NH Gent Belfort Hotel, Ghent, Belgium 22-24th June 2018
Annabel Greenwood ST3 Trainee, Wales Deanery
The 4th INAC was held in the beautiful and charming city of Ghent, Belgium. The INAC was established to provide a global platform for neonatologists and budding-neonatologists across the world to come together and share their work on the recent advances in neonatal medicine.
This year’s meeting was hosted by the Belgian Society of Neonatal Medicine, led by their President, Professor Filip Cools. An exciting programme was awaited, packed full of brilliant talks delivered by highly esteemed neonatologists, and included a showcase of diverse abstracts from all over the world. Delegates attended from over 50 countries across five continents.
The conference itself was perfectly situated, set upon a quaint cobbled street, running alongside the iconic canal that winds its way through the vibrant city.
From a personal perspective, I was extremely excited to present my work on organ donation on an international stage. Organ donation in neonatal medicine remains a fairly new concept, and I felt privileged to have the opportunity to fly the flag for organ donation, raising awareness and sharing my knowledge and experiences with others at such a prestigious event.
I was fortunate enough to be joined by my colleague and friend, Dr Chris Course, on the trip, who was presenting the WREN Project we collaborated on with Dr Zoe Howard, on postnatal antibiotic use across Wales. Our project fitted in perfectly with one of the principal themes of the conference, namely antibiotic stewardship.
There was a particular emphasis on neonatal neurology over the course of the weekend, and it was fascinating to learn of the latest developments in such a complex and challenging field. Professor Jose Honold discussed the concept of a ‘Neuro NICU’, a collaborative approach between neurologists, neonatologists, radiologists, neurosurgeons, neurophysiologists, and specially trained neonatal neurology nurses, using specialised equipment to optimise the management of conditions such as high grade IVH, meningitis and encephalitis, seizures, HIE, and those with congenital cerebral malformations.
Another highlight was learning about the recent advances in neonatal lung ultrasound by Dr Luigi Cattarossi, to help guide the diagnosis and management of a number of lung diseases including RDS, TTN, pneumonia and pneumothoracies. This quick and focused bedside diagnostic approach has been shown to be as reliable as CXR in demonstrating lung pathology, resulting in less exposure to radiation for the neonate.
It was also of great interest to learn about the challenges faced in neonatal medicine in developing countries, and demonstrated the importance of the implementation of simple interventions e.g. bubble CPAP, in making a huge difference in the survival of preterm infants with respiratory distress.
Aside from the conference, there was plenty of time to relax and explore the local delights of Ghent. The city was electric as fans set-up camp in the square to cheer-on their country in the Football World Cup! I certainly enjoyed sampling the local delicacies, Belgian waffles being a particular highlight!
As the weekend drew to a close, I reflected on what had been a truly fantastic conference. The INAC 2018 provided an excellent platform for learning and certainly inspired new project proposals and ideas to take back to Wales! Next year's conference is planned to be in Tijuana, Mexico with a pre-conference in San Diego, so a little further afield, but another couple of top destinations for sure!
Princess of Wales Hospital, Bridgend, Friday 8thJune 2018
Annabel Greenwood Paediatric ST3 Trainee
Broadly speaking, I feel our exposure to safeguarding training in the early years of paediatric training is limited.
Before you know it, you are the registrar on-call, out of hours, contacted with a complex child protection referral. As a junior paediatric trainee about to transition to middle-grade training, I will inevitably at some point, be faced with this scenario, and if I’m to be completely honest, the thought has previously caused a slight degree of tachycardia, hyperventilation and perspiration on my part, at the uncertainty of such a situation!
I therefore searched for a way to dispel my fears and came across a child protection simulation course set-up by Dr Emily Payne, ST8 Community Paediatric Trainee in Wales. This fantastic one-day, multiagency simulation course has certainly enhanced my confidence in the management of child protection cases and I would certainly recommend the day to my fellow trainees.
The course facilitates approximately 6-10 trainees, a perfect sized group to allow plenty of opportunity to ask questions and share our experiences with each other.
The day began with a couple of short lectures, setting the scene for the day, addressing some key safeguarding principles, including the rights and responsibilities of all doctors, and an outline of the child protection process. We also discussed the ‘ACE’ (Adverse Child Experiences) Study, which has demonstrated that for every 100 adults in Wales, 47 have suffered at least one ACE during their childhood, and 14 people suffered 4 or more events. ACE are stressful experiences occurring during childhood that directly harm a child e.g. sexual, physical or emotional abuse, or effect the environment in which they live e.g. domestic violence, mental health, parental separation. It has been shown that ACE impact across the life course, e.g. affecting neurodevelopment in the early years, potentially causing social, emotional, and cognitive impairment, and perhaps leading to the adoption of high-risk behaviours and crime later on in life.
Later in the morning we divided into pairs for 3 workshop sessions focusing on physical, emotional and sexual abuse respectively. These informal, small-group workshops were based on a clinical scenario and provided an excellent opportunity to voice any queries or concerns we had regarding the different categories of abuse.
In the afternoon, we worked through a number of simulation child protection scenarios with actors playing the role of the child’s parents, making the situation as realistic as possible. At the end of each scenario we re-grouped to provide feedback and discuss the case in more detail. I felt that this was a completely safe environment to practice leading challenging safeguarding scenarios, and found it extremely useful to receive constructive multiagency feedback, from doctors, social workers and the police.
The day was brought to a close with a simulated strategy meeting, and we all played the role of a different member of the multiagency team. This provided a fantastic insight into the role of each member of the team, and demonstrated how everyone works together to collate the evidence in order to generate an accurate account of events, to ensure the safety of the child.
I thoroughly enjoyed the course and feel that I will now make the transition to middle-grade training with enhanced knowledge and confidence to manage challenging safeguarding scenarios.
For further information, please contact Dr Emily Payne on Emily.email@example.com
22nd June 2018, Swansea Marriot Hotel
Gill Smith, ST4 Paediatrics Trainee, Wales Deanery
The spring 2018 WPS meeting was held in a very sunny Swansea. The sun shone down on the beach next to the Marriot hotel which provided a beautiful view during breaks between some excellent presentations and some very thought-provoking talks.
The morning presentations were on very varied and interesting topics, which included audits and quality improvement projects from medical students, paediatric trainees and consultants.
Presentations from neonatology to general paediatrics meant that there was something for everybody. I particularly enjoyed the presentation by the co-host of the WPS meeting, Dr Carol Sullivan who spoke with enthusiasm and wit about writing a student textbook in paediatrics. It looks like it will be a hit. Just before coffee, we were delighted to see Dr Peter Dale adorned in a bright pink wig and pink cape to highlight and talk about the approaching change to the RCPCH curriculum-progress. He went pink for Progress. Details can be found on the RCPCH website. More fantastic presentations ensued after coffee and the morning session was rounded off with a presentation on the problems encountered by babies born in the late pre-term period. Often thought to be close to term that physiologically they would be similar to those babies born at term. Evidence suggests this is not the case and is certainly gave us food for thought prior to lunch.
A brilliant and tasty selection of food was available for lunch, finished by coffee and a chance to chat with the exhibitors. The lunch break was also a great opportunity to pop outside and enjoy the glorious sunshine and beautiful views overlooking the mumbles.
After lunch we were kept from any thoughts of postprandial sleepiness by another set of wonderful and stimulating presentations. The first lecture back, presented by Dr Sheena Durnin was perfectly timed about of the use of paediatric pain relief practices in emergency departments in the UK and Ireland. These practices were evaluated across 40 hospitals in the UK and Ireland. It found a wide variety of practices in terms of analgesia used, timing of analgesia policies, and availability of play specialists to name a few. Dr Durnin earned the award of best presentation. Congratulations!
Next up, another award winning presentation by Dr Rachel Morris who spoke so eloquently and with such passion about the implementation of family integrated care in a tertiary neonatal unit. The results were encouraging in that since the introduction of Family integrated care there had been an increase in breast feeding rates and a reduction in the length of stay and an anecdotal feeling that parents felt more in control and were ready for discharge sooner. Dr Morris won the best trainee award and this was thoroughly deserved.
Following another round of superb presentations, the mid afternoon session was rounded off with an absolute gem of a talk from invited speaker Dr Mark Stacey, consultant anaesthetist and Associate Dean in Cardiff and Vale NHS Trust. The talk entitled ‘A Bakers’ Dozen Resilience Skills’ got us up and thinking. We had to write ourselves thirteen points to aid us in our resilience at work and life and included sleep, meditation and taking care of yourself. Some very important points and recommendations made. This talk left many feeling invigorated and gave us something to talk about during the afternoon tea break over coffee and cake before the late afternoon session.
Fuelled with caffeine and carrot cake we had a further four short quick fire talks and the day was completed with a guest lecture from Dr Michael Farquhar, Consultant Paediatrician in children’s sleep medicine at Evelina Children’s hospital. His talk entitled “Rounded with a sleep: Why We Need To Talk About Fatigue” discussed the importance of sleep and gave a convincing argument for the need for all of us to sleep well. Night shift workers are encouraged to take power naps as this will improve our senses, judgement skills and general wellbeing. This talk went beautifully well with the Resilience talk and is definitely something we should all try and think about. Driving tired can be as bad as if driving after drinking alcohol.
We made our way to the beach to enjoy the rest of the sunshine before a delightful dinner with colleagues and friends. A lovely end to a fantastic day.
Once again the WPS conference was a great success, showing a very talented bunch of people. It was thought-provoking and inspiring and a great way to meet up with colleagues and brilliant guest speakers. I’m off to get some sleep before the winter meeting (I prescribed it to myself)!
Guest post from Dr Laura Potts, Clinical Leadership Fellow, Paediatric Trainee, Wales Deanery
The Medical Women’s Federation (MWF) was founded in 1917. They aim to advance the personal and professional development of women in medicine, to change discriminatory attitudes and practices and to work on behalf of women patients and their families.
This year’s spring conference in Cardiff covered a broad range of topics affecting women from living and working with a disability through to antenatal screening and management of HIV.
The first talk ‘Prenatal testing ; risks or certainty’ was given by Dr Annie Procter, Consultant clinical geneticist. She discussed the evolution of antenatal testing and its future directions. The potential scope of antenatal screening is vast, especially with the introduction of fetal DNA analysis in maternal blood, but routine screening is currently limited to the three major trisomies. This thought provoking talk advised caution; should we test for everything we can, just because we can? It also highlighted the importance of managing families expectations effectively.
Dr Olwen Williams spoke about the progress in HIV and AIDS management in recent years. Huge advance have been made and are now close to enabling affected women to have normal deliveries and breastfeed. Women are however, still presenting with late disease and later in life, with and opportunistic infection and Kaposi sarcoma. She also reinforced the results of the recent PARTNER study which showed that in those with an undetectable viral load, transmission to their partner did not occur. There is a new public health initiative promoting Undetectable = untransmissable.
There were also a number of abstract presentations. Of particular interest was the work being done at Singleton neonatal intensive care unit on family integrated care (FiCare), presented by Dr Rachel Morris (ST5 Paediatric trainee and trainee representative for the MWF in Wales) .
Family integrated care is centred around four main themes – staff education, parent education, creating the right NICU environment and providing psychosocial support. The concept originated in Estonia and was developed by Professor Lee and colleagues in Toronto. It has been shown to reduce length of stay, retinopathy of prematurity and infections and increase breast feeding rates. Singleton have already had a lot of success, receiving excellent feedback from families and demonstrating reduced length of stay and increased breast feeding rates.
During the afternoon there were a number of workshops. I attended Dr Cora Doherty’s session on wellbeing and the healthy team. For optimal team effectiveness and performance mind, body and spirit must be considered, that is to say the team needs a clear vision, good morale and trust and have their physical needs met. The concept of the ‘fitness’ of team members to be part of the team was also considered and how we as team members and leaders have a responsibility to protect our own wellbeing and that of our team.
During the remainder of the afternoon there was an interesting talk titled ‘menopause behind the headlines’. Whilst not particularly relevant to our patients it was a delightful insight into what some of us have to look forward to!
Dr Clarissa Fabre, President elect of the Medical Women’s International Association (MWIA) shared the results of the most recent MWIA members survey. This included some worrying statistics such as 57% of respondents felt that they had been discriminated in their career, with 41% reporting that they had experienced sexual harassment or bullying in relation to their work. Unfortunately younger doctors reported lover job satisfaction, more sexual harassment and bullying and a higher incidence of stress and burnout.
The conference ended with the Dame Hilda Rose lecture, given by Dr Sally Davies, focusing on the importance of stories such as Dr Frances Morgan’s. She was the first woman to receive a doctorate in Medicine in Europe and the first female doctor registered in Wales. She was a pioneer in medical practice and social reform, working all over the world as well as working as a General Practitioner in Wales.
These stories demonstrated how far women have come in achieving gender equality but that there is more work to be done, as highlighted by the recent MWIA survey. The MWF work hard to fight discrimination against women in medicine, for example, challenging Jeremy Hunt on the lack of impact assessment for the new junior doctor contact in England and helping to tackle the gender pay gap. An interesting quote was offered at the end of her talk, ‘good practice benefits all, bad practice affects women more’. I wonder what you all think of this?
The key messages from this lecture and the conference in general were that huge progress has been made by women in medicine and in women’s health and that we all have a responsibility to report and challenge bad practice and behaviour, and make looking after ourselves and each other a priority.
For anyone interested in finding out more about the MWF their website can be found at www.medicalwomensfederation.org.uk
Dr Tim Warlow, Paediatric Palliative Care GRID trainee, Wales Deanery
Few of us can forget recent cases in the press of Alfie Evans and Charlie Gard. Such tragic cases of breakdown in relationship between families and care teams. I’m sure that alongside my own cries you have had the thought ‘Surely things didn’t have to get to this!’ These cases bring into stark clarity the importance of our skills of communication and our ability to put into practice the ethical and legal duties to involve of families and children in decision making. These cases are nightmare scenarios, but at some points in our career we will face similar challenging situations.
Aware of these issues, the All Wales Paediatric Palliative Care Team received £20,000 of Welsh Government funding to improve the skills of paediatricians in these areas. Our response was to organise a series of free workshops exploring issues of ‘communicating difficult news’, decision making and advanced care planning in paediatrics. April 2018 saw the first of these workshops in the fantastic Copthorne Hotel, Culverhouse Cross. Within a month we had filled all our places and the response on the day from delegates was fantastic.
The truly multidisciplinary event was attended by consultants, community nurses, therapists, trainees and hospice staff, all of whom engaged amazingly in communications skills breakout groups and seminars. There was time to explore advanced communication skills, read and use the Paediatric Advanced Care (PAC) Plan, and consider the views of families and young people in planning. The highlight of the day was without a doubt an interview with one of our parents whose son sadly died under the care of our service. She discussed the value of good communication, of doctors being prepared and sensitive, and the benefit of early and co-ordinated planning.
The good news is that there are several further days being organised, one for each of the health boards in Wales. The next of these is in Swansea where Dr Griffiths will be using trained actors to facilitate what will be an exhilarating day of interactive learning together with other professionals. Please contact firstname.lastname@example.org further information about upcoming days and to sign up. All workshops are free of charge and are in great venues with food provided.
If doing a good job of communicating and parallel planning with families excites your interest, these days are for you. If you want to run a mile, these days are even more for you!
Let’s get to grips with the really difficult stuff of paediatrics, lets help families to live well and for those whose lives are cut short, to live well right to the end.
by Chris Course, Chair WREN
The Welsh Research and Eduction Network (WREN) Spring Study Day took place at the Princess of Wales Hospital, Bridgend on 11th May 2018. Once again, attendance was well supported by doctors from across the training grades (and an Advanced Neonatal Nurse Practitioner!), as well as Dr Huma Mazhar (from Singleton Hospital), Dr Naomi Simmons (from Glan Clwyd Hospital) and Dr Judith van der Voort (Head of School) joining us for the day to learn more about how the network is getting on and our current activities.
Our educational programme was once again diverse, with talks from Dr Phil Connor and Rhian Thomas-Turner about the new Children and Young Adult’s Research Unit at Noah’s Ark Children’s Hospital for Wales and their plans for increasing junior doctor involvement. Dr Ian Morris then gave an excellent strategy for rapid-fire critical appraisal, with an emphasis on the START assessment (slides available on our website, or on request). Dr Gethin Pugh from the Quality Improvement Skills Team at the Wales Deanery also gave us an introductory workshop to Quality Improvement, as well as teaching us the basics of the Plan, Do, Act, Study model and signposting the further QI training opportunities available.
The WREN Blog continues to go from strength to strength and now receives over 500 hits a month on our articles, under the editorial leadership of Dr Rebecca Broomfield and Dr Annabel Greenwood. They are looking for contributors too, so if you have something to share or a topic you’d love to write about, please get in touch.
Four new projects are being undertaken via the network, three of which are starting now. Details of the WREN projects and their project leads are below. Project leads can be contacted on the Current Project Portfolio page. We will be disseminating these projects amongst the units, but if you would like to get involved in any of the projects in WREN’s current portfolio, please contact the project leads (details below). If you have an idea for a project you would like to develop with WREN’s help, please contact either myself or Siwan Lloyd via our website, or using the details at the top of this newsletter.
The next WREN study day is planned for November 2018 (confirmed date to follow), and we hope that you will be able to join us for another stimulating and thought-provoking study day, building on from the success of the last!
Newly Launched Projects
Project Title: ‘The Impact of the Meningococcal B Vaccination on Septic Screens’
Project Leads: Dr Ele Jones (ST5) and Dr Rebecca Towler (ST5)
Description: Pyrexia is a common adverse effect of the Meningocccal B vaccination. NICE guidelines exist for the management of fever <3 months of age and recommends investigations for sepsis for pyrexial infants but does not make comment of post-vaccination infants. This project aims to retrospectively assess how infants are managed in paediatric and neonatal units who are presenting with fever post-Meningococcal B vaccination over a 12-month period.
Project Title: ‘Aiming to improve paediatric trainees confidence with ECG interpretation’
Project Leads: Dr Ankita Jain (ST6)
Description: The Paediatric Cardiology department at UHW gets several referrals a month from various hospitals to provide their opinion on ECGs done on children for various clinical indications. We would like to help improve confidence in paediatric ECG interpretation, and have developed a structured online educational module. Using a pre- and post-quiz on ECG interpretation it is hoped to show how skills can be improved. The link for the quiz is https://goo.gl/forms/2Qj8NBZHBdOYL33d2
Project Title: ‘Can a resus drug App help improve accuracy and reduce stress in time-critical scenarios?’
Project Lead: Dr Jordan Evans (ST5)
Description: Accurate calculation of WETFLAG resus drugs is critical, but can be affected by stress and the time-critical nature of emergency scenarios. This project aims to assess whether a smartphone app can help to improve prescribing accuracy and reduce doctor stress levels in resus situations. A pilot study has shown an App to be effective, and this project aims to assess larger numbers of doctors and nurses using the technology in simulated scenarios.
Project Title: ‘Head injuries on the postnatal wards’
Project Lead: Siwan Lloyd, ST3
Description: A pilot study at UHW has demonstrated that infants being accidentally dropped on the postnatal ward is not an uncommon occurrence, however their management and level of investigation following injury was very variable. Following on from this, an all Wales study is underway to determine the incidence, risk factors and management used, with the aim of producing a best practice guideline for these infants and their parents.
Project Title: ‘Re-audit of the Management of Respiratory Distress Syndrome in Preterm Infants’
Project Lead: Chris Course, ST4
Description: Following the initial audit in 2014/2015 by WREN, a Wales Neonatal Network guideline was introduced for the Management of RDS in Preterm Infants in June 2016. The re-audit has commenced March 2018 and is running for six months to assess how the new national guideline has affected patient care.
Project Title: ‘Management of feverish illness in infants <3 months old’
Project Lead: Blanche Lumb, ST1
Description: Do we consistently meet the NICE standards set in the investigation of sepsis in <3 month old infants? This project aims to assess that the appropriate investigations occur in a timely manner, and that appropriate empirical treatment is commenced across paediatric assessment units in Wales. Where we chose to deviate from the guidance, are we documenting this appropriately?
Upcoming Projects (Planned Start September 2018)
Project Title: ‘Evaluating the impact of the introduction of the SEREN program on Type 1 Diabetes Management in Children’
Project Lead: Matthew Ryan, ST6
Description: SEREN is a structured education package for children newly diagnosed with T1DM. This project will assess SEREN’s impact by using Quality of Life questionnaires, serial HbA1c measurements and number of DKA admissions for children diagnosed with T1DM in the years pre and post introduction.
Guest blog post by Dr Kimberley Hallam
I’m an ST2 in paediatrics and unfortunately did not have the chance to attend the RCPCH conference last year. So, this year I was very excited when I realised, not only would I be able to attend for all 3 days, but it was also in Glasgow…a city which I love and where my twin sister lives.
Getting up to Glasgow itself was challenging! I travelled up after work on the Wirral on Monday night. Soon after leaving, there was an announcement that there were trespassers on the line. Unfortunately, this meant I didn’t arrive at Glasgow Central Station until 00:45! Luckily, I was staying with my sister so didn’t have the hassle of a late night check in.
Day one of the conference was entitled the ‘Science and Research’ day. Because of my late arrival to Glasgow, I didn’t attend the 8am ‘Personal Practice Sessions’, but started at 9am with a welcome from the (now ex-) President of the RCPCH, Neena Modi. During the course of the conference, she relinquished her presidential title to Russell Viner. She gave an eloquent opening talk which was followed by a presentation by the RCPCH & Us Network. This is a group of young people who work with the RCPCH to ensure that young people’s views are listened to in all matters within the RCPCH organisation. They spoke incredibly well and are clearly a group of passionate, intelligent young people who are forward thinking, keen to bring about change and ensure their voices are heard.
Another highlight from the morning included a talk by Prof. David Archard regarding children and parental rights. He took examples from recent high profile cases and presented ethical considerations regarding parental rights. He focussed on a public slogan taken from the Charlie Gard Case: ‘My Child, My Choice.’ After a fascinating discussion, he concluded that ‘disagreements [between medical staff and parents] will continue and [will] probably proliferate. Parents’ feelings and views count but they are not decisive.’ He closed the session with the remark that ‘we live in a time of post-truth and populism.’
Next came an interesting presentation from Dr Cherry Alviani and was entitled ‘Sleep for your own health: A Pan-UK Survey on Paediatricians Experience of Sleep Around Shift Work.’ She talked about a survey she completed which showed a lot of trainees do not have training on how to manage sleep around night shifts and that many hospitals do not provide somewhere for trainees to sleep on night shift and/or do not support them doing so. Given lack of sleep affects judgement and clinical performance, these are important issues to address. As an aside, the BMJ have recently published a brilliant article which gives general advice on how to survive night shifts and which I have personally found quite useful:
After the plenary session, I attended a workshop entitled ‘Press, Politics and Paediatricians; Campaigning for Child Health Across the UK.’ This was an interactive workshop and even had some role play where members of the audience acted as news reporters and grilled (a pretend) Jeremy Corbyn and Jeremy Hunt. Suffice to say, this became a little heated! Overall, the session introduced the idea that it is our duty as paediatricians to be advocates for child health. This may include being politically active (e.g lobbying government) or may involve speaking out on behalf of paediatricians/children in the press. The RCPCH have opportunities for members to become involved in such work on their Press and Parliamentary Panels (they include free training).
I’ve put this link here so you can have a wee look if you’re interested: https://www.rcpch.ac.uk/news/membership-benefit-month-media-and-parliamentary-training
The last session of the day I went to was run by the British Association of Paediatricians of Indian Origin (BAPIO) and covered ‘Hot topics in paediatric subspecialties.’ They had a number of insightful and interesting talks including ‘When do you need a gut specialist?’, ‘Chronic cough: when is it a cause for concern?’ and ‘Changing landscapes in paediatric epilepsy.’ They also had talks from Neena Modi and Russell Viner (who got a bit of a kind-hearted grilling from the audience after his talk ‘Paediatric services: fit for the future’.
I chose not to go to the meal out on the first night. Instead, I went to a fabulous place in Glasgow called Stravaigin with my sister and a Mersey trainee. It comes highly recommended!
Day two of the conference was the ‘Global Child Health Day’ and, I have to admit, the day I was most looking forward to. It did not disappoint.
The day kicked off at 8am with a session on how to include global health in your career which was delivered by a diverse group of trainees who all had experiences of working in global health during their training years. They introduced the variety of ways a trainee can take part in global health work. These include clinical work, teaching, quality improvement projects, research and public health. The session covered considerations such as the stage of training you should aim to do such work, what support you might receive and where you can do the work. They also talked about the courses you can go on to help prepare. For example, ETAT, CHILS, GIC and the Diploma of Tropical Medicine and Hygiene. I left this session feeling very inspired and excited about my potential future opportunities.
Next up was the plenary with the first person to speak Prof Anthony Costello (Director of the Department of Maternal, Child and Adolescent Health, World Health Organisation). He gave a keynote speech on ‘Global governance for child health and sustainable development.’ As his title suggests, he came across as a very inspirational person. He questioned ‘is everything getting better?’ He stated that, globally, child mortality is improving rapidly and maternal mortality is improving but not to the same extent. As currently projected, low income countries will not catch up with higher income countries for a great number of years. Globally, we are still falling short in harder to reach areas and there are still basic health needs which are not being met. For example, lack of access to clean water and sanitation.
Five key problems which act as a barrier to improving child health are as follows:
1. Fragmentation of global child health strategies undermines programming and limits impact
2. Child health goals will not be met without adequate funding and delivery to marginalised populations
3. Evidence is not systematically generated and integrated into policy and programs
4. Strategies are insufficiently tailored to country context, and tools need improved end-user design
5. Lack of accountability, clear targets and strong monitoring
He then went on to describe five key areas for WHO and UNICEF to address.
The next talk was regarding child refugee health and is something I have been interested in for a long time and passionate about since attending the Royal Society of Medicine’s study day ‘Child Refugee Health: Everyone’s Responsibility.’ Dr Marylyn Emedo presented data on ‘Adverse experiences of Unaccompanied Asylum Seeking children (UASC) and the impact on their emotional wellbeing and mental health needs.’ As a bit of background, there were 3290 unaccompanied asylum seeking children in the UK in 2016. Children from Afghanistan, Albania and Eritrea formed 48% of all UASC in 2016. Her study was a retrospective review of records of all UASC referred to a clinic run by a local authority in London between 1st January to 31st August, 2016. The study focussed on adverse experiences the children went through on their journey to the UK. It found that 51% of children experienced trauma on route to the UK including detention, beating, torture and sexual assault. All the children in the study were screened for mental health needs. Of these, 75% reported at least one symptom suggestive of PTSD, anxiety or depression and 43% accepted a referral to CAMHS. Her recommendations were for timely review in line with statutory guidelines and initiation of early support by mental health services.
Next, the workshop I chose to attend was ‘What should RCPCH’s global health priorities be?’ This started with a talk outlining some stark facts: 98 of every 100 children who die <5 years, die in developing countries, mainly from avoidable/treatable causes. There has also been a shift of mortality from communicable to non-communicable diseases. There followed a discussion surround how to address these issues as we work towards the Sustainable Development Goals (SDPs) set by the UN (http://www.un.org/sustainabledevelopment/sustainable-development-goals/). There was participation from the audience and good engagement from the RCPCH. I was particularly happy to hear that the RCPCH are launching a global health professional development framework to run alongside paediatric training in order to engage trainees in global health work.
I continued the global health theme by attending the International Child Health Group’s afternoon session. This took part in the main Clyde auditorium and was mainly delivered by people who had conducted projects related to international health.
The first talk was delivered by Dr Jonson and was entitled ‘The validation of transcutaneous bilirubin as a method to monitor newborn jaundice in a low income country.’ She had recognised there were significant problems with babies developing kernicterus as a result of untreated jaundice in Haiti. Despite having a reasonably small data set, her study suggested that transcutaneous bilirubin monitoring was a safe way of measuring bilirubin in a low income country. The unit she was working on had a lower incidence of kernicterus following the trial. However, she suggested a larger data set would be required to fully validate her findings.
Amongst the remainder of the afternoon talks, the one which stood out for me was given by Dr Christopher Hands and entitled ‘Delivering nurse-led emergency paediatric care in Sierra Leonean Hospitals: The effect on quality of care and mortality.’ This nurse-led care involved the introduction of triage systems, stream-lining the patient journey at the point of care and training nurses in ETAT. These basic interventions had resulted in a very impressive reduction in mortality. Anecdotally, nurses now recognised they had the skills to save the lives of individuals presenting with symptoms they previously thought they could do nothing for. For example, hypoglycaemia and seizures.
Other talks included ‘Neonatal outcomes from FGM/cutting in the Gambia; results from a multicentre prospective study’, ‘The use of satellite clinics in W Uganda to remove barriers to seeking care’ and ‘Identification of the health burden for street children and service provision available in Kismu, Kenya, through Focus Group Discussions.’
At the end of the second day, I was exhausted. However, thanks to this day and the enthusiastic way in which the RCPCH approach global health, I now have a renewed determination to pursue a career in this area.
Day three was entitled the ‘Health Services for Children day.’ The plenary in the auditorium started with a keynote speech from Prof. Jason Leitch, the National Clinical Director from Scottish Government. He was a very entertaining and enthusiastic speaker and it really was a pleasure to listen to him in his home city of Glasgow. He talked about the state of child health inequality in Scotland. He described how children living in Glasgow within a few miles of each other have a very different life expectancy (a phenomenon which is termed the ‘Glasgow Effect’). He then went on to talk about various local programmes which had been set up. For example, a programme in which fathers in prison are given intensive parenting classes and have their children visit the prison regularly. This even involved the inmates performing a play of the Gruffalo for the children and has the benefit of decreasing their chance of reoffending. There have also been programmes which involve intensive health visitor input. He ended with the following picture.
After the plenary and a short refreshment break, it was time for the final workshop session. As I seemed to be developing a political interest as the conference went on, I decided to attend the session ‘Child Health Policy Development: Why, What and How?’ This started with a presentation regarding the RCPCH health policy strategic direction for 2018. This states that the RCPCH wants to achieve the following:
1. To prioritise the health needs of infants, children and young people
2. To prevent ill health and promote health and wellbeing
3. To ensure continuous improvement in the quality of healthcare services
4. To reduce child health inequalities
They plan to achieve these aims in the following way:
1. Developing robust, evidence-based policy
2. Prioritisation and horizon scanning
3. Understanding the environment we work in
4. Influencing the right decision makers, at the right time
5. Having a tailored approach so the right messages reach decision makers across the UK
After the presentation, there was a discussion with audience participation and engagement from the new president. We discussed why and how the RCPCH develops policy, its impact and the role of paediatricians in influencing decision makers. We concluded that, as paediatricians, we have a duty to advocate on behalf of children and young people and part of that involves lobbying to push child health up the political agenda.
Following the workshop and lunch, I decided to start the first part of the afternoon with the ‘Children’s Ethics and Law Special Interest Group’ (CHELSIG). After an introduction to CHELSIG, there was a presentation ‘Children’s rights, UK healthcare and Brexit: Could things get worse for young people?’ This session discussed the UN rights of the child, including Article 16 (the views of the child), Article 24 (health and health services) and Article 16 (young people have the right to a private life). According to a study completed by the NIHR, 57% of children felt they were not involved or only involved a little in their care. This session encouraged paediatricians to involve children in decisions about their care and consider facilitating groups where children and young people can provide input into the running of paediatric services.
The next session was called ‘Moral distress, trauma and burnout in staff in relation to changes in PICU outcomes, challenging cases and media involvement in disagreements about end of life care.’ This session was led by Gillian Coleville who had studied the impact of the above in Great Ormond Street staff following the Charlie Gard case. The staff highlighted their main sources of distress are being accused of not caring, public condemnation without the right to reply, fears for their own safety, witnessing a child’s suffering, protracted legal proceedings, impact on other families and constant changes to care plan. 15% of staff had features of clinically significant post-traumatic stress syndrome. I was quite surprised at how high this was and also found it distressing to hear how the case had impacted upon their private lives.
The final session I went to on day 3 was one run by the Association of Paediatric Emergency Medicine. This was an afternoon focussing on the Manchester Arena bombing on 22nd May, 2017. We heard from Allan Courdwell, Head of Group Emergency Planning with the Northern Care Alliance who talked us through what happened on the day and how the trust managed the major incident. This was followed by an insightful talk by Fiona Murphy MBE, Associate Director of Nursing who covered the bereavement response after the bombing. She gave a moving description of how the bereavement officers supported those who suffered the death of a loved one. Her commitment to providing dignified support to the families was exceptional. She described various ways in which she co-ordinated and delivered the bereavement support. This included putting families up in a hotel together, having 24-hour access to a bereavement officer and finding out information regarding the victims so they could, for example, play their favourite music when families were viewing their bodies. She also arranged for the families to visit the arena (when safe to do so) where they had lit a candle where each of the victims was found so the families could further understand and come to terms with what had happened. This talk moved me and many others to tears and I was so overwhelmed by the dedication she and her team showed to support the families in the aftermath of the bombings.
So, that concluded my first attendance at an RCPCH conference and I really enjoyed the experience. It was great to see how proactive the college came across in providing advocacy for children and addressing global child health. It was also fabulous to catch up with old friends and be inspired by projects which other paediatric trainees are undertaking throughout the country. I’ll definitely aim to go again next year!
Guest blog by Dr Jemma Wright
I was delighted to attend the first day of the RCPCH annual conference this year and here is a brief summary of my day.
The day started early with a personal practice session about the new PROGRESS curriculum. Hopefully you are all aware of this new curriculum as it is going to be introduced this August. The session was an introduction to the new curriculum and it does seem like the college is trying to make it easier to engage with the new, much shorter curriculum. There is lots of information available on www.rcpch.ac.uk/progress including details of the mandatory 'key capabilities' we need to achieve and 'illustrations'/examples of how to evidence this on Kaizen. The main tip was to engage with this curriculum early as you can start producing evidence on your eportfolio now so it is already there to link to the new curriculum when it becomes live on 1st August 2018.
The overall theme of the conference was ‘Children First – Ethics, Morality and Advocacy in Childhood’ and the main plenary had a strong theme on ethics.
The first keynote speech was about “Putting the Child First” and was an extremely topical philosophical exploration of the interaction between best interests and parental rights. There has been some significant media attention in the last year on multiple cases of disagreement between the medical teams and the parents. He alluded to these cases including the common protest of ‘my child, my choice’, and put a spin on this statement by highlighting that a parent does not necessary have the right to choose anything for their child – his example being that parents have the right to choose what to feed their child but they cannot choose to feed them poison. Overall it was an interesting discussion concluding that the child must always come first.
This was followed by three project presentations:
The first was on the impact of austerity on families with disabled children across Europe. The conclusion of the project survey was that cuts since 2008 have resulted in worsening quality and access of services to disabled children with a significant negative impact on families in the UK, especially those in severe poverty.
The second was about delays in seeking legal judgements in cases of withdrawal of care, collecting data of 15 cases across the England over the last 5 years. They recommended considering alternative methods to avoid these delays such as mediation/dispute resolution, which have high success rates in avoiding litigation, and tend to have higher satisfaction rates.
The last project was about a UK survey on paediatricians experience of sleep education. It was found that around 75% of paediatric trainees have not received any teaching on sleep during their training. Interestingly they recommended that we should all be taking a 15 min nap during our night shifts to reduce fatigue and that this should be supported by our workplaces. For more information, they have recently published articles in ADC and BMJ to promote more awareness about how to approach sleep during shift work.
The plenary concluded with Professor Neena Modi talking about “Children in the 21st century’ focussing on the historical progression of a child’s role in society from possession, to protection, to partnership. She also talked about the increasing importance of non-communicable diseases in children especially childhood obesity and the interaction between child health and adult health. There is a whole section about these issues in the State of Child Health section on the RCPCH website.
Next up, I chose to go to a workshop about navigating academic training pathways. As a non-academic trainee, it was interesting to hear that the college is keen to support paediatricians interested in developing an academic element to their job. I found out about a research funding opportunities database on the RCPCH website (https://www.rcpch.ac.uk/research_funding_opportunities) and the new academic toolkit (http://apatoolkit.eastface.co.uk).
After lunch, I headed to the BPAIIG speciality group session.
We had a presentation from an epidemiologist at PHE taking about paediatric antimicrobial resistance followed by a talk by a paediatric ID consultant about balancing antimicrobial stewardship since the new NICE sepsis guidelines. The key learning point when prescribing antibiotics was to be mindful of antibiotic resistance and always ‘Start Smart then Focus‘.
There was a good representation from Wales in this session. I was asked to present my project about the epidemiology/microbiology of candidaemia over the last 15 years at Alder Hey Children’s Hospital followed by an excellent presentation by a Cardiff medical student looking at the risk of laceration when using an adrenaline auto-injector. There were also two further presentations about the impact of PCV on pneumococcal meningitis rates and two cases of INF a/b receptor 2 deficiency associated with immunodeficiency.
Finally there were two further talks by paediatric ID consultants about the use of biomarkers to guide length of antibiotic course and the novel use of old antibiotics or new antibiotic combinations to treat multi-resistant bacteria. Excitingly there is a new national trial entitled BATCH (biomarker guided duration of antibiotic treatment in children hospitalised with confirmed or suspected bacterial infection), which is being coordinated by the Centre for Trials Research in Cardiff and may guide further developments in this area.
Overall I had an excellent thought provoking day and enjoyed the excuse to visit Glasgow, my old FY2 home.
After the huge success of last year’s St David’s Day Conference, I was very much looking forward to this year’s event, and Abby Parish and her team once again certainly did not disappoint!
Nestled in the heart of Wales’ vibrant capital city, a stone’s throw away from the iconic sites of Cardiff Castle and the Millenium Stadium, Park Inn provided a classy, yet relaxed setting for an exciting day of learning ahead. Greeted with a lovely warm beverage and a selection of delicious pastries on arrival, there followed an opportunity to catch-up with paediatric colleagues both old and new before the opening lecture of the day.
The programme itself was particularly attractive this year, focusing on Ethics as the principal theme. On a personal note, I felt my knowledge of Ethics in Paediatrics was somewhat lacking, with minimal educational opportunities available previously to explore this complex but fascinating topic. I therefore jumped at the opportunity to attend this year’s St David’s Day Conference to broaden my knowledge and experiences.
The introductory lecture was provided by the President of the RCPCH, Professor Neena Modi. This fascinating lecture on the ethical issues in neonatal research emphasised the importance of the positive relationship between parents/patients and the medical profession, to enhance understanding about science and research methodology, whilst simultaneously strengthening trust between both parties. Professor Modi also discussed the concepts of ‘opt-out’ consent and mention of a possible ‘inclusion benefit’ in order to improve recruitment and efficiency of Randomised Controlled Trials.
The next lecture was one of three of the day by Dr Richard Hain, Consultant and all-Wales Clinical Lead in Paediatric Palliative Medicine. His ‘Introduction to Parental Authority’ talk gave an excellent insight into the difficulties often faced concerning parents’ influence on treatment and care decisions. He talked about the concept of “best interest,” discussing the differences between objective and subjective interests, and their importance in helping parents choose ‘the path of least regret’ with regards to treatment decisions.
Before morning coffee there was a case presentation session led by Wales Neonatal GRID Trainees Kate Burke and Zoe Howard. Their experiences of the management of three different babies born with Trisomy 18 highlighted the variability of genetic diagnoses, the postnatal role of perinatal palliative care, and the central role of the parents.
The final session of the morning featured a lecture on prenatal screening and the associated ethical dilemmas, by Professor Angus Clarke, Clinical Geneticist in Wales. He discussed the goals of antenatal screening programmes, particularly focusing on the permission of informed reproductive decisions, conveying ‘reproductive autonomy,’ whilst considering the balance of health economic assessments.
Dr Hain brought the morning session to a close with his lecture on ‘the value of a short life, who decides?’ This was an extremely thought-provoking session discussing the rights of the fetus, and the value of a child, particularly focusing on the views of the parents and that of the law.
The afternoon session, entitled ‘Costly care – because you’re worth it,’ focussed on the legal aspects of a number of ethical dilemmas, including reference to the relevant articles of the European Convention on Human Rights. The legal concepts were presented by Dr Rim Al-Samsam, Consultant in Paediatric Critical Care Medicine, who has a special interest in law in the context of healthcare. Dr Richard Hain then chaired an open session alongside Dr Al-Samsam, encouraging audience participation to discuss potential treatment dilemmas faced in a hypothetical case.
Following an incredibly profound and inspiring day, the CEO of the RCPCH hosted an interactive ‘road-show’ to discuss some of the topical issues faced by the RCPCH and their potential plans to improve them. Also discussed was the exciting new RCPCH curriculum, due to be launched over the coming weeks.
If you are yet to attend a St David’s Day Conference I could not recommend it more. I very much look forward to next year’s instalment already!
3rd-5th January 2018,
I had the pleasure of being able to attend the British Paediatric Neurology Association Annual Conference this year held at King’s College London. Despite a horrendous viral illness over the festive season which left me with significant post-viral fatigue, I managed to catch my early train to London on the 3rd of January (and had the pleasure of travelling first class in view of my tardiness in buying the ticket resulting in the first class ticket being cheaper!). Loaded up with free coffee and biscuits from the first class carriage, I arrived in London just in time for the first session. The venue was great, close to Waterloo Bridge, and there were beautiful views of the city to be seen in the evenings when crossing the bridge to attend the social events.
The conference had a packed programme full of interesting talks, clinical practice sessions, e-posters and symposia. One of the highlights included the opening talk by Dr. Charlie Fairhurst who discussed the creation of the NICE guideline for Cerebral Palsy in under 25’s in which he emphasised the importance of treating pain first and foremost because if a child is in pain, there is no point in complex interventions to improve their mobility/social interaction because the pain will hinder the child’s participation. Patients with Cerebral Palsy are particularly at risk of pain from numerous sources (e.g. orthopaedic/muscular problems, GI dysmotility, pressure sores, dystonia etc. in addition to the usual causes of pain that anybody can experience). I felt that the talk also provided a very important reminder of the need for holistic and multi-disciplinary care.
There were multiple presentations throughout the conference on current research ongoing in neurological disorders (including neuro-inflammation in psychiatric disorders, antibodies in neuro-inflammatory and demyelinating disorders, neurogenetics etc.) which really made me appreciate the rate at which our understanding of neurological disorders is advancing. There were also sessions on Neuroimaging including advances in fetal neuro-imaging (talk given by Prof. Mary Rutherford) and advances in PET scanning particularly in guiding epilepsy surgery.
On the first day, I attended a workshop on Childhood Sleep Disorders run by the tertiary sleep service at Evelina Children’s Hospital, which involved learning about methods of sleep assessment (including polysomnography, actigraphy and sleep diaries). Pharmacological therapy including melatonin and clonidine (for fragmented sleep) were discussed. We also discussed potential contributors to sleep fragmentation (e.g. pain, seizures, obstructive sleep apnoea) and also discussed basic sleep hygiene advice and psychological interventions to help with behavioural insomnia.
On day 2, I attended a workshop session on early epileptic encephalopathies and the emergence of underlying diagnoses related to epilepsy gene panels where the indications for genetic testing were discussed. We also discussed when a referral to a clinical genetics service is indicated and the common genetic mutations now being identified on epilepsy panels (SCN1a, SCN8a, SCN2a, KCNQ2, PRRT2 etc).
On the third day, I attended a workshop on movement disorder emergencies including how to manage status dystonicus. This was something I had never come across in clinical practice and therefore was a very useful session highlighting the management including pain relief, dystonia medications, checking CK, strict fluid management. The session also discussed common mutations causing dystonia (including DYT 1, PANK2, RRT1, TOR1A) and also discussed surgical management options including deep brain stimulation and pallidectomy.
This year’s conference used an app instead of the usual printed programme. The app allowed you to formulate your own personal programme and came with alerts to indicate which talks were about to start. During talks, you could also write notes on the app which were then linked to the talk. At the end of the conference you could then download all of your notes. There was also an option to ‘chat’ with other attendees during the talks (though I didn’t use this feature as I felt I didn’t have anything very intelligent to say as many of the topics were completely new to me!).
During the conference, I presented my poster on head injuries sustained following infant falls on the postnatal ward. The poster outlined the findings of a case series of infant falls in UHW between January 2015-September 2017. We found a high incidence of injury on CT imaging in these infants and therefore we propose a lower threshold for CT imaging in this group. We also found significant variation in monitoring, investigation and follow-up of these patients highlights a need for guideline development in this area. I am now planning to expand this project to a multi-centre WREN project collecting data from other units across Wales to gain more insight in to the scale of this problem and how cases are managed elsewhere across Wales.
I was very pleased to see that two other Wales Deanery Trainees also had posters to display at the conference. Anne-Marie Proctor with her poster on Improving EEG investigations: Child’s Play? This poster presented how extension of a child-centred approach to EEG (including play therapy and flexibly timed investigations) to a second site in ABMU improved EEG success rates. Qumrun Nahar also presented her poster on the delivery of Botulinum Toxin Injection for Children with Spasticity: a Service Evaluation Project in Pembrokeshire, West Wales which showcased the service model of Botulinum Injections delivered in a rural DGH.
This year’s conference displayed all of the posters as e-posters which meant that poster presenters were given a 3 minute slot to present their poster as part of a powerpoint presentation in a designated room. All presenters had 2 minutes to present and 1 minute for questions. Numerous poster presentations were running in parallel. The positive side of this was having an allocated time session to present your poster, and then you were free to listen to the other posters being presented with no obligation to stay standing next to your poster. The down-side was that because of the parallel sessions it was easy to miss out on seeing another poster that took your interest. For example, unfortunately I couldn’t attend both Anne-Marie and Qumrun’s poster presentations and was very sad to have to miss out on seeing one completely. There were also some posters which I felt could have generated much more than three minutes’ discussion and it was a shame to be limited to that timescale (some of the presenters struggled to describe their poster in any sort of detail in only 2 minutes!). It was an interesting and innovative way to display posters and it will be interesting to see if the idea is taken up at other conferences.
I was absolutely exhausted at the end of the three days, but know that I have learnt a great deal that will improve my interaction with children with neurological disorders, their families and the wider MDT.
You can download the BPNA app which has further information on upcoming BPNA courses and events. And if you have an interest in Paediatric Neurology I would thoroughly recommend attending the BPNA conference next year.
And if anybody is interested in getting involved in the upcoming WREN project looking at Head Injuries in Neonates on the Postnatal Ward please get in touch at email@example.com!