Showing papers in "Journal of Paediatrics and Child Health in 2016"

Socio-economic status and quality of life in children with chronic disease: A systematic review.

Abstract: Reduced quality of life (QoL) is a known consequence of chronic disease in children, and this association may be more evident in those who are socio-economically disadvantaged. The aims of this systematic review were to assess the association between socio-economic disadvantage and QoL among children with chronic disease, and to identify the specific socio-economic factors that are most influential. MEDLINE, Embase and PsycINFO were searched to March 2015. Observational studies that reported the association between at least one measure of social disadvantage in caregivers and at least one QoL measure in children and young people (age 2-21 years) with a debilitating non-communicable childhood disease (asthma, chronic kidney disease, type 1 diabetes mellitus and epilepsy) were eligible. A total of 30 studies involving 6957 patients were included (asthma (six studies, n = 576), chronic kidney disease (four studies, n = 796), epilepsy (14 studies, n = 2121), type 1 diabetes mellitus (six studies, n = 3464)). A total of 22 (73%) studies reported a statistically significant association between at least one socio-economic determinant and QoL. Parental education, occupation, marital status, income and health insurance coverage were associated with reduced QoL in children with chronic disease. The quality of the included studies varied widely and there was a high risk of reporting bias. Children with chronic disease from lower socio-economic backgrounds experience reduced QoL compared with their wealthier counterparts. Initiatives to improve access to and usage of medical and psychological services by children and their families who are socio-economically disadvantaged may help to mitigate the disparities and improve outcomes in children with chronic illnesses.

The effect of a classroom activity break on physical activity levels and adiposity in primary school children.

Abstract: Aim Despite recognition that regular physical activity is essential for good health, many children do not accumulate sufficient daily physical activity. The aim of this study was to examine the effect of a classroom-based activity break on accelerometer-determined moderate-to-vigorous intensity physical activity (MVPA) and adiposity in primary school children. Methods One hundred twenty children from seven primary schools in Northern Ireland participated in the study. In each school, one class of children was randomly assigned to an intervention group and another class to a control group. Teachers of the intervention classes led a 5-min activity break three times per day for 12 weeks. Accelerometer-determined MVPA, height, weight and four skinfolds were measured at baseline and post-intervention. Results Compared with the control group, the intervention group significantly increased weekday MVPA (+9.5 min) from baseline to post-intervention. There were no significant changes in BMI; however, an increase in sum-of-skinfolds of the intervention group was observed. Conclusions Classroom-based activity breaks led by the teacher are successful in increasing children's physical activity levels. The programme shows a positive step in improving overall physical activity levels and contributing to the goal of 60 min daily MVPA.

Sensitivity and specificity of General Movements Assessment for diagnostic accuracy of detecting cerebral palsy early in an Australian context

Abstract: Aim The aim of this study was to calculate the sensitivity and specificity of the General Movements Assessment (GMA) for estimating diagnostic accuracy in detecting cerebral palsy (CP) in an Australian context by a newly established NSW rater network. Methods A prospective longitudinal cross-sectional study was conducted. The GMA was blind-rated from conventional video by two independent certified raters, blinded to medical history. A third rater resolved disagreements. High-risk population screening for CP using the GMA during the fidgety period (12–20 weeks) was carried out in four neonatal intensive care units and one CP service over a 30-month period (2012–2013). Participants were 259 high-risk infants. Sensitivity and specificity values were calculated with true positives defined as a confirmed diagnosis of CP from a medical doctor. Results Of the 259 infants assessed, 1-year follow-up data were available for 187. Of these, n = 48 had absent fidgety (high risk for CP), n = 138 had normal fidgety (low risk for CP), and n = 1 had abnormal fidgety (high risk for a neurological disorder). Of the 48 with absent fidgety movements, 39 had received a diagnosis of CP by 18 months and another 6 had an abnormal outcome. Of the n = 138 normal fidgety cases, n = 99 cases had a normal outcome, n = 38 had an abnormal outcome but not CP, and n = 1 had CP. For detecting CP, we had a sensitivity of 98% and specificity of 94%. Conclusion GMA was feasible in an Australian context and accurately identified CP with a sensitivity and specificity comparable with European standards and published neuroimaging data.

Telling the truth.

Abstract: Thirty years ago, I was working in a teaching hospital in England. If a child, even a teenager, with a bone tumour needed their leg amputated, one consultant orthopaedic surgeon would never tell the child or permit anyone else to tell the child in advance. The child would go to the operating theatre being told they were to have a biopsy and ‘anything necessary’. The surgeon insisted that knowing in advance would make the child unnecessarily anxious, and it was kinder for the child not to know beforehand. He ignored any nurse, social worker or doctor who had the temerity to suggest it was kinder to let children prepare mentally for amputation and would probably help them cope better. Modern theories on anxiety disorders support the idea that children should be kept as informed as reasonably possible and so does modern bioethical thinking about the importance of respecting children’s autonomy.Was the surgeon lying to the child ormerely being ‘economical with the truth’, an expression used by Mark Twain, among others, about politicians as a euphemism for lying? Post-modern philosophy has agonised over what is truth and whether or not truth even exists. Western thinking has tended to treat scientific knowledge as being independent of context, persons and values and having its own static existence: something is true or false. However, to take such a strictly context-independent attitude to truth and knowledge in medicine ignores the subjective nature of disease and the values and beliefs that frame the apprehension of truth and knowledge by patients and doctors. The framing of information has a large effect on perception. In a randomised study, Harvard physicians told that a cancer treatment had a 90% survival rate were more likely to recommend treatment than their colleagues whowere told that the treatment had a 10%mortality. Theway information is perceived by physicians and the way it is framed and conveyed to patients is inherently value-laden. A doctor counsels a patient from a position of power and that brings ethical obligations and responsibilities. Doctors can err in being too directive or ‘paternalistic’ and constraining choice, aswith the example of the orthopaedic surgeon. But doctors can also err by excessive disclosure of information. Unfiltered information given to children or their parents, either because of the doctors’ own anxieties and fears or because of concern about litigation, may be unhelpful and unnecessary. Such ‘over-disclosure’ is unfortunately a common feature of the modern managerial policy of ‘open disclosure’. The patient(or parent-) doctor relationship is based on trust. Truth-telling in relationships is foundational to developing andmaintaining trust. Furthermore, truth-telling is broadly considered a virtue to cultivate (Fig. 1), and there is an almost universal acceptance that doctors have anobligation to tell the truth andnot to lie. In theUnited Kingdom, ‘the duty of candour’ has clear implications for paediatricians and other health professionals. The way we frame information should take into account the patient’s beliefs, culture and situation, what might be called their existential truth. This is part of the art of medicine. In his excellent book on end-of-life counselling, AtulGawande refers to this as an interpretive approach.Our primary aim should be to allow children and parents to make informed decisions about children’s lives. In order to achieve this, counselling should involve real communication, a bidirectional conversation rather than a unidirectional process of simply conveying information. In an increasingly complicated health-care environment, this sort of partnership with families may indeed help them find the truth.

Body mass index in ambulatory children with cerebral palsy: A cohort study.

Abstract: Aim Children with cerebral palsy (CP) have reduced levels of physical activity compared with children without physical disability and experience risk factors for becoming overweight or obese. In the Australian CP population, there is little information available about the weight status of children with CP. The aims of this study were to compare the distribution of body mass index (BMI) in a cohort of ambulant children with CP with the BMI distribution of Australian children and explore the relationship between BMI and gross motor function. Methods A retrospective cohort study of 587 children with CP Gross Motor Function Classification System (GMFCS) levels I–III who attended a Gait Laboratory between July 1995 and January 2012 was carried out. The BMI and Z-score were calculated at each assessment. Data were grouped into the categories of underweight, healthy, overweight and obese according to age-specific and sex-specific percentiles. Results There were 348 boys and 240 girls with a mean age 11.2 (standard deviation 3.2) years. Mean BMI Z-score was 0.11 (standard deviation 1.33). Seven percent of children were underweight, 73.6% healthy, 7.3% overweight and 12.1% obese. This was similar to the distribution of children without disability. The largest percentage of children in the healthy group were classified GMFCS I. The largest percentage of children in the obese group were classified GMFCS III. Conclusions In this cohort, 19.4% of ambulant children with CP were overweight or obese. This is of concern as BMI may impact on the outcomes of surgical intervention and rehabilitation. Further research is needed to determine the consequences of obesity for children with CP.

Vitamin A deficiency and xerophthalmia in children of a developed country.

Abstract: Aim We aim (i) to characterise the clinical features of vitamin A deficiency (VAD) in a small cohort of Australian children; (ii) to determine the effects of VAD; and (iii) to quantify the prevalence of ophthalmic review in this group. Methods Data collected from the charts incorporated patient demographics, laboratory results, past medical history, ophthalmic symptoms and dietary history. Outcome measures were (i) occurrence of VAD in our study population; (ii) presence of associated systemic effects and ocular manifestations in those diagnosed with VAD; and (iii) determination of whether children with VAD had an ophthalmology review. Results Fifty-two of the 146 children had VAD; their average age was 8.4 years (range 11 days to 18 years old). In this Australian cohort, the most common pre-existing medical conditions in those children whose vitamin A status was investigated were cystic fibrosis, gastro-oesophageal reflux disease, micronutrient deficiency and short gut syndrome. The most common medical conditions affecting children with measured VAD in this cohort include autism, coeliac disease and cystic fibrosis. A significant association was found between VAD and anaemia and serum iron levels. Of the 146 children, 28 had ophthalmology review, of whom 13 had VAD. The most common reason for ophthalmology review was retinopathy of prematurity; there was only one referral for review for xerophthalmia. There was one case of xerophthalmia referred due to microbial keratitis. Conclusion Vitamin A deficiency and xerophthalmia do exist in children of developed country. The potential for xerophthalmia should be considered, and there should be a consideration of an ophthalmology review.

Kangaroo Mother Care and neonatal outcomes: A meta‐analysis

Abstract: Kangaroo Mother Care (KMC) originated in South America as a low cost alternative to incubators for low birth weight (LBW) infants. The key feature of KMC is early, continuous, and prolonged skin-to-skin contact between LBW newborn and mother. Ideally, KMC also includes exclusive breastfeeding; early hospital discharge; and close follow-up at home. A recent systematic review and meta-analysis examined the association between KMC and neonatal outcomes. A total of 124 studies met inclusion criteria, of which half were randomized controlled trials and the others observational. Results were resoundingly positive. Among LBW newborns, KMC (compared to conventional care) was associated with a 36% reduction in mortality (RR = 0.64; 95% CI 0.46 to 0.89). KMC also significantly decreased risk of neonatal sepsis (RR = 0.53; 95% CI 0.34 to 0.83); hypothermia (RR = 0.22; 95% CI 0.12 to 0.41); hypoglycemia (RR = 0.12; 95% CI 0.05 to 0.32); hospital re-admission (RR = 0.42; 95% CI 0.23 to 0.76); and increased exclusive breastfeeding (RR =1.50; 95% CI 1.26 to1.78). Not surprisingly, the authors concluded; “interventions to scale up KMC implementation are warranted”. Scabies control with ivermectin

Childhood tuberculosis: A roadmap towards zero deaths.

Abstract: 'Every day, more than 200 children under the age of 15 die needlessly from tuberculosis (TB) - a disease that is preventable and curable. The World Health Organization estimates that as many as 1 in 10 TB cases globally (6-10% of all TB cases) are among this age group, but the number could be even higher because many children are simply undiagnosed.' Childhood TB is emerging from the shadows. This quote comes from the recently launched international roadmap towards zero TB deaths in children. We provide a brief update of new developments and remaining challenges related to childhood TB, with particular emphasis on the new roadmap.

Paediatric emergency and acute care in resource poor settings.

Abstract: Acute care of seriously ill children is a global public health issue, and there is much scope for improving quality of care in hospitals at all levels in many developing countries. We describe the current state of paediatric emergency and acute care in the least developed regions of low and middle income countries and identify gaps and requirements for improving quality. Approaches are needed which span the continuum of care: from triage and emergency treatment, the diagnostic process, identification of co-morbidities, treatment, monitoring and supportive care, discharge planning and follow-up. Improvements require support and training for health workers and quality processes. Effective training is that which is ongoing, combining good technical training in under-graduate courses and continuing professional development. Quality processes combine evidence-based guidelines, essential medicines, appropriate technology, appropriate financing of services, standards and assessment tools and training resources. While initial emergency treatment is based on common clinical syndromes, early differentiation is required for specific treatment, and this can usually be carried out clinically without expensive tests. While global strategies are important, it is what happens locally that makes a difference and is too often neglected. In rural areas in the poorest countries in the world, public doctors and nurses who provide emergency and acute care for children are revered by their communities and demonstrate daily that much can be carried out with little.

Diagnosing autism: Contemporaneous surveys of parent needs and paediatric practice.

Abstract: Aim Concurrence between parents' information needs and clinicians' practice when diagnosing autism is unknown but may influence families' uptake of management and adjustment. We aimed to[1] compare parents' experience and preferences with paediatrician report of (i) diagnosis delivery and (ii) information given at diagnosis and[2] identify types and usefulness of resources accessed by families post-diagnosis. Methods The design used for the study are parent and paediatrician surveys. Participants are parents of children aged 1.5–18 years, diagnosed with autism between 01 January 2010 and 30 September 2012 and their paediatricians who are members of the Australian Paediatric Research Network. Study-designed quantitative and qualitative questions about diagnosis delivery and information given at diagnosis (written and spoken vs. neither) and parent perceived importance and harms of information accessed post-diagnosis. Results Paediatricians (53/198 (27%)) identified 1127 eligible families, of whom 404 (36%) participated. Parents were more likely to report receiving adequate time to discuss diagnosis than paediatricians (71 vs. 51%). Parents (98%) rated information about accessing allied health professionals and the meaning of diagnosis as most important, yet paediatricians offered written or spoken information about each infrequently (allied health: 22%; diagnosis: 42%). Post-diagnosis, allied health was the most important source of information (83%). Harmful resources conveyed helplessness or non-evidenced-based therapies, but few parents (14%) reported this. Conclusions Parents want more information than can be conveyed in a single diagnostic consultation. Developing a tailored ‘autism action plan’ with written materials could improve parents' understanding of and satisfaction with children's autism diagnoses.

Medical clowns reduce pre‐operative anxiety, post‐operative pain and medical costs in children undergoing outpatient penile surgery: A randomised controlled trial

Abstract: Aim The aim of this paper is to investigate prospectively the potential benefits of the participation of the medical clowns in the outpatient paediatric penile surgery programme Methods Eighty children undergoing meatotomy, age 2 to 16 years, were randomised into two groups (40 each) In the first group, the medical clown was an integral part of the medical team, and in the second group, the treatment was given without participation of the medical clown The following parameters were measured: the level of pre-operative anxiety, the level of the post-operative pain, the amount of pain medication use in the first 24 h after surgery and the time needed to return to normal activities The operating room time and hospital costs were calculated Results The patients from the first group demonstrated a lower pre-operative anxiety index upon (P = 00319) and after surgery (P = 00042), required less induction time for anaesthesia (P < 0001), spent overall less time in the operating room (P < 00001) and required less time to recover from the surgery and to be discharged (P = 00172) The overall OR time and post-operative unit care savings of 20 and 155 min, respectively, led to the cost savings of $467 Conclusion Our data demonstrated that the use of the medical clown functioning as an integral part of the operating team reduces children pre-operative anxiety and leads to a shortening of the overall time in the hospital thereby reducing the overall medical cost justifying the participation of medical clown as an integral part of the health team in a paediatric urology outpatient surgical unit

'A short time but a lovely little short time': Bereaved parents' experiences of having a child with spinal muscular atrophy type 1.

Abstract: Aim Spinal muscular atrophy (SMA) type 1 is a relatively common, untreatable and invariably fatal neuromuscular disorder of early childhood. Psychosocial care is vital in management of families affected by this disease. There are few studies examining the impact of having a family member with a neuromuscular disorder, and none describing parents' experiences of having a child with SMA type 1. This study explored parents' perspectives of having a child with SMA type 1, from diagnosis to bereavement, in order to inform clinical practice by identifying aspects most meaningful to parents and to aid development of support strategies. Methods This qualitative study undertook thematic analysis of 11 in-depth interviews with 13 bereaved parents of children with SMA type 1. Results While individuals' experiences were unique, common themes emerging from the data include: experiencing shock and anticipatory grief, processing feelings of responsibility and helplessness, experiencing multiple losses including the loss of future reproductive freedom, feeling supported, regaining a sense of control by making decisions about the child's life and death, and finding peace in the dying process. Conclusion These findings highlight the importance of a multidisciplinary approach to the care of such families, including psychosocial support beginning from the time of diagnosis and continuing to bereavement. We suggest areas for further exploration, with a goal to develop family-centred and evidence-based psychosocial care guidelines to complement the current Standards of Care for Spinal Muscular Atrophy.

Melatonin versus midazolam premedication in children undergoing surgery: A pilot study

Abstract: Aim:Melatonin has been proposed as a premedication alternative to midazolam, preceding anaesthesia induction. However, to our knowledge, data concerning interaction between melatonin and intravenous anaesthetic drugs in children are not available. The aim of this prospective, randomized, double-blin

Risk factors for obstructive sleep apnoea in Australian children.

Abstract: Aim This study aims to determine whether demographic or clinical factors predict obstructive sleep apnoea (OSA) severity in Australian children. Methods Demographic details and medical histories of 301 Australian children (3–17 years old) referred for assessment of OSA were examined retrospectively. Children underwent overnight polysomnography and were classified as having primary snoring (PS) (obstructive apnoea hypopnoea index (OAHI) ≤ 1 event per hour; n = 150), mild OSA (>1 OAHI ≤ 5 events per hour; n = 76) or moderate/severe (MS) OSA (OAHI > 5 events per hour; n = 75). Information obtained from parent-report questionnaire determined the predictive value of the following factors for determining OSA severity: gender, ethnicity, body mass index, asthma and/or allergic rhinitis, socio-economic status and parental smoking status (mother/father/both). Chi-squared analyses were used to compare the distribution of the demographic and clinical factors across the three groups. Statistically significant risk factors were subsequently entered into logistic regression analysis. Results Ethnicity and parental smoking were significant risk factors for MS OSA. Children with non-Caucasian ethnicity were 36% more likely than Caucasian children to be diagnosed with MS OSA than PS (P = 0.002). Children with fathers who smoked were 53% more likely to have MS OSA than PS compared with those with fathers who did not smoke (P = 0.008). Obesity was associated with OSA severity in primary school-aged children only. Gender, socio-economic status and history of asthma and/or allergic rhinitis were not risk factors. Conclusions Non-Caucasian ethnicity, paternal smoking and obesity in older children were associated with an increased risk of polysomnography-confirmed MS OSA in Australian children.

Incidence, aetiology and outcome of pleural empyema and parapneumonic effusion from 1998 to 2012 in a population of New Zealand children.

Abstract: Aim To document rising incidence rates of childhood empyema and parapneumonic effusion (PPE) in South Auckland, New Zealand between 1998 and 2012; to compare epidemiology, pathogens and outcomes of children with empyema and PPE; and to ascertain whether primary care antibiotic prescribing, delayed presentation, or bacterial epidemiology might account for the rising incident rates. Methods Children aged 0 to14 years hospitalised with pleural empyema or PPE were retrospectively identified. Empyema was defined by ultrasound and pleural tap criteria. PPE was defined as the presence of pleural fluid on chest xray not fulfilling empyema criteria. Epidemiology, clinical features, microbiology and outcomes of empyema and PPE were compared and incidence rates analysed. Results Of 184 cases identified, 104 met the criteria for empyema. Empyema incidence increased from 1 per 100 000 children aged 0 to 14 years in 1998 to 10 per 100 000 in 2012, with a peak incidence of 13 per 100 000 in 2009. Staphylococcus aureus was most frequently detected (n=38), followed by Streptococcus pneumoniae (n=31). Cases of S. aureus empyema increased 4 fold over the 15 years. Dominant S. pneumoniae serotypes were 1 and 14. Thirty-five percent of empyema and 53% of PPE cases received pre-hospital antibiotics. Children who received pre-hospital antibiotics were more than 40% less likely to require surgical intervention than those not pre-treated. Conclusions Childhood empyema incidence has increased markedly in South Auckland. Paediatric S. aureus empyema is becoming increasingly common in South Auckland. Pre-hospital antibiotic prescribing may mitigate the need for surgical intervention in our population.

Impact of information and communication technology on child health.

Abstract: This article provides a general framework for understanding the use of information and communication technology in education and discusses the impact of computer usage on students' health and development. Potential beneficial and harmful effects of computer use by children are discussed. Early epidemiological and laboratory studies have indicated that children are at least of similar risk of developing musculoskeletal and vision problems as adults, and musculoskeletal and visual health problems developed in childhood are likely to persist into adulthood. This article, therefore, aims to provide a reflection on the deficits of existing policy and recommendations for child-specific guidelines in computer use.

Cryopyrin-associated periodic syndrome in Australian children and adults: Epidemiological, clinical and treatment characteristics.

Abstract: Aim Cryopyrin-associated periodic syndromes (CAPS) encapsulate three auto-inflammatory conditions, ranging in severity from mild (familial cold auto-inflammatory syndrome: FCAS), moderate (Muckle-Wells syndrome: MWS) and severe (neonatal onset multi-inflammatory disorder: NOMID). We aimed to describe the epidemiology, clinical features and outcomes of Australian children and adults with CAPS. Methods Patients were identified and clinical data collected through a questionnaire sent during 2012–2013 to clinicians reporting to the Australian Paediatric Surveillance Unit and subscribing to the Australasian Societies for Allergy/Immunology, Rheumatology and Dermatology. Results Eighteen cases of CAPS were identified (8 NOMID; 8 MWS, 2 FCAS); 12 in children <18 years of age. The estimated population prevalence of CAPS was 1 per million persons. Diagnostic delay was frequent, particularly in those with milder phenotypes (median diagnostic delay in MWS/FCAS 20.6 years compared with NOMID 2.1 years; P = 0.04). Common presenting features included urticaria (100%), periodic fever (78%), arthralgia (72%) and sensorineural hearing loss (61%). Almost all (90%) MWS patients had a family member similarly affected compared with none in the NOMID group (P = 0.004). A significant proportion of patients on anti-interleukin (IL)-1 therapy (n = 13) no longer had systemic inflammation. Only 50% with sensorineural hearing loss had hearing restored on anti-IL-1 therapy. Conclusions Although CAPS are rare, patients often endured prolonged periods of systemic inflammation. This is despite almost all MWS patients having family members with similar symptoms and children with NOMID presenting with chronic infantile urticaria associated with multi-system inflammation. Hearing loss in NOMID/MWS was frequent, and reversible in only 50% of cases.

Prevalence of comorbidities in obese New Zealand children and adolescents at enrolment in a community‐based obesity programme

Abstract: Aim The aim of this study was to describe the characteristics at enrolment of children and adolescents referred to an obesity programme and to determine how the prevalence of comorbidities differed in Indigenous versus non-Indigenous children. Methods Participants were residents of a semi-rural region of New Zealand (NZ). Eligibility was defined by a body mass index (BMI) of ≥98th percentile or >91st centile with weight-related comorbidities. Fasting blood, medical and physical assessments were obtained. Results During the recruitment period from January 2012 to August 2014, 239 participants, aged 4.8–16.8 years, undertook assessment. Average BMI standard deviation score was 3.09 (standard deviation (SD) = 0.60, range 1.52–5.34 SD). The majority of participants were of either Maori (NZ’s indigenous people (45%)) or NZ European (45%) ethnicity; 29% of participants were from the most deprived quintile of household deprivation. Maori participants were more likely than NZ Europeans to have a mother who smoked during pregnancy (52% vs. 28%, P = 0.001), a family history of type 2 diabetes (66% vs. 53%, P = 0.04), acanthosis nigricans on examination (58% vs. 20%, P < 0.0001), a low serum high-density lipoprotein cholesterol (27% vs. 14%, P = 0.03) or high serum triglyceride (38% vs. 24%, P = 0.03) concentration. Conclusion The unique aspect of this study was the ability to recruit high levels of Maori participants and those from most deprived areas, indicating a high level of acceptability for these target groups. Comorbidities were prevalent in this cohort of overweight/obese school-aged children. While there were some differences in comorbidity prevalence between Maori and NZ Europeans, the overall clinical picture in our cohort, irrespective of ethnicity, was of concern.

Brain attacks and stroke in children

Abstract: Emergency physicians are often the first point of contact in children presenting with acute neurological disorders. Differentiating serious disorders, such as stroke, from benign disorders, such as migraine, can be challenging. Clinical assessment influences decision-making, in particular the need for emergent neuroimaging to confirm diagnosis. This review describes the spectrum of disorders causing 'brain attack' symptoms, or acute onset focal neurological dysfunction, with particular emphasis on childhood stroke, because early recognition is essential to improve access to thrombolytic treatments, which have improved outcomes in adults. Clues to diagnosis of specific conditions are discussed. Symptoms and signs, which discriminate stroke from mimics, are described, highlighting differences to adults. Haemorrhagic and ischaemic stroke have different presenting features, which influence choice of the most appropriate imaging modality to maximise diagnostic accuracy. Improvements in the care of children with brain attacks require coordinated approaches and system improvements similar to those developed in adults.

Point-of-care ultrasound in paediatric emergency medicine

Abstract: Point-of-care ultrasound (POC US) is an adjunct to clinical paediatric emergency medicine practice that is rapidly evolving, improving the outcomes of procedural techniques such as vascular access, nerve blocks and fluid aspiration and showing the potential to fast-track diagnostic streaming in a range of presenting complaints and conditions, from shock and respiratory distress to skeletal trauma. This article reviews the procedural and diagnostic uses, both established and emerging, and provides an overview of the necessary components of quality assurance during this introductory phase.

A population study of respiratory rehospitalisation in very preterm infants in the first 3 years of life.

Abstract: Aim Very premature infants consume healthcare resources following discharge from neonatal intensive care units (NICU). This study aimed to evaluate the burden of respiratory related rehospitalisation within the first 3 years post discharge in very premature infants in an Australian population. Methods Rehospitalisation of a 4-year cohort of NICU survivors, born less than 32 weeks gestation, was derived from data linkage of three state-wide databases including NSW Neonatal Intensive Care Units' Data Collection, Admitted Patient Data Collection and the Death Registry. Rehospitalisation diagnoses were determined by ICD-10 AM codes. Results Of the 2939 survivors, 525 (18%) had bronchopulmonary dysplasia (BPD) and 261 BPD infants (50%) were discharged on home oxygen. Almost two-third (1860, 63%) of the survivors are required rehospitalisation, respiratory causes, including 394 respiratory syncytial virus (RSV)-related, accounted for 2668 (48%) of the 5599 rehospitalisations. Significantly more home oxygen BPD survivors had respiratory (70%) and RSV-related (22%) rehospitalisations than the BPD infants not needing home oxygen (58% and 18%, respectively), and the survivors without BPD had the lowest rates (32% and 10%, P < 0.001). Most respiratory (61%) and RSV-related (74%) rehospitalisations occurred during the first 12 months post discharge. No RSV-related fatality occurred. Amongst the total 17 562 hospital days, respiratory and RSV-related admissions accounted for 10 905 (62%) and 3031 (17.2%) days. In multivariable logistic analyses, home oxygen and maternal indigenous status were independently associated with high (3 or more) respiratory and RSV rehospitalisation rates. Conclusions Respiratory rehospitalisations are common in very premature survivors. Home oxygen and indigenous status are significant risk factors for respiratory and RSV-related rehospitalisations.

Formula and breast feeding in infant food allergy: A population-based study.

Abstract: Aim To determine whether infant-feeding practices, including duration of exclusive breastfeeding and use of partially hydrolysed formula, modify the risk of developing infant food allergy. Methods In an observational population-based study, 1 year olds were recruited from community immunisation clinics in Melbourne, Australia. Parent-reported data on infant-feeding practices and potential confounders were collected prior to infant skin prick testing for four food allergens. Sensitised infants attended hospital-based oral food challenges to establish food allergy status. Multiple logistic regression was used to investigate associations between breastfeeding and formula-feeding and infant food allergy adjusting for possible confounding variables. Results A total of 5276 (74% response) infants participated. Of the 4537 for whom food allergy status was determined, 515 (11.3%) were food allergic (challenge-proven in the context of skin prick testing positive (≥2 mm)). After adjusting for confounding variables, there was no association between duration of exclusive breastfeeding and food allergy. Use of partially hydrolysed formula did not reduce the risk of food allergy compared with cow's milk formula in the general population (adjusted odds ratios 1.03 (confidence interval 0.67-1.50)). Conclusion Duration of exclusive breastfeeding and use of partially hydrolysed formula were not associated with food allergy at 1 year of age in this large population-based study. These findings have implications for population-based infant-feeding guidelines and do not support the use of partially hydrolysed formula for food allergy prevention.

Diagnosing appendicitis: What works, what does not and where to go from here?

Abstract: Although acute appendicitis is the most common reason for emergency abdominal surgery in children, diagnosis is far from straightforward. Delays in diagnosis can result in significant complications, whereas over-diagnosis can result in costly inter-hospital transfers and unnecessary surgery. This article aims to describe current evidence-based assessment of children with possible appendicitis presenting to the emergency department. We provide an overview of the literature relating to the various available diagnostic approaches, including the application of history, examination, pathology tests, imaging, and clinical decision rules.

Transient liver elastography in unsedated control children: Impact of age and intercurrent illness

Abstract: Aim Transient elastography (TE) is a rapid, non-invasive, reproducible assessment of liver fibrosis by liver stiffness measurement (LSM). Uncertainty remains regarding utility in children, unsedated and <6 years of age. The importance of general health at the time of study has not been addressed. We report our experience of TE in unsedated control children, impact of intercurrent illness and using new published reliability criteria. Methods From April 2011 to March 2013, 173 studies were performed in unsedated, healthy control children and children with intercurrent illness without detectable liver disease presenting to the Royal Children's Hospital, Brisbane, Australia. LSM reliability was assessed using interquartile range/median (IQR/M ≤ 30%) of 10 valid measurements. Results A total of 123 (F:M, 52:71) of 173 studies (71.1%) gave reliable results. In children 0–2 years reliability was 36%, and >2 years reliable results were obtained in ~80%. LSM increased with age; 0–2 years (3.5 ± 0.5 kPa), 3–5 years (3.8 ± 0.3 kPa) and 6–11 years (4.1 ± 0.2 kPa) with healthy older children 12–18 years similar to adults (4.5 ± 0.2 kPa). LSM did not vary with gender (female, 4.5 ± 0.2 vs. male, 4.8 ± 0.2 kPa). Children with intercurrent, non-hepatological illnesses had higher LSM (5.2 ± 0.2 kPa (range, 2.8–11.1 kPa)) compared to healthy children ((4.1 ± 0.1 kPa, range, 2.1–6.3 kPa); P = 0.0001). Conclusions TE in unsedated children is feasible from infancy but most reliable after 2 years. Intercurrent illness increases LSM; hence, study context is important when interpreting results.

Children with Down syndrome: Clinical course and mortality-associated factors in a French medical paediatric intensive care unit.

Abstract: Aim To investigate clinical course and mortality-associated factors in children with Down syndrome (DS) managed in a medical paediatric intensive care unit. Methods A single-centre, retrospective study conducted between 2001 and 2010 in DS children aged 1 month to 16 years. Results Sixty-six patients with a median age of 24 months (1–192) and a male/female ratio of 1.5 were analysed. Patients presented with history of congenital heart disease (n = 52, 78.8%), mechanical ventilation (n = 40, 60.6%) and chronic upper airway obstruction (n = 10, 15.1%). The primary reason for admission was respiratory failure (n = 56, 84.8%). Pulmonary arterial hypertension (PAH) (n = 19, 28.8%), acute respiratory distress syndrome (ARDS) (n = 18, 27.2%) and sepsis (n = 14, 21.2%) were observed during their clinical course. Twenty-six patients died (39.4%). Mortality-associated factors included the following: (i) baseline characteristics: history of mechanical ventilation, chronic upper airway obstruction and congenital heart disease; (ii) clinical course during paediatric intensive care unit stay: sepsis, catecholamine support, ARDS, PAH and nosocomial infection. In multivariate logistic analysis, history of mechanical ventilation, ARDS and PAH remained independently associated with death. Conclusions The mortality rate in critically ill DS children admitted for medical reasons is high and is predominantly associated with respiratory conditions.

Diagnosing autism: Australian paediatric research network surveys.

Abstract: Aim Autism spectrum disorder (ASD) is a neurodevelopmental disorder with reported prevalence of more than 1/100. In Australia, paediatricians are often involved in diagnosing ASD and providing long-term management. However, it is not known how paediatricians diagnose ASD. This study aimed to investigate whether the way Australian paediatricians diagnose ASD is in line with current recommendations. Methods Members of the Australian Paediatric Research Network were invited to answer questions about their ASD diagnostic practice in a multi-topic survey and also as part of a study about parents needs around the time of a diagnosis of ASD. Results The majority of the 124 paediatricians who responded to the multi-topic survey and most who responded to the parent needs survey reported taking more than one session to make a diagnosis of ASD. Most paediatricians included information from preschool, child care or school when making a diagnosis, and over half included information from speech pathology or psychology colleagues more than 50% of the time. The main reasons for not including assessment information in the diagnostic process were service barriers such as no regular service available or long waiting lists. More than 70% reported ordering audiology and genetic tests more than half of the time. Conclusion Not all paediatricians are following current recommendations for diagnosing ASD more than 50% of the time. While there are good reasons why current diagnostic approaches may fall short of expected standards, these need to be overcome to ensure diagnostic validity and optimal services for all children and their families.

Association between waist circumference and childhood-masked hypertension: A community-based study.

Abstract: Aim The aim of this study is to determine the association between waist circumference (WC) and childhood-masked hypertension. Methods A territory-wide, school-based cohort of 1385 Hong Kong students (672 boys and 713 girls) aged 8–17 years was analysed. The ambulatory blood pressure-monitoring assessment was performed using validated oscillometric recorders (A&D TM-2430 (A&D Inc., Tokyo, Japan)) following American Heart Association's recommendations. Subjects were considered normotensive if their casual blood pressure, 24-h daytime and night-time average systolic blood pressure and diastolic blood pressure (DBP) were <95th percentile. If one or more of the ambulatory blood pressure parameters was ≥95th percentile, subjects would be considered suffering from masked hypertension (MH). Subjects who had three successive casual blood pressure measurements above the 95th percentile were excluded. Results By body mass index, 148 (10.7%) subjects were obese, 182 (13.1%) overweight and 359 (25.9%) having larger WC (≥85th percentiles). MH was diagnosed in 217 subjects (15.7%). Subjects with larger WC or obesity were significantly associated with higher 24-h daytime and night-time systolic blood pressure (≥95th percentile) (odds ratios from 1.84 to 2.09 and from 2.07 to 3.54 for larger WC and obese respectively, all P < 0.05) as well as 24-h DBP for larger WC (odds ratio = 2, P = 0.015) than normal subjects adjusted by sex, age and height. Conclusion Waist circumference and body mass index are independent risk factors of childhood and adolescent MH. WC appears a significant associated factor of elevated 24-h DBP in children aged 8–17 years.

Parental state anxiety correlates with preoperative anxiety in Chinese preschool children

Abstract: Aim Preoperative anxiety in children is largely dependent on age and is influenced by anxiety level in parents. The current study compared the level of preoperative anxiety in preschool children versus school-aged children and its relationship with the state and trait anxiety of the parents. Methods This study included 54 preschool children (2–5 years of age) and 48 school-age children (6–12 years) scheduled to receive ear, nose and throat, plastic or ophthalmologic surgeries. Preoperative anxiety of children was assessed in the holding area immediately prior to the surgery using a modified Yale Preoperative Anxiety Scale (m-YPAS). Compliance with anaesthesia induction was assessed using an Induction Compliance Checklist (ICC). The state and trait anxiety of the parent who accompanied the child was assessed using a State-Trait Anxiety Inventory (STAI) questionnaire. Results Both m-YPAS and ICC scores were higher in preschool children than in school-age children with significant correlation between the two measures. The STAI-S score of parents was higher in the preschool group than in the school-age group. No significant difference was found in STAI-T score between the two age groups. Children's m-YPAS score correlated with parental STAI-T score in both groups (rho = 0.297, P = 0.029 and rho = 0.338, P = 0.019, respectively) but only with STAI-S score in the preschool group (rho = 0.400, P = 0.003). Conclusions Both preschool children and their parents are more anxious than school-age dyads prior to surgery. The anxiety level of the children correlates with state anxiety of the parents in preschool children but not in school-age children.

Neonatal endotracheal intubation: How to make it more baby friendly

Abstract: Neonatal endotracheal intubation is commonly accompanied by significant disturbances in physiological parameters. The procedure is often poorly tolerated, and multiple attempts are commonly required before the airway is secured. Adverse physiological effects include hypoxemia, bradycardia, hypertension, elevation in intracranial pressure and possibly increase in pulmonary vascular resistance. Use of premedications to facilitate intubation has been shown to reduce but not eliminate these effects. Other important preventative factors include adequate training of the operators and guidelines to limit the duration of attempts. Pre-intubation stabilisation with optimal bag and mask ventilation should allow for better neonatal tolerance of the procedure. Recent research has described significant mask leak and airway obstruction compromising efficacy of neonatal mask ventilation. Further research should help in elucidating mask ventilation techniques which minimise mask leak and airway obstruction.

Characterising the ambient sound environment for infants in intensive care wards

Abstract: Aim The purpose of this study is to characterise ambient sound levels of paediatric and neonatal intensive care units in an old and new hospital according to current standards. Methods The sound environment was surveyed for 24-h data collection periods (n = 80) in the Neonatal and Paediatric Intensive Care Units (NICUs and PICUs) and Special Care Nursery of the old and new Royal Children's Hospital Melbourne. The ambient sound environment was characterised as the proportion of time the ongoing ambient sound met standard benchmarks, the mean 5-s sound levels and the number and duration of noise events. Results In the old hospital, none of the data collection periods in the NICU and PICU met the standard benchmark for ongoing ambient sound, while only 5 of the 22 data collection periods in the new hospital met the recommended level. There was no change in proportion of time at recommended L between the old and the new Special Care Nursery. There was strong evidence for a difference in the mean number of events >65 dBA (L) in the old and new hospital (rate ratio = 0.82, 95% confidence interval: 0.73 to 0.92, P = 0.001). The NICU and PICU were above 50 dBA in 75% of all data collection periods, with ventilatory equipment associated with higher ongoing ambient sound levels. Conclusions The ongoing ambient sound suggests that the background sound environment of the new hospital is not different to the old hospital. However, there may be a reduction in the number of noise events.