Categories
Articles

VOLUME 11, ISSUE 2 2022

Download (PDF, 2.53MB)

Categories
Book Reviews

Book Review: Clinical Cases in Obstetrics, Gynaecology and Women’s Health by Caroline de Costa, Stephen Robson and Boon Lim

A diverse range of scenarios are represented in this textbook with a particular focus on clinical management. This resource also provides perspective on social determinants that impact women’s health, which need to be considered by health professionals for the provision of holistic patient-centred care

Download (PDF, 991KB)

Categories
Feature Articles Articles

Tips to maximise medical students learning in neonatal intensive care placements

Dr Karanjeet Chauhan 1,2, Dr Simone Huntingford 3, Dr Sineth Wickramaarachchi 1,4, Dr Mustafa Siddiqui 1,5

  1. Faculty of Medicine, Monash University, Victoria, Australia
  2. Royal Melbourne Hospital, Victoria, Australia
  3. Department of Neonatology, The Royal Children’s Hospital, Victoria, Australia
  4. Monash Health, Victoria, Australia
  5. Goulburn Valley Health, Victoria, Australia

Available Online: 18/06/2024

Abstract

Summary: This article aims to provide guidance for medical students embarking on these rotations, often for the first time. The authors identify some of their own personal challenges in neonatal medicine and provide practical tips and resources to help students to maximise their learning experience. Introduction: It is essential that medical students and junior doctors develop an understanding of common and important medical conditions presenting in the neonatal period. Time pressure within the medical curriculum limits the amount of time that can be dedicated to paediatric and neonatal student placements. Rotations within a Neonatal Intensive Care Unit or Special Care Nursery can provide medical students with a wide range of learning opportunities; however, these experiences can sometimes be perceived by medical students as brief or overwhelming.

Introduction

The identification of newborn medicine as a subspecialty began relatively recently with the term “neonatology” being first introduced in 1960 [1]. A neonate refers to an infant less than 28 days of age, and the discipline of neonatology has rapidly expanded in recent decades. In Australia, around 18% of babies are admitted to a Neonatal Intensive Care Unit (NICU) or Special Care Nursery (SCN) [2]. NICUs are located in major maternity and paediatric hospitals. NICUs can provide babies with intensive care therapies such as invasive and non-invasive respiratory support, central vascular access, haemodynamic support, and perioperative management. SCNs provide fewer intensive therapies such as non-invasive respiratory support, intravenous antibiotics, gavage feeding, and phototherapy. Babies are often admitted to the NICU due to prematurity (from 22 weeks’ gestation onwards), respiratory distress, sepsis, Hypoxic Ischaemic Encephalopathy (HIE), and congenital malformations [3]. Babies are often admitted to the SCN due to prematurity (30-36 weeks’ gestation), mild respiratory distress, suspected sepsis, feeding difficulties or jaundice.

The importance of paediatric teaching within the medical curriculum has become increasingly recognised globally [4]. All medical students in Australia are required to undertake a paediatric rotation, often comprising time spent in the NICU/SCN. Despite a steady shift to online-based teaching, bedside teaching remains a crucial component of medical education for students worldwide [5] and there is much to be gained from clinical placements in the NICU/SCN.

To optimise learning and the acquisition of required proficiencies, students need guidance and a directed curriculum [6]. This paper is aimed to be used in conjunction with guidance from clinical educators, and with the student’s own medical school curriculum. The role of clinical educators has been extensively studied, however the role of the student in driving their own learning is also paramount. A study by Chipchase et al. looked at the characteristics of allied health students that served as indicators for their degree of preparedness for clinical learning as perceived by clinical educators [7]. “Willingness” was a major theme that emerged with student characteristics including willingness to ask questions and clarify their understanding, and willingness to take responsibility for their own learning. However the challenges and complexities in intensive care environment can be intimidating for medical students [8]. When anticipating a placement in the Intensive Care Unit, one study reported medical students using terms such as “scary”, “terrifying”, “intimidating”, and “nerve-wracking” [9].

The experiences from the authors below provide some of their own reflections from time spent as a medical student in the NICU/SCN. This will hopefully reassure the reader that they are not alone if sharing in some of these reactions. The article then aims to familiarise students with some aspects of the intensive care environment to lessen apprehensive about the rotation. Finally, the article directs students towards some useful learning opportunities in the NICU/SCN and some supporting resources.

Experience of the NICU as a medical student

Karanjeet Chauhan

I undertook a NICU placement in the fourth year of undergraduate medicine as part of the paediatrics rotation.  Prior to this, I had not stepped foot in an intensive care unit. Across medical school, the message has been clear that “you get out what you put in” when it comes to clinical rotation. However, my enthusiasm was quickly juxtaposed with tiny babies connected to dozens of wires, worried parents and complex medicine; all within the fast-paced intensive care environment.  I initially felt overwhelmed and disoriented, which was heightened by the COVID-19 pandemic which was concurrently in full swing. Senior doctors were agreeable to teaching students, and were generous with their time. However, there seemed to be fewer learning objectives specific to the NICU compared with other areas of paediatrics. Without a sense of direction, I often felt lost and soon realised that my previous experience taking histories and performing physical examinations on adult patients was challenging to apply to tiny complex babies and their worried families. This was a common theme experienced by many of my colleagues who rotated through a NICU. However, as the placement progressed, I grew more confident in my ability to examine babies and interact with families. One of my colleagues on NICU with me reiterated this and said, “I never truly grasped the impact that good communicational skills could have on the experiences of patients and their families until my NICU rotation.”  By the end of my term, I developed a newfound appreciation for the NICU. I strongly felt that it would have been useful to have had a medical student guide to the NICU environment and the learning opportunities within it.

Experiences of a neonatologist

Dr. Simone Huntingford

As a medical student, I completed a brief run through the NICU as part of my paediatric rotation. Despite being interested in paediatrics, and having tried to prepare for the placement, the NICU was different to what I had expected. Tiny babies in incubators connected to ventilators and pumps. An endless array of cords, monitors, numbers and alarms. Some of the things were familiar to me like heart rate and oxygen saturations. Most of them were a mystery. The doctors were kind, calm, and clever. But they often spoke a language that I did not understand. The nurses were skilled and gentle. They knew every detail about their patients. Sometimes it felt like they were fiercely protective of the little person that they cared for. I felt interested to learn but didn’t know where to start. NICU; a place I’ll probably never work….

I am now working as a neonatologist. I become fascinated with newborns. Their physiology. Their resilience. Their families. The NICU is now a familiar place for me, but I will always remember my first impressions as a student.

Strategies to get the most out of your NICU rotation

Familiarise yourself with the team

Introduce yourself to the team as early as possible and familiarise yourself with how the team usually functions. Every team is different. Make contact with students who have previously completed their rotation in the unit and ask for specific advice. Arrange to meet with your supervising clinician and discuss your university learning objectives and personal learning goals.

Safety is key

All neonates (especially those born prematurely) have an immature immune system and are yet to complete their childhood immunisation schedule. Therefore, neonates are susceptible to infection. Even common viral infections can be life-threatening. Before entering the unit, ensure you are “bare below the elbows” (a plain wedding band is generally acceptable) and wash your hands thoroughly. On the unit, ensure excellent hand hygiene and follow any PPE guidelines carefully. Stay home if you are unwell or have cold sores.

Seek support if needed

Although the majority of babies discharged from NICU/SCN go on to lead healthy lives [10], some babies may die or experience significant morbidity. As a student, it may be distressing to be involved in the care of babies who are acutely unwell or have adverse outcomes. NICU is a challenging environment, and health professionals have been found to experience moral distress at times in NICU [11]. It is important to seek appropriate support if needed. A number of support services will be available through your university or placement hospital. Have a plan for who you might reach out to if you need support.

Focus on the basics

The NICU is packed with opportunities to learn physiology and skills which will be relevant to all areas of medicine. Think and ask about lung mechanics, cardiac output, oxygen delivery, shock, sepsis, blood gas interpretation and chest X-ray interpretation. If you feel overwhelmed by the complexity of a patient, focus back on the basics.  It can be useful to write down any questions you have during the ward round and discuss them afterwards.

Review key paediatric topics

Review the university paediatric curriculum and learning objectives. Learning objectives cover clinically important topics and likely examination content. It is useful to read up on paediatric and perinatal history taking (Table 1) and common conditions presenting in the newborn period. Familiarise yourself with the commonly used terms in NICU listed in Table 2. Various studies have clearly shown that students who prepare ahead for rotations perform significantly better both in terms of academic performance and clinical competence [12,13]. Table 3 provides a framework of high yield questions to ask to further ones learning in a NICU/SCN. Before the end of your rotation, review complete the NICU quiz under Table 4 and consider reading around these topics. If you have an opportunity to attend births, review the Apgar scoring system and newborn resuscitation pathway.

Table 1. Key History Taking Areas for Medical Students in the NICU 

History Importance Example admission note
Antenatal
Gravity and parity  History of fetal/neonatal deathG2 P2  
Blood group and antibodiesRisk of haemolytic disease O+ve, antibody negative
Hepatitis, HIV and Rubella serology +/- Toxoplasma/CMV/HSV/Parvovirus Risk of vertical transmission +/-congenital infectionSerology negative Rubella immune
Group B Streptococcus (GBS) statusSeptic risk factor  GBS negative  
First trimester combined screening (FTCS) or non-invasive prenatal test (NIPT)Risk of genetic abnormalities  Low risk first trimester screening and NIPT  
Gestational diabetes (GDM) oral glucose tolerance test (OGTT)Risks for new-born (especially hypoglycaemia)  Gestational diabetes – on insulin  
Morphology Ultrasound     Fetal abnormalities    Morphology – small ventricular septal defect, otherwise normal
Complications or medications in the pregnancyIdentify other factors which may affect the new-bornNo other complications or medications in pregnancy
Social, smoking, alcohol and drug historySocial and pharmacological risksMother is teacher, no partner No smoking/alcohol/drugs
Birth
Weeks’ gestation  Prematurity?  39+2 weeks gestation  
Labour – induced or spontaneous or no labourReason for induction?  Induction of labour for fetal macrosomia
Rupture of membranes and liquor  Prolonged rupture >18 hours is septic risk factor Meconium liquor is risk factor for meconium aspiration syndrome (MAS)Membranes ruptured 24 hours prior to delivery, clear liquor  
Antibiotics given?Antibiotics often given if GBS+ve or prolonged rupture of membranes  Benzylpenicillin administered 4H prior to delivery  
Mode of delivery – vaginal, instrumental, caesarean sectionReason for assisted or caesarean section?Vaginal birth assisted by forceps for fetal distress  
Maternal feverSeptic risk factor No maternal fever
Neonatal
APGARS  Condition of newborn at birth  APGARS 5 (1min) and 8 (5min)  
Resuscitation at birth  Newborn compromise and interventions  CPAP with FiO2 50% for respiratory distress and desaturation in delivery room Weaned off by 10min life
Vitamin K injection  Reduces risk of Haemorrhagic Disease of Newborn (HDN)Vitamin K given  
Hepatitis B immunisationRoutine immunisationHepatitis B given

Table 2. Neonatal Intensive Care (NICU) Glossary terms

NICU Glossary
Usual pregnancy 40 weeks
>/= 37 weeks: Full term
<37 weeks: Preterm
<28 weeks: Extremely preterm  

Usual birthweight at term: 2.5-4kg
Approximate weight gain 150g/week (full term baby)
Small for Gestational Age (SGA) <10th centile for gestation
Large for Gestational Age (LGA) >90th centile for gestation
 
Total Fluid Intake (TFI): Daily fluid requirement in mL/kg/day
Used to prescribe milk or intravenous fluid amount  

Respiratory Support
Cot oxygen: increased FiO2 in incubator
Low Flow Oxygen (LFO2)
High Flow Nasal Prongs (HFNP)
Continuous Positive Airway Pressure (CPAP)
Endotracheal tube (ETT)  

Jaundice
Serum Bilirubin (SBR)
Direct Antiglobulin Test (DAT)

Table 3. Top 10 Questions to Ask in the Neonatal Intensive Care Unit or Special Care Nursery

1. What are some signs of sepsis in the newborn?
2. How do I approach the respiratory or cardiac exam in a newborn?
3. Could you show me a CXR demonstrating: Transient Tachypnoea of the Newborn? Respiratory Distress Syndrome?
4. Could you help me to interpret this blood gas?
5. What is a normal bloods sugar for a newborn? How do you manage hypoglycaemia?
6. What are the different types of respiratory support provided to newborns?
7. May I assist to perform a baby check?
8. What causes jaundice in the newborn?  Could I plot this newborn’s jaundice level on a treatment chart?
9. Could I join the team who attend deliveries?
TIP: Revise the Newborn Resuscitation Pathway, and calculate the APGARS
10. What is the prognosis for this patient?  

Table 4. NICU Quiz

1. What physiological changes occur after birth that facilitate the transition from fetus to newborn?
2. What are the “normal” feeding, stooling, and voiding patterns of a full-term newborn?
3. How do the newborn’s vital signs differ from children and adults?
4. What are 3 septic risk factors for newborns? What might be the source of sepsis in infants?
5. What are 5 complications of prematurity?
6. What are the causes of:
– Unconjugated jaundice?
– Conjugated jaundice?
7. What are 4 common and important respiratory causes of respiratory distress in the newborn?
8. Respiratory support modes include Low Flow Oxygen, High Flow Nasal Prongs. Which respiratory support modes provide newborns with:
– Oxygen?
– Positive End Expiratory Pressure (PEEP)?
– Positive Inspiratory Pressure (PIP)?
9. On the baby check, what is the clinical significance of assessing the 
– Femoral pulses?
– Hip examination?
– Red reflexes?  

Interacting with newborns and their families

Introduce yourself to families and ask about their baby. Use the baby’s name (referring to a baby as “it” will not be well received!). You may find it surprising to learn that newborns have unique personalities even when born prematurely. Parents will often be able to tell you about their baby’s likes and dislikes; for example, being soothed by a parent’s voice or disliking a nappy change.

Practice your history taking and examination skills

As a doctor, you will encounter neonates in many settings including the general practice clinic, emergency department, paediatric clinic, or hospital ward. Seize this opportunity to gain confidence working with them. In a recent study, medical students who took part in a NICU cuddler curriculum were more prepared for clinical practice by gaining a greater understandings of factors (including medical conditions) leading to NICU admission and of the social and emotional stressors faced by families of infants in the NICU [14].

Some families may stay in the NICU/SCN for many weeks, and they will often be willing to share their journey. Having a child in the NICU is a stressful experience for parents. Studies report a significant risk of mental health issues in NICU parents [15]. Check with the team which families might be suitable to practice history taking, and always use a compassionate and empathetic approach.

How to examine a baby?

You may feel worried about examining patients, especially babies, in the intensive care environment. However, there are many opportunities to develop your examination skills. Most importantly, you will be able to gain much information from observation alone. Check what monitoring and medical equipment the baby is connected to and why. Take note of the baby’s vital signs. Observe the baby’s colour, posture, tone, movements, level of alertness, and breathing effort.

Ask the team which babies are stable enough to be handled for an examination and if they might supervise you. Ask the junior doctors if any babies need a discharge examination. Seek consent from the family and the bedside nurse prior to handling a baby. Disturbing a sleeping baby should always be avoided. It may feel strange, but greet the baby by name and describe to them what you are doing. “Hello Jackson, I’m just going to move your blankets and have a listen to your breath sounds…”.  Undressing or moving a baby may unsettle them, so consider listening for heart and breath sounds first. Warm your hands before feeling the femoral pulses. Never perform a Moro reflex or hip examination without supervision [16–18]. Beware of abdominal palpation in the recently fed baby (or pack a change of clothes!).

It is fascinating and you might see rare or complex conditions

The neonatal period is a truly fascinating time to observe physiological changes and diagnose many rare and complex conditions. You may like to choose an interesting patient and read more about their condition. Be sure to learn the NICU basics but wander down some learning paths that interest you. This may include but is not limited to: shadowing the team during critical moments or procedures, antenatal consults, family meetings, high risk births, intubations and so on.

Conclusion

Time spent in the NICU/SCN was a challenging and rewarding experience for the authors as medical students. The NICU is an ideal environment for learning neonatal medicine and also for fine-tuning skills applicable to all areas of medicine, including communication with families, multi-disciplinary teamwork, and the application of basic sciences. As such, the authors encourage the reader to be proactive when engaging with the healthcare team, and to embrace the unique clinical opportunities they are presented with.

One of the unavoidable challenges that students are bound to face is the limited time they have learning neonatal medicine during their paediatric rotation. This article does not intend to provide an all-encompassing guide. It is always imperative for universities to have a structured curriculum with specific learning objectives to guide learning. However, this paper provides the student reader with practical framework and approach with which to maximise their learning opportunities in the NICU/SCN.

Conflicts of interest

None declared.

Funding

No funds, grants, or other support was received.

Authors’ Contributions

All co-authors were involved in preparing the article and revising it critically for important intellectual content. KC, SW and MS specifically provided their personal accounts as students and SH provided her advice as a former student and current neonatologist. All authors have approved the final version of the article to be published and agreed to be accountable for all aspects of the work.

References

  1. Schaffer AJ, Avery ME. Diseases of the newborn. Philadelphia: Saunders; 1977.
  2. Australian Institute of Health and Welfare. Australia’s mothers and babies, Admission to a special care nursery or neonatal intensive care unit [Internet]. 2023 [updated 2023 Jun 29; cited 2022 Nov 23]. Available from: https://www.aihw.gov.au/reports/mothers-babies/australias-mothers-babies/contents/baby-outcomes/admission-to-a-special-care-nursery-or-neonatal-in
  3. Aijaz N, Huda N, Kausar S. Disease burden of NICU, at a tertiary care hospital, Karachi. Journal of the Dow University of Health Sciences (JDUHS). 2012 Apr 10;6(1):32-5.
  4. Simon JL, Daelmans B, Boschi-Pinto C, Aboubaker S, Were W. Child health guidelines in the era of sustainable development goals. BMJ. 2018;362. doi:10.1136/bmj.k3151
  5. Qureshi Z. Back to the bedside: the role of bedside teaching in the modern era. Perspect Med Educ. 2014;3(2):69–72. doi:10.1007/s40037-014-0111-6
  6. Tainter CR, Wong NL, Cudemus-Deseda GA, Bittner EA. The “Flipped Classroom” Model for Teaching in the Intensive Care Unit: Rationale, Practical Considerations, and an Example of Successful Implementation. J Intensive Care Med. 2017;32(3):187–96. doi:10.1177/0885066616632156
  7. Chipchase LS, Buttrum PJ, Dunwoodie R, Hill AE, Mandrusiak A, Moran M. Characteristics of student preparedness for clinical learning: clinical educator perspectives using the Delphi approach. BMC Medical Education. 2012;12(1):112. doi:10.1186/1472-6920-12-112
  8. Swinny B, Brady M. The Benefits and Challenges of Providing Nursing Student Clinical Rotations in the Intensive Care Unit. Critical Care Nursing Quarterly. 2010;33(1):60–6. doi:10.1097/CNQ.0b013e3181c8df7c
  9. O’Connor E, Moore M, Cullen W, Cantillon P. A qualitative study of undergraduate clerkships in the intensive care unit: It’s a brand new world. Perspect Med Educ. 2017;6(3):173–81. doi:10.1007/s40037-017-0349-x
  10. Hossain S, Shah PS, Ye XY, Darlow BA, Lee SK, Lui K, et al. Outcome comparison of very preterm infants cared for in the neonatal intensive care units in Australia and New Zealand and in Canada. Journal of Paediatrics and Child Health. 2015;51(9):881–8. doi:10.1111/jpc.12863
  11. Prentice TM, Janvier A, Gillam L, Donath S, Davis PG. Moral Distress in Neonatology. Pediatrics. 2021 Aug 1;148(2):e2020031864.
  12. O’Brien A (Tony), McNeil K, Dawson A. The student experience of clinical supervision across health disciplines – Perspectives and remedies to enhance clinical placement. Nurse Education in Practice. 2019;34:48–55. doi:10.1016/j.nepr.2018.11.006
  13. Burford B, Whittle V, Vance GH. The relationship between medical student learning opportunities and preparedness for practice: a questionnaire study. BMC Med Educ. 2014;14(1):223. doi:10.1186/1472-6920-14-223
  14. Insley E, Tedesco K, Litman EA, Mangalapally N, Gicewicz C, Monaco -Brown Meredith L. The NICU Cuddler Curriculum: A Service-Learning Curriculum for Preclinical Medical Students in the Neonatal Intensive Care Unit. MedEdPORTAL. 2021;17:11069. doi:10.15766/mep_2374-8265.11069
  15. Mendelson T, Cluxton-Keller F, Vullo GC, Tandon SD, Noazin S. NICU-based Interventions To Reduce Maternal Depressive and Anxiety Symptoms: A Meta-analysis. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-1870
  16. French LM, Dietz FR. Screening for developmental dysplasia of the hip. American Family Physician. 1999 Jul 1;60(1):177-84.
  17. Modrell AK, Tadi P. Primitive Reflexes. [Internet]. StatPearls Publishing; 2021 [cited 2021 Dec 15]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554606/
  18. Sohn M, Ahn Y, Lee S. Assessment of Primitive Reflexes in High-risk Newborns. J Clin Med Res. 2011;3(6):285–90. doi:10.4021/jocmr706w

Categories
Letters

Child and adolescent psychiatry; an introduction to medical students

Parisa Fani-Molky, Aniqa Hussain, Dr Iain Perkes, Prof. Valsamma Eapen, Prof. Philip Hazell

Available Online: 17/04/2024

Abstract

Introduction: Child and adolescent psychiatry (CAP) is a subspecialty in the field of psychiatry focused on patients aged 0-18 years. CAP is unique, as children rarely seek help on their own, the engagement of parents or carers is always critical for appropriate management, and the relative effectiveness of intervention is unparalleled in clinical medicine.

Summary: Assessment by a child and adolescent psychiatrist is commonly triggered by a request from a general practitioner, paediatrician, school, welfare, or justice service. Management within CAP involves a multidisciplinary approach, including but not limited, to psychological therapy (individual and family), play and art therapy, occupational, speech and other allied health therapy, and pharmacological management. CAP utilises age-defined subspecialties (perinatal and infant, child and adolescent or youth psychiatry) as disorders are expressed differently at varying life stages and require different approaches to management. To attain training within the subspecialty of CAP in Australia and New Zealand, general psychiatry specialty training must first be completed. The outcomes of this CAP training as medical professionals include being able to integrate and apply the medical, developmental, and psychosocial knowledge gained to assist in managing psychopathologies in younger populations.

Key Learning Points:

  • Child and adolescent psychiatrists assess patients based on referrals from various sources, examining presenting symptoms, family history, and psychological factors.
  • Psychological therapy in CAP is tailored to each age group, and takes into consideration genetic, environmental, and cultural influences.
  • Child psychiatrists continue care into young adulthood, emphasizing autonomy and transition to adult services, with a focus on preventing relapse and loss of follow-up.
  • Becoming a child and adolescent psychiatrist in Australia involves specialized training, including completing an advanced certificate through RANZCP, with prerequisites and experiences in general psychiatry and CAP settings.

Introduction

There has been a cultural shift towards holistic care in modern medicine due to recent understandings regarding the various interconnections between physical and psychological health. However, the field of psychiatry has always understood the importance of holistically treating patients and basing treatment on a comprehensive assessment considering a patient’s biological, psychological (cognitive), family, financial, and cultural factors. This is particularly important in the subspecialty of child and adolescent psychiatry (CAP). Not only must we consider a child’s family, but also the developmental life stages and environments in which children interact. CAP focuses on a comprehensive bio-psychosocial assessment, justifying treatment plans which apply different modes of therapy to promote optimal mental health and quality of life.

It is estimated that one in seven Australian children aged between four and 17 experienced mental illness within the previous year [1]. However, as children may not be able to seek help by themselves, it is incumbent upon carers, school staff or agencies to recognise mental health issues in children and seek treatment on their behalf. Unfortunately, there has been a steady increase in the mental health needs of children and adolescents in Australia and New Zealand [2]. For example, the demand for hospital mental health admissions were 25-55% higher than predicted from July to November 2020 [2]. However, with the substantial increase in demand, their needs are not being adequately met due to a shortage of child and adolescent psychiatrists [3]. One factor influencing this shortage is a lack of awareness regarding CAP. Thus, we aim to summarise one common and one less common psychopathology seen and the unique clinical challenges faced across different age groups (early childhood, middle childhood, adolescence and transitioning to adult care). This is to highlight the importance of flexibility and adjusting clinical practise to best suit each patient to optimise overall outcomes. Additionally, we outline the basics of the CAP training pathway, with the aim to increase medical students’ understanding and appreciation of CAP.

Background

Assessments by child and adolescent psychiatrists are commonly triggered by a request from a general practitioner, paediatrician, school, welfare, or justice service [4,5]. The assessment of the child involves the clinician ascertaining the presenting symptoms and interacting with the child and relevant carers to obtain a developmental and family history and assess the mental, cognitive and behavioural state of the child [4-6]. A cognitive assessment by a psychologist and an assessment of speech and language, motor, sensory and daily living skills by allied health members and reports from the school form part of the bio-psychosocial assessment. A 2018 study conducted by Segal et al. examined the prevalence of CAP service usage in South Australia. It was found that from infancy to age 15, prevalence ranged from 5.3-7.6%, whereas in adolescence it increased to 16.3% [7]. Thus, it is essential to tailor therapeutic approaches for each age group as the prevalence of psychopathologies increases with adolescence [7].

Psychological therapy within CAP involves individual, family and group therapies, as well as psychotropic medication; the treatment mode recommended is dependent on service availability, patient preferences and clinical assessment and findings [8]. The main objective of the assessment is to ascertain the nature of the presenting complaint, precipitants, and its impact on the child’s life [4,5]. To establish a formulation regarding the current predicament, the clinician will consider both the child’s genetic predispositions, physical health, exposures from in utero through adolescence, and temperamental and cognitive traits and their wider environmental context, including parental mental health and the home and cultural factors like migration or indigenous heritage [4-6]. This approach aims to address any intergenerational trauma that may exist and other maladaptive behaviours that may have stemmed from their environments.

Overview of psychiatry in infancy and early childhood (0–5 years)

Social functioning evolves rapidly during the first three years of life, and infants vary considerably in their temperament [4,9]. Disorders with an onset in the first years of life usually reflect a disturbed infant-care relationship, in the context of parental mental illness, neurodevelopmental problems or other underlying medical conditions [4,6]. Infants with higher demands may place increased stress on carers, potentially compounding distress in both the infant and carer [4]. Hence, we have discussed both attachment disorders and autism spectrum disorders (ASD) within the context of early childhood psychiatry and appropriate clinical approaches.

Attachment disorders are thought to stem from an impairment between the infant and the parent to form healthy attachments [4,6,10,11]. Risk factors include parental mental illness such as maternal post-natal depression, neglect, abuse, abrupt separation from carers or frequent changes in care [11]. Assessment is age-specific and carried out by applying the ‘Strange Situation’ scenario where the child is separated from their carer, introduced to a stranger and then reunited with the carer with careful observation of behaviour [4]. Management of attachment problems includes therapies that focus on strengthening the relationship between primary caregivers and the infant to improve understanding of each other’s emotions in addition to programs focused on parenting skills with parent child psychotherapy and attention to feeding, sleeping and health difficulties of both caregiver and child [4].

Autism spectrum disorder (ASD) is one of a group of neurodevelopmental disorders that is characterised by social communication and interaction abnormalities together with restricted and repetitive patterns of behaviour [4,10,12]. Longitudinal cranial imaging studies have found excessive cortical thickening in early development, followed by cortical thinning during adolescence [4]. Those with ASD may present with stereotypic and repetitive behaviours, difficulty adapting to new situations, cognitive, social and communicative delays and differences [4,10,12]. Management consists of a multidisciplinary approach, including behavioural management, social skills training and carer support [4,12]. Individuals with ASD frequently experience other neurodevelopmental disorders such as attention deficit hyperactivity disorder (ADHD) as well as comorbid mood disorders such as anxiety and depression [10]. Second-generation antipsychotics have a role in reducing disruptive behaviours and dysregulation in extreme cases but must be used cautiously due to adverse cognitive and metabolic side-effects [4,12].

Overview of psychiatry in middle childhood (6–12 years) 

The primary school years see children moving their focus away from ties with their carers, beginning to explore complex relationships with others and acquiring social skills which will equip them to meet the social and learning demands of their school and peers [4]. They start developing ‘prosocial’ behaviour and empathy, including sharing and helping peers in distress [4]. Learning difficulties in these prosocial behaviours can disrupt the achievement of age-specific goals and may cause long-term implications, such as a mismatch between abilities and scholastic demands [4,9]. Two examples of psychopathologies that may appear within this age group are ADHD and conduct disorders and the differing clinical approaches required is generally discussed below.

ADHD is a neurodevelopmental disorder that manifests with developmentally excessive hyperactivity, distractibility, impulsivity and inattentiveness in multiple settings [4,10,13]. Children may have predominantly poor concentration (inattentive subtype), or overactivity and impulsivity (hyperactive-impulsive subtype) or a combined-type ADHD [4,10,13]. Functional neuroimaging shows underactivity in the frontal lobes, the caudate nucleus and overactivity in the amygdala [4]. Serial MRI studies show widespread, delayed thickening in cortical structures compared with controls [4]. Management is multimodal, with behavioural counselling, classroom strategies, parent education and central nervous system stimulants such as methylphenidate and amphetamine [4, 13]. The use of medication must be regularly reviewed for therapeutic response and side-effects.

Conduct disorder (CD) is described by repeated bullying, deception, thieving, cruelty and violence to people or animals, not better explained by another condition [4,10,14]. Early signs of aggression and defiance can be seen in children as young as two years old; however, an isolated antisocial act does not warrant the diagnosis [4,14]. There is reduced amygdala activity in response to frightening faces in those with callous-unemotional traits compared with those without; this hypoactivity is contrasted with amygdala hyperactivity (compared with healthy controls) in cases of CD without callous-unemotional attributes [4]. Established CD resists change, so early intervention is crucial [4]. Multisystemic therapy that utilises social and emotional learning and cognitive behavioural therapy (CBT) helps to reduce behavioural symptoms while selective use of antipsychotics and mood stabilisers can also be helpful [4, 14]. About half the children with CD will manifest an antisocial personality pattern or related psychopathology in adulthood [4, 14].

Overview of psychiatry in adolescence (13–18 years)

Adolescence is a phase of profound changes in social relationships, body morphology,

responsibilities, and personality traits [4,9]. These changes reflect a shift to a more autonomous role and greater internal control, the hallmarks of adult functioning [4]. Many serious psychiatric disorders—schizophrenia spectrum disorder, substance abuse, mood disorders, borderline personality disorder, anorexia and bulimia nervosa—can have their onset during this period, although there is often a developmental history of emotional and behavioural problems during childhood [4,9].

Although depression can occur in young children, its incidence increases in adolescence [4,15]. Depression is gradual in onset and may present atypically, with irritability, hypersomnia or binge eating [4,10,15]. Comorbidity is common, particularly with behaviour problems, substance abuse and anxiety. One in 10 adolescents suffers a major depressive episode that meets diagnostic criteria and leads to functional impairment [4,15]. Still, only a small proportion are accurately diagnosed and treated [4]. While mild symptoms may remit spontaneously, persistent mild to moderate symptoms require and are usually responsive to psychological treatment. Antidepressant medications are less effective than in adults but are prescribed in more severe cases with active monitoring of response and side-effects [4,15].

Schizophrenia, presenting with psychotic symptoms such as delusions and hallucinations, usually has its onset in late adolescence to mid-twenties and is exceptionally in those younger [4,10,16]. Prodromal symptoms include mood and behavioural changes, with obsessional thinking and odd beliefs [4,10,16]. When psychotic symptoms first manifest, organic aetiologies of psychosis such as central nervous system abnormalities, intoxication, metabolic derangements, and immune-mediated conditions need to be ruled out [4,16]. Treatment is multidisciplinary, including second-generation antipsychotics, psychological therapy and social support as well as psychoeducation for carers [4,16].

There is a clear evidence base for individual psychotherapy in children and adolescents including CBT, interpersonal psychotherapy, dialectical behavioural therapy, and mindfulness-based therapy depending on the psychopathology and cognitive ability [4]. Family therapy is utilised when structural or communication difficulties manifest within the family [4]. When assessing adolescents, the clinician may offer to see the patient on their own and then involve the parents [4,5]. Prior to this, confidentiality, and its limits—if there is risk of harm to the patient or third party—should be discussed with the adolescent [4]. Informed consent is required from parents and adolescents over 15 years of age, however children under 15 years of age can ‘assent’ to treatment but is not necessary when there is parental consent [4]. Regardless, a graded approach is used, and explanations are tailored to the patient’s intellectual and emotional capacity. Parents and children are provided psychoeducation regarding the nature of the condition and its recommended treatments [4,8]. Goals are formed in a collaborative manner by identifying specific behaviours or problems in both the home and outside environments [4].

Overview of psychiatry in young adulthood (18-25 years)

Although this demographic does not fit into childhood, child and adolescent psychiatrists may continue care of these patients due to factors such as a lack of resources and urgency of care. Clinical trial data specific to this age group is difficult to ascertain as it is usually captured in the age range of 18 to 65 years. However, a large focus in this age group is on transition of care to adult services [4]. The young person is now expected to act autonomously and manage themselves which may prove to be difficult [4]. Transition to adult care is more likely to succeed if they are jointly supported by both CAP and adult facilities during this period to prevent relapse, recurrence, or loss to follow up [4].

Pathway to a career in CAP

Child and adolescent psychiatrists need to complete a Certificate of Advanced Training of the Royal Australian and New Zealand College of Psychiatrists (RANZCP). Entry to CAP in Australia and New Zealand is via a RANZCP accredited general psychiatry training program and hospital/mental health service registrar employment (minimum five years) (Figure 1) [3,17]. All general psychiatry trainees undertake a six-month term in CAP, usually in the second or third year of training [3,16]. To specialise in CAP and complete the Certificate of Advanced Training, senior psychiatry trainees then spend their final 24 months of training in accredited CAP training posts, where they will be exposed to a full range of child and adolescent mental health conditions [3,17]. However, they can also complete the full five years of general psychiatry and graduate as a Fellow of the RANZCP and then subsequently decide to do CAP training [3,17]. The Advanced Certificate of CAP training involves placement in a community and inpatient setting (at least 6 months each), together with the accredited program of specialist education and the option to complete a research project [3,17]. There is no exit examination for CAP, but trainees are required to satisfactorily complete several work-based assessments during the two years of subspecialty training [3,17]. Figure 2 outlines a resource list for those interested in learning more about CAP in Australia and New Zealand.

Figure 1. The pathway to child and adolescent psychiatry. After three years of training in general psychiatry, trainees complete two years of subspecialist training, including of both inpatient and community settings. Four observed clinical assessments and eight entrustable professional activities are completed to demonstrate clinical competency.

Figure 2. Resources for emerging child and adolescent psychiatrists in Australia and New Zealand. The International Association for Child and Adolescent Psychiatry and Allied Professions (IACAPAP) is a free e-textbook of Child and Adolescent Mental Health, written by an international group of child and adolescent psychiatrists and allied professionals. The Psychiatry Interest Forum (PIF) provides information and opportunities for medical students and junior doctors interested in psychiatry. The Faculty of Child and Adolescent Psychiatry (FCAP) of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) advises on training, clinical practice, and research. The Foundations of Clinical Psychiatry (4th Edition) is an introductory textbook for medical students and covers all fields of psychiatry from a biological, psychological, and social lens. 


Conclusion

CAP is a dynamic subspecialty focused on early intervention with the aim of providing better long-term mental health outcomes for children and their families. A key benefit of intervening early through CAP is the impact medical practitioners can have in improving the trajectory of a child and their family’s lives. The outcomes of CAP training for medical professionals include being able to integrate and apply the knowledge gained within their training to the comprehensive assessment of childhood psychopathology and deliver targeted treatments and management plans. Through this, they will be able to facilitate effective service delivery for children, adolescents and their families and help them navigate the various multifaceted and complex dilemmas faced by children requiring psychiatric care. 

References

  1. Mental health services in Australia Australian Institute of Health and Welfare. 2022. Available from: https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-content/prevalence-impact-and-burden-of-mental-health?fbclid=IwAR0fvPYWrkdCAWKlC0POYvaZCVj-Rdgn5sgK6UfCVDIDFP0bEP6DWMJdfH0
  2. Hu N, Nassar N, Shrapnel J, Perkes I, Hodgins M, O’Leary F, et al. The impact of the COVID-19 pandemic on paediatric health service use within one year after the first pandemic outbreak in New South Wales Australia – a time series analysis. Lancet Reg Health West Pac. 2022;19:100311. doi: 10.1016/j.lanwpc.2021.100311
  3. Perkes IE, Eggleston M, Jacobs B, McEvoy P, Fung D, Robertson PG. The making of child and adolescent psychiatrists in Australia and New Zealand. Australian and New Zealand journal of psychiatry. 2021:486742110556-48674211055654. doi: 10.1177/00048674211055654
  4. Hazell P, Perkes IE. Child and Adolescent Psychiatry. In: Bloch S, et al., editor. Foundations of Clinical Psychiatry Fourth Edition. Melbourne, Australia: Melbourne University Publishing; 2017. p. 366-92.
  5. Lempp T, Lange Dd, Radeloff D, Bachmann C. The clinical examination of children, adolescents and their families. In: Rey JM, editor. IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions; 2012.
  6. Mares S, Woodgate S. The clinical assessment of infants, preschoolers and their families. In: Rey JM, editor. IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions; 2017.
  7. Segal, L., Guy, S., Leach, M., Groves, A., Turnbull, C., Furber, G., 2018. A needs-based workforce model to deliver tertiary-level community mental health care for distressed infants, children, and adolescents in South Australia: a mixed-methods study. The Lancet Public Health 3, e296–e303. doi:10.1016/s2468-2667(18)30075-6
  8. Lorberg B, Davico C, Martsenkovskyi D, Vitiello B. Principles in using psychotropic medication in children and adolescents. In: Rey JM, editor. IACAPAP Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions; 2019.
  9. IACAPAP Textbook of Child and Adolescent Mental Health. Rey JM, editor. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions; 2012.
  10. Diagnostic and statistical manual of mental disorders : DSM-5-TR. 5th edition, text revision. ed. Washington, DC: American Psychiatric Association Publishing; 2022.
  11. Erikson, Erik H. Childhood and Society. 2nd ed. London, England: Triad, 1977.
  12. Fuentes J, Bakare M, Munir K, Aguayo P, Gaddour N, Öner Ö. Autism spectrum disorder. In: Rey JM, editor. IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions; 2014.
  13. Sousa AdFd, Coimbra IM, Castanho JM, Polanczyk GV, Rohde LA. Attention deficit hyperactivity disorder. In: Rey JM, Martin A, editors. JM Rey’s IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions; 2020.
  14. Scott S. Conduct disorders. In: Rey JM, editor. IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions; 2012.
  15. Rey JM, Bella-Awusah TT, Liu J. Depression in children and adolescents. In: Rey JM, editor. IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions; 2015.
  16. Starling J, Feijo I. Schizophrenia and other psychotic disorders of early onset. In: Rey JM, editor. IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions; 2012
  17. Certificate of Advanced Training in Child and Adolescent Psychiatry: The Royal Australian and New Zealand College of Psychiatrists. 2015. Available from: https://www.ranzcp.org/pre-fellowship/about-the-training-program/certificates-of-advanced-training/child-and-adolescent-psychiatry
Categories
Review Articles

Pharmacotherapies for muscle wasting in older ICU patients: A narrative review of the current literature

Dr. Finn Dolan Cogswell, MD BSc

ABSTRACT

Background: The predominantly geriatric syndrome of frailty can result from the gradual reduction of function in multiple physiologic systems that occurs with increasing age. Critical illness accelerates the age-related loss of muscle that often accompanies frailty, and the combination of these two conditions creates a distinctly morbid state of vulnerability. Muscle wasting while in the intensive care unit (ICU) results in greater patient morbidity, making the preservation of muscle mass an important therapeutic target. This article narratively reviews the drug therapies that have been trialed for mitigating muscle wasting in older critically ill patients.

Materials and Methods: MEDLINE, PubMed, Web of Science and EMBASE were searched. Inclusion criteria were drug trials with muscle-related outcome measures in critically ill populations aged 50 or older. Exclusion criteria were non-pharmacological interventions, a lack of muscle related outcomes, review articles, case studies, case series and non-English articles. 

Results: From 4586 identified articles, 27 articles were included in the final review. While burn populations benefitted from oxandrolone, the only pharmacotherapy that demonstrated an improvement of muscle outcomes in older general ICU patients was intensive insulin therapy. However, due to the risk of hypoglycaemia, the use of intensive insulin therapy remains largely unfavourable.

Discussion: The requirement for an effective drug therapy targeting the preservation of muscle mass in older ICU populations remains unfulfilled. Several novel drug therapies targeting myostatin and activin receptors have recently been studied in frail, non-critically ill populations. Future research should focus on studying novel pharmacotherapies in the frail and critically ill. 

Download (PDF, 224KB)

Categories
Review Articles

Effectiveness of baclofen for the treatment of alcohol use disorder in patients with alcoholic liver disease: a narrative literature review

Available online: 24th February 2023

Luisa Wigg

James Cook University

Background: Alcohol use disorder (AUD) is linked to alcoholic liver disease (ALD), which contributes greatly to the global burden of disease. Baclofen has been studied in patients with these concurrent disorders. However, due to limited research, baclofen is only used off-label.

Aim: To determine the effectiveness of baclofen for the treatment of AUD and ALD.

Methods: MEDLINE, Scopus and The Cochrane Library were searched using the terms [((“alcohol use disorder” OR “alcohol dependence”) AND (“alcoholic liver disease” OR “cirrhosis”)) AND (“baclofen”)]. Additional papers were retrieved from the reference lists of relevant studies.

Results: We identified seventy-one studies and retrieved two from reference searching. Ten studies meeting inclusion and exclusion criteria were retained for review, four of which were randomised controlled trials (RCTs). Retrospective and prospective cohort studies were also included, along with one Markov model. The literature defined baclofen’s effectiveness in terms of abstinence, alcohol consumption, hospitalisations, cost-effectiveness, mortality rates, and side effects. While controlled evidence is limited, baclofen was found to promote abstinence, whilst also reducing drinking levels, long-term mortality, and days spent in hospital. Additionally, the drug had a favourable cost-effectiveness profile. However, acute confusion and overdoses have been reported, particularly with high dosages.

Conclusion: Our findings support the efficacy and use of baclofen to treat AUD and ALD. The risk of serious adverse events remains a concern, requiring vigilant prescribing and reporting from healthcare professionals. RCTs and studies with larger sample sizes are required to support these initial findings and confirm the viability of baclofen.

Keywords: Alcohol use disorder; alcoholic liver disease; baclofen; effectiveness; abstinence

Download (PDF, 335KB)

Categories
Letters

Trends in mental health service access and recent implementation of telehealth and online services for mental health

Download (PDF, 194KB)

Categories
Case Reports

Asherman’s syndrome – an important clinical update

The patient is a 36-year-old G2P2 female with a complex gynaecological history, including a previous diagnosis of Asherman’s syndrome. She presented to an outpatient clinic with complaints of increasing pelvic pain, intermenstrual bleeding and subfertility. The patient detailed a 12-month history of increasing pelvic pain. She also reported intermenstrual bleeding, lasting up to one week. The patient reported that her menstrual flow had significantly decreased over the last 12 months. The patient and her husband had a strong desire to have a third child and the ongoing implications of Asherman’s syndrome could be seen to have a significant emotional impact on the couple.

Download (PDF, 246KB)

Categories
Letters

The utility of the physical exam: a reflection

A reflection of my experiences of the physical examination This is an excerpt from an essay that won the 2020 UWA Quality and Safety Essay prize.

Download (PDF, 122KB)

GDE Error: Unsupported File Type (jpg)
Categories
Feature Articles

A bioethical case against using human challenge trials for COVID-19

Abstract

COVID-19 is a global health emergency for which vaccines are a key solution. A human challenge trial (HCT) is a way of studying vaccine efficacy where healthy volunteers are deliberately infected, in contrast to traditional phase III trials. Nearly 40 000 people worldwide have expressed willingness to participate in COVID-19 HCTs in hopes of accelerating vaccine development. This essay argues that HCTs may not only fail to deliver on this aim, but violate the bioethical principles of autonomy, beneficence, non-maleficence, and justice. For now, in the case of COVID-19, HCTs are inferior to tried-and-true phase III trials, which have already generated several vaccines at unprecedented speed.

Learning Points

  1. COVID-19 is a global health emergency for which vaccines are a key solution.
  2. The risks of human challenge trials for COVID-19 outweigh their benefits in terms of the bioethical principles of autonomy, beneficence, non-maleficence, and justice.
  3. Since traditional phase III trials have generated COVID-19 vaccines at unprecedented speed, there is currently negligible role for human challenge trials for COVID-19.

Download (PDF, 306KB)

Categories
Letters

Caesarean delivery on maternal request: a personalised approach informed by principle-based ethics

Learning Points

  • Caesarean delivery on maternal request (CDMR) is a commonly encountered clinical scenario in Australia, accounting for 17% of all caesarean deliveries.
  • The approach to CDMR should include assessment of medical suitability as well as discussion of the factors motivating the patient’s preference to ensure caesarean delivery will be in the interests of the overall health and wellbeing of the mother and fetus. Gaining genuinely informed consent through detailed and objective communication of potential risks and benefits is also vital in respecting patient autonomy.
  • A woman’s preference for caesarean delivery is often the product of a complex interaction between personal, cultural, and environmental factors. Consideration of ethical principles such as autonomy, beneficence, non-maleficence, and justice provides a suitable framework by which the clinician may evaluate the ethics of performing a caesarean delivery. However, it does not generate an ethical obligation to do so.

Download (PDF, 101KB)