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2022 - Weekly Paediatric Lectures 2022 – Weekly Paediatric Lectures Paediatric training overview and how to learn https://youtu.be/MzbUAiWAopo This teaching session focuses on the many ways we can learn paediatrics and child health, so that trainees can make the most of the learning opportunities, and include them into a learning plan for 2022 and beyond. COVID in 2022 and the other side of the pandemic https://youtu.be/WAP7soFUK6g This session covers where COVID is up to in 2022. We discuss the SARS Co-V-2 variant Omicron and its effect on children. We know a lot about this in the last months from what has happened in South Africa and other heavily affected countries. We need to understand the ways in which COVID in 2022 is different from 2021 and 2020, and what it means for paediatrics (mostly it will be good news!) In addition to vaccines, what other therapies are useful in COVID? Type 1 Diabetes in children https://youtu.be/44Iaw79ktZU In the past type 1 diabetes was rare in children in the Pacific, but it is now increasingly, as it is in all countries around the world. Children with diabetes need careful management of their initial presentation – usually ketoacidosis, and they need careful transition to chronic long-term treatment. There is a lot to think about when we are looking after a child with diabetes, but if we manage all issues then these children can have a very good outcome. In this session we cover all stages of management and describe the complications and pitfalls to avoid. Meningitis and encephalitis in children https://youtu.be/Z3q85tj5zVw This teaching session covers meningitis and encephalitis, and other causes of acute febrile encephalopathy. We cover diagnosis and treatment, including basic measures to prevent secondary brain injury – we will go through all the causes and how to prevent them. To care for such patients, we need to understand the rationale for using certain antibiotics in meningitis, antimalarial therapy in cerebral malaria, and how to monitor children properly to prevent secondary brain injury. We also cover identification and treatment of complications (such as cerebral abscess) and when to suspect other causes (tuberculosis, cryptococcosis, non-infective causes). Pneumonia and bronchiolitis https://youtu.be/UIEIiCBlSdI Pneumonia is the most common cause of child morbidity and mortality, and it is both simple and complicated. Treatment guidelines outline a Standard treatment approach for simple pneumonia, but many cases are complicated, and we need early recognition of such cases. We need to improve risk assessment for children with pneumonia, and this involves early recognition of risk factors. If we recognise these risks early, we can put in place measures to achieve a better outcome. These risks include hypoxaemia, WHO emergency signs, malnutrition, chronic comorbidity, neonates, special x-ray changes, and sometimes other laboratory tests. We need to identify complicated cases of pneumonia, especially empyema, and lung abscess, and cases that will not be treated with standard antibiotic therapy, including tuberculosis or Staph pneumonia. There are ways to do this, and we discuss in this teaching session. Antibiotics and antibiotic resistance https://youtu.be/LCL5wJEFeEo Antibiotics treat bacterial infections, but in the last 25 years bacteria causing common infections are becoming resistant to many antibiotics, in Papua New Guinea and in all countries. We need to understand the mechanisms of antibiotic resistance, the different types of resistance in different bacteria, and the options of treatment. Standard Treatment is still effective first line treatment for most common infections, but we need ways to identify clinically and with simple tests the patients most at risk of antibiotic resistance. We can put in place steps to limit antibiotic resistance in our hospitals and paediatric wards, this is called antibiotic stewardship, and we discuss the ways to do this. Epilepsy in children https://youtu.be/rhiUQQFbpCI Epilepsy is common in children, as high as 1-4% in some communities. We need to know how to diagnose epilepsy, an understanding of the types of childhood epilepsy, the anti-epileptic medications, why to choose certain drugs, their complications, what to do if one drug is not working, and the overall goals of care for children with epilepsy. Most children and adolescents with epilepsy can have a good outcome if they and their families are cared for in a holistic way. Fluid and electrolyte management https://youtu.be/6i37wZV1SVo In this session we cover the essentials of fluid and electrolyte management in children, including the type and volume of fluid to use, the dangers of low sodium containing intravenous fluids formerly commonly used in paediatrics, the risks of hyponatraemia and hypernatraemia and how to treat, the importance of clinical monitoring of oedema and dehydration, and how to calculate fluid replacement in a child with severe dehydration, including the deficit, maintenance, and ongoing losses. Neurological examination of children https://youtu.be/QN5vHMKXzMw In this session we go through the neurological examination of children and describe a practical approach to making clinical diagnoses – by first asking “where is the lesion”, to locate the neurological abnormality, and afterwards ask “what is the lesion”. With history and neurological and general examination, many clinical diagnoses can be made. Vaccines and vaccine preventable diseases https://youtu.be/SSBU5XcrHqo This session covers the basic information paediatric trainees need to know about vaccines and the diseases they prevent, the history of the expanded programme of immunisation (EPI), the different types of vaccines, and the recent changes to the vaccine schedule. This will help you become familiar with the current EPI schedule, and vaccine terminology, for example what live attenuated, inactivated, recombinant, conjugate, and adjuvant mean. We also cover the science of why measles outbreaks occur, and the reasons for recent polio and pertussis outbreaks in PNG. Failure to thrive https://youtu.be/II2C6KV2BPs Failure to thrive is a common paediatric presentation. It is not just malnutrition but encompasses the developmental impact of poor nutrition. Failure to thrive is often a combination of inadequate energy (calorie) or protein intake, inadequate absorption of nutrients in the gut, increased energy utilisation, underlying infectious or genetic condition, psychosocial and environmental factors. It is important to understand each component to manage these children properly. We will discuss the assessment of a child with failure to thrive, the stages of management of severe malnutrition according to WHO and Standard Treatment guidelines, and how to identify and manage refeeding syndrome, which can cause patients to deteriorate after recommencing feeds. Neonatology I: care of the very low birth weight baby https://youtu.be/LV-tib4RQJg In this teaching session we cover definitions of low birth weight and prematurity, gestational age assessment, multi-system complications of prematurity, respiratory complications and care for the developing lungs, nutrition and growth monitoring, gastrointestinal complications, retinopathy, anaemia, hospital discharge criteria and follow-up of very low birth weight babies. Neonatology II – infections https://youtu.be/rzlfrFFdyNc In this session we cover all common neonatal infections: bacterial, viral, including intrauterine, and post-natally acquired infections in newborns. Paediatric mortality and morbidity audit meetings https://youtu.be/ROiuFhpnPpQ Auditing of child deaths allows the identification areas that can be addressed to improve quality of care. About 50% of child deaths have at least one modifiable or preventable factor: in the community, in primary health care, or in hospitals. Audit is an important process, but it must be non-blameful, open to and supportive of all staff, and educational. This teaching session goes through how to run M&M meetings, and the importance of follow-up after such meetings by a quality improvement team to put changes in place. All hospitals should do regular audit, and paediatric trainees need to learn how to conduct these meetings. Cardiac disease in children I https://youtu.be/Iw7pDHKo_BE In this first of two sessions on paediatric cardiology, we will discuss the causes of heart failure at different ages, especially focus on acyanotic congenital heart disease, and the most common left to right shunts (ASD, VSD, PDA). We will go through how to assess cardiac function clinically, and how to integrate the history (age of presentation, severity, symptoms, associated features), the examination finding, the chest x-ray and ECG to make the diagnosis 90% of cases. We will cover the basics of echocardiography, but very often we can make a working diagnosis on clinical grounds and with proper interpretation of x-ray and ECG. Cardiac disease in children II – cyanotic CHD and pulmonary hypertension https://youtu.be/Hm5TyQ8GmwI In this session we will discuss cyanotic congenital heart disease (CHD), its different presentations in the newborn period, infancy, and older childhood. We will discuss how to manage the cyanosed neonate, who might have CHD, but also might have other conditions, such as persistent pulmonary hypertension of the newborn (PPHN), sepsis, or congenital lung disease. We will also discuss acquired pulmonary hypertension that arises due to chronic lung disease, severe pneumonia, high altitude, and nutritional issues, especially a problem in the highlands. In this session you will learn the ECG and x-ray changes of common forms of cyanotic CHD and pulmonary hypertension, so the diagnoses can be made using clinical features and basic investigations. Renal disease in children https://www.youtube.com/watch?v=utB37NOvkbA We cover nephrotic syndrome, post Streptococcal glomerulonephritis and congenital renal diseases that can lead to chronic renal failure. We also cover acute renal failure and its management, nephrotoxic drugs and management of complications, particularly hypertension. Adolescent health Part 1: https://youtu.be/styx0_YSIyA Part 2: https://youtu.be/REIx6UKoAhg This teaching session in 2 parts, by Dr Mary Paiva covers the main issues in adolescent health. Adolescent health is increasingly important in PNG, and paediatricians need a good understanding of the neurobiology, the neurodevelopmental transition and vulnerabilities of adolescence, the factors that influence health seeking behaviours of adolescents, and their health concerns, including sexual health, mental health, substance use, nutrition, and particular issues for adolescents with chronic diseases. Dr Paiva discusses the roles of health services for adolescents in hospitals and in the community, in prevention, education and treatment. Anaemia in children Video links (in 2 parts): https://youtu.be/Ra_eq54-7TY https://youtu.be/h8mQbv1bH1Q In 2021 anaemia was reported in at least 7% of all paediatric hospital admissions, the case fatality rate was 12%, and anaemia was a comorbidity in at least 17% of all child deaths. Anaemia increases the risks of infection, poor growth and development. In this session we will cover the common causes of anaemia in children, especially iron deficiency and nutritional anaemia. We will discuss how to assess the child with pallor, how to distinguish based on clinical features and an analysis of the FBC the different causes of anaemia. We will cover iron physiology, anaemia of malaria, anaemia due to haemolysis and anaemia due to bone marrow failure, and Thalassaemia. We will also discuss nutritional treatment of anaemia, safe use of iron, and indications for blood transfusion. Soil transmitted helminths in children Video link https://youtu.be/OyGiBaejNjQ WHO identifies soil-transmitted helminths as among the neglected tropical diseases (NTD). Many children in PNG are affected by these infestations, including from Ascaris, Human hookworm, Cutaneous larva migrans (dog hookworm), Whipworm, and Strongyloides. This session will discuss sources, lifecycles, clinical features, and treatment of these infections, which cause a lot of morbidity and nutritional problems in children. Trainees need a good understanding of the basics of helminth infections, as they are often truly neglected in our management of patients. Liver disease in children Video link: https://youtu.be/geKKZWi3VgA Liver disease is more common than may think, being caused by a variety of conditions directly affecting the liver, and systemic infections where liver dysfunction is a part of it. Liver disease can be a part of virus, bacterial and parasitic infections, cancer, and drug side effects. Paediatricians need to have a good understanding of liver anatomy and physiology, the different functions of the liver, the production and excretion of bile, and the significance of different tests of liver function. In this teaching session we discuss the differences between physiological and pathological jaundice in newborns, thresholds for phototherapy, the various forms of congenital liver disease such as biliary atresia and neonatal hepatitis. We also cover liver disease in older children, where we need to distinguish acute from chronic liver disease and recognise the effect of drugs on liver function. We can diagnose most liver diseases with a good history, clinical examination, and an understanding of the basic LFTs. Although there is often no specific treatment that can be given to children with liver disease, many types of liver disease resolve with time, and there are important ways to support such patients to give their liver the best chance of recovery. Paediatric x-rays Video link: https://youtu.be/xBNqltqj8P4 In this teaching session we will go through a series of x-rays to show common problems in seriously ill children and learn how to relate the changes you see on x-rays to the clinical picture and pathophysiology. So many diagnoses can be made by linking these things together (clinical, x-ray, pathophysiology). In the DCH and MMed exams you will need to be interpreting x-rays, so watch the session if you can. Management of critical illnesses in children I Video link: https://youtu.be/WGJ7G7tV5Aw In this session we will go through some common scenarios in the management of common severe illness in children, including severe acute respiratory distress, upper airway obstruction in infants, and sudden cardiac arrest in a previously well adolescent. We can use clinical signs and basic test to differentiate the causes of these clinical syndromes: for example, differentiating when severe respiratory distress is due to pneumonia or airways disease, and then considering the different causes of airways disease at different ages. This type of deductive reasoning allows for specific treatment that addresses the underlying pathophysiology, at the end we discuss a framework for thinking about children with critical illness on ward rounds. Common critical illness in children II Video link: https://youtu.be/4bZt2AkEIKc In this second teaching session on the management of critical illness in children we discuss a few case scenarios and how to approach them, including unusual causes of respiratory distress, the causes and management of shock in a child with Hirschsprung disease, and basic neuroprotection for children with meningitis or encephalitis. Differentiating causes of acute illness, understanding the pathophysiology, providing supportive care and monitoring, and giving time are all important for critically ill patients to recover. How to write a minor thesis Video link: https://youtu.be/KXavdZfRCrg In this teaching session, we cover the next step of how to write a thesis. Includes developing a spreadsheet, ensuring it is analysable, and how to construct and write a thesis. There are many things you can do to make the process easier, and that help you learn about doing research. HIV in children and adolescents YouTube recording did not work In this session we discuss all things related to HIV management. The diagnosis, types of anti-retroviral drugs, mechanisms of drug resistance, and the new recommendations for ART dolutegravir-based therapy. We also discuss chronic care for children and adolescents with HIV, which involves a lot more than ART, including consideration of nutrition, gastrointestinal, lung, cardiovascular, renal and bone health, development, and neurological issues. Care of children and adolescents with HIV also requires improving mental health, self-esteem, and school participation. Paediatric cancer YouTube video link is at: https://youtu.be/5ZxQQr-QsOg These 2 sessions on common cancers affecting children in PNG give an overview, covering acute leukaemia, lymphoma, retinoblastoma, chest tumours, and abdominal tumours. We discussed the diagnosis using important clinical signs, basic laboratory investigations, imaging cancer using ultrasound and CT, and cover treatments of the commonest cancers and their complications, and the management of common cancer emergencies. Acute kidney failure and encephalopathy case discussion Video link: https://youtu.be/dVusXDFI05c This session highlights the many cases of acute renal failure and encephalopathy in children in Indonesia. Dr Nina Putri, paediatrician from Jakarta presents a typical case, and other specialists from Indonesia also provide input. We discuss the likely causes, which include diethylene glycol contamination of cough and cold medicines, or a post-COVID complication that severely affects the kidneys. We discuss similar outbreaks in other countries from contaminated medicines including recently in Gambia, and previously in India, Bangladesh, Nigeria, South Africa, treatment options for acute renal failure, public health measures, and the reasons why some remedies have been contaminated in the manufacturing process.

Research 2018 Research 2018 Diploma of Child Health Benjamin Daur Outcomes of paediatric cancer in PNG DCH 2018 At Port Moresby General Hospital, between 2016 and 2018, 61 children with cancer were diagnosed. The mean time of diagnosis from first symptoms was 8 months, and the mean time from presentation to diagnosis was 9 days. Compared with earlier studies from 1998-2001 there has been an increase in retinoblastoma diagnoses and a decrease in the number of children diagnosed with lymphoma. The late presentation is a concern, and messages need to get out to health workers about the signs that could indicate childhood cancer: severe pallor, a lump, swelling of the abdomen, easy bleeding and progressive malnutrition. For retinoblastoma the early signs are leukocoria (white pupillary reflex), strabismus (squint) and eye inflammation or swelling which does not resolve with antibiotics. Heagi Lovai Waiting times in children’s emergency department PMGH DCH 2018 At Port Moresby General Hospital Children’s Emergency Department waiting times for 164 patients was assessed. A 5-tier Australasian Triage classification is used, but there is not consistency of classification between health care workers. Average overall waiting time was 119 mins; 96% of patients in category 1 (the most severe) and category 2 waited longer than specified by the Australasian Triage criteria. There is a need to use a Triage classification system that is easy to understand, such as WHO’s triage system (Emergency signs, Priority signs, or none of the above), and a need to improve staffing in the children’s emergency department, including more nurses and specialist paediatric cover to support the registrars. Rose Hosea Care seeking Behaviour in Mendi DCH 2018 In Mendi, care seeking behaviour of the parents of 100 children requiring admission with pneumonia (53), diarrhoea (43) or both (4) was assessed. 70% of the patients were infants. Many parents sought hospital treatment more than 24 hours after onset of illness despite residing within an hour of the hospital. Most parents who delayed care did so thinking that the symptoms were not serious, and waited at home for them to subside. The presence of more than one symptom of illness seemed to be a motivating factor to seek care, parents understanding that this indicates increased severity of illness. Some parents had false beliefs about the cause of diarrhoea, believing it was normal phase in child development, rather than an infection or illness. Gordon Pukai RCT of Nebulised saline in bronchioitis DCH 2018 In a randomised trial in the Port Moresby General Hospital Emergency Department, children under 2 years of age with clinical bronchiolitis were given either nebulisation with normal saline (x 3 over 4 hours) in addition to standard treatment (oxygen if SpO2<90%, antibiotics, minimal handling), or standard treatment alone. A change in Respiratory Distress Score, hypoxaemia and admission were the main outcomes. The 2 groups were similar to begin with in terms of RDS and oxygen saturation. There was a significant difference in the change in RDS at 4 hours between the 2 groups. Among the 100 that received nebulised Normal saline, the mean RDS fell by 3.41 (95% CI 3.0-3.8), whereas in the Standard group the RDS fell by only 1.96 (95% CI 1.5-2.4). P-value <0.0001. There was a significant difference in the change in SpO2 between the 2 groups. Among the 99 children who received standard therapy the SpO2 increased by 4% (95% CI 2.8-5.2) to a mean SpO2 of 87.5% at 4 hours, and among the 100 who received normal saline the SpO2 increased by 7% (6.0-7.9) to a mean SpO2 of 90.7% at 4 hours. There was a significantly higher discharge rate in those who received Normal saline. 58 of 100 (58%) were discharged, whereas only 24 of 99 (24.2%) who received Standard care were discharged (p<0.001). Master of Medicine Maylin Kariko Follow-up of LBW babies at PMGH MMed 2018 A follow-up study was conducted for 81 low birth weight babies recruited from the Special Care Nursery at Port Moresby General Hospital. The mean birth weight was 1495 g, and the mean gestational age was 34 weeks, meaning these LBW babies were significantly small for gestational age, as well as being preterm. The median length of stay was 19 days, and the discharge weight was 1.54kg. There were 16 known deaths: 13 while in hospital and 3 after discharge. Many infants were lost to follow up. 39 were followed up at a median of 9 months chronological age. The majority of these babies followed up were well nourished with a weight-for-length z-score of -0.3, and most had good head growth (40th centile). 47% had some degree of gross motor developmental delay, although it is too early to be sure. 15 (38%) were admitted to the children’s ward during the period of follow-up, mostly for respiratory and gastrointestinal infections, which highlights the increased vulnerability to community acquired infections in this population. Paul Wari Early infant diagnosis of HIV at PMGH MMed 2018 A descriptive study was done to assess the outcomes of children exposed to HIV in the Prevention of Parent to Child Transmission Programme at the Well Baby Clinic, of Port Moresby General Hospital. 135 children were followed. All received zidovudine for the first 6 weeks of life, and 118 received nevirapine. 58 were exclusively breast fed, 25 formula fed, 40 mixed fed, and in 12 the feeding method was unascertained. 95 received isoniazid prophylactic therapy. 14 (10%) had a positive HIV-PCR test at 6-8 weeks of age. Two thirds (90/135) did not have any follow-up testing at 6 or 18 months and nearly 2/3 were lost to follow-up by 18 months (85/135). 6 were known to have died. There has been a deterioration in PPTCT and HIV services for children since the loss of funding and coordination by the CHAI PNG, leading to high rates of loss to follow up and inadequate testing being done. Vela Solomon MDR TB at PMGH MMed 2018 50 children with multi-drug resistant TB were described at Port Moresby General Hospital. The numbers of children diagnosed from 2004 have increased each year. These children came from National Capital District, Central and Gulf Provinces, and Daru. 38 (76%) had previously undergone treatment for drug-sensitive TB, and 31 had completed this treatment. A contact source for drug-resistant TB was identified in 25 children, and in 10 children the contact was the child’s mother. The median length of illness until diagnosis was 7 months, but many children had received multiple courses of DS TB and other treatments, either complete or partial. 35 children had confirmation of rifampicin resistance on GeneXpert testing, and 15 were diagnosed on clinical grounds alone. 16 were TB culture positive, and drug resistance patterns were identified in 15 of these. Veronica Kalit Rheumatic Heart Disease study MMed 2018 48 children with rheumatic heart disease (RHD) were involved in a longitudinal cohort study, using quantitative and qualitative methods to understand their and their family’s perceptions of their condition, and secondary prophylaxis. These children had quite severe RHD, with 31 having moderate-severe mitral regurgitation, 20 having moderate-severe aortic regurgitation, and 31 on anti-heart failure medications. There were 4 deaths in the follow-up period, including 2 sudden deaths immediately after injections of benzathine penicillin in children with severe heart failure. The deaths lead to a change in secondary prophylaxis at Port Moresby General Hospital: from predominantly benzathine penicillin to daily oral penicillin V. Elizabeth Longa Anaemia in children in Kimbe MMed 2018 In Kimbe 214 children with anaemia (median Hb 6.72 g/dL) were studied. 14 children had a history of chronic illness, including pulmonary tuberculosis (6 cases previously diagnosed), HIV, hypothyroidism and cerebral palsy (1 each). Rapid diagnostic tests for malaria were done in 213 children: 133 were negative, 33 were positive for plasmodium falciparum, 43 were mixed, and 4 were plasmodium vivax 179 children were followed up and had a repeat Hb 5 months after first presentation. The mean change in Hb for the 179 children was 4.07 (SD 2.51) g/dL. Five children died from malignancies (AML and retinoblastoma), severe malaria, HIV and severe malnutrition and meningitis. The mortality rate for severe anaemia can be low if Standard Treatment is followed and comorbidities are identified and treated. Casparia Mond Epilepsy in children in NCD MMed 2018 47 children with epilepsy were studied over nearly 2 years at Port Moresby General Hospital, the median age of the children was 6.5 years. 21 (45%) had normal development, and 26 (55%) had some developmental delay. Most children had generalised tonic-clonic seizures or complex partial seizures. Over 20 months of close follow up and adjustment of medications the proportion of children with good control (less than 4 seizures per month) increased (73% at baseline and 92% good control at 20 months), and the proportion with very poor control decreased. Frequent stock-outs of phenobarbitone, lack of reliable availability of alternative anti-epileptic drugs (sodium valproate, carbamazepine, phenytoin), and financial challenges faced by parents effected the child’s seizure control. For the children with epilepsy stigma and discrimination affected the quality of their lives, but many had strong ambitions to do well in school and get good jobs in the future.