South African Journal of Child Health - Volume 7, Issue 1, 2013
Volume 7, Issue 1, 2013
Author D.F. WittenbergSource: South African Journal of Child Health 7 (2013)More Less
For the vast majority of newborn babies, birth and adaptation to extrauterine life happens as a completely normal process that does not require medical attention at all. For them, even the administrative routines of hospital admission are bypassed: they are cared for in 'nurseries' rather than in hospital wards, and they are usually registered together with their mothers (or not at all) in the obstetric service. Unavoidably, perhaps, the normal newborn infant and its mother's mothering ability are frequently virtually ignored and left to the most junior staff, who have almost certainly had inadequate training to deal with difficulties.
Source: South African Journal of Child Health 7, pp 4 –6 (2013)More Less
The transmission of HIV through breastmilk, with the potential to infect the newborn, has had a major impact on child health worldwide. Although South African studies confirmed that exclusive breastfeeding reduced rates of mother-to-child transmission of HIV, the recommendation of formula feeding for HIV-exposed newborn infants, provided their mothers had the facilities for safe preparation of formula milk and complied with the AFASS criteria (formula feeding to be Acceptable, Feasible, Affordable, Sustainable, Safe), was introduced. Observations made by the nursing staff, fully aware of the risks of formula feeding, in the neonatal unit at King Edward VIII Hospital in 2009 showed that an increasing number of small, sick newborns were being formula fed.
By conducting focus group discussions with nurses, mothers and counsellors and teasing out the confusions and misconceptions, relevant information was imparted to the groups to allow them to re-consider their misconceptions.
Within a period of 2 months nurses were confident about re-counselling mothers with respect to appropriate feeding choices. HIV-positive mothers were trained to flash-heat their milk. Subsequently, policies for the unit were derived from the focus group discussions. In addition, regional hospitals in the Durban area (eThekweni) considered the introduction of flash-heating to their units.
The South African Department of Health opted for infants to receive prophylaxis with daily nevirapine as long as they are breastfed, and the Nutrition Directorate decided to withdraw the issue of free replacement feeds in HIV-exposed babies. KwaZulu-Natal was the first province to institute this policy. The Department of Health has recommended that neonatal units no longer encourage HIV-infected mothers to flash-heat their breastmilk unless the infant is not receiving ARV prophylaxis or the mother is not on treatment.
Source: South African Journal of Child Health 7, pp 8 –12 (2013)More Less
Background. Optimal feeding regimens in babies weighing <1 000 g have not been established, and wide variations occur. In South Africa (SA) this situation is complicated by varied resource constraints.
Objective. To determine the preterm enteral feeding practices of paediatricians in SA.
Methods. We invited 288 paediatricians to participate in a cross-sectional web-based survey.
Results. We received responses from 31.2% of the paediatricians; 43.6% were from the state sector and 56.4% from the private sector. Most participants worked in medium-sized neonatal units with 6 - 10 beds. The proportions commencing feeds within the first 24 hours were 24% in infants of <25 weeks' gestational age, 36% in infants 25 - 27 weeks, and 65% in infants 28 - 31 weeks. Feed volumes were routinely advanced daily in 47% of infants <25 weeks, 68% of infants 25 - 27 weeks, and 90% of infants 28 - 31 weeks. Forty five per cent of infants <25 weeks received continuous intragastric feeds, while 50% of those in the 28 - 31 weeks group were on 3-hourly bolus feeds. The majority of the participants targeted full enteral feeds of 161 - 180 ml/kg/d, 66.7% had access to donor milk, and 77% used breastmilk fortifier.
Conclusion. This is the first study to survey feeding practices in SA. The survey did not highlight differences in feeding practices among paediatricians. These data could be valuable in the design of local collaborative trials to determine optimal feeding strategies.
Source: South African Journal of Child Health 7, pp 13 –16 (2013)More Less
Objectives. Survival of extremely low-birth-weight (ELBW) infants in a resource-limited public hospital setting is still low in South Africa. This study aimed to establish the determinants of survival in this weight category of neonates, who, owing to limited intensive care facilities, were not mechanically ventilated.
Design. A retrospective study in which patient data were retrieved from the departmental computer database.
Setting. The neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa.
Subjects. Neonates admitted at birth between January 2006 and December 2010 with birth weights of ≤900 g.
Outcome measures. Survival at discharge was the major outcome. Maternal variables were age, parity, gravidity, antenatal care, antenatal steroids, place and mode of delivery and HIV status. Neonatal variables were gestational age (GA), birth weight (BW), gender, place of birth, hypothermia, resuscitation at birth, sepsis, necrotising enterocolitis, intraventricular haemorrhage, jaundice, nasal continuous positive airway pressure (NCPAP) with or without surfactant, and Apgar scores.
Results. A total of 382 neonates were included in the study. Overall survival was 26.5%. The main causes of death, as per the Perinatal Problem Identification Programme (PPIP) classification, were extreme multi-organ immaturity and respiratory distress syndrome. The main determinants of survival were BW (odds ratio (OR) 0.994; 95% confidence interval (CI) 0.991 - 0.997) and GA (OR 0.827; 95% CI 0.743 - 0.919). Overall the rate of NCPAP use was 15.5%, and NCPAP was not associated with improved survival.
Conclusion. Survival of ELBW infants is low. BW and GA were the strongest predictors of survival. Effective steps are required to avoid extreme prematurity, encourage antenatal care, and provide antenatal steroids when preterm birth is anticipated.
Effect of prophylactic phenobarbital on seizures, encephalopathy and mortality in neonates with perinatal asphyxia : researchSource: South African Journal of Child Health 7, pp 17 –21 (2013)More Less
Background. Seizures after an asphyxial insult may result in brain damage in neonates. Prophylactic phenobarbital may reduce seizures.
Objective. To determine the effect of prophylactic phenobarbital on seizures, death and neurological outcome at hospital discharge.
Methods. Neonates with base deficit >16 mmol/l and Apgar score at 5 minutes <7 or requiring resuscitation for >5 minutes at the time of birth were randomised to prophylactic phenobarbital 40 mg/kg (n=50) or placebo (controls) (n=44) within the first 6 hours of life. They were monitored for clinical seizures, hypoxic ischaemic encephalopathy (HIE) and mortality.
Results. Seizures developed in 30.0% of the phenobarbital group as opposed to 47.7% of the control group (relative risk 0.63; 95% confidence interval -0.37 - 1.06; p=0.083). The proportions of patients who had died and/or had HIE II or III at time of discharge from hospital were similar in the two groups (42.0% v. 45.5%). There were no differences in mortality between the two groups (14.0% v. 15.9%).
Conclusion. In infants with asphyxia, prophylactic phenobarbital does not reduce the incidence of seizures, HIE and mortality.
Rebound hyperbilirubinaemia in neonates admitted to Mofid Children's Hospital, Tehran, Iran : researchSource: South African Journal of Child Health 7, pp 22 –24 (2013)More Less
Introduction and aim. Approximately 60% of term neonates and 80% of preterm neonates develop hyperbilirubinaemia in the first week of life. Rebound hyperbilirubinaemia may occur after cessation of phototherapy, especially when the Coombs test is positive, in premature infants, and in those treated with phototherapy for less than 72 hours. The main aim of this study was to evaluate the billirubin level 24 and 48 hours after cessation of phototherapy in neonates admitted to our hospital with jaundice. We also evaluated haemoglobin (Hb) levels and duration of phototherapy for a possible association with rebound hyperbilirubinaemia.
Patients and methods. The study was a clinical trial in term neonates (gestational age ≥37 weeks) with hyperbilirubinaemia who were admitted to the Department of Neonatology at Mofid Children's Hospital, Tehran, Iran. Exclusion criteria were neonatal infection, glucose-6-phosphate dehydrogenase deficiency, a history of neonatal exchange transfusion, and parental refusal. Phototherapy was delivered via a Philips TL 45/20W at 15 - 20 cm distance from the skin. We discharged patients after cessation of phototherapy. Total serum bilirubin (TSB) was checked in the neonates 24 and 48 hours after cessation of phototherapy. We included patients in whom follow-up tests were completed at 24 and 48 hours after discharge. Chi-square and Student's t-tests were used for data analysis using SPSS version 13.0 (SPSS Inc., Chicago, IL, USA).
Results. Twenty-five girls and 37 boys were included in the study. The mean admission age was 5.4 (standard deviation (SD) ±0.5) days for girls and 8.0 (SD ±0.6) days for boys (p=0.041). The mean Hb values for the girls and the boys were 15.0 (SD ±0.39) g/dl and 15.9 (SD ±0.36) g/ dl, respectively (p=0.108). The mean TSB levels for the girls and the boys were 322.6 (SD ±9.4) µmol/l and 322.3 (SD ±7.3) µmol/l, respectively (p>0.05). The mean admission and pre-discharge TSB levels of 322.3 (SD ±5.6) µmol/l and 187.9 (SD ±3.2) µmol/l were significantly different (p=0.0). The mean TSB levels 24 and 48 hours later were 197.8 (SD ±4.6) and 195.1 (SD ±5.3) µmol/l, respectively, with no significant difference between them (p>0.05).
Conclusion. We found no significant differences between mean TSB levels at the time of termination of phototherapy and 24 and 48 hours later. We therefore do not recommend checking for rebound bilirubinaemia after phototherapy.
Source: South African Journal of Child Health 7, pp 25 –29 (2013)More Less
Background and aim. Neonatal sepsis is a significant contributor to morbidity and mortality globally. Blood culture is the most reliable method for detection of bacterial infection. However, its sensitivity is low and its use in the diagnosis of bacteraemia is fraught with difficulties. CD64 antigen is up-regulated in neutrophils only when they are activated, and has been shown to be a potential biomarker for infection. The primary objective of this study was quantitation of neutrophil CD64 by flow cytometry in neonates with signs and symptoms suggestive of sepsis/infection in the first 4 weeks of life.
Methods and results. In this prospective observational study, patients were classified into categories of infection, namely definite, probable and possible. Of 76 neonates, 1 had definite infection, 5 probable infection, 30 possible infection, and 32 no infection. The neutrophil CD64 index at a cut-off value of 1.8 had a high negative predictive value (95.2%) in ruling out combined probable and definite infection.
Conclusions. We recommend inclusion of the neutrophil CD64 index into the diagnostic algorithm for neonatal sepsis, as it has a high negative predictive value and can be used to rule out infection. As the positive predictive value of the index was low in confirming infection, it should be used as a screening rather than a confirmatory test.
The profile of indications for radiography in the Neonatal Intensive Care Unit at Universitas Academic Hospital, Bloemfontein : researchSource: South African Journal of Child Health 7, pp 30 –34 (2013)More Less
Introduction. Radiography is a key diagnostic tool in paediatric care. A pro-active approach (including the use of radiography) is required to ensure effective management of these patients. Taking into account the widely documented harmful effects of ionising radiation and the small organ masses of neonates, the number of radiographs that neonates receive during hospital admission is of particular concern. A reduction in radiation exposure tailored to specific indications would be advantageous. The aim of this study was therefore to establish a profile of indications for radiographs in the Neonatal Intensive Care Unit at Universitas Academic Hospital, Bloemfontein, South Africa.
Methods. A retrospective, descriptive study was conducted over a 1-month period (8 September - 8 October 2010). Information was obtained from the online Medi-Tech system used to request radiographs.
Results. A total of 469 radiographs were performed on 51 neonates. Twenty-seven male and 24 female neonates received 226 (48.2%) and 243 (51.8%) radiographs, respectively. The radiographs were classified into routine (91.9%) and urgent (8.1%). Chest radiographs were requested most frequently (59.5%). The most commonly recorded indication was prematurity (37.1%), followed by respiratory-related indications (28.5%). The highest number of radiographs performed on a single neonate was 46.
Conclusions. All radiographs were requested online, supporting the validity of the study with regard to the number of radiographs performed and their respective indications. A representative profile of indications was successfully obtained, which can assist with the implementation of further research on the stratification of radiation exposure according to indications for radiographs.
An unusual case of neonatal meningococcal meningitis complicated by subdural empyema and hydrocephalus : case reportSource: South African Journal of Child Health 7, pp 35 –37 (2013)More Less
Neisseria meningitidis is a leading cause of pyogenic meningitis worldwide, as well as causing large epidemics in parts of Africa. With the dramatic decline in cases of Haemophilus influenzae B, N. meningitidis has emerged as one of the most common causes of acute bacterial meningitis in children and adults in South Africa. However, it remains an uncommon cause of meningitis in the neonatal period. Subdural empyema together with hydrocephalus has been infrequently described as a complication of meningococcal meningitis.
We report a rare case of neonatal meningococcal meningitis, complicated by subdural empyema and hydrocephalus. To the best of our knowledge only a few cases of neonatal meningococcal meningitis have been reported from South Africa, with none of these cases having the complication of subdural empyema.
Source: South African Journal of Child Health 7, pp 38 –39 (2013)More Less
Context. The dorsal cutaneous appendage, or so-called human tail, is often considered to be a cutaneous marker of underlying occult spinal dysraphism. Human tails have always elicited curiosity. A unique case of human dysraphism is described.
Case report. An interesting case of a child with a tail-like caudal appendage that had been present since birth is reported. Surgical excision of a pseudo-tail was done together with repair of a meningocele.
Conclusion. Before any form of treatment for a caudal appendage is undertaken, the patient must be evaluated carefully in case it coexists with a lesion of the intraspinal component.