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Cylchgrawn
Pediatrig Cymru
Cylchgrawn Cymdeithas
Pediatrig Cymru
The Welsh
Paediatric Journal
The Journal of the
Welsh Paediatric Society
www.welshpaediatrics.org.uk
Cyfrol 55 2021 Volume 55
WELSH PAEDIATRIC SOCIETY CYMDEITHAS PEDIATRIG CYMRU
Contents / Cynnwys
EDITORIAL
GOLYGYDDOL
Editorial – Powell CVE and Vallabhaneni P 2
ORIGINAL PAPERS
PAPURAU GWREIDDIOL
Ten-year review of congenital pulmonary malformations in South, Mid and West Wales –
Price L, King E, Parks E, Isaac R, Doull I, Forton JT, Thia LP
Optimising timing for pneumococcal vaccination in children undergoing emergency
splenectomy – Cawthra A, Vallabhaneni P
The COVID-19 pandemic and its impacts on the environment. The voices of
young people in Wales – Johns G, Khalil S, Ahuja S, Johns E, Ogonovsky M, Ahuja A
The use of warfarin and monitoring INRs in paediatric cardiology – Telfort S, Pateman A
Remote working in Child and Adolescent Mental Health Services (CAMHS) –
Williams J, Wright P, Johns G, Moore A, Bhardwaj A, Dubicka B, Ahuja A
4
8
13
17
21
EDUCATION AND TRAINING
ADDYSG A HYFFORDDIANT
Voice of the trainees – Walker O, Brzyska K
Quality improvement in focus – Brown L
Paediatric Trainee Representative update (North Wales) – Crawley L, Paquete B
Paediatric Trainee Representative update (South Wales) – Blundell P, Davies H
Investing in our future paediatricians – Dadnam C
Out of hours – Deacon L
26
27
30
31
31
32
BOOK REVIEW
ADOLYGIAD LLYFR
How Medical Education came to Wales – Vallabhaneni P 34
PERSONAL VIEW
GOLWG PERSONOL
A kaleidoscope from the past: memories of an earlier life (continued) – Davies DP 35
NOTICEBOARD / HYSBYSFWRDD Noticeboard 42
WALES MATERNITY AND
NEONATAL NETWORK
RHWYDWAITH MAMOLAETH A
NEWYDDENEDIGOL CYMRU
Abstracts from the 14 June 2021 Neonatal Annual Audit & Quality Improvement event 43
WELSH PAEDIATRIC SOCIETY
CYMDEITHAS PEDIATRIG CYMRU
President’s message – Tuthill D 49
INFORMATION FOR AUTHORS
GWYBODAETH I AWDURON
Information for Authors 50
WELSH PAEDIATRIC SOCIETY
CYMDEITHAS PEDIATRIG CYMRU
Autumn meeting 2021
Spring prize winners 2021
Abstracts for the Autumn meeting 2021
52
53
54
INDEX
MYNEGAI
Index 66
OFFICERS
Editor/Golygydd
Pramodh Vallabhaneni
Department of Paediatrics
Singleton Hospital
SWANSEA SA2 8QA
pramodh.vallabhaneni@wales.nhs.uk
Outgoing Editor/Golygydd Allanol
Professor Colin Powell
Department of Emergency Medicine
Sidra Medicine, Al Rayaan
Education City, Doha, QATAR
powellc7@cardiff.ac.uk
WPJ Manager/Rheolwr WPJ
Heather O’Connell
Department of Child Health
University Hospital of Wales
CARDIFF CF14 4XN
heather.oconnell@wales.nhs.uk
Past Editors Cyn Golygyddion
Professor B Ansari 1989-1999 Yr Athro B Ansari
Professor DP Davies 1993-2005 Yr Athro DP Davies
John Morgan 2005-2008 John Morgan
Trainee Representatives/
Cynrychiolwyr dan Hyfforddiant
Oliver Walker
Neonatal Unit
Singleton Hospital
SWANSEA SA2 8QA
oliver.walker@doctors.org.uk
Klara Brzyska
Department of Oncology/Haematology
Noah's Ark Children's Hospital for Wales
CARDIFF CF14 4XN
klara.brzyska@wales.nhs.uk
Editorial Team
Assistant Editors/
Golygyddion Cynorthwyo
Torsten Hildebrandt
Department of Paediatrics
Princess of Wales Hospital
BRIDGEND CF21 1RQ
torsten.hildebrandt@wales.nhs.uk
Mike Cosgrove
Department of Child Health
Singleton Hospital
SWANSEA SA2 8QA
mike.cosgrove@wales.nhs.uk
WPJ Advisory Committee/
Pwyllgor Ymgynghorol CPC
Academic Research Representative -
Claire Morgan (Swansea University)
Citability Representative -
Simon Fountain-Polley (HDUHB)
Community Representative -
Francesca Norris ST8 (CAVUHB)
Neonatal Representative -
Mallinath Chakraborty (CAVUHB)
North Wales Representative -
Artur Abelian - (BCUHB)
Social media/Podcasts Representative -
Assim Javaid ST5 (SBUHB)
Website/Social media Representative -
Andrew Hallett (CTMUHB)
2
Welsh Paed J 2021; 55: 2
WELSH PAEDIATRIC SOCIETY CYMDEITHAS PEDIATRIG CYMRU
Welcome to the Autumn 2021
edition of the Journal. You will
remember in my last editorial I
told you that WPJ is going green?
PDF versions of the journal will be
delivered via email to all members,
all articles will be accessible
through the Welsh Paediatric
Society website and libraries will
continue to receive a hard copy,
even when we return to face to face
meetings. As I write this the Autumn WPS meeting is, I hear, in
planning to be back to (nearly) normal, as a real meeting! Please
have as much fun as you can at the (masked up and distanced)
face to face meeting at a really splendid venue too for this terric
‘welcome back’ WPS meeting!
is will also be my last Editorial. One of the new editorial
team, Dr Pramodh Vallabhaneni in Swansea, will be fully taking
over from me as Editor for the 2022 editions; and I know he has
many exciting plans for the future of the WPJ. You know I would
only leave the Journal in good hands.
So, please nd the abstracts for the WPS meeting at the back
as usual. Further forward you will nd the Abstracts from the 14
June 2021 Neonatal Annual Audit & Quality Improvement event.
is is new this year, and courtesy of one of our new Editorial
Advisory Committee – Mallinath Chakraborty. Other members
are: Simon Fountain-Polley, Claire Morgan, Andrew Hallett,
Artur Abelian, Assim Javaid and Francesca Norris.
e Education section from Oliver Walker (Oli’s last one too,
as he has now completed his training – Good luck, Oli!) and Klara
Brzyska contains a brand-new section – Quality Improvement in
Focus. en we have interesting reports from the north and the
new south trainee reps, a report on the importance of investing
in our future paediatricians plus a typically Welsh sporty out of
hours report.
We have ve great original articles this time, a book review
from our new Editor, plus some more memories from former
WPJ Editor DP Davies about
his days’ as a houseman in
the sixties. Please submit any
articles, reports and reviews via
the WPS Journal webpage at
www.welshpaediatrics.org.uk or
directly to Heather O’Connell
and Pramodh Vallabhaneni.
A note to the presenters of
abstracts to the autumn meeting
– articles on any developments
from these presentations are most welcome! My thanks to the
people who kindly reviewed and proofed the articles during my
years as Editor.
Assistant Editor Mike Cosgrove will also be retiring from
the editorial board, though Torsten Hildebrandt and Heather will
still be there, with Klara, to support the new Team. Some people
who said they were interested (in the survey) forgot to leave their
details, so if you are keen to be involved (especially from north
Wales) please contact the new Editor!
It has been an honour and privilege to be Editor of the Welsh
Paediatric Journal over the years. I thank all those who have
contributed, all those who have peer reviewed, and all those who
have read the articles. I thank the editorial team, all the trainee
reps, the presidents, heads of school and college reps. I especially
thank Heather Oconnell. She is core to the Journal and I will be
ever thankful for her magnicent contribution to getting each
edition out on time and copy-edited, proof read and sorted!
ankyou
You are in good hands with the new editorial team. Pram will
be (is) great …. Everybody – stay well, be happy and care for each
other.
diolch yn fawr iawn
Colin Powell
Outgoing Editor
vvv
Croeso i rifyn Hydref 2021 y Cyfnodolyn. Byddwch yn coo
yn fy erthygl olygyddol ddiwethaf imi ddweud wrthych fod
CPC yn mynd yn wyrdd? Bydd fersiynau PDF o'r cyfnodolyn
yn cael eu cywyno drwy e-bost i'r holl aelodau, bydd yr holl
erthyglau ar gael drwy wefan Cymdeithas Pediatreg Cymru a
bydd llyfrgelloedd yn parhau i dderbyn copi caled, hyd yn oed
pan fyddwn yn dychwelyd i gyfarfodydd wyneb yn wyneb. Wrth
i mi ysgrifennu hwn, mae cyfarfod WPS yr Hydref, rwy'n clywed,
wrth gynllunio i fod yn ôl i (bron) normal, fel cyfarfod go iawn!
Cewch gymaint o hwyl ag y gallwch yn y cyfarfod wyneb yn
wyneb (wedi'i guddio a'i ymbellhau) mewn lleoliad gwych iawn
hefyd ar gyfer y cyfarfod WPS 'croeso yn ôl' gwych hwn!
Hwn fydd fy Golygyddol olaf hefyd. Bydd un o'r tîm
golygyddol newydd, Dr Pramodh Vallabhaneni yn Abertawe, yn
cymryd yr awenau'n llawn gennyf fel Golygydd rhifynnau 2022;
a gwn fod ganddo lawer o gynlluniau cyrous ar gyfer dyfodol y
CPC. Gwyddoch na fyddwn ond yn gadael y Cyfnodolyn mewn
dwylo da.
Felly, dewch o hyd i'r crynodebau ar gyfer cyfarfod CPC yn
y cefn yn ôl yr arfer. Ymhellach ymlaen fe welwch y Crynodebau
o'r digwyddiad Archwilio a Gwella Ansawdd Blynyddol
Newyddenedigol ar 14 Mehen 2021. Mae hyn yn newydd eleni,
a thrwy garedigrwydd un o'n Pwyllgor Cynghori Golygyddol
newydd – Mallinath Chakraborty. Dyma'r aelodau eraill: Simon
Fountain-Polley, Claire Morgan, Andrew Hallett, Artur Abelian,
Assim Javaid a Francesca Norris.
Mae'r adran Addysg gan Oliver Walker (un olaf Oli hefyd,
gan ei fod bellach wedi cwblhau ei hyorddiant – Pob lwc,
Oli!) a Klara Brzyska yn cynnwys adran newydd sbon – Gwella
Ansawdd mewn Ffocws. Yna mae gennym adroddiadau diddorol
gan y gogledd a chynrychiolwyr newydd dan hyorddiant y de,
adroddiad ar bwysigrwydd buddsoddi yn ein pediatregwyr yn
Editorial/Golygyddol
3
Welsh Paed J 2021; 55: 3
WELSH PAEDIATRIC SOCIETY CYMDEITHAS PEDIATRIG CYMRU
y dyfodol ynghyd ag adroddiad chwaraeon cymreig y tu allan i
oriau arferol.
Mae gennym bum erthygl wreiddiol wych y tro hwn,
adolygiad o lyfrau gan ein Golygydd newydd, ynghyd â mwy
o atgoon gan gyn Olygydd CPC DP Davies am ei ddyddiau'
fel dyn tŷ yn y chwedegau. Cywynwch unrhyw erthyglau,
adroddiadau ac adolygiadau drwy dudalen we WPS Journal
yn www.welshpaediatrics.org.uk neu'n uniongyrchol
i Heather O'Connell a Pramodh Vallabhaneni. Nodyn
i gywynwyr crynodebau i gyfarfod yr hydref – mae
croeso mawr i erthyglau ar unrhyw ddatblygiadau o'r
cywyniadau hyn! Diolch i'r bobl a fu'n adolygu ac yn
pro'r erthyglau yn ystod fy mlynyddoedd fel Golygydd.
Bydd y Golygydd Cynorthwyol Mike Cosgrove
hefyd yn ymddeol o'r bwrdd golygyddol, er y bydd
Torsten Hildebrandt a Heather yn dal i fod yno, gyda
Klara, i gefnogi'r Tîm newydd. Anghoodd rhai pobl
a ddywedodd fod ganddynt ddiddordeb (yn yr arolwg)
adael eu manylion, felly os ydych yn awyddus i gymryd rhan (yn
enwedig o ogledd Cymru) cysylltwch â'r Golygydd newydd!
Bu'n anrhydedd ac yn fraint cael bod yn Olygydd Cyfnodolyn
Pediatrig Cymru dros y blynyddoedd. Diolch i bawb sydd wedi
cyfrannu, pawb sydd wedi adolygu gan gymheiriaid, a phawb
sydd wedi darllen yr erthyglau. Diolch i'r tîm golygyddol, yr
holl gynrychiolwyr dan hyorddiant, llywyddion, penaethiaid
cynrychiolwyr ysgolion a cholegau. Diolch yn arbennig i Heather
Oconnell. Mae hi'n greiddiol i'r Cyfnodolyn a byddaf byth yn
ddiolchgar am ei chyfraniad gwych i gael pob rhifyn
allan ar amser a golygu copi, prawfddarllen a didoli!
Diolch yn fawr
Rydych mewn dwylo da gyda'r tîm golygyddol
newydd. Pram fydd (yw) gwych .... Pawb – arhoswch yn
dda, byddwch yn hapus a gofalwch am ei gilydd.
diolch yn fawr iawn
Colin Powell
Golygydd Allanol
I will keep this very brief
and short and perhaps use
the next editorial to inform
our readers of the plans for
the future. For now, we all
should celebrate and take
a moment to thank Colin
Powell for his contribution
to the Welsh Paediatric
Journal. His vision and
leadership have shaped the
journal in its current form.
When we recently met him
virtually with the newly formed editorial committee, it struck me
that all the new suggestions to improve the journal were already a
part of it. is is a small reminder of how visionary his ideas and
reforms have been for the journal. Perhaps it also reected that
we need to better publicise our journal for readers to benet from
its excellent content.
Colin is a tough act to follow, but I am excited and am looking
forward to this challenge. We have a great team with lots of ideas.
We met recently for a luncheon in Miskin Manor, and here is a not
so zoomed picture of it. Constructive feedback has been provided
to the amateur photographer!
ank you, Colin and special thanks to Heather, who is
helping me understand behind the scenes work.
Regards
Pramodh Vallabhaneni
New Editor
Byddaf yn cadw hyn yn
fyr ac yn fyr ac efallai'n
defnyddio'r golygyddol
nesaf i roi gwybod i'n
darllenwyr am y cynlluniau
ar gyfer y dyfodol. Am y
tro, dylem i gyd ddathlu a
chymryd eiliad i ddiolch i
Colin Powell am ei gyfraniad
i Gyfnodolyn Pediatrig
Cymru. Mae ei weledigaeth
a'i arweinyddiaeth wedi
llunio'r cyfnodolyn ar
ei urf bresennol. Pan gyfarfuom ag ef bron yn ddiweddar
gyda'r pwyllgor golygyddol newydd, fe'm trawodd fod yr holl
awgrymiadau newydd i wella'r cyfnodolyn eisoes yn rhan ohono.
Dyma nodyn bach i'ch atgoa o ba mor weledigaethol y bu ei
syniadau a'i ddiwygiadau ar gyfer y cyfnodolyn. Efallai ei fod
hefyd yn adlewyrchu bod angen inni roi cyhoeddusrwydd gwell
i'n cyfnodolyn er mwyn i ddarllenwyr elwa o'i gynnwys rhagorol.
Mae Colin yn weithred anodd i'w dilyn, ond rwy'n gyrous
ac rwy'n edrych ymlaen at yr her hon. Mae gennym dîm gwych
gyda llawer o syniadau. Cyfarfuom yn ddiweddar am ginio ym
Meisgyn Manor, a dyma lun heb ei chwyddo cymaint ohono. Mae
adborth adeiladol wedi'i roi i'r otograydd amatur!
Diolch, Colin a diolch arbennig i Heather, sy'n fy helpu i
ddeall y tu ôl i waith y llenni.
Coon
Pramodh Vallabhaneni
Golygydd Newydd
4
Welsh Paed J 2021; 55: 4-26
ORIGINAL PAPERS PAPURAU GWREIDDIOL
REVIEW ARTICLE ERTHYGL ADOLYGIAD
Ten-year review of congenital pulmonary
malformations in South, Mid and West Wales
Price L¹, King E ², Parks E², Isaac R², Doull I ¹, Forton JT 1,3, Thia LP ¹
¹Paediatric Respiratory Medicine, Noah's Ark Children’s Hospital for Wales, Cardiff;
²Paediatric Radiology, Noah's Ark Children’s Hospital for Wales, Cardiff; ³School of Medicine, Cardiff University, Cardiff
Abstract
Introduction Congenital pulmonary malformations (CPM) are
increasingly detected through antenatal screening but there is no
universal guidance on the management of small asymptomatic
lesions.
Objective To evaluate the management and outcome of CPM
detected antenatally and postnatally.
Design Ten years retrospective review
Setting & patients All infants in South, Mid and West Wales with
chest CT performed under one year of age from 2010-2019 at the
Noah’s Ark Children's Hospital for Wales, Cardi.
Interventions Surgery for CPM or observational monitoring
Main outcome measures Types of CPM from chest CT,
management and outcomes.
Results Seventy-ve infants had conrmed CPM. Six were
diagnosed postnatally due to respiratory symptoms of which ve
required surgery (1 bronchopulmonary sequestration (BPS), 3
congenital lobar overination (CLO), 1 benign tumour). Sixty-
nine antenatally detected conrmed cases of CPM consisted of 33
congenital pulmonary airway malformations (CPAM), 23 BPS, 9
CLO, 4 "others". Forty-ve (60%) of all CPM were resected due
to size of lesions, feeder vessels or symptoms. Fourteen (19%)
(7 CPAM, 3 BPS, 4 CLO) required early surgery for respiratory
distress or recurrent chest infections. One neonate died aer
surgery due to prematurity. irty-one (41%) were managed
conservatively and monitored over median duration of 12m
(range: 1-72m). No child developed recurrent lower respiratory
tract infections or malignancy.
Conclusion is study revealed that 60% of all CPM in Wales
had surgery with minimal complications. For this cohort
low complication rate also exists for small CPM managed
conservatively and its results could be used to counsel parents
about future treatment.
Keywords Congenital lung lesions, neonates
Introduction
Congenital pulmonary malformations (CPM) consist of
congenital pulmonary airway malformations (CPAM),
bronchopulmonary sequestrations (BPS), bronchogenic cysts,
congenital lobar overinations (CLO) and combinations of
these. Dierent literature will quote varying prevalence of
CPM however it generally ranges from 1-4 per 10,000 births.1,2
With advancement in foetal medicine using ultrasound (USS)
and magnetic resonance imaging (MRI), the detection of these
lesions has improved as such some studies are now suggesting an
increase of prevalence from more recent data. ere is a Welsh
Congenital Anomaly Register and Information Service (CARIS)
which has recorded 114 cases over a 20-year period, 1998-2017.
is gives a prevalence rate of 1.7 per 10,000 total births.
e mean gestational age at antenatal diagnosis is 21-24
weeks: very few of these lesions grow aer 28 weeks. ese lesions
may either completely resolve, reduce in size or enlarge. Some
large lesions may cause serious complications antenatally such as
foetal hydrops which has a high risk for miscarriage. Although
there are treatment options antenatally, there is currently little
evidence to support these treatments.6,7 A study by Cavoretto et
al demonstrated that only 44.7% of antenatally diagnosed lesions
were conrmed postnatally. Hence infants with antenatally
detected CPM soon aer birth would require careful clinical
examination to exclude respiratory compromise, and in South
Wales an initial chest radiograph (CXR) is performed (Figure
one). orough assessment to delineate CPM is conducted
through a chest computerised tomography (CT) scan performed
by 6 months of age even if a CXR is reported as normal. A chest
CT scan is performed to ensure complete resolution of antenatally
detected CPM. CPM can also present postnatally with respiratory
distress and mediastinal shi on postnatal CXR or later in life
with recurrent respiratory infections or incidentally in adulthood9
conrmed with a chest CT.
Figure 1 South Wales pathway of antenatally detected
congenital pulmonary malformations
5
Welsh Paed J 2021; 55: 4-26
ORIGINAL PAPERS PAPURAU GWREIDDIOL
Early symptoms of respiratory distress would lead to resection of
the CPM in the neonatal period or the rst year of life whether
CPM were detected antenatally or postnatally. Guidance for
asymptomatic lesions is less clear and its practice diers between
clinicians and centres. It is estimated that up to 70% of lesions
are resected worldwide10 irrespective of size of lesions or presence
of complications. Centres advocating surgical resection may
stem from the possibility of malignant potential and future
complications such as recurrent infections with chronic
respiratory symptoms. ere is also the possibility that patients
who have elective surgery early, rather than later resection due to
complications, have fewer surgical morbidity such as prolonged
durations of pleural drains, air leaks and haemorrhage.11 Early
resection may allow improved lung growth if resected earlier,
with proposed optimal elective resection being around six months
of age.12
e most common types of malignancy associated with
CPAM are pleuropulmonary blastoma (PPB) and bronchioalveolar
carcinoma (BAC) but these tumours are exceedingly rare and
are not all related to CPAMs. ese malignancies are usually
incidental histological ndings aer the resection of complicated
CPAM.13 However there is still limited data about the prevalence
and natural history of these tumours arising from CPAM and
long-term surgical complications, hence there is no universal
consensus on best practice to manage small asymptomatic CPAM
lesions.
e objective for this review is to evaluate the management
and outcome of children with CPM (detected antenatally and
postnatally) in South Wales who were investigated and treated at
the Noah’s Ark Children’s Hospital for Wales.
Method
is is a retrospective study where cases of CPM were identied
over a ten-year period from 2010 to 2019 in South, Mid and West
Wales. All antenatally detected lesions are assessed aer birth
and, in accordance with the South Wales management pathway
of antenatal CPM (Figure 1), infants were referred to specialist
respiratory service at the Noah’s Ark Children’s Hospital for
Wales in Cardi. Infants who presented postnatally at their local
hospitals were also referred to the specialist respiratory service at
the Children’s Hospital for further assessment and management.
ese cases were identied through the radiology database system
called ‘SYNAPSE’ and certain search criteria based on clinical
information given on chest CT request forms that were performed
at the Noah’s Ark Children’s Hospital for Wales in Cardi.
All eligible patients’ demographic details were recorded.
We documented the type of CPM identied, whether it was
antenatally or postnatally detected and the age at rst chest CT.
Clinical information such as presence of symptoms and indication
for surgical resections were recorded including age at the time of
surgery and post-operative complications through clinic letters
and operation notes.
For patients who were managed conservatively, clinical
indications were documented. All patients surgically or
conservatively managed were monitored for immediate, medium
and long-term complications.
As this is a service evaluation study, we did not register with
the local ethics committee.
Results
In the 10-year review, 79 patients (41 females, 38 males) underwent
a chest CT performed at the Noah’s Ark Children’s Hospital for
Wales within the rst year of age for possible CPM (Table 1). 73
were antenatally diagnosed whilst 6 were diagnosed postnatally
with respiratory symptoms within the rst four months of life.
e median time for CT scan performed was 88 days;
approximately 3 (2-11) months. ose who had CT at an earlier
age were oen because they were symptomatic.
Of the 73 antenatally detected cases, 69 were conrmed cases
of CPM; the majority, 33 (48%), were CPAM, 23 (33%) were BPS
and 9 (13%) were CLO. e remainder were rarer pulmonary
lesions such as bronchial atresia, ectopic thymus and a simple cyst
from the postnatal conrmatory chest CT. One was still awaiting a
postnatal chest CT. Four (5%) were classied as normal following
the CT scan.
Six patients were diagnosed postnally despite having normal
antenatal scans. ese postnatally detected lesions consisted of 4
patients with CLO, 1 with BPS with large feeder vessels and 1 with
a benign tumour (xanthogranulomatous tumour).
In the last 10 years, there were 75 children with conrmed
CPM managed at the Noah’s Ark Children’s Hospital for Wales.
Surgically versus conservatively treated CPM
More than half of all children 45/75 (60%) with CPM in the last
10 years have required surgical resection. Almost all, 5/6 (83%),
postnatally detected CPM required surgical resection within a
month of their presenting clinical symptoms and one was managed
conservatively, whilst 40/69 (58%) children with antenatally
diagnosed lesions have received or are awaiting surgery in view of
the size of the pulmonary lesions, feeder vessels, recurrent chest
infections, respiratory distress or parental choice. Median time
of surgery was 10 months with a range of day 2 of life for patients
with large antenatally detected lesions who presented soon aer
birth to 4 years of age for smaller lesions.
14 children (19% of all conrmed CPM) received
emergency/early surgery and there were 3 immediate post-
operative complications of hydrothorax, pleural eusions
requiring chest drain and 1 child died aer thoracic surgery
(however this complication was investigated and later felt to be
due to prematurity and sepsis rather than the surgical treatment
for CPM). Of those who underwent elective surgery, 1 had a
post-surgical haemothorax which resolved with a chest drain and
there was no surgical mortality in this group. Hence the overall
immediate post-operative complication rate for CPM was 3/45
(7%).
A total of 31/75 (41%) patients were managed conservatively.
Medium to long term complications of CPM
In the last 10 years, hospital records showed that 68/75 (91%)
children with CPM have received follow up appointments. Of
those who received surgery, 4 were lost to follow up and of those
managed conservatively, 7 were also lost to follow up. In total, 25
(32%) have completed their follow up and have been discharged
6
Welsh Paed J 2021; 55: 4-26
ORIGINAL PAPERS PAPURAU GWREIDDIOL
while 43 (54%) are still receiving ongoing hospital review. e
completed follow up period for each patient is variable with
median review completed by 1 year (range 1 month to 4 years) in
those receiving surgery, and being discharged earlier than those
managed conservatively (range 3 months to 6 years).
Two patients (5%) who underwent surgery (emergency
or elective) experienced longer-term respiratory morbidity
of recurrent cough and wheeze, viral upper respiratory tract
infections and exercise limitation. Two (6.5%) who were managed
conservatively also experienced persistent cough and recurrent
wheeze/croup during the follow up period.
ere were, however, no reported cases of lung malignancy
seen in patients with CPM who were managed conservatively
during the follow up period.
Table 1 Summary of surgically and conservatively managed
patients with congenital pulmonary malformations
Total cases 79
-antenatal 73
-postnatal 6
CT confirmed antenatally CPM 69
-C PA M 33
-BPS 23
-CLO 9
-Others 4
-Normal CT 4
Number of conservatively managed CPM 31/75 (41%)
-antenatally detected 30
-postnatally detected 1
Number of surgically treated CPM 45/75 (60%)
-emergency/early surgery 14
-elective surgery 31
Immediate post-surgical complications 3
Medium- term complications of all CPM 4
-conservatively managed 2
-surgically treated 2
Number of pulmonary malignancy of all CPM 0
Computerised tomography (CT); Congenital Pulmonary
Malformations (CPM); Congenital Pulmonary Airway
Malformation (CPAM); Bronchopulmonary Sequestration (BPS);
Congenital Lobar Overination (CLO)
Discussion
Large symptomatic CPM will be universally surgically removed.
However, to date the optimal management of asymptomatic
CPM is still debated. e potential of increased respiratory
morbidity and pulmonary malignancy remains a serious concern
for parents and clinicians looking aer patients with small CPM.
Consequently, there is increased advocacy from clinicians looking
aer these patients to opt for surgical intervention even in those
with small asymptomatic CPM.
From our single centre 10-year review, the majority of our
CPM were detected antenatally; similar to what has been reported
in the literature. Although early detection can be reassuring to
enable discussion with families and prior planning, it can also be
a worrying time. Hence it is important to have current data on
outcome from surgical and conservative approaches for CPM.
It is equally important for centres looking aer these new-borns
to have a standardised protocol for initial assessment of these
antenatally detected CPM and future management. is review
conrmed that the majority of our patients with large lesions were
delivered at the tertiary unit and received emergency surgery
in the neonatal period whilst those with smaller lesions were
clinically stable and had their chest CT within 3 months and
received their surgery electively by 10 months. is review has
conrmed the safety and diagnostic accuracy of the standardised
protocol currently in use across South, Mid and West Wales. is
will hopefully provide some reassurance for parents of babies with
small antenatally detected lesions, that their babies are unlikely
to present with severe respiratory distress or require respiratory
support at birth.
In our unit, 60% of CPM were surgically removed for
larger lesions in symptomatic patients. No patients with small
asymptomatic lesions received surgery, which is in contrast to
centres around the world where as many as 70% of CPM are
resected even for small asymptomatic lesions. In our experience
with medium term follow up, the complication rates between
those managed surgically or conservatively were similar and
importantly, there were no reported cases of malignancy if
small CPM were le untreated.13 Greater understanding of the
natural history and long-term outcomes of dierent management
approaches will aid us in counselling families with CPM.
Strengths and limitations
e strength of this review lies in the fact that the majority of
cases of antenatally and postnatally detected CPM in South, Mid
and West Wales are conrmed by chest CT at the Noah’s Ark
Children’s Hospital for Wales and are managed surgically and
conservatively by paediatric surgical and respiratory teams at the
Children’s Hospital. ere would only be a minority of babies,
albeit those who are asymptomatic with small or resolved lesions,
who would have had their chest CT performed in other centres
in South Wales, as local clinicians are advised to consult with the
specialist Paediatric Respiratory team at the Noah’s Ark Children’s
Hospital for Wales for all antenatally detected and postnatally
diagnosed symptomatic CPM.
is review captured cases in South, Mid and West Wales.
However, it does not include cases from North Wales. is is a
retrospective review and there may be loss of clinical information
about complications if not documented in the case notes. Patients
with CPM in North Wales are managed by teams at Alder Hey
Children’s Hospital in Liverpool. Hence it is dicult to be certain
of the incidence of CPM in the whole of Wales.
Current follow up period of patients with CPM is variable
and it is important to continue prospective monitoring of patients
for complications. Most patients in this review were followed up
to 1 year of age, with the longest follow up period of 6 years. In
larger studies where all patients with CPM were surgically treated,
there was higher respiratory morbidity and there were skeletal
abnormalities seen in the surgically treated compared to the non-
7
Welsh Paed J 2021; 55: 4-26
ORIGINAL PAPERS PAPURAU GWREIDDIOL
surgically treated group. Surgery itself may have contributed
to chest wall asymmetry, or severe respiratory distress may
have contributed to the chest wall deformities. Other possible
explanations might be that there are pre-existing molecular or
mesenchymal abnormalities in the lung tissue and the chest wall
structures irrespective of surgical intervention.14
e other important long-term complication is the
malignant potential occurring within CPM. In our cohort we
did not observe this. However, follow up period in our current
cohort is relatively short. In an International PBB registry,15 rare
PBB can present in the pre-school age. However, these cases have
genetic predisposition to developing PBB not due to CPM. Other
pulmonary malignancy (BAC) which may be associated with
CPM occurs in older children and adults (median age of 23 years;
range of 6 months to 60 years).13 is emphasises the importance
of long-term monitoring.
Functional outcomes such as pulmonary function as well as
cardiorespiratory tness in patients with CPM in this review have
not been studied. In a study consisting of 28 patients,16 patients
with lobectomy had lower pulmonary function tests than those
without surgery. However, the surgically treated group still have
lung function within the normal range.
Future directions
ere is an urgent need for prospective long-term follow up of
all patients who have CPM and for a systematic register of these
patients nationally in order to have a better understanding of
the natural history and the best treatment option for CPM. In
Wales, there is a national register of congenital malformations
(CARIS) so a future study, could include all the patients with
CPM identied in Wales.
Besides documenting complications in terms of respiratory
morbidity and skeletal abnormalities, there should be a
longitudinal study of pulmonary function, cardiorespiratory
tness and measurement of physical activity in these patients
born with CPM, whether they have had surgery or were managed
conservatively. Dierent surgical approaches and timing of
surgery may also aect the long-term outcomes so prospective
longitudinal observations are crucial for providing evidence-
based treatment for the management of patients with CPM.
Conclusion
In this 10-year review of patients with CPM in South, Mid and
West Wales, those with suspected large lesions antenatally were
symptomatic soon aer birth and were operated on within the
neonatal period, as well as clinically symptomatic postnatally
detected lesions. ere is an urgent need to have mandatory
monitoring of these patients prospectively, including those who
were managed conservatively, as clinical manifestations are
usually not particularly severe by measuring pulmonary function
and cardiorespiratory tness. ere were no serious immediate or
medium-term surgical complications. Further studies are needed
to explore the eect of dierent surgical approaches on patients
with CPM.
References
1. Kotecha A, Barbato A, Bush A, et al. Antenatal and postnatal
management of congenital cystic adenomatoid malformation.
Paediatric Respiratory Reviews 2012;13:162-171
2. Azizkhan RG, Crombleholme TM. Congenital cystic lung
disease: contemporary antenatal and postnatal management.
Paediatric Surgery International 2008 Jun;24(6):643-657
3. van Leeuwen K, Teitelbaum DH, Hirschl RB, et al. Prenatal
diagnosis of congenital cystic adenomatoid malformation and
its postnatal presentation, surgical indications, and natural
history. Journal of Paediatric Surgery 1999 May;34(5):794-798
4. CARIS Public Health Wales 2018. (CARIS) Congenital
Anomaly Register and Information Service. 3 August 2021.
(https://phw.nhs.wales/services-and-teams/caris/current-
infromation.com)
5. Cavoretto P, Molina F, Poggi S, et al. Prenatal diagnosis
and outcome of echogenic fetal lung lesions. Ultrasound in
Obstetrics and Gynaecology 2008 Nov;32(6):769-783
6. Liechty KW. Ex-utero intrapartum therapy. Seminars in Fetal
and Neonatal medicine 2010 Feb;15(1):34-39
7. Wilson RD, Baxter JK, Johnson MP, et al. oracoamniotic
shunts: fetal treatment of pleural eusions and congenital
cystic adenomatoid malformations. Fetal Diagnosis and
Theory 2004 Sep-Oct;19(5):413-420
8. Burke K, Barr S, Calvert J. Management of infants with
antenatally suspected congenital cystic lung lesions. Cardiff
Neonatal guidelines, University Hospital of Wales, Cardi
9. Greenough A, Nicolaidees KH, orpe-Beeston G.
Abnormalities of lung growth and development 1996:448-
463. Greenough A, Roberton NRC, Milner AD (Eds) Neonatal
Respiratory Disorders 1996; Arnold, London
10. Stanton M, Njere I, Deajayi N, et al. Systematic review and
meta-analysis of the postnatal management of congenital
cystic lung lesions. Journal of Paediatric Surgery 2009;44:1027-
1033
11. Conforti A, Aloi I, Trucchi A, et al. Asymptomatic congenital
cystic adenomatoid malformation of the lung: is it time to
operate? The Journal of Thoracic and Cardiovascular Surgery
2009;138(4):826-830
12. Rittié JL, Morelle K, Micheau P, et al. Long-term outcome
of lung malformation in children. Archives de Padiatrie
2004;11(6):520-521
13. Mani H, Shilo K, Galvin JR, et al. Spectrum of precursor and
invasive neoplastic lesions in type 1 congenital pulmonary
airway malformation: case report and review of the literature.
Journal of Histopathology 2007;51(4):561-565
14. Calzolari F, Braguglia A, Valfre L, et al. Outcome of infants
operated on for congenital pulmonary malformations.
Pediatric Pulmonology 2016;51:1367-1372
15. Messinger YH, Stewart DR, Priest JR, et al. Pleuropulmonary
blastoma: a report on 350 central pathology-conrmed
pleuropulmonary blastoma cases by the International
Pleuropulmonary Blastoma Registry. Cancer 2015;121(2):276-
285
16. Tocchioni F, Lombardi E, Ghionzoli M, et al. Long-term lung
function in children following lobectomy for congenital lung
malformation. Journal of Pediatric Surgery 2017;52:1891-1897
8
ORIGINAL PAPERS PAPURAU GWREIDDIOL
ORIGINAL PAPERS PAPURAU GWREIDDIOL
Optimising timing for pneumococcal vaccination in
children undergoing emergency splenectomy
Cawthra A¹, Vallabhaneni P²
¹Cardiff University, Cardiff; ²Singleton Hospital, Swansea
Introduction
Six-year old Paul suered a road trac accident which involved
emergency splenectomy. At handover, a fellow registrar mentions
they need post-splenectomy pneumococcal vaccine. You vaguely
recall that some patients don’t mount a decent vaccine response
when immunised aer major surgery. You wonder when is the
best time to administer this vaccine and is there any evidence to
delay the vaccine?
Objective
In children who undergo emergency splenectomy (patient),
does immediate administration of pneumococcal vaccine
(intervention) oer a more eective benet (outcome) compared
with delayed administration (comparison)?
Method
e search was conducted using the Cochrane Library (01/07/20)
and Medline via OVID (03/07/20) for relevant studies in the
English language. A total of 463 studies were identied. e initial
search criteria set out to exclude studies involving participants
outside the paediatric age bracket (less than 16 years of age).
However, as shown in the summary of evidence no studies were
identied which exclusively investigated patients <16 years old.
erefore, studies which involved participants 16 years of age and
greater were included as they were still deemed relevant to the
question by the authors. Appendices 1 and 2 show the key terms
used for the search.
Discussion
e spleen plays an integral role in the removal of encapsulated
organisms such as Streptococcus pneumoniae. Asplenic
patients have a diminished antibody response to pneumococcal
vaccination in comparison to healthy controls, making them
susceptible to infections. Children under 5 and particularly
infants have shown the highest infection rates when operated upon
for splenic trauma.3,4 Public Health England recommend the
administration of pneumococcal vaccine to children with asplenia
or splenic dysfunction. is guidance helps to schedule the
vaccination in elective cases. However, there is no clear guidance
for the timing of vaccine administration to children undergoing
emergency splenectomy. e question this leads us to consider
is whether the timing of vaccination aects antibody response.
Would administering the vaccine pre-emergency surgery be more
benecial compared to post splenectomy vaccination?
Current literature suggests there is lack of consensus
regarding optimal timing of vaccine administration. An early
study by Giebink, et al failed to identify a relationship between
the timing of vaccination and antibody response in children who
underwent splenectomy following trauma. Konradson, et al7
went on to complete a retrospective study which indicated that in
133 individuals (13 aged under 15), who were vaccinated within
14 days pre- or post-splenectomy were less likely to require re-
vaccination based upon antibody levels measured by ELISA. A
study by Shatz, et al included both child and adult patients and
recommended that prophylactic vaccination should take place at
14 days post-operatively. A further study by Shatz, et al added
to this evidence by evaluating the antibody response in adults
vaccinated at either 14 or 28-days post-splenectomy. ere
was negligible benet from delaying the vaccination beyond
14 days and thus 14 days postoperatively was concluded as the
most eective time for vaccine administration. Howardieshell,
et al10 suggested that the dierent techniques used to measure
antibody response to vaccination could have contributed to the
conicting evidence. Shatz, et al suggested that measurement
of opsonophagocytic antibody titers correlated more highly
with pneumococcal vaccine ecacy than between IgG antibody
concentrations measured by ELISA.
Since 2013 there has been no further development regarding
the timing of pneumococcal vaccine administration to children
requiring emergency splenectomy. Based on current evidence
there is no clear guidance on when is the best time to vaccinate
children pre- or post-emergency splenectomy. However, it is
vitally important that children are vaccinated and measures
should be in place in local departments to ensure this is not
missed. Further studies are needed to answer the current gap in
evidence with regards to timing of the vaccination.
Conclusion
Children need pneumococcal vaccine post emergency
splenectomy (Grade B).
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ORIGINAL PAPERS PAPURAU GWREIDDIOL
Citation Study group Study type
(Level of evidence)
Outcome Key results Comments
Rosado et al,
2013²
Asplenic paediatric
patients (n= 21) versus
healthy controls
(n=19)
Prospective cohort
(2b)
IgG concentration and
number of PnPS*-
specific memory B
cells (IgM and IgG
subtypes)
7 children receiving post
splenectomy PCV: Serum
α-IgGPnPS 40-290mg/L
3 children receiving pre-
splenectomy PCV: Serum
α-IgGPnPS 100-190mg/L
No data provided on specific
timing of administration;
response not seen in PPV23
given pre- or post-operatively
or PCV7 given pre-operatively.
Very small sample size.
Age of children not specified.
Sheikha et
al, 200711
52 patients
undergoing
splenectomy
for thalassemia.
Pneumococcal vaccine
administered ~4
weeks preoperatively
(n=22) vs no vaccine
administered (n=30)
Prospective cohort
(2b)
Postoperative
mortality
A significant difference was
found between the total
splenectomy fatalities in the 2
groups. There were 5 deaths in
the 30 enrolled Iraqi patients
(no vaccine administered) over
a 4 year follow up period.
One death over a 12-year follow
up period was reported in the
22 patients from Saudi Arabia
(vaccine administered ~4 weeks
preoperatively)
Age of patients not included.
Cohorts from two different
countries with significant
disparity in health resources.
Cross references Golematic
et al. “It is mandatory for
every patient undergoing
elective splenectomy to have
Pneumovax, optimally at about
1 month pre-surgery”
Shatz et al,
2002⁹
38 adults undergoing
emergent
splenectomy mean
age 36.8 +/- 16.6
years (range 17-78
years) patients were
analysed.
No patients
reported any
premorbid immune-
compromising
diseases.
The clinical status
of the patients was
similar between the
14- and 28-day groups
Randomized control
trial (1b)
Blood samples at
time of vaccination
and 4-weeks later.
Control group of 24
healthy adults used as
comparison.
IgG antibody
titres to 4 of most
common serotypes
were determined
by enzyme-linked
immunosorbent
assay (ELISA) and
opsonophagocytic
assay (OPA)
Only minor improvements
in immune response were
detected in those vaccinated 28
days postoperatively compared
with those at 14 days, which
would not justify the risk of
delaying vaccination.
Recommended that patients
undergoing emergency
splenectomy should receive
immunizations 14 days later
Study does not involve target
age group for clinical question.
Jugenburg
et al, 1999³
Paediatric patients
who had undergone
splenectomy (n=264)
Age range 3 weeks-19
years. Average age at
splenectomy 8.5 +- 4.5
years (mean +- SD).
Post splenectomy
infection (n=10) (3.8%)
Retrospective
cohort (2b)
Incidence of
post-splenectomy
sepsis morbidity
and mortality after
pneumococcal
prophylaxis
Findings indicated that early
pneumococcal immunisation
was associated with a lower risk
of infection, in both pre- and
postoperatively immunised
patients.
Average time of immunisation
pre-operatively was 2 weeks
in infected and 4.5 months in
non-infected patients
Average time of immunisation
post-surgery was 24.3 months
in infected and 23.0 months in
non-infected
Pre- operative immunisation
was associated with a lower
chance of developing a serious
infection than postoperative
immunization (2.6% v 7.1%)
Indication for splenectomy
not stated. No underlying
hematologic diagnosis
was associated with post
splenectomy sepsis in this
study.
Very small sample size.
Post-operative immunisations
were administered at a much
later date in comparison with
other studies.
All the patients who underwent
immunisation also received
prophylactic antibiotics
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ORIGINAL PAPERS PAPURAU GWREIDDIOL
Citation Study group Study type
(Level of evidence)
Outcome Key results Comments
Shatz et al,
1998⁸
Patients
splenectomised due
to traumatic injury,
13-67 years old (n=
59) Compared with
normal adult group
(n=12)
Randomised control
trial (1b)
IgG serum antibody
concentrations
against serogroup
4 and 3 other
serotypes measured
before vaccination
and 4 weeks after
vaccination.
Antibody
concentrations
were determined by
ELISA and functional
antibody titres by
opsonophagocytosis
Geometric mean antibody
concentrations measured by
ELISA were similar among
trauma patients immunized
at post splenectomy day
1, 7, or 14. Functional
antibody titers, measured by
opsonophagocytosis assay,
were significantly higher in the
14-day group
Delaying vaccination beyond
14 days did not appear to
improve the immune response
Likely a higher correlation
between opsonophagocytic
antibody titers and
pneumococcal vaccine efficacy
than between IgG antibody
concentrations measured by
ELISA.
Opsonophagocytic titres
could not be determined in a
significant number of patients
receiving antibiotic treatments
(n=23)
Konradsen
et al, 1997⁷
Splenectomised
children <15 years
old (n=14) in a total
cohort of 149
Retrospective
cohort (2b)
Pneumococcal
antibody titres to six
subtypes determined
using ELISA
Information relating
to initial vaccination
and re-vaccination
status
Of the 133 vaccinated
individuals (13 of which aged
<15) a significantly lower
(p=0.05) percentage of those
vaccinated >14 days pre- or
post-operatively required
revaccination compared to
patients vaccinated <14 days
pre- or post-operatively
6 of the children were
splenectomised due to
haematological illness and 8
following trauma
Ejstrud et al,
199712
Patients who
underwent
splenectomy (n=555)
Retrospective
cohort (2b)
Time of
pneumococcal
vaccination related to
different indications
for splenectomy
Only 23% of the patients were
vaccinated at the appropriate
time
More effort is needed to
reach an acceptable level
of prophylaxis against
pneumococcal infection after
splenectomy
Appropriate time of vaccination
not specified in abstract
Giebink et al,
1980⁶
Comparison between
children who had
been splenectomised
after trauma (n=32)
vs unsplenectomised
children (n=12)
Median age 13
years (range 5-20) in
splenectomised group
and 9 years (range
5-15 years) in the
un-splenectomised
children
Prospective cohort
(2b)
Type-specific (12
types) pneumococcal
antibody was
measured in serum
obtained from
patients using a
phagocytic radio-
immunoassay
10 children vaccinated <4
weeks post-splenectomy had
antibody responses equal to
the antibody responses of 5
children vaccinated 4-6 years
after splenectomy.
No relationship was identified
between interval between
splenectomy and vaccination
Both groups came from same
socioeconomic background
and geographical location.
Opsonic activity varied in
accordance to capsular
polysaccharide types.
Results suggest that some
children (from both groups)
may produce antibodies
after vaccination which do
not enhance pneumococcal
opsonisation.
Healthy non-vaccinated adult
volunteers showed little
fluctuation in opsonic activity
over the 4 weeks and acted as
a control
References
1. Lammers AJJ. e value of prophylactic vaccinations and
antibiotic treatment in post-splenectomy patients: a review.
Transplant Research and Risk Management 2012;4:19
2. Rosado MM, Gesualdo F, Marcellini V, et al. Preserved
antibody levels and loss of memory B cells against
pneumococcus and tetanus aer splenectomy: tailoring
better vaccination strategies. European Journal of Immunology
2013;43(10):2659-2670
3. Jugenburg M, Haddock G, Freedman MH, et al. e
morbidity and mortality of pediatric splenectomy: Does
prophylaxis make a dierence? Journal of Pediatric Surgery
1999;34(7):1064-1067
4. Lortan JE. Management of asplenic patients. British Journal of
Haematology 1993;84(4):566-569
5. Public Health England. Immunisation against infectious
disease. 2014[cited 13/09/20]Available from: https://www.
gov.uk/government/collections/immunisation-against-
infectious-disease-the-green-book - the-green-book
11
ORIGINAL PAPERS PAPURAU GWREIDDIOL
6. Giebink GS, Foker JE, Kim Y, et al. Serum Antibody and
Opsonic Responses to Vaccination with Pneumococcal
Capsular Polysaccharide in Normal and Splenectomized
Children. The Journal of Infectious Diseases. 1980;141(3):404-
412
7. Konradsen HB, Rasmussen C, Ejstrud P, et al. Antibody
levels against Streptococcus pneumoniae and Haemophilus
inuenzae type b in a population of splenectomized
individuals with varying vaccination status. Epidemiology and
infection 1997;119(2):167-174
8. Shatz DV, Schinsky MF, Pais LB, et al. Immune responses
of splenectomized trauma patients to the 23-valent
pneumococcal polysaccharide vaccine at 1 versus 7 versus 14
days aer splenectomy. The Journal of Trauma 1998;44(5):760-
766
9. Shatz DV, Romero-Steiner S, Elie CM, et al. Antibody
responses in postsplenectomy trauma patients receiving
the 23-valent pneumococcal polysaccharide vaccine at
14 versus 28 days postoperatively. The Journal of Trauma
2002;53(6):1037-1042
10. Howdieshell TR, Heernan D, Dipiro JT. erapeutic
Agents Committee of the Surgical Infection Society. Surgical
infection society guidelines for vaccination aer traumatic
injury. Surgical infections 2006;7(3):275-303
11. Sheikha AK, Salih ZT, Kasnazan KH, et al. Prevention of
overwhelming postsplenectomy infection in thalassemia
patients by partial rather than total splenectomy. Canadian
Journal of Surgery 2007;50(5):382-386
12. Ejstrud P, Hansen JB, Andreasen DA. Prophylaxis against
pneumococcal infection aer splenectomy: a challenge for
hospitals and primary care. The European Journal of Surgery
1997;163(10):733-738
Appendix 1: Search Medline OVID Total Results: 206 (03/07/20)
12
ORIGINAL PAPERS PAPURAU GWREIDDIOL
Appendix 2: Cochrane Library Database search (01/07/20)
13
ORIGINAL PAPERS PAPURAU GWREIDDIOL
ORIGINAL PAPERS PAPURAU GWREIDDIOL
The COVID-19 pandemic and its impacts on the
environment. The voices of young people in Wales
Johns G, Khalil S, Ahuja S, Johns E, Ogonovsky M, Ahuja A
Anenrin Bevan University Health Board, Technology Enabled Care Cymru, Pontypool
To understand the impacts of the COVID-19 pandemic, scientic
evidence alone isn’t the only reliable source to inform public and
policy. In Wales, a country where the pandemic has hit hard hit,
the experience has been a time unlike no other for our younger
population and an opportunity for them to voice their opinions
on a subject that concerns them greatly – the environment.
Objective Early in the pandemic, Technology Enabled Care (TEC)
Cymru identied environmental impacts as a signicant benet
to remote healthcare, and were keen to explore these impacts
further, particularly from the perspective of young people
Design To learn more about environmental impacts during this
time, a qualitative video study was conducted.
Participants TEC Cymru asked young people in Wales, ranging
between 2 and 23 years old, “How has the COVID-19 pandemic
impacted on the environment?”
Setting Homemade video clips were used to gather the data
from young people living in Wales. Full ethical permissions and
consent were granted.
Outcomes/Results A total of 22 videos were collected from 24
young people. Five dominant themes emerged, and a video of
the combined data was developed and included in this paper.
e themes include: ‘travel, emission and air pollution’; ‘water
pollution and beaches’; ‘animals and wildlife’; ‘recycling and
plastic waste’ and ‘food and energy waste’.
Discussion e young people shared comparable observations of
environmental impacts to that of world-wide experts, and present
a well-balanced debate, reecting on both positive and negative
environmental impacts of the pandemic.
Keywords Wales, young people, environmental impacts,
COVID-19, public policy
Introduction
ere are rarely subject matters that remain untouched by
the coronavirus (COVID-19) pandemic. One area in which
COVID-19 has caused positive and negative impacts, both
directly and indirectly, is our environment. e spread of the
coronavirus drew the economic activities of many countries to a
halt, causing the cancellation of ights and travel across national
and international borders. Many nations around the world
forced large proportions of their populations to socially isolate
and stay indoors, and in many countries these lockdown measures
lasted months. Not only is this likely to have vast impacts on
the psychological and physical wellbeing of human populations,
but it is likely to have unprecedented impacts on the physical
environment. Much of the environmental impacts remain
largely positive. However, negative impacts are reported to be
greater and more long-lasting. One noticeable, and potentially
positive, environmental impact is the reduction in air pollution
and greenhouse gas emissions. As previously mentioned,
lockdown measures enforced many global populations into their
homes for a signicant length of time, thus reducing the output
of major air pollutant sources such as human mobility and
industry and therefore reduced the associated emissions from
travel via ights, road and rail. It is estimated to be up to a 30%
reduction in NO (nitrogen dioxide) emissions, and up to an 80%
reduction in particulate matter (eg hazardous particles in the air)
over the USA, Europe and Southeast Asia but these impacts are
considered to be short-term.
One major, and most noticeable negative environmental
impact since the pandemic is the increase in plastic production
and waste. ere is an inherent need for clinical and personal
protective equipment (PPE) in order to ensure the safe functioning
of the health services such as the NHS, whereby since March
2020, an estimated 129 billion facemasks and 65 billion pairs
of plastic gloves have been used monthly. ese masks, gloves,
plastic aprons and visor shields have caused an unprecedented
amount of non-recyclable plastic waste and presented a huge
challenge to safely and sustainably dispose of the excess plastic. In
many countries, this impact has reversed recent single-use plastic
laws. e use and mismanagement of these plastics causes local
pollution, in that they are small/light enough to be transported in
breezes, streams and currents, therefore have potential to cause
widespread pollution.
Another environmental impact, due to the restriction of
human activity, has allowed many wildlife to reclaim previously
human dominating spaces. For example, there have been
reports of wild coyotes in the USA; rarely seen insects remerging
in England; and wild goat and peacock have been spotted in
North Wales. A recent report found a temporary reduction in
trac collisions involving wild animals during the pandemic.
Furthermore, the pandemic has indirectly impacted on improved
water quality, such as clearer water in Italian canals, allowing the
return of sh and marine life into urban waterways.10,11 It has
also been reported that there is up to 50% decrease of sewage and
industrial euent in rivers, and a noticeable reduction of 15.9%
in suspended particulate matter in lakes.12 A report also found
that more ecient household management and food practices
have reduced food waste during the pandemic.13 Restaurant and
hotel food expenditure dropped by 60%, and consumers switched
to frozen (31% increase) and cupboard food (37% increase) as
opposed to fresh food (15% reduction).14
14
ORIGINAL PAPERS PAPURAU GWREIDDIOL
e pandemic has presented a unique opportunity for global
experts to assess the impacts it has had on the environment, and the
recent literature illustrates this work.1-14 However, depending on
scientic evidence alone isn’t the only source to capture opinions
and standpoints as a way to inform public policy. COVID-19
has been a time unlike no other for our younger generation, and
therefore an opportunity for them to voice their opinions on a
subject area that is of great interest to them - the environment.
Objective
To investigate the opinions of young people in Wales on the
environmental impacts of the pandemic, Technology Enabled
Care (TEC) Cymru provided a virtual platform (via video clips)
to hear what they had to say.
TEC Cymru enable the sustainable use, scale-up and spread
of digital services in NHS Wales.15 Across the TEC Cymru
programmes, physical environmental impacts have been identied
as a perceived benet to remote healthcare, such as reduced travel
using services like Video Consulting.16 Welsh Government’s
Well-being of Future Generations Act17 seeks a commitment from
public bodies to consider the long-term impact of their decisions,
including health inequalities and climate change, which stresses
the importance of learning more from the perspective of our
young people.
Method
is is a qualitative study, using video clips to capture rich data.
To recruit the young people, TEC Cymru used two sampling
methods for one-week each. ese included opportunity
sampling, which involved an additional question being added to
a feedback survey, and snowball sampling via the use of a social
media platform (Twitter @teccymru) and through personal/
professional networks. e inclusion criteria for young people to
take part was being between the age of 2 years old (appropriate
'talking’ age) and 25 years old (maximum age as a ‘young person’
in Wales). e age of participants for the study ranged between 2
and 23 years old.
Participants’ parents, or young people over 18 years, were
initially asked to express their interest in the study via email/
telephone discussions, and were then asked to record and send
video clips to TEC Cymru. Each young person was asked one
simple question – “How has the COVID-19 pandemic impacted
on the environment?” e understanding of what ‘environment’
meant to them (eg social, physical), or the choice to talk about
good, bad or combined environmental impacts, was le to the
discretion of the partaking young person to decide, as was the
length of the video and its content.
In addition, the background literature search was conducted
independently by a team member unaware of the video clip
content(s) to ensure a fair comparison of experts versus young
people’s voices were made. e combined themes, and a video
designed by the young people is included in this paper. To ensure
that the ‘young voices’ are fully represented, two of TEC Cymru’s
Young Person Representatives are co-authors on this paper (SA,
EJ).
Due to the nature of the sampling methods taken, it is
unknown as to the exact response rate or declined oers to
partake in the study. All videos submitted were included in the
study, and there were no drop-outs.
Results
Over a two-week period (October 2020) a total of 22 video clips
(24 young people) were provided, with full written parental/young
person consent. Table 1 provides a breakdown of characteristics
of the young people.
Table 1 Frequency and proportion of gender, age, ethnicity
and place of young people
Frequency Proportion
Gender
Male 7 29.2%
Female 17 70.8%
Other 0 0%
Age
2–5 years old 5 20.8%
6–9 years old 8 33.3%
10–12 years old 5 20.8%
13–17 years old 3 12.5%
18–25 years old 3 12.5%
Ethnicity
White or White British 19 79.1%
Asian 2 8.3%
Black 0 0%
Mixed/multiple ethnic group 3 12.5%
Other ethnic group 0 0%
Health Board in Wales (place)
Aneurin Bevan UHB 2 8.3%
Betsi Cadwaladr UHB 2 8.3%
Cardiff and Vale UHB 4 16.6%
Cwm Taf Morgannwg UHB 13 54.1%
Hywel Dda UHB 0 0%
Powys Teaching HB 0 0%
Swansea Bay UHB 3 12.5%
The Coronavirus: In the words of the youngest
participants
Some of the younger participants dened what the
coronavirus is, and its overall impacts.
“It’s bad obviously because it’s killing people”
“e virus is making people sick”
“It is a bug… its green… its bad, because it makes you ill… like
chicken pox”
“…there’s very bad creatures that are ying around the place and
walking all over the place and they cause the virus”
e young people then went on to describe what they believed
had good, bad or combined impacts on the environment. ese
COVID-19 related impacts are split up into ve dominant themes,
to include: ‘travel, emission and air pollution’; ‘water pollution
and beaches’; ‘protection of animals and wildlife’; ‘recycling and
plastic waste’; and ‘food and energy waste’.
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ORIGINAL PAPERS PAPURAU GWREIDDIOL
Travel, emissions and air pollution
e most recurrent theme was the overuse of cars and public
transport, and the impact of CO emissions on the environment
expressed as a major concern pre-COVID. However, since the
pandemic, this was felt by many as a signicant improvement
to the physical environment, and something the young people
strongly felt needs long-term thought and improvement.
One of our younger participant’s stated;
“Nobody goes out in their cars anymore”
is was enlarged on by other young people, suggesting that
this reduction of travel is a ‘good’ environmental impact, in that it
reduces air pollution and hazardous gases.
“Well, there’s less cars, buses, trains, boats and all vehicles
a r o u n d …”
“So it reduces the gases in the air”
“Which means there’s less pollution in the environment”
“…and greenhouse gasses such as carbon have been predicted not
to be as low since World War 2”
Appreciation for this improvement was expressed by a young
person stating;
“So, yeah, good job protecting the o-zone layer, good job people”
However, one young person argues that as a result of the
reduction in public transport, this may have increased personal
travel and overuse of individual cars.
“However, public transport was a lot harder to use because you
have to social distance …so I think that other people, if they have
access to their own cars they’ll be using those… so there’s probably
an increase in cars”
Water pollution and beaches
e young people also consider a reduction in water pollution
since the COVID-19 pandemic;
“ere’s been a lot less water pollution because not many people
have been going on boats to get overseas and in Venice their water
has been clear for the rst time in ages, maybe forever”
“It’s good, because now there’s less plastic in the sea because
nobody’s allowed out”
“And there is an increase of beach clean ups”
“It’s better… the sea and the sky is bluer”
Protection of animals and wildlife
e coronavirus is considered by many of the young people to be
a protective factor for animals and wildlife;
“Wildlife are probably roaming in new areas… and less being
knocked over on main roads”
“Also less people were going around which kept natural habitats
intact so they weren’t being destroyed and wildlife was living freely”
Examples of this were provided about the wildlife in ailand and
Australia;
“…in ailand, where there’s normally a lot of people on holiday,
there isn’t lately and the sea turtles were able to cross the beach and
lay their eggs”
“Now because there’s not much people around to distract them,
there’s, monkeys on the streets and stu and also kangaroos in the
streets in Australia”
erefore, it is considered;
“…better because it takes care of all the animals and takes care of
the world, because the planet gets better cos it’s less dirty… so the
coronavirus is a good bug for that”
But, for some young people, there is more perceived danger to
animals because people are now more consumed by the concerns
relating to the virus than anything else.
“It’s like since COVID people don’t even care about the animals or
anything, they’re just throwing masks everywhere … they’re just
worrying about COVID too much like ‘oh no I’m going to catch it’,
but they’re not really looking aer anything by worrying”
“And, everybody’s so concerned about COVID … they’re not
worrying about, everything going on around them… turtles dying
and all of that, they’re just not caring. ey’re destroying the
world!”
“…where the strings of the mask are actually endangering animals
as they are becoming tangled up in them… sanctuaries aren’t
able to work due to the pandemic then animals aren’t getting the
attention they need and it’s destroying their habitats”
Recycling and plastic waste
e most negative environmental impacts reported by the young
people were plastic waste and littering, which were perceived
as a major contributing factor of the protective measures put in
place to protect humans from the coronavirus, such as the use of
disposable facemasks.
“All the gear for COVID, they’re, everybody… just litters them and
throws them onto the side of the road”
“A lot of people are choosing to use disposable, one-use masks more
and being reluctant to buy reusable ones”
“One of my biggest causes for concern … is our increase in single
use plastic waste. Before the pandemic it seemed to be a priority
for everyone to reduce their single use plastic consumption such as
straws and coee cups, but since the pandemic has arrived it seems
that concern has completely gone out the window”
“I think we all need to really focus on making sure we’re disposing
(of) this plastic waste correctly otherwise it’s going to end up in our
eco-systems… severely damaging to the environment…”
And other restrictions, such as the suspension of recycling
services during quarantine and lockdown periods were considered
to be adding to the physical impacts to the environment;
“…such as the suspension of our recycling programmes or the
reduction of reusable packaging”
Whereas for the younger of the participants, littering was
considered to be reduced due to less people socialising and limited
tourists in holiday resorts:
“No people around to drop rubbish, or drop rubbish down the
bea ch”
“Less people are going on holiday so not so many ights and not so
many tourists so less rubbish...”
Food and energy waste
For some young people, there were environmental improvements
associated to being at home more, such as food waste was
considered to be on the decrease.
“e positive impacts of COVID-19 have been that as people
are home they’re wasting less food and also in light of the recent
free school meals campaign I think people are more aware and
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ORIGINAL PAPERS PAPURAU GWREIDDIOL
conscious of their food waste and this is good because it’s less
damaging to the environment when we waste less food”.
However, for others, the more time spent at home meant
more food waste and also the overuse of other energy sources.
“Less children are in school so there’s more food waste and more
energy is being used at home for TV, laptops, Xboxes and washing
and more people are working from home”
Some of the young people ended their clips with some nal
thoughts, recommendations or reections.
“I believe if we tried to improve on these negative impacts and tried
to keep up the work with our positive ones we’re able to make a
better environment”
“e coronavirus outbreak has had an undeniable impact on the
way that we view the world… As a result, I feel like people are
being more conscious about the decisions they are making and
their long-term impacts on the environment”
“I love the world, and I love my family”
A video on environmental impacts by the young
people of Wales
https://vimeo.com/489439721/b1cb6f702c
Discussion
To understand the environmental impacts caused by the
unprecedented times of the recent pandemic, we turned to young
people in Wales and asked “How has the COVID-19 pandemic
impacted on the environment?” Despite the wide age range
of participants, and the observable dierence of age-related
knowledge or accuracy of denition of the environment or its
impacts, the young people provided similar perspectives, across
both positive and negative environmental impacts. e young
people identied ve dominant themes. e combined views and
standpoints within these themes are comparable to that of world-
wide experts, thus providing a well-balanced and informative
debate.1-14
As stated in the background literature, one noticeable and
positive environmental impact since the pandemic is the reduction
in air pollution and greenhouse gas emissions.3 Likewise, this was
recognised and understood in various ways across the age ranges
of our participants. is included responses from our much
younger participants, (as young as 4 years old), who recognised
the signicant reduction in travel during the pandemic. Whereas,
the young people 8-10 years old were better able to associate this
reduction to improvements in ‘gases in the air’ and ‘less pollution’.
is knowledge base generally improved with age, such as one
young person (age 15) was able to compare historic associations
by stating how this reduction is the lowest it’s been since World
War 2.
e background literature also claims that the pandemic has
indirectly impacted on improved water quality.4,10-12 Similarly, our
participants shared this point of view. eir perceptions varied
slightly from their own personal assumptions of ‘less people
on the beach’ thus resulting in ‘less plastic in the sea’. Whereas
others made more informed observations, which may have been
inuenced by education, the media or prior adult dialogue – eg
the reference to water quality in Venice, or the increase of beach
clean ups.
Another positive impact outlined in the literature is the
emergence of wildlife and reduction of trac collisions involving
animals. is was clearly pointed out by our participants, with
a mix of personal interpretations such as ‘no wildlife roaming
the streets’, to more knowledgeable points of view such as the
comments made on international wildlife eg in ailand.
One of the most noticeable negative environmental impacts
in the literature is the increase in plastic production and waste
since the pandemic began. is again was supported by our
participants arguing that this was the most negative environmental
impact relating to the pandemic. Opinions on this arose from the
majority of the young people, with an impressive knowledge base
across ages, particularly on the overuse of plastic and neglectful
disposable eorts. Our young people also went on to discuss this
in more depth, such as how recycling services being closed during
the pandemic had impacted littering further.
Finally, the background literatures found that more ecient
household management and food practices have reduced food
waste during the pandemic.13-14 is was supported by our
young people who argue that whilst having more people at home
generally means less food waste, on the ip-side, they also argue
that more people at home may also mean an overuse of other
energy sources.
Central to TEC Cymru aims and Welsh Government
policy, by utilising the perspectives of our young people we can
better inform public understanding and improve policy making
decisions by taking into consideration subject areas that are
of great importance to our future generations and their planet,
rather than merely relying on scientic evidence to deliver these
messages. As a response to this, the young people have agreed
to use their individual videos to develop a lm to showcase their
message to a wider audience.
It is acknowledged that the age range of participants between
2 and 23 years old is wide. However, the purpose of the study
was to provide a ‘voice to all’. We also understand that the
much younger participants may have been slightly prompted, or
required initial denitions by adults regarding the ‘environment’
prior to the study. e demographic distribution is considered a
fair representation of young people in Wales, for example despite
the majority of participants being white, this is reected in the
Welsh average (95%).
References
1.
Rupani P, Nilashi M, Abumalloh R, Asadi S, Samad S, Wang
S. Coronavirus pandemic (COVID-19) and its natural
environmental impacts. International Journal of Environmental
Science and Technology 2020;17(11):4655-4666
2. Espejo W, Celis J, Chiang G, Bahamonde P. Environment and
COVID-19: Pollutants, impacts, dissemination, management
and recommendations for facing future epidemic threats.
Science of the Total Environment 2020;747:141314
3. Helm D. e Environmental Impacts of the Coronavirus.
Environmental and Resource Economics 2020;76(1):21-38
4. Arora S, Bhaukhandi K, Mishra P. Coronavirus lockdown
helped the environment to bounce back. Science of the Total
Environment 2020;742:140573
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5. Kanniah K, Kamarul Zaman N, Kaskaoutis D, Latif M.
COVID-19's impact on the atmospheric environment in
the Southeast Asia region. Science of The Total Environment
2020;736:139658
6. Wong J, Goh Q, Tan Z, et al. Preparing for a COVID-19
pandemic: a review of operating room outbreak response
measures in a large tertiary hospital in Singapore. Canadian
Journal of Anesthesia 2020;67(6):732-745
7. Prata J, Silva A, Walker T, Duarte A, Rocha-Santos T.
COVID-19 Pandemic Repercussions on the Use and
Management of Plastics. Environmental Science & Technology
2020;54(13):7760-7765
8. Liubartseva S, Coppini G, Lecci R, Creti S. Regional approach
to modelling the transport of oating plastic debris in the
Adriatic Sea. Marine Pollution Bulletin 2016;103(1-2):115-127
9. Shilling F, Waetjen D. Special Report: Impact of COVID19 on
California Trac Accidents. Road Ecology Centre. California:
University of California 2020
10. Saadat S, Rawtani D, Hussain C. Environmental perspective of
COVID-19. Science of The Total Environment 2020;728:138870
11. Braga F, Scarpa G, Brando V, Manfè G, Zaggia L. COVID-19
lockdown measures reveal human impact on water
transparency in the Venice Lagoon. Science of The Total
Environment 2020;736:139612
12. Yunus A, Masago Y, Hijioka Y. COVID-19 and surface water
quality: Improved lake water quality during the lockdown.
Science of The Total Environment 2020;731:139012
13. Roe B, Bender K, Qi D. e Impact of COVID-19 on
Consumer Food Waste. Applied Economic Perspectives and
Policy 2020;43(1):401-411
14. Chetty R, Friedman J, Hendren N, Stepner M. Real-Time
Economics: A New Platform to Track the Impacts of
COVID-19 on People, Businesses, and Communities Using
Private Sector Data. Applied Economic Perspectives and Policy
2020;00(00):1-11
15. Technology Enabled Care (TEC) Cymru. Retrieved at: https://
digitalhealth.wales/tec-cymru
16. e NHS Wales Video Consulting Service (2020). Retrieved
at: https://digitalhealth.wales/tec-cymru/vc-service
17. Well-being of Future Generations (Wales) Act. Retrieved
at: https://www.futuregenerations.wales/about-us/future-
generations-act/
ORIGINAL PAPERS PAPURAU GWREIDDIOL
The use of warfarin and monitoring INRs in
paediatric cardiology
Telfort S¹, Pateman A²
¹School of Medicine, Cardiff University, Cardiff; ²University Hospital of Wales, Cardiff
Abstract
Background Warfarin is the anticoagulant of choice in paediatrics.
It is a highly eective medication used to reduce the risk of clot
formation, which may lead to cerebrovascular accidents, and
therefore death. It is vital that the risks and benets of warfarin
are considered for each patient individually, before being
prescribed. When used safely, warfarin saves lives; however,
it can cause detrimental complications if not used according to
guidelines and protocols. Some of these adverse eects include
excessive bruising, bleeding and unfortunately, death. us,
frequent audits are invaluable in good medical practice, to ensure
that doctors are managing patients as safely as possible.
Aims To investigate adherence to local guidelines when managing
patients with out-of-range international normalized ratio (INRs)
and to highlight areas which need rening to improve the
paediatric anticoagulation service in Cardi and Vale.
Method is audit reviewed the prescription of warfarin and the
monitoring of INRs between 2015 and 2018. Data in the form
of INR measurements were collected from the anticoagulation
booklets that all parents with a child on warfarin are provided
with.
Patients INR values over a three-year period were collected from
85 patients between the ages of 2 and 19.
Conclusion Overall, there was a 54% adherence to local guidelines
and there is a total success rate of over 50% when guidelines were
followed. Although the guidelines are eective, the success rate
of following guidelines is low, and this is due to INRs not being
measured for more than a few days for some patients, when they
are out of range.
Introduction
Warfarin is an anticoagulation medication used to treat and
prevent blood clots which may lead to profoundly serious
conditions such as deep vein thrombosis, pulmonary embolism,
or stroke.2,3 It works by inhibiting an enzyme called vitamin K
epoxide reductase. is enzyme is essential for the reactivation
of vitamin K: without active vitamin K, there is reduced hepatic
production of clotting factors II, VII, IX and X. Furthermore, the
anticlotting protein C and protein S are inhibited, albeit to a lesser
extent. e onset of warfarin takes a few days as clotting factors
have a half-life of up to 80 hours.
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Warfarin is oen used prophylactically in adult and
paediatric medicine to reduce the risk of clot formation in those
with a predisposition for blood clots. In adults, it is most used
in patients with atrial brillation, as these patients are vulnerable
to stroke. Like adult medicine, there are multiple indications
for warfarin in paediatrics. e drug is oen used in patients
with heart valve replacements to prevent valve thrombosis. e
replacement valve is a foreign material that comes into contact
with blood. erefore, this may stimulate the process of clot
formation on the valve, increasing a patient’s risk of stroke.
Moreover, warfarin is used aer certain surgical procedures such
as the Fontan procedure. is surgery is used in children with
univentricular hearts. e procedure diverts venous blood from
the inferior vena cava and superior vena cava to the pulmonary
arteries; there is no ow of blood through the right ventricle. is
means that the systemic and pulmonary circulations depend on
the functioning single ventricle. Patients with Fontan circulation
are predisposed to thromboembolic events for multiple reasons.
Firstly, the stagnant circulation due to the pumping absence of
the right ventricle increases the risk of thrombus formation.
Secondly, due to post-surgical anatomical changes, blood ow is
very turbulent, thus increasing the probability of clots developing.
Additionally, it has been well documented that patients with a
single functioning ventricle have substantial changes in anti-
coagulant factors in comparison to the general population.
ere are many adverse eects of warfarin, with the
most common side eect being bleeding. e risk of severe
bleeding whilst on warfarin is minute but denite. All other
types of bleeding occur more frequently. However, the most
extreme are those involving the brain and the spinal cord.
Less commonly, warfarin may lead to alopecia, which oen
causes emotional distress for many patients. Other side eects
include gastrointestinal dysfunction, skin necrosis and purple toe
syndrome. Many of warfarin’s side eects, particularly bleeding,
can be prevented if warfarin is prescribed carefully and patients
are monitored closely. Patients on warfarin are monitored using
the international normalised ratio (INR). INR is a laboratory
measurement of how long it takes for blood to form a clot.8-9
INR provides a standardized method of reporting the eects of
warfarin on blood clotting. In a healthy patient, the INR is about
1.1. If the INR is too low, this suggests that blood is clotting very
quickly, however, if the INR is too high, this may mean that the
patient is bleeding. A patient’s INR is regularly monitored in
order to balance the risk of excessive bleeding against the risk of
clot formation. Patients are given target INRs (most commonly
between 2 and 3 in paediatrics) depending on the reason why they
are on warfarin.
Aims
e aim of the audit was to get a better understanding of how
paediatric patients are anticoagulated with warfarin. e
main indications for warfarin were studied, to gain insight on
the role that indication plays in nding a target INR for each
patient. e audit looked to investigate how closely doctors at
the University Hospital of Wales, Cardi are adhering to national
and local guidelines, in addition to external literature for the use
of warfarin. Moreover, the success of the use of guidelines from
the year 2015 to 2018 was considered. e audit explored factors
which cause INRs to go out of range, such as intercurrent illness,
and time spent in and out of the target INR range. Furthermore,
adverse drug reactions and complications of INR being out of
range (particularly for patients with valve replacements) were
investigated.
Method
Data in the form of INR measurements were collected from the
anticoagulation booklets that all parents and guardians with a
child on warfarin are provided with. INR values from the year
2015 to 2018 were gathered from 85 patients of variable ages,
ranging from 2 to 19 years old. When INR values were out of
range, the action taken by the doctors and nurses was compared
to the ‘Children’s Heart Unit for Wales Clinical Guidelines,’ to
investigate if guidelines were adhered to for any dose changes that
occurred. e criteria were determined for best practice using
the guidelines previously mentioned and external literature. In
order for guideline adherence to be regarded as successful, out of
range INRs must have returned to target value within 48 hours of
clexane treatment or warfarin dose change.
Moreover, patient clinical history was accessed online
via ‘cardiobase’ to study what comorbidities most commonly
complicate management of INRs. ese online les were also
useful for providing information on admissions for clexane
administration and complications associated with out-of-range
INRs.
A thorough search of external literature on the use of
warfarin in paediatrics was performed to provide more insight
on the clinical uses of warfarin in children and its eectiveness
in reducing the risk of clot formation. Moreover, paediatric
cardiology clinics were attended, and this provided useful insight
on doctor-patient-parent interaction and helped give a better idea
of how well parents understand doctors during consultations.
is is imperative as parents play a signicant role in helping to
manage their child’s INR, and comprehensive communication
between healthcare professionals and guardians is vital if at-home
management is to happen safely.
Results
e audit focused on 85 patients who are on warfarin for
various conditions. Although Fontan circulation and heart valve
replacement are the most signicant indications for warfarin in
paediatrics, there are numerous other conditions that require long
term use of warfarin. A rare but important condition is Kawasaki
disease. Kawasaki disease is a systemic vasculitis; the cause of
the illness is unknown.10 It usually aects children under the
age of 5 and may have a severe impact on the coronary arterial
system.11 If Kawasaki disease is not treated, approximately 20% of
children aected will develop either coronary artery aneurysms
or ectasia.11 Warfarin plays a crucial role in reducing the risk of
coronary artery disease and managing patients who have had
giant aneurysms.11 Table 1 shows the most common indications
for warfarin in paediatric cardiology in University Hospital of
Wales.
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ORIGINAL PAPERS PAPURAU GWREIDDIOL
Table 1 Indications for warfarin amongst the 85 patients
involved in the audit
Indication for warfarin Number of patients
Fontan operation 73
Valve replacement 8
Pulmonary vein thrombus 1
Kawasaki disease 2
Heart valve dysplasia 1
e target INR for each patient is dependent on the
indication for warfarin. As shown on the pie chart (Figure 1),
87% of the patients have an INR target of 2-3. is target is used
for all patients apart from those who are on warfarin for valvular
reasons. Patients who have had an aortic valve replacement had a
lower target INR of 2.5-3.5, and those who have had a mitral valve
replacement had a target between 3 and 4. is is due to higher
rates of thromboembolic events being reported in mechanical
mitral valve replacements when compared to mechanical aortic
valve replacements.12
Figure 1
During the audit, 4107 INR values were counted and
recorded. e INRs were within target range for most of the time
at 59%. ere are many dierent factors which may lead to INRs
going out of range. e most common reason being intercurrent
illness, which is responsible for 70% of out-of-range INR values.
e other signicant reason for labile INRs is compliance. 15% of
the time, INR values were out of range because doses were missed
for one or more days. 15% may seem quite miniscule when
compared to the 70% caused by intercurrent illness; however,
poor compliance is a preventable factor, whereas illness is oen
not. If compliance improves, patients will have fewer occurrences
of out-of-range INRs, thus avoiding admission for treatment
when INR is too low.
Figure 2
Figure 3
When patient INRs are out of range, it is of extreme
importance that doctors, and nurses, are made aware so that
appropriate action can be taken. It is also equally important that
ocial guidelines are followed when making decisions about
warfarin dosage and any changes which may be necessary. In the
three-year period studied, guidelines were adhered to more for
patients with an INR target of 3-4 when compared to patients with
an INR target of 2-3. Guidelines were adhered to 63% of time
when INR target is between 3 and 4, compared to 45.5% when
INR target is 2-3. In certain cases, such as post Fontan procedure
and in Kawasaki disease, the role of warfarin, although important,
is much less stringent.13 is is reected in the slightly lower target
INR (2-3) and explains the lower guideline adherence rate when
compared to valve replacements. ere are greater implications
of out-of-range INRs (particularly subtherapeutic INRs) in
patients with mechanical valve replacements.13 In these patients,
thromboses are more likely to occur,13 hence the higher INR
targets, and the more aggressive approach to managing patients
with INRs that are out of range, as suggested by the audit. It is
important to note that with the guidelines, there is scope to vary
based on clinical experience and the clinical situation – hence a
‘low adherence rate’ is understandable and does not mean that
patients were unsafely managed.
One of the limitations of the audit was the criteria for guideline
success, which was that the INR must return to target range within
48 hours. However, due to the half-life of warfarin, best practice
does not recommend daily monitoring of INRs when out of
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ORIGINAL PAPERS PAPURAU GWREIDDIOL
range.14-15 In the absence of performing daily INR measurements
when out of range (which is supported by best practice), there
was no way of telling how long it actually took for INRs to return
to a safe value. When the INR target was 3-4, guidelines were
successful at an average of 53.5% of the time. is value is perhaps
considerably higher in reality. e highest percentage of guideline
adherence (73%) was seen in patients with a target INR of 3-4,
whose INR fell below 2 or close to 2. Admission for clexane and
an urgent echocardiogram is best practice for this situation. e
average INR value for which clexane is administered is 2.1, and
clexane rebounding occurred 38% of the time.
Overall, time spent in target INR range is greater than time
spent out of range. On average, patients spend 6.95 weeks in their
target INR range and 6.4 days out of the target INR range. Patients
with an INR target of 2-3 spend more time (12 weeks) in range
than patients with an INR target of 3-4 (1.9 weeks). However,
patients with a target of 3-4 spend less time (5.8 days) out of range
than patients with a target of 2-3 (7 days).
It is vital that INRs are stable for an appropriate amount of
time before intervals of measurement are increased. In patients
with an INR target of 2-3, INRs are measured every 1.7 days when
INRs are out of range. On average, INRs are stable for 2.3 weeks
before they are measured fortnightly, and 3.6 weeks before they
are measured at monthly intervals.
In patients with an INR target of 3-4, on average, INRs are
measured daily when out of range, until in range. When INRs are
in target range, frequency of measurement depends on what the
most previous out of range INR was. If the patient had an INR of
less than 2, their INR is measured every 3.5 days when it returns
in range. However, if the patient’s previous out of range INR
was greater than 5, their INR is measured every 4.9 days when it
returns to target value.
Of the 85 patients included in the audit, 26% of them have
a comorbidity which may aect INR control. e most notable
comorbidities are chromosomal abnormalities such as Down’s
syndrome and DiGeorge syndrome. Also, patients with previous
cerebrovascular accidents such as stroke may also be predisposed
to labile INRs. Table 2 shows other signicant clinical factors
which may complicate INR control. Between 2015 and 2018, there
have been complications related to valve replacements, albeit only
a few. Two patients with a valve replacement suered a stroke
between 2015 and 2018, and one patient had a valve thrombus.
Furthermore, in 2016, one patient died from complications of
being on warfarin. is patient always had quite labile INRs
which may have been a result of them suering with cystic bone
disease and idiopathic thrombocytopenic purpura. e patient
died from an intracranial bleed.
Table 2 Comorbidities that may have affected INR control
Patient co-morbidity Number of patients
Hypothyroidism 1
Asplenia 2
Down's syndrome 3
Previous stroke 5
Failure to thrive 6
Other 5
Conclusion and recommendations
In conclusion, warfarin is prescribed safely in Cardi and Vale
UHB. However, there is much more that can be done to make the
service even safer. Overall, guidelines were adhered to 54% of the
time and there is a total success rate of over 50% when guidelines
were followed. As previously mentioned, a ‘low adherence rate’
is understandable as there is scope to vary based on clinical
experience and the specic clinical situation. e success rate of
following guidelines is relatively low, and this is due to the criteria
for success and the frequency of INR measurements when they
are out of range, this therefore reecting the individual clinician
experience in the management of INRs.
Secondly, since over a quarter of the patients have
comorbidities and there is frequent intercurrent illness, it is of
paramount importance that medication reviews are carried out as
oen as needed to ensure that patients are not on any medications
that may increase or decrease the eect of warfarin. In addition,
communication with guardians is crucial if the anticoagulation
service is to be successful. e dosing regimes can become quite
complicated, and it is very easy for parents to misunderstand
the pattern in which the doses must be given. Comprehensive
teaching is essential. Parents and guardians should be taught
about warfarin, how it works, and the risks associated with unsafe
use of the medication. Only families that have completed this
training should be oered point of care INR testing at home.
It should be made clear to guardians what they must do if they
have any concerns or if the child’s INR is worryingly low or high.
Clear communication and training are already included in the
anticoagulation service. However, it can always be improved,
until it is near perfect. Lastly, it is critical that audits are carried
out as frequently as possible (ideally, every 2 years) to ensure that
the quality of the service is not declining or static but is steadily
improving in short periods of time.
Acknowledgements the Cardiac Liaison nursing team
References
1. Fiumara K, Goldhaber SZ. A patient’s guide to taking
coumadin/warfarin. Circulation 2009;119(8):220-222
2. Gruenwald CE, Manlhiot C, Crawford-Lean L. Management
and monitoring of anticoagulation for children undergoing
cardiopulmonary bypass in cardiac surgery. The Journal of
Extracoporeal Technology 2010;42(1):9-19
3. Lim J, Suri A, Sornalingham S, Chua TP. Audit of management
of atrial brillation at a district general hospital. The British
Journal of Cardiology 2010;17(2):89-92
4. Piper C, Hering D, Horstkotte D. Prosthetic valve thrombosis:
predisposition and diagnosis. European Heart Journal
Supplements 2001;3(Q):16-21
5. Goldberg DJ. e Fontan operation: improved outcomes,
uncertain future. Journal of the American College of Cardiology
2015;66(15):1711-1713
6. Viswanathan S. romboembolism and anticoagulation aer
Fontan surgery. Annals of Paediatric Cardiology 2016;9(3):236-
240
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7. Kuruvilla M, Gurk-Turner C. A review of warfarin dosing
and monitoring. Baylor University Medical Center Proceedings
2001;14(3):305-306
8. British National Formulary (2018) Warfarin sodium,
Available at: https://bnf.nice.org.uk/drug/warfarin-sodium.
html (Accessed: 21 June 2018)
9. Favaloro EJ, McVicker W, Lay M, et al. Harmonizing the
International Normalized Ratio (INR): Standardization of
Methods and Use of Novel Strategies to Reduce Interlaboratory
Variation and Bias. American Journal of Clinical Pathology
2016;145(2):191-202
10. Manlhiot C, Brandão LR, Somji Z, et al. Long-term
anticoagulation in Kawasaki disease: Initial use of low
molecular weight heparin is a viable option for patients with
severe coronary artery abnormalities. Paediatric Cardiology
2010;31(6):834-842.
11. Williams RV, Tcheng WY, Minicha LL. Anti-coagulation in
the acute and long-term management of Kawasaki disease.
Progress in Paediatric Cardiology 2004;19(2):179-188
12. Kamthornthanakarn I, Krittayaphong R. Optimal INR
level for warfarin therapy aer mechanical mitral valve
replacement. BMC Cardiovascular Disorders 2019;19(1).
Available at: https://doi.org/10.1186/s12872-019-1078-3
13. Vaidyanathan B, Jain S. Oral anticoagulants in pediatric
cardiac practice: A systematic review of the literature. Annals
of Pediatric Cardiology 2010;3(1):31
14. Cks.nice.org.uk. (2021). Scenario: Warfarin | Management
| Anticoagulation - oral | CKS | NICE. [online] Available
at: https://cks.nice.org.uk/topics/anticoagulation-oral/
management/warfarin/ [Accessed 23 August 2021]
15. Witt D, Clark N, Kaatz S, Schnurr T, Ansell J. Guidance for the
practical management of warfarin therapy in the treatment
of venous thromboembolism. Journal of Thrombosis and
Thrombolysis 2016;41(1):187-205
Remote working in Child and Adolescent Mental
Health Services (CAMHS)
Williams J¹, Wright P¹, Johns G¹, Moore A², Bhardwaj A³, Dubicka B⁴, Ahuja A¹
¹Aneurin Bevan University Health Board, Technology Enabled Care Cymru, Pontypool; ²Department of Psychiatry, Herchel Smith
Building for Brain & Mind Sciences, Cambridge; ³University of Cambridge, Developmental Psychiatry, Douglas House, Cambridge;
⁴Pennine Care Foundation Trust; University of Manchester, Manchester
Abstract
Aims and method e aim was to capture psychiatrists’ perspectives
of remote working within Child and Adolescent Mental Health
Services (CAMHS). A survey with both quantitative and
qualitative elements was sent to members of the Child and
Adolescent Faculty by the Royal College of Psychiatrists.
Results ere were 259 survey responses. Quantitative and
thematic analyses revealed interesting aspects of remote working
within CAMHS. Five themes emerged, which were suitability,
observable information, condentiality and privacy, technology,
and convenience.
Clinical implications e ndings suggest remote working may be
inappropriate in some clinical situations. However, benets were
reported in certain clinical situations, such as follow-ups and care
planning, although condence in making appropriate decisions
and conducting other aspects of work within these services
were uncertain. Further research is essential for the long-term
implementation of digital innovations specically considering the
patients’ perspective.
Keywords Children, digital, video consultations
Introduction
e COVID-19 crisis motivated reorganisation within the United
Kingdom’s (UK) National Health Service (NHS), including an
acceleration in the widespread uptake of remote working using
mediums such as telephone (TC) and video consultations (VC).
Such vast changes have been met with uncertainty by health care
professionals, including those working in Child and Adolescent
Mental Health Services (CAMHS). However, moving into the
‘new normal’ we are aware that digital innovations are here to
stay. Remote consultations have demonstrated suitability among
children presenting specic diculties such as ADHD, they
provide clinicians sucient contact with patients and enhance
the clinical experience. However, clinicians report a reluctance
to use VC and research demonstrates that it is unsuitable for
specic patient groups and appointment types eg patients needing
a physical examination, any safeguarding concerns etc.6,7,8 ere
is a clear lack of information surrounding the clinical experience
with remote care provision within CAMHS. e current study
aimed to capture Child and Adolescent Psychiatrists (CAP)
perspectives. is was conducted to inform the understanding
of the ‘use and value’ of remote consultation amongst CAMHS
CAPs in the future.
Method
A survey was designed by the clinical and research team in
TEC Cymru (Wales), CAMHS colleagues in Cambridge and
Peterborough NHS Trust and the Child and Adolescent Faculty
(RCPsych), and was emailed to all known Child and Adolescent
faculty members by the Royal College of Psychiatrists (RCPsych).
Information was included in the email, and CAPs consented to
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take part upon clicking the link. e survey focused on CAPs’
experiences, usage and perceived value of remote working, and
specically, the proportion of remote work being conducted
(telephone and video consultations), the preference for conducting
remote consultations, perceptions of ecacy, clinical condence,
and rapport building. Set responses were provided for each
question, and the CAPs were instructed to choose which was
most relevant to them. Text boxes followed each quantiable
question, requesting additional opinions and thoughts that may
not have been covered by the pre-set questions. All questions
were voluntary. e study was discussed with the relevant ethical
committees and their approval was obtained. (Survey sent to
clinicians https://www.surveymonkey.co.uk/r/LBTN8MV)
e survey received 261 responses. However, two general
adult psychiatrists were excluded (n=259). 83.01% of these were
from England, 3.86% from Wales, 8.88% from Scotland, and 4.25%
from Northern Ireland. e CAPs were asked to identify within
which service they worked, and these responses were organised
into 5 groups: Community CAMHS, Specialist CAMHS,
Neurodevelopmental, Inpatient/Tier 4, and Mixed services (See
Appendix 1 for organisation of services). e total population of
CAPs (including those in training) was calculated using publicly
available data from GMC and RCPsych Surveys. e number of
CAMHS consultants, independent psychiatrists and speciality
doctors were extracted from the RCPsych survey in 2019 and an
average response rate of 34.8% was calculated.
Analysis
A mixed-methods approach was adopted to capture the
complexities of remote working within CAMHS. e proportions
of responses for each question were calculated and summarised,
and statistical tests were conducted where appropriate. e
qualitative responses were extracted and analysed separately using
thematic analysis.
10
is reexive approach considers the common
themes that emerge from the data, through the iterative process
of coding, which formulate ideas about the data and produces
themes. e data were double-coded (JW & PW), and then triple
checked (GJ & AA). e themes were discussed, and discrepancies
were highlighted until a nal interpretation was decided.
Results
Proportion of remote working
CAPs were asked to report the proportion of time spent working
remotely for various clinical situations (initial assessments,
network/partnership meetings, mental health act (MHA)
assessments, follow-ups, crisis, and care planning). ese ndings
are displayed in Table 1. e clinical situation in which the least
amount of remote work was being conducted was for MHA work,
whereby 79.2% of CAPs stated that this was only being done
0-20% of the time. Partnership/network meetings, follow-ups,
and care planning were the most likely to be done remotely, with
the majority of responses for these being 80-100% of the time.
Table 1 The distribution of responses of proportion of time undertaking remote working for each clinical situation, including
number of responses (n) and percentage (%)
Clinical situation 0-20% 21-40% 41-60% 61-80% 81-100% Total
responses
Initial assessment n 55 13 21 20 130 239
% 23 5.4 8.8 8.4 54.4
Partnership/Network n 17 4 11 11 201 244
% 7 1.6 4.5 4.5 82.4
MHA work n 133 4 6 7 18 168
% 79.2 2.4 3.6 4.2 10.7
Follow ups n 21 6 17 36 173 253
% 8.3 2.4 6.7 14.2 68.4
Crisis n 84 26 17 25 52 204
% 41.2 12.8 8.3 12.3 25.5
Care planning n 21 8 9 20 173 231
% 9.1 3.5 3.9 8.7 74.9
Perception of the efficacy of remote working
Also, CAPs were asked to report the perceived amount of time
VC and TC would take compared to face-to-face. Table 2 displays
these results and shows that TC was perceived to take less time
than face-to-face by 59.0% of CAPs, and more time by only 10.9%.
In comparison, VC was perceived to take more time than face-to-
face by 42.0%, and only 14.2% of CAPs reported it takes less time.
Dierences in median scores were analysed and revealed that
CAPs rated VC as taking longer than TC, X(2) = 24.2, p < .001.
Table 2 CAPs’ perceptions of how long consultations using
the two modalities (telephone and video) compared with
FTF
More time Similar
time Less time Total
responses
n % n % n %
Telephone 20 10.9 55 30.1 108 59.0 183
Video 92 42.0 96 43.8 31 14.2 219
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Condence in receiving the right information to make an
appropriate clinical decision
CAPs rated their condence in making decisions in both clinical
(n = 254) and safeguarding situations (n = 100), using a 5-point
Likert scale, ranging from 1 (‘not at all condent’) to 5 (‘very
condent’). e distributions of responses are displayed in Figure
1. A small number of CAPs felt very condent in making the
right decisions while working remotely, in both situations, and the
majority felt ‘somewhat’ or ‘quite’ condent. However, there was
a trend for CAPs to feel slightly more condent in making clinical
decisions than safeguarding, although statistical analyses could
not be conducted to test this due to the small sub-group sizes.
Figure 1 The distributions of CAP confidence in making an
appropriate clinical decision
Rapport with patients
CAPs were asked to rate their condence in their rapport while
working remotely, on a Likert scale ranging from 1 (not at all) to
5 (very condent), with patients who were either ‘new’ or ‘known’
to them. e analysis of the distributions of scores between ‘new’
(n = 247) and ‘known’ (n = 232) patients revealed that condence
is higher for ‘known’ patients than ‘new’ (X2(3) = 45.5, p < .001).
Comparing remote working with face-to-face
To compare remote working with face-to-face, CAPs were asked
to rate eight dierent types of clinical situations, using a 5-point
Likert scale ranging from 1 (much worse than face-to-face) and 5
(much better than face-to-face). ese were initial assessments,
follow-ups, medication reviews, therapeutic work, partnership
meetings, care planning, group work, MHA work, and crisis
work. Overall, the most positive responses were for partnership/
network meetings, where there is a majority for ‘better’ or ‘much
better’ (53.0%) compared with face-to-face. Care planning was
suggested to be viewed as suitable for remote working, with only
14.0% of responses were ‘worse’ or ‘much worse’ than face-to-face.
However, MHA and crisis work were rated negatively, and there
was a majority agreement that these were ‘worse’ or ‘much worse’
than face-to-face (78.0% MHA and 77.0% crisis work). e
overall distributions of responses are displayed in Figure 2.
Figure 2 The distributions of responses for how ‘better’ or
‘worse’ remote working compared with FTF for each of the
eight proposed clinical situations
Qualitative analysis
Five dominant themes emerged: suitability, observable
information, condentiality and privacy, technology and
convenience.
Suitability
e suitability of remote working is determined by many factors,
including the nature of the consultation, level of risk, and whether
the patient was ‘new’ or ‘known’ to the CAP. For instance, specic
types of consultations were unsuitable, such as MHA work,
physical observations, and if there were safeguarding issues.
“I work with patients with eating disorders and physical
monitoring is best done face to face.”
“It’s ne for more straightforward cases but denitely hinders
assessment for more complex ones, especially where there is
ASD or systemic issues”.
“[Decision to use RC] Based on risk and whether we feel that
a remote consultation provides the same quality of assessment
and care that a F2F appointment would provide.”
CAPs found diculty in establishing, building, and
maintaining rapport with some patients while working remotely,
specically with ‘new’ patients. is introduced barriers between
the patient and the service, with some CAPs stating that they
would refuse to see new patients altogether unless face-to-face.
“It is so challenging to build rapport with children and families
if you have never seen them face-to-face before”.
“I would avoid meeting a new patient for a new assessment
online or on the phone as there is no relationship to build on”.
Other barriers to suitability were related to the patient,
including personal or disorder-specic issues and age. ere
were reports that children with autism spectrum disorders (ASD)
introduced challenges with engagement during assessments along
with young people with eating disorders who required physical
observations.
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“Remote consultations are very challenging with children with
ASD; engagement is more dicult.”
“It is impossible to manage children and teenagers with known
or suspected eating disorders without an accurate weight, and
other physical observations, which usually means a face-to-
face appointment.”
CAPs working with young children reported diculty
establishing a therapeutic relationship due to the patients’ refusal
to be on camera, inability to sit still, or increased boredom.
However, adolescents were reportedly more likely to engage in
VC.
“It is more dicult with younger children, below age 10,
especially with ADHD, who struggle to stand still and get bored
easily with VC.”
“More young-person friendly as that’s their main mode of
interaction with the world!”
Observable information
Visual information (body language, eye contact, social
interactions with family members, and other non-verbal cues)
typically available during face-to-face working was less easily
observed through mediums of remote working meaning that
clinically relevant information could be concealed or missed,
making clinical decisions more dicult.
“I rely a lot on the information I receive from seeing families’
face to face (non-verbal communication). e richness of the
information isn’t available during remote consultation”.
Additionally, CAPs had no control over the environment in
which the consultation took place, meaning that the information
typically used to assess safeguarding concerns or express emotions
could potentially be manipulated or obscured.
Confidentiality and privacy
Remote working meant that condentially and privacy was
more dicult to ensure. e CAP did not have full control of
the environment and could not provide a “safe space” for the
young person to feel comfortable, such as a room in a clinic.
CAPs were concerned that there was no way to ensure that family
members would not be present and overtly or covertly listening
to private conversations. Moreover, the CAP could not guarantee
condentiality, with some having a lack of access to private space
in their homes.
“Loses the sense of going to a safe place (clinic/hospital).”
“Clinician and [patient] both need to have a quiet, private
space for consultations.”
Technology
Issues with, and access to, technology introduced diculties for
consultations. CAPs faced challenges with ongoing technology
problems when using VC platforms. Sometimes, technology was
unfamiliar to CAPs, patients, and family members, resulting in
delays.
“Ongoing (unpredictable) tech issues causing signicant
disruptions.”
“I was able to get social work to join us on teams but they were
very restricted in what they could do…”
Additionally, there was a lack of access to equipment,
sucient internet connectivity, and VC platforms (such as licenses
and full versions), introducing barriers between the patients and
their service. One CAP stated that they had to buy their own
equipment to carry out their work remotely.
“I think a lot is determined by the fact that we are not properly
equipped with good video and audio technology for remote
consultations”.
“VC requires patient to have WiFi otherwise it is costly in
phone data charges”.
“Have had to buy my own laptop and headset.”
Convenience
e nal theme is convenience, which addresses one of the
potential advantages of working remotely in CAMHS. For
instance, remote working made it easier for patients and families
to access care, such as those who found diculty attending face to
face consultations; patients preferred remote consultations due to
travel cost savings. Many CAPs preferred meetings using remote
consultation platforms due to these being more time-ecient.
“Works for patients who cannot commute/dicult to get to
meetings or nd it hard to talk to people face to face, eg social
anxieties or prefer remote working for other reasons”.
“We have a regional service, so it is much easier for families to
access consultations more quickly remotely”.
“It has been most useful in terms of multi-professional and
multi-agency meetings, particularly in a rural region where
services are spread over a very large geographical area”.
Discussion
e rapid implementation of digital health interventions within
the NHS in response to the COVID-19 outbreak led to an increase
in remote working within CAMHS. is study aimed to capture
the experiences of CAPs using a mixed-method approach so that
some of the learning can be translated into future ways of working
in CAMHS. In agreement with two recent surveys of CAMHS
CAPs1,8 the current sample indicates mixed opinions on remote
working, which varied depending on the consultation’s type and
nature. e quantitative and qualitative ndings suggest that
remote working is unsuitable for specic clinical tasks such as
physical observations and whilst working with high-risk patients,
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in addition with crisis work and MHA work. Consistent with pre-
existing literature, it is suggested that barriers to remote working
are magnied when working with ‘new’ patients and during
the absence of non-verbal communication, making clinical and
safeguarding decisions more dicult. Finally, concerns regarding
access to a “safe space” for patients to discuss their feelings,
technical problems, lack of equipment, and knowledge contribute
to CAPs attitudes.
e diculties that CAPs noted with technology support the
notion that the introduction of digital innovations into healthcare
can amplify the inequalities and barriers that exist in terms of
accessing, and the availability of, technology, including adequate
equipment and internet connection.11 is lack of access has
implications beyond healthcare. However, it does impact on the
population’s access to services such as CAMHS when face-to-face
options are not available. It is clear that this divide needs to be
addressed, not just for patients, but for healthcare providers as
well, and the above results suggest that there is a great need for
additional resources to make this implementation more successful
in the future.
On the other hand, the ndings further imply that remote
consultations are useful for increasing access to healthcare during
the COVID-19 pandemic. A variety of consultations were being
conducted, and acceptability demonstrated amongst CAPs for
using these adapted methods for care planning, medication
reviews, and follow-ups. Furthermore, there were reports of
reduced travel time, enabling teams to cover larger geographical
regions, and increases in attendance and engagement at meetings,
facilitating better communication with team members and other
services. Although remote working presents benets for patients
and CAPs, this depended on clinician condence, patient and
service suitability, and technology access.
Limitations
e current investigation only considers the experience of CAPs
working in a range of dierent services and therefore does not
represent the dierence between disciplines in CAMHS. In
addition, these results may represent a biased response pattern,
in that these responses reect a more negative perspective as this
relatively new way of working within healthcare has been met
with reluctance to change by many clinicians.1 e matrix-style
survey design also resulted in diculties with statistical analyses
due to the small, self-selected sample, the use of categorical and
ordinal data, and the large amount of missing data.
Conclusions and future directions
Remote consultations can work well in several clinical situations
and healthcare services2,12,13,15 and the experience of remote
working is valuable in allowing aspects to be embedded in future
service delivery. Studies are consistently reporting4,6 that not all
clinical work can be delivered remotely, and CAPs and patients
encounter many technological challenges. ere is a need for
guidance and support to be provided on how to eectively adapt
remote working to services involving children and young persons,
specically considering the patients’ perspective in CAMHS,15
to strengthen the importance of patient-centred approaches to
healthcare planning when using digital innovations.16
Appendix 1 The groupings of CAPs services into the five
corresponding categories
Category Service types included
Community CAMHS Predominantly Community CAMHS, including
those who indicated they worked in a
community service that had a mixed caseload.
Specialist CAMHS Individuals who work with a specific caseload
in the community, including eating disorder,
looked after children and adoption services,
personality disorder pathways, psychotherapy,
early onset psychosis, liaison, forensic and
substance misuse services.
Neurodevelopmental Including neurodevelopmental and learning
disability services.
In patient/Tier 4 Includes all in patient units, day patient units
and national specialist T4 services.
Mixed in patients and
community/specialist/
neuro CAMHS
This included respondents who indicated they
worked with both inpatient services and one
or more other community-based services.
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11. Watts G. COVID-19 and the digital divide in the UK.
Lancet Digit Health 2020;2(8):e395-e396. doi: https://doi.
org/10.1016/S2589-7500(20)30169-2
12. Armeld N, Bradford M, Bradford N. e clinical use of
Skype – for which patients, with which problems and in
which settings? A snapshot review of the literature. Int J Med
Inform 2015;84(10):737-742
13. Duncan C, Macleod AD. Video consultations in ordinary
and extraordinary times. Pract Neurol 2020;20:396-403.
Doi:10.1136/practneurol-2020-002579
14. Fatehi F, Martin-Khan M, Smith AC, Russel AW, Gray LC.
Patient satisfaction with video teleconsultation in a virtual
diabetes outreach clinic. Diabetes Technol Ther 2015;17(1):43-
48. doi: https://doi.org/10.1089/dia.2014.0159
15. Technology Enabled Care (TEC) Cymru. NHS Wales Video
Consulting Service. End of Phase 1 ‘Live’ and ‘Retrospective’
Data from Patients & Clinicians.
16. Moreno C, Wykes T, Galderisi S, et al. How mental health care
should change as a consequence of the COVID-19 pandemic.
Lancet Psychiatry 2020;7(9):813-824
EDUCATION AND TRAINING ADDYSG A HYFFORDDIANT
Voice from the trainees, November 2021
Walker O, Brzyska K
Zip-lining
Welcome to the Autumn
2021 Trainee Section.
We hope you have had a
wonderful summer out
of lockdown! Oli has
been, unadvisedly, zip-
lining with his kids….
“Whilst suspended
four meters above the
ground by a steel cable
with my six- and nine-year olds among the trees in North Wales this
summer, I was intensely aware of the importance of that clip holding
me on to the steel safety cable. I wondered how many iterations
and improvements (not to mention broken limbs?) were involved
in optimising the quality of this component before it was certain to
hold us up in the air?”
Cue a not-so-subtle segue into quality improvement in
health care and its key role in allowingtrainees to improve patient
care and develop important professional skills. Participation in
quality improvement is an essential component of the RCPCH
curriculum and is integral to each trainee’s experience. To reect
this importance, we are excited to oer a regular showcase called
‘Quality improvement in focus’ to highlight the contributions
of trainees. To kick us o, Dr Lisa Brown, a senior neonatal
trainee at Singleton NICU, presents her work in a quality
improvement initiative to reduce term admissions to the unit due
to hypoglycaemia. In her article Lisa not only details the results
of her project but also guides us through the processes of its
implementation.
As well as our regular updates from the North and South
Wales trainee representatives, trainee Chris Dadnam gives us an
overview of his work enabling foundation year doctors to gain
taster experiences of paediatric training and help recruit the
next generation of paediatricians. In Out of hours, Lucy Deacon
provides an inspirational insight into her other career: playing
and coaching rugby.
Finally, we would like to welcome Assim Javaid to the team
and look forward to working with him over the coming editions.
Background
e rst step in quality improvement
is to identify an area for change and set
aims. e context of our project was
e Avoidable Term Admissions into
Neonatal Units (ATAIN) campaign
in 2017 that brought about a review
of the number of term admissions
to neonatal units in the UK. NHS
England required that all units should
achieve admission rates for term
infants of less than 6% by March 2019.
In the 20 months (January 2019 to August 2020) prior to
the new guideline implementation, hypoglycaemia accounted for
24.8% of all term admissions to the Neonatal Intensive Care Unit
(NICU) at Singleton Hospital, which is on average, 1.67% of all
live born term births. It was felt that this was unacceptably high
and needed to be improved upon.
Hypoglycaemia is well documented to aect a group of
infants with risk factors identied in pregnancy, see Table 1. ey
oen require management from both the maternity and neonatal
teams to protect them from developing signicantly low blood
glucose levels aer birth.
Table 1 To show the risk factors for hypoglycaemia as
defined for the Singleton maternity and neonatal unit
guideline³
IUGR <2nd centile
Infant of mother with IDDM or GDM
Birth weight >98th centile (infant of mother IDDM or GDM)
Beta blockers during 3rd trimester or at time of delivery
Preterm <37 weeks
Hypothermia <36 at anytime
Peri natal asphyxia: cord pH <7.1 or BE >-12
Baby with suspected/known sepsis
Other risk factors, familial or genetic
In 2017 BAPM released new guidance on the management of
hypoglycaemia in term infants. is put the Singleton guidance
out of line with BAPM guidance. A strong culture for evidence-
based medicine and quality improvement is promoted at Singleton
Hospital. Together, the ATAIN campaign and new guidance from
BAPM formed the drivers for change.
Aim
To decrease the number of term admissions due to hypoglycaemia
to the neonatal unit.
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EDUCATION AND TRAINING ADDYSG A HYFFORDDIANT
Quality improvement in focus
Reducing term admissions due to hypoglycaemia to the neonatal unit in
Singleton Hospital
Brown L, Singleton Hospital, Swansea
Background
e rst step in quality improvement
is to identify an area for change and set
aims. e context of our project was
e Avoidable Term Admissions into
Neonatal Units (ATAIN) campaign
in 2017 that brought about a review
of the number of term admissions
to neonatal units in the UK. NHS
England required that all units should
achieve admission rates for term
infants of less than 6% by March 2019.
In the 20 months (January 2019 to August 2020) prior to
the new guideline implementation, hypoglycaemia accounted for
24.8% of all term admissions to the Neonatal Intensive Care Unit
(NICU) at Singleton Hospital, which is on average, 1.67% of all
live born term births. It was felt that this was unacceptably high
and needed to be improved upon.
Hypoglycaemia is well documented to aect a group of
infants with risk factors identied in pregnancy, see Table 1. ey
oen require management from both the maternity and neonatal
teams to protect them from developing signicantly low blood
glucose levels aer birth.
Table 1 To show the risk factors for hypoglycaemia as
defined for the Singleton maternity and neonatal unit
guideline³
IUGR <2nd centile
Infant of mother with IDDM or GDM
Birth weight >98th centile (infant of mother IDDM or GDM)
Beta blockers during 3rd trimester or at time of delivery
Preterm <37 weeks
Hypothermia <36 at anytime
Peri natal asphyxia: cord pH <7.1 or BE >-12
Baby with suspected/known sepsis
Other risk factors, familial or genetic
In 2017 BAPM released new guidance on the management of
hypoglycaemia in term infants. is put the Singleton guidance
out of line with BAPM guidance. A strong culture for evidence-
based medicine and quality improvement is promoted at Singleton
Hospital. Together, the ATAIN campaign and new guidance from
BAPM formed the drivers for change.
Aim
To decrease the number of term admissions due to hypoglycaemia
to the neonatal unit.
Action
Our next step was to test and rene the ideas for change. We
used a PDSA (plan, do study, act) cycle as illustrated below.
Figure 1 illustrates a ow cycle showing the processes involved
with a successful quality improvement project. e team behind
the change is the primary factor in driving, implementing and
sustaining change.
Figure 1 Flow cycle diagram to show the processes involved
with the success of a quality improvement project.
Plan
e new BAPM guidance recommended dierent blood glucose
monitoring parameters. Importantly, it was stated that all blood
glucose levels be tested using a blood gas analyser to give more
accurate levels. New evidence included in the BAPM guidance
demonstrated lower acceptable limits for blood glucose levels
which were safe and may contribute to less involvement from the
neonatal team. A key change in managing blood glucose was with
the use of oral dextrose gel and milk feeds, which again may lead
to less intrusive medical intervention.
Do
1. New guidance was formulated for the management of infants at
risk of hypoglycaemia on the post-natal ward. It was to be in the
form of a care bundle that could be completed by the midwifery
team caring for the baby. is contained a ow chart that
incorporated guidance and simple charts to record the length and
volume of feeds, blood glucose levels, plus a NEWTs (Newborn
Early Warning) chart.
A separate pathway was designed for preterm infants which
highlighted the clear dierences in management for term and
preterm infants.
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EDUCATION AND TRAINING ADDYSG A HYFFORDDIANT
2. Guidance for the use of oral dextrose gel was highlighted by a
new departmental SOP. It required Dextrogel to be prescribed on
the ‘as required’ side of the infant’s drug chart aer delivery. e
midwifery team could utilise this when needed and not delay the
correction of low blood glucose levels.
3. e unit at Singleton Hospital already had in place a gas analyser
for utilisation by the maternity team and all sta were trained to
use this. e current guidance at the time already recommended
the use of dextrose gel to support blood glucose levels where
deemed appropriate. Further education highlighted its use and
its administration.
4. An educational package to incorporate all these strategies and
to promote the benets of keeping mothers and infants together
in the early days of life was designed. e implementation phase
occurred at the time of the COVID-19 pandemic and face to
face educational sessions were not possible. A video was made
and circulated to all those who would care for infants at risk of
hypoglycaemia. e roll out of the new guidance was to coincide
with a change in the medical sta in September 2020, therefore the
guidance was introduced at the doctors’ induction, to strengthen
its implementation. e guidance was discussed and explained
during further educational sessions with junior doctors.
Study
How to measure change? Outcomes
e data regarding admissions to the neonatal unit (NNU) was
collected from patient medical records and using the Badger data
system. Data was entered onto proformas completed by members
of the medical team, then entered onto Excel spreadsheets.
e principal outcomes would be measured, therefore, as the
percentage of term admissions with hypoglycaemia and the
percentage of live births that were admitted with hypoglycaemia
to the NNU. Other data would be used to review contributory
factors to hypoglycaemia and to review practice, such as timing of
rst feeds, hypothermia.
Data collection and analysis
Prior to the changes being implemented, an audit on all term
admissions with hypoglycaemia in the 8 months prior (January to
August 2020) was performed.
1. Following this, for the rst month of implementation a
prospective audit process was carried out to review all term
infants at risk of hypoglycaemia on the post-natal ward. is
was to determine if the pathways were being followed and to
look for any challenges with the completion of the care bundle
and safety issues.
2. For 8 months aer implementation, admissions to the
neonatal unit were prospectively reviewed to determine if the
pathway had been followed appropriately and to review the
individual factors leading to the admission. We scrutinised
the records for other controllable contributors, such as
late feeds, low temperatures and adequate milk volumes.
is allowed an opportunity to review whether or not the
admission was avoidable. It was important that any learning
points be recorded and shared with the clinical teams.
Results
It is clear from the results table that the average number of
admissions per month dropped considerably. e average length
of stay was close to double that prior to the guideline being
implemented.
Following an eight-month review process either side of the
implementation, data could then be presented in a run chart to
show if there were signicant trends in the outcome data.
Chart 1 Run chart to show the proportion of all term
admissions to the neonatal unit at Singleton Hospital
Table 2 to show the core results to compare key parameters before and after changes were implemented
Total number of
admissions
Sex
(F, M)
Mean gestational
age, weeks
Average no. admissions/mth
Mean, (Median)
Mean length
of stay
Pre implementation
Jan – Aug 2020 54 27, 27 38.39 6.75 (7) 2 days 2 hrs
Post implementation
Sept – April 2021 16 5, 11 38.43 2 (1) 4 days 1 hr
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EDUCATION AND TRAINING ADDYSG A HYFFORDDIANT
Chart 2 Run chart to show the proportion of all live
born term infants admitted with hypoglycaemia
Key observations from the results
• A reduction in the total number of admissions by 70% (n =
54, n = 16)
• Decrease in number of all live term infants admitted from
1.67% to 0.88%
• ere was a decrease in number of term infants who were
admitted where the admission reason was hypoglycaemia,
from 24.8% to 8.8%
• Longer admissions post implementation (suggesting more
appropriate): 20% of infants stayed for less than 24 hours
pre-implementation, and aer changes this was 0%
• Total NICU days used treating hypoglycaemia decreased
from 110 days to 59 days over an 8-month period
• Looking at each case in depth, all post-implementation
admissions were unavoidable
ere was a notable increase in the months of February and
March. e admissions were unavoidable and appropriate when
reviewed. It is expected to see some anomalies over time. Another
idea is that this rise in admissions was due to the eect of change
in community midwifery practice during the second COVID-19
lockdown, which preceded this time interval and would have
been the 3rd trimester for many of these infants. is highlights
the need to continue to monitor change and work through the
PDSA cycle to look for points in practice which can be changed or
rened to reach sustained change.
Act
e implantation of the new pathway proved to be very successful
as shown by the data. To sustain its use education will occur at
doctors’ induction for each new training rotation and the videos
will be accessible to sta. Posters to display results are regularly
printed and displayed where the users of the guideline can see
them and appreciate that their work is contributing to valuable
work with positive outcomes. Feedback to sta forms an
important part of successfully sustaining a change.
Following the analysis of the guidance which shows a
positive and a signicant reduction in term admissions due to
hypoglycaemia, the next stages are to convert the data into a
control chart. is has more statistical power than a run chart
and will add more evidence to the success of this project.
e admissions were unavoidable when reviewed. However,
we continue to collect data regarding the admissions to scrutinise
the appropriateness of the admission and to look at factors that
may have contributed to admissions. In time we aim to review the
data with the midwifery team to educate further on data regarding
temperature control and timing of feeds. e data, and the
process of implementation, are being shared at meetings through
the neonatal network. It is important that changes in practice are
shared to further improve practice.
Summary
We have shown how it is possible to reduce term admissions
to the neonatal unit and bring current practice in line with the
current guidance from BAPM. e changes will benet families
as the new guidance keeps mothers and babies together. e
importance of this was highlighted through the ATAIN campaign,
with multiple gains for mother and baby, including physiological
and psychological benets. An inherent cost saving is also seen
in reducing the number of days of neonatal unit care required for
these babies, most of whom are well infants.
e use of quality improvement models relies on a culture
which supports the team to review current practice and take
projects beyond the phase of implementation (Figure 1). is is
very present in the team on the neonatal unit at Singleton Hospital.
Excellent relationships between the neonatal and midwifery teams
is essential for change to occur across specialties. is at times
requires tenacity, new methods of teaching and the spread of
information regarding change. Sta need support to understand
why change is required, and how their eorts benet their team
and their patients. Spread of learning and shared practice is a key
part of successful quality improvement projects. It spreads the
will for change and encourages teams to review their practice and
look for areas for change. is project had been presented locally
to reach out to the teams involved with change, and through the
Welsh maternity and neonatal network. It has now been accepted
as the All Wales guideline for hypoglycaemia. Work will continue
to improve and maintain high standards of care for infants at risk
of hypoglycaemia.
References
1. NHS England. ATAIN. National Improving Value Scheme -
Avoiding Term Admissions into Neonatal Units 2017
2. BAPM Framework for Practice. Identication and
Management of Neonatal Hypoglycaemia in the Full Term
Infant (2017). Oxford University Hospitals
3. Evans J. Singleton Hospital Guideline for hypoglycaemia in
term infants on the post-natal wards 2020
4. NHS England. Online library of Quality, Service Improvement
and Redesign tools. Plan, do, study, act cycles and the model
for improvement. NHS England and NHS Improvement 2021
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EDUCATION AND TRAINING ADDYSG A HYFFORDDIANT
EDUCATION AND TRAINING ADDYSG A HYFFORDDIANT
Paediatric Trainee Representative update
(North Wales)
As one training year comes to an end and another begins, we
have reected on all of the challenges and diculties, but also the
exciting and new opportunities we have had. Overall, the North
Wales trainees feel very positive about what the future holds.
Here is a brief summary of the last few months and our
upcoming plans:
MRCPCH exams
Written exams virtual teaching - organised by Stacey Killick (ST8)
- has been a success and has received excellent feedback. Written
revision notes and summaries on the various topics have also
been emailed to all the trainees and were very well received.
Clinical exam teaching - co-ordinated by Isabel Wardach (ST8).
Isabel has supported trainees doing the clinical exam, by pointing
them to the right resources available, including teaching at Alder
Hey Hospital in Liverpool and local courses. Maelor General
Hospital in Wrexham usually oers a very popular course and are
planning to resume this either at end of 2021 or the beginning of
2022.
WREN (Welsh Research and Education Network)
Our North Wales representatives, Louise Collingwood and Leigh
Watson, have been encouraging and supporting NW trainees
taking part in WREN projects, as well as advertising the WREN
study days and events. is has been successful with NW trainees
being involved in projects collecting data for national studies. We
are working to encourage our trainees to develop projects of their
own.
PLANT website (Paediatric Learning Advice Networking
and Training in Wales)
Joe Mullaly is a NW trainee and part of the development team of
the website. is is now up and running and has received excellent
feedback. It clearly provides a great source of information to
everyone considering working in paediatrics in Wales.
AWEN (All Wales Wellness and Education Network) and
study days
NW trainees have been engaging well with educational
opportunities. Issues that have been raised locally regarding
diculty in attending study events have now been dealt with by
our Training Programme director (TPD) and Local Programme
director (LPD). We are aiming to do a North Wales study day
within the next few months – we will advertise this through the
appropriate channels soon.
St David’s Day Spring Conference
is was organised by North Wales trainees and has been once
again a great success. Excellent work from all around Wales was
presented, and the attendance was equally great! ank you to the
organisers and everyone that participated. For me, personally, it
was an honour to be oered the opportunity to co-chair one of the
sessions – an amazing experience!
Resolving issues
Issues were raised by the trainees at one of our NW STC meetings
about rest facilities and time allocated for admin aer clinics, as
well as for governance and portfolio. ese have been brought
to the attention of our TPD who has been very diligently dealing
with these issues and feeding back to the trainees.
Socials
We are aiming to resume our face-to-face social events/ “catch-
ups” soon - hopefully aer the new trainees start. Peach
Chartsakulkanajarn is our social buttery and is “on the case”!
North Wales STC
ree members of our North Wales STC are leaving us, as they are
achieving their CCT. We want to thank Katie McArthur, Stacey
Killick and Isabel Wardach for their service and dedication to
the STC over the years. We wish you the best of luck in your
“grown-up” lives and we are sure you’ll be amazing! We will see
you around ladies! We will be advertising for their posts soon.
Finally, myself and Louise Crawley helped with the induction
for the new trainees in September. We attended the face-to-face
induction in North Wales as well as welcoming everyone virtually
for all Wales induction. We were very much looking forward to it!
Paquete B
North Wales Trainee Representative
ST5 Paediatric trainee, North Wales
Crawley L
North Wales Trainee Representative
ST5 Paediatric trainee, North Wales
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EDUCATION AND TRAINING ADDYSG A HYFFORDDIANT
Paediatric Trainee Representative update
(South Wales)
With the new academic year come changes within the Welsh
Paediatric Specialty Training Committee (STC). We would like to
take this opportunity to introduce ourselves:
Hannah Davies as the new RCPCH Trainee Representative and
ST4-8 STC Trainee Representative, Patrick Blundell as the ST1-
3 STC Trainee Representative. We thank the amazing omas
Cromarty and Assim Javaid for their fantastic work in representing
South Wales trainees over the last few years. Together, Hannah
and I have a real passion for improving the standards of training
and welfare, and will be working hard to ensure the voices of
trainees across South Wales are heard.
With this in mind, we are pleased that the RCPCH Trainee
Charter is beginning to take a more prominent position at the
STC and within South Wales training units. In the coming year,
we will be pushing for ever-improved adherence to the charter,
including the plans to increase the dedicated portfolio time from
4 hours to 8 hours per month for Tier 1 trainees and 16 hours per
month for Tier 2 trainees.
From an examinations perspective, written and (virtual)
clinical exam teaching continues from the highly dedicated
team of trainees, with great success across all exams. e trainee
produced DragonBytes podcast led by Assim Javaid and Stacey
Harris goes from strength to strength, with around 30,000 listeners
from across the globe. With the recommencement of face-to
face deanery teaching, we look forward to this year’s educational
programme (and some much-needed social contact!).
In terms of research, WREN (the Welsh Research and
Education Network) continues to produce high quality work,
including recent submissions to Archives of Disease in Childhood.
Further networking has begun with Peninsula and West Midlands
deaneries to support research and educational activities. Trainee
delivered ‘return to work’ virtual mentorship has also begun
within the deanery, as well as ongoing support to International
Medical Graduates through the ‘Soft Landings’ programme.
As always, the brilliant PLANT (Paediatric Learning, Advice,
Networking & Training) Wales website is regularly updated and
home to vast amounts of useful information for all paediatric
trainees, including additional details on all of the above activities
(www.plantwales.com).
Blundell P
South Wales ST1-3 Trainee Representative
ST3 Paediatric Trainee , South Wales
Davies H
RCPCH Trainee Representative for Wales
South Wales ST4-8 Trainee Representative
ST5 Paediatric Trainee, South Wales
EDUCATION AND TRAINING ADDYSG A HYFFORDDIANT
Instead of a Course review, trainee Chris Dadnam gives us a fascinating overview of his work enabling foundation year doctors to gain taster
experiences of paediatric training and help recruit the next generation of paediatricians.
Investing in our future paediatricians
A paediatric emergency medicine trainee now working in
Leicester, I was previously a Welsh paediatric trainee. In 2019,
I designed and developed the Paediatric Foundation Liaison
Ocer post for Wales.
Motivation
During my training in Wales, I noticed that many consultant
colleagues would receive countless emails from foundation
trainees requesting taster days - my sister being one of them. A
survey of foundation trainees showed that they found it dicult
to organise a taster day in paediatrics, but also that their taster
experience didn't provide sucient insight into the vast world of
paediatrics. I thought about my own taster programme experience
in Great Ormond Street Hospital as a Severn foundation trainee,
which was well organised, supported, and had provided me with a
better understanding of what a career in paediatrics would be like.
Plan
Combining these issues, along with the decline in paediatric
recruitment nationally, I decided to develop a liaison ocer post,
which would provide tailored taster days across all paediatric
specialties, paediatric teaching, involvement in paediatric quality
improvement projects and career development.
Outcome
Since then, the rest has become a successful history! Twenty
foundation doctors have attended paediatric taster days with
excellent feedback, and signicant recruitment success. Following
their taster experience: all 20 trainees strongly considered a career
in paediatrics, with ve trainees successfully achieving an ST1
position and one taking an F3 position in paediatrics. Six of the
taster trainees went on to develop or join paediatric QI / Audit
projects, with two recent publications and a national presentation.
I presented my liaison ocer post project at the RCPCH
2021 Conference, highlighting its successful implementation, and
the project is being featured in Archives of Disease in Childhood.
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EDUCATION AND TRAINING ADDYSG A HYFFORDDIANT
Developing this post has been a real passion of mine and
I have enjoyed every aspect of it. As a national management
post, it has helped my career progression whilst also improving
my organisation skills for paediatric teaching sessions. I would
strongly encourage any trainee who wants to improve an aspect of
training to develop an idea and make it your own – honestly, you
won't regret it!!
I will be handing over the role to another trainee to hopefully
continue to provide a more streamlined, successful and enjoyable
taster experience, which will in turn encourage more trainees to
become paediatricians and share our love of the specialty.
I'd like to thank Dr Judith van der Voort for her support and
advice throughout, and my sister Dr Farah Dadnam for helping
me to develop the idea.
Dadnam C
ST6 Paediatric Emergency Trainee, Leicester Royal Inrmary,
Leicester
EDUCATION AND TRAINING ADDYSG A HYFFORDDIANT
For this issue, we have Lucy Deacon to give us an inspirational insight into her other career: playing and coaching rugby.
Out of hours
Playing and coaching women’s and girl’s rugby
What is it that comes to mind
when you think of Wales?
Sheep, male voice choirs,
rugby? It seems only right
that as the Wel sh Paediatric
Society we should be covering
something of this sport in
our out of hours discussions.
When I was in an end of placement supervisor meeting a few years
ago struggling to ll the box about evidencing health promotion,
I jokingly said to my supervisor that my greatest contribution to
the public health of this nation was through coaching girls to play
rugby. is prompted a discussion about my out of hours activity
and why I felt this. It ended with my supervisor strongly agreeing
with me to the point of writing it down in my end of year report!
I have thought about it more since then and, while I try to nd
opportunities for health promotion with each contact in my daily
work, my commitment and enthusiasm for girls playing sport
continues to be my most consistent contribution to the future
health of the nation. So here it is - my out of hours occupation is
playing and coaching women’s and girl’s rugby.
Having grown up in North West London as the sandwich
lling sister between two brothers, and with young uncles, we
were always playing rugby: on the beach, in the garden, on the
playing eld. Saturday aernoons were spent watching matches at
the school where my father taught and it was the sport that I knew
most about. Going back 30 years there were fewer opportunities
for girls to play rugby beyond the age of 13 years when you could
no longer play the mixed game, and so, aer a brief period of
being allowed to train with my younger brother’s age group, I
stopped playing. My sporting focus for the next few years was
very much swimming but playing rugby continued to be what I
wanted to do and so, heading o to a sports university, this is what
I was hoping for.
Arriving at freshers’ week my only real ‘to do’ was to nd the
sign-up sheet for the university rugby club. My time at medical
school was therefore spent either in lectures/ on placement/
studying, or training/ playing/ watching rugby! It was a huge
commitment to try to play university sport at the same time as
doing a medical degree and tting it in meant a lot of running
from early morning gym and track sessions over the canal and
railway line and then up the ve ights of stairs to the lecture
theatre to be seated ahead of the 9am start (an added HIIT session
three mornings a week!). A similar high-speed commute
happened at the end of the day to get to the pitch for eld training
and this was a seven days a week commitment. I was privileged to
be coached by the wonderful Bess Evans, former Welsh rugby
captain and this is where I started to realise the value of a female
coach as a role model. It was a wonderful ve and a half years
playing at high level in the University Premiership, being a focus
sport for the university and playing in the British University
Sports Association nals in front of crowds at Twickenham.
Where does this leave me now? I
moved to live in Mid Powys over ten
years ago. I wasn’t working at the time,
having been seriously ill. Being in a new
place where I didn’t have any friends, I
was invited to attend training at the local
rugby club by one of the nursing assistants
who had looked aer me in hospital.
It was one of the best decisions I have
made. It has integrated me into the local
community, which I would now struggle to
leave. It means I have a group of friends
from a diverse range of working and social backgrounds. As
a rotating itinerant junior doctor, it can oen be hard to feel a
part of the community in which you live. On reecting upon my
own experience in medical training, I think that this denitely
contributed to a feeling of loneliness and isolation, especially
when moving posts. Being able to become part of the community
in which I lived through sport has meant that I have something
constant away from work, and having non-medic friends helps
me to have better perspective when faced with challenges at work.
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Welsh Paed J 2021; 55: 26-34
EDUCATION AND TRAINING ADDYSG A HYFFORDDIANT
Five years ago, a Welsh Rugby Union
initiative to get more girls playing rugby
kicked o across Wales with the dierent
regions having girls’ rugby hubs based at a
particular club but drawing from a wider
catchment area. e hubs would run
rugby training for girls through the
summer months when the main rugby
season was over. Coaching was for girls
aged 7 up to 18 years old. It didn’t take
those girls playing mixed junior rugby
away from the game because it was in their
‘o season’ but it would allow others to
come and give it a go in a less threatening,
female only ,sporting environment. is is
where I started to dip my toes into
coaching which has subsequently become
a massive part of my life.
Having realised at university the value
of a role model whom I could relate to, I felt it was really important
that the girls coming to training should have at least one women’s
rugby player coaching their age group. I have recently thought
about this in the work context too and my own career plans. I
realise that having strong female consultants as my role models
has helped me to believe that achieving my career aspirations is
possible.
A key component of coaching technique is using the players
to demonstrate the drill or skill that you are wanting to teach
them. Rather than demonstrating yourself, you are encouraged
to talk them through what it is you want them to do. In order to
do this eectively you need to have a thorough grasp of the drill
and the desired outcome and to have trialled it yourself ahead of
coaching it. is can be challenging especially when coaching 6
to 9-year-old girls; clear verbal communication at an appropriate
level for their age and understanding is vital to a successful and
valuable session. Over the past two years, I have been developing
my role as a mentor in the workplace and the skills involved in
mentorship are not dissimilar. Someone will learn so much more
through doing a task themselves rather than watching you do it;
this has been realised and is implemented through the increasing
use of simulation in medical training.
We all know the benets of an active lifestyle for health and
disease prevention. I have always been a very active person but
I noticed as I got older and went through secondary school the
massive drop o in participation of PE at school and active out of
school activities. Women in Sport conducted research and found
that ‘only 14% of 8 to 10-year-old girls and 8% of 11 to 12-year-
old girls met the recommended guidelines for physical activity in
2012’. is was used to inform the Government Sports Strategy
published at the end of 2015, which had targets to increase
participation in sport among girls. It lls me with joy on a Friday
night to see over 100 girls at our hub, aged 5 to 15 years, running
around learning skills of teamwork and commitment as well as it
being a place where is ok to be hot and sweaty and where there is a
position on the team whatever your height, weight, size or speed.
While I live in a rural area with a greater proportion of the
younger generations meeting their physical activity targets, our
regions catchment (Cardi Blues) includes most of the Welsh
Valleys. Severe obesity among 4 to 5-year olds is highest in
Merthyr Tydl at 5.7%, almost double the national average.
Attending rugby festivals through the summer months, my
response has changed from shock at the size of some of the girls
participating to a feeling of pride that our sport is suciently
inclusive that they can come and play, develop a love for physical
activity and improve their health through tness.
An overhaul to the education curriculum in Wales will be
rolled out this coming academic year. Traditional PE is to be
replaced by ‘Health and Wellbeing’, recognising the lifelong
benets of such knowledge and skills: “This area can help learners
to understand the factors that affect physical health and well-being.
This includes health-promoting behaviours such as physical activity,
including but not limited to sport; balanced diet; personal care
and hygiene; sleep; and protection from infection. It also includes
an understanding of health-harming behaviours”. While I am
passionate about sport this more holistic approach to health and
wellbeing seems like a positive step in health promotion and
disease prevention.
e girls who I coached through the pathway ve years ago
are now training and playing for the women’s team at my local
club, Gwernyfed RFC, and seeing them grow into the women and
players they now are makes all of the hours planning training
sessions, washing kit, blowing a whistle and racing home at the
end of the working day worth it. I did wonder during lockdown,
with the absence of this sporting commitment, how it was that I
used to t it into my week as I was exhausted without the added
time and energy commitment. However, now that it is back up
and running again, I reap the benets of being outdoors, physical
tness, community, contribution and being completely away from
work. While it may take my time and energy out of hours it gives
back to me so much more.
References
1. Changing the Game for Girls, Women’s Sport and Fitness
Foundation, 2012
2. Child Health Measurement Programme, Public Health Wales
2019
3. https://hwb.gov.wales/curriculum-for-wales/health-and-
well-being/statements-of-what-matters/
Deacon L
ST3, Child Health, University Hospital of Wales, Cardi
34
Welsh Paed J 2021; 55: 26-34
EDUCATION AND TRAINING ADDYSG A HYFFORDDIANT
A nal note from us to say thank you to all of the authors for contributing to this trainee section. I hope you enjoy reading the articles, and if
you would like to submit an article for a future edition, please get in contact with us at oliver.walker@wales.nhs.uk or klara.brzyska@wales.
nhs.uk.
Walker O, Brzyska K
Trainee Representatives
BOOK REVIEW ADOLYGIAD LLYFR
Book Review: How Medical Education came to Wales
Vallabhaneni P
WPJ Editor
How Medical Education came to Wales by DP Davies. Pages: 204. Price: £13.00.
Published 26 June 2021 by Llanerch Press. ISBN: 978 1 861431 81 3
Over the summer months, with
curtailed travel, I did take this
book on my trip to Belfast (Chelsea
v Villareal, UEFA super cup nal).
So, these are my reections as I
read the book as a medical history
acionado. Who were the rst
medical educators in Wales? Do
you know the answer to that
question? I was totally fascinated
to read this book – “How Medical
Education came to Wales” - written
by Prof DP Davies (retired).
If you are a regular reader of the Welsh Paediatric Journal,
that name should be very familiar. In addition, Prof Davies has
written several well-regarded articles on the history of medical
education in Wales. is book takes you through a journey of
how medical education came to Wales and draws upon the rich
medical tapestry of early Welsh medical practitioners. I was
struck by the attention to detail, and it gave me great pleasure to
learn how medical schools in Wales came into being. Prof Davies
writes this book in an inimitable style that makes this book a
riveting read.
e thirteenth-century physicians of Myddfai (a north
Camarthenshire village), their inuence on the early medical
guidelines, the rst physiologists, the microscope, birth of
pathology…. I could go on about the fascinating snippets of
history that this book has. For example, halfway through you
read about how the foundations were laid to start the rst medical
school in Wales. e journey from Welsh National School of
Medicine to its transformation to School of Medicine, Cardi
University, is a must-read for every medical educator in Wales. I
was also delighted to read about how the Graduate Entry Medicine
programme was set up at Swansea University.
Overall, I feel inspired to do a video blog with Prof Davies
on each of the subsections of this book. Perhaps the ideal setting
would be to visit Myddfai for the launch. Are you interested in
joining us? Let me know.
D. P. Davies
How Medical Education
came to Wales
Thisisthestory of how medical education came to Wales towards the
endof the nineteenth and the early decades of the twentieth centuries. It
isamong the nest of the legacies of the Physicians of Myddfai
(MeddygonMyddfai), the thirteenth century family from
Carmarthenshire.
Thisabsorbing history begins from the time the Romans left Britain in
thefth century.From the Renaissance into the twentieth century there
wasa relentless growth of medical understanding across Europe,
centurieswhich also saw Wales’ literary and religious traditions develop.
Withhuge changes in Welsh society consequent on the nineteenth
centuryagrarian and industrial revolutions there would be great
improvementsin Welsh education culminating in the latter yearsof the
nineteenthcentury in the establishment of the federal University of
Walesand within which in 1893 would be born, in the University College
ofSouth Wales and Monmouthshire,Wales’ rst medical school. In 1931
itblossomed, despite Mabinogion-likeintrigues and jealousies into the
WelshNational School of Medicine. It changed its name in 1984 to the
Universityof Wales College of Medicine which grew to become an
internationallyrecognised all-Wales institution for clinical medical
educationand research which embraced all the health care professions.
Butthis is not the end of the story …
=
Theauthor was a consultant paediatrician and Professor of Paediatricsat
theUniversity of Wales College of Medicine in Cardiff.
=
Thisbook can be purchased from bookshops,
throughthe publisher’s website
www.llanerchpress.com
ordirectly from: Llanerch Press Limited,
LittleCourt, 48 Rectory Road,
Burnham-on-Sea,Somerset, TA8 2BZ
LlanerchPress
ISBN978 1 861431 81 3
How Medical Education
came to Wales
A Legacy of the Physicians of Myddfai
(Meddygon Myddfai)
35
Welsh Paed J 2021; 55: 35-42
OCCASIONAL ARTICLE ERTHYGL ACHLYSUROL
COVID-19 Meanderings
A kaleidoscope from the past: memories of an earlier medical life
…of a very junior doctor
Davies DP
Emeritus Professor of Child Health
This article concludes some of my earliest memories of a life in
medicine (my years as a medical student appeared in an earlier
edition of the Welsh Paediatric Journal.¹ But these reminiscences
continue to come with a danger warning! In no way are they a
definitive history of events that took place more than fifty years ago!
Far from it. They are merely some random flashbacks which for
some reason or another are still quite prominent, and at times may
be a little distorted, which have come back to me walking with my
dogs during a COVID-19 lockdown. My two years as a junior, then
senior, house officer in Cardiff were very happy years, before I left
for the big wide world. They offer a piece of medical social history
in Cardiff, painting a picture which might appear barely credible to
those young doctors now embarking on their careers in what is still
the noblest profession. In recalling these events I hope I have not
caused any hurt or offence to my earlier colleagues (and if I have I
am very sorry) whose company, both professional and social, played
such an important part in my early years as a very junior doctor.
To all these I would like to say a big ‘thank you’. Diolch yn fawr i
chi ‘gyd.
I graduated MB BCh from the Welsh National School of Medicine
(WNSM) in Cardi (then a constituent institution within the
federal University of Wales) in June 1966. I had what I believed to
be a well-deserved holiday(!) following a tough time revising for
and sitting my Final MB examination, enjoying home comforts in
Swansea and a two-week package holiday (much of it on a bicycle),
to Greece, including Athens, Rhodes and the island of Cos where I
dutifully bowed on landing to the memory of Hippocrates. en
on 1 August began to work for my living.
Medicine
CRI (Cardi Royal
Inrmary) was to
be my home for the
next year. It was like
living in a big family,
taking ten minutes
to walk along the
main corridor in the
morning to catching
up on gossip, where ‘Red’, the porter, was the main fount of
knowledge. What he didn’t know about all the goings-on was
nobody’s business. My rst six-month pre-registration job in
medicine was on the medical unit: William Diamond (men) and
Edward Nicholl (women) wards. My fellow houseman was Pete
Verrow, a nicer colleague you could not possibly have wished
for. I rarely le the wards and even following
an evening o - on average twice a week and
alternate weekends – I would oen call in to the
wards to prepare for the morning ward round,
which as housemen we were expected to lead. I
would then cook some food in the well-stocked
ward kitchens, maybe the real reason for calling
in on the wards!
e CRI residence was in Longcross House, opposite
Casualty. My room was tiny and very noisy, overlooking a main
road and close to the Splott pub which was a favourite haunt of
CRI sta and, by lucky chance, where the hospital ‘pagers’ would
work. On many occasions I would be woken up on a Sunday
morning by the band of the Salvation Army playing beneath the
windows of omas Andrews ward, opposite Longcross House.
We were looked aer well, with food in the hospital canteen
served around the clock. It was great to see Mrs Price there, who
had looked aer us so well in Med Club. Residence parties were
popular, the hospital pharmacy across the road making possible
interesting ingredients for punches.
Every day I wore a clean, well ironed, long white coat,
discarding for ever the short white, barber-like coat of the medical
student, thanks to the excellent laundry service in Longcross
House. In one pocket (not around the neck) was my trusty
stethoscope, in the other the ‘BNF’ (British National Formulary),
which would become a veritable, and well-used, pocket bible
of medicine and therapeutics. I always wore a tie to maintain
sartorial standards. In fact, the only word of advice my dad (a
general practitioner in Swansea, also a graduate of the WNSM)
gave me before starting was, “If you are ever called up to see a
patient at night, don’t forget to dress properly and with your tie on.
The patient, however ill, will always feel better.” is advice I took
with me throughout my career although I am afraid to say this
habit did tend to relapse on the children’s wards!
Professor Harold Scarborough, author of the medical
textbook beloved by all students, ‘BDS’ – Bell, Davidson and
Scarborough (believed by some to be a passport through the nal
MB in medicine) was a quietly spoken, highly
respected and eminent academic physician
leading the medical unit, who had a habit
of examining optic fundi under a big black
umbrella. Sister Wendy Smith, a superb senior
nurse from Yorkshire, ruled William Diamond
ward with a rod of iron and was greatly
admired, and indeed feared, by the Prof. She
looked aer the junior housemen and taught us
Cardi Royal Inrmary
Pete Verrow
Professor Harold
Scarborough
36
Welsh Paed J 2021; 55: 35-42
OCCASIONAL ARTICLE ERTHYGL ACHLYSUROL
so much common-sense medicine. Even as housemen we could
tell the standard of nursing on the wards was very high.
My rst nerve racking experience took
place when a lumbar puncture was indicated
on a senior academic from the university
who was suspected of having tuberculous
meningitis. e Prof of Bacteriology, Scott
ompson, a quietly spoken Scot, wanted to
collect the csf and take it to his laboratory.
About six people huddled around the bedside,
including Prof Scarborough. I had to perform
the lumbar puncture although I never
understood why my senior house ocer (SHO) ‘on call’ couldn’t
have done it. Cold feet? A few silent prayers and Oh! the relief
seeing csf coming out, although it looked ominously cloudy. e
diagnosis was later conrmed and the senior academic made, in
time, an excellent recovery.
Every patient’s urine had to be examined under the
microscope for white and red cells in the med unit laboratory
o the main ward, although how useful this was I have oen
wondered. It did remind me of the medieval uroscopists with
their matulas, as written by Meddygon Myddfai (Physicians of
Myddfai), famous thirteenth century Welsh doctors from the
village of Myddfai in Carmarthenshire.
“It was first necessary that the urine be collected in a glass
vessel and left to settle till the second hour when, by
the light of the sun the physician should judge the
indication thereof. If the urine should be thick,
oily, deep red not transparent in the rays of the
sun and sanguinolent, it indicates languishment
and weakness of body from excess of fever. If it be
black or red and there be sediment in the bottom,
with retention, pain in the kidneys and pain on
micturition, the patient is in danger. If the urine be
passed frequently, and in small quantities, then it indicates a stone
in the bladder.”
Marvellous! Meddygon Myddfai would have been very much
at home on med unit.
Early on, gowned and masked, I had the misfortune of setting
re to a trolley while taking a blood culture from an elderly
patient with suspected pneumonia. In those days it was routine
to have a ‘meths’ burner on the trolley to sterilise the top of the
blood culture bottle. Unfortunately, on this occasion the bottle
slipped and the trolley became a funeral pyre. “Are you ok doctor?”
questioned the patient from Rhymney, peering into Valhalla as
the alarms started ringing out across the oor. He recovered well
from his pneumonia and was home in ten days. It took me longer
to recover. But there were to be no more ‘meths’ burners.
I would oen take the late-night tea and Guinness trolley
round, killing two birds with one stone; writing follow up notes
and blood forms for the next day, for which I was richly rewarded
later in the kitchen where, as usual, there was a good supply of
exotic foods. Towards the end of my six months, during my
‘trolleying’ I was given a big surprise by the men on the ward -
a record of Berlioz’ ‘Harold in Italy’, which became a treasured
possession. It contains some great music for solo viola which by
chance had been the rst string instrument I had tried playing
in the West Glamorgan Youth orchestra under the gimlet eyes of
Morgan Lloyd until, defeated and baed by the alto clef, I took
the easy way out, sitting at the back of the second violins.
I received a phone call in the rst few weeks, from someone
whose identity I never discovered (though I will carry my suspicions
with me to the grave!), that a bus load of young people including
several with haemophilia had been involved in an accident on
their way to Coney Beach fun fair in Porthcawl. Med unit then
looked aer many boys with haemophilia, being
the regional centre. I mobilised all the available
fresh frozen plasma, contacted dear old Arthur
Bloom, an international gure in blood clotting
disorders (and a nicer, more modest doctor
would be hard to nd), and waited to have a
phone call from Casualty. Not one came. What
a dark hoax to play on a young, naïve houseman!
e care of haemophiliac boys always caused diculties,
their veins so overused from so many infusions. I am unable to
count the number of occasions that I would be ‘phoned in the cold
hours of early morning to re-site the terrible rigid steel needle, a
procedure causing so much pain to the patient. e boys were
an incredibly courageous group who had to put up with so much
pain from recurrent haemarthroses. For some light relief one
night, I once took a couple of the boys down to the hospital chapel
to show them how the organ worked. Night Sister did not exactly
approve of one of Bach’s organ preludes resounding up the main
corridor. Sheepishly we had to return to the ward.
When ‘on call’ we also had to cover Casualty, always a rich
source of medical problems. I used then to be amazed at how
many policemen would nd their way into Casualty’s coee
room. Another great mystery was the room o the main corridor
where, dodging the cockroaches on their nocturnal jaunts down
the main corridor, shadowy gures of doctors and nurses would
disappear at night to discuss patients. Or so I then thought! But
as lowly housemen we were forbidden to even knock on the door.
is was truly hallowed sanctuary: Night Sister was always highly
respected.
Christmas on the wards was not an unhappy time. Only
patients who had to be in hospital were kept on the wards. We
would go carol singing round the wards. Tradition had it that
only the senior consultants could carve the turkey on the wards
on Christmas day. With med unit this was, of course, Prof
Scarborough. Around Christmas time there would be wine and
beer in the ward kitchens but I cannot recollect any abuse of this
privilege. Quite simply, if you were ‘on call’ it was orange squash.
Any evenings we had o we would go either to Med Club
or one of the pubs close by, the Splott and the Adamstown. On
one occasion aer a corny ‘vicars and tarts’ residence party we
adjourned to the Adamsdown complete with ‘dog-collars’. ere
was surprise all round when who should walk in but the Salvation
Army on their weekly collection. Remembering their Herculean
work with the homeless in Tiger Bay and which we had visited
as students, and forgetting the dreadful din their band made on
Sunday mornings, they le with their pockets greatly enriched,
though declining a pint of Brains.
Professor Scott
omson
Arthur Bloom
37
Welsh Paed J 2021; 55: 35-42
OCCASIONAL ARTICLE ERTHYGL ACHLYSUROL
ere were so many ward rounds. Most enjoyable were
those with the quiet and unassuming Dr John Henry Jones, an
authority on calcium metabolism, whose MD we were told had
been awarded with distinction. His rounds were always highly
informative, relaxed and very enjoyable. Pete Verrow and I were
fortunate to have very good and helpful SHO’s to guide us through
our medical naivety and to teach us well (apart
from the episode of the lumbar puncture!). Jerry
Coles and John Hughes are two names I can recall,
supported by the ever present and very helpful
registrar John Rees who, as I recall, had an identical
twin brother who would sometimes appear on a
ward round allowing his brother to enjoy himself
elsewhere!
I have some memories of medical problems and their
treatment. Patients admitted with a suspected coronary would
be on complete bedrest for about four weeks, which was then
followed by graded exercises before going home. In fact, I
became quite competent at reading ECG’s, which I discovered
had been pioneered by eminent cardiologist Sir omas Lewis
(1981-1945) of Tas Well, when in the department of physiology
down the road, before he was to move to UCH in London to
continue his internationally respected scientic interests in
cardiovascular disease. omas Lewis was the rst to coin the
term ‘clinical science’. Peptic ulcer was common in these patients:
‘bland 1 and 2’ diets were commonly prescribed including milk,
jelly, porridge, semolina and sago puddings all carefully graded
and very confusing, and for a treat before discharge, bread and
butter pudding - but no Guinness. All strongly evidence-based
of course! Many would later nd their way into the arms of the
surgeons for a vagotomy and pyloroplasty. is medical approach
would have been loved by Meddygon Myddfai. We
would spend a lot of time collecting urines for Dr
Picton omas’ research into hirsute women. As a
senior lecturer in Medicine, Picton, whose brother
was a journalist and newscaster on BBC Wales,
was, I am told, a ‘heart throb’. He also had a lovely
bass voice and sang in our hospital choir. Another
senior lecturer was Bill Asscher who
had recently arrived from London. He was a very
exacting consultant whose clinical and research
interests were in renal medicine. is was the
time when peritoneal dialysis was developed
for patients with renal failure alongside renal
transplantation, which was also
a new mode of treatment. Stuart
Kilpatrick was another senior lecturer, a highly
articulate and courteous Scot, who used words
with great economy and precision. His interests
in chest diseases would be later rewarded with
the David Davies chair in Tuberculosis and Chest
Diseases in the Medical School.
Professor Alan Jacobs was an eminent haematologist on the
Unit. Iron absorption was one of his interests. One day he asked
if I would help his research by visiting a factory in the Rhondda
with bags of sherbert lemons for the men to suck. is was to look
into links between iron absorption and saliva enzyme activity, or
something like it. Aer overcoming the challenge
of rst nding the factory, going by bus into the
Rhondda, clutching my bag of sweets which I
had, I must confess, occasionally dipped into,
I introduced myself to a room full of muscular,
gnarled men waiting expectantly for their sweets.
I admit to feeling a bit da in front of a hundred
or so men with a stop watch and being the butt of
some ribald humour. ey had to suck the sherbert lemon sweet
vigorously for three minutes. ere happened to be a piano in
the room for some unapparent reason and aer some food and a
good old sing song I returned to CRI. A week later I came back
to nish the study. I had to weigh each sweet carefully before and
aer the sucking period. So was my academic career launched,
although I never read any publication, neither did I read an
acknowledgement for my Herculean eorts! But I did come to
understand more of the geography of the Rhondda valleys.
21 October 1966 will be forever be with me. We were having
a cup of coee in the dining room in the morning when someone
burst into the room with the tragic news from Aberfan, a village
outside Merthyr. A colliery tip which had been indecently
towering above the village school (as was then the case in so many
valley communities) had slid following heavy rain. Its slurry
buried part of the village including its primary school. ere were
reported scores of casualties. We wanted to go to Aberfan to help
out but were told to stay in CRI to treat casualties brought to the
hospital. We waited, waited, waited. No one came. 166 people
were killed including 111 children. I will comment no further and
let the reader pause to remind themselves of this terrible tragedy
which still lingers in the minds and the hearts of the community
of Aberfan.
Surgery
I nished my six months on med unit on 31
January. I had enjoyed my time there very much.
It provided a great introduction to the world of
medicine. Aer a good night out
in Med Club, the following day
I began six months as a surgical
houseman. My fellow houseman
was Liz Davies, another very pleasant colleague.
We got on very well. We would be on the surgical
unit (Elize Nixon ward - men; Edward Nicholl
ward - women) with Professor Pat Forest, recently
Professor Alan
Jacobs
Dr Picton
omas
Dr John
Henry Jones
Bill Asscher
Stuart
Kilpatrick
Aber fan
Liz Davies
Professor Pat
Forest
38
Welsh Paed J 2021; 55: 35-42
OCCASIONAL ARTICLE ERTHYGL ACHLYSUROL
down from Glasgow, and his team. A few names
stand out. Gwilym Griths was a very nice,
reliable senior registrar proud of his North Wales
roots; Wyn Jones and Alan Evans (a very good full
back for the Meds in his rugby playing days) were
very kind and tolerant SHO’s, Cardi graduates
both with their FRCS and very experienced;
Jim Lawrie (another CRI heart throb so I was
told) was a delightful lecturer who never became ummoxed
by anything; Mike Leonard was a research fellow
who years before, when I started at ‘Med School’,
was a very accomplished scrum half; Bobby Shields
was Prof’s senior lecturer, strict but very thorough
although, as I recall, he did appear to require several
pints of blood for his prostatectomies! ere would
be exciting times ahead of us with journal clubs
and research meetings, which we were expected to
join in and feel part of the team. e research interests which
would be regularly discussed would be: breast cancer (where Dr
Maureen Roberts and Dr Helen Stuart, who had both come down
from Scotland, were part of the Prof’s team); uid and electrolyte
balance; Bobby Shields’ interests; and gastric function.
Finally, there was the unappable senior
lecturer Arnold Aldis, a general surgeon, a superb
lecturer and teacher, and a devout lay-preacher,
but not an enthusiastic research worker - there
were enough of these around. He provided
a calming inuence over the various frenetic
activities of the unit - and there were many!
(To those interested Arnold would later in 1984
write a superb history of CRI
which should be essential reading
for anyone with an interest in
the development of medicine in
Cardi.
ere was a free bottle of
Guinness prescribed for patients
at night. Much better than
sleeping tablets. Standing out for
me was the excitement of a novel
initiative: showing lmed presentations of patients on the ward,
of course with their agreement, and relaying all this down to a
small lecture theatre on the main CRI corridor for the Friday
morning hospital meeting. is was all great chaotic fun, oen
tripping over the wires, masterminded by Ralph Marshall, then
in charge of the wonderful Medical Illustrations department
on the rst oor, who was the brains and inspiration behind
this initiative. ere is one presentation which has stuck in my
memory. I was asked to present an elderly ex-seaman who had
self-referred to Casualty. He complained of a whistling sound
when passing urine. But this was not a constant note. It wavered
between the tonic and the dominant of the major scale and was
of varying intensity. He performed well and I can but imagine
the reception in the meeting. Apparently, he had a recto-urethral
stula, an unusual complication of diverticulosis. e patient
later underwent surgery and went home a couple of weeks later,
a cured man. I have oen wondered if he suered withdrawal
symptoms, no longer being able to listen in to a Bach prelude
whilst passing urine.
e SHO’s and registrars were all very experienced and they
were very happy to help me develop what latent surgical skills I
might have possessed. But early on the writing was on the wall.
My rst appendicectomy, under supervision, convinced me I was
no surgeon. But I was allowed to have my own minor ops clinic
once a week on a Wednesday aernoon where I became expert
at shelling sebaceous cysts. When ‘on call’ I would spend a lot of
time in Casualty, with the opportunity to improve my suturing,
oen in men who might have had one too many in a local hostelry.
One weekend Prof Forest organised a Saturday walk up
the Brecon Beacons and a meal aer in Brecon, a ‘bonding’
experience (!). is was great fun, showing the
human side of the surgical unit sta. Surgical
lists were usually on Monday, Wednesday and
Friday, where the operating theatres were under
the strict control of Sister Marge Prosser who
scrupulously timed the preoperative scrubbing
routines. She was a dragon of a sister, feared
by all with no exceptions, but greatly respected.
Monday morning surgical lists were a sight to
behold. e senior anaesthetist was Professor William Mushin
(who had come down recently from Oxford where he was the rst
Professor of Anaesthetics in Britain) along with his anaesthetic
team and invariably a visitor or two. What with machines, tubes,
monitors and innumerable fancy gadgets, it was barely possible to
see the anaesthetised patient.
e rst intensive care bed in CRI was in a small side
ward o Elize Nixon ward, where I recall one occasion having
an emergency call to, only to nd the patient lying in his bed
having his breakfast, reading the paper. “What’s up Doc?” was
his surprised question, his quiet breakfast disturbed by a host of
doctors and nurses raring to try out new methods of resuscitation.
is would not have been out of place in a ‘Carry On Doctor’ lm.
On my last day I called in to say “Cheerio” to the
Prof. He generously thanked me, especially for my
TV skills, and gave me an exciting farewell present:
Bradford Hill’s ‘Textbook of Medical Statistics’
which would serve me well in future years of clinical
research. A treasured possession indeed.
An epilogue to my surgical unit experience
was to come een years later when I took up the
Foundation Chair in Paediatrics at the Chinese
University of Hong Kong. We were invited to meet members
of the Academic Advisory Committee in the rst week. Who
should be there but Prof, now Sir Patrick, Forest! I did not have
the temerity to remind him of the whistling seaman!
Obstetrics and gynaecology
Aer completing my surgery post I registered with the General
Medical Council. I had completed my general professional
training but I still had no idea how I wanted my career to develop.
So far, I had enjoyed almost everything. So, to build on my general
professional training I decided on another year as a houseman
but this time as a senior house ocer (SHO), now o the bottom
rung of the ladder.
Jim Lawrie
Bobby Shields
Arnold Aldis
Professor
William Mushin
39
Welsh Paed J 2021; 55: 35-42
OCCASIONAL ARTICLE ERTHYGL ACHLYSUROL
First up was obstetrics and gynaecology
in Glossop Terrace Maternity Hospital,
opposite CRI and around the corner from
Med Club, and ompson ward in CRI.
I recall asking Prof Scarborough for a
reference, only to be greeted with a sigh and
a rolling of his eyes asking, “Why, oh why,
Davies?” He was not over-enamoured with
my choice! My consultant
was Jimmy Lawson, yet
another Scot, very dry,
a man of few words but an excellent and kindly
doctor.
I spent my days (and nights) on B Floor in
‘Glossop,’ and ompson ward. I had three great
colleagues. Tony Davies, whom I had known
since our early years in University
Hall and Med Club (where we had shared a room
for a year), already a committed obstetrician
and gynaecologist if there ever was one. He was
SHO on A Floor with Professor Alec Turnbull
(recently down from Aberdeen and already a very
eminent scientist and obstetrician
whose main research was on the
acceleration of labour with oxytocic drugs. In fact,
Prof was such an enthusiast that late at night he
could be seen talking with great animation about
his work with a ward cleaning lady. Another
memory I have is when some years later as a
lecturer in paediatrics in the ‘Heath Hospital’, Alec
Turnbull would ask me to conduct a study into jaundice in the
newborn and its possible relationship with the early induction of
labour through oxytocic drugs. To my recollection
this was later published in the BMJ.
Another good colleague was Mike Wheeler,
who had earlier shone on the rugby eld. He was
SHO on C Floor with Mr Arwyn
Evans who was purported to be an
enthusiast for hypnosis in labour. His
father, David Evans, was a famous
Welsh musician, composer and a Professor of Music
at the university.
To complete my circle of close colleagues was
Pete Evans, then an SHO in paediatrics, who would
be ‘on call’ for the labour ward, a post I would later follow. I had
known Pete since our time as students. His father,
known as ‘Cyc’ Evans because of his speed on the
wing, was a colleague of my father in ‘Med School’.
We were all a very happy family of SHO’S. Tony
would later become a consultant in Withybush
Hospital in Haverfordwest, fullling his lifetime
ambition.
e ‘Residence’ in ‘Glossop’ was a converted set of storage
rooms next door to labour wards on each oor, understandably
not the quietest place to have a bedroom! So, the story went
that when the hospital was built in the 1930’s plans for a medical
residence were omitted! Our rota was two nights out of three ‘on
call’. is included standby for the ying squad where, with the
registrar and midwife, we would oen be called into the home
(usually by the community midwife) to deal with women with
complications aer delivery, including post-partum haemorrhage,
retained products and even seizures. Hospital admission would
invariably follow. is was quite an eye opener, and call outs then
were very frequent. I enjoyed these experiences very much. e
TV programme ‘Call the Midwife’ sums it all up: Cardi then was
no dierent from London. Flying squad was a true brush with
the real world.
ere were antenatal clinics every Monday, which were very
busy, seeing about thirty ladies under the watchful eye of Sister
Pressdee, a lovely person who guided us well. B Floor and its
labour ward, my home for six months, was under the care of Sister
‘Flo’ Jones, quite a ‘poshly’ spoken lady from west Wales. Sadly,
I can remember many years later visiting her in UHW where she
was suering terminal cancer. Her wicked sense of humour had
not deserted her.
e senior registrar, I seem to remember, was John Hughes,
a ‘god-like’ gure to us, who would wa in and out of the wards.
We had much more to do with the two registrars, Gwyn Daniel
and Jack Wingeld. ey always seemed to be around labour
ward and their presence was very reassuring. But there can be no
doubting where the power lay – with the midwives – who were a
great, sometimes frightening, bunch of people who taught me a
lot. Gwyn and Jack, being so experienced, would also teach me a
lot of practical obstetrics including forceps and ventouse assisted
deliveries and also helping in caesarian sections. Episiotomies
were a regular responsibility of the SHO. ere is no doubt that
the experience we had gained as students provided a wonderful
foundation for this. Aer six months I became a very reasonable
accoucheur, so much so, that I wondered whether this could be
my future specialty. But then I enjoyed most of what I did! Best
forgotten is during a Neville Barnes forceps assisted delivery I slid
backwards on the slippery oor hitting a radiator on the labour
ward wall. Concerned, the mother peered between the lithotomy
poles, “Are you all right Doctor?” Possibly my greatest achievement
was getting the mothers in labour another 50mg pethidine!
At the lower end of St Mary’s Street there was then a cinema,
the Prince of Wales, that had a reputation for showing rather
‘suggestive’ lms! An usherette from the cinema happened to
be on the antenatal ward. On one ward round with Mr Lawson,
registrar, senior midwife, medical student and myself, we paused
at her bedside. She began to wink at someone. I wonder if she had
recognised someone she had met as an usherette. I can but guess
who it was – not me – and certainly not Jimmy Lawson!
e gynaecology part of the job was on ompson ward in
CRI and in outpatients. As SHO I had to prepare the surgical
lists for the Monday aernoon. Every Sunday night my pager
would go o without fail at about 9pm. It was Dr Mike Rosen, the
consultant anaesthetist for Mr Lawson’s Monday list. He would
insist on knowing each patient’s haemoglobin to be sure surgery
could go ahead. Woe betide if you did not have the values to
hand. Mike Rosen was a very thorough, if sometimes irascible,
anaesthetist who would scare the living daylights out of us!
One treasured memory of ompson ward is playing the
ward piano on the occasional Saturday when I was ‘on call’, for the
Glossop Terrace
Maternity Hospital
Jimmy Lawson
Ton y D avi es
Professor Alec
Turnbull
Mike Wheeler
Arwy n
Evans
Pete Evans
40
Welsh Paed J 2021; 55: 35-42
OCCASIONAL ARTICLE ERTHYGL ACHLYSUROL
ladies to have a ‘sing-song’. And sing indeed they did! Mind you
some of the lyrics to popular songs were very alien to me. I let the
reader guess some of these! And aerwards I would have cooked
for myself a lovely meal. It was all worthwhile.
A momentous day was when I demonstrated to a group of
student midwives how to deliver the placenta using, as I recall,
the ‘Brandt-Andrews’ method of cord traction and to check
aerwards for its completeness. In the group was a pretty pupil
midwife, Georgina, whom I would later marry. Maybe this
was why my demonstration le much to be desired, as the cord
snapped, leaking blood everywhere, fortunately after the placenta
had been delivered.
I thought it worthwhile towards the end of the six months
to sit my DRCOG. I revised for this exam, helped by Georgina
who was also revising for her exam with the indispensable book
Maggie Myles. I travelled on the overnight sleeper to Paddington,
then underground to a hospital in the East End. Feeling famished
I had breakfast in a local Salvation Army hostel. e mother to
be who I had to see, and examined on, was a dicult case – twin
pregnancy. But I got it right, helped a little by the mother to be.
Georgina and I both passed.
I have very fond memories of ‘Glossop’. What a pity it is no
longer there, its ghost lost in the foundations of what is now a
university student hall of residence. I wonder if sometimes the
sounds of labour disturbs the students’ sleep in the cold early
hours of the morning.
Paediatrics
My nal six months as an SHO in Cardi was in paediatrics. (It
was several years later that the term child health would come more
and more to embrace the prevention and treatment of sickness in
children).
e time would be spent in three parts. e rst two months
belonged to the special care baby unit (SCBU) on C Floor in
Glossop Terrace, where we would also have to cover the labour
wards (a very familiar place for me) for ‘at risk’ deliveries and also
examine all newborn babies on each of the three oors. e second
two months would be spent
on John Nixon ward in CRI
and also covering Casualty.
e nal two months would
be in Llandough Hospital in
general paediatrics. ese six
months would give me a broad
understanding of the world of
paediatrics.
e care of the prematurely born baby – or low birth weight
baby (<2500g) as we were encouraged to call these babies – and the
sick newborn, was then growing its own specialty: neonatology.
e respiratory distress syndrome (RDS) was the major cause of
early morbidity and mortality. But oh, the frustrations! Hours
would be spent with the Loosco ventilator, specially designed
for sick babies with RDS. e settings on the ventilator were, I
hesitate to say, oen trial and error, so little then being understood
of the pathophysiology of RDS and how best to use the settings on
the Loosco. is would oen also provide an immense challenge
to the resident anaesthetist. ere would be many sad days.
Indeed, ventilation was oen introduced almost
as a preterminal gesture so, sadly, many very
small babies would succumb, causing immense
sadness to the parents. Very harrowing
times also for medical and nursing sta. e
pathophysiology of RDS was only then being
researched in earnest, led by paediatricians at
University College Hospital in London. e consultant/senior
lecturer was the kindly Peter Gray who would soon take the Chair
in Child Health on Prof ‘Pop’ Watkins’ retirement some years
later, and whom I would follow in twenty years.
It is salutary to recall that the decade of the 1960’s was
considered, in hindsight, as years of iatrogenesis as neonatology
was born. A few examples illustrate these concerns. Dangers of
too early feeding risked uid overload, so withholding milk for a
couple of days was by no means uncommon. But this of course
led so oen to hypoglycaemia and hypernatraemia, important
causes of brain damage. Too high dosage of vitamin K caused
signicant hyperbilirubinaemia, another risk factor for brain
damage. And a fear of causing retrolental broplasia from too
much oxygen meant that cutting down on oxygen with resulting
hypoxic brain damage was, without the means to monitor oxygen
therapy, always lurking in the background. Weekly Outpatient
follow up clinics were humbling. ere would always be some
young babies with varying degrees of cerebral palsy from perinatal
causes. So oen these children and their families would face a
lifetime of heartache.
I remember the neonatal nurses as being very skilled, not
only in the care of the sick newborn, but also in their kindness
to mothers and fathers of these babies at such a stressful time.
I learnt a lot from them, as indeed I did from all the nurses I
met throughout my time as a houseman. My favourite was Mrs
Keogh who organised the follow up of babies aer their discharge
home. She was remarkably dedicated and with an encyclopaedic
knowledge of these babies and their families.
Another common problem was the need for exchange
transfusion for the Rhesus baby. is important procedure was
very time consuming; from beginning to end it oen would take
up to three hours. It would mean gowning and masking, passing a
catheter into the umbilical vein and transfusing 10-20ml, waiting
a couple of minutes and then removing the same volume of
exchanged blood. Careful record had to be taken to be sure that
we were exchanging equal volumes, remembering my time as a
medical student in St David’s Hospital when as a resident student
we would help out by recording the blood volumes exchanged.
For some reason or another exchange transfusions would always
occur in the hours of darkness! We were also beginning to use
phototherapy to treat neonatal jaundice, accidentally discovered
in the 1950s when a senior nurse at Rochford Hospital in Essex
noticed that babies near a window were less jaundiced than those
more in the middle of the nursery. A great discovery indeed from
a chance observation.
Resuscitating the ‘at’ new born on labour ward was always
a stressful emergency. I could now view this emergency from
the paediatric angle. Successfully intubating the ‘at’ baby and
gradually seeing the baby begin to breathe with help from the
Llandough Hospital
Peter Gray
41
Welsh Paed J 2021; 55: 35-42
OCCASIONAL ARTICLE ERTHYGL ACHLYSUROL
‘Cardi bag and mask’; becoming pinker and moving the arms
and legs, was one of the most rewarding of emergency procedures.
Aer two months of
neonatal medicine I was now to
spend two months on John Nixon
ward in CRI. is was a lovely
ward on the ground oor, leading
from the top of the main corridor.
ere were some lovely paintings
on ceramic wall tiles, especially
in the side ward. As well as dealing
with typical emergency admissions via
Casualty, two aspects especially stand out
in my memory. e rst was the number
of ward rounds from the many specialties
who would be involved with the care of
children, remembering that these were
the days before Cardi had paediatric surgeons: neurosurgeons,
general surgeons, uro-genital surgeons, orthopaedic surgeons
especially. And, of course, there were rounds by paediatricians.
e only way I could cope was to be on the ward very early, at
about 7am, to take all the bloods ready for the avalanche which
began at 9am. I was not popular with the nursing sta but it
was the only way I could survive! Talking about surgeons, I can
recall one whose name eludes my memory who, when called in
one night to see a baby, placed his head through the perspex tent,
forgetting he was smoking his pipe. Somehow, we had to subtly
remind him of the error of his ways. Fortunately, the oxygen was
not turned on. Neither was his pipe alight.
A second memory is of the stresses looking aer babies
with spina bida and hydrocephalus. is was the era before
folic acid supplements for the mother. e incidence was higher
in South Wales than anywhere else. e problems were mostly
urinary infections, hydrocephalus with its Spitz-Holter valve and
orthopaedic. If it was stressful looking aer these babies this
was nothing compared to the anguish of the families who had a
lifetime ahead of them, caring for an oen much-loved, multiple
handicapped child. Seeing a baby with an enormous head due
to hydrocephalus, unable to move his head, was poignant in the
extreme. ese were harrowing times and the spina bida unit
took up a lot of my time. I would also see some of these children
in outpatients. We should never overestimate
the preventive power of later folic acid
supplementation during pregnancy. Much of the
basic research into spina bida was undertaken
by Dr Michael Laurence, paediatric pathologist
in Llandough Hospital, who was to become an
international authority on the subject of spina
bida.
Aer my two months on John Nixon ward
it was now time to go to Llandough Hospital. Pete Evans was
again my co-SHO. ere were then two wards for children:
downstairs for older children on West 4 and on the rst oor for
infants and young children, including a gastroenteritis unit. We
came into a lot of contact with the senior paediatricians who were,
then, all general paediatricians with their special interests: Percy
Bray (who was another colleague of my father in ‘Med School’)
had ward rounds which were relaxed, highly
informative and amusing. His specialty interest
was cystic brosis. is very sad condition
had then a poor prognosis: from the time of
diagnosis to the end of life was only a few years.
Joe Jacobs, a very intense person, was interested
in the psychological aspects
of illness to the child and
family. His ward rounds
were far from relaxed aairs.
Eileen ompson, to junior
doctors a rather fearsome
lady, had recently come down
from London to set up the
paediatric oncology unit.
en there was Professor
‘Pop’ Watkins, the ‘father of Welsh paediatrics’,
who would oen stand at the end of the ward
from where he would conduct his ward round.
On Wednesday aernoons we would have the
‘grand round’ in the solarium of West 4 ward.
As SHO’s we had to present clinical problems
and lead the discussion. I thoroughly enjoyed
these aernoons. e highlight was Percy Bray and Joe Jacobs
sparring with each other: always good value for money. A mention
also about Michael Laurence, our eminent paediatric pathologist
and clinical geneticist. He always came to the ‘grand round’ and,
as I have mentioned before, he played a very important part in
the unfolding history of maternal folic acid and the prevention
of spina bida. Michael Laurence, who I believe came to this
country from eastern Europe before the war, did, however, have
one problem. Aer ve minutes or so his head would nod and
he would invariably fall into the ‘Land of Nod’. But somewhat
remarkably he would wake up to participate in question time as
though he had been awake all the time. Michael also loved music.
On the occasions when I would visit the Reardon Smith Theatre
in the Museum (a habit I had begun as a medical student when
all students could go to these wonderful chamber music concerts
on Tuesday night free of charge), believe it or not, Michael, who
would also go to these concerts, would aer the rst ve minutes
close his eyes and enter dream-land. But when the next day I
would discuss the concert with him, he was aware of every single
crotchet and quaver!
Sister Phillips was in charge of West 4 ward. She was a warm-
hearted person, nearing her retirement, always supportive of
young doctors and who was worshipped by her nurses. She was
from Ystradgynlais, where my mother’s side of the
family came from and, not surprisingly coming
from the Swansea valley, was Welsh speaking.
Indeed, it was then very unusual to hear the
sounds of the Welsh language (my rst language)
in Cardi. How times have changed.
We were fortunate to have two lovely senior
colleagues. Our senior registrar was Roger
Verrier-Jones. e son of Provost Alan Trevor
Jones of the Welsh National School of Medicine, Roger was a great
support. He was always available to help us yet give us plenty of
John Nixon ward
Michael
Laurence
Percy Bray
Joe Jacobs
Eileen ompson
Professor ‘Pop’
Wat kin s
Roger Verrier-
Jones
42
Welsh Paed J 2021; 55: 35-42
OCCASIONAL ARTICLE ERTHYGL ACHLYSUROL
scope to look aer the children. John Cawdray was our registrar:
a ne paediatrician, he never raised his voice and his manner
towards children and their families was a model for us all.
Conclusion
I had now been qualied for two years. Very enjoyable years
they had been, but now I had to decide on my next step. In
those far o days climbing up a medical career ladder tended to
be unstructured and haphazard, with little guidance and where
jobs were almost invariably sought through the advertising
pages of the BMJ and the Lancet on Saturday mornings. I had
enjoyed all my earlier experiences in medicine, surgery, obstetrics
and gynaecology, and paediatrics. But as a future career adult
medicine did not quite appeal to me. Surgery was not on: life
as a surgical houseman had convinced me of that. For much
the same reasons obstetrics and gynaecology was not an option.
Pathology and the laboratory sciences, which I saw quite a lot of,
was not for me. Neither were public health and social medicine.
I was therefore le with a choice of paediatrics or eventually
general practice. My dad had a long chat with me about life as a
general practitioner: he had been in general practice in Swansea
since returning from the war in 1945. But in the end, I have to
admit that I did enjoy children’s company. I found the spectrum
of childhood illness and disease very interesting and especially
their impact on growth and development in the childhood years
and beyond. So, paediatrics it would be. But setting about this
possible future career in the specialty would be ‘hit and miss’.
e rst hurdle to overcome was passing the adult MRCP, there
being then no paediatric membership. Neurology for a year was a
sensible and popular rst move. It was also time for me to cut the
apron strings to my comfortable and secure Cardi alma mater.
A post as SHO in the department of neurology at the Churchill
Hospital in Oxford looked a good option. So, dreaming spires,
here I come ….
Addendum
Many of the pictures I have included in my two articles on
‘memories of an earlier life in medicine’ are to be found in the 1966
Final Year Book. It was then the custom for a final year committee
to put together, as a visual kaleidoscope, memories of our time as
medical students. These included photos of hospitals where we
had been taught, officers of the medical school and photos - and
pithy aphorisms - of our preclinical and clinical teachers and fellow
students.
More information
e book by Arnold Aldis, Cardiff Royal Infirmary 1883-1983.
University of Wales Press, Cardiff 1984, is an excellent read and
should be found in Cardi’s libraries.
1. Davies DP. COVID-19 Meanderings. A kaleidoscope from
the past: memories of an earlier life. Medical student years.
Welsh Paed J 2021;54:26-33
2. Textbook Of Physiology And Biochemistry by Bell GH,
Davidson JN, Scarborough H. First published by E & S
Livingstone Ltd 1959
3. Aldis A. Cardi Royal Inrmary 1883-1983. University of
Wales Press, Cardi 1984
4. Austin Bradford Hill. Principles of Medical Statistics. First
published 1937 and updated in each new edition. Renamed A
short Textbook of Medical Statistics in 1977
5. Myles MF. Textbook for Midwives. First published 1953 and
updated versions used for decades
WELSH PAEDIATRIC SOCIETY CYMDEITHAS PEDIATREG CYMRU
Noticeboard/Hysbysfwrdd
WRCPCH St David’s Day Lecture and
Study Afternoon:
2 or 9 March 2022
TBC
RCPCH Conference and exhibition 28 to 30 June 2022
Liverpool
SPRING MEETING OF THE WPS 2022
WPS Business meeting: Thursday May 2022
TBC
WPS Spring Conference: Friday May 2022
TBC
43
Welsh Paed J 2021; 55: 43-49
WALES MATERNITY AND NEONATAL NETWORK RHWYDWAITH MAMOLAETH A NEWYDDENEDIGOL CYMRU
Oral Abstracts
ORAL ABSTRACTS FROM THE NEONATAL ANNUAL AUDIT
AND QUALITY IMPROVEMENT EVENT 14 JUNE 2021
Achieving quality outcomes in twin and triplet pregnancies: a service
evaluation of the Multiple Pregnancy Clinic in UHW, Cardiff
Griffiths S, Francis HC, Goodman D, Thomas N, Phillips C, Robb AO
University of Cardiff Medical School, Cardiff; Department of Obstetrics and Gynaecology, University Hospital of Wales, Cardiff;
Department of Radiology, University Hospital of Wales, Cardiff
Aims
Women with a multiple pregnancy should have their care
provided by a multidisciplinary core team because of increased
risks and complications for both mothers and babies associated
with multiple births ( NICE 2019). In UHW, Cardi, a weekly
multiple pregnancy clinic (MPC) provides specialist antenatal
care to all mothers with a multiple pregnancy.
is service evaluation determined the adherence and
outcomes of the MPC, to the 8 Quality standards issued by NICE.
Method
Retrospective data from maternal and neonatal records was
collected for all mothers under the MPC between March 2020
and March 2021.
Results
108 mothers were cared for by the clinic in the 12-month period.
15 mothers either transferred care out of area or lost babies
before 24 weeks. 18 mothers remained undelivered. A nal
data set of 75 women delivered 150 live births within the time
frame. Improvements from a previous service evaluation in 2018
evidenced 6 of 8 NICE quality statements achieved in full. e 2
NICE quality standards not achieved at 100% (though improved
from 30% to 60%) were written evidence of twin-specic
counselling of preterm-birth risk before 24 and delivery planning
before 28 weeks.
21.7% of MCDA twins were aected by twin-to-twin
transfusion syndrome. 52% of all births were pre-term, 40% of
DCDA twins. 78% of women aiming for vaginal birth achieved
this.
Conclusion
Introduction of standardised documentation, schedules of care
for hand-held notes and counselling stickers have improved
adherence with NICE quality standards. Overall the MPC is
largely achieving its expectations.
Term and near term admissions to a tertiary neonatal unit
Agarwal A, Koshi S, Allman A
Neonatal Intensive Care Unit, Grange University Hospital, Cwmbran
Introduction
Analysis of care days provided by our tertiary neonatal unit
(NICU) has shown a high number of special care days. We aimed
to review term and near term admissions and benchmark with
national data.
Method
is was a retrospective observational study from January to
August 2020. Inclusion criteria were infants born ≥35 completed
gestational weeks (CGW) admitted to NICU. “Near term” was
≥35 to <37 CGW. Data were collected from BadgerNet and
analysed using Microso Excel.
Results
214 infants were identied, 170 term (9.5% of term births) and
44 near term (42.6% of near term births). 139 (65%) infants
were admitted for respiratory concern and 40 (29%) required <6
hours respiratory support. 49 (23% of the 214) were admitted for
hypoglycaemia and 32 (65%) required nasogastric feeding only.
18 infants (8.5%) were admitted for monitoring. Term infants
occupied 898 care days, 621 (69%) being special care. Near term
infants required 363 care days, and 282 (78%) were special care.
Average duration of stay was 5.3 and 8.3 days for term and near
term infants, respectively. Average separation days were 4.0 for
term infant and 6.9 for near term infant.
Conclusion
Our study demonstrates a rate of term and near term admissions
higher than the national ATAIN programme recommendation of
<6%. Our average separation days are above the 2020 NNAP unit
comparison data of 2.9 for term and 5.8 for near term infants. We
recommend adopting the 2017 BAPM transitional care standards
and subscribing to the ATAIN programme.
44
Welsh Paed J 2021; 55: 43-49
WALES MATERNITY AND NEONATAL NETWORK RHWYDWAITH MAMOLAETH A NEWYDDENEDIGOL CYMRU
Oral Abstracts
Reducing term admissions for hypoglycaemia in the NICU
at Singleton Hospital
Brown L, Evans J
Swansea Bay University Health Board
Aims
• To reduce NICU term admissions attributable to
hypoglycaemia in keeping with ATAIN principles
• To bring local guidance in line with the 2017 BAPM
framework for hypoglycaemia
Method
e rst step was a full update and roll out of guidelines for
management of hypoglycaemia on the postnatal ward in term
infants. A blood gas analyser was already in use so barriers to
change were few to progress to BAPM standards. Changes
included:
• Change of the intervention threshold to 2.0mmol/L for term
infants
• Development of care bundles
• Addition of a dextrose SOP to prevent delay of administration
of dextrose gel
• An educational video rather than face to face training due to
COVID-19 for sta education
Change was measured by reviewing term admissions for
hypoglycaemia prior to and aer the implementation of the new
guideline.
Results
Run charts showed that for the 8 months since implementation
the proportion of all term babies admitted to NICU for which the
admission cause was hypoglycaemia has been below the median.
For 5 months from implementation the proportion of all
live born term births requiring admission for hypoglycaemia fell
well below the median. We are seeing signicantly less avoidable
admissions.
Conclusion
e results show that there is a sustained change in term
admissions to the NICU with hypoglycaemia. We will continue
to monitor this change and explore the impact of other factors
such as maternal care of diabetes during COVID-19.
Success of the project has led to new All Wales Guidance
being produced.
NIPEs on NICU – exceeding the 72-hour performance threshold
Trad G, Hayward R, Dixit S, Ogunkanbi S
Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff
Aim
e Newborn and Infant Physical Examination (NIPE) is an
essential screening test for conditions present at birth. With
early identication and treatment there is an observed decrease
morbidity and mortality rate in the infant population. is
audit aimed to determine the reasons for delayed completion of
the NIPE within the newborn population admitted to a tertiary
Neonatal Intensive Care Unit (NICU).
Method
e NIPE screening proforma of 32 babies admitted to NICU
between 02/11/2020 and7/12/2020 were reviewed. All admissions
were included in the audit, with the exception of referrals and
those who passed away within 24 hours of admission.
Results
Within the study, 23% babies had their NIPE screening completed
within 72 hours of life, following RCPCH recommendations.
Delays in NIPE were due to non-invasive ventilation (32%) and
invasive ventilation (23%). Incomplete NIPE screening within 72
hours was also found relating to examination of hips (32%), eyes
(69%) and palate (32%). NIPE screening was mostly completed
following de-escalation of care to HDU, the postnatal ward or at
discharge. Incomplete NIPEs were not clearly documented in
the notes. Findings were comparable between preterm and term
neonates.
Conclusion
An All Wales Neonatal Network audit is proposed to determine
adjusted performance thresholds for NIPEs conducted in NICU
patient populations. is will be essential in advance of the
proposed Newborn and Infant Physical Examination Cymru
(NIPEC) and associated auditing of performance standards.
Clear documentation is required to ensure missing elements of
the NIPE are conducted in advance of discharge.
45
Welsh Paed J 2021; 55: 43-49
WALES MATERNITY AND NEONATAL NETWORK RHWYDWAITH MAMOLAETH A NEWYDDENEDIGOL CYMRU
Oral Abstracts
Newborn examination audit in Betsi Cadwaladr University Health Board
Ajitena O, Wong SY, Rackham O
Betsi Cadwaladr University Health Board
Aims
is audit aims to clarify the entire Betsi Cadwaladr University
Health Board’s compliance with National Public England (NPE)
guidance on Newborn Infant Physical Examination (NIPE). e
NIPE screening programme handbook recommends all eligible
newborn infants to have a NIPE within 72 hours.
Method
A 4-week prospective study was done in all 3 major sites of Betsi
Cadwaladr University Health Board between 25 January 2021
- 21 February 2021. All in-hospital babies born between this
time frame were identied and the data were collected using a
standardized proforma.
Results
A total of 371 babies were born from all the participating hospitals.
347 of them were included in this study. 97.85% (n=340) NIPE
was performed within 72 hours of being born. 93.74% (n=326)
NIPE was performed within 48 hours of being born.
Conclusion
Vast majority of in-hospital babies born received NIPE within
48 hours. Eorts have been taken to improve further NIPE rate
within 72 hours in certain sites.
Impact of 2016 All-Wales neonatal feeding policy on growth velocity
Pryjda P, Vintila A, Patel I, Crawley L, Harkness D, Callaghan F, Abelian A
Paediatrics, Maelor General Hospital, Wrexham
Aims
is study examined the impact of the 2016 All Wales neonatal
feeding policy (AWNF) on postnatal growth velocity (PGV).
Method
All babies treated on the neonatal unit at Wrexham Maelor
Hospital for at least two weeks within 18 months prior and aer
the implementation of AWNF policy were included. Babies were
weighed twice weekly. A two-point average weight model was
used to calculate PGV in gram/kg/day. e Mann-Whitney test
was used for statistical analysis.
Results
ere were 90 and 72 babies in the pre and post AWNF policy
groups, respectively. From birth to discharge, PGV was similar
(7.6 vs 8.1; p=0.147). Once birth weight (BWt) was regained,
PGV was greater in the AWNF group (13.9 vs 15.9; p=0.009).
ere were no signicant dierences in days to regain BWt and
days to dis-charge aer regaining BWt.
Across all gestations, AWNF policy was associated with a
reduced use of intravenous uids and with fewer days of volumes
>150 ml/kg/day. e duration of the period of NBM, the use of
breast milk (BM), BM fortier, formula, parenteral nutrition,
and time to full feeds were similar and so were the incidence of
necrotizing entero-colitis and raised CRP.
Babies <32 week gestation had a signicantly shorter period
of NBM and attained full feeds faster with AWNF policy.
Conclusion
e 2016 All Wales neonatal feeding policy was associated with
a small, but signicant increase in PGV once BWt was regained.
46
Welsh Paed J 2021; 55: 43-49
WALES MATERNITY AND NEONATAL NETWORK RHWYDWAITH MAMOLAETH A NEWYDDENEDIGOL CYMRU
Oral Abstracts
The SuPPORT Project – A scoping project
Supporting parents and professionals through neonatal
resuscitation in theatre
Godfrey E¹, Harris N², Kitchen T¹, Channon S³
¹Anaesthetics, University Hospital of Wales, Cardiff, ²Anaesthetics, Princess of Wales Hospital, Bridgend,
³Research Design and Conduct Service, Centre for Trials Research, Cardiff University, Cardiff
Aims
To determine recurrent themes surrounding communication
between healthcare professionals, the awake mother and her birth
partner during neonatal resuscitation in the obstetric theatre, by
exploration of parental voices.
A scoping project has explored parental voices to inform
the direction of a larger study, which will incorporate anaesthetic
team experiences and co-produce interventions which will aim
to improve communication and reduce psychological distress and
trauma for sta and families.
Method
631 parent responses were captured anonymously via
SurveyMonkey using a social media platform. 233 were focused
on neonatal resuscitation in theatre. Open and closed questions
captured parents’ accounts and reections on their experiences of
communication during the resuscitation of their baby in theatre.
Each respondent gave explicit consent for data to be stored
and used in line with project design. Responses were reviewed
thematically.
Results
Emergent themes were categorised into two areas, positive
experiences and challenging experiences. Positive experiences
included actively providing honest and continuous information,
calm and compassionate communication, sensitive behaviour
regarding the baby while recognising the new-borns identity and
using technology (photos). Challenging experiences included a
lack of information, use of insensitive processes and language,
impersonal care, good intentions that go wrong and a challenging
theatre environment.
Conclusion
is unique and under researched patient-professional
interaction could be readily improved. Building on principles of
communication relating to stillbirth and bereavement we will use
these themes to inform a larger study and develop novel guidance
to assist the anaesthetic team in reducing the impact of these
potentially traumatic events.
A service evaluation of the Rainbow Clinic in Cardiff and Vale,
caring for women in pregnancy after loss
Gannon U¹, Latibeaudiere M², Reen², Robb AO²
¹University of Cardiff Medical School, Cardiff; ²Obstetrics and Gynaecology, University Hospital of Wales, Cardiff
Aims
e Cardi Rainbow Clinic (est. 2017) provides consultant-led
care for women who have lost a baby during pregnancy or shortly
aer birth. It provides specialist obstetric and midwifery care
with continuity of carer as a priority. Currently the only Rainbow
Clinic in Wales, it is based on the clinic in Manchester. is study
reviewed the clinic from November 2019 - March 2021.
Method
119 patients were cared for in this time. Pregnancy and delivery
data was collected on current and previous pregnancies.
Results
Ethnic minorities were overrepresented (30%). e reasons for
previous loss were varied. Over 90% of women had perinatal
pathology for previous losses. Over 72% of women had an
explanation for their previous loss, which is higher than is reported
nationally. For 79% (n=84) this was the next pregnancy aer loss
and 8% (n=10) women had a formal investigation previously into
their pregnancy outcome. 10% (n=11) of women had a cervical
cerclage placed. Most women (76%) delivered at term, with 28%
delivering ≥39 weeks. ere was one early neonatal death and
one stillbirth.
Conclusion
is evaluation shows how specialist care is benecial in reducing
perinatal death recurrence. It reects how stillbirth rates are
higher in ethnic minorities. Women attending for rainbow care
are high-risk obstetrically with higher rates of preterm birth and
induction. Areas for improvement include ensuring all women
have their own letter regarding their previous loss and that data is
inputted correctly and completely in real time. Further evaluation
of the psychosocial impact would also be valuable.
47
Welsh Paed J 2021; 55: 43-49
WALES MATERNITY AND NEONATAL NETWORK RHWYDWAITH MAMOLAETH A NEWYDDENEDIGOL CYMRU
Oral Abstracts
‘Mind the Gap’
Maintaining neonatal normothermia: A Quality Improvement Project
Bhardwaj R, Kollamparambil T, Reddy S, Urrutia R, Beckett H, Harvey B, Hughes W, Morgan J
Neonatal Intensive Care Unit, Grange University Hospital, Cwmbran
Aims
Hypothermia at birth is a signicant risk factor for preterm babies.
e Resuscitation Council (UK) (2015) states that every 1°C drop in
temperature below 36.5°C increases mortality by 28%. e National
Neonatal Audit Programme (NNAP) (2019) data highlighted that
in our unit 67.2% babies born <32 weeks had temperatures on
admission between 36.5-37.5°C. is result prompted this QI
project; with the aim of normalising admission temperatures.
Method
A QI team was formulated and temperatures were collected at 5
points (at birth, before transfer, on arrival, at admission and 1 hr
post admission) for all admissions from delivery room or theatre.
Posters were displayed, temperature stickers introduced and the
importance of temperature measurement regularly reinforced.
ree interventions were introduced; humidication of gases
during resuscitation, humidication of gases during transport
and increasing the temperature of delivery rooms to 24°C.
Results
30 babies <32 weeks gestation were admitted from 28/10/2020
to 30/04/2021. 76.7% of babies <32 weeks had an admission
temperature between 36.5-37.5°C. Only 6.7% of babies born <32
weeks were admitted hypothermic and 16.6% were hyperthermic.
ere was a 9.5% improvement on NNAP criteria.
Conclusions
Our QI project has led to the introduction of humidication of
gases at resuscitation, which is a novel and exciting intervention
not routinely used in the UK. Our project has improved
normothermia at admission which will hopefully improve overall
outcomes for these babies.
Keeping babies optimally warm - a multidisciplinary initiative to improve
proportion of babies admitted in the normothermic range at Singleton NICU
Smith G, Hughes S, Vaughan A, Whiles M, Harris L, Perriam R, Lewis G, Smith L, Thomas J, Goyal S, Banerjee S
Neonatal Medicine, Singleton Hospital, Swansea
Aims
Maintaining normothermia (36.5-37.5C) in a narrow range
in neonates is particularly challenging due to delivery room
environment and need for prolonged stabilisation at birth.
Deviation from normothermia on admission to NICU is
associated with increased neonatal mortality and morbidity.
A multidisciplinary QI programme at Singleton NICU
aimed for a 10% improvement in admission normothermia from
theatre and delivery room from a baseline of 78% within the next
6 months
Method
Pareto analysis, process mapping and brain storming exercises
identied interventions that were tested and rened through
PDSA cycles. Renements of plastic bag application, introduction
of a ‘shuttle’ with adjustable overhead warmer along with
continuous skin and 3-point axillary temperature measurements
were the main interventions in the improvement package. e
QI was ocially launched in Nov 2019, interrupted during the
rst COVID peak and relaunched again in August 2020. Learning
points were displayed weekly on a dedicated QI board and
improvement data shared with sta using process control charts
on e-mail and newsletter.
Results
Baseline and post intervention admission temperature data are
depicted in a Shewart chart (Figure 1). Following the relaunch of
the QIP, the normothermia admissions improved from a baseline
mean of 78.2% to current mean of 88.5%, sustained over 6 months.
e initial improvement in 2019 could not be sustained during
the pandemic due to access restrictions of sta and equipments
to delivery room.
Conclusion
A 13% improvement in admission normothermia was sustained
by a multidisciplinary initiative applying the model for
improvement. ere are plans to extend good practices to the
birthing centre and postnatal ward.
48
Welsh Paed J 2021; 55: 43-49
WALES MATERNITY AND NEONATAL NETWORK RHWYDWAITH MAMOLAETH A NEWYDDENEDIGOL CYMRU
Oral Abstracts
How to prospectively audit deferred cord clamping without
influencing the outcome?
Whitley H, Murphy G, Abelian A
Children’s Ward, Maelor General Hospital, Wrexham
Aims
It is a challenge to prospectively audit deferred cord clamping (DCC)
practice without inuencing the outcomes. e Royal College of
Obstetricians and Gynaecologists recommends DCC in term babies
for at least 60 seconds with evidence of potential benets.
Method
We trialled prospective audit through opportunistic observation
of practice by the paediatricians whenever they were called to
attend a delivery between 01/09/2020 and 01/11/2020. e
timing to cord clamping was inconspicuously noted using the
Apgar counter and recorded. Only term babies were included
(≥37 weeks at birth). is was also discussed with a consultant
obstetrician who approved this methodology.
Results
In total, 43 births were recorded. Cord clamping was deferred by
at least 60 seconds in 21 babies (49%), for less than 60 seconds in
four babies (9%), and in 18 babies (42%) there was no deferral
in cord clamping. Of these 18 babies, ve needed immediate
intervention by a paediatrician.
Conclusion
e audit trialled a prospective methodology of DCC practice,
which avoided the pitfalls typically associated with such an audit.
is methodology can be applied for a larger, multicentre audit.
We recommend a large prospective audit utilising the above
methodology to ascertain the current practice of DCC.
WALES MATERNITY AND NEONATAL NETWORK RHWYDWAITH MAMOLAETH A NEWYDDENEDIGOL CYMRU
POSTERS from the NEONATAL ANNUAL AUDIT and
QUALITY IMPROVEMENT EVENT 14 JUNE 2021
Length of stay in NICU
Johnson J, Kollamparambil T
Aneurin Bevan University Health Board
APGAR scores
Nair C, Kannapiran R
Aneurin Bevan University Health Board
BCUHB infant feeding strategy
Jones A, Breward S, Owens S
Betsi Cadwaladr University Health Board
Effect of community transcutaneous bilirubinometer
provision on neonatal jaundice admission to Wrexham
Maelor Hospital
Patel I, Stevens L, Harkness D
Betsi Cadwaladr University Health Board
Quality improvement project aiming to improve confidence
and understanding of CFM monitoring and seizure
recognition
Morris S, Hookes S
Community PROMPT for Wales
Unexpected services responses in a pandemic,
tackling anaemia in pregnancy
Kogbe B, Tang P, Robb AO
Cardiff and Vale University Health Board
Communication surrounds deliveries – can we do better?
Evans E, Hayward R
Cardiff and Vale University Health Board
Neonatal parenteral nutrition: NICE vs BAPM
Matalliotakis M, Bakker S
Glan Clwyd Hospital, Rhyl
Using a neonatal discharge dashboard to improve
patient flow through NICUs
Hayward R
University Hospital of Wales, Cardiff
Communicating effectively during palliative /
end of life care on the neonatal unit
Griffiths E, Thomas K
Singleton Hospital, Swansea
A review of the provision of NLS training within
CAVUHB maternity and neonatal services
Hayward R, Evans L, Webb J
University Hospital of Wales, Cardiff
Service review of PDA assessment and
management in North Wales
Morton M, Onibere A
Ysbyty Glan Clwyd, Rhyl
49
Welsh Paed J 2021; 55: 43-49
WALES MATERNITY AND NEONATAL NETWORK RHWYDWAITH MAMOLAETH A NEWYDDENEDIGOL CYMRU
Oral Abstracts
Prescribing on the neonatal unit: A QI project
Patel I, Morton M, Farman J, Eastwood N,
Richards L, Abdalla E
Glan Clwyd Hospital, Rhyl
Remote neonatal neurodevelopmental follow up –
adapting to a pandemic: a patient centred approach
Abood L, Lawes A, Selman C, Owens S, Makri V,
Perkins L, Webb J
Singleton Hospital, Swansea
An audit of the quality of documentation of neonatal
resuscitation at birth
Jones E, Dr Camille Roberts C, Jones R
University Hospital of Wales, Cardiff
The correlation between early general movement
assessment and two-year neurodevelopmental
outcome in high risk infants
Paris D, Allman A
Aneurin Bevan University Health Board
Neurodevelopmental follow-up of ‘high risk’ infants:
an all Wales perspective
Rothschild-Pearson M, White E, Webb J, Makri V, Perkins L
Singleton Hospital, Swansea
Virtual huddle
Javaid A, Kandhari A
Swansea Bay University Health Board
WELSH PAEDIATRIC SOCIETY CYMDEITHAS PEDIATRIG CYMRU
President’s message
Dear friends and WPS members,
I think this has been a year like no
other for us all. We had been exing
our work to include virtual remote
clinics and trying to keep a grip on our
waiting lists. Remote conferencing
has almost become the norm. Whilst
this has some advantages and allows
greater digital participation from
across Wales, I have missed the ‘fellowship’ of our face-to-face
WPS meetings. us, it is with great joy that we can look forward
to our November meeting - hosted by Alok and Kate - as the
restarting of our peri-COVID meetings. In time we may be able
to do blended meetings, but for simplicity this one will be simply
face-to-face with no sponsors.
e WPS remains a strong group for paediatricians in Wales.
We have moved our meeting to be more ecological and sustainable.
We will try and dispense with paper as much as possible and I
have created a virtual form so we can calculate the Carbon oset
we need to use, that we agreed in our previous meetings. Please
full it in when you arrive, on your phone!
I need to pay tribute to Colin Powell in his role as Welsh
Paediatric Journal editor. He has been a magnicent advocate for
general paediatrics and, in particular, paediatric research in Wales
and subsequently in Qatar. His encouragement of authors and
development of the journal has been second to none. He will be
hard act to follow, but I believe Pramodh Vallabhaneni is absolute
the right person to develop the journal further. ere are some
interesting decisions ahead, including about its direction and
print/electronic distribution. ank you, Pram, for taking on this
special role in our Society. You will be ably supported by your
new Editorial Advisory Committee, who will consist of Simon
Fountain-Polley, Claire Morgan, Mallinath Chakraborty, Andrew
Hallett, Artur Abelian, Assim Javaid and Francesca Norris. ank
you to all who participate.
anks also to Johann who has led the ongoing success of
the Welsh Paediatric Surveillance Unit. is has required much
negotiation to secure ongoing funding. He has also been a reliable
source of wisdom as secretary of the WPS.
Aer a period of minor turbulence in our relationship with
the College, I am pleased that both parties are agreed on the
way forward. e memorandum of understanding between the
College and our own Society remains unchanged. It provides
unchanged ongoing administrative support for the Society,
fostering our symbiotic relationship.
We continue to encourage all trainees in their careers
especially as they have wisely chosen paediatrics. I hope the
Society will be able to support them through all of its roles,
whether this be its academic encouragement, friendship or
networking. Our society is almost 50 years old and continues to
be of the utmost relevance. Soon our thoughts should crystallise
about our 50th celebrations.
Best wishes
David
David Tuthill
President of the Welsh Paediatric Society and
Ocer for Wales (RCPCH)
50
Welsh Paed J 2021; 55: 50-51
INFORMATION FOR AUTHORS GWYBODAETH I AWDURON
Information for Authors/Gwybodaeth i Awduron
e Welsh Paediatric Journal (WPJ) / Cylchrawn Pediatrig Cymru
(CPC) / is the publication of the Welsh Paediatric Society (WPS).
e journal is published bi-annually; in the Spring and in the
Autumn, and is distributed to members and honorary fellows of
the society in PDF format, hard copies and PDFs to postgraduate
libraries throughout Wales, libraries of Departments of Child
Health in British Medical Schools, and to the National Library
and the British Library. It is also available on the WPS website at
www.welshpaediatrics.org.uk.
e WPJ publishes original articles, clinical and research reviews,
short reports, audits, editorials, education and training matters,
reports from ocers of the society, letters to the editor and
proceedings of the bi-annual scientic meetings of the Welsh
Paediatric Society, and the Neonatal Annual Audit & Quality
Improvement event. Topics of interest include all subjects that
relate to clinical practice and research and education in paediatrics
and child health. Articles are welcome from colleagues working
with and for children in all areas of healthcare. Although the
journal’s main mission is to provide a forum for the publication
of articles from within Wales, to oer a shop window of all that
is good in paediatrics and child health in Wales, we welcome
also articles from a widespread authorship outside Wales. It also
provides opportunities for paediatricians in training (and also
medical students) to have original work, case reports and audit
articles published to help them develop their curriculum vitae.
Article types
• Original articles. e text** should not usually exceed 3000
words, the number of tables, gures or both should normally
be no more than 6 and references no more than 30. An
abstract is required: no more than 250 words
• Short reports. Text should not exceed 1500 words. The
number of tables or gures should be no more than two and
references no more than 10. Short reports can also include
audit and clinical case reports, but be accompanied by
completed patient consent form. An abstract is required: no
more than 250 words
• Review articles of the clinical and scientific literature. Text
should not exceed 3000 words, tables, gures or both no
more than 6, and references should not exceed 30
• Ongoing research. Reviews of research in progress
highlighting important ndings. Text should not exceed
2000 words with no more than 4 tables and 20 references
• Letters to the Editor. Letters discussing a recent article in
the WPJ are welcome although original articles that do not
refer to the WPJ may also be considered. Letters should not
usually exceed 300 words and have no more than 5 references
** Tex t . Word count excludes abstracts, figures, tables,
references, and appendices
Ethics
Papers that have experimental investigations of human or animal
subjects must include a statement that approval of an ethical
committee has been obtained.
• Conflict of Interest - Please provide details of any conict of
interest or insert ‘None’.
• Consent - for Case Reports please provide a copy of signed
consent.
Manuscript preparation
Manuscripts should be word processed to have margins of 1 inch
(25mm). One electronic copy of the manuscript should be sent
by email to the editor pramodh.vallabhaneni@wales.nhs.uk and
one copy to heather.oconnell@wales.nhs.uk, or uploaded via the
WPS website (notify upload to H O’Connell). Authors must use a
common soware program (Microso Oce Version 10 or above
preferred). See Correspondence at the end of this document for
more information.
Manuscripts should be accompanied by a covering letter from
the chief author who will be responsible for correspondence
regarding the manuscript. e letter should give any additional
information that may be helpful to the editor, such as the type of
article the manuscript represents.
e contents should be arranged as follows:
Title page. A short title of no more than 40 characters or 10
words should be given, and should not include colons. If relevant
it should indicate whether the paper is a randomised control trial,
meta-analysis, audit, observational study etc. It must include
the full names, qualications and aliations of the authors. It
must include a full word count – excluding title page, abstract,
keywords, references, gures and tables.
Title should be in Arial 12, bold. Authors should be listed by
surname and initials: Surname S1, Surname DG2, Surname M2,
Surname AG1, Surname S1
Affiliation. Superscript should be at start of address:
1School of Medicine, Cardi University, Cardi; 2University
Hospital of Wales, Cardi
(Semi colon to be used between hospitals.)
Keywords - if desired only; insert no more than three
Abstracts should be no more than 250 words.
e following sub-headings should be used for abstracts in
original research:
• Objective
• Design
• Setting
• Patients
• Interventions
• Main outcome measures
• Results: Give numerical data rather than vague statements. Use
condence intervals rather than p values, and give the numerical
data on which any p value is based
• Conclusion: Claims should be supported by data in the abstract
Article or Report. e following sub-headings should be used in
the article or report:
• Keywords (if desired, not mandatory)
• Introduction
• Method
• Results
51
Welsh Paed J 2021; 55: 50-51
INFORMATION FOR AUTHORS GWYBODAETH I AWDURON
• Conclusion
• Recommendations (for audit)
• Discussion
• Tables and Figures should be in the same WORD format as your
text and included in the document where required. Tables should be
self-explanatory and the data they contain must not be duplicated
in the text or gures. Letters, numbers and symbols should be clear
and of sucient size to retain legibility when reduced. A brief but
concise legend for each is needed. Do not abbreviate Figure to g.
Please submit your gures in colour.
• Images and illustrations include electronic photographs, charts
and diagrams. ese should be embedded in the text or if saved
in anything other than WORD should be supplied as separate les
and mentioned in the text where these would most appropriately
ap pea r. NB any colour images will be reproduced in colour. Titles
and detailed explanations should be conned to legends and not
included in illustrations. Each gure should be identied clearly.
Photographs of persons must be amended to make the subject
unidentiable, or be accompanied by written permission from the
subject to use the photograph. All illustrations require legends,
which must be numbered with Arabic numbers corresponding to
the illustrations.
• Acknowledgements/collaborators - if desired insert details of
acknowledgements or collaborators here.
• References must be numbered consecutively in the order they are
rst mentioned in the text. References should be in superscript
aer commas and full stops, but before colons and semi-colons,
for example, .
3
and not
3
. Where more than one reference is cited,
separate by a comma – for example,
1,4,21
and where there are
sequential numbers use a hyphen, for example,
12-16
. References
should follow the Vancouver style (ie the style of the British Medical
Journal) and should appear in the text, tables and legends as Arabic
numerals. Journal title should be in italics and abbreviated in the
style of Medline, but if not listed it should be written out in full.
Check journal abbreviations using PubMed. All authors and all
editors up to six should be listed: if more than six list the rst three
and “, et al”. ere should be a space aer punctuation until Year,
aer which there must be no spaces; volume should be in bold.
Eg Pearson G, Shann F, Barry P, et al. Should paediatric intensive care
be centralised? Trent versus Victoria. Lancet 1997;349:1213-1217
Responsibility for the accuracy and completeness of references
rests entirely with the authors.
Style
General style
• Font - use Arial font, in size 10 for plain text
• Text – use single spacing and alignment should be justied
• Headings – please use bold sentence case in size 12 font for
title, and use bold sentence case in size 10 for headings and
italics sentence case in size 10 for sub-headings
• Punctuation – no full stops in initials, abbreviations or at
end of titles. Insert 2 spaces aer full stops, before the next
sentence. Colons not to be used in headings
• Capitalisation – use capitals only for names and proper
nouns. Do not capitalise names of studies or conditions. Use
capitals for brand names of drugs where used
• Numerals - Arabic numerals should be used for numbers
above nine, for designators (eg case 5, day 2, etc), and for
units of measure. Numbers should be spelled out if below 10,
at the beginning and end of sentences, and for fractions below
one
• Bullet points - do not start with capitals; do not use full stops
at the end of each point
• Latin - use italics for all latin terms eg vs, Streptococcus
pneumoniae, et al
Grammar
• Gender – avoid “he”; use “they”. Or use “he or she”
• Nouns and verbs – the data are; none is… The team
has… etc
Spelling
• use English spelling, not American: ie foetus and not fetus
Abbreviations
• minimise your use of abbreviations. Acronyms should
be used sparingly and be fully explained when rst used.
Glossary of terms, if used, should be at the end of the text and
before the references
Technical terms
• drugs should be referred to by their non-proprietary name
where appropriate
• raw numbers should be given alongside percentages, and as
supporting data for p values
Miscellaneous
All supplied articles will be sent to reviewers and editors in the
format in which you supply them, but with identiers removed.
Aer review, the Editorial Board reserves the right to make minor
amendments to a manuscript. e usual copyright regulations will
apply with regard to publications and materials published in this
journal, which can only be reproduced or published elsewhere aer
consent of the Editor has been obtained. Likewise, material or data
published elsewhere will be printed only aer consent of publication
from the previous publishers or authors has been procured.
It must be recognised that the opinions expressed in the journal are
solely the opinions of the authors and neither the Editor nor the
Publisher will be able to accept any liability arising from material
published.
Correspondence
All manuscript correspondence should be addressed to editor
Dr Pramodh Vallabhaneni, c/o Heather O'Connell, Welsh
Paediatric Journal, Department of Child Health, University
Hospital of Wales, CARDIFF CF14 4XW
Email correspondence to pramodh.vallabhaneni@wales.nhs.uk
and heather.oconnell@wales.nhs.uk
Telephone enquiries to 07974 182990
Website correspondence to www.welshpaediatrics.org.uk, and
follow the directions under ‘Journal’. Please also email heather.
oconnell@wales.nhs.uk to inform us when you submit an
article or correspondence to the Journal online.
52
Welsh Paed J 2021; 55: 52
WELSH PAEDIATRIC SOCIETY CYMDEITHAS PEDIATRIG CYMRU
Welsh Paediatric Society
Autumn Clinical Meeting 2021
Friday 19 November 2021
Hosts: Dr Kate Creese and Dr Alok Gaurav
Cymdeithas Pediatrig Cymru
Cyfarfod Clinigol Rhithwir yr Hydref 2021
Dydd Gwener 19 Tachwedd 2021
Gwestywyr: Dr Kate Creese and Dr Alok Gaurav
Elusen Cofrestrdig/ Registered Charity 1057744
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Welsh Paed J 2021; 55: 53
PRIZES GWOBRAU
The Welsh Paediatric Society ORAL Prize Spring 2021
Poacher A, Froud J, Marsh L, Carpenter C
University Hospital of Wales, Cardiff
Is extended screening effective for developmental dysplasia of the hip?
vvv
The Welsh Paediatric Society QUICKFIRE Prize Spring 2021
Whillis H, Creasey N, Hewitson R
Paediatric Emergency Unit, University Hospital of Wales, Cardiff
Ionising radiation in paediatric trauma: a CT too far?
vvv
54
Welsh Paed J 2021; 55: 54-62
WELSH PAEDIATRIC SOCIETY CYMDEITHAS PEDIATRIG CYMRU
Oral Abstracts
ORAL ABSTRACTS FOR WPS MEETING
Band-4 nurse-led constipation service in primary care – two-year evaluation
Hawkes E, Davies F, Lewis A, Pierrepoint M
Aneurin Bevan University Health Board
Background
Constipation aects 10-20% of children, accounting for 3-5% of
UK general paediatric consultations. Outcomes improve when
constipation is identied and treated promptly with laxative therapy
plus behavioural interventions with regular follow-up. Research
shows nurse-led constipation services have non-inferiority with
greater parent satisfaction compared with consultant-led clinics.
A novel service in ABUHB employs band-4 advisors to manage
patients aged 6mo-7y with idiopathic constipation. is study
evaluated this service in terms of treatment outcomes, parent
satisfaction and impact on secondary care referrals.
Method
Analysis of a prospectively collected database of patients referred
to the service from January 2019-March 2021 from community,
primary and secondary care, and questionnaires completed by
parents at discharge. Treatment was considered ‘successful’ if the
patient was discharged condently managing their constipation.
Impact on secondary care referrals was determined by analysis of
secondary care referrals database.
Results
1049 children were referred to the service, with a mean age of
4y. Median time from referral to rst contact was 3wks. e
service was ‘successful’ for 62.9% of children, 27.8% disengaged,
8.3% were referred elsewhere. 94.8% of parents who completed
the questionnaire felt ‘very condent’ managing future episodes.
37.5% of all children <7y referred to secondary care with
constipation in this period were directed to the service.
Conclusion
e band-4 led toileting service enabled rapid, eective treatment
of constipation for most families who engaged, with excellent
parent satisfaction. ere was a substantial reduction in secondary
care consultations for constipation.
Recommendation
Roll out band-4 led toileting services across Wales.
Leg pain – a red flag symptom for children’s meningococcal septicaemia
Zou’bi R¹, Perry M¹, Evans J²
¹Cardiff University, Cardiff; ²Paediatric Emergency Department, University Hospital of Wales, Cardiff
Introduction
Early recognition and diagnosis of meningococcal septicaemia – a
leading cause of septic shock in children – can reduce mortality
and morbidity. NICE guidance [CG102] and the petechiae in
children study identify leg pain as a ‘red ag’ symptom, however it
is unclear whether its predictive value is understood by paediatric
clinicians and nurses.
Method
An online survey was created for the paediatric MDT in Wales.
Participants had to select whether a symptom/sign was associated
with meningococcal septicaemia or, alternatively, non-specic.
Specic symptoms/signs of meningococcal septicaemia and
meningitis were selected from guidance [CG102]. Five non-
specic signs of febrile illness in children were included as ‘red
herrings’.
Results
41 participants: 28 doctors, 2 nurses, 11 nal-year medical
students (with paediatric exposure)
Symptoms/signs Selected as sign/
symptom of
meningococcal
septicaemia (%)
Selected as
non-specific
sign (%)
Specific for meningococcal septicaemia
Non-blanching rash 92.7 7.3
Unconsciousness 85.4 14.6
Shock 82.9 17.1
Altered mental state 80.5 19.5
Hypotension 73.2 26.8
Significant cold hands/feet 60.9 39.1
Capillary refill > 2 seconds 51.2 48.9
Leg pain 9.7 90.3
More specific for meningitis
Stiff neck 87.8 12.2
Photophobia 85.4 14.6
Brudzinski's sign 75.6 24.4
Kernig's sign 75.6 24.4
Back rigidity 58.5 41.5
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Welsh Paed J 2021; 55: 54-62
WELSH PAEDIATRIC SOCIETY CYMDEITHAS PEDIATRIG CYMRU
Oral Abstracts
Symptoms/signs Selected as sign/
symptom of
meningococcal
septicaemia (%)
Selected as
non-specific
sign (%)
Non-specific
Headache 24.4 75.6
Fever 17.1 82.9
Coryzal symptoms 0 100
Conjunctivitis 0 100
Cough 0 100
Conclusion
ere is limited awareness of leg pain as a ‘red ag’ symptom
amongst the paediatric MDT in Wales. Education is key to ensure
healthcare professionals are aware of this symptom’s predictive
value to enable appropriate suspicion and timely diagnosis.
Note - is abstract was presented at the (RCPCH) Conference
Online 2021. Additionally, it was published in the online Archives
of Disease in Childhood in August 2021.
What are the outcomes of pregnancies with oligohydramnios of a renal
origin?
Brant HA¹, van der Voort, J²
¹Cardiff University, Cardiff; ²KRUF Children’s Kidney Centre, University Hospital of Wales, Cardiff
Keywords - renal oligohydramnios, prognosis
Introduction
e foetal kidney produces amniotic uid (AF) aer 14 weeks,
which is essential for lung development. Renal malformations
can lead to AF reduction, lung hypoplasia and renal impairment.
Expectant mothers with renal oligohydramnios (ROH) need
appropriate counselling. is study aims to identify prognostic
factors associated with ROH and evaluate counselling.
Method
39 mothers with ROH were identied between 01/05/2015 and
01/05/2021. e severity, gestation at onset of ROH, counselling
content, pregnancy and neonatal outcomes were identied from
two databases.
Results
Of the 39 pregnancies, 19 ended in foetal death and 20 in livebirths
(LB). Of the 20 LB, 8 had normal renal function, 4 severe CKD, 1
a renal transplant and 7 died neonatally.
13 pregnancies had mild ROH, 11 ended in LB. 23 pregnancies
had severe ROH, with 5 LB, 3 stillbirths (SB), 14 terminations
(TOP) and 1 miscarriage. Of the LB, 4 died neonatally and 1
survived with normal renal function. 26 of the 39 pregnancies
had early ROH, with 8 LB, 2 SB, 14 TOP and 1 miscarriage.
A risk score, combining severity and ROH gestation onset showed
a positive correlation with pregnancy outcome score (Table 1),
where r= 0.708 (p≤ 0.05) (Figure 1).
Table 1 Risk score
Risk score
Gestation of ROH Score
1st Trimester 2
2nd Trimester 1
3rd Trimester 0
Severity of ROH
Anhydramnios 3
Severe 2
Moderate 1
Mild 0
Pregnancy Outcome
Death during pregnancy 4
Neonatal death 3
Transplant/ dialysis 2
CKD 1
Healthy 0
Calculation values
Figure 1 Correlation between risk score and pregnancy
outcome score
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Welsh Paed J 2021; 55: 54-62
WELSH PAEDIATRIC SOCIETY CYMDEITHAS PEDIATRIG CYMRU
Oral Abstracts
8 mothers had foetal, renal and neonatal counselling, 31 had
counselling from at least one specialty, 8 had no identied
counselling.
Conclusion
e outcome for ROH pregnancies is poor. e key prognostic
risk factors - severity and gestation at onset of ROH, should be
used with counselling, which was appropriate in the majority of
patients.
SLICS: a novel idea to foster learning and development
Evans AZ, Vallabhaneni P, Parish A
Morriston Hospital, Swansea
Introduction
Since their introduction in 2005, workplace-based assessments
have changed terms and are now known as SLEs. Intended as
learning tools, SLEs are formative but contribute to summative
assessments. However, published evidence suggests trainees nd
it dicult to arrange SLEs, and the educational value is oen
questioned. We created SLICS (Supervised Learning events
In Clinical Settings), an online system to help trainees access
supervisors and improve their learning experience.
Method
A survey was undertaken to appraise current trainee perceptions
of SLEs. Barriers to completion and ideas for improvement were
also explored. We set up SLICS to promote uptake of SLEs and
evaluated trainee feedback. We made SLEs more accessible using
an online booking system. Assessors with a range of expertise
were recruited to provide availability. Over several PDSA cycles,
practicalities were adjusted.
Results
46 trainees participated in the survey. Trainees opined that
SLEs were benecial for learning and development but dicult
to arrange and complete. Barriers cited were; forms not lled
in, lack of time, and perceptions of SLEs as tick-box exercises.
ese ndings were congruent with other studies. We received
overwhelmingly positive feedback from those who used SLICS for
their SLEs. Free text comments included; useful learning, easy to
arrange, amazing idea, and reduced anxiety around SLEs.
Conclusion and recommendations
e introduction of SLICS locally has been a success. We are now
oering SLICS to all trainees across Wales. e use of technology
and ipping the model of sourcing SLEs is a valuable addition to
Welsh paediatric training.
Delays in statutory health assessments for looked-after children
Owen DA¹, Williams BC²
¹Cardiff University, Cardiff; ²Community Child Health, Cardiff and Vale University Health Board
Keywords - delay, LAC, assessment
Introduction
Looked-aer children (LAC) are at more risk of negative outcomes
in terms of physical and mental health as a result of possible early
life adversity. is project revolves around the growing inability
to meet statutory timescales in Cardi and the Vale by the LAC
health team.
Method
Retrospective data for the years of 2019, 2020 and 2021 between 1
January and 31 March was collected. A total of 220 children taken
into care were found and each child’s electronic health record was
analysed using PARIS to evaluate delays in:
1) entering care and the LAC health team being notied
2) an initial health assessment being undertaken by the LAC
health team
Comparisons were made between the 3 years and the following
age groups: 0-5 years old; 5-10 years old and 10+ years old.
Results
Notication was received within 5 working days for 36% of
children in 2019, 50% in 2020 and 26% in 2021.
Health assessment’s (HA’s) in 2019 were overdue by an average of
149 days. is dropped to 78 days overdue in 2020. In 2021, 36%
of new children were still awaiting an initial health assessment.
Conclusion
Delays in seeing the LAC health team for looked-aer children
in Cardi and the Vale is not a new problem. However, it is a
problem that is worsening. e data has been presented to the
head of Safeguarding in Cardi and the Vale and to Cardi
Corporate Parenting Strategic Leads to help move towards nding
a solution.
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WELSH PAEDIATRIC SOCIETY CYMDEITHAS PEDIATRIG CYMRU
Oral Abstracts
Improving elbow injury neurovascular assessment in the paediatric
emergency department
Parry G¹, Fox M²
¹Cardiff University School of Medicine, Cardiff; ²Paediatric Emergency Department, University Hospital for Wales, Cardiff
Keywords - elbow, neurovascular, emergency
Introduction
Elbow injuries in children are common and may be associated
with neurovascular complications. Performing and documenting
a full neurovascular assessment in this group is essential. e
aim was to ensure that all children presenting to the emergency
department with an elbow injury had a neurovascular assessment
undertaken and documented.
Method
Quality improvement methodology led to four changes including;
the introduction and renement of a clerking proforma and an
examination stamp. Documentation of each relevant nerve and
vascular status was used as an audit standard and performance
indicators. e clinical notes of children who had elbow X-rays in
the emergency department were audited. is performance data
was collected aer each intervention to assess for improvement.
Results
e percentage of clinicians who documented neurovascular
status in some form increased from 74% (n=116) to 90% (n=87)
aer the rst intervention (p<0.01). Documentation of the
radial, median and ulnar nerves increased from 29% to 68%
(p<0.001). e largest improvement (8% to 55%, p<0.001) was
for the anterior interosseous nerve. Radial pulse documentation
improved from 41% to 80% (p<0.001) and capillary rell time
from 31% to 65% (p<0.001).
Conclusion
Use of documentation aids in conjunction with sta education
can improve neurovascular status documentation.
Recommendation
A strategy has been put in place to sustain and build on the
improvements achieved, which includes producing a minor
injuries guideline for the paediatric emergency department.
Continuing the audit of departmental performance is
recommended to guide future interventions.
Epidemiology and mapping of child road casualties in Wales
Smith A¹, Jones S², Hanna D³
¹Cardiff University Medical School, Cardiff; ²Public Health Wales; ³Paediatric Emergency Department,
University Hospital of Wales, Cardiff
Keywords - paediatric trauma, road trac collisions (RTCs)
Introduction
Paediatric trauma following road trac collisions (RTCs)
represents a signicant public health burden. is study aims to
inuence child road safety in Wales.
Method
Police (STATS19) and health databases covering all or part of
Wales were analysed from 2017-2019 for child pedestrians,
cyclists and car occupants aged 0-16 years involved in RTCs. We
studied age, gender, time of RTC occurrence, road type and speed
limit. Population-based injury rates were calculated for age group,
gender and deprivation h. e geographical distribution of
RTCs was mapped.
Results
STATS19 under-reports RTCs, recording 1,859 child RTCs for all
Wales compared to 1,170 attendances at one major trauma centre
in South East Wales. Males aged 11-16 years had the highest injury
rates (92.2 per 100,000 population). Injuries peaked at school
journey times. Most RTCs were located on single carriageways
(84.7%), 30 mph zones (66.9%) and between junctions (54.1%).
e rate ratio of injury was 2.03 (95% condence interval 1.72-
2.38) for the most deprived compared to the least deprived areas.
Conclusion
Collaboration between services and improvements in data quality
are essential to accurately inform national public health policy on
road safety. Emergency departments play an important role in
recording child casualties due to RTCs. Improved road safety is
needed in all of our communities but needs to be further enhanced
in the most deprived areas where the burden of injury is highest,
which will help to lessen the social inequality gap.
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Welsh Paed J 2021; 55: 54-62
WELSH PAEDIATRIC SOCIETY CYMDEITHAS PEDIATRIG CYMRU
Oral Abstracts
CCTGA: a single centre experience of clinical findings and long-term
outcomes
Cottenham LR1,2, Uzun O1,2
¹Paediatric Cardiology, University Hospital of Wales, Cardiff; ²Cardiff University School of Medicine, Cardiff
Keywords - cardiology, antenatal, outcomes
Introduction
is study aimed to analyse the survival and long-term outcomes
of patients with congenitally corrected transposition of the great
arteries (CCTGA).
Method
A retrospective cohort study of 59 patients diagnosed with
CCTGA between 1966 and 2021 at the University Hospital of
Wales (UHW), Cardi. Information was collected and analysed
on diagnosis, management, and prognosis of CCTGA in South
Wales.
Results
20 cases (36%) were diagnosed antenatally, with an increase
from 6% pre-2000 to 81% post-2000 and 100% since 2020. 50
patients (91%) showed other cardiac lesions, with no non-cardiac
or genetic associations. ere was a survival probability of 0.83
at 50 years, but freedom from heart block or surgery were 0.5
and 0.38 respectively. Tricuspid regurgitation, reduced ejection
fraction, and Q wave abnormalities were the most common
ndings, but exercise tests were underutilised. Pulmonary artery
banding surpassed Blalock-Taussig shunt and double switch
as preferred surgery, and pacemaker insertion decreased post
2000. ACE inhibitors were the most frequently utilised medical
management. 50 patients (91%) have NYHA of 1 or 2, but only 31
(56%) remained free from heart block.
Conclusion
CCTGA has high association with additional cardiac lesions and
complications, but no connection with genetic abnormalities.
Improved diagnostic process post 2000 has increased antenatal
detection and improved postnatal status. e survival rate in this
cohort is high, exceeding previous literature.
Can families believe websites’ information about COVID-19 vaccines’ side
effects?
Harvey-Nguyen L¹, Tuthill D²
¹Cardiff University, Cardiff; ²Noah’s Ark Children’s Hospital for Wales, Cardiff
Keywords - Covid-19, vaccine, website.
Introduction
Children are rarely severely aected by COVID-19 and mortality is
almost unheard of. COVID-19 vaccines may produce rare serious
side eects including thrombosis and myocarditis. e UK’s chief
medical ocers have just recommended that all children aged
12 to 15 be oered the Pzer-BioNTech Vaccine (13 September
2021). us, it is important that teenagers and their families are
well informed about the balance between the benets and genuine
side eects of vaccination, whilst avoiding misinformation.
Aims
To audit the accuracy of purported COVID-19 vaccine side
eects listed on websites against those listed in the BNF &
patient information leaets (PILS) which were taken as the “Gold
Standard”.
Method
Side eects of the COVID-19 vaccines listed in the BNF were
combined with those listed in each of the 4 manufacturer leaets
to create a “Gold Standard” list of correct side eects. Online
websites’ statements were then compared to this list for accuracy.
e rst 10 websites found on each of nine dierent search
engines were evaluated.
Results
From the 10 top hits found in each of 9 search engines, 44 unique
websites from a possible 90 were identied. Of these, 33 sites
(75%) documented only side eects found in the “Gold Standard”
list of side eects collated for this study. A quarter (11/44)
document at least one unsubstantiated side eect.
Conclusion
e majority of websites have acceptable information on side
eects. However, some contain unsubstantiated side eects which
could adversely aect the decision of those seeking accurate
information to make informed vaccination choices.
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WELSH PAEDIATRIC SOCIETY CYMDEITHAS PEDIATRIG CYMRU
Oral Abstracts
The approach to delayed cord clamping at Singleton Hospital
Merrison H¹, Mansour M²
¹Swansea Medical School, Swansea; ²Singleton Hospital, Swansea
Introduction
It has been demonstrated that delaying the clamping of the
umbilical cord for longer than 60 seconds can give a term infant
on average, an additional 100 ml of blood, therefore contributing
around a quarter of the neonatal blood volume at birth. is leads
to improvements in iron and haemoglobin levels in these babies.
is audit aimed to determine whether delayed cord
clamping (DCC) is common practice in Singleton Hospital and
whether there has been an improvement between the two loops
of the audit.
Method
Data was collected retrospectively by examining patient records
of the rst 100 records of babies born in January 2020 and July
2021 at Singleton Hospital. Lectures were delivered between audit
loops to the multidisciplinary team to raise awareness of benets
of DCC.
Standard: Greater than 90% of infants should have DCC recorded.
Results
e mean gestational age was 38+3 weeks in January 2020 and
39+3 weeks in July 2021. DCC was documented in 81.9% of births
in January 2020, compared to 94.7% in July 2021. In July 2021 the
mean delay was 137.8 seconds before cord clamping compared to
just 96.4 seconds in 2020.
Conclusion
ere have been substantial improvements in DCC documentation
and delay time in Singleton Hospital following teaching sessions
on the benets of DCC. Following these interventions, the
documentation rates at Singleton Hospital now meet the standard.
Recommendation
Biannual meetings should be held to promote DCC with updates
on how the unit is performing. Further studies are warranted to
examine DCC rates in pre-term infants.
Management of breastfed infants readmitted with weight loss
Marsh C, Joishy M
Ysbyty Gwynedd, Bangor
Introduction
We wished to audit the current management of breastfed infants
readmitted due to weight loss in the rst month of life, to due to
recent concerns about an apparent increase in such readmissions.
Method
is was a retrospective observational study. Breastfed infants
readmitted between 01/09/20 and 31/04/21 with >10% weight loss
in their rst month of life were included.
Results
ere were 21 admissions involving 19 patients, 15/19 were term
infants, and over half were admitted within the rst 5 days of
life. 19/21 had blood tests and a sodium >150 was identied in 4
patients. All had normal clinical examinations.
A feeding plan was provided to 18/21 babies as per the
trust guideline, with the most common (14/18) being continued
breastfeeding with top-ups. One patient required nasogastric
top-ups, and 2 received intravenous uids for jaundice.
Most infants were discharged within 48 hours (16/21). At
discharge, 3/21 remained exclusively breastfed, 15/21 were
breastfeeding with top-ups and 3/21 had changed to full bottle-
feeding.
Conclusion
Most infants were managed successfully with top-up feeds with a
brief readmission period and breastfeeding was preserved as the
primary mode of feeding in 18/21 patients at discharge, but three
mothers decided to change to bottle feeding.
Recommendation
Further multidisciplinary support involving infant feeding
coordinators, midwives and health visitors would be necessary for
breast feeding mothers.
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WELSH PAEDIATRIC SOCIETY CYMDEITHAS PEDIATRIG CYMRU
Oral Abstracts
CO environmental impact of salbutamol inhalers in Welsh primary care
Morgan L¹, Cromarty T², Payne E³, Powel Al⁴, Mistry E⁵, Crompton K⁶, Tuthill D⁷
¹Cardiff University, Cardiff; 2,7Cardiff and Vale UHB; ³Cwm Taf Morgannwg UHB; ⁴Pharmacy, Aneurin Bevan UHB;
⁵PCIC, Cardiff and Vale UHB; ⁶Pharmacy, Cardiff and Vale UHB
Introduction
In January 2020, NHS Chief Sir Simon Stevens announced the
Greener NHS campaign, making achieving a ‘net zero’ carbon
footprint a goal. e use of low carbon inhalers is being targeted
as dry powder devices produce less CO (1,950g CO per annum
per inhaler) and equivalent brands of salbutamol metered dose
inhalers vary, for example Ventolin (25,064g CO per annum per
inhaler) and Salamol (10,114g CO per annum per inhaler).
Method
A retrospective analysis into the brands of salbutamol prescribed
over ve years within primary care in Wales. Data is collected
from the comparative analysis system for prescribing audit
(CASPA) and PrescQIPP.
Results
In 2020/21, 1,676,913 salbutamol prescriptions were made.
Ventolin Evohaler 100mcg was the most common brand
prescribed, forming 67.29% of prescriptions. Generic
salbutamol, oen dispensed as Ventolin, formed 20.21% of the
total prescriptions. Salamol inhalers formed 4.71% of the total
salbutamol prescriptions. A further breakdown can be seen in
Figure 1.
Device Prescriptions
May 2020 - April 2021
CO per inhaler
per year (g)
Total CO produced
(tonnes/year)
Potential total CO
saved (tonnes/year) if
converted to Salamol
Potential total CO saved
(tonnes/year) if converted
to dry powder
Ventolin Evohaler
100mcg MDI 1,128,322 25,064 28,280 16,868 26,080
Salbutamol Inhaler
100mcg MDI 338,972 25,064 8,496 5,068 7,835
Salamol Inhaler
100mcg MDI 79,042 10,114 799 N/A N/A
Ventolin Accuhaler
200mcg DPI 44,636 1,950 87 N/A N/A
Other inhalers 94,730 N/A N/A N/A N/A
Figure 1 - the brands of salbutamol prescribed and a saving made following a conversion to Salamol or a dry powder inhaler
Conclusion
Habitual prescribing of Ventolin is more damaging to the
environment than Salamol or the use of dry powder devices.
Savings could be made in CO output if Salamol and dry
powder devices were promoted. is should be done alongside
considerations towards patient technique and plastic recycling
schemes.
Recommendation
• prescribe Salamol instead of Ventolin
• consider a switch to a dry powder device in children over six
• recycling of plastic inhalers should be developed
Screening for coeliac disease in children with type 1 diabetes mellitus
Arsac England T¹, Jain S²
¹Cardiff University, Cardiff; ²Princess of Wales Hospital, Bridgend
Keywords - coeliac disease, type 1 diabetes mellitus,
asymptomatic screening, national guidelines
Introduction
e prevalence of coeliac disease [CD] is 1% in the UK, rising to
7% in those with type 1 diabetes mellitus [T1DM]. We looked at
the current practice for screening and diagnosing coeliac disease
in children with T1DM within Cwm Taf Morgannwg University
Health Board (CTMUHB).
Method
A baseline cohort of T1DM children was obtained from the
national database (Twinkle). Patients identied with CD before
diagnosis of T1DM were excluded. Anti Immunoglobulin-A
tissue transglutaminase [anti-IgA tTG] for coeliac disease were
analysed in all T1DM patients at diagnosis and then annually.
e patients with high anti-IgA tTG (with or without symptoms)
were further investigated with a repeat anti-IgA tTG, endomysial
antibodies, HLA typing or biopsy (as appropriate) to conrm CD.
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Oral Abstracts
Results
Seventeen out of 260 (6.5%) patients with T1DM had raised anti-
IgA tTG levels. Eleven out of 17 patients (64.7%) were conrmed
with CD aer initial screening on diagnosis of T1DM. A further
six (35.3%) were identied on routine annual screening within 6
years of diagnosis; none presented with symptoms which qualied
for anti-IgA ttg tests.
Conclusion
At CTMUHB, screening for CD was undertaken at diagnosis of
T1DM and annually. In contrast, NICE 2015 guidelines suggest
screening at diagnosis of T1DM and then if symptomatic, which
would have missed one-third of our patients with CD. Our results
suggest that annual screening of asymptomatic T1DM patients
ensures early identication and avoids missing cases of CD. A
larger cohort should be studied to conrm our observations.
Screening for psychological distress in paediatric diabetes
multidisciplinary clinics
Ambrose J, Fountain-Polley S, Lynn S, Jeremy J
Paediatric Diabetes, Hywel Dda University Health Board
Keywords - psychological distress, diabetes
Introduction
Children and young people (CYP) with diabetes are at risk of
psychological distress. NICE recommends timely access to mental
health support: research regarding best practice for screening
distress in this population is limited.
Method
A systematic process including literature search, consultation
with the MDT (multidisciplinary team), CYP and families,
identied using the KINDL validated screening tool to screen
psychological distress (measuring overall quality of life and six
areas of functioning: physical health, emotional wellbeing, self-
esteem, family, friendships, and school). All CYP and parents
attending MDT paediatric diabetes clinics in Hywel Dda UHB
between May-September 2021 were invited to complete the
KINDL. Concurrently, clinician perceived psychological distress
was assessed using a RAG-rating scheme. Red = Distress,
immediate concerns about psychological functioning, Amber =
Distress, some concerns, Green = No current distress/concerns.
Results
134 CYP and 132 parents completed the KINDL (85% of
caseload). All CYP reported signicantly poorer quality of life.
Everyone aged 7-17 reported signicantly lower self-esteem,
females aged 7-17 signicantly poorer emotional wellbeing,
males aged 7-17 signicantly poorer school functioning. Across
localities Pembrokeshire residents reported signicantly poorer
quality of life. Comparing RAG-ratings to KINDL quality of
life questionnaire scores, 75% of CYP rated Red, 48% rated
Amber, scoring below the HDUHB average. 38 CYP scoring
below average quality of life, were rated Green by clinicians.
Qualitatively, clinicians reported RAG-ratings useful, quick, and
facilitated discussions.
Conclusion
Using the brief, validated KINDL identied psychological distress.
e KINDL identied distress potentially missed by clinician
derived RAG-ratings; combining tools potentially improves
identication, facilitating appropriate psychological intervention.
Experiences of a cystic fibrosis virtual clinic
Ostojic A1, 2, Jennings Z², Azzopardi K², Forton JT², Doull I², Thia LP²
¹Hywel Dda University Health Board; ²Paediatric Respiratory Medicine and CF Unit, Noah’s Ark Children’s Hospital for Wales, Cardiff
Keywords - virtual, clinic, paediatric
Introduction
During the COVID-19 pandemic, the cystic brosis (CF) unit
at the Noah’s Ark Children’s Hospital for Wales, Cardi started
a virtual clinic service. We subsequently surveyed those who
attended our virtual clinics to nd out how we might improve our
service as we provide “blended clinic visits”.
Method
Over three months, we surveyed full-care CF patients who had
attended telephone or video clinics. ey were asked to ll out
a brief questionnaire, either in person or over the phone, lasting
around 5 minutes, covering their experiences of the virtual clinics
and suggestions for future clinics.
Results
A total of 65 families were contacted and we received 47
questionnaires, completed by patients or their parents. 68%
wanted to continue with virtual appointments - this was 74% in
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Oral Abstracts
children <11 years and 56% in those >12 years. 43% had technical
issues - the most common problems were inability to use the
system, and having diculty seeing or hearing the team. Despite
this, 83% found the virtual system easy to use. One of the biggest
concerns with virtual clinics was the lack of cough swab collection
and lung function testing, however >50% of respondents wanted
to learn how to collect cough swabs and do hand-held lung
function at home.
Conclusion
CF virtual clinic was well received when it was dicult to regularly
review patients during the pandemic such that most would like to
continue with a combination of virtual and face to face clinics,
particularly those with children <11 years.
The hidden sexual abuse pandemic
Long R¹, Simpson C²
¹Cardiff University, Cardiff; ²Ynys Saff, Cardiff
Introduction
Children and young people have the potential to be signicantly
impacted by the indirect consequences of COVID-19. Being
placed in lockdown puts them at a higher risk of childhood
adverse events, such as sexual abuse. Ynys Sa is a sexual assault
referral centre that supports children and young people who have
reported a sexual assault.
Aim
e aim of this study was to determine the quantitative impact of
the coronavirus pandemic on the pattern of referrals, case details
and uptake of services.
Method
Retrospective review of Ynys Sa databases and PARIS clinical
notes.
Results
ere was a 36.61% decrease in the number of referrals to Ynys
Sa when comparing the 12 months pre-pandemic and the rst
12 months of the pandemic. 10% more referrals came from the
police during the pandemic, and 14% fewer disclosures were
made to trusted professionals during the pandemic. ere was
a signicant increase in the number of intrafamilial cases during
the pandemic and an increase in the number of violent sexual
crimes.
Conclusion
e pandemic has signicantly impacted disclosure patterns, type
of sexual crime and subsequent referrals of sexual violence crimes
against children and young people.
QUICK FIRE PRESENTATIONS
Is ADHD over diagnosed in children who are looked after?
Haynes T, Erin L, Williams B
Community Child Health & Enfys, Cardiff and Vale UHB
Keywords - developmental trauma, neurodevelopment
Introduction
It is well established that children who are looked aer have a
higher incidence of ADHD diagnosis. is population oen
have a large number of adverse childhood experiences, which can
result in developmental trauma, the symptoms of which mimic
that of neurodevelopmental conditions. is case series aims to
explore if ADHD may be over diagnosed.
Method
A sample of 16 cases in Cardi and Vale UHB were identied, with
a diagnosis of ADHD and a signicant trauma history considered
to be a possible confounder in diagnosis.
Results
All children displayed symptoms which matched ICD10 criteria
for ADHD, but no standardised DSM-V based criteria was used
for diagnosis. All children had ADHD questionnaires. However,
these are recommended to be used as a guide only. 6 children
were diagnosed with “ADHD phenotype” which is not in ICD10.
All 16 children were medicated with stimulants and most were
given melatonin. 10 of the 16 children stopped medication aer
becoming looked aer. 3 had diagnosis of ADHD removed.
Conclusion
is is a complex group of children who need specialised care
which considers the impact of their experiences. e case series
Quickfire Abstracts
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WELSH PAEDIATRIC SOCIETY CYMDEITHAS PEDIATRIG CYMRU
Quickfire Abstracts
reveals a lack of standardisation of ADHD diagnosis. is could
result in inappropriately medicating children who could be better
served with alternative treatment such as specialist trauma-based
therapy. We are in the process of publishing our research and
we are compiling a diagnostic checklist to standardise ADHD
diagnosis, aiming to provide clarity to clinicians working within
this eld.
World cups - promoting paediatric research within South Wales
Richards A¹, Knight A², Bains S¹, Evans J³
¹Cardiff University, Cardiff; ²Noah’s Ark Children’s Hospital for Wales, Cardiff; ³Paediatric Emergency Department, University Hospital of
Wales, Cardiff
Introduction
WORLD CUPS (Working paediatricians Overseeing Research
Led and Delivered by Cardi University Paediatric Society) was
founded to encourage research within paediatrics and child health
in Wales. is initiative brings undergraduates and paediatric
healthcare professionals (HCPs) together to undertake quality
improvement, research or audit projects. e objective of this
study was to evaluate the project.
Method
e initial recruitment of projects was performed via promotion
on social media, at conferences and study days. Projects were
advertised to healthcare students in Wales and all projects were
allocated within one hour, with the majority in < 10 minutes. A
retrospective review of the initiative was performed over a one-
year period from November 2019 to 2020. Feedback was collected
regarding student condence pre and post project.
Results
23 projects were undertaken by 28 healthcare students alongside
15 clinical supervisors. 7 projects have been completed.
Successes included one peer reviewed publication, three national
presentations, one paediatric podcast and six medical education
resources for use in local university health boards. 100% of
students reported they were enthusiastic towards paediatric
research and were excited to be involved. Aer completing a
project, 50% felt more condent with research techniques and
38% felt condent at project initiation. 100% agreed that they
had more awareness of how to undertake research alongside their
future clinical careers.
Conclusion
is simple initiative has supported multidisciplinary healthcare
students to gain condence, awareness and practical experience in
child health research and quality improvement and may provide a
framework for future undergraduate research initiatives.
A prolonged jaundice clinic - a need borne out of necessity
Oyibo I, Donnelly P, Mohite S
Princess of Wales Hospital, Bridgend
Keywords - prolonged jaundice, neonates, service
Introduction
Prolonged jaundice in neonates is common and usually self-
resolving. However, it is important that neonates with pathological
causes should be timely investigated. In our unit, these babies
presented to the paediatric assessment unit at random times
leading to increased PAU workload. is prompted an audit in
2019 which identied multiple hospital visits, haemolysed blood
samples, need for repeat bloods, delay in checking results, and
unclear follow up plans, as contributory factors.
Method
We set up a prolonged jaundice clinic in September 2020 as a new
service to improve patient experience, and identify babies needing
further intervention in a timely manner. All neonates coming to
the clinic had venous blood sampling with results chased within
24 hours. Results were discussed as per a revised pathway plan
and follow up arranged. A prospective data was collected to assess
the new service.
Results
A total of 42 babies attended the rst 6 months of the clinic.
80% were discharged at rst visit and the remaining by the 2nd
visit. Fourteen percent had to return for repeat bloods following
haemolysed sample, which was a signicant improvement from
28% in the previous audit. One baby was followed up but not
jaundice related, and there was no referral to tertiary care.
Conclusion
It was evident that a dedicated clinic with continuity of care was
reected in a better patient experience; also resulting in reduced
workload for the acute services.
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Quickfire Abstracts
Mortality in adolescent trauma – a comparison of children’s, mixed and adult
major trauma centres
Evans J¹, Murch H¹, Begley R², Roland D3,4, Lyttle MD2,5, Bouamra O⁶, Mullen S⁷ on behalf of PERUKI
¹Paediatric Emergency Department, University Hospital of Wales, Cardiff; ²Emergency Department, Bristol Royal Hospital for Children,
Bristol; ³Paediatric Emergency Medicine Leicester Academic (PEMLA) group, Leicester Royal Infirmary, Leicester;
⁴SAPPHIRE group, Health Sciences, Leicester University, Leicester; ⁵Faculty of Health and Applied Sciences,
University of the West of England, Bristol; ⁶The Trauma Audit & Research Network, The University of Manchester, Manchester;
⁷Paediatric Emergency Department, Royal Belfast Hospital for Sick Children, Belfast
Introduction
We aimed to compare adolescent mortality rates between dierent
types of major trauma centre (MTC or level 1; adult, children’s
and mixed).
Method
Data were obtained from TARN (Trauma Audit Research
Network) over a 6- year period (2012–2018), with adolescence
dened as 10–24.99 years. Results are presented using descriptive
statistics.
Results
21 033 cases met inclusion criteria. 30-day crude mortality rates by
MTC type were 2.5% (children’s), 4.4% (mixed) and 4.9% (adult).
Logistic regression accounting for injury severity, mechanism
of injury, physiological parameters and ‘hospital ID’, resulted in
adjusted odds of mortality of 2.41 (95% CI 1.31 to 4.43; p=0.005)
and 1.85 (95% CI 1.03 to 3.35; p=0.041) in adult and mixed
MTCs, respectively when compared with children’s MTCs. In
three subgroup analyses the same trend was noted. In adolescents
aged 14–17.99 years old, those managed in a children’s MTC had
the lowest mortality rate at 2.5%, compared with 4.9% in adult
MTCs and 4.4% in mixed MTCs (no statistical dierence between
children’s and mixed). In cases of major trauma (Injury Severity
Score >15) the adjusted odds of mortality were also greater in the
mixed and adult MTC groups when compared with the children’s
MTC.
Conclusion
Children’s MTC have lower crude and adjusted 30-day mortality
rates for adolescent trauma. Further research is required in
this eld to identify the factors that may have inuenced these
ndings.
A paediatric endoscopy pathway service evaluation,
examining patient satisfaction
Blake M¹, Wahid A², Trow E², Davies I²
¹Cardiff University, Cardiff; ²Noah’s Ark Children’s Hospital for Wales, Cardiff
Keywords - endoscopy, paediatric, satisfaction
Introduction
Paediatric endoscopies are becoming increasingly common in the
UK. e assessment of patient satisfaction can identify positive
and negative aspects of the patient experience which can be
utilised to improve the service and consequentially, improve the
patient experience.
Method
ree questionnaires were developed to assess patient satisfaction
throughout the paediatric endoscopy pathway at 3 stages: pre-
admission clinic, on the ward post-procedure and one-week post-
procedure. e questionnaires included both yes/no questions
and open questions. e data collection period spanned six
weeks, which encompassed two paediatric endoscopy lists which
consisted of nine procedures. Questions were asked in a semi-
structured interview style format.
Results
9 children took part. All completed the rst two questionnaires,
and 6 completed the third. Positive and negative aspects of
the endoscopy pathway were identied at each stage. Positive
aspects included good information sharing at the pre-admission
clinic, friendly nursing sta and a competent anaesthetic team.
Negative aspects included lack of patient information resources,
unsatisfactory communication on the ward and lack of clarity
about events post-procedure. Overall, there was a high level of
satisfaction with the pathway, with 5/6 participants rating their
overall experience an 8/10 or higher.
Conclusion
Participants were grateful for the friendly nursing sta and the
calming manner of the anaesthetic team. However, they would
have appreciated receiving patient information leaets, more
nurse presence on the ward and better communication regarding
discussion of ndings post-procedure.
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Quickfire Abstracts
Foundation for paediatrics - A missing link
Howard EO, Jones D, Vallabhaneni P
Morriston Hospital, Swansea
Introduction
Most foundation doctors face the challenge of managing
paediatric patients. Not all foundation rotations have paediatric
blocks. Anecdotally we noted that the local foundation teaching
programmes did not cover paediatric topics. erefore, we aimed
to investigate the extent of, and the demand for, further paediatric
teaching amongst foundation doctors in a large district general
hospital.
Method
An anonymous qualitative survey was undertaken. A mixed style
questionnaire was designed to prevent any bias. Both electronic
and face to face invites were oered to complete the survey.
Results
54 participants completed the survey. 86% of FY1s report having
no paediatric teaching provided to them by their foundation
school. 92% report having had delivered direct care to children.
81% of them report “little” or “no condence at all” in their ability
to manage them. 95% of all FY1s expressed their desire for further
paediatric teaching. Commonly suggested topic for teaching was
recognition of a sick child and common paediatric presentations.
85% of foundation doctors reported in house foundation teaching
as their preferred medium for further learning.
Conclusion
Our survey demonstrates a missing link between medical school
and foundation years. Foundation doctors have clearly expressed
their desire for ongoing paediatric teaching. We have approached
foundation school in Wales with our ideas on how to bridge the
gap. We believe paediatricians across Wales could participate in
this programme. We believe this could be an ideal platform for
foundation doctors to learn more about paediatrics and could
inuence career choices.
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INDEX MYNEGAI
The Welsh Paediatric Journal Cylchgrawn Pediatrig Cymru
Index: Volumes 54 and 55 Mynegai: Cyfrolau 54 ac 55
Volume Pages
ABSTRACTS
WPS Spring meeting 2021 54 38
WPS Autumn meeting 2021 55 52
WALES MATERNITY AND NEONATAL NETWORK
Abstracts from the 14 June 2021 neonatal annual audit & quality improvement event 55 43
BOOK REVIEW 55 34
EDITORIAL 54 2
55 2
EDUCATION AND TRAINING
Report from the Wales Deanery 54 18
St David’s Day Conference 2021
e future of children and young people in a more equal and diverse world 54 21
Voice from the trainees, May 2021 54 18
Voice from the trainees, November 2021 55 26
Paediatric trainee representative updates (North & South Wales) 54 19
Paediatric trainee representative updates (North & South Wales) 55 30
Quality improvement in focus 55 27
Out of hours: Lessons from the hive 54 21
Out of hours: Playing and coaching women’s and girl’s rugby 55 32
Training placement: Neonatal Transfer Service (NTS London) 54 25
Investing in our future paediatricians 55 31
INFORMATION FOR AUTHORS 54 34
55 50
NOTICEBOARD 54 33
55 42
OCCASIONAL ARTICLE
COVID-19 meanderings. A kaleidoscope from the past: memories of an earlier life 54 26
COVID-19 meanderings. Houseman years 55 35
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INDEX MYNEGAI
ORIGINAL PAPERS
Audit of the Paediatric ermal Injury Booklet in the ED 54 3
Mindfulness at work: An initiative for sta at Noah’s Ark Children’s Hospital for Wales 54 8
Audit of the transition from paediatric to adult congenital and acquired cardiac services 54 11
Suspected case of COVID-19-associated pancreatitis in a child 54 15
Ten-year review of congenital pulmonary malformations in South, Mid and West 55 4
Optimising timing for pneumococcal vaccination in children undergoing emergency splenectomy 55 8
e COVID-19 pandemic and its impacts on the environment. e voices of young people in Wales 55 13
e use of warfarin and monitoring INRs in paediatric cardiology 55 17
Remote working in Child and Adolescent Mental Health Services (CAMHS) 55 21
PRESIDENT'S MESSAGE 55 49
WELSH PAEDIATRIC SOCIETY
Spring Meeting 2021 54 36
Autumn meeting 2021 55 52
e Welsh Paediatric Society prize winners Autumn 2020 54 37
e Welsh Paediatric Society prize winners Spring 2021 55 53
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WELSH PAEDIATRIC SOCIETY CYMDEITHAS PEDIATRIG CYMRU
Notes
Officers of the 1973 - 2021 Swyddogion
Welsh Paediatric Society Cymdeithas Pediatrig Cymru
President / Llywydd
David Tuthill
Past President / Cyn Llywydd
Mair Parry
Secretary / Ysgrifennydd
Johann te Water Naudé
Executive Committee membership/ Aelodaeth y Pwyllgor Gweithredol
https://www.rcpch.ac.uk/membership/committees/
rcpch-wales-executive-committee-national-specialty-advisory-group
Head of School for Paediatrics and Child Health / Pennaeth yr Ysgol ar gyfer Pediatreg ac Iechyd Plant
Geraint Morris
v v v
Printed by / Argraffu gan Trustmark Design & Print Limited 01443 449350
President / Llywydd
Gwyn Griffiths 1973 - 1974
Percy Bray 1974 - 1976
E. G. Roberts 1976 - 1978
W. Davies 1978 - 1980
W. Forbes 1980 - 1982
R. Prosser 1982 - 1984
R. H. T. Jones 1984 - 1986
R. Verrier-Jones 1986 - 1988
Tony Griffiths 1988 - 1990
John Cawdery 1990 - 1992
Viv Woolley 1992 - 1994
B. M. Ansari 1994 - 1996
P. D. Ll. Edwards 1996 - 1998
R. J. H. Morgan 1998 - 2002
J. R. Sibert 2002 - 2005
G. Owen 2005 - 2008
Iolo Doull 2008 - 2013
Mair Parry 2013 - 2018
David Tuthill 2018 -
Secretary / Ysgrifenydd
Bob Prosser 1973 - 1978
Trefor Jones 1978 - 1984
Tom Yuille 1984 - 1987
Geraint Owens 1987 - 1990
Phil Edwards 1990 - 1993
Arabinda Palit 1993 - 1994
John Morgan 1994 - 1999
Duncan Cameron 1999 - 2002
Iolo Doull 2002 - 2006
Justin Warner 2006 - 2009
Mair Parry 2009 - 2013
Markus Hesseling 2013 - 2016
Johann te Water Naudé 2016 -
