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The COVID-19 pandemic necessitated rapid changes in healthcare systems and at Red Cross War Memorial Children's Hospital (RCWMCH), Cape Town, South Africa. Paediatric services in particular required adjustment, not only for the paediatric patients but also for their carers and the staff looking after them. Strategies were divided into streams, including the impact of COVID-19 on the hospital and the role of RCWMCH in Western Cape Province, communication strategies, adaptation of clinical services at the hospital, specifically with a paediatric-friendly approach, and staff engagement. Interventions utilised: (i) Specific COVID-19 planning was required at a children's hospital, and lessons were learnt from other international children's hospitals. A similar number of patients and staff were infected by the virus (244 patients and 212 staff members by 21 December 2020). (ii) Measures were put in place to assist creation of capacity at metro hospitals' adult services by accepting children with emergency issues directly to RCWMCH, as well as accepting adolescents up to age 18 years. (iii) The communication strategy was improved to include daily engagement with heads of departments/supervisors by earlymorning structured information meetings. There were also changes in the methods of communication with staff using media such as Zoom, MS Teams and WhatsApp. Hospital-wide information and discussion sessions were held both on social platforms and in the form of smallgroup physical meetings with senior hospital administrators (with appropriate distancing). Labour union representatives were purposefully directly engaged to assess concerns. (iv) Clinical services at the hospital were adapted. These included paediatric-friendly services and physical changes to the hospital environment. (v) Staff engagement was particularly important to assist in allaying staff anxiety, developing a staff screening programme, and provision and training in use of personal protective equipment, as well as focusing on staff wellness. In conclusion, visible management and leadership has allowed for flexibility and adaptability to manage clinical services in various contexts. It is important to utilise staff in different roles during a crisis and to consider the different perspectives of people involved in the services. The key to success, that included very early adoption of the above measures, has been hospital staff taking initiative, searching for answers and identifying and implementing solutions, effective communication, and leadership support. These lessons are useful in dealing with second and further waves of the COVID-19 pandemic.

Background: Paediatric intensive care is a costly, specialised and limited resource in low- and middle-income countries. The implications of extended paediatric intensive care unit (PICU) stay in South Africa (SA) are not known., Objectives: To describe the characteristics, outcomes and resource consumption of long-stay patients (LSPs) and to identify predictive factors for long PICU stay., Methods: A retrospective review of routinely collected data on all children admitted to an SA PICU over one calendar year. Long PICU stay was defined statistically as >19 days. Long- and short-stay patient (SSP) groups were compared, and variables significantly associated with long stay on univariate analysis were entered into a stepwise multiple regression model., Results: Over the study period, 1 126 children (median age 8 months, 60.9% male) were admitted to the PICU, occupying 5 936 bed-days; 54  LSPs (4.8%) utilised 1 807 (30.4%) bed-days. Mortality and the standardised mortality ratio (actual/mean predicted mortality) in LSPs and SSPs were 29.6% v. 12% (p=0.002) and 2.4 v. 0.7 (p=0.002), respectively. Median duration of stay for LSPs and SSPs was 29.5 days and 2 days, respectively (p<0.0001). LSPs were younger than SSPs (median 4 months (interquartile range 2 - 17) v. 9 months (2 - 34); p=0.03), and fewer were male (48% v. 61.6%, p=0.049). On multivariate analysis, only female gender was independently associated with long PICU stay., Conclusions: LSPs represent a small proportion of PICU admissions, yet have a higher mortality rate than SSPs and consume disproportionate PICU resources. No predictive model could be established for early recognition of potential LSPs to plan PICU bed allocation effectively.

Objective: Ventilator-associated pneumonia (VAP) has been poorly studied in South Africa, but is likely to be a significant problem, with resulting increased morbidity and mortality in the paediatric intensive care unit population. This guideline is intended to review the evidence and recommendations for prevention and management of VAP in children and to provide, where possible, clear advice to aid the care of these children, to limit costly and unnecessary therapies and--importantly--limit inappropriate use of antimicrobial agents,, Evidence: The Working Group was constituted. Literature on the aetiology, prevention and management of paediatric VAP is reviewed., Recommendations: Evidence-based clinical practice guidelines are provided for VAP diagnosis and prevention in South Africa. In addition, the current status of antimicrobial use has been reviewed and clear recommendations are set out.

The effect of initiating phototherapy at three different bilirubin concentrations in infants with physiological jaundice was studied in 98 clinically jaundiced term infants. Phototherapy was initiated at levels of 170, 257 and 300 mumol/l in groups A, B and C respectively. There was no difference between the groups in terms of days in hospital and bilirubin levels at entry or at exit from the study. Of group A, 97% received phototherapy v. 47% and 18% in groups B and C respectively. Peak bilirubin in those infants in group C receiving phototherapy was 318 mumol/l v. 282 mumol/l and 229 mumol/l in groups A and B. Two group C infants suffered complications of hyperbilirubinaemia. Rebound hyperbilirubinaemia was noted in infants with more severe jaundice after cessation of phototherapy. The threshold for toxicity in non-haemolytic hyperbilirubinaemia may be higher than the still widely accepted 340 mumol/l value, but pending definitive studies phototherapy will continue to be initiated at levels of greater than 257 mumol/l in term infants with hyperbilirubinaemia.

A newborn baby with acute respiratory distress caused by tension haemothorax is described. An abnormal clotting profile indicated that the haemothorax was possibly due to a clotting deficiency. Ultrasonography was useful in establishing that the cause of the radio-opacity was fluid. The baby's problem was rapidly resolved by drainage and blood transfusion.

Eosinophilia within the first 6 weeks of life was studied prospectively in 10 premature neonates. Mean birthweight was 1229 +/- 314 g, and mean gestational age 31.5 +/- 1.8 weeks. Simultaneous changes in eosinophil, neutrophil, total lymphocyte, suppressor and helper T-cell counts and IgE levels were monitored. Infants were designated as responders (eosinophils greater than 1000/microliter for greater than 5 days) and non-responders. In the 6 responders eosinophils increased from 353 +/- 76 (mean +/- SEM) at birth to a peak of 2783 +/- 430/microliter at 20-25 days. Responders had significantly lower neutrophil counts at birth (P less than 0.05), and in 5 of the 6 responders neutrophils increased by more than 100% within 10-15 days; this did not occur in any of the 4 non-responders (P less than 0.025). Lymphocytes and suppressor and helper T cells increased progressively in both groups over the period of study with no differences between responders and non-responders. Birthweight and gestational age were similar in both groups, and there were no apparent causes for the lower neutrophil counts in responders at birth. Eosinophilia was not related to an IgE response. The incidence of eosinophilia in this study is similar to that reported previously, and appears to be part of a biphasic granulopoietic response.

Twenty newborn infants with birth asphyxia were alternately assigned to ventilation with either the Samson or the Laerdal infant resuscitator. During resuscitation significantly greater percentage changes in pH (1,1% v. 0,2%; P less than 0,05), hydrogen ion concentration (-15,6% v. -2,1%; P less than 0,05) and partial arterial carbon dioxide pressure (-24,5% v. -11,9%; P less than 0,02) were seen in the Laerdal group. There was also a tendency towards improved oxygenation and lung compliance and quicker establishment of spontaneous respiration in the Laerdal group. We therefore conclude that the Laerdal resuscitator is superior to the Samson one in the management of infants with birth asphyxia.