Browsing by Subject "Paediatrics"

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    A biscuit fortified with iron, iodine and B-carotene as a strategy to address micronutrient deficiencies in primary school children
    (2001) Van Stuijvenberg, Martha Elizabeth; Hussey, G. D.; Benade, A. J. S
    Deficiencies of vitamin A, iron, and iodine continue to be prevalent in developing countries worldwide and can, in addition to the classic consequences such as nutritional anaemia, goitre, cretinism, xerophthalmia and blindness caused by severe deficiencies, also affect the growth, development and immunity of young children. The various internationally acknowledged strategies for combating micronutrient deficiencies include high-dose supplementation, food fortification, dietary diversification and nutrition education. The aim of this research was to evaluate a micronutrient-fortified biscuit as a strategy to address micronutrient deficiencies in primary school children from a poor rural community. The research comprised three phases. During the first phase the effect of a biscuit fortified with iron, iodine, and B-carotene on the vitamin A, iron and iodine status of 115 children was evaluated and compared with 113 controls, in a randomised placebo-controlled trial. To enhance the absorption of iron a vitamin C-fortified cold drink was given together with the biscuit. Anthropometric status, cognitive function and morbidity were assessed as secondary outcomes. The 12-month intervention resulted in a significant improvement in serum retinol, serum ferritin, transferrin saturation, haemoglobin and urinary iodine excretion. Morbidity and cognitive function, particularly the cognitive function in the children presenting with low iron status and with goitre! at baseline, were also favourably affected. Linear growth was positively affected only in the children with marginal iron stores at baseline. During the second phase of this study the long-term effectiveness of the biscuit programme, in terms of elimination of micronutrient deficiencies, compliance, acceptability and sustainability, was evaluated in a longitudinal study over a period of 30 months. In addition, cross-sectional data on vitamin A and iron status from subsequent studies conducted in the same school at 33, 42 and 45 months after the start of the original biscuit intervention, during which time the fortified biscuit continued to be distributed at the school, are reported. Although micronutrient status improved significantly during the 12 months of the first study, all variables (except urinary iodine) returned to pre-intervention levels when the schools reopened after the summer holiday. Serum retinol increased again during the next nine months, but was significantly lower in a subsequent survey, carried out directly after the summer holiday; this pattern was repeated in two further cross-sectional surveys. Iron status showed no recovery during a subsequent intervention period when the vitamin C-fortified cold drink was supplied on a less frequent basis, or during the period that ferrous bisglycinate was used as iron fortificant. Because of the compulsory iodisation of salt, that came into effect halfway through the first phase of the study, improved iodine status, as measured by urinary iodine excretion, was maintained. In the third phase of the research, red palm oil, a rich natural source of B-carotene, was examined as an alternative vitamin A fortificant in the biscuit. This study contained elements of both a randomised placebo-controlled trial and an equivalence trial. The biscuit with a red palm oil-based shortening was shown to be as effective as the biscuit with fl-carotene from a synthetic source in improving the vitamin A status of these children. In conclusion, the results of the studies described in this thesis showed that a micronutient-fortified biscuit is a feasible, practical and effective way of improving the micronutrient status of primary school children from a poor rural community. Long-term evaluation of this programme, however, showed that improved micronutrient status is not sustained during the long summer school holidays, and it is suggested that the biscuit programme is supplemented with other strategies, such as local food production programmes and nutrition education. Red palm oil, with all of its additional qualities (i.e. no trans fatty acids; rich source of antioxidants), appears to be an attractive alternative for use as a vitamin A fortificant. The choice of the iron compound to be used in the biscuit, however, needs further investigation.
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    A single-centre Preterm infant Retrospective Analysis of post 6-week Immunisation SideEffects, ‘PRAISE' study, in a busy neonatal unit in the Western Cape, South Africa between 2016-2018
    (2023) Petersen, Mishkah; Van Niekerk, Anika
    Background: Vaccine-Preventable Diseases (VPDs) are a leading cause of the high Underfive Mortality Rate (U5MR). Preterm infants are inherently at higher risk of mortality from VPDs. Studies irrefutably show the benefit of vaccinating preterm infants according to their chronological age with the benefit of timely vaccination outweighing unjustified delays. However, later studies have shown an increased risk of adverse events (AEs) following immunisation (AEFI) in preterm infants. This risk has not been uniformly accepted as statistically significant, but the multiple reports have led to subsequent proposed 48–72-hour cardio-respiratory monitoring recommendations which have not been uniformly adopted and may not be feasible in Low-and-Middle Income Countries (LMICs). Objectives: The main objective of this study is to identify the prevalence of major AEs following 6-week immunisation of preterm infants admitted to a busy neonatal unit in Cape Town over a two-year period. AEFI will be scrutinized to ascertain the timing, clinical severity and possible contributing factors. This study aims to identify any consistent variables or a subset of higher-risk preterm infants to inform a safe and practical in-hospital preterm vaccination and monitoring protocol. Methods: A retrospective audit was conducted on 260 eligible, in-patient, preterm infants receiving the 6-week vaccination as per the South African Expanded Programme on Immunisation (EPI) schedule from 01 March 2016 -31 March 2018 at a busy secondarylevel maternity referral hospital, Mowbray Maternity Hospital (MMH). Results: Two hundred and sixty (260) participants were included in the study, the median gestational age (GA) was 29 weeks, median birth weight 1 078 g and the median age at immunisation 44 days. Thirty-eight (38) out of the 260 participants (14.6%) experienced an AEFI with a median birth GA 28 weeks and median birth weight 988 g. Twenty-nine (29) out of 38 were deemed immunisation-related, since no other cause could be identified, with a prevalence of 11.15%. Majority (89.4%) of AEFI occurred within 24 hours. GA was inversely proportional to the risk of an AEFI. Respiratory support was needed by 73.7% and 97% were screened and treated for sepsis. Conclusion: Established benefit exists in vaccinating preterm infants according to chronological age. However, due cognisance should be paid to the early preterm infant's higher risk of AEFI, 11.15% in our study. Our study supports a clear unit-individualised preterm immunisation protocol with a minimum 24 hours of cardio-respiratory monitoring post vaccination, especially in the very preterm infants <32 weeks GA.
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    Acinetobacter baumannii infections in the paediatric intensive care unit of a tertiary hospital in South Africa
    (2014) Reddy, Deveshnee; Argent, Andrew; Morrow, Brenda M
    Acinetobacter baumannii (A. baumannii) is now increasingly recognised as an important cause of nosocomial infections in paediatric intensive care unit (PICU) patients, particularly in developing countries, where it contributes significantly to morbidity and mortality. Furthermore, it has been documented that emerging antimicrobial resistance patterns complicate antibiotic choice in these patients. At present, more paediatric data is needed regarding these infections. This is a retrospective case-control study that aims to document the demographic data and relevant clinical details of patients in whom A. baumannii was cultured, either from blood or respiratory specimens (thus including both infections and colonisation), in the PICU at Red Cross War Memorial Children's Hospital (RCWMCH) during 2010. Secondary objectives include comparing these patients with those in whom A. baumannii was not cultured and determining which isolates were causing infection and which were colonisers. In addition; of the isolates regarded as infections, documenting the antimicrobial sensitivities and resistance of the organisms cultured, determining whether infections were late or early onset and determining whether specific bed numbers were consistently involved.
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    Addressing the quality and scope of paediatric primary care in South Africa: evaluating contextual impacts of the introduction of the Practical Approach to Care Kit for children (PACK Child)
    (2020-05-29) Murdoch, Jamie; Curran, Robyn; Cornick, Ruth; Picken, Sandy; Bachmann, Max; Bateman, Eric; Simelane, Makhosazana L; Fairall, Lara
    Background Despite significant reductions in mortality, preventable and treatable conditions remain leading causes of death and illness in children in South Africa. The PACK Child intervention, comprising clinical decision support tool (guide), training strategy and health systems strengthening components, was developed to expand on WHO’s Integrated Management of Childhood Illness programme, extending care of children under 5 years to those aged 0–13 years, those with chronic conditions needing regular follow-up, integration of curative and preventive measures and routine care of the well child. In 2017–2018, PACK Child was piloted in 10 primary healthcare facilities in the Western Cape Province. Here we report findings from an investigation into the contextual features of South African primary care that shaped how clinicians delivered the PACK Child intervention within clinical consultations. Methods Process evaluation using linguistic ethnographic methodology which provides analytical tools for investigating human behaviour, and the shifting meaning of talk and text within context. Methods included semi-structured interviews, focus groups, ethnographic observation, audio-recorded consultations and documentary analysis. Analysis focused on how mapped contextual features structured clinician-caregiver interactions. Results Primary healthcare facilities demonstrated an institutionalised orientation to minimising risk upheld by provincial documentation, providing curative episodic care to children presenting with acute symptoms, and preventive care including immunisations, feeding and growth monitoring, all in children 5 years or younger. Children with chronic illnesses such as asthma rarely receive routine care. These contextual features constrained the ability of clinicians to use the PACK Child guide to facilitate diagnosis of long-term conditions, elicit and manage psychosocial issues, and navigate use of the guide alongside provincial documentation. Conclusion Our findings provide evidence that PACK Child is catalysing a transition to an approach that strikes a balance between assessing and minimising risk on the day of acute presentation and a larger remit of care for children over time. However, optimising success of the intervention requires reviewing priorities for paediatric care which will facilitate enhanced skills, knowledge and deployment of clinical staff to better address acute illnesses and long-term health conditions of children of all ages, as well as complex psychosocial issues surrounding the child.
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    Adenovirus-associated pneumonia in South African children : presentation, clinical course and outcome
    (2015) Mukuddem-Sablay, Zakira; Zampoli, Marco
    Background: Pneumonia is an important cause of morbidity and mortality in children. Viruses have emerged as important aetiological agents in childhood pneumonia. The aim of this study was to document the clinical presentation, severity and outcome of adenoviral-associated pneumonia (AVP) in children and identify risk factors associated with poor outcome. Methods: A retrospective study of laboratory-confirmed AVP cases was conducted between 1 January and 31 December 2011. The medical records of adenovirus PCR positive respiratory tract samples identified through the National Health Laboratory Service (NHLS) database were retrieved. Demographic, clinical and outcomes data of children with AVP were extracted and analysed. Outcome measures were death and development of chronic lung disease (CLD). Results: 1910 respiratory samples were submitted to the NHLS from which 206/1910 (11%) AVP cases were identified. The median age was 12 months (IQR 6-24), 70 (34%) children were malnourished and 14 (7%) HIV-infected. Fever was the commonest presenting symptom occurring in 159 (77%) of cases. Seventy six (37%) required intensive care unit (ICU) admission. There was a high prevalence of co-morbid conditions with 98 (47%) having at least one; cardiac disease was the most common (48 (23%). Twenty nine (14%) developed CLD which was associated with hypoxia at presentation (26/29, 90%, p = 0.01) and admission to ICU (18/29, 62%, p < 0.01). Eighteen (9%) children died. Admission to ICU (OR 8.3, 95% CI 2.3-29.0) and blood stream infection (OR 11.2; 95% CI 2.3-54.1) were independent risk factors for mortality. Conclusion: Adenoviral-associated pneumonia is an important cause of pneumonia and CLD in young children in South Africa. Admission to ICU and blood stream infection were associated with poor outcome
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    Aetiology and presentation of childhood pleural infections in the post-pneumococcal conjugate vaccine era in South Africa
    (2021) Golden, Lauren; Zampoli, Marco; Chaya, Shaakira
    Complications of respiratory infections include pleural effusion (PE), associated with a high morbidity. Differentiating between PE caused by bacterial infections and Mycobacterium tuberculosis (TB) in endemic areas is difficult in children, impacting treatment. We investigated the aetiology of PE and features distinguishing TB from bacterial PE in children. Methods In this prospective study, children with PE admitted to a tertiary hospital in Cape Town from December 2016 to December 2019 were enrolled. Clinical information and routine laboratory investigations were compared between children with bacterial, TB or unclassified PE, categorised according to study definitions. Results A total of 91 patients were included; their median age was 31 months (IQR 11.8–102.1). Aetiology was bacterial in 37 (40%), TB in 36 (39%) and unclassified in 18 (20%) patients. Staphylococcus aureus was the most common bacterial isolate, confirmed in 24/37 (65%) patients; and Streptococcus pneumoniae confirmed in only 3/37 patients (8%). TB was microbiologically confirmed in 12/36 (33%) patients. Patients with TB were older (median age 91.6 vs 11.8 months, p< 0.001), with more weight loss (28/36 (77.8%) vs 12/37 (32%) patients, p< 0.001), and longer cough duration (10 vs 4 days, p< 0.001) than those with bacterial PE. In contrast, the latter had significantly higher median values: serum C-reactive protein (250 vs 122 mg/L, p< 0.001), procalcitonin (11 vs 0.5 mg/L, p< 0.001) pleural fluid lactate dehydrogenase (7280 vs 544 U/L, p< 0.001), and adenosine deaminase levels (162 vs 48 U/L, p< 0.001) and lower glucose levels (1.3 vs 4 mmol/L, p< 0.001). Conclusion Post-PCV, S. aureus is the dominant cause of PE in children using traditional culture methods, while TB remains a common cause of PE in our setting. Useful clinical and laboratory differences between TB and bacterial PE were identified, but the cause of PE in 20% of children was underdetermined. Molecular testing of pleural fluid for respiratory pathogens may be useful in such children.
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    Ambulatory and hospitalized childhood pneumonia: a longitudinal study in a peri-urban low-income community with high vaccination coverage in Sub-Saharan Africa
    (2022) le Roux, David; Zar, Heather; Nicol, Mark
    Background Child pneumonia is a substantial cause of childhood mortality and morbidity; it is the largest single cause of under-5 mortality outside the neonatal period. Incidence of child pneumonia, and pneumonia mortality, have decreased substantially due to improved socio-economic attainment, improved HIV programs, coverage of new conjugate vaccines against Streptococcus pneumoniae (PCV) and Haemophilus influenzae type B (Hib), access to early antibiotic therapy, and changing prevalence of pneumonia risk factors. Measurement of community-based pneumonia incidence is difficult; risk factors for pneumonia incidence and factors associated with pneumonia mortality are poorly described in low- and middle-income countries. Careful measurement of pneumonia incidence, and prospective analysis of risk factors is necessary to appreciate the evolving complexities of pneumonia causality and mortality. The aim of this work was to describe the incidence and severity of pneumonia in a birth cohort of children in the first 2 years life; and identify risk factors for pneumonia and for severe outcomes. Methods A prospective birth cohort, the Drakenstein Child Health Study, enrolled mother-infant pairs in two communities outside Cape Town, South Africa. Pregnant women were recruited and followed through pregnancy, labour and delivery, and the first 2 years of the child's life. Comprehensive data collection of risk factors was done through the first 2 years of life. A community pneumonia surveillance system was established; active case finding was used for birth cohort participants over 4 respiratory seasons. Children were examined at scheduled visits and at the time of pneumonia events. Pneumonia or severe pneumonia was diagnosed according to revised World Health Organisation (WHO) guidelines. Chest x-rays were classified according to WHO guidelines. Predictors of ambulatory and hospitalized pneumonia were explored with Poisson regression using generalized estimating equations clustered on mother-infant pairs. Factors associated with death or admission to intensive care unit were analysed with prevalence ratios from modified Poisson regression with robust variance estimation. Findings From March 2012 to March 2015, 1137 pregnant women were enrolled, delivering 1143 live-born infants. Household environmental tobacco smoke exposure was common: 82% of children were exposed in the first 6 months of life. Maternal HIV infection was common: 249 (22%) of 1143 children were HIV-exposed, but only 2 children became HIV-infected. Coverage of primary series of hexavalent vaccine, PCV and Hib was excellent (92%). During the study period (2012 to 2017), there were 795 pneumonia episodes (621 (78%) ambulatory, 274 (22%) hospitalised) in the first 2 years of life. Pneumonia incidence was higher in the first year of life (0.51 episodes per child year (e/cy)) and decreased to 0.25 e/cy in the second year. Active case finding in the birth cohort was more accurate than passive surveillance performed at the community clinics; pneumonia incidence measured by passive surveillance was significantly lower (incidence rate ratio 0.72, 95% CI 0.58 – 0.89) compared to active surveillance. Pneumonia mortality was low: 1.7% of hospitalised cases, and 0.35% of all clinical cases. There was marked variability in pneumonia incidence from year to year during the study. Many risk factors for pneumonia did not have fixed effects, but had different impacts at different ages, and variable effect on ambulatory and hospitalised pneumonia. In multivariable regression, adjusted incidence rate ratios were calculated for 5 risk factors (age< 6 months, male sex, low birth weight (<2500g), maternal smoking, delayed vaccines), which were associated with consistent effects on ambulatory and hospitalised pneumonia. Risk factors for serious outcomes of pneumonia (death or admission to intensive care unit) were identified: age under 2 months, low birth weight and hypoxia. Conclusion In this birth cohort, with low socio-economic status but high vaccination coverage, we demonstrated higher-than expected incidence of pneumonia, but very low mortality, with specific risk factors identified. Active surveillance was important for accurate detection of pneumonia. Children born at low birth weight are at increased risk for pneumonia and for serious outcomes. Pulse oximetry to detect hypoxia, and access to oxygen for children with hypoxic pneumonia, should be included in guidelines. These data will have global applicability for estimation of child pneumonia incidence in regions where direct measurement is impossible. These data can be applied to epidemiology and disease-modelling for child health; they will contribute to long-term morbidity follow-up studies; and they will contribute to understanding the constantly-evolving epidemiology of child pneumonia.
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    An analysis of the phenotypic features of chromosomes 22q11.1 deletion syndrome at Red Cross War Memorial Children's Hospital
    (2018) Hendricks, Lesley Jill; De Decker, Rik
    Chromosome 22q11.2 deletion syndrome (22qDS) is an inherited autosomal dominant disorder. It is the second most commonly occurring syndrome, Trisomy 21 being the most common. It is the most common microdeletion syndrome. The clinical range of features with which affected individuals present is very broad and includes congenital heart disease (particularly conotruncal malformations), palatal abnormalities, characteristic facial features, and learning difficulties. In total, there are more than 180 different phenotypic features associated with 22qDS. Due to the wide variability of phenotypic features that can arise in 22qDS it is often difficult to know when to test for the syndrome. Oskarsdottir’s criteria are widely used in clinical recognition for 22qDS. However, in a study done previously at Red Cross War Memorial Children’s Hospital, this same criteria was found to only have a positive predictive value of 14% for 22qDS. This is likely due to the fact that Oskarsdottir’s study was based on a largely Caucasian study population. Our population in Southern Africa is largely non-Caucasian. Previous studies have confirmed that non-Caucasian population groups with 22qDS have different presenting phenotypic features. For this reason, in this study we sought to describe the typical phenotypic features with which children with 22qDS present in our local population in South Africa. A retrospective folder review was done of the phenotypic features of all patients who had had a FISH test done on the suspicion on 22qDS. A total of 144 patient folders were reviewed (72 patients who were FISH positive for 22qDS and 72 patients who were FISH negative and functioned as the control arm of this study). A review on the phenotypic features of children with 22qDS revealed the most common presentation to be congenital heart disease (44%), failure to thrive (33%), dysmorphic features (32%) and cardiac failure (25%). A positive family history was only noted in 13 patients. Of those patients with a positive family history of 22qDS, only 5% were proven FISH positive for 22qDS themselves (less than the 10% described in the literature). Younger children presented more frequently with CHD, while older children presented with developmental delay and dysmorphic features. In general, developmental delay, palatal abnormalities and feeding difficulties were less common in our study population than described in the literature. Our particular patient population presented with the following CHD: isolated VSD (46%), tetralogy of Fallot (20.8%), truncus arteriosus (14.5%), PS/pulmonary artery stenosis (20.8%) and interrupted aortic arch (6%). Interrupted aortic arch was found to be the most sensitive marker for 22qDS in children with cardiac lesions. The cardiac lesions with the highest positive predictive value for 22qDS was non-isolated VSD (54%). Dysmorphic features with the highest sensitivity for 22qDS included bulbous nose (75%), abnormal digits (64%) and posteriorly rotated ears (68%). Primary immune deficiency, thymus abnormalities, cleft palate and behavioural issues were described less in this study than previously described in the literature. In conclusion, it is clear that non-Caucasian populations have some unique phenotypic expressions of 22qDS. It is imperative that clinicians maintain a high index of suspicion for patients with 22qDS.
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    Aspect of tuberculosis case management at Red Cross Children's Hospital
    (2010) Moore, David Paul; Eley, Brian
    Aim: To describe the spectrum of tuberculosis in children <15 years of age attending Red Cross War Memorial Children's Hospital between January 2006 and December 2008. Methods: A retrospective review of a paper-based Notifications Register and a database of culture-confirmed tuberculosis were undertaken. Laboratory and clinical data were analysed. Results: 1,314 episodes of tuberculosis were identified amongst 1,300 children. 433 (33%) of all cases were culture-confirmed; however, 120 (27.7%) of all culture-confirmed cases were not recorded in the paper-based Notifications Register. Conclusions: To improve the clinical service, detection of HIV co-infection in children undergoing evaluation for tuberculosis should be enhanced and strategies adopted to ensure that all children with culture- confirmed disease are notified and access antituberculosis therapy.
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    Assessment of the efficacy and efficiency of rapid rehydration in children with dehydration due to gastroenteritis in the rehydration unit of Red Cross War Memorial Children's Hospital
    (2017) Webb, Nicholas Guy; Westwood, Anthony
    Background: Dehydration due to acute gastroenteritis (AGE) remains a leading cause of child death worldwide. The primary treatment is enteral rehydration. Children who fail a trial of oral fluids require rehydration in hospital, preferably via nasogastric tube. Traditionally, children have been rehydrated over 24 hours; 'Standard Rehydration' (SR). Most treatment guidelines now recommend 'Rapid Rehydration' (RR) over 4-6 hours. There are limited data comparing RR to SR, especially from low-resource settings. Objectives: To assess the efficacy and efficiency of RR in children with AGE in the Rehydration Unit of Red Cross War Memorial Children's Hospital, Cape Town. Methods: A retrospective cohort study was performed. The intervention cohort contained 67 children who received RR in March 2007. The control cohort contained 76 children who received SR in March 2006. The outcome measures were weight and hydration status at 4 hours and time to maximum weight to measure efficacy; and length of hospital stay (LOS) to measure efficiency. Results: Children in the intervention cohort experienced greater weight gain (p<0.01) and lower dehydration scores (p=0.01) at 4 hours. There was no difference in time to maximum weight. The LOS for the two groups were not statistically different. Conclusion: RR is an effective method of rehydrating children with AGE. In contrast to two studies in well-developed settings, reduction in LOS following RR could not be demonstrated. There is no reason not to adopt RR as the predominant rehydration method in settings such as ours. More research is required to evaluate the efficiency of RR.
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    An audit of endocrine dysfunction in children with craniopharyngiomas at Red Cross Children's Hospital and Groote Schuur Hospital from 1976 to 2004
    (2006) Omarjee, Zakiyya; Delport, Steven V
    Background: Craniopharyngiomas account for 6-10% of childhood brain tumours and are the third most common intracranial tumours of childhood. Despite their benign histological appearance, they are often associated with a poor outcome and have significant associated morbidity. Aim: To analyse the data of children with craniopharyngiomas at Red Cross Children's Hospital and Groote Schuur Hospital from 1976 to 2004 with respect to age at presentation, presenting symptoms and preoperative and post-operative endocrine dysfunction. Patients and methods: The records of 45 children aged between 9 months and 13 years were reviewed. The majority of children in the study were aged between 5 and 10 years. There was a considerable delay in the diagnosis in most cases especially in areas outside of Cape Town. Pre-operative tests prior to 2000 were incomplete but have improved since then. Twenty nine percent of our patients had a near total excision of the craniopharyngioma and 29% had partial excisions necessitating adjuvant radiotherapy. The endocrinological, neuro imaging and presenting symptoms were analysed and post-operative tests were reviewed. Where possible neuropsychiatric assessments were accessed as well in order to assess long term neurocognitive deficits Results: The age of presentation of craniopharyngiomas in our group of patients was much younger than in other studies with the largest group of affected children being between 5 and 10 years of age. The most common presenting symptoms in this group were headaches (62%) and visual disturbances (57%). Sixty four percent of the children had preoperative endocrine testing for pituitary dysfunction of which 59% were ACTH and TSH deficient and only 38% were growth hormone deficient. After surgery multiple endocrinopathies were universal with 56% of children having pan hypopituitarism at follow up. There was no reversal of pre-existing hormone deficits after surgery. The management of craniopharyngiomas remains controversial. Twenty nine percent of our patients had a near total excision and 29 % had a partial excision combined with radiotherapy with a further 6 patients receiving intratumoral bleomycin for recurrences. Post operatively the majority of children were on replacement therapy but only 6 patients (14%) received human growth hormone or are receiving human growth hormone currently due to a lack of funds to provide human growth hormone for children with growth hormone deficiency. Seventy percent of the children had central diabetes insipidus post operatively reflecting posterior pituitary damage. Our overall survival rate from 1976 to 2004 was 91 % with a mortality rate of 13%. Most of the deaths were attributed to recurrences of the craniopharyngioma and the complications of bleomycin treatment. Conclusion: Craniopharyngiomas remain tumours associated with significant morbidity. Total excision of the tumour remains a favourable option but the proximity of the craniopharyngioma to the pituitary gland and optic tracts results in devastating sequelae. Although the medical and surgical management of craniopharyngiomas has improved, a significant number of patients had endocrine sequelae. The management of craniopharyngiomas in an African context compares favourably internationally but with limited resources especially with regard to growth hormone replacement, a large proportion of our children are not receiving optimal treatment.
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    An audit of pelvi-ureteric junction obstruction at Red Cross Children's Hospital : a six year review
    (2010) Ocheke, Isaac Ejembi; McCulloch, Mignon; Gajjar, Priya; Nourse, Peter
    Pelvi-ureteric junction obstruction is an important cause of congenital renal and urinary tract abnormality. It is the commonest cause of antenatally detected hydronephrosis. The increasing use of antenatal ultrasound as a screening tool for congenital abnormalities in the developing foetus has resulted in a more frequent rate of detection of foetal hydronephrosis with the likely consequence of significant anxiety among parents. This is because most of these infants with antenatally detected hydronephrosis will be subjected to frequent radiological and other investigations and there will also be concern about outcome. Knowing what postnatal investigations are necessary for any child with this condition and when to do it becomes a priority. This is because it is known that a significant percentage of children with antero-posterior (AP) diameter of 12mm or less experienced complete and spontaneous resolution of the hydronephrosis in early life. This study is a retrospective folder review of one hundred children with PUJ obstruction managed at Red Cross Children’s Hospital over a six-year period from Jan 2002 to Dec 2007.
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    Bacterial meningitis in neonates and children South Africa
    (2013) Thomas, Karla Mari; Levin, M
    Acute bacterial meningitis is defined as the inflammation of the meninges. It is caused by various bacteria and the specific aetiology is age dependant. In the neonatal period the causative organisms are: Group B streptococci, Gram - negative bacilli (e.g.: E. coli, Klebsiella spp, Enterobacter spp, Salmonella spp) and Listeria monocytogenes. In infants and children up to the age of 5 the most common causative organisms include: Streptococcus pneumoniae, Haemophilus influenzae type B (Hib)and Neiseria meningitidis. The two chief causes of bacterial meningitis in children older than 5 are S. pneumoniae and N. meningitidis. Various studies have been performed to look at the profile of meningitis among the paediatric population. Objective: To investigate the aetiology of acute bacterial meningitis in South African newborns and children from 2005 - 2010.
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    Biliary atresia at Red Cross War Memorial Children's Hospital: A retrospective descriptive study reviewing the age of presentation, clinical course and outcome of infants presenting to RCWMCH with biliary atresia
    (2016) Levin, Lindsey Nicola; Goddard, Elizabeth; De Lacy, Ronalda; Pillay, Komala
    Background: Biliary atresia (BA) is a progressive obstructive cholangiopathy of unknown aetiology, occurring during the perinatal period. If left untreated it rapidly progresses to hepatic fibrosis and cirrhosis, with death occurring within 2 years. It is the leading cause of end-stage liver disease in the paediatric population and remains the most common indication for paediatric liver transplantation in South Africa. Objectives: Despite a wealth of information from developed countries, very little information is available in Africa and other developing nations. This study aimed to describe the age of presentation, clinical course and outcome of infants presenting to Red Cross War Memorial Children's Hospital (RCWMCH) with BA. Methods: A retrospective folder review was conducted on all patients with BA presenting to RCWMCH between January 2003 and December 2013. The main outcomes assessed were median time to presentation to tertiary services, clearance of jaundice post Kasai procedure (bilirubin <20μmol/L) and 2- and 5-year overall survival (OS) and survival with native liver (SNL). Results: The median age at presentation in the 80 cases reviewed was 70 days. Kasai procedure (KP) was performed in 62 (77.5%) patients at a median age of 68 days. 18 patients who presented late did not undergo KP. Clearance of jaundice was achieved in 39% of KPs. 13 patients underwent KP beyond 90 days with a success rate of 38%. 2- and 5-year SNL rates were 41% and 37.5% respectively with OS of 59% at 2-years and 56% at 5-years. Liver transplant was only performed in 12 of the 54 patients who showed progression to require transplantation. Conclusions: Jaundice clearance post KP and SNL compared favourably with international figures, however, lower overall survival rates reflected lack of access to transplantation. Age at KP was not a predictor of poor outcome.
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    Blood stream infections in oncology patients at Red Cross War Memorial Children's Hospital, Cape Town
    (2017) Mvalo, Tisungane Knox Titus; Davidson, Alan; Eley, Brian
    Background: Infections cause significant morbidity and mortality in children with cancer, which may be related to the cancer or treatment received. There is paucity of data on the epidemiology of bloodstream infection (BSI) in sub-Saharan Africa. To address this knowledge gap, the present study was conducted at Red Cross War Memorial Children's Hospital (RCWMCH) in Cape Town, South Africa. Methods: Structured literature review: From 1 April 2016 to 31 May 2016 a PubMed search was undertaken on BSI in Paediatric Oncology. The search string used was (bacteraemia OR blood stream infection) AND (paediatric OR pediatric) AND (oncology). Studies that did not describe infection patterns, risk factors for infection, morbidity/mortality, articles not in English and those exclusively describing neonatal or ICU patients were excluded from full review. Retrospective cohort study: A retrospective cohort study was conducted at the haematology-oncology unit of RCWMCH. All positive blood cultures from RCWMCH oncology patients taken between 1 January 2012 and 31 December 2014 were retrieved to identify patients who had BSI. Results: Structured literature review: 508 abstracts / articles were initially retrieved and screened. 478 studies were excluded as per the literature review exclusion criteria. Thus, 30 articles were included in full analysis, 17 retrospective studies, 4 prospective multicentre studies, 6 prospective single centre studies, 2 systematic reviews and 1 case report. All were observational studies. This literature review showed that BSI is a frequent and important cause of morbidity and mortality in paediatric oncology. Gram-positive bacteria was noted to be the leading type of pathogen causing BSI. Increased risk of BSI may be from the cancer itself, chemotherapy, hospitalisation, central venous catheter insertion, and oncology patients were at risk of multi-drug resistant infection. Research gaps noted included paucity of studies from Sub-Saharan Africa, limited analysis of the antimicrobial susceptibility of causative microorganisms and limited description of fungal BSI in oncology patients. Retrospective cohort study: From 436 positive blood culture results, 150 BSI episodes were identified amongst 89 patients; 49.1% of the culture isolates were Gram-positive bacteria, 41.6 were Gram-negative bacteria and 9.3% were fungal. Coagulase Negative Staphylococcus and Viridans Group Streptococcus were the most common Gram-positive isolates, and Escherichia coli and Klebsiella species the commonest Gram-negative isolates. The majority of BSI episodes occurred in patients with haematological malignancies (74%), in the presence of severe neutropaenia (76.4%) and whilst on or following chemotherapy (88%). Complications occurred in 14% of the BSI episodes. Fungal infections had the highest prevalence of complications (21.4%). Three children died during BSI as a result of multidrug resistant isolates, giving a case-fatality rate of 2%. Conclusion: The findings of our cohort study show that BSI are mainly caused by Gram-positive bacteria and associated with a low case-fatality rate. The results of this study are consistent with worldwide experience of BSI in paediatric oncology patients. This study provides an understanding of the spectrum of organisms causing BSI and the outcome of BSI in a sub-Saharan African context.
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    Characteristics and outcome of long-stay patients in a paediatric intensive care unit in Cape Town, South Africa
    (2015) Nupen, Tracey Lee; Morrow, B M; Argent, A C
    Objectives: To describe a rational basis for the definition of a long-stay patient (LSP) in a South African paediatric intensive care unit (PICU); to review the characteristics and outcomes of the patients who comply with the LSP definition; to assess the proportion of resources allocated to the LSP cohort; and to determine if the results of this study could be used as a predictive tool for future admissions. Methods: A retrospective descriptive study of routine data collected over one calendar year (2009) from a 20-bedded multidisciplinary PICU was conducted. The definition of a LSP in this setting was established using various models. The characteristics and outcomes of the long- and short- stay groups were compared using nonparametric Mann-Whitney U and Chi2 tests, with significant results entered into a stepwise multiple regression model. The proportion of ICU days consumed by LSP was calculated. Human Research Ethics Committee approval was obtained (Ref/Rec 105/2011).
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    Characteristics of childhood-onset Systemic Lupus Erythematosus in Cape Town, South Africa
    (2014) Spittal, Graeme William; Scott, Chris
    Includes bibliographical references.
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    Childhood sexual abuse : the Red Cross War Memorial Children's Hospital experience, 1986-1988
    (1990) McKerrow, Neil Hugh; Lachman, Peter Irwin; Jacobs, Marian
    This retrospective descriptive study reviews sexually abused children who presented to the Child Abuse Team at the Red Cross War Memorial Children's Hospital (RCWMCH) between 1 January 1986 and 31 June 1988. During this period 365 children were referred to the Child Abuse Team, of whom 357 were entered into this study. 297 of these were cases of confirmed sexual abuse. There were 48 male children and 123 children under 6 years of age. Most children were victims of a single episode of sexual abuse with only 13, 7% presenting following repeated abuse. More serious forms of sexual abuse, rape or sodomy, were common, accounting for 60% of the cases. Over 70% of the children had physical signs to substantiate their claims of having been sexually abused. Sexually transmitted disease was a common finding, being present in 15,6 % at presentation. All children were accompanied to hospital by an adult, usually a parent. 60% of the children presented directly to RCWMCH. A delay between abuse and presentation was common, only 42% of the children presenting within 48 hours of having been abused. Physical problems frequently required management. Very few children received more than crisis intervention for their emotional state and only 20% needed any form of intervention to ensure their safety. Only 1% of cases involved a female abuser. In general, the age of the abuser was older than previously reported with 18, 6% being under 20 years of age. The relationship between abused and abuser was similar to that described in the literature, as was the reaction of the family against the abuser. 27,4% were prosecuted and of those that appeared in court 7 4, 5% were convicted. Further comparison of the following sub-groups of abused children are presented: male and female, young and old, intrafamilial and extrafamilial abuse, a single episode of abuse and repeated abuse.
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    Chronic morbidities in perinatally HIV-acquired adolescents on antiretroviral therapy
    (2022) Mahtab, Sana; Zar, Heather; Myer, Landon
    of children perinatally infected with HIV, with an increasing number surviving into adolescence, accompanied by the development of chronic comorbidities. However, there is limited knowledge on the spectrum of comorbidities, determinants, and risk factors among youth living with perinatally acquired HIV (YLPHIV) especially in sub-Saharan Africa, with most data from high-income countries. There is a critical need for data on health and chronic comorbidities among YLPHIV from countries with a high HIV prevalence. Aim: To investigate the spectrum and determinants of HIV-associated comorbidities among YLPHIV on ART in Cape Town, South Africa. Specific objectives were to investigate cardiovascular, musculoskeletal, mental health and metabolic outcomes in YLPHIV compared to HIV-uninfected adolescents. Method: In a prospective study YLPHIV on ART were enrolled in the Cape Town Adolescent Antiretroviral Cohort (CTAAC) from seven health-care sites in Cape Town, South Africa, between July 2013 – April 2015. Eligibility criteria were adolescents, 9-14 years old, with perinatally acquired HIV, been on ART for at least six months, and who were aware of their HIV status. A control group of HIVuninfected adolescents' frequency-matched by age and sex was also enrolled. The cohort was longitudinally followed for development or progression of comorbidities with clinical and laboratory measurements. Comorbidities assessed included: (1) cardiovascular health: echocardiography was used to investigate cardiac structure and endothelial peripheral arterial tonometry technique (EndoPAT) was used for endothelial function. The pathobiological determinants of atherosclerosis in youth (PDAY) risk score was used to assess long-term cardiovascular risk for atherosclerotic disease at the coronary artery (CA) and abdominal aorta (AA). A PDAY score ≥1 was regarded as elevated; (2) bone health: quantitative ultrasound was used to evaluate calcaneal stiffness index (SI); (3) mental health: the Child Behavior Checklist (CBCL) and BECK youth inventories were utilised. The association of mental health with metabolic abnormalities was investigated. Statistical analyses included descriptive data and regression modelling analysis, using the software, Stata® 14.2 to 16 (Stata Corp LP. College Station, Texas, USA). Results: Overall, 515 YLPHIV and 110 HIV-uninfected participants with median age 12.0 years (IQR 11.9, 10.7) and 11.8 years (IQR 11.7, 10.0) were enrolled; YLPHIV with median duration of ART of 7.6 years (IQR: 4.6–9.2), also had a median CD4 cell count of 713 cells/mm3 (IQR: 561.0–957.5), and 387 (75%) had a viral load (VL) of 500 cell/mm3 (RR 1.04, p=0.76), VL (RR 1.01, p=0.78) or current ART class (protease inhibitor-based vs non-nucleoside inhibitor-based, RR 0.90, p=0.186) were not associated with ED after adjustment. At 48 months of follow-up, among YLPHIV, 8% (n=17) had sustained viraemia, and 54% (n=118) had transient viraemia through this period. The median duration on ART was 12 years (IQR 8-14); 57% (n=124) were on a non-nucleoside reverse transcriptase inhibitor-based ART, while the rest received protease inhibitor-based ART. Few YLPHIV met the criteria for hypertension (2%, n=4) or hyperglycaemia (0.5%, n=1). None of the HIV-uninfected youth had hypertension or hyperglycaemia. Fewer YLPHIV smoked compared to the uninfected youth (15.6% vs 11.5%, p=0.50. Elevated PDAY scores for CA (30.3% [n=66] vs 31.3% [n=10], p=0.74) and AA (18.4% [n=40] vs 21.9% [n=7], p=0.20), respectively among YLPHIV and HIV-uninfected adolescents differed slightly but did not reach statistical significance. Among YLPHIV, sustained viraemia [adjusted odds ratio (aOR)=18.4, p50 copies/ml (OR=2.06, p=0.023) were associated with an increased risk of low SI, while the use of efavirenz (OR=0.41, p=0.009) was associated with a decreased risk of low SI. YLPHIV had more impairment in mental health in several domains: functional competence (40% vs 25%, p=0.02), self-concept (23% vs 9%, p=0.03), higher depression (6% vs 2%, p< 0.01), anger (6% vs 2%, p=0.04), and disruptive behaviour (4% vs 0%, p p<0.01). Among YLPHIV, higher levels of anger were associated with increased total cholesterol and low-density lipoprotein (LDL) levels (ß=0.010, p=0.041 and ß=0.012, p=0.048, respectively), higher disruptive behaviour with increased LDL levels (ß=0.010, p=0.043), and severer CBCL-internalizing problems with low albumin levels (ß=-0.067, p=0.052) after adjusting for age, sex, and BMI z-score. Conclusion: YLPHIV are at higher risk of having subclinical cardiac structural abnormality and ED compared to uninfected adolescents. Both groups had a substantial proportion with high PDAY scores reflecting increased aggregate atherosclerotic risk. Bone health was worse among YLPHIV. HIV-related factors such as ART initiation at an older age, advanced clinical disease, and specific ARTs were significant risk factors for these conditions. Mental health impairment was common and associated with increased lipid concentration in YLPHIV. These data highlight a high prevalence of chronic comorbidities in YLPHIV, specific risk factors associated with these and provide information for strengthened strategies to prevent or monitor HIV-associated illnesses.
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    The clinical features and estimated incidence of MIS-C in Cape Town, South Africa
    (2022-05-02) Butters, Claire; Abraham, Deepthi R; Stander, Raphaella; Facey-Thomas, Heidi; Abrahams, Debbie; Faleye, Ayodele; Allie, Nazneen; Soni, Khushbu; Rabie, Helena; Scott, Christiaan; Zühlke, Liesl; Webb, Kate
    Background Multisystem inflammatory syndrome is a severe manifestation of SARS-CoV-2 in children. The incidence of MIS-C after infection is poorly understood. There are very few cohorts describing MIS-C in Africa despite MIS-C being more common in Black children worldwide. Methods A cohort of children with MIS-C and healthy children was recruited from May 2020 until May 2021 from the two main paediatric hospitals in Cape Town, South Africa. Clinical and demographic data were collected, and serum was tested for SARS-CoV-2 antibodies. The incidence of MIS-C was calculated using an estimation of population exposure from seroprevalence in the healthy group. Summary data, non-parametric comparisons and logistic regression analyses were performed. Results Sixty eight children with MIS-C were recruited with a median age of 7 years (3.6, 9.9). Ninety seven healthy children were recruited with a 30% seroprevalence. The estimated incidence of MIS-C was 22/100 000 exposures in the city in this time. Black children were over-represented in the MIS-C group (62% vs 37%, p = 0.002). The most common clinical features in MIS-C were fever (100%), tachycardia (98.5%), rash (85.3%), conjunctivitis (77.9%), abdominal pain (60.3%) and hypotension (60.3%). The median haemoglobin, sodium, neutrophil count, white cell count, CRP, ferritin, cardiac (pro-BNP, trop-T) and coagulation markers (D-dimer and fibrinogen) were markedly deranged in MIS-C. Cardiac, pulmonary, central nervous and renal organ systems were involved in 71%, 29.4%, 27.9% and 27.9% respectively. Ninety four percent received intravenous immune globulin, 64.7% received methylprednisolone and 61.7% received both. Forty percent required ICU admission, 38.2% required inotropic support, 38.2% required oxygen therapy, 11.8% required invasive ventilation and 6% required peritoneal dialysis. Older age was an independent predictor for the requirement for ionotropic support (OR = 1.523, CI 1.074, 2.16, p = 0.018). The median hospital stay duration was 7 days with no deaths. Conclusion The lack of reports from Southern Africa does not reflect a lack of cases of MIS-C. MIS-C poses a significant burden to children in the region as long as the pandemic continues. MIS-C disproportionately affects black children. The clinical manifestations and outcomes of MIS-C in this region highlight the need for improved surveillance, reporting and data to inform diagnosis and treatment.