Corrigendum to "Recent changes in growth trajectories: a population-based cohort study of over 5 million Brazilian children born between 2001 and 2014" [The Lancet Regional Health-Americas 2024; Volume 32, 100721, Published: March 27, 2024].

[This corrects the article DOI: 10.1016/j.lana.2024.100721.].

Recent changes in growth trajectories: a population-based cohort study of over 5 million Brazilian children born between 2001 and 2014.

Background: There is limited evidence on recent trends in childhood growth trajectories in Low-/middle-income countries. We investigated how age-trajectories for height and Body Mass Index (BMI) have changed among Brazilian children born in two different time periods after 2000. Methods: We used a population-based cohort (part of the "Cohort of 100-Million Brazilians") created by the linkage of three Brazilian administrative databases: the Cadastro Único of the Federal Government, the National System of Live Births and the National Nutritional and Food Surveillance System. We included longitudinal data on 5,750,214 children who were 3 to <10 years of age and born between 2001 and 2014 (20,209,133 observations). We applied fractional polynomial models with random-effects to estimate mean height and BMI trajectories for children. Findings: Compared to children born in 2001-2007, the cohort born in 2008-2014 were on average taller, by a z-score of 0.15 in boys and 0.12 in girls. Their height trajectories shifted upwards, by approximately 1 cm in both sexes. Levels of BMI increased little, by a z-score of 0.06 (boys) and 0.04 (girls). Mean BMI trajectories also changed little. However, the prevalence of overweight/obesity increased between cohorts, e.g., from 26.8% to 30% in boys and 23.9%-26.6% in girls aged between 5 and <10 years. Interpretation: An increase of 1 cm in mean height of Brazilian children during a short period indicates the improvement in maternal and child health, especially those from low-income families due to the new health and welfare policies in Brazil. Although mean BMI changed little, the prevalence of child overweight/obesity slightly increased and remained high. Funding: This work was supported by National Council for Scientific and Technological Development - CNPq; Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES; National Institute for Health Research (NIHR) Great Ormond Street Hospital Biomedical Research Centre; Society for the Study of Human Biology; Fundação de Amparo à Pesquisa do Estado de Minas Gerais - FAPEMIG; Departamento de Ciência e Tecnologia da Secretaria de Ciência, Tecnologia, Inovação e Complexo da Saúde do Ministério da Saúde - Decit/SECTICS/MS. The study also used resources from the Centre for Data and Knowledge Integration for Health (CIDACS), which receives funding from the Bill & Melinda Gates Foundation, the Wellcome Trust, the Health Surveillance Secretariat of the Ministry of Health and the Secretariat of Science and Technology of the State of Bahia (SECTI-BA).

Exposure to Chinese famine in early life and height across 2 generations: a longitudinal study based on the China Health and Nutrition Survey.

BACKGROUND: Poor nutrition early in life is associated with short stature, which is associated with increased risk of cardiovascular disease and mortality in later life. Less evidence is available about the impact of early-life nutrition on height growth in the subsequent generation. OBJECTIVES: This study investigated the associations of famine exposure in utero and early childhood with height across 2 generations. METHODS: We used longitudinal data from the China Health and Nutrition Survey. We included 5401 participants (F1) born in 1955-1966 (calendar year around the Chinese famine in 1959-1961) and their 3930 biological offspring (F2). We classified F1 participants into subgroups by famine exposure status (unexposed/exposed) and timing (fetal-/childhood-exposed) according to their birth year and grouped F2 by their parents' exposure. Linear regression models were applied to examine the associations of famine exposure with adult height of F1 and F2. Linear mixed effect models with fractional polynomial functions were performed to estimate the difference in height between exposure groups of F2 during childhood. RESULTS: Participants (F1) exposed to famine in utero or in childhood were shorter than those unexposed by 0.41 cm (95% CI: 0.03, 0.80) and 1.12 cm (95% CI: 0.75, 1.48), respectively. Offspring (F2) of exposed fathers were also shorter than those of unexposed parents by 1.07 cm (95% CI: 0.28, 1.86) during childhood (<18 y) and by 1.25 cm (95% CI: 0.07, 2.43) in adulthood (≥18 y), and those with exposed parents had a reduced height during childhood by 1.29 cm (95% CI: 0.68, 1.89) (all P values < 0.05). The associations were more pronounced among child offspring of highly-educated F1, particularly for paternal exposure and among female offspring (all P for interaction < 0.05). CONCLUSIONS: The findings support the intergenerational associations of famine exposure in early life with height in Chinese populations, indicating the public health significance of improving the nutritional status of mothers and children in the long run.

Development, acceptability and feasibility of a community-based intervention to increase timely initiation of antenatal care in an area of high ethnic diversity and low socio-economic status in the UK.

BACKGROUND: Antenatal care plays an important role in preventing adverse maternal and new-born outcomes. Women from ethnic minority backgrounds and of low socio-economic status are at greater risk of initiating antenatal care later than the recommended 10 weeks. There is a paucity of research exploring the development and evaluation of community-based interventions to increase the timely initiation of antenatal care. OBJECTIVE: To develop and evaluate the acceptability and feasibility of a co-produced community-based intervention to increase uptake of antenatal care in an area with high ethnic diversity and low socio-economic status. DESIGN: The intervention was developed using co-production workshops and conversations with 20 local service users and 14 stakeholders, underpinned by the theory of Diffusion of Innovation. The intervention was evaluated, on the domains of acceptability, adoption, appropriateness, and feasibility. Questionnaires (n=36), interviews (n=10), and focus groups (n=13) were conducted among those who received the intervention. Observations (n=13) of intervention sessions were conducted to assess intervention fidelity. Quantitative and qualitative data were analysed using SPSS and NVivo software respectively. RESULTS: Over 91% of respondents positively ranked the intervention. Qualitative findings with respect to 'acceptability' included four subthemes: how the intervention was communicated, the characteristics of the person delivering the intervention and their knowledge, and the reassurance offered by the intervention. The 'adoption' theme included three sub-themes: being informed helps women to engage with antenatal care, the intervention provides information for future use, and onwards conveyance of the intervention information. The 'appropriateness' theme included three sub-themes: existing gap in information, nature of information given as part of the intervention, and talking about pregnancy in public. The 'feasibility' theme included two sub-themes: value of delivering the intervention in areas of high footfall and relational aspect of receiving the intervention. Observations showed intervention fidelity of 100%. CONCLUSION: The community-based intervention, coproduced with women and maternity care stakeholders, was positively evaluated, and offered an innovative and promising approach to engage and educate women about the timely initiation of antenatal care in an ethnically diverse and socio-economically deprived community.

Ethnic minority women's experiences of accessing antenatal care in high income European countries: a systematic review.

BACKGROUND: Women from ethnic minority backgrounds are at greater risk of adverse maternal outcomes. Antenatal care plays a crucial role in reducing risks of poor outcomes. The aim of this study was to identify, appraise, and synthesise the recent qualitative evidence on ethnic minority women's experiences of accessing antenatal care in high-income European countries, and to develop a novel conceptual framework for access based on women's perspectives. METHODS: We conducted a comprehensive search of seven electronic databases in addition to manual searches to identify all qualitative studies published between January 2010 and May 2021. Identified articles were screened in two stages against the inclusion criteria with titles and abstracts screened first followed by full-text screening. Included studies were quality appraised using the Critical Appraisal Skills Programme checklist and extracted data were synthesised using a 'best fit' framework, based on an existing theoretical model of health care access. RESULTS: A total of 30 studies were included in this review. Women's experiences covered two overarching themes: 'provision of antenatal care' and 'women's uptake of antenatal care'. The 'provision of antenatal care' theme included five sub-themes: promotion of antenatal care importance, making contact and getting to antenatal care, costs of antenatal care, interactions with antenatal care providers and models of antenatal care provision. The 'women's uptake of antenatal care' theme included seven sub-themes: delaying initiation of antenatal care, seeking antenatal care, help from others in accessing antenatal care, engaging with antenatal care, previous experiences of interacting with maternity services, ability to communicate, and immigration status. A novel conceptual model was developed from these themes. CONCLUSION: The findings demonstrated the multifaceted and cyclical nature of initial and ongoing access to antenatal care for ethnic minority women. Structural and organisational factors played a significant role in women's ability to access antenatal care. Participants in majority of the included studies were women newly arrived in the host country, highlighting the need for research to be conducted across different generations of ethnic minority women taking into account the duration of stay in the host country where they accessed antenatal care. PROTOCOL AND REGISTRATION: The review protocol was registered on PROSPERO (reference number CRD42021238115).

Parental exposure to famine in early life and child overweight in offspring in Chinese populations.

BACKGROUND: Little is known about the transgenerational effect of nutrition deficiency in early life. This study aimed to evaluate the associations of fetal and childhood exposure to famine of parents with their offspring's risk of overweight during childhood. METHODS: This analysis included a total of 3734 participants of the China Health and Nutrition Survey aged 1-17 years whose fathers and/or mothers were born in 1955-1966. These children were classified into subgroups according to parental famine exposure status (unexposed and exposed) and timing (fetal-exposed and childhood-exposed). Random effects models were applied to evaluate the associations of parental famine exposure with body mass index (BMI) and overweight of offspring. Fractional polynomial functions were adopted to describe trajectories of BMI against age. RESULTS: Compared with children of unexposed parents, there was a lower risk of overweight among offspring of childhood-exposed fathers [OR (95%CI): 0.80 (0.61, 1.04)] or exposed parents [0.84 (0.68, 1.04)], particularly among male offspring, but not among those with exposed mothers only [0.98 (0.65, 1.47)]. For BMI, children with exposed mothers only had a slightly higher BMI [ß(95%CI): 0.17 (-0.15, 0.49)], while those with exposed fathers only had no difference [-0.02 (-0.23, 0.19)] or exposed parents had a slightly lower BMI [-0.17 (-0.33, 0.00)] (p < 0.05 for interaction between maternal and paternal exposures). Stratified analysis showed little heterogeneity between male and female offspring, but the association between paternal childhood exposure to famine and lower overweight risk in offspring was more evident in high (vs low) paternal education group (p for interaction< 0.05). CONCLUSIONS: The transgenerational associations of early-life exposure to famine with lower risks of child overweight may be via the paternal line and differ by the educational levels of parents. Further studies are warranted to confirm the results and reveal the biological mechanisms underlying.

Transgenerational associations of parental famine exposure in early life with offspring risk of adult obesity in China.

OBJECTIVE: The aim of this study was to investigate the transgenerational associations between exposure to famine in early life and obesity. METHODS: This study used the longitudinal data from the China Health and Nutrition Survey from 1989 to 2015. A total of 1113 fathers and 1207 mothers (946 mother-father pairs) born in 1955 to 1966 and 1895 adult offspring were included. Offspring were classified into subgroups according to the famine exposure of their parents (unexposed, maternal exposed, paternal exposed, parental exposed) and exposure timing (during fetal development, childhood). RESULTS: Maternal exposure to famine in early life was associated with elevated levels of BMI, waist circumference, overweight, and central obesity of their children, whereas paternal exposure was inversely associated with these measurements. Compared with children of unexposed parents (P0M0), the maternal exposed group (P0M1) had higher mean BMI, by 1.3 kg/m2 (95% CI: 0.3 to 2.4); waist circumference, by 1.5 cm (-1.0 to 3.9); overweight (odds ratio [OR] [95% CI]: 3.1 [1.6 to 6.1]); and central obesity (OR [95% CI]: 1.9 [1.02 to 3.7]). No significant heterogeneity was observed in the associations by sex of offspring. CONCLUSIONS: Fetal and early childhood exposure to famine in parents may be associated with their children's risk of obesity during adulthood. A better understanding of the transgenerational associations is important for developing strategies to reduce obesity risk in future generations.

Disparities in the timing of antenatal care initiation and associated factors in an ethnically dense maternal cohort with high levels of area deprivation.

BACKGROUND: Late access to antenatal care is a contributor to excess mortality and morbidity among ethnic minority mothers compared to White British in the UK. While individual ethnicity and socioeconomic disadvantage are linked to late antenatal care initiation, studies have seldom explored patterns of late initiation and associated factors in ethnically dense socially disadvantaged settings. This study investigated disparities in the timing of antenatal care initiation, and associated factors in an ethnically dense socially disadvantaged maternal cohort. METHODS: A retrospective cross-sectional study using routinely collected anonymous data on all births between April 2007-March 2016 in Luton and Dunstable hospital, UK (N = 46,307). Late initiation was defined as first antenatal appointment attended at > 12 weeks of gestation and further classified into moderately late (13-19 weeks) and extremely late initiation (≥ 20 weeks). We applied logistic and multinomial models to examine associations of late initiation with maternal and sociodemographic factors. RESULTS: Overall, one fifth of mothers (20.8%) started antenatal care at > 12 weeks of gestation. Prevalence of late initiation varied across ethnic groups, from 16.3% (White British) to 34.2% (Black African). Late initiation was strongly associated with non-White British ethnicity. Compared to White British mothers, the odds of late initiation and relative risk of extremely late initiation were highest for Black African mothers [adjusted OR = 3.37 (3.05, 3.73) for late initiation and RRR = 4.03 (3.51, 4.64) for extremely late initiation]. The odds did not increase with increasing area deprivation, but the relative risk of moderately late initiation increased in the most deprived ([RRR = 1.53 (1.37, 1.72)] and second most deprived areas [RRR = 1.23 (1.10, 1.38)]. Late initiation was associated with younger mothers and to a lesser extent, older mothers aged > 35 years. Mothers who smoked during pregnancy were at higher odds of late initiation compared to mothers who did not smoke. CONCLUSIONS: There is a need to intensify universal and targeted programmes/services to support mothers in ethnically dense socially disadvantaged areas to start antenatal care on time. Local variations in ethnic diversity and levels of social disadvantage are essential aspects to consider while planning services and programmes to ensure equity in maternity care provision.

Identifying adverse childhood experiences with electronic health records of linked mothers and children in England: a multistage development and validation study.

BACKGROUND: Electronic health records (EHRs) of mothers and children provide an opportunity to identify adverse childhood experiences (ACEs) during crucial periods of childhood development, yet well developed indicators of ACEs remain scarce. We aimed to develop clinically relevant indicators of ACEs for linked EHRs of mothers and children using a multistage prediction model of child maltreatment and maternal intimate partner violence (IPV). METHODS: In this multistage development and validation study, we developed a representative population-based birth cohort of mothers and children in England, followed from up to 2 years before birth to up to 5 years after birth across the Clinical Practice Research Datalink (CPRD) GOLD (primary care), Hospital Episode Statistics (secondary care), and the Office for National Statistics mortality register. We included livebirths in England between July 1, 2004, and June 30, 2016, to mothers aged 16-55 years, who had registered with a general practitioner (GP) that met CPRD quality standards before 21 weeks of gestation. The primary outcome (reference standard) was any child maltreatment or maternal IPV in either the mother's or child's record from 2 years before birth (maternal IPV only) to 5 years after birth. We used seven prediction models, combined with expert ratings, to systematically develop indicators. We validated the final indicators by integrating results from machine learning models, survival analyses, and clustering analyses in the validation cohort. FINDINGS: We included data collected between July 1, 2002, and June 27, 2018. Of 376 006 eligible births, we included 211 393 mother-child pairs (422 786 patients) from 400 practices, of whom 126 837 mother-child pairs (60·0%; 240 practices) were randomly assigned to a derivation cohort and 84 556 pairs (40·0%; 160 practices) to a validation cohort. We included 63 indicators in six ACE domains: maternal mental health problems, maternal substance misuse, adverse family environments, child maltreatment, maternal IPV, and high-risk presentations of child maltreatment. Excluding the seven indicators in the reference standard, 56 indicators showed high discriminative validity for the reference standard of any child maltreatment or maternal IPV between 2 years before and 5 years after birth (validation cohort, area under the receiver operating characteristic curve 0·85 [95% CI 0·84-0·86]). During the 2 years before birth and 5 years after birth, the overall period prevalence of maternal IPV and child maltreatment (reference standard) was 2·3% (2876 of 126 837 pairs) in the derivation cohort and 2·3% (1916 of 84 556 pairs) in the validation cohort. During the 2 years before and after birth, the period prevalence was 39·1% (95% CI 38·7-39·5; 34 773 pairs) for any of the 63 ACE indicators, 22·2% (21·8-22·5%; 20 122 pairs) for maternal mental health problems, 15·7% (15·4-16·0%; 14 549 pairs) for adverse family environments, 8·1% (7·8-8·3%; 6808 pairs) for high-risk presentations of child maltreatment, 6·9% (6·7-7·2%; 7856 pairs) for maternal substance misuse, and 3·0% (2·9-3·2%; 2540 pairs) for any child maltreatment (2·4% [2·3-5·6%; 2051 pairs]) and maternal IPV (1·0% [0·8-1·0%; 875 pairs]). 62·6% (21 785 of 34 773 pairs) of ACEs were recorded in primary care only, and 72·3% (25 140 cases) were recorded in the maternal record only. INTERPRETATION: We developed clinically relevant indicators for identifying ACEs using the EHRs of mothers and children presenting to general practices and hospital admissions. Over 70% of ACEs were identified via maternal records and were recorded in primary care by GPs within 2 years of birth, reinforcing the importance of reviewing parental and carer records to inform clinical responses to children. ACE indicators can contribute to longitudinal surveillance informing public health policy and resource allocation. Further evaluation is required to determine how ACE indicators can be used in clinical practice. FUNDING: None.

Socio-economic disparities in child-to-adolescent growth trajectories in China: Findings from the China Health and Nutrition Survey 1991-2015.

Backgrounds: Socio-economic disparities in growth trajectories of children from low-/middle-income countries are poorly understood, especially those experiencing rapid economic growth. We investigated socio-economic disparities in child growth in recent decades in China. Methods: Using longitudinal data on 5095 children/adolescents (7-18 years) from the China Health and Nutrition Survey (1991-2015), we estimated mean height and BMI trajectories by socio-economic position (SEP) and sex for cohorts born in 1981-85, 1986-90, 1991-95, 1996-2000, using random-effects models. We estimated differences between high (urbanization index ≥median, household income per capita ≥median, parental education ≥high school, or occupational classes I-IV) and low SEP groups. Findings: Mean height and BMI trajectories have shifted upwards across cohorts. In all cohorts, growth trajectories for high SEP groups were above those for low SEP groups across SEP indicators. For height, socio-economic differences persisted across cohorts (e.g. 3.8cm and 2.9cm in earliest and latest cohorts by urbanization index for boys at 10 year, and 3.6cm and 3.1cm respectively by household income). For BMI, trends were greater in high than low SEP groups, thus socio-economic differences increased across cohorts (e.g. 0.5 to 0.8kg/m2 by urbanization index, 0.4 to 1.1kg/m2 by household income for boys at 10 year). Similar trends were found for stunting and overweight/obesity by SEP. There was no association between SEP indicators and thinness. Interpretation: Socio-economic disparities in physical growth persist among Chinese youth. Short stature was associated with lower SEP, but high BMI with higher SEP. Public health interventions should be tailored by SEP, in order to improve children's growth while reducing overweight/obesity. Funding: MG is supported by UCL Overseas Research Scholarship and China Scholarship Council for her PhD study. WJ is supported by a UK Medical Research Council (MRC) New Investigator Research Grant (MR/P023347/1) and acknowledges support from the National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, which is a partnership between University Hospitals of Leicester NHS Trust, Loughborough University, and the University of Leicester.

Secular trends in blood pressure trajectories in Chinese children and adolescents: the impact of changing physical growth.

BACKGROUND: Globally, 80% of cardiovascular disease (CVD) occur in low-income /middle-income countries. High blood pressure (BP), a major risk factor for CVD, has its origins in early-life. We investigated how age trajectories of BP (childhood to late-adolescence) have changed recently in China and the mediating roles of physical growth. METHODS: Using the longitudinal data on 3785 children from the China Health and Nutrition Survey 1991-2015, we estimated mean BP trajectories (7-18 years) for cohorts born in 1981-1985, 1986-1990, 1991-1995 and 1996-2000 using random effect models. Models were adjusted for BMI and/or height growth to assess their impact on BP trends. RESULTS: BP trajectories shifted upwards across cohorts. Compared with the earliest cohort, mean BP was higher in the latest cohort throughout childhood to late adolescence. For example, the increment in SBP was 4.4 mmHg (95% confidence interval: 2.9-5.8) in boys and 4.0 mmHg (2.6-5.5) in girls at 9 years, narrowed slightly during adolescence, and was 3.0 mmHg (0.7-5.4) and 2.6 mmHg (0.4-4.8) respectively at 17 years. BMI and height trajectories also shifted upwards. The overall increment was greater for height than BMI. When adjusting for physical growth, the increment in BP trajectories reduced (more for height than BMI), but remained in childhood (P < 0.05). CONCLUSION: The upward shift of BP trajectories among Chinese youths was largely explained by trends in physical growth, especially increasing height. Other early-life factors might have also contributed to the BP trends. Substantial increases in mean BP in children within a short time frame is a public health concern and will affect future CVD, especially in the developing world.

Early childhood weight gain: Latent patterns and body composition outcomes.

BACKGROUND: Despite early childhood weight gain being a key indicator of obesity risk, we do not have a good understanding of the different patterns that exist. OBJECTIVES: To identify and characterise distinct groups of children displaying similar early-life weight trajectories. METHODS: A growth mixture model captured heterogeneity in weight trajectories between 0 and 60 months in 1390 children in the Avon Longitudinal Study of Parents and Children. Differences between the classes in characteristics and body size/composition at 9 years were investigated. RESULTS: The best model had five classes. The "Normal" (45%) and "Normal after initial catch-down" (24%) classes were close to the 50th centile of a growth standard between 24 and 60 months. The "High-decreasing" (21%) and "Stable-high" (7%) classes peaked at the ~91st centile at 12-18 months, but while the former declined to the ~75th centile and comprised constitutionally big children, the latter did not. The "Rapidly increasing" (3%) class gained weight from below the 50th centile at 4 months to above the 91st centile at 60 months. By 9 years, their mean body mass index (BMI) placed them at the 98th centile. This class was characterised by the highest maternal BMI; highest parity; highest levels of gestational hypertension and diabetes; and the lowest socio-economic position. At 9 years, the "Rapidly increasing" class was estimated to have 68.2% (95% confidence interval [CI] 48.3, 88.1) more fat mass than the "Normal" class, but only 14.0% (95% CI 9.1, 18.9) more lean mass. CONCLUSIONS: Criteria used in growth monitoring practice are unlikely to consistently distinguish between the different patterns of weight gain reported here.

Exposure to the Great Famine in Early Life and the Risk of Obesity in Adulthood: A Report Based on the China Health and Nutrition Survey.

Intrauterine malnutrition has a long-term effect on human health. This study aimed to evaluate the associations between exposure to famine in early life and obesity in adulthood in Chinese adults. A total of 5033 participants (22,132 observations) of the China Health and Nutrition Survey (CHNS) in 1991-2015 were classified into three famine exposure groups according to their birth year: unexposed (1963-1966), fetal-exposed (1959-1962) and childhood-exposed (1955-1958). Compared with the unexposed group, the fetal-exposed group had higher levels of body-mass-index (BMI) and waist-circumference (WC), and higher prevalence of overweight and central obesity, whereas the childhood-exposed group had lower levels of the measurements. However, the positive associations of fetal exposure with BMI, WC and prevalence of overweight and central obesity were attenuated by additionally adjusting for age at survey. Stratified analysis showed that the adverse effect of fetal exposure to famine was only observed in subjects at several specific age-groups, and in men living in rural areas and in women living in more severe famine exposed areas (p for interaction < 0.05). Our results provide evidence for the weak effect of fetal exposure to famine on body measurements in adulthood, and suggest the importance of severity of famine exposure and timing of exposure.

Distinct Body Mass Index Trajectories to Young-Adulthood Obesity and Their Different Cardiometabolic Consequences.

[Figure: see text].

Large-scale survey of parental antibiotic use for paediatric upper respiratory tract infections in China: implications for stewardship programmes and national policy.

BACKGROUND: Inappropriate use of antibiotics for upper respiratory tract infections (URTIs) in Chinese children is rampant. Parents' decision-making processes with respect to treatment choices and antibiotic use for paediatric URTIs were investigated to identify key constructs for effective interventions that target the public. METHODS: Data were collected between June 2017 and April 2018 from a random cluster sample of 3188 parents of children aged 0-13 years across three Chinese provinces, representing different stages of economic development. Risk factors of parents' treatment choices and antibiotic use for paediatric URTIs were assessed using binary and multinomial logistic regressions, adjusting for socio-demographic characteristics. RESULTS: A total of 1465 (46.0%) children of the 3188 parents who self-diagnosed their children with a URTI were given antibiotics, with or without prescription. Among these children, 40.5% were self-medicated with antibiotics by their parents and 56.1% obtained further antibiotic prescriptions at healthcare facilities. About 70% of children (n=2197) with URTI symptoms sought care; of these, 54.8% obtained antibiotic prescriptions and 7.7% asked for antibiotic prescriptions, with 79.4% successfully obtaining them. Those perceiving antibiotics as effective for treating the common cold and fever (adjusted odds ratio [aOR]=1.82[95% confidence interval, 1.51-2.19] and 1.77[1.47-2.13], respectively), who had access to non-prescription antibiotics (aOR=5.08[4.03-6.39]), and with greater perceived severity of infection (aOR=2.01[1.58-2.56]), were more likely to use antibiotics. CONCLUSIONS: Multifaceted, context-appropriate interventions are vital to untangle the perpetual problem of self-medication, over-prescription and ill-informed demands for antibiotics. The findings in this study emphasise the need to prioritise interventions that enhance clinical training, neutralise the pressure from patients for antibiotics, educate on appropriate home care, discourage antibiotic self-medication and improve antibiotic dispensing.

Predictive value of indicators for identifying child maltreatment and intimate partner violence in coded electronic health records: a systematic review and meta-analysis.

OBJECTIVE: Electronic health records (EHRs) are routinely used to identify family violence, yet reliable evidence of their validity remains limited. We conducted a systematic review and meta-analysis to evaluate the positive predictive values (PPVs) of coded indicators in EHRs for identifying intimate partner violence (IPV) and child maltreatment (CM), including prenatal neglect. METHODS: We searched 18 electronic databases between January 1980 and May 2020 for studies comparing any coded indicator of IPV or CM including prenatal neglect defined as neonatal abstinence syndrome (NAS) or fetal alcohol syndrome (FAS), against an independent reference standard. We pooled PPVs for each indicator using random effects meta-analyses. RESULTS: We included 88 studies (3 875 183 individuals) involving 15 indicators for identifying CM in the prenatal period and childhood (0-18 years) and five indicators for IPV among women of reproductive age (12-50 years). Based on the International Classification of Disease system, the pooled PPV was over 80% for NAS (16 studies) but lower for FAS (<40%; seven studies). For young children, primary diagnoses of CM, specific injury presentations (eg, rib fractures and retinal haemorrhages) and assaults showed a high PPV for CM (pooled PPVs: 55.9%-87.8%). Indicators of IPV in women had a high PPV, with primary diagnoses correctly identifying IPV in >85% of cases. CONCLUSIONS: Coded indicators in EHRs have a high likelihood of correctly classifying types of CM and IPV across the life course, providing a useful tool for assessment, support and monitoring of high-risk groups in health services and research.

Duration of obesity exposure between ages 10 and 40 years and its relationship with cardiometabolic disease risk factors: A cohort study.

BACKGROUND: Individuals with obesity do not represent a homogeneous group in terms of cardiometabolic risk. Using 3 nationally representative British birth cohorts, we investigated whether the duration of obesity was related to heterogeneity in cardiometabolic risk. METHODS AND FINDINGS: We used harmonised body mass index (BMI) and cardiometabolic disease risk factor data from 20,746 participants (49.1% male and 97.2% white British) enrolled in 3 British birth cohort studies: the 1946 National Survey of Health and Development (NSHD), the 1958 National Child Development Study (NCDS), and the 1970 British Cohort Study (BCS70). Within each cohort, individual life course BMI trajectories were created between 10 and 40 years of age, and from these, age of obesity onset, duration spent obese (range 0 to 30 years), and cumulative obesity severity were derived. Obesity duration was examined in relation to a number of cardiometabolic disease risk factors collected in mid-adulthood: systolic (SBP) and diastolic blood pressure (DBP), high-density-lipoprotein cholesterol (HDL-C), and glycated haemoglobin (HbA1c). A greater obesity duration was associated with worse values for all cardiometabolic disease risk factors. The strongest association with obesity duration was for HbA1c: HbA1c levels in those with obesity for <5 years were relatively higher by 5% (95% CI: 4, 6), compared with never obese, increasing to 20% (95% CI: 17, 23) higher in those with obesity for 20 to 30 years. When adjustment was made for obesity severity, the association with obesity duration was largely attenuated for SBP, DBP, and HDL-C. For HbA1c, however, the association with obesity duration persisted, independent of obesity severity. Due to pooling of 3 cohorts and thus the availability of only a limited number harmonised variables across cohorts, our models included adjustment for only a small number of potential confounding variables, meaning there is a possibility of residual confounding. CONCLUSIONS: Given that the obesity epidemic is characterised by a much earlier onset of obesity and consequently a greater lifetime exposure, our findings suggest that health policy recommendations aimed at preventing early obesity onset, and therefore reducing lifetime exposure, may help reduce the risk of diabetes, independently of obesity severity. However, to test the robustness of our observed associations, triangulation of evidence from different epidemiological approaches (e.g., mendelian randomization and negative control studies) should be obtained.

An overview of child maltreatment (neglect and abuse) associations with developmental trajectories and long-term outcomes in the 1958 British birth cohort.

Childhood maltreatment types (neglect and psychological, physical, or sexual abuse) are associated with many poor outcomes in adulthood. Yet, research mainly focuses on the cumulative adversity burden rather than specificities and commonalities of associations with adult outcomes and intervening pathways. To build understanding of life-course pathways to a range of outcomes, this overview summarises evidence from several original research studies using the 1958 British Birth Cohort on specific maltreatment types, child development trajectories, adult intermediaries and outcomes. About one-in-five participants were identified as neglected or abused in childhood (~10% were identified for neglect, 10% for psychological abuse, 6% for physical abuse and 1.4% for sexual abuse). Neglect was associated with key dimensions of development, for example, slower height growth, delayed maturation, faster BMI gain, and poorer emotional and cognitive development. Associated adulthood outcomes included harmful behaviours (notably smoking), poorer physical health (e.g. shorter height, excess BMI, poorer blood lipids and glucose, poor-rated health and physical functioning), worse mental health, lower socioeconomic circumstances (e.g. poorer living conditions) and elevated mortality in mid-adulthood. Childhood abuse associations were less widespread and were often only for specific types: most types were unrelated to childhood height and cognitive abilities, but all types were associated with poorer child emotional development, adult mental health, smoking, blood lipids and self-rated health. Additionally, physical abuse was associated with faster BMI gain, higher adult BMI, blood glucose, inflammation and mortality in mid-adulthood; sexual abuse with faster BMI gain, higher adult BMI, poor physical functioning at 50y and higher mortality in mid-adulthood. Adult health measures associated with neglect and abuse are key predictors of serious disease, disability and death. Therefore, neglect and abuse associations with these measures represent an important burden for individuals and society.

Adverse childhood experiences and adult inflammation: Single adversity, cumulative risk and latent class approaches.

BACKGROUND: Adverse childhood experiences (ACEs) have long been known to be related to poorer health across the life course. Previous studies typically relied on cumulative risk scores or individual adversities measured through retrospective self-reports. However, these approaches have important limitations. Cumulative risk scores assume equal weighting of adversities and the single adversity approach ignores the high probability that adversities co-occur. In contrast, latent class analysis (LCA) offers an alternative approach to operationalise ACEs that respects the clustering of adversities and may identify specific patterns of ACEs important for health outcomes. Furthermore, prospective and retrospective reports of ACEs show poor agreement. Therefore, it is important to compare findings based on prospective and retrospective measures in the same individuals. Despite an increasing number of studies applying LCA to ACEs data, no studies have yet simultaneously investigated LCA to cumulative risk and single adversity approaches in their relationships with adult inflammation. Identifying the specific ACEs or combinations of ACEs which are strongly related to inflammation is important for investigating the mechanisms involved and the planning of effective interventions. METHODS: Using data on 8810 members of the 1958 British birth cohort we investigated 12 ACEs - physical, psychological and sexual abuse, physical and emotional neglect, parental mental health problems, witnessing abuse, parental conflict, parental divorce, parental offending, parental substance misuse and parental death. LCA was applied to explore the clustering of prospectively and retrospectively reported ACEs separately. Associations between latent classes, cumulative risk scores and individual adversities with three inflammatory markers (C-Reactive Protein, fibrinogen and von Willebrand Factor) were tested using linear regression. RESULTS: There was co-occurrence between adversities, and particularly for retrospectively reported adversities. Three latent classes were identified in the prospective data - 'Low ACEs' (95.7%), 'Household dysfunction' (2.8%) and 'Parental loss' (1.5%) which were related to increased inflammation in mid-life, as were high ACE scores and individual measures of offending, death, divorce, physical neglect and family conflict. Four latent classes were identified in the retrospective data - 'Low ACEs', 'Parental mental health and substance misuse', 'Maltreatment and conflict' and 'Polyadversity.' The latter two (5.2%) were related to raised inflammation in mid-life, as was a retrospective ACE score of 4+ (8.3%) and individual measures of family conflict, psychological and physical abuse, emotional neglect and witnessing abuse. CONCLUSIONS: Specific ACEs or ACE combinations might be important for chronic inflammation. LCA is an alternative approach to operationalising ACEs data but further research is needed.