Child health

Objective: To document haemopoietic stem cell transplantation (HSCT) activity and trends among paediatric patients in Australia and New Zealand.Design, setting and participants: A retrospective analysis of data reported to the Australasian Bone Marrow Transplant Recipient Registry by the seven paediatric HSCT institutions in Australia and New Zealand over the 9-year period 1998–2006, with particular focus on the most recent years (2002–2006).Main outcome measures: Types of HSCT performed; transplant-related mortality (TRM); stem cell sources; indications for HSCT; causes of death after HSCT.Results: Over the period 1998–2006, 522 autologous HSCT procedures (41%) and 737 allogeneic procedures (59%) were performed. About 60% of allogeneic transplants involved alternative donors (donors other than a human leukocyte antigen-matched sibling). The use of umbilical cord blood as a source of haemopoietic stem cells has doubled since 1998, with 34% of allogeneic transplants in 2006 using cord blood. Over the period 2002–2006, the median age of patients receiving transplants was 7 years (range, 0–19 years). The most common indications for allogeneic HSCT were acute lymphoblastic leukaemia (33%) and acute myeloid leukaemia (24%). The most common indications for autologous HSCT were neuroblastoma (23%), medulloblastoma (21%) and Ewing sarcoma (10%). TRM at 1 year after transplant was 22% for alternative donor transplants, 7% for matched-sibling transplants and 5% for autologous transplants. Relapse or persistence of a child’s underlying condition accounted for 54% of all deaths within 1 year after transplant.Conclusions: HSCT is an important procedure for children with a range of life-threatening illnesses. Local trends in the indications for HSCT, donor selection and TRM reflect contemporary international practice.

Andrew S Moore MB BS · Peter J Shaw MB BS, MRCP, FRACP · Andrew R Hallahan BSc(Med), MB BS(Hons), FRACP · Tina L Carter MB BS, FRACP, PhD · Tatjana Kilo MD · Ian Nivison-Smith BSc, MAppStat · Tracey A O’Brien MB ChB, FRACP, MHL · Heather Tapp MB BS, FRACP, FRCPA · Lochie Teague MB ChB, FRACP, FRCPA · Shaun R Wilson MB ChB, DCH, MRPCH · Karin Tiedemann OAM, MB BS, FRACP

Severe childhood obesity and its associated comorbidities are increasing in prevalence. Extreme childhood obesity may be viewed as a mirror image of severe non-organic failure to thrive. Parental neglect may be a causative factor in both circumstances. When suspicion of parental neglect arises, health care professionals may have both an ethical obligation and a statutory duty to notify child protection services. Guidelines on the point at which medical practitioners should seek state assistance in cases of severe childhood obesity would be helpful, not only for medical practitioners, but also for child protection services.

Shirley M Alexander MB ChB, MRCPCH, FRACP · Louise A Baur BSc(Med), PhD, FRACP · Roger Magnusson BA, LLB(Hons), PhD · Bernadette Tobin MA, MEd, PhD

Objective: To explore the experiences of families with a baby with Down syndrome at the time of diagnosis, and their preferences for information and support in the early period after diagnosis.Design, setting and participants: A qualitative, interview-based study of 18 families living in Victoria with a child with Down syndrome born between 2002 and 2004 who had not been diagnosed with the syndrome before birth. Interviews were transcribed verbatim and interpretive content analysis was undertaken.Results: Parental coping with the unexpected diagnosis of Down syndrome in their infant was influenced by the time interval between birth and disclosure of clinical suspicion of Down syndrome, the level of certainty of the attending physician at the time of disclosure, and the time interval between disclosure of clinical suspicion and confirmation of karyotype. Initial uncertainty and a delay in the diagnosis were detrimental to parental coping, as was premature communication of the news. Perinatal complications increased parental anxiety regarding their child’s condition and future. Individual communication style of midwives and physicians was a powerful predictor of parental adaptation. Parental needs for support and information were facilitated through normalising postnatal care, ensuring privacy, and providing early access to peer support and up-to-date written information. Many parents would have appreciated access to a liaison worker.Conclusion: The experiences of parents in this study provide practice points for improving postnatal care with minimal changes to formal service systems.

Evelyne E Muggli MPH · Veronica R Collins PhD · Catherine Marraffa FRACP, FRCPCH

To the Editor: Accidental ingestion of foreign bodies is common in children. Most pass through the gastrointestinal tract spontaneously,1 but some, such as magnets and batteries, can cause serious problems. We treated three children, aged 4–11 years, who ingested magnets that caused multiple bowel perforations. All three children presented with abdominal pain and vomiting, and were initially treated for gastroenteritis as the history of ingestion was not available. Plain abdominal films were subsequently used to make the diagnosis of foreign body ingestion. The ingested objects were later found to be pieces from magnetic construction toy sets. The first patient was an 11-year-old child with autism. An initial laparoscopy revealed marked dilatation of the small bowel and interloop adhesions. Subsequent laparotomy revealed several magnets (rods, rings and balls) in adjacent loops of the small bowel (Box, A), as well as necrosis and 13 perforations of the small bowel. Segmental resection was performed with a defunctioning ileostomy. During surgery, radiography was performed to ensure that all foreign bodies were removed before closure of the abdomen. The child made a good recovery, and the ileostomy was closed 3 weeks later. The second patient was 4 years of age. An abdominal x-ray revealed a cluster of foreign bodies in the right lower quadrant of the abdomen, with a small gap between the fourth and fifth foreign bodies. A laparoscopy revealed a cluster of magnetic rings (Box, B) perforating the small bowel and the caecum. Two of the rings were on the caecal side and four were on the small bowel side, with an intervening fold of mesentery — the gap on the x-ray. The magnets were retrieved through a minilaparotomy, and the caecal perforation was oversewn. The third patient was a 5-year-old who presented with similar symptoms and x-ray findings. Laparotomy revealed an area of pressure necrosis underlying the magnet and causing perforation of the jejunum, which was repaired by segmental resection and primary anastomosis. As ingestion of foreign bodies is usually not witnessed, a high index of suspicion is required for correct diagnosis.2 Of confirmed cases, 50% of patients remain asymptomatic.3 Fewer than 10% of cases require intervention, and about 1% require surgery.4,5 Ingestion of multiple magnetic objects in children is particularly serious, because of their tendency to aggregate in the bowel and compress intervening tissue, and should be treated aggressively. These cases demonstrate the harmful consequences of magnets in toys. More stringent regulations on the use of magnets in toys — especially in toys for children younger than 5 years — and measures to increase public awareness of this issue are needed. Clusters of ingested magnets in children A: Magnets in loops of the small bowel. B: Magnetic rings perforating the small bowel and caecum, showing intervening fold of mesentery and bowel wall (arrow).

Manjunath B Siddaiah-Subramanya · Peter Borzi

Objective: To document general baseline data on the patterns of childhood malignant tumours at a teaching hospital in south-western Nigeria.Design, setting and participants: A retrospective study of childhood malignancy at Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria, during an 11-year period, from January 1996 to December 2006.Results: 77 children were diagnosed with malignant tumours (an average of seven diagnoses per year); 46 were boys (60%), giving a male-to-female ratio of 1.5 : 1. The age distribution of patients was 1–18 years. There were 42 diagnoses (55%) in the 1–5-year age group and 68 malignancies (88%) were diagnosed at ages of 12 years or younger. Lymphomas were the most prevalent malignancy identified, accounting for 31 diagnoses (40%). Burkitt’s lymphoma constituted the majority of malignancies (28 cases; 36%), followed by retinoblastoma (16 cases; 21%) and nephroblastoma (11 cases; 14%). Other malignancies included germ cell tumours (6), neuroblastomas (4), osteosarcomas (3), rhabdomyosarcomas (3) and non-Hodgkin’s lymphomas (3). One case each of medullary thyroid carcinoma, adenocarcinoma of the rectum, invasive mucinous carcinoma of the colon were also identified.Conclusion: These data suggest that Burkitt’s lymphoma is the most common childhood malignant tumour in our geographic area of south-western Nigeria. With the rising incidence of childhood malignancy in resource-poor countries, measuring the baseline occurrence of such tumours is imperative to provide much-needed resource allocation.

Ayodeji O J Agboola MB ChB, MSc · Folashade A Adekanmbi MB BS, FWACP · Adewale A Musa MB BS, FWACS · Adetoun S Sotimehin MB BS, FWACP · Anotu M Deji-Agboola BSc, MSc, PhD · Aderibigbe M O Shonubi MB BS, FWACS · Temitope Y Oyebadejo MB BS, FMCPath · Adekunbi A F Banjo MB BS, FMCPath

The time has arrived to sort out the decades-long ADHD debate The Royal Australasian College of Physicians is currently revising the 1997 National Health and Medical Research Council (NHMRC) guidelines on attention deficit hyperactivity disorder (ADHD).1 Also, the American Psychiatric Association is working towards the fifth edition of the Diagnostic and statistical manual of mental disorders (DSM), with an expected publication date of 2012. These are valuable opportunities to review existing diagnostic criteria for ADHD and consider alternatives. Recent refinements in psychiatric classification and advances in neuroscience research have jointly contributed to a clearer understanding of some childhood psychiatric disorders. Paradoxically, these developments also raise doubts about the diagnostic validity of ADHD — the most common psychiatric clinical presentation in childhood. These doubts arise from difficulties in conceptualising ADHD as a “disorder”. They also exemplify the growing turmoil that is part of the larger disillusionment with psychiatry,2 reflecting fundamental changes both within and beyond the profession in many Western countries, including Australia. A central concern is the increasing tendency of psychiatry to transform what many regard as normal emotional responses to life’s stresses and traumas into psychiatric disorders. The nosological conundrum of ADHD was highlighted in the United States National Institutes of Health’s ADHD consensus statement; it concluded that there is evidence supporting the validity of the disorder, but did not provide a consensus regarding which ADHD patients should be treated with psychostimulants.3 A response to the statement noted that: ... [the] “unproven” status of the disorder should give pause to both researchers and clinicians who may have reified ADHD as a “thing” or “true entity” (rather than a working hypothesis that serves scientific, communication, and clinical decision-making purposes).4 In addition, it has been noted that discussion of the diagnostic validity of ADHD is far from stale or easily dismissed, and that a renewed sense of urgency arises when a: ... diagnostic concept is listed in an official nomenclature and provided with a precise, complex definition [which] tends to encourage ... insidious reification.5 Such unintentional reification by DSM-IV6 — where so-called core symptoms of ADHD (poor impulse control and lack of sustained attention) are construed as a disorder — is illustrated by tracing the DSM’s successive revisions of ADHD as a diagnostic entity. Antecedents for ADHD range from “motoric disinhibition” in DSM-II (categorised as hyperkinetic reaction) and “inattention” in DSM-III (categorised as attention deficit disorder) to attention deficit hyperactivity disorder (ADHD) in both DSM-III-R and DSM-IV.7 The fact that such conceptual changes are part of the DSM’s stated aim (ie, to identify clinical conditions that can be considered as genuine medical disorders and to distinguish them from problems of living) results in a catch-22 error that has been noted in relation to major depressive disorder.8 This flaw in logic also applies to ADHD. Beyond this flawed logic, Russell Barkley — a respected American authority on ADHD — reviewed the criteria for ADHD and concluded that “what is clear is that the current DSM-IV approach has little clinical or research merit”.9 Further disenchantment with the disease entity assumptions of the DSM revisions has arisen from the serial increase in numbers of diagnostic categories: from 60 in 1952 (DSM) to 145 in 1968 (DSM-II) and 410 in 1994 (DSM-III). This led one author to comment: ... particularly badly affected by this constantly creeping diagnostic expansion have been children, whose least oddity or not quite normal (frequently confused with average) quirk is now assigned to some syndrome or other and treated with behaviour therapy and drugs. The ethics of all this is rarely called into question.10 At the ideological level, some see a process of “psychotherapeutic revisionism” in mental health care in the US.11 I have discussed how such a revisionist ideology views ADHD in detail elsewhere.12 In summary, it fails to distinguish between psychology as “science” and as “scientism”. As a consequence, the former holds that ADHD symptoms arise from the interaction of genetic and developmental influences during pregnancy through childhood, whereas the latter focuses on symptoms as utilitarian targets for treatment. The DSM’s atheoretical approach, which perpetuates the continuing absence of a “developmentally sensitive, interactive or longitudinal perspective in the DSM system”,13 sits within such revisionist ideology. These contrasting conceptual and ideological views have resulted in divergent perspectives on the conceptualisation of ADHD, reliability and validity of ADHD diagnosis, and treatment options for behaviour labelled as ADHD.14,15 Ethical dimensions and other subjects for consideration in the ADHD debate include: diagnostic decision making; inappropriate (over- or under-) medication; “performance enhancement” arguments; the relationship between the psychiatric profession and the pharmaceutical industry, raising possible conflicts of interest; third-party reimbursement for ADHD as a disability; the lack of childhood safety and efficacy data leading children to be termed “therapeutic orphans”; and purported aetiologies based on genetics versus “toxic environments”.16 Importantly, these purported aetiologies have been recast into integrative models that include both genetics and environmental factors,17 a new direction that has immediate implications for clinicians and researchers. Global expenditure on drugs to treat ADHD rose ninefold to US$2.4 billion in the decade to 2003.18 It would be naïve to think that market pressure does not influence evidence-based protocols in resource-starved health services. The revised practice parameters from the American Psychiatric Association relied on the DSM-IV text revision definition of ADHD. The limitations of their recommendations were explicit: These parameters are not intended to define the standard of care, nor should they be deemed inclusive of all proper methods of care or exclusive of other methods of care directed at obtaining the desired results.19 Let us hope that the committee created by the Royal Australasian College of Physicians to define and describe the current conceptualisation of ADHD will have the scientific rigour, maturity and wisdom as they undertake the revision of the 1997 NHMRC guidelines on ADHD1 to emphasise the distinction between ADHD as a set of symptoms and a disease concept. As we approach the critical crossroads between the fourth and fifth revisions of the DSM’s ADHD criteria, a glimmer of hope has emerged, signalling that the time has arrived to sort out the decades-long ADHD debate. The Psychodynamic diagnostic manual (PDM)7 offers an alternative to the DSM construct of ADHD — a relief to what I believe to be shortcomings of the current DSM.9 The PDM’s inclusive approach to diagnosis integrates the subjective experiences of patients with their neuropsychological capacities for regulation of relationships, intimacy and emotional experiences, as well as attention and behaviour. Ideally, such an approach will enable the next generation of children to be spared prescription medications in the current quantities and combinations, based on dubious diagnostic criteria for behaviour labelled ADHD.

George Halasz MRCPsych, FRANZCP

After several years suffering from Parkinson disease, Ian Reid, a paediatric surgeon, died on 20 March 2008. Ian was born on 5 July 1926 at Port Vila, New Hebrides (now Vanuatu). The family returned to Australia in his early childhood. After service in the Royal Australian Air Force, Ian graduated in medicine from the University of Melbourne in 1953. Three years later, he returned to the New Hebrides as Mission Doctor on the island of Tanna. During his years in Tanna, Ian observed at close hand the infamous “cargo cult”. A rather dramatised account of his part in stopping the intrusion of cult members into his hospital was written by David Attenborough in his book The quest for paradise. And his ways are ways of gentleness and all his paths are peace In 1959, Ian went to Papua New Guinea (PNG) to work as a Medical Officer at the Port Moresby General Hospital. He became Foundation Dean of the Papuan Medical College, where he lectured from 1961 to 1969. In 1968, he was awarded a World Health Organization travelling fellowship in paediatric surgery, which took him to Philadelphia Children’s Hospital and other children’s hospitals throughout the United States. During his time in Philadelphia, he worked with “Chick” (C Everett) Koop, one of the first surgeons to successfully separate Siamese twins. On his return from PNG to Australia, Ian worked at the Royal Children’s Hospital, Melbourne, from 1970 to 1971. The following year, he became a James Fairfax Surgical Research Fellow at the Children’s Medical Research Foundation and a Consultant Surgeon at the Royal Alexandra Hospital for Children, Sydney. The award of a Sir Denis Browne Memorial Travelling Fellowship in Paediatric Surgery in 1975 took him to Great Ormond Street Hospital for Children, London, and to other hospitals in the United Kingdom and Ireland. In 1980, Ian was invited to take up a lectureship at the newly established Medical School at the University of Newcastle (New South Wales), where he would help plan the surgical contribution to the paediatric curriculum. In Newcastle he was involved with neonatal work and with children requiring particularly difficult surgical procedures. He also helped to establish neonatal paediatric surgery at the Newcastle Mater Misericordiae Hospital and had the distinction of performing the first neonatal operation at the John Hunter Hospital. Ian’s gentle sense of humour, matched by his courage, invariably won the day. In the somewhat stormy days during the establishment of the Medical School in Newcastle, he quietly retired from the academic arena, citing his reason as “preferring to deal with premature babies than immature professors”. After retirement, he helped in a voluntary capacity with the Hunter Orthopaedic School and the Tingira Centre for blind and deaf children.

Thirty years ago, when general practice surgeries were attached to doctors’ houses, there was generally someone around to help in emergencies, even at awkward times. One Saturday morning, when I was working alone, a boy aged about 7 was brought in to the surgery by his mother. He needed a penicillin injection, and when I asked his mother if she could hold him, she said “The last time he had a needle it took three people to hold him, so I’ll wait outside”. I went upstairs to the house and enlisted the help of my veterinarian son, who was home for the weekend. “I’ll show you how to hold him”, I said. “We learnt how to hold all animals,” he replied. So I left him to it. In keeping with the fashion favoured by vets at the time, my son had long ginger brown hair, a beard and a bushy moustache. He pinned the child to the examination couch with two ginger-haired hands and grinned at him through his beard. Hypnotised by this spectacle, the boy didn’t move, breathe or make a sound. When it was all over, I took him back out to his mother, who had not seen my son enter the consulting room from upstairs. The boy said to her “Was that a bear?”. I didn’t disillusion them. Doubtless, they still tell the story about the odd assistants employed by the funny woman doctor in Brisbane.

Alison Miller MB BS

Objectives: To ascertain changes in: women’s knowledge of the role of folic acid in the prevention of neural tube defects (NTDs); intake of folic acid among pregnant women; and prevalence of NTDs in South Australia.Design, setting and participants: Computer-assisted telephone interviews of South Australian households from 1994 to 2007 over a period encompassing a statewide folate promotion campaign (1994–1995), continuing folate promotion, as well as the introduction of voluntary folate fortification of foods (1996); ascertainment of the total prevalence of NTDs from births and terminations of pregnancy from 1966 to 2007.Main outcome measures: Changes in women’s knowledge of the role of folic acid in the prevention of NTDs; changes in the prevalence of NTDs.Results: From 1994 to 2006 and 2007, knowledge about the role of folic acid increased from 25% to 77% (P < 0.001) and knowledge that folic acid needs to be taken in the periconceptional period increased from 12% to 39% (P < 0.001). The proportion of pregnant women who increased their periconceptional intake of folate rose from 61% in 1998 to 81% in 2006 and 2007 (P < 0.001), with significant increases in the consumption of fortified cereals (from 15% to 29%) and folic acid tablets (from 37% to 64%). The total prevalence of NTDs fell from 2.06 per 1000 births in 1986–1990 to 1.23 per 1000 births in 2002–2007 (relative risk, 0.60; 95% CI, 0.48–0.74; P < 0.001).Conclusions: Folate promotion and voluntary fortification of certain foods with folic acid were associated with increased awareness of the role of periconceptional folic acid, increased folate consumption and a reduction in the prevalence of NTDs in South Australia by 40% (95% CI, 26%–52%).

Annabelle C Chan DPH, DCCH, FAFPHM · Phillipa van Essen BHSc, MPH · Heather Scott · Eric A Haan BMedSc, MB BS(Hons), FRACP · Leonie Sage RN, RM · Joan Scott RN, RM · Tiffany K Gill MAppSc, CertHealthEc, PostGradDipHlthSc · Anh-Minh T Nguyen BSc(Hons)

Objective: To describe the prevalence of neural tube defects (NTDs) in Victoria, and to evaluate women’s knowledge and awareness of the importance of folate after the introduction of voluntary food fortification.Design and setting: Descriptive study, set in Victoria, Australia, based on routinely collected data from the Victorian Birth Defects Register (VBDR) for 1998–2006, and responses by women aged 18–50 years to five questions relating to folate on the 2005 and 2006 Victorian Population Health Surveys (2314 and 2488 women, respectively). Main outcome measures: Prevalence of NTDs, and extent of women’s knowledge of the importance of folate in NTD prevention, comparing the period before and since voluntary food fortification and a folate awareness campaign.Results: The total prevalence of pregnancies affected by NTDs declined from approximately 17 to 14 per 10 000 births from 1997 to 1999 (coinciding with the period when voluntary food fortification was introduced, and a 1-year folate awareness campaign was held). It has since remained static. Over the 9-year study period, the termination of pregnancy rate was 79%, resulting in three NTD-affected babies per 10 000 livebirths. Compared with women aged 30–34 years (the reference group), those aged 20–24 years had the greatest likelihood of having a baby with an NTD (adjusted odds ratio, 1.70; 95% CI, 1.33–2.18; P < 0.001). Women aged 18–24 years had the lowest rate of folate supplement use (15.9% in 2006), while women aged 30–34 years had the highest rate (30.3% in 2006).Conclusions: There has been no further reduction in prevalence of NTDs in Victoria since 1999, and this prevalence remains well above that achievable through adequate folate intake. Accurate knowledge of folate consumption, population-based NTD prevalence data and folate awareness data are essential in monitoring the effectiveness of the mandatory fortification program to be implemented in Australia in the next 2 years.

Louise du Plessis BSc(Hons), MB ChB, FRACP · Rod W Hunt BM BS, MMed, PhD · Ashley S Fletcher BSc, MEpi · Merilyn M Riley BApplSc, GradDipEpi, Biostat · Jane L Halliday BSc, PhD

Chronic neonatal lung disease (CNLD) is defined as a supplemental oxygen requirement beyond 36 weeks’ postmenstrual age, with more severely affected infants requiring oxygen beyond a full-term-equivalent age. Low-flow supplemental oxygen facilitates discharge from hospital of infants with CNLD who develop hypoxia in air. There is a lack of data on the most appropriate minimum mean target oxygen saturation (Spo2) level. Reflecting a variety of clinical practices and infant comorbidities (frequency of oxygen desaturation, presence of pulmonary hypertension, retinopathy of prematurity, and adequacy of growth), the minimum mean target range for Spo2 during overnight oximetry should be 93%–95%. The effect of supplemental oxygen on carbon dioxide retention should be considered before deciding on an oxygen flow. Most infants with CNLD are not ready for discharge until their supplemental oxygen requirement is ≤ 0.5 litres per minute delivered through a nasal cannula. The safety of short-term disconnection from supplemental oxygen should be assessed before discharge. Assessment of oxygenation during sleep with continuous overnight oximetry or polysomnography is recommended when weaning infants from supplemental oxygen. Discontinuation of oxygen therapy is based on clinical assessments and documentation of adequate oxygenation in room air. There is limited objective evidence on which to base recommendations.

Dominic A Fitzgerald MB BS, PhD, FRACP · R John H Massie MB BS, PhD, FRACP · Gillian M Nixon MB ChB, MD, FRACP · Adam Jaffe MD, FRCPCH, FRACP · Andrew Wilson MB BS, PhD, FRACP · Louis I Landau MD, FRACP · Jacob Twiss MB ChB, FRACP · Greg Smith MB ChB, FRACP · Claire Wainwright MB BS, MD, FRACP · Margaret Harris MB ChB, FRACP

To the Editor: Despite expert recommendation, Australian states have yet to enact legislation requiring use of child restraints beyond the age of 12 months. Our analysis of police crash records and linked hospital separation data for the period July 2000 to June 2001 in New South Wales found that a large proportion of children who were hospitalised following motor vehicle accidents were reported by police as having used adult (standard) seatbelts at the time of injury (Box). It is of particular concern that over 80% of 5–8-year-olds in this cohort were using standard seatbelts rather than child restraints (eg, booster seats). This pattern of premature “graduation” to seatbelts has also been reported in general populations of child motor vehicle passengers both overseas1 and in Australia,2 and also in presentations of child motor vehicle passengers after a crash to a NSW hospital’s emergency department.3 Child restraints are specifically designed to provide crash protection for children’s anthropometrical dimensions. Standard seatbelts are not designed to accommodate children, so they are unlikely to achieve the good fit to rigid body parts required for safety. Consequently, use of standard seatbelts by young children allows more head excursion during a crash, thereby negating their primary goal of protecting against central nervous system injury, and potentially causing Chance fractures and abdominal injuries.4 Our results provide further evidence that such seatbelt use may not protect, or may even cause injuries, during a crash. Child road trauma is largely preventable or controllable with the use of appropriate child restraints, including booster seats. A cost–benefit analysis showed that the use of booster seats produced a benefit–cost ratio for road trauma prevention of 9.4 (US$1854/US$197).5 To prevent child road trauma in Australia, all child motor vehicle passengers should use appropriate child restraints. Australian child road safety stakeholders recommend that child motor vehicle passengers use appropriate restraint systems according to their height, weight and age when travelling on road. Our findings provide further justification for proposed legislative changes that would require the compulsory use of appropriate child restraints for child motor vehicle passengers. Child restraint use among children (0–8 years) hospitalised for injury after a motor vehicle accident, compared with that of the general population, New South Wales Hospitalised children* General population† Restraint use 0–4 years 5–8 years Total 0–4 years 5–8 years Total Child restraint 9 (22%) 0 9 (10%) 295 (94%) 70 (31%) 365 (68%) Adult seatbelt 11 (27%) 42 (82%) 53 (58%) 12 (4%) 153 (67%) 165 (31%) Unknown/ no restraint 21 (51%) 9 (18%) 30 (33%) 6 (2%) 4 (2%) 10 (2%) Total 41 (100%) 51 (100%) 92 (100%) 313 (100%) 227 (100%) 540 (100%) * Linked hospital and police data from July 2000 – June 2001 were accessed from the NSW Injury Risk Management Research Centre. Case selection is based on corresponding codes in the International Classification of Diseases, 10th revision, Australian modification, 2nd edition. † Based on a telephone survey conducted in NSW during 2005–2006.

Wei Du · Caroline F Finch · Lynne E Bilston

Consensus recommendations for managing bronchiectasis in Indigenous children and adults living in rural and remote regions were developed during a multidisciplinary workshop and were based on available systematic reviews. Successful diagnosis, management and prevention of bronchiectasis in Indigenous Australians requires access to comprehensive health care services, as well as improved housing, education and employment and reduced poverty levels. Diagnosis of bronchiectasis requires a chest high-resolution computed tomography scan. Children who have bronchiectasis symptoms but non-diagnostic scans are described as having chronic suppurative lung disease (CSLD), rather than bronchiectasis. Untreated CSLD may progress to bronchiectasis. Chronic wet cough (> 4 weeks) or recurrent wet cough (> 2 episodes/year) are important but often under-reported symptoms. Bronchiectasis is suspected when chronic cough is excessively prolonged (> 12 weeks) or if a chest radiographic abnormality persists despite appropriate therapy. Intensive treatment aims to improve symptom control and quality of life while preserving lung function and reducing acute exacerbation frequency. Antibiotics should be prescribed for acute infective episodes according to culture results of respiratory secretions, local susceptibility patterns and clinical severity. Patients not responding promptly to oral antibiotics should be hospitalised for more intensive treatment. Ongoing care requires regular primary health care and specialist review, including monitoring for complications and comorbidities. Corticosteroids, bronchodilators and mucoactive agents may be used in individual cases, but routine use is not recommended. Physiotherapy and exercise should be encouraged, nutrition optimised, environmental pollutants (including tobacco smoke) avoided, and immunisations maintained.

Anne B Chang MPHTM, PhD, FRACP · Keith Grimwood MB ChB, FRACP, MD · Graeme Maguire MB BS, FRACP · Paul T King MB BS, FRACP, PhD · Peter S Morris MB BS, FRACP, PhD · Paul J Torzillo MB BS, FRACP

Objective: To determine whether a 5-day course of oral prednisolone is superior to a 3-day course in reducing the 2-week morbidity of children with asthma exacerbations who are not hospitalised.Design, setting and participants: Double-blind randomised controlled trial of asthma outcomes following a 5-day course of oral prednisolone (1 mg/kg) compared with a 3-day course of prednisolone plus placebo for 2 days. Participants were children aged 2–15 years who presented to the emergency departments of three Queensland hospitals between March 2004 and February 2007 with an acute exacerbation of asthma, but were not hospitalised. Sample size was defined a priori for a study power of 90%.Main outcome measures: Difference in proportion of children who were symptom-free at Day 7, as measured by intention-to-treat (ITT) and per-protocol analysis; quality of life (QOL) on Days 7 and 14.Results: 201 children were enrolled, and there was an 82% completion rate. There was no difference between groups in the proportion of children who were symptom-free (observed difference, 0.04 [95% CI, − 0.09 to 0.18] by ITT analysis; 0.04 [95% CI, − 0.17 to 0.09] by per-protocol analysis). There was also no difference between groups in QOL (P = 0.42). The difference between groups for the primary outcome was within the equivalence range calculated post priori.Conclusion: A 5-day course of oral prednisolone confers no advantage over a 3-day course for children with asthma exacerbations who are not hospitalised.Trial registration: Australian Clinical Trials Registry ACTRN012605000305628.

Anne B Chang MPHTM, PhD, FRACP · Ronald Clark PhD, FRACP · Theo P Sloots BSc, PhD · David G Stone FRACP · Helen L Petsky BN · Donna Thearle BN · Anita A Champion BPharm · Coralie Wheeler BN · Jason P Acworth FRACP

To the Editor: Spriggs and Gillam1 recently evaluated the updated guidance on ethical conduct in human research from the National Health and Medical Research Council (NHMRC),2 with particular reference to paediatric consent. The introduction in 2007 of the National Ethics Application Form (NEAF; http://www.neaf.gov.au) represented an attempt to streamline the process of obtaining ethics approval from multiple human research ethics committees (HRECs) for multicentre research. In 2007, just prior to mandatory introduction of the NEAF, we submitted identical NEAFs to 13 HRECs, covering all Australian states and territories, for an epidemiological study into childhood empyema. All but one HREC accepted the NEAF, but, despite use of the same form by the majority, we identified a variety of inconsistencies. With regard to child consent or assent, 11 HRECs required a single child information sheet and consent form; one required two separate age-appropriate forms; and one questioned the planned involvement of children in the consent/assent process and did not require a child’s consent. This latter response arguably contravenes the United Nations Convention on the Rights of the Child, which provides for a child’s right to information in a form they can comprehend, whether or not they have the ability to make decisions.3 Other inconsistencies included the time taken to obtain approval, which ranged from 1 day to 197 days (median, 31 days). One HREC defined a child as being aged less than 18 years; the others used a cut-off of 16 years. One HREC responded that the application did not specifically address local Aboriginal and Torres Strait Islander peoples’ issues, which suggests that the NEAF may not be sufficient to cover such site-specific requirements. One HREC required plain-language translation of consent and information sheets, and another required Aboriginal translation. Also of concern, the NEAF requires justification for the inclusion of Aboriginal or Torres Strait Islander children and other groups where ethical considerations may be different, such as children with intellectual impairment or mental illness. This approach places the wrong emphasis on the desired outcome, which is to give due consideration to cultural, social, health, psychological and local issues that may introduce ethical concerns that are not the same for all children, and it risks exclusion of some children from research that is relevant to them. We suggest the NEAF should instead include a justification for exclusion of any children as a result of cultural or religious background or social or psychological problems. This would provide an alternative way of gathering information about ethically relevant issues, to ensure best practice in ethical conduct or research. Clearly, there is a lack of consistency across Australia in engaging children in research, including the consent/assent process. We believe that use of the NEAF alone is insufficient to rectify these inconsistencies, and now is the time to consider a single national ethics committee for Australia, similar to the National Research Ethics Service recently introduced in the United Kingdom (http://www.nres.npsa.nhs.uk).

Adam Jaffe · Roxanne E Strachan · Katrina J Williams

To the Editor: We read with interest Rey’s interpretation of the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (MTA).1 The MTA was a large randomised study comparing the impact of stimulant medication, behavioural treatment, a combination of the two, and standard community care on attention deficit hyperactivity disorder (ADHD).2 The treatment phase lasted 14 months, during which the children taking medication showed more improvement than the other groups. Participants were then allowed to change their treatment and, at 36-month follow-up, the outcomes in all groups were similar. Rey concluded that, if stimulant medication is not associated with sustained improvement, its place in the treatment of ADHD is limited. This conclusion overlooks two important points. First, the greater initial improvement in symptoms of ADHD associated with stimulant medication might be important both clinically and socially. The second point is the expected impact of a relatively brief intervention: is it really plausible that an independent effect of 14 months of controlled treatment will be detectable after a further 22 months of self-selected management? The observation that the 14-month treatment phase becomes progressively less relevant as time passes is perhaps not altogether unexpected. In the unmedicated group, the 23% non-compliance rate during the 14-month treatment phase indicated greater dissatisfaction with treatment than the 10% non-compliance in the medication groups (P < 0.005, χ2 test). This could imply a parental preference for more immediate relief of symptoms, even if it involves their child taking medication. Parental preference can be accommodated if the family and treating physician discuss and agree on a treatment plan, adjusted to optimise functioning. Far from indicating a diminished role for medication, the evidence from the MTA study suggests that the clinical approach would involve most individuals with ADHD being treated with stimulant medication at some stage. Stimulant medication treats symptoms; it is not curative. It is likely that the role of stimulant medication in the treatment of ADHD decreases as children mature. However, temporary relief of symptoms can be highly valuable for affected children and their families.

Alison Poulton · Ralph K H Nanan

In reply: Poulton and Nanan question my statement that the role of psychostimulant medication in attention deficit hyperactivity disorder (ADHD) becomes less prominent when the 3-year results of the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (MTA) are taken into account.1 Studies such as the MTA that report dramatic short- to medium-term improvement have, in my experience, increased practitioners’ expectations and reliance on these medications. Their clinical use has gradually widened to preschool-aged children and to the, so far, poorly validated inattentive and impulsive–hyperactive subtypes of ADHD. I observe this increasing the pressure on parents — not necessarily from clinicians — to use stimulants through an emphasis on the consequences of non-treatment, such as underachievement and conduct problems. The 3-year follow-up of the MTA brings the early findings into perspective: a carefully titrated medication regimen produces no better results 3 years later than behavioural treatment and standard community care.2 In that sense, the role of stimulants versus other interventions has shrunk, and conscientious practitioners will inform parents and children of these findings when examining treatment options. My editorial did not query the many short-term benefits of stimulants but raised questions about when, and for how long, they should be used. Poulton and Nanan rightly emphasise that stimulants are a “symptomatic” treatment. Further, stimulants increase the ability to concentrate and be on task whether or not individuals meet criteria for ADHD.3 This is further compounded because ADHD, like intellectual disability in the case of intelligence, represents the extreme of a dimension of behaviour.4 The boundary between illness and non-illness depends on where you draw the line, not on qualitative differences. However, there is no good tool to measure ADHD, unlike intelligence, and asessment depends on clinicians’ thoroughness and skill, and on informants, who may or may not be reliable. The situation with ADHD is also similar to that for nocturnal enuresis, another disorder that lessens with increasing age, although it may persist. While behavioural treatment (the bell and pad alarm) is effective for enuresis, families and clinicians prefer using medication, even though the latter is “symptomatic” treatment and potentially harmful.5 This may be an alternative explanation for the higher non-compliance rate in the non-medicated group: behavioural treatments place more demands on parents, children and schools than a pill.

Joseph M Rey

Two children with advanced lung disease underwent successful cadaveric bilateral lobar lung transplantation, using lungs “cut down” from deceased adult donors — the first reported use of the technique in Australia. This approach, while it cannot address the lack of donor organs, may enable us to redress any size bias limiting paediatric lung transplantation. Clinical recordsPatient 1A previously healthy 9-year-old girl presented in early 2007 with an upper respiratory tract infection that progressed over 10 days to respiratory failure, requiring intubation and ventilation with high inspiratory pressures. Subsequent tracheal aspirates were positive for Mycoplasma (by polymerase chain reaction), with consistent serological results (antibody titres, 1 : 640). Computed tomography of the chest demonstrated widespread bronchiectasis (Box 1, A). Although she was extubated 6 weeks after initial presentation, she remained in hypercapnic respiratory failure (Pco2, 80 mmHg), requiring continuous oxygen supplementation (5 L/min) and bilevel non-invasive positive-pressure ventilation (BiPAP). She was listed for lung transplantation in May 2007, but, given the severity of her lung disease and in the absence of appropriately matched donor organs, the transplant team gave early consideration to cadaveric bilateral lobar transplantation using an adult “oversized” donor. This was performed in August 2007. Patient 2A 13-year-old girl with cystic fibrosis was referred for consideration of lung transplantation. She had been diagnosed with cystic fibrosis at birth (Δ508 homozygous, without liver, sinus or diabetic sequelae), and over the preceding 2 years developed progressive bronchiectasis (Box 1, B), necessitating supplemental oxygen and initiation of nocturnal BiPAP. She was initially listed for either lung transplantation or heart–lung transplantation; however, after 9 months of progressive respiratory failure (Pco2 increased to 46 mmHg; forced expiratory flow in 1 second [FEV1], 16%; forced vital capacity [FVC], 28% predicted), the transplant team considered cadaveric bilateral lobar transplantation, which was performed in September 2007. Surgical procedure and clinical courseBoth children underwent cadaveric bilateral lobar transplantation as described by Starnes and colleagues1 for living-related lung transplantation. Briefly, the donor right lower lobe was resected, and the right upper and middle lobes were implanted, the anastomosis being performed at the right main bronchus. On the left, the inferior pulmonary vein, interlobar artery distal to its lingular branch, and bronchus were transected, and the lower lobe removed. Size mismatch was compensated for by seating the donor bronchus inside the recipient bronchus, while pulmonary vessel mismatch was taken up in the suture lines. Neither patient required cardiopulmonary bypass, and resected lobes were not used further. Following surgery, both children were established on an internationally standardised immunosuppression regime, comprising prednisolone, tacrolimus and mycophenolate mofetil.2 Both patients made a good postoperative recovery, with short intensive care unit stays. Patient 1 required a longer inpatient stay for treatment of pneumonia. Neither patient developed allograft rejection, and lung function gradually improved (Box 2). Both patients were discharged to their respective tertiary hospitals for continuing follow-up. Both patients were well and without complication at follow-up 10 and 9 months postoperatively, respectively. DiscussionTo our knowledge, these are the first reported cases of cadaveric bilateral lobar transplantation in Australia. They demonstrate its efficacy as a means of reducing waiting-list mortality for paediatric lung transplantation recipients. Lung transplantation is now an established treatment for patients with severe end-stage lung or pulmonary vascular disease. Despite attempts to increase organ donation worldwide, the number of patients requiring lung transplantation far exceeds the availability of donor lungs. In Australia, this is of particular concern for children awaiting appropriate size-matched donor organs.3 Review of the Australian and New Zealand Organ Donation Registry between 2002 and 2006 revealed that very few lungs are retrieved from paediatric donors younger than 14 years (26/497 lung donors).4 The number of children with severe lung disease warranting consideration of lung transplantation, both globally and in Australia, is, fortunately, very small. The most recent data from the International Society for Heart and Lung Transplantation show that only 65 paediatric lung transplantations were performed worldwide in 2005.2 However, of concern is that waiting-list mortality is greater for children than for adults — a worrying trend as fewer paediatric lung transplantations have been performed per annum, while adult lung transplantation numbers have increased.5 In Australia during 2006, 181 donor lungs were offered for lung transplantation, with only seven paediatric donors contributing, all of whom were aged 6–14 years (Ross Pettersson, Australian and New Zealand Cardiothoracic Organ Transplant Registry and Heart Transplant Data Manager, St Vincent’s Hospital, Sydney, NSW, personal communication). Despite an active policy of utilising “extended” donor organs (eg, from older donors or donors with previous cancer, smoking or aspiration history) wherever possible, only 30%–50% of available lungs are actually suitable for transplantation,6 further diminishing the number of available donor lungs, which is low by international standards.7 In the absence of appropriately size-matched organs, children from our institution have died while on the waiting list (2/9 listed in 2000–2007); after reviewing the 2007 donor referrals, it became apparent that the children described here would most likely have died while waiting. Minimising paediatric waiting-list mortality requires consideration of non-traditional donor sources, such as live donors, who have been used in small numbers in the United States and Japan.8 The technique involves a bilateral lobar transplantation, typically taking one lobe from each of two larger, usually related, adult donors. Outcomes for living-donor bilateral lobar transplantation are similar to cadaveric lung transplantation, but there are significant ethical and technical issues with such an approach, and a potential 300% mortality rate. The number of these procedures being performed is declining.5 To our knowledge, no centre presently offers this service in Australia. In adults, cadaveric lungs have been cut down to facilitate lung transplantation where size mismatch between donor and recipient could prevent transplant.9 Typically, this involves non-anatomical “lung shaving” or anatomical lobar resection. Rarely is this a bilateral extensive procedure, given the potential complications, including persistent air leaks, airway stenoses and stump dehiscence. Lobar transplantation is not specific to lung transplantation and has become common practice in liver transplantation; lessons may be learned from these experiences.10 Paediatric lobar transplantation has not been widely performed outside of the living-related scenario, but despite the additional surgical complexity, outcomes have proven comparable to cadaveric lung transplantation.8,9 Starnes and colleagues’ work suggests our two patients can be expected to ultimately achieve near-normal lung function,11 and their total lung capacity will increase as they grow.12 Cutting down cadaveric adult donor lungs for use in paediatric recipients raises ethical and practical issues about removing donor lungs from an already insufficient adult pool. Should lungs that might “perfectly” match an adult be cut down for a paediatric patient? Is a child more deserving than an adult? Our approach to reducing waiting-list mortality is to perform transplantation on recipients with the most severe lung disease at the first opportunity, and both these children satisfied that criterion. In conclusion, our cases illustrate the difficulty experienced by many centres in acquiring an adequate number of donor lungs to service the needs of the paediatric lung transplantation waiting list. Using cut-down adult donor lungs had a good outcome in both our patients. Such an approach is likely to expand the donor pool available for children needing lung transplantation, thereby reducing the high waiting-list mortality experienced by this age group. 1 Computed tomography scans of the two patients’ lungs before transplantation A: Patient 1 had cysts and lung destruction after Mycoplasma infection (arrows). B: Patient 2 had severe cystic fibrosis-related bronchiectasis (arrows). 2 Clinical course after cadaveric bilateral lobar transplantation in two children Patient ICU days Hospital days Respiratory infection in first 3 months Biopsy (ISHLT grade) 30 days 90 days 180 days FEV1 (% pred) FVC (% pred) FEV1 (% pred) FVC (% pred) FEV1 (% pred) FVC (% pred) 1 2 27 Pseudomonas, Staphylococcus A0 0.89 (40%) 0.90 (37%) 1.02 (46%) 1.33 (54%) 1.26 (55%) 1.81 (78%) 2 2 11 Staphylococcus A0 1.12 (72%) 1.27 (71%) 1.17 (75%) 1.45 (81%) 1.11 (63%) 1.66 (94%) ICU = intensive care unit. ISHLT = International Society for Heart and Lung Transplantation. FEV1 = forced expiratory flow in 1 second. pred = predicted. FVC = forced vital capacity.

Dominic T Keating MD, MRCPI · Glen P Westall FRACP, PhD · Silvana F Marasco MS, FRACS · Jacquie H Burton DipAppSci(Nursing), BN, GradDipPaed · Mark R Buckland MB BS, FANZCA · Colin F Robertson MSc(Epi), MD, FRACP · Trevor J Williams MB BS, FRACP, MD · Gregory I Snell MB BS, FRACP, MD

To the Editor: Australian consensus guidelines for selecting formulas for infants with cows milk protein allergy (CMPA) have recently been published.1 We reviewed formula choices and outcomes for 51 children with immediate allergic reactions to cows milk protein who were referred to one of us (S S M) in a tertiary specialist clinic over a 2-year period before the guidelines were published. The formula was selected by the referring specialist medical practitioner in 44 cases (and by S S M in the other seven). Of the 51 children (mean age at initial reaction to cows milk protein, 7.8 months), 42 had skin and/or gastrointestinal features, and nine had an anaphylactic reaction with respiratory and/or cardiac features. Forty-six children had a positive skin prick test to cows milk protein, and one had a positive radioallergosorbent test. Four children with immediate (< 30 min) reactions of generalised erythema and/or angioedema (3) or vomiting (1), but a negative skin prick test, were also included. Soy was the most common formula used, followed by extensively hydrolysed formula (EHF) (Box). Three of eight children commenced on EHF had allergic reactions, with urticaria and angioedema, and one child also had a transient (60 s) cough. Three children were given partially hydrolysed formula (PHF), with one experiencing an immediate cutaneous reaction. These observations suggest that, in clinical practice, soy is frequently a satisfactory first choice for children with CMPA, as suggested in the guidelines.1 Some children with CMPA will also react to EHF, providing a rationale for choosing amino acid-based formula as a first-line treatment prior to allergy evaluation in children with anaphylaxis to cows milk protein. As about 5% of infants with CMPA also react to EHF,2 some allergists advocate the introduction of EHF under medical supervision in either all children with immediate CMPA3 or only those who have had severe life-threatening reactions.4 Although PHF is tolerated by a significant proportion of children (70%) with immediate CMPA,3 it is not recommended for the treatment of CMPA1 due to its high content of potentially allergenic cows milk protein. The fact that three children with CMPA were given PHF suggests there is confusion in the prescribing community, and that the availability of the new guidelines may help in achieving a more appropriate choice of formula. Feeding choice for 51 children referred with cows milk protein allergy Type of feeding selected No. of children Mean age at initial reaction to cows milk (months) No. who reacted to selected feeding Soy 29 9.5* 0 Extensively hydrolysed formula (EHF) 8 5.3 3 Amino acid-based formula (AAF) 6 4.2 0 Partially hydrolysed formula (PHF) 3 6.0 1 Breastfeeding 5 6.0 0 * P < 0.05 for soy versus PHF, EHF, AAF or continuing to breastfeed (t test).

Sam S Mehr · Andrew S Kemp

Re: “Bystander basic life support: an important link in the chain of survival for children suffering a drowning or near-drowning episode”, by Jeanette Marchant, Nicholas G Cheng, Lawrence T Lam, Fiona E Fahy, S V Sounndapound, Danny T Cass and Gary J Browne, in the 21 April 2008 issue of the Journal (Med J Aust 2008; 188: 484-485). The fifth author’s name was spelled incorrectly. The correct spelling of the author’s name is S V Soundappan. The web version of this article was corrected on 2 June 2008.

Jeanette Marchant · Nicholas G Cheng · Lawrence T Lam · Fiona E Fahy · S V Soundappan · Danny T Cass · Gary J Browne

Accurate data about Indigenous child health is vital to enable us to understand its current state, to acknowledge achievements, and to determine how to reduce inequalities between Indigenous and non-Indigenous children. We have identified a paucity of national, or nationally representative, data relating to Indigenous child health outcomes, and significant deficiencies in available data. A coordinated national approach will help address current data limitations, including lack of identification of Indigenous status, lack of currency, and lack of information about specific health disorders affecting Indigenous children. To ensure that health data collected are relevant and useful, Indigenous communities must have a role in data collection and management.

Emily Fremantle BA(Hons) · Yvonne A Zurynski BAppSc, MAppSc, PhD · Deepika Mahajan BSc(Hons), MSc, PhD · Heather D’Antoine BAppSc, MHEc · Elizabeth J Elliott MD, FRACP, FRCPCH

Objective: To determine whether installation of swimming pools in remote Aboriginal communities reduces infection-related outpatient attendances and prescription of antibiotics.Design and setting: Swimming pools were opened in Jigalong and Mugarinya, Western Australia, in September 2000. We examined local clinic records to document illnesses occurring in children and adolescents under 17 years of age between 1998 and 2005. In Jigalong, we examined records of those enrolled in an ongoing study evaluating the effect of swimming pools on health. In Mugarinya, we examined clinic records of those residing there permanently.Main outcome measures: Clinic attendance rates for skin, middle-ear and respiratory tract infections and trauma, and prescription rates for antibiotics were analysed by using a community-based selection method in Jigalong, and a clinic-based selection method in both communities for comparison of the two communities and the two methods.Results: We examined records of 131 children in Jigalong and 128 children in Mugarinya. After the pools had been installed, clinic attendance rates for skin infections declined by 68% in Jigalong and by up to 77% in Mugarinya. In Jigalong (where the pre-pool prevalence of infections was higher than in Mugarinya), rates of antibiotic prescription declined by 45%, as did clinic attendance for middle-ear infections (61% reduction) and respiratory tract infections (52% reduction).Conclusion: Swimming pools in remote communities are associated with reduced prevalence of skin infections. Where disease prevalence is high, pools are also associated with reduced rates of antibiotic prescriptions and middle-ear and respiratory tract infections. In communities with resident health staff, examination of clinic records is an efficient method of monitoring the effects of public health interventions on the burden of infectious diseases.

Desiree T Silva FRACP, MPH · Deborah Lehmann MB BS, MSc · Mary T Tennant RN, BAppSc, MPH · Peter Jacoby MSc · Helen Wright MB BS, FRACP · Fiona J Stanley MD, FAFPHM, FRACP

Reducing the growing burden of food allergy requires a chronic disease management model, clarification of responsibilities, and better communication of both risks and uncertainties Food allergy and anaphylaxis are increasing in the Australian community, particularly in preschool-aged children,1,2 although, paradoxically, mortality occurs almost exclusively in school-aged children and adults.3 Food allergy and anaphylaxis are high-stakes and highly uncertain issues, where the outcome may be the sudden and unpredictable death of a child.4 The concept that a patient is “at risk” inevitably invokes uncertainty. It is possible to prospectively identify those at risk by virtue of having food allergy, but diagnostic tests are not highly predictive of anaphylaxis. The population with food allergy is substantially larger (about 10–20-fold) than the population who will experience anaphylaxis. Patients and their carers therefore live with being at risk, while not knowing exactly what the nature or extent of the risk is. In clarifying what we mean by “anaphylaxis risk”, the conventional wisdom in risk communication literature is to avoid essentially meaningless terms such as “potential risk” or “high risk” and to instead employ techniques that more accurately convey quantitative estimates of risk. This is risk as numbers, or “the probability that an event will occur, eg, that an individual will become ill or die within a stated period of time”.5 Mortality figures for food anaphylaxis in New South Wales show that the numerical risk that a teenager allergic to peanut or tree-nut will die from anaphylaxis in the next year lies between 1 in 10 000 and 1 in 100 000 — in the same order as the chance of an Australian resident being murdered in the next year.6 The risk that a child aged under 5 years will die from food anaphylaxis in the next year lies between 1 in 1 million and 1 in 10 million — the same order as the risk of death from being struck by lightning.6 However, there are problems with this numerical approach to risk assessment: the data to calculate probabilistic risk for anaphylaxis are either unavailable or not generalisable; numerically small risks are difficult to communicate; and death by lightning or violence is not necessarily viewed in the same way as a child dying from eating food. Due to its emotive characteristics, the risk of food anaphylaxis is likely to be appreciated by experiential rather than analytical cognitive processes,7 which are intuitive, automatic, and greatly influenced by associations and affect. Fear of the unpredictable death of a child may outweigh any rational consideration of its numerical likelihood. Care must therefore be taken when discussing anaphylaxis risk with patients and parents, with a key consideration being the need to sensitively communicate uncertainty as much as communicate risk. As food is essential, some exposure to risk is unavoidable. Although food labelling is becoming clearer, there are persistent uncertainties about mislabelling and cross-contamination with allergens, coinciding with broader concerns about food quality and production, and societal expectations that parents and others will provide safe food for children. Accordingly, food allergy is as much a sociocultural as a medical issue, and, for some, the constant obligation to make careful decisions about what to eat or feed their child, together with ongoing uncertainty about the risks, can create an enormous burden. Reducing this burden requires a coordinated and intersectoral response, from consumers, the health care, teaching and childcare professions, the food and pharmaceutical industries, and statutory bodies at both state and federal level. Clarification of responsibilities is required for food labelling and production, care in schools and preschools, anaphylaxis education (involving anaphylaxis recognition and risk minimisation, as well as correct use of EpiPen autoinjectors [CSL Limited, Melbourne, Vic]), and monitoring EpiPen use. It is encouraging that, in recent months, the Victorian Government has announced legislation mandating a school anaphylaxis management standard8 and the Western Australian Government has committed $6.6 million to a program of interventions.9 Nevertheless, as with other “messy” and uncertain problems, pure science and rationality alone are not sufficient.10 In formulating policy, the process of representation, clarification of common aims and interests, and debate over what we mean by “anaphylaxis risk” may be more important for developing a coherent and coordinated framework for action than would identifying an elusive “right” response. At the service provision level, there has been a tendency for medical treatment of an acute emergency to be the focus of food allergy management. Emergency treatment itself brings additional uncertainties — guidelines for EpiPen prescription leave much to individual judgement, and one study found that only 2% of doctors in a major Australian paediatric teaching hospital could correctly demonstrate all steps in EpiPen administration.11 Fortunately, despite the many uncertainties, most food-allergic patients are generally well and the EpiPen is appropriately unused. Nevertheless, it is more appropriate for food allergy, with its unpredictable “exacerbations” or reactions, and its requirement for community management of risks, to adopt a chronic disease management model, centring on self-management, patient and carer education, continuity of care and multidisciplinary services. Such an approach, including ongoing support from dietitians and nurse educators, is likely to reduce the uncertainties of daily management. The need for parent and carer education is evidenced by an Australian survey of EpiPen use, which found that only 29% of parents administered the EpiPen when indicated.12 Parental satisfaction with information provision is also associated with less seeking of second opinions.13 Thus, adequate parent and carer education and follow-up may ease pressure on referral services, which currently have 10–14-month waiting times for hospital paediatric allergy consultations. The uncertainties surrounding food allergy arise from a lack of scientific, epidemiological and personal knowledge, the need to negotiate between different sectors and interests, and ambiguous language and concepts that are difficult to communicate. Different responses are required at interpersonal, service delivery and policy levels. While some uncertainties are irreducible, patients and carers are also experiencing unnecessary uncertainties. What is certain is that food allergy has become a significant concern for public health, paediatric and general medical practice.

Andrew S Kemp MB BS, PhD, FRACP · Wendy Hu MB BS, PhD, FRACGP

Objective: To describe the influenza-related morbidity and mortality in healthy children aged under 5 years in South Australia, in order to further understand the potential role of influenza vaccination.Design and setting: We undertook a descriptive analysis of SA hospital separations data and Australian Bureau of Statistics death data for children aged under 5 years admitted to hospital for influenza. All diagnoses related to an influenza admission were examined to determine whether children were at risk of complications from influenza, according to the criteria of the National Health and Medical Research Council.Main outcome measures: Mean influenza admission rates per 100 000 population per year in children aged under 5 years between 1996 and 2006, and the proportion of children admitted to hospital who did not have a secondary diagnosis putting them at higher risk of influenza-related complications.Results: From 1996 to 2006, 649 children aged under 5 years were admitted to hospital for influenza. Mean annual admission rates per 100 000 were highest in children aged under 1 year (151.0), and decreased with age. Aboriginal and Torres Strait Islander children aged under 5 years had a mean admission rate of 161.8 per 100 000. Most children under 5 years (81%) admitted to hospital did not have an underlying illness that would put them at risk of influenza-related morbidity.Conclusion: Healthy children aged under 2 years and Aboriginal and Torres Strait Islander children under 5 years old have high rates of hospital admission, which may have implications for the target group recommendations for influenza immunisation. Currently, vaccination is recommended only for children with specified chronic diseases.

Katina D’Onise MPHTM, FRACGP · Jane C A Raupach MPH, FAFPHM, FRACGP

Eight children suffered drowning or near-drowning in Sydney pools over an 11-day period in January 2007. Four received basic life support (BLS) within 5 minutes of immersion and survived with good functional neurological outcomes. The other four were not discovered for ≥ 5 minutes and all died. This cluster serves as a reminder that timely effective bystander BLS is crucial to survival and good clinical outcomes in near-drowning episodes. Clinical recordDuring an 11-day period in January 2007, eight children presented to several emergency departments in the Sydney metropolitan region after a drowning or near-drowning event. While these incidents are known to be more common in summer, it is relatively uncommon to have such a cluster of cases occurring within a short period of time. We retrospectively obtained information on these patients from clinical documentation of the hospitals involved, including ambulance run-sheets, hospital medical records, and coroner’s reports. Details of the patients are shown in Box 1. Seven of the children were from western Sydney, while the other child presented to a hospital in North Sydney. Six were girls and two were boys, with ages ranging from 1.5 to 6 years. In all cases, the children had not been adequately supervised. In seven cases, the approximate period of time for which the child had been unaccounted could be determined from the records. This time ranged from about 1 minute to 20 minutes. Seven of the events occurred in backyard residential swimming pools and the other in a public pool. Three episodes occurred while children were visiting relatives; these children all drowned. Four children had a period unaccounted for of < 5 minutes. Timely effective basic life support (BLS) (defined as adequate ventilation and/or chest compression administered within 5 minutes of non-breathing1) was performed on each of these children by either their parent or a bystander. One patient regained consciousness and BLS was ceased. All four children survived without any neurological deficits. Of the other four children, three had a period unaccounted for of ≥ 5 minutes and one for an unknown time, estimated by the paramedics at the scene to be about 10–20 minutes. BLS was attempted on only one of these four patients. Two of these children died in the emergency department, and the other two had intensive care support withdrawn due to brain death. DiscussionOver the past 10 years, there has been a significant reduction in the number of drowning and near-drowning events in children.2 Several factors have contributed to this decrease, including community education programs alerting parents to the importance of supervising their children; legislation to place fences around backyard swimming pools, and efforts to teach effective BLS in the community.3-5 However, evidence is lacking of good compliance with these preventive measures, particularly backyard pool fencing,6 highlighting the need to continually stress water safety messages to parents. In addition, a recent paradigm shift in resuscitation guidelines, coupled with differences in interpretation of the new guidelines by various resuscitation authorities, has led to confusion among lay rescuers and clouded the key messages that should be delivered to the public.7,8 It is recommended that the guidelines published by the Australian Resuscitation Council should be followed (Box 2).7 Of the eight patients reported here, four received timely effective bystander BLS and had a good clinical outcome. For the other four children, BLS was attempted late or not at all. It is possible that the prognosis of these four children would not have been good even with BLS, given their probable long duration of immersion. Even for children with a period unaccounted for of < 5 minutes, the likelihood of neurological damage increases if effective BLS is not provided immediately. Hence, timely effective BLS is not just crucial for survival but also important for a better clinical outcome. There are avenues for lay people to be trained in BLS, but doing so often requires considerable motivation, as there is a monetary and time burden involved, and retraining is required as guidelines change and skill levels deteriorate. Although community attitudes toward BLS are positive, theoretical knowledge of BLS is poor.9 At our emergency department, when parents are asked about their willingness and ability to perform BLS should their child need it, few respond positively. We believe that a more uniform community effort is required to ensure this vital link in the chain of survival, when the primary prevention measures of supervision and fencing fail. This effort could include universal provision of BLS training in workplaces and in high schools. 1 Details of eight children involved in drowning or near-drowning events in Sydney, January 2007 Patient no. Age (months) Incident location Time unaccounted for (min)* Time to BLS after retrieval Who gave BLS Outcome† 1 49 Relative’s home 20 na na Died in PICU 2 23 Own home < 5 Immediate Medical doctor‡ Survived 3 47 Own home 2–3 Immediate Mother Survived 4 26 Relative’s home 20 Immediate Father Died in PICU 5 17 Relative’s home 5–10 na na Died in ED 6 42 Own home 1–1.5 Immediate Father Survived 7 29 Public pool < 5 Immediate Bystander Survived 8 72 Own home 10–20 na na Died in ED BLS = basic life support. ED = emergency department. na = not applicable because BLS not given. PICU = paediatric intensive care unit. * Best estimate of the period of time the child was unaccounted for (ie, possible duration of immersion). † All children who survived had no neurological deficit. ‡ Present at the time of the event. 2 Basic life support flow chart*7 CPR = cardiopulmonary resuscitation. * Reproduced with permission of the Australian Resuscitation Council.

Jeanette Marchant MB ChB, DCH, MRCPCH · Nicholas G Cheng MB BS, DCH, FRACP · Lawrence T Lam MAppPsy, MPH, PhD · Fiona E Fahy RN, RM, MN(Perioperative) · S V Soundappan MB BS, MS(General Surgery), MCh(Paediatric Surgery) · Danny T Cass MB BS, PhD, FRACS · Gary J Browne MD, FRACP, FACEM