The authors have no conflicts of interest to declare.

Feeding a very low birthweight (VLBW, <1500 g) infant is challenging. Our aims were to study how prescribed enteral feeding is implemented in VLBW infants and to identify factors associating with slow enteral feeding progression. Our retrospective cohort included 516 VLBW infants born before 32 weeks of gestation during 2005-2013 and admitted to Children's Hospital, Helsinki, Finland, for at least the two first weeks of life. Nutritional data were collected from birth until the age of 14-28 days, depending on the length of stay. We found that enteral feeding progressed slower than recommended and implementation differed from the prescriptions, especially during the parenteral nutrition phase (milk intake 10-20 mL/kg/day): 71% [40-100], median [IQR], of the prescribed enteral milk was administered. The full prescribed amount was less likely administered if a higher volume of gastric residual was aspirated or if the infant did not pass stool during the same day. Longer opiate use, patent ductus arteriosus, respiratory distress syndrome and slower passage of the first meconium associated with slower enteral feeding progression. Enteral feeding of a VLBW infant is often not administered as prescribed, which possibly plays a significant role in the slow progression of enteral feeding.

The aim of this study was to investigate whether the choice reforms in healthcare in Stockholm county in 2008 and 2013 changed the sociodemographic user patterns of outpatient healthcare services for children. The study used regional data on healthcare use linked to sociodemographic data from national registers in the total population of children 0-15 years in the Stockholm county. Change in use of healthcare services was analysed in multiple linear regression in a difference in differences approach of socio-economic indicators. The choice reform of 2013 increased children's overall use of specialised care by around 30% until 2017 while primary care use decreased by the same degree. The mean number of physician visits in specialised care for children with severe asthma increased from 3.9 to 5.2 per year. Overall, children in families with low maternal education, low disposable income and a non-Western background increased their use of specialised care more than children from families with a more privileged socio-economic situation. There was no indication that the choice reform in Stockholm county increased the social disparities in use of primary and specialised outpatient care for children, rather the opposite.

Managing febrile infants has evolved without a generally accepted standard of care. We aimed to design quality indicators for managing infants ≤90 days old presenting to emergency departments (EDs) with fever without source. This multicentre Delphi study was carried out by the Febrile Infant Study Group of the Spanish Paediatric Emergency Research Network, from March 2021 to November 2021, and included paediatric emergency physicians from 24 Spanish EDs. A list of care standards was produced, following an extensive literature review and the involvement of all parties. Indicators were essential if they were voted by four panelists and also received a score of ≥4 from at least 95% of the 24 investigators. We established 20 indicators, including one related to having a protocol, two to triage, nine to diagnostic processes, six to treatment and two to disposition. The following indicators were considered essential: having an ED management protocol, performing urinalysis on every infant, obtaining a blood culture from every infant and administering antibiotics in the ED to any febrile infant who did not appear well. The Delphi method resulted in a comprehensive list of quality indicators for managing febrile young infants in Spanish EDs.

Acta PaediatricaAccepted Articles BRIEF REPORT National surveillance of severe microcephaly in Australia Carlos Nunez, Corresponding Author Carlos Nunez [email protected] orcid.org/0000-0002-5417-9582 The University of Sydney. Faculty of Medicine and Health, Discipline of Child and Adolescent Health, Sydney, NSW, Australia The Australian Paediatric Surveillance Unit (APSU). Sydney, NSW, Australia Correspondence Dr Carlos Nunez, the Australian Paediatric Surveillance (APSU), Level 2, Kids Research, The Children's Hospital at Westmead, Locked Bag 4001, Westmead NSW 2145, Australia. Email: [email protected]Search for more papers by this authorAnne Morris, Anne Morris The University of Sydney. Faculty of Medicine and Health, Discipline of Child and Adolescent Health, Sydney, NSW, Australia The Australian Paediatric Surveillance Unit (APSU). Sydney, NSW, Australia Kids Research, The Sydney Children's Hospitals Network (Westmead), Sydney, NSW, AustraliaSearch for more papers by this authorElizabeth J. Elliott, Elizabeth J. Elliott The University of Sydney. Faculty of Medicine and Health, Discipline of Child and Adolescent Health, Sydney, NSW, Australia The Australian Paediatric Surveillance Unit (APSU). Sydney, NSW, Australia Kids Research, The Sydney Children's Hospitals Network (Westmead), Sydney, NSW, AustraliaSearch for more papers by this author Carlos Nunez, Corresponding Author Carlos Nunez [email protected] orcid.org/0000-0002-5417-9582 The University of Sydney. Faculty of Medicine and Health, Discipline of Child and Adolescent Health, Sydney, NSW, Australia The Australian Paediatric Surveillance Unit (APSU). Sydney, NSW, Australia Correspondence Dr Carlos Nunez, the Australian Paediatric Surveillance (APSU), Level 2, Kids Research, The Children's Hospital at Westmead, Locked Bag 4001, Westmead NSW 2145, Australia. Email: [email protected]Search for more papers by this authorAnne Morris, Anne Morris The University of Sydney. Faculty of Medicine and Health, Discipline of Child and Adolescent Health, Sydney, NSW, Australia The Australian Paediatric Surveillance Unit (APSU). Sydney, NSW, Australia Kids Research, The Sydney Children's Hospitals Network (Westmead), Sydney, NSW, AustraliaSearch for more papers by this authorElizabeth J. Elliott, Elizabeth J. Elliott The University of Sydney. Faculty of Medicine and Health, Discipline of Child and Adolescent Health, Sydney, NSW, Australia The Australian Paediatric Surveillance Unit (APSU). Sydney, NSW, Australia Kids Research, The Sydney Children's Hospitals Network (Westmead), Sydney, NSW, AustraliaSearch for more papers by this author First published: 14 May 2023 https://doi.org/10.1111/apa.16846 This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi:10.1111/apa.16846. AboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Accepted ArticlesAccepted, unedited articles published online and citable. The final edited and typeset version of record will appear in the future. RelatedInformation

The Covid-19 pandemic necessitated virtual adaptation of the neonatal resuscitation programme Helping Babies Breathe (HBB). This study assessed one such virtually mentored and flipped classroom modification in Madagascar. A cross-sectional study was performed in September 2021 and May 2022. Healthcare providers were identified by local collaborating organisations. United States-based master trainers collaborated with local trainers on virtually mentored trainings followed by independent trainings. Master trainers were available for consultation via Zoom during the virtual training. A flipped classroom modification and traditional didactic method were compared. Primary outcomes were knowledge and skill acquisition, evaluated by written assessments and objective structured clinical examinations. Overall, 97 providers completed the curriculum. Written assessment scores improved in both training models (traditional-74.8% vs 91.5%, p < 0.001; flipped classroom-89.7% vs 93.6%, p < 0.05). There was no significant difference among written assessment scores (92.8% vs 91.5%, p = 0.62) and significantly higher objective structured clinical examination scores (97.3% vs 89.5%, p < 0.001) for the independent training compared to the virtually mentored training. The virtually mentored HBB training was followed by a successful independent training as measured by participant knowledge and skill acquisition, supporting the efficacy of virtual dissemination.

Clinical trials and the need for new treatments were recently listed among the most important factors for child health. The aim of the present study was to describe some of our experiences with budget preparations in paediatric clinical trials. We selected ten trials sponsored by the pharmaceutical industry at the Pediatric Clinical Research Center at Sahlgrenska University Hospital in Gothenburg, Sweden. We compared the sponsor´s initial budget (budget proposal from the sponsor), with the final budget (negotiated and agreed between sponsor and site) and identified areas where discrepancies may arise. The mean difference in total budget amount between the initial budget and the final budget was +60% (mean 59%, range 31 to 139%). The costs for preparation of the clinical trial, time spent for study activities, and costs for examinations were identified as key budget items for these differences. Our findings indicate that a substantial part of the trial-related costs would not be covered by the sponsor, had the initial budget been accepted. A thorough review and budget negotiation, as well as to have a dedicated team-member for this task, are essential to ensure equitable responsibility for the study-related costs and to avoid discontinuation of trials.

We determined the prevalence and predictors of formula supplementation for healthy, term newborn infants in hospital. A cross-sectional study was conducted from 1 June to 21 October 2020 among Croatian women who gave birth to healthy newborn infants of ≥37 weeks gestation and birth weight of ≥2500 g at the University Hospital of Split, Croatia. The mothers completed a questionnaire on hospital infant feeding practices and breastfeeding self-efficacy. Multinomial logistic regression investigated associations between perinatal factors and formula supplementation. We approached 392 mothers, and 355 (90.6%) were included: 286 (80.6%) said their newborn infant received formula in hospital and it was at their request in 173/286 (60.5%) of cases. The adjusted analyses identified factors associated with increased odd ratios (OR) and 95% confidence intervals (CI) for formula supplementation: no previous breastfeeding experience (OR 9.42, 95% CI 3.51-25.28), breastfeeding difficulties in hospital (OR 9.12, 95% CI 3.46-24.09) and older children who received formula during their birth hospitalisation (OR 11.51, 95% CI 4.4-30.1). Mothers were not routinely notified of the risks. An unacceptably high proportion of healthy newborn infants received formula in hospital.

Acta PaediatricaAccepted Articles A DIFFERENT VIEW Resuscitation thresholds were seen as guidance by Belgian neonatologists and other relevant factors were included in decision-making Alice Cavolo, Corresponding Author Alice Cavolo [email protected] orcid.org/0000-0002-3921-0617 Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium Correspondence Alice Cavolo, Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35 Box 7001, 3000 Leuven, Belgium. Email: [email protected]Search for more papers by this authorChris Gastmans, Chris Gastmans Centre for Biomedical Ethics and Law, KU Leuven, Leuven, BelgiumSearch for more papers by this author Alice Cavolo, Corresponding Author Alice Cavolo [email protected] orcid.org/0000-0002-3921-0617 Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium Correspondence Alice Cavolo, Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35 Box 7001, 3000 Leuven, Belgium. Email: [email protected]Search for more papers by this authorChris Gastmans, Chris Gastmans Centre for Biomedical Ethics and Law, KU Leuven, Leuven, BelgiumSearch for more papers by this author First published: 26 April 2023 https://doi.org/10.1111/apa.16803 This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi:10.1111/apa.16803. AboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Accepted ArticlesAccepted, unedited articles published online and citable. The final edited and typeset version of record will appear in the future. RelatedInformation