Polycythaemia

Cite this article as:
Jilly Boden. Polycythaemia, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.30144

Its 3 am and you are called by a midwife on the postnatal ward to review a ‘jittery baby’ with a respiratory rate of 70. The midwife informs you that Alice is a term baby born via Cat 2 LSCS (failure to progress, Apgar 9,9) following an uncomplicated pregnancy (although she does note that mum has admitted to smoking cannabis occasionally during pregnancy). She is currently establishing breastfeeding.

On examination, Alice is settled but does have some mild tremors on handling. They settle on containment and don’t appear to be rhythmic or jerking in nature. She is centrally pink, with a red face and purple hands and feet. All observations, other than the respiratory rate are within normal limits.

You decide its likely Transient Tachypnoea of the Newborn but as part of your assessment, you obtain a capillary blood gas.

 The decision is made to give the baby a full top-up of formula feed (with mum’s consent) and to do formal, free-flowing venous bloods in an hour’s time to re-assess, but what is the next step?

Some definitions

The term polycythemia refers to a raised red cell concentration >2 standard deviations above the expected normal values. It can either be defined as a haematocrit from a peripheral venous sample being >65 percent or the haemoglobin is >22 g/dL however the former is more commonly used in clinical settings. 

Normal ranges: (neonatal capillary whole blood)

Haematocrit peaks maximally at the mean age of 2.8hrs. Although capillary blood gas samples are a helpful guide to the diagnosis, the sample on which treatment should be based must be from a peripheral venous sample. Studies have shown that the haematocrit from true venous samples (depending on capillary gas sample technique) can be up to 15% lower than the capillary sample.

Causes

Most cases of polycythaemia occur in normal healthy infants and may result from a variety of reasons, which can be broadly categorised into:

Increased red cell volume from increased transfusion, causes include:

  • Twin to twin transfusion
  • Delayed cord clamping*
  • Maternal hypertension

Placental insufficiency with increased foetal erythropoiesis secondary to intra-uterine hypoxia. This may occur in association with:

Other causes of polycythaemia include:

  • maternal substance use such as smoking
  • maternal diabetes
  • large for gestational age infant
  • chromosomal abnormality (such as Down syndrome).

* A note on delayed cord clamping:

Interestingly, although delayed cord clamping in IUGR babies has been shown to double the likelihood of polycythemia, a recent study found there was no increase in babies with symptomatic polycythemia and nor was there any increase in the need for partial exchange transfusion. Delayed cord clamping as also been found not to have an effect on hyperbilirubinemia.

Complications

An increased red cell mass results in an increased blood viscosity and reduced blood flow, impaired tissue oxygenation and a tendency to microthrombus formation. This is exacerbated by hypoxia, acidosis and/or poor perfusion.

Thrombosis may result in:

  • renal venous thrombosis
  • adrenal insufficiency
  • necrotising enterocolitis (NEC)
  • cerebral infarction that may affect long-term neurological outcome

Hyperviscosity of blood results in increased resistance to blood flow and decreased oxygen delivery. Viscosity exponentially increases when an infant has polycythemia. In the neonate, this can lead to abnormalities of central nervous system function, hypoglycemia, decreased renal function, cardiorespiratory distress, and coagulation disorders. Hyperviscosity has been reported to be associated with long-term motor and cognitive neurodevelopmental disorders.

Signs and symptoms 

The majority of newborns with polycythemia as asymptomatic (74-90%). In symptomatic infants, the hyperviscosity causes a decrease in tissue perfusion and metabolic complications such as hypoglycemia and hypocalcemia. They are responsible for clinical signs and symptoms including: 

  • apnoea
  • cyanosis
  • feeding problems
  • vomiting
  • irritability/lethargy
  • jitteriness/tremor
  • respiratory distress
  • seizures
  • hypoglycaemia 
  • jaundice 

The most commonly encountered problems in severely symptomatic newborns with polycythemia are central nervous system disorders.

Pathophysiology

In addition to cerebral blood flow, glucose carrying capacity also decreases in polycythemia. As a result, plasma glucose concentration, especially venous is lower than normal. Hypocalcemia and hyperbilirubinemia may also be seen in polycythemic newborns. The level of calcitonin gene-related peptide (CGRP) has been shown to be high in polycythemic newborns. This peptide regulates vascular tone, stimulates vasodilatation, and leads to hypocalcemia. High levels of CGRP suggest a role in response to polycythemia.

Management

A 2010 cochrane review found there to be: 

‘No proven clinically significant short or long‐term benefits of PET (Partial Exchange Transfusion) in polycythemic newborn infants who are clinically well or who have minor symptoms related to hyperviscosity. PET may lead to an increase in the risk of NEC. The data regarding developmental follow‐up are extremely imprecise due to the large number of surviving infants who were not assessed and, therefore, the true risks and benefits of PET are unclear.’

With this in mind, it is broadly accepted that PET should only be undertaken if it is thought to be the primary cause of the symptoms, rather than a byproduct of dehydration from other causes e.g. feeding difficulties or metabolic disorders.

 The formal bloods reported as Hb 215 g/L with a Hct of 69% and a repeat gas shows a glucose of 3.2 mmol/L. The midwifery staff report she seems less ‘jittery’ and a plan is made for full formula top-ups and daytime review to ensure resolution of symptoms. 

References

Garcia-Prats, J. A. (2019, September 1). Neonatal Polycythemia. Retrieved October 19, 2019, from https://www.uptodate.com/contents/neonatal-polycythemia.

Wu, A. H. B. (2006). Tietz clinical guide to laboratory tests (3rd ed.). St. Louis, MO: Saunders/Elsevier

Alsafadi, T. R., Hashmi, S., Youssef, H., Suliman, A., Abbas, H., & Albaloushi, M. (2014). Polycythemia in neonatal intensive care unit, risk factors, symptoms, pattern, and management controversy. Journal of Clinical Neonatology3(2), 93. doi: 10.4103/2249-4847.134683

Safer Care Victoria. (2018, October). Polycythaemia in neonates. Retrieved from https://www.bettersafercare.vic.gov.au/resources/clinical-guidance/maternity-and-newborn-clinical-network/polycythaemia-in-neonates.

Özek, E., Soll, R., & Schimmel, M. S. (2010). Partial exchange transfusion to prevent neurodevelopmental disability in infants with polycythemia. Cochrane Database of Systematic Reviews20(1). doi: 10.1002/14651858.cd005089.pub2

Sarici, S. U. (2016). Neonatal Polycythemia: A Review. Clinical Medical Reviews and Case Reports3(11). doi: 10.23937/2378-3656/1410142

Jeevasankar, M., Agarwal, R., Chawla, D., Paul, V. K., & Deorari, A. K. (2008). Polycythemia in the newborn. The Indian Journal of Pediatrics75(1), 68–72. doi: 10.1007/s12098-008-0010-0

A., D. A. P., Werner, E. J., & Christensen, R. D. (2013). Neonatal hematology pathogenesis, diagnosis, and management of hematologic problems. Cambridge: Cambridge Univ. Press. 171-186.

Saggese, G., Bertelloni, S., Baroncelli, G. I., & Cipolloni, C. (1992). Elevated calcitonin gene-related peptide in polycythemic newborn infants. Acta Paediatrica81(12), 966–968. doi: 10.1111/j.1651-2227.1992.tb12155.x

The 45th Bubble Wrap

Cite this article as:
DFTB, T. The 45th Bubble Wrap, Don't Forget the Bubbles, 2021. Available at:
https://dontforgetthebubbles.com/the-45th-bubble-wrap/

With millions upon millions of journal articles being published every year it is impossible to keep up.  Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.

Introducing the curriculum mapping team

Cite this article as:
Team DFTB. Introducing the curriculum mapping team, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31674

One of the most wonderful things about DFTB is the tireless effort of our community of friends, friends who keep things bubbling away behind the scenes, never asking for recognition or thanks, but who help make DFTB as wonderful as it is.

Since DFTB’s conception in 2013, we’ve published over 1000 posts (1062 as of Christmas Eve 2020 – that’s phenomenal). In the background, our fabulous curriculum mapping team have been reading all our publications and mapping them to not one, not two… but five acute paediatric curricula from postgraduate colleges in the UK and Australasia. Just over a year ago the curriculum mapping team had mapped 102 posts of a little over 800 published. Now, 13 months later, a ginormous 900 post have been read, digested and mapped to each of the five curricula. We’ll unveil the curriculum tags in 2021 but until then, let us introduce you to the curriculum mapping team.

Dani and Henry are the lead and delegate of the team. But the recognition must go to these lovely people:

Aaron Buiza – joined October 2019. Aaron is a medical student from The University of Queensland who just wants to be a kind, wise and happy physician. He dreams of running a community paediatrics clinic one day. When procrastinating from his flashcard reviews, you can find him cooking up a new dish, trying out different restaurants in the city or playing board games with friends

Aisling Clarke – joined October 2020. Aisling is a final year medical student at University College Dublin, Ireland. She recently completed her paediatric rotation and fell in love with the speciality. In her spare time, she loves all things outdoors, especially running, sea swims and sunsets.

Stevie Barry – joined November 2020. Stevie is a medical student in the Royal College of Surgeons in Ireland with a keen interest in paediatrics and education. When he’s procrastinating his studies, he enjoys playing rugby, walking his dogs and spending time with friends and family.

Emma Chan – joined June 2019. Emma is a resident based in Brisbane, Australia. She loves teaching gym classes and going on long walks paired with a cosy mocha and almond croissant in hand.

Gemma Cooper-Hopson – joined December 2020. Gemma lives in England and is close to completing her training in General Paediatrics with an interest in High Dependency care.  She has two young girls, two dogs, a hamster and a husband. She enjoys cake, wine, the outdoors and afternoon naps. 

Diluxshy Elangaratnam – joined December 2020. Diluxshy is a paediatric registrar who has combined her love for medical education with clinical training. She enjoys seeing the light bulb moment when medical students have understood a diagnosis almost as much as she enjoys meticulously testing flat whites in St Albans. 

Jillian Fagan – joined October 2020. Jillian is a final year medical student in University College Dublin in Ireland and has just finished her placement in paediatrics. She has always thought she wanted to do paediatrics, but her emergency department placement piqued her interest in the speciality! In her spare time, she loves anything to do with music and cooking.

Jessica Hawkins – joined April 2019. Jessica is excited to start her role as an intern at the Royal Brisbane and Women’s Hospital in 2021. She has a keen interest in paediatrics and all of the wonderful joy and bubbles that it brings. She has a passion for all things sweet (brownies especially), enjoys experimenting with watercolour painting, and indulging in the perfect wine and cheese combo!

Barbara Jedelsky – joined October 2019. Barbara is a resident based in Cairns, Queensland. When not working, you can find her at the beach, and enjoying spending time with family and friends.

Ailbe Keane – joined October 2020. Ailbe is a final year medical student at University College Dublin, Ireland, with a particular interest in paediatrics. Outside of university she loves baking, running, swimming in the sea and spending time with her friends, family and dogs.

Demi Murphy – joined April 2019. Demi is originally from western Canada. She is currently an RBWH intern and is very excited to join the 2021 paediatrics team at QCH for her JHO year! She hopes to pursue a career in General Paediatrics and as the founder of UQ’s Paediatric Medicine Society she hopes to continue to help facilitate medical students with an interest in paediatric medicine to do the same. In her spare time Demi loves singing, rock climbing, and spending time with family.

Tulsi Patel – joined December 2020. Tulsi is a paediatric trainee in London. She has a passion for learning and teaching and is easily distracted by puppies and cake!

Alexandra Pelivan – joined October 2020. Alexandra is a PEM grid trainee in Leicester, UK. She is passionate about facilitating trainees’ access to PEM resources, but also enjoys adolescent emergency medicine and is interested in ways of making debriefing easier. When not at work, she says she will likely be in a coffee shop.

Calvin Skews – joined October 2019. Calvin is a paediatric trainee based in Newcastle, Australia. When not on the wards, you will find Calvin on a bushwalk, at the beach, or sipping coffee while enjoying a good book

Leah Tyndall – joined December 2020. Leah is a graduate entry medical student with a background in biomedical engineering. Her biggest interests are in paediatrics and neonatology, as well as in medical technology and device design.

This is our way of saying thank you to these hard-working people for helping make DFTB so special. Thank you.

Year End 2020

Cite this article as:
Damian Roland. Year End 2020, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.31631

How do you remember the major milestones of your life? Do you divide them into significant life events such the start of secondary school or use specific decades related to your age? Perhaps you may base it on geography – where your ‘home’ was at any given time?

There is a significant chance that the COVID19 pandemic may create a new form of reference point, that of everything pre- and then post-pandemic.

It’s actually quite difficult to go back to January 2020 and imagine what you thought 2020 might be like. So much has happened in the last 12 months that expectations have perhaps been irrevocably altered; leaving the retrospectoscope even more biased than it always has been.

I can objectively demonstrate that at the beginning of the year I had some funded research I would like to publish, that I was looking forward to a number of international conferences and was already wondering how winter 2020 would pan out (feeling that we’d got lucky in 2019 which hadn’t been quite as bad as 2018). I can’t quite remember what I was expecting in relation to new interventions and developments in paediatric emergency medicine but I think, even with hindsight bias, it’s reasonable to assume that I suspected many things were likely to remain in status quo.

At the beginning of 2020 there was no reliable biomarker for identifying serious bacterial illness in sepsis (and still isn’t) and by the end of 2020 management of asthma and wheeze still remains essentially unchanged (although we know magnesium sulphate nebulisers probably don’t add much). A systemic review of the management of asthma essentially said (with all respect to the authors who are just interpreting available evidence), “more research is needed”. There have been no major practice-changing studies in the management of gastroenteritis, seizures or bronchiolitis. In fact, in many countries of the world, the less is more approach to bronchiolitis was easy to implement as the public health response to #COVID19 appeared to completely remove it as a disease entity.

What about personal plans. Did you think about what you wanted to achieve at the beginning of this year?

Do you ever?

And if not why not? Should we not have a semblance of some goals, however small and sparse of detail? Or do you argue a random calendar month, which happens to be the one Julius Caesar determined a new year should start, is a poor method with which to do this?

Pushing philosophical questions aside it’s likely that COVID19 revised, or ripped up, many individuals, departments and organisations strategies. The consequences of this aren’t clear and it may never be possible to determine overall positive or negative impact. There is a delicate balance between what has been gained that wouldn’t have normally occurred versus those critical investments and interventions which haven’t. As the DFTB review has clearly highlighted the pathophysiological consequence of COVID19 on children is limited but the wider impact is potentially extreme. Regardless of which way the overall outcomes swing appropriately responding to many enforced changes is vital. The cancellation of DFTB20 was a great sadness but at the close of DFTB: Live + Connected it was clear it is possible to generate an atmosphere of collaboration and solidarity even when participants are distanced by thousands of miles. Future DFTB conferences, whether digital OR in-person, will utilise this learning for the benefit of either medium. 

Without wishing to overlook the immense emotional trauma and financial hardship #COVID19 has had on society it is important that we all use 2020 to examine its impact on us as individuals. This will be through both our personal and professional lives. For the former, lockdown may have brought your immediate family and friends together, or it may have pushed them apart. In the latter, the utter transformation of healthcare services, both adult and children, will have altered your role in your department. This may have placed you in positions of leadership or responsibility that you have thrived in, or perhaps opened your eyes to a stale status quo, which had been implicitly tolerating without really enjoying. Every year brings the chance to reflect and grow but this year has given everyone a different lens with which to view their lives.

#COVID19 will have changed the world around you but I’d argue it is possible you may have changed more. 2020 may well be the milestone with which many new life journeys begin.

Liberian Girl

Cite this article as:
Josie Goodyer. Liberian Girl, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.31426
Liberia, west Africa

In general, I hate going first. Ask anyone in my family, my friends, my colleagues, my supervisors, they will all attest to this. 

I woke New Year’s Day, 2020, in Canberra to the world’s worst air pollution with the knowledge friends and colleagues were in the midst of active bushfires engulfing the south coast of NSW during the worst bushfire season the country has seen. 

I spent time indoors, cogitating about what to pack for my first assignment with Médecins Sans Frontières/Doctors Without Borders (MSF), my first experience living in Africa, my first experience working overseas. 

I’d always wanted to work for MSF and to dedicate part of my career to humanitarian work, helping those most vulnerable whilst gaining experience working in fascinating areas of clinical medicine with limited resources. 

The day I flew out of Canberra to Sydney for my final debriefings and onward flights to Liberia, the town just south of the ACT border was evacuated. Residents in Canberra were told to activate their bushfire survival plans. I left with my bushfire survival plan stuck to the fridge with magnets. 

 A side view of the Bardnesville Junction Hospital in Monrovia, Liberia. © Josephine Goodyer/MSF

I was making my way to Liberia to take on a role as the paediatric doctor in MSF’s paediatric hospital. Liberia, on the west coast of Africa, is on the opposite side of the globe from the east coast of Australia. The MSF Paediatric Hospital, or Bardnesville Junction Hospital (BJH), was established in 2015 in response to the need for high acuity general paediatric care for children between one month and 15 years of age. MSF has had a longstanding presence in Liberia, a country that has experienced two civil wars, followed by a devastating Ebola outbreak, resulting in a significant depletion of its health workforce.

I arrived in Liberia after 28 long hours of travel. Driving into the capital, Monrovia, from the airport we passed long queues of cars and motorbikes waiting to get into petrol stations. There was a severe fuel shortage in the country. This had a huge economic impact and a direct effect on hospital staffing. 

As for firsts… The clinical medicine and acuity at the hospital was challenging, rewarding and career-changing. I ran simultaneous resuscitations in ICU on my first day and clinically diagnosed cardiac tamponade on my second. 

In six months, I witnessed cardiorespiratory arrest from all the reversible causes. A young patient named Surprise taught me to clinically diagnose severe hypokalemia (<1.5mmol/L, once we had access to electrolytes) in children with severe acute malnutrition, children who were so floppy that in Australia your top differential diagnosis would be a primary congenital neurological diagnosis. Without an ECG, Princess too was diagnosed with severe hyperkalaemia (based on bradycardia responsive to salbutamol). 

One-month-old Success presented with a temperature of 33.3̊C and a respiratory rate of 10, but her clinical severity was recognised and managed early, resulting in complete recovery within 48 hours. Promise had severe hypoxia from numerous causes managed well with our consistent, reliable supply of oxygen and bubble CPAP. 

Blessing presented with hypovolaemic shock secondary to severe anaemia, with significantly low haemoglobin levels. Like almost all children who were admitted to the ICU, Blessing’s condition resulted from acute illness in addition to complex co-morbidities including malaria, E. Coli sepsis and severe acute malnutrition. Blessing made a complete recovery following blood transfusion and early antibiotics – managed and initiated by the local emergency room staff. 

Prince had severe subcutaneous emphysema resulting from complications of bubble CPAP with likely tension pneumothorax. Godgift had unrecordably high liver transaminases from paracetamol toxicity (paracetamol being readily available in the community), and undefined local herbal treatments. Prayer had symptoms consistent with venous sinus thrombosis with ongoing neurological recovery. 

Not all children survived.

I was briefed before arriving that the mortality rate was unusually high, even for an MSF hospital in a low-resource setting. This is mainly because many children present very late to the hospital due to lack of access to primary healthcare and poor health-seeking behaviours. I have welcomed plenty of advice in my career. Some of it was pertinent during my time in Monrovia. Palliative care specialists and general practitioners have taught me not to abandon dying patients and to keep in mind that as doctors, although we do not treat dying patients differently, families can often feel abandoned. This advice was a stalwart of my practice in Liberia, however difficult it was to uphold. I’d read a blog before departing from a paediatrician who worked at BJH, which said, “you’ll never get used to the screaming [of grieving parents]”, and you don’t. 

I don’t know that any doctor, particularly a paediatric doctor, has a clear sense of how to professionally and personally deal with an overwhelmingly high mortality rate, though, the support and experience of the local staff and the wider MSF community has proven invaluable. 

MSF staff in the Bardnesville Junction Hospital in Monrovia (from left to right) Gibson, Richard, Josie, Richard, George, Samuel, and Comfort. © Josephine Goodyer/MSF

Those who worked in the project before me had suggested that the clinical work was not the only challenge. As an Australian paediatric trainee, we have excellent training, fabulous clinical skills and knowledge. In the project, however, there are additional difficulties that come from other aspects of the job: working in a new context, movement restrictions due to security reasons, the tropical and humid weather, and living with those you work with.

Despite that, outside of clinical work, I swam on the west coast of Africa for the first time, learnt to run in 96 per cent humidity and participated in my first friendly staff kickball match on the beach!

The COVID-19 pandemic made its way to Liberia in March 2020. Liberia was one of the first countries in the world to close its borders internationally and enforce a period of mandated quarantine in addition to a nationwide curfew. 

MSF staff and volunteers carry out a COVID-19 hygiene awareness campaign and distribute soap to households in Logan Town, near the capital city, Monrovia. © Ruud van der Linden/MSF

COVID-19 meant that the hospital had to suspend the surgical program due to even greater difficulties with staffing. The acute shortages led to my first experience writing recruitment tests, sitting on an interview panel and planning staff rosters. Staff transitioned to working in surgical masks, and arrangements were made to manage suspected or confirmed COVID-19 cases. The local staff adjusted their skills and ensured the hospital continued to function at a high level. 

Initially, I was worried that I would not be able to contribute more than what MSF, the hospital and Liberian staff would teach me. I experienced so many firsts and I am thankful to have done so in a setting with such a legacy – and most certainly didn’t expect to do so in the midst of a global pandemic! I am most thankful to the children of Liberia, the patients and their families, and their humour. From the nicknames: ‘Chinese woman’, ‘white woman’, ‘big doctor’; to teaching me the ‘ABC’, how to count, language, how to ‘bus’ and offering to accompany me home in my suitcase! 

This year has been like nothing else. Do I still hate going first? Absolutely. Would I do it again? Absolutely. 

Click here to find out more about working with Médecins Sans Frontières. 

About Liberia

According to the CIA World Factbook (yes, it is a thing!), has one of the lowest GDP per capita in the world, ranking at 221* (out of 228). Over 60% of the countries 5 million people are under the age of 25. Unfortunately, it also has one of the woods highest maternal mortality rates (661/100,000) that is heavily influenced by the high incidence of female genital mutilation.
And the name? Liberia was founded as a homeland for freed African-American slaves in 1847. The flag bears a remarkable similarity to the star-spangled banner. Perhaps one of the reasons that Steve Mnuchin got the two confused?

* In case you were wondering Ireland is 10th, USA is 19th, Australia is 29th and the UK is 39th.

Don’t Forget The Christmas Quiz: the Ho Ho Ho Holiday Hunt answers

Cite this article as:
Team DFTB. Don’t Forget The Christmas Quiz: the Ho Ho Ho Holiday Hunt answers, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.31403

Don’t forget to post your selfies using the hashtag #DFTBHolidayHunt

Question 1

Andy talks to us about frequency of critical procedures in the paediatric emergency department. How many years does Andy need to practice to get the required number of intubations to maintain competency?

Answer: 106 years (from Andy Never Enough)

In 2016, Andy reviewed Nguyen et al’s paper looking at paediatric critical procedures in the ED. The article was a retrospective chart review of every paediatric attendance that required a resuscitation cubicle in three Victoria hospitals in 2013. Of almost 55,000 attendances, only 37 required any form of critical procedure – approximately 7 per 10,000 presentation.

83% of doctors working at the campuses in the study did not perform a single critical paediatric procedure. At the time Andy was working part time in the hospital and may have seen no more than 20 children a week. He reckoned it could take him 17 months to perform a single critical procedure. 

Andy quotes Ross Hofmeyr who suggests clinicians need to perform 75 intubations a year to maintain their competency and calculated it would take him 106 years to get just get to 75 intubations (Ed: what a statistic!)

Question 2

Preparing for major trauma is a vital pre-patient step, and improvisation can be key. How does Shane say you can improvise a bite block for a Le Fort II/III fracture?

Answer: Use a few tongue depressors taped together! (from Shane Broderick’s Professionals Prepare Properly)

Shane talks us through his approach to preparing for trauma. Quoting his Cian McDermott he tells us that “professionals prepare properly”. He lays out a series of superb tips, with number 5 being “better to be looking at it than looking for it” (aka check and recheck equipment). And when you can’t find it, can you improvise? Shane says, “No McKesson bite blocks for your Le fort II/III? No problem! Use a few tongue depressors taped together (Thanks to Jason van der Velde).”

Question 3

Kids love talking about poo, as do paediatricians! But if you have a sibling with Hirschsprung’s Disease, how much more likely then the general population are you to have it too?

Answer: Siblings of children with Hirschprung’s Disease are 200 times more likely than the general population to have Hirschprung’s; 4% vs. 0.02% (from the post Hirschprung’s Disease by Peter Tormey)

Question 4

General David Morrison AO (Retd), an outspoken opponent of gender bias and discrimination, gave a talk on workplace bullying and harassment. Andy uses General Morrison’s talk to discuss bullying in the workplace: discrimination, unjustified criticism, verbal threats, undue pressure and having jokes made at someone’s expense. Which heroic duo does Andy say characterise ‘defenders’ in the bullying arena?

Answer: Hermione and Ron (from the post Playground behaviour – in adults)

This is such an important post. Andy concludes with “It is okay to speak up and speak out. If you witness bullying, in any off its forms, it is your moral duty to pluck up the courage of Neville Longbottom and stand up for what is right.”

Question 5

At DFTB 2019 Russ and Cian demonstrated how useful POCUS can be. What favourite snack can help you to do a supra-pubic aspiration?

Answer: Toast! (from the post POCUS: Russ Horowitz and Cian McDemott at DFTB19)

Question 6

And finally, our Christmas question. In 2016, the Journal of Happiness published an article entitled, “What makes a merry Christmas?” But, what does make a merry Christmas?

Answer: we are happier when our Christmas plans involve family or faith and less happy when spending money and receiving gifts is the overwhelming aim. (from the post Happy Holidays!)

And that’s our cue to wish you a wonderful festive season and safe and healthy 2021.

from the DFTB team x