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Social determinants of health (SDH) influence health and social outcomes in positive and negative ways. Understanding the impact of SDH on children with cerebral palsy (CP) is essential to improve health equity, optimize health outcomes, and support children with CP and their families to thrive in society. In this narrative review, we summarize the landscape of SDH impacting children with CP and their families worldwide. In high‐income countries, children from poorer neighbourhoods are more likely to have severe comorbidities, present with spastic bilateral CP, and report lower frequency of participation in community activities. In low‐ and middle‐income countries, socioeconomic disadvantage is associated with increased risk of malnutrition, living in poorer housing conditions, not having access to proper sanitation, and living below the poverty line. Low maternal education is associated with increased likelihood of the child with CP experiencing increased severity of gross motor and bimanual functioning challenges, and poorer academic performance. Lower parental education is also associated with reduced child autonomy. On the other hand, higher parental income is a protective factor, associated with greater diversity of participation in day‐to‐day activities. A better physical environment and better social support are associated with higher participation in daily activities. Clinicians, researchers, and the community should be aware of these key challenges and opportunities. Then adopt a range of approaches that target adverse SDH/social needs and foster positive SDH in the clinical setting. What this paper adds: Understanding how social determinants of health influence health and social outcomes is a critical step towards improving health equity and outcomes.Approaches are required that target the impact of adverse SDH on access to health care for children with cerebral palsy and that work towards ensuring equity of access for all. What this paper adds: Understanding how social determinants of health influence health and social outcomes is a critical step towards improving health equity and outcomes.Approaches are required that target the impact of adverse SDH on access to health care for children with cerebral palsy and that work towards ensuring equity of access for all. [ABSTRACT FROM AUTHOR]

Background: Universal child health services (UCHS) provide an important pragmatic platform for the delivery of universal and targeted interventions to support families and optimize child health outcomes. We aimed to identify brief, evidence-based interventions for common health and developmental problems that could be potentially implemented in UCHS.Methods: A restricted evidence assessment (REA) of electronic databases and grey literature was undertaken covering January 2006 to August 2019. Studies were eligible if (i) outcomes related to one or more of four areas: child social and emotional wellbeing (SEWB), infant sleep, home learning environment or parent mental health, (ii) a comparison group was used, (iii) universal or targeted intervention were delivered in non-tertiary settings, (iv) interventions did not last more than 4 sessions, and (v) children were aged between 2 weeks postpartum and 5 years at baseline.Results: Seventeen studies met the eligibility criteria. Of these, three interventions could possibly be implemented at scale within UCHS platforms: (1) a universal child behavioural intervention which did not affect its primary outcome of infant sleep but improved parental mental health, (2) a universal screening programme which improved maternal mental health, and (3) a targeted child behavioural intervention which improved parent-reported infant sleep problems and parental mental health. Key lessons learnt include: (1) Interventions should impart the maximal amount of information within an initial session with future sessions reinforcing key messages, (2) Interventions should see the family as a holistic unit by considering the needs of parents with an emphasis on identification, triage and referral, and (3) Brief interventions may be more acceptable for stigmatized topics, but still entail considerable barriers that deter the most vulnerable.Conclusions: Delivery and evaluation of brief evidence-based interventions from a UCHS could lead to improved maternal and child health outcomes through a more responsive and equitable service. We recommend three interventions that meet our criteria of "best bet" interventions. [ABSTRACT FROM AUTHOR]

Objective: We examine the prevalence of quality care (as measured by adherence to recommendations in clinical practice guidelines) for Australian paediatric patients (⩽15 years) with depression and/or anxiety, using data from the CareTrack Kids study; a population-based study of the quality of healthcare practice in inpatient and ambulatory healthcare settings. Methods: A multistage stratified sample identified records of 6689 children. Of these, 156 records were identified for depression and 356 for anxiety. These were assessed for adherence to 15 depression and 13 anxiety indicators, respectively, using a review of medical records. Results: Adherence to assessment and management guidelines was low for both conditions: assessment bundle (depression = 33%, 95% confidence interval = [20, 48]; anxiety = 54%, 95% confidence interval = [43, 64] and depression management bundle = 35%, 95% confidence interval = [15, 60]). Across both conditions, the highest adherence was recorded for indicators that addressed prescription of medications (e.g. venlafaxine, 100%; benzodiazepines, 100%; selective serotonin reuptake inhibitor, 94% and antidepressants, 91%), while compliance was the lowest for ensuring children with depression had an emergency safety plan (44%), informing parents of the risks and benefits of prescribed anxiety medication (51%) and assessment for other causes (59% for depression; 68% for anxiety). Conclusion: These findings suggest that strategies are needed to improve guideline adherence for mental health disorders in children and adolescents, particularly among general practitioners. Learning from these indicators could inform clinical prompts in electronic medical records, as well as links to additional information, to assist in decision-making and streamline work practices. [ABSTRACT FROM AUTHOR]

Objective: Suboptimal 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 <2 years in India.Design: Searches 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' and derivatives. Two researchers undertook study selection, data extraction and quality appraisal (EPPI-Centre Weight of Evidence).Results: From 45 712 abstracts screened, sixty-four cross-sectional, seven cohort, one qualitative and one case-control studies were included. Despite adopting the WHO Infant and Young Child Feeding guidelines, suboptimal CF practices were found in all studies. In twenty-nine of fifty-nine studies, CF was introduced between 6 and 9 months, with eight studies finding minimum dietary diversity was achieved in 6-33 %, and ten of seventeen studies noting minimum meal frequency in only 25-50 % of the study populations. Influencing factors included cultural influences, poor knowledge on appropriate CF practices and parental educational status.Conclusions: This is the first systematic review to evaluate CF practices in SA in India. Campaigns to change health and nutrition behaviour and revision of nationwide child health nutrition programmes are needed to meet the substantial unmet needs of these children. [ABSTRACT FROM AUTHOR]

Objective: Suboptimal 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 <2 years in Pakistan.Design: Searches 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).Results: From 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.Conclusions: This 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. [ABSTRACT FROM AUTHOR]

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Undernutrition and inadequate stimulation both negatively influence child health and development and have a long-term impact on school attainment and income. This paper reports data from India and Pakistan looking at how families interact, play with, and feed children; their expectations of growth and development; and the perceived benefits, consequences, opportunities, and barriers of adopting recommended feeding and developmental behaviors. These data were collected as part of formative research for the Sustainable Program Incorporating Nutrition and Games (SPRING) trial. This trial aims to deliver an innovative, feasible, affordable, and sustainable intervention that can achieve delivery at a scale of known effective interventions that maximize child development, growth, and survival and improve maternal psychosocial well-being in rural India and Pakistan. [ABSTRACT FROM AUTHOR]

The effectiveness of interventions promoting healthy child growth and development depends upon the capacity of the health system to deliver a high-quality intervention. However, few health workers are trained in providing integrated early child-development services. Building capacity entails not only training the frontline worker, but also mobilizing knowledge and support to promote early child development across the health system. In this paper, we present the paradigm shift required to build effective partnerships between health workers and families in order to support children's health, growth, and development, the practical skills frontline health workers require to promote optimal caregiving, and the need for knowledge mobilization across multiple institutional levels to support frontline health workers. We present case studies illustrating challenges and success stories around capacity development. There is a need to galvanize increased commitment and resources to building capacity in health systems to deliver early child-development services. [ABSTRACT FROM AUTHOR]

Objectives: To investigate whether measles, mumps, and rubella (MMR) vaccination is associated with bowel problems and developmental regression in children with autism, looking for evidence of a "new variant" form of autism. Design: Population study with case note review linked to independently recorded vaccine data. Setting: Five health districts in north east London. Participants: 278 children with core autism and 195 with atypical autism, mainly identified from computerised disability registers and born between 1979 and 1998. Main outcome measures: Recorded bowel problems lasting at least three months, age of reported regression of the child's development where it was a feature, and relation of these to MMR vaccination. Results: The proportion of children with developmental regression (25% overall) or bowel symptoms (17%) did not change significantly (P value for trend 0.50 and 0.47, respectively) during the 20 years from 1979, a period which included the introduction of MMR vaccination in October 1988. No significant difference was found in rates of bowel problems or regression in children who received the MMR vaccine before their parents became concerned about their development (where MMR might have caused or triggered the autism with regression or bowel problem), compared with those who received it only after such concern and those who had not received the MMR vaccine. A possible association between non-specific bowel problems and regression in children with autism was seen but this was unrelated to MMR vaccination. Conclusions: These findings provide no support for an MMR associated "new variant" form of autism' with developmental regression and bowel problems, and further evidence against involvement of MMR vaccine in the initiation of autism. [ABSTRACT FROM AUTHOR]

Background: The health and well-being of children in the first 2000 days has a lasting effect on educational achievement and long-term chronic disease in later life. However, the lack of integration between high-quality data, analytic capacity and timely health improvement initiatives means practitioners, service leaders and policymakers cannot use data effectively to plan and evaluate early intervention services and monitor high-level health outcomes. Objective: Our exploratory study aimed to develop an in-depth understanding of the system and clinical requirements of a state-wide paediatric learning health system (LHS) that uses routinely collected data to not only identify where the inequities and variation in care are, but also to also inform service development and delivery where it is needed most. Method: Our approach included reviewing exemplars of how administrative data are used in Australia; consulting with clinical, policy and data stakeholders to determine their needs for a child health LHS; mapping the existing data points collected across the first 2000 days of a child's life and geospatially locating patterns of key indicators for child health needs. Results: Our study identified the indicators that are available and accessible to inform service delivery and demonstrated the potential of using routinely collected administrative data to identify the gap between health needs and service availability. Conclusion: We recommend improving data collection, accessibility and integration to establish a state-wide LHS, whereby there is a streamlined process for data cleaning, analysis and visualisation to help identify populations in need in a timely manner. [ABSTRACT FROM AUTHOR]

Background: Chronic, non-communicable disease, accounts for the vast majority of all disability adjusted life years lost (DALYS), among children and young people in high income countries. Our current model of hospital-centred paediatric care was developed to deliver acute inpatient and high intensity specialist services rather than high quality care for children and young people (CYP) with long-term conditions. The CYPHP Evelina London model was developed with key stakeholders including CYP, carers, front line practitioners and health service commissioners in response to these evolving health care needs. The CYPHP Evelina London model is an innovative approach to reshaping everyday healthcare services, expanding on the principles of integrated care. CYPHP brings together physical and mental healthcare, addresses the social context of families, integrates primary and secondary healthcare, and links healthcare with local government efforts to improve the wider determinants of health. A major focus of the CYPHP Evelina London model is improving front line care for all CYP. Methods: The CYPHP model will be rolled out in phases, allowing an opportunistic evaluation using a cluster Randomised Controlled Trial (cRCT) design involving 90,000 children and young people in 23 clusters. The evaluation has four component parts: 1- Pseudonymised population-based evaluation for all children and young people in participating GP practices to assess health service use; 2- An evaluation of consented children with asthma, eczema, and constipation to assess impact on health-related quality of life, parental-reported disease severity, prevalence and severity of mental health difficulties, and mental wellbeing among parents, using validated questionnaires. 3- A mixed-methods process evaluation to understand the barriers and facilitators to implementing the model of care; 4- Economic evaluation. Results: Initial baseline results from the first 219 Health Checks showed poorly controlled symptoms for asthma, eczema and constipation in between 60 and 76% of young people. In total, 28% of CYP scored 'High'/'Very High' on Strengths & Difficulties Questionnaire for mental health difficulties. Over a quarter of families reported problems paying bills and 12% of parents expressed concerns regarding their own mental health. Discussion: The ongoing CYPHP evaluation is the largest population based evaluation of a pediatrics integrated care model to date in the UK. We will discuss the need for robust evaluation in the space of health transformation using CYPHP as an exemplar. Conclusions: Initial results show high levels of unmet physical, psychological and social needs in children and young people with common and chronic illness. Clinical academic partnerships are key to robust evaluation of health service models at scale. Lessons learned: The difficulties, of carrying out a large randomised controlled trial of a health systems transformation programme across two London Boroughs including partnership working, funding models, ethics approval and recruitment will be discussed. Limitations: Though final results are not available, initial results show high levels of unmet need in our population which the CYPHP model of care is meeting. Suggestions for future research: Robust evaluation using experimental designs is possible and needed in the health systems space. These evaluations at scale will inform new health system design. [ABSTRACT FROM AUTHOR]

Background: Children and young people's (CYP) health and healthcare outcomes are often poor. Demand for urgent healthcare is rising. The current model of care is primarily reactive and acute rather than proactive and preventative; leading to increased use and reliance on secondary healthcare services. Over the past 5 years there has been increases in non-elective admissions and attendances and outpatient appointments (1.7%, 3% and 3.2%). At a population level, these small increases incur increasing financial cost and burden on services already at capacity. The clinicalacademic Children and Young People's Health Partnership (CYPHP) is delivers new care models to improve CYP health; with evaluation using robust designs to determine the extent the new model of care is curbing rising healthcare use. Methods: CYPHP is a partnership between 3 large NHS Trusts, including mental health and children's, 2 Clinical Commissioning Groups and Local Authorities, and a University. Model design included analysis of segmented population need, systematic literature reviews, and extensive engagement with CYP, parents, health professionals, providers, and commissioners. An evidencebased implementation plan was agreed to roll out services to a child population of 120,000. We are opportunistically evaluating the service using a cluster randomised control trial (cRCT) design. Results: We are implementing and evaluating an evidence-based comprehensive new child and family-centred integrated cycle of care including individual and population health promotion; proactive case-finding and triage for ongoing conditions at a population-level; biopsychosocial assessment and self-referral via a patient portal; holistic tailored care, specialist clinics and increased education and training for professionals working with CYP. Services are delivered by multidisciplinary health teams to increase coordination across primary, community, and hospital settings and to better integrate physical and mental healthcare for CYP's social context. The cRCT evaluation design, with nested process evaluation and qualitative studies, will provide high quality evidence of the impact of the CYPHP model on outcomes including CYP health and wellbeing, healthcare quality, and health service and system measures. Implications: CYPHP is implementing and evaluating a new model of care to improve health, heathcare quality, and outcomes for local CYP, contribute generalizable evidence about children's health services and systems, and shape child health policy. [ABSTRACT FROM AUTHOR]

Introduction: New models of healthcare have largely focussed on adults, with increasing policy and practice interest in integrated care across many high-income countries. Integrated care models have been identified as a promising solution by children and young people (CYP), and by policymakers, to target the gaps in healthcare delivery for CYP with on-going conditions. However, there has been limited work on developing and evaluating integrated models of child healthcare, so there is an evidence gap in this important area of policy. This systematic review and meta-analysis assessed the effects of integrated care interventions on child health, health service use, and healthcare quality for CYP with on-going conditions. Methods: Articles were eligible for the review if they 1) reported randomised controlled trials (RCTs), published between 1996 and September 2018; 2) evaluated an integrated healthcare intervention designed to improve child health; 3) included CYP (0-18 years) with an on-going health condition; 4) included at least one health-related outcome. Descriptive data on a range of outcomes was synthesised for all included papers, and data homogeneity allowed further metaanalyses to explore the effects of integrated care interventions compared with usual care, on health-related quality of life (QOL) and number of emergency department visits. Results: Twenty-three randomised controlled trials were identified, describing 18 interventions. Studies had medium risk of bias, as assessed by the Cochrane Risk of Bias tool. Improvements were found for quality of care (87% of interventions found a positive effect for intervention) and child health (39% found a positive effect for intervention). The meta-analyses found that integrated care interventions have a positive effect in improving QOL over usual care (n=5 trials; SMD = 0.24; 95% CI = 0.03, 0.44; P=0.02), but no significant difference across groups for emergency department contacts (n=5 trials; OR=0.82; 95% CI = 0.53, 1.26; p=0.37). Conclusion and Discussion: Integrated care interventions for CYP with on-going conditions may deliver improved quality of life for children, health, and quality of care. However, no conclusions can be made about the direction or magnitude of the effect for integrated care interventions on emergency department contacts in CYP with on-going conditions. However, only 23 RCTs were included in this review, which were of moderate quality, highlighting the need for more robust trials to inform current health service delivery in this area and fully establish the effectiveness of integrated healthcare interventions on CYP outcomes. In collaboration with NHS Trusts, local councils, CYP and families, the findings from this review have been used to inform a fully integrated healthcare model for CYP that will be implemented at scale, and rigorously evaluated using an RCT design. [ABSTRACT FROM AUTHOR]

Purpose: While the association between socioeconomic deprivation and children's poor health is clear, the complex pathways linking socioeconomic deprivation with access to care and health inequalities are less well understood. This analysis sought to understand the root cause of these inequalities by exploring how mothers living in deprived neighborhoods support their sick children, and their experiences with primary care.Methods: Interview transcripts from eight mothers, living in socioeconomically deprived neighborhoods, were analyzed using interpretative phenomenological analysis.Results: Participants described their experiences in three distinct themes. Each theme highlights the importance of the mother's agency, voice, and power in supporting their child's health, and the crucial role played by the health system in addressing, maintaining, or reinforcing health inequalities. Participants used several strategies to address these health inequalities, which included fighting against the health system, using past experiences to explain health needs, and support from friends and family.Conclusion: Although the health system is an essential resource to support families, encounters with primary care may fail to address health inequalities and may therefore exacerbate existing health inequalities for families living in deprived neighborhoods, irrespective of health system financing and ability to pay. [ABSTRACT FROM AUTHOR]

CONTEXT: Integrated care models may improve health care for children and young people (CYP) with ongoing conditions. OBJECTIVE: To assess the effects of integrated care on child health, health service use, health care quality, school absenteeism, and costs for CYP with ongoing conditions. DATA SOURCES: Medline, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library databases (1996-2018). STUDY SELECTION: Inclusion criteria consisted of (1) randomized controlled trials, (2) evaluating an integrated care intervention, (3) for CYP (0-18 years) with an ongoing health condition, and (4) including at least 1 health-related outcome. DATA EXTRACTION: Descriptive data were synthesized. Data for quality of life (QoL) and emergency department (ED) visits allowed meta-analyses to explore the effects of integrated care compared to usual care. RESULTS: Twenty-three trials were identified, describing 18 interventions. Compared with usual care, integrated care reported greater cost savings (3/4 studies). Meta-analyses found that integrated care improved QoL over usual care (standard mean difference = 0.24; 95% confidence interval = 0.03-0.44; P = .02), but no significant difference was found between groups for ED visits (odds ratio = 0.88; 95% confidence interval = 0.57-1.37; P = .57). LIMITATIONS: Included studies had variable quality of intervention, trial design, and reporting. Randomized controlled trials only were included, but valuable data from other study designs may exist. CONCLUSIONS: Integrated care for CYP with ongoing conditions may deliver improved QoL and cost savings. The effects of integrated care on outcomes including ED visits is unclear. [ABSTRACT FROM AUTHOR]