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DCH / IPPC Monthly Newsletter

Newsletter # 1, 2015

Dear DCH / IPPC Participants, Tutors and Alumni,

This is our “Post-2014 Exam” Newsletter, with a key focus on providing educational feedback following the December 2014 Examination. In total in 2014, we have had 1029 successfully complete this program, including 15 Nurses, bringing our Alumni to a total of 4993. If each doctor and nurse consults with 20 children per day, that is an overall impact on more than a million child health consultations in a year… from this year alone. I would like to most warmly congratulate all those who were successful in this examination. I trust that you have felt a real sense of achievement an enjoyed celebrations as well as appreciation for those who have supported you in your study.

To those who have been unsuccessful: I know that this is a very challenging time. Please don’t lose your momentum to enhance your paediatric knowledge and skills; I urge you to use this opportunity to continue your journey and to achieve success when you next attempt the examination.

I would like to convey sincere thanks to:

Elizabeth Koff and Professor Louise Baur, leaders in our ‘parent institutions’, for their continued commitment.

Our Webcast Presenters from SCHN who tirelessly share their expertise each year.

Our team: Rita Gudinho, Catherine Zelinsky, Belinda Shephard, Dr Diana Steinberg, Dr Helen Somerville, Dr Mary Iskander, Dr Mohna Sharma, Kevin Brown, Dijana Sarcevic, Angela Ostojic, Rad Erceg, Matt Dundas and Anisha Rana

We are so fortunate to have access to programs such as the DCH / IPPC. It is a lens through which we see paediatric care more clearly……it brings true enlightenment to our clinical practice and adds significant clarity to our communications with colleagues, children and families. We know that you will treasure the opportunity you have had to enjoy this program and that you will use your new knowledge, confidence and skills in your day to day practice to enhance the health and wellbeing of the children and young people in your communities. I know you will embrace responsibilities that accompany your opportunity to learn, including:

Continuation of your personal development in paediatrics, seeking new knowledge as part of our Alumni

Encouraging and supporting the learning opportunities of others

Sharing your experiences and expertise in teaching colleagues, students, your paediatric patients and their families

Our Graduation Ceremony here at The Children’s Hospital at Westmead was an excited and meaningful occasion for all who attended. It was recorded and is soon to be available as a webcast for all to enjoy. I had the privilege of attending our first Graduation in Zimbabwe in January, hosted by our Australian Ambassador HE Matthew Neuhaus and conducted by his wife, Angela, who introduced DCH / IPPC there. The jubilation there was palpable, with their most senior, now retired, paediatric Matron saying that this was the highlight of her long and challenging career.

It is always inspiring to hear of your excitement in transforming your new knowledge directly into action at the bedside, and in the community in day-to-day practice. These stories are the best indicator of the true benefit of IPPC & IPPNC. Please share this with us and your DCH / IPPC colleagues as you whenever you can and in your formal application for ongoing free Alumni access each year. Thanks to all who have sent feedback already.

I look forward to hearing from you and to meeting again.

Kind regards,

Adjunct Associate Professor Kathryn Currow Discipline of Paediatrics and Child Health, University of Sydney Executive Principal, DCH/IPPC, Senior CMO Emergency Department, Sydney Children’s Hospitals Network, Executive President, COMHAD Deputy Chair, Commonwealth Health Professions Alliance

In this Issue

Principal’s Letter

Dates for Diaries

Important Notices

Dec 2014 Exam Review

Who are we? Matt Dundas

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Key Dates for Diaries

Course Key Dates – August 2015 Stream & December Stream 2015

August Stream

December Stream

Notes

Course Period:

Lecture Units

(lecture unit = recorded lecture, learning

outcomes, lecture notes, self-

assessment questions)

Start: September 2014

Conclude: August 2015

Start: 27 January 2015

Conclude: 11 November

2015

Live lectures at The Children’s Hospital at Westmead (8-9am Sydney time, Monday-Wednesday inclusive) Available online at: www.magga.org.au

Assessments

Due Date

Due Date

Notes

Report 1: Health Inequity

Case Report

13 February 2015 26 June 2015 1000 word case report: 5% of

final mark

Report 2: Medical Case

Report

27 March 2015 28 August 2015 1000 word case report: 5% of

final mark

Final Examination Date Date

Written & Oral 14 August 2015 4 December 2015 Written examination: 70% of

final mark *

Oral examination: 20% of final mark

Deadline to Advice DCH/IPPC

Office re

Final Examination Attendance

15 May 2015

14 August 2015

Deferral is available for those not wishing to sit the examination; fees & conditions apply.

Important Notices

Key dates: Case Report 1: August 2015 Steam August 2015 stream Participants are advised that the due date for receipt of their Health & Inequity Case Report is Friday, 13th February 2015. New Magga Website:

We are delighted to announce that our new website is live. This is effective from 29th January 2015.

For access to our platform, please ensure you use your User Name and password

We hope you enjoy the new look to our website and look forward to your feedback.

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Review of Examination Questions December 2014

We have reviewed a selection of topics covered in the recent examinations. Included are areas where Participants

experienced difficulties, as well as some common and important Paediatric conditions.

Chronic Constipation

Faecal soiling due to chronic constipation is a serious problem in 1-3% of children age 4-7 years of age. It is usually a

functional rather than an anatomical problem due to a variety of factors including: a low fibre diet, poor fluid intake,

slow colonic transit and lack of exercise. In younger children excessive cow’s milk intake and cow’s milk protein

allergy are additional causes.1

This leads to the development of hard stools, which are difficult to pass. When defecation occurs less than 3 times a

week, a vicious cycle develops where the rectum becomes dilated with excess stool and the child avoids passing stool

as it is painful. Eventually there is a loss of sensation of stool presence in the rectum leading to involuntary episodes

of defecation (encopresis).

Upon diagnosis of functional constipation, a child with encopresis should be treated with a combination of stool

softeners, and dietary and lifestyle changes. It is important to maintain therapy with stool softening agents for at least

6 months to allow the rectum time to recover normal size and sensation. Failure to do so will result in recurrent

constipation. Enemas may be necessary for disimpaction in some situations as an initial treatment, however they do

not provide adequate treatment for ongoing chronic constipation. Stool softeners may be successfully weaned after 6

months provided the necessary improvements in diet have also been made.

Spinal Dysraphism

Most (two thirds) of cases of spinal dysraphism are now diagnosed ante-natally during the routine foetal morphology

ultrasound scan at 18-20 weeks gestation. Many foetuses with severe spinal dysraphism are terminated. As a result

of this, and with improvement of peri-conception folic acid intake in Australia, the incidence of spinal dysraphism at

birth has declined here to 1:2000 live births.2

Occult spinal dysraphism includes a number of conditions such as low cord, tethered cord, extension of a cutaneous

pit into the central canal (diastematomyelia or split cord), anterior sacral meningocele, and spinal lipoma.3 Most spinal

defects occur in the lower lumbar or sacral regions. Most spinal defects (97%) are associated with a Chiari II

malformation where the cerebellum and the medulla are displaced caudally into the foramen magnum.2

Ultrasound scan of the spine is an excellent screening tool for occult dysraphism in children under the age of 3

months. All babies with cutaneous stigmata such as hair patches and skin pits in the lumbosacral area should have

an ultrasound to exclude occult spinal dysraphism. If the ultrasound is normal in this age group, no further

investigation is necessary unless there are neurological abnormalities on physical examination.3

Large Heads (Macrocephaly) in Infants

Macrocephaly is a common reason to refer infants for neurosurgical review. The most common cause of

macrocephaly in infants is benign familial megalencephaly (large brain). This may be associated with a mild external

hydrocephalus which does not require treatment or ongoing follow-up.4 The diagnosis of benign familial

megalencephaly is suggested by both parents having large heads (similar centile to the child); as well as a normal

neurological examination, and lack of abrupt increases in head circumference in the child.

Macrocephaly associated with a head circumference that is crossing centiles tends to have a more sinister aetiology.

If a child presents with no previous record of head circumference measurements during childhood birth records should

be consulted (such as the newborn record book) and parental head circumferences measured. If no records are

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available, and the child is developing normally and has a normal neurological examination, it is reasonable to monitor

head growth at 2-4 weekly intervals. In circumstances where there is crossing of centiles, or abnormalities on

neurological examination, an MRI scan of the brain is the gold-standard test. CT scan of the brain in a child <10 years

of age confers a 1 in 1000 lifetime risk of haematological malignancy, and therefore should not be used for routine

investigation of macrocephaly if MRI is available.

Scoliosis in adolescence

Idiopathic adolescent scoliosis is the most common type of scoliosis in this age group. It is often familial and affects

more girls than boys. It is first noted by screening in early adolescence and is asymptomatic. Treatment is advisable

if the Cobb angle is greater than 20 degrees, and includes bracing and observation for a period of time to monitor

progress.5

It is a good idea to refer to an orthopaediac surgeon for review if in doubt. If a GP or paediatrician is experienced in

spine X-ray interpretations, Cobb angles less than 20 degrees can be observed for progress every 6-12 months.

Further investigation of scoliosis becomes a necessity if the presentation is outside the adolescent period or is

symptomatic (painful).5 An MRI of the spine is the investigation of choice in those circumstances together with

orthopaedic review by a spinal surgeon.

Non-Tender Cervical Lymphadenopathy

Cervical lymphadenopathy is common in the paediatric population. Most cases are secondary to upper respiratory

tract infections or other infectious aetiologies such as EBV, CMV, and Toxplasmosis. These tend to be acute in onset.

Reactive lymph nodes are bilateral, small (<0.5 cm in diameter) in size, mobile, non-tender and have no overlying skin

changes.

Unilateral cervical lymphadenopathy brings the possibility of other pathogens into the picture such as cat scratch

disease (Bartonella henslae), or malignancies (eg lymphomas, thyroid cancer).

When there is overlying skin change and onset is chronic , the main differentials become tuberculous (TM) and non-

tuberculous mycobacterial (NTM) infections. The index of suspicion for tuberculous cervical lymphadenopathy

(scrofula) depends on the risk of exposure. In parts of the world where TB is rife, there should be a high index of

suspicion for tuberculous lymphadenitis. In these circumstances, a diagnostic fine needle aspiration is useful with a

sensitivity of 77% and a specificity of 93%. The positive predictive value approaches 100%. The most reliable criteria

for diagnosing tuberculosis is the presence of stainable acid fast bacilli and cultured organisms on aspiration.

Incisional and excisional biopsies for tuberculosis are hazardous as they may spread the disease.6

For NTM infections excisional biopsy is diagnostic and therapeutic. Core biopsies of NTM nodes should be avoided

as they commonly lead to a non-healing sinus.

Groin Lumps in infants

Differential diagnosis of groin lumps in infants includes inguinal hernias (most common), inguinal lymph nodes and

scrotal hydrocoeles. An inguinal hernia is the protrusion of intra-abdominal contents through the internal inguinal ring

via a patent processus vaginalis. In boys, the processus vaginalis normally closes following the descent of the testicle

into the scrotum. Hernias occur in 1-4% of all male infants, and the incidence may reach 30% in premature infants. In

female infants a groin lump may be a herniated ovary.

Most infants present with a history of intermittent inguinal swelling which, in males, may extend to the scrotum. The

presence of a mass or thickening of the spermatic cord is diagnostic. A paediatric inguinal hernia will not close

spontaneously and it must be repaired. While repair of a reducible inguinal hernia is not a surgical emergency, prompt

referral to a paediatric surgeon is recommended as complications (such as strangulation) of persistent inguinal

herniae occur at high rates in young infants.7

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Anorexia Nervosa in adolescents

Anorexia nervosa (AN) is an increasingly common chronic illness in young people. The outlook is generally good with

0.5% annual mortality. AN causes profound structural and functional changes including:

Localised brain dysfunction: inlcuding hypoperfusion of temporal lobe

Endocrine changes: including amenorrhoea

Bones: osteoporosis

Hepatic: hepatocellular steatosis

Circulation: bradycardia, prolonged QT interval, vagal hyperactivity

Immunological: reversible immunodeficiency

Most of these changes will fully reverse with re-feeding and maintenance of a healthy weight. The exception is

osteoporosis, which causes chronic bone problems in recovered anorexics. AN leads to 4-10% bone loss/year if

untreated. The loss of bone mass is related to increased osteoclast activity, decreased osteoblast activity, decreased

calcium intake and increased cortisol levels. It is important to treat bone health aggressively in AN to minimise the

long term effects of chronic osteoporosis, however it is almost impossible to completely reverse the damage.

Treatments include: anabolic strategies to increase osteoblast function, weight gain, restoration of gonadal function,

calcium supplementation, and weight bearing exercise.8

Infantile haemangiomas

Infantile haemangiomas are vascular tumours and are the most common benign soft tumours of childhood. They

occur in 1-2% of newborns and the clinical onset is within 1-2 weeks of birth. The growth period of the haemangioma

is from 3 to 9 months of age and it tends to regress in childhood. Ultrasound is a helpful diagnostic tool.

Complications of infantile haemangiomas include ulceration, interference with function, and cosmetic disfigurement.

Haemangiomas over the upper eyelid may cause amblyopia, those in the beard distribution may be associated with

laryngeal haemangiomas which can acutely compromise the airway as they grow.

Treatment with oral Propranolol (and close monitoring) can be very effective in the treatment of haemangiomas in

such circumstances, especially in preventing airway complications in children with neck / beard distribution

haemangiomas.9 Any child who is acutely unwell with signs of airway compromise should be admitted to hospital and

seen urgently by an ENT surgeon.

Growth in Children

Growth is a sensitive indicator of:

A child’s health and nutrition

Genetic background

Psychosocial environment.

Determinants of growth are either:

Prenatal OR

Postnatal

Prenatal causes are maternal, placental or genetic

Postnatal causes include genetic, nutritional, emotional and endocrine function10

Upon evaluation of a child’s growth, height measurement and plotting on centile chart is pivotal in determining whether

a child is short for age. A short child would be 2 SD or more below the mean (1st centile of the growth chart). Heights

above that cut-off do not require further investigation unless there are other reasons for concern such as dysmorphic

features, progressively decreasing height centiles or features of systemic disease.11

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Rib fractures in children

Rib fractures in children are said to be highly specific for non-accidental injury in the absence of a significant trauma

history (such as a high-speed motor vehicle accident) or underlying bone disease. Compression of a child’s rib-cage

can result in fractures at one or more of the sites shown in the figure below.12

Rib fractures due to NAI may be an incidental finding on a chest x-ray done for fever or respiratory illness. It is worth

taking the time to review the bones in a chest x-ray, as well as the soft tissues. When viewing chest x-rays, review the

area outside the lungs including all the visible bony skeleton.

Benign Rolandic Epilepsy

Benign Rolandic Epilepsy with Centro-Temporal spikes causes 10-20% of childhood epilepsy in school age children

(3-13 years). Seizures involve the lower portion of the precentral (rolandic) gyrus and tend to occur during sleep.

Clinically these seizures start with oral or facial sensory changes, followed by tonic or tonic-clonic unilateral

movements of the face. This causes difficulty swallowing, and drooling of saliva. If the child is awake, consciousness

is generally preserved but the seizures may sometimes spread to become generalised. If the seizures generalise, or

occur in sleep the child does not usually recall the event the next morning.13

A typical history and EEG showing centero-temporal spikes with classic features confirms the diagnosis. Most cases

remit spontaneously by the age of 12-13 years. Children should be referred to a paediatrician or neurologist for

discussion of whether there is a need to start anti-epileptic medication. As with all seizure disorders discussion with

the parents regarding supervision, first-aid, and safety issues is essential.

Wheezing in children: diagnosing asthma

The revised National Asthma Council guidelines were released online as the Australian Asthma Handbook in March

2014. Respiratory specialists and DCH / IPPC Lecturers A/Prof Peter Van Asperen and Dr Paul Robinson have

published an article in Medicine Today: Age Specific Management of Asthma in Children. A summary of the article

provides the potential diagnostic features of asthma in the paediatric population. These are:

History of recurrent or persistent wheeze

Presence of allergies or family history of asthma and allergies

Absence of physical findings that suggest an alternative diagnosis

Test results that support the diagnosis (eg; spirometry in children able to perform it)

A consistent clinical response to an inhaled bronchodilator or preventer.13

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Basic Life Support for infants and children

Basic life support (BLS) is critical for any child who appears lifeless or not breathing. Once you have established that

the child appears lifeless, and is not responsive, it is more important to start effective BLS than to spend time checking

for a pulse. The outcome of cardiac arrest in children depends on both the aetiology and the effectiveness of early

cardiopulmonary resuscitation (CPR).14

The BLS flow chart used by the Australian Resuscitation Council shown below follows the acronym DRABCD.

Please note that infants have a large occiput, and therefore the head needs to be placed in a neutral position to open

the airway. For older children and adults the airway is opened by tilting the head into the “sniffing” position. If spinal

injury is suspected the neck should be stabilised, and a jaw thrust manoeuvre is used to open the airway.

Don’t Ever Forget to check the Glucose!

Any child who presents with an altered level of consciousness should have a prompt bedside blood glucose level

done. Young children have small glycogen reserves and so can rapidly become hypoglycaemic when they are unwell

and not eating. Blood glucose levels of <2.8mmol/L can cause neurological damage and should be treated promptly.

If the child is conscious and able to swallow without airway compromise oral glucose in the form of sweetened juice, or

glucose gels may be given. Children who are more unwell should be given IV glucose (slow bolus of 2mL/kg 10%

dextrose solution); or IM glucagon if IV access is difficult to obtain.

If the cause of the hypoglycaemia is unclear, obtaining a critical blood sample for analysis of insulin levels, cortisol,

ketones, and other metabolic parameters just prior to giving glucose is extremely helpful; however treatment should

not be unduly delayed if there is difficulty obtaining a blood sample.

References:

1. Dr Patrina Caldwell, Enuresis and Faecal Incontinence; DCH/IPPC lecture 2014

2. Dr Antoinette Botman, Neural Tube Defects; DCH/IPPC lecture 2014

3. Dr Caplin N, Imaging of Paediatric Neurological Presentations; DCH/IPPC lecture 2014

4. Dr Chaseling R, Neurosurgery for GPs; DCH/IPPC lecture 2014

5. Dr Bellemore M, Postural Problems in Childhood, DCH/IPPC lecture 2014

6. McClay JE, Scrofula Overview of Scrofula; http://emedicine.medscape.com/article/858234-overview

7. Inguinal Hernias and Hydroceles in Infancy, Paediatric Child Health; 2000, 5 :462-463

8. Prof Kohn M, Medical Complications of Anorexia Nervosa in Adolescents; DCH/IPPC 2014

9. Dr Ming, A. Birth Marks, DCH/IPPC 2014

10. Cowell C, Growth Disorders in Children, DCH/IPPC 2014

11. Rogol AD. Diagnostic Approach to Children and Adolescents with Short Stature

12. Tucker J, Metaphyseal and Rib Fractures in Child Abuse, 2003

13. Van Asperen P, Robinson P, Age specific management of asthma, Medicine Today 2014; 15:14-28

14. Dr Lawson J, Epilepsy; DCH/IPPC 2014

15. Dr Cavazzoni E, Phin S, Paediatric Resuscitation; DCH/IPPC 2014

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Who Are We?

Matt Dundas

Administrations Officer

Diploma in Child Health / International Postgraduate Paediatric Certificate

Hi my name is Matt Dundas,

If you were lucky enough to call up the DCH/IPPC offices late last year to register for the amazing course on offer, you

may have just talked with me, a somewhat nervous stuttering newcomer eager to learn and excel in my new role. Well

here I am almost three months later and I am really enjoying working with all the lovely Participants and Staff and can

see that this year is going to be a great success.

Born and raised in Sydney, with a Diploma in Sound Engineering and a Degree in IT, in my free time away from the

office, you might just find up on a stage singing and playing songs I’ve written on my beloved acoustic guitar. I’ve been

playing music now for around ten years and writing songs for around the last five, I find it’s a great way to relax.

If music isn’t your thing though, perhaps keep an eye out for me at the next wedding you attend, because the guy

holding the camera just might be yours truly. I’ve been photographing weddings and various events now for the last

nine months. It’s a perfect way to spend the beautiful weekends here in Australia.

I’m really looking forward to this year at the DCH/IPPC, I feel honoured to be a part of such a great course that is

helping so many people. I hope that I can play my part in making the next year run as smoothly and stress free as

possible for all participants, from registration to graduation.