published_or_final_version / Paediatrics / Doctoral / Doctor of Philosophy

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There is little information available about the relationship of newborn vitamin D status with pregnancy outcome and infant health. The purpose of this cross-sectional study was to estimate the prevalence of vitamin D deficiency and insufficiency in newborns in the Saskatoon Health Region, identify risk factors for low neonatal levels of vitamin D, and determine whether any association exists between low levels of vitamin D and adverse pregnancy and neonatal outcomes. The Newborn Vitamin D Study was conducted between December, 2011 and February, 2012. Sixty-five maternal-fetal dyads delivering in the Saskatoon Health Region were included in the study. Mean cord blood vitamin D level was 64.1 nmol/L (standard deviation = 19.8 nmol/L), which is in the insufficient range. Cord blood vitamin D level was deficient (<50 nmol/L) in 22% and insufficient (50-75 nmol/L) in 48% of the 65 newborns studied. Simple linear regression indicated that low weight gain during pregnancy is significantly associated with low vitamin D levels (p = 0.04). However, younger maternal age (p < 0.01) and urban area of residence (p = 0.09) were the strongest predictors of low cord blood vitamin D levels in a multiple linear regression model (R2 of 0.519, p = 0.003). Cord blood vitamin D levels were not significantly associated with any pregnancy or neonatal outcomes. Despite 85% of mothers reporting having taken a daily prenatal supplement, 70% of newborns in our study population had either an insufficient or deficient cord blood vitamin D status. This suggests that prenatal supplements, which typically contain 400 IU of vitamin D, contain an inadequate dose of vitamin D to produce sufficient cord blood vitamin D levels in most newborns. Further research is necessary to inform maternal vitamin D supplementation guidelines and to investigate the role of vitamin D in pregnancy outcomes and infant health.

Neonatal sepsis remains a global health problem due to its significant contribution to morbidity and mortality. The blood culture is the most reliable method for detection of bacterial infections. However, the sensitivity of the latter method is low and using it as a gold standard in diagnosis of bacteremia is fraught with difficulties. Neutrophil CD64 levels are upregulated in response to inflammation and tissue injury. We quantitated neutrophil CD64 by flow cytometry in neonates with signs and symptoms suggestive of sepsis/infection within the 1st four weeks of life in a prospective observational study conducted at 3 hospitals in Johannesburg. Patients were classified into categories of infection namely definite, probable and possible according to signs and symptoms of infection and blood tests including blood culture results. Of 76 neonates, there was 1 infant with definite infection, 5 infants with probable, 30 infants with possible and 32 infants with no infection. The PMN CD64 at cut off of 1.8 had a high negative predictive value in ruling out definite (100%) or probable + definite infection (95.2%). We recommend the inclusion of PMN CD64 index into the diagnostic algorithm for neonatal sepsis, as it has a high negative predictive value and can be used to rule out infection. As the positive predictive value of the test was low in confirming infection, PMN CD64 should be used as a screening rather than confirmatory test.

MMed (Paediatrics), Faculty of Health Sciences, University of the Witwatersrand / The aim of regionalisation of neonatal services is to offer a basic level of care to the majority of the obstetric/neonatal population who are at low risk, with smaller numbers of more specialised hospitals offering higher levels of care to the fewer, higher-risk patients. On review of relevant literature there has long been a shortage of neonatal intensive care unit (NICU) beds in the South African public sector. This study was an audit within a referral system in the public sector. The aim was to identify the need for NICU beds, establish whether the need was being met, ascertain which patients required referral and which were accepted, and delineate factors that influenced the outcome of acceptance versus refusal. Subjects and Methods Data collection took place between 30 October and 11 December 2006. Seven health facilities in southern Gauteng were included as study sites. These included 2 primary healthcare clinics, 3 district, 1 regional hospital and the tertiary referral facility, Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). The study included all neonates requiring transfer to a NICU, for any reason, during the study period. Data collection relied upon completion of information sheets by doctors requesting or accepting transfer of ill neonates at each of the hospitals involved. The primary outcome was acceptance or refusal at CMJAH NICU. Secondary outcome was survival or death within the study period. Results Forty-seven external requests for NICU beds were recorded at CMJAH and another 22 requests came for births within CMJAH. Only 13 (28%) of external requests were accepted. All internal requests were accommodated. Most requests came from level 2 (district or regional) hospitals, many outside the designated referral system, mainly for infants with respiratory distress. Infants older than 24 hours of age (OR 0.16; 95% CI 0.04-0.65), those with congenital abnormalities, and those requiring surgery (OR 0.11; CI 0.23-0.57) were significantly more likely to be accepted. Greater numbers of staff on duty at CMJAH also correlated with the probability of acceptance into NICU. Conclusion Relatively few external requests were accepted. CMJAH provides sub-specialist services including paediatric surgery and therefore should accept patients requiring such management. However, there was a high number of patients refused admission for ‘simple’ neonatal respiratory conditions. Level 2 hospitals should be able to manage these. Furthermore, hospitals are not following strict referral protocols. The findings are indicative of the continued shortage of neonatal intensive care beds, poor adherence to referral guidelines, and a general failure of regionalisation within the sector under consideration.

Aim The aim was to determine the epidemiology of invasive fungal infections at Chris Hani Baragwanath Hospital. The specific objectives were to determine the 1) risk factors, 2) clinical presentation, 3) laboratory abnormalities, 4) organisms and their susceptibilities and 6) outcome in neonates with positive blood or CSF fungal cultures at Chris Hani Baragwanath Hospital. Methods This was a retrospective record review of patients who had positive blood or CSF cultures. Patients were identified by a computerized microbiological surveillance database. The data was collected over a three-year period from January 2002 to December 2004. Patient hospital files were reviewed for clinical signs, full blood count (FBC), C-reactive protein (CRP) and outcomes. Fungal culture results were reviewed for susceptibilities. To identify risk factors a convenient cohort was compared to the patients with fungal sepsis. The data was analysed using a Statistica software package. Results There were 150 patients with fungal sepsis among admissions over this 3 yearperiod giving an incidence of 1.3 per 100 admissions. Thirty-nine records were not found thus 111 patient records were reviewed. The median birthweight was 1280g and the gestational age 30 weeks. The median age of onset was 16 days and 6.3% had early onset fungal sepsis. There were 61 males. Twenty-eight percent of patients were born to HIV positive mothers. Candida parapsilosis was the commonest (56%) organism isolated followed by C. albicans (43%). All the C. albicans isolates and 93% of the C. parapsilosis isolates were susceptible to amphotericin B. Fluconazole susceptibilities were reported as, 96% for C. albicans, and 60% of the C. parapsilosis as being susceptible. Central venous catheters (CVCs) (p=<0.001), the use of TPN (p=<0.001) and third generation cephalosporins were identified as risk factors associated with fungal sepsis. The all-cause mortality and Candida–related mortality were 30% and 23% respectively. The non-survivors had lower platelet counts (p=0.007) than the survivors. Patients with Gram-negative sepsis had lower platelet counts than the fungal group (p=<0.001) on the repeat laboratory parameters. Conclusion The incidence is 1.3 per 100 admissions. Risk factors associated with fungal sepsis are very low birthweight and gestational age, the use of TPN, CVCs and third generation cephalosporins. Candida parapsilosis is the common organism causing fungal sepsis in neonates. Candida albicans was associated with a higher mortality. Thrombocytopenia is not organism specific to fungal sepsis.

dissertation submitted to the Faculty of Health Sciences for the degree of Masters in Medicine in the University of the Witwatersrand, Johannesburg. August ,2013 / South Africa is one of the countries in which neonatal mortality has either remained the same or decreased marginally over the past 20 years (1). Resource constraints result in early discharge of well newborns and curtailment of follow up home visits by nurses. This potentially high-risk group of infants may contribute to these neonatal deaths post hospital discharge. In addition, once a neonate has been home, they are no longer admitted to the neonatal unit but to the general paediatric wards that may lack specialized neonatal care. Numerous programs, algorithms, education drives and protocols have been devised in an attempt to improve the quality of healthcare offered to the newborn. These have led to a perceptible decline in the neonatal mortality and morbidity rates respectively. The neonatal mortality and morbidity rates remain unacceptably high however, particularly in resource poor settings. Aim: The aim was to determine the profile and outcome of neonates admitted to the general paediatric wards at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Methodology: Audit of all newborns (<28days) admitted to the general wards from 1 January 2011 to 30 April 2011. Patients transferred from other tertiary hospitals were excluded. Patients with incomplete records were also excluded Results: There were a total of 73 neonates admitted with a mean weight of 3.2kg (SD 0.65). The median age for 0-7 days was 4 days and for 8-28 days was 17 days. The majority of neonates 41/73 (56.2%) were male and 21/73 (28.8%) were HIV exposed. In the HIV exposed group only 16/21 (76%) were on HIV prophylaxis. Although antenatal care (ANC) was received by 76.7% of mothers, this is lower than ANC received by the general population. Lack of ANC could possibly be a risk factor for admission of neonates. Possible risk factors for serious illness included 8 (11%) were ex premature infants and 11 (15.1%) had a low birth weight (<2.5 kg). Individual indicators for severity of illness by World Health Organization (WHO) Integrated Management of Childhood and Neonate Illness (IMCNI) were used. The most frequent indicators were tachypnoea (RR>60) 34 (46.6%), jaundice 30 (41.1%) and only 1 (1%) presented with convulsions. Respiratory distress was very sensitive (100%) and relatively specific (76%) for detecting bronchopneumonia (BRPN) with a LR of 3.98. The other clinical indicators were neither specific nor sensitive in detecting serious illness. Most 45 (61%) were referred from the local clinic. The commonest diagnoses were bronchopneumonia (BRPN) 20 (27.4%), neonatal sepsis (NNS) 22 (30.1%) and jaundice 22 (30.1%). Two patients died (2.7%). Their diagnoses were NNS and BRPN Conclusions: There are a significant number of newborns admitted to the general paediatric wards, although the mortality rate in this group was low. IMCNI guidelines remain the most sensitive indicator of the need for admission, and “routine” blood investigations are often non-contributory Community based care and education programmes as well as targeted neonatal care in hospitals for this group is warranted.

In the United States, sudden infant death syndrome (SIDS) is the 3rd leading cause of death for infants; other unintentional sleep injuries are the 5th. In addition, the estimated newborn fall rate in the United States is 1.6 to 6.6 falls/10,000 live births. At the project facility, postpartum registered nurses observed parents engaging in behavior that did not contribute to a safe newborn environment such as placing the infant at risk for injury from a fall or from a sleep injury. This observation led to this current project, which examined the development of an educational program for post-partum nurses to educate families in the creation of safe newborn environments. The educational project was guided by the concepts of adult learning and social learning theories, and on the recommendations resulting from the review of the literature and of the American Academy of Pediatrics' for creating a safe sleep environment. The education program included a safe sleep environment education handout for nurses to give parents, a safe newborn environment policy, and a PowerPoint presentation describing the contents of the new policy and the handouts. The PowerPoint will be retained by the facility to present at the biannual skills days to approximately 120 registered nurses working on the postpartum unit. Evaluation measures included an assessment of nurses' comfort and confidence to teach families how to create a safe newborn environment. Process evaluation included a team member questionnaire assessing leadership, analysis of evidence, and meeting facilitation. An increase in comfort and confidence and a consistent method of teaching parents would represent positive social change. Far reaching effects of creating a safe newborn environment could include improving the health of infants and preventing future health problems.

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xiv, 228 leaves : / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Thesis (M.D. 1972) from the Dept. of Child Health, University of Adelaide