Paediatric bronchiectasis in the twenty-first century: experience of a tertiary children's hospital in New Zealand

OBJECTIVE: Despite its decline in developed countries, bronchiectasis appeared to be a common diagnosis in Auckland, New Zealand children. The aims of this study were: to document the number of children in Auckland with bronchiectasis, their severity, clinical characteristics and possible aetiologies; to assess whether there was a relationship between ethnicity and poverty; and to estimate a crude bronchiectasis prevalence rate for New Zealand. METHODS: A retrospective review of the case histories of all children attending a tertiary children's hospital in Auckland with bronchiectasis diagnosed by high-resolution chest computed tomography (CT) scan, during the period 1998-2000 was undertaken. Data collected included patient demographics, number of hospitalizations pre- and post-diagnosis, lung function tests, radiology and investigations. The New Zealand deprivation 1996 index was applied to the data to obtain a measure of socio-economic status. RESULTS: Bronchiectasis was found to be common, with an estimated prevalence of approximately one in 6000 in the Auckland paediatric population. It was disproportionately more common in the Pacific Island and Maori children. In Pacific Island children, bronchiectasis not caused by cystic fibrosis was nearly twice as common in the general population than cystic fibrosis. Socio-economic deprivation and low immunization rates may be significant contributing factors. The bronchiectasis seen was extensive. Ninety-three percent had bilateral disease and 64% had involvement of four or more lobes on chest CT scan. A wide range of comorbidities and underlying aetiologies were evident. CONCLUSIONS: Paediatric bronchiectasis in Auckland, New Zealand, is common but underresourced. Only the most severe cases are being recognized, providing a significant challenge for paediatric health professionals.     

Persistence of acute rheumatic fever in a tertiary children's hospital

Aim: To identify and describe all children admitted with acute rheumatic fever (ARF) to a tertiary paediatric hospital in Sydney over a 9‐year period and to describe their demographic and clinical characteristics, management and short‐term outcomes. Delays in diagnosis, recurrence of ARF and use of secondary prophylaxis were also documented. Methods: Retrospective review of medical records for children aged <15 years admitted to the Children's Hospital at Westmead, Sydney, with ARF (International Classification of Diseases (ICD)‐10 classification I0.0–I09.9) during 2000–2008. Only cases meeting the National Heart Foundation of Australia diagnostic criteria for ARF were included. Results: Twenty‐six children met the National Heart Foundation of Australia criteria for ARF. The median age was 11.5 years (range 5.8–14.6) and 15 (58%) were male. Ten (38%) identified as Pacific Islander, and 5 (19%) as Aboriginal and Torres Strait Islander (ATSI). Most (n= 20, 77%) lived in suburban Sydney, and 69% were classified in the two most disadvantaged quintiles on the Index of Relative Socioeconomic Disadvantage and Advantage. Four (15%) had Sydenham's chorea, and 81% had carditis (mitral and/or aortic regurgitation). Six (23%) children had previous ARF. Antibiotic prophylaxis to prevent recurrent ARF was prescribed in all cases, but 50% received oral penicillin, rather than by intramuscular injection. Barriers to timely diagnosis were identified in 81%, including delayed presentation and delayed referral. Conclusion: Most children presenting to the hospital with ARF lived in disadvantaged areas of Sydney. Pacific Islander and Aboriginal and Torres Strait Islander children were over‐represented. Mitigation of RHD requires early identification of ARF and appropriate delivery of secondary prophylaxis.     

Paediatric infective endocarditis: 19-year experience at a tertiary care hospital in a developing country

A retrospective study was undertaken to study children who presented with infective endocarditis (IE) to a university teaching hospital in Beirut, Lebanon, between January 1977 and May 1995. Of 41 patients with IE (24F, 17M), 28 (68%) were diagnosed between 1977 and 1985. Patients' ages ranged from 3 to 18 y (mean age 11.3+/-2.8 y), and 13 patients were <10 y of age. Clinical presentations included: fever (in 88%), heart failure (in 39%), neurologic findings (in 20%) and embolic phenomena (in 22%). Nineteen patients (46%) had underlying congenital heart disease (CHD) with tetralogy of Fallot and pulmonary stenosis being the most common. Sixteen patients (39%) had underlying rheumatic heart disease (RHD). A total of 5 children (12%) with normal cardiac anatomy had IE. One had underlying acquired viral myocarditis with mitral insufficiency. Echocardiography showed vegetations in 60%. Blood cultures were positive in 31 patients (76%). IE occurred in three patients following cardiac surgery. In one patient it occurred within 2 mo of surgery and in the other two it occurred within 6 mo. Streptococcus viridans and Staphylococcus aureus were the two most commonly isolated bacteria. Overall mortality rate was 29% (not statistically significant between patients presenting between 1977-1985 and 1986-1995; p = 0.17). There was no statistically significant difference in mortality among the groups (five in the group with CHD, six with RHD and one with structurally normal heart). This study demonstrates that RHD is an important underlying cause of IE in children in our community. This finding is similar to those in other developing countries and different from those in developed countries. Distribution of pathogens and CHD in our study is comparable to some reports in the literature, except for the higher proportion of patients with underlying pulmonary stenosis. Bacterial endocarditis prophylaxis should be emphasized in patients with RHD or pulmonary stenosis.     

Medical staff's knowledge of pulse oximetry: a prospective survey conducted in a tertiary children's hospital

OBJECTIVES: To assess the knowledge of pulse oximetry of senior (SMO) and junior medical officers (JMO) in a tertiary paediatric hospital. METHODS: A 16-item multiple choice questionnaire was administered to SMO and JMO without prior notice or instruction in the area. The questions were completed voluntarily and anonymously, then proctored and collated by the principal investigator. RESULTS: The mean test scores for SMO and JMO were 70 +/- 15% and 65 +/- 13%, respectively (P = 0.06). A significant negative correlation was found between the test scores and the years of paediatric experience with the SMO. CONCLUSIONS: The results of the survey showed there is an insufficiency of knowledge and understanding among medical staff concerning the principles, clinical applications and limitations of pulse oximetry. More emphasis needs to be placed on teaching these principles to ensure quality care for patients.     

Outcomes of a nutrition audit in a tertiary paediatric hospital: implications for service improvement

OBJECTIVE: To examine the process of anthropometric assessment of nutritional status in a tertiary paediatric hospital, to identify the barriers and to make recommendations for service improvement. METHODS: The accuracy of height and weight scales in wards was checked. Dietitians measured height and weight of a representative sample of 245 inpatients and checked whether these measurements had been recorded on bed charts. Patients were classified as overweight, obese or under-nourished. Diagnoses and procedures were obtained for each patient. Funding implications were modelled for inappropriate coding of nutritional status. RESULTS: The barriers to nutritional assessment and management of nutritional comorbidities were: (i) inaccurate height scales in seven out of 12 wards; (ii) under-recording of height and weight on patient bed charts (73% height missing, 12% both height and weight missing); (iii) under-reporting of obesity and under-nutrition in medical notes (one of eight obese patients, and none of 28 undernourished patients, reported); and (iv) low referral rate of obese or under-nourished children to dietetic services (two of 42 overweight/obese patients referred, five of 28 undernourished patients referred). Funding simulation showed that if under-nourished patients were correctly diagnosed then the potential facility reimbursement would have increased by $A52 326. CONCLUSIONS: Barriers to nutritional assessment can lead to failure to diagnose and treat both over- and under-nutrition, thereby affecting quality of patient care, and may have financial implications for hospitals. Suggestions for service improvement include provision of accurate equipment, adequate training of staff undertaking nutritional assessments and clear definitions of staff responsibilities in all aspects of the process.     

Survey of complementary and alternative medicine use at a tertiary children's hospital

OBJECTIVE: The use of complementary and alternative medicine (CAM) within the Australian community is common. The objective of this study was to determine the prevalence and pattern of CAM usage in children attending a tertiary children's hospital. METHODS: We conducted a cross-sectional survey of children attending the Royal Children's Hospital, Melbourne. Children were identified by consecutive acute admissions and attendance at outpatient clinics. A structured questionnaire with items about the use of CAM in the preceding year was administered by means of a face-to-face interview. RESULTS: Based on the 503 children surveyed, 51% reported CAM use in the preceding year. Forty-three percent had used at least one CAM medication. The most common medicinal CAM used were multivitamins, vitamin C, herbal remedies and homeopathic treatments. Non-medicinal CAM was used by 23% of the participants. The most commonly used therapies were chiropractic, naturopathy, aromatherapy, therapeutic massage and dietary restriction. The main reasons stated for CAM usage included promotion of general health and treatment of colds. Sixty-three percent of those reporting CAM use had not discussed this with their treating doctor. CONCLUSION: The use of CAM by children is common. Complementary and alternative medicine is particularly used for the treatment of common illnesses and conditions of childhood. Importantly, use is not always conveyed to treating physicians. Given the potential risk of adverse events associated with the use of CAM or interactions with conventional management, doctors should ask about their use as a part of routine history taking.     

Paediatric psychotherapy: a service in a general outpatient clinic.

The service of paediatric psychotherapy to a general paediatric outpatient clinic is described. Using techniques developed to suit paediatric patients a median of nine patients each clinic were treated. Referral symptoms resolved in a median time of four months after a median of seven sessions. This model for the management of paediatric patients with emotional and behavioural difficulties may allow an effective and efficient use of psychotherapy time.     

Neisseria meningitidis: evolution of penicillin resistance and phenotype in a children's hospital in Barcelona, Spain

Neisseria meningitidis is the most prevalent micro-organism involved in paediatric bacterial meningitis in the Barcelona area in children over 3 mo of age and it is an important cause of morbidity and mortality in Spain. A total of 498 strains of N. meningitidis, obtained between the years 1986 and 1997 from children with sepsis and/or meningitis, were characterized according to their serogroup and penicillin resistance; their distribution in serotypes and subtypes was studied from 1990. A decreasing tendency in the number of annual isolates was observed in this period. Most isolates belonged to serogroups B (403 strains) and C (77 strains). Serogroup C accounted for 1.8% of the strains in 1986 and 57.1% in 1997. The most prevalent phenotype between 1990 and 1996 was B:4:P1.15. but C:2b:P1.2,5 was the most prevalent in 1997. Overall penicillin-resistance rates ranged from 9.1% in 1986 (when a non-susceptible strain was isolated for the first time in the Hospital Sant Joan de Déu, Barcelona, Spain) to 71.4% in 1997, and it was more common among strains belonging to serogroup C (52% of resistant strains) than to serogroup B (22.1 % of resistant strains). The penicillin-resistance level was low, MIC always < or = 0.5 microg/ml. The present increase in N. meningitidis group C isolates, mainly C:2b:P1.2,5, and the availability of preventive measures for this highly pathological and resistant phenotype, argues strongly for the establishment of an epidemiological monitoring system. Detection of penicillin resistance should be standardized worldwide in order to unify data from all laboratories. CONCLUSION: A shift between serogroups B and C is observed in Barcelona from 1986 to 1997, as well as a rapid distribution of decreased penicillin susceptibility.