The ocular complications of vitamin A deficiency have been known for many years, however, recent studies have suggested that marginal vitamin A status enlarges the risk of common childhood infections and increases mortality. It is therefore important to assess the vitamin A status, and some of its consequences, in children who are most likely to be at risk for vitamin A deficiency as this has important implications for promoting the health of children and for formulating appropriate primary health care policies. In South Africa very little data is available on vitamin A nutrition of communities; therefore one of the objectives of this research programme was to document the vitamin A status of African children who, because of historical inequities, are most likely to be at risk for deficiency. Sound, epidemiologically based surveys of vitamin A intake and body levels were conducted in a typical established township (using dietary intake as the measuring tool) and in a typical peri-urban informal settlement (using serum retinol and conjunctival impression cytology as the measuring tools). These studies revealed that the majority (97%) of children living in the established township surveyed had an adequate intake of vitamin A, whereas 44% of the children in the informal settlement had low serum retinol levels (20 ug/dL), and 18% had insufficient vitamin A, as assessed by 2 abnormal disc specimens, using the conjunctival impression cytology test. In order to investigate the interrelationsnips between vitamin A, other micronutrients and some risk factors, an analysis was undertaken of anthropometry, parasite infestation and blood concentrations of vitamin E, calcium, magnesium, phosphorous, albumin, haemaglobin, serum iron and ferritin and percent transferrin saturation. Significant positive correlations were found between serum retinol and all the biochemical indicators of iron metabolism studied except for serum ferritin. Ninety one percent of the children sampled were infested with parasites. These results highlight the fact that in this population close interconnections exist among nutrients and suggest that attempts at correcting vitamin A deficiency in such communities should be based on comprehensive intervention programmes rather than on single nutrient replacement. The impact of infections on blood levels of vitamin A was investigated in African children with severe measles. In addition, substances related to vitamin A metabolism such as other micronutrients (zinc, vitamin E) and proteins (retinol binding protein, prealbumin, albumin) were measured in serum. In addition the changes induced in these substances by vitamin A supplementation (offered in a randomised, double blind, placebo controlled trial) were studied. Serum retinol as well as the other nutrients measured were significantly reduced early in the exanthem in measles patients as compared to healthy controls. Vitamin A and prealbumin levels on day 8 (of the intervention trial) were significantly increased in the supplemented group compared to the placebo group. vitamin A levels in serum correlated with those of retinol binding protein (RBP), prealbumin and zinc. These findings strengthen the hypothesis that hyporetinaemia during measles is the consequence of impaired mobilisation of retinol stores from the liver. The effect of reversing the temporary lowering of serum retinol concentrations during acute measles infections by supplementation with vitamin A was investigated in a hospital based, randomized, double-blind, placebo controlled trial. The two groups were comparable in known covariates of measles severity : weight/age centiles; overcrowding; rash; total 90% of the patients had blood lymphocytes; serum levels pre-albumin, RBP, vitamins A and E. of zinc, albumin, hyporetinaemia. Integrated Morbidity Scores ( IMS) derived from diarrhoea, herpes and respiratory tract infection (radiologically confirmed) were assigned on day 8, at 6 weeks and 6 months - these were reduced by 82%, 61% and 85% respectively in the supplemented group. This was mainly due to reduced respiratory tract infection. There was one death in the placebo group. At 6 weeks there was significant weight gain in the supplemented group. Despite the selected sample, attention to multiple covariates enhances the validity of the data obtained and supports the current WHO recommendations for vitamin A supplementation during measles. There are several mechanisms by which vitamin A is thought to have its effect of reducing morbidity, one of which is by improving immune responsiveness. This particular mechanism has not been adequately studied in children; most of the studies having been conducted in animals. The effect of vitamin A supplementation on selected factors of immunity in African children with complicated measles was therefore investigated during the randomized double-blind, placebo controlled, intervention trial described above. Placebo and treated groups had similar baseline characteristics. In the treated group there was a significant increase in total number of lymphocytes (day 42, P = .05) and measles IgG antibody concentrations (day 8, p = .02), both of which have consistently been shown to correlate more closely with outcome in measles than other immunological, clinical and radiological factors. Interleukin-2 (IL-2) and plasma complement (C3 ) values were unaffected by vitamin A supplement.at.Lon , These findings reinforce results from animal studies which show that the pathways of vitamin A activity in decreasing morbidity and mortality are partly founded on selective immunopotentiation. In conclusion epidemiological and biochemical methods which were used to assess the vitamin A status of African children in South Africa revealed that overt vitamin A deficiency is not a Public health issue to the extent it is in the poor rice eating nations of the world. Marginal vitamin A deficiency is however prevalent in informal settlements. Interventions to reverse this marginal vitamin A deficiency should be incorporated in comprehensive programmes to ensure food security. Infections such as measles which increase utilisation and inhibit mobilisation from body stores are damaging to vitamin A homeostasis in the individual. The morbidity associated with measles can be reversed by high dose vitamin A supplementation during the acute phase of the infection. Improving immune responsiveness is one of the likely paths of vitamin A activity in decreasing morbidity from measles. / Thesis (Ph.D.)-University of Natal, Durban, 1993.

Alexandria Luria's approach to neuropsychological assessment and his theory of brain functioning have been exploited in order to develop a neuropsychological evaluation procedure for children which incorporates a conceptualization of brain-behaviour development. Luria's Neuropsychological Investigation for adults was administered to intact children aged eight to 14 years in order to ascertain which tasks were beyond their capabilities. These were then adapted or deleted. The adapted version of the protocol was then administered to a second group of intact children to determine that the proposed adaptations were appropriate. This process was guided by the results of a statistical analysis which revealed significant findings with respect to age, socioeconomic status, and task performance. A model of brain-behaviour development and interpretive protocol were devised. Together these provide a conceptual and interpretive framework for the battery. Developmental trends which emerged whilst developing Luria's Neuropsychological Investigation for Children (LNI-C) were consistent with the progressive development of successively more complex forms of information processing as depicted in this model. They were also in keeping with prominent developmental theories such as those of Piaget and Vygotsky. These trends revealed that children made most mistakes on adult LNI tasks involving abstract reasoning, the simultaneous synthesis of data, and complex goal-directed behaviour - all of which apparently reflect tertiary cortical zone functioning. Fewer mistakes were related to a lack of training and inability to process the same quantity of information as adults - difficulties which seemed related to secondary zone functioning. None of the mistakes made appeared to reflect subcortical or primary zone functioning. The LNI-C was applied to brain-damaged children who had had a CT scan in order to demonstrate its application and the hypothetico-deductive process of interpreting findings using the concepts of syndrome analysis and double dissociation. The LNI-C findings were consistent with the general pattern of symptoms Luria described for different brain disorders and lesion localities in children, although additional insight into the nature of the sequelae present was gained in each case. In early brain damage, the most frequent disturbances were a disruption in the role played by executive functions and the ability to process data simultaneously - both of which are associated with the tertiary zones of the brain. Furthermore, these disturbances appeared to be important factors underlying disturbances to language and educationally acquired skills. The qualitative, process-orientated nature of the LNI-C proved effective for identifying the factors underlying disturbances described in paramedical reports. These seemed to be the linchpins on which retraining should focus. It was argued that the CT scan was limited in its ability to identify the type of diffuse and/or multifocal brain pathology frequently found in children. The usefulness of the model of brain-behaviour ontogeny and interpretive protocol for diagnosis, understanding and predicting the developmental consequences of childhood brain pathology was demonstrated on the basis of nine brain disorders. Finally, areas of future research were highlighted by the study. / Thesis (Ph.D.)-University of Natal, Durban, 1989.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

Optimising outcomes for children with hearing impairment (HI) requires a family centred approach that prioritises parent involvement. Families must be provided with information to encourage participation; and meet their need for emotional support and knowledge. Diagnostic audiology reports can help provide this information, but their delivery alone is insufficient. If these reports are not readable and comprehendible they cannot meet national and international legal standards, nor can they support the health literacy of parents. The majority of New Zealand adults have insufficient health literacy skills, a concerning fact given the strong association between poor health literacy and negative health outcomes. The aim of this study was to evaluate a paediatric diagnostic audiology report, revise it and verify the revision. A mock audiology report was evaluated via a readability analysis and semi-structured interviews with parent participants. Results confirmed that the report was difficult to read and understand. Next, the report was revised using best practice guidelines and parental recommendations. Verification of the revision process with 32 participants revealed that parents who read the revised report had significantly greater comprehension, self-efficacy and perception ratings than parents who read the unrevised report. Additionally, the report’s readability was markedly improved. These results may have critical implications for parents and their children with HI. Incomprehensible audiology reports fail to support parental health literacy, promote understanding, encourage participation or offer emotional support. Because knowledge is power for these families, it is hoped that the findings of this study will be recognised and implemented into clinical practice.

Introduction: Mild traumatic brain injury (mTBI) accounts for the vast majority of all paediatric TBI cases. It is an important public health concern, yet the long-term psychiatric and behavioural outcomes remain imperfectly understood. Aim. This study aims to examine the association between paediatric mTBI and psychiatric and offending outcomes in adulthood, while considering the impact of sex, age at injury and duration since injury on outcome. Participants: Participants with mTBI (n=57) were compared to those with moderate/severe TBI (n=62) and to orthopaedic injury controls (n=42). All participants were injured at age 17 or younger and were 18 years or older at the time of assessment. Outcome measures: Based on the DSM-IV-TR criteria, structured interviews were used to assess participants’ experience of symptoms consistent with major depressive disorder, anxiety disorders (including generalised anxiety disorder, panic attacks and panic disorder, agoraphobia, social phobia, post-traumatic stress disorder, and specific phobia), and substance abuse and/or dependence. Participants’ were asked to report on their lifetime involvement with offending, arrests, and diversions and/or convictions. Results: At age 18-31, participants with a paediatric mTBI were significantly more likely than orthopaedic injury controls to endorse symptoms consistent with major depressive disorder by 3.17 times, anxiety disorders by 5.81 times, and internalising disorders in general by 5.80 times and the risk in the mTBI group was greater than that for those with moderate/severe TBI. Females with mTBI were significantly more likely than males, by five times, to endorse an internalising disorder. Paediatric mTBI was not significantly associated with externalising problems when compared with controls; however, males with mTBI were 6.57 times more likely to endorse externalising behaviours than females. Conclusions: Paediatric mTBI is a risk factor for internalising disorders in adulthood, particularly for females. Such findings have implications for assessment and treatment of problems associated with paediatric mTBI.

Pediatric mental health nurses, working in an agency in the midst of introducing Trauma Informed Care, were interviewed to examine the factors influencing perceptions of aggression. Relational Inquiry (Hartrick Doane & Varcoe, 2005; 2007) framed the research and Kvale’s (1996) Interpretive Methodology informed the interview and analysis. The complexity of relationships impacted the participants’ perceptions. Two constructs interwoven throughout the findings: time to develop relationships and knowledge about the individuals with whom the relationships were to be formed. Five themes were identified however the Participant-Colleague relationship was critical to perceptions of aggression. The Participant-Child relationship and the functioning of the system of care were important. The participants recognized reflexivity as critical to the understanding of their perceptions. The participant’s created a common understanding of aggression. Recommendations include: 1) clinical supervision to explore issues of moral distress and burnout 2) create capacity for nursing research 3) expand research exploring ‘safety’, ‘support’ and observational studies. / Graduate

The overall aim of this thesis was to characterize single-channel aEEG/EEG, recorded during the first postnatal days in preterm infants, in relation to brain function and two-year outcome. Study I investigated if aEEG/EEG was associated with neonatal brain injury, inflammation and outcome in 16 very preterm (VPT) infants. The interburst interval (IBI) was prolonged, and aEEG amplitudes were lower in infants with brain injury, and in infants developing handicap. Cord blood TNF-α correlated with IBI. Study II investigated inter-rater agreement of visual burst detection, as compared to automated burst detection based on a non-linear energy operator (NLEO) in an EEG data set from 12 extremely preterm (EPT) and 6 VPT infants. The sensitivity of the NLEO was 64 % and 69 % (EPT and VPT infants, respectively) and the specificity 96 % and 88 %. The algorithm was then modified to further improve the accuracy. Study III investigated if arterial carbon dioxide and plasma glucose is associated with EEG continuity. In 247 sets of samples (PaCO2, plasma glucose, IBI) from 32 EPT infants there was a positive association between PaCO2 and IBI; higher PaCO2 was associated with longer IBI. Corrected for carbon dioxide, plasma glucose had a U-shaped association with IBI in infants with good outcome. Study IV investigated the predictive value of aEEG/EEG in 41 EPT and 8 VPT infants. All VPT infants had good outcome. Predictors of outcome in EPT infants included presence or absence of burst-suppression, continuous activity and cyclicity, median IBI and interburst%. Seizures were associated with neonatal brain damage but not with outcome. Improved preterm brain monitoring may in the future be used for early identification of infants at high risk of brain damage and adverse outcome, which may have implications for direction of care and for early intervention.

Children’s lifestyle has changed significantly during the recent decades, with an increasing prevalence of obesity as one outcome. Parents are usually the most influential people in young children’s lives. The overall aim of this thesis was to investigate parental perspectives on factors associated with 3-6 year-old children’s lifestyle, regarding eating habits and physical activity. Another objective was to compare different approaches to conducting postal questionnaires in terms of response rate, time consumption and cost-efficiency. The samples in the four studies were parents of 6-year-olds (n=158), parents of 3-year-olds (n=873), parents of 4-year-olds (n=30) and parents of 3-year-olds (n=353). In the first study, a questionnaire regarding practices and attitudes towards their child’s lifestyle, perceived obstacles and desired support was used. The second study included the Swedish Parenthood Stress Questionnaire (SPSQ), the Relationship Questionnaire (RQ) and the CFQ (Child Feeding Questionnaire). Parents also reported their child’s TV-viewing habits. The child’s measured height, weight and BMI were obtained from a register, BASTA. In the third study, focus group interviews were performed. The fourth study investigated three types of consent given for participation in a survey. The results showed that parents’ attitudes towards children’s lifestyle, in general, were “healthier” than their reports of their child’s daily practices. The practices differed depending on the parents’ educational background. Significant and dose-dependant associations were found between perceived maternal stress and children’s overweight, but also underweight. Parents felt that they were mainly responsible for their preschool child’s lifestyle. However, parents described challenges that limited and obstructed them from providing their child with a healthy lifestyle, citing the need to receive professional and peer support, while also requesting support from society. Allowing respondents to actively decline participation yielded a higher response rate and proved to be the most cost-efficient method for conducting a postal questionnaire.

The research investigates, qualitatively, the experience of primary caregivers of children who are ventilator-dependent and cared for at home. Advances in medical and nursing knowledge and technology have improved the biological outcome of children who are critically ill. As a result, there is an increasing number of children in hospital who are medically stable, however dependent upon long-term respiratory support. Due to the increasing change from healthcare delivery to home care, some ventilator-dependent children are discharged to their primary caregivers who undertake the medical and technical care of the children in their home. A review of the literature indicates limited research examining and addressing issues of pediatric home ventilation. Information concerning the experience and needs of the primary caregivers of an in-home ventilator-dependent child is thus unavailable for effective and appropriate clinical interventions and policy implementation. To address the gap in the literature, a phenomenographic research approach was used to identify and describe a limited number of qualitatively different ways in which the primary caregivers understood their experience of caring for a ventilator-dependent child at home. An in-depth interview was undertaken with each of those seventeen participants and recorded on audiotape for transcribing verbatim. Data was sorted using a qualitative software program--ATLAS.ti.--and analysed using a series of seven analytical steps recommended for a phenomenographic research (Dahlgren and Fallsberg, 1991). The outcomes of the research are seven categories of description with each representing a conception of the experience, and all categories combined constituting an outcome space that presents the structural relations between conceptions. The seven categories of description representing the care-giving experiences of the primary caregivers are: (1) 'Hospital is another world to me'; (2) 'It's a new world'; (3) An ambiguous social identity;(4) The medical technology associated with my child is frightening but necessary;(5) 'The difficulty is having the carers at home'; (6) Social isolation; and (7) The experience of changing as a person. Discussions on the outcomes of the research indicate a need for increased understanding of the 'new world' of the primary caregivers and a recognition and acknowledgement of the distinctive nature of the experience in caring for a ventilator-dependent child at home. Hence, increased financial, respite, psychological and social support are of central importance, in addition to ongoing healthcare research, education, and practice for appropriate policy development, implementation and evaluation.

This purpose of this work was to investigate the patient radiation doses and image quality of a Philips/Agfa computed radiographic (CR) system and a Philips indirect-capture digital radiographic (DR) system in a paediatric setting. A CDRAD digital radiographic contrast-detail phantom was used to assess radiographic image quality. Perspex slabs of three different thicknesses (6, 11 and 16 cm) were used to simulate paediatric patients of three arbitrary ages. These phantoms, in conjunction with the CDRAD digital radiographic contrast-detail phantom, were imaged under three different conditions. The CDRAD Analyser software package was used to assess the quality of each image. The first experiment conducted was a comparison of the two systems under standard conditions, with beam filtration of aluminium and copper, as recommended in European Guidelines on Quality Criteria for Diagnostic Radiographic Images in Paediatrics (European Commission 1996b). Image quality was compared for each phantom size at three doses with the same entrance exposure used for both systems. A visual comparison of the resulting contrast detail curves showed the DR system generally outperformed the CR system, especially at the lowest two doses. A chi-square analysis of the targets detected generally confirmed this visual impression. The second experiment performed was to compare the two systems under the conditions used in routine clinical practice at PMH. As a result of additional beam filtration not generally being employed, the image quality of the CR system was similar to the DR system for the two smaller phantom sizes but with a major dose cost - effective doses higher by between 38% and 100%. A chi-square analysis of the targets detected showed the CR system to be significantly better than the DR system at two of three doses for the thinnest phantom and no significant difference at any doses for the intermediate phantom size. For the largest phantom size, additional filtration - although different - was used for the CR and DR systems and so the X-ray beam spectra were more similar. Consequently, the results for this phantom size reflected those from the experiment conducted under standard conditions, ie the effective doses for both systems were similar and the image quality of the DR system superior. The chi-square analysis s howed the DR system to be significantly better than the CR at all three dose levels. A third experiment was undertaken to compare doses between the two systems at 'equal' image quality. The CDRAD Analyser software specific image quality parameter, IQFinv, was held constant for both systems. The entrance exposures required to achieve this image quality were measured and then converted to effective doses using the dose calculation software package PCXMC 1.5. The DR system offered effective dose savings of between 28 and 42% for the three phantom sizes. Overall, this work suggests that a Philips flat-panel system is superior to an Agfa CR system in paediatric radiography. This result generally reflects the findings of other authors who have conducted similar studies in adult patient settings.