Trends in admissions, morbidity and outcomes at Red Cross War Memorial Children’s Hospital, Cape Town, 2004 - 2013

Background. Routinely collected patient information has the potential to yield valuable information about health systems and population health, but there have been few comprehensive analyses of paediatric admissions at South African (SA) hospitals.Objectives. To investigate trends in hospitalisation and outcomes at Red Cross War Memorial Children’s Hospital (RCWMCH), a major referral hospital for children in the Western Cape and SA.Methods. Using routinely collected observational health data from the hospital informatics system, we investigated admissions between 2004 and 2013. Clinical classification software was used to group International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) codes to rank causes during 2008 - 2013, when ICD-10 codes were widely available. Analyses examined trends in medical and surgical admissions over time.Results. There were 215 536 admissions over 10 years of 129 733 patients. Admissions increased by 9.3%, with increases in the general medical wards (5%), medical specialty wards (74%), the burns unit (73%), and the intensive care unit (16%). In contrast, admissions decreased in the trauma unit (21%) and short-stay medical wards (1%). In-hospital mortality decreased by 54% (p-trend <0.001) over 10 years. Diarrhoea and lower-respiratory tract illness were the most common causes for medical admissions, although admissions and deaths due to these conditions decreased between 2008 and 2013, which coincided with the national introduction of related vaccines. Similarly, tuberculosis admissions and deaths decreased over this period. These trends could be owing to a concurrent decrease in HIV comorbidity (p-trend <0.001). Trauma was the most common reason for surgical admission.Conclusion. Paediatric in-hospital mortality decreased consistently over a decade, despite an overall increase in admissions. Pneumonia and diarrhoea admissions decreased markedly over a 6-year period, but remain the most important causes of hospitalisation

Acute viral bronchiolitis in South Africa : diagnostic flow

Bronchiolitis may be diagnosed on the basis of clinical signs and symptoms. In a young child, the diagnosis can be made on the clinical pattern of wheezing and hyperinflation. Clinical symptoms and signs typically start with an upper respiratory prodrome, including rhinorrhoea, low-grade fever, cough and poor feeding, followed 1 - 2 days later by tachypnoea, hyperinflation and wheeze as a consequence of airway inflammation and air trapping. The illness is generally self limiting, but may become more severe and include signs such as grunting, nasal flaring, subcostal chest wall retractions and hypoxaemia. The most reliable clinical feature of bronchiolitis is hyperinflation of the chest, evident by loss of cardiac dullness on percussion, an upper border of the liver pushed down to below the 6th intercostal space, and the presence of a Hoover sign (subcostal recession, which occurs when a flattened diaphragm pulls laterally against the lower chest wall). Measurement of peripheral arterial oxygen saturation is useful to indicate the need for supplemental oxygen. A saturation of <92% at sea level and 90% inland indicates that the child has to be admitted to hospital for supplemental oxygen. Chest radiographs are generally unhelpful and not required in children with a clear clinical diagnosis of bronchiolitis. Blood tests are not needed routinely. Complete blood count tests have not been shown to be useful in diagnosing bronchiolitis or guiding its therapy. Routine measurement of C-reactive protein does not aid in management and nasopharyngeal aspirates are not usually done. Viral testing adds little to routine management. Risk factors in patients with severe bronchiolitis that require hospitalisation and may even cause death, include prematurity, congenital heart disease and congenital lung malformations.http://www.samj.org.zaam2016Paediatrics and Child Healt

Acute viral bronchiolitis in South Africa : viral aetiology and clinical epidemiology

Bronchiolitis is a viral-induced lower respiratory tract infection that occurs predominantly in children <2 years of age, particularly infants. Many viruses have been proven or attributed to cause bronchiolitis, including and most commonly the respiratory syncytial virus (RSV) and rhinovirus. RSV is responsible for more severe disease and complications (including hospitalisation) in bronchiolitis patients. Whereas bronchiolitis is exclusively due to respiratory viral infections, with little evidence of bacterial co-infection, the former could nevertheless predispose to superimposed bacterial infections. Although data support an interaction between RSV and pneumococcal superimposed infections, it should be noted that this specifically refers to children who are hospitalised with RSV-associated pneumonia, and not to children with bronchiolitis or milder outpatient RSV-associated illness. As such, empiric antibiotic treatment against pneumococcus in children with RSV-associated pneumonia is only warranted in cases of hospitalisation and when the clinical syndrome is more in keeping with pneumonia than uncomplicated bronchiolitis. In South Africa, the peak in the RSV season varies only slightly by province, with onset in February, and lasting until June. The important implication of these new seasonality findings is that where prophylaxis is possible, as in the case of RSV, it should be commenced in January of each year.http://www.samj.org.zaam2016Paediatrics and Child Healt

Acute viral bronchiolitis in South Africa : strategies for management and prevention

Management of acute viral bronchiolitis is largely supportive. There is currently no proven effective therapy other than oxygen for hypoxic children. The evidence indicates that there is no routine benefit from inhaled, rapid short-acting bronchodilators, adrenaline or ipratropium bromide for children with acute viral bronchiolitis. Likewise, there is no demonstrated benefit from routine use of inhaled or oral corticosteroids, inhaled hypertonic saline nebulisation, montelukast or antibiotics. The last should be reserved for children with severe disease, when bacterial co-infection is suspected. Prevention of respiratory syncytial virus (RSV) disease remains a challenge. A specific RSV monoclonal antibody, palivizumab, administered as an intramuscular injection, is available for children at risk of severe bronchiolitis, including premature infants, young children with chronic lung disease, immunodeficiency, or haemodynamically significant congenital heart disease. Prophylaxis should be commenced at the start of the RSV season and given monthly during the season. The development of an RSV vaccine may offer a more effective alternative to prevent disease, for which the results of clinical trials are awaited. Education of parents or caregivers and healthcare workers about diagnostic and management strategies should include the following: bronchiolitis is caused by a virus; it is seasonal; it may start as an upper respiratory tract infection with low-grade fever; symptoms are cough and wheeze, often with fast breathing; antibiotics are generally not needed; and the condition is usually self limiting, although symptoms may occur for up to 4 weeks in some children.http://www.samj.org.zaam2016Paediatrics and Child Healt

Epidemiology and aetiology of community-acquired pneumonia in children : South African Thoracic Society guidelines (part 1)

BACKGROUND. Pneumonia remains a major cause of morbidity and mortality among South African (SA) children. Improved immunisation regimens, strengthening of HIV programmes, better socioeconomic conditions and new preventive strategies have influenced the epidemiology of pneumonia. Furthermore, sensitive diagnostic tests and better sampling methods in young children improve aetiological diagnosis. OBJECTIVES. To summarise current information on childhood community-acquired pneumonia (CAP) epidemiology and aetiology in children as part of the revised South African Thoracic Society guidelines. METHODS. The Paediatric Assembly of the South African Thoracic Society and the National Institute for Communicable Diseases expert subgroup on epidemiology and aetiology revised the existing SA guidelines.The subgroup reviewed the published evidence in their area; in the absence of evidence, expert opinion was accepted. Evidence was graded using the British Thoracic Society (BTS) grading system, and the relevant section underwent peer review. RESULTS. Respiratory viruses, particularly respiratory syncytial virus, are the key pathogens associated with hospitalisation for radiologically confirmed pneumonia in HIV-uninfected children. Opportunistic organisms, including Pneumocystis jirovecii, are important pathogens in HIV-infected infants, while non-typable Haemophilus influenzae and Staphylococcus aureus are important in older HIV-infected children. Co-infections with bacteria or other respiratory viruses are common in hospitalised children. Mycobacterium tuberculosis is common in children hospitalised with CAP in SA. CONCLUSIONS. Numerous public health measures, including changes in immunisation schedules and expansion of HIV prevention and treatment programmes, have influenced the epidemiology and aetiology of CAP in SA children. These changes have necessitated a revision of the South African Paediatric CAP guidelines, further sections of which will be published as part of a CME series in SAMJ.The SA Medical Research Councilhttp://www.samj.org.zaam2021Paediatrics and Child Healt

Diagnosis of community-acquired pneumonia in children : South African Thoracic Society guidelines (part 2)

BACKGROUND. Accurate diagnosis and attribution of the aetiology of pneumonia are important for measuring the burden of disease, implementing appropriate treatment strategies and developing more effective interventions. OBJECTIVES. To produce revised guidelines for the diagnosis of pneumonia in South African (SA) children, encompassing clinical, radiological and aetiological methods. METHODS. An expert group was established to review diagnostic evidence and make recommendations for a revised SA guideline. Published evidence was reviewed and graded using the British Thoracic Society grading system. RESULTS. Diagnosis of pneumonia should be considered in a child with acute cough, fast breathing or difficulty breathing. Revised World Health Organization guidelines classify such children into: (i) severe pneumonia; (ii) pneumonia (tachypoea or lower chest indrawing); or (iii) no pneumonia. Malnourished or immunocompromised children with lower chest indrawing should be managed as cases of severe pneumonia. Pulse oximetry should be done, with hospital referral for oxygen saturation <92%. A chest X-ray is indicated in severe pneumonia or when tuberculosis (TB) is suspected. Microbiological investigations are recommended in hospitalised patients or in outbreak settings. Improved aetiological methods show the importance of co-infections. Blood cultures have a low sensitivity (<5%), for diagnosing bacterial pneumonia. Highly sensitive, multiplex tests on upper respiratory samples or sputum detect multiple potential pathogens in most children. However, even in symptomatic children, it may be impossible to distinguish colonising from causative organisms, unless identification of the organism is strongly associated with attribution to causality, e.g. respiratory syncytial virus, Mycobacterium tuberculosis, Bordetella pertussis, influenza, para-influenza or severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Investigations for TB should be considered in children with severe pneumonia who have been hospitalised, in a case of a known TB contact, if the tuberculin skin test is positive, if a child is malnourished or has lost weight, and in children living with HIV. Induced sputum may provide a higher yield than upper respiratory sampling for B. pertussis, M. tuberculosis and Pneumocystis jirovecii. CONCLUSIONS. Advances in clinical, radiological and aetiological methods have improved the diagnosis of childhood pneumonia.HJZ and SAM are supported by the South African Medical Research Council.The South African Medical Research Councilhttp://www.samj.org.zaam2021Paediatrics and Child Healt

Egg quality determinants in cod (Gadus morhua L.): egg performance and lipids in eggs from farmed and wild broodstock

Lipids and essential fatty acids, particularly the highly unsaturated fatty acids, 20:5n-3 (eicosapentaenoic acid; EPA), 22:6n-3 (docosahexaenoic acid; DHA) and 20:4n-6 (arachidonic acid, AA) have been shown to be crucial determinants of marine fish reproduction directly affecting fecundity, egg quality, hatching success, larval malformation and pigmentation. In Atlantic cod (Gadus morhua L.) culture, eggs from farmed broodstock can have much lower fertilisation and hatching rates than eggs from wild broodstock. The present study aimed to test the hypothesis that potential quality and performance differences between eggs from different cod broodstock would be reflected in differences in lipid and fatty acid composition. Thus eggs were obtained from three broodstock, farmed, wild/fed and wild/unfed, and lipid content, lipid class composition, fatty acid composition and pigment content were determined and related to performance parameters including fertilisation rate, symmetry of cell division and survival to hatching. Eggs from farmed broodstock showed significantly lower fertilisation rates, cell symmetry and survival to hatching rates than eggs from wild broodstock. There were no differences in total lipid content or the proportions of the major lipid classes between eggs from the different broodstock. However, eggs from farmed broodstock were characterised by having significantly lower levels of some quantitatively minor phospholipid classes, particularly phosphatidylinositol. There were no differences between eggs from farmed and wild broodstock in the proportions of saturated, monounsaturated and total polyunsaturated fatty acids. The DHA content was also similar. However, eggs from farmed broodstock had significantly lower levels of AA, and consequently significantly higher EPA/AA ratios than eggs from wild broodstock. Total pigment and astaxanthin levels were significantly higher in eggs from wild broodstock. Therefore, the levels of AA and phosphatidylinositol, the predominant AA-containing lipid class, and egg pigment content were positively related to egg quality or performance parameters such as fertilisation and hatching success rates, and cell symmetry

Neonatal, infant and child health in South Africa : reflecting on the past towards a better future

Although the neonatal mortality rate in South Africa (SA) has remained stagnant at 12 deaths per 1 000 live births, the infant and under-5 mortality rates have significantly declined since peaking in 2003. Policy changes that have influenced this decline include policies to prevent vertical HIV transmission, earlier treatment of children living with HIV, expanded immunisation policies, strengthening breastfeeding practices, and health policies to contain tobacco and sugar use. The Sustainable Development Goals (2016 - 2030) have shifted the focus from keeping children alive, as expressed in the Millennium Development Goals (1990 - 2015), to achieving optimal health through the ‘Survive, thrive and transform’ global agenda. This paper focuses on important remaining causes of childhood mortality and morbidity in SA, specifically respiratory illness, environmental pollution, tuberculosis, malnutrition and vaccine-preventable conditions. The monitoring of maternal and child health (MCH) outcomes is crucial, and has improved in SA through both the District Health Information and Civil Registration and Vital Statistics systems, although gaps remain. Intermittent surveys and research augment the routinely collected data. However, availability and use of local data to inform quality and effectiveness of care is critical, and this requires ownership at the collection point to facilitate local redress. Potential game changers to improve MCH outcomes include mobile health and community-based interventions. In SA, improved MCH remains a crucial factor for human capital development. There is a pressing need to focus beyond childhood mortality and to ensure that each child thrives.http://www.samj.org.zapm2020Geography, Geoinformatics and MeteorologyPaediatrics and Child HealthSchool of Health Systems and Public Health (SHSPH