3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item An analysis of fifth year Paediatric teaching(1987) Skapinker, ReneeMuch teaching in paediatrics is done at the patient's bedside. The clinical ward round should integrate all the pertinent features of the case. A prospective study was undertaken at the Johannesburg Hospital to evaluate such teaching. Twenty-two fifth year medical students and ten paediatric consultants were studied during the students1 first exposure to clinical paediatrics. Analysis of the teaching showed that there were significant differences between ideal objectives set by the Department, what was actually taught during the clinical ward round and what students perceived as having been taught. Futhermore, consultants defined more objectives for the teaching session when this was done prior to the tutorial than after the tutorial. The correlation between objectives considered taught by consultants and those perceived by students as having been taught, was poorer when consultants defined their teaching objectives before the tutorials compared with when consultants defined their objectives after the tutorials. These findings indicate unrealistic expectations in terms of what tutors are able to cover in a ward round when the objectives are pre-defined. Further analysis of the data revealed a bias towards objectives which were inappropriate for students with limited clinical experience.Item Quality assurance of paediatric lateral chest radiographs(2017) Rajkumar, LeishaLateral chest radiographs are widely used, particularly in low and middle-income countries, for diagnosing pulmonary tuberculous lymphadenopathy. The World Health Organisation recommends that “good-quality chest radiographs (including lateral view, if and where possible) are essential for proper evaluation” of paediatric pulmonary tuberculosis. However, the quality of such radiographs has received little attention and there is no currently available quality assurance tool for evaluating these in children (or adults). AIM: To develop a quality assurance tick-sheet for paediatric lateral chest radiographs and to test it for quantifying radiographic errors. METHOD: A quantitative retrospective cross-sectional study, using a sample of 300 chest radiographs of paediatric patients being investigated for pulmonary tuberculosis for the period February 2008 to January 2013. A quality assurance tick-sheet and scoring system was created, using existing guidelines and reasonable radiological principles. Three readers applied the tick-sheet to the database of radiographs, to establish common errors affecting radiograph quality (radiographer-related and patient-related) and to determine the reliability of each criterion. A majority decision for the presence of each error and an average of the score was reported. Reliability of each quality assurance criterion was evaluated using raw agreement and the kappa statistic. RESULTS: Of the 300 radiographs, 67 (22.3%) were considered optimal using the tick-sheet’s scoring system i.e. had an average score of less than 1, and 182 (60.7%) demonstrated an average n score of 1-2. Patient-related errors were present in 208 (69.3%) of lateral radiographs, the most prevalent being left-to-right rotation in 153 (51%), under-inspired lungs in 82 (27.3%) and the presence of motion artefact in 27 (9%). Radiographer-related errors were present in 110 (36.7%), the most common of which were under-collimation 59 (19.7%) and over-exposure i.e. too dark 40 (13.3%). For 6 of the 11 criteria there was moderate, fair or substantial agreement (based on raw agreement or kappa): No side marker, Static artifact, Over-exposure i.e. too dark, Under-exposure i.e. too light, Under-collimation and Rotation:left-to-right. For the remaining 5 criteria there was slight agreement or less than chance agreement (based on raw agreement or kappa): Over-collimation, Rotation:sideto- side, Under-inspiration (described for the first time in this paper), Position and Motion artifact. CONCLUSIONS: Where the lateral chest radiograph is often key in diagnosing TB in children and diagnostic doubt resulting from the quality of the radiograph must be minimised, availability and use of the proposed quality assurance tick-sheet will foster more precise radiographic technique and also improve the radiological service offered. 5 of the 11 criteria with poor inter-rater agreement require improvement of the definition of the criterion to increase reliability.Item A case-control review of neonates with Meconium Aspiration Syndrome admitted to a Tertiary Hospital in Johannesburg, South Africa(2019) Jones, Lara AlexandraBackground: Neonates with meconium aspiration syndrome (MAS) represent a highrisk population. This study demonstrates the morbidity and mortality profile associated with this condition. Objectives: To isolate characteristics, complications and outcomes of neonates with MAS admitted to Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) and compare them with neonates born without MAS. Methods: The study was a case-control retrospective review of neonates admitted to the CMJAH neonatal unit between 1 January 2013 and 30 April 2015. Results: A total of 608 neonates were analysed. All cases were compared to the control group. The overall incidence of MAS was 7.6%. Neonates born with MAS had a higher mortality than controls (12.2% vs. 2.6%; p=0.001). Sixty-eight percent of neonates ventilated with MAS died. Neonates born with MAS were more likely to have a higher mean birth weight (3.1 kg vs. 2.6 kg) and to be term/post term (39.2 weeks vs. 36.2 weeks). Significantly more neonates with MAS were born small for gestational age compared to the control group (24.6% vs. 19.0%). Neonates with MAS were more likely to have poor Apgars (25.7% vs. 14.9%; p=0.001) and require ventilation (35.9% vs. 5.6%; p<0.001). Complications were higher in neonates born with MAS when compared to controls and included pneumothoraces (2.3% vs. 0.3%; p=0.003, PPHN (14.5% vs. 1%; p=0.001) and overall sepsis (13.3% vs. 7.6%; p=0.02). Factors associated with an increased mortality in the neonates with MAS were the development of HIE (p=0.001), PPHN (p=0.001) and the use of inotropes (p=0.001). Conclusion: Meconium aspiration syndrome is an important cause of morbidity and mortality in a resource limited setting. (261)Item The effect of parent administered infant massage on the developmental milestones of premature infants(2019) Perrie, MeganPrematurely born infants have been shown to have developmental delays in multiple areas when compared to infants who were born at term (Formiga & Linhares, 2010) (Guerra, et al., 2014). This study investigated the developmental milestones of infants who had and had not received parent-administered infant massage for the first four to six months of their lives. The Peabody Developmental Motor Scales Second Edition (PDMS-2) test was carried out on infants at birth and then again at four to six months actual age along with the Bayley Scales of Infant and Toddler Development Third Edition (BSID-III). Positive clinical effect sizes were shown in the massaged group in the Cognitive, Reflexes and Visual-Motor Integration sub-tests. There was also a strong correlation between frequency of massage and social-emotional development of the massaged infants. Larger scale research is still required to confirm the findings of this study.Item Effectiveness of a clinic-based newborn hearing screening programme in rural South Africa: parental perspectives(2018) Kgare, Khomotjo SharonNewborn hearing screening (NHS) has been successfully implemented in developed countries such as the United States of America and the United Kingdom. This is however not the case in developing countries such as South Africa. The challenges impact on the implementation of such programmes include lack of suitably trained personnel, financial resources for staff and equipment, institutional support and political will. The lack of NHS programmes in South Africa has resulted in the late detection of hearing loss in infants and children and subsequently delayed intervention. In order to address the lack of NHS, a rural clinic-based NHS programme was implemented in July 2014 at three primary health care (PHC) clinics in the Limpopo Province. The main aim of the study was to describe the parental/caregiver perspectives regarding the effectiveness of this rural clinic-based NHS programme. The effectiveness of the programme was also evaluated in terms of meeting national (HPCSA, 2007) and international (JCIH, 2007) benchmarks. A retrospective review of 2 302 audiological records of babies who underwent NHS between July 2014 to June 2015 was conducted. Concurrently, 18 parents of infants who underwent hearing screening as part of the programme were purposefully selected and semistructured interviews were conducted to explore the parental perspectives regarding the programme. The results of the retrospective record review revealed that the mean age of the infants screened during the review period was 112 days (2 – 341; ± 40.26). The overall coverage rate was 87% and the referral rate, 7%. The overall follow-up return rate was 32% and only 15% the infants who failed both the initial and rescreening underwent comprehensive diagnostic assessment to confirm their hearing status. The overall prevalence rate for significant sensorineural hearing loss was 0.4/1000 and 7.8/1000 for middle ear effusion. The parents/caregivers confirmed the perceived effectiveness of the NHS programme. All the participants were satisfied with the programme and confirmed the credibility of the screening programme and screeners. Parents indicated that they were empowered with knowledge regarding the importance of early detection of hearing loss in infants and young children. Accessibility was both a facilitator and a barrier with travel distance and cost the most often cited obstacles to attending follow-up appointments. The findings indicate it is feasible to implement clinic-based NHS programmes that effectively meet the needs of parents/caregivers of infants residing in rural areas of South Africa. Although not all the benchmarks were met within the first year of implementation, the high coverage- and low referral rates are the first steps in improving the outcomes of the screening programme. The study highlight the importance of regular monitoring and evaluation of the NHS programmes to keep track of key outcomes and impacts related to the different components of the programmeItem The accuracy of three weight estimation tools in children(2018) Manyoni, Mncedisi JuniorBACKGROUND One of the most important parameters that must be obtained when resuscitating a critically ill or injured paediatric patient is their weight. The best-known paediatric weight estimation system is arguably the Broselow Tape, but the tape has been shown to be very inaccurate. OBJECTIVES The study has two objectives, to determine and compare the accuracy of the Broselow tape, a modified Broselow tape system, the PAWPER XL tape and the hanging leg weight technique for potential utilisation in the paediatric resuscitation setting. METHODS A convenience sample of 200 children between the ages of 1 month and 16 years were enrolled. All the children’s weights were estimated using the Broselow tape, a habitusmodified Broselow tape system, the PAWPER XL tape and the hanging leg weight technique. Overall accuracy was evaluated using the percentage of weight estimations falling within 10% of actual weight (PW10). RESULTS The PAWPER XL tape performed the best, whilst the hanging leg weight technique performed the poorest with PW10s of 74% and 19.5%, respectively. The Broselow tape with and without habitus-modification only showed modest accuracy, with PW10s of 59.1% and 61.7% respectively. CONCLUSIONS The PAWPER XL tape performed notably better than the Broselow tape, modified Broselow system and the hanging leg weight technique. And is most appropriate for use in South African paediatric emergencies. The Broselow tape’s overall accuracy was only modestly improved upon by the habitus-modified Broselow system.Item The occurrence and management of postoperative pain in paediatric patients on discharge from the recovery room of the Charlotte Maxeke Johannesburg Academic Hospital(2017) Hlatshwayo, Nozipho PhilominahBackground Postoperative pain in children remains high despite an improvement in assessment and management. Assessment is done using developmentally appropriate tools including the Wong and Baker FACES® Scale (WBS). Management of immediate postoperative pain is done using intravenous or regional analgesic techniques. The aim of this study was to describe the occurrence and management of postoperative pain in paediatric patients on discharge from the recovery room of the Charlotte Maxeke Johannesburg Hospital operating theatres using the WBS. Methods A prospective, descriptive and contextual study was conducted over a three month period. Convenience sampling was used and 124 participants from various surgical disciplines aged 4 to 12 years were included in the study. Pain scores were assessed using the WBS in the recovery room immediately postoperatively. Results Of the 124 participants, 113 (91%) had adequate pain control. Fifteen percent (6/40) of general surgery and 9% (3/35) of orthopaedic patients that had pain 67% (4/6 and 2/3 respectively) had intravenous analgesia only whilst 33% ( 2/6 and 1/3 respectively) had a combination of intravenous and regional analgesic technique. One participant each from the ENT and ophthalmology groups had inadequate pain control and had received intravenous only analgesia. There was no statistically significant difference between those that had received intravenous only and combined intravenous and regional analgesic techniques (p= 0.199) or between males and females with regards to WBS score reported (p=0.511). Conclusion The assessment of pain scores in the recovery room show adequate pain control in the immediate postoperative period. A large percentage of those with inadequate pain control had undergone a general surgery or orthopaedic procedure. In addition a greater number of these participants had an intravenous only analgesic technique although the difference was not statistically different to those that had a combination of analgesic techniques.Item The usage of antibiotics in paediatric patients while admitted to the intensive care unit at a public tertiary hospital(2018) Sinyela, NkhumiseniBackground: The overuse and misuse of antibiotics decreases their effectiveness and results in increasing bacterial resistance which is considered an international public health crisis. Antibiotics are one of the most commonly used groups of medicines in peadiatric patients however there are limited data available on the usage of antibiotics in paediatrics globally but especially in South Africa. The aim of this study was to conduct a retrospective review of antibiotics used in paediatric patients in intensive care. Method: This study reviewed antibiotic therapy from patient charts in the Intensive Care Unit at Charlotte Maxeke Johannesburg Academic hospital. The review was done from 15 January 2016 to 15 February 2016 and 15 January 2017 to 15 February 2017. Results: There were 40 files reviewed for 2016 and 55 files for 2017. Most patients (2016: 78% and 2017: 60%) were neonates aged between 0 -3 months. There were 15 antibiotics prescribed in 2016 and 2017 that differed between the two study periods. The most frequently prescribed antibiotics in 2016 were: vancomycin (19%), imipenem (18%), ampicillin (11%) and gentamycin (11%). In comparison in 2017, the most frequently prescribed antibiotics were meropenem (21.7%) vancomycin (20.8%) and co-amoxiclav (11.7%). In both periods majority of patients received two antibiotics as therapy during their ICU stay, 47.5% in 2016 and 40% in 2017. The average numbers of days in ICU were 5 days in 2016 and 4 days in 2017. Diagnosis classifications were similar between the two study periods. Cultures (blood) were ordered in 73% (2016) compared to 75% (2017). C-reactive protein samples were taken from 85% of patients in 2016 and 82% in 2017. In 2017, there were 46.2% (n=36) of doses with a hang time less than 60 minutes and 32.5% (n=26) in 2016. Conclusion: This study showed that most antibiotics were prescribed empirically with imipenem and vancomycin the most used combination antibiotic therapy in 2016, meropenem and vancomycin in 2017. Majority of patients received two antibiotic therapies during their ICU stay. CRP and cultures (blood) were frequently ordered and hang time mostly documented. Prescription of antibiotics was mostly compliant with the unit antibiotic prescription guidelines.Item Sociodemographic characteristics and spatial distribution of Malaria in Nigerian children(2018) Ozougwu, Lovelyn UzomaBackground Malaria is a significant public health concern in the world. It causes mortality and morbidity especially in children under five years of age and pregnant women. Nigeria contributes about 25% to the malaria burden in Africa, with one million lives lost annually. Several factors including poverty, ownership of bed nets, socioeconomic status are associated with malaria morbidity. This study aimed to determine the factors associated with malaria morbidity and its spatial distribution in Nigerian regions among children under five years in 2010. Methods This study used cross-sectional data from the 2010 Nigeria Malaria Indicator Survey (NMIS) which was downloaded from DHS website. The primary sampling unit (PSU) which was referred as the cluster for the 2010 NMIS was defined based on the enumeration areas (EAs) from the 2006 EA census frame. The 2010 NMIS sample was selected using a stratified, two -stage cluster design consisting of 240 clusters, 83 clusters in the urban areas and 157 in the rural areas. The research was restricted to children under five years (6-59 months). The outcome variable was defined as the presence or absence of malaria. It was measured using rapid diagnostic test and microscopic examination of blood smear. Clustered adjusted Pearson’s chi-square test was used to show associations between explanatory variables and malaria. A clustered t-test was used to determine differences in the mean for continuous variables.Multilevel logistic regression models, taking into account random effects were fitted. Choropleth maps were used to display the distribution of malaria by geopolitical zones. Results There were 5137 children aged 6-59 months for this study out of 5612 children that were selected for the survey, 41.97%had malaria, and there was no difference in prevalence between males and females. The mean age was 34.96±0.33 months. There was a higher prevalence (60.19%) of malaria in the areas where there was no LLIN campaign coverage compared to areas with LLIN coverage (39.81%) (OR 0.65, 95% CI 0.43-0.97). Children from rural areas were three times more likely to have malaria than those from urban areas (OR 3.13,95%CI 2.18-4.49). The odds of malaria increased significantly with increasing age in months (OR 1.02, 95% CI 1.02-1.03, P-value<0.0001). The richest household children were less likely to have high prevalence of malaria compared to children from the poorest households (OR 0.23, 95%CI 0.15-0.37). Choropleth maps showed a high prevalence in the North-West and North-Central regions and lowest prevalence in the South-East region. Conclusion Although efforts have been made to control malaria in Nigeria, its elimination is not forthcoming. The prevalence in children under five years was high. Those who live in the rural areas, wealth index, geopolitical region and child’s age were the determining factors associated with the high prevalence of malaria in those children. There was a regional variation of malaria prevalence among the children. Children from the North-Central and North-West regions had the highest prevalence of malaria. All these factors could be as a result of policy issues, policy formulations, management, implementation, compliance and sustenance issues. However, a lot can be done in the malaria control and prevention programme in Nigeria towards vaccine development, policy formulation and implementation based on evidence, increased public health and environmental education, incorporation of the communities in activities towards malaria control, mapping of the spatial distribution of malaria as well as stepping up of ongoing control programmes. Keywords: children under five years, spatial analysis, Nigeria.Item Comparison of weight estimation formulae in paediatric patients at Chris Hani Baragwanath Academic Hospital(2018) Soni, ZakiyyaBackground Accurate weight determination is essential in providing optimal care to the paediatric population, as both over- and under-estimation can be detrimental. This study aimed to compare the accuracy and precision of three paediatric weight estimation formulae, the Advanced Paediatric Life support (APLS), the formula used by anaesthetists in academic hospitals affiliated to the University of Witwatersrand (Wits-A), and the Luscombe and Owens (LO) formula, to the measured weight of children at the Chris Hani Baragwanath Academic Hospital (CHBAH) outpatient department. Methods A prospective, contextual, descriptive study design was used with quota sampling. Four hundred children aged 1 - 10 years were recruited for the study. Age, gender, ethnicity, weight and height were recorded. Results On average the APLS formula performed the best with 49 % of estimates within 10% of the actual measured weight (PW10), the lowest mean percentage difference (MPD) of +0.7% and the narrowest 95% limits of agreement. The Wits-A formula followed with a PW10 of 41% and a MPD of -5.2% while the LO formula had a PW10 of 24% and a MPD of -19.4%. Conclusion An accurate and precise weight estimation technique remains elusive and the gold standard is a measured weight. The APLS formula was however found to be the most accurate in the CHBAH population and should be used over the Wits-A formula if a formula has to be used.