3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item Pregnancy outcomes in women receiving intrapartum epidural analgesia at the Chris Hani Baragwanath academic hospital a 6-month review(2017) Padayachee, VeneshreeObjectives This study had two objectives. The first was to describe the maternal outcomes and complications associated with epidural analgesia and the neonatal outcomes of babies born to women receiving intrapartum epidural analgesia. The second was to assess the progress of labour in women receiving epidural analgesia and the incidence of caesarean section and assisted vaginal deliveries. Study design This was a cross sectional retrospective descriptive study of all women who received intrapartum epidural analgesia and the neonates born thereof between 01/05/2015 and 31/10/2015. Methods Women who received intrapartum epidural analgesia were identified from the epidural registers at the Chris Hani Baragwanath Academic Hospital (CHBAH). The medical records of these women and their neonates were retrieved and the relevant data reviewed, captured and analysed. Results There were a total of 9305 women that delivered between 01/05/2015 and 31/10/2015, of which 302 received intrapartum epidural analgesia. The incidence of epidural use during this period was 3.24%. The median gestational age at delivery was 38.9 (37 - 42) weeks’ gestation. The incidence of epidural related complications was 17%, comprising of hypotension (13.4%) and other minor complications (3.6%) with no associated morbidity or mortality. Eighty-four (29.7%) of the women had poor progress of labour pre and post epidural and 13 (4.6%) women post epidural only. Oxytocin for augmentation of labour was used in 96 (32.8%) women. The incidence of prolonged second stage of labour was 26.9% with an average duration of 63 ±33 minutes, with a longer duration observed in primigravid women. There were 142 (50.2%) normal vaginal deliveries, 23 (8.1%) assisted vaginal deliveries and 118 (41.7%) caesarean sections, of which fetal distress (23%) was the main indication. v There were a total of 62 cardiotopographs (CTG), that changed from reactive to suspicious post epidural, of those 52 neonates were born with an Apgar score of >7. Of the 283 neonates delivered, 278 (98.2%) neonates were born alive with 258 (91.2%) neonates with Apgar scores of >7 and 23 (8.1%) with Apgar scores <7. The incidence of adverse neonatal outcomes was 4.2%. The fetal outcomes stratified by maternal, epidural and labour outcomes reflected neither associative nor causal relationship to adverse fetal outcomes. Conclusion At the CHBAH, intrapartum epidural analgesia uses resulted in a maternal complication rate of 17%, with no reported maternal morbidity or mortality. There was no statistical increase in the incidence of poor progress of labour, use of oxytocin and caesarean section or assisted vaginal deliveries. Two hundred and fifty eight (91.2%) neonates were born with Apgar scores of >7, and an adverse neonatal outcome rate of 4.2%. Therefore the benefits of epidurals analgesia outweigh the risks.Item To assess the accuracy of pulse oximetry screening as a tool to detect critical congenital heart disease in asymptomatic newborns at altitude(2018) Platten, MichaelIntroduction: Pulse oximetry screening (POS) in the newborn period has been shown to improve early detection of critical congenital heart disease (CCHD) before significant morbidity and/or mortality develop. Acceptable sea-level saturation thresholds range from 90-95% in newborns whereas at altitudes >1500m this decreases to 88-93% due to lower partial pressures of oxygen. Objective: To determine whether lower oxygen saturation thresholds would be better suited to direct POS in neonates born at altitude (>1500m), and to compare the revised cut-offs to those recommended by the American Academy of Pediatrics (AAP) guidelines for POS for CCHD. Methods: We performed a prospective descriptive study of well newborn patients born during a period of two months (October and November 2015) at Chris Hani Baragwanath Academic Hospital (CHBAH). POS was conducted in term newborns at >12 hours of age measuring saturations in the right hand (pre-ductal) and either foot (post-ductal). Using a modified version of the AAP POS guidelines (Pre-ductal saturations 93% and post-ductal 88% for CHBAH versus 95%/90% for AAP), all patients underwent echocardiogram to confirm the results of screening. Results were analysed assessing the effects of altitude on screening. Results: Three-hundred and forty eight infants were included in the study. No patients with CCHD were identified. Mean saturations were 94% for right hand and foot. Adjusted cut-offs of 93-88% result in 15.2% of patients requiring repeat screening and 41.3% using AAP guidelines (95-90%). Failed screens were attributed to physiological right-to-left or bi-directional shunting in 3/348 (0.8%). Accuracy is comparable internationally (sensitivity (100%), specificity (99.4%) and false positive rate (0.64%)). Conclusions: Altitude does not affect the accuracy of POS. If screening is to be implemented above 1700m, adjusted POS cut-offs of 93-88% should be considered at altitudes above 1700m.Item Maternal nutrition during pregnancy and its association with birth outcomes and neonatal body composition in the context of HIV in urban Black South Africans(2018) Wrottesley, Stephanie VictoriaBackground: Maternal pre-pregnancy overweight and obesity and excessive gestational weight gain (GWG) are established predictors of fetal growth, which substantially increase the risk of adverse birth outcomes, such as high birth weight and large-for-gestational age deliveries. While sub-optimal growth in utero has serious implications for infant health in the short term, nutritional insults during this critical period of plasticity may additionally impair growth and development of body tissues and thereby, increase long-term risk of obesity and non-communicable diseases in later life. This double burden of malnutrition (maternal overweight coupled with micronutrient deficiencies) is of particular relevance to low-or middle-income countries, such as South Africa, where rapid urbanisation and a transition towards diets high in saturated fat, sugar, salt and processed foods and decreased levels of physical activity has resulted in substantial increases in obesity. Although the implications of anthropometrically defined maternal nutritional status (MNS) on birth size have been well established, the role of dietary patterns within these relationships has not been thoroughly examined. In addition, the use of birth weight as a proxy for fetal growth does not distinguish between the components of body composition (i.e. fat mass and fat-free mass), which may be more indicative of metabolic risk. Lastly, the influence of other maternal factors such as human immunodeficiency virus (HIV) on the associations between maternal nutrition and infant outcomes and metabolic risk is yet to be explored. Aim: The overall aim of this thesis was to examine maternal nutrition (nutritional status; dietary patterns) of urban, black South African women and explore the relationship between maternal dietary patterns during pregnancy and birth outcomes (including neonatal body composition). Furthermore, the extent to which other maternal factors – i.e. HIV/antiretroviral treatment (ART) status, body mass index (BMI) at recruitment, GWG, demographics, socioeconomic status etc. - act as confounders or effect modifiers to these associations was explored. The following four specific study components addressed this aim: 1) To review and report on MNS in African women and its associations with fetal, birth, neonatal and infant outcomes in the first 1000 days; 2) to compare body composition measurements using two methods, namely (i) dual-energy x-ray absorptiometry (DXA) and (ii) air displacement plethysmography (ADP; Peapod), in black South African neonates; 3) to characterise, depict and report on maternal dietary patterns during pregnancy using multivariate dimension-reduction techniques in urban black South African women and to examine the association between dietary patterns and GWG in the context of other maternal lifestyle and socioeconomic factors; and 4) to examine the associations between maternal dietary patterns and birth size and neonatal body composition and explore how specific maternal factors – i.e. HIV/ART status, maternal BMI and GWG – may influence these associations. Methods: Comprehensive literature searches were independently performed by two researchers in May 2015 in order to identify all relevant studies conducted in Africa. The review used a systematic approach to search the following databases: Medline, EMBASE, Web of Science, Google Scholar, ScienceDirect, SciSearch and Cochrane Library. Full-text articles were obtained and reviewed and data were extracted from relevant publications into tables appropriately. Within a wider longitudinal cohort study taking place in Soweto, Johannesburg (the Soweto First 1000-Day Study; S1000), habitual dietary intake of 538 pregnant women was assessed using a quantitative food-frequency questionnaire and dietary patterns were depicted via principal component analysis. Associations between dietary patterns and BMI-specific GWG were analysed using linear and multinomial logistic regression. ―Traditional‖ diet pattern adherence (pattern score) was used to classify maternal diet for the final study objective (objective 4) and multiple linear regression models were used to examine associations between maternal ―traditional‖ diet pattern score, HIV/treatment status [three groups: HIV negative, HIV positive (antenatal ART initiation), HIV positive (pre-pregnancy ART initiation)], BMI and GWG (kg/week) and: newborn (1) weight-to-length ratio (WLR, kg/m) in 393 mother-neonate pairs; (2) Peapod estimated fat mass index (FMI, kg/m3) in a 171-pair subsample. Results: Twenty-six studies met the inclusion criteria for the literature review (objective 1). Overall, MNS in Africa showed features typical of the epidemiological transition; including higher overweight and obesity and lower underweight prevalences, alongside high anaemia prevalences’ and poor-quality diets. Maternal BMI and GWG were positively associated with birth weight; however, maternal overweight and obesity were associated with both increased macrosomia (birth weight >4kgs) and intrauterine growth restriction risk. In addition, maternal anaemia was associated with lower birth weight and both macro- and micronutrient supplementation during pregnancy was associated with improvements in GWG, birth weight and mortality risk. During the comparison of body composition assessment techniques (objective 2), significant correlations were observed between ADP and DXA measurements of fat mass (r = 0.766; p<0.001), fat-free mass (r = 0.942; p<0.001) and %fat (r = 0.630; p<0.001). However, fat mass (408 ± 172 g vs. 337 ± 165 g; p<0.001) and body fat percentage (12.9 ± 4.4% vs. 9.9 ± 4%; p<0.001) were significantly higher and fat-free mass (2681 ± 348 g vs. 2969 ± 375 g; p<0.001) significantly lower when estimated by ADP than by DXA. There was greater consistency in the estimation of fat-free mass between the methods when compared to estimates of fat mass and body fat percentage. Longitudinal assessment (objectives 3 and 4) identified three dietary patterns in urban black South African women during pregnancy: namely ―western‖, ―traditional‖ and ―mixed‖. ―Western‖ and ―mixed‖ diet patterns were associated with 35 g/week (p=0.021) and 24 g/week (p=0.041) higher GWG in normal weight and obese women respectively. High intakes of the ―traditional‖ diet pattern were associated with a reduced odds of excessive weight gain in the total sample (OR: 0.81; p=0.006) and in normal weight women (OR: 0.68; p=0.003). In the final, fully adjusted study models, maternal obesity and GWG were associated with 0.25 kg/m (P=0.008) and 0.48 kg/m (P=0.002) higher newborn WLR, while ―traditional‖ diet pattern score was associated with lower newborn WLR (-0.04 per +1 SD; P=0.033). Additionally, ―traditional‖ pattern score was associated with 0.13 kg/m3 (P=0.027) and 0.32 kg/m3 (P=0.005) lower FMI in the total sample and in newborns of normal weight women, respectively. HIV positive (pre-pregnancy ART) vs. HIV negative (ref) status was associated with 1.11 kg/m3 (P=0.002) higher newborn FMI in a fully adjusted model. Conclusion: This thesis confirms the rapid transition in MNS across urban African populations and demonstrates the implications that the rise in maternal overweight and obesity alongside poor dietary patterns and micronutrient deficiencies may have on birth outcomes, as well as potentially on longer term health trajectories. However, it also highlights a lack of data on infant outcomes beyond birth, and therefore, a need for longitudinal data that examines longer-term implications in the African setting. In South Africa in particular, the thesis indicates that promotion of a traditional-style diet pattern - high in whole grains, legumes, vegetables and traditional meats and low in processed foods - alongside a healthy preconception weight in urban, black women would significantly improve both maternal and infant adiposity profiles. This may have substantial benefits in reducing long-term risk of non-communicable diseases in both current and future generations. However, the need for a holistic approach which incorporates other health and lifestyle determinants of growth and adiposity in the infant is critical in optimising metabolic health trajectories. In HIV-positive women for example, development of targeted monitoring and management strategies is necessary in order to limit the treatment-specific effects on adiposity in the newborn.Item Iron storage in the neonatal period of the human infant(1950) Van Dongen, L. G. R.Iron is one of the vital elements of the human body. Without it respiration would be quite impossible. Haemoglobin, the transporter of oxygen throughout the body, has iron as an essential constituent, and it is in this protein complex that the greatest bulk of the metal is found. Iron also plays a very essential part in the respiration of the tissues, as it is a vital element in intracellular respiratory enzymes such as catalase, cytochrome, cytochrome oxidase, etc. Further it is found in the chromatin material of nuclei in the cells of all the tissues.Item A review of chronic lung disease in neonates at Charlotte Maxeke Johannesburg Academic Hospital from 1 January 2013 to 31 December 2014(2017) Mphaphuli, Aripfani VeronicaBackground. Chronic lung disease (CLD) remains a significant morbidity in preterm babies despite advances in neonatal care. The use of postnatal corticosteroids (PNCS) to treat CLD remains controversial. Objectives. To describe the clinical characteristics of babies with CLD at Charlotte Maxeke Johannesburg academic hospital (CMJAH) and to explore the use of PNCS for the prevention and treatment of CLD. Methods. This was a 2-year retrospective review of neonates admitted to CMJAH. Neonates who were in hospital for ≥28 days were included. Comparisons were made between neonates with evolving CLD and those with no CLD. Results. A total of 485 neonates were analysed, 237 had evolving CLD and 245 did not have CLD. Overall incidence of evolving CLD was 5%. More neonates with CLD needed resuscitation at birth (48.5% v. 39.8%; p=0.02) and had low 5 minutes Apgar scores (17.2% v.10.6%; p=0.001). Neonates with CLD had increased prevalence of patent ductus arteriosus (30.4% v. 7.7%; p=0.001) and late onset sepsis (56.5% v. 23.6%; p=0.001). The mortality rate was also higher in CLD babies (10.2 v. 2.4%; p=0.001). Necrotising enterocolitis (NEC) (29.2% v.8%; p=0.005) and sepsis (83.3% v. 53.8%; p=0.008) were associated with increased mortality. The use of PNCS was associated with less NEC (3.5% v. 17.2%; p=0.001) and improved survival (95.6% v. 81.7%; p=0.001). Conclusions. CLD remains a common morbidity in neonates despite advances in neonatal care. The use of PNCS was shown to have short-term benefits. To get the most out of PNCS use for CLD, further studies need to be conducted to determine the safest type of steroid, the safe doses and the duration of treatment. S Afr J Child Health 2016;106(6):xx-xx. DOI:10.7196/SAJCH.2016v106i4.1060 Background The clinical definition of neonatal chronic lung disease (CLD) also known as bronchopulmonary dysplasia (BPD) has evolved over time. It was first defined by Northway et al. in 1967 as persistent respiratory signs and symptoms along with the need for supplemental oxygen and an abnormal chest X-ray (CXR) at 28 days of age.[1] The definition of CLD was subsequently modified and defines BPD as oxygen dependence at 36 weeks post menstrual age (PMA) with or without the use of respiratory support and with or without the characteristic radiographic changes.[2] These definitions do not consider gestational age (GA) and do not indicate the level of oxygen dependence that can range from needing low-flow oxygen to being ventilator-dependent. To address this issue, the National Institute of Health has developed a consensus severity-based definition. This definition includes all babies born as needing more than 21% supplemental oxygen for at least 28 days. CLD is further classified into mild, moderate and severe, depending on the FiO2 needed and the duration of oxygen therapy for preterm babies.[3] Because of the complexity of the definition, some units just use the need for oxygen on day 28 of life and often refer to this as evolving CLD. The incidence of CLD as defined by the need for oxygen supplementation at 36 weeks PMA is ~30% of premature infants with birth weight (BW) <1 000 g and is uncommon in infants born at >30 weeks of gestation or weight of >1 250 g.[3] CLD has multifactorial aetiology and remains a major cause of morbidity in premature infants[1].Contributing factors include infection, exposure to high oxygen levels with the formation of toxic oxygen free radicals and ventilator-induced lung injury that results in arrested lung development and impaired lung function.[4] Several maternal risk factors including increasing age, hypertension, lack of antenatal steroid usage and chorioamnionitis have been associated with BPD.[4] Over the past few years, the pathophysiology and aetiology of BPD has changed. This pathophysiological and aetiological shift has been bought about by improved survival in extremely premature babies as a result of for instance, antenatal steroids and surfactant therapy. The classic BPD was characterized mainly by lung damage and fibrosis due to oxygen toxicity and mechanical ventilation. The new BPD is characterised by a disorder in lung development with fewer, larger and simplified alveoli. The management of CLD includes several preventive and therapeutic strategies that target several pathways and processes involved in pathogenesis of CLD. Some provide antioxidant protection; others minimise specific aspects of inflammation, reduce elastolytic and proteolytic injury or regulate growth. In addition, supportive pharmacological treatments that target the development of pulmonary oedema, bronchoconstriction and impaired gas exchange are used. The success of these interventions has been variable.[5] Postnatal corticosteroids (PNCS) have been extensively studied and have been found to be effective in weaning infants off mechanical ventilation.[6-8] This effect has been proven for dexamethasone, which is the most widely studied PNCS in randomized controlled trials (RCTs). Despite the short-term benefits, dexamethasone has not been shown to reduce the total days of hospitalisation, duration of supplemental oxygen therapy, or incidence of CLD.[6-8] In the era before PNCS treatment, the long-term neurodevelopmental outcome for survivors with CLD was worse than that in similar infants without CLD.[9] Adverse effects of PNCS that includes hyperglycaemia, gastrointestinal (GIT) perforation, hypertension, infection, steroid-induced cardiomyopathy, long-term neurodevelopmental effects and growth retardation complicate the use of PNCS. The most worrisome long term effect is increased risk for poor neurological outcome including cerebral palsy (CP). Corticosteroids can have direct toxic effects on the developing brain, including neuronal necrosis, interference with healing and inhibition of brain growth.[9,10] A systematic review showed a significantly higher rate of CP after corticosteroid treatment and a non-significant reduction in mortality.[11] A multicentre double blinded RCT testing early postnatal dexamethasone therapy for prevention of CLD had to be stopped before completion because of concern about serious side effects such as GIT perforation and periventricular leukomalacia (PVL).[12] The American Academy of Pediatrics (AAP) also recommended that alternative corticosteroids undergo studies and that all infants enrolled in RCTs for PNCS receive long-term neurodevelopmental follow up.[13] Due to concern about the safety of PNCS, in 2002 the AAP released a policy statement regarding the use of PNCS for prevention or treatment of CLD stating that the routine use of dexamethasone could not be recommended.[13] The AAP recommended that dexamethasone use be limited to RCTs with long-term follow up. Since the publication of the AAP statement, postnatal use of dexamethasone for CLD has reduced; however the incidence of CLD has not diminished. Some reports have suggested that the incidence and severity of CLD may have actually increased.[14] The data available for PNCS use in CLD are inconclusive and conflicting. As a result, clinicians are advised to use their own clinical judgment to balance potential adverse effects of CLD with the potential adverse effects of PNCS for each individual patient. The incidence of CLD in very low birth weight (VLBW) babies at Charlotte Maxeke Johannesburg academic hospital (CMJAH) is lower than that reported in the Vermont Oxford network (VON).[15] At CMJAH, babies who are on supplemental O2 for >28 days are given oral prednisolone (OP) for prevention/treatment of CLD. Babies who remain ventilator dependent are given dexamethasone. Alternative PNCS include hydrocortisone, nebulised dexamethasone and oral prednisone.[5] One study looking at the effect of short course of oral prednisone (OP) in infants with O2 dependent BPD provided evidence that OP is effective in a select patients with BPD.[16] Characteristics of babies with CLD and the use of PNCS have not been reviewed at CMJAH. This study aims to describe babies with evolving CLD and to explore the use of PNCS for evolving CLD at CMJAH. Methods This study is an institution-based retrospective audit conducted in the neonatal unit at CMJAH in Parktown, Gauteng Province. The objectives were to determine the incidence of CLD at CMJAH, to describe clinical and demographic characteristics and survival to discharge in babies with CLD and to compare these to those of babies without CLD. Evolving CLD was defined as oxygen use at 28 days of life and the need for supplemental oxygen at 36 weeks PMA was considered as definite CLD (VLBW babies only). Following approval by the Committee for Research in Human Subjects at the University of the Witwatersrand (Medical), the CEO and the HOD of Paediatrics at CMJAH, a 2-year (1 January 2013 to 30 December 2014) retrospective review of neonatal medical records was performed. Data from the existing CMJAH neonatal database (Research Electronic Data Capture hosted by the University of the Witwatersrand) was used for analysis. [17] The data are collected prospectively on an ongoing basis for the purpose of clinical audit from clinician completed hospital records. All babies admitted to the CMJAH neonatal unit within 72 hours of life (inborn and outborn), with BWs of ≥500 g, who were in hospital for ≥28 days were included. Babies with irretrievable data were excluded from the study. The group was divided into babies with evolving CLD and those without. The neonatal unit at CMJAH has 84 beds, 35 of which are high-care, 14 in paediatric/neonatal intensive care unit, 20 low-care beds and 15 kangaroo mother care beds. Respiratory support includes early rescue surfactant (SVT), supplemental oxygen via low-flow nasal cannulae (NPO2), nasal continuous positive airway-pressure ventilation (NCPAP), intermittent positive-pressure ventilation (IPPV) and high frequency oscillatory ventilation. Due to limited resources ventilatory support in the form of NCPAP was only offered to babies with BW ≥750 g who showed signs of respiratory 10 failure. Babies with BW ≥900 g who showed signs of respiratory failure on NCPAP or became apnoeic were offered IPPV. Respiratory failure was defined as O2 saturation <88% on 60% supplemental O2, respiratory acidosis (pH <7.25 with PaCO2 >60 mmHg) or markedly increased work of breathing. Definitions Maternal hypertension included both chronic and pregnancy induced hypertension. Chorioamnionitis was defined as premature and/or prolonged rupture of membranes, fever and foul smelling liquor in mothers. Resuscitation at birth was defined as the need for bag mask ventilation, chest compressions, or intubation and ventilation. The Ballard score was used to estimate gestational age (GA). Fenton growth charts (2013) were used to assess weight for gestational age.[18] The whole group of neonates was described and then stratified by BW category namely: •! ≥500-999 g, extreme low birth weight (ELBW) •! ≥1000 to 1499 g, very low birth weight (VLBW) •! ≥1500 to 2499 g, low birth weight (LBW) •! ≥2500 g, normal birth weight (NBW). Babies were considered to be small for GA if the BW was <10th percentile.[18] The 5 minute Apgar scores were categorised into two groups, namely Apgar score ≤5 and Apgar score >5. Babies were divided according to GA into two groups, namely <32 weeks and ≥32 weeks. PNCS was defined as steroids given in an attempt to facilitate weaning of patients off prolonged ventilation or supplemental oxygen. Dexamethasone is given to patients failing to wean off mechanical ventilation. NEC was considered as modified Bell’s stage ≥2.[19] Sepsis was classified as culture-proven bacterial or fungal blood stream sepsis only. Statistical analysis The data was assessed for missing information and erroneous or suspicious entries. These entries were verified as far as possible with the original patient records. Information not available from the database was obtained from hospital files drawn from the hospital record archives. The database was then exported to IBM SPSS Statistics version 23.0 for analysis. Babies with evolving CLD: Babies in different weight categories were compared in terms of therapeutic intervention and outcome. Babies who received PNCS were compared to those who did not, and babies who survived to discharge were compared to those who died. Finally the CLD group was then compared to the no CLD group. The data were normally distributed, so continuous variables were described using means and standard deviations (SD) while frequencies (percentages) were reported for categorical variables. For comparison Chi-square tests were used for categorical variables and independent t-tests for continuous variables. All analyses considered a value of p<0.05 as significant. Results There were 485 babies hospitalised for more than 28 days; records were not retrievable for 3 patients. Therefore, 482 patients were included, 237 with evolving CLD and 245 without CLD. The overall incidence of evolving CLD was 237/4570 (5.1%). The incidence in the VLB)W babies was 206/1,302 (15.8%) and 31/3,268 (0.94%) in the >1 500 g babies (p<0.0001).The incidence of definite CLD was 98/1,302 (7.5%) in the VLBW babies. Demographic and birth characteristics are shown in Table 1. There was no difference in the birth weight between babies with and without CLD (1017 grams (SD 101) vs 1041 grams (SD 104) p = 0.57). Similarly gestational age was not different between the two groups (CLD 28.2 weeks (SD1.9) vs no CLD 28.3 weeks (SD 1.9) p = 0.9). There were, however, more babies who were SGA in the no CLD group than in those with CLD (26.5% vs 12.9% p=0.03). The percentage of males with CLD was greater (50.2) than in the no CLD group (40.8%). There was no significant difference in maternal obstetric and labour room characteristics between CLD and no CLD babies (Table 1). There were more babies who had 5 minute Apgar scores ≤5 and needed resuscitation at birth in the CLD group.Item Determination of the adequacy of cranial ultrasound requests and reports at Charlotte Maxeke Johannesburg academic hospital and Rahima Moosa mother and child hopsital(2017) Mutshutshu, NJINTRODUCTION: Cranial ultrasound is a cheap, effectiveand easy to use modality for the evaluation of cranial pathology in very sick paediatric population.It can be performed as a portable imaging investigation and repeated as many times as possible. New improvements in sonography equipment and technique make it possible for cranial ultrasound to compete with CTscanners in terms of identifying pathology. AIM: To determine the adequacy of cranial ultrasound requests and reports atCharlotte MaxekeJohannesburg Academic (CMJAH) and Rahima Moosa Mother and Child Hospitals (RMMCH) with regards to their completeness, accuracy and clinical relevance. METHOD: A retrospective review of 191 cranialultrasound requests and reportswas performed at two academic centres.A collection sheet (Appendix B)was developedby the principal investigator and supervisor guided by literature with regards to the information required within the cranial ultrasoundreport. A scoring method was then developed with a maximum score of 3 givenfor therequestadequacy and of 14for report adequacy. RESULTS: Only 49.74 % of the requests met the criteria for an adequate request.The mean report adequacy score was7.03 out of 14 withastandard deviation (2.02. Overall 50.26 % of the requests, scored average (2) and below average score. The most commonly reported variable was the presence or absence of hydrocephalus and the least reported was resistive index. vi CONCLUSIONS:Results demonstrate that requests and reportsof cranial ultrasoundare not adequateat both centres. A cranial ultrasound template was therefore developed to assist with the standardization ofreports.Item Birth weight recovery among very low birth weight infants surviving to discharge from Charlotte Maxeke Johannesburg academic hospital, neonatal unit(2016-10-17) Mudahemuka, Jean ClaudeBackground: The recommended growth velocity of very low birth weight (VLBW) infants is 15 g/kg/day. Several factors have been associated with poor postnatal weight gain. Objective: The aim of the present study is to provide current information on the postnatal growth of VLBW infants at Charlotte Maxeke Johannesburg Academic Hospital. Methods: This is a retrospective longitudinal study of VLBW infants surviving to discharge from Charlotte Maxeke Johannesburg Academic Hospital, Neonatal Unit from August 2013 to October 2013. Results: Sixty nine infants were included in the study. The mean growth velocity was 13.2 g/kg/day, the median weight loss was 7.69% and the median time for regaining birth weight was 16 days. Fifty one infants (73.9%) regained their birth weight at or before 21 days. There was a decrease in mean Z scores for weight from -0.32±1.25 at birth to -1.94±1.35 at discharge. A multiple linear regression showed a negative association between Z scores for weight at discharge and number of days nil per os without parenteral nutrition. Antenatal steroids were associated with poor growth velocity. There were no factors associated with regaining birth weight after 21 days on multiple logistic regression. Conclusion: This study shows a growth velocity in VLBW infants approaching recommended standards. The number of days without parenteral nutrition and use of antenatal steroids are associated with poor postnatal growth.Item Feasibility assessment of a universal newborn hearing screening programme at Rahima Moosa mother and child hospital(2016-10-17) Bezuidenhout, Jacqueline KimContext: Universal Newborn Hearing Screening (UNHS) is not routinely performed in South African state-run hospitals. Early identification of hearing impairments and subsequent early intervention, results in improved speech and language development and overall better cognitive outcomes. Objectives: We aim to investigate the number of neonates which could be screened for hearing deficits using the currently available staff and equipment, at a single institution over a set period of time, and to describe the outcomes of the screening test. Design, setting and patients: A prospective feasibility assessment conducting screening hearing tests on neonates born at a secondary level hospital in Johannesburg, South Africa, during a three month period. Methods: Hospital-based Audiologists conducted a risk factor assessment, otoscopic examinations and Distortion-Product Otoacoustic emissions (DPOAE) testing on the ears of eligible neonates. Repeat testing was carried out on neonates who presented with refer findings on the screening test. Testing time and challenges encountered were recorded. Analysis: Data was entered into Microsoft Office Excel ©, and later analysed using STATA I/C version 11©. v Results: Of 2740 neonates born during the study period, 490 (17.9%) were identified for screening and DPOAE testing was conducted on 121 (4.4%). The majority (74.4%) were screened in the first 24 hours of life. Repeat testing was required in 57 (47.1%) neonates, but only 20 returned for follow-up. The presence of vernix caseosa and excessive ambient noise were factors negatively impacting on the screening process. No maternal or neonatal risk factors were found to be significantly associated with refer findings on the screening test. Conclusion: The existing staff was unable to screen a significant number of neonates using DPOAE testing during the study period. Implementation of UNHS under current circumstances at this research site would likely not be feasible. Key words: Universal Newborn Hearing Screening; feasibility study; resource-poor settings; otoacoustic emission; hearing loss.Item A descriptive study of the distribution and relative frequency of neonatal tumours at Chris Hani Baragwanath academic hospital from 1 January 1988 - 31 December 2012(2014) Schickerling, Tanya MarieBackground: To describe the relative frequency and distribution of neonatal tumours; to determine the age at presentation to the oncology unit and to determine the extent of the delay in referral. To describe any associated syndromes in individual malignancies. Material and methods: A retrospective case series was performed covering 24 years. Demographics, means of diagnosis, treatment and outcome details were reviewed. Results: There were a total of 2626 patients that presented to the oncology department with suspected malignancies. Out of that, 2308 patients were diagnosed with a malignancy and 318 patients had benign tumours. Over the 24 year period 117 tumours were diagnosed in neonates (4,4%). Due to incomplete data 29 patients were excluded. Of the remaining patients, 61 were diagnosed with benign tumours and 27 with malignant tumours. The male to female ratio was 1: 1,5. The mean age at presentation was 16 days. The mean age at diagnosis was 36 days. Histology and radiology were diagnostic in 40,9% and 19,3% respectively. A combination of histology and radiology was used to make a diagnosis in 21,6% of patients, 11,4% of diagnoses were based on clinical examination and 6,8% on biochemistry and haematology. Malignant soft tissue tumours were the most common malignancy (25,9%) followed by renal tumours (18,5%), leukaemia (14,8%), neuroblastomas (11,1%) and retinoblastomas (11,1%). Teratomas (45,9%) and benign vascular tumours (44,3%) were the most common benign tumours. Chemotherapy was used to treat 22 neonates, while 50 underwent surgical removal of the tumour. Half (51,9%) of the patients diagnosed with a malignant tumour died, while 11,1% of patients were iv lost to follow up. Just under 10% (8,2%) of the patients diagnosed with a benign tumour died, while 44,3% of patients were lost to follow up. The overall mortality amongst patients diagnosed with benign or malignant tumours was 21,6%. Conclusion: There is a much higher incidence of benign tumours diagnosed in neonates (69,3%) compared to older children (12,1%). Only 1,2% of all childhood malignancies in our unit occurred in the neonatal period, which is slightly lower than the reported 2%. Two of the major issues that need to be addressed in the future management of neonatal tumours are prompt referral for prompt diagnoses and better follow up.Item Outcomes of babies born before arrival at a tertiary hospital in Johannesburg, South Africa(2015-04-17) Bassingthwaighte, MairiBackground. Babies born before arrival to hospital (BBBAs) constitute a high-risk newborn population. The literature demonstrates that BBBAs have increased perinatal mortality and morbidity. Objectives. To describe the maternal and neonatal characteristics of BBBAs presenting to Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), South Africa, and assess whether they have increased morbidity and mortality compared with inborn babies. Methods. This was a matched case-controlled retrospective record review of newborns presenting to the neonatal unit of CMJAH between 1 January 2011 and 31 January 2013. BBBAs were matched 1:1 with the next consecutive inborn on birth-weight category and gender. Results. A total of 356 neonates were analysed. BBBAs had higher mortality than inborn controls within the first 24 hours of hospital presentation (7.9% v. 3.9%; p=0.05). Mothers of BBBAs were more likely to be unbooked (58.4% v. 10.7%; p<0.001) and of higher parity (p=0.0008). HIV prevalence was similar amongst cases and controls (24% v. 28.7%), however there were significantly more unknown HIV status in mothers of BBBA’s (49.6% v. 32%; p=0.01). Cases had a higher prevalence of early sepsis (22.9% v. 3.6%; p=0.03) and birth asphyxia (14.5% v. 0.8%; p<0.001) than controls. Overall, more deaths occurred in the very-lowbirth- weight (VLBW) (24% v. 10%; p=0.06) and low-birth-weight (LBW) (7.46% v. 0%; p=0.02) BBBA’s compared to controls. Conclusion. We demonstrated higher mortality in the immediate postnatal period and in the VLBW and LBW categories compared with hospital-delivered neonates. Once admitted, there was no difference in mortality, length of stay or number of ICU admissions between cases and controls. Mothers who delivered out of hospital were more likely to be multiparous and unbooked and to have unknown HIV, RPR and Rh results. Neonatal resuscitation, transport and immediate care on arrival at the hospital should be prioritised in the management of BBBAs.