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Aim: The aim of this study was to investigate the effect of the use of projector kaleidoscope and matching card on children's fear and physiological parameters in children aged 3-6 years receiving inhaled medication., Methods: This randomised controlled study was conducted with the guidelines of Consolidated Standards of Reporting Trials (CONSORT). The sample of children was allocated to the projector kaleidoscope group (n = 38), matching card group (n = 38) and control group (n = 38). Fear and vital signs were measured., Results: In the study, the mean age of the children in the projector kaleidoscope group was 4.39 ± 1.10, the mean age of the children in the matching card group was 4.34 ± 0.96 and the mean age of the children in the control group was 4.28 ± 1.18. There was a statistically significant difference between the post-test scores of the Children's Fear Scale in the evaluation of parents and nurses according to the groups of children. There was a statistically significant difference between the respiratory post-test scores according to the groups of children. It was observed that the mean heart rate of the control group participants was higher than that of the children in the matching card group. There were no statistically significant differences in the post-test saturation values among the groups of children., Conclusion: It was observed that the projector kaleidoscope and matching card reduced fear and prevented increased respiratory rate in children receiving inhaler medication. In addition, it was determined that matching card had more effect on heart and respiratory rate than projector kaleidoscope., (© 2024 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: We sought to determine the degree of agreement between clinical and laboratory methods for diagnosing scabies in school-aged children., Methods: Clinical information and samples were collected from children aged 7 months to 14 years attending educational institutions in Auckland, New Zealand. Two methods determined scabies status: the International Alliance for the Control of Scabies clinical criteria (IACS) and quantitative polymerase chain reaction (qPCR). Sensitivity and specificity of each method, as the reference or index standard, were estimated and agreement was determined using Cohen's kappa statistic., Results: Sixteen of 145 children were positive based on IACS criteria and 15 of 64 with a suspicious skin lesion returned a positive qPCR test. IACS sensitivity and specificity were 66.7% (95% confidence interval (CI): 39.9-93.3) and 94% (95% CI: 89.9-98.0), respectively (with qPCR as the reference). For qPCR, sensitivity and specificity were 50% (95% CI: 25.5-74.5) and 96.9% (95% CI: 94.0-100.0), respectively (with IACS as the reference). The kappa value was 0.53., Conclusion: Agreement between clinical and laboratory methods in the identification of scabies diagnosis was moderate. Both methods had low sensitivity but high specificity. Scabies diagnosis might be improved, thereby enhancing control measures, by relaxing the IACS criteria (as some IACS-negative participants returned positive qPCR tests, indicating mite DNA was present) and conversely supplementing clinical assessment with qPCR testing., (© 2024 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aims: To evaluate real-world glycaemic outcomes in children with type 1 diabetes (T1D) commencing advanced hybrid closed loop therapy (AHCL) and to explore these outcomes based on the cohort's clinical and socioeconomic characteristics., Methods: A single-centre, population-based retrospective study in children commencing AHCL (Smart Guard, Control IQ, CamAPS) with minimum 70% data from two-weeks CGM pre-AHCL was conducted between December 2021 and June 2023 in Western Australia. CGM metrics (time in range (TIR) 3.9-10 mmol/L, time below range (TBR) < 3.9 mmol/L, glucose management indicator (GMI)) were analysed at baseline, monthly and 6 months. HbA1c at baseline and 6 months were also collected. The proportion meeting glycaemic targets of TIR > 70%, TBR < 4% and GMI < 7.0% were determined. Change in TIR from baseline to 6 months was examined by the following characteristics: %TIR, age group and Index of Relative Socioeconomic Disadvantage (IRSD) of residential postcode., Results: CGM data of 309 children, mean (SD) age 12.4 (3.2) years were analysed. Glycaemia improved from baseline to 6 months with (mean) TIR +8% (95% CI 7, 9; P ≤ 0.001), GMI -0.3% (95% CI -0.3, -0.2; P < 0.001) and (median) TBR -0.3% (95% CI -0.4, -0.1; P < 0.001). Proportion meeting glycaemic targets increased from 13.3% at baseline to 30.6% at 6 months. Improvement in TIR did not differ based on age group or IRSD Quintile. Greater increase in TIR was seen in those with lowest TIR at baseline (+20.9%, -0.2%; P < 0.001 for baseline TIR < 40%, >70%). There was a 0.27% reduction in HbA1c in 6 months (n = 116) (P < 0.001)., Conclusions: AHCL improves glycaemia, irrespective of age and socioeconomic characteristics, with greatest changes seen in those with lowest baseline TIR., (© 2024 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Hypovitaminosis A is a leading cause of preventable childhood blindness, especially in developing nations. Vitamin A is a fat-soluble essential micronutrient that serves vital functions in the visual system and in regulating bone resorption. We report on a series of four children with mixed nutritional and compressive optic neuropathy and provide a review of the literature., Methods: A retrospective observational study of four males (ages 9-12), three with autism spectrum disorder who presented with loss of vision and multiple vitamin deficiencies including hypovitaminosis A., Results: Patients presented with unexplained visual loss or a change in visual behaviour. All patients had severely restricted diet comprising of predominantly carbohydrates. Two of the four cases demonstrated optic nerve pallor at initial presentation with marked optic atrophy developing in all patients over time. Electrophysiology available in two patients demonstrated optic nerve dysfunction with preserved retinal function. Extensive investigations revealed profound deficiency in multiple vitamins including vitamin A (<0.1-0.2 μmol/L, normal = 0.9-1.7 μmol/L). Three patients also had low vitamin B12 (90-111 pmol/L, normal = 170-800 pmol/L) with normal folate. All four cases had radiological evidence of skull base thickening indicative of low vitamin A. Genetic testing did not find any relevant pathogenic variants., Conclusions: Hypovitaminosis A is a crucial form of nutritional deprivation that results in significant visual loss with potential hyperostosis and optic nerve compression exacerbating nutritional optic neuropathy. Additional micronutrient deficiencies usually co-exist and may contribute. Extra vigilance in vitamin replacement is required of clinicians with patients with autism who have restricted diets., (© 2024 The Author(s). Journal of Paediatrics and Child Health published by John Wiley & Sons Australia, Ltd on behalf of Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Background: Typhoid is endemic in many low-income countries, including in Papua New Guinea. This study aimed to describe the burden and clinical features of typhoid in children in a provincial hospital, to describe environmental conditions that lead to typhoid, and to document the antibiotic sensitivity of Salmonella spp. in the Eastern Highlands Province., Methods: A combined retrospective and prospective study of children admitted to with clinical features of typhoid to the Goroka Hospital throughout 2022., Results: The study included 98 children, of which 54% were female. The median age was 8 (IQR 5-10.6) years. Over 60% of the patients were from Goroka District, the peri-urban area encompassing the town and surrounds. Ninety-four percent (92) of the patients used a pit latrine as a toilet and only 28% had access to treated water. Neuropsychiatric symptoms were common (60%), as was leukopenia (48%), thrombocytopenia (52%) and anaemia (42%). Thirty-seven patients had positive blood cultures for Salmonella typhi; all isolates were sensitive to third-generation cephalosporins, pefloxacin, ampicillin, trimethoprim and sulfamethoxazole, and only 54% sensitive to chloramphenicol. The median duration of hospitalisation was 6 days (IQR). There were no deaths., Conclusion: Prompt public health actions are needed to reduce the burden of typhoid infection in the Papua New Guinea. The conjugate typhoid vaccine should be considered in the highlands region, where typhoid is most endemic., (© 2024 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: To describe the characteristics of patients with chronic hepatitis B (CHB) presenting to a tertiary paediatric hospital in Perth, Western Australia. Review of implementation of previous follow-up recommendations for the cohort was also undertaken., Method: A retrospective data analysis of all individuals aged between 0 and 17 years presenting to the tertiary children's hospital who were hepatitis B surface antigen (HBsAg) positive over 8 years (2013-2020). Demographic features, clinical progress and follow up are described, including proportion transferred to adult services., Results: Seventy-four patients were identified to have CHB; mean age at diagnosis 11 years; standard deviation 4 years; 41 (55%) male. Cultural and ethnolinguistic diversity was high; 74% (n = 55) were from refugee-like backgrounds. Many did not demonstrate English proficiency (23/40; 75%) and 7 (10%) Australian born including 4 patients who were Aboriginal. Most patients (58%) with CHB were in the hepatitis B e antigen-positive chronic infection phase with no intervention provided. Seventeen children had undergone liver ultrasonography and one underwent liver biopsy; none received antiviral treatment. Follow up was concerning; 28 (38%) had at least one clinic non-attendance, 24 (32%) lost to follow-up and interpreter utilisation was poorly documented. Thirty-nine (53%) were transferred to adult services with only 56% attending follow-up., Conclusion: CHB burden is higher in those from culturally and ethnolinguistically diverse backgrounds. There is a significant loss to follow-up and suboptimal transfer to adult services. Improved recall, education and referral processes are necessary to overcome language, socioeconomic and cultural barriers. Although childhood complications are infrequent, longitudinal monitoring is crucial to prevent long-term complications and adult morbidity., (© 2024 The Authors. Journal of Paediatrics and Child Health published by John Wiley & Sons Australia, Ltd on behalf of Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Social media is increasingly a part of our personal and professional life and is here to stay. Here, I reflect on issues surrounding the use of social media (SMU) in the digital health context by clinicians in Australian paediatric health care. I aim to briefly highlight some inherent multifactorial and contextual ethical considerations which mainly relate to professionalism; including boundaries, obligations to patients and families within the therapeutic alliance, and balancing the help, hype and harm of SMU in clinical practice. I conclude that digital health and SMU are ubiquitous, and can be beneficial if used circumspectly with Hippocratic principles that have been updated for the modern era and are grounded in ancient moral codes. Unfettered SMU however, without adherence to ethical and legal guidelines is problematic, and may expose patients, families and clinicians to significant risk of harm and moral vulnerability. Justifiable, explicit, consistent and regularly reviewed boundaries, both professional and personal, are ethically advisable. These should reflect, and adapt to, the rapidly evolving nature of social media as imprudent digital health and SMU without proportionate limits, may undermine still relevant Hippocratic tenets, and the primacy of doing no harm., (© 2023 The Authors. Journal of Paediatrics and Child Health published by John Wiley & Sons Australia, Ltd on behalf of Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Rapid sequence intubation (RSI) in children is a low-incidence, high-risk event associated with cognitive overload and potential errors producing unfavourable outcomes. Cognitive aids, such as charts, algorithms and flow diagrams, are prompts that externalise and structure mental processes to reduce cognitive load, thereby reducing errors. The Paediatric Anaesthetic Emergency Drug Solution (PAEDS) approach combines a colour-coded chart and medication box with a simplified mathematical system of volume-based dosing; the effect of which on cognitive load during a simulated RSI has not previously been described., Methods: A randomised, cross-over trial was conducted with 26 multi-disciplinary emergency medicine clinicians (doctors and nurses) allocated to four groups, performing four high-fidelity RSI simulations, two mandating the use of the PAEDS approach. This mixed methods study followed the pragmatic ontology using grounded theory methodology. Qualitative data were collected from nine individual interviews by a process of thematic analysis via an inductive approach, to allow for appropriate open and axial coding to occur. Quantitative data collected included cognitive loading using the raw NASA-Task Load Index as well as time to intubation and drug dosage details to assess for safety., Results: Qualitative results showed that the PAEDS approach reduced cognitive loading through the use of both the labelled medication box and colour-coded medication charts. The PAEDS approach also showed improved perceived time pressure without feeling rushed, and with no recorded drug errors. Differences in the quantitative data for total cognitive load, error and time were not statistically significant, likely due to sample size., Conclusion: The PAEDS approach is a multifaceted system which is not inferior to current practice, with some components described as an improvement. Further research on a larger sample size needs to be conducted to assess the aspects of the PAEDS approach both collectively and independently., (© 2023 The Authors. Journal of Paediatrics and Child Health published by John Wiley & Sons Australia, Ltd on behalf of Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: High heart and respiratory rates are key indicators in many published guidelines to identify and treat serious bacterial infection and sepsis in children, but the credibility of evidence underpinning what is considered abnormal is questionable. This study established the distribution of heart and respiratory rates of children using a large data set to inform debate on what the 'normal' range of these should look like. The primary aim was to compare the distribution of heart and respiratory rates measured in children recruited from non-tertiary emergency care settings with those published by Advanced Paediatric Life Support (APLS). The secondary aim was to compare the distribution of this study's data set to other national guidance on what constitutes a severe (high-risk) measurement and previously published data sets., Method: Prospective study using anonymised patient data, extracted from electronic patient records of children and young people 0-16 years, recruited from three Emergency Departments and one Urgent Care Centre in Northwest England, UK., Results: Heart and respiratory rates, including the reporting of values at certain centiles and comparisons of averages. Distribution of heart and respiratory rate were consistently higher than those used by the APLS guidance, resulting in a large proportion exceeding the 'severe' cut-offs proposed. This varied greatly by age., Conclusions: This study's data set suggests normal heart rate ranges proposed by the APLS and others is too low and therefore 'abnormal' measurements encompass too large a proportion. The respiratory rate of this data set was more consistent with the guidelines and other published data sets., (© 2023 The Authors. Journal of Paediatrics and Child Health published by John Wiley & Sons Australia, Ltd on behalf of Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: To determine the prevalence of risk factors for type 2 diabetes in overweight and obese adolescents attending hospital-based paediatric care in Western Melbourne., Methods: One hundred overweight and obese adolescents (aged 10-17 years) who attended an outpatient clinic at Sunshine Hospital between May 2019 and May 2020 were randomly selected following a retrospective chart review of 10-17 years old for whom a height and weight had been documented. Additional risk factors for type 2 diabetes were ascertained via structured telephone interview. Data were analysed to determine the overall prevalence of risk factors for type 2 diabetes, and to evaluate for associations between each parameter with body mass index and the number of risk factors., Results: Of the 487 adolescents who had height and weight data recorded, 45% were overweight or obese. 77% of those who were interviewed had an additional risk factor for type 2 diabetes. No association between the number of risk factors and body mass index standard deviation score was found. Additionally, there was no association between the number of risk factors for type 2 diabetes and either family history of type 2 diabetes or ethnicity., Conclusions: This paediatric subpopulation had a high rate of risk factors for type 2 diabetes in addition to overweight and obesity, and are at risk of premature mortality and chronic morbidity should they develop type 2 diabetes., (© 2022 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Health literacy is the ability to understand and interpret health information and navigate the health-care system. Low health literacy is associated with poorer health knowledge and disease management, increased chronic illness, underutilisation of preventative health services and increased hospitalisations. The aim of the study is to review the available literature on the relationship between parental health literacy and health outcomes for children with chronic disease in high-income countries (HIC) and low- and middle-income countries (LMIC)., Methods: We systematically searched Medline, EMBASE and Web of Science, and assessed study quality using the Newcastle Ottawa Scale. We reviewed all relevant studies, and identified themes using thematic analysis., Results: Of 1167 studies assessed, 49 were included in the review. All studies were of adequate quality. Twenty-two were from LMIC and 27 from HIC. Six themes were identified: Parental health literacy, parental education, socio-economic conditions, identity and culture, family factors, and health behaviours. In both HIC and LMIC, lower parental health literacy was associated with poorer child health outcomes. Disease-specific knowledge was found in a number of papers to directly impact parent health behaviour and child health outcomes, and may mitigate the effects of low parental health literacy., Conclusion: There is a clear link between parental health literacy, health behaviour and health outcomes for children with chronic disease. Disease-specific knowledge as a target for health-care interventions holds promise for application in low-resourced settings with parents (particularly mothers) who have lower health literacy, where disease-specific education may improve child health outcomes, although more research is required to determine how we can best facilitate these programmes., (© 2022 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Post-circumcision topical steroids may reduce the number of patients with balanitis xerotica obliterans (BXO) who require subsequent meatal dilatation. However, their use has only been investigated in the presence of an abnormal urethral meatus. The aim of this study is to determine if post-operative topical steroids reduce the need for subsequent meatal dilatation in patients with histologically proven BXO independent of the appearance of the urethral meatus. To determine if post-operative topical steroids reduce the need for subsequent meatal procedures in patients with histologically proven BXO. To determine if the appearance of the meatus at circumcision affects the need for subsequent meatal procedure., Methods: We performed a retrospective review of all paediatric patients with histologically confirmed BXO post circumcision. We excluded all those with 'chronic inflammation' or 'early BXO'. Patients were divided into groups based on whether post-operative topical steroids were prescribed. The appearance of the urethral meatus at circumcision was recorded. Primary outcome was progression to subsequent meatal dilatation. Statistical significance was calculated using Fisher's exact test. A P value < 0.05 was considered significant., Results: One hundred and seventeen patients with histologically confirmed BXO were identified between October 2012 and December 2017. Fifty-nine patients were prescribed post-operative topical steroids (50%). Nine patients required subsequent meatal dilatation procedure (8%) and only one of these had been prescribed post-operative topical steroids (P = 0.0165). Abnormal meatus was noted in 24 (21%) patients. Three patients in this group required subsequent meatal dilatation compared with 6 in the group with a normal meatal appearance (P = 0.385)., Conclusions: Post-operative topical steroids can reduce the need for subsequent meatal dilatation in boys with BXO. The appearance of the urethral meatus at circumcision does not predict the need for subsequent meatal dilatation., (© 2022 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

The integration of the child or young person (CYP) in conversations around advance care planning (ACP) is an important area of paediatric practice. These discussions provide CYP with the opportunity to voice their values, goals and preferences, enabling health-care professionals to ensure they are aligned with their planned course of treatment. This process, often undertaken within the context of the child's family, empowers children to participate in decisions and experience the dignity of self-determination. It also facilitates an increased understanding between the CYP and those involved in their care. The objectives of this paper are to highlight the importance of these conversations for paediatricians and identify barriers, both real and perceived, that may prevent them from engaging with a CYP about their preferences for future care including focusing more on discussion with the parents, and concern about or not having the skills to engage the child in such sensitive conversations. Triggers that can prompt clinicians to undertake ACP are also discussed. A further complexity is that after seeking their perspective, it may become apparent that the CYP may hold different views and perspectives to their parents and/or clinician. This review article will especially examine elements of end-of-life conversations that are critical to support the important goal of listening to the voice of the CYP. This includes considerations around timing, legal aspects, ethical tensions that arise when amplifying a child's voice, clinician/team-member roles, clinical process considerations, and the use of specific interventions and ACP tools to facilitate these conversations with CYP., (© 2022 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: To understand parental awareness and appetite for virtual health modalities, including asynchronous communication and remote monitoring. To understand which socio-demographic characteristics are associated with greater awareness and appetite for virtual health., Methods: Nationally representative survey of Australian parents, recruited via an online panel in February 2021 as part of the Royal Children's Hospital National Child Health Poll. Participants were randomly selected from the consumer panel., Results: 1981 (59.4% response rate) parents completed the survey. 39.9% were aware of virtual health care, defined by digital technology and medical devices to support remote monitoring. Higher levels of awareness were associated with being male, having previous teleconsultation experience, higher education attainment and employment. Most parents reported an appetite for asynchronous communication using an app or website to either provide information prior to a consult (65.9%), provide a photo of a rash or similar (61.7%) or receive medical advice (58.1%). Appetite for wearable devices was similar at 59.9%., Conclusions: Whilst awareness of virtual healthcare was low, appetite exists amongst Australian parents to use technology to support their child's health care. Health-care models, which incorporate asynchronous communication or symptom monitoring through apps, are likely to be acceptable and offer an accessible and sustainable alternative to traditional face-to-face health care., (© 2022 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: To report the prevalence and clinical characteristics of children with rapid onset functional tic-like behaviours during the COVID-19 pandemic., Methods: Single centre, retrospective cohort study of children (<18 years) referred to the tic clinic from January 2018 to July 2021. We calculate the prevalence of newly diagnosed functional tics, and compare the clinical features to chronic tic disorder/Tourette syndrome (CTD/TS)., Results: A total of 185 new patients were referred to the tic clinic between 2018 and 2021. There was a significant increase in the percentage of functional tics in 2020 and 2021 (2% in 2018, 5.6% in 2019, 10.6% in 2020 and 36% in 2021). Differences between functional tics (n = 22) and CTD/TS (n = 163) include female predominance (100 vs. 28%, P < 0.0001), later age of onset (mean age 13.8 vs. 6.8 years, P < 0.0001) and higher rates of anxiety/depression (95 vs. 41%, P < 0.0001). The functional tic group were more likely to present with coprolalia-like behaviours (77 vs. 10%, P < 0.0001), complex phrases (45 vs. 0.6%, P < 0.0001), copropraxia (45 vs. 2%, P < 0.0001), self-injury (50 vs. 4%, P < 0.0001), hospitalisation/emergency visits (36 vs. 2%, P < 0.0001) and school absenteeism (56 vs. 7%, P < 0.0001). A total of 18.2% of patients with functional tics reported preceding exposure to social media content involving tics., Conclusions: There is an increase in adolescent females presenting with rapid onset functional tic-like behaviours during the COVID-19 pandemic. We highlight differences in clinical features between the functional tic group and CTD/TS to aid diagnosis and management in the community. Based on our findings, we propose a mixed model of neuropsychiatric vulnerability and social media contagion in this group of adolescents with functional tics., (© 2022 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: To identify maternal and neonatal factors associated with neonatal readmissions., Methods: A case controlled, cross-sectional, retrospective review of neonatal readmissions within 28 days from birth to a level 4 hospital in Western Sydney was conducted from January to December 2018. Maternal and neonatal factors for readmission were assessed. A control group of 122 neonates were randomly selected. Comparative statistics and logistic regression analysis were used to analyse the data., Results: Of the 3914 neonatal discharges following birth, there were 129 neonatal readmissions (3.3%). Following regression analysis, gestational age (odds ratio 0.82, 95% confidence interval 0.7-0.97, P = 0.02) and intrapartum intravenous (IV) fluids (odds ratio 2.78, 95% confidence interval 1.66-4.67, P < 0.001) were associated with readmission. The majority of readmissions were feeding-related (72.9%). Of these readmissions, 29.8% had feeding concerns noted by nursing or midwifery staff during the initial hospital stay. During the initial hospital stay following birth, neonatal feeding issues were significantly associated with primiparous mothers (P = 0.005). Mothers who did not receive IV fluids during labour were also more likely to experience feeding issues (P = 0.015)., Conclusion: Our findings indicate that hospital discharge prior to established feeding patterns may be associated with an increased incidence of neonatal readmission. The factors associated with neonatal readmission are earlier gestational age and intrapartum IV fluid administration. These findings suggest that more comprehensive feeding assessment prior to discharge, flexibility of discharge timing and increased community support may reduce neonatal readmission., (© 2022 The Authors. Journal of Paediatrics and Child Health published by John Wiley & Sons Australia, Ltd on behalf of Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aims: Children with severe needle phobia find vaccination extremely distressing and can remain unvaccinated, which puts them at an increased risk of contracting and transmitting vaccine preventable disease. Referral to a specialist or hospital service may occur when they cannot be safely vaccinated in the community, but engagement of allied health services can be inconsistent. The aim of the study was to assess the impact of a multidisciplinary, consumer-oriented model of care on vaccinations for needle phobic children., Methods: Needle phobic children aged between 6 and 16 years attended multidisciplinary consultation, as part of a care package, to assess previous experiences and determine the level of intervention that was required to support vaccination. A multidisciplinary case meeting followed this appointment and an individualised plan formulated for each patient. The main outcome of the project was rate of successful vaccination., Results: The care package resulted in a successful vaccination rate of 83% (n = 20) with 69 vaccines administered across three clinics. Of those successful, 90% required multiple injections per visit. The majority of patients indicated moderate to high level of anxiety. Supportive care was escalated and de-escalated as tolerated., Conclusions: Results demonstrate the diversity of patients presenting with needle phobia and indicate an individualised, collaborative approach is preferable to a 'one size fits all' model of care. The study highlights a need for the development of guidelines that streamline the assessment and individualisation of procedural anxiety plans to meet patient needs and embed these processes into standard care., (© 2022 The Authors. Journal of Paediatrics and Child Health published by John Wiley & Sons Australia, Ltd on behalf of Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: The aim of this study is to characterise the nature and caseload of general paediatric outpatient clinics in rural Queensland and to compare the findings with national data., Methods: A retrospective clinical audit of medical records in paediatric clinics at two rural hospitals was undertaken over a 6-month period. Data extracted included demographics, diagnostic category and onward referral outcomes. The same diagnostic categories were used as the national Children Attending Paediatricians Study (CAPS) to facilitate comparison., Results: A total of 346 records were reviewed, 56 (16.2%) documented Aboriginal and Torres Strait Islander descent. Compared to national data, significantly more children with behavioural/developmental diagnoses were seen in the rural clinics (CAPS 33.8%; rural 59.2%; P < 0.001). In contrast, children presenting with medical conditions (CAPS 48.2%; rural 28.6%; P < 0.001) and mixed medical/developmental conditions (CAPS 17.9%; rural 12.1%; P = 0.006) were seen less frequently in the rural clinics. Referral rates from the rural sites were lower than the rates reported by CAPS for children with behavioural/developmental diagnoses (CAPS 35.9%, rural 24.9%; P = 0.002) and mixed diagnoses (CAPS 40.6%, rural 19.0%; P = 0.005), while there was no difference in referral rates for children with medical diagnoses (CAPS 16.1%, rural 18.2%; P = 0.575)., Conclusions: Rural paediatricians' caseloads are dominated by developmental/behavioural conditions, however children with these conditions are less likely to be referred to allied health and psychology services. The reasons for lower referral rates and specific pressures upon rural health services need to be investigated in future studies to provide better health services for rural children., (© 2022 The Authors. Journal of Paediatrics and Child Health published by John Wiley & Sons Australia, Ltd on behalf of Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: This quality assurance project aims to describe the provision of an ultrasound-guided vascular access education package to paediatric emergency department staff. It subsequently aims to measure clinician and departmental responses to this educational intervention to support future effective education provision., Methods: Participants were opt-in emergency department staff. Staff were required to be approved to insert intravenous cannulae in the department. A minimum of 50% were non-rotational staff. The educational package consisted of a theory phase (pre-learning video, information document), a practical phase (intensive 90-120 minute individualised session using a mix of live subjects/training equipment), and an embedding phase (education group available for procedural supervision). Data collection was via de-identified, encoded self-reported survey data and logbooks., Results: Twenty-three staff were enrolled for training. Sixteen (69.9%) were non-rotational. Prior to the education intervention, 18 trainees (78.3%) had placed no successful ultrasound-guided peripherally inserted venous cannulae. By 15 weeks following training, six participants (28.6%) had achieved a predetermined competency benchmark; 61.9% had placed at least one successful ultrasound-guided cannula. Difficult intravenous (IV) access predictors were present in 46.3% of patients throughout the data collection period, with infants overrepresented in this group (64.9% with difficult IV access predictors). IV access attempts by staff with prior ultrasound experience increased from 11.0 to 81.8% post-education intervention., Conclusions: A low-resource brief educational intervention around ultrasound-guided vascular access is achievable. Several barriers to education uptake were presented. Targeting the group of trainees with a high degree of motivation led to the highest yield of benchmark competency acquisition., (© 2021 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Victoria experienced two 'waves' of COVID-19 between March and September 2020 and more cases than any other jurisdiction in Australia. Although world-wide reports of COVID-19 reflect that children are less likely to experience severe disease compared with adults, hospitalisations and deaths have been reported. We report testing and outcomes of children with SARS-CoV-2 infection presenting to a tertiary paediatric hospital in Melbourne., Methods: We conducted a prospective cohort study at The Royal Children's Hospital (RCH), including all children and adolescents (aged 0-18 years) who presented and were tested for SARS-CoV-2 over a 6-month period, between 21 March 2020, up to the 21 September 2020. Detailed epidemiological and clinical data were recorded., Results: A total of 19 708 tests for SARS-CoV-2 were performed in 14 419 patients. One hundred and eighty patients tested positive for SARS-CoV-2 (1.2%). 110 (61%) were symptomatic, 60 (33%) were asymptomatic and 10 (6%) were pre-symptomatic. Close contacts of a positive case were associated with a higher risk of a testing positive for SARS-CoV-2 (120/2027 (6%) vs. 60/14589 (0.4%), RD 5.5 (95% CI 4.5 to 6.5), P < 0.001). Eighteen (10%) SARS-CoV-2-positive patients were admitted to hospital with one patient requiring intensive care. All patients recovered fully with no deaths., Conclusion: In Victorian children presenting to a tertiary hospital, SARS-CoV-2 infection caused predominantly mild or asymptomatic infection, with most children not requiring hospitalisation., (© 2021 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: To assess the degree to which timely audiological assessment of congenital hearing loss is achieved at our institution - Perth Children's Hospital, Western Australia, and to review cases which breached this timeframe in order to address barriers to timely assessment. The benchmark used to determine timely assessment is that set out by The Joint Committee on Infant Hearing (JCIH) in which diagnostic audiological testing occurs by three months of age for those who do not pass newborn hearing screening., Methods: A retrospective chart review of infants who underwent diagnostic auditory assessment at Perth Children's Hospital between 2016-2019. A total of 151 children were identified as meeting the inclusion criteria and their medical files were reviewed. Time to first dABR was the time point for whether testing was achieved within the 3 month timeframe., Results: Of the 151 children who underwent dABR assessments, 1 was identified as having breached the 90 day time limit (tested on day 91) for which no valid reason for delay could be identified. The timely delivery of dABR assessments in 99.3% of cases within this cohort compares favourably with the literature., Conclusions: Conclusion Timely diagnostic audiological assessment is achievable for children with congenital hearing loss. The reasons for patients breaching this timeframe are explored in the paper along with factors which may help avoid delays., (© 2021 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Paediatric health-care professionals have a primary duty to promote the best interests of their patients. This is reiterated in article 3 of the United Nations Convention on the Rights of the Child and is predicated on promoting children's health and wellbeing. However, there is ambiguity over what standard applies when evaluating whether a paediatric health-care decision supports good outcomes. Values like 'best interests', 'doing no harm' or 'quality of life' may be indeterminate or vague and clinicians may have difficulty in conceptualising what exactly constitutes 'a good life' for children. This uncertainty leads to the question: how do we best evaluate paediatric health decisions and outcomes? Patient-reported outcome measures (PROMs) are questionnaires that aim to achieve this by attaining data on a patient's quality of life and wellbeing. While PROMs originated with adult cohorts, they have since been applied to paediatric populations. Children are vulnerable due to their interdependency; and this raises ethical tensions regarding the potential benefits of such data, respect for autonomy and assent/consent of the individual child in clinical settings. These inherent tensions should be balanced by realising a collective good for children. PROMs should be a robust data collection source that facilitates substantive justice, both procedurally and in distributing limited health resources via accurate quality-adjusted life-years generation. This article aims to (i) overview the traditional and emerging paediatric PROMs; (ii) outline the tensions of using PROMS for children in a clinical setting and (iii) analyse the ability of traditional and emerging PROMs to promote justice in paediatric resource allocation., (© 2021 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: To describe the incidence, demographics, diagnostic clinical manifestations and long-term outcomes of juvenile dermatomyositis (JDM) in Maori and Pacific Island compared to European children., Methods: A chart review was conducted of children with JDM seen by the Starship Rheumatology service between 2000 and 2020. Diagnostic clinical manifestations, demographics, disease course and significant complications were collated. The incidence, clinical manifestations and severity of JDM were determined and compared between ethnic groups, in particular Maori and Pacific Island, and European children., Results: The overall incidence of JDM was 0.24/100 000 per year with no significant ethnic variation. Maori children were less likely to achieve a clinical response (71 vs. 100%, P = 0.08), Maori and Pacific less likely to achieve clinical remission (56 vs. 40%, P = 0.69), with Maori (71 vs. 44%, P = 0.37) and Maori and Pacific (60 vs. 44%, P = 0.69) children more likely to follow a chronic course compared to European children. Calcinosis (50 vs. 13%, P = 0.07), cutaneous vasculopathy (30 vs. 0%, P = 0.05) and interstitial lung disease (30 vs. 6%, P = 0.26) were more common in Maori and Pacific compared to European children., Conclusion: The incidence of JDM among a cohort of New Zealand children was established, with Maori and Pacific children more likely to experience a chronic continuous disease course, calcinosis, cutaneous vasculopathy and interstitial lung disease compared to European children., (© 2021 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Bedwetting is a common paediatric condition. #Bedwetting has been established as the official hashtag to structure Twitter discussions about the condition. We analysed online Twitter discussions for #Bedwetting., Methods: Symplur, a Twitter analytics service was employed to aggregate Twitter activity, users and content including #Bedwetting, between October 2013 and November 2018. Activity was analysed via tweet volume and user adoption. Users were assorted using geographic location, occupation and affiliation data. Content in #Bedwetting Tweets was undertaken by retrieving information about retweets, links, frequently used words and hashtags., Results: A total of 101 412 tweets and 9957 users utilising #Bedwetting were identified. Most tweets were sent with links (93%). The average ± SD number of tweets using #Bedwetting per month increased from 96 ± 87 in 2013 to 2935 ± 1644 in 2015. Tweet volume decreased to 1960 ± 257 in 2016 and subsequently increased to 2901 ± 1110 in 2017. New users increased from 4 in 2013 to 9957 users in 2018. Users tweeted from 69 countries. Advocacy organisations comprised 35% of the top 100 influencers. Common words in #Bedwetting tweets were 'potty', 'best' and 'training'. Popular associated hashtags were #Pottytraining, #Solutions and #Moms. Hyperlinks in #Bedwetting tweets included advocacy, academic and commercial websites., Conclusions: Our analysis of #Bedwetting highlights that Twitter is frequently used to discuss the condition's diagnosis and management. Various stakeholders in health care are utilising the platform to build awareness about bedwetting. We identified that Twitter is being employed to drive web traffic to other internet websites., (© 2021 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: To develop a feeding scale for parents/care givers of individuals of all ages with genetic syndromes experiencing extensive feeding and swallowing problems. Second, to assess its validity and reliability in CHARGE syndrome., Methods: The new Feeding Assessment Scale (FAS) was adapted from a scale for children who need prolonged tube feeding (Paediatric Assessment Scale for Severe Feeding Problems, PASSFP). Ten parents piloted the new scale before it was sent out with the PASSFP and feeding history questions. A subset completed the new scale again 4-8 weeks later., Results: One hundred parents of individuals with CHARGE syndrome participated from around the world. The new scale had good construct validity, with a significant effect for an increased number of feeding risk factors having higher scale scores (P < 0.001). Face validity was high, as scores significantly differed between individuals whose parents identified their feeding difficulties as very mild, mild, moderate, severe and very severe (P < 0.001). Test-retest reliability (r = 0.94, P < 0.001) and internal consistency (Cronbach's alpha 0.91) were both high. There was significant convergent validity between the new scale and the PASSFP (r = -0.79, P < 0.001)., Conclusions: This new tool is reliable and valid for parents/care givers of individuals with CHARGE syndrome. It can be used to assess the current severity of feeding difficulties and to track progress before and after treatment. It expands upon previous existing tools in that it can be used in both individuals who are not tube fed, as well as in those who are, as well as across the life-span., (© 2021 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: To characterise the physical, psychological, and quality of life burden associated with serogroup B invasive meningococcal disease (IMD) in children., Methods: Children aged up to 14 years at the time of serogroup B IMD, who were admitted to intensive care units of two tertiary paediatric hospitals in New South Wales, Australia between January 2009 and December 2013 were recruited. Children underwent clinical and neuropsychological assessments up to 6 years post-disease., Results: Eleven children were assessed, with a median age of 16 months (range 4-46 months) at time of disease. The median follow-up time was 50 months (range 10-67 months). Seven (63.6%) cases had one or more long-term sequelae involving permanent and evolving physical disability. Three cases had ongoing medical conditions including two with seizures and one with ataxia and hypermetropia. Five required ongoing medical and allied health care. Other complications identified included anxiety, speech delay, low average full-scale IQ score (median 85, interquartile range 89-103) and borderline memory impairment., Conclusions: Serogroup B IMD is associated with significant long-term morbidity and burden on the child and family with substantial economic implications. The impact of this on the total cost of IMD needs to be further quantified, and better considered in vaccine cost-effectiveness analyses., (© 2021 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Referral wait times for paediatric neurological patients are increasing, leading to an increased burden on the emergency department (ED). The paediatric Rapid Access Neurology (pRAN) clinic was created for paediatric patients who are clinically stable, but require an urgent paediatric neurology consultation. The objectives were to evaluate the pathways of referral, accuracy of referring diagnoses, adherence to clinic appointments, impact of clinic visitation on ED visits and patient satisfaction., Methods: Data were collected from the pRAN clinic from March 2018 until April 2019. Information was obtained from patient charts including the referring and final diagnosis, management plan and the number of visits made to the ED before and after visiting the pRAN clinic., Results: Of the 256 referred patients, 91 met inclusion criteria. The most frequent referral diagnosis was a seizure. Referring physicians and pRAN clinic neurologists differed significantly in the level of diagnostic agreement for patients <2 years of age (P = 0.03; 95% confidence interval (CI) -0.294, 0.373). There was a significant reduction in visits to the ED made by patients 3 months after the pRAN appointment compared with before the visit (P < 0.001; 95% CI -0.9070, -0.4088). The majority of patients felt that the clinic had high value and were satisfied with their follow-up plan., Conclusion: This pilot study showed that a pRAN clinic can improve the accuracy of neurological diagnoses and management, especially for children <2 years of age. In addition, pRAN clinic patients make fewer subsequent visits to the ED and express high satisfaction with their care., (© 2021 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aims: Whilst a centralised model of care intuitively makes sense and is advocated in other subspecialty areas of medicine, there is a paucity of supportive evidence for General Paediatrics. Following ward restructuring at our tertiary paediatric centre in preparation for the COVID-19 pandemic, a new dedicated General Paediatrics ward was established. We evaluated medical and nursing staff well-being, morale and perceived impacts on care after the ward's establishment., Methods: Experiences were sought from medical and nursing staff whom had worked across both previous wards caring for General Paediatrics patients, as well as the new dedicated General Paediatrics ward. Mandated responses used the format of much better, better, same, worse and much worse., Results: A total of 73/82 (89%) medical and nursing staff completed the survey. A greater than 90% improved or neutral response was noted for 31/35 (89%) questions. About 80% of staff reported the new dedicated General Paediatrics ward provided a better or much better team-based approach, time efficient approach and overall model of care. A much better or better response was reported for communication between medical and nursing staff in 68%, team comradery in 69%, supportive/helpful nursing staff in 74%, job stress level in 66% and staff morale in 60% of respondents., Conclusions: Overwhelmingly positive responses from this study support a centralised or "home" ward model of care for General Paediatrics patients in a tertiary paediatric setting. Our findings may be relevant to General Paediatrics teams in other centres currently using multiple wards to manage their patients., (© 2020 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Pain associated with immunisations can result in distress and/or anxiety for children and parents. We assessed the feasibility and acceptability of two novel devices; Coolsense (cold) and Buzzy (vibration ± cooling pads) versus standard care to minimise pain during immunisations. We also evaluated compliance to the devices and parent's perception of the effectiveness of the devices/standard care for minimising pain during immunisation., Design: Open label, pilot, randomised controlled trial (RCT)., Methods: Forty children aged 3.5 to 6 years attending an Immunisation Centre at The Royal Children's Hospital in Melbourne, Australia, were randomised (1:1:1:1) into four groups: (i) Coolsense plus standard care; (ii) Buzzy with cold plus standard care; (iii) Buzzy without cold plus standard care; and (iv) Standard care alone (distraction with bubbles)., Results and Analysis: Recruitment was completed in 12 days. Seventy percent were compliant with Buzzy (±cold), 82% with Coolsense, and 60% with standard care. Buzzy (with cold) was identified as effective by 70% of parents, Coolsense by 64%, Buzzy without cold by 50% and standard care by 60%., Conclusions: This pilot study demonstrated feasibility. A larger RCT is needed to provide definitive evidence to inform best practice for minimising immunisation pain in young children., (© 2020 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: To describe and compare the incidence of type 1 diabetes (T1D) in South Australia by individual and area-level socio-economic characteristics among children aged ≤11 years., Methods: This is a whole-of-population, data linkage study (n = 231 685) conducted in South Australia, and included children born from 2002 to 2013, hospitalisation followed from 2002 to 2014. The study used de-identified, linked administrative hospitalisation, birth and perinatal data from the South Australian Early Childhood Data Project. Incidence was calculated by identifying T1D cases from T1D-related hospitalisations using International Classification of Disease, 10th Revision, Australian Modification diagnosis codes (E10, E101-E109)., Results: Overall, 333 children aged ≤11 years (173 boys) were identified as having T1D. The T1D incidence rate was 23.0 per 100 000 person-years (95% confidence interval (CI): 20.7-25.7), with no sex difference. T1D incidence was higher among children whose mothers were Caucasian, private patients and whose parents were employed. For example, T1D incidence was 26.0 per 100 000 (95% CI: 22.8-29.5) among children with both parents employed, compared to 20.0 per 100 000 (95% CI: 12.3-30.6) among children with both parents unemployed. There was no clear gradient in the association between area-level socio-economic position and T1D, with highest incidence for the fourth quintile (26.5 per 100 000 (95% CI: 20.9-33.1)). The most advantaged area (19.4 per 100 000 (95% CI: 13.8-26.5)) had lower incidence than the most disadvantaged area (23.5 per 100 000 (95% CI: 18.9-28.9))., Conclusion: T1D incidence rates differed depending on the measures of socio-economic characteristics. Individual-level indicators showed higher incidence among more advantaged children; however, there was no clear area-level socio-economic patterning of T1D., (© 2020 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Paediatric gastroenterology in Australia has undergone remarkable changes over the more than six decades since Charlotte Anderson's pioneering work, and is now a well-established specialty in its own right. Australian paediatric gastroenterologists have made important contributions nationally and internationally., (© 2020 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

We conducted a systematic review of the literature to establish the prevalence of and predictive factors for parental decision regret in hypospadias surgery. A search strategy without language restrictions was developed with expert help, and two reviewers undertook independent study selection. Five studies were included in this review (four for quantitative analysis) with a total of 783 participants. The mean overall prevalence of parental decision regret was 65.2% (moderate to severe - 20.3%). Although significant predictors of regret were identified (post-operative complications, small size glans, meatal location, decision conflict between parents, parental educational level and others), they had unexplained discordance between studies. Parental decision regret after proximal hypospadias surgery and refusing surgery was inadequately reported. In conclusion, even though the prevalence of parental decision regret after consenting for the hypospadias repair appears to be high, risk factors associated with it were discordant suggesting imprecision in estimates due to unknown confounders., (© 2020 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Neonatal early onset sepsis (EOS) is a low-incidence, high-risk disease which has prompted significant overtreatment with antibiotics for the standard duration of 48 h. The aims of this study were to determine whether blood cultures collected from term and late preterm neonates for EOS would return a positive result for pathogenic bacteria within 24 h and to review the literature to supplement the results., Methods: This is a retrospective observational study of time to positive blood culture in the BACTEC culture system from neonates ≥34 weeks in a single referral centre between 1999 and 2018. A literature review was conducted through PubMed, MEDLINE and Embase using search terms of 'neonatal sepsis' AND 'blood culture'. Studies were included if they reported time to positive blood culture in EOS., Results: Forty positive cultures were included in this report, with 39 (98%) showing bacterial growth within 24 h. One culture, obtained after commencement of antibiotics, became positive at 3 days. Sixteen papers were included in our literature review and six presented data for an EOS cohort; a median of 96.5% of pathogenic EOS blood cultures become positive within 24 h., Conclusions: All pathogenic blood cultures collected pre-therapy from neonates ≥34 weeks suspected of EOS returned a positive result within 24 h of incubation. Similar studies have found that 92-100% of cultures are positive by 24 h. This data could contribute to re-evaluation of the current standard duration of antibiotic use in term and late preterm neonates with suspected EOS., (© 2020 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Kawasaki disease (KD) is an important cause of childhood vasculitis and a common cause of acquired heart disease in children world-wide. The emergence of Paediatric Multisystem Inflammatory Syndrome-Temporally Associated with SARS-CoV-2, a KD-like hyperinflammatory syndrome and the recent death of Dr Tomisaku Kawasaki make this a timely review. Although KD was described by Dr Kawasaki over 50 years ago, there is still no specific diagnostic test and the aetiology remains elusive. This article summarises the latest evidence, highlights important myths and misconceptions and discusses some of the mysteries that surround this disease., (© 2020 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Bronchiolitis is the commonest cause of hospitalisation for infants. Evidence-based Australasian bronchiolitis guideline was developed and introduced in 2017. This audit was to determine if the knowledge translation process of the updated local tertiary hospital bronchiolitis guideline (based on the Australasian guideline) reduced unnecessary interventions., Methods: A retrospective chart review of infants with bronchiolitis diagnosis during the pre-guideline (1 July to 31 August 2015) and post-guideline (1 July to 31 August 2017) period, with the primary outcome of the number/proportion of unnecessary interventions., Results: Presentations between 1 July to 31 August 2015 (n = 465) were compared with 2017 (n = 343). There was no difference in undertaking chest X-ray (24 (5.2%) vs. 17 (5.0%), odds ratio (OR) 0.98 (95% confidence interval (CI) 0.71-1.35), P = 0.911), salbutamol (23 (4.9%) vs. 10 (2.9%), OR 0.86 (95% CI 0.65-1.13), P = 0.279), glucocorticoids (2 (0.4%) vs. 5 (1.5%), OR 1.89 (95% CI 0.83-4.31), p = 0.129), antibiotics (11 (2.4%) vs. 5 (1.5%), OR 0.86 (95% CI 0.65-1.15), P = 0.307) or nasopharyngeal aspirate (172 (37%) vs. 124 (36.2%), OR 1.00 (95% CI 0.87-1.67), P = 0.937) in hospital. Adrenaline was not administered in both years. There was reduced hospital admissions (303 (65.2%) vs. 192 (56.0%), OR 0.82 (95% CI 0.71-0.95), P = 0.008) with no difference in paediatric intensive care unit admissions (10 (2.2%) vs. 8 (2.3%), OR 1.04 (95% CI 0.65-1.67), P = 0.863)., Conclusion: The dissemination process of the updated local hospital bronchiolitis guideline did not show any statistically significant reduction of unnecessary interventions in the hospital. Further studies are required to determine the effective process to instigate changes in health services., (© 2020 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

In 2016, a global consensus on the prevention, diagnosis and management of nutritional rickets was published. The bone and mineral working group of the Australasian Paediatric Endocrine Group provides a summary and highlights differences to previous Australian and New Zealand (ANZ) guidelines on vitamin D deficiency and their implications for clinicians. Key points are: (i) The International Consensus document is focused on nutritional rickets, whereas the ANZ guidelines were focused on vitamin D deficiency. (ii) Definitions for the interpretation of 25-hydroxy vitamin D (25OHD) levels do not differ between statements. (iii) The global consensus recommends that routine 25OHD screening should not be performed in healthy children and recommendations for vitamin D supplementation are not based solely on 25OHD levels. The Australasian Paediatric Endocrine Group bone and mineral working group supports that screening for vitamin D deficiency should be restricted to populations at risk. (iv) Recommendations from the global consensus for vitamin D dosages for the therapy of nutritional rickets (diagnosed based on history, physical examination, biochemical testing and a confirmation by X-rays) are higher than in ANZ publications. (v) The global consensus recommends the implementation of public health strategies such as universal supplementation with vitamin D from birth to 1 year of age and food fortification. We conclude that updated global recommendations for therapy of nutritional rickets complement previously published position statements for Australia and New Zealand. Screening, management and the implementation of public health strategies need to be further explored for Australia., (© 2020 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Vancomycin guidelines for therapeutic drug monitoring (TDM) aim to maximise efficacy while minimising toxicity and resistance. Vancomycin is effective against Staphylococcus aureus when it achieves area under the concentration-time curve (AUC)/minimum inhibitory concentration (MIC) > 400. Studies in children have shown that target trough concentrations poorly correlate to AUC/MIC > 400; however, they are used in practice for clinical convenience. This review in paediatric inpatients aims to audit performance against TDM guidelines and consider what changes are needed to optimise vancomycin monitoring., Methods: Vancomycin prescriptions in patients younger than 18 years old were collected over a 15-month period. Primary outcome measures were vancomycin initial dose (mg/kg/day) and the timing and result of first trough concentration (mg/L). Secondary outcome measures were the numbers achieving recommended targets and whether appropriate dose adjustments were made in response to TDM., Results: A total of 133 courses reached the time when TDM should occur. Average patient age was 6.5 years, and the average initial dose was 52.55 mg/kg/day (range 19.05-86.54 mg/kg). Only 25% of courses (n = 34) had a trough concentration measured at the recommended time. The mean trough concentration was 11.6 mg/L (range < 2.0-39.7). Of 40 patients with a low trough concentration, 50% continued without dose adjustment., Conclusion: As shown in the literature, there is a poor correlation between the vancomycin dose given and the trough concentration achieved. Given that recommendations for trough concentration monitoring are designed to simplify the process yet are poorly adhered to, a strategic plan to address these issues is needed., (© 2019 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Safe tip placement of umbilical venous catheters (UVCs) in sick neonates is critical in minimising risk. We aimed to demonstrate the utility of clinician-performed ultrasound (CPU) in identifying UVCs that are placed within small intrahepatic portal vessels or within the heart despite the appearance of being well placed on X-ray., Methods: This was a retrospective observational study of preterm and term neonates who had a UVC placed and the position assessed by X-ray and/or CPU according to the Royal Prince Alfred Hospital level 3 neonatal intensive care unit (NICU) guideline. Cases were identified by exporting the records of all admissions between 1 April 2015 and 30 June 2016 from the NICU's data collection database. Paper-based medical records, NICU's data collection database records and the ultrasound reporting system were reviewed to determine X-ray and CPU findings., Results: A total of 157 neonates had 169 UVCs placed. CPU was performed in 77% (111). In 15 cases (14%), UVC placement on X-ray appeared appropriate based on estimated vertebral level; however, CPU demonstrated the line to be in an unsafe position (small intrahepatic portal vessel (3); right atrium (9); left atrium (3))., Conclusions: Assessment of safe UVC placement by estimations according to vertebral level on X-ray alone is inadequate. CPU offers confident localisation of the UVC tip and enables corrective manipulation of intracardiac or intrahepatic UVCs in real time. We recommend CPU as an adjunct to X-ray to ensure safe UVC placement., (© 2019 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Self-reporting and/or data from medical records are frequently used in studies to ascertain health history. Data on the discrepancies between these information sources is lacking for Indigenous Australians. This study reports such data for selected respiratory and atopic conditions common among Indigenous Australians., Methods: Data were extracted from the Indigenous respiratory reference value study, a multicentre cross-sectional study of Indigenous children and young adults (3-25 years) between June 2015 and November 2017. Only those living in rural/remote regions were included. Self-reported history was collected from parents (if participants <18 years) or participants. Medical records were manually reviewed. Participants with incomplete data (missing self-reported and/or medical record information) were excluded. Agreement between sources was examined using Cohen's kappa., Results: Of 1097 participants, 889 (97.1% <18 years) had sufficient self-reported and medical record histories for comparison. Asthma was self-reported by 15.7% of participants and was reported in medical records for 10.3% (κ = 0.53, 95% confidence interval (CI) 0.45-0.61). For bronchiectasis, the reported rates were 1.5 and 0.7% (κ = 0.52, 95% CI 0.25-0.80), pneumonia 1.1 and 5.8% (κ = 0.15, 95% CI 0.02-0.27), allergic rhinitis 6.6 and 0.6% (κ = 0.05, 95% CI -0.03, 0.13) and eczema 5.8 and 6.2% (κ = 0.30, 95% CI 0.18-0.42)., Conclusions: Within our cohort, agreement was moderate for asthma and bronchiectasis, fair for eczema and poor for pneumonia and allergic rhinitis. These results highlight the challenges associated with how best to obtain an accurate health history within Australian Indigenous rural/remote communities. Generalisability of findings and contributions of poor health knowledge and/or poor medical record documentation need further exploration., (© 2019 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Childhood obesity continues to be a major health issue for children world-wide, with well-recognised major health effects. This study evaluated the prevalence of obesity in children presenting to secondary care in Southern New Zealand, as well as their clinical management., Methods: Obesity prevalence was determined by a review of data contained in the electronic anthropometry database in the region for the period 19 July 2010-16 July 2015. All clinical records were further examined using a standard data extraction form for 333 obese children regarding their clinical management., Results: A total of 8551 individuals were identified in the database for review. The prevalence of overweight and obesity was higher than the average national rates but stable over the 5-year period. Children of Maori and Pacific Island ethnicity, those most deprived and males were over-represented in terms of obesity. Of the 333 obese children whose clinical management was examined, 45.0% received a diagnosis of obesity. Of those diagnosed, 24.7% had further investigations related to possible obesity complications, and 72.7% were given management plans. Older females were more likely to receive clinical intervention, while Maori and Pacific Island children were less likely., Conclusions: Of the children seen in this secondary care setting, 40% are overweight or obese, and yet the rate of clinical intervention left room for improvement, suggesting a need for further staff education and clear guidelines. Maori and Pacific Island children have higher obesity burden but were less likely to receive clinical intervention. This may highlight a need for specific education regarding cultural practices., (© 2019 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Bronchiolitis is one of the most common lower respiratory tract infections in young children, associated with significant morbidity, but limited therapeutic options. Nebulised hypertonic saline (HS) has been a supportive treatment until current guidelines advised against its routine use. Accordingly, the University Hospital of Antwerp recently changed their policies to stop using it, allowing us to evaluate retrospectively if HS influences the duration of respiratory support. Because, to our knowledge, the effect of HS on children with severe bronchiolitis admitted to a paediatric intensive care unit (PICU) has not been studied yet, we aimed to investigate the effect in this specific patient group., Methods: Retrospective study including children up to the age of 2, admitted to the PICU with bronchiolitis from October 2013 until March 2016. The primary end point is the duration of respiratory support, including high flow nasal cannula, continuous positive airway pressure and invasive ventilation., Results: A total of 104 children admitted to the PICU with bronchiolitis were included, with an average age of 3.4 months. In respiratory syncytial virus (RSV) positive patients, the use of nebulised HS was correlated with a decrease in the duration of respiratory support and the length of stay by factors 0.72 (P = 0.01) and 0.81 (P = 0.04), respectively., Conclusions: A significant correlation was found between the use of HS and a decreased duration of respiratory support and admission in the PICU in patients with RSV bronchiolitis. This finding may warrant new prospective studies investigating HS specifically in children with severe bronchiolitis., (© 2019 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: To define the impact of demographics on the incidence, aetiology and clinical course of viral bronchiolitis in infants younger than 2 years of age., Methods: Retrospective case review of all viral bronchiolitis admissions for patients aged younger than 2 years old from January 1 2014 to 31 December 2015 at Wellington Regional Hospital, New Zealand. Demographic data, second-hand smoke exposure (SHSE) and presence of predisposing conditions were collected, along with outcome data including use of respiratory support and intensive care unit (ICU) admission. This was compared to background rates calculated from regional census data., Results: There were 556 admissions included (11% of paediatric medical admissions); 49% tested positive for respiratory syncytial virus (RSV) (84% tested), and 40% of admissions received positive pressure respiratory support and 10% ICU admission. Admission rates ranged from 9.6 to 77 per 1000/year, with higher rates seen in those from areas of high deprivation. Admission rates by deprivation varied according to aetiology. RSV-positive admission rates increased from 9.7 per 1000/year to 24.6 per 1000/year in the least to most deprived areas, whereas non-RSV admissions showed even greater disparity, increasing from 10.1 per 1000/year to 37.5 per 1000/year (both P < 0.0001)., Conclusions: This study further reinforces that material deprivation contributes significantly to poor health outcomes that are apparent in infancy. SHSE is a potent risk factor for adverse respiratory outcomes in this patient population. Ongoing efforts to eradicate smoking and reduce material inequality need to continue., (© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: The Townsville Hospital cares for babies in a large geographical area, many of who are outborn, are of Aboriginal or Torres Strait Islander origin and have families who reside in areas of deprivation. This study examined the outcomes of babies born at all locations in North Queensland to assess the predictors of poor outcomes., Methods: A retrospective observational study examined the survival of 313 babies born from 22 completed weeks gestation to 27 + 6 weeks gestation in North Queensland between January 2010 and December 2016. Additional analyses were performed for the 300 non-syndromal babies whose mothers usually resided in North Queensland, studying demographics of gestation, gender, birthweight, Indigenous status, regionality of maternal residence and adequacy of antenatal steroids. Short-term morbidities of intraventricular haemorrhage/periventricular leukomalacia (IVH/PVL), surgical necrotizing enterocolitis, retinopathy of prematurity requiring treatment and chronic lung disease and death were studied in relation to demographic factors and clinical treatment., Results: Adequacy of steroids was significantly associated with a decreased mortality odds ratio of 2.872 (95% confidence interval 1.228-6.715), whilst no difference in outcome was seen by retrieval status or ethnic origin. Babies from remote locations were at increased risk for IVH/PVL, 2.334 (1.037-5.255). Male babies suffered more chronic lung disease, 1.608 (1.010-2.561), and IVH/PVL, 2.572 (1.215-5.445). Aboriginal and Torres Strait Islander babies were at lower risk of IVH/PVL., Conclusions: Steroids should be administered wherever there is any possibility of the provision of intensive care for periviable babies. Place of birth and ethnicity of mother should not unduly influence antenatal counselling., (© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Spinal muscular atrophy (SMA) is the most common genetic cause of infant mortality. SMA is a spectral disorder and is categorised based on symptom onset and severity. The median life expectancy for infants with SMA presenting before 6 months of age is less than 2 years without respiratory support. To date, there is no cure for SMA. In June 2017, nusinersen was approved in Canada as the first disease-modifying drug for SMA because of its demonstrated benefits on motor function and survival in clinical trials. However, with a price tag of almost 1 million dollars for the first year of therapy, careful clinical, treatment-based and ethical consideration of the principles of (i) best interests; (ii) universality; (iii) portability; (iv) public administration; (v) accessibility; and (vi) comprehensiveness are important guideposts to ensure transparent and equitable allocation of health-care resources for nusinersen and all other future orphan drugs., (© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Palivizumab prevents respiratory syncytial virus (RSV) in children at high risk of severe disease. This paper reviews the use and effectiveness of palivizumab at two tertiary paediatric hospitals (hospitals A and B) in New South Wales, Australia., Methods: Children prescribed palivizumab during the pre-intervention period, 1 January 2013 until 31 December 2014, were compared with children under 2 years of age who were admitted to paediatric intensive care units (PICUs) with an RSV infection. Eligibility for palivizumab was determined. To improve evidence-based utilisation of palivizumab, a 'streamlined palivizumab individual patient use' (IPU) pro forma was introduced at hospital A during 2015, and its applicability was reviewed., Results: In the 2 years prior to implementing the streamlined IPU, 47 children received palivizumab, with 87% at hospital A. Of the children at hospital A, 32% did not meet the guidelines, and 32% did not complete the course. While 13% of children admitted to PICU for RSV infection were eligible for palivizumab, none received it prior to admission. In 2015, 16 streamlined IPUs were submitted, and 11 patients received palivizumab. Of these patients, 27% did not meet the guidelines, and 63% did not complete the course. Of the children who received palivizumab during the three RSV seasons, one developed an RSV infection, and none were admitted to PICU., Conclusions: Palivizumab is often prescribed without meeting recognised best practice guidelines, and patients eligible are frequently not prescribed palivizumab. The streamlined IPU, implemented in hospital A, excluded patients who did not meet guidelines. The pro forma needs further refinement, and complementary strategies introduced to improve compliance., (© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aim: Our study aimed to assess physicians' experiences and education regarding advance care planning (ACP) in paediatrics. We aimed to assess barriers to ACP initiation, including the adequacy of exposure and education regarding ACP and whether practitioners would deem improved education and resource provision useful., Methods: A 25-question survey was designed following literature review. Paediatricians, intensivists and advanced trainees at Sydney Children's Hospital were invited to complete the online survey. Ninety-two responses were obtained over a 10-week period., Results: Patients with life-limiting conditions are encountered frequently, with 57% of respondents caring for at least 10 such patients during the last 2 years. In total, 64% of respondents felt that ACP discussions should occur early around the time of diagnosis or during a period of stability; however, 57% observed discussions occurring late in illness after multiple acute, severe deteriorations. In total, 46% felt that multidisciplinary teams were the most appropriate to initiate ACP discussions. Prognostic uncertainty was the most common barrier to ACP initiation. Lack of experience and education were identified as barriers by 43 and 32%, respectively. The majority of respondents regarded exposure to ACP and education during training as inadequate., Conclusions: ACP discussions are being initiated later than physicians deem optimal. Of concern, clinicians prefer ACP discussions to be initiated by multidisciplinary teams, which may create a barrier to timely initiation. Barriers due to lack of education and experience could be overcome with improvements in training. Provision of education and resources would be welcomed and improve clinician skills in this area., (© 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Aims: New Zealand (NZ) Māori and Pacific children have high rates of acute rheumatic fever (ARF). Around 150 new cases arise each year. As part of the national ARF prevention programme, funding is available to improve housing. To obtain maximum benefit from interventions, an effective tool is needed for targeting high-risk children. This study aimed to assess the effectiveness of using hospitalisations for identifying children at risk of subsequent ARF., Methods: Three potentially avoidable hospitalisation (PAH) groups were investigated, including diseases thought to be influenced by housing. All were developed using expert opinion or systematic reviews. These were: (i) the PAH conditions associated with the housing environment (PAHHE) group; (ii) the Crowding group; and (iii) the Ministry of Health (MoH) group. We analysed NZ public hospital discharge data (2000-2014). The prevalence of ARF among patients hospitalised in each group was calculated to estimate sensitivity and potential effectiveness. The number needed to screen (NNS) to identify one ARF case was estimated as a measure of efficiency., Results: Nearly one-third of ARF patients experienced a PAH as children (before developing ARF). Sensitivity for detecting future ARF ranged from <5% (MoH group) to 27% (PAHHE group). NNS ranged from 502.4 (PAHHE) to 707.5 (MoH)., Conclusions: Because ARF is relatively rare, observing hospitalisations is not particularly efficient for targeting prevention activities for this condition alone. However, housing interventions are likely to improve multiple outcomes; thus, the hospital setting is still useful for identifying at-risk children who could benefit from such programmes., (© 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)