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EPA Newsletter / Issue 09/ April 2011
Dear Colleagues and Friends!
EPA/UNEPSA is advancing and renewing itself following the pattern of a positive metabolic turnover. The coming Vienna Congress will show all of us these favorable changes particularly in the pediatric health field. In the chapter on news it is worth mentioning the increasing number of individual memberships. This is very important because these can now reach the Society, apart from the traditional way, through the national societies, directly and probably more quickly and at the same time getting a personalized answer, not to mention the advantage and security of being a straight member of a society well placed in the international field. Another achievement is the creation of an Ethics Committee. Although an EPA/UNEPSA document on the ethical conduct and fund raising existed, the new Committee ensures a personalized and thorough study of the projects and questions related to industry and consequently issues framed by integrity, scientifically based and truly promoting child and adolescent health. The last intervention of this committee has proved so. EPA/UNEPSA has since a longtime ago a firm feeling against endogamy, this spirit has been present when the ‘advisory groups' were created with people from outside our society but with recognized experience in the moving fields of interest: Nutrition, Infectious Diseases, Respiratory, Neurodevelopment... this is the initial step and some of them are already working.
As regards as the 5th Europaediatrics Congress, the scientific programme has been completely settled and can be qualified as one of the best ones for general and also subspecialized pediatrics. The work of the scientific committee and its President, Professor Armido Rubino, has been really remarkable. It is worth mentioning that this foundation is experiencing a substantial rate of organic growth with an increasing number of new members being registered. As regards free time we can certainly take the opportunity to go to a classic concert once we are in this temple for music that is Vienna.
Moving on to the progress of our Newsletter in the ‘Update in Pediatric General Practice' we are going to include here some issues related to evidence based medicine that would progressively coincide with the expert articles that have been the norm up till now. This means that we are not renouncing the participation of our wide group of advisers with such proven experience of clinical matters. Due to our connection with Cochrane, we intend to incorporate into this section some of the published articles and comment and facilitate them to all our members.
In this issue besides the usual sections, you will find a very useful approach for the common problem of chronic functional constipation in children written by the well-experienced gastroentelogist, Professor Mercedes Juste. You will also see interesting opinions about how EPA/UNEPSA can interact with other societies dealing with some specific aspects of pediatric health in Europe by Professor Jochen Erich.
We are also very excited with the official launch of the new highly interactive version of the EPA website (www.epa-unepsa.org) which provides a platform for paediatric e-learning focusing on the concept of «working and learning together». The new website includes utilities for individual members and national societies, information on available research grants and a new forum for paediatricians amongst others.
Finally, it can be said that Professor Andreas Konstantopoulos our president and next president of the International Pediatric Association, the world pediatric umbrella, is involved together with Professor Cabral, in an important project for developing new inputs in the Board of the IPA Foundation. This coordinated way of work is already giving results for new wider actions that can be applied to the big pediatric Regions.
Manuel Moya Editor of Newsletter.
P. S. If you wish to receive an e-alert for new issues, all you have to do is send an e-mail to epa-unepsa@candc-group.com
Excellence in Paediatrics 2011
The third edition of the high-profile international conference series brings forward dermatology in a joint collaboration between the European Paediatric Association (EPA/ UNEPSA) and Cochrane Child Health Field.
The 3rd Excellence in Paediatrics annual conference will be taking place in Istanbul, Turkey from 30th November to 3rd December. This international event series aims to provide a comprehensive understanding of paediatrics through the latest insights and developments via outstanding speakers and demand driven interactive sessions.
Excellence in Paediatrics has garnered high accolade through the receipt of an award for the ‘Best New Conference Launch' in 2009 by the Conference Awards 2010. The 2010 edition drew approximately 1,000 delegates from 73 countries; the 2011 edition is anticipated to draw approximately 1,500 delegates from all over the world.
Aiming for worldwide outreach, Excellence in Paediatrics looks to establish the professional network in paediatrics.
The end result is to further promote the continuous exchange of information within the medical community to help address issues that currently are of concern within this area of expertise.
EPA/UNEPSA is one of the centres of excellence in paediatric health care, that have been invited to contribute to the Scientific Programme of this conference. This year, EPA, in collaboration with the Cochrane Child Health Field and the Excellence in Paediatrics Steering Committee, provides a number of sessions focused on Dermatology. These specific sessions will be taking place at the Excellence in Paediatrics conference spanning from the 1st December to the 3rd December. The dermatology sessions will focus on aspects of potential interventions, prevention and treatment surrounding:
Preventive Dermatology
• Round table
Common Dermatologic Problems in Primary Care
• Interactive Case Study
Acne — Update on Management
• Parallel Lecture
Birthmarks: When to Reassure and When to Worry
• Workshop
Sun-Protection as a Preventative Strategy in Children: Truths, Myths and Misconceptions
• Parallel Lecture
Management of Warts and Molluscum in Children
• Parallel Lecture
Excellence in Paediatrics continues with its mantra of «cutting edge topics presented by outstanding speakers.» This year will prove to be no different.
For regular updates about the conference please visit: www.excellence-in-paediatrics.org
ANNOUNCEMENT European Paediatric Association (EPA/UNEPSA)
Join the most extensive paediatric network in Europe!
Since the launch of the individual membership scheme, the European Paediatric Association (EPA/UNEPSA) embraces a constantly increasing number of individual members from all over Europe.
EPA/UNEPSA welcomes all doctors who are certified as paediatricians in Europe and are members of their respective National Paediatric Society/Association participating in EPA/UNEPSA.
By joining EPA/UNEPSA, you gain access to a network of 40 national European associations and open yourself to a new world ofopportunities.
BENEFITS
The individual membership is offered at a privileged 50 Euro annual fee and encompasses a set of benefits that aim to provide value to the wide community of European paediatricians.
• On line access to the Evidence Based Child Health Journal is a core benefit of individual membership to our association and we are excited by the prospect of
making such a valuable resource widely available to paediatricians across Europe.
• Our members will enjoy reduced registration fees to Europaediatrics as well as to other events organised by our Association.
• The quarterly e-newsletter aims to be a source of current information relevant to the interests of European paediatricians.
• Finally, our members will find in our new website a valuable tool and resource (access to the members-only section, members' forum and working groups, access to educational programmes, complimentary or privileged prices for additional on-line services, etc.)
Individual membership is offered on an annual basis starting
on the 1st January of each year and ending on the 31st of
December.
You may apply on line for an individual membership.
Please visit our website www.epa-unepsa.org for more
details and to fill out a registration form.
We look forward to welcoming all of you in EPA/UNEPSA!
PRESENTATION
What do EPA, HOPE and EPPOSI have in common?
There are probably more than 50 paediatric societies and associationsin Europe, all of which aim at improving paediatric health care. Unfortunately many of these societies lack visibility in the 51 different European countries and the individual paediatrician may never have heard of their existence. EPA's aim is to create a network of these European paediatric societies with national paediatric societies and individual paediatricians.
EPPOSI is the European platform for Patients' Organisations, science and industry. It was founded in 1994 and is an independent, non-profit foundation of patients' organisations, scientific organisations and companies involved in healthcare, to work together with authorities, policy makers and politicians on patientcentered health care policies. This think tank is based in Brussels and works at the cutting edge of European Health policy-making based on consensus building, knowledge exchange and dissemination and, last but not least, bridging the gap between health care innovation and improved public health outcomes
(www.EPPOSI.org). The most recent EPPOSI conference on 9th December 2010 was attended by over 70 people from 16 countries. Participants included physicians, representatives of patients' organisations and of the pharmaceutical industry, as well as of European institutions and government offices, and was organised under the umbrella of the Belgian EU Presidency. Other past EPPOSI conferences focused on Parttering for Development of rare disease Therapies, the Value of Innovation, Biobanks, Rare Disease Registries, and the role of patients in HTA. This specific conference aimed at developing a holistic European model for the management of chronic diseases in children. It resulted in a mind map on:
1. Medical dimensions, 2. The E4HEALTH dimension. 3. The socioeconomic dimension of health care for children and adults with chronic diseases. The multi-stakeholder approach of EPPOSI involves patients, medical caregivers, politicians and industry, to fight for empowerment and social inclusion of patients as well as for the harmonised valuation of efficacy and safety of treatment.
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Chronic diseases are characterised by the lack of complete recovery, slow disease progression and longtime duration, the impact of the current episode of disease on the patient, and substantial comorbidity in addition to the effect on primarily affected organs or tissues. Chronic diseases must be diagnosed early during the preclinical stage. Health insurances should play a crucial role offering preventive care by screening and prophylaxis. Health education plays an essential role in the care of children with chronic diseases. Adequate schooling and vocational training of adolescents will also reduce unemployment later in life. Inclusion and wellbeing at work must be achieved for adult patients developing chronic diseases.
Pharmacists are important, though under-used, stakeholders. It has recently been shown that intensified consulting of patients by pharmacists has improved outcome. Challenges lie in the improvement of cooperation between pharmacists and physicians as well as in developing a paradigm of intervention of pharmacists inthe identification of the type of treatment, of in-vivo drug interaction, if multiple drugs were prescribed, and of adverse effects of drugs.
The EPPOSI conference came to the conclusion that the E4HEALTH dimension has not yet been fully established. It should enable communication between all caregivers, other involved stakeholders and patients in order to lead to a co-creation of a care model. E4HEALTH should be based on a user-friendly digital technology for «analogue» patients. Data protection must be guaranteed and patients should own their own personal electronic health record. Last but not least, the socio-economic aspects of health care for patients with chronic diseases were discussed. It was concluded that new concepts on health care management should include reward systems for all stakeholders to implement integrated care by a multistakeholder team.
In summary, EPA welcomes cooperation with EPPOSI in developing a road map that will show all stakeholders how to
proceed in this direction. In future, guidelines should follow the concept: first the patient and then the disease. Priorities should be respected and implemented and it has to be remembered that what percentage of the national budget has to be given to health systems is up for constant review depending on societal choices.
The Hospital Organisation of Pedagogues in Europe (HOPE) (www.hospitalteachers.eu) is an association of European hospital teachers who work in hospitals and in specialised schools or services for sick children, or at home with sick children. It is registered as an NGO with the Council of Europe. Through school and education activities sick children are provided with a positive environment and with a chance to carry on their education, no matter what the illness. Teachers in hospitals provide adequate schooling for children with somatic diseases, psychosomatic disorders and psychiatric diseases. Most European countries have specialised schools for mentally handicapped children. However, there are major differences in how national education systems provide continuity in education to students with medical needs.
Most importantly, there is a lack of adequate academic preparation for pedagogues teaching children with medical conditions attending normal schools. Last but not least, HOPE aims at improving access to education for sick children and adolescents and at ensuring their educational (re-)integration. During the 7th HOPE Congress in November 2010 in Munich, approximately 500 European pedagogues discussed the topic «The sick child — supported by a network of medicine and education». HOPE and EPA aim to perform a demographic study on the differences of education for children and adolescents with medical conditions in Europe.
Jochen H. H. Ehrich (EPA) Erik T. F. A. Tambuyzer (EPPOSI) Maria Schmidt (НОРЕ)
Mercedes Juste
Head of the Pediatric Gastroenterology Section, University Hospital S. Joan, Alicante, Spain
UPDATE IN PAEDIATRIC GENERAL PRACTICE Chronic Functional Constipation
Functional constipation (FC) is nowadays a very frequent condition in paediatric ages. It is an important cause for medical advice and it quite often disturbs the child and parents life. Its importance grows because it is proved that more than a third of constipated children will be constipated adults.
In recent years there have been significant advances in the understanding of FC and it is defined as a delay or difficulty in passing stools, with two or more week's duration, and sufficient to cause significant distress to the patient.
It is considered, beyond the neonatal period, a functional condition because only a 2% of all cases recognise an organic origin (systemic or gastrointestinal disorders). The term idiopathic should not be used because actually we know the pathophysiology better of this common problem and perhaps this term can lead to a symptomatic laxative therapy that normally finalizes in a failure.
The first step in the origin of FC is voluntary withholding because the child wants, consequently followed by avoiding an unpleasant defecation. Many events can lead to a painful emission of enlarged faeces as changes in diet, acute illnesses, and lack of access or time to an easy toilet. The faecal retention in the last part of large intestine gives way to fluid reabsortion and an increase in the consistence and size of the faeces. So, the passage will be more and more difficult as it causes pain due to the stretching of the anus. It makes the child respond to the urge of defecation but they avoid it by contracting their anal sphincter and gluteal muscles and adopt unusual postures such as crossing legs..often behind the door. If that situation persists, the faecal mass enlarges and becomes harder and it generates a lack of sensitivity to the distension pressure, consequently the sphincter can become incompetent allowing faecal soiling.
Diagnosis: the main step for doing a correct clinical evaluation is a medical history (Table 1) and it is necessary to address the question to look for the clues that suggest organic or functional disease. There are two important questions, one is what the family or child means when using the term «constipation» and the second one is what they think is a normal defecation because sometimes they do not identify the problem and constipation problems are detected in a medical visit for some other medical condition.
The clinical examination should be complete, the existence or not of abdominal distension and the detection of retained faecal masses in the lower abdomen (impactation) are important aspects.
The physical exam needs to include looking for fissures, abscesses dermatitis or fistulae in the anal area and the important presence of anal wink of anus. The digital examination, which may be done by a pediatric gastroenterologist, allows to asses the tone and at the same time it is possible to acknowledge the existence of a short sphincter with a full distal part of the intestine.
This evidence usually rules out Hirsprung's disease because in this case the rectum is usually empty. If there are not general symptoms as weight loss, abdominal distension, and the physical examination does not show any striking detail we can do the diagnosis of functional constipation. In this case no laboratory or image technique is necessary because they do not help. Anorectal manometry is only performed in the case that medical questions, physical examination or a bad condition of child making it necessary to leave out Hirsprung's disease or any other organic condition.
Clinical management: The aim of the complete treatment is to get bowel movements at normal intervals, with no symptoms and with a complete evacuation. An explanation about why and how the situation has been generated is the first thing to do. It must be clear to the parents and to the child, if she or he is old enough to understand. This explanation helps to demystify the problem and it leads to remove negative consideration (very important if soiling is present) and to adopt a consistent positive attitude in the treatment and evolution.
Desimpaction is necessary before starting any other treatment. It can be done by the oral or rectal route, the second one being more invasive but it is usually more effective and it is inevitable in many cases alone or in conjunction with the oral medication.
To empty by a retrograde way the distal part of the large intestine there is an agreement about whether enemas are necessary and if saline or glycerine should be used. Phosphate enemas have been prescribed but they are not recommended for long term because of their potential toxicity.
When the impaction is resolved or it does not exist it is possible to start medical treatment which includes dietary changes, behaviour modification and medication.
Dietary changes: It is clear that fibre intake in constipated children is lower than in the same age population. What is not so evident is if indicating a larger amount of fibre can resolve an important constipation. It seems the most practical recommendation is to indicate a balanced diet with fruits, vegetables, pulses and probably wholemeal cereal. In recent times cow's milk has been considered a not well defined cause of constipation and its elimination from the diet is taking place in the treatment of FC with probably weak evidence of benefit.
Table 1. Relevant questions
• Time of first bowel movement
• Age of onset of constipation
• Frequency, size and consistency of stool
• Withholding behaviour
• Faecal soiling
• Pain or bleeding when passing stool
• Associated symptoms (abdominal pain)
• Developmental and psychosocial history
• Growth situation
• Long lasting medications
Table 2. Medications and doses
• Lactulose: 1-3 ml/kg/day
• Magnesium hydroxide: 1-3 ml/kg/day
• Mineral oil: 1-3 ml/kg/day
• PEG 3350 electrolite: 1,2 g/kg/day
Behaviour Modification: Toilet training to get regular habits requires including the toilet time, preferably after meals, in an unhurried moment. It ought to be a pleasant moment and the child should be helped. A calendar with a mark on the successful day will help a lot and allows to quantify the evolution and to maintain the solution.
Medications may be needed to achieve and maintain a normal and regular evacuation. The drugs usually taken are safe but as they have to be used for quite long periods stimulant laxatives should be avoided. Although there are other medications such as lactulose, sorbitol, magnesium hydroxide... mineral oil and polyethilenglycol 3350 plus electrolytes have been shown as the most effective, well accepted and tolerated even in younger children. The doses need to be adapted to each child, but the usual ones are in table 2.
So, FC is a very common condition and quite often is ignored by the family and sometimes not completely assessed when the child comes for an acute illness For the correct medical management of FC it is necessary to include collaboration of the family and to keep in mind that this treatment is a long process. Relapses are quite frequent, and they should be objet of prevention and avoided if possible as they affect quality of life of the child and family.
1. Pijpers M., Bongers M., Benninga M., Berger M. Functional constipation in children: a systematic review on prognosis and predictive factors. J Pediatr Gastroenterol Nutr 2010: 50 (3): 256-268.
2. Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 2006; 43 (3): e-12.
3. Pijpers M., Tabbers M., Benninga M.A. Currently recommended treatments of childhood constipation are not evidence based. A systematic literature review on the effect of laxative treatment and dietary measures. Arch Dis Child 2009; 94:117-131.
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NEWS FROM AROUND THE WORLD
EPA announces the launch of its new official website
A fundamental part of EPA's role as a pan-European association of 40 member societies is to understand and embrace diversity and foster the exchange of experiences and cooperation. General paediatricians from all over Europe can benefit tremendously from learning from each other and from specialists.
To this end, on Wednesday, April 6th, EPA unveiled a new highly interactive version of the website which is designed to provide a platform for paediatric e-learning focusing on the concept of «working and learning together». With the launch of its new website, EPA aims to encourage cooperation amongst paediatricians in Europe and create a learning hub for the paediatric community, enabling members to exchange experiences and share best practices.
The new website includes utilities for individual members and national societies and up-to-date contents such as news surrounding latest developments through interactive learning opportunities, information on available research grants and discussion threads for visitors.
Visit the new EPA website now and join the most extensive paediatric network in Europe! http://www.epa-unepsa.org
RUSSIA
The XV Congress of Pediatricians of Russia was held in Moscow on 14-17th February 2011. Attendance at the event reached a total of 5044 healthcare professionals from all sectors of public health stemming from many countries including the Russian federation.
The venue for the opening ceremony and the plenary session was the grand Christ-Saviour cathedral, with the novel opportunity for both the current IPA president (Professor Sergio Cabral) and former IPA president (President Chok wan Chan) to greet all the participants, making it a historic event at the congress.
All the presentations at the plenary session surrounded issues both at the country level in Russia and globally, led by IPA leaders and heads of state healthcare services in Russia. The scientific meeting itself took place in the Moscow World Trade Centre between the 15-17th of February. With 160 symposia and lectures taking place in the venue's 10 large halls, current issues in paediatrics surrounding allergies, vaccinations, rheumatology, paediatric surgery, hygiene and social paediatrics were discussed with great vigor.
The highly scientific and educational content of the congress was contributed by both well respected Russian and international experts in their respective fields, with participation from Germany, UK, Slovenia, Ireland, Netherlands, France, USA, Switzerland, Russia and Lithuania to name a few.
The special factor that was deemed a huge success was the coordination of 5 master classes that took place prior to the congress. These master classes were chaired and structure by leading Russian and international specialists located in the Scientific Centre of Children's health of the Russian Academy of medical sciences. These sessions were devoted to discussing the cutting edge approaches to laboratory tests (In collaboration with Professor M. Angastiniotis from the International Federation of Thalassaemia), vaccinations, treatment of allergies, paediatric rheumatology, paediatric surgery and antibacterial therapy in children.
As a result this congress has provided Russia the opportunity to become a prominent figure within the field of paediatrics, providing networking opportunities for healthcare professionals worldwide to share their viewpoints and take part in high quality educational sessions. This congress series has helped contribute to the foundation of paediatrics worldwide and provided the right steer for the future development of this field of expertise.
CALENDAR OF EVENTS
EPA/UNEPSA MEETINGS 5th Europaediatrics 2011
23-26 June 2011, Vienna, Austria
MEMBER SOCIETIES' MEETINGS
47th National Turkish Paediatric Association Congress
10-14 May 2011
Congres Societe Francaise de Pediatrie (SFP)
11-14 May 2011, Marseille, France
Early Intervention and Development Disorders
19-21 May 2011, Ohrid, FYROM
31st Congress of the Polish Society of Paediatrics
9-11 June 2011, Szczecin, Poland
67° Congresso Nazionale di Societa Italiana di Pediatria (SIP)
7-10 June 2011, Milan, Italy
49th Panhellenic Congress of Paediatrics
10-12 June 2011, Messinia, Costa Navarino, Greece,
60° Congreso de la Asociacion Espanola de Pediatria (AEP)
16-18 June 2011, Valladolid, Spain
Annual Congress of the Swiss Society of Paediatrics — SSP 2011
1-2 September 2011, Montreux, Switzerland
Hungarian Paediatric Association, Annual National Paediatric Congress
1-3 September 2011, Pecs, Hungary
DGKJ Annual Meeting (German Society of Paediatric and Adolescent Medicine)
22-25 September 2011, Bielefeld, Germany
Romanian Paediatric National Congress (Congresul National de Pediatrie cu participare internationala 2011)
28 September — 1 October 2011, Bucharest, Romania
Annual Conference of Lithuanian Paediatric Society
7 October 2011, Vilnius, Lithuania
5th Congress of Paediatric Association of Macedonia
5-9 October 2011, Ohrid, FYROM
CME Study Day & Ralph Counahan Lecture
14 October 2011, Dublin, Ireland
Albanian Pediatric Society — National Congress of Pediatrics
28-29 October 2011, Tirana, Albania
32nd Annual Congress, Pediatric Association of the Netherlands
2-4 November 2011, Veldhoven, The Netherlands
OTHER PAEDIATRIC MEETINGS
9th Congress of the European Pediatric Neurology
Society (EPNS)
11-14 May 2011, Cavtat-Dubrovnik, Croatia
12th International Congress of Pediatric Laboratory Medicine (ICPLM)
13-15 May 2011, Berlin, Germany
1st Baltic Paediatric Congress
19-21 May 2011, Vilnius, Lithuania
XII Jornadas Nacionais de Infecciologia Pediatrica
19-21 May 2011, Braga, Portugal
29th Annual Meeting of the European Society for Paediatric Infectious Diseases (ESPID)
7-11 June 2011, Hague, The Netherlands
16th Congress of the European Union for School and University Health and Medicine (EUSUHM)
9-11 June 2011, Moscow, Russian Federation
European Society for Developmental Perinatal & Paediatric Pharmacology (ESDP 2011)
15-17 June 2011, Oslo, Norway
12th European Congress of Paediatric Surgery (EUPSA)
15-18 June 2011, Barcelona, Spain
23rd Congress of the International Association of Paediatric Dentistry (IAPD)
15-18 June 2011, Athens, Greece
15° Congresso Nazionale Societa Italiana per la Malattie Respiratorie Infantili (SIMRI)
16-18 June 2011, Catania, Italy
58th Annual International Congress of the British Association of Paediatric Surgeons (BAPS)
19-22 July 2011, Belfast, United Kingdom
2nd Signa Vitae International Conference in Pediatric/Neonatal Intensive Care and Anesthesiology
2-3 September 2011, Split, Croatia
Scientific-practical conference«Pharmacotherapy and Nutrition in Pediatrics»co-organised with IX Forum «Children and medicines» and 5th Forum» Nutrition and Health»
14-16 September 2011, Kazan, Russian Federation
44th Annual Scientific Meeting of European Society for Paediatric Nephrology (ESPN)
14-17 September 2011, Dubrovnik, Croatia
XXIII Congresso Nazionale Societa Italiana di Pediatria Preventiva e Sociale (SIPPS)
15-17 September 2011, Milan, Italy
11th International Conference of Osteogenesis Imperfecta
2-5 October 2011, Dubrovnik, Croatia
XVIII Congresso Nazionale Societa Italiana Gastroenterologia Epatologia e Nutrizione Pediatrica (SIGENP)
13-15 October 2011, Padova, Italy
17° Congresso Nazionale della Societa Italiana di Neonatologia (SIN)
11-14 October 2011, Sorrento, Italy
Excellence in Paediatrics
30 November — 3 December 2011, Istanbul, Turkey
Excellence in Child Mental Health
30 November — 3 December 2011, Istanbul, Turkey
1st PNAE — Congress on Paediatric Nursing
1-2 December 2011, Istanbul, Turkey
XVIII Congresso Nazionale Societa Italiana di Endocrinologia e Diabetologia Pediatrica (SIEDP/ISPED)
1-3 December 2011, Genova, Italy
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