COVID-19: Experience of a tertiary children's hospital in Western Cape Province, South Africa.

The COVID-19 pandemic necessitated rapid changes in healthcare systems and at Red Cross War Memorial Children's Hospital (RCWMCH), Cape Town, South Africa. Paediatric services in particular required adjustment, not only for the paediatric patients but also for their carers and the staff looking after them. Strategies were divided into streams, including the impact of COVID-19 on the hospital and the role of RCWMCH in Western Cape Province, communication strategies, adaptation of clinical services at the hospital, specifically with a paediatric-friendly approach, and staff engagement. Interventions utilised: (i) Specific COVID-19 planning was required at a children's hospital, and lessons were learnt from other international children's hospitals. A similar number of patients and staff were infected by the virus (244 patients and 212 staff members by 21 December 2020). (ii) Measures were put in place to assist creation of capacity at metro hospitals' adult services by accepting children with emergency issues directly to RCWMCH, as well as accepting adolescents up to age 18 years. (iii) The communication strategy was improved to include daily engagement with heads of departments/supervisors by earlymorning structured information meetings. There were also changes in the methods of communication with staff using media such as Zoom, MS Teams and WhatsApp. Hospital-wide information and discussion sessions were held both on social platforms and in the form of smallgroup physical meetings with senior hospital administrators (with appropriate distancing). Labour union representatives were purposefully directly engaged to assess concerns. (iv) Clinical services at the hospital were adapted. These included paediatric-friendly services and physical changes to the hospital environment. (v) Staff engagement was particularly important to assist in allaying staff anxiety, developing a staff screening programme, and provision and training in use of personal protective equipment, as well as focusing on staff wellness. In conclusion, visible management and leadership has allowed for flexibility and adaptability to manage clinical services in various contexts. It is important to utilise staff in different roles during a crisis and to consider the different perspectives of people involved in the services. The key to success, that included very early adoption of the above measures, has been hospital staff taking initiative, searching for answers and identifying and implementing solutions, effective communication, and leadership support. These lessons are useful in dealing with second and further waves of the COVID-19 pandemic.

Diagnosis and management of community-acquired pneumonia in children: South African Thoracic Society guidelines.

BACKGROUND: Pneumonia remains a major cause of morbidity and mortality amongst South African children. More comprehensive immunisation regimens, strengthening of HIV programmes, improvement in socioeconomic conditions and new preventive strategies have impacted on the epidemiology of pneumonia. Furthermore, sensitive diagnostic tests and better sampling methods in young children improve aetiological diagnosis. OBJECTIVES: To produce revised guidelines for pneumonia in South African children under 5 years of age. METHODS: The Paediatric Assembly of the South African Thoracic Society and the National Institute for Communicable Diseases established seven expert subgroups to revise existing South African guidelines focusing on: (i) epidemiology; (ii) aetiology; (iii) diagnosis; (iv) antibiotic management and supportive therapy; (v) management in intensive care; (vi) prevention; and (vii) considerations in HIV-infected or HIVexposed, uninfected (HEU) children. Each 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. Sections were synthesized into an overall guideline which underwent peer review and revision. RECOMMENDATIONS: Recommendations include a diagnostic approach, investigations, management and preventive strategies. Specific recommendations for HIV infected and HEU children are provided. VALIDATION: The guideline is based on available published evidence supplemented by the consensus opinion of SA paediatric experts. Recommendations are consistent with those in published international guidelines.

Characteristics and outcome of long-stay patients in a paediatric intensive care unit in Cape Town, South Africa.

BACKGROUND: Paediatric intensive care is a costly, specialised and limited resource in low- and middle-income countries. The implications of extended paediatric intensive care unit (PICU) stay in South Africa (SA) are not known. OBJECTIVES: To describe the characteristics, outcomes and resource consumption of long-stay patients (LSPs) and to identify predictive factors for long PICU stay. METHODS: A retrospective review of routinely collected data on all children admitted to an SA PICU over one calendar year. Long PICU stay was defined statistically as >19 days. Long- and short-stay patient (SSP) groups were compared, and variables significantly associated with long stay on univariate analysis were entered into a stepwise multiple regression model. RESULTS: Over the study period, 1 126 children (median age 8 months, 60.9% male) were admitted to the PICU, occupying 5 936 bed-days; 54  LSPs (4.8%) utilised 1 807 (30.4%) bed-days. Mortality and the standardised mortality ratio (actual/mean predicted mortality) in LSPs and SSPs were 29.6% v. 12% (p=0.002) and 2.4 v. 0.7 (p=0.002), respectively. Median duration of stay for LSPs and SSPs was 29.5 days and 2 days, respectively (p<0.0001). LSPs were younger than SSPs (median 4 months (interquartile range 2 - 17) v. 9 months (2 - 34); p=0.03), and fewer were male (48% v. 61.6%, p=0.049). On multivariate analysis, only female gender was independently associated with long PICU stay. CONCLUSIONS: LSPs represent a small proportion of PICU admissions, yet have a higher mortality rate than SSPs and consume disproportionate PICU resources. No predictive model could be established for early recognition of potential LSPs to plan PICU bed allocation effectively.

Childhood drowning in South Africa: local data should inform prevention strategies.

STUDY OBJECTIVE: Drowning is an important cause of childhood injury, however, little is known about drowning in Africa. The aim of this study is to investigate submersion incidents in Cape Town, South Africa and provide specific prognostic factors as well as to develop age-appropriate prevention strategies. METHODS: A retrospective chart review performed at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa. Patients admitted because of 'drowning' or 'near-drowning' between January 2007 and April 2013 were included. RESULTS: 75 children were included. 63 (84 %) survived without complications, 8 (10.7 %) died and 4 (5.3 %) had permanent neurological sequelae. The median age was 2.2 years (range 0.1-12.4). 46 (60.5 %) incidents happened in or around the home, only 14 (18.7 %) were witnessed. 42 (56 %) took place in a pool (29 private, 13 public). Significant predictors of the outcome were: estimated submersion time, duration of apnea, unresponsive and dilated pupils, intubation and use of inotropes. On arrival at the ER we found these significant predictors of the outcome: CPR, a GCS <5, hypothermia, bradycardia, asystole, as well as the PIM2-calculated mortality risk for patients admitted to the ICU. CONCLUSION: The majority of incidents were unwitnessed and occurred in or around the home. Prevention programs should be focused on adult supervision for younger children and creating awareness on the dangers of drowning in the home environment. While bathing in baths or buckets, children should never be left alone and parents should be made aware of the dangers. In our study, the majority of incidents occurred in swimming pools and limiting access to these could prevent many incidents of drowning among older children. Although children of all language groups are at risk for drowning, English- or Afrikaans-speaking children were particularly at risk for drowning in private pools while Xhosa-speaking children mostly drowned in baths or buckets. We also report multiple prognostic factors for the outcome, but none of them were absolute predictive of the outcome, indicating that each victim of submersion deserves full resuscitative treatment.

Review article: ventilator-associated pneumonia in major burns.

Major burns victims are particularly susceptible to pneumonia, especially ventilator-associated pneumonia (VAP). VAP remains a prominent cause of morbidity and mortality, despite improvements in intensive care and burns surgery in recent times. Length of ventilation, type and size of burn (especially inhalational burns) are related to the incidence of VAP. Other risk factors (number of re-intubations, theatre visits) are also important. Effective preventative strategies should be adhered to, and protocols should be implemented to aid in the diagnosis and treatment of VAP. Clinical criteria, radiology, and broncho-alveolar lavage should be used to determine the causative organism, and there should be a low threshold for the early initiation of empiric therapy, based on the prevailing resistance patterns in the unit. Major burns should be managed in centres where there is ready access to multidisciplinary resources and expertise.

Les patients grands brûlés sont très vulnérables à la pneumonie et en particulier à la pneumonie sous ventilation assistée (PVA). La PVA reste une cause importante de morbidité et de mortalité, en dépit de l'amélioration des soins intensifs et de la chirurgie dans ces derniers temps. La longue durée de la ventilation, le type et l'extension des brûlures (les brûlures par inhalation en particulier) sont liés à la fréquence de la PVA. Autres facteurs de risque (nombre d'interventions, de ré-intubations et chirurgicales) sont également importants. Des stratégies efficaces de prévention doivent être respectées, et les protocoles doivent être mis en oeuvre pour faciliter le diagnostic et le traitement des la PVA. Les critères cliniques et radiologiques et la lavage bronchoalvéolaire doivent être utilisés pour déterminer le germe en question, et il faut avoir un seuil bas pour l'initiation précoce de la thérapie empirique, basée sur les profils de résistance en vigueur dans l'unité de brûlures. Les brûlures graves devraient être traitées dans des centres ayant accès à des ressources et à des connaissances multidisciplinaires.

Guideline for the diagnosis, prevention and treatment of paediatric ventilator-associated pneumonia.

OBJECTIVE: Ventilator-associated pneumonia (VAP) has been poorly studied in South Africa, but is likely to be a significant problem, with resulting increased morbidity and mortality in the paediatric intensive care unit population. This guideline is intended to review the evidence and recommendations for prevention and management of VAP in children and to provide, where possible, clear advice to aid the care of these children, to limit costly and unnecessary therapies and--importantly--limit inappropriate use of antimicrobial agents, EVIDENCE: The Working Group was constituted. Literature on the aetiology, prevention and management of paediatric VAP is reviewed. RECOMMENDATIONS: Evidence-based clinical practice guidelines are provided for VAP diagnosis and prevention in South Africa. In addition, the current status of antimicrobial use has been reviewed and clear recommendations are set out.

Managing HIV in the PICU--the experience at the Red Cross War Memorial Children's Hospital in Cape Town.

The HIV pandemic has affected children throughout the developing world. This article describes the experience of the Paediatric Intensive Care Unit at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa. Over the last 20 years we have improved our management of HIV infected children requiring intensive care admission. In the absence of anti-retroviral therapy, long term outcomes from PICU admission of HIV infected children have not improved significantly, and it is debatable whether PICU admission is justified. Once anti-retroviral therapy is available to children, there may be significant improvements in outcome and possible affected children should be admitted to the PICU if resources are available.

The effect of epinephrine by nebulization on measures of airway obstruction in patients with acute severe croup.

OBJECTIVES: To demonstrate that tests of pulmonary function applicable to sick infants and small children with acute severe viral croup would provide clear, objective evidence of responsiveness to therapy with nebulized epinephrine. STUDY DESIGN: Oesophageal pressure changes and airflows at the mouth were measured in 17 patients with acute severe croup, before and after nebulization with epinephrine. RESULTS: In 12 of the 17 patients there was a significant improvement in respiratory mechanics following epinephrine nebulization. Six of the 12 patients who responded to adrenaline also received 0.9% saline by nebulization, without improvement. No measures derived from combined flow and volume data showed any statistically significant change following epinephrine nebulization. Measures combining flow and pressure data, specifically inspiratory airway resistance, expiratory airway resistance, work of breathing, rate of work of breathing and volume for effort, showed changes of 26%, 33%, 16%, 16% and 46% respectively. The most statistically significant measures were pressure-rate product, pressure-time integral, oesophageal pressure alone and expiratory resistance. These changes persisted for at least 10 min after inhalation although there was some evidence of decline in pharmacologic effect at that time. CONCLUSIONS: Nebulized epinephrine results in a short-lived improvement in some but not all patients with croup. This reduction in respiratory effort occurs secondary to a decline in inspiratory and expiratory airway resistance. Oesophageal pressures measured via a feeding tube are satisfactory for quantification of the acute response and may be a useful continuous monitoring device. Flow measurements are unhelpful, and continuous administration of nebulized epinephrine should be investigated.

Intracranial pressure and cerebral oxygenation changes after decompressive craniectomy in children with severe traumatic brain injury.

INTRODUCTION: There has been a resurgence of interest in decompressive craniectomy for traumatic brain injury (TBI), but the impact of craniectomy on intracranial pressure (ICP) and cerebral oxygenation has not been well described for diffuse injury in children. METHODS: ICP and brain tissue oxygenation (PbtO2) changes after decompressive craniectomy for diffuse brain swelling after TBI in children were analysed. FINDINGS: Decompressive craniectomy was performed for diffuse brain swelling in 18 children under 15 years old. For 8 patients, craniectomy was performed as an emergency for malignant brain swelling, and in 10, for sustained ICP > 25 mmHg refractory to conventional medical treatment. In 6 of these patients, PbtO2 was also monitored. Median ICP was reduced from 40 mmHg before craniectomy to 16 mmHg for 24 hours thereafter, and PbtO2 improved from a median of 17.4 to 43.4 mmHg. Clinical outcome was favourable in 78%. CONCLUSIONS: In selected pediatric patients with TBI, craniectomy for diffuse brain swelling can significantly improve ICP and cerebral oxygenation control. The use of the procedure in appropriate settings does not appear to increase the proportion of disabled survivors.

Intracranial pressure and cerebral oxygenation changes after decompressive craniectomy in a child with traumatic brain swelling.

CASE REPORT: The authors present the case of a 5-year-old child with severe traumatic brain injury in whom decompressive hemicraniectomy was performed for progressive increased intracranial pressure (ICP) unresponsive to medical treatment. Data from ICP and cerebral tissue oxygenation monitoring in the contralateral hemisphere were recorded, which demonstrated the immediate and delayed mechanical and physiological changes occurring after bony and dural decompression. DISCUSSION: The role of the procedure and that of the monitoring approach are discussed.

Tracheostomy in human immuno-deficiency virus infected children at the Red Cross War Memorial Children's Hospital, Cape Town, South Africa.

UNLABELLED: Tracheostomy in adults with HIV/AIDS has been reported to be associated with both high and early mortality of 47-100%. There is minimal data regarding the role of tracheostomy in HIV infected children. We did a retrospective analysis of HIV positive children that underwent tracheostomy at our institution over a 5-year period, 2002-2006. A total of 70 tracheostomies were done during the period and 15 (21.4%) of these children were confirmed as HIV infected. The average age at presentation for HIV infected children with upper airway obstruction resulting eventually in tracheostomy was 9.4 months and 60% were under 1 year of age. Only three (20%) were on Anti-Retroviral Therapy (ART) prior to presentation. The cause of upper airway obstruction was croup in 14 (93%) of these 15 children. Following tracheostomy all were treated with ART. To date six children have been successfully decannulated (40%) and there have been three deaths (20%) which were unrelated to tracheostomy. CONCLUSION: Tracheostomy in HIV positive children is not associated with the high mortality that has been reported in adults provided such children are started on treatment with antiretroviral therapy.

A family showing recessively inherited multisystem pathology with aberrant splicing of the erythrocyte Band 7.2b ('stomatin') gene.

The case of a French child, born of consanguineous parents of Tunisian origin, is described. He showed a severe multisystem disease with dyserythropoietic, sideroblastic anaemia, delayed neurological development with hypotonia and convulsions, salt-losing nephropathy, chronic watery diarrhoea, lactic acidosis with mitochondrial dysfunction, brittle hair, hypergammaglobulinaemia, fatty liver with intermittent transaminasaemia, and terminal pulmonary fibrosis. Two siblings, of both sexes, were stillborn; two more lived only a short time. One sister is alive and well. SDS gel analysis of the red cell membranes showed a deficiency within 'Band 7' at 32 kDa. Analysis of the gene encoding 'stomatin', or 'erythrocyte membrane protein 7.2b', the principal protein of 'Band 7', revealed a complex series of aberrant spliceforms centred around exon 3, for which no explanatory genomic lesion could be found. The true underlying molecular cause of this condition remains obscure, but it suggests that the stomatin gene should be studied in other cases.

Utilization of an 86 bp exon generates a novel adducin isoform (beta 4) lacking the MARCKS homology domain.

A novel isoform of beta-adducin has been amplified and characterized from a human bone marrow cDNA library (GenBank #U43959). This isoform arises from the insertion of an 86 bp alternatively spliced and previously unrecognized exon (now termed exon 15) within codon 581 of the human red blood cell beta-adducin sequence. This results in an insertion of 28 novel amino acids. The remainder of the red cell beta-adducin mRNA is then translated in a different reading frame, adding an additional 35 novel amino acids prior to the stop codon. This new isoform, thus, replaces beta 1-adducin sequence after residue 580 with a total of 63 new amino acids. Sequences from genomic clones of the human beta-adducin gene show that this alternate exon is flanked by splice consensus sequences and is appropriately located in the genomic map between exons encoding up-stream and down-stream sequences, thus defining a new exon. The COOH-terminus of this new isoform, which we designate beta 4, lacks a 22 amino acid lysine-rich sequence common to both the human red cell alpha- and beta-adducin subunits and homologous to a highly conserved region in MARCKS, a filamentous actin-cross linking protein regulated by protein kinase C and calcium/calmodulin. beta 4-adducin preserves a previously identified calmodulin binding domain. PCR analysis indicates that this new beta-adducin isoform is expressed in fetal brain and liver, bone marrow, and NT-2 (neuroepithelial) cells, but is not detected in several other tissues. We anticipate that this new beta 4 isoform of beta-adducin will display unique and tissue-specific functional properties.

Guillain-Barré syndrome in South Africa associated with Campylobacter jejuni O:41 strains.

Over a 20-month period, 3 adult and 6 pediatric patients were diagnosed with Guillain-Barré syndrome (GBS) at Groote Schuur and Red Cross Hospitals in Cape Town. All 9 GBS patients had Campylobacter jejuni biotype 2, serotype O:41 in their stools. C. jejuni infection was confirmed by ELISA testing of patient sera. Strains of this sero-biotype are rare: Only 12 such strains, including the GBS-associated strains, were recognized among 776 Campylobacter strains isolated and identified at Red Cross Hospital from March 1994 to October 1995. This is the first known association of C. jejuni biotype 2, serotype O:41 with GBS. Patients infected with this Campylobacter strain had a particularly severe form of the infection, requiring hospitalization and ventilation much longer than GBS patients infected with other Campylobacter species and patients with Campylobacter-negative stools. The O:41 Campylobacter isolates from the GBS patients are identical by phenotypic, serologic, and molecular criteria, and they are clonal.

Campylobacter 0:41 isolation in Guillain-Barré syndrome.

Over a period of 15 months, 17 children were admitted to the Red Cross War Memorial Children's Hospital (RCWMCH) in Cape Town with Guillain-Barré syndrome. Stool specimens were collected from 14 children and campylobacter was isolated from nine. Six of the nine isolates of Campylobacter jejuni were further identified as C jejuni biotype 2, serotype 0:41. This biotype 2, serotype 0:41 has been identified in only 12 of the 7119 campylobacter isolates at the RCWMCH over a 19 year period. Eight of the nine patients with campylobacter isolates and one of five with negative stool cultures required ventilation. Patients with C jejuni biotype 2, serotype 0:41 were ventilated for a mean (SD) of 33.5 (19.4) days, whereas patients with other campylobacter isolates were ventilated for 17.3 (3.8) days. This is the first report of campylobacters of serotype 0:41 in Guillain-Barré syndrome and could reflect a geographical isolation of this strain.

Child abuse services at a children's hospital in Cape Town, South Africa.

UNLABELLED: Since the establishment of a Child Abuse Management Service at the Red Cross War Memorial Children's Hospital in the early 1980s, there has been a steady increase in patient numbers. In order to assess the profile of patients, and also the allocation of staff to the service, all child abuse related patients seen at the Red Cross War Memorial Children's Hospital in Cape Town over the period of June 1989 through July 1990 were reviewed. Five hundred and three children with a median age of less than 7 years were seen. Abuse was confirmed in 389 (160 physical abuse and 229 sexual abuse). Abuse was suspected and not confirmed in 114 (41 physical and 73 sexual). Half of the patients presented to the hospital outside of normal working hours. Eighty-one percent of children less than 5 years of age were seen in the Trauma Unit by surgical residents with minimal pediatric training. One hundred and thirty four of the patients were Xhosa speaking while only one social worker and no medical staff could speak Xhosa. Pediatric residents were involved in the care of less than 2% of cases. CONCLUSION: Management of child abuse constitutes a significant commitment and appropriate staff allocation is essential. Although it is not possible for each child in whom abuse is suspected to be seen by a specialist, they should be seen by those staff with the most expertise. Staff allocation must take into account the needs for education, training, and audit as well as service provision.

Sexually transmitted diseases in children and evidence of sexual abuse.

During the period June 1989 to March 1991, laboratory evidence of sexually transmitted diseases (STDs) was found in 107 patients at the Red Cross War Memorial Children's Hospital in Cape Town. Data was available on 96 patients aged 23 months to 14 years (mean 75.9 months). Vaginal discharge was the most frequent presenting symptom (76%), particularly in those less than 5 years of age (90%). Although a history of abuse was not given on presentation in 62%, evidence of abuse was subsequently elicited in 67% of patients. Neisseria gonorrhoeae was the most common sexual pathogen (61 isolates, 8 penicillin resistant), followed by G vaginalis (17 isolates), Trichomonas vaginalis (7 infections), and T pallidum (9 TPHA positive, 5 with VDRL 1:4 or higher). Chlamydia trachomatis was demonstrated by immunofluorescence in 14 children. Multiple STDs were demonstrated in 10 patients. Although evidence of CSA was not found in all patients with STDs it was likely that the vast majority of patients had acquired these infections by CSA. Symptomatic prepubertal children with G vaginalis isolates should be investigated for CSA. Chlamydial immunofluorescence tests did not assist the diagnosis of CSA in children and should not be used, as they have no medicolegal significance.

PIP: This study examines the nature and extent of sexually transmitted diseases related to sexual abuse among patients seeking treatment during June 1989-March 1991 at the Red Cross War Memorial Children's Hospital in Rondebosch, Cape Town, South Africa. 107 patients aged 23-174 months (about 2-15 years of age) were identified by laboratory testing as having a sexually transmitted disease. Analysis pertained to 96 patients. 10 children had multiple infections. 60 patients were assessed after 2-3 months, of whom 20% (12 cases) indicated evidence of child sexual abuse. 47% of the 36 patients who were not followed-up had evidence of child sexual abuse. Age was unrelated to follow-up or sexual abuse. Genital symptoms were evident at the initial visit among 87 patients (91%), of whom 65% had no prior history of abuse. 26% had a history of sexual abuse. 8 patients had a history of sexual abuse but no genital symptoms. 79% had genital symptoms of vaginal discharge. 39 patients aged under 5 years had a vaginal discharge, and 10 had a history of sexual abuse. 29 cases were determined not to be related to sexual abuse. There were 61 children infected with Neisseria gonorrhoea, 17 children with Gardnerella vaginalis, 14 children with Chlamydia trachomatis, 9 children with Trichomonas vaginalis, and 9 children with Treponema pallidum (positive cultures for syphilis, but without clinical features). Sexual child abuse was found to be higher than previously reported at this center. The approach in this study was to deny sexual abuse until confirmation of a sexually transmitted disease. Almost 33% of children in this study had no physical evidence of sexual abuse. The hospital policy is to teach children and caregivers safety skills and awareness and to develop a rapport with parents. Ceftriaxone was administered as therapy, since most children had gonorrhea, and there was resistance to penicillin and poor follow-up. The authors find that all children with Gardnerella vaginalis should be investigated for child sexual abuse. There was an express need for follow-up of patients due to the almost 10% with multiple infections.