Amniotic fluid volume at presentation with early preterm prelabor rupture of membranes and association with severe neonatal respiratory morbidity.

OBJECTIVE: Amniotic fluid volume (AFV) plays an important role in early fetal lung development, and oligohydramnios in early pregnancy is associated with pulmonary hypoplasia. The aim of this study was to evaluate the association between AFV at the time of presentation with early preterm prelabor rupture of membranes (PPROM) and severe neonatal respiratory morbidity and other adverse pregnancy outcomes. METHODS: This was a retrospective study of all women with a singleton pregnancy, admitted to a single tertiary referral center between 2004 and 2014, for expectant management of PPROM at 20 + 0 to 28 + 6 weeks' gestation. The primary exposure was AFV at presentation, classified according to sonographic maximum vertical pocket (MVP) as: normal AFV (> 2 cm), oligohydramnios (≤ 2 cm and > 1 cm) or severe oligohydramnios (≤ 1 cm). The primary outcome was a composite variable of severe respiratory morbidity, defined as either of the following: (1) need for respiratory support in the form of mechanical ventilation using an endotracheal tube for ≥ 72 h and need for surfactant; or (2) bronchopulmonary dysplasia, defined as requirement for oxygen at postmenstrual age of 36 weeks or at the time of transfer to a Level-II facility. Adjusted odds ratios (aOR) and 95% CI for the primary and secondary outcomes were calculated for each AFV-at-presentation group (using normal AFV as the reference), adjusting for gestational age (GA) at PPROM, latency period, birth weight, mode of delivery and chorioamnionitis. RESULTS: In total, 580 women were included, of whom 304 (52.4%) had normal AFV, 161 (27.8%) had oligohydramnios and 115 (19.8%) had severe oligohydramnios at presentation. The rates of severe respiratory morbidity were 16.1%, 26.7% and 45.2%, respectively. Compared with normal AFV at presentation, oligohydramnios (aOR, 3.27; 95% CI, 1.84-5.84) and severe oligohydramnios (aOR, 4.11; 95% CI, 2.26-7.56) at presentation were associated independently with severe respiratory morbidity. Other variables that were associated independently with the primary outcome were GA at PPROM (aOR, 0.54; 95% CI, 0.43-0.69), latency period (aOR, 0.94; 95% CI, 0.91-0.98) and Cesarean delivery (aOR, 2.01; 95% CI, 1.21-3.32). CONCLUSIONS: In women with early PPROM, AFV at presentation, as assessed by the MVP on ultrasound examination, is associated independently with severe neonatal respiratory morbidity. This information may be taken into consideration when counseling women with early PPROM regarding neonatal outcome and management options. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Digital radiographic measurement of the main bronchi: a pilot study.

BACKGROUND: Conventional chest radiographs do not afford consistently good visualisation of the main bronchi and sub-carinal angle. Improved visualisation would facilitate accurate measurement of the airways, definition of normal radiographic anatomy and, possibly, earlier identification of extrinsic compression or displacement. AIM: The main objective of this study was to establish whether the paediatric main bronchi and sub-carinal angle could be measured consistently on AP supine chest images obtained using a specific digital radiographic system (DRS). SUBJECTS AND METHODS: The proximal bronchial diameters were measured on supine DRS chest images of 102 children between the ages of 6 months and 13 years. RESULTS: The left and right main bronchi could be seen clearly and measured in over 90% of cases, with intraclass correlation co-efficients of reliability indicating high intra- and inter-observer agreement. The sub-carinal angle had lower intra- and inter-observer agreement. CONCLUSION: Supine chest images acquired using DRS facilitate accurate measurement of the main bronchi and sub-carinal angle in children. Further work is required to establish population-specific age-related norms for bronchial dimensions. These could serve as reference standards for early detection of deviations from normal.

Miliary tuberculosis in children: a review of 94 cases.

This is a retrospective review of the clinical, radiologic and laboratory features of 94 cases of childhood miliary tuberculosis seen during a 5-year period, 1985 to 1989. A history of Bacillus Calmette-Guérin vaccination was documented in 88% of children. The median age at presentation was 10.5 months, 52% of cases occurring in those younger than 1 year. The presenting symptoms were nonspecific: cough (72%); fever (61%); loss of appetite and weight (40%); and diarrhea and vomiting (33%). The main presenting signs were hepatomegaly (82%), splenomegaly (54%), lymphadenopathy (46%) and pyrexia (39%). Most of the patients were malnourished and anergic. Meningitis occurred in 19% of patients and this was the only significant risk factor identified for mortality, the overall case fatality rate being 14%. The diagnosis in the vast majority was made on the clinical presentation supported by a classic miliary pattern on chest roentgenogram (91% of cases). Mycobacterium tuberculosis was cultured in 33% of cases. In addition a review of hospital admissions from 1981 to 1989 revealed that annually miliary tuberculosis in children and adults accounted for 8.3 and 1.3%, respectively, of all tuberculosis admissions. This study confirms that miliary tuberculosis is a relatively common complication of tuberculosis in young children.

Twice weekly vs. daily chemotherapy for childhood tuberculosis.

BACKGROUND: Treating childhood tuberculosis places a large burden on health services, and ways of lessening this were sought. METHODS: A randomized controlled trial was conducted to determine the effectiveness of fully intermittent twice weekly treatment for intrathoracic childhood tuberculosis and its effect on adherence to treatment, in comparison with daily (weekday) treatment. The setting was a district of Cape Town, South Africa, an area of high incident tuberculosis. We randomized 206 children with confirmed (4%), probable (94%) and suspected (2%) intrathoracic tuberculosis: 89 (median age, 25 months) received intermittent treatment; and 117 (median age, 28 months) received daily treatment. Intermittent treatment (twice weekly for 6 months) was isoniazid 15 mg/kg/dose, rifampin 15 mg/kg/dose and pyrazinamide 55 mg/kg/dose for 2 months, followed by isoniazid and rifampin only for 4 months. Daily treatment was isoniazid 10 mg/kg/day, rifampin 10 mg/kg/day and pyrazinamide 25 mg/kg/day on weekdays for 6 months. RESULTS: At 6 months 97% of subjects were discharged, with treatment outcomes in the two groups equivalent at that time (P = 0.90) and at the 18- to 30-month follow-up. One relapse occurred in the twice weekly group (P = 0.25). Adherence was equivalent; 70 children (79%) on intermittent and 90 (77%) on daily treatment took 75% or more of the prescribed doses (P = 0.90). Nonadherence over the full course of therapy was significantly associated with nonadherence during the first month of treatment (P = 0.0002) and household crowding (P = 0.002). CONCLUSIONS: Six month fully intermittent antituberculosis treatment is an effective and acceptable alternative to daily treatment.

Age-related tuberculosis incidence and severity in children under 5 years of age in Cape Town, South Africa.

SETTING: Limited data are available on the characteristics of tuberculosis (TB) disease in young children, especially in high-burden countries. OBJECTIVE: To assess the incidence and severity of TB in children aged <5 years. METHODS: TB records and chest radiographs of children born in Cape Town in 1999 and diagnosed with TB between 1999 and 2004 were reviewed retrospectively. RESULTS: A total of 1607 cases were registered. The cumulative incidence of definite (bacteriologically confirmed) and probable (radiological evidence and > or =1 TB clinical feature) TB in children aged <5 years was 2.9% and was highest between the ages of 12 and 23 months. Of 1233 children with definite or probable TB, 506 (41%) had severe disease (dissemination, cavities or >1 lobe involved). The under 5 years incidence of disseminated TB was 0.33%. Of 239 (15%) cases that were bacteriologically confirmed, clinical features typical of TB disease were individually present in <60%. The most common combined symptoms were cough for >2 weeks and weight loss, occurring in 43/239 (18%). CONCLUSION: TB incidence was high, and peaked in children aged 12-23 months. Many children experienced severe disease. A fifth of children with microbiologically confirmed disease presented with only one feature typically associated with TB.

The serodiagnosis of tuberculosis in children: an evaluation of an ELISA test using IgG antibodies to M. tuberculosis, strain H37 RV.

An enzyme-linked immunosorbent assay (ELISA) for detecting serum IgG antibodies to an autoclaved suspension of Mycobacterium tuberculosis H37 RV was evaluated as a diagnostic tool in 132 clinical cases of childhood tuberculosis. The mean (SD) optical density value in these patients was 0.115 (0.122) compared with 0.022 (0.017) in the control group of patients who had non-tuberculous acute respiratory tract infections. Using as a cut-off level the mean of the control plus 2 standard deviations, the test sensitivity was 62% and the specificity was 98% in all the patients with a clinical diagnosis of tuberculosis. In the culture-positive group (n = 35), the sensitivity was 69%. A positive correlation was shown between the optical density levels and increasing age and chronicity of infection but not with respect to tuberculin skin reactivity, nutritional status and the duration of prior therapy. In addition, BCG vaccination (presence of a scar) did not affect the ELISA result. We conclude that this ELISA test is a useful diagnostic test in children.

Postneonatal mortality in the Matroosberg Divisional Council area of the Cape Western Health Region.

Postneonatal deaths in the Matroosberg Divisional Council area were studied with particular reference to social and nutritional factors. Adverse social circumstances were strongly associated with death during the first year of life. The children who died had fathers who were less educated and held lower rated jobs than fathers of children in a control group. They were less likely to have belonged to a nuclear family and were more likely to have had families with social problems. They were also more frequently bottle-fed, were more likely to have been underweight, and were less often fully immunised. The study illustrates the need for a GOBI-FFF intervention strategy in the area.

An urban strategy towards the EPI.

Rapidly increasing urbanisation, fragmentation of health services, and civil unrest can constitute threats to the efficiency of the excellent immunisation services developed in most South African cities. Among children attending hospital outpatient departments are many who have escaped the net of the preventive services. A system has been developed to immunise all children entering the Red Cross War Memorial Children's Hospital, Cape Town, in whom immunisation is incomplete for age. The Community Health Liaison Group, which co-ordinates these and other health preventive/promotive activities in the hospital, is described.

Immunisation in a rural setting. The EPI as a vital arm of primary health care.

Immunisation forms an integral part of any health care system. In certain areas in the western Cape the immunisation cover has been analysed over several years. This data indicates an effective immunisation programme in these areas. Promotive, preventive and curative services are effectively provided within the limitations of the conditions pertaining in the areas.

Combined phenylketonuria and pyruvate kinase deficiency. A case report.

We report on a 14-year-old boy who has both phenylketonuria (PKU) and pyruvate kinase deficiency (PKD). Each of these autosomal recessive conditions is a rarity in itself, and we believe that this is the first reported instance of PKU and PKD occurring in the same individual.

Sleeping positions of infants in the Cape Peninsula.

The prone position is thought to be an important factor in the sudden infant death syndrome (SIDS). The sleep positions of unselected infants aged 6 months and younger attending clinics in the Cape Peninsula were studied; 62.4% slept prone with the face to the side. This position differs between the ethnic groups (whites 50.0%; blacks 58.7%; coloureds 69.8%) and the respondents' social class (higher classes 54.1%; lower classes 69.2%). The sex of the baby, the sleeping place and the educational level of the mother did not influence the position used. Ninety-four per cent of black infants slept with their mothers compared with 71% of coloured and 4% of white babies. The study confirmed that there are cultural differences in sleeping positions adopted by infants. The role this plays in SIDS among different ethnic groupings still needs to be clarified.

Ear and hearing disorders in rural grade 2 (Sub B) schoolchildren in the western Cape.

Four hundred and one children living in rural areas with a high level of poverty were assessed for ear and hearing disorders in their second year of schooling. Overall, only 40.3% of these children had both normal-appearing ear drums and normal hearing thresholds bilaterally; 14% had obstructing wax plugs; 17% had evidence of past acute otitis media with scarring or progression to chronicity--6% having perforations; 31% had middle-ear effusions and/or their sequelae; and 33% had some impairment of hearing but, if the effect of testing in the classroom environment is considered, there was probably only significant impairment in 9%. It is suggested that the prevalence of chronic ear disorders is a useful marker of the quality of primary care in rural communities.

The child health card--a cornerstone of preventive and promotive paediatrics.

When properly used, the child health card is a relatively cheap and effective measure in the promotion of health and in the early detection and prevention of disease in infants and children. It serves as a record of birth data, growth in mass, immunization, neurological development and episodes of illness; it can also facilitate advantageous family spacing. At present the card is not achieving its full potential in southern Africa. We suggest the active promotion of its benefits to the public and especially to potential mothers via school education.