Moira Stewart

Long term renal prognosis of Henoch-Schönlein Purpura in an unselected childhood population

All 270 patients presenting with Henoch-Schönlein Purpura over a 13-year period from a total childhood population of 155000 were studied. This is an incidence of 13.5/100000 children per year. Fifty-five (20%) were found to have initial evidence of renal involvement, and were re-examined at a mean of 8.3 years later. The 37 with isolated haematuria or haematuria with mild proteinuria (67%) recovered completely. Eighteen (33%) had nephritic or combined nephritic/nephrotic features, of these one died in the acute phase of the illness, only three others have persistent urinary abnormalities but have no biochemical evidence of renal impairment and only minor histological changes. The overall prognosis in this unselected population is therefore good with a mortality <1% overall and low long term morbidity of 1.1%. This study indicates a more optimistic outcome in this condition than the majority of published estimates based on more selected groups of patients.

Predictors of psychological functioning in mothers and fathers of infants born with severe congenital heart disease

This study examined mental health and coping styles in both mothers and fathers of infants born with a severe congenital heart defect. Factors associated with mental health outcomes were elucidated. Parents of 70 infants, recently born with a severe congenital heart defect, completed questionnaires which examined psychological functioning and coping strategies. Disease, surgical and psychosocial factors were examined for their significance in predicting psychological functioning. Findings indicated elevated levels of clinically significant psychological distress in mothers, compared to fathers, and differences between parents in coping styles. Regression analyses suggested that the extent of distress in both parents was not primarily predicted by illness or demographic factors. Rather, certain coping styles, knowledge, subjective worry and family functioning emerged as significant predictive variables. Implications for early intervention are discussed.

A RCT of peer-mentoring for first-time mothers in socially disadvantaged areas (The MOMENTS Study)

Objective Interventions to reduce health inequalities for young children and their mothers are important: involving peers is recommended, but evidence of value for this approach is limited. The authors aimed to examine the effect of an innovative tailored peer-mentoring programme, based on perceived needs, for first-time mothers in socio-economically deprived communities. Design Randomised controlled trial; parallel qualitative study with purposive samples using semistructured interviews. Setting Socio-economically disadvantaged areas, Belfast. Participants Primigravidae, aged 16–30 years, without significant co-morbidity. Intervention Peer-mentoring by a lay-worker fortnightly during pregnancy and monthly for the following year, tailored to participants wishes (home visits/telephone contacts), additional to usual care. Main outcome measures Infant psychomotor and mental development (Bayley Scales of Infant Development (BSID-II)) at 1 year, assessed by an observer blinded to group allocation. Mothers health at 1 year postnatal (SF-36). Results Of 534 women invited, 343(64%) participated; 85%, with their children, completed outcome assessments (140 of 172 intervention; 152 of 171 controls). Intervention and control groups did not differ in BSID-II psychomotor (mean difference 1.64, 95% CI −0.94 to 4.21) or mental (−0.81, −2.78 to 1.16) scores, nor SF-36 physical functioning (−5.4, −11.6 to 0.7) or mental health (−1.8, −6.1 to 2.6). Women valued advice given in context of personal experience of child-rearing. Mentors gained health-related knowledge, personal skills and new employment opportunities. Conclusions Despite possible longer-term social advantage, this peer-mentoring programme showed no benefit for infant development or maternal health at 1 year. Further rigorous evaluation of important outcomes of complex interventions promoting health for children in socially disadvantaged communities is warranted. Trial registration no ISRCTN 55055030

Peer-mentoring for first-time mothers from areas of socio-economic disadvantage: a qualitative study within a randomised controlled trial.

BackgroundNon-professional involvement in delivering health and social care support in areas of socio-economic deprivation is considered important in attempting to reduce health inequalities. However, trials of peer mentoring programmes have yielded inconsistent evidence of benefit: difficulties in implementation have contributed to uncertainty regarding their efficacy. We aimed to explore difficulties encountered in conducting a randomised controlled trial of a peer-mentoring programme for first-time mothers in socially disadvantaged areas, in order to provide information relevant to future research and practice. This paper describes the experiences of lay-workers, women and health professionals involved in the trial.MethodsThematic analysis of semi-structured interviews with women (n = 11) who were offered peer mentor support, lay-workers (n = 11) who provided mentoring and midwives (n = 2) who supervised the programme, which provided support, from first hospital antenatal visit to one year postnatal. Planned frequency of contact was two-weekly (telephone or home visit) but was tailored to individuals needs.ResultsDespite lay-workers living in the same locality, they experienced difficulty initiating contact with women and this affected their morale adversely. Despite researchers attempts to ensure that the role of the mentor was understood clearly it appeared that this was not achieved for all participants. Mentors attempted to develop peer-mentor relationships by offering friendship and sharing personal experiences, which was appreciated by women. Mentors reported difficulties developing relationships with those who lacked interest in the programme. External influences, including family and friends, could prevent or facilitate mentoring. Time constraints in reconciling flexible mentoring arrangements with demands of other commitments posed major personal difficulties for lay-workers.ConclusionDifficulties in initiating contact, developing peer-mentor relationships and time constraints pose challenges to delivering lay-worker peer support. In developing such programmes, awareness of potential difficulties and of how professional support may help resolve these should improve uptake and optimise evaluation of their effectiveness.Trial Registration Number: ISRCTN55055030

A Randomized Controlled Trial of Interventions to Promote Adjustment in Children With Congenital Heart Disease Entering School and Their Families

OBJECTIVEnTo report on a randomized controlled trial of psychological interventions to promote adjustment in children with congenital heart disease and their families.nnnMETHODnFollowing baseline assessment, 90 children (aged 4-5 years) and their families were randomly assigned to an Intervention or Control group before entering school. 68 (76%) were retained at 10-month follow-up.nnnRESULTSnGains were observed on measures of maternal mental health and family functioning. Although no differences were found on measures of child behavior at home or school, children in the intervention group were perceived as sick less often by their mother and missed fewer days from school. A regression model, using baseline measures as predictors, highlighted the importance of maternal mental health, worry and child neurodevelopmental functioning for child behavioral outcomes almost a year later.nnnCONCLUSIONSnThe intervention promoted clinically significant gains for the child and family. The program is of generalizable significance.

Examination of the physical and psychosocial determinants of health behaviour in 4-5-year-old children with congenital cardiac disease

OBJECTIVESnTo assess the general health and activity levels of 4- and 5-year-old children after intervention for congenital cardiac disease.nnnMETHODSnHealth behaviour outcomes were assessed in 91 children who had surgery or catheter intervention for congenital cardiac disease. The children were classified into four groups according to severity. The main parameters of classification were the presence of residual symptoms, frequency of visits to general practitioner or the Accident and Emergency Department, and ability to participate in physical activity according to a calculated activity score.nnnRESULTSnChildren had very few residual symptoms after corrective surgery. Those with complex congenital cardiac disease post-Fontan-type repair still had symptoms on average 18.2 days per month. Surprisingly, the complex group had fewer days sick from non-cardiac causes and had fewer visits to general practitioner or Accident and Emergency Departments. Regression analysis indicates that three variables had significant relevance to the general practitioner or Accident and Emergency visits: complex congenital cardiac disease, fewer visits; Townsend score - more deprivation - more visits; and maternal worry - higher maternal worry score - more visits. Regression analysis indicates that lower activity score is significantly related to complex cardiac disease and higher maternal worry score.nnnCONCLUSIONSnThe majority of this group of 4- and 5-year-old children had few residual symptoms and had good exercise tolerance. Maternal worry is a significant factor in influencing both activity levels and frequency of unscheduled health service demands - general practitioner or Accident and Emergency visits.

Neuro-developmental outcome of a large cohort of growth discordant twins.

AbstractOur aims were to study the effect of birthweight growth discordance (≥20xa0%) on neuro-developmental outcome of monochorionic and dichorionic twins and to compare the relative effects of foetal growth discordance and prematurity on cognitive outcome. We performed a cross-sectional multicentre prospective follow-up study from a cohort of 948 twin pregnancies. One hundred nineteen birthweight-discordant twin pairs were examined (24 monochorionic pairs) and were matched for gestational age at delivery with 111 concordant control pairs. Participants were assessed with the Bayley Scales between 24 and 42xa0months of age. Analysis was by paired t test for intra-twin pair differences and by multiple linear regression. Compared to the larger twin of a discordant pair, the smaller twin performed significantly worse in cognition (mean composite cognitive score differenceu2009=u2009−1.7, 95xa0% confidence interval (CI)u2009=u20090.3–3.1, pu2009=u20090.01) and also in language and motor skills. Prematurity prior to 33xa0weeks’ gestation, however, had a far greater impact on cognitive outcomes (mean cognitive composite score differenceu2009=u2009−5.8, 95xa0% CIu2009=u20091.2–10.5, pu2009=u20090.008).n Conclusion: Birthweight growth discordance of ≥20xa0% confers an independent adverse effect on long-term neuro-development of the smaller twin. However, prior to 33xa0weeks’ gestation, gestational age at birth adversely affects cognitive development to a greater extent than foetal growth discordance.What is known:• Growth discordance is a common problem encountered in monochorionic and dichorionic twin pregnancies.• Previous studies have demonstrated adverse developmental outcomes in one or two areas of development.What is new:• Growth discordance has a negative impact on all three areas of development: cognition, language and motor skills.• The current study is amongst the first to compare the impact of growth discordance and prematurity on cognitive outcomes.

Fetal Umbilical Artery Doppler Pulsatility Index as a Predictor of Cardiovascular Risk Factors in Children - A Long-Term Follow Up Study

Abstract Objective: To determine if high umbilical artery Doppler (UAD) pulsatility index (PI) is associated with cardio-vascular (CV) risk-factors in children at age 12 years. Methods: We studied 195 children at age 12 years who had had in-utero UAD studies performed at 28 weeks’ gestation. The children were grouped according to whether their umbilical Doppler PI was high (indicating poor feto-placental circulation) or normal. At age 12 years we assessed CV risk factors, including anthropometric measures, blood pressure, pulse wave velocity (a measure of arterial compliance), cardio-respiratory fitness, and homocysteine and cholesterol serum levels. Results: Compared with children with a normal UAD PI (Nu2009=u200988), the children (Nu2009=u2009107) with high UAD PI had higher resting pulse rate (pu2009=u20090.04), higher pulse wave velocity (pu2009=u20090.046), higher serum homocysteine levels (pu2009=u20090.032) and reduced arterial compliance (7.58 versus 8.50u2009m/s, pu2009=u20090.029) using univariate analysis. These differences were not present when adjusting for cofounders was modeled. Conclusion: High PI on UAD testing in-utero may be associated with increased likelihood of some CV risk factors at age 12-years but confounding variables may be as important. Our study raises possible long-term benefits of in-utero UAD measurements.

Fetal umbilical artery Doppler pulsatility index and childhood neurocognitive outcome at 12 years

Objective To determine whether an elevated fetal umbilical artery Doppler (UAD) pulsatility index (PI) at 28u2005weeks’ gestation, in the absence of fetal growth restriction (FGR) and prematurity, is associated with adverse neurocognitive outcome in children aged 12 years. Methods Prospective cohort study, comparing children with a normal fetal UAD PI (<90th centile) (n=110) and those with an elevated PI (≥90th centile) (n=40). UAD was performed at 28, 32 and 34u2005weeks gestation. At 12u2005years of age, all children were assessed under standardised conditions at Queens University, Belfast, UK to determine cognitive and behavioural outcomes using the British Ability Score-II and Achenbach Child Behavioural Checklist Parent Rated Version under standardised conditions. Regression analysis was performed, controlling for confounders such as gender, socioeconomic status and age at assessment. Results The mean age of follow-up was 12.4u2005years (±0.5 SD) with 44% of children male (n=63). When UAD was assessed at 28u2005weeks, the elevated fetal UAD group had lower scores in cognitive assessments of information processing and memory. Parameters included (1) recall of objects immediate verbal (p=0.002), (2) delayed verbal (p=0.008) and (3) recall of objects immediate spatial (p=0.0016). There were no significant differences between the Doppler groups at 32 or 34u2005weeks gestation. Conclusions An elevated UAD PI at 28u2005weeks gestation in the absence of FGR or prematurity is associated with lower scores of declarative memory in children aged 12u2005years. A potential explanation for this is an element of placental insufficiency in the presence of the appropriately grown fetus, which affects the development of the fetal hippocampus and information processing and memory long-term. These findings, however, had no impact on overall academic ability, mental processing and reasoning or overall behavioural function.

The impact of fetal umbilical artery Doppler pulsatility index on childhood respiratory function and atopy - A prospective case-control study

Abstract Objective: To determine if an elevated fetal umbilical artery Doppler pulsatility index is associated with abnormal respiratory function and atopy in children aged 12u2009years. Methods: This prospective case-control study compared children that had an elevated fetal umbilical artery Doppler pulsatility index (>90th centile) to those with a normal pulsatility index (<90th centile). All subjects were delivered at full-term and with appropriate growth for gestational age. Outcome measures included; (i) presence of asthma and/or atopy; (ii) spirometry measurements and (iii) serum C-reactive protein and leptin. Multiple regression was used to account for parental smoking, childhood age, gender and socioeconomic status. Results: 174 children with an average age of 12.1 (±0.6 SD), 48% of who were male were included in the analysis. Of the 174, 99 (57%) were in the normal umbilical artery Doppler pulsatility index group and 75 (43%) elevated umbilical artery Doppler pulsatility index groups. The overall proportion of subjects with asthma was 28% (48/174) and atopy 56% (98/174). No association was found between elevated fetal umbilical artery Doppler pulsatility index and asthma (pu2009=u2009.47) or atopy (pu2009=u2009.75) at age 12u2009years. Similarly there was no association between FEV1(%) (pu2009=u2009.96), forced vital capacity (FVC)(%) (pu2009=u2009.98), elevated serum C-reactive protein (pu2009=u2009.69) or leptin (pu2009=u2009.20) and an elevated fetal umbilical artery Doppler pulsatility index. Conclusions: An elevated umbilical artery Doppler at 28-weeks gestation in the absence of prematurity or fetal growth restriction is not associated with altered respiratory function or the presence of atopy in children aged 12u2009years. These findings support the theory that such disease has a multifactorial pathophysiology.