the Journal
A premier service for private patients Winter Edition, February 2016
Chelsea and Westminster Hospital
Who’s who guide to paediatric consultants
New biological therapies for inflammatory bowel disease
Developments in paediatric minimal access surgery
Mini-guide to daytime and nighttime childhood wetting
Welcome from Amanda Grantham General Manager, Private Care Chelsea and Westminster Hospital has a number of specialities held in high regard by clinical experts and patients. One we are unfailingly proud of is our comprehensive and world-leading paediatric centre, the Chelsea Children’s Hospital—our hospital within a hospital. The Chelsea Children’s Hospital was officially opened in 2014 by Their Royal Highnesses the Prince of Wales and Duchess of Cornwall and spans the entire first floor of our hospital on Fulham Road, Chelsea. This specialist centre, led by world renowned paediatricians, benefits from a highly specialised paediatric surgical programme including the UK’s first designated paediatric da Vinci robot. But as important as the quality of care we provide is the patient experience. We aspire to make the Chelsea Children’s Hospital a ‘home away from home’ with child friendly artwork, a dedicated school for children in hospital and a brand new, state of the art cinema facility funded by our charity CW+ where children and their families can watch the latest cinema releases while receiving care from us. If you would like further information about our private patient services please get in contact. Additionally we would love you to experience the MediCinema environment first hand and invite you to join us at our Paediatric showcase and ‘From Conception to Birth’ events—full details on the adjacent page. Amanda Grantham General Manager, Private Care T: 020 3315 8411 E: amanda.grantham@chelwest.nhs.uk
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Contents Upcoming events
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Introducing Chelsea Children’s Hospital: A vision of integrated paediatric care Chelsea Children's Hospital facts and figures
4-5
Leading surgical innovation at Chelsea Children's Hospital
6-7
The cutting edge of paediatric surgery: Introducing Pluto the robot
8-9
Should parents be concerned by late walking?
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Driving developments in paediatric minimal access surgery
10–11
Mini-guide to causes and management of daytime and night-time wetting in children
12–13
Who’s Who guide to our Paediatric Consultants
14–15
Light at the end of the ureteric tunnel: The modern management of Vesico-Ureteric Reflux
16–17
The craniofacial team continue to turn heads The charitable face of the NHS
18–19
New biological therapies available for IBD patients Paediatric clinical research
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A nursing perspective of Chelsea Children’s Hospital
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Meet the private paediatric psychology team Common misconceptions about psychology support
22–23
Movie Magic: CW+ MediCinema opens
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Hospital Young Peoples' Forum
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Innovation at Chelsea Children's Hospital
26–27
Upcoming Events wcase o h S ic r t ia 6 Paed Spring 201 March, 6.30pm-9pm y 16 Wednesda
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Introducing Chelsea Children’s Hospital: A vision of integrated paediatric care
Located in the heart of London, Chelsea Children’s Hospital within Chelsea and Westminster Hospital is one of London’s largest providers of children’s services, caring for more than 75,000 children a year. It is the designated lead centre for specialist paediatric and neonatal surgery in North West London, carrying out complex surgery on babies, children and adolescents. Mr Simon Eccles
The Chelsea Children’s Hospital was formalised as a specialist paediatric unit in 2013 bringing burns, craniofacial surgery, dentistry, ENT, general surgery, ophthalmology, plastic surgery and urology into a single unit within the hospital. ‘We are one of the biggest children’s hospitals in London’ says Mr Simon Eccles, Associate Medical Director for Neonates, Children and Young Peoples' services and Craniofacial Consultant Surgeon. Mr Eccles is an advocate in reducing fragmentation and providing integrated care for children and young people, many of who are referred from different parts of the UK and abroad. The Chelsea Children’s Hospital represents this shift to integrating care and paediatric services of the future. A major £40 million redevelopment has seen four new state-of-the-art children’s operating theatres, improved children’s wards, high dependency unit and burns unit. A new children’s emergency unit is currently under construction and the next phase we hope will include a new adolescent ward and an acute assessment ward. When this is completed, all paediatric services will be located on the hospital’s first floor. Creative studio Thomas Matthews has designed the look and feel of the new wards with an overarching Outer Space theme, where illustrated characters interact with the visitors and provide comfort, reassurance and advice.
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The care of all the children at Chelsea Children's Hospital in underpinned by the general paediatricians who take a holistic view of patients' care. The Chelsea Children’s Hospital has a large neonatal unit that covers complex neonatology. It also has a new children’s burns unit with a large outpatients department that has what Mr Eccles describes as ‘a wonderful environment’. It is the only burns unit in London for children that require care in a high dependency setting. ‘One of my first tasks when I took over my new role was to secure specialist children’s surgical services here for the whole of North West London,’ says Mr Eccles. ‘Often children with complex facial problems also have heart, gastrointestinal and neurology problems so you need the expertise of lots of clinicians to help you. We have multi-professional teams made up of doctors, nurses and other allied health professionals so the pathway is no longer sequential, which can cause long delays. Chelsea and Westminster has a caring focus and people recognise our innovation and understand that we are trying to do something different,’ says Mr Eccles. ‘We have a state-of-the-art facility dedicated to providing high-quality healthcare for children and young people in a safe and child-friendly environment.’ Mr Simon Eccles is a Consultant Plastic Surgeon at Charing Cross Hospital and a Consultant in Craniofacial surgery at Chelsea and Westminster Hospital. He was awarded the McGregor Medal at the Royal College of Surgeons in the Specialist Fellowship FRCS Plast.
Chelsea Children’s Hospital: Facts and Figures
treat 75, 0
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35,000 ch
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A hospital within a hospital
10 play specialists 113 doctors
Paediatric Consultant 24hr onsite presence
153 nurses
£40M redevelopment since 2013
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The largest in London
spec i
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high d ep
special units level 3 ne
4 modern theatres
Swallowing station 1 housing the UK’s first paediatric dedicated Da Vinci robot
Showing the latest film releases to patients and families free of charge!
An accredited museum with over 1000 pieces of art!
1 Hospital school Rated outstanding by OFSTED in 2014
Hospital Radio
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Leading surgical innovation at Chelsea Children's Hospital
Interview with Mr Simon Clarke, Consultant Paediatric Surgeon and Service Director for Children’s Surgical Services
What changes have you seen as Service Director for paediatric surgery at Chelsea and Westminster Hospital? As service lead of the Chelsea Children’s Hospital surgical department, I have witnessed some incredibly exciting developments over the past few years. In 2010 we were designated as the lead centre for all complex surgery in Northwest London as well being asked to establish London’s first managed clinical network for paediatric surgery which aims to keep as much activity as close to the patients’ homes as possible. Through the hard work and dedication of our surgical team we are now able to offer the shortest waiting times to be seen in clinic in the capital. Our new integrated operating theatre suite allows us to bring the most advanced state of the art surgical technology to all of our paediatric patients. Chelsea and Westminster Hospital works closely with the hospital charity CW+ and in May 2013, a Da Vinci Surgical Robot was introduced to the Chelsea Childrens’ Hospital following a successful fundraising drive. Mr Munther Haddad (Consultant Surgeon and Charity Chair) and I carried out the first robotic procedure over two years ago with five consultants now trained in robotic surgery as we continue to expand this exciting programme. Can you tell us about the team at Chelsea and Westminster? Paediatric surgery at Chelsea and Westminster Hospital has been at the forefront of advanced minimal access surgery for years and all eight consultants now carry out these complex techniques. Mr Haddad initiated the minimally invasive surgical programme both at Chelsea Children's Hospital as well as across the South of England and under his leadership, this programme has gone from strength to strength over the past two decades. Mr Haddad even taught me as a registrar! The team are supported greatly by our excellent nursing and management team, without which no progress would have been possible. Our neonatal team also offers a world class service and together, with our advanced operating platform we are one of the few centres in the country able to perform delicate minimally invasive endoscopic operations such as oesophageal and duodenal atresia repair on newborns (see opposite). Why did you choose to develop minimal access surgery and to work with children? I am often asked that it must be so hard looking after children, but to me children are by far the most honest bunch of people you will ever work with—which actually makes it a lot easier! If they don’t like what you are doing they soon let you know. When they are better they don’t thank you—there is no need—they just run off and start playing again. For me it is one of the most privileged jobs you can have. Minimal access surgery was developed for adults, but over the years we have worked closely with industry all over the world to develop the systems that now allow us to fix an oesophagus through three tiny 3mm incisions on the baby’s chest. Pain, scarring and trauma are all significantly reduced as a result of this.
Mr Simon Clarke
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Why would you recommend private surgery at Chelsea Children’s Hospital? The private patient service developments now offer a dedicated service from booking to discharge. Private rooms are all state of the art for medical safety as well as patient comfort. The close proximity to the critical care unit gives parents the reassurance that Chelsea is an ultra-safe option for their child. Our scope of practice ranges from simple day case surgery such as hernia, testicular surgery and circumcision (newborn as well as older child) to the more complex procedures for congenital anomalies as well bowel disorders such as gasto-oesophageal reflux. This breath of expertise and wealth of experience underpinning every aspect of patient’s care at Chelsea Children’s Hospital is really very special.
Mr Simon Clarke is Service Director for Children’s Surgical Services as well a Consultant Paediatric and Neonatal Surgeon for over a decade at Chelsea and Westminster Hospital. He is the Chairman of the Education Committee for the British Association of Paediatric Surgeons as well as Chairman of the Evidence-based Practice Committee for the International Paediatric Endoscopic Group of Surgeons. He is Director for two national courses on minimal access surgery and simualtion and has been awarded eight clinical excellence awards. Referrals to Mr Clarke and the paediatric surgical service can be made via: T: 0203 315 8484 E: private.enquiry@chelwest.nhs.uk
Patient Story: “Operating in a matchbox” Patience Willoughby’s courageous weight loss journey as featured on Embarrassing Bodies
Case study: Alys was born with oesophagal atresia. The upper part of her oesophagus was not connected to the lower and the lower oesophagus was connected to her trachea. Alys was the first child at Chelsea to undergo a thoracoscopic separation of the oesophagus from the trachea and reconnection with the upper oesophagus.
Alys in incubatur
“Alys’s recovery has been nothing short of amazing. Now at 4.5 years old, she has had no dilatations, eats a full range of foods, copes with all of childhood’s colds and coughs and her scars are practically non-existent. Alys attended nursery part time from 5 months, swims, does karate and everything any 4 year old loves to do. We can’t thank Mr Clarke and his team enough for such a successful outcome.” Jane—Alys’ mother Alys aged four
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The cutting edge of paediatric surgery: Introducing Pluto the Robot Three years ago, when we first started our robotic surgery programme, Mr Clark and I, with a team of nurses, went to Strazburg to train. We now have five consultant paediatric surgeons trained in robotic surgery at Chelsea Children’s Hospital—Mr Clarke and I carry out general paediatric robotic surgery while Miss De Caluwe, Miss Farrugia, Miss Rahman carry out robotic paediatric urology procedures. Mr Munther Haddad
Consultant Paediatric Surgeon, Mr Munther Haddad has been at the forefront of paediatric surgical innovations and developments at Chelsea and Westminster Hospital for over 20 years. Mr Haddad’s arrival at the hospital in 1995 paved the way for our paediatric minimally invasive surgical programme but it is his latest colleague, Pluto the Robot, that is causing quite a stir! We caught up with Munther to find out about this unusual partnership and to learn more about how robotic surgery is changing paediatric surgery at Chelsea Children’s Hospital. What’s the appeal of robotic surgery? Robotic surgery represents the next generation of minimally invasive surgery as the robot enables greater hand eye coordination, 3D vision, improved ergonomics and mimics the movements of the human wrist. The Endowrist™ component of the surgical console is modelled after the human wrist but eliminates even the slightest tremors and enables ambidexterity—every surgeon’s dream! I first saw robotic surgery in action at a conference in the States in 2002 and was completely captivated by the potential of robotic surgery for the team at Chelsea and the opportunity for optimising patient care. As Chairman of the Children’s Hospital Trust Fund, we started the Pluto appeal and sucessfully raised the £1.5million needed to purchase the Da’Vinci robot in 2013. Why is the robot's name 'Pluto'? All the wards in the Chelsea Children’s Hospital are named after elements of the solar system and ‘Pluto’ seemed fitting because this robot is out of this world! While robotic surgery is well established in the US and the clinical outcome data supports robotic surgery as the next generation of minimally invasive surgery, with reduced complications and improved patient safety, we are leading the way in the UK with Pluto, the UK’s only dedicated paediatric robot. How different is robotic surgery to conventional open or laproscopic surgery? The best comparison for robotic surgery is the cockpit of a plane; there are a number of instruments to manoeuvre and viewers to manage. Robotic surgery allows for increased hand to eye alignment and increased precision for intricate movements which decreases any damage to tissues and facilitates earlier recovery, less pain and a shorter hospital stay for patients. Being a step removed from the patient also reduces possibility of infection transmission during surgery.
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What procedures are suitable for robotic surgery? All procedures traditionally done laproscopically can be done via the robot (with the exception of very small babies). The procedures we perform via the robot include: Abdominal • Fundoplication • Cholecystectomy • Splenectomy • Oophorectomy • Repair Diaphragmatic Hernia • Hemicolectomy • Heller Myotomy • Choledochal cysts • Hepaticojejunostomy • Endorectal pull- through Urology • Pyeloplasty • Nephrectomy • Replantation of urethers
Thoracic • Resection Pulmonary Sequestration • Resection Mediastinal Mass • Resection Bronchogenic Cyst • Thymectomy • Lobectomy • Trachial Oesphageal Fistual Head & Neck • Thyroidectomy • Parathyroidectomy
What’s next for innovation at Chelsea Children’s Hospital? Robots like Pluto are amazing but it is still critical to have a trained and experienced surgeon as the brains of the machine. At the moment I am keen to explore more about mini robotic surgery and the surgical applications of nanotechnology. Here at Chelsea and Westminster, we never stand still for long. The cutting edge is where I like to be! Mr Munther Haddad is a Senior Consultant Paediatric Surgeon who came to Chelsea and Westminster Hospital in 1995. Mr Haddad specialises in minimally invasive and robotic surgery. He introduced the paediatric minimally invasive surgical programme at Chelsea and Westminster Hospital and is renowned nationally and internationally. To find out more about our robotic surgical programme or to refer patients to Mr Haddad and Pluto, contact the private enquiry office on T: 0203 315 8484 E: private.enquiry@chelwest.nhs.uk
Mr Haddad giving Their Royal Highnesses The Prince of Wales and The Duchess of Cornwall a test drive on Pluto
Should parents be concerned by late walking? by Dr Yiannis Ioannou Every child is different and delays reaching milestones are not always a sign of a more significant problem. Many children start walking around or just after their first birthday, however, if a child is not walking by 18 months old, it is time for a more detailed assessment by a paediatrician. Parents should not panic, as everything could still be normal, and it may not be an indication of any underlying health problems. Common causes of delayed motor milestones include hereditary family traits—for example, the parents were late walkers and these babies often bottom shuffle rather than crawl. Late walking can also be associated with having low muscle tone or hypermobile joints. Other causes include neurological issues affecting muscle tone, inherited conditions affecting muscle strength or bones and hip
joints all of which may be identified earlier than 16 months old. If all other aspects of development are fine and there are no other concerns, it is advisable for the GP to monitor until the baby reaches 18 months old and involve physiotherapy to help motor development if necessary. Once the baby approaches 18 months old or other concerns emerge—especially delay in other aspects of development—an assessment by a paediatrician is recommended. In some cases a paediatrician may carry out investigations that could include blood tests, genetic/chromosome analysis, and very occasionally brain imaging. The majority of children who are not walking at 16 months will just be late walkers with no underlying problems; they may just need physiotherapy and reassurance.
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Driving developments in paediatric minimal access surgery
Mr Amulya Saxena
Mr Amulya Saxena is an award-winning Consultant Paediatric Surgeon at Chelsea and Westminster Hospital. He was trained in paediatric and neonatal surgery at the Medical University of Munster, Germany and was a research fellow in surgery at Boston’s Children Hospital part of Harvard Medical School. Before joining Chelsea, he served as Associate Professor and Deputy Director in the Department of Paediatric and Adolescent Surgery at the Medical University of Graz in Austria where he also was Head of the Experimental Foetal Surgery and Tissue Engineering Unit. As Chairman of the Education Office of the European Paediatric Surgeons Association (EUPSA) and Executive Board member of the European Society of Paediatric Endoscopic Surgery (ESPES) Mr Saxena frequently travels across Europe to perform complex procedures abroad, and to train local surgeons in minimal access surgery. At the same time he is invited to lecture in master classes and as instructor for paediatric minimal access across Europe, North Africa and Asia.
for paediatric minimal access surgery which are presently being manufactured and on sale worldwide. Over time, standard techniques for paediatric minimal access surgery have been developed for abdominal and thoracic procedures which has improved the outcofor patients. For the surgeon, laparoscopy is a particularly attractive option for operations in deep cavities of small children especially the hiatus and the pelvis, because of good illumination and magnification. Whereas the observers’ traditional view of open surgical procedures in small children is limited, video imaging of laparoscopy allows surgical assistants, anaesthetists and nurses to see what the laparoscopic surgeon is doing and to participate actively in the procedure in their respective roles. Outcomes are constantly evaluated to ensure evidence-based medicine in this field to neonates, children and adolescents. This vigilance has made advanced paediatric minimal access surgery as successful as more routine procedures at Chelsea and Westminster Hospital.
What does your role of Chairman of EUPSA and as Executive Board member of the European Society of Paediatric Endoscopic Surgery entail? The European Paediatric Surgical Organisations have the vision to support education and training of paediatric surgeons and trainees throughout Europe. With the extension of the European boundaries, support is being extended towards paediatric surgeons in countries that have commenced with paediatric minimal access surgery. Although aiding the implementation of these surgical procedures is the goal in these countries, I assist teams in complex surgical procedures in some of the newer centres which require advanced skills. Paediatric surgeons and trainees from various countries also visit Chelsea and Westminster Hospital to observe these techniques being practised here.
Of your achievements to date, what are you most proud of? That Europe along with the U.S. has been a pioneer in the development of minimal access surgery in the paediatric age group. Success in paediatric minimal access surgery depends on the infrastructure. The advantages of access to high quality instruments from leading manufacturers of endoscopic equipment, standardised training and robust safety protocols in performing these procedures engenders the leadership necessary to develop new techniques in Europe. I am particularly proud to be working with the team at Chelsea and Westminster Hospital who specialise in minimum access surgery with the aim of offering these procedures to all patients in the paediatric age group that qualify for this surgery. Close to 80% of procedures in the abdomen and thorax can now be performed with minimal access surgery.
What has changed in recent years for paediatric minimal access surgery? Paediatric minimal access surgery started in the early 1990s. Development of instruments and equipment especially manufactured for the paediatric patient has played a crucial role in offering these surgeries to neonates. Over the past two decades the 10mm instruments that were developed for adult surgery, were miniaturized for paediatric use and are presently available in sizes varying from 5mm-2mm. I am involved in designing and developing instruments
What are the benefits of minimal access surgery? Minimal access surgery results in shorter hospital stays, smaller scars and less pain in children when compared to open procedures of the same kind. Minimal access surgeries are performed with scopes that offer large magnification of the areas of interest which enable excellent visualisation of some difficult to access areas by the operating team. Also as small incisions are used postoperative recovery is quick facilitating early mobilisation and a swift return to regular activities.
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What procedures do you specialise in? I perform basic and advanced procedures within the thorax and abdomen for children with pathologies that qualify for minimal access surgery including: Thoracic Procedures • • • • • • • • • • •
Diaphragmatic hernia Diaphragmatic eventration Mediastinal cysts and tumours Bronchogenic cysts Enlarged lymph nodes Pulmonary sequestration Cystic Pulmonary Airway Malformation (CPAM) Lobar emphysema Empyema Pneumothorax Chylothorax
Abdominal Procedures • • • • • • • • • • • • • •
Inguinal hernia Pyloric stenosis Gastro-oesophageal reflux (Fundoplications) Congenital duodenal obstruction (duodenal atresia, stenosis web, annular pancreas) Meckel diverticulum Intussusception Malrotation Intestinal obstruction from adhesions Intestinal duplication Inflammatory bowel disease (Ulcerative colitis, Crohn disease) Mesenteric and omental cysts Appendicitis Hirschsprung’s disease High Imperforate anus
The following procedures are suitable for management by minimal access surgery and are performed by the paediatric surgical team here at Chelsea and Westminster Hospital: Liver: Gallstones—removal of Gallbladder (Cholecystectomy); Choledochal cysts; Liver biopsies Spleen: Splenic pathologies (Splenectomy or partial-splenectomy) Genitourinary: Undescended testicles; Ovarian cysts and masses; Varicoceles Chest Wall Procedures: Pectus excavatum (Funnel Chest); Pectus carinatum (Pigeon Chest) With such a wide range of procedures being performed using minimal access surgery in the paediatric age group, parents can be assured they will receive state of the art management depending on their condition and suitability to undergo minimal access procedures. Furthermore, the parents can be reassured that there will be an early return to activities of their child. Who is not a candidate for Minimal Access surgery? Patients who have an unstable haemodynamic status are not suitable for laparoscopic procedures which involve prolonged operating times. Laparoscopy should also be avoided in patients with severe cardiac diseases, pulmonary insufficiency or bleeding disorders. Laparoscopy is not offered in patients with abdominal scars and adhesions resulting from repeated abdominal procedures, and in patients with ileus or intestinal obstruction. Why would you recommend referring partners refer paediatric surgical cases to Chelsea Children’s Hospital? Chelsea and Westminster Hospital has endoscopic operating suites offering excellent ergonomics to perform these procedures, including operating room suites specifically designed for paediatric minimal access surgery. These suites have a state of the art equipment system with instruments centrally integrated and a central command system which allows for optimal ergonomics in performing basic and advanced procedures. With over two decades of experience in performing paediatric minimal access surgery, the team can manage a wide spectrum of pathologies in children. 11
Mini-guide to causes and management of daytime and night-time wetting in children by Miss Diane DeCaluwe
Miss Diane DeCaluwe
Wetting is defined as ‘the involuntary loss of urine from the urinary tract’. Less than 1% of referrals from general practice have an organic aetiology and need to be excluded first since mostly, they will require surgical treatment. Most of the others aetiology is functional. Organic causes of urinary incontinence in children include: • Urine infection (intermittent leakage) • Neuropathic (continuous / intermittent) • Bladder Outlet obstruction ( intermittent) • Structural (continuous) ◊ Extrophy / epispadias ◊ Ectopic ureter in girls ◊ Congenital short urethra in girls ◊ Urovaginal confluence in girls Most common functional causes of urinary continence in children 1. The overactive bladder Most children with daytime wetting have urgency, mostly at the end stage of filling. This is likely related to delayed maturity of bladder control. There is a short interval between the first desire to void and the actual voiding. Sometimes the child does not realise that he/she is actually voiding. Some children will try to avoid leakage by contraction of the striated urethral sphincter and pelvic floor muscles and by crouching with the heel pressed into the perineum. Leakage consists mainly of damp patches (damp smelly pants) or occasional flooding. Predisposing factors include certain drinks, i.e. fizzy or caffeinated drinks, cold weather. Quite often, there is also an element of frequency and nocturnal enuresis. 2. Uncomplicated urgency These children usually have a normal uninterrupted urinary stream and they empty well. They rarely present with a urinary tract infection. Urodynamics are normal and the condition is mostly self-limiting. 3. Dysfunctional voiding These children, mostly girls, typically present with a staccato interrupted voiding pattern. They often don’t empty well. Urodynamics will show detrusor-sphincter dyssynergia. They have learned to deal with their overactive bladders by contracting the urethral sphincter and hence don’t relax adequately during micturition. Often they will present with urinary tract infections and secondary reflux due 12
to high pressures in the bladder as a consequence of the detrusor overactivity and detrusor-sphincter dyssenergia. 4.Giggle incontinence Giggle incontinence is a typical problem presenting in young pre-pubertal girls and often continues through puberty into adulthood. There's often a family history and micturition pattern is mostly normal, but leakage occurs with giggling or laughing. Urodynamics are usually normal. Treatment can be medical and often physiotherapy can be useful. How to investigate? a) Fluid input and output calenders Calenders are very useful to identify how much and what fluids the child is taking during the day and how often toilet visits happen. It also gives a good idea of frequency and bladder capacity. b) Renal and pre and post void bladder ultrasound This will identify abnormalities of the upper tracts as well as help identify children with bladder emptying issues who can benefit from double voiding exercises. c) Flowrates (uroflow) This test assesses the quality of the urinary stream, average and maximum flow and volume, i.e. children with frequency due to meatal stenosis. d) Non–invasive urodynamics (NIUD) This investigation is carried out by our Paediatric Specialist Incontinence Nurse. It is an excellent test to determine bladder capacity and bladder emptying with three cycles of bladder filling and emptying are observed. Treatment is based on the outcome of the test and a follow up NIUD can be repeated after six months to assess improvement and progress. e) Invasive urodynamics This test requires insertion of a urethral (measuring intravesical pressure) and rectal catheter (measuring intra-abdominal pressure) and a quick general anaesthetic is required in most children with urethral sensation. The bladder is filled and simultaneously intravesical pressure is recorded. Invasive urodynamics identifies patients with high pressure bladders. It also provides anatomical information by using radiographic contrast for the study.
Nocturnal enuresis PNE is a very common problem with an estimated ¾ million children in the UK having issues with bedwetting. In each class in primary school, there will be a few children that wet the bed at night. There can be a family history and the symptoms usually decrease with age. It can influence the child socially, emotionally and interfere with the child’s self-image. Why does it happen? 1. Lack of vasopressine release Too much urine is produced at night. Wetting usually happens early in sleep, the urine is clear but can result in large wet patches which the child typically sleeps through. 2. Bladder over activity Here contraction of the detrusor muscle before the bladder is full results in small concentrated wet patches, the child wakes up after accident. Often there will be associated daytime frequency and urgency 3. Failure to wake up to bladder signals The child does not wake up easily.
Available services for children experiencing day or night time wetting include: Paediatric Urology Team Miss De Caluwe, Miss Farrugia and Miss Rahman are available for consultations. Paediatric specialist Incontinence nurse Miss Elisabeth Colton and Miss Niamh Geoghan perform non-invasive and invasive urodynamics and uroflow studies. Paediatric Physiotherapy department The team offer treatment for children with day time wetting, including giggle incontinence.
How to treat nocturnal enuresis? a. Bladder training Advice on adequate fluid intake in daytime, 6 cups a day with corresponding advice on regular bladder emptying, 5-6 toilet visits a day b. Alarm training There are 2 types of alarms available on the market, body types attached to the pyama, and bedtypes with a sensor mat of the bed. The sensor inside the mat detects when wetting starts and goes off. It is usually tried for 2-3 weeks and if unsuccessful, discontinued c. Desmopressin The most prescribed form, Desmomelt, a small tablet that melts under the tongue (120, 240, 360 mcg) taken 0.5-1 hour before sleep. The effect of Desmomelt is very quickl in reducing urine production. It is advised to stop the Desmopressin after 3 months for a week to assess if the medicine is still required. d. Bladder medication The aim is to increase bladder capacity and reduce premature bladder contractions by relaxing Detrusor muscle. There is usually a more gradual improvement of symptoms. There are several forms; • Oxybutinin tablets, 5 mg od or BD • Lyrinel XL, OD, slow release over 24 hours, usually less side effects • Tolteridine, OD, 4 mg • Vesicare (Solifenacil), OD, 5-10-15 mg table Refer patients via the private enquiry office on T: 0203 315 8484 or E: private.enquiry@chelwest.nhs.uk
Recommended resource for further information: ERIC (Education and Resource for Improving Childhood Continence) Helpline: 01179 603 060 | Website: www.eric.org.uk 13
Paediatric consultants: Who’s Who
Chelsea Children’s Hospital delivers family and child centred care with multi-professional teams spanning specialist paediatric nurses, psychologists, dieticians, physiotherapists, play team specialists and consultants, including:
Paediatric Medical Consultants Medical Specialty
Consultant
Particular interest
Child Development
Dr Skandhini Carthigesan
Assessments for developmental delay, Autism, ADHD, neurogenetic & congenital disorders.
Dermatology
Dr Bisola Laguda
Laser therapy, haemangioma
Dr Nerys Roberts
All paediatric dermatology
Endocrinology
Dr Saji Alexander
Type 1 Diabetes, endocrine late effects of bone marrow transplant/chemotherapy and Vitamin D deficiency
Gastroenterology
Dr John Fell
Paediatric endoscopy, childhood nutrition, inflammatory bowel disease, food allergy
Dr Warren Hyer
Nutrition including abdominal pain, paediatric endoscopy, rectal bleeding and inflammatory bowel disease
Dr Wathik Alsaud
Food allergies, eczema, common respiratory problems including asthma, paediatric oncology
Dr Kingi Aminu
Diabetes, endocrinology and high dependency care
Dr Gary Hartnoll
Neonatology, child development 0-5 years
Dr Yiannis Ioannou
All general paediatrics
Dr Michael Markiewicz
Allergies, rheumatology
Dr Jonathan Penny
Acute paediatrics, high dependency
Dr Charles Stewart
Sports injuries and musculoskeletal problems, emergency medicine
Neurology
Dr Maria Kinali
Epilepsy, complex headaches, greater occipital nerve injections, botox injections for migraines, progressive neurodegenerative, movement disorders and general neurology, neuro-genetics and neuro-rehabilitation
Pain Medicine
Dr Ben Thomas
Post-surgical pain management, musculoskeletal pain, neuropathic pain, complex regional pain syndrome, adolescent/transitional pain management.
General Paediatrics
Psychology—emotional wellbeing Dr Jonathan Gibbins and psychological support with general health conditions Dr Aayesha Mulla
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Gastroenterology, burns, urology including toileting, self-esteem, rehabilitation and behaviour Diabetes, Prader Willi syndrome, oncology, dermatology, long term conditions, transition
Paediatric Surgical Consultants Surgical Specialty
Consultant
Particular interest
Burns and Plastic Surgery
Miss Isabel Jones
Skin bioengineering, burns
Mr Jorge Leon-Villapalos
Burns surgery, burns reconstruction, complex wound and scar management and reconstruction after massive weight loss
Mr Chris Abela
Craniofacial reconstruction, management of skin cancer, cosmetic surgery/ body contouring
Mr Jonathan Collier
Craniomaxillofacial deformity and surgery for congenital conditions
Mr Simon Eccles
Craniofacial reconstruction, head and neck reconstruction, management of skin malignancy
Dentistry
Miss Ghaida Al-Jaddir
All paediatric dentistry
ENT
Mr Jonathan Harcourt
Otology
General Surgery
Mr Simon Clarke
Robotic surgery, minimally invasive surgery, gastrointestinal surgery and gastro-oesophageal reflux
Mr Munther Haddad
Robotic surgery, minimally invasive surgery, gastrointestinal surgery and gastro-oesophageal reflux, anal rectal anomalies, Hirschsprung's disease
Mr Amulya Saxena
Thoracic wall deformity, minimal access surgery, acute neonatal and premature infant surgical procedures, gastrooesophageal reflux, congenital malformation surgery
Mr William Sherwood
Minimally invasive surgery, gastrointestinal surgery, Hirschsprung's disease
Mr Giles Bantick
General plastic surgery, hand surgery, cosmetic surgery
Miss Effie Katsarma
Body contouring including post-bariatrics, hands—elective and emergency, carpal tunnel, Dupuytren's, ganglion management
Mr Gordon McArthur
Adult and paediatric hand and wrist surgery, general plastic surgery
Hand and Orthopaedic Surgery
Mr Maxim Horwitz
Hand and wrist trauma, congenital hand surgery, treatment of hands in people with cerebral palsy, brain and spinal cord injury, nerve surgery, ganglion management
Ophthalmology
Ms Luna Dhir
Strabismus (squint)
Orthopaedics
Mr Stuart Evans
Fractures of the upper and lower limbs, developmental problems of the lower limb including hip and foot
Miss Alison Hulme
Club foot, paediatric limb reconstruction, developmental dysplasia of the hip (DDH), orthopaedic surgery for neuromascular disorders, children's fractures
Miss Diane De Caluwe
Robotic surgery, management of hydronephrosis (obstruction and reflux), hypospadias and other genital anomalies, urinary track infections, day and night time wetting
Miss Marie-Klaire Farrugia
Robotic surgery, pre-natally diagnosed urological anomalies, minimally invasive surgery and wetting
Miss Nisha Rahman
Robotic surgery, hyperspadias, hydronephrosis, wetting, minimally invasive surgery
Craniofacial and Plastic Surgery
Plastic and Hand Surgery
Urology
To refer patients to any of our consultants, please contact the private booking office: Telephone: 0203 315 8484 | Email: private.enquiry@chelwest.nhs.uk | Fax: 0203 315 8921 15
Light at the end of the ureteric tunnel: The modern management of Vesico-Ureteric Reflux (VUR) by Miss Marie-Klaire Farrugia •
Miss Marie-Klaire Farrugia
Until recently, common clinical practice has been that all children diagnosed with vesicoureteric reflux (VUR) are maintained on prophylactic antibiotics for an undefined length of time or subjected to aggressive surgical management in the hope that this would prevent further infection and scarring from recurrent pyelonephritis. However, a long-term Australian study has shown that rates of renal disease secondary to VUR have remained unchanged for 3 decades, suggesting that the identification and treatment of reflux have not reduced the incidence of clinically-significant reflux nephropathy. In an era of healthy living and minimally-invasive techniques, parents often question the indication for longterm antibiotics or the suggestion of open surgery. The literature, and the aggressive management of VUR, has therefore been questioned and the management of VUR literally turned on its head. It has become clear that high-grade reflux (International Reflux Classification III-V—Figure 1) and renal dysplasia/ scarring often co-exist and are the result of a congenital urinary tract “field-defect” during embryological development. One does not necessarily lead to the other, especially in the absence of infection. Moreover, aggressive treatment of VUR will not change the outcome of the scarred or poorly-functioning kidney: Therefore investigation and intervention has become more selective and aimed at preventing symptoms rather than curing. Decision-making is complex and is best managed by a specialist Paediatric Urologist.
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•
Figure 1: Bilateral VUR
Figure 2: Endoscopic injection
In summary: • There is no correlation between the presence and degree of prenatal hydronephrosis and the postnatal diagnosis of VUR. In spite of extensive prenatal scanning, VUR still most commonly presents with a febrile UTI in children who have normal prenatal scans. Therefore invasive investigation of mild prenatal hydronephrosis with an Micturating Cystourethrogram (MCUG) is not warranted. • Low-grade (I-II) VUR does not require prophylaxis and is rarely symptomatic. No follow-up is required. • Resolution of high-grade (III-V) VUR is spontaneous in only 38% of cases maintained on prophylactic antibiotics alone. The presence of a renal abnormality on ultrasound (duplex system or para-ureteric diverticulum), renal scarring, break-through UTIs and underlying bladder dysfunction are the major risk-factors for non-resolution.
•
An ongoing-prospective study by one group showed that the presence of renal scarring on DMSA (a nuclear medicine study which shows the differential kidney function and the presence of cortical defects) was the most significant predictor of progression to surgical intervention—whereas VUR grade, patient age, gender, laterality, diagnosis following prenatal hydronephrosis, presence of duplex or para-ureteric diverticula and timing of reflux did not reach statistical significance. A consensus session by the British Association of Pediatric Urologists (www.bapu.org.uk) concluded that surgical intervention is indicated after the first break-through UTI, and after underlying bladder dysfunction has been addressed. First-line treatment should be endoscopic injection (most commonly with Deflux, a biodegradable compound injected into the base of the refluxing ureteric orifice via cystoscopy)— performed as a day-case—with success rates of up to 95% (Figure 2). Endoscopic injection may be repeated 2-3 times before a ureteric reimplantation is considered. Boys with VUR also benefit from a circumcision, which has been shown to reduce infection rates ten-fold. This procedure may be performed under the same anaesthetic as an endoscopic injection.
In conclusion, VUR is a spectrum and its management depends on a number of anatomical and functional factors. Please seek advice early and avoid a vicious cycle of recurrent infections and antibiotic courses: There is a light at the end of the (ureteric) tunnel! Article references may be requested via m.farrugia@nhs.net Patients can be referred via E: private.enquire@chelwest.nhs.uk T: 0203 315 8484
Patient Story: “Surgery success for little Joe” Patience Willoughby’s courageous weight loss journey as featured on Embarrassing Bod
Miss Farrugia, Miss Rahman and Miss DeCaluwe
For the last two years, nine year old Joe has been ill with an obstructed kidney. His condition seriously affected his day-to-day life: He had to stop swimming, playing football and missed days off school. Last summer, paediatric surgeons at Chelsea Children’s Hospital based at Chelsea and Westminster Hospital employed the robotic system, Pluto to carry out the surgery and repair the blockage. Joe is a big fan of robots and asked if his favourite robot Optimus Prime would be carrying out the operation with her! Joe underwent a robotic-assisted left pyeloplasty for a left pelvic-ureteric junction onstruction. Miss Marie-Klaire Farrugia, Consultant Paediatric Surgeon, confirmed ‘We are delighted with the results. Joe has three
small scars, required minimal pain killers during and after the procedure and recovered more quickly that he would have done using conventional surgical techniques.’ Joe’s mother, Vicky added: ‘Since the surgery he is a different child and is now back playing for Ruislip Rangers. He has never been better, no more sickness and his sense of humour is better than ever. Without all the nurses and doctors and of course, Pluto the robot, Joe would still be seriously ill and unable to do the things he loves the most. The care and attention that all the staff attending to Joe took deserves 6 stars. Dr Farrugia is still Joe’s favourite doctor and the inspiration for his Halloweeen costume this year. We recently had our first holiday in two years where Joe wasn’t sick or suffered chronic pain.’
Joe dressing up as his favourite doctor
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The craniofacial team continue to turn heads Mr Simon Eccles has played a leading role as consultant in the Craniofacial unit at Chelsea and Westminster Hospital for ten years. During this time, he has spearheaded paediatric craniofacial services and in his role as head of paediatric services, has led the organisation through the establishment of the Chelsea Childrens’ Hospital within Chelsea and Westminster. The craniofacial department has gone from strength to strength during this period and now performs more craniofacial procedures than any other unit in the country. To complement our Craniofacial service we also offer a comprehensive maxillofacial service, headed up by Mr Jonathan Collier. Simon and his craniofacial consultant colleague, Mr Chris Abela, have cared for many patients over the years and their specialist interests include: ◊ ◊ ◊ ◊ ◊ ◊ ◊ ◊ ◊ ◊ ◊ ◊ ◊ ◊
Facial plastic surgery Head and neck cancer Skin cancer Congenital craniofacial conditions Paediatric plastic surgery Surgery for neurofibromatosis Vascular malformations Craniofacial trauma Secondary craniofacial reconstruction following trauma/cancer surgery Computer aided design and modelling for craniofacial reconstruction Facial palsy Orthognathic surgery Cosmetic surgery and body contouring Non-surgical treatments
Simon and Chris present internationally on craniofacial clinical outcomes, with particular reference to reconstruction and the unit’s world-class experience in Plexiform Neurofibromatosis Type I. With this in mind, the department is proud to announce the launch of the Country’s most up-to-date 3D camera, which will be used in a pilot study for babies with asymmetric heads (plagiocephaly) and to aid the planning and measurement of the outcomes of surgery. It will also help families decide whether helmet therapy or surgery for their babies is appropriate. Simon and Chris have been working with Amanda Grantham (General Manager Private Care) to improve access to private patient care. This has involved the organisation of ‘care packages’ for selfpay patients across all the subspecialty areas of plastic surgery, including cosmetic surgery. This should make paying for private services more transparent and straight forward. If you would like further information about these packages you can contact the Private Enquiry office on 0203 315 8484. To discuss any referrals with Simon you can contact him via E: simon.eccles@chelwest.nhs.uk To discuss any referrals with Chris you can contact him via E: christopher.abela@chelwest.nhs.uk 18
Profiles: Chris has been a part of the Plastic and Craniofacial unit at Chelsea and Westminster since 2005 as specialist registrar and senior registrar, prior to his consultant appointment in January 2015. Chris undertook a fellowship at Great Ormond Street Hospital, specialising in craniofacial Mr Chris Abela malformations in children and helped coordinate the separation of conjoint craniopagus twins, supported by the charity ‘Facing the World’. Simon is Associate Medical Director for Neonatal, Children and Young People’s services and President of the Plastic Surgery Section of the Royal Society of Medicine. He is Secretary and Trustee of the charity Facing the World and Patron of the charity Elizabeth’s Legacy of Hope. Simon Mr Simon Eccles specialises in paediatric and adult craniofacial reconstruction, head and neck reconstruction and management of skin malignancy. Jonathan is qualified in both medicine and dentistry. He is on the specialist register for OMFS and oral surgery. Mr Collier has a specific interest in the correction of craniomaxillofacial deformity in both adults and children as part of the craniofacial team. This includes surgery for congenital conditions, complex oral and Mr Jonathan Collier dentoalveolar surgery, facial trauma and reconstruction following skin cancer.
The charitable face of the NHS
On top of their hard work caring for UK patients, nurses and doctors often give their time free of charge to help charities involved in important healthcare projects. A significant number of medical volunteers for the charity, Facing the World, work at Chelsea and Westminster Hospital. Facing the World strives to achieve lasting improvements in the quality of life of severely disfigured children in developing countries by providing or co-ordinating reconstructive surgery; primarily by training local medical staff and establishing centres of excellence abroad in order to enable children to receive treatment locally.
Niall Kirkpatrick in Vietnam with Facing the World
An important focus of the charity’s work is its medical training mission in Vietnam. The occurrence of severe facial birth defects is by some estimates ten times higher in Vietnam than in neighbouring countries owing to the effects of Agent Orange. The dioxin from Agent Orange has caused a mutation in the genetic make-up. Each new generation carries the problems. As a result, Vietnam is a natural choice for the charity’s expansion plans. Erika John, before and after surgery
The mission is intended to provide a sustainable means of caring for many more children who would otherwise struggle to find medical help. The charity also runs fellowship programmes to train Vietnamese surgeons in the UK. It’s estimated that each doctor who participates in the fellowship programme will be able to perform more than 100 complex surgeries upon his or her return to Vietnam. Facing the World has been conducting annual medical training missions in Da Nang since 2008. In April 2015, a team of medical volunteers returned to fulfil the charity’s eighth training mission. The team was led by Chelsea and Westminster Craniofacial Consultants, Niall Kirkpatrick, the charity’s Chair, and Trustees Simon Eccles, Richard Young and Jonathan Collier. The volunteers spent a successful two weeks in Da Nang, expanding the local teams’ skills in craniofacial surgery-via lectures, training and by treating patients jointly with Vietnamese surgeons to enable knowledge sharing. The charity is extending the current mission to include Viet Duc University Hospital, Hanoi, and Cho Ray Hospital, Ho Chi Minh City, in the further training of their Plastic Maxillofacial Surgery Departments. The charity ran a feasibility mission in April 2015 with the aim of establishing medical missions at Viet Duc, starting in 2016 and at Cho Ray in 2017. Returning in November, they discussed logistics and the specific equipment which will be required to support the training of these hospitals’ medical staff. During 2016’s missions to Da Nang and Hanoi, the charity’s medical volunteers will see many children who need help. The volunteers plan to operate on Duong Hoang Long; Luu Thanh Son, and Pham Ngoc Duc “Tam”. Duong Hoang Long suffers from a lymphatic
malformation, Luu Thanh Son has orbital neurofibromatosis, and Tam was born in 2014 with a severe facial cleft and has no sight. One patient who has already benefitted from Facing the World is Erika John. Erika John Rwabirire had a large tumour on his face which had been growing for over ten years. It made eating and sleeping almost impossible. In January 2015, Erika John, then 17 years old, came to the attention of a German charity called BigShoe. They contacted Facing the World for help. Living in Ragundo, Uganda, Erika John slept on a sheet on the floor and was reluctant to go outside because of the shame of the growing tumour. Erika John weighed only 23kg when he arrived in London in June 2015. Before undergoing complex surgery, he had to put on sufficient weight. He ate nutritional supplements as well as three meals a day but as he put on weight, the tumour continued to grow too. Erika John had a gastrostomy tube fitted as well as a tracheostomy tube to help him breathe and his weight increased enough for the charity’s medical volunteers to operate successfully. His aftercare, and subsequent operations have all taken place at the Chelsea and Westminster Hospital and we are delighted to report that Erika John is now preparing to return home. Whilst the medical volunteers give their time for free, Facing the World must still meet the set up and running costs for the mission and fellowship training. But for the medical teams involved in helping the children, the reward of seeing the children live happy and fulfilling lives is unsurpassed. www.facingtheworld.net 19
Biological therapies available for IBD patients
Dr John Fell
Dr Warren Hyer
Dr John Fell and Dr Warren Hyer head up the private gastroenterology paediatric service at Chelsea and Westminster Hospital. The team have nationally recognised expertise in inflammatory bowel disease, allergic gastrointestinal disease, intravenous feeding and endoscopy training. The paediatric gastroenterology unit takes referrals directly from GPs, other hospitals and disciplines across London. The department prides itself on ease of access, ability to see patients within days for urgent referrals, inpatient care and multi-disciplinary working. The team of four consultants, three dedicated gastroenterology nurses, dieticians, psychology and a speech and language therapist aim to provide swift diagnostic procedures such as endoscopy and clinical care for children age 0 to 16 years. They work closely with the paediatric surgeons, often assisting each other with complex cases with daily endoscopy lists with paediatric anaesthetists. Much of the workload includes children and young adults with inflammatory bowel disease, feeding difficulties, abdominal pain, infantile colic, reflux and other bowel diseases. The inpatient work includes children dependent on intravenous feeding. A typical case for us is a child with newly diagnosed inflammatory bowel disease coming to the department referred from a GP or another hospital with new onset diarrhoea and weight loss. One of the consultant team assess the child, organise the relevant endoscopy and radiology and the diagnosis would be achieved at gastroscopy
and colonoscopy under anaesthesia. The department prides itself in high standards of endoscopic assessment. Treatment would commence at diagnosis aiming to start treatment within a week. Options include drugs, dietary change or new innovative biological therapies. The department has been at the forefront of developing therapies in the UK for inflammatory bowel disease, with Dr Fell leading research and development in nutrition for Crohn's disease and introducing novel intravenous therapies looking at timing and patient safety for this new class of drugs. Dr Fell oversees a team of consultant colleagues attracting referrals for colitis and Crohn's disease spanning the South East. The department seeks to provide personalised care specific to the disease extent and location for each child following international agreed guidelines. Dr Hyer is jointly appointed with St Mark’s Hospital (a national centre for endoscopy training) and Chelsea and Westminster with attendant advanced endoscopic experience in complex colonoscopy and interventional endoscopy including insertion of feeding tubes, or removal of colonic polyps. Appointments and opinions can be made via T: 0203 315 8484
Paediatric clinical research Clinical research is a core part of health care: It enables us to improve the current and future health of the people it serves by providing safer and more effective ways of treating and caring for patients. Paediatric research at Chelsea and Westminster is varied and this continues to grow. We have a portfolio of observational and interventional research studies that not only look at testing new drugs but that also look at ways in which we can improve quality of care and the experiences for our patients. The following two observational studies are currently open to recruitment: The DEVELOP Registry: A multicentre, prospective, longterm registry of paediatric patients with Crohn’s disease or Ulcerative Colitis The objective of the study is to obtain long-term safety and clinical status information on paediatric patients with IBD (i.e. Crohn’s and 20
Ulcerative Coilitis). The registry will involve approximately 64,000 subjects with Crohn’s disease and Ulcerative Colitis in approximately 125 study centres in North America and the EU who are between 6 and 14 years of age at time of recruitment, with Chelsea and Westminster Hospital being an active site. PANTS—Personalised Anti-TNF Therapy in Crohn’s disease The study is run by Royal Devon and Exeter NHS Foundation Trust and is inviting 1200 patients across the UK to participate. The primary objective of the study is to investigate the mechanisms that underlie primary non–response, loss of response and adverse drug reactions to anti-TNF drugs. Children between 6 and 15 years with active luminal Crohn’s disease who require treatment with anti-TNF drugs, Infliximab or Adalimumab who are naïve will be invited to take part.
A nursing perspective of Chelsea Children’s Hospital by Nathan Askew, Divisional Nurse
Nathan Askew
Chelsea Children’s Hospital, part of Chelsea and Westminster NHS Foundation Trust, is an ideal choice for private patients wishing to experience the very highest standards of care in a dedicated Paediatric setting.
The national inpatient and outpatient survey undertaken by the Picker Institute UK found that 85% of parents rated their child’s care 7 or above out of 10 and 92% of parents felt there child was always cared for safely on the ward.
The Chelsea Children’s Hospital officially opened in March 2014 and now sees all paediatric services on the same floor within the main hospital. The refurbishment of the hospital has provided specifically designed wards which are light, bright and spacious. The environment ensures that patients are cared for in the most modern and beneficial surroundings.
he same national survey demonstrated that compared to the national average Chelsea Children’s hospital performed significantly better in the following areas:
Chelsea Children’s Hospital offers a full range of paediatric services and includes a number of dedicated private patient beds. Patients are cared for by highly trained, dedicated nurses and support staff. Staff have undergone extensive clinical and customer care training to ensure that the physical and pastoral needs of children and their families are met. We aim to not only meet but exceed expectations whilst reducing the impact of hospitalisation on the child and family at every opportunity available.
“We aim to not only meet but exceed expectations while reducing the impact of hospitalisation on the child and family at every opportunity available”.
By being situated in one of London’s leading NHS Foundation Trust, private patients at Chelsea Children’s Hospital have access to an extensive range of medical, surgical and support services. With access to leading clinicians in a variety of specialities, patients and their families are cared for in a safe and paediatric focuses environment. In addition to the excellent consultant led care, children and young people have access to the full range of clinical nurse specialists and other support to enable patients and their families to understand their condition and to be supported in their recovery and follow-up.
• • •
Quality of overnight facilities for parents and carers The child was fully aware of what would be done during the operation Parents were given good information about how their child should use their medications
In addition to the clinical services offered, Chelsea Children’s Hospital also has a dedicated Hospital School. For children who are long stay admissions the school can provide a pivotal support and link to the child or young person’s educational institution, keeping their education on track and keeping good peer support. In addition to the school the hospital has a new MediCinema where age appropriate new releases and family favourite films are screened. The primary benefits of choosing Chelsea Children’s Hospital are that your patients will have access to the highest standards of clinical care, delivered in a state of the art environment with modern resources. Chelsea and Westminster Hospital NHS Foundation Trust has a long history of providing safe effective and cutting edge care to children and families. As we move into the future Chelsea Children’s Hospital is committed to expanding its private patients’ service provision whilst maintaining the high levels of clinical care and customer focus. 21
Meet the private paediatric psychology team Dr Aayesha Mulla and Dr Jonathan Gibbins are both registered practitioner psychologists with the Health and Care Professions Council (HCPC) and chartered psychologists with the British Psychological Society (BPS). In paediatric psychology our job is to help children, young people and families cope with the psychological aspects of health and illness including: • • • • • • • • • • • • • • •
Preparation for hospital procedures eg surgery and injections Coping with treatment Coping with pain Boundaries and parenting support Adjustment to diagnosis and illness Stress related symptoms Relaxation and distraction techniques Emotional wellbeing; anger, worries, upsets Difficulties with feeding, sleeping and toilet training Problems with taking medicine or sticking to a special diet Grief and bereavement Recovery following an accident Support for the parents/siblings of an unwell or sick child Difficulties at school Transition into adolescence and early adulthood
What happens during a psychology assessment? At the initial assessment we will talk through the main concerns with the child, young person and/or their parents and take a comprehensive developmental and medical history. This enables us to formulate an understanding of the current difficulties and help identify goals and a focus for the therapy. The number of sessions will be agreed upon at the initial assessment and reviewed during therapy. How to refer: We accept direct referrals from families. Alternatively, the medical professionals involved in the child or young persons’ care can refer with the consent of the family.
Dr Aayesha Mulla, CPsychol
Dr Jonathan Gibbins, CPsychol
M: 07519 911 537 E: aayeshamullacp@gmail.com
M: 07715 613 355 E: drjonathangibbins@gmail.com
Specialist areas • • • • • • • • • • • •
Diabetes Prader Willi Syndrome Oncology Psychological support to dental treatment, needle phobias Orthopaedic conditions Dermatology Adjustment to diagnosis of longterm health conditions Learning difficulties; behavioural support and parenting Emotional support for children and young people (worries, fears and upsets), traumatic events ‘Transition’, managing life changes, particularly adolescence and early adulthood School stresses Multiple cultural identities; spirituality
• • • • • • • • • • • • • • • •
Gastroenterology Burns Urology Adjusting to conditions Adherence to medication/diet/lifestyle changes Managing acute and chronic pain Procedural anxiety/ needle phobia Appearance related concerns Self-esteem related concerns Toileting, constipation/withholding, soiling/wetting Rehabilitation following long-term illness Anger management Behavioural difficulties/boundaries Self-care, relaxation and self-compassion School stress and health related difficulties in a school setting Transitioning to adult services
• • •
Cognitive behavioural therapy Systemic family therapy Narrative therapy
Treatment approaches • • •
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Systemic family therapy Narrative therapy Cognitive behavioural therapy (informed by psychodynamic thinking)
Common misconceptions preventing patients accessing paediatric psychology support? In recognition of the importance of psychological support for children and families undergoing treatment, Chelsea Children's Hospital has an established team of clinical psychologists who support patients and their families undergoing treatment. We have found that patients and families can sometimes be reluctant to access psychological support and we are keen to address the most common misconceptions that can discourage patients and families accessing psychological support.
“People think my illness is all in my head, that I’m making it up” Sometimes when a healthcare professional suggests seeking support from paediatric psychology, people may feel they are not being believed, or that their illness is not being taken seriously. When exploring options with patients, it is helpful to highlight that research has shown that having psychological support alongside medical intervention improves outcomes for many physical illnesses and should be considered as part of a comprehensive treatment plan. The team at Chelsea specialise in supporting children, young people and families in managing their conditions in a way that improves their overall quality of life. We do not see the body and mind operating independently of each other, but that they are closely linked. It may be that sometimes, someone’s sadness or worry is communicated through physical pain or illness. At other times, living with pain or illness may lead to someone experiencing sadness or worry. In both cases, a cycle of behaviour can be set up which increases symptoms of the health condition, sadness or worry and be detrimental to quality of life. Psychologists can support individuals to find a different relationship with sadness or worry in a way that improves quality of life.
“Seeing a psychologist must mean I’m ‘mad’” People can be reluctant to see psychologists due to a fear people may think they are “mad”. Some medical professionals can also find it difficult to suggest psychology out of concern that the patient may be offended. The reason why psychologists work in hospitals and see patients is because we are aware that it can be very difficult to live with health conditions. Conditions can have a big impact on an individual’s quality of life and will also often have a negative impact on the whole family. Psychologists work with the understanding that the patient is the expert of their life and we have tools and techniques that can be
helpful to boost their ability to cope with their difficulties. Therapy is a collaboration between the person and the psychologist. People manage distress in different ways and someone’s natural coping strategies, which work in other areas of their lives may not work so well for managing their health difficulties. Similarly, when a family member becomes ill, families will naturally react and put coping strategies in place to help the family to cope. What works well in the short term, can cause difficulties if the condition becomes long term and chronic, with families then feeling stuck in unhelpful patterns. Psychologists can help patients and families articulate these difficulties. It is important that the difficulties resulting from chronic health conditions are validated and normalised. It is understandable that the individual themselves, parents, siblings and family members may all struggle and find it stressful to manage the condition and the disruption it can cause to school, work, socialising, and general quality of life. It is important that people feel able to access this support.
“Seeing a paediatric psychologist is a ‘last resort’” In many chronic or acute health conditions, paediatric psychologists can be involved from the outset: the point of diagnosis (e.g. diabetes); as soon as a medical procedure has been scheduled; or when an injury happens. Early involvement from paediatric psychologists can help to spot patterns that have been helpful in the past, but may not be so helpful in these new and extraordinary circumstances, providing alternatives before a ‘problem’ sets in.
“My pain is real so why am I being sent to the psychologist?” Pain can be a very difficult symptom to live with, as it can negatively impact on people’s mood, quality of life, concentration, energy levels, and their social lives, as the natural tendency is to withdraw and rest. In consequence, people often end up with less distractions in their lives and their body’s become deconditioned, which can cause more pain. People will naturally rely on pain medication but this can also leave people feeling they need increasingly stronger medication and feel less control over their own health. Psychologists can help formulate the impact that pain has had on a person’s life and then help to develop relaxation, distraction and other strategies and techniques that will help the individual to build their confidence in managing the pain and pace their rehabilitation, while they build their energy and activity levels back up. This work helps to improve quality of life and improve pain management and enable the individual to decrease the impact that pain has on their life. 23
Movie magic CW+ MediCinema opens
Patients are now enjoying the latest film releases free of charge, in the heart of Chelsea and Westminster Hospital. CW+, the hospital’s charity, joined forces with fellow charity MediCinema to build the CW+ MediCinema which opened in September. The state-of-the-art cinema has capacity for 40 seats, six wheelchairs and five beds, which enables patients to enjoy time away from wards with their loved ones. Two nurses are present at every screening so patients can continue to be cared for. Twelve-year-old Jack has been in hospital for over eight months. His mum Steph said: “It can be hard to keep Jack entertained, especially as he has been in here so long, so the CW+ MediCinema is really great”. Seventy-five-year-old Harry has also been enjoying the screenings. He said: “It feels like a real cinema. It’s incredible really. If I was marking it, I would give it eleven out of ten”. When the space is not being used for film screenings, it provides a state-of-the-art teaching and conferencing facility for clinical staff. CW+ also commissioned artist Andy Council to produce two bespoke murals, which span the exterior walls of the cinema. Following consultation with patients, Andy created a fox and a rhino artwork, which are made up of buildings and local landmarks in the Chelsea and Fulham area. They are breathtaking additions to the hospital’s extensive art collection.
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Experience the magic of the MediCinema for yourself! On the evening of Wednesday 16 March, Mr Simon Clarke and Dr Kingi Aminu are hosting the Spring 2016 Paediatric Showcase encompassing daycase surgical conditions and common paediatric endocrine problems. On the evening of Monday 25 April, Mr Dimitrios Nikolaou, Mr Nigel Borley, and Miss Gubby Ayida are hosting a conception to birth session covering common causes of male and female infertility and how we optimise patients caesarean section recovery. A tour of our maternity facilities will also be available. If you are interested in attending either of these sessions, please contact caroline.pooley@chelwest.nhs.uk
Hospital Young Peoples Forum by Jasmyn Ofosu
Chelsea and Westminster Hospital's Youth Forum was established in May 2014 when the hospital hosted its first Youth Forum meeting and welcomed its four founding members. The Youth Forum consists of a group of young people aged between 12 to 17 all of who are inspirational, articulate, positive and passionate about maintaining high standards and creating change within Chelsea and Westminster Hospital. The members meet every 6 to 8 weeks to share and discuss their views of what young people want and need in a hospital setting, and what changes could be made. It is a chance for their views to be heard, as well as a useful platform to engage with governors and executives. The members of the Youth Forum are either current patients, former patients or have a sibling, family member or friend who has been hospitalised. Members of the forum find the experience rewarding as well as practical through enhancing CVs, Duke of Edinburgh for Community Service applications as well as College and University applications. The aim of the Youth Forum is to work on projects, act on issues raised, plan activities, and create an even better Chelsea Children’s Hospital.
The Youth Forum have proved instrumental in finessing the adolescent food menu. Since the young people brought up their issues with patient food, they have met with the head of the catering to do a ‘back of house’ tour and the young people were involved in a food tasting session. As a result the adolescents menu has been modified and healthy lunch time snacks such as fruits are now being offered. The forum have also been involved in developing the adolescent leaflets. They felt that the information previously provided was not as young people friendly as it could be. As well as the assistance the Youth Forum provides for the staff, they also participate and engage in creative activities outside of the Hospital. In August, they attended a pizza party at Pizza Express: The young people learnt how to make a pizza and learnt about ingredients, but most importantly bonded with one another. The Youth Forum is still developing but we hope it will act as a voice for young people at Chelsea and Westminster Hospital for years to come. All of the Youth Forum members are passionate about finding solutions to problems they find; they are very creative and have an over flow of ideas to make Chelsea Children's Hospital equally restorative for toddlers and teenagers alike. 25
Innovation at Chelsea and Westminster Hospital
Award winning app revolutionising clinical care
A small idea making a big difference to patients and staff: When children become stressed before an operation, it can delay surgery or result in operations being cancelled. Dr. Peter Brooks, Consultant Anaesthetist at Chelsea and Westminster Hospital, notes that “the amount of time spent during induction of anaesthesia represents a significant proportion of the workload of the theatre, even in simple cases”. In response to this problem, Dr Peter Brooks and Dr Corina Lee, with support from CW+, designed the app platform ‘RELAX Anaesthetics’. This innovative digital solution, developed by imagineear, provides a better experience for anxious children (and their families), saves valuable time, and reduces the cost of anaesthetic drugs. The app received a 2015 NHS Innovation Acorn Challenge Award which recognises early stage innovations that have the potential to make a big impact to patient care. RELAX Anaesthetics also won a Staff Innovation Award presented by James Caan (BBC1 Dragons’ Den) in September 2014. CW+ is currently validating the use of RELAX Anaesthetics in a clinical environment as part of an ongoing clinical study. The preliminary results of this study show a positive impact of RELAX Anaesthetics on patients’ experience, and we hope it will allow us to quantify their anxiety reduction. Patients are already raving about their experience including Kate, mother of six year old patient Rosa: “it’s fantastic. Last operation, she had no distraction [… and] it took a long time to anaesthetise her. This time it took just four minutes”. Additionally, Rachel (mother of
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William) says that “as a mother, seeing William panic when he saw the operating table was very difficult. However, I needn’t have worried. He instantly calmed down when he was offered to play a game chosen by the RELAX anaesthetics app […]. It completely distracted him and within a minute he was successfully anaesthetised—it was like magic!” Expanding the idea: How you can get involved in an exciting digital opportunity to improve patient care in your practice The success of RELAX Anaesthetics to date has generated a chain of additional products designed to improve patient care. We believe GP surgeries could also benefit from using RELAX in their surgeries as a distraction tool to reduce patient anxiety during cannulation, or inoculation and even concealing the needle when blood samples are being taken. RELAX Hospital, which is an exciting spin-off currently in development, could also be useful in the waiting areas of GP surgeries for example. RELAX Hospital uses games, films and music to distract patients during hospital procedures and on the wards and is designed to be used wherever patients require distraction. If you are interested in finding out how the RELAX products can complement the service you are providing, or if you would be interested in trialling the app at your practice, please contact: Drew Davy, Enterprising Health Partnership Executive at CW+ via email drew.davy@chelwest.nhs.uk or visit www.cwplus.org.uk/ehp/relax.
New laser service for vascular anomalies
Dr Bisi Laguda
In 2015, we established a laser service as part of the vascular anomalies service at the Chelsea and Westminster Hospital. The service is run by Dr Bisola Laguda, a Consultant in Paediatric Dermatology. Dr Laguda works in conjunction with clinical nurse specialist Catherine Sheehan.
Treatment can be done under general and local anaesthesia (as clinically indicated) and follows an initial consultation. The number of sessions required is dependent on the condition, for example a typical port wine stain could require about 6–8 sessions with standard intervals ranging between 6 and 12 weeks.
Currently we have a pulsed dye laser (V-beam Perfecta) which is the treatment of choice for vascular lesions. Pulsed dye laser is a light based technique that uses a narrow beam of light to selectively target the oxyhaemoglobin in blood vessels via a process called selective photothermolysis.
Treatments under general anaesthetic can start from about age 1–2 years but laser therapy can be administered at any age and would still be effective in adults. The treatment itself is sometimes described as a tingling sensation or the snapping of a rubber band against the skin.
It can be used to treat the following conditions:
The V-beam pulsed dye laser has an in built cooling device that delivers a stream of cold air prior to the administration of the laser. Immediately following treatment, an ice pack may be applied to soothe the treated area.
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Capillary malformation such as port wine stains Superficial haemangiomas and a variety of acquired cutaneous vascular lesions, including telangiectasia, angiomas, poikloderma of civatte Pyogenic granulomas Acne scars Stable psoriasis Plane warts
Pulsed dye laser treatment is safe, effective and is the gold standard for treating cutaneous vascular lesions. Referrals via the private enquiry office: T: 0203 315 8484 or E: private.enquiry@chelwest.nhs.uk
UK’s first swallowing station for children The Children’s Hospital Trust Fund has bought a digital swallowing workstation, called Gulp which is revolutionising the way babies and children are diagnosed and treated for swallowing problems. This is the first swallowing station available in a children’s hospital in the whole of UK. This state of the art equipment offers the most comprehensive insight and understanding of a patient’s swallowing process currently available in the world. The value of the information the specialists will receive from this new medical equipment will significantly improve the lives of the babies and children via: • • • • • •
Instant access to results eliminating repeat appointments Faster patient access for an objective assessment reducing the stress on families waiting for a diagnosis Earlier diagnosis leading to more immediate treatment Precision understanding of the swallowing problem which could avoid surgery Earlier weaning off feeding tubes Elimination of exposure to X-rays
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In situ assessment in the Neonatal Unit reducing the chance of infection
As this is a mobile system, it can be easily moved to a patient’s bed or cot on the wards, clinic and X-ray department and therefore patients do not have to be transported. This is especially important with premature babies in the Neonatal Unit who often cannot be transported out of the unit due to their ventilation requirements. Dr Krishna Soondrum, Consultant Paediatric Gastroenterologist at Chelsea Children’s Hospital said: “We are so thrilled to have this revolutionary equipment that will allow us to treat patients much quicker and in a very safe way as far as babies and premature babies are concerned. It will also allow us to treat more patients, which is a great news knowing the huge and increasing number of babies and children suffering from swallowing problems today. We are extremely grateful to the Children’s Hospital Trust Fund who is a tremendous support for us.”
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