Masters Degrees (Paediatrics and Child Health)

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    Wrap and cap: prevention of admission hypothermia in very low birth weight infants in a resource restricted hospital: a pilot study.
    (Stellenbosch : Stellenbosch University, 2023-11) Jones, Thomas Ryan; Kali, Gugu; Van Wyk, Lizelle; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.
    ENGLISH ABSTRACT: Background: Neonatal hypothermia is both common, and a significant contributor to morbidity and mortality in very low birth weight (VLBW) infants. The objective of this pilot study was to determine if a new “wrap and cap” protocol would be able to ensure normothermia (36.5◦C-37.5◦C) in VLBW infants upon admission. Materials and methods: This was a prospective cohort study involving the introduction of a “wrap and cap” protocol for post-delivery thermoregulatory care in VLBW infants born in a tertiary centre in the Western Cape, South Africa. The “wrap and cap” protocol involved the use of plastic bags and woollen hats. Axillary temperatures were recorded post-resuscitation, on admission to the admission ward, and at 1 hour of age. Ambient delivery and admission room temperatures were recorded for each infant. The prevalence of admission hypothermia was calculated as well as risk factors for admission hypothermia. Results: A total of 53 VLBW infants were enrolled. The “wrap and cap” protocol was unable to prevent admission hypothermia with all infants being hypothermic on admission, and 83% of infants remaining hypothermic at 1 hour of age. Important contributing factors included the use of antenatal corticosteroids (OR = 3.45; p = 0.023), low delivery room temperatures (OR = 4.0; p = 0.065), and male sex (OR = 3.75; p = 0.080). Conclusion: Admission hypothermia in the VLBW infants remains highly prevalent. The Wrap and Cap protocol was unable to increase admission normothermia due to low delivery room temperatures and faulty equipment.
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    Respiratory management of low birth weight neonates with respiratory distress in rural district and regional hospitals in the Western Cape during 2019
    (Stellenbosch : Stellenbosch University, 2023-11) Read, Jo-Mari; Slogrove, Amy; Engelbrecht, Arnold; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.
    ENGLISH ABSTRACT: Background Respiratory distress in low birth weight (LBW; <2500g) neonates is associated with prolonged morbidity and high mortality. Neonatal transport to specialized facilities can lead to complications and increased mortality. Improving care for LBW neonates with respiratory distress at district and regional hospitals and avoiding transport to specialized centres, may improve South Africa's neonatal mortality rate. Objectives This study aimed to compare the respiratory care received by LBW neonates in three rural Western Cape hospitals during 2019, to assess adherence to recommendations and to describe the outcomes. Methods A retrospective cohort study was conducted including LBW neonates with signs of respiratory distress within the first 24 hours of life born in 2019 at three rural hospitals. Neonates were categorised into mutually-exclusive groups: regional (all care at regional hospital), district (all care at district hospital) and transferred (transferred from district to regional hospital). Respiratory management was assessed according to the Western Cape Provincial Peri-viability Decision Support Framework, utilising the Downe score to classify severity of respiratory distress upon admission. The proportion (95% confidence interval) receiving recommended respiratory care was compared between groups. Results Among 210 included neonates, 145 (69%) were in the regional group, 53 (25%) in the district group and 12 (6%) in the transferred group. A total of 197 (94%) neonates received respiratory support as recommended or more with no significant difference between the groups. There was a higher proportion of neonates with moderate or severe distress in the regional (61/145;42%) compared to the district group (18/53;34%). Escalation of respiratory support occurred more frequently in the district (N=8/53;15%) compared to the regional group(N=12/145;8%). Neonates at regional level received a longer period of respiratory support (median 36.5 hours; IQR 13.5-82.5 hours) compared to district level (median 21 hours; IQR 9-48 hours). Specialized interventions were more prevalent at the regional level, with surfactant administration to 35/145 (24%) neonates compared to 4/53 (8%) at district level. However, there was no meaningful difference in mortality between the regional and district groups Conclusion Reassuringly 94% of neonates in rural Western Cape received respiratory support as recommended or more. While the regional hospital cared for neonates with more severe respiratory distress, requiring longer respiratory support and more specialized interventions, no difference in mortality between the regional and district level was observed which requires further investigation.
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    Hypernatraemic dehydration in children with acute gastroenteritis requiring intensive care in a tertiary hospital, Cape Town, South Africa.
    (Stellenbosch : Stellenbosch University, 2023-11) Abu-Hajer, Hasan; Parker, Noor; Smit, Liezl; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.
    ENGLISH ABSTRACT: Background: Limited data is available on the management and outcome of hypernatremia as complication of acute gastro-enteritis (AGE) in children requiring paediatric intensive care in the developing world, and Africa in particular. Objectives: To describe the proportion, management, morbidity and mortality of children admitted with AGE, and hypernatraemia, to the paediatric intensive care unit (PICU) at Tygerberg Hospital, South Africa. Methods: This is a retrospective descriptive study from 1 January 2015 to 31 December 2020. Data were obtained from the intensive care unit data base, the National Health Laboratory Services and hospital electronic patient records. Demographic-, clinical-, and laboratory data, with complication events and mortality were determined. Results: There were 251 admissions of children with AGE, a proportion, of 5.9%; with 195 included in the final data analysis. Hypernatraemia was recorded in 47.2% (92/195) of AGE admissions; these infants had a median age of 5 months, 76% (70/92) had normal weights for age on admission and 6% (6/92) were HIV infected. The median sodium (Na) on admission was 159 mmol/L (IQR 150-168), improving to a median of 147 mmol/L (IQR 142-152) after 48 hours of admission. The acidosis improved significantly within 48 hrs of admission (p<0.001). Seizures, hypocalcaemia, and hyperglycaemia were more common in the group with hypernatraemic dehydration. The majority (84%, 65/77) of hypernatraemic dehydration patients were managed with a chloride free solution during the first 24 hours of admission and two thirds (67%, 48/71) required intubation and ventilation before transfer to the PICU. Most children with AGE were referred from another hospital (79%, 154/195). Most children presented initially with severe dehydration (97%, 190/195) and shock (89%,174/195); half (49%, 96/195) were still shocked on admission to PICU. Overall, the mortality rate in children admitted with acute gastro-enteritis was 7.2% (14/195); it was 4.3% (4/92) in the hypernatremic, 5.7% (4/69) in the isonatremic, and 17.6% (6/34) in the hyponatraemic dehydration groups. All patients who died (100%, 14/14) required intubation and ventilation before transfer, with a third (36%, 5/14) having coinciding sepsis with a positive blood culture. Most deaths in the hypernatraemic and isonatraemic dehydration groups occurred within the first 2 days of admission, with deaths in the hyponatraemic group occurring later. Conclusion: Complicated AGE remains a significant contributing factor to child morbidity and mortality in South Africa irrespective of the blood sodium level, but hypernatremia was not the major contributor as expected from the literature. Infants younger than 1 year of age, those with underlying malnutrition and sepsis, and those requiring intubation and ventilation at the referring facility may be at highest risk of death.
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    Exposure to paediatric end-of-life care: the experiences and coping strategies of paediatric registrars in South Africa
    (Stellenbosch : Stellenbosch University, 2023-05) Sullivan, Audrey Louise; Kling, Sharon; Kruger, Mariana; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.
    ENGLISH ABSTRACT: Introduction: The death of a paediatric patient is challenging but inevitable for paediatric doctors in South Africa. This study aimed to document how paediatric registrars in South Africa experience end-of-life care and death, which coping strategies they utilise and what the barriers to and facilitators are for coping with paediatric deaths in the South African context. Method: This was a cross sectional electronic survey of university registered paediatric registrars in South Africa. A total of 326 paediatric registrars were contacted from eight out of nine universities with medical schools that offer paediatric postgraduate training from March to June 2021. Results: Paediatric registrars in South Africa had high exposure to paediatric deaths with a reported mean of 14 paediatric deaths in a year. More than a third (37/98) of paediatric registrars did not feel prepared to cope with the death of a child, and more than 40% (39/96) had considered leaving the specialty due to difficulties with coping with paediatric death. This study showed no significant difference in perceived ability to cope with a death when comparing registrar demographics, experience, or prior training. Overall, coping strategies were largely adaptive. Emotion-focused and problem focused coping styles were used equally. Individual sub facets for coping styles were scored. Acceptance (emotion-focused) scored highest, followed by religion (emotion-focused) and self-distraction (avoidant). Overtly maladaptive coping strategies scored low. The mode of death and circumstances surrounding death might impact on the registrar’s ability to cope and should be considered. Debriefing was only superficially assessed but appeared to be used inconsistently to support staff following paediatric deaths. Most participants indicated that holistic paediatric end-of life care training would be valuable. Conclusion: South African paediatric registrars experience considerably more deaths than high income country counterparts, in more challenging socioeconomic conditions. Paediatric training facilities should provide registrars with formal end-of-life care training and ensure adequate support when paediatric registrars are involved in paediatric deaths to protect their mental wellbeing and improve end-of-life care for paediatric patients and their families.
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    Isolated left main bronchus compression in children identified with bronchoscopy
    (Stellenbosch : Stellenbosch University, 2023-11) Barker, Larissa; Goussard, Pierre; Van Wyk, Lizelle; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.
    ENGLISH ABSTRACT: Background: Vascular compression of the paediatric airway, particularly the left main bronchus (LMB), is often associated with congenital cardiac disease. However, cases of LMB compression unrelated to cardiac pathology are rare. This study aims to investigate the aetiology, clinical presentations, and imaging findings of children with isolated LMB compression. Methods: A retrospective analysis of bronchoscopy data was conducted on children (n = 100) aged 3 months to 12 years who underwent bronchoscopy between January 2018 and June 2023. The study included all children with left main bronchus (LMB) compression and persistent respiratory symptoms identified during bronchoscopy. The respiratory symptoms included recurrent wheezing, recurrent infections, clinically significant airway obstruction, or a combination of these. Clinically significant airway obstruction on high-quality chest X-rays (CXR) was defined as clear narrowing of the trachea or one of the main bronchi. Bronchoscopy was performed under general anaesthesia with systematic assessment of airway obstructions and grading of LMB compression. Further diagnostic tests included bronchoalveolar lavage (BAL), imaging findings and echocardiography. Results: Isolated LMB compression was identified in 9.6% of the bronchoscopy cases. The most common indications for bronchoscopy were recurrent pneumonia (73%) and recurrent wheezing (31%). Dual symptoms were present in 4% (n = 4). CXR revealed abnormalities in 85% of cases, including hyperlucent left lung (29%) and LMB nonvisibility (49%). Aetiology of LMB compression was attributed to vascular compression (48%), tuberculosis (TB) (50%), and other causes (2%). Vascular compression of the LMB is due to compression between decending aorta and proximal left pulmonary artery. Neutrophilic airway inflammation was observed in both vascular and nonvascular compression cases. Viral co-infections were common (85%) with CMV and adenovirus being predominant. Conclusion: Isolated LMB compression in paediatric patients can result from vascular compression or TB. Bronchoscopy plays a crucial role in diagnosing and characterizing airway compression, especially when associated with recurrent respiratory symptoms and abnormal chest X-rays. Vascular compression cases tend to exhibit more severe obstruction on bronchoscopy, while lymphadenopathy may contribute to non-vascular compression. Viral co-infections are prevalent in children with large airway pathology. This study highlights the importance of bronchoscopy as a diagnostic tool in paediatric patients with persistent respiratory symptoms and provides insights into the diverse aetiologies of LMB compression.