Showing papers in "South African Journal of Child Health in 2013"
TL;DR: The results of this study showed that SA scores were statistically significantly higher than the US norms, however, the difference is small when one considers the variability of development.
Abstract: Background. A suitable tool is needed to assess child development in South Africa (SA). Using Western normed tools presents difficulties. Aim. To determine whether the Bayley Scales of Infant Development III (Bayley-III) can be used on black African urban infants in SA. Method. One hundred and twenty-two black African infants in Gauteng, SA, were assessed using the Bayley-III. Results. Overall the SA mean score was 103.4, which is statistically significantly higher ( p =0.0007) than the mean of 100 for the USA. For subtests, the mean score was 99.7 for the cognitive, 106.8 for the language and 103.5 for the motor subtests as opposed to 100 for the USA. Conclusion. The results of this study showed that SA scores were statistically significantly higher than the US norms. Clinically, however, the difference is small when one considers the variability of development. Recommendation. The Bayley-III is a suitable tool for use on the black urban African population in Gauteng, SA.
67 citations
TL;DR: Schoolchildren from industrially exposed communities experienced higher covariate-adjusted prevalences of persistent asthma and marked AHR than children from communities distant from industrial sources.
Abstract: Objectives. To examine associations between ambient air pollutants and respiratory outcomes among schoolchildren in Durban, South Africa. Methods. Primary schools from within each of seven communities in two regions of Durban (the highly industrialised south compared with the non-industrial north) were selected. Children from randomly selected grade 4 classrooms were invited to participate. Standardised interviews, spirometry, methacholine challenge testing and skin-prick testing were conducted. Particulate matter (PM), sulphur dioxide (SO 2 ) and carbon monoxide were monitored at each school, while nitrogen oxides (NO x ) and other pollutants were monitored at other sites. Results. SO 2 was significantly higher in the south than in the north, while PM concentrations were similar across the city. The prevalence of symptoms consistent with asthma of any severity was 32.1%. Covariate-adjusted prevalences were higher among children from schools in the south than among those from the north for persistent asthma (12.2% v. 9.6 %) and for marked airway hyperreactivity (AHR) (8.1% v. 2.8%), while SO 2 resulted in a twofold increased risk of marked AHR (95% confidence interval 0.98 - 4.66; p =0.056). Conclusions. Schoolchildren from industrially exposed communities experienced higher covariate-adjusted prevalences of persistent asthma and marked AHR than children from communities distant from industrial sources. Our findings are strongly suggestive of industrial pollution-related adverse respiratory health effects among these children.
57 citations
TL;DR: The profile of children with PDD attending a tertiary hospital developmental clinic in the Western Cape revealed that a high proportion had severe language impairment, behavioural problems and complex autism.
Abstract: Background. Little has been published on autism in Africa, and it is not known whether South African children present with the same characteristics and challenges as described internationally. Objectives. To describe the demographics, history, clinical features, co-morbidity and yield of aetiological investigations in children diagnosed with a pervasive developmental disorder (PDD). Methods. This was a retrospective review of medical records of children fulfilling Diagnostic and Statistical Manual of Mental Disorders , 4th edition, text revision (DSM-IV-TR) criteria for a PDD who attended a tertiary developmental clinic at Tygerberg Hospital, Western Cape, South Africa, over a 2-year period (2008 - 2010). Results. Fifty-eight children were included. The median age at diagnosis was 42 months (range 15 - 106 months), and 45 (77.6%) were boys. Forty per cent had complex autism (dysmorphism with or without microcephaly), and 12.1% were macrocephalic. Most children (72.4%) were non-verbal (using fewer than 10 non-echoed words), and 89.0% had behavioural problems as reported by caregivers. The diagnostic yield of investigations was low. Conclusion. The profile of children with PDD attending a tertiary hospital developmental clinic in the Western Cape revealed that a high proportion had severe language impairment, behavioural problems and complex autism.
55 citations
TL;DR: Effective steps are required to avoid extreme prematurity, encourage antenatal care, and provide antenatal steroids when preterm birth is anticipated: BW and GA were the strongest predictors of survival.
Abstract: Objectives. Survival of extremely low-birth-weight (ELBW) infants in a resource-limited public hospital setting is still low in South Africa. This study aimed to establish the determinants of survival in this weight category of neonates, who, owing to limited intensive care facilities, were not mechanically ventilated.
Design. A retrospective study in which patient data were retrieved from the departmental computer database.
Setting. The neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa.
Subjects. Neonates admitted at birth between January 2006 and December 2010 with birth weights of ≤900 g.
Outcome measures. Survival at discharge was the major outcome. Maternal variables were age, parity, gravidity, antenatal care, antenatal steroids, place and mode of delivery and HIV status. Neonatal variables were gestational age (GA), birth weight (BW), gender, place of birth, hypothermia, resuscitation at birth, sepsis, necrotising enterocolitis, intraventricular haemorrhage, jaundice, nasal continuous positive airway pressure (NCPAP) with or without surfactant, and Apgar scores.
Results. A total of 382 neonates were included in the study. Overall survival was 26.5%. The main causes of death, as per the Perinatal Problem Identification Programme (PPIP) classification, were extreme multi-organ immaturity and respiratory distress syndrome. The main determinants of survival were BW (odds ratio (OR) 0.994; 95% confidence interval (CI) 0.991 - 0.997) and GA (OR 0.827; 95% CI 0.743 - 0.919). Overall the rate of NCPAP use was 15.5%, and NCPAP was not associated with improved survival.
Conclusion. Survival of ELBW infants is low. BW and GA were the strongest predictors of survival. Effective steps are required to avoid extreme prematurity, encourage antenatal care, and provide antenatal steroids when preterm birth is anticipated.
39 citations
TL;DR: The high overall survival and survival after ICU admission provides a benchmark for further care and the high incidence of HIE suggests that a therapeutic hypothermia service including a long-term follow-up component would be beneficial.
Abstract: Background. Perinatal asphyxia is a significant cause of death and disability. Aim. To determine the outcomes (survival to discharge and morbidity after discharge) of neonates with perinatal asphyxia at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Methods. This was a descriptive retrospective study. We reviewed information obtained from the computerised neonatal database on neonates born at CMJAH or admitted there within 24 hours of birth between 1 January 2006 and 31 December 2011, with a birth weight of >1 800 g and a 5-minute Apgar score <6. Results. Four hundred and fifty infants were included in the study; 185 (41.1%) were females, the mean birth weight (± standard deviation) was 3 034.8±484.9 g, and the mean gestational age was 39.1±2.2 weeks. Most of the infants were born at CMJAH (391/450, 86.9%) and by normal vaginal delivery (270/450, 60.0%). The overall survival rate was 86.7% (390/450). Forty-two infants were admitted to the intensive care unit (ICU). The ICU survival rate was 88.1% (37/42). Significant predictors of survival were place of birth ( p =0.006), mode of delivery ( p =0.007) and bag-mask ventilation at birth ( p =0.040). Duration of hospital stay ( p =0.000) was significantly longer in survivors than in non-survivors (6.5±6.6 days v. 2.8±9.8 days). The remaining factors, namely gender, antenatal care, chest compressions, diagnosis of meconium aspiration syndrome or persistant pulmonary hypertension, did not differ significantly between the two groups. The rate of perinatal asphyxia (5-minute Apgar score <6) was 4.7/1 000 live births, and there was evidence of hypoxic ischaemic encephalopathy (HIE) in 3.6/1 000 live births. Of the 390 babies discharged from CMJAH, 113 (29.0%) had follow-up records to a mean corrected age of 5.9±5.0 months. The majority (90/113, 79.6%) had normal development. Conclusions. ( i ) The high overall survival and survival after ICU admission provides a benchmark for further care; ( ii ) obtaining adequate data for long-term follow-up was not possible with the existing resources – surrogate early markers of outcome and/or more resources to ensure accurate follow-up are needed; and ( iii ) the high incidence of HIE suggests that a therapeutic hypothermia service including a long-term follow-up component would be beneficial.
38 citations
TL;DR: Meal skipping was associated with an increased prevalence of overweight and obesity among adolescent schoolgirls, and the two leading reasons cited by participants for skipping breakfast were lack of appetite and time.
Abstract: Background. Obesity in adolescence is common, and eating habits are a key determinant. Eating habits in adolescence often differ substantially from those in any other phase of life. Objective. To assess the weight status and eating habits of adolescent urban secondary school girls in Benin City, Nigeria. Methods. In this school-based cross-sectional study, data were obtained on the subjects’ eating habits via a structured anonymous self-administered questionnaire, while their weights and heights were obtained by direct measurements. The body mass index (BMI), calculated as weight/height (kg/m 2 ), was used in assessing the weight status of the participants. The study sample was 2 097 adolescent urban public school girls, aged 12 - 19 years. Information was obtained on frequencies of skipping meals, reasons for skipping meals and food choices, as well as the socio-demographic characteristics of the participants. All the students at the two study schools were invited to participate. Results. The mean age of the participants (± standard deviation) was 14.8±1.9 years (95% confidence interval (CI) 14.7 - 14.9). Slightly over half (52.6%) were from families of middle socio-economic status, and 84.7% of them lived with their parents. Of the 2 097 participants, 1 009 (48.1%) admitted to skipping at least one meal a fortnight. Of the three main meals, breakfast was the most frequently skipped (46.3%) and dinner the least frequently skipped (21.5%). With regard to age, the frequency of skipping meals was 30.1%, 50.4% and 58.5% among participants aged <14 years, 14 - 16 years and ≥17 years, respectively ( p <0.001). The two leading reasons cited by participants for skipping breakfast were lack of appetite and time. Only 15.2% of the participants reported daily consumption of fruits and vegetables. Over half of the participants (60.2%) ate fast food at least once a week, with more than three-quarters of them (76.4%) consuming fast food along with soft drinks. The prevalences of both overweight (24.5% v. 13.2%) and obesity (2.5% v. 1.1%) were higher among girls who skipped meals compared with their peers who did not skip meals (odds ratio 0.4, 95% CI 0.32 - 0.50). Conclusion. Meal skipping was associated with an increased prevalence of overweight and obesity among adolescent schoolgirls.
21 citations
TL;DR: Patients who presented with DKA had a shorter duration of symptoms than the non-DKA group, and there was an unacceptable rate of missed diagnoses of type 1 diabetes in both the private and public sectors.
Abstract: Background. The clinical presentation of type 1 diabetes in children can be acute or insidious, and symptoms may be subtle and frequently misinterpreted. Presentation with diabetic keto-acidosis (DKA) may be associated with significant morbidity and mortality in the paediatric population. This study set out to determine the characteristics of children presenting to the paediatric endocrine service at Inkosi Albert Luthuli Central Hospital (IALCH) with DKA at the time of diagnosis, and to determine the frequency of missed diagnoses in the previous month. Methods. A retrospective study was done at IALCH, the paediatric tertiary referral centre for KwaZulu-Natal, South Africa. The study sample included all children with an initial diagnosis of type 1 diabetes between January 2008 and June 2010. Children presenting with DKA were compared with those who presented without DKA. Results. During the period under review, 63 children presented with type 1 diabetes. Of these, 44 (69.8%) had DKA at the time of diagnosis. The median duration of symptoms preceding diagnosis in the DKA group was 2 weeks, versus 4 weeks in the non-DKA group ( p =0.002). There was no significant difference between the groups when ethnicity, gender and age at presentation were compared. Of 42 patients who presented to healthcare facilities in the month preceding diagnosis, 27 (64.3%) were misdiagnosed. Conclusion. Patients who presented with DKA had a shorter duration of symptoms than the non-DKA group. Ethnicity had no effect on characteristics at presentation. There was an unacceptable rate of missed diagnoses of type 1 diabetes in both the private and public sectors.
18 citations
TL;DR: The triage tools discussed are the World Health Organization Emergency Triage Assessment and Treatment (ETAT), the South African adaptation of this tool known as ETAT-SA, theSouth African Triage Scale (SATS), and the Revised Paediatric SATS (P-SATS).
Abstract: Reducing child mortality is a high priority in sub-Saharan Africa, and swift, appropriate triage can make an important contribution to this goal. There has been a lot of interest and work in the field of triage of sick children in South Africa over the past few years. Despite this, in many parts of South Africa no formal system for triage of children in acute and emergency settings is used. This article aims to explain some of the key paediatric triage tools being considered and developed in South Africa. The triage tools discussed are the World Health Organization Emergency Triage Assessment and Treatment (ETAT), the South African adaptation of this tool known as ETAT-SA, the South African Triage Scale (SATS), and the Revised Paediatric SATS (P-SATS). The article describes how they were developed and their relevance to the country.
17 citations
TL;DR: Most caregivers do give ORT, but advice given at primary care level is often suboptimal, and ongoing strategies are needed to ensure optimal prevention policies, pre-hospital management and nutritional rehabilitation.
Abstract: Background. Diarrhoea remains a major cause of childhood morbidity and mortality in the developing world. Implementation of World Health Organization Integrated Management of Childhood Illness (IMCI) guidelines and pre-hospital use of oral rehydration therapy (ORT) in the Western Cape Province of South Africa are not well described. Objectives. To document pre-hospital home and primary care management of diarrhoea, and certain risk factors and complications of diarrhoea. Methods. We used a prospective descriptive convenience sample of children admitted to the short-stay ward at Tygerberg Hospital, Parow, Cape Town, between 1 February 2007 and 31 May 2008. Caregivers were interviewed, and demographic, clinical and laboratory variables were collected. Results. We recruited 142 children, median age 8.9 months. A third had moderate malnutrition. Twenty–four (16.9%) were HIV-exposed, with 9 (6.3%) HIV-infected. HIV-exposed children were significantly younger than unexposed children ( p =0.03). Weight-for-age Z -scores (WAZ) were significantly lower in HIV-infected than in HIV-exposed, uninfected children ( p =0.02). Eighty per cent of caregivers gave ORT and 35.2% stopped feeds. Only 1 of 43 children aged under 6 months was exclusively breastfed. Advice at primary care level rarely complied with IMCI guidelines. Conclusions. Most caregivers do give ORT, but advice given at primary care level is often suboptimal. Many hospitalised children with diarrhoea are malnourished. Children with HIV infection are at increased risk of diarrhoeal disease and malnutrition, and HIV exposure appears to increase the risk of early presentation with diarrhoea. Ongoing strategies are needed to ensure optimal prevention policies, pre-hospital management and nutritional rehabilitation.
16 citations
TL;DR: There is a need for periodic clinical audits and mortality review meetings to reduce deaths from childhood malnutrition so as to meet the WHO mortality target of less than 5% and improve child survival.
Abstract: Background. Swaziland adopted the World Health Organization (WHO) guidelines for the inpatient treatment of severely malnourished children in 2007, with the aim of reducing high case fatality rates for childhood malnutrition. However, no follow-up studies have been conducted to determine the reduction in these rates after implementation of the guidelines. Objectives. To determine the case fatality rate for childhood malnutrition after implementation of the WHO treatment guidelines. Methods. A retrospective observational study was undertaken. Demographic, anthropometric and clinical characteristics and outcomes for all children aged under 5 years admitted for inpatient treatment of malnutrition between January 2010 and December 2011 were recorded and analysed. Results. Of the 227 children who met the study inclusion criteria, 179 (64.6%) were severely malnourished and 98 (35.4%) had moderate malnutrition; 111 children died during admission, giving an overall case fatality rate of 40.1%. Mortality was significantly higher among severely malnourished children than among those with moderate malnutrition (46.9% v. 27.6%) (odds ratio (OR) 3.0, 95% confidence interval (CI) 1.7 - 5.3). Co-morbid pneumonia and gastroenteritis were significant predictors of mortality (OR 2.0, 95% CI 1.2 - 3.4 and OR 1.9, 95% CI 1.1 - 3.2, respectively). Conclusion. Case fatality rates for childhood malnutrition remain high despite adoption of the WHO treatment guidelines. There is a need for periodic clinical audits and mortality review meetings to reduce deaths from childhood malnutrition so as to meet the WHO mortality target of less than 5% and improve child survival.
12 citations
TL;DR: The neutrophil CD64 index has a high negative predictive value and can be used to rule out infection in neonates with signs and symptoms suggestive of sepsis/infection in the first 4 weeks of life, and should be used as a screening rather than a confirmatory test.
Abstract: Background and aim. Neonatal sepsis is a significant contributor to morbidity and mortality globally. Blood culture is the most reliable method for detection of bacterial infection. However, its sensitivity is low and its use in the diagnosis of bacteraemia is fraught with difficulties. CD64 antigen is up-regulated in neutrophils only when they are activated, and has been shown to be a potential biomarker for infection. The primary objective of this study was quantitation of neutrophil CD64 by flow cytometry in neonates with signs and symptoms suggestive of sepsis/infection in the first 4 weeks of life.
Methods and results. In this prospective observational study, patients were classified into categories of infection, namely definite, probable and possible. Of 76 neonates, 1 had definite infection, 5 probable infection, 300 possible infection, and 322 no infection. The neutrophil CD64 index at a cut-off value of 1.8 had a high negative predictive value (95.2%) in ruling out combined probable and definite infection.
Conclusions. We recommend inclusion of the neutrophil CD64 index into the diagnostic algorithm for neonatal sepsis, as it has a high negative predictive value and can be used to rule out infection. As the positive predictive value of the index was low in confirming infection, it should be used as a screening rather than a confirmatory test.
TL;DR: The anthropometric parameters of the Nigerian infants studied were within the range previously reported for Africa and other developing countries, but lower than figures from some developed countries.
Abstract: Background. Weight and length at birth reflect the quality of intra-uterine growth and exert a strong influence on postnatal survival. Objective. To determine the current range of anthropometric measurements of term Nigerian neonates. Methods. Consecutive term singleton mother-baby pairs were surveyed in the first 24 hours after birth. Weight, length, occipitofrontal circumference (OFC) and ponderal index were determined. Results. A total of 825 babies (440 males and 385 females) were studied. The overall mean birth weight (± standard deviation (SD)) of the study subjects was 3 233±539 g, the mean ±SD length 49.0±2.5 cm, the mean ±SD OFC 34.6±1.4 cm, and the mean ±SD ponderal index 2.7±0.4 g/cm 3 . Conclusion. The anthropometric parameters of the Nigerian infants studied were within the range previously reported for Africa and other developing countries, but lower than figures from some developed countries.
TL;DR: This is the first study to survey feeding practices of paediatricians in SA, and the data could be valuable in the design of local collaborative trials to determine optimal feeding strategies.
Abstract: Background. Optimal feeding regimens in babies weighing <1 000 g have not been established, and wide variations occur. In South Africa (SA) this situation is complicated by varied resource constraints.
Objective. To determine the preterm enteral feeding practices of paediatricians in SA.
Methods. We invited 288 paediatricians to participate in a cross-sectional web-based survey.
Results. We received responses from 31.2% of the paediatricians; 43.6% were from the state sector and 56.4% from the private sector. Most participants worked in medium-sized neonatal units with 6 - 10 beds. The proportions commencing feeds within the first 24 hours were 24% in infants of <25 weeks’ gestational age, 36% in infants 25 - 27 weeks, and 65% in infants 28 - 31 weeks. Feed volumes were routinely advanced daily in 47% of infants <25 weeks, 68% of infants 25 - 27 weeks, and 90% of infants 28 - 31 weeks. Forty-five per cent of infants <25 weeks received continuous intragastric feeds, while 50% of those in the 28 - 31 weeks group were on 3-hourly bolus feeds. The majority of the participants targeted full enteral feeds of 161 - 180 ml/kg/d, 66.7% had access to donor milk, and 77% used breastmilk fortifier.
Conclusion. This is the first study to survey feeding practices in SA. The survey did not highlight differences in feeding practices among paediatricians. These data could be valuable in the design of local collaborative trials to determine optimal feeding strategies.
TL;DR: This research report is submitted in partial fulfillment of the requirements for the degree of Master of Medicine in the Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, November 2014.
Abstract: This research report is submitted in partial fulfillment of the requirements for the degree of
Master of Medicine in the Department of Paediatrics and Child Health, Faculty of Health
Sciences, University of Witwatersrand, Johannesburg
November 2014
TL;DR: At term, AF size has no relationship to GA or such growth parameters as head circumference, birth weight and length, and the relationship of the findings to some factors reported to affect AF size is evaluated.
Abstract: Background. Several factors, including gestational age (GA), gender, race and geographical/regional area, contribute to variations in the size of the anterior fontanelle (AF). While the impact of GA and gender are clearly established, the influences of region and ethnicity vary in the published literature. Objectives. To assess AF sizes in normal newborn Igbo babies in south-eastern Nigeria, establish baseline values for our population, and evaluate the relationship of our findings to some factors reported to affect AF size. Methods. AF size was measured in 269 healthy term newborn babies using the method proposed by Popich and Smith and modified by Faix. Measurements were taken 24 - 48 hours after birth. Results. The mean AF size was 2.97 cm (± standard deviation (SD) 0.71, range 2.0 - 4.8). Female babies had slightly larger anterior fontanelles than males (2.98±0.75 cm v. 2.97±0.67 cm, respectively), although this was not statistically significant ( p >0.05). Size of the AF had no significant correlation with head circumference (Pearson correlation coefficient r =-0.01; p =0.89), birth weight ( r =-0.05; p =0.39) or length ( r =-0.00; p =0.99) of these term babies. Neither GA nor mode of delivery influenced AF size ( p >0.05). The mean anteroposterior dimension of the AF (3.22±0.82 cm) was significantly longer than the mean transverse dimension (2.71±0.65 cm) ( p <0.01). Conclusions. At term, AF size has no relationship to GA or such growth parameters as head circumference, birth weight and length. The mean AF size of 2.97±0.71 cm obtained in this study is recommended for use in assessing term Igbo newborns.
TL;DR: The Tshwane DCST is used as a case study to describe the challenges encountered in establishing the team within the complex district health system and the cross-disciplinary approach has proved itself a winning combination.
Abstract: District Clinical Specialist Teams (DCSTs) are part of the primary healthcare re-engineering process in South Africa. These multidisciplinary clinical teams were established throughout the country in 2012, and their main role is reduction of maternal and childhood mortality and morbidity through improvement of service delivery at primary care level in their health districts. The Tshwane DCST is used as a case study to describe the challenges encountered in establishing the team within the complex district health system. On the other hand, the cross-disciplinary approach has proved itself a winning combination if the team shares a common vision and has a work plan to guide the priorities and facility support visits. Through their clinical expertise, and using extensive networking, DCSTs are well positioned in the health system to have a strong positive effect on child health.
TL;DR: In infants with asphyxia, prophylactic phenobarbital does not reduce the incidence of seizures, HIE and mortality.
Abstract: Background. Seizures after an asphyxial insult may result in brain damage in neonates. Prophylactic phenobarbital may reduce seizures.
Objective. To determine the effect of prophylactic phenobarbital on seizures, death and neurological outcome at hospital discharge.
Methods. Neonates with base deficit >16 mmol/l and Apgar score at 5 minutes 5 minutes at the time of birth were randomised to prophylactic phenobarbital 40 mg/kg (n=50) or placebo (controls) (n=44) within the first 6 hours of life. They were monitored for clinical seizures, hypoxic ischaemic encephalopathy (HIE) and mortality.
Results. Seizures developed in 30.0% of the phenobarbital group as opposed to 47.7% of the control group (relative risk 0.63; 95% confidence interval -0.37 - 1.06; p=0.083). The proportions of patients who had died and/or had HIE II or III at time of discharge from hospital were similar in the two groups (42.0% v. 45.5%). There were no differences in mortality between the two groups (14.0% v. 15.9%).
Conclusion. In infants with asphyxia, prophylactic phenobarbital does not reduce the incidence of seizures, HIE and mortality.
TL;DR: The only statistically significant predictor of poor outcome of AIR was time delay before attempted reduction, and the institution’s radiological reduction outcomes were not comparable to international standards.
Abstract: Background. Intussusception remains the most common cause of bowel obstruction in infants and toddlers and can result in considerable morbidity and mortality if not properly treated. The aim of this study was to determine the success rate of air intussesception reduction (AIR), and to identify factors predicting an unsuccessful procedure, among paediatric patients diagnosed with idiopathic intussusception at the Bloemfontein Academic Hospital Complex, Free State, South Africa. Methods. This retrospective analytic cohort study assessed data from the records of all paediatric patients with the diagnosis of idiopathic intussusception discharged from the Department of Paediatric Surgery between 1 January 2003 and 30 September 2011. Results. Thirty-five children with intussusception were identified. AIR enemas were performed in 18 children (51.4%), with successful reduction in 2 (11.1%). Seventeen children (48.6%) were primarily treated surgically without attempting radiological reduction. Successful AIR was more likely if the duration of symptoms was <48 hours. Sixteen patients in whom AIR was attempted eventually required surgical intervention, either due to perforation during AIR or irreducibility. Approximately 94% of children required bowel resection at surgery. In 37.5% of cases AIR was complicated by perforation, making surgical treatment mandatory. Nine patients (56.3%) had unsuccessful AIR without perforation, but needed bowel resection at surgery. One patient (6.3 %) required manual reduction only, without the need for bowel resection at surgery. No deaths were recorded during the period covered by this audit. Conclusions. Our institution’s radiological reduction outcomes were not comparable to international standards. The only statistically significant predictor of poor outcome of AIR was time delay before attempted reduction.
TL;DR: MCD is the predominant lesion in children with SRNS at this institution, followed by FSGS and IgAN, and histopathological lesions seen on renal biopsy specimens comprised minimal-change disease (MCD), focal segmental glomerulosclerosis (FSGS) and immunoglobulin A nephropathy (IgAN).
Abstract: Background. Steroid-resistant nephrotic syndrome (SRNS) is a common problem in paediatric nephrology practice. There is currently little information on the spectrum of histopathological lesions in children presenting with SRNS in India and other south-east Asian countries. Objective. To determine the histopathological lesions in children presenting with SRNS at our institution. Methods. The study was conducted at Sardar Vallabh Bhai Patel Postgraduate Institute of Paediatrics and Sriram Chandra Bhanja Medical College, Cuttack, Odisha, India, from January 2009 to March 2013. All children aged 1 - 14 years presenting with primary SRNS and in whom renal biopsies were performed were included in the study. Their demographic, clinical, laboratory and histopathological data were retrieved from files and original renal biopsy forms. Results. A total of 40 children had a clinical diagnosis of SRNS; 23 were males and 17 females (male:female ratio 1.35). Their mean age (± standard deviation) was 4.47 (±2.98) years (range 1 - 14 years). The histopathological lesions seen on renal biopsy specimens comprised minimal-change disease (MCD) ( n =18), focal segmental glomerulosclerosis (FSGS) ( n =12), immunoglobulin A nephropathy (IgAN) ( n =5), immunoglobulin M nephropathy ( n =2), membranous nephropathy ( n =2) and idiopathic mesangial proliferative glomerulonephritis ( n =1). Conclusion. MCD is the predominant lesion in children with SRNS at our institution, followed by FSGS and IgAN.
TL;DR: The administration of 200 mg/kg poractant alpha led to a significant improvement in oxygenation and a reduction in the need for further doses of surfactant during the period December 2008 - December 2011.
Abstract: Background. The treatment guideline for the management of respiratory distress syndrome in the newborn unit at Auckland City Hospital (ACH), Auckland, New Zealand, was amended in July 2010. In keeping with current evidence, the initial dose of poractant alpha was increased from 100 mg/kg to 200 mg/kg. The outcomes of newborns requiring treatment with surfactant before and after this change were reviewed. Methods. Electronic clinical records were reviewed of infants admitted to ACH who received surfactant during the period December 2008 - December 2011. There were two groups: group A were infants who received 100 mg/kg of poractant alpha as an initial dose (December 2008 - June 2010), and group B were infants who received 200 mg/kg as an initial dose (July 2010 - December 2011). Infants with congenital anomalies and those treated with surfactant before transfer to ACH were excluded. Results. A total of 256 infants were included in the analysis, 118 in group A and 138 in group B. Infants in group B had a higher median gestational age (28 v. 27 weeks; p =0.52) and birth weight (1 065 g v. 930 g; p =0.08) compared with infants in group A. Significantly more infants in group A received more than one dose of surfactant (33.9% v.15.9%; odds ratio 2.7; p =0.0008). Infants in group B showed a significant reduction in oxygen requirement after the administration of surfactant ( p =0.0003). Conclusion. The administration of 200 mg/kg poractant alpha led to a significant improvement in oxygenation and a reduction in the need for further doses of surfactant.
TL;DR: A rare case of neonatal meningococcal meningitis, complicated by subdural empyema and hydrocephalus is reported from South Africa.
Abstract: Neisseria meningitidis is a leading cause of pyogenic meningitis worldwide, as well as causing large epidemics in parts of Africa. With the dramatic decline in cases of Haemophilus inuenzae B, N. meningitidis has emerged as one of the most common causes of acute bacterial meningitis in children and adults in South Africa. However, it remains an uncommon cause of meningitis in the neonatal period. Subdural empyema together with hydrocephalus has been infrequently described as a complication of meningococcal meningitis. We report a rare case of neonatal meningococcal meningitis, complicated by subdural empyema and hydrocephalus. To the best of our knowledge only a few cases of neonatal meningococcal meningitis have been reported from South Africa, with none of these cases having the complication of subdural empyema.
TL;DR: To determine internipple distance and the internipple index and their correlation with gender, birth weight, length, chest circumference and gestational age in term Indian newborns, full-term newborn infants of both genders within 72 hours of birth were measured and calculated.
Abstract: Background. Anthropometric parameters such as the distance between the nipples and the internipple index are important signs of some genetic disorders. Indian data on these measurements are scarce. Objectives. To determine internipple distance and the internipple index and their correlation with gender, birth weight, length, chest circumference and gestational age in term Indian newborns. Methods. Internipple distance was measured and the internipple index was calculated in 1 077 full-term newborn infants of both genders within 72 hours of birth at a tertiary care hospital in North India. The chest circumference was measured and the internipple index was calculated. Values for male and female infants were compared and correlated with weight, length, chest circumference and gestational age. Results. The mean internipple distance (± standard deviation) was 8.5±1.4 cm and the mean internipple index was 27.04±3.5% in male and female infants taken together. The 3rd and 97th percentile values for internipple distances were 7.3 cm and 9.5 cm, respectively. Male infants had a larger mean internipple distance than females ( p =0.03), but the two groups had a similar mean internipple index. Weight, length, chest circumference and gestation had a positive correlation with internipple distance and internipple index in both genders ( p 9.5 cm apart (>97th percentile) and narrowly spaced if <7.3 cm apart (<3rd percentile). Internipple distance tended to be significantly greater in male neonates than in females.
TL;DR: Treatment consisted of eight courses of chemotherapy with vincristine, actinomycin-D and cyclophosphamide, followed by surgical removal of the remaining mass, and the outcome was impressive and encouraging.
Abstract: Desmoid tumours are a rare group of locally aggressive, non-malignant tumours ofbroblastic origin that can result in signicant morbidity due to local invasion. Facial involvement in children with aggressivebromatosis is uncommon. We present the case of a 14-month-old Rwandan child with an aggressive desmoid tumour involving the lemid-facial region. �e patient presented with severe stertor due to massive nasal obstruction. Aer intensive supportive care the diagnosis was conrmed histopathologically. Treatment consisted of eight courses of chemotherapy with vincristine, actinomycin-D and cyclophosphamide, followed by surgical removal of the remaining mass. �e outcome was impressive and encouraging. S Afr J CH 2013;7(3):117-118. DOI:10.7196/SAJCH.593
TL;DR: The result was that the emotionally charged work of caring for children reaching the end of their lives became more challenging for the caregivers because they were not prepared for cultural complexities.
Abstract: Background. In general, the principles of palliative care suggest that, at some stage, patients should be given ‘bad news’ about poor illness prognosis. The information is often important for care planning, especially when it involves disclosure to children. Although there are ongoing debates about whether to tell or not to tell children bad news, these debates have largely been informed by patients who live in a developed-world context. In contrast, this paper focuses on telling bad news to children and their families from a rural, developing-world context. Objective. The objective was to analyse the experiences of providers of palliative care to children when they attempted to fulfil one of their roles as palliative caregivers, i.e. to prepare patients and families for a child’s poor illness prognosis. Method. This was an exploratory study that was approached qualitatively. Five nurses and eight home-based care workers who provided palliative care for children in rural areas of South Africa formed a purposive, information-rich, self-selected sample. Data were produced through discussions with participants, using photographs taken by the caregivers to stimulate and contextualise the discussions. Results. Participants experienced four dilemmas with regard to telling bad news: when families did not want to be told any bad news; when participants felt uncomfortable about telling bad news; when participants and patients shared dissimilar values about telling bad news; and when participants were unsure about when to tell bad news. Conclusion. In the rural areas where the study was conducted, children are not usually given bad news about their illness. Disclosing poor prognosis led to the dilemmas faced by caregivers. The result was that the emotionally charged work of caring for children reaching the end of their lives became more challenging for the caregivers because they were not prepared for cultural complexities. In view of the findings of this study, there is a need for ongoing research into paediatric palliative caregiving in context.
TL;DR: Before any form of treatment for a caudal appendage is undertaken, the patient must be evaluated carefully in case it coexists with a lesion of the intraspinal component.
Abstract: Context. The dorsal cutaneous appendage, or so-called human tail, is often considered to be a cutaneous marker of underlying occult spinal dysraphism. Human tails have always elicited curiosity. A unique case of human dysraphism is described.
Case report. An interesting case of a child with a tail-like caudal appendage that had been present since birth is reported. Surgical excision of a pseudo-tail was done together with repair of a meningocele.
Conclusion. Before any form of treatment for a caudal appendage is undertaken, the patient must be evaluated carefully in case it coexists with a lesion of the intraspinal component.
TL;DR: A 14-month-old boy is described with the typical dysmorphic facies and other congenital abnormalities characteristic of FVS, which results from teratogenic effects of valproic acid exposure in the prenatal period.
Abstract: Anti-epileptic drugs administered during pregnancy can cause structural defects in the growing fetus and result in adverse neurodevelopmental outcome later in life. Fetal valproate syndrome (FVS) results from teratogenic effects of valproic acid exposure in the prenatal period. It is characterised by a distinctive dysmorphic facies and a cluster of minor and major anomalies, as well as developmental and behavioural abnormalities. We describe a 14-month-old boy with the typical dysmorphic facies and other congenital abnormalities characteristic of FVS. There was a history of maternal intake of sodium valproate during pregnancy. The mechanism of teratogenicity and methods for prevention are discussed.
TL;DR: The main reason for discontinuing caffeine early was the baby’s ability to feed satisfactorily, a demonstration of physiological maturity, and as feeding behaviours mature significantly between 33 and 36 weeks, the ability toFeed may be a good indication that caffeine therapy can be stopped.
Abstract: Background. Methylxanthines such as caffeine have been proven to reduce apnoea of prematurity and are often discontinued at 35 weeks’ corrected gestational age (GA). Objective. To ascertain whether a caffeine protocol based on international guidelines is applicable in our setting, where GA is often uncertain. Methods. A prospective folder review was undertaken of all premature infants discharged home over a 2-month period. Results. Fifty-five babies were included. All babies born at less than 35 weeks’ GA were correctly started on caffeine as per protocol. GA was assigned in 85.5% of cases by Ballard scoring and in 14.5% from antenatal ultrasound findings. Caffeine was discontinued before 35 weeks in 54.5%. Discussion. The main reason for discontinuing caffeine early was the baby’s ability to feed satisfactorily, a demonstration of physiological maturity. As feeding behaviours mature significantly between 33 and 36 weeks, the ability to feed may be a good indication that caffeine therapy can be stopped.
TL;DR: The main aim of this study was to evaluate the billirubin level 24 and 48 hours after cessation of phototherapy in neonates admitted to the authors' hospital with jaundice and also evaluated haemoglobin levels and duration ofPhototherapy for a possible association with rebound hyperbilirubinaemia.
Abstract: Introduction and aim. Approximately 60% of term neonates and 80% of preterm neonates develop hyperbilirubinaemia in the first week of life. Rebound hyperbilirubinaemia may occur after cessation of phototherapy, especially when the Coombs test is positive, in premature infants, and in those treated with phototherapy for less than 72 hours. The main aim of this study was to evaluate the billirubin level 24 and 48 hours after cessation of phototherapy in neonates admitted to our hospital with jaundice. We also evaluated haemoglobin (Hb) levels and duration of phototherapy for a possible association with rebound hyperbilirubinaemia.
Patients and methods. The study was a clinical trial in term neonates (gestational age ≥37 weeks) with hyperbilirubinaemia who were admitted to the Deptartment of Neonatology at Mofid Children’s Hospital, Tehran, Iran. Exclusion criteria were neonatal infection, glucose-6-phosphate dehydrogenase deficiency, a history of neonatal exchange transfusion, and parental refusal. Phototherapy was delivered via a Philips TL 45/20W at 15 - 20 cm distance from the skin. We discharged patients after cessation of phototherapy. Total serum bilirubin (TSB) was checked in the neonates 24 and 48 hours after cessation of phototherapy. We included patients in whom follow-up tests were completed at 24 and 48 hours after discharge. Chi-square and Student’s t-tests were used for data analysis using SPSS version 13.0 (SPSS Inc., Chicago, IL, USA).
Results. Twenty-five girls and 37 boys were included in the study. The mean admission age was 5.4 (standard deviation (SD) 0.5) days for girls and 8.0 (SD 0.6) days for boys (p=0.041). The mean Hb values for the girls and the boys were 15.0 (SD 0.39) g/dl and 15.9 (SD 0.36) g/dl, respectively (p=0.108). The mean TSB levels for the girls and the boys were 322.6 (SD 9.4) µmol/l and 322.3 (SD 7.3) µmol/l, respectively (p>0.05). The mean admission and pre-discharge TSB levels of 322.3 (SD 5.6) µmol/l and 187.9 (SD 3.2) µmol/l were significantly different (p=0.0). The mean TSB levels 24 and 48 hours later were 197.8 (SD 4.6) and 195.1 (SD 5.3) µmol/l, respectively, with no significant difference between them (p>0.05).
Conclusion. We found no significant differences between mean TSB levels at the time of termination of phototherapy and 24 and 48 hours later. We therefore do not recommend checking for rebound bilirubinaemia after phototherapy.
TL;DR: A representative profile of indications was successfully obtained, which can assist with the implementation of further research on the stratification of radiation exposure according to indications for radiographs in the Neonatal Intensive Care Unit at Universitas Academic Hospital, Bloemfontein, South Africa.
Abstract: Introduction. Radiography is a key diagnostic tool in paediatric care. A pro-active approach (including the use of radiography) is required to ensure effective management of these patients. Taking into account the widely documented harmful effects of ionising radiation and the small organ masses of neonates, the number of radiographs that neonates receive during hospital admission is of particular concern. A reduction in radiation exposure tailored to specific indications would be advantageous. The aim of this study was therefore to establish a profile of indications for radiographs in the Neonatal Intensive Care Unit at Universitas Academic Hospital, Bloemfontein, South Africa.
Methods. A retrospective, descriptive study was conducted over a 1-month period (8 September - 8 October 2010). Information was obtained from the online Medi-Tech system used to request radiographs.
Results. A total of 469 radiographs were performed on 51 neonates. Twenty-seven male and 24 female neonates received 226 (48.2%) and 243 (51.8%) radiographs, respectively. The radiographs were classified into routine (91.9%) and urgent (8.1%). Chest radiographs were requested most frequently (59.5%). The most commonly recorded indication was prematurity (37.1%), followed by respiratory-related indications (28.5%). The highest number of radiographs performed on a single neonate was 46.
Conclusions. All radiographs were requested online, supporting the validity of the study with regard to the number of radiographs performed and their respective indications. A representative profile of indications was successfully obtained, which can assist with the implementation of further research on the stratification of radiation exposure according to indications for radiographs.
TL;DR: A case of a toddler with LCH with skeletal involvement, who primarily presented to an orthopaedic surgeon, which is presented to a paediatric oncologist for risk stratification and further management.
Abstract: Langerhans cell histiocytosis (LCH) is a disease of unknown aetiology. It is characterised by extreme clinical heterogeneity that can bring it to the attention of a variety of healthcare workers. A high index of suspicion is key to early diagnosis. Once the diagnosis has been confirmed, all cases should be referred to a paediatric oncologist for risk stratification and further management. We present a case of a toddler with LCH with skeletal involvement, who primarily presented to an orthopaedic surgeon. Relevant knowledge about this condition is reviewed.