Our experience of a paediatrician-led clinic for the medical management of children with obstructive sleep-disordered breathing.

BACKGROUND: Obstructive sleep-disordered breathing (OSDB) is very common in children. Adenotonsillectomy is usually curative, but there is emerging evidence that topical nasal steroids can also be effective for some children and may avoid the need for surgery. The number of children referred for assessment of OSDB is increasing and in some departments, waiting times are long. We established a paediatrician-led clinic for assessment and initial medical management of OSDB and in this study we report the proportion of children who avoided the need for surgery. METHOD: Referral letters to the otolaryngology department were screened and those with suspected OSDB and no significant co-morbidities were diverted to the paediatrician-led clinic. We recorded data for a consecutive series of children seen in this clinic with suspected OSDB over a 3-month period. Parents completed a 5-item subset of questions from the OSA-11 questionnaire before and after treatment with 6 weeks of topical nasal steroids. RESULTS: In the 3-month study period, 103 children were seen, with a mean age of 6 (range 1-16). Six (5.8%) had improved spontaneously before clinic attendance. Of the 97 children who were still symptomatic, 17 (17.5%) were referred directly for surgery on the basis of the severity of their symptoms, or because of other coexisting conditions that required surgical treatment (such as recurrent tonsillitis or otitis media). Three declined intranasal steroids. Seventy-seven had a trial of intranasal steroids, of whom 34 (35%) reported enough improvement to avoid surgery, and 29 (28%) failed to improve and were referred for surgery. Fourteen (14%) failed to attend after the trial of steroids: of these, 5 (5%) were contactable by phone and confirmed improvement after topical steroids. OSA-5 scores were significantly improved following intranasal steroids. DISCUSSION: A paediatrician-led clinic can be an effective way to ease the workload of an over-stretched otolaryngology service, and judicious use of topical nasal steroids can help around 40% of children with OSDB avoid surgery.

Childhood constipation.

BACKGROUND: Constipation is best defined as difficulty passing stools that may be infrequent (≤2 per week), painful and associated with stool retention. Childhood constipation is common, with a prevalence of 3-30% worldwide. Most constipation in children is functional and related to behavioural withholding after an unpleasant stool event. Successful diagnosis and management can occur in primary care, and specialist referral is only needed for refractory cases or concerns regarding organic pathology. OBJECTIVE: This article aims to provide a structure for evaluating, diagnosing and managing childhood functional constipation in general practice. DISCUSSION: Structured history and examination can screen for organic pathology or red flags that require specialist referral. Investigations such as abdominal X-ray are not routine. Early management of childhood constipation provides improved quality of life for patients and their families. Management, including disimpaction and maintenance, should maintain continuity of care and provide long-term support for families.

Phototherapy in transport for neonates with unconjugated hyperbilirubinaemia.

AIM: In Victoria, neonates with severe unconjugated hyperbilirubinaemia at risk of requiring exchange transfusion are retrieved by the Paediatric Infant Perinatal Emergency Retrieval Service and transferred to a Neonatal Intensive Care Unit where an exchange transfusion can be performed if necessary. Transfer may result in prolonged periods without phototherapy in neonates at risk of developing bilirubin encephalopathy. We aimed to describe our experience of the introduction of phototherapy using a portable phototherapy unit during transport. METHODS: Neonates with a primary diagnosis of severe unconjugated hyperbilirubinaemia were identified from the Paediatric Infant Perinatal Emergency Retrieval clinical database over an 11-year period. Demographic and clinical data including gestation, age at transport, serum bilirubin levels pre- and post-transport, use of phototherapy during transport (PTDT), likely diagnosis, and use of exchange transfusion were included. RESULTS: A total of 147 neonates were included with 104 neonates receiving PTDT and 43 who did not. Neonates who received PTDT were less likely to require exchange transfusion, 19.2% versus 34.9%, odds ratio 0.44 (95% CI 0.2-0.98), P = 0.05. However, after correction for factors appearing to be related to use of exchange transfusion, the odds ratio increased to 0.58 (95% CI 0.21-1.63), P = 0.3. There was a greater reduction in the pre- to post-transport total serum bilirubin levels (µmol/L) for the group receiving PTDT (mean 46.3, SD 64.6) versus no PTDT (mean 26.1, SD 62.5), but this did not reach significance, P = 0.08. CONCLUSIONS: Phototherapy during neonatal transport is feasible and safe and may result in a decreased requirement for subsequent exchange transfusion.