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During a one year longitudinal study, the dietary intake and growth of 50 vegetarian children aged 7-11 years was compared with that of 50 age-, sex- and race-matched omnivores. Diet was assessed at 6 month intervals using three, 3-day diet diaries and follow-up interviews. Anthropometric measurements (height, weight, mid-arm circumference, biceps and triceps skinfolds) were similarly taken 3 times. Multiple stepwise regression was used to control for non nutritional factors that affect growth. A questionnaire was administered at baseline to all children and their parents, to determine socio-economic status, health related behaviour and parents, ' height. Finger-prick blood samples were obtained from a sub-sample to measure haemoglobin (n=35 pairs) and cholesterol (n=32 pairs). Activity profiles were obtained using 12 hour heart-rate telemetry (n=20 pairs). Vegetarian and omnivorous groups were similar for socioeconomic group and health related behaviour. The predicted growth increment (0.47cm) of the vegetarians was significantly greater (p=0.05)' than that of the omnivores. Energy and sugars intakes of the vegetarians were significantly lower than those of the omnivores, fat and iron intakes were similar, whilst P: S ratio, NSP and calcium intakes were higher. The mean (SD) haemoglobin level of the vegetarians (11.8 (0.2g/dl)) was significantly below (p=0.04) that of the omnivores (12.4 (0.2)g/dl) but cholesterol levels were similar. Heart-rates were slightly higher for the vegetarians than the omnivores. The diet of the vegetarian children more closely resembled current recommendations although they need to be as vigilant as omnivores to reduce their intake of fat, and care is needed to ensure optimal iron status. The results of this study suggest that vegetarian children who include dairy products grow at least as well as those children who eat meat.

Background: Safeguarding children is a priority area, yet the experiences of those statutorily charged with offering strategic direction and clinical leadership in health organisations has received little research attention. This study focuses on the experiences of Designated nurses and doctors as they transition from working as an organisation’s sole expert to sharing tasks and responsibilities across many organisations as part of a countywide clinically-led Network. Method: This qualitative study used a participatory action research methodology that allowed the author – a participant Designated nurse – together with colleagues to address concerns and ensure improvements during the course of the study. Data was collected at two points: during the consultation on the Network’s form; and 12-18 months after its implementation. Results: The first data, gathered when Designates were working as sole practitioners, illustrated their isolation, difficulties in accessing knowledge and anxieties about their capacity to respond to changing demands. Further analysis demonstrated that participants’ experiences were shaped by local circumstances and the concerns raised by the newly announced NHS reforms. The second data set, gathered a year after the Network’s launch and contemporaneous with the implementation of the NHS reforms, showed that team working had addressed most of their earlier concerns. The Network had legitimised sharing tasks, combatted isolation, improved access to new knowledge, and benefitted the professionals’ authority through the reputation the Network had achieved for innovation in safeguarding. However, professionals raised concerns regarding collective responsibilities and individuals’ accountability to the team. Conclusion: The study’s inability to completely separate the effects of this change in working practice from the NHS reforms limits its generalisability. The research offers insights into whether small groups of practitioners endeavouring to deliver scarce expertise to multiple organisations would benefit from a team approach, and whether voluntary participation and shared objectives are enough to sustain such teams.

The World Health Organisation (WHO) recommends exclusive breastfeeding during the first six months of life for optimal growth. However, the rapid growth of early infancy is limited by undernutrition, and this has been assumed rare. Nonetheless, there has been reported evidence of this problem, particularly in infants with underlying disease. Identifying infants at the risk of undernutrition using growth charts is simple, quick, invaluable, but suggested ineffective. The possible cause is poor health staff understanding, application and interpretation of growth patterns in early infancy, particularly in developing countries. In Nigeria, little is known about patterns of growth, how growth velocity relate to nutritional status, standardised methods for assessing nutrition risk, and prevalence of undernutrition in infants younger than 6 months, particularly hospitalised infants. Therefore, this project based at the University of Nigeria Teaching Hospital (UNTH), Enugu, set out to answer the following research questions: 1) What is the prevalence of undernutrition in infants younger than 6 months, particularly hospitalised infants? 2) What are the implicated feeding patterns and medical conditions of these infants? 3) Can feeding information and growth patterns be used to predict undernutrition in these infants? 4) Is health staff use of growth patterns in identifying undernutrition in early infancy effective? Methods: Data were collected for the project’s three cross-sectional, observational studies. 1) Feeding information from birth to date of assessment was collected from mothers/carers of healthy infants attending the Infant Welfare Clinic (IWC) of the UNTH, Enugu. Their retrospective weight measurements at birth, 6 weeks, 3 months and 6 months were documented from their mother-held Road-to-Health (RTH) growth charts. 2) Feeding and growth information was collected from infants at admission (from birth to 26 weeks of age) to the Hospital Wards of the UNTH. These data were collected using a structured interviewer-administered questionnaire based on the Subjective Global Nutrition Assessment (SGNA); including anthropometric measures of weight, length, head circumference, mid-upper arm circumference, and skinfolds (triceps and subscapular). 3) Paediatric Health Staff were surveyed in two teaching hospitals and four government-controlled primary health facilities using a structured self-completion questionnaire to: - determine how growth charts are used to detect childhood undernutrition - determine the accuracy in plotting and rating/applying/interpreting weight gain patterns shown on the RTH and WHO growth charts for appropriate action - test the understanding of growth trajectories displayed on charts. Results: Infant Welfare Clinic Study: The retrospective weights of 411 healthy infants (0 – 26 weeks old) attending the IWC of the UNTH, Enugu was compiled and used to generate a reference to compare that of their hospitalised peers in the same hospital. There was a steady weight gain increase in the first half and slower gain in the latter half of first six months of life. During this period, the weight Z-scores distribution of the infants compared well to the WHO Child Growth Standards (WHO-CGS). Moreover, 5% of the infants had -2SD (CWG), setting the 5th percentile as slow weight gain threshold, the reference to compare the weight velocity of their hospitalised peers. Therefore, the data compiled from the IWC was transformed successfully into a dataset qualified as a norm for comparing the data collected from the hospitalised infants. However, suboptimal breastfeeding patterns were observed in the majority (391, 95%) of the infants at assessment. Hospital Ward Study: Assessment of growth was done in 210 infants admitted to the paediatric wards from birth to 6 months, of which 143 (80.6%) were younger than 3 months. These younger infants were most commonly admitted for respiratory tract disorders 39 (18.6%), while the older infants were most commonly admitted for sepsis 21 (10.0%). The least of the morbidities were diarrhoea/vomiting 10 (4.8%) and severe undernutrition 8 (3.8%). SGNA-rating showed that the majority (161, 76.7%) of the infants were at low risk for undernutrition. The mean CWG of the hospitalised infants from birth was low, with 23% of the infants recording weight gain since birth below the 5th percentile for slow weight gain. Around one quarter of the hospitalised infants recorded low anthropometric Z-scores of weight, CWG, length, BMI or MUAC. A reference for skinfolds for under-3-month-olds was not available in the WHO-CGS. On applying a reference developed using the infant Paediatric Yorkhill Malnutrition Screening Group’s UK data (iPYMS Reference), over one third of all the infants recorded low sum of skinfolds. Using crude MUAC measurements, two-thirds of the infants were moderately undernourished (<115mm) and over a half severely undernourished (<110mm), significantly (P<0.0001) decreasing with increase in age of admission. The majority (184, 87.6%) of the infants was initially breastfed, however, only 43 (20.5%) of the infants were exclusively breastfed (breastfed without water or other liquids) at any age. Breastfeeding status was related to the reasons for admission and nutritional status: the mean weight change for exclusively breastfed infants was -0.6 Z-score as compared to -1.1 Z-score for partially breastfed infants. Health Staff Study: Of the 222 health staff that responded to the survey in 2 referral hospitals and 4 government-controlled primary health facilities in Enugu city, 78% were hospital-based, 55% nurses, 46% highly experienced. About a third of the respondents often plotted; 87.8% often interpreted growth charts; over a half often identified and treated undernutrition, 88.7% with confidence. However, low accuracy was observed in recognising slow weight gain, particularly with average size; and fast weight gain was also poorly recognised. The respondents were as likely to be as worried about a small infant growing fast as an average weight infant growing slowly. Growth trajectories were better understood and interpreted on the WHO than RTH chart format. Most correct responses came from the medical doctors and moderately experienced respondents. Conclusions: The growth of young Nigerian infants fit the WHO-CGS well and the SGNA-rated nutrition risk is low, but other measures suggest undernutrition in up to one third of the hospitalised infants. Moreover, faulty breastfeeding patterns were prevalent and need to be addressed in future studies involving this population. Furthermore, the ineffectiveness of health staff understanding, application and interpretation of growth trajectories displayed on growth charts as practical tools, suggests the need for training.

Bronchiolitis is a viral lower respiratory tract infection of infancy and a major cause of infant morbidity. Respiratory syncytial virus is the most common cause of bronchiolitis. The majority of infants infected with bronchiolitis will have mild symptoms, lasting up to five days with the infant being successfully managed at home. However, up to 3% of all infants will be admitted to hospital for supportive therapy, such as oxygen and/ or fluids. A small proportion of these hospitalised infants (10%) will rapidly deteriorate further and require critical care admission for either invasive or non-invasive ventilation. Many clinical trials have been undertaken to evaluate a number of pharmaceutical interventions used to treat bronchiolitis. However, no treatment intervention has been proven to be effective. A large proportion of these clinical trials used clinical severity scores as an outcome measure. These clinical severity scores had not undergone any rigorous development and validation as recommended by the Food and Drug Agency (FDA) when developing an outcome measure for clinical trials. This thesis sets out the psychometric methods used to develop and validate the Liverpool Infant Bronchiolitis Severity Score – Proxy Reported Outcome Measure (LIBSS-PRO). The premise of the LIBSS-PRO is two-fold. Firstly, the LIBSS-PRO has been primarily developed for use in daily clinical management to identify infant improvement or deterioration. This will contribute to the standardisation of patient care and facilitate clinical decision making. Secondly, by fulfilling the FDA criteria as an outcome measure the LIBSS-PRO will improve the quality of future clinical trials of treatment interventions for bronchiolitis. The study was divided into three phases over three bronchiolitis seasons. The first phase was concerned with the development of the LIBSS-PRO. Items were identified from the literature and through stakeholder group workshops. A conceptual framework of bronchiolitis severity was developed. Consensus methods were used to identify which items were considered the most important and to develop criteria for mild, moderate and severe bronchiolitis. The second phase determined the content validity of the LIBSS-PRO. The LIBSS-PRO was evaluated by a range of health care professionals working in a variety of clinical environments by applying the score to eligible infants. Cognitive interviewing of health care professionals was used to assess comprehension and interpretation of each section of the LIBSS-PRO. Finally, in phase three, clinical field testing was undertaken in a variety of clinical locations by health care professionals to establish construct and criterion validity and reliability of the LIBSS-PRO. Responsiveness to change and cross cultural validation will be assessed in future clinical trials.

The HIV/AIDS prevalence rate in the Caribbean is second only to Sub-Saharan Africa and higher than the global rate. HIV/AIDS presents a real threat to children as they account for one in six global AIDS-related deaths and one in seven new global HIV infections. Furthermore, the number of new cases of children in the region is growing. Despite the impact of HIV/AIDS on Caribbean children, few research studies have been undertaken on the psychosocial issues that affect them and studies that include children’s perspectives seem to be even more lacking. This thesis is based on original research carried out in the Republic of Trinidad and Tobago. This study has examined the psychosocial issues that exist for children living with HIV in Trinidad and Tobago and has explored, from the perspectives of both children and their mothers, the types of supports that are available or accessed. The aims of the research were to 1) examine the psychosocial issues that affect children with acquired HIV/AIDS in Trinidad (the children in this research acquired HIV from their mothers) and 2) to explore the support that exists and gaps that may be necessary for their improved quality of life. It is hoped that intervention strategies will be gleaned from this research to assist future interdisciplinary teams that interact with this population. The methodology was based on a grounded theory approach (Strauss & Corbin 1990), and consisted of theoretical sampling and constant comparison throughout data analysis (open, axial, and selective coding) using a case triad (triad refers here to perspectives of three different actors). Four cases were purposively selected, each ‘case’ comprising a mother who was HIV positive, an “HIV Friend” (primary support figure, 4 in total) identified by the mother, and a child living with HIV (there were two children in one family, making five children in total, aged between five and thirteen years) – each of whom was interviewed. In addition, three mothers who did not tell their children of their status were also interviewed. These additional interviews were the result of theoretical sampling to explore two themes that emerged as significant in the first stage of analysis: 1) How “secrecy” was manifested in the lives of families coping with HIV and 2) The role of mothering. In total sixteen persons were interviewed. The findings produced three core categories, namely 1) the cyclical and complex nature of secrecy as a strategy to protect children from stigma and discrimination, 2) the impact on children of living with HIV-AIDS, including their role as protectors of HIV-positive mothers and 3) Mothering with HIV-AIDS. The study showed that these families, though impacted by uncertainty about the future, fear of dying and societal rejection, and for the large part financially and materially disadvantaged, were in-tact and functioned well. Furthermore these families had created a ‘new normal’ in which the secrecy about HIV was central and around which a range of behaviours, social codes and perceived consequences for breaches (of the secret) shaped relationships in both explicit and implicit ways. This indicates a high level of resourcefulness and resilience on the part of the women and their children. However the pressure to maintain the secret created additional challenges for women and children already impacted by a high level of stress because of HIV. Additionally, the rules of secrecy meant that women were unable to talk about their circumstances or needs and consequently had very little support either for themselves or their children. From the child’s point of view, the secret required them to be conscious of what they said and to whom and although not able to talk about HIV, paradoxically the secret had the effect of making HIV more dominant in their lives. This was despite the fact that children themselves did not seem to regard HIV as central in their everyday worlds. Mothering was also a significant theme to emerge from the study and it appeared that such was the importance of the role of mother, as a primary signifier of Caribbean womanhood, that the decision to have children was more important than the risk of passing on HIV. Two of the mothers had gone on to have more children even though their first child had been born with the virus. The study showed that being a good mother in a family affected by HIV means being able to protect children from the implications of the virus being known about outside the family and thus mothering was intertwined with the creation and maintenance of the secret. New understandings about the effects of HIV/AIDS on children and several recommendations aimed at improving services and resources for these children and their families have emerged from the study. Implementation of these recommendations would auger well for improved quality of life in the future, as children continue to live with the chronic illness of HIV/AIDS. The sample was small (16 participants in all) and as a qualitative study, no claims are made about with respect to any generalisations of the findings.

Background: Despite the growing evidence about acute pain management in children and the availability of practice guidelines, children still experience unnecessary pain when in hospital. Involving parents in their child’s pain care has been identified as being central to the pain management in children. However, little is known about how parents and nurses work in partnership in acute children’s wards to care for the child experiencing pain. This thesis explored the experiences and perceptions of parents and nurses and the extent to which parents are involved and partners in the child’s pain care, and the factors that influence parental involvement in care. The family-centred care practice continuum was the theoretical framework that underpinned the study. Methods: A qualitative ethnographical study using non-participant observation and follow up interviews was undertaken. Fourteen nurses and 44 parents/grandparents participated, recruited from the children’s wards of two district general hospitals. The framework approach underpinned data analysis. Findings: While some evidence of parental involvement was identified, the study revealed variations in the way parents are involved in their child’s pain care. A range of challenges were highlighted in relation to the implementation of family-centred care as an approach to promote parental involvement in care. Parents wanted to be more involved in their child’s pain care, and act as an advocate for their child, particularly when they perceived their child’s pain care to be sub-optimal. At times nurses created barriers to parental involvement in pain care, for example, by not communicating effectively with parents and planning pain care without involving parents. The ‘Pillars of Partnership in Pain Care Model’ is offered as an alternative approach to engaging with parents, to address the barriers to involvement and assist nurses shift from a paternalistic approach to involvement to one of working collaboratively with parents in the context of the care of child in pain. Conclusions and implications for practice: Parental involvement in their child’s acute pain care can improve the child’s pain experience, increase parents’ satisfaction in care and reduce parental anxiety. The challenge for nurses is to embrace parental contribution to care and develop the confidence to support parents to advocate for their child.

Collecting and aggregating timely and rigorous data for sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH) services and outcomes evaluation in humanitarian settings is essential for accountability and transparency. However, reliable SRMCNAH data are scarce in such settings, and the quality of available data often varies across different humanitarian settings. Establishing a core set of SRMNCAH indicators that are feasible to collect in all humanitarian settings is the first step in developing and implementing a common core framework for monitoring SRMNCAH programs in such settings. Led by the World Health Organization, in 2018 a group of global experts in the SRMNCAH field proposed a core list of indicators for inclusion in routine data collection systems. In 2019-2022, a team at the University of Ottawa in partnership with local investigators led multi-method feasibility assessments in Afghanistan, Bangladesh, the Democratic Republic of Congo, and Jordan to understand the feasibility, relevance, and acceptability of the proposed core indictors. In this thesis I report on the results from the multi-methods assessment in Afghanistan. Based on a desk review, key informant interviews, facility assessments, facility observation sessions, and focus group discussions in three provinces, we explored national stakeholders’ perspectives on SRMNCAH data collection, in general, and the proposed indicator list, in particular. The findings of this assessment and the results from the other three countries will help stakeholders reach a consensus on the final list of SRMNCAH indicators that are feasible for collection in all humanitarian settings.

Two studies were performed to detect aetiology of acute diarrhoea in hospitalized children aged under five years in Tripoli, Libya. In the first study, two hundred and thirty-six stool samples were obtained. Of these, 118 were from patients admitted for acute diarrhoeal disease, and 118 age and sex-matched concurrent controls were admitted for other reasons. In the second study, eight hundred and ten stool specimens were collected 405 from patients and the same number from controls. All were admitted to the AIjala Children’s Hospital, Tripoli, Libya. The first study was conducted between August 1st 1997 and 31st October 1997 and the second study was conducted between January 1st 2003 and 31st December 2003. One or more enteric pathogens were isolated from 55.9% of patients and 13.6% of controls in the first study and 68.1 % of patients and 12.6% of controls in the second study. In the first study, the organisms were identified from stool of patients; Escherichia coli 22.9%, rotavirus 15.3%, Campylobacter 7.6%, Proteus 7.6%, Klebsiella 4.2%, Entamoeba histolytica 4.2%, Cryptosporidium 2.5% and Giardia lamblia 1.7%, Salmonella was not isolated in both studies, because not growth on ordinary media were used (MacConkey agar and Blood agar) but usually growth on Salmonella-Shigella medium where not used. In the second study, enteropathogens identified were: rotavirus 30.4%, Escherichia coli 16.5%, Entamoeba histolytica 12.5%, Campylobacter 6.7%, Giardia lamblia 3.7%, Cryptosporidium 3.2%, Klebsiella 2.9%, Proteus 2.2%. Libyan children under six months of age were the most susceptible to acute diarrhoea requiring admission to the hospital. This was remarked in 46.6% of patients in the first study and 43.2% in the second. Exclusive breast feeding in Libyan children was of a very low percentage. In the first study it was 19.5% and in the second 29.1%. Children use dummies were about 3 times more at risk of diarrhoea than the non users in the first study (OD: 5.95,95%, CI: 1.120-2.37, p<0.001) and RR: 3.1 and (0: : 2.986ý 95%. Cl: 2.13-4.16, P<0.001) and RR: 23 in the second, this fell to children being twice as much at risk of contracting diarrhoea. Watery stool was the most common stool consistency of patients in both studies. Fever was the most common clinical feature associated with acute diarrhoea in the two studies (72.9% and 71.6% respectively). Vomiting was present in 51.7% of patients among the first study and 58.3% among the second. Moderate and isotonic dehydration were the most common degree and type of dehydration across both studies. In the second study, Rotavirus peaked during the winter (cold season) while bacteria and parasites peaked during the summer and autumn seasons. API 20E and API Campy were used to identify bacterial isolated by cultures and the number of confirmed cases decreased from 142 to 112 samples. Polymerase Chain Reaction was adopted in the second study to confirm detection of Campylobacter spp. these were identified by API Campy technique, where all Campylobacter spp. were identified as the same as detected by API Campy and for 24 samples.

Molluscum contagiosum (MC) is a common skin condition in children presenting to primary care in the United Kingdom (UK) and is typically diagnosed based on its distinct appearance. There are limited data on the epidemiology of MC in UK children. Little is known about its presenting symptoms, time to resolution, likelihood of transmission and impact on quality of life (QoL), highlighted within a systematic review of the epidemiology of childhood MC presented early in this thesis. This thesis aimed to address this gap in evidence. A retrospective longitudinal cohort of 9,245,847 children registered at primary care centres in the UK extracted routinely collected data from the Clinical Practice Research Datalink (CPRD). The study highlighted decreasing trends in consultation rates for MC by 50% during the 10 year study period 2004-13. Children who were previously diagnosed with atopic eczema were more likely to have a future MC consultation than controls. The ‘Molluscum Contagiosum Diagnostic Tool for Parents’ (MCDTP) was developed to aid parents in diagnosing spots, lumps or bumps on a child’s skin as being MC or not. The MCDTP was assessed in primary care centres to measure its diagnostic accuracy (n=203, sensitivity=92%, specificity=88%), and used to recruit a prospective community cohort of 306 UK children with MC. Results showed that MC lesions were most common on legs and arms, and nearly 70% of children had lesions in more than one site. The average time to resolution was 12 months, however over a quarter still had lesions after 18 months and 12% after 24 months. Nearly half of households reported transmission to one or more children from an index case. Overall MC had a small effect on QoL however, 1 in 10 children experienced a very severe effect on QoL. The findings presented in this thesis can facilitate self-care of MC in the community where parents can self-diagnose their child’s spot, lumps or bumps on the skin as MC or not using the MCDTP. These data can provide parents, and other interested stakeholders, with accurate information of the epidemiology of the condition to aid the management in both clinical and community settings.