Kathleen Falster

Objectives: We quantified the risk of developmental support needs at school entry among children with and without prenatal substance exposure, to inform service delivery initiatives in the first 2000 days of children’s lives. Methods: We assembled a cohort using population-level perinatal, birth registration, hospital and education data linked for the New South Wales Child E-Cohort. Children born 2008–2014, with Australian Early Development Census data collected 2015, 2018, 2021 (n=262 968), were grouped into children with and without prenatal substance exposure (using indicators in mother/child hospital, emergency department, mental health outpatient, opioid treatment and/or child protection report data). We quantified the risk of developmental support needs, including teacher-reported developmental vulnerability on ≥1 of five domains or medically diagnosed conditions with support needs at school entry. Results: Half of prenatal substance-exposed children (n=4306) had developmental vulnerability on ≥1 domains or ≥1 medically diagnosed conditions at school entry, compared with 24% of all other children. Developmental vulnerability on ≥2 domains was more common among prenatal substance-exposed children (24%) than all other children (9%). 11% of prenatal substance-exposed children had ≥1 medically diagnosed conditions, versus 5% of all other children. Autism spectrum disorder, attention deficit hyperactivity disorder, global developmental delay and fetal alcohol spectrum disorder were the most common conditions among prenatal substance-exposed children. Conclusions: Half of prenatal substance-exposed children had developmental support needs during the first 2000 days of life, highlighting the importance of interagency prevention responses spanning substance use in pregnancy services through to the postnatal and early childhood support services for affected children.

Objective: The burden of bloodstream infection (BSI) is highest among infants. We aim to describe temporal trends in the incidence and characteristics of BSI in young infants. Design: Birth cohort study. Setting: Queensland, Australia. Patients: All Escherichia coli (21%, n=501), Group B Streptococcus (GBS) (21%, n=493) and Staphylococcus aureus (14%, n=338). Overall incidence was 2.98 per 1000 live births (early-onset 1.01, late-onset 1.96), which increased over time (incidence rate ratio 1.01 (95% CI 1.00 to 1.01)). The incidence of Enterobacterales BSI increased by 1.96% each year (1.02 (1.01 to 1.03)) and GBS by 1.91% (1.02 (1.01, 1.04)). Early-onset GBS increased by 11% per year from 2014 to 2019 (1.11 (1.04 to 1.19)). The overall case fatality rate was 8.8% (early onset 6.4%, late onset 10%). Conclusions: The incidence of GBS and Enterobacterales BSI has risen in young infants in Queensland, especially for early-onset GBS since 2014. These findings highlight the increasing importance of Enterobacterales infections in young infants and the need to reconsider prevention strategies for early-onset GBS.

Summary: Background: First Nations children are over-represented in child protection systems in Australia and other colonised countries. Here, we apply a prevention and equity lens to the use of child protection data, to inform early opportunities to support Aboriginal children and families at risk of escalating child protection contact, from pregnancy to adolescence. Methods: We followed 15 whole-population cohorts (born 2006-2020) of Aboriginal (n=119,716) and non-Aboriginal (n=1,456,698) children in New South Wales (NSW), Australia, to December 2021, using birth and child protection datasets linked for the NSW Child E-Cohort. In each Aboriginal and non-Aboriginal cohort born 2006 to 2020, we calculated the cumulative incidence (risk) of first-time child protection contacts from the prenatal period up to age 15 years: reports to child protection, screened in reports, investigations, child protection- defined substantiations (of actual harm or risk of significant harm assessed in the investigation), and OOHC placements. Risk differences and relative risks were also calculated. Findings: By birth, 10-15% of Aboriginal children born 2006-2020 had a first report to child protection, with 48-54% by age 5y (2006-2016 births), and 74% by age 15y (2006 births), with similar risks of screened-in reports (e.g. 68% by age 15y). The risk of first-time substantiation was 1- 5% of Aboriginal children by birth, 17-20% by 5y, and 32% by 15y, with higher risks in more contemporary cohorts. By age 1y, 3-4% of Aboriginal children born 2006-2020 had a first OOHC placement, with 7-9% by 5y, and 14% by 15y. The risk differences between Aboriginal and non-Aboriginal children were 23 and 3 percentage points for reports and OOHC by age 1y (2020 births), respectively, increasing as children age. Interpretation: Despite extensive inquiries, calls for prevention and Closing the Gap targets, our study shows the lifetime risk of child protection involvement for Aboriginal families has not improved and inequities persist. These findings support the call for Aboriginal-led approaches and greater investment in early supports for First Nations children and families. Research in Context: Evidence before this study: We searched PubMed and Medline for studies on the lifetime risk of child protection contacts among First Nations child populations, published January 2005 to May 2025. Thirteen studies reported various child protection contacts, from the perinatal period through childhood, among birth or synthetic cohorts of First Nations children, born between 1990 and 2018, created from population data sources in jurisdictions in Australia (n=5), the United States(US) (n=6), and Aotearoa/New Zealand (NZ) (n=2) (Table E1). The most recently published study included First Nations children born 2000 to 2013 in Western Australia, which quantified the risk of reports, investigations, substantiations and removals into OOHC, from age 1 to 16 years. By age 1, 12% were reported and 3% were removed into OOHC. By age 16, 52% were reported, and 14% were removed into OOHC. Prior studies of birth or synthetic cohorts of First Nations children born 1990-2018, in the USA, NZ, and South Australia showed similar results. By age 5 years, 16% to 54% for reports, 20% for investigations, 7% to 11% for substantiations and 8% for removals into OOHC. Among the five studies with cohorts followed to 18 years, 42% were reported, 28% to 50% were investigated, 9% to 27% were substantiated, 7% to 16% were removed into OOHC and 0.8% to 3.8% had termination of parental rights. Added value of this study: This is the largest and most contemporary study to quantify the lifetime risk of child protection contact among whole-populations of First Nations children internationally. Among 15 consecutive whole-population cohorts of First Nations children in New South Wales (NSW), Australia, born 2006 to 2020, we reported—for the first time—the full spectrum of child protection contacts, from the prenatal period. By birth, 16% were reported to child protection, 14% were investigated and 5% were substantiated in the most contemporary cohort born 2020. By age 1 year, 2.8% were removed into OOHC. In the oldest cohort born 2006, 74% were reported and 14.4% removed into OOHC by age 15 years. We also reveal the magnitude of the inequity in child protection contacts between First Nations and non-Indigenous children across the lifecourse. For example, among 2006 births, the risk of first-time reports to child protection for Aboriginal and non-Aboriginal children, respectively, was 10.5% versus 1.5% by birth (risk difference (RD), 9 percentage points; risk ratio (RR), 7.0), 53% vs 16% by age five (RD, 38pp; RR, 3.4) and 74% vs 33% by age 15 (RD, 41pp; RR 2.2). Implications of all the available evidence: This study unequivocally shows that the lifetime risk of child protection involvement in the lives of First Nations families has not reduced in more contemporary whole-population cohorts and that inequities persist. This is consistent with evidence from prior studies internationally. It is critical that First Nations-led responses and investment in early family supports must be at the centre of system reform to realise the long-called-for shift toward prevention and to re-dress the pervasive inequities experienced by First Nations children and families in colonised countries such as Australia.

Objectives To estimate the prevalence of maternal substance use problems during the first 1000 days of children’s lives, to inform planning and resourcing of antenatal screening and substance use in pregnancy services, alongside antenatal and postnatal health, parenting and social support services for pregnant women/new mothers and their babies. Method This whole-population cohort was assembled from birth registration, perinatal and hospital data for children born 2008–2017, and their mothers, using data linked for the New South Wales (NSW) Child E-Cohort Project. The primary outcome was maternal substance use conditions and treatment recorded in six health, death and child protection data sources from the child’s conception to age 2 years (the first 1000 days), including illicit substances, alcohol, opioid-agonist treatment and misuse of psychoactive medicines or substances. Results Of 970 470 children born to 625 856 mothers, 3.4% (N=32 647) had ≥1 maternal substance use problem records in the first 1000 days, including alcohol use (N=13 637; 1.4%) and other drug use (N=23 485; 2.4%). Maternal substance use problems were recorded during the pregnancy period for 1.4% of children, and from 28 to 1000 days postbirth for 2.7% of children. Outcome ascertainment was highest from child protection records (N=26 045), followed by mother’s (N=10 793) then children’s hospital records (N=3827). Child protection records more than doubled the prevalence of health and death records alone (1.4%). Social and health disadvantage was more common among children with maternal substance use problems. Conclusions During the first 1000 days of life, 3.4% of NSW children had ≥1 maternal substance use problem recorded in health, child protection and death data sources. Child protection data enhance public health intelligence on the burden of maternal substance use problems among whole child populations. Near universal health system contact during pregnancy and birth is an opportunity to initiate early support for maternal substance use and co-occurring health and social disadvantage, to promote child health and development.

Objectives To quantify developmental vulnerability at age 5 by child protection contacts before school in two Australian states. Methods All children with birth, child protection and/or 2009, 2012, 2015 and 2018 Australian Early Development Census (AEDC) data in New South Wales (NSW) and South Australia (SA) were grouped according to child protection contact before school: no contact, child protection reports, screened-in reports, investigations, substantiations and out-of-home care (OOHC). The outcome was developmental vulnerability on ≥1 AEDC domains or medically diagnosed conditions with support needs at school entry. Results 56 650 (14.2%) NSW children and 12 617 (15.6%) SA children had ≥1 child protection contact before school. Developmental vulnerability on ≥1 domains or medically diagnosed conditions was lowest in the no child protection group (NSW, 21–22%; SA, 24–25%), with progressively higher risk in the child protection report (NSW, 35%; SA, 41–46%) through to the OOHC (NSW, 50–54%; SA, 59–66%) groups in all AEDC years. Developmental risk was higher among children aged Conclusions A single child protection report before school was an early indicator of higher developmental risk at age 5, with higher developmental risks among children with earlier, more serious and frequent child protection contacts. Beyond child safety screening, child protection reports represent an opportunity to mobilise early health and social support for children with developmental support needs.

Objectives: To estimate the prevalence of maternal substance use during the first 1000 days of children’s lives, to inform planning and resourcing of antenatal screening and substance use in pregnancy services, alongside antenatal and postnatal health, parenting and social support services for pregnant women/new mothers and their babies. Method: This whole-population cohort was assembled from birth registration, perinatal, and hospital data for children born 2008-2017, and their mothers, using data linked for the New South Wales (NSW) Child E-Cohort Project. The primary outcome was maternal substance use and treatment recorded in six health, death, and child protection data sources from the child’s conception to age 2-years (the first 1000 days), including illicit substances, alcohol, opioid-agonist treatment, and misuse of psychoactive medicines or substances. Results: Of 970,470 children born to 625,856 mothers, 3.4% (N=32,647) had ≥1 maternal substance use records in the first 1000 days, including alcohol use (N=13,647; 1.4%) and other drug use (N=23,485; 2.4%). Maternal substance use was recorded during the pregnancy period for 1.2% of children, and from 28-1000 days post-birth for 2.4% of children. Outcome ascertainment was highest from child protection records (N=26,045), followed by mother’s (N=12,956) then children’s hospital records (N=3,826). Child protection records more than doubled the prevalence from health and death records alone (1.4%). Social and health disadvantage was more common among children with maternal substance use. Conclusion: During the first 1000 days of life, 3.4% of NSW children had ≥1 maternal substance use record in health, child protection and death data sources. Child protection data enhances public health intelligence on the burden of maternal substance use among whole-populations of children. Near universal health system contact during pregnancy and birth is an opportunity to initiate early support for maternal substance use and co-occurring health and social disadvantage, to promote child health and development. What is already known on this topic: Population-level evidence of maternal substance use during the first 1000 days is limited by heterogenous study designs. Cross-sectional surveys and self-reports illustrate low-level use from 10-18%; studies linking one-four whole-population health datasets provide estimates of 0.2-3% for more harmful use. What this study adds: Of 970,000 children born 2008-2017 in NSW, Australia, 3.4% had a maternal substance use record during their first 1000 days of life in six linked administrative datasets. Adding child protection to health and death data more than doubled prevalence estimates. How this study might affect research, practice or policy: Public health intelligence to inform screening and support services for pregnant women, new mothers and children affected by maternal substance use can be enhanced using child protection data, in addition to health and death data sources. Near universal health system contact during pregnancy and birth is an opportunity to initiate early support for maternal substance use and co-occurring health and social disadvantage, to promote child health and development.