Academic literature on the topic 'Paediatrics / paediatrics'

Background: In paediatrics, the limited documentation to guide medication, the lack of suitable dosage forms, and the continuous development in childhood present a scenario where safety of medication is a particular challenge. Aim: To explore reported adverse drug reactions (ADRs) and the challenges in prescribing and administering medicines in paediatrics, in order to identify and suggest areas needing international surveillance within medication safety and improvement in the clinical setting. Methods: Four exploratory studies were conducted. Worldwide reporting of suspected ADRs (individual case safety reports, ICSR) with ages 0-17 years were examined overall. Twenty published case reports and ICSRs for adolescents, who developed a rare and incompletely documented ADR (rhabdomyolysis) during antipsychotic medicine use, were analysed in-depth. Prescribed doses of anti-inflammatory medicines were studied in a UK electronic health record database. Transcribed focus group interviews with 20 registered nurses from four paediatric wards in Sweden were analysed for factors that may promote or hinder safe medication practices. Descriptive statistics, multiple regression, and content analyses were used. Results: Although, skin reactions and anti-infective medicines were most frequently reported, and more reported in paediatric patients than in adults, medication errors and adverse reactions related to psychostimulant medicines were reported with increased frequency during 2005 to February 2010. The in-depth case analysis emphasised the need for increased vigilance following changes in patients’ medicine regimens, and indicated that ICSRs could contribute with clinically valuable information. Prescribed dose variations were associated with type of dosage form. Tablets and capsules were prescribed with a higher dose than liquid dosage forms. Six themes emerged from the interviews: preparation and administration was complex; medication errors caused considerable psychological burden; support from nurse colleagues was highly valued; unfamiliar medication was challenging; clear dose instructions were important; nurses handling medications needed to be accorded higher priority. Conclusions: Age-specific screening of ICSRs and the use of ICSRs to enhance knowledge of ADRs and medication errors need to be developed. Access to age-appropriate dosage forms is important when prescribing medicines to children. To improve medication safety practices in paediatric care, interdisciplinary collaborations across hospitals on national or even global levels are needed.

The purpose of this study was to determine the indicators of customer satisfaction and service success of a newly established paediatric outreach nursing service. Referring agents and care recipients were both consumers of the paediatric outreach nursing service. Both groups of consumers were surveyed to determine their satisfaction with the service delivery. Two satisfaction survey tools were developed to measure customer satisfaction. The tools were piloted and refined prior to distributing them. Both tools had a series of closed-ended questions and 3 open-ended questions. Eight service indicators were developed. These were designed to test the effectiveness of the service provided. The service indicators were piloted over two periods of three months and then modified based on the findings of the pilot period. The Paediatric Outreach Service (POS) is a positive service model for health care delivery. The survey results indicated that stakeholders were generally satisfied with the service delivery. When measured against service indicators that were developed for POS, the service performance was above average, with some opportunity to improve practice. Underpinned by a family-centered framework, POS has the capacity to empower children and their families in the planning and implementation of a management plan for the child’s illness. Such empowerment may lead families to practice better healthcare, develop better health-seeking practices and ultimately lead to healthier children. The results from this study has implications for nursing practice. The data obtained from this study may be useful to service providers considering commencing a paediatric outreach nursing service. Data may also be useful for existing service providers to use in order to review the aspects that consumers value against the service they currently provide. Keywords ambulatory care; paediatrics; home-nursing; community; evaluation; satisfaction; success; indicators

Background. There is an increasing trend in the use of long-term oral anticoagulation therapy in children. Monitoring the international normalised ratio (INR) is an integral part in management of these patients, but standard laboratory testing of the INR presents challenges in this age group. Point-of-care INR monitors such as the Mission® PT/INR monitor provide advantages in efficiency and accessibility but have not been evaluated for accuracy in the South African paediatric setting. Objectives. This is a feasibility study with the aim to evaluate the accuracy of the Mission® PT/INR Monitor in comparison to standard laboratory INR measurement, in children presenting for INR testing. Methods. We compared the accuracy of the Mission® PT/INR monitor to the Sysmex Cs2100i laboratory analyser in 37 children aged between 1 year and 17 years, who presented for INR testing. The sample size was limited due to time constraints. 40 paired POC INR and laboratory INR values were obtained. Results. The majority of participants in the study were outpatients (62%) and required INR testing as part of screening in non-cardiac disease (81%) - the majority had chronic liver disease, and a minority were on warfarin therapy (13.5%). The mean INR value on the Mission® PT/INR was 1.49 (standard deviation (SD) 0.73) and was comparable to the Sysmex Cs-2100i (mean INR value 1.39 with SD 0.69). The Bland-Altman difference plot revealed good agreement. Bias between the two methods was 0.13 (SD 0.23). In total, 92.5% of POC INR values were within 0.5 units of laboratory INR value. Conclusion. The Mission® PT/INR point-of-care monitor has a clinically acceptable level of accuracy in children when compared with laboratory INR measurement, but larger studies are needed in the paediatric setting to evaluate patient safety and clinical outcomes. There is a need for implementing POC INR monitoring in outpatient settings but this practice will require robust assessment of infrastructure and quality control before application.

Background Neonatal infection is an important cause of morbidity and mortality in babies. The causative pathogens and their antibiotic susceptibility patterns should be monitored so that treatment regimens can be adjusted to maintain efficacy and avoid selection of resistant organisms. Objectives To compare the incidence of culture positive neonatal sepsis; and to describe the pathogens and antibiotic resistance profiles for significant organsims over a 15-year period in a tertiary nursery in Cape Town. Methods Retrospective blood culture data for 12 months were collected at three time points over a 15-year period. Blood cultures from 2004, 2013 and 2017 were analysed. All neonates with growth on blood cultures were included. Results During 2004 a total of 817 (43.3% of total admissions) blood cultures were taken, 171 (9.1% of total admissions) were culture positive. The most common invasive organisms were Klebsiella pneumoniae (31.8% of invasive organisms), S.aureus (26.1%) and enterococcus species (7.3%). There were 102 contaminants (12.5% of total cultures) of which 7.8% were due to Coagulase-negative Staphylococcus (CONS). In 2013 a total of 1070 (46.8% of total admissions) blood cultures were taken, 124 (5.4% of total admissions) were culture positive. Common invasive organisms were Klebsiella pneumoniae (53.8% of invasive organisms), E. coli (12.8%) and S. aureus (10.3% ). Forty-six blood cultures were deemed contaminated (4.3% of all cultures) and of these 2.1% were due to CONS. In 2017, there were 581 blood cultures taken (26.5% of total admissions), 56 were culture positive (2.6% of total admissions). Commonly occuring invasive organisms were Klebsiella pneumoniae (32.4% of invasive organisms), Group B streptococcus (16.2%) and Acinetobacter (13.5%). Twenty-nine blood cultures were considered contaminated (5.6% of cultures) of which 1.7% were CONS. The gram-negative organisms showed an increasing resistance to penicillin, ampicillin and aminoglycosides but remained sensitive to carbapenems. Conclusions The initial reduction in positive blood cultures from 2004 to 2013 was primarily due to the reduction of contaminants, probably reflecting improved blood sampling techniques. The large reduction in Gram-negative organisms from 2013 to 2017 suggests improved infection control measures , but gram-negative organisms remained prominent in all three cohorts. Emergence of resistant organisms is concerning and in keeping with other nurseries worldwide. These data illustrate the need for antibiotic stewardship, infection control measures and ongoing surveillance.

Changing body position is commonly used in the management of individuals with respiratory diseases and those receiving mechanical ventilation, in order to optimise ventilation and oxygenation. In acute respiratory distress syndrome (ARDS), prone positioning is reported to improve oxygenation by recruiting collapsed dorsal lung regions, although this has not been confirmed in children. Ventilation distribution is well established in adults as being gravity dependent. Clinical practice in the paediatric population has been guided by the notion that all children, irrespective of the presence or absence of disease and age, consistently demonstrate the opposite ventilation distribution pattern to adults and this pattern is said to occur until the second decade of life. Studies in the paediatric population are limited to a few reported from the 1980's, on very heterogeneous populations. With advances in technology, new methods of examining regional ventilation, such as electrical impedance tomography (EIT), have become available. Recent neonatal studies using EIT have reported a dissimilar ventilation distribution to the conventional paediatric pattern. Despite a growing number of studies examining the effects of various interventions on ventilation distribution, very few exist in infants and children older than 6 months of age. Furthermore, differing methodologies and the manner in which ventilation distribution is described and analysed makes pooling the available data in the paediatric population extremely difficult. An understanding of how ventilation is distributed under normal conditions is imperative when examining the effects of different interventions and medical conditions on ventilation distribution. This thesis aimed to describe the effects of body position, head position, age, and respiratory muscle activity on ventilation distribution in children between six months and nine years of age under normal conditions, with respiratory disease, neuromuscular disease, and during mechanical ventilation. Furthermore, the effect on ventilation distribution of prone positioning in children with ARDS was evaluated. Regional ventilation distribution was measured using thoracic EIT and respiratory muscle activity was measured using surface electromyography (sEMG) using standardised methodology. Results of a series of sub-studies indicate that ventilation distribution is more complex and variable than previously thought, with no standard "paediatric pattern" of ventilation. Overall, greater ventilation occurred in the right and dorsal lungs, respectively, in different positons. Head position did not affect regional ventilation in the children studied. Age had a variable effect on ventilation distribution, with healthy children under 12 months of age more likely to follow the paediatric pattern, particularly in side lying positions; however the response was not uniform. The presence of mechanical ventilation, disease state and respiratory muscle activity did not affect ventilation distribution with these children also showing variable patterns of regional ventilation distribution. Data suggests that turning children with ARDS into the prone position does not result in recruitment of the dorsal lung regions, but rather more homogenous ventilation throughout the lungs. Furthermore, results suggest that children with greater ventilation inhomogeneity at baseline are more likely to respond positively (improvement in oxygenation index) to prone positioning. This research provides novel insights into ventilation distribution and respiratory muscle activity in infants and children older than six months of age under a number of different conditions. These results contribute to a better understanding of the factors influencing the distribution of regional ventilation and the mechanisms by which prone positioning in ARDS may improve oxygenation in this population. These findings have potentially important clinical implications, as well as providing baseline data for future clinical studies. Given the variability observed, these studies highlight the potential clinical utility of EIT to monitor different interventions and outcomes. An important strength of the studies presented in this thesis, is that they were performed in a standardised manner, using relatively homogenous individual populations and validated measures of describing ventilation distribution. This methodology could provide a template for future studies in the paediatric population, to allow for comparison between studies.

Background: Lung disease is a common complication of human immunodeficiency virus (HIV) infection in children and adolescents. As antiretroviral programmes have strengthened and HIV diagnosed earlier, survival of perinatally HIV-infected children has improved. Therefore, an increasing number of perinatally HIV-infected children are surviving into adolescence, with development of chronic multisystem disease including chronic lung disease (CLD). However, there is limited information on the determinants, spectrum and progression of lung disease. Lung function testing, an objective, non-invasive, reproducible tool, is useful in characterising CLD and in monitoring disease progression. Aim: To investigate the spectrum, determinants and progression of lung function in perinatally HIV-infected adolescents on antiretroviral therapy (ART) in Cape Town, South Africa. Specific objectives included describing the spectrum and determinants of lung function; investigating cardiopulmonary dysfunction and investigating progression of lung function over two years. Methods: The study population was from a prospective cohort, the Cape Town Adolescent Anti-retroviral cohort (CTAAC), that enrolled 515 perinatally HIV-infected adolescents on ART and 110 age-matched HIV-uninfected adolescents followed six-monthly for two years in Cape Town, South Africa. Eligibility criteria were adolescents, aged 9-14 years, with perinatally acquired HIV, who had been on ART for at least six months. Comprehensive lung function testing was done, and clinical and lung function data collected at baseline, 12 and 24 months. Results: At baseline, HIV-infected adolescents had lower forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), FEV1/FVC, diffusing capacity for carbon monoxide, respiratory system compliance and functional residual capacity; and higher airway resistance and lung clearance index compared to HIV-uninfected adolescents, p< 0.05 for all. At 24 months, FEV1 and FVC remained lower in the HIV-infected compared to the uninfected, p< 0.05 for both. Impaired cardiopulmonary function was detected in 13% of HIV-infected adolescents and 8% of HIV-uninfected adolescents, p=0.136. Past PTB was significantly associated with a low cardiopulmonary function, OR 2.3, 95%CI 1.2-4.4. Conclusion: Perinatally HIV-infected adolescents had lower lung function and higher resistance and ventilation inhomogeneity compared to age-matched HIV-uninfected adolescents at baseline. Lung function tracked, remaining lower at two years. Previous PTB or severe LRTI were predictors of lower lung function. Co-existent cardiopulmonary dysfunction occurred in a minority. These data highlight respiratory disease risk in this vulnerable group and may inform policy to strengthen strategies to prevent and manage HIV-associated lung or cardiopulmonary disease. Four of the chapters (2-5) of this thesis are presented as published manuscripts. Chapter 1 encompasses an overview of the burden of HIV disease and the spectrum of HIV associated chronic lung disease in adolescents and the utility of lung function in the diagnosis of chronic lung disease. Study methodology is also detailed in this chapter. Chapter 2 (published manuscript) comprises a comprehensive review of published data on lung function (over and above the literature included in the individual papers) in HIV infected children and adolescents and summarises studies that have been done in Africa, USA, Europe and Asia. Chapter 3 (published manuscript) describes the spectrum and determinants of comprehensive lung function parameters (flow, volume, compliance, resistance, ventilation inhomogeneity) in perinatally HIV-infected adolescents with a comparator group of age-matched HIV-uninfected adolescents. Chapter 4 (published manuscript) further explores the prevalence and determinants of coexistent cardiopulmonary dysfunction in perinatally HIV-infected adolescents on ART. Chapter 5 (published manuscript) describes the progressive changes in spirometry over two years in perinatally HIV-infected adolescents compared to HIV-uninfected age matched controls. It also addresses the associations of low lung function, factors amenable to public health interventions. Chapter 6 is a summary of the study findings and recommendations.

Includes bibliographical references.<br>Hypoxic ischaemic encephalopathy (HIE) after birth is an important cause of neonatal morbidity and mortality, particularly in resource-limited regions. Therapeutic hypothermia initiated within the first 6 hours of life, in settings that can offer neonatal intensive care, is a therapy that can reduce death or severe disability in newborn infants with moderate or severe HIE. Therapeutic hypothermia has not been shown to be safe or effective in low-resource settings where neonatal intensive care is not available; however, there are situations such as in some centres in South Africa, where limited neonatal intensive care (NICU) is available against a background of moderate neonatal mortality rates, relatively low socio-economic conditions and limited capacity for long-term follow-up. In such settings, accurate case definition and early prediction of HIE and outcome may assist with the appropriate allocation of resources. The amplitude-integrated electro-encephalogram (aEEG) is an ideal tool to use for prediction of outcome and the need for cooling, but it’s availability is limited, particularly at primary and secondary hospitals.

The outcome of high risk infants provides an important audit of neonatal care. This audit renders valuable information to clinicians, parents and health care planners. Available outcome data from the developing world are sparse and urgently needed. This work was compiled with three aims in mind: to provide data from Cape Town on outcome of high risk infants (including both infants of very low birthweight and infants who have survived hypoxic ischaemic encephalopathy); to evaluate selected early neurodevelopmental assessments of these infants; and to propose a protocol for their effective follow-up. Three separate cohorts were selected and studied in order to achieve these aims. A prospective six-year follow-up study of infants with birth weights less than 1250 g was undertaken at Groote Schuur Hospital's Neonatal Intensive Care Unit. The aim of the study was to document the morbidity, mortality and neurodevelopmental outcome of these infants. Of 235 liveborn infants, 143 (61 %) survived to discharge. Better survival was documented for infants who weighed more than 900 g and were over 30 weeks gestation and whose mothers attended antenatal care. One hundred and six infants (83% of survivors) underwent clinical assessment at one year of age and were evaluated with the Griffiths Scales of Mental Development. Ninety six (91 %) of these survivors were seen and tested at two years of age and 80 (76%) were seen at six years of age together with 70 matched controls who had normal birthweights. Of the 106 infants assessed at one year of age, six infants were diagnosed as cerebral palsied, six were globally developmentally delayed without signs of cerebral palsy and one infant showed significant motor delay with a normal developmental quotient. At two years of age one further infant had cerebral palsy and nine more infants were developmentally delayed. At six years of age five infants had cerebral palsy, one was intellectually disabled and three were intellectually borderline. The major disability rate at one year of age was 11%, at two years of age was 22% and at six years of age was eight percent. The incidence of low birthweight children with possible learning disability was three times that of their matched controls and overall, the low birthweight children scored significantly less in all developmental measures. Forty-five infants who developed hypoxic ischaemic encephalopathy after birth were studied prospectively. A numeric scoring system for the assessment of hypoxic ischaemic encephalopathy during the neonatal period which had previously been developed at Groote Schuur Hospital was tested. The value of the score in predicting neurodevelopmental outcome at one year of age was assessed. Thirty five infants were evaluated at 12 months of age by full neurological examination and the Griffiths Scales of Mental Development. Five infants were assessed at an earlier stage, 4 who died before 6 months of age and one infant who was hospitalised at the time of the 12-month assessment. Twenty three (58%) of the infants were normal, 17 (42%) were abnormal, 16 with cerebral palsy and one with developmental delay. 25 infants were re-evaluated at 3 years of age. 15 of these 25 had been normal at one year of age and were evaluated with ten controls who had had an uneventful perinatal course. The Hypoxic lschaemic Encephalopathy Score was highly predictive for outcome. The best correlation with outcome was a combination of the peak score and evaluation on day seven; giving a positive predictive value of 92% and a negative predictive value of 100% for abnormal outcome, with a sensitivity of 100% and specificity of 93%. At three years of age the HIE survivors without cerebral palsy scored as well as their matched controls on Griffiths developmental evaluation. In these normal survivors no correlation between severity of HIE and developmental quotient was demonstrated. Infants with neurodevelopmental abnormality need to start therapy early and because of this, should be detected as soon as possible. Currently, no widely accepted method of early evaluation exists. A Perinatal Risk Rating, the Dubowitz Neurological Assessment and the Infant Neuromotor Assessment were compared in terms of predicting neurodevelopmental outcome at one year of age. A cohort of 130 consecutive neonatal intensive care unit graduates were selected according to high risk criteria. Each infant was examined at term gestational age on the Dubowitz Neurological Assessment and a Perinatal Risk Rating was allocated. The study infants were seen again at 18 weeks corrected age, when an Infant Neuromotor Assessment was done, and at one year of age the Griffiths Scales of Mental Developmental and full neurological examination were carried out. Of the 130 infants assessed at term, all were seen at 18 weeks. Thereafter five were lost to follow-up and two died. The outcome of all the remaining 123 infants is known. Prediction of a normal outcome at 1 year of age on the Dubowitz Neurological Assessment was 96% and for the Perinatal Risk Rating, 98%, but for an abnormal outcome they predicted only 56% and 42% respectively. The Infant Neurological Assessment at 18 weeks of age predicted a normal outcome at one year in 99% and an abnormal outcome in 82%. Very low birthweight infants are at higher risk for cerebral palsy and intellectual disability. In Groote Schuur Hospital, at six years of age, the major disability rate for infants with birthweights less than 1250 g was eight percent. Forty percent of term infants who survived hypoxic ischaemic encephalopathy had cerebral palsy with associated intellectual disability. The use of the Perinatal Risk Rating is appropriate in newborn facilities where cranial ultrasound is available. Otherwise the Dubowitz Neurological Assessment is an appropriate screening tool in the newborn period. Use of the Hypoxic Ischaemic Encephalopathy Score is recommended for clinical evaluation, prognostication and risk rating. It is proposed that high risk infants should be evaluated at 18 weeks corrected age with the Infant Neuromotor Assessment at a tertiary centre. If this assessment is normal, the infant can then be discharged to community clinic follow-up. Infants with more than one deviant sign at this age need continued review and those with more than three signs should be referred for neurodevelopmental therapy to a comprehensive neurodevelopmental clinic. Even those high-risk infants whose assessments are normal should be enrolled in a pre-school centre at five years of age to facilitate detection of learning problems prior to school entry.

Includes bibliographical references.<br>Background: The prevalence of food allergy in South Africa is unknown, but previously thought to be low, particularly in black South Africans. We hypothesised that food allergies would be low in Xhosa patients, even those at increased risk of food allergy such as children with atopic dermatitis (AD). This study aimed to determine the prevalence of, patterns and risk factors for, IgE-mediated food allergy in South African children with moderate to severe AD. It is the first food allergy prevalence study in South Africa to utilise controlled food challenges and component analysis, and is unique for its comparison of food allergy patterns between ethnic groups in the same geographical area. Methodology: This was a prospective, observational study in a paediatric university hospital in Cape Town. Children with moderate to severe AD, aged 6 months to 10 years, were randomly recruited from the dermatology clinic. They were assessed for sensitisation and allergy by questionnaire, skin prick tests (SPT), Immuno Solid Phase Allergen Chip (ISAC) test and incremental food challenges. Sensitised patients were also tested for specific IgE by ImmunoCAP test. Results: One hundred participants (59 black Africans and 41 of mixed race) were enrolled, median age 42 months. There were high overall rates of food sensitisation (66%) and food allergy (40%). Egg (25%) and peanut (24%) were the most common allergies. Black participants had comparable sensitisation (69% vs 61%) but lower allergy rates (34% vs 46%) than mixed race participants. This was especially evident for peanut allergy (15% vs 37%, p=0.01). Early onset AD (< 6 months), severe eczema, and young age < 2 years were significant risk factors for food allergy. The ISAC test was less sensitive than SPT and ImmunoCAP tests. Only 42% of cases of perceived food allergy were confirmed as true food allergy.

Objective: To document the demographics, the pattern of clinical and laboratory characteristics at the time of diagnoses for all the newly diagnosed diabetics younger than 14 years reviewed at the Diabetic clinic at the Red Cross War Memorial Children's Hospital (RCWMH) during 2005-2009. Method: A retrospective folder review was done of all the newly diagnosed diabetics younger than 14 years old at the age of diagnosis. 225 patients were included for analysis. Patients were grouped according to age into a young group (1 month to < 5 years old), a middle group (5years - < 9 years) and an older group (9years - <14 years). Neonates were excluded as well as children who became diabetic secondary to another condition. Results: 58% of the patients were female and most of the patients were diagnosed with type 1 diabetes (96%). The median age at diagnosis was 8.5 years with a mean HbA1c of 11, 3%. 68% of the patients were in the normal weight category while 8, 4% of the patients were obese. 148 (65%) of the 225 patients presented in diabetic ketoacidosis (DKA). Only one of the patients classified with type 2 diabetes presented in DKA. 51 (22,67%) of the patients were less than 4 years old at the time of diagnosis. 53% of the Caucasian children were less than 4 years old at diagnosis while most of the children in the black and coloured group were diagnosed after 10 years of age. A seasonal variation was seen especially in the young age group with 66% presenting in autumn or winter months. Conclusions: Almost a quarter of diabetic children presented before the age of 4 years. A large proportion of patients presented in diabetic ketoacidosis which can be life threatening. Due to lack of information at diagnosis, this could be under reported significantly and calls for increase awareness amongst physicians and parents to recognise symptoms earlier. Prospective studies on childhood diabetes in South Africa are needed as well as a registry for childhood diabetes.