Child health

You were only 2 months old. I met you in the children’s intensive care unit one night, almost 3 years ago. Intracranial haemorrhage, they said. What happened? We were trying to keep you alive. You were tiny in that large hospital cot, dwarfed by technology and oversized pyjamas, your bedtime lullaby the hissing of the ventilator and suction machines. We calculated fluid requirements, made your blood pressure and electrolytes look ...

Alison M Snodgrass MB BS, MRCPCH(UK) · Hong Liang Tey MB BS, MRCP(UK)

A tale of anxiety, innocence and trust in the anaesthetic roomAs I entered the busy paediatric ward, I scanned the room for my patient — they’re often not easy to find among the other children, the visiting parents and siblings, and the staff, and are rarely anywhere near, let alone in, their assigned beds. I was eventually directed to a small child sitting quietly on his ...

Geoffrey C Mullins MB BS, FANZCA, FRCPC

We read with interest the report by Handelsman describing an increase in Australian testosterone prescriptions, including a particular increase in prescribing of topical testosterone gel. The topically applied formulation of testosterone has a unique adverse-effect profile because of inadvertent exposure to it via direct skin contact. We report progressive virilisation in a 2-year-old girl who presented in 2011 with an 18-month history of body ...

Jacqueline K Hewitt · Margaret R Zacharin

To the Editor: On 5 June 2012, the forum “Eliminating childhood lead toxicity in Australia — a little is still too much” was held at Macquarie University to examine new evidence on the toxicity of lead and its implications for Australian children and communities. Presently, the National Health and Medical Research Council (NHMRC) recommends an increasingly obsolete intervention level that was established in 1993: blood lead levels ...

Mark P Taylor · Chris Winder · Bruce P Lanphear

To the Editor: Alkali drain cleaner has previously been reported to cause oral, oesophageal and cutaneous burns.-4 The risk of these cleaners causing full thickness cutaneous burns in children needs to be emphasised. Two toddlers recently presented to our hospital with severe burns after exposure to alkali drain cleaning products. An 18-month-old boy opened the box and bit open the silver foil packet of a foaming ...

Rachel A D’Cruz · Erik R La Hei · Andrew J A Holland

To the Editor: In describing 8 years of experience in managing adolescent gender identity disorder (GID) at a paediatric hospital clinic, Hewitt and colleagues highlight a small group of patients who require momentous life-long clinical decisions made in a timely manner.1 However, the rarity of this condition means that experience in any centre is limited. The authors state that authorisation from the Family Court of Australia is ...

Ann J Conway · Julie C Hamblin · David J Handelsman

To the Editor: I welcome the article by Hewitt and colleagues,1 but their protocol is problematic. Suppression of puberty improves mental health and general functioning, but not body image and dysphoria.2 For this, cross-sex hormones and/or surgery are the only effective treatments.2 Withholding cross-sex hormones until children are 16 years of age may worsen their mental health,3 cause resentment, and encourage self-medication. Increasingly, young transsexual people are ...

Zoë Hyde

In reply: We thank Hyde and Conway and colleagues for their correspondence following our report on treatment for young people with gender identity disorder (GID).1 We follow current international consensus recommendations for management,2,3 but accept that as more research is performed, there may be future adjustments to endorsed protocols. At present, patients can apply to the Family Court of Australia for authorisation of treatment that ...

Jacqueline K Hewitt · Campbell Paul · Louise K Newman

Cunningham’s perspective provides a timely review of the literature relating to the maternal psychological outcomes of holding stillborn babies, which remains controversial. It is unfortunate that some popular media sources reported it incorrectly as saying that seeing and holding stillborn babies may cause harm. The correct conclusion is that the literature is inconclusive. The Australian and New Zealand Stillbirth Alliance strongly supports Cunningham’s ...

Vicki J Flenady · Christine Carroll · Ros M Richardson

DISTURBANCES OF SLEEP and daytime function are important diagnostic symptoms. Although most of us are well versed in the features and important impacts of sleep apnoea, a search for insomnia should be an indispensable part of most history-taking.Almost a third of our symptomatic patients present with symptoms of stress or mood disorder, where investigations of physical symptoms such as fatigue, dizziness, daily headache, chest pain ...

John M Worthington

The publication of the Australasian Creatinine Consensus Working Group’s position statements in 2005 and 2007 resulted in automatic reporting of estimated glomerular filtration rate (eGFR) with requests for serum creatinine concentration in adults, facilitated the unification of units of measurement for creatinine and eGFR, and promoted the standardisation of assays. New advancements and continuing debate led the Australasian Creatinine Consensus Working Group to reconvene in 2010. ...

Australasian Creatinine Consensus Working Group

John Brown was born on 5 August 1934 in Meadowbank, New South Wales. He lost both parents early in his teenage years and was then raised by his aunt, Doris Johnson. Despite these setbacks, he attended Fort Street Boys’ High and subsequently studied medicine at the University of Sydney. On graduating in 1957, he entered the emerging specialty of paediatrics. While training at the Royal Alexandra Hospital for ...

Lachlan T Brown

Nathan Grills examines unhealthy alliances that highlight corporate social irresponsibilityIndustry sponsorship of charitable causes is increasingly promoted and practised across the corporate sector in Australia and overseas. But should such “corporate social responsibility” be limited in certain circumstances? Apart from tobacco companies, there are currently very few restrictions on which industries are allowed to support which charities. But there is a need to consider whether ...

Nathan J Grills MB BS, DPhil, MPH

IT WAS always going to be a difficult task to summarise all possible paediatric presentations into a single book to help junior medical staff “on call”, so the authors of this effort are to be commended.This is an Australian adaptation of the popular American handbook, and all three Australian authors — Browne, McCaskill and Cheng — are senior staff in the emergency department at the ...

Julian J Kelly

Objective: To determine the nutrient intakes and status of preschool children from a representative population sample in Adelaide.Design, setting and participants: Cross-sectional survey of children aged 1–5 years, using a stratified random sampling method and a doorknocking strategy, between September 2005 and July 2007.Main outcome measures: Dietary intake, assessed using a 3-day weighed-food diary; anthropometrics, biomarkers of iron, zinc and vitamin ...

Shao J Zhou PhD · Robert A Gibson BSc, PhD · Rosalind S Gibson PhD · Maria Makrides BSc, PhD

To describe the experience of hormone treatment of gender identity disorder (GID) in children and adolescents within a specialist clinic. Design, patients and setting: Cohort study by medical record review of children aged 0–17 years referred during 2003–2011 for management at the GID clinic in a tertiary paediatric referral centre — the Royal ...

Jacqueline K Hewitt MB BS, FRACP · Campbell Paul MB BS, FRANZCP · Porpavai Kasiannan DPM, MD, FRANZCP · Sonia R Grover MB BS, MD, FRANZCOG · Louise K Newman MB BS, PhD, FRANZCP · Garry L Warne MB BS, FRACP

To the Editor: The possible extension of the Australian preadolescent female vaccination program against human papillomavirus (HPV) to preadolescent males is not a sensible use of public health resources. In Australia, 71% of 15-year-old girls completed ...

Peter D Massey · David N Durrheim

Objective: To determine the incidence of and factors associated with vitamin D deficiency rickets in Australian children.Design: 18-month questionnaire-based prospective observational study, using Australian Paediatric Surveillance Unit (APSU) data.Setting: ...

on behalf of the APSU Vitamin D Study Group

To the Editor: In Australia, when melatonin is requested in doses higher than those available in preprepared formulations, in different dosage forms, or for people under 55 years of age, private prescriptions and extempora-neous preparations are often used. There is evidence of efficacy of melatonin in shiftwork-related sleep disorders, jet lag, circadian rhythm disorders, and for older people with chronic insomnia, but not for insomnia generally.1-3 There is concern over increasing use of melatonin in children, but no current data exist for actual melatonin usage patterns in Australia. In September 2010, we conducted a 2-week prospective drug use audit of melatonin prescriptions dispensed to patients by Australian compounding pharmacies. All pharmacies of the Professional Compounding Chemists of Australia (PCCA) (n = 153) received audit forms and explanatory information sheets, followed up by two telephone calls. The audit form requested patient details, the melatonin prescription, prescriber, dose amount and formulation prescribed, directions on prescription, and purpose of medication. This study was approved by the Human Research Ethics Committee of the University of Sydney. Forty-one pharmacies completed 228 audits, a response rate similar to recent pharmacy-based surveys.4 Also, 42 pharmacies estimated melatonin prescriptions in the audit period without completing patient details. The demographic details of respondents (Box) were similar to those in a previous survey of Australian compounding pharmacies.5 A total of 1463 melatonin prescriptions were reported as dispensed in the 2 weeks by 83 pharmacies (17.63 per pharmacy). In the detailed audit, the median age of people for whom melatonin was prescribed was 12 years; 56.4% (128/227) were male; the average dose prescribed was 4.3 mg ± 2.5 mg (range, 0.5 mg–20 mg); the most common reason for prescribing melatonin was to help sleep in cases of attention deficit hyperactivity disorder (ADHD); and paediatricians were the most common prescriber (43.0%; 96/223). Analysis of the non-responders showed that responders were not different to non-responders in age, sex, years of experience or pharmacy prescription volume. Extrapolating the results, 70 132 prescriptions (17.63 × 26 × 153) are estimated to be compounded in the 153 compounding pharmacies annually. This staggering figure does not include non-PCCA pharmacies, compounding hospital pharmacies, melatonin purchases without prescription (generally via the internet), or Circadin (Neurim Pharmaceuticals) prescriptions. Circadin was not included in our study as it was introduced in mid 2010 and there had been only a few sales by September 2010, and it is approved only for people over 55 years of age with primary insomnia. In conclusion, we found that melatonin was frequently dispensed, with many cases of off-label use, to both adults and children, particularly for insomnia in children with ADHD and autism. Melatonin has limited long-term safety data, and the long-term effect on gonadal development, particularly with high doses, is unclear. The efficacy and safety of melatonin in children will only be established through well designed trials of high methodological quality and sufficient sample size. Melatonin prescription details for 227 patients Demographic details of patients and prescribers Proportion or mean ± SD (range) (n = 227) Details of patients for whom melatonin was prescribed Age (years) 22.8 ± 20.9 (1–83) Age bracket 0–2 years 1.4% 3–5 years 10.1% 6–10 years 32.0% 11–18 years 19.6% 19–34 years 8.7% 34–55 years 19.6% > 55 years 8.2% Male 56.7% New prescription 29.1% (42.3% using > 6 months) Details of prescribers (from 227 audit forms*) Type of prescriber General practitioner 41.4% Paediatrician 43.2% Sleep specialist 5.7% Psychiatrist 4.8% Other specialist 3.5% Reason for prescription† Primary insomnia 26.4% Secondary insomnia 14.5% Jet lag, travelling, shift worker, CRD 12.8% Help sleep in children with ADHD 24.2% Help sleep in children with autism and behaviour problems other than ADHD 19.4% Anxiety, trauma, stress and sleep problems 3.5% Sleep problems related to pain and cancer 0.8% Sleep problems related to other comorbidities (gastro-oesophageal reflux disease, Grave’s disease) 0.8% Unsure of reason 0.8% Dose (mg) (n = 213) 4.3 ± 2.5 (0.5–20) Total amount prescribed for liquid formulations (mL) (n = 99) 55.2 ± 53.2 (5–300) Total amount prescribed for solid formulations (number of capsules, tablets, troches) (n = 123) 72.9 ± 37.9 (15–300) Repeats authorised (n = 221) 2.3 ± 2.1 (0–10) Prescription duration (months) (n = 200) 7.9 ± 9.7 (0–60) Formulation prescribed† Tablets 3.5% Capsules, slow release capsules 49.7% Liquids (suspension, oral, sublingual drops) 43.5% Troches 2.6% CRD = circadian rhythm disorder. ADHD = attention deficit hyperactivity disorder. * Some data missing on one record of 228, so 227 used for tabulation. † Percentages may not add to 100% because of some missing data, and some patients may have reported two reasons.

Jane Nikles · Victor Lo · Jennifer A Giam · Bandana Saini

Each year, over 1000 medical device incidents are reported to the Australian Therapeutic Goods Administration (TGA). The most recent published statistical reports from this scheme show 926 reports in 6 months (January–June 2009), of which 597 resulted in serious injury and 25 were associated with patient death. The 3 Fr peripherally inserted central catheter (PICC) is a medical device commonly used in infants ...

Joel M Dulhunty MB BS, MTH, PhD · Andreas Suhrbier BA, PhD · Graeme A Macaulay BEng(Med) · Jennifer C Brett BEng(Med) · Alexa V A van Straaten BA(Hons), MA, MPhil · Ian M Brereton BSc, PhD · Jillann F Farmer MB BS, FRACGP, FRACMA

Your guide to paediatric anaesthesia. Craig Sims, Chris Johnson. Sydney: McGraw-Hill 2011 (374 pp, $129.95). ISBN 9780071000222. THIS GUIDE aims to provide expert practical information across the breadth of paediatric anaesthesia without getting bogged down by details. The vast clinical experience of the editors (and their team of contributors) ensures that these aims are fulfilled in an informed, practical way. Chapters covering basic science and techniques relating to anaesthesia and resuscitation for children are complemented by others discussing anaesthesia for a comprehensive range of surgical subspecialities as well as for specific paediatric conditions. Care has been taken to include discussion of current issues that have generated controversy. The target audience includes trainees wanting a pithy summary of paediatric anaesthesia to inform their clinical experience and assist in preparation for exams. Both editors are examiners for the Australian and New Zealand College of Anaesthetists, which means they understand how high the bar is for those exams. The general anaesthetist with an interest in paediatrics wanting an easy-to-read update will also be well served. The book reads very comfortably, often with the tone of the consultant who has an interest in teaching, but the style does not allow for exhaustive explanation, detailed debate over alternative approaches or extensive referencing. However, it is sure to be stimulating for the career paediatric anaesthetist. The search for academic defensibility has led to some bloated, heavily referenced texts that often leave the reader wondering what they would actually do when confronted with a clinical scenario. The source of much clinical teaching is expert opinion, as a consultant works with a trainee. This volume gives expert opinion a voice. Neither online resources nor standard tomes on the topic address the needs of those this volume aims to assist. It is a great resource for trainees and anaesthetists with a paediatric interest and promises to be a springboard for discussion among paediatric anaesthetists.

Ian M McKenzie

Staff safety is improved by clear procedures for managing abuse and assault. Hopper and colleagues describe a scenario familiar to many hospital clinicians and managers: staff reports of verbal abuse and physical assaults from patients.This is often in an organisational context of scarce reliable data about the phenomenon, an ad-hoc management response and no specific training of staff to manage aggression....

Brett McDermott MD, FRANZCP, CertCAPsy