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Introduction: Collaborative studies have contributed to improved survival of pediatric Hodgkin lymphoma in well-resourced settings, but few are documented in resource-constrained countries. The South Africa Children’s Cancer Study Group initiated harmonization of management protocols in 2015. This article analyzes barriers and enablers of the process. Methods: Clinician-researchers at 11 state-funded pediatric oncology units completed preparatory questionnaires in June 2018. Parameters included infrastructure, access to therapeutic modalities and clinician numbers. A reassessment of 13 sites (two new pediatric oncology unit) in February 2021 ascertained changes in resources and identified challenges to full participation. Questions investigated the presence and quality of diagnostic radiology, availability of surgeons, cytology/pathology options and hematology laboratory facilities. Results: The response rate was 11/11 to survey 1 and 13/13 to survey 2. The anticipated pre-study barriers to participation of pediatric oncology units included time constraints and understaffing. PET-CT was unavailable to two centers. The majority of pediatric oncology units met the minimum criteria to participate. The interim survey confirmed chemotherapy and radiotherapy availability nearly 100% of the time. One site reported improved access to radiotherapy while another reported improved access to PET-CT. Barriers to participation included excessive times to obtain regulatory approvals, time constraints and lack of dedicated research staff. Enablers include the simple management algorithm and communication tools. Conclusion: This study demonstrates that multicenter collaboration and harmonization of management protocols are achievable in a middle-income setting. Minimal funding is required but full participation to run high-quality studies requires more financial investment. Focused funding and increased prioritization of research may address systemic barriers to full participation.

Therapeutic hypothermia (TH) has become the standard of care to reduce neurological damage following perinatal asphyxia. Current recommendations call for implementation of a standard, evidence-based protocol for the provision of TH. This is particularly challenging in resource-limited settings. This is a retrospective, descriptive study to determine whether neonates at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) are receiving TH according to the unit protocol in place. The study included all neonates with a birth weight greater than 1800 g admitted to the CMJAH neonatal unit from January 1, 2013, to June 30, 2017, before 24 hours of life. Neonates were assessed as to whether they met the criteria for TH according to the protocol, and reasons for not providing TH to those who qualified were investigated. The total number of neonates enrolled for the study was 485. Three hundred patients met the criteria for TH. 185/300 appropriately received TH. One hundred fifteen patients were not cooled, despite meeting TH criteria. Reasons for this included severe clinical conditions (73/115) and a lack of equipment (26/115). Of the remaining 185 patients who did not meet TH criteria, 21 patients inappropriately received TH. A total of 206 neonates received TH. TH at CMJAH is largely being practiced as per protocol. Still, more resources are needed, not only to optimize the number of patients who have access to this treatment modality but also in terms of imaging and support strategies.

ObjectiveTo gain an understanding of the variation in available resources and clinical practices between neonatal units (NNUs) in the low-income and middle-income country (LMIC) setting to inform the design of an observational study on the burden of unit-level antimicrobial resistance (AMR).DesignA web-based survey using a REDCap database was circulated to NNUs participating in the Neonatal AMR research network. The survey included questions about NNU funding structure, size, admission rates, access to supportive therapies, empirical antimicrobial guidelines and period prevalence of neonatal blood culture isolates and their resistance patterns.Setting39 NNUs from 12 countries.PatientsAny neonate admitted to one of the participating NNUs.InterventionsThis was an observational cohort study.ResultsThe number of live births per unit ranged from 513 to 27 700 over the 12-month study period, with the number of neonatal cots ranging from 12 to 110. The proportion of preterm admissions ConclusionAMR is already a significant issue in NNUs worldwide. The apparent burden of AMR in a given NNU in the LMIC setting can be influenced by a range of factors which will vary substantially between NNUs. These variations must be considered when designing interventions to improve neonatal mortality globally.

Background: The global spread of the novel coronavirus 2019 (COVID-19) has been sudden shock to the world and resulted in many questions that remain unanswered. Limited data has been published in low-middle-income country settings (LMICS) Objectives: To describe the clinical characteristics and outcome of mothers and neonates delivered from COVID-19 positive mothers, and to identify the incidence of COVID-19 positive neonates.Methods: A prospective, descriptive study, from 1 August 2020 to 31 March 2021 conducted at a tertiary hospital, in JohannesburgAll neonates born to mothers that were COVID-19 positive and that required admission to the neonatal unit were included. Informed consent was obtained from mothers prior to enrolment.Results: A total of 111 COVID-19 positive pregnant women delivered neonates at the tertiary hospital. In this study, only 28 of the 111 (25%) neonates born to COVID-19 positive mothers were admitted. The majority of the COVID-19 pregnant mothers were asymptomatic or had mild symptomatic disease (80%). Two (2/111 (2%) mothers required ICU admission and three (3/111 (3%) of them demised. In relation to neonatal outcomes, the majority of the neonates were delivered at a gestational age of 35 weeks with a birth weight of 2400 grams .The most common symptom was respiratory distress (89 %). The one (3%) neonate that tested positive for COVID-19 was born moderately preterm with a low birth weight and respiratory distress syndrome. Two (2/28 (7%) neonates demised, however the cause of death was not related to COVID-19. All the remaining (26/28 (93%) neonates were discharged and were well on follow up. Conclusion: Our study has shown that the risk of neonatal transmission from pregnant COVID-19 mothers is relatively low, and the majority of neonatal disease ranged from asymptomatic to mildly symptomatic disease. Further research efforts are essential to improve neonatal care in LMICS.

Background: Neonatal sepsis is associated with high mortality, but there is limited clinical data on outcomes in hospital facilities in low and middle income countries (LMIC). The NeoOBS study aimed to determine the clinical features, pathogens and clinical outcomes of infants presenting with neonatal sepsis in hospitals globally. Methods: Infants

South African children with Hodgkin lymphoma (HL) and human immunodeficiency virus (HIV) have low 5-year overall survival (OS) rates. In this retrospective multicenter study, 271 South African pediatric patients with HL were studied to determine OS and prognostic factors in those with HIV and HL. Univariate risk factor analysis was performed to analyze prognostic factors. The 29 HIV-infected patients were younger (

The burden of neonatal surgical conditions is not well documented in low- to middle-income countries (LMICs). These conditions are thought to be relatively common, with a considerable proportion of neonates admitted to the neonatal intensive care unit (NICU) requiring surgical intervention.To review neonates with surgical conditions admitted to the NICU in our hospital setting.This was a retrospective, descriptive study of neonates with surgical conditions admitted to the NICU at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), South Africa, between 1 January 2013 and 31 December 2015. The characteristics and survival of these neonates were described using univariate analysis. The NICU at CMJAH is combined with a paediatric intensive care unit, to a total of 15 beds, and serves as a referral unit.Of 923 neonates admitted to the NICU, 319 (34.6%) had primarily surgical conditions. Of these 319 neonates, 205 survived (64.3%). There were 125/319 neonates (39.2%) with necrotising enterocolitis (NEC), 55 of whom survived (55/125; 44.0%), making the presence of NEC significantly associated with poor outcome (plt;0.001). Other significant predictors of poor outcome were the patient being outborn (p=0.029); the presence of late-onset sepsis (plt;0.001), with Gram-negative organisms (p=0.005); and lesser gestational age (p=0.001) and lower birth weight (plt;0.001). Major birth defects were present in 166/319 neonates (52.0%). The abdomen was the most prevalent site of surgery, with 216/258 procedures (83.7%) being abdominal, resulting in a mortality rate of 76/216 (35.2%).Neonates with major surgical conditions accounted for one-third of NICU admissions in the present study. The study highlights the considerable burden placed on paediatric surgical services at a large referral hospital in SA. Paediatric surgical services, with early referral and improvement of neonatal transport systems, must be a priority in planned healthcare interventions to reduce neonatal mortality in LMICs.

Background and objectives: Children with Hodgkin lymphoma (HL) and Human Immunodeficiency Virus (HIV) have low 5 year overall survival rates in South Africa, home to the world’s largest HIV population. We aimed to explore factors impacting on survival in children with HIV and HL by comparing those with and without HIV, and to determine long term survival. Methods: A retrospective study was conducted to determine survival rates and prognostic factors in South African children and adolescents with HL. Univariate risk factor analysis was performed to analyse prognostic factors. Results: Between January 2000 and December 2010, 271 children and adolescents with HL were eligible for analysis. Compared to the 242 HIV-uninfected patients, the 29 HIV-infected patients were younger (median 7.2 vs 10.0 years, p=0.052) and more likely to present with Stage IV disease (p=0.000) The 5-year overall survival rate (OS) of HIV-infected patients of 49% versus 84% for HIV-uninfected patients (p=0.001) appeared to be associated with hypoalbuminaemia (

Background. Neonatal hypoxic ischaemic encephalopathy (NHIE) is an important cause of long-term handicap in survivors. There is limited information on the burden of handicap from NHIE in sub-Saharan Africa. Objectives. To determine the developmental outcomes in survivors of NHIE in South Africa (SA). Methods. In this prospective observational study, the developmental outcomes in 84 infants who had survived hypoxic ischaemic encephalopathy (the NHIE group) were compared with those in 64 unaffected infants (the control group). The Bayley Scales of Infant Development version III were used for assessment of developmental outcomes. Results. Significant differences were found between the developmental outcomes of the two groups, with a significantly lower composite language score and higher proportions with language, motor and cognitive developmental delays in the NHIE group than in the control group. Cerebral palsy (CP) was present in 13 of the infants with NHIE (15.5%) and none in the control group ( p

BACKGROUND Increased carotid intima media thickness (cIMT) is one of the early changes seen in chronic kidney disease (CKD) associated cardiovascular disease. This study aimed to determine cIMT measurements and its association with cardiovascular risk factors, including fibroblast growth factor-23 (FGF-23) and fetuin-A, in South African children with CKD. MATERIALS AND METHODS 72 children (5 - 18 years) with CKD; 20 with CKD I, 23 with CKD II - IV, 29 with CKD V (on dialysis) were recruited. Each patient had a clinical examination and blood samples assessed for creatinine, urea, albumin, calcium, phosphorus, parathyroid hormone, alkaline phosphatase, total cholesterol, hemoglobin, C-reactive protein, vitamin D, fetuin-A, and FGF-23. cIMT was measured with high-resolution ultrasound. RESULTS The mean age was 10.8 (3.5) years, and there were 49 males and 23 females (2 : 1). The overall median (range) cIMT was 0.505 mm (0.380 - 0.675) and was highest in patients with dialysis-dependent CKD (p = 0.003). Mean arterial pressure (MAP), hemoglobin, and PTH showed a significant correlation with cIMT (p < 0.001, p = 0.034, and p = 0.002, respectively). After adjusting for confounders in a multivariable analysis, disease duration, MAP, hemoglobin, and estimated glomerular filtration rate (eGFR) were independently associated with cIMT, p = 0.039, 0.001, 0.006, and 0.001, respectively. No significant relationship between cIMT and plasma levels of fetuin-A and FGF-23 was found. CONCLUSION This study reports high cIMT measurements and their independent association with disease duration, MAP, hemoglobin, and eGFR. However, no similar association was found with fetuin-A and FGF-23.

Background Survival of extremely low birth weight (ELBW; birth weight less than 1000 g) infants has improved significantly since the 1990s. Consequently, growth monitoring in ELBW infants has gained more relevance. Methods We conducted this study to describe the growth of ELBW infants at a tertiary hospital, to audit macronutrient intake and explore the association of prematurity complications with growth. This was a retrospective study on 92 ELBW infants born at Charlotte Maxeke Johannesburg Academic Hospital. The association between good growth (regaining birth weight in 21 days or less and subsequent growth velocity > 15 g/kg/day) and complications of prematurity was explored. Results Only 11infants (13%) had a discharge weight above the 10th centile when the Fenton growth chart was used compared to 20 infants (22.4%) when the Intergrowth 21st Project growth standard was used. The mean weight velocity was 13.5 g/kg/day and the mean number of days to regain birth weight was 18.2 days. Factors associated with poor growth were late-onset sepsis, persistent patent ductus arteriosus, continuous positive airway pressure for more than 2 days, invasive ventilation, oxygen on day 28 and being kept nil per os. Protein and caloric intake correlate positively with growth velocity. Unlike the Fenton Growth Charts, use of the Intergrowth 21st Project growth standards revealed the association between neonatal factors and poor growth. Conclusion Growth outcome in infants is poor at 36 weeks postmenstrual age at our institution. Intergrowth 21st Project growth standards were superior to Fenton Growth Charts, however a multicentre study is required before adoption.

Objective The aim of this study was to explore the prevalence of congenital HIV infection of neonates at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) between 2015 and 2017, as well as compare the HIV PCR positive and HIV PCR negative neonates. Results A total number of 1443 HIV exposed neonates was examined for the study period out of a total of 5029 admissions (HIV exposure 28.6%) The study found that the rate of HIV transmission at birth was 2.52%. The majority of infants had low birth weight and were also born prematurely. These results show that, despite the introduction of the extended mother to child transmission programme, HIV transmission is high.

Clinical pharmacokinetic studies of antibiotics can establish evidence-based dosing regimens that improve the likelihood of eradicating the pathogen at the site of infection, reduce the potential for selection of resistant pathogens, and minimize harm to the patient. Innovations in small volume sampling (50 μL) or 'microsampling' may result in less-invasive sample collection, self-sampling and dried storage. Microsampling may open up opportunities in patient groups where sampling is challenging.The challenges for implementation of microsampling to assure suitability of the results, include: acceptable study design, regulatory agency acceptance, and meeting bioanalytical validation requirements. This manuscript covers various microsampling methods, including dried blood/plasma spots, volumetric absorptive microsampling, capillary microsampling, plasma preparation technologies and solid-phase microextraction.The available analytical technology is being underutilized due to a lack of bridging studies and validated bioanalytical methods. These deficiencies represent major impediments to the application of microsampling to antibiotic pharmacokinetic studies. A conceptual framework for the assessment of the suitability of microsampling in clinical pharmacokinetic studies of antibiotics is provided. This model establishes a 'contingency approach' with consideration of the antibiotic and the type and location of the patient, as well as the more prescriptive bioanalytical validation protocols.

Background. Both fibroblast growth factor-23 (FGF-23) and fetuin-A levels have been implicated in mineral and bone disorders associated with chronic kidney disease (CKD), and several single nucleotide polymorphisms (SNPs) of the fetuin-A gene have also been associated with fetuin-A levels. Objectives. This study aimed to determine the relationship between FGF-23 and fetuin-A and to determine the role of fetuin-A SNPs with respect to fetuin-A levels and markers of bone mineralisation in black South African children. Methods. Blood samples from 93 children (5 - 18 years) with various stages of CKD were assessed for C-reactive protein (CRP), calcium, phosphate, parathyroid hormone, 25-hydroxyvitamin D, FGF-23 and fetuin-A levels. Genomic DNA was extracted from whole blood and regions of the fetuin-A gene amplified by polymerase chain reaction. SNPs were genotyped by restriction fragment length polymorphism analysis or by direct sequencing. Results. The median FGF-23 and fetuin-A levels were 28.9 (11.7 - 147.1) pg/mL and 57.7 (37.7 - 71.8) mg/dL, respectively. A significant negative relationship between fetuin-A and FGF-23 was only observed in the CKD V group ( p =–0.60, p

CITATION: Fairlie, L. et al. 2020. COVID-19 in pregnancy in South Africa : tracking the epidemic and defining the natural history. South African Medical Journal, 110(9):728-731, doi:10.7196/SAMJ.2020.v110i9.15012.

Objective Paediatric intensive care resources are limited in sub-Saharan Africa. The mortality rate in a combined Paediatric/Neonatal Intensive Care Unit in Johannesburg, South Africa was almost double that in a dedicated paediatric intensive care unit in the same country. This study aimed to compare the raw mortality rate with that predicted with the Paediatric Index of Mortality (version 3), by doing a retrospective analysis of an existing database. Results A total of 530 patients admitted to the intensive care unit between 1 January 2015 and 31 December 2017 were included. The raw mortality rate was 27.1% and the predicted mortality rate was 27.0% (p = 0.971). Cardiac arrest during ICU admission (p

Background Late preterm infants, previously considered low risk, have been identified to be at risk of developmental problems in infancy and early childhood. There is limited information on the outcome of these infants in low and middle income countries. Methods Bayley scales of infant and toddler development, version III, were done on a group of late preterm infants in Johannesburg, South Africa. The mean composite cognitive, language and motor sub-scales were compared to those obtained from a group of typically developed control infants. Infants were considered to be “at risk” if the composite subscale score was below 85 and “disabled” if the composite subscale score was below 70. Infants identified with cerebral palsy were also reported. Results 56 of 73 (76.7%) late preterm infants enrolled in the study had at least one Bayley assessment at a mean age of 16.5 months (95% CI 15.2–17.6). The mean birth weight was 1.9 kg (95%CI 1.8–2.0) and mean gestational age 33.0 weeks (95% CI 32.56–33.51). There was no difference in the mean cognitive subscales between late preterm infants and controls (95.4 9, 95% CI 91.2–99.5 vs 91.9.95% CI 87.7–96.0). There was similarly no difference in mean language subscales (94.5, 95% CI 91.3–97.7 vs 95.9, 95% CI 92.9–99.0) or motor subscales (96.2, 95% CI 91.8–100.7 vs 97.6, 95% CI 94.7–100.5). There were four late preterm infants who were classified as disabled, two of whom had cerebral palsy. None of the control group was disabled. Conclusions This study demonstrates that overall developmental outcome, as assessed by the Bayley scales of infant and toddler development, was not different between late preterm infants and a group of normal controls. However, 7.1% of the late preterm infants, had evidence of developmental disability. Thus late preterm infants in low and middle income countries require long term follow up to monitor developmental outcome. In a resource limited setting, this may best be achieved by including a parental screening questionnaire, such as the Ages and Stages Questionnaire, in the routine well baby clinic visits.

Background Vaccinating pregnant women may prevent invasive Group B Streptococcus (GBS) disease in their young infants. In a low-middle income setting, we sought to determine an association between natural maternal antibody responses and the development of invasive GBS disease. Methods We undertook a matched case-control study in Johannesburg, South Africa. Maternal and infant antibody concentrations were compared between serotype-specific Ia and III GBS cases and well-baby controls in which the mother was colonized with the same serotype. Results The median maternal serotype Ia and III antibody concentrations (in μg/mL) were 0.05 (IQR: 0.02–0.24; n = 27) and 0.14 (IQR: 0.08–0.33; n = 29) in cases, and 0.29 (IQR: 0.06–1.60; n = 43) and 0.29 (IQR: 0.13–0.58; n = 31) in homotypic controls, respectively. A smaller proportion of cases as compared to homotypic controls had higher serotype Ia and III maternal antibody concentrations. Using Bayesian modeling, we demonstrated that the risk of invasive GBS disease was less than 10% with maternal antibody concentrations ≥6 μg/mL and ≥3 μg/mL for serotypes Ia and III, respectively. Conclusions Maternal capsular antibody concentrations are associated with the risk of invasive GBS disease in infants. In a low-middle income setting with a high burden of invasive disease, we have demonstrated a sero-correlate of protection for GBS serotypes Ia and III which could facilitate vaccine licensure.

Group B Streptococcus (GBS) surface-proteins have been shown to be immunogenic and potential vaccine candidates. We aim to determine the association between maternal IgG antibodies to select GBS surface-proteins and invasive GBS disease in their infants.Using a matched case-control study, maternal antibody levels for GBS-immunogenic bacterial adhesin, fibrinogen-binding protein A and pilus-island (PI) PI-1, PI-2a, PI-2b were compared between infants with invasive GBS disease and well-baby controls.The absolute risk of disease did not differ between cases and colonized controls with increasing antibody concentrations for these surface-proteins. There was, however, a relative risk reduction in invasive disease associated with fibrinogen-binding protein A, with an adjusted odds ratio of 0.04 (95% CI: 0.01-0.69) at antibody levels ≥10,000 AU/ml.We have not demonstrated an association between naturally occurring fibrinogen-binding protein A, GBS-immunogenic bacterial adhesin, and PI surface-protein antibodies and the risk of invasive disease in young infants. These surface-proteins may not be suitable GBS vaccine candidates.

Background Congenital rubella syndrome (CRS) includes disorders associated with intrauterine rubella infection. Incidence of CRS is higher in countries with no rubella-containing vaccines (RCV) in their immunization schedules. In the World Health Organization African region, RCVs are being introduced as part of the 2012–2020 global measles and rubella strategic plan. This study aimed to describe the epidemiology of confirmed CRS in South Africa prior to introduction of RCVs in the immunization schedule. Methods This was a descriptive study with 28 sentinel sites reporting laboratory-confirmed CRS cases in all 9 provinces of South Africa. In the retrospective phase (2010 to 2014), CRS cases were retrieved from medical records, and in the prospective phase (2015 to 2017) clinicians at study sites reported CRS cases monthly. Results There were 42 confirmed CRS cases in the retrospective phase and 53 confirmed CRS cases in the prospective phase. Most frequently reported birth defects were congenital heart disease and cataracts. The median age of mothers of CRS cases was 21 years in the retrospective phase (range: 11 to 38 years) and 22 years in the prospective phase (range: 15 to 38 years). Conclusion Baseline data on laboratory-confirmed CRS will enable planning and monitoring of RCV implementation in the South African Expanded Programme on Immunization program. Ninety-eight percent of mothers of infants with CRS were young women 14–30 years old, indicating a potential immunity gap in this age group for consideration during introduction of RCV., Sentinel site surveillance for congenital rubella in South Africa identified 95 cases from 2010 through 2017. Mothers of infants with congenital rubella were 14–38 years old. This information will inform planning of rubella vaccine introduction in the region.

Background: The increasing intensity of treatment of paediatric malignancies has led to improved survival rates, but often necessitates intensive supportive care. The decision to admit a child to the paediatric intensive care unit (PICU) is based on the probability of both short-term and long-term survival in the context of severe resource constraints. Resource constraints in South Africa result in limited access of children with cancer to PICU facilities.Objectives: The aim of this study was to determine whether referrals by paediatric oncologists to a PICU in Johannesburg were appropriate by analysing indications for admission, underlying diagnoses, duration and costs of admissions, and overall outcomes.Methods: A retrospective review of consecutive PICU admissions over a 12-year period was performed. Data from all patients with histologically proven malignant conditions were included and analysed using descriptive statistical methods, Kaplan–Meier curves, log-rank analysis and Fisher’s exact test.Results: There were 5704 recorded admissions to PICU in the study period. Of these admissions, 120 (2.1%) were for patients with malignancies. The majority of PICU oncology admissions were for post-operative care, and the median duration of stay was 1 day (interquartile range: 1–3 days). The short-term mortality rate of oncology patients in PICU was 13.3% in comparison with 16.2% in the overall PICU population. The 4-year overall survival rate post PICU discharge was 54%.Conclusion: The documented short-term mortality rate indicates that referrals by paediatric oncologists are consistent with current PICU admission policies. Oncologists should assess the prognosis for survival before requesting admission to PICU, and, resources permitting, these patients should be accepted to PICU.

Background. Antenatal corticosteroid (ANS) use in premature neonates has become a standard of practice. However, there is low ANS coverage in low- to middle-income countries (LMICs). Recent studies have questioned the efficacy of ANSs in such countries. Objective. To review the use of ANSs in preterm neonates at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), South Africa. Methods. This was a retrospective observational study of all neonates with a birth weight of 500 - 1 800 g born at CMJAH between 1 January 2013 and 30 June 2016. Neonatal and maternal characteristics of neonates exposed to ANSs were compared with those of neonates who were not exposed. Results. The ANS coverage of the final sample was 930/2 109 (44.1%). The mean (standard deviation (SD)) birth weight was 1 292.4 (323.2) g and the mean gestational age 30.2 (2.9) weeks. Attending antenatal care and maternal hypertension were associated with increased use of ANSs, whereas vaginal delivery was associated with decreased use. In neonates weighing

Background. The Bayley Scales of Infant and Toddler Development (III) is a tool developed in a Western setting. Aim. To evaluate the development of a group of inner city children in South Africa with no neonatal risk factors using the Bayley Scales of Infant and Toddler Development (III), to determine an appropriate cut-off to define developmental delay, and to establish variation in scores done in the same children before and after one year of age. Methods. Cohort follow-up study. Results. 74 children had at least one Bayley III assessment at a mean age of 19.4 months (95% CI 18.4 to 20.4). The mean composite cognitive score was 92.2 (95% CI 89.4 to 95.0), the mean composite language score was 94.8 (95% CI 92.5 to 97.1), and mean composite motor score was 98.8 (95% CI 96.8 to 101.0). No child had developmental delay using a cut-off score of 70. In paired assessments above and below one year of age, the cognitive score remained unchanged, the language score decreased significantly (p=0.001), and motor score increased significantly (p=0.004) between the two ages. Conclusion. The Bayley Scales of Infant and Toddler Development (III) is a suitable tool for assessing development in urban children in southern Africa.

Background. Periventricular-intraventricular haemorrhage (IVH) and cystic periventricular leukomalacia (cPVL) contribute to neonatal mortality and morbidity. Low birth weight and gestational age are among the risk factors for IVH and cPVL. Objectives . To assess how many very low birth weight (VLBW) infants had cranial ultrasound screening at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) and to determine the prevalence of cranial ultrasound abnormalities. To compare the characteristics and risk factors of those VLBW infants with cranial ultrasound abnormalities to those with normal cranial ultrasound findings. Methods. This was a retrospective case-controlled study of infants

Background: The novel coronavirus disease 2019 (COVID-19) pandemic has spread to South Africa and poses an infection risk in pregnant women and their newborns, as well as health-care workers and other patients. Objective: To discuss the implementation of international and local recommendations, and any additional actions undertaken at our Neonatal Unit in order to prepare for COVID-19. Discussion: Standard precautions in order to prepare a facility and its personnel to safely care for COVID-19 patients as outlined by the World Health Organization procedures have been implemented. Further actions undertaken in our Neonatal Unit included the creation of standard operating procedures, increased communication between neonatal and obstetric teams, limiting staff exposure, the creation of disposable resuscitation boxes to attend deliveries, reallocation of a triage area in the high care ward to an isolation area for sick newborns of suspected or confirmed maternal COVID-19 cases, staff training on personal protective equipment procedures and initiation of an online resources portal for neonatal staff. Conclusion: A rational approach to suspected cases and infection control in-line with local and international guidelines as well as ongoing education should diminish anxiety amongst health-care professionals and provide the best possible care to patients. South Africa is a low-to-middle income country, and the lack of resources available means we cannot increase our capacity, staffing numbers or available equipment. Yet, we must be as prepared, adaptable and efficient as possible to maximize the resources and equipment we have available to us.

A research report submitted to Faculty of Health Sciences, as a requirement for completion of Masters of Medicine in Paediatrics, University of the Witwatersrand, Johannesburg, 2018

The shortage of resources in the public healthcare sector in South Africa (SA) means that healthcare providers face difficult choices in terms of rationing of care. This is particularly challenging in paediatrics. This article reviews the ethical and legal issues that arise in this regard. Principlism is the ethical framework most commonly used by clinicians, but perhaps other approaches, such as the ethics of caring, and ubuntu , would be more appropriate for the SA situation.

Aims: In children with chronic kidney disease (CKD), fetuin-A and fibroblast growth factor-23 (FGF-23) have been implicated in the mechanism and progression of several cardiac changes. This study aimed to determine the types and rates of cardiac changes in children with CKD and their association with fetuin-A, FGF-23, and other cardiovascular risk factors (CVRFs). Methods: This comparative cross-sectional study recruited 88 children (5-18 years): 27 CKD I with a glomerular filtration rate (GFR) >90 mL/min/1.73 m2 and 61 with a GFR of 2 (29 CKD II-IV, 32 CKD V-dialysis). Each patient had a short demographic and clinical history taken along with a physical examination. Blood was taken and sent for routine tests and for fetuin-A and FGF-23 assay. All patients had an echocardiogram to evaluate cardiac structure and function. Results: The distribution of left atrial diameter (LAD) and left ventricular (LV) mass differed significantly (p < 0.05) across the different CKD groups. Abnormal LAD was seen in 10% of patients; LV hypertrophy (LVH) in 27%; LV systolic dysfunction in 6% and diastolic dysfunction in 1 patient. Fetuin-A was the only independent predictor for abnormal LAD; mean arterial pressure was independently associated with concentric LVH, and age and hypoalbuminemia with eccentric LVH. Overall, the dialysis group had the highest rate of cardiac changes and associated risk factors. Conclusion: Though not common, the importance of left atrial changes in children with CKD is highlighted along with the need to address modifiable CVRFs such as hypertension and hypoalbuminemia.

Objectives Systemic sclerosis (SSc) is a heterogeneous autoimmune disease associated with several antinuclear autoantibodies useful to diagnosis and prognosis. The aim of the present multicentric study was to determine the clinical relevance of anti-fibrillarin autoantibodies (AFA) in patients with SSc. Methods The clinical features of 37 SSc patients positive for AFA (AFA+) and 139 SSc patients without AFA (AFA-) were collected retrospectively from medical records to enable a comparison between AFA- and AFA+ patients. Anti-fibrillarin autoantibodies were screened by an indirect immunofluorescence technique using HEp2 cells and identified by an in-house Western blot technique and/or an EliA test. Results Comparing AFA+ and AFA– patients, AFA+ patients were significantly younger at disease onset (36.9 vs. 42.9; p=0.02), more frequently male (p=0.02) and of Afro-Caribbean descent (65% vs. 7.7%; p

Purpose With a decreasing supply of antibiotics that are effective against the pathogens that cause sepsis, it is critical that we learn to use currently available antibiotics optimally. Pharmacokinetic studies provide an evidence base from which we can optimize antibiotic dosing. However, these studies are challenging in critically ill neonate and pediatric patients due to the small blood volumes and associated risks and burden to the patient from taking blood. We investigate whether microsampling, that is, obtaining a biologic sample of low volume ( Methods We performed a literature search to find relevant articles using the following search terms: sepsis , critically ill , severe infection , intensive care AND antibiotic , pharmacokinetic , p(a)ediatric , neonate . For microsampling, we performed a search using antibiotics AND dried blood spots OR dried plasma spots OR volumetric absorptive microsampling OR solid-phase microextraction OR capillary microsampling OR microsampling . Databases searched include Web of Knowledge, PubMed, and EMbase. Findings Of the 32 antibiotic pharmacokinetic studies performed on critically ill neonate or pediatric patients in this review, most of the authors identified changes to the pharmacokinetic properties in their patient group and recommended either further investigations into this patient population or therapeutic drug monitoring to ensure antibiotic doses are suitable. There remain considerable gaps in knowledge regarding the pharmacokinetic properties of antibiotics in critically ill pediatric patients. Implementing microsampling in an antibiotic pharmacokinetic study is contingent on the properties of the antibiotic, the pathophysiology of the patient (and how this can affect the microsample), and the location of the patient. A validation of the sampling technique is required before implementation. Implications Current antibiotic regimens for critically ill neonate and pediatric patients are frequently suboptimal due to a poor understanding of altered pharmacokinetic properties. An assessment of the suitability of microsampling for pharmacokinetic studies in neonate and pediatric patients is recommended before wider use. The method of sampling, as well as the method of bioanalysis, also requires validation to ensure the data obtained reflect the true result.

Summary Antibody detection plays an important role in diagnosis and classification of autoimmune hepatitis. Antibodies to soluble liver antigen are considered to be a specific marker of type 1 autoimmune hepatitis. Their detection is of interest in patients who are negative for conventional markers of the disease (antinuclear antibodies and anti-smooth muscle antibodies reacting specifically against actin cables). Actually, these antibodies allow us to reclassify as type 1 autoimmune hepatitis, 15 to 20% of hepatitis regarded as cryptogenic. The pronostic value of antibodies to soluble liver antigen has seldom been studied and is controversial. They might be used to evaluate the risk of relapse of the inflammatory process after corticosteroid therapy and to recurrence of autoimmune hepatitis after orthotopic liver transplantation.

Research report submitted in partial fulfilment of requirements for a Master of Medicine degree in Paediatrics and Child Health (MMed). November 2014

Background. Severe hyperbilirubinaemia requiring exchange transfusion has become less common in recent years; however, kernicterus still occurs. The aim of this study was to review babies undergoing exchange transfusion for severe hyperbilirubinaemia in a Johannesburg hospital.Methodology. This was a retrospective review of babies who required exchange transfusion in both the neonatal and the paediatric wards from June 1, 2006, to December 31, 2011.Results. There were 64 patients who underwent 67 exchange transfusions. Isoimmune haemolysis (both Rh and ABO incompatibility) was the cause of jaundice in 9/64 (14%). Most babies who underwent exchange transfusion were sick or preterm and were admitted in hospital after birth (38/64; 59.5%); three of these babies died, but not during the exchange transfusion (3/38; 7.9%); all three had signs suggestive of neonatal sepsis. The remaining 26 babies (40.6%) were readmitted to the paediatric wards for exchange transfusion. Six of these babies (6/26; 23.0%) had signs of kernicterus. The most significant complication of exchange transfusion was apnoea requiring mechanical ventilation in three patients (3/64; 4.6%).Conclusion. Despite a relatively low number of babies undergoing exchange transfusion, kernicterus still occurs and must be prevented. Proper protocols for screening and management of severe hyperbilirubinaemia need to be enforced.