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.

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.

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.

Distribution of blood lead levels in schoolchildren in selected Cape Peninsula suburbs subsequent to reductions in petrol lead.

OBJECTIVE: To determine blood lead levels among children attending schools in selected Cape Peninsula suburbs, and to assess the impact of a reduction in the lead content of petrol. DESIGN: A cross-sectional analytical study of children's blood lead levels and associated risk factors. SETTING: Selected inner city, suburban, and peri-urban schools in the Cape Peninsula, expected to have differing levels of environmental exposure to lead. SUBJECTS: Grade 1 schoolchildren for whom prior written parental consent had been obtained, and who were present at school on the day of the study. OUTCOME MEASURES: Blood lead levels (microgram/dl), associated with a wide range of potential risk factors. RESULTS: Median blood lead levels in suburbs varied from 14 to 16 micrograms/dl, the lowest levels occurring in the peri-urban suburb and the highest in the inner city suburb. Within the inner city suburb of Woodstock, variations in mean blood lead concentrations among schools were substantial, varying from 13 to 19 micrograms/dl. Overall, no change occurred in blood lead levels in this suburb subsequent to the lowering of the lead content of petrol. CONCLUSION: Every effort should be made in South Africa to control sources of lead in the urban environment. The study will serve as a useful baseline against which to measure the impact on blood lead levels of further actions which have been taken to promote the use of lead-free petrol in South Africa.

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.

Carriage of Haemophilus influenzae in Cape Town children.

Little is known about the epidemiology of Haemophilus influenzae infections in South Africa. This study was designed to determine the prevalence, serotype distribution, antimicrobial susceptibility pattern and effect of age and hospitalisation on the carriage of H. influenzae in 322 Cape Town children. The overall and type b specific carriage rates in normal children (N = 107) were 45.8% and 4.7% respectively. The yield following nasopharyngeal culture was twice that following throat culture (P < 0.001). Children hospitalised with tuberculosis (N = 62) had significantly greater carriage rates, 66.1% and 37.1% respectively (P = 0.02). Institutionalised mentally handicapped children (N = 77) and children with tuberculosis attending an outpatient clinic (N = 76) had lower carriage rates (P < 0.02). Antimicrobial resistance was a major problem only in children hospitalised with tuberculosis (rifampicin 100%, penicillin 43.9%, erythromycin 85.4%, co-trimoxazole 82.9%). This universal resistance to rifampicin has not been reported previously. There was no difference in the mean age of children with positive or negative cultures, with the exception of those hospitalised with tuberculosis. In this group children infected with type b were much younger (mean 19.7 months) than those with other and non-typeable infections (32.1 months) and the non-infected (50.1 months) (P = 0.04). Duration of hospitalisation or outpatient therapy in the patients with tuberculosis did not influence carriage rates.(ABSTRACT TRUNCATED AT 250 WORDS)

Childhood tuberculosis and tuberculous meningitis: high incidence rates in the Western Cape of South Africa.

In recent years higher incidence rates of tuberculosis (TB) have been reported from the Western Cape than from other health regions of South Africa. In contrast to the various pulmonary forms of tuberculosis, tuberculous meningitis (TBM) always requires hospital admission, and can thus be used as an indicator of the extent of the infection in a community, as well as providing a measure of the effectiveness of primary and secondary preventive measures. In the present study an attempt was made to identify all cases of tuberculous meningitis aged 14 years and younger which occurred in the region, by checking notifications and the records of all hospitals, and verifying diagnosis against set criteria. Rates for the entire period were calculated according to updated census data. There was a total of 689 confirmed cases, of which only 55% had been notified. Of the 238 cases confirmed in the 3-years period, 1985-1987, 25.2% were under 1 year, 51.7% under 2 years, and 79.8% under 5 years of age. Age-specific incidence per 100,000 children were respectively 31.5 (0-1 years), 17.1 (1-4 years), 4.8 (5-9 years), and 0.7 (10-14 years). Rates in rural areas were far higher than in metropolitan regions. Utilizing tuberculin test data and total notifications, the following risks could be calculated for 'Coloured' children (of mixed race) aged 0-4 years: 2-3% annual risk of infection; 15.7% risk of TB in infected population; 0.5% risk of TBM in infected population; 0.9% risk of TB in children aged 5-14 years; 0.01% risk of TBM in children aged 5-14 years.

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.

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.

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.

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.