[show abstract][hide abstract] ABSTRACT: Puberty is a multifaceted developmental process that begins in late-childhood with a cascade of endocrine changes that ultimately lead to sexual maturation and reproductive capability. The transition through puberty is marked by an increased risk for the onset of a range of health problems, particularly those related to the control of behaviour and emotion. Early onset puberty is associated with a greater risk of cancers of the reproductive tract and cardiovascular disease. Previous studies have had methodological limitations and have tended to view puberty as a unitary process, with little distinction between adrenarche, gonadarche and linear growth. The Childhood to Adolescence Transition Study (CATS) aims to prospectively examine associations between the timing and stage of the different hormonally-mediated changes, as well as the onset and course of common health and behavioural problems that emerge in the transition from childhood to adolescence. The initial focus of CATS is on adrenarche, the first hormonal process in the pubertal cascade, which begins for most children at around 8 years of age.Methods/design: CATS is a longitudinal population-based cohort study. All Grade 3 students (8--9 years of age) from a stratified cluster sample of schools in Melbourne, Australia were invited to take part. In total, 1239 students and a parent/guardian were recruited to participate in the study. Measures are repeated annually and comprise student, parent and teacher questionnaires, and student anthropometric measurements. A saliva sample was collected from students at baseline and will be repeated at later waves, with the primary purpose of measuring hormonal indices of adrenarche and gonadarche.
CATS is uniquely placed to capture biological and phenotypic indices of the pubertal process from its earliest manifestations, together with anthropometric measures and assessment of child health and development. The cohort will provide rich detail of the development, lifestyle, external circumstances and health of children during the transition from childhood through to adolescence. Baseline associations between the hormonal measures and measures of mental health and behaviour will initially be examined cross-sectionally, and then in later waves longitudinally. CATS will make a unique contribution to the understanding of adrenarche and puberty in children's health and development.
[show abstract][hide abstract] ABSTRACT: School factors are associated with many health outcomes in adolescence. However, previous studies report inconsistent findings regarding the degree of school-level variation for health outcomes, particularly for risk behaviours. This study uses data from three large longitudinal studies in England to investigate school-level variation in a range of health indicators. Participants were drawn from the Longitudinal Study of Young People in England, the Me and My School Study and the Research with East London Adolescent Community Health Survey. Outcome variables included risk behaviours (smoking, alcohol/cannabis use, sexual behaviour), behavioural difficulties and victimisation, obesity and physical activity, mental and emotional health, and educational attainment. Multi-level models were used to calculate the proportion of variance in outcomes explained at school level, expressed as intraclass correlations (ICCs) adjusted for gender, ethnicity and socio-economic status of the participants. ICCs for health outcomes ranged from nearly nil to .28 and were almost uniformly lower than for attainment (.17-.23). Most adjusted ICCs were smaller than unadjusted values, suggesting that school-level variation partly reflects differences in pupil demographics. School-level variation was highest for risk behaviours. ICCs were largely comparable across datasets, as well as across years within datasets, suggesting that school-level variation in health remains fairly constant across adolescence. School-level variation in health outcomes remains significant after adjustment for individual demographic differences between schools, confirming likely effects for school environment. Variance is highest for risk behaviours, supporting the utility of school environment interventions for these outcomes.
[show abstract][hide abstract] ABSTRACT: OBJECTIVE: To investigate trends in health inequality among children and young people between 1999 and 2009, using outcomes consistent with the current NHS reforms. DESIGN/DATA: Secondary analysis of participants aged 0-24 in the Health Surveys for England (HSE) undertaken in 1999, 2004, 2006 and 2009. MAIN OUTCOME MEASURES: Changes in the absolute and relative risks of four health outcomes by deprivation tertiles, based on occupation of the head of household▸ self/parent-reported general health,▸ presence of a long-standing illness (LSI),▸ obesity▸ smoking. RESULTS: No indicator showed a reduction in relative or absolute inequality between 1999 and 2009. For children (0-12 years), the relative risk comparing the most and least deprived tertiles increased significantly for poor general health (1999:1.6 (95% CI 1.2 to 2.2); 2009:3.9 (2.4 to 6.2), while the absolute difference in LSI prevalence(%) increased from 1.3 (-2.9 to 5.5) to 7.4 (3.6 to 11.4). Among young people (13-24 years), the absolute difference in LSI prevalence increased from -5.9 (-10.9 to -1.1) to 3.1 (-4.1 to 10.7). Absolute inequality in having tried smoking among children aged 8-15(%) increased significantly in the first half of the decade before decreasing in the second half (1999:3.3 (-1.1 to 7.7); 2004:14.1 (9.6 to 18.8); 2009:4.1 (0.1 to 8.8)). However, the increase in absolute inequality for smoking prevalence among young adults (16-24 years) was maintained throughout the decade (1999:-7.0 (-15.6 to 1.3); 2004:11.6 (3.7 to 20.0); 2009:8.2 (-0.3 to 16.9)). CONCLUSIONS: The national programme between 1999 and 2009 was not successful in reducing inequality in four key indicators of health status and future health risk among children and young people. Some inequality measures for general health, LSI prevalence and smoking increased over this time.
Archives of Disease in Childhood 05/2013; · 3.05 Impact Factor
[show abstract][hide abstract] ABSTRACT: OBJECTIVE: To identify the socio-demographic and behavioural characteristics associated with perceptions of weight-related health risk among the parents of overweight children. METHODS: Baseline data from a cohort of parents of children aged 4-11years in five areas in England in 2010-2011 were analysed; the sample was restricted to parents of overweight children (body mass index ≥91(st) centile of UK 1990 reference; n=579). Associations between respondent characteristics and parental perception of health risk associated with their child's weight were examined using logistic regression analyses. RESULTS: Most parents (79%) did not perceive their child's weight to be a health risk. Perception of a health risk was associated with recognition of the child's overweight status (OR 10.59, 95% CI 5.51 to 20.34), having an obese child (OR 4.21, 95% CI 2.28 to 7.77), and having an older child (OR 2.67, 95% CI 1.32 to 5.41). However, 41% of parents who considered their child to be overweight did not perceive a health risk. CONCLUSIONS: Parents that recognise their child's overweight status, and the parents of obese and older children, are more likely to perceive a risk. However, many parents that acknowledge their child is overweight do not perceive a related health risk.
[show abstract][hide abstract] ABSTRACT: In most high-income countries, fewer children now acquire meningitis, and many of those who do will survive. Globally, however, meningitis still remains a significant cause of child morbidity and mortality. In this article, the authors review recent evidence on the morbidity faced by childhood survivors of bacterial meningitis. Outcomes vary by bacterial pathogen, with around a 20 % risk for severe sequelae (most commonly, neurocognitive) by all pathogenic causes. Pneumococcal, tuberculosis, and group B streptococcal meningitis lead to the highest rates of sequelae. Recent epidemiological shifts in the major pathogens causing meningitis, as well as varied regional settings between studies, limit generalizability of evidence in the literature, and better research using longitudinal data and case-control methodology is required, especially in low-income countries. However, the consistently high levels of complications described in the literature call for more widespread vaccination programs for prevention and a greater focus on potential complications by educators and health-care providers to support childhood survivors of bacterial meningitis and their families.
[show abstract][hide abstract] ABSTRACT: Aims: In 2010, the English Department of Health launched a radical new public health strategy, which sees individual factors, such as self-esteem, as the key to improving all aspects of young people's health. This article compares the strength of association between key adolescent health outcomes and a range of individual and social factors Methods: All participants aged 12-15 in the nationally representative 2008 Healthy Foundations survey were included. Six individual factors related to self-esteem, confidence and personal responsibility, and seven social factors related to family, peers, school and local area were investigated. Single-factor and multivariable logistic regression models were used to calculate the association between these factors and seven health outcomes (self-reported general health, physical activity, healthy eating, weight, smoking, alcohol intake, illicit drug use). Odds ratios were adjusted for gender, age and deprivation. Results: Individual factors such as self-esteem were associated with general health, physical activity and healthy eating. However, the influence of family, peers, school and local community appear to be equally important for these outcomes and more important for smoking, drug use and healthy weight. Conclusion: Self-esteem interventions alone are unlikely to be successful in improving adolescent health, particularly in tackling obesity and reducing substance misuse.
Perspectives in Public Health 03/2013; 133(2):122-31. · 1.09 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Safe assessment of severe underweight in children is important but experience suggests a frequent lack of understanding. Here we sought evidence from a wide spectrum of trainees. METHODS: Cross-sectional telephone survey of an on-call middle-grade paediatric doctor in hospitals providing acute inpatient general paediatric care in England and Wales. RESULTS: Response rate was 100%. Only 50% identified BMI as the appropriate measure for underweight in children. Most did not identify any clinical cardiovascular complications of severe underweight. Only 13% identified corrected QT time (QTc) as an important ECG finding. Knowledge of the refeeding syndrome was poor with 20% unable to define it at all, 21% able to identify some clinical features and 57% aware of potential phosphate abnormalities. CONCLUSIONS: Knowledge base among middle-grades doctors in England and Wales on this topic is worryingly poor, particularly in relation to several life-threatening features. Existing and new training approaches should recognise this.
Archives of Disease in Childhood 01/2013; · 3.05 Impact Factor
[show abstract][hide abstract] ABSTRACT: Revised You're Welcome (YW) quality criteria for adolescent health services were published by the English Department of Health in 2011. These are the first national standards to include inpatient services and the first of their kind to be endorsed by the World Health Organization. This article investigates the relationship between the YW criteria and young people's overall satisfaction in national inpatient surveys.
We identified the most recent national surveys that contain adolescent data: the Inpatient Survey (IS) 2009 (ages 16-19 years) and the Young Patient Survey (YPS) 2004 (ages 12-17 years). Logistic regression was used to calculate the odds of increased overall satisfaction when YW criteria were met, adjusting for sex and use of health services. Spearman rank correlation coefficients were used to identify the 10 questions in each survey that best correlated with overall satisfaction. We assessed the degree to which these 10 items were included in the YW criteria.
In all, 7,657 (12-17 years old) and 988 (16-19 years old) adolescents completed the YPS and the IS, respectively. Twenty-eight of 29 questions that mapped to YW criteria were significantly associated with overall satisfaction (IS = 14/15; YPS = 25/25; all p < .01). Of the 10 questions that best correlated with overall care rating, 9 mapped directly to YW criteria in the YPS, as did all 10 in the IS. Provider characteristics were the strongest correlates of the overall care rating.
Although limited by lack of data relating to access, publicity, and confidentiality, our study provides strong support for the face validity and content validity of the remaining YW quality criteria in inpatient settings.
Journal of Adolescent Health 01/2013; 52(1):50-57.e1. · 2.97 Impact Factor
[show abstract][hide abstract] ABSTRACT: Overweight and obesity in adulthood are established risk factors for adverse cardiovascular outcomes, but the contribution of overweight in childhood to later cardiovascular risk is less clear. Evidence for a direct effect of childhood overweight would highlight early life as an important target for cardiovascular disease prevention. The aim of this study was to assess whether overweight and obesity in childhood and adolescence contribute to excess cardiovascular risk in adults.
Data from three British birth cohorts, born in 1946, 1958 and 1970, were pooled for analysis (n = 11,447). Individuals were categorised, based on body mass index (BMI), as being of normal weight or overweight/obese in childhood, adolescence and adulthood. Eight patterns of overweight were defined according to weight status at these three stages. Logistic regression models were fitted to assess the associations of patterns of overweight with self-reported type 2 diabetes, hypertension, and coronary heart disease (CHD) in adulthood (34-53 years). Compared to cohort members who were never overweight, those who were obese in adulthood had increased risk of all outcomes. For type 2 diabetes, the odds ratio was higher for obese adults who were also overweight or obese in childhood and adolescence (OR 12.6; 95% CI 6.6 to 24.0) than for those who were obese in adulthood only (OR 5.5; 95% CI 3.4 to 8.8). There was no such effect of child or adolescent overweight on hypertension. For CHD, there was weak evidence of increased risk among those with overweight in childhood. The main limitations of this study concern the use of self-reported outcomes and the generalisability of findings to contemporary child populations.
Type 2 diabetes and to a lesser extent CHD risk may be affected by overweight at all stages of life, while hypertension risk is associated more strongly with weight status in adulthood.
PLoS ONE 01/2013; 8(7):e70684. · 3.73 Impact Factor
[show abstract][hide abstract] ABSTRACT: Clustering of abnormal metabolic traits, the Metabolic Syndrome (MetS), has been associated with an increased cardiovascular disease (CVD) risk. Several algorithms including the MetS and other risk factors exist for adults to predict the risk of CVD. We discuss the use of MetS scores and algorithms in an attempt to predict later cardiometabolic risk in children and adolescents and offer suggestions for developing clinically useful algorithms in this population. There is little consensus in how to define the MetS or to predict future CVD risk using the MetS and other risk factors in children and adolescents. The MetS scores and prediction algorithms we identified had usually not been tested against a clinical outcome, such as CVD, and they had not been validated in other populations. This makes comparisons of algorithms impossible. We suggest a simple two-step approach for predicting the risk of adult cardiometabolic disease in overweight children. It may have advantages in terms of cost-effectiveness since it uses simple measurements in the first step and more complex, costly measurements in the second step. It also takes advantage of the continuous distributions of the metabolic features. We suggest piloting and validating any new algorithms.
[show abstract][hide abstract] ABSTRACT: This article compares the inpatient experience of young versus older adults, and assesses the relative importance of different aspects of health care in these two groups.
The study comprised adult inpatients in 161 English hospitals.
Standardized scores were calculated covering overall care and eight domains of patient experience (consistency, respect, involvement, nursing, doctors, cleanliness, pain control, and privacy). Values for young and older adults were compared. Additionally, Fisher r-to-z transformation was used to assess age differences in the strength of correlation between overall care and individual care domains.
Young people reported a poorer experience across all aspects of inpatient care (p < .01). Compared with older adults, young men's overall care rating was more strongly correlated to pain control, and young women's to respect and doctors' characteristics (p < .05).
These findings provide a quantitative national-level evidence base regarding young people's priorities in inpatient care.
Journal of Adolescent Health 11/2012; 51(5):528-32. · 2.97 Impact Factor
[show abstract][hide abstract] ABSTRACT: Serogroup B meningococcal disease is the commonest cause of meningitis and septicaemia in high-income countries. Assessment of new serogroup B meningococcal vaccines is hampered by a scarcity of data on the burden of disease in survivors. We aimed to estimate the disease burden in children having survived serogroup B meningococcal disease.
In this case-control study, we recruited children from the UK National Meningococcal Registry between May, 2008, and September, 2010. Eligible children were survivors who had had serogroup B meningococcal disease confirmed by culture or PCR and were aged 1 month to 13 years at disease. Age-matched and sex-matched controls were recruited through the family doctor of the children who had the meningococcal disease. Physical, psychological, neurocognitive, and educational outcomes were assessed through a standardised interview with validated instruments. We did matched analyses using generalised estimating equations (GEE). Researchers were masked to the children's serogroup B meningococcal status.
Of the 537 children who had serogroup B meningococcal disease and were available for recruitment, 245 were assessed. 328 controls were also recruited; 221 controls were matched with a case and 107 were additional unmatched controls. The mean age was 6·5 (SD 2·8) years in children with serogroup B meningococcal disease and 6·9 (2·9) in controls. In the full sample, children who had serogroup B meningococcal disease were more likely than controls to have bilateral sensorineural hearing loss of 40 dB or more (unmatched 11 [5%] of 232 children with meningococcal disease vs three [<1%] of 318 controls; matched odds ratio [OR] 4·8, 95% CI 1·3 to 17·4, p=0·02), lower full-scale IQ (matched mean 99·5 for children with meningococcal disease and 107·2 for controls; matched coefficient -7·6, 95% CI -9·9 to -5·4, p<0·0001), and psychological disorders (61 [26%] of 235 children with meningococcal disease vs 33 (10%) of 322 controls; matched full sample OR 2·6, 1·6 to 4·2, p<0·0001). Disabling amputations were noted in three (1%) of 239 children who had serogroup B meningococcal disease compared with none of the 322 controls. Children with meningococcal disease were also more likely to have deficits in executive function and multiple aspects of memory. Deficits were identified in 87 (36%) of 244 children with serogroup B meningococcal disease and 49 (15%) of 328 controls (matched OR 2·7, 1·8 to 4·1, p<0·0001). Major disabling deficits were identified in 21 (9%) of 244 children with meningococcal disease compared with six (2%) of 328 controls (matched OR 5·0, 2·0 to 12·6, p=0·001). No significant differences were noted in attentional function or post-traumatic stress disorder between children with serogroup B meningococcal disease and controls.
Most children survive serogroup B meningococcal disease without major sequelae. However, about a tenth have major disabling deficits and more than a third have one or more deficits in physical, cognitive, and psychological functioning, with the additional burden of memory deficits and executive function problems. These findings should help to guide assessments of new vaccines and suggest that all survivors of serogroup B meningococcal disease should be screened for psychological disorders and cognitive deficits in addition to hearing loss.
Meningitis Trust and Big Lottery Fund, UK.
The Lancet Neurology 08/2012; 11(9):774-83. · 23.92 Impact Factor
[show abstract][hide abstract] ABSTRACT: Little is known about the physical burden of early onset eating disorders (EOEDs). Most published data on physical instability and growth in malnutrition come from specialist centres, or from the developing world where aetiology differs. The authors present data on physical status at presentation from population-based surveillance systems in the UK and Ireland.
Prospective surveillance study.
All suspected cases of EOED in children under 13 years of age reported by paediatricians and psychiatrists via the British Paediatric Surveillance System (BPSU) and Child and Adolescent Psychiatric Surveillance System (CAPSS) in the UK and Ireland from March 2005 to May 2006 (15 months).
208 cases were identified (24% reported by paediatricians). Median age was 11.8 years (IQR 1.74). 171 (82%) were female (78% premenarcheal and 60% prepubertal). 74% of males were prepubertal. 35% of cases had medical instability at presentation (60% bradycardia, 54% hypotension, 34% dehydration, 26% hypothermia). 52% of cases required admission at diagnosis (73% to a paediatric ward). 41% of cases with medical instability were not underweight, that is, they had body mass index (BMI) z-scores above -2.0 (2nd centile). Sensitivities for identifying medical instability with BMI z-score <-3 or 70% median BMI were 31% and 15%, respectively. Menarcheal status did not predict risk of medical instability.
EOEDs present with severe levels of physical instability and frequently to paediatricians. As anthropological indices alone are poor markers for medical instability, clinical assessment is essential. Doctors providing care for children have a central role in both the recognition and management of EOEDs.
Archives of Disease in Childhood 06/2012; 97(9):779-84. · 3.05 Impact Factor
[show abstract][hide abstract] ABSTRACT: Communication with young people (YP) can be problematic. However, effective communication can improve health outcomes and there is randomised clinical trial-level evidence that communication skills can be learnt. Key issues when communicating with YP: (1) The young person should be central in the communication, with discussions primarily focused on him/her; (2) The young person should be offered time alone with the clinician; (3) Conditional confidentiality should be discussed, and does not reduce rates of disclosure; (4) Ambivalence is normal--techniques can be learnt to help the young person resolve ambivalence and change behaviour; (5) A psychosocial history is a key part of the adolescent consultation, and should include resilience factors as well as risk. We also discuss pragmatic techniques to use in busy consultations to improve communication and promote behaviour change in YP.
Archives of Disease in Childhood - Education and Practice 06/2012; 97(3):93-7. · 1.32 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: The childhood obesity epidemic is one of the foremost UK health priorities. Childhood obesity tracks into adult life and places individuals at considerable risk for diabetes, cardiovascular disease, liver disease and other morbidities. There is widespread need for paediatric lifestyle programmes as change may be easier to accomplish in childhood than later in life. STUDY DESIGN/METHOD: The study will evaluate the management of adolescent obesity by conducting a Medical Research Council complex intervention phase III efficacy randomised clinical trial of the Healthy Eating Lifestyle Programme within primary care. The study tests a community delivered multi-component intervention designed for adolescents developed from best practice as identified by National Institute for Health and Clinical Excellence. The hospital based pilot reduced body mass index and improved health-related quality of life.Subjects will be individually randomised to receiving either the Healthy Eating Lifestyle Programme (12 fortnightly family sessions) or enhanced standard care. Baseline and follow up assessments will be undertaken blind to allocation status. A health economic evaluation is also being conducted.200 obese young people (13-17 years, body mass index > 98th centile for age and sex) will be recruited from primary care within the greater London area.The primary hypothesis is that a motivational and solution-focused family-based weight management programme delivered over 6 months is more efficacious in reducing body mass index in obese adolescents identified in the community than enhanced standard care.The primary outcome will be body mass index at the end of the intervention, adjusted for baseline body mass index, age and sex.The secondary hypothesis is that the Healthy Eating Lifestyle Programme is more efficacious in improving quality of life and psychological function and reducing waist circumference and cardiovascular risk factors in obese adolescents than enhanced standard care assessed at 6 and 12 months post baseline assessment.Improvement in quality of life predicts on-going lifestyle change and maximises the chances of long-term weight reduction. We will explore whether improvement in QOL may be intermediate on the pathway between the intervention and body mass index change. TRIAL REGISTRATION: ISRCTN: ISRCTN99840111.
[show abstract][hide abstract] ABSTRACT: To investigate what data are available on the National Health Service (NHS) experience of children and young people (0-24 years), and how their experience compares with that of older patients. DESIGN AND DATA SELECTION: Review of 38 national surveys undertaken or planned between 2001 and 2011, identified by the Department of Health (2010). Detailed analysis performed on the most recent completed surveys covering primary, inpatient and emergency care, and children's services.
Patients under 16 were included in 1/38 national surveys, comprising <0.6% of over 10 million respondents. The majority of young people aged 16-24 reported a positive experience of NHS care. However, satisfaction was lower than in older adults. 80.7% of 16-24 year olds reported good emergency department care, compared with 89.2% of older adults (Emergency Department Survey 2008, N=49 646, OR=0.51, 95% CI 0.47 to 0.55, p<0.001). In the Inpatient Survey 2009, 86.5% of 16-24 year olds reported good care, compared with 92.7% of older adults, (N=69 348, OR=0.51, 95% CI 0.45 to 0.57, p< 0.001). Satisfaction with primary care was reported by 83% of 18-24 year olds, compared with 90% of older adults (GP Patient Survey 2009-10 (N=2 169 718, OR=0.52, 95% CI 0.51 to 0.53, p<0.001). Young people also reported a poorer experience than older adults for their perceived involvement in care, having confidence and trust in their doctor and being treated with respect and dignity.
Despite the current focus on services for young people and the importance of patients' views in improving services, the voice of under 16s is not included in most national surveys. Despite high levels of overall satisfaction, young adults report a poorer experience of care than older adults.
Archives of Disease in Childhood 09/2011; 97(7):661-6. · 3.05 Impact Factor
[show abstract][hide abstract] ABSTRACT: Metformin is the most commonly prescribed oral anti-diabetic drug in young people. It is also prescribed for polycystic ovarian syndrome (PCOS) and obesity treatment in adults in an unlicensed fashion. Little is known as to the extent metformin has been used in young people. We investigated the use of metformin in children and adolescents aged 0-18 years in the UK.
Population-based prescribing data were obtained from the UK IMS Disease Analyzer between January 2000 and December 2010.
A total of 2674 metformin prescriptions were issued to 337 patients (80% female) between 2000 and 2010. The prevalence of metformin prescribing increased from 0.03 per 1000 person-years [95% confidence interval (CI) 0.02, 0.05] to 0.16 per 1000 person-years (95% CI 0.12, 0.20) (P= 0.001). There was a steady increase in metformin prescribing in girls aged 16-18 years. There were 290 metformin treated patients (81% female; n= 235) who had at least one diagnosis of diabetes, PCOS or obesity. Among these patients, PCOS was the most common indication for metformin prescribing in girls (n= 120) followed by diabetes. There were 22 patients (7.6%) who received metformin for obesity treatment only.
Prescribing of metformin increased between 2000 and 2010, in particular amongst girls aged 16-18 years. The main indication for metformin prescribing was PCOS. At present, metformin is not licensed for PCOS and obesity treatment in adults or children. As there is a steady increase in the prescribing of metformin in young people, further studies are required to investigate the efficacy and safety of these prescriptions.
British Journal of Clinical Pharmacology 07/2011; 73(1):135-9. · 3.58 Impact Factor