Paediatric trauma

Abstract:  Trauma remains the most common cause of death in childhood after the first year of life. It accounts for considerable morbidity that may extend into adult life at great cost to the community. Despite the scale of the disease, paediatric trauma and injury prevention research attract little funding. International data indicate that children in Australia and New Zealand would benefit from improved injury prevention strategies and the introduction of a more formalized paediatric trauma system. Such a system would need to take account of Australasian geographical and population distribution characteristics, which mandate local provision of expert and immediate care in rural areas. There would appear to be economic and clinical arguments for the introduction of an ambulance trauma bypass system for stable but severely injured children in metropolitan areas with a paediatric trauma centre.     

Paediatric management practices in Down syndrome: A follow-up survey

In a follow-up survey to a 1984 study, 339 paediatricians in Australia were invited to complete a brief questionnaire in 1990, in which they indicated their usual recommendations, practices and advice when managing children with Down syndrome. The response rate was 67%. The results indicated that the most frequent paediatrician-initiated referrals were for early intervention and for discussion with other parents; these options were selected more frequently in 1990 than in 1984. While referral to a social worker was the next most frequent choice, it occurred less in 1990 than in 1984. Other increases in referrals were for physiotherapy and speech therapy. Paediatricians were more likely to support referral to a geneticist, speech therapist or cosmetic surgeon in response to a specific parental enquiry, and less likely to support referral to a social worker or to full-time care. There had been significant increases since 1984 in the likelihood that paediatricians would order audiology and investigation of thyroid and cardiac function. There was less opposition to the use of sedatives, and virtual cessation of the use of tryptophan. Paediatricians were more optimistic about the likelihood of persons with Down syndrome living independently, caring for their own finances, and marrying, but not about other developmental areas.     

Childhood tuberculosis: A roadmap towards zero deaths

‘Every day, more than 200 children under the age of 15 die needlessly from tuberculosis (TB) – a disease that is preventable and curable. The World Health Organization estimates that as many as 1 in 10 TB cases globally (6–10% of all TB cases) are among this age group, but the number could be even higher because many children are simply undiagnosed.’ Childhood TB is emerging from the shadows. This quote comes from the recently launched international roadmap towards zero TB deaths in children. We provide a brief update of new developments and remaining challenges related to childhood TB, with particular emphasis on the new roadmap.     

Paediatric palliative care: distinctive needs and emerging issues

Palliative medicine has developed as a specialized field of practice in recent decades but the focus has been very much on older adults with incurable malignancies. The needs of dying children have not been addressed adequately and the question of who is best placed to provide care to this group remains the subject of some contention. Although the principles of palliative care apply equally to children, a number of fundamental differences influence their application in the paediatric setting. These include a heterogeneous patient population, physiological factors, developmental issues, parental involvement in care giving and decision making and the desire of most paediatricians to maintain close involvement with their patients. Families generally prefer home care and even quite severe symptoms can be managed in this environment with appropriate planning, expertise and support. The delivery of effective palliative care in the paediatric setting is contingent upon overcoming barriers between hospital and community and sharing expertise between paediatricians and palliative care physicians. Research is also required to increase the evidence base for practice.     

Invasive pneumococcal infection in children, 1981-92: A hospital-based study

Objective: To document the pattern and sequelae of invasive pneumococcal infection in hospitalized children.
Methodology Retrospective review of Streptococcus pneumoniae (Sp) isolates from normally sterile sites from 1981 to 1992 at three paediatric centres in Sydney for demographic data, spectrum of disease, predisposing conditions, mortality, and sequelae from meningitis.
Results: Four hundred and thirty-one episodes in 417 patients were identified. Foci of infection were: meningitis, 34%; pneumonia, 29%; bacteraemia without apparent focus, 30%; and other foci, 7%. Sixty-one per cent of all cases and 64% of cases with meningitis were less than 2 years old. Predisposing conditions were present in 37%, were significantly more common in patients over age 2 years and were more common with foci other than meningitis. Overall mortality was 6.6% whereas the mortality for those with meningitis was 8%. Neurological sequelae were identified in 34% of previously normal children, and severe hearing loss occurred in 11.5%.
Conclusions The high morbidity and mortality from invasive pneumococcal infection in children justifies further evaluation of preventive strategies.     

Australian Paediatric Surveillance Unit : progress report

The Australian Paediatric Surveillance Unit (APSU), through active surveillance, collects information on the epidemiology of rare or uncommon childhood conditions. This research resource allows paediatricians to collaborate at State, national and international levels. The APSU sends a monthly report card to all (currently 971) paediatricians in Australia, who in turn indicate whether or not they have seen a patient in the last month with any of the conditions listed (98% response rate in 1999). Study investigators, notified by the APSU of positive case reports, obtain demographic and clinical data on the patient from the reporting doctor by postal questionnaire (90% response rate in 1999). Since 1993, the APSU has monitored 27 conditions, including conditions that are vaccine-preventable, otherwise infectious, genetic, congenital and non-communicable. Information collected is disseminated to paediatricians and other health professionals via an annual report, newsletters and publications and is made available to the International Network of Paediatric Surveillance Units. Information provided by the APSU has raised awareness among paediatricians of rare and uncommon childhood conditions, and has been used by health authorities for planning of prevention and intervention strategies and allocation of health resources.     

The cot in cot deaths

Little attention is paid to the cot in cot deaths. We report two cases of cot deaths which occurred in practically identical circumstances, with the infants lying face downwards in soft woven-type carrying baskets. The infants were probably unable to turn their heads to one side to maintain ventilation, due to the construction of these soft baskets with soft mattresses. This probably played an important role in the deaths.     

Paediatric renal stone disease: investigation and management for the paediatrician

Paediatric renal stone disease is uncommon but its incidence is increasing. There has been a shift from predominantly infective stones to a higher rate of metabolic stones. It may present with non-specific symptoms of abdominal pain, haematuria, recurrent urinary tract infections, or may even be found incidentally. Ultrasound scanning should be the first line of imaging in children with suspected renal calculi. If detected, this should be followed by a thorough investigation of underlying causes with blood and urinary analyses to investigate metabolic causes, and further imaging to detect anatomical anomalies and for surgical planning, if required. Acute management consists primarily of good analgesia, hydration and management of sepsis, if present. Surgery may rarely be indicated in an obstructed system. There is a range of surgical options for the definitive management of renal calculi. The selection of a particular treatment modality is dependent on multiple factors. Renal calculi can recur and cause co-morbidities including renal impairment leading to the need for renal replacement therapy. Therefore, patients should be managed proactively. This short article outlines what paediatricians and healthcare professionals caring for children need to know about the diagnosis, management and appropriate referral onwards of children with renal stone disease.     

Paediatric resuscitation by phone: the call back

OBJECTIVE: To assess whether the nationwide introduction of standardized paediatric resuscitation training has resulted in an increase in resuscitation knowledge from 1995 and whether this increase in knowledge is greater in those who have attended a resuscitation training course within the last year. METHODS: National telephone survey of paediatric residents. RESULTS: A total of 128 out of a possible 140 residents responded. The mean score in 2002 was significantly higher than in 1995. Those 2002 respondents who had attended a course scored significantly higher than both 1995 respondents, and those 2002 respondents who had not attended a course. There was no significant difference between those 2002 respondents who had not attended a course and the 1995 respondents. CONCLUSION: There has been a significant increase in resuscitation knowledge from 1995 to 2002. This improvement has occurred over a period coinciding with the nationwide introduction of standardized resuscitation training. The authors suggest that this improvement is, in part, due to the introduction of standardized paediatric resuscitation training.     

Paediatric cardiology: The last 50 years

In the last half‐century, the outlook for children with heart disease has changed dramatically. Morphologists have transformed our understanding of heart defects. Improved imaging methods, such as echocardiography, computed tomography and magnetic resonance imaging, have made diagnostic cardiac catheterisation almost redundant. However, interventional catheterisation has flourished as transcatheter procedures have replaced surgery for many lesions. The ability to pharmacologically manipulate the duct has revolutionised the management of the sick neonate with major heart disease. Better surgical techniques, such as deep hypothermia and circulatory arrest, allow repair of lesions in early infancy before irreversible complications develop. Advances in anaesthesia and intensive care have been integral. New sub‐disciplines, such as fetal cardiology and electrophysiology, have emerged. The sum of these numerous developments is enormous. Lesions that were previously considered lethal are now routinely treated. Consequently, the great majority of children with major heart disease now reach adulthood in good health.     

Paediatric melioidosis in the Northern Territory of Australia: an expanding clinical spectrum

OBJECTIVE: The objective of this study was to present the laboratory and clinical features of the six cases of paediatric melioidosis diagnosed from 1997-2000. METHODOLOGY: All cases of melioidosis confirmed by the pathology department of Royal Darwin Hospital were prospectively identified by culture and/or serology. RESULTS: Four children were Aboriginal and all six cases presented during the rainy season (November-April) in rural areas in the tropical Top End of the Northern Territory. Delay in diagnosis ranged from 5 and 11 days. Two cases had localized melioidosis, two cases had underlying disease and were likely to be colonized with Burkholderia pseudomallei (B. pseudomallei). Two cases had neurological melioidosis with major residual disability. No deaths occurred. CONCLUSIONS: Melioidosis remains an unusual disease in children in the tropical Northern Territory. The average annual incidence since 1997 is 5.48 per 100 000. This series demonstrates that children in Australia can have serious neurological complications from B. pseudomallei infection. All children living in or visiting tropical Australia are at risk, especially those residing in rural areas in the rainy season. Melioidosis remains a difficult disease to manage, and expert opinion should be sought if B. pseudomallei is cultured from any site.     

Medico-legal child deaths in Istanbul: data from the Morgue Department

BACKGROUND: Before determining health policies, finding solutions to problems and taking precautions, one should define the problems and their regional and national dimensions. Data about causes of death vary from country to country and, therefore, it is clear that precautions should be based on regional data and needs, which will be more effective. METHOD: The authors reviewed deaths among children aged 1 month to 18 years, whose autopsies were performed in the Morgue Department, State Institute of Forensic Medicine, Istanbul, Turkey, between 2000 and 2002. RESULTS: The authors evaluated autopsy reports about 736 child deaths. The mean age of the children was 8.77 +/- 6.25 years and 62.8% of the children were male. As to causes of death, the most frequent was asphyxia. Almost half of them were caused by mechanical asphyxia due to drowning. A total of 48.5% of the deaths were accidental. There was a significant difference in causes of death between children aged 11 years or younger and those aged over 11 years. Death due to nontraumatic conditions and poisoning was predominant among children aged 11 years and younger, while death due to gunshot wounds and stab wounds was predominant among children aged more than 11 years. There was a significant difference in causes of death between females and males. CONCLUSION: Asphyxia, poisoning and blunt traumatic injuries were found to be the leading causes of death, which can be prevented or decreased by certain precautions. As a result, new regulations should be enacted to protect children against accidents, injuries and hazards and a child protection program is needed in Turkey.     

Socio-biological factors in underfive deaths in a rural area

In 1985–86, 286 underfive deaths occurred among a population of 30,000 in a rural area of Haryana. Two hundred and eighty one were analysed for socio-biological factors related to under five mortallty. Females had a higher mortality. About 2/3 of the deaths were in infants, and 90% in first 3 years. Most of the deaths (94%) occurred in the village itself, 58.4% did not seek any medical care during the terminal illness, 80–90% did not receive even a single dose of BCG, DPT or O.P.V., and 36.7% died in the first attack of illness. Though 68% had at least one episode earlier, 31.0% had been admitted in hospitals for an earlier episode of illness. In 42.8% of deaths, the birth order was IV or above. Deaths in socially and economically disadvantaged cases constituted 77.6%. The triad of diarrhea, ARI and malnutrition claimed 56% deaths. In 93% of the deaths, the mothers were illiterate and 96.4% were house wives. There was a sibling death earlier in the family in 78.3%, and 60.1% deaths were of those living in poor housing conditions. About 50% had radio for communication, 85.8% had bicycle for conveyance, and in 66.9% the family had piped water supply. All these findings have been discussed in the study.