Rationale Gestational age is a strong determinant of neonatal mortality and morbidity. Early obstetric ultrasound is the clinical reference standard, but is not widely available in many developing countries. There is a well recognised need to identify reliable and simple methods of postnatal gestational age estimation. Methods A prospectively designed methods comparison study in a tertiary referral hospital in a developing country. Early ultrasound (<20 weeks) was the clinical reference standard. Methods evaluated included anthropometric measurements (including foot-length), vascularity of the anterior lens, the New Ballard Score and Last Menstrual Period. Clinicians' non-structured global impression “End of Bed” Assessment was also evaluated. Results 106 babies were included in the study. Median age at birth was 34 weeks (IQR 29-36). Ballard Score and “End of Bed” Assessment had a mean bias of -0.14 and 0.06 weeks respectively but wide 95% limits of agreement. The physical component of the Ballard score, the total Ballard score and Foot-length's ability to discriminate between term and preterm infants gave an AUROC of 0.97, 0.96 and 0.95 respectively. Discussion Although “End of Bed” Assessment and Ballard score had small mean biases, the wide confidence intervals render the methods irrelevant in clinical practice. Foot-length was particularly poor in Small for Gestational Age infants. None of the methods studied were superior to a non-structured clinician's informal “End of Bed” Assessment. Conclusion None of the methods studied met the a priori definition of clinical usefulness. Improving access to early ultrasound remains a priority. Instead of focusing on chronological accuracy, future research should compare the ability of early ultrasound and Ballard score to predict morbidity and mortality.

The purpose of this dissertation was to gain a better understanding of how emerging adult children respond to their parents’ advice, and uncover connections between advice and parent-child relationship satisfaction. Because emerging adults may experience uncertainty as they move toward adulthood, they may reach out to their parental figures when making new or important decisions. The current study took a closer look at the role elements of advice response theory (ART) played in an emerging adult’s decision-making process when asking a parental figure for advice. The study also considered the potential relationship between elements of ART and parent-emerging adult child relationship satisfaction. A total of 503 participants between the ages of 18 to 25 were recruited from a medium-sized Midwestern land grant institution. Participants completed an online survey to measure elements of ART, parent-child relationship satisfaction, and demographic questions. Six hierarchical multiple regression analyses were performed. According to the findings of this dissertation, emerging adults consider parental advice characteristics and parent as advisor characteristics when deciding on the quality of the advice, and the intention to implement the advice received from their parental figures. Also, emerging adults reported that elements of ART play a role in parent-emerging adult child relationship satisfaction. Findings highlight that it is important for emerging adults to perceive their parental figures as trustworthy because perceived trustworthiness plays a large role in implementation intention, perceived advice quality, and perceived parent-child relationship satisfaction. Also, advice limitations do not play as large a role as previously expected.

Introduction: Neonatal encephalopathy (NE) is an important condition which may result in mortality or severe and permanent morbidity placing much strain on busy under-resourced health care services, parents and families, and the greater community. There is much debate on its aetiology; whether it is caused by antepartum conditions or intrapartum obstetric complications (known as sentinel events); and the relative contribution of intrapartum hypoxia. Unlike perinatal mortality, NE rates are not routinely audited by maternity facilities. At Mowbray Maternity Hospital, a formal audit was conducted in 2008, which measured the NE rate, focussed on obstetric factors associated with NE and identified avoidable factors in the care provided. It was thought to be of clinical value to repeat this audit to identify whether there were any trends in rates and the pattern of obstetric factors. Aims and objectives: The aim was to describe the obstetric factors occurring in patients who delivered neonates at MMH, diagnosed with NE. Specifically, it was planned to determine the NE rate, to describe obstetric factors occurring in these patients and to assess the avoidable factors related to the patients, health system and clinical management. Methodology: This was a retrospective descriptive study which included patients whose neonates were diagnosed with NE and were born at MMH in 2016. The diagnosis of NE was made according to the MMH NE protocol where NE is defined as a voltage suppression in amplitude-integrated electroencephalography (aEEG) or seizures; or clinical seizures or dystonic movements; or moderate to severe clinical signs of NE as defined by Shankaran and a level of consciousness which is decreased with abnormal tone. The neonates’ names were retrieved from a NE register in the neonatal unit and the corresponding mothers’ folders retrieved. Data on relevant obstetric and clinical management factors were collected from the folders using a data collection tool developed in the Western Cape and all cardiotocographic tracings were assessed by the researcher. Ethics approval was granted by the University of Cape Town Human Research Ethics Committee (UCT HREC) prior to the commencement of the study. STATA 14 was used for the analysis. Results: In 2016, 53 neonates with NE were identified out of 9,702 live births (LB) at MMH. The NE rate was 5.5 per 1000 LB. Of the 53 neonates, 48 maternal patient files were retrieved and analysed. There were 58% who had been referred to MMH from the midwife obstetric units (MOUs), and 42% fully managed at MMH. All patients were booked for 14 antenatal care, the mean age was 27.5 years and 50% were nulliparous. The mean gestational age at delivery was 39 weeks. The majority (87.5%) experienced labour, spontaneous in 72.9% and induced in 14.6%. Antenatal complications occurred in 77.1%, the most frequent being prolonged pregnancy (25%) hypertensive disorders (18.8%), antepartum haemorrhage (8.3%) and prelabour rupture of membranes (8.3%). Obstetric problems in labour included prolonged second stage of labour (25% of patients who had a second stage of labour); multiple vaginal examinations (28.6%) and prolonged first stage of labour (17.9%). Fetal monitoring at the MOUs was done according to protocol in 70% of patients in the latent phase but only 12.5% of those in the active phase of labour. At MMH, all patients in labour had Cardiotocograph (CTG) monitoring with 90.6% of CTGs being pathological and 6.3% suspicious, as assessed by the researcher. Meconium stained liquor occurred in 40.5% of patients. The mode of delivery was normal vertex, (27.1%), Caesarean sections (58.3%) and assisted vaginal delivery (14.6%). Most CS (71.4%) were done for pathological CTGs. Sentinel events occurred in 15 (31.3%) patients; approximately two-thirds occurring intrapartum and one- third antenatal. Sentinel events included shoulder dystocia (10.4%), prolonged second stage of labour (10.4%), abruptio placenta (6.3%), cord prolapse (2.1%) and eclampsia (2.1%). Of the 37 (68.7%) without a sentinel event, 75.8% had a pathological CTG. Considering avoidable factors, there was an ambulance delay in 42.9%, and a delay in accessing theatre for 53.6% of patients requiring a CS. Poor quality CTG tracing and monitoring occurred in 20.8% of patients; and for 34.4%, the researcher identified an abnormal CTG but it was not detected by the attendant health care workers. Discussion and conclusion: The NE rate for MMH is 5.5 per 1000 LBs, this is higher than the 3.7 found in the previous 2008 MMH study, despite a higher CS rate. Possible reasons for the increase include changes in case ascertainment, increased workload with same staff component, or a shift from perinatal hypoxic mortality to morbidity, notably NE. This NE rate compares with other lower resource settings and the previous MMH audit, as does the high proportion of intrapartum obstetric sentinel events. This is in contrast to findings from high resource settings. Areas for service improvement include regular and ongoing intrapartum care training, including fetal heart monitoring, for medical and nursing staff; and addressing the health system issues identified.

Background: In South Africa, the exclusive breastfeeding prevalence at six months is low at 24% and the under-5 mortality rate remains high. Improving breastfeeding rates is the most cost-effective intervention to reduce under-5 mortality and morbidity. Data on the effect of infant hospitalisation on breastfeeding may inform facility-based interventions to protect and support exclusive and prolonged breastfeeding. Aim: To assess the impact of hospitalisation on breastfeeding and explore reasons for stopping or continuing breastfeeding. Methods: We conducted a prospective cohort study of infant feeding practices among mother-infant dyads admitted to general paediatric wards at a tertiary children’s hospital in Cape Town, South Africa. Medical, demographic and feeding practice data were collected through semi-structured interviews on admission, again during hospitalisation and a third interview was conducted telephonically post discharge. Logistic regression analysis was used to assess factors associated with different feeding practices. Results: Between January and April 2018, 119 mothers (median age 26 years, IQR 22-32; 28% HIV-positive) were interviewed at admission; 39% (46/119) breastfed exclusively (EBF) and 28 (24%) reported no breastfeeding. Most infants (median age 1.8 months, IQR 1.0-3.2; 34% preterm) were admitted for lower respiratory tract infection (59%) or diarrhoea (14%). EBF at admission was associated with younger infant age (per month increase, aOR 0.18, 95% CI 0.07-0.43); none of the children admitted for diarrhoea had been EBF. A second in-hospital interview occurred at median 4 days (IQR 2-6) after admission. The overall prevalence of any breastfeeding declined from 77% at admission to 61% in-hospital. Risk factors for in-hospital breastfeeding cessation included low birth weight (<2500g; OR 3.81, 95% CI 1.35-10.74) and feeding via either bottle/tube (OR 51.00, 95% CI 6.38-407.71). Maternal expression of breastmilk (vs no expression in-hospital) was protective against in hospital breastfeeding cessation (OR 0.07, 95% CI 0.01-0.33). Post-discharge telephonic interviews (median 5 months after discharge) were available for 92 mother-infant dyads; 21 infants were ≤ six months of age, of whom 24% (5/21) were still exclusively breastfeeding. Breastfeeding cessation at any time after admission and before post-discharge telephonic interview was associated with maternal HIV infection (OR 2.82, 95% CI 0.84-9.40), full time employment (OR 4.95, 95% CI 1.40-17.46) and preterm birth (OR 3.53, 95% CI 1.27-9.81). Conclusion: Prevalence of both any and exclusive breastfeeding was low at admission to hospital, and lack of breastfeeding strongly correlated with increased risk of an infectious morbidity diagnosis. In addition, hospitalisation substantially reduced the probability of continued breastfeeding. In-hospital breastfeeding support and facilitation of breastmilk expression while infants are unable to breastfeed should be increased. Implementation research may define effective in-hospital breastfeeding support interventions.

Background: Inherited hemoglobinopathies are a global health burden. Sickle cell disease (SCD) is the most common genetic disorder of haemoglobin in Africa but is uncommon in the South African population. Objectives This study aimed to describe the presentation and experience managing paediatric patients with SCD at two regional hospitals in Cape Town. Methods This retrospective study used routine data of children aged 0-13 years with SCD managed at New Somerset and Victoria Hospitals in Cape Town from January 2010 to December 2018. Data analysed included demographics, diagnosis, out- and in-patient episodes, and the need for transfers to tertiary level. Results We identified 63 patients of which three did not fit the study criteria and four had missing clinical records. Of the 56 children included, most were diagnosed at the regional hospital (n=32 [58%]) and only a third (n=18 [32%]) were down-referrals from tertiary level facilities. The annual number of new patients per year varied with the most in 2009 and 2015. The median age at first presentation was 20.1 months (interquartile range [IQR] 7.1-43.9 months). There was a male predominance. The majority (n=39 [67%]) were born in South Africa, eleven were born in the Democratic Republic of Congo (DRC) and six in other African countries. None of the parents were born in South Africa. The majority of parents were from DRC (73/110) and Nigeria (11/110). Approximately one third (39%) of patients had a family history of SCD and a quarter (25%) had an affected sibling. Most children were diagnosed incidentally via full blood count findings (66%); others presented with symptomatic anaemia (28%) or were screened because of an affected sibling (11%). The mean number of hospital days was 3.0 (range 0-13). Infections, bone crises and symptomatic anaemia accounted for the majority of hospital admissions. Referral for tertiary level care occurred in 23/56 (41%) patients with most requiring specialist opinion from haematology and/or other specialist disciplines. Nine (16%) children were lost to follow-up, one was transferred to another province and one died at another institution. Conclusion An increasing number of children diagnosed with SCD are being seen in health facilities in Cape Town and probably other parts of South Africa due to migration and children being born to families with SCD ancestries. Recognising the presentation and complications of SCD and developing competency at all levels of care in providing appropriate, protocolised management are important to reduce morbidity and mortality among children with SCD in our setting

Background: Gastrointestinal endoscopy has evolved to become an important diagnostic, therapeutic as well as surveillance and follow-up modes of management in children with diverse gastrointestinal diseases. There is a paucity of data on gastrointestinal endoscopy in children in the sub- Saharan African region. The objectives of the study were to describe the socio-demographic characteristics; presenting symptoms; indications; endoscopic yield; impact of endoscopy on management; as well as its safety profile and complications. In addition algorithms for the indications of medical gastrointestinal endoscopy in children were designed using the results derived from the presenting symptoms and indications for gastrointestinal endoscopy among the patients. Methods: This was a cross sectional descriptive study. Subjects were children < 18 years attending Red Cross War Memorial Children’s Hospital (RCWMCH) who underwent medical gastrointestinal endoscopic procedures from 2007 to 2016. Study ethical approval was obtained from University of Cape Town while written permission from the RCWMCH Research and Management Committee prior to the commencement of the study. Data sheet was used in retrieving relevant patients variables from the hospital’s medical records and the Division of Paediatric Gastroenterology endoscopy and laboratory (histopathology) databases. Data was analysed using Stata 13.1. A p- value of less than 0.05 was considered statistically significant. Results: A total of 402 children were studied with 773 endoscopies performed comprising 670 oesophagogastroduodenoscopies (OGD) and 103 colonoscopies. For OGD: 179 (26.7%), 287(42.8%) and 204 (30.4%) procedures were for diagnostic, therapeutic and follow - up indications. A total of 78 (10.1%) combined OGD/colonoscopy were carried out. Out of 103 total colonoscopies performed, 67 (65.0%), 30(29.1%), and 6 (5.8%), were for diagnostic, follow - up and therapeutic indications respectively. vi Feeding difficulty 112 (25.4%) and rectal bleeding 11 (2.7%) were the main presenting symptoms for OGD and colonoscopy respectively. Main diagnostic indications for OGD, combined OGD/colonoscopy and colonoscopy alone respectively were chronic abdominal pain 51 (12.6%) and probable inflammatory bowel disease (IBD) 30 (7.5%) and IBD 30 (7.5%). Change 143 (35.6%)/ insertion 87(21.6%) of percutaneous gastrostomy were the most common therapeutic indications for OGD and polypectomy 8 (2.7%) for colonoscopy. Abnormal (positive) macroscopic findings on endoscopy were reported on 79/179(44.1%), 35/68(51.55%), and 46/67(53.7%) of OGD, combined OGD with lower scope, and colonoscopy alone respectively. Also, positive histological findings on OGD, combined OGD with colonoscopy, and colonoscopy alone were reported in 62/179(34.6%), 34/68(50.0%), and 32/67(47.8%) respectively. The overall normal endoscopic findings (both abnormal macroscopic findings on endoscopy and histological findings) were 63/179(35.3%) and 25/67(37.3%) for OGD and colonoscopy while overall diagnostic (endoscopic) yield was 116/179(64.8%) for OGD and 42/67(62.7%) for colonoscopy respectively. For OGD the main endoscopic yield reported were gastritis in 50(27.9%) and oesophageal varices 31(17.3%) while inflammatory bowel disease (Crohn’s disease 9(13.4%), ulcerative colitis 7(10.4%), juvenile polyps 9(13.4%) and intestinal tuberculosis 7(10.4%) were observed in colonoscopy respectively. A significant impact of endoscopy on the management of subjects were recorded in 298(74.1%) (p < 0.001) including diagnostic (change of medication, addition of new medication) and therapeutic (insertion/change of PEG; sclerotherapy 29 (9.8%) , band ligation of oesophageal varices 28 (9.4%), and polypectomy 8(2.7%)). The overall complication rate was 4.0% (16 patients). Conclusion: Feeding difficulty and rectal bleeding were the most common presenting symptoms for OGD and colonoscopy; with chronic abdominal pain and IBD being the most common indication for performing OGD and colonoscopy respectively. Therapeutic modalities of endoscopy performed were PEG insertion/change, polypectomy, sclerotherapy/band ligation for varices. vii Endoscopic yield was 116/179(64.8%) for OGD and 42/67(62.7%) for colonoscopy respectively a significant impact of endoscopy on the management of subjects were recorded in 298(74.1%) (p < 0.001). No mortalities were recorded following the procedures, however 16(4%) had some complications. Use of societal guidelines in selecting children with appropriate indications for gastrointestinal endoscopy will result in higher diagnostic yield and application of therapeutic modalities in children with gastrointestinal disorders resulting in significant impact on patient’s management and minimize complications.

No description available.

No description available.

Childhood bronchiectasis is a common cause of chronic lung disease globally, particularly in lower-middle-income countries (LMIC). Data from LMIC is lacking. We aimed to describe the disease burden, aetiology, and clinical spectrum of bronchiectasis in children attending a tertiary hospital in Cape Town, South Africa. Methods Data was collected by chart review of all patients 3 months to 15 years attending the respiratory clinic at red cross war memorial children's hospital between January – December 2019. We included children who had a diagnosis of bronchiectasis based on history of a recurrent (> 3 episodes/year) or persistent (> 4 weeks) wet cough, a clinical phenotype characterized by any of; exertion dyspnea, recurrent chest infections, growth failure, finger clubbing and chest deformity associated with radiographic features of bronchiectasis on plain chest radiography or HRCT reported by a paediatric radiologist. Patients with cystic fibrosis were excluded. Results Of 337 children seen during the study period, 58 (17.2%) had bronchiectasis that was diagnosed at a mean age of 34 months (SD 26). There were 32 (55.0%) female participants. The commonest causes of bronchiectasis were post-infectious (25, 43.1%), and underlying immunodeficiencies (19, 32.8%) including 16/58 (27.6%) who were HIV-infected and 3 (5.1 %) with primary immunodeficiency. Other causes included aspiration syndrome (8, 13.8 %) and anatomical abnormalities (4, 6.9%). Of the participants with post infectious bronchiectasis, tuberculosis was the commonest organism that was isolated (16, 64.0%) and commonest in children living with HIV (11/16, 68.8%). Cough was common (48, 82.8%) with wet cough being predominant (41, 85.4%), course crepitations accounted for 37 (63.8%), hyperinflation 24 (41.4%) finger clubbing 21 (36.2%), wheeze 16 (29.3%) and exertional dyspnea in 7 (12.0%). Conclusion: Bronchiectasis is a common cause of chronic lung disease in South African children mostly resulting from previous pneumonias, with tuberculosis being the commonest infective cause. The importance of identifying underlying treatable causes is highlighted.

Some investigators have proposed that concept learning in humans can best be explained in terms of internalized processes mediating between the external stimulus and overt response. This approach contrasts with "single-unit" theory, emphasizing direct association between stimulus and response. Some psychologists advocate the developmental hypothesis that single-unit theory applies to lower organisms but that mediational theory holds for advanced organisms. Comparative psychological studies have yielded inconclusive findings with respect to this hypothesis. Some investigators have tried to experimentally influence the hypothesized mediating process by teaching subjects verbalizations which could serve as mediating responses. In general, findings suggest that older children utilize verbal mediators more readily than younger children. The current investigation stems from interest in whether young children have a specific inability to mediate verbally or a more general deficiency in mediation. Are mediating processes in young children possible on a “sensori-motor” level? The purpose of the present research is to compare younger and older children in their use of perceptual cues as a basis for mediation and in their preferences for perceptual versus verbal cues when these are in conflict. Fifty nursery-school children and seventy-five second-grade children learned two successive discriminations. The stimuli, cylinders varying in size (large-small) and brightness (black-white), were arranged on a tray before a vertical clown's face. The child put one of two stimuli taken from the tray into the clown's mouth and was rewarded, when correct, by the clown's nose blinking, an edible item, and praise. In the first discrimination a large, black cylinder was positive; in the second task the "small" object was rewarded, regardless of brightness. Since the first discrimination was solvable on the basis of either size or brightness (or both), the experimenter could attempt to influence the subject to make a mediating response to a particular dimension. The major experimental variables manipulated for this purpose during the initial discrimination were (1) kind of object arrangement on the tray, and (2) kind of verbal label children applied to the stimuli. The size arrangement, for example, had same-sized objects in proximity; but brightness was randomly distributed. In the size verbalization condition the child was instructed to precede his choices with the appropriate size label, i.e., "big" or "little." Independent groups received the following treatments at each age level: (1) size arrangement, (2) brightness arrangement, (3) size arrangement and brightness verbalization, simultaneously,(4) brightness arrangement and size verbalization, simultaneously, and (5) random arrangement, no verbalization (control). The major dependent variable was the mean number of trials to criterion on the second task, as it was assumed that ease of learning the "small" concept was an index of availability of the size dimension relative to the brightness dimension. The results indicated that both younger and older children responded in a mediational manner to the perceptual arrangements, suggesting that previous findings regarding lack of verbal mediation in young children should not be generalized to include other modes of mediation. The interfering effect of perceptually emphasizing an irrelevant dimension was stronger for younger children than for older children. Older children were more influenced than the younger children by relevant verbal cues. When relevant verbal cues were pitted against irrelevant perceptual cues, the former dominated with older children, but the latter with younger children. Younger children, however, were not influenced as predicted by relevant perceptual cues nor older children by irrelevant verbal cues . These discrepancies were discussed in terms of the nature of the experimental manipulations. It was tentatively concluded, subject to further verification, that younger children favor perceptual mediation and older children verbal mediation. / This thesis was digitized as part of a project begun in 2014 to increase the number of Duke psychology theses available online. The digitization project was spearheaded by Ciara Healy.