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).
​
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:
​

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
​

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.
​
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.





​

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
​
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. 
​
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.
​
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. 
​
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
​

​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.
​

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

​

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.

​
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.

​

​"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.

​

​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….

​

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. 


​

'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!'

​
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. 

​

​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.
​
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
​

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.
​
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!

This talk focused on Dr Rebeccah Slaters work on how noxious information is transmitted to the neonatal brain.
Her research focuses on how the brain behaves at rest and then differs with noxious activity  with the aim of improving neonatal pain management. Throughout the discussion the speakers explored how to assess pain in neonates such as scoring systems and assessing facial expressions; although this is much harder in more preterm infants.  Speakers then suggested possible analgesics such as sucrose, morphine, fentanyl or light touch.
Dr Slater discussed her POPPI trial - which assessed if morphine was a suitable analgesic for ROP screening in infants however this trial was quickly stopped due to safety concerns.

The rest of the discussion then focused on ethical issues surrounding pain management for example in patients with HIE, those requiring multiple and frequent blood tests or those having ROP.

This series of talks demonstrated the difficulty in assessing neonatal pain but also the rapidly increasing knowledge and evidence. It did raise the question of which analgesic is best and when it is needed with ongoing evidence hopefully able to answer this more.

Cardiff and Vale have recently purchased the Patients Know Best patient portal (PKB).  PKB is licensed such that any patient of Cardiff and Vale UHB secondary and tertiary services can use it.  Primary care is licensed separately, and that cost is under consideration.
 
Mike Bailey:
PKB is presented as a website, accessible from any patient devices that feature one of the common internet browsers (PC, laptop, tablet, phone) and is responsive, even where there is a low signal strength.
 
PKB addresses a number of our strategic priorities.  We are committed to “Information for You” and as such, PKB will provide patients with access to as much of their clinical data as possible.  This will include (past and current) diagnosis, meds, care plans, live results, appointments, letters, images, reports.  This should mean that patients will genuinely want to use PKB and positively support patient sign-up rates.
 
There are also a number of operational gain that PKB will facilitate:
 
·         Empower the Person. Through various functionality, including online care plans that can be shared with the patient’s care network, support the patients in taking an increased ownership and role in their care.
 
·         Facilitate significant elements of service redesign. Including community-based services. Self-reporting, for instance, will enable a significant reduction in outpatient attendance. The capacity freed up in outpatients can be directed to further improvements such as early, supported discharge, with an open ticket back to the ward if becomes necessary.
·         Facilitate operational savings (time/resource/cost). Very similar activity within Sussex & Surrey IBD process, reduced priority admission waiting time from 6 weeks to 1 week.
Reduced admissions (average 5 day stay) by 90% and reduced surgery by 80%.  Cheaper medications were also utilised as condition did not reach the same level of severity.
 
·         Home First.  In addition to early supported discharge, PKB will facilitate the use of online questions and telephone/video conferencing to reduce the need for patients to attend site. 
 
·         Outcomes that matter to people. Trials within CAV Audiology have demonstrated that when patients are able to complete pre-clinic questionnaires at home, in their own time, the response are much more meaningful and hence enable improved focus on the required care and support.
 
By facilitating a fully informed consent, patients are able to fully understand post treatment impact and actively make a decision on the pathway that suits their needs.  This significantly reduced DNAs at the outset of treatment and at the latter stages, when patients fully realise the pending impact on an impending procedure.
 
·         Reducing health inequalities. ENT and Audiology have demonstrated that the time saved via unnecessary appointments and improved processes has allowed specialist nurses to target those, often elderly and isolated patients, which have disengaged from their services.  PKB also enables patients to delegate access to their records within PKB to their circle of care, thus enabling increased support, through better informed carers - who can see appointments, care plans, letters, meds, help to self-report etc.
 
·         Compliance. ENT and Audiology have confirmed that issuing compliance related questionnaires and surveys via PKB has resulted in a significantly higher return rate.
 
·         Prehabilitation.  PKB can automatically receive and display data from smartwatches and related apps, in order to, with the patients’ permission, track exercise, diet and sleep, as part of prehabilitation programme or just general wellbeing.
 
·         Provide cashable savings (letters).  Letters to patients will be accessible within PKB, rather than via traditional postage.  This is much cheaper than current methods.  Even if a patient does not open a letter, it can be rerouted to an outsourced provider, which will send a paper letter cheaper than can be produced internally within CAV.
There are many other benefits, specific to each specialty. 
 
Initial rollouts will include Gastro, ENT and Audiology.  ENT and Audiology already have PKB but, now that we have purchased a full license, we will now be integrating PKB with UHB and NWIS systems to full enable the above benefits.
 
Whilst we await the completion of the integration work, we are also launching PKB for the national Talipes service.  This will launch during May 2019, before integration is available but will provide a significant improvement over the current paper-based data collection process
 
Aurey Tong:
Whilst we await the completion of the integration work, we are also developing PKB for the Cardiff and Vale Talipes service.  This is for parents whose children have congenital talipes equinovarus. The aim is to empower parents via information and support. They will have an electronic version of the talipes passport, a library of resources including top tips, and the opportunity to support each other.

​I attended the conference entitled "The Importance of a Supportive Environment for Healthcare Professionals". Awareness of burnout, mental health difficulties, and bullying affecting doctors and others in healthcare is at last increasing. We heard several moving accounts from those at all stages of training. A common thread was that all our speakers could objectively be considered high flyers, on the surface coping well with tough jobs. Yet all had felt like failures inwardly: because they were bending under demands of critically understaffed rotas; because they felt responsible for a tragic patient death; because they had been targeted for victimisation, for no evident reason. They had all looked around at peers seeming not to struggle, and thought "what must be wrong with me, that I can't cope". As a profession, our high standards and sense of duty make it hard to take stock and realise that we ourselves need help. Our speakers all mentioned this as the hardest and the most critical step.
 
The stories we heard stimulated round table discussions discussing what we had heard - how can individuals and institutions value and support our professionals and maintain their resilience throughout a medical career. We had access to well presented research data from the posters on display. I would highly recommend to anyone to raise these issues with their colleagues - those not giving them thought might well be the ones in most need. I hope this conference is replicated again soon and that these voices are heard at local levels too.

Katie Richards

​As part of my Master’s (MA) in Music Therapy and my training to become an HCPC-registered qualified Music Therapist (one of the allied health professions), I am fast approaching the end of my final placement, in a regional tertiary-level Neonatal Intensive Care Unit (NICU), which consists of an intensive care unit (ITU), a high-dependency unit (HDU), a low-dependency unit (LDU) and a nursery. Part of the requirements for our final placement, which forms most of our Advanced Professional Practice module, was that we had to set up a new music therapy service somewhere which had never had it before (one day per week for around 24 weeks). We could choose any client group or setting, and I was drawn to working with neonates ever since reading an article (scroll to see some reading recommendations!)by chance during the first year of this three-year part-time MA course. I was absolutely thrilled when the Senior Nurse emailed me back within minutes to say they’d love to have me on board!
 
I did lots of preliminary reading around music therapy in the NICU and observed a qualified music therapist working in a different regional NICU prior to commencing my placement, so I had a pretty good idea of what to expect. As with all our placements, this involved six weeks’ observations at the start, before commencing our own clinical work. Our placements are very varied, with my first-year placement having been in a Special Educational Needs (SEN) school working with a child with autism and my second-year placement in a private psychiatric hospital working with in-patient adults with acute mental health issues (and some with complex mental health issues, e.g. chronic schizophrenia and dementia co-morbidly). This sets us up for our future work, where the client groups could be incredibly varied (from pre-birth to end of life, and everything in between). 
 
The thing about music therapy is that you usually need a wide variety of musical instruments for different circumstances. Because we often work ‘in the moment’, you just don’t know when you may need something in particular, so it’s better to have it with you than not to. Because of this, I start my day by loading myself up like a Buckaroo – one more stringed instrument and my arm might fall off! Neonatal music therapy sessions can look quite different depending on the patient you’re working with and are adjusted to what that particular baby/parent needs at that moment in time, keeping in line with their broader clinical goals. For example, when working with a term baby who was quite aware of their surroundings and in a quiet-alert state, I used musical instruments with more of a sensory impact to encourage visual tracking (e.g. the shiny, reflective tambourine, the colourful rattle or the colourful wave drum – see photo). Of course, these instruments all work on auditory stimulation, but with the added benefit of visual stimulation and tactile stimulation if the baby swipes or grabs one of these instruments. I purposely selected rattles which would be easy for tiny fingers to grip, or instruments which don’t take much physical effort to make a sound, be that with their hand, foot, arm or leg. I was careful to ensure that all of my instruments could be easily wiped clean and sterilised after working with each patient, to reduce the risk of infection.

​Before beginning each music therapy session, I check with the baby’s nurse (and the parent, when they’re present) if it’s okay for me to work with the baby at that time, or whether they’d rather I came back later that day or the following week. It’s important to check that it’s suitable timing, and to be able to be flexible if not. Checking what state the baby is in (whether they are fairly alert, irritable or sleeping) is also important, and determines whether or not I work with them at that moment and, if so, which instruments I would use for that session. Different instruments would be used for different states and clinical goals, and also for different aged babies.
 
For babies born at very early gestational ages (e.g. 25 weeks), if they’re not many weeks old yet I tend not to work with them. Their mother’s voice will be the best and safest thing for them to listen to, whether that is through talking, humming or singing quietly. It’s crucial not to over-stimulate very young babies, as they need to adjust to the world first, which takes time. The sensory input from bright lights, noises around the ward, smells and touch can be too over-stimulating if they all occur simultaneously. It can calm them just hearing Mum’s voice (and indeed her heartbeat), whilst feeling the vibrations of her voice and heartbeat during skin-to-skin time. With this aged baby, I would only offer emotional support to the parents, and provide suggestions of how they could use humming/gentle lullaby singing, or even just reading or talking to their baby to support their wellbeing and development at that time, being sure to let parents know to watch out for signs of over-stimulation in their baby, explaining what these might be.
 
For babies born at gestational ages such as 34 weeks, I might work with them while their parent is holding them. In this scenario, I would use gentle (and very simple) guitar playing with just two chords, often accompanying improvised quiet singing (e.g. singing “Jacob, Jacob, how are you today?” [don’t worry – no actual patients’ names have been used in this example!]). I try to encourage parents to sing or hum along quietly, but often find that they are perhaps too embarrassed or self-conscious to do so on the ward, which I can completely understand. It’s not the same as being at home and having your own space, with no-one else watching or listening to your every move while you try to get to know your baby. Research has shown the importance of using the mother’s own voice, as this is what the baby will respond to best. The familiar sounds from being in utero (the whooshing of the amniotic fluid, the strong pulse of the mother’s heartbeat and the muffled sounds of the mother’s own voice, as well as those of people she sees regularly – so often the father’s voice is also recognisable to the baby) create a feeling of security for the baby as it tries to adjust to its new surroundings, so re-creating this in an informed and cautious way whilst watching for any signs of over-stimulation is important. During the music therapy session, I’m constantly looking out for any signs of over-stimulation (there are many!) and checking the baby’s monitor for their heart rate, oxygen saturation levels and respiratory rate, which further helps me to assess their mood and current state. I also check the sound levels of my musical interaction via a decibel-monitoring device.
 
With a more relaxed baby comes development, the ability to sleep and feed better and better emotional wellbeing, which is crucial for the often-traumatic environment they now find themselves in. The gato box (see photo – the two-tone wood block) is used to gently re-create sounds of the mother’s heartbeat, and with this you can help the baby to entrain their own heartbeat to a slower pulse, inducing relaxation and often sleep. Using the wave drum (see photo – the oceanic disc, complete with cartoon octopus!) very slowly and quietly (this can take a bit of mastering in itself!) can re-create sounds of the amniotic fluid whooshing around, also helping to calm the baby, reminding them of a time where they felt safe, secure and contained. The music has the power to ‘hold’ them when they are not being physically held, which is also a really effective way of helping them to feel safer. The predictable characteristics of the music, when used in an informed and careful clinical way by a trained music therapist, are purposefully used to help the baby feel more relaxed. When there is a predictableconstant for a period of time (the non-alerting style of the music used), the baby is less likely to become startled by the unpredictablesounds of bins closing, taps running, monitors beeping, doors closing and telephones ringing etc., as they have that predictable sound (the music) to tune into, which provides a sense of security. It’s also important for my sessions to be quite short – often 10 minutes is plenty. I observe for any signs of over-stimulation and bring the session to a close sooner if this occurs.
 
For term babies who are quite alert and aware of their surroundings, perhaps having been on the unit for a while and becoming increasingly bored by the blank white ceiling tiles above them, I work with them in order to increase neuro-development, where sensory stimulation is key. I would most likely use the reflective tambourine (see photo), the easy-grip rattle (see photo) and the wave drum, as well as my guitar and voice. Simple nursery rhymes with lots of repetition can help with early language development. The rattle, wave drum and tambourine are good for visual tracking, and any of these can be used to encourage them to move their arms and legs more, building up their physical development as they reach out to touch them. Music and sounds used can also encourage a baby who usually only looks to one side to explore the other side too, which can be good for their physical development. When the baby touches one of the instruments, it can also teach them about cause and effect, as they learn that when they touch it, it makes that sound. It can also help babies to learn the (unwritten) ‘rules’ of conversation – they make a sound, then I make a sound, then it’s their turn again, then mine, and so on. This can also provide them with a sense of security – the anticipation of knowing whether they will get their turn again, consistently having those needs successfully met, builds trust and a secure attachment, which is important for their future development, and can last long into adulthood.
 
It can be a bit of a balancing act at times, as I have sometimes worked with term babies who have been on the unit for quite some time who need sensory stimulation and a more lively session, yet they’ve been on the same ward as a baby who is only 28 weeks (gestational age) (e.g. in ITU). In this case, I factor in the rest of the babies on that ward, whilst trying to tailor the sessions to the individual baby I’m working with, so ensuring I’m quiet and perhaps sticking more to guitar and singing simple nursery rhymes, or improvised observational singing based on what the baby is doing, whilst slowly moving the rattle from left to right for the baby to track it visually. I often leave them a small square cut from some thin emergency blanket material (bought especially for this purpose) to play with (supervised!) on the days I’m not there – it makes a fascinating crinkly sound and is very cheap, as toys come! After each session I sanitise the musical instruments, then have to negotiate the notes… who knew it could be such a mammoth task adding a new continuation sheet half-way through a patient’s file?!
 
I attend the MDT meeting when possible, where most of the patients are discussed. This helps me to be more informed about the family situation of the babies (including any psycho-social issues), and also helps me to prioritise who to work with (babies andparents). A big part of my clinical work on the NICU, which people may not initially think of, is talking to (and, more importantly, listeningto) parents and providing much-needed emotional support to them. I also ran a music therapy support group for parents, using relaxation techniques and providing a confidential space for them to meet other parents and explore their experiences on the NICU, using music to help in the process. Parents can be experiencing trauma in the NICU, so it’s vital to provide that emotional support, which can be invaluable for helping them cope. Some parents don’t necessarily have much of a support network around them in the form of friends and family, so it’s important for them to have someone to talk to.
 
We have regular confidential clinical supervision and peer supervision, as well as clinical seminars in university. This helps us to think about the work in different ways, which ensures it remains patient-focussed and helps to achieve clinical goals. Reflective practice also plays a big part in our work as music therapists. If you’d like to get more of an idea of how music therapy sessions look in NICU work, you can watch these two short videos on YouTube (though they’re from America, so it’s not exactly the same):  
 
https://youtu.be/bwKCK3W-96E   
https://youtu.be/4qjx2BrrQJg
 
Reading recommendations:
 
Loewy, J., Stewart, K., Dassler, A., Telsey, A. and Homel, P. (2013) The effects of music therapy on vital signs, feeding, and sleep in premature infants. Pediatrics. 131 (5), pp. 902-918.
 
Loewy, J. (2011) Music therapy for hospitalized infants and their parents. In: Edwards, J., ed. (2011) Music Therapy and Parent-Infant Bonding. Oxford: Oxford University Press, pp. 179-190.
 
Shoemark, H., Hanson-Abromeit, D. and Stewart, L., (2015) Constructing optimal experience for the hospitalized newborn through neuro-based music therapy. Frontiers in Human Neuroscience. 9: 487.

Dr Tom Cromarty 

​The term “Burnout” has become somewhat of a dirty word in the healthcare lexicon over the last few years. The insinuation that healthcare staff have somehow failed to build enough resilience or resourcefulness to manage the stressors of life on the front-line. The concept of “front-line” comes from war battlefields and it’s no co-incidence that this metaphor is used in healthcare. Soldiers get diagnosed with PTSD, whilst healthcare professionals suffer burnout. Both of these have at their core the issue of “Moral injury”.
 
If doctors were “in it for the money” then I’m pretty sure they would be astute enough to pursue another line of work. Caring for patients and their families is a vocation for most doctors, or at least it started off that way at some point in the “life choices” decision making process. However, when doctors are not able to deliver the high standards of care they intended for a variety of reasons, this takes a toll on personal wellbeing.
The symptoms of burnout are really a “signal” of a healthcare system that is failing to look after its assets.
 
If we want compassionate, engaged and highly skilled doctors leading the charge on the frontline then we need to provide the working environment to facilitate it. This starts with senior leadership recognising that >50% of doctors are experiencing these symptoms and they “Cannot give what they don’t have”! Many organisations now recognise the urgency of the situation and are starting to offer support.  However, there are a number of skills which we can develop as individuals to equip us for “combat in the healthcare battlefield”.
 
I have looked up to Dr Mark Stacey for a number of years. An obstetric anaesthetist and human factors expert, he has put together a “Bakers Dozen” of skills. Written as a prescription to yourself, these can all be practiced and developed, in our quest for becoming “Anti-Fragile” (the opposite of fragile funnily enough). I have been lucky enough to hear this talk a couple of times, taking new learning points from it on each occasion. I would highly recommend contacting Mark.Stacey2@wales.nhs.ukand see the talk in person, but in the meantime here is a short summary of 'The Baker’s Dozen' by the legend himself;

Do you view your problems as a challenge or a threat? From a practical (and physiological) point of view it is more useful to frame problems as a challenge (problem solving mode) versus a threat (fight/flight mode). This also means reflecting on your self-talk about life eg “life is unfair”, sadly we know that, we see proof of it on a daily basis. ​

Imagine a bucket, while at work fill it with the stressors of the day, at the end of your shift find a trigger (for me it is unlocking my bike) to empty the bucket. Now you are going home with an empty bucket ready to be filled with the stressors of home. Set a second ‘empty bucket’ trigger (like brushing your teeth before bed) to set you up for the next day and of course...

“Scientists have discovered a revolutionary new treatment that makes you live longer. It enhances your memory, makes you more attractive. It keeps you slim and lowers food cravings. It protects you from cancer and dementia. It wards off colds and flu. It lowers your risk of heart attacks and stroke, not to mention diabetes. You’ll even feel happier, less depressed and less anxious. Are you interested?” (see number 7)

​The above quote is from Matthew Walker’s recent book and if that hasn’t convinced you then I’m not sure that I will. Sleep – ignore it at your peril, it is possibly the most important performance enhancing agent available to you. 

Learning assertive skills is worth the effort particularly as there will always be conflict in our jobs. 

Learning is a fantastic skill that does not just teach us the skill – it also teaches us about learning – in particular how, as an expert, it is difficult to understand why the novice is struggling to learn the skill. 

You could read the enjoyable and academic “Thinking Fast and Slow” by Daniel Kahneman or more readable “Decisive” by Chip and Dan Heath that teaches the WRAP model. In particular note the prepare for failure – we can do everything right in our job but bad things will still happen. 

Are you Hungry, Angry, Late or Tired? Avoid these factors in yourself and look out for them in your co-workers/friends/partners/ children. They will look out for HALT in you. The HALTcampaign, lead by Michael Farquhar and Guy’s hospital, is a model worth following.

​…..And there you have it.
These are all skills! And as such they will all get better after practice and less easy when neglected. Just get started and have a go at two or three of them. I have found the gratitude diary and sleep (earlier bed times) particularly useful in recent weeks and have seen benefits in my overall wellbeing.
 
Mark reminded us that if you never meditate, you are spending more time cleaning your teeth than on your mental health. Some people say “We don’t have time for any of this” but the truth is “We don’t have time to neglect it”. If you want to be the compassionate, healthy, high performing doctor you always dreamt of, the remember “You can’t give what you don’t have!”
 
 
Baker’s Dozen of Mental Toughness. Your stress management and resilience toolkit
 





​The Happy MD – Dr Dike Drummond
Mission Statement: Revolutionize the quality of healthcare by improving the health, happiness, humanity and effectiveness of the people providing patient care.
Physician Burnout Symptoms
 
ZDoggMD – Moral Injury
 
 
Reading List from Mark Stacey:
 
Human factors and resilience 
Mastering Resilience in Oncology: Learn to Thrive in the Face of Burnout. Fay J. Hlubocky, PhD, MA. Miko Rose, MD, and Ronald M. Epstein, MD
 
Practical Human Factor training
Martin and Elaine Bromiley – “How mistakes can save lives”
 
Decision making and brain training!
Brain rules: John Medina
The Decisive moment: Jonah Lehrer
Decisive: Chip and Dan Heath
 
Three books: three slightly different takes on human error
Safety at the Sharp end: Rhona Flin
Field guide to understanding Human error:Sydney Dekker
Why hospitals should fly-much lighter than the above: Nance J.
 
Mind management recommendations:
The Chimp Paradox:  Steve Peters (it works for the Sky cycling team)
Search inside yourself: Chade Meng Tan (it works for google!)
10 % happier - Dan Harris- true life story with loads of practical advice-advice-done be put off by the title!
 
 
 
 
 
 

26th March 2019, Cardiff

Dr Annabel Greenwood ST4

​I am currently in the process of implementing a mentorship programme on the Neonatal Unit at UHW. As a trainee, it’s hard not to feel overwhelmed and at times, emotionally drained by the demands and expectations of our training.  Our wellbeing and a positive mindset are paramount in ensuring we can optimise our potential, but how can this be achieved without an appropriate support network in place?
 
Last month, I was fortunate enough to attend the RCPCH Mentoring Skills Workshop in Cardiff to learn more about mentorship and the key principles involved.  This was a fantastic one-day workshop lead by Matt Driver and Sandra Grealy, who have a wealth of experience in coaching and leadership.  I feel passionately that mentorship is an invaluable process for both the mentor and the mentee, and would like to use this platform to share with you some of the key concepts involved…
 

​Mentoring is the process of supporting and guiding a mentee in the development of their own ideas and agenda.  The mentor is usually a more experienced professional who aims to help nurture the potential of the mentee.  

The relationship between a mentor and mentee relies on the right balance between ‘push’ and ‘pull.’

• PUSH: suggesting, telling
• PULL: exploration, listening, drawing-out information 

This balance helps us understand the differences between coaching, mentoring, directing, and a more hands-off approach.  Depending on the situation and the needs of the person, the balance between ‘push’ and ‘pull’ will need to be adjusted accordingly;

Coaching: The agenda is set by the coach rather than the subject.  ‘Pull’ behaviours outweigh ‘push’ in this case.
 
Directive: The agenda is set by the ‘director.’  It is an important approach where the subject needs to have information.  ‘Push’ behaviour outweighs ‘pull.’
 
Hands-off: The subject is encouraged to do things for themselves, without ‘push’ or ‘pull.’

​So, what are the key core skills to be an effective mentor?
 

1. Good Rapport
2. Active listening 
3. Goal-setting 
4. Summarising 
5. Questioning 

 
 

​Let’s face it, if someone comes to you with a problem, it’s all too easy to jump-in with our own opinion or advice, often backed up by personal experiences. 
However, this approach is not useful in the case of mentoring, as it discourages the mentee from exploring their own possible options or solutions and driving their own agenda.
 
During the workshop we worked through a useful exercise to help appreciate this difference.

• In pairs we were asked to think of something you want to do but have not yet manged to

 
After listening to the mentee, the mentor was given the task of adopting two different approaches; 
a) Give advice
b) Work through a structured set of questions instead;
 

1. What specifically do you want?
2. How will you know you have succeeded?
3. What benefits will success bring?
4. How do you stop yourself succeeding?
5. When have you had some success?
6. What can you learn?
7. What is the next step?

 
As you can see, approach b) focusses on ‘success’ and positivity.  These are open questions, allowing the mentee to create and explore their own agenda. 

The ‘T-GROW’ pneumonic provides a very useful structure to shape a mentoring session;
 
Topic

• What is on your mind?

 
Goal

• What outcome do you want?
• What do you want to focus on?

​
Reality

•  What is going on now?

 
Options

• What are your options for moving things forward?
• What resources do you have available to you?

 
Will

• Action
• What will you do?

​Before embarking on a mentorship session it is important to address ‘the contract.’  This defines the relationship between the mentor and the mentee, and provides the opportunity to explore each other’s expectations at the outset.  It is important to emphasise the confidential nature of the meeting, unless of course any alarming information is shared.
 

Dr Tim Warlow