Masters Degrees (Paediatrics and Child Health)
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- ItemThe aetiology of hypophosphatemia in children recovering from Kwashiorkor(Stellenbosch : Stellenbosch University, 2015-12) Nicol, Simone; Nel, Etienne De la Rey; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child HealthENGLISH ABSTRACT : Abstract Background The aetiology of hypophosphatemia in children recovering from kwashiorkor is poorly understood. Current theory of the pathophysiology of hypophosphatemia due to refeeding syndrome in adults describes intracellular phosphate trapping, mediated by a metabolic shift from lipid-based catabolism to carbohydrate metabolism. Treatment of hypophosphatemia associated with severe acute malnutrition (SAM) presents a challenge to the control of serum phosphate levels. Hypothesis This study explores the hypothesis that hypophosphatemia is caused by impaired renal tubular phosphate reabsorption in children recovering from oedematous malnutrition. Study Design A prospective pilot study was based at the Tygerberg Children’s Hospital Gastroenterology Unit, a tertiary referral unit in Cape Town, South Africa. Written informed consent was obtained from the legal guardian and ethical approval was obtained from Stellenbosch University’s Human Research Ethics Committee. Ten children between the ages 6-59 months admitted to the Gastroenterology Unit and classified as having kwashiorkor or marasmic kwashiorkor were included. Children were excluded if they were known with pre-existing renal or endocrine disease involving phosphate, magnesium or calcium metabolism. Additionally patients transferred from referring hospitals who had already initiated a refeeding and treatment regimen, any patient with a haemoglobin of ≤6g/dl on admission or any child known to be HIV positive were also excluded from the study. Methods Biochemical and anthropometric variables were monitored during the course of treatment and refeeding. Management of the patients was standardised as per the Tygerberg Children’s Hospitals protocol for refeeding in severe acute malnutrition, which is in accordance with the WHO 10 step protocol. Treatment of hypophosphatemia included oral administration of 75-100 mg/kg/day of 0.8g Na2HPO4 + 0.2g KH2PO4 + 10 ml H2O providing a solution of 100 mg PO4/ml (7.8 mmol of phosphate per 10 mls solution). If patients were unable to tolerate oral feeds intravenous KPO4 was administered at 1 mmol/kg/day of phosphate. Results On admission 70% of children were assessed as severely underweight for age (median WAZ: -2.77, IQR: -5.07; -1.10) and 60% as stunted (median HAZ: -2.52, IQR: -5.23; -1.14) based on the WHO Z-score classification. All children were oedematous. Serum phosphate levels fell within the reference range for age (median: 1.3 mmol/l, IQR: 0.9; 1.4) and decreased to a nadir on day 7 (median: 1.15 mmol/l, IQR: 0.82; 1.5) despite routine phosphate supplementation. Low serum ionised calcium concentration at baseline (median: 1.8, IQR: 1.6; 1.88) reached a nadir at day 3 of treatment (median: 1.71, IQR: 1.53; 1.98), associated with a peak in PTH secretion on day 7 (median: 11.35, IQR: 9.1; 13.6), and an increased urinary phosphate (median: 3.85 IQR: 0.9; 37.85) on day 14. Renal threshold for phosphate reabsorption remained low throughout the course of refeeding and none of the patients developed biochemical evidence of refeeding syndrome. A significant positive correlation between ionised calcium and phosphate (p=0.004) was determined when calculating the Spearman Rank co-efficient; indicating that low serum ionised calcium concentration contributed to hypophosphatemia. This finding was confirmed by appropriate physiologic response to ionised serum hypocalcaemia by the parathyroid hormone axis. Although a positive correlation between urinary and serum phosphate; and a negative correlation between urinary phosphate and serum calcium were observed as expected; these were not found to be statistically significant, possibly due to the limited sample size and missing variables. However, a significant negative correlation (p=0.0012) was demonstrated between ionised calcium levels and PCT; this finding is previously undescribed in the setting of SAM. Conclusion This study demonstrated that in children recovering from SAM, low serum ionised calcium levels are a potential driver for phosphaturia in the face of hypophosphatemia. This is mediated via an appropriate PTH response. Further investigation of calcium supplementation and the contribution of vitamin D to phosphate homeostasis in SAM should be undertaken.
- ItemAnalysis of care received by very-low-birthweight neonates at Worcester Provincial Hospital in 2018 after implementation of the Western Cape Provincial Peri-viability Decision Support Framework(Stellenbosch : Stellenbosch University, 2022-08) van der Merwe, Carine; Slogrove, Amy; Engelbrecht, Arnold; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH ABSTRACT: Background: A significant proportion of very-low-birthweight (VLBW; <1500g) infants are born at regional hospitals in South Africa (SA) and little is known regarding their care and outcomes. Since 2017, clinicians at regional hospitals throughout the Western Cape (WC) have utilized the WC Department of Health Periviability Decision Support Framework to guide care of VLBW infants. Objectives: To describe care of VLBW infants at Worcester Provincial Hospital (WPH) in 2018, compared to recommendations in the Framework and to secondarily compare differences in shortterm outcomes of VLBW infants managed before (2016) and after (2018) the implementation of these guidelines. Methods: A retrospective cohort study was conducted of all live-born VLBW infants ≤7 days managed at WPH, in 2016 and 2018. Information related to neonatal care was collected from medical records of patients born in 2018 only, and compared with Framework recommendations according to birthweight categories (500-799g; 800-999g; 1000-1499g). Information regarding mortality at discharge and at age 12 months, readmission before age 12 months, and length of neonatal stay was captured for all included neonates. Results were reported using frequencies, percentages, and proportions with corresponding 95% confidence intervals. Results: In total 227 infants were included, of which 115 were born in 2018 and included in the primary objective analysis. Infant and maternal characteristics were similar for the 2016 and 2018 cohorts. Complete framework adherence was achieved in 54% (n=90) of infants 1000-1499g, 42% (n=12) of infants 800-999g, and no infants of 500-799g were managed with complete adherence. Adherence to ≥80% of recommendations was achieved in 69% of infants. For the secondary objectives, survival to discharge (73.2% in 2016 vs 71.9% in 2018) and 1 year (70.5% in 2016 vs 70.4% in 2018) did not change significantly after Framework implementation. Clinically meaningful reductions in neonatal readmissions (30.6% in 2016 vs 23.5% in 2018) and length of stay (33 days in 2016 vs 28 days in 2018) were observed from 2016 to 2018. Conclusions: The majority of VLBW infants at WPH in 2018 were managed with ≥80% adherence to the Framework, but considerable differences in adherence were noted by birthweight categories. A clinically important decreased length of neonatal stay and readmission were observed postimplementation; this in combination with no increase in mortality represents a potential gain for a resource-restricted healthcare system.
- ItemAntibiotic use profile in a South African paediatric intensive care unit: A Prospective cohort description(Stellenbosch : Stellenbosch University, 2022-10) Gobetz, Charle; Rabie, Helena; Parker, Noor; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH ABSTRACT: Background Antibiotic overuse and emerging bacterial resistance is a growing threat to global health and an important point of intervention to protect future effectiveness of antibiotics. Critically ill children who are admitted to an intensive care unit are generally started on broad-spectrum antibiotics as this is necessary within the first hour of identification of sepsis to improve survival. In describing the indications and patterns of antibiotic use in our PICU we aim to reveal opportunities to improve antibiotic stewardship practices and contribute to overcoming a growing problem of antimicrobial resistance. Objectives To comprehensively describe antibiotic utilization in the PICU at Tygerberg Hospital and to assess the appropriateness of antibiotic prescribing. Methods We conducted a prospective observational antibiotic utilization study which enrolled 150 children between 1 January 2020 and 23 March 2020. Results There were 133 children admitted to PICU representing 150 admission episodes. The median age of the children at admission were 20.6 months (IQR 4.4 – 64.0). Hundred and five (70%) children had a medical reason for admission with sepsis being the most common diagnosis among the youngest age groups. There was a significant difference in reason for admission between the different age groups (p=0.007) with surgical reasons becoming more likely with increasing age. Of 150 admissions 70 (46.6%) were noted to have one or more comorbid conditions with chronic lung disease and prematurity being the most common. Only 93 (66.9%) of admissions had a weight for age z-score (WAZ) in the -2 to +2 z-score range. A substantial number of admissions (24.5%, n=34) had a WAZ of <-3. In 121 (80.6%) admissions patients received antibiotics in the week prior to PICU admission. There were also 7 (5.8%) instances of carbapenems given prior to PICU admission. Twenty-five admissions (16.7%) did not receive any antibiotic. The total antibiotic use was 1256 days of therapy (DOT) /1000 patient days. Most of the antibiotic prescriptions (79.6%, n=535) were classified as empiric prescriptions. Meropenem was the antibiotic most frequently started in PICU and used for the greatest total number of days (n=140). Of the 125 admissions where antibiotics were used 66 (52.8%) were appropriate for all prescriptions and all revisions to prescriptions. We found a blood culture pathogen yield of 11.2% and a contamination rate of 7.5%. Conclusion We confirmed a high rate of empiric antibiotic utilization with evidence of overuse and inappropriate escalation decisions. Inappropriate use was mostly related to incorrect empirical choices, and prolonged courses of antibiotics.
- ItemAssessing the rate and factors associated with unscheduled return visits to a medical paediatric emergency department in a resource-limited setting(Stellenbosch : Stellenbosch University, 2018-12) Scheepers, Lynn; Redfern, Andrew; Schaaf, Hendrik Simon; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH ABSTRACT: Background: An unscheduled return visit is defined as a patient presenting to the emergency department (ED) within 72 hours after being discharged, with the same primary complaint. It is commonly assumed that patients who returned shortly after discharge were misdiagnosed or mismanaged. Unscheduled return visits are used as an indicator of quality of care in the ED’s. Studies to determine rates of unscheduled return visits in paediatric EDs have been conducted in developed countries with well-resourced health care systems; unexpected return visit rates varied between 2-5.2% in these studies. No such study has been conducted in South Africa. Objective: The purpose of this study was to determine the rate of returning patients to a paediatric emergency department within 72 hours after discharge, the factors associated with unexpected return visits and the outcome of these patients. The following factors were hypothesised to be potentially affecting return visits rate: age of patient, nutritional status, HIV status, triage category, predisposing medical condition, time of day of initial visit, income level of parents/caregiver and diagnosis at initial visit. Time of year was also noted to identify seasonal influences on patient returns. Method: This was a retrospective case control study. This study was done in a paediatric emergency department within an academic hospital in a resource limited setting, observing the rate of returning paediatric patients within 72 hours of discharge over a period of one year. Cases for the study were obtained from the hospitals data base system (Clinicom). Cases were defined as patients who returned unscheduled to the emergency department within 72 hours of being discharged. Scheduled returning patients, patients participating in research studies and those with surgical conditions were excluded from the study. Controls were selected using a simple random sampling excel tool and were matched for month of presentation only. All patient information was accessed from medical files which are stored on a web database system. All data was then entered onto a Microsoft excel spread sheet and analysed with assistance of a biostatistician. Results: The rate of returning patients in our setting was 1.07%. One-hundred fifty-eight patients out of a total of 14827 patients seen in our ED department returned unscheduled. We found that returning patients were of a younger age than controls and with every 1-month increase in age, there was a 0.6% decrease in the odds of returning. Weight-for-age within normal limits was found in >80% in both groups. Being underweight-for-age was associated with an increased risk of returning (p=0.003), as was having a predisposing medical condition (p= 0.027). There was no difference found in gender, HIV status or income category of parents. Day of week and time of day did not contribute as a factor for returning. The grade of doctor seeing the patient did impact the risk of returning as more patients who returned were seen by inexperienced doctors (interns). Returning patients had a higher percentage of orange vs green triage categories. No specific diagnoses were found to be associated with returning patients. Seven percent of the returning patients were associated with an adverse event. Conclusion: The rate of returns in our setting is lower than rates found in countries with well-resourced health care settings. This may be influenced by the short stay unit which is linked to our emergency department and the possibility of patients returning to another health care facility. Poor nutritional status, having a predisposing medical condition, being referred from a general practitioner, having a triage category of orange (vs green) and being seen by an inexperienced doctor, are associated with increased risk of return.
- ItemThe association between admission temperature and adverse outcomes in very low birthweight neonates admitted to a tertiary neonatal service in South Africa(Stellenbosch : Stellenbosch University, 2021, 2021-12) Jones, Thomas; Kali, Gugu; Holgate, Sandi; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH ABSTRACT: Background: Neonatal hypothermia is commonly seen in the early neonatal period and has been shown to contribute significantly to both short and long term morbidity and mortality. This is particularly true in high risk neonates including pre-term and low birth weight neonates. The incidence of neonatal hypothermia in sub-Saharan African countries has been shown to be anywhere from 60 – 85%, and is a major public health issue in low resource countries. Our goal was to calculate the prevalence of admission hypothermia in very low birth weight (VLBW) neonates, and to establish relationships between admission hypothermia and adverse short and long-term outcomes. Methods: This was a retrospective descriptive cohort study looking at all VLBW neonates admitted to the Tygerberg Hospital neonatal wards between the 1st of January 2016 and the 31st of December 2017. Demographic data and short-term outcomes such as respiratory distress needing surfactant, necrotising enterocolitis and severe intraventricular haemorrhage were recorded from the Vermont Oxford Network (VON) database. Long-term outcome data (cerebral palsy, developmental delay, and vision or hearing impairment) were collected from the Tygerberg Hospital high risk neonatal clinic notes. All the patients were categorized into one of five temperature categories as per the WHO definitions prior to data analysis. Categorical data was analysed using the standard Chi-squared test and Fisher’s exact test. Multivariate analyses were performed using logistic regression comparing outcomes between the temperature categories, in order to identify any associations between admission hypothermia and both short and long term outcomes. Other perinatal variables (i.e. gestational age, antenatal steroids, and need for resuscitation) were included in these multivariate analyses. Statistical significance was defined as a P-value of < 0.05. Results: The final cohort after exclusions consisted of 1492 VLBW neonates. The prevalence of admission hypothermia was 68.9%. Of those neonates with admission hypothermia, 297 (28%) had mild, 718 (69.5%) had moderate, and 13 (1.2%) had severe hypothermia according to the WHO classification. We noted a significant delay between time of birth and time of admission to the neonatal unit across the cohort, with a median time of admission being 71 minutes (IQR: 51 – 115 minutes). In-hospital mortality was 15.1%, with the majority of deaths occurring within the first week of life. Taking significant confounders into account, there was no statistically significant relationship between admission hypothermia and any of the short- and long-term adverse outcomes on the multivariate analysis. Conclusion: Admission hypothermia is common amongst VLBW neonates admitted to the neonatal service in Tygerberg Hospital. However, there was no significant association between admission hypothermia and adverse short- or long-term outcomes. Further research is needed to fully understand the impact that admission hypothermia has in this setting, however it is clear that the procedures in place to prevent admission hypothermia need to be strengthened, with the first critical step being shortening of the time between birth and admission to the nursery.
- ItemAssociation of limited joint mobility in childhood and adolescent diabetes mellitus patients with HBA1C, microalbuminuria, and retinopathy at Tygerberg Hospital, Western Cape, South Africa(Stellenbosch : Stellenbosch University, 2020-03) Sekgabo, Nightingale; Zollner, Ekkehard; Kruger, Mariana; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH SUMMARY: BACKGROUND: Limited joint mobility (LJM) is the earliest clinically apparent long-term complication of diabetes mellitus (DM) in children and adolescents. The importance of LJM in young diabetic patients is that it is related to serious microvascular complications, especially retinopathy and nephropathy. OBJECTIVES: The primary objective of this study was to determine the relationship of LJM with blood HbA1c levels, microalbuminuria, and diabetic retinopathy. The secondary objective was to determine the prevalence of LJM in all children with DM. METHODS: This was a retrospective folder review done at the Tygerberg Hospital paediatric diabetes clinic over a10 year period. Pre-pubertal patients were included if they had DM for ≥5 years, and pubertal patients were included if they had DM for ≥2 years. The following data was recorded: Age, sex, type of DM, duration of DM, absence/presence of LJM, HbA1c, insulin regimen, urine albumin/Cr, and absence/presence of retinopathy. RESULTS: Of the 129 patients enrolled in the study, only 74 patients fulfilled the entry criteria. They had Type 1 diabetes (T1DM), with a median age of 8 years (IQR 4- 10.75) at diagnosis. LJM occurred in 60.8% (45/74). Of these, 37 had HbA1c of 8.5% and above, 2 had retinopathy, and a total of 12 patients had microalbuminuria (> 2mg/mmol). There was no statistically significant association between LJM and HbA1c [OR=1.038 (95% CI 0.303 to 3.550)], retinopathy (P value 1.000), and microalbuminuria, (p value 0.594). Sex, the type of insulin regimen, and age at diagnosis also did not influence the outcome [OR=0.988,95% CI (0.365,2.673), p value 0.202,OR=1.063,95% CI (0.877,1,290), respectively)]. A borderline association was observed between LJM and duration on DM (p-value=0.053). This association is not confirmed in the multiple regression model that accounts for the effect of potential confounders [OR=1.215 (95% CI 0.941, 1.569)]. The diagnostic performance of LJM as a screening tool for poor glycaemic control is as follows: Sensitivity = 82.2%, (95% CI 71.1-93.3) %, specificity = 17.24 % (95% CI 3.49-30.99%), Positive Predictive Value=60.66%, 95% (CI 48.4%, 72.91%), and Negative Predictive Value=38.46%, 95% CI (12.02%, 64.91%). ROC model is not better than chance (95% CI 0.413,0.592), and the p value of 0.9534 also confirms this. LJM has a good sensitivity and poor specificity. CONCLUSION: Although most studies describe LJM as a common and early long-term complication in diabetes patients, it is not a useful screening test for poor glycaemic control or microvascular complications. Diabetes duration seems to be an important determinant of LJM. A larger multicentre prospective study to better investigate this relationship should be performed. Knowing that there is an association between LJM and microvascular complications would provide an inexpensive clinical alternative to investigations not readily available in a low resource setting, for the early identification of poor control and increased risk of other microvascular complications.
- ItemThe association of nucleated red blood cells with the severity and outcome in full-term Hypoxic Ischaemic Encephalopathy infants treated with therapeutic hypothermi(Stellenbosch : Stellenbosch University, 2018-12) Mfingwana, Lunga; Smith, Johan; Kali, Gugulabatembunamahlubi; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH ABSTRACT: Abstract Title: The association of nucleated red blood cells with the severity and outcome in full-term Hypoxic Ischaemic Encephalopathy infants treated with therapeutic hypothermia. Background: Birth asphyxia results from deprivation of oxygen to a newborn infant during the peripartum and/or intrapartum period causing harm to the brain, heart, and other major organs. The damage to the injured brain may be permanent, depending on the severity of the insult. Birth asphyxia resulting in hypoxic ischaemic encephalopathy (HIE) is a worldwide problem commonly occurring in South Africa, accounting for thousands of perinatal deaths and stillbirths annually. There are limited biomarkers with a high sensitivity and specificity to accurately predict the severity of birth asphyxia, the risk of dying from the HIE and which newborn infants require referral to regional hospitals for therapeutic intervention. Ideally, the biomarkers should be applicable at a primary health care level, which contribute significantly to the number of HIE cases. Numerous publications have drawn attention to the association between the number of nucleated red blood cells (NRBC) and birth asphyxia. In contrast there are few biomarkers that predict the risk of developing severe HIE and even less that predict the long-term outcome of HIE. Objectives: We aimed to describe the association between NRBC, the severity of HIE, and 1year outcome in newborn infants treated for HIE with therapeutic hypothermia. Methods: This was a prospective descriptive sub-study of a larger study investigating therapeutic hypothermia (TH) of neonates with HIE at Tygerberg Hospital (TBH). A cohort of 100 patients with varying degrees of HIE admitted for cooling were recruited into the study. Clinical notes on Enterprise Content Management (ECM) database and cooling booklets, used routinely to prospectively record data on all therapeutically cooled neonates, were reviewed. NRBC done within 6 hours of admission were analyzed. Patients were followed up after discharge, over a period of 12 months, by a single developmental specialist. They were assessed using the Bayley Scales of Infant Development Third Edition Screening Test (Bayley-111® Screening Test). Results: 75 patients had complete data. The mean gestation and birth weight was 38.6 (4.8) weeks and 3116.8 (+610) grams, respectively. Patients were divided into mild (n=42), moderate (n=20) and severe (n=13) HIE using the Thompson score. Using the NRBC patients were stratified into 3 categories; NRBC 0/100WBC (n=36), NRBC 1-29/100WBC (n=31) and NRBC 30/100WBC (n=8). We found no statistically significant difference in HIE severity between infants born inside and outside TBH (p =0.473). The inborn infants had a significantly higher number of infants with NRBC 30/100WBC (p= 0.005;Odds ratio 8.167 95% CI 1.5-44.27). There was no significant association between the category of NRBC and HIE severity (p=0.265). There was a significant association between infants with cerebral palsy and/or neurodevelopmental delay at 12 months of age and NRBC 30/100WBC (P=0.013; Odds ratio 20.17; 95% CI 1.017 – 399.6); Similarly, children that died on the initial admission to the NICU for therapeutic hypothermia had significantly higher levels of NRBC when compared to those that survived; (P=0.008; Odds ratio 9.40; 95% CI 1.7791 to 49.6649). Conclusion: In newborn infants suffering from HIE requiring therapeutic cooling a NRBC 30/100 WBC, collected in the first 6 hours of life, had a significant correlation with early mortality and neurodevelopmental impairment at 1 year of age.
- ItemBurden, spectrum and outcome of community-acquired infections among paediatric ward admissions to Tygerberg Hospital(Stellenbosch : Stellenbosch University, 2020-12) Mapala, Lydia; Bekker, Adrie; Dramowski, Angela; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH ABSTRACT: Introduction: Community acquired infections (CAIs), both bacterial and viral in origin, are the most common reason for hospitalization in general paediatric wards. Data from South Africa on the burden, pathogen spectrum, antimicrobial therapy and outcome of paediatric CAIs is limited. Methods: We conducted secondary analysis of data from a prospective cohort of consecutive paediatric admissions to a general ward at Tygerberg Hospital (May - November 2015). Demographics, admission history, laboratory investigations, antimicrobial prescription and hospital outcome data were collected. Results: Of 451 admissions, 364 (81%) were for CAI episodes. Median age and weight of patients with CAI was 4.8 months (IQR 1.5-17.5) and 5.4 kg (IQR 3.6-9.0) respectively. Male gender predominated (210/364; 58%), and HIV-infection prevalence was 6.0% (22/364). Sources of referral were: home (139/364, 38%), other hospitals (113/364, 31%) and clinics (112/364, 31%). Pre-hospital antibiotics (commonly ceftriaxone) were given to 152/364 (42%) of patients. The most prevalent CAI types (n=364) were: respiratory tract infections (197; 54%), gastroenteritis (51; 14%), bloodstream/serious bacterial infections (33; 9%), meningitis (17; 5%) and urinary tract infections (8; 2%). Of 274 blood cultures submitted, 5% yielded a pathogen and 8% were contaminated. Of 140 cerebrospinal fluid samples sent, only 2% yielded a pathogen. Of investigations for respiratory infection, respiratory syncytial virus (RSV), adenovirus (AV) and parainfluenza virus predominated from shell vial culture, whereas RSV, cytomegalovirus and rhinovirus were most frequently identified on polymerase chain reaction testing. Most frequent CAI antibiotic treatment regimens included: ampicillin alone (53%); ampicillin plus gentamicin (25%) and ampicillin plus cefotaxime (20%). Unfavourable outcomes were uncommon (1% died; 4% required re-admission within 30 days of discharge). The majority of antibiotic prescriptions for CAI (323/364; 89%) were compliant with the Essential Drug List (EDL) guidelines. The overall estimated cost of CAI episode management was R 8.2 million or R22,527 per CAI admission episode. Conclusion: CAI's are the most frequent reason for hospitalization and a major driver of antimicrobial use and hospital costs in general paediatric wards. Improved diagnostic stewardship should be implemented in South African paediatric wards to reduce culture contamination, improve pathogen yield, minimize use of unnecessary investigations and reduce inappropriate antimicrobial prescriptions. Despite a high burden and hospital cost of CAI admissions, paediatric clinical outcomes were generally favourable.
- ItemCase series on methamphetamine exposure in pregnancy : heart rhythm patterns of newborns in the first week of life(Stellenbosch : Stellenbosch University, 2020-12) Ebrahim, Mohamedraza; Kali, Gugulabatembunamahlubi; Fourie, Barend; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH ABSTRACT: Methamphetamine use is a significant problem in the Western Cape province. Antenatal exposure of the foetus to methamphetamine has been reported to have deleterious effects, including effects on the cardiovascular system. In this case series, we report on thirteen infants who had been exposed to methamphetamine in utero, with last documented use ranging from 2 days to a month before delivery. The infants were either born at Tygerberg Hospital (TBH), or had been outborn and referred to TBH within 72 hours of birth. They all had methamphetamine screens in the urine and echocardiographic studies, and 9 neonates had 24-hour Holter electrocardiogram monitoring. Four (30.8%) of the neonates tested positive for methamphetamine. Five (38.5%) infants had acyanotic cardiac lesions diagnosed, and 2 (15.4%) had abnormal heart rhythm patterns. 3/5 (60%) of the cardiac lesions were most likely related to prematurity. Further large prospective studies are needed to clearly delineate the effects of methamphetamine exposure on the cardiovascular system in neonates.
- ItemCentral line-associated bloodstream infections in a resource-limited South African neonatal intensive care unit(Stellenbosch : Stellenbosch University, 2016-12) Geldenhuys, Chandre; Bekker, Adrie; Dramowski, Angela; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH SUMMARY: Background: The rate of central line-associated bloodstream infection (CLABSI) in South African public sector neonatal intensive care units (NICU) is unknown. Tygerberg Children’s Hospital (TCH) introduced a neonatal CLABSI surveillance and prevention programme in August 2012. Objectives: To describe CLABSI events and identify risk factors for development of CLABSI in a resource-limited NICU. Methods: A retrospective case-control study was conducted using prospectively collected NICU CLABSI events matched to four randomly selected controls, sampled from the NICU registry between 9 August 2012 and 31 July 2014. Clinical data and laboratory records were reviewed to identify possible risk factors using stepwise forward logistic regression analysis. Results: Seven hundred and six central lines were inserted in 530 neonates during the first two years of the programme. Nineteen CLABSI events were identified with a CLABSI rate of 5.9/1000 line days. CLABSI cases were of lower gestational age (28 vs 34 weeks; p=0.003), lower median birth weight (1170g vs 1975g; p=0.014), had longer catheter dwell times (> 4 days) (OR 5.1 [95% CI 1.0-25.4]; p=0.04) and were more likely to have surgery during their NICU stay (OR 3.5 [95% CI 1.26-10]; p=0.01). Significant risk factors for CLABSI were length of stay > 30 days (OR 20.7 [95% CI 2.1-203.2]; p=0.009) and central line insertion in the operating theatre (OR 8.1; [95% CI 1.2-54.7]; p=0.03). Gram-negative pathogens predominated (12/22; 54%), with most isolates 10/12 (83%) exhibiting multi-drug resistance. Conclusion: The TCH NICU CLABSI rate is similar to that reported from resource-limited settings but far exceeds that of high-income countries. Prolonged NICU stay and central line insertion in the operating theatre were important risk factors for CLABSI development. Intensified neonatal staff training regarding CLABSI maintenance bundle elements and hand hygiene is key to reducing CLABSI rates.
- ItemChanges in cerebral blood flow and cardiac output in premature neonates in the first 72 hours of life(Stellenbosch : Stellenbosch University, 2019-12) Gericke, Sebastian; Smith, Johan; Van Wyk, Lizelle; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.Background: A vital contributor of adverse neurodevelopmental outcome is the early acquisition of prematurity related brain injury associated with perturbations of cerebral haemodynamics. Several impediments however exist in describing the temporal relationship between systemic haemodynamic disturbances and prematurity related brain injury. Methods and results: A cohort of preterm neonates, nested in a prospective cardiac output methods study, and involved infants admitted to a tertiary level neonatal high care unit. An interim analysis of 63 premature infants meeting the inclusion criteria of gestational age between 26-34 weeks with recorded cranial ultrasound and echocardiographic data was performed. Excluded infants were those with birth weight <800g, gestational age <26 weeks, congenital defects and infants with asphyxia. Left ventricular cardiac output (LVO), as measured by echocardiography, was correlated to anterior cerebral artery flow velocities, derived from cranial ultrasound Doppler. Measurements were recorded at six hourly intervals up to 72 hours of life and analysed in two subgroups: 31 infants (gestational age 28.6 ± 1.25 weeks, range 26-30 weeks) and 32 infants (gestational age 32.4 ± 1.0 weeks, range 30-34 weeks). LVO remained constant across gestational age categories. Peak-systolic flow velocity (PSV) and end-diastolic flow velocity (EDV) had initial low values with gradual increase over time. Lower mean values were detected in the 26-30 week gestational age group representing intrinsic differences in cerebral vasculature of the developing brain. Neither PSV nor EDV had a strong correlation with LVO. Conclusion: In this population of relatively stable premature infants changes in PSV and EDV did not correlate with LVO.
- ItemChildhood necrotizing pneumonia in a region with high burden of tuberculosis and HIV(Stellenbosch : Stellenbosch University, 2017-03) Jacobs, Carmen; Goussard, Pierre; Gie, Robert Peter; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH ABSTRACT: The causes and outcome of children treated for necrotizing pneumonia (NP) in low- and middle-income countries have not been reported. The aim of this retrospective descriptive study was to investigate childhood NP in a region with a high prevalence of tuberculosis (TB) and HIV. Material and methods: Children with radiological features of childhood NP treated in a referral hospital in Western Cape, South Africa between 2004 -2007 were included. Results: Children (n=32), median age 16.5 (IQR 10-33 months) of whom 9 (32%) were HIV-infected were studied. Of the HIV-infected children, with a median blood CD4 count of 310 cells/ml, 67% were on antiretroviral treatment. On chest CT scan alveolar disease (100%), lung necrosis with cysts (88%) and pleural effusion (91%) were the commonest features; no features suggestive of pulmonary TB were observed. A causative organism was isolated in 66%. The commonest causes being: Streptococcus species (27%), Staphylococcus aureus (34%) and Mycobacterium tuberculosis (M.tb) (25%). In the TB group M.tb was cultured in 75% and the pleural fluid AFB positive in 25%. Where NP was caused by M.tb 75% were HIV-infected (p=0.007). In 47% (n=15) a surgical intervention was required: (25%) was an isolated pleural drainage. No patients died and at follow-up 6 months after admission (n=17) 82% had complete radiological resolution including the M.tb group. Conclusion: These findings indicate that in TB and HIV-prevalent countries in children with NP, TB must be actively excluded especially in HIV-infected children.
- ItemChildhood tuberculous meningitis: a thirty year review of clinical and cerebrospinal fluid factors associated with bacteriological confirmation(Stellenbosch : Stellenbosch University, 2017-12) Roos, Michelle; Van Toorn, Ronald; Solomons, Regan; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH ABSTRACT: Background: Tuberculous meningitis (TBM) is one of the most devastating complications of tuberculosis (TB)3 and contributes significantly to the morbidity and mortality of children in high burden TB countries.2 Early diagnosis of TBM is notoriously difficult due to its inconsistent clinical presentation and lack of a rapid, sensitive and specific diagnostic test. Decision-making in resource-constrained countries is most often guided by use of simple cerebrospinal fluid (CSF) analysis. However, the classical CSF findings of lymphocyte predominance, low glucose and high protein,5,7,16-20 are only simultaneously present in one third of cases5, whilst bacteriological confirmation only occurs in 15-40% of cases.17,18,21,23 Neutrophil predominance,22,24,26 high protein concentrations and Human Immunodeficiency virus (HIV) infection24 is thought to increase likelihood of microbiological culture. Defining the CSF parameters that are associated with confirmation of Mycobacterium Tuberculosis will allow for an increased suspicion, and hopefully earlier diagnosis and treatment; especially if those parameters identified are associated with a traditionally atypical TBM CSF picture, higher bacillary load and is influenced by HIV status. Aim: To describe the CSF parameters that affect the sensitivity of bacteriological confirmation of TBM in 491 CSF samples of children diagnosed with the disease in the past 30 years, at Tygerberg Children’s Hospital (TCH) in the Western Cape Province of South Africa. Methods: Retrospective analysis of 491 cases, meeting the diagnostic criteria of definite and probable TBM. Conclusion: 46% of TBM cases do not display the characteristic CSF profile traditionally associated with TBM. Clinico-diagnostic features including neutrophil predominance is not predictive of bacteriological confirmation. However neutrophil predominance was associated with earlier disease manifestations.
- ItemClinical characteristics and outcome of children evaluated and treated at Tygerberg Children’s Hospital during a measles epidemic(Stellenbosch : Stellenbosch University, 2014-04) Ferreira-Van Der Watt, Talita Aletta; Finlayson, Heather; Rabie, Helena; Cotton, Mark F.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH ABSTRACT: Objective: To describe the clinical characteristics and outcome of children presenting to Tygerberg Children’s Hospital with measles infection Methods: This was a retrospective, descriptive study of children presenting to Tygerberg Children’s Hospital, from 1 February to 31 March 2010 with a diagnosis of measles, during the measles epidemic of 2009/2010. Folders of every second admission were reviewed. Data was analysed using Statistica version 10 of 2012. The study was approved by Stellenbosch University Ethics Committee. Results: Five hundred and eighty five children were seen and evaluated for complicated measles, 239 patients were included. Seventy nine percent (n=189/239) were admitted of which 54.3% were male. The median age at admission was 9 (Interquartile range 6 to 19) months. Children less than 9 months accounted for 50.2% (n=120) and 25.9% (n=62) were less than 6 months of age. The median WHO weight-for-age Z-score (WAZ) was 0.69 (IQR - 1.82 to 0.29), malnutrition was found in 39.9% (n=81) of children less than 5 years. Children residing in the Khayelitsha sub-district accounted for 43.1% (n=103) of the study population. Uptake of the first dose of measles vaccine was 31.1% and of the second dose of measles vaccine was 23.8%. The median length of stay (LOS) was 3 days (IQR 2 – 5 days). Gastroenteritis (67.4%; n=161) and pneumonia (54.4%; n=130) were the most common complications. The majority assessment. A single dose of children had more than one complication at the time of of vitamin A was received by 71.1% (n=170/239) of children during evaluation and 47.6% (n=114/239) received 2 doses. Seven (2.9%; n=7/239) patients required ICU care. Four (57.1%; n= 4/7) were less than 9 months of age. Pneumonia (85.7%; n=6) was the most common reason for admission. Four (1.7%; n=4/239) children died. The median age at death was 9 months (IQR 7 – 14 months). Pneumonia (75%; n=3/4) was the most common cause of death. HIV testing was done in 40.6% (n=97/239) of children. HIV exposure was found in 28.9% (n=69/239) on history. HIV infection was present in 8.4% (n=20/239) of children, of these, 60% (n=12/20) were on HAART. HIV-infected children were older than HIV-uninfected children (median 40 and 9 months respectively, p=0.003). Thirty percent (n=6/20) of HIV- infected children had received any measles vaccination prior to admission. Five percent (n=1/20) of HIV-infected children died vs 4.2% (n=3/72) of children who were confirmed HIV negative. Conclusion: Our study showed that measles causes a significant burden of morbidity and mortality in children. HIV infection however did not increase the morbidity and mortality due to measles co-infection. Interventions to improve vaccination rates and practices at community level are required in order to prevent further epidemics in the future. Further research is needed to determine whether the first measles vaccine dose should be given earlier rather than 9 months of age in order to prevent early infection.
- ItemClinical determinants distinguishing communicating and non-communicating hydrocephalus in childhood tuberculous meningitis at presentation(Stellenbosch : Stellenbosch University, 2022-12) Bovula, Siyabulela; Solomons, Regan; Van Toorn, Ronald; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH ABSTRACT: Introduction: Hydrocephalus occurs in up to 80% of children with tuberculous meningitis (TBM), of which the majority (70-80%) is of a communicating nature. Communicating hydrocephalus develops when cerebrospinal fluid (CSF) obstruction occurs at the level of the tentorium, whilst non-communicating hydrocephalus emanates from basal exudates that obstruct the outflow foramina of the fourth ventricle. Identifying the type of hydrocephalus is of critical importance since communicating hydrocephalus can be medically treated with diuretics whilst non-communicating hydrocephalus requires surgical CSF diversion. Conventional neuroimaging does not allow differentiation of the type of hydrocephalus. In resource-limited settings, air-encephalography is the only investigative modality that allows differentiation. Objective: We aimed to investigate whether there are clinical features at baseline that allow differentiation between communicating and non-communicating hydrocephalus in children with TBM. Design: A retrospective hospital-based cross-sectional study spanning 30 years (1985-2015). Results: Out of 441 children with tuberculous hydrocephalus, 122 (27.7%) and 319 (72.3%) had non-communicating and communicating hydrocephalus respectively. Children with noncommunicating hydrocephalus exhibited longer duration of symptoms (p=0.03) and were more inclined to develop hyponatremia (p=0.10). No children with TBM and HIV co-infection had non-communicating hydrocephalus. No differences were identified in relation to the age of onset, stage of TBM disease, Glasgow Coma Scale (GCS), cranial neuropathies, hemiplegia; signs and symptoms of raised intracranial pressure and/or brainstem dysfunction. Conclusion: No clinical useful determinants were identified in children with tuberculous hydrocephalus that reliably allow differentiation between communicating and noncommunicating hydrocephalus. This finding is explained by the fact that common TBM related complications such as brainstem ischaemia and raised intracranial pressure (ICP) share similar clinical signs, thereby mimicking of each other’s clinical determinants. The absence of non-communicating hydrocephalus in children with TBM and HIV co-infection likely reflects their defective host-inflammatory response. Air-encephalography remains the gold standard of determining the level of CSF block in resource-limited settings.
- ItemClinical features and outcomes of children with staphylococcus aureus bacteraemia at Tygerberg Hospital(Stellenbosch : Stellenbosch University, 2021-03) Kandetu, Tjijandjeua; Lawrenson, John; Rabie, Helena; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH ABSTRACT: Background: Staphylococcus aureus is thought to be an important cause of pneumonia, neonatal sepsis as well as Staphylococcus aureus bacteraemia. In Africa, the epidemiology and the aetiology of paediatric blood stream infections are poorly documented. Methods: A retrospective study was conducted at Tygerberg Hospital in Cape Town, South Africa, to investigate the clinical features, foci of infection, treatment and outcomes of neonates and children treated for Staphylococcus aureus bacteraemia over a period of 2.5 years. Results: Over a period of 2.5 years, 138 episodes of S. aureus bacteraemia were identified of which 56.5% were in neonates and 43.5% were from the paediatric service. MRSA was responsible for 42.7% of the episodes. 63.7% of the S. aureus bacteraemia episodes were hospital associated infections and 96.6% of the MRSA bacteraemia episodes were also hospital associated infections. Previous ICU admission (p=0.00), duration of hospitalisation (p=0.00), preterm gestation (p=0.00), low birthweight (p=0.00), indwelling intravascular device (p=0.03), age (p=0.00), HIV infection (p=0.03), were associated with an increased risk for MRSA bacteraemia on univariate analysis. Bone and joint infections, skin and soft tissue infections and bacteraemia with no source were the most common source of infection in MSSA bacteraemia. Bacteraemia with no source was the most common presentation in MRSA bacteraemia. There were 24 deaths recorded over the study period of which 79.2% were directly attributed to S. aureus bacteraemia. Factors significantly associated with death on multivariate analysis include MRSA bacteraemia (p=0.01) and admission to the ICU (p=0.04). In addition to these findings, specific neonatal risk factors for death were birthweight (p=0.02), age at the time of the positive blood culture (p<0.01) and the time, in days, to initiation of appropriate antibiotics in neonates with MRSA bacteraemia (p=0.01). Conclusion: S. aureus bacteraemia most commonly occurred in the neonatal population over the 2.5-year study period. MRSA bacteraemia is predominantly of nosocomial origin in children.
- ItemClinical presentation and treatment outcomes of infants with tuberculosis in Cape Town, South Africa(Stellenbosch : Stellenbosch University, 2020-12) Aryao, Ruth; Bekker, Adrie; Dramowski, Angela; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH ABSTRACT: Introduction: Limited data are available regarding the presentation, clinical course and outcome of infants (<12 months of age) treated for drug-susceptible tuberculosis. Methods: Infants with tuberculosis admitted at Tygerberg, Khayelitsha District and Brooklyn Chest Hospitals (March 2014-March 2015) were prospectively enrolled with follow-up evaluations at 3- and 6-months post-treatment initiation. Results: Among 39 infants diagnosed with tuberculosis, 21 (54%) had known contact with an adult tuberculosis source case. The median age of infants at diagnosis was 6 months (IQR 3-7) and median weight 5.2 kg (IQR 3.2–10.2). Twenty-two of 39 (56%) were exposed to HIV of whom 5 were HIV infected. Growth faltering (25; 68%) and persistent cough (13; 33%) were frequent presenting symptoms. Most infants were diagnosed with intrathoracic tuberculosis (37/39; 95%) while 5% had disseminated tuberculosis and (14/39; 36%) had culture-confirmed tuberculosis. Alveolar opacification (22; 56%), mediastinal lymphadenopathy (13; 33%) and large airway obstruction (8; 20%) were common chest radiography findings. Tuberculosis treatment outcomes were favourable in 33/39 (85%) infants, but with additional intervention 37 (95%) completed treatment. Conclusions: Intrathoracic tuberculosis was the predominant disease type and one-third of the cohort had culture-confirmed tuberculosis. More than half on the infants were born to a mother with HIV. An adult tuberculosis source case was identifiable in half of the cases. Additional interventions improved favourable treatment outcomes.
- ItemClinical utility of next-generation sequencing in children with cryptogenic cerebral palsy; a cohort study from a tertiary paediatric neurology clinic in the Western Cape Province of South Africa(Stellenbosch : Stellenbosch University, 2023-11) Mohammed, Hiba Hamid Ahmed; Van Toorn, Ronald; Solomons, Regan; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health. Paediatric Neurology.ENGLISH ABSTRACT: Introduction: Cerebral palsy (CP) is the most common motor disability in childhood. Both genetic and environmental factors contribute to the aetiology of CP. Recent advances in molecular genetics such as next generation sequencing (NGS) and whole exome sequencing (WES) have revolutionized the understanding of aetiology by more precisely classifying these disorders with a molecular cause. This study aimed to determine the clinical utility of NGS/WES in children with cryptogenic CP. Methods: Data was collected from 218 consecutive children with CP aged 3.6-10.5 years, referred over an 18-month period, to the tertiary paediatric neurology service at Tygerberg Academic Hospital. Results: Cryptogenic CP cases accounted for 24.3% (53/218) of cases. NGS/WES was performed in 66% (35/53). Pathogenic/likely pathogenic variants were identified in 37.2% (13/35) within the following genes: ATP1A3, SCN2A, ATM, FOXG1, UBE3A, KCNA2, ADAR1, QDPR, GCDH, SAMHD1, PLP1 duplication and SLC16A2. Cryptogenic CP cases were more likely to exhibit dyskinetic (odds ratio (OR)= 2.86; P-value=0.01; 95% CI=1.34-6.11) or hypotonic (OR =24.96; P-value=0.01; 95% CI=2.99-208.05) phenotypes, and less likely present with seizures (OR=0.23, P-value=0.01; 95% CI=0.11-0.46). Conclusion: The high rate of detecting causative genetic variants in the study, 37.2%, suggests that NGS/WES should be considered as first-line investigations in children with cryptogenic CP, especially those with dyskinetic or hypotonic subtypes and normal or non-specific MRI findings.
- ItemClinical value of a uniform research case definition of tuberculous meningitis(Stellenbosch : Stellenbosch University, 2014-04) Wessels, Marie; Solomons, Regan Shane; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH ABSTRACT: BACKGROUND: Tuberculous meningitis (TBM) research remains important but obtaining adequate sample sizes of microbiologically-confirmed TBM cases is difficult, therefore clinical cases of TBM need to be included. A uniform research case definition for TBM was developed to assist diagnostic standardization. METHODS: Our study evaluated the proposed uniform research case definition in a group of children diagnosed with TBM. A subgroup of 66 children with cultureconfirmed TBM was compared to culture-confirmed bacterial meningitis controls. RESULTS: The uniform case definition was applied to 554 TBM patients. Sixty-six (11.9%) patients had definite TBM, 408 (73.6%) had probable TBM and 72 (13.0%) had possible TBM. Symptom duration >5 days, weight loss or persistent cough >2 weeks, recent TB contact, focal neurological deficit, clear cerebrospinal fluid (CSF) appearance and basal meningeal enhancement predicted TBM when compared to definite bacterial meningitis with a sensitivity and specificity of 97.0% and 93.7%, respectively. When using a probable TBM score as the diagnostic measure, sensitivity was 86% and specificity was 100%. When using a possible TBM score as the diagnostic measure, sensitivity was 100% but specificity was 56%. CONCLUSION: The uniform research case definition for TBM performed well when using a probable TBM score as the diagnostic marker. A regression model also differentiated TBM from bacterial meningitis with good accuracy, but caution is needed in its application to early TBM.
- ItemCluster feeding in newborns and infants : mothers and health care workers' knowledge and experiences(Stellenbosch : Stellenbosch University, 2022-03) Sebitosi-Van Jaarsveld, Sandra; Kruger, Mariana; LLoyd, Lizel; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH ABSTRACT: Background: Cluster feeding is a phenomenon noted in normal human infants during the first year of life. The infant’s feeds are spaced closer together than is usual for certain times of the day, over several days, and during multiple specific age periods. It is not well noted in scientific literature though it is discussed widely in anecdotal reports worldwide. It is not mentioned in any guidelines to support breastfeeding in South Africa and data is also lacking in formula feeding infants. Objectives: This was a prospective descriptive study with two main objectives:1) to identify the periods, specific times and duration of cluster feeding in both breastfed and formula fed infants and 2) to examine the extent of knowledge regarding cluster feeding in health care workers and advice given by them to mothers. Methods: Two questionnaires were used to collect quantitative and qualitative data: one targeted to mothers and the second targeted to health care workers based in Cape Town, South Africa. 40 mothers with healthy normal babies born at term, from 2 weeks up to 52 weeks of age, and 66 health care workers in current paediatric practice were recruited from both the public and private sector. The study focused on the first 12 weeks of life. Mothers reported normal and unusual feeding behaviours in their infants. Health care workers reported on their knowledge regarding cluster feeding by answering open and close-ended questions on advice they would give to a mother with a child during cluster feeding. Results: Most mothers (85%, n=35/40) reported cluster feeding in their infants. Infants were shown to cluster feed at various periods in the first 12 weeks of life. The most recorded periods were at five to six weeks of age (42%, n=17/40) and at 11 to 12 weeks of age (42%, n=17/40). The time for cluster feeding noted by most mothers (45%, n=19/40) was between 6 p.m. to 9 p.m. in the evening. More than half of the mothers (58%, n=23/40) experienced cluster feeding in their babies for a few hours every day for a few consecutive days. Over half of the health care workers in the study (53%, n=35/66) had never heard of the term ‘cluster feeding’. A minority (16%, n=11/66) could accurately describe it according to the definitions in literature. Health care workers were more familiar with the term ‘growth spurts’. Most (83%, n=55/66) recognised increased feeding as a sign of cluster feeding but did not easily recognise other signs of cluster feeding or growth spurts. Advice given to mothers was diverse. Conclusion: To the authors knowledge, this was the first study of its kind to date in South Africa. The periods and times that cluster feeding were found to occur in this study concurred with the current literature. Health care workers were not familiar with the term “cluster feeding” and gave differing advice. Training about cluster feeding should be given to health care workers through formal courses and standardized in order to inform mothers effectively. Information about cluster feeding should be incorporated into the South African breastfeeding guidelines.