Includes bibliographical references. / The assessment of pain and anxiety in South Africa is complicated by language barriers, cultural differences, socio-economic difficulties and delayed cognitive development. The high number of paediatric burn injuries (annually 2000) treated at the Red Cross War Memorial Children's Hospital, the need to accurately assess pain and drug efficacy and the current lack of specifically designed methods to do so, led to the development of the Burn Observational Pain and Anxiety Scale (BOPAS). This scale is believed to be the first of its kind and was designed to measure both pain and anxiety in burned children. The aim of this study was: - To develop an observational pain and anxiety scale that can overcome ianguage barriers by excluding patient involvement in the assessment process. - To develop a scale that can differentiate between pain and anxiety during wound care procedures. - To develop a method that facilitates the translation of nominai information into numerical data. - To develop a scale that can evaluate drug and dose efficacy. A total of 105 chiidren, (M = 65, F = 40) aged 2-12 (average age 6.8 years), admitted for minor to moderate burn injuries to the Burns Unit of the Red Cross War Memorial Children's Hospital, were included in the sample. Five different consecutive studies varying between explorative and quasi-experimental were conducted to determine different levels of validity and reliability.

Background: The World Health Organisation estimates approximately 10% of neonatal deaths in sub-Saharan Africa and South Asia are due to congenital malformations. Neonatal mortality in the Republic of South Africa needs to be benchmarked against high income countries' (HIC) standard of care to identify means to reduce infant mortality, much of which is due to congenital anomalies amenable to surgical correction. Objectives: (1) Assess 30-day, 6-month and 12-month post-operative mortality for neonates operated for gastrointestinal and abdominal wall defects at a tertiary freestanding paediatric hospital in Western Cape, South Africa, over a 12-year period. (2) Ascertain the causes and risk factors associated with 30-day post-operative mortality. Method: A retrospective folder audit of all neonates that underwent gastrointestinal & abdominal wall surgery within the neonatal period at Red Cross War Memorial Children's Hospital (RCWMCH) during the 12-year period from 1 January 2007 to 31 December 2018. Results: The 30-day post-operative mortality rate was 73/762 (11%). Mortality was found in 9 conditions. An additional 57/762 patients (7%) died post-surgery between 30 days from surgery and 6 months of age. A further 34 patients (4%) died between 6 and 12 months of age. Mortality resulted from: sepsis (74%), palliation due to ultra-short bowel length (12%); in patients with necrotizing enterocolitis, intestinal atresia and malrotation with volvulus, ventilation associated pneumonia (10%), associated congenital cardiac lesions (3%) and intestinal failure associated liver disease (1%). Most neonates (69%) who died were prematurely born. Mean age at surgery was 10 days (median 6 days; interquartile range (IQR) 3-16) and mean age at death was 6 days (median 5 days; IQR 2-12; range 1-30). Nearly all patients who died were managed in the intensive care unit post-operatively (97%), with a median stay of 7 days (IQR 1-10) and overall hospital stay of 8 days (IQR2-12). Mortality in patients from referral hospitals more than an hour drive from RCWMCH was high (15/39, 38%). The odds ratio for death for patients with travel time over one hour from the referral hospital was 3.6 [95% confidence interval 1.8 to 7.3; z-statistic 3.6; p=0.0003]. The majority of surgical procedures in patients who died were for abdominal surgery 70/73 (96%). Surgery for necrotizing enterocolitis (NEC) had the greatest mortality (38%), followed by spontaneous intestinal perforation at (29%), gastroschisis (18%). Thirty-day mortality for oesophageal atresia, congenital diaphragmatic hernia and malrotation with volvulus was 9% each, followed by intestinal atresia at 8%, anorectal malformation (5%) and inguinal hernia (3%). No post-operative mortality was reported for Hirschsprung disease, choledochal malformation, hypertrophic pyloric stenosis, biliary atresia and omphalocele. Relook procedures were conducted for 37%, with the highest percentage of revision surgery for necrotizing enterocolitis at 42%. Abdominal compartment syndrome was noted post operatively in 15% patients. Significant modifiable risk factors for sepsis in patients who died were central lineassociated bloodstream infections (65%), respiratory tract infections (41%) and surgical complications [anastomotic breakdown (7%) and wound infection (24%)]. Conclusion: The 30-day post-operative mortality rate in this middle-income setting is similar to the overall mortality rate in HIC, despite excluding pre-operative mortality in this study. Prevention and improvement strategies for infection control are imperative to improve outcomes in surgical neonates, including optimizing timing of surgical intervention for bowel perforation or obstruction through timeous patient transfer for definite management and intensive care unit capacity optimization, central line care and post-operative infection surveillance. Liberal abdominal compartment pressure monitoring and delayed abdominal closure in selected patients may further reduce mortality. Addressing modifiable factors for morbidity and mortality in this vulnerable patient group is required for comparable outcomes to HIC.

Background: Anorectal malformations (ARMs) are a major birth anomaly worldwide. South Africa has ethnically and geologically diverse populations. A recent publication indicated an increased birth prevalence of ARMs in the Witwatersrand referral area between 2005 and 2010. The purpose of this study was to determine the birth prevalence of ARM and its various sub - types in the Western Cape referral district over an 8 year period Methods: For an eight year period from 01 January 2005 to 31 December 2012; retrospective data was collected from the Paediatric Surgical Departments of Red Cross War Memorial Children's Hospital, Tygerberg Children's Hospital as well as the private sector health registries. The number of live births per year for a specific municipal district was obtained from the National Department of Health. The Chi square for trend test was used to determine statistical significance. Results: The birth prevalence for ARM in the Western Cape Province in 2012 was shown to be 1:5572 live births (1.79/10 000 live births). The West Coast Municipality district had the highest average birth prevalence rate of 1:3063 (3 .26/10 000) live births for years studied. There was a male predominance (1.6:1), the most common ARM was the vestibular fistula (19.2%) and in 26% of the patients there was an initial delay in the diagnosis. Conclusion: This study has provided some recent data for ARMs for the Western Cape Province. There was no statistical significant change in the prevalence of ARMs over the eight year period for the Western Cape Province as well as in any of the individual six municipal health districts. ( χ2 for trend p=0.52) . The number of delayed diagnosis of ARM is of concern.

Post-operative analgesia currently relies on multimodal therapy including epidural analgesia, intravenous morphine and/or paracetamol (Perfalgan ®) infusion. Local wound infusion has been effectively utilized in adults with promising results but has not been prospectively tested in children undergoing different abdominal operations. The aim of this study was to compare continuous local anesthetic wound infusion to the current standard of care in post-operative pain control in children. Methods: We conducted a prospective randomized, pain assessor blinded trial comparing Bupivacaine wound infusion {Continuous Local Anaesthetic Wound Infusion - CLAWI) in addition to intravenous paracetamol (Perfalgan®) and morphine for rescue analgesia. This was compared to: (a) epidural bupivacaine plus intravenous morphine and Perfalgan® [EPI] for children undergoing open abdominal surgery and (b) intravenous morphine and Perfalgan® infusion alone [standard post-operative analgesia - SAPA] in children undergoing Lanz incision laparotomy for complicated appendicitis. Patients aged between 3 months and 12 years undergoing laparotomy or open appendectomy were randomly selected for local anesthetic wound infusion (CLAWI) versus EPI or CLAWI versus (SAPA) respectively. Exclusion criteria were neurological impairment, post-operative ventilation and history of adverse reaction to bupivacaine. Consent from the guardian, assent from patients above the age of 7 years and ethics approval from the University of Cape Town Human Ethics Research Committee was obtained. The wound infusion catheter ('lnfiltralLong', PANJUNK®) was placed sub-fascially after suture of the peritoneum and 0.2 % bupivacaine 2mls/kg infused on anesthetic reversal followed by 0.2ml/kg/hour thereafter for 48 hours. Pain assessments were performed for each patient at regular intervals by a single assessor who had training in pediatric pain management and who was blinded to the group allocation. The duration of surgery, length of incision, perioperative antibiotics, wound class risk of surgical site infection, time to return to full feeds, drug reactions; hospital stay, surgical site infection and wound catheter and epidural catheter complications were recorded for each patient. Primary outcome measure was total morphine used in the appendectomy-SAPA vs appendectomy-CLAW! group and rescue morphine requirements in the laparotomy-EPI vs laparotomy-CLAWI group. The secondary outcomes were pain control as measured using the FLACC scale, time to full feeds, mobilization and requirement for urinary catheter.

Introduction: Technecium (Tc) 99m Sucralfate scan has been shown to be a reliable and non-invasive screening modality after caustic substance ingestion, followed by oesophagoscopy under general anaesthesia to grade the extent and severity of injury. Aim: To determine a correlation between the 99mTc Sucralfate scan and the endoscopy findings in children presenting with caustic oesophageal injury. Methods: An observational analytic study of children who had both 99mTc Sucralfate scan and endoscopy after caustic substance ingestion at Red Cross War Memorial Children’s Hospital in a period between January 2009 and September 2016. The oesophageal injury was classified into low grade and high grade according to the degree of adhesion on 99mTc Sucralfate scan and modification of Zargar endoscopic grading. Approval of the study by the University of Cape Town Faculty of Health Sciences Human Research Ethics Committee was obtained, REF. 049/2017. Results: Out of a total of 197 children, 40 children were identified who had both investigations done on average 26hours post injury. Low grade adhesion on 99mTc Sucralfate scan was found in 27 children (68%), and all had low grade Zargar’s oesophageal injuries. None of these subsequently developed residual pathology. Thirteen had high grade adhesion and five of these had high grade injury on endoscopy. Three (23%) developed oesophageal strictures. Correlation of 99mTc Sucralfate and endoscopic findings reached statistical significance with a p-value of 0.0014. No morbidity was associated with either the scan or endoscopy. Conclusions: Low grade Sucralfate scan finding has potential to successfully eliminate the need for invasive endoscopy under general anaesthesia and thereby reducing procedure related morbidity, hospitalization and associated costs. However, mandatory endoscopy is required in children with high grade adhesion seen on 99mTc Sucralfate scan. This requires confirmation using a larger prospective study.

Background: Portal hypertension (PH) is a common complication of chronic liver or portal vein pathology in children. It is defined as a pathological increase in the pressure of the portal venous system. There are two leading causes for PH in children, pre and post sinusoidal liver disease and pre-hepatic non-cirrhotic portal vein obstruction, also referred to as extrahepatic portal vein obstruction (EHPVO). Management of EHPVO is primarily surgical, with surgical portosystemic shunting representing a safe and effective method for the long-term management of portal hypertension in the paediatric population. Although different shunts have been proposed for EHPVO, both the MesoRex shunt and distal splenorenal shunt have shown the most promising results as effective and definitive approaches to alleviating EHPVO. Aim: To review surgical management of extrahepatic portal vein obstruction (EHPVO) at Red Cross War Memorial Children's Hospital (RXH) and compare MesoRex shunt (MRS) with distal splenorenal shunt (DSRS). To determine and compare the shunt success rate, defined as longterm patency at 24 months of the MesoRex shunt and distal splenorenal shunt, the factors that could have influenced the patency of the Rex vein and the effect of these procedures on the long-term synthetic liver function. Methods: This study followed a retrospective study design, conducted at a single centre documenting pre- and post-operative data in 21 children, 14 MRS and 7 DSRS, All patients presented to RCWMCH with EHPVO over an 18-year period (2001-2019) were eligible for inclusion either for MRS or DSRS. Exclusion criteria included patients lost to follow up, patients who had atypical shunts not falling into either the DSRS or MRS operation and those with insufficient or missing clinical records over 18 years. Details of patient demographics included age, gender, aetiology, preoperative symptomatology, Rex vein patency, history of neonatal umbilical vein catheterization (UVC), age at shunt surgery and shunt patency were compiled over an average follow up period of 11 years (2-18). Bloodwork analysis included albumin, prothrombin time (PT), partial thromboplastin time (PTT), International normalized ratio (INR), fibrinogen, total bilirubin, liver enzymes and platelets prior to and two-years-post shunt surgery. Rex vein patency was assessed preoperatively. Statistical significance was determined at P<0.05 following a two-tailed t-test. Results: Out of 23 patients presenting with EHPVO, two children lost follow up immediately after diagnosis and were excluded. Twenty-one patients were operated on and followed up long term, with 14 patients (66%) in the MesoRex shunt group and seven patients (33%) in the distal splenorenal shunt group. Fourteen of the 15 MesoRex procedures (93%) were deemed successful in comparison to five out of seven (71%) in the distal splenorenal shunt group. Significant improvements were seen in MesoRex shunt recipients regarding the levels of Albumin, PT, PTT, and platelets. The other liver functions measured, including INR, fibrinogen, total bilirubin, ALT, AST, GGT, and ALP, were within the normal physiological range. The distal splenorenal shunt cohort only yielded a significant improvement in the platelet count, increasing from a mean value of 100 to 149.83 (P = 0.02). Out of those who showed successful surgical intervention in the long term (14 in MRS and 5 in DSRS cohorts), only one child with MRS experienced 2 episodes of variceal bleeding despite having patent shunt with adequate flow (more than 20cm/second). However, no further surgical intervention was needed, and the bleeding resolved spontaneously. Conclusion: This study highlights that MesoRex shunt has a better long-term outcome in extra hepatic portal vein obstruction and improves liver synthetic function and must be considered as the primary definitive intervention. DSRS does control variceal bleeding due to extra hepatic portal hypertension but may have a negative effect on liver function on long term and is only considered when MRS is not technically feasible or as a salvage procedure when MRS fails.

Purpose: There is very little documented evidence regarding the training of paediatric surgeons in South Africa since its inception as a formal speciality in 2007. This study aims to assess South African paediatric surgical trainees' perspectives regarding their training. Methods: A prospective study was conducted via an emailed electronic survey. The sample population included all current paediatric surgical trainees in South Africa. The questionnaire covered the trainees' demographics, exposure to different aspects of paediatric surgery, extent of after-hours clinical service, self - reported surgical competency and consultant supervision. Results: Forty one (95%) out of 43 trainees responded to the survey with 29 (71%) being female. Reported training deficits included lack of exposure to burn care in 12 trainees (30%), no urology exposure in 8 (20%), no paediatric trauma or minimally invasive surgery exposure in 6 (15%). Eighteen trainees (44%) reportedly worked more than 65 hours per week with clinical responsibilities being the biggest hindrance to attending academic teaching. Trainees were more comfortable performing open procedures compared to laparoscopic but most respondents felt adequately supervised. Conclusion: There exists a significant heterogeneity amongst the different training institutions with protected academic time and exposure to burns, urology and minimally invasive surgery remaining major obstacles in training.

This study began in 1990 in the Burn Unit of The Red Cross War Memorial Children's Hospital (RCWMCH) in Capetown. It came to our attention that children in the Burn Unit developed respiratory problems. These were complications of fireburns, smoke inhalation, explosions and even hot water scalds. They presented with a wide and confusing array of symptoms and many failed to improve with the symptomatic treatment given. Greater understanding of the pathology was needed in order to investigate and manage these problems correctly. The ultimate aim of this study was to establish a treatment protocol that could be followed by junior staff.

Bibliography: pages 113-118. / This study aims to investigate the use of hospitalized children's free drawings to assess the presence of post-operative pain in patients where language barriers previously prevented the use of existing pain assessment methods. This research involved 50 children ages 6 - 13 years, mostly from impoverished families, treated at the Red Cross Children's Hospital. The design is exploratory-descriptive in nature. The methodology was to collect drawings (110) on admission, after surgery (described as minor to moderate), when the children were expected to be experiencing pain, and also on discharge from hospital. These drawings were compared for picture content and children's responses to a combination of two scales developed and tested elsewhere (Word Graphic Scale and the Pain Ladder Scale), in an attempt to devise an alternative route to gauge subjective pain through drawings. Parental (44) and respondent (6) interviews provided information on parental reaction to children when in pain, and patient pain behaviour. Evidence suggests that children's free drawings can be successfully used in assessing the presence of pain but not the intensity thereof, and are recommended for use in the treatment process.

The aim of this thesis was to find out how much and in what way children are prepared for surgical procedures. For the research were selected children at the Department of Paediatric Surgery of the Kolín Regional Hospital, from February to June 2018. In the theoretical part, risk factors for developing anxiety disorders in childhood are described. In particular, anxiety and nervousness, fear, phobia, situational anxiety and mental resilience are defined. A mixed method was used in the research. The main tool was a written questionnaire. In the case of unclear answers, an oral interview was used. In the practical part, two types of questionnaires were used. One is for hospitalized children aged 7-15 and the other for their parents. The research found that seventeen children, out of seventy, were not informed at all, or immediately before surgery. All these children were restless, or even hysterical, they were screaming and crying. The children who were informed of the operation in some way tolerated it quite well. So we can say that most of the children were prepared. Mostly it was only by conversation with parents. The educational material was not used because there is not currently appropriate one.