Paediatrics (RCH) - Theses
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ItemImproving pain and distress management of children in the emergency department( 2015)This thesis represents a compilation of peer-reviewed papers addressing the care for children in pain or undergoing painful or distressing procedures in the emergency department. After an introductory chapter, papers related to one of several themes are briefly introduced and placed in context with each other. The papers, and their compilation in this thesis, aim to provide guidance for paediatricians and emergency physicians caring for children on how to prepare for and reduce procedural and non-procedural pain and distress. Many aspects of this work, including certain research findings, evolving approaches to pain and sedation management and evidence-based teaching materials, are being used by, or have been implemented in, the Emergency Department at Royal Children’s Hospital and other emergency departments across Victoria, Australia, as well as interstate and overseas.
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ItemStructural and functional evaluation of gas-trapping in infants with cystic fibrosis( 2014)Air-trapping is frequently identified in infants with cystic fibrosis (CF) on chest CT scans. Aim was to examine the association between the measured functional residual capacity (FRC) using infant lung function under sedation, and air-trapping scores obtained from chest CT images, acquired under general anaesthesia. Thirty-eight lung function tests were analysed from CF infants aged 3-24 months. Twenty CT scans were performed on the infants. No statistical significance was found between the lung function and CT results when simple linear regression was applied. In conclusion, no associations were found between measured FRC and air-trapping CT scores in infants with CF.
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ItemAbnormalities in linear growth and the growth hormone-insulin like growth factor axis in children with chronic inflammatory disease( 2015)Impaired linear growth is commonly encountered in children with chronic inflammatory conditions such as juvenile idiopathic arthritis (JIA) and inflammatory bowel disease (IBD), especially those with Crohn's disease (CD). Sub-optimal nutrition, prolonged use of glucocorticoid (GC) and chronic inflammation mediated by pro-inflammatory cytokines all play a role in contributing to the underlying aetiology of growth retardation by their effects on the secretion and sensitivity of systemic factors and directly at the level of target organs. In a group of children with JIA at acute relapse requiring intra-articular glucocorticoid injections, systemic IGF1 and IGFBP3 were noted to be normal but ALS was disproportionately low. Interleukin (IL5) and IL15 were noted to be associated with height in these children. In children with IBD and growth retardation who underwent evaluation of the GH axis with insulin tolerance test, my study demonstrated for the first time that a spectrum of abnormalities in secretion and sensitivity of GH and IGF1 may exist. Exposing fetal metatarsals to serum and synovial fluid of children with JIA at relapse show variable deficits in local bone growth not reversed by addition of blocking antibodies to TNFα, IL1β and IL6 did not reverse bone growth. In the first randomized controlled trial of rhGH at 0.067 mg/kg/day in children with IBD and growth retardation, my study showed that height velocity in the treated group improved by 140% over a 6 months period compared with only 17.4% in the control group. Similar to rhGH trials in other groups of children with chronic disease, reduction in insulin sensitivity was noted with no evidence of abnormalities in glucose homeostasis. Finally, systemic IGF1 increased in the rhGH treated group but remained within 2 standard deviation during the treatment period.
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ItemAssessment of pulmonary function in childhood neuromuscular weakness( 2004)Children with neuromuscular weakness may have severe or progressive weakness that results in pulmonary restriction. Weakness can also result in spinal deformity that worsens the pulmonary restriction. Corrective spinal surgery carries significant respiratory risk. Accurate respiratory assessment is important for pre-operative risk assessment. Aims: 1) to evaluate the current clinical practice of pulmonary function testing and their role in respiratory assessment in children with neuromuscular weakness undergoing corrective spinal surgery and 2) to develop a precise method of predicting pulmonary function tests in children with neuromuscular weakness.
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ItemClinical management strategies for disorders of gonadal function from infancy to late( 2013)This body of work defines problems of altered sex hormone function from birth to the end of adolescence and demonstrates the ability of interventions to optimize outcomes. The breadth and prevalence of sex hormone alterations in these conditions is outlined and a range of rational and beneficial treatment options to optimize outcomes, reduce risks and increase understanding across the medical and family spectrum is provided. Evidence is given for a clear plan for identification and management, for paediatricians working in resource constrained environments. The document describes normal processes of development, growth and puberty, indicates aberrations due to structural or functional changes, either primary or secondary to acquired health disorders and complications of treatment omission or failure and provides information based on my publications in the area, as to management considerations and strategies at different ages and for different conditions together with implications for health outcomes in the face of adequate treatment or otherwise. New concepts and new treatments are discussed, with particular reference to offering improved outcomes whilst bearing in mind ethical principles underlining management.
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ItemInhalation pneumonitis in children with severe cerebral palsy( 1999)Aspiration occurs frequently in children with severe cerebral palsy. Our study demonstrated at least one positive test for aspiration in 68% of children. The salivagram was positive in 56%, the barium video-fluoroscopy in 39%, and the milk scan in only 6%. The study demonstrates poor agreement between radiological tests of aspiration. This suggests that the tests measure different aspects of swallowing, that the intermittent nature of aspiration results in poor agreement, or that the tests are poor measures of aspiration. Positive radiological tests of aspiration are associated with a history from parents that the child has asthma and with poorer motor skills. A history of cough or wheeze, of cough with feed, of regurgitation and of recent asthma are associated with positive tests. Poorer overall adaptive ability, smaller head circumference centile, higher resting respiratory rate and abnormal measures of gastro-oesophageal reflux are associated with positive tests of aspiration. Chronic respiratory acidosis occurred in some children. Our study of this abnormality was hampered by the problem of defining normal values, and the appropriate reference range for our methodology. Using the Arbus nomogram definition of chronic respiratory acidosis we found an association between chronic respiratory acidosis and larger angle of scoliosis, poorer clearance of aspiration from the lung on salivagram, poorer clearance of acid from the oesophagus on pH probe, a history of pneumonia, and better weight for height Z score. Gastro-oesophageal reflux is associated with aspiration as mentioned. Both younger age and decreasing levels of ability are associated with greater frequency of gastro-oesophageal reflux. A history of asthma, regurgitation, a parental impression that the child aspirates but not a history of vomiting, were more frequent in children with gastro-oesophageal reflux. Altered voice following liquid feeding was associated with gastro-oesophageal reflux. We found less gastro-oesophageal reflux amongst children with more severe scoliosis, though this may have been the result of inadequate probe placement. There is poor agreement between the pH probe and milk scan in the diagnosis of gastro-oesophageal reflux.
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ItemThe quality of life of young women with a menstrual problem and families attending a hospital-based gynaecological clinic in Melbourne, Australia( 2010)BACKGROUND: Menstrual disorders are very common among young women and have been shown to have negative effect on physical and psychosocial health. Despite high prevalence of menstrual dysfunction in young women, only small percentage seeks medical help. Very few papers have examined health related quality of life (HRQL) in younger population with menstrual problem. AIMS: The aim of the study was to assess young women’s and their parents’ perception on the impact of menstrual problem on the young women’s quality of life and identified factors that have impact on it. It was also aimed to describe the quality of life of parents of young women with menstrual problems and factors influencing their quality of life (QoL). METHOD: This was a descriptive, cross-sectional study conducted in Royal Children’s Hospital, Melbourne between 1st October 2008 till 30th June 2010. Research tools used for young women were PedsQL 4.0 generic module (Teen-report) and Parent Bonding Instrument whereas tools for parents include PedsQL 4.0 generic module (Parent-report), SF12v2 and Kessler Psychological Distress Scale. RESULTS: A hundred and eighty four young women and parents completed self-administered questionnaires. The most common menstrual problems seen in our gynaecological clinic were dysmenorrhoea (38.6%), followed by heavy menstrual bleeding (33.6%), oligomenorrhoea (19.6%) and amenorrhoea (8.2%). The mean overall score was 70.48+16.44 with 42.5% having a score below one standard deviation from the norms. Young women with dysmenorrhoea had the poorest score in physical function whereas those with amenorrhoea had the lowest score in psychosocial function. Higher body mass index, smoking, alcohol drinking, sexual activity, parental anxiety and parental overprotection were associated with poorerscore. Overall, parents rated lower QoL scores than young women themselves in all four domains (physical, emotional, social and school). Parent-child agreements were moderate to good with best agreement in school functioning. Parents’ of young women with menstrual problems reported lower QoL scores than the norm in all domains with worse scores in ‘role emotional’ and ‘mental health’ domain. Parental anxiety and medical illnesses were associated with poorer parental QoL. CONCLUSION: Although menstrual problems are not life threatening, they can pose a significant impact not only on the quality of life of these young women but also their parents. Identification of these impacts might lead to recognition of potential services or education to improve this. Understanding the characteristics that predict QoL may help clinician identify patients who are risk for poor QoL.