Child health

Objective: To identify the adequacy of first aid care following minor burns in children.Design: Prospective case series.Setting: Emergency Department and Acute Wound Clinic, the Children's Hospital at Westmead (CHW), Sydney.Participants: 109 children who presented with minor burns (10% body surface area or less) to CHW over the five months from 2 November 1998 to 23 March 1999.Main outcome measures: Comparison of the adequacy of first aid delivered by parents and carers, general practitioners, local hospitals, and CHW.Results: Burns included scalds, contact, flame, chemical or electrical burns. Adequate initial first aid had been given by parents or carers in only 24 of 109 cases (22%). The 85 children who presented to medical care after inadequate initial first aid was given by parents or carers included 14 of 14 (100%) who had presented to their general practitioner (GP), 22 of 31 (71%) who had presented to their local hospital, 22 of 38 (58%) who had presented to CHW, and 2 of 2 (100%) who had had first contact with other health professionals.Conclusions: This study shows that there is a need to educate parents and health professionals regarding appropriate first aid for burns.

Rebecca A McCormack MB BS(Hons), RN, GradDipMid · Erik R La Hei MB BS, FRACS · Hugh C O Martin MB BS, FRACS, FRCS

Background: In 1941, a Sydney ophthalmologist, Norman McAlister Gregg, correctly identified the link between congenital cataracts in infants and maternal rubella early in pregnancy. Fifty of Gregg's subjects with congenital rubella, born in 1939–1944, were reviewed in 1967 and again in 1991. We reviewed this cohort in 2000–2001, 60 years after their intrauterine infection.Methods: The subjects underwent full clinical assessment, plus pathology tests, an ophthalmological and cardiological review (including electrocardiography and echocardiography) and HLA histocompatibility testing.Results: Since they were first seen in 1967, 10 have died (cardiovascular causes [4], malignant disease [4], AIDS [1], and hepatitis C-related cirrhosis [1]). All surviving men came for review (19) and 13 women (eight women declined). Echocardiography showed mild aortic valve sclerosis in 68%. The prevalence of diabetes (22%), thyroid disorders (19%), early menopause (73%) and osteoporosis (12.5%) was increased compared with the Australian population; 41% had undetectable levels of rubella antibodies. The frequency of HLA-A1 (44%) and HLA-B8 (34%) antigens was increased, and the haplotype HLA-A1, B8, DR3, said to be highly associated with many autoimmune conditions, was present in 25%.Conclusions: This cohort of people with congenital rubella has illuminated our understanding of viral teratogenesis.

Jill M Forrest MD BS · Fiona M Turnbull MB, ChB · Gary F Sholler MB BS, FRACP · Richard E Hawker MB BS, FRACP · Frank J Martin FRANZCO, FRACS · Margaret A Burgess MD, FRACP · Trevor T Doran MSc, PhD

Current controversy about diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) reflects the divergence between developmental and non-developmental approaches. While there is growing evidence for biological vulnerabilities associated with ADHD, we believe that environmental factors, including early problems in parental attachment, are also important in determining the type and timing of deficit that a child develops, the risk to academic and social performance and eventual outcome. We warn against labelling children with ADHD simply because they fulfil the cross-sectional diagnostic symptom criteria of the Diagnostic and statistical manual of mental disorders — 4th edition (DSM-IV). We advocate an integrated biopsychosocial approach to diagnosis and management with a thorough developmental assessment to identify developmental factors, such as deficits in early attachment, contributing to the presentation.

George Halasz MRCPsych, FRANZCP · Alasdair L A Vance MD, FRANZCP

Ted Stuckey epitomised "quiet achievement". Born on 15 June 1908, he grew up in Inverell, in northern New South Wales, where he was dux of his school. Later, as a medical student living at St Andrew's College, Sydney University, he excelled academically and in sport. He represented the College in rowing, and played hockey for the College, the University, and a combined Australian universities' team. After doing his residency at the Royal Prince Alfred Hospital and the Royal Alexandra Hospital for Children (RAHC), Ted married Joan Vowell and moved into general practice in Scone, NSW. While working in this practice he obtained his Master of Surgery degree. Ted returned to Sydney in 1939 to become a paediatric surgeon, and was appointed Honorary Relieving Assistant Surgeon at RAHC. When war intervened, he joined the Field Ambulance Service. He served until late 1944 in Queensland, then New Guinea, becoming second-in-charge of the 111th Casualty Clearing Station and attaining the rank of Major. From 1945, as Honorary Assistant Surgeon at RAHC, Ted and his colleagues did pioneering work in cardiothoracic and abdominal surgery. Ted's brother Doug was also part of the Congenital Heart Disease team that was involved in the early development of cardiac catheterisation and angiocardiography. In 1948, Ted gained his Fellowship of the Royal Australasian College of Surgeons. In 1958 he was awarded a Fulbright scholarship to study at Harvard Medical School. From 1958 to 1966 he lectured in paediatric surgery at the University of Sydney. He continued at RAHC as an Honorary Consultant Surgeon until 1973. In later years, Ted adopted a more relaxed lifestyle, doing sessional work with the Commonwealth Health Department until 1988 and Surgical Assistant work until 1994 (then aged 86!). Ted was a founding member of the Medical Benefits Fund in 1945 and served on its Council until 1971. He was also heavily involved with the Australian Medical Association. He was a member (1953–1966) and president (1961–1962) of the NSW Branch Council; a member of the AMA Federal Council (1964–1966); Assistant General Secretary, then Deputy Secretary General (1966–1972); and Secretary General (1972–1973). He was made a Fellow of the AMA in 1964. He was secretary of the AMA/benefit fund working party, which produced a plan for a voluntary health insurance scheme that was largely adopted by the federal government and introduced in 1970. He was also a member of the Medical Benefits Schedule Advisory Committee. Although deeply committed to his profession, Ted remained a devoted husband and father to his five children. Over the years, he built for his family a swimming pool, a terraced garden with a badminton court, and three unique folding caravans in which he loved to take them on camping holidays. Ted died on 7 June 2002 of acute renal failure.

Michael EV Stuckey MB BS FRCS FRACS

Significant perinatal distress and depression affects 14% of women, producing short and long term consequences for the family. This suggests that measures for early detection are important, and non-identification of these women may exacerbate difficulties. Screening provides an opportunity to access large numbers of women and facilitate pathways to best-practice care. A valid, reliable, ...

Anne E Buist MD, FRANZCP · Jeannette Milgrom PhD, FAPS · Bryanne E W Barnett MD, FRANZCP · Sherryl Pope PhD · John T Condon MD, FRANZCP · David A Ellwood MA, DPhil, FRACOG, FRANZCOG · Phillip M Boyce MD, FRANZCP · Marie-Paule V Austin MD, FRANZCP · Barbara A Hayes DNSc, FRCNA

While we have learnt much of the molecular and immunological basis of childhood asthma and treatment has changed dramatically, the impact on lifestyle, especially in early childhood, has not moved forward as rapidly. This is predominantly due to the difficulty of collecting objective data on the very young. To understand the causes of asthma and improve outcomes, with particular emphasis on primary prevention, it is ...

Craig M Mellis MD, MPH · Louis I Landau MD, FRACP

What we knowWhat we need to know

Louis I Landau MD FRACP

What we knowWhat we need to know

Peter N Le Souëf MD FRACP

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Colin F Robertson MD, FRACP

What we knowWhat we need to know

Karen O McKay LLB, PhD · James C Hogg MD, PhD

What do we know?What do we need to know?

Gary P Anderson PhD

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David Isaacs MD, FRACP, FRCPCH · Preeti Joshi PhD, FRACP

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Andrew S Kemp PhD, FRACP

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Stephen M Stick MD, PhD, FRACP

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Richard L Henry MD, FRACP

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Stephen M Stick MD, PhD, FRACP

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Sandra D Anderson PhD, DSc

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Peter P Van Asperen MD, FRACP

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Gary P Anderson PhD

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Peter N Le Souëf MD, FRACP

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Susan M Sawyer MD, FRACP

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Mimi LK Tang FRACP, FRCPA

What we knowWhat we need to know

Craig M Mellis MD, MPH

Improving glycaemic control in children and adolescents presents unique problems Type 1 diabetes affects one in 500 children and adolescents, and vascular complications remain a major cause of mortality and morbidity in adult life. Blood glucose targets have fallen since confirmation of the unequivocal relationship between glycaemic control and microvascular complications.1,2 In this issue of the Journal (page 235), Craig et al present a population-based, cross-sectional study of 1190 children and adolescents with type 1 diabetes in New South Wales and the Australian Capital Territory.3 Their median HbA1c level of 8.2% probably reflects some selection bias, because 571 (33%) of the population did not participate. However, this level of glycaemic control still represents a considerable improvement over the past 10 years4 and is comparable to levels found in international studies of children with type 1 diabetes.5 This trend accompanies the increasing use of intensive management in children and adolescents, but also the worrying rise in the incidence of severe hypoglycaemia. There are compelling reasons to recommend intensive therapy in adolescents with type 1 diabetes — either multiple daily injections or continuous subcutaneous insulin infusion. The effectiveness of intensive therapy in improving and maintaining good glycaemic control is well established in adolescents under research trial conditions.6 More recent data also indicate that the benefits of intensive therapy and improved glycaemic control persist even when HbA1c levels later rise.7 After completion of the Diabetes Control and Complications Trial (DCCT), adolescents from the former intensive therapy and conventional therapy groups returned to routine care and were advised to use intensive therapy. Despite no difference in their glycaemic control for four years after the end of the DCCT, the benefits of previous better control in the intensive therapy group persisted. Their prevalence of progression to proliferative or severe non-proliferative retinopathy was reduced by 78% during the four years. Suboptimal control during adolescence appears to have a lasting harmful effect, even when better glycaemic control is achieved later. Those caring for children and adolescents with type 1 diabetes may worry about the demands on the family and child of achieving good glycaemic control with intensive therapy. However, good glycaemic control is associated with better quality-of-life scores (QOL) in adolescents and less perceived burden by their parents.8 The intensity of the insulin regimen does not adversely affect QOL. Clearly, the demands of achieving good control are less than the consequences of poor control.8 The limiting factor of achieving ideal glycaemic control remains hypoglycaemia, excluding other problems of adherence or family functioning. Adolescents in the DCCT had higher rates of hypoglycaemia than their adult counterparts, despite having higher HbA1c levels.6 Glucagon secretion, which stimulates hepatic glycogenolysis, is blunted early in the course of type 1 diabetes, increasing the patient's vulnerability to hypoglycaemia. Further, the blood glucose threshold level for catecholamine release in response to hypoglycaemia is lowered in patients with better glycaemic control and this counter-regulatory response is most blunted during sleep.9 Recently available continuous blood glucose monitoring devices have shown that nocturnal hypoglycaemia is frequent in children. However, both new insulin analogues and continuous subcutaneous insulin therapy hold promise of improving control without the attendant increased risk of hypoglycaemia. In Western Australia, children with type 1 diabetes had more hypoglycaemia in association with falling HbA1c levels until 1995;4 since then their control has improved further, but without increased hypoglycaemia. Can the DCCT recommendations that adolescents receive intensive therapy be reproduced in routine care? The Hvidore Study Group has followed more than 2500 children and adolescents over three years in Europe, Canada and Japan.5 Despite more use of intensive therapy, glycaemic control did not necessarily improve with wide differences between paediatric centres. Intensive therapy demands intensive follow-up, education and support, as well as resources that many Australian paediatric diabetes units do not have if most patients are to be supported in this way. Most success in implementing the DCCT recommendations is reported from well-resourced units using diabetes clinical nurse consultants. While it is recommended that adolescents with type 1 diabetes receive intensive therapy, schedules need to be individualised. For example, some schoolchildren need insulin at afternoon tea, most adolescents need longer-acting insulin before bed for night control, and many preschoolers are managed on intermediate-acting insulin in the morning with small doses of insulin analogues to cover hyperglycaemia later in the day. Insulin pumps may provide the best solution for some patients, especially those with frequent hypoglycaemia or hypoglycaemic unawareness, but without government subsidy they are not affordable for most families. None of these options are easy for children and their families and, for some, intensive therapy is not possible. Insulin omission and chronic poor glycaemic control remain problems in adolescence and require ongoing intervention.10 The NSW and ACT study has demonstrated a relatively fast decline in HbA1c levels3 since the DCCT findings. However, glycaemic control (and risk of long term vascular complications) is unlikely to improve further in population studies unless multidisciplinary resources increase. It is especially relevant for more educators to be trained in the unique problems of improving control in this age group, and for their expertise to be available to all children.

Jennifer J Couper MB ChB, MD, FRACP

Objectives: To audit glycaemic control and incidence of severe hypoglycaemia in children and adolescents with type 1 diabetes in New South Wales (NSW) and the Australian Capital Territory (ACT).Design: A multicentre, population-based, cross-sectional study from 1 September to 31 December, 1999.Participants: 1190 children and adolescents aged 1.2–15.8 years with type 1 diabetes, identified from three hospital-based paediatric diabetes units, four private city-based paediatric practices and 18 regional outreach clinics in NSW and the ACT.Main outcome measures: HbA1c level and incidence of severe hypoglycaemia (defined by unconsciousness or seizures).Results: The response rate was 67% (1190 of a target group of 1765). The median HbA1c level was 8.2% (interquartile range, 7.6%–9.1%). Significant predictors of HbA1c level in a multiple regression model were duration (b = 0.05; 95% CI, 0.02–0.07) and insulin dose/kg (b = 0.46; 95% CI, 0.27–0.66). At least one episode of severe hypoglycaemia in the previous three months was reported in 6.7%, and the rate of severe hypoglycaemia was 36/100 patient-years. Significant predictors of hypoglycaemia in a Poisson regression model were younger age (P = 0.03), male sex (P = 0.04), longer diabetes duration (P = 0.02), and > 3 daily insulin injections (P = 0.02), but not HbA1c level. Children with diabetes had higher BMI standard deviation scores compared with population standards, and those in the highest quartile of BMI standard deviation score were younger, had shorter diabetes duration and had higher HbA1c level.Conclusions: Many children and adolescents with type 1 diabetes have suboptimal glycaemic control, placing them at high risk of developing microvascular complications. Those with longer diabetes duration are at increased risk of suboptimal glycaemic control and severe hypoglycaemia and should be targeted for interventional strategies.

for the NSW/ACT HbA1c Study Group