Risk and protective factors for falls on stairs in young children: multicentre case-control study.

AIM: To investigate risk and protective factors for stair falls in children aged <5 years. METHODS: Multicentre case-control study at hospitals, minor injury units and general practices in and around four UK study centres. Cases were children with medically attended stair fall injuries. Controls were matched on age, sex, calendar time and study centre. A total of 610 cases and 2658 controls participated. RESULTS: Cases' most common injuries were bangs on the head (66%), cuts/grazes not requiring stitches (14%) and fractures (12%). Parents of cases were significantly more likely not to have stair gates (adjusted OR (AOR) 2.50, 95% CI 1.90 to 3.29; population attributable fraction (PAF) 21%) or to leave stair gates open (AOR 3.09, 95% CI 2.39 to 4.00; PAF 24%) both compared with having closed stair gates. They were more likely not to have carpeted stairs (AOR 1.52, 95% CI 1.09 to 2.10; PAF 5%) and not to have a landing part-way up their stairs (AOR 1.34, 95% CI 1.08 to 1.65; PAF 18%). They were more likely to consider their stairs unsafe to use (AOR 1.46, 95% CI 1.07 to 1.99; PAF 5%) or to be in need of repair (AOR 1.71, 95% CI 1.16 to 2.50; PAF 5%). CONCLUSION: Structural factors including having landings part-way up the stairs and keeping stairs in good repair were associated with reduced stair fall injury risk. Family factors including having stair gates, not leaving gates open and having stair carpets were associated with reduced injury risk. If these associations are causal, addressing these factors in housing policy and routine child health promotion could reduce stair fall injuries.

Keeping children safe at home: protocol for a case-control study of modifiable risk factors for scalds.

BACKGROUND: Scalds are one of the most common forms of thermal injury in young children worldwide. Childhood scald injuries, which mostly occur in the home, result in substantial health service use and considerable morbidity and mortality. There is little research on effective interventions to prevent scald injuries in young children. OBJECTIVES: To determine the relationship between a range of modifiable risk factors for medically attended scalds in children under the age of 5 years. DESIGN: A multicentre case-control study in UK hospitals and minor injury units with parallel home observation to validate parental reported exposures. Cases will be 0-4 years old with a medically attended scald injury which occurred in their home or garden, matched on gender and age with community controls. An additional control group will comprise unmatched hospital controls drawn from children aged 0-4 years attending the same hospitals and minor injury units for other types of injury. Conditional logistic regression will be used for the analysis of cases and matched controls, and unconditional logistic regression for the analysis of cases and unmatched controls to estimate ORs and 95% CI, adjusted and unadjusted for confounding variables. MAIN EXPOSURE MEASURES: Use of safety equipment and safety practices for scald prevention and scald hazards. DISCUSSION: This large case-control study will investigate modifiable risk factors for scalds injuries, adjust for potential confounders and validate measures of exposure. Its findings will enhance the evidence base for prevention of scalds injuries in young children.

Integrating children's services in England: national evaluation of children's trusts.

BACKGROUND: Poor co-ordination of services can have severe consequences for disadvantaged children with complex needs. Since 2003 national and local governments in England embarked on sweeping reforms aimed at improving and integrating local health, education and social services for children. These were to be organized locally by children's trusts and piloted by 35 children's trust pathfinders. METHODS: This study described and compared the experience of integrating children's services in all 35 children's trust pathfinders, covering 20% of children in England. It had a prospective mixed-methods design. Over 3 years we interviewed 147 managers and professionals working in the children's trusts, including 172 semi-structured interviews, carried out two questionnaire surveys of the 35 children's trusts and analysed official documents. RESULTS: In most areas different agencies jointly commissioned children's services, especially for mental health, disabilities and multi-purpose children's centres, and increasingly pooled finances. Provision of multi-agency and multi-professional services was increasing. Professionals generally supported these changes but found them stressful. All children's trusts appointed directors of children's services and established boards representing multiple agencies. Systems for sharing information about individual children were mostly in place but were still underused. Health services were generally less involved in joint work than were local authorities' education and social care services, with notable exceptions. Areas where local authorities and health authorities shared geographical boundaries made most progress. Some children's trusts made few changes beyond their statutory obligations. CONCLUSION: Children's trusts enabled major changes to services in areas where local actors and organizations were motivated and empowered. In other areas the remit of children's trusts was often too broad and vague to overcome entrenched organizational and professional divisions and interests. Policymakers need to balance facilitation of change in areas with dynamic change agents with methods for ensuring that dormant areas and agencies are not left behind.

What are children's trusts? Early findings from a national survey.

BACKGROUND: The Children Act 2004 and National Service Framework for Children, Young People and Maternity Services require fuller integration of health, education and social services for children and young people in England and Wales. The UK government supported the establishment of 35 experimental children's trust pathfinders (henceforth called children's trusts) in England. METHODS: A questionnaire was completed by managers in all 35 children's trusts a year after their start. Children's trust documents were examined. Census and performance indicators were compared between children's trust areas and the rest of England. RESULTS: Children's trust areas had demographic and social characteristics typical of England. All children's trusts aimed to improve health, education and social services by greater managerial and service integration. All had boards representing the three sectors; other agencies' representation varied. Two-thirds of children's trusts had moved towards pooling budgets in at least some service areas. At this stage in their development, some had prioritized joint procurement or provision of services, with formal managerial structures, while others favoured an informal strategic planning, co-ordination and information sharing approach. The commonest priorities for services development were for disabled children (16 children's trusts), followed by early intervention (11) and mental health services (8). CONCLUSIONS: The diverse strategies adopted by these 35 children's trusts during their first year is due to their own characteristics and to the way government strategy developed during this period. Whilst some prioritized organizational development, joint financing and commissioning, and information sharing, others laid more emphasis on mechanisms for bringing front-line professionals closer together. Their experiences are of value to others deciding how best to integrate children's services.

Managing medication in schools.

Increasing numbers of children and young people are prescribed medication to be taken in school. This article discusses general principles of prescribing medication for use in school, specific conditions for which medicines may be prescribed, and the key role of nurses in liaison with schools. Decisions about prescribing medication for use in schools do not only depend on evidence of therapeutic effectiveness but need to take into account other social and educational benefits and harms that may occur when children need to use medication in school.

The importance of acknowledging clinical uncertainty in the diagnosis of epilepsy and non-epileptic events.

BACKGROUND: Failure to recognise diagnostic uncertainty between the epilepsies and non-epileptic events may be a factor in high rates of misdiagnosis. AIMS: To explore the results of acknowledging diagnostic uncertainty in a cohort of children presenting with paroxysmal events. METHODS: Children (29 days-16th birthday) with new presentations of paroxysmal disorders were ascertained through outpatients, admissions, and accident and emergency over a two year period in a district hospital with a catchment population of 500,000. Cases were classified by diagnosis at entry and 6-30 months later. A random selection of cases was independently assessed. RESULTS: A total of 684 cases were ascertained. Attacks were initially classified as febrile seizures (n = 212), acute symptomatic epileptic seizures (n = 5), epilepsies (n = 83), unclassified (possible epilepsy) (n = 90), isolated epileptic seizures (n = 51), and non-epileptic events (n = 243). Case review enabled reclassification of 61 of those initially unclassified--31 to an epilepsy and 27 to non-epileptic events. In 29 the final diagnosis was never clarified. These were 23 cases with confusing or absent histories and six with short lived seizure clusters. Prognosis for these 29 cases was good; 75% had been discharged. None were on long term medication. The diagnosis in the 131 cases confirmed as epilepsy was stable. Independent review of a random sample showed full concordance with one neurologist and 20% uncertainty with another. CONCLUSION: In addition to definite epilepsy or non-epileptic events it is helpful to recognise a group of cases where the diagnosis is uncertain-unclassified paroxysmal events. Reassessment of these cases enables accurate diagnosis and may prevent a hasty and incorrect diagnosis of epilepsy.

A national evaluation of school breakfast clubs: evidence from a cluster randomized controlled trial and an observational analysis.

STUDY OBJECTIVE: To measure the health, educational and social impacts of breakfast club provision in schools serving deprived areas across England. DESIGN: A cluster randomized controlled trial and an observational analysis. SETTING: England, the UK. INTERVENTION: funding to establish a school-based breakfast club vs. control (no funding). MAIN RESULTS: Intention to treat analysis showed improved concentration (Trail Making Test Part A) amongst the intervention group at 3 months. Fewer pupils within the intervention group reported having skipped classes within the last month and fewer pupils within the intervention group reported having skipped 1 or more days of school within the last month at 1 year. Observational analysis at 1 year showed a higher proportion of primary-aged breakfast club attendees reported eating fruit for breakfast in comparison to non-attendees. A higher proportion of breakfast club attendees had borderline or abnormal conduct and total difficulties scores (primary-aged pupils) and prosocial score (secondary-aged pupils). CONCLUSIONS: Analyses revealed a mixed picture of benefit and apparent disbenefit. This study illustrated the challenges of evaluating a complex intervention in which the evaluators had less control than is usual in randomized trials over recruitment, eligibility checking and implementation. If the impact of new policy initiatives is to be assessed using the most robust forms of evaluation, social policy needs to be organized so that evaluations can be constructed as experiments. This is likely to prove most difficult where the perceived value of implementing an intervention rapidly is high.

A national evaluation of school breakfast clubs: where does economics fit in?

STUDY OBJECTIVE: To describe the economics of UK school breakfast clubs, to estimate costs resulting from clubs and to investigate relationships between costs and outcomes. DESIGN: A postal survey of schools with a 1-year follow-up, a cluster randomized controlled trial, case studies, semi-structured interviews with parents and a secondary econometric analysis. SETTING: England, the UK. MAIN RESULTS: Key economic differences were identified between clubs based in primary schools and those based in secondary schools in terms of both funding levels and cost structures. However, funding levels were not a significant determinant of the observed outcomes in either type of school. CONCLUSIONS: For formal economic evaluation to succeed during implementation of a new initiative, a clearer understanding of relevant outcomes and the distinction between short- and long-term outcomes and potential individual, institutional and societal benefits are required from an early stage.

How is money spent on children's services?

Finance and activity data for the year 1999-2000 were used to identify the money spent on children's services in health and social care in a county with a population of 790,000. Total costs were almost pound 80m. Considerable amounts were spent on high cost, low volume activity. Local health and social care commissioners require this information to implement and monitor changes in children's services, particularly in light of the UK government proposals for children's trusts.

Learning and behavioural difficulties but not microcephaly in three brothers resulting from undiagnosed maternal phenylketonuria.

Universal screening introduced in the 1960s has reduced the incidence of learning disability resulting from phenylketonuria (PKU), which is a treatable condition. Nonetheless, PKU may still be having an impact on the paediatric-age population. We report a woman with previously undiagnosed PKU who was born before the onset of universal screening. She is of normal intelligence, and so the diagnosis was not suspected until after the birth of her three children. Her serum phenylalanine concentration was found to be in excess of 1 mmol/L, well into the toxic range. She has had three sons, all of whom have a significant degree of learning disability resulting from intrauterine exposure to toxic levels of phenylalanine. None of the sons had microcephaly, a physical sign that, if present, might have helped to point towards the correct diagnosis. We suggest that maternal PKU should be suspected where there is sibling recurrence of cognitive impairment, particularly where the mother was born before the initiation of the neonatal screening programme for PKU.

A population genetic comparison of argali sheep (Ovis ammon) in Mongolia using the ND5 gene of mitochondrial DNA; implications for conservation.

We sequenced 556 bp of the mitochondrial ND5 gene to infer aspects of population structure and to test subspecific designations of argali sheep (Ovis ammon) in Mongolia. Analysis of molecular variance (AMOVA) revealed greater variation within than among putative subspecies and populations, suggesting high levels female-mediated gene flow. Compared with bighorn sheep (O. canadensis) in North America, substantially less differentiation in mitochondrial DNA was found among argali populations over 1200 km than was found among bighorn populations over 250 km. This result is consistent with differences in argali and bighorn life history traits. Argali run for long distances across open terrain in the presence of a threat rather than running up into steep escape terrain like bighorn sheep do. Our results suggest recognizing only one Evolutionary Significant Unit (subspecies) of argali in Mongolia, but they may support recognizing two Management Units, because two regions do exhibit slightly different haplotype frequencies at the ND5 gene of mtDNA.

Emergency asthma inhalers in school.

Despite there being a lack of direct evidence of the effectiveness of providing emergency inhalers to schools, the balance of evidence at present suggests the benefits outweigh any possible harm. However, unless UK prescribing law or its interpretation is changed, this will remain an action which opens teachers, nurses, and doctors to possible legal and professional sanctions, and may nullify their institutional or professional indemnity. As a consequence, provision will remain patchy and research into the value of emergency inhalers will be inhibited. A position statement from one or more responsible organisations such as the Royal College of Paediatrics and Child Health, the British Thoracic Society, or the British Paediatric Respiratory Society could persuade a reassessment from the Medicines Control Agency. This is also an issue which could be addressed in the forthcoming National Service Framework for children.

The recruitment and training crisis in community paediatrics: what do registrars think?

OBJECTIVE: There is currently a crisis in the recruitment of trainees into community paediatrics. Focus groups were conducted to explore the views of paediatric specialist registrars about this crisis. DESIGN: A total of 18 registrars participated in two focus groups. Data were analysed qualitatively by content analysis. RESULTS: The overriding theme was the poor status and image of community compared with acute paediatrics. This existed at five levels, which could be arranged from a 'macro' structural level down to a 'micro' individual level. These were: the hospital/community divide, issues related to training, practical experience, the influence of role models, and personal factors. CONCLUSIONS: We identified several specific implications for community paediatric training. However, the deep divide between acute and community paediatrics, as perceived by registrars, is unlikely to change unless training programmes are designed to produce paediatricians suited to the needs of future child health services rather than existing models of acute and community paediatricians.

Citizens advice in primary care for families with young children.

BACKGROUND: Citizens advice can help clients avoid the worst consequences of poverty and hence has the potential to reduce inequalities in health. Previous studies of providing citizens advice from primary care have concentrated largely on older clients. AIM: To measure the benefits obtained by families with young children from a citizens advice service in primary care. METHOD: An advice worker was placed in three practices. Eligible families had a child less than 1 year of age. Quantitative analysis of data on benefits obtained by all families using the service was performed. Qualitative analysis of interviews with five users and five non-users of the service was undertaken. RESULTS: Out of 107 families recruited, 23 used the CAB service, seeking advice on 49 different problems and obtaining benefit on 32 of these, most frequently on welfare benefits, debt management and housing. One-off financial benefits totalled pound sterlings 17 857 with annual recurring payments of pound sterlings 6480. The interviews raised five general themes: (1) the stresses surrounding the birth of a child; (2) factors associated with uptake of the service; (3) the content and value of the advice received; (4) the benefits to their health of the advice; and (5) their perception of the links between health and financial adversity. CONCLUSIONS: Citizens advice offers considerable benefits to families with young children. It may have positive effects on maternal and child health. An advice service is a useful component of primary health care for young families.

Debt, social disadvantage and maternal depression.

Depression is common among women with young children, and is strongly associated with financial adversity. Debt is a common feature of such adversity, yet its relationship with depression has not been examined before. We have used longitudinal data, collected over six months, on 271 families with young children, to examine this relationship. Multiple regression was used to identify independent predictors of the total Edinburgh Post-natal Depression Scale score from a range of socioeconomic, demographic, social support and child health related variables. Worry about debt was the strongest independent socioeconomic predictor of the depression score at both initial and follow-up occasions. To account for the possibility of reverse causation, i.e. depression causing worry about debt, alternative regression models are reported which show that owing money by itself predicts depression and earlier debt worries predicts depression six months later. We were unable to show that earlier debt worries independently predicted subsequent depression scores after the initial depression score had been taken into account in the analysis. Although debt has not been shown to be an independent prospective predictor of depression, our results suggest it has a central place in the association between socioeconomic hardship and maternal depression. Evidence from qualitative studies on poverty and from studies on the causes of depression support this hypothesis. The implications for policy are that strategies to enable families to control debt should be an explicit part of wider antipoverty measures which are designed to reduce depression and psychological distress among mothers of young children.

An assessment of need for health visiting in general practice populations.

BACKGROUND: An index of the need for health visiting in general practice populations in the United Kingdom was developed, using routinely held data, to inform decisions about the deployment of health visitors. METHODS: The following indicators of need for health visiting were developed by consensus among health visitors and others: the population aged under 5 years; elective admissions under 5 years; births under 2,500 g; deaths under 65 years; all expressed as rates per 10,000 people registered with general practices in Norfolk. All indicators were compared with the number of health visitors per 10,000 people, obtained by a postal survey of health visitors. The indicators were converted to Z-scores and summed to produce a composite score of need for each general practice. The results were compared with the results of a workload profile using data compiled by health visitors within one Primary Care Group. RESULTS: Health visitors are not allocated according to need at either the practice or Primary Care Group level. The Pearson's correlation coefficient between the allocation suggested by this method and current allocation is 0.37 (p < 0.01). The correlation between this method and the allocation suggested by health visitors' workload profiling in one Primary Care Group was 0.76 (p < 0.01). CONCLUSIONS: Health visitors are currently distributed according to historic patterns rather than need. This paper describes a simple method of determining need at general practice level, which can be used to allocate health visitors equitably.

Back-casting sociality in extinct species: new perspectives using mass death assemblages and sex ratios.

Despite 150 years of interest in the ecology of dinosaurs, mammoths, proto-hominids and other extinct vertebrates, a general framework to recreate patterns of sociality has been elusive. Based on our recent discovery of a contemporary heterospecific mass death assemblage in the Gobi Desert (Mongolia), we fit predictions about gender-specific associations and group living in extant ungulates to extinct ones. We relied on comparative data on sex-ratio variation and body-size dimorphism, basing analyses on 38 additional mass mortality sites from Asia, Africa, Europe and North America that span 50 million years. Both extant and extinct species died in aggregations with biased adult sex ratios, but the skew (from 1:1) was greater for extinct dimorphic taxa, suggesting that sociality in these extinct species can be predicted from spatial and demographic traits of extant ones. However, extinct rhinos, horses and zebras were inconsistent with predictions about adult sex ratios, which underscores the inherent difficulty in backcasting historic patterns to some monomorphic taxa. These findings shed light not only on the sociality of extinct species but provide a sound, although limited, footing for interpretation of modern death assemblages within the context of the emerging science of taphonomy and palaeobehaviour.

Cluster randomised trials in maternal and child health: implications for power and sample size.

BACKGROUND: Interventions based in the community can be evaluated by randomising clusters, such as general practices, rather than individuals, as in conventional randomised trials. This increases the sample size needed because of intracluster correlation. AIMS: To estimate sample size requirements for cluster randomised trials of interventions based in general practice directed at common health problems affecting mothers and infants. METHODS: Data were collected from a pilot trial of the effect of Citizen's Advice Bureau services involving six general practices. Outcome measures included the Edinburgh postnatal depression score, the Warwick child health and morbidity profile, number of visits to the general practitioner, and two questionnaires delivered at the beginning and end of the study. Intracluster correlation coefficients and inflation factors (the ratio of the sample size required for a cluster randomised trial to that required for an individually randomised trial) were calculated. RESULTS: Intracluster correlation coefficients ranged from 0 (sleeping problems, accidental injury, hospitalisation) to 0.09 (maternal smoking), with most being < 0.04 (for example, maternal depression, breast feeding, general health, minor illness, behavioural problems, and visits to the general practitioner). Assuming 50 cases/practice, cluster randomised trials require sample sizes up to 3 times greater than individually randomised trials for most health outcomes measured. CONCLUSIONS: These data enable sample sizes to be estimated for cluster randomised trials into a range of maternal and child health outcomes. Using such a design, approximately 40 practices would be sufficient to evaluate the effect of an intervention on maternal depression, sleeping, and behavioural problems, and non-routine visits to the general practitioner.