Antidepressants in pregnancy: applying causal epidemiological methods to understand service-use outcomes in women and long-term neurodevelopmental outcomes in exposed children.

Background: Antidepressants are commonly prescribed during pregnancy, despite a lack of evidence from randomised trials on the benefits or risks. Some studies have reported associations of antidepressants during pregnancy with adverse offspring neurodevelopment, but whether or not such associations are causal is unclear. Objectives: To study the associations of antidepressants for depression in pregnancy with outcomes using multiple methods to strengthen causal inference. Design: This was an observational cohort design using multiple methods to strengthen causal inference, including multivariable regression, propensity score matching, instrumental variable analysis, negative control exposures, comparison across indications and exposure discordant pregnancies analysis. Setting: This took place in UK general practice. Participants: Participants were pregnant women with depression. Interventions: The interventions were initiation of antidepressants in pregnancy compared with no initiation, and continuation of antidepressants in pregnancy compared with discontinuation. Main outcome measures: The maternal outcome measures were the use of primary care and secondary mental health services during pregnancy, and during four 6-month follow-up periods up to 24 months after pregnancy, and antidepressant prescription status 24 months following pregnancy. The child outcome measures were diagnosis of autism, diagnosis of attention deficit hyperactivity disorder and intellectual disability. Data sources: UK Clinical Practice Research Datalink. Results: Data on 80,103 pregnancies were used to study maternal primary care outcomes and were linked to 34,274 children with at least 4-year follow-up for neurodevelopmental outcomes. Women who initiated or continued antidepressants during pregnancy were more likely to have contact with primary and secondary health-care services during and after pregnancy and more likely to be prescribed an antidepressant 2 years following the end of pregnancy than women who did not initiate or continue antidepressants during pregnancy (odds ratioinitiation 2.16, 95% confidence interval 1.95 to 2.39; odds ratiocontinuation 2.40, 95% confidence interval 2.27 to 2.53). There was little evidence for any substantial association with autism (odds ratiomultivariableregression 1.10, 95% confidence interval 0.90 to 1.35; odds ratiopropensityscore 1.06, 95% confidence interval 0.84 to 1.32), attention deficit hyperactivity disorder (odds ratiomultivariableregression 1.02, 95% confidence interval 0.80 to 1.29; odds ratiopropensityscore 0.97, 95% confidence interval 0.75 to 1.25) or intellectual disability (odds ratiomultivariableregression 0.81, 95% confidence interval 0.55 to 1.19; odds ratiopropensityscore 0.89, 95% confidence interval 0.61 to 1.31) in children of women who continued antidepressants compared with those who discontinued antidepressants. There was inconsistent evidence of an association between initiation of antidepressants in pregnancy and diagnosis of autism in offspring (odds ratiomultivariableregression 1.23, 95% confidence interval 0.85 to 1.78; odds ratiopropensityscore 1.64, 95% confidence interval 1.01 to 2.66) but not attention deficit hyperactivity disorder or intellectual disability; however, but results were imprecise owing to smaller numbers. Limitations: Several causal-inference analyses lacked precision owing to limited numbers. In addition, adherence to the prescribed treatment was not measured. Conclusions: Women prescribed antidepressants during pregnancy had greater service use during and after pregnancy than those not prescribed antidepressants. The evidence against any substantial association with autism, attention deficit hyperactivity disorder or intellectual disability in the children of women who continued compared with those who discontinued antidepressants in pregnancy is reassuring. Potential association of initiation of antidepressants during pregnancy with offspring autism needs further investigation. Future work: Further research on larger samples could increase the robustness and precision of these findings. These methods applied could be a template for future pharmaco-epidemiological investigation of other pregnancy-related prescribing safety concerns. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (15/80/19) and will be published in full in Health Technology Assessment; Vol. 27, No. 15. See the NIHR Journals Library website for further project information.

About one in seven women experience depression during pregnancy. Left untreated, this may harm them and their unborn babies. However, the decision to take antidepressants during pregnancy is difficult because women often worry about the risks to their unborn baby. Research findings have been inconsistent, so women often do not have clear information to enable them to make informed decisions. We studied women's and children's outcomes after starting (compared with not starting) or continuing (compared with stopping) antidepressants in pregnancy. We used a large UK primary care database and several novel methods of analysis. We tracked 80,103 pregnancies of women with depression for up to 2 years after pregnancy. We also tracked 34,274 children from these pregnancies for at least 4 years to check for developmental outcomes. Women prescribed antidepressants were more likely than women not prescribed antidepressants to use general practice and mental health services during and after pregnancy, and to be prescribed antidepressants 2 years after pregnancy. This suggests that antidepressants were being prescribed to women with greater clinical need. Women who continued antidepressants in pregnancy had no higher likelihood than those who discontinued antidepressants of autism, attention deficit hyperactivity disorder or intellectual disability in their children. This should reassure women making the decision to continue taking their medications in pregnancy. Women who started antidepressants in pregnancy may possibly have had a slightly higher likelihood of autism in their children than those who did not start them. These findings were not seen in all analyses and were based on smaller numbers; therefore, they should be viewed with caution. Importantly, over 98 in every 100 children of women who initiated or continued antidepressants in pregnancy did not receive an autism diagnosis. The findings may help women and clinicians make informed decisions on treatment with antidepressants in pregnancy.

Social, emotional and behavioural difficulties associated with persistent speech disorder in children: A prospective population study.

Purpose: Social, emotional and behavioural difficulties (SEBD) in childhood are associated with negative consequences across the life course. Children with developmental language disorder have been identified as being at risk of developing SEBD but it is unclear whether a similar risk exists for children with speech sound disorder, a condition which impacts on children's ability to make themselves understood and has been shown to be associated with poor educational outcomes. Methods: Participants were children who attended the 8-year-old clinic in the Avon Longitudinal Study of Parents and Children (N = 7390). Children with speech sound disorder that had persisted beyond the period of typical speech acquisition (persistent speech disorder [PSD]) at age 8 were identified from recordings and transcriptions of speech samples (N = 263). Parent-, teacher- and child-reported questionnaires and interviews including the Strengths and Difficulties Questionnaire, Short Moods and Feelings Questionnaire and measures for antisocial and risk-taking behaviour were used to provide outcome scores for SEBD at 10-14 years in a series of regression analyses. Results: Following adjustment for biological sex, socio-economic status and Intelligence Quotient, children with PSD at age 8 were more likely to show peer problems at age 10-11 years compared with their peers, as reported by teachers and parents. Teachers were more likely to report problems with emotionality. Children with PSD were no more likely to report symptoms of depression than their peers. No associations were observed between PSD, risk of antisocial behaviour, trying alcohol at age 10 or smoking cigarettes at age 14. Conclusions: Children with PSD may be at risk in terms of their peer relationships. This could impact on their wellbeing and, while not observed at this age, may lead to depressive symptoms in older childhood and adolescence. There is also the potential that these symptoms may impact on educational outcomes.

The impact of a clinical prediction tool (BuRN-Tool) for child maltreatment on social care outcomes for children attending hospital with a burn or scald injury.

Burns are common childhood injuries and 10-20% are associated with maltreatment. This prospective before/after study investigated the impact of introducing the BuRN-Tool (a child maltreatment clinical prediction tool), on actions taken by children's social care department (CSC). Before introduction (pre-intervention): we collected standardised data on cause and characteristics of burns, in four regional hospitals. A BuRN-Tool-score was calculated retrospectively pre-intervention and by the attending clinician post-intervention. CSC involvement and actions taken relative to BuRN-Tool-score were compared pre- and post-BuRN-Tool. Data were collected for 1688 children from 17 local authorities. The percentage that received a CSC action decreased post-BuRN-Tool (pre: 58.0%, 51/88; post: 37.5%, 33/88, p = 0.007). A greater percentage of cases with a BuRN-Tool-score of ≥ 3 had a CSC action, than those with a BuRN-Tool-score 3, pre-intervention (≥3 70.0%, 35/50; = 0.04) and post-intervention (≥3 50.0%, 21/42; = 0.01). Children with a BuRN-Tool-score ≥ 3 but no contact/referral recorded by CSC for the burn, and those who had a contact/referral but no action taken, were significantly more likely than those scoring 3 to have new CSC involvement within six months following the burn. The BuRN-Tool-score ≥ 3 has the potential to alert clinicians to maltreatment concerns.

Problem Gambling in Early Adulthood: a Population-Based Study.

The aims of this study were to investigate stability of problem gambling between 20 and 24 years of age, and the antecedents and consequences of problem gambling at age 20 years. Young adult participants in the Avon Longitudinal Study of Parents and Children (ALSPAC) completed computer-administered gambling surveys on paper, or online. Responses to the Problem Gambling Severity Index (PGSI) were complete for 2624 participants at 20 years, and 1921 participants at 24 years. Responses were categorized into 'non-problem' (71-78%), 'low-risk gambling' (16-21%), 'moderate-risk gambling' (4-5.5%), and 'problem gambling' (1-1.5%). The overall frequency of moderate-risk/problem gambling varied little between age 20 and 24 years, and scratch cards, online betting and gambling were the most frequent activities. Problem gamblers at age 20 years had a history of hyperactivity and conduct problems in adolescence, high sensation seeking, and an external locus of control. They were more likely to have mothers who had problems with gambling, reported less parental supervision, and higher social media usage. Moderate-risk/problem gambling at age 20 years was associated with regular cigarette smoking, high levels of illicit drug use, and problematic use of alcohol at age 24 years. A significant minority of young adults (mainly males) showed problem gambling behaviours which appeared to be established by the age of 20 years and were associated with other potentially addictive behaviours.

Gambling by Young Adults in the UK During COVID-19 Lockdown.

Gambling is a common activity amongst young adults in the UK, and was a behavior of interest during the early mitigation against COVID-19 (first lockdown). The Avon Longitudinal Study of Parents and Children (ALSPAC) was used to investigate attitudes, moods and behavior during lockdown in England. ALSPAC participants were invited to complete online questionnaires in May 2020, including a set of questions about frequency of gambling and gambling activities which had been asked three years previously. Mental health and wellbeing data and alcohol use were also collected as part of lockdown questionnaires. Gambling questions were completed by 2632 young adults, 71% female, with a mean age of 27.8 years. Overall, gambling frequency reduced during lockdown for both males and females, but more males engaged in regular (weekly) gambling. Gambling activities became more restricted compared to previous reports, but online gambling (e.g. online poker, bingo, casino games) was more frequent. Previous gambling behaviour predicted gambling frequency during lockdown. No associations were apparent between gambling frequency and measures of mental health and well-being. Heavy alcohol use was strongly linked with regular gambling during lockdown. Gamblers were more than twice as likely as non-gamblers to have experienced financial difficulties pre-COVID, but gambling frequency was not related to employment status during lockdown. Online gambling increased during lockdown, whilst offline gambling activities decreased in frequency. A small minority of regular weekly gamblers, who tended to be male and heavy users of alcohol, participated in a wide range of online and offline gambling activities.

Depression in childhood: The role of children's exposure to intimate partner violence and maternal mental disorders.

BACKGROUND: Intimate partner violence (IPV) is a global problem with high prevalence rates, and is linked to maternal mental disorders (MMD). Children's exposure to IPV (CEIPV) can have impacts on their physical and mental health, including depression. OBJECTIVE: To analyze the associations between exposure to both CEIPV and MMD and depression in schoolchildren. PARTICIPANTS AND SETTING: 630 mother-child pairs were evaluated in a poor urban district in Recife, Northeast Brazil. METHODS: A cohort study investigated the effects of IPV during pregnancy, postpartum and six to nine years after delivery. Women were asked about their experience of IPV, their own mental health, and the exposure of their child to violence. The child's mood was reported by the mother, using the Short Mood and Feelings Questionnaire (SMFQ). Ten types of CEIPV, and the age of onset of exposure, were compared with the child's subsequent risk of depression. RESULTS: IPV was associated with MMD in 31.9% of the women at some period of time. Depressive symptoms were reported in 15.7% of school-age children. All types of CEIPV were associated with depression at school age. Multivariable analyses of exposure to IPV and MMD at different ages showed that exposure to both IPV and MMD in the first year of life had the strongest association with childhood depression (OR = 9.1; 95% CI: 2.4-33.9). CONCLUSIONS: The frequency of CEIPV and MMD, and the high prevalence of depression at school age, shows the importance of assessing MMD and identifying exposure to IPV in pregnancy and the early years.

Evaluation of the efficacy and impact of a clinical prediction tool to identify maltreatment associated with children's burns.

Background: An estimated 10%-24% of children attending emergency departments with a burn are maltreated. Objective: To test whether a clinical prediction tool (Burns Risk assessment for Neglect or abuse Tool; BuRN-Tool) improved the recognition of maltreatment and increased the referral of high-risk children to safeguarding services for assessment. Methods: A prospective study of children presenting with burns to four UK hospitals (2015-2018), each centre providing a minimum of 200 cases before and after the introduction of the BuRN-Tool. The proportions of children referred to safeguarding services were compared preintervention and postintervention, and the relationship between referral and the recommended cut-off for concern (BuRN-Tool score (BT-score) ≥3) was explored. Results: The sample was 2443 children (median age 2 years). Nurses and junior doctors mainly completed the BuRN-Tool, and a BT-score was available for 90.8% of cases. After intervention, 28.4% (334/1174) had a BT-score ≥3 and were nearly five times more likely to be discussed with a senior clinician than those with a BT-score <3 (65.3% vs 13.4%, p<0.001). There was no overall difference in the proportion of safeguarding referrals preintervention and postintervention. After intervention, the proportion of referrals for safeguarding concerns was greater when the BT-score was ≥3 (p=0.05) but not for scores <3 (p=0.60). A BT-score of 3 as a cut-off for referral had a sensitivity of 72.1, a specificity of 82.7 and a positive likelihood ratio of 4.2. Conclusions: A BT-score ≥3 encouraged discussion of cases of concern with senior colleagues and increased the referral of <5 year-olds with safeguarding concerns to children's social care.

Educational outcomes associated with persistent speech disorder.

BACKGROUND: Children with persistent speech disorder (PSD) are at higher risk of difficulties with literacy, with some evidence suggesting an association with poorer educational attainment. However, studies to date have either used small clinical samples, which exclude children who have not been referred to clinical services, or relied on parent-teacher report of children's speech development. There is a need for an inclusive study to investigate the impact of PSD on educational outcomes using a population-based sample and robust measures of speech development. AIM: Using a large prospective UK population-based study-the Avon Longitudinal Study of Parents and Children (ALSPAC)-this study investigated: (1) how children identified with PSD at age 8 years perform on educational attainment tests at ages 10-11 and 13-14 years in comparison with children without PSD; and (2) whether children identified with PSD at age 8 years are more likely to receive a label of special educational needs (SEN) in secondary school. METHODS & PROCEDURES: We examined the data for 263 children with PSD and 6399 controls who had speech assessed at age 8 years in a research clinic. Educational attainment was measured using data from English school standard attainment tests. Data on SEN categorization were obtained between 11 and 13 years of age. Children with PSD and controls were compared using regression analyses adjusted for biological sex, maternal age, verbal, performance and full-scale IQ. OUTCOMES & RESULTS: Children with PSD at age 8 years were more likely to achieve lower attainment scores at ages 10-11 years in English and mathematics and across all three subjects of English, mathematics and science at ages 13-14 years after controlling for biological sex and maternal education; score below target levels for English at both time points after controlling for verbal IQ, and at ages 13-14 years after controlling for performance IQ; and receive a label of SEN (typically for the category of cognition and learning needs or communication and interaction needs) in secondary school. CONCLUSIONS & IMPLICATIONS: PSD identified at age 8 years is associated with poor educational attainment at ages 10-11 and 13-14 years in the core subjects of English, mathematics and science. Children with PSD at age 8 years are more likely to be identified with SEN at ages 11-13 years, particularly cognition and learning needs, and communication and interaction needs. We need to be aware of the potential for the long-term impact of PSD on educational attainment in providing appropriate and effective support throughout school. What this paper adds What is already known on the subject Speech-sound disorder is associated with reading and spelling difficulties, with some evidence to suggest that PSD is associated with a higher risk of literacy difficulties. Limited evidence also suggests that speech-sound disorder may be associated with poorer educational attainment. However, studies to date have used small clinical samples or parent-teacher report of speech development and there is a need to determine whether the association is observed in larger and more inclusive population-based samples. What this paper adds to existing knowledge This prospective, longitudinal study of a large community-based sample of English children has shown that PSD is associated with poorer educational attainment at the end of primary school and at ages 13-14 years. Children with PSD are also more likely to be identified as having SEN in secondary school, especially communication and interaction needs but also including cognition and learning needs. What are the potential or actual clinical implications of this work? Understanding the long-term implications of PSD on educational attainment highlights the importance of ongoing monitoring and support to enable children to reach their potential throughout primary and secondary school. The identification of children with a history of PSD during transition to secondary school will enable effective support to be put in place. The intervention for children with PSD should involve close collaboration between speech and language therapists and education professionals.

Mixed-methods process evaluation of SafeTea: a multimedia campaign to prevent hot drink scalds in young children and promote burn first aid.

OBJECTIVES: SafeTea is a multifaceted intervention delivered by community practitioners to prevent hot drink scalds to young children and improve parents' knowledge of appropriate burn first aid. We adapted SafeTea for a national multimedia campaign, and present a mixed-methods process evaluation of the campaign. METHODS: We used social media, a website hosting downloadable materials and media publicity to disseminate key messages to parents/caregivers of young children and professionals working with these families across the UK. The SafeTea campaign was launched on National Burns Awareness Day (NBAD), October 2019, and ran for 3 months. Process evaluation measurements included social media metrics, Google Analytics, and quantitative and qualitative results from a survey of professionals who requested hard copies of the materials via the website. RESULTS: Findings were summarised under four themes: 'reach', 'engagement', 'acceptability' and 'impact/behavioural change'. The launch on NBAD generated widespread publicity. The campaign reached a greater number of the target audience than anticipated, with over 400 000 views of the SafeTea educational videos. Parents and professionals engaged with SafeTea and expressed positive opinions of the campaign and materials. SafeTea encouraged parents to consider how to change their behaviours to minimise the risks associated with hot drinks. Reach and engagement steadily declined after the first month due to reduced publicity and social media promotion. CONCLUSION: The SafeTea campaign was successful in terms of reach and engagement. The launch on NBAD was essential for generating media interest. Future campaigns could be shorter, with more funding for additional social media content and promotion.

Multicentre observational study describing the systemic response to small-area burns in children.

BACKGROUND AND OBJECTIVES: Burns of less than 10% total body surface area (TBSA) are common injuries in children under five years of age. The inflammatory response to burn injury is well recognised for burns greater than 20% TBSA but has not been described for smaller burns. The aim of this study was to describe the systemic response to burn injury in young children with small-area burns. METHODS: The Morbidity In Small Thermal Injury in Children study (MISTIC) was a multicentre prospective observational cohort study that recruited 625 patients under five years of age with burns of less than 10% TBSA over eighteen months across three sites in England. Prospectively collected data included physical observations and laboratory blood tests taken in hospital as part of routine care. Additional information was sourced from temperature recordings taken at home following discharge. RESULTS: Elevated temperatures were observed in children with scald or contact burns between 2-10% TBSA, with a peak on day one after burn followed by a fall over days four to seven after burn. No temperature rise was seen in children with burns of <2% TBSA. Higher temperature readings were associated with larger burn size, age under two years and male sex. Heart rate and C-Reactive Protein levels showed a peak on day three after burn. CONCLUSIONS: An identifiable systemic inflammatory response to small-area burns in young children is reported. This knowledge can be used to aid in the diagnosis of children with a burn injury who re-present with a pyrexia, and no other symptoms to indicate clinical infection.

Gambling in children and adolescents.

INTRODUCTION: Children are susceptible to problems with gambling because of developmental and cognitive immaturities, as well as a sensitivity to peer pressure and marketing. SOURCES OF DATA: This review uses recent UK data from the Gambling Commission and from the Avon Longitudinal Study of Parents and Children, and evidence from recent reviews of gambling in children and adolescents. AREAS OF AGREEMENT: The prevalence of gambling in children worldwide and in the UK is stable, having generally decreased since 2013. Online gambling is increasing in children and young people. A small minority of adolescents who gamble develop a gambling disorder. Adolescents who have problems with gambling tend to have lower self-esteem and a history of hyperactivity and impulsivity, are more likely to have parents who gamble, report less parental supervision and to use more alcohol than their peers. AREAS OF CONTROVERSY: Children's access to slot machines, the relationship between gaming and gambling, and social media advertizing of gambling targeting children. GROWING POINTS: An increase in online gambling and in-play sports betting by adolescents and the use of skins betting in video gaming.Areas timely for developing research: impact on young people of betting on e-gaming. How best to protect children from early exposure to gambling in the current internet age. IMPLICATIONS FOR CLINICIANS: Need to be aware of the growing and complex phenomenon of gaming and gambling, and implications for the mental health of children and adolescents. The effective management of gambling disorders in children and adolescents requires close working with families.

Child and adolescent mental health trajectories in relation to exclusion from school from the Avon Longitudinal Study of Parents and Children.

BACKGROUND: As the prevalence of childhood mental health conditions varies by age and gender, we explored whether there were similar variations in the relationship between psychopathology and exclusion from school in a prospective UK population-based birth cohort. METHOD: The Avon Longitudinal Study of Parents and Children collected reports of exclusion at 8 years and 16 years. Mental health was assessed at repeated time points using the Strengths and Difficulties Questionnaire (SDQ). RESULTS: Using adjusted linear mixed effects models, we detected a nonlinear interaction between exclusion and age related to poor mental health for boys [adjusted coefficient 1.13 (95% confidence interval 0.55-1.71)] excluded by age 8, but not for girls. The SDQ scores of boys who were excluded in primary school were higher than their peers from age 3, and increasingly diverged over time. As teenagers, these interactions appeared for both genders [boys' adjusted coefficient 0.18 (0.10-0.27); girls 0.29 (0.17-0.40)]. For teenage girls, exclusion by 16 was followed by deteriorating mental health. Family adversity predicted exclusion in all analyses. CONCLUSION: Prompt access to effective intervention for children in poor mental health may improve both mental health and access to education. KEY PRACTITIONER MESSAGE: Children who were subsequently excluded from school often faced family adversity and had poor mental health, which suggests the need for an interdisciplinary response and a multiagency approach. Poor mental health may contribute to and result from exclusion from school, so both mental health and education practitioners have a key role to play. Boys who enter school with poor mental health are at high risk of exclusion in primary school, which prompt assessment and intervention may prevent. Both boys and girls who are excluded between the ages of 15 and 16 years may have poor, and in the case of girls, deteriorating, mental health.

Gambling in Young Adults Aged 17-24 Years: A Population-Based Study.

A large contemporary UK cohort study, the Avon Longitudinal Study of Parents and Children, was used to investigate gambling behavior and to explore the antecedents of regular gambling in the 17-24-year age group. Participants completed computer-administered gambling surveys in research clinics, on paper, and online. The sample sizes were 3566 at age 17 years, 3940 at 20 years, and 3841 at 24 years; only 1672 completed all three surveys. Participation in gambling in the last year was reported by 54% of 17-year-olds, rising to 68% at 20 years, and 66% at 24 years, with little overall variance. Regular (weekly) gambling showed a strong gender effect, increasing among young men from 13% at 17 years to 18% at 20 years, and 17% at 24 years. Although gambling frequency increased between the ages of 17 and 20 years, gambling behaviors showed little variance between 20 and 24 years, except online gambling and betting on horseraces. The commonest forms of gambling were playing scratchcards, playing the lottery, and private betting with friends. Gambling on activities via the internet increased markedly between 17 and 24 years, especially among males. In the fully adjusted model, individual antecedents of regular gambling were being male, and having a low IQ, an external locus of control, and high sensation seeking scores. Parental gambling behavior and maternal educational background were associated with regular gambling in both sexes. Regular gambling was associated with smoking cigarettes and frequent and harmful use of alcohol, but no associations with depression were found.

Feasibility of Safe-Tea: a parent-targeted intervention to prevent hot drink scalds in preschool children.

OBJECTIVE: Despite the high prevalence of preventable hot drink scalds in preschool children, there is a paucity of research on effective prevention interventions and a serious need to improve parents' knowledge of first aid. This study investigates the feasibility of 'Safe-Tea', an innovative multifaceted community-based intervention delivered by early-years practitioners. METHODS: 'Safe-Tea' was implemented at Childcare, Stay&Play and Home Visit settings in areas of deprivation in Cardiff, UK. A mixed-methods approach was used, including preintervention and postintervention parent questionnaires and focus groups with parents and practitioners to test the acceptability, practicality and ability of staff to deliver the intervention, and parents' knowledge and understanding. RESULTS: Intervention materials, activities and messages were well received and understood by both parents and community practitioners. Interactive and visual methods of communication requiring little to no reading were most acceptable. Parents' understanding of the risk of hot drink scalds in preschool children and knowledge of appropriate first aid improved postintervention. Parents knew at baseline that they 'should' keep hot drinks out of reach. Focus group discussions after intervention revealed improved understanding of likelihood and severity of scald injury to children, which increased vigilance. Parents gained confidence to correct the behaviours of others at home and pass on first aid messages. CONCLUSION: This feasibility study is a vital step towards the development of a robust, evidence-based behaviour change intervention model. Work is underway to refine intervention materials based on improvements suggested by parents, and test these more widely in communities across the UK.

The development and evaluation of a picture tongue assessment tool for tongue-tie in breastfed babies (TABBY).

Background: The presence of a tongue-tie (ankyloglossia) in an infant may lead to breastfeeding difficulties, but debate continues about which babies should be treated with frenotomy. The Bristol Tongue Assessment Tool (BTAT), a clear and simple evaluation of the severity of tongue-tie, is being used worldwide and translated into different languages. We aimed to produce a simple picture version of the BTAT to aid and enhance consistent assessment of infants with tongue-tie. Methods: The Tongue-tie and Breastfed Babies (TABBY) assessment tool was developed from the BTAT by a graphic designer, with iterative discussion with four practicing NHS midwives. The TABBY tool consists of 12 images demonstrating appearance of the infant tongue, its attachment to the gum and the limits of tongue mobility. The TABBY tool is scored from 0 to a maximum of 8.Two initial audits of the TABBY were undertaken at a large maternity unit in a secondary care NHS Trust, in Bristol UK from 2017 to 2019. TABBY was evaluated by five midwives on 262 babies with tongue-ties and experiencing breastfeeding difficulties who were referred for assessment to a tongue-tie assessment clinic using both BTAT and TABBY. Each pair of scores was recorded by one midwife at a time. A further training audit with 37 babies involved different assessors using BTAT and TABBY on each baby. Results: All midwives found the TABBY easy to use, and both audits showed 97.7% agreement between the scores. We suggest that a score of 8 indicates normal tongue function; 6 or 7 is considered as borderline and 5 or below suggests an impairment of tongue function. Selection of infants for frenotomy required an additional breastfeeding assessment, but all infants with a score of 4 or less in the audits had a frenotomy, following parental consent. Conclusions: The TABBY Assessment Tool is a simple addition to the assessment of tongue-tie in infants and can provide an objective score of tongue-tie severity. Together with a structured breastfeeding assessment it can inform selection of infants for frenotomy. It can be used by clinical staff following a short training and will facilitate translation into other languages.

Impact of co-occurring hearing and visual difficulties in childhood on educational outcomes: a longitudinal cohort study.

BACKGROUND: Mild hearing and visual difficulties are common in childhood, and both may have implications for educational achievement. However, the impact of co-occurring common hearing and visual difficulties in childhood is not known. OBJECTIVE: To determine the prevalence and impact of co-occurring common hearing and visual difficulties of childhood on educational outcomes in primary and secondary school. METHODS: The sample was drawn from the Avon Longitudinal Study of Parents and Children, a longitudinal birth cohort study in England. The exposures were hearing and visual difficulties at age 7 (defined as conductive hearing loss or otitis media with effusion, and amblyopia, strabismus or reduced visual acuity, respectively). The outcomes measured were achievement of level 4 or above at Key Stage 2 (KS2) in English, Maths and Science, respectively, at age 11, and attainment of five or more General Certificate of Secondary Education (GCSEs) at grades A*-C at age 16. Multiple logistic regression models assessed the relationship between hearing and visual difficulties and educational outcomes, adjusting for potential confounding factors. RESULTS: 2909 children were included in the study; 261 had hearing difficulties, 189 had visual difficulties and 14 children had co-occurring hearing and visual difficulties. Children with co-occurring hearing and visual difficulties were less likely to achieve the national target at KS2 compared with children with normal hearing and vision, even after adjustment for confounding factors (OR 0.30, CI 0.15 to 0.61 for KS2 English). Differences in IQ, behaviour, attention and social cognition did not account for this relationship. The impact of co-occurring hearing and visual difficulties on GCSE results was explained largely by poor performance at KS2. CONCLUSIONS: Co-occurring hearing and visual difficulties in childhood have an enduring negative impact on educational outcomes. Identification of affected children and early intervention in primary school is essential.

Does maternal somatic anxiety in pregnancy predispose children to hyperactivity?

The objective of this study is to explore the association between maternal somatic anxiety in pregnancy and hyperactivity symptoms and ADHD diagnosis in children. Data from the Avon Longitudinal Study of Parents and Children cohort were used to examine the association between somatic anxiety symptoms in pregnancy measured with five items of the Crown-Crisp Experiential Index, ADHD diagnosis in children at 7.5 and 15 years (obtained with the Development and Well-Being Assessment-DAWBA) and hyperactivity at 4 and 16 years (measured with the Strengths and Difficulties Questionnaire hyperactivity subscale-SDQ). Maternal somatic anxiety was associated with ADHD diagnosis at age 7.5 [crude OR = 1.87 (95% CI = 1.21-2.91)], adjusted model [OR = 1.57 (95% CI = 0.99-2.48)]. There was no evidence of association with ADHD at 15: crude OR = 2.27 (95% CI = 0.90-5.71), adjusted OR = 1.65 (95% CI = 0.63-4.35). An association was found at 4 and 16 with the SDQ hyperactivity subscale: crude OR at 4: 1.70 (95% CI =1.37-2.11), adjusted OR = 1.34 (95% CI = 1.07-1.69); crude OR at 16: 1.95 (95% CI = 1.47-2.58), adjusted OR = 1.62 (95% CI = 1.21-2.17).Thus, there was evidence for an association between maternal somatic anxiety in pregnancy and increased hyperactivity symptoms (SDQ) at 4 and 16. There was no association with ADHD diagnosis.

Mental health of children exposed to intimate partner violence against their mother: A longitudinal study from Brazil.

BACKGROUND: Exposure to intimate partner violence (IPV) is an important adverse childhood experience, but there are few longitudinal studies in low and middle-income countries. OBJECTIVE: To investigate the consequences of exposure to IPV for a child's mental health. PARTICIPANTS AND SETTING: 614 mother-child pairs were evaluated in a poor urban district in Recife, northeastern Brazil. METHODS: Women were interviewed in pregnancy, postpartum and six to nine years after delivery, and asked about their experience of IPV, and the exposure of their child to violence. The Strengths and Difficulties Questionnaire (SDQ) was completed by child's mother and teacher. Ten types of child experience of IPV and the age of onset of exposure were compared with the child's behavioral profile at school age. RESULTS: The mothers reported that 372/614 (60.6%) children had been exposed to IPV. The commonest types of child exposure to IPV were "prenatally", "overheard", "eyewitnessed", and 10.0% of children were physically or verbally involved in the IPV. Mothers reported high SDQ Total Difficulties scores in 71.7% of all children exposed to IPV and teachers in 59.8%. Multivariate logistic regression analysis demonstrated the strongest association with behavioral difficulties was with exposure to IPV in the age group 1-2 years (OR 2.5 [95% CI: 1.3-4.8]). CONCLUSION: Young children are sensitive to the age of first exposure to IPV and to the type of IPV. Interventions to reduce IPV should be targeted on vulnerable women from poor urban communities during their pregnancies and in the first two years of their child's life.

Prediction of school outcome after preterm birth: a cohort study.

OBJECTIVE: To identify if the educational trajectories of preterm infants differ from those of their term peers. DESIGN: This work is based on the Avon Longitudinal Study of Parents and Children (ALSPAC). Educational measures were categorised into 10 deciles to allow comparison of measures across time periods. Gestational age was categorised as preterm (23-36 weeks) or term (37-42 weeks). Multilevel mixed-effects linear regression models were derived to examine the trajectories of decile scores across the study period. Gestational group was added as an interaction term to assess if the trajectory between educational measures varied between preterm and term infants. Adjustment for possible confounders was performed. SUBJECTS: The final dataset contained information on 12 586 infants born alive at between 23 weeks and 42 weeks of gestation. MAIN OUTCOME MEASURES: UK mandatory educational assessments (SATs) scores throughout educational journal (including final GCSE results at 16 years of age). RESULTS: Preterm infants had on average lower Key Stage (KS) scores than term children (-0.46 (-0.84 to -0.07)). However, on average, they gained on their term peers in each progressive measure (0.10 (0.01 to 0.19)), suggesting 'catch up' during the first few years at school. Preterm infants appeared to exhibit the increase in decile scores mostly between KS1 and KS2 (p=0.005) and little between KS2 and KS3 (p=0.182) or KS3 and KS4 (p=0.149). CONCLUSIONS: This work further emphasises the importance of early schooling and environment in these infants and suggests that support, long after the premature birth, may have additional benefits.