Legal capacity, developmental capacity, and impaired mental capacity in children under 16: Neurodevelopment and the law in Northern Ireland.

When people of any age, despite all possible support being provided, are unable to make a necessary decision, then it is important to have a legal framework which promotes and protects their rights. There is ongoing debate about how this can be achieved, in a non-discriminatory way, for adults but it is also an important consideration for children and young people. In Northern Ireland, the Mental Capacity Act (Northern Ireland) 2016, when fully implemented will provide a non-discriminatory framework for those aged 16 and over. Arguably this addresses discrimination based on disability but continues to discriminate based on age. This article explores some of the possible ways the rights of those aged under 16 could be further promoted and protected. These approaches may include: retaining the current combination of statute law but developing new guidance to inform practice for those aged under 16; codifying Gillick to clarify under what circumstances those aged under 16 can accept, and possibly also refuse, interventions; amend the Children (Northern Ireland) Order 1995 to provide a more comprehensive framework for health and welfare decision making; amend and extend the Mental Capacity Act (Northern Ireland) 2016 to apply to those aged under 16; or develop a new law specifically focused on the emerging capacity of those aged under 16. There are complex issues involved including how to consider emerging or developmental decision-making ability, and the role of those with parental responsibility, but the complexities involved should not prevent these issues being addressed.

Harmonizing allergy care-integrated care pathways and multidisciplinary approaches.

There is a wide time gap between the publication of evidence and the application of new knowledge into routine clinical practice. The consequence is sub-optimal outcomes, particularly concerning for long-term relapsing/remitting conditions such as allergic diseases. In response, there has been a proliferation of published guidelines which systematically review evidence for the gold-standard management of most allergic disorders. However, this has not necessarily been followed by improved outcomes, partly due to a lack of coordination across the patient pathway. This has become known as the "second translational gap". A proposed solution is the development and implementation of integrated care pathways (ICPs) to optimize patient outcomes, with the notion that evidence-based medicine requires evidence-based implementation. ICP implementation is shown to improve short-term outcomes for acute conditions and routine surgery, including reduced length of hospital stay, improved documentation and improved patient safety. However, this improvement is not reflected in patient experience or patient-centered functional outcomes. The implementation of life-long, cost-effective interventions within comprehensive pathways requires a deep appreciation for complexity within allergy care. We promote an evidence-based methodology for the implementation of ICPs for allergic disorders in which all stakeholders in allergy care are positioned equally and encouraged to contribute, particularly patients and their caregivers. This evidence-based process commences with scoping the unmet needs, followed by stakeholder mapping. All stakeholders are invited to meetings to develop a common vision and mission through the generation of action/effect diagrams which helps build concordance across the agencies. Dividing the interventions into achievable steps and reviewing with plan/do/study/act cycles will gradually modify the pathway to achieve the best outcomes. While the management guidelines provide the core knowledge, the key component of implementation involves education, training, and support of all healthcare professionals (HCPs), patients and their caregivers. The pathways should define the level of competence required for each clinical task. It may be useful to leave the setting of care delivery or the specific HCP involved undefined to account for variable patterns of health service delivery as well as local socioeconomic, ethnic, environmental, and political imperatives. In all cases, where competence is exceeded, it is necessary to refer to the next stage in the pathway. The success and sustainability of ICPs would ideally be judged by patient experience, health outcomes, and health economics. We provide examples of successful programs, most notably from Finland, but recommend that further research is required in diverse settings to optimize outcomes worldwide.

Allergy education and training for physicians.

The increasing prevalence of allergic diseases has placed a significant burden on global healthcare and society as whole. This has necessitated a rapid development of "allergy" as a specialist area. However, as allergy is so common and, for most, relatively easy to diagnose and control, all clinicians need to have basic knowledge and competence  to manage  mild disease and recognize when referral is required. The allergology specialty has not yet been recognized in many countries and even where allergy is fully recognized as a specialty, the approach to training in allergy differs significantly. In the light of recent developments in allergy diagnosis and management, there is an urgent need to harmonize core competences for physicians, as well as the standardization of core principles for medical education and post-graduate training in allergy. All physicians and allied health professionals must appreciate the multidisciplinary team (MDT) approach to allergy, which is key to achieving the highest standards in holistic care. Due to worldwide variation in resources and personnel, some MDT roles will need to be absorbed by the treating physician or other healthcare professionals. We draw particular attention to the role of psychological input for all allergy patients, dietetic input in the case of food allergy and patient education to support all patients in the supported self-management of their condition on a daily basis. A strong appreciation of these multidisciplinary aspects will help physicians provide quality patient-centered care. We consider that harmonization of allergy components within undergraduate curricula is crucial to ensure all physicians develop the appropriate allergy-related knowledge and skills, particularly in light of inconsistencies seen in the primary care management of allergy. This review from the World Allergy Organization (WAO) Education and Training Committee also outlines allergy-related competences required of physicians working with allergic patients and provides recommendations to promote harmonization of allergy training and practice worldwide.

Reviewing the evidence on breast milk composition and immunological outcomes.

A large number of biologically active components have been found in human milk (HM), and in both human and animal models, studies have provided some evidence suggesting that HM composition can be altered by maternal exposures, subsequently influencing health outcomes for the breastfed child. Evidence varies from the research studies on whether breastfeeding protects the offspring from noncommunicable diseases, including those associated with immunological dysfunction. It has been hypothesized that the conflicting evidence results from HM composition variations, which contain many immune active molecules, oligosaccharides, lactoferrin, and lysozyme in differing concentrations, along with a diverse microbiome. Determining the components that influence infant health outcomes in terms of both short- and long-term sequelae is complicated by a lack of understanding of the environmental factors that modify HM constituents and thereby offspring outcomes. Variations in HM immune and microbial composition (and the differing infantile responses) may in part explain the controversies that are evidenced in studies that aim to evaluate the prevalence of allergy by prolonged and exclusive breastfeeding. HM is a "mixture" of immune active factors, oligosaccharides, and microbes, which all may influence early immunological outcomes. This comprehensive review provides an in-depth overview of existing evidence on the studied relationships between maternal exposures, HM composition, vaccine responses, and immunological outcomes.

Growth and Persistence of Place-Based Mortality in the United States: The Rural Mortality Penalty.

OBJECTIVES: To examine 47 years of US urban and rural mortality trends at the county level, controlling for effects of education, income, poverty, and race. METHODS: We obtained (1) Centers for Disease Control and Prevention WONDER (Wide-ranging ONline Data for Epidemiologic Research) data (1970-2016) on 104 million deaths; (2) US Census data on education, poverty, and race; and (3) Bureau of Economic Analysis data on income. We calculated ordinary least square regression models, including interaction models, for each year. We graphed standardized parameter estimates for 47 years. RESULTS: Rural-urban mortality disparities increased from the mid-1980s through 2016. We found education, race, and rurality to be strong predictors; we found strong interactions between percentage poverty and percentage rural, indicating that the largest penalty was in high-poverty, rural counties. CONCLUSIONS: The rural-urban mortality disparity was persistent, growing, and large when compared to other place-based disparities. The penalty had evolved into a high-poverty, rural penalty that rivaled the effects of education and exceeded the effects of race by 2016. Public Health Implications. Targeting public health programs that focus on high-poverty, rural locales is a promising strategy for addressing disparities in mortality.

Anxiety and stress in mothers of food-allergic children.

BACKGROUND: Previous reports suggest that parents especially mothers of food-allergic children may have increased anxiety. Studies with an appropriate control group have not been undertaken, and the determinants of such anxiety are not known. We compared measures of anxiety and stress in mothers of food-allergic children and atopic non-food-allergic children, with anxiety and stress in mothers of children with no chronic illness. METHODS: Cross-sectional study of mothers attending a hospital appointment for their 8- to 16-year-old child. Mothers of children with food allergy, asthma but no food allergy or no chronic illness completed questionnaires including State-Trait Anxiety Inventory, Perceived Stress Scale and measures of anxiety and psychologic adjustment in their child. RESULTS: Forty mothers of food-allergic children, 18 mothers of asthmatic children without food allergy and 38 mothers of children with no chronic illness (controls) were recruited. Mothers of food-allergic children showed increased state anxiety ­ median anxiety score 38.0 (IQR 30.0, 44.0) food allergy, 27.0 (22.0, 40.0) control p = 0.012; and increased stress ­ median stress score 18.5 (12.0, 22.0) food allergy, 14.0 (7.5, 19.5)control p = 0.035. No significant differences were seen between mothers in the asthmatic group and controls. In multivariate analysis, previous food anaphylaxis(p = 0.008) and poorly controlled asthma (p = 0.004) were associated with increased maternal anxiety. Child anxiety and adjustment did not differ between food-allergic and control groups. CONCLUSIONS: Mothers of food-allergic children have increased anxiety and stress compared with mothers of children with no chronic illness. Anaphylaxis and poorly controlled asthma are associated with maternal anxiety.

Anxiety and stress in mothers of food-allergic children.

BACKGROUND: Previous reports suggest that parents especially mothers of food-allergic children may have increased anxiety. Studies with an appropriate control group have not been undertaken, and the determinants of such anxiety are not known. We compared measures of anxiety and stress in mothers of food-allergic children and atopic non-food-allergic children, with anxiety and stress in mothers of children with no chronic illness. METHODS: Cross-sectional study of mothers attending a hospital appointment for their 8- to 16-year-old child. Mothers of children with food allergy, asthma but no food allergy or no chronic illness completed questionnaires including State-Trait Anxiety Inventory, Perceived Stress Scale and measures of anxiety and psychologic adjustment in their child. RESULTS: Forty mothers of food-allergic children, 18 mothers of asthmatic children without food allergy and 38 mothers of children with no chronic illness (controls) were recruited. Mothers of food-allergic children showed increased state anxiety - median anxiety score 38.0 (IQR 30.0, 44.0) food allergy, 27.0 (22.0, 40.0) control p = 0.012; and increased stress - median stress score 18.5 (12.0, 22.0) food allergy, 14.0 (7.5, 19.5) control p = 0.035. No significant differences were seen between mothers in the asthmatic group and controls. In multivariate analysis, previous food anaphylaxis (p = 0.008) and poorly controlled asthma (p = 0.004) were associated with increased maternal anxiety. Child anxiety and adjustment did not differ between food-allergic and control groups. CONCLUSIONS: Mothers of food-allergic children have increased anxiety and stress compared with mothers of children with no chronic illness. Anaphylaxis and poorly controlled asthma are associated with maternal anxiety.

Use of paid child care health care consultants in early care and education settings: results of a national study comparing provision of health screening services among Head Start and non-Head Start centers.

INTRODUCTION: Child care health consultants (CCHCs) are health professionals who provide consultation and referral services to child care programs. The use of CCHCs has been recommended as an important component of high-quality child care. The purpose of this study was to examine the potential association between the use of paid CCHCs and child care center director reports of (a) center maintenance of health records and emergency procedures and (b) center facilitation of health screenings and assessments. METHOD: A national, randomized telephone survey of directors of 1822 licensed child care center directors was conducted. RESULTS: With a response rate of 93%, most directors (72.7%) reported that they did not employ a CCHC. However, directors employing CCHCs were more likely to report provision of health-promoting screenings and assessments for children in their center. This pattern held true for both Head Start and non-Head Start centers. DISCUSSION: This study suggests that CCHCs can serve as health promotion advocates in early care and education settings, helping centers establish appropriate policies and arranging for health assessments and screenings for children.

Oral health of young children in Mississippi Delta child care centers: a second look at early childhood caries risk assessment.

OBJECTIVES: To identify the predictors of early childhood caries and urgent dental treatment need among primarily African-American children in child care centers in the Delta region of Mississippi. The purpose of this study was to replicate predictors of caries and urgent dental treatment needs that were identified in an earlier study conducted in Delta child care centers and to assess additional caries risk factors not collected in the original study. METHODS: Children in 19 child care centers were examined by the dentists, and the parents provided data on oral health practices, oral health history, and on children's oral health-related quality of life (QOL). The dentists also assessed visible plaque and tested levels of mutans streptococci. Predictors of caries and treatment need among children 24 to 71 months of age were examined using logistic regression. RESULTS: Two parent predictors of caries identified in the earlier study (parent flossing and soft/sugary drink consumption) were not predictive in the current study. Parent history of abscess continued to predict their child's urgent need for treatment. Young children's level of salivary mutans streptococci, maxillary incisor visible plaque, and parents' reports of child oral health-related QOL measures predicted the presence of both caries and urgent treatment need. Some expected predictors, such as frequency of child's toothbrushing, were not predictive of caries. CONCLUSIONS: Parental abscess and parent's report of the child's oral health-related OOL are risk indicators for poor oral health outcomes that could be used by nondental personnel to identify young children in need of early preventive intervention and dental referral

Oral health status of mississippi delta 3- to 5-year-olds in child care: an exploratory study of dental health status and risk factors for dental disease and treatment needs.

OBJECTIVES: For poor and minority young children, disparities exist in dental health and treatment. In rural impoverished areas, institutions that reach young children and potentially offer access to care are limited. In the current Mississippi Delta study, child care centers were examined as potential venues for oral health intervention and research, and potential risk factors for dental caries and treatment urgency in high-risk preschool children were explored. METHODS: Child care centers were selected and attending children recruited. Data on oral health practices were collected from surveys of center directors and parents/caregivers. Children were examined for caries and treatment urgency at centers by dentists. Bivariate and multivariate analyses with a 0. 05 alpha were used to examine data. RESULTS: A total of 346 preschool children at 15 participating centers were examined: 46% were female, 68% minority. Minority children and those with public insurance were more than twice as likely to have caries and urgent treatment needs as non-minorities or those with private insurance. The odds of children having caries were half as great if parents reported using floss and nearly twice as great if the parent had experienced a dental abscess. For every soft drink the parent consumed daily, the odds of dental caries for children increased by 44%. CONCLUSIONS: Conducting oral health exams and research in child care venues was possible, yet presented challenges. The combined use of two parental variables, reported soft drink consumption and abscess history, appears promising for caries prediction. Implementation of oral health programs and research in child care venues merits further exploration.