Showing papers in "Journal of Paediatrics and Child Health in 2021"

Impact of the COVID-19 pandemic on the well-being of children with neurodevelopmental disabilities and their parents.

Abstract: Aims To examine the impact of COVID-19 pandemic on child mental health and socio-emotional and physical well-being (including sleep, diet, exercise, use of electronic media; care giver perceptions of symptoms of child neurodevelopmental disability [NDD] and comorbidities), and care giver mental health and well-being, social support and service use. Methods An online cross-sectional self-report survey was distributed via disability service providers and support groups. Care givers of children aged 2-17 years with a NDD were invited to respond to questions on child symptom severity and well-being, parent well-being and service access and satisfaction. Results Overall, 302 care givers (94.7% female) completed the survey. Average child age was 9.7 years and 66.9% were male. Worsening of any child NDD or comorbid mental health symptom was reported by 64.5% of respondents and 76.9% reported child health and well-being was impacted by COVID-19. Children were viewing more television and digital media (81.6%), exercising less (68.0%), experiencing reduced sleep quality (43.6%) and had a poorer diet (32.4%). Almost one fifth (18.8%) of families reported an increase in the dosage of medication administered to their child. Parents reported COVID-19 had impacted their own well-being (76.1%). Over half of respondents were not satisfied with services received during COVID-19 (54.8%) and just 30% reported that telehealth works well for their child. Conclusion Targeted interventions are required to address worsening child neurodevelopmental disability, mental health symptoms and poor diet, sleep and exercise patterns. Improved access to telehealth services is indicated, as is further research on barriers and enablers of effective telehealth services.

Hyperinflammatory shock related to COVID-19 in a patient presenting with multisystem inflammatory syndrome in children: First case from Iran.

Abstract: Hyperinflammatory shock related to COVID-19 in a patient presenting with multisystem inflammatory syndrome in children: First case from Iran Ahmad Bahrami, Maryam Vafapour, Bobak Moazzami 3,4 and Nima Rezaei Division of Allergy and Immunology, Ali-Asghar Hospital, Iran University of Medical Sciences, Ali-Asghar Hospital, Department of Pediatrics, Iran University of Medical Sciences, Research Center for Immunodeficiencies, Children’s Medical Center, Tehran University of Medical Sciences, Department of Immunology, School of Medicine, Tehran University of Medical Sciences and Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran

Increased child abuse in Uganda amidst COVID-19 pandemic.

Abstract: Globally, COVID-19 lockdown measures have exposed children to more sexual, physical and emotional abuse and neglect. Although the COVID-19 pandemic is likely to have long-lasting adverse psychological effects on children, there have been comparatively few studies on children's health as compared with adults, particularly in low-income countries. Uganda implemented one of the most stringent lockdowns with bans on transportation and gatherings as well as the closure of schools, stores and places of worship. In order to address the dearth of information in less developed regions, the article aims to provide an insight into the increased cases of child abuse in Uganda during the COVID-19 pandemic. The data and information were primarily compiled from government and child welfare organisation open-source databases. The psychosocial impacts of COVID-19 have greatly disrupted the living conditions of children, limiting their access to basic needs such as food and health care. In addition, there is a lack of social support, thus putting children at an increased risk of different forms of child abuse. Since the implementation of the COVID-19 lockdown in Uganda, there has been a rise in the incidence of child abuse. Increased cases of physical and sexual abuse against children have been reported in different parts of the country as well as increased cases of child labour. To strengthen child protection during the COVID-19 pandemic, this article highlights a need for multi-level stakeholder cooperation to ensure increased funding, increased community awareness and sensitisation, early detection and effective management and referral of child abuse cases.

COVID-19 in children. II: Pathogenesis, disease spectrum and management.

Abstract: The global disruption of the COVID-19 pandemic has impacted the life of every child either directly or indirectly. This review explores the pathophysiology, immune response, clinical presentation and treatment of COVID-19 in children, summarising the most up-to-date data including recent developments regarding variants of concern. The acute infection with SARS-CoV-2 is generally mild in children, whilst the post-infectious manifestations, including paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) and 'long COVID' in children, are more complex. Given that most research on COVID-19 has focused on adult cohorts and that clinical manifestations, treatment availability and impacts differ markedly in children, research that specifically examines COVID-19 in children needs to be prioritised.

COVID-19 in children: I. Epidemiology, prevention and indirect impacts.

Abstract: Children globally have been profoundly impacted by the coronavirus disease 2019 (COVID-19) pandemic. This review explores the direct and indirect public health impacts of COVID-19 on children. We discuss in detail the transmission dynamics, vaccination strategies and, importantly, the 'shadow pandemic', encompassing underappreciated indirect impacts of the pandemic on children. The indirect effects of COVID-19 will have a long-term impact beyond the immediate pandemic period. These include the mental health and wellbeing risks, disruption to family income and attendant stressors including increased family violence, delayed medical attention and the critical issue of prolonged loss of face-to-face learning in a normal school environment. Amplification of existing inequities and creation of new disadvantage are likely additional sequelae, with children from vulnerable families disproportionately affected. We emphasise the responsibility of paediatricians to advocate on behalf of this vulnerable group to ensure the longer-term effects of COVID-19 public health responses on the health and wellbeing of children are fully considered.

COVID-19 and the metaphor of war.

Abstract: The metaphor of war is in danger of over-use. Politicians talk of the war on poverty or crime or drugs. The media refer to the war on infectious diseases such as human immunodeficiency virus or tuberculosis or the war against antibiotic resistance. Infectious disease physicians and oncologists both use the term ‘magic bullets’. There is nothing new about use of the war metaphor: it commenced as early as the 17th century with Thomas Sydenham, who one could say made a chorea out of it, and was perpetuated by Louis Pasteur among many others. Is it reasonable to use the metaphor of war so commonly in reference to the COVID-19 pandemic (Fig. 1)? Psychologists have cautioned against blanket dismissal of war metaphors. The widespread use of war metaphors in various situations in various societies suggests they have a resonance owing to their ability to simplify complex issues, improve communication, capture attention and motivate action. War metaphors are context-dependent: the metaphor may have positive or negative outcomes depending on the context. For example, a war metaphor for COVID-19 may resonate with the public, may help people recognise the threat to public health, may help them take their obligations such as physical distancing seriously. Projection may be a defence mechanism: fears and anxieties are projected into a war with a sub-microscopic enemy, giving a sense of power and control. On the other hand, over-simplifying complex issues reduces ethical complexity, risking the transformation of complex moral choices into goodies-and-baddies trivialisation. US writer Susan Sontag warned of the danger of using metaphors in medicine. In her book, Illness as Metaphor, written when recovering from the cancer which eventually killed her, she describes how metaphors regarding tuberculosis and cancer can lead to a shift from fighting the disease to fighting, blaming and stigmatising the patient. About war, she wrote: ‘Abuse of the military metaphor may be inevitable in a capitalist society, a society that increasingly restricts the scope and credibility of appeals to ethical principle, in which it is thought foolish not to subject one’s actions to the calculus of self-interest and profitability’. Use of the war metaphor in medicine has been criticised as being ‘ironic, unfortunate, and unnecessary’. Ironic because a primary aim of medicine is to save lives, while the aim of war is to take lives. Unfortunate because military metaphors can inadvertently stigmatise patients, and can endorse the legitimacy of war and of social and political violence. Unnecessary because positive alternatives, such as talk of the journey or the cure, are available but under-used. White male political leaders like Boris Johnson, Scott Morrison and Donald Trump always relate the war against COVID-19 to World War II, a ‘justified’ war which united their people and

CoVID-19: Parent and caregiver concerns about reopening New Zealand schools.

Abstract: Aim Children generally have a milder CoVID-19 disease course and better prognosis than adults. Many countries have closed schools as part of measures to limit transmission and this has had a considerable impact on children world-wide. This includes New Zealand (NZ), where rates of CoVID-19 have been very low. The aims of this study were to investigate parents' and caregivers' knowledge of CoVID-19 in children, to understand their levels of concern and to identify their most trusted sources of information. Methods Participants were recruited via NZ parenting support and interest groups on Facebook.com. Knowledge was assessed by way of a self-administered questionnaire during the 10 days prior to NZ schools reopening on 18 May 2020. Results Of the 1191 study participants, 721 (60%) expressed some level of worry (14.5% very or extremely worried) that their child would catch CoVID-19 at school. A high proportion (79%, 941) thought it likely or very likely that their child would catch CoVID-19 at school if there were to be widespread community transmission. Fear scores for CoVID-19 were generally high, and 828 (80%) of participants said they would vaccinate their child if a newly developed vaccine were available. Conclusions Parents and caregivers were generally fearful of their children acquiring CoVID-19 at school. This was despite messaging from multiple trusted sources that transmission in schools is unlikely, and the number of NZ CoVID-19 cases being extremely low. These findings have implications for policy development and public health messaging both in NZ and in countries with ongoing community transmission of CoVID-19.

Impact of the coronavirus pandemic on anorexia nervosa and atypical anorexia nervosa presentations to an Australian tertiary paediatric hospital.

Abstract: AIM: The coronavirus (COVID-19) pandemic has led to increased concerns about adolescent mental health. This study aimed to determine the effect of the pandemic on adolescent eating disorders (EDs) by measuring changes in the number and severity of presentations to an Australian paediatric ED service that utilises a standardised approach to triage and assessment. METHODS: A 4-year retrospective chart review (2017-2020) of all patients (n = 457) presenting to the Royal Children's Hospital Eating Disorder Service, Melbourne, was undertaken. The incidence of each diagnosis and measures of condition severity were extracted from the database and patient medical records. Clinical comments relating to the impact of COVID-19, on both ED behaviours and treatment, were also noted. RESULTS: Annual presentations increased from a mean of 98.7 per annum from 2017 to 2019 to 161 in 2020 (63% increase). COVID-19 restrictions were reported to be a trigger for ED behaviours in 40.4% of adolescents diagnosed with anorexia nervosa in 2020. There was no significant difference in severity across years despite increased cases. CONCLUSIONS: The dramatic increase in presentations has implications for primary health and paediatric care as well as specialist ED services. Increased support is needed for EDs during this time.

Adaptive innovations to provide services to children with developmental disabilities during the COVID-19 pandemic

Abstract: Children with developmental disabilities are experiencing significant challenges to service access due to suspension of in-person assessments during the current COVID-19 pandemic. Telehealth is rapidly becoming the new service delivery model, which presents a unique opportunity for innovation in care that could be beneficial in the post-pandemic period. For example, using a combination of in-home video and telehealth options could form the first step in developmental assessment, allowing children to receive the necessary supports without delay. Recent telehealth funding is welcome but additional Medicare items for joint consultations including general practitioners (GPs), and paediatric, mental health and allied health professionals is critical.

COVID-19 public health measures and respiratory viruses in children in Melbourne.

Abstract: AIM: To describe the epidemiology of respiratory viruses in children before and during the 2020 SARS-CoV-2 pandemic and the relationship to public health measures instituted by the Victorian government. METHODS: Retrospective audit of respiratory viruses at a tertiary paediatric hospital in Melbourne from January 2015 up to week 47, 2020 in children under 18 years of age. The proportion of positive cases in weeks 1-47 in 2015-2019 (period 1) were compared to weeks 1-47, 2020 (period 2), and reviewed in the context of public health restrictions in Victoria. RESULTS: An annual average of 4636 tests were performed in period 1 compared to 3659 tests in period 2. Proportions of positive influenza A virus, influenza B virus, respiratory syncytial virus (RSV) and human parainfluenza virus were significantly reduced in period 2 compared to period 1: 77.3, 89.4, 68.6 and 66.9% reductions, respectively (all P < 0.001). From week 12-47, 2020, 28 893 SARS-CoV-2 tests were performed with a 0.64% positivity rate. Influenza viruses were not detected after week 17, RSV was not detected after week 35. CONCLUSIONS: Strict public health measures and border closures were successful in eliminating community transmission of SARS-CoV-2 in Melbourne. This was associated with a significant reduction in other respiratory virus infections in children. Identifying sustainable and effective ongoing public health interventions to reduce transmission of RSV and influenza could result in reduced morbidity and mortality in children and requires further research.

Paediatric appendicitis during the COVID-19 pandemic.

Abstract: AIM: The repercussions of the pandemic on patients without COVID-19 have been well documented. Although there is evidence that adult patients present later with complicated appendicitis, the impact on the paediatric population is unknown. Therefore, the aim of this study was to assess the impact of the COVID-19 pandemic on the presentation and management of paediatric appendicitis. METHODS: Data from consecutive paediatric patients admitted with right iliac fossa pain to a teaching hospital from 1 March 2020 until 30 June 2020 (COVID-19) were compared with patients admitted from 1 March 2019 until 30 June 2019 (control). RESULTS: One hundred and seventy-two patients were admitted with right iliac fossa pain (control = 97, COVID-19 = 75). Seven patients had a normal diagnostic laparoscopy in the control group compared with none in the COVID-19 group. The proportion of patients diagnosed with appendicitis was significantly higher during the COVID-19 pandemic (24% vs. 10%, P = 0.03). They presented later (3 days vs. 1 day, P < 0.01) with higher inflammatory markers (white cell count 15.8 vs. 13.2 × 109 cells per litre, P = 0.02; C-reactive protein 53 vs. 27 mg/L P = 0.04). The majority of patients underwent surgery within 1 day of admission (94% COVID-19 vs. 70% control, P = 0.13). Although there was a trend towards a greater proportion of complicated appendicitis (22% vs. 10%, P = 0.6) during COVID-19, this did not affect outcomes (no morbidity in both groups, length of hospital stay 4 vs. 2.5 days, P = 0.29). CONCLUSION: Despite presenting later during COVID-19, paediatric patients with appendicitis were treated expediently with good outcomes.

How long and how much? Wait times and costs for initial private child mental health appointments.

Abstract: AIM: To determine: (i) wait times and out-of-pocket costs for children attending private specialists for initial mental health appointments; and (ii) whether these differed between specialists working in metropolitan versus rural areas and in low, medium and high socio-economic areas. METHODS: Prospective secret shopper study whereby a researcher posed as a parent seeking an appointment for her child with anxiety or attention-deficit/hyperactivity disorder. We contacted 317 private paediatrician, psychiatrist and psychologist practices in Victoria and South Australia between 12 March and 5 May 2019. RESULTS: One third (29.8%) of private practices were closed to new referrals. The average wait times for paediatricians, psychiatrists, and psychologists were 44, 41 and 34 days, respectively. Average out-of-pocket costs quoted were AU$120 for paediatricians, AU$176 for psychiatrists and AU$85 for psychologists. CONCLUSION: Parents face extensive wait times and substantial out-of-pocket costs when seeking private mental health services for their child.

Outcomes following admission to paediatric intensive care: A systematic review.

Abstract: Aim To describe the long-term health outcomes of children admitted to a paediatric intensive care unit Methods A systematic review of the literature was performed Studies of children under 18 years of age admitted to a paediatric intensive care unit were included Studies focussed on neonatal admissions and investigating specific paediatric intensive care unit interventions or admission diagnoses were excluded A table was created summarising the study characteristics and main findings Risk of bias was assessed using the Newcastle Ottawa Quality Assessment Scale for observational studies Primary outcome was short-, medium- and long-term mortality Secondary outcomes included measures of neurodevelopment, cognition, physical, behavioural and psychosocial function as well as quality of life Results One hundred and eleven studies were included, most were conducted in high-income countries and focussed on short-term outcomes Mortality during admission ranged from 13 to 50% Mortality in high-income countries reduced over time but this trend was not evident for lower income countries Higher income countries had lower standardised mortality rates than lower income countries Children had an ongoing increased risk of death for up to 10 years following intensive care admission as well as increased physical and psychosocial morbidity compared to healthy controls, with associated poorer quality of life Conclusions There is limited high-level evidence for the long-term health outcomes of children after intensive care admission, with the burden of related morbidity remaining greater in poorly resourced regions Further research is recommended to identify risk factors and modifiable factors for poor outcomes, which could be targeted in practice improvement initiatives

Early detection of cerebral palsy in high-risk infants: Translation of evidence into practice in an Australian hospital.

Abstract: Aim The early diagnosis of cerebral palsy (CP) allows children timely access to early intervention. In 2018, Monash Children's Hospital established an Early Neurodevelopment Clinic based upon evidence-based guidelines for the early diagnosis of CP in high-risk infants. In this study, we aimed to characterise the infants presenting to the clinic and determine the rate of CP diagnosis. Methods This study analysed data from infants attending the Early Neurodevelopment Clinic between May 2019 and April 2020. Infants at high-risk for CP attended the clinic at 3 months corrected age. Neuroimaging reports were reviewed, and a Prechtl's General Movement Assessment and Hammersmith Infant Neurological Examination were performed. Infants were diagnosed as having typical development, delayed development, high-risk of CP or CP at the time of clinic attendance and referred on to the appropriate pathway. Results Ninety-six high-risk infants attended the clinic over the 1 year study period. Sixty-eight (71%) infants were extremely preterm or extremely low birthweight, and 28 (29%) were infants at born at older gestation with evidence of moderate to severe brain injury. Nine (9.6%) infants received a CP diagnosis and 12 (12.5%) were considered high-risk of CP. All infants with CP or high-risk of CP were referred to the Victorian Paediatric Rehabilitation Service. Conclusions It is feasible to implement the early CP diagnosis guidelines into a high-risk infant follow-up clinic. Implementation of the guidelines allows for early diagnosis of CP and appropriate referral of high-risk infants.

Psychologically informed physiotherapy as part of a multidisciplinary rehabilitation program for children and adolescents with functional neurological disorder: Physical and mental health outcomes.

Abstract: AIM Children and adolescents with functional neurological disorder (FND) present with physical impairment and mental health comorbidities. Specialist physiotherapy programs for treating FND have been developed over the last two decades. This article reports outcome data from three cohorts of children treated with a multidisciplinary rehabilitation intervention - the Mind-Body Program - in which a psychologically informed physiotherapy intervention, known as the wellness approach to physiotherapy, was a key component. METHODS For three cohorts of children (n = 57, n = 60 and n = 25, respectively) treated in the Mind-Body Program, data about functional impairment and mental health concerns were collected at presentation and at follow-up (4 years, 12 months and 18 months, respectively). RESULTS Outcome data show that FND symptoms resolved in 54/57 (95%), 51/60 (85%) and 22/25 (88%) of children in the three cohorts, and that 31/57 (61%), 32/60 (53%) and 13/25 (52%) of children returned to full health and to full-time school attendance. Changes in Global Assessment of Function (GAF) were significant (t(54) = 21.60, P < 0.001; t(55) = 9.92, P < 0.001; t(24) = 6.51, P < 0.001). Outcomes were less favourable for children with chronic FND symptoms at presentation; those whose comorbid mental health disorders or other (comorbid) functional somatic symptoms did not resolve; and those who subsequently developed chronic mental health problems. CONCLUSIONS Implementation of a multidisciplinary rehabilitation intervention - with psychologically informed physiotherapy as one of the key treatment components - resulted in resolution of FND symptoms and return to health and well-being in the large majority of patients.

Paediatric periorbital cellulitis: A 10-year retrospective case series review.

Abstract: Aim To identify the predictors of poor outcome and need for surgical management in paediatric patients with periorbital cellulitis. To assess the adherence to local guidelines in the management of periorbital cellulitis. Methods Retrospective descriptive analysis of clinical, laboratory and radiological characteristics of 175 paediatric periorbital cellulitis presentations at a UK teaching hospital over a 10‐year period. Regression investigated correlations for continuous and categorical variables. Results A total of 175 paediatric presentations were diagnosed as periorbital infections over the 10‐year period. Of these, 139 had pre‐septal cellulitis, 27 had a subperiosteal abscess, 6 had an orbital cellulitis, 1 had an orbital abscess, 1 a cavernous sinus thrombosis and 1 an extradural abscess. Median age at presentation was 5 years (range: 1 month–17 years). In total, 169 (97%) cases received systemic antimicrobial treatment. Cross‐sectional imaging occurred in 30% of cases and 18% required surgical intervention. Increasing C‐reactive protein was associated with greater risk of post‐septal disease and requiring surgery. The best predictors of post‐septal disease in the multivariate analysis (R2 = 0.49, P = ≤0.001) were ophthalmoplegia (P = 0.009), proptosis (P = 0.016) and pain on eye movement (P = 0.046). Proptosis was the single most significant predictor of surgical management (R2 = 0.53, P = <0.001). Conclusion Multidisciplinary involvement and early medical management can improve outcomes for most patients. Those who deteriorate despite medical management should be considered for prompt imaging and surgical management to avoid serious life‐threatening or sight‐threatening complications.

Revealing the clinical phenotype of atypical neuronal ceroid lipofuscinosis type 2 disease: Insights from the largest cohort in the world

Abstract: Aim Neuronal ceroid lipofuscinosis type 2 (CLN2) disease is an autosomal recessive inherited neurodegenerative lysosomal storage disorder caused by deficient tripeptidyl peptidase 1 (TPP1) enzyme, leading to progressive deterioration of neurological functions commonly occurring in children aged 2-4 years and culminating in early death. Atypical cases associated with earlier or later symptom onset, or even protracted course, have already been reported. Such variable manifestations may constitute an additional challenge to early diagnosis and initiation of appropriate treatment. The present work aimed to analyse clinical data from a cohort of Latin American CLN2 patients with atypical phenotypes. Methods Experts in inborn errors of metabolism from Latin America selected patients from their centres who were deemed by the clinicians to have atypical forms of CLN2, according to the current literature on this topic and their practical experience. Clinical and genetic data from the medical records were retrospectively revised. All cases were presented and analysed by these experts at an Advisory Board Meeting in Sao Paulo, Brazil, in October 2018. Results Seizures, language abnormalities and behavioural disorders were found as the first manifestations, appearing at the median age of 6 years, an older age than classically described for the late infantile form. Three novel mutations were also identified. Conclusion Our findings reinforce the inclusion of CLN2 in the differential diagnosis of children presenting with seizures, behavioural disorders and language abnormalities. Early diagnosis will allow early initiation of specific therapy.

What affects programme engagement for Māori families? A qualitative study of a family-based, multidisciplinary healthy lifestyle programme for children and adolescents.

Abstract: Aim It is important that intervention programmes are accessible and acceptable for groups most affected by excess weight. This study aimed to understand the barriers to and facilitators of engagement for Māori in a community-based, assessment-and-intervention healthy lifestyle programme (Whānau Pakari). Methods Sixty-four in-depth, home-based interviews were conducted with past service users. Half of these were with families with Māori children and half with non-Māori families. The interviews were thematically analysed with peer debriefing for validity. Results Māori families experienced barriers due to racism throughout the health system and society, which then affected their ability to engage with the programme. Key barriers included the institutionalised racism evident through substantial structural barriers and socio-economic challenges, the experience of interpersonal racism and its cumulative impact with weight stigma, and internalised racism and beliefs of biological determinism. Responses to these barriers were distrust of health services, followed by renewed engagement or complete disengagement. Participants identified culturally appropriate care as that which was compassionate, respectful, and focused on relationship building. Conclusions While Whānau Pakari is considered appropriate due to the approach of the delivery team, this is insufficient to retain some Māori families who face increased socio-economic and structural barriers. Past instances of weight stigma and racism have enduring effects when re-engaging with future health services, and inequities are likely to persist until these issues are addressed within the health system and wider society.

Impact of climate change and biodiversity collapse on the global emergence and spread of infectious diseases.

Abstract: The reality of climate change and biodiversity collapse is irrefutable in the 21st century, with urgent action required not only to conserve threatened species but also to protect human life and wellbeing. This existential threat forces us to recognise that our existence is completely dependent upon well-functioning ecosystems that sustain the diversity of life on our planet, including that required for human health. By synthesising data on the ecology, epidemiology and evolutionary biology of various pathogens, we are gaining a better understanding of factors that underlie disease emergence and spread. However, our knowledge remains rudimentary with limited insight into the complex feedback loops that underlie ecological stability, which are at risk of rapidly unravelling once certain tipping points are breached. In this paper, we consider the impact of climate change and biodiversity collapse on the ever-present risk of infectious disease emergence and spread. We review historical and contemporaneous infectious diseases that have been influenced by human environmental manipulation, including zoonoses and vector- and water-borne diseases, alongside an evaluation of the impact of migration, urbanisation and human density on transmissible diseases. The current lack of urgency in political commitment to address climate change warrants enhanced understanding and action from paediatricians - to ensure that we safeguard the health and wellbeing of children in our care today, as well as those of future generations.

Appraisal of clinical practice guidelines for the evaluation and management of neck masses in children.

Abstract: Aim The purpose of this systematic review was to use the Appraisal of Guidelines for Research and Evaluation tool to assess the methodological quality of clinical practice guidelines (CPGs) for the workup and management of paediatric neck masses. Methods MEDLINE, Embase, Cochrane and grey literature were searched to identify CPG incorporating paediatric neck masses. Four authors with previous training of the Appraisal of Guidelines for Research and Evaluation tool evaluated the included studies. Results Nine studies met inclusion criteria. The highest scoring domains were 'Scope and Purpose' (74.0 ± 4.5) and 'Clarity of Presentation' (72.9 ± 6.3). The lowest scoring domains were 'Rigour and Development' (18.8 ± 7.5) and 'Applicability' (23.7 ± 6.1). One study was 'High' quality, three received scores of 'Average' and five were found to be 'Low' quality. Conclusion The majority of paediatric neck mass CPGs were low to average quality. The domains in need of greatest improvement were 'Rigour and Development' and 'Applicability', suggesting significant concerns in current CPGs focused on paediatric neck masses.

Emergency mental health presentations in children with autism spectrum disorder and attention deficit hyperactivity disorder.

Abstract: F.E. Babl, Emergency Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia. E-mail: franz.babl@rch.org.au S.M. O'Donnell, Emergency Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia. E-mail: sinead.o'donnell@rch.org.au

Does detection of fetal growth restriction improve neonatal outcomes

Abstract: AIM: Timely delivery of fetal growth restriction (FGR) is a balance between avoiding stillbirth and minimising prematurity. We sought to assess the neonatal outcomes for babies suspected of FGR, both true and false positives. METHODS: This population cohort study examined all singleton births in Victoria, Australia from 2000 to 2017 (n = 1 231 415). Neonatal morbidities associated with neonatal intensive care unit (NICU) admission were assessed for babies born ≥32 weeks' with severe FGR (<3rd centile) and babies with birthweight ≥10th centile who were iatrogenically delivered for suspected FGR. RESULTS: Babies with severe FGR iatrogenically delivered for suspected FGR were more likely to require NICU admission than babies with severe FGR who were not detected (3.0% vs. 1.1%, P < 0.001). After adjusting for potential confounders, the odds of NICU admission were increased (adjusted odds ratio (aOR) = 3.00, 95% confidence interval = 2.45-3.67; P < 0.001). Rates of NICU admission were also higher in ≥10th centile babies iatrogenically delivered for suspected FGR than for ≥10th centile babies who entered labour spontaneously (1.8% vs. 0.5%, P < 0.001). After adjustments, the odds of NICU admission were increased (aOR = 3.91, 95% confidence interval = 3.40-4.49; P < 0.001). NICU admissions were associated with morbidities related to iatrogenic prematurity. CONCLUSIONS: Detection and planned delivery of FGR reduces stillbirth but may be associated with increased neonatal morbidity related to iatrogenic prematurity.

Morbidity in the COVID-19 era: Ethanol intoxication secondary to hand sanitiser ingestion.

Abstract: A 6-year-old girl was brought by her carer to the emergency department (ED) of a local hospital with a decreased Glasgow Coma Scale (GCS), diplopia and slurred speech. The history provided was that about 1 h and 15 min after she had been playing alone, she reported to her mother feeling dizzy and was noted to have slurred speech. Her older sister commented that her breath smelled like hand sanitiser. On arrival to ED she vomited twice (described as ‘sweet smelling’). She had a patent airway, respiratory rate of 17 breaths/ min, heart rate of 77 beats/min and blood pressure 92/59 mmHg. Her GCS was initially 13 (eye response 4, motor response 5, verbal response 4). Within 30 min, she had increased vomiting and dropped her GCS to 9 (E2, M4, V3). Her pupils were 3 mm bilaterally and responsive to light. She had widespread decreased tone, but no focal neurological deficit. There were no visible injuries on examination. The patient’s medical history included one previous seizure at 14 months of age. She had normal development, was fully immunised and was not on any regular medications. Venous blood gas revealed a metabolic acidosis (pH 7.31, base excess −2, bicarbonate level 20 mmol/L, lactate 2.5, CO2 48); blood sugar level was 7.9 mmol/L. She was hypokalaemic with potassium of 3.3 mmol/L. Other electrolytes, full blood count examination, C-reactive protein, kidney and liver function tests, were normal. A non-contrast computed tomography scan of her brain did not reveal an acute intracranial pathology. A toxicology screen, performed due to the non-specific and unexplained presentation, was negative for salicylates and paracetamol. However, her serum ethanol concentration was found to be 41.1 mmol/L or 0.19% (NSW legal blood ethanol limits for driving <10.9 mmol/L or 0.05%). Considering the drop in GCS and persistent vomiting, her airway was assessed as being at risk, and she was intubated and ventilated in the ED. She was not clinically assessed to be septic or dehydrated by the treating physicians at the time; however, she was prophylactically treated with one dose of intravenous ceftriaxone and transferred to a tertiary paediatric intensive care unit. Her sedation was rapidly weaned, and she was extubated within 3 h of arriving in the intensive care unit. Subsequent serum ethanol level performed 6 h later showed a level of 14 mmol/L (0.06%). Her GCS returned to 15 and her neurological examination was normal. Thorough history obtained from the parent confirmed that there were no alcoholic drinks in the house. Once awake, the patient disclosed that she had often tasted the hand sanitiser over the last few months and had done so the previous night. She was unable to report the volume that she consumed but the NSW Poisons Information Centre estimated it to be in the region of 50 mL. She reported liking the smell and taste of the hand sanitiser, which her mother noted had been missing for a few days. The particular brand of hand sanitiser ingested contains between 62 and 70% ethanol, which is standard for most alcohol-based hand sanitisers sold in Australia. The child remained well and was discharged home 24 h later.

Lessons learnt during the COVID-19 pandemic: Why Australian schools should be prioritised to stay open.

Abstract: In 2020, school and early childhood educational centre (ECEC) closures affected over 1.5 billion school-aged children globally as part of the COVID-19 pandemic response. Attendance at school and access to ECEC is critical to a child's learning, well-being and health. School closures increase inequities by disproportionately affecting vulnerable children. Here, we summarise the role of children and adolescents in Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) transmission and that of schools and ECECs in community transmission and describe the Australian experience. In Australia, most SARS-CoV-2 cases in schools were solitary (77% in NSW and 67% in Victoria); of those that did progress to an outbreak, >90% involved fewer than 10 cases. Australian and global experience has demonstrated that SARS-CoV-2 is predominantly introduced into schools and ECECs during periods of heightened community transmission. Implementation of public health mitigation strategies, including effective testing, tracing and isolation of contacts, means schools and ECECs can be safe, not drivers of transmission. Schools and ECEC are essential services and so they should be prioritised to stay open for face-to-face learning. This is particularly critical as we continue to manage the next phase of the COVID-19 pandemic.

Predictors and outcomes of extubation failure in extremely preterm infants

Abstract: AIM: To determine predictors and outcomes of extubation failure in extremely preterm (EP) infants born <28 weeks' gestational age (GA). METHODS: Retrospective clinical audit across two tertiary-level neonatal intensive care units in Melbourne, Australia. Two-hundred and four EP infants who survived to their first extubation from mechanical ventilation. Extubation failure (re-intubation) within 7 days after the first extubation. RESULTS: Lower GA (odds ratio [OR] 0.71, 95% confidence interval (CI), 0.61-0.89, P < 0.001) and higher pre-extubation measured mean airway pressure (MAP) on the mechanical ventilator (OR 1.9 [95% CI 1.41-2.51], P < 0.001) predicted extubation failure. The area under a receiver operating characteristic curve for GA and MAP was 0.77 (95% CI 0.70-0.82). After adjustment for GA, infants who experienced extubation failure had higher rates of bronchopulmonary dysplasia (P < 0.001), post-natal systemic corticosteroid treatment (P < 0.001), airway trauma (P < 0.003), longer durations of treatment with mechanical ventilation (P < 0.001), non-invasive respiratory support (P < 0.001), supplemental oxygen therapy (P = 0.05) and longer hospitalisation (P = 0.025). CONCLUSIONS: Lower GA and higher pre-extubation measured MAP were predictive of extubation failure within 7 days in extremely preterm infants. Extubation failure was associated with increased morbidity and extended periods of respiratory support and hospitalisation.

Importance of early diagnosis for developmental dysplasia of the hip: A 5-year radiological outcome study comparing the effect of early and late diagnosis.

Abstract: AIM Australia utilises a selective ultrasound screening programme. The rate of late diagnosis of developmental dysplasia of the hip (DDH) in Australia is increasing. The aim of this study is to quantify the treatment required and compare the 5-year radiological outcomes between early and late diagnosis in children with DDH with frank dislocation. METHODS We performed a case-matched control study of children with frank DDH dislocations from 2000 to 2010 comparing three groups: children with an early diagnosis successfully treated in a Pavlik harness (SP), children with an early diagnosis who failed Pavlik harness treatment (FP) and children with a late diagnosis (LD). Minimum follow-up was 4 years. RESULTS A total of 115 hips were included. Patients in the LD group required significantly more open reductions (P < 0.001), acetabular osteotomies (P < 0.001) and femoral osteotomies (P < 0.001). LD was also associated with significantly higher rates of growth disturbance at 46.3%, compared to 20.6% in the FP group and 5% in the SP group (P < 0.001). Overall, there were excellent radiological outcomes in 58.5% of the LD group compared to 79.4% in the FP group and 100% in the SP group. CONCLUSION In Australia, high rates of LD in DDH persist in the context of selective ultrasound screening. While good radiological outcomes are achievable, a significantly greater level of surgical intervention is required and this is associated with significantly higher rates of growth disturbance. Optimisation of screening in Australia is vital.

Delayed access to care and late presentations in children during the COVID-19 pandemic New Zealand-wide lockdown: A New Zealand Paediatric Surveillance Unit study.

Abstract: AIM: Describe paediatricians' experience of adverse health outcomes for children during the New Zealand-wide level 4 lockdown in response to the COVID-19 pandemic. METHODS: Weekly national survey of paediatricians with an open-ended questionnaire. RESULTS: During the 6-week study survey period, the New Zealand Paediatric Surveillance Unit received 33 reports about 55 instances where paediatricians believed care may have been compromised, about half (56%) relating to infants aged from birth to 6 weeks. Compromised care was for acute presentations in 75%, acute complications of a chronic illness in 14%, with 11% for chronic conditions. Paediatricians reported the outcome as moderately severe (short-term morbidity, increased length of stay, higher level of care) in 38 cases (69%) and in a further 4 (7%) as severe (potential to be life-threatening or result in permanent disability). CONCLUSION: Despite clear messaging, hospital avoidance and reduced access to primary and secondary care were associated with significant potential harm for children in New Zealand during a strict lockdown, with newborn infants disproportionately affected. During the implementation of interventions to eliminate community transmission of COVID-19, New Zealand paediatricians note the importance of face-to-face post-natal visits for newborns and primary care services for children with acute illness, to avoid preventable harm.

Risk factors associated with household transmission of SARS-CoV-2 in Negeri Sembilan, Malaysia.

Abstract: Aim Households are a significant venue for the transmission of SARS-CoV-2. We conducted a study to characterise the transmission dynamics and identify risk factors for household transmission of SARS-CoV-2 in Negeri Sembilan, Malaysia. Methods This retrospective observational study included 185 families of paediatric COVID-19 cases from 1 February 2020 to 31 December 2020. We identified the index case for each household and gathered the socio-demographic, epidemiological investigation results and risk factors for household transmission from medical case records. The secondary attack rate was calculated, and logistic regression analyses were used to identify risk factors associated with secondary household transmission of SARS-CoV-2. Results Of the 848 household contacts, 466 acquired secondary infections, resulting in a secondary attack rate of 55%. The median age of the secondary cases was 12 years. Female household contacts and household contacts who slept in the same room with the index case were significantly associated with increased risk for COVID-19. Other independent risk factors associated with higher transmission risk in the household included an index case who was symptomatic, a household index case aged greater than 18 years and a male household index case. Conclusions High rates of household transmission of COVID-19 were found, indicating households were a major setting of transmission of SARS-CoV-2. Our data provide insight into the risk factors for household transmission of SARS-CoV-2 in Malaysia.