South African Journal of Child Health

Association of attention deficit and hyperactivity disorder symptoms with visual functioning difficulties in Grade 1 learners

BACKGROUND: Children with attention deficit and hyperactivity disorder (ADHD) can experience visual motor control difficulties. Therefore, early identification of such difficulties is importantOBJECTIVE: To determine whether ADHD symptoms are associated with visual motor control difficulties in Grade 1 learnersMETHOD: In total, 382 children participated in the study. To determine the presence of ADHD symptoms, the educators completed the Strength and Weaknesses of ADHD symptoms Normal behaviour scale (SWAN) for each learner after six months of observing their class behaviour. Two kinderkineticists applied two tests, namely the Pyfer Sensory Input Systems Screening test and one subtest of the Quick Neurological Screening Test-II (QNST-II). Fisher's exact test was used to determine if ADHD symptoms were associated with visual functioning difficultiesRESULTS: ADHD symptoms were found to be significantly associated with 10 out of 21 visual functioning difficulties. These skills included fixation with both eyes (p=0.0491), fixation with the right eye (p=0.0003), fixation with the left eye (p=0.0042), ocular alignment of the right eye (p=0.0029), visual tracking with both eyes on X shape (p=0.0284), visual tracking with the right eye (p=0.0301), and visual tacking with the left eye on a circle (p=0.0032). Furthermore, ADHD symptoms were significantly associated with the QNST-II tracking test normal range (p=0.0028), moderate discrepancy (p=0.0028) and severe discrepancy (p=0.0075CONCLUSION: ADHD symptoms are significantly associated with approximately half of the tested visual functioning of Grade 1 learners. Appropriate interventions should be implemented by professionals to assist these learners

Bilateral Wilms' tumour: A ten-year experience of two academic centres in Johannesburg

BACKGROUND: Nephroblastoma is the most common paediatric renal malignancy, affecting 1 in 10 000 children worldwide. Between 5% and 10% present bilaterallyOBJECTIVE: To review two centre's experience of bilateral Wilms' tumour in order to improve future management practicesMETHODS: This was a retrospective case review of nephroblastomas treated at the Chris Hani Baragwanath and Charlotte Maxeke academic hospitals from 1 January 2003 to 31 December 2013RESULTS: Eighteen patients (8.04%) presented with bilateral disease and were younger than those with unilateral disease. Three patients presented with metachronous disease at a median age of 23 months; initial presentation was at a median age of 2 months. The remaining 15 patients presented with synchronous disease at a median age of 27 months. Treatment followed aspects of the SIOP 9 protocol. Two patients died before surgery. Thirteen kidneys were removed. Twelve patients underwent nephron-sparing surgery, with microscopically positive resection margins seen in six kidneys post surgery. Two patients with residual microscopic disease relapsed. Three kidneys demonstrated unfavourable histology. Nephroblastomatosis was identified in one kidney. Eight patients were alive and disease free and three were alive with disease. An overall and disease-free survival rate of 66.67% and 55.56%, respectively, was found for this cohort. Neither age >2 years nor metachronous disease was associated with a poorer prognosisCONCLUSION: Bilateral nephroblastoma is a complex disease. The majority of patients in this series presented with advanced local disease. Relapse was more commonly influenced by the presence of microscopically positive margins than metastatic disease at presentation

Associations between arterial stiffness and cardiovascular disease risk factors among black South African children

BACKGROUND: A limited number of studies have researched the associations between conventional cardiovascular disease (CVD) risk factors and arterial stiffness in childrenOBJECTIVES: To explore the associations between specific conventional CVD risk factors and arterial stiffness in black South African (SA) childrenMETHODS: This cross-sectional study included 59 children (male:17; female:42). The mean age (and associated standard deviation) of the participants was 11.15 (1.40) years. Conventional CVD risk factors included body mass index (BMI), waist circumference (WC), hip circumference, systolic blood pressure (SBP), resting heart rate (RHR), peak oxygen consumption (VO2peak) and physical activity. Pearson's correlation was used to measure associations between arterial stiffness, expressed as the stiffness index (SI), and CVD risk factors. Hierarchical multiple regression analysis adjusting for age was performed to identify associations between the independent variables (VO2peak, SBP, BMI, physical activity, RHR and WC) and the dependent variable (SIRESULTS: Arterial stiffness was found to be significantly positively correlated with age (r=0.52; p=0.03) and significantly negatively correlated with VO2peak (r=-0.53; p=0.03) in male participants. Following regression analysis, the association with age (r²=0.27; p=0.03) and SI remained significantly independent. When means were combined across the two gender groups, age (r=0.27; p=0.04) and RHR (r=0.26; p=0.05) were found to be significantly positively correlated with SI. Following regression analysis, both age (r²=0.07; p=0.04) and RHR (r²=0.15; p=0.02) remained significantly independently associated with SICONCLUSION: Age and RHR appear to be strong predictors of arterial stiffness in black SA children

Exploring determinants of under-5 stunting in Malawi using a generalised linear mixed model

BACKGROUND: Although several studies have examined determinants of stunting, most fail to account for unobserved heterogeneity in clustered survey dataOBJECTIVE: To investigate the determinants of stunting among Malawian children under-5 years of ageMETHODS: The study utilised cross-sectional data on 5 686 children aged 0 - 59 months extracted from the 2015 - 2016 Malawi Demographic and Health Survey dataset. Data were analysed using a generalised linear mixed model applied to clustered dataRESULTS: Children who were female (adjusted odds ratio (aOR) 0.83; 95% confidence interval (CI) 0.73 - 0.94), from wealthier households (aOR 0.68; CI 0.58 - 0.81), and whose mothers were overweight/obese (aOR 0.78; CI 0.65 - 0.94), aged 25 - 34 years (aOR 0.76; CI 0.62 - 0.93) or had at least a secondary level education (aOR 0.73; CI 0.56 - 0.94) were less likely to be stunted. The likelihood of stunting was higher among children who were anaemic (aOR 1.38; CI 1.20 - 1.59) and in whom respondents reported small birth size (aOR 1.61; CI 1.34 - 1.93). Age >12 months, being a twin or triplet and living in the Central region of Malawi also increased a child's risk of being stunted. About 3.0% of the variance in likelihood of being stunted occurred across communities (clustersCONCLUSIONS: Hidden community variations of child stunting in clustered-survey data need to be accounted for. Stunting strategies should be context specific

Hypoglycaemia in children aged 1 month to 17 years admitted to the children's emergency room of Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria

BACKGROUND: Hypoglycaemia is a common presenting feature of illness among children admitted with various conditions into the paediatric emergency roomOBJECTIVE: To determine the prevalence of hypoglycaemia among children admitted into a Nigerian teaching hospital, identify some of its associated factors and assess its relationship to patient outcomeMETHODS: In this cross-sectional study, 388 children were consecutively recruited. Their sociodemographic characteristics, clinical features and management outcome were obtained. Plasma glucose was measured using the glucose oxidase method and classified as hypoglycaemia (<3.4 mmol/L), low glycaemia (3.4 - <4.4 mmol/L) , normoglycaemia (4.4 - 7.7 mmol/L) and hyperglycaemia (>7.8 mmol/LRESULTS: Hypoglycaemia occurred in 50 (12.9%) subjects, while 55 (14.2%) had low glycaemia. At bivariate analysis, hypoglycaemia was associated with age (p=0.012), >6 hours from the last meal (p=0.004), medication use before presentation (p=0.014) and some markers of illness severity such as loss of consciousness (p<0.001), respiratory distress (p=0.004), dehydration (p=0.002), shock (p=0.004), and hypoxia (p=0.001). After logistic regression, a time > 6 hours from last meal (adjusted odds ratio (aOR) 2.98; 95% confidence interval (CI) 1.27 - 6.98), hypoxia (aOR 3.10; 95% CI 1.39 - 6.90), and passage of watery stools (aOR 2.92; 95% CI 1.26 - 6.78) were associated with hypoglycaemia. Hypoglycaemic subjects were 2.9 times more likely to die than normoglycaemic ones (p<0.001) but this association was lost at multivariable analysisCONCLUSION: Hypoglycaemia complicates common childhood illnesses and may be associated with poorer outcomes. Plasma glucose measurement and subsequent appropriate action should be core parts of the immediate management of ill children

Paediatric out-of-theatre procedural sedation at a tertiary children's hospital: A prospective observational study

BACKGROUND: Red Cross War Memorial Childrens Hospital (RCWMCH) is one of the largest paediatric hospitals in Africa. Despite an increasing number of surgical and diagnostic procedures being performed annually, a formal out-of-theatre sedation service does not exist. Procedural sedation and analgesia (PSA) is an important adjunct in behavioural management for invasive procedures in childrenOBJECTIVE: A prospective, observational study was performed at RCWMCH, aimed primarily at defining the number of cases of PSA performed outside the operating theatreMETHODS: Data were collected over a period of 3 months from all procedural out-of-theatre sedations performed, including ward patients and outpatient departments. All children <13 years of age were includedRESULTS: A total of 639 sedations were performed. Of these sedations, 288 (45.1%) paper responses were captured and analysed. The reported incidence of airway obstruction was 4.9% (n=14/288), desaturation 4.2% (n=12/288), laryngospasm 0.3% (n=1/288) and nausea and vomiting 2.4% (n=7/288). Three cases required conversion to general anaesthesia, and four cases were abandoned as a result of inadequate sedation. In 16.3% (n=47/288) of cases, the clinician was an operator sedationist (the same person performing the sedation and the procedure). In 90.6% of cases, the intravenous route was utilised, with dexmedetomidine, ketamine and propofol being the three most commonly used agentsCONCLUSION: A total of 639 PSA events were recorded in 3 months. The 288 events analysed were safely performed with minimal serious reported events. These results compare favourably with international studies and provide quantitative evidence as a prelude to setting up a dedicated sedation service at RCWMCH

Response to corticosteroid treatment in paediatric nephrotic syndrome: A retrospective review from Mozambique

BACKGROUND: First-line treatment for paediatric nephrotic syndrome, a chronic disease characterised by proteinuria, hypoalbuminaemia and oedema, is corticosteroid therapy. An association between African ethnicity and steroid resistance has been reported, but published data from sub-Saharan Africa are limited and lack consensus on the prevalence of steroid-resistant diseaseOBJECTIVE: We aimed to describe a cohort of paediatric patients with nephrotic syndrome, determine the frequency of steroid resistance, and investigate factors associated with steroid resistance at Hospital Central de Maputo, MozambiqueMETHODS: A retrospective chart review was performed for paediatric patients (1 - 14 years old) admitted with nephrotic syndrome between 2010 and 2015 with at least one follow-up visit by 31 March 2016. Patients with HIV or malaria were excluded. Descriptive statistics and frequencies disaggregated by treatment response were produced. Associations of treatment response with sociodemographic, clinical and laboratory variables were investigated by appropriate univariable statistical testsRESULTS: Twenty-eight patients met inclusion criteria and were characterised as having steroid-sensitive or steroid-resistant nephrotic syndrome based on response to an initial corticosteroid regimen. There were 15 boys (53.6%) and 13 girls (46.4%), with a median age of 5.5 years. Fifteen (53.6%) were steroid-sensitive, and 13 (46.4%) were steroid-resistant. Steroid-resistant patients had significantly lower diastolic blood pressure (p=0.004), lower serum haemoglobin (p=0.003), lower serum albumin (p=0.03) and higher platelet counts (p=0.008) compared with sensitive cases. Only 4 (30.8%) steroid-resistant patients received a kidney biopsyCONCLUSION: Given the relatively high occurrence of steroid resistance in this study, expanding access to kidney biopsy and second-line medications for paediatric patients not in remission after an initial course of corticosteroid therapy is needed to meet the current standard of care. Factors associated with steroid resistance need to be studied prospectively in larger cohorts of Mozambican children

Illness episodes in a cohort of preterm infants in their first year of life

BACKGROUND: There are limited data available regarding the illness episodes and hospital admissions of preterm infants after initial discharge in low- and middle-income countriesOBJECTIVE: To prospectively follow a cohort of HIV-unexposed preterm infants (29 - 34 weeks) and describe their illness episodes, admissions and associated risk factors over a one-year periodMETHODS: The study was nested in a parent study evaluating the efficacy of a monoclonal antibody against respiratory syncytial virus from January 2017 to March 2017, comprising 53 infants enrolled from two government neonatal nurseries in Cape Town, South Africa. Descriptive data were collected regarding perinatal history and socioeconomic factors of the infants' households. All infants received careful follow-up. Logistic regression was performed to assess the association between hospitalisation and socioeconomic factorsRESULTS: All 53 infants who were recruited were followed up over one year. There were 436 illness episodes, of which 31 were hospital admissions. One infant died at home. The most common illnesses were respiratory (53%) and dermatological (17%) in nature. Lower respiratory tract infections (LRTIs) accounted for 71% of all hospital admissions. There were no significant associations between socioeconomic subgroups when comparing illness episodes or hospital admissionsCONCLUSION: This study is one of the few to record all illness episodes and not solely admissions over a one-year period for HIV-unexposed infants. There are high rates of intercurrent respiratory infection and hospitalisation of preterm infants in their first year of life. Public health interventions to reduce the risk of LRTI must be strengthened. Larger studies need to be done to be able to report on the associations with socioeconomic determinants in developing countries

Multifocal kaposiform haemangioendothelioma: Another sirolimus success story

Kaposiform haemangioendothelioma (KHE) is a rare, infiltrative, vascular tumour of infancy and early childhood that is often complicated by the Kasabach-Merritt phenomenon (KMP), a consumptive coagulopathy. We describe the case of a 7-year-old boy who presented with a left shoulder mass, splenic hypodensities, bony lesions, and a coagulopathy. The histopathological findings were consistent with KHE. Emergent treatment of KHE involves correction of the coagulopathy with blood products, while pharmacotherapy is aimed at reducing the tumour size. Emerging data suggest a role for mammalian target of rapamycin (mTOR)-inhibitors, e.g. sirolimus, in the treatment of progressive KHE, to which our patient had an excellent clinical response. Our recommendation is that KHE should be considered in the differential diagnoses of an ill-defined, infiltrating, soft-tissue mass. Pharmacotherapy including an mTOR-inhibitor should be instituted in patients with symptomatic KHE. Long-term follow-up of residual KHE lesions is essential as they follow an unpredictable course.

Abetalipoproteinaemia arising from a new variant of microsomal triglyceride transfer protein in a child presenting with chronic fat malabsorption

This case report describes a patient who failed to thrive and lagged in development in the first year of her life and did not grow as expected. Though a history of diarrhoea was present, stool analysis was not conclusive for malabsorption of fat. Fat malabsorption may be due to various disorders of exocrine function of the pancreas as well as problems in the intestine. Abetalipoproteinaemia is a rare inherited condition in which neither the intestine nor the liver can secrete lipoproteins. This diagnosis was made on lipoprotein investigation by demonstrating the absence of lipoproteins containing apolipoprotein B (apoB). Lipoprotein investigation is generally normal in the parents of the recessively inherited condition of microsomal triglyceride transfer protein (MTTP) deficiency but in homozygous hypobetalipoproteinaemia owing to mutations in apoB that also impair lipoprotein assembly, the parents have low cholesterol concentrations. Patients with abetalipoproteinaemia improve markedly on dietary fat restriction but may benefit from medium-chain triglycerides as part of supplying their energy needs and, importantly, require high doses of vitamin F as well as other fat-soluble vitamins, to avoid neuromuscular degeneration and retinitis pigmentosa.