Interpersonal Violence and Gender Inequality in Adolescents: A Systematic Analysis of Global Burden of Disease Data From 1990 to 2019.

PURPOSE: Interpersonal violence is a leading cause of adolescent deaths and disability. This study investigates sex differences in burden of interpersonal violence for adolescents and explores associations with gender inequality. METHOD: Using data from the 2019 Global Burden of Disease study, we report numbers, proportions, rates of interpersonal violence deaths and disability adjusted life years (DALYs) for all ages, and rate of change (from 1990 to 2019) in adolescents aged 10-24 years disaggregated by sex and geography. We explored associations with gender inequality using gender inequality index. RESULTS: One in four (24.8%) all-age interpersonal violence deaths are in adolescents. In 2019, the rate of deaths in adolescent males was almost six times higher than females (9.3 vs. 1.6 per 100,000); and since 1990, the rate of decline in DALYs for females was double than that for males (-28.9% vs. -12.7%). By contrast, the burden of sexual violence is disproportionately borne by adolescent females, with over double the rate than males (DALYs: 42.8 vs. 17.5 per 100,000). In countries with greater gender inequality, the male-to-female ratio (deaths and DALYs) was increased among older adolescents, pointing to benefits for males in more gender equal settings. DISCUSSION: Social identities, relationships, and attitudes to violence are established in adolescence, which is an inflection point marking the emergence of disproportionate burdens of interpersonal violence. Our findings affirm that global agendas must be expanded to address interrelated factors driving multiple forms of interpersonal violence experienced by adolescents and reverberating to the next generation.

Towards responsive policy and actions to address non-communicable disease risks amongst adolescents in Indonesia: insights from key stakeholders.

Background: Non-communicable diseases (NCDs) such as cancer, diabetes, heart disease, mental disorder and chronic lung conditions are the leading cause of death and disability in Indonesia. Adolescence is when risks for NCDs emerge and it is also an important life stage for intervention, yet young people are often at the margins of NCD policy and actions. This study aimed to understand how policies and actions should address NCD risks (tobacco smoking, inadequate physical activity, and diet) for adolescents in Indonesia, and how young people can be meaningfully involved. Methods: Qualitative in-depth interviews over videoconference (n = 21) were conducted in English or Bahasa with stakeholders in Indonesia. Participants included policymakers, implementation partners, and advocates who were focused on adolescent health or NCDs. Interviews were recorded, transcribed, translated, and thematically analysed using NVivo12. Findings were disseminated to participants for validation and feedback. Youth participants (n = 7) attended an additional workshop and considered recommendations and actions arising from this research. Findings: Participants identified that government and non-government organisations are acting on NCDs in Indonesia, but few of the existing initiatives target adolescents, and adolescent services rarely addressed NCD risks. Participants also felt that policies to protect adolescents from NCD risks (i.e., smoke-free areas in public) were not always enforced. For programs or initiatives focused on adolescent health, those that had engaged adolescents as co-creators and leaders were perceived to be more successful. As such, participants recommended more meaningful engagement of young people, including young people's leadership of initiatives. Additional recommendations included the need for intersectoral engagement and a 'whole-of-government' approach to prevention given the complex determinants of NCD risks, and the need for evidence-based actions that are underpinned by quality data to enable monitoring of progress. Interpretation: There is a recognised need to strengthen policies and actions to address NCD risks amongst adolescents in Indonesia. Meaningful youth engagement that allows young people to take the lead, intersectoral actions, and evidence-based data driven responses were key strategies identified. Funding: UNICEF East Asia and Pacific Regional Office.

Intratracheal budesonide mixed with surfactant to increase survival free of bronchopulmonary dysplasia in extremely preterm infants: statistical analysis plan for the international, multicenter, randomized PLUSS trial.

BACKGROUND: Bronchopulmonary dysplasia (BPD), an inflammatory-mediated chronic lung disease, is common in extremely preterm infants born before 28 weeks' gestation and is associated with an increased risk of adverse neurodevelopmental and respiratory outcomes in childhood. Effective and safe prophylactic therapies for BPD are urgently required. Systemic corticosteroids reduce rates of BPD in the short term but are associated with poorer neurodevelopmental outcomes if given to ventilated infants in the first week after birth. Intratracheal administration of corticosteroid admixed with exogenous surfactant could overcome these concerns by minimizing systemic sequelae. Several small, randomized trials have found intratracheal budesonide in a surfactant vehicle to be a promising therapy to increase survival free of BPD. The primary objective of the PLUSS trial is to determine whether intratracheal budesonide mixed with surfactant increases survival free of bronchopulmonary dysplasia (BPD) at 36 weeks' postmenstrual age (PMA) in extremely preterm infants born before 28 weeks' gestation. METHODS: An international, multicenter, double-blinded, randomized trial of intratracheal budesonide (a corticosteroid) mixed with surfactant for extremely preterm infants to increase survival free of BPD at 36 weeks' postmenstrual age (PMA; primary outcome). Extremely preterm infants aged < 48 h after birth are eligible if (1) they are mechanically ventilated, or (2) they are receiving non-invasive respiratory support and there is a clinical decision to treat with surfactant. The intervention is budesonide (0.25 mg/kg) mixed with poractant alfa (200 mg/kg first intervention, 100 mg/kg if second intervention), administered intratracheally via an endotracheal tube or thin catheter. The comparator is poractant alfa alone (at the same doses). Secondary outcomes include the components of the primary outcome (death, BPD prior to or at 36 weeks' PMA), and potential systemic side effects of corticosteroids. Longer-term outcomes will be published separately, and include cost-effectiveness, early childhood health until 2 years of age, and neurodevelopmental outcomes at 2 years of age (corrected for prematurity). STATISTICAL ANALYSIS PLAN: A sample size of 1038 infants (519 in each group) is required to provide 90% power to detect a relative increase in survival free of BPD of 20% (an absolute increase of 10%), from the anticipated event rate of 50% in the control arm to 60% in the intervention (budesonide) arm, alpha error 0.05. To allow for up to 2% of study withdrawals or losses to follow-up, PLUSS aimed to enroll a total of 1060 infants (530 in each arm). The binary primary outcome will be reported as the number and percentage of infants who were alive without BPD at 36 weeks' PMA for each randomization group. To estimate the difference in risk (with 95% CI), between the treatment and control arms, binary regression (a generalized linear multivariable model with an identity link function and binomial distribution) will be used. Along with the primary outcome, the individual components of the primary outcome (death, and physiological BPD at 36 weeks' PMA), will be reported by randomization group and, again, binary regression will be used to estimate the risk difference between the two treatment groups for survival and physiological BPD at 36 weeks' PMA.

Immunization Coverage in Young People Experiencing Homelessness and the Impact of a Nurse-led Program.

OBJECTIVES: To identify the proportion of young people experiencing homelessness who are immunized against vaccine-preventable diseases, and to evaluate the impact of a nurse-led immunization program to improve vaccination coverage in this population. METHODS: A retrospective audit of electronic medical records included 400 participants aged 15 to 24 years who had an encounter with the Young People's Health Service, a nurse-led clinic co-located with a specialist youth homelessness service in Melbourne, Australia, between February 2019 and May 2021. RESULTS: Integrating an immunization nurse within a youth specialist homelessness service increased the percentage of young people who were up-to-date with routine vaccinations from 6.0% (n = 24) to 38.8% (n = 155). Intersecting social determinants of health that increased participants' risk of vaccine preventable diseases, and of missing routine vaccines, were common. CONCLUSIONS: Incomplete coverage of routine vaccines is common in young people accessing homelessness services, and this coverage was improved when young people encountered an immunization nurse while accessing support from a specialist youth homelessness service. As a service model, nurse-led community health clinics co-located within homelessness providers can improve vaccination coverage, and therefore health outcomes, of young people experiencing or at risk of homelessness.

Child marriage and the mental health of adolescent girls: a longitudinal cohort study from Uttar Pradesh and Bihar, India.

Background: There has been much speculation about the role of inequitable gender norms and early marriage in mental health and suicide risks in girls and young women, but no prospective study has yet investigated this relationship. Understanding these links has become particularly important in the context of the COVID-19 pandemic which has led to increased risk of child marriage in the most vulnerable girls. Methods: We examined the association between early marriage and mental health in girls using data from Understanding the Lives of Adolescents and Young Adults (UDAYA), a longitudinal study in adolescents in Uttar Pradesh and Bihar, India. The study included girls who were unmarried at wave 1 (2015-2016) and participated at wave 2 data collection (2018-2019). Information on mental health (Patient Health Questionnaire-9 (PHQ-9)), suicidal thoughts, plans and attempts were collected at both waves. Logistic regression with survey weights was used to estimate the association between marrying between the two waves and mental health. Findings: Between waves 1 and 2, 1825 (23%) participants (n = 7864) married. Unmarried girls with depressive symptoms (PHQ score≥9) at wave 1 had greater odds of transitioning into marriage by wave 2 than those without (adjusted-OR 1.5; 95% CI 1.1 to 2.0). The odds of wave 2 depressive symptoms were higher in newly married vs unmarried girls (adjusted-OR 2.0; 95% CI 1.6-2.5). Among newly married girls, the odds of depressive symptoms were higher for those who experienced any abuse than those who did not (adjusted-OR 1.6; 95% CI 1.2-2.2). This effect was larger for girls who had not given birth (adjusted-OR 2.2; 95% CI 1.4-3.3). Interpretation: Our findings show poor mental health preceded and was a consequence of child marriage. Mental health should be considered in policies and programming aimed at reducing early marriage; equally the mental health of young brides should be a focus for community and maternal health services. Funding: Bill and Melinda Gates Foundation and David and Lucile Packard Foundation.

Comparative inequalities in child dental caries across four countries: Examination of international birth cohorts and implications for oral health policy.

Child dental caries (i.e., cavities) are a major preventable health problem in most high-income countries. The aim of this study was to compare the extent of inequalities in child dental caries across four high-income countries alongside their child oral health policies. Coordinated analyses of data were conducted across four prospective population-based birth cohorts (Australia, n = 4085, born 2004; Québec, Canada, n = 1253, born 1997; Rotterdam, the Netherlands, n = 6690, born 2002; Southeast Sweden, n = 7445, born 1997), which enabled a high degree of harmonization. Risk ratios (adjusted) and slope indexes of inequality were estimated to quantify social gradients in child dental caries according to maternal education and household income. Children in the least advantaged quintile for income were at greater risk of caries, compared to the most advantaged quintile: Australia: AdjRR = 1.18, 95%CI = 1.04-1.34; Québec: AdjRR = 1.69, 95%CI = 1.36-2.10; Rotterdam: AdjRR = 1.67, 95%CI = 1.36-2.04; Southeast Sweden: AdjRR = 1.37, 95%CI = 1.10-1.71). There was a higher risk of caries for children of mothers with the lowest level of education, compared to the highest: Australia: AdjRR = 1.18, 95%CI = 1.01-1.38; Southeast Sweden: AdjRR = 2.31, 95%CI = 1.81-2.96; Rotterdam: AdjRR = 1.98, 95%CI = 1.71-2.30; Québec: AdjRR = 1.16, 95%CI = 0.98-1.37. The extent of inequalities varied in line with jurisdictional policies for provision of child oral health services and preventive public health measures. Clear gradients of social inequalities in child dental caries are evident in high-income countries. Policy related mechanisms may contribute to the differences in the extent of these inequalities. Lesser gradients in settings with combinations of universal dental coverage and/or fluoridation suggest these provisions may ameliorate inequalities through additional benefits for socio-economically disadvantaged groups of children.

Nasal High-Flow Therapy during Neonatal Endotracheal Intubation.

BACKGROUND: Neonatal endotracheal intubation often involves more than one attempt, and oxygen desaturation is common. It is unclear whether nasal high-flow therapy, which extends the time to desaturation during elective intubation in children and adults receiving general anesthesia, can improve the likelihood of successful neonatal intubation on the first attempt. METHODS: We performed a randomized, controlled trial to compare nasal high-flow therapy with standard care (no nasal high-flow therapy or supplemental oxygen) in neonates undergoing oral endotracheal intubation at two Australian tertiary neonatal intensive care units. Randomization of intubations to the high-flow group or the standard-care group was stratified according to trial center, the use of premedication for intubation (yes or no), and postmenstrual age of the infant (≤28 or >28 weeks). The primary outcome was successful intubation on the first attempt without physiological instability (defined as an absolute decrease in the peripheral oxygen saturation of >20% from the preintubation baseline level or bradycardia with a heart rate of <100 beats per minute) in the infant. RESULTS: The primary intention-to-treat analysis included the outcomes of 251 intubations in 202 infants; 124 intubations were assigned to the high-flow group and 127 to the standard-care group. The infants had a median postmenstrual age of 27.9 weeks and a median weight of 920 g at the time of intubation. A successful intubation on the first attempt without physiological instability was achieved in 62 of 124 intubations (50.0%) in the high-flow group and in 40 of 127 intubations (31.5%) in the standard-care group (adjusted risk difference, 17.6 percentage points; 95% confidence interval [CI], 6.0 to 29.2), for a number needed to treat of 6 (95% CI, 4 to 17) for 1 infant to benefit. Successful intubation on the first attempt regardless of physiological stability was accomplished in 68.5% of the intubations in the high-flow group and in 54.3% of the intubations in the standard-care group (adjusted risk difference, 15.8 percentage points; 95% CI, 4.3 to 27.3). CONCLUSIONS: Among infants undergoing endotracheal intubation at two Australian tertiary neonatal intensive care units, nasal high-flow therapy during the procedure improved the likelihood of successful intubation on the first attempt without physiological instability in the infant. (Funded by the National Health and Medical Research Council; Australian New Zealand Clinical Trials Registry number, ACTRN12618001498280.).

Prevention of infant eczema by neonatal Bacillus Calmette-Guérin vaccination: The MIS BAIR randomized controlled trial.

BACKGROUND: Bacille Calmette-Guérin (BCG) vaccine could play a role in counteracting the rising prevalence of atopic diseases, through its beneficial off-target effects. We aimed to determine whether neonatal BCG vaccination reduces the incidence of eczema in infants. METHODS: Randomized controlled trial with 1272 infants allocated to receive BCG-Denmark or no BCG at birth. The primary outcome was the 12-month incidence of eczema based on 3-monthly questionnaires. Eczema was also assessed at a 12-month clinic visit. ClinicalTrial.gov: NCT01906853. RESULTS: The 12-month eczema incidence was 32.2% in the BCG group compared with 36.6% in the control group (adjusted risk difference (aRD) -4.3%, 95% CI -9.9% to 1.3%, multiple imputation model). In addition, comparing infants in the BCG group with the control group, 15.7% vs. 19.2% had eczema lesions at the 12-month visit (aRD -3.5%, 95% CI -8.0% to 1.0%); 35.7% vs. 39.0% reported using topical steroids (aRD -3.3, 95% CI -9.2 to 2.7); and 7.3% vs. 10.2% had severe eczema scores (aRD -3.0%, 95% CI -8.8% to 2.7%). In 344 high-risk infants (two atopic parents), the 12-month eczema incidence was 35.3% in the BCG group compared with 46.8% in the control group (aRD -11.5%, 95% CI -21.9% to -1.2%; number needed to treat 8.7, 95% CI 4.6 to 83.3). CONCLUSION: There is insufficient evidence to recommend neonatal BCG vaccination in all infants for the prevention of eczema in the first year of life; however, a modest beneficial effect was observed among high-risk infants. A single dose of BCG-Denmark soon after birth could reduce the incidence of eczema in infants with two atopic parents.

Refining diagnostic criteria for paediatric bronchiectasis using low-dose CT scan.

BACKGROUND: There is a current lack of consensus amongst paediatric radiologists and respiratory paediatricians as to the correct CT definition of bronchiectasis in children. Using contemporary low-dose CT, our objectives were to determine the upper limit of normal for broncho-arterial ratio (BAR) in children and to evaluate the effect of age and general anaesthesia. METHODS: Measurements of 330 broncho-arterial ratios from 51 children (0-19 years) undergoing low-dose CT chest for non-respiratory indications were performed by 3 blinded observers (two radiologists, one respiratory physician) using four different methods. Inter-observer reliability, mean BAR and reference ranges (mean±2SD) were calculated. Correlation between age and BARs were examined. Mean BAR for CT under general anaesthesia and CT awake were compared. RESULTS: Inter-observer correlation was extremely high for all measurements (0.93-0.97). There was a weak positive correlation between age and BAR in the CT-awake group (r = 0.33, 95%CI: 0.03-0.57; p = 0.031) using the inner-bronchial wall to artery, short-axis measurement. CT under general anaesthesia showed significantly higher BAR compared to CT-awake [mean difference 0.13 (95%CI: 0.05-0.22; p = 0.004)]. For the CT-awake group, the mean BAR was 0.65 (range: 0.42 to 0.89), with no child having a BAR above 0.9. CONCLUSION: Using a standardised approach, we have shown that a broncho-arterial ratio above 0.9 in children undergoing awake CT is abnormal and suggests airway widening or radiological bronchiectasis. Children undergoing CT under anaesthesia have higher BARs than those undergoing awake CT. A weak positive correlation between broncho-arterial ratio and age was observed, hence, age-adjusted cut-offs for BAR warrant further study.

Promoting proactive bystander responses to racism and racial discrimination in primary schools: a mixed methods evaluation of the 'Speak Out Against Racism' program pilot.

BACKGROUND: Racism and racial discrimination are fundamental causes and determinants of health and health inequalities globally, with children and adolescents particularly vulnerable. Racial discrimination is a common stressor in the lives of many children and adolescents, with growing evidence of negative associations between racial discrimination and multiple domains of child and adolescent health. Addressing racism and racial discrimination must be core public health priorities, even more so among children and young people. Schools are key settings in the lives of children and adolescents and become increasingly more important to identity formation. School communities, teachers and peers greatly influence children and adolescents' beliefs about race and difference. Schools are therefore key sites for the delivery of population-based programs to reduce racism and promote proactive bystander behaviour and healthy resistance to racism among all children and adolescents as well as among the adults. METHODS: This study examines the feasibility and acceptability of the 'Speak Out Against Racism (SOAR)' program, a whole of school, multi-level, multi-strategy program that aimed to promote effective bystander responses to racism and racial discrimination in primary schools. A mixed-methods, quasi-experimental design was used. Students in Years 5 and 6 (10-12 years) across six schools completed surveys pre- and post- intervention (N = 645; 52% female; 6% Indigenous, 10% Middle Eastern, African, Latinx or Pacific Islander, 21% Asian, 52% Anglo/European). Focus groups with students and interviews with staff collected qualitative data about their experiences of the program and their views about the program's perceived need, implementation, impacts and suggested improvements. RESULTS: Quantitative data showed student prosocial skills and teacher inter-racial climate improved in intervention schools compared to comparison schools. Qualitative data highlighted teacher attitudinal and behaviour change regarding racism, and student reduced interpersonal racial discrimination, improved peer prosocial norms, commitment to anti-racism, knowledge of proactive bystander responses and confidence and self-efficacy to intervene to address racism. CONCLUSIONS: This study provides quantitative evidence of the potential of the SOAR program to improve the prosocial skills of students and their perceptions of the inter-racial school climate provided by their teachers. This program also provided qualitative evidence of the potential to promote teacher and student attitudinal and behavioural change. Further refinement and testing of the program in a large scale implementation trial is recommended.

Neonatal Bacille Calmette-Guérin Vaccination and Infections in the First Year of Life: The MIS BAIR Randomized Controlled Trial.

BACKGROUND: Bacille Calmette-Guérin (BCG) vaccination has beneficial off-target effects that may include protecting against non-mycobacterial infectious diseases. We aimed to determine whether neonatal BCG vaccination reduces lower respiratory tract infections (LRTI) in infants in the Melbourne Infant Study: BCG for Allergy and Infection Reduction (MIS BAIR) trial. METHODS: In this investigator-blinded trial, neonates in Australia were randomized to receive BCG-Denmark vaccination or no BCG at birth. Episodes of LRTI were determined by symptoms reported in parent-completed, 3-month questionnaires over the first year of life. Data were analyzed by intention-to-treat using binary regression. RESULTS: A total of 1272 neonates were randomized to the BCG vaccination (n = 637) or control (n = 635) group. The proportion of participants with an episode of LRTI in the first year of life among BCG-vaccinated infants was 54.8% compared to 58.0% in the control group, resulting in a risk difference of -3.2 (95% confidence interval, -9.0 to 2.6) after multiple imputation. There was no interaction observed between the primary outcome and sex, maternal BCG, or the other prespecified effect modifiers. CONCLUSIONS: Based on the findings of this trial, there is insufficient evidence to support the use of neonatal BCG vaccination to prevent LRTI in the first year of life in high-income settings.

Matching action to need: an analysis of Global Burden of Disease 2017 and population health data to focus adolescent health policy and actions in Myanmar.

Background: Myanmar is a country undergoing rapid transitions in health. Its national strategic policy for young people's health is being revised but there is a paucity of population data to inform local priorities and needs. Objective: In this paper we describe a comprehensive profile of adolescent health in Myanmar to focus policy and health actions. Methods: We used available primary data, and modelled estimates from the GBD 2017, to describe health outcomes (mortality and morbidity), health risks and determinants for adolescents in Myanmar between 1990-2017. A governance group of key stakeholders guided the framing of the study, interpretation of findings, and recommendations. Results: Overall health has improved for adolescents in Myanmar since 1990, however adolescent mortality remains high, particularly so for older adolescent males; all-cause mortality rate for 10-24 years was 70 per 100,000 for females and 149 per 100,000 for males (16,095 adolescent deaths in 2017). Overall, the dominant health problems were injuries for males and non-communicable disease for females in a context of ongoing burden of communicable and nutritional diseases for both sexes, and reproductive health needs for females. Health risks relating to undernutrition (thinness and anaemia) remain prevalent, with other health risks (overweight, binge alcohol use, and substance use) relatively low by global and regional standards but increasing. Gains have been made in social determinants such as adolescent fertility and modern contraception use; however, advances have been more limited in secondary education completion and engagement in employment and post education training. Conclusions: These results highlight the need to focus current efforts on addressing disease and mortality experienced by adolescents in Myanmar, with a specific focus on injury, mental health and non-communicable disease.

Sleep problems and solution seeking for children with cerebral palsy and their parents.

AIM: Sleep problems are common in school-aged children with cerebral palsy (CP). Despite the significant impact of sleep disturbance and deprivation, there is a paucity of research in the area. The aims of this study were to (i) investigate the frequency of sleep problems in children with CP and their parents and (ii) understand what happens when parents ask for help with sleep problems from their health-care professionals. METHODS: This was a prospective cohort study using an online survey sent to parents/primary care givers of children with CP aged 6-12 years recruited through the Victorian Cerebral Palsy Register. The following sleep assessment tools: The Children's Sleep Habits Questionnaire, the Pittsburgh Sleep Quality Index and the Gross Motor Function Classification System Parent Rating Tool were administered along with custom-designed questions that were informed by a preceding qualitative scoping study. RESULTS: Complete data sets were received from 126 parents/care givers. Almost half (46%) of the parents reported their child had sleep problems. Of the 64 parents who reported seeking help for a child's sleep problem, only 21 indicated that their attempt was successful. If a child had poor sleep, the parent was more likely to have a sleep problem than parents who did not report poor child sleeping. CONCLUSION: Sleep problems are common in children with CP and their parents. Parents do not always seek help, and those who do may not find an effective solution. Future research should explore how sleep problems can be effectively prioritised for children with CP and their parents/care givers.

Australian lessons for developing and testing a culturally inclusive health promotion campaign.

The purpose of the study was to develop and test culturally appropriate health promotion materials that were seen to be socially inclusive in regard to blood donation within the Australian-African community. Materials were produced in multiple languages (English, Arabic, Swahili and Kirundi) and were initially developed based on previous pilot data, with feedback from the project partner (Australian Red Cross Blood Service) and the African community. Seven formative focus groups with 62 participants were then conducted to ensure the materials would be effective, credible and culturally acceptable to the target audience, including preferred messages, taglines and images. The response confirmed that quotes and images from community members (as opposed to actors) were critical to ensure messages were engaging and believable, and had meaningful taglines that were perceived to be authentic. The refined materials were then used in a community intervention study. The evaluation included an assessment of respondents' views of the messages post-intervention. Of the 281 African migrants who saw the campaign materials during the intervention period, the majority (75.8%) strongly agreed that the materials made them feel part of the wider Australian community. These results suggest that engagement in developmental activities with targeted communities is important for creating positively viewed culturally targeted public health campaigns. A six-step process is suggested that could be used by other organizations to ensure that messages are acceptable to targeted migrant communities.

Cause-specific neonatal morbidity and mortality in the Solomon Islands: An assessment of data from four hospitals over a three-year period.

AIM: Data on stillbirths and neonatal morbidity and mortality in low-middle income Pacific Island Nations such as Solomon Islands is limited, partly due to weak health information systems. We describe the perinatal mortality and clinical factors associated with poor newborn outcomes at four hospitals in Solomon Islands. METHODS: This was a registry based retrospective cohort study at three provincial hospitals and the National Referral Hospital (NRH) from 2014-2016 inclusive. RESULTS: 23 966 labour ward births and 3148 special care nursery (SCN) admissions were reviewed. Overall still birth rate was 29.2/1000 births and the perinatal mortality rate was 35.9/1000 births. PNMR were higher in provincial hospitals (46.2, 44.0 and 34.3/1000) than at NRH (33.3/1000). The commonest reasons for admission to SCN across the hospitals were sepsis, complications of prematurity and birth asphyxia. SCN mortality rates were higher in the 3 provincial hospitals than at NRH (15.9% (95/598) vs. 7.9% (202/2550), P value <0.01). At NRH, the conditions with the highest case fatality rates were birth asphyxia (21.3%), congenital abnormalities (17.7%), and prematurity (15.1%). Up to 11% of neonates did not have a diagnosis recorded. CONCLUSIONS: The perinatal mortality rates are high and intrapartum complications, prematurity and sepsis are the main causes of morbidity and mortality for neonates at hospitals in Solomon Islands. Stillbirths account for 81% of perinatal deaths. These results are useful for planning for quality improvement at provincial level. Improved vital registration systems are required to better capture stillbirths and neonatal outcomes.

The age of paediatrics.

The epidemiological transition towards non-communicable diseases is characterised by an upward shift in age of disease burden across the lifecourse. One response, within a suite of wider actions, would be to extend the upper age limit of paediatric practice to embrace adolescent health. We did an online survey to explore the upper age limit of paediatric care, obtaining responses from 1372 paediatricians in 115 countries. Marked variation in the upper age limit was apparent. Among high-income countries, a higher upper age limit was associated with greater disease burden in adolescents relative to young children (<5 years). Although paediatricians reported the mean upper age limit of paediatrics had risen over the past 20 years, the mean preferred age of 18·7 (SD 2·6) years was higher than the mean current age of 17·4 (SD 2·5) years (p<0·0001). Paediatricians reported the main reasons for the rising age over time was their greater awareness of adolescent health and leadership by professional associations. Reports of the quality of adolescent health education within national paediatric training suggest that this education is largely inadequate. A greater focus on adolescent health is required within paediatrics to ensure that the future paediatric workforce is appropriately equipped to respond to the changing disease burden across childhood and adolescence.

Interventions to Increase Blood Donation among Ethnic/Racial Minorities: A Systematic Review.

Ethnic/racial minorities are under-represented in blood donor populations in most developed countries. This is of particular concern where minorities differ from a country's majority population in terms of blood or tissue typing, especially where type matching is required for effective management of rare disorders such as sickle-cell disease that require multiple transfusions. This systematic review assessed the effectiveness of interventions to increase blood donation among ethnic/racial minority populations in developed countries. We searched MEDLINE, EMBASE, CINAHL, and ProQuest on 20 March 2017 with no date restrictions and supplemented this with searches on Google Scholar, blood collection agency websites, reference lists of included studies, and a forward search of citations of included studies. We included intervention studies designed to increase recruitment and/or retention of adult, ethnic/racial minority blood donors in developed countries. The review identified eight studies reported in nine publications. Six were conducted in the USA with African Americans. Four studies reported on multifaceted, community-based interventions; three reported on one-off information and educational video interventions, presented face-to-face, or delivered via post or e-mail. The level of evidence for efficacy was low, and the majority of studies were assessed as having some risk of bias related to one or more methodological issues. All eight studies reported positive outcomes in blood donation and/or intention to donate. Seven trials found that the intervention increased presentation for donation, and three found an increase in the percentage of new donors from the ethnic minority targeted. The review findings demonstrate that it is possible to design and implement effective interventions to motivate individuals from ethnic/racial minority groups to donate blood. One-off interventions may be as effective as multifaceted, community-based interventions. There was insufficient evidence to recommend particular interventions, and future research should empirically assess alternative interventions using robust study designs.

Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial.

BACKGROUND: Phenytoin is the current standard of care for second-line treatment of paediatric convulsive status epilepticus after failure of first-line benzodiazepines, but is only effective in 60% of cases and is associated with considerable adverse effects. A newer anticonvulsant, levetiracetam, can be given more quickly, is potentially more efficacious, and has a more tolerable adverse effect profile. We aimed to determine whether phenytoin or levetiracetam is the superior second-line treatment for paediatric convulsive status epilepticus. METHODS: ConSEPT was an open-label, multicentre, randomised controlled trial conducted in 13 emergency departments in Australia and New Zealand. Children aged between 3 months and 16 years, with convulsive status epilepticus that failed first-line benzodiazepine treatment, were randomly assigned (1:1) using a computer-generated permuted block (block sizes 2 and 4) randomisation sequence, stratified by site and age (≤5 years, >5 years), to receive 20 mg/kg phenytoin (intravenous or intraosseous infusion over 20 min) or 40 mg/kg levetiracetam (intravenous or intraosseous infusion over 5 min). The primary outcome was clinical cessation of seizure activity 5 min after the completion of infusion of the study drug. Analysis was by intention to treat. This trial is registered with the Australian and New Zealand Clinical Trials Registry, number ACTRN12615000129583. FINDINGS: Between March 19, 2015, and Nov 29, 2017, 639 children presented to participating emergency departments with convulsive status epilepticus; 127 were missed, and 278 did not meet eligibility criteria. The parents of one child declined to give consent, leaving 233 children (114 assigned to phenytoin and 119 assigned to levetiracetam) in the intention-to-treat population. Clinical cessation of seizure activity 5 min after completion of infusion of study drug occurred in 68 (60%) patients in the phenytoin group and 60 (50%) patients in the levetiracetam group (risk difference -9·2% [95% CI -21·9 to 3·5]; p=0·16). One participant in the phenytoin group died at 27 days because of haemorrhagic encephalitis; this death was not thought to be due to the study drug. There were no other serious adverse events. INTERPRETATION: Levetiracetam is not superior to phenytoin for second-line management of paediatric convulsive status epilepticus. FUNDING: Health Research Council of New Zealand, A+ Trust, Emergency Medicine Foundation, Townsville Hospital Private Practice Fund, Eric Ormond Baker Charitable Fund, and Princess Margaret Hospital Foundation.

Progress in adolescent health and wellbeing: tracking 12 headline indicators for 195 countries and territories, 1990-2016.

BACKGROUND: Rapid demographic, epidemiological, and nutritional transitons have brought a pressing need to track progress in adolescent health. Here, we present country-level estimates of 12 headline indicators from the Lancet Commission on adolescent health and wellbeing, from 1990 to 2016. METHODS: Indicators included those of health outcomes (disability-adjusted life-years [DALYs] due to communicable, maternal, and nutritional diseases; injuries; and non-communicable diseases); health risks (tobacco smoking, binge drinking, overweight, and anaemia); and social determinants of health (adolescent fertility; completion of secondary education; not in education, employment, or training [NEET]; child marriage; and demand for contraception satisfied with modern methods). We drew data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016, International Labour Organisation, household surveys, and the Barro-Lee education dataset. FINDINGS: From 1990 to 2016, remarkable shifts in adolescent health occurred. A decrease in disease burden in many countries has been offset by population growth in countries with the poorest adolescent health profiles. Compared with 1990, an additional 250 million adolescents were living in multi-burden countries in 2016, where they face a heavy and complex burden of disease. The rapidity of nutritional transition is evident from the 324·1 million (18%) of 1·8 billion adolescents globally who were overweight or obese in 2016, an increase of 176·9 million compared with 1990, and the 430·7 million (24%) who had anaemia in 2016, an increase of 74·2 million compared with 1990. Child marriage remains common, with an estimated 66 million women aged 20-24 years married before age 18 years. Although gender-parity in secondary school completion exists globally, prevalence of NEET remains high for young women in multi-burden countries, suggesting few opportunities to enter the workforce in these settings. INTERPRETATION: Although disease burden has fallen in many settings, demographic shifts have heightened global inequalities. Global disease burden has changed little since 1990 and the prevalence of many adolescent health risks have increased. Health, education, and legal systems have not kept pace with shifting adolescent needs and demographic changes. Gender inequity remains a powerful driver of poor adolescent health in many countries. FUNDING: Australian National Health and Medical Research Council, and the Bill & Melinda Gates Foundation.

An audit of the dietary intake of Australian children with type 1 diabetes.

To understand what children with type 1 diabetes in a representative tertiary hospital clinic are eating compared to their peers and explore dietary intake impact on HbA1c outcome. An open cross-sectional dietary audit of children and adolescents with diabetes aged 2-17 years attending the Royal Children's Hospital, Melbourne was conducted using an age-appropriate validated Food Frequency Questionnaire. Total energy, macronutrient intake and diet quality were calculated and compared to dietary advice provided and national intake data. Body weight, and dietary intake influences on glycaemic control were investigated. Overall, 785 patients were recruited, from which 429 dietary surveys were completed. Dietary intakes were overall nutritionally adequate with macronutrient distribution (% total energy intake) being lower carbohydrate (48.6%), higher total sugars (22.4%), fat (32.9%), saturated fat (14.9%) and protein intake (19.1%) than recommendations, but similar to their peers. Energy intakes were excessive compared to their peers in the 4-13 year olds. Rates of overweight (30%) were significantly higher than national data (18%). Overall, 43% achieved optimal glycaemic control (HbA1c < 7.5%; <58 mmol/mol). HbA1c prediction via linear regression indicated that the following factors were associated with lower HbA1c values: being male, on pump regimen, lower rates of insulin per kg, shorter duration of disease. This audit has identified areas requiring targeted education/support to improve health outcomes including dietary adherence, rates of overweight/obesity, appropriate energy intakes and optimal glycaemic targets. Furthermore, it provides baseline data to evaluate efficacy of future interventions.