Raewyn Mutch

Tertiary paediatric refugee health clinic in Western Australia: Analysis of the first 1026 children

Aim:  Children account for approximately half of the humanitarian refugees currently resettled in Australia. A multidisciplinary refugee health clinic (RHC) was established at the tertiary paediatric hospital in Western Australia to address burgeoning referrals of refugee children following voluntary post‐resettlement health assessment. The aim of this study is to describe the epidemiology of common conditions in resettled paediatric refugees attending a tertiary multidisciplinary RHC.

Comparison of single-breath and tidal breathing exhaled nitric oxide levels in infants

The aim of this study was to compare two different methods, tidal breathing (TB) and single-breath (SB), for measuring fractional exhaled nitric oxide (FENO) in infants. FENO was measured in 71 infants with either recurrent wheeze (n=32), recurrent cough (n=16) or no symptoms (healthy, n=23) using both methods. For TB measurements five breaths were collected into a gas sampling bag (off-line reservoir sampling). The SB method was modified from the raised volume rapid thoraco-abdominal technique. Agreement between the two methods was investigated and both methods were used to compare FENO in infants with and without symptoms. Flow dependence of SB FENO was demonstrated using two expiratory flows (11 and 40 mL·s−1). There was a moderate correlation (r=0.60) but poor agreement between levels using the TB and SB methods. A significant difference in FENO between healthy children and children with wheeze was found using the SB but not the TB method. Due to lower expiratory flow and reduced nasal nitric oxide contamination the single-breath technique may be more sensitive than the tidal breathing method for detecting differences in exhaled nitric oxide between infants with and without respiratory symptoms.

Parental smoking increases exhaled nitric oxide in young children

The present study investigated the association between reported parental smoking and exhaled nitric oxide fraction (FeNO) in young children. In total, 78 children (24 females, mean age 51.3 weeks) were recruited. Fourteen lived with one smoking parent and eight with two smoking parents. FeNO was measured using the modified single-breath technique. Mean±sd FeNO levels were 33.0±18.9, 38.3±15.0 and 48.3±14.7 ppb for children with no, one and two smoking parents, respectively. There was a significant linear trend across the groups and, after controlling for other relevant factors, a significant difference between the groups. In the present study, exposure to environmental tobacco smoke was associated with increased exhaled nitric oxide fraction in young children. Furthermore, there was evidence of a dose–response relationship between childhood exhaled nitric oxide fraction and the number of smoking parents.

Paediatricians' knowledge, attitudes and practice following provision of educational resources about prevention of prenatal alcohol exposure and Fetal Alcohol Spectrum Disorder.

Aim:  The study aims to provide paediatricians in Western Australia (WA) with educational resources (http://www.ichr.uwa.edu.au/alcoholandpregnancy) about the prevention of prenatal alcohol exposure and fetal alcohol spectrum disorder, and assess changes in their knowledge, attitudes and practice about fetal alcohol syndrome (FAS) and alcohol consumption in pregnancy.

Recommendations from a consensus development workshop on the diagnosis of fetal alcohol spectrum disorders in Australia

BackgroundFetal alcohol spectrum disorders (FASD) are underdiagnosed in Australia, and health professionals have endorsed the need for national guidelines for diagnosis. The aim of this study was to develop consensus recommendations for the diagnosis of FASD in Australia.MethodsA panel of 13 health professionals, researchers, and consumer and community representatives with relevant expertise attended a 2-day consensus development workshop to review evidence on the screening and diagnosis of FASD obtained from a systematic literature review, a national survey of health professionals and community group discussions. The nominal group technique and facilitated discussion were used to review the evidence on screening and diagnosis, and to develop consensus recommendations for the diagnosis of FASD in Australia.ResultsThe use of population-based screening for FASD was not recommended. However, there was consensus support for the development of standard criteria for referral for specialist diagnostic assessment. Participants developed consensus recommendations for diagnostic categories, criteria and assessment methods, based on the adaption of elements from both the University of Washington 4-Digit Diagnostic Code and the Canadian guidelines for FASD diagnosis. Panel members also recommended the development of resources to: facilitate consistency in referral and diagnostic practices, including comprehensive clinical guidelines and assessment instruments; and to support individuals undergoing assessment and their parents or carers.ConclusionsThese consensus recommendations provide a foundation for the development of guidelines and other resources to promote consistency in the diagnosis of FASD in Australia. Guidelines for diagnosis will require review and evaluation in the Australian context prior to national implementation as well as periodic review to incorporate new knowledge.

A modified Delphi study of screening for fetal alcohol spectrum disorders in Australia

BackgroundThere is little reliable information on the prevalence of fetal alcohol spectrum disorders (FASD) in Australia and no coordinated national approach to facilitate case detection. The aim of this study was to identify health professionals’ perceptions about screening for FASD in Australia.MethodA modified Delphi process was used to assess perceptions of the need for, and the process of, screening for FASD in Australia. We recruited a panel of 130 Australian health professionals with experience or expertise in FASD screening or diagnosis. A systematic review of the literature was used to develop Likert statements on screening coverage, components and assessment methods which were administered using an online survey over two survey rounds.ResultsOf the panel members surveyed, 95 (73%) responded to the questions on screening in the first survey round and, of these, 81 (85%) responded to the second round. Following two rounds there was consensus agreement on the need for targeted screening at birth (76%) and in childhood (84%). Participants did not reach consensus agreement on the need for universal screening at birth (55%) or in childhood (40%). Support for targeted screening was linked to perceived constraints on service provision and the need to examine the performance, costs and benefits of screening.For targeted screening of high risk groups, we found highest agreement for siblings of known cases of FASD (96%) and children of mothers attending alcohol treatment services (93%). Participants agreed that screening for FASD primarily requires assessment of prenatal alcohol exposure at birth (86%) and in childhood (88%), and that a checklist is needed to identify the components of screening and criteria for referral at birth (84%) and in childhood (90%).ConclusionsThere is an agreed need for targeted but not universal screening for FASD in Australia, and sufficient consensus among health professionals to warrant development and evaluation of standardised methods for targeted screening and referral in the Australian context. Participants emphasised the need for locally-appropriate, evidence-based approaches to facilitate case detection, and the importance of ensuring that screening and referral programs are supported by adequate diagnostic and management capacity.

Health of adolescent refugees resettling in high-income countries

Adolescent refugees are a vulnerable population with complex healthcare needs that are distinct from younger and older age groups. Physical health problems are common in this cohort with communicable diseases being the focus of attention followed by an emphasis on nutritional deficiencies and other chronic disorders. Adolescent refugees have also often experienced multiple traumatic stressors and are at a heightened risk of developing mental health problems. Navigating these problems at the time of pubertal development adds further challenges and can exacerbate or lead to the emergence of health risk behaviours. Educational difficulties and acculturation issues further compound these issues. Adolescents who have had experiences in detention or are unaccompanied by parents are particularly at risk. Despite a constantly growing number of adolescent refugees resettling in high-income countries, knowledge regarding their specific healthcare needs is limited. Research data are largely extrapolated from studies conducted within paediatric and adult cohorts. Holistic management of the medical and psychological issues faced by this group is challenging and requires an awareness of the socioeconomic factors that can have an impact on effective healthcare delivery. Legal and ethical issues can further complicate their management and addressing these in a culturally appropriate manner is essential. Early identification and management of the healthcare issues faced by adolescent refugees resettling in high-income countries are key to improving long-term health outcomes and future healthcare burden. This review article aims to increase knowledge and awareness of these issues among paediatricians and other health professionals.

Need to establish a national diagnostic capacity for foetal alcohol spectrum disorders

Alcohol exposure in pregnancy can induce a broad range of physical and developmental defects in the child, collectively known as foetal alcohol spectrum disorders (FASD). In Australia, there are proven gaps in our knowledge and practice for recognising and diagnosing FASD. The challenge for the Australian health professional is agreeing on a model for diagnosing and treating FASD. The diagnostic method must be evidence based, sensitive and specific, and account for other exposures during pregnancy and early life events. Training in application of the diagnostic method needs to be readily available in metropolitan and regional Australia. The University of Washington FASD 4‐digit diagnostic code fulfils all of these best practice criteria, recommending itself as the method of choice.

Health professionals' perceptions about the adoption of existing guidelines for the diagnosis of fetal alcohol spectrum disorders in Australia

BackgroundDespite the availability of five guidelines for the diagnosis of fetal alcohol spectrum disorders (FASD), there is no national endorsement for their use in diagnosis in Australia. In this study we aimed to describe health professionals’ perceptions about the adoption of existing guidelines for the diagnosis of FASD in Australia and identify implications for the development of national guidelines.MethodsWe surveyed 130 Australian and 9 international health professionals with expertise or involvement in the screening or diagnosis of FASD. An online questionnaire was used to evaluate participants’ familiarity with and use of five existing diagnostic guidelines for FASD, and to assess their perceptions about the adoption of these guidelines in Australia.ResultsOf the 139 participants surveyed, 84 Australian and 8 international health professionals (66.2%) responded to the questions on existing diagnostic guidelines. Participants most frequently reported using the University of Washington 4-Digit Diagnostic Code (27.2%) and the Canadian guidelines (18.5%) for diagnosis. These two guidelines were also most frequently recommended for adoption in Australia: 32.5% of the 40 participants who were familiar with the University of Washington 4-Digit Diagnostic Code recommended adoption of this guideline in Australia, and 30.8% of the 26 participants who were familiar with the Canadian guidelines recommended adoption of this guideline in Australia. However, for the majority of guidelines examined, most participants were unsure whether they should be adopted in Australia. The adoption of existing guidelines in Australia was perceived to be limited by: their lack of evidence base, including the appropriateness of established reference standards for the Australian population; their complexity; the need for training and support to use the guidelines; and the lack of an interdisciplinary and interagency model to support service delivery in Australia.ConclusionsParticipants indicated some support for the adoption of the University of Washington or Canadian guidelines for FASD diagnosis; however, concerns were raised about the adoption of these diagnostic guidelines in their current form. Australian diagnostic guidelines will require evaluation to establish their validity in the Australian context, and a comprehensive implementation model is needed to facilitate improved diagnostic capacity in Australia.

Perspective: ‘The forgotten children: National inquiry into children in immigration detention (2014)’

Perspective: ‘The forgotten children: National inquiry into children in immigration detention (2014)’ Georgia Paxton, Shidan Tosif, Hamish Graham, Andrea Smith, Colette Reveley, Jane Standish, Kate McCloskey, Grant Ferguson, David Isaacs, Hasantha Gunasekera, Ben Marais, Philip Britton, Ameneh Khatami, Karen Zwi, Shanti Raman, Elizabeth Elliott, David Levitt, Joshua Francis, Paul Bauert, Peter Morris, Annie Whybourne, Sarah Cherian, Raewyn Mutch, David Forbes, David Rutherford and Suzanne Packer