The annual St Davids Day conference was held this year at the centrally located Marriott Hotel. The conference was dedicated to the Wellbeing and Health of the child in Wales. With a program as exciting and varied from talk to workshops and a whole host of guest speakers it is clear to see why it was a sell-out. Huge congratulations to our very own Tom Crom on getting such a program together. 
 
This month’s blog post is dedicated to the St Davids Day conference. It has given us as trainees a time to reflect on the health of the child in Wales and the importance of the role we play here as well as remembering why we chose the Paediatric specialty. With the conference closing with the PAFTAs the day was also a chance to celebrate our achievements and successes throughout the year.
 
Dydd Gwyl Dewi Hapus i bawb now let’s hear from our trainees…
Celyn Kenny
ST3
 
A chance to be inspired

Any healthcare professional who looks after children on a regular basis, knows that treating a physical illness is often only a temporary measure. Children living in poverty are, on average, much more likely to contract physical and psychological illnesses, whilst almost always lacking the means to improve their living standards. This is true for children living in Wales today, where it is estimated that 29% of children and young people live in poverty (a significantly higher proportion, compared with the adult and elderly population). It is also true that the gap between the richest and poorest is widening. 
These figures were no surprise to me. I have worked in Paediatrics for nearly four years, both in England and Wales, and have looked after countless children, whose parents did not have sufficient money or education to give them the care they deserved. It is therefore essential, as Professor Viner clearly highlighted, that we all have to take small steps to address health inequality, and be advocates for our children in any way we can. We have a voice and it is time for that voice to be heard. Isn’t that the reason we decided to do what we do? 
The St David’s Day conference this year was a brilliant chance to network, socialise, and learn. I am extremely grateful to all the speakers for inspiring us, and giving us food for thought; needless to say, the organisation was excellent.
 
Davide Paccagnella, ST3 Trainee
 
A byte-size snapshot 
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Well, blow me down, that was a brilliant conference! So many excellent speakers on a range of whole range of topics! Perhaps for me, the best thing about it was just how approachable the speakers were. Stacey Harris and I managed to catch up with pretty much every speaker (apart from a couple who had to head home early) and interview them for Dragon Bytes. Turns out you can be the Chief Medical Officer for Wales or a famous television presenter and still be the most down-to-Earth people ever. It was lovely discussing the talks further with such renowned speakers, getting additional insights into their areas of expertise. Also, the PAFTA event after the conference was fabulous! I’ve never been so proud to be a Wales trainee. Hats off to both Tom Cromarty and Hannah Davies for doing so much hard work for this event!
Hope that's alright! Let me know if you need more.
Assim Javid 
ST4
A celebration 
I really enjoyed the St David’s Day conference in the Marriott. It was a great experience both to learn more on the topics discussed and to have the chance to speak to others trainees who work in different hospitals or departments. It was uplifting to have a segment on celebrating trainees and to see it having defined area of the day. It is so common to hear about how bad things are in paediatrics especially with rota gaps, trainee unhappiness, high number of patients. However, it was very enjoyable and amazing to see all of the good things that current trainees are doing and to see this being celebrated!
 
Lizzie Sharpe 
ST3 
 
Being a Welsh Trainee
Having done my 8 years of Paediatric training across three deaneries, I've always had the fortune of recognising what a special, wonderful place Wales is for paediatric training.
 
Smaller hospitals, tight knit professional communities and a fabulous network for training, learning and providing patient care are at the centre of it. 
 
But also, Wales is a fascinating place - culturally, linguistically, geographically and in terms of its pathologies and medical system. I came here is 2012 and was hooked in weeks.
 
The St David's Day Conference is central to that, with both social and educational benefits. It's wonderful to work in a system with real local Accountability, proximity to policy makers and experts and the opportunity to be among friends in similar circumstances. So many of the people I work with every day are an inspiration. The quality of the work we do here is astounding, supported by our training infrastructure (thanks, Dr Body!) and other networks, such as WREN.
Kate Burke ST8 
Inspiration from our colleagues 
 
This was the first year I was able to attend the St David's Day conference and so I was looking forward to it greatly. The programme was exciting with current topics such as childhood obesity and use of screen time. A highlight for me was the talk from Dr Jennifer Evans and a previous patient of hers, Mercy. The talk was engaging and interesting, hearing the challenges of managing a chronic condition from both perspectives. I found it very inspiring to hear the exceptional doctor- patient relationship that can be made and how that positively impacts on management of a chronic condition. It was quite emotional hearing how much Mercy thought of Dr Evans, and how they had both impacted each other’s lives. 
 
Not only were the talks a great part of the day, but the opportunity to catch up with colleagues was brilliant. It reminded me how lucky we are to have such a tight knit deanery where we all know one another so well. As an ST3 approaching the daunting step up to registrar, it was so lovely to have such encouragement and advice from colleagues and friends. We in the welsh deanery are exceptionally lucky to have such support in one another, which ultimately contributes to making training here in Wales so great. It was lovely to acknowledge this by finishing the day with the PAFTAs. It was wonderful to hear so much praise and recognition for our tutors, peers and allied health colleagues. 
 
The St David's Day conference was educational, enjoyable and highlighted the fantastic family feeling trainees here in Wales are lucky to have.
 
Caitlin O’Donovan  
ST3
 
 
 
 
 
The PAFTAs
 
I had the pleasure of organising the Wales PAFTA awards this year.
 
The response to the survey was incredible!
It was amazing to see the volume of votes for so many inspirational wonderful people. 
 
We are so very lucky in the Wales paediatric deanery. It’s a very inclusive, welcoming and supportive environment. It made me realise we aren’t just an academic body but more of a family who champion each other’s journeys and achievements.
 
The comments highlighted academic success and messages or acts of support. It was a real eye opener to see that even little acts of kindness/inspiration go such a long way in the sometimes very harsh medical environment we work in daily.
 
It was very important to me that all of this year’s nominees received an email notification. Without everyone’s amazing contributions, large or small, our experience in the deanery would be very different. 
 
This year’s winners were presented their awards following the incredible St.Davids day conference In Cardiff. The atmosphere was one of incredible positivity... which may or may not have had something to do with the prosseco wall! 
 
I hope all those who attended or received a notification felt their contribution was valued and that the positivity helps us strive to make 2020/21 an even more successful inspirational year.
 
Hannah Davies
ST4

​Considering how often we refer to the CAHMS team as Paediatric trainees we have very little opportunity to work with the service and more importantly learn from the service. What better way to learn than from an integrated joint CAHMS and Paediatric study day.
 
The study day was held at the brand new CUBRIC building at Cardiff university which was as modern as they come! You really could see how the University is now up and coming within the research world from its facilities. The programme for the day was varied and the topics diverse with up to date evolving research especially in the Neurodevelopment world.
 
What better way to start the day than with a talk given by Kate Burke, who has the talent of making the most complicated of topics understandable and interesting, that topic being Genetics. Kate gave us an update on genetic testing for children and adolescence and how it’s now becoming part of mainstream medicine especially with the Neurodevelopment pathway.  More children are having genetic testing done as there are more test available and also there is now a greater scope of phenotype. Requesting a CGH array has now become a normal part of every working day within Community Paediatrics and Neonatal medicine. They are very easy to order however we learnt that awaiting the result can take up to a year with the increasing demands on the genetic services. Kate also gave us of the brief different types of genetic testing available and why we use them.

This was then followed by Safeguarding cases. In small groups we worked through four different cases and focused on how we would take the history and manage the patients. As an ST3 trainee I found this very useful as it gave an overview of how to manage different Safeguarding topics from a child in need, to Munchausen by Proxy, Sexual Exploitation and the importance of when a Section 47 is indicated.
 
 
Safeguarding tips:
 
Section 47:
A Section 47 Enquiry is initiated to decide whether and what type of action is required to safeguard and promote the welfare of a child who is suspected of, or likely to be, suffering significant harm. The enquiry is carried out by undertaking or continuing with an assessment in accordance with the guidelines.
 
 
Sexual exploitation:

• Contact duty social worker who will then contact the police
• Complete a SERAF (sexual exploitation referral assessment framework)
• Forms available in all A&E departments

 
 
Fabricated induced illness:

• Form a chronology
• Speak to and involve as many members of the wider MDT as possible
• Involve the safeguarding officer and social services
• Use the RCPCH document - Fabricated or Induced Illness

 
Following some coffee and cookies the next talk was given by Dr Joanna Martin a research fellow in Child and Adolescent Psychiatry. Dr Martin spoke of her recent research work in ADHD and sex differences. It is well documented that boys are more likely than girls to be affected and diagnosed with ADHD; every 3-7 boy to every one girl. Most studies have found that ADHD symptoms and impairment levels are similar in diagnosed girls and boys however girls may in fact have more inattentive difficulties. This raising the questions are there sex specific symptoms? Girls may show their ADHD traits through social interactions and impulsivity whereas boys have more of classic ADHD symptoms. Research is emerging that girls displaying traits of ADHD may be missed as they have genetic protective factors; and if picked up correctly and commenced on medication these patients may respond better. These girls are more likely to get diagnosed with anxiety and depression in future. I found this talk interesting and eye opening and will make me more open minded for future cases.
 
After lunch came a Neurodevelopmental Update. In Wales, this essentially encapsulates Autism and ADHD however it should be seen as impairment in growth and development of brain. This includes ADHD, ASD, intellectual disability, tics, specific learning disorders, motor co-ordination disorders all are part of developmental trajectory which presents in childhood. Statistics from the ND steering group showed that 80% CAMHS workload is related to Neurodevelopment. The funding from 2016 of ‘together for children and young people’ was spent in forming a national pathway for ND, with guidance for assessment, autism toolkit, ADHD toolkit and how to do assessment – a very useful and practical resource which can be found on 1000 lives Wales website. ‘Together for children and young people’ finished in October and is now moving to more integrated whole-systems approach. every team now has single point of access (now have data for referrals, accepted and rejected). Over the next few years we are likely to see expansion in these services…… watch this space.

This then led nicely into a talk on Autism in females and other aspects of variation by Consultant Community Paediatrician Cath Norton. The female phenotype is now recognised as being camouflaging by hiding unwanted autistic behaviours and or explicitly using more socially acceptable behaviours. When it comes to social relationships they are interested in making friends but do not quite get it right and may be more interested in relational objects e.g youtube, animals, reading. They have internalising difficulties. There are mental health implications for camouflaging and sadly one of leading predictors of suicide in autistic adults.

We then learnt from work conducted by Rutter in 1996 on the “Quasi autism”; autistic type symptoms seen in children adopted following an early experience of institutional care and who also can get deprivation linked ADHD which can be pervasive. There is a higher prevalence of ASD and ADHD in LAC population (as well as prevalence attachment issues, trauma, neglect etc) and maltreated children more likely to be hypervigilant. The term attachment disorder likely overused, and possible presumed due to this social background. A useful resource is the Coventry grid when looking at autism in LAC children as they may have different attachment needs. In the future, there is going to be more training to look at a holistic approach assessment of these children i.e. no further unilateral diagnoses or doing autism and not ADHD. The work from steering groups in this development is working towards integrated services with education, families and social services. And the hope is to adapt national IT systems so there is a place the information can all be pulled together forming a ‘clinic profile’. The information in one place, including what families are hoping to get from their experience. To finish we learnt of the integrated autism service who do the assessments in people over 18 years and is where we refer patients when they transition. This service cares and provides for older children with neurodevelopmental variation and functionality in college and workplace.

The last topic of the day was about ACEs, a topic we are now getting more familiar with and used to recognising. Public health Wales Adverse Childhood Experiences study back in 2015-2018 which looked at traumatic experiences in childhood and their impact this included child maltreatment and indirect trauma from childhood household e.g. parental separation, DV, mental illness. It is know well known that ACEs increase individuals risks of developing health-harming behaviours (high risk drinking, unintended teenage pregnancy, smoking, prison and interestingly from recent American studies also affects academic potential and contributes to developmental delay. We discussed a case of a 14year old whose parents had been exposed to many significant ACEs which has subsequently affected the nurturing environment for the chid to grow up. This encompasses that ACEs are vicious circle and interventions are required for both child and parent. 
​
To close we touched briefly on attachment disorder, an emotional and physiological dysregulation and how it can present clinically. These children often have a poor self-concept and a fragmented sense of self (i.e. child doesn’t have a sense of their own body so doesn’t recognise hunger etc), poor social interaction and sensory processing difficulties. With attachment, the intervention will depend on developmental stage of child. There is a lot of focus on something called ‘theraplay’ which is based on helping the carer enjoy the relationship with the child. It is clear that in order to make an impact we have to help the child and the parents to help build their relationship to create a therapeutic environment.
 
Reflecting on this study day it really was a whistle stop tour into the work done by our community colleagues and as a current ST3 community trainee and excellent crash course to consolidate what I have seen and learnt over the last few months. I would like to thank the organisers for a very interesting and diverse day, I highly recommend attending!
 
Celyn Kenny
ST3 

​The Wales Neonatal Network Annual Audit day took place at the Life Sciences Hub in Cardiff Bay on 9th January 2020. The Wales Neonatal Network was established in Autumn 2010 and brings together NHS health professionals and partners from other organisations, with the aim of ensuring equitable, high quality and clinically effective neonatal care is available to babies and their families in Wales. The Annual Audit day is an opportunity to share experiences and changes in practice from across the network, to learn from other good practice, and to identify areas for future development.
 
The programme this year was again full of interesting topics covering respiratory care, neurology, National Neonatal Audit Data for Wales and transport to name a few. Particular highlights came from Dr Lucy Perkins, Consultant Neonatologist at Singleton Hospital, Swansea. Dr Perkins was sharing her units experience in optimising the early respiratory management of preterm infants, and the quality improvement project that had been undertaken to reduce the rates of intubation and mechanical ventilation. This talk fitted in well, as it followed a presentation by me on the ongoing audit into the management of Respiratory Distress Syndrome in Wales, which has been a very successful WREN project. Having the opportunity to discuss these two initiatives together showed how practice can be positively changed by sharing ideas and information.
 
Another exciting innovation came from Dr Kate Burke, Neonatal Grid Trainee, who shared her ongoing work with creating a Hypoxic-Ischaemic Encephalopathy Care Protocol and ‘Passport’ that would help to standardise care and assist information sharing across the level 2 and 3 neonatal units in the network. There were also updates from the units in Newport and Swansea regarding the introduction of General Movements Assessments at 3 months of age for those infants at higher risk of poor neurodevelopmental outcome, and how this new assessment was helping to identify and target early intervention for those babies showing early signs of neurological impairment.
 
The day rounded off with an update on CHANTS (Wales’ Neonatal Transfer Service) activity from the past year, and how Wales were performing on the NNAP programme (which overall was quite favourably!). I would recommend the audit day to anyone who has an interest in neonatal care, either at level 2 or level 3 units, as an opportunity to hear the latest news in the care that the units in the Wales Neonatal Network are offering. It is also a fantastic opportunity to present your own project data to a receptive audience and help to shape clinical care. The network are actively looking to undertake multi-centre projects and are in discussion with WREN as to how we can take these new initiatives forward, so if you’re keen to get involved, please get in touch!

​Professor Ronan Lyons (Professor of Public Health at Swansea University) then highlighted some of the amazing Public Health work that he has been involved with, focussing on the SAIL Databank (over the past 10 years) and current developments such as Health Data Research UK (@HDR_UK).
 
The Secure Anonymised Information Linkage Databank started in 2009 and is continuing to collect data which is then 'de-identified' so that it can be analysed by researchers across the world. This data from patients in Wales combines health and population data for >5 million people, so far creating 26+ billion rows of data.

SAIL Datasets

​Privacy is absolutely paramount, meaning that this is the only dataset that is globally accessible as long as researchers meet the criteria of being safe and accredited. Every project proposed must also meet some strict inclusion criteria, such as ensuring that the research’s purpose is to protect people and it is in the public interest, etc.
 
This resource of ‘big data’ has already enabled a number of research projects which have guided policies and public health advice to families across Wales. Many of these projects have involved Paediatrics:

• Gestational Age, Birth Weight, and Risk of Respiratory Hospital Admission in Childhood. DOI: https://doi.org/10.1542/peds.2013-1737. Showing differences in hospital admission rates between babies born at 39 and 40 weeks’ gestation at a population level.

 

• Change in alcohol outlet density and alcohol-related harm to population health (CHALICE): a comprehensive record-linked database study in Wales. Showing the link between alcohol-related harm and outlet density. Therefore helping to guide policies and the regulation of alcohol outlets in a given population.

 

• Population data also showed the positive effect of the Welsh ‘Warm homes NEST scheme’. This provided evidence of its impact on the health of the population and helped secure continued funding at a time when austerity saw many other public schemes discontinued. 

HealthData Research UK (@HDR_UK) is aiming to do the same as SAIL in Wales but across the whole UK with a larger data set.
 
Ronan made it clear that we are coming to a tipping point with the vast amounts of health data that is being collected. This gives huge potential for positive impacts if used safely and correctly. There are exciting innovations such as the ‘Personalised Genome’ enabling personalised medical interventions, whilst wearables (and other technology) can encourage the self-monitoring of health and disease. The challenge is to reduce inequalities in health without reducing gross disparities in wealth.
 
The public are rightly concerned about the security of their data, especially with the data security scandals of various social platforms in recent years. Public trust needs to be built and earned. SAIL has a consumer panel, composed of members of the public. These individuals are involved with the accreditation of certain projects and often help them throughout the research process.

The whole lecture will be available to view on the BMA website in due course.

Check it out!
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​If there are any questions then please get in touch.

Dr Fiona Astill, Leadership Fellow

Leaders in Healthcare is a conference in association with the Faculty of Medical Leadership and Management (FMLM). It was a huge event with hundreds of attendees. Additional to the plenary sessions, much of the groups were workshop-based with themes around self, team, organisation and systemto choose from.
Personal highlights included:

1. Lord Victor Adebowale - possibly the most down-to-earth Lord I’ve ever seen who marched on to the stage and promptly announced he was here to “gob off at us” for a while! His speech was discussing the challenges that faced the health service and felt these were equity, access and technology. He talked about leadership not being about just your own organisation but that we have a duty as healthcare professionals to consider population health, and the need for a credible team. There is no right way to lead:

• Be like you. People are led by humans. Be human first
• Be open about your vision
• You are your values and values are what you do.
• Additionally a fish rots from the head (slightly disturbing image, and I’d imagine made some directors in the audience a little uncomfortable!)

2. Military leadership – an interesting discussion from senior ranking officers in the army and the RAF, regarding the concepts of leadership and followership. Their advice for leadership and followership:

1. 1. Learn from yesterday
   2. Focus on today’s capability
   3. Address the customer’s/service user’s hopes for tomorrow
   4. Invite internal holding to account
   5. Invite external holding to account
   6. Work collaboratively
   7. Set measures of success   
      

3. Forum theatre – this started off with us feeling a little apprehensive that we might have to get up and act. Luckily, actors were provided and the initial scene played concerned a conversation between a medical director and a chief registrar. The scenes were initially played, followed by discussion with the audience as to why what they had done did or didn’t work. It was quite enlightening to watch the situation play out and I think we could all remember a time when we’d been in a similar situation with a dismissive ‘leader’. Changing one’s body language, speech and attitude made a big difference to the conversation and ended with both parties satisfied. 

‘Problems only exist in the absence of the right conversation’ Werner Erhard

4. Seven Transformations of Leadership – what differentiates leaders is not their personality, management style or leadership philosophy but their internal ‘action logic’ – reacting to their environment and challenges. http://hbr.org/2005/04/seven-transformations-of-leadership in case you were interested in finding out more about your current style?

5. Speed coaching – the FMLM organised a series of short sessions that attendees could sign up to, to discuss a problem or barrier in their own leadership style. Of the fellows that went I think we all found this valuable to an extent, and a current theme of this year is definitely to question yourself, and to be more aware of your own strengths and weaknesses. 

6. Wellbeing – lots of workshops and talks around this topic. ‘Doctors as Second Victims’- in a room full of people 86% have had personal involvement in a near miss or adverse event. Of those 70% felt this affected them personally and professionally. We need to encourage open and transparent conversations about errors, without the blame. We need to be compassionate towards our colleagues and supportive.

Dr Davide Paccagnella ST3

​WREN study days are best described as a regular opportunity to do exactly what we are all about: meet, make friends, network, and learn from each other. If you are new to Paediatric Training, or have recently moved to Wales, they happen twice a year and are an essential component of the work we do. 

This autumn, we had some excellent speakers. Making a start was John Watkins, statistician working at Cardiff University and well-known in the world of medical statistics. It would be unfair to say that he taught us the “basics”, as I found myself reading up on quite a few statistic-related topics over the following days. What he managed to give us, however, was a very thorough overview beginning from the core elements of data analysis, all the way up to statistical tests and multivariate linear regression. In a word, intense! I cannot recall having been taught “Statistics” in a 2-hour session when I was at university. And it was not always easy to keep up, but my neurons enjoyed the early morning stimulation!

Next up, it was time to hear updates from ongoing projects around Wales. There is truly no limit as to what can be achieved if you put your mind to it. Multicentre trials have recently been completed in cooperation with PRAM (Paediatric Research Across the Midlands) and PENTRAIN (Peninsula Trainee Research Audit and Improvement Network). Details are on our website, and you can have a look to see what other trainees are up to elsewhere in the country – www.wrenpaediatrics.com;www.pramnetwork.com; www.pentrain.org.uk– exciting projects, trainee-led, getting national and international recognition!

Following on from this, Alex Richards, Cardiff University Paediatric Society (CUPS) president, introduced a new project – called WORLD CUPS (Working Paediatricians Overseeing Research Led and Delivered by CUPS). This is based on the idea paediatric professionals can request help from interested students, and vice-versa. Jordan Evans, ST8 Paediatric trainee, is the CUPS liaison and has already got multiple projects going. Involving students in research is vital, and I wish my medical school offered me anything that was even remotely similar! Interestingly, the Welsh National Student Paediatric Society Conference will take place on Saturday 1st February 2020 at the University Hospital of Wales, Cardiff. Paediatric professionals are needed to share experiences with students, and promote our specialties! What better chance to meet people and network? Have a look at https://www.facebook.com/events/788342174927002/

New projects and ideas are coming up all the time. And the potential to transform your idea into a multi-centre trial is always there. If you attended the study day, you might have heard about some of these projects. The best way to get involved, if you have a new idea, or data you have already collected, is to speak to like-minded people and get the ball rolling. We can help with that, especially if you are struggling to find enough people to take your project on at a local level.
To close off the day, we had the privilege to have two great lecturers. Firstly, Dr Martin Edwards, Consultant Paediatrician at UHW, provided us with a practical guide to systematic reviews and meta analyses. Personally, I came to the realisation that performing a systematic review does not have to be regarded as a complex, unachievable task. Certainly, it requires patience, and knowledge of how to research and analyse evidence. But it did not discourage me from thinking that yes, it could be done. Just think how often we, as clinicians, base our decisions on evidence from meta-analyses – all the time, I would say. It is therefore imperative that we develop a good understanding of how it all works, and contribute to this essential area of research.

Last but not least, Dr Ian Wacogne, the edition editor of Archives of Disease in Childhood – Education and Practice, and consultant paediatrician in Birmingham, very kindly visited us in Bridgend for the afternoon. He talked to us about “how to write”. And what a talk it was! Firstly, he engaged us all in an honest discussion about the type of readers we thought we were. So think about it: are you a systematic reader (do you read in a structured, organised manner)? Or perhaps you are a “just in time” reader (if you manage to extract the information you need at the last minute); you could also be an “on the bus” reader, and enjoy taking in small amounts of information at a time. When we write, it’s good to know who we are writing for – what is our target audience? Most importantly, do we have anything interesting to say, and would we enjoy reading what we wrote? Those of you familiar with the journal edited by Dr Wacogne will know that it can be a pleasant read in a number of different situations, and that it has something for everyone. So why not write? Submitting an article can seem daunting but there is plenty of guidance on https://authors.bmj.com/

In conclusion, I hope I have convinced you to attend the next WREN study day, which will take place on 19thMay 2020!

Dr Celyn Kenny ST3

This year’s Autumn WPS clinical meeting took place on the 8th of November at the famous Celtic Manors sister hotel, the beautiful, Coldra Court Hotel. I can see why its described as a ‘Celtic convenience’, located at the gateway between England and Wales, the Coldra Court Hotel is close to glorious Welsh countryside and is situated just off the M4 motorway at Junction 23 and really is a hidden gem. ​

WPS meetings are recognised and renowned for their educational presentations, from medical students to consultants, and as a great way to network professionally, and of course socially, with our Paediatric Colleagues. They also bridge the gap between Hospitals not only on the M4 corridor but also with our colleagues in the far away land of North Wales. This was even more evident this year as we were also joined by our Paediatric Anaesthetic colleagues, making it an extra special multidisciplinary networking event. As said by the chairman himself Dr David Tuthill “It is a meeting that appreciates Junior Doctors on their journey through training from medical student to higher training”.
 
 
The day started with a welcome talk from the president that then led into the introduction of the first guest lecturer Dr Hannah Gill. Hannah, who originates from Wigan, is a Consultant Anaesthetist at Bristol Royal Hospital for Children. She moved to Bristol to work on an RCT administering Xenon to term babies born in poor condition and completed a PhD studying the dose-response relationships of Xenon and volatile anaesthetics in immature rodents. How refreshing it was to hear a talk titled Anaesthetic neurotoxicity: does it exist, in such a strong Wigan accent. 
 
 
Then the presentations began.  The first session saw a range of topics from post-operative analgesia to medication errors then to respiratory distress in the newborn. Focus was given to the experienceof introducing minimally invasive surfactant therapy on a neonatal unit; theuse of MIST which is interchangeable technique as LISA therapy and how numbers of intubations and oxygen requirements have been reduced following this introduction on a Neonatal Unit; this in turn may lead to the reduction of BPD. This talk led nicely to Chris Course’s hard work on re-auditing the Improvement on the management of respiratory distress syndrome in preterm infants across Wales. Chris has done so much for research projects across Wales and should be commended for all his hard-work and dedication. Following this it was time for coffee and the mingling with colleagues began!
 
 
Following the caffeine ingestion, the presentations continued and again a great variety of topics were seen. A focus was given to Paediatric Palliative medicine, an area I would definitely like to learn more. Fran Norris presented on Advancing access to advanced care plans which was very informative and she was commended by going on to win one of the WPS awards. Safeguarding also featured heavily with our very own Assim Javid presenting his work on burns which he completed during his academic ST3 year. Assim spoke of the influence of causative agents and mechanisms of injury on anatomical locations of burns from scalds and contact burns in children less than 5 years old. This age group is recognised as when most burns happen and he opened our eyes to when safeguarding concerns arise. Enthusiastic and engaging to his audience Assim rightly went on to win the trainee award. Well done Assim!
 
Before lunch the second guest lecturer was Dr Jayne Sutherland, an Anaesthetic Trainee in the Wales Deanery (ST6) with an interest in global health, medical education and paediatric anaesthesia. ‘Take a deep breath and open your eyes’, a talk focused on Jayne’s year in Zambia as part of her out of programme experience. She told us some frightening figures of how 5 billion people lack access to surgery world-wide and that 143 million additional surgeries are required annually to meet this demand.Zambia, a low economic country,is facing an uphill struggle with an expanding population. Jayne worked with theZADP charity and told us of her role with the charity; teaching, initiation of mentorship, battling to get the basic services required and learning all this through the politics and hierarchy. What she gained from this experience was a greater understanding of the politics of safe surgical provision, a bucketful of experiences, huge job satisfaction, new perspective, new coping strategies and the importance of taking time to stop and disconnect. Following this was our time to stop and disconnect for lunch!
 
 
Following a fantastic buffet lunch with choices aplenty there was no post prandial lull as Mr Oliver Jackson, Consultant Paediatric Surgeon at the Noah's Ark Children's Hospital for Wales, took to the stage.  He moved to Cardiff in July 2018 and since his arrival has been at the forefront of Paediatric Surgical advances in Wales and the services now offered to the children of South Wales. A talk entitledHidden Surgery, Visible Results – How laparoscopic paediatric surgery in Cardiff is helping our patients; Mr Jackson took us on a journey of the evolution of laparoscopic surgery. The talk started withthe question “who are the Surgeons?” and was a great introduction to the new surgical team at UHW. We then learnt of the new services offered at the Children’s hospital and how the transferable skill of laparoscopic surgery has led to the surgical advancement of these services. A laparoscopic technique is now being offered for procedures such as pyloric stenosis, inguinal hernia repair and even Neuroblastoma. This talk was so inspiring it made me reconsider my career path and channel my inner Meredith Grey (for a total of five minutes!)
 
Then came the third set of presentations and it was clear to see that wellbeing would play a big role. A presentation which stood out for me was one given by Fiona Astill on the Evaluation of burnout in paediatric staff. As Paediatric trainees we could take so much from this,69.2% of staff in Wales at risk of burnout,what can we do to improve our work-life balance? Protective factors are key to help reduce this risk with supportive colleagues and good managers playing big roles. In a world, full of shortages and increasing rota demands we really must remember the importance of these factors. 
 
This led nicely onto the final talk “The three emotional systems” by Dr Nicole Parish, a Clinical Psychologist working within the Noah's Ark Children's Hospital for Wales.She started with a game of ‘stand up’ where we stood up if we had felt certain emotions or experiences at work. Then Dr Parish went into the main body of her talk which was describing the three emotional regulatory systems. The first, the threat system, where we get our motivation and strong physiology. However, it can make us more likely to recognise negative behaviour even in a room full of positive, and jump to conclusions because of this threat system. This goes back to the primitive part of brain and its often easy to get stuck in this threat system. Next came the drive system which is related to evolutionary need to forage and our need to hunt such as pursuing our goals. Which is highly relatable to us within medicine as we strive to achieve our goals. However, this can get exhausting which led into the importance of the third system, the soothing system. This is our feel-good system and the need to be relaxed and calm that leads to the feeling of being safe and content. Within the context of hospital medicine, we will see a lot of threat and sometimes are unable to think of things in a constructive way and are more likely to be angry and critical of ourselves.  Dr Parish highlighted the importance of balance and the need of all three systems for this as they all are beneficial in their own way. It is important to think if there is an imbalance how we can help each other through and it is often the soothing system that’s missing. It is a necessity that we take time to stop, think, reflect and show gratitude to ourselves and reinstate this balance.

 
The evening was brought to a close with a three-course meal and a much needed social! A fantastic day full of variety and wonderful topics from medical students to Consultants and of course with our Anaesthetic colleagues adding to it. The next meeting has just been confirmed May 22nd2020; who will join me in making the journey to The Quay Hotel in Deganwy, North Wales?! 

​

Dr Annabel Greenwood ST5

​​When a flyer advertising the Welsh Paediatric Cardiovascular Network (WPCN) Autumn Meeting popped up in my inbox, I jumped at the chance to attend in the hope of broadening my (somewhat limited!) paediatric and neonatal cardiology knowledge.  I’m sure many fellow trainees would agree with me when I say that the subspecialty of paediatric cardiology can at times feel a little overwhelming and complex, so any additional learning opportunities in this field are certainly invaluable. 
 
This year’s Autumn meeting was held at the Radisson Blu Hotel in the centre of Wales’ capital city, and was attended by a range of representatives from the paediatric multidisciplinary team with an interest in cardiology.

The principal theme of the day was pulmonary artery hypertension (PAH), and the morning session was particularly neonatal-focussed, emphasising the relationship between prematurity and PAH.  To set the scene, the day began with a case presentation of an ex-premature baby with chronic lung disease and a patent ductus arteriosus who subsequently developed PAH.
 
Then followed a talk on cardiovascular outcomes in chronic lung disease (CLD) of prematurity. Professor Kotecha, Consultant Neonatologist at UHW, discussed the effects of CLD of prematurity on the left and right sides of the heart independently.  With regards to the left-side of the heart, he considered the theory that those born prematurely will have higher systolic blood pressures later in life.   This was based on the concept of arterial stiffness, and that prematurity and low birth weight are inversely related to arterial stiffness, and also that lung function is inversely related to development of arterial stiffness.  However, he then went on to discuss the results of an ongoing respiratory study, the ‘RHINO’ Study, (Respiratory Health Outcomes in Neonates), whereby children aged 7-12 years, born prematurely at <34/40 gestation, were assessed in terms of their lung function, including spirometry measurement pre and post-bronchodilator therapy.  The study found that there was no significant difference in peripheral systolic BP between those born prematurely with CLD, those born prematurely without CLD, and term controls.  There was, however, a significant difference in peripheral diastolic pressure (higher in preterm CLD patients).  This difference could perhaps be explained by measurement error or even steroid use.  
 
As for the right-side of the heart, pulmonary pressures increase in those born prematurely, but the key point to note is that by improving lung function and a child’s overall general health, then pulmonary pressures won’t be such a major issue. 
 
Dr Kevin Poon, Consultant Neonatologist at Royal Gwent Hospital then took us through the echocardiographic assessment of PA pressure.  He highlighted the echocardiographic parameters used to assess PA pressures, and also surrogate markers of raised PA pressure.  

The following measurements can be used routinely to assess PA pressure:

• TR jet – provided there is a good envelope, no RVOT obstruction or large VSD, and good RV function
• PR jet 
• PAAT:RVET ratio (PA Acceleration Time: RV Ejection Time) – in addition to TRJV, or if unable to obtain good TR envelope
• TAPSE (Tricuspid Annular Plane Systolic Excursion)
• LV eccentricity index - when septal flattening or bowing seen 
• Myocardial velocity – if you have a tissue doppler package

These are measurements that I am on the whole unfamiliar with, given my limited exposure to performing echocardiograms, however, it was very useful to learn more…and of course, the key message was to ‘leave the fancy stuff’ to the cardiologists!


After a brief refreshment break, Karina Parson-Simmonds, Children’s Cardiology Nurse Specialist at UHW, presented about the ‘6 Minute Walk Test.’  This is a test to determine the distance a person can walk at a constant, uninterrupted, unhurried pace in 6 minutes, and is widely used to assess exercise capacity of paediatric patients with CV disease.  It can also be used to monitor disease progression, to evaluate patients’ exercise tolerance pre/post-operatively or to measure response to an intervention, and can provide longitudinal data for a patient if repeated at intervals over a period of time.  It is not however ‘gold standard,’ as this remains the cardiopulmonary exercise test, and the BORG index score (rating of perceived exertion) is subjective, possibly causing discrepancy in results. 
 
 
 
Continuing with the multidisciplinary theme, Dr Lena Thia, Paediatric Respiratory Consultant at UHW, then discussed the respiratory management of the child with CLD and PAH. There are a number of respiratory causes of PAH, all associated with hypoxia;  

• CLD
• Pulmonary hypoplasia (congenital diaphragmatic hernia, single lung)
• Chronic interstitial lung disease
• Sleep disordered breathing 
• Severe airway malacia with hypoxia
• Severe CF with end stage lung disease
• Neuromuscular disease with night time hypoventilation

Co-existing cardiac disease predisposes to developing PAH in CLD, and infants with Trisomy 21 with or without structural lung or heart disease are at increased risk of developing PAH.
 
Key investigations to consider are;

• CXR

• Blood gas – how much compensation? How high is the CO2?
• Overnight sleep study
• Lung function tests (spirometry, transfer factor)
• Exercise testing with saturation – evidence of desaturation when exercising 
• CT chest, CTPA
• Bronchoscopy 
• VQ scan
• Lung biopsy

With regards to optimising respiratory management;

• O2 for any daytime or night time hypoxia
• Ambulatory O2 for exercise
• Supplementary O2 for air travel
• O2 for emergency use at home
• Treat infections promptly – annual influenza vaccine, palivizumab, prophylactic abx
• Safe feeding assessment, and management of GORD

​The final session of the morning was an impromptu session by Dr Dirk Wilson, Consultant Cardiologist at UHW, as the planned speaker was unable to attend.  This was a fantastic session on ECHO interpretation of common structural defects (ASD, VSD, AVSD), with the use of ECHO videos to enhance learning.
 
Unfortunately due to on-call commitments, I was unable to stay for the afternoon session, however, Dr Maria Mendoza (Neonatal Clinical Fellow at UHW), has kindly provided us with a great summary…
 
"The afternoon was a fun, interactive session amongst all participants of the meeting to culminate everything we learned during the day. Each table consisted of a multidisciplinary team of consultants, trainees, nurses or cardiac physiologists where a well-informed discussion was made possible. Different cases were presented and each team was able to analyse the case together, view the different imaging results available such as ECG, Chest X-ray and Echocardiogram findings and come up with a diagnosis and subsequent management. Some of the cases were Hypoplastic Left Heart Syndrome, Possible Noonan Syndrome with Pulmonary Stenosis, Atrial Septal Defect and Hypertrophic Cardiomyopathy. We also discussed the risk of acquiring RSV especially during the winter season and which babies are at risk and need RSV prophylaxis. Overall, it was a very high-yield discussion of different clinical cases with many learning points."

​

Dr Tom Cromarty ST6

Earlier this month I travelled to Barcelona with the EU funded TALK Debrief research project. This is part of the Research and Innovation Staff Exchange (RISE) programme, where Medical staff from Cardiff (Wales), Barcelona (Spain) and Stavanger (Norway) visit each other’s hospitals to learn and help with the implementation with TALK debrief, as well as experiencing other healthcare systems.
 
TALK is designed to guide structured team self-debriefing after any learning event in clinical environments. The Structure can be seen in the figure below, with more information and FREE resources are available at TALKdebreif.org
​

​Whilst on my latest placement in Barcelona, I was able to attend the only specific Children’s Hospital in Barcelona called Sant Joan de Déu (SJD). This large tertiary referral hospital is mostly public funded and is going through a series of renovations. I was fortunate enough to visit the brand new PICU which in Spanish is called the Pediatric UCI (Unidad de Cuidados Intensivos), and experience the innovative Simulation centre. I was particularly impressed with the Simulation team which was created and lead by José María Quintillà Martínez. Over the past 15 years he has been incredibly passionate about simulation in healthcare, starting off with a very low fidelity mannequin and no support, to now having an integrated simulation service.
 
José and his team were incredibly enthusiastic about Simulation, ensuring that the focus stays on the intended output and the methodology, rather than the expensive shiny technology. After developing a relationship with the world leading Boston Children’s Hospital Simulator programme, José and his team have developed a Simulation service that has the backing of the hospital board and is fully integrated with the hospital, rather than a stand-alone medical education tool.
 
Other than Simulation courses, which they run on >150 days of the year, the majority of the time for hospital staff, the team was recently involved with the architectural planning of the new PICU. Having created a mock bed space in the Simulation centre, they replicated the clinical scenarios which would need the most people and equipment, such as an unwell patient requiring ECMO (Extra Corporeal Membrane Oxygenation) or Dialysis. They modified the design and size of the room, from the location of sinks, equipment & monitors, to establish the optimum environment with the floorspace available.
 
Once the ward renovations had been finished, they again brought in the Simulation team to practice common procedures and daily routines. This meant that the teething issues which inevitably come up, were corrected without a patient in sight or put at risk. This forms part of the SIMTest function of their integrated Simulation Program which can be seen below.

​
​SIMTrain is the traditional work of Simulation in Healthcare, however the team in SJD aim to develop personal and team skills, as well as training patients and families. Trainers from the Boston Simulation programme visit the hospital to train a multidisciplinary group (Doctors, Nurses and Physios), forming a core Simulation faculty who can practice and train others in their departments. The PICU had five nurses and five doctors trained up, who would run a two-hour scenario on three occasions every Thursday. The simulation philosophy is so embedded, that any new department being renovated (including PICU and NICU) has a separate ‘Simulation’ room (see below), specifically reserved and always ready for use. This also enables teams to put rented equipment and new protocols to the test before investing in them and practicing on patients.

Permanent Simulation room on the PICU unit

José’s team have used the Kerr-Patrick education model to validate learning from Simulation, currently working on levels 3 and 4 to demonstrate changes in behaviour and patient outcomes. The backing they receive from the organisations leaders has enabled them to hire an innovation team, subsequently creating the 3D4H (3D for health) unit. After a complicated oncological surgery was abandoned due to the challenging anatomy, the team used imaging to create a 3D version of the patient’s head. This meant the surgical team could make an accurate surgical plan and even practice the surgery as many times as possible. By saving money on theatre and anaesthetic time, this method saves time, money and makes the procedure safer for the patients.
 
As the specialist centre for MPS (Mucopolysaccharidosis) in Spain, they receive many referrals for management and perform up to fifteen maxilla reconstructive surgeries per year. These patients have complicated upper airway anatomy, making the intubation difficult. 3D4H printed a number of typical MPS heads with accurate upper airway anatomy and put this onto a traditional high-fidelity mannequin for simulations. This enabled anaesthetists to practice this complicated skill a number of times, demonstrating their proficiency before the patient had even arrived.
 
The 3D4H team have developed been used in a number of other ways.

• Tracheostomy’s: They have printed multiple versions of anterior necks with tracheostomies. They then run simulation scenarios for ‘blocked Trachy tubes’ for staff and parents to practice their skills and improve their confidence.
• Skin: Various printed skins help staff practice suturing, wound management, accessing tunnelled central lines and USS guided cannulation. Much cheaper than buying the material from external companies.

Simple 3D printer

Trachy and various skins printed from 3D4H team

​Integrated Simulation is a new way of designing and improving medical environments, teams and the care they provide, by exploring and learning from reality before it happens! I was completely inspired by the number of functions which their Simulation team performed as an integrated service with the hospital, and the incredible number of cost-effective uses for 3D printing. 3D printing is being used more and more in medicine, with the materials becoming cheaper and technical printing skills advancing every year.  
 
How could you use Simulation or 3D Printing where you work? Perhaps Barack can inspire you?

​As always feedback or questions are always welcome.
Twitter. @tomcromarty
Email. Thomas.Cromarty@wales.nhs.uk

Davide Paccagnella, ST3 Paediatric Trainee

​When I attended the 4th Annual Paediatric Medication Error Prevention (PMEP) Study day (which took place in Morriston Hospital, on 8th October 2019), I already knew that it was going to be a great experience!
For the past four years, Morriston has achieved great results in the field of medication error reduction and prevention. They have done this by forming a revolutionary tripartite alliance between Paediatrics, Nursing and Pharmacology. It all makes sense – by nature, prescribing, administering, checking and supplying medication is a multi-disciplinary exercise, and improving the safety of these processes can only be achieved by working together across different specialties.

This annual study day has become increasingly popular, year after year, with almost 100 registered attenders this time around. Which meant that, on the day, the lecture theatre was nearly full, making me feel like I was attending a national conference as opposed to a local study day!

The morning was kick-started by Professor Philip Routledge, CBE, from the All Wales Therapeutics and Toxicology Centre. His keynote address provided us with a global perspective on drug manufacturing, testing and marketing. When it comes to prescribing, I did not know that the largest avoidable cost, worldwide, is non-adherence to prescribed medication!  Prof. Routledge also highlighted important steps (often taken as a result of tragedy) that helped make drugs safer over the course of time. Some of these stories were very moving and sobering. Overall, it was a brilliant lecture, and I’m certainly hoping that Prof. Routledge will consider returning to Swansea to inspire us all, again, next year.

​

We were privileged to have Alana Adams, Principal Pharmacist from the Welsh Medicines Information Centre, and Dr Alison Thomas, Medical Director of YCC Wales, who came to give us an overview of the Yellow Card Scheme. Perhaps unsurprisingly, it turned out that not many audience members had filled a Yellow Card out before – this lecture was therefore a necessary reminder of just how important it is to provide this information, and what reactions need to be reported.

Dr Davide Paccagnella

​When I submitted an abstract to the 2019 Europaediatrics conference in Dublin, I knew little about it. As my abstract was accepted for poster display, I started reading about the European Paediatric Association (EPA), and got more and more interested. But no amount of reading could really prepare me for the experience of going there – so I thought I’d share a few thoughts with all of you. If you’re interested in going to a great conference, make connections, perhaps display/present a poster, and (last but not least) learn some pearls of wisdom from professionals on top of their game, please read on…

 ​The European Paediatric association is, in their own words, a “pan-European scientific association, whose main objective is to encourage scientific co-operation between not-for-profit National European Paediatric Societies/Associations and between European paediatricians working in primary, secondary and tertiary paediatric care in Europe, in order to promote child health and comprehensive paediatric care.” It was founded in 1976 in Rotterdam, and now represents 50 National European Paediatric Societies and Associations.
So far, 9 Europaediatrics Conferences have been held. The one I’ve been to was held in Dublin, between the 13th and the 15th June 2019.

1. The topics – it would be virtually impossible to list all the topics covered at the conference. From neonatology and critical care, to adolescent medicine and health promotion, from local issues such as social media and obesity, to global child health concerns, such as increasing migration and ongoing conflicts, all interests were catered for. Although I was only able to attend a handful of lectures and workshops (as most of the sessions ran contemporaneously), I felt excited, stimulated, impressed, and humbled by many of the accounts and experiences that were being shared. 
From a “paediatric trainee” perspective, I particularly enjoyed a “Meet the Expert” session on the diagnosis and management of seizures by leading experts Sophia Varadkar and Mary King, as well as a heated debate between Professors Chiarelli and Viner (both Diabetes and Adolescent Health specialists) on whether childhood obesity should be considered a form of abuse. 
I learnt a lot and made quite a few useful notes by attending some of the satellite symposia on allergy (desensitisation therapies) and Duchenne muscular dystrophy.
And the truth is, I wish I’d had more time to attend all of them! Whether the topic was educationally relevant to me at the time, or whether I learnt about global child health and how the world works, I left feeling more hopeful about life in general!

2. The speakers – Where do I start? Some of the very best of Healthcare professionals from all over Europe (and the World) seemed to be there. If I was to name them all, you might be reading on for a while...
But just to give you a flavour, the president of the International Paediatric Association, Zulfiqar Bhutta, spoke about Child and Adolescent Global Health Challenges.
You may have met or listened to our former RCPCH President, Neena Modi, or our current one, Russell Viner – well, they both delivered powerful and moving speeches.
And the list goes on...It would be fair to say that everyone I have listened to presented a topic they were not only competent at, but also interested in sharing with the audience. This made every lecture/workshop that I attended stimulating and interactive.
Finally, I had a moment of wonder – the Health Minister of Ireland gave a speech at the Introductory Plenary. Although elements of his speech were, by nature, political, I was deeply impressed by his manners – he came across as knowledgeable, humble, and respectful of the medical profession.  Made me hopeful that a few other Health Ministers across the world may do the same.

3. The atmosphere - I’d never been to Dublin but I can only recommend it. It was a busy couple of days as I was also preparing for an exam, so I did not fully enjoy all that Dublin could have offered. The venue was spectacular (by the river, with great views over the city and the Wicklow mountains). I met a few colleagues from Ireland with whom we chatted about a variety of things ranging from politics to travelling (and medicine). I also spoke to a few Italians about paediatric training and the differences between our systems – which made me really appreciate the structure of our curriculum and the opportunities we get as members of the RCPCH.

​I felt that more could have been done to allow professionals whose first language was not English, to express themselves in their full capacity.
Although everyone had prepared presentations in English, the quality of the translations varied significantly. It just seemed a shame that highly-knowledgeable professors should struggle to express complex concepts in a language that wasn’t theirs. I understand that having translators would have been logistically complicated (and perhaps not justifiable), but I think it would have made a positive difference to both speakers and audience.
Otherwise, it is difficult to be objectively critical of anything – hot food would have been nice (but the sandwiches were acceptable) and better velcro to attach posters may have come handy, although I should probably blame my fabric poster for that (which was, by the way, a good investment, as I could fold it and pack it in my luggage without incurring Ryanair fees).

​Yes – simple answer. Expensive (450 Euros) but good value for three days of excellent opportunities for learning, networking, and much more.
I ‘m glad I went, for all the reasons I explained above, but mostly because it gave me a boost of motivation and hope for the work we do as Paediatricians.
If you’d like to attend the Conference in 2020, have a look at the links below.
 
http://www.epa-unepsa.org; https://www.europaediatrics2020.org/
 

Dr Thomas Cromarty ST6

​Session delivered by:
Sara Hughes – Speciality Reg in Paediatric Dentistry,
University Dental Hospital Cardiff

​Earlier on in the month I was able to attend an incredibly enlightening session on Oral Health in Paediatric patients. Aside from teaching me how to brush my own teeth properly at the age of thirty-five, there were some really useful nuggets of information. Especially for questions which my friends who are parents ask, starting “You’re a Paediatric doctor, you should know this” (Spolier..often I have no idea). Well when it comes to kids and teeth, now I do, and in 5 minutes so will you. I thought it would be easiest to go for a Q&A format, so I’ll jump straight in.

Turns out that apart from the Natal Teeth which you sometimes see whilst on the Post-Natal ward (check it’s not loose and airway obstructable, then send to a dentist):

• The first teeth usually come through at 6 months.
• You get a full set of primary teeth (20 teeth, EDCBA,ABCDE) by six months
• The full rack of secondary gnashers (32 teeth, 87654321,12345678) by age twelve.

BabyCenter – Baby Teeth Order of Appearance
​

 Eat sugar -> Bacteria in the mouth use the sugar to produce acid -> Acid then demineralises the enamel -> Hole is formed. Think of it like the “Battle of the Bouche”, with protective factors versus destructive factors. On the good side we have Saliva (buffers the acid), Fluoride (strengthens enamel) and a healthy diet (low sugar, coarse food cleanses teeth). On the bad side there are caries causing bacteria, xerostomia (low saliva levels) and poor diet (high sugar).

​Actually No, the bacteria which are implicated in causing caries are acquired, and usually from adults that can transfer the bacteria to the child. So please don’t recommend doing that.
 
“Yeah, the baby teeth aren’t in good nick, but we’ll sort out his teeth cleaning when the adult teeth come through….we cool?”
 
Decay and Caries in the baby tooth can track down to the adult tooth and affect the development of the crown, making it more likely to break down and need extraction. Also, if baby teeth need to be removed prematurely, adult teeth then drift in and either can’t erupt or erupt abnormally, causing “crowding” of teeth. Sometime adult teeth to be removed as well.

Figure 1. The baby tooth above the adult tooth (circled) was removed so hasn’t erupted properly due to drift of the tooth to the right.

​Answer: Frequency is worse than Total amount

​The ‘Stephan Curve’ (above) shows that after sugary foods/drinks, bacteria use the sugar which makes acid (lowering the pH). When the pH in the mouth is below the ‘Critical pH’ of 5.5 then tooth decay happens. The longer cumulative time the mouth’s pH is in the ‘critical zone’ then the worse the decay. So you can compare a day without sugary snacks Versus a day with sugary snacks! (below).

 
How big is the problem? What are the REAL stats? (UK data from 2013)

​8 year olds: 46% have ‘Obvious evidence of dental decay’
Socio-Economic Inequality:
57% (children who qualified for free school meals)
45% (did not qualify for free school meals)
 
12 year olds: >30% had obvious decay in the permanent teeth
15 year olds: >40% had obvious decay in the permanent teeth

​Dental Health DOES impact on General Health!
Children with decay and tooth pain who are not used to visiting the dentist are scared, so don’t tell their parents and suffer in silence. Some of these effects can be seen below:

​ Sugar Smart app: This breaks down daily recommendations into sugar cubes rather than grams, which is much easier to understand.
NHS food factsis useful: Maximum Daily allowance of sugar in children is 4-7 cubes (each cube is 4g sugar)

​Drinks!Fizzy drinks, Fruit juices.
Hidden sugars:Tomato Ketchup (not so bad when consumed with a meal). Petit Filous (1.5 sugar cubes each)
Dried Fruit:Lots of sugar and sticks to teeth as well

• Reinforce key messages
• Brush Twice a Day
• Use fluoride toothpaste
  1. If child <3yr – 1000ppm fluoride
  2. >3 – 1350 – 1500ppm fluoride (adult concentration
• Spit! Don’t rinse.
• Do not eat or drink after brushing at night

 
2. Give Tooth Friendly Advice:

• Keep foods and drinks containing sugar to mealtimes only
• Drink only milk or water between meals
• Do not eat or drink after brushing at night
  • No bottles of squash or juice in bed to sleep
  • Cut the top off the teat, off to transition off bottles
• Stop bottle/breast feeding from 12 months – Use expressed milk in a free flow cup
  1. Breastmilk does have lots of sugar so try to avoid giving breastmilk as going to sleep. Milk will be left on the teeth and increase chances of decay. Drink breast milk then brush teeth. (Milk in the day much safer!)

”Bottle Caries” where milk sits on the teeth overnight (and saliva reduction is low)

​Remember: Sugar free squash  or just no added sugar

3. Recommend  safe snacks

• Raw Vegetables
• Fresh fruit
• Savoury foods

4. Encourage regular dental visits
Ask the question as part of your regular history taking E.g. Who is their Dentist?  - Just asking the question can be enough
“How often?” - depends on risk level, 6/12 to 18/12.

​Unflavoured & Non-foaming (SLS free) for children with autism. (e.g. OraNurse)
DO NOT Recommend: Fluoride-free toothpastes, Toothpastes containing baking soda (stains only), Charcoal toothpastes.

​Check that the patient has a Dentist. Otherwise can register with NHS Direct.
Other Options:

• General Practice
• Community Dental Service – can do domiciliary check-up.
• Hospital Service – Check if there is an electronic Referral System?

If there is significant swelling or severe pain, then contact Max Fax

Dr Chris Course, ST6 Neonatal GRID Trainee

The 3rd Congress of joint European Neonatal Societies (jENS) took place between 17th-21st September 2019. jENS is  jointly organised by the European Society for Paediatric Research (ESPR), the Union of European Neonatal and Perinatal Societies (UENPS) and the European Foundation for the Care of Newborn Infants (EFCNI) and occurs on an alternate-yearly basis. It is one of the largest neonatal conferences in Europe, and around 2,000 delegates attended to hear the over 120 speakers discuss the latest scientific advances in basic, translational and clinical research, as well as latest clinical guidelines and recommendations in patient centred care, all within the field of neonatology and perinatal care.

​jENS is a perfect conference for anyone with an interest in neonatology. I think as a new GRID trainee it was really inspiring to hear about all the latest developments in the field and see what treatments and management strategies we may be employing in the next 5-10 years. I suspect the programme is probably too intensive care/tertiary neonates-focused for anyone within higher level general paediatric training, but for anyone more junior who is still deciding on later career aspirations, it certainly gave a good insight of the ever-evolving field of neonatology.

​The main conference ran over 3½ days and the programme was mainly centred around 4-6 concurrent sessions running simultaneously with different themes, covering nutrition, lung, neurology, cardiovascular and other topics. A mixture of poster walks, poster presentations and oral abstract presentation allowed delegates to also present their work, in addition to the invited speakers and plenaries. The whole conference then came together in the main auditorium at the end of most of the days for some diverse and thought-provoking plenary sessions, with a broad range of topics including integrating and undertaking research within daily clinical practice (Prof. Neena Modi, great to listen to as always), how to grade the quality of evidence (Prof. Roger Soll, head of the Cochrane Neonatal Group and Chair of Vermont-Oxford Network, making a dry-sounding topic really engaging and relevant) and how do we make end-of-life care decisions ethically and also involve parents and families actively in our decision-making process. There really was something for everyone!

​I also had the opportunity to share some work I’ve been involved with through WREN on improving the management of Respiratory Distress Syndrome in Wales. I was quite nervous leading up to the presentation, but the audience were friendly and supportive (and didn’t ask too many difficult questions!). It was a fantastic opportunity to do some CV-building and gain some experience presenting to some really eminent neonatologists who are leading their field. 
 
It also meant I was eligible to apply for and be awarded an Educational Bursary (courtesy of the charity Bliss, funded by Chiesi) which made the conference more financially viable for me to attend. The opportunities for funding to attend these big international meetings are out there, but often not well advertised to trainees – it’s definitely worth asking around (and talking to relevant pharmaceutical reps and companies) if you’d like to attend any of these big meetings. I find it enthuses me about my speciality and I can really recommend trying to attend whichever conference would be relevant for your interests.

​The conference was also an opportunity to visit Maastricht, a place I knew nothing about and would never have visited otherwise. Maastricht is a beautiful, historical city, and walking around in the morning and evenings, as well as finding some great little Dutch restaurants, was a lovely way to relax around a packed conference programme.

​The 4thjENS Congress will be taking place in Athens from 14th-18thSeptember 2021. I plan on attending again and look forward to discussing some of the ideas and new knowledge I’ve gained with my colleagues in NICU on my return from this trip!

​More information:
www.jencongress.eu
@JENS_Congress

Dr Siwan Lloyd ST5

Action for children Family Intervention Team: supporting children in the community
 
I am coming to the end of my community paediatric placement and have learnt a huge amount about the way that vulnerable children and families are supported in the community. Whilst sitting in on MDT referral meetings, I realised that I previously had very little understanding of the huge team of allied professionals, charities and agencies offering support out in the community. I therefore made it a PDP to increase my understanding and awareness of the way that the wider community supports children.

I was over the moon to be invited to an Action for Children Family Intervention Team (FIT) team meeting. The team had a psychologist and family intervention workers who all had their own caseload. The team discussed their active case-load and I was really inspired to hear about the support that they provide for children living in very difficult circumstances (e.g. living with parental mental health disorders, acrimonious parental separation, children struggling with issues surrounding gender identity, children presenting with behavioural challenges, children displaying sexualised behaviour, children living in households with domestic violence, children displaying anger and aggression etc.). The team usually perform an initial assessment and then work with a family for 12 weeks.

Many of the children had received support from their Wellbeing project (a project funded by Caerphilly families first and run by Action for Children) which supports families suffering from low motivation or low mood, anxiety, depression, social isolation or traumatic life experiences. The aim is to build resilience, improve emotional wellbeing and support for families to feel more positive and confident. The process is provided by a family support practitioner delivering engagement sessions followed by either group sessions or individual support. They work on confidence building, self-esteem, regulating emotions and feelings and preventing social isolation.

I was particularly impressed by the way the team discussed a safeguarding issue of a family who would not engage with any other service (e.g. paediatrician, social services) and who were withdrawing and becoming socially isolated but this family had built a trusting relationship with their action for children family intervention team case worker. The team discussed the way in which this was so important in maintaining this relationship and slowly getting the family and child to trust professionals.

I was also impressed by the way the team highlighted each child’s wellbeing as their utmost priority but always discussed this in the context of the wider family. There have been many times in community paediatrics when I have seen a child presenting with behavioural difficulties when it is evident that the family environment is affecting them. This team is able to provide support to the wider family and by doing so improve the life and mental health of the young person which is an invaluable resource. Action for children can arrange Family Therapy which can work on issues such as building consistent parenting.
 
I learnt about some of the psychological techniques that can be used to support parenting for example PACE – “playful acceptance, curious and empathetic” a form of parental psychotherapy developed by Daniel Hughes that can be undertaken in groups or 1:1 and works to support forming secure attachment and encourages parents to give children vocabulary for discussing emotions. There was also discussion about ACT “acceptance and commitment therapy” which can be offered to parents struggling with difficult circumstances to allow them to accept these things that they have no control over. There was also discussion surrounding teaching and supporting parents to use NVR (non-violent resistance) as a technique to manage difficult and aggressive behaviours.

I was embarrassed to admit that I had no idea how many sources of support there are for families that Action for Children can signpost and refer to (for example “Confident with Cash” is  a resource led by families first and the citizen’s advice bureau that can give advice on benefit entitlements, consolidating debt and managing household budgets to families that are struggling, TYFE (targeted youth and family engagement) is a group led by families first that take children out to participate in group activities aiming to build their social skills, confidence and self-esteem).

The team also discussed referrals on to other agencies as sources of support including Llamau (e.g. “domestic abuse children and young people outreach”), Caerphilly Council’s Youth Respect programme (a Supporting Family Change project for young people who show early indications or abusive, aggressive and controlling behaviours), NYAS (National Youth Advocacy Service – a confidential independent service that supports children and young people by helping them to be heard and exploring their views, wishes or feelings on a particular issue or circumstance), Barnados (e.g. “confident parents, stronger families” – aims to assist development of parenting skills and increase parental capacity offering support with things such as routines and managing behaviour).
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This team works with families who are reaching crisis point and struggling to cope and I firmly believe that the vital support that they offer is likely to reduce child neglect, child emotional and physical abuse and supports the child’s overall wellbeing. It was truly inspirational to see the way that they provide support for these families (and I was so inspired I was briefly tempted to change careers in order to become one of them!).

​Image: https://www.actionforchildren.org.uk/what-we-do/parents-and-families/
 

Learning points:
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1. When meeting vulnerable children and families always remain aware of local charities and agencies that can provide support and offer a referral to families if appropriate
2. We as medical professionals are really only a very small part of the jigsaw in supporting the wellbeing of children and young people in the community
3. There are a large variety of agencies available that we can turn to for advice and support when we encounter vulnerable children and struggling families

I hope to be able to attend further team meetings or shadow other agencies in order to continue to increase my understanding and awareness of their valuable work e.g. Barnados, Supporting Family Change. I would encourage every paediatric trainee to take every opportunity to increase their awareness and understanding of these sources of support for families in the community.
 
For more information about the work that Action for Children undertake see - https://www.actionforchildren.org.uk/. I would be very happy to share contact details with any trainee who is also interested in using some Study Days to attend an Action for Children Team meeting.
Other resources:
https://www.barnardos.org.uk/
https://www.llamau.org.uk/
https://www.nyas.net/

Dr Ciara Duggan ST4

The Professional Support Unit (PSU) was created in 2008 and aims to provide support to all doctors and dentists in training in Wales. At the recent deanery study day we had a workshop from the PSU to let us know what services are available to support us throughout our paediatric training.  They aim to support trainees early with confidential, targeted support they have a number of different resources and services available to them in order to do this.
 
Either trainees can self refer or supervisors can recommend referral to the PSU. Initially when the PSU was first set up they were primarily getting referrals from supervisors or following an undesirable ARCP outcome. However self referrals are increasing year on year as trainees have become more aware of the services available.  The PSU also has a presence on ARCP panels in order to support trainees and also offer additional support to any trainees with an outcome 2 or 3.
 
The PSU can provide an initial meeting where they explore the support needs and the best options for that trainee.   They provide health support, discussion about career options, eportfolio/ARCP support and help with those struggling with exams. They have links to a counselling service which trainees will be able to access within 24 hours of referral and they will try and link trainees to services as close to home as possible. They try and identify trainees who need adjustments for health or disability in advance so that each job can be prepared prior to the trainee starting.
 
I was interested to hear about the exam support which they can offer to trainees. They are seeing more and more trainees accessing their services for help surrounding passing postgraduate exams and the anxiety that these exams can cause. They can help with revision techniques and planning, dealing with the anxiety surrounding exams and dyslexia assessments where this is appropriate leading to extra time or support during exams.
 
Part of the workshop highlighted the success of the PSU in helping trainees. They show an increase in exam passing rate after input, an increase in outcome 1 at ARCP and a high level of satisfaction from the trainees who have been supported. All in all the session highlighted this resource, made it sound accessible and useful and I think it ties in with the recent push from trainees talking about our own wellbeing in work. The link is below if any one would like to access the PSU you can call them or email.
https://psu.walesdeanery.org
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The Wales Deanery recently organised a study day themed around health policy and practice in Wales, and our role as Paediatricians in influencing these policies.

Below we have two separate accounts of the day, one from a trainee perspective, and the other from the Head of Monitoring at 'Positif' - Wales' largest public affairs company.

Dr Lucy Deacon ST1

How much do you know about the structure of Welsh Government? Would you recognise a photo of our Health Minister? Why does it even matter?

I have to be honest, I had no idea about any of these things before I went to regional teaching a few weeks ago. At the start of the afternoon session I didn’t know what to expect, mainly because I knew so little about the National Welsh politics. It was, however, one of the steepest and valuable learning curves for me in training this year- I am left feeling both educated and empowered as a Welsh citizen and member of the medical profession within Wales.

Twenty one areas of government are devolved to Wales. Within those twenty one areas is Health and Social Services and together they receive half the budget given to Wales to spend. The Welsh Government really does care about Health.
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The training, delivered by positif, was engaging and relevant. We learnt about which departments are devolved to Welsh Government and who the big names are within the Welsh Assembly. Knowing this structure and then how policy decisions are proposed, debated and approved equips us as medics to be able to influence health policy within Wales. We learnt about choosing who to write to and how to start a national conversation about the issues that matter to us. Creating a conversation comes not only from research, and published articles and papers, but from making the relevant people, in power, aware of these findings, joining working groups, responding to national policy documents in consultation and identifying champions to join us in fighting for the change we want to see. And timing. Timing is important and very relevant to writing this piece because, now is the time to be writing to Assembly Members. The election cycle means now is the time to be making proposals, ahead of parties writing manifestos next year, this is the time to be raising our questions and lobbying the government to discuss them. Questions for the Health Minister can be oral or written and he answers questions every 4 weeks on Wednesday. Asking for more money is what everyone does but proposing solutions is what is listened too.
 
We finished the afternoon planning and presenting our ‘Lift Lobbying’ pitches. Individuals came up with an issue they wanted to change, among them – rest facilities for junior doctors, what to do with the national report on Adverse Childhood Experiences, making CAMHS a 7 day a week service for children in crisis and having a drug and alcohol service for children in need of support. We were challenged to think ‘what is it you are actually trying to do?’ The room became impassioned as we worked on compressing the proposals into a 2 minute pitch you could give if you found yourself in a lift with Vaughan Gething.
 
So, I left at the end of the day, having been involved in lively debate and feeling better informed about how health policy is formed within Wales. But more importantly I left feeling a sense of privilege and of responsibility as a doctor because now I knew how to get my voice heard on the issues that matter to me. It was clear from our pitches that as junior paediatric doctors we wanted better services for the children we care for and that we are uniquely positioned to identify the issues as they confront us in work on a daily basis. What we see every day is the health of our nation, and indeed our nation’s future, so safeguarding it is in the Welsh Government’s interests. There are routes to get our voices heard and knowing more about how policy decisions are proposed, empowers us as doctors to influence discussion and debate.





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Rhodri ab Owen
Head of Monitoring,  'Positif'

​A common misconception is that you need to be “in politics” in some way to have a political impact and influence. You do not. This was the biggest take away I wanted to give a group of paediatricians who came to a session at the Princess of Wales Hospital in Bridgend on how to influence politicians and key stakeholders.
 
Context is the key to successful political influencing. It is about talking to the right person, or an influencer on the right person, in the right way, about the right things, at the right time. Politicians in Wales are much closer to the people than in other parts of the UK, and it is far easier to influence and organise a meeting with Assembly Members, than other politicians across the UK. Most policy development and legislation have come from an individual or a group of individuals influencing politicians. For example, the system of presumed consent for organ donation came about after several years of campaigning from a cross section of interested organisations. Kidney Wales may have led the campaign, but it was actively supported by others with an interest in increasing organ donation rates such as the British Heart Foundation and the Cystic Fibrosis Trust. It also gathered support from the British Medical Association, which provided additional gravitas in making the case.
 
While discussing allies as part of the context, it is also perhaps worth reflecting on who your opponents might be. You might not think you have opponents but every interest group chasing the same pound, or every organisation seeking attention to their policy asks, is potentially an opponent. Even those you might assume to be allies are not necessarily so – UK Transplant was one of the most lukewarm organisations in respect of a policy of presumed consent for organ donation in Wales.
 
The legislation for presumed consent in Wales which reached the statute book in Wales in 2013 began six years earlier with the building of a coalition and an information gathering exercise. This helped establish the context of the campaign. Data and statistics were gathered, best practice examples were observed in other countries, and a bank of knowledge was created to ensure depth and consistency. From this firm foundation, not only was political action taken, but steps were taken to create and shape the context of a wider public discussion. This included becoming part of Welsh Government working groups, inputting into consultations, and publishing articles in newspapers. All of which elevated the issue and gave it clear context to support the campaign and its key asks.
 
TOP TIP: Make sure you have spent a decent amount of time planning, evidence gathering and sounding out potential allies before you embark on any campaign, especially if it is impactful or high profile in nature. Getting things right from the outset can avoid problems and disappointments later down the line.

Dr Assim Javaid ST3 

Provider: Bristol Medical Simulation Centre

Course Length: 1 day
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Cost: £85 (Free for Peninsula and Severn Trainees)

A one day course aimed at dealing with paediatric emergencies that can happen on the ward, in ED or on an admissions unit. It’s aimed at level 2 trainees and provides more difficult and challenging simulations than seen in other simulation courses. There’s a mix of resuscitation and communication scenarios aimed to push junior registrars out of their comfort zone and to make senior registrars think harder about their leadership styles. 

​The Bristol Medical Simulation Centre, if you’ve never been there, is fantastic. There are a number of beds, made to simulate the ward, theatres and side rooms, and this, alongside an excellent range of mannequins, really help to minimise a lot of simulation artefact by making the scenarios feel that bit more real. The faculty are friendly and approachable. They also provide a really good debrief session, which I find the most useful part of simulation.

​Bristol is a bit of a nightmare to get into! But that’s always been the case and something you’ll just need to factor in when making your way there. Other than that, the only other downside is that the vast majority of the attendees will be Severn trainees. They’ll all know each other relatively well and, unsurprisingly, will take to working together in simulations easily. If you come from outside this deanery, be ready to be the unknown factor in the group. That’s not necessarily a bad thing but it’s worth being aware of beforehand.

​In a word, absolutely! The scenarios are challenging (I won’t say what they are as that would defeat the purpose) but in no way unfair and closely related to our practice. The focus is very much on gauging and developing how you work as a leader of a team in an emergency and this is the best course I’ve been on for developing that aspect of our professional behaviour. Though there is a cost for Welsh trainees, it’s certainly nowhere near as high as other similar courses and I think the value for money is excellent.

Oliver Walker ST6, Neonatal GRID Trainee

Preparing for consultant interviews may feel like a very distant problem in the early years of paediatric training.  However, thinking early about what you’d like your future consultant job to be and how to get it can help guide your priorities in the last years of your training.  For many of us this may well be the first interview we have had since applying for paediatric training.
 
Dr Helen Jeffries and Dr Rachel Rayment gave an instructive talk on consultant interview skills at the recent junior doctor leadership session at UHW.  They talked from personal experience of being both the interviewer and interviewee. A key message was the importance of preparation well in advance.  As well as building your CV in the later years of training, try to demonstrate an interest that will be a selling point to the panel, be it an area of clinical expertise, management experience, research or education.  
​Look online for consultant interview scoring criteria and identify areas of strength as well as weaknesses that you can address in advance.  When looking for jobs try to think carefully about whether it is right for you, remember that consultant jobs are often still a career long position.  Dr Jeffries and Rayment told us that if you feel the job doesn’t quite fit your needs (e.g. you have a research interest you’d like to pursue) you can discuss any specific changes with your future employer.  They suggested that this should be done early in the process as once you are appointed renegotiation can be very difficult.
 
Once an interview has been offered, visit the department, make contact with and ideally meet as many members of the interview panel and department as you can.  This will give you a valuable insight into the priorities of the department and likely interview questions.  It is as important to meet non clinical as clinical staff.  Visiting will stop you being an unknown quantity at interview.  Make sure you are aware of local issues and practices - this can be especially true if moving regions or countries.  For example, NHS England has a very different structure to NHS Wales with different bodies for service commissioning and service delivery and this alters an organisation’s priorities.  Look at the values of the trust or board you are applying to, try to see what the its plans for the future are and how you complement these.
 
When preparing for the interview practice as much as you can with friends and especially consultant colleagues who can offer valuable feedback.  There are also services that provide professional advice and training for interview skills.  
 
Dr Jeffries and Dr Rayment emphasised that clinical skills are taken as a given - it is how your other skills and experience will fit the needs of the department that really matters. 
 

Dr Christopher Course ST5, Neonatal GRID Trainee

The first South Wales & West BPD/CLD Symposium took place at the Holiday Inn Cardiff North on 12th June 2019. The day aimed to update delegates on the latest topics on the prevention and management of chronic lung disease of prematurity (CLD), also known as bronchopulmonary dysplasia (BPD). We attracted nearly sixty delegates from a multi-professional background from across the South Wales and West Country regions.
 
The morning session focused on hot topics in the prevention of CLD. It started with an overview of the current trends in management of respiratory distress syndrome of prematurity, presented by Dr Chris Course. This talk highlighting changes in practice since the introduction of the Wales Neonatal Network RDS Management Guideline in 2016. Progress has been made in mechanical ventilation support and supportive care, but the data highlighted the ongoing need to optimise early care in the delivery room and aiming to stabilise on non-invasive respiratory support.

This was followed by Professor Sailesh Kotecha (Cardiff University) presenting his groups ground-breaking work on the influence of pulmonary microbiome on the development of CLD, the negative impact of ureaplasma colonisation, and potential therapeutic interventions. ​

​Dr Malli Chakraborty  (NICU, Cardiff)followed with an overview of the current evidence base for different mechanical ventilation strategies in preventing CLD, stressing the importance of minimising duration of mechanical ventilation, gentle ventilation modes (such as Targeted Tidal Volume mode) and future directions for support, such as NAVA (neutrally-adjusted ventilatory assist). The morning was rounded off with Dr Lieve Boel (NICU, Cardiff) giving an update on the latest research in antenatal and postnatal steroid management, discussing the emerging role of early postnatal hydrocortisone, and potential advances with intracheal instillation of steroids.
 
The focus of the afternoon then shifted towards the management of CLD and the longer-term outcomes of CLD and premature birth. The afternoon started with a discussion on the role of palivizumab in reducing RSV-related morbidity and mortality for those babies with chronic lung disease, and the possible expanded role it may have for late preterms, who still have a higher RSV-related morbidity. Dr Aung Soe, (Medway Hospital Kent) Topic Expert for the NICE guideline on Specialist neonatal respiratory care for babies born preterm (https://www.nice.org.uk/guidance/ng124) highlighting some of the challenges of the NICE review process and summarising the recommendations. 

​This was followed with a moving talk from two parents, whose daughter had been born extremely preterm and suffered with CLD. Their experiences were vitally important in bringing all of the science and guidelines discussed so far during the day to impact it really has on families. We rounded the day off with Dr Martin Edwards (Consultant Paediatrician, Children’s Hospital for Wales) presenting his research on the long-term respiratory outcomes of premature birth, stressing that abnormal lung function and increased respiratory morbidity persists through childhood and into adulthood, highlighting that if we can optimise their early respiratory care, we can have a positive impact on their health for the rest of their lifespan.
 
We would like to thank Abbvie ltd for their help in supporting the day and we hope to organise a similar symposium next year – please stay tuned to the WREN twitter feed and website for more information.

                                                                            Dr Rebecca Broomfield 

​Sony is a large company which has adapted and remodelled to make the factory and business viable in the current market. They are very flexible in their workforce and their production lines. They are able to upscale and descale production depending on demand and they have diversified in order to maintain the company. The have a variety of space which are able to be utilised for multiple things … but what about their workforce?
The site which Sony currently occupies has expanded quickly with increasing number of staff and therefore a greater focus on them. Sony wants to make a quality product as their output and recognise that the staff which they employ are large contributors to the input variables contributing to a quality end product. The staff do shift work and are mainly local within south wales. Sony wanted to ensure that they remained a well thought of employer and therefore surveyed staff about their wellbeing. Prehaps more importantly they have responded to their staff survey with a variety of positive projects. 

​Sony employees fed back that they did not feel that they had enough information to stay healthy. Sony have responded to this, as a good tech company should, by collecting data on the health of their employees. They have knowledge of the BMI’s of their employees, and promote their staff knowing their blood pressure and health status. They have managed to decrease their percentage of abnormal blood pressure readings over a 5 year period from 46% to 13% (a 33% reduction) simply by having the resources to make people more aware of their own health and its importance. 

Research suggests that 1 in 4 people suffer a mental health problem each year. 55% of Sony employees surveyed stated that they would like more support and information on mental health. But beyond that it was also contributing to the companies work absences with 12% of short term absences and 32% of long term absences contributed to by mental health issues. 
 
They have then acted on the responses to their survey but providing things for both mental and physical health. Examples of the mental health initiatives include mental health awareness training for their managers teaching them how to recognise and support members of their teams suffering from mental health problems. They have introduced mindfulness workshops and created more informal ‘tea and talk’ events which also feature facilitated discussions on a variety of topics such as emotional intelligence and understanding triggers. 

They have responded to the employees wish to be more informed on their health by putting in sessions in the canteen focused on healthy eating, ensuring that their menu is well balanced and promoting the benefits of cooking. They have also increased the availability of physical health projects to their staff.
They have fitness classes which are free of charge, that take place outside of normal working hours, they have a gym onsite with showers and changing facilities and promote taking part in events such as the Cardiff half. They have also focused on physical activity as a part of their team working days hosting a mini Olympics. They have access to a cycle to work scheme and have step challenges and a running club. 




As a part of all of this they have also remembered that a lot of their employees have families and have hosted family days out to encourage a positive work life balance for their team members.

As well as the wellbeing initiatives they have also listened to the feedback from employees with regards to education and career progression. They have an onsite academy with well structures career pathways and modules to complete for career progression within a person’s interests. They have dedicated time to study and complete these. Importantly, Sony have recognised that some people do not want to progress through a career pathway, they want to turn up to work and be able to do the best job which they can. They have also therefore ensured that even if people do not want to progress through a career pathway they have relevant training and opportunities to keep them up to date within the role they are currently doing.

Through the development of the education centre and career pathways Sony recognised that >70% of their employees report to and are managed by their first line supervisors. Therefore they have invested in providing them with appropriate training to coach and support the staff under them, whether it be on a production line or within a more managerial position. There senior executive is also regularly available to all staff, having a drop in breakfast session in the staff canteen. 
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And finally, something which we can all relate to they have Sony version of the Greatix. Sony has some core company principles and all team members are invited to submit nominations for those who have fulfilled a key principle. The person who is selected nominated gets a reward, a picture on the wall detailing their achievement and which core principle they were nominated under but also, uniquely the person nominating also gets mentioned and recognised. 

​While working as a trainee within the NHS is obviously different to working within Sony I feel that there are many points of good practise which can be effectively transferred in order to improve wellbeing and maintain a healthy workforce. 

We need to as a team embrace change, as numbers of trainees gets smaller, rota gaps get bigger and the demand for our service and skills increases we need to be ready to embrace the changes necessary to adapt to this. I have been privileged to work alongside a variety of extremely skilled healthcare professionals from nursing, pharmacy, physiotherapy and other allied health categories. The benefits of utilising this multidisciplinary team more effectively would be beneficial for the best use of our staff and improve work life balance and job satisfaction. 

As a profession we need to continue to support wellbeing initiatives and in fact expand on these from local teams all individually creating their own micro environment to deanery lead wellbeing initiatives. When I started working as a doctor it was not unusual to have a cake rota providing cake during a weekly teaching session or a breakfast journal club where you met to discuss a paper over coffee and croissants. While I am sat here writing this I am struggling to remember when this was last a regular feature of my job. Small gestures like this have the potential to contribute to a positive working culture and a sense of feeling valued within teams, both of which contribute to improved wellbeing.
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Like Sony we too can also focus on physical and mental health aspects. I know that the Calm app offer a year’s free membership for healthcare professionals with an NHS email address (go to: https://blog.calm.com/healthto benefit from this) Could this be promoted by our educational supervisors or Head’s of schools so that more people at least know that resources are available. 

​Welsh Paediatrics have recently attempted to promote physical activity and a team mentality by suggesting people sign up to complete a trail half marathon – while this might be madness, it was promoted by our Head of School, was distributed via a HEIW email and demonstrates that our deanery recognises the importance of having different challenges outside of work to focus on, using these to draw us together creating a team environment and contributing to an increased sense of value. If you too want to sign up for something utterly stupid then the link is here: https://toughrunneruk.com/events/cardiff-trail-half-marathon/(note I am a VERY slow runner, I will come last and you would be welcome to join me at the back! I have been promised that no troll will be left behind!)

We need to expand our Greatix system including recognising the people who regularly nominate people. While we do not have the budget which Sony has and will not have financial rewards or fancy tech available, the scattered systems which we have currently could be brought together, more centrally co-ordinated and recognised more effectively. Greatix works well in a lot of places but I feel we could expand this initiative significantly within Wales. 

Another thing which we should take from Sony was the way which they handle feedback. They have links which employees can feedback anything at any point as well as regular access to the chief executive. They are also, and perhaps more importantly, excellent at feeding back to employees actions which they have taken based on feedback. As trainees we are often asked for feedback but rarely get any response or see any change from the feedback we have given. I know that our feedback is acted on but a more transparent way of communicating this could open channels of communication and once again increase a feeling a value, team work and promote an open culture. 
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And finally, it’s not all about the trainees! As I become more senior within my training I am looking to my consultants for not only for clinical guidance but also looking at whether they are well supported, do they have a good work life balance, do they actually appear to enjoy their jobs??! As a deanery or school should we also be focusing on supporting the people who are supporting our trainees looking after their wellbeing and giving them the resources to be able to inspire the next generation of paediatricians. 

Camille Roberts ST1

​In paediatrics, as in other specialties, a large number of pre transfusion blood samples are rejected as a result of labelling and sampling errors. Over 200 paediatric pre-transfusion blood samples were rejected in UHW in 2018. We wanted to find out where errors were occurring and whether we could make any improvements.

​Questionnaires were completed by 43 staff members across paediatrics including senior and junior doctors and nurses. 49% had never received training or none within the last 3 years. 26% were ‘somewhat’ or ‘not at all’ confident with pre-transfusion sampling, and 79% admitted to having a sample rejected previously.
 
We also undertook an audit of rejected Paediatric samples between March to May 2018. 45 pre-transfusion samples were rejected, of which 75% were due to labelling errors. The most common labelling errors were a lack of signature, date of birth, first line of address, and no declaration completed.

​We have put together an informative poster with key points for pre-transfusion sampling, focussing on accurate labelling. This is located in treatment rooms and doctors’ offices across the children’s hospital, including theatres and paediatric A&E. It will also be provided to new doctors at induction. We are working on improving staff competency training rates and have had doctors trained as assessors to facilitate this.
 
We will subsequently re-audit and repeat questionnaires to assess whether rates of sample rejection have improved.

​Having to repeat blood samples following errors can be particularly emotive in Paediatrics. However, it is of relevance across all specialties as incorrectly labelled samples are more likely to lead to ‘wrong blood in tube’ errors, necessitate additional procedures for the patient, lead to delays in treatment, and add to staff workload.

​If you have any suggestions or if you are interested in expanding the project to your area please get in touch, we would love to hear from you.
Dr Camille Roberts (ST1 in Paediatrics)
Camille.Roberts@wales.nhs.uk

​Ann Patterson, Dr Sally Richards, Dr Ifeoma Ujomu, Samantha Mcwilliam

Dr Huw Davies ST5

#ChildhoodObestiy
Welsh Obesity Society, @WelshObesity
The Association for the Study of Obesity,@UK_ASO
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​What if we faced an infectious disease outbreak that affected 25% or more of our paediatric population by age 5? 50-80% of those worst affected by it will carry the adverse effects for life. It is a key cause of chronic ill health, linked to Type 2 Diabetes, Sleep Apnoea, Cardiovascular Disease, and Stroke. Insidiously, it creates barriers that prevent those affected from engaging with its cure. It might shorten lives for 20 years or more and is set to create a huge drain on healthcare and social care funding.

​There would be surely be an outcry against such a plague, and we would marshal all of society’s resources to fight it....

This is the situation for the obesity outbreak, with the greatest implications being for children. In Wales, obesity adds significantly to the burden of disease for society’s poorest. A key thread running through the Child and Adult Obesity meeting, held on the 26thof June, was that childhood sets the trajectory for a lifetime, for the better or the worse.
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Lucy O’Loughlin (@oloughlin_lucy) from Public Health Wales (@PublicHealthW) presented the scale of the problem. Current surveillance at reception demonstrates clearly that while the proportion who are overweight and obese is stabilising (albeit at the highest levels in the UK), severe obesity is increasing in prevalence. 2/3 of those overweight in reception will be obese adults. Meanwhile parents stress over “skinny-looking” or “under-fed” children because we can no longer accurately picture how a child should look; only <1% of those entering reception class are underweight.

Public Health Network Cymru: Obesity
Public Health Wales Observatory: Obesity in Wales (2019)Public Health Wales: Overweight & Obesity
Welsh Government Consultation Document: Healthy Weight: Healthy Wales
BBC: Obesity overtaking smoking as biggest Welsh health risk
 

The findings of the Genetics Of (Severe) Obesity Study (GOOS) were presented by Dr Agatha van der Klaauw. Genetic screening approaches show potential to understand the mechanisms of weight gain and appetite in the most severe obese, particularly if presenting at an early age or associated with liver or gastrointestinal problems. Some genetic obesity syndromes are also associated with Autistic Spectrum Disorder; children with ASD already face a high risk of obesity because of their challenges with diet and engagement with physical activity.

GOOS Useful Resources

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Aneurin Bevan Health Board are leading the way with “Connect”, a multidisciplinary service aimed at the most obese which provides intensive psychological, dietetic, behavioural and medical support for whole families. We heard from several members of their team, including Drs Hazel Baker and Naomi Swift (@ClinPsychNome) on the impact of cultural, social and psychological factors. Adverse childhood events are being highlighted over and over as serious contributors to poor population health and sadly in Wales we carry a high burden of these. Obesity is not the simple consequence of a lack of willpower, but is a highly stigmatised disease produced predictably by a combination of societal factors, family circumstances, and leads to a psychological hole which is extremely hard to escape. Olivia Colleypriest (@livveycolley22) also gave a dietician’s view on the evidence around very low calorie diets in children and adolescents – an underdeveloped area of study.




​Sara Jones of Swansea University also provided evidence that the very earliest childhood behaviours are formative and crucial. Breastfed infants are less likely to become obese; while formula fed can often mean over-fed, with pressure to achieve a schedule interfering with the development of appropriate hunger cues from the baby. With the introduction of solids disparities clearly emerge between those receiving high calorie loads from infant food products which set the tone of over-exposure to calories and sugary taste experiences. Infants whose early exposure is instead to whole foods, especially vegetables, seem to benefit throughout childhood and beyond. For the most impact we must seek to promote the healthiest feeding choices for every family.

​HENRY(@HENRYHealthy) is an early childhood intervention programme piloted in Leeds, which seeks to build health parenting behaviours while reducing stress and pressure on parents. We heard from the charity’s CEO, Kim Roberts, on the impact the programme has had and their hopes to spread its lessons elsewhere including Wales.

Dr Nalda Wainwright (@naldaw) of Trinity St David gave a fascinating presentation on “Physical Literacy” (@Phys_Lit_Wales) – how early motor competence supports engagement with physical activity for a lifetime. Motor delay is common in areas of deprivation and this leads to a downward spiral of lack of confidence and disengagement, with exclusion by peers all the attendant psychological harms. She highlighted the SKIP programme as an early years intervention which can mitigate this serious inequality in outcomes. Over the past decades children have lost many opportunities to play, particularly missing the instruction of older children in basic skills such as throwing, catching, even running.


The final presentation, from Dr. Rebekah Pryce (General/Endocrine Paediatrician at ABUHB), reiterated the need for urgent action, from clinicians but also at all levels of society. Setting up Connect required perseverance and they faced several false starts. However, the business case for obesity interventions should be overwhelming – even small reductions could have huge health and economic implications, let alone the multigenerational impact on individual families. Connect aims to provide person-centred care for some of the most at-risk children and families; the psychological, behavioural and dietary interventions required are not trivial.

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The meeting’s organisers were proud to provide an all-female panel for the Q&A, with a truly multidisciplinary range of voices. The need for leadership at all levels to prioritise population health and preventive approach was highlighted. Education for parents and professionals is a must, with an emphasis on care and support rather than simply another lecture or source of anxiety. Health visitors were identified as the professionals with the greatest scope to work with families to build skills for life; however, this is one of the greatest areas of shortage and under-resourcing at present. With Welsh Government support we can hope that a change is going to come....

Annabel Greenwood ST4

As a Neonatal Registrar, it is not uncommon to be faced with the situation of an equivocal or borderline CSF result when testing for neonatal meningitis.  Even when considered together with the clinical picture, it can often be difficult to interpret.  Should the baby be started on antibiotics? And if so, for how long?  A diagnostic conundrum.
 
It was therefore an exciting prospect to hear that our Neonatal Unit was participating in the ‘PCRctic Study’ for the diagnosis of neonatal meningitis.  But what exactly does this study involve I hear you cry?!...

​A multi-centre prospective study designed to enhance the diagnostic accuracy of neonatal meningitis.

​Neonatal bacterial meningitis is a serious illness that can be fatal if not treated.  Early diagnosis is key.  However, the diagnosis of neonatal meningitis is often challenging, both clinically and microbiologically, resulting in uncertainty regarding antibiotic initiation and duration of treatment.  The negative predictive value of bacterial culture is low and can be inaccurate in confidently excluding bacterial meningitis.

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​"PCRctic" is a novel assay based on 16S rDNA PCR technology.  It aims to detect a single intact bacterium whilst eliminating free DNA from dead and/or contaminating bacteria, therefore enhancing diagnostic accuracy, eliminating false positive results, in a rapid, cost-effective fashion.   This new diagnostic assay could lead to reduced antibiotic use and hospital stay for many newborn babies tested for meningitis.

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​CSF is collected in the standardised way.  At least 5 drops are to be collected in each bottle; two of which are standard universal containers, and one an Eppnedorf tube.  Parents are consented before inclusion into the study.  The samples are then sent to the lab for further analysis….

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PCRctic has already shown promising results for the diagnosis of neonatal bacterial meningitis.  The study is currently ongoing across a number of tertiary neonatal units in the UK.  Such novel molecular techniques have the potential to replace bacterial culture and enhance our antibiotic stewardship. 


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'Multi-centre diagnostic accuracy study of PCRctic - a novel 16s rDNA PCR assay for exclusion of neonatal bacterial meningitis' Dr A Abelian, Betsi Cadwaladr University Health Board

Dr Roisin Begley, ST8 PEM

I recently attended the RCPCH annual conference in Birmingham and to nobody’s surprise spent the Tuesday PM at the Association of Paediatric Emergency Medicine (APEM) session.

The key talks this year were themed on adolescents. These can be a particularly challenging group for us to cater for at times in the ED.

The first speaker was Dr David James, PEM consultant in Southampton.  He covered why adolescents are different and why we need to give them special considerations. Key messages were: new thinking/definition of adolescence is from 10-24 years. This has come from the paper in the lancet ‘The age of adolescence’ by Prof Susan M Sawyer et al. The adolescent brain is still developing and lots of the risky behaviours associated with adolescents can be attributed to this.

Neuroscientists have shown ‘Evidence points to a dissociation between the relatively slow, linear development of impulse control and response inhibition during adolescence versus the nonlinear development of the reward system, which is often hyper-responsive to rewards in adolescence. This suggests that decision-making in adolescence may be particularly modulated by emotion and social factors, for example, when adolescents are with peers or in other affective (‘hot’) contexts’ (Decision Making in the Adolescent Brain, Sarah-Jayne Blakemore & Trevor W Robbins, 2012)

So what is our role in this…..

Dr James explains, as paediatrician’s we have a role to use the health encounters to identify risk-taking behaviour and perform psychological assessment: the HEADSS screening tool (Home, Education/employment, peer group Activities, Drugs, Sexuality, and Suicide/depression). The aim is then to signpost on to services locally for support. (ie drugs and alcohol, sexual health clinic, bullying services). Locally in Wessex they have developed an app to help with this. Web based version. iOS and Android on the way.

Dr David James runs a RCEM day called the ‘forgotten tribe: adolescent in the emergency department’ if you want further insight.



The second speaker was Dr Damien Wood, who explained his role in the eating disorder team in the Nottingham region. He was accompanied by Emily (an ex patient) who told us what it was like to life with an eating disorder and her experience of healthcare. She said ‘mental and physical health shouldn’t be seen as separate- it should just be health’. Emily recommended we all watch: Things Not To Say to someone with an eating disorder.


The third speaker was Dr Annette Langseth, Consultant paediatrician at The CYP Haven. Her key messages were that we need to feel comfortable and confident talking to CYP (Children and Young People) about sex. If we feel uncomfortable or ‘judgey’ then they will not feel able to have conversations to us, disclose honest information or ask important questions. So get used to saying ‘vagina, anal and sex toys!'

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So lastly from me…. I missed this talk and seriously regret it. Dr Mike Farquhar gave a plenary talk on the Wednesday about his experience of growing up LBGT+ in the UK today, but you can get highlight of this issue through his twitter story: ‘ you can exhale now’ and by following him @DrMikeFarquhar and @RainbowNHSBadge. 

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​Key themes from this year’s annual conference were investing in the workforce and the future paediatrician with many plenaries and breakout sessions having a focus on staff wellbeing. Considering the ever increasing number of articles regarding dissatisfaction and junior doctor burnout, and the well-known case of Dr Bawa-Garba it was a pleasure to see the college taking on board the struggles of trainee wellbeing and taking the occasion to explore this further.

It was an enjoyable experience to have the opportunity to listen to so many inspirational speakers and hear their experiences and to discuss the projects that they had been involved with.
For the early risers, Tuesday morning began with a 5K run or a yoga session – I have to admit that I wasn’t there for either due to being on a train but I thought a nice session to include in the programme and begin the day with, and so I hear enjoyable.

Dr Adrian Plunkett, Consultant Paediatric Intensivist in Birmingham, gave the initial plenary session on “Learning from Excellence” for what proved to be a highly motivational talk. He discussed how for so long the focus of health care has been avoiding harm and improving care, by learning from errors already made. He feels it is almost ingrained within us as part of our training to find the mistake, rather than focussing on the positive.

​He gave the example of a series of sums, and asked the audience what we saw:

Honestly, what did you focus on first? The one wrong calculation, or the four that were correct?

His take was that we should be taking the time to appreciate and reward excellence and hard work as a way to learn, rather than focussing on what an individual or organisation has done wrong.

“Success has a much greater influence on the brain than failure” - Earl Miller (MIT Neuroscientist)

Dr Plunkett wants us to ask ourselves, when regarding our peers and colleagues:

1. Who achieved excellence?
2. Where do they work?
3. What did they do?

His group were the first to spearhead the emerging certificates of appreciation and now has a whole group focussed studying excellence in healthcare to help create new opportunities for learning and improving resilience and staff morale.

​For those interested www.learningfromexcellence.com and I believe a conference in the planning for February 2020.

Dr Hilary Cass (previous RCPCH president) and Dr Caroline Elton (psychologist and author of “Also Human”) lead a stimulating seminar exploring how the traditional view of patient-centred care wasn’t enough, and more consideration needed to be given to the health professionals providing that care. The “Triple Aim” was an initiative designed to optimise health performance by focusing on (unsurprisingly) three aims - enhancing patient experience, improving population health, and reducing costs.

BUT...

It is increasingly felt that this is not enough and many organisations are now moving towards the “Quadruple Aim” with the fourth aim being the goal of improving the work life of health care providers. 

Dr Cass spoke about doctors, and particularly paediatricians being over-represented in those that access professional counselling services. Anecdotally, she describes paediatricians being at higher risk of stress, burnout and depression than some specialities but at lower risk of addiction to alcohol or drugs.
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Dr Elton discussed her book which many members of the audience had read and appreciated and then discussed her own practice, particularly focusing on career planning for doctors and helping doctors make the right decisions for them when trying to balance the work and lives.
www.careerplanningfordoctorsanddentists.com
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Dr Judith Johnson (psychologist) discussed causes of burnout and expressed what the majority of healthcare workers are feeling. Many causes of burnout were identified and discussed – excessive workload, low staffing levels, poor leadership, lack of support and lack of resources. These are known, accepted and still people have difficulty challenging that this isn’t right or appropriate.
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She gave the example of the Mid-Staffordshire inquiry “when staff are burnt-out terrible things can happen”. Burnt out and disengaged staff were present on all levels resulting in a catalogue of events and lack of care.
 
 

Dr Dan Magnus (PED Consultant, Bristol) kicked off the trainees’ session with a lively discussion on wellbeing within medicine. Opening with a comparison between doctors and the crew of Apollo 13. I’ll admit I was slightly alarmed by this statement as I didn’t think things were that bad, only to realise later I’d mixed up Apollo 13 with the Challenger spacecraft disaster, and rather than our careers coming down in flames it was more – “Medicine you got a problem”.

Dr Magnus has done much work, particularly in ED, looking at the need for recovery after shifts and traumatic scenarios. Taking 10 minutes and having a cup of tea after a difficult event is not enough. He described working in Toronto where doctors don’t work more than 2 long day shifts or nights in a row (living the dream)!
www.yougotthiswellness.com/

He describes three essential components of wellbeing within the NHS – belonging, competence and autonomy. Perhaps surprisingly he’s not particularly a fan of resilience training “encouraging doctors and medical staff to ‘be more resilient’ is just a crafty way of diverting attention from understaffed rotas and deteriorating working conditions in an effort to get individuals to be more accepting of clinical environments”.

He highlights one of the main barriers to improving wellbeing as establishing what people want as every doctor or health professional will have a different take on what’s important to them. Saying that the general view is: better rotas, better facilities for rest and relaxation and more civility and kindness in the workplace”.

He identified 5 key statements for improving wellbeing:

1. Feel happy at work
2. Strive to be healthy
3. Manage nightshifts and sleep
4. Be “mindful”
5. Think about stress and fatigue

People were directed towards the EMTA (Emergency Medicine Trainee Association) resources for working well at night and left with a slightly disturbing fact that driving after being awake for 16-18 hours was equivalent to being over the legal limit for alcohol.

www.emtraineesassociation.co.uk/fatigue-shift-work--rotas
http://www.emtraineesassociation.co.uk/rest
 






​Overall, an enjoyable conference with lots of food for thought!