Browsing by Author "Morrow, Brenda"

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    A Description of the Use of Sildenafil in the Paediatric Intensive Care Unit at Red Cross War Memorial Children's Hospital
    (2024) El-Boraei, Samah; Morrow, Brenda
    Background. The clinical profiles of African children with pulmonary hypertension (PH) are largely unknown. Sildenafil is the only available oral treatment for PH in South Africa (SA) and is widely used, mostly off-label, despite little evidence for safety or efficacy. Objectives. To describe the use of sildenafil in the Paediatric Intensive Care Unit (PICU) at Red Cross War Memorial Children's Hospital (RCWMCH), to provide insights into the clinical profiles and outcomes of children with PH Methods. A retrospective descriptive study of all children treated with sildenafil in the PICU between 1 January 2017 and 31 December 2019. Results. 108 patients in 162 PICU admissions were included (median age 5 months; 54.6% male), accounting for 4.1% of all PICU admissions during the study period. Most patients (n=92, 85.2%) had congenital heart disease (CHD), which was associated with survival on univariate analysis (p=0.009). The majority (n=37, 34.3%) were classified as World Health Organisation PH Classification Group 1: Pulmonary Arterial Hypertension. Sildenafil was initiated in PICU in 98 (72.1%) cases and for inhaled nitic oxide (iNO) weaning in 56 (57.1%). For most patients, sildenafil was continued after PICU (n=104, 76.5%) and hospital (n=66, 48.5%) discharge. The three-year survival rate was 75.9 % (n=82). Conclusions. In our PICU population, sildenafil is used predominantly for CHD related PH. Sildenafil is used to facilitate iNO weaning and is frequently continued long-term after hospital discharge. Survival rates were acceptable. Research is needed to determine the true prevalence of PH and the safety profile of sildenafil in SA.
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    Acquired infections in paediatric patients after cardiac surgery
    (2015) Appel, Ilse Nadine; Argent, Andrew; Morrow, Brenda
    Introduction: Hospital acquired infections (HAIs) are an important cause of morbidity and mortality following paediatric cardiac surgery. Aim: To determine the incidence, risk factors for and outcome of postoperative HAIs in the Paediatric Intensive Care Unit (PICU) of the Red Cross War Memorial Children's Hospital (RCWMCH) in Cape Town. Methods: A prospective observational study of all postoperative cardiac patients admitted to PICU from September 2011 to March 2012. The definitions of laboratory confirmed blood stream infections (BSI), urinary tract infections (UTI), and surgical site infections were based on the Centres of Disease Control criteria. Ventilator associated pneumonia (VAP) was diagnosed using a modification of the Clinical Pulmonary Infection Score (CPIS). Results: 110 patients (median age 19 months; 43% male) undergoing 126 surgical procedures were enrolled. Sixty HAIs occurred in 43 (39%) patients (68.3% pulmonary; 13.3% blood; 11.7% wound; 3.3% urine; 3.3% tissue). Nine (8.2%) patients died and their deaths were not related to HAIs.
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    Children admitted to Paediatric Intensive Care at Red Cross War Memorial Children?s Hospital with Non-Accidental injuries (2012-2020): a retrospective descriptive study
    (2025) Bowes, Lynelle; Morrow, Brenda; Rossouw Beyra
    Objectives: To describe the characteristics and outcomes of patients admitted to the paediatric intensive care unit (PICU) with suspected non-accidental injury (NAI). Methods: A retrospective descriptive study of routinely collected data from all children admitted to the PICU with suspected NAI from 1 January 2012 to 31 December 2020. Results: Of 11345 children admitted to PICU, 42 (0.4%) patients with suspected NAI (median (IQR) age 20.3 (7.9 – 62.6) months; 61.9% male) were included in the data analysis. Most patients sustained physical injury (n=31; 73.8%) from assaults (n=19; 45.2%), and head injuries were the most common injury site (n=24; 57.1%). Of the patients, 37 (88.1%) received invasive mechanical ventilation for median 2.0 (IQR) (1.0 – 3.8) days. PICU mortality was 28.6% (n=12), with a risk adjusted mortality (observed/mean predicted mortality) of 3.2. Of the 30 PICU survivors, 7 (23.3%) were discharged with long-term disability, whilst the functional outcome of 16 (53.3%) survivors is not known. A multivariable binary logistic regression was conducted to determine the effect of inotropes, type of NAI, mechanism of injury, injury site (head, skin – eye injuries removed from the model for reasons of collinearity), and multiple injuries on patient survival. The model was significant (p = 0.001) and a good fit for the data (Nagelkerke R square 0.78) and was able to correctly predict 85.7% of cases. None of the variables in the model were r found to be independently associated with survival (p > 0.1 for all). Conclusions: Children who have sustained NAI represent a small proportion of PICU admissions, with higher-than-expected mortality and considerable morbidity. Patient follow-up is recommended to determine long-term functional and psychosocial outcomes.
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    Cystic fibrosis in South Africa: spectrum of disease, diagnosis, and determinants of outcome
    (2023) Zampoli, Marco; Morrow, Brenda
    Cystic fibrosis (CF) occurs with varying incidence in all populations throughout the world but much less is known about the epidemiology and outcomes of CF in low-or-middle income countries (LMIC) compared with high income settings. Continued improvement in CF-related outcomes and survival witnessed in the past decades is attributed to multiple factors yet sub-optimal quality of CF care, and limited CF diagnosis capacity continue to exist in most LMIC, including South Africa (SA). CF treatment and prognosis have been transformed by the recent introduction of highly effective cystic fibrosis transmembrane conductance regulator modulator drugs (CFTRm). However, access to these transformative drugs for those with eligible genotypes is currently limited to high-income countries. Understanding the clinical spectrum of CF in SA and investigating novel techniques to diagnose CF is important to advocate for improved quality of CF care including CFTRm drugs. The overall aim of this work was to document the spectrum and outcomes of CF in South Africans and to investigate more sensitive measures to diagnose CF and CFTR-related disorders in this population. The studies included in this thesis are divided into two components. This first component comprises observational cohort studies derived from a single-centre CF clinic dataset in Cape Town, SA, and the nation-wide South African CF registry, which was established in 2018 in preparation for this thesis. The CF registry cohort in SA was then compared in a cross-sectional study to a matched Canadian CF registry cohort, and differences in lung function and nutrition outcomes adjusted for known factors. The second component was a prospective study investigating the feasibility and diagnostic utility of the novel β-adrenergic sweat test in a cohort of South Africans with inconclusive CF diagnosis. The chapters of this thesis are presented as published manuscripts, which collectively address the overall aim of this body of work. The SA CF registry in its first year of inception captured a total of 447 people with CF across both private and public health sectors. Summary demographic descriptions of the cohort include median age of 14.7 years with self-identified White race making up 70% of the CF population, followed by Mixed-race ancestry (19%) and Black Africans (10%). Genotype pattern mirrored ancestry with F508del is the most common variant in Whites and people with Mixed-race ancestry, and 3120+1G>A (class I) the most common variant in Black Africans. Overall, 81% of people with CF (pwCF) in SA have at least one copy of F508del and are, thus, eligible for elexacaftor/tezacaftor/ivacaftor. A key finding of the registry-based studies was that lung function and nutrition outcomes in SA were significantly lower across all ages compared with Canada, attributed to differences in the quality of CF care and social determinants of CF health between the two countries. In SA, poor nutrition was the strongest factor independently associated with severe lung disease and was more prevalent in people living in lower 10 socioeconomic conditions, including people who were not White. Another key finding was despite significant improvement in overall CF survival at a single centre in Cape Town over the past 40 years, disparities between race groups still exist in SA with increased risk of mortality observed in young children who were not White. People with Black African ancestry, who form the majority of the SA population, are likely to be underrepresented in the SA CF registry, raising concern that CF is being missed or underdiagnosed in the majority of South Africans. Furthermore, the genotype of Black Africans means that none are eligible for CFTRm, which has serious implications for future treatment. These registry-based studies highlight disparities in CF care and outcomes both within SA and compared with a high-income setting – novel findings because SA is one of only a few LMIC with CF registries. Addressing these disparities affecting people with CF in SA will require interventions such as greater awareness of CF in SA, universal newborn screening for CF, focused attention on improving nutrition and overall improvement in the quality of essential CF care, especially as LMIC have disproportionally more pwCF who are ineligible for CFTRm drugs. The diagnosis of CF using standard approaches may remain inconclusive in a small proportion of individuals, which leads to unnecessary anxiety for families and inappropriate treatment where people do not actually have CF or a CFTR-related disorder. Furthermore, accurate diagnosis of CF is important for research and submission of registry data. The β-adrenergic sweat test was proposed as an easier alternative to other electrophysiological measurements of CFTR function such as nasal potential difference and intestinal current measurements, which are not available in SA. We therefore conducted a study evaluating this hypothesis in adult subject controls, and 32 individuals (mostly children) whose CF diagnosis was inconclusive. Key findings of this study were that the β-adrenergic sweat was superior to sweat chloride test in excluding CF in the majority of subjects and that βadrenergic sweat secretion in children was lower compared to adults. Implications and novelty of this research are that existing reference ranges for this test may not be applicable in children, and confirmation that the β-adrenergic sweat test is a viable alternative for measuring CFTR function. A number of families benefited from this study by reversal of their incorrect CF diagnosis. The overriding finding and impact of this work has been to highlight disparities in diagnosis, treatment, and outcomes of CF within SA and in the global context. The current status of CF care in SA mirrors many other LMIC that share similar challenges and barriers to improving CF care, including access to affordable CFTRm drugs. The findings of this thesis have made valuable contributions to local and global advocacy initiatives to improve CF care and access to CFTR drugs for many thousands of pwCF living in LMIC who are being left behind in this new era of CF treatment.
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    Developing a home-based program to mitigate musculoskeletal complications in children with severe cerebral palsy in resource limited settings: a modified Delphi study
    (2025) Van Aswegen, Shayne Robyn; Morrow, Brenda; Richards, Mark
    Background: Children living in resource-limited settings (RLS) with severe cerebral palsy (CP) are at considerable risk of developing secondary musculoskeletal (MSK) complications, which can cause substantial discomfort and significantly restrict activity and age-appropriate participation. Current clinical guidelines do not adequately address complication prevention or promotion of participation for this population. Aim: To develop the components of a home-based intervention programme (HBIP) to mitigate musculoskeletal complications in children with severe cerebral palsy (non-or partially ambulant or Gross Motor Function Classification System level III to V), so as to promote inclusion, suitable for use in resource-limited South African (SA) settings. Method: First, a scoping review of the literature was completed to identify potential programme components, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). Focus group discussions were conducted with 15 caregivers of children with severe CP from a peri-urban setting in KwaZulu Natal, SA, to explore their contextual needs and preferences for a caregiver-delivered intervention. Then, in accordance with the Appraisal of Guidelines Research and Evaluation (AGREE II) tool, the results of the scoping review and focus group discussions were collated as statements and presented to an expert panel to produce a proposal for a HBIP, using a modified Delphi methodology. The panel rated their agreement on a Likert scale, requiring three Delphi rounds for modification and re-iteration until consensus was reached. The final proposed HBIP was returned to the caregivers for comment and approval before being finalised. Results: Fifteen multidisciplinary healthcare experts participated in producing the final set of 62 consensus statements. These statements were grouped into five sections: the importance of the intervention; programme elements; caregiver training; and the implementation and community support mechanisms. Panellists agreed that caregivers should be trained in “24- hour postural management” and “splinting” interventions to prevent musculoskeletal (MSK) deformities, given strategies to assist with activities of daily living (e.g., feeding), and provided with tools for communication, cognitive development, and social participation. Community-based therapists should provide caregiver training and oversight, but community health workers should play a pivotal role in supporting programme implementation. Conclusion: This consensus guideline document provides a detailed and actionable home-based intervention suitable for resource-limited SA settings, to mitigate complications and increase participation opportunities for children with severe CP. Implementation studies are recommended to determine feasibility, acceptability, and efficacy in real-world settings.
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    Gravity assisted continuous flow peritoneal dialysis (CFPD) in children with acute kidney injury
    (2025) Nourse, Peter; Morrow, Brenda
    Background: Peritoneal dialysis (PD) has long been a mainstay of acute kidney injury (AKI) management in children of all ages, and it remains the most commonly used modality in low-income regions, where continuous kidney replacement therapy (CKRT) is not widely available. Compared to extracorporeal therapies, PD has lower clearance as well as lower and less precise fluid removal. We previously demonstrated increased ultrafiltration and clearances using continuous flow peritoneal dialysis (CFPD) in children with AKI, however the technique described required expensive high-volume CKRT pumps to circulate fluid, as well as high level technical expertise, limiting its utility in resource-constrained settings. Identifying safe, effective and low-cost techniques for CFPD may improve access to dialysis for children with AKI in low-resource settings.
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    Improved detection of Pneumocystis jirovecii in upper and lower respiratory tract specimens from children with suspected pneumocystis pneumonia using real-time PCR: a prospective study
    (BioMed Central Ltd, 2011) Samuel, Catherine M; Whitelaw, Andrew; Corcoran, Craig; Morrow, Brenda; Hsiao, Nei-Yuan; Zampoli, Marco; Zar, Heather
    BACKGROUND: Pneumocystis pneumonia (PCP) is a major cause of hospitalization and mortality in HIV-infected African children. Microbiologic diagnosis relies predominantly on silver or immunofluorescent staining of a lower respiratory tract (LRT) specimens which are difficult to obtain in children. Diagnosis on upper respiratory tract (URT) specimens using PCR has been reported useful in adults, but data in children are limited. The main objectives of the study was (1) to compare the diagnostic yield of PCR with immunofluorescence (IF) and (2) to investigate the usefulness of upper compared to lower respiratory tract samples for diagnosing PCP in children. METHODS: Children hospitalised at an academic hospital with suspected PCP were prospectively enrolled. An upper respiratory sample (nasopharyngeal aspirate, NPA) and a lower respiratory sample (induced sputum, IS or bronchoalveolar lavage, BAL) were submitted for real-time PCR and direct IF for the detection of Pneumocystis jirovecii. A control group of children with viral lower respiratory tract infections were investigated with PCR for PCP. RESULTS: 202 children (median age 3.3 [inter-quartile range, IQR 2.2 - 4.6] months) were enrolled. The overall detection rate by PCR was higher than by IF [180/349 (52%) vs. 26/349 (7%) respectively; p < 0.0001]. PCR detected more infections compared to IF in lower respiratory tract samples [93/166 (56%) vs. 22/166 (13%); p < 0.0001] and in NPAs [87/183 (48%) vs. 4/183 (2%); p < 0.0001]. Detection rates by PCR on upper (87/183; 48%) compared with lower respiratory tract samples (93/166; 56%) were similar (OR, 0.71; 95% CI, 0.46 - 1.11). Only 2/30 (6.6%) controls were PCR positive. CONCLUSION: Real-time PCR is more sensitive than IF for the detection of P. jirovecii in children with PCP. NPA samples may be used for diagnostic purposes when PCR is utilised. Wider implementation of PCR on NPA samples is warranted for diagnosing PCP in children.
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    Lung function determinants and mortality of children and adolescents with cystic fibrosis in South Africa 2007-2016
    (2019) Vandenbroucke, Natalie Joëlle; Morrow, Brenda; Zampoli, Marco
    Objectives: Cystic fibrosis (CF) is one of the commonest inherited disorders in South Africa, affecting all population groups. Progressive pulmonary disease with declining forced expiratory volume in one second (FEV1) is the main predictor of morbidity and mortality in individuals with CF. This study aimed to describe the change in lung function, nutritional status and mortality of children and adolescents with CF, attending the Red Cross War Memorial Children’s Hospital (RCWMCH) CF Clinic and to identify factors associated with poor pulmonary function outcomes and mortality. Methods: A retrospective study was conducted of the clinical records and annual pulmonary function tests, with matched body mass index (BMI), of children between 5 and 18 completed years of age attending the RCWMCH CF clinic in Cape Town, South Africa, between January 2007 and December 2016. Results: A total of 143 study participants (51.4% male; median age at diagnosis 5.5 months) were included. Population mean FEV1 and body mass index (BMI) Z scores improved from -2.5  1.70 to -1.9  1.70 (p = 0.1) and from -0.7  1.2 to -0.4  1.2 (p = 0.3) respectively from 2007 to 2016. FEV1 Z score declined by an average of 0.17 per year of age and this was mirrored by an average decline in BMI Z scores of 0.07 for each year of advancing age. FEV1 decline was greater in patients who died compared to those who survived (p = 0.03). Of the factors postulated to influence lung function decline, there was no significant correlation between FEV1 at any age and age of diagnosis, sex, ethnicity, genotype, geographical location, pancreatic status, or Methicillinresistant S. aureus or Aspergillus spp. infection. Participants who were ever infected or colonised with P. Aeruginosa had consistently lower FEV1, however this difference only became significant at certain ages. On multiple stepwise regression analysis, only FEV1 at age 6 was found to be a significant independent predictor of mortality (adjusted odds ratio (95% CI) 0.5 (0.3 – 0.8); p = 0.005). Conclusion: Pulmonary function of children with cystic fibrosis improved non-significantly over the 10-year study period. FEV1 at age 6 was identified as an independent predictor for CF-related mortality. Early diagnosis and measurement of pulmonary function in young children with CF is essential to identify children at risk of poor outcomes.
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    Mobility Practices, Attitudes and Perceptions of Nurses, Doctors and Physiotherapists Regarding Early Mobilisation of Critically Ill Patients in Intensive Care Units in Namibia. A Retrospective Record Review and Cross sectional Survey
    (2021) Francis, Savarna Olivia; Du Plessis, Ilse; Morrow, Brenda
    Background: The main focus of care in intensive care units (ICU) has historically been on preventing mortality. With advancing knowledge and technology, more patients now survive their ICU stay. Therefore, critical care priorities have recently shifted to preventing critical illness related morbidities, including ICU-acquired weakness (ICUAW) and delirium, in order to optimise functional, psychosocial, cognitive, and quality of life outcomes for survivors of critical illness and their families. Early mobilisation and ICU-based rehabilitation are recommended interventions to achieve these clinical objectives. There are no published studies describing early mobilisation practice in Namibia. Aims: This study aimed to describe the profile of patients admitted to two private intensive care units in Windhoek, Namibia, and to describe practices, attitudes and perceptions of nurses, doctors, and physiotherapists regarding early mobilisation of critically ill patients in those ICUs. Methodology: A retrospective, descriptive record review was conducted to describe the ICU patient profile and documented mobility practice. Charts of 870 patients admitted between 01 January 2016 and 31 December 2016 to two private Windhoek ICUs were included in the record review. A descriptive, cross-sectional, self-administered survey was used to assess knowledge of ICUAW and early mobilisation, reported mobility practice, personal views on early mobilisation, perceived contraindications/precautions to early mobility, the perceived barriers to the provision of early mobility, perceived permissible activity levels based on patient physiological status, and sedation practices. A total 39 nurses, doctors, and physiotherapists were included in the survey. Results: Record Review: 538 (61.8%) patients were male. Mean age was 56 (SD 14.9, range 18-90) years. Most admissions were elective (n=577; 66.3%). Coronary angiogram (n=179; 20.6%), cardiac conditions (n=113; 13%) and cardiac surgery (n=90; 10.3%) were the main admission diagnoses. Most patients (n=697; 80.1%) did not receive mechanical ventilation; average length of stay in ICU was 3.41 (1-37) days, and duration of mechanical ventilation was 0.7 (0-20) days. The mortality rate was 5.2%. Three hundred and fifty-two (40.5%) patients received physiotherapy treatment, with the majority (n=271; 78.6%) being mobilised once daily. Most patients (n=253; 73.3%) who were mobilised were done so within 48 hours of ICU admission. Physiotherapy techniques used were manual chest physiotherapy, mobilisation to a chair, and active range of motion exercises. Five (1.4%) patients experienced adverse events during physiotherapy treatment (change in systolic blood pressure to 200mmHg during treatment). Delirium was not assessed or monitored in any included patient. Survey: The overall response rate was 24.1% (n=42). Clinician group response rates were physiotherapists 10.2% (n=13); nurses 65.6% (n=21); and doctors 55.6% (n=5). Most participants underestimated the incidence of ICUAW (n=17; 44.7%) and reported unfamiliarity with the literature on early mobilisation (n=19; 51.4%). Twenty-five (38.5%) of sixty-five total physiotherapist responses reported they would mobilise patients once daily, while thirty-one (47.7%) responses reported they would mobilise patients twice daily. Twenty-seven (41.5%) physiotherapist responses reported they spend 16-30 minutes mobilising a patient. The mobilisation team described consisted mainly of physiotherapists, nurses, and porters. Routinely used physiotherapy techniques included manual chest physiotherapy, bed mobility, pre-gait activities and strengthening exercises. Providers reported conservativism in permissible patient activity levels, especially in ventilated patients. The most commonly reported barriers to early mobilisation were requiring a doctor's referral for mobilisation, medical instability, excessive sedation, safety concerns, inadequate training, and lack of communication. Conclusion: Patients were admitted electively, mainly post-cardiac surgery or for cardiac-related diagnoses. Delirium is not being standardly monitored in ICU. This could contribute significantly to poor patient outcomes. Quality improvement programmes to implement and optimise delirium monitoring and prevention in Namibian ICUs are recommended. Physiotherapists routinely use manual chest techniques, bed mobility, pre-gait activity, and strengthening exercises in ICU. Survey participants underestimated the likely incidence of ICUAW and lacked sufficient knowledge and training on early mobilisation. Many barriers to early mobilisation were identified in this study, which should be addressed through implementing quality improvement programmes to direct and improve ICU mobility practice. Future point-prevalence studies are recommended with larger sample sizes from both the private and public sectors to increase the generalisability of results.
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    Mothering a neonate/young infant with feeding and swallowing difficulties: barriers, facilitators, and support
    (2025) Meyer, Cecilia; Norman, Vivienne; Morrow, Brenda
    Background: The anticipation of a new infant is typically characterised by feelings of joy, excitement, and hopeful expectations for the future. However, these positive emotions can be altered when mothers are faced with the reality of caring for an ill, hospitalised infant, particularly one with feeding and swallowing difficulties (FSD). FSD in infants significantly impacts not only the infant's health and development but also the mother's emotional and psychological wellbeing. Caring for neonates and young infants with FSD in hospital settings presents unique challenges, especially in resource-constrained environments like South Africa. Limited research exists exploring mothering an infant with FSD, highlighting a gap in understanding the maternal experience. Research aim and objective: This research aimed to explore ‘mothering' a neonate/young infant with FSD in a South African healthcare context. To achieve the aim, mothers' experiences of barriers, facilitators and support needs within a neonatal healthcare context are described. Methods: A qualitative, exploratory case study design was used. Semi-structured interviews were conducted with mothers whose infants presented with FSD in neonatal/infant units. A total of seven mothers were interviewed (n=7) whose infants (aged from birth to three months) were admitted at either Mowbray Maternity Hospital or Red Cross War Memorial Children's Hospital, for a minimum of seven days. The data were thematically analysed, allowing the emergence of key themes that represent maternal experiences. Results: The overarching theme of ‘mothering' emerged, encapsulated by the quote: “Baby comes first in everything.” Six distinct themes then emerged from the overarching theme, represented by relevant quotes from the participants: “Information helps”; “They help a lot”, “It's not home”, “Everything on you”, “It affects me emotionally”, “Not on your own” and lastly, “It's my baby”. These themes emerged from the accounts of the mothers, which were then described in terms of barriers such as separation and burden of care, facilitators such as information and maternal strength, and support structures. The findings outline the dedication and resilience of mothers when navigating the challenges of caring for infants with FSD, while also highlighting the intricate and often dichotomous realities they face in the hospital setting. Conclusion: This study highlights the complex experiences of mothers caring for infants with FSD in South African healthcare settings. While deeply committed to their infants' wellbeing and feeding, mothers face barriers such as inadequate communication, separation, and limited support, which heighten stress and guilt. Facilitators, including clear communication, practical support from healthcare professionals, and peer and family networks empower mothers and alleviate their emotional burden. A collective effort by healthcare professionals, families, and hospital systems is essential to ensure care that supports both the recovery of infants and the wellbeing of their mothers. These insights can inform healthcare practices and future research in similar resource-limited settings.
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    Outcomes following admission to paediatric intensive care: A systematic review
    (2020) Procter, Claire; Argent, Andrew; Morrow, Brenda
    Introduction Paediatric Intensive Care has developed rapidly in recent years with a dramatic increase in survival rates. However, there are increasing concerns regarding the impact that admission to a Paediatric Intensive Care Unit (PICU) has on both the child and their family. Following discharge from PICU, children may be living with complex medical problems as well as dealing with the psychosocial impact that their illness has had on them and their family. Objectives To describe the long-term health outcomes of children admitted to a paediatric intensive care unit (PICU). Methods A full literature search was conducted including the databases; MEDLINE via PubMed, Cochrane Central Register of Controlled Trials, (CENTRAL), Scopus, Web of Science, CINAHL, ERIC, Health Source Nursing/Academic, APA PsycInfo. All studies including children under 18 admitted to a PICU were included. Primary outcome was short- and longerterm mortality. Secondary outcomes were neurodevelopment/cognition/school performance; physical function, psychological function/behaviour impact, quality of life outcomes and social/family implications. Studies focused on Neonatal Intensive Care Admission and articles with no English translation were excluded. Results One hundred and five articles were included in the analysis. Mortality in PICU ranged from 1.3% to 50%. Mortality in high income countries reduced over time but the data did not show the same trend for low- and middle-income countries. Higher income countries were found to have lower Standardised Mortality Rates (SMRs) than low- and middle-income countries. Children had an ongoing risk of death for up to 10 years following PICU admission. Children admitted to PICU also have more ongoing morbidity than their healthy counterparts with more cognitive/developmental problems, more functional health issues, poorer quality of life as well as increased psychological problems. Their parents also have an increased risk of Post Traumatic Stress Disorder (PTSD). Discussion Most of the studies identified are from high income countries and only include short-term follow up. More data is needed from low- and middle-income countries and over longer terms. The studies were markedly heterogenous and were all observational. Agreement is needed regarding which outcomes are most important to measure as well as standardised methods of assessing them. Further research is needed to identify the risk factors which cause children to have poorer outcomes as well as to identify predictive and modifiable factors which could be targeted in practice improvement initiatives.
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    Paediatric acute kidney injury management in an African setting
    (2025) Mc, Culloch Mignon; Andrew, Argent; Morrow, Brenda; Luyckx, Valerie
    Kidney disease is a growing public health concern, affecting adults but also children who face challenges of access in low-resource settings including Africa. We studied our own paediatric dialysis results, our fellows training in the field of acute kidney injury (AKI) and reviewed innovative techniques for acute peritoneal dialysis, which also included costing of forms of acute dialysis in children. Dialysis for Paediatric AKI in Cape Town, South Africa A review of our dialysis database of over 593 cases for AKI at Red Cross War Memorial Children's Hospital (RCWMCH) over 20 years focusing on ‘Peritoneal dialysis (PD) first for our paediatric AKI program' whereby most children received PD as a first modality, despite having extracorporeal dialysis available. Types of dialysis were reviewed, as well as complications with acceptable outcomes described. Lessons learned from regional training of paediatric nephrology fellows in Africa There is a significant shortage of staff managing children with AKI in Africa and this is a review of our training program (1999 – 2021) of 38 African paediatric nephrology fellows. The emphasis is on training in paediatric AKI, including a review of hands-on training and length of training time in our unit, including subspecialty exams and research. Although a 100% return rate was noted to their home institutions, a survey was performed of our trainees on return home. This survey identified specific challenges faced and allowed for appropriateness of our training. Use of locally prepared peritoneal dialysis fluid for acute PD in children and infants in Africa including documentation of innovation of PD catheters and fluid, in the absence of conventional equipment, with good outcomes in our centre (4% peritonitis rate). Costing of our dialysis modalities included a short review in costing of dialysis modalities for acute kidney injury in our program. Conclusion: My thesis presents the development of services for children with acute kidney injury in Africa over 20 years. For me the future should be that ‘No child should die of acute kidney injury, without an attempt at peritoneal dialysis'.
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    Peri-extubation practices and extubation failure in a South African tertiary paediatric intensive care unit
    (2018) Kilba, Marie-Charlyne Fatima; Salie, Shamiel; Morrow, Brenda
    Objectives To describe the peri-extubation practices in a South African paediatric intensive care unit and to determine the prevalence, risk factors and outcomes of extubation failure. Design Prospective observational study. Setting A multi-disciplinary paediatric intensive care unit in Cape Town, South Africa. Patients All intubated and ventilated patients between May and September 2017. Interventions There were no research- related interventions Measurements and Main Results Extubation failure was defined as requiring re-intubation within 48 hours of planned extubation. Two hundred and sixteen intubations in 204 children, with a median age of 8 months (IQR 1.6 – 44.4) and median PIM3 risk of mortality score 0.03 (IQR 0.01 – 0.07) were included. There were 184 planned extubations; 21 (10.3%) patients died before extubation; two (1%) had tracheostomies; two (1%) were transferred intubated and seven (3.4%) had ventilation withdrawn. Non-invasive ventilation was implemented in 97 cases (52.7%) after planned extubation. There were 21 (11.4%) failed extubations. Indications for re-intubation were: upper airway obstruction (n=7; 33.3%); respiratory failure (n=4; 19.0%); heart failure (n=3; 14.3%); diaphragm paralysis, hypoventilation and cardiac arrest (n=2; 9.5% each); and reduced level of consciousness (n=1; 4.8%). Prematurity (adjusted OR 1.8 (95% CI 0.05 – 0.6); p =0.004), dysmorphology (OR 1.8 (95% CI 0.05 – 0.6); p=0.022), decreased level of consciousness (OR 4.8 (95% CI 1.96 – 11.7); p=0.001) and ventilation ≥48 hours (OR 0.2 (95% CI 0.05 – 0.7); p = 0.003) were independently associated with extubation failure on multivariate analysis. Children who failed extubation had longer duration of ventilation (median 231 versus 53 hours; p < 0.0001), PICU length of stay (median 15 versus 5 days; p < 0.0001) and hospital length of stay (32 versus 15 days; p=0.009); and higher mortality (28.6% versus 6.7%; p = 0.001) compared to those successfully extubated. Conclusion Extubation failure is associated with significant morbidity and mortality. Independent risk factors of extubation failure identified in our context were prematurity, dysmorphology, impaired consciousness and ventilation for more than 48 hours.
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    Provision of physiotherapy services for children in Intensive Care Units in Uganda: A descriptive study
    (2024) Sendagala, Idah; Morrow, Brenda
    Background: Child morbidity and mortality are still high in Uganda but the provision of critical care services is sub-optimal, characterized by limited accessibility and minimum standardization of services provided in the intensive care units (ICU). The nature and extent of the provision of physiotherapy services for children in ICUs in Uganda is not known, as no published studies have described this before. Aims: This study aimed to describe the provision of physiotherapy services for children in ICUs in Uganda, to lay a foundation for future practice improvements. Methodology: Routinely collected data documented in the medical files and specific data relating to physiotherapy service provision within the preceding 24 hours were extracted for all infants and children admitted to three participating Ugandan ICUs- the national referral hospital, a public tertiary level health facility, and a private hospital, on two study days per week, from January to June 2023. Demographic and clinical admission data were collected as well as specific details regarding referral to physiotherapy, frequency of treatment, and modalities used. One on-site physiotherapist was trained in research methodology and collected data for the specific study site. The data were analyzed using IBM SPSS Statistics version 28.0.1.1 (14). The data were tested for normality using the Shapiro Wilks W test. Continuous data are presented in the results as median (interquartile range), as appropriate for nonparametric data. Categorical data are presented as frequencies and percentages of total. Results: 326 patients were enrolled in this study, 161(49.1%) of which were male. 190 (58.2%) patients received any form of physiotherapy throughout the study period, and 164 (50.3%) patients received treatment in the preceding 24 hours before data collection on the study day. 68.1% of children had a good health status before the ICU admission, and 65.6% of the children were invasively mechanically ventilated on the study day. In 80.5% of patients, physiotherapy referrals were made by the attending doctor. On multivariable analysis, neither the study site nor any specific admission diagnostic category was independently associated with being referred for physiotherapy. Chest physiotherapy (CPT), using passive manual techniques of percussions (89.6%) and vibrations (88.8%), was the most common form of physiotherapy. Passive limb exercises in bed were the most common type of mobilization exercises given (63.4%), more commonly in younger children 6 years of age (p = 0.002). Active out-of-bed mobilization activities were provided in <20% of cases and were more common among older children >6 years of age (p < 0.05). Out of bed mobilization activities were associated with low or no respiratory support requirements (p < 0.001). The majority of children (71.3%) were treated once over the 24 hours preceding the study day. On multivariable analysis, being admitted for the management of an infection (adjusted OR 10.4, 95% CI 1.7 – 63.1; p = 0.01) and increased duration of ICU stay (aOR 1.4; 95% CI 1.2 – 1.5; p < 0.001) were independently associated with increased odds of being treated by a physiotherapist in the 24 hours preceding the study day. Conclusion: Physiotherapy was only provided to approximately half the children admitted to ICUs in Uganda, mostly following a referral from a doctor. Chest physiotherapy using passive manual techniques was the most common technique administered, followed by passive mobilization techniques. Active out-of-bed activities were performed in a minority of cases, more commonly in older children. These findings suggest that physiotherapy practice for children in ICUs in Uganda does not currently meet internationally recommended standards. Practice improvement initiatives are recommended, through research, training, and protocol development, to reach a minimum standard of acceptable physiotherapy care amongst this vulnerable population.
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    The effect of inspiratory muscle training on clinical outcomes and health-related quality of life in children with neuromuscular disease and respiratory muscle weakness.
    (2021) Human, Anri; Morrow, Brenda
    Background: Progressive respiratory muscle weakness and ineffective cough contributes to pulmonary morbidity and mortality in children with neuromuscular disease. Inspiratory muscle training aims to preserve or improve respiratory muscle strength, reduce respiratory complications and improve health-related quality of life. Objectives: To describe South African physiotherapists' knowledge and respiratory management strategies and determine the safety, viability, acceptability and efficacy of inspiratory muscle training for children 5-18 years with neuromuscular disease. Methods: Four studies were conducted: i) a quantitative descriptive survey; ii) a systematic review using Cochrane methodology; iii) a prospective, pre-experimental observational study and iv) a prospective, cross-over randomised controlled trial using a standardised 12-week inspiratory muscle training intervention. Results: i) South African physiotherapists (n=64) reported being aware of international clinical practice recommendations, however they favoured manual airway clearance techniques. The use of inspiratory muscle training in chronic management was well supported by South African physiotherapists. ii) Results of the systematic review (seven included studies; n=168) suggested that inspiratory muscle training may be effective in improving inspiratory muscle strength. There was insufficient evidence for an effect on patient morbidity or health-related quality of life. iii) The pre-experimental, pilot study (n=8) suggested that a six-week inspiratory muscle training programme was safe, viable, acceptable and associated with a significant increase in inspiratory muscle strength. iv) The cross-over randomised controlled trial (n=23) did not show evidence of a difference in the primary outcome measures (number of hospitalisations and respiratory tract infections) between intervention and control periods. There were no adverse events related to inspiratory muscle training. Inspiratory muscle strength (Pimax) and peak expiratory cough flow increased by 14.57 (±15.67)cmH2O and 32.27 (±36.60)L/min respectively during the intervention period compared to a change of 3.04 (±11.93)cmH2O (p=0.01) and -16.59 (±48.29)L/min (p=0.0005) during the control period. There was no evidence of change in spirometry, functional ability or total health-related quality of life scores following the intervention. Overall participant satisfaction with inspiratory muscle training was high and adherence was good. Conclusions: Inspiratory muscle training in children with neuromuscular disease is well tolerated, appears to be safe and is associated with significant improvements in inspiratory muscle strength and cough efficacy.
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    The validation of a screening tool for the identification of feeding and swallowing difficulties in the paediatric population aged 0-2 years admitted to general medical wards
    (2019) Sibanda, Cynthia; Norman, Vivienne; Morrow, Brenda
    Background: Feeding and swallowing difficulties (FSD) have been found in typically developing children as well as in children with complex medical conditions and developmental disabilities. These difficulties cause negative health consequences such as aspiration pneumonia, chronic lung disease, failure to thrive, prolonged hospital stay and even death. The early identification and management of feeding and swallowing difficulties is important as it prevents the negative effects on health and quality of life. Hence, there is a need for a validated screening tool to use in the general hospitalized paediatric population. Research Aims: The aim of this study was to validate the Feeding and Swallowing Questionnaire as a screening tool, in the paediatric population aged 0 – 2 years admitted to general medical wards. The secondary aim was to describe the FSD presenting in the paediatric population aged 0 - 2 years who are hospitalized in the general medical wards. Methodology: A prospective, descriptive, clinimetric design was utilized. A sample of 107 participants admitted to the general medical wards at Steve Biko Academic Hospital were included in the study. Participants’ feeding and swallowing was screened by a research assistant using the Feeding and Swallowing Questionnaire. After the screening, a clinical feeding and swallowing assessment was conducted for comparison, the assessment was conducted by the student researcher using the Clinical Feeding and Swallowing Assessment Tool. Results: There was a 27% FSD prevalence, with the majority of cases (92%) occurring in children under one year of age. One hundred and three children (63% male; median (IQR) age 5.2 (2.1 – 12.8) months) underwent screening and clinical assessment for feeding and swallowing disorders. The criterion validity of the Feeding and swallowing Questionnaire was established with a sensitivity of 88% and a specificity of 32%. Internal consistency was achieved with an acceptable Cronbach’s alpha of 0.79, and good inter-rater reliability (80%). Participants presented with feeding difficulties in all the phases of swallowing, while some participants had behavioural feeding difficulties. Those who had FSD had the following medical conditions: cardiorespiratory, neurological and gastrointestinal disorders namely acute gastroenteritis and liver disease. Feeding and swallowing difficulties were associated with increased mealtime duration (p=0.005) and supplementary oxygen support (p=0.03). Conclusion: The results confirm that the Feeding and Swallowing Questionnaire shows promising findings as a reliable and valid tool for the identification of FSD in the general hospitalized paediatric population. However, further research in other setting with general paediatric medical wards is required to increase the robustness of the screening tool.
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    Why, how and when do children die in a Paediatric Intensive Care Unit (PICU) in South Africa?
    (2020) Wege, Martha Helena; Morrow, Brenda; Rossouw, Beyra; Argent, Andrew
    Objectives: To describe the characteristics of children who died and their modes of dying in a South African Paediatric Intensive Care Unit (PICU). Design: Retrospective review of data extracted from the Child Healthcare Problem Identification Programme (Child PIP)and the PICU summary system (admission and death records) on children of any age who died in the PICU between 01 January 2013 and 31 December 2017. Setting: Single-centre tertiary institution. Patients: All children who died during PICU admission were included. Measurements and Main Results: Four-hundred and fifty-one (54% male; median (IQR) age 7 (1-30) months) patients died in PICU on median (IQR) 3 (1-7) days after PICU admission; 103 (22.8%) had a cardiac arrest prior to PICU admission. Mode of death in 23.7% (n=107) was withdrawal of life sustaining therapies; 36.1% (n=163) died after limitation of life sustaining therapies; 22.0% (n=99) died after failed resuscitation and 17.3% (n=78) were diagnosed brain dead. Ultimately, 270 (60%) children died after the decision to limit or withdraw life sustaining therapies. There was no difference in the number of deaths during office and after-hours periods (45.5% vs. 54%; p = 0.07). Severe sepsis (21.9%) was the most common condition associated with death, followed by cardiac disease (18.6%).Ninety-four (20.8%) patients were readmitted to the PICU within the same year; 278 (61.6%) had complex chronic disorders. During the last phase of life, 75.0% (n=342) were on inotropes, 95.9% (n=428) were ventilated, 12.0% (n=45) received inhaled nitric oxide and 10.8% (n=46) renal replacement therapy. Only 1.5% (n=7) of children became organ donors and postmortems were done in 47.2% (n=213) of the patients. Conclusions: Most PICU deaths occurred after a decision to limit or withdraw life-sustaining therapy. Severe sepsis was the most common condition associated with death. Referral for organ donation was extremely rare.