Anthony Zehetner

Why fairy tales are still relevant to today's children

Are fairy tales outdated to a modernised 21st century society? In 1976, clinical psychologist Professor Bruno Bettelheim wrote a book examining the power and utility of fairy tales in childhood development. Forty years later, his work maintains its importance. Through a Freudian lens, Bettelheim examines the emotional and symbolic facets of traditional children’s fairy tales alongside contemporary developmental child psychology. Bettelheim believes that when children find meaning within these socially evolved stories, they engage in emotional growth and transcend their self-centred natures. This would allow them to attain a greater sense of meaning and purpose to their own lives, which would prepare them better for their own futures to be in a position to contribute significantly to others. Through the fairy tale narrative, the child makes sense of life’s bewilderment. The imagery in fairy tales (such as personified animals, adults represented as giants and allegorical magic vegetables) allows the child to explore their fears in remote and symbolic terms (Fig. 1). The child is able to sort through their inner pressures and moral obligations in an environment that is not belittling to them. Should parents still recount these tales of make believe to the children of today or are they passe? Unlike myths, which tend to be detailed historical tragedies inaccessible to a child’s mind, fairy tales are a screenplay of adversity, quest, struggle and acceptance – with a happy ending. They tend to be universally translatable and are edited and embellished with every generation. The emphasis is on choice of action rather than the title of the characters themselves. Hansel and Gretel were so named because these were the prevailing children’s names at the time. Fables demand the reader to choose a moral outcome. Fairy tales allow the reader to explore each virtue and path of action through the different characters’ fates. The child decides their own personal stance after deliberating each consequence. Through the telling, the child is exposed to ethical reasoning without being preached at. The little pig who worked hard building his house out of bricks was safe, while the pigs that used the easier straw and sticks and went off to play got gobbled up. Without being explicitly told so, the child learns that hard work pays off and that sometimes delayed gratification is necessary. Fairy tales provide answers to what the world is really like and the child’s place within it. Numbers play an important part in the world and fairy tales are no exception. Here, the magical number is three: three bears, three little pigs, three wishes, etc. Apart from religious connotations to the Holy Trinity, the child sees their place in the mother, father and child triad. As in the fairy tale, the child usually chooses the third path from the other two characters: their own. Many fairy tales follow a set pattern similar to ‘rite of passage’ stories. A poor vulnerable child loses a parent, and then must set off on an arduous journey testing their courage and outwitting their foes, before realising their true place in the world, usually by bonding with another (‘Prince Charming’). This simplistically echoes the process of adolescence, whereby a child emancipates from their parents, forms a self-identity and vocation, and begins to enter into mutually exclusive adult relationships. Cinderella typifies this with the glass slipper fitting only the right person. The child realises that their potential spouse must suit them wholly and not just be wealthy, attractive or popular. Goldilocks tries out the porridge and the beds to find the right one. Teenagers traverse many phases of fashion, music, friends and hairstyles before finding their ‘home’. Correspondence: Dr Anthony Zehetner, Department of Adolescent Medicine, The Children’s Hospital at Westmead, Corner Hawkesbury Road and Hainsworth Street, Locked Bag 4001, Westmead, NSW 2145, Australia. Fax: +61 298452517; email: anthony.zehetner@health.nsw.gov.au

Addressing adolescent substance use in a paediatric health‐care setting

The aim of this study is to review the operation of a specialist adolescent drug and alcohol consultation liaison service in a tertiary paediatric hospital.

Paediatricians should do more to address male adolescent sexual health.

Young people have the right to be informed and access appropriate health-care services about their health, including sexual matters. They also have the right to be treated in a confidential, culturally appropriate, positive and respectful manner. While components of a sexual history and health discussion vary and are tailored to the individual and their own circumstances, it is paediatricians who are failing our young people by not providing them with the opportunity for sexual health discussion, with males missing out the most. A recent study by Alexander et al. found that 35% of annual adolescent health visits made no mention at all of sex. When such ‘discussions’ took place, they lasted an average of 36 seconds and rarely involved any input from the young person. None of the 253 adolescents (aged between 12 and 17 years and just over half being female) initiated discussions on sex. Half of all conversations were responses to yes or no (closeended) questions. Females were twice more likely to spend time talking about sex than males. Unfortunately, these are not new or surprising findings. Sexual health is raised more often with females and older youth. American primary care providers are three times more likely to take sexual health histories from female than male patients and twice as likely to counsel female patients on the use of condoms. There appears to be greater ease in covering issues of menstruation, sexually transmitted illnesses (STIs) and contraception than male sexual health issues. While the ‘physiological agenda’ of doctors is to provide information on contraception and screen and treat STIs, adolescents are more interested in the course of normal pubertal progression, making sense of relationships and countering sexual misinformation. Ignoring their concerns leads to disengagement, so it is vital to meld the two, like in any good conversation. It is important to raise the issue of dating violence, which occurs in approximately 10% of adolescents and males may be perpetrators, victims or both. A significant concern is that a quarter of adolescent sexual encounters involve alcohol (in up to 34% of Australian male reports) or drug use and that 50% of new STI cases occur among young men and women. All sexual experiences should be free of coercion, discrimination and violence. Many Australian teenagers perceive the age of sexual consent of 16 years as a barrier to be overcome. After all, many teenagers will drink and smoke before they can legally purchase and use these substances at age 18. The thrill of an illicit action is lost when it is made legal. Loss of virginity is occasionally seen as a milestone akin to attaining a driver’s licence (with similarly perceived attached kudos), and some teenagers will initiate sex to ‘get it out of the way’ or as practice and experience for a future partner. A generational culture of YOLO (‘You Only Live Once’) does not help. In 2008 in Australia, 70% of Year 10 and 88% of Year 12 students had experienced some form of sexual activity, 40% had experienced sexual intercourse and 44% had experienced oral sex. Thirty-two per cent had reported ever having unwanted sex. The majority of male adolescents practice serial monogamy, averaging one sexual partner per year, and male Australian Year 12 students are more likely to have three or more sexual partners than females (43% and 34%, respectively). Pubertal initiation is trending earlier, particularly among nonHispanic white boys, at approximately 10 years of age. While there is no evidence to suggest cognitive development and maturation are occurring at a similar earlier time, exposure to social and peer influences tends to support the need for education. Viewing videos of sex predicts adolescent initiation of sexual behaviour. Increasingly, because of access, children learn about sex online via the use of pornography. Pornography as sex educator skews the young person’s view of sex and sexual roles. It is known that earlier maturing boys engage in more risk-taking behaviours and late developers (associated with obesity) experience teasing, bullying, mental health issues (poor self-esteem, anxiety and depression) and substance use. This emphasises the need for dialogue about quality sex education and parental discussion. In Australia, the most popular source of sexual information among males was school programmes (49%) and among females was their mother (62%). Many secondary school teachers feel unsupported in teaching sex education to their students, with few receiving formal training in the area. Counselling of the normalcy of pubertal progression and velocity is indicated by paediatricians to counter misinformation, investigate pathology (folliculitis from currently ‘fashionable’ pubic hair shaving, trauma, tinea cruris, varicocoeles, etc) and allay fears (such as gynaecomastia and pearly penile papules). Klinefelter syndrome affects approximately 1 in 600 males and may have gone undetected. Testicular cancer Correspondence: Dr Anthony A Zehetner, Department of Adolescent Medicine, The Children’s Hospital at Westmead, Cnr Hainsworth Street and Hawkesbury Road, Locked Bag 4001, Westmead, Sydney, NSW 2145, Australia. Fax: +61298452517; email: Anthony.Zehetner@health.nsw.gov.au

Early onset neonatal serogroup B meningococcal meningitis and septicaemia.

A male baby age 7 days presented to the Emergency Department with an 11-h history of reduced feeding. He was afebrile but had a petechial rash, lethargy and poor perfusion. He was born by uncomplicated, term vaginal delivery and went home at 5 days of age with his parents and a fully immunised 2-year-old sister. There were no reports of contacts with unwell persons, and there was no household overcrowding. The number of visitors to the baby in the preceding days was not recorded. The neonate was resuscitated with intravenous fluids, and cefotaxime, penicillin and gentamicin were administered. He improved somewhat following fluid administration and proceeded to a full septic screen when stable. Investigations revealed a normal full blood count, coagulation profile, electrolytes and C-reactive protein. Urine showed a high specific gravity (>1.03) indicative of dehydration, with the final negative culture. Cerebrospinal fluid contained 1 ¥ 10/L leucocytes, 371 ¥ 10/L erythrocytes, protein 1.06 g/L and glucose 2.2 mmol/L (blood glucose 3.2 mmol/L). Nasopharyngeal aspirate was negative, and the chest X-ray was normal. Due to the infant’s state on presentation, the paediatric team decided to arrange early transfer to a tertiary centre for likely intensive care management. However, while awaiting the arrival of the transfer team, the baby developed irregular breathing, prolonged apnoeas and finally cardiorespiratory arrest. The presence of disseminated intravascular coagulation complicated intubation and ventilation. Bleeding caused recurrent obstruction of the endotracheal tube, requiring multiple suctioning and re-intubation. The baby died despite prolonged cardiopulmonary resuscitation. Cerebrospinal fluid and blood cultures both grew Neisseria meningitidis serogroup B. Family members and exposed staff members were provided with antibiotic prophylaxis immediately following the decease of the infant. Only 11 cases of early neonatal meningococcal disease (<7 days) have been reported, with an age range of 1 to 4 days. Five neonates died as a result of their infection. None of the 11 cases was reported as serogroup B Neisseria meningitidis. Our patient is the youngest case with serogroup B disease in the medical literature. Very few neonates present with the classic signs and symptoms of meningococcal disease, presumably as the neonatal immature immune system is unable to mount this form of vascular inflammation. The rarity of meningococcal disease in neonates is believed to be attributed to protective transplacental bactericidal antibodies at birth, with levels decreasing until 18–24 months of age, and low rates of nasopharyngeal colonisation. In Australia, both monovalent conjugate (covering serotype C) and multivalent polysaccharide and conjugate (covering serotypes A, C, W135 and Y) vaccines are available. The serotype C conjugate vaccine forms part of the National Immunisation Program, given routinely at 12 months of age. The duration of immunity is as yet uncertain but appears to be improved by administering the first dose after the first birthday. Quadrivalent vaccines are recommended for high-risk groups, such as travellers to endemic areas, and have shown poor responsiveness in young children: immunity further reduces over the 3 years subsequent to vaccination. Intense efforts are being made to develop a meningococcal serotype B vaccine, and several promising avenues are being explored. The challenge with the B serotype lies in its structure – the polysaccharide capsule is an autoantigen, expressed in multiple human tissues (including developing neural tissue), and is poorly immunogenic. While we are now able to prevent meningococcal A, C, W-135 and Y disease through immunisation, to date we have no available serogroup B vaccine (though there are candidates), and its arrival cannot come soon enough.

Review of Teenlink: A health service for children and adolescents of parents with substance use.

To evaluate Teenlink, a wide‐ranging medical and psychological health service addressing the needs of children and adolescents in substance‐using families, who are at increased risk of developmental and psychosocial problems.

Iron supplementation reduces the frequency and severity of breath-holding attacks in non-anaemic children.

Iron supplementation reduces the frequency and severity of breath-holding attacks (BHAs), particularly in children with iron deficiency. The issue of iron supplementation is less clear for Westernized children with BHAs who present to an outpatient community clinic and are not iron-deficient. This is the first reported case series of iron-replete children with frequent and disabling breath-holding attacks who have responded to a course of oral iron supplementation. This intervention is safe, improves quality of life for both child and carer, and is significantly cost-effective in terms of health resource utilization.

Does iron therapy affect the frequency of breath-holding attacks in children?

A two-year-old girl presents with repetitive episodes of facial cyanosis with occasional collapse. The episodes last for less than a minute and occur up to three times a day. She makes a rapid recovery after each episode and her mother states that the episodes are worse when Chloe is tired, irritable or does not get her own way. Her physical examination and past medical history is unremarkable. Blood tests are within the normal range with a low normal haemoglobin result 101 g/L. Her electrocardiogram and electroencephalogram are normal. Breathholding attacks (BHAs) are diagnosed. It has been postulated that iron may be beneficial for treatment.

Bilateral natal clefts in a neonate

A term female neonate is found to have bilateral natal clefts terminating in a lipomatous nodule (see Fig. 1). The anus is located proximally. What is the likely diagnosis, and how would you investigate this further? (Answer on page 791).

The nature of celebrity: a poisoned chalice for today's children?

Since attaining my Fellowship with the Royal Australasian College of Physicians in 2010, I have been working as a Specialist General Paediatrician at Gosford Hospital, as well as a Staff Specialist in Adolescent Medicine at The Children’s Hospital at Westmead. There, I run the Teenlink Service for 8to 16-year-olds who are from families affected by substance abuse. I also have interests in behavioural disorders and psychopharmacology, and have recently published a chapter in a textbook on the subject. I continue to pursue my research into breath-holding attacks in toddlers and have been busy establishing a paediatric practice on the Central Coast. The nature of ‘celebrity’ in our society is a poisoned chalice. Like progress in Medicine, it may be a force for benevolent altruism or great harm. When asked what they want to be when they grow up, today’s children will often reply with ‘famous’, whereas their predecessors might have supplied a vocation such as a ‘fire-fighter’, ‘teacher’ or ‘nurse’. The advent of the Internet promises (unattainable?) dreams of fame and stardom. Networking web sites create a social paradox of increased ‘connectedness’ to others in the setting of an isolated user. Increasingly, I am seeing young people with symptoms of ‘internet addiction’ in my clinic. Is our current generation of youth missing out on developing effective interpersonal skills? My own brush with a public luminary came at the end of 2006, when I was working as a Paediatric Registrar at Royal North Shore Hospital (see photo). A visit from Paris Hilton was bestowed upon the Children’s Ward inpatients and staff at short notice. Outside, a media circus had gathered. To her credit, Ms Hilton was gracious and considerate to the children she met, even though most did not know who she was. I am sure that many a signed photo and plaster cast was sold on eBay that day and made children happy that they could buy what they really wanted! I still have (and use) my stethoscope which she wore for the photo. It did not end up on eBay. I hold onto it because it is a reliable tool rather than for any sentimental reason. I do recall asking Ms Hilton what she had wanted to do when she was a little girl. She looked pensive and thoughtful. I said, ‘If you ever wanted to be a medical receptionist, I will need one for my practice!’ A genuine and heartfelt smile broke out. I thought I’d go in for the deal clincher. ‘I pay above the award wage’, I offered. The grin deepened. She said, ‘I’ll think about it’. To this day, she has not yet said no!