Evaluating the health assessments of migrant children in Europe: exploring the experience of service providers

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Over the past three decades, Europe has experienced the largest increase in international migration. However, research focused on health of migrant children remains limited. While European guidelines for their care exist, evidence regarding implementation of these recommendations is limited. This study explores practices and experiences of healthcare professionals in Europe who conduct initial health assessments (IHAs) for children and young people seeking asylum and refugees (CYPSAR). Methods : A qualitative study was conducted (between July and August 2022), using questionnaires and semi-structured interviews to explore perspectives of healthcare providers who care for migrant children in Europe. Participants were recruited through snowball sampling from European expert networks, with 16 clinicians from eight European countries taking part. Data were analysed thematically using NVivo12. Results: We found considerable variation in content and delivery of IHAs, particularly with regard to screening for communicable and non-communicable diseases. Although immunisation was prioritised, some services lacked vaccination capabilities. Mental health services were limited, with minimal standardised screening. Key barriers to care included insufficient documentation, limited funding, staffing, patient mobility, and inadequate infrastructure to support migrant health. Conclusion: Care delivery for migrant children across Europe remains variable despite existing guidelines.. Significant barriers to delivery of equitable, quality care exist. There is a need for resources tailored to address challenges in migrant health. Further research is needed to inform evidence-based practice and achieve high quality equitable care for migrant children in Europe. Refugee Asylum-seeking children Unaccompanied minor Immunisation Europe Tuberculosis Figures Figure 1 Introduction In 2023, there were 36.4 million refugees worldwide, and 6.1 million people sought asylum globally —the highest number on record [1][2]. Of these, 38% were under 18 years of age (children and young people seeking asylum and refugees, or CYPSAR) [2]. The rise in international migration to Europe has been more significant than in any other region over the past three decades [2]. In 2022, 19% of people seeking asylum in Europe were unaccompanied minors (CYPSAR-U), often referred to as unaccompanied asylum-seeking children (UASC) [3]. Ongoing geopolitical instability, including conflicts in Sudan, Ukraine, and the Middle East, indicates that the number of child migrants to Europe is likely to continue increasing. Under the Convention on the Rights of the Child (CRC), which has been signed by all European countries, children seeking asylum or in an irregular situation are entitled to the same rights as those with legal residency. The CRC specifically affirms the child's right to enjoy the highest attainable standard of health and to have access to treatment and rehabilitation for illness [4] . Most child migrants and refugees arrive in Europe after long, arduous journeys with limited access to care[5] and present with health needs that may differ from those of children born in Europe[6] , [7]. Therefore, the WHO recommends a holistic and comprehensive health assessment delivered by a healthcare worker with a background in paediatrics as soon as possible after arrival to the destination country[5]. Although evidence related to, and research into, migrant child health remain scarce, several European recommendations for the care of CYPSAR have been developed, including the consensus recommendations of the European Academy of Paediatrics (EAP), based on the recommendations of 31 European countries[8]. However, research on actual practice and implementation of existing recommendations across Europe is lacking. We explore the practice and experiences of clinicians across Europe performing initial health assessments (IHAs) for CYPSAR. Methods This is a qualitative research study, in which data was collected using a questionnaire and semi-structured interviews following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [9]. The literature on migrant children uses a variety of terms (asylum-seeker, refugee, displaced) interchangeably. Here, we use the term CYPSAR to mean a child or young person (<18 years) who has moved to or settled in another country and experienced unfavourable conditions, including war and violence, socioeconomic deprivation, health care, and education limitations[10] , [8]. Study Population and Sampling : The target population for this study consisted of clinicians working in European (European Union member states and UK and Switzerland) countries who provide IHA for CYPSAR. Participants were initially recruited through the investigators' existing networks (EuroTravNet, ESPID), as well as by contacting national paediatric associations and employing snowball sampling. Once potential participants were identified, they were invited to participate in the study and sent an informed consent form via email. After consent was obtained, participants received a questionnaire, and an interview date was scheduled. An estimated sample size of 15 was considered sufficient for data saturation [11], however participants who responded beyond the point of active recruitment were still allowed to participate. Data Collection: Data was collected between July and August 2022. The design of both the structured questionnaires and the topic guide for semi-structured interviews were informed by European recommendations for health assessment of migrant children[8]. Questionnaire responses were collected via Google Forms, then pseudo-anonymised using a participant code. Interviews were performed online via Zoom (version: 5.7.6) and transcribed via the Happy Scribe audio transcription platform. The principal researcher (MA) pilot-tested the questionnaire and interview guide with a UK doctor with experience in refugee healthcare to refine these prior to use. Questionnaire and Semi-Structured Interview Procedure: A questionnaire in English, distributed by email, was used to collect specific factual descriptive data about the healthcare workers and the services in which they worked (Appendix 1). Responses were then discussed in-depth in interviews conducted by MA. No prior relationship had been established between the participants and MA, and participants were informed about MA's background and interest in the study. No non-participants were present during interviews. Interviews were conducted using semi-structured, open-ended questions based on a topic guide (Appendix 2). Interviewees were encouraged to introduce new topics and themes they deemed relevant. Interviews were video-recorded, lasting between 50 and 90 minutes. No repeat interviews were conducted, field notes were not made during interviews, and transcripts were not returned to participants. Data analysis: Questionnaire data was summarised and triangulated with the themes identified in interviews. The interviews transcripts were proof-read against recording and were then uploaded to NVivo12 (QSR International Pty Ltd 2018), and content thematic analysis was used (by MA) to analyse data and themes.[11] Following familiarisation with the data, three interview transcripts were analysed to develop the first version of the coding framework. This analysis was both deductive and inductive, with open coding applied.[12] Codes were then organised into themes based on the literature and concepts from the dataset. Themes were then reviewed and refined to develop a final coding framework (Appendix 3), which was then applied to the data. Finally, the coding framework was summarised into Key Themes to facilitate reporting the results. Participants did not give feedback on the findings. Ethical consideration: Ethical approval was obtained from the London School of Hygiene and Tropical Medicine (ref. 27582). Informed consent was provided by all study participants. Study records were kept secure and confidential with restricted access, and no participant identifiable data were shared. Results Participant Demographics : The study included 16 participants from 8 European countries within the continent of Europe, working in different specialties and levels of care (Table 1). Half the participants were specialists in Paediatric Infectious Disease; the remainder represented a range of other specialities. Key themes: The key themes identified are summarised in Table 2. These are explored below, first in terms of description of the service provided and then in terms of barriers and facilitators to providing IHAs as discussed by the interviewees. Description of the Service: Service Structure The participants provided health assessments of CYPSAR in a variety of settings, including refugee shelters, hospitals and community-based services. Healthcare providers interviewed encountered CYPSAR at different points in the patient journey. Some performed a rapid standardised assessment after arrival, mainly focused on Tuberculosis (TB) screening. Others provided an individualised health assessment (often in a hospital setting). Participants working in hospital-based settings often referred to primary care for immunisations and follow-up care. Figure 1 summarises the situations in which CYPSAR encountered health professionals in the study. Demographics of service users: Multiple countries of origin of assessed CYPSAR were described, most commonly Afghanistan and Syria. All informants reported encountering more male than female patients. Some described their services as only or predominantly providing care to either CYPSAR who are unaccompanied or to families with young children. 11 participants saw both groups. Features of the Initial Health Assessment Most health assessments described included a medical history and physical examination. Immunisation was offered in some settings, although many referred to primary care or other services to complete immunisations (Table 3). Both the infectious diseases screened for and the context for screening varied significantly, as shown in Table 4. Some participants offered asymptomatic screening to all patients, whilst others screened based on symptoms or countries of origin. Tests for HIV, TB, Hepatitis B and Hepatitis C were frequently offered universally. In many cases, TB screening was carried out by independent services, most commonly with a chest radiograph for minors over 15 years of age and a tuberculin skin test or interferon gamma release assay (IGRA) bloodtest in younger children. However, there was significant variation in practice. Testing for intestinal parasites and neglected tropical diseases such as schistosomiasis and strongyloidiasis was usually based on symptoms or country of origin. Three services routinely treated patients empirically with anti-helminthics. Regarding general paediatric health screening, of 16 participants, 13 reported conducting a developmental assessment, particularly those who commonly saw families with young children. Many offered nutrition advice, whilst only 3 participants mentioned performing vision or hearing tests. With regards to routinely performed blood tests (participants were specifically asked about screening for anaemia, haemoglobinopathy, and vitamin D levels); 11 services routinely tested haemoglobin for anemia, whilst 6 tested for vitamin D deficiency in all patients. Almost all participants discussed mental health and trauma during the IHA. Most took an unstructured approach through questions regarding quality of sleep, headaches, or school performance. However, some interviewees used specific questionnaires (Table 3) to screen for mental health problems. Many highlighted the importance of appropriate mental health follow-up for their patients. "There is often a bit of what I call the honeymoon period, (…), but if we see them six months down the line, all the trauma and the problems, you know, they do not go away.” Only three of the services offered universal testing for sexually transmitted infections, ten offered symptomatic screening only and the three remaining sites did not routinely offer testing (Table 4). Sexual health discussions, addressing infection, safety, consent, and abuse, were offered in most, but not all, services seeing adolescents. Only a few services could direct patients to sexual health services. Some informants approached the topic of female genital mutilation (FGM), although most did not. A few informants reported being able to refer patients to gynecology services with FGM expertise. "If there has been a history of abuse, trauma, or rape. then we screen, and sometimes if someone tells us that they have been in prison (…) even if they do not tell you that they have been abused, well...you assume it." Resources within the service: Health reports were provided in the national language across all services. In some cases, comprehensive reports were sent to patients after follow-up consultations, while in others, brief reports were given directly to patients. However, not all services provided written documentation of assessments to service users. With the exception of one respondent, all had access to translation services, which included face-to-face, telephone, and video-call options. Participants reported significant variation in staffing models. For example, while some services have nurses working independently, administrative staff, social workers, community health workers, or case coordinators, others have only one doctor and one assistant. Staff had limited training specific to migrant health, however most had some background in infectious disease, tropical medicine or international health, and national guidelines were usually available. Barriers and Facilitators: Identified Barriers and Facilitators are summarised in Table 5 by Themes. We have removed participant identification numbers to preserve anonymity. Discussion We present qualitative data from 16 clinicians working in a range of settings in 8 European countries. There was significant variation in the content of IHAs offered to migrant children, especially with regard to assessment for infectious diseases and non-communicable diseases. Respondents shared the experience of challenges in provision of appropriate mental healthcare for migrant children. Interviews revealed significant shared experience regarding barriers and facilitators to delivery of high quality IHAs despite the variation in settings and available healthcare provision. Similarities in services provided by our participants include a common approach of history and examination, as well as inclusion of immunisation history in the healthcare assessment. This overall structure is in line with European[ 8 ] , [ 17 ] and international recommendations[ 5 ] , [ 10 ]. However, the infectious diseases screening offered varied widely, and many of the settings only offered TB screening universally. This is consistent with recent surveys of infection screening in European migrant populations[ 18 ] , [ 19 ] , [ 20 ] , [ 21 ] however, there is evidence to suggest that screening for a wider panel of infections may be more effective[ 20 ] , [ 22 ] , particularly in the CYPSAR-U population[ 23 ] , [ 24 ]. The literature suggests that there is significant inter-country [ 25 ], as well as intra-country, variation in recommendations and practice for infection screening (for example, regional variation within Germany)[ 26 ]. Nearly all participants perform some form of mental health assessment. Approaches varied widely from unstructured to structured. However, most informants reported significant resource challenges in providing adequate mental healthcare to this population to address any issues identified. This is consistent with existing literature, which shows that mental health problems are very common in this population [ 27 ] , [ 28 ] , [ 29 ] , [ 30 ] and that, currently, mental health provision for migrants is under-resourced in most European countries [ 31 ] , [ 32 ] , [ 33 ] , [ 21 ]. Participants supported the use of a mental health questionnaire, which is consistent with recent research[ 34 ] , [ 35 ] and guidance[ 36 ] , [ 10 ]. Further research is needed into early effective and cost-effective mental health stabilisation in this vulnerable and traumatised population. Despite the wide variation in services offered, experiences of barriers and facilitators to high quality IHAs were largely consistent amongst participants. Informants shared the experience of lengthy and complex consultations due to the need for translators, complex previous history of patients as well as the need to explore difficult and unstable social situations. As a result, challenges around resources and funding for these assessments were nearly universal. Furthermore, most of our interviewees reported inadequacy of documentation systems making sharing of information between healthcare settings and other sectors challenging. Facilitators identified to providing complex consultations were also supported by existing evidence. Participants emphasised the importance of qualified professional translators, consistent with current understanding of factors addressing cultural barriers in migrant health care[ 37 ] , [ 38 ]. Additionally, our participants highlighted the value of multidisciplinary teams including nurses, community health workers, safeguarding and social care teams in facilitating appropriate IHAs. Recent literature promoting a ‘whole child’ approach to IHAs for migrant children also highlights the importance of multidisciplinary team working[ 39 ] , [ 6 ] as well as the need to listen to the voices of service-users to develop appropriate services[ 38 ] , [ 40 ]. Further research is needed into cost-effectiveness of various models of care, and the use of peers and lower cost staff to support some aspects of the IHA. Our findings highlight the variability in health assessments across Europe and lack of standardization in practice. This variability in provided services is not explained by differences in national guidelines, which are very similar in their content[ 18 ] , [ 41 ] , [ 42 ] , [ 43 ] , [ 44 ]. High variability may be due to resource limitations, scarcity of research and evidence regarding the needs of migrant children[ 45 ], difficulty in implementing existing guidelines due to political context (including lack of political will and funding)[ 22 ] ,inter-country variation in national policies[ 21 ] and demographics of children arriving. Furthermore, in the broader context of paediatric healthcare, there is evidence that much variation may simply be due to the country in which clinicians are working[ 46 ]. Further research is required to fully understand variation in practice between countries. As no new themes emerged throughout the coding of the data, it is likely that saturation was reached. However, an important limitation of the study is possible reflexivity, as all coding and interviews were performed by the same researcher, who, at the time of the study was a MSc student with a background in paediatrics. Further, not all European countries were included, and some (e.g. Germany with four participants) were represented more than others (e.g. Switzerland and Greece with one participant each). There are therefore limits to the generalizability of our work, within Europe and beyond. Conclusions We show that IHAs for migrant children are delivered in a range of settings and services across European countries. Despite some commonality in content and approach, there is wide variation in implementation. There is significant shared experience, however, around factors which may make delivery of care challenging, and factors which mitigate against these. There is a need for further standardised data collection to determine and evidence best practice and inform robust guidelines to ensure equitable and consistent delivery of care to this vulnerable population. It is imperative that the voice of the child should be central to this approach. Further, there is a need for advocacy for migrant health care from health workers, national authorities and civil organizations alike to ensure prioritization of development of appropriate high-quality services. Healthcare for migrant children requires significant resources (including infectious diseases diagnostics, translators, vaccination facilities and time). Consequently, it remains a significant challenge to adequately support this group within standard health care services in most European countries. There is a need for investment in migrant child health services to ensure an adapted quality health assessment but also to support the integration of these children into standard health care systems for ongoing care following initial health assessment. Abbreviations CYPSAR - Children and young people seeking asylum and refugees CYPSAR-U - Children and young people seeking asylum and refugees - unaccompanied CRC - Convention on the Rights of the Child EAP - European Academy of Paediatrics FGM - Female genital mutilation HIV – Human immunodeficiency virus Hep B – Hepatitis B Hep C – Hepatitis C ID - Infectious Diseases; IGRA – Interferon-gamma release assay IHA - Initial Health Assessments NCD - Non-Communicable Diseases PSA - People seeking asylum STI – Sexually transmitted infections TB - Tuberculosis UASC – Unaccompanied asylum seeking children WHO – World Health Organization Statements and Declarations Acknowledgments: We would like to thank the following colleagues for their time and valuable contributions to this work, and for generously sharing their expertise and experiences. Albertine Baauw , Director Traininginstitute Global Health, Utrecht, the Netherlands Allison Ward , Camden Integrated Services for Children, Central and North West London NHS Foundation Trust, London, United Kingdom . Andreas Lindner and Gabriela Equihua Martinez , Institute of International Health, Charité-Universitätsmedizin Berlin, Germany. Benedikt Spielberger , Division for Paediatric Infectious Diseases and Rheumatology, Department of Paediatrics and Adolescent Medicine, University Medical Centre, Medical Faculty, University of Freiburg, Freiburg, Germany. Christian Harkensee , Dumfries & Galloway Royal Infirmary, Dumfries, Scotland, United Kingdom Claire Leblanc , Service de pédiatrie générale, maladies infectieuses et médecine interne Hôpital Robert Debré, Assistance Publique - Hôpitaux de Paris, Paris, France. Cristina Epalza , Paediatric Infectious Diseases Unit, Department of Paediatrics, Hospital Universitario 12 de Octubre, imas12, Madrid, Spain. Florian Götzinger , Department of Paediatric and Adolescent Medicine & Austrian Reference Centre for Childhood Tuberculosis, Klinik Ottakring, Vienna Healthcare Group, Vienna, Austria. Hannah Seeba , Gesundheitsamt Bremen Referat 41 – Abschnitt UmA, Bremen, Germany. Haude Cogo and Camille Bréhin , General paediatrics - Pediatric infectious diseases, Children Hospital, University Hospital of Toulouse, France. Johannes Pfeil , Kinder- und Hausarztpraxis, Schwaigern, Germany. Malte Kohns Vasconcelos and Chloé Schlaeppi , Department of Paediatric Infectious Diseases and Vaccinology, University Children's Hospital Basel (UKBB), Basel, Switzerland. María Espiau , Paediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain. Nathalie Dournon , Maladies infectieuses et tropicales, Hôpital Raymond Poincaré, Assistance Publique - Hôpitaux de Paris, France. Nuria Serre and Fernando Salvador , International Health Unit Vall d’Hebron-Drassanes, Infectious Diseases Department, Vall d’Hebron University Hospital, PROSICS Barcelona, and Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC); Instituto de Salud Carlos III, Madrid, Spain. Sara Sahba , medical doctor in Youth Healthcare GGD Flevoland, the Netherlands. Stayroula Papailiou and Alexandros Panos , National and Kapodistrian University of Athens, School of Medicine, Second Department of Pediatrics, Aglaia Kiriakou Children's Hospital, Athens, Greece. Ulrich von Both , Division of Paediatric Infectious Diseases, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich; German Center for Infection Research (DZIF), Partner Site Munich, Munich, Germany. Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests: The authors have no relevant financial or non-financial interests to disclose. Author Contributions: S.E. and N.L. contributed equally to this work and share last authorship. M.A. conducted the interviews, administered the questionnaires, performed the data analysis, and wrote the initial manuscript. S.E. and N.L. provided critical input during drafting, contributing to the design, analysis, and intellectual content of the manuscript. S.P. revised the manuscript for submission, incorporating feedback, and made substantial contributions to data interpretation. M.A. developed the tables and figures. S.Y. reviewed and provided critical feedback on the final manuscript. Ethics approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the London School of Hygiene and Tropical Medicine Ethics Committee (Date: 04.07.2022/ refNr: 27582). 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Hollifield et al. , “The Refugee Health Screener-15 (RHS-15): development and validation of an instrument for anxiety, depression, and PTSD in refugees,” Gen Hosp Psychiatry , vol. 35, no. 2, pp. 202–209, Mar. 2013, doi: 10.1016/J.GENHOSPPSYCH.2012.12.002. RCPCH, “Refugee and asylum seeking children and young people - guidance for paediatricians | RCPCH,” RCPCH Guidelines. Accessed: Nov. 04, 2023. [Online]. Available: https://www.rcpch.ac.uk/resources/refugee-asylum-seeking-children-young-people-guidance-paediatricians S. K. Clarke, J. Jaffe, and R. Mutch, “Overcoming Communication Barriers in Refugee Health Care,” Pediatr Clin North Am , vol. 66, no. 3, pp. 669–686, Jun. 2019, doi: 10.1016/J.PCL.2019.02.012. T. Van Loenen et al. , “Primary care for refugees and newly arrived migrants in Europe: a qualitative study on health needs, barriers and wishes,” Eur J Public Health , vol. 28, no. 1, pp. 82–87, Feb. 2018, doi: 10.1093/EURPUB/CKX210. N. S. Clemente, P. Cinardo, A. Ward, N. Longley, C. Harkensee, and S. Eisen, “A Whole-child, whole-family approach to health assessments for asylum-seeking children,” BMJ Paediatr Open , vol. 6, p. 1575, 2022, doi: 10.1136/bmjpo-2022-001575. M. Driedger et al. , “Accessibility and Acceptability of Infectious Disease Interventions Among Migrants in the EU/EEA: A CERQual Systematic Review,” Int J Environ Res Public Health , vol. 15, no. 11, Nov. 2018, doi: 10.3390/IJERPH15112329. M. Buettcher, L. Kantonsspital, J. Trück, C. Berger, and N. Ritz, “Guidance for testing and preventing infections and updating immunisations in asymptomatic refugee children and adolescents in Switzerland,” 2016. WHO European Region, “Health of refugees and migrants,” WHO Europe , no. December, p. 28, 2018. “NUOVE INDICAZIONI GLNBM-SIP PER L’ACCOGLIENZA SANITARIA AL MINORE MIGRANTE Roma-30 Novembre 2013 STANDARD OPERATING PROCEDURE FOR HEALTH ASSISTANCE OF NEWLY ARRIVED MIGRANT MINORS NATIONAL WORKING GROUP FOR MIGRANT CHILDREN ITALIAN SOCIETY OF PEDIATRICS,” 2013. O. for H. I. and Disparities, “Children’s health: migrant health guide - GOV.UK.” Accessed: Nov. 16, 2023. [Online]. Available: https://www.gov.uk/guidance/childrens-health-migrant-health-guide T. Noori et al. , “Strengthening screening for infectious diseases and vaccination among migrants in Europe: What is needed to close the implementation gaps?,” Travel Med Infect Dis , vol. 39, Jan. 2021, doi: 10.1016/J.TMAID.2020.101715. J. E. Dewez et al. , “Availability and use of rapid diagnostic tests for the management of acute childhood infections in Europe: A cross-sectional survey of paediatricians,” PLoS One , vol. 17, no. 12, Dec. 2022, doi: 10.1371/JOURNAL.PONE.0275336. Tables Tables 1 to 5 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Tables.docx SupplementaryInformation.docx Cite Share Download PDF Status: Published Journal Publication published 12 Sep, 2025 Read the published version in European Journal of Pediatrics → Version 1 posted Editorial decision: Revision requested 27 May, 2025 Reviews received at journal 26 May, 2025 Reviewers agreed at journal 08 May, 2025 Reviews received at journal 01 May, 2025 Reviewers agreed at journal 17 Apr, 2025 Reviewers agreed at journal 26 Mar, 2025 Reviewers invited by journal 21 Mar, 2025 Editor assigned by journal 21 Mar, 2025 Submission checks completed at journal 21 Mar, 2025 First submitted to journal 11 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Image 1: \"\u003ca href=\"https://www.flickr.com/photos/14214150@N02/9616711348\"\u003eGetting a check-up with the International Rescue Committee\u003c/a\u003e\" by \u003ca href=\"https://www.flickr.com/photos/14214150@N02\"\u003eDFID - UK Department for International Development\u003c/a\u003e is licensed under \u003ca href=\"https://creativecommons.org/licenses/by/2.0/?ref=openverse\"\u003eCC BY 2.0\u003c/a\u003e. Image 2: \"\u003ca href=\"https://www.flickr.com/photos/28650594@N03/5333327810\"\u003eWinter Setting in, ISAF Troops Provide Comfort to Afghan Refugees [Image 4 of 4]\u003c/a\u003e\" by \u003ca href=\"https://www.flickr.com/photos/28650594@N03\"\u003eDVIDSHUB\u003c/a\u003e is licensed under \u003ca href=\"https://creativecommons.org/licenses/by/2.0/?ref=openverse\"\u003eCC BY 2.0\u003c/a\u003e. Image 3: \"\u003ca href=\"https://www.flickr.com/photos/33227787@N05/20667746949\"\u003e150824-girl-school-first-day.jpg\u003c/a\u003e\" by \u003ca href=\"https://www.flickr.com/photos/33227787@N05\"\u003er.nial.bradshaw\u003c/a\u003e is licensed under \u003ca href=\"https://creativecommons.org/licenses/by/2.0/?ref=openverse\"\u003eCC BY 2.0\u003c/a\u003e.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6205010/v1/6875b2e6d401b314c3f7a99b.png"},{"id":91817649,"identity":"fb439401-f5bf-4baf-b15f-bbcfb5952db4","added_by":"auto","created_at":"2025-09-22 07:00:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":962824,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6205010/v1/ab710020-6b58-44ef-8be9-4bec7bd4da19.pdf"},{"id":79787042,"identity":"4107fa3f-17a7-42ba-9c1a-752508dde71b","added_by":"auto","created_at":"2025-04-02 17:01:03","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":55057,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6205010/v1/0636762a5773fff654bb3383.docx"},{"id":79787044,"identity":"33b0dbbb-c476-41d7-bae5-680846e57120","added_by":"auto","created_at":"2025-04-02 17:01:03","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":1322180,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryInformation.docx","url":"https://assets-eu.researchsquare.com/files/rs-6205010/v1/84783012466a986ac9004f20.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluating the health assessments of migrant children in Europe: exploring the experience of service providers","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn 2023, there were 36.4 million refugees worldwide, and 6.1 million people sought asylum globally\u0026nbsp;\u0026nbsp;—the highest number on record [1][2]. Of these, 38% were under 18 years of age (children and young people seeking asylum and refugees, or CYPSAR)\u0026nbsp;[2]. The rise in international migration to Europe has been more significant than in any other region over the past three decades\u0026nbsp;[2]. In 2022, 19% of people seeking asylum in Europe were unaccompanied minors (CYPSAR-U), often referred to as unaccompanied asylum-seeking children (UASC)\u0026nbsp;[3]. Ongoing geopolitical instability, including conflicts in Sudan, Ukraine, and the Middle East, indicates that the number of child migrants to Europe is likely to continue increasing.\u003c/p\u003e\n\u003cp\u003eUnder the Convention on the Rights of the Child (CRC), which has been signed by all European countries, children seeking asylum or in an irregular situation are entitled to the same rights as those with legal residency. The CRC specifically affirms the child's right to enjoy the highest attainable standard of health and to have access to treatment and rehabilitation for illness\u003cem\u003e[4]\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eMost child migrants and refugees arrive in Europe after long, arduous journeys with limited access to care[5] and present with health needs that may\u0026nbsp;differ from those of\u0026nbsp;children born in Europe[6]\u003csup\u003e,\u003c/sup\u003e[7].\u0026nbsp;Therefore,\u0026nbsp;the WHO recommends a\u0026nbsp;holistic and\u0026nbsp;comprehensive health assessment delivered by a healthcare worker with a background\u0026nbsp;in paediatrics\u0026nbsp;as\u0026nbsp;soon as possible after arrival to\u0026nbsp;the destination country[5]. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough evidence related to, and research into, migrant child health remain scarce, several European recommendations for the care of CYPSAR have been developed, including the \u0026nbsp;consensus \u0026nbsp;recommendations of the European Academy of Paediatrics (EAP), based on the recommendations of 31 European countries[8]. However, research on actual practice and implementation of existing recommendations across Europe is lacking. We explore the practice and experiences of clinicians across Europe performing initial health assessments (IHAs) for CYPSAR.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is a qualitative research study, in which data was collected using a questionnaire and semi-structured interviews following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [9].\u003c/p\u003e\n\u003cp\u003eThe literature on migrant children uses a variety of terms (asylum-seeker, refugee, displaced) interchangeably. Here, we use the term CYPSAR to mean\u0026nbsp;a child or young person (\u0026lt;18 years) who has moved to or settled in another country and experienced unfavourable conditions, including war and violence, socioeconomic deprivation, health care, and education limitations[10]\u003csup\u003e,\u003c/sup\u003e[8].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Population and Sampling\u003c/strong\u003e\u003cem\u003e:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe target population for this study consisted of clinicians working in European (European Union member states and UK and Switzerland) countries who provide IHA for CYPSAR. Participants were initially recruited through the investigators' existing networks (EuroTravNet, ESPID), as well as by contacting national paediatric associations and employing snowball sampling. Once potential participants were identified, they were invited to participate in the study and sent an informed consent form via email. After consent was obtained, participants received a questionnaire, and an interview date was scheduled.\u003c/p\u003e\n\u003cp\u003eAn estimated sample size of 15 was considered sufficient for data saturation [11], however participants who\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eresponded beyond the point of active recruitment were still allowed to participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData was collected between July and August 2022. The design of both the structured questionnaires and the topic guide for semi-structured interviews were informed by European recommendations for health assessment of migrant children[8]. Questionnaire responses were collected via Google Forms, then pseudo-anonymised using a participant code. Interviews were performed online via Zoom (version: 5.7.6) and transcribed via the Happy Scribe audio transcription platform.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe principal researcher (MA) pilot-tested the questionnaire and interview guide with a UK doctor with experience in refugee healthcare to refine these prior to use.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQuestionnaire and Semi-Structured Interview Procedure:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA questionnaire in English, distributed by email, was used to collect specific factual descriptive data about the healthcare workers and the services in which they worked (Appendix 1). Responses were then discussed in-depth in interviews conducted by MA. No prior relationship had been established between the participants and MA, and participants were informed about MA's background and interest in the study. No non-participants were present during interviews. Interviews were conducted using semi-structured, open-ended questions based on a topic guide (Appendix 2). Interviewees were encouraged to introduce new topics and themes they deemed relevant. Interviews were video-recorded, lasting between 50 and 90 minutes. No repeat interviews were conducted, field notes were not made during interviews, and transcripts were not returned to participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuestionnaire data was summarised and triangulated with the themes identified in interviews. The interviews transcripts were proof-read against recording and were then uploaded to NVivo12 (QSR International Pty Ltd 2018), and content thematic analysis was used (by MA) to analyse data and themes.[11]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFollowing familiarisation with the data, three interview transcripts were analysed to develop the first version of the coding framework. This analysis was both deductive and inductive, with open coding applied.[12] Codes were then organised into themes based on the literature and concepts from the dataset. Themes were then reviewed and refined to develop a final coding framework (Appendix 3), which was then applied to the data. Finally, the coding framework was summarised into Key Themes to facilitate reporting the results. Participants did not give feedback on the findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical consideration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the London School of Hygiene and Tropical Medicine (ref. 27582). \u0026nbsp; Informed consent was provided by all study participants. Study records were kept secure and confidential with restricted access, and no participant identifiable data were shared.\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Demographics\u003cem\u003e:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study included 16 participants from 8 European countries within the continent of Europe, working in different specialties and levels of care (Table 1). Half the participants were specialists in Paediatric Infectious Disease; the remainder represented a range of other specialities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKey themes:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe key themes identified are summarised in Table 2. These are explored below, first in terms of description of the service provided and then in terms of barriers and facilitators to providing IHAs as discussed by the interviewees.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescription of the Service:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eService Structure\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe participants provided health assessments of CYPSAR in a variety of settings, including refugee shelters, hospitals and community-based services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHealthcare providers interviewed encountered CYPSAR at different points in the patient journey. \u0026nbsp;Some performed a rapid standardised assessment after arrival, mainly focused on Tuberculosis (TB) screening. \u0026nbsp;Others provided an individualised health assessment (often in a hospital setting). Participants working in hospital-based settings often referred to primary care for immunisations and follow-up care. Figure 1 summarises the situations in which CYPSAR encountered health professionals in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDemographics of service users:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMultiple countries of origin of assessed CYPSAR were described, most commonly Afghanistan and Syria. All informants reported encountering more male than female patients. Some described their services as only or predominantly providing care to either CYPSAR who are unaccompanied or to families with young children. 11 participants saw both groups. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFeatures of the Initial Health Assessment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost health assessments described included a medical history and physical examination. Immunisation was offered in some settings, although many referred to primary care or other services to complete immunisations (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBoth the infectious diseases screened for and the context for screening varied significantly, as shown in Table 4. Some participants offered asymptomatic screening to all patients, whilst others screened based on symptoms or countries of origin. Tests for HIV, TB, Hepatitis B and Hepatitis C were frequently offered universally. In many cases, TB screening was carried out by independent services, most commonly with a chest radiograph for minors over 15 years of age and a tuberculin skin test or interferon gamma release assay (IGRA) bloodtest in younger children. However, there was significant variation in practice.\u003c/p\u003e\n\u003cp\u003eTesting for intestinal parasites and neglected tropical diseases such as schistosomiasis and strongyloidiasis was usually based on symptoms or country of origin. Three services routinely treated patients empirically with anti-helminthics.\u003c/p\u003e\n\u003cp\u003eRegarding general paediatric health screening, of 16 participants, 13 reported conducting a developmental assessment, particularly those who commonly saw families with young children. Many offered nutrition advice, \u0026nbsp;whilst only 3 participants mentioned performing vision or hearing tests. With regards to routinely performed blood tests (participants were specifically asked about screening for anaemia, haemoglobinopathy, and vitamin D levels); 11 services routinely tested haemoglobin for anemia, whilst 6 tested for vitamin D deficiency in all patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlmost all participants discussed mental health and trauma during the IHA. Most took an unstructured approach through questions regarding quality of sleep, headaches, or school performance. However, some interviewees used specific questionnaires (Table 3) to screen for mental health problems. Many highlighted the importance of appropriate mental health follow-up for their patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;There is often a bit of what I call the honeymoon period, (\u0026hellip;), but if we see them six months down the line, all the trauma and the problems, you know, they do not go away.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOnly three of the services offered universal testing for sexually transmitted infections, ten offered symptomatic screening only and the three remaining sites did not routinely offer testing (Table 4). Sexual health discussions, addressing infection, safety, consent, and abuse, were offered in most, but not all, services seeing adolescents. Only a few services could direct patients to sexual health services. Some informants approached the topic of female genital mutilation (FGM), although most did not. A few informants reported being able to refer patients to gynecology services with FGM expertise.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;If there has been a history of abuse, trauma, or rape. then we screen, and sometimes if someone tells us that they have been in prison (\u0026hellip;) even if they do not tell you that they have been abused, well...you assume it.\u0026quot; \u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResources within the service:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHealth reports were provided in the national language across all services. In some cases, comprehensive reports were sent to patients after follow-up consultations, while in others, brief reports were given directly to patients. However, not all services provided written documentation of assessments to service users. With the exception of one respondent, all had access to translation services, which included face-to-face, telephone, and video-call options.\u003c/p\u003e\n\u003cp\u003eParticipants reported significant variation in staffing models. For example, while some services have nurses working independently, administrative staff, social workers, community health workers, or case coordinators, others have only one doctor and one assistant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStaff had limited training specific to migrant health, however most had some background in infectious disease, tropical medicine or international health, and national guidelines were usually available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBarriers and Facilitators:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIdentified Barriers and Facilitators are summarised in Table 5 by Themes. We have removed participant identification numbers to preserve anonymity.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe present qualitative data from 16 clinicians working in a range of settings in 8 European countries. There was significant variation in the content of IHAs offered to migrant children, especially with regard to assessment for infectious diseases and non-communicable diseases. Respondents shared the experience of challenges in provision of appropriate mental healthcare for migrant children. Interviews revealed significant shared experience regarding barriers and facilitators to delivery of high quality IHAs despite the variation in settings and available healthcare provision.\u003c/p\u003e \u003cp\u003e Similarities in services provided by our participants include a common approach of history and examination, as well as inclusion of immunisation history in the healthcare assessment. This overall structure is in line with European[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and international recommendations[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, the infectious diseases screening offered varied widely, and many of the settings only offered TB screening universally. This is consistent with recent surveys of infection screening in European migrant populations[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] however, there is evidence to suggest that screening for a wider panel of infections may be more effective[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e particularly in the CYPSAR-U population[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The literature suggests that there is significant inter-country [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], as well as intra-country, variation in recommendations and practice for infection screening (for example, regional variation within Germany)[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNearly all participants perform some form of mental health assessment. Approaches varied widely from unstructured to structured. However, most informants reported significant resource challenges in providing adequate mental healthcare to this population to address any issues identified. This is consistent with existing literature, which shows that mental health problems are very common in this population [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and that, currently, mental health provision for migrants is under-resourced in most European countries [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Participants supported the use of a mental health questionnaire, which is consistent with recent research[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] and guidance[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Further research is needed into early effective and cost-effective mental health stabilisation in this vulnerable and traumatised population.\u003c/p\u003e \u003cp\u003eDespite the wide variation in services offered, experiences of barriers and facilitators to high quality IHAs were largely consistent amongst participants. Informants shared the experience of lengthy and complex consultations due to the need for translators, complex previous history of patients as well as the need to explore difficult and unstable social situations. As a result, challenges around resources and funding for these assessments were nearly universal. Furthermore, most of our interviewees reported inadequacy of documentation systems making sharing of information between healthcare settings and other sectors challenging.\u003c/p\u003e \u003cp\u003eFacilitators identified to providing complex consultations were also supported by existing evidence. Participants emphasised the importance of qualified professional translators, consistent with current understanding of factors addressing cultural barriers in migrant health care[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Additionally, our participants highlighted the value of multidisciplinary teams including nurses, community health workers, safeguarding and social care teams in facilitating appropriate IHAs. Recent literature promoting a \u0026lsquo;whole child\u0026rsquo; approach to IHAs for migrant children also highlights the importance of multidisciplinary team working[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] as well as the need to listen to the voices of service-users to develop appropriate services[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Further research is needed into cost-effectiveness of various models of care, and the use of peers and lower cost staff to support some aspects of the IHA.\u003c/p\u003e \u003cp\u003eOur findings highlight the variability in health assessments across Europe and lack of standardization in practice. This variability in provided services is not explained by differences in national guidelines, which are very similar in their content[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. High variability may be due to resource limitations, scarcity of research and evidence regarding the needs of migrant children[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], difficulty in implementing existing guidelines due to political context (including lack of political will and funding)[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] ,inter-country variation in national policies[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and demographics of children arriving. Furthermore, in the broader context of paediatric healthcare, there is evidence that much variation may simply be due to the country in which clinicians are working[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Further research is required to fully understand variation in practice between countries.\u003c/p\u003e \u003cp\u003eAs no new themes emerged throughout the coding of the data, it is likely that saturation was reached. However, an important limitation of the study is possible reflexivity, as all coding and interviews were performed by the same researcher, who, at the time of the study was a MSc student with a background in paediatrics. Further, not all European countries were included, and some (e.g. Germany with four participants) were represented more than others (e.g. Switzerland and Greece with one participant each). There are therefore limits to the generalizability of our work, within Europe and beyond.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWe show that IHAs for migrant children are delivered in a range of settings and services across European countries. Despite some commonality in content and approach, there is wide variation in implementation. There is significant shared experience, however, around factors which may make delivery of care challenging, and factors which mitigate against these.\u003c/p\u003e \u003cp\u003e There is a need for further standardised data collection to determine and evidence best practice and inform robust guidelines to ensure equitable and consistent delivery of care to this vulnerable population. It is imperative that the voice of the child should be central to this approach. Further, there is a need for advocacy for migrant health care from health workers, national authorities and civil organizations alike to ensure prioritization of development of appropriate high-quality services.\u003c/p\u003e \u003cp\u003eHealthcare for migrant children requires significant resources (including infectious diseases diagnostics, translators, vaccination facilities and time). Consequently, it remains a significant challenge to adequately support this group within standard health care services in most European countries. There is a need for investment in migrant child health services to ensure an adapted quality health assessment but also to support the integration of these children into standard health care systems for ongoing care following initial health assessment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul\u003e\n \u003cli\u003eCYPSAR - Children and young people seeking asylum and refugees\u003c/li\u003e\n \u003cli\u003eCYPSAR-U - Children and young people seeking asylum and refugees - unaccompanied\u003c/li\u003e\n \u003cli\u003eCRC - Convention on the Rights of the Child\u003c/li\u003e\n \u003cli\u003eEAP \u0026nbsp;- European Academy of Paediatrics\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eFGM \u0026nbsp;- Female genital mutilation\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHIV – Human immunodeficiency virus\u003c/li\u003e\n \u003cli\u003eHep B – Hepatitis B\u003c/li\u003e\n \u003cli\u003eHep C – Hepatitis C\u003c/li\u003e\n \u003cli\u003eID - Infectious Diseases;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIGRA – \u0026nbsp;Interferon-gamma release assay\u003c/li\u003e\n \u003cli\u003eIHA - Initial Health Assessments\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eNCD - \u0026nbsp;Non-Communicable Diseases\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePSA - People seeking asylum\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSTI – Sexually transmitted infections\u003c/li\u003e\n \u003cli\u003eTB - Tuberculosis\u003c/li\u003e\n \u003cli\u003eUASC – Unaccompanied asylum seeking children\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eWHO – World Health Organization\u003c/p\u003e"},{"header":"Statements and Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the following colleagues for their time and valuable contributions to this work, and for generously sharing their expertise and experiences.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAlbertine Baauw\u003c/strong\u003e, Director Traininginstitute Global Health, Utrecht, the Netherlands\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAllison Ward\u003c/strong\u003e, Camden Integrated Services for Children, Central and North West London NHS Foundation Trust, London, United Kingdom\u003cstrong\u003e.\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAndreas Lindner and Gabriela Equihua Martinez\u003c/strong\u003e, Institute of International Health, Charit\u0026eacute;-Universit\u0026auml;tsmedizin Berlin, Germany.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eBenedikt Spielberger\u003c/strong\u003e, Division for Paediatric Infectious Diseases and Rheumatology, Department of Paediatrics and Adolescent Medicine, University Medical Centre, Medical Faculty, University of Freiburg, Freiburg, Germany.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eChristian Harkensee\u003c/strong\u003e,\u0026nbsp;Dumfries \u0026amp; Galloway Royal Infirmary, Dumfries, Scotland, United Kingdom\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eClaire Leblanc\u003c/strong\u003e, Service de p\u0026eacute;diatrie g\u0026eacute;n\u0026eacute;rale, maladies infectieuses et m\u0026eacute;decine interne H\u0026ocirc;pital Robert Debr\u0026eacute;, Assistance Publique - H\u0026ocirc;pitaux de Paris, Paris, France.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCristina Epalza\u003c/strong\u003e, Paediatric Infectious Diseases Unit, Department of Paediatrics, Hospital Universitario 12 de Octubre, imas12, Madrid, Spain.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFlorian G\u0026ouml;tzinger\u003c/strong\u003e, Department of Paediatric and Adolescent Medicine \u0026amp; Austrian Reference Centre for Childhood Tuberculosis, Klinik Ottakring, Vienna Healthcare Group, Vienna, Austria.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eHannah Seeba\u003c/strong\u003e, Gesundheitsamt Bremen Referat 41 \u0026ndash; Abschnitt UmA, Bremen, Germany.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eHaude Cogo and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCamille Br\u0026eacute;hin\u003c/strong\u003e, General paediatrics - Pediatric infectious diseases, Children Hospital, University Hospital of Toulouse, France.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eJohannes Pfeil\u003c/strong\u003e, Kinder- und Hausarztpraxis, Schwaigern, Germany.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMalte\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eKohns Vasconcelos\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eand\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eChlo\u0026eacute; Schlaeppi\u003c/strong\u003e, Department of Paediatric Infectious Diseases and Vaccinology, University Children\u0026apos;s Hospital Basel (UKBB), Basel, Switzerland.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMar\u0026iacute;a Espiau\u003c/strong\u003e, Paediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d\u0026apos;Hebron, Barcelona, Spain.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eNathalie Dournon\u003c/strong\u003e, Maladies infectieuses et tropicales, H\u0026ocirc;pital Raymond Poincar\u0026eacute;, Assistance Publique - H\u0026ocirc;pitaux de Paris, France.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eNuria Serre and Fernando Salvador\u003c/strong\u003e, International Health Unit Vall d\u0026rsquo;Hebron-Drassanes, Infectious Diseases Department, Vall d\u0026rsquo;Hebron University Hospital, PROSICS Barcelona, and Centro de Investigaci\u0026oacute;n Biom\u0026eacute;dica en Red de Enfermedades Infecciosas (CIBERINFEC); Instituto de Salud Carlos III, Madrid, Spain.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSara Sahba\u003c/strong\u003e, medical doctor in Youth Healthcare GGD Flevoland, the Netherlands.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eStayroula Papailiou and Alexandros Panos\u003c/strong\u003e, National and Kapodistrian University of Athens, School of Medicine, Second Department of Pediatrics, Aglaia Kiriakou Children\u0026apos;s Hospital, Athens, Greece.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eUlrich von Both\u003c/strong\u003e, Division of Paediatric Infectious Diseases, Dr. von Hauner Children\u0026apos;s Hospital, University Hospital, LMU Munich; German Center for Infection Research (DZIF), Partner Site Munich, Munich, Germany.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.E. and N.L. contributed equally to this work and share last authorship. M.A. conducted the interviews, administered the questionnaires, performed the data analysis, and wrote the initial manuscript. S.E. and N.L. provided critical input during drafting, contributing to the design, analysis, and intellectual content of the manuscript. S.P. revised the manuscript for submission, incorporating feedback, and made substantial contributions to data interpretation. M.A. developed the tables and figures. S.Y. reviewed and provided critical feedback on the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the London School of Hygiene and Tropical Medicine Ethics Committee (Date: 04.07.2022/ refNr: 27582).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003e\u0026ldquo;International Migration Outlook 2024 | OECD.\u0026rdquo; Accessed: Jan. 16, 2025. [Online]. Available: https://www.oecd.org/en/publications/2024/11/international-migration-outlook-2024_c6f3e803.html\u003c/li\u003e\n\u003cli\u003eU. Migration, \u0026ldquo;Interactive World Migration Report 2022.\u0026rdquo; Accessed: Feb. 05, 2024. [Online]. Available: https://worldmigrationreport.iom.int/wmr-2022-interactive/\u003c/li\u003e\n\u003cli\u003eEurostat, \u0026ldquo;Children in migration - asylum applicants - Statistics Explained.\u0026rdquo; Accessed: Nov. 14, 2023. [Online]. 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Eisen, \u0026ldquo;Optimizing Early Diagnosis of Infectious Diseases in Migrant and Refugee Children: An Overview of Best Practices and Strategies,\u0026rdquo; \u003cem\u003ePediatr Infect Dis J\u003c/em\u003e, vol. 43, no. 8, pp. e278\u0026ndash;e281, Aug. 2024, doi: 10.1097/INF.0000000000004406.\u003c/li\u003e\n\u003cli\u003eK. Bozorgmehr, S. N\u0026ouml;st, H. M. Thaiss, and O. Razum, \u0026ldquo;Die gesundheitliche Versorgungssituation von Asylsuchenden : Bundesweite Bestandsaufnahme \u0026uuml;ber die Gesundheits\u0026auml;mter,\u0026rdquo; \u003cem\u003eBundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz\u003c/em\u003e, vol. 59, no. 5, pp. 545\u0026ndash;555, May 2016, doi: 10.1007/S00103-016-2329-4/FIGURES/5.\u003c/li\u003e\n\u003cli\u003eA. Kadir, A. Battersby, N. Spencer, and A. 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Pr\u0026uuml;fer-Kr\u0026auml;mer, \u0026ldquo;Health status and disease burden of unaccompanied asylum-seeking adolescents in Bielefeld, Germany: cross-sectional pilot study,\u0026rdquo; \u003cem\u003eTrop Med Int Health\u003c/em\u003e, vol. 21, no. 2, pp. 210\u0026ndash;218, Feb. 2016, doi: 10.1111/TMI.12649.\u003c/li\u003e\n\u003cli\u003eA. Laukamp, L. Pr\u0026uuml;fer-Kr\u0026auml;mer, F. Fischer, and A. Kr\u0026auml;mer, \u0026ldquo;Health of Syrian unaccompanied asylum seeking adolescents (UASA) at first medical examination in Germany in comparison to UASA from other world regions,\u0026rdquo; \u003cem\u003eBMC Int Health Hum Rights\u003c/em\u003e, vol. 19, no. 1, Feb. 2019, doi: 10.1186/s12914-019-0192-8.\u003c/li\u003e\n\u003cli\u003eE. Satinsky, D. C. Fuhr, A. Woodward, E. Sondorp, and B. Roberts, \u0026ldquo;Mental health care utilisation and access among refugees and asylum seekers in Europe: A systematic review,\u0026rdquo; \u003cem\u003eHealth Policy (New York)\u003c/em\u003e, vol. 123, no. 9, pp. 851\u0026ndash;863, Sep. 2019, doi: 10.1016/J.HEALTHPOL.2019.02.007.\u003c/li\u003e\n\u003cli\u003eH. Siddiq, A. Elhaija, and K. Wells, \u0026ldquo;An Integrative Review of Community-Based Mental Health Interventions Among Resettled Refugees from Muslim-Majority Countries,\u0026rdquo; \u003cem\u003eCommunity Ment Health J\u003c/em\u003e, vol. 59, no. 1, pp. 160\u0026ndash;174, Jan. 2023, doi: 10.1007/S10597-022-00994-Y.\u003c/li\u003e\n\u003cli\u003eF. K. Nkulu Kalengayi, A. K. Hurtig, A. Nordstrand, C. Ahlm, and B. M. 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Hollifield \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;The Refugee Health Screener-15 (RHS-15): development and validation of an instrument for anxiety, depression, and PTSD in refugees,\u0026rdquo; \u003cem\u003eGen Hosp Psychiatry\u003c/em\u003e, vol. 35, no. 2, pp. 202\u0026ndash;209, Mar. 2013, doi: 10.1016/J.GENHOSPPSYCH.2012.12.002.\u003c/li\u003e\n\u003cli\u003eRCPCH, \u0026ldquo;Refugee and asylum seeking children and young people - guidance for paediatricians | RCPCH,\u0026rdquo; RCPCH Guidelines. Accessed: Nov. 04, 2023. [Online]. Available: https://www.rcpch.ac.uk/resources/refugee-asylum-seeking-children-young-people-guidance-paediatricians\u003c/li\u003e\n\u003cli\u003eS. K. Clarke, J. Jaffe, and R. Mutch, \u0026ldquo;Overcoming Communication Barriers in Refugee Health Care,\u0026rdquo; \u003cem\u003ePediatr Clin North Am\u003c/em\u003e, vol. 66, no. 3, pp. 669\u0026ndash;686, Jun. 2019, doi: 10.1016/J.PCL.2019.02.012.\u003c/li\u003e\n\u003cli\u003eT. Van Loenen \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Primary care for refugees and newly arrived migrants in Europe: a qualitative study on health needs, barriers and wishes,\u0026rdquo; \u003cem\u003eEur J Public Health\u003c/em\u003e, vol. 28, no. 1, pp. 82\u0026ndash;87, Feb. 2018, doi: 10.1093/EURPUB/CKX210.\u003c/li\u003e\n\u003cli\u003eN. S. Clemente, P. Cinardo, A. Ward, N. Longley, C. Harkensee, and S. Eisen, \u0026ldquo;A Whole-child, whole-family approach to health assessments for asylum-seeking children,\u0026rdquo; \u003cem\u003eBMJ Paediatr Open\u003c/em\u003e, vol. 6, p. 1575, 2022, doi: 10.1136/bmjpo-2022-001575.\u003c/li\u003e\n\u003cli\u003eM. Driedger \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Accessibility and Acceptability of Infectious Disease Interventions Among Migrants in the EU/EEA: A CERQual Systematic Review,\u0026rdquo; \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e, vol. 15, no. 11, Nov. 2018, doi: 10.3390/IJERPH15112329.\u003c/li\u003e\n\u003cli\u003eM. Buettcher, L. Kantonsspital, J. Tr\u0026uuml;ck, C. Berger, and N. Ritz, \u0026ldquo;Guidance for testing and preventing infections and updating immunisations in asymptomatic refugee children and adolescents in Switzerland,\u0026rdquo; 2016.\u003c/li\u003e\n\u003cli\u003eWHO European Region, \u0026ldquo;Health of refugees and migrants,\u0026rdquo; \u003cem\u003eWHO Europe\u003c/em\u003e, no. December, p. 28, 2018.\u003c/li\u003e\n\u003cli\u003e\u0026ldquo;NUOVE INDICAZIONI GLNBM-SIP PER L\u0026rsquo;ACCOGLIENZA SANITARIA AL MINORE MIGRANTE Roma-30 Novembre 2013 STANDARD OPERATING PROCEDURE FOR HEALTH ASSISTANCE OF NEWLY ARRIVED MIGRANT MINORS NATIONAL WORKING GROUP FOR MIGRANT CHILDREN ITALIAN SOCIETY OF PEDIATRICS,\u0026rdquo; 2013.\u003c/li\u003e\n\u003cli\u003eO. for H. I. and Disparities, \u0026ldquo;Children\u0026rsquo;s health: migrant health guide - GOV.UK.\u0026rdquo; Accessed: Nov. 16, 2023. [Online]. Available: https://www.gov.uk/guidance/childrens-health-migrant-health-guide\u003c/li\u003e\n\u003cli\u003eT. Noori \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Strengthening screening for infectious diseases and vaccination among migrants in Europe: What is needed to close the implementation gaps?,\u0026rdquo; \u003cem\u003eTravel Med Infect Dis\u003c/em\u003e, vol. 39, Jan. 2021, doi: 10.1016/J.TMAID.2020.101715.\u003c/li\u003e\n\u003cli\u003eJ. E. Dewez \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Availability and use of rapid diagnostic tests for the management of acute childhood infections in Europe: A cross-sectional survey of paediatricians,\u0026rdquo; \u003cem\u003ePLoS One\u003c/em\u003e, vol. 17, no. 12, Dec. 2022, doi: 10.1371/JOURNAL.PONE.0275336.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Refugee, Asylum-seeking children, Unaccompanied minor, Immunisation, Europe, Tuberculosis","lastPublishedDoi":"10.21203/rs.3.rs-6205010/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6205010/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/u\u003e\u003cstrong\u003e: \u003c/strong\u003eIn 2023, the number of people seeking asylum globally reached a record high, with 38% aged under 18. Over the past three decades, Europe has experienced the largest increase in international migration. However, research focused on health of migrant children remains limited. While European guidelines for their care exist, evidence regarding implementation of these recommendations is limited. This study explores practices and experiences of healthcare professionals in Europe who conduct initial health assessments (IHAs) for children and young people seeking asylum and refugees (CYPSAR).\u003cu\u003e\u003cstrong\u003e\u003cbr\u003e\nMethods\u003c/strong\u003e\u003c/u\u003e\u003cstrong\u003e: \u003c/strong\u003eA qualitative study was conducted (between July and August 2022), using questionnaires and semi-structured interviews to explore perspectives of healthcare providers who care for migrant children in Europe. Participants were recruited through snowball sampling from European expert networks, with 16 clinicians from eight European countries taking part. Data were analysed thematically using NVivo12.\u003cstrong\u003e\u003cbr\u003e\n \u003c/strong\u003e\u003cu\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/u\u003e\u003cstrong\u003e \u003c/strong\u003eWe found considerable variation in content and delivery of IHAs, particularly with regard to screening for communicable and non-communicable diseases. Although immunisation was prioritised, some services lacked vaccination capabilities. Mental health services were limited, with minimal standardised screening. Key barriers to care included insufficient documentation, limited funding, staffing, patient mobility, and inadequate infrastructure to support migrant health.\u003cstrong\u003e\u003cbr\u003e\n \u003c/strong\u003e\u003cu\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/u\u003e\u003cstrong\u003e \u003c/strong\u003eCare delivery for migrant children across Europe remains variable despite existing guidelines.. Significant barriers to delivery of equitable, quality care exist. There is a need for resources tailored to address challenges in migrant health. Further research is needed to inform evidence-based practice and achieve high quality equitable care for migrant children in Europe.\u003c/p\u003e","manuscriptTitle":"Evaluating the health assessments of migrant children in Europe: exploring the experience of service providers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-02 17:00:58","doi":"10.21203/rs.3.rs-6205010/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-27T19:27:29+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-26T05:23:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"244236825914192999992145265894957195840","date":"2025-05-08T20:58:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-01T21:53:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124560474023851632373785506069630016049","date":"2025-04-17T06:29:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186694195534523504308935671948118594469","date":"2025-03-26T15:12:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-21T20:28:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-21T07:22:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-21T07:17:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Pediatrics","date":"2025-03-11T15:58:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"2cacd799-1020-4b14-83ed-38b20c89a0f8","owner":[],"postedDate":"April 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-22T06:51:31+00:00","versionOfRecord":{"articleIdentity":"rs-6205010","link":"https://doi.org/10.1007/s00431-025-06431-y","journal":{"identity":"european-journal-of-pediatrics","isVorOnly":false,"title":"European Journal of Pediatrics"},"publishedOn":"2025-09-12 15:57:20","publishedOnDateReadable":"September 12th, 2025"},"versionCreatedAt":"2025-04-02 17:00:58","video":"","vorDoi":"10.1007/s00431-025-06431-y","vorDoiUrl":"https://doi.org/10.1007/s00431-025-06431-y","workflowStages":[]},"version":"v1","identity":"rs-6205010","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6205010","identity":"rs-6205010","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}