Masters Degrees (Paediatrics and Child Health)

Permanent URI for this collection

https://scholar.sun.ac.za/handle/10019.1/3785

Browse

Browsing Masters Degrees (Paediatrics and Child Health) by browse.metadata.advisor "Engelbrecht, Arnold"

Now showing 1 - 6 of 6
  • Thumbnail Image
    Item
    Analysis of care received by very-low-birthweight neonates at Worcester Provincial Hospital in 2018 after implementation of the Western Cape Provincial Peri-viability Decision Support Framework
    (Stellenbosch : Stellenbosch University, 2022-08) van der Merwe, Carine; Slogrove, Amy; Engelbrecht, Arnold; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.
    ENGLISH ABSTRACT: Background: A significant proportion of very-low-birthweight (VLBW; <1500g) infants are born at regional hospitals in South Africa (SA) and little is known regarding their care and outcomes. Since 2017, clinicians at regional hospitals throughout the Western Cape (WC) have utilized the WC Department of Health Periviability Decision Support Framework to guide care of VLBW infants. Objectives: To describe care of VLBW infants at Worcester Provincial Hospital (WPH) in 2018, compared to recommendations in the Framework and to secondarily compare differences in shortterm outcomes of VLBW infants managed before (2016) and after (2018) the implementation of these guidelines. Methods: A retrospective cohort study was conducted of all live-born VLBW infants ≤7 days managed at WPH, in 2016 and 2018. Information related to neonatal care was collected from medical records of patients born in 2018 only, and compared with Framework recommendations according to birthweight categories (500-799g; 800-999g; 1000-1499g). Information regarding mortality at discharge and at age 12 months, readmission before age 12 months, and length of neonatal stay was captured for all included neonates. Results were reported using frequencies, percentages, and proportions with corresponding 95% confidence intervals. Results: In total 227 infants were included, of which 115 were born in 2018 and included in the primary objective analysis. Infant and maternal characteristics were similar for the 2016 and 2018 cohorts. Complete framework adherence was achieved in 54% (n=90) of infants 1000-1499g, 42% (n=12) of infants 800-999g, and no infants of 500-799g were managed with complete adherence. Adherence to ≥80% of recommendations was achieved in 69% of infants. For the secondary objectives, survival to discharge (73.2% in 2016 vs 71.9% in 2018) and 1 year (70.5% in 2016 vs 70.4% in 2018) did not change significantly after Framework implementation. Clinically meaningful reductions in neonatal readmissions (30.6% in 2016 vs 23.5% in 2018) and length of stay (33 days in 2016 vs 28 days in 2018) were observed from 2016 to 2018. Conclusions: The majority of VLBW infants at WPH in 2018 were managed with ≥80% adherence to the Framework, but considerable differences in adherence were noted by birthweight categories. A clinically important decreased length of neonatal stay and readmission were observed postimplementation; this in combination with no increase in mortality represents a potential gain for a resource-restricted healthcare system.
  • Thumbnail Image
    Item
    Descriptive review of the health supervision received by children with Down syndrome at Worcester Provincial Hospital from 2010 to 2015
    (Stellenbosch : Stellenbosch University, 2018-12) Schoonraad, Leilah; Slogrove, Amy; Engelbrecht, Arnold; Urban, Mike; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.
    ENGLISH ABSTRACT: Background: In 2011, the American Academy of Paediatrics (AAP) published revised guidelines for health supervision of children with Down syndrome (DS). In the absence of South African guidelines, we described the health supervision received by children with DS at a regional (level 2) Western Cape Hospital and compared it to the AAP guidelines. Methods: This was a 5 year retrospective description of implementation of the 2011 AAP recommendations at the DS clinic at Worcester Provincial Hospital (WPH), specifically related to cardiac, thyroid, hearing and haematological disorders. Data was extracted from patient medical folders and the National Health Laboratory Database. The proportion receiving screening components was compared between the children using WPH as their primary care facility and children referred from peripheral hospitals. Results: Sixty-two children received care at WPH DS clinic during the study period. Thirty-six (58%) children lived in Worcester while 26 (42%) were referred from peripheral hospitals. The median age at first clinic visit was 0.5 years (interquartile range (IQR) 0.2-1.2), there was a total of 177 person-years of follow up with a median duration of follow up of 1.8 years (IQR 0.3-4.8) and 2 deaths occurred in the study period. Forty nine children (79%) had a screening echocardiogram performed, the median age at first echocardiogram was 0.8 years (IQR 0.2-1.4). Five (13.9%) children from WPH compared to no children from the peripheral hospitals received the echocardiogram within the first month of life (p =0.056). Those requiring cardiac surgery were operated on at a median age of 2years (IQR 0.9-2.3). Compared to the AAP recommendations, within the first month of life 17 (27.4%) children had a thyroid screen, 20 (32.3%) children had a full blood count and 7 (11.3%) children had a hearing assessment. Conclusion: AAP recommendations for health supervision in DS are challenging to achieve within our local health system. The development and advocacy for a South African DS health supervision guideline might improve the care of children with DS.
  • Thumbnail Image
    Item
    An evaluation of fluid management strategies and outcomes for children with acute diarrhoea and dehydration admitted to a regional hospital in the Western Cape
    (Stellenbosch : Stellenbosch University, 2021-12) Greyling, Marnel; Slogrove, Amy; Engelbrecht, Arnold; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.
    Introduction Globally, acute diarrhoea remains one of the most common ailments in children. Despite the fluid management of diarrhoeal disease being based on relatively simple principles, many different clinical practice guidelines have been published with variations in fluid choice, volume, rate and preferred route of rehydration. Consensus on the ideal resuscitation fluid in children has not yet been reached. Children admitted to Worcester Provincial Hospital (WPH) with dehydration due to diarrhoeal disease are managed according to a fluid management protocol that has been standard of practice for more than 10 years. Children assessed as critically dehydrated, defined as hypovolaemic shock and/or severe (10% or more) dehydration and/or severe metabolic acidosis (base deficit ≥ 10), receive empiric correction of metabolic acidosis as part of fluid resuscitation by means of a 20ml/kg fluid bolus consisting of 15ml/kg 0.9% saline and 5ml/kg 4.2% sodium bicarbonate. The aim of this study was to compare fluid management strategies received in children with acute diarrhoea managed at WPH who were non-critically dehydrated compared to critically dehydrated and to describe metabolic and electrolyte consequences in response to the fluid management strategies used. Methods A retrospective cohort study was conducted in children 3-59 months of age admitted to WPH from 1 December 2017 to 31 May 2018 with acute diarrhoea and dehydration by comparing non-critically to critically dehydrated children. Categorical and numerical data was compared for non-critically and critically dehydrated children with p-values determined by chi-squared and t-test respectively. Metabolic and electrolyte parameters were evaluated by calculating absolute change at individual level and subsequent comparison of means and paired t-test to compare values pre- and post-resuscitation using empiric correction of metabolic acidosis. Results One-hundred-and-twenty-five children were included in the study, 63 non-critically dehydrated and 62 critically dehydrated children. Seventy-two (58%) were male children with median age of 11.5 (interquartile range (IQR) 7.1-16.9) months with no difference between the two groups. Rehydration was required in 120 children, 116 (96.7%) were rehydrated intravenously and 4 (3.3%) received exclusive enteral rehydration. Empiric correction of metabolic acidosis was given in 100 (80%) children with varied effect on metabolic and electrolyte parameters. Metabolic and electrolyte changes were assessed in 67 children who had a repeat blood gas analysis within 6 (median 2.8, IQR 1.6-4.6) hours. Forty-six/67 (68.7%) children had improvement or resolution of metabolic acidosis and 15/67 (22.4%) children developed metabolic alkalosis. Six/63 (9.5%) children developed hypernatraemia. Worsening or persistence of hypokalemia was found in 28/64 (43.8%) children. Six/125 (4.8%) children required ICU admission and all 125 children survived to discharge. Conclusion Although the fluid management protocol under study is unconventional, there were no major clinical morbidities documented, there were no mortalities during the study period and very few children needed ICU admission. Suboptimal use of enteral rehydration and management of non-critically dehydrated children as critically dehydrated was demonstrated. Most children had improvement in their metabolic parameters, but electrolyte derangements developed or worsened in others, although a direct association with the evaluated fluid management protocol cannot definitively be made.
  • Thumbnail Image
    Item
    The influence of parental immigration status on outcomes of children with severe acute malnutrition at Worcester Provincial Hospital
    (Stellenbosch : Stellenbosch University, 2022, 2021-12) Thomas, Aldona EC.; Slogrove, Amy; Nel, Etienne De la Rey; Engelbrecht, Arnold; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.
    ENGLISH ABSTRACT: Background: Severe acute malnutrition (SAM) accounts for ±30% of in-hospital deaths in South Africa. Children of immigrants with vulnerable legal status are also vulnerable to malnutrition as they have limited economic rights and are excluded from national social interventions. As there is often a perception that children of immigrant parents with SAM do worse than other children, this study aimed to evaluate the relationship between parent immigrant status and outcomes of children with SAM admitted to Worcester Provincial Hospital (WPH), a rural regional hospital in the Western Cape. The primary objective was to compare in-hospital outcomes of children with SAM who had immigrant parents with those who had South African parents. The secondary objectives were: 1) to estimate the proportion of children admitted with SAM whose parents were immigrants; 2) to describe socio-economic, nutritional and medical characteristics associated with severe acute malnutrition. Methods: A retrospective cohort study of children <5 years with SAM, admitted to WPH, between 01 June 2015 and 30 June 2017 was conducted. Participants were identified from the dietician and ward registers. SAM was defined as WHO weight-for-height Z-score below minus 3 or the presence of nutritional oedema or severe wasting with a MUAC less than 11.5cm (19,20). Hospital records and regional dietician’s notes were used to determine outcomes including in-hospital death, recurrent admission and discharged without readmission. Results: A total of 109 children were admitted to WPH with SAM, 14 (13%) were excluded due to missing records, resulting in a final sample of 95 children. Thirty one children (33%) were children of immigrant parents and 64 (67%) were children of South African parents. Median (interquartile range) age at admission was 12 (8-18) compared to 10 (8-13) months in children of South African and immigrant parents respectively. No significant difference was seen in the age or HIV status of immigrant compared to South African mothers. There was no difference between groups in preterm delivery, breastfeeding practices, concurrent illness, duration of hospital stay or number of previous admissions. However, 24 (38%) children of South African parents had low birth weight in comparison to 3 (10%) children of immigrant parents. No children of immigrant parents received a child support grant in comparison to 29 (45%) South African children. Sixty one (95%) children of South African parents were discharged well compared to 23 (74%) children of immigrant parents (p=0.005). In-hospital deaths occurred in 6 (19%) and 3 (5%) children of immigrant and South African parents respectively. One specific deeply impoverished neighbourhood accounted for 52/95 (51%) children admitted with SAM and 24/31 (77%) children of immigrant parents. By multivariable analysis correcting for possible factors associated with child mortality there was an at least four times greater odds of in-hospital SAM-associated mortality among children of immigrant compared to South African parents. Conclusion: In this rural setting, 33% of children admitted with SAM were of immigrant parents and experienced in-hospital SAM-associated mortality at least four times higher than children of South African parents. This was despite no difference in birth weight, gestational age and breastfeeding exposure, suggesting a role for socioeconomic factors associated with migration and vulnerability of children of immigrant parents.
  • Thumbnail Image
    Item
    Respiratory management of low birth weight neonates with respiratory distress in rural district and regional hospitals in the Western Cape during 2019
    (Stellenbosch : Stellenbosch University, 2023-11) Read, Jo-Mari; Slogrove, Amy; Engelbrecht, Arnold; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.
    ENGLISH ABSTRACT: Background Respiratory distress in low birth weight (LBW; <2500g) neonates is associated with prolonged morbidity and high mortality. Neonatal transport to specialized facilities can lead to complications and increased mortality. Improving care for LBW neonates with respiratory distress at district and regional hospitals and avoiding transport to specialized centres, may improve South Africa's neonatal mortality rate. Objectives This study aimed to compare the respiratory care received by LBW neonates in three rural Western Cape hospitals during 2019, to assess adherence to recommendations and to describe the outcomes. Methods A retrospective cohort study was conducted including LBW neonates with signs of respiratory distress within the first 24 hours of life born in 2019 at three rural hospitals. Neonates were categorised into mutually-exclusive groups: regional (all care at regional hospital), district (all care at district hospital) and transferred (transferred from district to regional hospital). Respiratory management was assessed according to the Western Cape Provincial Peri-viability Decision Support Framework, utilising the Downe score to classify severity of respiratory distress upon admission. The proportion (95% confidence interval) receiving recommended respiratory care was compared between groups. Results Among 210 included neonates, 145 (69%) were in the regional group, 53 (25%) in the district group and 12 (6%) in the transferred group. A total of 197 (94%) neonates received respiratory support as recommended or more with no significant difference between the groups. There was a higher proportion of neonates with moderate or severe distress in the regional (61/145;42%) compared to the district group (18/53;34%). Escalation of respiratory support occurred more frequently in the district (N=8/53;15%) compared to the regional group(N=12/145;8%). Neonates at regional level received a longer period of respiratory support (median 36.5 hours; IQR 13.5-82.5 hours) compared to district level (median 21 hours; IQR 9-48 hours). Specialized interventions were more prevalent at the regional level, with surfactant administration to 35/145 (24%) neonates compared to 4/53 (8%) at district level. However, there was no meaningful difference in mortality between the regional and district groups Conclusion Reassuringly 94% of neonates in rural Western Cape received respiratory support as recommended or more. While the regional hospital cared for neonates with more severe respiratory distress, requiring longer respiratory support and more specialized interventions, no difference in mortality between the regional and district level was observed which requires further investigation.
  • Thumbnail Image
    Item
    Risk factors associated with the severity of pneumonia in a cohort of hospitalised children in a rural setting
    (Stellenbosch : Stellenbosch University, 2022-01) Mikhail Barday; Slogrove, Amy; Engelbrecht, Arnold; Kling, Sharon; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.
    ENGLISH ABSTRACT: Title Risk factors associated with the severity of pneumonia in a cohort of hospitalised children in a rural setting Background Pneumonia remains a leading cause of death in South African children under 5 years of age. Known risk factors have been the focus of public health strategies to mitigate disease. This study aimed to determine adverse household environmental factors associated with severe pneumonia in children admitted to Worcester Provincial Hospital (WPH). We compared the odds of adverse household environmental factors with severe pneumonia to non-severe pneumonia in children under 5 years admitted to WPH. Methods We conducted a prospective case control study at WPH from the 1st of January 2019 to 31 December 2019 including children aged 0-59 months admitted with pneumonia. Using the WHO definition, children were categorised as having severe or non-severe pneumonia. Structured interviews with consenting primary caregivers were conducted in both groups on weekdays throughout the year. We compared demographic, social, maternal, infant, and household factors in children with severe pneumonia and non-severe pneumonia using multivariable logistic regression. Results A total of 305 children were assessed, comprising of 134 (43.9%) cases with severe pneumonia and 171 (56.1%) controls with non-severe pneumonia. Baseline characteristics of children including a median age of 6.9 months (IQR 2.5-17.5), exclusive breastfeeding practice (51.5%; n=157), term gestation at birth (65%; n=199), appropriate nutritional status (81.6%; n=249), appropriate immunisation status (86.9%; n=265), and HIV unexposed uninfected status (81.3%; n=248) were similar between groups. Caregiver characteristics were also comparable between groups including a median age of 28 years (IQR 23-33), South African citizenship (94.7%; n=288), some secondary schooling education (71.2%, n=217), and reported HIV negative status (81%; n=247). Univariable regression analysis did not demonstrate an association between severe pneumonia and adverse household environmental factors including indoor tobacco smoke exposure (unadjusted odds ratio (uOR) 0.73; 95% confidence interval (CI) 0.46-1.16), overcrowding (uOR 0.72; 95% CI 0.45-1.15) or indoor biomass fuel exposure (uOR 1.49; 95% CI 0.91-2.43). Multivariable analysis, adjusting for factors known to be associated with severe pneumonia in children (including age <3 months, birth weight <1500g, any breastfeeding, complete immunisation status, child’s HIV infection status, young maternal age, and caregiver education less than matric), did not demonstrate an association between severe pneumonia and adverse household environmental factors. However, children with severe pneumonia had at least a five times greater odds (aOR 5.42; 95% CI 1.10-26.65) of living in a household with a pit latrine toilet compared to any other toilet than children with non-severe pneumonia. Conclusion Within a fairly homogenous group of children admitted with pneumonia, few factors were found to be associated with pneumonia severity, except for living in a household with pit latrine toilet . Broadly, this may represent socioeconomic vulnerability and the risk associated with developing severe pneumonia and should be further explored in this setting. We did not identify any specific modifiable household environmental factors to be associated with severe pneumonia, however these factors could still be important risk factors for incident pneumonia, even if not associated with the severity of the pneumonia episode.