Immunogenicity of rVSVΔG-ZEBOV-GP Ebola vaccination in exposed and potentially exposed persons in the Democratic Republic of the Congo.

Despite more than 300,000 rVSVΔG-ZEBOV-glycoprotein (GP) vaccine doses having been administered during Ebola virus disease (EVD) outbreaks in the Democratic Republic of the Congo (DRC) between 2018 and 2020, seroepidemiologic studies of vaccinated Congolese populations are lacking. This study examines the antibody response at 21 d and 6 mo postvaccination after single-dose rVSVΔG-ZEBOV-GP vaccination among EVD-exposed and potentially exposed populations in the DRC. We conducted a longitudinal cohort study of 608 rVSVΔG-ZEBOV-GP-vaccinated individuals during an EVD outbreak in North Kivu Province, DRC. Participants provided questionnaires and blood samples at three study visits (day 0, visit 1; day 21, visit 2; and month 6, visit 3). Anti-GP immunoglobulin G (IgG) antibody titers were measured in serum by the Filovirus Animal Nonclinical Group anti-Ebola virus GP IgG enzyme-linked immunosorbent assay. Antibody response was defined as an antibody titer that had increased fourfold from visit 1 to visit 2 and was above four times the lower limit of quantification at visit 2; antibody persistence was defined as a similar increase from visit 1 to visit 3. We then examined demographics for associations with follow-up antibody titers using generalized linear mixed models. A majority of the sample, 87.2%, had an antibody response at visit 2, and 95.6% demonstrated antibody persistence at visit 3. Being female and of young age was predictive of a higher antibody titer postvaccination. Antibody response and persistence after Ebola vaccination was robust in this cohort, confirming findings from outside of the DRC.

The effects of doxapram and its potential interactions with K2P channels in experimental model preparations.

The channels commonly responsible for maintaining cell resting membrane potentials are referred to as K2P (two-P-domain K+ subunit) channels. These K+ ion channels generally remain open but can be modulated by their local environment. These channels are classified based on pharmacology, pH sensitivity, mechanical stretch, and ionic permeability. Little is known about the physiological nature of these K2P channels in invertebrates. Acidic conditions depolarize neurons and muscle fibers, which may be caused by K2P channels given that one subtype can be blocked by acidic conditions. Doxapram is used clinically as a respiratory aid known to block acid-sensitive K2P channels; thus, the effects of doxapram on the muscle fibers and synaptic transmission in larval Drosophila and crawfish were monitored. A dose-dependent response was observed via depolarization of the larval Drosophila muscle and an increase in evoked synaptic transmission, but doxapram blocked the production of action potentials in the crawfish motor neuron and had a minor effect on the resting membrane potential of the crawfish muscle. This indicates that the nerve and muscle tissues in larval Drosophila and crawfish likely express different K2P channel subtypes. Since these organisms serve as physiological models for neurobiology and physiology, it would be of interest to further investigate what types of K2P channel are expressed in these tissues. (212 words).

Blasting off: persistent hypertension in a child with neuroblastoma.

Hypertension in children with neuroblastoma is uncommon and can be difficult to control due to the potential for multiple underlying causes. We present the case of a pediatric patient with high-grade neuroblastoma which was complicated by hypertensive emergency. The patient had imaging suggestive of renal artery compression, as well as significantly elevated normetaphrine levels. Multiple anti-hypertensive agents, including an angiotensin converting enzyme inhibitor, α- and ß-adrenergic receptor blockers, and a tyrosine hydroxylase inhibitor, were initiated prior to tumor excision. While her blood pressure improved during the post-operative period, she continued to require multiple antihypertensive medications due to residual tumor burden. In this report, we highlight the importance of careful, multidisciplinary management to avoid peri-operative complications in patients with catecholamine-producing tumors.

Maternal perinatal social support and infant social-emotional problems and competencies: a longitudinal cross-cohort replication study.

PURPOSE: Maternal perinatal social support is theorised to promote offspring social-emotional development, yet few studies have prospectively examined this relationship. Findings may inform preventative intervention efforts, to support a healthy start to emotional life. METHODS: This study examined whether maternal social support perinatally predicts infant social-emotional development at 12 months of age in two longitudinal cohort studies: The Australian Temperament Project (ATP) (n = 1,052 mother-infant dyads [653 mothers, M age_at_birth = 32.03, 88% Australian-born; 1,052 infants, 52% girls]) and The Triple B Pregnancy Cohort Study (Triple B) (n = 1,537 dyads [1,498 mothers, M age_at_birth = 32.53, 56% Australian-born; 1,537 infants, 49% girls]). Social support was assessed at pregnancy (third trimester) and eight-weeks post-birth. Infant social-emotional competencies (ATP: Brief Infant and Toddler Social and Emotional Assessment (BITSEA), Competencies Scale; Triple B: Bayley Scales of Infant and Toddler Development-Social Emotional Scale) and problems (ATP: BITSEA, Problems Scale; Triple B: Ages and Stages Questionnaires: Social-Emotional Scale), were assessed at 12-months of age. RESULTS: In ATP, social support was associated with lower offspring problems (pregnancy: ß = -0.15; post-birth: ß = -0.12) and greater competencies (pregnancy: ß = 0.12; post-birth: ß = 0.16) at 12 months. In Triple B, social support also predicted lower offspring problems (pregnancy: ß = -0.11; post-birth: ß = -0.07) and greater competencies (pregnancy: ß = 0.07) at 12 months. Findings did not indicate an association between support at eight-weeks post-birth and subsequent competencies (ß = 0.06). CONCLUSIONS: Evidence suggests that perinatal social support promotes healthy infant social and emotional development. These results underscore the critical importance of social support for mothers transitioning into parenthood.

Efficacy of cannabinoids in neurodevelopmental and neuropsychiatric disorders among children and adolescents: a systematic review.

A better understanding of the endocannabinoid system and a relaxation in regulatory control of cannabis globally has increased interest in the medicinal use of cannabinoid-based products (CBP). We provide a systematic review of the rationale and current clinical trial evidence for CBP in the treatment of neuropsychiatric and neurodevelopmental disorders in children and adolescents. A systematic search of MEDLINE, Embase, PsycINFO, and the Cochrane Central Register of Trials was performed to identify articles published after 1980 about CBP for medical purposes in individuals aged 18 years or younger with selected neuropsychiatric or neurodevelopmental conditions. Risk of bias and quality of evidence was assessed for each article. Of 4466 articles screened, 18 were eligible for inclusion, addressing eight conditions (anxiety disorders (n = 1); autism spectrum disorder (n = 5); foetal alcohol spectrum disorder (n = 1); fragile X syndrome (n = 2); intellectual disability (n = 1); mood disorders (n = 2); post-traumatic stress disorder (n = 3); and Tourette syndrome (n = 3)). Only one randomised controlled trial (RCT) was identified. The remaining seventeen articles included one open-label trial, three uncontrolled before-and-after trials, two case series and 11 case reports, thus the risk of bias was high. Despite growing community and scientific interest, our systematic review identified limited and generally poor-quality evidence for the efficacy of CBP in neuropsychiatric and neurodevelopmental disorders in children and adolescents. Large rigorous RCTs are required to inform clinical care. In the meantime, clinicians must balance patient expectations with the limited evidence available.

Acute Flaccid Paralysis in Australian Children from 2007 to 2017.

INTRODUCTION: Acute flaccid paralysis (AFP) surveillance continues globally as part of the World Health Organization's goal to eradicate poliomyelitis. The Australian Paediatric Surveillance Unit (APSU), Paediatric Active Enhanced Disease Surveillance (PAEDS) network, and National Enterovirus Reference Laboratory (NERL) collaborate in AFP surveillance in Australia, capturing and reviewing cases of AFP for all aetiologies in order to exclude poliovirus. We aimed to describe the AFP epidemiology in childhood over an 11 year period. METHODS: Data were reported nationally by paediatricians via prospective APSU surveillance, PAEDS surveillance nurses at five tertiary paediatric hospitals and NERL from 2007 to 2017. Children aged 0-15 years with AFP were included. We combined APSU, PAEDS, and NERL datasets, analysed epidemiological trends, and described clinical features and investigations for major diagnoses. RESULTS: Of 590 AFP-compatible cases, 49% were male; 47% were aged 0-4 years, 9% aged <1 year. Annual incidence of AFP was 1.3 cases per 100,000 children aged <15 years. Lower limb paralysis was the most frequent presenting symptom. The most frequent diagnoses were Guillain-Barre syndrome (GBS; 36%), transverse myelitis (TM; 17%), and acute disseminated encephalomyelitis (ADEM; 15%). No secular trend was seen in frequency of AFP cases nor amongst major diagnoses. Seasonality was observed with ADEM occurring more frequently in winter. We observed periods of increased AFP frequency in 2013 and 2016, coinciding with increased reporting of non-polio anterior horn cell disease (AHCD) and detection of non-polio enterovirus (NPEV). CONCLUSIONS: Estimated incidence of GBS, ADEM, and TM in Australian children was comparable with international rates. There was stable incidence of AFP in Australian children between 2007 and 2017. GBS, ADEM, and TM are the major causes of AFP. We observed clustering of cases associated with NPEV that emphasises a need for ongoing vigilance in surveillance given continue emerging infectious disease threats.

NLRP3 inflammasome as a key molecular target underlying cognitive resilience in amyotrophic lateral sclerosis.

Up to 50% of amyotrophic lateral sclerosis patients present with cognitive deficits in addition to motor dysfunction, but the molecular mechanisms underlying diverse clinical and pathological presentations remain poorly understood. There is therefore an unmet need to identify molecular drivers of cognitive dysfunction to enable better therapeutic targeting and prognostication. To address this, we employed a non-biased approach to identify molecular targets using a deeply phenotyped, clinically stratified cohort of cognitively affected and unaffected brain regions from three brain regions of 13 amyotrophic lateral sclerosis patients with the same cognitive screening test performed during life. Using NanoString molecular barcoding as a sensitive mRNA sequencing technique on post-mortem tissue, we profiled a data-driven panel of 770 genes using the Neuropathology Panel, followed by region and cell type-specific validation using BaseScope in situ hybridisation and immunohistochemistry. We identified 50 significantly dysregulated genes that are distinct between cognitively affected and unaffected brain regions. Using BaseScope in situ hybridisation, we also demonstrate that macromolecular complex regulation, notably NLRP3 inflammasome modulation, is a potential, therapeutically targetable, pathological correlate of cognitive resilience in ALS. © 2021 The Authors. The Journal of Pathology published by John Wiley & Sons, Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Action on the social determinants for advancing health equity in the time of COVID-19: perspectives of actors engaged in a WHO Special Initiative.

Since the 2008 publication of the reports of the Commission on Social Determinants of Health and its nine knowledge networks, substantial research has been undertaken to document and describe health inequities. The COVID-19 pandemic has underscored the need for a deeper understanding of, and broader action on, the social determinants of health. Building on this unique and critical opportunity, the World Health Organization is steering a multi-country Initiative to reduce health inequities through an action-learning process in 'Pathfinder' countries. The Initiative aims to develop replicable and reliable models and practices that can be adopted by WHO offices and UN staff to address the social determinants of health to advance health equity. This paper provides an overview of the Initiative by describing its broad theory of change and work undertaken in three regions and six Pathfinder countries in its first year-and-a-half. Participants engaged in the Initiative describe results of early country dialogues and promising entry points for implementation that involve model, network and capacity building. The insights communicated through this note from the field will be of interest for others aiming to advance health equity through taking action on the social determinants of health, in particular as regards structural determinants.

Toppling television injuries in children and adolescents: a systematic review and meta-analysis.

CONTEXT: Toppling televisions (TVs) are a source of childhood injury but meta-analysis has not assessed the likelihood of TV injuries in children. OBJECTIVE: To present pooled results for injuries, following a systematic review. DATA SOURCES: MEDLINE, Scopus, Google Scholar and EMBASE databases were searched to 5 December 2022. STUDY SELECTION: Included studies met the following criteria: (1) assessed toppling TV injuries in paediatric populations; (2) reported point estimates as an OR or enabled its calculation and (3) used a comparison group. DATA EXTRACTION: A standardised form was used to include information on publication year, study design, population type, country, sample size, mean age, risk factors, point estimates or data used to calculate ORs. RESULTS: A total of 12 803 TV injuries were identified (five studies). Head and neck injuries (OR: 2.13, 95% CI: 1.21 to 3.75) and hospital admission (OR: 2.28, 95% CI: 1.80 to 2.90) were more likely in children aged under 6 years than over 6 years. Conversely, torso injuries were less likely in younger children (OR: 0.60, 95% CI: 0.51 to 0.70). Children under 6 were two and a half times more likely to die or be admitted to an intensive care unit (ICU) as a result of toppling TVs, although this was not statistically significant. Males did not sustain more TV injuries than females. CONCLUSIONS: Children aged under 6 years are more likely to die, sustain head injuries and require hospital treatment from toppling TVs. Strategies for injury prevention must go beyond warning labels to include community education, promotion and use of tip restraint devices, mandatory safety standards and a commitment from manufacturers to improve TV sets stability.

Medication safety in pediatric anesthesia: An educational review and a call to action.

Children presenting for anesthesia are at high risk for medication error during their care. In this educational review, we address the rates of medication error in pediatric patients undergoing anesthesia, why they are at higher risk than adults, and why reporting chronically underestimates the number of medication errors incurred during the anesthetic care of children. We also introduce the Anesthesia Patient Safety Foundation and Wake Up Safe, two safety organizations that have led the call to decrease medication errors. We discuss various tools to increase medication safety, as championed by Anesthesia Patient Safety Foundation and Wake Up Safe, including human factors research and highlight a few studies that have evaluated and addressed medication safety in the anesthesia environment.

Reducing the environmental impact of mask inductions in children: A quality improvement report.

BACKGROUND: Inhalational anesthetic agents are potent greenhouse gases with global warming potential that far exceed that of carbon dioxide. Traditionally, pediatric inhalation inductions are achieved with a volatile anesthetic delivered to the patient in oxygen and nitrous oxide at high fresh gas flows. While contemporary volatile anesthetics and anesthesia machines allow for a more environmentally conscious induction, practice has not changed. We aimed to reduce the environmental impact of our inhalation inductions by decreasing the use of nitrous oxide and fresh gas flows. METHODS: Through a series of four plan-do-study-act cycles, the improvement team used content experts to demonstrate the environmental impact of the current inductions and to provide practical ways to reduce this, by focusing on nitrous oxide use and fresh gas flows, with visual reminders introduced at point of delivery. The primary measures were the percentage of inhalation inductions that used nitrous oxide and the maximum fresh gas flows/kg during the induction period. Statistical process control charts were used to measure improvement over time. RESULTS: 33 285 inhalation inductions were included over a 20-month period. nitrous oxide use decreased from 80% to <20% and maximum fresh gas flows/kg decreased from a rate of 0.53 L/min/kg to 0.38 L/min/kg, an overall reduction of 28%. Reduction in fresh gas flows was greatest in the lightest weight groups. Induction times and behaviors remained unchanged over the duration of this project. CONCLUSIONS: Our quality improvement group decreased the environmental impact of inhalation inductions and created cultural change within our department to sustain change and foster the pursuit of future environmental efforts.

Using the Acute Flaccid Paralysis Surveillance System to Identify Cases of Acute Flaccid Myelitis, Australia, 2000‒2018.

Since 2012, the United States has reported a distinct syndrome of acute flaccid paralysis (AFP) with anterior myelitis, predominantly in children. This polio-like syndrome was termed acute flaccid myelitis (AFM). Australia routinely conducts AFP surveillance to exclude poliomyelitis. We reviewed 915 AFP cases in Australia for children <15 years of age during 2000‒2018 and reclassified a subset to AFM by using the US Council of State and Territorial Epidemiologists case definition. We confirmed 37 AFM cases by using magnetic resonance imaging findings and 4 probable AFM cases on the basis of cerebrospinal fluid pleocytosis. Nonpolio enteroviruses were detected in 33% of AFM cases from which stool samples were tested. Average annual AFM incidence was 0.07 cases/100,000 person-years in children <15 years of age. AFM occurred sporadically in Australia before 2010 but regularly since then, indicating sustained, albeit rare, clinical manifestation in children. The AFP surveillance system in Australia is well-positioned to identify future AFM cases.

Ear Abnormalities Among Children with Fetal Alcohol Spectrum Disorder: A Systematic Review and Meta-Analysis.

OBJECTIVE: To systematically review and conduct meta-analysis on studies that report the type and prevalence of functional and structural ear abnormalities among children with prenatal alcohol exposure and/or fetal alcohol spectrum disorder (FASD). STUDY DESIGN: MEDLINE, PubMed, Embase, Web of Science, PsycINFO, ERIC, CINAHL, and Maternity and Infant Care were searched from 1806 through March 2021. Reference lists of relevant articles were manually searched. Studies reporting on functional and/or structural ear abnormalities among children (<18 years) with prenatal alcohol exposure and/or FASD were eligible. Data extraction and quality assessment were performed by one reviewer and independently checked by another. A random effects meta-analysis was conducted. RESULTS: A total of 31 studies met the inclusion criteria and 25 were included in the meta-analyses, representing a total of 843 children with prenatal alcohol exposure and 1653 children with FASD. Functional ear abnormalities with the highest pooled prevalence were chronic serous otitis media (88.5%; 95% CI, 70.4%-99.3%), abnormal auditory filtering (80.1%; 95% CI, 76.5%-84.3%), and unspecified conductive hearing loss (68.0%; 95% CI, 51.9%-82.2%). Structural ear abnormalities with the highest pooled prevalence were microtia (42.9%; 95% CI, 26.8%-59.7%), railroad track ear (16.8%; 95% CI, 8.1%-27.7%), and misplaced ear (12.3%; 95% CI, 7.6%-17.9%). CONCLUSIONS: Our findings highlight the importance of examining the ears during assessment for FASD, and the need for public health messaging regarding the harms of prenatal alcohol exposure.

Early-onset eating disorders in Australian children: A national surveillance study showing increased incidence.

OBJECTIVE: The aim of this study was to collect prospective national data on early-onset eating disorders (EOEDs) in children in Australia to document changes in clinical presentations, medical complications, management, and incidence since initially described in 2002-2005. METHOD: Each month pediatricians reported children aged 5-13 years newly diagnosed with an eating disorder to the Australian Paediatric Surveillance Unit and provided de-identified clinical data. RESULTS: Between 2016 and 2018, 184 children were confirmed with EOED with a minimum estimated national incidence of 2.79 per 100,000 children aged 5-13 years (95% confidence interval [CI] 2.40-3.23), nearly double the previously recorded incidence. The mean age at diagnosis was 12.2 years; 43(24%) were boys who were younger than girls (11.85 vs. 12.33 years; p = .03). All had food avoidance. Common symptoms included fear of weight gain 140 (76%), preoccupation with body weight 134 (73%), and misperception of body size 116 (63%). Bradycardia was present in 83 (45%) and 117 (64%) who required hospital admission. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5) criteria for anorexia nervosa were met for 144 (78%). DISCUSSION: Children with eating disorders continue to present with severe illness. Near doubling in incidence in just over a 10-year period highlights the need for increased clinical resourcing and comparable international data. PUBLIC SIGNIFICANCE: The incidence of new presentations of eating disorders in children aged 5-13 years has nearly doubled since a similar study was conducted over 10 years ago. Children were unwell for an average of 8 months before diagnosis; approximately 80% had a clear diagnosis of anorexia nervosa and 64% needed hospital admission due to medical complications. This highlights the need for improvements in education and clinical resources for this age group.

Practice change intervention to improve antenatal care addressing alcohol consumption during pregnancy: a randomised stepped-wedge controlled trial.

BACKGROUND: Clinical guideline recommendations for addressing alcohol consumption during pregnancy are sub-optimally implemented and limited evidence exists to inform practice improvements. The aim of this study was to estimate the effectiveness of a practice change intervention in improving the provision of antenatal care addressing alcohol consumption during pregnancy in public maternity services. METHODS: A randomised stepped-wedge controlled trial was undertaken with all public maternity services in three sectors (one urban, two regional/rural) of a single local health district in New South Wales, Australia. All antenatal care providers were subject to a seven-month multi-strategy intervention to support the introduction of a recommended model of care. For 35 months (July 2017 - May 2020) outcome data were collected from randomly selected women post an initial, 27-28 weeks and 35-36 weeks gestation antenatal visit. Logistic regression models assessed intervention effectiveness. RESULTS: Five thousand six hundred ninety-four interviews/online questionnaires were completed by pregnant women. The intervention was effective in increasing women's reported receipt of: assessment of alcohol consumption (OR: 2.63; 95% CI: 2.26-3.05; p < 0.001), advice not to consume alcohol during pregnancy and of potential risks (OR: 2.07; 95% CI: 1.78-2.41; p < 0.001), complete care relevant to alcohol risk level (advice and referral) (OR: 2.10; 95% CI: 1.80-2.44; p < 0.001) and all guideline elements relevant to alcohol risk level (assessment, advice and referral) (OR: 2.32; 95% CI: 1.94-2.76; p < 0.001). Greater intervention effects were found at the 27-28 and 35-36 weeks gestation visits compared with the initial antenatal visit. No differences by sector were found. Almost all women (98.8%) reported that the model of care was acceptable. CONCLUSIONS: The practice change intervention improved the provision of antenatal care addressing alcohol consumption during pregnancy in public maternity services. Future research could explore the characteristics of pregnant women and maternity services associated with intervention effectiveness as well as the sustainment of care practices over time to inform the need for, and development of, further tailored practice change support. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry (Registration number: ACTRN12617000882325; Registration date: 16/06/2017) https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372985&isReview=true.

Trampoline centre injuries in children and adolescents: a systematic review and meta-analysis.

CONTEXT: No evidence-based review has compared injury risks sustained on trampolines at home and in trampoline centres. OBJECTIVE: To present pooled results for injury type, site and treatment from studies reporting injuries that occurred on trampolines at home and in trampoline centres. DATA SOURCES: MEDLINE, Scopus, Google Scholar and Embase databases were searched to 31 December 2021. STUDY SELECTION: Inclusion criteria: (1) assessment of trampoline injuries (home and trampoline centres); (2) children and adolescents; (3) the point estimate was reported as an odds ratio (OR); and (4) an internal comparison was used. DATA EXTRACTION: Data were reported according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A random-effects model was used to estimate effect. RESULTS: There were 1 386 843 injuries (n=11 studies). There was an increased likelihood of musculoskeletal and/or orthopaedic injuries (OR 2.45, 95% CI 1.66 to 3.61, p<0.001), lower extremity injury (OR 2.81, 95% CI 1.99 to 3.97, p<0.001), sprains (OR 1.64, 95% CI 1.36 to 1.97, p<0.001) and a need for surgery (OR 1.89, 95% CI 1.37 to 2.60, p<0.001) at trampoline centres compared with home trampolines. Conversely, upper extremity injury (OR 0.49, 95% CI 0.25 to 0.95, p=0.03), concussion (OR 0.48, 95% CI 0.35 to 0.65, p<0.001) and lacerations (OR 0.46, 95% CI 0.35 to 0.59, p<0.001) were less likely to occur at trampoline centres than at home. CONCLUSIONS: Children using trampoline centres are more likely to suffer severe trauma and require surgical intervention than children using home trampolines. Development and implementation of preventative strategies, public awareness, and mandatory safety standards are urgently required for trampoline centres.

Microcephaly in Australian infants: A retrospective audit.

AIM: To describe clinical characteristics, outcomes and causes of microcephaly in children whose condition was identified within the first year of life. METHODS: Retrospective review of medical records of microcephalic children born between 2008 and 2018 and admitted for any reason during the same period to a tertiary paediatric hospital. Microcephaly was defined as occipitofrontal circumference (OFC) more than two standard deviations below the mean (>-2 SD). RESULTS: Between January 2008 and September 2018, 1083 medical records were retrieved. Of the children, 886 were ineligible and 197 were confirmed cases of microcephaly. Of cases, 73 (37%) had primary microcephaly (at birth) and 72 (37%) had severe microcephaly (OFC > -3 SD). Of microcephalic children, 192 (98%) had congenital anomalies, of whom 93% had major anomalies, mostly cardiovascular or musculoskeletal. Neurological signs or symptoms were reported in 148 (75%), seizures being the most common. Of the 139 children with abnormal central nervous system (CNS) imaging, one or more structural brain abnormalities were identified in 124 (89%). Failure to reach developmental milestones was observed in 69%, visual impairment in 41% and cerebral palsy in 13%. Microcephaly was idiopathic in 51% and 24% had diagnosed genetic disorders. There was no association between developmental outcomes or structural brain anomalies and severity of microcephaly or timing of diagnosis. CONCLUSION: Our results suggest the need for a systematic investigative approach to diagnosis, including a careful history, examination, genetic testing and neuroimaging, to determine the underlying cause of microcephaly, identify co-morbidities, predict prognosis and guide genetic counselling and therapy.

Health-related out-of-pocket expenses for children living with rare diseases - tuberous sclerosis and mitochondrial disorders: A prospective pilot study in Australian families.

AIM: We aimed to describe health-related out-of-pocket (OOP) expenses incurred by Australian families living with children with chronic and complex diseases. METHODS: A prospective pilot study of OOP expenses in families with children with tuberous sclerosis (TS) or mitochondrial disorders (MD) in 2016-2017. An initial survey assessed the family's financial situation, child's health functioning and estimated previous 6 months' and lifetime OOP expenses. Thereafter, families completed a survey each month for 6 months, prospectively tracking OOP expenses. RESULTS: Initial surveys were completed by 13 families with 15 children; median age 7 years (range: 1-12); 5 with MD, 10 with TS. All families reported OOP expenses: 38% paid $2000 per annum, more than double the annual per-capita OOP costs reported for Australia by the Organisation for Economic Co-operation and Development. Eight families estimated $5000-$25 000 in OOP expenses over their child's lifetime and 62% of mothers reduced or stopped work due to caring responsibilities. Eleven families paid annual private health insurance premiums of $2000-$5122, but 72% said this was poor value-for-money. Prospective tracking by eight families (9 children) identified the median OOP expenditure was $863 (range $55-$1398) per family for 6 months. OOP spending was associated with visits to allied health professionals, non-prescription medicines, special foods, supplements and disposable items. Eight families paid for 91 prescription medications over 6 months. CONCLUSION: All families caring for children with TS or MD reported OOP expenses. A larger study is needed to explore the affordability of health care for children living with a broader range of chronic diseases.

Pre-operative fasting in children: A guideline from the European Society of Anaesthesiology and Intensive Care.

Current paediatric anaesthetic fasting guidelines have recommended conservative fasting regimes for many years and have not altered much in the last decades. Recent publications have employed more liberal fasting regimes with no evidence of increased aspiration or regurgitation rates. In this first solely paediatric European Society of Anaesthesiology and Intensive Care (ESAIC) pre-operative fasting guideline, we aim to present aggregated and evidence-based summary recommendations to assist clinicians, healthcare providers, patients and parents. We identified six main topics for the literature search: studies comparing liberal with conservative regimens; impact of food composition; impact of comorbidity; the use of gastric ultrasound as a clinical tool; validation of gastric ultrasound for gastric content and gastric emptying studies; and early postoperative feeding. The literature search was performed by a professional librarian in collaboration with the ESAIC task force. Recommendations for reducing clear fluid fasting to 1 h, reducing breast milk fasting to 3 h, and allowing early postoperative feeding were the main results, with GRADE 1C or 1B evidence. The available evidence suggests that gastric ultrasound may be useful for clinical decision-making, and that allowing a 'light breakfast' may be well tolerated if the intake is well controlled. More research is needed in these areas as well as evaluation of how specific patient or treatment-related factors influence gastric emptying.

Fetal alcohol spectrum disorder resources for educators: A scoping review.

Children with foetal alcohol spectrum disorder (FASD) can experience neurodevelopmental, physical, psychological and behavioural impairments that can result in a disrupted school experience. However, educators often have limited knowledge or experience in the identification and support of students with FASD, and there is a critical need for effective tools and resources to ensure students with FASD are supported in their ongoing learning and development. This scoping review aimed to identify and evaluate publicly available educator resources that aid in the identification, and support of students with FASD in primary/elementary school. In addition, educators and FASD experts were consulted to obtain feedback on currently available resources, and key issues and priorities for FASD resources. In total, 124 resources were identified by searching peer-reviewed and grey literature databases, app stores, podcast services and contacting FASD experts. Information was found on identification (23 resources) and support of students with FASD (119 resources). No resources provided information on the referral. Most resources were average (40%) to good (33%) quality, as measured by a composite tool based on adaptions of the NHMRC FORM Framework and iCAHE Guideline Quality Checklist. A minority of resources had been formally evaluated (7%). Review findings and consultations with experts and educators indicate a critical need for referral guides, evidence-based short-format resources and centralised access for school communities to high-quality resources. Taken together, this study has identified key areas for future resource development and research to better support primary school students with FASD.