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Introduction: The Kids Guided Personalised Service (KidsGPS) is an integrated model of care coordination for children and young people (CYP) living with medical complexity. After successful implementation in an urban setting, the model of care will be rolled-out at scale to four rural regions in New South Wales, Australia to establish RuralKidsGPS. This paper describes the approach and methods for the outcome and implementation evaluation of RuralKidsGPS., Description: The evaluation aims to assess health, economic and implementation outcomes and processes whilst identifying barriers and enablers to inform future rollouts. Measures of health service utilisation (primary outcome), child health related quality of life and parent/carer experiences will be assessed. The implementation evaluation will occur alongside the outcomes evaluation and is underpinned by the Consolidated Framework for Implementation Research and informed by validated quantitative measures and qualitative interviews with patients, families, healthcare providers and service managers. An economic analysis will determine incremental cost effectiveness ratios for the new model of care using health service utilisation data., Conclusion: RuralKidsGPS, if effective, has the potential to improve equity of access to integrated care for CYP and their families and this protocol may inform other evaluations of similar models of care delivered at scale., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2023 The Author(s).)

Objectives: 'Healthier Wealthier Families' (HWF) seeks to reduce financial hardship in the early years by embedding a referral pathway between Australia's universal child and family health (CFH) services and financial counselling. This pilot study investigated the feasibility and short-term impacts of HWF, adapted from a successful Scottish initiative., Methods: Setting: CFH services in five sites across two states, coinciding with the COVID-19 pandemic., Participants: Caregivers of children aged 0-5 years experiencing financial hardship (study-designed screen)., Design: Mixed methods. With limited progress using a randomised trial (RCT) design in sites 1-3 (March 2020-November 2021), qualitative interviews with service providers identified implementation barriers including stigma, lack of knowledge of financial counselling, low financial literacy, research burden and pandemic disruption. This informed a simplified RCT protocol (site 4) and direct referral model (no randomisation, pre-post evaluation, site 5) (June 2021-May 2022)., Intervention: financial counselling; comparator: usual care (sites 1-4). Feasibility measures: proportions of caregivers screened, enrolled, followed up and who accessed financial counselling. Impact measures: finances (quantitative) and other (qualitative) to 6 months post-enrolment., Results: 355/434 caregivers completed the screen (60%-100% across sites). In RCT sites (1-4), 79/365 (19%-41%) reported hardship but less than one-quarter enrolled. In site 5, n=66/69 (96%) caregivers reported hardship and 44/66 (67%) engaged with financial counselling; common issues were utility debts (73%), and obtaining entitlements (43%) or material aid/emergency relief (27%). Per family, financial counselling increased income from government entitlements by an average $A6504 annually plus $A784 from concessions, grants, brokerage and debt waivers. Caregivers described benefits (qualitative) including reduced stress, practical help, increased knowledge and empowerment., Conclusions: Financial hardship screening via CFH was acceptable to caregivers, direct referral was feasible, but individual randomisation was infeasible. Larger-scale implementation will require careful, staged adaptations where CFH populations and the intervention are well matched and low burden evaluation., Trial Registration Number: ACTRN12620000154909., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Objective: To assess the impact of hospitalization for chronic health conditions on early child development and wellbeing at school start., Methods: We conducted a longitudinal cohort study of children starting school using population-based record linkage of routinely collected admitted hospital data and standardized assessment of early childhood development (Australian Early Developmental Census: AEDC). Developmental vulnerability (DV) was defined as children scoring <10th centile in any one of five developmental domains. Children scoring <10th centile on two or more domains were considered developmentally high-risk (DHR). Children hospitalized with chronic health conditions were compared to children without hospitalizations prior to school start., Results: Among 152,851 children with an AEDC record, 22,271 (14·6%) were hospitalized with a chronic condition. Children hospitalized with chronic health conditions were more likely to be DHR (adjusted odds ratio 1.25, 95% CI: 1.18-1.31) compared to children without hospitalizations. Children hospitalized more frequently (>7 times) or with longer duration (>2 weeks) had a 40% increased risk of being DHR (1.40, 95% CI: 1.05-1.88 and 1.40, 95% CI: 1.13-1.74, respectively). Children hospitalized with mental health/behavioral/developmental conditions had the highest risk of DHR (2.23, 95% CI: 1.72-2.90). Developmental vulnerability was increased for physical health (1.37, 95% CI: 1.30-1.45), language (1.28, 95% CI: 1.19-1.38), social competence (1.22, 95% CI: 1.16-1.29), communication (1.17, 95% CI: 1.10-1.23), and emotional maturity (1.16, 95% CI: 1.09-1.23)., Conclusions: Frequent and longer duration hospitalizations for chronic health conditions can impact early childhood development. Research and interventions are required to support future development and well-being of children with chronic health conditions who are hospitalized., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: To examine the changing health needs of refugee children and young people (CYP) entering Australia, in relation to key government policy changes., Study Design: Retrospective analysis of health service use data over 11 years., Setting: Paediatric refugee clinics in South Western Sydney (SWS), the Australian region with the largest annual resettlement of refugees., Participants: Refugee CYP (≤25 years) attending the SWS paediatric refugee clinics for their first visit between 2009 and 2019., Measures: Clinician defined health conditions categorised as communicable and non-communicable disease (NCD)., Results: Data were analysed for 359 CYP, mean age 9.3 years; 212 male (59.1%). Most CYP (n=331, 92.2%) had health problems identified; 292 (81.3%) had ≥1 NCD and 24 (6.7%) had ≥1 communicable disease. The most frequent individual NCDs were dental disease (n=128, 35.7%) and vitamin D deficiency (n=72, 20.1%). Trend analysis showed increased odds of identifying an NCD from 2013 onwards (crude OR 1.77, 95% CI 1.06 to 2.96). Neurodevelopmental problems, especially Global Developmental Delay (n=31, 8.6%), emerged as more prevalent issues in the latter half of the decade. There were significantly increased odds of identifying a neurodevelopmental problem in 2016-2019, especially in 2016-2017 (adjusted OR 2.93, 95% CI 1.34 to 6.40). Key policy changes during this period included acceptance of refugees with disabilities from 2012, additional Australian Humanitarian Programme intake from the Eastern Mediterranean region and mandatory offshore processing for those seeking asylum by boat from 2013. In response to the changing needs, local health services adopted nurse-led primary healthcare screening, early childhood services, youth and disability clinics., Conclusions: Refugee CYP in Australia are presenting with a growing burden of NCDs, with neurodevelopmental problems contributing. Government policy changes affect the sociodemographics of resettled populations, influencing health profiles. Paediatric refugee health services need to be responsive to the changing needs of these populations to optimise well-being., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

There is a high prevalence rate of co-occurring alcohol use and mental health problems in young people. This is associated with adverse outcomes and poses a substantial public health concern. We identified and synthesized evidence on the effectiveness of family-involved interventions in reducing alcohol use and mental health problems in young people aged 12-17. Seven databases were searched from inception to January 2023. Data from 19 articles reporting on 14 trials were pooled through random-effects meta-analysis for each outcome using Review Manager 5.3. Pooled estimates resulted in non-significant findings for alcohol use (SMD -0.60; 95% CI -1.63 to 0.42; p = 0.25; 6 trials; 537 participants), internalizing symptoms (SMD -0.13; 95% CI -0.37 to 0.10; p = 0.27), externalizing symptoms (SMD -0.26; 95% CI -0.66 to 0.15; p = 0.22) and substance use (SMD -0.33; 95% CI -0.72 to 0.06; p = 0.10). In contrast, significant intervention effects were identified for the mechanism of change, family conflict (SMD -0.30; 95% CI -0.51 to -0.09; p = 0.005). Consequently, addressing family functioning may not be sufficient in reducing co-occurring alcohol use and mental health problems. Non-significant intervention effects could be due to a lack of content addressing the relationship between alcohol use and mental health problems. Future intervention development could explore whether to incorporate such content and how best to involve the family.

Objectives: To examine the prevalence of socioemotional and behavioural difficulties (SEBDs) in children with chronic physical conditions (CPCs) and to analyse how this prevalence varied with the type and number of CPCs and the age of the child., Design: Cross-sectional study of a secondary data analysis of the Longitudinal Study of Australian Children., Setting: An Australian nationally representative sample of general population of children., Participants: 15 610 children-waves aged 6-14 years., Intervention/exposure: Children reported to have at least 1 of the 21 CPCs by their parents., Main Outcome Measures: Clinically relevant SEBDs were defined using standardised cut-offs of the parent-administered Strengths and Difficulties Questionnaire., Results: Children with a CPC have significantly increased odds of total, internalising and externalising SEBDs than those without (total SEBDs, adjusted odds rartio or OR 3.13, 95% CI 2.52 to 3.89), controlling for sex, age, socioeconomic status and parental mental health status. The highest prevalence of total SEBDs was found in children with chronic fatigue (43.8%), epilepsy (33.8%) and day wetting (31.6%). An increasing number of comorbid CPCs was associated with a rising prevalence of SEBDs. On average, 24.2% of children with at least four CPCs had SEBDs. These children had 8.83-fold increased odds (95% CI 6.9 to 11.31) of total SEBDs compared with children without a CPC. Age was positively related to the odds of SEBDs., Conclusion: Children with a CPC have a significantly increased risk of having SEBDs than those without. These findings highlight the need for routine assessment and integrated intervention for SEBDs among children with CPCs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: The Child Health Utility-9 Dimensions (CHU9D) is a patient-reported outcome measure to generate Quality-Adjusted Life Years (QALYs), recommended for economic evaluations of interventions to inform funding decisions. When the CHU9D is not available, mapping algorithms offer an opportunity to convert other paediatric instruments, such as the Paediatric Quality of Life Inventory™ (PedsQL), onto the CHU9D scores. This study aims to validate current PedsQL to CHU9D mappings in a sample of children and young people of a wide age range (0 to 16 years of age) and with chronic conditions. New algorithms with improved predictive accuracy are also developed., Methods: Data from the Children and Young People's Health Partnership (CYPHP) were used (N = 1735). Four regression models were estimated: ordinal least squared, generalized linear model, beta-binomial and censored least absolute deviations. Standard goodness of fit measures were used for validation and to assess new algorithms., Results: While previous algorithms perform well, performance can be enhanced. OLS was the best estimation method for the final equations at the total, dimension and item PedsQL scores levels. The CYPHP mapping algorithms include age as an important predictor and more non-linear terms compared with previous work., Conclusion: The new CYPHP mappings are particularly relevant for samples with children and young people with chronic conditions living in deprived and urban settings. Further validation in an external sample is required. Trial registration number NCT03461848; pre-results., (© 2023. The Author(s).)

Introduction: Almost 250 million children fail to achieve their full growth or developmental potential, trapping them in a cycle of continuing disadvantage. Strong evidence exists that parent-focussed face to face interventions can improve developmental outcomes; the challenge is delivering these on a wide scale. SPRING (Sustainable Programme Incorporating Nutrition and Games) aimed to address this by developing a feasible affordable programme of monthly home visits by community-based workers (CWs) and testing two different delivery models at scale in a programmatic setting. In Pakistan, SPRING was embedded into existing monthly home visits of Lady Health Workers (LHWs). In India, it was delivered by a civil society/non-governmental organisation (CSO/NGO) that trained a new cadre of CWs., Methods: The SPRING interventions were evaluated through parallel cluster randomised trials. In Pakistan, clusters were 20 Union Councils (UCs), and in India, the catchment areas of 24 health sub-centres. Trial participants were mother-baby dyads of live born babies recruited through surveillance systems of 2 monthly home visits. Primary outcomes were BSID-III composite scores for psychomotor, cognitive and language development plus height for age z -score (HAZ), assessed at 18 months of age. Analyses were by intention to treat., Results: 1,443 children in India were assessed at age 18 months and 1,016 in Pakistan. There was no impact in either setting on ECD outcomes or growth. The percentage of children in the SPRING intervention group who were receiving diets at 12 months of age that met the WHO minimum acceptable criteria was 35% higher in India (95% CI: 4-75%, p = 0.023) and 45% higher in Pakistan (95% CI: 15-83%, p = 0.002) compared to children in the control groups., Discussion: The lack of impact is explained by shortcomings in implementation factors. Important lessons were learnt. Integrating additional tasks into the already overloaded workload of CWs is unlikely to be successful without additional resources and re-organisation of their goals to include the new tasks. The NGO model is the most likely for scale-up as few countries have established infrastructures like the LHW programme. It will require careful attention to the establishment of strong administrative and management systems to support its implementation., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Kirkwood, Sikander, Roy, Soremekun, Bhopal, Avan, Lingam, Gram, Amenga-Etego, Khan, Aziz, Kumar, Verma, Sharma, Panchal, Zafar, Skordis, Batura, Hafeez, Hill, Divan and Rahman.)

The inSCALE cluster randomised controlled trial in Uganda evaluated two interventions, mHealth and Village Health Clubs (VHCs) which aimed to improve Community Health Worker (CHW) treatment for malaria, diarrhoea, and pneumonia within the national Integrated Community Case Management (iCCM) programme. The interventions were compared with standard care in a control arm. In a cluster randomised trial, 39 sub-counties in Midwest Uganda, covering 3167 CHWs, were randomly allocated to mHealth; VHC or usual care (control) arms. Household surveys captured parent-reported child illness, care seeking and treatment practices. Intention-to-treat analysis estimated the proportion of appropriately treated children with malaria, diarrhoea, and pneumonia according to WHO informed national guidelines. The trial was registered at ClinicalTrials.gov (NCT01972321). Between April-June 2014, 7679 households were surveyed; 2806 children were found with malaria, diarrhoea, or pneumonia symptoms in the last one month. Appropriate treatment was 11% higher in the mHealth compared to the control arm (risk ratio [RR] 1.11, 95% CI 1.02, 1.21; p = 0.018). The largest effect was on appropriate treatment for diarrhoea (RR 1.39; 95% CI 0.90, 2.15; p = 0.134). The VHC intervention increased appropriate treatment by 9% (RR 1.09; 95% CI 1.01, 1.18; p = 0.059), again with largest effect on treatment of diarrhoea (RR 1.56, 95% CI 1.04, 2.34, p = 0.030). CHWs provided the highest levels of appropriate treatment compared to other providers. However, improvements in appropriate treatment were observed at health facilities and pharmacies, with CHW appropriate treatment the same across the arms. The rate of CHW attrition in both intervention arms was less than half that of the control arm; adjusted risk difference mHealth arm -4.42% (95% CI -8.54, -0.29, p = 0.037) and VHC arm -4.75% (95% CI -8.74, -0.76, p = 0.021). Appropriate treatment by CHWs was encouragingly high across arms. The inSCALE mHealth and VHC interventions have the potential to reduce CHW attrition and improve the care quality for sick children, but not through improved CHW management as we had hypothesised. Trial Registration:ClinicalTrials.gov (NCT01972321)., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Källander et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The majority of post-neonatal deaths in children under 5 are due to malaria, diarrhoea and pneumonia (MDP). The WHO recommends integrated community case management (iCCM) of these conditions using community-based health workers (CHW). However iCCM programmes have suffered from poor implementation and mixed outcomes. We designed and evaluated a technology-based (mHealth) intervention package 'inSCALE' (Innovations At Scale For Community Access and Lasting Effects) to support iCCM programmes and increase appropriate treatment coverage for children with MDP., Methods: This superiority cluster randomised controlled trial allocated all 12 districts in Inhambane Province in Mozambique to receive iCCM only (control) or iCCM plus the inSCALE technology intervention. Population cross-sectional surveys were conducted at baseline and after 18 months of intervention implementation in approximately 500 eligible households in randomly selected communities in all districts including at least one child less than 60 months of age where the main caregiver was available to assess the impact of the intervention on the primary outcome, the coverage of appropriate treatment for malaria, diarrhoea and pneumonia in children 2-59months of age. Secondary outcomes included the proportion of sick children who were taken to the CHW for treatment, validated tool-based CHW motivation and performance scores, prevalence of cases of illness, and a range of secondary household and health worker level outcomes. All statistical models accounted for the clustered study design and variables used to constrain the randomisation. A meta-analysis of the estimated pooled impact of the technology intervention was conducted including results from a sister trial (inSCALE-Uganda)., Findings: The study included 2740 eligible children in control arm districts and 2863 children in intervention districts. After 18 months of intervention implementation 68% (69/101) CHWs still had a working inSCALE smartphone and app and 45% (44/101) had uploaded at least one report to their supervising health facility in the last 4 weeks. Coverage of the appropriate treatment of cases of MDP increased by 26% in the intervention arm (adjusted RR 1.26 95% CI 1.12-1.42, p<0.001). The rate of care seeking to the iCCM-trained community health worker increased in the intervention arm (14.4% vs 15.9% in control and intervention arms respectively) but fell short of the significance threshold (adjusted RR 1.63, 95% CI 0.93-2.85, p = 0.085). The prevalence of cases of MDP was 53.5% (1467) and 43.7% (1251) in the control and intervention arms respectively (risk ratio 0.82, 95% CI 0.78-0.87, p<0.001). CHW motivation and knowledge scores did not differ between intervention arms. Across two country trials, the estimated pooled effect of the inSCALE intervention on coverage of appropriate treatment for MDP was RR 1.15 (95% CI 1.08-1.24, p <0.001)., Interpretation: The inSCALE intervention led to an improvement in appropriate treatment of common childhood illnesses when delivered at scale in Mozambique. The programme will be rolled out by the ministry of health to the entire national CHW and primary care network in 2022-2023. This study highlights the potential value of a technology intervention aimed at strengthening iCCM systems to address the largest causes of childhood morbidity and mortality in sub-Saharan Africa., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Soremekun et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Social determinants of health (SDH) are contributors to health inequities experienced by some children with cerebral palsy and pose barriers to families engaging with complex and fragmented healthcare systems. There is emerging evidence to support 'social prescribing' interventions that systematically identify SDH concerns and refer patients to non-medical social care support and services to address their needs. To date, social prescribing has not been trialled specifically for children with neurodevelopmental disabilities, including cerebral palsy, in Australia. This study aims to codesign a social prescribing programme to address SDH concerns of children with cerebral palsy and their families who attend one of the three tertiary paediatric rehabilitation services in New South Wales, Australia., Methods and Analysis: This is a qualitative multi-site study conducted at the three NSW paediatric hospitals' rehabilitation departments using a codesign approach. Children aged 12-18 years with cerebral palsy, parents/caregivers of children (aged 0-18 years) with cerebral palsy, and clinicians will be involved in all stages to codesign the social prescribing programme. The study will consist of three components: (1) 'what we need', (2) 'creating the pathways' and (3) 'finalising and sign off'. This project is overseen by two advisory groups: one group of young adults with cerebral palsy and one group of parents of young people with cerebral palsy. The study will be guided by the biopsychosocial ecological framework, and analysis will follow Braun and Clark's thematic approach., Ethics and Dissemination: The study protocol was approved by the human research ethics committee of the Sydney Children's Hospitals Network. This codesign study will inform a future pilot study of feasibility and acceptability, then if indicated, a pilot clinical trial of efficacy. We will collaborate with all project stakeholders to disseminate findings and undertake further research to build sustainable and scalable models of care., Trial Registration Number: ACTRN12622001459718., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To assess the effect of digital health (DH), biomarker feedback (BF) and nurse or midwife-led counselling (NoMC) interventions on abstinence in pregnant smokers during pregnancy and postpartum., Settings: Any healthcare setting servicing pregnant women, including any country globally., Participants: Pregnant women of any social, ethnic or geographical background who smoke., Methods: We searched Embase, Medline, Web Of Science, Google Scholar, PsychINFO, CINAHL and PubMed between 2007 and November 2021. We included published original intervention studies in English with comparators (usual care or placebo). Two independent assessors screened and abstracted data. We performed a random-effects meta-analysis, assessed risk of bias with the Cochrane Tool and used Grading of Recommendations Assessment, Development and Evaluation to assess the quality of evidence., Results: We identified 57 studies and included 54 in the meta-analysis. Sixteen studies assessed DH (n=3961), 6 BF (n=1643), 32 NoMC (n=60 251), 1 assessed NoMC with BF (n=1120) and 2 NoMC with DH interventions (n=2107). DH interventions had moderate certainty evidence to achieve continuous abstinence (CA) at late pregnancy (4 studies; 2049 women; RR=1.98, 95% CI 1.08 to 3.64, p=0.03) and low certainty evidence to achieve point prevalence abstinence (PPA) postpartum (5 studies; 2238 women; RR=1.46, 95% CI 1.05 to 2.02, p=0.02). NoMC interventions had moderate certainty evidence to achieve PPA in late pregnancy (15 studies; 16 234 women; RR=1.54, 95% CI 1.16 to 2.06, p<0.01) and low certainty evidence to achieve PPA postpartum (13 studies; 5466 women; RR=1.79, 95% CI 1.14 to 2.83, p=0.01). Both DH and BF interventions did not achieve PPA at late pregnancy, nor NoMC interventions achieve CA postpartum. The certainty was reduced due to risk of bias, heterogeneity, inconsistency and/or imprecision., Conclusion: NoMC interventions can assist pregnant smokers achieve PPA and DH interventions achieve CA in late pregnancy. These interventions may achieve other outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe the health and well-being of children and young people (CYP) seeking asylum subjected to Australia's immigration policy of indefinite mandatory detention on Nauru., Design: Cross-sectional analysis of a cohort of CYP seeking asylum., Setting: Australian paediatric clinicians from 10 health services completed detailed health assessments around the time of transfer from Nauru, mostly to Australia., Participants: Sixty-two CYP who were ≤18 years on entry into offshore immigration detention on Nauru between 2013 and 2019. Mean age at health assessment was 9 years., Main Measures: Health outcomes were categorised as physical, mental or neurodevelopmental concerns/conditions. Risk and protective factor data were collected using the adverse childhood experiences and refugee-specific adverse childhood experiences tools., Results: Over half of the CYP (n=32, 52%) were held on Nauru for ≥4 years. The vast majority of CYP had physical health (n=55, 89%) and mental health (n=49, 79%) concerns including self-harm or suicidal ideation/attempt (n=28, 45%). Mental health concerns were more likely in CYP who were school-aged (p=0.001), had been held on Nauru for ≥1 year (p=0.01); originated from the Eastern Mediterranean region (p<0.05); witnessed trauma (p<0.05) or had exposure to ≥4 refugee-specific adverse childhood experiences (p<0.05). Neurodevelopmental concerns were seen in eight children (13%)., Conclusions: This study highlights the almost universal physical and mental health difficulties in a sample of CYP who experienced forced migration and were subjected to Australia's offshore immigration detention policy. Immigration detention in recipient countries, a known adverse childhood experience, may contribute to or exacerbate harmful outcomes in CYP seeking asylum., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Despite advancements in the use of body mass index (BMI) to categorize obesity severity in pediatrics, its utility in guiding individual clinical decision making remains limited. The Edmonton Obesity Staging System for Pediatrics (EOSS-P) provides a way to categorize the medical and functional impacts of obesity according to the severity of impairment. The aim of this study was to describe the severity of obesity among a sample of multicultural Australian children using both BMI and EOSS-P tools., Methods: This cross-sectional study included children aged 2-17 years receiving obesity treatment through the Growing Health Kids (GHK) multi-disciplinary weight management service in Australia between January to December 2021. BMI severity was determined using the 95th percentile for BMI on age and gender standardized Centre for Disease Control and Prevention (CDC) growth charts. The EOSS-P staging system was applied across the four health domains (metabolic, mechanical, mental health and social milieu) using clinical information., Results: Complete data was obtained for 338 children (age 10.0 ± 3.66 years), of whom 69.5% were affected by severe obesity. An EOSS-P stage 3 (most severe) was assigned to 49.7% of children, the remaining 48.5% were assigned stage 2 and 1.5% were assigned stage 1 (least severe). BMI predicted health risk as defined by EOSS-P overall score. BMI class did not predict poor mental health., Conclusion: Used in combination, BMI and EOSS-P provide improved risk stratification of pediatric obesity. This additional tool can help focus resources and develop comprehensive multidisciplinary treatment plans., Competing Interests: The authors have no conflicts of interest to disclose., (© 2022 The Authors. Obesity Science & Practice published by World Obesity and The Obesity Society and John Wiley & Sons Ltd.)

Objectives: Implementing support and services early in the life course has been shown to promote positive developmental outcomes for children at high likelihood of developmental conditions including autism. This study examined parents'/caregivers' experiences and perceptions about a digital developmental surveillance pathway for autism, the autism surveillance pathway (ASP), and usual care, the surveillance as usual (SaU) pathway, in the primary healthcare general practice setting., Design: This qualitative study involves using a convenience selection process of the full sample of parents/caregivers that participated in the main programme, 'General Practice Surveillance for Autism', a cluster-randomised controlled trial study. All interviews were audio-recorded, transcribed and coded using NVivo V.12 software. An inductive thematic interpretive approach was adopted and data were analysed thematically., Participants: Twelve parents/caregivers of children with or without a developmental condition/autism (who participated in the main programme) in South Western Sydney and Melbourne were interviewed., Settings: All interviews were completed over the phone., Results: There were seven major themes and 20 subthemes that included positive experiences, such as pre-existing patient-doctor relationships and their perceptions on the importance of knowing and accessing early support/services. Barriers or challenges experienced while using the SaU pathway included long waiting periods, poor communication and lack of action plans, complexity associated with navigating the healthcare system and lack of understanding by general practitioners (GPs). Common suggestions for improvement included greater awareness/education for parents/carers and the availability of accessible resources on child development for parents/caregivers., Conclusion: The findings support the use of digital screening tools for developmental surveillance, including for autism, using opportunistic contacts in the general practice setting., Trial Registration Number: ANZCTR (ACTRN12619001200178)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Internationally, there is increasing emphasis on early support for pregnant women to optimize the health and development of mothers and newborns. To increase intervention reach, digital and app-based interventions have been advocated. There are growing numbers of pregnancy health care apps with great variation in style, function, and objectives, but evidence about impact on pregnancy well-being and behavior change following app interaction is lacking. This paper reports on the qualitative arm of the independent multicomponent study exploring the use and outcomes of first-time mothers using the Baby Buddy app, a pregnancy and parenting support app, available in the National Health Service App Library and developed by a UK child health and well-being charity, Best Beginnings., Objective: This study aims to understand when, why, and how first-time mothers use the Baby Buddy app and the perceived benefits and challenges., Methods: This paper reports on the qualitative arm of an independent, longitudinal, mixed methods study. An Appreciative Inquiry qualitative approach was used with semistructured interviews (17/60, 28%) conducted with new mothers, either by telephone or in a focus group setting. First-time mothers were recruited from 3 study sites from across the United Kingdom. Consistent with the Appreciative Inquiry approach, mothers were prompted to discuss what worked well and what could have been better regarding their interactions with the app during pregnancy. Thematic analysis was used, and findings are presented as themes with perceived benefits and challenges., Results: The main benefit, or what worked well, for first-time mothers when using the app was being able to access new information, which they felt was reliable and easy to find. This led to a feeling of increased confidence in the information they accessed, thus supporting family and professional communication. The main challenge was the preference for face-to-face information with a health care professional, particularly around specific issues that they wished to discuss in depth. What could have been improved included that there were some topics that some mothers would have preferred in more detail, but in other areas, they felt well-informed and thus did not feel a need to seek additional information via an app., Conclusions: Although this study included a small sample, it elicited rich data and insights into first-time mothers' app interactions. The findings suggest that easily accessible pregnancy information, which is perceived as reliable, can support first-time mothers in communicating with health care professionals. Face-to-face contact with professionals was preferred, particularly to discuss specific and personalized needs. Further studies on maternal and professional digital support preferences after the COVID-19 global pandemic and how they facilitate antenatal education and informed decision-making are recommended, particularly because digital solutions remain as a key element in pregnancy and early parenting care., International Registered Report Identifier (irrid): RR2-10.1017/S1463423618000294., (©Elizabeth Bailey, Samantha Nightingale, Nicky Thomas, Dawn Coleby, Toity Deave, Trudy Goodenough, Samuel Ginja, Raghu Lingam, Sally Kendall, Crispin Day, Jane Coad. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 21.11.2022.)

Introduction: Implementation evaluations provide insight into how interventions are delivered across varying contexts and why interventions work in some contexts and not in others. This manuscript outlines a detailed protocol of an implementation evaluation embedded in a stepped-wedge cluster randomised controlled trial of a model of care, Strengthening Care for Children (SC4C), that integrates paediatric care in general practice. The purpose of this manuscript is to describe the pragmatic methods that will be used to capture implementation evaluation process and outcome data within this trial., Methods and Analysis: Our implementation evaluation will use a mixed methods design, with data collected in the intervention arm of the SC4C trial guided by a logic model developed using the Consolidated Framework for Implementation Research (CFIR) and Proctor and colleague's taxonomy of implementation outcomes. Data collection will be via questionnaires and semistructured interviews with general practitioners, paediatricians, general practice administrative staff and children and families. Each of the 21 general practices recruited into the study will be described in terms of staffing, patient throughput and location, in addition to the nuanced inner and outer contexts, use of the intervention and its acceptability. We will quantify implementation effectiveness in each general practice clinic using the CFIR validated scoring system. Importantly, we have embedded data collection post intervention to enable assessment of the sustainable adoption of the intervention. An inductive approach to the analysis of qualitative data will identify additional emerging themes that may not be covered by the formal frameworks underpinning our analysis., Ethics and Dissemination: Ethical approval was granted by the Royal Children's Hospital Ethics Committee in August 2020 (HREC: 65955). Results will be submitted for publication in peer-reviewed journals and presented at relevant conferences., Trial Registration Number: Australia New Zealand Clinical Trials Registry 12620001299998 on 1 December 2020., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Australia's current healthcare system for children is neither sustainable nor equitable. As children (0-4 years) comprise the largest proportion of all primary care-type emergency department presentations, general practitioners (GPs) report feeling undervalued as an integral member of a child's care, and lacking in opportunities for support and training in paediatric conditions. This Strengthening Care for Children (SC4C) randomised trial aims to evaluate a novel, integrated GP-paediatrician model of care, that, if effective, will improve GP quality of care, reduce burden to hospital services and ensure children receive the right care, at the right time, closer to home., Methods and Analysis: SC4C is a stepped wedge cluster randomised controlled trial (RCT) of 22 general practice clinics in Victoria and New South Wales, Australia. General practice clinics will provide control period data before being exposed to the 12-month intervention which will be rolled out sequentially each month (one clinic per state) until all 22 clinics receive the intervention. The intervention comprises weekly GP-paediatrician co-consultation sessions; monthly case discussions; and phone and email paediatrician support, focusing on common paediatric conditions. The primary outcome of the trial is to assess the impact of the intervention as measured by the proportion of children's (0-<18 years) GP appointments that result in a hospital referral, compared with the control period. Secondary outcomes include GP quality of care; GP experience and confidence in providing paediatric care; family trust in and preference for GP care; and the sustainability of the intervention. An implementation evaluation will assess the model to inform acceptability, adaptability, scalability and sustainability, while a health economic evaluation will measure the cost-effectiveness of the intervention., Ethics and Dissemination: Human research ethics committee (HREC) approval was granted by The Royal Children's Hospital Ethics Committee in August 2020 (Project ID: 65955) and site-specific HRECs. The investigators (including Primary Health Network partners) will communicate trial results to stakeholders and participating GPs and general practice clinics via presentations and publications., Trial Registration Number: Australia New Zealand Clinical Trials Registry 12620001299998., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Continuity of child and family healthcare is vital for optimal child health and development for developmentally vulnerable children. Migrant and refugee communities are often at-risk of poor health outcomes, facing barriers to health service attendance including cultural, language, limited health literacy, discrimination and unmet psychosocial needs. 'Integrated health-social care hubs' are physical hubs where health and social services are co-located, with shared referral pathways and care navigation., Aim: Our study will evaluate the impact, implementation and cost-benefit of the First 2000 Days Care Connect (FDCC) integrated hub model for pregnant migrant and refugee women and their infants., Materials and Methods: This study has three components. Component 1 is a non-randomised controlled trial to compare the FDCC model of care with usual care. This trial will allocate eligible women to intervention and control groups based on their proximity to the Hub sites. Outcome measures include: the proportion of children attending child and family health (CFH) nurse services and completing their CFH checks to 12 months of age; improved surveillance of growth and development in children up to 12 months, post partum; improved breastfeeding rates; reduced emergency department presentations; and improved maternal well-being. These will be measured using linked medical record data and surveys. Component 2 will involve a mixed-method implementation evaluation to clarify how and why FDCC was implemented within the sites to inform future roll-out. Component 3 is a within-trial economic evaluation from a healthcare perspective to assess the cost-effectiveness of the Hubs relative to usual care and the implementation costs if Hubs were scaled and replicated., Ethics and Dissemination: Ethical approval was granted by the South Eastern Sydney Local Health District Human Research Ethics Committee in July 2021 (Project ID: 020/ETH03295). Results will be submitted for publication in peer-reviewed journals and presented at relevant conferences., Trial Registration Number: ACTRN12621001088831., Competing Interests: Competing interests: The views expressed are those of the author(s) and not necessarily those of the funding partners. NSW Health has no direct role in study design; data collection, analysis and interpretation, or writing of final reports, presentations or publications., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The increasing prevalence of developmental disorders in early childhood poses a significant global health burden. Early detection of developmental problems is vital to ensure timely access to early intervention, and universal developmental surveillance is recommended best practice for identifying issues. Despite this, there is currently considerable variation in developmental surveillance and screening between Australian states and territories and low rates of developmental screening uptake by parents. This study aims to evaluate an innovative web-based developmental surveillance programme and a sustainable approach to referral and care pathways, linking primary care general practice (GP) services that fall under federal policy responsibility and state government-funded child health services., Methods and Analysis: The proposed study describes a longitudinal cluster randomised controlled trial (c-RCT) comparing a 'Watch Me Grow Integrated' (WMG-I) approach for developmental screening, to Surveillance as Usual (SaU) in GPs. Forty practices will be recruited across New South Wales and Queensland, and randomly allocated into either the (1) WMG-I or (2) SaU group. A cohort of 2000 children will be recruited during their 18-month vaccination visit or opportunistic visit to GP. At the end of the c-RCT, a qualitative study using focus groups/interviews will evaluate parent and practitioner views of the WMG-I programme and inform national and state policy recommendations., Ethics and Dissemination: The South Western Sydney Local Health District (2020/ETH01625), UNSW Sydney (2020/ETH01625) and University of Queensland (2021/HE000667) Human Research Ethics Committees independently reviewed and approved this study. Findings will be reported to the funding bodies, study institutes and partners; families and peer-reviewed conferences/publications., Trial Registration Number: ANZCTR12621000680864., Competing Interests: Competing interests: DN is a non-executive director of BSPHN., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Risk factors for oral disease can potentially be ameliorated by school-based interventions. This review evaluates the effectiveness of primary school-based interventions in improving oral health among children in low-and middle-income countries (LMICs)., Methods: Our systematic review was conducted in accordance with the Joanna Briggs Institute methodology for systematic reviews of effectiveness. Medline, Embase, Global Health, CINAHL, Emcare, Scopus, Web of Science, WHO website, Google Advanced and Google Scholar were searched for experimental and observational studies published between 1995 and 2021 in English. Quality assessment and data extraction of the articles were performed by two independent reviewers. The primary outcome was decayed, missing, and filled teeth/surfaces [dmft(s)/DMFT(S)] scores. Seven meta-analyses were conducted., Results: The search yielded 1178 publications and after removing duplicates, 753 remained. A further 648 publications were excluded after screening titles and abstracts. 105 publications were reviewed in full and 34 were included. Narrative synthesis showed school-based interventions had a positive effect on oral health outcomes. Meta-analysis showed a significant positive effect on dental caries measured by DMFT scores (standardised mean difference (SMD) =  - 0.33; 95% CI - 0.56 to - 0.10; P = 0.005), net increment in DMFS scores (SMD =  - 1.09; 95% CI - 1.91 to - 0.27; P = 0.009), dmft and DMFT/S score > 1 (Risk Ratio = 0.70; 95% CI 0.53 to 0.94; P = 0.02) and plaque scores (SMD =  - 0.32; 95% CI - 0.46 to - 0.18; P < 0.00001). Non-significant positive effect was observed for dental caries measured by net increment in DMFT scores (SMD =  - 0.34; 95% CI - 0.69 to 0.02; P = 0.06) and DMFS scores (SMD =  - 0.26; 95% CI - 0.70 to 0.18; P = 0.24), and gingival health (SMD = 0.12; 95% CI - 0.32 to 0.55; P = 0.60). Certainty of evidence was assessed as very low for all oral health outcomes., Conclusion: School-based interventions can be effective in reducing the burden of oral disease among primary school children in LMICs, with skills-based education, teacher training, provision of access to oral health services and parental engagement emerging as particularly promising. Further research is required to provide evidence of effectiveness of primary school-based interventions to improve oral health. Systematic review registration The title of this review was registered with PROSPERO (registration number: CRD42020202599)., (© 2022. The Author(s).)

Background: Dental caries remains the most prevalent non-communicable disease globally affecting 60-90% of children. The World Health Organisation's (WHO) health-promoting school program offers a framework for dental intervention in low- and middle-income countries (LMICs). This study explored teacher contributions to children's oral health in relation to the WHO health-promoting school framework in rural Uganda., Methods: Semi structured interviews were conducted with a purposive sample of 18 teachers. All interviews were transcribed verbatim and analysed thematically., Results: Many teachers reported preparing children to practise proper oral hygiene care through skills training and demonstrations around proper teeth brushing. Teachers' roles included raising health awareness by providing information on oral health topics using different educational methods. Many teachers mentioned performing oral health examinations on children at the school, first aid, referral for dental treatments and engaging parents, students and health workers in oral health promotion., Conclusions: Teachers play an essential role in oral health promotion in countries like Uganda. Teachers are implementing key principles of the WHO's health-promoting school framework on the ground and need to be considered as a key public health resource. If improvements in oral health are to be attained in Sub-Saharan Africa and other LMICs, government interventions need to harness teachers' contributions in delivering oral health promotion., (© 2022. The Author(s).)

Financial counselling and income-maximisation services have the potential to reduce financial hardship and its associated burdens on health and wellbeing in High Income Countries. However, referrals to financial counselling services are not systematically integrated into existing health service platforms, thus limiting our ability to identify and link families who might be experiencing financial hardship. Review evidence on this is scarce. The purpose of this study is to review "healthcare-income maximisation" models of care in high-income countries for families of children aged between 0 and 5 years experiencing financial difficulties, and their impacts on family finances and the health and wellbeing of parent(s)/caregiver(s) or children. A systematic review of the MEDLINE, EMBase, PsycInfo, CINAHL, ProQuest, Family & Society Studies Worldwide, Cochrane Library, and Informit Online databases was conducted according to the Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) statement. A total of six studies (five unique samples) met inclusion criteria, which reported a total of 11,603 families exposed to a healthcare-income maximisation model. An average annual gain per person of £1661 and £1919 was reported in two studies reporting one Scottish before-after study, whereby health visitors/midwives referred 4805 clients to money advice services. In another UK before-after study, financial counsellors were attached to urban primary healthcare centres and reported an average annual gain per person of £1058. The randomized controlled trial included in the review reported no evidence of impacts on financial or non-financial outcomes, or maternal health outcomes, but did observe small to moderate effects on child health and well-being. Small to moderate benefits were seen in areas relating to child health, preschool education, parenting, child abuse, and early behavioral adjustment. There was a high level of bias in most studies, and insufficient evidence to evaluate the effectiveness of healthcare-income maximisation models of care. Rigorous (RCT-level) studies with clear evaluations are needed to assess efficacy and effectiveness.

Objectives: Housing is a social determinant of health that impacts the health and well-being of children and families. Screening and referral to address social determinants of health in clinical and social service settings has been proposed to support families with housing problems. This study aims to identify housing screening questions asked of families in healthcare and social services, determine validated screening tools and extract information about recommendations for action after screening for housing issues., Methods: The electronic databases MEDLINE, PsycINFO, EMBASE, Ovid Emcare, Scopus and CINAHL were searched from 2009 to 2021. Inclusion criteria were peer-reviewed literature that included questions about housing being asked of children or young people aged 0-18 years and their families accessing any healthcare or social service. We extracted data on the housing questions asked, source of housing questions, validity and descriptions of actions to address housing issues., Results: Forty-nine peer-reviewed papers met the inclusion criteria. The housing questions in social screening tools vary widely. There are no standard housing-related questions that clinical and social service providers ask families. Fourteen screening tools were validated. An action was embedded as part of social screening activities in 27 of 42 studies. Actions for identified housing problems included provision of a community-based or clinic-based resource guide, and social prescribing included referral to a social worker, care coordinator or care navigation service, community health worker, social service agency, referral to a housing and child welfare demonstration project or provided intensive case management and wraparound services., Conclusion: This review provides a catalogue of housing questions that can be asked of families in the clinical and/or social service setting, and potential subsequent actions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The first wave of the COVID-19 pandemic hit New South Wales (NSW) Australia in early 2020, followed by a sharp state-wide lockdown from mid-March to mid-May. After the lockdown, there had been a low level of community transmission of COVID-19 over a year. Such pandemic experiences provide unique opportunity to understand the impact of the pandemic on paediatric health service use as countries emerge from the pandemic., Methods: We examined the difference between the observed and the predicted numbers of inpatient admissions and emergency department (ED) attendances, respectively, related to chronic, acute infectious and injury conditions, for each month during the COVID-19 period (January 2020-February 2021), based on the numbers from 2016 to 2019, using records from two major paediatric hospitals in NSW. All analyses were conducted using autoregressive error models and were stratified by patient age, sex and socioeconomic status., Findings: Health service use was significantly lower than predicted for admissions and/or ED attendances related to chronic conditions, acute infections, and injury during the lockdown in 2020. Change in health service use varied by chronic conditions, from the largest decrease for respiratory conditions (40-78%) to non-significant change for cancer and mental health disorders. After the lockdown, health service use for most health conditions returned to pre-COVID-19 predicted levels. However, for mental health disorders, increased health service use persisted from June 2020 up to February 2021 by 30-55%, with higher increase among girls aged 12-17 years and those from socioeconomically advantaged areas. There was persistently lower health service use for acute infections and increased health service use for injuries. Differences by socio-demographic factors were noted for mental health disorders and injuries., Interpretation: The immediate return to pre-COVID-19 levels for most chronic conditions after the first lockdown in NSW highlights the healthcare needs for children affected by chronic conditions. Persistently lower health service use for acute infections is likely attributable to the decreased social contact. Sustained and targeted mental health support is essential to address the potentially increased demand for services among children during and beyond the pandemic., Funding: Financial Markets Foundation for Children Chair (RL, NN) , NHMRC Investigator Grant (APP1197940) (NN) , NHMRC Career Development fellowship (GNT1158954) (SW)., Competing Interests: We declare no competing interests., (© 2021 The Authors.)

Background: There is increasing evidence that integrated care improves child related quality of life and reduces health service use. However, there is limited evidence on family perspectives about the quality of integrated care for children's services. This study aimed to understand children, young people, and caregivers' perceptions of a new integrated care service, and to identify essential components of integrated care for children and young people with ongoing conditions., Methods: A qualitative analysis of in-depth interviews with caregivers and children included families (N = 37) with children with one of four ongoing conditions (asthma, eczema, epilepsy, constipation) who had experienced a new integrated care service delivered in South London, UK., Results: Four key components of integrated services identified were: that the key health-worker understood the health needs of the family in context; that professionals involved children and caregivers in treatment; that holistic care that supported the family unit was provided; and that families experienced coordination across health, social, and education systems., Conclusions: Children and families identify care navigation and a holistic approach as key components that make high quality integrated care services. Service developments strengthening these aspects will align well with family perspectives on what works and what matters.

Aim: The inverse care law suggests that those with the greatest need for services are least likely to receive them. Our aim of this study was to test the inverse care law in relation to the use of health services by children aged 4-5 years in Australia who were developmentally vulnerable and socioeconomically disadvantaged., Method: Cross-sectional data were collected from the Longitudinal Study of Australian Children birth cohort when the children were aged 4-5 years. Children were grouped according to the combination of developmental vulnerability (yes, no) and socioeconomic disadvantage (lower, higher), resulting in four groups (reference group: developmentally vulnerable and disadvantaged). Multivariate regression was used to examine the impact of the combination of developmental vulnerability and disadvantage on health service use, adjusting for other sociodemographic characteristics., Results: 3967 (90%) of children had data on developmental vulnerability at 4-5 years. A third of children (32.6%) were classified as developmentally vulnerable, and 10%-25% of these children had used health services. Non-disadvantaged children who were developmentally vulnerable (middle need) had 1.4-2.0 times greater odds of using primary healthcare, specialist and hospital services; and non-disadvantaged children who were not developmentally vulnerable (lowest need) had 1.6-1.8 times greater odds of using primary healthcare services, compared with children who were developmentally vulnerable and disadvantaged (highest need)., Conclusion: We found some evidence of the inverse care law. Equity in service delivery remains a challenge that is critically important to tackle in ensuring a healthy start for children., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

The United Kingdom, like all European countries, is struggling to strengthen health systems and improve conditions for child health and survival. Child mortality in the UK has failed to improve in line with other countries. Securing optimal conditions for child health requires a healthy society, strong health system, and effective health care. We examine inter-sectoral and intra-sectoral policy and governance for child health and survival in England. Literature reviews and universally applicable clinical scenarios were used to examine child health problems and English policy and governance responses for improving child health through integrating care and strengthening health systems, over the past 15 years. We applied the TAPIC framework for analysing policy governance: transparency, accountability, participation, integrity, and capacity. We identified strengths and weaknesses in child health governance in all the five domains. However there remain policy failures that are not fully explained by the TAPIC framework. Other problems with successfully translating policy to improved health that we identified include policy flux; policies insufficiently supported by delivery mechanisms, measurable targets, and sufficient budgets; and policies with unintended or contradictory aspects. We make recommendations for inter-sectoral and intra-sectoral child health governance, policy, and action to improve child health in England with relevant lessons for other countries., (Copyright © 2017 The Author(s). Published by Elsevier B.V. All rights reserved.)

There is growing evidence of the effectiveness of early childhood interventions to improve the growth and development of children. Although, historically, nutrition and stimulation interventions may have been delivered separately, they are increasingly being tested as a package of early childhood interventions that synergistically improve outcomes over the life course. However, implementation at scale is seldom possible without first considering the relative cost and cost-effectiveness of these interventions. An evidence gap in this area may deter large-scale implementation, particularly in low- and middle-income countries. We conduct a literature review to establish what is known about the cost-effectiveness of early childhood nutrition and development interventions. A set of predefined search terms and exclusion criteria standardized the search across five databases. The search identified 15 relevant articles. Of these, nine were from studies set in high-income countries and six in low- and middle-income countries. The articles either calculated the cost-effectiveness of nutrition-specific interventions (n = 8) aimed at improving child growth, or parenting interventions (stimulation) to improve early childhood development (n = 7). No articles estimated the cost-effectiveness of combined interventions. Comparing results within nutrition or stimulation interventions, or between nutrition and stimulation interventions was largely prevented by the variety of outcome measures used in these analyses. This article highlights the need for further evidence relevant to low- and middle-income countries. To facilitate comparison of cost-effectiveness between studies, and between contexts where appropriate, a move towards a common outcome measure such as the cost per disability-adjusted life years averted is advocated. Finally, given the increasing number of combined nutrition and stimulation interventions being tested, there is a significant need for evidence of cost-effectiveness for combined programmes. This too would be facilitated by the use of a common outcome measure able to pool the impact of both nutrition and stimulation activities., (Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2014; all rights reserved.)

Aim of the study was to investigate whether 7-9 year old children with severe motor difficulties are more at risk of additional difficulties in activities in daily living, academic skills, attention and social skills than children with moderate motor difficulties. Children (N=6959) from a population based cohort, the Avon Longitudinal Study of Parents and Children (ALSPAC), were divided into three groups based on their scores on the ALSPAC Coordination Test at age 7: control children (scores above 15th centile; N=5719 [82.1%]); children with moderate (between 5th and 15th centile; N=951 [13.7%]); and children with severe motor difficulties (below 5th centile N=289 [4.2%]). Children with neurological disorders or an IQ<70 were excluded. Logistic regression was used to compare children with moderate and severe motor coordination difficulties with each other and with control children regarding their risk of co-morbidity defined as significant (<10th centile) difficulties with activities of daily living (ADL); academic skills (reading, spelling and handwriting); attention; social skills (social cognition and nonverbal skills). Children with severe motor difficulties demonstrated a higher risk of difficulties in ADL, handwriting, attention, reading, and social cognition than children with moderate motor difficulties, who in turn had a higher risk of difficulties than control children in five out of seven domains. Screening and intervention of co-morbid problems is recommended for children with both moderate and severe motor difficulties., (Copyright © 2013. Published by Elsevier Ltd.)

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.