tag:theconversation.com,2011:/ca/topics/paediatric-health-101251/articlespaediatric health – The Conversation2023-12-11T12:37:21Ztag:theconversation.com,2011:article/2195182023-12-11T12:37:21Z2023-12-11T12:37:21ZWhooping cough cases increasing in the UK – what you need to know<figure><img src="https://images.theconversation.com/files/564677/original/file-20231210-29-ny65no.jpg?ixlib=rb-1.1.0&rect=35%2C0%2C7904%2C5297&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/child-got-sick-virus-little-boy-1693664527">Zdan Ivan/Shutterstock</a></span></figcaption></figure><p>You may have read recent alarming reports of a cough that “<a href="https://www.thesun.co.uk/health/24974770/highly-contagious-cough-fractured-ribs-whooping-cough/">lasts 100 days</a>” is “<a href="https://www.mirror.co.uk/news/health/100-day-cough-quickly-spreading-31622932">quickly spreading across the UK</a>” and can “<a href="https://nypost.com/2023/12/07/lifestyle/100-day-cough-highly-contagious-infection-that-could-fracture-ribs-soars-250-in-uk/">fracture ribs</a>”. If you didn’t look beyond the headlines, you might have missed the fact that the reports are about <a href="https://www.nhs.uk/conditions/whooping-cough/">whooping cough</a>.</p>
<p>So, what is going on?</p>
<p>Whooping cough (or pertussis) is what is known in the UK as a “notifiable infectious disease”, which means any doctor who diagnoses a case has a legal duty to report the infection to the local authority. Notifications of whooping cough are indeed much higher this year, particularly in the five months since July than at any time during the previous three years. </p>
<p>In the 21 weeks to November 27, <a href="https://www.gov.uk/government/publications/notifiable-diseases-weekly-reports-for-2023">there were 716 notifications</a> compared with just 217 in the same period in 2022, 213 in 2021 and just 72 in 2020. That is more than a threefold rise this year compared with the previous year. </p>
<p>Like most respiratory infections, whooping cough was suppressed during the COVID years. Notifications for whooping cough this year are still <a href="https://www.gov.uk/government/publications/notifiable-diseases-weekly-reports-for-2023">markedly down on 2019</a> where there were 1,842 notifications over the same 21-week period. </p>
<p>What we are seeing now is a partial return to the pre-COVID situation and not an unprecedented surge in infections. (Although the reported cases represent only a <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-147">fraction of all cases</a> in the community.)</p>
<p>The fact that whooping cough notifications are still relatively low should not distract from the fact that infections in the 2010s were still much <a href="https://www.gov.uk/government/publications/notifiable-diseases-historic-annual-totals">higher than in the previous decade</a>. Since the mid-1950s and the introduction of a vaccine, whooping cough was <a href="https://www.gov.uk/government/publications/pertussis-the-green-book-chapter-24">generally in decline</a> until this most recent decade. </p>
<h2>What is whooping cough?</h2>
<p>Whooping cough is a chest infection caused by the bacterium <em>Bordetella pertussis</em> – although another bacterium <em>Bordetella parapertussis</em> can also cause it. </p>
<p>The illness lasts for about six weeks or more and <a href="https://emedicine.medscape.com/article/967268-overview">progresses through three stages</a>. The first stage is very similar to a bad cold with a runny nose, sneezing and sore eyes. </p>
<p>The second phase, which starts after about two weeks, is characterised by bouts of intense coughing. Each bout can last several minutes and is occasionally followed by the loud whoop that gives the disease its name. Afterwards, a chronic cough can remain for several weeks.</p>
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<figcaption><span class="caption">What whooping cough sounds like.</span></figcaption>
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<p>Most people eventually make a full recovery, but in babies under three months old <a href="https://emedicine.medscape.com/article/967268-overview#a6">1% to 3% may die</a>. And most children under six months will require hospitalisation. </p>
<p>About one in 50 babies under one year will <a href="https://www.cdc.gov/pertussis/about/complications.html">suffer convulsions</a> and one in 150 (0.6%) will have encephalopathy (swelling of the brain). </p>
<p>Other even more serious neurological problems, such as paralysis and blindness, have been reported but are rare. In older children and adults, fainting, rib fractures, <a href="https://www.cdc.gov/pertussis/about/complications.html">pneumonia and urinary incontinence</a> can occur. </p>
<p>Antibiotics have limited value in <a href="https://onlinelibrary.wiley.com/doi/10.1002/ebch.1845">treating whooping cough</a>. They can reduce the time that the patient is infectious to others, but they have limited effect on preventing symptoms. </p>
<h2>How to avoid getting it</h2>
<p>There is an effective vaccine for whooping cough that in the UK is given in <a href="https://www.gov.uk/government/publications/routine-childhood-immunisation-schedule/routine-childhood-immunisations-from-february-2022-born-on-or-after-1-january-2020">combination with other vaccines</a> at eight, 12 and 16 weeks old. Then there is a booster shot given when the child is three years and four months. </p>
<p>The vaccine is also now recommended for pregnant women. This is not to protect the mother but to protect their baby during the first weeks of the child’s life before the first course of vaccine – when the infant would be at the highest risk of death.</p>
<p>Concerns about the safety of the vaccine, particularly during the 1970s, led to a significant fall in vaccine coverage and a re-emergence of whooping cough. </p>
<p>A committee of the US Institute of Medicine concluded that the evidence was “<a href="https://www.ncbi.nlm.nih.gov/books/NBK234367/">consistent with a causal relationship</a>” between the vaccine and acute encephalopathy, with a risk estimated at between zero and ten cases per million jabs administered. </p>
<p>However, subsequent studies suggested that many of the cases in the biggest study had a particular <a href="https://pubmed.ncbi.nlm.nih.gov/20447868/">genetic abnormality known as Dravet syndrome</a> and the whooping cough vaccine was merely bringing forward the date of onset of problems that would have happened anyway. </p>
<p>In any event, the studies reported above were of a time when whole-cell vaccines were being used (made from killed whole bacteria). Since 2004, whooping cough vaccines made with just parts of the bacterium (so-called acellular vaccine) have been used in the UK and these are associated with a <a href="https://pubmed.ncbi.nlm.nih.gov/12706690/">lower risk of side-effects</a>.</p>
<h2>Far from clear</h2>
<p>The recent increase in notifications of whooping cough, as mentioned above, is due to COVID suppression measures – lockdowns, mask-wearing and hand hygiene – coming to an end. But why there were more whooping cough cases during the years 2010 to 2019 compared with the previous decade is far from clear. </p>
<p>Vaccine coverage in the years before COVID up to 2019 was <a href="https://www.gov.uk/government/publications/pertussis-the-green-book-chapter-24">no lower than ten years previously</a>. <a href="https://karger.com/mpp/article/31/4/313/825084/Whole-Cell-and-Acellular-Pertussis-Vaccine">Possible explanations</a> include waning immunity, greater awareness of whooping cough among doctors (so more diagnoses), and improved laboratory diagnosis. </p>
<p>My take on the evidence is that the increasing infections in the years before COVID was down to the shift from whole-cell to acellular vaccine. Although the acellular vaccines cause fewer side-effects, they also generate <a href="https://karger.com/mpp/article/31/4/313/825084/Whole-Cell-and-Acellular-Pertussis-Vaccine">less powerful immunity</a>.</p>
<p>While both vaccines are highly effective at preventing severe disease, the acellular vaccine does not prevent mild infections that can be <a href="https://karger.com/mpp/article/31/4/313/825084/Whole-Cell-and-Acellular-Pertussis-Vaccine">infectious for others for as long</a>, so allowing the infection to continue to spread in the community. </p>
<p>The whole-cell pertussis vaccines were able to achieve herd immunity, which the acellular ones probably cannot. So the chance that young babies come into contact with an infectious older child or adult is now greater. </p>
<p>With the falling vaccination coverage in <a href="https://www.gov.uk/government/publications/pertussis-immunisation-in-pregnancy-vaccine-coverage-estimates-in-england-october-2013-to-march-2014/pertussis-vaccination-coverage-for-pregnant-women-in-england-january-to-march-and-annual-coverage-2021-to-2022">pregnant women</a> this puts babies at risk in their most vulnerable first weeks of life.</p><img src="https://counter.theconversation.com/content/219518/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Hunter consults for the World Health Organization. He receives funding from National Institute for Health Research and has received funding from the World Health Organization and the European Regional Development Fund.</span></em></p>Antibiotics aren’t very effective against it, but we do have a vaccine.Paul Hunter, Professor of Medicine, University of East AngliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2126602023-09-25T16:24:24Z2023-09-25T16:24:24ZGlue ear: there’s a better alternative to grommet surgery<figure><img src="https://images.theconversation.com/files/547562/original/file-20230911-8216-e3b4kk.jpg?ixlib=rb-1.1.0&rect=23%2C0%2C5152%2C3453&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/body-language-saying-5-year-old-716074861">Mama Belle and the kids/Shutterstock</a></span></figcaption></figure><p>Glitches in <a href="https://global.oup.com/ukhe/product/the-cradle-of-humanity-9780198704539?cc=gb&lang=en&">our evolutionary development</a> mean that 80% of four-year-olds get glue ear, a temporary loss of hearing. Many have costly and unnecessary surgery despite there being excellent non-surgical alternatives. </p>
<p><a href="https://www.magonlinelibrary.com/doi/abs/10.12968/bjsn.2014.9.7.335">Glue ear</a> or secretory otitis media, to give it its medical name, is caused by a <a href="https://mh.bmj.com/content/37/2/110">build up of fluid in the middle ear</a>. It can affect a child’s <a href="https://www.sciencedirect.com/science/article/abs/pii/S0165587698000755">hearing, speech, learning and behaviour</a>.</p>
<p>Although glue ear usually resolves on its own, <a href="https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599811409862">it can last for many months</a>. During this time, most children receive no treatment and have to face the consequences of considerable hearing loss for weeks or months at an important stage of their development. </p>
<p>The default treatment for glue ear is <a href="https://www.gosh.nhs.uk/conditions-and-treatments/procedures-and-treatments/treatment-glue-ear-grommets/">grommet surgery</a>, which is where a small tube is inserted in the eardrum to regulate the pressure in the middle ear. However, surgery is costly and not risk free. There is also a lack of good-quality evidence that <a href="https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599811409862">surgery achieves a long-term solution</a> to recurrent bouts of glue ear. </p>
<h2>Evolutionary glitches</h2>
<p>The human ear is an amazing and complex system. It has two roles, <a href="https://global.oup.com/ukhe/product/the-cradle-of-humanity-9780198704539?cc=gb&lang=en&">hearing and balance</a>. </p>
<p>The mechanical part of hearing is related to the normal movement of the eardrum, and the three bones in our middle ear that carry the sound vibrations to the inner ear. </p>
<p>In the inner ear, the sound waves are transformed into electric impulses that are sent to the brain, <a href="https://pubmed.ncbi.nlm.nih.gov/20018154/">allowing us to hear</a>. In contrast, birds and reptiles only have <a href="https://www.cell.com/trends/neurosciences/fulltext/S0166-2236(22)00240-5">one little ear bone and no empty middle ear space</a>. The human ear evolved this middle air-filled space to provide room for the three inner ear bones, and this evolved from ancestors with a much simpler ear anatomy.</p>
<p>The first evolutionary glitch is the development of the <a href="https://www.britannica.com/science/nasopharynx">Eustachian tube</a> – which connects the middle ear to the nose and throat and thus the outside, ensuring pressure equalisation and the clearance of secretions. </p>
<p>The Eustachian tube is made up of cartilage surrounded by soft tissue of muscles. In children it is short, floppy, horizontal and functions poorly, leading to negative pressure in the middle ear and a build-up of fluid <a href="https://academic.oup.com/jid/article-abstract/160/1/83/986098">causing glue ear</a>. </p>
<p>The maturation of the tube and its function is a gradual process during growth, which explains the high prevalence of <a href="https://journals.lww.com/pidj/citation/1996/04000/pathogenesis_of_otitis_media__role_of_eustachian.2.aspx">glue ear in young children</a>.</p>
<p>The second evolutionary glitch is caused by how the middle ear was created in the first place. <a href="https://www.science.org/doi/10.1126/science.1232862">Research in mice shows</a> that the lining of the middle ear comes from two different types of tissues that were in the ear before the space opened: “endoderm cells” that are covered in cilia (hairs) and “neural crest” cells that are not. The lack of hairs in parts of the middle ear means they are less efficient at cleaning, leaving it susceptible to fluid accumulation and infections.</p>
<p>The third evolutionary glitch is related to the lack of maturity in the child’s immune system against viruses and bacteria. Young children are exposed to many infections during the first years of life, typically from <a href="https://journals.lww.com/pidj/fulltext/2000/05001/viral_and_bacterial_interaction_in_acute_otitis.5.aspx">two to four years</a>. Each infection leads to excessive mucus production in the upper airways and accumulation of liquid behind the eardrum causing glue ear.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/YchcCEEnf-Y?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">How glue ear develops.</span></figcaption>
</figure>
<p>Because glue ear does spontaneously fix itself – most countries’ clinical guidelines recommend waiting <a href="https://www.nice.org.uk/guidance/NG233">three months</a> before any intervention. The most common form of intervention after this period is <a href="https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599811409862">grommet surgery</a>. </p>
<p>A review of <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001801.pub3/full">studies</a> conducted in 2010 suggests that there are initial benefits from surgery, but this diminishes after six to nine months, with no overall improvement seen at 12 to 18 months. </p>
<p>Long-term follow-up studies after grommet insertion show a high rate of recurrence of glue ear, increased risk of a <a href="https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599811409862">permanently perforated eardrum</a>, and a high chance of hearing loss in the <a href="https://www.sciencedirect.com/science/article/pii/S0165587623000757?via%3Dihub">higher frequencies in later life</a>. </p>
<h2>Auto-inflation</h2>
<p>There are, of course, alternatives to surgery, such as auto-inflation. </p>
<p>Auto-inflation dates back to the 17th century when Italian anatomist Antonio Valsalva described the Eustachian tube and the act of holding the nose and mouth closed and forcing air into the middle ear to remove negative pressure in the ear – something that adults do when flying or diving. </p>
<p>Several auto-inflation devices to treat glue ear in children were developed including the nasal balloon, first introduced in <a href="https://www.cambridge.org/core/journals/journal-of-laryngology-and-otology/article/abs/method-for-maintaining-middleear-ventilation-in-children/5642D7C59B80104914C19BFF5B0F770A">1968 by Professor Hunt-Williams</a>. All the devices focused on <a href="https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/620393">autoinflation by nose</a>, which is efficient in adults but difficult to perform in children. So there is <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006285.pub2/full">no consensus about the effectiveness of auto-inflation</a>, and grommet surgery remains the most common surgery performed on children.</p>
<p>The new generation of devices have a <a href="https://www.sciencedirect.com/science/article/abs/pii/S0165587613004941">face mask</a> that is used to cover the nose and mouth of a child. The mask is connected to a tube with a balloon on one end and a one-way valve on the other that allows air to enter.</p>
<p>The child can breathe in without resistance and every time they breathe out it inflates the balloon a little bit more, increasing the pressure and helping to open the Eustachian tube to balance the pressure and help ventilate the fluid out of the middle ear. </p>
<figure class="align-center ">
<img alt="A child using an auto-inflation device" src="https://images.theconversation.com/files/548120/original/file-20230913-23-hqmfdd.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/548120/original/file-20230913-23-hqmfdd.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/548120/original/file-20230913-23-hqmfdd.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/548120/original/file-20230913-23-hqmfdd.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/548120/original/file-20230913-23-hqmfdd.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/548120/original/file-20230913-23-hqmfdd.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/548120/original/file-20230913-23-hqmfdd.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The new generation of auto-inflation device to treat glue ear.</span>
<span class="attribution"><span class="source">Dr. Armin Moniri</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
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<p>The new generation devices, which look like a toy, allow children as young as one year to be treated for chronic glue ear, with up to 80% of patients getting <a href="https://www.sciencedirect.com/science/article/abs/pii/S0165587614002833">significant relief from the symptoms</a>. </p>
<p>The success rate is related to using the mouth for auto-inflation instead of the nose, which was the only described method previously, and by creating auto-inflation games adapted to the age and collaboration of the child to make it fun. Adding a pump also allows for gradual pressure increase without the active collaboration of the child.</p>
<p>The golden rule in medicine is that surgery should be the last resort, but in the case of glue ear, it seems to be the default. We need a change in medical culture, and the question should always be: is there a better, less invasive procedure we can use?</p><img src="https://counter.theconversation.com/content/212660/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Maslin is the UNFCCC designated point of contact for UCL. He is co-director of the London NERC Doctoral Training Partnership and a member of the Climate Crisis Advisory Group. He is a member of the Sopra-Steria CSR Board, Sheep Included Ltd, Lansons and NetZeroNow advisory boards. He has received grant funding from the NERC, EPSRC, ESRC, DFG, Royal Society, DIFD, BEIS, DECC, FCO, Innovate UK, Carbon Trust, UK Space Agency, European Space Agency, Research England, Wellcome Trust, Leverhulme Trust, CIFF, Sprint2020, and British Council. He has received funding from the BBC, Lancet, Laithwaites, Seventh Generation, Channel 4, JLT Re, WWF, Hermes, CAFOD, HP and Royal Institute of Chartered Surveyors.</span></em></p><p class="fine-print"><em><span>João Lino does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A new generation of auto-inflation devices helps children relieve glue ear. And they look like toys.Mark Maslin, Professor of Natural Sciences, UCLJoão Lino, PhD Candidate, Medical Sciences, Universidade do PortoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1776342022-03-03T19:13:33Z2022-03-03T19:13:33ZWe checked the records of 6,000 kids entering care. Only a fraction received recommended health checks<figure><img src="https://images.theconversation.com/files/449085/original/file-20220301-21-11j2nvn.jpg?ixlib=rb-1.1.0&rect=38%2C19%2C4197%2C2800&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://images.unsplash.com/photo-1495900593237-22dc861b231d?ixlib=rb-1.2.1&ixid=MnwxMjA3fDB8MHxwaG90by1wYWdlfHx8fGVufDB8fHx8&auto=format&fit=crop&w=2670&q=80">Unsplash/Caleb Woods</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>More than <a href="https://www.education.vic.gov.au/childhood/professionals/health/outofhomecare/Pages/about.aspx">10,000 Victorian children and young people</a> live with a foster or kinship (relative) carer. They enter such care because of court orders aiming to protect them from abuse or neglect. </p>
<p>These children have more physical, developmental and mental health needs than others, which is why they are meant to have a number of health checks when they enter care. </p>
<p>But when we checked the records of more than 6,000 children who were in foster or kinship care for the first time, we found <a href="https://www.sciencedirect.com/science/article/abs/pii/S0190740921004357?via%3Dihub">just 41 of them</a> had attended all of the recommended health appointments.</p>
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Read more:
<a href="https://theconversation.com/for-children-in-foster-care-the-coronavirus-pandemic-could-be-extremely-destabilising-135190">For children in foster care, the coronavirus pandemic could be extremely destabilising</a>
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<h2>High needs</h2>
<p>The <a href="https://onlinelibrary.wiley.com/doi/10.1111/jpc.14472">health needs of children in out-of-home care are high</a> across all areas of health. Around half will have behavioural, mental health and developmental problems. Most have some physical health concern, such as asthma, constipation or hearing difficulties. </p>
<p>These high rates are not surprising, given their experiences of abuse, neglect or trauma and increased likelihood of living in adverse socioeconomic circumstances. This is why there are <a href="https://www.dss.gov.au/sites/default/files/documents/pac_national_standard.pdf">National Standards for out-of-home care</a> which specifically state that health needs need to be assessed and addressed in a timely manner. </p>
<p>There is also a <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/cyp-oohc-framework">national framework</a>, adopted by Victoria, that spells out the details: an initial health check by 30 days and a thorough check within three months, led by a paediatrician and including hearing, vision and dental checks.</p>
<p>Nine years ago, specialised health care clinics with paediatricians, psychologists and speech pathologists <a href="https://www.health.vic.gov.au/populations/vulnerable-children#children-in-out-of-home-care">were established</a> in some areas of Melbourne for vulnerable children to provide a comprehensive assessment and develop health management plans. Such clinics are now in Gippsland too, but they have not been rolled out to the rest of the state. </p>
<p>In the <a href="https://services.dffh.vic.gov.au/victorian-handbook-foster-carers-word">handbook for foster carers</a>, Victorians are told to take a child to a GP, dentist, optometrist and for a hearing test within a month. The comprehensive health check is not mentioned.</p>
<p>We were concerned many children were missing out on these important health visits that could identify health issues and make a plan to address them. So we applied for federal and state de-identified administrative health data for Victorian children in care. This showed us health visits through Medicare (say, for GPs and optometrists) and at Victorian community, mental, dental and hospital outpatient health services. </p>
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Read more:
<a href="https://theconversation.com/does-the-governments-new-national-plan-to-combat-child-sexual-abuse-go-far-enough-170707">Does the government's new national plan to combat child sexual abuse go far enough?</a>
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<h2>Too little, too late</h2>
<p>We looked at health visits for all children who entered care and stayed at least three months – long enough to see a doctor. We analysed visits within the first year of care to all the recommended health professionals: GPs, paediatricians, dentists, optometrists and audiologists. </p>
<p>We found only one in every 130 children attended all the services within 12 months (far fewer attended all services within three months). It was good to see nine out of ten children saw a GP – but only 37% saw one within the recommended 30 days. </p>
<p>Using Medicare data meant we couldn’t see why a child had gone to the GP – it’s likely some visits were not for a check-up, but were for a specific issue or illness. About one-third of children made it to a paediatrician within a year, but less than 20% saw an optometrist, audiologist or community dentist. Very few attended these services within three months.</p>
<p>Because we looked at data over more than five years, we could see that in areas where a dedicated specialised health clinic was started up to provide health assessments, more children attended paediatricians, audiologists and optometrists. Even before the strains the COVID pandemic has placed on our health system, foster and kinship carers <a href="https://www.sciencedirect.com/science/article/abs/pii/S0190740919312915">said there were not enough health services</a> and very long waiting lists at those that did exist. </p>
<p>To make sure access to health care does not depend upon a child’s postcode, we need statewide paediatric health services that can provide health assessments and ongoing care. </p>
<p>Those children in foster care had higher odds of attending all health services than those in kinship care. We think this is because kinship carers do not receive as much training, support or financial compensation as foster carers. While it is good Victoria has world-leading rates of kinship care – children in kinship care tend to have <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/384260">better outcomes for behavioural and mental health</a> than children in foster care – it is important all children in care get access to health assessments and the services they need.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/449087/original/file-20220301-25-16cpg5r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Little girl in health care setting with bandaid or arm" src="https://images.theconversation.com/files/449087/original/file-20220301-25-16cpg5r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/449087/original/file-20220301-25-16cpg5r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/449087/original/file-20220301-25-16cpg5r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/449087/original/file-20220301-25-16cpg5r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/449087/original/file-20220301-25-16cpg5r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/449087/original/file-20220301-25-16cpg5r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/449087/original/file-20220301-25-16cpg5r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Victorian kids in out-of-home care are supposed to have an initial health check by 30 days and a thorough check within three months.</span>
<span class="attribution"><a class="source" href="https://images.unsplash.com/photo-1576766125535-b04e15fd0273?ixlib=rb-1.2.1&ixid=MnwxMjA3fDB8MHxwaG90by1wYWdlfHx8fGVufDB8fHx8&auto=format&fit=crop&w=2669&q=80">Unsplash/CDC</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/reunifying-first-nations-families-the-only-way-to-reduce-the-overrepresentation-of-children-in-out-of-home-care-175513">Reunifying First Nations families: the only way to reduce the overrepresentation of children in out-of-home care</a>
</strong>
</em>
</p>
<hr>
<h2>Listen to those inside the system</h2>
<p>To improve these rates, and to get in early to meet children’s health needs, we need to address what carers have told us <a href="https://www.sciencedirect.com/science/article/abs/pii/S0190740919312915">present barriers to health care</a>. They report limited paediatric and mental health services and difficulty navigating the systems. </p>
<p>Bureaucratic delays in <a href="https://onlinelibrary.wiley.com/doi/10.1111/jpc.15157">providing Medicare numbers to carers</a> and getting consent for health care need to be reduced. We could, as in the <a href="https://www.gov.uk/government/publications/promoting-the-health-and-wellbeing-of-looked-after-children--2">United Kingdom</a>, make health assessments a legal requirement of care.</p>
<p>More data is also important. Our research only looked at Victorian children – each state and territory has its own approach to health care for children in care. But there are no publicly available data anywhere in Australia, and therefore no public accountability for some of the children who need it the most. </p>
<p>Because it takes years to get permission, analyse data and publish, we do not yet know the impact of COVID upon this group of children. With reports of <a href="https://link.springer.com/article/10.1007/s00787-021-01790-x">worsened mental health</a> and longer wait times for services, it is unlikely things have improved.</p>
<p>If we have a system that removes children from families when we believe they are being harmed or their needs neglected, then we need to make sure we don’t overlook them any further.</p><img src="https://counter.theconversation.com/content/177634/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karen McLean received funding from the state and federal government and a Learning System Grant (from the Centre for Excellence in Child and Family Welfare) for this research. </span></em></p><p class="fine-print"><em><span>Harriet Hiscock receives funding from NHMRC</span></em></p><p class="fine-print"><em><span>Sharon Goldfeld receives funding from ARC, NHMRC</span></em></p>Children are removed from families and placed in care when we think they are being harmed or their needs neglected. But data shows the vast majority aren’t getting recommended health care.Karen McLean, Paediatrician, Royal Children’s Hospital; Research officer, Murdoch Children's Research InstituteHarriet Hiscock, Principal Fellow, Department of Paediatrics, The University of Melbourne, Murdoch Children's Research InstituteSharon Goldfeld, Director, Center for Community Child Health Royal Children's Hospital; Professor, Department of Paediatrics, University of Melbourne; Theme Director Population Health, Murdoch Children's Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1586352021-05-06T20:08:56Z2021-05-06T20:08:56ZADHD affects girls too, and it can present differently to the way it does in boys. Here’s what to look out for<figure><img src="https://images.theconversation.com/files/399122/original/file-20210506-19-qp2hyx.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5863%2C3896&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Two female Australian comedians recently revealed they’ve been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD).</p>
<p>In an interview before her shows at the Melbourne International Comedy Festival, <a href="https://www.theage.com.au/culture/comedy/it-s-good-to-come-back-fiona-o-loughlin-on-comedy-adhd-and-asexuality-20210326-p57eev.html">Fiona O’Loughlin</a> alluded to lifelong challenges including disorganisation and inability to sustain attention. </p>
<p>O'Loughlin, 57, described her diagnosis as a “seismic shift” in her life, and said medication has helped her immensely. But her struggle with focus will be a story familiar to many girls with ADHD.</p>
<p>And in an article published <a href="https://www.bodyandsoul.com.au/health/em-rusciano-on-being-diagnosed-with-adhd-as-an-adult/news-story/8df3c0ca7e38b4de5f8516d9367011ec">this week</a>, Em Rusciano also revealed she’s been diagnosed with ADHD. For Rusciano, too, treatment has been transformative. The 42-year-old wrote <a href="https://www.facebook.com/EmRuscianoOfficial">on Facebook</a>:</p>
<blockquote>
<p>I don’t feel the world coming at me at 100 all the time anymore. The constant sensory overload has stopped. I don’t feel overwhelmed by life quite as much.</p>
</blockquote>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1388629305215889413"}"></div></p>
<p>While some of us might perceive ADHD as a condition that affects males (particularly boys), it affects girls and women too. And it’s important to understand that the way it presents in girls can be quite different to the way it manifests itself in boys.</p>
<h2>What is ADHD?</h2>
<p>Best understood as a persistent, and sometimes lifelong, neurodevelopmental disorder, <a href="https://www.guilford.com/books/Attention-Deficit-Hyperactivity-Disorder/Russell-Barkley/9781462538874">ADHD</a> <a href="http://ndl.ethernet.edu.et/bitstream/123456789/42255/2/Lily%20Hechtman.pdf#page=206">includes problems</a> with sustaining attention, resisting distraction, and moderating activity levels to suit the environment (for example, sitting in a classroom).</p>
<p>Young people with ADHD <a href="http://www.russellbarkley.org/factsheets/TheWorldFederationOfAdhdGuide.pdf">vary considerably</a> in their behaviours. A child might exhibit symptoms of hyperactivity-impulsivity (for example, fidgeting and squirming, or frequently leaving their seat in class), or inattention (careless mistakes, trouble focusing in class, difficulty keeping their belongings in order), or more commonly, both. Hyperfocus (an intense fixation on one activity) can also be a symptom.</p>
<p>Of course, these behaviours are common in childhood to varying degrees. Diagnosis is based on whether symptoms are excessive for the child’s age, developmental level, and cultural background (parents across <a href="https://central.bac-lac.gc.ca/.item?id=NR50775&op=pdf&app=Library&oclc_number=720806889">different cultures</a> <a href="https://journals.lww.com/jrnldbp/Abstract/2006/04000/Mothers__Views_on_Hyperactivity__A_Cross_Cultural.6.aspx">may differ</a> in whether they see a child’s behaviour as hyperactive or normal).</p>
<p>A <a href="https://www.psychiatry.org/psychiatrists/practice/dsm">diagnosis</a> is only made if there’s clear evidence that the symptoms impair functioning across several life domains such as at school, at home and with friends.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/its-not-a-crime-to-have-adhd-26307">It's not a crime to have ADHD</a>
</strong>
</em>
</p>
<hr>
<h2>Does ADHD look different in girls?</h2>
<p>Researchers have only recently <a href="https://journals.sagepub.com/doi/abs/10.1177/1087054711416909">started to unravel</a> the expression of ADHD in girls. </p>
<p>The way ADHD presents in girls and boys is <a href="https://psycnet.apa.org/record/2014-57877-009">in many ways similar</a>, but there are <a href="https://www.sciencedirect.com/science/article/abs/pii/S0890856709614258">a few noteworthy differences</a>. Most importantly, while symptoms of hyperactivity-impulsivity are present across genders (with some studies showing more hyperactivity in boys), <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4195638/">symptoms of inattention</a>, which can be easier to overlook, are seen more frequently in girls. </p>
<p>Further, the onset of ADHD symptoms can <a href="https://www.sciencedirect.com/science/article/abs/pii/S0890856709626125">differ across gender</a>. Symptoms of hyperactivity tend to present early in school life. Inattentiveness, by contrast, has a slightly later onset. So girls with ADHD can often <a href="https://journals.sagepub.com/doi/abs/10.1177/1087054711416909">go undetected</a> until academic and organisational demands increase in late primary and high school. </p>
<p>Girls with ADHD are also at higher risk of developing <a href="https://ir.canterbury.ac.nz/bitstream/handle/10092/6292/44177_final%20version%20of%20gender%20paper%20to%20AACAP.pdf?sequence=1">depression and anxiety</a> than boys. If depression and anxiety occur at the same time as ADHD, it can be <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4195638/">more difficult</a> to diagnose ADHD. </p>
<p>A <a href="https://journals.sagepub.com/doi/abs/10.1177/1087054711416909">range of possible mechanisms</a> have been implicated in the difference in ADHD expression between genders, from hormonal changes, to cognitive differences, to social factors. But we need more research to truly understand the reasons behind the disparity. </p>
<figure class="align-center ">
<img alt="Two boys in a classroom." src="https://images.theconversation.com/files/399130/original/file-20210506-20-1hwztxk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/399130/original/file-20210506-20-1hwztxk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/399130/original/file-20210506-20-1hwztxk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/399130/original/file-20210506-20-1hwztxk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/399130/original/file-20210506-20-1hwztxk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/399130/original/file-20210506-20-1hwztxk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/399130/original/file-20210506-20-1hwztxk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">ADHD tends to be recognised in boys earlier than it is in girls.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>Boys versus girls</h2>
<p>ADHD is the <a href="https://www.health.gov.au/resources/publications/the-mental-health-of-children-and-adolescents">most common</a> psychological disorder among Australian youth. The second Australian Child and Adolescent Survey of Mental Health and Wellbeing, published in 2015, reported <a href="https://www.health.gov.au/resources/publications/the-mental-health-of-children-and-adolescents">7.4% of 4-17-year-olds</a> had ADHD over the previous 12 months. </p>
<p>Interestingly, more than twice as many boys have ADHD than girls. The disparity in prevalence may be a result of ADHD being <a href="https://psycnet.apa.org/record/2014-57877-009">historically viewed as a male disorder</a>.</p>
<p>This gender difference in prevalence has prompted controversy about diagnostic criteria and brought the female expression of ADHD into sharper focus. </p>
<p>There’s some suggestion the current <a href="https://psycnet.apa.org/record/1995-09976-001">diagnostic framework</a>, developed on male-dominated samples, is inadequate for girls and sees more boys than girls get a diagnosis. Some researchers have suggested symptom thresholds for diagnosis in girls should be modified. </p>
<p>Are there female expressions of hyperactivity-impulsivity (for example, internal feelings of restlessness) that could be added to the diagnostic criteria? Should there be <a href="https://journals.sagepub.com/doi/abs/10.1177/1087054711416909">gender-specific cut-offs</a> for current criteria (for example, a lower threshold for hyperactivity for girls)? </p>
<p>Until further research is conducted, <a href="https://link.springer.com/article/10.1007/BF01670100">the jury is out</a> on any changes to the current system.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/imaging-study-confirms-differences-in-adhd-brains-73117">Imaging study confirms differences in ADHD brains</a>
</strong>
</em>
</p>
<hr>
<p>Importantly, many parents and teachers have long-held <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1395774/">stereotypes of an ADHD child</a> as a disruptive and hyperactive boy with difficulties staying still and keeping on-task. This perceptual bias <a href="https://www.sciencedirect.com/science/article/pii/S0165178118317347">influences who they recognise</a> as potentially having ADHD and refer to treatment. </p>
<p>Research shows even when students display equivalent levels of impairment, <a href="https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.973.2615&rep=rep1&type=pdf">teachers still refer more boys</a> than girls for ADHD treatment.</p>
<h2>Some signs of ADHD in girls</h2>
<p>Does your child do the following <em>more than other children of her age</em>?</p>
<ul>
<li>make careless mistakes</li>
<li>daydream or appear spaced out</li>
<li>fail to pay close attention to details</li>
<li>have difficulty remaining focused in class, reading, homework, conversations</li>
<li>doesn’t seem to listen (appears distracted)</li>
<li>have difficulty organising tasks and materials</li>
<li>is reluctant to engage in tasks that require mental effort (schoolwork, homework)</li>
<li>often loses everyday things</li>
<li>is forgetful in daily activities.</li>
</ul>
<p>Keep an eye out for an increase in symptoms in late primary or early high school, as workload increases.</p>
<p>A good rule of thumb for when it’s time to seek help is when a child is starting to fail, fall behind or perform significantly below their ability either in schoolwork, friendships or family relationships. </p>
<p>There’s no cure for ADHD, but treatment aims to manage symptoms. Across genders, the first line of treatment for children is stimulant medication (such as Ritalin, Adderall or Concerta) and <a href="https://www.tandfonline.com/doi/abs/10.1080/15374416.2013.850700?journalCode=hcap20">behaviour management</a> (parent training and classroom management).</p>
<p>As more research on female ADHD emerges, we can consider treatment modifications specific to gender. </p>
<p>For many girls, ADHD is a serious and debilitating illness. Ensuring girls are identified early and accurately and that they receive evidence-based treatment is crucial. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/3-out-of-4-kids-with-mental-health-disorders-arent-accessing-care-118597">3 out of 4 kids with mental health disorders aren't accessing care</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/158635/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachael Murrihy does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A better understanding of ADHD in girls will enable earlier recognition, diagnosis and, importantly, treatment for girls, than currently exists.Rachael Murrihy, Director, The Kidman Centre, Faculty of Science, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1564922021-03-09T19:06:34Z2021-03-09T19:06:34ZRSV is a common winter illness in children. Why did it see a summer surge in Australia this year?<figure><img src="https://images.theconversation.com/files/388442/original/file-20210309-19-1xk1uml.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C5742%2C3837&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Winter typically brings a surge in respiratory viral infections, when we see many children running around with runny noses and phlegmy coughs. </p>
<p>But the 2020 Australian winter was very different. Public health measures in place to control the spread of COVID-19 saw a major shift in the typical seasonal pattern of other respiratory viruses. </p>
<p>This has perhaps been most notable with respiratory syncytial virus (RSV), a very common cause of hospitalisation in young children over winter months in <a href="https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30322-2/fulltext">many parts of the world</a>, including <a href="https://www.mja.com.au/journal/2019/210/10/respiratory-syncytial-virus-associated-hospitalisations-australia-2006-2015">Australia</a>.</p>
<p>But following an abnormal winter that saw a significant drop in rates of RSV — we found there were <a href="https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1475/5912591">98% fewer winter cases</a> in Western Australian children — paediatric hospitals around Australia have seen unexpectedly large numbers of children presenting with RSV over summer.</p>
<p>So, what is RSV, and why are these changing trends important?</p>
<h2>A winter lurgy</h2>
<p>RSV typically circulates during winter in temperate climates, <a href="https://theconversation.com/kids-are-more-vulnerable-to-the-flu-heres-what-to-look-out-for-this-winter-117748">much like influenza</a>.</p>
<p>It’s the <a href="https://www.sciencedirect.com/science/article/pii/S0140673617309388?via%3Dihub">major cause of lung infections in children</a>, commonly causing bronchiolitis. Symptoms of RSV <a href="https://www.rch.org.au/kidsinfo/fact_sheets/Respiratory_syncytial_virus_RSV/">include</a> a runny nose, cough, reduced feeding and fever. Complications include wheezing and difficulty breathing, which can develop into pneumonia. </p>
<p>Severe cases <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30344-3/fulltext">occasionally lead to death</a>, predominantly in very young infants.</p>
<p>Almost all children have had an RSV infection <a href="https://www.cdc.gov/rsv/high-risk/infants-young-children.html">by age two</a>, but infants in their first year of life are more likely to experience severe infections requiring hospitalisation, because their airways are smaller. Babies have also not built up immunity to RSV from previous years (we call this being RSV-naïve).</p>
<p>RSV is spread through respiratory secretions, when an infected person sneezes or coughs. In this way it’s similar to COVID-19. But <a href="https://theconversation.com/coronavirus-school-closures-whats-the-evidence-154210">in contrast to the coronavirus</a>, children are more vulnerable to RSV infection than adults. As a result, RSV is readily spread among children, especially at daycare, kindergarten and school.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/is-it-really-the-flu-the-other-viruses-making-you-ill-in-winter-14895">Is it really the flu? The other viruses making you ill in winter</a>
</strong>
</em>
</p>
<hr>
<h2>How is RSV treated?</h2>
<p>Most children will recover without needing specialist care in hospital, and children with mild infection can be <a href="https://www.rch.org.au/kidsinfo/fact_sheets/Respiratory_syncytial_virus_RSV/">treated with rest at home</a>. </p>
<p>However, many children, particularly young infants, those born prematurely, and children with underlying health issues, are admitted to paediatric wards with severe RSV every year. </p>
<p>Treatment for RSV is focused on helping children with their breathing (for example, giving them oxygen) and feeding (for example, administering fluids through a drip).</p>
<p>There’s no licensed vaccine for RSV, but the <a href="https://www.who.int/immunization/research/development/ppc_rsv_vaccines/en/">World Health Organization</a> considers this a priority, and a number of vaccines are currently in development.</p>
<figure class="align-center ">
<img alt="A doctor holds a stethoscope to a baby's chest." src="https://images.theconversation.com/files/388446/original/file-20210309-19-1wi9rrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/388446/original/file-20210309-19-1wi9rrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=403&fit=crop&dpr=1 600w, https://images.theconversation.com/files/388446/original/file-20210309-19-1wi9rrq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=403&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/388446/original/file-20210309-19-1wi9rrq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=403&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/388446/original/file-20210309-19-1wi9rrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=506&fit=crop&dpr=1 754w, https://images.theconversation.com/files/388446/original/file-20210309-19-1wi9rrq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=506&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/388446/original/file-20210309-19-1wi9rrq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=506&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Infants under one are more vulnerable to a serious case of RSV.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>What happened to RSV in 2020?</h2>
<p>The stay-at-home orders across Australia from late March 2020, and the implementation of quarantine for international arrivals, coincided with the start of the usual RSV and <a href="https://theconversation.com/the-dreaded-duo-australia-will-likely-hit-a-peak-in-coronavirus-cases-around-flu-season-132964">influenza season in Australia</a>. </p>
<p>With these measures in place, <a href="https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1256/5897048">RSV and influenza cases dropped dramatically</a> and <a href="https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2020.25.47.2001847">remained very low throughout winter</a>. </p>
<p>In Western Australia, despite a relaxation of COVID-related restrictions, including schools reopening from May 2020, there was still a <a href="https://www.telethonkids.org.au/news--events/news-and-events-nav/2020/october/rsv-and-influenza-detections-hit-record-low-levels/">dramatic reduction in RSV cases</a> through winter. This suggests border closures were important in reducing transmission from arriving overseas travellers.</p>
<p>RSV cases remained low until late spring, when a large surge was observed <a href="https://www.health.nsw.gov.au/Infectious/covid-19/Documents/covid-19-surveillance-report-20201212.pdf">in New South Wales</a> and <a href="https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1906/6140790">WA</a>. </p>
<p>The <a href="https://ww2.health.wa.gov.au/-/media/Corp/Documents/Health-for/Infectious-disease/Paediatric-Respiratory-Pathogen-Weekly-Report/2020/Paediatric-Respiratory-Pathogen-Report-Week-53-2020.pdf">speed and magnitude of this increase</a> was greater than the usual winter peak of RSV. </p>
<p>More recently, other states including <a href="https://www.theage.com.au/national/victoria/doctors-on-high-alert-after-surge-in-serious-respiratory-illness-among-children-20210224-p575cu.html">Victoria</a> and <a href="https://www.abc.net.au/news/2021-02-24/rsv-cases-surging-in-south-east-queensland/13186788">Queensland</a> have seen a similar unseasonal rise in RSV cases. </p>
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Read more:
<a href="https://theconversation.com/why-do-kids-tend-to-have-milder-covid-this-new-study-gives-us-a-clue-155555">Why do kids tend to have milder COVID? This new study gives us a clue</a>
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<p>It’s likely reductions in COVID-19 restrictions have opened the door for increased RSV spread. Reduced immunity to RSV may also have contributed through both an increase in number of RSV-naïve children and possibly waning RSV immunity in older children related to the delayed season. </p>
<p>Studies seeking to understand exactly why we’ve seen a rise in RSV cases are ongoing.</p>
<h2>Why might the Australian surge be important elsewhere?</h2>
<p>Australia’s experience may carry important lessons for Northern Hemisphere countries, including <a href="https://www.cdc.gov/surveillance/nrevss/rsv/natl-trend.html">the United States</a> and <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/964754/Weekly_Flu_and_COVID-19_report_w8.pdf">the United Kingdom</a>, which saw similar reductions in RSV cases during their winter. </p>
<p>Relaxing of COVID restrictions, which is beginning in many Northern Hemisphere countries now, may provide an opportunity for rapid spread of RSV. Our experience should serve as a warning for paediatric hospitals in the Northern Hemisphere to ensure adequate staffing and available resources to meet the possible increased need.</p>
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<img alt="Three young children playing with various toys." src="https://images.theconversation.com/files/388448/original/file-20210309-23-1087dc2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/388448/original/file-20210309-23-1087dc2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/388448/original/file-20210309-23-1087dc2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/388448/original/file-20210309-23-1087dc2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/388448/original/file-20210309-23-1087dc2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=500&fit=crop&dpr=1 754w, https://images.theconversation.com/files/388448/original/file-20210309-23-1087dc2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=500&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/388448/original/file-20210309-23-1087dc2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=500&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Children mixing less as a result of COVID-19 restrictions likely contributed to the drop in RSV cases during winter.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>Our RSV experience may also be applicable to influenza, which still <a href="https://www.who.int/influenza/surveillance_monitoring/updates/latest_update_GIP_surveillance/en/">remains at very low levels globally</a>. Reduced immunity to influenza due to the skipped 2020 season may result in a very severe season when influenza returns. Seasonal influenza vaccines could be particularly important in 2021 to protect against a possible large resurgence.</p>
<h2>Let’s hold on to our good COVID habits</h2>
<p>The COVID-19 pandemic has shown us the spread of respiratory viruses can be reduced by physical distancing and increased hygiene measures. </p>
<p>While we are (hopefully) unlikely to see prolonged stay-at-home orders again in Australia, ongoing basic measures including hand washing, cough etiquette and keeping snotty children at home can all help reduce the spread of RSV and influenza moving forward. </p>
<p>As we approach the 2021 Australian winter, by doing these simple things, as well as getting our flu vaccines, we can all help protect children, including those most vulnerable, from these important respiratory viruses.</p>
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Read more:
<a href="https://theconversation.com/kids-are-more-vulnerable-to-the-flu-heres-what-to-look-out-for-this-winter-117748">Kids are more vulnerable to the flu – here's what to look out for this winter</a>
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<img src="https://counter.theconversation.com/content/156492/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Daniel Yeoh is supported by an Australian Government Research Training Program Postgraduate Scholarship. </span></em></p><p class="fine-print"><em><span>Hannah Moore receives funding from the Australian National Health and Medical Research Council (NHMRC), Commonwealth and Western Australian State Government.
</span></em></p><p class="fine-print"><em><span>David Anthony Foley and Mejbah Bhuiyan do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Public health measures have helped control COVID-19 in Australia. But they’ve affected other winter viruses, too.Daniel Yeoh, Paediatrician and Infectious Diseases Physician, The University of MelbourneDavid Anthony Foley, Infectious diseases epidemiologist, Telethon Kids InstituteHannah C Moore, Co-Head, Infectious Diseases Epidemiology, Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids InstituteMejbah Bhuiyan, Post-Doctoral Researcher, Telethon Kids InstituteLicensed as Creative Commons – attribution, no derivatives.