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ObjectiveTo describe the health and well-being of children and young people (CYP) seeking asylum subjected to Australia’s immigration policy of indefinite mandatory detention on Nauru.DesignCross-sectional analysis of a cohort of CYP seeking asylum.SettingAustralian paediatric clinicians from 10 health services completed detailed health assessments around the time of transfer from Nauru, mostly to Australia.ParticipantsSixty-two CYP who were ≤18 years on entry into offshore immigration detention on Nauru between 2013 and 2019. Mean age at health assessment was 9 years.Main measuresHealth outcomes were categorised as physical, mental or neurodevelopmental concerns/conditions. Risk and protective factor data were collected using the adverse childhood experiences and refugee-specific adverse childhood experiences tools.ResultsOver half of the CYP (n=32, 52%) were held on Nauru for ≥4 years. The vast majority of CYP had physical health (n=55, 89%) and mental health (n=49, 79%) concerns including self-harm or suicidal ideation/attempt (n=28, 45%). Mental health concerns were more likely in CYP who were school-aged (p=0.001), had been held on Nauru for ≥1 year (p=0.01); originated from the Eastern Mediterranean region (pConclusionsThis study highlights the almost universal physical and mental health difficulties in a sample of CYP who experienced forced migration and were subjected to Australia’s offshore immigration detention policy. Immigration detention in recipient countries, a known adverse childhood experience, may contribute to or exacerbate harmful outcomes in CYP seeking asylum.

Paediatric spondylodiscitis (SD) (discitis) is a rare bacterial infection involving the inter-vertebral disc space and adjacent vertebrae. The non-specific manifestations of SD can lead to delayed diagnosis, which may ultimately result in spinal deformities and even devastating neurological complications. The main purpose of this review is to discuss the epidemiology, clinical, laboratory and radiological features, management and outcome of paediatric SD to help paediatricians recognise and treat this important condition.

Because of the broad clinical spectrum, heritable autoinflammatory diseases present a management and therapeutic challenge. The most common genetic interferonopathy, Aicardi Goutières Syndrome (AGS), is associated with early onset neurologic disability and systemic inflammation. The chronic inflammation of AGS is the result of dysregulation of interferon (IFN) expression by one of nine genes within converging pathways. While each AGS subtype shares common features, distinct patterns of severity and potential for systemic complications amongst the genotypes are emerging. Multilineage cytopenias are a potentially serious, but poorly understood, complication of AGS. As immunomodulatory treatment options are developed, it is important to characterize the role of the disease versus treatment in hematologic abnormalities. This will allow for better understanding and management of cytopenia.In total, 142 individuals with molecularly-confirmed AGS were included. Information on genotype, demographics, and all available hematologic laboratory values were collected from existing medical records. As part of a clinical trial, a subset of this cohort (n = 52) were treated with a janus kinase inhibitor (baricitinib), and both pre- and post-treatment values were included. Abnormal values were graded based on Common Terminology Criteria for Adverse Events (CTCAE v5.0), supplemented with grading definitions for thrombocytosis, and were compared across genotypes and baricitinib exposure.In total, 11,184 laboratory values were collected over a median of 2.54 years per subject (range 0-22.68 years). To reduce bias from repeated sampling within a limited timeframe, laboratory results were restricted to the most abnormal value within a month (n = 8485). The most common abnormalities were anemia (noted in 24% of subjects prior to baricitinib exposure), thrombocytopenia (9%), and neutropenia (30%). Neutropenia was most common in the SAMHD1 cohort and increased with baricitinib exposure (38/69 measurements on baricitinib versus 14/121 while not on baricitinib). Having an abnormality prior to treatment was associated with having an abnormality on treatment for neutropenia and thrombocytopenia.By collecting available laboratory data throughout the lifespan, we were able to identify novel patterns of hematologic abnormalities in AGS. We found that AGS results in multilineage cytopenias not limited to the neonatal period. Neutropenia, anemia, and thrombocytopenia were common. Moderate-severe graded events of neutropenia, anemia, and leukopenia were more common on baricitinib, but rarely of clinical consequence. Based on these results, we would recommend careful monitoring of hematologic parameters of children affected by AGS throughout the lifespan, especially while on therapy, and consideration of AGS as a potential differential diagnosis in children with neurologic impairment of unclear etiology with hematologic abnormalities. Trial registration ClinicalTrials.gov Identifier: NCT01724580 ClinicalTrials.gov Identifier: NCT03921554.

To assess the postoperative timeline for the return to activities of daily living (ADLs) in pediatric patients after arthroscopic drilling of a stable osteochondritis dissecans (OCD) lesion of the knee and to determine the rate of and risk factors for complications after the procedure.In a retrospective chart review, data from all patients aged 18 years or younger who underwent arthroscopic drilling for a stable OCD lesion of either femoral condyle from May 2009 through July 2017 were collected. Demographic data, lesion characteristics, operative data, postoperative course, radiographic outcomes, and complications were recorded. Statistical analysis was performed to determine the risk factors for reoperations.A total of 139 knees in 131 patients were evaluated, with a mean age of 12.7 years, of which 102 (73%) were male knees. The average follow-up period was 17.8 ± 13.2 months after surgery. All patients regained full extension and flexion within 5° of the contralateral knee at a mean of 12.9 ± 3.2 weeks postoperatively, with 95% having returned fully to ADLs by the 3-month postoperative visit. No cases of infection, stiffness, arthrofibrosis, or other procedure-related complications were recorded. A total of 133 knees (95.7%) showed healing on radiographs, whereas 6 knees (4.3%) underwent additional surgical procedures, all of which were performed for treatment failure related to nonhealing lesions (including loose body removal, chondroplasty, and repeated drilling). Lesion size was the only significant risk factor for reoperation (Our findings suggest that arthroscopic drilling for stable, intact OCD lesions in the pediatric knee is a safe procedure with reliable outcomes and return to ADLs and a minimal risk of complications. Most patients return to their preoperative daily activity level with a full range of motion of the knee by 3 months after surgery. Complications, including reoperations, are related to the progression of the OCD lesion rather than to the surgical procedure. Each 1-cmLevel IV, therapeutic case series.

Anosognosia can manifest as an unawareness of neurobehavioral symptoms in individuals with Huntington disease (HD). Measurement of anosognosia is challenging, but the Anosognosia Scale (AS) represents a brief option with promising findings in small samples.To replicate application of the AS in a larger HD sample than previous studies in order to assess psychometrics and demographic correlates and to investigate the genetic, motor, and neuropsychological correlates of the AS in individuals with HD.We retrospectively reviewed the AS ratings of 74 genetically confirmed Huntington gene carriers, nearly all early motor manifest, who had been referred for clinical neuropsychological assessment. Concurrent clinical neurologic examination and neuropsychometric assessment data were compiled, where available (ns = 35-74). The severity of the anosognosia per AS ratings was characterized for the HD sample.The AS ratings did not correlate with demographic variables, genetic markers, or motor dysfunction severity. Correlation analyses revealed that higher AS ratings correlated with worse recognition-discrimination memory performance (r = 0.38, P0.05) but not cognitive control on executive functioning performance or on collateral-reported frontal-behavioral symptoms. Higher AS ratings also correlated with fewer patient-reported depressive symptoms (r = -0.38, P0.01) and diurnal hypersomnia symptoms (r = -0.44, P0.01).Anosognosia (per AS) is associated with recognition-discrimination deficits and fewer self-reported neuropsychiatric symptoms in individuals with pre-to-early manifest HD, though not with HD severity per genetic or motor markers, nor to executive dysfunction or collateral-reported frontal-behavioral symptoms.

BACKGROUND Respiratory syncytial virus (RSV) is a leading cause of acute lower respiratory tract infection and an important contributor to child mortality. In this study, we estimated the frequency and described the clinical features of RSV-attributable deaths in Australian children. METHODS We conducted a retrospective observational study of RSV-associated deaths in hospitalized children

Background: Juvenile Osteochondritis Dissecans (JOCD) is a common knee condition that can cause significant morbidity if the lesion does not heal. Arthroscopic drilling is a common surgical treatment for low-grade intact lesions, but its success rate and complications have not been well defined in a large series. Purpose: This study seeks to determine the reoperation rate and the incidence of major complications following arthroscopic drilling of JOCD lesions of the knee. Methods: A query of patients in the Pediatric Health Information System (PHIS) database from 2013 to 2018 was performed for the diagnosis and billing codes specific for arthroscopic drilling of an intact JOCD lesion. Subsequent surgical procedures on ipsilateral and contralateral knees were then analyzed for evidence of additional surgical procedures related to non-healing of the lesion. Results: We identified 1027 patients, 6-17 years of age, who underwent arthroscopic drilling as their initial surgical treatment for a diagnosis of JOCD of the knee. Within 6 months of the original surgery, 27 patients (3%) had a secondary surgery on the ipsilateral knee and 27 patients (3%) had surgery on the contralateral knee. By 2 years, 84 patients (8%) had a secondary surgery on the ipsilateral knee and 38 patients (4%) had surgery on the contralateral knee. Patient age was a significant factor in both the frequency and invasiveness of secondary surgeries, with older patients requiring repeat procedures and more invasive procedures more frequently. Less than 1% of patients underwent another surgical procedure of the knee not specifically to treat the JOCD lesion. Conclusions: The 2-year reoperation rate following drilling of an intact juvenile OCD lesion was 8%. Younger patients were less likely to undergo a subsequent procedure compared to older patients. In addition, if they did require a second procedure, younger patients were less likely to require a salvage-type cartilage procedure. The rate of complications requiring additional knee surgeries was less than 1%.

Children have been underrepresented in research into the mental health needs of refugee and asylum-seeking cohorts. This study aimed to determine the prevalence of symptoms of post-traumatic stress in children presenting to the Health Assessment for Refugee Kids (HARK) clinic at The Children’s Hospital at Westmead, New South Wales, Australia. Children older than 6 years presenting to HARK between April 1, 2015, and December 31, 2016, were screened using the Child Trauma Screening Questionnaire (CTSQ). Demographic and clinical data were collected through medical record review. Of 365 children over the study period, 198 (54%) were eligible for inclusion, of whom 65 (33%) completed the CTSQ. There were 33 (50.8%) males; the median age was 11 years (IQR 8; 14). The CTSQ screened positive (score ≥ 5) in 40 (62%; 95% CI 49%–74%) children who completed the questionnaire. Children from refugee and asylum seeker backgrounds in this sample showed a high prevalence of symptoms associated with post-traumatic stress and higher than previous estimates. These results emphasise the importance of PTSD screening and mental health support in this population.

Neuropsychiatric manifestations of Huntington's disease (HD) can present years before motor symptoms. Nurses with specialized training provide superior care for HD patients, but HD exposure in nursing education is limited. Here we aimed to describe the historical neuropsychiatric burden in 50 HD patients and discuss implications for psychiatric nurses. Fifty patients with HD were assessed by a board-certified psychiatrist and completed surveys about symptoms, social history, medication use, and quality of life outcomes. Descriptive statistics were used to summarize patient characteristics, and correlation analyses assessed the relationships between neuropsychiatric symptoms and quality of life outcomes. Most patients (72%) reported a history of neuropsychiatric symptoms prior to their HD diagnosis. Prodromal anger/irritability was most common (52%), though few patients received treatment for this. Anxiety was the most common current symptom (78%), yet 40% of patients had never been prescribed an SSRI. Anxiety was associated with poorer patient-reported quality of life outcomes (p < .01). HD patients in this sample experienced frequent, early-onset neuropsychiatric symptoms. In coming years, psychiatric nurses in community settings will be more likely to encounter gene-positive HD patients before they develop motor symptoms. Psychiatric nurses can address identified gaps through enhanced screening and encouraging early intervention in those at risk.

(2021). ‘Unfinished to perfection’: Geoffrey Hill, revision, and the poetics of stone. Textual Practice. Ahead of Print.

In this paper, we nominally propose three dimensions of medical ethics, using the term medical ethics rather than clinical ethics to focus on the professional obligation of paediatricians in and beyond the ward and clinic. We argue there exists a duty to children along the continuum of all three dimensions. In this taxonomy, the first dimension is the obligation of paediatricians to serve the best interests of their individual patients. The second dimension involves public health aspects and communitarian concerns with a focus on utilitarian principles, such as cost-effectiveness and just resource allocation. The third dimension of medical ethics is the obligation we hold in trust to support and respect the well-being of future generations. As our ecological footprint, characterised by climate change and biodiversity collapse, will adversely affect the health of today's children and those yet unborn, paediatricians have a contemporaneous moral obligation to speak out and act as both advocates and activists.

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.

Background Sensory hypersensitivity, defined as heightened awareness of and reactivity to external stimuli, is a bothersome symptom that affects up to 80% of adults with Tourette syndrome (TS). Such widespread prevalence suggests sensory hypersensitivity is a core feature of the disorder, but its severity and association with other clinical features of TS remain largely unexplored. Complicating matters, sensory hypersensitivity has been observed in two neurodevelopmental disorders commonly comorbid with TS: obsessive-compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD). Objective We sought to measure sensory hypersensitivity in TS patients relative to healthy controls and to investigate the relationship of sensory hypersensitivity with OCD and ADHD symptoms in the context of TS. Methods We recruited 34 adults with TS or chronic tic disorder to undergo evaluation with the Yale Global Tic Severity Scale (YGTSS) and a battery of validated self-report instruments assessing sensory hypersensitivity (Sensory Gating Inventory, SGI; Sensory Perception Quotient, SPQ), premonitory urge (Premonitory Urge to Tic Scale, PUTS), OCD (Dimensional Obsessive-Compulsive Scale, DOCS), and ADHD (Adult ADHD Self-Report Screening Scale for DSM-5, ASRS-V). Age- and sex-matched healthy controls were recruited to complete SGI and psychiatric measures. Results SGI and SPQ scores strongly correlated (rs = -0.73, p < 0.0001) within patients. SGI total score was significantly higher in patients versus controls (119.0 vs 67.6, U =-5.3, p < 0.0001), indicating greater sensory hypersensitivity in the tic disorder group. SGI score correlated modestly with PUTS, DOCS, and ASRS-V scores but not with YGTSS total tic score. Hierarchical linear regression analysis revealed that, of the tested variables, only DOCS score contributed significantly to mean SGI score, with β ranging from 1.03 (p = 0.044) to 1.41 (p = 0.001). A simple linear regression model with DOCS as the independent variable accounted for 31.9% of SGI score variance. Conclusion Sensory hypersensitivity is prominent in adults with tic disorder and is independently associated with obsessive-compulsive symptom severity.

Objective:To evaluate the performance of telehealth as a screening tool for spasticity compared to direct patient assessment in the long-term care setting.Design:Cross-sectional, observational study.Setting:Two long-term care facilities: a 140-bed veterans’ home and a 44-bed state home for individuals with intellectual and developmental disabilities.Subjects:Sixty-one adult residents of two long-term care facilities (aged 70.1 ± 16.2 years) were included in this analysis. Spasticity was identified in 43% of subjects (Modified Ashworth Scale rating mode = 2). Contributing diagnoses included traumatic brain injury, spinal cord injury, birth trauma, stroke, cerebral palsy, and multiple sclerosis.Main measures:Movement disorders neurologists conducted in-person examinations to determine whether spasticity was present (reference standard) and also evaluated subjects with spasticity using the Modified Ashworth Scale. Telehealth screening examinations, facilitated by a bedside nurse, were conducted remotely by two teleneurologists using a three-question screening tool. Telehealth screening determinations of spasticity were compared to the reference standard determination to calculate sensitivity, specificity, and the area under the curve (AUC) in receiver operating characteristics. Teleneurologist agreement was evaluated using Cohen’s kappa.Results:Teleneurologist 1 had a specificity of 89% and sensitivity of 65% to identify the likely presence of spasticity ( n = 61; AUC = 0.770). Teleneurologist 2 showed 100% specificity and 82% sensitivity ( n = 16; AUC = 0.909). There was almost perfect agreement between the two examiners at 94% (kappa = 0.875, 95% CI: 0.640–1.000).Conclusion:Telehealth may provide a useful, efficient method of identifying residents of long-term care facilities that likely need referral for spasticity evaluation.

Tourette syndrome (TS) is a neurodevelopmental disorder defined by tics, but most patients also experience bothersome sensory phenomena, in the form of premonitory urges and/or sensory hypersensitivity. Whereas premonitory urges are temporally paired with tics, sensory hypersensitivity is a constant, heightened awareness of external and/or internal stimuli. The intensity of sensory hypersensitivity does not strongly correlate with the severity of tics or premonitory urges, suggesting it is a dissociable clinical phenomenon. At least 80% of TS patients report subjectively enhanced perception of various sensory stimuli. These same patients demonstrate normal static detection thresholds. However, individuals with TS habituate abnormally to repetitive stimuli, indicating incapacity to appropriately filter redundant sensory input, i.e. impaired sensory gating. Physiologic support for this hypothesis is provided by abnormal pre-pulse inhibition (PPI) and event-related potential (ERP) investigations. Preclinical data implicates parvalbumin-positive (PV+) interneuron dysfunction in altered sensory gating in TS and other neurodevelopment disorders. Studies probing TS sensory hypersensitivity must methodically account for comorbid psychiatric conditions, namely obsessive compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), and autism spectrum disorder (ASD), as these entities appear to involve pathophysiologic processes shared with TS. The presence of psychiatric comorbidities in TS is associated with even more profound sensory processing dysfunction. A deepened understanding of TS sensory hypersensitivity will afford novel insights into disease mechanisms, clinical phenotype, and therapeutic management.

Refugees often come from countries with histories of human rights violations and can face multiple challenges in building a new life in Australia. Little is known about the specific experiences of ...

Summary Background Very low birthweight or preterm infants are at increased risk of adverse outcomes including sepsis, necrotising enterocolitis, and death. We assessed whether supplementing the enteral diet of very low-birthweight infants with lactoferrin, an antimicrobial protein, reduces all-cause mortality or major morbidity. Methods We did a multicentre, double-blind, pragmatic, randomised superiority trial in 14 Australian and two New Zealand neonatal intensive care units. Infants born weighing less than 1500 g and aged less than 8 days, were eligible and randomly assigned (1:1) using minimising web-based randomisation to receive once daily 200 mg/kg pasteurised bovine lactoferrin supplements or no lactoferrin supplement added to breast or formula milk until 34 weeks' post-menstrual age (or for 2 weeks, if longer), or until discharge from the study hospital if that occurred first. Designated nurses preparing the daily feeds were not masked to group assignment, but other nurses, doctors, parents, caregivers, and investigators were unaware. The primary outcome was survival to hospital discharge or major morbidity (defined as brain injury, necrotising enterocolitis, late-onset sepsis at 36 weeks' post-menstrual age, or retinopathy treated before discharge) assessed in the intention-to-treat population. Safety analyses were by treatment received. We also did a prespecified, PRISMA-compliant meta-analysis, which included this study and other relevant randomised controlled trials, to estimate more precisely the effects of lactoferrin supplementation on late-onset sepsis, necrotising enterocolitis, and survival. This trial is registered with the Australian and New Zealand Clinical Trials Registry, ACTRN12611000247976. Findings Between June 27, 2014, and Sept 1, 2017, we recruited 1542 infants; 771 were assigned to the intervention group and 771 to the control group. One infant who had consent withdrawn before beginning lactoferrin treatment was excluded from analysis. In-hospital death or major morbidity occurred in 162 (21%) of 770 infants in the intervention group and in 170 (22%) of 771 infants in the control group (relative risk [RR] 0·95, 95% CI 0·79–1·14; p=0·60). Three suspected unexpected serious adverse reactions occurred; two in the lactoferrin group, namely unexplained late jaundice and inspissated milk syndrome, but were not attributed to the intervention and one in the control group had fatal inspissated milk syndrome. Our meta-analysis identified 13 trials completed before Feb 18, 2020, including this Article, in 5609 preterm infants. Lactoferrin supplements significantly reduced late-onset sepsis (RR 0·79, 95% CI 0·71–0·88; p Interpretation Lactoferrin supplementation did not improve death or major morbidity in this trial, but might reduce late-onset sepsis, as found in our meta-analysis of over 5000 infants. Future collaborative studies should use products with demonstrated biological activity, be large enough to detect moderate and clinically important effects reliably, and assess greater doses of lactoferrin in infants at increased risk, such as those not exclusively receiving breastmilk or infants of extremely low birthweight. Funding Australian National Health and Medical Research Council.

Children have not been severely affected by SARS‐CoV‐2‐related illness but are vulnerable to the economic and social deprivation arising from the pandemic. This document describes unique risks and burdens for children and their care givers during the COVID‐19 pandemic. The principles for the allocation of health‐care resources apply to the whole population; however, there are particular paediatric considerations. The experience internationally is that paediatric intensive care resources are being utilised to support adult services during the emergency. Ethical tensions also arise from decisions about usual service restriction as a strategy for controlling the pandemic. This guidance provides a framework for health services and authorities to ensure paediatric concerns are considered during the development of COVID‐19 related guidelines and decision‐support tools, when resources may be constrained by the emergency response. It was developed by a working group of paediatric clinical ethicists, and intensive care and other specialty clinicians. This document is an extension to the other general documents available. It is intended to be read by clinicians and executive of paediatric and general hospitals, and by health‐related government departments.