Research 2021 Research 2021 Diploma of Child Health Dr Geraldine Lagani Paediatric referrals from Gerehu Hospital Dr Shedrick Wadigi Child injuries in Angau Hospital Dr Dorothy Namba Antibiotic audit in Mt Hagen Master of Medicine Dr Mathilda Aloich Polio vaccine in Sandaun Province Dr Tina Yarong Knowledge and Perceptions of HIV among parents in Port Moresby Dr Andree Zumanu Intravenous cannula complications in children at Port Moresby Hospital Dr Anna Toti Birth defects in Rabaul Dr Winnie Sadua Thiamine status of malnourished children in Port Moresby

CME Continuing Medical Education Q&A 2018 2017 2016 2015 Because Every Child Counts

PHR Reports Paediatric Hospital Reporting Annual Child Morbidity and Mortality Reports The National Health Department’s Child Health Advisory Committee has produced an Annual Morbidity & Mortality Report since 2010. These reports summarise paediatric admissions and outcomes in hospitals in PNG. The reports contain important clinical and public health recommendations for improving child health. Disease Surveillance Case Reporting Forms The World Health Organisation declared Papua New Guinea free of polio and leprosy in 2000. However surveillance is still essential for polio and for other diseases. PNG has a program for reporting of acute flaccid paralysis (for polio surveillance), and acute fever and rash (for measles and rubella surveillance). Reporting forms for these and other notifiable diseases can be downloaded here. Reporting of these diseases requires that health workers know how to identify a suggestive clinical syndrome and take the appropriate test to confirm or exclude the diseases under surveillance. PNG also has surveillance for rheumatic fever and rheumatic heart disease, and severe acute watery diarrhoea (to identify cholera outbreaks). Stronger Communities Begin with Healthier Children

Research 2017 Research 2017 Diploma of Child Health Andree Zamunu Antibiotics for the common cold in Popendetta DCH 2017 In Popendetta, antibiotic prescribing for children with a common cold or minor upper respiratory tract infection was common, occurring in 82% of 108 cases. Children under the age of 1 year, and those with symptoms longer than 5 days were more likely to be inappropriately prescribed antibiotics. When health workers prescribed antibiotics for the common cold they were less likely to give basic symptomatic advice. Annette Garae The spectrum of paediatric cardiac disease in Vanuatu DCH 2017 In Vanuatu, 212 children with congenital (166) and rheumatic heart disease (44) were identified between 2010 and 2016. Through a collaboration with New Zealand 61 children underwent surgery in Auckland, with 60 survivors. 20% of the 212 children were on conservative care, many because of inoperable severe pulmonary hypertension from left to right shunts. 12% of the 212 had been lost to follow-up. Justin Kali Adoption and Feeding Practices among children in Southern Highlands DCH 2017 In Mendi Hospital and rural health facilities in Southern Highlands, 85 adopted children were identified. 61 were subject of customary adoption, 24 infants were bought, and there were no legal adoptions. Most mothers had no knowledge of legal adoption practices, or of appropriate infant feeding practices, and 53 (62%) were adopted in the neonatal period. Nearly half of the adoptive mothers had no formal education. Merlisa Birth asphyxia in Goroka DCH 2017 In Goroka over 6 months 52 babies with birth asphyxia were identified, with an incidence of 2.4%. They had a case fatality rate of 23%. 67% were delivered by midwives and in 58% of cases no partograph was used. The major predictor of death was a low Apgar score at 5 minutes (Apgar of 5 or less). Rachel Masta Malnutrition in Kimbe DCH 2017 In Kimbe, the parents of 20 children with severe malnutrition were interviewed to explore the diversity of the diet given to their children. While most children ate carbohydrates and vitamin A containing food daily, more than half of these children did not have a daily source of protein or other vitamins, and more than half did not have a weekly source of calcium in their diets. Rhondi Kauna Oral Rehydration and outpatient treatment of moderate dehydration DCH 2017 Among 129 children with gastroenteritis and moderate dehydration monitored in the children’s emergency department at PMGH, 63 tolerated oral rehydration and zinc well, taking 25ml/kg of ORS over 2¼ hour of observation without vomiting. All these children recovered with home treatment, and 97% of mothers understood how to give ORS. Of the 66 children who did not tolerate ORS under observation in the CED, all improved with half-strength Darrow’s solution. Outpatient management of children with gastroenteritis and moderate dehydration is safe as long as appropriate safeguards are in place: particularly that the family can access the hospital 24 hours a day, the child has 2-4 hours of observation in ED and tolerates 25-40ml/kg ORS and oral zinc without vomiting, parent education is provided on danger signs and when to return, and the child can be reviewed on day 2. Venao Seta Bempu bracelet and hypothermia DCH 2017 Among 97 low birth weight babies monitored with the new Bempu wrist bracelet, which is designed to detect neonatal hypothermia, 6 hourly temperatures were taken by thermometer 1491 times. On 124 occasions the babies temperature was measured by thermometer as <36 C. On 102 of these 124 occasions that the neonate had hypothermia the Bempu bracelet had an orange alarm, with a sensitivity (true positive) rate of 82%. All the Bempu bracelets lasted the expected life of 4 weeks, there was a high alert for hypothermia and prompt actions, including swaddling and skin-to-skin warming. Illiterate mothers were able to recognise hypothermia with use of band. The study is ongoing. Master of Medicine Diana Olita’a Minimal antibiotics in PROM MMed 2017 Among 133 well babies born at term after prolonged rupture of membranes, with a minimal or no antibiotic treatment approach, any signs of sepsis occurred in only 10 (7.5%) in the first week of life, and an additional 3 between 8 and 28 days. There was only one case of proven bacteraemia, and no deaths. Most of the suspected sepsis cases were a transient fever or skin pustules. Minimal use of antibiotics in PROM in well term babies is safe as long as safeguards are in place to monitor for signs of sepsis. In this study nearly 90% of newborns avoided antibiotic exposure and went home at 48-72 hours. This approach can protect against adverse consequences of antibiotics, including overgrowth with resistant organisms and wheezing. Janella Solomon Malnutrition in Honiara MMed 2017 At the National Referral Hospital in Honiara, 62 of 144 children admitted in a 3 month period had some degree of malnutrition. Of the 62, 27% had severe acute malnutrition, 30% had moderate acute malnutrition, 18% had chronic severe malnutrition and 16% had moderate chronic malnutrition. Only 4 children with malnutrition died (CFR 6.5%), after a major campaign to improve the management of malnutrition at NRH, with training, guidelines, monitoring and audit. Kunera Kiromat JE virus and quality of care for children with encephalopathy in PMGH MMed 2017 Among 97 children with febrile encephalopathy, 5 had Japanese encephalitis, 5 had Dengue, 6 had meningitis due to Streptococcus pneumonia, 1 had meningitis due to Haemophilus influenzae, 6 had malaria, and 19 had suspected tuberculous meningitis. Many aspects of supportive care for children with febrile encephalopathy were frequently not done, including monitoring of blood pressure, blood glucose, anticonvulsant therapy, pupillary assessment and recording, and head elevation to reduce intracranial pressure and prevent aspiration. Other aspects of supportive care were done in more than half the cases, but there was still scope to improve on oxygen administration, Glasgow Coma Score monitoring, recording weight, basic vital signs and providing enteral nutrition. Rose Morre Outpatient treatment of moderate peumonia MMed 2017 Among 120 children assessed as having moderate pneumonia at PMGH, outpatient treatment was successful in 92%. 3 patients were recognised as having clinical signs of severe pneumonia on day 1, and admitted. 117 were treated as outpatients with a single dose of benzylpenicillin, followed by oral amoxicillin for 5 days. Three children were admitted on day 2 with signs of severe pneumonia, and on day 6, 2 children were admitted for non-pneumonia causes. In total 15 children were lost to follow-up. 97 children were cured by day 6. There were no deaths. This study shows that outpatient treatment of moderate pneumonia is safe and effective, as long as safeguards are in place. These include: excluding high risk patients (HIV, neonates), checking for danger signs and hypoxaemia using pulse oximetry, a protocol for education of mothers, including teaching about danger signs and when to return (use structured teaching materials and video), and follow-up and reassessment if a child is not improving to detect undiagnosed conditions which may look like moderate pneumonia (TB, congenital heart disease, HIV). Steven Lumasa PHR in Honiara MMed 2017 Using the Paediatric Hospital Reporting Program as a tool, the case mix and epidemiology of children admitted to Honiara National Referral Hospital was identified. The study identified the more complex diagnoses not summarised in the summary sheet of the PHR, including the different types of TB, the types of cancer, the different types of neonatal sepsis and congenital malformations, and the comorbidities associated with severe malnutrition (anaemia, infectious complications, and underlying chronic conditions). Key findings included: 25% of all admissions were readmissions, suggesting many children have chronic conditions; the highest CFR was for sepsis in older children (63% died); and just over half the childhood cancers did not receive a proper diagnosis of the cancer type. Temane Korowi Neonatal epidemiology in Goroka MMed 2017 In a retrospective study describing 5 years of neonatal admissions at Goroka General Hospital, there were over 5176 admissions, of which 82% were born in hospital, 4% in health centres and 14% at home. The overall neonatal mortality rates was 9.7%, and annual CFRs were 8.07% to 13.1%. The highest causes of mortality were low birth weight, birth asphyxia and meconium aspiration syndrome, and neonatal sepsis. In a multivariate regression the significant independent predictors of neonatal death were LBW, health centre birth and village birth. Babies born in HCs and in villages who are referred to EHPH have higher mortality rates than hospital delivered babies who are admitted to NNU, partly because of referral bias (sicker babies are referred). Bardley Ludawane RHD in Solomon Islands MMed 2017 In a qualitative study of children and adolescents with Rheumatic Heart Disease, the understanding of RDH was explored. Many adolescents knew that RHD affected their heart, and that they needed regular injections, but knowledge among affected patients was often limited. Parents of these children knew they had some sort heart problem, and thought that treatment would make their child better. They showed a sense of trust in doctors, and had a fear of their child missing injections. Because of recent adverse events related to benzathine penicillin injection, and difficulties with syringes being obstructed by powder if not shaken adequately, some clinic health workers were reluctant to give injections. This is a challenge for the RHD program in Solomon.

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Research 2019 Research 2019 Master of Medicine Dr Rupert Marcus Congenital malformations among 1000 consecutive live births in Milne Bay Province Background: Birth defects contribute 7-10% to neonatal mortality, worldwide 2.3 million children survive each year with lifelong disabilities from birth defects and 90% of birth defects occur in developing nations. Data on birth defects from developing countries such as Papua New Guinea are scarce. We describe the profile of birth defects seen in a birth cohort in a provincial hospital in Papua New Guinea. Aim: To describe the specific types of birth defects in the cohort, to identify possible risk factors, and to direct prevention measures. Methods: Between February and August of 2018, one thousand consecutive babies born alive were assessed for birth defects at Milne Bay Provincial Hospital. Cases were identified and described by the use of the World Health Organization Classification of Disease (ICD-9). Controls were compared with cases utilizing pretested questionnaires. Results: In this study the incidence of birth defect was 28/1000 live births. Defects of the nervous system was most common with 17.9% of cases followed by cardiovascular, genitourinary, ENT and musculoskeletal defects which all comprised 14.3% each. Some characteristics were more represented in cases compared to controls, including maternal age <19 years (OR: 11.9), maternal smoking (OR: 3.8) and lack of folate supplements (OR: 3.5), however, in this relatively small sample of birth defects these were not statistically significant. Conclusion: Birth defects will increasingly play a major part in child mortality and morbidity in developing nations such as Papua New Guinea. Strategies in family planning, adolescent health, maternal health care and folate supplementation/fortification appear important in Papua New Guinea. Dr Allanie Rero Child neglect in Modilon Hospital, Madang – incidence and characteristics Neglect is an important form of child maltreatment which can result in death or permanent poor health throughout life. For the purpose of this study, child neglect was defined when a child’s basic developmental and health needs have not been met by acts of omission by parents or guardians, leading to ill health and hospitalization. Between March 2017 and December 2017 there were 231 patients admitted to the Paediatric ward, 91 of whom fulfilled the definition of neglect. From those that had been neglected in some way 30 (33%) of children were adopted compared to 3 (3.3%) of controls, bottle fed 21 (23.1%) compared to (4.4%), unvaccinated 41 (45%) from 17 (18.7%) respectively. Among the children who had been neglected, severe acute malnutrition 42 (46.2%), followed by tuberculosis 26 (28.6%) and acute gastroenteritis 12 (13.2%), were the leading causes of hospital admissions, while malaria, pneumonia and anaemia were the leading causes in the controls. Mortality was high in the neglected group with a case facility rate of 23%, with severe acute malnutrition accounting for 9 of the 21 deaths (43%). Associated with child neglect were financial stress 25 (28%), parental issues 23 (25%), uneducated parents 15 (17%), closely spaced pregnancies 13 (14.3%), domestic violence 4 (4.4%) and a child with disability 3 (3.3%). Diploma of Child Health Dr Dasha Pomat Management of severe pneumonia in Nonga Base Hospital, a systematic audit In PNG pneumonia remains the most common cause of admission in children with CFR of 9.62% in 2018 for severe pneumonia. This systemic audit was aimed at identifying where care is adequate and where it is lacking and needs improvement in the current management practices of severe pneumonia in Nonga General Hospital, East New Britain Province. The objective of the study was to audit the clinical standard of practice of the management of severe pneumonia in children aged 1 month to 59 months, using a proforma checklist of clinical standards outlined by the Paediatric Society of PNG and the WHO. Dr Clyde Kamo Child death audit meetings at Mt Hagen General Hospital – processes and outcomes Auditing is a vital tool to improve quality of any endeavour. Good auditing with regard to death auditing and reviews depends on the availability of updated credible records, a standard widely accepted auditing protocol and the objective to make adjustments and needed changes to ultimately improve patient care. Over 5 months, the paediatric team in Western Highland Provincial Health Authority has been carrying out monthly death reviews based on the WHO death reporting forms with the aim of identifying common avoidable modifiable causes of deaths. Strategies can then be put in place to improve these factors. This paper looks at the effects of establishing a regular death auditing program and the implications it has for the future care of paediatric patients. Dr Maxon Lifigao Congenital syphilis at National Referral Hospital in Honiara, Solomon Islands This presentation discusses the incidence and clinical features of congenital syphilis, and the incidence of mothers who are VDRL positive delivering at the National Referral Hospital in Honiara, Solomon Islands. In Honiara in 2018-19 of 1535 live births: 130 (8.5%) mothers were VDRL positive; 72 babies (4.7%) babies were VDRL positive; 67 (4.3%) babies were TPHA positive; 7 (0.5%) babies had clinical features of congenital syphilis. The rates doesn’t take into account still births, which are likely to have higher VDRL positive rate. Dr Wilma Luan-Kasso Kangaroo Mother Care amongst preterm newborns in Modilon General Hospital, Madang Kangaroo Mother Care (KMC) was introduced to Modilon General Hospital in 2015 but there were many implementation challenges due to limited resources and a limited level of a supportive and enabling environment. Aim: To assess the impact of intermittent KMC on preterm/low birth weight neonates on discharge outcomes. Methods: This prospective observational study included educational sessions for special-care-nursery staff and mothers about KMC. This was followed by an assessment provided on the care of 38 neonates with birth weights between 1200-2000 grams who received intermittent KMC. Results: Overall, 84% were preterm with 83.3% of the newborns delivered at health facilities with hypothermia on admission. KMC hours ranged from 0-8 hours per day. More than half absconded/leaving hospital against medical advice and 72.7% and 41.7% had weight gains of <5 grams/kg/day and 10 grams/kg/day, respectively. Conclusion: Early essential newborn care practices for preterm/low birth weight newborn and an enabling supportive environment and resources for both the health care worker and mother/career would improve the implementation of intermittent KMC.

2022 - Weekly Paediatric Lectures 2022 – Weekly Paediatric Lectures Paediatric training overview and how to learn https://youtu.be/MzbUAiWAopo 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 https://youtu.be/WAP7soFUK6g 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 https://youtu.be/44Iaw79ktZU 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 https://youtu.be/Z3q85tj5zVw 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 https://youtu.be/UIEIiCBlSdI 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 https://youtu.be/LCL5wJEFeEo 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 https://youtu.be/rhiUQQFbpCI 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 https://youtu.be/6i37wZV1SVo 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 https://youtu.be/QN5vHMKXzMw 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 https://youtu.be/SSBU5XcrHqo 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 https://youtu.be/II2C6KV2BPs 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 https://youtu.be/LV-tib4RQJg 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 https://youtu.be/rzlfrFFdyNc 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 https://youtu.be/ROiuFhpnPpQ 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 https://youtu.be/Iw7pDHKo_BE 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 https://youtu.be/Hm5TyQ8GmwI 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): https://youtu.be/Ra_eq54-7TY https://youtu.be/h8mQbv1bH1Q 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.

Paediatric Teaching Resources Paediatric Teaching Resources Below are the links to some good teaching videos about clinical history taking and examination for different systems, and some procedures. They are all freely available from the Internet, and the sources are acknowledged. Thanks to Dr Paulus Ripa and others for finding these. Gastrointestinal assessment https://www.youtube.com/watch?v=932E4B9UApg&t=103s https://www.youtube.com/watch?v=oJ1CsJJHZCQ https://www.youtube.com/watch?v=H0e8XkYe7uQ&t=47s Respiratory assessment https://www.youtube.com/watch?v=gcS7RS8pXqs https://www.youtube.com/watch?v=gcS7RS8pXqs&t=11s https://www.youtube.com/watch?v=rKgbIEPYqQ8&t=44s Cardiovascular assessment https://www.youtube.com/watch?v=Mu0C_of6Aw0 https://www.youtube.com/watch?v=hTClmf8egGM&t=343s https://www.youtube.com/watch?v=y-n6MWmT1YA Neurological assessment https://www.youtube.com/watch?v=_XTY8YYhkGU https://www.youtube.com/watch?v=HDDVqEa_MpY How to perform a lumbar puncture This is an excellent video from Dr Osama Naga on how to safely perform an LP and how to interpret the CSF findings. https://youtu.be/Md4Bp4HD5xE Developmental assessment https://www.youtube.com/watch?v=RfemPAlDzN4 https://www.youtube.com/watch?v=ThNsIohZzAY&t=208s https://www.youtube.com/watch?v=nxvAaQm659M Airway videos by Sydney intensive care ambulance officers (input the same password to watch each video: “AiRblogVideos”) https://sydneyhems.com/airway-registry/cmac-videos/

Research 2018 Research 2018 Diploma of Child Health Benjamin Daur Outcomes of paediatric cancer in PNG DCH 2018 At Port Moresby General Hospital, between 2016 and 2018, 61 children with cancer were diagnosed. The mean time of diagnosis from first symptoms was 8 months, and the mean time from presentation to diagnosis was 9 days. Compared with earlier studies from 1998-2001 there has been an increase in retinoblastoma diagnoses and a decrease in the number of children diagnosed with lymphoma. The late presentation is a concern, and messages need to get out to health workers about the signs that could indicate childhood cancer: severe pallor, a lump, swelling of the abdomen, easy bleeding and progressive malnutrition. For retinoblastoma the early signs are leukocoria (white pupillary reflex), strabismus (squint) and eye inflammation or swelling which does not resolve with antibiotics. Heagi Lovai Waiting times in children’s emergency department PMGH DCH 2018 At Port Moresby General Hospital Children’s Emergency Department waiting times for 164 patients was assessed. A 5-tier Australasian Triage classification is used, but there is not consistency of classification between health care workers. Average overall waiting time was 119 mins; 96% of patients in category 1 (the most severe) and category 2 waited longer than specified by the Australasian Triage criteria. There is a need to use a Triage classification system that is easy to understand, such as WHO’s triage system (Emergency signs, Priority signs, or none of the above), and a need to improve staffing in the children’s emergency department, including more nurses and specialist paediatric cover to support the registrars. Rose Hosea Care seeking Behaviour in Mendi DCH 2018 In Mendi, care seeking behaviour of the parents of 100 children requiring admission with pneumonia (53), diarrhoea (43) or both (4) was assessed. 70% of the patients were infants. Many parents sought hospital treatment more than 24 hours after onset of illness despite residing within an hour of the hospital. Most parents who delayed care did so thinking that the symptoms were not serious, and waited at home for them to subside. The presence of more than one symptom of illness seemed to be a motivating factor to seek care, parents understanding that this indicates increased severity of illness. Some parents had false beliefs about the cause of diarrhoea, believing it was normal phase in child development, rather than an infection or illness. Gordon Pukai RCT of Nebulised saline in bronchioitis DCH 2018 In a randomised trial in the Port Moresby General Hospital Emergency Department, children under 2 years of age with clinical bronchiolitis were given either nebulisation with normal saline (x 3 over 4 hours) in addition to standard treatment (oxygen if SpO2<90%, antibiotics, minimal handling), or standard treatment alone. A change in Respiratory Distress Score, hypoxaemia and admission were the main outcomes. The 2 groups were similar to begin with in terms of RDS and oxygen saturation. There was a significant difference in the change in RDS at 4 hours between the 2 groups. Among the 100 that received nebulised Normal saline, the mean RDS fell by 3.41 (95% CI 3.0-3.8), whereas in the Standard group the RDS fell by only 1.96 (95% CI 1.5-2.4). P-value <0.0001. There was a significant difference in the change in SpO2 between the 2 groups. Among the 99 children who received standard therapy the SpO2 increased by 4% (95% CI 2.8-5.2) to a mean SpO2 of 87.5% at 4 hours, and among the 100 who received normal saline the SpO2 increased by 7% (6.0-7.9) to a mean SpO2 of 90.7% at 4 hours. There was a significantly higher discharge rate in those who received Normal saline. 58 of 100 (58%) were discharged, whereas only 24 of 99 (24.2%) who received Standard care were discharged (p<0.001). Master of Medicine Maylin Kariko Follow-up of LBW babies at PMGH MMed 2018 A follow-up study was conducted for 81 low birth weight babies recruited from the Special Care Nursery at Port Moresby General Hospital. The mean birth weight was 1495 g, and the mean gestational age was 34 weeks, meaning these LBW babies were significantly small for gestational age, as well as being preterm. The median length of stay was 19 days, and the discharge weight was 1.54kg. There were 16 known deaths: 13 while in hospital and 3 after discharge. Many infants were lost to follow up. 39 were followed up at a median of 9 months chronological age. The majority of these babies followed up were well nourished with a weight-for-length z-score of -0.3, and most had good head growth (40th centile). 47% had some degree of gross motor developmental delay, although it is too early to be sure. 15 (38%) were admitted to the children’s ward during the period of follow-up, mostly for respiratory and gastrointestinal infections, which highlights the increased vulnerability to community acquired infections in this population. Paul Wari Early infant diagnosis of HIV at PMGH MMed 2018 A descriptive study was done to assess the outcomes of children exposed to HIV in the Prevention of Parent to Child Transmission Programme at the Well Baby Clinic, of Port Moresby General Hospital. 135 children were followed. All received zidovudine for the first 6 weeks of life, and 118 received nevirapine. 58 were exclusively breast fed, 25 formula fed, 40 mixed fed, and in 12 the feeding method was unascertained. 95 received isoniazid prophylactic therapy. 14 (10%) had a positive HIV-PCR test at 6-8 weeks of age. Two thirds (90/135) did not have any follow-up testing at 6 or 18 months and nearly 2/3 were lost to follow-up by 18 months (85/135). 6 were known to have died. There has been a deterioration in PPTCT and HIV services for children since the loss of funding and coordination by the CHAI PNG, leading to high rates of loss to follow up and inadequate testing being done. Vela Solomon MDR TB at PMGH MMed 2018 50 children with multi-drug resistant TB were described at Port Moresby General Hospital. The numbers of children diagnosed from 2004 have increased each year. These children came from National Capital District, Central and Gulf Provinces, and Daru. 38 (76%) had previously undergone treatment for drug-sensitive TB, and 31 had completed this treatment. A contact source for drug-resistant TB was identified in 25 children, and in 10 children the contact was the child’s mother. The median length of illness until diagnosis was 7 months, but many children had received multiple courses of DS TB and other treatments, either complete or partial. 35 children had confirmation of rifampicin resistance on GeneXpert testing, and 15 were diagnosed on clinical grounds alone. 16 were TB culture positive, and drug resistance patterns were identified in 15 of these. Veronica Kalit Rheumatic Heart Disease study MMed 2018 48 children with rheumatic heart disease (RHD) were involved in a longitudinal cohort study, using quantitative and qualitative methods to understand their and their family’s perceptions of their condition, and secondary prophylaxis. These children had quite severe RHD, with 31 having moderate-severe mitral regurgitation, 20 having moderate-severe aortic regurgitation, and 31 on anti-heart failure medications. There were 4 deaths in the follow-up period, including 2 sudden deaths immediately after injections of benzathine penicillin in children with severe heart failure. The deaths lead to a change in secondary prophylaxis at Port Moresby General Hospital: from predominantly benzathine penicillin to daily oral penicillin V. Elizabeth Longa Anaemia in children in Kimbe MMed 2018 In Kimbe 214 children with anaemia (median Hb 6.72 g/dL) were studied. 14 children had a history of chronic illness, including pulmonary tuberculosis (6 cases previously diagnosed), HIV, hypothyroidism and cerebral palsy (1 each). Rapid diagnostic tests for malaria were done in 213 children: 133 were negative, 33 were positive for plasmodium falciparum, 43 were mixed, and 4 were plasmodium vivax 179 children were followed up and had a repeat Hb 5 months after first presentation. The mean change in Hb for the 179 children was 4.07 (SD 2.51) g/dL. Five children died from malignancies (AML and retinoblastoma), severe malaria, HIV and severe malnutrition and meningitis. The mortality rate for severe anaemia can be low if Standard Treatment is followed and comorbidities are identified and treated. Casparia Mond Epilepsy in children in NCD MMed 2018 47 children with epilepsy were studied over nearly 2 years at Port Moresby General Hospital, the median age of the children was 6.5 years. 21 (45%) had normal development, and 26 (55%) had some developmental delay. Most children had generalised tonic-clonic seizures or complex partial seizures. Over 20 months of close follow up and adjustment of medications the proportion of children with good control (less than 4 seizures per month) increased (73% at baseline and 92% good control at 20 months), and the proportion with very poor control decreased. Frequent stock-outs of phenobarbitone, lack of reliable availability of alternative anti-epileptic drugs (sodium valproate, carbamazepine, phenytoin), and financial challenges faced by parents effected the child’s seizure control. For the children with epilepsy stigma and discrimination affected the quality of their lives, but many had strong ambitions to do well in school and get good jobs in the future.

Registrars Registrars MMED and Diploma of Child Health Program Post-graduate paediatric training for doctors is conducted by the School of Medicine and Health Sciences at the University of PNG. Doctors who have completed 2 years post-residency (working as a service registrar) begin by doing a one-year Diploma of Child Health (DCH). This can be done from any hospital in the country that has a paediatrician who can provide supervision. The Master of Medicine in paediatrics is a 4 year course, in addition to the DCH year, during which trainees work as paediatric registrars. The course includes the Part I examination process, one year of a research project, and at least one year working at Port Moresby General Hospital. More details on the Diploma of Child Health and the Master of Medicine can be downloaded at: UPNG Post graduate curriculum DCH and MMed in Paediatrics Keep a log book of your training Paediatric cases log-book 2021 This log-book is designed to be used throughout the 5 years of paediatric training, commencing in the DCH year. Trainees should record details of procedures learnt and practiced, cases managed, courses attended, and research projects. Along with the curriculum, the log-book can guide trainees in the skills and knowledge required to be a paediatrician in PNG. Supervisors should review this log-book as part of regular supervision. How to do a DCH and MMed project and write a minor thesis How to do a research project and write a minor thesis ADC 2018 This paper describes the steps in conducting a Diploma or Masters research project and writing up a project report (a minor thesis). Read it before you start! Epidemiology and practical research methods course slides 2020 A series of 5 lectures: teaching slides on basic epidemiology, research methods and statistical tests Clinical practice for paediatric exams How to do a long case 2019 Paediatric Lectures 2021 Lectures Weekly Paediatric Lecture 1 Covid-19 update Feb 1 2021 Weekly Paediatric Lecture 2 Pneumonia and bronchiolitis Feb 8 2021 Weekly Paediatric Lecture 3 Fever in children Feb 15 2021 Weekly Paediatric Lecture 4 Anaemia in children February 22 2021 2020 Lectures Lecture 1 Covid-19 and children May 2 2020 Lecture 2 HIV in children May 11 2020 Lecture 3 Dengue in children May 18 2020 Lecture 4 Meningitis and encephalitis in children May 25 2020 Lecture 5 Common kidney diseases in children June 1 2020 Lecture 6 Anaemia in children June 10 2020 Lecture 7 Paediatric oncology June 22 2020 Lecture 8 Epilepsy in children July 6 2020 Lecture 9 Child health epidemiology in PNG July 13 2020 Lecture 10 Congenital heart disease July 20 2020 Lecture 11 Congenital heart disease II July 27 2020 Lecture 12 Diagnosis of tuberculosis in children August 3 2020 Lecture 13 Management of CNS TB and TB-related chronic lung disease August 11 2020 Lecture 14 Fluid and electrolyte management in children August 17 2020 Lecture 15 Antibiotics and antibiotic resistance in children August 24 2020 Lecture 16 Neglected Tropical Diseases in children August 31 2020 Lecture 17 Endocrine problems in children September 7 2020 Lecture 18 Failure to thrive in infants and children September 14 2020 Lecture 19 Paediatric mortality auditing September 21 2020 Lecture 20 Neonatal problems September 28 2020 Lecture 21 Neurological examination of children October 12 2020 Lecture 22 Jaundice and liver disease in children October 19 2020 Your Care Today Shapes Their Tomorrow

Research 2024 Research 2024 Below are the research presentations by the 2024 DCH and MMed II registrars. They cover a wide variety of relevant topics, including unvaccinated children, adoption, abdominal tuberculosis, neonatal outcomes in the provinces, pulmonary hypertension of the newborn, thalassaemia, retinoblastoma, severe pneumonia, bronchiectasis, and quality improvement through mortality auditing and having a quality improvement team. DCH 2024 Elaine Waine Challenges in the management of β-thalassemia major ESPH DCH 2024 Elina Kuri Unvaccinated children at Mt Hagen Hospital DCH 2024 Ernestine Gugu Neonatal Admissions to Kavieng DCH 2024 Melisha Barr Adoption a social contributor to malnutrition in Kundiawa DCH 2024 Sylvia Orapa TB Abdomen in Children PMGH 2024 Thomas Du Retinoblastoma DCH 2024 MMed 2024 Vanessa Binene Bronchiectasis MMed 2024 Dasha Namor-Pomat Management of Severe Pneumonia in Children at Rabaul MMed 2024 Mathew Sandakabatu Quality improvement team and mortality auditing in Honiara MMed 2024 Merlisa Kuama Persistent Pulmonary Hypertension of the Newborn MMed

Child Death Review Meetings Child Death Review Meetings Mortality Review Meetings WHO January 2019 This is a description of how to conduct regular child mortality review meetings. The forms below are used for summarising the cases for discussion, identifying diagnoses, and drawing up a plan for actions and recommendations from the meeting. Below is a lecture describing child death review meetings https://youtu.be/Ec51GpWwhtM Death Register Form 01 The Death registrar form is held in the ward, and the names of children who died are recorded. This is so that at the designated time each week that the audit meeting is going to be held, you will have a list of the cases for discussion. This form is taken to the meeting to ensure that all cases, or the selected cases, are discussed. Child Mortality Reporting Form Final Version 2017 02 The Child Mortality Reporting Form is the main form used at the weekly audit meeting to record information about the case. It is best if the person who is coordinating the meeting fill some of the demographic information in before the meeting, so the meeting can focus on discussing the story, and determining if there are any avoidable factors, and what action needs to be taken. Cause of Death Codes 03 The Cause of death codes is a list of standardised diagnoses. These are common in PNG, and all are included in the PHR. This is in an effort to assign an accurate and standardised cause(s) of death. 04 Action Plan Summary Form 04 The Action plan summary form is a summary each week of the meetings resolutions, which should be reviewed at the next and subsequent meetings to determine if the required action was taken. Over time, by filling out this form and reviewing all outstanding actions, it should be possible to determine if progress is being made.