South African Journal of Child Health

An evaluation of challenges with the South African PMTCT HIV programme seen from the perspective of HIV-positive children admitted to the PICU

BACKGROUND: Mother-to-child transmissions (MTCT) accounts for 90% of the 370 000 new HIV-positive children, globally. Despite progress in the prevention of mother-to-child transmission (PMTCT) of HIV, children still acquire HIV infectionOBJECTIVE: To identify and describe the prevalence of maternal, infant and/or health system-related risk factors gleaned from the literature for HIV transmission in HIV-positive children admitted to the paediatric intensive care unit (PICU) at Inkosi Albert Luthuli Central Hospital (IALCH), Durban, South AfricaMETHOD: A retrospective electronic chart review identifying all HIV-positive children under 2 years admitted to the PICU at IALCH between January 2017 and December 2019 was undertaken. Individual patient records were analysed using a standardised template RESULTS: Of the 80 mothers and children with HIV enrolled in the present study, 38.8% (n=31/80) of mothers were diagnosed prior to pregnancy, 42.5% (n=34/80) were diagnosed during pregnancy (unsure when exactly transmission occurred), and 18.8% (n=15/80) of mothers were diagnosed after delivery. The median (range) time of antiretroviral treatment (ART) was 225 (30 - 365) days for mothers. More than half of mothers (56.3%, n=45/80) whose babies became HIV-positive had poor adherence to antiretroviral drugs (HIV viral load >1 000 copies/mL). An HIV-positive diagnosis in the children of these mothers occurred throughout infancy and early childhood, especially in the first 6 months (87.5%, n=70/80). A third of mothers practised mixed feeding. Health system deficiency, mainly via cancellation of tests without notifying healthcare workers, was typical in infants (33%; n=26/80) and mothers (68.8%, n=55/80). All others (100%) were not counselled about the importance of PMTCT and 93.8% of mothers were not counselled about the importance of follow-up. Almost all HIV-positive infants (95%, n=76) presented with severe respiratory illness, mainly severe acute respiratory distress syndrome (62.5%, n=50/80) and pneumonia with hypoxic respiratory failure (32.5%, n=26/80). The overall mortality of the cohort was 22.5% (n=18/80), and most deaths were associated with cytomegalovirus (CMV), Pneumocystis jirovecii pneumonia (PJP) or both (61.1%, n=11/18) CONCLUSION: This present study confirmed that a new diagnosis of HIV positivity occurs throughout pregnancy and early childhood in infants. Poor adherence to ART in mothers and their infants, poor counselling, failure to attend antenatal and postnatal care, mixed feeding, and challenged laboratory services were common modifiable factors that need addressing

The epidemiology and treatment outcomes of clubfoot in a South African tertiary academic hospital

BACKGROUND: Clubfoot is a common congenital condition with a global incidence estimated at 1 in 1 000 live births. There is a paucity of information regarding the epidemiology and incidence of clubfoot in South AfricaOBJECTIVES: To describe the epidemiology, clinical characteristics, and the treatment outcomes of children with clubfoot who were treated at a tertiary hospital in South Africa. A secondary objective was to determine the incidence rate of clubfoot in our direct catchment area (within 40 km from Tygerberg hospital) for the study periodMETHODS: We conducted a retrospective cohort study of all records of children with clubfoot from 2014 - 2018. Demographic and clinical information, treatment progression and short-term outcomes including early relapse were collected. A subset of the total cohort, including only clubfoot patients from the direct catchment area of the hospital, together with the number of live births in the direct catchment area, was utilised to calculate the incidence rate of clubfoot in our settingRESULTS: A total of 197 patients were included over a 60-month period. Two-thirds of the patients were male (63.5%; n=125). A positive family history was reported in 12.2% (n=24) of cases, and 88.8% (n=175) and 11.2% (n=22) of patients were diagnosed as having idiopathic clubfoot or syndromic clubfoot, respectively. Relapsed clubfoot was diagnosed in 22.9% (n=40) and 22.7% (n=5) of patients with idiopathic and syndromic clubfoot, respectively. The overall incidence rate of idiopathic clubfoot in our direct catchment area was 1.02 per 1 000 live birthsCONCLUSION: The epidemiology, treatment outcomes and incidence rates observed at our institution are like those reported globally. We report a low positive family history and relapse rate, which could be under reported and should be the focus of future investigations

Challenges in the provision of tuberculosis preventive therapy to children in Gauteng Province, South Africa

BACKGROUND: Tuberculosis preventive therapy (TPT) offered to children who come into contact with infectious adult pulmonary tuberculosis (TB) cases is an important childhood TB prevention strategyOBJECTIVES: To document paediatric TPT coverage as per South African national TB guidelines, to measure basic knowledge of TPT in adult TB patients and healthcare workers (HCWs), and to determine challenges in TPT delivery in eligible childrenMETHODS: We conducted a descriptive, cross-sectional study at primary healthcare clinics in South-West Tshwane, Gauteng Province, South Africa (SA). Structured interviews were conducted with adult TB patients to obtain socio-demographic data, TB and HIV history, data on child contacts and TPT knowledge. A separate questionnaire probed HCWs' knowledge of TPT. Patient folders and the clinical process flow of adult TB cases and children on TPT were also assessedRESULTS: We interviewed 100 adult TB patients and identified 28 child contacts who were eligible for TPT, including six children (21%, n=6/28) on TPT, all HIV-uninfected and <5 years of age. Instability in household configuration was the most common reason for eligible children not having been brought to health facilities for assessment (57%; n=4/7). Almost all adult TB patients were aware of their TB diagnosis (98%; n=98/100), but only half (48%; n=48/100) had knowledge of their TB type, and 55% (n=6/11) of the adult TB patients with drug-resistant TB were aware of the drug resistance. In addition, we interviewed 71 HCWs, and more than one-third of HCWs (37%; n=26/71) were fully knowledgeable about paediatric TPT eligibility criteria, with 63% (n=45/71) unaware that HIV-infected children of all ages qualified for TPT after exposureCONCLUSIONS: TPT provision in eligible child TB contacts in an urban district in SA was found to be suboptimal, especially for HIV-infected children. Instability in household configuration was an important reason for suboptimal TPT provision. Training of HCWs on paediatric TPT guidelines is required, together with knowledge sharing on TPT with the TB patients

The relationship between menstrual hygiene management, practices, and school absenteeism among adolescent girls in Johannesburg, South Africa

BACKGROUND. Factors associated with menstrual hygiene management (MHM) and practices affect school absenteeism, with up to 7 million girls missing 25% of their given school year each month in South Africa (SA). OBJECTIVE. To identify the most significant factors associated with MHM and practices affecting school absenteeism among adolescents in Johannesburg, SA. METHODS. A secondary data analyses of a cross sectional study among 489 adolescent girls from 30 schools in Johannesburg, SA was conducted. Data was collected using a self-administered questionnaire. Logistical regression analysis was conducted for all variables affecting school absenteeism using STATA version 14. RESULTS. Female adolescents who had pre-menarcheal training were more likely to attend school (odds ratio (OR) 1.96; 95% confidence interval (CI) 1.04 - 3.73; p= 0.038). Those who disposed of their absorbent materials by burning, throwing them by the roadside or on farmland were almost 2x more likely to be absent from school (OR 2.07; 95% CI 1.05 - 4.08; p= 0.038). Dysmenorrhea (painful menstruation) was associated with higher likelihood of being absent from school (OR 2.6; 95% CI 1.29 - 5.29; p=0.008). CONCLUSION. This present study reveals that MHM and practices related to school absenteeism extend beyond the availability of sanitary materials. These findings can be used to create dialogue between various stakeholders about best practices for reducing school absenteeism related to MHM.

Parenting amid COVID-19: Challenges and supports for families with young children in South Africa

BACKGROUND. National response mechanisms, including lockdown regulations and financial and food aid, have exacerbated adversity and provided support. They have also exposed existing inequalities, with individuals and families able to cope and recover to varying degrees. Families with young children, specifically those under the age of 5, are rarely the focus of outreach, although they care for the most vulnerable group in our society. OBJECTIVE. To rapidly gather as much nationally representative information as possible on the challenges experienced by families with children under 5 years of age and the support they most urgently require. Methods. A short online survey was launched in late 2020 on a zero-cost mobile application reaching over 2 million users. A total of 15 912 individuals were eligible for participation and 13 224 parents (caring for 18 858 children under 5 years) were included in the analytic sample. Outcomes were grouped by (a) negative impacts of the pandemic, including disruptions in childcare, missed clinic visits, feeding challenges, difficulties in showing affection, behavioural challenges, and violence in the home; and (b) support received and required by the family. Chi-squared tests examined outcomes across the socio-demographic variables and standardised adjusted residuals were calculated to measure strength of differences. RESULTS. Fathers made up 30% of the sample. Just over half of parents cared for one child under 5 and 41% for 2 - 3 children under 5. More than three-quarters (82%) of parents reported experiencing at least one challenge, with the most common being disruptions in childcare (69%), difficulties feeding their child (50%) and showing affection (41%). The main underlying factors were fear of infection, lack of money and negative affect in the household including stress, tension and a sense of hopelessness and depression. Fathers and families living in rural areas reported the most challenges. They were more likely to report difficulties showing affection, struggles in providing meals for young children, and higher levels of violence towards children in the home. Although needs considerably outweighed support received, government compared with civil society organisations and communities had the highest penetration of support to families, reaching between a quarter and a third of families. CONCLUSION. Families with young children face many challenges with little outside support for their material and psychosocial needs. It is essential that those mandated with ensuring the wellbeing of young children understand the needs of families and have the capacity to reach them in general, and particularly during times of crisis.

The effects of armed conflict on children - should we remain silent?

**The emergence of Elizabethkingia meningoseptica infections in a quaternary-level paediatric intensive care unit in Durban, South Africa**

BACKGROUND: Elizabethkingia meningoseptica is an emerging pathogen in adult intensive care settings, but there are limited data on infections in children. OBJECTIVE: To describe the clinical presentation, risk factors for acquisition and management of infection in a quaternary-level paediatric intensive care unit (PICU). METHODS: This was a retrospective observational analysis of E. meningoseptica infections at the Inkosi Albert Luthuli Central Hospital, Durban, from January 2017 to December 2019. RESULTS: Eleven cases were identified, of which seven formed part of an outbreak cluster over an 11-week period. Enhanced infection control was implemented after the seventh case had been identified, resulting in immediate control. E. meningoseptica was identified exclusively from endotracheal aspirates. The clonality of outbreak isolates was confirmed from genotypic analysis. Five patients (45.4%) presented with nosocomial ventilator-associated pneumonia or systemic inflammatory response syndrome; one patient had possible meningitis. All patients were mechanically ventilated, with infection developing within 2-21 days. Exposure to multiple broad-spectrum antimicrobials (median: 5, range: 2-8) was identified as an acquisition risk. Seven of the nine patients who received targeted antimicrobial therapy survived. Of the untreated cases, one was discharged and the other died before isolate results were received. Overall, three patients (27%) demised. CONCLUSION: E. meningoseptica infection is emerging as a potential cause of nosocomial pneumonia in the PICU setting, which may also extend to other paediatric critical care settings. Excessive antimicrobial use is a likely risk factor for acquisition. Effective infection control measures remain a cornerstone of limiting nosocomial spread.

The profile of ancillary laboratory tests in neonates with positive blood and/or cerebrospinal fluid cultures

BACKGROUND: Blood and cerebrospinal fluid (CSF) cultures are used as a gold standard to diagnose neonatal sepsis/meningitis. A challenge in their use is low yield, and limited availability, especially in low-resource settingsOBJECTIVE: To evaluate profiles of full blood count (FBC), C-reactive protein (CRP), and CSF cell count and protein in neonates with culture-proven sepsis/meningitisMETHODS: Neonates with positive blood and/or CSF cultures who had results for FBC, CRP, CSF cell count and protein performed within 24 - 48 hours of culture were enrolled. The proportion of neonates with abnormalities in these tests was calculated and comparisons among different types of pathogens was performedRESULTS: A total of 942 isolates were cultured in blood and/or CSF. Organisms isolated were Gram-negative (GN) bacteria (62.0%), Gram-positive (GP) bacteria (23.4%) and Candida species (14.6%). Common abnormality in FBC was thrombocytopenia, which was observed in 30% of neonates with culture-proven sepsis. There was a higher proportion of neonates with thrombocytopenia among those infected with GN bacteria (39.9%) and Candida species (44.6%) compared with those infected with GP bacteria (15.1%; p<0.001). Leukopenia was relatively more common among neonates infected with GN bacteria than those infected with GP bacteria (20.8% v. 8.4%; p<0.001). More than two-thirds (70%) of neonates had high CRP (>10 mg/L). Finally, less than a third of neonates (26.7%) with positive CSF cultures had abnormal CSF cell count (>20 cells/mm³) and 61.6% had high protein (>150 mg/dLCONCLUSION: Majority of neonates with positive blood or CSF cultures have normal FBC or CSF cell count; therefore, the absence of abnormalities in these parameters cannot be used solely to exclude sepsis. CRP appears to be the most useful test for diagnosing sepsis, as it is raised in 70% of patients with culture-proven sepsis

Outcomes of periviable neonates born and admitted to a resource-limited hospital, Cape Town, South Africa

BACKGROUND: Periviability, defined as a gestational age of 20 0/7 to 25 6/7 weeks, is considered the limit of foetal maturity where a reasonable chance of survival exists. The outcome of these neonates in sub-Saharan Africa is poorly describedOBJECTIVE: To describe the mortality and morbidities of periviable neonates admitted to a resource-limited public hospital in South Africa (SAMETHODS: This was a retrospective, descriptive study performed at Tygerberg Hospital, Cape Town, SA, between January 2017 and December 2018. Records of all periviable neonates (gestational age <27 weeks or birthweight <750 g) born at or admitted to Tygerberg Hospital within 24 hours of birth were includedRESULTS: The study population consisted of 186 periviable neonates, of whom 157 (84.4%) had a gestational age <27 weeks, 101 (54.3%) weighed <750 g and 72 (38.7%) were <27 weeks and weighed <750 g at birth. Severe intrauterine growth restriction was noted in 16% of cases. Neonatal mortality varied with gestational age. The overall survival rate was 51%, with survival increasing with increasing gestational age. Morbidities are described according to gestational age and birthweight, and also varied with gestational age. Most periviable neonates received comfort care or specific supportive care only, congruent with the provincial policy guidelinesCONCLUSION: This is the first study to describe survival and morbidities of neonates delivered at the periviable limit at Tygerberg Hospital, a resource-limited public hospital in SA. Despite restricted resources and limited care, ~50% of these periviable neonates survived

Trends in neonatal mortality in a regional hospital in the Eastern Cape, South Africa: Quality improvement in action

BACKGROUND: Dora Nginza Hospital had a high neonatal mortality rate (NMR) in 2016. Quality improvement (QI) strategies were subsequently introduced to improve outcomesOBJECTIVE: To report changes in the NMR at Dora Nginza Hospital from 2016 to 2019, following the introduction of QI interventionsMETHODS: A retrospective comparison was conducted of unit-based data from before and after the introduction of QI interventions. Outcomes included total, early and late NMR, NMR by birthweight categories and causes of neonatal deaths. A chi-squared test and relative risk were used to compare groups, with p<0.05 considered significantly differentRESULTS: Total NMR declined from 34.4/1 000 live births to 19.4/1 000 (p<0.01). Early NMR decreased across all birthweight categories (p<0.01). Late NMR decreased in neonates >500 g (p=0.02) but not in those >1 000 g (p=0.99). Relative risk of early or late neonatal death was 0.57 (0.46 - 0.69). Total deaths due to prematurity decreased from 108 in 2016 to 39 in 2019 (p<0.01). There was no significant change in deaths due to congenital abnormalities (p=0.051), infection (p=0.1) or intrapartum events (p=0.08CONCLUSION: We report a significant reduction in NMR following QI interventions, largely due to a decrease in prematurity-related early neonatal mortality. Similar interventions may be beneficial in other poorly resourced settings. Adequate kangaroo-mother care facilities, availability of nasal continuous positive-pressure ventilation to all preterm neonates, promotion of breastfeeding and protocol-driven management of premature newborns are key