Identifying and describing alcohol-related paediatric emergency department attendances amongst under 16 year olds including time trends, incidence rates, and sociodemographic factors associated with alcohol-related harm

Nicholas Davies; Dimitrios Charalampopoulos; Abigail Rose; Shrouk Messahel

doi:10.1371/journal.pone.0329502

Peer Review History

Original SubmissionDecember 12, 2024
13 May 2025 Decision Letter - Nik Hisamuddin Nik Ab. Rahman, Editor Dear Dr. Davies, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jun 27 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. 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Thank you for stating the following in the Acknowledgments Section of your manuscript: “We thank the Hugh Greenwood Legacy and the University of Liverpool for supporting this research.” We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: “This research was part of a PhD studentship funded by an external sponsor (Hugh Greenwood Legacy, Alder Children’s Hospital) and the University of Liverpool. The studentship was awarded to AR and SM and the PhD student was ND. The funders had no involvement in the methods, analysis, or interpretation of the research. Hugh Greenwood (https://liverpoolhealthpartners.org.uk/the-hugh-greenwood-legacy-for-childrens-health-research/) University of Liverpool (https://www.liverpool.ac.uk/ )” Please include your amended statements within your cover letter; we will change the online submission form on your behalf. 3. We note that you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Before we proceed with your manuscript, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible. Please update your Data Availability statement in the submission form accordingly. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: Overall, I think this article is on an important topic to look at alcohol-related paediatric ED attendances among patients under 16 years of age and provides valuable information on trends and associated harms. It presents new insights on the area and is well written. My general comments are: Page 2, line 29: ONS abbreviation needs to be explained as not previously used or explained. Abstract: Page 2-3: needs to include details of the years involved in the study. Page 7, line 160-162: Cohort analyses is plural and you only reference a single cohort analysis -13 in references. Should more articles be included in the references? Material and Methods, Data set: the paragraph causes confusion over what is actually included in the data as its hospital attendances from 2/4/2010 – 31/08/2023 which is not even a full month for April. And then the mention in the final line that only complete calendar years were included. This is not explained further or detailed in the results and leaves me unsure how it was actually done. This needs to be amended to either have the data set from 1/1/2011 to 31/12/2022 which seems the best option or to details all the presentations for the dates 2/4/2010 – 31/08/2023 which is not clearly detailed currently. Results: no details are provided on the proportion of attendances which required involvement of mental health services or involved injures which I think detracts from the data being presented. No details are provided on any data that was excluded. Page 25, Lines 469-471 you say: "While a girl’s or women’s alcohol use should have no bearing on how sexual assault is viewed or treated, individuals can place more responsibility on women if they have been drinking alcohol prior to the assault (25)." To date in the article you have made no mention of sexual assault in the results or provided any details on this. I think this statement needs to be removed as it doesn’t seem to follow the flow of the article and there is no details on injury patterns or assaults. Page 25-26, Lines 483-484 you say: "These concerns included a range of adverse experiences, including sexual abuse, domestic violence and being in social care." This is actual results and should be detailed in the results section rather than discussion. It might be beneficial to have further detail on this in the results to understand the frequency. Figures: there is inconsistency between the tables in the use of capital letters and this should be consistent in the labels. Figure 1: This 3 axis graph is harder to read as the 3rd axis (attendances resulting in admission) is offset against the gridlines presented. This chart might be easier to read if different colour gridlines were used to match corresponding sides or the gridlines were removed altogether and a vertical line was placed next to each axis with small horizontal lines corresponding to each point. The two zeros after the decimal point are not needed in the % side and would be easier to read if they were removed. Figure 2: X axis is labelled attendances rate which appears incorrect and I think should be proportion of alcohol related attendances. The two zeros after the decimal point are not needed and would be easier to read if they were removed. Reviewer #2: In terms of strength, the study utilizes ED attendance data rather than just admission data, giving a complete picture of alcohol-related harm among this vulnerable population group. The 11 years timeframe allows for meaningful trend analysis. The methodology seems to be rigorous including population-adjusted rates and multivariable models. However, data taken from a single paediatric ED may not be generalizable to other regions or setting. There's no validation of how accurately alcohol-related attendances were identified in the electronic records which potentiates missed cases if alcohol involvement wasn't properly documented. The author also did not explore if there is potential changes in coding practices over the 11-year period that might influence trends. There was no information of severity of intoxication, types of injuries or other clinical details that might provide more context. However, it may be beyond the scope intended by the author. Overall, this study provides valuable insights into trends and patterns of alcohol-related ED attendances among young population. The authors work are commendable. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: Yes: Sheena Durnin Reviewer #2: Yes: Nurul Huda Ahmad ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0329502.r001
Revision 1
2 Jul 2025 Author Response Dear reviewers, Thank you for reviewing our submission. Please see below for responses to each of your points raised during the review process. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. • I have checked the file naming and I cannot see which files do not follow the style requirements – could you please advise? 2. Thank you for stating the following in the Acknowledgments Section of your manuscript: “We thank the Hugh Greenwood Legacy and the University of Liverpool for supporting this research.” We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: I have removed the funding information from the acknowledgements section in the manuscript – could you please update the funding statement as given below: “This research was part of a PhD studentship funded by an external sponsor (Hugh Greenwood Legacy, Alder Children’s Hospital) and the University of Liverpool. The studentship was awarded to AR and SM (as supervisors) and the PhD student was ND. The funders had no involvement in the methods, analysis, or interpretation of the research. Hugh Greenwood (https://liverpoolhealthpartners.org.uk/the-hugh-greenwood-legacy-for-childrens-health-research/) University of Liverpool (https://www.liverpool.ac.uk/)” 3. We note that you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Before we proceed with your manuscript, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible. Please update your Data Availability statement in the submission form accordingly. • As detailed in the Data Availability Statement, the individual level data underlying this study cannot be made publicly available due to restrictions outlined in the Data Management Plan agreed with the NHS provider, this is because sharing would pose a risk to patient confidentiality. • The form has been updated to include the institutional body to which data requests could be sent. Comments to the Author – see tracked changes for full details Page 2, line 30: ONS abbreviation needs to be explained as not previously used or explained. • “Attendance rates per 100,000 were computed using UK national mid-year population estimates” removed reference to ONS as this is not necessary detail for abstract Abstract: Page 2-3: needs to include details of the years involved in the study. • Added, 2011 to 2022 (page 2, line 26) Page 7, line 160-162: Cohort analyses is plural and you only reference a single cohort analysis -13 in references. Should more articles be included in the references? • Updated to singular analysis (it was one study) (page 7, line 164) Material and Methods, Data set: the paragraph causes confusion over what is actually included in the data as its hospital attendances from 2/4/2010 – 31/08/2023 which is not even a full month for April. And then the mention in the final line that only complete calendar years were included. This is not explained further or detailed in the results and leaves me unsure how it was actually done. This needs to be amended to either have the data set from 1/1/2011 to 31/12/2022 which seems the best option or to details all the presentations for the dates 2/4/2010 – 31/08/2023 which is not clearly detailed currently. • Updated to refer to study period as 1/1/2011 to 31/12/2022 as only these cases were included in the analysis. (Page 9, Line 193). Removed text in page 9 (lines 206 to 207) to avoid confusion). Results: no details are provided on the proportion of attendances which required involvement of mental health services or involved injures which I think detracts from the data being presented. No details are provided on any data that was excluded. • Proportion of attendances which required involvement of mental health services was not captured in the data – this is why we used safeguarding concerns as a proxy measure (as safeguarding would include these cases, as well as other concerns e.g. children in social care) • Similarly, proportion of attendances involving injuries was not complete in the data and included a free text variable which would be difficult to code reliably. Therefore, we used admission to hospital as a proxy for injury severity. Page 25, Lines 469-471 you say: "While a girl’s or women’s alcohol use should have no bearing on how sexual assault is viewed or treated, individuals can place more responsibility on women if they have been drinking alcohol prior to the assault (25)." To date in the article you have made no mention of sexual assault in the results or provided any details on this. I think this statement needs to be removed as it doesn’t seem to follow the flow of the article and there is no details on injury patterns or assaults. • We have reworded this paragraph (Page 25, Lines 472 to 479). Page 25-26, Lines 483-484 you say: "These concerns included a range of adverse experiences, including sexual abuse, domestic violence and being in social care." This is actual results and should be detailed in the results section rather than discussion. It might be beneficial to have further detail on this in the results to understand the frequency. • This isn’t results – it is how the safeguarding variable was defined (see page 10, line 229 in methods). The safeguarding concerns variable includes cases where children are flagged on the system as being in social care, have had a previous mental health referral, have domestic violence reported etc. It is not possible to split within this variable to see how many fall in each category as it was a binary variable (reported concerns either Yes or No). We did not have access to this sensitive information in more detail, due to data management contracts with the NHS host. Figure 1: This 3 axis graph is harder to read as the 3rd axis (attendances resulting in admission) is offset against the gridlines presented. This chart might be easier to read if different colour gridlines were used to match corresponding sides or the gridlines were removed altogether and a vertical line was placed next to each axis with small horizontal lines corresponding to each point. The two zeros after the decimal point are not needed in the % side and would be easier to read if they were removed. • Removed gridlines and decimal points for Fig 1 and added vertical line next to each acis (with small horizontal lines corresponding to each point). Figure 2: X axis is labelled attendances rate which appears incorrect and I think should be proportion of alcohol related attendances. The two zeros after the decimal point are not needed and would be easier to read if they were removed. • Updated label and removed decimal places However, data taken from a single paediatric ED may not be generalizable to other regions or setting. There's no validation of how accurately alcohol-related attendances were identified in the electronic records which potentiates missed cases if alcohol involvement wasn't properly documented. The author also did not explore if there is potential changes in coding practices over the 11-year period that might influence trends. There was no information of severity of intoxication, types of injuries or other clinical details that might provide more context. However, it may be beyond the scope intended by the author. • The strategy for identifying and defining alcohol related attendances was devised with input from data technicians at Alder Hey and the clinical supervisor (a consultant in paediatric emergency medicine), based on availability of data . • Severity of intoxication was determined by whether patients were admitted to hospital or discharged. Including other clinical details would be beyond the scope of this study. • In the limitations section, we had highlight potential for demographic changes within the catchment area over time, diagnostic coding errors, barriers for clinicians to obtain alcohol info in children/young people’s ED settings etc. We also state that findings may not generalise to other regions (line - 541-543). This data comes from Alder Hey Children’s NHS Foundation Trust, one of Europe’s largest and busiest children’s hospitals, providing care for over 450,000 children and young people (from birth to 16 years) each year. • We have added an outline for future research to build on this evidence Kind regards, Nicholas Davies and Abi Rose Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0329502.r002
16 Jul 2025 Decision Letter - Nik Hisamuddin Nik Ab. Rahman, Editor Identifying and describing alcohol-related paediatric emergency department attendances amongst under 16 year olds including time trends, incidence rates, and sociodemographic factors associated with alcohol-related harm PONE-D-24-56004R1 Dear Dr. Davies, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Nik Hisamuddin Nik Ab. Rahman Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0329502.r003
Formally Accepted
Acceptance Letter - Nik Hisamuddin Nik Ab. Rahman, Editor PONE-D-24-56004R1 PLOS ONE Dear Dr. Davies, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Professor Dr Nik Hisamuddin Nik Ab. Rahman Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0329502.r004

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