Regulatory and Educational Initiatives to Prevent Food Choking Injuries in Children: An Overview of the Current Approaches.

Choking injuries are one of the major causes of death among children ages 0-3, and most of these injuries are related to food. This work provides an overview of the current recommendations for food choking prevention and educational targets as a basis for developing a unified common set of knowledge for primary prevention policies development. Guidelines published by professional membership organizations and national governments in the English language were considered. All of these guidelines provide lists of hazardous food items and recommendations for food preparation to minimize choking hazard. Together with recommendations for food preparation, also recommendations aimed at stakeholders (food manufacturers, health care providers, and public authorities) are provided, underlining that this severe public health problem should be further addressed by adopting integrated public health interventions. Our overview stressed the importance of developing educational and primary prevention policies to sensitize adult supervisors and to regulate dangerous food products in the market.

'H-type' tracheoesophageal fistula in an infant: A case report.

Congenital isolated 'H-type' tracheoesophageal fistula (TOF) is a rare disorder which is difficult to diagnose. Clinical presentation is characterised by a triad consisting of paroxysmal coughing and cyanosis during feeds; recurrent chest infections and failure to thrive; and abdominal distention secondary to gaseous loading of the bowel. It is often difficult to diagnose 'H-type' TOF because the continuity of the oesophagus is not interrupted. The diagnosis is often missed or delayed, leading to complications such as chronic lung disease and failure to thrive.

Surgical challenges in Limpopo.

Introduction on Surgical Challenges in Limpopo.

A brief overview of the past, present, and future of the Department of General Surgery at Pietersburg and Mankweng hospitals in Limpopo Province, South Africa.

A brief overview of the Department of Surgery in the past, present and future.

Audit of surgical specialty patients and beds at Pietersburg Hospital, Limpopo Province, South Africa in 2021.

BACKGROUND: While the absolute number of hospital beds is usually discussed, adequate utilisation of beds is a far better instrument to measure departmental efficiency. OBJECTIVE: To measure the number of beds for each surgical specialty in Pietersburg Hospital as well as the average length of stay (LoS) to compare bed utilisation. METHOD: We conducted a 1-day descriptive cross-sectional audit of patients admitted to surgical wards on 21 April 2021 at Pietersburg Hospital. RESULTS: There were huge discrepancies in the number of beds per surgical specialty as well as the LoS. Over one-third of surgical beds were occupied by patients waiting for either a computed tomography scan, surgical procedure, or transfer. CONCLUSION: There is a need to address the functioning of the surgical specialties with regards to the number of beds allocated as well as the ideal average length of stay.

Audit of surgical procedures in regional and central hospitals in Limpopo Province, South Africa.

BACKGROUND: There is a paucity of data on the functioning and surgical procedures performed in rural hospitals in South Africa. OBJECTIVE: To determine the category of procedures performed at regional and tertiary hospitals in Limpopo Province, South Africa. METHOD: We conducted a retrospective analysis of surgical procedures performed in the regional and tertiary hospitals in Limpopo Province during a 1-year period from 1 March 2019 to 29 February 2020. RESULTS: A total of 24 263 surgical procedures were performed during the study period. More than half of all cases (50.4%; n=12 252) were operated on at the tertiary hospitals while regional hospitals performed the remaining 12 011 operations. CONCLUSION: There is a great necessity to alleviate the central hospitals from the bulk of surgical procedures.

Repeat injuries in childhood.

BACKGROUND: Injury remains a leading cause of childhood morbidity and mortality in the developing world. The probability of injury occurrence is influenced by agent, host and environmental factors. Studies of repeat injuries in childhood therefore provide insight into factors in the epidemiological triad predisposing children to injury. OBJECTIVES: To determine the proportion of children and the factors associated with repeat presentations to the Red Cross War Memorial Children's Hospital Trauma Unit (RCWMCH TU) in Cape Town, South Africa, for all non-transport-related injuries in childhood. METHODS: This was a retrospective cohort study using data from the RCWMCH TU. We included children aged 0 - 10 years with first presentation from January 1997 to June 2013 and followed up until the earlier of age 13 years or June 2016. We assessed individual and population-level factors associated with repeat injury using multilevel Poisson regression analysis. Child dependency ratios were derived from the 2011 National Census. RESULTS: Between 1997 and 2013, 72 490 children aged <10 years (59% male) presented to the RCWMCH TU for the first time with injuries. After the initial injury, 9 417 (13%) presented with a repeat injury by 2016 and before age 13 years. After adjusting for health subdistrict, distance from RCWMCH TU and age at first presentation, factors associated with reduced repeat presentation were injury identified as due to abuse (adjusted incidence rate ratio (aIRR) 0.6; 95% confidence interval (CI) 0.4 - 0.7), fluid burn (aIRR 0.6; 95% CI 0.6 - 0.7), foreign body ingestion (aIRR 0.7; 95% CI 0.7 - 0.9), and moderate and severe (v. minor) initial injury (aIRR 0.9; 95% CI 0.8 - 0.9 and aIRR 0.7; 95% CI 0.6 - 0.8, respectively), while boys were more likely to have repeat injury presentations (aIRR 1.4; 95% CI 1.4 - 1.5). CONCLUSIONS: Repeat presentations were substantial and associated with male gender. They occurred less commonly after fluid burn injuries, foreign body ingestion and moderate to severe injuries. Children with intentional injuries were also less likely to have a repeat presentation. Further research is indicated for childhood injuries with greater propensity to repeat, including non-height falls and sport-related injuries. Secondary injury prevention education should not neglect patients with unintentional and minor injuries. These results strengthen the hypothesis that injuries arise as a result of sustained exposure to agent, host and environmental risk factors.

A review of blood transfusions in a trauma unit for young children.

BACKGROUND: Trauma is the leading cause of mortality and morbidity worldwide. Blood transfusions play an incremental role in the acute phase, yet practice varies owing to variations in transfusion thresholds and concerns about potential complications, especially in children. OBJECTIVES: To evaluate protocol adherence to blood transfusion thresholds in paediatric trauma patients and determine the degree of blood product wastage, as defined by discarded units. METHODS: A retrospective, descriptive study of trauma patients (age 0 - 13 years) who received a blood transfusion in the trauma unit at Red Cross War Memorial Children's Hospital, Cape Town, South Africa, over a 5.5-year period (1 January 2009 - 1 July 2014). Haemoglobin (Hb) transfusion thresholds were defined as 10 g/dL for neurotrauma patients and patients requiring skin grafting or a musculocutaneous flap (group 1). All other trauma patients had an Hb transfusion threshold of 7 g/dL (group 2). RESULTS: A total of 144 patients were included (mean age 5.2 years (standard deviation (SD) 3.3), 68.1% male). The mean Hb increase after transfusion was 3.5 g/dL (SD 1.7). Adherence to the transfusion Hb threshold protocol was 96.7% for group 1 v. 34.0% for group 2. No complications were reported. Average blood wastage was 3.5 units per year during the study period. CONCLUSIONS: Adherence to paediatric blood transfusion protocol was low in the Hb threshold group <7 g/dL. However, transfusion-related complications and wastage were minimal. Further prospective research is required to determine optimal blood transfusion guidelines for paediatric trauma patients.

Management of paediatric liver trauma.

Of all the intra-abdominal solid organs, the liver is the most vulnerable to blunt abdominal trauma. The majority of liver ruptures present in combination with other abdominal or extra-abdominal injuries. Over the last three decades, the management of blunt liver trauma has evolved from obligatory operative to non-operative management in over 90% of cases. Penetrating liver injuries more often require operative intervention and are managed according to adult protocols. The greatest clinical challenge remains the timely identification of the severely damaged liver with immediate and aggressive resuscitation and expedition to laparotomy. The operative management can be taxing and should ideally be performed in a dedicated paediatric surgical centre with experience in dealing with such trauma. Complications can occur early or late and include haemobilia, intrahepatic duct rupture with persistent biliary fistula, bilaemia, intrahepatic haematoma, post-traumatic cysts, vascular outflow obstruction, and gallstones. The prognosis is generally excellent.

Traumatic chylothorax in a young child: Case report and management.

INTRODUCTION: A chylothorax is an uncommon feature of paediatric chest trauma. CASE REPORT: We report a case of traumatic chylothorax following blunt chest trauma in an eight year-old girl with polytrauma after being hit by a motor vehicle. She was initially found to have a bilateral frontal skull fracture extending into the left parietal area, pulmonary contusions, left posterior rib fractures, left clavicular fracture and a degloving injury of her left foot. On the fifth day of her admission she developed progressive dyspnoea with signs of a pleural effusion, which was confirmed radiologically and drained by tube thoracostomy. Biochemical analysis confirmed chylothorax, which was managed conservatively with a fat free diet. The chest tube was removed after it stopped draining over 20 mL per 12 hours and she made a full recovery. DISCUSSION: Initial management of chylothorax is conservative with tube thoracostomy drainage and fat free diet. Traumatic chylothroax is a rare complication following chest trauma and can take days to develop and to become clinically apparent. It is therefore important to be vigilant for potential late complications in blunt chest trauma in children, especially if there are extensive rib fractures, a sign of major transmission of force to the thorax.

INTRODUCTION: Un chylothorax est une caractéristique clinique peu fréquente des traumatisme du thorax chez l'enfant. OBSERVATION: Nous signalons un cas de chylothorax traumatique suite à un traumatisme du thorax contondant chez une fillette de huit ans souffrant d'un polytraumatisme après avoir été percutée par un véhicule motorisé. Elle a d'abord été diagnostiquée avec une fracture frontale bilatérale du crâne s'étendant à la zone du pariétal gauche, des contusions pulmonaires, des fractures de la cage thoracique au niveau postérieur gauche, une fracture de la clavicule gauche et un dégantage du pied gauche. Au cinquième jour de son admission, elle a développé une dyspnée progressive avec des signes d'effusion pleurale, confirmée par radiologie, et drainée par tube de thoracostomie. Les analyses biochimiques ont confirmé un chylothorax, géré de manière conventionnelle par un régime sans matières grasses. Le drain thoracique a été retiré une fois le drainage passé à moins de 20 millilitres toutes les 12 heures et elle s'est totalement rétablie. DISCUSSION: La gestion initiale du chylothorax est conventionnelle, avec un drainage par tube de thoracostomie et un régime alimentaire sans matières grasses. Le chylothorax est une complication rare des traumatismes du thorax et peut mettre plusieurs jours à se développer et à apparaître cliniquement. Par conséquent, il est important de rester vigilant afin de détecter d'éventuelles complications tardives en cas de traumatisme du thorax contondant chez les enfants, notamment en cas de fractures graves de la cage thoracique, un signe de transmission de force majeure au niveau thoracique.

Treatment and outcome of unusual animal bite injuries in young children.

BACKGROUND: Animal bites are a major cause of preventable traumatic injuries. OBJECTIVES: To provide more epidemiological information on animal bites, and assist in increasing awareness of the problem. METHODS: A retrospective chart review was performed including children aged >13 years presenting with bite injuries (excluding dog and human bites) to the trauma unit at Red Cross War Memorial Children's Hospital, Cape Town, South Africa, over a 25-year period. RESULTS: Two hundred and thirteen children were eligible to be entered into the study. The median age was 2.9 years (range 1.2 - 6.5), with boys slightly predominating (54.9%). Most (74.6%) of the bite injuries were inflicted by mammals, the majority (64.8) of mammalian bites being rat bites. The proportions of boys and girls in the age group 0 - 4 years bitten by rats significantly differed from the proportions in the age group >4 years (p=0.039). In the age group 0 - 4 years more girls suffered rat bites, while more boys were bitten in the age group >4 years. Of 91 rat bites, 81 (89.0%) occurred inside the house. The hands (43.9%) and the head/face/neck region (39.0%) were most affected. The underdeveloped suburbs of Philippi, Gugulethu and Khayelitsha in Cape Town represented a disproportionate number (41.6%) of rat bites. CONCLUSION: There is a relationship between poverty, unemployment, poor housing, informal settlements and rodent infestation. These high-risk populations need to be the target for government rat eradication programmes.

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.

Management of physical child abuse in South Africa: literature review and children's hospital data analysis.

BACKGROUND: The reason for this review is the lack of data on the management of physical abused children in Africa. The primary goal of the first part is to outline the management of physical child abuse in (South) Africa and provide suggestions for other governments in Africa on which to base their management of physical child abuse, at both governmental and hospital management level. The main aim of the second part is to outline the extent of the problem as seen at the Red Cross Memorial Children's Hospital (RCH) in Cape Town. MATERIAL AND METHODS: The National Library of Medicine's PubMed database was searched for articles specifically about the management of physical child abuse. Hospital data were analysed in two phases: one addressed various types of assault in order to assess the number of patients admitted to the trauma unit of RCH between 1991 and 2009, and the other to identify all children with suspected non-accidental injury (NAI) presenting to the trauma unit at RCH from January 2008 until December 2010. RESULTS: Information on physical abuse of children in Africa in the English scientific literature remains disappointing with only two articles focusing on its management. RCH data for the period 1991-2009 recorded a total number of 6415 children hospitalised with injuries following assault, who accounted for 4.2% of all trauma admissions. Types of abuse included assault with a blunt or sharp instrument, rape/sexual assault and human bite wounds. Over the last 2 decades, there has been a minor decline in the number of cases of severe abuse requiring admission; admissions for other injuries have remained stable. More detailed analysis of hospital data for 2008-2010, found that boys were far more commonly assaulted than girls (70.5% vs 29.5%). Physical abuse appeared to be the most common cause of abuse; 89.9% of all boys and 60.5% of all girls presented after physical abuse. CONCLUSION: In order to eradicate child abuse, awareness of it as to be promoted in the community at large. Because the types of child abuse vary between countries, each requires its own research in order to develop a policy tailored to their particular requirements. In summary, an increased focus on the prevention of violence against children is urgently needed in order to curb the increasing trend of assaults on children. As the causes and risk factors for violence against children vary, multi-disciplinary and multi-sectoral co-operation and collaboration will be required. It is hoped that this report will help raise awareness among health-care practitioners of NAI and its complexities.

Firearm injuries to children in Cape Town, South Africa: impact of the 2004 Firearms Control Act.

BACKGROUND: Before the introduction of the Firearms Control Act in 2004, the epidemiology of childhood firearm injuries from 1991 to 2001 in Cape Town, South Africa, was reported. This study analyses current data as a comparator to assess the impact of the Act. METHODS: Firearm injuries seen at Red Cross War Memorial Children's Hospital, Cape Town, from 2001 to 2010 were respectively reviewed. Data recorded included the patients' folder numbers, gender, date of birth, age, date of presentation, date discharged and inpatient stay, firearm type, number of shots, circumstances, injury sites, injury type, treatment, resulting morbidities and survival. These data were compared with the 1991 - 2001 data. RESULTS: One hundred and sixty-three children presented with firearm injuries during this period. The results showed a decrease in incidence from 2001 to 2010. Older children and males had a higher incidence than younger children and females. Most injuries were to an extremity and were unintentional. Mortality had reduced significantly from the previous study (6% to 2.6%), as did the total number of inpatient days (1 063 to 617). CONCLUSIONS: Compared with the earlier study, this study showed a significant reduction in the number of children presenting with a firearm-related injury. Mortality and inpatient stay were also significantly reduced. The study shows the impact that the Firearms Control Act has had in terms of paediatric firearm-related injury and provides evidence that the medical profession can play an important role in reducing violence.

A comparison of the epidemiology of paediatric burns in Scotland and South Africa.

In South Africa burns affect 3.2% of the population annually and are particularly common among children. In Scotland paediatric burns are generally much less common and less severe. This study aimed to explore the epidemiological differences in the emergency presentation of paediatric burns in the Royal Aberdeen Children's Hospital (RACH) in Scotland and the Red Cross War Memorial Children's Hospital (RXH) in Cape Town. Data was retrieved retrospectively for all paediatric burns presenting in 2009 from RACH patient records and the RXH trauma database. Data was recorded in Microsoft Excel for subsequent statistical analysis. During 2009 RACH received 192 children with burns (1% total emergencies) and RXH received 994 (11% total emergencies). Children ≤ 2 years old were the most commonly injured age group in both centres. At RXH most children came from informal settlements and were of low socioeconomic status, while RACH patients were evenly distributed among all socioeconomic groups. Burn injuries were significantly more likely to present in the evening at both centres (p<0.05), and during Cape Town's winter (p<0.05), but no significant monthly variation occurred in Aberdeen. At RACH most burns involved the hands and were single site (79%) while at RXH most were multiple site (76%) and involved the face. At RACH the commonest modes of injury were scald (45%) and contact burn (43%), while at RXH scalds accounted for the majority (77%). At RACH 89% children were discharged immediately, whereas 49% of RXH patients were admitted to the burn unit. Paediatric burns are more common and generally more severe in Cape Town than in Aberdeen. All children have the right to a safe environment and protection from harm; to reduce the high burns incidence in Cape Town preventative strategies should be targeted at creating safer homes.