Browsing by Subject "children"

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    Open Access
    A prospective study to assess the value of liquid chromatography-tandem mass spectrometry in the management of paediatric poisoning at Red Cross War Memorial Children's Hospital, Cape Town, South Africa
    (2020) Washaya, Norbertta Nzwisisayi; Buys, Heloise; Muloiwa Rudzani
    Background: Paediatric poisoning is a common presentation to emergency departments worldwide. There is a paucity of data on the role of liquid chromatography-tandem mass spectrometry (LC-MS/MS), in the management of paediatric poisoning in low-and middle-income countries (LMICs). In high-income countries, most studies are retrospective, and few include children. Objective: The study describes the prevalence of liquid chromatography-tandem mass spectrometry confirmed paediatric poisoning at Red Cross War Memorial Children's Hospital, Cape Town, South Africa. Methods Children admitted with suspected poisoning between 1 January 2017 and 31 December 2017, were recruited. All patients had a urine and/or blood sample sent for LC-MS/MS toxicology. Data collected included demographic data, clinical features, investigations, management, outcome and social interventions. Results 152 children, with median age of 39 (IQR 25 -61) months were enrolled of which 128 (84%) were poisoning cases. Of the 128 poisoning cases, 88 (69%) presented with a history of ingesting a known substance, 16(12%) an unknown substance and 24(19%) were cases of occult poisoning. LC-MS/MS was able to identify a substance in 92% of the cases of occult poisoning. In those who had presented with a seemingly known substance, LC-MS/MS found a different substance in 15 cases. LC-MS/MS was also able to detect multiple drugs in 40 patients. Of the poisoning cases, six (5%) cases were attempted homicide cases and 5 (4%) cases were attempted suicide cases. No children died. Individualized social interventions were instituted in poisoning cases. Emergency placement safety reasons was required in 6 children. Conclusion: When the limitations are known, LC-MS/MS is useful in identifying cases of occult poisoning; identifying patients who have ingested multiple substances and/or an unknown substance and when targeted towards child protection. As LC-MS/MS is an expensive test, it should be used judiciously in LMICs.
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    Open Access
    Active Play: perceived and actual motor performance among Ghanaian children
    (2021) Doe-Asinyo, Rosemary Xorlanyo; Gretschel, Pamela
    Background: There is limited data on active play both in terms of perceived competence and actual motor performance in children living in low- and middle-income countries. Promotion of active play in children is crucial for enhancing participation in physical activity and reducing the burden of obesity. Regular engagement in active play is important for promoting optimal development and increasing physical activity levels in children. Despite the increased interest in active play and physical fitness worldwide, many children in low-resource settings are thought to be physically inactive due to the lack of physical activity-promoting resources and programmes. The 2018 Ghana Report Card on physical activity reports that a high proportion of Ghanaian children do not achieve recommended physical activity levels and a high percentage of these children have poor motor skills. To date, no published study has examined active play among school-aged children in Ghana. Investigating the nature of active play by assessing perceived and actual motor performance among Ghanaian children can serve to increase our understanding of activity deficits, movement difficulties and associated factors in this population. Aim: The aim of this study was to investigate the nature of active play in children aged 6-12 years in Ghana. Specific Objectives: 1. To determine children and caregivers' perceptions of children's motor performance in active play using the Motor Coordination Questionnaire (MCQ). 2. To determine children and caregivers' perceptions of the importance of active play. 3. To identify additional forms of active play and games (which are not listed on the MCQ) that children and caregivers perceive to be important and meaningful. 4. To determine the relationship between MCQ ratings by caregivers and children. 5. To determine the relationship between children's MCQ and actual motor performance. 6. To determine the relationship between caregivers' MCQ and actual motor performance. Methodology: A cross-sectional descriptive and analytical design was used. Three primary schools were purposively selected for this study. The study recruited 406 children and their caregivers for this study. Ethical approval was sought from the Ethics Review Committee of the Ghana Health Service (GHS-ERC 052/05/19) and the University of Cape Town Faculty of Health Sciences Human Research Ethics Committee (HREC REF: 112/2020). Data was collected from both caregivers and children (aged 6-12 years) using questionnaires and the Performance and Fitness (PERF-FIT) test battery. The MCQ-caregivers and MCQ-children were used to assess perceived motor performance, and the PERF-FIT test was used to measure children's actual motor performance. In using the Statistical Package for Social Sciences (SPSS) version 24.0 (SPSS Inc, IBM Company, Armonk, NY), Pearson or Spearman's correlation coefficient was calculated to determine the relationship between children and caregivers' perceptions as well as the relationship between the perceptions and the actual motor performance of the children. Results: Both children (75.6%-94.2%) and their caregivers (69.3%-95.4%) perceived good motor performance of the children during active play. Children (82.8%-96%) and their caregivers (83.2%-94.4%) also regarded active play as very important. Twenty-four additional games were found to be of importance to Ghanaian children and their caregivers. Weak negative, weak positive and sometimes moderate positive correlation between MCQ items and the PERF-FIT items were found. Conclusions: This study shows that we can't rely solely on perceptions, but need actual motor performance, to accurately measure motor performance during active play. We found that parents and children do not accurately estimate the actual level of motor performance. Further studies should be done to understand confounding variables that may have caused poor relationship between perceived and actual motor performance. There is a need for a valid tool like the PERF-FIT to help in accurate measurement of motor performance.
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    An adapted triage tool (ETAT) at Red Cross War Memorial Children’s Hospital Medical Emergency Unit, Cape Town: An evaluation
    (2013) Buys, H; Muloiwa, R; Westwood, C; Richardson, D; Cheema, B; Westwood, A
    Objective. To evaluate the efficacy of an adapted Emergency Triage Assessment and Treatment (ETAT) tool at a children’s hospital. Design. A two-armed descriptive study. Setting. Red Cross War Memorial Children’s Hospital, Cape Town, South Africa. Methods. Triage data on 1 309 children from October 2007 and July 2009 were analysed. The number of children in each triage category (red (emergency), orange (urgent or priority) and green (non-urgent)) and their disposal were evaluated. Results. 1. The October 2007 series: 902 children aged 5 days - 15 years were evaluated. Their median age was 20 (interquartile range (IQR) 7 - 50) months, and 58.8% (n=530) were triaged green, 37.5% (n=338) orange and 3.8% (n=34) red. Over 90% of children in the green category were discharged (478/530), while 32.5% of children triaged orange (110/338) and 52.9% of children triaged red (18/34) were admitted. There was a significant increase in admission rate for each triage colour change from green through orange to red after adjustment for age category (risk ratio (RR) 2.6; 95% confidence interval (CI) 2.2 - 3.1). 2. The July 2009 cohort: 407 children with a median age of 22 months (IQR 7 - 53 months) were enrolled. Twelve children (2.9%) were triaged red, 187 (45.9%) orange and 208 (51.1%) green. A quarter (101/407) of the children triaged were admitted: 91.7% (11/12) from the red category and 36.9% (69/187) from the orange category were admitted, while 89.9% of children in the green category (187/208) were discharged. After adjusting for age category, admissions increased by more than 300% for every change in triage acuity (RR 3.2; 95% CI 2.5 - 4.1). Conclusions. The adapted ETAT process may serve as a reliable triage tool for busy paediatric medical emergency units in resource-constrained countries and could be evaluated further in community emergency settings.
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    Care Through Family: a conceptual model of children’s nursing care
    (2021) North, Natasha; Leonard, Angela; Bonaconsa, Candice; Coetzee, Minette
    This project aimed to work with nurses to describe and document their practice. Nurse researchers from CNPDI worked with five teams of nurses in diverse paediatric settings in southern Africa to develop detailed descriptions of how nurses involve families in the care of their hospitalised child. We observed care and interviewed nurses and families to develop detailed descriptions of practice. We used visual research methods including graphic facilitation, sociograms and photographic elicitation to construct a detailed picture of routines, activities and environments. Holistic accounts of ‘real’ nursing practices were constructed through 1:1 and group interviews, exploring the underlying rationales and values. Comprehensive case study reports were produced for each setting and reviewed by key nurse participants. Together, researchers and nurses developed statements reflecting the model of care. After analysis of the data we constructed a description of nursing practice in the form of a model of nursing care which we call ‘Care Through Family’. The model is ordered around six themes. Each theme has a guiding principle, in the form of an illustrative statement reflecting the philosophies of care observed. Implementation of the model is supported by a self-assessment tool to guide nursing teams through a facilitated process of reflection and further practice development.
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    Children's constructions of gender: A participatory project
    (2019) Mohana, Malini; Boonzaier, Floretta
    Studies on the construction of gender have largely focussed on adolescents and young adults in South Africa. This leaves a significant gap in understanding the ways in which gender is constructed and negotiated by younger children. This study, therefore, investigated how younger children narrate and experience their gendered lives, and whether these stories resisted or maintained dominant narratives of gender. Twelve participants between the ages of eight and fourteen participated. The research used participatory action research (PAR) methods. Specifically, Photovoice, journaling, collages and drawing were used to represent the stories and narratives that the participants chose to share. The Photovoice component culminated in a community exhibition which showcased the participants’ photos. In addition, the participants took part in focus groups and individual interviews. The focus group transcripts, individual interview transcripts, collages, photographs, drawings and journal entries were analysed using thematic narrative analysis. The study showed that children construct gender based on contradictory messaging, and exercise defiance of normative gendered constructs within the limits of heteronormative gender identity. Four main narrative themes emerged: Negotiating gendered expression; Normalisation of gendered violence; Subjugating female bodies; Narratives of conformity and resistance. Based on the findings, the recommendation was made to use play as both a means of exploration and education in children’s understanding of gender.
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    Children's Institute submission on the draft regulations to the Children's Act 38 of 2005
    (Children's Institute, 2008-08) Proudlock, Paula; Meintjes, Helen; Moses, Sue
    Written submission to the national Department of Social Development, 11 August 2008.
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    Children's social networks and their implications for mental health and well-being
    (2025) Williamson, Elizabeth; Wild, Lauren
    The convoy model of social relations examines social networks as complex and evolving support structures. The exploration of children's social convoys is in its early stages, with limited research investigating how social network characteristics are associated with children's mental health and well-being. The current study aimed to fill this gap by examining the composition of preadolescent South African children's social convoys, as well as the implications of various structural features for mental health and well-being. Cross sectional data from 126 children aged 9- to 12-years-old from five schools across Cape Town and their parents were used in this study. The data were collected using standardised questionnaires and interviews. The findings revealed that children generally nominated parents, siblings, and often grandparents in their inner circles, and placed extended family members, friends, and professionals in the middle and outer circles of their social networks. Correlational and multiple regression analyses indicated that greater inner circle diversity had a positive association with both child- and parent-reported positive affect, and greater contact frequency with friends was negatively associated with total difficulties. Hierarchical multiple regression analyses showed that father absence from the inner circle was associated with more psychological difficulties and a poorer quality of life. Sibling and extended family member presence in the inner circle were associated with more child-reported positive affect, while grandparent presence was associated with more prosocial behaviour. Overall, the findings support both universal and culture-specific trends in children's social network composition, as well as the presence of relationships between specific structural features and mental health and well-being. It is recommended that interventions supporting children's mental health and well-being focus on fostering diverse inner circles by strengthening bonds with fathers and siblings as well as grandparents and extended family members.
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    Constipation in children
    (South African Academy of Family Physicians, 2013) Brown, R A; Wood, R J
    Constipation in children is a universal problem, occurring in 0.7-28% of the population. The exact aetiology is unknown, but the majority of children have a functional, rather than organic, aetiology. Symptoms associated with constipation include abdominal pain, a poor appetite and faecal incontinence, all of which interfere with the quality of life of the child and his or her family. Early intervention with appropriate management is necessary to prevent ongoing sequelae. Once an organic cause has been excluded, a programme of intervention should be implemented, namely evacuation of any faecal mass present, followed by regular maintenance therapy to encourage evacuation of a daily soft stool for at least 2-3 months, prior to gradual withdrawal. Emotional support, exercise and dietary modification are linked to the therapy and will ensure a successful outcome. Failure to implement the protocol may result in ongoing problems in up to 50% of children as they enter adulthood.
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    Correlates of tuberculosis and non-tuberculosis morbidity and immunity in sub-Saharan African HIV-exposed, uninfected infants
    (2024) Iwase, Saori Christina; Jaspan, Heather; Happel, Anna-Ursula
    Background: Perinatal HIV transmission has been considerably reduced due to successful intervention programs. Consequently, there is a growing population of infants who are HIV-exposed but uninfected (iHEU), particularly in sub-Saharan Africa. These infants experience an increased risk of morbidity compared to infants who are HIV-unexposed and uninfected (iHUU), predominantly due to infectious diseases. Although the mechanisms underlying this increased vulnerability remain unclear, it may be associated with their altered immunity and/or gut microbiota. Bacillus Calmette-Guérin (BCG) vaccination is an effective intervention to prevent severe tuberculosis (TB) disease in children. BCG vaccination also enhances heterologous protective immunity against infections through epigenetic reprogramming of innate immune cells (known as “trained innate immunity”). However, whether iHEU receive comparable protection from BCG induced immunity against TB and non-TB infection as iHUU remains elusive. Gut microbiota plays a critical role in immune development during infancy. A close relationship between gut microbiota and vaccine responses has been reported in iHUU, including tetanus toxoid (TT) vaccination. However, a limited number of studies longitudinally investigated the effect of in utero HIV exposure on the gut microbiota, and results are often conflicting. In addition, not many studies have compared the trajectory of gut microbiota between iHEU and iHUU across multiple countries. While several studies have indicated reduced immune responses against TT vaccination in iHEU compared to iHUU, the interplay between HIV exposure, gut microbiota, and vaccine response is largely unexplored. Aims: In this dissertation, we examined three potential contributing factors that may underlie the higher risk of morbidity observed among iHEU in sub-Saharan Africa. The specific aims were to examine whether BCG affords the same protection against TB infection (TBI) and disease in iHEU (corresponds to Aim 1), effect of HIV exposure on longitudinal gut microbiota composition and its association with TT vaccine response (corresponds to Aim 2), and optimization of epigenetic assay protocol, intended for future investigation of BCG-induced histone modifications in iHEU (corresponds to Aim 3). Methods and results: To assess TBI prevalence among iHEU and iHUU, a total of 418 mother-infant pairs from South Africa and Botswana were included. All infants received BCG vaccination at birth as per standard of care. T-SPOT.TB (ELISpot-based interferon-gamma release assay) was performed using cryopreserved peripheral blood mononuclear cells (PBMCs) from infants aged 9-18 months. The prevalence of TBI did not differ by the infant HIV exposure status, with 10 cases (3.4%) among iHEU and four cases (3.2%) among iHUU, none with symptoms of active TB disease. This trend was the same across two different African countries where the burden of HIV and TB is high. However, because of the lower T-SPOT.TB positivity than initially anticipated, we were under powered to conclude the effect. To assess whether gut microbial succession alters immunity in iHEU, we profiled longitudinal gut microbiota composition and associated this with TT vaccine responses in 354 mother-infant pairs from South Africa and Nigeria. Stool samples were collected at 1 and 15 weeks of life, and 16S ribosomal ribonucleic acid (rRNA) gene sequencing was performed. Plasma IgG anti-tetanus antibody titers were measured by enzyme-linked immunosorbent assay (ELISA). The effect of HIV exposure on infant gut microbiota composition was relatively modest compared to the impact of age and geographical factors. However, HIV exposure and specific gut microbes were independently associated with the TT vaccine response at 15 weeks of age. Results for South Africa and Nigeria differed, possibly due to higher maternal anti-tetanus IgG titers and hence infant baseline titers in Nigeria. To optimize an epigenetic assay that can be applied to infant samples, monocytes and natural killer (NK) cells were isolated from cryopreserved PBMCs using fluorescence-activated cell sorting (FACS). Cleavage Under Targets and Tagmentation (CUT&Tag) was optimized for assessing the histone modifications, acetylation of histone H3 at lysine 27 (H3K27Ac), trimethylation of histone H3 at lysine 4 (H3K4me3), and trimethylation of histone H3 at lysine 27 (H3K27me3; also used as a positive control). The optimized protocol was then applied to a subset of infant samples (n = 14; aged between six and seven weeks). Optimal input cell number, polymerase chain reaction (PCR) cycles, and sequencing depth were carefully determined for the CUT&Tag assay. These adjustments were necessary to achieve the assay's feasibility and data quality. The optimized CUT&Tag protocol and fine-tuned data analysis strategy successfully exhibited its capability to analyze multiple histone modifications using only 5,000 infant monocytes or NK cells as an input sample. Conclusions: Prenatal HIV exposure and gut microbiota may independently influence infant TT vaccine response. This supports the existing notion that iHEU exhibit altered immunity. Although previous studies have indicated that iHEU experience a higher risk of infection than iHUU, our data suggested that BCG vaccination was equally protective against TBI, irrespective of HIV exposure status. The optimized CUT&Tag protocol will offer a useful tool for investigating histone modifications using ultra-low input samples. This will be employed in the future study to explore whether iHEU exhibit comparable epigenetic modifications induced by BCG vaccination as for iHUU, providing valuable insight into whether iHEU receive similar non-specific protection from BCG vaccination compared to iHUU.
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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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    Empathy in autism spectrum disorder: Predictions from child/adolescent temperament, parenting styles, and parenting stress
    (2019) Ross, Toni Carmen Faith; Malcolm-Smith, Susan; Hamilton, Katie
    Individuals with autism spectrum disorder (ASD) exhibit definitional impairments in social relatedness; a phenomenon that can be explained, in part, by their deficits in empathy. Despite the extent of these deficits, relatively little is known about which factors promote or impede empathic functioning within this group. To date, studies of neurotypical children and adolescents suggest the explanatory power of temperament, parenting style, and parenting stress; associations which have yet to be adequately explored with ASD. Thus, the overarching aim of this investigation was to test whether the aforementioned intra- and interindividual features would predict empathy amongst children and adolescents with ASD. To account for some of the heterogeneity in ASD, two groups of parent-child dyads were recruited: one comprising male children and adolescents with intact receptive and expressive language (n = 40, M = 7.68 years); the other, males with little to no language use in either domain (n = 40, M = 9.09 years). A third group of parent-child pairs comprising male neurotypical children and adolescents with age-appropriate language functioning was included as a comparison sample (n = 40, M = 9.53 years). Parents completed wellestablished questionnaires pertaining to child/adolescent temperament and empathy, as well as parenting style and parenting stress, primarily via telephonic interviews. Results showed that temperamental regulation and negative affectivity were linked to empathy within the neurotypical group in positive and inverse directions, respectively. Only regulatory processes were positively associated with empathy within the non-verbal ASD group, whilst only negative affectivity was inversely associated to empathy within the verbal ASD group. Further, warm, responsive, autonomy-promoting parenting was positively associated with empathy within the neurotypical group, whilst punitive and lax parenting were inversely associated with empathy. Positive forms of parenting were also found to predict empathy within both ASD groups – though somewhat less so within the verbal ASD group. Perhaps a consequence of the severity of their empathic deficits, lax and permissive parenting techniques were not tied to empathy within the ASD groups. Finally, parenting stress was inversely linked to empathy within the non-verbal ASD and neurotypical groups only. Results highlight that findings obtained within neurotypical samples cannot always be extrapolated to ASD. Results further underscore the need for ASD interventions to adopt a family systems perspective, teaching parents how to perceive and respond to their children in adaptive ways.
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    Laboratory findings that occur in Klebsiella pneumoniae blood stream infection in HIV-infected children compared to HIV uninfected children, at a South African children's hospital, Cape Town, 2006–2011: a nested-descriptive cross-sectional study
    (2022) Shapaka, Johanna Tekla; Buys, Heloise; Muloiwa, Rudzani
    Background: Bloodstream infection (BSI) caused by Klebsiella pneumoniae (KP), is a leading cause of hospitalassociated childhood mortality. There are limited data on how poor outcomes of KPBSI can be predicted in poorly resourced areas. This study aimed to assess if the profile of differential counts from full blood counts (FBC) taken at two time points in children <13 years with KPBSI could be used to predict the risk of death. Methods We conducted a retrospective study of a cohort of children admitted to hospital between 2006-2011 with KPBSI. FBC collected within 48 hours (T1) of blood culture and 5-14 days later (T2), were reviewed. Differential counts were classified as abnormal if they were higher or lower than laboratory ranges for normal results. The risk of death was assessed for each category of differential counts. Risk ratios adjusted (aRR) for potential confounders were used to estimate the effect of cell counts on risk of death using multivariable analysis. Data were stratified by HIV status. Results: Of 296 children included, median age 5 (IQR:2-13) months, 82 were HIV -infected. Ninety-five (32%) of the children with KPBSI died. Mortality in HIV-infected and uninfected children was 39/82 (48%) and 56/214 (26%), respectively (p <0.001). Independent associations with mortality were observed with leucopenia, neutropenia and thrombocytopenia. Risk of mortality in children with thrombocytopenia at T1 and T2 was aRR 2.5 (95% CI: 1.34-4.64) and 3.18 (95% CI: 1.31-7.73) respectively in the HIV-uninfected group, whereas the risk for mortality in the HIV-infected group with thrombocytopaenia at T1 and T2 was aRR 1.99 (95% CI: 0.94-4.19) and 2.01 (95% CI: 0.65-5.99) respectively. Neutropenia in the HIV-uninfected group at T1 and T2, showed aRR 2.17 (95% CI: 1.22- 3.88) and 3.70 (95% CI 1.30-10.51) respectively, while in the HIV-infected group, they were aRR 1.18 (95% CI 0.69-2.03) and 2.05 (0.87-4.85) at similar time points. Risk of mortality related to leucopenia at T2 was associated with mortality in HIV-uninfected and HIV-infected patients was aRR 3.22 (95%CI 1.22-8.51) and 2.34 (1.09-5.04) respectively. Persistently high band cell percentage at T2 in HIVinfected children indicated a risk of mortality of aRR 2.91 (95% CI 1.20-7.06). Conclusion Abnormal neutrophil counts and thrombocytopenia are independently associated with significant mortality in children with KPBSI. In resource-limited countries haematological markers have the potential to predict KPBSI mortality.
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    Neuropsychiatric complications of efavirenz in children with HIV-1 infection
    (2018) Hammond Charles; Eley Brian
    Background: Efavirenz is associated with transient neuropsychiatric manifestations but the impact on neurocognition is unknown. Genetically determined black South Africans who are slow metabolizers of efavirenz may be at risk of toxicity. This study describes neuropsychiatric and neurocognitive manifestations of South African children with suspected efavirenz neurotoxicity. Method: This retrospective study describes clinical features of 12 children with suspected efavirenz neurotoxicity (2008 – 2014). Results: Twelve children were referred (aged 3 years 4 months to 12 years, mean 7 years 8 months; 8 indigenous African (black) and 4 mixed ancestry). Six had acute neuropsychiatric manifestations after 2-8 weeks (mean 5 weeks) on efavirenz including drowsiness, seizures, sleep disturbances, behavioural changes, ataxia and slurred speech. Symptoms resolved over a few weeks in four. Two black children were phenotypically slow metabolizers with high plasma efavirenz concentrations above normal range resulting in discontinuation of efavirenz. Nine children had neurocognitive concerns potentially exacerbated by long-term efavirenz (6-72 months therapy; mean 31 months), and showed poor performance in all neurocognitive domains. Conclusion: Efavirenz causes transient neuropsychiatric adverse effects and may contribute to poor longterm neurocognitive outcomes in HIV-infected children. Genetically slow metabolizers are at risk of neurotoxicity. Prospective studies comparing efavirenz-treated and efavirenz-naïve children are needed.
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    Paediatric epilepsy surgery in a middle-income country: the red cross war memorial children's hospital experience
    (2023) Louw, Lizet; Enslin, Johannes; Wilmshurst Joanne; Fieggen, A G
    Purpose While epilepsy surgery has been shown to reduce seizure frequency and severity and even cures seizures in children with drug-resistant epilepsy, data from middle-income countries (MIC) are lacking. Method This study is a retrospective review of children with drug-resistant epilepsy who underwent surgical treatment at Red Cross War Memorial Children's Hospital (RCWMCH) between 1 January 2000 and 31 December 2021 (HREC: 140/2020). Results During the 21-year study period, 60 patients underwent epilepsy surgery for drugresistant epilepsy. The median age of the children was seven years (IQR 4.81-10.27years) at the time of surgery, with a male predominance of 33 patients. The most common surgical procedure performed was an anterior temporal lobectomy for temporal lobe epilepsy in 19 cases (31.7%), followed by peri-insular hemispherotomy in 9 cases (15.0%) and frontal lobectomy in 8 cases (13.3%). Of the 60 patients, complete records were available for 55 patients noting complications in 11 (20.0%), of which 4 cases (7.3%) had major complications. Notably, 2 patients (3.6%) had new-onset psychiatric symptoms. The long term outcomes after surgery showed 1-year seizure freedom in 32 patients (58.2%); among these, 21 patients (38.2%) could stop ASM one year after surgery, 17 patients (30.9%) had a recurrence of their seizures, and three had to restart ASM after 2-3 years. Eight patients (14.5%) required repeat surgery. The one-year-Modified Engel scoring for the study population was: 1-A in 52.7%, I-B in 3.6%, I-C in 1.8%, II-A in 15.8%, III-A in 10.9%, IV-A in 3.6% and IV-B in 10.9%. The most common histological finding in anterior temporal lobectomy (ATL) was focal cortical dysplasia (FCD), found in 11 patients (57.9%). The periinsular hemispherotomy (PIH) cases had equal numbers of FCD and Rasmussen's encephalitis in 4 patients (44.4%). The number of FCD in this series is much higher than in international data. Conclusion Epilepsy surgery is an effective and attainable intervention for drug-resistant epilepsy in the paediatric population despite limited resources and challenging aetiological profiles. Low complication rates were comparable to international data, with good seizure freedom outcomes.
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    Paediatric triage in South Africa
    (Health and Medical Publishing Group, 2013) Cheema, B; Stephen, C; Westwood, A
    Reducing child mortality is a high priority in sub-Saharan Africa, and swift, appropriate triage can make an important contribution to this goal. There has been a lot of interest and work in the field of triage of sick children in South Africa over the past few years. Despite this, in many parts of South Africa no formal system for triage of children in acute and emergency settings is used. This article aims to explain some of the key paediatric triage tools being considered and developed in South Africa. The triage tools discussed are the World Health Organization Emergency Triage Assessment and Treatment (ETAT), the South African adaptation of this tool known as ETAT-SA, the South African Triage Scale (SATS), and the Revised Paediatric SATS (P-SATS). The article describes how they were developed and their relevance to the country.
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    Patterns of mortality in children presenting to a tertiary paediatric emergency unit in Sub-Saharan Africa: a cross sectional study
    (2020) Josephs, Tracey; Buys, Heloise; Masu, Adelaide; Muloiwa, Rudzani
    Background Pneumonia, diarrhoea and perinatal factors are the foremost killers of South African children as in other low- and middle-income countries. Poverty, poor access to care and pre-hospital care are reported major pre-hospital factors and lack of triage, poor skills, delays, poor adherence to treatment protocols and inadequate emergency care determining mortality have been reported to increase in-hospital mortality. Objectives To describe the clinical presentation and management of children admitted via the medical emergency unit (MEU) of the Red Cross War Memorial Children's Hospital (RCWMCH) who subsequently died. Methods We did a retrospective study undertaking a cross-sectional review of children who died following admission via RCWMCH MEU in 2008. Demographic information, clinical data, time factors and mortality data were reviewed and summarised by descriptive and inferential statistics. The unit utilised the WHO Emergency Triage Assessment and Treatment (ETAT) triage tool, categorising children into Red (emergency), orange (priority) and Green (non-urgent). Patient management was assessed by means of ETAT and the Integrated Management of Childhood Illness (IMCI) tools, which is used to identify severity of illness and strategize treatment plans accordingly. Results A total of 135 children met the inclusion criteria. The crude mortality rate was of 6.25 per 1000 admissions. Of the 135 children who died, 119 (88%) were under five years of age, 33(24%) were HIV-infected, of whom (88%) were under 5 years old. In 67 (50%), a chronic medical condition could be identified while 67 (50 %) were moderately or severely malnourished. There were 29 (22%) deaths within 24 hours of arrival at the MEU. Fifty-five (41%) presented after hours. Community health centres referred 65 (48%) patients, general practitioners referred 20 (15%) and 38 (28%) were self-referred. Ambulance services provided pre-hospital transport to 69 (51%). The two top presenting illnesses in 88 (65%) of the children were acute respiratory illness and acute gastroenteritis. Prior to referral, oxygen was not provided in 57 (59%) children, 35 (71%) with suspected sepsis did not receive antibiotics and glucose was not checked in 39 (80%) with depressed level of consciousness. The median time to ward transfer was 3.23 (IQR: 2.12-4.92) hours. Twelve deaths (9%) occurred in the MEU, 57 (42%) in PICU, 56 (42%) in medical wards and 10 (7%) in specialist wards. The five most common causes of death were acute respiratory infections in 45 (33%), acute gastroenteritis in 27 (20%), septicaemia 22 (16%), meningitis in 13 (10%) and cardiac conditions in 12 (9%) children. Conclusion The top causes of mortality in this hospital cohort in 2008 were pneumonia, acute gastroenteritis, and septicaemia. Using the IMCI and ETAT standard of care, suboptimal management was identified in pre-hospital management, as well as MEU management. Appropriate training and protocol implementation to improve morbidity and mortality should be undertaken.
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    PReS-FINAL-2253: A case series of HIV arthropathy in Cape Town
    (BioMed Central Ltd, 2013) Webb, K; Scott, C; Brice, N
    HIV arthropathy is well described in adults. Few studies have looked in depth at HIV arthropathy in children, and the characteristics of this entity have not been fully described.
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    Prevalence and Determinants of Vitamin D Deficiency in 1825 Cape Town Primary Schoolchildren: A Cross-Sectional Study
    (Multidisciplinary Digital Publishing Institute, 2022-03-16) Middelkoop, Keren; Walker, Neil; Stewart, Justine; Delport, Carmen; Jolliffe, David A.; Nuttall, James; Coussens, Anna K.; Naude, Celeste E.; Tang, Jonathan C. Y.; Fraser, William D.; Wilkinson, Robert J.; Bekker, Linda-Gail; Martineau, Adrian R.
    Vitamin D deficiency (25-hydroxyvitamin D[25(OH)D] <50 nmol/L) is common among adults in Cape Town, South Africa, but studies investigating vitamin D status of children in this setting are lacking. We conducted a cross-sectional study to determine the prevalence and determinants of vitamin D deficiency in 1825 Cape Town schoolchildren aged 6–11 years. Prevalence of vitamin D deficiency was 7.6% (95% Confidence Interval [CI] 6.5% to 8.9%). Determinants of vitamin D deficiency included month of sampling (adjusted odds ratio [aOR] for July–September vs. January–March 10.69, 95% CI 5.02 to 22.77; aOR for October–December vs. January–March 6.73, 95% CI 2.82 to 16.08), older age (aOR 1.25 per increasing year, 95% CI: 1.01–1.53) and higher body mass index (BMI; aOR 1.24 per unit increase in BMI-for-age Z-score, 95% CI: 1.03–1.49). In a subset of 370 participants in whom parathyroid hormone (PTH) concentrations were measured; these were inversely related to serum 25(OH)D concentrations (p < 0.001). However, no association between participants with hyperparathyroidism (PTH >6.9 pmol/L) and vitamin D deficiency was seen (p = 0.42). In conclusion, we report that season is the major determinant of vitamin D status among Cape Town primary schoolchildren, with prevalence of vitamin D deficiency ranging from 1.4% in January–March to 22.8% in July–September.
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    PW03-022 - Neutrophilic skin disease and inflammation
    (BioMed Central Ltd, 2013) Webb, K; Hlela, C; Scott, C
    Robert Sweet first described a syndrome with a painful, erythematous nodular plaques, neutrophilic dermal infiltrates, fevers and peripheral neutrophilia. This cluster of syndromes became known as Sweet's syndrome. There have been many published cases in children of neutrophilic dermatoses and fever which are labeled as Sweet's syndrome. Recently, however, neutrophilic dermatoses have been associated with some autoimmune and autoinflammatory diseases .
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    Reconstitution of antimycobacterial immune responses in HIV-infected children receiving HAART
    (2006) Kampmann, B; Tena, G; Nicol, MP; Levin, M; Eley, BS
    Objective: Recent epidemiological studies in adults suggest that HAART can prevent the development of tuberculosis in HIV-infected individuals, but the mechanisms are incompletely understood and no data exist in children. We investigated whether changes in mycobacterial-specific immune responses can be demonstrated in children after commencing antiretroviral therapy. Design: We measured mycobacterial growth in vitro using a novel whole-blood assay employing reporter-gene tagged bacillus Calmette–Guérin (BCG) in a prospective cohort study in the tuberculosis-endemic environment of South Africa. Key cytokines were measured in supernatants collected from the whole-blood assay using cytometric bead array. Patients: A cohort of 15 BCG-vaccinated HIV-infected children was evaluated prospectively for in-vitro antimycobacterial immune responses before and during the first year of HAART. All children had advanced HIV disease. Nine children completed all study timepoints. Results: Before HAART, blood from children showed limited ability to restrict the growth of mycobacteria in the functional whole-blood assay. The introduction of HAART was followed by rapid and sustained reconstitution of specific antimycobacterial immune responses, measured as the decreased growth of mycobacteria. IFN-γ levels in culture supernatants did not reflect this response; however, a decline in TNF-α was observed. Conclusion: This is the first study using a functional in-vitro assay to assess the effect of HAART on immune responses to mycobacteria in HIV-infected children. Our in-vitro data mirror the in-vivo observation of decreased susceptibility to tuberculosis in HIV-infected adults receiving antiretroviral agents. This model may be useful for further characterizing immune reconstitution after HAART.