Electronic Integrated Management of Childhood Illness (eIMCI): a randomized controlled trial to evaluate an electronic clinical decision-making support system for management of sick children in primary health care facilities in South Africa.

BACKGROUND: Electronic clinical decision-making support systems (eCDSS) aim to assist clinicians making complex patient management decisions and improve adherence to evidence-based guidelines. Integrated management of Childhood Illness (IMCI) provides guidelines for management of sick children attending primary health care clinics and is widely implemented globally. An electronic version of IMCI (eIMCI) was developed in South Africa. METHODS: We conducted a cluster randomized controlled trial comparing management of sick children with eIMCI to the management when using paper-based IMCI (pIMCI) in one district in KwaZulu-Natal. From 31 clinics in the district, 15 were randomly assigned to intervention (eIMCI) or control (pIMCI) groups. Computers were deployed in eIMCI clinics, and one IMCI trained nurse was randomly selected to participate from each clinic. eIMCI participants received a one-day computer training, and all participants received a similar three-day IMCI update and two mentoring visits. A quantitative survey was conducted among mothers and sick children attending participating clinics to assess the quality of care provided by IMCI practitioners. Sick child assessments by participants in eIMCI and pIMCI groups were compared to assessment by an IMCI expert. RESULTS: Self-reported computer skills were poor among all nurse participants. IMCI knowledge was similar in both groups. Among 291 enrolled children: 152 were in the eIMCI group; 139 in the pIMCI group. The mean number of enrolled children was 9.7 per clinic (range 7-12). IMCI implementation was sub-optimal in both eIMCI and pIMCI groups. eIMCI consultations took longer than pIMCI consultations (median duration 28 minutes vs 25 minutes; p = 0.02). eIMCI participants were less likely than pIMCI participants to correctly classify children for presenting symptoms, but were more likely to correctly classify for screening conditions, particularly malnutrition. eIMCI participants were less likely to provide all required medications (124/152; 81.6% vs 126/139; 91.6%, p= 0.026), and more likely to prescribe unnecessary medication (48/152; 31.6% vs 20/139; 14.4%, p = 0.004) compared to pIMCI participants. CONCLUSIONS: Implementation of eIMCI failed to improve management of sick children, with poor IMCI implementation in both groups. Further research is needed to understand barriers to comprehensive implementation of both pIMCI and eIMCI. (349) CLINICAL TRIALS REGISTRATION: Clinicaltrials.gov ID: BFC157/19, August 2019.

Patterns of disease on admission to children's wards and changes during a COVID-19 outbreak in KwaZulu-Natal Province, South Africa.

BACKGROUND: Major causes of under-5 child deaths in South Africa (SA) are well recognised, and child mortality rates are falling. The focus of child health is therefore shifting from survival to disease prevention and thriving, but local data on the non-fatal disease burden are limited. Furthermore, COVID-19 has affected children's health and wellbeing, both directly and indirectly. OBJECTIVES: To describe the pattern of disease on admission of children at different levels of care, and assess whether this has been affected by COVID-19. METHODS: Retrospective reviews of children's admission and discharge registers were conducted for all general hospitals in iLembe and uMgungundlovu districts in KwaZulu-Natal Province, SA, from January 2018 to September 2020. The Global Burden of Disease framework was adapted to create a data capture sheet with four broad diagnostic categories and 37 specific cause categories. Monthly admission numbers were recorded per cause category, and basic descriptive analysis was completed in Microsoft Excel. RESULTS: Overall, 36 288 admissions were recorded across 18 hospital wards, 32.0% at district, 49.8% at regional and 18.2% at tertiary level. Communicable diseases, perinatal conditions and nutritional deficiencies (CPNs) accounted for 37.4% of admissions, non-communicable diseases (NCDs) for 43.5% and injuries for 17.1%. The distribution of broad diagnostic categories varied across levels of care, with CPNs being more common at district level and NCDs more common at regional and tertiary levels. Unintentional injuries represented the most common cause category (16.6%), ahead of lower respiratory tract infections (16.1%), neurological conditions (13.6%) and diarrhoeal disease (8.4%). The start of the local COVID-19 outbreak coincided with a 43.1% decline in the mean number of monthly admissions. Admissions due to neonatal conditions and intentional injuries remained constant during the COVID-19 outbreak, while those due to other disease groups (particularly respiratory infections) declined. CONCLUSIONS: Our study confirms previous concerns around a high burden of childhood injuries in our context. Continued efforts are needed to prevent and treat traditional neonatal and childhood illnesses. Concurrently, the management of NCDs should be prioritised, and evidence-based strategies are sorely needed to address the high injury burden in SA.

Introducing an Ethics Framework for health priority-setting in South Africa on the path to universal health coverage.

BACKGROUND: South Africa (SA) has embarked on a process to implement universal health coverage (UHC) funded by National Health Insurance (NHI). The 2019 NHI Bill proposes creation of a health technology assessment (HTA) body to inform decisions about which interventions NHI funds will cover under UHC. In practice, HTA often relies mainly on economic evaluations of cost-effectiveness and budget impact, with less attention to the systematic, specific consideration of important social, organisational and ethical impacts of the health technology in question. In this context, the South African Values and Ethics for Universal Health Coverage (SAVE-UHC) research project recognised an opportunity to help shape the health priority-setting process by providing a way to take account of multiple, ethically relevant considerations that reflect SA values. The SAVE-UHC Research Team developed and tested an SA-specific Ethics Framework for HTA assessment and analysis. OBJECTIVES: To develop and test an Ethics Framework for use in the SA context for health priority-setting. METHODS: The Framework was developed iteratively by the authors and a multidisciplinary panel (18 participants) over a period of 18 months, using the principles outlined in the 2015 NHI White Paper as a starting point. The provisional Ethics Framework was then tested with multi-stakeholder simulated appraisal committees (SACs) in three provinces. The membership of each SAC roughly reflected the composition of a potential SA HTA committee. The deliberations and dedicated focus group discussions after each SAC meeting were recorded, analysed and used to refine the Framework, which was presented to the Working Group for review, comment and final approval. RESULTS: This article describes the 12 domains of the Framework. The first four (Burden of the Health Condition, Expected Health Benefits and Harms, Cost-Effectiveness Analysis, and Budget Impact) are commonly used in HTA assessments, and a further eight cover the other ethical domains. These are Equity, Respect and Dignity, Impacts on Personal Financial Situation, Forming and Maintaining Important Personal Relationships, Ease of Suffering, Impact on Safety and Security, Solidarity and Social Cohesion, and Systems Factors and Constraints. In each domain are questions and prompts to enable use of the Framework by both analysts and assessors. Issues that arose, such as weighting of the domains and the availability of SA evidence, were discussed by the SACs. CONCLUSIONS: The Ethics Framework is intended for use in priority-setting within an HTA process. The Framework was well accepted by a diverse group of stakeholders. The final version will be a useful tool not only for HTA and other priority-setting processes in SA, but also for future efforts to create HTA methods in SA and elsewhere.

Parental access to hospitalised children during infectious disease pandemics such as COVID-19.

The COVID-19 pandemic has resulted in many hospitals severely limiting or denying parents access to their hospitalised children. This article provides guidance for hospital managers, healthcare staff, district-level managers and provincial managers on parental access to hospitalised children during a pandemic such as COVID-19. It: (i) summarises legal and ethical issues around parental visitation rights; (ii) highlights four guiding principles; (iii) provides 10 practical recommendations to facilitate safe parental access to hospitalised children; (iv) highlights additional considerations if the mother is COVID-19-positive; and (v) provides considerations for fathers. In summary, it is a child's right to have access to his or her parents during hospitalisation, and parents should have access to their hospitalised children; during an infectious disease pandemic such as COVID-19, there is a responsibility to ensure that parental visitation is implemented in a reasonable and safe manner. Separation should only occur in exceptional circumstances, e.g. if adequate in-hospital facilities do not exist to jointly accommodate the parent/caregiver and the newborn/infant/child. Both parents should be allowed access to hospitalised children, under strict infection prevention and control (IPC) measures and with implementation of non-pharmaceutical interventions (NPIs), including handwashing/sanitisation, face masks and physical distancing. Newborns/infants and their parents/caregivers have a reasonably high likelihood of having similar COVID-19 status, and should be managed as a dyad rather than as individuals. Every hospital should provide lodger/boarder facilities for mothers who are COVID-19-positive, COVID-19-negative or persons under investigation (PUI), separately, with stringent IPC measures and NPIs. If facilities are limited, breastfeeding mothers should be prioritised, in the following order: (i) COVID-19-negative; (ii) COVID-19 PUI; and (iii) COVID-19-positive. Breastfeeding, or breastmilk feeding, should be promoted, supported and protected, and skin-to-skin care of newborns with the mother/caregiver (with IPC measures) should be discussed and practised as far as possible. Surgical masks should be provided to all parents/caregivers and replaced daily throughout the hospital stay. Parents should be referred to social services and local community resources to ensure that multidisciplinary support is provided. Hospitals should develop individual-level policies and share these with staff and parents. Additionally, hospitals should ideally track the effect of parental visitation rights on hospital-based COVID-19 outbreaks, the mental health of hospitalised children, and their rate of recovery.

Child health services during a COVID-19 outbreak in KwaZulu-Natal Province, South Africa.

BACKGROUND: Current evidence indicates that children are relatively spared from direct COVID-19-related morbidity and mortality, but that the indirect effects of the pandemic pose significant risks to their health and wellbeing. OBJECTIVES: To assess the impact of the local COVID-19 outbreak on routine child health services. METHODS: The District Health Information System data set for KwaZulu-Natal (KZN) provincial health services was accessed, and monthly child health-related data were extracted for the period January 2018 - June 2020. Chronological and geographical variations in sentinel indicators for service access, service delivery and the wellbeing of children were assessed. RESULTS: During April - June 2020, following the start of the COVID-19 outbreak in KZN, significant declines were seen for clinic attendance (36%; p=0.001) and hospital admissions (50%; p=0.005) of children aged <5 years, with a modest recovery in clinic attendance only. Among service delivery indicators, immunisation coverage recovered most rapidly, with vitamin A supplementation, deworming and food supplementation remaining low. Changes were less pronounced for in- and out-of-hospital births and uptake rates of infant polymerase chain reaction testing for HIV at birth, albeit with wide interdistrict variations, indicating inequalities in access to and provision of maternal and neonatal care. A temporary 47% increase in neonatal facility deaths was reported in May 2020 that could potentially be attributed to COVID-19-related disruption and diversion of health resources. CONCLUSIONS: Multiple indicators demonstrated disruption in service access, service delivery and child wellbeing. Further studies are needed to establish the intermediate- and long-term impact of the COVID-19 outbreak on child health, as well as strategies to mitigate these.

Child health services during a COVID-19 outbreak in KwaZulu-Natal Province, South Africa.

BACKGROUND: Current evidence indicates that children are relatively spared from direct COVID-19-related morbidity and mortality, but that the indirect effects of the pandemic pose significant risks to their health and wellbeing. OBJECTIVES: To assess the impact of the local COVID-19 outbreak on routine child health services. METHODS: The District Health Information System data set for KwaZulu-Natal (KZN) provincial health services was accessed, and monthly child health-related data were extracted for the period January 2018 - June 2020. Chronological and geographical variations in sentinel indicators for service access, service delivery and the wellbeing of children were assessed. RESULTS: During April - June 2020, following the start of the COVID-19 outbreak in KZN, significant declines were seen for clinic attendance (36%; p=0.001) and hospital admissions (50%; p=0.005) of children aged <5 years, with a modest recovery in clinic attendance only. Among service delivery indicators, immunisation coverage recovered most rapidly, with vitamin A supplementation, deworming and food supplementation remaining low. Changes were less pronounced for in- and out-of-hospital births and uptake rates of infant polymerase chain reaction testing for HIV at birth, albeit with wide interdistrict variations, indicating inequalities in access to and provision of maternal and neonatal care. A temporary 47% increase in neonatal facility deaths was reported in May 2020 that could potentially be attributed to COVID-19-related disruption and diversion of health resources. CONCLUSIONS: Multiple indicators demonstrated disruption in service access, service delivery and child wellbeing. Further studies are needed to establish the intermediate- and long-term impacts of the COVID-19 outbreak on child health, as well as strategies to mitigate these.

A health systems strengthening intervention to improve quality of care for sick and small newborn infants: results from an evaluation in district hospitals in KwaZulu-Natal, South Africa.

BACKGROUND: Many newborn infants die from preventable causes in South Africa, often these deaths occur in district hospitals. A multipronged intervention aiming to improve quality of newborn care in district hospitals was implemented comprising training in clinical care for sick and small newborns, skills development for health managers, on-site mentoring, and hospital accreditation. We present the results of the project evaluation. METHODS: We conducted three sequential cross-sectional surveys in 39 participating district hospitals at baseline, midpoint and endpoint of the three-year intervention period. Data were collected by a trained midwife using a series of checklists including: availability of trained staff, drugs and equipment; newborn care practices; perinatal mortality audits; neonatal unit staff skills; quality of record keeping. A scoring system was developed for three domains: resources; care practices; resuscitation equipment, and a composite score that included all variables measured. Health worker (HW) knowledge was assessed at midpoint and endpoint. RESULTS: The average score for resources increased from 13.5 at baseline to 22.6 at endpoint (maximum score 34), for care practices from 17.7 to 22.6 (maximum score 29), and for resuscitation equipment from 10.8 to 16.1 (maximum 25). Average composite score improved significantly from 42.0 at baseline to 55.7 at midpoint to 60.7 at endpoint (maximum score 88) (p = 0.0012). Among 39 participating hospitals, 38 achieved higher scores at endpoint compared to baseline. Knowledge was higher among HWs trained during the project at midpoint and endpoint. Gaps that remained included poor infrastructure, lack of resuscitation equipment in some areas, poor postnatal care and lack of a dedicated doctor. CONCLUSIONS: This intervention achieved measurable improvements in many important elements contributing to newborn care. A scoring system was used to track progress, compare facilities' performance, and identify areas for improvement. Various methods were used to generate the quality of care score, including skills assessment and record reviews. However, measuring quality of clinical care and outcomes was challenging, and we were unable to determine whether the intervention improved clinical care and lead directly to improved outcomes for babies. In developing a future score for quality of care, a stronger focus should be placed on assessing clinical care and outcomes.

Neonatal, infant and child health in South Africa: Reflecting on the past towards a better future.

Although the neonatal mortality rate in South Africa (SA) has remained stagnant at 12 deaths per 1 000 live births, the infant and under-5 mortality rates have significantly declined since peaking in 2003. Policy changes that have influenced this decline include policies to prevent vertical HIV transmission, earlier treatment of children living with HIV, expanded immunisation policies, strengthening breastfeeding practices, and health policies to contain tobacco and sugar use. The Sustainable Development Goals (2016 - 2030) have shifted the focus from keeping children alive, as expressed in the Millennium Development Goals (1990 - 2015), to achieving optimal health through the 'Survive, thrive and transform' global agenda. This paper focuses on important remaining causes of childhood mortality and morbidity in SA, specifically respiratory illness, environmental pollution, tuberculosis, malnutrition and vaccine-preventable conditions. The monitoring of maternal and child health (MCH) outcomes is crucial, and has improved in SA through both the District Health Information and Civil Registration and Vital Statistics systems, although gaps remain. Intermittent surveys and research augment the routinely collected data. However, availability and use of local data to inform quality and effectiveness of care is critical, and this requires ownership at the collection point to facilitate local redress. Potential game changers to improve MCH outcomes include mobile health and community-based interventions. In SA, improved MCH remains a crucial factor for human capital development. There is a pressing need to focus beyond childhood mortality and to ensure that each child thrives.

A study of self-reported handwashing practices of caregivers in relation to acute respiratory infections and gastroenteritis in infants in a peri-urban community in KwaZulu-Natal Province, South Africa

Background. Handwashing is a recognised cost-effective intervention for the prevention of common childhoodinfections, including pneumonia and diarrhoeal disease. Globally, handwashing practices may be poor and little is known about handwashing practices in South Africa.Objectives. To describe and compare handwashing practises of caregivers whose infants are admitted with acute gastroenteritis and acute lower respiratory tract infection with those of healthy infants who are attending primary healthcare clinics for routine immunisation.Methods. A cross-sectional study of self-reported handwashing practices was conducted among caregivers of infants from the Vulindlela area,Pietermaritzburg. Respondents were interviewed regarding household structure, services and handwashing practices.Results. During the 3-month study period, 137 respondents were interviewed. Of these, 41 (30%) had infants with pneumonia, 41 (30%) with diarrhoea and 55 (40%) had healthy infants. A high rate of handwashing with soap and water (81.8%) was found in this study, with 58.4% of the respondents using running rather than stagnant water. Logistic regression identified some variables associated with higher odds of having a healthy infant, namely: a monthlyhousehold income >ZAR2 000 (odds ratio (OR) 4.74; 95% confidence interval (CI)1.99 - 11.25); washing hands with soap and running water (OR 3.88; 95% CI 1.55 - 9.76); washing hands before eating (OR 7.41; 95% CI 0.79 - 68.76), and washing hands after household chores (OR 9.24; 95% CI 1.85 - 46.25).Conclusion. A higher than anticipated number of participants washed their hands with soap and running water and at critical moments

Short-term outcomes of infants with an extremely low birth weight in a resource-limited neonatal intensive care unit, Grey's Hospital, KwaZulu-Natal

Background. Neonates with an extremely low birth weight (ELBW) constitute a small proportion of live births. However, there is limited information about the outcome of this specific group in developing countries, including South Africa (SA). Objective. To determine the outcome to discharge of ELBW neonates admitted to a resource-limited neonatal intensive care unit (NICU). Methods. A retrospective chart review was conducted of neonates admitted to the NICU at Grey's Hospital between 1 July 2011 and 30 June 2014. All neonates with a birth weight of <1 000 g and admitted to the unit within 24 hours of birth were included. Results. A total of 142 neonates met the inclusion criteria. Owing to lost files or incomplete data, 105 files were analysed in the final sample. The mean birth weight was 819.1 g and the mean gestational age was 27.5 weeks. The survival rate to discharge was 49.5%. Neonates born after 28 weeks of gestation and those with a birth weight of >900 g had better outcomes but without statistical significance. There were no statistically significant associations between outcome and any maternal variables. Nasal continuous positive airway pressure ventilation was associated with higher survival, but without statistical significance. Conclusion. The survival rate of ELBW neonates in this study is comparable to what has been reported in other developing countries, but higher than for other NICUs in SA with similar resource limitations. More studies are required to determine factors that may influence the survival rate of the ELBW neonates

Factors underlying the changing of antibiotics in a paediatric intensive care unit in Pietermaritzburg, KwaZulu-Natal

Background. Antibiotics are among the most commonly used drugs in a paediatric intensive care unit (PICU). Despite guidelines and protocols for the use of antibiotics, inappropriate use may contribute to an increase in antibiotic resistance. The factors behind changes in antibiotic prescriptions in the PICU at Grey's Hospital are unknown. Objective. To establish the frequency, process and rationale behind antibiotic prescription changes in the picu. Methods. A retrospective descriptive study of all eligible patients admitted to the PICU during a 6-month period.Results. Three-quarters of patients admitted to the PICU received antibiotics during their stay. The ofantibiotic prescription was changed in 80 (58%) of the138 patients, with most changes (63.4%) occurring within 3 days of admission. Patients younger than 1 year and those who were malnourished accounted for 57% of the changes. The majority (65%) of the changes entailed the escalation of antibiotics and 89% of these were empiric therapy. De-escalation accounted for 35% of the changes. The rationale for a prescription change was not documented in 80% of cases.Conclusion. Antibiotic use in this PICU and changes to prescriptions were common. Changes were generally made on an empirical basis soon after admission and were more likely to occur in young malnourished children and patients admitted for a medical reason or surgical emergency

Factors Present on Admission Associated with Increased Mortality in Children Admitted to a Paediatric Intensive Care Unit (PICU)

Background. The admission of children to an intensive care unit (ICU) necessitates the selection of children who will benefit most from scarce ICU resources. Decisions should be based on objective data available on outcomes related to particular conditions and resource availability. Objective. To determine which sociodemographic factors and paediatric scoring systems can be used on admission to identify patients who would derive the most benefit.Methods. A retrospective review was undertaken of the charts of children admitted to a paediatric ICU (PICU) over a 6-month period. Charts were analysed according to health status; biographical and demographic data; as well as Pediatric Risk of Mortality (PRISM); Pediatric Logistic Organ Dysfunction (PELOD) and Paediatric Index of Mortality 3 (PIM3) scores to determine which factors were associated with an increased mortality risk.Results. Two hundred and two children were admitted during the study period. Ninety-six children were included in the study; 79 files were not found and 27 children were ineligible. The median age was 14 months and the mortality rate was 15.6%. The significant factor associated with mortality was severe malnutrition. In total 88% of required data were available for the calculation of both the PRISM and PELOD scores and 95% for PIM3 score. The PRISM; PELOD and PIM3 standardised mortality ratios were 2.5; 4.8 and 2.9; respectively. P-values for PRISM; PELOD and PIM3 were 0.05.Conclusion. Severe malnutrition is a statistically significant factor in predicting mortality. This possibly reflects the social context in which the children live. PRISM; PELOD and PIM3 underpredict mortality in our setting. A larger sample is required to verify these outcomes and to determine whether other factors play a role

The Existence of Policies; Practices and Perceptions Regarding Children as Visitors to Public Hospitals in uMgungundlovu; KwaZulu-Natal Province

Background. Current policies and practices regarding child visitors in hospitals in uMgungundlovu; KwaZulu-Natal Province; South Africa; are unknown. Existing literature focuses on provision for child visitors in specialised units in well-resourced countries.Objective. To identify policies; describe current practices and determine the perceptions of healthcare workers to child visitors.Methods. Interviews were conducted with 7 nursing managers regarding the existence and content of a hospital visitors' policy; 12 operational managers (OMs) to describe ward practices regarding child visitors; and 12 professional nurses and 11 doctors to determine their attitudes towards children as visitors in all four general state hospitals in uMgungundlovu between October 2013 and July 2015.Results. Five out of seven nursing managers were aware of a visitors' policy in their hospital. These policies allowed children to visit family or parents in adult wards; but only 2 would allow children to visit a family member and only 1 would allow visits to a friend in the children's wards. According to the nursing managers; policy was that the visitor must be over 5 years of age to visit in an adult ward while 2 out of 3 nursing managers allowed only children over 12 years of age to visit in children's wards. Visits must occur during prescribed visiting times and the visitor must be accompanied by an adult. In practice; 7 out of 12 OMs allow child visitors in their wards. Only 2 out of 7 OMs allow unrestricted visitation by children and only to non-infectious patients in children's wards - this is subject to variable age restrictions in adult wards and an age limit of 12 years in children's wards. In all wards; visits by children are restricted to prescribed visiting times and conditional on an adult escort. Three out of seven OMs allow 2 visitors only; although most (5 out of 7) allow visits of unlimited duration. Staff who favoured child visitors were more likely to be younger; male and employed as health professionals for 5 years. More doctors than nurses believed that children should be allowed to visit family and/or friends in hospital. Justifications for not allowing children to visit centred on infection risks and the emotional trauma of visiting a sick loved one. The child; patient and health professional were seen to benefit socially from child visitors; although there are positive and negative emotional consequences for the patient and the child.Conclusion. Hospitals do make provisions for visitors; but most exclude young children; particularly those who are most vulnerable to the negative consequences of separation from a parent or family member. While policies do exist to guide child visitation in uMgungundlovu; such policies are restrictive; inconsistent and do not necessarily reflect day-to-day practices

A Retrospective Review of the Transfer of Critically ill Children to Tertiary Care in KwaZulu-Natal; South Africa

Background. Obtaining care for an acutely ill child in specialised paediatric services relies on referral from lower-level facilities. In South Africa; it is common practice for acutely ill children to be transported far distances by non-specialist teams with limited equipment; knowledge and skills. Objectives. To describe the transfer of these children and to determine whether they deteriorate from the time of referral to the time of arrival at a tertiary centre. Furthermore; we sought to identify modifiable factors that might improve outcomes during resuscitation and transfer. Methods. The study was a retrospective review of emergency referrals of children aged 1 month - 12 years to Grey's Hospital paediatric ward or paediatric intensive care unit (PICU); from lower-level facilities in KwaZulu-Natal between January and June 2012. In conjunction with an assessment by the receiving clinician at Grey's Hospital; Triage Early Warning Signs (TEWS) scores were obtained during telephonic referral and compared with the TEWS score on arrival in order to determine if a deterioration had occurred.Results. A total of 57 PICU referrals and 79 ward referrals were analysed. The mortality rate prior to transportation was 8.8%. Mean transfer distance was 131 km and mean transfer time 9 hours. Advanced life support teams undertook transportation in 76.7% of PICU and 25% of ward transfers and few adverse events were reported in transfer logs. However; 31.5% of PICU and 11.3% of ward referrals required immediate resuscitation on arrival. When the TEWS scoring system was applied 78.5% of PICU and 30.4% of ward referrals fell into the 'very urgent' and 'emergency' categories. Conclusion. Pretransport and in-transit care failed to stabilise children and this may reflect lack of skill of attending healthcare workers; transport delays or illness progression. Interventions to improve resuscitation and transfer are needed; and the use of retrieval teams should be investigated

Hospital-Acquired Klebsiella Pneumoniae Infections in a Paediatric Intensive Care Unit

Background. Hospital-acquired infections (HAI) are a significant problem in the delivery of intensive care services. Each nosocomial infection prolongs an affected patient's stay in hospital by 5 - 10 days. Methods. A retrospective case control chart review of children admitted to the paediatric intensive care unit (PICU) in Grey's Hospital between July 2003 and December 2010; who developed a hospital-acquired Klebsiella pneumoniae infection; was undertaken to describe the trend in HAI in a newly commissioned PICU and to identify any association with the patient demographics and modalities of care. Patients with a K. pneumoniae infection were identified through the PICU infection control surveillance system. Each case was matched to a control of the same age admitted during the same period; with a similar clinical diagnosis. Results. During the 7.5-year period; 2 266 children 12 years of age were admitted to the PICU. Of these; 113 had K. pneumoniae cultured from a body fluid 48 h after admission; including 23 cultured from the blood. Clinical records were obtained for 14 of these patients and matched to control cases of similar age and gender who were admitted at the same time. The length of stay in both the PICU and hospital was longer in children with an HAI compared with the control group (3.7 v. 2.9 and 18.5 v. 9.14; respectively; p=0.04). There was no significant difference in the treatment modalities provided to the two groups; although most patients in the sample group required invasive treatment. Conclusion. K. pneumoniae nosocomial infection was a significant problem encountered in Grey's Hospital paediatric intensive care. It has major cost implications; as it prolongs the length of stay in intensive care and hospital

Guideline for the prevention, screening and treatment of retinopathy of prematurity (ROP).

BACKGROUND: Retinopathy of prematurity (ROP), one of the most common causes of preventable blindness in preterm neonates, is emerging as a 'third epidemic' in middle-income countries including South Africa. This is due to the increasing survival of preterm neonates, insufficient monitoring of oxygen saturation (SaO2) in most centres, and lack of an ROP screening guideline in most neonatal units. OBJECTIVE: To guide the standard of care for SaO2 and ROP screening in preterm neonates weighing <1 500 g. VALIDATION: This guideline, endorsed by the United South African Neonatal Association (USANA), the Ophthalmological Society of South Africa (OSSA), and the South African Vitreoretinal Society, was developed by the ROP Working Group of South Africa, comprised of neonatologists, ophthalmologists and paediatricians. RECOMMENDATIONS: All healthcare professionals involved in the care of preterm neonates should be aware of SaO2 and ROP screening guidelines. Mothers should be counselled about the possible complications of prematurity.

Biochemical and molecular diagnosis of glutaric aciduria type 1 in a black South African male child: case report.

Glutaric aciduria type 1 (GA-1) is an inborn error of metabolism caused by a deficiency of the mitochondrial enzyme glutaryl-Co enzyme A dehydrogenase. GA-1 is not uncommon amongst Caucasians but to the best of our knowledge, it has previously not been reported in black African children. We present a case of GA-1 in a black South African boy who was referred to hospital at the age of five years and ten 10 months with dyskinesia and dystonia accompanied by chorea and athetosis. Radiological examination revealed enlarged basal cisterns with bilateral fluid collection around the sylvian fissures suggestive of GA-1. Analysis of urine showed raised levels of glutaric acid at 520 micromol/mmol creatinine (normal <2.0), 3-hydroxyglutaric acid at 113 micromol/mmol creatinine (normal <3.0) and a low blood carnitine level of 31.5 micromol/l (normal 35-84). A definitive diagnosis was reached through DNA analysis which revealed homozygosity for an A293T mutation in the glutaryl-Co-enzyme A dehydrogenase (GCDH) gene.

Hepatitis B infection in black children from residential care facilities in KwaZulu-Natal. Implications for adoption and foster care.

OBJECTIVES: A study was undertaken to assess the prevalence of hepatitis B infection in selected residential child care facilities in Natal. DESIGN: All residents at three facilities in the Durban and Pietermaritzburg areas of KwaZulu-Natal were tested for markers of hepatitis B infection as part of a broader health status assessment. RESULTS: One hundred and ninety-five children between the ages of 3 and 194 months (78 +/- 47) were studied. Overall 66.2% of children had evidence of past exposure to hepatitis B virus. Of these 14.9% were positive for hepatitis B surface antigen, 13.3% for hepatitis B e antigen, 47.7% for hepatitis B surface antibody and 59.5% for hepatitis B core antibody. Relative rates of infection increased with age from 18.2%, 20% and 27.8% in the 1st, 2nd and 3rd years of life respectively to 72.2% and 88.2% in the 4th and 5th years of life. Relative rates of infection increased with duration of stay from 40% by the end of the 1st year to 100% by the end of the 5th year. CONCLUSIONS: This study has demonstrated a very high rate of infection with hepatitis B virus and a high prevalence of hepatitis B surface antigenaemia in residential care facilities. It has also shown that the infection is horizontally transmitted within these facilities, that infection increases with duration of stay, that there is a dramatic increase in infection rates after the 3rd year of life, that the highest carrier rates are occurring in children between the ages of 2 and 4 years, and that the vast majority of carriers are highly infectious. These children are not only at risk themselves for the long-term complications of this disease but also constitute an important reservoir of hepatitis B infection within the larger community. There is an urgent need for uniform national guidelines for the screening and management of children in residential care facilities and children being prepared for adoption or foster care. There is also a need for a wider investigation into conditions at residential care facilities previously designated for black children in this country.