Child health

Ambulatory monitoring or hospital in the home may reduce presentations and admissions to hospital of children with COVID-19

Laila F Ibrahim · Doris Tham · Vimuthi Chong · Mark Corden · Simon Craig · Paul Buntine · Shefali Jani · Michael Zhang · Shane George · Amit Kochar · Sharon O’Brien · Karen Robins‐Browne · Shidan Tosif · Andrew Daley · Sarah McNab · Nigel W Crawford · Catherine Wilson · Franz E Babl

A 75-year-old woman presented to her general practitioner with several weeks of dyspnoea

Jessica Phillips · Jonathan Foo

Laws requiring doctors to report consensual adolescent sexual activity present legal, clinical and ethical problems Many Australian teenagers engage in consensual sexual intercourse with similar aged peers.1 They require confidential medical care, including contraception and sexually transmitted infection testing. However, adolescents’ rights to access medical care may confront legal barriers. In several Australian states and territories, new criminal laws require adults to report sexual offences against children. Other criminal laws make it an offence for adolescents aged under 16 years to engage in sexual intercourse. Accordingly, a question for clinical practice is whether the new criminal law reporting duty applies to adolescents’ confidential communications regarding consensual sexual activity. Law, ethics and practice must protect children, but must not criminalise consensual peer sexual activity or compromise clinical care. Here, we review literature regarding adolescents’ lived experience, findings from developmental science, and analyses of consensual and lawful sexual activity. We conduct a comparative analysis of Australian criminal law reporting duties for child sexual offences. We identify situations where laws inappropriately require clinicians to report adolescent sexual activity, and we make recommendations for reform. Background A 2018 national survey found 47% of 14–18‐year‐olds engaged in vaginal or anal intercourse, including 34% of those in Year 10.1 For most Year 10s (aged 14–16 years), the most recent sexual partner was a peer aged under 17 years (92%). However, 6.5% of sexually active Year 10s reported their most recent partner was aged 18–19 years. Of Year 10 females, over one‐third (37%) had engaged in intercourse, and for 10% of these their most recent partner was aged 18 years or older. General practitioners were the most trusted source of sexual health information, from whom 40.6% of females sought clinical advice.1 Clinician engagement was further evidenced by 43.5% of females using the contraceptive pill. However, adolescents experience multiple barriers in accessing health services, including perceived lack of confidentiality, and youth friendly service guidelines recommend confidential care approaches.2,3,4 The Lancet commission on adolescent health acknowledged the complex interplay of adolescent neurodevelopment and legal principles of capacity.5 Australian legal milestones differ, indicating how laws attempt to attain policy goals while grappling with scientific knowledge: 10‐year‐olds can be liable for criminal offences; 15‐year‐olds can obtain a Medicare card; and 17‐year‐olds can drive. Developmental neuroscience has shown adolescents aged 15–16 years possess adult‐like cognitive ability,8,9 while psychosocial and neurobiological maturity continues into the mid‐20s.8 It has been shown that, especially when in “calm and emotionally‐neutral contexts”,5 adolescents possess cognitive capacity to weigh costs and benefits and make reasoned judgements about courses of action, including about consenting to medical treatments involving contraception and sexual health.6,7 Much consensual peer sexual activity occurs in such settings; even in more emotionally “hot” circumstances, the capacity to consent to sex with similar aged peers is consistent with findings from developmental neuroscience. Legal requirements for consent, and the age of consent Lawful consent to sex requires full, free and voluntary agreement, and the absence of threat, intimidation and abuse of power (Box 1). Social science models of child sexual abuse are similarly premised on consent requiring full, free, voluntary and uncoerced participation.10 Laws must navigate a tension between protecting the developing adolescent and respecting and promoting their capacity and autonomy.11,12 In this setting, legislatures, as the bodies in each state and territory able to pass and amend criminal laws (legislation), must protect children and youth from sexual abuse, while allowing consensual peer sexual activity in both heterosexual and same‐sex relationships. Currently, the legal age of consent prohibits intercourse with minors under a specified age, presuming that children under this age lack capacity to provide true consent. This age is 16 years in most jurisdictions (Box 2). Legal defences embody legislatures’ acknowledgement that sex between adolescents may be consensual and permissible. Criminal laws in five jurisdictions provide a close‐in‐age defence to offences where the act involves consenting people who are both minors aged under 16 years or are similar in age (Box 2). Prosecution guidelines Similarly, official guidelines in every jurisdiction13,14 regarding prosecution of criminal offences recommend against prosecuting consensual activity between minors. These guidelines acknowledge it is against the public interest to prosecute these cases, because of the oppressive consequences, and the trivial and merely technical nature of any breach. Victoria’s guidelines are particularly strong, and specifically refer to situations where both adolescents are under 16 years of age, and where they are aged 15 and 18 years: a prosecution is contraindicated where a young person “has committed an offence in the context of a consenting sexual relationship with another young person [including] sexual penetration of a child under 16 where the offender is 18 and the complainant is 15”.13 In such cases, prosecutors should consider: the adolescents’ ages and maturity; whether they are in a relationship; whether they consented; and whether the person wishes a prosecution to proceed.13 In our hypothetical clinical case of Anna and David (Box 3), a prosecutor should conclude that despite technical commission of an offence (due to Anna and David being 15 and 18, respectively), prosecution should not occur because they are mature, near aged peers in a consenting sexual relationship with no coercion. They were responsibly acting to obtain contraception and advice from a medical practitioner, and Anna would not want David prosecuted. Prosecution is against the public interest for reasons including adverse effects on adolescents’ willingness to seek medical advice, which may result in further consequences including unintended pregnancies, sexually transmitted infections, and effects on education, employability and health. Criminal law reporting duties Child protection legislation has long required professionals to report sexual abuse to child welfare agencies.15 Recent inquiries into institutional abuse and cover‐ups catalysed recommendations for new reporting duties in criminal law, applied to all adults.16,17 Victoria, New South Wales, the Australian Capital Territory and Tasmania have since enacted new reporting duties in criminal law, advancing social norms to protect children.15 Queensland has recently enacted a duty, which has not yet commenced. (Supporting Information, Table 1). These laws require adults to report information to police about a sexual offence committed against a child. To accommodate exceptional circumstances and navigate ethical tensions, exceptions apply to requests of non‐disclosure, and confidential disclosures (Supporting Information, Table 1). Comparative analysis: six dimensions of legal inconsistency and uncertainty The relevant laws differ between jurisdictions, and exceptions are of uncertain application. Comparative statutory analysis reveals that for medical practitioners treating adolescents in consensual peer relationships, the laws present six problems. First, only NSW expressly excludes medical practitioners from the duty to report sexual offences against children (Supporting Information, Table 1). This creates a clear inconsistency: NSW practitioners are exempt from the duty, while their counterparts elsewhere are not. However, exempting NSW practitioners may mean sexual offences are less likely to be reported. Second, three jurisdictions apply the duty to report sexual offences both to situations involving two minors aged under 16 and to situations involving a minor and an adult. In contrast, Victoria only applies the duty to situations involving a minor and an adult. Accordingly, Victoria’s duty is narrower, acknowledging that otherwise it may inappropriately embrace consensual behaviour; yet it is important not to discourage Victorian practitioners from reporting non‐consensual sexual offences between minors, so this limit may be suboptimal. The problem elsewhere is that the duty may capture consensual peer activity. Third, only Victoria excludes the duty where the adolescent “victim” aged 16 or 17 requests non‐disclosure. Elsewhere, this exemption applies only to requests by victims aged 18 or over. This creates inequality in recognising adolescent capacity and autonomy. Fourth, the concept of a “reasonable excuse” for non‐reporting is not exhaustively defined (Supporting Information, Table 1). It is unclear whether a reasonable excuse for non‐disclosure includes a medical practitioner’s choice not to report a confidential disclosure in a therapeutic setting of consensual acts constituting a sexual offence. This leaves practitioners in all jurisdictions unsure whether they would be legally protected for not reporting. Fifth, Victoria, NSW and Tasmania enable prosecution only if approved by the Director of Public Prosecutions. This suggests multiple situations do not warrant prosecution. However, it is not clear when approval would be given, leaving clinicians in doubt about exemptions to the duty. The ACT lacks this mechanism, indicating higher likelihood of prosecution. Sixth, health professionals may be exempt from the duty where a patient confidentially discloses a sexual offence (Supporting Information, Table 1). This exemption is founded on the concept of professional confidential relationship privilege. However, these exemptions are unclear, rely on networks of laws, and apply to different practitioners. Tasmania and the ACT lack clear confidentiality exceptions (Supporting Information, Table 2). NSW has a clear exemption. Victoria has an express exemption if the information is a “confidential communication” as defined by other legislation (Box 4). However, in Victoria, the exemption applies only to communications from the younger adolescent (Box 4). In Anna’s hypothetical case, David attending the consultation would technically trigger the GP’s duty to report (Box 3). Discussion The new duties in criminal law to report sexual offences against children are consistent with policy values in protecting children, and with bioethical principles of justice and beneficence. Requiring adults to report child sexual offences is justified by diminishing harm to individuals, and by enhancing community protection and a protective social fabric for vulnerable children.18 Sexual activity between adults and children should generally be considered abusive, due to absence of consent and presence of coercion.10 However, legislatures must ensure an appropriate balance between protecting children and youth from sexual offences, and recognising their capacity and promoting autonomy, privacy and freedom of expression.11,12 Genuinely consensual sexual activity between under‐aged minors is not abusive.10 In addition, a grey zone of cases may involve two adolescents aged almost 16, and 18. Here, where sexual activity may be genuinely consensual, ethical analysis, findings from developmental science, and clinical needs all suggest the duty should be moderated by nuanced individual consideration by clinicians (Box 3). In our view, the central concept that should inform legal principles and practice is consent, and its presence or absence in circumstances which do not involve threat, intimidation or abuse of authority. On our analysis, three conclusions seem clear. First, legislative reforms are required so that disclosures in therapeutic contexts of clearly consensual sexual activity between similar aged peers under 16 are expressly exempt from the reporting duty. This is consistent with policy animating Victoria’s law reform requiring adults to report “a serious indictable offence involving the abuse of a child”,16 and Royal Commission recommendations.17 If protected by such an exemption, clinicians consulting with adolescents who are having sex with similar aged peers can be unhindered in providing preventive health interventions including contraception for mature minors, and screening for sexually transmitted infections.18 Clinicians routinely enquire about age of sexual partners and otherwise consider risk of abuse and patient capacity when providing treatment.7 If they reasonably conclude the adolescents are consenting, confidential treatment should be provided and this is clearly incompatible with reporting to police. Such an exemption also allows clinicians to create a safe environment to encourage adolescent help‐seeking, check for other health risks,19 explore family dynamics, and connect the adolescent with parents or others to benefit wellbeing.18,19 Second, this legislative exemption could extend to clearly consensual activity between adolescents aged 15 and 18. Legal attribution of capacity to consent to sex using simple age cut‐offs is convenient, but sometimes incongruent with developmental science, lived experience and clinical scenarios.9 In situations of clearly consensual activity, a margin of error should favour patient autonomy and clinical care. This is consistent with prosecutorial guidelines and Tasmania’s similar age exemptions. Clinicians would prefer this slight extension of the exemption so they can promote health and encourage future help‐seeking. Our hypothetical patients Anna and David would be unwilling to seek future care if the GP reported David to police. Third, the different models for exempting clinicians as recipients of confidential information are complex, uncertain and unsatisfactory. Legislative reforms are required to create a clear, unified approach. Any legislature that seeks to include an exemption for confidential disclosures about abusive incidents made to medical practitioners within therapeutic contexts should enact a specific exemption, using the NSW model. This would solve difficulties ascertaining whether this constitutes a “confidential communication” or is protected by privilege. It would also solve problems in the requested non‐disclosure exemptions; for abusive incidents, application only to those over 18 is inconsistent with developmental science, which suggests Victoria’s age 16 is justifiable, and could be extended to those aged 15. This three‐pronged approach aligns with clinicians’ duty of confidentiality in codes of ethics,20 and organisational policy on sexual and reproductive health.21 National principles recognise medical practitioners’ central role in supporting sexual and reproductive health through confidential care, with youth a priority population.18,21 This medico‐legal context is increasingly complex. Our analysis has focused on adolescent peers in genuinely consensual relationships whose ages mean technically they are committing an offence, exemplified by peers aged 15 and 18 years (Box 1). We unequivocally support duties to report child sexual abuse,15,22 and do not here consider other situations where different outcomes may transpire. We also caution that where disclosures of abusive incidents may be exempt from the criminal duty, a clinician may have a separate overriding legal duty to report. For example, Victorian doctors may be exempt under s 327(7)(c) of the Crimes Act 1958 from disclosing a 10‐year‐old’s confidential disclosure of sexual assault, but must report under child protection legislation.15 Health practitioners therefore need to know their responsibilities under different laws, and need ongoing professional education to promote legal literacy. Progress towards reform may require several steps. Since legislative limitations differ, agencies representing medical practitioners could urge reform at state and territory level, informed by research and clinical experience. However, ideally, a harmonised national approach should be adopted. National medical regulatory bodies and government ministries could mobilise to support a single model law that balances the need to protect Australian children from sexual offences, while promoting adolescents’ rights to consensual sexual activity. Box 1 – Requirements of consent to sexual intercourse, by Australian states and territories Conditions for consent to sexual intercourse Jurisdiction Free and voluntary agreement Not by threat, intimidation, or abuse of authority Australian Capital Territory Crimes Act 1900, s 67 (not expressly defined) s 67(1): consent to sexual intercourse with another person is negated if that consent is caused: “(a) by the infliction of violence or force on the person, or on a third person …; or (b) by a threat to inflict violence or force on the person, or on a third person …; or (c) by a threat to inflict violence or force on, or to use extortion against, the person or another person; or (d) by a threat to publicly humiliate or disgrace, or to physically or mentally harass, the person or another person; or … (h) by the abuse by the other person of his or her position of authority over … the person” New South Wales Crimes Act 1900, s 61HE(2): “A person ‘consents’ to a sexual activity if the person freely and voluntarily agrees to the sexual activity” s 61HE(5)(c): A person does not consent to a sexual activity if the person consents “because of threats of force or terror (whether the threats are against, or the terror is instilled in, that person or any other person)” s 61HE(8): “The grounds on which it may be established that a person does not consent include … (b) if the person consents to the sexual activity because of intimidatory or coercive conduct, or other threat, that does not involve a threat of force, or (c) if the person consents to the sexual activity because of the abuse of a position of authority or trust” Northern Territory Criminal Code Act 1983, s 192(1): “consent means free and voluntary agreement” s 192(2): “Circumstances in which a person does not consent to sexual intercourse … include circumstances where: (a) the person submits because of force, fear of force, or fear of harm of any type, to himself or herself or another person” Queensland Criminal Code 1899, s 348(1): “consent means consent freely and voluntarily given by a person with the cognitive capacity to give the consent” s 348(2): “consent to an act is not freely and voluntarily given if it is obtained—(a) by force; or (b) by threat or intimidation; or (c) by fear of bodily harm; or (d) by exercise of authority …” South Australia Criminal Law Consolidation Act 1935, s 46(2): “a person consents to sexual activity if the person freely and voluntarily agrees to the sexual activity” s 46(3): a person does not freely and voluntarily agree to sexual activity if “(a) the person agrees because of (i) the application of force or an express or implied threat of the application of force or a fear of the application of force to the person or to some other person; or (ii) an express or implied threat to degrade, humiliate, disgrace or harass the person or some other person” Tasmania Criminal Code 1924, s 2A(1): “‘consent’ means free agreement” s 2A(2):”a person does not freely agree to an act if the person … (b) agrees or submits because of force, or a reasonable fear of force, to him or her or to another person; or (c) agrees or submits because of a threat of any kind against him or her or against another person; or … (e) agrees or submits because he or she is overborne by the nature or position of another person” Victoria Crimes Act 1958, s 36(1): “consent means free agreement” s 36(2): ”Circumstances in which a person does not consent to an act include, but are not limited to, the following—(a) the person submits to the act because of force or the fear of force, whether to that person or someone else; (b) the person submits to the act because of the fear of harm of any type, whether to that person or someone else” Western Australia Criminal Code Compilation Act 1913, s 319(2)(a): “consent means a consent freely and voluntarily given” s 319(2)(a): “a consent is not freely and voluntarily given if it is obtained by force, threat, intimidation, deceit, or any fraudulent means” Box 2 – Close‐in‐age defence for sex with a minor under the legal age of consent, where intercourse is consensual Jurisdiction Legislation Age of consent Express defence for intercourse with someone under the legal age of consent if similar in age, and consent is provided Australian Capital Territory Crimes Act 1900, s 55(2) 16 Yes — if accused was not more than 2 years older than the child, and the child was aged 10 or over: s 55(3)(b) New South Wales Crimes Act 1900, s 66C(3) 16 Yes — if accused was not more than 2 years older than the child, and the child was aged 14 or 15: s 80AG Northern Territory Criminal Code Act 1983, s 127(1) 16 No Queensland Criminal Code Act 1899, s 215(1) 16 No South Australia Criminal Law Consolidation Act 1935, s 49(3) 17 Yes — if accused was under 17, and child was 16: ss 49(4)(a) and (4)(b)(i) Tasmania Criminal Code Act 1924, s 124 17 Yes — age gap not more than 5 years, if child was aged at least 15: s 124(3)(a); and age gap not more than 3 years, if child was aged at least 12: s 124(3)(b) Victoria Crimes Act 1958, s 49B 16 Yes — if accused was not more than 2 years older than the child, and the child was aged 12 or over: s 49V Western Australia Criminal Code Act 1913, s 321(2) 16 No Box 3 – Hypothetical clinical case study Anna is 15 years of age and in Year 10 at a co‐educational high school in Victoria. She has been getting good grades and has a part‐time job at a supermarket. David is 18 years of age, in Year 12 at Anna’s school, and works at the same supermarket. They have been dating for 3 months. Anna presents to her general practitioner for contraceptive advice. She has become sexually active with David and wants contraception additional to condoms. Her GP confirms Anna is a mature minor, since she understands fully the range of contraceptive options open to her, how they work, and their side effects. She has carefully considered all options with David, and has chosen a long‐acting reversible contraceptive implant. She intends to inform her mother, but she is not quite ready yet. She is certain she does not want to experience an unintentional pregnancy. Anna describes her relationship with David as very positive. She feels completely safe with him and under no coercion. She feels she could stop the relationship at any time if she wanted to, and so could he. The age of consent for sexual intercourse in Victoria is 16. Where sex involves a minor aged 12–15, no offence is committed if the other person is less than 2 years older than the minor, and the sex is consensual. Technically, David is committing a sexual offence by having sex with Anna, because he is 3 years older than her; if he was 17 there would be no offence. However, the GP is satisfied this relationship is consensual, and previously would not have reported this situation under either criminal law or child protection law. However, the criminal law on failure to disclose that commenced in Victoria in 2014 has now presented a dilemma for the GP. These laws aim to protect children from sexual abuse and require adults to report knowledge of a sexual offence with a child under 16 years to police. Anna has not expressly stated to the GP that she does not want the situation reported to police, since it has not occurred to her that anything wrong has happened. The GP studies the government website on the new laws to understand what she should do. She is relieved to learn health practitioners are exempt from the criminal law duty to report if they are told about the offence in the course of a confidential consultation. However, because of other legal definitions (Box 4), this exemption only applies if consulting exclusively with the person against whom the offence has been committed. The next day, Anna and David consult the GP together for a baseline sexually transmitted infection screen. The GP was happy to see them, but was perplexed that the exemption did not apply if consulting with the offender, in this case David. She was very reluctant to call the police about David and Anna, due to her knowledge about the consensual nature of their relationship, and their responsible behaviour in obtaining contraception. The GP also understands that other adults who know about the situation, such as Anna’s and David’s parents and school teachers, would appear to be required to report by the criminal law duty, since no clear exemptions apply to them. Box 4 – Health Practitioner Regulation National Law: definitions and application In Victoria, a “confidential communication” is “a communication, whether oral or written, made in confidence by a person against whom a sexual offence has been, or is alleged to have been committed to a registered medical practitioner or counsellor in the course of the relationship of medical practitioner and patient or counsellor and client”: Evidence (Miscellaneous Provisions) Act 1958, s 32B. Under the Health Practitioner Regulation National Law Act 2009 (Qld) Schedule s 5, “health practitioner means an individual who practises a health profession”. A “registered health practitioner means an individual who (a) is registered under this Law to practise a health profession, other than as a student; or (b) holds non‐practising registration under this Law in a health profession”. A “health profession” is defined to include a list of 15 professions (including recognised specialties in these), and most relevantly here includes the following professions: medical, nursing, pharmacy, and psychology. In Victoria, a “registered medical practitioner” under the Health Practitioner Regulation National Law is defined through the application of the Health Practitioner Regulation National Law Act 2009 (Qld) Schedule s 5. Victoria incorporated the Queensland Act into Victorian law, through the Health Practitioner Regulation National Law (Victoria) Act 2009, s 4 (Application of Health Practitioner Regulation National Law). The Health Practitioner Regulation National Law is also incorporated into other jurisdictions’ laws: Health Practitioner Regulation National Law (Tasmania) Act 2010, s 4; Health Practitioner Regulation (Adoption of National Law) Act 2009 (NSW), s 4; Health Practitioner Regulation National Law (ACT) Act 2010, s 6.

Ben Mathews · Lena A Sanci

Responses to the health care needs of this vulnerable group have improved, but further progress is needed

David I Ben‐Tovim · Kim Vien

To the Editor: Hoffman and colleagues’1 excellent review highlights the tightrope women walk when pursuing both a career and children. It is clear that, internationally, inflexible workplace policies as well as more insidious outdated attitudes towards working women cause significant damage to society as a whole. While mothers evidently bear the brunt, such discrimination also negatively affects fathers and we would argue that the real issue is “parenthood and medicine” rather than just “motherhood”. A culture that presents balancing a career and children as being a goal that only women should struggle with is itself part of the underlying problem. In recent generations, the traditional expectation for women to assume the role of primary childcarer has undergone a paradigm shift. It is increasingly commonplace for men to take paternity leave and even to return to part‐time work in order to achieve greater presence in their family life. A growing number of same‐sex couples are also choosing to have a family and face additional, unique challenges. Unfortunately, public policy is lagging far behind; in Australia, partners are entitled to only 2 weeks of paid leave after the birth of a child.2 Better access to spousal leave exists overseas, particularly in Scandinavia; for example, in Sweden, parents can share up to 480 days off work after the birth or adoption of a child, divided as however suits the individuals.3 In the United Kingdom, additional paternity leave of up to 50 weeks is available after the standard 2 weeks.4 A study from 2013 found uptake of the additional leave had been disappointingly low, highlighting poor awareness, practical deterrents, concerns around impact on finances and training, and fear of negative perceptions as key underlying reasons.5 With the majority of doctors in Australia having children at some point in their careers, it is time for further research, education and policy change to support all individuals.

Elizabeth Wootton · Gerard Forrest

Objectives: To examine associations between community cultural connectedness indicators and suicide mortality rates for young Aboriginal and Torres Strait Islander people. Study design: Retrospective mortality study. Setting, participants: Suicide deaths of people aged 10‒19 years recorded by the Queensland Suicide Register, 2001‒2015. Main outcome measures: Age‐standardised suicide death rates, by Indigenous status, sex, and age group; age‐standardised suicide death rates for young First Nations people by area level remoteness and Index of Relative Socioeconomic Advantage and Disadvantage, and by cultural connectedness indicators (at statistical area level 2): cultural social capital index score, community Indigenous language use, and reported discrimination. Results: The age‐specific suicide rate was 21.1 deaths per 100 000 persons/year for First Nations young people and 5.0 deaths per 100 000 persons/year for non‐Indigenous young people (rate ratio [RR], 4.3; 95% CI, 3.5‒5.1). The rate for Aboriginal and Torres Strait Islander young people was higher in areas with low levels of cultural social capital (greater participation of community members in cultural events, ceremonies, organisations, and community activities) than in areas classified as having high levels (RR, 1.8; 95% CI, 1.2‒2.7), and also in communities with high levels of reported discrimination (RR, 2.7; 95% CI, 1.7‒4.3). Associations with proportions of Indigenous language speakers and area level socio‐economic resource levels were not statistically significant. Conclusion: We found that suicide mortality rates for Aboriginal and Torres Strait Islander young people in Queensland were influenced by community level culturally specific risk and protective factors. Our findings suggest that strategies for increasing community cultural connectedness at the community level and reducing institutional and personal discrimination could reduce suicide rates.

Mandy Gibson · Jaimee Stuart · Stuart Leske · Raelene Ward · Robert Tanton

Influenza vaccine uptake in children has grown in response to increased awareness and progressive expansion of funding Over the past decade, multiple initiatives have been implemented to strengthen influenza vaccination programs in Australia, with an increasing focus on children. In this article, we review these changes, the events that prompted them, and how they have influenced influenza vaccine uptake in Australia. Burden of influenza Before the coronavirus disease 2019 (COVID‐19) pandemic, influenza was responsible for a higher disease burden and overall health impact than any other vaccine‐preventable disease in Australia.1 Historically, Australian influenza notification rates have been highest in children, particularly in those aged less than 2 years.2 The highest annual hospitalisation rates for influenza overall have been recorded in children aged less than 6 months (192 per 100 000 per year), followed by children aged 6–23 months (109 per 100 000 per year).2 Although paediatric hospitalisation rates are high, annual rates of influenza‐associated deaths in children are low compared with adults: 0.20–0.39 per 100 000 children aged under 5 years compared with 0.65 per 100 000 in people aged 65–74 years and 3.66 per 100 000 in people aged 75 years or more.2 While it appears that influenza may have become more burdensome for children in recent years due to an increase in disease notifications (Box 1), the notification rates also reflect an increase in influenza testing rates. For example, in New South Wales, there was a seven‐fold increase in tests done in 2019 compared with 2009.3 However, influenza notifications dramatically declined in 2020 in all age groups (Box 1), most likely due to increased hygiene and physical distancing measures and the implementation of border closures to reduce transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) — the virus that causes COVID‐19. Influenza‐associated morbidity and mortality rates also likely underestimate the true influenza‐associated burden related to underascertainment bias and other factors. Influenza vaccination recommendations and funding All people in Australia aged 6 months or more are recommended to receive annual influenza vaccination, with free influenza vaccines for the highest risk groups provided by the National Immunisation Program (NIP).4 Vaccination is only contraindicated for people who have experienced anaphylaxis in association with a previous dose or any component of an influenza vaccine.4 Children aged 6 months to 9 years receiving the vaccine for the first time require two doses at least 4 weeks apart; those aged 9 years or more require only one dose in their first year of receipt.4 Until recently, there was limited funding for, and promotion of, influenza vaccination in children. In 2018, following the large 2017 influenza season (Box 1), and underpinned by evidence of paediatric disease burden, vaccine safety and efficacy,2,6,7 all Australian states and territories, except the Northern Territory, followed Western Australia’s 2008 initiative in funding influenza vaccination for all children aged 6–59 months; the NT followed in 2019 (Box 2). The NIP expanded in 2019 to include Aboriginal and Torres Strait Islander peoples of all ages (closing the funding gap for those aged 5 to < 15 years), and in 2020, the influenza vaccine was added to the NIP for all children aged 6–59 months.5 Influenza vaccine effectiveness Influenza vaccine effectiveness is usually measured against either all laboratory‐confirmed influenza (using disease notification data) or influenza‐associated hospitalisation (a proxy for severe disease) and varies each year. In 2015, influenza vaccine effectiveness in children aged under 18 years estimated from data collected from sentinel general practitioner networks was 54%,8 indicating that influenza‐associated primary care visits more than halved in vaccinated children compared with unvaccinated children. In 2017, a year dominated by the influenza A subtype H3N2, for which the vaccine typically performs less well, the influenza vaccine effectiveness against hospitalisation for influenza was estimated to be 30% in children;6 however, in 2018, an influenza A subtype H1N1 predominant year, vaccine effectiveness against paediatric influenza hospitalisation was 78%.9 Despite moderate effectiveness, at an individual and population level, influenza vaccination still prevents significant morbidity and mortality. For example, with 55% of population coverage and an adjusted vaccine effectiveness of only 32% (95% CI, 16–44%) for children aged 5–17 years during the 2017–2018 influenza season in the United States, vaccination was still estimated to have prevented 1.4 million illnesses, 711 000 medical visits, 3700 hospitalisations, and 89 deaths of children aged 5–17 years.10 Influenza vaccine safety In April 2010, early in the Australian influenza vaccination season, the Australian Government’s Chief Medical Officer suspended the use of influenza vaccine in children aged 5 years or less due to an unexpectedly high rate of fever and febrile seizures in the 4–24 hours following influenza vaccine administration.11 Influenza vaccination in children aged 5 years or less continued with non‐CSL influenza vaccines from August 2010 onwards,12 given they had no safety issues. The program suspension had negative effects on influenza vaccine attitudes, confidence and coverage in children in the following years.13 However, recent evidence suggests that influenza vaccine safety concerns may no longer be a significant barrier to influenza vaccination of children in Australia. Rather, significant barriers include a lack of recommendation from a health care provider, difficulties in either remembering to make or getting an appointment for vaccination, a general lack of support for influenza vaccination, or a lack of history of influenza vaccine uptake by the child or their parent.14 An independent review into the national response to the Fluvax (CSL) safety incident identified ways to strengthen the safe delivery of influenza (and other) vaccines in Australia.15 In response to these recommendations, a national sentinel vaccine active safety surveillance system, known as AusVaxSafety (www.ausvaxsafety.org.au) was established in 2014. In this system, people of all ages who receive an influenza vaccine (or their carers) at more than 350 participating sentinel clinics (as at March 2021) are sent a short message service (SMS) text message and/or email in the days after vaccination with questions on whether they or their child experienced an adverse event following immunisation.7 Overall, data from this system have shown a safety profile consistent with that expected from clinical trials for all vaccine brands: approximately 10% of children’s carers report an adverse event following immunisation in their child within 3 days of influenza vaccination, the most common being fever or pain, swelling or redness at the injection site.7 Data from this ever‐expanding vaccine safety monitoring system have consistently shown low and expected reporting rates of mild transient adverse events known to be associated with the influenza vaccine. Recorded influenza vaccine uptake Since 2007, the number of influenza vaccine doses distributed and the recorded population coverage have increased in Australia, but with fluctuating uptake in children. Following the rapid attainment of high coverage in Western Australia in both Aboriginal and Torres Strait Islander and non‐Aboriginal children aged 6–59 months from 2008, coverage decreased substantially after the 2010 safety incident (Box 3 and Box 4). Coverage in Aboriginal and Torres Strait Islander children increased after the NIP funding in 2015, with highest rates in the NT (55.8%) in 2015 (Box 3). Coverage also increased dramatically in non‐Aboriginal children in 2018 (Box 4) following the introduction of state‐ and territory‐based programs for all children aged 6–59 months. In 2020, the first year of NIP‐funding for children aged 6–59 months, the reported uptake was 43.9%.16 This estimate may be higher given the uptake was calculated using doses recorded between March and August 2020 (rather than a full 12‐month period),16 and overall, actual coverage is likely higher due to issues of under‐reporting to the Australian Immunisation Register.17 The number of influenza vaccine doses available around Australia for all ages has also increased, with 8.3 million distributed in 2017, to 18 million in 2020.18 While a 43.9% uptake in children aged 6–59 months in 2020 in Australia represents an improvement from past low vaccination rates, Australia needs strategies to improve and sustain high coverage. These could include personalised vaccination reminders19 and provision of greater access to influenza vaccination services.20 Furthermore, given the influence of a recommendation from a health care provider on vaccine uptake,14 implementing a combination of education, communication training, electronic prompts and standing order protocols21 may assist health care providers in recommending influenza vaccination to all patients. Mandatory reporting of vaccination data to the Australian Immunisation Register, recently implemented in the context of the COVID‐19 vaccine roll‐out in Australia and extended to include other vaccines,22 should also assist in ensuring more accurate vaccine coverage estimations of influenza and all vaccines. Conclusion Influenza vaccine uptake in young children in Australia has increased in response to the progressive expansion of funding and is now delivered under the NIP. Further gains in uptake should ensure that protection against influenza disease in children is optimised during the ongoing COVID‐19 pandemic and in years to come. Box 1 – Notification rates of laboratory‐confirmed influenza in children aged less than 5 years in Australia, 2007–2020* * Influenza testing rates also increased over this time period.3 Source: National Notifiable Diseases Surveillance System, as at 18 February 2021. Box 2 – Significant events in influenza disease and vaccination policy in Australia ACT = Australian Capital Territory; NSW = New South Wales; NT = Northern Territory; QLD = Queensland; SA = South Australia; TAS = Tasmania; VIC = Victoria; WA = Western Australia; QIV = quadrivalent influenza vaccine. * Vaccine funded for Aboriginal and Torres Strait Islander people aged 15 years or more since 1999 (for all Aboriginal and Torres Strait Islander people aged ≥ 50 years, and Aboriginal and Torres Strait Islander people aged 15–49 years who have at least one of a range of underlying medical conditions that increase their risk of influenza or complications). Source: National Centre for Immunisation Research and Surveillance.5 Box 3 – Trends in recorded coverage of any dose of seasonal influenza vaccine among Aboriginal and Torres Strait Islander children aged 6 months to less than 5 years, by jurisdiction, 2007–2019 ACT = Australian Capital Territory; NSW = New South Wales; NT = Northern Territory; QLD = Queensland; SA = South Australia; TAS = Tasmania; VIC = Victoria; WA = Western Australia. Source: Australian Immunisation Register, data as at 31 March 2020. Box 4 – Trends in recorded coverage of any dose of seasonal influenza vaccine among non‐Aboriginal children aged 6 months to less than 5 years, by jurisdiction, 2007–2019 ACT = Australian Capital Territory; NSW = New South Wales; NT = Northern Territory; QLD = Queensland; SA = South Australia; TAS = Tasmania; VIC = Victoria; WA = Western Australia. Source: Australian Immunisation Register, data as at 31 March 2020.

Samantha J Carlson · Christopher C Blyth · Frank H Beard · Alexandra J Hendry · Allen C Cheng · Helen E Quinn · Julie Leask · Kristine Macartney

To the Editor: Public health strategies to control coronavirus disease 2019 (COVID‐19) in Australia aim to test, identify and isolate all cases including those among children.1 We investigated the intended actions of parents if their child developed COVID‐19 symptoms, such as a runny nose, sore throat, cough, fever, chills, loss of smell, diarrhoea, and/or nausea and vomiting.1 We collected data during 15–23 June 2020 via an online survey of 1834 Australian parents of children aged 3–17 years who attended childcare, kindergarten and/or school.2 The sample was limited to these respondents as one of our objectives was to test if children would be kept home from childcare and/or school (isolate). The questionnaire was administered by a private vendor as part of the Royal Children’s Hospital National Child Health Poll, a recurring periodic online survey. Participants were randomly selected from a representative consumer panel of over 350 000 Australian adults — who were recruited onto the panel via online and offline methods such as door knocking, phone calls, letters etc — using quotas to achieve a nationally representative sample reflective of age, sex and state populations. The sample size was justified based on the commonly used margin of error of 3% for estimating a proportion. Only one parent per household could complete the questionnaire and households were not permitted to participate in more than one poll. Participants had no direct contact with the research team. Responses were voluntary and anonymous. Respondents were incentivised for participation in the form of points towards shopping gift cards. The study protocol was approved by the Royal Children’s Hospital Human Research Ethics Committee (RCH HREC 35254). Intended actions of parents if their child developed possible COVID‐19 symptoms are presented in the Box. We classified parents as “seeking COVID‐19 test or medical advice” or not. The sample characteristics are presented in the Supporting Information. We found that 1458 of 1834 parents (78.95%, weighted) of children with symptoms compatible with COVID‐19 intended to seek a COVID‐19 test for their child. There is little published research exploring why some parents may not present children for COVID‐19 testing. A recent Australian study has identified barriers to testing among adults, including a belief that testing is painful, a lack of knowledge about how to get tested, and worry about getting infected at the testing centre.3 These barriers may also apply to parents in relation to testing for children. Additional barriers may include financial implications of time off work to take a child for testing and fear of the social stigma associated with a diagnosis of COVID‐19.4 As upper respiratory tract infections are common among children and often present with similar symptoms to COVID‐19,1 parents may misattribute possible COVID‐19 symptoms to the common cold. Messages from governments may be unclear and parents may not believe that general directives apply to children.5 Timely testing is a critical aspect of containing the pandemic in Australia. With one in five parents indicating they would not present their symptomatic child for COVID‐19 testing, further research is urgently needed to identify and understand barriers to testing in order to inform targeted strategies and messaging to enhance testing uptake in children. Box – Intentions of parents if child developed symptoms compatible with coronavirus disease 2019 (COVID‐19), Australia, 2020 Number (%)*† Keep child home from school or child care until all their symptoms have gone 991 (53.22%) Take child to a doctor (GP or hospital) for a COVID‐19 test 810 (44.66%) Keep child home from school or child care for a couple of days 672 (36.34%) Call the GP for advice 618 (33.62%) Take child to a COVID‐19 testing centre 452 (23.33%) Call the COVID‐19 hotline for advice 415 (22.69%) Send child to school or childcare if they seem well enough 47 (2.66%) Not sure what to do 34 (1.73%) Take child for test‡* 1458 (78.95%) GP = general practitioner. * The cumulative percentage is greater than 100% as respondents could select more than one option. † The sample was nationally representative in terms of the distribution of national resident population by state; however, the distribution of parent sex by state and socio‐economic status was slightly over‐representative of female and more advantaged residents (Supporting Information). Hence, the data were weighted by state, sex and the Index of Relative Socio‐economic Advantage and Disadvantage (IRSAD). ‡ “Take child for test” was defined as at least one of the following options: take child to doctor or testing centre for a test, call GP for advice or call the COVID‐19 testing centre.

Mary‐Anne Measey · Monsurul Hoq · Anthea L Rhodes

To the Editor: Hereditary cancer predisposition syndromes (HCPS) account for at least 10% of paediatric cancers.1 Li‐Fraumeni syndrome (LFS) is a dominant HCPS caused by mutations in the TP53 gene and is associated with an 80–90% lifetime risk of cancer, commencing in infancy.2 Children of affected individuals are at 50% risk of inheriting the family mutation. Surveillance programs, involving clinical review and medical imaging, are being used in paediatric populations with HCPS, as significantly higher overall survival is reported with early tumour detection.3 In 2018, the Paediatric Surveillance Clinic was established at Perth Children’s Hospital to provide surveillance for asymptomatic children with, or at 50% risk of developing, LFS and with other HCPS, and to address the needs of their families. Families with at‐risk children can choose to attend the clinic, allowing them to receive information, support and sufficient time to make a decision regarding genetic testing. The quarterly clinic is in a general paediatric setting and offers surveillance for mutation‐positive children in line with eviQ guidelines — a free resource of evidence‐based, consensus‐driven cancer treatment and genetic testing protocols hosted by Cancer Institute NSW.4 Children at 50% risk of LFS, who have not had genetic testing, receive a six‐monthly clinical review and prompt assessment of any concerning symptoms during the interim period. Over an 18‐month period, the Paediatric Surveillance Clinic has seen 11 children from five families, aged from 3 months to 14 years. Most of these children are at risk of or have a TP53 mutation and one child has a VHL (Von‐Hippel‐Lindau) mutation. The Paediatric Surveillance Clinic offers a holistic service with a multidisciplinary team consisting of a general paediatrician, a paediatric nurse, a paediatric oncologist, a genetic counsellor and a clinical geneticist. The clinic has highlighted the specific and unmet needs of families dealing with HCPS and has allowed for essential integration of genetic, paediatric and oncology services for these families.5 As the number of identified HCPS grows, the Paediatric Surveillance Clinic will continue to offer a flexible service that supports families, assisting with decisions around genetic testing and surveillance for malignancy during childhood and adolescence.

Nicholas Leedman · Murray Princehorn · Nicholas Gottardo · Claire Franklin · Rebecca D'Souza · Catherine E Kiraly‐Borri

To the Editor: The Australian Therapeutic Goods Administration (TGA) categorisation system for prescribing medicines in pregnancy lists doxylamine as a Category A medicine — “Drugs which have been taken by a large number ofpregnantwomen … without any proven increase in the frequency of malformations”.1 However, despite this categorisation, many single‐ingredient non‐prescription doxylamine products continue to carry misleading product and consumer information. While correctly assigning Category A, they then contradictorily include warnings such as “do not use during pregnancy” and/or “studies to prove it is safe for the developing baby have not been done”. There is no validity or justification to such statements, which are inconsistent with both available data and the Category A status. Studies on the safety of doxylamine in pregnancy date from the 1980s, when the first meta‐analysis demonstrated that doxylamine was not a human teratogen and should not have been removed from the market by the manufacturer.2 Subsequently, there have been several studies, reinforcing both the safety and efficacy of doxylamine for the treatment of nausea and vomiting in pregnancy (NVP).3 This resulted in the United States Food and Drug Administration (FDA) once again approving doxylamine (with pyridoxine) in 2014 as safe to use in pregnancy, with a specific indication for managing NVP. Furthermore, the Society of Obstetric Medicine of Australia and New Zealand’s practice guidelines recommend doxylamine (and pyridoxine) as first line treatment for NVP.4 MotherSafe — a New South Wales‐based teratogen information service — receives about 20 000 calls annually from health care providers and consumers. Many women call this service after receiving conflicting advice about using doxylamine in pregnancy from pharmacists and other health care professionals, including general practitioners and obstetricians. Moreover, pharmacists also identify a knowledge gap and concerns about off‐label use and discrepancies between the product information, categorisation and other available information sources.5 In some cases, pharmacists have refused to sell doxylamine to women with NVP because of the product information, considering the use of doxylamine for NVP to be off‐label and thus not indicated or safe. Despite raising our concerns with the TGA about the confusing labelling, we are yet to see any progress in correcting this significant misinformation among health professionals and patients. This specific issue highlights wider concerns around Australia’s confusing pregnancy risk classification and the imperative for the TGA to abandon the current alphabetical categorisation and move to a format similar to the one used by the FDA Pregnancy and Lactation Labeling Rule, which requires all packaging and consumer information to include consistent evidence‐based information on medication use in pregnancy and breastfeeding.6

Debra S Kennedy · Ronald P Batagol

A 1-year-old boy presented with a 6-month history of a brown plaque on his left forearm

Samuel A Der Sarkissian · Deshan F Sebaratnam

Introduction: The 2001 Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Islander populations were revised in 2010. This 2020 update by the Centre of Research Excellence in Ear and Hearing Health of Aboriginal and Torres Strait Islander Children used for the first time the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Main recommendations: We performed systematic reviews of evidence across prevention, diagnosis, prognosis and management. We report ten algorithms to guide diagnosis and clinical management of all forms of otitis media. The guidelines include 14 prevention and 37 treatment strategies addressing 191 questions. Changes in management as a result of the guidelines: A GRADE approach is used. Targeted recommendations for both high and low risk children. New tympanostomy tube otorrhoea section. New Priority 5 for health services: annual and catch‐up ear health checks for at‐risk children. Antibiotics are strongly recommended for persistent otitis media with effusion in high risk children. Azithromycin is strongly recommended for acute otitis media where adherence is difficult or there is no access to refrigeration. Concurrent audiology and surgical referrals are recommended where delays are likely. Surgical referral is recommended for chronic suppurative otitis media at the time of diagnosis. The use of autoinflation devices is recommended for some children with persistent otitis media with effusion. Definitions for mild (21–30 dB) and moderate (> 30 dB) hearing impairment have been updated. New “OMapp” enables free fast access to the guidelines, plus images, animations, and multiple Aboriginal and Torres Strait Islander language audio translations to aid communication with families.

Amanda J Leach · Peter S Morris · Harvey LC Coates · Sandra Nelson · Stephen J O'Leary · Peter C Richmond · Hasantha Gunasekera · Samantha Harkus · Kelvin Kong · Christopher G Brennan‐Jones · Sam Brophy‐Williams · Kathy Currie · Sumon K Das · David Isaacs · Katherine Jarosz · Deborah Lehmann · Jarod Pak · Hemi Patel · Chris Perry · Jennifer S Reath · Jessica Sommer · Paul J Torzillo

The increasing use of split livers for in children has effectively increased the donor organ supply

James Neuberger

A 5-year-old girl sustained partial thickness facial burns from oleander leaves that she applied as pretend make-up

Sarah Oudtshoorn · Sanchita Gera · Parshotam Gera

Objective: To evaluate associations between exposure during early life to mine fire smoke and parent‐reported indicators of respiratory and atopic illness 2–4 years later. Design, setting: The Hazelwood coalmine fire exposed a regional Australian community to markedly increased air pollution during February – March 2014. During June 2016 – October 2018 we conducted a prospective cohort study of children from the Latrobe Valley. Participants: Seventy‐nine children exposed to smoke in utero, 81 exposed during early childhood (0–2 years of age), and 129 children conceived after the fire (ie, unexposed). Exposure: Individualised mean daily and peak 24‐hour fire‐attributable fine particulate matter (PM2.5) exposure during the fire period, based on modelled air quality and time‐activity data. Main outcome measures: Parent‐reported symptoms, medications use, and contacts with medical professionals, collected in monthly online diaries for 29 months, 2–4 years after the fire. Results: In the in utero exposure analysis (2678 monthly diaries for 160 children exposed in utero or unexposed), each 10 μg/m3 increase in mean daily PM2.5 exposure was associated with increased reports of runny nose/cough (relative risk [RR], 1.09; 95% CI, 1.02–1.17), wheeze (RR, 1.56; 95% CI, 1.18–2.07), seeking health professional advice (RR, 1.17; 95% CI 1.06–1.29), and doctor diagnoses of upper respiratory tract infections, cold or flu (RR, 1.35; 95% CI, 1.14–1.60). Associations with peak 24‐hour PM2.5 exposure were similar. In the early childhood exposure analysis (3290 diaries for 210 children exposed during early childhood, or unexposed), each 100 μg/m3 increase in peak 24‐hour PM2.5 exposure was associated with increased use of asthma inhalers (RR, 1.26; 95% CI, 1.01–1.58). Conclusions: Exposure to mine fire smoke in utero was associated with increased reports by parents of respiratory infections and wheeze in their children 2–4 years later.

Gabriela A Willis · Kate Chappell · Stephanie Williams · Shannon M Melody · Amanda Wheeler · Marita Dalton · Shyamali C Dharmage · Graeme R Zosky · Fay H Johnston

Our new birthweight charts may facilitate more accurate diagnosis and improve care for small-for-gestational age babies

Farmey A Joseph · Jonathan A Hyett · Philip J Schluter · Andrew McLennan · Adrienne Gordon · Georgina M Chambers · Lisa Hilder · Stephanie KY Choi · Bradley Vries

The incidence of paediatric type 2 diabetes has increased in Australasia parallel to paediatric obesity and international guidelines available do not address the specifics for high risk ethnic groups

Alexia S Peña · Jacqueline A Curran · Michelle Fuery · Catherine George · Craig A Jefferies · Kristine Lobley · Karissa Ludwig · Ann M Maguire · Emily Papadimos · Aimee Peters · Fiona Sellars · Jane Speight · Angela Titmuss · Dyanne Wilson · Jencia Wong · Caroline Worth · Rachana Dahiya

Caution is needed so that population‐level reductions in the stillbirth rate are not offset by iatrogenic harm to healthy babies The federal Minister for Health the Honourable Greg Hunt MP recently launched the Safer Baby Bundle — a national stillbirth program that aims to reduce stillbirth in Australia by 20% by 2023.1 The program is one of the responses to recommendations arising from the federal Senate's Select Committee on Stillbirth Research and Education.2 It draws from similar bundles of care in the United Kingdom that have been associated with successful reductions in stillbirth.3,4 Undoubtedly, these whole‐of‐population level programs are important and effective. However, because late pregnancy stillbirth can be prevented simply by delivering all babies early, they have the potential for harm. There are five components of the Safer Baby Bundle: supporting women to stop smoking in pregnancy; improving awareness of a safe maternal sleeping position; improving decision making about timing of birth; improving the detection and management of fetal growth restriction (FGR); and raising awareness and improving care for women with decreased fetal movements (DFM). Of these five components, the latter two have the potential to increase early delivery. FGR is the strongest contributor to the burden of stillbirth. If detected and managed, the risk of stillbirth is 20‐fold lower than if FGR remains undetected.5 Improving the detection of FGR is central to any program aiming to reduce stillbirth. But increasing FGR detection may also cause harm. In a French population, half of the babies suspected of FGR antenatally had normal growth.6 In Victoria, a greater focus on improving the detection of FGR quadrupled the number of babies delivered early for suspected FGR, from 741 in 2000 to 2996 in 2017.5 The number and proportion of these babies with a birthweight in the 10th centile or greater increased from 307 (41%) to 1597 (53%).5 Striving to increase the sensitivity of FGR detection decreased specificity. This is a problem because unwarranted early delivery is harmful to both immediate perinatal5,6 and longer term developmental outcomes.7 Similar risks exist for increasing awareness of DFM. It has long been recognised that there is a relationship between DFM and stillbirth. Women who report DFM have a 2.4‐fold increased risk of stillbirth.8 However, translating this into an effective intervention has been challenging. Thirty years ago, it was shown that the use of formal fetal movement counting charts failed to reduce stillbirth.9 More recently, a large randomised controlled trial — the AFFIRM trial — assessed a care package for women presenting with DFM. In over 400 000 women attending 33 health services in the UK, increasing the awareness of DFM and standardising the care of those women presenting with DFM did not significantly reduce stillbirth.10 Moreover, there was evidence of harm to both mother and baby. Despite clear guidance for clinicians about what investigations to offer women with DFM and under what circumstances delivery was merited,11 there was an increase in the rates of induction of labour and caesarean delivery,10 with an additional 500 babies born between 32 and 34 weeks’ gestation and 5000 more born between 34 and 37 weeks’ gestation. The number of babies requiring admission to a neonatal unit also increased.10 The fact that most women with DFM will go on to give birth to a healthy baby suggests that the care package assessed by AFFIRM needs to be better targeted to women at risk. So what lessons can be drawn from these experiences for the Australian Safer Baby Bundle? Foremost, it is to be aware of the potential harm of any intervention and to look for this harm. This is possible with the use of balance performance measures12 —essentially, measures of unnecessary early delivery such as the proportion of babies delivered for suspected FGR but who were normally grown, or the number of neonatal unit admissions of term babies. Stillbirth programs elsewhere did not embed balance measures as part of their planned evaluation. Benefiting from the lessons learned by others, the Australian Safer Baby Bundle will include these measures to ensure that strategies designed to reduce stillbirth are targeted towards babies who are at most risk.1 The ultimate goal of balance measures is to reduce the unintended harm of our interventions. At present, no strategy has been shown to increase the sensitivity of FGR detection without causing harm. Neither is there a reliable tool to differentiate patterns of fetal movement that correspond to adverse outcome from those that are just a normal event. It is likely that more discriminatory screening tools reside in improved use of ultrasonography and biomarkers that assess fetoplacental function13 or in a better understanding of circadian patterns of fetal movements.14 Until then, caution is needed so that population‐level reductions in the stillbirth rate are not offset by iatrogenic harm to healthy babies. It is crucial that the potential for unintended harm is made explicit and that measures of unnecessary early delivery are used to monitor progress of the Safer Baby Bundle implementation in Australia.

Roshan Selvaratnam · Mary‐Ann Davey · Euan M Wallace

The negative impact of cannabis use by pregnant women is independent of tobacco use

Luke E Grzeskowiak · Jessica A Grieger · Prabha Andraweera · Emma J Knight · Shalem Leemaqz · Lucilla Poston · Lesley McCowan · Louise Kenny · Jenny Myers · James J Walker · Gustaaf A Dekker · Claire T Roberts

The prevalence of food allergy among Victorian children is rising.1 In Victoria, children with suspected food allergies can be on hospital outpatient clinic waiting lists for months before being assessed.2 This may lead families to consider alternative avenues, which can lead to poor allergy management and the need for emergency care. Increasing numbers of Victorian children are presenting to emergency departments,3 but we do not know whether the number visiting with food allergy is also rising. We analysed Victorian Emergency Minimum Dataset (VEMD) data for the period 2005–06 to 2014–15. The VEMD is a statewide administrative dataset that includes non‐identifiable patient‐level data for all Victorian public emergency department encounters. We included all food allergy‐related presentations by children and young people aged 0–19 years, selected according to International Classification of Diseases, tenth revision, Australian modification (ICD‐10‐AM) codes: T78.0 (anaphylactic shock due to a food reaction), T78.1 (other adverse food reactions, not elsewhere classified), T78.4 (allergy, unspecified: includes non‐food‐related allergies), and L27.2 (dermatitis due to ingested food). Presentation rates by age group were calculated using Australian Bureau of Statistics (ABS) age‐stratified population data for Victorians aged 0–19 years;4 rates for regions were calculated using ABS population data for Statistical Areas 2 (SA2).5 The study was deemed exempt from the need for formal ethics approval by the Royal Children's Hospital Human Research Ethics Committee. The number of children presenting to emergency departments with food allergy‐related problems increased from 2368 in 2005–06 to 4263 in 2014–15; the presentation rate increased from 18 to 29 per 10 000 population (Box 1). About half the children who presented with food allergy‐related problems were aged 0–4 years, the rate for this age group increasing from 38 to 55 per 10 000 population (Box 2). The proportion of presentations triaged as being more urgent (triage categories 1–3) also increased, from 51% to 63% (Box 1). The rate of presentations to metropolitan hospitals increased more (from 18 per 10 000 in 2005–06 to 32 per 10 000 in 2014–15; 78% increase) than did the rate for rural hospitals (26 per 10 000 in 2005–06 to 36 per 10 000 in 2014–15; 38% increase) (Box 1). Hospitals in the North‐West Melbourne region received about one‐third of all allergy‐related emergency department visits, and the number in this region doubled over the study period (706 in 2005–06; 1536 in 2014–15) (Box 3). These data indicate that the demand for emergency services associated with food allergy‐related problems in children increased during 2005–15. The increase was particularly marked for children aged 0–4 years and for children and young people in the North‐West Melbourne and Southern Melbourne regions. While the reason for the increased burden is not clear — that is, whether the prevalence of allergy had increased (including because of a change in population composition), management plans had changed, or access to community services was reduced — the consequence is greater demand on emergency services across Melbourne. Box 1 – Presentations to Victorian public emergency departments by childen and young people (0–19 years) with food allergy‐related problems 2005–06 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 2012–13 2013–14 2014–15 All food allergy presentations Number 2368 2680 2754 2991 3082 3159 3185 3422 3881 4263 Rate (per 10 000 population)* 18 20 21 22 23 23 23 24 27 29 ICD‐10‐AM diagnostic codes T78.0 141 (6.0%) 152 (5.7%) 154 (5.6%) 168 (5.6%) 233 (7.6%) 283 (9.0%) 289 (9.1%) 339 (9.9%) 437 (11.3%) 501 (11.8%) T78.1 800 (33.8%) 948 (35.4%) 962 (34.9%) 1127 (37.7%) 1167 (37.9%) 1152 (36.5%) 1117 (35.1%) 1288 (37.6%) 1464 (37.7%) 1624 (38.1%) T78.4 1234 (52.1%) 1351 (50.4%) 1441 (52.3%) 1488 (49.8%) 1552 (50.4%) 1597 (50.6%) 1633 (51.3%) 1702 (49.7%) 1881 (48.5%) 2031 (47.6%) L27.2 193 (8.2%) 229 (8.5%) 197 (7.2%) 208 (7.0%) 130 (4.2%) 127 (4.0%) 146 (4.6%) 93 (2.7%) 99 (2.6%) 107 (2.5%) Age Number 0–4 years 1202 (50.8%) 1364 (50.9%) 1424 (51.7%) 1537 (51.4%) 1520 (49.3%) 1595 (50.5%) 1593 (50.0%) 1759 (51.4%) 2015 (51.9%) 2152 (50.5%) 5–9 years 466 (19.7%) 515 (19.2%) 521 (18.9%) 573 (19.2%) 673 (21.8%) 608 (19.3%) 660 (20.7%) 702 (20.5%) 813 (21.0%) 967 (22.7%) 10–14 years 305 (12.9%) 335 (12.5%) 355 (12.9%) 405 (13.5%) 403 (13.1%) 426 (13.5%) 383 (12.0%) 433 (12.7%) 515 (13.3%) 561 (13.2%) 15–19 years 395 (16.7%) 466 (17.4%) 454 (16.5%) 476 (15.9%) 486 (15.8%) 530 (16.8%) 549 (17.3%) 528 (15.4%) 538 (13.8%) 583 (13.7%) Rate (per 10 000 population)* 0–4 years 38 42 43 45 43 45 44 47 53 55 5–9 years 15 16 16 18 21 18 19 20 22 26 10–14 years 9 10 11 12 12 13 12 13 15 16 15–19 years 12 13 13 13 14 15 15 15 15 16 Sex Number Boys 1284 (54.2%) 1435 (53.5%) 1476 (53.6%) 1625 (54.3%) 1663 (54.0%) 1723 (54.5%) 1779 (55.9%) 1867 (54.6%) 2158 (55.6%) 2388 (56.0%) Girls 1084 (45.8%) 1245 (46.5%) 1278 (46.4%) 1366 (45.7%) 1419 (46.0%) 1436 (45.5%) 1406 (44.1%) 1555 (45.4%) 1723 (44.4%) 1875 (44.0%) Rate (per 10 000 population)* Boys 19 21 21 23 24 25 25 26 29 32 Girls 17 19 20 21 21 22 21 22 24 26 Hospital region Number Metropolitan† 1560 (65.9%) 1860 (69.4%) 1907 (69.2%) 2008 (67.1%) 2071 (67.2%) 2194 (69.5%) 2186 (68.6%) 2345 (68.5%) 2781 (71.7%) 3149 (73.9%) Rural‡ 808 (34.1%) 820 (30.6%) 847 (30.8%) 983 (32.9%) 1011 (32.8%) 965 (30.5%) 999 (31.4%) 1077 (31.5%) 1100 (28.3%) 1114 (26.1%) Rate (per 10 000 population)* Metropolitan† 18 22 22 23 23 25 24 25 29 32 Rural‡ 26 27 27 32 33 31 32 35 35 36 Triage category Categories 1–3 1198 (50.6%) 1429 (53.3%) 1568 (57.0%) 1707 (57.0%) 1830 (59.3%) 1861 (59.0%) 1807 (56.8%) 2047 (59.8%) 2365 (61.0%) 2694 (63.2%) Categories 4, 5 1170 (49.4%) 1251 (46.7%) 1186 (43.0%) 1284 (43.0%) 1252 (40.7%) 1298 (41.0%) 1378 (43.2%) 1375 (40.2%) 1516 (39.0%) 1569 (36.8%) ICD‐10‐AM = International Classification of Diseases, tenth revision, Australian modification. * All presentation rates are per 10 000 children in Victoria aged 0–19 years in the corresponding category. † Victorian Emergency Minimum Dataset (VEMD) regions: North‐West, Southern, and Eastern Melbourne. ‡ VEMD regions: Loddon Mallee, Gippsland, Barwon South West, Hume, Grampians. Box 2 – Presentations to Victorian public emergency departments by people aged 0–19 years with food allergy‐related problems: rates per 10 000 population, by age group Box 3 – Presentations to Victorian public emergency departments by people aged 0–19 years with food allergy‐related problems, by hospital campus region

Rachel O'Loughlin · Harriet Hiscock

Without specific investments in the health of adolescents, Australia will not redress health inequalities experienced by Aboriginal and Torres Strait Island peoples

Peter Azzopardi · Ngaree Blow · Tara Purcell · Ngiare Brown · Tirritpa Ritchie · Alex Brown

As the incidence of childhood cancer rises, challenges include delivering personalised precision medicine and minimising the late effects of disease and treatment

Neevika Manoharan · Tracey O'Brien

The causes of childhood cancers must be understood before interventions to reduce their incidence can be developed

Danny R Youlden · Peter D Baade · Adèle C Green · Patricia C Valery · Andrew S Moore · Joanne F Aitken