Royal Children's Hospital Melbourne Research Articles

The late effects of haematopoietic stem cell transplants in paediatric patients: a 25 year review.

A rare, large single centre study covering all long-term health outcomes of paediatric allogeneic HSCT survivors, to provide comprehensive local data, and identify gaps and future directions for improved care. To document endocrine sequelae and other late effects of all HSCT recipients. Retrospective review. Royal Children's Hospital Melbourne. 384 children and adolescents received HSCT. 228 formed the study cohort; 212 were alive at commencement of data accrual. None. Incidence of endocrinopathies; fertility, growth, bone and metabolic status; subsequent malignant neoplasms (SMNs). Gonadotoxicity was more common in females (p<0.001). Total body irradiation (TBI) conditioning was more toxic than chemotherapy alone. All females receiving TBI or higher cyclophosphamide equivalent doses (CED) developed premature ovarian insufficiency (POI) . In males, impaired spermatogenesis +/- testicular endocrine dysfunction was associated with increasing testicular radiation exposure. Preservation of gonadal function was associated with younger age at HSCT. Of sexually active females, 22% reported spontaneous pregnancies. Short stature was common, with growth hormone axis disruption in 30% of these. Of patients exposed to thyroid radiation 51% developed nodules, 30% malignant. Metabolic disturbances included hypertension, dyslipidemias, with both excess and underweight reported. Fragility fractures occurred in 6%; avascular necrosis in 6%. 13% developed SMNs, risk continuing to rise throughout follow-up. We confirm gonadal dysfunction, multiple endocrine and metabolic abnormalities, thyroid cancer and SMNs, as common sequelae of HSCT, and identify gaps in management - particularly the need for informed fertility counselling and pretreatment fertility preservation, evaluation and management of bone health, and underline need for early lifestyle modification, long-term surveillance, and prospective planned studies aimed at reducing complication risk.

Australian Infant Food Allergy Emergency Presentations Following Updated Early Food Introduction Guidelines

The Australasian Society of Clinical Immunology and Allergy food allergy prevention guidelines were updated in 2016 to recommend home introduction of allergenic foods actively in the first year of life, including to infants at high risk of allergy. An important consideration for parents and providers is whether this practice increases food allergy reactions or anaphylaxis. We aimed to determine whether the 2016 update of food allergy prevention guidelines was associated with an increase in food allergy or anaphylaxis emergency department (ED) presentations. We obtained hospital electronic medical records for infants aged 4 to 12 months who attended the Royal Children's Hospital Melbourne ED in 2015 or in 2018 with a presenting problem or an encounter diagnosis of food allergy or anaphylaxis. Emergency department presentations owing to food allergy increased from 1.0% (95% CI, 0.85-1.23) in 2015 to 1.4% (95% CI, 1.22-1.67) in 2018 (P= .006). There was no increase in the number of anaphylaxis presentations (28 in 2015 and 22 in 2018) or peanut anaphylaxis presentations (three in 2015 and three in 2018). Overall, the proportion of food allergy presentations attributed to IgE-mediated food allergy was similar (82.1% in 2015 and 84.1% in 2018), whereas peanut allergy presentations increased slightly, although not statically significantly, from 14.6% to 21.2% (P= .09). Food protein-induced enterocolitis syndrome ED presentations were five in 2015 (4.3%) and 12 in 2018(7.6%), although not statistically significant (P= .25). Changes to food allergy prevention guidelines recommending the earlier introduction of allergenic food may have led to a small increase in ED presentations for food allergy but not anaphylaxis.

LIMBDREAM: THE LIMB RECONSTRUCTION REGISTRY OF EXPERIENCE, ASPIRATION, AND MEASURES

IntroductionPatient-reported outcome measures (PROMs) has gained momentum in the orthopaedic literature. The GOAL-LD (Gait Outcomes Assessment List for Limb Deformity) incorporates the framework of The WHO International Classification of Functioning, Disability and Health and correlates highly with the Paediatric Outcomes Data Collection Instrument (PODCI) when applied in a limb reconstruction setting. The Royal Children's Hospital Melbourne, Australia, supported by The University of Melbourne is designing and implementing a Limb Reconstruction Registry, prospectively enrolling patients with a number of key conditions and provide a mechanism for capturing surgical data and PROMs at regular follow-up intervals. LimbDREAM (The Limb Reconstruction Registry of Experience, Aspiration and Measures) has begun recruiting participants, and this paper serves as a narrative review of our design and implementation process.Materials &amp; MethodsAfter provision of a research grant, audit was conducted to examine local case mix and estimate recruitment based on conditions selected. Literature review was focussed on (i) registries in the paediatric limb reconstruction domain and (ii) use of PROMs across conditions selected. A high-level process-flow chart was constructed in order to inform governance and staffing requirements in addition to REDCap Database structure. Local as well as scalable deployment was considered. Alpha and beta testing was performed by principal and associate investigators prior to participant recruitment.ResultsAudit identified 6 condition streams for inclusion: Congenital limb deficiencies, congenital pseudarthrosis of the tibia, bone dysplasias, bone tumours, amputation, and complex deformity of other etiology. Literature review identified 20 PROMs used across these conditions, with limited validation studies and significant implementation heterogeneity. REDCap database design took longer than anticipated (planned 10 months, actual 18 months) before being recruitment ready, due to the complexity of ensuring data collection logic would work across highly diverse patient journeys. Initial recruitment across all streams has been promising. Email and text message reminders have proved helpful in increasing survey return rates.ConclusionsProspective collection of PROMs as well as surgical data via a standardized dataset will provide the basis for future condition-specific research, with the ability to support nested trials. Implementation requires forethought with regard to time frames and staffing for non-automated steps as well as data integrity review. The next phase of the LimbDREAM project will be to integrate use of the Registry into our weekly Limb Reconstruction Meeting to ensure that operative plans and data are captured close to the point of care.

Utilising in situ simulation within translational simulation programmes to evaluate and improve multidisciplinary response to anaphylaxis in the paediatric emergency department.

The prevalence of paediatric anaphylaxis is rising in Australia. Treatment requires timely administration of intramuscular (IM) adrenaline. Study goals included utilising in situ simulation (ISS) within a translational simulation (TS) programme as a diagnostic tool to identify the frequency and cause of IM adrenaline errors in a paediatric ED, and utilising ISS to evaluate multidisciplinary emergency team response to anaphylaxis. A prospective observational study was conducted in the Royal Children's Hospital Melbourne ED utilising an ISS anaphylaxis scenario with a debrief pro forma within an established ISS/TS programme. Twenty-three anaphylaxis ISS were delivered over 16 months. One hundred and sixty-four multidisciplinary staff participated (mean of 8 per session). Median times (in minutes) for the total ISS were 12:33 (interquartile range [IQR] 9:06-15:19), consisting of the scenario 4:07 (IQR 3:33-4:44) and debriefing 9:00 (IQR 5-11). IM adrenaline was administered in all ISS within 5min, median 2:57 (IQR 2:30-3:40). Adrenaline medication errors occurred in 30% ISS (7/23). Errors included three (13%) administrations and four (17%) potential or 'near misses' associated with a verbal order or medication preparation error. A weight-based medication cognitive aid was utilised in 56% (13/23) ISS but was not utilised in all three administration errors. ISS within TS programmes was successfully utilised as a diagnostic tool in identifying that medication errors were common during anaphylaxis management in the ED. Improving access to adrenaline in dosing boxes and promoting the utilisation of weight-based cognitive aids alongside ISS education will likely reduce errors and improve patient safety.

Characterizing chylothorax in the pediatric population with Congenital Heart Disease

BackgroundChylothorax is characterized by the accumulation of chyle in the pleural space which can occur post operatively in Congenital Heart Disease patients. Ongoing losses of chyle can promote malnutrition, immunosuppression, and can increase the risk of infection. ObjectivesTreatment type and length vary in the pediatric cardiac ward at The Royal Children's Hospital in Melbourne; therefore, this study aims to characterize the patient profile and management strategies of these patients who develop a chylothorax post cardiac surgery. MethodsA retrospective audit was conducted of 66 cardiac patients with chylothorax admitted to a tertiary pediatric cardiac ward between April 2016 and January 2018. Data was collected from the Electronic Medical Record at The Royal Children's Hospital in Melbourne, Australia. Data was examined for variables and analyzed using descriptive statistics. ResultsMost patients (26/66, 39 %) were infants, with an equal ratio between genders (1:1). Of the 15 patients with genetic anomalies, the majority had Trisomy 21 (6/15, 40 %). Nine percent of patients had vascular ring surgery (n = 6), with 78 % of patients having a sternotomy incision (n = 51). Most drain specimens appeared bloodstained (55 %, n = 36) and monogen was the most common treatment (71.2 %, n = 47). Average treatment duration and drain length insitu were 23 and 17.5 days, respectively, with most patients hospitalized for 7–31 days (52.3 %, n = 34). ConclusionsThis study provides novel insights into the baseline demographics of pediatric cardiac patients who develop chylothorax post operatively. This is invaluable data to form a basis for further research and interventions to develop best-practice clinical care of children post cardiac surgery. Already to date, this information has led to the development of a Clinical Practice Guideline for chylothorax management at The Royal Children's Hospital Melbourne and serves to further strengthen the limited repertoire of pediatric chylothorax patient profile knowledge currently available in the literature.

Pediatric lower limb peripheral nerve blocks: Indications, effectiveness, and the incidence of adverse events.

While the proportion of pediatric anesthetics with regional anesthesia in pediatric patients has steadily increased, there are only a few series that describe the use of lower limb peripheral nerve blocks in children. Our aim was to describe the indications, anesthetic approach, and complications associated with lower limb blocks in children undergoing orthopedic surgery in a center with a large caseload of complex patients. In a retrospective analysis of prospectively collected data, we reviewed children who had a peripheral nerve block for orthopedic surgery placed between January 2016 and January 2021 at the Royal Children's Hospital Melbourne. Block data were sourced from the electronic medical record and departmental regional anesthesia database. Data collected included demographics, the site of catheter placement and technique of nerve block, presence of sensory/motor blockade, the use of perioperative opioids, and any complications related to peripheral nerve block. A total of 1438 blocks were performed in 1058 patients. Four patients had clinical features of perioperative neurological injury giving an incidence of 3 per 1000 blocks (95% CI 1.1-8:1000). Only one patient had a sensory deficit persisting longer than 6months for an incidence of 0.8 per 1000 blocks (95% CI 0.1-5:1000). All four peripheral nerve injury followed tibial osteotomy for lengthening procedures or correction of tibial torsion. The etiology of the injury could not be determined despite imaging and surgical exploration and the contribution of popliteal sciatic nerve block to the subsequent PNI could not be confirmed. There were no cases of local anesthetic systemic toxicity. An increased risk of perioperative peripheral nerve injury is associated with pediatric tibial osteotomy for congenital deformity. While popliteal sciatic nerve block was not directly implicated in the nerve injury the presence of a prolonged sensory block can delay early recognition and treatment of peripheral nerve injury.

Characteristics, management and changing incidence of children with empyema in a paediatric intensive care unit.

AimPaediatric intensive care unit (PICU) admissions for empyema increased following the 13‐valent pneumococcal conjugate vaccine (PCV13). We describe the clinical characteristics, management and outcomes for children with empyema and compare incidence before and after PCV13.MethodsRetrospective study of patients <18 years admitted to The Royal Children's Hospital Melbourne PICU with empyema between January 2016 and July 2019. We investigated the incidence of empyema during two time periods: 2007–2010 (pre‐PCV13) and 2016–2019 (post‐PCV13).ResultsSeventy‐one children (1.9% of all PICU admissions) were admitted to PICU with empyema between 2016 and 2019. Sixty‐one (86%) had unilateral disease, 11 (16%) presented with shock and 44 (62%) were ventilated. Streptococcus pneumoniae and group A Streptococcus were the most commonly identified pathogens. Forty‐five (63%) were managed with video‐assisted thoracoscopic surgery (VATS).There was a 31% reduction in empyema hospitalisations as a proportion of all hospitalisations (IRR 0.69, 95% CI 0.59–0.8), but a 2.8‐fold increase in empyema PICU admissions as a proportion of all PICU admissions (95% CI 2.2–3.5, P < 0.001). For the PICU cohort, this was accompanied by reduction in PIM2 probability of death (median 1% vs. 1.9%, P = 0.02) and duration of intubation (median 69 h vs. 126.5 h, P = 0.045).ConclusionsIn children with empyema in PICU 62% required ventilation, 16% had features of shock and 63% received VATS. Empyema admissions, as a proportion of all PICU admissions, increased in the era post‐PCV13 compared to pre‐PCV13 despite no increase in illness severity at admission.

Surveillance of End-Organ Damage in Fontan Patients Prior to Transition to Adult Care: Are We There Yet?

Recently published guidelines and consensus statements have outlined recommended screening practices for monitoring of end-organ dysfunction in Fontan patients. We reviewed the current approach to end-organ screening in a local population of Fontan patients at the time of transition to adult care. Patient data from the Australia and New Zealand Fontan Registry and patient medical records were used to review investigations performed in Fontan patients transitioned from The Royal Children's Hospital Melbourne to an adult centre between 1 July 2015 and 30 June2020. A total of 32 patients were referred for transition to an adult centre between 1 July 2015 and 30 June 2020 at a mean age of 18.5±0.7 years (12.7±2.5 years post-Fontan). Liver function tests were performed in 22 patients (69%) within 5 years prior to transition and were abnormal in 15 patients (68%). Liver ultrasound was performed in 13 patients (41%) within 5 years prior to the date of transition, of whom 10 (77%) had abnormal findings (features suggestive of hepatic fibrosis in seven [54%], cirrhosis in two [15%], and portal hypertension in three [23%]). Fourteen (14) patients (44%) had no record of a liver ultrasound being performed between the date of the Fontan procedure and the time of transition to adult care. Hepatocellular carcinoma was diagnosed in one patient at 18 months following transition. A total of 24 patients (75%) had a serum creatinine measured within the 5 years prior to transition, and two (8%) had an estimated glomerular filtration rate (eGFR) less than 90 mL/min/1.73 m2. No patient had a urine protein-creatinine ratio measured between the date of the Fontan procedure and the time of transition to adult care. In this study we have identified that the majority of patients transitioned from a tertiary paediatric centre to an adult centre within the last 5 years did not undergo routine surveillance for end-organ dysfunction. Routine screening for end-organ complications of the Fontan circulation should be incorporated into clinical practice and is an important part of Fontan patient care both pre- and post-transition to adult services.

Impact of antibiotic allergy labels on patient outcomes in a tertiary paediatric hospital.

Antibiotic allergies are reported in 5-15% of children. This study aimed to evaluate the impact of common β-lactam antibiotic allergy labels (AALs) on hospital treatment, focusing on length of stay and appropriateness of antibiotic prescribing. This was a retrospective cohort study over 21 months at the Royal Children's Hospital Melbourne, Australia. A subset of children with the most common β-lactam allergies, and who required admission for intravenous antibiotics over a 12-month period, was analysed for appropriateness of prescribing. Non-allergic patients were matched to evaluate associations between AALs and hospital treatment. There were 98 912 children admitted over the study period, of whom 938 (1%) had at least one AAL on first admission. Of all encounters, 5145 (2.5%) were for children with AALs. The most common AALs were to amoxicillin and amoxicillin-clavulanic acid combinations (40.8%), cefalexin (14.4%) and trimethoprim-sulfamethoxazole (9.7%). For the subset, there were 66 admissions for children who required intravenous antibiotics. Documentation was adequate for 27% of AALs. Inappropriate prescribing occurred in almost half (47%). Hospital stay was longer for children with AALs (median 4.7days; IQR 2.3-9.2) compared to non-allergic controls (median 3.9days; IQR 1.9-6.8; P = .02). Children with AALs were more likely to receive restricted antibiotics (aOR 3.03; 95% CI, 1.45-6.30; P = .003). This is the first study to demonstrate high rates of inappropriate prescribing in children with AALs. Children with AALs were significantly more likely to receive restricted antibiotics and had a longer length of stay compared with non-allergic controls.

Association of Pediatric ASPECTS and NIH Stroke Scale, Hemorrhagic Transformation, and 12-Month Outcome in Children With Acute Ischemic Stroke.

We aimed to determine whether a modified pediatric Alberta Stroke Program Early CT Score (modASPECTS) is associated with clinical stroke severity, hemorrhagic transformation, and 12-month functional outcomes in children with acute arterial ischemic stroke (AIS). Children (age 29 days-<18 years) with acute AIS enrolled in 2 institutional prospective stroke registries at the Children's Hospital of Philadelphia and Royal Children's Hospital Melbourne, Australia were retrospectively analyzed to determine whether modASPECTS, in which higher scores are worse, correlated with acute pediatric NIH Stroke Scale (PedNIHSS) scores (children ≥2 years of age), was associated with hemorrhagic transformation on acute MRI, and correlated with 12-month functional outcome on the Pediatric Stroke Outcome Measure. One hundred thirty-one children were included; 91 were ≥2 years of age. Median time from stroke to MRI was 1 day (interquartile range [IQR] 0-1 day). Median modASPECTS was 4 (IQR 3-7). ModASPECTS correlated with PedNIHSS score (ρ = 0.40, p = 0.0001). ModASPECTS was associated with hemorrhagic transformation (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.02-1.25, p = 0.018). Among children with follow-up (n = 128, median 12.2 months, IQR 9.5-15.4 months), worse outcomes were associated with higher modASPECTS (common OR 1.14, 95% CI 1.04-1.24, p = 0.005). The association between modASPECTS and outcome persisted when we adjusted for age at stroke ictus and the presence of tumor or meningitis as stroke risk factors (common OR 1.14, 95% CI 1.03-1.25, p = 0.008). ModASPECTS correlates with PedNIHSS scores, hemorrhagic transformation, and 12-month functional outcome in children with acute AIS. Future pediatric studies should evaluate its usefulness in predicting symptomatic intracranial hemorrhage and outcome after acute revascularization therapies. This study provides Class II evidence that the modASPECTS on MRI is associated with stroke severity (as measured by the baseline PedNIHSS score), hemorrhagic transformation, and 12-month outcome in children with acute supratentorial ischemic stroke.

The clinical features that contribute to poor bone health in young Australians living with cystic fibrosis: A recommendation for BMD screening

For Australians living with cystic fibrosis (CF), increased longevity means greater consideration needs to be given to long-term endocrine sequelae such as CF-related bone disease. Deficits in bone mass accrual are most likely to occur during childhood and adolescence. Current guidelines in Australia suggest repeat dual-energy X-ray absorptiometry (DXA) scans every 2 years. This study aims to stratify clinical factors that determine future bone health in the Australian CF population and use this to guide a more streamlined approach to bone health screening. This study was a retrospective audit of all patients diagnosed with CF who were treated at the Royal Children's Hospital Melbourne, Australia from 2000 to 2016 (n = 453). Two hundred and two patients had a DXA scan in the study period (191 with height-adjusted data) and 111 patients had more than one scan (108 with height-adjusted data). An investigation into the associations between bone mineral density (BMD) Zscore and potential risk factors was conducted using DXA and historical data. The main predictor of future BMD was the previous BMD Zscore (p < .001). Other factors found to be determinants of BMD included nutritional status, lung function (FEV1 ), age, history of previous fracture, oral corticosteroid use, and the number of hospital admissions. However, after adjusting for previous BMD, evidence of an association remained only with nutritional status, FEV1 , and number of hospital admissions. Second yearly scans may be unnecessary in children with an adequate DXA score on the initial scan who remain clinically stable. However, clinical deterioration in those whose BMD was previously normal, may require closer monitoring of bone health. We propose a guideline for the frequency of DXA monitoring in relation to clinical risk factors.

Medical and dental characteristics of children with chromosome 22q11.2 deletion syndrome at the Royal Children's Hospital, Melbourne.

Chromosome 22q11.2 deletion syndrome (22q11.2DS) is a multifaceted syndrome with a variable phenotype. Few studies have described the associated dental characteristics and their relationship with medical co-morbidities; and no Australian data exist. To determine the clinical manifestations and correlations between oral and medical conditions in children with 22q11.2DS. A retrospective observational study. Children genetically diagnosed with 22q11.2DS at the Royal Children's Hospital Melbourne were selected; their medical and dental characteristics were collated and analysed. The study population (n=57; mean age 11.5years, range 2-27years) experienced a range of medical conditions involving multiple medical systems; of whom 44 (77.2%) had caries experience, 7 (12.3%) developmentally missing teeth, and 31 (54.4%) developmental defects of enamel (DDE). Smaller proportions of primary teeth were affected by DDE in children with congenital heart disease (2.2% vs 9.7%; P=.02), and cardiac surgery (0.2% vs 9%; P=.001). Conversely, children with hypoparathyroidism (n=2) had significantly higher proportions of primary teeth affected by DDE (27.5% vs 4%; P=.02). Significant associations existed between medical conditions (congenital heart disease, history of cardiac surgery, and hypoparathyroidism) and primary dentition DDE in children with 22q11.2 DS.

Electronic Task Management System: A Pediatric Institution's Experience.

Electronic medical task management systems (ETMs) have been adopted in health care institutions to improve health care provider communication. ETMs allow for the requesting and resolution of nonurgent tasks between clinicians of all craft groups. Visibility, ability to provide close-loop feedback, and a digital trail of all decisions and responsible clinicians are key features of ETMs. An embedded ETM within an integrated electronic health record (EHR) was introduced to the Royal Children's Hospital Melbourne on April 30, 2016. The ETM is used hospital-wide for nonurgent tasks 24 hours a day. It facilitates communication of nonurgent tasks between clinical staff, with an associated designated timeframe in which the task needs to be completed (2, 4, and 8 hours). This study aims to examine the usage of the ETM at our institution since its inception. ETM usage data from the first 3 years of use (April 2016 to April 2019) were extracted from the EHR. Data collected included age of patient, date and time of task request, ward, unit, type of task, urgency of task, requestor role, and time to completion. A total of 136,481 tasks were placed via the ETM in the study period. There were approximately 125 tasks placed each day (24-hour period). The most common time of task placement was around 6:00 p.m. Task placement peaked at approximately 8 a.m., 2 p.m., and 9 p.m.-consistent with nursing shift change times. In total, 63.16% of tasks were placed outside business hours, indicating predominant usage for after-hours task communication. The ETM was most highly utilized by surgical units. The majority of tasks were ordered by nurses for medical staff to complete (97.01%). A significant proportion (98.79%) of tasks was marked as complete on the ETM, indicating closed-loop feedback after tasks were requested. An ETM function embedded in our EHR has been highly utilized in our institution since its introduction. It has multiple benefits for the clinician in the form of efficiencies in workflow and improvement in communication and also workflow management. By allowing collection, tracking, audit, and prioritization of tasks, it also provides a stream of actionable data for quality-improvement activities.

COVID-19 in health-care workers: Testing and outcomes at a Victorian tertiary children's hospital.

In this global pandemic, health-care workers are an invaluable resource.1 With the state of Victoria, Australia experiencing increasing numbers of COVID-19 cases, the proportion of affected health-care workers remains unclear; as is the source of infection.2 Health-care workers providing care to children are in a unique situation, primarily because children are less likely to acquire COVID-19 infection, show symptoms and have milder disease compared to adults.3 To date, children comprise 1891/12 335 (15%) of positive cases in Victoria with those <10 years being the lowest affected age group at 49 cases per 100 000.4 Specific efforts to minimise exposure to SARS-CoV-2 are critical to protect against nosocomial transmission and front-line health-care workers.5 The Royal Children's Hospital Melbourne implemented infection prevention and control strategies to reduce the risk of COVID-19 among staff. Individual focused strategies included access to supports such as a dedicated clinic with prioritised testing and result notification, a well-being programme and COVID-19 leave. Campus transmission reduction strategies included regular COVID-19 updates from hospital executive on use of personal protective equipment (PPE), access to appropriate PPE, daily staff temperature and symptom screening, supporting work from home, cohorting staff into teams and creating patient zones to reduce unnecessary interaction, as well as expedient internal contact tracing when appropriate. This study aimed to describe COVID-19 testing and infection in health-care workers at the Melbourne Children's Campus, encompassing Royal Children's Hospital Melbourne, Murdoch Children's Research Institute and University of Melbourne (Paediatrics) during the first 5 months of the pandemic. Health-care workers presenting for testing to the emergency department or the respiratory infection clinic were asked to complete a web-based questionnaire to report risk factors (defined as close contact with SARS-CoV-2 or overseas travel in the previous 14 days), symptoms and comorbidities. Institutional ethics approval was obtained. Health-care workers who underwent testing externally and informed the research team were included. Demographic data and SARS-CoV-2 test results were extracted from the hospital medical records. Descriptive data were presented as mean (standard deviation) for continuous variables and number (%) for categorical variables. Continuous variables were compared using t tests and mean differences presented; categorical variables were compared using χ2 test and risk differences presented. A two-sided α less than 0.05 was considered statistically significant. Over 5 months, 1964 health-care workers were tested for SARS-CoV-2 with 2796 tests performed (Table 1). There were 1387 (71%) who tested once, 322 (16%) tested twice and 255 (13%) tested three or more times. Of 2796 tests, 11 (0.4%) were positive, consistent with 11/1964 (0.6%) of healthcare-workers with COVID-19, nine of whom were clinical staff. Eight were aged under 50 years and none had comorbidities. During March/April, three of four staff with COVID-19 were returned travellers (Fig. 1). In May, a single case was detected during asymptomatic testing with no known risk factors. During June/July, five of six had no risk factors. The remaining health-care worker tested positive during asymptomatic testing of all staff in the neonatal unit, where a patient and two parents were infected. Nine staff recovered at home without hospital admission, with two still recovering. Seventy-three staff were placed into 14 days of quarantine following close contact with a SARS-CoV-2 positive patient or other staff member. This assessment of SARS-CoV-2 testing in a children's hospital, including a recent outbreak identified a low rate of infection in health-care workers. This is consistent with early data at our institution that showed a low proportion of children testing positive at <1%.6 Measures were taken when an outbreak was identified to reduce, contain and limit nosocomial infection including temporarily closing the neonatal unit to admissions (diverted to the paediatric intensive care unit), allocating single-rooms for all patients, widespread testing and furloughing of all potentially exposed staff. Our current positive test rate of 0.4% is similar to the overall Victorian rate (0.7%).7 Those affected recently were less likely to have a source identified despite contact tracing which reflects growing community transmission. Exposure to relatively few COVID-19 cases in children, together with measures currently in place support a safe environment for staff, patients and their families. Ongoing vigilance and a rapid response to evolving outbreaks, with strict adherence to the use of PPE, hand hygiene and physical distancing continue to be important with rising community case numbers. Ethics approval was obtained from the Royal Children's Hospital Human Research Ethics Committee (63013). LF Ibrahim is supported in part by a Melbourne Campus Clinician Scientist Fellowship. PA Bryant is in part supported by a National Health and Medical Research Council Investigator grant. FE Babl was supported in part by a National Health and Medical Research Council Practitioner Fellowship, Canberra, Australia.

Impact of Australian mandatory policies on immunisation services, parental attitudes to vaccination and vaccine uptake in a tertiary paediatric hospital

Abstract Introduction 'No Jab, No Play' and 'No Jab, No Pay' mandatory immunisation policies were introduced in the state of Victoria and Australia nationally in January 2016. They restrict access to childcare/kindergarten and family assistance payments respectively, for under-vaccinated children. We aimed to describe the proportion of attendees to immunisation services of a tertiary hospital, the Royal Children's Hospital Melbourne (RCH), who were motivated by the policies to discuss or catch up vaccination. We also explored the association between policy motivation, vaccine hesitancy (VH) and intent to seek medical exemption, with vaccine-uptake. Referrals to the Specialist Immunisation Clinic (SIC) were also reviewed. Methods Parents/Guardians and clinicians completed surveys October 2016-May 2017 from the nurse-led immunisation Drop in Centre (DIC) or physician-led SIC. Vaccine-uptake was measured using the Australian Immunisation Register at baseline, 1 and 7 months post-attendance. The association between vaccine-uptake, policy motivation and VH was explored by logistic regression. Results Of 607 children included, 393 (65%) were from the DIC and 214 (35%) SIC. 74 (12%) of parents were motivated by the policies to attend immunisation services and 19% were VH. Only 50% of VH parents planned to catch-up vaccination for enrolment to childcare/kindergarten. Fewer children were fully immunised at 7 months if their parents were VH (difference 18%; OR 0.24, CI 0.1-0.54,p&amp;lt;0.001) or seeking medical exemption (difference 33%, OR 0.08, CI 0.01-0.6, p 0.015). Conclusions The 'No Jab' policies motivated attendance to a tertiary immunisation service but children of vaccine hesitant parents and those seeking medical exemption to immunisation were less likely to be fully immunised post attendance, compared to baseline. These data will be used to inform a comprehensive evaluation of the impact of the policies, particularly the educational impact from loss of early childhood education.

Transfer of patients from a regional centre to a tertiary paediatric hospital for acute otolaryngology management: When is it necessary?

Transfer of patients from a regional to a tertiary paediatric facility is sometimes required for management of otolaryngological conditions when the expertise available locally is insufficient to deal with the complexity of the case. A retrospective analysis was carried out over a 3-year period of all patients under 18 years of age who were transferred to the Royal Children's Hospital Melbourne, primarily for otolaryngology management, from a regional hospital with an inpatient paediatric service and located 100 km or far from the Royal Children's Hospital. Thirty-nine patients (30 male, 9 female) were identified. The majority of patients (29, 74%) required surgical management, with the most common procedures being rigid bronchoscopy with or without foreign body removal (7 patients, 24%), drainage of deep neck space infection (7 patients, 24%) and bilateral choanal atresia repair (4 patients, 13%). Notwithstanding the cost and inconvenience, transfer was necessary in essentially all cases in this study for either specialist surgical management or medical management of conditions that could have otherwise escalated in acuity. By inference, it would appear that most routine acute paediatric otolaryngology conditions are managed successfully in a regional setting.

Simulation-Based Education for Staff Managing Aggression and Externalizing Behaviors in Children With Autism Spectrum Disorder in the Hospital Setting: Pilot and Feasibility Study Protocol for a Cluster Randomized Controlled Trial.

BackgroundChildren with autism spectrum disorder (ASD) frequently demonstrate aggression and externalizing behaviors in the acute care hospital environment. Pediatric acute care nursing staff are often not trained in managing aggression and, in particular, lack confidence in preventing and managing externalizing behaviors in children with ASD. High-fidelity simulation exercises will be used in this study to provide deliberate practice for acute care pediatric nursing staff in the management of aggressive and externalizing behaviors.ObjectiveThe purpose of this study is to conduct a pilot and feasibility cluster randomized controlled trial (RCT) to evaluate the effectiveness of simulation-based education for staff in managing aggression and externalizing behaviors of children with ASD in the hospital setting.MethodsThis study has a mixed design, with between-group and within-participant comparisons to explore the acceptability and feasibility of delivering a large-scale cluster RCT. The trial process, including recruitment, completion rates, contamination, and completion of outcome measures, will be assessed and reported as percentages. This study will assess the acceptability of the simulation-based training format for two scenarios involving an adolescent with autism, with or without intellectual disability, who displays aggressive and externalizing behaviors and the resulting change in confidence in managing clinical aggression. Two pediatric wards of similar size and patient complexity will be selected to participate in the study; they will be randomized to receive either simulation-based education plus web-based educational materials or the web-based educational materials only. Change in confidence will be assessed using pre- and posttraining surveys for bedside nursing staff exposed to the training and the control group who will receive the web-based training materials. Knowledge retention 3 months posttraining, as well as continued confidence and exposure to clinical aggression, will be assessed via surveys. Changes in confidence and competence will be compared statistically with the chi-square test using before-and-after data to compare the proportion of those who have high confidence between the two arms at baseline and at follow-up. The simulation-based education will be recorded with trained assessors reviewing participants’ abilities to de-escalate aggressive behaviors using a validated tool. This data will be analyzed using mean values and SDs to understand the variation in performance of individuals who undertake the training. Data from each participating ward will be collected during each shift for the duration of the study to assess the number of aggressive incidents and successful de-escalation for patients with ASD. Total change in Code Grey activations will also be assessed, with both datasets analyzed using descriptive statistics.ResultsThis study gained ethical approval from The Royal Children's Hospital Melbourne Human Research Ethics Committee (HREC) on November 1, 2019 (HREC reference number: 56684). Data collection was completed in February 2020. Data analysis is due to commence with results anticipated by August 2020.ConclusionsWe hypothesize that this study is feasible to be conducted as a cluster RCT and that simulation-based training will be acceptable for acute care pediatric nurses. We anticipate that the intervention ward will have increased confidence in managing clinical aggression in children with ASD immediately and up to 3 months posttraining.Trial RegistrationAustralian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000139976; http://www.ANZCTR.org.au/ACTRN12620000139976.aspxInternational Registered Report Identifier (IRRID)DERR1-10.2196/18105

Nutritional challenges in children with primary immunodeficiencies undergoing hematopoietic stem cell transplant.

Nutritional profile and management of patients with primary immunodeficiencies (PID) undergoing hematopoietic stem cell transplant (HSCT) has not been described in the literature. We aim to report the nutritional challenges and practices peculiar to this population before and after HSCT and suggest clinical pathways for their management. We conducted a single-centre retrospective study. Inclusion criteria were children aged less than 20 years with a diagnosis of PID who have undergone HSCT at the Royal Children's Hospital Melbourne since April 2014 with a minimal follow-up of 1 year. Nutritional parameters were collected in the pre-transplant period, at conditioning, and at 1, 3, 6 and 12 months post-HSCT. Descriptive analysis were used. Between April 2014 and December 2018, 27 children received 31 HSCT. Before transplant, 33% had a weight and/or height ≤-2 standard deviations (SD). Forty percent required nutritional support before transplant: 33% had enteral nutrition (EN) while 7% required long-term parenteral nutrition (PN) due to intestinal failure. After transplant, although most children were started on EN, 82% required PN with a mean duration of 67 days. Mean time to full oral diet was 154 days. Pre-transplant mean weight and height were-0.57 SD and-0.88 SD respectively. After a decrease in anthropometric parameters the first 3 months post-transplant, progressive catch up was noticeable for weight (-0.27 SD) with no catch up for height at 1 year (-0.93 SD). Our work highlights the nutritional challenges and specificities of children with PID in the peri-transplant period. An approach to nutrition assessment and management in the pre- and post-transplant period is proposed.

Thoracostomy in children with severe trauma: An overview of the paediatric experience in Victoria, Australia.

Thoracic trauma is a leading cause of paediatric trauma deaths. Traumatic cardiac arrest, tension pneumothorax and massive haemothorax are life-threatening conditions requiring emergency and definitive pleural decompression. In adults, thoracostomy is increasingly preferred over needle thoracocentesis for emergency pleural decompression. The present study reports on the early experience of thoracostomy in children, to inform debate regarding the best approach for emergency pleural compression in paediatric trauma. Retrospective review of Ambulance Victoria and The Royal Children's Hospital Melbourne, Trauma Registry between August 2016 and February 2019 to identify children undergoing thoracostomy for trauma, either pre-hospital or in the ED. Fourteen children aged 1.2-15 years underwent 23 thoracostomy procedures over the 31 month period. The majority of patients sustained transport-related injuries, and underwent thoracostomies for the primary indications of hypoxia and hypotension. Two children were in traumatic cardiac arrest. Ten children underwent needle thoracocentesis prior to thoracostomy, but all required thoracostomy to achieve the necessary definitive decompression. All patients were severely injured with multiple-associated serious injuries and median Injury Severity Score 35.5 (17-75), three of whom died from their injuries. Thoracostomy in our cohort had a low complication rate. In severely injured children, thoracostomy is an effective and reliable method to achieve emergency pleural decompression, including in the young child. The technical challenges presented by children are real, but can be addressed by training to support a low complication rate. We recommend thoracostomy over needle thoracocentesis as the first-line intervention in children with traumatic cardiac arrest, tension pneumothorax and massive haemothorax. [Correction added on 23 September 2019 after first online publication: in the second sentence of the conclusion, the words "under review process" were mistakenly added and have been removed.].

Mycobacteria-Specific Mono- and Polyfunctional CD4+ T Cell Profiles in Children With Latent and Active Tuberculosis: A Prospective Proof-of-Concept Study.

Background: Current immune-based TB tests, including the tuberculin skin test (TST) and interferon-gamma release assays (IGRA), have significant limitations, including the inability to distinguish between latent TB infection (LTBI) and active TB. Few biomarkers with the potential to discriminate between these two infection states have been identified.Objective: To determine whether functional profiling of mycobacteria-specific T cells can distinguish between TB-infected and -uninfected children, and simultaneously discriminate between LTBI and active TB.Methods: One hundred and forty-nine children with suspected active TB or risk factors for LTBI were recruited at the Royal Children's Hospital Melbourne. Whole-blood stimulation assays, using ESAT-6, CFP-10, PPD, and heat-killed M. tuberculosis as stimulants, were done, followed by intracellular cytokine staining and flow cytometric analysis.Results: Eighty-two participants in the well-defined diagnostic categories ‘uninfected individuals’ (asymptomatic, TST 0 mm / IGRA-; n = 61), LTBI (asymptomatic, TST ≥10 mm / IGRA+, normal chest radiograph; n = 15), or active TB [microbiologically-confirmed (n = 3) or fulfilling stringent criteria (n = 3)] were included in the final analysis. The proportions of mycobacteria-specific single-positive TNF-α+ and double-positive IFN-γ+/TNF-α+ CD4+ T cells were significantly higher in participants with active TB than in those with LTBI and uninfected individuals. Additionally, the frequency of IL-17-expressing CD4+ T cells, predominately with single-positive IL-17+ and double-positive IL-2+/IL-17+ phenotypes, was higher in participants with active TB than in the other two groups.Conclusions: The frequencies and functional profiles of mycobacteria-specific CD4+ T cells differ significantly both between TB-infected and TB-uninfected children, and between LTBI and active TB. Although confirmation in further studies will be required, these findings indicate that functional profiling of mycobacteria-specific CD4+ T cells could potentially be exploited for novel immune-based TB assays that enable the distinction between infection states based on a blood sample alone.