Pedi-R-MAPP: The development of a nutritional awareness tool for use in remote paediatric consultations using a modified Delphi consensus.

BACKGROUND & AIMS: The Remote Malnutrition Application (R-MAPP) was developed during the COVID-19 pandemic to provide support for health care professionals (HCPs) working in the community to complete remote nutritional assessments, and provide practical guidance for nutritional care. The aim of this study was to modify the R-MAPP into a version suitable for children, Pediatric Remote Malnutrition Application (Pedi-R-MAPP), and provide a structured approach to completing a nutrition focused assessment as part of a technology enabled care service (TECS) consultation. METHODS: A ten-step process was completed: 1) permission to modify adult R-MAPP, 2) literature search to inform the Pedi-R-MAPP content, 3) Pedi-R-MAPP draft, 4) international survey of HCP practice using TECS, 5) nutrition experts invited to participate in a modified Delphi process, 6) first stakeholder meeting to agree purpose/draft of the tool, 7) round-one online survey, 8) statements with consensus removed from survey, 9) round-two online survey for statements with no consensus and 10) second stakeholder meeting with finalisation of the Pedi-R-MAPP nutrition awareness tool. RESULTS: The international survey completed by 463 HCPs, 55% paediatricians, 38% dietitians, 7% nurses/others. When HCPs were asked to look back over the last 12 months, dietitians (n = 110) reported that 5.7 ± 10.6 out of every 10 appointments were completed in person; compared to paediatricians (n = 182) who reported 7.5 ± 7.0 out of every 10 appointments to be in person (p < 0.0001), with the remainder completed as TECS consultations. Overall, 74 articles were identified and used to develop the Pedi-R-MAPP which included colour-coded advice using a traffic light system; green, amber, red and purple. Eighteen participants agreed to participate in the Delphi consensus and completed both rounds of the modified Delphi survey. Agreement was reached at the first meeting on the purpose and draft sections of the proposed tool. In round-one of the online survey, 86% (n = 89/104) of statements reached consensus, whereas in round-two 12.5% (n = 13/104) of statements reached no consensus. At the second expert meeting, contested statements were discussed until agreement was reached and the Pedi-R-MAPP could be finalised. CONCLUSION: The Pedi-R-MAPP nutrition awareness tool was developed using a modified Delphi consensus. This tool aims to support the technological transformation fast-tracked by the COVID-19 pandemic by providing a structured approach to completing a remote nutrition focused assessment, as well as identifying the frequency of follow up along with those children who may require in-person assessment.

A review of the use of high-flow nasal cannula oxygen therapy in hospitalised children at a regional hospital in the Cape Town Metro, South Africa.

BACKGROUND: High-flow nasal cannula (HFNC) oxygen is a non-invasive alternative to nasal continuous positive airway pressure (CPAP) therapy for infants and children requiring respiratory support. There is a paucity of data to support its use in children, with no published data from sub-Saharan Africa. OBJECTIVES: To describe the outcomes of and adverse events related to HFNC in the first year of its use in a level 2 (L2) general paediatric ward, and to compare these outcomes with those of a historical cohort when this intervention was unavailable. METHODS: This retrospective descriptive study included children aged <13 years who received HFNC in the first 12 months after its introduction (HFNC-availability group, n=66). Demographic data, clinical characteristics and outcomes (death, treatment failure, length of HFNC and HFNC-related adverse events) were assessed. A comparative description of children who required transfer to level 3 (L3) for any form of respiratory support (other than the available standard low-flow oxygen) during the 12-month period prior to HFNC availability (pre-HFNC group, n=54) was made. All analyses were performed in the paediatric wards, New Somerset Hospital, Cape Town, South Africa. Outcomes were compared using standard descriptive and comparative statistics. RESULTS: The median age of the cohort was 5 months (interquartile range (IQR) 1.9 - 14.6). Sixteen children (13.3%) were malnourished, 10 (8.3%) were HIV-infected, and 30 (25.0%) had been born prematurely. The most common diagnoses were pneumonia, bronchiolitis and asthma. Asthma, anaemia and cardiac abnormalities were the most prevalent underlying comorbidities. Two children died in each group. All 54 children in the pre-HFNC group were transferred to L3; 38 (70.4%) needed CPAP or invasive ventilation. In the HFNC-availability period, 85 children were assessed as needing more than standard low-flow oxygen therapy: of the 19 immediately transferred to L3, 17 (89.4%) received CPAP or invasive ventilation; of the 66 who received HFNC at L2, 16 (24.2%) subsequently required transfer to L3 for CPAP or invasive ventilation. The median duration of HFNC was 46.3 hours (IQR 19.5 - 93.5) overall, and it was 12 hours (IQR 4 - 28) and 58.5 hours (IQR 39.5 - 106) for those who failed or were successfully managed on HFNC, respectively. No HFNC-related serious adverse events were recorded. CONCLUSIONS: HFNC is a safe, effective, feasible option for non-invasive ventilation of children with respiratory illnesses in a resource-limited L2 setting. A greater proportion of children with lower respiratory tract infections in the HFNC-availability group than in the pre-HFNC group required support, but the intervention reduced the bed pressure on L3. Improved ways to identify HFNC failures would be beneficial.

Endoscopy findings in HIV-infected children from sub-Saharan Africa.

BACKGROUND: The causes of persistent gastro-intestinal symptoms in HIV-infected children from sub-Saharan Africa remain poorly documented. METHODS: The clinical, radiological and endoscopic findings of all HIV-infected children who underwent upper GI endoscopy at Red Cross Children's Hospital, Cape Town, South Africa, from February 2003 to October 2005 were documented. RESULTS: Twenty-six HIV-infected children underwent endoscopy; median age 1 year (range: 0.17-10.9 years). The majority had advanced HIV disease; 18 (69%) were WHO Stage 4; median CD4 10.7% (range: 1-39.8%). Presenting symptoms included persistent vomiting (18), dysphagia (4) and GIT bleed (6). Observational and histological findings showed poor correlation. Pathogens were identified in 10 children: cytomegalovirus infection in seven (two with cryptosporidium co-infection), Candida in two, Helicobacter pylori in one. Age and CD4 count were not associated with the pathogens. Endoscopy findings influenced clinical management in 21 (81%) cases. CONCLUSION: Upper-GI endoscopy identified a diverse spectrum of disease and provided information that would be clinically relevant to most HIV-infected children with upper gastro-intestinal symptoms.