preventive measures of the epidemic to an extractive firm, ArcelorMittal, using data in the epidemic region from March 2014 to December 2015. ArcelorMittal is the worlds largest steel producer and particularly important in West Africa, where the extractive industry is economically crucial. Methods: Qualitative methods, in-depth interviews and focus group discussions, were used to investigate the events and channels of impact of the epidemic on the firm, as perceived by employees and contractors. Quantitative data regarding these costs was also collected. Retrospective cost analysis estimated the actual cost of preventive methods adopted. Results: Most respondents indicated the largest cost impact was suspension of Phase II expansion, a series of projects designed to increase iron ore production in Liberia. The next largest cost was the preventive measures adopted to counter disease spread. Total costs incurred for adopting preventive measures was USD 10.58-11.11 million. The overall direct costs of preventive measures adopted within the fence, meaning within the physical boundary of the firms sites, shared 30-31% of the total costs incurred. The share of external donation supporting humanitarian response was 11-12% of the total costs, followed by 7-12% of relational costs. Conclusions: The firms response during the EVD epidemic focused on its employees and operations, which was later expanded to the wider community and then in supporting the international humanitarian response.

Background The Indonesia National Task Force for the Acceleration of COVID-19 Mitigation has developed an integrated monitoring system to measure community compliance with the health protocol Bersatu Lawan COVID-19. The current study aims to evaluate compliance with the health protocol in Indonesia through the Bersatu Lawan COVID-19 digital mobile application. Methods Data was collected from the National Task Force between Oct 1, 2020, and May 2, 2021. A total of 437 093 front-line public order forces (eg, police and the military) and Behavioural Change Ambassadors reported real-time community compliance on mask wearing and physical distance keeping at public places such as markets, malls, schools, offices, and worship places. Individuals who did not comply were reprimanded and educated. Findings As of May 2, 2021, more than 165 million reports were gathered, with 469 million people were monitored in 514 districts or cities across 34 provinces in Indonesia. The overall national figures show a compliance of 322 736 010 (85·9%) of 375 711 304 people in mask wearing, and of 315 973 207 (84·1%) of 375 711 304 people in keeping physical distance, as a cumulative estimate. The results showed the variation of compliance rates among districts and cities in provinces. An analysis of data gathered in the week of April 26 to May 2, 2021, showed that mask wearing compliance was low (defined as observed by less than 75% of people) in 103 (29·6%) of 348 districts and cities across Indonesia, and that physical distance compliance was low in 99 (28·4%) of 348 districts and cities. The temporal pattern analysis estimated that compliance decreased in November and December, 2020 (before the peak of the second wave of the pandemic), and that it increased between January and May, 2021 (during and after the second wave). 321 million people were reprimanded and educated on the importance of adherence to the health protocol. Interpretation This paper discusses an example of the use of the Bersatu Lawan COVID-19 application in Indonesia, the most populous country in southeast Asia. We report the first time that an application for digital health, introduced nationally, produced data that could be analysed on a real-time basis, thus enabling central and local government to strengthen enforcement of the health protocol to stop the potential transmission of COVID-19 in public places. Funding No funding to declare.

ObjectiveSuboptimal nutrition among children remains a problem among South Asian (SA) families. Appropriate complementary feeding (CF) practices can greatly reduce this risk. Thus, we undertook a systematic review of studies assessing CF (timing, dietary diversity, meal frequency and influencing factors) in children aged DesignSearches between January 2000 and June 2016 in MEDLINE, EMBASE, Global Health, Web of Science, OVID Maternity & Infant Care, CINAHL, Cochrane Library, BanglaJOL, POPLINE and WHO Global Health Library. Eligibility criteria: primary research on CF practices in SA children aged 0–2 years and/or their families. Search terms: ‘children’, ‘feeding’ and ‘Asians’ with their derivatives. Two researchers undertook study selection, data extraction and quality appraisal (EPPI-Centre Weight of Evidence).ResultsFrom 45 712 results, seventeen studies were included. Despite adopting the WHO Infant and Young Child Feeding guidelines, suboptimal CF was found in all studies. Nine of fifteen studies assessing timing recorded CF introduced between 6 and 9 months. Five of nine observed dietary diversity across four of seven food groups; and two of four, minimum meal frequency in over 50 % of participants. Influencing factors included lack of CF knowledge, low maternal education, socio-economic status and cultural beliefs.ConclusionsThis is the first systematic review to evaluate CF practices in Pakistan. Campaigns to change health and nutrition behaviour are needed to meet the substantial unmet needs of these children.

Informal settlements are home to over 1 billion people worldwide and are characterised by high population densities and poor environmental conditions. The authors identify the impact of COVID-19 on existing water and sanitation practices and potential pathways for the transmission of COVID-19 in informal settlements in India and Indonesia. In the short term, there is an urgent need for mobile and contactless hand washing, washing/bathing facilities and toilets. In the long term, COVID-19 provides an opportunity to invest in centralised water and sanitation networked solutions appropriate for high-density settings to integrate those settlements into cities and improve environmental conditions and health in these cities.

Asthma outcomes are significantly worse for minority groups, including South Asians (SAs), in high-income settings. Despite this, comparatively few existing studies have focused on SAs when studying the effectiveness of behavioral interventions on asthma self-management, and no prior study has synthesized these findings. We review the effectiveness of behavioral interventions on asthma management in adults and children of SA origin across low- (LICs), middle- (MICs), and high-income countries (HICs). Data sources included EMBASE, MEDLINE, Cochrane Library and Trial registries: WHO, ICTRP and ClinicalTrials.gov. Eligibility criteria: randomized controlled trials (RCTs), quasi-RCTs and non-RCTs (controlled before-after [CBA] studies), published in English, with no publication year or country restrictions in adults and children of South Asian origin. Exclusion criteria: those focusing solely on pharmacological interventions. Search terms were “asthma” and “South Asian”. We included 33 studies, 27 from MICs and 6 from HICs (education [n = 10], self-management plans [n = 6], yoga/breathing exercises [n = 10]) organizational interventions [n =1], diet therapy [n = 1] and combined interventions [n = 5]). Outcome measures included: blood biochemistry, lung function, healthcare utilization and quality of life. A meta-analysis was not performed due to significant study heterogeneity. Behavioral interventions for asthma management in SAs are effective. Educational interventions that aim to optimize asthma knowledge, control, and inhaler technique, and yoga/breathing exercises are most effective for improved long-term outcomes in adults and children across LICs and MICs. Further research is needed to evaluate the effectiveness of all behavioral interventions for SAs in HICs to better inform current guidance by policy makers and health care providers.

Aims This systematic review seeks to collate studies from low- and middle-income countries (LMICs) to identify links between consumption of alcohol by household members and adolescent behavioural health outcomes. Methods Five databases (Medline, EMBASE, OVID Global Health, Cochrane Library and PsycInfo) were searched from 1990–2018, including terms ‘alcohol use’, ‘household’, ‘adolescent’ and ‘neurodevelopmental/behavioural outcome(s)’. Studies were eligible if they explicitly investigated alcohol misuse (or synonyms e.g. abuse, dependency), with misuse being defined as a pattern of alcohol consumption putting the individual or dependents at risk of physical and mental health problems. Eligibility was also assessed for participants, behavioural outcomes, and language. A Cochrane LMIC filter was utilised to screen abstracts and World Bank definitions were used to define LMICs. Quality appraisal utilised the National Institute of Heart, Lung and Blood (NIHLB) Quality Assessment Tools. Since the range of outcomes differed significantly by age group, we split the review into studies of children and studies of adolescents. Studies of the impact of household alcohol misuse on adolescents are included in this paper. Adolescents were defined as being within 10–18 years of age. Results Searches identified 24 844 studies across five databases. After filtering and screening processes, 22 were included in the review. Across the studies, 39 428 participants were included, from 12 different LMICs. Studies assessed parental exposure (8 studies), family (5), the caregiver (4), paternal exposure (3), and maternal and household exposure (one each). Behavioural outcomes assessed included suicidal ideation and behaviour, which showed a positive association in all five relevant studies; depression and anxiety disorders (four studies, all with a positive association); substance use (excluding alcohol) (7); problem behaviour (3); emotional problems (2); teenage pregnancy (3); and self-harm (1). Conclusions Despite a variety of settings and designs, this review found a significant association between exposure to household alcohol misuse and adverse adolescent behavioural outcomes, including a range of mental health disorders, problem behaviours, and suicidality. The mechanisms through which exposure to household alcohol misuse may lead to adverse adolescent outcomes may be numerous and complex. Further prospective studies, with careful quantification of amounts of alcohol consumption, are called for.

Aims This systematic review seeks to collate studies from low- and middle-income countries (LMICs) to identify links between consumption of alcohol by household members and children’s neurodevelopmental health outcomes. Methods Five databases (Medline, EMBASE, OVID Global Health, Cochrane Library and PsycInfo) were searched from 1990–2018 including terms ‘alcohol use’, ‘household’, ‘child’ and ‘neurodevelopmental/behavioural outcome(s)’ and derivatives. A Cochrane LMIC filter was utilised to screen abstracts and World Bank definitions to define LMICs. Studies were eligible if they explicitly investigated alcohol misuse (or synonyms e.g. abuse, dependency), with misuse being defined as a pattern of alcohol consumption putting the individual or dependents at risk of physical and mental health problems. Studies of fetal alcohol syndrome were excluded. Eligibility was also assessed for participants, neurodevelopmental outcomes, and language. Quality appraisal utilised the National Institute of Heart, Lung and Blood (NIHLB) Quality Assessment Tools. Since the range of outcomes differed by age group, we split into studies of children and studies of adolescents. This study reports developmental outcomes for children, aged 18 months to 16 years. Results From 24 844 results, 25 studies were included. Across these studies, there were 43 007 participants from 12 different LMICs. Most studies reported paternal drinking (n=10), followed by parental/caregiver (n=9), maternal (n=3) and household members (n=3). The most commonly investigated outcome related to household alcohol exposure was children’s behavioural problems/disorders (16 studies). Overall all the studies reported a positive association between household alcohol misuse and childhood behavioural problems/disorder. Other outcomes included cognitive delay/disorder related to intelligence and academic performance (4 studies) and risky behaviour in children such as suicide attempts, self-harm, substance abuse/misuse and risky behaviour (5 studies). Conclusion This is the first study to document household alcohol misuse as an adverse childhood experience and its impact on neurodevelopmental outcomes in LMICs. Despite varying settings and designs, this review found that alcohol misuse by household members in LMICs is associated with adverse child neurodevelopmental outcomes, although it cannot be established whether this is an independent risk factor. Future studies should consider clearly defined neurodevelopmental outcomes, careful standardized quantification of alcohol and adjustment for confounders.

Children with Down's syndrome (DS) are prone to respiratory tract infections (RTIs) due to anatomical variation, immune system immaturity and comorbidities. However, evidence on RTI-related healthcare utilisation, especially in primary care, is incomplete. In this retrospective cohort study, we use routinely collected primary and secondary care data to quantify RTI-related healthcare utilisation in children with DS and matched controls without DS.Retrospective cohort study of 992 children with DS and 4874 matched controls attending English general practices and hospitals as identified in Clinical disease research using LInked Bespoke studies and Electronic health Records (CALIBER) from 1997 to 2010. Poisson regression was used to calculate consultation, hospitalisation and prescription rates, and rate ratios. Wald test was used to compare risk of admission following consultation. The Wilcoxon rank-sum test was used to compare length of stay by RTI type and time-to-hospitalisation.RTI-related healthcare utilisation is significantly higher in children with DS than in controls in terms of GP consultations (adjusted RR 1.73; 95% CI 1.62-1.84), hospitalisations (adjusted RR 5.70; 95% CI 4.82-6.73), and antibiotic prescribing (adjusted RR 2.34; 95% CI 2.19-2.49). Two percent of children with DS presenting for an RTI-related GP consultation were subsequently admitted for an RTI-related hospitalisation, compared to 0.7% in controls.Children with DS have higher rates of GP consultations, hospitalisations and antibiotic prescribing compared to controls. This poses a significant burden on families. Further research is recommended to characterise healthcare behaviours and clinical decision-making, to optimise care for this at risk group.

Background Consanguinity refers to relationships between blood relatives. Consanguineous relationships are prevalent in many parts of the world, especially in South Asian and Middle Eastern populations with particularly high prevalence in those of Asian Pakistani descent. There are potential health risks associated with consanguinity due to the increased risk of children with consanguineous parents being diagnosed with an autosomal recessive genetic disorder. This study explores perceptions of consanguinity by reporting the experiences and opinions of women in an ethnically diverse community in London. Methods An estimated 200 women living in the London Borough of Newham were approached by a community facilitator through selective sampling and invited to attend a discussion group on consanguinity as part of a qualitative study. Field notes from four group discussions were coded manually to derive common themes for thematic analysis. Results 36 women attended, of whom 56% identified as Asian Pakistani (n=20). The identified themes included (1) wide variation in participants’ views of consanguinity and associated health risks, (2) the value of informed decisions and (3) preferences for information distribution (figure 1). Although participants had diverse opinions on consanguineous marriages with variation in awareness, awareness of risks was favoured and thought to be central to educated decision making. Participants were in favour of structured education on genetic literacy for children, with the aim of ensuring everyone is able to make informed decisions regarding consanguinity. Conclusion Identified themes highlight the importance of involving the community in efforts to increase awareness around consanguinity and genetic risk. This study emphasises the need for awareness and education to enable informed decisions regarding consanguinity and the value of co-developing educational efforts with the community in light of variation in views and values. We recommend further engagement through focus groups to inform the provision of information on consanguinity in local communities.

Aims 98% of the estimated 2.7 million neonatal deaths in 2015 occurred in low- and middle-income countries (LMICs). Within this group, neonates who are preterm or small for gestational age are at higher risk given the notable incidence of cardiopulmonary and neurodevelopmental disorders, and infectious complications, in this group. Quality Improvement (QI) initiatives can reduce the burden of morbidity and mortality for hospitalised neonates in LMICs. We undertook a systematic review to synthesise evidence from LMICs on QI approaches used, outcome measures employed, and the nature of any barriers or promoters for efficacy. Methods Database searching included Medline, EMBASE, WHO Global Health Library, Cochrane Library, WHO ICTRP and ClinicalTrials.gov, and we conducted citation searching of identified studies and reviews. Search terms were ‘neonates’, ‘quality improvement’, ‘hospitalised’ and derivatives. Studies were excluded if they took place in high income countries, did not include QI interventions, did not include small/sick hospitalised neonates. Included studies were published between January 2000–April 2017. Quality appraisal was conducted with use of Cochrane Risk of Bias tools for interventions. Results A total of 28 studies were included, covering 23 LMICs and 57 902 participants. The interventions mostly took place at the district and clinic level, and secondly at the level of patient-provider interaction. Educational interventions were most common, and other popular interventions included service organisation and referencing material dissemination. Mortality was the most commonly assessed outcome, and length of admission, sepsis rates and infection rates were also commonly investigated. Barriers included overburdened staff and insufficient equipment; promoters included motivation of key figures and monitoring. Conclusion To our knowledge this is the first systematic review to examine QI initiatives in this specific population. The majority of QI initiatives for hospitalised small and sick neonates are aimed at the district and clinic level. Outcomes tended to focus on the delivery of safe and effective care, but rarely focused on people-centred, timely or equitable care. Programme planners should aim for coordinated, larger-scale interventions, sustainable information systems, and to be mindful of barriers.

Background and aims Childhood asthma places a significant physical, financial, and psychological burden on patients, families, communities and the healthcare system. Current research indicates certain minority ethnic groups, especially South Asian children, encounter inequalities in asthma management and outcomes. Furthermore, children’s views and aspirations are infrequently evaluated. We report here the process of encouraging children’s participation in a multiphase participatory the Management in Asthma (MiA) study. The aim of this study was to explore the perceptions and experiences of asthma and its management in British South Asian (BSA) and White British (WB) children, using adapted qualitative methods. Methods Two qualitative methods were used: semi-structured interview and prioritisation workshop, adapted to encourage children’s participation (table 1). 14 themes for optimising asthma management identified from the semi-structured interviews and were used in the ranking exercises. Children ranked these themes by linear (LI, non-equal ranking), diamond (DA, equal ranking permitted) and budget pie (BP, ranking by funds allocation). Results Semi-structured interviews with children, with or without parents/guardian present (33 BSA and 14 WB children with asthma aged 5–12-years-old) revealed considerable similarities in experiences of asthma, notably inadequate holistic approach to asthma management amongst healthcare professionals and the role of schools and peers in children’s asthma perception and management. Barriers to health information provision existed in both groups. Consistently, WB children’s perception of asthma aetiology was different from BSA children. In all the ranking methods, children (21 BSA and 1 WB child aged 5––12-years-old) highly prioritised acute attacks according to their perceived health importance. ‘Strength of opinion’ was demonstrated in BP, as acute attack received £1430 in total, whilst the 2nd place theme only received £610. Conclusion Future intervention in children with asthma may wish to focus on managing acute attacks by a holistic approach, by involving schools, families and healthcare professionals. Furthermore, ethnospecific divergent beliefs about asthma aetiology can be tackled by a targeted educational programme.

Aims Sub-optimal nutrition among children remains a problem across South Asia (SA). Appropriate complementary feeding practices (CFP) can greatly reduce this risk. We aimed to undertake a systematic review of studies assessing CFP in SA children aged 0– 2 years in Bangladesh, India and Pakistan. Methods Searches undertaken between January 1990 to June 2016; MEDLINE, EMBASE, Global Health, Web of Science, OVID Maternity and Infant Care, BanglaJOL, Cochrane Library, CINAHL, POPLINE and WHO Global Health Library. Eligibility criteria: primary research on CFP in SA children aged 0–2 years and/or their families. Search terms were: ‘children’, ‘feeding’ and ‘Asians’ with their derivatives. Two researchers undertook study selection, data extraction and quality appraisal (EPPI-Centre Weight of Evidence). Results From 45,712 studies identified, 126 descriptive studies (105 cross-sectional, 11 cohort, 8 qualitative, 1 case-control and 1 mixed studies) were included. 73 from India, 17 Pakistan and 36 Bangladesh. Despite each adopting WHO Infant and Young Children Feeding (IYCF) Guidelines, CFP were sub-optimal in all three countries. In Pakistan, of 15 studies reporting CFP timings, 8 recorded timely initiation (between 6–9 months). Of those reporting dietary diversity, 3 of 9 studies met minimum dietary diversity requirements across 4 of 7 WHO IYCF food groups. 2 of 3 studies observed minimum meal frequency in over 50% of participants. In India 35 of 59 studies reported timely initiation of CFP. 7 of 9 studies noted minimum dietary diversity achieved between 10%–23% of the study population. 5 of 15 studies noted minimum meal frequency achieved between 25%–96% of the study population. In Bangladesh, in 13 of 36 studies timely initiation of CFP ranged from 42%–64%. 3 of 17 studies noted minimum dietary diversity achieved between 19.8%–57.7% of the study population. 1 of 7 studies noted minimum meal frequency achieved between 33%–81% of the study population. Influencing factors included poor education about CFP, cultural beliefs and socioeconomic variables. Conclusion This is the first SR to evaluate CFP in infants in India, Pakistan and Bangladesh. There is a great need for revision of nationwide child health programmes and campaigns to change health and nutrition behaviour.

Aims Children with well-controlled asthma can exercise safely and asthma management guidelines recommend physical activity (PA), yet many children with asthma fail to achieve recommended levels of PA. Some barriers to PA might specifically affect children and young people with asthma, so tailored interventions are likely needed to improve this patient group’s access to the benefits associated with PA. To inform future interventions, we systematically reviewed studies exploring barriers and facilitators to PA for children and young people with asthma. Methods Multiple databases were searched for ‘asthma’, ‘children’, ‘exercise’, ‘physical activity’ and their derivatives. All study designs were considered. Studies focused on athletes, published before 1995 or without an English translation were excluded. Two researchers independently selected studies, extracted data and appraised quality (EPPI-Centre weight of evidence frame-work). A third researcher reviewed disagreements. This review is PROSPERO registered, number CRD42015030067. Results The search returned 5161 results. 166 abstracts and 33 studies satisfied the inclusion criteria. Subjects of included studies were children and young people aged 6–20 years, parents/caregivers and teachers. Twenty studies used quantitative methods, including three intervention studies; ten studies used qualitative methods and three used mixed methods. Qualitative interviews revealed that children with asthma identify positive benefits of PA and feel they should be physically active. Identified barriers and facilitators to PA included patient, family, healthcare professional (HCPs), environmental, psychosocial, school and medication factors. Five qualitative studies discussed HCPs. These suggested that doctors often do not provide specific advice for PA, contributing to children not participating in PA. One quantitative study provided supporting data; 58.7% of students undertaking high levels of PA had a doctor who approved their activity, compared with only 33.8% of students with low levels of PA. Four quantitative studies examined the effect of parental activity restrictions. Restrictions had no influence on children’s activity levels in two studies and were associated with lower PA levels in the other two. Conclusion PA barriers and facilitators were identified within medical, home and school domains. HCPs might influence children with asthma’s PA participation by promoting good asthma control and by educating and supporting parents and school staff.

Background Sub-optimal nutrition among children remains a significant problem in South Asian (SA) families across the world and is related to micronutrient deficiencies, obesity and dental caries. The optimisation of complementary feeding practices (CFP) in the first two years of life is vital in tackling these issues. Aims To undertake a systematic review of studies assessing CFP, timing, dietary diversity, and influencing factors in children under two years of age in SA in developed countries (DC). Methods We searched Medline, Embase, Global Health, Web of Science, OVID Maternity and Infant Care, Cochrane Library, Popline, and WHO Global Health Library from January 1st 1990 to June 30th 2016. Eligibility criteria were all primary research studies on CFP in SA children aged 0–2 years, their families, or both, restricted to the English language. Search terms were ‘children’, ‘feeding’, and ‘Asians’ with their derivatives. Study selection, data extraction, and quality appraisal (EPPI-Centre weight of evidence) were performed by two independent researchers in a narrative synthesis approach. Results From 45 712 studies screened, 860 full-text articles were assessed for eligibility with 135 included in the synthesis. 10 studies from developed countries (UK, USA and Australia) were finally extracted. Despite adopting the WHO Infant and Young Children Feeding (WHO IYCF) guidelines, sub-optimal CFP were found in all studies. In 3 of 4 studies which addressed timing, CF was introduced before 6 months; and was not introduced between 6–12 months in any study despite recommendations. Coverage of The Pregnancy Book and Birth to Five ranged from 94% among Caucasian mothers but fell to 68%–88% among SA mothers. Dietary diversity was inadequate in 6 of 7 studies which discussed it with sweet convenience foods commonly used. Factors affecting practices included: acculturation, socioeconomics and conflicting sources and content of information. Conclusions This is the first systematic review to evaluate complementary feeding practices in SA across DC. In comparing the findings to those from reviews assessing developing countries, similar sub-optimal practices were noted between families from both types of countries despite ratification of WHO IYCF guidelines. This review will contribute towards informing future intervention development.

Aim Impact assessment of an adjunct to standard teaching on knowledge gain and self-assessed confidence for students undertaking their paediatric attachment and evaluation of an acute breathing difficulties (ABDs) learning package. Methods Pragmatic cluster randomized controlled trial involving 248 UK medical undergraduates within six paediatric clinical rotations. Intervention groups received an online ABD learning package consisting of symptom-based decision-making pathways underpinned by a ratified ABD evidence-based guideline. Control groups received an online dummy package. Outcome measures were a pre- and post-intervention multiple choice question assessment and confidence questionnaire utilising 5-point Likert scales. Results Significant knowledge gain in the intervention group (mean 6.84, 95% CI 5.56-8.12) versus no such difference in the control group, significant improvement in self-assessed confidence in intervention group versus no such difference in control group and significant confidence differences in ABD-specific statements were noted. In the satisfaction questionnaire, the learning content was noted to be new to only 16% participants. Conclusion Supplementation of standard teaching with an interactive delivery method resulted in cognitive gain and self-assessed confidence improvement in interaction with children with ABDs. This indicates that a well-designed tool can help prepare students for direct interaction with sick children as a junior clinician. Trial Registration: ISRCTN27499282.

Aims: To systematically review the effectiveness of preventative and therapeutic interventions for respiratory tract infections (RTIs) in people with Down's syndrome. Methods: Databases were searched for any published and ongoing studies of respiratory tract diseases in children and adults with Down's syndrome. These databases were searched for controlled trials, cohort studies and controlled before-after studies. Trial registries were searched for ongoing studies. Initially, all study types were included to provide a broad overview of the existing evidence base. However, those with a critical risk of bias were excluded using the Cochrane Risk of Bias tool. Results: A total of 13,575 records were identifed from which 5 studies fulflled the eligibility criteria and 3 fulflled our criteria for data extraction. One randomized controlled trial of moderate risk of bias compared zinc therapy with placebo. Outcome data were only reported for 50 (78%) children who presented with extreme symptoms; no beneft of zinc therapy was found. One non-randomized controlled trial with serious risk of bias included 26 children and compared pidotimod (an immunostimulant) with no treatment; pidotimod was associated with fewer upper RTI recurrences compared with no treatment (1.43 vs. 3.82). A prospective cohort study with moderate risk of bias compared 532 palivizumab treated children with 233 untreated children and found that children treated with palivizumab had fewer respiratory syncytial virus-related hospitalization (23 untreated and 8 treated), but the same number of overall RTI-related hospitalizations (73 untreated and 74 treated) in the frst 2 years of life. Conclusions: The evidence base for the management of RTIs in people with Down's syndrome is incomplete; current studies included children only and carry a moderate to serious risk of bias. Methodologic rigorous studies are warranted to guide clinicians in how best to prevent and treat RTIs in children with Down's syndrome.

Neonatal hypoglycaemia is common; however, there is an ongoing controversy regarding its operational definition, with recent guidance from the Paediatric Endocrine Society (PES) recommending using significantly higher blood glucose thresholds and longer periods of monitoring than existing guidance.1 A 2014 survey of Australasian neonatal units identified that the most common clinical threshold for the treatment of hypoglycaemia was 2.6 mmol/L, and some units used potentially unreliable nearside blood glucose monitoring devices.2 The most recent published survey of British neonatologists showed wide variation in definitions of neonatal hypoglycaemia from

Background Specific allergen immunotherapy (SIT) is an effective allergy treatment, but it is unclear whether SIT is effective for atopic eczema (AE). We undertook a systematic review to assess SIT efficacy and safety for treating AE. Methods We searched databases, ongoing clinical trials registers, and conference proceedings up to July 2015. Randomized controlled trials (RCTs) of SIT using standardized allergen extracts, compared with placebo/control, for treating AE in patients with allergic sensitization were eligible. Results We identified 12 eligible trials with 733 participants. Interventions included subcutaneous (six trials), sublingual (four trials), oral or intradermal SIT in children/adults allergic to house dust mite (10 trials), grass pollen or other inhalants. Risk of bias was moderate, with high loss to follow-up and nonblinding as the main concerns. For our primary outcomes, three studies (208 participants) reported no significant difference – patient-reported global disease severity improvement RR 0.75 (95% CI 0.45, 1.26); and eczema symptoms mean difference −0.74 on a 20-point scale (95% CI −1.98, 0.50). Two studies (85 participants) reported a significant difference – SIT improved global disease severity RR 2.85 (95% CI 1.02, 7.96); and itch mean difference −4.20 on a 10-point scale (95% CI −3.69, −4.71). Meta-analysis was limited due to extreme statistical heterogeneity. For some secondary outcomes, meta-analyses showed benefits for SIT, for example investigator-rated improvement in eczema severity RR 1.48 (95% CI 1.16, 1.88; six trials, 262 participants). We found no evidence of adverse effects. The overall quality of evidence was low. Conclusion We found no consistent evidence that SIT is effective for treating AE, but due to the low quality of evidence further research is needed to establish whether SIT has a role in AE treatment.

Despite efforts in prevention worldwide including recent advances in vaccine therapy, childhood community acquired pneumonia (CAP) remains a major cause of morbidity and mortality both in the developed and the developing world. Traditionally, qualifying the aetiology of CAP proved to be fraught with challenges particularly due to low yields from blood and sputum specimens. In recent years however, new advances in techniques such as enzyme-linked immunosorbent assay and polymerase chain reaction have dramatically improved detection rates of both bacteria and viruses. In addition to qualifying the true burden of disease by known organisms such as Streptococcus pneumoniae it has led to the identification of organisms such as human bocavirus which have not previously been associated with CAP. This article aims to provide a brief update to the clinician on the current epidemiology of CAP in this post-vaccination era. It is based on a combination of recommendations from existing clinical practice guidelines, recent systematic reviews and the current literature.

Clinical practice guidelines (CPG) developed by the National Institute for Health and Clinical Excellence (NICE) aim to address National Health Service (NHS) practice inequalities by supporting clinicians deliver best patient care to address practice inequalities. As the future NHS workforce, it is important to quantify medical students’ knowledge of and attitude towards evidence based medicine (EBM) and NICE CPGs to identify barriers influencing evidence based medicine and CPG implementation. We administered an online survey to medical students in England and Wales to study attitudes and knowledge of EBM and CPGs. We performed Mann-Whitney and Kruskal-Wallis tests to compare different groups’ continuous variable means. We received 323 responses across seven medical schools. A scale reliability alpha of 0.71 reflected satisfactory questionnaire internal consistency. Students were unsure regarding development processes such as 3 year implementation timeframes (74%) and role of academic medical colleges, drug companies and lay public. Students understood the scientific evidence application in decision-making processes (83%) and that clinicians should practice EBM (87%). 77% and 51% of students believe CPG’s influence drug availability and decrease practice autonomy respectively. Two thirds of students felt guidelines reduced patient choice. The majority of medical students understood the importance and role of evidence based medicine and NICE guidelines. However, poor knowledge on processes of guideline development and negative views on aspects of NICE CPGs may be construed as barriers that may affect implementation in future evidence-based practice. Research is warranted to develop an educational framework for future educational strategy implementation.

Background Risk factors for preterm births include sociodemographic factors and obstetric history. Consequently, preterm births and their consequences can be reduced through antenatal surveillance, implementation of interventions for mothers before and during pregnancy, and interventions targeted at preterm infants after birth. Following the identification of a persistent number of preterm births in the London borough of Southwark, we aimed to review the evidence from high-income countries for interventions to reduce premature births. Methods With a narrative review approach, data were synthesised according to the intervention category and strength of effect, and then stratified into primary, secondary, and tertiary level. Key search terms were “preterm birth”, “premature birth”, and “intervention”. The websites and databases of the following institutions and groups were searched systematically: National Institute for Health and Care Excellence, NHS Choices, Tommy's charity, Royal College of Obstetricians and Gynaecologists, WHOLIS, Centers for Disease Control and Prevention, Cochrane Library, Medline, and grey literature, supplemented with expert opinion. Searches were done between Feb 2 and Feb 6, 2018, for articles published in English between Jan 1, 1990, and Jan 31, 2018. Strength of evidence was classified according to the hierarchy of evidence provided by the National Health and Medical Research Council, with findings from randomised control trials (RCTs) given the most weight. Findings 16 articles were included, of which 13 different interventions were identified for alleviating preterm births. The evidence reviewed was mixed in quality and reliability; most interventions did not exhibit consistent benefit in RCTs. Identified interventions with strong evidence of benefit were smoking cessation, progesterone supplementation, cervical cerclage, preterm surveillance clinics and screening, diagnosis and preparation, corticosteroids, magnesium sulphate, and tocolysis; moderate evidence was cervical pessaries; weak evidence was weight management services; and mixed evidence included nutritional supplementation and artificial reproduction treatments. Interpretation The interventions identified have the potential to radically reduce the health and economic burdens associated with preterm births, deaths, and disability. This review therefore provides recommendations for implementation of interventions not only at the local level, within Southwark, but also at the regional and national level. Recommendations include targeting determinants of preterm birth, effective mapping and surveillance of at-risk women ensuring that service provision matches demand, and provision of healthy start vitamins and vitamin D to all pregnant women. Funding None.

Journal Article; Meta-Analysis; Research Support, Non-U.S. Gov't; Review; BACKGROUND Specific allergen immunotherapy (SIT) is a treatment that may improve disease severity in people with atopic eczema (AE) by inducing immune tolerance to the relevant allergen. A high quality systematic review has not previously assessed the efficacy and safety of this treatment. OBJECTIVES To assess the effects of specific allergen immunotherapy (SIT), including subcutaneous, sublingual, intradermal, and oral routes, compared with placebo or a standard treatment in people with atopic eczema. SEARCH METHODS We searched the following databases up to July 2015: the Cochrane Skin Group Specialised Register, CENTRAL in the Cochrane Library (Issue 7, 2015), MEDLINE (from 1946), EMBASE (from 1974), LILACS (from 1982), Web of Science™ (from 2005), the Global Resource of EczemA Trials (GREAT database), and five trials databases. We searched abstracts from recent European and North American allergy meetings and checked the references of included studies and review articles for further references to relevant trials. SELECTION CRITERIA Randomised controlled trials (RCTs) of specific allergen immunotherapy that used standardised allergen extracts in people with AE. DATA COLLECTION AND ANALYSIS Two authors independently undertook study selection, data extraction (including adverse effects), assessment of risk of bias, and analyses. We used standard methodological procedures expected by Cochrane. MAIN RESULTS We identified 12 RCTs for inclusion in this review; the total number of participants was 733. The interventions included SIT in children and adults allergic to either house dust mite (10 trials), grass pollen, or other inhalant allergens (two trials). They were administered subcutaneously (six trials), sublingually (four trials), orally, or intradermally (two trials). Overall, the risk of bias was moderate, with high loss to follow up and lack of blinding as the main methodological concern.Our primary outcomes were 'Participant- or parent-reported global assessment of disease severity at the end of treatment'; 'Participant- or parent-reported specific symptoms of eczema, by subjective measures'; and 'Adverse events, such as acute episodes of asthma or anaphylaxis'. SCORing Atopic Dermatitis (SCORAD) is a means of measuring the effect of atopic dermatitis by area (A); intensity (B); and subjective measures (C), such as itch and sleeplessness, which we used.For 'Participant- or parent-reported global assessment of disease severity at the end of treatment', one trial (20 participants) found improvement in 7/9 participants (78%) treated with the SIT compared with 3/11 (27%) treated with the placebo (risk ratio (RR) 2.85, 95% confidence interval (CI) 1.02 to 7.96; P = 0.04). Another study (24 participants) found no difference: global disease severity improved in 8/13 participants (62%) treated with the SIT compared with 9/11 (81%) treated with the placebo (RR 0.75, 95% CI 0.45 to 1.26; P = 0.38). We did not perform meta-analysis because of high heterogeneity between these two studies. The quality of the evidence was low.For 'Participant- or parent-reported specific symptoms of eczema, by subjective measures', two trials (184 participants) did not find that the SIT improved SCORAD part C (mean difference (MD) -0.74, 95% CI -1.98 to 0.50) or sleep disturbance (MD -0.49, 95% CI -1.03 to 0.06) more than placebo. For SCORAD part C itch severity, these two trials (184 participants) did not find that the SIT improved itch (MD -0.24, 95% CI -1.00 to 0.52). One other non-blinded study (60 participants) found that the SIT reduced itch compared with no treatment (MD -4.20, 95% CI -3.69 to -4.71) and reduced the participants' overall symptoms (P < 0.01), but we could not pool these three studies due to high heterogeneity. The quality of the evidence was very low.Seven trials reported systemic adverse reactions: 18/282 participants (6.4%) treated with the SIT had a systemic reaction compared with 15/210 (7.1%) with no treatment (RR 0.78, 95% CI 0.41 to 1.49; the quality of the evidence was moderate). The same seven trials reported local adverse reactions: 90/280 participants (32.1%) treated with the SIT had a local reaction compared with 44/204 (21.6%) in the no treatment group (RR 1.27, 95% CI 0.89 to 1.81). As these had the same study limitations, we deemed the quality of the evidence to also be moderate.Of our secondary outcomes, there was a significant improvement in 'Investigator- or physician-rated global assessment of disease severity at the end of treatment' (six trials, 262 participants; RR 1.48, 95% CI 1.16 to 1.88). None of the studies reported our secondary outcome 'Parent- or participant-rated eczema severity assessed using a published scale', but two studies (n = 184), which have been mentioned above, used SCORAD part C, which we included as our primary outcome 'Participant- or parent-reported specific symptoms of eczema, by subjective measures'.Our findings were generally inconclusive because of the small number of studies. We were unable to determine by subgroup analyses a particular type of allergen or a particular age or level of disease severity where allergen immunotherapy was more successful. We were also unable to determine whether sublingual immunotherapy was associated with more local adverse reactions compared with subcutaneous immunotherapy. AUTHORS' CONCLUSIONS Overall, the quality of the evidence was low. The low quality was mainly due to the differing results between studies, lack of blinding in some studies, and relatively few studies reporting participant-centred outcome measures. We found limited evidence that SIT may be an effective treatment for people with AE. The treatments used in these trials were not associated with an increased risk of local or systemic reactions. Future studies should use high quality allergen formulations with a proven track record in other allergic conditions and should include participant-reported outcome measures. Yes

A 75-year-old woman presented with severe abdominal pain and diarrhoea. Symptoms started 10 years earlier but multiple investigations failed to offer a clear diagnosis. On recent admission, blood tests, endoscopies and CT scans indicated chronic colonic inflammation. Treatment strategies for bowel inflammation were unsuccessful and the patient was subsequently discussed at a multidisciplinary team meeting with surgeons for consideration of colectomy. A drug review highlighted that the patient was taking an antiangina drug, nicorandil, thought to cause bowel ulceration. This was discontinued, which dramatically improved symptoms and avoided surgery and the patient was discharged within days. Follow-up colonoscopy showed much improved colitis, and the diarrhoea had resolved. It is important that clinicians are aware of the link between pharmacotherapy, specifically nicorandil and gastrointestinal ulceration and inflammation causing severe diarrhoea. Drug cessation is the only necessary and immediately effective treatment. Awareness of this will become more clinically relevant as nicorandil use increases.

Background Many health, education, and voluntary groups provide services for children and their families, but this care tends not to be integrated. In a deprived borough of London, we aimed to test whether providing short training and networking sessions would improve knowledge and referrals between services supporting children. Methods This uncontrolled longitudinal study was completed as a service evaluation. Three sets of workshops were offered in each of four geographical localities from December, 2016, to February, 2017. Relevant local organisations were invited to send attendees to all sessions. The sessions involved case discussions, team-working exercises, and presentations from teams such as local health visitors and child and adolescent mental health services. Mixed methods were used to assess impacts including preworkshop and postworkshop surveys with a Likert scale for statements such as "I know a lot about local health services". These covered knowledge of health, education, social care, and voluntary sectors; confidence in navigating local services; and communication between different services. Analysis of quantitative data used unpaired t tests since questionnaires were anonymised. Other methods included structured telephone interviews and a 1 month follow-up survey. Findings There were 302 attendances from 202 unique individuals. Attendees came from 22 local services from the health (n=99), education (145), social care (39), and voluntary (19) sectors. The preworkshop and postworkshop surveys (completed across 254 [84%] and 220 [73%] of attendances, respectively) demonstrated significant increases in self-assessed knowledge of health, education, social care, and voluntary services, and of confidence in intersector working (all p Interpretation We found that participants had transient increases in self-assessed knowledge and confidence in intersector working. The findings imply that professionals may find such integrated schemes useful, but further development is required to embed knowledge and connections long term. Further research should assess the impact of such schemes on patients or clients. Funding This study was funded by Newham Together, the Newham Community Education Provider Network, hosted by NHS Newham Clinical Commissioning Group. LM is funded by a National Institute for Health Research doctoral research fellowship (DRF-2014-07-005).

Background Sub-optimum nutrition among children remains an important problem among South Asian families in the UK. Appropriate complementary feeding practices in the first 2 years of life greatly reduce the risk of obesity and stunting. The UK diaspora is hypothesised to have similar complementary feeding practices to their countries of origin (India, Pakistan, and Bangladesh); if so, this could inform practice in the UK via reverse translation of evidence. We aimed to undertake a systematic review and narrative synthesis of studies assessing complementary feeding practices, and the beliefs that underpin them, in children under 2 years old within South Asian families living in the UK, India, Pakistan, and Bangladesh. Methods We searched Medline, Embase, Global Health, Web of Science, OVID Maternity and Infant Care, Cochrane Library, Popline, and WHO Global Health Library from Jan 1, 1990, to June 30, 2016. The eligibility criteria were all primary research studies on complementary feeding practices in South Asian children aged 0–2 years, their families, or both, restricted to the English language. The search terms used were "children", "feeding", and "Asians" with their derivatives. Study selection, data extraction, and quality appraisal (EPPI-Centre weight of evidence) were performed by two independent researchers in a narrative synthesis approach. This study is registered with PROSPERO, number CRD42014014025. Findings From 45 702 studies identified, 157 descriptive studies (115 cross-sectional, 19 cohort, 14 qualitative, one case-control, and eight mixed studies) were included. Ten were from the UK, 17 Pakistan, 84 India, 43 Bangladesh, and three a combination of these countries. Despite adoption of the WHO Infant and Young Children Feeding Guidelines (particularly timing and food choice), substantial evidence of non-recommended complementary feeding practices was identified. Factors that affected these practices persisting after migration included bicultural issues or low acculturation levels and conflicting information between health professionals, extended family, and religious and community leaders. By contrast, barriers to enforcement of WHO-recommended complementary feeding practices in South Asian countries included early marriage, conflicts about best use of mother's time, rural life, short birth intervals, and poverty. Interpretation This is the first systematic review, to our knowledge, to study complementary feeding practices across these countries. Similar themes were noted between UK families and countries of origin despite their receiving close National Health Service input from birth (eg, health visitors, general practitioners). This study will inform reverse translation of effective interventions to the UK from their countries of origin to improve complementary feeding practices in these communities. Funding None.

Aims To systematically review the effectiveness of preventive and therapeutic interventions for RTIs in children and adults with DS. Methods PubMed, Embase.com, CINAHL, the Cochrane Library and trial registries were searched for published and ongoing studies of respiratory tract diseases, cardiovascular diseases and obstructive sleep apnoea to provide a broad overview of the existing evidence base. These databases were searched for controlled trials, cohort studies and controlled before-after (CBA) studies and trial registries were searched for ongoing studies. Initially, all before mentioned study types were included to provide a broad overview of the existing evidence base. However, those with a critical risk of bias were excluded using the Cochrane risk of bias tool. Results A total of 13,575 records were identified from which five studies fulfilled the eligibility criteria and three fulfilled our criteria for data extraction. These three studies assessed the effectiveness of drugs for preventing RTIs in children with DS. One randomised controlled trial (RCT) of moderate risk of bias compared zinc therapy with placebo. Outcome data were only reported for 50 (78%) children who presented with “extreme” symptoms; no benefit of zinc therapy was found. One non-RCT with serious risk of bias included 26 children and compared pidotimod (a synthetic dipeptide with immunomodulatory properties) with no treatment; pidotimod was associated with fewer upper RTI recurrences compared with no treatment (1.43 vs. 3.82). A prospective cohort study with moderate risk of bias compared 532 palivizumab treated children under the age of 2 with 233 untreated children and found that children treated with palivizumab had fewer RSV-related hospitalisation (23 untreated, 8 treated) but the same number of overall RTI-related hospitalisations (73 untreated, 74 treated) in the first two years of life. Conclusions The evidence base for the management of RTIs in people with DS is incomplete. Methodological rigorous studies are warranted to guide clinicians in how best to prevent and treat RTIs in people with DS.

Down’s Syndrome (DS) is one of UK’s commonest genetic conditions with a stable incidence of 1 in 1000 live births. Despite this, there is a paucity of research on the most cost-effective management options. A systematic review was undertaken to map original UK and ROI research and identify gaps. In a follow-on study, we will undertake a prioritisation exercise involving experts, stakeholders and carers to prioritise future research investment. A systematic review of Medline, Embase, Cinahl-Ovid and Cochrane Library was undertaken utilising terms related to DS, UK and ROI. Exclusion criteria: (a) Studies were categorised by participant demographics, study type, research and clinical themes, funding amount and type. Grey literature searches (Google Scholar), research networks (eg. Trisomy 21 Research Society, Down’s Syndrome Medical Interest Group), charities (eg. Down Syndrome Association) are ongoing and will be reported at the conference. 2331 published articles were retrieved from electronic database searches. We excluded 2174 studies after screening titles/abstracts of which 80% were prenatal studies. After reviewing full text of the remaining 157 articles, a further 26 were excluded. This left 131 studies (Figure 1). A large number of articles (58; 44%) focused on disease epidemiology (eg. incidence, prevalence) with little studies undertaken (8; 6%) to improve their management. Data extraction is ongoing with further findings reported at the conference. With incidence remaining static and DS continuing to be a high-burden condition in the UK, DS should be an area of high priority for funders, policymakers and researchers. Once completed, this review will provide an insight into funding trends and research gaps in this vulnerable population. This will facilitate subsequent identification and prioritisation of research investments and priorities.

Sexually transmitted infections (STI) comprise a variety of infections transmissible through sexual contact. Mutually consenting sexual relationships have become commonplace in adolescence and sexual abuse or exploitation awareness has risen, resulting in increased presentations of children with sexual health concerns. Difficulties persist in diagnosing and managing STIs in children. With increased emphasis on paediatrician's involvement in transitional care, competence in sexual history taking and clinical presentation recognition remains essential. Additionally, an awareness of strengths and limitations of diagnostic modalities needs to be present. Furthermore, specific additional issues in this age group such as independent consent for diagnosis and treatment, fear of pregnancy and privacy and confidentiality concerns should be addressed carefully. Failure to address these issues may lead to disengagement with health services resulting in potentially adverse short- and long-term health and social consequences in young persons. This review aims to provide an overview of an approach to diagnosing and managing a pubertal child with an STI and the consideration of the unique issues surrounding children's care.

We report a six-week-old boy with genitourinary structural abnormalities who presented with profound hyponatraemia and hyperkalaemia due to transient type 1 pseudohypoaldosteronism (PHA) precipitated by a urinary tract infection (UTI), which responded rapidly to intravenous saline and antibiotics. In infants with structural abnormalities of the urinary tract, we wish to highlight the importance of recognizing type 1 PHA and its association with a UTI since prompt and appropriate treatment rapidly corrects the associated metabolic abnormalities. Conversely, the identification of type 1 PHA in an infant should precipitate a search for a UTI and structural abnormalities of the urinary tract.

Background The National Health Service Plan (July 2000) aimed to empower patients with more influence upon their own treatment. Provision of additional educational health information (AEHI) serves to inform families about health conditions and to allow them to manage their own health after discharge. However, to date, it is unknown how parents or carers perceive this information. Objectives To identify parents9 and carers9 views towards the current provision of AEHI following discharge of their child from an emergency care service, to assess their needs concerning AEHI and to provide recommendations for subsequent research. Methods Between 11 April and 19 June 2007, a piloted questionnaire was handed out at random times to each family attending the children9s emergency department while they were waiting to be clinically assessed. 1046 families chose to participate and answered questions about their ethnicity, language preference and ability, media access and their sources of health information. The data were analysed using descriptive methods. Results A majority of families wish to receive hospital AEHI as leaflets. Additionally, families frequently use a variety of other resources such as extended family and friends and the Internet to address their information needs. Poor literacy is a barrier to understanding in 15.6% of the study population. 73% of carers with children aged between 10 and 16 years wish their children to receive AEHI. Conclusions The authors identified a gap in the provision of health information with respect to appropriate educational material for children and young persons, for families with poor literacy skills and those with language barriers.

Background The role of the internet in propagating anti-vaccine information is well researched. However, there remains little information about vaccination resources available in public libraries. We undertook an electronic review of vaccination information in London libraries to ascertain the extent to which they contain messages that undermine the National Health Service (NHS) childhood vaccination schedule. Methods A serial keyword search of The London Libraries Consortium (an electronic catalogue for public libraries across 17 boroughs of London) was performed on March 12, 2015. All searchable print media with a title or description containing "vaccination", "vaccine", "immunisation", or "MMR" were included (eg, books, newspapers, posters, leaflets, and eBooks). No language restrictions were specified. We manually selected search results to identify publications that met criteria for relevance as a vaccine information resource and availability (more than two copies of a title in the whole consortium). Content analysis was performed by reading individual titles, which were deemed to be anti-vaccination if they contained at least one message that supported omission or delay of childhood vaccinations as a potentially valid choice. Findings 105 copies of publications (11 unique titles, appendix) were identified that met criteria for relevance and availability out of 118 copies identified in the record search. A single copy of an information booklet on vaccination produced by Public Health England was excluded from the analysis because of its restricted availability. 60% of these publications (n=63, four unique titles) contained messages that countenanced either delaying or omitting vaccination. 40% of publications (n=42, seven unique titles) contained no anti-vaccine messages. Interpretation Books that are commonly available to parents on vaccination in the London Libraries Consortium promote messages that seem to discredit the NHS childhood vaccination schedule. Provision of educational resources for dissemination across UK public libraries is urgently needed to give parents clear unbiased information about the benefits and risks of the NHS childhood vaccination schedule. Funding None.

Aims To undertake a prioritisation exercise involving healthcare professionals (HCPs) and South Asian (SA) families to develop child health research and public awareness agendas’ Methods A two-stage process was adopted. A HCP scoping survey was undertaken to generate topics important for SA child health (1) research (2) public awareness and (3) outcome indicators. Ranked lists were discussed in four focus groups of SA adolescents and families. A Punjabi and Urdu speaking community facilitator moderated groups with a British Sign Language interpreter assisting in the deaf group. Concordant and discordant themes between HCPs and SAs were identified. Results 27 HCPs participated in the survey. Table 1 summarises their priorities 35 individuals (Age range: 16–74 and UK stay length: 3–57 years) participated. Groups varied by settings (Inner vs. Outer city), religion, descent and disability. Engagement was highest on public awareness and lowest on outcome indicators. Lack of awareness of research undertaken by funders (NIHR, Wellcome Trust, MRC) were cited. Table 2 summarises their priorities. Conclusion Community engagement yielded research and public awareness priorities which differed with HCPs. In line with NHS England and NIHR national strategies, collaboration with communities whose views are not traditionally considered is essential to determine service and research agendas important to families, professionals and providers.

A 74 year old man presented to the ear, nose, and throat department with breathlessness on exertion, intermittent voice hoarseness, and a sensation of catarrh in his throat. After a laryngoscopy with biopsy was performed, he was diagnosed as having a low grade chondrosarcoma of the larynx. Before surgical debulking of the lesion was carried out he underwent computed tomography of the chest, abdomen, and pelvis. This confirmed the presence of a subglottic mass in the larynx but also showed a mixed lytic and sclerotic expansile lesion (5.8 cm (longitudinal)×1.6 cm (axial)×4.5 cm) in the left iliac blade of the pelvis. The pelvic lesion was well corticated, with internal ossified septae and calcification. Expansion of the left iliac wing was noted, with no breach in the cortex. He had no symptoms other than those that he presented with, which resolved after surgical debulking of the chondrosarcoma. He denied any pain and was independently mobile with a normal gait. He had never smoked and drank less than 7 units of alcohol a week. He had no comorbidities and was not taking any drugs. All blood results and a chest radiograph were normal. A plain radiograph of the pelvis was taken to help characterise the pelvic lesion. This showed a solitary well corticated lesion in the left iliac bone. There was evidence of ossification within the lesion but an absence of periostitis (figure⇓). Calcification of the lesion, endosteal scalloping, and expansion of …

Cobbold and colleagues state that γ-glutamyltransferase should be measured in all patients with raised serum alanine aminotransferase because if raised it would indicate alcohol related liver disease.1 Because of its ubiquitous distribution within the …