Paediatric training overview and how to learn
This teaching session focuses on the many ways we can learn paediatrics and child health, so that trainees can make the most of the learning opportunities, and include them into a learning plan for 2022 and beyond.
COVID in 2022 and the other side of the pandemic
This session covers where COVID is up to in 2022. We discuss the SARS Co-V-2 variant Omicron and its effect on children. We know a lot about this in the last months from what has happened in South Africa and other heavily affected countries. We need to understand the ways in which COVID in 2022 is different from 2021 and 2020, and what it means for paediatrics (mostly it will be good news!) In addition to vaccines, what other therapies are useful in COVID?
Type 1 Diabetes in children
In the past type 1 diabetes was rare in children in the Pacific, but it is now increasingly, as it is in all countries around the world. Children with diabetes need careful management of their initial presentation – usually ketoacidosis, and they need careful transition to chronic long-term treatment. There is a lot to think about when we are looking after a child with diabetes, but if we manage all issues then these children can have a very good outcome. In this session we cover all stages of management and describe the complications and pitfalls to avoid.
Meningitis and encephalitis in children
This teaching session covers meningitis and encephalitis, and other causes of acute febrile encephalopathy. We cover diagnosis and treatment, including basic measures to prevent secondary brain injury – we will go through all the causes and how to prevent them. To care for such patients, we need to understand the rationale for using certain antibiotics in meningitis, antimalarial therapy in cerebral malaria, and how to monitor children properly to prevent secondary brain injury. We also cover identification and treatment of complications (such as cerebral abscess) and when to suspect other causes (tuberculosis, cryptococcosis, non-infective causes).
Pneumonia and bronchiolitis
Pneumonia is the most common cause of child morbidity and mortality, and it is both simple and complicated. Treatment guidelines outline a Standard treatment approach for simple pneumonia, but many cases are complicated, and we need early recognition of such cases. We need to improve risk assessment for children with pneumonia, and this involves early recognition of risk factors. If we recognise these risks early, we can put in place measures to achieve a better outcome. These risks include hypoxaemia, WHO emergency signs, malnutrition, chronic comorbidity, neonates, special x-ray changes, and sometimes other laboratory tests. We need to identify complicated cases of pneumonia, especially empyema, and lung abscess, and cases that will not be treated with standard antibiotic therapy, including tuberculosis or Staph pneumonia. There are ways to do this, and we discuss in this teaching session.
Antibiotics and antibiotic resistance
Antibiotics treat bacterial infections, but in the last 25 years bacteria causing common infections are becoming resistant to many antibiotics, in Papua New Guinea and in all countries. We need to understand the mechanisms of antibiotic resistance, the different types of resistance in different bacteria, and the options of treatment. Standard Treatment is still effective first line treatment for most common infections, but we need ways to identify clinically and with simple tests the patients most at risk of antibiotic resistance. We can put in place steps to limit antibiotic resistance in our hospitals and paediatric wards, this is called antibiotic stewardship, and we discuss the ways to do this.
Epilepsy in children
Epilepsy is common in children, as high as 1-4% in some communities. We need to know how to diagnose epilepsy, an understanding of the types of childhood epilepsy, the anti-epileptic medications, why to choose certain drugs, their complications, what to do if one drug is not working, and the overall goals of care for children with epilepsy. Most children and adolescents with epilepsy can have a good outcome if they and their families are cared for in a holistic way.
Fluid and electrolyte management
In this session we cover the essentials of fluid and electrolyte management in children, including the type and volume of fluid to use, the dangers of low sodium containing intravenous fluids formerly commonly used in paediatrics, the risks of hyponatraemia and hypernatraemia and how to treat, the importance of clinical monitoring of oedema and dehydration, and how to calculate fluid replacement in a child with severe dehydration, including the deficit, maintenance, and ongoing losses.
Neurological examination of children
In this session we go through the neurological examination of children and describe a practical approach to making clinical diagnoses – by first asking “where is the lesion”, to locate the neurological abnormality, and afterwards ask “what is the lesion”. With history and neurological and general examination, many clinical diagnoses can be made.
Vaccines and vaccine preventable diseases
This session covers the basic information paediatric trainees need to know about vaccines and the diseases they prevent, the history of the expanded programme of immunisation (EPI), the different types of vaccines, and the recent changes to the vaccine schedule. This will help you become familiar with the current EPI schedule, and vaccine terminology, for example what live attenuated, inactivated, recombinant, conjugate, and adjuvant mean. We also cover the science of why measles outbreaks occur, and the reasons for recent polio and pertussis outbreaks in PNG.
Failure to thrive
Failure to thrive is a common paediatric presentation. It is not just malnutrition but encompasses the developmental impact of poor nutrition. Failure to thrive is often a combination of inadequate energy (calorie) or protein intake, inadequate absorption of nutrients in the gut, increased energy utilisation, underlying infectious or genetic condition, psychosocial and environmental factors. It is important to understand each component to manage these children properly. We will discuss the assessment of a child with failure to thrive, the stages of management of severe malnutrition according to WHO and Standard Treatment guidelines, and how to identify and manage refeeding syndrome, which can cause patients to deteriorate after recommencing feeds.
Neonatology I: care of the very low birth weight baby
In this teaching session we cover definitions of low birth weight and prematurity, gestational age assessment, multi-system complications of prematurity, respiratory complications and care for the developing lungs, nutrition and growth monitoring, gastrointestinal complications, retinopathy, anaemia, hospital discharge criteria and follow-up of very low birth weight babies.
Neonatology II – infections
In this session we cover all common neonatal infections: bacterial, viral, including intrauterine, and post-natally acquired infections in newborns.
Paediatric mortality and morbidity audit meetings
Auditing of child deaths allows the identification areas that can be addressed to improve quality of care. About 50% of child deaths have at least one modifiable or preventable factor: in the community, in primary health care, or in hospitals. Audit is an important process, but it must be non-blameful, open to and supportive of all staff, and educational. This teaching session goes through how to run M&M meetings, and the importance of follow-up after such meetings by a quality improvement team to put changes in place. All hospitals should do regular audit, and paediatric trainees need to learn how to conduct these meetings.
Cardiac disease in children I
In this first of two sessions on paediatric cardiology, we will discuss the causes of heart failure at different ages, especially focus on acyanotic congenital heart disease, and the most common left to right shunts (ASD, VSD, PDA). We will go through how to assess cardiac function clinically, and how to integrate the history (age of presentation, severity, symptoms, associated features), the examination finding, the chest x-ray and ECG to make the diagnosis 90% of cases. We will cover the basics of echocardiography, but very often we can make a working diagnosis on clinical grounds and with proper interpretation of x-ray and ECG.
Cardiac disease in children II – cyanotic CHD and pulmonary hypertension
In this session we will discuss cyanotic congenital heart disease (CHD), its different presentations in the newborn period, infancy, and older childhood. We will discuss how to manage the cyanosed neonate, who might have CHD, but also might have other conditions, such as persistent pulmonary hypertension of the newborn (PPHN), sepsis, or congenital lung disease. We will also discuss acquired pulmonary hypertension that arises due to chronic lung disease, severe pneumonia, high altitude, and nutritional issues, especially a problem in the highlands. In this session you will learn the ECG and x-ray changes of common forms of cyanotic CHD and pulmonary hypertension, so the diagnoses can be made using clinical features and basic investigations.
Renal disease in children
https://www.youtube.com/watch?v=utB37NOvkbA
We cover nephrotic syndrome, post Streptococcal glomerulonephritis and congenital renal diseases that can lead to chronic renal failure. We also cover acute renal failure and its management, nephrotoxic drugs and management of complications, particularly hypertension.
Adolescent health
Part 1: https://youtu.be/styx0_YSIyA
Part 2: https://youtu.be/REIx6UKoAhg
This teaching session in 2 parts, by Dr Mary Paiva covers the main issues in adolescent health. Adolescent health is increasingly important in PNG, and paediatricians need a good understanding of the neurobiology, the neurodevelopmental transition and vulnerabilities of adolescence, the factors that influence health seeking behaviours of adolescents, and their health concerns, including sexual health, mental health, substance use, nutrition, and particular issues for adolescents with chronic diseases. Dr Paiva discusses the roles of health services for adolescents in hospitals and in the community, in prevention, education and treatment.
Anaemia in children
Video links (in 2 parts):
In 2021 anaemia was reported in at least 7% of all paediatric hospital admissions, the case fatality rate was 12%, and anaemia was a comorbidity in at least 17% of all child deaths. Anaemia increases the risks of infection, poor growth and development. In this session we will cover the common causes of anaemia in children, especially iron deficiency and nutritional anaemia. We will discuss how to assess the child with pallor, how to distinguish based on clinical features and an analysis of the FBC the different causes of anaemia. We will cover iron physiology, anaemia of malaria, anaemia due to haemolysis and anaemia due to bone marrow failure, and Thalassaemia. We will also discuss nutritional treatment of anaemia, safe use of iron, and indications for blood transfusion.
Soil transmitted helminths in children
Video link
https://youtu.be/OyGiBaejNjQ
WHO identifies soil-transmitted helminths as among the neglected tropical diseases (NTD). Many children in PNG are affected by these infestations, including from Ascaris, Human hookworm, Cutaneous larva migrans (dog hookworm), Whipworm, and Strongyloides. This session will discuss sources, lifecycles, clinical features, and treatment of these infections, which cause a lot of morbidity and nutritional problems in children. Trainees need a good understanding of the basics of helminth infections, as they are often truly neglected in our management of patients.
Liver disease in children
Video link: https://youtu.be/geKKZWi3VgA
Liver disease is more common than may think, being caused by a variety of conditions directly affecting the liver, and systemic infections where liver dysfunction is a part of it. Liver disease can be a part of virus, bacterial and parasitic infections, cancer, and drug side effects. Paediatricians need to have a good understanding of liver anatomy and physiology, the different functions of the liver, the production and excretion of bile, and the significance of different tests of liver function. In this teaching session we discuss the differences between physiological and pathological jaundice in newborns, thresholds for phototherapy, the various forms of congenital liver disease such as biliary atresia and neonatal hepatitis. We also cover liver disease in older children, where we need to distinguish acute from chronic liver disease and recognise the effect of drugs on liver function. We can diagnose most liver diseases with a good history, clinical examination, and an understanding of the basic LFTs. Although there is often no specific treatment that can be given to children with liver disease, many types of liver disease resolve with time, and there are important ways to support such patients to give their liver the best chance of recovery.
Paediatric x-rays
Video link: https://youtu.be/xBNqltqj8P4
In this teaching session we will go through a series of x-rays to show common problems in seriously ill children and learn how to relate the changes you see on x-rays to the clinical picture and pathophysiology. So many diagnoses can be made by linking these things together (clinical, x-ray, pathophysiology). In the DCH and MMed exams you will need to be interpreting x-rays, so watch the session if you can.
Management of critical illnesses in children I
Video link: https://youtu.be/WGJ7G7tV5Aw
In this session we will go through some common scenarios in the management of common severe illness in children, including severe acute respiratory distress, upper airway obstruction in infants, and sudden cardiac arrest in a previously well adolescent. We can use clinical signs and basic test to differentiate the causes of these clinical syndromes: for example, differentiating when severe respiratory distress is due to pneumonia or airways disease, and then considering the different causes of airways disease at different ages. This type of deductive reasoning allows for specific treatment that addresses the underlying pathophysiology, at the end we discuss a framework for thinking about children with critical illness on ward rounds.
Common critical illness in children II
Video link: https://youtu.be/4bZt2AkEIKc
In this second teaching session on the management of critical illness in children we discuss a few case scenarios and how to approach them, including unusual causes of respiratory distress, the causes and management of shock in a child with Hirschsprung disease, and basic neuroprotection for children with meningitis or encephalitis. Differentiating causes of acute illness, understanding the pathophysiology, providing supportive care and monitoring, and giving time are all important for critically ill patients to recover.
How to write a minor thesis
Video link: https://youtu.be/KXavdZfRCrg
In this teaching session, we cover the next step of how to write a thesis. Includes developing a spreadsheet, ensuring it is analysable, and how to construct and write a thesis. There are many things you can do to make the process easier, and that help you learn about doing research.
HIV in children and adolescents
YouTube recording did not work
In this session we discuss all things related to HIV management. The diagnosis, types of anti-retroviral drugs, mechanisms of drug resistance, and the new recommendations for ART dolutegravir-based therapy. We also discuss chronic care for children and adolescents with HIV, which involves a lot more than ART, including consideration of nutrition, gastrointestinal, lung, cardiovascular, renal and bone health, development, and neurological issues. Care of children and adolescents with HIV also requires improving mental health, self-esteem, and school participation.
Paediatric cancer
YouTube video link is at: https://youtu.be/5ZxQQr-QsOg
These 2 sessions on common cancers affecting children in PNG give an overview, covering acute leukaemia, lymphoma, retinoblastoma, chest tumours, and abdominal tumours. We discussed the diagnosis using important clinical signs, basic laboratory investigations, imaging cancer using ultrasound and CT, and cover treatments of the commonest cancers and their complications, and the management of common cancer emergencies.
Acute kidney failure and encephalopathy case discussion
Video link: https://youtu.be/dVusXDFI05c
This session highlights the many cases of acute renal failure and encephalopathy in children in Indonesia. Dr Nina Putri, paediatrician from Jakarta presents a typical case, and other specialists from Indonesia also provide input. We discuss the likely causes, which include diethylene glycol contamination of cough and cold medicines, or a post-COVID complication that severely affects the kidneys. We discuss similar outbreaks in other countries from contaminated medicines including recently in Gambia, and previously in India, Bangladesh, Nigeria, South Africa, treatment options for acute renal failure, public health measures, and the reasons why some remedies have been contaminated in the manufacturing process.