Intravenous opioids for chemotherapy-induced severe mucositis pain in children: Systematic review and single-center case series of management with patient- or nurse-controlled analgesia (PCA/NCA).

BACKGROUND: Chemotherapy-induced oral mucositis can result in severe pain. Intravenous (IV) opioids are recommended, but management protocols vary. We systematically reviewed studies reporting IV opioid use for pain related to chemotherapy-induced severe oral mucositis in children and conducted a large single-center case series. METHODS: Ovid MEDLINE, PubMed, and Cochrane databases were searched for studies reporting IV opioid duration and/or dose requirements for severe mucositis. Secondly, our pain service database was interrogated to describe episodes of opioid administration by patient- or nurse-controlled analgesia (PCA/NCA) for children with mucositis and cancer treatment-related pain. RESULTS: Seventeen studies (six randomized trials, two prospective observational, three retrospective cohort, six retrospective case series) included IV opioid in 618 patients (age 0.3-22.3 years), but reported parameters varied. Mucositis severity and chemotherapy indication influenced IV opioid requirements, with duration ranging from 3 to 68 days and variable dose trajectories (hourly morphine or equivalent 0-97 mcg/kg/h). Our 7-year series included PCA/NCA for 364 episodes of severe mucositis (302 patients; age 0.12-17.2 years). Duration ranged from 1 to 107 days and dose requirements in the first 3 days from 1 to 110 mcg/kg/h morphine. Longer PCA/NCA duration was associated with: higher initial morphine requirements (ρ = 0.46 [95% CI 0.35, 0.57]); subsequent increased pain and need for ketamine co-analgesia (118/364 episodes with opioid/ketamine 13.9 [9.8-22.2] days vs opioid alone 6.0 [3.9-10.8] days; median [IQR]); but not with age or sex. CONCLUSIONS: Management of severe mucositis pain can require prolonged IV opioid therapy. Individual and treatment-related variability in analgesic requirements highlight the need for regular review, titration, and management by specialist services.

Evolving pediatric epidural practice: An institution's clinical experience over 20 years-A retrospective observational cohort study.

BACKGROUND AND OBJECTIVES: Epidural analgesia is an effective, established perioperative intervention in all age-groups. In children, however, epidural-related data are limited compared to the adult population. The aim of this study was to examine the use of pediatric epidural analgesia in our institution and, thereby, add to the existing data pool. METHODOLOGY: Patients who received epidural analgesia as part of their perioperative management between 1996 and 2016 at Great Ormond Street Hospital, London, UK, were studied to determine how epidural practice has changed over time, associated incidence of serious adverse events, complications, and patient/parent satisfaction. Epidural use and monitoring were in accordance with standard hospital protocols. Data were prospectively collected and entered into a secure database by trained personnel. These data were subsequently extracted for retrospective analysis. RESULTS: A total of 3876 patients were included. The median age was 4.4 years (range 1 day to 20 years), and the median weight was 20.3 kg. Across all age-groups, the lumbar region was the most common site of epidural insertion while urology (42.2%) and general surgery (37.3%) were the specialities for which it was most utilized. Over the study period, the number of epidurals performed declined while the number of surgical procedures performed simultaneously increased. The infusate most commonly used was local anesthetic with preservative-free morphine (71.9%). In 923 (23.2%) patients, systemic opioids were additionally used for analgesic management by means of patient-controlled analgesia or nurse-controlled analgesia. There was one serious adverse event in the form of permanent nerve injury, giving an overall incidence of approximately 1:3800. Other complications included postoperative nausea and vomiting (35.9%), urinary retention (4.4%), and pruritus (31%). Overall global satisfaction with the service was generally high, with 95% providing a rating of "very good" or "good." CONCLUSION: This study evaluated two decades of epidural practice in our institution. Epidural analgesia remains a safe, effective option for postoperative analgesia, but its use has declined over time, and this trend is likely to continue. Rates of serious adverse events and complications were low and comparable to those published in other similar studies. Global satisfaction among patients/parents remains high.

Sensitivity and Specificity of a Neuropathic Screening Tool (Self-Report Leeds Assessment of Neuropathic Symptoms and Signs, S-LANSS) in Adolescents With Moderate-Severe Chronic Pain.

Neuropathic screening tools improve recognition of neuropathic pain in adults. Although utilized in pediatric populations, the sensitivity, specificity and methodology of screening tool delivery have not been compared in children. We evaluated the Self-Report Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) in adolescents (10-18 years) referred to a tertiary pediatric pain clinic. History and examination by specialist clinicians and multidisciplinary assessment informed classification of the primary pain type. In a prospective cohort, scores were obtained at interview (S-LANSS interview; n = 161, 70% female), and following substitution of self-reported signs with examination findings in the primary pain region (Leeds Assessment of Neuropathic Symptoms and Signs, LANSS examination). Secondly, we retrospectively retrieved questionnaires self-completed by adolescents at their initial clinic appointment (S-LANSS self-completed; n = 456, 73% female). Thirdly, we explored relationships between patient-reported outcomes and S-LANSS scores. S-LANSS interview scores varied with pain classification, and S-LANSS self-completed scores were similarly highest with neuropathic pain (median [interquartile range]: 18 [11, 21]) and complex regional pain syndrome (21 [14, 24]), variable with musculoskeletal pain (13 [7, 19]) and lowest with visceral pain (6.5 [2, 11.5]) and headache (8.5 [4, 14]). As in adults, the cutpoint score of 12/24 was optimal. Sensitivity was highest with inclusion of examination findings and lowest with self-completion (LANSS examination vs S-LANSS interview vs S-LANSS self-completed: 86.3% vs 80.8% vs 74.7%), but specificity was relatively low (37.8% vs 36.7% vs 48%). High S-LANSS scores in non-neuropathic groups were associated with female sex and high pain catastrophizing. The S-LANSS is a sensitive screening tool for pain with neuropathic features in adolescents, but needs to be interpreted in the context of clinical evaluation (clinicaltrials.gov NCT03312881). PERSPECTIVE: This article reports high sensitivity of the S-LANSS screening tool for identifying pain with neuropathic features in adolescents with moderate-severe chronic pain. However, as sensitivity is lower than in adult populations, further interdisciplinary evaluation is necessary to inform diagnosis and management.

Risk of school exclusion among adolescents receiving social care or special educational needs services: A whole-population administrative data cohort study.

BACKGROUND: Exclusion from school is associated with health, well-being and social detriments and disproportionately affects vulnerable children. No study in England has examined the total cumulative risk of exclusion across secondary school among children with a history of children's social care (CSC) or special educational needs (SEN). OBJECTIVE: To assess the risk of any secondary school exclusion among adolescents receiving CSC or SEN services compared with their peers. METHODS: An administrative data cohort study comparing children in English state schools (n = 1,031,500) with no history of CSC or SEN provision with children who had received different levels of CSC and SEN in combination. Outcomes were proportions of students with any fixed-term or permanent exclusion in years 7 to 9 (age 11 to 14) and years 10 to 11 (age 14 to 16). RESULTS: Overall, 13 % of children were excluded at least once across years 7 to 11. CSC exposure was associated with exclusion risk: 32 % of children in need (or formerly in need) and 40 % of current or former children looked after and those subject to child protection plans were excluded at least once across years 7 to 11, compared to 12 % of the non-exposed group. After adjusting for confounders, children with SEN history were more at risk of exclusion, regardless of CSC exposure category (except for exclusions among children looked after during years 10 to 11). Rates of exclusion varied significantly between local authorities. CONCLUSIONS: Large inequalities in school exclusion rates between CSC-exposed and unexposed children were observed, with even higher rates observed for children with SEN history. These inequalities undermine the right to education of these vulnerable groups of children.

Umbrella systematic review finds limited evidence that school absence explains the association between chronic health conditions and lower academic attainment.

Introduction: Absence from school is more frequent for children with chronic health conditions (CHCs) than their peers and may be one reason why average academic attainment scores are lower among children with CHCs. Methods: We determined whether school absence explains the association between CHCs and academic attainment through a systematic review of systematic reviews of comparative studies involving children with or without CHCs and academic attainment. We extracted results from any studies that tested whether school absence mediated the association between CHCs and academic attainment. Results: We identified 27 systematic reviews which included 441 unique studies of 7, 549, 267 children from 47 jurisdictions. Reviews either covered CHCs generally or were condition-specific (e.g., chronic pain, depression, or asthma). Whereas reviews found an association between a range of CHCs (CHCs generally, cystic fibrosis, hemophilia A, end-stage renal disease (pre-transplant), end-stage kidney disease (pre-transplant), spina bifida, congenital heart disease, orofacial clefts, mental disorders, depression, and chronic pain) and academic attainment, and though it was widely hypothesized that absence was a mediator in these associations, only 7 of 441 studies tested this, and all findings show no evidence of absence mediation. Conclusion: CHCs are associated with lower academic attainment, but we found limited evidence of whether school absence mediates this association. Policies that focus solely on reducing school absence, without adequate additional support, are unlikely to benefit children with CHCs. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=285031, identifier: CRD42021285031.

Evaluation of pushing out of children from all English state schools: Administrative data cohort study of children receiving social care and their peers.

BACKGROUND: Pushing out (off-rolling) occurs where pupils are illegally excluded from school. Those receiving children's social care (CSC) services (children in need (CiN), on child protection plans (CPPs) or looked after (CLA)) are thought to be at increased risk, but limited evidence inhibits understanding of this phenomenon. The extent of pushing out can be inferred from non-enrolment in administrative data. OBJECTIVE: To estimate proportions of children not enrolled across secondary school (aged 11-16, up to year 11) and to explore the association between CSC history and non-enrolment in year 10/11. PARTICIPANTS AND SETTING: >1 M pupils in year 7 (aged 11/12) in English state schools, 2011/12 and 2012/13. METHODS: We estimated the proportion of children not enrolled across years 8 to 11, disaggregated by CSC history. We assessed with regression modelling the association between CSC history and non-enrolment in years 10/11. RESULTS: Of children without CSC history, 3.8% had ≥1 year not enrolled by year 11. This was higher in those with a history CiN (8.1%), CPP (9.4%) or CLA (10.4%) status. The odds of non-enrolment in years 10/11 were higher among those with CLA history vs non-exposed peers (OR 4.76, 95% CI 4.49-5.05) as well as in those with CPP history (3.60, 3.39-3.81) and CiN history (2.53, 2.49-2.58). History of special educational needs further increased non-enrolment odds, including after confounder adjustment. CONCLUSIONS: Findings imply that children with CSC history are more likely to be pushed out from school than children without, especially those with special educational needs.

What makes administrative data "research-ready"? A systematic review and thematic analysis of published literature.

Introduction: Administrative data are a valuable research resource, but are under-utilised in the UK due to governance, technical and other barriers (e.g., the time and effort taken to gain secure data access). In recent years, there has been considerable government investment in making administrative data "research-ready", but there is no definition of what this term means. A common understanding of what constitutes research-ready administrative data is needed to establish clear principles and frameworks for their development and the realisation of their full research potential. Objective: To define the characteristics of research-ready administrative data based on a systematic review and synthesis of existing literature. Methods: On 29th June 2021, we systematically searched seven electronic databases for (1) peer-reviewed literature (2) related to research-ready administrative data (3) written in the English language. Following supplementary searches and snowball screening, we conducted a thematic analysis of the identified relevant literature. Results: Overall, we screened 2,375 records and identified 38 relevant studies published between 2012 and 2021. Most related to administrative data from the UK and US and particularly to health data. The term research-ready was used inconsistently in the literature and there was some conflation with the concept of data being ready for statistical analysis. From the thematic analysis, we identified five defining characteristics of research-ready administrative data: (a) accessible, (b) broad, (c) curated, (d) documented and (e) enhanced for research purposes. Conclusions: Our proposed characteristics of research-ready administrative data could act as a starting point to help data owners and researchers develop common principles and standards. In the more immediate term, the proposed characteristics are a useful framework for cataloguing existing research-ready administrative databases and relevant resources that can support their development.

Special educational needs, social care and health.

Better understanding of the proportion of children who ever receive special educational needs (SEN) provision or social care services during school years is highly relevant for healthcare as reductions in one or more of these services could impact on healthcare. Using the National Pupil Database linked to the all-of-England children looked after return and children in need census, we estimated the cumulative incidence of SEN status among (1) children ever in care during school, (2) children in need but not care, and (3) neither. We observed a very high proportion of children who were in care or need during school years had SEN provision at some point (83% and 65%, respectively), and that a high proportion of children in neither of these groups did so, too (37%). Healthcare, SEN provision and social care services focus on a similar population of children. Better integration of these services could lead to synergies and cost-efficiencies and better support for these children and their families.

Characterizing newborn and older infant entries into care in England between 2006 and 2014.

BACKGROUND: The risk of entry to state care during infancy is increasing, both here in England and abroad, with most entering within a week of birth ('newborns'). However, little is known about these infants or of their pathways through care over early childhood. OBJECTIVE: To characterize infant entries to care in England. PARTICIPANTS AND SETTING: All children in England who first entered care during infancy, between April 2006 and March 2014 (n = 42,000). METHODS: We compared sociodemographic and care characteristics for infants entering care over the study period by age at first entry (newborn: <1wks, older infant 1-51wks). Among those who entered before April 2010, we further characterized care over follow-up (i.e. 4 years from first entry) and employed latent class analysis to uncover any common pathways through care. RESULTS: Almost 40 % of infants first entered care as a newborn. Most infants first entered care under s 20 arrangements (i.e. out-of-court, 60 % of newborns vs 47 % of older infants). Among infants entering before April 2010, most were adopted over follow-up (60 % vs 37 %), though many were restored to parental care (20 % vs 32 %) or exited care to live with extended family (13 % vs 19 %). One in six infants (17.7 %) had particularly unstable care trajectories over early childhood, typified by three or more placements or failed reunification. CONCLUSIONS: Evidence-based strengthening of pre-birth social work support is needed to improve preventive interventions before birth, to more effectively target infant placement into care. Linkages between child protection records and information on parents are needed to inform preventive strategies.

Educational outcomes of children in contact with social care in England: a systematic review.

BACKGROUND: In England, the state intervenes in the lives of children through Children's Social Care (CSC) services with the aim of supporting and maintaining their welfare. It is known from government cross-sectional data that children who experience these CSC interventions (such as state care) have consistently poorer educational outcomes than the general population. However, these data are limited in providing crude estimates of association and in ignoring longitudinal histories. This systematic review aimed to appraise the extant research evidence from longitudinal studies and answer the question: how do educational outcomes differ between children in contact with CSC and the general population in the UK? METHODS: According to a pre-defined protocol, we searched 16 health, social care, education and legal databases for population-level quantitative studies conducted on UK children with exposure to CSC, a general population comparison group and an educational outcome. We also conducted snowball searches and searches of Google Scholar and grey literature. Data on whether each study met inclusion criteria were extracted, and findings of included studies were synthesised narratively. Risk of bias was assessed using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. RESULTS: In total, 5482 sources were screened which resulted in seven studies being included in the narrative synthesis. Only three were published in peer-reviewed journals. All but one used administrative education data and five used administrative data from CSC services. In all studies, exposure to CSC interventions was measured crudely, ignoring heterogeneity in the experiences of children. All agreed that children in contact with CSC services perform worse than their peers on all outcomes (variously: exam results, absences, exclusions, school moves, being missing from school, higher education aspirations and quality of school). CONCLUSIONS: Despite employing a search across 16 databases supplemented with additional searches of other online sources, we found only seven studies that met our inclusion criteria. This review throws into sharp relief the urgent need to conduct more population-level research into the educational prospects of children in contact with CSC services. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018089755.

Cohort profile: Children in Need Census (CIN) records of children referred for social care support in England.

PURPOSE: The Children in Need Census (CIN) is a case-based administrative dataset on children referred to social care services in England. CIN includes information on the 'needs' of children, and whether they received social care support. Local and national government bodies in England currently use CIN for evaluation purposes. Data are accessible to researchers under certain conditions, allowing researchers to investigate the health implications of adverse childhood experiences. However, CIN suffers from lack of metadata, meaning it can be challenging for researchers to process and interpret data, particularly if researchers are unfamiliar with the English children's social care system. To address this issue, we provide the background to CIN and describe the available data from 2008 to 2016. PARTICIPANTS: CIN is derived from case records held by English local authorities on all children referred to children's social care for a 'needs assessment', regardless of whether they are eventually assessed as 'in need of social care support'. Local authorities submit these case records to the UK Department for Education for collation. CIN holds information on an estimated 2.76 million children from October 2008 to March 2016. Since 2013/2014, just under 900 000 children have been recorded in the CIN annually, equivalent to around 8% of children in England (annual prevalence). Approximately, 650 000 children enter or renter the dataset each year, equivalent to 5% of children in England (annual incidence). DATA SUMMARY: Of the estimated 2.76 million children in the data, 50% are male and 47% female. 45% are referred to children's social care services due to abuse or neglect. 10.7% of children in CIN went onto a child protection plan, meaning they were judged to be (at risk of) suffering significant harm. FUTURE PLANS: CIN data collection is annual and ongoing. Data from the most recent census period typically become available for researchers in the following Spring.

Lifetime socioeconomic circumstances and chronic pain in later adulthood: findings from a British birth cohort study.

OBJECTIVES: To investigate associations between a range of different indicators of socioeconomic position (SEP: occupational class, education, household overcrowding and tenure, and experience of financial hardship) across life and chronic widespread and regional pain (CWP and CRP) at age 68. DESIGN: Prospective birth cohort; the Medical Research Council National Survey of Health and Development. SETTING: England, Scotland and Wales. PARTICIPANTS: Up to 2378 men and women who have been followed-up since birth in 1946 to age 68. PRIMARY OUTCOME MEASURES: On the basis of their self-report of pain at age 68, participants were classified as: CWP (American College of Rheumatology criteria), CRP (pain of at least 3 months' duration but that does not meet the definition of CWP), other pain (<3 months in duration) or no pain. RESULTS: At age 68, the prevalence of CWP was 13.3% and 7.8% in women and men, respectively, and that of CRP was 32.3% and 28.7% in women and men, respectively. There was no clear evidence that indicators of SEP in childhood or later adulthood were associated with pain. Having experienced (vs not) financial hardship and being a tenant (vs owner-occupier) in earlier adulthood were both associated with an increased risk of CWP; for example, moderate hardship adjusted relative risk ratio (RRRadj) 2.32 (95% CI: 1.19 to 4.52) and most hardship RRRadj 4.44 (95% CI: 2.02 to 9.77). Accumulation of financial hardship across earlier and later adulthood was also associated with an increased risk of CWP. CONCLUSIONS: Consideration of socioeconomic factors in earlier adulthood may be important when identifying targets for intervention to prevent CWP in later life.

Inequalities in access to a tertiary children's chronic pain service: a cross-sectional study.

BACKGROUND: Poor health, including chronic pain, has been consistently shown to be associated with lower socioeconomic status (SES). OBJECTIVE: To describe the SES of a clinical population of children with chronic pain referred to tertiary care in England, and to determine if access to, and utilisation of, the service is related to SES. PATIENTS AND METHODS: Using a retrospective cross-sectional study design, all children referred to a tertiary chronic pain management service between 2000 and 2014 were included. SES was determined using the English Index of Multiple Deprivation for the area in which they lived. Distance from the study site, using Ordinance Survey National Grid coordinates, and service utilisation, from hospital records, were also calculated. RESULTS: 737 children were included. The proportion of patients referred from the most socially deprived areas was substantially lower (14%) than from the least deprived (25%). In addition, the proportion of patients from the most deprived areas fell with increasing distance from the study site. Patients from the most deprived areas were more likely not to attend hospital appointments. CONCLUSIONS: Contrary to expectations, there were fewer patients from the most deprived areas. The proportion of children from more deprived areas fell with increasing distance from the study site, and those children who were referred were less likely to attend scheduled appointments. Our results imply that there is a social gradient in access to tertiary services for children's chronic pain management.