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Newsletter # 1, 2015
In this Issue
Principals Letter
Dates for Diaries
Important Notices
Dec 2014 Exam Review
Who are we? Matt Dundas
To those who have been unsuccessful: I know that this is a very challenging time. Please dont lose your momentum to enhance
your paediatric knowledge and skills; I urge you to use this opportunity to continue your journey and to achieve success when you
next attempt the examination.
I would like to convey sincere thanks to:
Elizabeth Koff and Professor Louise Baur, leaders in our parent institutions, for their continued commitment.
Our Webcast Presenters from SCHN who tirelessly share their expertise each year.
Our team: Rita Gudinho, Catherine Zelinsky, Belinda Shephard, Dr Diana Steinberg, Dr Helen Somerville, Dr Mary
Iskander, Dr Mohna Sharma, Kevin Brown, Dijana Sarcevic, Angela Ostojic, Rad Erceg, Matt Dundas and Anisha Rana
We are so fortunate to have access to programs such as the DCH / IPPC. It is a lens through which we see paediatric care more
clearlyit brings true enlightenment to our clinical practice and adds significant clarity to our communications with colleagues,
children and families. We know that you will treasure the opportunity you have had to enjoy this program and that you will use your
new knowledge, confidence and skills in your day to day practice to enhance the health and wellbeing of the children and young
people in your communities. I know you will embrace responsibilities that accompany your opportunity to learn, including:
Continuation of your personal development in paediatrics, seeking new knowledge as part of our Alumni
Encouraging and supporting the learning opportunities of others
Sharing your experiences and expertise in teaching colleagues, students, your paediatric patients and their families
Our Graduation Ceremony here at The Childrens Hospital at Westmead was an excited and meaningful occasion for all who
attended. It was recorded and is soon to be available as a webcast for all to enjoy.
I had the privilege of attending our first Graduation in Zimbabwe in January, hosted by our Australian Ambassador HE Matthew
Neuhaus and conducted by his wife, Angela, who introduced DCH / IPPC there. The jubilation there was palpable, with their most
senior, now retired, paediatric Matron saying that this was the highlight of her long and challenging career.
It is always inspiring to hear of your excitement in transforming your new knowledge directly into action at the bedside, and in the
community in day-to-day practice. These stories are the best indicator of the true benefit of IPPC & IPPNC. Please share this with
us and your DCH / IPPC colleagues as you whenever you can and in your formal application for ongoing free Alumni access each
year. Thanks to all who have sent feedback already.
I look forward to hearing from you and to meeting again.
Kind regards,
August
Stream
December
Stream
Notes
Course Period:
Lecture Units
Conclude: 11 November
2015
Due Date
Due Date
Notes
13 February 2015
26 June 2015
27 March 2015
28 August 2015
Date
Date
14 August 2015
4 December 2015
Assessments
Report 1: Health Inequity
Case Report
Report 2: Medical Case
Report
Final Examination
Written & Oral
15 May 2015
14 August 2015
Important Notices
Key dates:
Case Report 1: August 2015 Steam
August 2015 stream Participants are advised that the due date for receipt of their Health & Inequity Case
Report is Friday, 13th February 2015.
New Magga Website:
We are delighted to announce that our new website is live. This is effective from 29th January 2015.
For access to our platform, please ensure you use your User Name and password
We hope you enjoy the new look to our website and look forward to your feedback.
Chronic Constipation
Faecal soiling due to chronic constipation is a serious problem in 1-3% of children age 4-7 years of age. It is usually a
functional rather than an anatomical problem due to a variety of factors including: a low fibre diet, poor fluid intake,
slow colonic transit and lack of exercise. In younger children excessive cows milk intake and cows milk protein
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allergy are additional causes.
This leads to the development of hard stools, which are difficult to pass. When defecation occurs less than 3 times a
week, a vicious cycle develops where the rectum becomes dilated with excess stool and the child avoids passing stool
as it is painful. Eventually there is a loss of sensation of stool presence in the rectum leading to involuntary episodes
of defecation (encopresis).
Upon diagnosis of functional constipation, a child with encopresis should be treated with a combination of stool
softeners, and dietary and lifestyle changes. It is important to maintain therapy with stool softening agents for at least
6 months to allow the rectum time to recover normal size and sensation. Failure to do so will result in recurrent
constipation. Enemas may be necessary for disimpaction in some situations as an initial treatment, however they do
not provide adequate treatment for ongoing chronic constipation. Stool softeners may be successfully weaned after 6
months provided the necessary improvements in diet have also been made.
Spinal Dysraphism
Most (two thirds) of cases of spinal dysraphism are now diagnosed ante-natally during the routine foetal morphology
ultrasound scan at 18-20 weeks gestation. Many foetuses with severe spinal dysraphism are terminated. As a result
of this, and with improvement of peri-conception folic acid intake in Australia, the incidence of spinal dysraphism at
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birth has declined here to 1:2000 live births.
Occult spinal dysraphism includes a number of conditions such as low cord, tethered cord, extension of a cutaneous
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pit into the central canal (diastematomyelia or split cord), anterior sacral meningocele, and spinal lipoma. Most spinal
defects occur in the lower lumbar or sacral regions. Most spinal defects (97%) are associated with a Chiari II
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malformation where the cerebellum and the medulla are displaced caudally into the foramen magnum.
Ultrasound scan of the spine is an excellent screening tool for occult dysraphism in children under the age of 3
months. All babies with cutaneous stigmata such as hair patches and skin pits in the lumbosacral area should have
an ultrasound to exclude occult spinal dysraphism. If the ultrasound is normal in this age group, no further
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investigation is necessary unless there are neurological abnormalities on physical examination.
available, and the child is developing normally and has a normal neurological examination, it is reasonable to monitor
head growth at 2-4 weekly intervals. In circumstances where there is crossing of centiles, or abnormalities on
neurological examination, an MRI scan of the brain is the gold-standard test. CT scan of the brain in a child <10 years
of age confers a 1 in 1000 lifetime risk of haematological malignancy, and therefore should not be used for routine
investigation of macrocephaly if MRI is available.
Scoliosis in adolescence
Idiopathic adolescent scoliosis is the most common type of scoliosis in this age group. It is often familial and affects
more girls than boys. It is first noted by screening in early adolescence and is asymptomatic. Treatment is advisable
if the Cobb angle is greater than 20 degrees, and includes bracing and observation for a period of time to monitor
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progress.
It is a good idea to refer to an orthopaediac surgeon for review if in doubt. If a GP or paediatrician is experienced in
spine X-ray interpretations, Cobb angles less than 20 degrees can be observed for progress every 6-12 months.
Further investigation of scoliosis becomes a necessity if the presentation is outside the adolescent period or is
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symptomatic (painful). An MRI of the spine is the investigation of choice in those circumstances together with
orthopaedic review by a spinal surgeon.
Most of these changes will fully reverse with re-feeding and maintenance of a healthy weight. The exception is
osteoporosis, which causes chronic bone problems in recovered anorexics. AN leads to 4-10% bone loss/year if
untreated. The loss of bone mass is related to increased osteoclast activity, decreased osteoblast activity, decreased
calcium intake and increased cortisol levels. It is important to treat bone health aggressively in AN to minimise the
long term effects of chronic osteoporosis, however it is almost impossible to completely reverse the damage.
Treatments include: anabolic strategies to increase osteoblast function, weight gain, restoration of gonadal function,
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calcium supplementation, and weight bearing exercise.
Infantile haemangiomas
Infantile haemangiomas are vascular tumours and are the most common benign soft tumours of childhood. They
occur in 1-2% of newborns and the clinical onset is within 1-2 weeks of birth. The growth period of the haemangioma
is from 3 to 9 months of age and it tends to regress in childhood. Ultrasound is a helpful diagnostic tool.
Complications of infantile haemangiomas include ulceration, interference with function, and cosmetic disfigurement.
Haemangiomas over the upper eyelid may cause amblyopia, those in the beard distribution may be associated with
laryngeal haemangiomas which can acutely compromise the airway as they grow.
Treatment with oral Propranolol (and close monitoring) can be very effective in the treatment of haemangiomas in
such circumstances, especially in preventing airway complications in children with neck / beard distribution
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haemangiomas. Any child who is acutely unwell with signs of airway compromise should be admitted to hospital and
seen urgently by an ENT surgeon.
Growth in Children
Growth is a sensitive indicator of:
Prenatal
Postnatal
OR
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Upon evaluation of a childs growth, height measurement and plotting on centile chart is pivotal in determining whether
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a child is short for age. A short child would be 2 SD or more below the mean (1 centile of the growth chart). Heights
above that cut-off do not require further investigation unless there are other reasons for concern such as dysmorphic
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features, progressively decreasing height centiles or features of systemic disease.
Rib fractures due to NAI may be an incidental finding on a chest x-ray done for fever or respiratory illness. It is worth
taking the time to review the bones in a chest x-ray, as well as the soft tissues. When viewing chest x-rays, review the
area outside the lungs including all the visible bony skeleton.
Please note that infants have a large occiput, and therefore the head needs to be placed in a neutral position to open
the airway. For older children and adults the airway is opened by tilting the head into the sniffing position. If spinal
injury is suspected the neck should be stabilised, and a jaw thrust manoeuvre is used to open the airway.
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