Scielo RSS <![CDATA[South African Journal of Child Health]]> vol. 9 num. 4 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[<b>Cerebral palsy in SA: Perinatal factors and later neurological handicap in infants born at or near term</b>]]> <![CDATA[<b>Immunisation and vitamin A capsule coverage in a semi-urban area of KwaZulu-Natal Province, South Africa</b>]]> BACKGROUND: The Expanded Programme on Immunisation (EPI) in South Africa (SA) has had a large effect on vaccine-preventable illnesses, yet there is little in the literature describing access to and utilisation of the programme beyond 1 year of age. Coverage of vitamin A supplementation is examined through District Health Information System data, but this does not give a fair assessment of the lifetime coverage in a child or provide any correlation with the immunisation status of the child. OBJECTIVES: To describe utilisation and dropout rate with the vitamin A and immunisation programmes over the first 6 years of life among children aged 6 - 8 years in a semi-urban population in KwaZulu-Natal (KZN) Province, SA. A secondary objective was to investigate whether access and dropout rates are associated between these two programmes. METHODS: A retrospective cohort analysis was performed on 923 anonymised Road-to-Health cards, extracting information on immunisation and vitamin A coverage. RESULTS: Overall, 92.9% (95% confidence interval (CI) 91.2 - 94.6) and 88.5% (95% CI 86.4 - 90.5) of children were fully immunised by 12 months and 18 months of age, respectively. The percentage of children fully immunised by 6 years of age dropped to 44% (95% CI 41.2 - 47.6). The dropout rates for measles, and diphtheria, pertussis and tetanus 1 - 3 vaccination were 2.4% and 1.2%, respectively. Vitamin A had an overall coverage of 34.9% during 6 - 60 months of life for this population, with children receiving, on average, three doses (interquartile range 2 - 5). CONCLUSION: Despite good immunisation coverage in the first 18 months of life, there was relatively poor vitamin A coverage, suggesting a need for re-evaluation of the current vitamin A capsule distribution programme. <![CDATA[<b>A retrospective review of the transfer of critically ill children to tertiary care in KwaZulu-Natal Province, South Africa</b>]]> BACKGROUND: Obtaining care for an acutely ill child in specialised paediatric services relies on referral from lower-level facilities. In South Africa, it is common practice for acutely ill children to be transported far distances by non-specialist teams with limited equipment, knowledge and skills. OBJECTIVES: To describe the transfer of these children and to determine whether they deteriorate from the time of referral to the time of arrival at a tertiary centre. Furthermore, we sought to identify modifiable factors that might improve outcomes during resuscitation and transfer. METHODS: The study was a retrospective review of emergency referrals of children aged 1 month - 12 years to Grey's Hospital paediatric ward or paediatric intensive care unit (PICU), from lower-level facilities in KwaZulu-Natal between January and June 2012. In conjunction with an assessment by the receiving clinician at Grey's Hospital, Triage Early Warning Signs (TEWS) scores were obtained during telephonic referral and compared with the TEWS score on arrival in order to determine if a deterioration had occurred. RESULTS: A total of 57 PICU referrals and 79 ward referrals were analysed. The mortality rate prior to transportation was 8.8%. Mean transfer distance was 131 km and mean transfer time 9 hours. Advanced life support teams undertook transportation in 76.7% of PICU and 25% ofward transfers and few adverse events were reported in transfer logs. However, 31.5% of PICU and 11.3% of ward referrals required immediate resuscitation on arrival. When the TEWS scoring system was applied 78.5% of PICU and 30.4% of ward referrals fell into the 'very urgent' and 'emergency' categories. CONCLUSION: Pretransport and in-transit care failed to stabilise children and this may reflect lack of skill of attending healthcare workers, transport delays or illness progression. Interventions to improve resuscitation and transfer are needed, and the use of retrieval teams should be investigated. <![CDATA[<b>Acute pain management in children with sickle cell anaemia during emergency admission to a teaching hospital in Lagos, Nigeria</b>]]> BACKGROUND: Optimal pain management in children with sickle cell anaemia (SCA) begins with accurate and thorough pain assessment. However, little or no evidence of this practice exists among SCA patients in developing countries. OBJECTIVES: To evaluate pain management in children with SCA during emergency admission. METHODS: Children with SCA who were <12 years old, on admission for a painful crisis and who were not using herbal remedies for pain relief, were prospectively studied at the Lagos University Teaching Hospital (LUTH) over a period of 1 year. A proforma data collection form was used to obtain information about the demographics of the patients and their parents, as well as pain score, and non-pharmacological and pharmacological treatments documented in the patients' case files. Pain was assessed for each patient using the Wong-Baker Faces Pain Rating Scale. RESULTS: The median age and weight of the patients were 4 years and 16 kg, respectively. Pain assessment by the physicians was documented in 10 (8.3%) patients. However, among those assessed for pain by the researchers, 90 (75%) had a moderate pain score of 5 - 8. Fluid therapy (n=110, 91.7%) and prayers (n=120, 100%) were the most common non-pharmacological therapies administered to the patients while admitted. Analgesics, either in combinations or as a single medicine, were administered to 100 (83.3%) patients. Paracetamol (n=90, 75%) and pentazocine (n=80, 66.7%) were the most frequently used analgesics. The dosage of the analgesics prescribed did not conform to the recommendations of the World Health Organization (WHO). CONCLUSION: The SCA children in this study were managed sub-optimally with analgesics. Pain management among this group of children did not fully conform to the guidelines of the WHO. <![CDATA[<b>Factors associated with bacteraemia in febrile, non-neonatal children <5 years old at the paediatric outpatient clinic of the University of Port Harcourt Teaching Hospital, Nigeria</b>]]> BACKGROUND: Fever is one of the most common presenting symptoms in the emergency room. Bacteraemia can be a cause of febrile illness in children and can have a fatal outcome if untreated. Therefore, it is important to identify factors associated with bacteraemia in febrile children in order to aid its early diagnosis and prompt treatment. OBJECTIVES: To determine the factors associated with bacteraemia among febrile, non-neonatal, under-five children seen in the Children's Clinic of the University of Port Harcourt Teaching Hospital, Nigeria. METHODS: Febrile children aged 29 days - 59 months who presented at the outpatient clinic and whose parents gave consent were recruited between September 2010 and January 2011. Information on their age, gender, weight, symptoms, physical examination and blood culture results was collected and analysed. RESULTS: A total of362 children were studied. The prevalence rate of bacteraemia was 11.5% and 22.2% in moderately and severely malnourished children, respectively (p=0.010). Children with systemic inflammatory response syndrome (SIRS) had the highest bacteraemia prevalence rate (66.7%; p<0.001), while children with focal infection and children with fever without other symptoms or signs had bacteraemia rates of 7.1% and 3.7%, respectively. There was no significant relationship between the magnitude of fever and bacteraemia (p&gt;0.050). CONCLUSION: Blood cultures should be performed in febrile children who are malnourished or who have SIRS. Antibiotics should also be commenced while blood culture results are awaited. <![CDATA[<b>Persistent and new-onset anaemia in children aged 6 - 8 years from KwaZulu-Natal Province, South Africa</b>]]> BACKGROUND: Anaemia impairs normal development in children and has wide-ranging social and economic implications. Existing anaemia control strategies primarily target anaemia in infancy. The contribution, however, of anaemia in preschool- and school-aged children as well as its long-term effects has not been extensively evaluated. OBJECTIVES: To determine the prevalence of anaemia in the same children on two occasions at least 18 months apart. METHOD: We carried out a longitudinal study in a rural community of KwaZulu-Natal, South Africa. Haemoglobin (Hb) levels were measured using the HaemoCue at baseline when the children were aged 4 - 6 years, and the follow-up assessment was done at age 6 -8 years. HIV screening and helminth testing was offered to all the children. RESULTS: Hb levels at both baseline and follow-up were available for 181 children. The baseline anaemia prevalence was 56.9% (mean Hb 11.2, standard deviation (SD) 1.14) and at follow-up the anaemia prevalence was 41.9% (mean Hb 11.7, SD 1.19). There were 21/180 (11.7%) children with new-onset anaemia at follow-up, while anaemia from baseline persisted in 43/103 (41.8%). CONCLUSIONS: The findings suggest a high burden of anaemia in these school-aged children, which might be reduced with early interventions. Interventions targeting screening and management of anaemia, chronic infections and nutritional deficiencies are recommended. <![CDATA[<b>The effect of lactose-free formula feeds on growth responses among severely malnourished HIV-infected children in Durban, South Africa</b>]]> BACKGROUND: The co-occurrence of HIV infection and severe malnutrition contributes to high rates of morbidity and mortality among children in resource-limited settings. Lactose-free, ready-to-use therapeutic feeds (RUTFs) may be most appropriate in this population because of underlying mucosal damage secondary to inflammation and infection. OBJECTIVES: To describe the effect of lactose-free RUTFs on the growth parameters of severely malnourished HIV-infected children in Durban, South Africa (SA). METHODS: This was a prospective, observational study of nutritional recovery in HIV-infected, severely malnourished children, aged 6 months to 5 years, who received lactose-free RUTFs following admission to King Edward VIII Hospital in Durban, SA. The primary outcome was nutritional recovery, defined as 15% weight gain from enrolment to end of study. Secondary outcomes included z-scores for weight-for-height, weight-for-age, height-for-age, triceps skinfold thickness (SFT) and subscapular SFT calculated at baseline and 7, 14, 30 and 45 days after admission. Univariate analysis was done to compare outcomes among antiretroviral therapy (ART)-naive and ART-experienced children; the effect of ART on nutritional recovery was evaluated in a logistic regression model. RESULTS: A significant improvement in most nutritional parameters was found at 45 days; 59% of children attained nutritional recovery. There was no significant difference in the proportion of children reaching recovery based on ART status at admission (p=0.08). CONCLUSION: Lactose-free formula feeds may be an effective strategy for nutritional rehabilitation of severely malnourished and HIV-infected children in resource-limited settings. It remains to be determined how ART initiation affects nutritional recovery in these children. <![CDATA[<b>Audit of feeding practices in the neonatal wards at the Charlotte Maxeke Johannesburg Academic Hospital</b>]]> BACKGROUND: Breastfeeding is the preferred choice of infant feeding. The Baby-Friendly Hospital Initiative (BFHI) is a ten-step plan to help establish successful breastfeeding and is adapted by public sector hospitals in Gauteng. Despite this, rates of breastfeeding in sick and preterm neonates remain low. OBJECTIVE: To determine feeding practices of neonates in the neonatal wards of the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) on discharge METHODS: A retrospective review of the CMJAH neonatal database of feeding choices of neonates discharged from the CMJAH neonatal unit between 1 January 2013 and 30 April 2013 was conducted. RESULTS: The records of 404 neonates were studied. A total of 98 (24%) were very low birth weight (VLBW) (<1 500 g), while 306 (75.7%) were &gt;1 500 g or more. Only 94 (23.2%) were discharged on exclusive breastmilk, 232 (57.4%) were discharged on exclusive formula milk and 78 (19.3%) babies were discharged on mixed feeds (both formula milk and breastmilk). Significant variables associated with feeding choices were HIV exposure, perinatal asphyxia and resuscitation at birth and, particularly in the VLBW group, necrotising enterocolitis was found to be statistically significant. CONCLUSION: Despite the fact that the CMJAH was involved in the BFHI, rates of exclusive breastfeeding were still low. This needs to be urgently addressed with employment of lactation consultants and improved counselling of mothers exposed to HIV on the importance and benefits of breastfeeding. <![CDATA[<b>Posterior reversible encephalopathy syndrome: Some novel associations</b>]]> Posterior reversible encephalopathy syndrome (PRES) (also called reversible posterior leukoencephalopathy syndrome) is a mostly transient and reversible neurological disorder clinically characterised by headache, seizures, blindness and altered consciousness associated with radiological abnormalities in the posterior white matter. Hypertension has been implicated as the most common association. We report four cases of PRES associated with non-hypertensive causes together with a review of the literature. Two cases occurred following cerebral anoxia due to accidental strangulation and near-drowning, respectively. The third patient, a child known to have E-β thalassaemia, presented with transient encephalopathy following blood transfusion but involving the anterior brain rather than the posterior part classically described in PRES. The fourth patient developed PRES while recovering from toxic epidermal necrolysis syndrome. None of these four cases had hypertension at any point during their illness. <![CDATA[<b>Congenital nephrotic syndrome: A diagnostic and management dilemma</b>]]> Congenital nephrotic syndrome (CNS) is characterised by heavy proteinuria, hypoproteinaemia and oedema presenting in the first 3 months of life. We present a 27-day-old female patient admitted to the Inkosi Albert Luthuli Central Hospital with CNS; one of twins and HIV exposed but uninfected. The child had a cytomegalovirus (CMV) polymerase chain reaction (PCR) positive result in the urine, confirmed on two separate occasions. The CMV PCR for qualitative testing of CMV DNA was negative and quantitative testing was not done. CMV retinitis and central nervous system involvement were absent. Despite treatment with gancyclovir, the CNS did not improve. Further management required indomethacin followed by unilateral nephrectomy to decrease administration of albumin infusions to control oedema. Unfortunately, due to loss to follow-up, the patient demised from probable sepsis. We discuss the challenges we faced with respect to the diagnosis and management of CNS in a resource-limited setting where transplantation is not readily available.