Medico Issue 17

Médico October to December 2013

A quarterly publication of GP Liaison Centre, National University Hospital.

MICA (P) No. 018/08/2012

Medical Sp

tlight

Childhood Cancer – Our Past, Present and Future Common Conditions seen at the Children’s Emergency

The Ronald McDonald House @ NUH

Associate Professor Daniel Goh Cluster Chair, KTP-NUCMI Head, Department of Paediatrics

02-03 Medical Notes • 04-05 Medical Spotlight • 06-10 Treatment Room • 11-16 Insight • 17-20 Event Roundup • 20-23 Doctor’s Heartbeat

M EDIC AL N O TES Dr Tan Poh Lin

Senior Consultant, Division of Paediatric Haematology and Oncology Dr Tan Poh Lin is an Assistant Professor in the Department of Paediatrics in Yong Loo Lin School of Medicine (YLLSoM), National University of Singapore (NUS) and a Senior Consultant in the Khoo Teck Puat-National University Children’s Medical Institute (KTP-NUCMI), National University Hospital (NUH). Her area of clinical expertise is in paediatric oncology and blood / marrow stem cell transplantation (BMT).

Caring Goes Beyond Medicine - Providing a home

away from home for families whose children are hospitalised

Email: poh_lin_tan@nuhs.edu.sg

Dr Thong Wen Yi

Associate Consultant, Division of Paediatric Critical Care Dr Thong Wen Yi is currently an Associate Consultant in the Paediatrics Intensive Care Unit (PICU) of the Khoo Teck Puat-National University Children’s Medical Institute (KTP-NUCMI), National University Hospital (NUH). She completed her paediatric training in Singapore. She is actively involved in undergraduate teaching and is also a faculty member for the Paediatric Residency Programme at the National University Health System (NUHS). Her areas of interests include home and palliative care, as well as working with children with chronic medical needs.

Email: wen_yi_thong@nuhs.edu.sg

About the Khoo Teck Puat - National University Children’s Medical Institute (KTP-NUCMI) The KTP-NUCMI is the paediatric arm of the National University Hospital (NUH) in Singapore, and comprises the Departments of Paediatrics, Paediatric Surgery and Neonatology. It houses the national paediatric liver and kidney transplant programmes as well as the chronic renal replacement programme for children. It is a tertiary institution equipped to provide comprehensive and specialised medical and surgical services for newborns, children and adolescents. Through a generous gift from the estate of Tan Sri Khoo Teck Puat for the advancement of paediatric patient care, education and research, KTP-NUCMI is undergoing major expansion to further enhance its standing as an international centre of excellence in paediatric healthcare. NUH Kids is the brand of the KTP-NUCMI. 02 • ME D ICO

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The Ronald McDonald House at National University Hospital– provides a temporary “home away from home” for families whose children are hospitalised

In January 2013, the Ronald McDonald HouseTM (RMH) opened its doors at National University Hospital (NUH).

Developed and managed by Ronald McDonald House Charities (RMHC) Singapore, it operates round-the-clock 365 days a year. Located inside NUH, this temporary “home away from home” is adjacent to the Paediatric Intensive Care Unit (PICU) and has four en-suite bedrooms, living room, dining room, kitchen, laundry facilities and playroom/ library. The House in Singapore joins over 329 other RMHs around the world.

The National University Hospital (NUH) has been in full support of this programme as it is in line with the hospital’s aim of providing holistic care for patients and their families. Families of children who are ill often have needs beyond the medical care of their children. Simple needs like a place to rest and refresh, getting laundry done and having a meal are essential tasks of daily living, but yet, often not possible in the situation of having to stay by the bedside of sick children.

At the RMH, families are provided with a place to shower, rest and refresh; catch

a nap and prepare a quick meal before going back to continue their vigil by their sick child’s hospital bed. Studies have shown that children heal faster when parents are close by. Funded with public and corporate donations, RMHC offers the RMH at no cost to the families who stay here. Families whose baby or child is in the Paediatric Intensive Care Unit (PICU) at NUH are given priority.

Caring for children and their families often goes beyond medicine. The stress of suddenly seeing one’s child becoming ill and requiring hospitalisation is often overwhelming; even more so if a child is critically ill and needs intensive care. At RMH, families who wish to interact and share experiences can also find listening ears from RMH staff who are most willing to provide the appropriate level of support whilst ensuring privacy and confidentiality. Having access to these means of open communication and listening ear often help families cope better with their circumstances.

Easing these families of the physical and emotional stresses enables parents or guardians and the medical teams to care for the sick child more effectively. An

M EDIC AL N O TES Ms. Judy Chun

Executive Director, Ronald McDonald House Charities (RMHC)Singapore Ms Judy Chun joined the Ronald McDonald House Charities (RMHC), Singapore, as Executive Director on 22 July 2013. Judy has 12 years of experience in overseeing various social programmes and services for children, youth and elderly in Singapore as well as in Malaysia. With her passion to serve people of various needs, Judy, together with her team at RMHC Singapore, aims to create more services and programmes in the near future, and also establish more partnership opportunities with NUH and other local hospitals in Singapore for the betterment of children’s health and well-being.

Email: judy.chun@rmhc.org.sg

exhausted mother who had been sitting next to her daughter in the PICU for days once commented: “I was crying as I laid down to rest. I was crying and crying.... and the next moment I was surprised to find myself wake up in the comfort of a bed...and that I had actually slept and woken up to a new day...”

Getting that much needed rest helped this mother and many parents cope with the exhaustion and confusion that often come with the complexities of medical care in dire times. Since its opening, the RMH has been a respite for over 70 families.

One couple shared this sentiment, “Can you imagine taking care of a small baby at PICU who needs an intensive 24 hours of parents’ attention and not able to be there 24 hours? The RMH has helped to close those barriers and enabled us to be with our child 24 hours. We can only repay your sincere help through our prayers for you and the big family of RMHC. Thank you so much!” said Mr and Mrs Shanker Ramchand.

Mr and Mrs Shanker stayed at the House for 12 days before their son was discharged.

Another mother, Mrs Ganesh, expressed similar sentiments. Her 6-month-old baby girl had been admitted to PICU for several weeks. In the beginning, she had to make her way down from her home in Bishan to be with her baby every day.

That would require about 1.5 hours of travelling time via a bus ride and MRT before she could reach NUH. In addition, she needed to take care of the 6-monthold twin brother at home in between the visits to NUH. ‘I was so tired, and it was such a long journey from home to NUH”, she said, “Now, I can spend time daily with my baby girl in ICU and catch up on some rest in the RMH room.”

Having a room in RMH meant that Mrs Ganesh was able to be with her baby girl in PICU for most part of the day and get some rest in the RMH room in between before returning home in the evening to be with her other baby. Mr Ganesh would take over in the evening after work to be with his baby and he would stay in the RMH room overnight.

This had allowed them more time with their baby in the hospital. It had also allowed them to spend quality time to care for their other baby at home.

Staying in RMH is also like being in a small community where families with children who are ill get to share their experiences and provide support for one another. The mother of another admitted to PICU, felt that “through RMH, she and other parents get to meet and encourage each other in these difficult circumstances” and this had helped her cope with the stresses of caring for her ill child.

When families return to the ‘House That Love Built’ to share how they are coping and/or their child has been recovering; they would usually ‘pay it forward’ with generous contributions or donations they feel would help others; such acts affirm and encourage the RMH team of their roles; and seal their commitment as helpers to the many journeys of healing.

About Ronald McDonald House Charities® (RMHC) The mission of RMHC Singapore is to create, find or support programs that directly improve the health and well-being of children. In Singapore, the charity was incorporated in 1984 and has helped over 900 Singaporean children receive urgent medical, surgical and rehabilitative treatment.

Motivated by our mission, the first Ronald McDonald HouseTM (RMH) in Singapore was constructed and opened in January 2013 at National University Hospital (NUH).

The charity is registered under the Societies Act and depends purely on the generosity of supporters.

Words aren’t enough to show our appreciation for our volunteers. We thank you for helping us find the strength in numbers.

In order for RMHC Singapore to fulfil its mission and to operate the RMH, we need the support of volunteers and sponsors to work together with our staff and management.

To find out more, please visit our website at www.rmhc.org.sg or contact us through:

Alvyn Lim

Manager, Ronald McDonald House Ronald McDonald House Charities® Singapore 5 Lower Kent Ridge Road, Main Building Level 4, Singapore 119074 E: contact@rmhc.org.sg

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M EDIC AL S PO TLIGHT Dr Frances Yeap

Registrar, Division of Paediatric Haematology and Oncology Dr Frances Yeap graduated from the Queen Mary University of London (UK) in 2006. She joined the Department of Paediatrics, Khoo Teck PuatNational University Children’s Medical Institute (KTP-NUCMI), National University Hospital (NUH), in 2008, and is currently undergoing her Advanced Specialty Training in Paediatrics, with an interest in oncology and blood & marrow transplant.

Childhood Cancer – Our Past, Present and Future

Gone are the days childhood cancer was a death sentence. Children diagnosed with cancer now have an 80% chance of being alive 5 years later, with childhood leukaemia having even better chances of survival and cure. 10 years ago, childhood cancer was still stigmatised with the words: “relapse, palliation and death”. These days, it resounds with the words: “remission, cure and survivor”.

Over the last decade the practice of Paediatric Oncology has changed dramatically. Firstly, the cure rate has increased further over these years. Using Acute Lymphoblastic Leukemia (ALL, the most common childhood cancer) as an example – when our department just initiated treatment for ALL in the 1970s and 80s, the cure rate was around 60%.

Now, it’s more like 90%! Improving the cure rate for children with cancer is the life-long goal for all paediatric oncologists. We are able to improve cure rates because of better understanding of the biology and pathology of these malignancies, the invention of new drugs and also the ability to use them more effectively with better control of the toxicity.

Associate Professor Quah Thuan Chong (Head, Division of Paediatric Oncology) always tells us that when he first started his career in paediatric oncology, there were only three modes of therapy, “CBP Therapy” – Cut, Burn, and Poison! If the surgeon can remove the tumour, it will be better to let him do it (except for lymphomas – these are so chemosensitive that they can be cured just with chemotherapy alone). If the tumour is radiation-sensitive, let the radiotherapist do his job (though radiotherapy is used much less in childhood cancers compared to adult cancers, partly because of the more severe postradiation sequelae in children). Most paediatric cancers are sensitive to chemotherapy, and hence, most children with cancer will undergo chemotherapy and thankfully most are cured!

Secondly, we have gone beyond “Cut, Burn and Poison”. Our department did the first bone marrow transplant (for a child with leukaemia) in 1983, and since then, the transplant arena has improved tremendously, especially over the past 2 years when we started doing specialised cell therapies (T-cell depleted haploidentical transplants, NK-cell transplants, chimeric-antigenreceptor-modified T-cell therapies, etc.) Patients no longer need to be in remission before transplant, and in fact, cell therapy is sometimes used to induce remission when the disease is otherwise chemo-refractory. This has only been possible through the hard work of our BMT (Blood & Marrow Transplantation) team – led by Dr Tan Poh Lin and our laboratory staff who need to be very meticulous in processing the cells and

Email: frances_yeap@nuhs.edu.sg

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ever ready to work through the night so that the cells we infuse into our kids are in its most optimal state. We are proud that we are the first and only one in Asia to be accredited by the Foundation for the Accreditation of Cellular Therapy (FACT). This internationally-recognised accreditation is the gold standard for hospitals and medical institutions offering stem cell transplant, and indicates that we have met the most rigorous standards in every aspect of stem cell therapy.

Thirdly, we have learnt to customise our treatment, so that it’s no longer a onesize-fit-all approach. Paediatric Oncology used to be thought as only about PROTOCOLS, but nowadays, the therapy is so directed and individualised, every patient’s treatment is different. Associate Professor Allen Yeoh (Senior Consultant, Paediatric Haematology & Oncology) runs an advanced paediatric leukaemia laboratory, enabling us to analyse the genetics of each patient to great detail and therefore, better prognosticate each patient.

We are also able to use Minimal Residual Detection (MRD) to evaluate response to treatment and escalate or reduce the intensity of therapy accordingly.

This has helped us tremendously to intensify treatment early for high-risk patients and, at the same time, deescalate therapy for low-risk patients thus reducing their toxicity. There are also many other new modalities of therapy, such as anti-CD52 alemtuzumab in immunotherapy and tyrosine kinase

inhibitors imatinib and desatinib in small molecule therapies, which provide targeted therapy. By better understanding the biology of the malignant cells and its cell surface antigen expression, we can use targeted therapy to cause cell apoptosis and also turn on the “killing mechanism” of bystander cells to help kill these cancer cells.

We are also greatly honoured to have Professors Dario Campana and Elaine Coustan Smith joined us from St Jude Children’s Hospital, Memphis, USA. Together as a husband-and-wife team, they have brought tremendous wealth of experience and knowledge in flow cytometry and cell therapy and they now run a world-renowned flow cytometry laboratory in the Centre for Translational Medicine at the National University of Singapore.

And finally, all this would not be possible without the excellent mentorship of Prof Quah and a wonderful Paediatric Department where we are always fully supported by our intensive care team and sub-specialty colleagues. Whether it may just be for a simple consultation, or as complex as renal dialysis, or even extracorporeal membrane oxygenation (ECMO), our colleagues are always ready

to help. We also have a wonderful team of paediatric surgeons who will always try their best to give us clear margins to work with and are ever ready to insert central lines (porta-cath or hickman lines) for administration of chemotherapy or other medications. This reduces the pain and trauma for our children who need long-term intravenous access.

In addition, we also have an excellent team of nurses who are passionate and proud of what they do and they provide excellent supportive care to our patients.

Supportive care is extremely important in Paediatric Oncology because it not only translates into lower infection rates, but also impacts length of inpatient stay and overall survival.

Last but not least, we have a dedicated team of social workers from various non-governmental organisations (e.g.

Children’s Cancer Foundation, Viva Foundation for Children with Cancer) who provide tremendous emotional support to our kids. Through play, reading, art and various other activities, they help to divert attention away from the physical and emotional pain our kids may be going through and rebuild their confidence. Hair for Hope and Make a Wish Foundation are examples of the programmes we have to raise funds for

our children as well as grant the wishes of those with life-threatening conditions.

There are also now specialised schools like ARC Children’s Centre and Place for Academic Learning and Support (PALS) that children with cancer can attend – this is so that they can continue to interact with other children, learn and develop skills so they can adjust more easily when they return to mainstream schools.

Sometimes, the side effects may just be too intense and the child may succumb to the toxicity and infections as a result.

Or sometimes, the cancer evades all the immune surveillance and chemotherapy that we give – no matter what we do, the cancer wins. As paediatric oncologists, we almost never give up, but sometimes, as difficult as it is, we have to. We grow with our children and their families – we laugh, cry and pray together – that is the beauty of the Paediatric Oncology Division in the National University Hospital (NUH). As Danny Thomas – the founder of St Jude Children’s Hospital, who was also a famous comedian and entertainer in the 1950’s – once said, “No child should die in the dawn of life”. This remains the ethos of all paediatricians and paediatric oncologists and this is why every single child is so important to us here in NUH.

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T REAMENT R OOM Dr Elizabeth Tham

Registrar, General Paediatrics & Adolescent Medicine Dr Elizabeth Tham is a Registrar in the Division of Allergy & Immunology, Khoo Teck Puat-National University Children’s Medical Institute (KTP-NUCMI), National University Hospital (NUH). She obtained her MBBS degree from the National University of Singapore and her postgraduate degree in Paediatrics from the Royal College of Paediatrics and Child Health (UK).

She enjoys working with children and her practice involves all areas of general paediatrics, with special interests in managing children with food and drug allergies, allergic rhinitis, asthma and immune diseases.

Email: elizabeth_tham@nuhs.edu.sg

The prevalence of allergy has been increasing worldwide in the last decade.

It has been estimated that about 30-40% of the world’s population suffer from one or more allergic disorders1 which include asthma, allergic rhinitis, atopic dermatitis and food allergies.

Asthma is one of the most common chronic diseases among children and is one of the major causes of hospitalisation among children younger than 15 years of age. In Singapore, some 10-12% of school-aged children have recurrent wheeze. About 42% of 12-15 year-olds have symptoms of allergic rhinitis2 and 4-5% of them have food allergy3. The burden of chronic disease is especially great among children and significantly affects their quality of life, school attendance and performance.

Food allergy is also the most common cause of anaphylaxis in this age group.

The current management of these allergic disorders focuses mainly on symptom control – pharmacotherapy, patient education and secondary prevention via lifestyle modifications and allergen avoidance. However in recent years, immunotherapy has emerged as a possible means of “cure” for such 06 • ME D ICO

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Immunotherapy patients who suffer from chronic allergic diseases refractory to conventional treatment.

What is Immunotherapy?

Allergen immunotherapy is the gradual administration of incremental doses of allergen to an individual over time to induce immune tolerance to the inciting allergen. Two forms of allergen administration currently in practice include sublingual immunotherapy (SLIT) and subcutaneous immunotherapy (SCIT).

Numerous clinical trials have shown the efficacy of SLIT and SCIT in reducing symptom scores, medication use and improving quality of life4. The choice of route of administration is affected by drug availability, efficacy through established protocols, cost, physician practice and patient characteristics.

Sublingual immunotherapy (SLIT) involves the delivery of a small amount of commercially-prepared allergen extract under the tongue. In subcutaneous immunotherapy (SCIT), small amounts of the allergen extracts are injected into the subcutaneous layer of the skin. The allergen proteins are taken up by dendritic cells in the oral mucosa or skin and presented to T cells in the draining lymph nodes. The precise mechanisms through which immune tolerance is achieved have not been fully elucidated, but it has been proposed that likely mechanisms of action include activation of T regulatory cells and increased IL-10 production, shifting the cytokine milieu away from T-helper cellmediated IgE production (i.e. from Th2 to Th1 cytokine production)5. This results in down-regulation of mucosal mast cell activation and subsequent IgE mediated histamine release.

Therapy generally begins with a build-up phase which comprises administration

of increased doses for a few months, followed by a maintenance phase for up to 3-5 years. The ultimate aim is alteration of the natural history of the allergic disorder with long-term sustained effects which will persist even after discontinuation of therapy.

Indications for Immunotherapy Allergic Rhinitis Sublingual immunotherapy (SLIT) is indicated in the treatment of pollen and house dust mite proven allergic rhinitis, for patients who remain symptomatic and desire further improvement in their condition after being compliant with conventional therapy (intranasal steroids and antihistamines) for at least 3 months. Improvements in symptom and quality of life scores have been shown as early as 3 months into therapy.

Side effects are common but are usually mild and localised to the gastrointestinal tract, such as irritation and itching in the mouth, abdominal pain and diarrhoea.

SLIT has also been shown to decrease the risk of subsequent development of asthma6.

SCIT is also effective in rhinitis, but is now replaced by SLIT, the latter being a more child-friendly treatment.

Atopic Dermatitis Current evidence supports the use of SCIT and SLIT in patients with mild to moderate atopic dermatitis who are sensitised to house dust mites. The benefit is marginal in children with severe atopic dermatitis 7,8.

Asthma Subcutaneous immunotherapy (SCIT) shows convincing results in the treatment of asthma with improved symptom scores and medication usage9.

Severe asthma should still first be optimally managed with conventional medical therapy. The efficacy of SLIT in

References 1. World Allergy Organization White Book 2011 – 2012. http://www.worldallergy.org/ publications/wao_white_book.pdf

asthma is less established with variable, conflicting results and most studies have only been carried out in small numbers of patients, hence precluding its widespread usage currently. More studies on SLIT, especially in young asthmatic children, are needed.

Stinging insect venom allergy Subcutaneous immunotherapy (SCIT) is indicated in patients with systemic reactions to stinging insects and who have positive skin tests or specific IgE. Patients with a suggestive clinical history of insect venom allergy should first receive venom skin prick tests specific to the insect species. Serum IgE should be tested if initial skin prick tests are negative. If both are negative, they should be repeated in 3-6 months.

Baseline tryptase levels should also be obtained in patients with moderate or severe anaphylaxis following a sting.

Higher levels correlate to an increased risk of systemic reactions during therapy, a greater failure rate, and a greater relapse rate following discontinuation of treatment.

Bee venom immunotherapy is protective within a week of reaching the maintenance dose10 and complete protection is achieved in 75-100% of patients and improves quality of life.

Food allergy Intense research is ongoing on the effect of SLIT and oral immunotherapy in food allergy, especially in peanut allergy. The first results are encouraging. Therefore, in the future, this might become a standard treatment for food allergy.

Safety and compliance considerations SLIT is generally well-tolerated and more readily acceptable to patients, especially children, as compared to SCIT. Side effects are minimal, mainly confined to the gastrointestinal tract such as itching or irritation of the oral mucosa, abdominal pain or diarrhoea. It can also be easily administered at home, whereas

SCIT injections are usually supervised by trained medical personnel in the healthcare facility as there is a risk of systemic adverse effects11.

Compliance is a common problem in immunotherapy as duration of therapy is prolonged - over a few years, and missing doses results in inability to achieve the desired outcome. This is especially so in SCIT due to the discomfort associated with multiple injections and the added inconvenience of travelling to the clinic or hospital.

The future of immunotherapy Given the greater acceptability of SLIT over SCIT, research is still ongoing for its use in asthma and atopic dermatitis.

Studies in younger children are also needed, as immunotherapy has been shown to be the only treatment able to modulate the natural history of allergic diseases, including halting the progression of the Allergic March and improving the long-term prognosis of these allergic disorders.

Oral immunotherapy (OIT) for food allergies are currently mainly in the domain of research only. Studies in the use of OIT in selected peanut, cow’s milk and egg allergic children under controlled settings have been promising, but translation to standard of care has been tempered by the significant risk of severe systemic reactions and the need for better definition of dosing regimens and patient selection.

New ground-breaking research into the expansion of Immunotherapy in Singapore is ongoing in KTP-NUCMI. A new Immunotherapy Centre, which will be set up within the NUH campus in the next few years, will offer immunotherapy services for adults and children who suffer from chronic allergic disorders.

We hope to provide a one-stop centre for immunotherapy in the region and beyond, offering specialised expertise in allergy diagnosis and treatment to improve our patients’ disease control and quality of life.

2.

Wang XS, Tan TN, Shek LP, Chng SY, Hia CP, Ong NB, Ma S, Lee BW, Goh DY. The prevalence of asthma and allergies in Singapore; data from two ISAAC surveys seven years apart. Arch Dis Child.

2004 May;89(5):423-6.

3.

Kemp A, Chiang WC, Gerez I, Goh A, Liew WK, Shek L, Van Bever HP, Lee BW. Childhood Food Allergy: a Singaporean perspective. Ann Acad Med Singapore. 2010 May;39(5):404-11

4.

Calderon MA, Casale TB, Togias A, Bousquet J, Durham SR, Demoly P. Allergen specific immunotherapy for respiratory allergies: from meta-analysis to registration and beyond.

J Allergy Clin Immunol 2011;127:30-8

5.

Frati F, Moingeon P, Marcucci F, Puccinelli P, Sensi L, Di Cara G, Incorvaia C. Mucosal immunization application to allergic disease: sublingual immunotherapy.. Allergy Asthma Proc.

2007;28(1):35.

6.

Jacobsen L, Niggemann B, Dreborg S, Ferdousi HA, Halken S, Høst A, Koivikko A, Norberg LA, Valovirta E, Wahn U, Möller C, (The PAT investigator group). Specific immunotherapy has long-term preventive effect of seasonal and perennial asthma: 10-year follow-up on the PAT study. Allergy. 2007;62(8):943

7.

Pajno GB, Caminiti L, Vita D, et al. Sublingual immunotherapy in mite-sensitized children with atopic dermatitis: a randomized, double-blind, placebo-controlled study. J Allergy Clin Immunol 2007;120:164-70, Ib.

8.

Milani M. Approaching atopic dermatitis treatment differently: from skin barrier preservation to allergen-specific immunotherapy.

Immunotherapy. 2012 Jun;4(6):561-4.

9. Erekosima N, Suarez-Cuervo C, Ramanathan M, Kim JM, Chelladurai Y, Segal JB, Lin SY. Laryngoscope. 2013 Jul 6. doi: 10.1002/ lary.24295. [Epub ahead of print] Effectiveness of subcutaneous immunotherapy for allergic rhinoconjunctivitis and asthma: A systematic review.

10. Goldberg A, Confino-Cohen R. Bee venom immunotherapy – how early is it effective?

Allergy 2010; 65: 391–395 11. Boyle RJ, Elremeli M, Hockenhull J, Cherry MG, Bulsara MK, Daniels M, Oude Elberink JN. Venom immunotherapy for preventing allergic reactions to insect stings. Cochrane Database Syst Rev. 2012 Oct 17;10:CD008838. doi: 10.1002/14651858.CD008838.pub2.

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T REAMENT R OOM Dr Soh Jian Yi

Atopic Dermatitis

Associate Consultant, Division of Paediatric Allergy, Immunology and Rheumatology Dr Soh Jian Yi is an Associate Consultant at the Division of Rheumatology, Allergy and Immunology, Khoo Teck Puat-National University Children’s Medical Institute (KTP-NUCMI), National University Hospital (NUH).

His special interests are in food allergy and immunotherapy. He also enjoys undergraduate and postgraduate teaching. In his spare time, he volunteers at TOUCH Community Services to help the needy families.

Atopic dermatitis (AD) is a chronic inflammatory skin disorder that affects 10-15% of school-age children in Singapore. Most people with AD manifest symptoms/signs by the age of 5 years, though a minority do so only in adulthood. It is one component of the “atopic march”, often appearing in children who subsequently develop allergic rhinitis and asthma.

Email: jian_yi_soh@nuhs.edu.sg

Dry skin, itching and scratching are the main problems, resulting in the characteristic eczematous lesions. Where the lesions are often in the flexures of the extremities in older children, in contrast, infants and toddlers have involvement of the face, neck, and extensor aspects of the extremities.

AD is a clinical diagnosis. Investigations are usually not warranted.

Is there a related Food Allergy/ Trigger?

In certain cases, referral to a paediatrician specialising in allergy, for evaluation for an associated food allergy/ trigger, is necessary. These are: 1. Severe AD 2. History of AD exacerbated by particular foods 3. Moderate/Severe AD with onset in infancy

Table 1

A non-specialist in allergy should not:

Rationale

Order or perform unproven tests for food allergy

The results of unproven tests cannot be reliably used to diagnose allergy,

“Confirm” a diagnosis of food allergy based on results of tests (including proven tests).

Tests show sensitisation, not true allergy.

• For instance, some atopic patients have very high food-specific serum IgEs’ to multiple foods, but do not have a true allergy.

All tests can have false positive and false negative results. Therefore they should only be interpreted by specialists familiar with their characteristics.

Recommend elimination diets based on results of previous tests

Elimination diets should only be recommended where the diagnosis of food allergy is likely, and this is often misdiagnosed by non-specialists in allergy: •Some foods are nutritionally important.

•Food avoidance is difficult, and attempting to do so impairs the quality of life of the child and caregivers.

The physician should refer such patients to a specialist in allergy for review and management.

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A physician should not skip this referral to a specialist in allergy, nor attempt to order unproven tests (as per the MOH Clinical Practice Guidelines for Management of Food Allergy) for food allergy, nor make recommendations on an elimination diet based on results of any tests previously done. This is discussed in Table 1.

Patients are often inappropriately told to avoid certain foods; this can deprive the child of nutritionally important foods, in addition to creating tremendous anxiety in the family, impairing the quality of life of the child and the caregivers.

In the setting of a history of a classic IgE-mediated reaction to a specific food, the physician can make a preliminary diagnosis of food allergy. However, the physician must then consider potentially cross-reactive foods and an elimination diet. These considerations still warrant an early referral to a specialist in allergy.

Treatment of AD In treatment of AD, a systematic, multipronged approach is required: 1. Pharmacotherapy 2. Avoidance of triggers

Pharmacotherapy These comprise skin hydration, skin cleansers, topical anti-inflammatory drugs, anti-pruritic therapy, and antibacterial measures. The medications below are commonly used for mild and moderate AD. First-line therapy should be moisturisers over everything else.

Skin hydration The pathophysiological mechanism in AD is reduced skin barrier function, which in turn leads to increased water loss and dry skin, which drives the vicious cycle of scratching and further skin barrier damage. Thus the first choice of therapy is skin hydration.

Warm soaking baths for at least 10 minutes should be recommended, followed by application of moisturisers.

Moisturisers can be applied as many times in a day as are needed to maintain skin hydration. Furthermore, some patients respond better to one moisturiser over another, so a “trial of different moisturisers” may be of help where results are unsatisfactory.

Skin cleansers/antiseptic washes Multiple skin cleansers and antiseptic washes exist on the market. These are safe and may be effective in some patients. As with moisturisers, response can be variable and some patients may find these irritating to the skin.

Topical corticosteroids Topical steroids fall into 7 potency classes, with Class 7 with the least potent, and Class 1 as the highestpotency steroids.

The primary concern with these drugs is thinning of the skin. For this reason, steroids are not recommended as maintenance therapy in mild AD. In addition, high-potency steroids should not be prescribed for use over the face, eyelids, genitals, intertriginous areas, or in young infants. They should be used only for a maximum period of 1-2 weeks at a time.

I generally recommend a maximum period of use of 2 weeks within any 1-month period, and only where the underlying severity of AD warrants it.

In addition, I strive to optimize the maintenance regime for the patient, as the goal of management in any chronic disease is always sustained control, rather than “firefighting”.

Topical calcineurin inhibitors Topical tacrolimus (Protopic ointment) has been shown to be effective and safe in both adults and children older than

2 years for the treatment of AD, with most patients experiencing a reduction of pruritus within 3 days of initiating therapy. It comes in 2 strengths: 0.03%, for aged 2-15 years, and 0.1% for those 16 years and older.

These drugs can be used on the face, eyelids and skinfolds, and therefore should be considered in these areas if low-potency steroids are ineffective.

They are considered second-line therapy, and should not be used in mild AD. Patients should be counseled on the following: a transient localised burning and itching can occur, especially in the first week of use. Sun and ultraviolet light avoidance should be advised. For medico-legal purposes, they should also be made aware of the US FDA “Black Box” warning regarding use, just as it should also be pointed out that this is based on theory. There is minimal systemic absorption, and current evidence does not show systemic immunosuppression or an increased rate of malignancies in humans prescribed topical calcineurin inhibitors, over those without.

A comprehensive factsheet for patients is available at: www.eczema.org/ documents/152y Anti-pruritic medications Patients may benefit from oral antihistamines for relief of pruritus, especially if this occurs at night and disturbs sleep. Use of sedating antihistamines is not recommended in the daytime.

Dilute bleach baths may be considered for patients with recurrent skin infections.

There have been no randomised controlled trials demonstrating efficacy of tar preparations in the treatment of AD.

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Anti-bacterial medications Topical and oral antibiotics are often overly and inappropriately prescribed.

These should only be used intermittently for acute flares, and then only after consultation with the physician.

Avoidance of triggers Common triggers of pruritus/flares in AD vary from patient to patient, and should be avoided. These can include excessive sweating from heat/exercise/humidity, dust, the “Haze”, animal dander, and chemicals.

Patient Communication As with any chronic illness, adequate education of the patient and caregivers is an important cornerstone of care.

They should be educated on the chronic nature of the disease, avoidance of triggers, use and possible side effects of the medications.

The sheer number of drug types and different brands can be bewildering to the patient, especially if prescribed any other medication on top of moisturisers.

Therefore, a physician must ensure patient understanding before the patient walks out of the door of the clinic. The physician must cover the Why, and the When, to use each medication.

Otherwise, non-compliance, treatment failure and doctor-hopping follows.

Many patients who seek me out, do so not because their doctor prescribed the wrong medication; they simply did

not understand why and when each medication had to be used.

To facilitate patient understanding on medication use, I explain it by using an analogy for preventing fires and firefighting. This analogy has been extremely effective in sorting out any confusion. It is applicable to the medications for most chronic illnesses, and it applies in AD. See Table 2.

In real life, we emphasize prevention of fires; when fires break out, we use water to put them out. If it happens too often, we need to improve our preventive measures to address the underlying risk of a fire, rather than keep firefighting.

Going by the above analogy, “preventive” medications are those used daily to maintain control. The first line is moisturisers. If more preventive measures are needed, washes and antipruritic medications are added.

When the “fire” breaks out, ie. an acute flare of AD, the “firefighting” may include sedating antihistamines for night use, topical steroids, and seeing the physician again for review. Just as there is no point pouring water if there is no fire, there is no point using topical steroids or other such medications if there is no flare.

Topical calcineurin inhibitors are typically used as “firefighters”, ie. only when needed, and then only after other

measures are unsuccessful.

If “fires” break out too often, just as we increase our preventive measures to prevent future fires in real life, we need to optimise the regime of preventive medications/care to minimise future flares.

Some patients’ parents feel guilty over their inability to completely prevent flares. I point out that they should not chastise themselves so; just as no preventive measure can prevent fires with 100% certainty, no parent can prevent AD flares with 100% certainty.

The cliché doctors favor, “Prevention is better than cure” is often difficult for some patients to understand, which is why I don’t use it when explaining medication use in any chronic illness: strictly speaking, medications can’t cure the chronic illness.

Referral to a Specialist in Allergy/ Dermatology AD can prove refractory to the above treatment. A physician should consider possible differential diagnoses that can mimic refractory AD, such as scabies.

Patients with refractory AD should be referred to a specialist in Allergy/ Dermatology.

Patients with AD where food allergy/ trigger should be evaluated for (see above criteria) or managed, should be referred to a specialist in Allergy.

Table 2: Categorising and explaining uses of common medication, to patients

Preventers: Safe to Use. Use Every Day. Use as often as needed.

Firefighters/Flare relief: Use only when needed.

Moisturisers (1st-line) Cleansers/Antiseptic wash

Topical Steroids Sedating Antihistamines (Antibiotics: should not be prescribed without a consult)

Topical Calcineurin Inhibitors: Use only in moderate AD or worse. Mainly for Firefighting purposes.

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ITNSIGHT Dr Diana Lin

Associate Consultant, Children’s Emergency Dr Diana Lin is currently an Associate Consultant with the Children’s Emergency in the Department of Paediatrics, Khoo Teck Puat-National University Children’s Medical Institute (KTP-NUCMI), National University Hospital (NUH). She is also a member of the National University Health System (NUHS) Residency Core Faculty in Paediatrics.

Her academic accreditations include Bachelor of Medicine and Bachelor of Surgery from the National University of Singapore (NUS) in 2005, as well as Master of Medicine in Paediatrics from NUS and Member of the Royal College of Paediatrics and Child Health in 2009. She also attained the accolade of Nestle Silver Medal and Book Prize for the 2009 Master of Medicine. She is a fully-registered Paediatric Specialist with Singapore Medical Council since November 2012.

Dr Lin was a member of the Singapore National Resuscitation Council, Neonatal & Paediatric Resuscitation Workgroup in 2010-2011, where she contributed towards the Paediatric & Neonatal Resuscitation Guidelines 2011, Singapore. In addition to resuscitation, she also has special interests in simulation teaching and transport medicine.

Email: diana_lin@nuhs.edu.sg

One may learn over time that certain medical practices are ineffective, obsolete or even harmful. With the current advances in medical technology, it is essential to keep up-to-date with the management of medical conditions.

In this article, we will be covering a myriad of illnesses in children – including the common, not so common and the rare but important conditions. Relevant aspects of current and new concepts of management in the primary care setting will also be discussed.

Gastroenteritis (GE) A 20-month-old child presents with a one day history of persistent non-bilious vomiting and non-bloody diarrhoea associated with low grade fever. She is mildly dehydrated. You diagnose her

Common Conditions Seen at the Children’s Emergency with GE and wonder whether there are any suitable anti-emetics. You refer her to the Children’s Emergency as she is unable to retain any fluids. She is subsequently discharged after sublingual ondansetron and a successful trial of fluids.

Traditional medications such as promethazine, dimenhydrinate and metoclopramide have not demonstrated a beneficial effect in the management of vomiting in GE. In fact, their use may be associated with adverse effects.

Ondansetron is a 5-hydroxytryptamine-3 antagonist that blocks receptors in the gastrointestinal tract and the central nervous system. It is administered sublingually and has been shown to be effective in several large-scale studies.

However, it has no proven role in subsequent or multiple doses in reducing vomiting. Uncommon side effects include accentuation of diarrhoea. This drug should not be administered if the cause of vomiting is not confidently attributed to GE, or, if the patient is not a suitable candidate for oral rehydration.

Contraindications include age less than 12 months, drug allergy, as well as cautioned use in patients with hepatic impairment.

Other pharmacological aspects of managing GE include anti-diarrhoeal drugs such as Smecta, which is an adsorbent and probiotics such as lacteol forte, which may shorten the duration of illness and stool frequency. Antimotility agents such as Loperamide are not recommended, as there are potential adverse effects of abdominal ileus and distension.

The mainstay of GE management remains administering adequate fluids and electrolytes. Caregivers should be advised to feed small, frequent amounts of suitable fluids (oral rehydration fluids, breast-milk, diluted fruit juice, rice water or non fizzy energy drinks).

Resume solids or the usual diet when the child is ready. There is no evidence in diluting formula milk. For children with suspected secondary lactose intolerance (diarrhoea more than 7 days, severe buttock excoriation), consider a trial of lactose free milk for 2 weeks.

Development of red flag symptoms should prompt caregivers to re-seek medical attention or referral for further evaluation in tertiary institutions. These include: • Bilious/bloody/faeculent vomiting • Bloody stools • Prolonged duration of illness/symptoms • Painless/isolated vomiting • Associated CNS symptoms • Early morning vomiting • Severe abdominal pain • Recent head injury • Reduced urine output • Lethargy or drowsiness

Urinary tract infection (UTI) A previously well 6-month-old baby presents with 5 days of persistent fever and no localising symptoms. Physical examination does not reveal a focus. You refer him to the Children’s Emergency for further workup and management.

Subsequent investigations are suggestive of a UTI. The child is discharged with a course of antibiotics and an early outpatient follow-up.

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I NSIGHT Dr Lim Yang Chern Registrar, Children’s Emergency

Dr Lim Yang Chern is currently a Registrar in the Department of Paediatrics, Khoo Teck PuatNational University Children’s Medical Institute (KTP-NUCMI), National University Hospital (NUH), and a Clinical Lecturer at the Yong Loo Lin School of Medicine, National University of Singapore (NUS).

He graduated from NUS in 2004 and received his post-graduate Paediatric training in NUH. In 2012, he attained his higher academic qualifications both in the Master of Medicine in Paediatrics (NUS) and Membership of the Royal College of Paediatrics and Child Health (UK).

Dr Lim’s interest is in Paediatric Emergency Medicine and he has working experience in both of the Children’s Emergency Departments in Singapore.

Email: yang_chern_lim@nuhs.edu.sg

It is important to remember that signs and symptoms of a UTI differ according to age. Infants can present with nonspecific signs and symptoms, therefore diagnosis of a UTI requires a high index of suspicion. Do not forget that a viral fever is a diagnosis of exclusion!

We suggest testing a child’s urine in the following circumstances: i. All infants and children with unexplained fever of T > 38.5oC ii. Infants and children with alternative site of infection who remain unwell iii. Infants and children with signs and symptoms suggestive of UTI Investigating for a UTI would include a screening urine dipstick, urine microscopy and the gold standard of diagnosis with a urine culture. The method of collection will influence the interpretation of a positive culture. A bagged sample of urine has a high rate of contamination and hence, should not be tested for culture. In addition, this method has been associated with increased risk of unnecessary treatment, radiological investigation, 12 • ME D ICO

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hospitalisation, delayed diagnosis and treatment.

A change in international guidelines now recommends that even upper tract UTI in infants (older than 3 months) can be managed with oral antibiotics. There are no new recommendations for treatment regimes. However, the patient should be given an early review in 48 hours to assess clinical response and for the doctor to follow-up on the microbial investigations.

Intravenous antibodies are still indicated in the following patients: • Infants less than 3 months old • Poor oral intake • Organism resistant to effective oral antibiotics • Dilating vesicoureteric reflux grades III to IV • Atypical or complicated UTI Other than the first episode of lower tract UTI, all patients with UTI will need follow-up radiological investigations and should be referred for further management in a tertiary institution.

Prolonged Fever – a focus on Kawasaki Disease (KD) A 6-year-old Chinese boy initially presented on day three of his illness. Physical examination then revealed bilateral conjunctivitis and an injected pharynx. He was treated with oral Augmentin. He now presents for the second time with persistent fever of 5 days’ duration. The parents report no particular irritability except he is febrile. His fever occurs daily with a maximum temperature of 40 degrees Celsius. The conjunctivitis has since resolved. He does not have significant lymphadenopathy or any rash. You refer him to the Children’s Emergency for further workup and management.

The child was admitted and the clinical diagnosis of incomplete Kawasaki’s Disease was made. He responded well to intravenous immunoglobulin and was discharged with a Cardiology follow-up.

Kawasaki Disease, also known as acute mucocutaneous lymph node syndrome, is an acute self-limiting vasculitis of unknown cause. It is important to consider this diagnosis in children with prolonged fever as the vasculitis has a marked tendency to affect coronary vessels, and potentially confer life-long cardiovascular mortality and morbidity risk to the patient. About three-quarters of children with KD are younger than five years of age.

Clinical criteria are well-established for the diagnosis of KD. There are no definitive diagnostic tests for KD. Classical diagnostic criteria are based on presence of five or more days of fever and four or more of five main clinical features, namely: 1. Bilateral dry conjunctivitis 2. Mucous membrane changes – injected pharynx, fissured lips, strawberry tongue 3. Polymorphous rash 4. Extremity changes – peripheral edema, erythema, periungal desquamation 5. Cervical adenopathy Fever is typically high-spiking and unremitting. Desquamation is usually a late sign and does not aid in early diagnosis. Earlier signs within the first few days of fever typically are that of bilateral dry conjunctivitis, a polymorphous rash and the typical mucosal changes.

The rash is usually non-specific, and usually comprises scattered macules and erythematous papules. Bullae or vesicles are not typical and their presence would warrant considering other differentials first. Infrequently one may see a scarlatiniform rash, erythroderma and even erythema multiforme. Very rarely it can even be a micropustular eruption.

The presence of bilateral, painless and dry conjunctivitis may be a useful clue to the diagnosis. The conjunctivitis of KD is typically non-exudative and conjunctival edema is usually absent. It has been in the authors’ experience that the presence of this sign often helps clinch

References GE Rimon and Freeman. Recent advances in the treatment of acute gastroenteritis. Clin Peds Emer Med 2010 Vol 11 No 3 Pg 163 - 170 Ramsook C, Sahagun-Carreon I, Kozinetz CA, Moro-Sutherland D. A randomized clinical trial comparing oral ondansetron with placebo in children with vomiting from acute gastroenteritis. Ann Emerg Med 2002;39:397-403.

DeCamp LR, Byerley JS, Doshi N, Steiner MJ. Use of antiemetic

the diagnosis especially when the clinical scenario is that of possible incomplete KD. Another feature that the authors have found useful is the presence of digital swelling (dactylitis).

Mucosal changes typically include erythema, dryness, fissuring, peeling, cracking and/or bleeding from the lips.

The classical strawberry tongue is helpful when present, but does not exclude KD when absent. Presence of oral ulcers and/or pharyngeal exudates should prompt the consideration of other diagnoses.

Cervical adenopathy occurs least commonly. It is usually unilateral and in the anterior cervical triangle and usually defined as more than 1.5cm in the largest diameter. They are typical firm, non-tender and have no overlying erythema.

It is important to remember that children may have gastrointestinal and joint complaints in KD. Abdominal pain, vomiting, and/or diarrhea are common in a third of KD patients. Arthralgia and even arthritis may also occur during the first week of fever. Hence, the presence of rash or conjunctivitis in a patient with gastroenteritis should prompt the physician to consider KD. KD can also occur in infants and older children. In those cases, incomplete KD is often found, whereby patients have fever for five days or more and only fulfil two or three of the five criteria. In these cases, laboratory tests are performed to aid in making the diagnosis. Hence, when seeing a patient who is out of the typical preschool age group for prolonged fever, consider looking for signs of incomplete KD and referring for laboratory tests.

It is important to make the diagnosis of KD early as there are good treatment options to prevent cardiac complications. Intravenous immunoglobulin given within the first ten days of illness (counting from day one of fever), has been shown

agents in acute gastroenteritis: A systematic review and metaanalysis. Arch Pediatr Adolesc Med 2008;162:858-65.

UTI KTPH-UCMI Nephrology guidelines on UTI updated 2011 NICE guidelines on UTI 2007 KD Paediatrics in Review Sept 2008 Uptodate

to decrease the risk of coronary abnormalities.

In the patient above, the eventual diagnosis was incomplete KD as he only fulfilled two of the five clinical criteria. Subsequent laboratory tests and inpatient evaluation further helped clinch the diagnosis.

Myocarditis A 10-year-old girl presents with 3 days of fever and vomiting, associated with an episode of syncope. You are concerned as she is pale, diaphoretic, poorly perfused and tachycardic. You quickly arrange an ambulance to the nearest hospital where you learnt subsequently that she was diagnosed with myocarditis complicated by unstable ventricular tachycardia requiring cardiopulmonary resuscitation, defibrillation and initiation of extra-corporeal membrane oxygenation. After a protracted and eventful hospitalisation, she is discharged well.

Infectious causes of myocarditis, particularly viral aetiology remain the most common amongst children. The initial prodrome may be misleading due to the non-specificity of symptoms.

The complications resulting from inflammation of the heart can also run the gamut from arrhythmias, cardiac failure and the catastrophic presentation of cardiopulmonary collapse. Studies have quoted mortality rates for infants and children with myocarditis to be as high as 75% and 25% respectively.

Evaluation of a child with suspected myocarditis includes looking for important signs and symptoms of dyspnoea at rest, decreased effort tolerance, syncope, tachycardia, tachypnoea and hepatomegaly. Fulminant myocarditis can present as low cardiac output syndrome with hypotension, poor perfusion, weak pulses, malignant arrhythmias and resultant cardiovascular collapse. Sudden death can be a manifestation of myocarditis.

Myocarditis Freedman SB, Haladyn JK, Floh A, et al. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation.

Pediatrics 2007; 120:1278.

Durani Y, Egan M, Baffa J, et al. Pediatric myocarditis: presenting clinical characteristics. Am J Emerg Med 2009; 27:942.

Levine MC, Klugman D, Teach SJ. Update on myocarditis in children. Curr Opin Pediatr 2010; 22:278.

However, some children may present with respiratory or gastrointestinal complaints, and this may lead to the misdiagnosis of other illnesses such as sepsis, pneumonia, asthma or gastroenteritis. Only a minority actually reports chest pain. For such children, excessive administration of intravenous fluids may exacerbate the heart failure. The actual frequency of such presentations is unknown.

Diagnostic tests for myocarditis include a chest radiograph, electrocardiogram (ECG), and cardiac enzymes. Currently, the gold standard of endomyocardial biopsy possesses a historical role in the diagnosis of myocarditis and is not performed routinely. Besides the invasive risks, patchy myocardial inflammation decreases the yield and sensitivity of this procedure. There is emerging interest in the use of ancillary non-invasive modalities such as cardiac magnetic resonance imaging.

Treatment of myocarditis remains supportive, just like our patient who received inotropes, afterload reduction, mechanical ventilation and ECMO. Newer therapies like intravenous immunoglobulin and immunosuppressants are being looked into as adjuncts at preventing long-term cardiac compromise.

Despite today’s advances in diagnosis and treatment, the initial management of a child with suspected myocarditis remains dependent on the physician’s high index of suspicion and recognising the need to refer the child urgently to a hospital.

Conclusion We hope that this article has been useful to you in your practice and beneficial to all your patients. Of note, we hope that the red flags mentioned in all sections will be valuable in helping you decide which patients to refer and how urgently. Do please write in to us if you have any further queries.

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I NSIGHT

Effective Pain Management in Children

Dr Tay Kwang Hui

Consultant, Department of Anaesthesia Dr Tay is a Consultant and the Director of Pain Management Unit at the Department of Anaesthesia, National University Hospital. Dr Tay completed his anaesthesia training in Singapore in 2006. He obtained the Fellowship of the Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists in 2008 after a year of training in Sydney, Australia.

He provides both pharmacotherapy and interventional pain therapy for acute, chronic and cancer pain management services to paediatric and adult inpatients as well as outpatients. The Pain Management Unit in National University Hospital provides outpatient multi-disciplinary pain management clinic sessions 3 days per week.

Email: kwang_hui_tay@nuhs.edu.sg

All of us have dealt with children in pain. Trying to comfort a child who is in pain and upset is challenging and at times even distressing to a healthcare worker. The parents’ or caregivers’ input and assistance is very useful in helping the child. A multi-modal approach combining both non-pharmacological and pharmacological therapies often work much better than using each therapy in isolation. The goal of treatment is to keep the child within “the analgesic corridor” in order to optimise efficacy whilst minimising adverse effects.

To guide appropriate pain treatment, a proper evaluation of the pain is essential.

Unfortunately, studies have shown that even in acute hospitals, pain is often assessed infrequently or inadequately.

Pain assessment in children, especially in infants and in the cognitively-impaired children, can be extremely challenging even for practitioners in experienced centres.

Telling Pain in Children Fortunately, self-reported pain assessment tools can be used in children as young as 4 years of age. However, choice of assessment tool is dependent on the cognitive and emotional maturity of the child. Important factors that need consideration, apart from age, include: ability to differentiate levels of intensity of pain as well as ability to differentiate emotional and physical aspects of pain. Staff familiarity and ease of use is also essential in determining success in implementing of the selected pain assessment tool.

From 4 to 5 years of age, most children can differentiate “more”, “less” or “the same as” and should be able to use pain scales with limited options such as the Faces Pain Scale. Proper explanation of the pain scales should be given preferably prior to a painful stimulus or procedure. However, inaccuracies in reporting may exist as they tend to choose extremes of scales. Tools anchored with smiling or crying faces such as the Wong-Baker Faces Rating Scale, may lead children to confuse pain with emotional states such as happiness, sadness, or distress, and as a result, under- or over-rate pain score. These

children often exhibit stranger anxiety which affects or even impede pain assessment.

Useful Tools to Report Pain From 7 to 10 years of age, children acquire skills of measurement and ability to arrange items in ascending or descending orders. There is better translation of pain experience to a grade on either Faces Pain Scale or even the Visual Analog Scale. After the age of 10 to 12 years old, the verbally competent adolescent should be able to understand pain intensity and affective emotional component of pain; and may even respond to comprehensive pain assessment tools such as McGill Pain Questionnaire.

Two systemic reviews have found six self-report tools; and and , to have well-established evidence of reliability and validity in acute pain assessment in children between the ages of 3-18 years.

A rough guide based on age will be to use Pieces of Hurt for ages 3-4, Faces Pain Scale-Revised for ages 4-12 and VAS

The Wong-Baker Faces Rating Scale. © Copyright, Wong-Baker FACES Foundation. www.WongBakerFACES.org. Used with permission

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score for 8 years and above. However, pain reporting as in adults will be affected by emotional or cognitive state of the child. Observational assessments as well as parental or care-giver’s input are usually very useful.

For children less than 4 years of age and cognitively-impaired patients, selfreport tools are generally inappropriate.

Composite behavioral or physiological scores either directly, or, based on observation by parents, are used instead. Examples of validated scores include

Pain Management Techniques Pain perception is affected by cognitive, emotional, social and behavioural factors. Although pharmacological agents offer the most immediate and effective method of pain relief, they often do not address the associated anxiety and emotional distress that contribute to the pain experience. Nonpharmacological approaches, when used appropriately, can have excellent results in infants, children or adolescents.

These approaches can be divided broadly into cognitive and behavioural methods, biophysical techniques and complementary medicine therapies.

and Cognitive and behavioural methods aim to reduce fear, anxiety and emotional distress. Cognitive strategies centre on

.

FLACC Scale (For 2 months to 7 years and whenever a behavioural assessment is indicated)

Category

Scoring 0

1

2

Face

No particular expression or smile

Occasional grimace or frown, withdrawn, disinterested

Frequent to constant quivering chin, clenched jaw

Legs

Normal position or relaxed

Uneasy, restless, tense

Kicking, or legs drawn up

Activity

Lying quietly, normal position, moves easily

Squirming, shifting back and forth, tense

Arched, rigid or jerking

Cry

No cry (awake or asleep)

Moans or whimpers; occasional complaint

Crying steadily, screams or sobs, frequent complaints

Content, relaxed

Reassured by occasional touching, hugging or being talked to, distractible

Consolability

Difficult to console or comfort

changing the way the patient perceive pain while behavioural interventions focus on changing the patient’s response to pain. Cognitive approaches are most effective above the age of 8; younger children will need a coach, usually a parent. For the technique to be effective, the child needs to be a willing participant and have the energy and concentration to learn the strategies.

Age-appropriate preparation is a commonly used intervention to reduce anxiety for children undergoing a painful or operative procedure. As the fear of the unknown is often greater than the known, providing the child with information should decrease the fear and anxiety leading to a change in perception of pain. Four types of information seem to be most helpful: 1) Reason to perform the procedure; 2) Description of the procedure; 3) Expected sensations or feelings; and 4) Suggestions for how the child may cope with the procedure.

Distraction is commonly used by parents instinctively to manage noxious or painful stimulus. By engaging the child in an activity that helps the child refocus attention on something other than the painful stimulus, it reduces pain perception and increases pain tolerance. Distracting activity needs to be appropriate to age, developmental level and interest. Possible options include viewing videos, reading to the child, color pictures, singing to the child, counting, telling stories or playing video games. Music therapy involving singing, playing, listening or moving to the music, provides distraction, relaxation and anxiolysis and pain reduction.

Relaxation and imagery reduces fear and anxiety, increasing pain tolerance.

Relaxation can be achieved by simply holding or rocking a young child. Older children may benefit from rhythmic deep breathing, progressive muscle

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contraction-relaxation exercise and imagery. Imagery dulls the awareness of reality by encouraging the child to use his or her imagination to focus on something familiar or pleasant and unrelated to the pain. It can be used in children as young as 3 years old.

Relaxation and guided imagery can induce a hypnotic state, during which the patient’s attention is intensity focused, and he or she becomes highly receptive to suggestions. Hypnosis has been used for managing procedural and cancer pain in children.

Biophysical techniques used in pain management range from simple techniques such as cutaneous stimulation, transcutaneous electrical nerve stimulation (TENS), cold and heat therapy, and massage, to comprehensive physical therapy regimes. The goal of physical therapy includes pain relief as well as restoration and maintenance of musculoskeletal function.

Complementary therapies such as acupuncture are commonly used locally.

It is relatively safe, acceptable to most patients and is effective in management of acute and chronic pain as well as nausea and vomiting.

Specific non-pharmacological techniques are also effective for infants. Nonnutritive sucking on pacifier or nipple, sucrose (12-24%) or breastfeeding effectively attenuates pain response.

Physical actions such as swaddling, holding, stroking or massaging head and back comforts and relaxes the infant.

Rocking settles the infant and promotes sleep after a painful stimulus.

Managing Pain the Pharmacological Way Implementation of non-pharmacological methods should not prevent the use of pharmacological agents when indicated.

Topical agents such as Eutectic Mixture of Local Anaesthetic (EMLA®) is effective

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in decreasing needle-related procedural pain such as heel stick and venipuncture, and should be used whenever available.

Regional anaesthesia and analgesia can be used, but rarely in children who are awake.

Systemic analgesic agents can be divided into conventional analgesics and adjuvants. Conventional analgesics include paracetamol, non-steroidal antiinflammatory agents (NSAIDs) or cyclooxygenase 2 (COX-2) selective agents and opioids. Adjuvants can be useful when the pain has neuropathic features.

Examples of adjuvants commonly used in outpatient settings include: anticonvulsants such as Gabapentin, local anaesthetics such as lidocaine, and antidepressants such as amitryptyline.

Paracetamol is very safe and can be administered in infants as young as 30 weeks post-conception age when the dose is adjusted appropriately. It can be given in oral, rectal or intravenous form for management of mild to moderate pain. Up to 90mg/kg/day given orally in divided doses is safe in infants more than 6 months of age for 2-3 days.

NSAIDs are generally more efficacious than paracetamol. Though safety for children less than 2 years old are not rigorously established in trials, clinical experience suggests that it is safe for infants as young as 6 months old.

Aspirin should be avoided to minimise risk of Reye’s Syndrome. The choice of ibuprofen, diclofenac and ketorolac depends on available formulation and route of administration. The use of COX-2 selective agents in children is off label. Though based on clinical experience, their efficacy is comparable to conventional NSAIDs. Complications of NSAIDs and COX-2s in children are similar to adults and a limit should be set for duration of therapy, to be extended only after further review.

Opioid usage is commonly limited to inpatient use following surgery or acute medical conditions such as muscositis or sickle cell crisis. Tramadol is recommended for use for adolescents at least 16 years old, although clinically, 1-2mg/kg 6hourly have been efficacious without major adverse effects. Other opioids such as morphine, pethidine, fentanyl and oxycodone have been used and found to be safe in appropriate doses, even in young infants. Opioid adverse effects such as nausea, vomiting, sedation and constipation are common and should be treated aggressively during opioid therapy.

Gabapentin, at starting doses of 10mg/ kg/day and titrated up to 35mg/kg/day in divided doses, is useful for the treatment of neuropathic pain for patients beyond age of 2 years old. Pregabalin has been shown to have possible benefit for neuropathic pain; however, clinical experience is still limited. Amitryptyline at 1-2mg/kg/day can also be use in addition or as an alternative for treatment for neuropathic pain.

Lidocaine appears in a few preparations which are useful. EMLA® applied on unbroken skin is a safe modality to decrease procedural pain. Lidocaine gargle and gel can be used to relieve pain from broken or inflamed mucosal membranes. Lidocaine 5% patch is effective against neuropathic pain although clinical experience with children is limited.

Conclusion In summary, managing pain starts with pain assessment using inputs from both child and caregivers. A combination of pharmacological and nonpharmacological methods, together with the collaboration of a multidisciplinary team, the caregivers and the child, will often bring the pain under control.

E VENT R OUND-UP Dr Mahesh babu Ramamurthy Senior Consultant, Division of Paediatric Pulmonary and Sleep

Dr Mahesh babu Ramamurthy is Head and Senior Consultant at the Division of Paediatric Pulmonology and Sleep Services, Khoo Teck PuatNational University Children’s Medical Institute (KTP-NUCMI), National University Hospital (NUH).

The Division is actively involved in helping children with acute and chronic lung disorders and sleep disordered breathing. Dr Mahesh’s special interests are in paediatric sleep disorders and flexible bronchoscopy in children.

Email: mahesh_babu_ramamurthy@nuhs.edu.sg

Dr Theodric Lee

Registrar, Division of Paediatric Pulmonary and Sleep Dr. Theodric Lee is a Registrar in the Division of Pulmonology and Sleep, Khoo Teck Puat-National University Children’s Medical Institute (KTPNUCMI), National University Hospital (NUH). He grew up as a patient being taken care of by the doctors in the Division many years ago, and he now finds his destiny in the same Division.

His research interests include home ventilation, role of vitamin D in asthma and pneumococcal disease. He was a finalist for the Young Investigator Award in the 12th International Congress on Paediatric Pulmonology (CIPP) 2013.

Email: jun_theodric_lee@nuhs.edu.sg

The Paediatric Bronchoscopy Course and Paediatric Respiratory Primer 2013 Flexible bronchoscopy is a timehonoured procedure which is gaining wider applicability in paediatric practice.

Its use in children dates back to over 30 years ago and the technique has been continually developed over time. With advances in technology and anaesthetic care, coupled with increasing experience with its use globally, flexible paediatric bronchoscopy is now an established skill with well-defined indications and methodology. The development of smaller scopes has also allowed flexible bronchoscopy to be carried out in smaller babies, including premature neonates. With proper training, the technique is relatively safe. Despite these advances, paediatric flexible bronchoscopy is still an under-used tool in many parts of the world, including the Southeast Asian region. One big reason for the under-utilisation in our region is the low number of paediatricians trained in flexible bronchoscopy, with limited access to formal training courses that are often expensive and conducted further abroad in Western countries.

The Pulmonology and Sleep Division of the Department of Paediatrics at the National University Hospital (NUH) recently organised the first intensive hands-on paediatric flexible bronchoscopy workshop in the Southeast Asian region incorporating live animal models. This was held here in Singapore, at the Advanced Surgical Training Centre (ASTC) of NUH, on the

18th and 19th of July 2013. Participation was open to doctors across Asia interested in learning the technique. To ensure sufficient hands-on experience for each participant, registration for the workshop was limited to first 36 registrants, and the response was positive, with the workshop places fully booked more than three months in advance. There were registrants from 10 different countries spanning Asia – including China, Hong Kong and India.

The core faculty was made up of the three Paediatric Pulmonology Consultants from the Department of Paediatrics at NUH (A/Prof Daniel Goh, Dr. Mahesh babu and Dr. Michael Lim), and two trainees from the same department (Dr. Theodric Lee and Dr. Bharath Kumar). They were joined by a guest faculty member, Dr. Gary Connett, a Consultant Paediatric Pulmonologist from Southampton, UK. The workshop was conducted over two days. The first day comprised the majority of the workshop lectures, and introduced participants to hands-on training on lung models. The second day comprised mainly hands-on training on live rabbits, with the remaining lectures delivered in small groups. For the live hands-on sessions, the rabbits were sedated to allow participants to performed flexible bronchoscopy on them. Each rabbit was assigned only a few doctors at a time, to allow each 2 013 O C T O B E R

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T

participant enough time to practice and refine their technique throughout the day.

doctors keen to learn more about airway physiology, airway clearance, aspiration syndromes and interstitial lung disease.

The whole workshop was enhanced by the advanced facilities available at the ASTC, as well as the very supportive staff based there. The bronchoscopes for the workshop were provided by Olympus, who was involved in some of the logistics of running the workshop. They were also instrumental in the success of this workshop.

The conference was well-attended by a multi-national audience from more than 10 different countries, with many of them also attendees of the bronchoscopy course. The core faculty featured prominent international doctors including Prof Anne Chang from Brisbane, Australia, a leading authority on paediatric cough; Dr Gary Connett from Southampton, UK, the regional director of cystic fibrosis; Prof YK Amdekar from Mumbai, India, a prominent medical educator and author of several books; Dr Daniel Ng from Hong Kong, the president of the Hong Kong Society of Paediatric Respirology.

The local faculty included staff from pulmonology, allergy, gastroenterology, radiology and ENT.

The feedback forms received from the participants showed a very positive response, and reflected a clear demand for such a workshop in our region. In view of this, the Division plans to make this workshop an annual event in our Department’s training calendar.

The Primer in Paediatric Pulmonology for Asia was an intensive CME course held over the weekend of 20-21 July 2013 closely following the bronchoscopy course. This was targeted towards an audience of general paediatricians, paediatric trainees and even general practitioners – it aimed to cover a wide range of topics to give the participants a “crash course”, yet at the same time cover common and relevant topics.

These included asthma, obstructive sleep apnoea, allergy, pneumococcal disease, chronic cough and radiology.

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The conference was designed to be interactive, even fun, and this was achieved by a variety of different presentation styles. This included hotlycontested debates on controversial topics with audience participation; clinical case presentations which incorporated multiple choice quizzes to be answered in real time; “meet the experts” sessions which allowed participants to discuss updates on current issues with the international faculty; a challenging chest x-ray quiz

featuring 10 challenging x-rays; even a clinico-pathological conference which put one of the experts in the hot seat as he skillfully dissected the approaches and differential diagnoses of a difficult clinical case.

From the perspective of a junior faculty member, there were several gains from the conference. One of the most invaluable was learning from the wisdom of the international faculty. My personal highlights included: clinical pearls from Prof Amdekar as he teased out details in clinical history and examination which pointed to the diagnosis without requiring sophisticated investigation; learning about Prof Chang’s research on cough over the past decade – how she elegantly unravelled a common presenting complaint into an evidencebased practice; Dr Gary Connett’s historical perspective on asthma and how asthma control is linked with the psychological well-being of the patient.

Through its relaxed and interactive style, we had also made new friends and rekindled old ties with the foreign delegates. We received plenty of good feedback from the delegates, with many of them expressing an interest in training further in paediatric pulmonology.

Truly this conference was a primer in promoting the advancement of paediatric pulmonology in the region, as well as fostering greater collaboration!

E VENT R OUND-UP Dr Jacqueline Ong Consultant, Division of Paediatric Critical Care

Dr. Jacqueline Ong is currently a Consultant in the Division of Paediatric Critical Care, Khoo Teck PuatNational University Children’s Medical Institute (KTP-NUCMI), National University Hospital (NUH).

She graduated from the University of Cambridge in 2003 and received her post-graduate paediatric training in NUH. She attained her Masters of Medicine (Paediatrics) and Membership in the Royal College of Paediatrics in 2007. She was awarded the Academic Medicine Development Award in 2011 and underwent further specialist training in the Division of Paediatric Critical Care, Hospital for Sick Children, Toronto, Canada from 2011-2012. Dr. Ong was also the Chief Fellow of the Critical Care Fellowship Programme during the latter half of her time in Toronto.

Dr. Ong’s clinical interests include the postoperative care of children with congenital cardiac disease and the use of extra-corporeal life support techniques. She has a myriad of teaching responsibilities to medical students, residents and nurses and is a Paediatric Advanced Life Support (PALS) Instructor. Outside of work, she relaxes by baking and cooking for friends and family.

Email: jacqueline_ong@nuhs.edu.sg

The University Department of Paediatrics was founded in 1962 on the Singapore General Hospital campus and led by the Founding Professor of Paediatrics, Professor Wong Hock Boon. In 2012, our Department, now renamed the Khoo Teck Puat – National University Children’s Medical Institute (KTP-NUCMI), celebrated our 50th anniversary of the University Department of Paediatrics. The Inaugural Wong Hock Boon Paediatric Masterclass was a key highlight of our celebrations, marking the start of an annual series of educational symposia with international experts as keynote speakers. The Masterclass will showcase selected major cutting-edge topics in Paediatrics every year.

Professor Wong Hock Boon headed the Department of Paediatrics from 19621988 and is known by many as the

Highlights from the 2nd Wong Hock Boon Paediatric Masterclass

“Father of Paediatrics” in Singapore.

His dedication to education, research and above all, clinical care, shaped a generation of paediatricians, many of whom have gone on to be paediatric leaders in their own right. Though Professor Wong passed away in 2008, his memory and multiple contributions to paediatric education are being sustained through the creation of an eponymous endowment fund for a Professorship of Paediatrics at the National University of Singapore (NUS). The visiting Wong Hock Boon Professors not only contribute to the Masterclass but are also deeply involved in the teaching and clinical work of the Department, participating in ward rounds, clinics and contributing to patient care.

This year, our focus for the Masterclass was in the areas of Cardiology, Pulmonology and General Paediatrics.

We had the privilege of having 3 Wong Hock Boon visiting professors in each of these areas spend time teaching and lecturing in our Department. For Paediatric Cardiology, we had Professor Daphne Hsu from Children’s Hospital at Montefiore, New York. Apart from

general paediatric cardiology, Prof Hsu’s interests lie in the areas of paediatric heart failure, cardiomyopathies and paediatric heart transplantation. For Paediatric Pulmonology, we had the energetic and effervescent Prof Anne Chang from Royal Children’s Hospital in Brisbane. Previously a native of Johor, Malaysia, Prof Chang has spent most of her professional life in Australia. Her major interests include chronic cough and suppurative lung disease in children and she has published extensively in these areas.

Our third Wong Hock Boon visiting Professor was Prof YK Amdekar, from BJ Wadia Children’s Hospital in Mumbai, India. Over a distinguished career spanning 50 years, Prof Amdekar has taught generations of paediatricians in India, focusing in particular, on the importance of clinical bedside assessment and critical thinking in diagnosis. Prof Amdekar also brought with him a wealth of experience in all aspects of general paediatrics with a focus on childhood chronic disease, nutrition and immunisation.

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Our 2nd Wong Hock Boon Paediatric Masterclass was held on the weekend of July 27-28th, 2013. Each morning commenced with a series of Masterclass lectures delivered by not only the Wong Hock Boon Professors but also by senior clinicians from KTP-NUCMI such as A/ Professor Daniel Goh (Head of KTPNUCMI) and A/Prof Loke Kah Yin, (Head, Division of Endocrinology, KTP-NUCMI).

The 1st set of Masterclass Lectures on the 27th of July focused on approaches to common problems in paediatric medicine. Prof Amdekar began the proceedings with his lecture on “Achieving Bedside Diagnosis”, highlighting how this basic clinical skill is often overlooked and poorly achieved. His vast store of clinical vignettes both intrigued and delighted the audience, enabling us to understand the principles he wanted to convey.

Prof Chang followed up with a lecture about the challenges of investigating a child with chronic cough, highlighting the importance of a careful definition of chronic cough, the necessary assessment of specific cough pointers and subsequent investigations.

A/Prof Daniel Goh continued the morning series with a comprehensive summary to the approach to assessing paediatric sleep disorders and their impact on child health. Finally, Prof Hsu spoke on the approach to assessing chest pain – again, a common complaint in paediatric medicine that gives rise to significant parental anxiety.

The 2nd set of Masterclass lectures, held on Sunday morning, focused on the different aspects of growth and development in children. A/Prof Loke spoke on physical growth - how early life influences may shape the trajectory from

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childhood obesity to adult metabolic disease. This was a fascinating, well researched lecture on the field of epigenetics and how the environment may influence gene expression, resulting in varying phenotypes. Prof Amdekar followed with a clinical discussion of how nutrition impacts cognitive and physical development. Along with physical and cognitive development, emotional development in families and children is also crucial. Dr. Jennifer Kiing, Consultant in our Child Development Unit, spoke on how resilience can be fostered in children and families of children with disability.

On Saturday afternoon on the 27th of July, the Masterclass lectures were followed by the KNOW (Kids’ Needs on Wellness) Medical Symposium. The KNOW Medical Symposia are held yearly as part of an educational outreach programme to general practitioners and paediatricians throughout Singapore and is currently in its 17th year. Through this programme, both general practitioners and paediatricians are kept up to date with new developments in paediatric medicine. Prof Chang started the ball rolling with a follow-up to her morning lecture and spoke about the treatment of chronic cough, suggesting the use of a standardised clinical algorithm as well as careful assessment of the “time to response” for any medications. Prof Amdekar carried on with an overview of how to assess a poorly feeding child, illustrated by multiple clinical scenarios.

The afternoon was rounded off with a focus on new developments in allergy and immunology by key leaders in the field here in Singapore. Adjunct

Professor Lee Bee Wah of the National University of Singapore gave an update on the challenges of new vaccines and changes in the Singapore vaccine schedule. Professor Hugo van Bever (Senior Consultant, KTP-NUCMI), spoke about new developments in paediatric allergy – in particular, the role of epigenetics and the interplay of host and environmental factors in allergy as well as new treatments such as sublingual immunotherapy.

For the final afternoon of the Masterclass on the 28th of July, participants were split into 2 workshops. The first workshop had a cardiology/neurology focus, aptly named “Fits, Faints and Funny Turns” while the second workshop, termed “Growing Well”, focused on nutrition and growth. These workshops allowed greater audience interaction with our specialists and the Wong Hock Boon Professors and were lively affairs. Key topics such as recurrent syncope, migraine, palpitations as well children with recurrent abdominal pain and failure to thrive generated plenty of discussion and learning by all.

All in all, the 2nd Wong Hock Boon Masterclass was a weekend rich in learning and discussion. Participants deeply appreciated the wealth of knowledge and experience brought by not only Wong Hock Boon Professors but also from our local specialists. In keeping with Professor Wong’s legacy, we aim to continue to enrich and educate medical and allied health professionals here and in the region. The 3rd Wong Hock Boon Masterclass will be in August 2014 – we certainly hope to see you there!

D OCT OR’S H EAR TBEAT

Specialists in Focus Division of Developmental and Behaviourial Paediatrics

Dr Chong Shang Chee Dr Jennifer Kiing

1

You love children and are an extremely patient person. Were these the traits that led you to choose a specialisation in Paediatrics?

Dr Chong SC: I find babies and children to be such genuine, wonderful beings. Whenever I see kids, I feel overwhelmed with an instinct to want to help them and love them. And when I did Medicine, choosing Paediatrics was really a calling of the heart.

Dr Kiing: I chose to do paediatrics because when I was a medical student, I observed that acutely sick children often got better and did so quickly. I felt it was very rewarding to manage acutely unwell children and have them leave the hospital in a day or two with a smile on their face.

2

Who, or what, inspired you to train in behaviourial paediatrics?

just kept growing, as developmental, behavioural and learning issues became the “new morbidities” in children’s health, so to speak. In this field, there is a combination of medicine, education and policy work for children of special needs that make it interesting for me.

It is not just the science, but also the knowledge of families and communities that enhance development and learning outcomes of children.

Dr Kiing: I never did set out to be a behavioural paediatrician. I really enjoyed general paediatrics and paediatric neurology and endocrinology at NUH. In 2003 I was at crossroads and needed to decide between further training in either Developmental and Behavioural Paediatrics (DBP) or Endocrinology and I really couldn’t decide. I really enjoyed both. So I prayed about it and a very clear thought came to me one evening: “Why am I not in developmental paediatrics?’

Dr Chong SC: Behavioural Paediatrics is a relatively young specialty. I was, in fact, training in Paediatric Neurology and we co-existed as one specialty. But the demands of training and knowledge in this field

I therefore took this as a clear direction and trained further in this field. I have been blessed to have incredible mentors who agreed to provide supervision while I was accredited in

community paediatrics with the Royal Australasian college of Physicians.

Two individuals in particular, Dr Roby Marcou and Dr Maureen Neihart, have been instrumental in providing encouragement and mentorship for me along the way.

3

What kind of challenges and difficulties did you experience when you first started off working with children?

Dr Chong SC: Before I had my own children, and as a young intern, it was not the children themselves but rather, the parents’ anxieties and worries that I found difficult to understand and was quite ill-equipped to handle. No one can provide you with such training; but motherhood was the most special gift to me to become a good paediatrician. The insight was then personal, enlightening.

I no longer gave “book advice” but I gave advice like I would like to hear myself as a mother.

Dr Kiing: Coming from an acute care model, I thought I was very clever when I declared to parents that their child had a particular diagnosis because certain

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Dr Kiing’s daughters

diagnostic criteria were fulfilled. When I first started off, I didn’t have the tools to help parents and families cope with the grief of having children with disabilities, and often found myself at a loss as to how break bad news and give families hope.

4

What do you enjoy most about your work now?

Dr Chong SC: I am a people-centred person, so I love the way I work with my team — the doctors, therapists and psychologists.

At the same time, in Developmental and Behavioural Paediatrics, we push into the community too, into preschools and Early Intervention Services (EIPIC).

I also get to participate as a voice of the parents in meeting with the relevant ministries. So I do not just get to help the child per se, but also get to help and develop the whole system that helps him/ her — through supporting the parents, the families, the community and the policies. It is, therefore, so meaningful and I get to be a better doctor who understand the broader contexts of medicine and care systems.

Dr Kiing: It is very rewarding to have parents leave a consultation filled with hope about their child’s abilities and future, seeing their strengths and accepting

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their children for who they are. I find this most fulfilling about my work.

I enjoy working with my colleagues in the Child Development Unit and the Department of Paediatrics at NUH. We have a shared vision to be of service to children and their families and always strive to do better. I feel incredibly privileged to work in a department where doctors really care for their patients and pursue excellence in all that they do.

5

What excites you about the future or advancements in your field of treating these kids?

Dr Chong SC: Increasingly, our expertise is required in the fields of education, pre-school care, early intervention centres. In hospitals, our expertise is now tapped on not only for children with disabilities, but also children who have chronic diseases and complex diseases. Development, learning and behaviours are as important in each child as health is. I see that the specialty will continue to grow in depth in many areas.

misbehave, or when others think they are lazy, not trying, or have no strengths. No child will deliberately want to experience failure, so our adult misconceptions about what they cannot do must be lifted, and we must always be positive about their unique strengths.

Dr Kiing: I think the common misconception is that these children are a burden for families and the society. Families themselves may also wrongly label their child as ‘lazy’ or ‘stubborn’ when in fact, their child may have a developmental disorder.

7

Dealing with pain and sadness in children can be quite depressing, especially so when you face anxious and worried parents and relatives. How do you maintain a “brave face” for your young patients, yourself and the people close to you? What keeps your spirits up?

Dr Chong SC: Honestly, I cannot always maintain a brave face because it breaks my heart when mothers cry. If you are a mother, then you would understand the kind of challenges they face. As a Christian, I think God gives me the strength to be in this special place to help them in whichever way I can. This is enough for me to keep my spirits up and do my best.

Dr Kiing: I am excited by the commitment of our government to put resources into supporting children with special needs and look forward to the day when children with special needs are fully integrated into our society.

6

What are some common misconceptions about children with developmental, learning or behavioural issues?

Dr Chong SC: Children will do well if they can. So they are very misunderstood if they

Dr Kiing: When parents see that we care and we understand their worries and pain, we don’t need to maintain a brave face. I think believing that every parent will be the best parent and care-giver for their child helps me to keep optimistic and hopeful.

I try to start my day in prayer and I find that usually sets the tone for the day.

When I am at peace within myself I am more likely to be a calming instrument than when I start the day in agitation.

Dr Chong with her family

8

What’s the most important lesson you’ve learned from your patients and their families?

Dr Chong SC: I tell my close friends that I can’t imagine myself being in the shoes of my patients’ parents sometimes. They demonstrate such courage, resilience, patience — given a child with special needs, and faced with a mostly-unforgiving educational or social environment, but still, they navigate the system to the best of their ability.

The most important lesson they teach me is to deal with grace whatever life gives you. I see in my clinics that guilt can be overwhelming for parents when things go wrong with their children. I learn that as a physician, I will have to lift that for them so that they can smile again.

Dr Kiing: I’ve learnt that my role is not to fix the problem, but to help parents and their families ‘see differently’ by calling up the strengths in their child and in themselves. When parents leave the consultation with hope in their child and in their ability to be the best parents for their child, I am humbled.

9

What do you do in your free time when you’re not taking care of patients?

Dr Chong SC: I have a 2-month-old baby, so sleep is

considered a luxury and I have much less free time. After work, I am also busy with my 5-year-old. I spend as much as time I can with him doing fun stuff or bringing him out. And if I do have help with the kids and some time on my hands, I like to catch up with good friends over coffee or a meal. Swimming helps me relax or takes my mind off worries, as does music and a good book.

My husband and I like to go for concerts by the Singapore Symphony Orchestra and musicals too.

Dr Kiing: Really ‘exciting’ stuff like doing homework with my children or trying to prepare a meal my children refuse to eat. Haha… I play tennis once a week with my best friend who is also a paediatrician and I exercise regularly with my sister. And every night without fail, my husband and I take a walk in our neighbourhood as we catch up on each other’s day. This has been great for deepening our marriage and helping to relieve the stresses of the day.

10

If you weren’t a doctor, what would be your dream alternate career? / If you weren’t practicing medicine, what would you be?

Dr Chong SC: I was doing Science and Medicine my whole life. So may be if I’m not a doctor, I will just go the opposite way and try something a bit different with risks, like an entrepreneur.

An idea will be to merge work with some leisure – perhaps I will open a few resort hotels in the Maldives and other exotic islands.

Dr Kiing: I would love to be an inventor and make something with my hands! But I don’t think I will be giving up my day job anytime soon.

11

Any personal heroes or models?

Who are they?

Dr Chong SC:

Not really. Because I believe I can learn something from everyone.

Dr Kiing: My father is my personal hero. He was a small town doctor in Kuching, Malaysia, but really well loved by all his patients.

There would always be long queues in his waiting room. He is smarter than anyone I know. Did you know he got into medical school in Australia when he could barely speak English one year before and only started school when he was 9 years old?

He also sacrificed a lot for my siblings and I to give us the opportunities we have today. When we were growing up, he was always there for us and encouraged us in all our interests. He never had a harsh word for us and never used physical punishment. I try to model his parenting style with my own children.

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UPCOMING

EVENTS

NUH GP CME Programme 2013 Please refer to our GPLC website for online registration.

October SATURDAY

November 26

Orthopaedic Surgery New developments in the treatment of and approach to common sports injuries of the ankle and knee

SATURDAY

16

Psychological Medicine Neuropsychiatry & Psychocardiology - Practical Aspects

SATURDAY

30

Psychological Medicine Dementia Management and Community Care

Event information listed is correct at time of print.

While every attempt will be made to ensure that all events will take place as scheduled, the organisers reserve the rights to make appropriate changes should the need arises.

Please refer to our events calendar at www.nuh.com.sg/nuh_gplc for more updates and information.

A Publication of NUH GP Liaison Centre (GPLC) Advisors A/Prof Goh Lee Gan Editor Esther Lim Editorial Member Lisa Ang We will love to hear your feedback on MĂŠdico.

Please direct all feedback to: The Editor, MĂŠdico GP Liaison Centre, National University Hospital 1E Kent Ridge Road, NUHS Tower Block, Level 6, Singapore 119228 Tel: 6772 5079 Fax: 6777 8065 Email: gp@nuhs.edu.sg Website: www.nuh.com.sg/nuh_gplc Co. Reg. No. 198500843R The information in this publication is meant purely for educational purposes and may not be used as a substitute for medical diagnosis or treatment. You should seek the advice of your doctor or a qualified healthcare provider before starting any treatment, or, if you have any questions related to your health, physical fitness or medical condition(s).

Copyright (2013). National University Hospital All rights reserved. No part of this publication may be reproduced without permission in writing from National University Hospital.

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